Advanced Practice - Arterial —
Training activity: 6

Details

Perform optimised ultrasound scans and correctly identify a:

• Peripheral aneurysm (non-aortic)
• Pseudo aneurysm

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
• Equipment selection
• Anatomy and physiology
• Patient history and symptoms
• Flow characteristics
• Consequences of mis-diagnosis
• Multidisciplinary working and pathways
• Artifact causes and corrections
• Scope of personal and professional practice
• Limitations of the scan
• Acting on urgent findings
• Patient safety and communication

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 differentiate between a peripheral aneurysm (non-aortic) and a pseudoaneurysm.
• Consider how the learning outcomes apply, specifically in relation to accurate measurement and characterisation of the lesion.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the precise diagnostic criteria, typical locations, and expected ultrasound appearances (e.g., neck of pseudoaneurysm, swirling flow, mural thrombus) for each type.

What is your prior experience of this activity?

• Think about what you already know about the formation and ultrasound characteristics of peripheral aneurysms or pseudoaneurysms.
• Consider possible challenges you might face during the activity, such as distinguishing these two entities, especially in complex anatomical regions or when there is extensive thrombus.
• 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 diagnosing or characterising a complex or unusually located aneurysm/pseudoaneurysm.
• Acknowledge how you feel about accurately identifying and characterising these distinct vascular pathologies.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as measurement accuracy for vascular lesions, assessing flow patterns within aneurysms, and enhancing differentiation skills between true aneurysms and pseudoaneurysms.
• Identify the specific insights you hope to gain into the clinical implications and management pathways for peripheral aneurysms and pseudoaneurysms.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of vascular masses or abnormal flow patterns.
• Identify important information you need to consider before embarking on the activity, such as diagnostic criteria and typical ultrasound findings for both true and pseudoaneurysms.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing scans to correctly identify a peripheral aneurysm (non-aortic) or a pseudoaneurysm?
• Are you encountering situations such as:
  • The neck of a pulsatile mass is not easily visualised, making it difficult to confirm communication with the native artery and differentiate a true aneurysm from a pseudoaneurysm?
  • A suspected pseudoaneurysm sac contains dense, heterogeneous material, confusing the typical Colour Doppler assessment of the characteristic ‘to-and-fro’ flow?

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 identifying the lesion type by utilizing multiple imaging planes or optimizing flow detection settings?
• Consider the steps you are taking in the moment, such as:
  • Immediately employing power Doppler or low PRF Colour Doppler to maximise flow detection within the sac and neck to confirm the pseudoaneurysm diagnosis
  • Carefully obtaining multiple measurements of the sac diameter and lesion morphology to ensure accurate characterization
• How are you feeling in that moment? For instance, are you finding it difficult to remain focused on technical precision while managing the potentially complex flow dynamics? Is it affecting your confidence in accurately classifying the lesion?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully documenting the precise size and flow characteristics to differentiate a true aneurysm from a pseudoaneurysm? Or are you needing support because the aneurysm size is critically close to rupture criteria or the lesion is highly complex, requiring activation of an emergency clinical protocol?
• What are you learning as a result of the unexpected development? For example, are you mastering advanced flow optimisation techniques to accurately assess the pseudoaneurysm neck? Or gaining insight into the critical measurements required for monitoring a peripheral aneurysm?

On action

What happened?

• Begin by summarising the key steps you took when performing the ultrasound scan and correctly identifying peripheral aneurysms (non-aortic) and pseudoaneurysms.
• Consider specific events, actions, or interactions which felt important, such as how you obtained accurate B-mode measurements of the sac diameter or how you used Spectral and Colour Doppler to confirm the characteristic flow patterns (e.g., ‘to-and-fro’ flow in the neck of a pseudoaneurysm).
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded to correctly identify these aneurysmal conditions, for instance, immediately employing multiple imaging planes and switching to Power Doppler to visualise the neck of a suspected pseudoaneurysm obscured by heterogeneous thrombus.
• How did you feel during this experience, e.g., did you feel focused on differentiating between the pathologies or stressed by the potential need to escalate an unexpected finding?

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience of scanning for aneurysms. What strengths did you demonstrate, e.g., technical accuracy in measuring vascular lesions or the ability to apply correct flow characteristics to differentiate true vs. pseudoaneurysm?
• What skills and/or knowledge gaps were evident, e.g., uncertainty regarding the precise criteria for diagnosing rupture or difficulty distinguishing complex surrounding hematoma from a pseudoaneurysm sac?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development in aneurysm identification achieved? Has your practice improved in correctly identifying a peripheral aneurysm or pseudoaneurysm?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding a complex or unexpectedly large aneurysm requiring immediate escalation, 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 measurement accuracy and flow assessment for aneurysmal conditions.
• What will you do differently next time you approach an ultrasound scan for peripheral aneurysms or pseudoaneurysms, for instance, by proactively reviewing the precise diagnostic criteria and typical flow dynamics for each condition before the scan?
• Do you need to practise any aspect of the activity further, such as refining B-mode measurement techniques or key learning outcomes related to assessing peripheral aneurysms using ultrasound?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of scanning and identifying peripheral aneurysms (non-aortic) and pseudoaneurysms 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 pseudoaneurysm required meticulous Colour Doppler assessment of a non-visualised neck forced you to re-evaluate the rigour of your flow characterisation techniques you applied during your first attempt at differentiating these lesions.
• Considering what you understand about diagnostic criteria for aneurysms/pseudoaneurysms, colour flow dynamics, and measurement accuracy 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 aneurysm identification skills based on further learning and experiences? For example, how you proactively integrated multiple plane measurement protocols to ensure precise diameter assessment of the vascular lesion.
• Has discussing challenging aneurysm cases (e.g., extensive mural thrombus obscuring the true lumen, complex pseudoaneurysm necks) with your peers changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where a complex aneurysm was misclassified refined your understanding of the critical importance of accurate documentation of size and morphology.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent aneurysm scanning experiences, contributed to your overall confidence and competence in identifying and differentiating peripheral aneurysms and pseudoaneurysms, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in meticulous B-mode measurement and flow assessment now enables you to confidently assess vascular anatomy using ultrasound during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to identifying peripheral aneurysms and pseudoaneurysms? 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 an aneurysm size is critically close to rupture criteria, recognising this requires senior input for assessing vascular anatomy using ultrasound.
• Looking holistically at your training journey, how has this initial aneurysm identification experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to assessing vascular anatomy using ultrasound and analysing and interpreting the results of a range of vascular scans? For example, how this foundational experience has supported your development in enhancing differentiation skills between distinct vascular pathologies.

Relevant learning outcomes

#	Outcome
# 3	Outcome Assess peripheral aneurysms 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.