Upper Limb Arterial Doppler - Part 3

Aorta Arthritis

The other condition which affects the upper limb
and does not affect the lower limbs is aorta arthritis.

Aorta arthritis is an inflammatory disease
of unknown etiology, which first affects larger artery
of the body, especially branches of aorta.

It is described as aortic arch syndrome, pulseless disease,
reversed tation, occlusive, thrombo, arthropathy,
young female arthritis or tsu arthritis.

Typically, the arterial wall becomes markedly thickened
and the lumen becomes narrow.

This is now commonly described as a Marconi sign.

Diagnosis

Aorta is diagnosed by looking at certain
clinical conditions, so we have what are known
as obligatory criteria, major criteria and minor criteria.

This has now undergone modification
and we no longer look at obligatory criteria,
but there are modified major and minor criteria.

But what is very important is
that subclavian arteries are almost always
involved in aorta arthritis.

And this is a major consideration here.

Subclavian Artery Involvement

For example, we have a patient whose mid
undistilled subclavian artery shows marked wall thickening
and narrowing of the lumen
with localized increase in velocity.

Another patient who has got a subclavian artery occlusion
because of aoto arter
and we can see a reversal
of flow in the distal subcate artery
coming from a collateral.

So involvement of subcate artery is a very important finding
in aoto arthritis.

And in our own study we saw almost involvement in 75%
of the cases, but there are some studies which show
involvement in almost 85 to a hundred percent of the cases.

Multiple Artery Involvement

Another diagnostic feature of a O2 arthritis is involvement
of multiple arteries or multiple areas.

Here, for example, we have a patient
where the right arteries as well as left arteries
of the upper arm are involved.

Other Conditions Affecting Larger Arteries

Besides aorta, arthritis,
we can have other common conditions which can affect larger
arteries like thrombosis and stenosis.

This is a patient who has a left auxiliary artery thrombosis
and again, we can see few collaterals there.

This patient, again, has a thrombosis
in the auxiliary artery,
but if you look at the waveform in the subclavian artery,
it's a very high resistance waveform telling us
that there is some TAL obstruction.

So we have a quick systolic up stroke
and we have a downward diastolic flow
with multiple peaks in the diastolic and rightly so.

The sub auxiliary artery shows a thrombosis.

There is a very good collateral there
And distally. We
have dampen flow, which is very often referred to
as a TARDIS parvis effect.

We can have auxiliary artery stenosis.

This patient has an auxiliary artery stenosis,
we can see localized ing there.

Perivascular tissue vibration on color OBL
with very high velocities happening under the
site of stenosis.

This patient has a brachial artery thrombosis ag.

Again, we can appreciate that there are a lot of collaterals
around the brachial artery.

And if you look at the distal radian in artery NAR arteries,
we have at TARDIS Parvis effect.

This patient had upper ischemia.

There were a lot of digital changes.

However, this patient was asymptomatic for many months
and years simply
because there were extensive collaterals in the forearm.

So as I said earlier,
very often there are very good collaterals in the upper arm
and therefore the patient remain
asymptomatic for quite some time.

This patient has an occlusion of the paricular artery
and there is also an occlusion of the radial
and as well as the older artery.

So sometimes the disease can be very extensive involving all
the arteries of the upper arm.

If you look at this patient on colored oler,
the auxiliary artery
and the brachial artery look quite okay,
but if you look at the waveform,
it's a very hard resistance waveform.

There is a quick sharp systolic up stroke
and there are multiple small peaks in the diastole.

This suggests that there is something happening distally
and rightly so.

If you look at the forearm arteries, the forearm arteries,
the radial as well as the ular, are completely occluded
beyond their, beyond the bra artery occlusion
right up to the distal lens.

So it's very important to appreciate proximal waveforms
to find out if something is happening distally
and one can get clues to the proximal waveforms.

This patient has a complete occlusion of the NAR artery
as well as on the digital arteries on the NAR side.

So we talked of larger arterial obstructive lesions.

Small Arteries

Let us come to the small arteries.

When we talk of small arteries, we are referring
to arteries in the hand.

In these patients, typically the pulse
and the pressure up to the elbow and the wrist is normal.

And whenever we think of small arterial disease, one has
to think of a systemic disorder in the upper limb.

This is very important.

Atherosclerosis can affect the small arteries in the hand,
but this is not so common.

On the other hand, systemic disorders are more common.

This patient has an occlusion of the distal mid
and distal artery in the index finger.

This person was in fact a laparoscopies who worked a lot
with the hand, and this was
Probably because of a professional injury.

So whenever we think of small arterial disease, as I said,
we think of systemic disorders
and very often they present with vasospasm.

Cold Stimulation Test

a test to find out if the patient has an abnormal vaso
Spastic response is known as cold stimulation test.

So what we do here is we look at the radial
and the NAR artery at rest.

Then we ask the patient to hold eyes in the hand
and while the patient is holding eyes in the hand,
we look at the waveform.

Typically, the patients are not able to hold the eyes
for a long time, and what we observe is a disappearance
of the diastolic flow with UPS and diastolic flow,
or one can have a reversal
of flow in the diastolic telling us
that this there is a vasospasm,
but this is a normal vasos spastic response to eyes.

What happens in normal patients is that
after they leave their eyes,
the diastolic wave forms comes back
to normal within a matter of three minutes
or sometimes within a matter of five minutes.

Whereas a patient
who has got an abnormal vasos spastic response
or one who has got a positive cold stimulation test,
the diastolic flow does not come back to normal even
after some time.

Here's a very typical example.

Patient has a quick systolic up stroke,
a very high resistance flow,
and an absent flow in the diastolic, which remained
for quite some time even
after the patient had left the eyes.

This is a patient who has an SLE at rest.

We observe that there is a very high resistance flow in the
radial artery with a quick systolic up stroke,
which is dampen and multiple small peaks in the diastole.

After doing a cold stimulation test, we see
that the flow is further dampen.

The diastolic flow is almost absent,
and we have multiple small peaks in the diastole.

In this patient. Even
after releasing the eyes,
the waveform did not come back to normal.

Sometimes the recovery time from a cold stimulation can be
as much as 30 minutes,
and this is a very good test
to find out if the patient has an abnormal vasos Spastic
response.