Advanced Practice - Arterial —
Training activity: 7

Details

Perform optimised ultrasound scans to correctly determine patency of a lower limb bypass graft

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
• Synthetic vs vein
• Alternative findings
• Determining age of thrombus
• Haemodynamics to determine severity of stenoses
• Referral criteria for grafts at risk of occlusion
• Graft surveillance, local and national practice.
• 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 determine the patency of a lower limb bypass graft.
• Consider how the learning outcomes apply, specifically in relation to assessing flow throughout its length, and recognising signs of graft failure or complications.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the specific protocol for bypass graft surveillance, expected normal findings for various graft types, and haemodynamic criteria for assessing graft patency and stenosis.

What is your prior experience of this activity?

• Think about what you already know about different graft types (e.g., vein, prosthetic) and common sites of stenosis or failure.
• Consider possible challenges you might face during the activity, such as scanning tortuous grafts, assessing anastomotic sites, or identifying subtle changes indicative of graft compromise.
• 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 graft findings or suspected graft failure.
• Acknowledge how you feel about thoroughly assessing a lower limb bypass graft and accurately determining its patency.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as technique for navigating and assessing the entire length of bypass grafts, enhancing your ability to identify subtle changes indicating graft compromise, and refining your haemodynamic assessment skills.
• Identify the specific insights you hope to gain into graft surveillance protocols and the clinical significance of graft patency.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of assessing complex vascular conduits or identifying flow disturbances.
• Identify important information you need to consider before embarking on the activity, such as different types of bypass grafts and their common failure mechanisms.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst scanning a lower limb bypass graft for patency?
• Are you encountering situations such as:
  • An unexpected finding of severe stenosis or occlusion is identified within the body of a graft where the patient was previously asymptomatic, requiring immediate confirmation?
  • Severe oedema or deep placement complicates the visualisation of the distal anastomosis, challenging the comprehensive assessment protocol?

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 ensure comprehensive visualization of the entire graft length and all anastomotic sites?
• Consider the steps you are taking in the moment, such as:
  • Immediately reviewing the entire length of the graft using B-mode and Colour Doppler to localise and quantify the most severe lesion
  • Carefully acquiring pre-stenosis and in-stenosis velocity measurements to accurately calculate the velocity ratio for grading stenosis severity
• How are you feeling in that moment? For instance, are you finding it difficult to process the finding of unexpected graft compromise? Is it affecting your confidence in accurately determining the graft’s patency status?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully documenting all necessary measurements and determining the patency status based on established haemodynamic criteria? Or are you needing support because the severe flow drop suggests imminent graft failure, requiring senior clinical escalation and urgent notification?
• What are you learning as a result of the unexpected development? For example, are you mastering a more efficient technical workflow for comprehensive graft surveillance? Or gaining insight into the specific haemodynamic patterns associated with different types of graft failure?

On action

What happened?

• Begin by summarising the key steps you took when performing the ultrasound scan to correctly determine the patency of a lower limb bypass graft.
• Consider specific events, actions, or interactions which felt important, such as how you systematically assessed the entire length of the graft, including both anastomotic sites, or how you managed to obtain clear spectral Doppler data despite tortuosity.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded to accurately assess graft patency, for instance, immediately adjusting technical settings and compression to enhance visualisation when faced with a deeply placed, thrombosed segment.
• How did you feel during this experience, e.g., did you feel focused on systematic coverage or anxious about the complexity of the graft anatomy?

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience of scanning bypass grafts. What strengths did you demonstrate, e.g., meticulous adherence to the graft surveillance protocol or accurate haemodynamic assessment of potential stenosis sites?
• What skills and/or knowledge gaps were evident, e.g., uncertainty regarding the expected flow characteristics for specific graft types (e.g., prosthetic vs. vein) or difficulty distinguishing low flow from occlusion?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development in graft patency assessment achieved? Has your practice improved in correctly determining patency of a lower limb bypass graft?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding a severe flow drop indicating imminent graft failure, requiring urgent clinical 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 the technical efficiency and haemodynamic assessment of bypass grafts.
• What will you do differently next time you approach an ultrasound scan for bypass graft patency, for instance, by proactively reviewing the expected flow parameters and failure mechanisms associated with the specific graft type before the study?
• Do you need to practise any aspect of the activity further, such as refining your technique for assessing anastomotic sites or key learning outcomes related to assessing disease in the lower limb arteries using ultrasound?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of scanning bypass grafts for patency 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 scan required immediate localisation and grading of a significant mid-graft stenosis forced you to re-evaluate the speed and thoroughness of your surveillance protocol adherence you applied during your first attempt at graft assessment.
• Considering what you understand about graft surveillance protocols, haemodynamic criteria for stenosis, and flow disturbances 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 graft patency assessment technique based on further learning and experiences? For example, how you proactively implemented systematic velocity measurements at pre- and post-anastomotic sites to identify areas of flow compromise consistently.
• Has discussing complex cases of bypass graft assessment (e.g., graft failure, surveillance protocols for specific graft types) with colleagues or mentors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a vascular surgeon about a compromised graft that required immediate thrombectomy refined your understanding of the critical nature of early identification of graft failure.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent bypass graft scanning experiences, contributed to your overall confidence and competence in correctly determining patency of a lower limb bypass graft, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in identifying flow changes indicative of graft compromise now enables you to confidently assess the haemodynamic status of a graft during a practical assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to determining patency of a lower limb bypass graft? 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 have a more acute awareness of when graft assessment is complex and routinely seek assistance when severe flow drops suggest imminent graft failure, recognising this requires senior input for analysing and interpreting the results of a range of vascular scans.
• Looking holistically at your training journey, how has this initial bypass graft patency assessment 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 assessing vascular anatomy using ultrasound? For example, how this foundational experience has supported your development in enhancing your ability to identify subtle changes indicating graft compromise.

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.