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Collateral blood flow on ultrasound criteria. Characteristics of main public transport modes

In each case, in addition to the examination, we are asked to undergo a bridle test of the lower extremities. What kind of procedure is this and what diseases can be diagnosed with its help?

What is ultrasound and what is studied with its help?

Ultrasound Dopplerography is an abbreviation for the name of one of the most informative methods for studying blood circulation in blood vessels - Doppler ultrasound. Its convenience and speed, coupled with the absence of age-related and special contraindications, make it the “gold standard” in the diagnosis of vascular diseases.

The ultrasound examination procedure is carried out in real time. With its help, within minutes the specialist receives sound, graphic and quantitative information about the blood flow in the venous apparatus of the legs.

Greater and lesser saphenous veins;
Inferior vena cava;
Iliac veins;
Femoral vein;
Deep veins of the leg;
Popliteal vein.

When performing an ultrasound scan of the lower extremities, the most important parameters of the condition of the vascular walls, venous valves and the patency of the vessels themselves are assessed:

The presence of inflamed areas, blood clots, atherosclerotic plaques;
Structural pathologies – tortuosity, kinks, scars;
The severity of vascular spasms.

During the study, the compensatory capabilities of blood flow are also assessed.

When is a Doppler study necessary?

Overdue problems in blood circulation make themselves felt to one degree or another with severe symptoms. You should rush to see a doctor if you begin to notice difficulty putting on shoes and your gait is losing its ease. Here are the main signs by which you can independently determine the likelihood that you have impaired blood circulation in the vessels of your legs:

Mild swelling of the feet and ankle joints, appearing in the evening and completely disappearing by the morning;
Discomfort when moving – heaviness, pain, rapid leg fatigue;
Convulsive twitching of legs during sleep;
Rapid freezing of the feet at the slightest drop in air temperature;
Stopping hair growth on the legs and thighs;
Skin tingling sensation.

If you do not consult a doctor when these symptoms appear, then the situation will only worsen in the future: varicose nodes, inflammation of the affected vessels and, as a consequence, trophic ulcers will appear, which already threatens disability.

Vascular diseases diagnosed using Doppler ultrasound

Since this type of study is one of the most informative, the doctor, based on its results, can make one of the following diagnoses:

Any of the diagnoses requires the most serious treatment and immediate initiation of treatment, since the above-mentioned diseases themselves cannot be cured, their course only progresses and over time causes severe consequences up to complete disability, in some cases even death.

How is a Doppler study performed?

The procedure does not require preliminary preparation of patients: there is no need to follow any diet or take medications other than those that you usually take to treat existing diseases.

When you come for an examination, you need to remove all jewelry and other metal objects and provide the doctor with access to your legs and thighs. The ultrasound diagnostic doctor will ask you to lie down on the couch and apply a special gel to the device’s sensor. It is the sensor that will capture and transmit all signals about pathological changes in the vessels of the legs to the monitor.

The gel improves not only the glide of the sensor over the skin, but also the speed of transmission of data obtained as a result of the study.

After completing the examination in a lying position, the doctor will ask you to stand on the floor and continue to study the condition of the blood vessels to obtain additional information about the suspected pathology.

Normal values for ultrasound examination of the lower extremities

Let's try to understand the results of the study of the lower arteries: the VSD has its own normal values, with which you just need to compare your own result.

Digital values

ABI (ankle-brachial complex) - the ratio of ankle blood pressure to shoulder blood pressure. The norm is 0.9 and above. An indicator of 0.7-0.9 indicates arterial stenosis, and 0.3 is a critical figure;
The maximum speed of blood flow in the femoral artery is 1 m/s;
The maximum speed of blood flow in the lower leg is 0.5 m/s;
Femoral artery: resistance index – 1 m/s and above;
Tibial artery: pulsation index – 1.8 m/s and higher.

Types of blood flow

They can be designated as follows: turbulent, mainline or collateral.

Turbulent blood flow is recorded in places of incomplete vasoconstriction.

The main blood flow is the source of all large vessels - for example, the femoral and brachial arteries. The note “main altered blood flow” indicates the presence of stenosis above the study site.

Collateral blood flow is recorded below the places where there is a complete absence of blood circulation.

Studying the condition of blood vessels and their patency using Dopplerography is an important diagnostic procedure: it is easy to perform, does not take much time, is completely painless and at the same time provides a lot of important information about the functional state of the venous apparatus of the legs.

My great-grandmother developed inflammation and blood clots on her legs, they advised her to check her legs using Doppler ultrasound, so I read the article. Everything is well described and explained, there are even digital values of the norms. The symptoms are also similar to those presented here, she experiences discomfort when moving, her legs hurt very much. I hope that I have good doctors and that they will help me find out what’s wrong with my legs and how it can be treated, the main thing is that they prescribe the right treatment. Good health to everyone, don't get sick!

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Doppler sonography of peripheral vessels. Part 1.

N.F. Beresten, A.O. Tsypunov

In modern functional diagnostics, ultrasound techniques are increasingly used to study blood vessels. This is due to its relatively low cost, simplicity, non-invasiveness and safety of the study for the patient with a fairly high information content compared to traditional X-ray angiographic techniques. The latest models of ultrasound tomographs from Madison make it possible to conduct a high-quality examination of blood vessels, successfully diagnose the level and extent of occlusive lesions, identify aneurysms, deformations, hypo- and aplasia, shunts, valvular insufficiency of the veins and other vascular pathologies.

To conduct vascular studies, you need an ultrasound tomograph operating in duplex and triplex modes, a set of sensors (table) and a software package for vascular studies.

The studies presented in this material were carried out on an SA-8800 Digital/Gaia ultrasound tomograph (Medison, South Korea) during screening among patients sent for ultrasound examination of other organs.

Vascular ultrasound technology

The sensor is installed in a typical area of passage of the vessel under study ( Fig.1).

2, 3 - vessels of the neck:

OSA, VSA, NSA, PA, JAV;

4 - subclavian artery;

5 - vessels of the shoulder:

brachial artery and vein;

6 - vessels of the forearm;

7 - vessels of the thigh:

10 - dorsal artery of the foot.

MF1 - upper third of the thigh;

MF2 - lower third of the thigh;

MZhZ - upper third of the leg;

MJ4 - lower third of the leg.

To clarify the topography of the vessels, scanning is performed in a plane perpendicular to the anatomical course of the vessel. During transverse scanning, the relative position of the vessels, their diameter, thickness and density of the walls, and the condition of the perivascular tissues are determined. By using the function and tracing the internal contour of the vessel, its effective cross-sectional area is obtained. Next, a transverse scan is performed along the studied segment of the vessel to search for areas of stenosis. When stenoses are identified, a program is used to obtain a calculated stenosis index. Then a longitudinal scan of the vessel is performed, assessing its course, diameter, internal contour and wall density, their elasticity, pulsation activity (using M-mode), and the state of the vessel lumen. The thickness of the intima-media complex is measured (along the far wall). Doppler examination is carried out in several areas, moving the sensor along the scanning plane and examining the largest possible area of the vessel.

The following scheme for Doppler examination of blood vessels is optimal:

color Doppler mapping based on direction analysis (CDA) or flow energy analysis (FEA) to search for areas with abnormal blood flow;
Doppler sonography of the vessel in pulsed mode (D), which allows one to evaluate the speed and direction of flow in the studied volume of blood;
Doppler sonography of a vessel in a continuous wave mode for studying high-speed flows.

If the ultrasound examination is carried out with a linear transducer, and the axis of the vessel is almost perpendicular to the surface, use the Doppler beam tilt function, which allows you to tilt the Doppler reward front relative to the surface. Then, using the function, the angle indicator is combined with the true path of the vessel, a stable spectrum is obtained, the image scale (,) and the position of the zero line (,) are set. It is customary to place the main spectrum above the baseline when studying arteries, and below it when studying veins. A number of authors recommend that for all vessels, including veins, the antegrade spectrum be placed at the top, and the retrograde spectrum at the bottom. The function swaps the positive and negative semi-axes on the ordinate (velocity) axis and thus changes the direction of the spectrum on the screen in the opposite direction. The selected time base speed should be sufficient to observe 2-3 complexes on the screen.

Calculation of the speed characteristics of flows in the pulse Doppler mode is possible at a flow speed of no more than 1-1.5 m/sec (Nyquist limit). To obtain a more accurate idea of the velocity distribution, it is necessary to establish a control volume of at least 2/3 of the lumen of the vessel under study. The programs are used to study the vessels of the extremities and to study the vessels of the neck. Working in the program, note the name of the corresponding vessel, record the values of the maximum systolic and minimum diastolic velocities, after which one complex is outlined. After carrying out all these measurements, you can receive a report including the values of V max, V min, V mean, PI, RI for all examined vessels.

Quantitative Doppler sonographic parameters of arterial blood flow

V max - maximum systolic (or peak) velocity - the real maximum linear velocity of blood flow along the axis of the vessel, expressed in mm/s, cm/s or m/s.

V min is the minimum diastolic linear velocity of blood flow along the vessel.

V mean is the velocity integral under the curve enveloping the spectrum of blood flow in the vessel.

RI (Resistivity Index, Purcelo index) - vascular resistance index. RI = (V systolic - V diastolic)/V systolic. Reflects the state of resistance to blood flow distal to the measurement site.

PI (Pulsatility Index, Gosling Index) - pulsation index, indirectly reflects the state of resistance to blood flow PI = (V systolic - V diastolic)/V mean. It is a more sensitive indicator than RI, since the calculations use V mean, which responds earlier to changes in the lumen and tone of the vessel than V systolic.

It is important to use PI, RI together, because they reflect different properties of blood flow in the artery. Using only one of them without taking into account the other can cause diagnostic errors.

Qualitative assessment of the Doppler spectrum

There are laminar, turbulent and mixed types of flow.

Laminar type is a normal variant of blood flow in vessels. A sign of laminar blood flow is the presence of a “spectral window” on the Dopplerogram at the optimal angle between the direction of the ultrasound beam and the flow axis (Fig. 2a). If this angle is large enough, then the “spectral window” can “close” even with a laminar type of blood flow.

Rice. 2a Main blood flow.

The turbulent type of blood flow is characteristic of places of stenosis or incomplete occlusion of the vessel and is characterized by the absence of a “spectral window” on the Dopplerogram. With CDK, a mosaic pattern of staining is revealed due to the movement of particles in different directions.

The mixed type of blood flow can normally be determined in places of physiological narrowing of the vessel, arterial bifurcations. Characterized by the presence of small zones of turbulence during laminar flow. With CDK, a point mosaic of the flow is revealed in the area of bifurcation or narrowing.

In the peripheral arteries of the extremities, the following types of blood flow are also distinguished based on analysis of the envelope curve of the Doppler spectrum.

The main type is the normal variant of blood flow in the main arteries of the extremities. It is characterized by the presence on the Dopplerogram of a three-phase curve, consisting of two antegrade and one retrograde peak. The first peak of the curve is systolic antegrade, high-amplitude, peaked. The second peak is a small retrograde peak (blood flow in diastole until the aortic valve closes). The third peak is a small antegrade peak (reflection of blood from the aortic valve leaflets). It should be noted that the main type of blood flow can be preserved even with hemodynamically insignificant stenoses of the main arteries. ( Rice. 2a, 4 ).

Rice. 4 Options for the main type of blood flow in the artery. Longitudinal scanning. CDC. Dopplerography in pulsed mode.

Main altered type of blood flow - recorded below the site of stenosis or incomplete occlusion. The first systolic peak is changed, of sufficient amplitude, expanded, more flat. The retrograde peak may be very weakly expressed. The second antegrade peak is absent ( Fig.2b).

Rice. 2b Main altered blood flow.

Collateral type of blood flow is also recorded below the site of occlusion. It appears close to a monophasic curve with a significant change in systolic and the absence of a retrograde and second antegrade peak ( rice. 2v) .

Rice. 2c Collateral blood flow.

The difference between Dopplerograms of the vessels of the head and neck and Dopplerograms. limbs is that the diastolic phase on Dopplerograms of the arteries of the brachycephalic system is never below 0 (i.e., it does not fall below the Base line). This is due to the characteristics of the blood supply to the brain. At the same time, on Dopplerograms of the vessels of the internal carotid artery system, the diastolic phase is higher, and the external carotid artery system is lower ( rice. 3).

Rice. 3 Difference between Dopplerograms of the ECA and ICA.

a) envelope of the Dopplerogram obtained from the ESA;

b) envelope of the Dopplerogram obtained from the ICA.

Examination of neck vessels

The sensor is installed alternately on each side of the neck in the area of the sternocleidomastoid muscle in the projection of the common carotid artery. In this case, the common carotid arteries, their bifurcations, and internal jugular veins are visualized. The contour of the arteries, their internal lumen are assessed, the diameter is measured and compared on both sides at the same level. To distinguish the internal carotid artery (ICA) from the external carotid artery (ECA), the following signs are used:

the internal carotid artery has a larger diameter than the external one;

the initial section of the ICA lies lateral to the ECA;

The ECA on the neck gives branches and may have a “scattered” type of structure, while the ECA on the neck does not have branches;

On the Dopplerogram of the ECA, a sharp systolic peak and a low-lying diastolic component are determined (Fig. 3a), on the Dopplerogram obtained from the ICA, a wide systolic peak and a high diastolic component are determined (Fig. 36). For control, the D.Russel test is performed. After obtaining a Doppler spectrum from the located artery, short-term compression of the superficial temporal artery (immediately in front of the ear tragus) is performed on the side of the study. When the ECA is located, additional peaks will appear on the Dopplerogram; when the ICA is located, the shape of the curve will not change.

When examining the vertebral arteries, the sensor is placed at an angle of 90° to the horizontal axis, or directly above the transverse processes in the horizontal plane.

Using the Carotid program, Vmax (Vpeak), Vmin (Ved), Vmean (TAV), PI, RI are calculated. Compare the indicators obtained from opposite sides.

Vascular examination of the upper extremities

The patient's position is on his back. The head is tilted back slightly and a small cushion is placed under the shoulder blades. The study of the aortic arch and the initial sections of the subclavian arteries is carried out with the sensor in a suprasternal position (see Fig. 1). The aortic arch and the initial sections of the left subclavian artery are visualized. The subclavian arteries are examined from the supraclavicular approach. The indicators obtained on the left and right are compared to identify asymmetry. If occlusions or stenoses of the subclavian artery are detected before the departure of the vertebrates (1 segment), a test with reactive hyperemia is performed to identify the “steal” syndrome. To do this, compress the brachial artery with a pneumatic cuff for 3 minutes. At the end of compression, the blood flow velocity in the vertebral artery is measured and the air from the cuff is sharply deflated. Increased blood flow through the vertebral artery indicates a lesion in the subclavian artery and retrograde blood flow in the vertebral artery. If there is no increase in blood flow, blood flow in the vertebral artery is antegrade and there is no occlusion of the subclavian artery. To examine the axillary artery, the arm on the side of the study is retracted outward and rotated. The scanning surface of the sensor is installed in the axillary fossa and tilts down. Compare indicators on both sides. The study of the brachial artery is carried out with the sensor located in the medial groove of the shoulder (see. rice. 1). Systolic blood pressure is measured. A tonometer cuff is placed on the shoulder, and a Doppler spectrum is obtained from the brachial artery below the cuff. Blood pressure is measured. The criterion for systolic blood pressure is the appearance of the Doppler spectrum during Doppler ultrasound. Compare the indicators obtained from opposite sides.

The asymmetry indicator is calculated: PN = BP syst. dext. - Blood pressure syst. sin. [mm. Hg Art.]. Normally -20

Study of the femoral arteries. The initial position of the sensor is under the inguinal ligament (transverse scanning) (see Fig. 1). After assessing the diameter and lumen of the vessel, scanning is performed along the common femoral, superficial femoral and deep femoral arteries. The Doppler spectrum is recorded and the obtained values are compared on both sides.

Examination of the popliteal arteries. The patient's position is lying on his stomach. The sensor is installed in the popliteal fossa across the axis of the lower limb. A transverse and then a longitudinal scan is performed.

To clarify the nature of blood flow in the altered vessel, regional pressure is measured. To do this, apply a blood pressure cuff first to the upper third of the thigh and measure systolic blood pressure, then to the lower third of the thigh. The criterion for systolic blood pressure is the appearance of blood flow during Doppler ultrasound of the popliteal artery. The regional pressure index is calculated at the level of the upper and lower third of the thigh: RID = syst blood pressure (thigh) / syst blood pressure (shoulder blood pressure), which normally should be greater than 1.

Study of the arteries of the leg. With the patient lying on his stomach, a longitudinal scan is performed from the site of division of the popliteal artery along each of the branches alternately on both legs. Then, with the patient in the supine position, the posterior tibial artery in the area of the medial malleolus and the dorsalis pedis artery in the area of the dorsum of the foot are scanned. High-quality location of arteries at these points is not always possible. An additional criterion for assessing blood flow is the regional pressure index (RPI). To calculate the RID, a cuff is sequentially applied first to the upper third of the lower leg, the systolic pressure is measured, then the cuff is applied to the lower third of the lower leg and the measurements are repeated. During compression, scan a. tibialis posterior or a. dorsalis pedis. RPI = BP syst (calf) / BP syst (shoulder), normally >= 1. RPI obtained at level 4 of the cuff is called the ankle pressure index (API).

Examination of the veins of the lower extremities. It is carried out simultaneously with the study of the arteries of the same name or as an independent study.

The study of the femoral vein is carried out with the patient in the supine position with the legs slightly apart and rotated outward. The sensor is installed in the area of the inguinal fold parallel to it. A transverse section of the femoral bundle is obtained, and the femoral vein is found, which is located medial to the artery of the same name. The contour of the vein walls and its lumen are assessed, and a Dopplerogram is recorded. By unfolding the sensor, a longitudinal section of the vein is obtained. A scan is performed along the vein, the contour of the walls, the lumen of the vessel, and the presence of valves are assessed. A Dopplerogram is recorded. The shape of the curve and its synchronization with breathing are assessed. A breathing test is performed: take a deep breath, hold your breath, and strain for 5 seconds. The function of the valve apparatus is determined: the presence of vein dilatation during the test below the level of the valve and a retrograde wave. When a retrograde wave is detected, its duration and maximum speed are measured. The deep femoral vein is examined using a similar technique, with Doppler ultrasound setting the control volume behind the vein valve.

The examination of the popliteal veins is carried out with the patient in the prone position. To enhance independent blood flow through the vein and facilitate obtaining a Dopplerogram, the patient is asked to rest his straightened big toes on the couch. The sensor is installed in the area of the popliteal fossa. A transverse scan is performed to determine the topographic relationships of the vessels. A Dopplerogram is recorded and the shape of the curve is assessed. If the blood flow in the vein is weak, compression of the leg is performed, and an increase in blood flow through the vein is detected. When scanning a vessel longitudinally, pay attention to the contour of the walls, the lumen of the vessel, the presence of valves (usually 1-2 valves can be identified) ( rice. 5).

Rice. 5 Study of blood flow in a vein using color flow and pulsed Dopplerography.

A proximal compression test is performed to detect a retrograde wave. After obtaining a stable spectrum, compress the lower third of the thigh for 5 seconds to detect retrograde current. The examination of the saphenous veins is carried out with a high-frequency (7.5-10.0 MHz) sensor according to the scheme described above, having previously installed the sensor in the projection of these veins. It is important to scan through the gel pad while holding the probe above the skin, as even slight pressure on these veins is enough to reduce blood flow into them.

Ultrasound scanning of the main arteries of the lower extremities

The study of the main arteries of the lower extremities was carried out in 62 patients using duplex scanning on expert-level ultrasound scanners. Ultrasound examination of the lower extremities was also carried out in 15 healthy individuals who formed the control group

The study of the iliac arteries was carried out with a convex multifrequency sensor 3-5 MHz, the femoral, popliteal, posterior and anterior tibial arteries and the dorsal artery of the foot - with a linear velocity sensor with a frequency of 7-14 MHz (83).

Scanning of the arterial bed was carried out in the longitudinal and transverse scanning planes. Transverse scanning clarifies the anatomy of arteries in the areas of their bifurcations or bends.

When examining the abdominal aorta, the probe was installed at the level of the umbilicus, slightly to the left of the midline, and stable visualization of the vessel was achieved. Then the sensor was moved to the border of the middle and inner third of the Pupart ligament and the iliac arteries were located. Below the ligament, the mouth of the femoral artery was visualized. The common femoral artery (COA) and its bifurcation were visualized without difficulty, while the orifice of the deep femoral artery (DFA) could be accessible for examination in an area only 3-5 cm from the orifice. If the mouth of the GBA is located on the side wall of the BOTH sensor, the sensor was turned slightly laterally. The superficial femoral artery (SFA) is well traced to the level of the entrance to Gunter's canal, in the medial and downward direction. When examining the popliteal artery (PclA), the sensor was placed longitudinally in the upper corner of the popliteal fossa, moving it distally to the border of the upper and middle third of the leg.

The upper and middle thirds of the posterior tibial artery (PTTA) are located from the anteromedial approach between the tibial bone and the gastrocnemius muscle. To study the distal portions of the TPAA, the sensor was placed longitudinally in the recess between the medial malleolus and the edge of the Achilles tendon.

The anterior tibial artery (ATA) is located from the anterolateral approach - between the tibia and fibula. The artery of the dorsum of the foot is located in the space between the I and II metatarsal bones.

The screening technique is based on assessing the quantitative and qualitative parameters of blood flow at standard research points, where the artery is as close as possible to the surface of the skin and is connected to certain anatomical landmarks (Fig. 2.11).

Fig.2.11. Standard locations for the main arteries of the lower extremities.

If changes in the hemodynamic parameters of blood flow were detected at any of the standard points, the arterial bed was examined along its entire length in two projections.

The arteries of the foot and leg are the most difficult to visualize and qualitatively assess intraluminal changes, so B-mode was used to study peripheral hemodynamics. In this mode the following is normal:

the lumen of the arteries is homogeneous, hypoechoic, and does not contain additional inclusions.
permissible asymmetry of the diameters of paired vessels is up to 20%.
pulsation of the arterial wall.
complex “intimacy-media”.

Qualitative assessment: smooth, clearly differentiated into layers. Quantitative assessment: its thickness in BOTH is no more than 1.2 mm (Fig. 2.12).

Rice. 2.12. The main type of blood flow is normal in B-mode in patient L., 37 years old.

To assess the patency of the arteries, in addition to the B-mode, color and spectral Doppler modes were used, and when studying small-caliber superficial vessels, the sensor frequency can be increased.

Rice. 2.13. The norm of the color circulation of patient L. is 37 years old.

In color Doppler mapping mode, the lumen of the arteries is stained evenly. Physiological flow turbulence is recorded at arterial bifurcations (Fig. 2.13).

Qualitative and quantitative parameters were assessed in Doppler mode.

The main three-phase type of blood flow is recorded.
lack of spectral expansion, presence of a “Doppler window”
absence of local acceleration of blood flow Quantitative parameters.
diastolic blood flow velocity (Vd)

Indices that indirectly characterize the state of peripheral resistance in the studied vascular area:

peripheral resistance index (IR)
pulsation index (IP)
systole-diastolic ratio (S/D)

Indices that indirectly characterize the tone of the vascular wall:

acceleration time (AT); acceleration index (AI) (Fig. 2.14).

Rice. 2.14. The main type of blood flow is normal in patient B. 43 years old.

The measured speed and calculated parameters of blood flow in the study of the arteries of the lower extremities obtained in the control group aged 18 to 45 years are shown in Table 2.12.

Average values of linear blood flow velocity and pulse wave acceleration time

Peak systolic blood flow velocity (Vs)

Arterial blood flow

Arterial blood flow is the movement of blood along the arterial bed.

The energy that gives this movement is created by the main muscular organ - the heart, which constantly, cyclically pumping blood into the aorta, provides high hydrostatic pressure in the vessels.

Types and parameters of arterial blood flow

The main characteristic of arterial blood flow is its speed, which depends on several parameters:

elasticity and course of the vessel;
blood viscosity;
total lumen of blood vessels.

In this regard, several types of arterial blood flow are distinguished:

laminar blood flow is a normal, physiological type of blood flow in vessels;
turbulent blood flow is determined in places of narrowing or incomplete occlusion of the vessel and is a pathological variant of blood flow;
mixed type - determined in places of physiological narrowing of the vessel and represents the presence of small areas of turbulence against the background of laminar blood flow.

In peripheral arteries, some other types of blood flow are distinguished:

main type - normal type of arterial blood flow in the main vessels;
altered main type - recorded below the area of stenosis or incomplete narrowing;
collateral type - also recorded below the site of narrowing.

Relevance of the problem

The study of arterial, arterial blood flow, its types, physiology is the main method of preventing, detecting and treating such dangerous vascular diseases as coronary atherosclerosis and the resulting ischemic heart disease, obliterating endarteritis, acute vascular diseases of the abdominal organs.

Doppler sonography of peripheral vessels. Part 2.

In Part I of this article, the main methodological approaches to the study of peripheral vessels were outlined, the main quantitative Doppler sonographic parameters of blood flow were identified, and the types of flows were listed and demonstrated. In Part II of the work, based on our own data and literary sources, we present the main quantitative indicators of blood flow in various vessels in normal conditions and in pathology.

% - filling the spectral window, increasing the maximum speed, expanding the envelope contour;

% - filling the spectral window, flattening the velocity profile, increasing the LSC. Reverse flow possible;

% - the spectrum approaches a rectangular shape. "Stenotic wall";

- > 90% - the spectrum approaches a rectangular shape. A decrease in BSC is possible.

Occlusion of the common carotid artery. Carotid Doppler ultrasound reveals a lack of blood flow in the CCA and ICA on the affected side.

Occlusion of the vertebral artery. Lack of blood flow at the location.

Occlusion of the terminal aorta. Collateral blood flow is recorded at all standard points on both limbs.

2, 3 - vessels of the neck:

OSA, VSA, NSA, PA, JAV;

4 - subclavian artery;

5 - vessels of the shoulder:

brachial artery and vein;

6 - vessels of the forearm;

7 - vessels of the thigh:

8 - popliteal artery and vein;

9 - posterior tibial artery;

10 - dorsal artery of the foot.

MF1 - upper third of the thigh;

MF2 - lower third of the thigh;

MZhZ - upper third of the leg;

MJ4 - lower third of the leg.

In conclusion, we note that ultrasound scanners from Madison meet the requirements of screening examinations of patients with peripheral vascular pathology. They are most convenient for departments of functional diagnostics, especially at the outpatient level, where the main streams of primary examinations of the population of our country are concentrated.

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Unpleasant sensations in the legs sooner or later force us to see a doctor to find out the causes of swelling, pain, heaviness and night cramps. In each case, in addition to the examination, we are asked to undergo a bridle test of the lower extremities. What kind of procedure is this and what diseases can be diagnosed with its help?

What is ultrasound and what is studied with its help?

The ultrasound examination procedure is carried out in real time. With its help, the specialist receives sound, graphic and quantitative information about the blood flow in the venous apparatus of the legs within 15-20 minutes.

The following are subject to research:

Greater and lesser saphenous veins;
Inferior vena cava;
Iliac veins;
Femoral vein;
Deep veins of the leg;
Popliteal vein.

The presence of inflamed areas, blood clots, atherosclerotic plaques;
Structural pathologies - tortuosity, kinks, scars;
The severity of vascular spasms.

During the study, the compensatory capabilities of blood flow are also assessed.

When is a Doppler study necessary?

Mild swelling of the feet and ankle joints, appearing in the evening and completely disappearing by the morning;
Discomfort when moving - heaviness, pain, rapid leg fatigue;
Convulsive twitching of legs during sleep;
Rapid freezing of the feet at the slightest drop in air temperature;
Stopping hair growth on the legs and thighs;
Skin tingling sensation.

Vascular diseases diagnosed using Doppler ultrasound

Since this type of study is one of the most informative, the doctor, based on its results, can make one of the following diagnoses:

How is a Doppler study performed?

The procedure does not require preliminary preparation of patients: there is no need to follow any diet or take medications other than those that you usually take to treat existing diseases.

The gel improves not only the glide of the sensor over the skin, but also the speed of transmission of data obtained as a result of the study.

Normal values for ultrasound examination of the lower extremities

Let's try to understand the results of the study of the lower arteries: the VSD has its own normal values, with which you just need to compare your own result.

Digital values

ABI (ankle-brachial complex) - the ratio of ankle blood pressure to shoulder blood pressure. The norm is 0.9 and above. An indicator of 0.7-0.9 indicates arteries, and 0.3 is a critical figure;
Limit in the femoral artery - 1 m/s;
The maximum speed of blood flow in the lower leg is 0.5 m/s;
Femoral artery: resistance index - 1 m/s and above;
Tibial artery: pulsation index - 1.8 m/s and higher.

Types of blood flow

They can be designated as follows: turbulent, mainline or collateral.

Turbulent blood flow is fixed in places of incomplete vasoconstriction.

Main blood flow is noma for all large vessels - for example, the femoral and brachial arteries. The note “main altered blood flow” indicates the presence of stenosis above the study site.

Collateral blood flow is registered below the places where there is a complete absence of blood circulation.

The maximum number of anterior radiculomedullary arteries found in the specimen was 5, the minimum was 1, and the average was 1.6 (Table 1).

Table 1. Distribution of drugs by number of anterior
radiculomedullary arteries

Number of anterior radiculomedullary arteries	Number of drugs
Number of anterior radiculomedullary arteries	abs.

All studied drugs were divided according to the Skoromets classification, which distinguishes types of blood supply to the anterior spinal artery: mainline (options 1, 2, 3) and loose (option 4).

1. Main type - all segments of the spinal cord below T2-T3 are supplied by one large radiculomedullary artery - the artery of Adamkiewicz (Fig. 4).

Rice. 4. Main type of blood supply to the spinal cord: 1 - artery of Adamkiewicz; 2 - anterior spinal artery, descending section; 3 - anterior spinal artery, ascending section; 4 - posterior spinal arteries.

2. Main type - in addition to the Adamkiewicz artery, there is one more additional radiculomedullary artery, next to the second lumbar or first sacral root.

3. Main type - in addition to the Adamkiewicz artery, there is another artery accompanying one of the thoracic roots - the superior accessory radiculomedullary artery.

4. Scattered type - the thoracolumbar spinal cord is supplied with blood by three or more radiculomedullary arteries, one of which has a larger diameter than all the others (Adamaevich’s artery) (Fig. 5).

Rice. 5. Scattered type of blood supply to the spinal cord: a - with uniform; b - with an uneven arrangement of additional radiculomedullary arteries; 1 - artery of Adamkiewicz; 2 - anterior spinal artery, descending section; 3 - anterior spinal artery, ascending section; 4 - additional radiculomedullary artery.

The main type of blood supply was identified in 57 (75%) preparations, and the loose type - in 19 (25%) (Table 2).

Table 2. Distribution of drugs by type of blood supply

Blood supply

Number of drugs

Type

Option

abs.

Trunk

loose

The diameters of the greater anterior radiculomedullary artery (GRMA) and the descending anterior spinal artery were identical. The ascending section of the anterior spinal artery, as a rule, narrowed by 54%, but this only applied to its bifurcation at the confluence of the BPRMA.

Data on the diameter of the anterior spinal artery and BPRMA depending on the type of blood supply were not found in the literature. The measurement of the arteries using angiograms using a micrometer showed the following:

The largest diameter of the arteries was observed in option 1 of the main type of blood supply: the cross-section of the Adamkiewicz and anterior spinal arteries ranged from 700 to 1400 µm (on average 1040 µm);

With options 2 and 3 of the main type of blood supply, these arteries had a diameter from 600 to 1100 µm (on average 850 µm);

In option 4 (loose type of blood supply), their diameter ranged from 500 to 900 µm (average 760 µm).

On the obtained angiograms, the BPRMA always entered the anterior spinal artery system first in the caudal direction, all additional anterior radiculomedullary arteries entered higher (Fig. 6).

Rice. 6. Main type of blood supply to the spinal cord, catatrauma: 1 - artery of Adamkiewicz; 2 - anterior spinal artery, descending section; 3 - anterior spinal artery, ascending section; 4 - posterior spinal arteries; 5 - rupture of the ascending section of the anterior spinal artery.

In all studied specimens, including those obtained from those killed as a result of catatrauma, preservation of the vascular system of the anterior spinal artery throughout its entire length was noted. The exception was one case of catatrauma with direct mechanical damage to the substance of the spinal cord, in which damage to the anterior spinal artery was found.

In the area where the BPRMA enters the anterior spinal artery, as a rule, contrasting of the perimedullary network to the system of the posterior spinal arteries was observed.

Through the vascular network of the conus, the posterior spinal arteries were contrasted to the level of the radicular branches.

The so-called “islands” described in the literature—areas of bifurcation of the anterior spinal artery—were found in the studied material only in the cervical spinal cord.

In three cases, in the system of the descending anterior spinal artery in the area of the cone, an S-shaped bend was found, from one of the apexes of which a thin artery, no more than 100-150 μm, departed, which could qualify for the definition of an additional radiculomedullary, but in no case did it Recalibration of the anterior spinal artery in this area was noted.

A change in diameter along the anterior spinal artery was detected only in option 1 of the main type of blood supply - at the confluence of the BPRMA, as mentioned above.

Recalibration of the anterior spinal artery along the length between the main and accessory anterior radiculomedullary arteries flowing into it was often found in the scattered type and variants 2 and 3 of the main type.

According to the literature, the anterior radicular arteries enter the spinal cord along its length, either on the left or on the right. The symmetrical approach of two such arteries to one spinal segment in humans (as opposed to animals) is rare. It is noted that much more often these arteries enter the spine and spinal cord on the left side. However, no specific quantitative data on this issue were found in the literature.

Related materials:

This information is intended for healthcare and pharmaceutical professionals. Patients should not use this information as medical advice or recommendations.

Doppler sonography of peripheral vessels. Part 1.

N.F. Beresten, A.O. Tsypunov
Department of Clinical Physiology and Functional Diagnostics, RMAPO, Moscow, Russia

Introduction

In modern functional diagnostics, ultrasound techniques are increasingly used to study blood vessels. This is due to its relatively low cost, simplicity, non-invasiveness and safety of the study for the patient with a fairly high information content compared to traditional X-ray angiographic techniques. The latest models of ultrasound tomographs from "Medison" make it possible to conduct a high-quality examination of blood vessels, successfully diagnose the level and extent of occlusive lesions, identify aneurysms, deformations, hypo- and aplasia, shunts, valvular insufficiency of the veins and other vascular pathologies.

To conduct vascular studies, you need an ultrasound tomograph operating in duplex and triplex modes, a set of sensors (table) and a software package for vascular studies.

Vascular ultrasound technology

The sensor is installed in a typical area of passage of the vessel under study ( Fig.1).

Rice. 1 Standard approaches for Doppler sonography of peripheral vessels. Levels of application of compression cuffs when measuring regional SBP.

1 - aortic arch;
2, 3 - vessels of the neck:
OSA, VSA, NSA, PA, JAV;
4 - subclavian artery;
5 - vessels of the shoulder:
brachial artery and vein;
6 - vessels of the forearm;
7 - vessels of the thigh:
BOTH, PBA, GBA,
corresponding veins;
8 - popliteal artery and vein;
9 - posterior tibial artery;
10 - dorsal artery of the foot.

MF1 - upper third of the thigh;
MF2 - lower third of the thigh;
MZhZ - upper third of the leg;
MJ4 - lower third of the leg.

The following scheme for Doppler examination of blood vessels is optimal:

color Doppler mapping based on direction analysis (CDA) or flow energy analysis (FEA) to search for areas with abnormal blood flow;
Doppler sonography of the vessel in pulsed mode (D), which allows one to evaluate the speed and direction of flow in the studied volume of blood;
Doppler sonography of a vessel in a continuous wave mode for studying high-speed flows.

If an ultrasound examination is carried out with a linear probe, and the axis of the vessel is almost perpendicular to the surface, use the Doppler beam tilt function, which allows you to tilt the Doppler front by 15-30 degrees relative to the surface. Then, using the function, combine the angle indicator with the true path of the vessel, obtain a stable spectrum, and set the image scale ( , ) and the position of the zero line ( , ). It is customary to place the main spectrum above the baseline when studying arteries, and below it when studying veins. A number of authors recommend that for all vessels, including veins, the antegrade spectrum be placed at the top, and the retrograde spectrum at the bottom. The function swaps the positive and negative semi-axes on the ordinate (velocity) axis and thus changes the direction of the spectrum on the screen in the opposite direction. The selected time base speed should be sufficient to observe 2-3 complexes on the screen.

Calculation of the speed characteristics of flows in the pulse Doppler mode is possible at a flow speed of no more than 1-1.5 m/sec (Nyquist limit). To obtain a more accurate idea of the velocity distribution, it is necessary to establish a control volume of at least 2/3 of the lumen of the vessel under study. The programs are used to study the vessels of the extremities and to study the vessels of the neck. Working in the program, note the name of the corresponding vessel, record the values of the maximum systolic and minimum diastolic velocities, after which one complex is outlined. After taking all these measurements, you can get a report including the values V max, V min, V mean, PI, RI for all examined vessels.

Quantitative Doppler sonographic parameters of arterial blood flow

2 D% stenosis - %STA = (Stenosis Area/ Blood Vessel Area) * 100%. Characterizes the actual reduction in the area of the hemodynamically effective cross-section of the vessel as a result of stenosis, expressed as a percentage.
Vmax- maximum systolic (or peak) velocity - the real maximum linear velocity of blood flow along the axis of the vessel, expressed in mm/s, cm/s or m/s.
Vmin- minimum diastolic linear velocity of blood flow along the vessel.
V mean- velocity integral under the curve enveloping the spectrum of blood flow in the vessel.
R.I.(Resistivity Index, Purcelo index) - vascular resistance index. RI = (V systolic - V diastolic)/V systolic. Reflects the state of resistance to blood flow distal to the measurement site.
P.I.(Pulsatility Index, Gosling index) - pulsation index, indirectly reflects the state of resistance to blood flow PI = (V systolic - V diastolic)/V mean. It is a more sensitive indicator than RI, since the calculations use V mean, which responds earlier to changes in the lumen and tone of the vessel than V systolic.

Qualitative assessment of the Doppler spectrum

Highlight laminar, turbulent And mixed stream types.

Rice. 2a Main blood flow.

In the peripheral arteries of the extremities, the following types of blood flow are also distinguished based on analysis of the envelope curve of the Doppler spectrum.

The main type is the normal variant of blood flow in the main arteries of the extremities. It is characterized by the presence on the Dopplerogram of a three-phase curve, consisting of two antegrade and one retrograde peak. The first peak of the curve is systolic antegrade, high-amplitude, peaked. The second peak is a small retrograde peak (blood flow in diastole until the aortic valve closes). The third peak is a small antegrade peak (reflection of blood from the aortic valve leaflets). It should be noted that the main type of blood flow can persist even with hemodynamically insignificant stenoses of the main arteries. ( Rice. 2a, 4 ).

Rice. 4 Options for the main type of blood flow in the artery. Longitudinal scanning. CDC. Dopplerography in pulsed mode.

Main altered type of blood flow - recorded below the site of stenosis or incomplete occlusion. The first systolic peak is changed, of sufficient amplitude, expanded, flatter. The retrograde peak may be very weakly expressed. The second antegrade peak is absent ( Fig.2b).

Rice. 2b Main altered blood flow.

Rice. 2c Collateral blood flow.

Rice. 3 Difference between Dopplerograms of the ECA and ICA. a) envelope of the Dopplerogram obtained from the ESA;
b) envelope of the Dopplerogram obtained from the ICA.

Examination of neck vessels

the internal carotid artery has a larger diameter than the external one;

the initial section of the ICA lies lateral to the ECA;

The ECA on the neck gives branches and may have a “scattered” type of structure, while the ECA on the neck does not have branches;

When examining the vertebral arteries, the sensor is placed at an angle of 90° to the horizontal axis, or directly above the transverse processes in the horizontal plane.

Using the Carotid program, Vmax (Vpeak), Vmin (Ved), Vmean (TAV), PI, RI are calculated. Compare the indicators obtained from opposite sides.

Vascular examination of the upper extremities

The asymmetry indicator is calculated: PN = BP syst. dext. - Blood pressure syst. sin. [mm. Hg Art.]. Normally -20

To study the ulnar and radial arteries, the sensor is installed in the projection of the corresponding artery, further examination is carried out according to the above-described scheme.

The study of the veins of the upper extremities is usually carried out simultaneously with the study of the arteries of the same name from the same accesses.

Examination of the vessels of the lower extremities

When describing changes in the femoral vessels, the following terminology is used, which differs slightly from the standard anatomical classification of vessels:

To clarify the nature of blood flow in the altered vessel, regional pressure is measured. To do this, apply a blood pressure cuff first to the upper third of the thigh and measure systolic blood pressure, then to the lower third of the thigh. The criterion for systolic blood pressure is the appearance of blood flow during Doppler ultrasound of the popliteal artery. The regional pressure index is calculated at the level of the upper and lower third of the thigh: RID = BP (thigh) / BP (shoulder), which normally should be greater than 1.

Study of the arteries of the leg. With the patient lying on his stomach, a longitudinal scan is performed from the site of division of the popliteal artery along each of the branches alternately on both legs. Then, with the patient in the supine position, the posterior tibial artery in the area of the medial malleolus and the dorsalis pedis artery in the area of the dorsum of the foot are scanned. High-quality location of arteries at these points is not always possible. An additional criterion for assessing blood flow is the regional pressure index (RPI). To calculate the RID, a cuff is first sequentially applied to the upper third of the lower leg, the systolic pressure is measured, then the cuff is applied to the lower third of the lower leg and the measurements are repeated. During compression, scan a. tibialis posterior or a. dorsalis pedis. RPI = BP syst (calf) / BP syst (shoulder), normally >= 1. RPI obtained at level 4 of the cuff is called the ankle pressure index (API).

Examination of the veins of the lower extremities. It is carried out simultaneously with the study of the arteries of the same name or as an independent study.

The examination of the femoral vein is carried out with the patient in the supine position with the legs slightly apart and rotated outward. The sensor is installed in the area of the inguinal fold parallel to it. A transverse section of the femoral bundle is obtained, and the femoral vein is found, which is located medial to the artery of the same name. The contour of the vein walls and its lumen are assessed, and a Dopplerogram is recorded. By unfolding the sensor, a longitudinal section of the vein is obtained. A scan is performed along the vein, the contour of the walls, the lumen of the vessel, and the presence of valves are assessed. A Dopplerogram is recorded. The shape of the curve and its synchronization with breathing are assessed. A breathing test is performed: take a deep breath, hold your breath, and strain for 5 seconds. The function of the valve apparatus is determined: the presence of vein dilatation during the test below the level of the valve and the retrograde wave. When a retrograde wave is detected, its duration and maximum speed are measured. The deep femoral vein is examined using a similar technique, with Doppler ultrasound setting the control volume behind the vein valve.

Rice. 5 Study of blood flow in a vein using color flow and pulsed Dopplerography.

Literature

Zubarev A.R., Grigoryan R.A. Ultrasound angioscanning. - M.: Medicine, 1991.

Larin S.I., Zubarev A.R., Bykov A.V. Comparison of Doppler ultrasound data of the saphenous veins of the lower extremities and clinical manifestations of varicose veins.

Aelyuk S.E., Lelyuk V.G. Basic principles of duplex scanning of the main arteries // Ultrasound diagnostics.- No. 3.-1995.

Clinical guide to ultrasound diagnostics / Ed. V.V. Mitkova. - M.: "Vidar", 1997

Clinical ultrasound diagnostics / Ed. N.M. Mukharlyamova. - M.: Medicine, 1987.

Doppler ultrasound diagnosis of vascular diseases / Edited by Yu.M. Nikitina, A.I. Trukhanova. - M.: "Vidar", 1998.

NTsSSKh them. A.N. Bakuleva. Clinical Dopplerography of occlusive lesions of the arteries of the brain and limbs. - M.: 1997.

Savelyev V.S., Zatevakhin I.I., Stepanov N.V. Acute obstruction of the bifurcation of the aorta and main arteries of the extremities. - M.: Medicine, 1987.

Sannikov A.B., Nazarenko P.M. Clinical imaging, December 1996. Frequency and hemodynamic significance of retrograde blood flow in the deep veins of the lower extremities in patients with varicose veins.

Amerizo S, et al. Pulseless Transcranial Doppler Finding in Takayasu's Arteritis. J. of Clinical Ultrasound. Sept. 1990.

Bums, Peter N. The Physical principles of Doppler Spectral Analysis. Journal of Clinical Ultrasound, Nov/Dec 1987, Vol. 15, No. 9.ll.facob, Normaan M. et al. Duplex Carotid Sonography: Criteria for Stenosis, Accuracy, and Pitfalls. Radiology, 1985.

Thomas S. Hatsukami, Jean Primozicb, R. Eugene Zierler & D. Eugene Strandness, ]r. Color doppler characteristics in normal lower extremity arteries. Ultrasound in Medicine & Biology. Vol 18, No. 2, 1992.

Scanning of the arterial bed was carried out in the longitudinal and transverse scanning planes. Transverse scanning clarifies the anatomy of arteries in the areas of their bifurcations or bends.

Fig.2.11. Standard locations for the main arteries of the lower extremities.

If changes in the hemodynamic parameters of blood flow were detected at any of the standard points, the arterial bed was examined along its entire length in two projections.

The arteries of the foot and leg are the most difficult to visualize and qualitatively assess intraluminal changes, so B-mode was used to study peripheral hemodynamics. In this mode the following is normal:

the lumen of the arteries is homogeneous, hypoechoic, and does not contain additional inclusions.
permissible asymmetry of the diameters of paired vessels is up to 20%.
pulsation of the arterial wall.
complex “intimacy-media”.

Qualitative assessment: smooth, clearly differentiated into layers. Quantitative assessment: its thickness in BOTH is no more than 1.2 mm (Fig. 2.12).

Rice. 2.12. The main type of blood flow is normal in B-mode in patient L., 37 years old.

Rice. 2.13. The norm of the color circulation of patient L. is 37 years old.

In color Doppler mapping mode, the lumen of the arteries is stained evenly. Physiological flow turbulence is recorded at arterial bifurcations (Fig. 2.13).

Qualitative and quantitative parameters were assessed in Doppler mode.

Qualitative parameters:

The main three-phase type of blood flow is recorded.
lack of spectral expansion, presence of a “Doppler window”
absence of local acceleration of blood flow Quantitative parameters.
diastolic blood flow velocity (Vd)

Indices that indirectly characterize the state of peripheral resistance in the studied vascular area:

peripheral resistance index (IR)
pulsation index (IP)
systole-diastolic ratio (S/D)

Indices that indirectly characterize the tone of the vascular wall:

acceleration time (AT); acceleration index (AI) (Fig. 2.14).

Rice. 2.14. The main type of blood flow is normal in patient B. 43 years old.

The measured speed and calculated parameters of blood flow in the study of the arteries of the lower extremities obtained in the control group aged 18 to 45 years are shown in Table 2.12.

Table 2.12

Average values of linear blood flow velocity and pulse wave acceleration time