Upper extremity arterial eval and anatomy

Bovine arch

Most common anatomic variant of the aortic arch

Only two direct branches of the arch

The innominate and left CCA originate as one short segment and then split

Second branch is left subclavian artery

Double aortic arch and pulmonary sling

Compresses the anterior aspect of the trachea and the posterior aspect of the esophagus

Left aortic arch with aberrant right subclavian and right aortic arch with left aberrant left subclavian both cause

Compression of the esophagus

Brachial artery

Extends from the distal axilla to the antecubital fossa

Divides into the radial and ulnar arteries just proximal to the antecubital fossa

Radial artery

Courses laterally on the forearm

Branch joins the superficial palmar arch

Terminates at the deeper palmar arch

Ulnar artery

Courses medially on forearm

Branch joins the deep palmar arch

Supplies the majority of the blood to the hand

Velocity ratio used to assess disease:

PSV at stenosis divided by the PSV proximal to the stenosis

• Ratio >2 indicates hemodynamically significant disease in the vessel

Finger pressures should be taken with the pt sitting …

Upright

Abnormal finger brachial index:

<0.8

Reduced pressures in the digits of the hand indicates…

Palmar arch disease

Reduction in the pressure of all the digits indicates …

Disease in the radial and ulnar arteries or the palmar arch

Abnormal PPG seen with stenosis or TOS

Prolonged upstroke, rounded peak, loss of dicrotic notch, delayed downstroke

Raynaud’s syndrome will produce a PPG tracing with

A double peak with stimulation

Cold sensitivity testing

Used to assess pts with symptoms related to cold exposure

PPG tracing obtained from the digits before and after immersion in ice water for up to 3min

Document pt signs and symptoms after stimuli

Immediately after immersion the amplitude of the waveform will decrease

Abnormal if the amplitude of the waveform does not return to normal in 5 mins

Radial artery mapping

Can be used for coronary artery BPG

Usually harvested from the non-dominant arm

Diameter over 2mm can be used but >2.5mm is preferred

Preferred over GSV for coronary bypass because lumen size is suitable for procedure

Thicker wall layers

Easier to access for harvesting

The innominate artery bifurcates:

Posterior to the sternoclavicular joint

What anatomic variant is associated with dysphagia due to esophageal compression

Aberrant right subclavian artery

What artery courses posterior to the anterior scalene muscle

Subclavian artery

The internal thoracic artery is a branch of the ___________ and the lateral thoracic artery is a branch of the __________

Subclavian artery; Axillary artery

What artery extends from the distal axilla to the antecubital fossa

Brachial artery

The radial artery terminates into the ___________ and the ulnar artery terminates into the ______

Deep palmar arch; Superficial palmar arch

Correct pt position of an upper extremity arterial duplex exam

Supine with the arm externally rotated, palm face up

What is a normal result in an upper extremity segmental exam?

<20mmHg difference between pressures obtained at the same level on both arms

The upper arm, forearm and wrist pressures are within normal limits, but 2 of the digital pressures are abnormal. What would cause these findings?

There is most likely an obstruction in the palmar arch circulation

Normal results for cold sensitivity testing

Asymptomatic during hand submersion in ice water

The PPG waveform returns to baseline levels within 5mins after hand removal from the ice water

The amplitude of the PPG will increase after removal of the hand from ice water