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Features of lower limb arterial stenosis
• Intermittent claudication
• Rest pain
• Cold, numb, paraesthesia, colour change
• Decreased temperature
• Sensation decreased
• Movement diminished or lost
• Arterial pulsation diminished or absent
• Arterial bruit
• Slow venous email@example.com
• Stage I Asymptomatic,
• Stage II - Mild claudication pain in limb
Stage IIA -Claudication at a distance > 200 m
Stage IIB -Claudication at a distance < 200 m
• Stage III - Rest pain, mostly in the feet
• Stage IV -Necrosis and/or gangrene of the limb
• TASC A - excellent results from endovascular
• TASC B - good results from endovascular
management, and endoluminal interventions
should be the first treatment approach.
• TASC C lesions - surgical management provides
superior long-term results and endovascular
techniques should be reserved for patients who
are surgically high risk.
• TASC D lesions- should be treated by open
• Tests relevant to diabetes, abnormal lipid metabolism, anaemia
• conditions causing high blood viscosity (e.g. polycythaemia and
thrombocythaemia) include a full blood count (including platelets),
plasma fibrinogen, blood and urine glucose, and a blood lipid profile
(triglycerides, total cholesterol, and high- and low-density
• Cardiac failure, myocardial ischaemia, hypertension and age-related
diseases such as chronic obstructive pulmonary disease and
neoplasia – related to these
• chest radiograph
• pulmonary function tests.
• Tests for renal function (serum creatinine) required, especially if
contrast agents are to be used at angiography
• Patients themselves are poor at assessing
claudicating distance and it might be thought that
a treadmill assessment would provide a useful
objective measurement of distance to onset of
• a simple measured walk along a hospital corridor
is even more reliable.
A good use for the treadmill (with a slight incline) is
the detection of a fall in ABPI after exercise,
indicating occult arterial stenosis
• one of the earliest methods used to
investigate intermittent claudication.
• measuring the amplitude of the pressure wave
in arteries at different levels in the leg.
• strain gauge plethysmography is still often
used as a standard for measuring limb blood
flow when new methods are being evaluated.
• used in the assessment of limb blood flow
• Plethysmographic methods are by their nature
quantitative, do not yield specific information
about the sites of arterial occlusions
• tend to involve the use of cumbersome
equipment which is not easy to use.
• The investigation of choice for the anatomical
definition of peripheral vascular disease
• Seldinger described his percutaneous
technique for catheter placement. which is
• biplanar views solve the problem of
• Sodium diatrizoate (Urografin, Hypaque)
• Sodium metrizoate (Triosil)
• On-table arteriography has an established
place in the performance of femorodistal
Arteriography – seldingers technique
• right femoral artery is most commonly accessed.
• 18-gauge Seldinger needle.
• Good pulsatile flow confirms arterial access.
• wire is then inserted up into the aorta under fluoroscopic guidance.
• After removing the needle, a catheter is inserted over the wire.
• The catheter and wire can be steered to the target vascular bed
• dye injected to opacify the vessels.
• Contrast angiography provides a lumenogram, so thrombus-filled
aneurysms can be easily missed.
• Digital subtraction angiography (where bony landmarks are
electronically removed) provides the best delineation of vascular
• Once the procedure is complete, the catheter is removed from the
femoral artery and pressure applied.
• This technique forms the basis for all interventional procedures.
Digital subtraction angiography
• The increased contrast detection and
subtracting the preinjection ’mask’ image.
• The advantages of an intravenous injection
• decreased patient discomfort.
• However, problems persist. The quality of
image is inferior to that produced by a
Ultrasound and Doppler flow meas-
• frequency of reflected ultrasound waves is
dependent on the speed of flow of the blood
from which the waves have been reflected.
• pulsed Doppler flow meter, allowed ’ultrasonic
arteriography’ to become a reality. This is
because it allows the depth from which the
returning ultrasound waves are reflected to be
• The simplest use of Doppler ultrasound lies in the hand-
held pencil probe used clinically for the detection of the
presence or absence of flow in a vessel.
• Duplex scanning is a more recent innovation, combining
real time ultrasonic imaging with Doppler flow
measurements which have undergone sound spectrum
analysis for visual display. It gives precise information
about the functional significance of any arterial stenoses
• The advent of Colour Duplex scanning, in which flow is
represented on the real time image by a colour scale, has
made the detection of local flow disturbances even easier.
• create a gray-scale anatomic image, Doppler ultrasound
B MODE/ 2D MODE (brightness)
• B MODE+ PULSE WAVE DOPPLER + COLOUR DOPPLER = ACTUALLY
TRIPLEX = colour duplex scan
• permits measurement of peak systolic velocity and end-diastolic
• Velocity therefore is proportional to the degree of narrowing of the
vessel under investigation
• Although surgeons largely depend upon flow velocities in the
arterial system, they rely even more on the anatomic appearance of
the vessel when examining for thrombosis in the venous system. An
occluded vein typically is larger than normal, not completely
compressible, lacks respiratory variation, does not show flow
augmentation with calf compression, and may have collateral flow.
• has led to the increased use of imaging in the
vascular surgeon's office for diagnosis of
• mapping of veins for arteriovenous fistulas
• evaluation of patency of lower extremity
• In the operating room, duplex scanning is
helpful in image-guided venous access and
completion ultrasound scanning
Computed Tomographic Angiography
• Contrast-dependent method for imaging the arterial
• The IODINATED contrast-filled vessels can be extracted
from the slices and rendered in three-dimensional
• The extracted image can be rotated and viewed from
several different directions.
• CTA is increasingly being used for imaging the carotid
bifurcation, and as computing power increases, the
speed of image acquisition and image resolution will
continue to increase.
Magnetic Resonance Angiography
• MRA has the advantage of not requiring iodinated
contrast agents to provide vessel opacification .
• Gadolinium is used as a contrast agent for MRA
studies, and as it is generally not nephrotoxic, it can be
used in patients with elevated creatinine.
• As with other MR tests, it is contraindicated in patients
with pacemakers, severe claustrophobia, and most
metallic foreign bodies.
• MRA tests are, however, relatively slow and very
• Like CTA, MRA is being increasingly used for imaging of
the lower extremity vasculature, the carotid
bifurcation, and the aorta and its branches.