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DMS Vascular
RVT
| Question | Answer |
|---|---|
| 1st branch off ascending AO | Coronary Arteries |
| 1st branch of AO arch | Innominate/Brachiocephalic A. |
| Brachiocephalic A divides into which 2 arteries? | RT CCA and RT Subclavian A. |
| 2 branch of AO arch | LT CCA |
| 3 branch of AO arch | Lt Subclavian A |
| Subclavian A becomes | Axillary A |
| Name some branches of the subclavian A | Vertebral, thyrocervical, costocervical |
| Axillary A becomes | Brachial A |
| Brachial A branches into | Radial and Ulnar |
| Brachail A branches at the inner aspect of elbow AKA | antecubital fossa |
| Radial A branches to form | Superficial palmar (volar) arch. Terminates in deep palmer arch by joining deep branch of ulnar a |
| ulnar A branches to form | deep palmer (volar) arch terminates in superficial palmer arch |
| Celiac A supplies | stomach, liver, pancreas, duodenum, spleen |
| CA branches into | L. gastric, splenic, common hepatic a |
| SMA supplies | small intestine, cecum, parts of colon |
| SMA is located | about 1cm below CA, |
| T/F: CA and SMA share a common trunk | True |
| Renal A Supplies | kidneys, suprarenal glands,ureters |
| in Trv, a landmark for locating the LRA is, | the LRV. the LRV crosses the AO anteriorly; the artery being just posterior |
| IMA supplies | transverse, decending colon and part of rectum |
| IMA is located | 3-4 cm above AO bifurcation |
| T/F Ima can act as a collateral connection | True |
| Internal iliac A AKA | hypogastric |
| the external A passes under the ___ to become the CFA | inguinal ligament |
| CFA divides into | SFA and DFA |
| SFA passes through an opening in the tendon called _____,______ or____. it enters the pop fossa behind the knee | Adductor hiatus, adductor canal, or Hunters Canal |
| T/F: DFA can act as a collateral conncetion | true |
| Name the 3 arteries in the trifurcation | Anterior tibial, posterior tibial, peroneal |
| 1st branch off distal pop a | ata |
| ata becomes | Dorsalis pedis A (DPA) |
| Major branch of Dpa | deep plantar artery; penetratinf the sole of the foot, it unites with lateral plantar artery to complete plantar arch |
| short segment bt ATA branch and branches of PTA and peroneal A | Tibioperoneal trunk |
| Major branches of PTA | medial and lateral plantar arteries |
| the plantar arch consists of the | deep plantar artery (branch of DPA) |
| the _________ unites with the deep plantar artery | lateral plantar artery (branch of PTA) |
| Arteries: | transport gases, nutrient and other essentials |
| Arterioles: | considered resistance vessels; assist with regulating blood flow through contraction and relaxation |
| capillaries: | nutrients and waste products and exchanged bt the tissue and blood |
| tunica intima/ inner layer | thin, consisting of a surface layer of smooth endothelium, base membrane and connective tissue |
| tunica media/ intermediate layer | thicker, composed of smooth muscle and connective tissue, largely of the elastic type |
| tunica externa/ outter layer (adventitia) | thinner than media, contains fibrous connective tissue, some muscle fibers |
| vasa vasorum: | tiny vessels that carry blood to the walls of the larger arteries |
| which artery layer contains vasa vasorum | adventitial layer (outter) |
| during cardiac contraction pressure in the ______ rises rapidly | lt ventrical |
| pumping action of heart results in high volume of blood in arteries to maintain a high ____ ____ be the arteries and veins | pressure gradient |
| ____ ____ governs th eamount of blood that enters the arterial system | Cardiac output |
| Arterial pressure and ___ ___, determines the amount of blood that leaves arterial lsystem | peripheral resistance |
| each cardiac contractions distends the arteries, which serve as reservoirs to store some blood volume and ____ energy supplie to the system | potential |
| movement of any fluid medium bt 2 points requires 2 things: | 1. a pathway along which fluid can flow 2. difference in energy levels (pressure difference) |
| the amount of flow depends on: | 1.energy difference: includes losses resulting from fluid movement. 2.any resistance which tends to oppose such movement |
| HINT resistance vs flow rate | Lower resistance=higher flow rate; higher resistance=lower flow rate |
| Pressure (potential)energy: | stored energy and is the major form of energy for circulation of blood; expressed in mmHg |
| Kinetic energy: | fluid density, Velocity measurements |
| gravitational energy: | hydrostatic pressure(HP)weight of the column of blood |
| ex. in a supine pt what is the Hp at ankle level | 0mmHg (HP) against art and veins. |
| when standing, HP increases, adding about ___ mmHg against vessels | 100mmHg |
| a ___ ___ is needed to move blood from one point to another | energy gradient |
| inertia: | relates to the tendency of a fluid to resist changes in its velocity (body at rest tends to stay at rest) |
| A change in __ __ greatly effects vessel resistance | vessel diameter |
| list 2 things that can effect resistance | viscosity, vessel length, and vessel diameter(most dramatic) |
| an elevated hemocratic ___ blood viscosity | increases (thickness of blood) |
| severe anemia ___ blood viscosity | decreases |
| HINT viscosity vs velosity | increased viscosity= decreased velocity decreased viscosity= increased velocity |
| laminar flow | consists of layers of fluid particles moving against each other |
| Laminar flos is considered stable flow | with fasting moving flow in the center; stationary layer remains at the wall |
| plug flow (blunted) is likely seen at | vessel origin |
| ___ energy loss is due to increased friction bt molecules and layers which ultimately causes energy loss | viscous |
| ___ losses occur with deviations from laminar flow, due to changes in direction and/or velocity | Inertial (prominent cause of energy loss, most significant) |
| what happens with inertial energy loss: | parabolic flow profile is flattened, disorganized flow, loss occurs at the EXIT of a stenosis |
| poiseuille's equation defines the relationship bt: | pressure, volume flow, resistance |
| poiseuille's equation helps answer the question of: | howa much fluid moves through the vessel |
| poiseuille's equation | Q=P/R Q=voulme flow P=Pressure R=resistance |
| radius of vessel is ___ proportional to volume flow | directly |
| the law of conservation of mass ezplains the realationship bt velosity and area | Q=AxV |
| velocity changes: area va velocity in a aneurysm= | Area is increased velocity is decreased |
| Bernoulli; pressure/velocity HINT | increased velocity=decreased pressure decreased velocity=increased pressure |
| with in a stenosis what is happening with velocity and pressure? | velocity is increased, pressure is decreased |
| what happens post-stenosis with velocity and pressure | velocity is decreased, pressure is increased |
| flow separations occur bc of | geometry changes w/or w/o dz and curves Know pic on pg 18=curve, and change in color is an expected finding |
| flow separations result in regions with stagnant or little movement. EX: | bypass graft anastamosis site, valve cusp site |
| Reynolds number predicts | when fluid becomes unstable/disturbed. >2000(unitless number) means laminar flow tends to become disturbed |
| low resistance flow | continuous steady flow, feeding a dilated vascular bed. |
| low resistance flow; EX:arteries | ICA, Vertebral, Renal, Celiac, Splenic, Hepatic. feeds organs cant be w/o flow |
| High resistance flow | pulsatile nature |
| high resistance flow ex: arteries | ECA, subclavian, AO, extremitys, FASTING sma. |
| doppler flow distal to a significant stenosis is ____resistance | lower |
| doppler flow prox to a significant stenosis is ____ resistance | higher |
| NOTE: as the inflow pressure falls as a result of stenosis, the natural response in periphery is to | vasodilate to maintain flow |
| at rest blood flow may seem normal even in the presence of stenosis/occlusion. why? | Collaterals! |
| exercise should induse ___ which lowers distal ____ and increases blood flow | vasodilation, peripheral resistance |
| vasoconstriction and vasodilation of vessels within skeletal muscles help regulated____ | body temp |
| ____is probably the best single vasodilator of resistance vessles within skeletal muscles | Exercise |
| autoregulation: | ability of most vascularbeds to maintain constant level of blood flow over a wide range of perfusion pressure |
| BP rise=constriction of vessels | BP falls=dilation of resistance vessels |
| T/F mono flow can be a normal finding? | True, may be seen after vigorus exercies |
| a hemodynamically significant stenosis causes a | notable reduction in volume flow and pressure |
| cross sectional area reduction of 75%= | diameter reduction of 50% |
| prox to a stenosis: flow freq are usually ___, with or w/o disturbance | Dampened |
| Entrance to a stenosis an ___ in doppler shift freq (DSF), resulting in ___ and ___ | increased, spectral broadening and elevated velocities |
| list the 3 chronic arterial occlusive dz's | claudication, ischemia rest pain, tissue loss |
| pain in muscles usually occurring during exercise; subsides with rest | Claudication |
| claudication results from | inadequate blood supply to muscles |
| With claudication, the level of dz is usually ___ to location of symptoms | prox |
| pseudo-cladication mimics vascular symptoms but is ____ in origin | Neurogenic or orthopedic |
| ex: pt history of 4 block claudication means what? | pt c/o pain after walking 4 blocks |
| T/F Claudication symptoms are always predictible and reproducable | true! |
| a more severe symptom of diminished blood flow | ischemic rest pain |
| ischemic rest pain occurs when | limb is not dependent; BP decreased (such as when sleeping) |
| Necrosis | death of tissue, tissue loss |
| necrosis is due to | deficient or absent blood supply |
| name the 6 P's (symptoms) of Acute arterial occlusion | pain, pallor, pulselessness , paresthesia, polar |
| acute arterial occlusion may result from ___, ___, or___ | thrombus, embolism, or trauma |
| why is acute arterial occlusion an emergent situation? | since the abrupt onset does not provide for the development of collateral channels |
| pallor: | whiteness, pale skin, result of deficient blood supply |
| cyanosis | bluish, concentration of deoxygenated hemoglobin |
| rubor | dark red, suggest dilated vessels, or vessels dilated secondary to reactive hyperemia |
| Raynaud's phenomenon | condition that exist when symptoms of intermittent digital ischemia occure in response to cold exposure or emotional stress |
| Primary Raynauds | ischemia due to digital arterial spasm (artery is of but stressed) |
| Primary Raynauds symptoms | common in young women, may be hereditary, bilateral, history of symptoms for 2 years w/o progression/ evidence of cause. |
| t/f primary raynauds is a benign condition? | true |
| secandary raynauds AKA | obstructive raynauds syndrome |
| Secondary Raynaud's is where: | normal vasoconstrictive responses of arterioles superimposed on a fixed artery obstruction. (artery is damaged) ischemia is constantly present |
| secondary Raynauds may be the 1st manifestation of | Buerger's Dz |
| arterial ulcerations are located: | tibial area, foot, toes |
| What is the shape of an arterial ulcer? | deep and more regular in shape |
| are arterial or venous ulcers more painful? | arterial |
| an increase in the capillary refill time denotes ____ arterial perfusion | decreased |
| cadaveric pallor during elevation with ruborous red discoloration with dependency is known as | dependent rubor |
| thrills vs bruits | thrills are palpable (fill the thrill) bruits are ascultations (heard) |
| a palpable thrill over pulse site may indicate: | fistula, post-stenotic turbulence, or a patent dialysis access site |
| palpable pulses | AO, femoral, pop, DPA, PTA peroneal is not palpable |
| site you may hear a bruit | carotid, heart, AO,fem, pop |
| name the 5 risk factors for arterial dz | 1. Diabetes-atherosclerosis 2. hypertension 3.hyperlipidemia 4. smoking 5. other (not controllable) age, family history |
| most common arterial pathology | atherosclerosis (obliterans) |
| atherosclerosis is | thickening, hardening, loss of elasticity of the arterial walls |
| atherosclerosis affects which wall layers? | intima and media. does not affect outter |
| what are the 3 major risk factors of atherosclerosis? | smoking, hpyerlipidemia, family history |
| most common site for atherosclerosis | 1.carotid bifurcation 2. vessel orgin 3. infra-renal aorto-iliac system 4. CFA bifurcation 5. SFA at the adductor canal level 6. trifurcation region |
| ____ syndrome is caused by obstruction of the AO, occurs in males | Leriche |
| 4 symptoms of leriche syndrome | 1 Fatigue in hips, thighs, or calves with exercise 2 absence of femoral pulses 3 impotence 4 often times, pallor and coldness of LE |
| obstruction of vessel by foreign substance or blood clot | Embolism |
| most freq cause of embolism | small plaque breaks loose and travels distally until it lodges in small vessel |
| ex of embolism; Blue Toe Syndrome- | toe ischemia |
| a true aneurysm is dilation of which wall layers? | all 3 |
| characteristics of Fusiform aneurysm | diffuse, circumferential dilation |
| Characteristics of saccular aneurysm | localized out-pouching |
| a small tear of the inner wall allows blood to form a cavity bt 2 wall layers, is known as | dissecting aneurysm |
| dissecting aneurysm often occurs where? | Thoracic AO |
| a ____ results from a defect (ex: post catheter stick) in the main artery wall | pseudo aneurysm |
| what must be present to confirm a pseudo aneurysm? | a communicating channel (neck) from main artery to the pulsatile structure outside vessel walls |
| the most common location of a true aneurysm is | infra renal |
| locations for an aneurysm include | infra renal, thoracic AO, Abd AO, fem, pop, renal |
| most freq complication of an AAA is | rupture |
| most freq complication of a peripheral aneurysm is | embolization |
| Arteritis affects what arteries | tibial, peroneal. distal/small arteries |
| arteritis is | inflammation of arterial wall, can lead to thrombosis of vessel |
| most common type of arteritis is | Burgers dz |
| burgers dz AKA | thromboangiitis obliterans |
| arteritis is associated with | heavy cigarette smoking |
| arteritis occurs primarily in | young men <40 yrs. old |
| congenital narrowing or stricture of thoracic AO but may affect abd AO | Coarctation of the AO |
| clinical finding of Coarctation | seen in young pediatric pts, with hypertension due to decreased kidney perfusion |
| the distinguishing ultrasound feature of dissection is | a thin membrane dividing the arterial lumen into 2 compartments. tear in the intima causes blood to leak into media (false lumen) know image pg 29 |
| complication of dissection is | stenosis, occlusion, thrombosis |
| PARKS helps confirm diagnosis and | approximate the location of arterial occlusive dz. indicates severity of occlusive process. is combined with segmentals |
| PARKS is unable to discriminate stenosis from | occlusion |
| The Doppler effect | when a wave is reflected from a moving target, the freq of the wave received is different (doppler shift) from the transmitted wave. this effect is relative motion bt the source and the receiver of the sound. |
| Doppler shift EX. | blood is moving target, transducer is stationary source |
| Analog | employs a zero crossing freq meter to display the signals graphically on a strip chart recorder. Paper speed= 25mm/sec |
| zero crossing freq meter | circuitry county each time the input signal crosses through zero(baseline) w/in a time span. machine estimates freq present in reflected signal & displays them |
| high freq waves have many oscillations; | low freq waves have few |
| Analog | has acceptable accuracy. Drawbacks include: noise less sensitivity high velocities underestimated low velocities overestimated |
| Spectral analysis: individual freq displayed by Fast Fourier Transform (FFT) | time is X-axis, freq shifts Y-axis free of many analog drawbacks |
| PARKS uses what probe | a 8-10 MHz CW |
| With PARKS | audible and wave form qualities are observed, documented, and combined with doppler segmental pressure |
| A monophasic/dampened (pulsatile) signal is often abtained ___to an obstruction | prox |
| Vasodilation of the ____vessel often occur w/ prox obstruction, reducing the pulsatility; causing the signals to have lower resistant steady flow qualities | Distal |
| analog doppler is not capable of portraying velocities of less than ____ | 6 cm/sec |
| Troubleshooting: "60cycle" noise on tracing? | decrease gain, turn system off/on, increase filter,try another plug |
| Pulsatility index calculated by | dividing peak to peak freq difference (P1-P2) by the mean avg. |
| The PI differentiates | inflow dz from outflow ex. aorto-iliac from femoral |
| Acceleration Time | helps to differentiate inflow dz from outflow prox art obst results in a slowing of the time interval bt the onset of systole to the point of max peak |
| ex criteria of acceleration time: | an acceleration time of >133 msec suggest presence of prox dz |
| Segmental pressure LE help to | assess presence/ severity of arterial dz. combined with doppler velocity or volume pulse waveforms |
| t/f segmental pressures can discriminate bt stenosis and occlusion | FALSE segmental cannot distinguish bt stenosis and occulsion or precisely localize area of obstructions |
| when doing segmentals, calcified vessels render falsely ___ pressures | elevated |
| uncompensated CHF may result in ___ abi | decreased |
| when using a narrow cuff on the high thigh will cause | artifactually elevated high thigh pressures |
| how long should a pt rest before starting segmentals? | 20 min |
| HINT: if cuff is too large for a limb segment, BP is falsely lower; | if cuff is too narrow for limb segment, BP is falsely higher |
| width of cuff should be ___% > than diameter of limb | 20% |
| where do you place cuffs for $cuff method | Brachial, high thigh, above knee (AK), below knee (BK), ankle |
| what size cuff is used on thigh for 4 cuff method? | 12's (12x40) |
| where do you place cuffs for 3 cuff method | brachial, thigh, below knee, ankle |
| what sized cuff is placed on knee for 3 cuff method? | 19x40 |
| order of segmentals | brachial, ankle, calf, above knee, high thigh |
| NOTE: you must start at ___ and move ___ to eliminate the possibility of underestimating the systolic pressure measurement. | ankle, prox |
| how high do you inflate the cuff during segmentals | 20-30 mmHg beyond last audible signal, OR 20-30mmHg above highest brachial |
| How do you calculate abi's? | divide ankle pressures by HIGHEST brachial |
| A normal ABI calculation is >____ | 1.0 |
| an abi of ___-___ may suggest asymptomatic dz or mild arterial dz | >0.9-1.0 |
| an ABI of ___-___ suggest Claudication (moderate dz) | 0.5-0.9 |
| an abi calculation of ,___ suggest rest pain (severe arterial dz) | 0.5 |
| an abi of >1.3-1.5 is considered ____ | incompressible |
| segmential pressure drops of >30mmHg bt 2 consecutive levels suggest ___ dz | Significant |
| a horizontal difference of >20-30 mmHg suggest obstructive dz where? | at or above the level in the leg with the lower pressure see ex. pg 41 |
| in 3 cuff technique, the thigh pressure should be similar to the ___ | highest brachial |
| in the 4 cuff technique the high thigh pressure is normally >30mmHg than ____ | highest brachial |
| toe pressures of ___ are evident in foot and toe ulcers that fail to heal | <30mmHg |
| In diabetic pts, are abi or toe pressures more reliable? | toe pressures due to calcifications |
| contraindications for exercise testing include: | SOB, server hypertension, signif cardiac problems, stroke, walking problems |
| what does pt walk on for exercising exam? | a constant load treadmill at 12% elevation, 1.5 mph, for 5 min or until unbearable |
| what do you document during exercise testing? | duration of walk, MPH, onset, location and progression of symptoms |
| post exercise ABI is normally ___ | increased |
| if post-exercise is ABN, obtain pressures every ___ until pre-exercise pressures are obtained | 2 min |
| Single level Dz take ___-___ for the ABI to increase back to resting levels after they dropped to low levels after exercise | 2-6 |
| Multi-level dz takes ___-___ min for the abi to increase back to resting levels after exercise | 6-12 min |
| reactive hyperemia is | an alternative method for stressing the peripherial circulation. used when pts cannot use treadmill testing |
| reactive hyperemia technique: | bilateral thigh cuff (19's) inflated to supersystolic pressure levels (usually 20-30mmHg above the highest brachial) maintain pressure for 3-5 mins |
| reactive hyperemia technique produces: | ischemia and vasodilation distal to the occluding cuffs |
| single level dz ____% drop in ankle pressure w reactive hyperemia | <50% |
| multi level dz ____% anlke pressure drop w reactive hyperemia | >50% |
| UE segmential pressure technique | 12 cuff on upper arm, 10 cuff on forearm |
| allen test evaluates: | patency of palmer arch. determins which artery supplies blood to arch in order to harvest radial artery |
| allen test technique | manual compression of Radial A. my tech, Pt clenches fist 1min, inducing pallor increasing resistance. pt then relaxes hand. |
| normal interpretation for allen test | reappearence of normal color to indicate the ulnar artery is providing flow to the palmer arch |
| ABN interpretation for allen test | color does not reappear to indicate: an ulnar artery occlusion, or palmer arch obstruction |
| documentation for allen test | PPG on index finger to document arterial pulsation |
| a 15-20 mmHg difference bt brachials suggest a >50% stenosis of | subclavian artery |
| a >15-20 mmHg drop from upper arm to forearm suggest: | brachial A obstruction distal to upper cuff, obstruction of both radial and ulnar A, obstruction in single forearm artery which has decreased pressure |
| Penile doppler helps determine: | if impotence is related to peripheral vascular insufficiency |
| technique for non imaging penile doppler | doppler CFA,PTA,DPA calculate ABI penile pressure obtained w PPG end point detector cuff size 2.5 cm |
| penile/brachial index: Normal | >0.75 |
| penile/ brachial index: Marginal | .65-.74 |
| penile/brachial index: ANB | <.65 consistance with vasculogenic impotence |
| reduced pressure highly suggestive of ___ | prox arterial dz(aorto-iliac:internal iliac arteries) |
| technique for penile imaging: which arteries are measured? | cavernosal aeteries measured in trv, PSV/EDV obtained |
| what freq probe is used for penile imaging | 7-10 MHz |
| medication in injected to induce erection, obtain measurement ___ post injection | 1-2 min |
| which vein velocity is measured during penile imaging? | Dorsal vein velosity |
| if ridgid erection is maintained for up to ___, pt must contact urologist immediatley to reverse the _______ | 3 hrs, priapism |
| penile imaging interpretation: NORMAL | diameter of cavernous arteries should increase post-injection, PSV should be 30cm/sec higher, dorsal vein velocity should remain the same(<3cm/sec). |
| dorsal vein veolcity normal vs abn | normal <3 cm/sec Abn >20 cm/sec |
| combined w/segmentals, Plethysmography helps differentiate ____ | true claudication from non-vascular sources. |
| Plethysmography detects: | presence/absence of arterial dz while defining its functional aspects |
| Plysmography helps ___ the level of obstruction | localize |
| PPG is mainly used for evaluation of ___ and ____ | digits, penile vessels |
| plethysmography is used for ____ treatment | assessment of follow up treatment |
| can plethysmography discriminate between major arteries and collaterals | NO |
| is Plethysmography specific to one vessel | NO |
| volume (air) plethysmography = measurement of | volume change |
| in Volume-PG, a measured about of air is sequentially inflated into a cuff to pressures ranging ____to _____mmHg | 10-65mmHg |
| as arterial flow moves under the cuff , momentary ____ changes in the limb segment occur | volume |
| PPG (photo-phleysmography) detects: | cutaneous blood flow, rather than truly measureing volume change |
| ppg photo cell consists of | light emitting diode and photo-sensor |
| diode transmits ___light into subcutaneous tissue w backscattered light reflected back to the adjacent photo sensor | infrared |
| the ____ determines the reflection | cutaneous blood flow |
| blood attenuates light in proportion to its content in tissue= | increased blood flow results in decreased reflection. HOwever, that is displayed as an increased/positive deflection on the waveform. (alot of blood flow sucks up light, decreasing what is returned= positive deflection which is a good sign) |
| w volume-PG a 3 or 4 cuff method is used. begin w/ ___ part of extremity, moving ___ | upper, distally |
| w PPG abn waveforms always reflect hemo signif dz ____ to level of tracing | Prox |
| what is displacement plethysmography? | any change in volume of the enclosed part will displace an equal amount of water |
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candaceh71