Upper Extremity Arterial Testing Flashcards
1
Q
What side has a brachiocephalic artery only?
A
The right side.
2
Q
What is the first branch off the ascending aorta from the heart?
A
Brachiocephalic Artery
3
Q
What does the brachiocephalic artery split into?
A
It splits into the right common carotid to feed the brain and the right subclavian artery to feed the arm.
4
Q
Label:
A
5
Q
What is the axillary artery?
A
A large vessel that is starts from the first rib and becomes the brachial artery.
6
Q
Is the axillary artery superficial or deep?
A
It is deep because it lies underneath the pectoral muscle.
7
Q
Where does the brachial artery start?
A
It srats at the lower axilla (armpit) and runs down the elbow.
8
Q
What is the major branch of the brachial artery?
A
The deep brachial artery.
9
Q
What does the brachial artery branch into?
A
It branches into the ulnar and radial arteries below the anticubital fossa.
10
Q
What does it mean for the brachial artery to be variant?
A
The brachial artery can have a very proximal bifurcation into the radial and ulnar arteries, sometimes above the antecubital fossa and sometimes below the axilla.
11
Q
Where is the radial artery located?
A
Thumb side of the hand (lateral)
12
Q
Where is the ulnar artery located?
A
On the pinky side of the hand. (medial)
13
Q
What is the most proximal arch in the hand?
A
Deep palmar arch.
14
Q
What does the superfical palmar arch give rise to?
A
Common digit arteries.
15
Q
Which of the two arches is the most dominant?
A
The superficial Palmar Arch.
16
Q
What is another name for the brachiochepalic artery (BCA)?
A
Innominate
17
Q
What are the 5 UE arterial diseases?
A
- Atherosclerois
- Subclavian steal syndrome
- Thoracic Outlet Compression (TOC)
- Vasopastic Disease, aka Raynaud’s.
- Emboli
18
Q
Where is atherosclerosis found?
A
Typically in the subclavian artery.
19
Q
What are the symptoms of artherosclerosis?
A
Pain on arm extersion.
20
Q
What is Thoracic Outlet Compression?
A
It is compression of the brachial plexus, the subclavian artery and/or subclavian vein in the thoracic outlet or space between the clavicle and the first rib.
21
Q
What is most commonly affected in TOC?
A
the nerve, then vein, then artery.
22
Q
What causes TOC?
A
- Accesory rib at clavicle
- Overdevelopment of scalene muscle
- Trauma
- Fibrous bands
23
Q
The artery, vein and never plexus can be compressed by what?
A
- By the first rib and the clavicle.
- By the first rib and the scalene muscle.
- Between the coracoid process and pectoralis muscle.
24
Q
What are the 5 symptoms of TOC?
A
- Pain
- Digital discoloration (emboli)
- Swelling
- Color change
25
What is the **subclavian steal syndrome**?
It is an obstruction in the subclavian artery that causes the ipsilateral vertebral artery to act as a collateral to fill it.
**To do this, the vertebral artery must reverse in direction esentially "stealing" blood from the brain to feed the arm.**
26
Where is the subclavian steal syndrome mostly prevalent?
On the left side.
27
What are the symptoms of subclavian steal syndrome?
Rarely causes symptoms, but the most common symptoms include:
* dizziness
28
What is **vasospasm**?
It is a condition that occurs when an artery spasms causing vasoconstriction limiting blood flow through the artery in spasm.
29
How long does a vasospasm last?
Typically temporary, but prolonged.
30
Where do vasospasm occur?
digital, brain coronary, or other arteries.
31
What is prolonged digital vasospasm triggered by?
* cold exposure.
* emotion
* chemicals (nicotine)
* occupational trauma to the hands.
32
What is vasospasm also known as?
Raynaud's Syndrome.
33
Is Raynaud's syndrome uniaterally or bilaterally?
Bilateral.
34
What are the types of Raynaud's disease?
* Primary Raynaud's
* Secondary Raynaud's
35
What is **Primary Raynaud's**?
* no underlying disease.
* After the vasospasm, the arterial size returns to normal.
* Does **NOT** result in sevre ischemia resulting in amputation.
36
What is **Secondary Raynaud's**?
* Underlying disease such as scleroderma or lupus.
* **CAN** lead to severe digital ischemia, which would lead to an amputation.
37
What is a **digital emboli**?
Substance from a proximal location flows downstram and gets stuck in the small digital arteries, causing ischemia.
38
What are the 3 sources of emboli?
1. Cardiac (artial fibrilation)
2. Proximal artherosclerotic plaque
3. Proximal aneurysm (mural thrombus)
39
What are the symptoms of digital emboli?
pain and discoloration.
40
What is the purpose of a CW Doppler?
* detect the presence of an obstructive disease that is hemodynamically significant.
* To check the severity of perfusion.
* Obtain the general location of obstruction.
* To detect any changes since the previous exam.
41
What is the probe and angle used in a CW doppler?
* 8-10 MHz Doppler transducer
* 45-60° angle to the skin
42
Where do you want to point the probe in a CW Dopper?
Point probe parallel to the artery towards the heart.
43
How should a patient be positioned for a CW Doppler exam?
* Supine with arms relaxed at the sides.
* head can be slightly elevated.
44
Where do you obtain CW Doppler waveforms?
1. Subclavian
2. Axillary
3. Brachial
4. Radial
5. Ulnar
45
What is considered a normal CW Doppler waveform?
* Normal is a triphasic signal but the reverse flow phase is often missing in a normal UE.
* Normal is more liekly "multiphasic" due to the inflection points on the downslope and hitting the baseline with or without going below it.
46
What is an abnormal CW Doppler waveform?
It is biphasic, monophasic, or absent signal.
47
What is considered significant in a CW Doppler waveform?
A change in a waveform shape from one level to the next or to the other side.
48
In a CW Doppler, where would you find most obstructions?
At the subclavian artery level.
49
What are the limitations to a CW Doppler?
* Poor skin integrity
* Obesity
* Extensive bandages or casts.
* Unable to distinguish stenoisis from occlusion.
* Highly technologist dependent.
50
Why are UE segmental pressures preformed?
* Identify obstructions \>50% (hemodynamically significant.)
* Asses severity of disease.
* Identify general location of the disease.
* Evaulate change after treatment.
51
How should a patient be positoned for a UE segmental pressure exam?
* SUpine, head can be elevated.
* Arms relaxed at side, palms up.
* 12 cm pressure cuffs
* one on forearm
* one on arm
52
Where do you obtain a brachial artery doppler?
Anticubital fossa (ACF)
53
What is considered significant in a UE Segmental Pressures?
* **A difference of \>20 mmHg comparing right and left brachial pressures is significant.**
* Indicates \>50% stenosis in the subclavan, axillary or brachial.
* **typically the subclavian artery.**
54
True or False:
The forearm pressures are normally higher than the arm.
True.
55
What should the **forearm/brachial ratio** be?
1.0 or greater.
56
What are some of the contraindications to preforming UE Segmental Pressures?
* IV or line under cuff
* Dialysis graft
* Mastectomy on that side.
57
What are some limitations to UE Segmental Pressures?
* Cannot differentiate between stenosis and occlusion.
* Calcification
* Bandages or cast
* Obesity
* Technologist dependent.
58
What is the procedure for a UE excersise test?
* Lift a two pound weight for 3 minutes one cycle per second.
* Post-occlusive reactive hyperemia (suprasystolic brachial pressure for 3 min)
* Repreat brachial pressures every minute until baseline values are reached or a maximum of 10 minutes.
59
What is a normal interpretation for the UE excersise test?
Normal responsw is a slight increase or no change in pressure.
60
What is an abnormal interpretation of an UE excersis test?
A decrease in pressure from resting values with slow return to baseline.
61
What are some UE excersise test limitations?
* Poor patient cooperation.
* Patient unable to lift weights
* Patient unable to stand reactive hyperemia.
62
Why is UE PVR used?
* Presence and severity of \>50% obstruction.
* can localize level of obstruction.
* Can be easily used for follow ups.
63
What is the UE PVR procedure?
* Patient supine.
* 12 cm cuff arm and forearm
* Cuffs inflated to 60 mmHg on armand held until PVR tracings are obatined.
* 40 mmHg on digits
* Run bilateral tracings simultaeously.
64
What is a normal interpretation of a UE PVR?
Rapid upstroke with a dicrotic notch.
65
What is a abnormal interpretation of a UE PVR ?
Loss of dicrotic notch, rounding and flattening of wave as disease progresses.
66
What are the limitations to an UE PVR test?
* Can not distinguish stenosis vs occlusion.
* Obesity, edema may cause lower than expected amplitudes.
67
What is the purpose of the **Palmer Arch Exam**?
To determine if the palmer arch is complete or incomplete.
68
What does the **Palmer Arch Exam** do?
It can determine if adequate flow would enter the hand/digits through the palmar arches if the radial or ulnar artery was not patent.
69
What are radial arteries frequently used for?
Used as conduits for coronary bypass grafts.
70
What is the procedure for the Palmar Arch Exam?
1. PPG on digit-Test at least the thumb or index finger and the fifth finger.
2. Run waveform on slow speed.
3. place your hand under the patients wrist
4. Compress the radial and ulnar arteries with a finger on each.
5. Pulse should dissapear.
6. Release radial, and note if the pulse remains, decreases or is lost.
7. Release ulnar, and note if the pulse remains, decreases or is lost.
71
What are some limitations do the Palmar Arch test?
* Obesity
* Calcification
* Poor skin integrity
* Movement.
72
For digital pressures and PPG waveforms, what should the patient avoid?
The patient should avoid caffeine, food, and smoking.
73
What is the size of the cuff placed around the middle of the finger? (mid phalanx)
2.0-2.5
74
if you use a 1.5 cm cuff, what would happen?
It would yield a falsely elevated pressure.
75
What method can you use to avoid interference with a PPG?
Place a towel over the fingers.
76
What is the **normal** digital/brachial ratio?
.80
77
What is considered abnormal for a digital/brachial pressure?
\<.80
78
What is an abnormal digital **pressure**?
\<70 mmHg
79
What should the digital differences be between eachother?
15 mmHg of eachother.
80
What do you call a PPG waveform that is barely pulsatile or flat?
Critically abnormal.
81
What are some digital pressure limitations?
* Cold fingers may give false positive results due to vasocontriction
* Cold fingers will reduce the PPG waveform amplitude.
* Finger movement
* Poor skin integrity.
82
What is the purpose of the cold challenge testing for Raynaud's disease?
To elicit vasospasm in patients with symptoms of Raynaud's disease.
83
What is the procedure for the ice stress test?
1. Take PPG waveform, and temps, and pressures for a baseline.
2. Immerse fingers in ice water for **30s to 2 mins.**
3. Document any symptoms and color changes.
4. Dry quickly and lightly.
5. Take PPG waveforms, temps. and pressure following immersion.
6. **Continuous loss of amplitude in the waveform or pressure of temperature with slow return to baseline is abnormal.**
84
What are the limitations to the cold challenge testing?
1. Patient unable to stand the cold immersion.
2. Finger movement during PPG waveforms
3. Do **not** ice stress with any evidence of ulceraation or gangrene.
85
What is the **purpose** of thoracic outlet testing?
To find an arm.shoulder/head position that causes the artery to be compressed at the thoracic output.
86
What is the **procedure** to thoracic outlet testing?
1. Place PPG on THIRD finger with cable draped towards arm or taped lightly on forearm.
2. Baseline PPG waveform is taken with the patient's hands on a pillow on lap.
3. Patient is instructed to put arms, shoulders, and head in various positions while monitoring the blood flow.
87
What are the 3 thoracic outlet testing positions?
1. Head side to side with shoulders back in "exaggerated military position"
2. Extended arm 90° to 180° with head turned side to side.
3. pledge position turning head each way.
88
What is "causative position" in thoracic outlet testing?
The position that patient states gives them symptoms.
**Considered 4th position for testing.**
89
What is the most important positions for thoracic outlet testing?
1. The arm up 180° with shoulders back.
2. Causative position.
90
91
What is considered **normal** in thoracic outlet testing?
* No loss of PPG waveform
92
What is considered **abnormal** in thoracic outlet testing?
**\*compression will reduce blood flow\***
* Complete loss of PPG wave in any position.
* **MUST** be accompanied by symptom
* Up to 25% of asymmptomatic people have abnormal exam.
93
What are the limitations to thoracic outlet testing?
1. Poor patient cooperation
2. Obesity
3. Poor skin integrity
4. Technologist training.
