1. Diagnostic Medical Sonography Program Vascular Technology
Holdorf
LECTURES 3 & 4 Part ONE
Arterial Testing
Signs, Symptoms, and Disease Mechanisms

2. Contents Arterial Testing Chronic occlusive disease
Acute arterial occlusion
Physical exam
Palpation (pulses and Aneurysms)
Bruits
Risk Factors
Mechanisms of disease
Non-Atherosclerotic Lesions
Doppler waveform analysis

4. Arteriosclerosis vs. Arteriolosclerosis vs
Arteriosclerosis vs. Arteriolosclerosis vs. Atherosclerosis What’s the difference?

5. Arteriosclerosis Arteriolosclerosis Atherosclerosis
The WHAT that Happens in Large to Middle sized Arteries
Arteriolosclerosis
The WHAT that happens in small arteries and arterioles
Atherosclerosis
THE HOW bad stuff happens in Large and Middle sized arteries
Formation of Plaque that causes an artery to LOSE COMPLIANCE

6. Arteriolosclerosis
HOW bad stuff happens in small arteries and arterioles
Hyaline/ Hyperplastic arteriolosclerosis
Caused by high blood pressure HTN
Malignant Hypertension (HTN)
Causes damage to the arterial wall

7. Arterial Testing
NOTE: It is important to obtain pertinent clinical history and lab values, findings or physical examination, and appropriate indication for testing to perform the study.
Essential to maintain a warm environment for the patient in order to permit warming (and peripheral dilation) to occur. An adequate amount of acoustic coupling gel is applied to the skin for all types of Doppler exams.

8. SIGNS AND SYMPTOMS I. Chronic occlusive disease Claudication
Ischemic Rest Pain
Tissue Loss

9. A. Claudication
Pain in muscles usually occurring during exercise (activity); subsides with rest
Results from inadequate blood supply to muscle
Discomfort is predictable and subsides within minutes after exercise (activity)
Level of disease usually proximal to location of symptoms.
Pseudo-claudication mimics vascular symptoms but is neurogenic or orthopedic in origin
NOTE: A patient may state: 4 block claudication. This means the patient complains of pain after walking 4 blocks.

10. Claudication

11. Necrosis or death of tissue Due to deficient or absent blood supply
B. Ischemic Rest Pain
A more severe symptom of diminished blood flow
Occurs when limb not dependent: Blood pressure decreases (such as when sleeping)
Affects forefoot, heel and toe
C. Tissue Loss
Necrosis or death of tissue
Due to deficient or absent blood supply

12. 2. Acute Arterial Occlusion
Symptoms include the 6 P’s:
Pain
Pallor: Pale color of the skin
Pulselessness
Paresthesia: Tingling, pricking, burning of the skin
Paralysis
Polar: Cold skin
May result from thrombus, embolism, or trauma
Emergency situation since the abrupt onset does not provide for the development of collateral channels

13. 3. Vasospastic Disorders
Raynaud's phenomenon: A condition that exists when symptoms of intermittent digital ischemia occurs in response to cold exposure or emotional stress
Changes in skin color may include pallor (whiteness), cyanosis (bluish color), or rubor (dark red color)
Primary Raynaud’s
Ischemia due to digital arterial spasm
Common in young women; may be hereditary, bilateral, history of symptoms for 2 years without progression/evidence of cause
Benign condition with excellent prognosis

14. Secondary Raynaud’s Also known as obstructive Raynaud’s syndrome
Normal vasoconstriction responses of arterioles superimposed on a FIXED artery obstruction. Ischemia constantly present.
May be the first manifestation of Buerger’s disease
Buerger’s Disease
Inflammation and thrombosis in small and medium-sized blood vessels, typically in the legs and leading to gangrene. It has been associated with smoking.

15. 4. Physical Exam Skin Changes Color
Pallor: result of deficient blood supply: Skin Pale
Rubor: Suggests dilated vessels or vessels dilated secondary to reactive hyperemia: skin is reddened
Cyanosis: A concentration of deoxygenated hemoglobin, causes bluish discoloration.
Reactive Hyperemia: The transient increase in organ blood flow that occurs following a brief period of ischemia (e.g., arterial occlusion).

16. C. Lesions (Will refer more to this in the Venous Lecture)
b. Temperature
Touch patient’s skin to determine warm/cold
Utilize skin thermometer to document precisely
C. Lesions (Will refer more to this in the Venous Lecture)
Ulcerations located: tibial area, foot, toes
Deep and more regular in shape
Quite painful as compared to venous ulcers
Duration of ulcer(s) is important (i.e., days, weeks)
Gangrene: Death of tissue; usually due to deficient or absent blood supply

17. e. Elevation/Dependency changes
d. Capillary filling
An increase in the capillary refill time denotes decreased arterial perfusion.
e. Elevation/Dependency changes
Pallor during elevation and ruborous red discoloration with dependency (dependent rubor)

18. Pallor during elevation: Elevation Pallor in a patient with severe peripheral arterial disease

19. Dependent Rubor

20. Palpation (Pulses, Aneurysms)
Rhythmic throbbing of artery in time with heartbeat signifies adequate circulatory status. Diminished/absent pulse suggests arterial insufficiency
Grading pulses on a scale of 0 (none) – 4+ (bounding) is fairly standard.
Aneurysms can be palpated and described as bounding

21. Palpation (Pulses, Aneurysms) continued:
Palpable “vibration” or “thrill” over pulse site may indicate a fistula, post-stenotic turbulence, or a patent dialysis access site.
FISTULA: An abnormal connection between 2 body parts: two hollow or tubular organs.
Palpable Pulses:
Aorta, femoral, popliteal, dorsalis pedis (DPA), posterior tibial (PTA)
The peroneal artery is not palpable

22. Auscultation (Bruits)
Bruit auscultation is more often done with carotid examination
Other than stethoscope use for carotid vessels and heart, additional sites include:
Aorta
Femoral
Popliteal arteries
Additional details regarding bruits will be discussed in the cerebrovascular testing lecture

23. Risk Factors for Arterial Disease
Diabetes
Atherosclerosis: more common: Occurs at a younger age
Higher incidence of disease: distal Pop and tibial arteries
Medial calcification develops in Lower Extremity arteries
Poor sensation (neuropathy) may lead to increased injury
Higher incidence of gangrenous change, amputations

24. Hypertension Unclear whether high blood pressure is a causative factor or enhances the development of the atherosclerotic process. Systemic hypertension is associated with greater incidence of coronary atherosclerosis. Increased BP taxes the heart Hyperlipidemia Elevated plasma lipids closely associated with development of atherosclerosis Frequent Cause: Diet high in animal fat; metabolic problems associated with heredity. Smoking Studies suggest the chemicals in cigarettes irritate the endothelial lining of vessels, causing vasoconstriction Others (not controllable): Age, Family History

25. Mechanism of Disease Atherosclerosis (Obliterans)
Most common arterial pathology: thickening, hardening, loss of elasticity of artery walls.
Changes occur in intima and media layer of the vessel
MAJOR RISK FACTORS: smoking, hyperlipidemia, family history.
Less important factors: Hypertension, diabetes, sedentary lifestyle, and arterial wall shear/stress.
Most common sites:
Carotid bifurcation
Vessel origins
Infra-renal aortic-iliac system
Common Femoral Artery Bifurcation
Superior Femoral Artery at the adductor canal level
Trifurcation region

26. Embolism Obstruction of vessel by foreign substance or blood clot
Emboli may be solid, liquid, or gaseous; may arise from the body or enter from without.
Most frequent cause: Small plaque breaks loose (e.g. atherosclerotic lesion, arteritis, or angiographic procedure) and travels distally until it lodges in small vessel.
Example: Blue toe syndrome. Toe ischemia results.

27. Aneurysm: True Aneurysm is dilatation of all three arterial wall layers; Examples are: Fusiform = diffuse, circumferential dilatation Saccular = localized out-pouching

28. Fusiform/Saccular

29. Dissecting aneurysm occurs when a small tear of the inner wall allows blood to form a cavity between two wall layers. Often occurs in the thoracic aorta.

30. Pseudoaneurysm: Results from a defect in main artery wall (e. g
Pseudoaneurysm: Results from a defect in main artery wall (e.g.,) post catheter insertion). Must be a channel communication from main artery to pulsatile structure outside vessel walls.

31. Most common location of a true aneurysm is infra- renal aorta
Most common location of a true aneurysm is infra- renal aorta. Other locations include: Thoracic aorta, femoral, popliteal, renal
Patients with one aneurysm have higher incidence of 2.
More often of the CFA or popliteal Artery as opposed to elsewhere.
Cause unknown?? Poor nutrition, congenital defect, infection, or atherosclerosis.
MOST FREQUENT COMPLCATION OF ANEURYSM:
Rupture of the aortic aneurysm: embolization of the peripheral aneurysms. NOTE: Both types can accumulate thrombus inside.

32. Non-Atherosclerotic Lesions
Arteritis
Can affect tibial and peroneal arteries, as well as the smaller more distal arterioles and nutrient vessels
Inflammation of arterial wall leads to thrombosis of vessel
Type: Buerger’s disease (thromboangitis obliterans)
Associated with heavy cigarette smoking
Occurs primarily in men <40 years old
Patients present with occlusions of distal arteries
Rest pain and ischemic ulceration present

33. Coarctation of the aorta
One of several congenital anomalies of the arterial system
Congenital narrowing or structure of thoracic aorta, but may affect abdominal aorta
Clinical findings:
Hypertension due to decreased kidney perfusion
Manifestations of Lower extremity ischemia (e.g., decreased pulses and or segmental pressures)

34. Coarctation of the aorta Note: just distal to the origin of the Left Subclavian artery

35. Dissection Can affect aorta and peripheral arteries
Distinguishing ultrasound feature: Thin membrane dividing the arterial lumen into 2 compartments
Media is weakened; intima develops tear through which blood leaks into the media (false lumen)
Flow velocities differ in each lumen
Aortic dissections which can extend to iliacs, may occur consequent to hypertension or severe chest trauma
Complications: stenosis, occlusion, or thrombosis
Death from rupture of the aortic dissection can occur. Ultrasound thought to be extremely important in diagnosis
Vasospastic disorders: Future lecture
Entrapment Syndrome: Future lecture

36. Aortic Dissection

37. General Considerations for Interpretation
VERY IMPORTANT
General Considerations for Interpretation
Include clinical indication(s) for exam
Adequate description of the exam performed
Description of positive as well as negative findings
Characterization of the disease
Reasons for a technically limited or incomplete exam
Comparison with previous studies if applicable or possible
Identification of the technologist/sonographer who performed the exam
Preliminary findings provided according to protocol