VASCULAR SURGERY COURSE

VASCULAR INVESTIGATIONS

By the end of this Lecture , Students will be able to :

Know the different kinds of vascular investigative tools Understand the initial differences between them Choose best approach for diagnosing vascular problems Interpret the findings of each investigation

PLAN
WE WILL DISCUSS THE FOLLOWING :

Clinical suspicion ,
How to confirm , How to prepare for intervention , How to follow it up.

Clinical suspicion

Your ear , eye , hand & mind : Good history

Careful examination

Bed side testing

?????????

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 ?

PLAN
WE WILL DISCUSS THE FOLLOWING :
Clinical suspicion ,

How to confirm ,
How to prepare for intervention , How to follow it up.

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

How to confirm
1- Hand Held Doppler (HHD)
(EAR)
Doppler probe sends high frequency sound waves penetrate tissues sound waves reflected by moving blood particles audio signal draw pulse waveform

How to confirm

2- Specific diagnostic imaging : Non-invasive( vascular lab.)

Doppler waveforms Ankle-Brachial Index Stress testing Segmental pressure measurements Segmental plethysmography Duplex scan

How to confirm 2- Specific diagnostic imaging : Non-invasive( vascular lab.)

Doppler waveforms
(EAR+EYE)
bed side easy, rapid not expensive repetitive physiology probe / depth direction restricted area

problem

How to confirm
2- Specific diagnostic imaging : Non-invasive( vascular lab.)

Ankle-Brachial Index

(ABI)

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

How to confirm 2- Specific diagnostic imaging : Non-invasive( vascular lab.)

Stress testing:
when Doppler examination and ABI tests are borderline, need to amplify the effect of PAD by increasing the blood demand of the tissues

Treadmill exercise

How to confirm
2- Specific diagnostic imaging : Non-invasive( vascular lab.)

Segmental pressure measurement:

significant drop of pressure bet. two cuffs arterial blockage in between

How to confirm
2- Specific diagnostic imaging : Non-invasive( vascular lab.)

Segmental plethysmography:
photo ( with resp. ) & electrical (normal Vs. are good conductors)
detects minute changes in limb volume with every arterial pulse wave draw pulse waveform

How to confirm
2- Specific diagnostic imaging : Non-invasive( vascular lab.)

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

+
Pulsed Doppler to show blood flow ( physiology )

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 area
Cervical Extremities Visceral

How to confirm

Bed side test (H H D.) Specific diagnostic imaging : Non-invasive( vascular lab.)

Invasive imaging
Laboratory investigations Complementary

How to confirm
2- Specific diagnostic imaging :

Invasive imaging

Angiography CT Angiography MR Angiography

How to confirm
2- Specific diagnostic imaging :

Invasive imaging

Angiography :
Arteries
-Arteriography

Veins

Lymphatics

- Venography - Lymphangiography Ascending Descending - Phlebography - Varicography

How to confirm
2- Specific diagnostic imaging :

Angiography
the gold standard
X-ray + contrast

Invasive imaging

clear true picture

essential pre-op. invest.

How to confirm
2- Specific diagnostic imaging :

Angiography
intra-arterial inj. most invasive test shows lumen only

Invasive imaging

contrast-induced nephropathy or even anaphylaxis cannot be repetitive

How to confirm
2- Specific diagnostic imaging :

Invasive imaging
CT Angiography
(CT scan + contrast) less contrast injected IV (less invasive) rapid ( helical) 3D image + reconstruct. transverse cuts (wall details)

high dose of radiation measurements calcifications

How to confirm
2- Specific diagnostic imaging :

Invasive imaging
Magnetic resonance Angiography: (MRA)
high quality image, no contrast, good alternative .
time consuming, expensive, claustrophobia (open), obese patients (open), metals ( new gener.) .

How to confirm
3. Laboratory investigations etiology Thrombogenicity BT, CT, PT, PTT, AT3, Ptn. C&S Plasminogen, Fibrin, FDPs. Platelets count & function Lipids profile

Autoimmune * Anti- DNA Ab. - Nuclear - Smooth Ms. - Phospholipids - Cardiolipin

* Factor V Leiden Macroglobulins Cold agglutinins Homocysteine

How to confirm
4. Complementary etiology

Cardiac Functions

(CXR, ECG, EchCG)

Arrythm., Fail., Thromb.

PLAN
WE WILL DISCUSS THE FOLLOWING :
Clinical suspicion , How to confirm ,

How to prepare for intervention ,

How to follow it up.

How to prepare for intervention ,

Fitness
Kidney Liver Hb.

PLAN
WE WILL DISCUSS THE FOLLOWING :
Clinical suspicion , How to confirm , How to prepare for intervention ,

How to follow it up.

1.Duplex - untreated cases - graft patency - recurrence/ progression

2.Angio/CTA - confirm - distribution - planning

Arterial
1.Diagnosis : Duplex / Angio / CTA 2.Severity : Duplex + Pressures /Angio 3.Distribution : Angio/CTA 4.follow up : Duplex

Venous
1.Deep system : 2.Superf. System : 3.Valves : 4.Perforators : Duplex Duplex Duplex Duplex

Thank you