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    Body in anatomic standing position
  2. Sagittal Plane
    • aka Long
    • Vertical plane that divides the body into 2 halves w/c is the rt/lt portions
  3. Transverse plane
    • aka Axial plane
    • Horizontal plane w/c divides the body into Superior/Inferior portions.
  4. Coronal plane
    • aka Frontal plane
    • Vertical plane w/c divides the body into front and back portions
  5. Proximal
    • Closer to the point of attachment
    • Origin of flow in cardio vascular relationship
  6. Distal
    • Farther fr. the point of of attachment
    • Farther from origin of flow in cardio vascular relationship
  7. Hemodynamic
    • Hemo=blood
    • Dynamic=power
  8. Pressure gradient
    • Po difference betw 2 pts in a vessel
  9. Viscosity
    • Thickness or stickiness of a fluid 
    • Unit: Poise
    • Bl viscosity is 4x that of water
  10. Friction
    • Resistance to motion caused by 2 moving obj that are touching each other
    • Vessel walls and flow of blood causes friction, therefore, providing Resistance to flow
  11. Inertia
    Velocity of a fluid changes

    If at rest it tends to stay at rest.  If moving, it tends to stay moving; therefore, Po must rise to a level that will overcome inertia
  12. Poiseuille's equation
    • Mathematical equation used to predict the vol flow rate in long straight vessels
    • Q=ΔP/R

    • Image Upload 1
    • Resistance =r(Biggest factor)
  13. Plug flow
    • Flow vel is uniform across the lumen
    • Found at entrance of large vessels
    • "Normal" flow
  14. Laminar flow
    • Fastest in the center
    • Vel drops as it moves closer to the walls known as Parabolic flow
    • "normal" flow
  15. Pulsatile flow
    • Contraction of the heart produces a change in Po.  
    • Art expand in systole and Contract in diastole
    • Due to change in diameter, Resistance to flow also changes
  16. Turbulent flow
    • Many diff vel
    • Chaotic
    • Caused by abrupt changes in vessel's lumen
    • Usually due to Stenosis caused by build-up of plaque
  17. Phasicity flow
    Venous flow patterns in lower extremities
  18. Inspiration
    • Diaph: Down ↓
    • Venous ret from legs: Decr ↓
    • Venous ret to heart: Incr ↑
  19. Expiration
    • Diaph: Up ↑
    • Venous ret from legs: Incr ↑
    • Venous ret to heart: Decr ↓
  20. Hydrostatic Pressure
    • Gravitational forces
    • Venous Po changes when pt is supine or standing
    • Supine: 15 mm/Hg 
    • Standing: 102 mm/Hg

    Art Po changes are much less dramatic w/supine or standing positions
  21. Doppler U/S
    • Image Upload 2
    • Difference between reflected (fr) & transmitted/incident (fi)
    • Meas. by Velocity
    • No fD occurs at a 90o angle
    • If fr is > fi = +fD 
    • If fr < fi = -fD
    • Image Upload 3
  22. +fD (positive doppler shift)
    • Reflectors (RBC's) moving toward the sound source  0 <60
    • Above Baseline
    • Image Upload 4
  23. -fD (negative doppler shift)
    • Reflectors (RBC's) moving away from the sound source 0 <60(away)
    • Below baseline
    • Image Upload 5
  24. Spectral Broadening
    • Band is broader
    • Peak systolic vel is increased
    • Represents disturbed or Turbulent flow pattern
    • May be assoc w/ critical Stenosis
    • Image Upload 6
  25. Pulsatility Index (PI)
    Calculated by dividing the Max (A) - Min (B) velocity by the mean (avg of the signals) velocity

    Image Upload 7
  26. Resistive Index (RI)
    Calculated by subtracting the Min (B)- Max (A) and dividing by the Max (A) velocity

    Image Upload 8
  27. 3 layers of the Artery
    • Tunica Intima
    • Tunica Media
    • Tunica Externa
  28. Tunica Intima
    • Thin layer
    • Consists of Endothelium over a base membrane and connective tissue
    • Image Upload 9
  29. Tunica Media
    • Intermediate layer of the ART wall
    • Thicker than Intima
    • Composed of smooth muscle and connective tissue (elastic type)
    • Arranged in a circular pattern for strength
    • Image Upload 10
  30. Tunica Externa
    • Outermost layer
    • Thinner than media
    • Contains fibrous connective tissue & a few smooth muscle fibers
    • Arranged in longitudinal patternImage Upload 11
  31. Aneurysm
    Bulging of all 3 layers of the Arterial wall
  32. 2 things blood needs to travel through
    • 1. Route - ART system is a conduit (tube)
    • 2. Pressure gradient = Vol of bl flow (Q)

    Flow occurs from HIGH to LOW 
  33. HIGH Resistance flow
    Has a High Systolic peak & Low Diastolic flow
  34. LOW Resistance flow
    Has a more Rounded Systolic peak and a relative high level flow in Diastole
  35. Carotid Anatomy
    • Innominate Art (IA) divides into RT Subclavian Art and RT CCA
    • LT Subclavian Art & LT CCA originate dir fr the AO arch
    • Variation occurs to LT CCA arises fr IA
    • Image Upload 12
  36. Internal Carotid Art (ICA)
    Commences at the carotid art bif at the sup border of the thyroid cartilage
  37. 4 Segments of the ICA
    • 1.Cervical portion of the neck
    • 2.Petrous portion
    • 3.Cavernous portion
    • 4.Cerebral portion in the brain
    • Image Upload 13
    • Ophthalmic Art is the 1st branch off the ICA in the skull

    • No branches arising fr the ICA in the neck
    • ICA is usually (not always) post-lat to the ECA
    • It is usually larger than the ECA
  38. 8 Branches of ECA
    • 1. Superior Thyroid Art
    • 2. Ascending Pharyngeal Art
    • 3. Lingual Art
    • 4. Occipital Art
    • 5. Facial Art
    • 6. Posterior Auricular Art
    • 7. Maxillary Art
    • 8. Superficial Temporal ArtImage Upload 14
  39. Key methods of differentiating ICA/ECA
    • ECA has extra-cranial branches
    • ICA has lower resistance flow than ECA
    • ICA is larger in diameter (but can appear smaller if there is a disease)

    The wishbone or turning fork bif is only found in approx 15-20% of pts.
  40. Vertebral Art
    • Important branches of the Subc Art
    • Travels betw the TRV spinal processes toward the brain
    • LT Vert Art is usually larger than the RT & enters the skull thru the Foramen magnum
    • Supplies the POST portion of the brain
    • Vertebrals join to make the Vertebrobasilar circulation (Circle of Willis)
    • Image Upload 15
  41. Pitfalls in Cartotid Art duplex Scanning
    • Incorrect differentiation of the ICA & ECA in diseased bif
    • ECA is usually smaller than ICA but NOT always
    • Improper Doppler waveform patterns & characteristics sounds to distinguish the ECA from ICA
  42. Plaque Evaluation
    • Calculate the % of diameter reduction:
    • Measure true vessel diameter (TD) and residual lumen (RL) in TRV plane= Plaque diameter. This is only a rough estimate of the degree of stenosis
    • Image Upload 16
  43. Percentage Diameter Stenosis
    %D=PD/TD x 100

    • PD: Plaque diameter (true vessel diamter-residual lumen)
    • TD: True diameter of the ART

    If PD=4mm TD=10 answer: 40%
  44. Grading Carotid Stenosis
    • Tool to indicate when carotid endarterectomy is warranted
    • Intersocietal Commission for the Accreditation of Vascular Labs (ICAVL) requires from these popular ones:  Univ of Washington duplex criteria and North American Symptomatic Carotid Endarterectomy Trial (NASCET).
  45. Carotid Stenosis criteria
    Image Upload 17
  46. Degree of stenosis
    • 0Stenosis         ICA PSV             Plaque Est
    • Normal            <125cm/s               None
    • <50%             <125cm/s            <50% DR
    • 50-69%         125-230 cm/s         ≥50% DR
    • ≥70% but        ≥230 cm/s           ≥50% DR
    • >near occlusion

    • Near occlusion  high, low or         Visible
    •                       undetectable

    • Total occlusion   undetectable       Visible, no
    •                                                lumen seen
  47. Normal Vert Spectral Waveform
    • Low resistance pattern
    • Well defined systolic flow
    • Sustained flow in diastole
    • Broader BW
    • Peak Systolic Vel range fr 20-60 cm/s
    • One may be larger than other
  48. Subclavian Steel Syndrome
    • Most common condition affecting the Vert Art
    • Bl that is destined for the brain thru the Vert Art is shunted away due to high grade stenosis or complete occlusion of the IA or the Subc Art proximal to the take off of the Vert Art
    • Flow is reversed in the Vert Art that is supplying the arm

    *There will be a substantial diff in Brachial BP
  49. LT Subc Steal
    • Pathway of bl flow in the LT Vert Art when there is occlusion in the LT Subc Art proximal to the take off of the Vert Art
    • Image Upload 18
  50. RT Subc Steal
    • Pathway of bl flow in the RT Vert Art when there is occlusion in the RT Subc Art proximal to the take off of the Vert Art
    • Image Upload 19
  51. RT Subc Steal due to occlusion of IA
    • RT Subc Steal due to occulsion of the IA
    • Flow in the RT Vert Art is reversed
    • BP in the RT arm is decr ↓

    Image Upload 20
  52. LT Partial Subc Steal
    • Flow in the RT Vert Art is antegrade 
    • Flow in the LT Vert Art is demonstrates antegrade and retrograde flow components
    • Image Upload 21
    • Image Upload 22
  53. Facts about Subc Steal Syndrome
    • Most pt are asymptomatic
    • Claudication is rare
    • Brachial BP diff of 15-20 mm/hg
    • Pulses ↓ on affected side

    Flow resistance in supplying Vert may ↑

    Surg. treament: Stent, by-pass graft, endarterectomy
  54. Subc Art Anatomy
    • On the Rt side of the body, the Subc arises fr the short IA (brachiocephalic art)
    • On the Lt side of the body, the Subc arises dir fr the AO arch
    • RT/LT Subc supply bl to the head & arms
    • It is located below the clavicle
  55. Branches of Subc Art (both sides)
    • Internal Thoracic Art
    • Vert Art
    • Thyrocervical trunk
    • Costocervical trunk

    • At the Lat border of the 1st rib, the Subc Art becomes the Axillary Art
    • Image Upload 23
  56. Spectral Waveform of the Subc Art
    • High Resistance
    • The Incr resistance feeds the high resitance art of the extremities
    • Image Upload 24
  57. Cerebrovascular Disease Symptoms:
    • 1.Cerebrovascular Accident (CVA)-complete brain stroke cause:
    • Embolism, Thrombosis, Hemorrhage
    • 2.Transient Ischemic attack (TIA)-Symptoms resolve w/in 24 hrs
    • 3.Reversible Ischemic Neurologic Deficit (RIND)-Symptoms resolve, but not w/in 24 hrs
    • 4.Death is also a possible consequence of stroke
  58. Common Hemispheric Symptoms & Assoc. Hemisphere
    • Aphasia
    • Dysphasia
    • Dysarthria
    • Lateralized paresthesia
    • Hemiparesis
    • Hemiplegia
    • Amaurosis fugax (AF)
    • Ataxia
  59. Aphasia
    Inability to speak or express oneself (dominant Hemisphere, usually LT)
  60. Dysphasia
    Impairment of speech, lack of coordination & failure to arrange words in proper order (dominant hemisphere)
  61. Dysarthria
    Imperfect articulation of speech due to disturbance of muscle control, slurring, etc (dysfunction of any # of brain centers)
  62. Lateral Paresthesia
    Tingling & numbness (contra lateral hemisphere)
  63. Hemiparesis
    Lateralized weakness (contralateral hemisphere)
  64. Hemiplegia
    Lateralized paralysis (contralateral hemisphere)
  65. Amaurosis Fugax (FA)
    • aka Transient Monocular blindness (TMB)
    • Related to ipsilateral art
  66. Ataxia
    Gross uncoordinated of muscle movements, clumsiness of limb (contralateral hemisphere)
  67. What is STROKE?
    • 3rd leading killer in the US
    • Occurs when a bl vessel in the brain or feeding the brain bursts (hemorrhagic stroke) or is blocked (ischemic stroke) causing a sudden disruption in the vascular blood supply to the brain
    • One of the warning signs of stroke is a TIA
  68. TIA Transient Ischemic Attack
    • Neurologic deficit that reverses w/in 24 hrs, but usually resolves w/in minutes
    • Has no lasting damage
    • Affects Anterior circulation
    • Bl clot temporarily clogs an Art w/c is feeding the brain and it doesn't get bl
  69. Risks of TIA
    • If you've previously suffered it b4
    • Risk for CVA is ↑ Incr by 10% w/in the ff 3 mos 
    • 17x Incr during the next 5 years
  70. TIA Symptoms
    • Blindness in 1 eye (Amaurosis fugax)
    • Dysphasia or Aphasia (Speech difficulties)
    • Contralateral hemiparesis/monoparesis (paralysis)
    • Behavioral disturbances
  71. RIND symptoms
    • Neurologic deficit that last longer than 24 hrs but less than 72 
    • Occurs when bl flow to brain is temp restricted sudden onset of symptoms
  72. Amaurosis Fugax Symptoms
    • Transient blindness in one eye
    • Last from seconds to minutes
    • Similar to shade being pulled up or down
    • Caused by temp blockage of small bl vessels in eye
    • May be occasional or repeated many times/day
    • Disease is on same side as affected eye
  73. Bruit
    • Abnormal low rumbling sound 
    • Heard thru stethoscope over the CCA
    • Caused by turbulent bl flow as it rushes by an obstruction
  74. Bruit may indicate:
    • Stenotic area
    • Tortuous vessel

    *Majority of pts w/ bruits have a stenosis of 50% or more
  75. Hemispheric Symptoms
    • Aphasia-LT Hemi
    • Dysphasia-LT Hemi
    • Dysarthria-LT/RT Hemi
    • Lateralized Paresthesia-LT/RT Hemi
    • Hemiparesis-Contralat Hemi of Brain
    • Lateralized Weakness- Contralat Hemi of Brain
  76. Vertebro-Basilar Insufficiency (VBI)
    • Post circulation affected
    • Flow in Vert or Basilar Art disturbed
    • Symptoms usually bilat
  77. VBI Symptoms
    • Vertigo (most common)
    • Ataxia -muscle coordination
    • Weakness in limbs
    • Drop attacks
    • Paresthesia
    • Visual Disturbances
    • Numbness around lips/mouth
  78. Vertigo
    Sensation of things moving around in space
  79. Drop attack
    falling to the ground w/o loss of consciousness
  80. Paresthesia
    Numbness or tingling
  81. Carotid Artery Aneurysm
    • Dilation of all 3 layers of the Art
    • RARE
    • Caused by trauma, infection, congenital carotid art, thrombus may form around vessel walls

    Portions of thrombus may break off and travel to the brain
  82. Atypical Disease Condition
    Pulsatile neck mass in the CCA
  83. Atypical Disease Conditions include:
    • Fibromuscular Dysplasia (FMD)
    • Carotid Body Tumor
    • Carotid Dissection
  84. FMD
    • Dysplasia of the media w/ overgrowth of collagen
    • Part of collagen vascular sys disorder grp
    • Mainly in WOMEN
    • Bead like appearance on angiography
    • ↓ Bl supply to the brain
  85. Carotid Body Tumor
    • aka Paraganglioma
    • Located next to carotid sinus betw ECA/ICA
    • Small mass of vascular tissue
    • Functions as chemoreceptor
    • ↑ Vascularity
    • Bl supply via ECA
    • May require surgical treatment
  86. Carotid Dissection
    • Separation of Intima fr media
    • Separate flow channel w/in dissected wall
    • Proximal dissection
    • Distal ICA dissection

    Image Upload 25Image Upload 26
  87. Causes of Carotid Dissection
    • FMD
    • Trauma to neck
    • Congenital weakness of the media
    • Chiropractic treatment
    • Idiopathic (don't know)
  88. Surgical Intervention of Atypical Disease Condition
    • Endarterectomy
    • Bypass Graft
  89. Endarterectomy
    • Surgical removal of the intraluminal atherosclerotic material
    • Surgery not performed w/ complete occulsion of cervical CCA or ICA
    • Decision based on extent of disease, severity of disease, pt symptoms & medical condition
  90. ByPass Graft
    • Provides alt pathway around stenosis
    • Rarely performed for ICA disease
    • May be performed for stenosis in 
    • Proximal CCA
    • Subc Art
    • IA
    • Image Upload 27
  91. Correction of Coiling, Kinking, tortuosity
    • Shortening procedures
    • Sometimes performed w/ endarterectomy
  92. Tortuous Vessel
    • May cause bruit to be heard over the area
    • Due to ↑ Vel & turbulent flow assoc w/ tortuous vessel

    Image Upload 28
  93. Circle of Willis Description
    • Most important pathway for collateral circulation to brain
    • Vascular channel of intracranial comm.
    • Located at the base of the brain
    • Connects Ant/Post circulation
    • Image Upload 29
  94. Circle of Willis Anatomy
    • Hexagon like arrangement
    • Ant Cerebral art
    • Middle Cerebral art
    • Post cerebral art
    • JOINED BY:
    • Ant/Post Comm Art
    • ICA & Basilar Art
    • Image Upload 30
  95. Circle of Willis Collateral Pathways
    • 1. Hemisphere pathway
    • 2. Post-to-Ant pathway
    • Both ensure bl will not be compromised in the event of stenosis or occlusion
  96. Contralateral Hemisphere of Circle of Willis
    • ⇒AO
    • ⇒To LT CCA
    • ⇒To LT ICA
    • ⇒To LT ANT Cerebral Art
    • ⇒To Ant Comm Art
    • ⇒RT Ant Cerebral Art
    • ⇒To RT Mid Cerebral Art
  97. Post-to-Ant Pathways of Circle of Willis
    • ⇒AO
    • ⇒To Subc Art
    • ⇒To Vert Art
    • ⇒To Basilar Art
    • ⇒To RT PCA (Post Cerebral Art)
    • ⇒RT Post Comm Art
    • ⇒To Dist ICA
    • ⇒To RT Mid Cerebral Art
  98. Transcranial Doppler Technique (TCD)
    • Duplex imaging of intracranial circulation
    • Pt position: Supine
    • Pt must abstain fr movement during exam
    • TX: 1.5 Mhz - 2.5 Mhz small footprint sector
  99. Acoustic Windows for TCD
    • Transtemporal approach
    • Transorbital 
    • Transoccipital
    • Submandibular
  100. Transtemporal approach for TCD
    • Cephalad to zygomatic arch
    • Ant & slightly Sup to ear
    • Can visualize the terminal portion of ICA, ant cerebral, mid cerebral & post cerebral art
  101. Transtemporal Windows for TCD
    • Art         Depth(SV)      Flow dir        MeanVel
    •                 (mm)                             (cm/s)
    • MCA         30-60           towards        55 +/-

    • MCA/        55-65           Bi-dir
    • ACA        

    ACA          60-80           away           50 +/-

    PCA          60-70          towards        39 +/-
  102. Transorbital approach for TCD
    • Probe placed on closed eyelid @ inner canthus of eye
    • PWR must be reduced
    • Ophthalmic art & carotid siphon can be eval
  103. Transoccipital approach to TCD
    • Probe placed bet post margin of foramen magnum (FM) and 1st cervical vertebra
    • Basilar Art & Intracranial portions of Vert Art can be eval
    • Pt s/b in prone or sitting position
  104. Transoccipital Window for TCD
    • Art         Depth(SV)      Flow dir   MeanVel                    (mm)                          (cm/s)
    • OA          40-60          towards      21+/-5

    • Carotid 
    • Siphon     55-80

    • Supraclinoid
    • genu        55-80        away/         41+/-11
    •                               bi-dir    

    Parastellar 55-80       towards       47+/-14
  105. Submandibular Approach for TCD
    • Probe placed under the mandible
    • Petrous portion of ICA can be eval
  106. Submandibular Window for TCD
    • Art         Depth(SV)      Flow dir        MeanVel                (mm)                             (cm/s)
    • Vert        60-90            away          38+/-
    • Basilar    80-120           away          41+/-
  107. Peripheral Arterial Duplex Imaging Lower Ext
    • 1. Rt SFA
    • 2. Rt Tibioperoneal Trunk
    • 3. Rt. Peroneal Art
    • 4. Rt. CFA
    • 5. Abd AO
    • 6. Rt. CIA
    • 7. Rt. Post Tibial Art
    • 8. Rt. Ant Tibial Art
    • 9. Rt. EIA
    • 10. Rt. Internal IA
    • 11. Rt. POP Art
    • 12. Rt. DFA (Deep Femoral Art) or Profunda Femoris Art
    • Image Upload 31
  108. PAD Diagram Lower Ext
    • CFA bif into SFA & DFA
    • CFA arises inf to Inguinal Lig
    • Then divides into DFA and SFA
    • Profunda Art (DFA) lies Post & Lat to SFA
    • Then supplies bl to thigh muscle & hip joint
    • DFA is deep to the SFA
    • SFA runs the length of the thigh
    • Terminates after it passes through an opening in the tendon of the adductor hiatus (aka hunter's canal)
    • Proximal SFA is superficial but dives deep as it travels into distal portion of the thigh
    • POP Art begins the opening of the adductor magnus muscle & travels behind the knee →
    • Pop fossa
    • Major branches of POPA incl sural & genicular art. Gastrocnemius may also be seen as it takes of fr the POPA
  109. PAD Lower Ext Diag
    ATA → PTA
    • ATA branches fr the POPA and travel laterally & anteriorly to the ankle
    • Dorsalis pedis art is a continuation of the ATA on top of the foot
    • Tibioperoneal trunk is the next branch off the POPA.  Pero Art and PTA arises from it
    • Peroneal Art supplies Lateral side of calf & calcaneal region
    • PTA extends obliquely down POST and Med side of leg & passes POST to Med malleolus
    • PTA runs obliquely down the Med POST part of the calf.  It is POST to the tibia & terminates POST to the Med malleolus
    • It then terminates as the Med, Lateral and Plantar Art of the foot
  110. PAD Lower Ext Diagram
    Plantar Arch
    • Composed of the deep plantar art (branch of DPA) and the lateral plantar art (branch of PTA)
    • Arteries of the plantar arch give rise to the dorsal metatarsal art w/c feed the digital art of the toes
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