Upper Extremity Arterial Protocol

Structure Scan Label Images Stored
Plane Identify RT or LT
Innominate Sagittal INNOM ART Color Doppler
Artery (aka (This image is Color and spectral Doppler -
Brachiocephal only included in a measure PSV
ic Artery) RUE exam. There
*Only is no LT INNOM
included in a ART since the LT
RUE exam* SUBCL branches
directly off of the
aortic arch)
Subclavian Sagittal SUBCL ART PROX Color Doppler
Artery Color and spectral Doppler -
Proximal measure PSV
Subclavian Sagittal SUBCL ART MID Color Doppler
Artery Mid Color and spectral Doppler -
measure PSV
Subclavian Sagittal SUBCL ART DIST Color Doppler
Artery Distal Color and spectral Doppler -
measure PSV
Axillary Sagittal AXIL ART Color Doppler
Artery Color and spectral Doppler -
measure PSV
Brachial Sagittal BRACH ART PROX Color Doppler
Artery Color and spectral Doppler -
Proximal measure PSV
Brachial Sagittal BRACH ART MID Color Doppler
Artery Mid Color and spectral Doppler -
measure PSV
Brachial Sagittal BRACH ART DIST Color Doppler
Artery Distal Color and spectral Doppler -
measure PSV
Radial Artery Sagittal RAD ART Color Doppler
Color and spectral Doppler -
measure PSV
Ulnar Artery Sagittal ULN ART Color Doppler
Color and spectral Doppler -
measure PSV

Tips
 For a right upper extremity exam, the protocol begins at the innominate artery.
 For a left upper extremity exam, the protocol begins at the proximal subclavian
artery.
 Patient set-up - very important for ease of completing the examination (for the
sonographer and patient) – multiple positions will be used throughout the exam
 When scanning the right arm, allow enough room on the side of patient closest
to you for the patient to rest their arm on the bed.

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Upper Extremity Arterial Protocol

 When scanning the left arm, position the patient as close to you as safely
possible.
 If patient is unable to raise arm for axillary images, ask for assistance.
 Follow the vessels in their entirety in color, taking the appropriate images at the
described locations
 If abnormalities are seen with color Doppler in any segment of vessel, include a gray
scale image of that segment of vessel to document pathology in gray scale.

Color Doppler
 Will vary with the presence/absence of pathology & curvature of the vessel
 Color images should relay the same information as your spectral images
 Color box should be steered (angled) with the vessel direction
 Color in a normal vessel should be free of aliasing and extend to vessel walls

 Utilize preset color PRF (scale) and gain, and adjust according to the type of blood
flow (velocities) being imaged
 If flow is normal and the color is outside the vessel wall or aliasing in center of
vessel, slowly increase PRF and/or decrease color gain until color is no longer
outside the vessel wall or aliasing.
 If flow is normal and the color in the vessel is not filled in, slowly decrease PRF
and/or increase color gain until the color fills the vessel without aliasing or
bleeding.

Spectral Doppler
 Must use angle correct – Angle correct must be less than 60 degrees
 Gate (SV length) must be in center of vessel & small width.
 Use color Doppler appearance to aid in placement of gate for spectral interrogation.
Your goal is to document the highest velocities present.
 Set the PRF (scale) appropriately for the velocities imaged.
 Adjust the PRF (scale) to display a large waveform.
 Adjust the spectral gain so that there is no background noise on the spectral trace.
 Normal waveforms in the extremities are high-resistive and triphasic, with a sharp
systolic upstroke followed by a brief period of diastolic flow reversal, ending with
minimal forward flow in diastole
 Elevated velocities with spectral broadening indicate a stenosis
 Record velocities in the stenotic area as well as approximately 2 cm prior to
(prestenotic) and after (poststenotic) the area of stenosis
 Stenosis is considered hemodynamically significant if the flow in stenotic area is
twice the velocity of an area just previous (prestenotic) to it
 Waveforms distal to a significant stenosis will become monophasic

Pathology Seen
Atherosclerosis (plaque)
o Walls will appear thick
o Calcified plaque will produce acoustic shadowing
o Use color Doppler to evaluate for flow disturbances (aliasing)
Aneurysm
o Vessel diameter will be 1.5 times larger than adjacent more proximal segment
o Measure in sagittal (AP) and transverse (width) from outer wall to outer wall

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Upper Extremity Arterial Protocol

o Document intramural thrombus in sagittal and transverse with gray scale and
color Doppler
Document any soft tissue abnormalities seen in proximity to the arteries.
Document any venous thrombosis seen.

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