Doppler Segmental Pressures (LE)

Question 1

What are limitations of a Doppler segmental pressures exam

Answer 1

• cannot discriminate between stenosis and occlusion, or the precise area of obstruction
• cannot discriminate between CFA and external iliac disease
• may give falsely elevated Doppler on calcified vessels (patients with diabetes and end stage renal disease are common with this)
• wrong cuff size can give false pressures
• difficult to interpret multi-level diseases
• patients with CHF may have decreased ankle/brachial indices

Question 2

Patients with these conditions may not be able to get pressure scans
(6)

Answer 2

DVT, dialysis access, lymphedema, stent, bypass graft, patients who had mastectomy

Question 3

How long should patients rest before having this exam done

Answer 3

20 minutes

Question 4

Ideally the cuff bladder should be placed over the______

Answer 4

Artery

Question 5

It is VERY important that the width of the cuff is around ____% greater than the diameter of the limb

Answer 5

20%

Question 6

With the four cuff (Bilateral) the cuffs are placed on the brachial (upper arm) and what other four areas?

Answer 6

High thigh (with a longer cuff for thighs)
Low thigh/above the knee (AK)
Below the knee (BK)/calf
At the ankle

Question 7

With the three cuff method, the cuffs are placed at the brachial(upper arm), and what other 3 locations

Answer 7

One thigh cuff (19 X 40cm)
Below the knee/calf
At ankle

Question 8

What is the average cuff size (excluding the thigh cuffs)

Answer 8

12 X 40 cm

Question 9

For optimal Doppler signal the probe should be at a __ to __ degree angle to skin, with the blood flow moving ___ to the probe.

Answer 9

45-60 degree angle ( at the knee it may be closer to 90 degrees bc of vessel angulation)

Blood flowing towards the probe (Antegrade)

Question 10

What is a sphygmomanometer

Answer 10

A hand held automatic cuff inflator

Question 11

What is the order for a sphygmomanometer pressure exam, starting with
1. brachial artery

Answer 11

2. At ankle (for PTA and DPA, **if necessary peroneal A.)
3. Calf/BK (for PTA or DPA, use the HIGHEST pressure for this level)
4. Above the knee/AK (same as calf, may need popliteal A. If difficult to obtain)
5. High thigh/HT (same as above the knee)

Question 12

Why are we performing segmental pressures from ankle to thigh?

Answer 12

To eliminate the possible underestimation of the systolic pressure measurements

Question 13

Cuffs need to inflate ____ to ____ mmHg beyond last audible Doppler signal OR the same amount of mmHg higher than the highest brachial pressure

Answer 13

20-30 mmHg higher for both examples

Question 14

For repeat measurements be sure to deflate completely and wait ____ minute(s) before repeat.

Answer 14

About one minute

Question 15

To calculate ABI’s, divide the ankle pressure by _____

Answer 15

Ankle pressure divided by the HIGHER of the two brachial pressures

Question 16

ABI use the following chart to detect severity
> 1.0 = ?
> 0.9-1.0 =?
0.8-0.9 = ?
0.5-0.8 = ?

Answer 16

> 1.0 = normal
0.9-1.0 = may be within normal limits
0.8-0.9 = mild arterial disease
0.5-0.8 = claudication (moderate disease)

Question 17

Incompressible vessels will give false elevations making it inaccurate, what is the range on the ABI index to consider it incompressible?

Answer 17

> 1.3-1.5

Question 18

T/F
Some authors think that an absolute ankle pressure of less than 50mmHg, rather than the ABI of .5 has a stronger weight for predicting symptoms at rest

Answer 18

TRUE

Question 19

An ABI of greater than and equal to ___ represents SINGLE segment disease

Answer 19

Greater or equal to .5

Question 20

ABI of less than .5 suggests ______ lesions

Answer 20

Multiple lesions

Question 21

Segmental pressure drop between two consecutive levels needs to be greater than what mmHg in order to suggest SIGNIFICANT obstruction

Answer 21

Greater than 30 mmHg

** some authors suggest greater than 20 mmHg

Question 22

If there is a pressure difference of greater than or equal to 20 or 30 mmHg between the right and left legs, this suggests?

Answer 22

Obstructive disease at or above the level in the leg with the lower pressure

Question 23

With a 4 cuff technique, the HIGH THIGH is normally how much higher than the brachial pressure?

Answer 23

Normally greater than or equal to 30 mmHg in thigh than brachial

Question 24

3 cuff methods, the thigh pressure should be what in comparison to the brachial pressure?

Answer 24

Should be similar in pressures

Question 25

Toes pressures of less than or equal to 30 mmHg are present in foot/toe ulcers that [did or did not] heal

Answer 25

Did not heal

Question 26

Toe pressures may be more reliable in what kind of patient

Answer 26

Diabetic patients

Question 27

What does exercise during segmental pressure tests help to differentiate?

Answer 27

True VS false claudication

Question 28

Name a few contraindications for ABI's with exercise

Answer 28

``` Shortness of breath Severe hypertension Significant cardiac problems Stroke Walking problems ```

Question 29

For the exercise portion of the ABI, the patient walks on a ____ ____ treadmill at a less than or equal to _____% elevation

Answer 29

Constant load treadmill at a < or equal to 12% elevation

Question 30

What is the speed and maximum time the patient walks for this test

Answer 30

1. 5mph for a max of 5 minutes | * *or until symptoms are too severe for patient to continue

Question 31

With exercise ABI, we document these 3 things

Answer 31

Duration of walk MPH onset/location/progression of symptoms

Question 32

Post-exercise pressures are obtained on both _____, then ______

Answer 32

``` Both ankles (abnormal first) Higher of the two brachials ```

Question 33

Immediately after exercise, a normal ABI will ______ and an abnormal ABI will ______

Answer 33

``` Normal = ABI increases Abnormal = ABI decreases ```

Question 34

With a decreased ABI post-exercise (aka abnormal), we obtain pressures every 2 minutes untill......

Answer 34

Untill pre-exercise pressures are attained

Question 35

Post-exercise, _____ level disease will take 2-6 minutes for ABI to increase to the pre-exercise ABI. While _____ level disease takes 6-12 minutes.

Answer 35

SINGLE level disease takes 2-6 minutes | MULTI-level disease takes 6-12 minutes

Question 36

T/F | Reactive hyperemia patients for the most part CANNOT walk

Answer 36

True

Question 37

When a patient cannot walk (reactive hyperemia), what is the alternative method to exercise for an ABI

Answer 37

We inflate bilateral thigh cuffs (19 X 40) to a SUPRASYSTOLIC pressure level (usually 20-30mmHg above the higher BP), and maintain the pressure for 3-5 minutes **this produces ischemia and vasodilation distal to the occluding cuffs

Question 38

With the "non-exercise" technique of ABI, what is the range for a normal limb drop

Answer 38

Normal limbs may show a transient drop of 17-34%

Question 39

With reactive hyperemia ( non-exercise) patients, a single level disease is < or = a 50% drop in ankle pressure, and a multi-level disease will have what

Answer 39

Multi-level disease is a >50% ankle pressure drop

Question 40

Why is the treadmill testing the preferable test for exercise ABI

Answer 40

It produces a physiologic stress that reproduces a patients ischemic symptoms