Advanced Practice - Arterial —
Training activity: 5

Details

Analyse and interpret the results of a lower limb arterial ultrasound scans for:

• Acute occlusion
• Chronic disease/occlusion

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

• Local SOPs and national guidance
• Determining disease severity
• Arterial pathology and ultrasound characteristics
• Effects of arterial disease on arterial haemodynamics
• Aging disease and treatment options
• Stents
• Limitations of the scan or protocol
• Consequences of misdiagnosis
• Acting on urgent findings
• Scope of personal and professional practice
• Multidisciplinary working and pathways

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 accurately analyse and interpret ultrasound findings to differentiate between acute and chronic lower limb arterial occlusions.
• Consider how the learning outcomes apply, specifically in relation to a critical understanding of the disease processes and their distinct ultrasound appearances.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the specific ultrasound features (e.g., thrombus echogenicity, vessel wall changes, collateral development) that distinguish acute from chronic occlusion.

What is your prior experience of this activity?

• Think about what you already know about key differentiating features (e.g., presence/absence of collaterals, flow patterns distal to occlusion).
• Consider possible challenges you might face during the activity, such as ambiguous cases, or when distinguishing a very severe chronic stenosis from a complete 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 interpretation of complex occlusive disease, particularly if there are urgent clinical implications.
• Acknowledge how you feel about making the critical distinction between acute and chronic arterial occlusion, given its significance for patient management.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as diagnostic criteria for acute versus chronic occlusion and improving your ability to provide a structured and comprehensive interpretation.
• Identify the specific insights you hope to gain into the clinical urgency and treatment pathways associated with acute arterial symptoms and occlusions.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting complex flow or distinguishing between different disease states.
• Identify important information you need to consider before embarking on the activity, such as case presentations and imaging findings for both acute and chronic occlusions.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst analysing and interpreting the results for acute or chronic lower limb arterial occlusions?
• Are you encountering situations such as:
  • The anatomical findings suggest a fresh, non-collateralised thrombus (acute occlusion), but the clinical history indicates long-standing symptoms, complicating the classification?
  • Difficulty in reliably differentiating a very tight, pre-occlusive stenosis from a complete occlusion based solely on B-mode and Colour Doppler information?

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 re-evaluating thrombus characteristics (echogenicity) or assessing flow in distal segments?
• Consider the steps you are taking in the moment, such as:
  • Immediately reviewing the B-mode image carefully to assess thrombus homogeneity and age (e.g., acute vs. chronic thrombus echogenicity)
  • Applying Doppler settings designed to detect extremely low flow states to rule out slow flow through a near-occlusion
• How are you feeling in that moment? For instance, are you finding it difficult to reconcile the imaging features with the clinical history? Is it affecting your confidence in making the critical acute versus chronic distinction?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully using haemodynamic criteria (e.g., presence/absence of collaterals, distal waveform characteristics) to classify the occlusion status? Or are you needing support because the findings suggest an urgent acute occlusion requiring immediate clinical escalation outside of routine reporting time, necessitating senior sign-off?
• What are you learning as a result of the unexpected development? For example, are you mastering a systematic approach for differentiating between acute and chronic thrombus based on B-mode appearance? Or gaining insight into the flow dynamics distal to a severe stenosis?

On action

What happened?

• Begin by summarising the key steps you took when analysing and interpreting the results of lower limb arterial ultrasound scans for acute occlusion and chronic disease/occlusion.
• Consider specific events, actions, or interactions which felt important, such as how you assessed the presence and maturity of collateral circulation or how you used thrombus echogenicity to help age an occlusion.
• Include any ‘reflect-in-action’ moments where you had to adapt your interpretation based on unfolding information or new insights during the analysis, for instance, immediately revising the diagnosis from chronic stenosis to acute-on-chronic occlusion when fresh, non-collateralised thrombus was identified proximal to a previously known severe lesion.
• How did you feel during this experience, e.g., did you feel acutely aware of the patient management implications or challenged by the difficulty of reconciling imaging findings with clinical history?

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience of analysing and interpreting scan results. What strengths did you demonstrate, e.g., ability to systematically assess flow distal to an occlusion or meticulous review of B-mode characteristics to age the thrombus?
• What skills and/or knowledge gaps were evident, e.g., uncertainty regarding the specific haemodynamic criteria used to differentiate a near-occlusion from a total occlusion?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development in analysis and interpretation achieved? Has your practice improved in differentiating acute vs. chronic occlusion?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding urgent escalation when findings suggested a high-risk acute occlusion, 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 accuracy and speed of classification for occlusive disease.
• What will you do differently next time you approach scan analysis and interpretation, for instance, by proactively structuring your review checklist to ensure the presence or absence of collaterals is documented early in the analysis?
• Do you need to practise any aspect of the activity further, such as reviewing case presentations and imaging findings for both acute and chronic occlusions or key learning outcomes related to analysing and interpreting the ultrasound findings of diseased arteries?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of analysing and interpreting results for acute and chronic occlusions since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent case required immediate, urgent differentiation between acute-on-chronic and purely acute thrombus forced you to re-evaluate the speed and rigour of your thrombus characterisation and collateral assessment you applied during your first attempt at interpretation.
• Considering what you understand about B-mode thrombus characteristics, collateral flow development, and the clinical urgency of acute occlusion 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 analytical and interpretive skills for occlusions based on further learning and experiences? For example, how you proactively integrated a systematic check for thrombus echogenicity and age to consistently differentiate acute from chronic occlusion.
• Has discussing complex cases of occlusion interpretation (e.g., ambiguous collateral flow, near-occlusion vs. total occlusion) with colleagues changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior clinician about an acute occlusion that was initially misclassified as chronic refined your understanding of the critical importance of rapid, accurate diagnosis of acute events.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent occlusion analysis experiences, contributed to your overall confidence and competence in analysing and interpreting ultrasound results for acute and chronic occlusions, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in differentiating between acute and chronic flow patterns now enables you to confidently discuss the diagnostic value of specific haemodynamic findings 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 analysing and interpreting results for occlusions? 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 routinely seek advice immediately when a case presents with equivocal findings that could indicate acute, high-risk pathology, recognising this requires specialist input for analysing and interpreting the results of a range of vascular scan.
• Looking holistically at your training journey, how has this initial occlusion analysis and interpretation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to analysing and interpreting the results of a range of vascular scans and preparing the associated diagnostic clinical reports? For example, how this foundational experience has supported your development in applying a critical understanding of disease processes and their distinct ultrasound appearances.

Relevant learning outcomes

#	Outcome
# 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.