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105 Cards in this Set
- Front
- Back
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PAD
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Peripheral Arterial Disease
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Layers of arterial wall
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intima, media, adventitia
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inner vessel wall layer/ with endothelial lining
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intima
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middle vessel wall layer/ consists of smooth muscle cells
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media
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outer vessel wall layer/ consists of connective tissue
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adventitia
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What controls theblood flowin the lower extremeties?
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Cardiac output, intraluminal wall resistance, arterial wall compliance, and the dynamics of arteriolar vasoconstriction in the distal vascular beds
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small arteries that lead into thin walled capillaries
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arterioles
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where exchange of CO2, O2, and metabolic nutrients and wastes takes place
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capillaries
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In the basal or resting state, the arterioles are ___.
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vasoconstricted/ this contributes immensely to the high resistance found in the arterial system below the renal arteries.
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When the atunomicnervous system is triggered by exercise or other stimuli/more blood volume is allowedto enter muscle tissue in order to maintain pressure, sustain exercise, and carry out metabolic waste.
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vasodilate
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When are arterioles vasocontricted?
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in a resting or basal state.
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When are arterioles vasodilated?
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during exercise, etc
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How does the waveform change after exercise?
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low resistance
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pain when walking, usually right above occlusion
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claudication
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ABI
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Ankle Brachial Index
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In severe arterial disease, the arterioles will ____ and resistance will decrease.
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vasodilate at rest
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If severe proximal disease is present, the waveform may be ____.
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monophasic with a delayed rise time
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Vasoreactivity occurs in response to...
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exercise, temperature, emotion, certain chemicals, and ischemia
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Mild arterial disease symptoms
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Asymptomatic/may have decreased pedal pulses or abdominal bruit/with exercise, mild decrease in ankle pressure
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Moderate arterial disease symptoms
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asymptomatic at rest/intermittent claudication/ with exercise, a sig. decrease in ankle pressure.
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Severe arterial disease symptoms
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ischemic rest pain in feet and toes/ non-healing wounds on feet, toes/ ulceration/ tissue necrosis, gangrene.
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often originatingfrom aneurysms
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Thromboemboli
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acute onset, painful cyanotic regoins on toes or foot, caused by thromboemboli
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Blue toe syndrome
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small vessel disease
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Raynaud's syndrome
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pulsatile masses
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aneurysms, pseudo-aneurysms
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claudication in young athletes due to entrapment of popliteal artery
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Popliteal Entrapment syndrome
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Atherosclerosis Risk Factors
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Fam hx of stroke, MI, TIA/ cholesteral > 240 mg/dl/ hypertension/ diabetes mellitus/ severe obesity/ elevated triglycerides (cholesterol)/ hypercholesterolemia/ LDL > 160 mg/dl/ tobacco abuse/ depressed fibrinolytic system/ increased oxidation of LDLs.
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a single cell layer that lines the inner surface of the artery and is in contact withthe intraluminal moving blood
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Endothelium/Intima
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Functions of the intima/endothelium
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1. Permeability (provides a barrier between blood and the artery wall that allows molecule exchange between blood plasma and the wall). 2.) Antithrombogenic (prevents platelets and monocytes from adhering to the artery wall) 3) Vasoreactivity (release endothelin and prostacyclin which cause the artery wall to vasoconstrict and vasodilate)
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Middle layer of arterial wall/ consists primarily of smooth muscle cells and some collagen/ allows rhythmic changes inthe arterial size that occurs during cardia cycle
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Media
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Outer layer of the artery wall/ contains connective tissue, collagen, and the vasa vasorum,tiny blood vessels that supply the artery wall
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Adventita
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endothelial injury/ deposition of LDL into intima/ recruitment of lymphocytes, monocytes
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Early athero
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Number 1 cause of vascular problems
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Early Atherosclerosis
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monocytes in intima become macrophages/ macrophages ingest lipids,lipoproteins/ macrophages become foam cells/ fatty streak
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Athero Inflammatory Response
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migration, proliferation of smooth muscle cells from media/ neovasculature supplies plaque, feeds LDL and macrophages/ fibromucular cap formation
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Athero Thickening
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Cell necrosis/ scar tissue formation (fibrosis)/ macrophage lysis/ intraplaque hemorrhage/ rupture of fibrous cap
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Late changes/ Advanced Atherosclerosis
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Goals of lower extremeity physiologic arterial testing
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1. Determine if there is objective evidence for arterial disease/ 2. Determine if the arterial disease is causing the pt's symptoms/ 3. To assess increasing or decreasing limb perfusion during serial follow-up exams
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Advantages of indirect physiologic arterial testing
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Simple/easy to learn/ short testing time/ accurate for hemodynamically sig. disease/ provides objective, quantitative info/ relatively inexpensive equipment
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Arterial Physiologic testing Limitations
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inability to identify precise location of disease/ will not detect minor levels of diffuse athersclerotic disease
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Methods of Indirect Physiologic Testing
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Pulse Volume Recordings (PVR), Doppler analog (or spectral) waveform analysis, Segmental Limb Pressures(SLP) and calculated Ankle-Brachial Indices, Exercise stress test(or post-reactive hyperemia).
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Questions to ask for pt hx for arterial physiologic testing
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Leg pain when walk? Where? In which leg or both? Which leg is worse? What part of the leg is painful? Progressive pain or keep you from walking? How many blocks can you walk before stopping? Does the pain go away when stop walking? Have you ever had a bypass graft or arterial operation?
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Grades of palpated limb pulses
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0 = no pulse
1 = weak pulse 2 = normal pulse 3 = very strong pulse or aneurysmal pulse |
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Where to obtain palpable pulses
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Groin (distal EIA or CFA)
Popliteal fossa (pop artery) Ankle (DPA and PTA) |
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Physical signs of arterial disease
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Pallor, pain, paresis, pulselessess/ coldness/ dependent rubor/ cyanotic toes/ ulceration/ non-healing wound
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compares limb blood pressures to systemic pressures obtained in arms/ systolic pressure in each limb segment should be equal or greater than arm pressure in normal pts/ a sig. drop in pressure between contiguous segments signals the presence of occlusive disease in that region/ pt supine and in warm room/ 3 cuff or 4 cuff method
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Segmental Systolic Limb Pressures
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Where should the blood pressure cuff be positioned in the upper arm for segmental pressures?
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Bladder over the brachial artery
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How to calculate Ankle-Brachial Index (ABI)
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Divide each ankle pressure by the higher of the two brachial pressures to calculate an ankle/brachial index
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Useful in evaluating small vessel disease and in diabetic pts with calcified, uncompressible large vessels.
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Toe Pressures
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May be calculated by dividing each toe pressure by the higher brachial pressure/What is considered abnormal?
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Toe/Brachial Index
TBI of less than 0.60 |
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What indicates subclavian stenosis with brachial pressures? Which side is the occlusion on?
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Gradient of 20 mmHg or more between brachial pressures/ The side with the lower pressure
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ABI values:
>0.96 = 0.95 - 0.91 = <0.90 = <0.8 = <0.5 = <0.3 = |
>0.96 = normal
0.95 - 0.91 = gray area <0.90 = abnormal, do stress test <0.8 = probably claudication <0.5 = multi-level disease, or long segment occlusion <0.3 = ischemic rest pain |
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If ABIs are abnormal, but Doppler or PVRs appear normal...
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recheck brachial pressure as it may have dicreased prior to obtaining ankle pressures
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Normal Segmental Three-Cuff Technigue normal
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All segmental pressures, including the thigh, should be equal to or slightly greater than the brachial pressure
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With calcific medial sclerosis and incompressible vessels...
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limb perfusion must be assessed with other methods, ex PVR, Doppler waveform analysis, or toe pressures
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Indications of calcified arteries
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Noncompressible, ABI exceeding 1.35, high closing pressure (cessation of doppler signal during inflation) with low opening pressure
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Normal thigh and calf PVR with abnormal ankle recording suggests....
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tibial disease
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Are PVRs affected by calcified arteries?
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No
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Exercise stress test contraindications
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questionalbe cardiac status, known cardio-vascular disease/ severe pulmonary disease/ inability to walk at treadmill speed/ ischemic rest pain/ ischemic limb ulceration
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An immediate post exercise ankle pressure of ___ confirms a vascular cause for claudication
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60 mmHg or less
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may be substituted for treadmill stress test/ not well tolerated by many pts b/c of the severe pain caused by the occlusive thigh pressure
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post occlusive reactive hyperemia (PORH)
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alternative to PORH as a form of stress exercise
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toe raises
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Goes of color duplex imaging for lower extremeties arterial
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adjunt to physiologic testing/ identify exact site of disease/ determine stenosis versus occlusion/ intraoperative and post-op eval of bypass grafts
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Stenosis Criteria for LEA
normal- 30-49% stenosis- 50-75%- >75%- occlusion- |
normal- < 150 cm/s peak velocity, <1.5:1 ratio
30-49% stenosis- 150-200 cm/s, 1.5:1 - 2:1 50-75%- 200-400 cm/s, 2:1-4:1 >75%- >400 cm/s, >4:1 occlusion- no color saturation |
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2:1 ratio =
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50% stenosis for LEA
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LEA occlusion criteria
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no flow in artery by color and spectral doppler/ identify collateral run-off/ identify distal reconstitution/ chronically occluded arteries may be difficult to see
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Disadvantages of color duplex LEA
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time-consuming/ difficult/ aorto-iliacs are hard to get with high freq transducer
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Pt should be ___ for LEA in order to image aorto-iliacs
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npo for 8 hours prior
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LEA scan zones
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1: aorta, CIA
2: Int and Ext iliac 3: CFA, SFA, PFA |
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Aorto-iliac disease is usually...
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bilateral
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Tibial Artery CDI (color doppler)
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pre-op for distal bypass/ tim consuming in abnormals/ work from distal to prox
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Most common disease site below groin
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SFA Adducter canal (at pop)
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Conservative treatment of lower arterial disease
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cessation of smoking/ reg exercise/ lowering cholesterol and LDL/ med options: trental, pletal
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Intervention procedures for treatment of lower arterial disease
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bypass graft (synthetic or autogenous vein grafts)/ percutaneous angioplasty (PTA)/ stents
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stripping out valves for graft
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ligation
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Femoral-distal in situ vein graft
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uses GSV in native bed/ valves leaflets are excised/ perforators-tributaries are ligated/ proximal and distal ends are anastomosed to artery
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Reverse vein graft
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GSV harvested/ perforating veins and tributaries are ligated and cut/ vein reversed and implanted as bypass/ valves are not excised/ small diameter proximally, large diameter distally is advantageous
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Bypass graft surveillance
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identify graft type/ perform abi/ map graft and record spectral waveforms prox, mid, and distally/ measure PSV
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With bypass graft surveillance, a ___ drop in ABI suggests graft stenosis
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.15
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___ is more sensitive than ABI for stenosis
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Duplex u/s
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> 50% graft stenosis
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Peak velocities > 150 cm/s
Velocity ratio > 2.0 Post stenostic turbulence |
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Threshold for graft revision
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>300 cm/s
VR > 3.5 low velocity < 40-45 cm/s low ABI |
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balloon deployed stent
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Palmaz
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self expanding stent
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Wallstent
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Peripheral vascular stent sites
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aorta, renals, iliacs, femoral-popliteal, carotid
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Hemodialysis Access grafts and fistula facts
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Created to sustain pts with end-stage renal failure/ 200,000 pts in USA are dialysis dependent/ pts are likely to undergo multiple revisions, fistulas, or grafts
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Signs of possible access failure
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Difficult cannulation or thrombus aspiration/ elevated venous pressure >200 Hg/ Access recirculation of 12% or greater/ Unexplained urea reduction ratio < 60%/ palbable water hammer effect/ shunt collapse
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Indications for duplex scan of hemodialysis access grafts and fistulas
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peri-graft mass/ distal limb ischemia/ loss of "thrill"
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Pre-operative assessment of hemodialysis access
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arterial inflow/ venous outflow/ vein size/ palmer patency
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Post-op assessment of hemodialysis access
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graft thrombosis-stenosis/ flow volume/ arterial steal/ venous outflow/ peri-graft mass
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Pre-op arterial exam for hemodialysis access
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measure bilateral arm systolic pressures/ image brachial, radial, and ulnar arteries/ look for stenosis, sclerosis, occlusion
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Arterial evaluation hemodialysis access normal exam
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less than a 20 mmHg pressure gradient between brachials/ arterial lumen diameter > or equal 2 mm/ Absence of radial artery stenosis/ patent palmer arch
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Pre-op venous hemodialysis access exam
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image cephalic and basilic veins/ measure vein diameter in forearm and arm/ determine vein outflow tract patency
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Normal venous hemodialysis access exam
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absence of stenosis or thrombosis/ patent deep veins in upper arm/ venous luminal diameter
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Pre-op exam has been shown to....
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significantly reduce early graft/fistula failure rate
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With post-op assessment, grafts/fistulas are allowed to mature for...
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4-6 weeks
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Dialysis access grafts/fistulas Complications
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thrombosis-stenosis/ infection/ arterial steal-digit ischemia/ distal venous hypertension/ aneurysms, pseudoaneurysms
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radio-cephalic/ autogenous/ known for long term patency/ low complication rate/ ulnar art to basilic vein may also be created
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Brescia-Cimino fistula
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Radial artery to median cubital, basilic, or cephalic vein/ straight or tapered/ most common/ highest success rate
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PTFE Straight Graft
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PTFE Graft Loop
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brachial art to cephalic or basilic vein/ lower ext: SFA to saphenous vein
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Graft Flow Volumes
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<250 - poor dialysis
300-1000 - normal >1400 - possible CHF |
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Graft Stenosis Criteria
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focal velocity acceleration/ 2:1 increase/ severe post-stenotic turbulence
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Dialysis Graft Stenosis > or equal to 50%
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Velocity increase 2:1
Peak systole > 300 cm/s |
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Complications of Hemodialysis Access Graft
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Pseudo-aneurysm, infection, venous hypertension, graft occlusion
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Venous Hypertension in Dialysis Graft
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forearm loop graft with venous stenosis/ retrograde venous flow/ pt with hand swelling and venous stasis
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Do NOT obtain blood pressure on arm with...
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graft or fistula
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