Lower Extremity Wounds: The role of the vascular technologist Jesse Thomas, RVT UNC Health Care
Feb 25, 2016
Lower Extremity Wounds: The role of the vascular technologist
Jesse Thomas, RVTUNC Health Care
DISCLOSURES
NO RELEVANT CONFLICTS OF INTEREST TO DECLARE
Objectives
• Review types of wounds• Discuss risk factors• Role of Duplex Imaging• Role as a Technologist
• This presentation will NOT address the use of ultrasound as a wound management and/or treatment tool.
Types of Wounds
•Arterial•Venous•Neuropathic• Small vessel/Vasculitis•Pressure ulcers
Arterial• Ischemic wounds• Result of
inadequate blood supply• Tissue hypoxia and
tissue damage• Most commonly
result of atherosclerotic disease (PAD)
PAD
• Narrowing of arteries to the limbs that reduces blood flow•More common in
LE• Atherosclerosis –
build up of fatty deposits (plaque)
Arterial• Risk Factors• High cholesterol• Aging• HTN• Diabetes• Smoking• Family hx of
cardiovascular disease• Obesity
PAD• Approximately 8
million people in the US• 12-20% in those
>60• Public awareness
around 25%• Associated with
significant morbidity and mortality
Source: National Center for Chronic Disease Prevention and Health Promotion
PAD• May present with
variety of signs/symptoms• Claudication – to
limp• Aching, cramping
pain brought on by exercise and relieved with rest• Calf, thigh, hips or
buttocks
PAD
• Rest pain• Non-healing
ulceration• gangrene
Arterial Ulcers• Characteristics• “punched out”
appearance• Smooth wound edges• Surrounding skin may
exhibit dusky erythema• Cool to touch• Hairless, thin, brittle
with shiny texture
Arterial Ulcers
• Typically lower leg• Lateral foot• Toes• Pressure points
or where injury has occurred
Arterial Ulcers
• Jesse, why do I care what these look like and are you done showing these nasty pictures?
Role of Sonographer
• Patient history• Physical exam• ABI’s• Clues to what is
going on before you put the transducer on the patient
Role of Duplex• Presence or absence of disease• Severity• Physiologic• Anatomic
• Location• Single level• Asymptomatic• claudication
• Multi-level • Claudication• Rest pain• ulcerations
Pressures
• Ankle/Brachial Index (ABI)• 1.0-1.2 Normal• 0.92-0.99 may indicate
presence of arterial obstruction • <0.92 Evidence of
arterial obstruction, claudication• <0.40 associated with
rest pain or tissue loss
Pressures--Toe
• Photoplethysmography (PPG)• Infrared light which
responds to changes in blood content near the surface of the skin• Waveform analysis and
pressure measurement
Pressures--Toe
• Disease from the level of the ankle to the toe• Diabetics•Wound healing
potential• Absolute number
and index
Pressures--Toe• A toe/ankle index >0.60
suggests the absence of hemodynamically significant obstruction between the ankle and the toe
• A toe/brachial index >0.60 suggests the absence of hemodynamically significant obstruction between the heart and the digit
Pressures--Toe
TCPo2• Transcutaneous oxygen tension• Evaluates oxygen delivery to tissue• Indirect measure of local blood flow• Aids in determining wound healing potential
• Patient in supine position• Small electrodes placed at chest, below knee, and 2 over dorsum
of foot• Electrodes in the sensors heat area underneath the skin to dilate
capillaries• Results recorded and measured in mmHg• >30 mmHg – greater success for wound healing• <30 mmHg - suggests high likelihood of wound not healing
Pressures--Segmental
• Typically 3 or 4 cuff system•High thigh, above knee, calf, ankle•Measures pressure at each level• >30mmHg gradient from level to level
is significant• >40mmHg indicates occlusion• >20mmHg from side to side is also
significant
Pressures--Segmental
• Pitfalls include• Medial arterial
calcification• Limb girth• Inappropriate cuff
size• Can be
uncomfortable for patient
Pressures--Segmental
Pulse Volume Recordings (PVR)
•Measures pressure changes in the bladder of the cuff wrapped around the leg• These changes reflect change in cuff
volume•Can use same cuffs as used for
segmental pressures
PVR
•A 1mmHg pressure change detected in the cuff produces a 20mm deflection (amplitude) on the chart recorder•Using appropriate size cuffs, a preset
pressure is obtained•A recording is then obtained
PVR
PVR/Segmental Pressures
• PVR waveforms and segmental pressures are complimentary tests• If differences exist
then a source of error should be investigated
Duplex• Image based
evaluation• Looking for
anatomic disease and physiologic disease
Duplex – Segmental
Duplex
PW Doppler--Duplex
Velocity Ratio (VR) = 6.1
Velocity Ratio = v2/v1
V2= highest peak systolic velocity
V1= proximal normal vessel
Arterial Ulcers• Role of Duplex
essential to understanding presence, location, and severity of disease• Guides intervention
and management• Indicator wound
healing potential
Changing Gears
Venous Ulcers
• Result of sustained venous hypertension (Chronic venous insufficiency)• Incompetent valves or poor calf muscle pump• Local venous dilatation and pooling• Traps leukocytes that may release proteolytic
enzymes that destroy tissues• May also “trap” important growth factors within
vein rendering them unavailable for wound repair
Venous
•70%-90% of chronic wound cases• Estimated 2.5 million patients in the
US•Rarely fatal - can severely diminish
quality of life
Venous Ulcers• CVI Risk factors• > Age• Hx DVT• Surgery• Restricted mobility• CHF• Cancer• Obesity• Smoking• Family hx VTE• Hypercoable state (Factor V Leiden, Protein C/S deficiency, etc.)
• Sedentary lifestyle• Varicosities
Venous Ulcers• Wound characteristics• Gaiter region –
medial malleolus• Superficial, irregular
shape• Skin shiny and tight
(edema)• Brown or purple
discoloration – “stasis skin changes”
Stasis Skin Changes
Varicose Veins
Varicose Veins
Varicose Veins
Varicose Veins • Complications• Swelling• Pain/aching• itching• Leg heaviness• Phlebitis – inflammation of vein• Superficial thrombophlebitis• bleeding• Cosmetic
• Not commonly associated with venous ulcers when isolated to the superficial system
Role of the Sonographer
•Patient history•Physical exam•Clues to what is
going on before you put the transducer on the patient
Role of Duplex• Presence or absence of disease• Severity• Physiologic• Anatomic
• Location• Deep• Superficial
Venous Obstruction
• Presence or absence of deep or superficial venous obstruction• Compression
ultrasound
Venous Obstruction• Thrombus Characteristics• Acute
• Softly echogenic• Spongy• Dilated vein• Smooth borders
• Chronic• Brightly echogenic• Rigid• Contracted vein• Irregular borders• Presence of collaterals
Acute or Chronic?
• These distinguishing characteristics are not absolute• “Can be useful in estimating the age of a
thrombus and the risk of its embolization.” (Techniques of Venous Imaging. Talbot, Oliver. 1992)
Venous Duplex• Complete and careful evaluation• Deep
• CFV• Fv• Pop• Tibials• Gastrocs, soleals, etc.
• Superficial• Great Saphenous Vein (GSV)• Small Saphenous Vein (SSV)• tributaries
Venous Insufficiency
• Evaluation of reflux (deep and superficial)• Supine•Manual hand augments
• Standing• Rapid inflation/deflation cuff system• “stresses” vein – hydrostatic pressure
• Valsalva• Patient unable to stand
Venous Insufficiency
• Patient standing• Cuff around calf• Rapidly inflates•Measure reflux on
cuff deflation• Ergonomic
challenges• Patient
limitations
Venous Insufficiency• Normal values• < 0.5 seconds
• Abnormal• > 0.5 seconds
• Indication of valvular incompetency (reflux)
Perforator Assessment• Connection between
deep and superficial systems• Drains superficial into
deep system• Contain valves• Associated with ulcer
formation
Perforator Assessment
• Dodd’s• Boyd’s• Cockett’s• Name given by
1st physician who described them
Venous Duplex• Other considerations• Size of veins• May help determine
intervention method• Too large may not
respond well to local sclerotherapy or some types of venous ablation
• “map” of veins• Anatomical blueprint
sometimes required• Help guide intervening
physician
Venous Ulcers• Role of Duplex
essential to understanding presence, location, and severity of disease• Guides intervention
and management
Conclusion
• Patients presenting with ulcerations to the vascular lab is a common occurrence• Technologist and physician education important• Use all available skills and tools to assess your
patients• Wound management is complex and your role is
critical in providing the necessary vascular information
Thank you!