Advanced Practice - Arterial —
Training activity: 3

Details

Perform optimised ultrasound scans and correctly identify and grade significant disease of the:

• Suprainguinal arteries
• Femoral artery
• Popliteal artery

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Patient centred care and support
• Local SOPs
• National and international guidance
• Clinical presentation of acute and chronic disease
• Image optimisation
• Flow measurements
• Anatomy and physiology
• Escalating complex cases to senior colleagues
• Limitations of the scan
• Scope of personal and professional practice
• Acting on urgent findings
• Patient safety and communication
• Artifact causes and corrections
• Multidisciplinary working and pathways
• Targeted scanning principles
• Stents

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to performing optimised ultrasound scans and correctly identify and grade significant disease (e.g., atherosclerotic, embolic, thrombotic occlusions).
• Consider how the learning outcomes apply, specifically in relation to analysing and interpreting the ultrasound findings with reference to haemodynamics.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the criteria for grading stenoses (e.g., velocity ratios, peak systolic velocity values) and the expected appearance of various pathologies in these arterial segments.

What is your prior experience of this activity?

• Think about what you already know about the presentation and ultrasound characteristics of significant arterial disease.
• Consider possible challenges you might face during the activity, such as heavy calcification causing shadowing, complex flow patterns in tortuous vessels, or distinguishing severe stenosis from occlusion.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example on interpreting complex diseased segments or grading findings.
• Acknowledge how you feel about identifying and accurately grading significant disease in these crucial arterial segments.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as differentiating subtle disease from normal variations, refining haemodynamic assessment skills, and gaining precision in grading stenoses.
• Identify the specific insights you hope to gain into the clinical significance of different grades of disease and their implications for patient management.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting spectral waveforms or colour Doppler images.
• Identify important information you need to consider before embarking on the activity, such as guidelines for arterial stenosis grading.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst identifying and grading significant disease in the suprainguinal, femoral, or popliteal arteries?
• Are you encountering situations such as:
  • Heavy calcification causes intense acoustic shadowing, completely obscuring the true lumen and complicating the acquisition of accurate spectral Doppler velocity measurements required for grading?
  • Haemodynamic findings suggest a severe stenosis (e.g., high PSV) but the corresponding velocity ratio is borderline, complicating the final grade classification?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to using specific technical manoeuvres (e.g., heel-toe rocking) or calculating ratios to ensure accurate grading?
• Consider the steps you are taking in the moment, such as:
  • Immediately shifting the sample volume location to obtain the maximum velocity jet just distal to the stenosis
  • Adjusting the Colour Doppler velocity scale to confirm the presence of high-velocity flow without aliasing, thereby aiding in the visual assessment of severity
• How are you feeling in that moment? For instance, are you finding it difficult to maintain composure and precision when faced with acoustic shadowing? Is it affecting your confidence in the resultant stenosis grading?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying the established grading criteria (e.g., PSV ratios) to classify the disease severity despite technical impediments? Or are you needing support because complex tortuosity or extensive calcification prevents reliable velocity measurement, requiring senior interpretive input?
• What are you learning as a result of the unexpected development? For example, are you mastering a more robust technical method for acquiring spectral Doppler data in heavily calcified vessels? Or gaining insight into the variability of PSV measurements in tortuous arterial segments?

On action

What happened?

• Begin by summarising the key steps you took when performing the ultrasound scan and identifying/grading significant disease in the suprainguinal, femoral, and popliteal arteries.
• Consider specific events, actions, or interactions which felt important, such as how you calculated velocity ratios for stenosis grading or how you managed acoustic shadowing caused by heavy calcification.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately changing the angle of insonation and filtering settings to obtain a clear maximum velocity signal for accurate haemodynamic assessment.
• How did you feel during this experience, e.g., did you feel determined to achieve accurate classification or stressed by the diagnostic uncertainty caused by technical challenges?

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience of scanning for significant arterial disease. What strengths did you demonstrate, e.g., technical precision in acquiring spectral Doppler data or systematic application of grading criteria?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the appropriate grading thresholds for borderline lesions or difficulty differentiating between severe stenosis and occlusion?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development in disease grading achieved? Has your practice improved in correctly identifying and grading significant disease?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding a complex grading where haemodynamic findings contradicted B-mode appearance, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the efficiency and accuracy of stenosis grading.
• What will you do differently next time you approach an ultrasound scan for significant arterial disease, for instance, by proactively reviewing the guidelines for handling artefacts that complicate haemodynamic assessment (e.g., spectral broadening)?
• Do you need to practise any aspect of the activity further, such as refining technical manoeuvres to overcome shadowing or key learning outcomes related to analysing and interpreting the ultrasound findings with reference to haemodynamics?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of scanning and grading significant disease in the suprainguinal, femoral, and popliteal arteries since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where heavy calcification severely complicated spectral Doppler acquisition for stenosis grading forced you to re-evaluate the initial technical manoeuvres you applied during your first attempt at assessing severe disease.
• Considering what you understand about stenosis grading criteria, haemodynamic interpretation, and managing artifacts now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your disease identification and grading technique based on further learning and experiences? For example, how you proactively reviewed and integrated the standard PSV ratio criteria to ensure consistency in classifying borderline lesions.
• Has discussing challenging cases of disease identification and grading (e.g., distinguishing severe stenosis from occlusion) with others changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about an under-graded stenosis that led to a delayed intervention refined your understanding of the critical importance of accurate velocity measurement for grading significant disease.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent significant disease scanning experiences, contributed to your overall confidence and competence in identifying and accurately grading significant disease, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in systematic grading now enables you to confidently analyse and interpret the results of a range of vascular scans during a Case-Based Discussion.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to identifying and grading significant disease? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now readily recognise when a complex case is beyond your current scope for grading and routinely seek assistance for analysing and interpreting ultrasound images with reference to haemodynamics.
• Looking holistically at your training journey, how has this initial scanning and grading significant disease experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to analysing and interpreting ultrasound images with reference to haemodynamics and analysing and interpreting the results of a range of vascular scans? For example, how this foundational experience has supported your development in systematic application of diagnostic criteria for arterial disease.

Relevant learning outcomes

#	Outcome
# 2	Outcome Assess disease in the lower limb arteries using ultrasound.
# 4	Outcome Apply ultrasound physics to correctly optimise an ultrasound scan of the lower limb arteries.
# 5	Outcome Analyse and interpret the ultrasound findings of diseased arteries of the lower limb with reference to haemodynamics.
# 9	Outcome Appraise the impact of research evidence on national guidelines.