Peripheral Arterial Screening and Microvasculature Diagnostics

Module details

Title

Peripheral Arterial Screening and Microvasculature Diagnostics

Type

Specialist

Module code

SPS131

Credits

10

Requirement

Compulsory

Aim of this module

This module provides trainees with the knowledge that underpins this third year specialist module in Vascular Science. It will provide trainees with the knowledge, understanding and practical skills to safely contribute to the diagnosis and screening of peripheral arterial disease (macro and microvascular), abdominal aortic aneursyms and intracranial lesions (for sickle cell). This module will provide trainees with the knowledge, understanding and practical skills to safely contribute to the screening of patients with suspected abdominal aortic aneursym (AAA) and peripheral arterial disease (ABPIs). It will also provide trainees with the knowledge, understanding and practical skills to obtain transcranial Doppler (TCD) images and measurements of the peripheral microvascular system.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1	Competency Perform an ultrasound scan using B Mode to identify and measure a normal abdominal aorta.	Action View
# 2	Learning outcome 1	Competency Perform an ultrasound scan using colour Doppler and spectral Doppler to demonstrate the haemodynamics of a normal abdominal aorta.	Action View
# 3	Learning outcome 1	Competency Perform ultrasound scans to identify and measure an AAA.	Action View
# 4	Learning outcome 2	Competency Obtain and fully interpret resting Doppler signals from all pedal pulses, measure blood pressure and calculate resting ABPI.	Action View
# 5	Learning outcome 2	Competency Exercise the patient obtaining and fully interpreting resting and post- exercise ABPI measurements.	Action View
# 6	Learning outcome 3	Competency Obtain transcranial Doppler spectra of the intracranial cerebrovascular circulation identify the middle cerebral artery (MCA), anterior cerebral artery (ACA) and posterior cerebral artery (PCA).	Action View
# 7	Learning outcome 4	Competency Obtain measurements of the microvascular system using thermography, laser Doppler, transcutaneous O2 or nailfold	Action View

Assessments

You must complete:

• 2 case-based discussion(s)
• 2 of the following DOPS/ OCEs:

Perform and interpret a complete AAA screening B Mode scan on a new patient	DOPS
Perform and interpret a resting ABPI on a new patient	DOPS
Obtain and measure Doppler TCD spectra of the intracranial cerebrovascular circulation.	DOPS
Obtain measurements of the microvascular system using one technique.	DOPS
Perform and interpret a complete diagnostic scan on a AAA surveillence patient, including assessment of the iliac and common femoral arteries.	DOPS
Perform and interpret resting and exercise ABPIs on a new patient referred for claudication.	DOPS
Perform and interpret a microvascular investigation on a new patient	DOPS
Perform and interpret a complete AAA diagnostic scan on patient referred from the screening programme for non visualisation of aorta.	DOPS
Perform and interpret an ABPI on a patient with critical ischaemia.	DOPS
Perform and interpret an ABPI on an immobile patient with leg ulcers on the ward.	DOPS
Explain the AAA scan procedure and purpose to the patient	OCE
Explain the ABPI procedure and purpose to the patient	OCE
Obtain patient consent for the AAA scan	OCE
Obtain the relavant clinic history and symptoms pertinent to the ABPI test.	OCE
Prepare and position a mobile patient for a microvascular investigation.	OCE
Prepare and position a patient for a TCD scan.	OCE
Communicate with the patient during the exercise testing to ensure safe compliance and elicit clinical information.	OCE
Explain the ABPI findings findings to the patient.	OCE
Explain the microvascular scan findings to the patient	OCE
Explain what happens with the AAA scan results	OCE

Learning outcomes

1. Perform ultrasound scans on patients with suspected abdominal aortic aneurysm (AAA).
2. Perform resting and post-exercise Doppler assessment of patients with suspected peripheral arterial disease.
3. Obtain transcranial Doppler (TCD) spectra of the intracranial cerebrovascular circulation.
4. Obtain measurements of the microvascular system.

Learning outcomes

1. Recognise and identify normal intracranial and peripheral arterial anatomy and pathology at macro- and microvascular level.
2. Explain the normal haemodynamics and physiology of the intracranial and peripheral arterial system and evaluate the numerous effects of pathology on blood flow at a macro- and microvascular level.
3. Recognise the clinical use of microvascular instrumentation in the diagnosis of microvascular diseases, the linkages with other imaging techniques and the clinical importance of selecting the appropriate technique for the best management of the patient. 
4. Describe and evaluate the clinical use of continuous wave Doppler ultrasound, segmental pressure measurements, photoplethsmography and exercise testing in the diagnosis and screening of peripheral arterial disease, the linkages with other imaging techniques and the clinical importance in selecting the appropriate technique for the best management of the patient.
5. Describe and evaluate the clinical use of ultrasound imaging in the diagnosis and screening of abdominal aortic aneurysm (AAA), the linkages with other imaging techniques and the clinical importance in selecting the appropriate technique for the best management of the patient.
6. Describe and evaluate the clinical use of transcranial pulsed Doppler ultrasound in the diagnosis and screening of intracranial lesions in sickle cell, the linkages with other imaging techniques and the clinical importance in selecting the appropriate technique for the best management of the patient. 
7. Explain and recognise the diversity and urgency of presenting signs and symptoms, and critically evaluate expected underlying haemodynamics and pathology.
8. Describe the expected co-morbidity associated with arterial disease and evaluate the health and safety risks during the investigation and how they are managed. 
9. Explain the infection risks associated with arterial ultrasound and patients with suspected arterial disease and how these are managed.
10. Explain the principles and consequences of national screening guidelines for AAA and sickle cell disease and the impact this has on diagnostic vascular services and patient managememt. 
11. Explain and critically evaluate the need to convey complex scientific information to inform multidisciplinary teams of the diagnostic results, conclusions and consequences, in clear reports, in a clinically appropriate timeframe.

Indicative content

NHS AAA Screening Programme

• Organisation of a screening service
• Ultrasound effectiveness, sensitivity and risk
• Clinical assessment
  • AAA incidence and mortality statistics
  • Training and accreditation
  • Quality assurance and quality control

NHS Sickle Cell Screening Programme

• Organisation of a screening service
• Ultrasound effectiveness, sensitivity and risk
• Clinical assessment
• Stroke incidence and mortality statistics
• Training and accreditation
• Quality assurance and quality control

Scientific principles of pulsed wave Doppler Scientific principles of plethysmography

• Photoplethysmography
• Impedance plethysmography
• Displacement (pneumatic cuff)
• Strain gauge
• Oculoplethysmography pressure

 

Scientific principles of techniques used to investigate the microcirculation

• TCPO2
• Laser Doppler
• Thermography
• Capillaroscopy

Anatomy and physiology of the lower limb arterial circulation

Pressures (patient positioning, technique, interpretation, capabilities,limitations)

• Lower extremity
• Segmental
• Resting ankle
• Stress test
• Toe pressures

Transcranial Doppler (patient positioning, technique, interpretation, capabilities, limitations, indications)

• Intraoperative monitoring
• Closure of patent foramen ovale (PFO)

 Plethysmography (venous occlusion technique, volume pulse measurements – techniques, interpretation, capabilities, limitations)

• Upper extremity
• Lower extremity
• Digits

 

Assessment of microvasculature

• TCP02
• Laser Doppler
• Thermography
• Capillaroscopy

 

Other non-invasive tests (patient positioning, technique, interpretation, capabilities, limitations)

• Hand-held Doppler examination
  • Upper limb
  • Lower limb

Activities

• Observe a series of patients reviewed as new and follow-up patients in the National Abdominal Aortic Aneurysm Screening Programme (NAAASP) and critically appraise the process of screening and treatment options, including the range of healthcare professionals who contribute to the care of each patient and how the inter-professional team work together.
• Identify a patient with an AAA requiring repair and, with permission, follow the progress of the patient from the initial consultation through investigation, intervention and follow-up appointment, and reflect on your learning from this process.
• Attend a meeting at which the outcome of a clinical audit, research, innovation or service development is presented and discuss with your training supervisor how evidence-based practice is implemented with respect to vascular science.
• Prepare a portfolio of case studies and images and diameter measurements from a series of patients that demonstrate the normal and aneurysmal characteristics of the abdominal aorta on ultrasound, including any variations in anatomy.
• Critically appraise the role of ultrasound in the assessment of AAA and reflect on the effect technique and probe positioning have on the images and artefacts. A portfolio of evidence should include images obtained from the aorta and clearly demonstrate the relationship with other structures used as landmarks (e.g. the vertebra, the vena cava, superior mesenteric artery) and the effects of probe positioning (e.g. anterior/sagital or decubitus/coronal views) and artefacts (e.g. bowel gas).
• Critically appraise inner-to-inner (iti) versus outer-to-outer (oto) measurements of aortic diameter and reflect on the significance of each method. A portfolio of evidence should include images and diameter measurements (iti and oto) obtained from a variety of aortic sizes (<3.0 cm, >3.0 cm) in both transverse and longitudinal views.
• Identify two patients with lower limb peripheral arterial disease requiring intervention and critically reflect on the effect on the lifestyle of the patient and the role of the healthcare scientist in the diagnosis and treatment of patients.
• Prepare a portfolio of case studies with resting and post-exercise ABPI measurements (where appropriate) on a series of patients with a range of symptoms (e.g. claudication, critical limb ischaemia, ulcers).
• Critically appraise the role of ABPI measurements in the diagnosis/exclusion of peripheral arterial disease, in particular the TASC II recommendations, and reflect on your learning from this process. A portfolio of evidence should include ABPI reports for a range of values (<0.5, 0.5–0.8, 0.8–1.3, >1.3) with a range of Doppler signals (monophasic, biphasic, triphasic).
• Prepare a portfolio of TCD spectra and/or images from a series of volunteers that demonstrate the normal characteristics of the intracranial circulation and critically reflect on the process of screening outlined in the NHS Sickle Cell and Thalassaemia Screening Programme.
• Prepare a portfolio of measurements of the microvascular system from volunteers or patients using at least two of thermography, laser Doppler, transcutaneous O2 or nailfold capillaroscopy, and critically appraise how the techniques are used to aid diagnosis.
• Keep a portfolio/logbook of all clinical scans performed/observed, noting challenges and risks encountered with reflections on learning achievements.