Advanced Practice - Extra Cranial —
Training activity: 3

Details

Analyse and interpret the results of an extracranial arterial ultrasound scans, including:

• Minimal disease
• Moderate disease
• Severe disease
• Occlusive disease

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

• B mode, colour and spectral Doppler findings to determine disease severity
• Local SOPs
• National and international guidelines and guidance
• Effect of disease on cerebrovascular haemodynamics
• Selection of methodology
• Limitations of the scan or protocol
• Scope of personal and professional practice
• Consequences of misdiagnosis
• Acting on urgent findings
• Referrals and escalation

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 effectively planning and preparing to undertake upper limb nerve conduction studies, specifically analysing and interpreting extracranial arterial ultrasound results for various disease states (Minimal, Moderate, Severe, Occlusive).
• Consider how the learning outcomes apply, specifically in relation to planning and preparing and applying legislation, guidelines, and managing risk when planning and preparing for the studies, specifically analysing and interpreting the ultrasound findings for extracranial arteries with reference haemodynamics, and critically evaluating the clinical significance of incidental findings.
• Discuss with your training officer to gain clarity of what is expected of you in relation to expectations for equipment setup, patient flow logistics, and integrating necessary safety protocols, specifically expectations for result interpretation.

What is your prior experience of this activity?

• Think about what you already know about planning medical procedures or preparing clinical rooms, specifically interpreting ultrasound findings.
• Consider possible challenges you might face during the activity, such as logistical issues with moving NCS equipment, ensuring necessary resources (e.g., limb temperature monitors) are available, or understanding procedural requirements, specifically complex waveforms, distinguishing between minor and moderate disease.
• 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 if the complexity of the planned study requires specialised equipment or protocols not covered in routine procedure, or if findings are equivocal or suggest complex incidental findings.
• Acknowledge how you feel about making your analysis and interpretations of the results from the ultrasound scans for a range of diseases.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as planning complex clinical procedures, specifically analysing and interpreting ultrasound results, drawing upon previous experiences of the activity.
• Identify the specific insights you hope to gain into the detailed requirements for upper limb NCS planning, including patient flow, equipment setup, and integrating safety protocols, specifically critical evaluation of haemodynamics or clinical significance of incidental findings.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of similar planning or preparation activities, specifically interpreting similar scans.
• Identify important information you need to consider before embarking on the activity, such as the anatomy of upper limb nerves (median, ulnar, radial) and the procedures for motor/sensory nerve conduction studies, as this knowledge is foundational for planning, specifically knowledge of spectral waveforms, plaque characterisation, or complementary diagnostic imaging.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst analysing and interpreting the scan results for various disease severities?
• Are you encountering situations such as:
  • Ambiguous findings, conflicting data (e.g., velocity indices contradict B-mode appearance), or highly complex pathology that challenges routine interpretation?
  • Unexpected incidental findings (e.g., thyroid nodules or complex non-arteriosclerotic pathology) whose clinical significance needs critical evaluation?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding appropriately to the situation when faced with an unexpected or challenging interpretation? Are you adapting or changing your analytical approach, such as re-evaluating specific images or seeking additional patient history?
• Consider the steps you are taking in the moment, such as:
  • Immediately reviewing spectral waveforms across multiple segments to reconcile discrepancies between peak systolic velocity (PSV) and end diastolic velocity (EDV).
  • Pausing analysis to consult diagnostic criteria for classifying a borderline minimal/moderate lesion.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your interpretation strategy to reconcile unexpected findings? Is it affecting your confidence in providing an accurate interpretation of the scan results?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully classifying the disease severity using standardised haemodynamic criteria? Or are you needing support because the interpretation of complex pathology requires consultation with a more experienced colleague for a definitive interpretation?
• What are you learning as a result of the unexpected development? For example, are you mastering techniques for classifying complex haemodynamic patterns? Or gaining insight into the significance of incidental findings?

On action

What happened?

• Begin by summarising the key points of your experience analysing and interpreting scan results for minimal, moderate, severe, or occlusive disease.
• Consider specific events, actions, or interactions which felt important, such as reconciling ambiguous findings, classifying a borderline stenosis, or discussions with colleagues.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately consulting urgency protocols when the findings suggested a high-risk severe stenosis, complicating the initial minimal/moderate assessment.
• How did you feel during this experience, e.g., did you feel acutely aware of the patient management implications or challenged by the ambiguity of the findings?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience. What strengths did you demonstrate, e.g., in identifying minimal, moderate, severe, or occlusive disease?
• What skills and/or knowledge gaps were evident, e.g., understanding specific haemodynamics or complex waveforms?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in analysing and interpreting scan results?
• Identify any challenges you experienced, such as needing to seek advice or clarification on an interpretation, or escalating a critical finding, and how you reacted to this.
• Acknowledge any changes in your own feelings now that you are looking back on the experience.

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 classification.
• What will you do differently next time you approach analysis and interpretation of extracranial arterial ultrasound scan results, for instance, by proactively reviewing haemodynamic criteria for near-occlusion versus total occlusion to standardize reporting?
• Do you need to practise any aspect of the activity further, such as interpretation of specific disease patterns (e.g., occlusive disease)?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of analysing and interpreting extracranial arterial ultrasound results 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 complex differentiation between minimal and moderate disease based on borderline velocity indices forced you to re-evaluate the rigidity of your initial interpretation checklist you applied during your first attempt at analysis.
• Considering what you understand about haemodynamic interpretation, critical evaluation of incidental findings, and research evidence on national guidelines (e.g., NASCET/ECST) 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 scan interpretation methodology based on further learning and experiences? For example, how you proactively reviewed and integrated the departmental protocols for assessing the clinical significance of thyroid nodules or incidental venous thrombosis based on further learning.
• Has discussing ambiguous interpretation cases (e.g., conflicting PSV/EDV values) or the impact of uncritical evaluation of incidental findings with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a missed incidental finding refined your understanding of the critical nature of systematic data analysis.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent scan analysis experiences, contributed to your overall confidence and competence in analysing and interpreting ultrasound findings for extracranial arteries, particularly in preparing for assessments like Case-Based Discussions (CBDs)? For example, how your accumulated ability in reconciling conflicting data now enables you to confidently discuss haemodynamic parameters and critique incidental findings during a CBD assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to analysing and interpreting extracranial arterial ultrasound scans? 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 the clinical significance of a complex, atypical incidental finding (e.g., suspected dissection) requires critical evaluation outside routine analysis scope.
• Looking holistically at your training journey, how has this initial scan analysis and interpretation experience, revisited with your current perspective, contributed to your development in meeting the objectives related to analysing and interpreting the ultrasound findings and critically evaluating the clinical significance of incidental findings? For example, how this foundational experience has supported your development in appraising the impact of research evidence on national guidelines.

Relevant learning outcomes

#	Outcome
# 2	Outcome Assess disease in the extracranial arteries using ultrasound.
# 3	Outcome Apply ultrasound physics to correctly optimise an ultrasound scan.
# 4	Outcome Analyse and interpret the ultrasound findings for extracranial arteries with reference haemodynamics.
# 7	Outcome Appraise the impact of research evidence on national guidelines.
# 8	Outcome Critically evaluate the clinical significance of incidental findings.
# 9	Outcome Summarise surgical and endovascular interventions performed for carotid disease.