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- The Subclavian artery becomes the axillary as it travels along the shoulder to the upper arm.
- The Axillary artery becomes the brachial after giving off 7 branches.
- The Brachial artery courses down the arm, ending about 1 cm beyond the bend of the elbow where it divides into the radial and ulnar arteries.
- The Radial artery travels down the lateral side of the forearm into the hand.
- The Ulnar artery travels down the medial side of the forearm into the hand.
- The Digital arteries arise from the palmer arches, extend into the fingers, and divide into lateral & medial branches.
- The Subclavian artery arches above the clavicle, in front of the apex of the lung and behind the scalenus anterior muscle.
- - It runs laterally & downward to the outer border to the 1st rib; there it becomes the axillary artery.
- The landmark to the Brachial artery is the antecubital fossa; is a triangular region located anterior to and below the elbow.
- Radial Artery Harvest for coronary artery bypass graft (CABG)
- Thoracic Outlet Syndrome
- Raynaud's Syndrome
- Thromboembolism: Acute obstruction of distal arteries caused by emboli from subclavian arteries, proximal aneurysm or the heart. The site of obstruction depends on the size of the embolus relative to the size of the artery.
- Atherosclerotic obstruction is common in subclavian artery.
- Diagnosed with comparisons of the bilateral brachial systolic pressure (with B/P cuffs)
-- A >20mmHg gradient is suggestive of subclavian artery disease on the side with the lower pressure
-- Color Duplex Examination (ultrasound) of the subclavian arteries is more sensitive in detecting stenosis
- Inflammatory condition of palmar arch and or digital artery leading to small vessel obstruction.
-- Found most often in male smokers.
-- Thromboemboli: small emboli that occlude the vessels of the hand and digits.
- Raynaud's Syndrome - vasopastic disorder without underlying disease. The digital and palmer arteries are without obstruction.
-- Symptoms of primary syndrome - include pallor (white) of digits during vasospasm cyanosis and rubor (red) upon release of spasm. The spasm may take 10-30 minutes to release.
- Secondary Raynaud's Syndrome - Vasospasm associated with underlying autoimmune disease or connective tissue.
- The digital or palmer arteries often have a fixed obstruction.
- A normal response to cold is vasoconstriction which can cause a severe ischemic reaction.
- 70 -90 % cases occur in females.
- 40% related to connective tissue disorders (scleroderma (hardening of skin), lupus, rhematoid artheritis)
- 40% are idiopathic (no known cause)
- 20% other etiology - frostbite, repetive vibration injury
- Radial artery harvest for CABG
* Intermittent pain, numbness/weakness of arm position. Caused compression of artery or nerve by anterior scalene muscle, clavicle, rib or congenital muscular anomalies.
- 95% of TOS is of neurogenic etiology compression of brachial plexus
- 5% is vascular compression of the sub/axillary inflow
- May cause: thrombosis, fibrosis, and aneurysm of subclavian or axillary artery
- The arm in which the patient is experiencing symptoms is raised and rotated while the head is turned to the opposite side. The physician tests to see if the pulse strength at the wrist is reduced. If the strengthof the pulse is reduced in either of these two tests it indicates compression of the subclavian artery.
-- The allen test can be used to test palmer arch patency and pre-operative for grafts.
- Veins course adjacent to Arteries
- There are 2 venous systems in the leg
Inferior Vena Cava
Common Iliac Vein
Internal Iliac Vein
External Iliac Vein
Common Femoral Vein
Profunda Femoris Vein/Deep Femoral Vein
Anterior Tibial Veins
Peroneal Veins Paired (2 Veins to 1 Artery) - Vena Commitentae
Posterior Tibial Veins
Great Saphenous Vein (largest vein in the body)
Small Saphenous Vein
- Sapheno-Femoral Junction is located at the inguinal crease: (Mickey Mouse)
-- CFV, CFA, GSV
- Slightly inferior to the SFJ you will visualize:
-- CFV, FA, PFA (DF)
- Proximal to distal medial thigh:
-- FA (top), FV (bottom)
- At the knee or slightly below you will visualize:
-- PV (top), PA (bottom), Gastrocnemious Artery, GV, Small Saphenous Vein
- Continue downward and you may visualize the anterior tibials and then the tibioperonal trunk
- Slightly below you will find that you can visulize the paired posterior tibials and the paired peroneals with their accompanying artery:
-- PTV's (2)
-- PTA's (1)
-- PV's (2)
-- PA's (1)
* When the skeletal muscle contracts it forces the blood back to the heart.
- Proximal valves of deep veins are forced open
- Distal valves prevent back flow of blood or caudal flow
* Foot Pump
- During dorsiflexion
- Pumps blood to calf veins
- "Primes" the calf veno-motor pump
* Calf veno-motor
- Primary venous return mechanism
* Thigh Pump
- Primary in the deep femoral vein
- Half of all DVT cases cause no symptoms
- Swelling in one or both legs. (typically unilateral)
- Pain or tenderness in one or both legs, which may occur only while standing or walking
- Warmth in the skin of the affected leg
- Red or discolored skin in the affected leg
- Leg fatigue
- Shortness of Breath (PE?)
- Low Echogenicity
- Venous Distention
- Loss of compressibility
- Doppler Signal Abnormality
-- Continuous Flow
- Increased echogenicity
- Decreased Thrombus & Vein size
- Attached to wall
- Flow will normalize
- Wall Thickening
- Echogenic Intraluminal Material
- Fibrous Cord
- Valve Abnormality
- Doppler Abnormalities (sometimes)
-- Lack of phasicity
-- Subnormal or absent Aug
* Inflammation of the vein wall. Causes include:
- nearby infection
* The area over the vein is painful, swollen, red, and hot. A tender, cordlike mass may be felt under the skin.
* Can be treated with
- pain relievers
- bed rest
- Swelling in the legs and/or ankles (often the first sign)
- Heavy, tight, tired, achy or restless legs
- Varicose Veins
- Skin that becomes discolored (usually brawny), feels leathery, flaky and/or itchy
- Ulcers and/or sores that won't heal
* Incompetent venous valves in the deep and superficial system
- caused by congenital absence of valves or weakened valves
- Valve Damage
-- previous DVT
- Identifies anatomical location of arterial occlusive dx
- Differentiates stenosis from total occlusion
- Define length of occlusion
- Identify pseudoaneurysm
-Identify arterio-venous malformation
- Evaluation of bypass graft
- Color duplex imaging should not be performed to rule out arterial occlusion (it differentiates stenosis from occlusion)
- It is not a good test to rule out arterial occlusion because it is labor intensive and time consuming
* Asymptomatic (mild dx)
* Decreased Pedal Pulses (mild dx)
* Intermittent Claudication
- Pain in calf, thigh, or buttocks with exercise (mild to moderate dx)
* Resting Pain (severe dx)
* Non-healing wound (severe dx)
* Tissue necrosis (severe dx)
- In early Atherosclerosis, increases in LDL cause injury the wall
- Monocytes' and platelets become adhere to the endothelial wall
- Excess blood lipids get transferred by endothelial cells through to the subendothelial space. This then accumulates in the intima lining
- This is usually seen at branches and bifurcations
- Plaque Excision Procedure
- It is a minimally invasive procedure performed through a small puncture site in the leg or arm.
* Four Types
- False aneurysm
- Pseudoaneurysm do not have a true arterial wall and generally are the result of a vascular injury due to trauma or prior surgery
- It lies outside the arterial walls, while a true aneurysm lies with in the arterial lumen
- Ultrasound findings of a pseudoaneurysm are a pulsating mass adjacent to the native vessel
- Most common
- Gradual dilation of vascular lumen
- May be eccentric so one aspect of the wall can be more severely affected
- Spheric of 1 to 1.5cm
- Connected to a vascular lumen by a mouth
- Partially or completely filled with thrombosis
- Sudden tear in the intima that creates a false lumen, which may gradually extend proximally or distally
- Blood in the false lumen may thrombose
* Indirect Physiological testing of the lower extremities is performed to detect hemodynamically significant arterial occlusive disease
- Example disease enough to reduce arterial pressure and perfusion distally, whether at rest or during exercise
- To determine if there is any evidence for arterial disease
- To determine if the arterial disease is causing the patient's symptoms
- Physiologic testing may be the only objective way to determine which condition is causing the patients symptoms
- The segmental limb pressure are (in addition) useful in predicting whether sufficient perfusion exists to heal ulcerations and wounds
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