Upper

Extremity Arterial Protocol

Structure Scan Plane Label Images Stored

Identify RT or LT
Innominate Artery Sagittal INNOM ART Gray scale
(aka (This image is only Color Doppler
Brachiocephalic included in a RUE exam. Color and spectral Doppler - measure PSV
Artery) There is no LT INNOM
*Only included in a ART since the LT SUBCL
RUE exam* branches directly off of
the aortic arch)
Subclavian Artery Sagittal SUBCL ART PROX Gray scale
Proximal Color Doppler
Color and spectral Doppler - measure PSV
Subclavian Artery Sagittal SUBCL ART MID Gray scale
Mid Color Doppler
Color and spectral Doppler - measure PSV
Subclavian Artery Sagittal SUBCL ART DIST Gray scale
Distal Color Doppler
Color and spectral Doppler - measure PSV
Axillary Artery Sagittal AXIL ART Gray scale
Color Doppler
Color and spectral Doppler - measure PSV
Brachial Artery Sagittal BRACH ART PROX Gray scale
Proximal Color Doppler
Color and spectral Doppler - measure PSV
Brachial Artery Sagittal BRACH ART MID Gray scale
Mid Color Doppler
Color and spectral Doppler - measure PSV
Brachial Artery Sagittal BRACH ART DIST Gray scale
Distal Color Doppler
Color and spectral Doppler - measure PSV
Radial Artery Sagittal RAD ART Gray scale
Color Doppler
Color and spectral Doppler - measure PSV
Ulnar Artery Sagittal ULN ART Gray scale
Color Doppler
Color and spectral Doppler - measure PSV

Tips
• For a right upper extremity exam, the protocol begins at the innominate artery.
• For a left upper extremity exam, the protocol begins at the proximal subclavian artery.
• Patient set-up - very important for ease of completing the examination (for the sonographer and patient)
– multiple positions will be used throughout the exam
• When scanning the right arm, allow enough room on the side of patient closest to you for the
patient to rest their arm on the bed.
• When scanning the left arm, position the patient as close to you as safely possible.
• If patient is unable to raise arm for axillary images, ask for assistance.
• You should scan the vessels in the arm without lifting the probe
• Follow the vessels in their entirety in color, taking the appropriate images at the described locations

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 Upper Extremity Arterial Protocol

Color Doppler
• Will vary with the presence/absence of pathology & curvature of the vessel
• Color images should relay the same information as your gray scale & spectral images
• Color box should be steered (angled) with the vessel direction
• Color in a normal vessel should be free of aliasing and extend to vessel walls
• Utilize preset color PRF (scale) and gain, and adjust according to the type of blood flow (velocities) being
imaged
• If flow is normal and the color is outside the vessel wall or aliasing in center of vessel, slowly
increase PRF and/or decrease color gain until color is no longer outside the vessel wall or aliasing.
• If flow is normal and the color in the vessel is not filled in, slowly decrease PRF and/or increase
color gain until the color fills the vessel without aliasing or bleeding.

Spectral Doppler
• Must use angle correct – Angle correct must be less than 60 degrees
• Gate (SV length) must be in center of vessel & small width.
• Use color Doppler appearance to aid in placement of gate for spectral interrogation. Your goal is to
document the highest velocities present.
• Set the PRF (scale) appropriately for the velocities imaged.
• Adjust the PRF (scale) to display a large waveform.
• Adjust the spectral gain so that there is no background noise on the spectral trace.
• Normal waveforms in the extremities are high-resistive and triphasic, with a sharp systolic upstroke
followed by a brief period of diastolic flow reversal, ending with minimal forward flow in diastole
• Elevated velocities with spectral broadening indicate a stenosis
• Record velocities in the stenotic area as well as approximately 2 cm prior to (prestenotic) and after
(poststenotic) the area of stenosis
• Stenosis is considered hemodynamically significant if the flow in stenotic area is twice the velocity of an
area just previous (prestenotic) to it
• Waveforms distal to a significant stenosis will become monophasic

Pathology Seen
• Atherosclerosis (plaque)
o Walls will appear thick
o Calcified plaque will produce acoustic shadowing
o Use color Doppler to evaluate for flow disturbances (aliasing)
• Aneurysm
o Vessel diameter will be 1.5 times larger than adjacent more proximal segment
o Measure in sagittal (AP) and transverse (width) from outer wall to outer wall
o Document intramural thrombus in sagittal and transverse with gray scale and color Doppler
• Document any soft tissue abnormalities seen in proximity to the arteries.
• Document any venous thrombosis seen.

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