Hemodynamics for the

Vascular Surgeon

David L. Dawson, MD, FACS

Professor
Texas A&M University
College of Medicine
 Disclosures
• No financial conflicts of interest

✗
Diagnostic imaging provides
the pictures, hemodynamic
information provides the
soundtrack.

To fully experience
vascular surgery, an
appreciation for both is
needed.
Physiologic Testing

• Tools for hemodynamic

assessment developed
• Research laboratories
created for non-invasive
diagnostic
testing based
on hemodynamic
principles
D. Eugene Strandness, Jr.
 Hemodynamics for Surgeons
University of Washington
• Described a physiologic
Chief Residents, General Surgery
approach to diagnosis and
treatment of vascular
disease
• Combined basic science,
engineering, medicine, and
surgery
• Introduced the concept of
Published 1975, 698 pages
New York: Grune & Stratton
noninvasive testing
D. Eugene Strandness, Jr. David S. Sumner
1962 1966
 Acknowledgement

R. Eugene Zierler, MD Chapter 8:

Arterial Hemodynamics
 Overview: Hemodynamics

1. Basic concepts
2. Arterial stenosis
3. Venous return to
the heart
Basic •
•
Fluid energy
Poiseuille’s law
Concepts • Vascular resistance
• Normal pressure and
flow
• Blood flow patterns
 Fluid Energy
• Potential Energy (Ep)
– Intravascular pressure (P)
– Gravitational energy (+ρgh)
Ep = P + (ρgh)
Ep = potential to do work
• Kinetic Energy (Ek)
Ek = 1/2 ρv2
• Total Fluid Energy
(E in ergs/cm3)
E = P + (ρgh) + (1/2 ρv2)
Fluid in motion can do work
 Fluid Pressure
• Pressure = Force per unit area (dynes/cm2)
• Intravascular Arterial Pressure (P)
– Dynamic pressure (cardiac)
– Hydrostatic pressure (-ρgh)
– Static filling pressure (5 to 10 mmHg)

= + +
 Bernoulli’s Principle

• Swiss mathematician
and physicist
• Early kinetic theory of
fluids

Daniel Bernoulli
1700-1782
 Fluid Energy Losses:
Bernoulli’s Principle

• When fluid flows, total energy (E) remains

constant, provided there are no frictional losses
P1 + ρgh1 + 1/2 ρv12 = P2 + ρgh2 + 1/2 ρv22

• Energy lost in flowing blood is dissipated as heat

P1 + ρgh1 + 1/2 ρv12 = P2 + ρgh2 + 1/2 ρv22 + Heat

Conservation of Energy
 Bernoulli’s Principle

• Area increases
• Velocity decreases
• Pressure rises

• The fall in Ek (velocity)

is balanced by a rise in
Ep (pressure)

Idealized Fluid System

 Fluid Energy Losses
• Viscous Losses
– Result from friction between
adjacent layers of blood or
between blood and the vessel
wall
• Inertial Losses
– Related to changes in the
velocity or direction of blood
flow
 Difference from Idealized System
• Viscosity is not constant
– Affected by flow characteristics, hematocrit,
serum proteins, etc.
• Pulsatile flow
• Branching, curving conduits
• Energy stored in elastic arteries
 Windkessel Effect
• Interaction between stroke volume and the
aorta (and other large elastic arteries)
• Net storage of blood during systole
• Outflow during diastole
• Distensibility of large
elastic arteries is analogous
to a capacitor
 Capacitors in Circuits
• Tune radios to specific frequencies in
resonant circuits
• Stabilize voltage and power flow in power
transmission
systems
• Smooth output
of power supplies
 Poiseuille’s Law
Pressure = Flow x Resistance
8Lη
P1 - P 2 = Q
πr4
P1 - P2 = pressure gradient
Q = volume flow
L = length of tube
η = fluid viscosity
r = tube radius
 Poiseuille’s Law:
Viscous Energy Losses
8Lη
P 1 - P2 = Q
π r4
• Describes the viscous energy losses in an
idealized fluid system (steady laminar flow,
Newtonian fluid, straight rigid cylindrical tube)
• Estimates the minimum pressure gradient
expected for arterial flow
• Inertial energy losses typically exceed these
viscous losses, particularly in diseased arteries
 Inertial Energy Losses
• Result from:
– Acceleration/deceleration (pulsatile flow)
– Changes in lumen size
– Changes in flow direction at
points of curvature or branching

∆E = k 1/2 ρv2

∆E = energy change due to inertial effects

k = constant
ρ = density of blood Isaac Newton
v = blood flow velocity 1642-1727
 Pressure Drop at Varying Flow Rates
Viscous
only

Viscous
and
Inertial
 Ohm’s Law

V=IR
V = Potential (volts)

I = Current (amperes, coulombs/second)

R = Resistance (ohms) Georg Ohm

1789 - 1854
 Potential (volts)

Current (amperes, coulombs/second)

V
I= Resistance (ohms)
R
 Ohm’s Law Analogy in Fluid Systems
Pressure change = ∆ P
Flow = Q
Resistance = R

V
I=
R
Electrical

∆P
Q=
R
Fluid
 Peripheral Vascular Resistance
• “Resistance” term from Poiseuille’s Law
• Radius is the predominant factor influencing
resistance (r4)
8Lη
8Lη R=
∆P= Q
π r4 πr4
• Resistance of an arterial segment increases as
velocity increases due to inertial effects (v2)
Pressure Drops in the Vascular System

The arterial
segments commonly
affected by
atherosclerosis (SFA)
are normally very
low resistance
vessels
Flow Patterns
 Arterial Flow Patterns
• Determined by:
– Arterial geometry
– Flow (velocity, volume)
– Properties of vessel wall
 Lamina
• Latin noun
• Definitions:
– blade
– money/cash
– plate
– thin sheet of metal or
other material
– veneer
 Wind tunnel testing of airfoil
Boundary layer separates from surface of wing
Layer of air flow flows attaches to
boundary-interface with leading
edge of wing

Vortices and turbulence

behind wing (stalled airfoil)

Layer of air flow flows smoothly along

interface of wing and moving air,
laminar flow maintained

Smooth air flow with

layers of smoke to
show direction of
movement
 Boundary Layer
• Term used in physics and fluid mechanics
• The layer of fluid immediate adjacent to a
surface
• Effects of viscosity are most significant
– Friction between fluid elements and surface
 Laminar Flow in Tubes
• Flow is parallel to walls (vector direction)
• Slowest flow at the boundary layer
– Where viscous interaction with wall is greatest
• Fastest flow at point farthest from wall
– Center of a cylindrical tube
• Flow profile can be represented by concentric
layers (laminae)
• Flow profile is parabolic for viscous fluid in
absence of turbulence
Laminar Flow
 Laminar Flow
Narrow band
Velocity

Highest
velocities
Time Windo
w
Spectral Color-flow Image
Waveform
 Energy Losses Change When Ideal
Fluid Flow Properties Are Disrupted

• The application of Poiseuille's law in the

circulatory system assumes laminar flow
– Flow is directly proportional to the pressure
gradient
• Greater fluid energy losses occur with
turbulent flow
– Flow rate is proportional to the square root of
the pressure gradient
 Turbulence
• Irregular flow state – random variations in
pressure and velocity
• Random flow pattern result in
dissipation of fluid energy as heat
• Flow profile blunt, not parabolic
 Reynolds Number
• Dimensionless number for dynamic
similarity
– Ratio of inertial forces to viscous forces
𝜌𝜌VL
Re =
𝜇𝜇
Re = Reynolds number
ρ = fluid density (kg/m3)
V = velocity (m/s)
L = length of travel (m) Osborne Reynolds
µ = fluid dynamic viscosity (kg/(m × s) 1842 –1912

Higher Reynolds Number

associated with
transition from laminar
to turbulent flow
 Flow Disturbances

Flow velocity
increase

Turbulence

Low velocity
eddy currents
 Turbulence in Duplex Ultrasound
PSV
Velocity

EDV

Color aliasing
Spectral
“mosaic” pattern
broadening
Time

Spectral Color-flow Image

Waveform
Boundary Layer Separation in Vessels
• Boundary layer: layer of fluid adjacent to the
vessel wall
• Changes in vessel geometry create local
pressure gradients that cause the boundary
layer flow to change direction
Boundary Layer Separation
Boundary Layer Separation in the
Normal Carotid Bulb

Flow separation with organized,

non-axial flow
Normal Carotid Bulb Flow Patterns
 Tangential Stress

Stress describes the stretching forces exerted

on the tube wall by pressure within the tube
r
τ=P δ

τ = stress (dynes/cm2)
P = fluid pressure
r = internal tube radius
δ = tube wall thickness
Tangential Stress on Arterial Wall

3-fold increase
in diameter
results in 12-fold
increase in wall
stress

τ=P r
δ
Arterial Stenoses
Energy Losses In Arterial Stenoses
 Energy Losses In Arterial Stenoses
• Radius of a stenotic segment has much greater
effect on viscous energy losses than length
• Inertial energy losses occur at the entrance and
exit of a stenosis
– Contraction and expansion effects
• Geometry of stenosis affects flow
– Less energy loss with gradual tapering compared to
abrupt change in lumen size
• Flow rate (velocity/volume) has effect
 Critical Arterial Stenosis
• Narrowing required to produce a significant
reduction in distal pressure or flow
• Approximately 50% diameter reduction or
75% area reduction
• Value depends on flow rate
• Moderate stenosis that is not limiting at
resting flow rates may become “critical” when
flow is increased (i.e. exercise)
Critical Arterial Stenosis
(AREA)

Critical stenosis
threshold varies
with flow velocity

Typically ~ 50%
diameter reduction
Autoregulation

Flow is maintained
by vasodilatation
with a drop in
distal pressure
 Arterial
Waveforms
 Arterial Flow Velocity

1 - Forward flow
3 systole
1 2
2 - Reverse flow
late systole
3
1 3 - Forward flow
diastole
2
Arterial flow velocity Flow profile at
throughout a different points of
cardiac cycle the cardiac cycle
Variations in Vascular Resistance

Intermediate flow
Common Carotid
pattern

Forward flow only

Internal Carotid
High diastolic
Low resistance
flow

External Carotid Triphasic pattern

High resistance Reverse flow
Flow Changes in Arterial Stenoses

Damped monophasic High-velocity jet

waveform Post-stenotic
turbulence
Femoral Doppler Waveforms Distal to Iliac Lesions
Indirect Findings

Normal iliac artery

Multiphasic femoral

Stenotic iliac artery

Monophasic femoral

Occluded iliac artery

Monophasic and
damped femoral
 Ankle/Brachial Index (ABI)
Ankle pressure
ABI =
Arm pressure
• Measurements performed supine
– No hydrostatic pressure effect)
• Ankle pressure (for each side) = higher of pressures
measured at dorsalis pedis and posterior tibial arteries
• Arm pressure = higher of brachial artery pressures
 Ankle/Brachial Index (ABI)

• Normal 1.00 to 1.40

• Borderline 0.90 to 0.99
• Abnormal less than 0.90
• Incompressible greater than 1.40

Paradox: Normal ABI > 1.0

How can arterial blood from from area
of lower to higher pressure?
Central Peripheral
 Pressure and Velocity
Wave Propagation
Systolic pressure
increases
Diastolic pressure
Arm Ankle
decreases
Pulse pressure
widens
Velocity
decreases
Central Peripheral
Collateral Circulation
 Collateral Circulation
• Pre-existing vessels that enlarge when flow
through the parallel major artery is reduced
• Abnormal pressure gradient across the
collateral system is the principal stimulus for
collateral development
• Resistance of collateral pathway is always
greater than that of normal parallel artery
– Collateral resistance is “fixed”
– Minimal change in resistance during exercise
 Collateral Circulation

Superficial Femoral Artery

Occlusion
High
Resistance
Stem: Profunda femoris
Midzone: Muscular branches
Re-entry: Genicular arteries
(Flow reversed in the
re-entry vessels)
Distribution Of Vascular Resistance
• Segmental Resistance (fixed)
– Main conduit artery (normal/diseased)
– Collateral vessels (disease present)

• Peripheral Resistance (variable)

– Calf muscle arterioles
– Distal cutaneous circulation
 Distribution of Vascular Resistance

Normal Response to
Exercise
(low segmental resistance)

Large increase in flow

Response to
Exercise
with Arterial
Occlusion
(high resistance collaterals)
Little increase in flow
Treadmill Exercise Test
Moving Fluid Against Gravity:
You need a pump!
Vascular and Endovascular Surgery - Moore
William Harvey
1578-1657
Rutherford’s Vascular and Endovascular Therapy – Sidawy and Perler
Ambulatory Venous Hypertension
Failure of the musculovenous pump to
reduce venous pressure
Direct Pressure Measurements

Normal

Abnormal
 Summary
• Circulation of blood based on principles of
pressure and flow
• Knowledge of hemodynamics is the
foundation for:
– Understanding clinical presentations of
vascular disease
– Interpreting vascular laboratory tests
– Making best informed
surgical decisions