Physiological Part II PDF

PHYSIOLOGICAL PART PHYSIOLOGICAL PART IIII When evaluating suspected thoracic outlet A. 2nd digit, on the radial artery syndrome, a PPG exam can be performed with ; the sensor placed on the are...

PHYSIOLOGICAL PART PHYSIOLOGICAL PART IIII When evaluating suspected thoracic outlet A. 2nd digit, on the radial artery syndrome, a PPG exam can be performed with ; the sensor placed on the are e when evaluating suspected thoracic outlet Doppler exam can be performed with the syndrome transducer placed F e a PPG exam can be performed with sensor placed on the 2nd digit or a doppler exam can be performed with e transducer placed on the radial artery Condition Examination Type Sensor/Transducer Placement Suspected Thoracic Outlet Syndrome PPG Exam 2nd digit Doppler Exam Radial artery Thoracic Outlet Syndrome (TOS) Description General Muscular band, cervical rib, or fibrous band crosses the brachial plexus in an abnormal Description location causing compression with certain arm maneuvers. Most patients are asymptomatic. Symptoms Dull aching pain radiating from the point of compression, paresthesia (numbness), pain, increased symptoms with certain arm/neck positions or exercise, swelling with venous TOS, intermittent symptoms that vary with patient position. Types of TOS Description Symptoms Neurogenic Most common type (>90%). Compression of the Paresthesia, numbness, pain. Ultrasound TOS brachial plexus from cervical ribs, anterior scalene evaluation may not identify symptoms muscles, and ligaments. if only the nervous system is affected. Arterial TOS Least common (1%). Subclavian artery compression from the head of the humerus. Venous TOS Subclavian vein compressed against the first rib and scalenus anticus muscle with abduction of the arm. Also called Paget-Schroetter syndrome or effort thrombosis. Exam Technique Description General Necessary to evaluate the patient first for atherosclerosis. Establish normal flow patterns for the Procedure patient and then evaluate changes in flow with changes in position. Patient is seated with palms up and resting on thighs. Record waveforms with the sweep speed reduced to better demonstrate changes with maneuvers. The waveforms should be similar to or larger than the resting position waveforms. Reduction in amplitude or “flatline" waveform indicates a positive exam. PPG or PVR evaluation methods are preferred over Doppler (transducer can move when patient moves, negatively affecting the evaluation). PPG and Perform PPG tracings of the 2nd digit (index finger) at rest and with maneuvers. Perform PVR PVR tracings with a brachial cuff at rest and with maneuvers. Doppler Evaluate the radial artery at the wrist. Obtain Doppler samples. Perform TOS maneuvers. Repeat Evaluation - Doppler samples. Arterial Doppler Evaluate the distal subclavian vein. Establish baseline flow with Doppler. Perform TOS maneuvers. Evaluation - Repeat Doppler samples. Venous Maneuver Instructions Neutral Position - Use this position to obtain baseline tracings before performing any TOS maneuvers to initiate symptoms. Always record the positions that are used to evaluate the patient. When symptoms or waveform changes occur, note the patient position that caused the changes. 90 Degree Raise the arm up with hand at same level as the shoulder, palm up. Turn the Abduction - TOS head toward the affected arm and then away, while recording waveforms. 180 Degree Raise the arm straight up with the palm toward the head. Turn the head Abduction - TOS toward the affected arm and then away, while recording waveforms. Adson Maneuver From neutral position, ask the patient to sit tall with their chest forward. - TOS Instruct them to take in a deep breath and hold it. Ask the patient to turn their head toward the affected side, extend the arm and raise it slightly. Finally, the patient should be evaluated with their head turned toward the unaffected side. Note symptoms and waveform changes that occur at any time during the maneuver. Costoclavicular From neutral position, push the elbows back, shoulders down and stick the Maneuver - TOS chest out. Face forward with chin level. Turn the head toward the affected side and away, while recording waveforms. I Category Details TOS Maneuvers — Inspiration/Expiration used with the change of position in some maneuvers 1, Resting neutral position, hand on lap 2, Arm at 90-degree angle to body 3. Arm at 180-degree angle to body 4, Adson's maneuver 5. Exaggerated military posture (costoclavicular) 6. Neutral position with head left/head nght maneuver 7, Any position that the patient experiences symptoms Adson's - Palpate the radial pulse on the affected side with the elbow fully extended. Have the patient rotate Maneuver their head to the side being tested and extend the neck - Then abduct, extend, and laterally rotate the shoulder - From this position, have the patient take a deep breath and hold - Assess the pulse response - A positive test is a decrease in pulse vigor from the starting position to the final position Abnormal PPG/PVR - significantly reduced amplitude or absent signal with patient maneuvers Findings Arterial Doppler - significantly reduced or absent signal with patient maneuvers Venous Doppler - venous signal will become continuous or disappear - When a change in the waveform is noted, ask the patient if they are experiencing symptoms Abnormal exam results + patient symptoms = positive exam for TOS. 9. pt presents with a history of HTN, A. THE ABI VALUES ARE ABNORMALLY ELEVATED e diabetes and claudication e the arterial doppler evaluation demonstrate: > DIABETIC COMPLICATION ¢ monophasic flow in all calf vessels > MEDIAL CALCIFICATION ABI: ¢ monophasic flow in the extermities is LT: 1.36 normally accompanied with an ABI less than A132 0.9 which of the following correctly describes the e Diabetes can lead to medial calcification of findings? the arterial walls which will falsely elevate the ankle pressures The ankle brachial index is commonly performed as Exercise testing Exercise testing a part of which of the following exams? e the ABI is performed at rest and with exercise e if the ABI decreases with exercise e arterial disease is present An arterial duplex exam demonstrates monophasic A. Digit plethysmography flow in the popliteal and calf arteries. The bilateral ABI calculations are over 1.0. ¢ Digit Diethysmogiaphy can be performed What type of testing can be used to better evaluate © to evaluate flow and systolic pressure the pressures in the lower extremities in this measurements of the toes patient? if the ABI is normal and the doppler evaluation does not correspond with the ABI digital tracings > pressures should be obtained to carify the findigns e medial calcification can result in a normal ABI with monophasic flow in the calf arteries © the digital arteries are not typically affected by medial calcification Digital Plethysmography Information Parameter Details Purpose Evaluate flow and systolic pressure measurements of the toes. When to Use If ABI is normal but Doppler evaluation does not correspond with ABI results. Procedure Obtain digital tracings and pressures to clarify findings. Effect of Medial Calcification - Can result in a normal ABI with monophasic flow in calf arteries. - Digital arteries are not typically affected by medial calcification. Test Purpose/Explanation Digital Used to evaluate blood flow and systolic pressure measurements in the toes. plethysmography ABI and Doppler If the ABI is normal but Doppler results don't match, digital tracings and pressures Discrepancy should be obtained to clarify the findings. Medial calcification Medial calcification can result in a falsely normal ABI despite the presence of effect monophasic flow in the calf arteries. The digital arteries are typically unaffected by medial calcification. A diabetic patient presents with an injury to his big A: Digital pressures and PPG evaluation toe that won't seem to heal and has been open for over 3 weeks. Which of the following exam * digital pressures are more accurate in techniques should be used to evaluate this patient? evaluating flow » in the legs/feet than the ABI due to medical calcification of the calf/ankle vessels Photoplethysmography uses to detect changes in venous volume in the leg. A. LIGHT Topic Details Photoplethysmography: Principle - Infrared light released into tissues - Red blood cells reflect the light to photocells where it is measured - Detects cutaneous blood flow/volume changes - Hemoglobin absorbs the light; the lower the blood volume in the leg, the more reflection of the light demonstrated - If there is little change in blood volume due to arterial disease, there will be only small changes in the amplitude of the waveform Exam Preparation: - Perform exam in a warm room - A towel can be used to cover the digits and sensors to reduce effects of surrounding light - Digits can be warmed to increase pulse amplitude Procedure: - The patient is supine and the sensor attached to plantar surface of toes - Several waveforms recorded with the size control set to 10 for consistency of evaluation of different vessels and on different exams - If the size control is adjusted, it must be recorded on the tracings Waveforms: - Waveforms are similar to PVR tracings; both are volume assessments by different methods (air vs light) - Normal tracing demonstrates rapid upstroke, sharp systolic peak and prominent reflection (dicrotic notch) - Mild disease causes loss of the reflection but maintains the sharp peak - Severe disease causes a damped wave with slow upslope, low amplitude peak, and slow downslope with minimal difference between systolic and diastolic volumes PPG Recordings: - PPG recordings are NOT affected by calcified vessels (medial calcification) - Used in diabetic patients due to medial calcification of calf/leg arteries - If the ABI is normal and the Doppler evaluation does not correspond with the ABI, digital PPG tracings and pressures should be obtained to clarify the findings - Medial calcification can result in a normal or elevated ABI with monophasic flow in the calf arteries - The digital arteries are not typically affected by medial calcification Limitations: - Strap around digit is too tight - Poor sensor contact - Patient movement - Cold room, warm room - Patient anxiety - Smoking before exam | R) 2nd Digit: L) 2nd Digit: PRSSEPESESSEEIGEsO4 Ved Dee cues? | Gain %:36 Amp: 7mm Gain %:100 Amp: 14 mm | Abnormal: blunted tracing, low amplitude Normal: peaked tracing, high amplitude Arterial PPG Exam Description Right 2nd Digit Abnormal: blunted tracing, low amplitude Gain % (Right) 36% Amplitude (Right) 7mm Left 2nd Digit Normal: peaked tracing, high amplitude Gain % (Left) 100% Amplitude (Left) 14mm The difference in systolic pressure between two D. 30 adjacent levels in the same leg should be no more than mmHg. e drop in pressure of 30mmHg or more e btwn segments indicates disease btwn the two segments When a patient performs exercise on a treadmill, | ©: Unchanged or mild increase what will be the normal change in the ankle- e the pressure in the ankles and arms may brachial indices? demonstrate a mild increase in pressure with exercise but the brachial and ankle pressure will increae together in a normal patient > this will lead to a consistent ABI calculation a mild increase in the ABI may also be normal > a decrease in ankle pressure indicates an abnormal response Condition Description Normal initial flow response to reactive Should include a flow velocity that is more than double the resting hyperemia flow velocity. Reactive Hyperemia Testing Details Definition Reactive hyperemia is the transient increase in blood flow that occurs after a brief period of ischemia. Common Following the removal of a tourniquet, unclamping an artery during surgery, or after vessel Occurrence recanalization caused by a device or medication. Post-Occlusive Uses occlusive cuffs to simulate exercise in patients unable to perform treadmill testing. Reactive Hyperemia Testing Needed for Poor cardiac output, history of angina, difficulty walking or breathing, short walking Patients tolerance, pulmonary problems, amputation of the leg. Untreated Disease Limits treadmill tolerance when evaluating symptoms in the opposite leg. Cuffs Effect Cause muscular ischemia and capillary vasodilation; releasing cuffs is the same as stopping exercise. Exercise Testing Preferred due to the ability to reproduce symptoms related to disease as patient walks on treadmill. Cuff Method 1. Elevate legs to 45° to drain venous blood. 2. Inflate wide thigh cuff to 30-50mmHg above brachial pressure. 3. Lower legs back to table and maintain pressure in thigh cuff for up to 5 minutes. 4. Obtain pressures upon release of cuff (may also obtain flow velocity). 5. Obtain pressures every 30 seconds until pressures return to baseline. NORMAL - Ankle pressure drops < 35% and returns to baseline within 1 minute. - Velocity of flow increases >100% from resting velocity when cuff released. ABNORMAL - Ankle pressure drops 35-50% = single level disease. - Ankle pressure drops >50% = multiple level disease. - 140ms, aortic disease is suspected While performing an arterial Duplex exam, you C: Upper Thigh 175mmH4g, Distal Thigh 120mmHg, obtain a triphasic waveform in the proximal femoral | Popliteal 110 mmHg, PTA 95mmHg artery but the mid segment of the femoral artery and the rest of the leg arteries demonstrate a monophasic waveform. The brachial pressure is 140mmHg. Which of the following lists the correct expected pressures from the four cuff segmental exam on the same patient? Condition Details Pressure Drop A drop in pressure >30mmHg between two adjacent segments indicates significant Significance disease in the artery between the two cuffs. Suspected If there is a suspected mid Superficial Femoral Artery (SFA) stenosis or occlusion, there will Condition be a significant drop in pressure between the two thigh cuffs. Aspect Details Waveform Findings - Triphasic in the proximal femoral artery (normal flow) - Monophasic in the mid-segment of femoral artery and distal arteries (indicates obstruction) Four-Cuff Segmental Measures pressures at different levels: Upper Thigh, Distal Thigh, Popliteal, and Exam Proximal Tibial Artery (PTA) Significance of A drop in pressure >30mmHg between two adjacent segments indicates significant Pressure Drop disease in the artery between the two cuffs Suspected Condition Mid Superficial Femoral Artery (SFA) stenosis or occlusion Correct Answer C: Upper Thigh 175mmuHg, Distal Thigh 120mmHg, Popliteal 110mmHg, PTA 95mmHg Reasoning Significant pressure drop from Upper Thigh to Distal Thigh indicates mid-SFA stenosis or occlusion a pt presents for a bilateral segmental pressure B. the patient most likely has reduced cardiac exam complains of mild leg pain output causing since their heart attack of last year the recorded pressures are follows: e the right ABI : 0.84 right arm: 110 mmHg e and left ABI 0.82 right PTA: 88mmHg right DPA: 92 mmHg leftarm: 105 mmHg left PTA: 90 mmHg left DPA: 94 mmHg the doctor orders a duplex exam to follow which shows medium velocity triphasic flow with minimal atherosclerosis in the bilateral arteries which of the following could explain the findings? Calculation of ABI The Ankle-Brachial Index (ABI) is calculated by dividing the highest ankle pressure by the highest arm pressure for each side. Here are the pressures given: e Right Arm: 110 mmHg e Right PTA: 88 mmHg e Right DPA: 92 mmHg e Left Arm: 105 mmHg e Left PTA: 90 mmHg e Left DPA: 94 mmHg The ABI is calculated as follows:. __ Highest Ankle Pressure (Right) 92 Right ABI = Highest Arm Pressure —~ 110 ~ 0.84 Left ABI — Highest Ankle Pressure (Left) __ 94 ~ 0.90 Highest Arm Pressure 105 Interpretation ¢ Normal ABI: 1.0 - 1.4 e Borderline ABI: 0.91 - 0.99 e Abnormal ABI (indicating PAD): < 0.90 e Severe PAD: < 0.50 The calculated ABls (0.84 for the right leg and 0.90 for the left leg) are slightly below the normal range but indicate borderline to mild Peripheral Arterial Disease (PAD).. 87. 9 years old presents with chronic fatigue A. There is most likely a coarctation of the and decreased palpable femoral pulses descending aorta. the ankle branchial index is performed with e the arm pressures are significantly higher following results than normal LT arm: 168 mmHg e the leg pressures are lower than normal LT ankle: 95 mmHg e the bilateral occurrence indicates an aortic Rt arm : 174 mmHg abnormality Rt ankle: 86 mmHg Key Points to Analyze in the Question Which of the following is the most likely Stem: explanation of the findings? 1. Patient's Age: © The patient is 9 years old, so congenital or structural abnormalities are more likely than conditions like atherosclerosis, which are typically seen in adults. 2. Symptoms: © Chronic fatigue: Suggests poor perfusion or oxygen delivery. > Decreased palpable femoral pulses: Indicates diminished blood flow to the lower extremities, pointing to an obstruction or narrowing in the arterial supply. 3. Ankle-Brachial Index (ABI) Results: e ABI is calculated as the ratio of ankle systolic pressure to arm systolic pressure. e Left ABI: 168 2°. = 0.57 (abnormal, indicating arterial insufficiency). ¢ Right ABI: 8& 174 — 0.49 (abnormal, indicating arterial insufficiency). e Both ABls are significantly below the normal range (>0.9), suggesting severe arterial insufficiency in both lower extremities. Condition Details Coarctation of the descending aorta Arm pressures Significantly higher than normal Leg pressures Lower than normal Bilateral occurrence Indicates an aortic abnormality Blood Pressure Values: e« High arm pressures (168 mmHg and 174 mmHg) with low ankle pressures (95 mmHg and 86 mmHg) indicate a pressure gradient, which is a hallmark of coarctation of the aorta. Pattern of Findings: ¢ The bilateral nature of the findings (both legs affected) and the pressure gradient between the upper and lower extremities suggest a systemic issue, such as coarctation of the aorta. Rationale for the Correct Answer: Answer: A. There is most likely a coarctation of the descending aorta. e Reasoning: 2° Coarctation of the aorta is a congenital condition characterized by narrowing of the aorta, typically distal to the origin of the left subclavian artery. © This narrowing results in: = High blood pressure in the arms (proximal to the narrowing). =» Low blood pressure in the legs (distal to the narrowing). =» Weak or absent femoral pulses. ° The described findings (high arm pressures, low ankle pressures, and reduced femoral pulses) match this condition. Why Not the Other Options? e B. Atherosclerotic vascular disease: Unlikely in a 9-year-old; this is more common in older adults. C. Subclavian steal syndrome: Involves blood flow reversal in the vertebral artery due to subclavian artery stenosis, leading to symptoms like arm claudication or dizziness —not systemic pressure gradients. D. Bilateral ABIs are normal: Clearly incorrect as both ABls are well below the normal range (>0.9). Approach to Answering: il Focus on age: Consider congenital or pediatric conditions first in a child.. Look for key clinical clues: Chronic fatigue, decreased femoral pulses, pressure gradient between arms and legs.. Use the ABI values: Calculate the ratios and identify the abnormality (severe arterial insufficiency). 4. Eliminate unlikely options: Based on the patient's age and clinical presentation. By systematically analyzing the stem and using clinical reasoning, you can confidently identify coarctation of the aorta as the most likely diagnosis.. A patient comes in late for his scheduled exam B. Have him rest for 20-30 minutes to allow flow in and states he walked to the facility after his car the legs to normalize. broke down. Registration passes him through to the vascular department and he is still e if the patient does not rest, slightly SOB. What is the first thing you should 2 the exercise from his long walk can do when starting his exam? affect the results of the expected resting arterial exam © this can lead to overestimation of the severity of the disease ° identified on the resting exam The following pressures were obtained in a RT: 0.98, LT : 0.94 patient with left claudication what are the ABI values for both legs? right : Right: 128 mmHg/130 mmHg PTA 128 mmHG = 0.98 DPA: 124 mmHg left: 122mmHg/ 130 mmHg Calf: 130 mmHg =0.94 Thigh: 140 mmHg Brachial : 130 mmHg To calculate ABI, you use the formula: LEFT: Ankle Pressure PTA: 98 mmHG ana Brachial Pressure DPA: 122 mmHg For the Right Leg: Calf: 126 mmHg Thigh: 138 mmHg e Ankle Pressure (PTA): 128 mmHg Brachial : 126 mmHg ¢ Brachial Pressure: 130 mmHg 128 ABI = — =0.9 130 For the Left Leg: ¢ Ankle Pressure (DPA): 122 mmHg ¢ Brachial Pressure: 130 mmHg 122 ABI = = ().94 130 These ABI values help assess the severity of peripheral artery disease (PAD). An ABI of 1.0 to 1.4 is considered normal, while lower values, such as 0.98 and 0.94 in this case, may indicate mild arterial obstruction, though they are still relatively close to normal. In summary: e Right ABI = 0.98 e Left ABI = 0.94 1. Right Leg ABI Calculation: e Right Ankle Pressure (PTA): 128 mmHg e Right Brachial Pressure: 130 mmHg e Right ABI: 128 / 130 = 0.98 2. Left Leg ABI Calculation: e Left Ankle Pressure (PTA): 98 mmHg (note: use the higher of PTA or DPA if not specified which to use; often DPA is used in clinical practice) e Left Brachial Pressure: 126 mmHg e Left ABI: 98 / 126 = 0.94 Final ABI Values: ® Right ABI: 0.98 e Left ABI: 0.94 Thus, the correct answer is B. RT 0.98, LT 0.94. Question:Which of the following exams does not B. PULSE VOLUME RECORDING use PW (Pulsed Wave) or CW (Continuous Wave) ° pulse volume recording is performed Doppler? using blood © pulse volume recording is performed using blood pressure cuffs to measure volume © changes under cuffs. The following pressure readings from a segmental B. neurogenic claudication pressure evaluation were obtained in a pt suffering from low back and e when lower extremity symptoms are caused thigh pain when walking which of the following by ambulation and the ABI exam is normal describes a possible reason for the pts symptoms? e the symptoms are called LT Ankle: 136 pseudoclaudication of neurogenic Rt Ankle: 128 claudication the most common cuase of Lt ARM: 124 pseudoclaudication due to Rt ARM: 120 e lumbar spinal stenosis a condition that occurs when the spaces narrow btnw the vertebrae in your lower back Instructor Feedback Explanation When lower extremity symptoms are caused by ambulation and the ABI exam is normal, the symptoms are called pseudoclaudication or neurogenic claudication. The most common cause of pseudoclaudication is due to lumbar spinal stenosis, a condition that occurs when the spaces narrow between the vertebrae in your lower back. Types of TOS (Thoracic Outlet Syndrome) Neurogenic TOS - Most common type (>90%) - Compression of the brachial plexus from cervical ribs, anterior scalene muscles, and ligaments - Causes paresthesia, numbness, and pain - Ultrasound evaluation will not identify the cause of the symptoms if only the nervous system is affected When evaluating arterial pressures in the toes, the C: supine patient should be: e arterial pressures should be evaluated with the pt supine to eliminate the effects of hydrostatic pressure. It is important to wait at least one minute B. Ankle blood pressure before repeating what measurement? When you are obtaining a blood pressure for a second time, it is important to wait at least 1 minute between cuff inflations. Pressure results may be inaccurate if the system is not given the opportunity to normalize after the first pressure measurement. NEVER perform a blood pressure assessment on an arm with a hemodialysis graft. Procedure Instructions Reason Taking a Blood Pressure for Wait at least 1 minute between Allows the system to normalize; prevents the Second Time cuff inflations inaccurate pressure results Blood Pressure Assessment Never perform on an arm with To avoid complications or inaccurate readings a hemodialysis graft due to the presence of the graft 99. Which of the following statements is true C. Prolonged venous refill time (>20s) indicates regarding a PPG exam for venous competent venous valves insufficiency? PPG: ¢ PPG sensors must be placed on areas of intact skin © tourniquets are used in conjuction with PPG exam to depict © the extent of venous insufficiency © longer VRT values are desired, © short refill times indicate reflux of venous outflow  Parameter Observation PPG Sensor Placement Must be placed on areas of intact skin Tourniquet Use Used in conjunction with PPG exams to depict the extent of venous insufficiency Desired VRT Values Longer VRT (Venous Refill Time) values are preferred Short Refill Time Indicates reflux of venous outflow Indication. 80 yr old female pt asks you to explain the D. tell her the exam uses blood pressures cuffs to purpose of a segmental pressure exam of the take her blood pressure in her legs to evaluate the lower extremities circulation to her feet. which of the following is best response? B. VASODILATION e resistance decreases in the capillary beds to allow an increase in flow volume with exercise ¢ normal arteriess do not demonstrate any change in pressue with exercise The pre and post-exercise pressure information displayed from the right leg demonstrates which of the following? Exercise Pressure Measurement Data: Exercise Pressure Measurement Data: Location Rest 1 2 R Ankle (PT) 149 88 125 L Ankle (DP) 170 96 131 138 162 Brachial 175 194 193 191 191 A) Single level stenosis Condition Pressure Return Time Single Level Obstruction Pressure Returns to normal 2-6 minutes post-exercise Multi Level Obstruction Pressure Returns to normal 6-12 minutes post-exercise Explanation: To determine the correct answer, we must analyze the changes in ankle pressures relative to the brachial pressure before and after exercise. ABI Calculation and Interpretation: e Resting ABI (Right Ankle): 14 Resting ABI = ee ~ 0.85 175 e Post-Exercise ABI (Right Ankle at time 1): Post-Exercise ABI = Ll ~~ 0.45 vn 194 When performing post-occlusive reactive D. Immediately After Cuff Release and every 30 hyperemia, pressure measurements in the seconds until pressures return to baseline lower extremities are obtained: levels e when performing post occlusive reactive hyperemia ¢ of the lower extremities e pressure measurements are obtained immediately after cuff release e and every 30 seconds until pressures return to baseline levels e recovery time is shorter for reactive hyperemia than treadmill testing. which of the following techniques can be used A. COLOR DOPPLER to assess the presence and timing of reflux in multiple vessels simulatenously? e a transverse view can demonstrate the GSV and one of its tributaries e color doppler with augmentation can demonstrate the presence e timing of reflux in both veins e this is very helpful in identifying recirculating reflux. (A) The waveform shown in Figure 4—56 is a classic e peaked pulse waveform where the dicrotic notch is higher than normal e and is commonly seen in patients with Raynaud's disease The waveform shown in Figure 4—56 is a characteristic waveform for which condition? While reviewing the segmental pressures on a pressure gradient >30 mm Hg indicates that patient you notice that the patient has a e there is disease present at or above the cuff right thigh pressure of 155 mm Hg and a right with the lower pressure. calf pressure of 90 mm Hg. e A pressure gradient >30 mm Hg between The patient’s brachial pressure is 120 mm Hg. the thigh and calf cuffs indicates femoral Based on just these findings, what level of popliteal disease. disease does this patient have The passage describes segmental pressure measurements in a patient's lower extremity and outlines the interpretation of these findings regarding the presence and level of arterial disease. Let's break it down: 1. Right Thigh Pressure: 155 mmHg 2. Right Calf Pressure: 90 mmHg 3. Brachial Pressure: 120 mmHg The key observation is the significant difference in pressure between the thigh and calf segments, with the thigh pressure notably higher than the calf pressure.  e The interpretation provided states that a pressure gradient greater than 30 mmHg between two segments indicates disease ¢ present at or above the cuff with the lower pressure. e In this case, the pressure gradient between the thigh and calf segments is substantial (155 mmHg - 90 mmHg = 65 mmHg), indicating a significant pressure drop from the thigh to the calf. e According to the provided interpretation, a pressure gradient exceeding 30 mmHg between the thigh and ¢ calf cuffs suggests the presence of femoral popliteal disease. e This type of disease affects the arteries in the upper thigh and behind the knee, leading to decreased blood flow to the calf and lower leg. e In summary, based on the segmental pressure measurements described, the patient likely has femoral popliteal disease, as indicated by the significant pressure gradient (>30 mmHg) between the thigh and calf segments. What is the first component that is lost on a PVR (C) The dicrotic limb is the first component that is waveform when arterial disease exists? lost ina PVR waveform when any arterial disease is present. Figure 4-57 shows a resting noninvasive arterial (C) Right mild iliac and moderate femoral examination of a 76-year-old patient with popliteal occlusive disease and left mild intermittent claudication bilaterally. femoral popliteal occlusive disease Based on the examination data below what is the extent of this patient’s disease?  VRE WS Vg Ly High Thigh TTT r——— Segmental BP ——— Segment/Brachiai Index 168 Brachial 176 0.50 Ankle/Brachiallndex 0.79 Here is the information from the images and explanations formatted into a tabular chart: Category Right Side Left Side High Thigh Pressure 166 mmHg, Segment/Brachial Index: 0,92 176 mmHg, Segment; Brachial Index 1,79 Low Thigh Pressure 162 mmHg, Segment/Brachial Index: 0.92 210 mmHg, Segment Brachial Index 1,79 Calf Pressure 150 mmHg, Segmeni/Brachial Index: 0.85 156 mmHg, Segment’ Brachial Index 1,77 Ankle Pressure a5 mmHg, Segment/Brachial Index: 3.46 147 mmHg, Segment’ Brachial Index: 0.64 Metatarsal Pressure 66 mmHg, Segment/Brachial Index: 0.50 139 mmHg, Segment’ Brachial Index 0,79 Pulse Volume Slight rounding and decrease in amplitude, Absent dicrotic notch Recording (P¥R) dampened waveform between low thigh and between low thigh and calf Waveform calf Interpretation Mild iliac disease (decrease in high thigh Mild femoral popliteal pressure) and moderate femoral popliteal disease (pressure drop > 30 disease (pressure drop > 30 mmHg between mmHg between low thigh low thigh and calf} and calf Conclusion Right mild iliac and moderate femoral Left mild femoral popliteal popliteal occlusive disease occlusive disease Explanation: e Right Side: o High Thigh Pressure: Slight decrease, suggesting mild iliac disease. o Pressure Drop between Low Thigh and Calf: More than 30 mmHg with a dampened PVR waveform, indicating moderate femoral popliteal disease. e Left Side: o Pressure Drop between Low Thigh and Calf: More than 30 mmHg with an absent dicrotic notch on the PVR waveform, consistent with mild femoral popliteal disease. (A) Aorta and bilateral severe iliac occlusive disease Option Analysis: Option Analysis: (B) Right mild femoral popliteal and mild tibial artery occlusive disease and left moderate iliac occlusive disease (C) Right mild iliac and moderate femoral popliteal e Option A: Option A: Aorta Aorta andand bilateral bilateral severe severe iliac iliac occlusive disease occlusive disease occlusive disease and left mild femoral popliteal occlusive disease ○ o Not Not consistent consistent withwith the data; there the data; there is is (D) Right severe iliac and femoral popliteal occlusive no evidence of severe iliac disease no evidence of severe iliac disease disease and left on both on both sides. sides. mild iliac occlusive disease e Option B: Option B: Right Right mild mild femoral femoral popliteal popliteal and and mild tibial mild tibial artery artery occlusive occlusive disease disease and and left left moderate iliac occlusive disease moderate iliac occlusive disease ○ o DoesDoes not not match match the pressure drops the pressure drops and waveform and waveform analysis analysis provided. provided. e Option C: Option C: Right Right mild mild iliac iliac and and moderate moderate femoral popliteal occlusive disease and femoral popliteal occlusive disease and left left mild femoral mild femoral popliteal popliteal occlusive occlusive disease disease ○ o Correct Correct Option: Option: Matches Matches the the findings: findings: m Right Right side side shows shows mildmild iliac iliac and moderate and moderate femoral femoral popliteal occlusive popliteal occlusive disease. disease. m Left Left side side shows shows mild mild femoral femoral popliteal occlusive disease. popliteal occlusive disease. e Option D: Option D: Right Right severe severe iliac iliac and and femoral femoral popliteal occlusive popliteal occlusive disease disease and and left left mild mild iliac iliac occlusive disease occlusive disease ○ o Not consistent Not consistent withwith the data; right the data; right iliac disease iliac disease is is mild, mild, notnot severe, severe, and and left iliac left iliac occlusive occlusive disease disease is is not not evident. evident. Conclusion: Conclusion: Option CC is Option is correct correct because because the the data data shows: shows: e Right mild Right mild iliac iliac disease disease (slight (slight decrease decrease in in high thigh high pressure) thigh pressure) e Right moderate Right moderate femoral femoral popliteal popliteal occlusive occlusive disease (pressure disease (pressure drop drop between between low low thigh thigh and calf) and calf) e Left mild Left mild femoral femoral popliteal popliteal occlusive occlusive disease disease (pressure drop (pressure drop between between lowlow thigh and calf thigh and calf with absent with absent dicrotic dicrotic notch notch onon PVR PVR waveform) waveform) This analysis aligns This analysis aligns with with the the interpretation interpretation of of the the segmental pressures segmental pressures and and pulse pulse volume volume recordings recordings provided in provided in the the images. images. what level of disease is present on the patient’s right side? Fem ] | | | ] | AA H | [air 294 15) (OPiowen ] 1.13} 171} var} | Gain: 239%) 157 [49 Post Tblat wt) mi Tit Gare S19) ob |0.38 122 DP) O20} Gaal ASI ‘A) Right iliac disease ‘B) Right femoral popliteal disease 'C) Right tibial disease ‘D) There is no disease present on the right side (C) Right tibial disease e The analog Doppler waveforms are multiphasic and bidirectional down to the popliteal level. ¢ Below that level in the posterior tibial and dorsalis pedis arteries the waveforms are monophasic e and unidirectional indicating tibial disease.. Anormal toe pressure is of the higher (C) 60% to 80% brachial pressure. e (C) Anormal toe pressure is 60% to 80% of the higher brachial pressure. Which statement is accurate related to blood (C) If the width of the blood pressure cuff is pressure cuff artifact? 30 mm Hg) between the right thigh and calf indicating femoral popliteal disease as well as a reduced systolic pressure ¢ and pressure index at the left thigh level indicating left iliac disease. Segmental BP Readings: e Right Side: © Brachial: 118 mmHg, Index not provided > Thigh: 151 mmHg, Index 1.24 > Calf: 100 mmHg, Index 0.82 » Ankle (PTA): 99 mmHg, Index 0.81 ° Ankle (DPA): 97 mmHg, Index 0.80 e Left Side: © Brachial: 122 mmHg, Index not provided © Thigh: 95 mmHg, Index 0.78 > Calf: 92 mmHg, Index 0.75 > Ankle (PTA): 96 mmHg, Index 0.79 © Ankle (DPA): 95 mmHg, Index 0.78 Differences and Interpretation: 1. Right Side: © Thigh to Calf: There is a significant drop in systolic pressure from 151 mmHg to 100 mmHg (a drop of 51 mmHg).  # LTS HlUICAales a PlovaviIe obstruction between the thigh and the calf, suggesting right femoral popliteal disease. 2. Left Side: ° Thigh to Brachial: There is a reduced systolic pressure at the thigh level compared to the brachial (95 mmHg vs. 122 mmHg). This indicates a significant drop in pressure at the thigh level. = This suggests an obstruction in the iliac artery, causing a reduced flow to the thigh. Conclusion: e Right Side: The significant drop in pressure from the thigh to the calf indicates right femoral popliteal disease. e Left Side: The reduced pressure at the thigh level indicates left iliac disease. Therefore, the correct option is: B) Right femoral popliteal disease and left iliac disease. This matches the explanation provided, highlighting the significant drops in pressure and their respective locations, indicating the levels of disease. What instrumentation uses infrared light that Photoplethysmography reflects off the red blood cells as they flow through the body to create a e Photoplethysmography uses infrared light waveform? that © reflects off the red blood cells as they flow through the body to create a © waveform and is typically used to obtain the digital waveforms and © pressures during a noninvasive assessment of the lower extremities An ankle-brachial index of 0.60 correlates with (C) Claudication which symptom? (A) Rest pain (B) Tissue loss (C) Claudication (D) Gangrene study that is positive for reflux will demonstrate a C) >0.5 second, flow reversal time of e A flow reversal time that exceeds 0.5 (A) 0.05 second (C) >0.5 second e the venous system is considered significant for reflux. (D) >0.005 seconds e There is some literature that allows e longer flow reversal times for the deep system due to the e large size of the veins and longer valve closure times. e A flow reversal time that e exceeds 1 second in the deep system would be e considered sianificant for reflux. Which of the following is an advantage of (B) Venous duplex is noninvasive , venous duplex over venography? Lower extremity venous duplex is a noninvasive, (A) Venous duplex uses ionizing radiation (B) Venous duplex is noninvasive painless examination that utilizes only sound (C) Venous duplex uses an iodinated contrast waves (ultrasound) agent to produce an image. There is no contrast (D) Venous angiography is painless needed as with venography. For these reasons ultrasound has become the preferred method of assessment for the lower extremity veins over venography and other modalities YOU ARE PERFORMING AN UPPER >. Obstruction of the distal brachial artery EXTREMITY SEGMENTAL PRESSURE =xplanation: EVALUATION AND THE OBTAIN THE e In anormal upper extremity segmental FOLLOWING INFORMATION: pressure evaluation, brachial : 140 mmHg e the pressures should gradually decrease as upper forearm: 132 mmHg you move distally along the arm due to the wrist- radial: 108 mmHg tapering of the arterial tree and resistance wrist- ulnar : 130 mmHg encountered. which of the following correctly describes the e In this case, the pressure drops significantly findings? between the upper forearm and wrist-radial A. obstruction of the mid radial artery measurements, B. obstruction of the mid ulnar artery e indicating an obstruction between these two C. obstructuon of the distal brachial artery points. D. subclavian steal e Since the pressure at the upper forearm (132 mmHg) is relatively close to the brachial pressure (140 mmHg), e it suggests that the obstruction is likely in the distal brachial artery, ¢ as opposed to the radial or ulnar arteries. e Therefore, option C, obstruction of the distal brachial artery, best describes the findings Condition Criteria Obstruction of the - Significant drop in pressure between upper forearm and wrist-radial Brachial Artery measurements in segmental pressure evaluation - Pressure at the upper forearm is relatively close to brachial pressure, suggesting obstruction in the distal brachial artery Conclusion - This indicates that the obstruction is specifically in the distal brachial artery the recommended sample size for PW doppler 1-1.5mm evaluation of an artery is? In a patient undergoing ultrasound evaluation Correct Answer: C. Adequate blood flow in the for peripheral arterial disease, if abnormal digit larger arteries proximal to the digits tracings are observed alongside normal ankle- ¢ Explanation: brachial indices (ABIs), what does this finding suggest about blood flow in the larger arteries 0 When abnormal digit tracings coexist with normal ABls, proximal to the digits? = it indicates a discrepancy in blood flow between the smaller arteries within the digits = and the larger arteries proximal to the digits. © Normal ABls suggest that blood flow in the larger arteries, such as the © femoral and popliteal arteries, is relatively normal. o Therefore, = the finding suggests that there is adequate blood flow in the larger arteries proximal to the digits, = despite impaired distal perfusion indicated by the abnormal digit tracings.  Correct Answer: C. Adequate blood flow in the larger arteries proximal to the digits Explanation: - When abnormal digit tracings coexist with normal ABls: - It indicates a discrepancy in blood flow between the smaller arteries within the digits and the larger arteries proximal to the digits. - Normal ABls suggest that blood flow in the larger arteries, such as the femoral and popliteal arteries, is relatively normal. - Conclusion: The finding suggests that there is adequate blood flow in the larger arteries proximal to the digits, despite impaired distal perfusion indicated by the abnormal digit tracings. During an upper extremity segmental pressure | Suspected disease of the left palmar arch or exam, the following pressures are recorded: ¢ Brachial: digital artery of the 3rd digit o Right 150 mmHg, » Left 140 mmHg e Radial: o Right 160 mmHg, o Left 155 mmHg e Ulnar: ° Right 155 mmHg, o Left 145 mmHg * 3rd digit: o Right 160 mmHg, ° Left 110 mmHg Which of the following best describes the interpretation of these findings?  e The reduced pressure in the left 3rd digit (110 mmHg) compared to the right 3rd digit (160 mmHg) suggests abnormal perfusion in the left hand. e Since the brachial, radial, and ulnar pressures are normal bilaterally, © the abnormal pressure in the left 3rd digit indicates localized disease, likely in the left palmar arch or digital artery of the 3rd digit. e Further evaluation of additional digits on the left hand is recommended to confirm if the © reduced pressure is limited to the single digit or > if there is more widespread disease in the left palmar arch. e Therefore, option A correctly describes the interpretation of the findings and outlines the subsequent steps for evaluation. Aspect Details Reduced Pressure The reduced pressure in the left 3rd digit (110 mmHg) compared to the right 3rd digit Observation (160 mmHg) suggests abnormal perfusion in the left hand. Brachial, Radial, and Normal bilaterally Ulnar Pressures Indication of Abnormal The abnormal pressure in the left 3rd digit indicates localized disease, likely in the left Pressure palmar arch or digital artery of the 3rd digit. Further Evaluation Recommended for additional digits on the left hand to confirm if: - Reduced pressure is limited to the single digit - There is more widespread disease in the left palmar arch. Conclusion Option A correctly describes the interpretation of the findings and outlines the subsequent. Question:In an upper extremity segmental Correct Answer: A. Suspected disease of the pressure exam, the following pressures are left palmar arch or digital artery of the 4th digit obtained: Explanation: e The reduced pressure in the left 4th digit (90 Brachial: mmHg) compared to the right 4th digit (130 » Right 130 mmHg, mmHg) suggests abnormal perfusion in the > Left 128 mmHg left hand. Radial: e Since the brachial, radial, and ulnar > Right 140 mmHg, pressures are normal bilaterally, the > Left 135 mmHg abnormal pressure in the left 4th digit Ulnar: indicates localized disease, > Right 132 mmHg, e likely in the left palmar arch or digital artery 2 Left 130 mmHg of the 4th digit. 4th digit: e Further evaluation of additional digits on the © Right 130 mmHg, left hand is recommended to confirm if the » Left 90 mmHg reduced pressure is limited to the single digit or if there is more widespread disease Which of the following best describes the in the left palmar arch. interpretation of these findings? e Therefore, option A correctly describes the interpretation of the findings and outlines the subsequent steps for evaluation.. Question:In an ankle-brachial index (ABI) Correct Answer: B. Left ABI: 0.86, Right ABI: calculation, the following pressures were 1.04 obtained: Explanation: To calculate the ABI, the higher of the Left Posterior Tibial Artery (PTA): 120 mmHg two ankle pressures (PTA or DPA) is divided by the Left Dorsalis Pedis Artery (DPA): 130 mmHg higher of the two brachial pressures (right or left Left Arm: 140 mmHg arm). Therefore: Right Arm: 135 mmHg e Left ABI: 130/140 = 0.93 Right Posterior Tibial Artery (PTA): 125 mmHg e Right ABI: 130/135 = 0.96 Right Dorsalis Pedis Artery (DPA): 130 mmHg What is the proper ABI calculation? Option B correctly represents the ABI calculation for the left and right sides, with a left ABI of 0.86 and a right ABI of 1.04. Question:You are performing an upper A. Suspected obstruction of the mid radial extremity segmental pressure evaluation for artery suspected obstruction of the mid radial artery. why it could indeed be interpreted as a mid radial During the examination, the following artery obstruction based on the provided data: pressures are recorded: e In a segmental pressure evaluation, * Brachial: 150 mmHg ea aignincant drop in Pressure between ¢ Upper forearm: 145 mmHg adjacent measurement points suggests arterial obstruction at the segment in e Wrist - radial: 130 mmHg between. e Wrist - ulnar: 140 mmHg e In this case, Which of the following best describes the > there is a notable decrease in interpretation of these findings? pressure between the Upper foreaim (145 mmHg) and the wrist-radial measurement (130 mmHg). © This pressure drop indicates compromised blood flow through the radial artery, suggesting an obstruction in the mid radial artery segment. e Given that the pressure drop occurs specifically at the radial measurement site, © it is reasonable to suspect an obstruction in the mid radial artery as the cause. © However, it's important to note that this interpretation relies on the assumption that collateral circulation from the © ulnar artery is not fully compensating for the reduced flow in the radial artery. Parameter Observation Brachial Pressure Normal Upper Forearm Pressure Normal Radial vs. Ulnar Pressure 22 mmHg difference Implication The vessel with the lower pressure has an obstruction proximal to the wrist. Condition Explanation Suspected Obstruction of In a segmental pressure evaluation, a significant drop in pressure between Mid Radial Artery adjacent measurement points suggests arterial obstruction at the segment in between. Pressure Drop Noted There is a notable decrease in pressure between the upper forearm (145 mmHg) and wrist-radial measurement (130 mmHg), indicating compromised blood flow. Interpretation Given that the pressure drop occurs specifically at the radial measurement site, it's reasonable to suspect an obstruction in the mid-radial artery as the cause. Assumptions This interpretation assumes that collateral circulation from the ulnar artery is not fully compensating for the reduced flow in the radial artery.. Question: B. Suspected obstruction of the mid ulnar artery You are performing an upper extremity segmental Here's why it is interpreted as a mid ulnar artery pressure evaluation for suspected obstruction of obstruction: the mid ulnar artery. During the examination, the 1. Pressure Drop: The drop in pressure from following pressures are recorded: the upper forearm to the wrist-ulnar ¢ Brachial: 140 mmHg measurement is substantial, indicating a e Upper forearm: 138 mmHg significant reduction in blood flow through e Wrist - radial: 130 mmHg the ulnar artery. e Wrist - ulnar: 110 mmHg 2. Site of Pressure Drop: Since the pressure drop occurs specifically at the ulnar Which of the following best describes the measurement site, it implicates an issue interpretation of these findings? within the ulnar artery itself, rather than the radial artery or another arterial segment. 3. Consistency with Anatomy: The ulnar artery is a major arterial supply to the forearm and hand, and a pressure drop in this segment suggests a localized issue within the ulnar artery. Given these considerations, it is reasonable to suspect an obstruction or impairment in the mid ulnar artery segment as the cause of the pressure drop. Question: During the examination, the e In the scenario provided, there is a following pressures are recorded: significant pressure drop between the upper forearm (145 mmHg) and the wrist-radial ¢ Brachial: 150 mmHg measurement (140 mmHg). e Upper forearm: 145 mmHg e This pressure drop suggests compromised e Wrist - radial: 140 mmHg blood flow through the arterial pathway ¢ Wrist - ulnar: 138 mmHg supplying the radial artery. e Given that the radial artery typically Which of the following best describes the branches from the brachial artery before interpretation of these findings? reaching the wrist, * a pressure drop at the radial site could imply an obstruction in the distal portion of the brachial artery, affecting blood flow to the radial artery. Here's why it could be interpreted as an obstruction of the distal brachial artery: 1. Pressure Drop: The drop in pressure specifically at the radial measurement site suggests a localized issue affecting blood flow through the radial artery. 2. Anatomical Considerations: The radial artery originates from the brachial artery, and a pressure drop in the radial segment could indicate an obstruction or impairment in the arterial pathway upstream, potentially in the distal portion of the brachial artery. 3. Consistency with Pathophysiology: Obstructions in the distal brachial artery can lead to compromised blood flow downstream, affecting arterial pressures in the radial artery. Given these considerations, it is reasonable to suspect an obstruction or impairment in the distal brachial artery as the cause of the pressure drop at the wrist-radial measurement site.  Scenario Description Details Significant pressure drop between upper forearm (145 Suggests compromised blood flow through the mmHg) and wrist-radial measurement (140 mmHg). arterial pathway supplying the radial artery. Radial artery typically branches from the brachial A pressure drop at the radial site could imply an artery before reaching the wrist. obstruction in the distal portion of the brachial artery. Interpretation of Distal Brachial Artery Obstruction Explanation 1, Pressure Drop The drop in pressure specifically at the radial measurement site suggests a localized issue affecting blood flow. 2. Anatomical Considerations The radial artery originates from the brachial artery, so a pressure drop in the radial segment could indicate an obstruction in the distal brachial artery. 3. Consistency with Obstructions in the distal brachial artery can compromise blood flow Pathophysiology downstream, affecting pressures in the radial artery.. During the examination, the following pressures D. Suspected subclavian steal phenomenon are recorded: Pressure Gradient: The pressure in the e Brachial: 140 mmHg brachial artery (140 mmHg) is higher than the e Upper forearm: 138 mmHg pressures measured in the distal arteries, such e Wrist - radial: 135 mmHg as the wrist-radial (135 mmHg) and wrist-ulnar e Wrist - ulnar: 140 mmHg (140 mmHg) measurements. Which of the following best describes the This pressure gradient suggests that blood interpretation of these findings? flow is being redirected away from the distal arteries, potentially due to steal phenomenon. 1. Location of Pressure Drop: The pressure drop is noted specifically at the wrist-radial measurement site, which is consistent with reduced blood flow in the radial artery. In the context of subclavian steal phenomenon, this pressure drop occurs because blood flow is diverted from the distal arteries to supply the vertebral artery, leading to reduced pressure in the affected arm  2. Clinical Correlation: Subclavian steal phenomenon typically occurs when there is significant stenosis or occlusion in the