 I am Dr. Nitin Sopran and I am going to talk on Apolym Artidial Doppler. So what is very unusual about Apolym Artidial Doppler is that first of all, symptomatic arterial disease is less common in the Apolym as compared to the Aeolium. One of the most common present feature of Apolym Ischemia is Reynolds phenomena. That means the patient gets a p-source of discoloration in the fingertips typically during coalescence or sometimes even with an emotional trauma. In the Apolym we need to think of systemic disorders, collagen disorders. We need to think of Aeol-2 arthritis, thoracic outlets, syndrome, subclim and steel embolisms which are more common in the Apolym as compared to the Aeolium. And then of course in the Apolym very often patients 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 subclimate 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 Apolym, vascular trauma typically either industrial accidents or agricultural accidents, electrocution injuries are very common in the Apolym. Very often one of the most common indication for looking at Apolym arteries is of course evaluating arteries prior to an AV fistula or a graft for dialysis. And then of course we look at the palmarage patency for before taking up the ventilatory force which is surgery. You have to be very familiar with the anotomy just like any other examination. We always begin with the vertebratory that means we ask the patient to lysopine extend the neck on the pillow and then evaluate the vertebratory along its entire extent in grayscane on color and in palestopola. On color make sure that the direction of flow in the carotid artery and the direction of flow in the vertebratory are the same and this is very important to pick up a subclimate steel. Then keeping the position same we look at the subclimate artery. Typically we try and go as close to the origin as possible and we tilt the beam towards the manoebrate sternum in the proximal position of the subclimate artery and of course as we go distantly towards the axilla then we like to tilt the probe on the opposite side. The subclimate 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 subclimate arteries is looking at origins of the subclimate artery, the origin of left subclimate artery and the origin of the brachycephalic 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 transversion probe and try and look at origin but this is important because very often stenosis is at the origin of the subclimate artery. 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 if you are also looking at a vein, the vein can get compressed. The brachycephalic artery typically we go medially and trace it all along its extent right from the axilla to its modification. Now it is very important to evaluate the brachycephalic artery in a transverse plane also. This is because not only can we see the lumen well but when you evaluate the brachycephalic artery in a transverse plane we can pick up any anomalies of the brachycephalic artery for example very often we see a high bifurcation of the brachycephalic 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 brachycephalic artery bifurcation. So that is a brachycephalic artery bifurcation with the radial artery of course going superficially and the ulnar artery going down. So then we trace the entire radial 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 we get a very high resistance waveform in the radial artery. Then we look at the ulnar artery as we know that ulnar artery dips down at its solution. 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 Lunar's Allen's test. This is done to look at palmarage patency to find out if the palmarage is patent 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, compress the 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 Allen's test. 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 radial artery and then again looking out for this increase in velocity. There is something known as a modified duplex Allen's test where we typically keep the probe, a small foot head probe in the stuff box, 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 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 history. Now this test tells us whether the artery is able to dilate adequately after history, not only after history, but once there is a fistula done as we know that there is an increased demand in the blood flow 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 that is the patient we are looking at the 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 a response. We can also look at the 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 typically 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 weak either clinically or what we can also do is keep our ultrasound pro and look out for alteration in the waveform. There is a test known as neck tilting 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 that does not have a thoracic outlet then there is no significant alteration in the waveform. There are other tests for example there is something known as a costoclavicular compression test. There is Wright's test which is an hyper abduction test. There is a Roos 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 abduction and then move the fingers. You can look at a radial artery but this becomes very cumbersome. So commonly what we do is look at sub-neural artery or the axillary artery and we will see a case a little subsequently. Then there is a test which is known as coal stimulation test for rarosclerosis. So again when you are suspecting a systemic disorder like an SLE, a patient is symptomatic as clinically a renaught syndrome then what we do is a coal 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 typically 15 seconds or so. Look at a waveform typically after holding the ice 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 ice 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 diastolic flow. This is a normal response to coal stimulation test. So why do we look at the vertebral first is to pick up subclimins team because once you have a subclimins team your 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, the vertebral artery is blue and there is an occlusion of the subclimin artery and on the right side there is a partial steel that's a typical funny bunny sign and the patient has a stenosis at the origin of the rectal spalic tract. We can have subclimin artery occlusion. So typically when you have a thrombus prior to the occlusion you get this high resistance waveform. You get this multiple wave typically happening in the diastolic because the blood goes and hits against an end wall and distantly of course you get a dampened flow. Now that's a patient who had a thoracic outlet symptoms. So we can see that the subclimin artery at rest has a velocity of about 80. After the Roost test 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 and if you look at a vein that's a normal subclimin vein at rest and after the hyperabduction, hyperextension maneuver there is narrowing of the subclimin vein with an increase in the velocity of the subclimin vein. So that is typical of thoracic outlet. In fact me and Dr. Raju Wadhwa from Hinduja were the first to describe venous changes in the thoracic outlet many years back. Autoartritis is very common in the upper limb. Typically subclimin artery is very often affected and what you typically get is a long segment of narrowing of wall thickening in the subclimin artery or the carotid artery. That's very classical of autoartritis, very common in the upper limb. We can have axillary artistinosis with aliasing and narrowing of flow channels and very high velocities. We can have briculatory occlusion. Now look at this number of co-laters. Very often there are a lot of co-laters which come up in the upper limb but this patient of course has a tampon flow as we went this way. This lady had severe discrepancy of the hand. You look at the fingers and of course the cause was occlusion of the briculatory both the alder and the adrenatory is also occluded. It's 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 hypercoagulatory state, there can of course be thrombosis and the versure stride consists of abnormal vessel wall, abnormal flow and hypercoagulatory state and typically in COVID there are a lot of factors which contribute to these factors and ultimately can give rise to a hypercoagulatory state and thrombosis. So we have seen patients presenting with upper limb ischemia who have subsequently turned out to be COVID positive. There's a patient, a young patient who came, I did not have fever. I had only upper limb pain and there is an occlusion of the subclavian artery, the axillary radial and the under arteries with severely dampened 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 adrenatory 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 distril under artery and subsequently he had to be operated from the arteries. We can have changes in the fingers, typically in this can be because 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 I said. So these patients, so what we need to differentiate in the upper limb is an obstructive disease from a visuospastic disease and we need to separate out a small artery disease from major artery disease. So typically major artery diseases are up to the distril 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 visuospasm or a visuospastic disorder and a good test to look out for visuospasm as we said is the cold stimulation test. So what happens here is that after the patient, we ask the patient to hold her eyes and release the eyes, the waveforms do not come back to normal. We persistently see a high-resistant waveform and the patient typically complain of lot of pain. So here's a young lady we did and she had SLE and there's a persistent high-resistant waveform and this lasted for almost 20-25 minutes and the patient had severe pain in the hand and almost repented having done this test because of the pain which she had. Ambolism is very common in the upper limb as compared to lower limb. Here's a person who came with upper limb pain early in the morning in fact and what we saw was a complete oblution of the axillary artery because of an emblem. So we just put a probe on the heart and saw a source of embolism on the mitral valve. Here's a known case of mitral valve disease of course. This is a person who had an accident in the industry 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 oblution. This is a gentleman who was traveling 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 of the radial artery. But this is a gentleman working at the MSCB accidentally touched live wire and then had an electric injury 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. Upper limb evaluation is quite different from lower limb evaluation the diseases are again quite different and most important remember that there are some special tests you need to do in the upper limb as compared to lower limb. Thank you so much.