RVS Part V

• -Veins
• -LE: GSV & LSV
• -UE: Basilic & Cephalic Vns
• -ART
• -Radial A
• -Internal Mammary A
• -Epigastric A

• -Capabilities:
• -Visualize & measure Length & Diameter of vessel
• -Document any areas of pathology & anomalies
• -Limitations:
• -Presence of wounds, staples or incisions can limit imaging areas
• -Previous harvesting of vessels may limit the ID of vessel segments

• -Saphenous vn mapping determines vn suitability & marks the course of the saphenous vns
• -Pt Positioning:
• -Reverse Trendelenburg w/ upper body & head elevated
• -Sitting w/ leg in a dependent position for ID & marking of perforators & comm vns

• -Eval PROX Deep Vns to r/o obstruction
• -Scan the course of Saphenous vns for Patency, Residual thrombus & Duplicate sys
• -Meas Diameter of GSV @ these locations:
• -Upper, Mid, Lower Thigh
• -Upper, Mid, Lower Calf
• -If GSV is unsuitable, meas LSV @ PROX, MID, DIST locations
• -If indicated mark the course of Saphenous Vn on skin prior to surgery
• -If indicated, Perf & Comm Vns s/b ID & marked

• -Normal/adequate for harvesting
• a. Saphenous Vn diameters of 2.5 mm or >
• b. Phasic flow
• -Abnormal/unsuitable for harvesting
• a. Saphenous vn <2mm or 0.2 cm
• b. Saphenous vn varicosities
• c. Perf diameter >3mm=Incompetence
• d. Perf reflux (retrograde flow) lasting longer than 1 sec.

• -Advantages of RA over Saphenous Vn for harvesting:
• 1. Better availability
• 2. Thicker medial walls
• 3. More appropriate vessel diameter
• -Contraindications
• 1. Incomplete Palmar Arch
• 2. Raynaud's syndrome
• 3. Ischemic digits
• 4. Stenosed or occluded RA

• -PPG w/ compression on RA & UA
• -Eval digital Art during Alt comp of Radial/Ulnar A to determine Palmar Arch patency
• -Digital PVR for Palmar Arch testing
• -Digital Po w/ RA comp
• -Duplex imaging for vessel diameter, stenosis & occlusion
• -Eval entire RA for Ca+ segments, Stenosis/Occlusion
• -Meas diameter in PROX, MID, DIST locations
• -Meas PSV in PROX & DIST locations

• a. Good perfusion of Bl to the digits fr UA as indicated by PPG, PVR or digital Po
• b. Diameter meas of @ least 2mm but 2.5 mm or > is preferred
• c. NO indication of stenosis
• d. Normal Triphasic flow w/ no turbulence

• -Radial A dominance
• -Incomplete Palmar Arch
• -Vessel Diameter <2 mm
• -Stenotic or Occluded vessel

• -Hole in the Art wall causing Bl to escape & form a pulsating hematoma in tissue around the vessel
• -Direct: Duplex scanning & color flow imaging
• -Capabilities: Able to determine a Pseudoaneurysm vs a hematoma (usually an ART puncture Post angiogram or ♡ catheterization)
• -Limitations: Surgical dressing, wounds, staples or incisions
• -Pt Positioning: Supine

• -Locate & meas size of Pseudoaneurysm
• -Locate comm channel (neck) to the native art 
• -Tx is firmly comp against skin dir over the neck of pseudo to the point neck is fully comp
• -Comp is @ 10 min intervals for up to 1 hr
• -During comp, check pts foot w/ a CWD to ensure ART is NOT being blocked off & that there is a pedal pulse
• -Comp is contraindicated if:
• -Pseudo is above Inguinal Lig
• -Graft Pseudoaneurysm
• -Pt is on Anticoagulants

• -Location & size of pseudoaneurysm & location neck to native Art is important to document
• -Thrombin is inj→body of the pseudo as Bl flows into it
• -Care must be taken to avoid injecting thrombin→Bl flowing toward the main Art
• -Thrombosis w/in pseudo is most often instantaneous

• -Pseudoaneurysm diameter
• -Neck length & diameter

• -Normal:
• -Single Pseudoaneurysm w/ comm neck to the native Art
• -Abnormal:
• -Multilocular Pseudo: 2 or more distinct lumens comm w/ native Art via a single neck
• -Simultaneous AVF

• -Spectral Doppler:
• -FWD & Reverse flow ('to & fro' flow) w/in the body of the pseudoaneurysm
• -Color Doppler:
• -Detects presence/absence of flow w/in fl coll
• -Determines Dir of flow
• -Swirling pattern w/in pseudo will show 'yin-yang' appearance (red/blue)

• -Abnormal connection betw an ART & a VN
• -Traumatic:
• -Most commonly has a Single connection betw an ART & VN
• -Can occur as a complication of an invasive ART procedure 
• -Common location to form is betw CFA & CFV due to catheterization procedures
• -Congenital:
• -Many small connections betw ART & VNS w/in tissue mass

• -Hematoma may be present
• -When located close to the ♡, there is ↑ risk of Cardiac failure
• -Peripheral Fistula is likely to cause Ischemia of the extremity
• -Diameter & length of fistula will predict the R

• -Loss of Triphasic flow in the Art
• -↑ ART diastolic flow (signal becomes Low R) in the Art PROX to fistula
• -Turbulence & high Vel jet w/in fistula
• -BP is ↓ in the DIST Art
• -Pulsatile Venous flow in PROX Vn
• -Large Chronic fistula may elevate Venous Po; Incompetent Valves & Retrograde flow may be seen in DIST Vns

-Degree of physiologic change depends on the size & location of the fistula

• -Color shows presence or absence of flow w/in the fistula
• -Color pixels indicate Dir of flow
• -Flow Characteristics

• 1. Brescia-Cimino AVF 
• -RA to Cephalic Vn (Most common)
• 2. Straight or looped Synthetic graft
• -Usually PTFE
• -ART to VENOUS anastamoses
• 3. Indwelling catheters
• -For short-term dialysis access

• -Capabilities:
• -Eval Fistula & grafts for defects, stenosis/occlusion
• -Preoperatively assess ART Inflow & Suitability of efferent Vn
• -Limitations:
• -Difficult to examine anastamotic sites bec of graft angulation
• -Diff to eval the Outflow Vn in Obese pt
• -Pt Positioning:
• -Supine w/ arm externally rotated & extended 45^o fr the body

• -Pre-op mapping of inflow/outflow vessels
• a. Eval ART inflow (Brachial, Radial/Ulnar A) for intimal thickening, stenosis or occlusion
• -Eval Venous outflow vessels
• a. Determine patency of Basilic, Cephalic, Axillary, Subc & Innominate Vns
• b. Eval for defects, Residual Thrombus, Diameter & Depth fr surface of skin

• Vessel                             Min Diam (cm)
• AVF Vn                                0.25
• Graft Vn                              0.40
• ART (graft or AVF)               0.20

• -Eval ART inflow PROX to Graft/Fistula
• -Eval ART flow DIST to anastamosis
• -Eval graft @ these locations for Aneurysm, puncture site leaks, Peri-graft fl coll, stenosis or occlusion
• -Eval outflow vn & entire outflow track

• -Record Systolic Vel:
• -Native ART PROX to ART anastamosis
• -ART anastamosis
• -Graft body @ PROX, MID & DIST locations
• -Venous anastamosis
• -Native Vn DIST to Venous anatamosis

• -Flow pattern will be disorganized w/ Spectral broadening
• -High Flow Volumes

• -Stenosis/Occlusion: 
• 1. No flow in graft
• 2. No flow in efferent vn DIST to graft/fistula
• 3. High R in Art PROX to graft/fistula
• 4. Low Venous Outflow

• -Arterial Inflow Art PROX to graft equals Low R, High Diastolic flow
• -Arterial Art DIST to graft anastamosis equals High R, antegrade flow
• -Diastolic Vel are significantly elevated w/in patent access grafts/fistulas

• -High R flow in Inflow A
• -Stenosis or Occlusion w/in graft/fistula or Outflow Venous track
• -Most common sites for stenosis are Venous anastamosis & Outflow Vn
• -Stenosis is usually caused by:
• 1. ↑ Art Po & flow in Vn (thrombus)
• 2. Intimal Hyperplasia

• -Normal:
• -PSV=100-400 cm/s
• -EDV=60-200 cm/s
• -Vel ratios:
• -PSV ratio of 2.0= >50% Diameter stenosis
• -PSV ratio of 3.0= >75% Diameter stenosis
• -Flow Vol: mL/min
• <250=poor dialysis; pending graft failure
• 300-1000=normal range
• >1200=possible CHF

• -CHF causes ↑ systemic Venous Po
• a. ↑ in size of IVC & HV seen due to inability of RT Atrium to rcv all of the Venous Ret
• b. Pts often develop edema in LE due to ↑ Po on the RT side of the ♡ & Venous sys
• -ART Steal
• a. Retrograde flow in the Art DIST to the fistula or graft anastamosis
• b. May result in digit or limb ischemia if collateral pathways are inadequate
• c. NOT all ART steals are symptomatic
• d. Digit Po are useful in determining reduced perfusion due to ART steal

• -Presence/absence of flow w/in the Inflow & Outflow vessels & graft
• -Dir of flow
• -Flow characteristics: ↑ in Vel, turbulence or vessel narrowing can indicate Stenosis

• -Duplex/color flow imaging eval Pre &/or Post-op, Renal & Liver transplants for:
• 1. Stenosis or occlusion of vessels
• 2. Signs of transplant rejection
• 3. Abnormal fl collections

• -Bowel gas overlying the vessels or transplant
• -Depth of penetration (obese pt)
• -Scar tissue
• -Shortness of breath or rapid respirations
• -Types:
• 1. Kidney
• 2. Liver

• -Transplanted Kid will be located subcutaneously in the pelvic region
• -Native Kid is NOT removed @ time of transplant
• -Procedure:
• -Pt Supine
• -Meas Kid length (pole-to-pole)
• -Allograft enlarges over a per of mos & should NOT be considered a sign of rejection

• -Eval Renal transplant in Longitudinal & TRV for:
• 1. Hydro
• 2. Perinephric fl coll: hematoma, abscess, Urinoma, Lymphocele

• -↑ in Renal Vol
• -↑ in Cortical Echogenicity
• -↑ Prominence of Renal Pyramids
• -Cortical Hypoechoic regions (edema, hemorrhage, infarction)
• -↓ echogenicity of Renal Sinus
• -↑ flow R in Parenchymal Art

• -Obtain PSV/EDV meas fr:
• -AO
• -CIA
• -IIA or EIA
• -Donor RA
• -EIV
• -Anastomotic sites
• -Donor RV
• -Allograft Vessels

• -Obtain Doppler waveforms of Parenchymal flow & Calc a RI & PI fr:
• -Segmental A
• -Interlobar A
• -Arcuate A

• -Normal flow:
• -Vel= 80 - 118 cm/s
• -Vol flow=346 - 422 mL/min
• -Parameters for Stenosis exceeding 50% or 60% ↓ in diameter:
• -PSV >190 cm/s w/ PST
• -PSV ≥ 250 cm/s
• -Systolic Vel ration > 3 w/ PST
• -Ratio of PSV fr stenotic area to EIA PSV

• -High R waveform 
• -Sharp, narrow systolic peaks
• -Second Systolic peak higher than the first
• -Minimal or absent Diastolic flow
• -Flow reversal early in Diastole
• -PI ≥ 1.8
• -RI ≥ 0.7

• -Document patency of the:
• 1. PV
• 2. SV
• 3. SMV
• 4. HV
• 5. IVC
• 6. HA
• -Assess Liver parenchyma for masses
• -Eval the Biliary tree

• -Document patency of the:
• *Same as Preoperative Assessment
• -Normal PV flow=HEPATOPETAL
• -Size is ≤ 1-1.5 cm
• -Asses location for abnormal fl collections:
• -Hematoma, Abscess, Biloma, Ascites, Seroma

• -Allograft rejection:
• a. Heterogeneous echo pattern w/in liver
• b. ↓ in Liver echogenicity
• c. Poorly defined Liver margins
• d. ↑ in Periportal Echogenicity
• -Pseudoaneurysm @ the anastamosis sites
• -Hepatic infarction
• -Thrombosis of the PV, IVC &/or HA

• -It is difficult to obtain proper Doppler angle in the HA due to its location
• -Best to obtain a Doppler meas in the PROX HA as it branches fr the CA

• -Determines if ART Po is sufficient for erection
• -Can NOT determine other Vascular etiologies of erectile dysfunction
• -Obtain Brachial & Ankle Po and Calc bilat ABI
• -An Abnormal ABI=Aorto-Iliac dis resulting in abnormal Penile Perfusion & erectile dysfunction
• -Calc Penile to Brachial Index (PBI)

-Use a 2.5 x 9 cm penile Po cuff & a CWD

• 
• -Normal PBI= <0.75
• -Marginal= 0.65-0.74
• -Abnormal=<0.65 (indicates Penile Art Insuff)

• -Normal diam meas of cavernosal Art is 0.5 mm
• -Bl flow in cavernosal Art s/b High R

• -PSV & EDV will ↑ (Low R)
• -PSV >35 cm/s, EDV <5 cm/s during erection
• -75% or > ↑ in diam of cavernosal Art
• -Deep Venous flow normally does NOT ↑
• -Normal Venous flow=<3 cm/s

• -PSV 25 - 29 cm/s=Marginal Art Inflow
• -PSV < 25 cm/s= Insuff Art Perfusion
• -PSV >35 cm/s, but EDV is >6 cm/s suspect Venous leak
• -Vessel Diameter ↑ is <75%

• -Comp (impingement) of the Subc A @ the Thoracic Outlet by the Scalenus muscle, Cervical Rib (1st rib) or the Clavicle
• -Can be caused by:
• 1. Subc A passing betw the ANT & MIDDLE Scalene muscles
• 2. Subc A passing betw the 1st rib & clavicle
• 3. Presence of an additional rib-cervical rib
• 4. ↑ scar tissue due to previous inj
• 5. Can be completely neurogenic due to compression of the brachial plexus-90% of cases
• -Art is compressed when Arm is in certain positions

• -Sensory changes such as 'pins & needles' in hands
• -Pain
• -Hand weakness
• -May see hand & limb atrophy
• -Arm becomes cyanotic in certain positions

• -R/O Subc A Comp as cause of pt sx
• -PPG waveforms may 'flatline' when arm is raised over head in some positions
• -Normal exam cannot R/O TOS completely, only that sx are NOT being caused by Vascular compression

• -Use of PVR, PPG
• -Pt s/b sitting erect w/ hands resting in lap
• -Procedure:
• Perform a baseline resting physiologic exam of the UE
• -Pt Hx, CWD, Segmental Po, PVR
• -Attach PPG sensor to Index finger & monitor Radial A
• -Obtain PPG waveforms while pt: 
• -Is resting w/ hand in lap
• -Arm @ 90^o angle (straight out @ side)
• -Arm in 180^o angle (straight above head)
• -Arm in an exaggerated military 'salute'
• -Document PPG waveform in any position that brings on pts sx
• -Perform PPGs Bilat

-While taking a deep breath & hands in lap, pt turns their head & extends their neck as far as possible to the RT & then LT side

• -Normal:
• -Amplitude of waveform should NOT change or remain similar in any arm position
• -Abnormal:
• -A damping in Systole will signify a partial compression
• -Total loss of the signal or damping to an almost straight line will signify complete compression

• -Pt in Supine position
• -Subc A s/b examined fr the Supraclavicular & Infraclavicular fossa
• -Eval Subc A for Plaque, thrombosis, stenosis or occlusion
• -Observe for narrowing of vessel during various arm positions
• -Obtain PSV in Subc A w/ arm in various positions

• -Using CFI, document Subc A, in various arm positions:
• -W/ arm in Neutral position
• -W/ arm fully abducted & hand drawn towards back of pts head
• -W/ hand placed completely behind head
• -Apply gentle Po to the arm to push it backwards

• -Normal:
• -Triphasic flow w/ PSV betw 70 & 120 cm/s
• -Vel should NOT change w/ position change, but flow pattern may change fr triphasic
• -Abnormal:
• -An impingement on the Subc A will show a ↓ Vel as well as color Aliasing in the area
• -TOS may cause thrombosis, fibrosis & aneurysm of the Art

• -Partial or complete compression of the CA origin by the Arcuate Ligament of the diaphragm
• 1. Acruate Lig crosses ANT to the AO just SUP to the CA
• 2. Upon Expiration, the Lig intermittently compresses the CA as it slides over it
• 3. Sx vary making diagnosis difficult

• -During Expiration
• 1. Vel in the CA will ↑ suggesting a flow reducing stenosis
• 2. Luminal diameter of the CA is compressed
• -During Inspiration
• 1. Vel will immed ↓ (normalize) as the Median Arcuate lig slides off the CA & compression is released
• 2. Luminal diameter of the CA is restored to normal

• -3 types:
• 1. Cranial (Art of face, head & Post Cereberal circulation)
• 2. Large Vessel (axillary & subc)
• 3. Aortic (Aneurysmal degeneration of Ascending AO & AO Valve insufficiency)

• -Autoimmune disorder
• -Long segment steoses, occlusion or aneurysms of Superficial Temp & Facial A
• -Can involve Ophthalmic A leading to Retinal Ischemia
• -Inflammation of ART wall often resulting in thrombosis w/in the vessel
• -Commonly seen in Elderly White Females

• -Polymyalgia
• -Rheumatica
• -Malaise
• -Elevated Sedimentation Rate (ESR)
• -Headaches
• -Focal Temporal Pain

• -Inflammation of vessel wall causes an abnormal 'Halo' appearance around vessel
• -Stenosis will have ≥ two-fold ↑ in PSV & PST
• -Always do BILAT study

• -Difficult diagnosis
• -Must meet 3 of 5 criteria:
• -Age ≥ 50 y/o
• -New headache
• -Temporal Art abnormality on physical exam
• -Elevated ESR ≥ 50 mm/hr
• -Abnormal Temporal Art biopsy

• -Steroidal Therapy
• -Surgical bypass: contraindicated when disease is in active state

• -Inflammatory process of Tunica Media secondary to collage-related disorders
• -Originates @ the AO Arch & progresses outward
• -May affect Subc A
• -Frequently seen in young Asian females
• -Diminishing pulse over a period of time

• -Malaise
• -Myalgia
• -Fever
• -Night Sweats
• -Anorexia
• -Wt loss

• -U/S may show thickening of Subc A
• -Segmental Po may show ↓ Brachial systolic Po
• -PVR waveforms may be abnormal
• -Treatment:
• -Steroidal Therapy
• -Surgical bypass-contraindicated when dis is in active state

• -2ndary to radiation exposure:
• a. Neck
• b. Breast/axilla
• c. Thorax/mediastinum
• -Involves Subc & Axillary A
• -Leads to critical Limb Ischemia
• -Treatment difficult due to radiation inj
• a. Autogenous Vn bypass possible

• -Eval vessels for damages occured fr blunt or penetrating trauma to vessel such as:
• -Acute occlusion
• -Thrombosis
• -Stenosis
• -Pseudoaneurysm
• -Hemorrhage
• -Hematoma
• -Absent distal pulses
• -Intimal flaps

• -Depending on severity of inj, vessel evaluation may be difficult due to hemorrhage or hematoma
• -Open wounds or dressings make access to vessel difficult

• -Allows meas of systolic BP in affected extremity
• -Limitations:
• -Can NOT be used where extensive wounds prevent placement of pneumatic cuff on extremity
• -Can NOT diff betw: Intrinsic Art Lesion, Extrinsic Comp or Vasospasm
• -Distal limb Po measurements cannot detect inj to nonaxial Art

-Used mainly as a screening & ff up in suspicion of ART inj

-Obst w/in the Lymphatic sys causing an accumulation of extracellular fl & protein w/in the subcutaneous tissue & skin

• -Congenital or primary: Vascular dysplasia in utero
• -Acquired or secondary:
• Malignancy, Radiation, Surgery, Pyogenic infection, Trauma

• 1. Limb swelling (starts on dorsum of the foot)
• 2. Heaviness
• 3. Recurrent Lymphangitis
• 4. Skin Changes
• 5. Fungul infections

• 1. Nonpitting limb edema
• 2. Dorsal 'buffalo hump'
• 3. Elephantine distribution of tissue/fl
• 4. Flushed skin color

• 1. Sustained ↑ in capillary Po
• 2. ↓ in plasma oncotic Po
• 3. ↓ in tissue Po
• 4. ↑ in capillary permeability
• 5. Lymphatic obstruction
• 6. Dilation of the pre-capillary sphincters

• -CHF
• -Venous outflow obstruction
• -Cirrhosis
• -Kidney failure
• -Venous Insufficiency

• -Elevation of affected limb(s)
• -↑ of external Po w/ either massage or tight hose/stockings
• -↑ in Bl albumin levels to ↑ osmosis
• -Resolve cause of obst

*Acute Lymphedema is like other edemas in its response to treatment

• -Lymphedema lasting over 1 year
• -Edema becomes non pitting
• -Elevation & external Po ↓ ability to relieve edema
• -Skin becomes thickened, dimpled, 'woody,' 'pig-skin/football-ish'
• -Does NOT have a tendency toward Venous ulceration

• -Biopsy
• -Thrombin inj of pseudoaneurysm
• -Tx compression therapy for pseudoaneurysm
• -Intraoperative surveillance of vessels

• -2 methods:
• 1. Open surgical
• 2. Angioplasty or stenting
• -Duplex is typically performed after the ART repair & prior to incision closure or removal of catheter for angioplasty procedures
• -Vessels eval: Carotid, UE/LE, Visceral ART

• -Flat Linear (w/ small footprint)
• -10-15 MHz for open surgical w/ Dir placement of Tx on vessel wall
• -5-8 MHz for pre or post angiography assessment (Best F for optimal Res)
• -Tx is inserted in a sterile plastic sleeve filled w/ gel
• -Saline is used as the couplant betw Tx  & Vessel for open incision repair in operative wound

• -Select appropriate Tx
• -Assist w/ Sterile technique
• -Image vessel in both TRV & SAG planes
• -Optimize B-mod & Color Doppler
• -Obtain Doppler Vel w/ vessel in Long axis & incident angle ≤ 60^o

• -Inflow
• -Attachment site (PROX)
• -Reconstructed segment (PROX, MID, DIST)
• -Attachment site (DIST)
• -Outflow/runoff
• -Compare results & Vel to prior exams

• -Cause for Post Procedural stenosis:
• 1. Residual plaque
• 2. Suture stenosis
• 3. Kink
• 4. Clamp inj
• 5. Dissection
• 6. Anastomotic
• 7. Entrapment
• 8. Stent Fractures
• -Thrombus
• -Inadequate runoff

• -Elevated PSV &/or EDV
• -PST
• -Absent diastolic flow
• -Reperfusion syndrome or spasm=High Peak & End Diastolic flow

• -Minimally invasive & non-surgical technique to treat Venous Insufficiency or Varicosities
• -Treatment is thru creation of a thermal inj to the Venous luminal wall w/ a sequelae of thrombosis that seals off Vn
• -Radio(F) or Laser Fiber (more curr technique) are utilized for Ablation

• -GSV
• -LSV
• -Accessory branches
• -Perforator Vns

• -Document incompetent Superficial Vns, junctions, Varicosities & Perforators w/ B-mode, color & Spectral Doppler
• -Meas GSV & LSV diameters
• -Confirm non saphenous sources for varicosities
• -Note Depth of Saphenous Vns
• -Assess Deep Venous Sys for DVT

• -Physician performing procedure may hold Tx and perform imaging w/ sonographer operating controls on equipment
• -Sonographer performs imaging & duplex assessment during procedure

• -Pre scan: Document presence or absence of changes since pre-assessment vn mapping
• -Venous access:
• -CTR vessel in cross-section
• -Optimize for Max image quality
• -Access is gained
• -Confirm wire placement in Long axis fr insertion to desired point
• -Confirm tip of laser fiber is @ least 2 cm fr junction

• -Confirm fl above vn containing sheath & laser fiber
• -Confirm Vn is surrounded by fl & is collapsed
• -Ablation:
• 1. FF movement of laser tip as it is pulled back
• 2. Visualize steam bubbles to verify laser firing
• -Verify Vn closure
• -Assess venous junction to confirm absence of thrombus extension→deep vns

• -Assess LE for DVT
• -Verify Vein closure

• -Miniature Tx is positioned @ tip of an Intraluminal catheter
• -F range is usually 20 MHz or higher
• -Provides high resolution vessel imaging of lumen, vessel wall, & lesion morphology
• -Assists in decisions for the most appropriate intervention option