Vascular Exam 2 - Peripheral Arterial

Which vessel wall layer regulates arterial size?

Tunica media

Which vessel wall layer has valves?

Tunica intima

Which vessel wall layer contains the vasa vasorum?

Tunica adventitia

Upper Extremity

• Three branches of the aorta:

  • _____ (_____) artery

  • _____ _____

  • _____ _____ artery

• Brachiocephalic artery branches into the _____ _____ and _____ _____ artery

• Right subclavian artery continues laterally, passing below the _____ to become the _____ artery

• Axillary artery continues down the bicep to become the _____ artery

• Brachial artery bifurcates at the _____ to become the _____ and _____ arteries

Brachiocephalic, Innominate, Left CCA, Left subclavian, right CCA, right subclavian, clavicle, axillary, brachial, elbow, radial, ulnar

Upper Extremity – About

• _____ = border of first rib; becomes axillary

  • Can be found either above or below the clavicle depending on the patient

• _____ = passes behind the clavicle

• _____ = main blood supply to the arm, forearm, and hand

• _____ = thumb side; terminal branch that forms the deep palmar arch

• _____ = pinky side; terminal branch forms the superficial palmar arch

• Palmar arches AKA _____ arch – not always complete!

  • _____ Test

Subclavian, Axillary, Brachial, Radial, Ulnar, volar, Allen’s

Allen’s Test is a physical exam that assesses the patency of the…

palmar arch

The state of being open, clear, and unobstructed

Patency

• Palmar arch may be “_____”

  • If a palmar arch is _____, that means that it is not connecting back to the other side of the _____

incomplete, incomplete, wrist

• Palmar Arches

  • _____ = supplied primarily by the radial artery with contribution from the ulnar artery

  • _____ = supplied primarily by the ulnar artery with contribution from the radial artery

  • If one of these arches were to be _____, the radial artery wouldn’t be connected to the ulnar artery and vice versa

• _____ branch → main blood supply

Deep, Superficial, incomplete, Terminal

The difference between the right and left upper extremity is that the _____ _____ is a branch of the brachiocephalic artery and the _____ _____ is a branch directly from the aortic arch. All of the other branches after the _____ artery are the same on both sides.

right subclavian, left subclavian, subclavian

Lower Extremity – Thigh to Knee

• Aorta bifurcates into the left and right _____ _____ arteries

• Common iliac arteries bifurcate into _____ and _____ iliac arteries

  • _____ iliac artery AKA hypogastric artery

• External iliac artery continues medially down the thigh passing below the _____ _____ to become the _____ _____ _____ (_____)

• CFA bifurcates into the _____ (_____) and _____ _____ (_____) arteries

  • With ultrasound, we only really image the _____ profunda

• SFA continues down the leg, then passes behind the _____ where it becomes the _____ artery (_____)

common iliac, internal, external, internal, inguinal ligament, common femoral artery, CFA, profunda, deep, superficial femoral, SFA, proximal, knee, popliteal, Pop A

Lower Extremity – Knee to Ankle

• The _____ continues down the leg, then passes behind the knee where it becomes the popliteal artery (Pop A)

• Popliteal artery terminates into a _____:

  • _____ _____ artery (_____) - Lateral

  • _____ _____ artery (_____) - Medial

  • _____ artery (_____) - Middle

  • ^^^All part of the Tibial/Peroneal trunk

• ***The trifurcation is technically just _____ branches

  • A “trunk” which bifurcates into the _____ artery and _____

  • The _____

• ATA crosses the ankle and becomes the _____ _____ artery (_____) on top of the _____

  • The DPA is the first major branch of the _____ _____ artery (arch)

• The peroneal artery is _____ than the PTA

SFA, trifurcation, Anterior tibial, ATA, Posterior tibial, PTA, Peroneal, Pero A, two, peroneal, PTA, ATA, doralis pedis, DPA, foot, deep plantar, deeper

State the location of each vessel in regards to the leg and each other:

• Anterior tibial artery (ATA) - _____

• Posterior tibial artery (PTA) - _____

• Peroneal artery (Pero A) - _____

Lateral, Medial, Middle

Lower Extremity – Foot

• _____ _____ and _____ form the plantar arch

  • _____ plantar artery (distal branch of the DPA)

  • Medial and lateral plantar artery (branches of the _____)

  • Deep plantar and lateral plantar arteries unite to form the _____

• Plantar and dorsal metatarsal arteries arise from the plantar arch and supply blood to the _____

Dorsalis pedis, PTA, Deep, PTA, arch, toes

Lower Extremity

Understand the “_____” of vessels (where does one vessel become the next):

• EIA to CFA

  • At the _____ _____

• CFA becomes the _____ artery and _____

  • The SFA is _____ to the initial origin of the profunda artery, but the profunda then passes behind (posterior) and deep to run more _____ or posterolaterally as it descends.

  • We only image the _____ profunda

  • We image the entire _____

• SFA becomes the _____ artery

  • At the _____

• Pop A and the trunk

  • _____, _____, _____

change, inguinal ligament, profunda, SFA, medial, medially, proximal, SFA, popliteal, knee, ATA, PTA, peroneal

Normal Sono Appearance for Peripheral Arteries

• 2D and color will be similar to your normal _____ appearance

  • _____ lumen free of defects

  • Smooth, thin, _____ walls

  • Complete, even _____ fill – varies with the _____ _____! _____ flow!

• _____: waveform will dip below the baseline

• Spectral Doppler

  • _____ or _____ waveform → _____ = normal, _____ = abnormal

  • Spectral _____ present

• Normal peripheral arterial waveforms will have bigger _____ _____ and thinner _____ than carotid waveforms

carotid, Anechoic, echogenic, color, cardiac cycle, PULSATILE, Variations, Triphasic, multiphasic, Multiphasic, Monophasic, window, spectral windows, tracings

Arterial Hemodynamics

Factors that control arterial flow:

• _____ _____

  • How much blood is being pushed out of the heart

• Intraluminal wall _____

  • Are the vessels healthy and elastic or are this rigid and calcified

• Total body _____

• Arterial wall _____

  • The ability of an arterial wall to expand and recoil passively in response to changes in blood pressure and volume

• Arteriolar _____ or _____

  • Remember that arterioles control _____ and _____

Cardiac output, resistance, resistance, compliance, vasoconstriction, dilation, vasoconstriction, dilation

• At rest, arterioles are _____

• With movement, arterioles are _____

• Peripheral artery Doppler waveforms demonstrate _____

  • _____ is reflected by the projections above and below the _____

• Blood flows towards the feet in _____ (away from the heart) (first above baseline peak), back towards the heart in _____ _____ (below baseline), then towards the feet again before the next _____ begins (above baseline)

  • Shown on image

• A normal waveform should be _____ or _____

  • _____ waveforms are also considered multiphasic and normal

vasoconstricted, dilated, resistance, Resistance, baseline, systole, early diastole, cycle, triphasic, multiphasic, Biphasic

At rest…

• _____ demand for blood supply

• _____ occurs at the arteriole level

• Little blood going to the _____ _____

• Most blood is going to the _____/_____ circulation

  • _____ = organs

• _____-resistance flow observed

During exercise…

• Metabolic demand of skeletal muscles _____

• Heart rate and cardiac output _____

• _____ occurs at the arteriole level

• Blood is shunted from the _____ to the _____ _____

• Substantial _____ in blood volume in peripheral arteries and blood volumes may _____ significantly

• As a result, arterial Doppler waveforms will exhibit _____ resistance flow

Low, Vasoconstriction, skeletal muscles, viscera, cerebral, Viscera, High, increases, increase, Vasodilation, viscera, skeletal muscles, increase, increase, low

During exercise…

• Peripheral resistance dramatically _____ during this time, and blood flows in an _____ direction throughout the cardiac cycle. Distal intraluminal _____ is maintained during vasodilation due to the increase in _____. Remember Poiseuille’s law:

  • Q ↑ (_____) x R ↓ (_____) = distal P (_____ _____)

• _____ in the lower vascular beds occurs quickly with the onset of even mild exercise

decreases, antegrade, pressure, volume, increases, decreases, no change, Vasodilation

• Increase in blood flow to tissues or organs

• Can be normal or abnormal

  • Normal = in response to exercise or digestion

  • Abnormal = in response to infection or heart failure

• Two types:

  • Active – result of increased metabolic activity

  • Passive – result of obstructed blood flow

Hyperemia

Two types of hyperemia:

• _____ – result of increased metabolic activity

• _____ – result of obstructed blood flow

Active, Passive

When scanning the upper and lower arterial protocols, if the _____ waveform is normal, there is a pretty good chance that everything _____ is normal as well.

distal, proximal

The distal SFA will _____ similar to the distal ICA

• It will look “_____” like the distal ICA when you add color

dive, junky

• You will see various vessels at the proximal popliteal artery and the vessel will be going _____ the screen

• The distal popliteal artery will be going _____ the screen

up, down

What is the difference between a stenosis and occlusion?

• A stenosis is the _____ of a vessel that still lets some blood flow go through. An occlusion is the complete _____ of a vessel that doesn’t let any blood flow through it.

narrowing, blockage

According to Bernoulli, how are pressure and velocity related?

Inversely

What do we expect to find, in terms of waveform and velocity, when we encounter a stenosis?

• At a stenosis, you should expect to see a smaller _____ and increased _____, which would cause the waveform to dip below the _____. The velocity in a stenosis _____. You generally see _____ flow (waveform) after a stenosis and a _____ velocity.

• Proximal to stenosis: _____ _____ may or may not be altered depending upon the severity and where the sample is obtained

• Stenosis: velocity _____, the flow becomes disorganized - spectral _____

• Post-stenosis: _____ (e.g., flow reversal, eddy currents, vortices)

radius, resistance, baseline, increases, turbulent, decreased, flow pattern, increases, broading, turbulence

With proximal disease, what will happen to our waveforms downstream (distally)? Why?

• The waveform will have a _____ _____ shape due to decreased blood flow through a stenosis.

• An arterial occlusion or stenosis may result in decreased _____ distally (depends on the severity)

• Vessels will _____ to maintain flow volume

  • If tissue demand exceeds available blood volume, _____ will result

  • Dilation of the vessels _____ pressure and resistance, but _____ flow volume

  • Peripheral resistance will _____ as a result (depending on severity and demand)

• Delayed _____ _____ (_____) – time interval between onset of systole and PSV; how long does it take from the start of systole to reach max velocity

tardus parvus, pressure, vasodilate, vasodilation, decreases, increases, decrease, acceleration time, AT

What should a normal waveform look like in a peripheral artery?

• _____phasic with an open spectral _____ and _____ tracing

• Peripheral artery Doppler waveforms demonstrate _____

  • _____ is reflected by the projections above and below the baseline

Multi, window, thin, resistance, Resistance

Peripheral Arterial Disease (PAD) – Risk Factors

• Family or personal history (Hx) of cardiovascular disease

• Diabetes

• Hypertension (HTN)

• Hyperlipidemia

  • High cholesterol

• Tobacco abuse

• Age

• Genetic disposition

PAD =

Peripheral Arterial Disease

• Exertional pain that subsides with rest

• Most common symptom of PAD

• Result of inadequate blood flow with increased demand

• Pain has predictable onset and resolution

  • The patient can tell you when the symptom occurs and how long the symptoms last

• Symptom typically occurs distal to site of disease

  • Ex: If a patient has pain in their calf after walking for a certain/specific amount of time, it makes you believe that maybe they have peripheral arterial disease in either the popliteal artery or the distal SFA, which are proximal to the calf.

Claudication

Claudication

• _____ pain that subsides with _____

• Most common symptom of _____

• Result of inadequate blood flow with _____ demand

• Pain has _____ onset and resolution

  • The patient can tell you when the symptoms occur and how long the symptoms last

• Symptom typically occurs _____ to site of disease

  • Ex: If a patient has pain in their calf after walking for a certain/specific amount of time, it makes you believe that maybe they have peripheral arterial disease in either the popliteal artery or the distal SFA, which are _____ to the calf.

Exertional, rest, PAD, increased, predictable, distal, proximal

• The same symptoms but not due to vascular etiology

• Neurogenic claudication; exertional pain due to neurogenic causes (spinal stenosis, nerve compression)

• Could also be orthopedic in nature

Pseudo-claudication

• Aorto/iliac obstruction or occlusion

• A specific type of claudication

• Typically a bilateral disease

• Common in males

• Profound exertional pain in hips, thighs, and calves

• Pallor or coldness

• Impotence

Leriche Syndrome

PAD signs and symptoms:

• _____ _____ _____

• _____ _____

Ischemic rest pain, Tissue loss

PAD – Signs and Symptoms

• _____ = reduced blood flow to a part of the body

• Ischemic rest pain

  • Pain at _____

  • Typically indicates _____ disease

  • _____ blood flow even at rest

  • Foot, toes, heel

  • Improved with _____ (elevation)

  • Ischemic rest pain is pain that occurs at _____, typically with the patient in the _____ position. This pain is relieved with _____ – when the patient _____ _____ or _____ their legs. This is due to an _____ in hydrostatic pressure that _____ perfusion.

• Tissue loss

  • Ischemic _____

    • _____: the formation of an open sore or break on the skin or on the inner lining of an organ, caused when surface cells die and shed

  • Insufficient flow to maintain cell _____

  • _____ – GROSS

    • The death of body tissue caused by a loss of blood supply or a severe bacterial infection

    • Like when people start losing toes

Ischemia, rest, severe, Inadequate, dependency, rest, supine, dependency, stands up, lowers, increase, increases, ulceration, Ulceration, metabolism, Gangrene

Reduced blood flow to a part of the body

Ischemia

The death of body tissue caused by a loss of blood supply or a severe bacterial infection

Gangrene

6 P’s of Arterial Disease

• _____

• _____

  • Paleness, loss of color

• _____

• _____

  • Tingling, pins & needles

• _____

  • Inability to move

• _____/_____

  • Coldness

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Polar/Poikiloderma

Particles flowing in parallel lines or layers

Laminar flow

Laminar flow types:

• _____ – middle layers are faster than the outer layers

  • In the arterial system, this type of flow is most commonly seen

• _____ – all layers moving at the same velocity

• _____ – non-laminar flow; chaotic

Parabolic, Plug, Turbulent

• Turbulent flow occurs when _____ _____ is exceeded

• _____ or greater

• Turbulent flow seen _____ to a significant stenosis

Reynold’s number, 2000, distal

The _____ _____ (arrow) represents the aortic valve closure in a pulsatile flow waveform

dicrotic notch

Pulsatile Flow

• Early _____ (A)

  • Cardiac _____

  • Aortic valve _____

  • _____-velocity ejection of blood

• Late _____ / Early _____ (B)

  • Rapid _____ and aortic valve _____

  • _____ _____ (arrow) represents the aortic valve _____ - variable in appearance and not always disernable

  • Pressure wave hits the distal peripheral _____

  • Possible hydraulic reflection of the pressure wave, which may result in temporary flow _____

• Late _____ (C)

  • _____ velocity or no _____ flow

  • Depends upon the _____ of the vascular bed

Systole, contraction, opens, High, Systole, Diastole, deceleration, closes, Dicrotic Notch, closure, resistance, reversal, Diastole, Low, forward, resistance

Flow Characteristics of a Stenosis

• Remember:

  • _____ = narrowing of the lumen, typically due to plaque

• Changes in flow _____ at area of decreased diameter due to the disease

• Velocity _____ at narrowest point

• _____ at the exit (post-stenotic)

• Changes in resistance _____ (downstream), depending on the severity of disease

  • Severe – flow and pressure remain _____ distal to the stenosis

  • Hemodynamically significant stenosis is defined as one that causes a notable reduction in flow and pressure (approximately _____% diameter reduction)

  • 50% diameter reduction = _____% area reduction

Stenosis, direction, increase, Turbulence, distally, decreased, 50, 75

Normal Waveform

• Rapid _____ _____

• Systole flow _____

  • Projections _____ the baseline

• Minimal _____ flow

• _____phasic

acceleration time, reversal, below, diastolic, Multi

• Flow Limiting Stenosis Waveform

  • _____ resistance

  • Slightly delayed _____ _____

  • Loss of flow _____

  • Forward _____ flow

  • _____phasic with _____ flow

Decreased, acceleration time, reversal, diastolic, Mono, diastolic

• Significant Stenosis Waveform

  • Significantly decreased _____ _____

  • No _____ flow

  • _____ velocity

acceleration time, diastolic, Decreased

• Ability of most tissues and organs to maintain constant blood flow despite changes in perfusion pressure

• Sympathetic nervous system causes dilation of arterioles and capillaries when flow is decreased

• Pressure is lowered, flow is increased

• May be the result of:

  • Systemic hypotension (low blood pressure)

  • Stenosis

• In short: if blood pressure drops, vasodilation occurs

Autoregulation

If blood pressure drops, _____ occurs.

vasodilation

Stenosis Interpretation

• Velocity Ratio (Vr) – highest PSV in _____ divided by _____-_____ PSV

  • > 2:1 ratio increase = > _____% diameter reduction

  • > 4:1 ratio increase = > _____% diameter reduction

• Stenotic PSV > 400 cm/s = > _____% diameter reduction

• What to think: Is the stenosis PSV __x or __x greater than the pre-stenosis PSV?

stenosis, pre-stenosis, 50, 75, 75, 2, 4

What is the velocity ratio and percent diameter reduction if the stenosis PSV is 360 cm/s and the pre-stenosis PSV is 150 cm/s?

2.4, 50%

What is the velocity ratio and percent diameter reduction if the stenosis PSV is 240 cm/s and the pre-stenosis PSV is 110 cm/s?

2.2, 50%

What is the percent diameter reduction if the stenosis PSV is 409 cm/s and the pre-stenosis PSV is 183 cm/s?

75%

***Stenotic PSV > 400 cm/s = > 75% diameter reduction AUTOMATICALLY

What is the most common arterial pathology?

Atherosclerosis (plaque)

• Most common arterial pathology

• Thickening, hardening, and loss of elasticity of the arterial wall

• Deposition of plaque between the intimal and media layers of the vessel wall

• Systemic disease process

  • Symptomatic patients will have disease in multiple spots – CCA bifurcation, AO/Iliac, CFA bifurcation

  • Progression of disease results in increased severity, extension of the disease, and number of lesions

Atherosclerosis

Atherosclerosis

• Most common _____ pathology

• Thickening, hardening, and loss of elasticity of the arterial _____

• Deposition of _____ between the _____ and _____ layers of the vessel wall

• Systemic disease process

  • Symptomatic patients will have disease in _____ spots – CCA bifurcation, AO/Iliac, CFA bifurcation

  • _____ of disease results in increased severity, extension of the disease, and number of lesions

arterial, wall, plaque, intimal, media, multiple, Progression

Treatment for Atherosclerosis

• Control _____ _____ – stop smoking, diet & exercise

• Pharmacological – control blood _____, cholesterol, and diabetes

  • Beta blockers, diuretics, statins

• Surgical – _____

  • Removal of atherosclerotic _____ from arteries

  • May be followed by _____ or _____ to keep lumen open

  • “_____ _____” – rotational atherectomy

    • Spinning brush that knocks off the plaque

risk factors, pressure, atherectomy, plaque, stent, angioplasty, Roto rooter

• The process/condition of a blood clot forming inside a blood vessel and blocking or reducing blood flow

• Result of disease progression

• Stenosis eventually completely occludes

• Acute occlusion can occur in less severe lesions resulting in minimal collateralization

  • Acute: rapid or new onset

  • An occlusion forms quickly meaning that the body has less time to respond by forming collaterals

  • Very dangerous

Thrombosis

Thrombosis

• The process/condition of a _____ _____ forming inside a blood vessel and blocking or reducing blood flow

  • A _____ is the actual blood clot that forms

• Result of disease _____

• Stenosis eventually completely _____

• _____ occlusion can occur in less severe lesions resulting in minimal _____

  • _____: rapid or new onset

  • An occlusion forms quickly meaning that the body has less time to respond by forming _____

  • Very _____

blood clot, thrombus, progression, occludes, Acute, collateralization, Acute, collaterals, dangerous

• Obstruction of a vessel by a foreign substance

• Most frequent cause is thrombus or plaque

• Once plaque is dislodged, it is called this

• Travels distally through the vessel until it lodges in an artery smaller than it is

Embolus

Embolus

• _____ of a vessel by a _____ substance

• Most frequent cause is _____ or _____

• Once plaque is dislodged, it is called an _____

• Travels distally through the vessel until it lodges in an artery _____ than the embolus

Obstruction, foreign, thrombus, plaque, embolus, smaller

• Alternate pathways that may supply blood around an arterial obstruction

• In most cases – small, already existing vessels that dilate over time in response to chronic vasodilation

  • In a chronic condition, the body already kind of knows what to do

  • Ex: patient with an SFA occlusion walks regularly for a year and the small vessel already present dilates in response to the perfusion need

• May result in “false ok-ness,” meaning the vessel is diseased but because these are present, we see adequate flow. This is particularly tricky with physiologic testing.

Collaterals

Collaterals

• Alternate pathways that may supply blood around an arterial _____

• In most cases – small, already existing vessels that dilate over time in response to _____ vasodilation

  • In a _____ condition, the body already kind of knows what to do

  • Ex: patient with an SFA occlusion walks regularly for a year and the small vessel already present _____ in response to the perfusion need

• May result in “false ok-ness,” meaning the vessel is diseased but because these are present, we see adequate flow. This is particularly tricky with _____ testing.

obstruction, chronic, chronic, dilates, physiologic

The image shows _____ collateralization.

• Complete artery occlusion with _____ collateralization allows _____ blood flow, no significant _____, waveform remains similar or only minimally altered _____ to an occlusion.

adequate, good, adequate, vasodilation, distal

The image shows _____ collateralization.

• Complete artery occlusion with _____ collateralization. _____ is decreased distally with results in _____ and therefore the waveform is altered exhibiting _____ flow.

insufficient, inadequate, Pressure, vasodilation, diastolic

The image shows _____ collateralization.

• Complete artery occlusion with very _____ collateralization. Arterioles are maximally _____ BUT _____ is insufficient to maintain flow during _____.

poor, poor, vasodilated, pressure, diastole

Aorto-Iliac Imaging

• _____ – may present with exertional pain in the hips, thigh, or calf in the case of aorto-iliac disease

• Aorta evaluation is often limited due to _____ _____

• Evaluate the AO (proximal, mid, distal), then the internal and external iliac arteries

  • _____ – dilated 1.5x normal diameter

  • _____ – narrowing interpretation criteria is the same as peripheral arteries

  • _____ – segment of vessel with no detectable flow

• _____ _____: aorto/iliac obstruction or occlusion, most common in males

Claudication, bowel gas, Aneurysm, Stenosis, Occlusion, Leriche Syndrome

An aneurysm occurs when the vessel is dilated __x the normal diameter

1.5

Inflammation of the arterial wall

Arteritis

Inflammatory condition of the palmar arch/digital arteries leading to small vessel obstruction; occurs primarily in men over 40 who are heavy smokers

AKA: Thromboangitis obliterans

Buerger’s disease

Rare, chronic autoimmune condition that causes inflammation of the aorta (arch) and its primary branches; most common in females

Takayasu’s arteritis

Serious inflammatory autoimmune disease that affects the larger arteries, especially in the head, eyes, and neck

Affects the temporal artery, which is a branch of the ECA

AKA: Giant cell arteritis

Temporal arteritis

• Arteritis is most common in _____ vessels

• Chronic inflammation may lead to _____

• Arteritis is a type of _____ – group of disorders characterized by inflammation of blood vessels

smaller, thrombosis, vasculitis

Intermittent digital ischemia due to small vessel vasospasm secondary to cold exposure or emotional stress

• Affected digits will turn white

• Most common in females

Raynaud’s Phenomenon

Vasospastic Disorders

• _____ – vasospastic disorder without underlying disease; digital and palmar arteries are without obstruction, and perfusion to the digits at rest is normal

• _____ – vasospasm associated with underlying autoimmune disease or connective tissue diseases

Primary, Secondary

A sudden, abnormal tightening or constriction of an artery's muscular wall that reduces or temporarily blocks blood flow to downstream tissues

Vasospasm

• Popliteal artery is compressed by the medial head of the gastrocnemius muscle

• May result in stenosis, aneurysm, or occlusion

• Typical in young athletes who present with exertional pain

Popliteal Artery Entrapment

• Compression of the neurovascular bundle by the shoulder structures

• Symptoms occur when the arm is in a certain position

• Primarily neurogenic; minority of cases caused by compression of the vasculature

Thoracic Outlet Syndrome (TOS)

True or False: Patients with an aneurysm in one location are more likely to have an aneurysm elsewhere

True

The most likely complication of a peripheral artery aneurysm

Embolization

A _____ artery aneurysm seems to be the most common location of embolization (intraluminal thrombus) in the lower extremities

popliteal

Ulnar artery aneurysm due to repetitive blunt trauma

Hypothenar hammer syndrome

• Pocket of swirling flow adjacent to an artery

• Typically the result of an injury or tear to the vessel wall such as…

  • Percutaneous arterial catheterization

  • Penetrating trauma

  • Bypass graft anastomosis blowout

• There are no walls encapsulating the structure

• Treatment: thrombin injection and manual compression

Pseudoaneurysm

• Option for “longer” areas of occlusion/severe disease

• Basically a man made collateral

• Alternative to amputation or limb loss

Bypass grafts

Bypass Graft Types:

• _____ _____ _____

  • When the patient’s own GSV is tied to the artery to redirect blood around the area of blocked flow

• _____

  • Man made material graft that is sewn into the proximal and distal arteries that redirects blood around the area of blocked flow

Great saphenous vein, Synthetic

Vein Graft

• _____ _____ _____ is typically used

  • Assess during a “vein mapping” exam

• Most common GSV graft: _____ to _____

  • Most likely the _____ _____ _____

• May be left in place or _____

  • _____ _____ – vein left in “normal” position, valves are excised (taken out)

  • _____ – vein is flipped valves are left alone since they are in the direction of flow; will stay open

Great saphenous vein, femoral, popliteal, common femoral artery, reversed, In situ, Reverse

• Synthetic Graft

  • PTFE or Dacron material

  • From the CFA to _____ or sometimes _____

  • Typically do not go below the _____ to avoid risk of kinking with motion of the patient’s leg

SFA, popliteal, knee

Graft Images

• Bottom right: the double _____ lines of the vessel are very characteristic of a synthetic graft

• A bypass graft runs pretty _____

• Middle left: the bypass graft is the _____ vessel with _____ in it. The _____ vessel is the _____ vessel.

  • As you can see, the bypass graft runs _____ to the _____ vessel

• When you assess a bypass graft, you will do the same protocol that you would do on a _____ vessel

  • The only additional images that you would obtain would be of the proximal and distal _____

    • This is where the bypass graft is sewn in or connected to the _____ vessel

    • This is shown in the bottom left image

echogenic, superficially, top, color, bottom, native, superficial, native, native, anastomosis, native

• Guide wire introduced through the skin via needle through the CFA

• Guide wire is advanced to the stenotic area where a catheter with a long balloon is pressed over the guidewire and into the area of plaque

• Balloon is inflated to a fixed size, plaque is “smooshed” against the vessel walls, and a wire stent is opened

• Balloon is withdrawn, stent is left

• Complications: restenosis, neointimal hyperplasia, thrombosis, stent shift, aneurysm at stent edge

Percutaneous Transluminal Angioplasty

BPG =

Bypass graft

Which vessel is a continuation of the anterior tibial artery (ATA)?

Dorsalis pedis artery (DPA)

DISTAL to a significant stenosis →

DILATION

Your tissues always need blood flow. The demand for blood flow distal to a stenosis does _____ change, but _____ occurs so that the perfusion of blood to the tissues continues.

NOT, vasodilation