LEA Anatomy 2018 PDF

Chapter 4 LEA Anatomy Ann Marie Kupinski Edited by Caryn Souza Rorabaugh, BS, RDMS, RVT Edited by Tara Bartholomay MS, RT(R), RDMS, RVT Copyright © 2018 Wolters Kluwer · All Rights Reserved Objectives ► List indications for the LEA exam ► List symptoms f...

Chapter 4 LEA Anatomy Ann Marie Kupinski Edited by Caryn Souza Rorabaugh, BS, RDMS, RVT Edited by Tara Bartholomay MS, RT(R), RDMS, RVT Copyright © 2018 Wolters Kluwer · All Rights Reserved Objectives ► List indications for the LEA exam ► List symptoms for the LEA exam ► Define the major components of the lower arterial vascular system ► Describe the arrangement of the blood vessel walls ► Identify the major vessels of the lower arterial system in the protocol with ultrasound images. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Vessel Walls ► Three layers ► Tunica intima ► Tunica media ► Tunica adventitia Cross-section of an arterial wall. The black arrow is indicating the thick layer of smooth muscle cells within the tunica media. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Arterial Wall Layers: Tunica Intima ►Innermost layer ►Consists of endothelial cell lining with connective tissue beneath Tunica Media ►Middle layer ►Thickest component ►Composed mainly of smooth muscle ►Varying amounts of elastic fibers and collagen Tunica Adventitia ►Outermost layer ►Composed of connective tissue, nerve fibers, and small vessel capillaries ►In contact with surrounding tissue Copyright © 2018 Wolters Kluwer · All Rights Reserved Schematic of an Arterial Wall Copyright © 2018 Wolters Kluwer · All Rights Reserved Arteries ► Arterioles ► “Stopcocks“ of the vascular system ► Circular smooth muscle layers control contraction and resistance ► Small- and medium-sized arteries ► Approximately 4 mm in diameter ► Well-developed smooth muscle layers ► Include all arteries except aorta and major branches ► Large arteries ► Elastic arteries with less smooth muscle ► Aorta and its largest branches Copyright © 2018 Wolters Kluwer · All Rights Reserved Arterial Anatomy ►Aorta Main artery of the body arising from the outflow tract of the left ventricle. Shaped like an umbrella handle or a candy cane First portion is the ascending aorta which then curves to become the aortic arch. o Three vessel arise and course cephalad  Brachiocephalic/Innominate Artery Branches into right subclavian and common carotid arteries  Left common carotid artery  Left subclavian artery Anatomy ► After the three aortic arch vessels the aorta dips down and becomes the descending thoracic aorta. Once it pierces the diaphragm it transforms into the abdominal aorta. ► Aorta continues to travel down giving off branches to the intestines and abdominal viscera finally terminating in a bifurcation. These two vessels are known as the common iliac arteries. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Anatomy ► The common iliac arteries bifurcate into external and internal iliac arteries (EIA and IIA). ► The EIA continues caudally turning into the common femoral artery (CFA) Inguinal ligament ► CFA bifurcates into the superficial femoral (SFA) and deep femoral artery (aka profunda femoris). ► The SFA then converts into the popliteal artery Adductor canal ► Pop. art. bifurcates into the tibioperoneal trunk and anterior tibial artery (ATA). ► The tibioperoneal trunk bifurcates into the posterior tibial artery (PTA) and the peroneal artery. ► The anterior tibial artery descends further to become the dorsalis pedis artery (DPA). Ankle Arteries of the Abdomen View of the branches of the abdominal aorta, including the renal arteries. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Arteries of the Pelvis ► Aorta terminates at the level of the 4th lumbar vertebra. ► Bifurcates into right and left common iliac arteries ► Each common iliac artery bifurcates into external and internal iliac arteries. ► Internal iliac arteries ► AKA hypogastric arteries. ► Supply pelvic organs ► External iliac arteries ► Continue distally to supply lower extremities ► Becomes a common femoral artery at the inguinal ligament Copyright © 2018 Wolters Kluwer · All Rights Reserved  Common Copyright © 2018 Wolters Kluwer · All Rights Reserved Arteries of the Lower Extremities ► Common femoral artery ► Continuation of the external iliac artery below the inguinal ligament ► Divides into superficial femoral and profunda femoris arteries ► Profunda femoris artery ► AKA deep femoral artery ► Courses posterior and lateral to superficial femoral artery ► Gives off branches into the thigh Copyright © 2018 Wolters Kluwer · All Rights Reserved Arteries of the Lower Extremities—(cont.) ► Superficial femoral artery (SFA) ► Courses distally, passing through the adductor canal ► Becomes popliteal artery ► Popliteal artery ► Continuation of SFA ► Courses behind knee in popliteal fossa ► Branches include sural and genicular arteries around the knee ► Terminates in anterior tibial and tibioperoneal trunk art. (posterior tibial and peroneal arteries) Copyright © 2018 Wolters Kluwer · All Rights Reserved  Arteries of the Lower Extremities—(cont.) ► Popliteal artery initially bifurcates into anterior tibial artery and tibioperoneal trunk. ► Tibioperoneal trunk continues for a short distance and bifurcates again into posterior tibial and peroneal arteries. ► Anterior tibial artery ► Passes through interosseous membrane ► Courses distally in the anterior compartment of leg ► Continues anterior to ankle joint and becomes the dorsalis pedis artery Copyright © 2018 Wolters Kluwer · All Rights Reserved Arteries of the Lower Extremities—(cont.) ► Posterior tibial artery ► Courses medially in the posterior compartment of the leg ► Runs behind the medial malleolus ► Terminates into medial and lateral plantar arteries ► Peroneal artery ► Located deep within leg; descends along medial aspect of fibula ► Terminates into branches that communicate with the posterior and anterior tibial arteries Copyright © 2018 Wolters Kluwer · All Rights Reserved Arteries of the Lower Extremities—(cont.) ► Arteries of the foot ► Medial and lateral plantar and dorsalis pedis arteries help to give rise to the plantar arches. ► Arising off plantar arches are the metatarsal arteries. ► Digital arteries arise from the metatarsal arteries. Copyright © 2018 Wolters Kluwer · All Rights Reserved Arteries of the Lower Extremities Copyright © 2018 Wolters Kluwer · All Rights Reserved Arteries of the Lower Extremities Copyright © 2018 Wolters Kluwer · All Rights Reserved Common Iliac Artery Copyright © 2018 Wolters Kluwer · All Rights Reserved External Iliac Artery Copyright © 2018 Wolters Kluwer · All Rights Reserved Common Femoral Artery Copyright © 2018 Wolters Kluwer · All Rights Reserved CFA Bifurcation: SFA/DFA Copyright © 2018 Wolters Kluwer · All Rights Reserved SFA: Prox, Mid, Distal Copyright © 2018 Wolters Kluwer · All Rights Reserved Popliteal Artery Copyright © 2018 Wolters Kluwer · All Rights Reserved Tibioperoneal Arterial Trunk Copyright © 2018 Wolters Kluwer · All Rights Reserved PTA Copyright © 2018 Wolters Kluwer · All Rights Reserved ATA Copyright © 2018 Wolters Kluwer · All Rights Reserved Dorsalis Pedis Artery (High Frequency!) Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved The _______ is the continuation of the EIA. A. IIA B. DFA C. CFA D. SFA Copyright © 2018 Wolters Kluwer · All Rights Reserved The _______ is the continuation of the EIA. C. CFA Copyright © 2018 Wolters Kluwer · All Rights Reserved What are the two main branches of the popliteal artery? Copyright © 2018 Wolters Kluwer · All Rights Reserved What are the two main branches of the popliteal artery? Tibioperoneal Trunk & ATA Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Symptoms: Many people with peripheral artery disease have mild or no symptoms. Some people have leg pain when walking (claudication). Claudication symptoms include muscle pain or cramping in the legs that begins during exercise and ends with rest. The pain is most commonly felt in the calf. The pain ranges from mild to severe. Severe leg pain may make it hard to walk or do other types of physical activity. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Symptoms of PAOD Claudication: The most common symptom of peripheral arterial occlusive disease (PAOD) affecting the lower extremities is leg discomfort caused by activity, BUT becomes less intense when the activity stops!. This is termed intermittent claudication. Symptoms of intermittent claudication --Fatigue or tiredness sensation --Cramping or aching --Usually starts in the calf then can progress to the thigh and/or buttocks *The amount of activity that produces the symptoms can remain fairly reproducible for long periods, unless there is accelerated progression of PAOD *Based on the site and severity of disease *The site of the symptoms indicate the site(s) of the disease, because the symptoms occur distal to the disease process: For example: Claudication limited to the calf is associated with superficial femoral, popliteal or posterior tibial artery disease, thigh symptoms with common femoral or iliac artery disease and buttock claudication with either ipsilateral iliac artery disease (if unilateral) or aortoiliac disease when bilateral. Other Symptoms of PAOD Coldness in the lower leg or foot, especially when compared with the other side Leg numbness or weakness No pulse or a weak pulse in the legs or feet Painful cramping in one or both of the hips, thighs or calf muscles after certain activities, such as walking or climbing stairs Shiny skin on the legs Scaly skin Skin color changes on the legs Slower growth of the toenails Thickened toenails Sores on the toes, feet or legs that won't heal Erectile dysfunction Hair loss or slower hair growth on the legs Copyright © 2018 Wolters Kluwer · All Rights Reserved Symptoms: Copyright © 2018 Wolters Kluwer · All Rights Reserved  Symptoms: Claudication: The pain is DISTAL to the disease with activity! This patient’s disease is proximal to his hand: PTA, Pop A, or SFA. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Symptoms: Claudication: The pain is DISTAL to the disease with activity! This patient’s disease is proximal to his hand: Iliac arteries or aorta if both sides of buttocks have pain. Copyright © 2018 Wolters Kluwer · All Rights Reserved Indications for LEA Exam ► 1. Detection of stenosis or occlusion in segments of the peripheral arteries. 2. Monitoring of sites of previous surgical interventions, including sites of previous bypass. 3. Monitoring of sites of various percutaneous interventions. 4. Follow-up of previously diagnosed disease. 5. Evaluation of arterial integrity in the setting of trauma. Copyright © 2018 Wolters Kluwer · All Rights Reserved Techniques Remember the rule of inversion when using scale and gain. If you go up in your gain go down in your scale. If you go down in your scale, go up in your gain. Little increments at a time. If your scale is too low you will get aliasing, so increase your scale. Make small movements do not turn the knob/dial too much!! Optimizing your images not only is aesthetically pleasing but also provides for accurate data to make a CORRECT diagnosis. Copyright © 2018 Wolters Kluwer · All Rights Reserved Just right…. Copyright © 2018 Wolters Kluwer · All Rights Reserved Angle vessel down by “rocking” or aka “heel-toe” the probe. NO!! YES!!!! Superior Inferior Notch Toe Heel Copyright © 2018 Wolters Kluwer · All Rights Reserved Angle vessel up by “rocking” or aka “heel-toe” the probe. Heel Toe Notch Inferior Superior Copyright © 2018 Wolters Kluwer · All Rights Reserved Other parameters you need to consider: *Sweep speed *Wall filters *Color box size and orientation *Sample box size *Whether the scale is inverted. Copyright © 2018 Wolters Kluwer · All Rights Reserved TGC Is this artifact or disease??? Perfect: you want to be able to see Too many artifact echoes the intima of the wall of the vessel but have a clear clean vessel without artifacts. Copyright © 2018 Wolters Kluwer · All Rights Reserved PRF/SCALE Copyright © 2018 Wolters Kluwer · All Rights Reserved Speed Sweep of waveform Too fast……………………..Too Slow…………………….Just right! Copyright © 2018 Wolters Kluwer · All Rights Reserved Steer the color box the correct direction Make sure the steered ultrasound beam and vessel meet an acute angle of 60 degrees or less. “Ski down the vessel” not up the vessel. Copyright © 2018 Wolters Kluwer · All Rights Reserved Review Direction of Flow Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Lower Extremity Protocol Video Copyright © 2018 Wolters Kluwer · All Rights Reserved Lower Extremity Protocol Copyright © 2018 Wolters Kluwer · All Rights Reserved  References How to Determine Blood Flow Direction with Ultrasound and Doppler. (Oct. 11, 2008). RVT Pro. https://www.youtube.com/watch?v=YC5Fz7W_jJA&t=3s. Accessed Jan. 16, 2024. Kupinski, A. M., & Schifrin, G. The Vascular System.(3rd ed.). Gurnick Academy of Medical Arts. Wolters Kluwer Health, 2022. Chapter 4, pp. 39-53. Lower Extremity Arterial Duplex anatomy and Protocol. (Feb. 5, 2019). Sonographic Tendencies. https://www.youtube.com/watch?v=asGR_FOFljA. Accessed Jan. 16, 2024. Copyright © 2018 Wolters Kluwer · All Rights Reserved