 I am going to talk about Appalem Artificial Doppler. So what is very unusual about Appalem Artificial Doppler is that first of all, symptomatic arterial disease is less common in the Appalem as compared to the O-Lem. One of the most common present in the feature of Appalem Ishimera is Redox Phenomena, that means the patient gets a p-source of discoloration in the fingertips, typically during cold season or sometimes even with an emotional trauma. With Appalem we need to think of systemic disorders, collagen disorders, we need to think of erotro arthritis, thoracic outlets, syndrome, subliminal steel, embolisms which are more common in the Appalem as compared to O-Lem. And then of course in the Appalem, very often patients has have very good colactals and therefore symptoms are very often less. Here for example, we have a patient who has got a complete occlusion of the subliminal artery but there is an excellent colactal coming from the internal memory artery and ultimately the symptoms were not too bad. Trauma is very common in the Appalem, vascular trauma, typically either industrial accidents or agricultural accidents, very often one of the most common indication for looking at Appalem arteries is of course evaluating arteries prior to an AV fistula or a graft for analysis. And then of course, we look at the palmarage patency for the TQ of the Ritulacine for C-MG surgery. You have to be very familiar with the anotomy just like any other examination. We always begin with the vertebral artery that means we ask the patient to lysofine extend the neck on a pillow and then evaluate the vertebral artery along its entire extent in grayscale on color and in palestopula. On color, make sure that the direction of flow in the carotid artery and the direction of flow in the vertebral artery are the same and this is very important to pick up subliminal steel. Then, keeping the position same, we look at the subliminal artery. Typically, we try and go as close to the original as possible and we tilt the beam towards the manoeuvring sternum in the proximal portion of the subliminal artery and of course, as we go distantly towards the axilla, then we like to tilt the probe on the opposite side. The subliminal artery typically is a very high resistance sort of artery with a reversal of diastolic flow and you might get a little forward flow a little later, but it is a very high resistance sort of a waveform. Now, one of the most important problems in subliminal artery is looking at origins of the subliminal artery, the origin of left subliminal artery and the origin of the requisite chronic trunk and this is because they are hidden by the bones. So, what we do typically is either you use a cardiac probe which has got a very small foot head or we use a pulse machine probe and try and look at origins. But this is important because very often stenosis is at the origin. The axilla artery of course, we evaluate by extending the arm and then it is easy to evaluate but we should not give too much of pressure otherwise very often the if you are also looking at a beam, the beam can get compressed. The brachial artery typically we go medially and trace it all around its extent right from the axilla to its bifurcation but it is very important to evaluate the brachial artery in a transverse plane also. This is because not only can we see the movement well but when you evaluate the brachial artery in a transverse plane, we can pick up any anomalies of the brachial artery. For example, very often we see a high bifurcation of brachial artery coming up in upper arm and this is a very important information which we need to give to surgeons before doing a fistula surgery. It is very important to look at the brachial artery bifurcation. So that is a brachial artery bifurcation with the brachial artery of course going superficially and the other artery going down. So then we trace the entire brachial artery right from its origin. It is easy to evaluate because it is superficial and as you go distally again we see a sort of a high resistance waveform. This patient is elderly and usually in elderly people have very high resistance waveform in the brachial artery. Then we look at the ulnar artery as we know that ulnar artery dips down at its solution and the mid portion of ulnar artery is very often difficult to see but once you come closer to the risk then the ulnar artery becomes superficial and again it becomes easy to evaluate. There are some tests which we need to do in the upper limb. One test is the island stress. This is done to look at a palmarage patency to find out the palmarage patency before we take the radial artery for bypass surgery. So what we do is look at the radial artery, compress the ulnar and look out for this increase in velocity. Then we look at the ulnar complex radial and again look out for increase in velocity. This increase in velocity typically should be at least 30 to 40 centimeters per second. So here we are doing the island stress we are looking at the radial artery compressing the ulnar artery and then we look out for this increase in velocity. Here we are looking at the ulnar artery compressing the ulnar artery and then again looking out for this increase in velocity. There is something known as a modified duplex island stress where we typically keep the probe a small foot head probe in the stock box and look at the radial artery here and then compress the proximal radial artery. So if the palmarage is patent then again we get reversal of flow coming from the ulnar artery and once you see a reversal like this that means again that the palmarage is patent. Then there is a test known as reactive hyperemia. This is done typically again before fistula. Typically what we are looking out for is an increment in the blood flow after a period of fistula. Now this test tells us whether the artery is able to dilate adequately after ischemia not only after ischemia but once there is a fistula done as we know then there is an increased demand in the blood and the artery should be able to cope up this increased demands and this test is good for that. So typically what we do is ask the patient to hold the fist tight and then evaluate the radial artery. Typically what we see is a very high resistance sort of a waveform. Then we ask the patient to release the fist and after releasing fist typically what we see is an increase in the diastolic flow that tells us that the artery is good for dialysis. This is what we are doing here patient we are looking at a radial artery the fist is very tight and we can see there is a high resistance. In fact there is a reversal of flow and after releasing the fist there is a reactive hyperemia and we can see that there is increase in the diastolic flow. This is a normal sort of response. We can also look at a palmarage and we can also look at the flow in the digital arteries. Now this typically we do when the patient is suspected to have a small artery disease that means for example if everything is fine up to the radial artery but the patient still has denotes that is the time you will start looking at small arteries in the palm or in the fingers. There are some other tests like for example we look for thoracic outlet compression there are three or four tests which you can do one is adjacent test in this what we do is ask the patient to stand drop down the epsilon hand which you are evaluating and ask the patient to tilt on the same side of where you are enacting and take a deep breath in. So typically if the patient has a thoracic outlet problem then we can see that the radial artery becomes deep and the clinically what we can also do is keep our ultrasound probe and look out for alteration in the waveform. There is a test known as neck teething test or a reverse accent typically what we do here is ask the patient to look on the opposite side of the examination and again if the patient does not have a thoracic outlet then there is no significant alteration in the waveform. There are other tests for example there is a constrict labicular compression test, there is writes which is an hyper abjection test, there is a loose test. This is what we commonly do in our practice. So what we do is ask the patient to raise the hands hyper extend, hyper abject and then move the fingers. You can look at the radial artery but this becomes very cumbersome. So commonly what we do is look at the sub-neural artery or the axillary artery and we will see a case a little as a subsequently. And then there is a test which is a cold stimulation test for radot syndrome. So again many are suspecting a systemic disorder like an SLE patient is symptomatic as clinically a radot syndrome. Then what we do is a cold stimulation test. So here what we do is ask the patient to hold some ice in the hand till the patient is able to hold it maybe 15 seconds or so and look at the waveform typically after holding the eyes. It's a very high resistance waveform and you can see a reversal of flow in the diastole. Then we ask the patient to release the eyes and typically in a normal patient after 1 minute, 2 minutes or at the most 3 minutes you can see that the waveforms can come back to normal. Very often you might get a higher diastole flow. This is a normal response to a cold stimulation test. So why do we look at the what we do first is to pick up sub-clement steel because once you have a sub-clement steel then the diagnosis is simple and the examination is over in the matter of 2 minutes. So here for example we have a patient who has got a complete steel on the left side where the multiple artery is blue and there is an operation of the sub-clement artery and on the right side there is a partial steel that is a typical funny bunny side and the patient has a stenosis at the original of the decrysopallic drug. We can have sub-clement artery occlusion. So typically when you have a thrombus prior to the occlusion you get this high resistance waveform. It is multiple waves typically happening in the diastole because the blood goes and fits against a dead wall and this really of course you get a napkin flow. That is the patient who had a thoracic outlet symptoms so we can see that the sub-clement artery at rest has a velocity of about 80. After the root stress we can see that the velocity is increasing to about 300 or 400 centimeters per second telling us that the artery is sort of narrowed down. If you look at a vein that is the normal sub-clement vein at rest and after the hyperindex and hyperextension maneuver there is the narrowing of the sub-clement vein with an increase in the velocity of the sub-clement vein. So that is typical of the thoracic outlet. In fact me and Dr. Raju Vada from Hinduja were the first to describe venous changes in the thoracic outlet syndrome many years back. Auto-artritis is very common in the upper limb. Typically sub-clement artery is very often affected and what you typically get is a long segment of narrowing of wall thickening in the sub-clement artery or the carotid artery. That is very classical of auto-artritis, very common in the upper limb. We can have axillary artistinosis and with aliasing and narrowing of flow channels and very high velocities. We can have brachylarty occlusion. Now look at this number of co-lattles, very often there are a lot of co-lattles which come up in the upper limb but this patient of course has a dampen flow as we went this way. This lady had severe discoloration of the hand you could look at the fingers and of course the cause was occlusion of the brachylarty both the ulnar and the adelarty is also occluded is a very bad case. In this era of Covid we are seeing upper limb arterial occlusion because of the disease we know that whenever there is a hyperparallel state then again of course there is thrombosis and the versure consists of abnormal vessel wall, abnormal flow and hyperparallel state and typically in Covid there are a lot of factors which contribute to these factors and ultimately can give rise to hyperparallel state and thrombosis. So we have seen patients presenting with upper limb ischemia who have subsequently turned out to be Covid positive. There is a young patient who came and did not have fever and only upper limb pain and there is an occlusion of the supply of the artery that is very radial and the ulnar arteries with severely dampen flow Another patient 45 years old who had pain in both the forearms again not very symptomatic had fever for one or two days and both the radial artery and the ulnar artery in both the forearms were occluded. And this is a patient again where ischemic changes in the hand and there was thrombosis of the right superficial power arch in the distal ulnar artery and subsequently he had to be operated. We can have changes in the fingers typically in the scandalous of a thrombosis but typically when we think of small artery disease we need to think of collagen disorders or systemic disorders like for example LSD. So what we need to differentiate in the upper limb is an obstructive disease from a viscous spastic disease and we need to separate out a small artery disease from major artery disease. So typically major artery diseases are up to the distal radial and ulnar and they present more commonly with either obstruction or stenosis. Whereas typically a small artery disease of the palm typically for example collagen disorders they present with typically as a viscous spasm or a viscous spastic disorder and a good test to look out for viscous spasm as we said is the core stimulation test. So what happens here is that after the patient we ask the patient to hold their eyes and release the eyes the waveforms do not come back to normal. We persistently see a high resistive waveform and the patient typically complain of a lot of pain. So here is a young lady we did and she had SLE and there is a persistent high resistive waveform and this lasted for almost 20-25 minutes and the patient said we have pain in the hand and almost repented having done this test because of the pain which she had. Abolism is very common in the upper limb as compared to lower limb. Here is a person who came with upper limb pain early in the morning in fact and what he saw was a complete occlusion of the axillary artery. So we just put the probe on the heart and saw a source of embolism on the mitral valve. He has a known case of mitral valve disease. This is a person who had an accident in the industry he was working on some machine and his hand sort of went partly in one of the part of the machine and he developed a complete tear of the biceps muscle with the brachyl artery occlusion. This is a gentleman who was travelling in the train, local train of Mumbai and then someone hit a stone from outside and he injured his brachyl artery and had a traumatic handle some of the brachyl artery. This is a gentleman working with the MSCB accidentally touched a live wire and then had an electric change area of the left hand and when he came to us the entire hand was discoloured and there was occlusion of the radial and the artery. So thank you so much for your attention for the evaluation is quite different from lower limb evaluation the diseases are getting quite different and most important remember that there are some special tests we need to do in the upper limb as compared to lower limb. Thank you so much.