ABC of Arterial and Venous Disease - ...

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ABC of arterial and venous disease
Non-invasive methods of arterial and venous assessment
Richard Donnelly, David Hinwood, Nick J M London
Although diagnostic and therapeutic decisions in patients with
vascular disease are guided primarily by the history and
physical examination, the use of non-invasive investigations has
increased significantly in recent years, mainly as a result of
technological advances in ultrasonography. This article
describes the main investigative techniques.
Principles of vascular
ultrasonography
In the simplest form of ultrasonography, ultrasound is
transmitted as a continuous beam from a probe that contains
two piezoelectric crystals. The transmitting crystal produces
ultrasound at a fixed frequency (set by the operator according
to the depth of the vessel being examined), and the receiving
crystal vibrates in response to reflected waves and produces an
output voltage. Conventional B mode (brightness mode)
ultrasonography records the ultrasound waves reflected from
tissue interfaces, and a two dimensional picture is built up
according to the reflective properties of the tissues.
Handheld pencil Doppler being used to measure ankle brachial pressure
index
Doppler ultrasonography
Ultrasound signals reflected off stationary surfaces retain the
same frequency with which they were transmitted, but the
principle underlying Doppler ultrasonography is that the
frequency of signals reflected from moving objects such as red
blood cells shifts in proportion to the velocity of the target. The
output from a continuous wave Doppler ultrasonograph is
usually presented as an audible signal, so that a sound is heard
whenever there is movement of blood in the vessel being
examined.
Tight 7x
Pulsed ultrasonography
Continuous wave ultrasonography provides little scope for
restricting the area of tissue that is being examined because any
sound waves that are intercepted by the receiving crystal will
produce an output signal. The solution is to use pulsed
ultrasonography. The investigator can focus on a specific tissue
plane by transmitting a pulse of ultrasound and closing the
receiver except when signals from a predetermined depth are
returning. This allows, for example, the centre of an artery and
the areas close to the vessel wall to be examined in turn.
Significant 3x
Duplex scanners
An important advance in vascular ultrasonography has been
the development of spectral analysis, which delineates the
complete spectrum of frequencies (that is, blood flow velocities)
found in the arterial waveform during a single cardiac cycle.
The normal (“triphasic”) Doppler velocity waveform is made up
of three components which correspond to different phases of
arterial flow: rapid antegrade flow reaching a peak during
systole, transient reversal of flow during early diastole, and slow
antegrade flow during late diastole.
Doppler examination of an artery distal to a stenosis will
show characteristic changes in the velocity profile: the rate of
rise is delayed, the amplitude decreased, and the transient flow
reversal in early diastole is lost. In severe disease, the Doppler
4x
Left: Doppler velocity waveforms: (
a
) triphasic waveform in normal artery;
(
b
) biphasic waveform, with increased velocity, through a mild stenosis; (
c
)
monophasic waveform, with greatly increased velocity, through tight stenosis;
and (
d
) dampened monophasic waveform, with reduced velocity, recorded
distal to tight stenosis. Right: Anatomical chart used to record position of
stenoses, showing three stenoses with velocity increases of 7
´
, 4
, and 3
´
compared with adjacent unaffected arteries
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Clinical review
waveform flattens; in critical limb ischaemia it may be
undetectable.
Examination of an arterial stenosis shows an increase in
blood velocity through the area of narrowing. The site(s) of any
stenotic lesions can be identified by serial placement of the
Doppler probe along the extremities. The criteria used to define
a stenosis vary between laboratories, but a twofold increase in
peak systolic velocity compared with the velocity in an adjacent
segment of the artery usually signifies a stenosis of 50% or
more.
Relation between increased blood velocity and degree of
stenosis
Spectral analysis of blood velocity in a stenosis, and
unaffected area of proximal superficial femoral artery. The
velocity increases from 150 to 300 m/s across the stenosis
Diameter of
stenosis (%)
Peak sytolic
velocity* (m/s)
Peak diastolic
velocity* (m/s)
Internal: common
carotid artery
velocity ratio†
0-39
< 1.1
< 0.45
< 1.8
4-59
1.1-1.49
< 0.45
< 1.8
60-79
1.5-2.49
0.45-1.4
1.8-3.7
80-99
2.5-6.1
> 1.4
> 3.7
> 99 (critical) Extremely low NA
NA
*Measured in lower part of internal carotid artery
†Ratio of peak systolic velocity in internal carotid artery stenosis
relative to proximal measurement in common carotid artery
By combining the pulsed Doppler system with real time B
mode ultrasound imaging of vessels, it is possible to examine
Doppler flow patterns in a precisely defined area within the
vessel lumen. This combination of real time B mode sound
imaging with pulsed Doppler ultrasonography is called duplex
scanning. The addition of colour frequency mapping (so called
colour duplex or triplex scanners) makes the identification of
arterial stenoses even easier and reduces the scanning time.
Colour duplex scanning of blood flow through stenosis of superficial
femoral artery. Colour assignment (red or blue) depends on direction of
blood flow and colour saturation reflects velocity of blood flow. Less
saturation indicates regions of higher blood flow and deeper colours
indicate slower flow; the absence of flow is coded as black
100
ABPI < 0.4
ABPI 0.4-0.85
ABPI > 0.85
800
Investigations of arterial disease
60
40
Ankle brachial pressure index
Under normal conditions, systolic blood pressure in the legs is
equal to or slightly greater than the systolic pressure in the
upper limbs. In the presence of an arterial stenosis, a reduction
in pressure occurs distal to the lesion. The ankle brachial
pressure index, which is calculated from the ratio of ankle to
brachial systolic pressure, is a sensitive marker of arterial
insufficiency.
The highest pressure measured in any ankle artery is used
as the numerator in the calculation of the index; a value >1.0 is
normal and a value < 0.9 is abnormal. Patients with
claudication tend to have ankle brachial pressure indexes in the
range 0.5-0.9, whereas those with critical ischaemia usually have
an index of < 0.5. The index also has prognostic significance
because of the association with arterial disease elsewhere,
especially coronary heart disease.
20
0
2
4
6
8
10
Years
Patient survival according to measurements of ankle brachial pressure index
(adapted from McKenna et al,
Atherosclerosis
1991;87:119-28)
Diabetic limbs
Systolic blood pressure in the lower limbs cannot be measured
reliably when the vessels are calcified and incompressible—for
example, in patients with diabetes—as this can result in falsely
high ankle pressures. An alternative approach is to use either
the pole test or measurement of toe pressures. Normal toe
systolic pressure ranges from 90-100 mm Hg and is 80-90% of
brachial systolic pressure. A toe systolic pressure < 30 mm Hg
indicates critical ischaemia.
Pole test for measurement of ankle pressures in patients with calcified
vessels: the Doppler probe is placed over a patent pedal artery and the foot
raised against a pole that is calibrated in mm Hg. The point at which the
pedal signal disappears is taken as the ankle pressure
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Walk test
Exercise testing will assess the functional limitations of arterial
stenoses and differentiate occlusive arterial disease from other
causes of exercise induced lower limb symptoms—for example,
neurogenic claudication secondary to spinal stenosis. A limited
inflow of blood in a limb with occlusive arterial disease results
in a fall in ankle systolic blood pressure during exercise induced
peripheral vasodilatation.
The walk test is performed by exercising the patient for 5
minutes, ideally on a treadmill, but walking the patient in the
surgery or marking time on the spot are adequate. The ankle
brachial pressure index is measured before and after exercise. A
pressure drop of 20% or more indicates significant arterial
disease. If there is no drop in ankle systolic pressure after a 5
minute brisk walk, the patient does not have occlusive arterial
disease proximal to the ankle in that limb.
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
Normal
0.2
Intermittent claudication
0.1
0
0
Rest
1
5
10
20
Min after exercise
Fall in ankle brachial pressure index with exercise in patient with
intermittent claudication and normal subject (adapted from Creager,
Vasc
Med
1997;2:231-7)
Duplex scanning
Duplex ultrasonography has a sensitivity of 80% and a
specificity of 90-100% for detecting femoral and popliteal
disease compared with angiography, but it is less reliable for
assessing the severity of stenoses in the tibial and peroneal
arteries. Duplex scanning is especially useful for assessing the
carotid arteries and for surveillance of infrainguinal bypass
grafts where sites of stenosis can be identified before complete
graft occlusion occurs and before there is a fall in ankle brachial
pressure index. The normal velocity within a graft conduit is
50-120 cm/s. As with native arteries, a twofold increase in peak
systolic velocity indicates a stenosis of 50% or more. A peak
velocity < 45 cm/s occurs in grafts at high risk of failure.
Uses of colour duplex scanning
Arterial
x
Identify obstructive
atherosclerotic disease:
Carotid
Renal
Venous
x
Diagnosis of deep vein thrombosis
above the knee
x
Assessing competence of valves in
deep veins
x
Surveillance of
infrainguinal bypass grafts
x
Superficial venous reflux:
Assessing patient with recurrent
varicose veins
Identify and locate reflux at
saphenopopliteal junction
x
Surveillance of lower limb
arteries after angioplasty
x
Preoperative mapping of saphenous
vein
Identification of distal vessels for arterial bypass grafting
In critically ischaemic limbs, where occlusive disease tends to be
present at multiple levels, arteriography often fails to show
patent calf or pedal vessels as potential outflows for
femorodistal bypass grafting. Alternative non-invasive
approaches have been developed for preoperative assessment,
including pulse generated run off and dependent Doppler
assessment.
Clinical use of transcranial Doppler scanning in adults
x
Intraoperative monitoring during carotid endarterctomy:
Shunt function
Cerebral perfusion
x
Postoperative montoring after carotid endarterectomy:
Detection of emboli
Formation of carotid thrombus
Transcranial Doppler ultrasonography
Lower frequency Doppler probes (1-2 MHz) can be used to
obtain information about blood flow in arteries comprising the
circle of Willis and its principal branches. Mean flow velocities
> 80 cm/s in the middle cerebral artery, or > 70 cm/s in the
posterior and basilar arteries, indicate a serious stenosis.
Transcranial Doppler scanning has several applications but is
especially useful for intraoperative and postoperative
monitoring of patients having carotid endarterectomy.
x
Detection of intracranial vasospasm after subarachnoid
haemorrhage
x
Detection of middle cerebral artery disease
x
Evaluation of collateral circulation in patients with carotid disease
x
Evaluation of arteriovenous malformations of the brain
Helical or spiral computed tomography
Spiral computed tomography is a new, minimally invasive
technique for vascular imaging that is made possible by
combining two recent advances: slip ring computed
tomography (which allows the
x
ray tube detector apparatus to
rotate continuously) and computerised three dimensional
reconstruction. A helical scan can cover the entire region of
interest (for example, the abdominal aorta from the diaphragm
to the iliac bifurcation) in one 30-40 second exposure, usually in
a single breath hold. This minimises motion artefact and allows
all the scan data to be collected during the first pass of an
intravenous bolus of contrast through the arterial tree—that is
during the time of maximal arterial opacification. A large
number of finely spaced slices from one scan can then be
reconstructed to produce high quality two or three dimensional
images of the contrast enhanced vessels.
Spiral computed tomogram of both carotid systems showing a tight stenosis
in the proximal segment of left internal carotid artery
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Magnetic resonance angiography
Magnetic resonance angiography has developed rapidly over
the past five years. It has the advantage of imaging a moving
column of blood and does not require ionising radiation or
iodinated contrast, but the technique has obvious drawbacks in
terms of cost efficiency and accessibility to scanners. A variety of
imaging sequences are used depending on the vessels being
studied and the field strength of the machine. The most
commonly used techniques include time of flight, two and three
dimensional angiography and phase contrast.
Use of a magnetic resonance imaging scanner with a high
field strength (which allows rapid acquisition of data) and a
carefully timed bolus of gadolinium contrast enables high
quality angiographic images to be obtained in a single breath
hold. Magnetic resonance angiography is well established for
examining the cerebral vessels and the carotid arteries, and its
role in other territories is being extended.
Magnetic resonance angiogram using an intravenous bolus of
gadolinium contrast showing normal renal arteries
Investigations of venous disease
Venous thrombosis
Colour Duplex scanning is both sensitive and specific (90-100%
in most series) for detecting proximal deep vein thrombosis.
Deep veins and arteries lie together in the leg, and the normal
vein appears as an echo-free channel and is usually larger than
the accompanying artery.
Venous ultrasonography is a very accurate method of
identifying deep vein thrombi from the level of the common
femoral vein at the groin crease to the popliteal vein but is less
reliable for diagnosing calf vein thrombosis.
Artery
Artery
Artery
Vein
Criteria for diagnosis of deep vein thrombosis
x
Vein
Vein
Failure of vein to collapse on direct compression
Ultrasound detection of deep vein thrombosis. The probe is held lightly on
the skin and advanced along the course of the vein (left). Pressure is applied
every few centimetres by compressing the transducer head against the skin.
The vein collapses during compression if no thrombus is present (middle)
but not if a deep vein thrombus is present (right)
x
Visualisation of thrombus within lumen
x
Absent or abnormal venous pulsation on Doppler scanning
Venous reflux
Colour duplex scanning has revolutionised the investigation of
the lower limb venous system because it allows instant
visualisation of blood flow and its direction. Thus, reflux at the
saphenofemoral junction, saphenopopliteal junction, and
within the deep venous system, including the popliteal vein
beneath the knee and the gastrocnemius veins, can be detected
without invasive techniques. Although venous reflux can be
assessed with a pencil Doppler, this technique misses 12% of
saphenofemoral and 20% of saphenopopliteal junction reflux
compared with colour duplex scanning.
We thank Jean Clarke for expert secretarial assistance; Frances Ryan and
Tim Hartshorne (vascular technicians) and colleagues in the vascular labo-
ratories at Derbyshire Royal Infirmary and Leicester Royal Infirmary; Ken
Callum and Roddy Nash (vascular surgeons) for helpful input to the
manuscript and illustrations; and Jane Wain and staff of the audiovisual
department at Derbyshire Royal Infirmary.
David Hinwood is consultant vascular radiologist, Derbyshire Royal
Infirmary, Derby.
The ABC of arterial and venous disease is edited by Richard
Donnelly, professor of vascular medicine, University of Nottingham
and Southern Derbyshire Acute Hospitals NHS Trust
(richard.donnelly@ nottingham.ac.uk) and Nick J M London,
professor of surgery, University of Leicester, Leicester
(sms16@leicester.ac.uk). It will be published as a book later
this year.
Colour duplex scanning of saphenopopliteal junction. The calf muscles are
manually compressed producing upward flow in the vein (top), which
appears as a blue colour for flow towards the heart (panel A). Sudden
release of the distal compression causes reflux, seen as a red colour
indicating flow away from the heart (panel B)
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ABC of arterial and venous disease
Acute limb ischaemia
Ken Callum, Andrew Bradbury
Limb ischaemia is classified on the basis of onset and severity.
Complete acute ischaemia will lead to extensive tissue necrosis
within six hours unless the limb is surgically revascularised.
Incomplete acute ischaemia can usually be treated medically in
the first instance. Patients with irreversible ischaemia require
urgent amputation unless it is too extensive or the patient too ill
to survive.
Classification of limb ischaemia
Terminology
Onset:
Acute
Acute on chronic
Definition or comment
Ischaemia < 14 days
Worsening symptoms and
signs ( < 14 days)
Ischaemia stable for > 14 days
Chronic
Severity (acute, acute on chronic):
Incomplete
Complete
Irreversible
Clinical features
Limb not threatened
Limb threatened
Limb non-viable
Apart from paralysis (inability to wiggle toes or fingers) and
anaesthesia (loss of light touch over the dorsum of the foot or
hand), the symptoms and signs of acute ischaemia are
non-specific or inconsistently related to its completeness. Pain
on squeezing the calf indicates muscle infarction and
impending irreversible ischaemia.
Acute arterial occlusion is associated with intense spasm in
the distal arterial tree, and initially the limb will appear “marble”
white. Over the next few hours, the spasm relaxes and the skin
fills with deoxygenated blood leading to mottling that is light
blue or purple, has a fine reticular pattern, and blanches on
pressure. At this stage the limb is still salvageable. However, as
ischaemia progresses, stagnant blood coagulates leading to
mottling that is darker in colour, coarser in pattern, and does
not blanch. Finally, large patches of fixed staining progress to
blistering and liquefaction. Attempts to revascularise such a
limb are futile and will lead to life threatening reperfusion
injury. In cases of real doubt the muscle can be examined at
surgery through a small fasciotomy incision. It is usually
obvious when the muscle is dead.
Comment
Occasionally absent in complete ischaemia
Also present in chronic ischaemia
Also present in chronic ischaemia
Unreliable as ischaemic limb takes on ambient
temperature
Leading to anaesthesia (unable to feel touch
on foot or hand)
Unable to wiggle toes or fingers
*Anaesthesia and paralysis are the key to diagnosing complete ischaemia
that requires emergency surgical treatment
Paraesthesia*
Paralysis*
Aetiology
Acute limb ischaemia is most commonly caused by acute
thrombotic occlusion of a pre-existing stenotic arterial segment
(60% of cases) or by embolus (30%). Distinguishing these two
conditions is important because treatment and prognosis are
different. Other causes are trauma, iatrogenic injury, popliteal
aneurysm, and aortic dissection.
More than 80% of peripheral emboli arise from the left
atrial appendage in association with atrial fibrillation. They may
also arise from the left ventricle, heart valves, prosthetic bypass
grafts, aneurysmal disease, paradoxical embolism, and atrial
myxoma (rare). In 15% of cases the source of embolus is
obscure. Thrombosis in situ may arise from acute plaque
rupture, hypovolaemia, or pump failure (see below).
Marble white foot (left of picture) in
patient with acute ischaemia
Differentiation of embolus and acute arterial thrombosis
(thrombosis in situ)
Clinical features
Severity
Embolus
Complete (no
collaterals)
Seconds or minutes
Leg 3:1 arm
Up to 15%
Present (usually atrial
fibrillation)
Absent
Soft, tender
Absent
Present
Thrombosis
Incomplete
(collaterals)
Hours or days
Leg 10:1 arm
Rare
Absent
Management
Onset
Limb affected
Multiple sites
Embolic source
General measures
When a patient is suspected to have an acutely ischaemic limb
the case must be discussed immediately with a vascular surgeon.
A few hours can make the difference between death or
amputation and complete recovery of limb function. If there are
no contraindications (acute aortic dissection or multiple trauma,
particularly serious head injury) give an intravenous bolus of
heparin to limit propagation of thrombus and protect the
collateral circulation.
Previous claudication
Palpation of artery
Bruits
Contralateral leg
pulses
Diagnosis
Treatment
Present
Hard, calcified
Present
Absent
Clinical
Embolectomy,
warfarin
Angiography
Medical, bypass,
thrombolysis
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Symptoms and signs of acute limb ischaemia
Symptoms or signs
Pain
Pallor
Pulseless
Perishing cold
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