Advanced Practice - Arterial

Module details

Title

Advanced Practice - Arterial

Type

Specialist

Module code

S-V-S2

Credits

10

Phase

3

Requirement

Compulsory

Aim of this module

This module aims to equip trainees with an introduction to assessment of lower limb arterial pathology. Trainees should, on completion of this module, be confident to triage, examine and report investigations for lower limb arterial disease including obstructive and aneurysmal conditions.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1	Competency Triage incoming referrals	Action View
# 2	Learning outcome 2,4,9	Competency Perform optimised ultrasound scans following a set protocol to identify normal lower limb arterial anatomy (Aorta to ankle)	Action View
# 3	Learning outcome 2,4,5,9	Competency Perform optimised ultrasound scans and correctly identify and grade significant disease of the: Suprainguinal arteries Femoral artery Popliteal artery	Action View
# 4	Learning outcome 2,4,5,9	Competency Perform optimised ultrasound scans and correctly identify calf artery disease	Action View
# 5	Learning outcome 5,9	Competency Analyse and interpret the results of a lower limb arterial ultrasound scans for: Acute occlusion Chronic disease/occlusion	Action View
# 6	Learning outcome 3,4,5,9	Competency Perform optimised ultrasound scans and correctly identify a: Peripheral aneurysm (non-aortic) Pseudo aneurysm	Action View
# 7	Learning outcome 2,4,5,9	Competency Perform optimised ultrasound scans to correctly determine patency of a lower limb bypass graft	Action View
# 8	Learning outcome 6,9	Competency Produce descriptive clinical reports of ultrasound scan analysis	Action View
# 9	Learning outcome 7,8	Competency Communicate findings of arterial scans to: The multidisciplinary team A patient	Action View
# 10	Learning outcome 4	Competency Identify and minimise artefacts caused by pathology during  ultrasound scans of the lower limb arteries using: B mode Colour Doppler Spectral Doppler	Action View

Assessments

Complete 2 Case-Based Discussions

Complete 2 DOPS or OCEs

Direct Observation of Practical Skills Titles

• Complete an arterial scan from aorta to ankle on a patient with pathology.
• Perform and interpret a routine surveillance duplex scan of a lower limb bypass graft.

Observed Clinical Event Titles

• Discuss risk factors and modification with a patient.
• Gather a clinical history from a patient with acute arterial symptoms.

Learning outcomes

#	Learning outcome
1	Review and triage referrals for lower limb arterial disease.
2	Assess disease in the lower limb arteries using ultrasound.
3	Assess peripheral aneurysms using ultrasound.
4	Apply ultrasound physics to correctly optimise an ultrasound scan of the lower limb arteries.
5	Analyse and interpret the ultrasound findings of diseased arteries of the lower limb with reference to haemodynamics.
6	Produce an interpretive clinical report of the lower limb arterial ultrasound findings.
7	Identify and communicate the results of the scan to both patients and the multidisciplinary team.
8	Summarise the treatment pathways for lower limb PAD.
9	Appraise the impact of research evidence on national guidelines.

Activities

1. Observe arterial assessment of the upper limb.
2. Observe diabetic foot/podiatry clinic.
3. Observer vascular outpatient clinics.
4. Observe lower limb arterial surgery.
5. Observe interventional radiology procedure.
6. Observe conservative management – e.g. claudication exercise class.
7. Observe measurements being taken of the microvascular system (thermography, nailfold capillaroscopy and laser Doppler).

Learning outcomes

On successful completion of this module the trainee will be able to:

1. Critically evaluate expected underlying haemodynamics and pathology of lower limb arterial disease, demonstrating a critical awareness of the diversity and urgency of presenting signs and symptoms.
2. Critically evaluate the expected co-morbidity associated with arterial disease and explain the health and safety risks during the investigation and how they are managed.
3. Critically appraise the infection risks associated with arterial ultrasound of patients with suspected arterial disease and how these are managed.
4. Critically evaluate the need to convey complex scientific information to inform multidisciplinary teams of the diagnostic results, conclusions and consequences.
5. Critically appraise evidence-based guidelines relating to arterial disease investigation and management.

Indicative content

Lower Limb Arteries and PAD

Vascular Anatomy and Pathology

• Anatomical variations relevant to ultrasound scanning
• Symptoms, definitions and signs (introduced in year 1)
• Atherosclerotic, embolic, thrombotic occlusions
  • Trash foot, diabetic foot
• Acute and chronic obstructive disease
• Aneurysms

Patient management

• Medical and lifestyle modifications
• Endovascular
  • Percutaneous revascularisation
  • Angioplasty
  • Atherectomy
  • Embolectomy
  • Stents
• Surgical
  • Grafts
  • Graft types
  • Amputations
• Pathways, guidelines and recommendations
• Emerging treatments, procedures and trials

Ultrasound scanning

• Role of ultrasound in assessing lower limb arteries
  • Spectral waveforms and haemodynamic grading of stenoses
• Role of ultrasound in assessing arterial bypass grafts
  • Graft failure causes
• Protocol recommendations
• Limitations and technical challenges
  • Calcification and shadowing, diabetes
  • Deep vessels, small vessels
• Ultrasound reporting recommendations and guidelines
  • Graft surveillance

Complementary lower limb imaging (introduced in year 1)

• CTA and MRA, DSA

Abdomen

Abdominal vascular anatomy and pathology

• Aorta, renal arteries, hepatic arteries, mesenteric arteries and portal vein
• Symptoms, definitions and signs
• Aneurysms, stenoses, fibromuscular dysplasia, hypertension, organ pathology, including chronic liver disease and transplantation

Patient management

• Medical and lifestyle modifications
• Endovascular
  • Percutaneous revascularisation
  • Stents
• Surgical
  • AAA repair and stents

Role of ultrasound in assessing abdominal vessels

• B mode measurements and AAA, renal length
• Spectral waveforms and haemodynamic grading of stenoses in renal arteries, mesenteric ischaemia, flow in portal vein, hepatic artery and organ transplantation assessment-liver and kidney
• CEUS and assessing endovascular leaks, and organ perfusion
• 3D ultrasound and abdominal vessel measurements
• Organ and transplant assessment
• Complementary diagnostic imaging
  • Role of MRA/DSA/MRA (introduced in year 1)
  • Intravascular ultrasound
• Limitations and technical challenges
• Ultrasound guidelines
  • Principles of screening
  • AAA surveillance

Emerging technology and research

• Fusion imaging
• Microflow
• 3D imaging

Non-atherosclerotic ultrasound

Role of ultrasound in assessing arteries for vascular conditions and syndromes:

• TOS
• Popliteal or other large vessel entrapment
• Buerger’s disease
• Arterial assessment for flap formation in reconstructive surgery
• Takayasu’s arteritis
• Fibromuscular dysplasia

Microvascular

Anatomy relevant to microvascular imaging

Technology: imaging and non-imaging

• Thermography
• Laser Doppler
• Capillaroscopy
• Oxygen based assessments
• Pre-scanning protocols

Pathology and clinical applications

• Raynaud’s
• Amputation level
• Tissue viability
• Oxygen status and perfusion

Emerging microvascular technology and research

• Alternatives to conventional BP assessments, PPG

Specialty code	Specialty title	Action
Specialty code SPS1-2-22	Specialty title Vascular Science [2022]	Action View