the upper extremity arterial examination...10/20/2012 2 the upper extremity arterial examination...
TRANSCRIPT
10/20/2012
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THE UPPER EXTREMITY ARTERIAL
EXAMINATION
Phillip J Bendick, PhD
William Beaumont Hospital
Royal Oak, Michigan
THE UPPER EXTREMITYARTERIAL EXAMINATION
History / Physical examination
Duplex ultrasound
Physiologic (non-imaging)
testing: CW Doppler
Plethysmography
Temperature
THE UPPER EXTREMITYARTERIAL EXAMINATION
History
When
Type of onset
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Physical examination - Acute
Pain
Pallor / Temperature
Pulses
Sensory / Motor Loss
Arm pressure difference
THE UPPER EXTREMITYARTERIAL EXAMINATION
Physical examination - Chronic Pulses
Weakness
Arm pressure difference (> 20mmHg)
History - Chronic Pain with exertion (claudication)
THE UPPER EXTREMITYARTERIAL EXAMINATION
Atherosclerotic disease (ASO)
Non-atherosclerotic disease
No disease
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Atherosclerotic disease (ASO)
Duplex ultrasound
Innominate Artery
Rt Subclavian Artery
ASO
THE UPPER EXTREMITYARTERIAL EXAMINATION
Innominate Artery
Rt Subclavian ArteryLt Subclavian Artery
ASO
THE UPPER EXTREMITYARTERIAL EXAMINATION
Axillary Artery
ASO
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Subclavian / Axillary artery:
Normal hemodynamics
Multiphasic
High resistance
THE UPPER EXTREMITYARTERIAL EXAMINATION
Subclavian / Axillary artery:
Normal hemodynamics
THE UPPER EXTREMITYARTERIAL EXAMINATION
Subclavian / Axillary artery:
Normal hemodynamics
BTW:What is this
vessel ?
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Atherosclerotic disease:
Characteristics of a stenosis
Focal elevation in velocity
Post-stenotic turbulence
Damped* flow signals distally
* Monophasic, or theso-called “tardus parvus” waveform
THE UPPER EXTREMITYARTERIAL EXAMINATION
THE UPPER EXTREMITYARTERIAL EXAMINATION
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Bilateral subclavian artery stenosis
THE UPPER EXTREMITYARTERIAL EXAMINATION
Proximaldisease
THE UPPER EXTREMITYARTERIAL EXAMINATION
Right – LeftCommunication
Proximaldisease
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Subclaviansteal
THE UPPER EXTREMITYARTERIAL EXAMINATION
Evolution of subclavian steal
THE UPPER EXTREMITYARTERIAL EXAMINATION
Subclavian / Axillary artery:
BTW #2
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Atherosclerotic disease (ASO)
Non-atherosclerotic disease
No disease
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Large vessel disease Intraluminal obstruction
Structural (wall) integrity
defects
Extraluminal factors
Small vessel disease
Each study type will have a slightly different testing protocol
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Large vessel disease Intraluminal obstruction
Structural (wall) integrity
defects
Extraluminal factors
Small vessel disease
Duplex
ultrasound
Physiologic
testing
Physiologic testing
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Large vessel intraluminal obstruction Thromboembolism
Vasculitis / Arteritis
(Inflammatory diseases)
Fibromuscular dysplasia
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Thromboembolism
THE UPPER EXTREMITYARTERIAL EXAMINATION
Vasculitis
Inflammatory disease
Immunologic disorders
(Inflammatory bowel disease/
Crohn’s disease)
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Giant cell arteritis
Temporal arteritis
Takayasu’s arteritis
Molecular imaging
(18FDG PET)
THE UPPER EXTREMITYARTERIAL EXAMINATION
Takayasu’s arteritis
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Fibromuscular dysplasia
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Fibromuscular dysplasia
Rare “orphan” disease
< 1 per 2,000 prevalence
www.orpha.net
Image courtesy of: Mike Ledwidge, RDMS RVT
University of Wisconsin
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Fibromuscular dysplasia ~ 10% familial
~ 90% female
30-50 years of age
(Has been seen as young as 14 years)
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Fibromuscular dysplasia Renal artery ~ 70%
(Bilateral ~ 35%)
Carotid artery ~ 30%
Multiple vessels ~ 30%
Subclavian / Brachial Rare (< 3%)
Exact frequency unknown
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Structural (wall) integrity defects Dissection
Aneurysm
Pseudoaneurysm
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Dissection
Spontaneous
Traumatic / Iatrogenic
Associated with an underlying disease
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Dissection
Associated conditions - Marfan syndrome
Ehlers-Danlos syndrome (Type IV)
Penetrating atherosclerotic ulcer
Fibromuscular dysplasia
Cystic medial necrosis
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Dissection
Thoracic aorta
Involvement of arch vessels
Common carotid artery
Subclavian artery
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Dissection
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
True Aneurysm (Uncommon)
Subclavian / Axillary Artery
CRT* 100% in most published series
(Nehler et al Arch Surg 1997)
JR Richard; Jeremy Bonderman; . . .
* Chronic Repetitive Trauma
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
True AneurysmRSI
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
True Aneurysm (Uncommon)
Subclavian / Axillary Artery
CRT 100% in most published series
Distal to Axillary Artery
Blunt trauma (All age groups)
Mayo Clinic: 12 in 20 years
Gray J Vasc Surg 1998
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease Pseudoaneurysm (Increasingly common)
- aka Iatrogenic misadventures -
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease Pseudoaneurysm (Increasingly common)
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Extraluminal factors Compartment syndrome
(Blunt trauma)
Compression syndromes
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Thoracic outlet syndrome
Symptoms typically neurogenic
Etiology – Skeletal abnormalities
Etiology – Soft tissue abnormalities
Etiology – Postural factors
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Thoracic outlet syndrome
Etiology – Skeletal abnormalities
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Thoracic outlet syndrome
Etiology – Skeletal abnormalities
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Thoracic outlet syndrome
Etiology – Skeletal abnormalities
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Thoracic outlet syndrome
Etiology – Soft tissue abnormalities
Probe positions
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic
disease
Thoracic
outlet
syndrome
Physiologic testing
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Small vessel disease Vasospastic disorders
(Raynaud’s syndrome)
Thromboangiitis obliterans
(Buerger’s disease)
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Raynaud’s syndrome (Maurice Raynaud – 1862)
Triggered by stressor (frequently cold exposure)
Functional defect (not structural)
Tricolor changes:
White – Ischemia
Blue – Cyanosis
Red - Reperfusion
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Raynaud’s syndrome
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Raynaud’s syndrome
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Raynaud’s syndrome
Physiologic testing:
Digit waveforms pre- and post-cold exposure
Digit pressures pre- and post-cold exposure
Temperature recovery post-cold exposure
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Raynaud’s syndrome Physiologic testing – Digit plethysmography
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Raynaud’s syndrome Physiologic testing –
Temperature response
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Raynaud’s syndrome Physiologic testing – Temperature response
60
65
70
75
80
85
90
2 Min 4 Min 6 Min 8 Min 10 Min
Normal
Raynaud's
Cold Exposure
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Buerger’s disease (Leo Buerger – 1908)
Inflammatory disease affecting smaller arteries
Cellular / inflammatory thrombosis
Predominantly in males, 4th-5th decade
Smoking cessation is key to treatment
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Buerger’s disease
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Buerger’s disease
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Buerger’s disease
Amputation in 25%
of patients
Role of therapeutic
angiogenesis ??
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Buerger’s diseasePhysiologic testing
Doppler waveforms
Radial, Ulnar, Palmar arteries
Digit PPG waveforms / Pressures
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Buerger’s diseasePhysiologic testing – Doppler
THE UPPER EXTREMITYARTERIAL EXAMINATION
Non-atherosclerotic disease
Buerger’s diseasePhysiologic testing – Digit plethysmography
THE UPPER EXTREMITYARTERIAL EXAMINATION
Atherosclerotic disease (ASO)
Non-atherosclerotic disease
No disease
(Pre-operative evaluations)
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Pre-operative evaluation
CRF Dialysis
CAD CABG
THE UPPER EXTREMITYARTERIAL EXAMINATION
Pre-operative evaluation
Principles and Practice of Surgery: ACS
Arterial - Luminal diameterCentral obstructionPalmar arch
CRF Dialysis
THE UPPER EXTREMITYARTERIAL EXAMINATION
Pre-operative evaluation
Successful dialysis access:
Arterial inflow> 2.0mm
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THE UPPER EXTREMITYARTERIAL EXAMINATION
Pre-operative evaluation
Successful dialysis access:
Arterial inflow> 2.0mm
THE UPPER EXTREMITYARTERIAL EXAMINATION
Pre-operative evaluation
Radial arteryfor CABG:
Radial Artery> 2.5mm
RadialArtery
Ulnar Artery
THE UPPER EXTREMITYARTERIAL EXAMINATION
Pre-operative evaluation
Radial arteryfor CABG:
Radial Artery> 2.5mm
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THE UPPER EXTREMITYARTERIAL EXAMINATION
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THE UPPER EXTREMITYARTERIAL EXAMINATION