Vascular Exam 3 - Physiologic Testing (Notes)

• Introduction to Physiologic Testing

  • Physiologic testing is the _____ assessment of _____

  • Used to detect hemodynamically significant arterial _____ disease

  • Assessing the degree of _____, not the degree of _____

indirect, arteries, occlusion, disease, stenosis

• Goals of Physiologic Testing:

  • Determine if there is _____ (factual) evidence of _____ disease

  • Determine if _____ disease is causing the patient’s _____

  • Assess increasing or decreasing _____ _____ during serial follow-up exams

objective, arterial, arterial, symptoms, limb perfusion

• Methods of Physiologic testing:

  • _____ _____ _____ (PVR)

  • _____ _____ _____ analysis or _____ analysis

  • _____ pressures (calculate _____)

  • _____ stress testing

Pulse volume recording, Doppler analog waveforms, spectral, Segmental, ABI, Exercise

• Physiologic Testing Baseline Exam:

  • Wrap blood pressure cuffs on the upper _____ and _____, obtain _____ _____ pressures __laterally

  • Obtain _____ _____ _____ from the same sites OR acquire _____ doppler waveform tracings from the axillary, brachial, radial, and ulnar _____

  • Obtain _____ (PPG) waveforms from both _____ fingers

  • Interpret _____ and _____ obtained

arms, forearms, systolic segmental, bi, pulse volume recordings, CW, arteries, photoplethysmography, index, pressures, waveforms

Compression of the subclavian artery and vein and the nerves of the brachial plexus. However, the majority of cases are neurogenic in origin.

Thoracic Outlet Syndrome (TOS)

Thoracic Outlet Syndrome (TOS): compression of the _____ artery and vein and the nerves of the _____ _____. However, the majority of TOS cases are _____ in origin.

subclavian, brachial plexus, neurogenic

Thoracic Outlet Testing:

• After performing the _____ exam, obtain waveforms with one of the following methods to serve as a baseline reference for the positional study

  • _____

  • _____

  • _____ _____ tracings

• Obtain _____ waveforms __laterally

• Obtain tracings from the _____ arm using the following maneuvers:

  • __ducted _____ degrees

  • _____ _____ – abduct the arm 30 degrees at the shoulder while the arm is manually extended, then have the patient extend their neck and turn their head towards the affected arm

  • _____-_____ _____ – place arms in “surrender” position, shoulders abducted 90 degrees with elbows flexed at 90 degrees; patient slowly opens and closes their hands

  • _____ _____ – have patient move their arm to whatever position elicits (provokes) the symptoms most

baseline, PPG, PVR, CW Doppler, resting, bi, symptomatic, Ab, 90, Adson’s maneuver, Stick-up position, Symptomatic position

_____ maneuver – __duct the arm _____ degrees at the _____ while the arm is manually _____, then have the patient extend their _____ and turn their _____ towards the _____ arm

Adson’s, ab, 30, shoulder, extended, neck, head, affected

_____-_____ position – shoulders __ducted _____ degrees with elbows _____ at _____ degrees; patient slowly opens and closes their _____

Stick-up, ab, 90, flexed, 90, hands

The stick-up position for thoracic outlet testing is AKA:

Costoclavicular

Indirect or non-imaging assessment of blood vessels, typically arteries

Physiologic testing

Physiologic Testing:

• _____ or non-_____ assessment of blood vessels, typically _____

Indirect, imaging, arteries

What vessels are we assessing when performing physiologic testing?

The _____ can technically also be assessed with physiologic testing (but we don’t focus on this)

Arteries, veins

Physiologic Testing:

• Provides information about _____ _____, which _____ alters – we call it “_____” information

• Only detects _____ disease

• Tells us:

  • Presence of _____ disease

  • Relative _____ of disease

  • _____ impairment

  • Reliably tells us if symptoms are due to vascular _____

  • Useful for _____ patients

  • _____ (toe, finger) measurements

  • _____ potential

blood flow, disease, functional, significant, significant, severity, Functional, insufficiency, diabetic, Digital, Healing

What are the four methods of physiologic testing?

Doppler waveform analysis, segmental pressure assessment, exercise testing, plethysmography

True of false: Typically you won’t see just one method of physiologic testing done but rather a combination of more than one method

True

_____ level evaluation

• Generally the ankle

• ABI

• Quick method to determine presence and relative severity of disease

Single

_____ evaluation

• Two or more levels

• Segmental pressures or PVR

• Determines the presence and relative severity as well as the region (location) of disease

Multilevel

Single level evaluation

• Generally the _____

• _____

• Quick method to determine _____ and relative _____ of disease

ankle, ABI, presence, severity

Multilevel evaluation

• _____ or more levels

• _____ pressures or _____

• Determines the _____ and relative _____ as well as the _____ (location) of disease

Two, Segmental, PVR, presence, severity, region

Indications for Physiologic Testing

***Basically the same indications as arterial _____ imaging

• _____ (always)

• _____ _____ pain

• Arterial _____

• _____ _____ _____ (PAD)

• _____-procedure assessment – angioplasty, stent, bypass graft

• Follow-up _____ procedure – angioplasty, stent

• Prognosis for _____ – ulcerations, amputations

duplex, Claudication, Ischemic rest, ulceration, Peripheral arterial disease, Pre, endovascular, healing

Limitations of Physiologic Testing

• Detects only hemodynamically _____ disease

  • So if someone has _____ disease, physiologic testing will likely show _____ results

• Usually cannot distinguish between a _____ or _____

  • If the exam is abnormal, typically the patient will get an actual _____ exam anyways

• Provides the region, but not the precise _____ of disease

• Duplex scanning provides _____ AND _____ information

significant, mild, normal, stenosis, occlusion, duplex, location, anatomic, physiologic

Doppler Waveform Analysis

• _____ wave Doppler probe

  • Two _____ crystals – one that constantly _____, one that constantly _____

  • Two types:

    • _____ – waveforms on a graph-like presentation; averages the frequencies obtained into a single line tracing

    • _____ – this is your fast fourier transform (FFT), what you’re used to seeing as a spectral Doppler waveform; displays ALL the frequencies moving through a sample area

Continuous, piezoelectric, transmits, receives, Analog, Digital

• Type of Doppler waveform analysis

• Waveforms on a graph-like presentation; averages the frequencies obtained into a single line tracing

Analog

• Type of Doppler waveform analysis

• This is your fast fourier transform (FFT), what you’re used to seeing as a spectral Doppler waveform; displays ALL the frequencies moving through a sample area

Digital

Limitations of Doppler Waveform Analysis:

• Cannot differentiate _____ from _____ disease or _____ from _____

• Patient must be able to cooperate/tolerate or remain _____ through the exam

• Potential for _____ quality signals

• Takes a lot of _____/skill to perform correctly

normal, mild, stenosis, occlusion, still, poor, practice

Think of this exam as duplex imaging…without the imaging. We are obtaining waveforms ONLY!

Doppler Waveform Analysis

How a Doppler Waveform Analysis is performed:

• _____ wave Doppler (_____) probe, patient is positioned _____

• Use _____ for appropriate contact

• Doppler _____ still applies!

  • Tilt your transducer on the patient’s skin to create a Doppler _____ between __-__ degrees

• Obtain signals (_____ and _____) from:

  • _____ extremity – CFA, SFA, Pop A, PTA, ATA, Pero A

  • _____ extremity – Subclavian A, Axillary A, Brachial A, Radial A, Ulnar A

Continuous, pencil, supine, gel, angle, angle, 40, 60, audible, visible, Lower, Upper

What vessel is being interrogated here?

PTA

True or False: Interpretation of a Doppler Waveform Analysis is quantitative

False (QUALITATIVE)

Doppler Waveform Analysis Interpretation: QUALITATIVE! (How does it look?)

• Compare signals from one location to another – was there _____?

  • When saying _____ in this case it means _____ up the leg or up the arm

    • Ex: The signal in the PTA compared to the signal in the Pop A compared to the signal in the SFA

• Look at the overall appearance of a waveform; indicates _____ vs. _____ and relative _____

• A vessel that is well collateralized even with a significant stenosis or occlusion may appear _____ – this is another limitation

• Original descriptors: triphasic, biphasic, monophasic…

  • HOWEVER…there are discrepancies specifically with the _____ waveform

  • Biphasic waveforms can be _____

• New terminology: multiphasic or monophasic

  • Triphasic and biphasic are considered _____ → _____

    • HOWEVER, biphasic waveforms can also be _____

  • Monophasic is still monophasic → _____

deterioration, location, location, normal, abnormal, severity, NORMAL, biphasic, NORMAL, multiphasic, NORMAL, ABNORMAL, ABNORMAL

What type of waveform is being described?

• Rapid systolic upstroke

• Sharp peak

• Rapid mid systolic downstroke

• Late systolic flow reversal

  • Projection below baseline

• Forward flow in diastole

Triphasic

What type of waveform is being described?

• Rapid upstroke

• Sharp peak

• Slightly slowed mid systolic downstroke

• Late systolic flow reversal

• No final forward diastolic flow component

Biphasic

What type of waveform is being described?

• Delayed systolic upstroke

  • Delayed acceleration time

• Rounded peak

• Slowed mid systolic downstroke

• Absence of systolic flow reversal and forward diastolic flow component

Monophasic

True or False: A biphasic waveform is not considered multiphasic

False (is IS considered multiphasic)

True or False: A biphasic waveform can be normal or abnormal

True

Normal – Multiphasic (Triphasic)

• Rapid _____ upstroke

• _____ peak

• Rapid mid systolic _____

• Late systolic flow _____

  • Projection _____ baseline

• Forward flow in _____

systolic, Sharp, downstroke, reversal, below, diastole

Normal/Abnormal – Multiphasic (Biphasic)

• Rapid _____

• _____ peak

• Slightly _____ mid systolic downstroke

• Late systolic flow _____

  • _____ baseline

• No final forward _____ flow component

upstroke, Sharp, slowed, reversal, below, diastolic

Abnormal – Monophasic (Monophasic)

• Delayed systolic _____

  • Delayed _____ time

• _____ peak

• Slowed mid systolic _____

• Absence of systolic flow _____ and _____ diastolic flow component

upstroke, acceleration, Rounded, downstroke, reversal, forward

• Peak to peak frequency difference divided by the average frequency

• (P1-P2)/average frequency

• Typically calculated by the machine

• Normal = >4.0

• Abnormal = <4.0

Pulsatility Index

What is the range for a normal pulsatility index?

> 4.0

What is the range for an abnormal pulsatility index?

< 4.0

• Time from onset of systole to peak systole – how long it takes to get to the max velocity

• Normal = <133 milliseconds

• Abnormal = >133 milliseconds

Acceleration Time

What is the normal range for acceleration time?

< 133 milliseconds

What is the abnormal range for acceleration time?

> 133 milliseconds

Segmental Pressure Evaluation

• Blood pressure cuffs are used to obtain _____ pressures throughout the limbs

• Cuff is inflated to _____ flow, then slowly deflated…the _____ Doppler signal heard is recorded as the _____ pressure at that location

• Flow is detected using a _____ wave probe

• Pressure drops or significant differences between cuffs (segments) indicate _____ _____ _____

systolic, cease, first, systolic, continuous, flow limiting stenosis

Segmental Pressure Evaluation Limitations:

• Only detects _____ disease

• Patient limiting factors – _____, _____ areas of the limb

• _____

  • Cold → vaso_____

  • Hot → vaso_____

• _____ _____

  • Very common in diabetic patients

  • The vessel walls are calcified to a point where they are non-compressible

  • Stiff to the point where we cannot completely close them off to briefly cease blood flow

• _____ _____ _____ (DVT), fistula or grafts, _____ (swelling due to lymphatic system damage), post _____ _____ (BPG) procedure

  • If ordered at the same time, a DVT study should be done _____ a physiologic testing study.

significant, tolerance, inaccessible, Temperature, constriction, dilation, Medial calcinosis, Deep vein thrombosis, lymphedema, bypass graft, before

Medial calcinosis

• Very common in _____ patients

• The vessel walls are _____ to a point where they are non-_____

• Stiff to the point where we cannot completely close them off to briefly _____ blood flow

diabetic, calcified, compressible, cease

A serious medical condition where a blood clot (thrombus) forms in a deep vein, most commonly in the lower leg, thigh, or pelvis, though it can also occur in the arms.

Deep vein thrombosis (DVT)

What position should patients be lying in for all physiologic testing exams?

Supine

NOTE – _____ position for all physiologic testing exams…WHY?

• To eliminate _____ _____ caused by _____

• Lying flat removes this _____ variable, allowing baseline pressures and blood flow to be measured accurately and consistently

supine, hydrostatic pressure, gravity, gravitational

What are the two methods of segmental pressure evaluation?

4 cuff and 3 cuff

***4 and 3 refer to the number of blood pressure cuffs that are on the lower extremity (excludes the brachial cuffs)

Segmental Pressure Evaluation:

• 4 Cuff

  • __lateral brachial cuffs

  • Two _____ cuffs – high _____ (1) & low _____/above knee (2)

  • _____ cuff (3)

  • _____ cuff (4)

• 3 Cuff

  • __lateral brachial cuffs

  • One (larger) _____ cuff (1)

  • _____ cuff (2)

  • _____ cuff (3)

Bi, thigh, thigh, thigh, Calf, Ankle, Bi, thigh, Calf, Ankle

The width of the cuff should be 20% greater than the diameter of the limb (or 40% of the limb circumference)

20% Rule

20% Rule – the width of the cuff should be __% greater than the _____ of the limb (or __% of the limb _____)

20, diameter, 40, circumference

Using too small of a cuff in a segmental pressure evaluation results in artifactually _____ limb pressure

high

4 Cuff Method:

• Two thigh cuffs provide _____ and _____ thigh measurements

• Can differentiate between _____-_____ (inflow) disease and _____ _____ _____ (outflow) disease

• Two thigh cuffs violate the _____ _____; results in artifactually _____ thigh pressures, approximately _____ mmHg higher

3 Cuff Method:

• Provides _____ thigh pressure measurements

• If abnormal, cannot differentiate _____-_____ (inflow) disease from _____ _____ _____ (outflow) disease

proximal, distal, aorto-iliac, superficial femoral artery, 20% rule, elevated, 30, accurate, aorto-iliac, superficial femoral artery

Aorto-iliac disease is what type of disease?

Inflow

Superficial femoral artery disease is what type of disease?

Outflow

1. Obtain __lateral _____ pressures – do NOT take an _____ pressure if the patient has a shunt or a dialysis graft!

2. Obtain leg pressures starting at the _____ and work your way _____ the leg

• _____ and _____ pressures first

• Calculate _____ – use highest _____ pressure (Lt or Rt) and highest _____ pressure (DPA/PTA)

  • _____ divided by _____

  • Example: If you are calculating the right sided ABI you would use – HIGHEST _____ REGARDLESS OF _____ (Lt or Rt), and highest _____ pressure between the right _____ and _____

3. Obtain _____ pressures

4. Obtain _____ pressures

• Notes Box:

  • Multiple inflations of a cuff beyond _____ pressure may result in transient ischemic-induced _____ affecting the pressure –  this is why it is recommended to start at the _____ and work your way _____ the leg. HOWEVER, I will be honest…I have not seen a clinical site perform it this way.

bi, brachial, arm, ankle, up, DPA, PTA, ABI, brachial, ankle, ANKLE, ARM, ARM, LATERALITY, ankle, DPA, PTA, calf, thigh, systolic, vasodilation, ankle, up

Important to keep in mind: Segmental Pressures

• Complete _____ of blood flow is required – inflate the cuff __ to __ mmHg beyond the _____ audible signal

• Record the _____ from the _____ audible signal upon deflating the cuff

• If you need to repeat a measurement, fully _____ the cuff, wait a minute, then try again. Give the body time to _____ before trying again.

• _____ _____ can result in “non-compressible” vessels

• The pressure being measured represents the pressure directly _____ the cuff

  • If you inflate the thigh cuff but use an ankle vessel to record your signal, your pressure represents the _____

cessation, 20, 30, last, pressure, first, deflate, autoregulate, Medial calcinosis, UNDER, thigh

How do you solve for an Ankle Brachial Index (ABI)?

Highest ankle pressure / highest arm (brachial) pressure

***Longer word on top!

Solve for the right and left ABIs in this example:

• Right Brachial Pressure = 147 mmHg, Left Brachial Pressure = 140 mmHg

• Right DPA = 142, Right PTA = 148

• Left DPA = 126, Left PTA = 130

Right ABI: 148/147 = 1.01

Left ABI: 130/147 = 0.88

What is the normal ABI range?

0.9-1.35

***Greater than 1.35 is abnormal

List the ABI values that correspond to the following interpretations:

• Normal…usually

• Normal, consider exercising the patient

• Probable claudication, single level disease

• Multi-level disease

• Ischemic rest pain

>1.0, >0.9 to <1.0, <0.8, <0.5, <0.3

An ABI value >_____ is USUALLY normal because someone with _____ _____ can have a really high pressure and a high ABI of for example 1.8, which is pretty high and abnormal.

1.0, medial calcinosis

ABI Values:

< 0.8 = _____ disease, < 0.5 = _____ disease, < 0.3 = _____ disease (gangrene, ulcerations, etc.)

mild, moderate, severe

Interpretation: Segmental Pressures

4 Cuff

• NORMAL

  • High _____ pressure should be at least _____ mmHg _____ than the _____ pressure

  • ***With the 4 cuff method, the _____ pressures are going to be artificially _____ because we are not obeying the _____ _____. So that is why the _____ pressure should be at least _____ mmHg greater than the _____ pressure.

• ABNORMAL

  • Thigh pressure _____ than the brachial pressure

  • _____ mmHg or greater drop in pressure between segments

thigh, 20, greater, brachial, thigh, elevated, 20% rule, thigh, 20, brachial, less, 30

Interpretation: Segmental Pressures

3 Cuff

• NORMAL

  • All segmental pressures should be _____ to or slightly _____ than the _____ pressure

• ABNORMAL

  • _____ mmHg or greater drop in pressure between segments

equal, greater, brachial, 30

Interpretation: Segmental Pressures

• *Arm pressures – gradient of 15-20 mmHg (typically 20) between brachial pressures indicates _____ _____ or _____/_____

• Horizontal pressures – _____ mmHg pressure drop from one side to the other in the legs is _____ (left vs. right side)

subclavian steel, stenosis, occlusion, 30, abnormal

Interpretation Tips for Segmental Pressures

• Step #1: Look at the _____ used – _____ _____ vs. _____ _____, what type of _____

• Step #2: Look at/compare the _____

• Step #3: Look at the _____, start by comparing the (high) thigh to the arm (brachial) pressures, then go down the leg. Determine where (if at all) things become abnormal (location). → Abnormal if there is more than a _____ mmHg difference from one segment to the next

• Step #4: Look at the _____. Determine where (if at all) things become abnormal.

• Step #5: Make a conclusion on disease _____ and _____

method, 3 cuff, 4 cuff, waveforms, ABIs, pressures, 30, waveforms, location, severity

When interpreting segmental pressures you compare _____ to _____ and _____ and _____

side, side, up, down

Segmental Pressure Example:

• Step #1: What method was used? What type of waveforms?

• Step #2: Look at/compare the ABIs

• Step #3: Look at/compare the pressures

• Step #4: Look at/compare the waveforms

• Step #5: Make a conclusion on disease location and severity

1. 4 cuff, no waveforms

2. Both ABIs are normal

3. Normal high thigh and brachial pressure differences; normal segmental pressure differences except from 153 to 119 on the left leg

   • Remember that in the 4 cuff method, high thigh pressures are going to be at least 20 greater than the brachial pressures

   • From 153 to 119, the pressure difference is 34 but since the ABI is still normal, this could be due to artifact or incorrect recording. We are still going to consider it NORMAL.

4. No waveforms

5. Normal, no disease

Segmental Pressure Example:

• Step #1: What method was used? What type of waveforms?

• Step #2: Look at/compare the ABIs

• Step #3: Look at/compare the pressures

• Step #4: Look at/compare the waveforms

• Step #5: Make a conclusion on disease location and severity

1. 3 cuff, no waveforms

2. Right ABI is abnormal (0.74), left ABI is normal (1.06)

   • With the ABI being 0.74, this is likely a mild disease (<0.8).

3. Abnormal right thigh (89) and brachial (126) pressure difference; all other pressure differences are normal

   • Remember that in the 3 cuff method, the thigh pressure should be equal to, or potentially slightly greater than the brachial pressure

4. No waveforms

5. Right-sided proximal disease

   • Remember that with the 3 cuff method, because we are only using one thigh cuff, we cannot differentiate between aorto-iliac (inflow) disease and SFA (outflow) disease.

Exercise Testing Evaluation

• Metabolic demand _____ during exercise, requiring _____ blood flow to supply oxygen (vaso_____)

• And what do we know is the most common symptom of PAD???

  • _____ → pain with _____

• Patients with mild to moderate disease may have normal blood flow at _____

  • This is why in the ABI chart > _____ to < _____, the interpretation was “normal but consider _____ the patient.”

  • The patient may have a normal ABI value while at _____ and in the _____ position but if they exercise, an _____ ABI can be visualized!

• Exercise testing allows for the differentiation of vasculogenic claudication from _____-_____

  • _____-_____ is going to be either _____ or _____ in nature

increases, increased, dilation, Claudication, exertion, rest, 0.9, 1.0, exercising, rest, supine, abnormal, pseudo-claudication, Pseudo-claudication, neurogenic, orthopedic

Limitations of Exercise Testing:

• _____ _____ (COPD, congestive heart failure), _____ (HTN), _____ _____ _____ (SOB) → patients that physically cannot exercise long enough for the exam

• ABI < _____ – patients with evident disease

• Resting _____ (ABI < 0.3)

• Poor _____ status → patients who cannot walk well

Cardiac status, hypertension, shortness of breath, 0.5, ischemia, ambulatory

True or False: There is little to no benefit of exercise testing for patients with severe PAD, resting ischemia, ulceration, and who cannot walk well enough to elicit (provoke) claudication

True

***We already know that disease is present anyways

How To: Exercise Testing

• Complete resting _____

  • Patient will be _____

  • Obtain brachial, PTA, and DPA _____

• There are several ways to exercise your patient (calf raises, walking, treadmill…)

  • Treadmill – easily _____

    • Patient walks on treadmill at < _____% grade (incline)

    • Speed _____ mph for max of _____ minutes or until the patient complains of symptoms

    • Document the duration and speed that the patient walked

    • Immediately obtain _____ pressures (PTA, DPA); don’t have to do the brachial pressures again

  • Normal = ankle pressures are the _____ or slightly _____

  • Abnormal = pressure _____

    • < _____% drop = _____ level disease

    • > _____% drop = _____ level disease

ABI, supine, pressures, reproducible, 12, 1.5, 5, ankle, same, higher, drop, 50, single, 50, multi

Arterial Plethysmography

• Volume/Air (PVR)

  • *PVR operates under the physical principle that blood flowing through any given limb segment results in changes in the limb’s _____ → How does the limb get bigger or smaller based on the blood flowing underneath that cuff

  • _____ cuffs are placed around the limb at specific levels (segments)

  • Cuffs are inflated with a measured amount of _____ (_____ to _____ mmHg) → We are _____ cutting off circulation like we did in a _____ pressure

  • As arterial flow moves through the vessel, the limb gets slightly _____

  • The increase in limb volume displaces the _____ in the cuff

  • Pressure transducer converts this change into an _____ waveform

volume, Pneumatic, air, 40, 65, NOT, segmental, bigger, air, analog

Arterial Plethysmography

• Photo (PPG)

  • Detects _____ blood flow

  • LED transmits light into the tissue and the _____ light is measured by the adjacent photo-sensor

  • Blood in the _____ tissue _____ the amount of light reflected back to the sensor → _____ is the gradual loss of amplitude and intensity as a wave propagates through a medium

  • Increased blood content in the tissue results in increased _____ (more scattering, less being sent back to the photosensor (decreased reflected signal)) and displays as a _____ upstroke _____ waveform

cutaneous, reflected, subcutaneous, attenuates, Attenuation, attenuation, positive, analog

Both PVRs and PPGs display _____ waveforms

analog

PPG =

Photoplethysmography

PVR =

Pulse Volume Recording (Volume Plethysmography)

True or False: The interpretation of Pulse Volume Recording (Volume Plethysmography) is QUALITATIVE

True

Pulsatile Flow Waveform:

• Early _____ (A) – _____-velocity ejection of blood; aortic valve _____

• Late _____/Early _____ (B)

  • Rapid deceleration and aortic valve _____ (_____ _____)

  • Results in temporary flow _____

• Late _____ (C)

  • Flow depends upon vascular _____

Systole, High, opens, Systole, Diastole, closes, dicrotic notch, reversal, Diastole, resistance

PVR Waveform Interpretation: QUALITATIVE!

• An abnormal waveform reflects hemodynamically significant disease _____ to the level of the waveform

  • If you are getting an abnormal waveform at the ankle, the disease is _____ to the ankle (_____ in the leg)

• Severity is often _____estimated

  • Someone might have moderate disease but we’re getting a _____ abnormal waveform

• Reduced _____ with no changes in the _____ (outline) of the waveforms MAY represent insignificant disease unless there is a notable difference between levels (up and down) or sides (laterality)

  • This is saying that a waveform may have a normal _____ but a reduced _____ and therefore look normal-ish (insignificant disease) but if the levels or sides have notable differences, then you know that there is disease

• PVR should be done with _____ measurements to get accurate diagnostic information

• Reflected wave = _____ _____

proximal, proximal, higher, under, mildly, amplitude, contour, shape, amplitude, pressure, dicrotic notch

PVR Interpretation:

• Normal: Rapid systolic _____ with reflected wave (_____ _____)

• Mildly abnormal: _____ peak, absent _____ wave, downslope “_____” away from the baseline

• Moderately abnormal: _____ systolic peak, upslope and downslope are _____, _____ _____ absent

• Severely abnormal: low _____ throughout

acceleration, dicrotic notch, Sharp, reflected, bowed, Flattened, delayed, reflected wave, amplitude

The _____ _____ (_____ _____) is the single most important feature of a normal PVR waveform.

reflected wave, dicrotic notch

Photoplethysmography (PPG)

• Limitations:

  • _____ skin for good contact of sensor

  • Patient’s resting _____ state

  • Cuff or sensor _____

  • _____

• Patient Position:

  • _____ position

  • Place sensors on _____ and _____

  • _____ room

Intact, basal, placement, Tremors, Supine, fingers, toes, Warm

Summary