Theoretical and Methodological Challenges
1. Introduction: what is corpus annotation?
9.2.1 Aortoiliac disease with an open distal system 9.2.1a Decreased or absent femoral pulse.
9.2.1b Femoral bruit at rest or after exercise.
9.2.1c Resting plethysmography and segmental pressures: The thigh plethysmography may be normal, slightly abnormal (absence of a dicrotic notch) or reduced in amplitude with a damped, rounded configuration. Calf plethysmography will be augmented as compared to the thigh and the ankle plethysmography will be similar to that at the thigh.
Segmental pressures may be near normal or have the "pressure gradient" present at the thigh level (as compared to the brachial blood pressure) with little further decrease at calf and ankle levels.
9.2.1d Exercise data:
Symptoms during exercise may involve calf, thigh, hip, and/or buttocks. If the disease is well collateralized, plethysmography may remain good with the decrease in ankle pressure being the most abnormal finding. If poorly collateralized, the
plethysmography will become flat or barely pulsatile (but returns quickly to resting form) and the ankle pressure will fall precipitously to correlate with the
plethysmography.
9.2.2 Aortoiliac and outflow disease 9.2.2a Absent or reduced femoral pulse.
9.2.2b Femoral bruits at rest or after exercise.
9.2.2c Absent or diminished popliteal, DP, and PT pulses.
9.2.2d Resting plethysmography and segmental pressures:
The thigh plethysmography may be as described above (aortoiliac disease with open distal system). Calf and ankle plethysmography will be further reduced in amplitude and contour as compared to the thigh. Pressure gradients may be noted at all levels (thigh, calf, and ankle) as compared to the brachial blood pressure.
9.2.2e Exercise data:
Symptoms may be as noted above or, depending on the individual patient's stamina, be localized to only one segment of the lower extremity. Post exercise plethysmography and pressures will deteriorate markedly from resting levels.
9.2.3 High SFA disease or SFA disease with profunda involvement:
9.2.3a Normal or slightly diminished femoral pulse.
9.2.3b No femoral bruits.
9.2.3c Decreased or absent popliteal, DP and/or PT pulses.
9.2.3d Resting plethysmography and segmental pressures: The thigh plethysmography is abnormal (i.e., reduced in amplitude and configuration), with further deterioration in
amplitude and contour noted at the calf and ankle levels. The thigh pressure may
demonstrate the largest gradient (as compared to the brachial blood pressure) with further pressure decreases noted at calf and ankle levels.
9.2.3e Exercise data:
Symptoms may involve thigh, calf and ankle. Post exercise plethysmography
demonstrates a further diminution in amplitude (but usually remains pulsatile). Ankle pressure decreases from resting level after exercise.
9.2.4 SFA disease: Either in the mid SFA or at the level of the adductor canal:
9.2.4a Normal femoral pulse.
9.2.4b No femoral bruit.
9.2.4c Reduced or absent popliteal, DP, and/or PT pulses.
9.2.4d Resting plethysmography and segmental pressures:
The thigh plethysmography is normal. Calf plethysmography may be markedly reduced in amplitude or maintain a good amplitude (depending on the degree of collateralization) with an abnormal, blunted contour. Ankle plethysmography will have the same characteristics as the calf but be further reduced. Usually the thigh pressure shows no significant
gradients as compared to the brachial blood pressure. The major gradient is observed at the calf level with further deterioration noted at the ankle level.
9.2.4e Exercise data:
Symptoms are classically limited to the calf level. Post exercise ankle plethysmography and pressures deteriorate further from the resting levels, but the plethysmographic recordings usually remain pulsatile.
9.2.5 Distal popliteal/tibial vessel disease only 9.2.5a Normal femoral pulse.
9.2.5b No femoral bruit.
9.2.5c Absent or diminished popliteal, DP, and/or PT pulses.
9.2.5d Weak or absent Doppler signals at the PT or DP levels. This may be the only abnormality noted if disease is localized to one vessel or is well collateralized.
9.2.5e Resting plethysmography and segmental pressures:
If the popliteal artery is diseased, calf and ankle plethysmography and pressures may be decreased.
If only the tibial vessels are diseased, the only significant abnormality in plethysmography and pressure may be localized to the ankle level.
Obtaining plethysmography with the cuff snuggly positioned around the knee may
differentiate popliteal from tibial-only disease. If a normal recording (i.e., sharp upstroke, a reflected wave, and a greater plethysmographic amplitude than that obtained at the calf level) is noted in this position, one can presume that the disease is localized to the distal
popliteal/ tibioperoneal trunk rather than at the mid popliteal artery.
9.2.5f Exercise data:
Symptoms include calf, ankle, and sometimes foot pain. Post exercise plethysmography and pressures decrease from the resting levels. The amplitude is decreased and the contour of the plethysmography is further damped, as compared to the resting plethysmography, but generally remains pulsatile.
10 REPORTING
10.1 Preliminary reports:
10.1.1 For all inpatients, a preliminary report is written by the examiner in the progress notes of the patient's chart before the patient is returned to the floor.
10.1.2 For outpatients who have an appointment scheduled with the requesting physician on the same day as the vascular laboratory examination, a preliminary report is written by the examiner and sent with the patient.
10.1.3 If the patient has been seen in the vascular laboratory previously, the date of the last visit is noted in the report and current results compared to prior results (e.g.,
progression of disease, no change, etc.). If the patient has had a surgical or interventional procedure (e.g., PTA, urokinase therapy, etc.), hemodynamic and/or other changes
produced by therapy are noted and compared to the results of the previous examination.
10.2 The examiner writes an impression for the designated physician reviewer to accompany the data to be reviewed the day of the exam.
10.3 The study is reviewed and signed (in the appropriate place on the evaluation form) by the reviewing physician, returned to the laboratory secretary, typed in final form, and signed by the examiner.
10.4 Final reports are generated within 24 hours:
10.4.1 A copy of the typed, signed final report is mailed to the requesting physician.
10.4.2 A copy of the final report is mailed to medical records for outpatients.
10.4.3 A copy of the final report is hand delivered to the inpatient's hospital record.
10.5 The entire completed report is placed in the patient's vascular laboratory chart and filed alphabetically in the vascular laboratory files.
11 CLEANING AND CARE OF EQUIPMENT
11.1 The stethoscope is cleaned with alcohol after each use.
11.2 The volume pulse recording machine is cleaned with alcohol weekly or more frequently as needed.
11.3 The Doppler probe is cleaned with soap and water according to the manufacturer's directions.
11.4 The blood pressure cuffs are washed with soap and water and hung to dry periodically. If contact with patient drainage is made, cuffs are immediately washed.
11.5 The ECG machine is cleaned with alcohol weekly.
11.6 The bar on the treadmill used to guide the patient while walking is cleaned with alcohol after each patient use.
12 REFERENCES
1 Raines JK: The pulse volume recorder in peripheral arterial disease. In Bernstein EF: Noninvasive Diagnostic Techniques in Vascular Disease, 3rd ed. St. Louis, Mosby, 1985, pp 563-571.
2 Buckley CJ, Darling RC, Raines JK: Instrumentation and examination procedures for a clinical vascular laboratory. Med Instrum 9:181-187, 1975.
3 Darling RC et al: Quantitative segmental pulse volume recorder: a clinical tool.
Surgery 72:873-881, 1972.
4. Reidy NC, Walden R, Abbott WM, et al: Anatomic localization of
atherosclerotic lesions by hemodynamic tests. Arch Surg 116:1041-1044, 1981.
4 Kempczinski RF, Yao JST: Segmental volume plethysmography: the pulse volume recorder. In Kempczinski RF, Yao JST (eds): Practical Noninvasive Vascular Diagnosis.
Chicago, Year Book Medical Publishers, 1982, pp 105-117.
5 Raines JK, Darling RC, Buth J, et al: Vascular laboratory criteria for the
management of peripheral vascular disease of the lower extremities. Surgery 79:21-29, 1976.
6 Rutherford RB, Lowenstein DH, Klein MF: Combining segmental systolic pressures and plethysmography to diagnose arterial occlusive disease of the legs. Am J Surg
138:211-219, 1979.
7 McCabe C, Reidy NC, Abbott WM, et al: EKG monitoring during vascular lab treadmill testing for peripheral vascular disease. Surgery 89:183-187, 1981.
Non imaging Study UPPER EXTREMITY ARTERIAL PRESSURES AND WAVEFORMS Arterial Procedures Revised/Approved Date:
1 PURPOSE
To identify, localize, and quantify obstruction in the arterial circulation to the arms.
2 INDICATIONS
2.1 To assess arterial component of arm pain of questionable etiology.
2.2 To assess arterial component of hand pain of questionable etiology.
2.3 To assess arterial component of digital pain of questionable etiology.
2.4 To assess arterial system in the presence of a nonhealing lesion.
2.5 To verify the presence and location of arterial obstruction in patients with claudication.
2.6 To assess arterial component of arm or hand ischemic symptoms distal to an arteriovenous fistula.
3 CONTRAINDICATIONS AND LIMITATIONS
3.1 Arm pressure measurements are contraindicated in the presence of deep venous thrombosis in the arm and therefore in the presence of arm edema until deep venous thrombosis is ruled out.
3.2 The study is contraindicated in the presence of any condition that could be worsened by compression with a blood pressure cuff, such as recent surgery or trauma.
3.3 Nonremovable casts or bandages that limit access to the arm or hand may limit or contraindicate the study.
3.4 Inaccurate pressure measurements result when one or both limbs are too large for the standard cuff (12 cm in width).
3.5 Falsely elevated pressures may be attributable to calcified vessels (rarely found in the arms).
4 EQUIPMENT AND SUPPLIES
4.1 Continuous-wave Doppler instrument with appropriate transducer(s) such as 8 MHz and spectrum analyzer (preferred) with recorder or analog recorder.
4.2 Photoplethysmograph with recording capability, photocells, and double-stick tape.
4.3 Two- or four-arm pressure cuffs (12 cm wide).
4.4 Two digit cuffs (2.5 cm wide).
4.5 Sphygmomanometer.
4.6 Acoustic coupling gel and washcloths or tissues to remove gel from skin.
5 PATIENT PREPARATION
5.1 Explain the procedure to the patient.
5.2 Document the symptomatology, the indications for examination, and relevant medical history as listed above under Indications.
5.3 Have patient in the supine position in a room sufficiently warm to keep him/her from being chilled; warm patient with blankets if necessary.
6 PROCEDURE: GENERAL CONSIDERATIONS