help from Sarah

where is P highest & lowest in stenosis?

highest P: after stenosis

lowest P: w/in stenosis

what does this waveform indicate w stenosis?

“tardus parvus”

distal to stenosis

bc P drop & resistance from stenosis

what does this waveform indicate w stenosis?

“staccato”

proximal to stenosis

high resistance & absent/reversed diastolic flow

what does this waveform indicate w disease?

“staccato”

arterial disease is distal to waveform

high resistance, blunted/monophasic, low flow in diastole

‘spikes’ bc flow struggles to overcome high resistance in obstruction

what does this waveform indicate w disease?

“tardus parvus”

arterial disease is upstream/proximal to waveform

round upstroke, low amplitude

VRT

place sensor on medial malleolus (seated patient w feet dangling)…

pt dorsiflexions (move blood to heart)…

record VRT

normal VRT: >20s

if VRT >20s w/out cuff…

normal venous filling

if VRT <20s w/out cuff & then >20s w cuff below knee…

SSV reflux

if VRT <20s w/out cuff & >20s w cuff above knee…

GSV reflux

if VRT <20s w & w/out cuff…

deep & superficial reflux

CRT

time it takes for blood to refill capillary beds after applied P

• apply P to fingertip until white & time to return to color

normal CRT: 1-3 sec

CRT >3s (poor tissue perfusion, dehydration, shock)

order of renal vessels

1. renal a

2. interlobar a

3. arcuate a

4. interlobular a

5. interlobular v

6. arcuate v

7. interlobar v

8. renal v

RI

peripheral resistance of flow in renal arteries

normal<0.7

*high RI=less diastolic flow

RI for renal transplants

<0.7 (good perfusion)

0.7-0.9 (possible rejection)

>0.9 (probable rejection)

RRA runs…

post to IVC

ant to vertebral

*longer than LRA

RRV vs LRV

RRV

• into post-lat IVC

• sup to RRA

• no tributaries

LRV

• btwn AO & SMA

• inf to panc

• larger & longer than RT

• accepts LT adrenal, LT gonadal, LT inferior phrenic

kidney anatomy

bunny rabbit sign is seen w what disease?

subclavian steal

vertebral waveform @pre-stenosis/pre-steal

subclavian steal

retrograde vertebral flow

• bi-directional or bunny sign if ‘pre’

LT subclavian/innom occlusion that is proximal to vertebrals

brachial BP difference 15-20mmHg

ICA

larger

posterolateral (95%)

post to mastoid

NO extracranial branches

low resistance & high diastolic flow

ICA branches

ECA

smaller

anteromedial

ant to face

high resistance

*temporal tap

*supplies neck, face scalp (not brain)

ECA branches

super thyroid

ascending pharyngeal

lingual

facial

occipital

posterior auricular

maxillary

superficial temporal

when ICA is occluded, what are collateral pathways?

from ECA…OP branches

• supraorbital

• frontal

• nasal

AT

time from systolic onset to systolic peak

long AT (slow flow) may suggest arterial stenosis

paget-schroetter syndrome

‘stress/effort thrombosis’

compression & thrombosis of subclavian/axillary v

• w intense, repetitive activity

*form of TOS

*young active people

pop entrapment syndrome

pop artery compression by gastrocnemius

• bc repetitive trauma or pop artery stenosis/thrombosis

*calf pain w exercise

*<30yo men

buergers disease

“thromboangitis obliterans”

small vessel ‘fixed’ occlusive disease

spares vessel walls

mc arteritis

*<40yo male smoker

*rest pain, claudication, ulcers

raynauds color change order

pallor (white), cyanosis (blue), erythema (red)

EVAR endoleak types

**repairs AAA w stent graft (groin-AO)

type I: incomplete seal at ends

type II: sac fill via branch vessel (retrograde)

type III: stent defect/tear

type IV: porous graft

type V: AAA expansion w/out leak site

kidney AT

normal <0.07s (<70ms)

kidney size

normal: 10-13cm (4-5in)

• 12cm (long)

• 8cm (wide)

• 5cm (thick)

nutcracker syndrome

LRV compressed btwn AO & SMA

*flank pain, hematuria

breathing affects venous flow

inspiration…decreases thoracic P & increases abdominal P

• less flow from LE

expiration…increases thoracic P & decreases abdominal P

• less flow from UE

median arcuate ligament syndrome

“celiac artery compression syndrome”

celiac a compressed by diaphragm fibrous band (median arcuate lig)

recurrent abdominal pain

in expiration…celiac is compressed

phlegmasia alba dolens

‘painful white inflammation’

DVT progresses to occlusion of LE w/out ischemia bc collaterals present

swelling, no pulse

phlegmasia cerulea dolens

‘painful blue inflammation’

complete LE thrombosis including collaterals

worsening edema, gangrene, tissue death

may thurner syndrome

LIV compressed by RIA

*high risk of left LE DVT

*left LE pain & edema

*<20yo female

*oral contraceptives, pregnancy

post enhancement vs post shadowing

post enhancement:

• sound waves easily pass thru

• increased echos; brighter

post shadowing:

• sound waves blocked

• less echoes; darker

likely artifact at subclavian artery

mirror image

• waves bounce off strong reflector (pleura) to create duplicate image

1: AO

2: CHA

3: splenic artery

4: celiac artery

5: IVC

spectral broadening

vertical thickening in systole

filling in spectral window bc lots of frequencies

• high flow V

• vessel branching

• small d vessels

SMA & celiac disease V markers

SMA: significant stenosis (PSV >275cm/s)

celiac: significant stenosis (PSV >200cm/s)

• PSV >200cm/s also w celiac artery compression syndrome (median arcuate ligament)

pre-prandial & post-prandial SMA/celiac

pre-prandial:

• (SMA) high resistance

post-prandial:

• (SMA) low resistance

MPV vs HA

MPV:

• hepatopetal, low V, monophasic, slight respiratory variation

• SMV + SV

• supplies 70-75%

• nutrient rich

HA:

• hepatopetal, biphasic

• supplies 25-30%

• oxygen rich

MPV vs HA ultrasound

MPV:

• post to pancreas & ant to IVC

• echogenic walls

HA:

• ant to MPV

• hypoechoic

TIPS

shunt to reduce portal HTN

• RPV-to-RHV

normal V: 90-190cm/s

suspect stenosis if…

-TIPS V <90cm/s or >190cm/s

-dizziness, dehydration

brescia cimino AVF

for dialysis (radial artery & cephalic vein)

• @wrist

• low infection & clot risk

• requires 1-3M to mature

****common place for cephalic stenosis is at cephalic arch over shoulder

MCA identification

transtemporal

40-60mm depth

antegrade

ACA identification

transtemporal

65-75mm depth

retrograde

PCA identification

transtemporal

60-75mm depth

antegrade

opth identification

transorbital

40-60mm depth

antegrade

vert identification

transforamen (suboccipital)

50-75mm depth

antegrade????

basilar identification

transforamen (suboccipital)

75-110mm depth

retrograde

AComA identification

transtemporal

68mm depth

retrograde

ICA identification

transtemporal

65mm depth

antegrade