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Vascular Surgery - 101 Vascular Assessment and PAD

Vascular Surgery - 101 Vascular Assessment and PAD. Peter R. Nelson, MD Assistant Professor of Surgery UF College of Medicine Malcom Randall VAMC Deanna Shelpman, RVT Lead Technologist, Vascular Laboratory Shands at UF Medical Center. Objectives. General vascular concepts

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Vascular Surgery - 101 Vascular Assessment and PAD

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  1. Vascular Surgery - 101Vascular Assessment and PAD Peter R. Nelson, MD Assistant Professor of Surgery UF College of Medicine Malcom Randall VAMC Deanna Shelpman, RVT Lead Technologist, Vascular Laboratory Shands at UF Medical Center

  2. Objectives • General vascular concepts • Vascular history and physical • Vascular diagnostic testing • Demonstration and practical • Shadowing at Shands

  3. Cap (macrophages) Media Core (LDL) Pole (SMC) Lymphocytes AtherosclerosisMature plaque

  4. General Concepts • Atherosclerosis is a systemic disease • Be thorough in both history and PEx • Examine every major arterial system • Synthesize your diagnosis with historical and physical exam clues • Support your diagnosis with studies

  5. History – Risk Factors • Smoking • Diabetes • Hypertension • Hyperlipidemias • Male Gender • Thrombophilias • DVT/PE • Family history

  6. History – Cardiac Disease • Overall 30% of patients presenting with PVD also have severe coronary disease • 31% in aneurysm patients • 26% in patients with cerebrovascular disease • 21% in patients with lower extremity ischemia • Of patients undergoing vascular procedure • 20% have had a previous MI • 7% have had significant CHF • 4% have had previous arrythmia • 60% have abnormal EKG • 7% have had a previous stroke

  7. Lower Extremity PAD Symptoms • Acute Ischemia • 6 P’s • Intermittent Claudication • Thigh/buttock vs. calf • Leriche Syndrome • Classic triad • Critical Limb Ischemia • Rest pain • Tissue loss • Ulceration/cellulitis • Gangrene • Osteomyelitis

  8. Spectrum of Extremity PAD Majority of patients with a decreased ABI or absent pedal pulses are asymptomatic and do not require further evaluation Claudication -perfusion unable to meet demand with exercise Limb Threatening Ischemia -perfusion unable to meet demand at rest

  9. Atheroembolization

  10. Key Components on an H&P

  11. General Physical Exam • Full cardiopulmonary exam • Arrhythmias, murmurs, rubs • Transmitted murmurs may mimic or mask bruits • Full neurologic exam • Cranial nerves • Thorough motor sensory exam • Coordination • MMSE • Ophthalmoscopic exam

  12. Vascular Exam • Bilateral brachial blood pressures • Palpate pulses • Range 0 - 4+, > 4+ is aneurysmal (note: some people use a 2+ scale) • Carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial • Ankle-brachial index (ABI) • Listen for bruits • Turbulent flow, more harsh with increasing stenosis, may be lost with critical stenosis • Carotid, subclavian, abdominal (aortic, renal, mesenteric), femoral • Ischemic changes • Shiny skin, hair loss • Dependent rubor, pallor on elevation • Palpate for aneurysms/masses • Aortic, carotid, femoral, popliteal, other

  13. What is an ABI?

  14. The ABI - Ankle Brachial Index ABI = Ankle systolic pressure (mmHg) Brachial systolic pressure (mmHg) • The ratio of the BEST doppler pressure at the ankle to the BEST brachial pressure • Normal: > 0.96 • Claudication: 0.5 – 0.95 • Rest pain: < 0.3 – 0.5 • Tissue Loss: < 0.3 • Palpable >0.7 • Incompressible >1.3 (without palpable pedal pulses)

  15. Initial Testing - ABI

  16. ABI

  17. Pulse Exam You should be able to draw the arteriogram based on your pulse exam......(and ABIs)

  18. Pulses - Example 1 NORMAL

  19. Pulses - Example 2 R iliac stenosis

  20. Pulses - Example 3 R iliac occlusion

  21. Pulses - Example 4 B iliac disease/L SFA disease (R radial occlusion)

  22. Pulses - Example 5 R SFA occlusion

  23. Pulses - Example 6 R SFA/tibioperoneal disease

  24. Pulses - Example 7 Diabetic - R tiboperoneal disease

  25. Pulses - Example 8 ?? - Medical Student Exam

  26. Pulses - Example 9 Get a new Doppler

  27. Other Diagnostic Studies • Segmental Dopplers/PVRs • 20 mmHg drop across arterial segment • Exercise treadmill testing • 15% drop in ABI • Photoplethysmography • toe pressures • Duplex arterial examination • 2-2.5 X step-up in PSV • Arteriogram • 10 mmHg resting, 20 mmHg induced gradient • CTA/MRA

  28. CW / Continuous Wave Doppler • CW involves a 2 crystal transducer that produces a spectral waveform from the Doppler shift data being received

  29. Triphasic Waveforms

  30. “Bi-Phasic” Waveform

  31. Monophasic Waveforms

  32. Pulse Volume Recording (PVR)

  33. PVR Waveform • The Pulse Volume Recording (PVR) method measures blood volume changes that occur in the extremities

  34. CW / PVR Testing

  35. Photoplethysmography (PPG) Waveform • A PPG waveform is created by the emission of a non-visible infrared light into the skin • Depending on the blood volume in the tissue, more or less light is absorbed and a waveform is created from the backscattered light • Most useful for assessing digital (i.e. toe) pressures/perfusion

  36. PPG Illustration

  37. Arteriography Aortogram “Runoff”

  38. CT Angiography

  39. CT Angiography

  40. Demonstration/Practical Questions?

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