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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