St. Joseph Mercy Health System endorses the Essentials and Standards of the Accreditation Council for Continuing Medical Education: Faculty are expected to disclose to the audience all relationships with pharmaceutical companies, biomedical device manufacturers, and other healthcare- related for-profit entities... Michalene McPharlin has nothing to disclose DISCLOSURE
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A, B, Cs of Arterial Studies - St. Joseph Mercy Ann Arbor
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St. Joseph Mercy Health System endorses the Essentials and Standards of the Accreditation Council for Continuing Medical Education: Faculty are expected to disclose to the audience all relationships with pharmaceutical companies, biomedical device manufacturers, and other healthcare-related for-profit entities...
Michalene McPharlin has nothing to disclose
DISCLOSURE
‘A’ is for ANATOMY
Aortic Arch &Major Vessels ofUpper Extremity
Aorta and Major Vessels of Abdomen
Major Vessels of Aorto-iliac Segment
Major Vesselsof LowerExtremity
Example of Normal AngiogramExample of Normal Angiogramof Lower Extremity (AP)of Lower Extremity (AP)
SG: Supreme SG: Supreme geniculargenicular
SLG: Superior SLG: Superior lateral genicularlateral genicular
SMG: Superior SMG: Superior medial genicular medial genicular
Example of Normal AngiogramExample of Normal Angiogramof Lower Extremity (AP) of Lower Extremity (AP)
SMG: Superior SMG: Superior medial genicular medial genicular
SLG: Superior SLG: Superior lateral genicularlateral genicular
4601 Presidents Drive, Suite 260, Lanham, MD 20706-4831 Toll-free: 800-788-8346
Telephone: 301-459-7550 Fax: 301-459-5651
svunet.org
Professional Performance Guidelines
Screening For Abdominal Aortic Aneurysms (AAA)(2/5/13)Mesenteric/Splanchnic Artery Duplex Imaging (2/5/13)Renal Artery Duplex Imaging (11/15/12)Lower Extremity Arterial Duplex Evaluation (8/10/12)Upper Extremity Vein Mapping for Creation of a Dialysis Access or Peripheral Vascular Bypass Graft (8/10/12)Transcranial Doppler in Pediatric Patients with Sickle Cell Anemia: (Non-Imaging) (04/11/12)Evaluation of Dialysis Access (04/11/12)Lower Extremity Arterial Segmental Physiologic Evaluation (04/11/12)
Professional Performance Guidelines
Radial Artery Assessment for Coronary Artery Bypass(04/11/12)Intracranial Cerebrovascular Evaluation Transcranial Doppler (Non-Imaging) and Transcranial Duplex Imaging (TCDI) (04/11/12)Quality Assurance Guidelines for Accuracy of Examinations in the Vascular Laboratory (3/13/12)Upper Extremity Arterial Segmental Physiologic Evaluation (Arterial, TOS, Cold) (revised 12/22/11)Upper Extremity Arterial Duplex Evaluation (revised 11/11)Abdominal Aortoiliac Duplex Evaluation (revised 11/11)Extracranial Cerebrovascular Duplex Ultrasound Evaluation (revised 06/11)
Scope of Practice
Diagnostic Ultrasound Professionals…Perform patient assessmentsAcquire and analyze data obtained using
ultrasound and related diagnostic technologiesProvide a summary of findings to the physician to
aid in patient diagnosis and managementUse independent judgment and systematic
problem solving methods to produce high quality diagnostic information and optimize patient care.
Intersocietal Commission on the Accreditation of Vascular Laboratories
(ICAVL)
6021 University Blvd, Suite 500, Ellicott, MD 21043
Toll-free: 800-838-2110 Fax: 866-663-5663
Intersocietal.org/vascular
3.6.3B Duplex ultrasound of lower extremity arteries (if performed) must include:
3.6.3.1B Grayscale and/or color Doppler images must be documented as required by the protocol and must include at a minimum:
i. common femoral artery; ii. superficial femoral artery; iii. proximal deep femoral artery; iv. popliteal artery; and v. aorta, common and external iliac arteries and tibial
arteries (when appropriate); vi. bypass graft(s) when present including anastomoses.
3.6.3B Duplex ultrasound of lower extremity arteries (if performed) must include:
3.6.3.2B Spectral Doppler waveforms and velocity measurements must be documented as required by the protocol and must include at a minimum waveforms from:
i. common femoral artery; ii. superficial femoral artery; iii. proximal deep femoral artery; iv. popliteal artery; v. tibial arteries; vi. aorta, common and external iliac arteries (when
appropriate); and vii. bypass graft when present, including proximal and
distal anastomoses, inflow and outflow arteries.
Remember to ‘Think Outside the Box’…
Protocols are guidelines that represent ‘best practice’ in the majority of patient situations.
Thinking Outside the Box…
Atypical signs/symptoms or unusual findings compel you to obtain additional information, e.g., more anatomic images and/or flow patterns than stated in protocol.Innovative surgical procedures may require additional documentation in post-op or surveillance studies.Our goal should be to help answer the clinical question whether it follows a ‘protocol’ or not.
‘C’ COMPLETES THE PROCESS
Did you help answer the clinical question/s?
“Listen to your patients, at least 90% of your diagnosis is based on the history and physical examination. The other 10% depends on diagnostic tests”
D. Eugene Strandness, Jr., M.D.
A Critical Component of All Noninvasive Evaluations…
Requires thinking outside the box: Truly listening to the patientA willingness to do more than what is stated in the protocol
Diagnostic Tests: Noninvasive Evaluations…
Serves to refine the clinical evaluation by providing objective information about anatomy and physiologyRequires knowledge of:
Suggested Criteria For Doppler Diagnosis of ICA Ste nosis
Additional Parameters
Stented VesselsStented Vessels
Elevated velocities are expectedElevated velocities are expected
However, greatly elevated However, greatly elevated velocities are abnormalvelocities are abnormal
Image and velocity measurements Image and velocity measurements are critical in the evaluation of are critical in the evaluation of stented vesselsstented vessels
Additional Data Obtained…
Pressure Measurements
Four cuff method
Three cuff method
Interpretation: LE Pressures
Ankle/brachial Index (ABI): divide ankle BP by higher brachial BP
> 1.0 = Normal
>0.9 - 1.0 = May be within normal limits
0.8 - 0.9 = Mild arterial disease
0.5 - 0.8 = Claudication (moderate disease)
< 0.5 = Rest pain (severe disease)(Incompressible vessels can cause falsely elevated BP)
Additional Guidelines:
Segmental P drops of >30 mmHg between 2 adjacent levels is significant
Horizontal P difference of >20-30 mmHg suggests obstructive disease
Interpretation: UE Pressures
15-20 mmHg difference from arm - arm
>15-20 mmHg drop from upper arm to forearm suggests…– Brachial A obstruction distal to upper cuff– Obstruction in both radial and ulnar A– Obstruction in single forearm A
>20 mmHg between radial and ulnar
Interpretation: Digits
UE digits : Finger/brachial indices 0.8-0.9
LE digits :Toe/brachial indices 0.6-0.8
Interpretation: Penile Pressures
Normal = > 0.75
Marginal = 0.65 – 0.74
Abnormal = < 0.65
Completing the Process Includes…
Generating waveforms, gray-scale images, color-flow Doppler, and variouscalculations Knowing when additional information is needed to help answer the clinical question
The Process isn’t Complete Until the Paperwork is Done…
Storing/processing the diagnostic information obtainedProviding preliminary reportCompleting billing documentsSubmitting data for final report
In conclusion...In conclusion...
Know the A, B, Cs of arterial testingKnow the A, B, Cs of arterial testing …It will help you provide important diagnostic information critical to the medical and/or surgical management of your patient.However, the value of that information is directly related to your knowledge, skill, and willingness to sometimes ‘think outside the box’ in order to answer the clinical question.
YOU make the Difference...YOU make the Difference...
Between an adequate study and an exceptional oneDetermining whether additional diagnostic information is neededAssisting with possible treatment optionsEvaluating the success of traditionaland/or non-traditional treatment
YOU make the Difference...YOU make the Difference...