Sectional Vascular Test

What do the arrows represent ?

Yellow: systole (peak systole)

Orange: diastole

Compliance

blood vessels stretching with increased pressure, ability is lost in the presence of plaque build up

High resistant multiphasic/triphasic doppler velocty waveform (3 components)

1) Rapid antegrade flow reaching a peak during systole

2) Transient reversal of flow during early diastole

3) Slow antegrade flow (recoil) during late diastole

Low resistance wave form

flow profile with antegrade flow throughout the cardiac cycle (systole and diastole).

What do low resistance vascular beds need?

a constant blood supply throughout systole and diastole (high resistance vascular beds do not)

antegrade flow

flow that is going in the right direction

Extracranial

• Vessels in the neck, outside the skull

• Includes common carotid, external carotid (including branches), and cervical internal carotid arteries

• Supplies face, neck, scalp, and flow to the Circle of Willis

Intracranial

• Vessels inside the skull

• Includes internal carotid (intracranial segment), vertebral-basilar system, and the Circle of Willis

• Supplies brain, eyes, and meninges

Artery classification

3 Aortic Arch Branches

Supplies blood to the head, neck, and upper extremities

• Brachiocephalic (Innominate) Artery → Right common carotid + right subclavian

• Left Common Carotid Artery

• Left Subclavian Artery

Subclavian Arteries

Supplies upper extremities, neck, and thoracic structures

• Right Subclavian originates from the Brachiocephalic (Innominate)

• Left Subclavian originates directly from the Aortic Arch Major branches include:

• Vertebral Artery

• Internal Thoracic (Internal Mammary) Artery

• Thyrocervical Trunk

• Costocervical Trunk

Common Carotid

• Right CCA originates from the brachiocephalic trunk

• Left CCA arises directly from the aortic arch

• Ascends to thyroid cartilage (C2–C3) → bifurcates into ICA & ECA

• Normal diameter: 0.75 – 1.25 cm

Carotid Bifurcation

• Carotid bulb = dilation at bifurcation → contains baroreceptors & chemoreceptors

• ECA: anterior/medial, multiple neck branches

• ICA: usually posterior/lateral, no branches in neck

• Common site for atherosclerotic plaque due to disturbed flow

• Level of bifurcation varies → usually near thyroid cartilage (C3–C4)

Interal vs External Carotids Key Differences

collateral = backroads

Typical

Tortuous

Kinked

coiled

Vertebral Artery

• First branch of subclavian artery

• Enters transverse foramina at C6 → ascends to brain

• Supplies ~25% of blood to brain

• Segments: extracranial, intravertebral, horizontal, intracranial

• left usually larger, possible trifurcation

Goals of Extracranial Duplex

• Detection of nonatherosclerotic conditions

• Identify patients who are at risk for stroke

• Facilitate treatment

• Document disease progression

Mechanisms of Cerebrovascular Symptoms

• Emboli from atherosclerotic plaques

  • Ulcerated plaque

• Reduction of flow due to high-grade stenoses (usually plaque build up)

• Arterial thrombosis

Causes & Risk Factors of cerebrovascular

• Atherosclerosis (≈90%)

• Dissection or trauma

• Fibromuscular dysplasia (FMD)

• Tumors, vasculitis, compression

Primary Risk Factors of cerebrovascular

• Hypertension

• Diabetes mellitus

• Hyperlipidemia

• Smoking

• Age, obesity, family history

Indications of cerebrovascular

• Bruit on physical exam

• Transient ischemic attack (TIA) symptoms

  • Amaurosis fugax (transient (temporary) monocular blindness)

  • Hemiparesis, syncope, vertigo

  • Speech issues

• Stroke

• Pre-op screening/clearance before
  vascular/cardiac surgery

Indications for Extracranial Duplex Exam

• Asymptomatic neck bruit

• Hemispheric cerebral or ocular Transient Ischemic Attacks (TIAs)

• History of stroke

• Screening prior to surgery

• Follow-up after carotid endarterectomy or stenting

General History for extracranial duples exam

• Sudden onset = embolic/stroke

• Transient episodes = TIA

• Risk factor history

  • HTN

  • DM

  • Smoking

  • Prior vascular disease

TIA

Neurologic deficits that occur intermittently, lasting from several minutes to a few hours

• Symptoms resolve within 24 hours

CVA or completed stroke

Cerebrovascular accident

FIxed or permanant neurological deficits

RIND

Reversible ischemic neurologic deficit

• Neurologic deficits that last between 24 and 72 hours

Paralysis

focal weakness

Paresthesia

• numbness involving some combination of face, arm, and leg on one side of body (opposite to the affected cerebral hemisphere)

Dysphasia or Aphasia

• difficulty speaking or inability to speaking

Amaurosis fugax

• Loss of vision in one or both eyes

What are the four symptoms of Carotid Artery lesions?

paralysis, paresthesia, dysphasia/aphasia, amaurosis fugax

What are the three symptms of vertobrobasilar insufficiency (vertebral arteries)?

dizziness, diplopia, ataxia

(less specific than carotid circulation)

diplopia

double vision

ataxia

losing coordination, balance, or speech

Arteriosclerosis

• General term for hardening and loss of elasticity of arteries.

• leads to restriction of blood flow to the organs and tissues.

“hard pipes”

Atherosclerosis

• a specific form of arteriosclerosis causing plaque build up in the tunica intima

  • Plaque contains cholesterol, fat/lipids, inflammatory cells, fibrous tissue, and calcium.

  • Plaque can restrict blood flow and lead to stenosis

“clgged pipes”

What is the veolcity of blood at this point ?

speeds up at the narrowest part of the stenosis

What is the ICA PSV (internal coratid artery peak systole velocity) that would be concerning ?

180-230 cm/sec, causing 50-69% stenosis

Normal ICA PSV

less than 180 cm/sec (less than 50% stenosis)

greater than 230 cm/sec ICA PSV means …

greater than 70% stenosis, but less than near occlusion

Stenosis

a narrowing most often from atherosclerosis (plaque build up).  Blood flows fastest

Where does stenosis commonly occur ?

in vessels going to the BRAIN (carotids), HEART (coronary arteries) and LEGS (iliac and femoral arteries).

**In abdomen we see it mesenteric arteries and renal arteries.

Carotid Exam Protocol Images

• CCA (proximal, mid & distal)

• CCA near flow bifurcation

• ICA (ostia, proximal, mid, distal)

• ECA (look for branches)

• Vertebral artery

• Subclavian artery

How are carotid vessels usually evaluated ?

both transverse and longitudinal planes and with B-mode imaging, color, and spectral Doppler.

Technical Standards for carotid images

• Doppler angle at 60°

• Record PSV & EDV at each segment

• Use color Doppler to localize disturbed flow

B-Mode / Grayscale normal characteristics

• Smooth vessel walls

• Intimal-medial layer clearly visible and uniform (thin, gray-white line on innermost part of vessel wall)

• Lumen is anechoic.

Carotid Bulb

• Doppler from CCA into proximal ICA

• Document flow separation in bulb

  • Flow reversal located along outer wall of bulb

  • Indicates normal flow in bulb

  • Velocity measurement is not needed on this signal.

Internal Carotid Artery: Scanning Technique

• Must evaluate the entire length

  • proximal, mid, and distal segments

  • Measure peak systolic velocity (PSV) and end diastolic velocity (EDV) throughout

  • Distal segment may be difficult beyond the angle of the jaw

External Artery: Scanning Technique
ICA vs. ECA Differentiation

• ECA has multiple branches within the neck.

• ECA spectral waveform will oscillate with “temporal tap.”

• Note:

  • ICA typically is larger (contains bulb).

  • ICA typically lies posterior to ECA.

Vertebral Artery

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• Place transducer at anteromedial aspect of midneck on long axis

• Identify CCA and slide or angle posteriorly to identify vertebral artery between transverse processes of vertebrae

• Take care to identify flow direction and waveform contour

Spectral Doppler

Normal Doppler arterial flow through the CCA.

Forward flow throughout the cardiac cycle (systole and diastole)

Systole is when the heart contracts and pumps out blood.

Diastole is when the heart relaxes and fills with blood.

Spectral Doppler ICA vs ECA

ICA is lower resistance than the ECA. 
Lower resistance means the vascular bed the flow is going to needs more flow.  So, your BRAIN (lower resistance) needs more flow than your FACE (higher resistance).  Therefore, the ICA has a lower resistance waveform example more flow in diastole.

Triphasic Doppler velocity waveform

made up of three components which correspond to different phases of arterial flow: rapid antegrade flow reaching a peak during systole, transient reversal of flow during early diastole, and slow antegrade flow during late diastole

low resistance waveform:

flow profile with antegrade flow throughout the cardiac cycle (systole and diastole).

Triphasic Doppler velocity waveform:

made up of three components which correspond to different phases of arterial flow:

rapid antegrade flow reaching a peak during systole

transient reversal of flow during early diastole

slow antegrade flow during late diastole

Would the legs (vascular bed) be high resistance as you are sitting in class? What about when you are running a marathon?

hight when sitting class because more resistance = less flow and your legs don’t need a lot of blood flow when you’re sitting down

low when running a marathon because less resistance=more flow and your legs need blood to run

Claudication:

• walking-induced muscular discomfort of thigh, hip, buttock due to ischemia

• cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.

• relieved by resting 2 to 5 minutes.

• Physical signs: elevation pallor and dependent rubor, ischemic ulcers, gangrene, bruits, and decreased peripheral pulses

Peripheral Arterial Disease

narrowed blood vessels, often from atherosclerotic plaque decreased blood flow to the limbs.

Risk factors of Peripheral Arterial Disease

• Increasing age

• Hypertension

• Diabetes mellitus

• Elevated cholesterol

• Tobacco smoking

• Documented atherosclerosis in coronary or carotid system

• Family history of atherosclerosis

Symptoms of Peripheral Arterial Disease

• claudication and pain at rest.

• Weakened Pulses

Duplex Ultrasound

• the method of choice for imaging DVT (deep vein thrombosis).

  • Can be used to diagnose, localize, and determine age of thrombus

  • Also uncover vascular and nonvascular incidental findings as

  • Very sonographer dependent

Duplex ultrasound is used to assess ….

• Presence or absence of thrombus

• Relative risk of thromboembolism

• Competence of contained valves

• Virchow’s triad

Virchow’s triad

• Venous stasis

• Hypercoagulability

• Vessel wall injury

Where is thrombosis more common ?

upper extremities: due to injury to vessels wall

• More frequent introduction of needles and catheters into arm veins

Signs & Symptoms of DVT (Write Out)

• Extremity pain and tenderness

• Swelling

• Venous distention

• Discoloration

• Palpable cord

• Pulmonary Embolism (PE)

Signs and symptoms of Pulmonary embolism (WO)

• Tachypnea

• Chest pain

• Tachycardia

Clinical markers that can aid in diagnosis of DVT and PE include

• Well’s criteria

• D-dimer

  • Both have poor sensitivity and specificity

Superficial Phlebitis

Affects veins near skin surface (superficial)

Symptoms:

• Tenderness, redness, warmth

• Hardness or swelling along vein

• Visible red line, itching, mild fever

• Usually mild but should be evaluated

Deep Vein Phlebitis (DVT)

• Involves deeper leg veins

Symptoms:

• Significant pain, swelling (one leg)

• Warmth, skin discoloration

• Pain with walking or flexing foot

Complications if untreated:

• Pulmonary embolism (PE)

• Chronic venous insufficiency

• Venous ulcers

Common Causes of superficial and deep phlebitis

• Blood clots after surgery, injury, or IV lines

• Immobility (long flights, hospital stays)

• Poor circulation, smoking, or inactivity

• pregnancy

• Medical conditions: cancer, varicose veins

• Excess weight adds vein pressure

Patient Preparation & Positioning for phlebetis patients

• Bed should be tilted in reversed Trendelenburg position.

• Patient lie flat on back with knee slightly bent and hip slightly externally rotated.

• Allows veins to fill with blood, so easier visualize.

• Legs dangled off edge of bed to visualize calf veins

• Some legs need more probe pressure to compress

Deep veins

• Main conduit for blood returning to the heart

• Accompany (travel with) an artery of the same name

• Higher risk for embolism due to squeezing action of surrounding muscles

• contained within the muscular fascia

• Thrombus in deep system is usually larger than in superficial system—more likely to be life-threatening pulmonary embolism (PE).

Superficial veins

saphenous trunks and tributaries.

• Travel close to skin surface

• lie between the dermis and muscular fascia

• Smaller than deeper veins

• do not have an artery

• Play a major role in regulating body temperature

• Less likely to cause life-threatening PE as thrombus is smaller and veins are not surrounded by muscles

  • Greater potential for embolus if thrombus is near junction with deep system

Communicating system:

veins connect the superficial to deep systems

Perforators cross muscular fascia; tributaries cross saphenous fascia.

Scanning technique for lower venous in transverse plane

• Exam begins at groin crease

• Require transducer compressions

  • Transverse plane, pressure is applied over the vein using transducer.

  • Veins under relatively low pressure, walls will collapse/close together.

  • Compressions performed every 2–3 cm down the entire leg.

Scanning technique for lower venous in sag plane

• After compressions are completed, the vein evaluated in longitudinal /sag plane.

  • Compressions are NOT performed in longitudinal plane.

  • Color and spectral Doppler are performed in longitudinal plane.

    • Assess for spontaneity, phasicity with respiration, augmentation with distal compression, and cessation of flow with proximal compression

Common Femoral Vein

• transverse plane: lies next to common femoral artery (CFA) just below inguinal ligament

CFV is medial to the CFA

Great Saphenous Veins

• Courses medially and superficially to CFV

• enters femoral vein at saphenofemoral junction

• Longest vein in the body

• Travels close to the skin in saphenous compartment

• Becomes more anterior below the knee

Small Saphenous Vein

• Superficial vein that terminates into popliteal vein (saphenopopliteal junction)

  • May terminate into FV or even GSV

• courses along middle of posterior calf.

• Receives tributaries from medial and lateral calf

Vein of Giacomini

extension of SSV above popliteal fossa

Gastrocnemius Veins

• Small tributaries that join into popliteal vein

• Drain gastrocnemius muscles

• Paired veins with accompanying artery

• When isolated painful calf muscle look here for clot.

Soleal Sinus Veins

• Major storage area for blood in the calf

• Common site of thrombus formation

  • Blood only moves out when calf muscles contract

  • Prone to thrombus formation due to stagnation (following surgery, long plane trip, etc.)

• Communicate with PTV and peroneal veins

  • Thrombus can easily extend into deep system.

Doppler signals should display the following:

• Spontaneous Doppler signals in all major vessels

• Respiratory phasicity

• Augmentation with distal compression

• Cessation of flow with proximal compression or Valsalva maneuver

• Flow should be unidirectional toward the heart.

1

common tibial trunk

2

great saphenous vein

3

perforating veins

4

medial malleolus

5

posterior tibial veins

6

peroneal veins

7

soleal veins

8

common peroneal trunk

9

popliteal vein

1

inferior vena cava

2

common iliac vein

3

internal iliac vein

4

external iliac vein

5

common femoral vein