Test #4 Review - Arterial Lower and Upper Extremities Daigle and Davies

CDI

Color Duplex Imaging

True or False: CDI can be used to identify the exact anatomical location of arterial occlusive disease

true

high pressure extravasation of blood out of an artery and into the surrounding tissue

pseudoaneurysm

What segments of the lower extremities should be imaged before attempting to scan the aorto-iliac segment?

femoral-popliteal segments

for lower extremities, select a transducer based on patient ________. A _________ transducer. Or in thin patients, a ______ may work.

body habitus; 2.5-3.5 curved array or phased array; low-frequency flat linear array

There are three scanning "zones" along the length of the iliac arteries. The first zone is usually seen on most patients. Which zone is the most difficult to interrogate?

the second zone (with the distial CIA, the IIA and the EIA)

The normal spectral waveform in the distal aorta and iliacs is ________ and similar to that found in the _________.

triphasic; femoral artery

What is the most reliable indicator for the presence of a 50% or greater stenosis aortoiliac segment?

2:1 systolic velocity ratio with focal velocity acceleration (twice as fast flow) and post stenotic turbulence

What are the most common segments for arterial occlusive disease in the lower extremities?

common femoral; superficial femoral; popliteal

when identifying the common femoral artery and common femoral vein in transverse at the inguinal ligament, where does the vein lie?

medial to the artery

the demarkation point where the EIA ends and the CFA begins is the ________. Can you see it in the ultrasound image?

inguinal ligament; nope

what type of waveform in the femoral popliteal segment would indicate iliac disease?

low amplitude, delayed rise time (>144 msec), or turbulence

CFA waveform with tardus parvus could indicate

distal aortic stenosis; iliac disease

what would this process help you do:
if there is no detectable flow in the segment, identify collateral runoff proximally, follow the segment distally using the vein as a guide, and identify the region of inflow/reconstitution.

estimate the length of an occlusion (find the beginning and end)

the ________ at the adductor canal is difficult to evaluate and frequently the site of atherosclerotic disease.

distal SFA

What acceleration time (AT) in the distal external iliac artery (or CFA) suggests significant iliac disease (greater than 75% diameter reduction)

greater than 144 msec

velocity acceleration over a stenotic lesion that achieves a 2:1 systolic ratio and is followed by post-stenotic turbulence indicates what?
This is in the lower extremity chapter

50% or greater stenosis

what is the velocity ratio?

velocity proximal to the stenosis divided by the maximum stenotic velocity

criteria for SFA-Popliteal stenosis:
Normal

PSV <150 cm/s; Velocity Ratio 1.5:1

criteria for SFA-Popliteal stenosis:
30-49%

PSV 150-200 cm/s; Velocity Ratio 1.5:1-2:1

criteria for SFA-Popliteal stenosis:
50-75%

PSV 200-400 cm/s; Velocity Ratio 2:1-4:1

criteria for SFA-Popliteal stenosis:
>75%

PSV >400 cm/s; Velocity Ratio >4:1

True or False: It is uncommon to find retrograde flow in the profunda femoris artery to supply the SFA in the event of a CFA occlusion.

false: common.

True or False: it is common to find reversed flow in the internal iliac artery to feed the external iliac artery

true

which lower extremity arteries are difficult and time consuming to study in patients with atherosclerotic occlusive disease?

posterior tibial; peroneal; anterior tibial

first branch of the popliteal artery

anterior tibial artery

the popliteal bifurcates into the

first the anterior tibial and tib-pero trunk; the tibial-peroneal trunk bifurcates into the peroneal and posterior tibial artery

flow direction INTO the tibial artery most likely represents

reconstitution distal to occlusion

use _____ as landmarks. From chapter on lower extremeties

paired veins

begin the scan of the posterior tibial artery just posterior to the ______ and follow the artery proximally along the course of the ______.

medial malleolus; tibia

occluded segments of the tibial artery should be noted and confirmed by what?

presence of collateral outflow and inflow

what divides the ATA from the DPA?

ankle crease

In a transverse view, the ATA will lie just above the ________ that courses _________. The peroneal artery is ________.

interosseous membrane; between the tibia and fibula; deeper than the membrane

popliteal artery aneurysms:
If thrombosed, what is the amputation rate?
How often bilateral?
Likelihood of AAA in these patients?

40-75% amputation; 50-70% bilateral; 43% AAA

symptoms of popliteal artery aneurysms:

claudication; rest pain; limb ischemia; blue toe; nerve compression/pain

true or false: a pseudoaneurysm has no arterial wall encapsulating the aneurysm

true

what flow pattern usually exists in the pseudoaneurysm neck?

a "to and fro" flow pattern

Causes of pseudoaneurysm

percutaneous arterial catheterization; penetrating trauma; graft anastomosis "blowout

Why does blood flow back in the artery during diastole (in a pseudoaneurysm)?

the pressure in the pseudoaneurysm is higher than in the artery during diastole, so it flows to where the pressure is lower

arterialized venous flow can be seen when?

arterio-venous fistula

P-an

pseudoaneurysm

CABG

coronary artery bypass graft

what veins are used as arterial conduit for CABGs?
Or to revascularize leg with a femoro-popliteal or femoro-tibial bypass graft?
What arteries:

saphenous veins; superficial cephalic veins; basilic veins;
radial or ulnar artery

When scanning the arms, note the position of the ___________. It is important to know if it is in the ______ or if it bifurcates higher in the arm.

brachial artery bifurcation into the radial and ulnar arteries; antecubital fossa

what provides collateral pathway so that the entire hand and all digits can be perfused by either the ulnar or radial artery?

the palmar arches

goal of palmar arch test (Allen test)?

confirm patency of the arch

The test for palmar arch patency can be performed with

an Allen test

The Allen test for Palmar arch patency is performed with what physiologic testing devices?

Photoplethhysmography (PPG) sensors placed on thdumb or index finger and the 5th digit

3 Above Inguinal Ligament Grafts

1. Aorto-bifemoral graft;
2. Femoral to femoral "jump" graft;
3. Axillo-femoral, fem-fem bypass

which above inguinal ligament graft is used to bypass a diseased distal aorta and/or iliac arteries?

aorto-bifemoral graft

what scars will a patient have with an aorto-bifemoral graft?

a scar near the umbilicus and one in each groin region

what graft is used to bypass a single iliac artery?

a femoral to femoral "jump" graft

what is the intended flow direction with a femoral to femoral "jump" graft?

should be from asymptomatic leg to preoperative symptomatic leg

what scars are expected with a femoral to femoral "jump" graft?

scar at each groin

which graft is used to bypass the abdominal aorta?

axillo-femoral, fem-fem bypass

what is the proximal anastomosis for the axillo-femoral, fem-fem bypass?

axillary artery

autogenous

made by or from one's own tissues

with the in situ fem-pop or (fem-tibial) vein graft the procedure uses the ________ for arterial conduct. The valves are _______.

great saphenous vein (GSV); excised

in what procedure is the GSV removed, turned upside down and sewn back in? The valves are not removed or excised as in the in situ method.

reversed vein graft

a significant number of bypass grafts are performed for

limb salvage

if a graft occludes, a thrombectomy is usually performed to restore patency. However, there is a ______% re-occlusion rate.

50-80%

Scan Method for Bypass Grafts:
Obtain ABIs and ankle PVRs or Doppler Waveforms and compare to _________; A drop of ________ in the ABI from the previous exam suggests progressive graft stenosis.

previous exams; 0.15

Scan Method for Bypass Grafts:
Use image, color, and spectral Doppler to evaluate:
1. Graft ______.
2. The entire graft lumen for: stenosis, wall irregularity, aneurysums, pseudoaneurysms (graft blow out), A-V fistulas from non-ligated perforators, and __

inflow; valve leaflets; stenosis; defects; neo-intimal hyperplasia; seroma; profunda femoris

the most common cause for restenosis with an arterial bypass graft using a vein?

neo-intimal hyperplasia

***Your patient undergoes carotid endarterectomy. Six months later angiography is performed because of symptoms referable to the other side. The angiogram reveals that the operated carotid is significantly narrowed. The most likely cause is:

Neo-intimal hyperplasia (rapid proliferation of intimal cells causing wall thickening and lumen encroachment)

vein grafts often develop ______ due to the shear stress of arterial flow on a thin vein wall.

neo-intimal hyperplasia

blood flow in the aortic arch flows

clockwise

Arm Arteries

axillay; brachial; interosseous; radial; ulnar

indications for upper extremity arterial evaluation:

arterial insufficiency; weakness in the arm; thoracic outlet syndrome; vasospastic disorder (digital cold sensitivity); digit ischemia; abnormal vertebral artery waveform; preoperative assessment (hemodialysis access or radial artery harvest for coronary

preoperative assessments for arterial upper extremities include

hemmodialysis access and radial artery harvest for CABG

contraindications for arterial evaluation of the upper extremeties

no arm pressure measurements on an arm with a hemodialysis access

you can't take arm pressure measurements on an arm with a hemodialysis access. What is okay?

PVRs, with reduced inflation pessure, or Doppler waveforms

weakness in the arm is a sign of

obstruction on that side

Disease processes that may indicate the need for an arterial upper extremity exam include:

large vessel occlusive disease; thoracic outlet syndrome; small vessel occlusive disease (fixed); small vessel occlusive disease (vasospastic disorder); Raynaud's phenomenon

Of the upper extremities, atherosclerotic obstruction occurs predominantly where?

subclavian and innominate

true or false: the axillary, brachial, radial, and ulnar arteries are likely to be involved with large vessel occlusive disease

false - less likely (subclavian and innominate are likely)

autoimmune disorders that affect the aortic arch and proximal vessels in young to middle-aged females of Asian descent.

Takayasu's and giant cell arteritis (Large Vessel Occlusive Disease)

what upper extremity arteries may be involved in Takayasu's and giant cell arteritis (Large Vessel occlusive disease)

brachiocephalic, subclavian, and left common carotid

what bilateral brachial systolic pressure gradient suggests subclavian artery disease (or possibly innominate if on the right) on the side with the lower pressure?

greater than or equal to 20 mmHg

subclavian stenosis/occlusion is diagnosed by comparing

bilateral brachial systolic pressures. A greater than or equal to 20 mmHg gradient suggests stenosis/occlusion on the side with the lower pressure.

Right Brachial Pressure: 145 mmHg
Left Brachial Pressure: 115 mmHg
What would this indicate?

subclavian stenosis or occlusion (30 mmHg difference)

acute obstruction of the distal arteries caused by emboli from subclavian artery disease, proximal aneurysm, or the heart;
What does the site of obstruction depend on?

thromboembolism; the size of the embolus relative to the size of the artery

intermittent pain, numbness, or weakness of the arm(s) related to arm position may indicate:

thoracic outlet syndrome (TOS)

TOS is caused by compression of the _____ or ______ by the _________ muscle, clavicle, rib, or congenital muscular anomalies.

artery; nerve; anterior scalene muscle

TOS is common in ______.

body builders

what percent of TOS is neurogenic (rather than due to compression of the artery)

95%

what percent of symptomatic TOS is caused by compression of the subclavian or axillary arteries?

less than 5%

TOS may cause

thrombosis, fibrosis, and aneurysm of the subclavian or axillary arteries.

small vessel occlusive disease - fixed - includes:

Buerger's disease (thromboangiitis obliterans) and Thromboemboli

another name for Buerger's disease

thromboangiitis obliterans

inflammatory condition of the palmar arch and/or digital arteries.

Buerger's disease (thromboangiitis obliterans)

Buerger's disease is found most often in whom?

male smokers

small emboli that occlude the arteries of the hands and digits

thromboemboli

small vessel occlusive disease (vasospastic)

Raynaud's Phenomenon

Raeynaud's Phenomenon is episodic, prolonged, _________ brought about by cold exposure, ________, emotion, or occupational trauma. The toes can also be affected.

digital vasospasm; chemicals (nicotine)

Which form of Raynaud's disease has no underlying cause. The digital and palmar arteries are without obstruction, and perfusion to the digits at rest is normal

Primary (Raynaud's Disease)

Which form of Raynaud's disease is associated with an underlying autoimmune disease or connective tissue disease. The digital/palmar arteries often have fixed obstruction

Secondary Raynaud's (Syndrome)

In secondary Raynaud's (syndrome) even a normal vasoconstrictive response to cold can cause

severe transient ischemia

which autoimmune conditions are associated with secondary Reynaud's (syndrome)?

lupus, scleroderma, rheumatoid arthritis

Symptoms of Raynaud's include _______ of digits during vasospasm, followed by ________ and _______ upon release of the spasm.

pallor; cyanosis; rubor

How long might the spasm take to release in Reynaud's?

10-30 minutes

what percent of Raynaud's phenomenon cases occur in females?

70-90%

what percent of Raynaud's cases are related to connective tissue disorders (scleroderma, lupus, rheumatoid arthritis)?

40%

What percent of Raynaud's are idiopathic?

40%

What percent of Reynaud's cases are caused by other etiology such as frostbite or repetitive vibration

20%

Treatment for Reynaud's includes:
sympathetic blocking agents; treat associated disease; cervico-thoracic sympathectomy;
What else?

stop smoking; avoid cold/stress; calcium channel blockers (Procardia, Nicardipine); micro-revascularization; relocation to warm climate

PVR

pulse volume recording

After the baseline study (segmental pressures and PVRs or PPGs), obtain a waveform with one of the following methods to serve as a baseline reference for positional THORACIC OUTLET TEST (TOS)

PPG on index fingers; PVRs of arms; CW-Doppler tracings from radial or ulnar arteries

After obtaining a waveform to serve as a baseline reference for positional TOS study, obtain tracings from both arms in following arm positions:

abducted 90 degrees to torso; elevated 180 degrees above head; pledge position (first with head turned toward, and then away, from the hand); "Stick-Up" position; symptomatic position

what exam is essential prior to radial artery harvest for coronary artery bypass surgery and prior to ipsilateral hemodialysis fistula or graft implantation

Allen test for Palmer Arch Patency

If the radial artery is removed in a patient that is radial dominant and if the palmar arch is not intact, what may result?

severe ischemia in the fingers and hand

what should be performed on all fingers prior to the Allen test?

a standard resting digit exam

Allen test may be performed ________ or with monitoring devices (______, _______, or _______) on the thumb and index finger.

manually without instrumentation; PPG: PVR: digit pressures

absence of capillary refilling during an Allen test suggests what?

an occluded palmar arch or radial/ulnar dominance

Signs and symptoms of chronic occlusive disease

Claudication, ischemic rest pain, tissue loss (necrosis)

signs and symptoms of acute arterial occlusion

The 5 Ps: pallor, pain, pulselessness, paresthesia, paralysis, polar, purplish

Pain in muscles occurring during exercise but subsiding with rest

claudication

True claudication results from inadequate blood supply to the exercising muscle, which may be caused by any of or a combination what 4 things?

arterial spasm; atherosclerosis; arteriosclerosis; occlusion

various types of claudication include

buttock (aortoiliac disease); thigh (distal external iliac/common femoral disease); calf (femoral/popliteal)

buttock claudication strongly suggests ________. If the symptoms are unilateral, this suggests ________

aortoiliac disease; iliofemoral disease

thigh claudication suggests ___ disease

distal external iliac/ common femoral

calf claudication suggests ___ disease

femoral/popliteal disease

what is a more severe symptom (than claudication) of diminished blood flow to the most distal portion of the extremity?

ischemic rest pain

With Ischemic Rest Pain the patient will have pain at rest(sleeping), symptoms occur in the _____________, _________, and _________, but
NOT IN THE CALF

forefoot, heel, toes

what is the most severe symptom or arterial insufficiency?

tissue loss (necrosis)

acute arterial occlusion may result from

thrombus, embolism, or trauma

acute arterial occlusion is an ___________. Why?

emergency; abrupt onset does not provide for development of collateral channels

cold sensitivity symptoms include

changes in skin color (pallor, cyanosis, rubor), paresthesia, and pain

intermittent ischemia of the fingers or toes in response to cold exposure as well as emotional stress

Reynaud's phenomenon

Risk factors and contributing diseases for Chronic occlusive disease and acute arterial occlusion

diabetes mellitus; hypertension; hyperlipidemia; smoking; age, family history; male gender

atherosclerosis is more common among ______ and occurs _______.

diabetics; at a younger age

chemicals in cigarettes irritate the endothelial lining of the arteries in addition to causing

vasoconstriction

what is the most common arterial pathology?

atherosclerosis

another term for atherosclrosis

arteriosclerosis obliterans

atherosclerosis (thickening, hardening, and loss of elasticity of the walls) occurs most often where?

carotid bifurcation; origins of brachiocephalic; origins of visceral vessels (SMA/Celiac); SFA; Popliteal trifurcation

true aneurysm

dilation (bulging) of all three layers of the arterial wall

pseudoaneurysm

pulsing hematoma

arteritis

inflammation of the arterial wall - often results in thrombosis

several types of arteritis

Takayasu's, temporal, polyarteritis, Buerger's disease

the most common form of arteritis

Buerger's disease

Buerger's disease is associated with:

heavy smoking; men younger than 40; occlusions of distal arteries; rest pain and ischemic ulceration; superficial thrombophlebitis

Primary Raynaud's is also called _______; and _________. It involves intermittent digital ischemia caused by digital arterial spasm. Common in _________; may be hereditary; usually _________. No evidence of cause; rather benign with excellent prognosis

spastic Raynaud's; Raynaud's disease; young women; bilateral;

secondary Reynaud's is also known as _______. It consists of normal vasoconstrictive responses of the arterioles superimposed on a ________. Ischemia is constantly present. Associated with underlying autoimmune condition.

obstructive Reynaud's syndrome; fixed arterial obstruction;

secondary Raynaud's may be the first manifestation of what?

collagen disorder; Buerger's disease; or anatomic abnormality

The most written about entrapment syndrome?

entrapment of the popliteal artery

entrapment of the popliteal artery is commonly found in ______, and is bilateral in about ______ of cases.

young men; one third

pallor is a result of _____. Skin color is pale

deficient blood supply.

Rubor (reddish discoloration) suggests

damaged, dilated vessels

cyanosis (bluish discoloration) occurs due to

lack of O2 in the blood

Purple patches (similar to bruising) on the skin of the dorsum of the foot. Usually the result of dilated capillaries and venule filling, not arterial obstruction.

Livedo reticularis

death of tissue caused by deficient or absent blood supply

gangrene

grading pulses on a scale of 0-4 is fairly standard. Always compare the pulse palpated on one side to the pulse at the same site on the other. How does the grading go?

0 = none; 1+ = weak; 2+ = good; 3+ = strong; 4+ = bounding

For the lower extremities, Doppler velocity waveforms are recorded from the following arteries bilaterally:

CFA; DFA; SFA; POP; PTA; ATA; Peron; DPA

normal upper and lower extremity arterial waveforms are

triphasic or multiphasic with rapid upstroke

abnormal upper and lower extremity arterial waveforms are

monophasic, nonpulsatile, or absent

segmental pressures are used to look for

PAD

true or false:
Doppler segmental pressures of the lower extremities can discriminate between stenosis and occlusion and precisely locate the area of obstruction

false - cannot; can identify only a general location

true or false: ABI is calculated by dividing the ankle pressure by the lower of the two brachial pressures

false - higher

normal ABI

>1.0

severe arterial disease ABI (rest pain)

<0.5

asymptomatic minimal obstructive disease ABI result

>0.9-1.0

moderate disease ABI (claudication)

0.5-0.8

Mild arterial disease ABI

0.8-0.9

moderate arterial disease causes

claudication

severe arterial disease causes

rest pain

with ABI, a decrease in pressure of _________ between two consecutive levels is considered significant and would suggest significant obstruction. Other sources indicate a decrease in pressure of _______ suggests significant obstruction

>30 mmHg; greater than or equal to 20 mmHg

incompressible vessels are _________ and therefore inaccurate. What ABI is considered to be the result of incompressible vessels?

falsely elevated; >1.3-1.5 or higher

pressures that are not reproducible are also considered to be

incompressible

Normally, the ankle systolic pressure is _________ than the higher brachial pressure.

the same as or greater than

Dopppler segmental pressure study is usually combined with what?

Doppler velocity waveforms or plethysmographic waveforms (volume pulse)

which are more important with the ABI? Horizontal or vertical pressure differences?

vertical

as limb girth increases from the ankle to the thigh, what happens with pressure measurements?

they also increase

technique for Duplex scanning of upper extremities

patient supine; extremity close to examiner; arm externally rotated and postitioned at 45 degree angle in pledge position

re: upper extremity Duplex scanning:
for a patient with a dialysis graft, be sure to do what? Keeping in mind that both a graft stenosis and the high volume of blood flow through a dialysis graft will produce this.

ausculate for bruit/palpate for a thrill

what frequency transducer is used for upper extremity imaging?

multifrequency (5-7MHz) linear array

Upper extremity Duplex scanning is performed at the following anatomic sites in this order:

subclavian a; axillary a; brachial a; radial a; ulnar a; palmar arch if necessary

spectral Doppler of the brachial artery should be

triphasic; high resistance

is it common or uncommon for arteries in the upper extremities to become stenotic?

uncommon

main use for duplex and color flow imaging in the upper extremities (since it's rare for these arteries to become stenotic) is?

evaluation of hemodialysis access grafts, vein mapping, evaluation for thrombosis

hemodialysis grafts are evaluated in the following order:

eval inflow artery; eval arterial anastomosis; eval body of the graft; look for abnormalities (aneurysm, puncture site leaks, perigraft fluid); use color to look for frequency increases, turbulence, and flow channel changes; eval venous anastomoses; eval

types of dialysis access include

Brescia-Cimino fistulas (i.e. radial artery and cephalic vein); straight synthetic grafts (i.e. brachial artery to axillary vein); looped synthetic grafts

popliteal artery entrapment syndrome is thought to be caused by

compression of the popliteal artery by the medial head of the gastrocnemius muscle or fibrous bands

abnormal plethysmographic (PPG) waveforms noted in both dorsiflexion and plantar flexion on one side with normal PPG waveforms on the other side with the same activity suggest

popliteal entrapment

popliteal artery entrapment syndrome is most commonly found in ________. How often bilateral? Repeated trauma to the pop a. may result in what?

young male athletes; one-third bilateral; development of aneurysm, thrombosis, atherosclerosis, and emboli

how do patients with popliteal entrapment syndrome present?

symptomatic arterial occlusion or intermittent claudication

with popliteal entrapment syndrome, what happens to pulses and waveforms when the knee is extended and with active plantar flexion or passive dorsiflexion?

pulses may diminish and waveforms (Doppler, PPG) may be altered

A young male complains of pain in the calf muscle following exercise. Vascular lab findings reveal normal pressures, pulses, and plethysmographic waveforms at rest, but abnormal decreases during active plantar flexion or passive dorsiflexion of the foot.

popliteal artery entrapment syndrome

thoracic outlet syndrome (TOS) occurs when?

neurovascular compression by the shoulder structures (cervical rib, costoclavicular ligament, scalene muscle)

symptoms of TOS

numbness or tingling of the arm and pain in or aching of the shoulder and upper arm; hand may have symptoms of pain, numbness/tingling, and weakening grip.

what exascerbates symptoms of TOS?

exercise and upward arm positions

what percent of the population have asymptomatic compression (brought up in the paragraph about TOS)

25-30%

Technique for determining TOS

PPG and/or Doppler waveform analyis to detect arterial changes in the radial artery (resting waveforms and then waveforms as patient's arm is placed in various positions)

During assessment for TOS, patient sits erect with legs danging from table. Arm positions include:

resting (hands in lap); 90 degrees; 180 degrees; exaggerated military stance; adson maneuver (head turning); causative position

with TOS... a normal finding would be _______ and abnormal would be _______.

the resting waveform obtained by PPG or CW Doppler is maintained throughout the various arm positions; if waveforms are reduced or flatlined by positional changes.

Hypogastric artery is another name for the:

internal iliac artery

geniculate artery

circles around the knee

gastrocnemius artery

part of the popliteal artery?

what artery continues on as the Dorsalis pedis on the dorsum of the foot?

anterior tibial

one layer of endothelial cells suppported by internal elastic lamina

intima

the endothelium of the intima provides the following functions:

permeability - barrier that allows nutrient exchange; antithrombogenic - prevents platelets and monocytes from adhering to wall; vasoreactivity - realeses endothelin and prostacyclin causing vasoconstriction and dilation

middle layer of the arterial wall is called ______. What does it consist of?

media; smooth muscle cells and collagen

outer layer of artery wall is called _____. What does it contain?

adventitia; connective tissue, collagen, and vasa vasorum

smallest vessels in circulatory tree

capillaries

what controls blood flow in the lower extremities?

cardiac output; intraluminal wall resistance; arterial wall compliance; vasoconstriction and dilation in the distal vascular beds

the the basal or resting state, arterioles are _______. There is arteriovenous _______ in muscle capillary beds as not much blood is flowing to skeletal muscles. In this situation flow is ______ from aorta to arterioles.

vasoconstricted; shunted; high resistance

during exercise, _______ occurs. Triggers to this include:

vasodilation; low oxygen, increased CO2, increased lactic acid

During heavy exercise cardiac output increases, there is dermal vasoconstriction, but overall the theme is _______. blood is shunted from viscera to skeletal muscles. What percent of capillaries open? So therefor the A-V shunts do what?

vasodilation; 100%; close

In normal individuals a substantial increase in blood volume in peripheral arteries occurs mduring and volumes increase significantly over resting states. Arterial Doppler waveforms will exhibit what?

low resistance

If flow volumes are obtained from a popliteal artery at rest and compared to flow volumes after 3 minutes of exercise. Would the following finding be normal or abnormal?
resting volume was 55 cc/min; following exercise 914 cc/min
20 FOLD INCREASE IN VOLUM

normal

what decreases dramatically during exercise _________. So how is the pressure maintained?

peripheral resistance; by the increase in volume

vasodilation in lower vascular beds occurs _____ with onset of exercise

quickly

in patients with arterial occlusive disease, adequate distal perfusion may exist when? What happens when this is not the case?

at rest; during exercise, vasodilation occurs but the expected increase in blood volume does not occur, and skeletal muscles cannot obtain the necessary oxygen

if peripheral resistance decreases (due to vasdodilation) and flow volume doesn't increase, then what?

distal pressure will drop and patients may experience pain, fatigue, or cramping in the calf, thigh, or buttock (claudication)

intermittent claudication

pain, fatigue, or cramping in the calf, thigh, or buttock with exercise

if severe proximal disease is present, the Doppler waveform may be

monophasic with delayed rise time

risk factors for atherosclerosis (Daigle)

genetic; hypertension; diabetes mellitus; obesity; LDL >160; tobacco

arterial symptoms of mild arterial disease (PAD)

asymptomatic; decreased pedal pulses or abdominal bruit; mild decrease in ankle pressure w/exercise; may be seen with ultrasound, but doesn't reduce flow

arterial symptoms of moderate (claudication) arterial disease (PAD)

asymptomatic at rest; significant decrease in ankle pressure w/exercise; intermittent claudication (the most common symptom)

transient ischemic event in the muscles

claudication

the most common symptom of peripheral arterial disease?

claudication

arterial symptoms of severe arterial disease (PAD)

night pain in feet or toes; persistent ischemic rest pain; non-healing wounds; ulceration; tissue necrosis; gangrene; surgical intervention to revascularize or amputation

another name for atherosclerosis

arteriosis obliterans

all of the following are considered ______.
atherosclerosis
thrombosis
thromboemboli
blue toe syndrome
small vessel fixed occlusive disease (Buerger's)
digit vasospastic disorder (Raynaud's)
pulsatile masses
arteritis
entrapment syndromes

arterial pathologies

thromboemboli often originate from

aneurysms

blue toe syndrome is caused by

thromboemboli

the small vessel fixed occlusive disease called Buerger's disease is also known as

thromboangiitis obliterans

digit vasospastic disorder is

Raynaud's

pulsatile masses are

aneurysms and pseudoaneurysms

All of the following are examples of what?
popliteal artery entrapment; nutcracker syndrome; medial arcuate syndrome; SMA syndrome; thoracic outlet syndrome

entrapment syndromes

popliteal artery entrapment causes

claudication-like symptoms

Nutcracker syndrome occurs when the left renal vein is compressed by the _______.

SMA

median arcuate syndrome aka MALS

compression of the celiac axis

SMA syndrome

- compression of the 3rd part of the duodenum by the SMA

thoracic outlet syndrome

compression of the subclavian or axillary artery

in early atherosclerosis there is an endothelial ______ and deposition of _____ into the intima. This is followed by an __________ in which monocytes become macrophages that ingest lipids and lipoproteins and then become foam cells.
This is most likely to

injury; LDL; branch points and bifurcations; inflammatory response

As atherosclerosis progresses what happens?

migration/proliferation of smooth muscle cells from media wall off foam cells; fibromuscular cap formation over plaque

In late, advanced atheroclerosis necrosis occurs in the center of the plaque and macrophages may lyse. The hallmarks to remember are

rupture of fibrous cap; rupture of vasa vasorum

material within the necrotic core of advanced atherosclerosis is very thrombogenic. Which lesions are most likely to rupture?

those with a necrotic core and fibrous cap