8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 1/34

VASCULAR SURGERY COURSE

VASCULAR INVESTIGATIONS

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 2/34

By the end of this Lecture ,

Students will be able to :

• Know the different kinds of vascularinvestigative tools

• Understand the initial differences betweenthem

• Choose best approach for diagnosingvascular problems

• Interpret the findings of each investigation

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 3/34

PLAN

• WE WILL DISCUSS THE FOLLOWING :

 – Clinical suspicion ,

 – How to confirm ,

 – How to prepare for intervention ,

 – How to follow it up.

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 4/34

Clinical suspicion

• Your ear , eye , hand & mind :

Good + Careful + Bed side

?????????

history examination testing

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 5/34

Clinical suspicion

• Is it a vascular problem ?

• What is the possible diagnosis ?

• How severe it is ?

• What is the etiology ?

• Is he / she fit for intervention ?

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 6/34

PLAN

• WE WILL DISCUSS THE FOLLOWING :

 – Clinical suspicion ,

 –How to confirm ,

 – How to prepare for intervention ,

 – How to follow it up.

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 7/34

How to confirm

1. Bed side test (H H D.)

2. Specific diagnostic imaging :

Non-invasive( vascular lab.)

Invasive imaging

3. Laboratory investigations

4. Complementary

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 8/34

How to confirm

1- Hand Held Doppler (HHD)

(EAR)

Doppler probe sends high

frequency sound →

waves penetrate tissues →

sound waves reflected bymoving blood particles →

audio signal ± draw pulse

waveform

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 9/34

How to confirm

• Doppler waveforms• Ankle-Brachial Index

• Stress testing

• Segmental pressure measurements

• Segmental plethysmography• Duplex scan

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 10/34

How to confirm

Doppler waveforms

(EAR+EYE) problem

-  bed side

- easy, rapid

- not expensive

- repetitive

- physiology

- probe / depth

- direction

- restricted area

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 11/34

Ankle-Brachial Index

  severity

• determine the pressure in the upper limb

(brachial artery) and at the ankle (tibial vessels)and calculate the ratio (ankle/brachial pressures)

• normally it is 1.1

• if ABI<0.95 →PAD, ( ABI disease ) 

• if ABI>1.3 → heavily calcified incompressible

vessels e.g. in Diabetics

(ABI)

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

How to confirm

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 12/34

How to confirm

Stress testing:

when Doppler examination and ABI tests are

borderline, need to amplify the effect of PADby increasing the blood demand of thetissues

 – Treadmill exercise

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 13/34

How to confirm

Segmental pressure measurement:

significant dropof pressure bet.

two cuffs →

arterial blockage

in between

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 14/34

How to confirm

Segmental plethysmography:

photo ( with resp. ) &

electrical (normal Vs. are good conductors)

detects minute changes in limb volume with every arterial pulse wave → drawpulse waveform

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 15/34

How to confirm

• Duplex scan:B mode ( Real time ) U/S

( morphology )

+Pulsed Doppler to show

blood flow

( physiology )

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 16/34

How to confirm

2- Specific diagnostic imaging :

Non-invasive( vascular lab.)

Duplex scan

- bed side

- easy, rapid- not expensive

- repetitive

- physiology

- probe / depth

- direction

- restricted areaCervical

Extremities

Visceral

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 17/34

How to confirm

• Bed side test (H H D.)

• Specific diagnostic imaging :

Non-invasive( vascular lab.)

Invasive imaging• Laboratory investigations

• Complementary

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 18/34

How to confirm

• Angiography

• CT Angiography

• MR Angiography

2- Specific diagnostic imaging :

Invasive imaging

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 19/34

How to confirm

• Angiography :

Arteries Veins Lymphatics

-Arteriography - Venography - Lymphangiography

Ascending

Descending

- Phlebography

- Varicography

2- Specific diagnostic imaging :

Invasive imaging

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 20/34

How to confirm

• Angiography

2- Specific diagnostic imaging :

Invasive imaging

• the gold standard

• X-ray + contrast

• clear true picture

• essential pre-op. invest. 

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 21/34

How to confirm

• Angiography

2- Specific diagnostic imaging :

Invasive imaging

• intra-arterial inj.

• most invasive test

• shows lumen only

• contrast-induced nephropathyor even anaphylaxis

• cannot be repetitive

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 22/34

How to confirm

CT Angiography (CT scan + contrast)

2- Specific diagnostic imaging :

Invasive imaging

less contrast

injected IV (less invasive)

rapid ( helical)

3D image + reconstruct.

transverse cuts (wall details)

high dose of radiation

measurements

calcifications

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 23/34

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 24/34

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 25/34

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 26/34

How to confirm

• Magnetic resonance• Angiography: (MRA)

2- Specific diagnostic imaging :

Invasive imaging

•  high quality image,

• no contrast,• good alternative .

• time consuming,• expensive,

• claustrophobia (open),

• obese patients (open),

• metals ( new gener.) .

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 27/34

How to confirm

 

3. Laboratory investigations

etiology

ThrombogenicityBT, CT, PT, PTT, AT3, Ptn. C&S

Plasminogen, Fibrin, FDPs.

Platelets count & function

Lipids profile

Autoimmune

* Anti- DNA Ab. * Factor V Leiden- Nuclear Macroglobulins

- Smooth Ms. Cold agglutinins

- Phospholipids Homocysteine

- Cardiolipin

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 28/34

How to confirm

 

Cardiac Functions (CXR, ECG, EchCG)

Arrythm., Fail., Thromb.

4. Complementary

etiology

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 29/34

PLAN

• WE WILL DISCUSS THE FOLLOWING :

 – Clinical suspicion , – How to confirm ,

 – How to prepare for intervention ,

 – How to follow it up.

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 30/34

How to prepare for intervention , 

Fitness

Kidney

Liver

Hb.

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 31/34

PLAN

• WE WILL DISCUSS THE FOLLOWING :

 – Clinical suspicion , – How to confirm ,

 – How to prepare for intervention ,

 – How to follow it up.

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 32/34

1.Duplex

- untreated cases

- graft patency

- recurrence/ progression

2.Angio/CTA

- confirm- distribution

- planning

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 33/34

 

Arterial

1.Diagnosis : Duplex / Angio / CTA 2.Severity : Duplex + Pressures / Angio

3.Distribution : Angio/CTA

4.follow up : Duplex

Venous

1.Deep system : Duplex2.Superf. System : Duplex

3.Valves : Duplex

4.Perforators : Duplex

8/4/2019 1 Vascular Investigations

http://slidepdf.com/reader/full/1-vascular-investigations 34/34

 

Thank you