Arterial Duplex What You Need To Know Michigan Society Of .
UNC REX HEALTHCAREArterial DuplexWhat You Need To KnowMichigan Society Of UltrasoundFem-Fem By- Pass RightLeft Superficial Femoral Artery Mid Aspect
UNC REX HEALTHCAREUNC Rex Heart and Vascular HospitalPeripheral Vascular Lab Team S. Wayne Smith M.D.,RVT,RDMS,FSVM,RVPIPatrick A Washko BSRT,RDMS,RVT,FSVURobert Mendes M.DBrian Stull, RDMS,RVTLauren Odom RDMS,RVTBrandy O’hara RDMS, RVSElvira Castellanos RDMS,RVTHillary Sawyer RVTLeah Gaydos, BS RDMS,RVTDarryl Smith RDMS,RVTLauren Littenden BS, RVTAnna Moore BS, RDMS,RVSJim Morgan MS, RVTLiliana Nanez M.D.RPVIDorian de Frietas M.D. ,RVPIJason Kim M.D. ,RVPIMartyn Knowles M.D. RPVIAaron Thomas, P.A.C, RVTSuman Wasan M.D. , RPVISharon Wertz RDMS,RDCS,RVSKelly Edwards RDMSDaniel Sherril RVTAnna Moore BS RDMS
UNC REX HEALTHCAREAlso Special Thanks Go Out To Wayne C. Leonhardt BA, RDMS, RVT Robert Mendes M.D Bob Scissions RVT,FSVU Wayne Smith M.D. RVT,RDMS, RPVI,FACP,FSVM
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UNC REX HEALTHCAREMy Ultimate Goal EverydayMake DuplexTheGoldStandard
UNC REX HEALTHCARE#1 Imaging Goal Is To Strive ToBe Gold Standard !
UNC REX HEALTHCAREGoalsProvide reproducible noninvasive procedureGather morphologic and physiologic data that defines the location of DiseaseQuantify hemodynamic significance of disease
UNC REX HEALTHCAREDuplex Implementation & SetupSmall Sample Size ( 1.5 mm )Compound (B-Mode Color) ImagingPRF High enough to prevent aliasingLow Wall Filter ( 50 Hz ) to display low flowMultiple focal zones to promote image enhancement
UNC REX HEALTHCARENormal Peak Systolic VelocitiesCM/SAorta80 25External Iliac119 22Common Femoral114 25SFA Proximal91 14SFA Distal94 14Popliteal69 14
UNC REX HEALTHCAREClassification of DiseaseNormalMild :Lipid DepositRepair / GrowthThrombosisSymptomatic; decreased pulses; bruitModerate : Asymptomatic at rest; claudication with stress; significant drop in ABI with stressSevere : Rest pain in feet and/or toes; poor wound healing; ulcer(s); tissue necrosis; gangrene
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for Peripheral Arterial Disease (PAD)Abnormal Criteria “Waveforms”OcclusionCommon Iliac Art Stenosis Proximal to an Occlusion; Low Velocity HighResistance ( monophasic/biphasic)Distal to an Obstruction; Low Velocity, LowResistance (monophasic)Acceleration Time 144 msec; proximal obstruction 75% Stenosis Iliac Artery (Delayed SystolicAcceleration) Low Velocity, Low Resistance(monophasic)Low Velocity High Resistance (proximal to an Occlusion)Tardus- Parvus CFA Waveform (Iliac Disease)Monophasic Distal to an ObstructionTechniques in Noninvasive Vascular Diagnosis, 2010
UNC REX HEALTHCAREInterpretation Criteria% StenosisPeak VelocityVelocity RatioNormal 150 cm/sec 1.5:130% - 49%150 – 200 cm/sec1.5:1 – 2:150% - 75%200 – 400 cm/sec2:1 – 4:1 75% 400 cm/sec 4:1OcclusionNo color Doppler
UNC REX HEALTHCARELower Extremity Arterial Duplex Imaging for Peripheral Arterial Disease (PAD)Abnormal Criteria “Velocity Ratios”% STENOSISPEAKVELOCITYVELOCITYRATIONormal 150 cm/sec 1.5:130%-49%150-200 cm/sec1.5:1 - 2:150%-75%200-400 cm/sec2:1 - 4:1 75% 400 cm/sec 4:1DenominatorOcclusionNo Color SaturationNumeratorJVS, 1989,10:522-529Rumack, In Diagnostic Ultrasound, 4th ed, 2011
UNC REX HEALTHCAREArterial Duplex Imaging CaseHistory: 64 yr old female, history of CAD, PAD, smokerPost intervention ABI .26 What is your diagnosis?Thrombosed SaphenousVeinOccluded SFAAVFOccluded insitu fem popgraftOccluded Graft
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for Peripheral Arterial Disease(PAD)Overview- Purpose- Overview of PeripheralArterial Disease (PAD)- Definition of Terms- Clinical Examples of PAD- Acute/Chronic Symptoms of PAD- Clinical Indications-Exam ComponentsPatient Preparation and Assessment (ABIexamination/limitations)- Instrumentation- Patient Position- Color Flow Imaging- Arterial Anatomy (Aorta/Iliac/Common/ SuperficialFemoral, Profunda/Popliteal/ Tibioperoneal Arteries
UNC REX HEALTHCARELower Extremity Arterial Duplex Imaging for Peripheral Arterial Disease(PAD)Overview (continued)- Imaging Technique and Procedure- Documented Images- Normal/Abnormal Diagnostic Criteria-Waveform Interpretation-Native/Synthetic Grafts & Stents-Examples of Lower Extremity Arterial Disease- Ancillary Findings- Technical Considerations- Limitations- Summary
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for PeripheralArterial Disease (PAD)PAD Overview:- Narrowing of blood vessels characterized by Atherosclerotic Occlusive Disease;inadequate perfusion to the lower extremity results in a non-healing wound,which often leads to infection, tissue loss, and amputation- Affects approximately 8 to 12 million Americans- Prevalence of PAD increases with age- 12%-20% of Americans age 65 plus (4.5 to 7.6 million) have PAD- Affects men and women equally- African Americans have a higher incidence than CaucasiansCirculation. 94:3026-3049, 1996
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for Peripheral ArterialDisease (PAD)PAD Overview Continued:- Atherosclerosis accounts for 90% of cases- Plaques tend to localize at the bifurcations or proximal segments, as well as in thedistal femoral and adductor canal segments in the lower extremities- Femoral/Popliteal Arteries are affected in 80%-90% of symptomatic PAD patients, theTibioperoneal Arteries in 40%-50%, and Aortoiliac Arteries in 30%- Diabetic patients develop lower extremity obstruction primarily in the Tibioperoneal ArteriesCirculation. 94:3026-3049, 1996
UNC REX HEALTHCAREDiagnosis of PAD increases risk for M.I. or CVA by 5 times
UNC REX HEALTHCAREArteriosclerosis At Junctional Regions Usually
UNC REX HEALTHCAREKnow Your Patient HistoryPathologyRisk FactorsPhysical SignsCurrent medications or therapiesResults of previous noninvasive studiesResults of previous vascular interventions
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for PeripheralArterial Disease (PAD)PAD Risk Factors:- Diabetes Mellitus- Cigarette Smoking- Increasing age (65 Years Plus)- Hypertension- Coronary Artery Disease- Family history of Cardiovascular DiseaseCirculation. 94:3026-3049, 1996
UNC REX HEALTHCAREOne Of The Many Reasons To Quit Smoking To Keep Your BulldogHappy And In Alignment
UNC REX HEALTHCAREPERIPHERAL ARTERIAL DISEASESymptomatic34%Asymptomatic66%Hiatt WR. N Engl J Med. 2001;344:1608-1621.
UNC REX HEALTHCAREPrevalence of PAD Increases with Age1Rotterdam Study (ABI 0.9)2San Diego Study (PAD by noninvasive tests)Percentage ofPatients with 9Age GroupFigure adapted from Creager M. Management of Peripheral Arterial Disease. Medical, Surgical,and Interventional Aspects. 2000.1 Criqui MH, Arnost F, Barret-Connor E, et al. Circulation. 1985;71:510-515.2 Meijer WT, Hoes A, Rutgers D, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-92.26
UNC REX HEALTHCAREBasic Starting Points Warm room temperature, especially if digit assessment is going to take placevasoconstriction may take place in digits if room 70 degrees Have patient rest a few minutes (3-5) before starting the examinationRecent ambulation can cause change in arterial waveform patterns
UNC REX HEALTHCAREEstablish An Algorithm Remember Patients Are #1 ConcernAnkle brachial indicesPVR/Segmental PressuresDuplexLevel of diseaseInsonate proximal
UNC REX HEALTHCAREPatient Positioning and PreparationPatients should take all scheduled prescription medications as usual, e.g.Heart, B/P, DiabetesNo Smoking (Vasoconstriction)Supine / Reversed TrendelenburgExternal Hip rotation; Knee flexedIf Prone—pillow under ankles foruse with Popliteal; Peroneal; PT
UNC REX HEALTHCARELower Arterial Duplex ImagingLimitationsObesity—visualization difficultiesWound incision tenderness, hematomaVessel wall calcification / acoustic shadowingOpen wounds, cast / dressings, skin staples, sutures
UNC REX HEALTHCAREThe Arterial Duplex Work Sheet“Old School”Communication
UNC REX HEALTHCAREProtocolAortaCommon / External IliacHypogastric (Internal Iliac)Common FemoralProfunda FemorisSuperficial FemoralPoplitealAnterior / Posterior TibialPeronealDorsalis PedisPlantar &/or Pedal Arch
UNC REX HEALTHCAREPopliteal ArteryBranches:Posterior tibial artery (largest)Anterior tibial artery (smallest)Geniculate branches collateral sourceEvaluate for aneurysm and Baker’s Cyst
UNC REX HEALTHCARECommon IndicationsEvaluation / Follow-up:-- Claudication-- Ischemic rest pain-- Ischemic ulcer(s)Evaluation of arterial traumaIntervention (surgery; PTA; stent) assessmentPost - intervention follow-up (BPG; PTA; stent)Evaluation for aneurysm; pseudoaneurysm; A-V
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for Peripheral Arterial Disease(PAD)Definition of Terms:- Intermittent Claudication; Muscle cramping, tightening,& burning pain produced duringexercise (walking) due to insufficient blood flow to the legs- Arterial insufficiency occurs with exercise –Pulses are detected at rest and disappearimmediately after exercise-Pain is relieved by stopping the exercise/walking and standing for 2-5 minutes-Patients describe muscular pain and cramping in the calves, thigh, and or buttocks-The site of Claudication is distal to the obstructed arterial segment ie Calf Claudication seenwith Femoral/Popliteal disease, thigh symptoms seen with Iliofemoral diseaseIntroduction to Vascular Ultrasonography, 2012
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for Peripheral Arterial Disease(PAD)Definition of Terms Continued:- Pseudoclaudication/Neurogenic Claudication; Term often used to describe leg symptoms (pain,numbness, weakness) in the buttocks, thighs, legs, and feet occurring with prolong standing orambulating that mimic true Claudication- Such symptoms are related to spinal, neurologic, orthopedic, or non-vascular etiologies ie.arthritis- Examples of such etiologies include; spinal stenosis, herniated lumbar disc, hypertrophicosteoarthritis of the lumbar spine and hip- Relief of pain usually 10 min, patients need to lie down, sit, or bend at the waist (positional) torelieve discomfortIntroduction to Vascular Ultrasonography, 2012
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for PeripheralArterial Disease (PAD)Definition of Terms:- Rest Pain: Critical ischemia (insufficient blood flow to tissues) of the distal limb when the patient isat rest (usually occurs at night), pain or tingling is so severe that the weight of bed sheets increasesthe discomfort- Pain is aggravated in the horizontal position- Pain is relieved by hanging the leg in a dependent position- Patients with ischemic rest pain present with asymmetric discomfort- Patients with peripheral neuropathy have pain in both extremities and the discomfort is notrelieved by dependencyIntroduction to Vascular Ultrasonography, 2012
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for PeripheralArterial Disease (PAD)Definition of Terms Continued:- Elevation Pallor/Dependent Rubor: Significant clinical signs of arterial insufficiency- Patients with rest pain or near critical ischemic flow reduction will manifest pallor (from pinkto pale) in fair-skinned people and to gray or ashen color in dark-skinned people of theplantar surface and toes upon elevation and rubor, (purplish-red hue) upon dependency. Theextremity is cool to the touch-Postural Assessment; (Normally the foot and leg should remain the same color with elevationand dependency) Feet are elevated above the head 60 degrees for 1 minute then placedsuddenly in a dependent position. Pallor within 25 seconds of elevation indicates severe Dz.Rubor that appears within 25-40 seconds indicates severe ischemia. If rubor disappears quicklywith elevation and returns in 25 seconds, consider reflux DzJDMS 20:5-13, Jan/Feb 2004
UNC REX HEALTHCARELower Extremity Arterial Duplex Evaluation for PeripheralArterial Disease (PAD)Definition of Terms Continued:- Gangrene: Critical limb ischemia resulting in localized areas of tissue death; common sites; toes,feet, fingers, hands- Usually appears in a toe as a focal blackened area; without treatment it may spread to other toesand eventually the foot and lower leg- Two major types “Dry and Wet” most cases of dry gangrene are not infected; all cases of wetgangrene considered to be infected- “Wet” gangrene results from an untreated infected wound- “Dry” gangrene caused by reduction of blood flow, tissue becomes cold and black, dries andeventually sloughs offIntroduction to Vascular Ultrasonography, 2012
UNC REX HEALTHCAREThe Ankle-Brachial Index (ABI) ABI measurement is the optimal method to detect PADInexpensive, accurate, and office-based– Provides an international standard, validated by angiographic detection, fordefining PAD prevalence– Predicts limb survival, propensity for wound healing, and short- and long-termpatient survival1,2 When is an ABI measurement indicated?– Presence or suspicion of claudication; pain at rest; or nonhealing foot ulcer– Age 70 years or 50 years with risk factors (diabetes, smoking)–et al. Atherosclerosis. 1991;87:119-128.2 Newman et al. JAMA. 1993;270:487-489.1 McKenna40
10090Survival (%)UNC REX HEALTHCAREABI: Predictor of Survival80ABI 0.85706050ABI 0.4-0.854030ABI 0.4200246810YearMcKenna M, Wolfson S, Kuller L. Atherosclerosis. 1991;87:119-128.41
UNC REX HEALTHCAREGo And Complete your Assessment With The Old Pocket Doppler
UNC REX HEALTHCAREANKLE-BRACHIAL INDEX Obtain bilateral brachial systolic pressures Acquire Doppler signals and pressures in the PTA,DP and Peroneal arteries Use the highest ankle and brachial pressures toobtain an ABIABI Highest ankle pressure(P T, DP, PERA)Highest brachial systolic pressureABI Scale (resting) 0.96 normal 0.95 abnormal 0.8 probable claudication 0.5 multi-level disease, or long segment occlusion 0.3 ischemic rest pain43
UNC REX HEALTHCAREANKLE-BRACHIAL INDEX Obtain bilateral brachial systolic pressures Acquire Doppler signals and pressures in the PTA,DP and Peroneal arteries Use the highest ankle and brachial pressures toobtain an ABIABI Highest ankle pressure(P T, DP, PERA)Highest brachial systolic pressureABI Scale (resting) 0.96 normal 0.95 abnormal 0.8 probable claudication 0.5 multi-level disease, or long segment occlusion 0.3 ischemic rest pain44
UNC REX HEALTHCARELimitations of resting ABI’s Diabetic tibial-peroneal calcification Elderly patient’s calcify also Renal failure patients
UNC REX HEALTHCAREAnkle Brachial IndexInterpretation – High ABI – Non-compressible vessels
UNC REX HEALTHCAREHigh ABI Spells Trouble ABI 1.3 is abnormalNon-compressible ABI’s65% increased risk of heart failure, CVASingular assessment vs Global
UNC REX HEALTHCARETOE PRESSURE Useful for evaluating small vesseldisease and when the larger vessels arenon-compressible Small cuff is placed around the base ofthe great toe and inflated until signalsdisappear Slowly deflate cuff until signals return Record pressure and calculateToe/Brachial IndexTBI less than 0.6648is considered abnormal
UNC REX HEALTHCAREPPG (Photoplethysmography) LED (Light Emitting Diode) Measures cutaneous blood content Infrared light from red blood cells in cutaneouscapillaries Warm room to prevent capillaries fromvasoconstricting (no smoking) Scission’s Research Study
UNC REX HEALTHCAREPPG PPG is a very useful diagnostic tool of choice to monitor digits perfusion. Contralateral comparison of digits are very important Also incorporate bilateral assessment on all patients when the situation allows.
UNC REX HEALTHCAREPHOTOPLETHYSMOGRAPHY NormalSteep acceleration with a notched reflected diastolic wave Mild diseaseSteep acceleration but a decreased rate of fall during deceleration Moderate diseaseSlower acceleration and marked slowing of deceleration Severe diseaseLoss of amplitude and pulsatility with no definable configuration51
UNC REX HEALTHCAREPPG Always compare contralateralflow parameters in any form ofduplex when questions exist! Any difference on right? Is this normal?RightLeft
UNC REX HEALTHCAREPPGRight NO! Note the abnormal perfusion seenbilaterally Minimal to no flow was seen in theright 2nd,3rd,4th and 5th digitsLeft
UNC REX HEALTHCAREToe/Brachial Indices Relationship of systolic pressure to prognosis for healing of skin lesions of the toes or feet Absolute Toe Pressure (mm Hg) Below 20 20 to 30 30 to 55 Above 55(%)Probability of healingNo diabetes Diabetes292573401008510097
UNC REX HEALTHCARERelationship to Peripheral Vascular DiseaseNormal: 0.97 to 1.25Normal: 0.80Mild:Claudication:0.75 to 0.96Moderate: 0.50 to 0.740.20 to 0.50Severe : 0.50Rest Pain: 0 .20Critical: 0.30
UNC REX HEALTHCARERun-off Disease Tibial vessels–Anterior Tibial Artery (Dorsalis Pedis) Anterior and lateral to tibia–Posterior Tibial Artery Posterior to medial malleolus–Peroneal Artery Lateral calf Non-healing ulcers (foot or lower leg) Diabetic patients
UNC REX HEALTHCARERun Off CalcificationLeft Posterior Tibial Artery
UNC REX HEALTHCARERigidity Of Calcified Wall vs Peripheral StentingRight SFA Stent
UNC REX HEALTHCAREDigital Artery Calcification
UNC REX HEALTHCAREHow Long Does It Take To Go To The Darn Hospital ? E.R. 53 year old Pain in his left foot for the past 1-2 months Been soaking feet in Epsom salts Uses Black Salve Couldn’t take odor nor appearance anymoreArthritis, Back pain, Cancer, HairGrowth, Erectile Dysfunction Etc.
UNC REX HEALTHCARELeft Lower Leg
UNC REX HEALTHCARELeft Foot
UNC REX HEALTHCAREPhysical Signs Chronic Cutaneous skin changes:- Hair loss- Shiny looking skin- Brittle, thickened, deformed nails- Exercise limiting activity due to limb pain
UNC REX HEALTHCAREPhysical Signs General Pulses diminished or absentIf pulse(s) “bounding” suspect aneurysmBruit can stenosis or arteriovenous fistula
UNC REX HEALTHCAREPathology ThrombosisAtherosclerosisThrombo-emboliSmall Vessel- Raynaud’s- Buerger’s Aneurysm ArteritisTraumaEntrapment- TOS- Popliteal
UNC REX HEALTHCAREPhysical Signs CriticalDependent RuborArterial UlcerLimb cooling; If ulcers—minimal bleedingLimb pallor with 2-3’ elevation—dependent rubor upon lowering limb below heart levelNight pain; Sleeping with limb in dependent position—arterial flow assisted by gravity
UNC REX HEALTHCAREPhysical Signs AcuteTypically thrombotic or embolic in originThe “P ’s”: Pain, Pallor, Paresthesias Pulselessness, Paralysis“THE” P sudden onset of ACUTE painLimb threatening—needs immediate attention tissue death can occur within 4 to 6 hours
UNC REX HEALTHCAREIs this Arterial or Venous disease ?
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UNC REX HEALTHCAREArterial or Venous ?
UNC REX HEALTHCARELeft External Iliac Artery
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UNC REX HEALTHCAREBasic LE Hemodynamics ( Normal)Triphasic BiphasicBiphasic, HyperemicNormal flow is laminar with multiphasic waveform Flow reversal due to high peripheral vascular resistance Reverse flow less prominent with decreased resistance due to vasodilatation, e.g. reactive hyperemia; warm limb
UNC REX HEALTHCARELower Artery AnatomyExternal IliacCommon FemoralProfunda FemorisSuperficial FemoralPoplitealAnterior TibialPosterior TibialPeronealDorsalis Pedis
UNC REX HEALTHCAREWhat is Normal? Waveform–60 degree angle (or less)–Quick rise time ( 144msec)–Clean spectral window–Triphasic Color–Smooth (laminar), No Aliasing–Forward and reverse components Gray Scale–Clean lumen–Smooth borders
AbnormalUNC REX HEALTHCARENormal
UNC REX HEALTHCARENormal Waveform
UNC REX HEALTHCAREMinimal Plaque InLower Arterial SystemLeft CFANormalAbnormal
UNC REX HEALTHCAREClinical Correlation Secondary imaging does not always provide significant insight Sometimes it does!!! Keep a folder of such events Q.A. Departmental education
UNC REX HEALTHCARELeft Foot
UNC REX HEALTHCARECloser Look
UNC REX HEALTHCAREArea ofConcern
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UNC REX HEALTHCAREThis is ReallyBLUE TOE SYNDROMEBlue –Footed Booby
UNC REX HEALTHCAREClinical History 48 year male 3 PPD smoker 35 years Left lower leg pain Twisted leg and felt pain and “ pop” Rural physician ( Rice treatment) 5 days Patient lives 1.5 hrs. away F/u apt 5 days could tolerate discomfort
UNC REX HEALTHCARELeft Common Femoral Artery
UNC REX HEALTHCARELeft Deep Femoral Artery ( Profunda)
UNC REX HEALTHCARELeft SFA Proximal Aspect
UNC REX HEALTHCAREArterial Duplex Pearl161cm/s62cm/s
UNC REX HEALTHCARECFA-SFA–DFA ( Profunda)SFABifurcation and SFA adductor canal level are common sites for development of PADProfunda Femoris Major collateral- Note disease severity for treatment optionsMay require lower frequency transducer at the distal thigh (adductor hiatus) level- Posterior approach may offer better view
UNC REX HEALTHCARETake Home In resting normal cases with no evidence of profunda stenosis ,the flow is seen istypically lower than that of the proximal SFA due to branch distribution. Take home note in this case the velocity difference in the mid SFA image thevelocity decrease along with the waveform breakdown.
UNC REX HEALTHCARERight Lower Digits
UNC REX HEALTHCARELeft Lower Digits
UNC REX HEALTHCAREQuestionWhat would one most likely expect tosee after seeing the image to theright?A.B.C.D.E.Acute DVTAortic AneurysmTakayasu’s ArteritisMultilevel arterial diseaseB and D
UNC REX HEALTHCAREBasics-Basics-BasicsArteries Bifurcate Before Veins
UNC REX HEALTHCARELeft Common Femoral Vein
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UNC REX HEALTHCAREPopliteal Artery Aneurysm
UNC REX HEALTHCAREWhat Else Should One Always Insonate ?
UNC REX HEALTHCAREContralateral Arterial SystemAlways check the contralateral CFA, ,Popliteal, Iliac andAbdominal Aorta
UNC REX HEALTHCARERight CommonFemoral Artery
UNC REX HEALTHCARERight CommonFemoral Artery1981982
UNC REX HEALTHCARERight CFA DissectionType B Dissection
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UNC REX HEALTHCAREArterial DiseaseIf present must be characterized by: Severity* Location*( Inflow - -Outflow - Run-off- Multilevel) Extent Etiology, when possible
UNC REX HEALTHCAREVisual Break
UNC REX HEALTHCAREEverything Is Not Alwaysat Is Appears .
UNC REX HEALTHCARE43 year old maleMy darn toes have been killing methe past 2 weeksNo cardiac disordersNo Migraine drug useQuit Smoking 20 years agoFarmer working in the field,Feet were wet and coldDid a little drinking after workAorta, CFA,SFA and Pop clean as a whistle.What you think is going on?Wild Turkey Induced Frostbite
UNC REX HEALTHCAREThis Past Week
Run Off and PoplitealUNC REX HEALTHCARE
UNC REX HEALTHCARENo Color FlowProximal SFA
UNC REX HEALTHCARESilent Doppler Flow
UNC REX HEALTHCAREArteriographyPrePTAPostPTATraditional gold standard for LE-PAD assessmentHowever: expensive, invasive, poor screeningtool and provides only anatomic(no hemodynamic) data
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UNC REX HEALTHCAREGiant Cell ArteritisGiant cell arteritis (GCA), the most common form of systemicvasculitis in adults, preferentially involves large andmedium-sized arteries in patients over the age of 50.
UNC REX HEALTHCARETransducer Selection5 MHz-- CFA, SFA, Profunda, Deep Tibial7.5 MHz-- Very superficial (near field) imaging2 to 3 MHz-- Aorta and Iliac-- 2 MHz best color, 3 MHz best Image
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UNC REX HEALTHCAREPVR and Segmental Pressuresvs. Duplex What's Better ?Why ?What's Faster ?What's Cheaper ?What's easier to understand ?
UNC REX HEALTHCARETechnique: PVRWaveform Technique Measures volume changes--changes in cuff volumereflect blood volume changes Air injected into PVR cuff at preset pressure Waveforms resemble intra-arterial pressure pulsecontoursLE Waveform Protocol Thigh cuff(36 x 18 cm) @ 65 mmHgCalf and AnkleTransmetatarsalDigit(s)(22 x 12 cm) @ 65 mmHg(12 x 7 cm) @ 65 mmHg(9 x 3 or 7 x 2 cm) @ 40 mmHg
UNC REX HEALTHCARETechnique: PVRPressure Technique Measures limb pressure (beneath cuff)-- Bernoulli Principle Bladder (20% wider than limb diameter)-- Too narrow: Falsely elevated pressures Limbs level with heart; 15' pre-exam rest Inflate (20-30 mmHg) above suprasystolic B/P-- Slow drop (2 - 4 mmHg / sec) until first beat LE Pressure Protocol:3 Cuff: Thigh (22 cm)Calf and Ankle – PT / DP (10-12 cm)4 Cuff: Upper/Lower Thigh Cuffs (11 cm)Calf and Ankle – PT / DP (10-12 cm)
UNC REX HEALTHCAREPVR vs. Duplex
UNC REX HEALTHCARENormalBilateral
UNC REX HEALTHCARENormal—RightFem-Pop—Left
UNC REX HEALTHCAREInflowBilateral
UNC REX HEALTHCARETechnique: Arterial DuplexTechnique Imaging:B-Mode; B-FlowImaging: Doppler: Color-Flow; PowerDoppler: Pulsed wave spectral analysesAppropriate probes/settings– yada, yada, yadaLE Protocols Aortoiliac to ankle levelCFA to ankle levelSite-specific level(s)Fem Pop distal PT/AT
UNC REX HEALTHCAREPVR ( Pressures) YES -- defines global limb perfusion and not vessel specific YES -- can not differentiate arterial stenosis vs. occlusion YES, YES, YES, YES -- Cheap, Quick, Simple, Reproducible Historically -- as accurate as duplex; ? Current accuracy YES -- exam pays less, but productivity & revenue potential YES -- waveforms affective with calcification; NO, not pressures Difficult to interpret -- not relatable to Doppler -- DependsDuplex YES -- Equipment costs more than PVR YES -- Duplex produce direct and PVR indirect assumptions YES -- Limited reliability with vessel calcification YES -- can localize region(s) of disease and severity YES -- more time consuming and technically challenging YES -- vessel specific; can differentiate stenosis vs. occlusion Accuracy similar to angiography -- Depends
UNC REX HEALTHCAREQuestions .
UNC REX HEALTHCAREThank YouPatrick A Washko BSRT,RDMS,RVT,FSVUTechnical DirectorRex Hospital ( UNC Rex Healthcare)Vascular Diagnostic CenterRaleigh, NCPatrick.Washko@Unchealth.unc.edu
The Ankle-Brachial Index (ABI) ABI measurement is the optimal method to detect PAD – Inexpensive, accurate, and office-based – Provides an international standard, validated by angiographic detection, for defining PAD prevalence – Predicts limb survival, propensity for wound healing, and short- and long-term patient survival1,2
What is the “Family” Lean Duplex SS – lower nickel and no molybdenum – 2101, 2102, 2202, 2304 Duplex SS – higher nickel and molybdenum - 2205, 2003, 2404 Super Duplex – 25Chromium and higher nickel and molybdenum “plus” – 2507, 255 and Z100 Hyper Duplex – More Cr, Ni, Mo and N - 2707
cleaner for use in all Duplex machines. Can be applied by trigger spray if using Duplex with Steam. 2 x 5ltr Hydrowash 2 x 5ltr Standard 280 280B 380B 340 420 620 Duplex Hydrofresh - Multi surface cleaner with urine neutraliser can be used in conjunction with Hydrowash. Can be applied by trigger spray if using Duplex with Steam. 2 x 5ltr .
ABI Interpretation 1.4: Falsely elevated 0.95-1.39: Normal 0.75-0.94: Mild arterial insufficiency 0.50-0.74: Moderate arterial insufficiency 0.50: Severe arterial insufficiency 15. PVR/Segmental Pressures Helps to identify levels of disease Compare to proximal segments and
Peripheral Arterial Disease (PAD) a disorder causing lower extremity arterial obliteration that limits blood flow to the limbs and may lead to arterial insufficiency Chronic Limb Threatening Ischemia (CLI) a state of arterial insufficiency m
activa de personas con hipertensión arterial no diagnosticadas o con riesgo de desarrollar la enferme-dad. Procedimiento para la detección las acciones de detección de la hipertensión arterial consisten en: A. la medición de hipertensión arterial se efectuará de conformidad con los procedimientos que a continuación se describen: 1.
improved corrosion performance in super-duplex welds practical aspects of welding for duplex and super-duplex stainless steels and overcoming challenges in corrosion testing . contents the challenge 3 abstract 4 introduction 5 welding challenges 6 experimental procedure 9 results 11
Welding duplex and super duplex stainless steels is similar to welding austenitic stainless steels; however, critical steps must be taken to maximize both corrosion resistance and mechanical properties. Where maximum results are necessary, such as in corrosive service applications, selecting the proper
Sonic Single Tube Rotary Duplex Rotary Percussive Duplex (Eccentric) Double Head Duplex Bentonite Polymer Self Hardening Rotary Percussive Duplex (Concentric) Stem Auger . Type I/II cement (ASTM C150/AASHTO M85), in bag or bulk
