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Appendix A: Doppler Ultrasound and Ankle–Brachial Pressure Index

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Appendix A: Doppler Ultrasound and Ankle–Brachial Pressure Index Appendix A: Doppler Ultrasound and Ankle–Brachial Pressure Index Camila Silva Coradi, Carolina Dutra Queiroz Flumignan, Renato Laks, Ronald Luiz Gomes Flumignan, and Bruno Henrique Alvarenga Abstract The ankle–brachial index is one of the simplest, costless, and with utmost importance tool for the diagnosis, screening, and segment of peripheral arterial disease and we need to know how to use it. The simplicity of the examination with Doppler ultrasound is undoubtedly the factor that most contributes to the adoption of this device as vascular preliminary tool. As a blood velocity detec- tor, Doppler ultrasound can be used to determine the systolic pressure of the arteries, which are the targets of the study. In this case, a sphygmomanometer is also required. They will be used in determined limb segments (upper and lower limbs) to temporarily occlude the blood flow and consequently assess the related blood pressure. The normal value of the index is 0.9–1.1. Values less than 0.9 indicate peripheral arterial disease and it is correlated with increased risk of future cardiac events. The index can be related with symptoms accord- ing to its value. When the ABI falls to 0.7–0.8 it is associated with lameness, 0.4–0.5 indicates pain, and 0.2–0.3 is typically associated with gangrene and nonhealing ulcers. Doppler Ultrasound The Austrian physicist Johann Christian Andreas Doppler (1803–1853) observing the different colorations that certain stars had questioned why this phenomenon. In 1842, he discovered the modifying effect of the vibration frequency caused by the relative movement between the source and the observer. This became known as the “Doppler effect.” The Doppler effect is a part of the modern theories of the early universe (Big Bang and the red shift). It is currently used in radar, navigation, the study of the movement of the stars, and the study of cardiovascular diseases. © Springer International Publishing Switzerland 2017 253 T.P. Navarro et al. (eds.), Vascular Diseases for the Non-Specialist, DOI 10.1007/978-3-319-46059-8 254 Appendix A: Doppler Ultrasound and Ankle–Brachial Pressure Index In vascular diseases, the Doppler effect applies to the frequency change caused by the speed of the blood cells. Portable Doppler apparatus used in clinical practice sends continuous wave ultrasound produced by a crystal. The other crystal located in the same transducer receives the echo. It works with frequencies between 5 and 10 MHz. Since these are wide frequencies, the lower (5 MHz) capture deeper vessels because they have greater tissue penetration power; and the highest (10 MHz) capture more superficial vessels, being better for the study of the distal veins of the limbs. The simplicity of the examination with Doppler ultrasound is undoubtedly the factor that most contributes to the adoption of this device as vascular preliminary tool. As a blood velocity detector, Doppler ultrasound can be used to determine the systolic pressure of the arteries, which are the targets of the study. In this case, a sphygmomanometer is also required. They will be used in determined limb seg- ments (upper and lower limbs) to temporarily occlude the blood flow and conse- quently assess the related blood pressure. Sphygmomanometer The correlation between the size of the pneumatic cuff and ankle circumference is not well established, so it should adopt the same ratio used in the upper limb. Therefore, the pneumatic cuff should cover at least 40 % of the limb circumference in which will be measured the systolic blood pressure. Schematically the technique for obtaining the ankle–brachial index is: • Make sure that the patient did not smoke at least 2 h before the test. • Put the patient in the supine position with the head and heels completely sup- ported on the bed. Next, we should expect a rest period, which varies between 5 and 10 min. • Ask the patient to remain still during the examination. • The sequence of statements should preferably be in this order: right arm, right ankle (preferably the posterior tibial artery), left ankle, left arm, and right arm again. Repeat the first step performed to avoid falsely high values resulting from anxiety or ‘white-coat effect.’ • Place the sphygmomanometer involving at least 40 % of limb, apply the gel on the Doppler sensor and place it on the pulse zone at an angle of 60° with probable trajectory of the vessel analyzed. Ordinarily it means 60o to 45o with the skin. The probe must be moved until the clearest sound is audible. • The cuff should be progressively inflated to 20 mmHg above the level of disap- pearance of the flow signal, and then deflated slowly to detect the pressure level at the reappearance of flow signal. After this, divide the value of the target artery pressure by the value of the bra- chial artery pressure. Usually, the index is expressed in terms of the highest value in the tibial arteries; it is called the ankle–brachial pressure index. It can be similarly determined the index of popliteal pressure or from the arteries of the arms with respect to each other. Appendix A: Doppler Ultrasound and Ankle–Brachial Pressure Index 255 Ankle–Brachial Pressure Index The normal value of the index is 0.9–1.1. Values less than 0.9 indicate peripheral arterial disease and it is correlated with increased risk of future cardiac events. The index can be related with symptoms according to its value. When the ABI falls to 0.7–0.8 it is associated with lameness, 0.4–0.5 indicates pain, and 0.2–0.3 is typi- cally associated with gangrene and nonhealing ulcers. In general, diseases like diabetes and chronic renal failure leave patients to have calcified arteries and this may be difficult for the index measurement, because it can have aberrant pressure reading above 1.4. In these cases, additional noninvasive studies are required, such as pulse volume recording, which gives a waveform, typi- cally not affected by medial calcification. In addition to the application of the index to characterize the degree of limb isch- emia, their use is recommended for routine evaluation of the following patients for the detection of peripheral arterial disease: • all patients who present symptoms in the lower limbs in walking; • all patients aged between 50 and 69 and have a cardiovascular risk factors (dia- betes or smoking); • all patients aged 70 or older regardless of cardiovascular risk factor; and • all patients with a risk score of Framingham between 10 and 20 %. This is one of the simplest, costless, and with utmost importance tool for the diagnosis, screening, and segment of peripheral arterial disease and we need to know how to realize the ankle–brachial index. Appendix B: Vascular Imaging Techniques Alexandre de Tarso Machado Abstract This chapter is about the most frequent diagnostic exams in angiology and vas- cular surgery practiced nowadays. The highlights of ultrasound, computed tomography, magnetic resonance imaging, and scintigraphy are described in top- ics divided into definition, basic physical principle, best indications, and limitations. Ultrasonography (Ultrasound) Ultrasonography is characterized as innocuous, noninvasive, relatively cheap, and widely spread tool that uses the echo produced by sound from the body tissues’ reflections to generate images [1]. The images in grayscale, named as Mode B, are bidimensionals and they can be associated with blood flow velocity (Doppler) resulting in duplex ultrasound, useful in the study of arterial and venous systems [1]. The lymphatic system cannot be well studied by US due to its small diameter resulting in limited indications [1]. In vascular imaging, the ultrasonography stands out for allowing study of the vessels anatomy, by determining the caliber, tortuosity, branches, stenosis, throm- bus, and blood flow velocity [1, 2]. The most frequent indications involve venous and arterial systems of upper and lower limbs, carotid, aorta and iliac arteries, iliac veins, inferior vena cava, visceral arteries (especially liver and kidney), vascularized tumors, malformations, and arteriovenous fistulae [1–3]. Also, it is possible to perform image-guided procedures using the ultrasonogra- phy, such as vascular punctures or arteriovenous malformation embolizations3. Due to the inability to generate images from air and bones, ultrasonography is not indicated to study the lungs, gastrointestinal tract, vessels, or other structure © Springer International Publishing Switzerland 2017 257 T.P. Navarro et al. (eds.), Vascular Diseases for the Non-Specialist, DOI 10.1007/978-3-319-46059-8 258 Appendix B: Vascular Imaging Techniques Fig. B.1 Echo Color Doppler imaging of carotid vessels. (a) Left common carotid artery (LCCA), left internal carotid artery (LICA), and left external carotid artery (LECA) are patent demonstrated by color and bidimensional mode ultrasonography (Duplex scan). (b, c) Left internal carotid artery (LICA) with monophasic flow and left external carotid artery (LECA) with biphasic flow obtained by duplex with Doppler ultrasonography. (d) Right common carotid artery (RCCA), right internal carotid artery (RICA), and right external carotid artery (RECA) in bidimensional mode ultrasonog- raphy (grayscale). Note that in this last case, the blood flow cannot be identified and studied hidden inside or near the bones such as the cranium, chest, maxilla, or vertebral column, for example. Besides that, it is an operator-dependent diagnostic method that could compromise the quality of the exams. Computed Tomography It is one of the main diagnostic imaging for the evaluation of anatomical structures throughout the body. The images are obtained from the detected x-ray voltage val- ues and converted into grayscale images based on digital units (Hounsfield Unit) [1]. It is possible to generate three-dimensional and multiplanar reconstructions to calculate stenosis and to manipulate images with the postprocessing resources, increasing its potential in diagnostic and therapeutic planning. For example, detail- ing the anatomy of the aortic aneurysm to choose the best technique and material to be used in this situation [4].
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