Chapter 13 Upper extremity arterial duplex scanning

Thoracic outlet

The superior opening of the thoracic cavity, which is bordered by the clavicle and first rib. The subclavian artery, subclavian vein, and brachial nerve plexus pass through this opening.

Raynaud's syndrome

A vasospastic disorder of the digital vessels.

Takayasu's arteritis

A form of large vessel vasculitis, resulting in intimal fibrosis and vessel narrowing.

vasospasm

A sudden constriction of a blood vessel, which will reduce the lumen and blood flow rate

Diagram 1: Principle upper extremity arteries

1: Aortic Arch

2: Brachiocephalic Trunk

3: Rt CCA

4: Rt Vertebral Artery

5: Rt Subclavian Artery

6: Axillary Artery

7: Profunda Brachial Artery

8: Brachial Artery

9: Radial Artery

10: Ulnar Artery

11: Interosseous Artery

12: Superficial Palmar Artery

13: Deep Palmar Artery

Diagram 2: Anatomy of the thoracic Outlet

1: Clavicle

2: Anterior scalene muscle

3: Subclavian vein

4: 1st Rib

5: Subclavian Artery

6: middle scalene muscle

what percentage of extremity peripheral arterial disease do upper extremity arterial diseases represent?

5%

Which of the following is NOT a prominent etiology of arterial diseases in the upper extremities?

diffuse atherosclerosis of the axillary or brachial artery

what is a dilated segment of the proximal descending aorta which may give rise to the takeoff of a n aberrant subclavian artery

kommerell's diverticulum

which of the following is NOT a common site for compression of the subclavian artery?

compression by the brachial plexus

which of the following is NOT a potential consequence of compression of the subclavian artery at the thoracic outlet?

Thrombosis

Injury of what artery may result in hypothenar hammer syndrome?

the ulnar artery at the wrist

which arteries do the sternal notch window, and the infraclavicular and supraclavicular approaches, all used to visualize?

the subclavian arteries

under normal conditions, what is the flow-velocity range of the arteries in the forearm?

40 to 60 cm/s

with what condition are aneurysms of the subclavian arteries often associated?

thoracic outlet syndrom

what is the landmark that marks the transition from the axillary artery to the brachial artery?

inferolateral border of the teres major muscle

how is primary Raynaud's syndrome distinguished from secondary Raynaud's syndrome or Raynaud's phenomenon?

there are underlying diseases

although rare, digital artery occlusion from embolization may occur. which of the following is NOT a predominant source of embolization?

thromboangiitis obliterans

To efficiently assess perfusion and/or vasospasm of digital arteries, how should one record waveforms obtained with PPG?

pre and post cold immersion

compression of structures at the thoracic outlet may happen with all of the following EXCEPT:

hypertrophy of the pectoralis minor muscle

which statement regarding compression of the brachial plexus and vascular structures at the thoracic outlet is FALSE?

compression of both often occurs concomitantly

how is "arterial minor" form of thoracic outlet syndrome defined?

intermittent compression of the subclavian when arm is raised overhead

which condition is associated with significant stenosis or occlusion of arteries of the arm and/or forearm from atherosclerosis?

diabetes and/or renal failure

a 47 year old male smoker presents to the vascular lab with ulcerations of his fingertips. what disease process should be suspected in this patient?

Buerger's disease

which form of arterial inflammation can affect the ophthalmic artery well as the subclavian or axillary?

Giant cell arteritis

what is the most significant difference between giant cell arteritis and Takayasu's disease when both affect the subclavian artery?

the age of the patient

the ________ artery is the first major branch of the aortic arch and divides into the right common carotid and subclavian arteries

innominate

on the left, the ______ artery arises directly from the aortic arch in 4% to 6% of patients

vertebral

The artery resting between the biceps muscle anteriorly and triceps muscle posteriorly is the _____ artery

Brachial

the artery, which lies deep to the pectoralis major and minor, the the _______ artery

Axillary

A high takeoff occurs most commonly as a variant of the ______ artery

Radial

The interosseous artery commonly takes off from the _____ artery

Ulnar

The evaluation of the axillary artery by duplex is often accomplished with the arm in the _____ position

Pledge

Using the sternal notch window, the origin of the subclavian artery us usually first identified with color doppler in a ________ plane

Transverse

With doppler, all arteries i n the upper extremities should, under normal conditions, exhibit ____ resistance

High

To assist in the visualization of the relatively small caliber arteries in the forearm, the sonographer may use _____ of the arm to increase blood flow

Heating

the most common systemic condition resulting in secondary Raynaud's syndrome is ______

scleroderma

Digital artery necrosis associated with Raynaud's symptoms will rarely be seen with _____ Raynaud's syndrome

Primary

Provocative maneuvers demonstrating subclavian artery compression at the thoracic outlet may occur in 20% of ________ individuals

Normal

Unilateral digital ischemia should prompt the sonographer to look for a source of __________ from more proximal arteries.

Embolism

Duplex ultrasound has been shown to be an effective means of evaluating for upper extremity _____ even though computed tomographic arteriography or direct surgical exploration is currently the standard of care

Trauma

Clinically, significant stenosis or occlusion of upper extremity arteries from atherosclerosis is typically confined to the _________ artery

Proximal subclavian

Symptoms of fever, malaise, arthralgia, and myalgia are not uncommon in the _____ phase of Takayasu's disease

Acute

Immunosuppressant and anti-inflammatory medications are the primary treatment for several forms of ______

Arteritis

A definite diagnosis for Buerger's disease is best achieved with ______

Angiography

When evaluating a vessel for aneurysm, it is important to visualize in a true _____ plane to not falsely overestimate the diameter

Axial

What is a retroesophageal subclavian artery? What, if any, symptoms may the patient have as a result?

- When the right subclavian artery branches directly off the Aorta distal to the Left subclavian artery.

- Can cause difficulty swallowing and Ortner's Syndrome

How are the vertebral arteries distinguished from the thyrocervical and costocervical trunks

Vertebral arteries have multiple branches, as well as lower resistance and lower end diastolic velocities

While there are not accepted velocity criteria to determine the degree of stenosis in the upper extremity arteries, what are the general guidelines correlating with >50% stenosis?

- PSV ratio >2

- increase in focal velocity

- monophasicity

- color bruit

When trauma occurs in the upper extremity, what pathologic findings should the vascular technologist be concerned about, and are often visualized on the B-mode imaging?

Intimal dissection or tear, vessel occlusion or thrombosis

Which of the doppler spectrums (A) or (B) would best represent what could be expected at the area designated by the arrow on angiogram (C)?

A

Which artery is showing pathology in these images?

Left Subclavian artery

Where could you find Doppler spectrum (B)- Distal or proximal to the stenosis?

Distal to the stenosis

Based on the landmarks visible on this angiogram, the arrow points to a defect is which vessel?

Brachial artery

What would you expect to see with corresponding doppler and color doppler on ultrasound?

- focally elevated PSV's with loss of systolic reverse flow

- post-stenotic turbulence

- monophasic waveform

A healthy 45-y.o. female presents to the vascular lab (located in Vermont) in mid-February, with ischemic and color changes in several digits of her hands and feet. What should your initial questions focus on? She reveals that she is an avid skier and spends most of her free time "on the slopes". What do you expect the results of your exam to reveal?

- Ask if she has any underlying diseases to rule out Primary Raynaud's

- Secondary Raynaud's due to frostbite

A 25-y.o. male working for the civil engineering department of the city presents with a pulsatile mass on the level of the medial aspect of the wrist extending slightly to the upper palm of his right hand. Small ischemic changes are also evident at the tip of the fourth and fifth fingers. What is the most probable cause for this presentation? What is the best test you could use for diagnosis in the vascular lab? What do you expect the results to be?

- Hypothenar Hammer Syndrome

- Conduct an Allen Test

- Possible Aneurysm