Eco-color-doppler of the upper extremity: technique, indications and semeiotics

Transcription

1 Eco-color-doppler of the upper extremity: technique, indications and semeiotics Poster No.: C-0029 Congress: ECR 2012 Type: Educational Exhibit Authors: S. Pollice, P. Pollice, R. Stanzione, P. Maggi, N. Maggialetti, A. Maggialetti ; Andria/IT, andria/it, Bari (BA)/IT, Bari/IT, 5 Molfetta/IT Keywords: Blood, Education, Ultrasound-Colour Doppler, Extremities DOI: /ecr2012/C-0029 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 34

2 Learning objectives Eco-color-doppler of the upper extremity: technique of execution, indications and semeiotics. Background ANATOMY The axillary artery, continuation of the subclavian artery starts at the level of the first rib on its outer edge, to end at the lower margin of the pectoralis major muscle. In his first stretch the artery is wrapped together with the axillary vein (medial to the artery) and the brachial plexus in the aponeurotic sheath of the axilla. The humeral or brachial artery is the direct continuation of the axillary artery. It ends an inch below the elbow joint and divide into radial and ulnar arteries. The radial artery descends lateral to the forearm and wrist (where it is available as a peripheral pulse). The ulnar artery, moves medially in the distal forearm. Distally the two arteries come together through the deep and supercial arches. The venous system is equipped as a deep and superficial circle anastomosed extensively with each other. Superficial veins flow under the skin, deep veins accompany the arteries between the muscles (satellites). In both systems valves are present. The cephalic vein starts from the dorsal venous network of the hand, continue going up the arm and opens into the axillary vein just below the clavicle. The basilic vein originates on the medial side of the ulnar dorsum of the hand, go up and below the elbow is achieved by the median vein of the elbow to go superficially. Usually ends in a brachial vein. The deep venous circle is made of: the deep veins of the hand, the deep veins of the forearm, brachial veins, axillary vein. They are generally two-fold, alongside the corresponding artery and are joined together by short transverse branches. Images for this section: Page 2 of 34

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4 Fig. 0: Anatomy Page 4 of 34

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10 Fig. 0: Anatomy Page 10 of 34

11 Imaging findings OR Procedure details Technique of execution. Examination involves the use of high-frequency linear probes (greater than or equal to 7.5 MHz) and begins with a B-mode sonography of arterial and/or venous districts (the assessment of subclavian district may be made with convex probes in selected cases) Study is done with the patient supine. The abduction of the limb facilitates the sampling of the subclavian district. The study of the of the arm and forearm is encouraged by abduction of the extremity. The patient is examined in a sitting position when you need to perform dynamic maneuvers. For easily sampling, the operator stands behind or beside the patient. In the arterial system the normal flow path is typical of muscle resistance vessels with high flow rates. In the venous evaluation is important to verify the vessel compressibility by slowly venous pressure with the probe; flow characteristics; wall thickness. Patology Arterial district:reduction of caliber/obstruction of one or more arteries resulting in flow reduction and implications for function related to the imbalance between metabolic demand and availability of blood SUPERIOR THORACIC OUTLET SYNDROME Considerable importance is also the condition called: superior thoracic outlet syndrome. It is a pain-dysfunctional syndrome caused bycompression of the artery, vein and/or nerve plexus for upper limb occuring in an anatomic space between the clavicle and first rib. Page 11 of 34

12 Most frequent causes of the neurovascular bundle compression are: accessory cervical ribs: a supernumerary ribs or fibrous septum that fits into this area and has a compressive effect; hypertrophy of the scalene: it is a neck muscle that under certain conditions (abnormalities or hypertrophy) can cause narrowing of the rib-clavicle space; hypertrophy of the pectoralis minor muscle: effects of compression exercised by mechanisms similar to the scalene; abnormalities of the clavicle or first rib: congenital or following fractures. Related disorders depend on the degree of compression and structures involved: arterial compression:patients refer of not being able to make movements with their arms raised, except for a few seconds, paresthesias, intermittent claudication with easy tiredness and inability to perform manual precision movements, pallor and/or cyanosis, pain and, in cases of severity, the rare occurrence of ischemic ulcers in the fingers of the hand, the radial pulse may be missing or less perceptible compared to contralateral. venous compression: swelling of the veins of the arm and hand until a possible deep venous thrombosis; nerve compression:pain, arterial vasospasm (Raynaud's phenomenon), paresthesia of the arm in certain positions expecially during night. It's important to make a clinical evaluation and differentiate this syndrome from other forms of painful arm and shoulder. Some examination must therefore be taken into account, especially in cases of doubt: radiographs of the cervical spine, arterial and venous eco-color-doppler of upper limb with dynamic maneuvers; electromyography, blood tests in case of concomitant Raynaud's phenomenon. Roos Test consists of opening and closing of hands at a moderate speed for 3 minutes, with the arms raised to 90 in abduction and external rotation and elevation the shoulder. Page 12 of 34

13 This maneuver causes in affected patients severe pain on the back of the neck and shoulder, irradiating to the arm. In the case of suspected compression, the patient can be evaluate by palpation of the wrist while performing Adson, Eden and Wright maneuvers, who can produce reduction or complete absence of the flow. Adson Maneuver Contraction of the scalene muscles and reduction of space interposed Maneuver Wright Reduction of the space between the first rib and clavicle Maneuver of Eden / Falconer Reduction of the space between the superficial and deep muscular plane at chest. interscalene triangle In this space, bordered anteriorly by the anterior scalene muscle, posteriorly by the scalenus medius, below by the first rib, we find the brachial plexus and subclavian artery. The course of subclavian vein is anterior to the anterior scalene. The dynamic maneuver indicated is Adson rib-clavicular channel In this channel, bounded by the clavicle and from the first rib, we find the brachial plexus, the subclavian vein and artery. The dynamic maneuvers indicated are: Adson's, Eden andr Wright subpectoral space In this space the neurovascular bundle runs under the coracoid process of the scapula and behind the tendon of the pectoralis minor muscle to move towards the arm. The dynamic maneuver indicated is Wright Page 13 of 34

14 Veins of upper extremity are affected by disease with a lower frequency than those of the lower limb. The disease most often affects the venous system is fundamentally thrombosis and can result from: compression causes, thoracic outlet syndrome extrinsic causes such as lymphnodes intrinsic causes as the presence of intraluminal catheters In symptomatic patients the upper limb venous vascular disease may occur with: deep vein thrombosis (DVT):an important condition because the thrombosis of the deep veins and the possible extension of the proximal (subclavian vein) can develop an embolus through the heart chambers that reach the right lung, giving rise to the clinical disease of 'pulmonary embolism". acute thrombophlebitis:is an acute thrombosis involving the superficial venous segment. In this case the vessel wall inflammation plays a predominant role in the genesis and evolution of thrombotic disease. Rare secondary involvement of the deep venous system. Incompressibility of deep and superficial venous vascular walls, echogenicity of the thrombus and stage of organization, absence of blood flow with both spectral analysis:eco-duplex and eco-color, morphology of the thrombus and its extension. Spectral analysis can show poor or no phasic activity in relation to cardio-respiratory activity, due to loss of elasticity Arteriovenous fistulas in hemodialysis patients (AVF) are created for the need to connect to the artificial kidney for a large number of times a year (up to 150) a vessel with a high blood flow rate ( ml /min) with (14-16) gauge needles, to attend to the hemodialysis session in the shortest possible time. The aretrovenous fistula (AVF) is usually created on the surface of the forearm and generally can be of three types: TT (terminal-terminal) - TL (terminal-lateral) - LL (lateral-lateral). Page 14 of 34

15 The evaluation of the functioning AVF begins with the examination and identification of the classical trills palpable under the skin. The examination is carried out using high-frequency linear probes, and of course provides for an evaluation in B-mode, color mode, and an analysis of the color-doppler path. The patient may be supine or eventually sit-down with the affected arm on the bed. Afferent artery is characterized by variable increase of size, presence of tortuosity. The characteristics of the flow in the artery approaching to anastomosis are variably dependent on the type of anastomosis, but in general we will have a gradual and steady increase speed, both systolic and diastolic phase, progressive flare spectrum, appearance of profiles of turbulence. Efferent vein is characterized by increase of size for the overloaded blood, with the detection on the skin of varicosities, turbulence and arterialized flow with systolic-diastolic phasic gradually decreaseing as moves away anastomosis. Images for this section: Page 15 of 34

16 Fig. 0: Linear probe Page 16 of 34

17 Fig. 0: Physiological arterial flow Page 17 of 34

18 Fig. 0: Compression of venous wall Page 18 of 34

19 Fig. 0: Phisiological venous flow Page 19 of 34

20 Fig. 0: Thoracic outlet syndrome: rib-clavicular space and neurovascular bund Page 20 of 34

21 Fig. 0: Thoracic outlet syndrome: accessory cervical rib and fibrous band Page 21 of 34

22 Fig. 0: Neurovascular bund Page 22 of 34

23 Fig. 0: Roos test. Page 23 of 34

24 Fig. 0: Accessory rib Page 24 of 34

25 Fig. 0: Thoracic outlet syndrome: anatomy Page 25 of 34

26 Fig. 0: Cervical rib Page 26 of 34

27 Fig. 0: Thoracic outlelt syndrome: compression of artery and vein Page 27 of 34

28 Fig. 0: Thoracic outlet syndrome: anatomy Page 28 of 34

29 Fig. 0: TT AVF Page 29 of 34

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31 Fig. 0: TL AVF Fig. 0: LL AVF Page 31 of 34

32 Fig. 0: Afferent artery Page 32 of 34

33 Fig. 0: Afferent artery Page 33 of 34

34 Conclusion The eco-color-doppler is an excellent method for the evaluation of the normal and pathological upper extremity. It is also useful in assessing the functionality of arteriovenous fistulas in hemodialysis patients. This test is quickly and easy execution, its costs are low because an ultrasound doppler module is present in every hospital and, moreover it is repeatable. It's importantis to consider, that it's a technique-operator dependent examination and therefore before the test it's needfull a proper medical training. Personal Information Saverio Pollice MD. Department of Radiology. "L. Bonomo" Hospital. ASL BAT - Andria (BT) - ITALY. Chief Alberto Maggialetti MD. References Manuale teorico-pratico di eco-color-doppler. Carriero, Saponaro Fossaceca, Sibilio. Idelson gnocchi 2010 Page 34 of 34