All Davies

The absence of a bruit at the common femoral level: A. rules out significant stenosis at that level B. cannot rule out significant stenosis at that level C. suggests stenosis distal to that level D. suggests total occlusion at that level E. suggests stenosis proximal to that level

B. Cannot rule out significant stenosis at that level. Explanation: Bruits heard on physical examination are useful: Although the absence of a bruit does not rule out significant arterial obstruction, the presence of a bruit does suggest stenosis.

A 12-year-old is noted by the pediatrician to have decreased femoral artery pulses and is referred to the laboratory for evaluation. Bilateral arm blood pressures are 210/100, and femoral artery pulses bilaterally are indeed diminished, as are the ankle pressures. Femoral artery Doppler waveforms are abnormal. The diagnosis that should be entertained in this child is: A. aortoiliac occlusive disease B. coarctation of the aorta C. compartment syndrome D. patent ductus arteriosus E. renal artery stenosis

B. Coarctation of the aorta. Explanation: Both coarctation of the aorta and renal artery stenosis can cause the hypertension, but only coarctation will also cause the abnormal femoral pulses.

The usual site of puncture for percutaneous lower extremity (or any) angiography) is: A. axillary artery B. common femoral artery C. posterior tibial artery D. internal jugular vein E. brachial artery

B. Common femoral artery. Explanation: This is a large, relatively superficial artery that usually provides the easiest access to the arterial system.

Patients presenting with symptoms of claudication complain of: A. nocturnal muscle cramps B. cramping pain in the calf, thigh, or buttocks with exercise and relieved by rest C. numbing weakness in the legs while standing D. pain in hips or knees not relieved by rest E. cramping pain in the calf, thigh, or buttocks with exercise not relieved by rest

B. Cramping pain in the calf, thigh, or buttocks with exercise and relieved by rest.

The greatest pressure of venous hypertension in secondary varicose veins occurs: A. at rest B. during muscle contraction C. during muscle relaxation D. while standing quietly E. while sleeping

B. During muscle contraction. Explanation: Muscle contraction forces blood out to the superficial veins via incompetent perforating veins.

Which of the following is NOT one of the commonly assessed characteristics of CW venous Doppler? A. spontaneity B. gaiety C. augmentation D. competence E. phasicity

B. Gaiety. Explanation: This would be a characteristic of a cheerful vascular technologist. The others are normal venous flow characteristics.

Continuous-wave Doppler assessment of the posterior tibial level reveals nonspontaneous flow that augments with foot compression. This finding: A. confirms deep vein thrombosis B. is within normal limits in a cold patient C. is within normal limits in a warm patient D. confirms valvular incompetence proximally E. suggests CHF

B. Is within normal limits in a cold patient. Explanation: It is not uncommon to have nonspontaneous flow in either the posterior tibial or great saphenous veins, especially if the patient is nervous and/or cold and therefore vasoconstricted.

What is represented on this waveform from a left vertebral artery? A. it is within normal limits B. it suggests transitional vertebral steal C. it suggests retrograde flow throughout the cardiac cycle D. it suggests severe vertebral stenosis E. it is nondiagnostic

B. It suggests transitional vertebral steal. Explanation: Flow is pulled retrograde during systole, then reverts to antegrade during diastole. This suggests a changing abnormal pressure gradient caused by the progression of proximal subclavian artery obstruction.

The endarterectomy procedure (removal of plaque from an artery): A. is used only for carotid stenosis B. may be used for obstructed lower extremity arteries C. is never used for infrarenal arteries D. is a relatively recent surgical option E. is the treatment of choice for obstructed renal arteries

B. May be used for obstructed lower extremity arteries. Explanation: While endarterectomy is most often performed on carotid arteries and has been largely superceded in the lower extremity arteries by the use of bypass grafts, it is still sometimes a useful option for revascularization of iliac or femoral arteries. New techniques have improved the outcomes for this procedure in the lower extremity arteries.

Which vein in the antecubital fossa connects the cephalic and basilic veins? A. axillary veins B. median cubital vein C. cephalic vein D. basilic vein E. ulnar vein

B. Median cubital vein.

The angiogram suggests: A. normal carotid bifurcation B. moderate ICA stenosis C. severe ICA stenosis D. total occlusion of ICA E. it is nondiagnostic

B. Moderate ICA stenosis.

The angiogram in the previous question suggests: A. normal carotid bifurcation B. moderate ICA stenosis C. severe ICA stenosis D. total occlusion of ICA E. it is nondiagnostic

B. Moderate ICA stenosis. Explanation: This one is moderate rather than severe, but you can see the wavy protrusion into the lumen of the ICA origin.

Pulsatile venous Doppler from the portal vein may suggest: A. cardiac dysrhythmia B. portal hypertension C. respiratory variations D. hepatic artery obstruction E. normal flow

B. Portal hypertension. Explanation: Portal vein flow is normally gently phasic with respiration and not pulsatile in character.

A Doppler signal from the subclavian vein is expected normally to be: A. triphasic B. pulsatile C. absent in older patients D. nonspontaneous except in warm patients E. retrograde

B. Pulsatile. Explanation: The presence of pulsatility, reflecting right atrial activity, should be noted. Its absence may suggest obstruction between the right atrium and the subclavian vein.

A patient complains of digital pallor or cyanosis induced by cold exposure or emotional stimuli. These symptoms are characteristic of: A. arterial embolism to the digits B. Raynaud's phenomenon C. thoracic outlet syndrome D. carpal tunnel syndrome E. Klippel-Trenaunay-Weber syndrome

B. Raynaud's phenomenon. Explanation: Raynaud's phenomenon causes prolonged digital pallor or cyanosis, followed by rubor on reperfusion.

This digital photoplethysmographic waveform might suggest: A. primary Raynaud's disease B. secondary Raynaud's disease C. venous valvular incompetence D. nerve compression E. this is a normal digital PPG waveform

B. Secondary Raynaud's disease. Explanation: This finding is not universally supported in the literature.

The acoustic windows through which ultrasound may pass in performing transcranial Doppler and transcranial imaging examinations include all except: A. the temporal bone B. the medial part of the frontal bone C. the orbit of the eye D. the suboccipital window E. the submandibular area

B. The medial part of the frontal bone.

With inspiration, a Doppler signal from the subclavian vein will usually: A. augment B. diminish C. change direction D. not respond E. become biphasic

A. Augment.

To evaluate blood flow within the splanchnic arteries, you should examine the following vessels: A. celiac artery, SMA, and IMA B. MPV, right portal vein, and left portal vein C. right and left renal arteries and veins D. right and left common iliac and external iliac arteries E. all of the above

A. Celiac artery, SMA, and IMA. Explanation: The splanchnic arteries are the vessels that supply blood to the gut. These primarily are the celiac artery, SMA, and IMA. Stenosis or occlusion involving these vessels can result in chronic ischemia of the bowel, known as mesenteric ischemia.

In continuous-wave Doppler reflux testing, a normal result is: A. cessation of flow with proximal compression, resuming on release B. cessation of flow with distal compression, remaining absent on release C. augmentation of flow with proximal compression, ceasing with release D. augmentation of flow with distal compression, continuing with release E. augmentation of flow with Valsalva maneuver

A. Cessation of flow with proximal compression, resuming on release. Explanation: Augmentation with proximal compression or on release of distal compression indicates insufficiency.

Select the factor least likely to contribute to deep venous thrombosis: A. diabetes B. pelvic mass C. previous DVT D. hip replacement surgery E. pregnancy and delivery

A. Diabetes. Explanation: Diabetes is a risk factor for atherosclerosis, not deep venous thrombosis. All the rest are risk factors for DVT.

Your measurement of a patient's abdominal aorta gives a diameter of 6.5cm. The probable management of this patient would involve: A. elective repair B. percutaneous angioplasty C. follow-up scan in one year D. endarterectomy E. no course of action; this finding is within normal limits

A. Elective repair. Explanation: The risk of rupture increases dramatically as an abdominal aortic aneurysm exceeds 5-6cm in diameter.

The agent of choice in the initial management of pulmonary embolism is: A. heparin B. streptokinase C. urokinase D. coumadin E. tissue plasminogen activator

A. Heparin. Explanation: Since the age of deep vein thrombosis is unknown, heparin remains the drug of choice to initiate treatment.

A patient presents with bilateral lower extremity edema and nephrotic synddromee. Thrombus is suspected at which level? A. IVC B. iliac veins C. femoropopliteal veins D. portal veins E. this does not suggest thrombosis

A. IVC. Explanation: To create bilateral edema, thrombus would have to involve either both iliac veins or, more likely, the inferior vena cava. This situation might also cause renal dysfunction due to obstructed renal vein outflow.

The type of revascularization surgery that requires the use of a valvulatome is: A. in situ saphenous graft B. reversed saphenous graft C. end-to-side synthetic graft D. side-to-side synthetic graft E. graft vein taken from upper extremity

A. In situ saphenous graft. Explanation: The valvulatome disables the valves in the unresituated vein, allowing blood to flow unimpeded from proximal to distal. (In situ: in place).

The internal carotid artery in Color Plate 3 demonstrates: A. interruption of the color flow due to acoustic shadowing B. ICA occlusion with reconstitution via ophthalmic artery collateralization C. ICA occlusion with reconstitution via CoW collateralization D. extrinsic compression of the ICA E. probable carotid body tumor

A. Interruption of the color flow due to acoustic shadowing. Explanation: This is just more acoustic shadowing, interfering this time not just with the B-mode but also with the color flow. The collateralization answers are fanciful and unlikely.

This image of the proximal internal carotid artery might suggest: A. intraplaque hemorrhage B. minimal homogeneous plaque at the ICA origin C. pronounced calcification D. severe stenosis of ICA origin E. ICA occlusion

A. Intraplaque hemorrhage. Explanation: One must be careful when suggesting intraplaque hemorrhage, since acoustic shadowing can often create convincing dark areas in a far-wall plaque. However, in this case, the surface of the plaque is readily visible, with a hypoechoic area under it. This image is pretty suggestive of intraplaque hemorrhage.

You perform TCD, insonating the left ACA. The flow is toward the beam. This finding suggests: A. ipsilateral carotid obstruction, with right-to-left collateralization B. contralateral carotid obstruction, with left-to-right collateralization C. ipsilateral carotid obstruction, with posterior-to-anterior collateralizaiton D. contralateral siphon disease E. nothing of diagnostic signficance

A. Ipsilateral carotid obstruction, with right-to-left collateralization. Explanation: flow in the ACA is normally away from the beam, so this is not normal. It suggests flow coming across from the other hemisphere via the anterior communicating artery.

A normal response of ankle pressure to exercise testing (such as treadmill) is: A. no change B. a dramatic increase, 50% or more C. a dramatic increase, at least 50% in normals D. a gradual decrease of 50% over five to ten minutes E. a gradual increase of 50% over five to ten minutes

A. No change.

Unilateral claudication in the calf and foot of a young individual suggests: A. popliteal artery entrapment B. anterior tibial compartment syndrome C. "restless" leg syndrome D. lumbar disc disease E. arteriosclerosis

A. Popliteal artery entrapment. Explanation: Popliteal artery entrapment is the most common of unilateral claudication in a young person.

This image from the mid calf suggests: A. pronounced edema B. hematoma C. multiple collaterals D. pseudoaneurysm E. tumor

A. Pronounced edema. Explanation: All those dark spaces under the skin suggest edema, probably more chronic than acute.

This angiogram is taken in AP view. It represents: A. RRA stenosis B. RRA occlusion C. LRA stenosis D. LRA occlusion E. hypoplastic IMA

A. Right renal artery stenosis. Explanation: This is a right renal artery stenosis just prior to the installation of a stent.

The vertebral artery usually arises from the: A. subclavian artery B. thyrocervical trunk C. costocervical trunk D. superior thyroid artery E. dorsal scapular artery

A. Subclavian artery. Explanation: The vertebral artery arises from the dorsosuperior aspect of the ascending (first) portion of the subclavian artery. A not-uncommon variant is the vertebral artery arising directly from the aortic arch.

A Baker's cyst is a collection of: A. synovial fluid from the knee joint B. red blood cells in a venous sinus C. interstitial fluid along a fascial border D. fibrous tissue just beneath the skin E. white cells and other debris along an infected graft

A. Synovial fluid from the knee joint.

The TCD window used for assessing the MCA is: A. temporal B. suboccipital C. orbital D. submandibular E. nasal

A. Temporal.

Regarding the use of magnetic resonance arteriography (MRA) for evaluation of lower extremity arteries, which is FALSE? A. MRA cannot achieve the accuracy of conventional angiography B. MRA does not have the potential side effects that conventional angiography entails C. MRA is more sensitive than conventional angiography in identifying patent runoff arteries D. MRA is more cost-effective than conventional angiography E. MRA can be used alone before bypass surgery (without conventional angiography)

A. This statement--"MRA cannot achieve the accuracy of conventional angiography" is--FALSE. Explanation: MRA can be as accurate as conventional angiography. The other statements are true.

In TCD, the normal direction of flow in the MCA is: A. toward the beam B. away from the beam C. bidirectional D. dependent on the cardiac cycle E. not detectable with TCD

A. Toward the beam.

The image in Color Plate 8 demonstrates normal flow in the common carotid artery. This statement is: A. true B. false

A. True. Explanation: This is a common illustration of how color flow works. The CCA is not quite horizontal all the way across; it has a gentle slope from each side toward the middle. The red display on the left is slightly toward the beam, the blue on the right is slightly away.

In Kappa statistics, if there is no relationship between the two variables being compared, the Kappa value is: A. 0 B. 1.00 C. -1.00 D. greater than 1.00 E. less than 1.00

A. Zero. Explanation: A Kappa value of zero indicates that the observed results occurred because of chance--absolutely no relationship. A Kappa of 1.0 indicates complete agreement between the two variables.

This ultrasound image shows an internal carotid artery with: A. a calcified plaque B. an ulcerated lesion C. a normal arterial wall D. an intraplaque hemorrhage E. a homogeneous plaque

A. a calcified plaque.

The most effective lytic treatment for acute arterial thrombosis is: A. tPA B. heparin C. sodium warfarin D. vasopressors E. inotropic agents

A. tPA. Explanation: The usual thrombolytic of choice is tPA (tissue plasminogen activator).

And in this same cross section, which letter represents the small saphenous vein? A B C D E

B

Stenosis of the following vessel presents the highest risk for a TIA: A. left main coronary artery B. common carotid artery C. internal carotid artery D. external carotid artery E. middle cerebral artery

C. internal carotid artery.

The abbreviation TIA stands for: A. terminal internal artery B. temporary ischemic attack C. transient ischemic attack D. transient internal artery E. temporary internal attack

C. transient ischemic attack.

A congenital arteriovenous fistula involves: A. a single arteriovenous pair B. being easily occluded with microspheres C. being easily ligated surgically D. a multitude of arteriovenous channels E. the lymphatic channels

D. A multitude of arteriovenous channels. Explanation: A congenital fistula (AV malformation) usually has many small channels from artery to vein. An acquired (traumatic or dialysis) fistula has a single channel.

Color Plate 2 represents the internal carotid artery with the color flow demonstrating: A. flow reversal due to pronounced stenosis B. aliasing, suggesting increased velocities due to stenosis C. aliasing, suggesting increased velocities due to flow running downhill D. aliasing caused by changing frequency shifts E. blunted flow due to distal occlusion

D. Aliasing caused by changing frequency shifts. Explanation: The color is indeed aliasing, moving from one color through the brighter hues to the opposite color. The reason is the direction of flow relative to the beam. The flow-to-beam angle at the right of the color box is 70 degree or even a bit above, making for a rather low frequency shift. The angle in the distal ICA toward the left of the color box is more like 0 degrees, the angle which creates the highest frequency shift. Therefore the colors go brighter and even alias, even though the velocity is probably essentially the same (allowing for a bit of slowing in the carotid bulb). No stenosis here.

When assessing a digital artery with Doppler, patency of the palmar arch can be determined by: A. compressing the brachial artery while listening for changes in the digital artery signal B. compressing the radial artery while listening for changes in the digital artery signal C. compressing the ulnar artery while listening for changes in the digital artery signal D. alternately compressing the radial and ulnar arteries while listening for changes in the digital artery signal E. inflating a digital cuff to suprasystolic pressure

D. Alternately compressing the radial and ulnar arteries while listening for changes in the digital artery signal. Explanation: While B and C are partly true, you must compress both arteries (alternately) to see whether flow persists to the hand.

This spectral waveform from the distal internal carotid artery suggests: A. severe proximal ICA stenosis B. severe common carotid artery stenosis C. occlusion at the ICA origin D. brain death E. postendarterectomy flow changes

D. Brain death. Explanation: This characteristic to-and-fro flow pattern has been shown to suggest brain death in cerebral arteries (by TCD), and also in the extracranial ICA.

The abdominal vessel that is most commonly compromised by compression of the median arcuate ligament of the diaphragm is the: A. IVC B. left gastric artery C. superior mesenteric artery D. celiac artery E. none of the above

D. Celiac artery. Explanation: The median arcuate ligament of the diaphragm crosses the anterior aspect of the aorta slightly above the celiac trunk. In some patients, during expiration, this anatomic situation can lead to compression of the celiac artery and high velocities. The abnormally high velocities are present during expiration but return to normal during inspiration. These patients may present with an abdominal bruit.

Aneurysms are most often caused by: A. trauma B. systemic infection C. pregnancy D. congenital arterial wall weakness E. bifurcated laminar flow

D. Congenital arterial wall weakness. Explanation: Although aneurysmal disorders may be related to trauma, congenital weakness and atherosclerosis are the most common causes of aneurysmal disease.

Normally, venous flow in the calf is from the superficial to the deep veins through perforating veins. However, this flow might be reversed when: A. there is superficial vein phlebitis B. the individual is ambulatory C. there are varicosities D. deep venous obstruction is present E. congestive heart failure is present

D. Deep venous obstruction is present. Explanation: When deep venous obstruction is present, congestion and resulting increased deep venous pressure may back out into the perforating veins. With distention, valve leaflets cannot coapt, and flow can travel abnormally from deep to superficial veins. Secondary varicosities may result.

In a patient with portal hypertension, the most likely result of increased portal venous pressure would be: A. cavernous transformation B. aortic dissection C. hepatic artery aneurysm D. enlarged coronary vein E. each of these results is equally likely

D. Enlarged coronary vein. Explanation: The coronary vein normally drains into the splenic vein. With portal hypertension, the increased portal venous pressure decreases flow into the portal system. Consequently, vessels that normally drain into the portal system become enlarged and often find alternate routes of flow. The coronary vein may reverse its flow direction and feed into esophageal varices. These can break down, causing life-threatening bleeding episodes. Cavernous transformation may occur in patients with portal hypertension, but only in the presence of portal vein thrombosis and recanalization. Cavernous transformation of the portal vein most commonly occurs when the liver is normal. Most patients with portal hypertension have underlying liver cirrhosis. Aortic dissection and hepatic artery aneurysm are not associated with portal hypertension.

A patient is seated with legs dangling and a photoplethysmograph sensor placed just above the medial malleolus. After dorsiflexion of the foot five times, this tracing is made. The tracing is consistent with: A. superficial venous insufficiency B. calf vein obstruction C. deep venous insufficiency D. essentially normal venous refilling E. superficial vein incompetence

D. Essentially normal venous filling. Explanation: Venous incompetence is illustrated by refill times of less than 20 seconds. This well exceeds that refill time.

Angiography is generally considered only when the information is necessary for surgery or other urgent patient management because of all of these factors EXCEPT: A. it is expensive. B. it carries a risk of stroke. C. it carries a risk of anaphylactic complications. D. it is often nondiagnostic. E. it is an invasive procedure.

D. It is often nondiagnostic. Explanation: Despite some pitfalls, noted elsewhere, angiography is the definitive imaging study of the arterial system.

The "gold standard" test for pulmonary embolus, though it carries its own risk for compromised patients, is: A. ascending venography B. descending venography C. V/Q scan D. pulmonary angiography E. IVC opacification testing

D. Pulmonary angiography.

Rubor is defined as: A. abnormal stiffness of digits B. small, purple areas of discoloration on the dorsum of the foot C. thickened, wrinkled skin D. red skin color E. slackening of the muscles of the ischemic foot

D. Red skin color. Explanation: Examples are the cherry-red color of digits in a Raynaud's patient when the digital arteries reopen after prolonged spasm, or the bright red foot on dependency after elevation in a patient with advanced arterial occlusive disease.

The first major arterial branch of the aorta is the: A. right common carotid artery B. left common carotid artery C. right subclavian artery D. innominate artery E. left subclavian artery

D. The innominate artery. Explanation: The innominate artery (also called the brachiocephalic trunk) is the first of the three great vessels to arise from the aorta.

Signs that a general practitioner may use in an attempt to diagnose deep venous thrombosis include all of the following EXCEPT: A. passive dorsiflexion of foot (Homans' sign) B. anteroposterior calf compression (Bancroft's sign) C. inflating a sphygmomanometer to 80mmHg on calf (Lowenberg's sign) D. tourniquet test E. physical findings of edema

D. Tourniquet test. Explanation: The tourniquet test is primarily used to diagnose superficial venous incompetence. Note that Homan's sign is actually worse than useless as a diagnostic sign, since it gives the illusion of doing something useful, when in fact it is neither sensitive nor specific for deep venous thrombosis. In fact, the edema is the only potentially useful physical finding here.

Takayasu's arteritis is most often found in: A. young men B. middle-aged men C. elderly men D. young women E. elderly women

D. Young women. Explanation: Takayasu's arteritis is usually found in young women in the second or third decade of life. It occurs most frequently in Asian women.

A duplex image of the carotid bifurcation that demonstrates a goblet-like configuration of the internal and external branches curving around a highly vascularized mass suggests: A. carotid aneurysm B. severe ICA stenosis C. myointimal hyperplasia D. carotid body tumor E. temporal arteritis

D. carotid body tumor.

The most common medical treatment of acute ischemic stroke consists of: A. aspirin B. dextran C. heparin D. rtPA E. dipyridamole

D. rtPA. Explanation: Recombinant tissue plasminogen activator (rtPA) is useful in improving outcomes only if administered within three hours of the onset of symptoms.

The chance of a patient dying from a rupture of an abdominal aortic aneurysm averages: A. 25% B. 35% C. 45% D. 55% E. 80%

E. 80%. Explanation: 30-50% of patients with AAA rupture die before reaching a hospital, and operative mortality is 40-50%. These facts highlight the desirability of catching abdominal aortic aneurysms before they rupture.

The five-year risk for rupture of abdominal aortic aneurysm of 4cm is approximately: A. >50% B. 40% C. 30% D. 20% E. <10%

E. <10%. Explanation: There is a very small risk of rupture with a 4cm aneurysm; the risk increases to 3-15% per year at 5-6cm, and 30-50% per year at 8cm or larger. Other risk factors figure into the risk of rupture.

Which of the following would alter the frequency shift of the internal carotid artery Doppler signal? A. tapering of the vessel from the bulb to the distal visualized segment B. increasing the transmitted frequency C. readjusting the angle-correct cursor D. lowering the system threshold sensitivity E. A and B F. C and D

E. A and B. Explanation: Anatomic narrowing of an artery can increase the velocity; increasing the operating or transmitted frequency will increase the frequency shift. Readjusting the angle-correct cursor will change the velocity estimate for a given frequency shift, but won't change the shift itself. The threshold sensitivity does not affect frequency shift.

A vibration noted while palpating pulses is called: A. a buzz B. a bruit C. a scintillation D. a pulse E. a thrill

E. A thrill. Explanation: A thrill is the palpable manifestation of a bruit. Both are caused by wall vibration.

Which of the following statements is FALSE regarding smoking? A. it accelerates the onset and progression of atherosclerosis B. it increases the oxygen-carrying capacity of blood C. cigarette smoke contains nearly 5,000 chemicals D. it causes swelling of endothelial cells E. it increases platelet aggregation and adherence

B. This statement about smoking--"It increases the oxygen-carrying capacity of blood"--is false. Explanation: Carbon monoxide is one of many byproducts of smoking. Carbon monoxide decreases the oxygen-carrying ability of red blood cells. Smoking is really, really bad for you.

Some causes of deep venous thrombosis may be: A. trauma B. hypercoagulability C. extrinsic compression upon deep veins D. lymphangiitis E. All except D

E. All except D.

The tortuous internal carotid artery in Color Plate 6 demonstrates: A. the French tricolor B. helical flow pattern beyond the tortuosity C. faster flow along the outer wall (at left) D. aliasing E. all of the above

E. All of the above. Explanation: All are true. The flow going around the tortuosity is swirling in a helical pattern. The reason for those stripes is that the velocities vary somewhat across the lumen. The red flow is what we expect with this color assignment: away from the beam is red. The velocities are somewhat higher on the outer (left) wall, creating an aliased blue display. The white area represents the intermediate zone between the two, as the red assignment moves through white into blue as aliasing occurs.

Most often, the settings for venous color flow imaging of the lower extremities: A. are the same as those for peripheral arterial studies B. are the same as those for abdominal arterial scanning C. are the same as those for carotid scanning D. are the same as those for abdominal venous scanning E. are different from any of the above

E. Are different from any of the above. Explanation: A low PRF (scale) setting is necessary for the slower flow in lower extremity veins.

The examiner scans a patient with pain and swelling in the calf. A large dark area is noted in the medial popliteal space, and no vascular communication is found. This most likely represents: A. popliteal aneurysm B. cystic adventitial degeneration C. cellulitis D. necrosis E. Baker's cyst

E. Baker's cyst.

You are examining hardcopy of a TCD exam. One printout shows a spectral waveform labeled "suboccipital window" and the depth is indicated to be 90mm. This is most likely the: A. ACA B. PCA C. MCA D. vertebral artery E. basilar artery

E. Basilar artery.

The "kissing stent" angioplasty/stent technique is useful for: A. renal arteries B. the adductor canal region C. total occlusions D. infrarenal arteries only E. bifurcations

E. Bifurcations. Explanation: This is a method of deploying balloon angioplasty and arranging stents at bifurcations, avoiding occlusion of one branch while dilating the other. The technique can be used anywhere, including coronary arteries.

The name for the type of graft described in the previous question is: A. Budd-Chiari B. Swan-Ganz C. McNeil-Lehrer D. PTFE E. Cimino-Brescia

E. Cimino-Brescia. Explanation: The flow rates in this type of dialysis fistula are expected to be somewhat lower than those in a PTFE (synthetic) graft.

Patients being evaluated for portal hypertension may have liver-dysfunction symptoms including all of the following EXCEPT: A. jaundice B. clotting abnormalities C. malnutrition D. ascites E. claudication

E. Claudication. Explanation: The others are all possible manifestations of hepatic dysfunction.

The condition which typically shows up on angiography as a "string of beads" is: A. diabetes mellitus B. Raynaud's syndrome C. Takayasu's arteritis D. polyarteritis nodosa E. fibromuscular dysplasia

E. Fibromuscular dysplasia.

In using continuous-wave Doppler with spectral analysis to assess the internal carotid artery, which of the following operator-induced errors would most likely result in a falsely LOW frequency shift? A. overdriving the Doppler signal gain B. allowing the signal beam to overlap both an artery and a vein C. changing to a higher-frequency transducer D. leaving the wall filter on E. increasing the beam angle to 70 degrees

E. Increasing the beam angle to 70 degrees. Explanation: This would create a lower frequency shift than the proper 60 degree angle (Doppler equation again). The other choices would more likely increase, not decrease, the frequency shift.

A left arm blood pressure that is 40mmHg lower than the right can be the result of any of the following EXCEPT: A. thoracic outlet syndrome B. subclavian steal C. coarcation of the aortic arch D. axillary artery embolus E. innominate artery occlusion

E. Innominate artery occlusion Explanation: If the innominate were involved, it would lower pressure on the right, not the left. The other answer choices are at least dimly possible, if not always likely.

An occlusive disease of medium and small arteries in the distal upper and lower limbs of primarily young male heavy smokers is: A. Raynaud's syndrome B. Thromboangitis obliterans C. atherosclerosis obliterans D. periarteritis nodosa E. hyperlipoproteinemia

B. Thromboangitis obliterans. Explanation: Thromboangitis obliterans, also known as Buerger's disease, is usually seen in young males with a pronounced addiction to cigarette smoking. As legend has it, this addiction is so severe that patients with stumps for hands may continue to smoke.

The prominence of the larynx is formed by the: A. hyoid bone B. thyroid cartilage C. cricoid cartilage D. thyroid gland E. greater cornu

B. Thyroid cartilage. Explanation: The thyroid cartilage forms a prominence that is especially visible in tall, thin, socially awkward males.

A radioisotope test for pulmonary embolism that involves both breathing and injection of the isotope, and is usually reported in "high, medium, or low probability" of pulmonary embolus, is called: A. IVC opacification testing B. V/Q scan C. Swan-Ganz catheterization D. arterial blood gasses E. pulmonary function testing

B. V/Q scan.

The blood supply to vascular tissue is provided by: A. media perforators B. vasa vasorum C. osmosis across the intima only D. septal capillary networks E. tunica vasum

B. Vasa vasorum. Explanation: Vasa vasorum is Latin for "vessels-vessels" --i.e., vasculature to perfuse the tissue of the vasculature.

Lower extremity ulcers are not overwhelmingly the result of: A. arterial disease B. venous disease C. lymphatic disease D. cardiac disease and chronic right-heart congestion E. hyperlipidemia

B. Venous disease.

Compared to patency rates in the iliac arteries, patency rates for angioplasty of the infrainguinal arteries are: A. better B. worse C. approximately equal D. angioplasty is not performed on infrainguinal arteries E. angioplasty is not performed on iliac or infrainguinal arteries

B. Worse. Explanation: Patency results of femoral and popliteal angioplasty have been consistently poorer than those in the iliac arteries.

A correlation of a noninvasive test to its gold standard yields a sensitivity of 93%. Which of the following statements regarding the specificity is correct? A. it must be greater than the sensitivity B. it must be less than the sensitivity C. it must be equal to the sensitivity D. it must be within 10 to 15% of the sensitivity E. it must be a value from 0 to 100%

E. It must be a value from 0 to 100%. Explanation: The sensitivity and specificity are mathematically unrelated. The two calculations utilize all the data points in the series, but no single data point is used in both; that is, the two groups are mutually exclusive. Thus, for a value of sensitivity, the specificity can be any value.

A decreased pulse at mid neck is suggestive of: A. carotid aneurysm B. common carotid stenosis if the contralateral pulse is normal C. common carotid stenosis if the contralateral pulse is decreased D. internal carotid stenosis if the contralateral pulse is normal E. internal carotid stenosis if the contralateral pulse is also decreased

B. common carotid stenosis if the contralateral pulse is normal. Explanation: Sometimes, however, the right neck pulse can feel reduced because of the larger muscles overlying the carotid.

The patient in the previous question is right-handed. Which area of circulation is suspect? A. right hemisphere B. left hemisphere C. occipital cortex D. vertebrobasilar territory E. brainstem circulation

B. left hemisphere. Explanation: the speech area of the cortex is in the temporal lobe of the dominant hemisphere.

A TIA of the right anterior hemisphere of the brain will likely affect: A. the entire body B. the left side of the body C. the right side of the body D. the right side of the face E. the back of the head

B. the left side of the body.

Which of the following is a vertebrobasilar symptom? A. aphasia B. vertigo C. amaurosis fugax D. right anterior hemisphere TIA E. unilateral paresis

B. vertigo. Explanation: bilateral or global symptoms are more likely to be from the vertebrobasilar system.

A patient with pulmonary embolus might have any of these EXCEPT: A. chest pain B. reduced arterial blood gasses C. diaphoresis D. shortness of breath E. rest pain

E. Rest pain. Explanation: Rest pain is a chronic arterial symptom. The others are symptoms of pulmonary embolism, many of which are quite similar to symptoms of myocardial infarction.

Virchow's triad includes: A. aging, cancer, and bed rest B. stasis, increased thrombogenesis, and aging C. stasis, aging, and venous injury D. aging, hypercoagulability, and intimal injury E. stasis, hypercoagulability, and intimal injury

E. Stasis, hypercoagulability, and intimal injury. Explanation: The other answers refer either to later thrombotic stages or to atherosclerosis.

Which of the following describes what is seen on the left lower extremity of patient "Bob"? A. aortoiliac obstruction B. iliac obstruction C. femoral obstruction D. tibial obstruction E. within normal limits

E. Within normal limits. Explanation: This side is fine: multiphasic waveforms throughout, and all indices >1.00.

Which of these conditions is LEAST likely to cause a bruit in the neck? A. severe stenosis of the internal carotid artery B. severe stenosis of the external carotid artery C. hyperdynamic carotid flows D. cardiac valvular disease E. critical preocclusive stenosis of the internal carotid artery

E. critical preocclusive stenosis of the internal carotid artery. Explanation: bruits in the neck often disappear when the stenosis is very high-grade or preocclusive.

Which of the following is an anterior circulation symptom? A. ataxia B. drop attack C. syncope D. binocular visual disturbance E. facial assymetry

E. facial assymetry. Explanation: dizziness, ataxia, or other bilateral/global symptoms (such as bilateral concurrent vision loss) come from the vertebrobasilar system. Facial asymmetry (i.e., lateralizing weakness) is a carotid-territory symptom.

A stronger pulse is palpated in the right neck than on the left. This could result from all of the following EXCEPT: A. tortuous CCA B. carotid aneurysm on the right C. tech error D. left carotid obstruction E. innominate occlusion

E. innominate occlusion. Explanation: innominate occlusion would expected to make the right carotid pulse weaker, not stronger.

The most prevalent type of stroke is: A. aneurysmal B. hemorrhagic C. septic embolic D. venous thrombotic E. ischemic

E. ischemic Explanation: Approximately 85% of strokes are ischemic in nature; only 15% of strokes are caused by intracerebral hemorrhage. Strokes caused by hemorrhage, however, account for most stroke fatalities.

Dysphagia is a: A. hormone imbalance causing loss of appetite B. psychological, not physiological, problem C. left-hemisphere symptom (if patient is right-handed) D. right-hemisphere symptom (if patient is left-handed) E. symptom associated with vertebrobasilar insufficiency

E. symptom associated with vertebrobasilar insufficiency. Explanation: dysphagia (with a "g") is difficulty with swallowing

The arrow in the same angiogram is pointing to: A. the ACA B. the PCA C. the ophthlamic artery D. the ECA E. the ICA

E. the ICA. Explanation: That's the carotid siphon, where the distal ICA turns anterior, then posterior, just before it bifurcates into MCA and ACA. The ophthalmic artery does not come off the siphon, but the arrow isn't pointing to it.

In this cross section, which letter represents the fibula? A B C D E

C.

Match the symptoms with the likely ankle/arm index: 1. claudication 2. rest pain a. ABI >1.30 B. ABI between 1.00 and 1.30 C. ABI between 0.5 and 0.80 D. ABI <0.5 A. 1-b and 2-c B. 1-b and 2-d C. 1-c and 2-d D. 1-c and 2-a E. 1-a and 2-d

C. 1-c and 2-d. Explanation: Claudication usually occurs with indices between 0.50 and 0.80, and rest pain with indices less than 0.50 (often less than 0.20).

This angiogram demonstrates: A. abdominal aortic aneurysm with mural thrombus B. abdominal aortic aneurysm occlusion with multiple collaterals C. abdominal aortic stenosis D. SMA occlusion E. double left renal arteries

C. Abdominal aortic stenosis. Explanation: The waviness along the narrowed walls shows moderate diffuse aortic atheroma.

A common manifestation of portal hypertension is: A. claudication B. vasculogenic impotence C. bleeding esophageal varices D. homonymous hemianopia E. clubbing of digits

C. Bleeding esophageal varices. Explanation: This results from abnormally high venous pressures due to cirrhosis or other liver disorders. As noted elsewhere, esophageal hemorrage is often lethal.

The smallest vessels in the body are: A. arterioles B. venules C. capillaries D. intimas E. adventitias

C. Capillaries.

The examiner scans the femoral veins and notes a very small venous lumen, with bright, thickened venous walls along most of the thigh. These findings suggest: A. acute DVT B. AV fistula C. chronic thrombosis D. congenitally hypoplastic veins E. arterial, not venous, insufficiency

C. Chronic thrombosis. Explanation: The bright walls with a small recanalized lumen suggest an older episode.

Early atherosclerosis of the lower extremities will be associated with: A. rest pain B. blue toe C. claudication D. pregangrene E. swelling

C. Claudication. Explanation: All of the rest of the symptoms generally come with acute or late chronic occlusive changes (except for swelling, which often accompanies venous thrombosis).

At the inguinal ligament, the external iliac artery becomes the: A. internal iliac artery B. profunda femoral artery C. common femoral artery D. superficial femoral artery E. common iliac artery

C. Common femoral artery

What information CANNOT be determined by cerebrovascular angiography? A. degree of narrowing of ICA by diameter B. presence of ulceration C. degree of narrowing of ICA by cross-sectional area D. total occlusion of ICA E. crossover collateralization from the contralateral hemisphere

C. Degree of narrowing of ICA by cross-sectional area. Explanation: Angiograms are longitudinal pictures of vessels; they cannot provide cross-sectional information.

This vessel courses along the medial aspect of the psoas muscle: A. femoral artery B. internal iliac artery C. external iliac artery D. inferior mesenteric artery E. none of the above

C. External iliac artery

Computed tomography is useful in the lower extremities primarily for detection of: A. arterial occlusion B. venous thrombosis C. femoral or popliteal aneurysm D. arteriovenous malformation E. esophageal varices

C. Femoral or popliteal aneurysm. Explanation: Answers A, B, and D are possible, but other modalities are more accurate and/or more cost-effective for these problems. Esophageal varices do not occur in the lower extremities.

The combination of neuropathy and peripherally distributed atherosclerosis makes the diabetic patient especially vulnerable to: A. aortoiliac disease B. poploiteal entrapment syndrome C. foot lesions D. abdominal aortic aneurysms E. renal artery lesions

C. Foot lesions. Explanation: Foot lesions are often found in diabetic patients with peripheral neuropathy (with or without peripheral atherosclerosis).

Which vessel would be imaged in a patient referred to rule out Budd-Chiari syndrome? A. innominate vein B. internal jugular vein C. hepatic vein D. common femoral vein E. circumflex vein

C. Hepatic vein. Explanation: This condition results from acute obstruction of the hepatic vein.

Systolic thigh pressures could be accurately measured with standard (12cm wide) arm cuffs: A. in all patients B. in patients with large thighs C. in patients with similar thigh and arm diameters D. in all patients without arterial incompressibility E. in no patients

C. In patients with similar thigh and arm diameters. Explanation: Accurate measurement of blood pressure requires a cuff that is 1.2 times the limb diameter. If the arm cuff were 1.2 times the arm and thigh diameter, then it would work for both. The usual situation is use of the four-cuff method, with the high-thigh cuff being narrower than the 1.2 rule for all but the most slender limbs. This almost always leads to some degree of cuff artifact, which we live in our interpretations.

Temporal arteritis is commonly characterized by: A. dissection B. aneurysm C. intimal thickening D. tortuosity E. ectasia

C. Intimal thickening. Explanation: Temporal arteritis causes marked thickening of the intima. It may be localized, focal, or widespread. Patients tend to present with severe headache. Other symptoms may include scalp tenderness, visual disturbance, joint pain, and painful chewing. Blindness can occur as a result of ischemic optic neuropathy in fewer than 20% of patients.

Contrast venography is: A. dangerous B. not sensitive C. invasive D. not specific E. not indicated when DVT is clinically suspected

C. Invasive. Explanation: Contrast venography is a very sensitive and specific test, which has some hazard. It may be considered as a diagnostic tool in a patient with suspected deep venous thrombosis, especially in the event of equivocal noninvasive studies. Its major drawback is that it is invasive.

While performing an abdominal ultrasound on a kidney transplant, you find that the renal artery and vein are patent, but the arteries of the transplanted kidney do not have diastolic flow. Which statement is true? A. lack of systolic flow is normal for the kidney B. lack of diastolic flow is normal for the transplanted kidney C. lack of diastolic flow is abnormal for the transplanted kidney D. lack of diastolic flow is to be expected in the immediate post-transplantation period E. diastolic flow does not provide useful information in the study of kidneys

C. Lack of diastolic flow is abnormal for the transplanted kidney. Explanation: Absence of diastolic flow in the transplanted kidney suggests rejection. Other causes of failure, such as ischemic cytosporine injury, may be shown by increased resistance.

Distal to an aortoiliac occlusion, the common femoral artery signal is typically: A. multiphasic B. biphasic C. low-pitched and monophasic D. impossible to distinguish from a pulsatile venous signal E. high-pitched

C. Low-pitched and monophasic. Explanation: Any arterial signal distal to a total occlusion represents flow via collaterals; much of the original energy is damped out, although the degree of damping varies with the quality of the collaterals.

In the patient from the previous question, you would expect arm pressures to be: A. normal B. lower on the right C. lower on the left D. reduced compared to lower-extremity pressures E. immeasurable

C. Lower on the left. Explanation: You would expect lower pressure on the left due to the left subclavian obstruction.

Using the temporal window for TCD, you find a strong signal with considerable diastolic flow at a depth of 50mm. This is most likely: A. ACA B. PCA C. MCA D. vertebral artery E. basilar artery

C. MCA.

Diastolic flow reversal: A. is always present in all abnormal limbs B. is always present in vasodilated limbs C. may be absent in vasodilated limbs D. is absent in vasoconstricted limbs E. none of the above

C. May be absent in vasodilated limbs. Explanation: Vasodilated limbs have low distal resistance ad exhibit the reduction or absence of diastolic flow reversal.

In the presence of tibial arterial calcification in the diabetic patient, the ankle/arm index: A. is reliable unless immeasurable because of arterial incompressibility B. cannot be in the normal range C. may be in the normal range or abnormally decreased, yet falsely elevated D. is always nondiagnostic E. may be in the abnormal range yet falsely reduced

C. May be in the normal range or abnormally decreased, yet falsely elevated. Explanation: Ankle/arm indices in the presence of calcification may indicate the presence of disease or no disease. In either state the pressures may be artificially elevated because of the calcification making the vessels harder to compress. Any pressure taken in a diabetic patient should be analyzed with suspicion.

You are performing a Doppler exam on a patient with suspected renovascular hypertension. Which diagnostic parameter is the best indicator of renovascular disease? A. pulsatility index B. A/B ratio C. renal/aortic ratio D. systolic/diastolic ratio E. none of the above

C. Renal/aortic ratio. Explanation: Renovascular hypertension is caused by renal artery stenosis. Stenosis of the renal artery can be determined by obtaining a renal/aortic ratio (RAR). This is a ratio of the highest velocity obtained in the renal artery to the normal velocity of the aorta obtained at the level of the renal artery origins. A ratio of > or equal to 3.5 is considered by most to indicate a significant renal artery stenosis. This would mean that the velocity in the renal artery is 3.5 times faster than the velocity in the aorta.

Noninvasive diagnosis of renal artery stenosis: A. can be made by B-mode images of atherosclerotic plaque B. cannot be made since the renal arteries are too deep for ultrasound penetration C. requires a duplex system with spectral signal analysis D. can be accomplished with a non-Duplex Doppler system E. requires spiral CT technology

C. Requires a duplex system with spectral signal analysis. Explanation: Low-frequency ultrasound probes can image structures in the retroperitoneal space, but their images are not of sufficient quality to demonstrate plaque; the only studies utilized for this type of assessment have been with a Doppler. However, an imaging system is critical to assure that the correct vessel is being sampled.

All of the following are consistent with total occlusion of the internal carotid artery EXCEPT the: A. absence of flow in the ICA lumen B. decreased velocity proximal to occlusion C. retrograde flow in the distal internal carotid artery D. increase in flow through collateral pathways E. inability to be reconstructed surgically

C. Retrograde flow in the distal ICA. Explanation: While the flow in the segment of the carotid artery distal to a new total occlusion conceivably could have eddy currents, it could not have purely retrograde flow. An important fact to remember is that, with rare exceptions, occluded internal carotid arteries may not be reconstructed by surgical means.

Two of the major branches of the external carotid arteries include the: A. supraorbital and frontal arteries B. internal maxillary and ophthalmic arteries C. superficial temporal and facial arteries D. vertebral and internal maxillary arteries E. supraorbital and middle cerebral arteries

C. Superficial temporal and facial arteries. Explanation: The supraorbital, frontal, and ophthalmic arteries are all fed by the internal carotid. The vertebral artery is part of the posterior circulation.

The artery pulsations felt in front of the ear and just above the zygomatic arch are from which artery? A. maxillary B. transverse facial C. superficial temporal D. facial E. occipital

C. Superficial temporal. Explanation: The superficial temporal artery is the terminal branch off the external carotid.

The disease/syndrome associated with compression of subclavian artery and brachial plexus by the cervical rib is: A. subclavian steal syndrome B. cervical spine disease C. TOS D. causalgia E. vertebral stenosis

C. TOS.

The area in the lower extremity where it is usually most difficult to bring about vein-wall coaptation with probe compression is: A. the saphenofemoral junction B. the mid thigh C. the distal thigh D. the popliteal space E. the mid calf

C. The distal thigh. Explanation: This level, with its taut distal adductor muscles, is difficult to compress with the probe, but it need not be a problem. Some technologists scan more anteriorly, to use the quadriceps muscle as an acoustic window, and compress with the non-probe hand behind the thigh. Works well and doesn't hurt the patient.

In a cross section of the aorta and surrounding regions, the vein that is visualized superficial to the aorta and the origins of the right and left renal arteries and deep to the superior mesenteric artery is the: A. superior mesenteric vein B. right renal vein C. left renal vein D. inferior mesenteric vein E. celiac vein

C. The left renal vein. Explanation: The left renal vein travels anterior to the aorta to reach across to the inferior vena cava.

The arrow is pointing to: A. the superficial temporary artery B. the facial artery C. the superior thyroid artery D. the angular artery E. the vertebral artery

C. The superior thyroid artery. Explanation: It's the first branch off the ECA, coming off near the origin and heading south.

The image in Color Plate 4 is from the carotid bifurcation, with the distal CCA just visible at the right of the color box. The superficial branch is the ICA. Which of the following is TRUE? A. the flow in the superficial branch is retrograde B. the flow in the deeper branch is retrograde C. the vertical segment is the ICA D. the vertical segment is the ECA E. A and C

C. The vertical segment is the ICA.

The TCD window used for assessing the ophthalmic artery and the carotid siphon is: A. temporal B. suboccipital C. orbital D. submandibular E. nasal

C. Orbital.

Atherosclerosis is a disease that begins in the: A. adventitia B. intima C. transverse fibers D. inner media E. outer media

B. intima Explanation: The intimal lining of endothelial cells becomes disrupted in the first stage of the atherosclerotic process.

In this cross section of the calf, which letter represents the posterior tibial vessels? A B C D E

E.

Cerebrovascular fibromuscular dysplasia occurs in: A. males B. females C. australians D. infants E. hypoglycemics

B. Females

The strongest risk factor for stroke is: A. poor diet B. obesity C. hypertension D. hypocholesterolemia E. alcohol abuse

C. Hypertension.

A venule contains which vessel layers? A. tunica adventitia, tunica media, and tunica intima B. tunica adventitia and tunica media C. tunica adventitia and tunica media D. tunica media and tunica intima E. tunica media and tunica adventitia

C. Tunica adventitia and tunica intima.

If a hypertensive patient has experienced multiple TIAs and has an 80% diameter stenosis of the ICA on the side referable to the symptoms: A. carotid endarterectomy is probably recommended B. treatment of hypertension must be initiated immediately C. diabetes must be diagnosed D. renal artery stenosis should be treated first E. hypertension is not a significant risk factor in the development of carotid occlusive disease

A. Carotid endarterectomy is probably recommended. Explanation: The symptomatology of a patient with any stenosis of the internal carotid artery makes it likely that endarterectomy will be recommended. Treatment of hypertension is usually a good idea, but is not the primary urgent issue here.

Which disorder is most likely the cause of the condition in the preceding image? A. cellulitis B. chronic arterial obstruction C. acute deep vein thrombosis D. acute arterial occlusion E. trauma

A. Cellulitis. Explanation: The edema is unlikely to result from either chronic or acute arterial obstruction. Acute DVT and trauma are also unlikely to look like this, as acute edema tends to be more diffuse, without these discrete spaces of collected fluid.

The upper extremity vein most commonly used for an arterial bypass in the leg is the: A. cephalic vein B. basilic vein C. brachial vein D. axillary vein E. radial vein

A. Cephalic vein. Explanation: The cephalic and basilic veins are the upper extremity veins most commonly used for arterial bypasses. The cephalic vein is used most often.

While mapping the saphenous vein in a patient scheduled for coronary artery bypass operation, you discover that the saphenous veins are not adequate for harvesting. Which of the following veins would be best to evaluate as an alternate graft? A. cephalic vein B. deep femoral vein C. popliteal vein D. axillary vein E. B, C, or D

A. Cephalic vein. Explanation: The lesser saphenous, cephalic, and/or basilic veins may be mapped as possible conduits for bypass surgery when the saphenous vein is too small, diseased, or absent. Deep veins such as the deep femoral, popliteal, or axillary are not used.

Parameters usually assessed in exercise testing include all EXCEPT: A. changes in thigh-to-ankle index B. time required for recovery to pre-stress pressure level C. patient complaint of leg pain during exercise D. length of time of exercise E. magnitude of pressure drop

A. Changes in thigh-to-ankle index. Explanation: Thigh-to-ankle index is not a diagnostic parameter in exercise testing.

The vascular technologist knows that chronic venous insufficiency and ulceration are: A. chronic but controllable B. curable and controllable C. chronic and uncontrollable D. uncontrollable only E. always severely disabling

A. Chronic but controllable. Explanation: Although it should be noted that some surgeons are replacing venous valves to "cure" venous incompetency, this is not yet standard treatment. It is difficult but possible to control the symptoms.

In the preceding question, which disorder would necessitate TIPS? A. cirrhosis B. multiple episodes of pulmonary embolus C. splenomegaly D. diabetes E. myocardial infarction

A. Cirrhosis. Explanation: The most common cause of portal hypertension in the industrialized western world is cirrhosis. The TIPS helps to relieve the excess pressure.

The most common arterial puncture site for all forms of angiography (including cerebral) is the: A. common femoral artery B. brachial artery C. axillary artery D. dorsal artery E. it depends on the area of the body being studied

A. Common femoral artery.

The venous puncture for introducing contrast in venography to assess for valvular insufficiency is done at what level? A. common femoral vein B. contrast is not used for insufficiency testing C. popliteal vein D. dorsal vein on the foot E. internal jugular vein, to avoid influencing lower extremity hemodynamics

A. Common femoral vein.

An analog Doppler waveform of the subclavian or axillary artery in a normal individual would typically resemble: A. a common carotid artery waveform B. a vertebral artery waveform C. a common femoral or superficial femoral artery waveform D. none of the above E. a renal artery waveform

C. A common femoral or superficial femoral artery waveform. Explanation: The upper extremity is a high-resistance system similar to the legs. Although flow reversal is usually not as dramatic as in the lower extremities, there will be the same type of Doppler waveform as in other high-resistance beds.

Doppler examination alone, without B-mode, is unlikely to detect the presence of venous thrombosis in: A. the femoral vein B. the subclavian vein C. a peroneal vein D. the popliteal vein E. the common femoral vein

C. A peroneal vein. Explanation: Since the calf veins are paired, CW flow signals may continue to sound normal in one branch even if the other branch is thrombosed. Additionally, peroneal veins are seldom assessed with handheld CW Doppler.

The key technology in arterial pneumoplethysmography is: A. two pairs of electrode bands monitoring impedance changes in a limb segment B. two photocells monitoring subcutaneous color changes C. a pressure transducer monitoring cuff pressure over a limb D. a silastic tube filled with mercury that changes resistance with changes of limb circumference E. a large air cuff enclosing the entire calf

C. A pressure transducer monitoring cuff pressure over a limb. Explanation: The electrode bands are used in impedance plethysmography, the photocells are used in photoplethysmography, the mercury-filled silastic tube is used in strain-gauge plethysmography, and the big air cuff is used in APG (air plethysmography, the modality designed specifically for testing of chronic venous insufficiency.)

A pulsatile mass in the groin after catheterization of a cardiac patient most likely will be: A. a femoral artery aneurysm B. a hematoma C. a pseudoaneurysm of the femoral artery D. a false aneurysm of the femoral vein E. an arteriovenous fistula

C. A pseudoaneurysm of the femoral artery. Explanation: Femoral artery pseudoaneurysms are often found after catheterization. Hematomas after cardiac catheterization are also frequent but usually do not pulsate.

A long, brightly-echogenic streak is noted in the common femoral vein, which is otherwise patent and compressible. It moves with probe compression and appears to move with venous flow. This is most likely: A. an artifact due to excessive imaging gain and reverberation B. a valve leaflet C. a remnant of recanalized old DVT D. acute thrombosis in evolution E. embolic material from an aneurysmal popliteal vein

C. A remnant of recanalized old DVT. Explanation: This is a fairly common finding in patients with a history of deep venous thrombosis.

The primary concern in patients with acute deep venous thrombosis is: A. damage to venous valves may occur B. pulmonary embolism may occur C. venous hypertension may occlude arterial inflow D. extension of deep vein thrombus may occlude the superficial veins E. deep venous thrombosis causes the patient severe pain

B. Pulmonary embolism may occur. Explanation: While damage to deep venous valves and pain are concerns with patients exhibiting acute deep venous thrombosis, the most severe manifestation and the biggest fear is that of pulmonary embolism. Pulmonary embolism is an extremely severe sequela of deep venous thrombosis.

The great vessels arising from the aortic arch include all of the following EXCEPT the: A. innominate artery B. right subclavian artery C. left common carotid artery D. left subclavian artery E. all arise from the aortic arch

B. RIght subclavian artery Explanation: The right subclavian artery arises from the innominate artery (brachiocephalic trunk). Obviously this question assumes normal anatomy; there are frequent variants with the brachiocephalic arteries.

Arteriography would be contraindicated or approached very cautiously in a patient with: A. diabetes mellitus B. renal failure C. cancer D. peripheral vascular disease E. mad cow disease

B. Renal failure. Explanation: Contrast can cause severe complications in patients with compromised renal function. To be sure, diabetic patients might fall into this category (answer A), but B is the best answer.

A patient presents with a swollen right lower extremity. Duplex imaging demonstrates patency of the femoral, popliteal, and calf veins. However, Doppler at the common femoral level on the right is continuous, not changing with respiration, while Doppler on the left common femoral vein is phasic. These findings might suggest: A. thrombosis of the profunda femoris vein B. right iliac thrombosis C. left iliac thrombosis D. vena cava thrombosis E. this is not a diagnostically useful finding

B. Right iliac thrombosis. Explanation: If respiratory pressure changes are not transmitted to the lower extremity venous signals, the technologist should be suspicious of proximal obstruction.

Varices resulting from deep-venous valvular insufficiency and incompetent perforators are called: A. primary varices B. secondary varices C. congenital varices D. genicular veins E. spider veins

B. Secondary varices. Explanation: As noted above, secondary varices result from chronic excessive intravenous pressure transmitted from the incompetent deep system.

Little or no increase of blood flow velocity in response to postocclusive reactive hyperemia (PORH), using an inflated thigh cuff, would most likely indicate: A. an adequate, well-developed collateral bed B. significant obstructive disease C. small vessel disease in the foot D. a normal arterial segment E. venous reconstitution

B. Significant obstructive disease. Explanation: A normal PORH response is a major velocity increase; see the next question.

The intermal mammary artery is a branch of the: A. innominate artery B. subclavian artery C. vertebral artery D. axillary artery E. aorta

B. Subclavian artery.

Normal Doppler waveform morphology for a peripheral artery includes: A. phasicity with respiration B. augmentation with distal compression maneuver C. a sharp upslope and downslope and a prominent reverse flow component D. a delayed systolic peak with a downslope bowed away from the baseline E. a rounded, extended acceleration with no diastolic wave

C. A sharp upslope and downslope and a prominent reverse flow component. Explanation: Answer choices A and B are characteristics of venous flow. Answer choice D refers to an abnormal volume recording. Answer choice E is just plain abnormal.

A normal ankle-pressure response to reactive hyperemia is: A. a gradual decrease of approximately 50% B. a quick, transient drop of greater than 50% C. a transient decrease of approximately 20% D. a transient increase of approximately 50% E. a gradual increase of approximately 50%

C. A transient decrease of approximately 20%. Explanation: This decrease is normally quite brief and may not be registered unless pressures are taken immediately on thigh-cuff deflation. Pellerito says the response may range from 20% to 30%. Quiz question

Delayed return of the capillary blush after pressure on the pulp of the digit is a sign of: A. thoracic outlet syndrome B. venous occlusive disease C. advanced ischemia D. hyperlipidemia E. hypercholesterolemia

C. Advanced ischemia. Explanation: Capillary blush usually is seen after 1-2 seconds. In patients with significant ischemia, it may be delayed for many seconds.

Doppler waveform abnormalities in the lower extremity arterial circulation distal to a hemodynamically significant stenosis include: A. increased peak-to-peak amplitude B. the presence of a dicrotic notch on the downslope C. an absent flow reversal component, blunting of the peak velocity, and prolonged upslope and downslope D. absent Doppler signal E. a triphasic waveform

C. An absent flow reversal component, blunting of the peak velocity, are prolonged upslope and downslope. Explanation: Doppler waveforms distal to a significant stenosis reflect to some degree the loss of energy caused by the stenosis. It has been said that a stenosis acts as a low-pass filter; that is, it tends to filter out the high-frequency changes in the waveform, such as the dicrotic notch.

Normal arterial waveforms in the renal hilum: A. are phasic with respiration B. are high-resistance in character (little diastolic flow) C. are low-resistance in character (much diastolic flow) D. cannot be obtained with duplex instrumentation E. cycle with right-atrial activity

C. Are low-resistance in character (much diastolic flow).

The proximal common femoral artery has high diastolic flow but the distal common femoral artery has a significantly increased reverse flow. The noninvasive study was performed after cardiac catheterization. The likely cause of these findings is: A. pseudoaneurysm that can be compressed with the probe B. pseudoaneurysm that is too large to be compressed by the probe C. arteriovenous fistula D. superficial femoral occlusion E. distal vasodilatation

C. Arteriovenous fistula. Explanation: The abrupt change of flow character, and the high diastolic flow in the proximal segment, suggest an AV fistula creating a localized low-resistance pathway.

A disease that affects primarily the intima and may extend into the media is: A. Buerger's disease B. aneurysmal disease C. atherosclerosis D. Takayasu's disease E. diabetes

C. Atherosclerosis.

The vertebral arteries branch from the subclavian arteries to unite and form the: A. ophthalmic artery B. anterior cerebral artery C. basilar artery D. superficial temporal artery E. posterior communicating artery

C. Basilar artery. Explanation: This system is called the vertebrobasilar system and is responsible for the circulation to the posterior portion of the brain.

Evaluation of an abdominal aortic aneurysm is facilitated if the study is done: A. after lunch but before dinner B. after breakfast but before lunch C. before breakfast D. after dinner E. this study does not depend on patient preparation

C. Before breakfast. Explanation: Patients for AAA or SMA evaluation should be tested first thing in the morning if possible and NPO (nothing by mouth) past midnight to minimize shadowing due to bowel gas.

Where are carotid body tumors located? A. medial to the origin of the external carotid artery B. within the internal jugular vein C. between the internal and external carotid arteries D. in the submandibular gland E. in the intracranial internal carotid artery

C. Between the internal and external carotid arteries.

A normal spectral waveform from the hepatic veins is: A. continuous B. unidirectional C. bidirectional D. triphasic E. A and B

C. Bidirectional. Explanation: This is the result of this vessel's proximity to the right atrium; it reflects right atrial pressure changes.

The NASCET trial indicated that the best treatment for carotid stenosis in the symptomatic patient is: A. aspirin for stenosis greater than 70% in diameter B. aspirin for stenosis greater than 70% in area C. carotid endarterectomy for stenosis greater than 70% in diameter D. carotid endarterectomy for stenosis greater than 70% in area E. warfarin for stenosis less than 70% in diameterr

C. Carotid endarterectomy for stenosis greater than 70% in diameter. Explanation: Carotid surgery is recommended for symptomatic patients in this trial.

A patient presents with acute pronounced bright red discoloration and edema of the skin along the anterior calf. The most likely diagnosis is: A. superficial thrombophlebitis B. deep vein thrombosis C. cellulitis D. chronic venous insufficiency E. incompetent perforating veins

C. Cellulitis. Explanation: Cellulitis--inflammation of skin and deeper tissues caused by an infectious process--is one of the common differential diagnoses for deep venous thrombosis.

Brawny skin changes at the ankle most likely represent: A. acute valvular insufficiency B. acute deep venous thrombosis C. chronic venous insufficiency D. acute arterial ischemia E. chronic arterial ischemia

C. Chronic venous insufficiency. Explanation: Brawny (toughened and swollen) changes almost always indicate venous insufficiency.

This image is at the popliteal level and suggests: A. calcific plaque creating arterial occlusion B. acute deep vein thrombosis C. chronic venous thrombosis D. Baker's cyst E. valve leaflets in the popliteal vein

C. Chronic venous thrombosis. Explanation: The structure designated with the cursors is a bright, streaky echo seen frequently in patients with a history of DVT. It represents old, mostly recanalized thrombus that has become organized and dense, creating this bright echo, which will have flow on both sides with color flow.

Pulsatile lower extremity venous Doppler signals would be associated with: A. deep vein thrombosis B. acute arterial occlusion C. congestive heart failure D. severe superficial vein valvular insufficiency E. CVA

C. Congestive heart failure. Explanation: Anything that increases overall venous pressure, like congestive heart failure, can bring about pulsatility of the venous Doppler signals in the lower extremities.

The following are all possible complications of heparin EXCEPT: A. thrombocytopenia B. formation of antiplatelet antibody C. decreased activated partial thromboplastin time D. intraabdominal bleeding E. increased bruising

C. Decreased activated partial thromboplastin time. Explanation: This would be expected to increase, and in any case the increase isn't a complication but a desired result for therapy.

Which of the following is NOT a common feature of renal allograft rejection? A. increased allograft size B. increased cortical echogenicity C. decreased flow resistance in parenchymal arteries D. increased prominence of the renal pyramids E. all are common features of rejection

C. Decreased flow resistance in parenchymal arteries is NOT a common feature of renal allograft rejection. Explanation: In renal allograft rejection the flow resistance in the parenchymal arteries tends to increase. This will be manifested as a decrease in diastolic flow. Normal flow in the parenchymal arteries of a renal allograft is low-resistance with forward flow throughout the cardiac cycle. A decrease, absence, or reversal of flow in diastole is indicative of rejection.

In Color Plate 1 the tibioperoneal trunk artery is: A. demonstrating retrograde flow due to collateralization B. demonstrating aliasing, suggesting greatly increased velocities C. demonstrating antegrade flow D. demonstrating absence of flow due to occlusion E. not visible in this image

C. Demonstrating antegrade flow. Explanation: The tibioperoneal trunk is flowing just as it should; this was taken in a student in her twenties. It is blue instead of red because of the direction of flow relative to the color beam. Check the color assignment bar to the left: blue is toward, red is away from the beam.

Of the following vein segments, which is imaged LEAST commonly? A. distal femoral vein B. proximal deep femoral vein C. distal deep femoral vein D. distal popliteal vein E. common femoral vein

C. Distal deep femoral vein. Explanation: Because of its depth, the distal deep femoral vein is usually very difficult to image.

The Doppler diagnostic criterion that is most important for calling greater than 80% stenosis is: A. mean or time-average velocity B. peak-systolic velocity C. end-diastolic velocity D. minimum mid-diastolic average velocity E. percent window reduction

C. End-diastolic velocity. Explanation: This is the most widely used criterion, although of course no number all by itself should determine an interpretation. Some investigators have had success with velocity ratios.

Diastolic reversal of flow is most likely in: A. the renal arteries B. the internal carotid artery C. extremity arteries at rest D. extremity arteries immediately following exercise E. the vena cava

C. Extremity arteries at rest. Explanation: The renal and internal carotid arteries supply low-resistance vascular beds, which bring about increased forward flow during diastole. During exercise, peripheral resistance decreases, diminishing or eliminating diastolic reversal. Diastolic flow reversal is not a characteristic of venous flow.

Patients presenting with a diagnosis of ischemic rest pain may complain of: A. foot pain at night which occurs on an irregular basis B. tingling in the foot which is relieved by elevation C. foot pain while in a horizontal position, relieved by standing or dangling the foot in a dependent position D. a numbing weakness produced by standing E. pain in feet with walking which is relieved by rest

C. Foot pain while in a horizontal position, relieved by standing or dangling the foot in a dependent position. Explanation: Rest pain almost always occurs at night and is relieved by placing the leg in a dependent position or by exercise, which increases cardiac output and thereby blood flow to the periphery.

From this cross-sectional diagram of the thigh, reading from superficial to deep, identify the vessels marked: A. great saphenous vein, superficial femoral artery, profunda femoris artery B. femoral vein, common femoral vein, common femoral artery C. great saphenous vein, femoral vein, profunda femoris vein D. superficial femoral artery, common femoral artery, deep femoral artery E. great saphenous vein, superficial femoral artery, deep femoral vein

C. Great saphenous vein, femoral vein, profunda femoris vein.

A traumatic arteriovenous fistula produces: A. high diastolic arterial flow in the arteries distal to the fistula B. high, pulsatile venous flow in the veins distal to the fistula C. high, pulsatile venous flow in the veins proximal to the fistula D. low systolic flow in the arteries proximal to the fistula E. low, continuous flow in the veins proximal to the fistula

C. High, pulsatile venous flow in the veins proximal to the fistula. Explanation: The four components of an AV fistula are proximal artery, distal artery, proximal vein, distal vein--and then of course there is the fistula itself. Flow in the proximal artery becomes low-resistance in character, since the fistula and vein offer much less resistance than the usual vascular bed. Flow in the proximal vein increases and becomes somewhat pulsatile because of hte direct arterial inflow and higher volume.

Maneuvers used to assess the patient with possible thoracic outlet syndrome include all EXCEPT: A. hyperabduction of arms B. Adson maneuver C. Hobbs maneuver D. costoclavicular maneuver E. positioning to reproduce symptoms

C. Hobbs maneuver. Explanation: The other answer choices are maneuvers that may produce diminished or absent distal arterial flow as monitored by PPG, Doppler, etc. Unfortunately, these results may be obtained in many people without symptoms as well.

This image is from the carotid bifurcation. It demonstrates: A. widely patent arteries B. heterogenous plaque that appears to create moderate (<50%) stenosis C. homogeneous plaque that appears to create moderate (<50%) stenosis D. heterogeneous plaque that appears to create severe (>80%) stenosis E. homogeneous plaque that appears to create severe (>80%) stenosis

C. Homogeneous plaque that appears to create moderate (<50% stenosis). Explanation: This plaque is homogeneous in character; heterogeneous plaque would have mixed soft and bright echoes. It looks like a 40-50% stenosis in this view, certainly not >80%, but estimating stenosis in the longitudinal view can be dangerous.

In this same patient who has had four episodes of amaurosis fugax in the last week, the most likely course of action would be: A. restudy in six months B. restudy in one month C. immediate angiography D. immediate endarterectomy E. neurological consult

C. Immediate angiography. Explanation: These repeated TIAs call for action, assuming the patiemnt to be otherwise a reasonable surgical candidate. Since this stenosis falls into a somewhat borderline category, angiography would be the likely next step before going to the OR. Yes, the NASCET threshold is 70%, and ACAs is 60%, but it does not appear that surgeons are jumping to operate on patients with these thresholds of stenosis at this time.

Ankle/arm indices in claudicating patients are usually: A. not a useful test for this condition B. in the range of 1.0-1.5 C. in the range of 0.5-0.9 D. in the range of 0.1-0.3 E. artificially elevated

C. In the range of 0.5-0.9. Explanation: This is the traditional answer, but lots of patients with ABIs as low as 0.3 are still claudicators--that is, they have not reached the rest-pain stage.

Major complications of cerebrovascular angiography include all of the following EXCEPT: A. death B. stroke C. inadvertent venous puncture D. arterial occlusion at the access site E. renal failure

C. Inadvertent venous puncture. Explanation: Inadvertent venous puncture would not constitute a major complication; the others are much more severe outcomes.

The test on the aforementioned patient is repeated, this time with a tourniquet around the leg just below the knee. There is no appreciable change in the tracing. This finding: A. suggests superficial valvular incompetence only B. suggests deep venous valvular incompetence C. is equivocal D. rules out venous causes for the edema E. using a tourniquet is not part of the usual PPG reflux protocol

B. Suggests deep venous valvular incompetence. Explanation: The tourniquet eliminates the influence of the superficial system. Had the tracing reverted to normal with the tourniquet, the superficial system would then be implicated. In this case it is the deep veins--instead of or in addition to the superficial veins--that appear to be incompetent.

In a patient with intestinal ischemia, the cause might be revealed by a duplex scan finding of stenoses in the following arteries: A. right and left renal arteries B. SMA and IMA C. the splenic and MSA D. aorta and SMA E. aorta and IMA

B. Superior and inferior mesenteric artery. Explanation: In order for there to be intestinal ischemia, severe stenoses must be present in two of the three main supplying arteries (celiac, SMA, and IMA).

Doppler velocity waveforms from upper extremity vessels may vary slightly from lower extremity waveforms because: A. the upstroke is not as sharp B. the peripheral resistance is usually lower in the upper extremity C. the peripheral resistance is usually higher in the upper extremity D. there is never a diastolic flow reversal component at rest E. B and D

B. The peripheral resistance is usually lower in the upper extremity. Explanation: A brachial artery waveform without flow reversal is a common finding.

Which of these patients would LEAST likely be considered at high risk for deep venous thrombosis? A. a 62-year-old woman with a fractured hip B. A 36-year-old man with Hodgkin's disease C. A 75-year-old woman admitted for transient ischemic attack D. An 18-year-old male recovering from multiple injuries sustained in a motorcycle accident E. A 72-year-old, overweight woman with congestive heart failure

C. A 75-year-old woman admitted for transient ischemic attack. Explanation: Venous disease is not particularly prevalent in individuals admitted for carotid artery disease, though age is a risk factor. However, individuals with cancer, fractured hips, multiple injuries, CHF, and obesity are at greater risk for deep venous thrombosis.

Chronic venous insufficiency frequently leads to ulceration. The vascular technologist knows that the patient can help prevent ulceration by: A. elevating the legs above heart level more than 4 times a day for 20 minutes B. using support stockings when ambulatory C. A and B above D. chelation therapy E. taking aspirin

C. A and B above. Explanation: Elevation and surgical support hose both tend to decrease venous hypertension and therefore increase the chances for ulcer healing and decrease pain and other problems of chronic venous insufficiency.

Four hundred patients underwent noninvasive venous testing with subsequent venography. The noninvasive test and venographic results were compared. Of the 300 normal venograms, 15 were abnormal by noninvasive testing. Of the 100 abnormal venograms, 90 were abnormal by noninvasive testing. Overall accuracy is: A. 105/400 B. 105/300 C. 375/400 D. 295/300 E. 295/400

C. 375/400. Explanation: Of 400 total exams, 90 were true positives and 285 were true negatives. Accuracy equals all the agreements (positive and negative) divided by all the tests.

The incidence of new strokes per year is: A. 150,000 B. 250,000 C. 500,000 D. 1,000,000 E. 2,600,000

C. 500,000.

Because of the location of the inferior vena cava, the left renal vein: A. crosses anterior to the aorta, inferior to the left renal artery B. crosses posterior to the aorta, proximal to the renal artery C. crosses posterior to the aorta, distal to the renal artery D. does not cross the aorta E. is displaced superior to the origin of the celiac axis

A. Crosses anterior to the aorta inferior to the left renal artery. Explanation: The aorta is to the left of midline, while the vena cava is to the right. Thus, structures located in the left side of the abdomen must have their venous outflow across the aorta. The left renal vein is anterior to the aorta, usually just inferior to the level of the renal artery.

One complication of deep venous recanalization is: A. damage to venous valves, allowing reflux B. embolization of thrombus C. less prominent superficial veins D. pain in the area of thrombus E. thickening of toenails and loss of hair growth

A. Damage to venous valves, allowing reflux.

Transcutaneous partial pressure of oxygen (TcPO2) studies can be useful for all EXCEPT: A. determination of arterial level of obstruction B. determination of amputation level C. assessment of skin-graft viability D. assessment of foot perfusion E. assessment of healing of stump

A. Determination of arterial level of obstruction. Explanation: Like ankle/arm indices, TcPO2 can assess only at the site of measurement; it cannot localize the level of proximal obstruction.

Given the following information, overall accuracy can be: sensitivity=91.3% specificity=83.4% positive predictive value=94.3% negative predictive value=80.7% A. 78% B. 82% C. 85% D. 93% E. 96%

C. 85%. Explanation: Overall accuracy must fall between sensitivity and specificity and between positive predictive and negative predictive values. Answer choice C is the only response that meets these criteria.

Four hundred patients underwent noninvasive venous testing with subsequent venography. The noninvasive and venographic results were compared. Of the 300 normal venograms, 15 were abnormal by noninvasive testing. Of the 100 abnormal venograms, 90 were abnormal by noninvasive testing. For a correlation of carotid angiography and noninvasive carotid testing the specificity was calculated at 94.6% and the sensitivity was calculated at 90.3%. The overall accuracy can be: A. 24.3% B. 88.5% C. 92.3% D. 94.6% E. 95.1%

C. 92.3%. Explanation: Again, accuracy must fall between sensitivity and specificity.

A common evaluation for advanced lower extremity ischemia involves raising thee supine patient's leg and then having the patient sit and dangle the leg. A positive result is described as: A. elevation pallor, dependent rubor B. elevation rubor, dependent pallor C. elevation paresthesia, dependent pain D. elevation rubor, dependent cyanosis E. elevation pallor, dependent cyanosis

A. Elevation pallor, dependent rubor. Explanation: Elevation creates negative hydrostatic pressure, decreasing lower extremity perfusion, so the foot turns cadaverously pale. Having the patient then dangle the leg restores perfusion, and the foot turns very red.

The infraorbital artery is a terminal branch of the: A. maxillary artery B. facial artery C. inferior alveolar artery D. transverse facial artery E. superficial temporal artery

A. Maxillary artery. Explanation: The infraorbital artery is a terminal branch of the maxillary artery. It creates one of the potential anastomoses with orbital branches that can provide collateral pathways in the event of carotid obstruction.

Helical flow with flow separation in the posterolateral aspect of the carotid bulb is a sign of: A. normal flow dynamics B. thrombosis C. dissection D. stenosis E. intraplaque hemorrhage

A. Normal flow dynamics. Explanation: Flow separation at the posterior wall of the carotid bulb occurs because the linear momentum of the flow is disrupted by the large sinus and sharp curve at the carotid bulb. Flow separation depends on a relatively disease-free bulb.

In duplex assessment of the portal vein, flow: A. normally is phasic with respiration B. normally is continuous with respiration C. is minimally altered during portal hypertension D. is minimally diverted from the liver with portocaval shunt E. is minimally modulated by abdominal pressure

A. Normally is phasic with respiration.

Lymphedema may be caused by all EXCEPT: A. obesity B. trauma or surgical excision of lymph pathways C. infection D. inflammation E. radiation and chemotherapy

A. Obesity. Explanation: Lymphatic dysfunction may be caused by any of the other causes B through E.

In the cerebrovascular system, atherosclerosis occurs most commonly in the: A. origin of the internal carotid artery B. intracranial internal carotid artery C. left subclavian artery D. innominate artery E. proximal common carotid artery

A. Origin of the internal carotid artery.

Reasons to perform reactive hyperemia instead of treadmill testing include all EXCEPT: A. patient's inability to tolerate application of pressure cuffs B. patient's inability to stand or walk C. patient's poor cardiac status D. patient has pulmonary problems E. patient has very severe disease in one leg, making exercise assessment of the other leg difficult

A. Patient's inability to tolerate application of pressure cuffs. Explanation: One needs to apply cuffs for both exercise and reactive hyperemia testing. Indeed, some patients cannot tolerate the suprasystolic pressures needed for reactive hyperemia testing.

Of the following techniques, which would be the least effective in detecting significant DVT? A. photoplethysmography B. duplex ultrasound C. impedance plethysmography D. pneumoplethys,ography E. strain-gauge plethysmography

A. Photoplethysmography. Explanation: PPG is not helpful in diagnosing acute thrombosis; it is used for diagnosing chronic venous insufficiency. IPG, SPG, and air plethysmography are all capacitance/outflow modalities, and their tracings look essentially the same.

The superior mesenteric artery typically originates from the: A. aorta between the celiac trunk and the renal arteries B. common mesenteric trunk or axis C. aorta inferior to the renal arteries D. aorta superior to the celiac trunk E. celiac trunk

A. The aorta between the celiac trunk and the renal arteries. Explanation: The superior mesenteric artery may originate from the celiac trunk.

Patients complaining of pain, swelling, and erythema of the lower extremity may have deep venous thrombosis, but the vascular technologist knows that diagnosing DVT by these symptoms alone is approximately: A. 20-25% accurate B. 46-62% accurate C. 75-80% accurate D. 85-90% accurate E. 95-100% accurate

B. 46-62% accurate.

Normal values in TcPO2 assessment are: A. not yet established B. 60-80mmHg C. approximately 760mmHg (atmospheric pressure) D. 10-20mmHg E. 0mmHg, changing to 10-20mm with O2 challenge

B. 60-80mmHg.

A PTFE graft can be identified during ultrasonographic imaging by: A. a zigzag appearance of the graft walls B. a double-line appearance of the graft walls C. a single-line appearance of the graft walls D. a distinct color pattern E. the graft cannot be identified ultrasonographically

B. A double-line appearance of the graft walls. Explanation: PTFE(Gore-Tex) graft is characterized by a double-line appearance of the graft walls.

The most widely used interpretive technique for analog Doppler waveforms is: A. a quantitative approach evaluating the diagnostic features of the waveform B. a qualitative approach or pattern recognition C. purely subjective (neither qualitative or quantitative information can be derived from the waveform) D. spectral analysis of the velocity profiles within a waveform E. B-mode ultrasound evaluation

B. A qualitative approach or pattern recognition. Explanation: Most analog Doppler analysis is qualitative--assessing for presence or absence of characteristics, such as the reverse-flow component.

The image in Color Plate 1 on the previous pages represents the popliteal artery bifurcating into its branches, taken from a posteromedial approach just distal to the popliteal space. (In the image, the distal popliteal vein lies just superficial to the artery, with its cephalad flow shown in blue.) The branch going vertical/deep in the center is the: A. PTA B. ATA C. peroneal artery D. tibioperoneal trunk E. supreme genicular artery

B. ATA. Explanation: From the posteromedial approach, the ATA takes off from the popliteal artery and dives almost directly away from the beam to go anteriorly.

The vascular disease that presents as back, abdominal, or flank pain is: A. intracranial arterial disease B. abdominal aortic aneurysm C. iliofemoral occlusive disease D. superior mesenteric stenosis E. renal artery stenosis

B. Abdominal aortic aneurysm. Explanation: Abdominal aortic aneurysm (particularly if rupturing) often present with back, abdominal, or flank pain.

Thrombosis that appears on duplex scan to be dark, homogeneous in character, and poorly attached to the venous wall suggests: A. old, partially recanalized thrombosis B. acute thrombosis C. artifactual echoes D. acoustic "doubling" of the image due to the presence of a strong interface E. a nondiagnostic image

B. Acute thrombosis. Explanation: These characteristics are consistent with (but do not guarantee) acute thrombus.

This image from the proximal thigh suggests: A. acute arterial occlusion B. acute venous thrombosis C. chronic peripheral arterial disease D. chronic venous obstruction E. hematoma

B. Acute venous thrombosis. Explanation: This is an acute-appearing venous thrombus: The echoes are very soft and homogeneous, and the thrombus does not appear to adhere very well to the wall. Chronic thrombus would tend to appear brighter and more heterogeneous.

While performing a treadmill test, the patient complains of pain in the left arm and jaw, but denies any other pain. The examiner should consider that this could possibly be: A. arm claudication B. angina C. unimportant symptoms D. subclavian steal E. carotid artery disease

B. Angina. Explanation: The classic description of angina is chest pain, sometimes with radiation to the jaw and/or arm. However, some patients do not have the chest pain component, but do have the other symptoms. This patient must be assumed to have angina until proven otherwise.

Toe pressures: A. are falsely elevated as frequently as tibial ankle pressures B. are falsely elevated less frequently than tibial ankle pressures C. are falsely elevated more frequently than tibial ankle pressures D. are falsely decreased due to arterial incompressibility E. cannot be measured in the presence of tibial artery incompressibility

B. Are falsely elevated less frequently than tibial ankle pressures. Explanation: Toe pressures can be a useful adjunct in the diabetic patient with artificially high ankle pressures.

Stenting procedures of the internal carotid artery: A. are technically more demanding than stenting of coronary arteries B. are technically less demanding than stenting of coronary arteries C. are not currently being performed in the USA D. carry a much lower risk of complications than carotid endarterectomy E. are much less expensive than carotid endarterectomy

B. Are technically less demanding than stenting of coronary arteries. Explanation: Stents are now widely used in coronary and peripheral arteries, but their use in carotid arteries is controversial at this time. No long-term studies have demonstrated the safety or efficacy of this procedure, and it is not significantly less expensive than surgery. It is indeed simpler from a purely technical standpoint to place a stent in a carotid artery than in coronary or peripheral arteries.

Acute deep venous thrombosis is commonly indicated in venography as: A. area of increased contrast taken up by the thrombus B. area of no contrast, often with "railroad track" lines along walls C. area of intermittently reduced contrast, commonly referred to as a "string of pearls" D. primarily well-developed collaterals around the knee and groin E. complete blockage of the superficial veins and perforators

B. Area of no contrast, often with "railroad track" lines along walls. Explanation: This is a filling defect. The "string of pearls" sign is associated with fibromuscular hyperplasia. Well-developed collaterals would suggest a chronic rather than acute episode. Answer choice E does not address the deep system.

To optimize carotid vessel image data, lateral resolution should be: A. as small as possible, to differentiate calcified lesions from fresh thrombus B. as small as possible, to resolve side-by-side lesions C. as small as possible, to determine vessel wall and plaque thickness D. as large as possible, to identify hemodynamically significant lesions E. as large as possible for optimal sample volume placement

B. As small as possible, to resolve side-by-side lesions.

In TCD, the normal direction of flow in the anterior cerebral artery is: A. toward the beam B. away from the beam C. bidirectional D. dependent on the cardiac cycle E. not detectable with TCD

B. Away from the beam.

In TCD, the normal direction of flow in the vertebral artery is: A. toward the beam B. away from the beam C. bidirectional D. dependent on the cardiac cycle E. not detectable with TCD

B. Away from the beam. Explanation: From the suboccipital (foramen magnum) approach, flow should normally be away from the beam.

All of the following devices, utilized in a standard fashion, can measure ankle pressures EXCEPT: A. Doppler ultrasound B. B-mode ultrasound C. strain-gauge plethysmography D. photocell plethysmography E. air plethysmography

B. B-mode ultrasound. Explanation: B-mode ultrasound does not provide hemodynamic information about the arteries, only images. All other cited methods can be and have been used to minor pulses for pressure measurement.

This image, from the medial popliteal space of a patient with pain behind the knee and calf edema, most likely suggests: A. pseudoaneurysm B. Baker's cyst C. popliteal artery aneurysm D. hematoma E. cystic adventitial degeneration

B. Baker's cyst. Explanation: It's a fairly large Baker's cyst, a collection of synovial fluid that often causes symptoms similar to those of deep venous thrombosis.

In an emergency room patient with stroke symptoms, the initial diagnostic exam of choice would likely be: A. carotid duplex B. CT C. MRI D. cerebral angiography E. radionucleotide study

B. CT. Explanation: Computed tomography is the usual first choice of exam, since it can distinguish hemorrhagic stroke from ischemic infarction and is usually more readily available. In addition, it is better tolerated because examination time is shorter. The other exams are quite possible as well, but less likely for initial evaluation.

Which of the following is NOT a deep vein of the upper extremity? A. ulnar vein B. cephalic vein C. axillary vein D. radial vein E. brachial vein

B. Cephalic vein. Explanation: The deep veins of the upper extremity include the deep palmar venous arch, radial veins, ulnar veins and interosseous veins of the forearm, brachial veins, and axillary vein. The deep veins accompany the same named arteries and are usually paired. The cephalic, basilic, and median cubital veins are superficial veins. They do not accompany an artery and are not paired.

In the United States the most common cause of portal hypertension is: A. hepatic carcinoma B. cirrhosis C. hypertension D. schistosomiasis E. hyperlipidemia

B. Cirrhosis.

A condition which might result from reperfusion edema following bypass surgery, causing ischemia due to compression, and which might call for treatment by fasciotomy, is called: A. Marfan's syndrome B. compartment syndrome C. Raynaud's disease D. thoracic outlet syndrome E. China syndrome

B. Compartment syndrome.

More than 90% of infrarenal abdominal aneurysms are of: A. traumatic origin B. degenerative origin C. anastomotic origin D. infectious origin E. syphilitic origin

B. Degenerative origin. Explanation: Most aneurysms, especially in the abdominal aorta, are degenerative because of atherosclerosis.

Which technique is LEAST likely to be used to record digital pulses or changes in arterial volume? A. air plethysmography B. duplex ultrasonography C. pneumatic technique D. strain gauge E. photoplethysmography

B. Duplex ultrasonography. Explanation: All of the rest of these are able to detect digital pulse and/or changes in arterial volume.

You perform percussion maneuvers on the superficial temporal artery and see oscillations on the spectral display. The artery being insonated is most likely: A. ICA B. ECA C. vertebral artery D. thyrocervical trunk E. a low-resistance artery

B. ECA Explanation: This percussion maneuever--the "temporal tap"--must be used only cautiously to help identify the ECA in difficult situations. One report suggests that you can get pretty good oscillations in the ICA with temporal artery percussions in a large proportion of patients. It is better to differentiate the ICA and ECA by evaluating waveform characteristics, vessel positions, and the presence of branches.

A patient with a history of rest pain, 100-foot calf and thigh claudication, and an ulcer on the great toe of the left foot has a lef ankle pressure of >300mmHg. This result is: A. diagnostic of a diabetic foot B. erroneous due to probable arterial calcification C. consistent with small vessel disease D. demonstrable of severe hypertension E. elevated due to a cuff that is too narrow

B. Erroneous due to probably arterial calcification. Explanation: The result is likely due to calcified and incompressible arteries. This is very common in diabetic patients, so answer choice A is quite possible but not proven.

The patient with advanced chronic mesenteric ischemia is most likely to be: A. obese B. malnourished C. in atrial fibrillation D. hyperactive E. free of discernable symptoms

B. Malnourished. Explanation: Since eating causes severe ischemic abdominal pain, patients with mesenteric ischemia tend to avoid eating and to have pronounced weight loss.

This internal carotid artery waveform has a peak systolic velocity of 272cm/sec and an end-diastolic velocity of 88cm/sec. It is compatible with: A. moderate (<50%) stenosis B. moderately severe (50-80%) stenosis C. severe (>80%) stenosis D. distal total occlusion E. the waveform is nondiagnostic

B. Moderately severe (50-80%) stenosis. Explanation: By most velocity criteria, a peak systolic velocity >125cm/sec is compatible with >50% stenosis, while you would want to get the end-diastolic velocity over 100cm/sec to call >80% stenosis.

The most reliable method for establishing the diagnosis of pulmonary embolism is: A. duplex ultrasound B. pulmonary angiography C. V/Q scan D. chest x-ray E. ECG

B. Pulmonary angiography. Explanation: This exam is not undertaken lightly, but it is the definitive test for pulmonary embolism.

The Valsalva maneuver: A. increases pressure in the thoracic cavity, decreases pressure in the abdominal cavity B. decreases pressure in the thoracic cavity, increases pressure in the abdominal cavity C. slows down or stops venous flow everywhere in the body D. increases venous flow everywhere in the body E. affects arterial, not venous, flow

C. Slows down or stops venous flow everywhere in the body. Explanation: Since the Valsalva maneuver increases pressure within both the thoracic and abdominal cavities, venous flow everywhere diminishes or ceases. This can help at times to distinguish pulsatile venous signals from arterial signals.

The common carotid artery divides into its external and internal branches usually at the level of the upper border of the: A. hyoid B. cricoid C. thyroid cartilage D. cricothyroid membrane E. carina

C. Thyroid cartilage. Explanation: The external and internal carotid arteries are formed from the common carotid artery, usually at the upper border of the thyroid cartilage.

The layer of arterial or venous wall composed entirely of endothelial cells is the: A. tunica adventitia B. tunica media C. tunica intima D. no layer is composed of only one type of tissue E. each layer is composed entirely of endothelial tissue

C. Tunica intima.

The customary format for the 2 x 2 table places the false positives in the: A. upper left box B. lower left box C. upper right box D. lower right box E. center box

C. Upper right box. Explanations: True positives (they say positive, you say positive) go in the upper left box. True negatives (they say negative, you say negative) go in the lower right box. False negatives (you say negative, but they say positive) go in the lower left box. False positives (you say positive, but they say negative) go in the upper right box.

A patient with mild claudication-like symptoms has an ankle/brachial index for the affected leg of 1.02. This finding: A. indicates the disease is limited to the tibial arteries B. rules out the presence of any arterial disease C. is an incomplete evaluation of this patient D. demonstrates calcific arteries E. implicates neurogenic claudication as the cause of symptoms

C. Is an incomplete evaluation of this patient. Explanation: Arterial pressures at rest may be in the normal range, with only stress bringing out the abnormalities. To completely evaluate this patient, the circulation must be challenged by exercise or reactive hyperemia. Until that test is performed, significant vascular disease cannot be ruled out.

A patient complains of rest pain. On physical examination, elevation pallor and dependent rubor are present. There are no palpable pulses in the leg. A pressure of 120mmHg is measured in the ankle. This pressure: A. is consistent with the patient presentation B. is lower than expected C. is higher than expected D. suggests the physical examination is erroneous E. obviates the need for arteriography

C. Is higher than expected. Explanation: Due to the physical examination this pressure is much higher than suggested and would lead one to think that the pressures might be artificially higher than normal, perhaps due to calcification. Patients with rest pain usually have pressures less than 60mmHg and ABI <0.30.

The amplitude of arterial volume recording waveforms: A. is identical at all four levels B. is highest distally, where hydrostatic pressure is highest C. is only marginally meaningful diagnostically D. is normally approximately one-third the width of the waveform E. should equal the reverse component

C. Is only marginally meaningful diagnostically.

In a study of the upper extremities, pulse volume recordings show lack of dicrotic notch at all levels of a patient with warm hands and fingers bilaterally. The patient: A. has bilateral subclavian artery stenoses B. has a lacunar stroke C. is vasodilated D. has had a sympathectomy in the past E. is vasoconstricted

C. Is vasodilated. Explanation: Loss of the dicrotic notch is generally the first abnormality to show in volume recording, but this finding is not definitive. Vasodilatation will often eliminate the dicrotic notch, and since we know nothing about any previous history we cannot state anything about the sympathectomy. Lacunar strokes are unlikely to be related to vasomotor state.

A hypertensive, diabetic 65-year old male presents for cerebrovascular testing because of an asymptomatic bruit on the right side. You are considering all of the following to be potential sources of the bruit EXCEPT: A. stenosis of the external carotid artery B. stenosis of the subclavian artery C. occlusion of the common carotid artery D. dissection of the common carotid artery E. all of the above may produce a bruit

C. Occlusion of the common carotid artery. Explanation: A bruit is the result of vibration in the tissue surrounding a stenotic vessel. An occluded vessel cannot produce a bruit.

You are examining a patient who presents with weight loss, postprandial pain, and an abdominal bruit. Obstruction of which vessel is most likely to be at least partly responsible for these symptoms? A. portal vein B. renal arteries C. SMA D. splenic vein E. none of the above

C. SMA. Explanation: Chronic mesenteric ischemia may result from obstruction of the arteries that supply the gut. The primary vessel supplying the intestine is the superior mesenteric artery. The IMA and celiac trunk may also contribute. Symptoms usually do not occur unless 2 of these 3 arteries are obstructed. A rich collateral network exists between these three vessels, making chronic mesenteric ischemia a rare disorder.

In liver transplants, the native common hepatic artery is anastomosed to the donor hepatic artery: A. in the posterior aspect of the right lobe of the liver B. in the medial segment of the left lobe of the liver C. several centimeters proximal to the hepatic hilum D. at the porta hepatis where the hepatic artery enters the liver E. none of the above

C. Several centimeters proximal to the hepatic hilum.

This rather busy angiogram demonstrates: A. aortic stenosis, right iliac occlusion, and left iliac stenosis B. aortic stenosis, left iliac occlusion, and right iliac stenosis C. aortic aneurysm, right iliac occlusion, and left iliac stenosis D. aortic aneurysm, left iliac occlusion, and right iliac stenosis E. aortic occlusion with multiple collaterals reconstituting the iliacs

D. Aortic aneurysm, left iliac occlusion, and right iliac stenosis. Explanation: You can just see the right iliac stenosis at lower left of the image. The aneurysm is not severe as yet.

The common radiologic terms "inflow, outflow, runoff" refer respectively to: A. arterial side, capillaries, and venous side B. right heart, pulmonary bed, and systemic circulation C. arterial side, venous side, and perforating veins D. aortoiliac, femoropopliteal, and trifurcation arteries E. upper extremity, lower extremity, and torso arteries

D. Aortoiliac, femoropopliteal, and trifurcation arteries.

To minimize error during the measurement of the systolic pressures using a manometer having 2mmHg marks, the deflation rate should be: A. approximately 5mmHg per second B. less than 1mmHg per second C. varies with the severity of the disease D. approximately 2mmHg per heart beat E. depends on the size of the cuff

D. Approximately 2mmHg per heart beat. Explanation: Approximately 2mmHg per heartbeat gives the most accurate measurement of blood pressure; deflating too fast or too slowly may give inaccurate results. It is especially important not too bleed the cuff too quickly for a patient with cardiac arrhythmia.

After walking for 5 minutes on the treadmill, a patient experiences decreases in ankle pressure of 45% on the right and 15% on the left. These findings: A. suggest bilateral femoral artery occlusions B. suggest right femoral artery occlusion C. are within normal limits D. are typical for patients with claudication E. are not diagnostically useful

D. Are typical for patients with claudication. Explanation: One cannot call occlusion vs. stenosis based on this information. These decreases suggest mild disease on the left and more pronounced disease on the right, typical findings in a claudicating patient.

All of the following are causes of or risk factors for acute deep venous thrombosis EXCEPT: A. trauma B. extrinsic compression upon deep veins C. hypercoagulability D. arthritis E. cancer

D. Arthritis. Explanation: Of the answer choices, arthritis is the least likely cause of deep venous thrombosis. Patients with cancer are at increased risk because of systemic fibrinolytic changes.

Which of the following vessels joins the brachial veins to form the axillary vein? A. subclavian vein B. innominate vein C. cephalic vein D. basilic vein E. ulnar vein

D. Basilic vein. Explanation: The basilic vein is a superficial vein of the upper extremity that joins with the brachial veins to form the axillary vein. It begins on the ulnar side of the forearm and crosses ventrally at the antecubital region. The basilic vein lies medial to the brachial artery in the upper arm.

Normal flow in the hepatic vein is: A. hepatopetal B. retrograde C. triphasic D. bidirectional E. not detectable with duplex

D. Bidirectional. Explanation: Due to the proximity to the right atrium, hepatic vein flow is normally bidirectional and reflects right-atrial pressure changes.

This waveform from an internal carotid artery is measured at >273cm/sec peak systolic velocity and 125cm/sec end-diastolic velocity. It suggests: A. normal ICA velocities B. 30-40% stenosis C. borderline for 50% stenosis D. borderline for 80% stenosis E. >90% stenosis

D. Borderline for 80% stenosis. Explanation: The end-diastolic velocity is around the borderline for calling a stenosis greater than 80% by most criteria. EDV would not be especially accelerated in a 50% stenosis, and would be expected to be a good deal higher for the designation ">90% stenosis".

You are performing a carotid study on a patient who suffers cardiac arrest. You should first immediately: A. administer a precordial thump B. deliver three mouth-to-mouth breaths C. adminster 15 chest compressions D. call a code E. try to find the patient's medications

D. Call a code. Explanation: The very first thing to do is to get emergency team on its way, since any measures you are capable of taking are strictly temporary. Call 911 if the incident occurs in a facility that does not have a code team or other procedure. Many labs and institutions have written policies and procedures that cover medical and other emergencies. Familiarize yourself with the emergency procedures and follow them when the need arises.

The circle of Willis receives its blood supply from which combination of arteries? A. internal and external carotid arteries B. subclavian and vertebral arteries C. posterior cerebral artery and basilar artery D. carotid and vertebral arteries E. right and left vertebral arteries

D. Carotid and vertebral arteries. Explanation: This remarkable connection of the carotid and vertebral arteries--illustrated below--makes possible the ability of the brain to withstand (sometimes) extracranial carotid occlusion without significant symptoms.

The splenic, common hepatic, and left gastric arteries arise from this abdominal artery: A. inferior mesenteric artery B. proper hepatic artery C. superior mesenteric artery D. celiac trunk E. they are not branches of the same artery

D. Celiac trunk. Explanation: The celiac is the first major branch of the abdominal aorta. It divides into the common hepatic, splenic, and left gastric arteries.

The symptom or sign most likely NOT associated with acute arterial occlusion is: A. blue toe B. pain of sudden onset C. pale or white extremity D. claudication E. paresthesia

D. Claudication. Explanation: Claudication may be experienced months or years prior to an acute arterial occlusion, or it may not be felt at all prior to the episode. The other symptoms are consistent with an acute event.

A vascular lab calls a stenosis 60-70% by diameter based on its duplex assessment, but angiography the next day calls it 90% by diameter. Possible reasons for this discrepancy might include all EXCEPT: A. the stenosis is long and smooth, changing its Doppler character compared to that of a shorter lesion B. only one plane of visualization was used for angiography. C. poor angle-correction with the duplex, creating artificially low velocity estimates. D. acoustic shadowing prevented Doppler assessment of the maximal narrowing. E. color flow PRF set too low, creating aliasing and overestimation of velocities.

E. Color flow PRF set too low, creating aliasing and overestimation of velocities.

The following ultrasound image shows an internal carotid artery with: A. abnormal internal carotid artery wall B. a calcified plaque on the posterior wall C. a heterogenous plaque D. a homogenous plaque E. an intraplaque hemorrhage

D. Homogeneous plaque. Explanation: These echoes are soft and gray and have essentially the same character throughout. This plaque also has some rather forbidding-looking scooped-out areas, although of course duplex ultrasound does not have a strong track record in the literature for calling ulceration.

Potential complications of venography include all EXCEPT: A. allergic reaction to contrast B. toxicity to kidneys C. arteriovenous fistula D. iatrogenic CVA E. thrombophlebitis

D. Iatrogenic CVA. Explanation: Actually, there is indeed a rare phenomenon called "paradoxical stroke," with DVT embolizing to the arterial side through a patent foramen ovale in the right atrial wall and thence to the brain. We often get a flurry of orders for venous exams on stroke patients from a resident who has just learned of this.

Demonstration of vein-wall coaptation in the extremities is best performed: A. in a longitudinal plane with the color flow documenting cephalad flow B. in a longitudinal plane without color flow C. in a transverse plane with the color flow documenting patency D. in a transverse plane without color flow E. coaptation is seldom diagnostic in duplex imaging

D. In a transverse plane without color flow. Explanation: The transverse plane allows careful visualization of the coapting walls as well as of multiple vessels. This part of the study is a gray-scale procedure; color flow should be left off to allow scrutiny of walls.

Another name for the hypogastric artery is: A. external iliac artery B. gastroduodenal artery C. hepatic artery D. internal iliac artery E. celiac artery

D. Internal iliac artery.

Which of the following statements about this continuous-wave Doppler waveform is TRUE? A. it represents the PTA B. it represents the brachial artery C. it is a high-resistance waveform D. it is a low-resistance waveform E. it is proximal to a total occlusion

D. It is a low-resistance waveform. Explanation: Because all flow is well above the baseline, this must represent flow to a low-resistance distal vascular bed. It may well be from the brachial artery--okay, it is from the brachial artery--but we can't know that for sure just from this tracing.

What is on the left lower extremity of patient "Myra"? A. distal femoral stenosis B. popliteal stenosis C. proximal posterior tibial stenosis and mid anterior tibial stenosis D. mid posterior tibial stenosis and proximal anterior tibial stenosis E. proximal posterior tibial and anterior tibial stenosis

D. Mid posterior tibial stenosis and proximal anterior tibial stenosis. Explanation: This is a tricky one. The popliteal waveform is multiphasic, so the problem is probably distal to the popliteal crease. The low-thigh to calf pressure decrease is 38mmHg to the AT, but only 8mmHg to the PT. Therefore, there is proximal AT stenosis, while the PT pressure decrease of 36mmHg between calf and ankle suggests mid PT stenosis. (Because the decrease is between the cuffs, the problem is between the cuffs.)

All of the following may be found in the clinical presentation of pulmonary embolism EXCEPT: A. chest pain B. dyspnea C. pleural effusion D. positive lower extremity venous ultrasound E. tachypnea

D. Positive lower extremity venous ultrasound. Explanation: Ultrasonography is not a clinical sign but an exam. In any case, venous duplex is usually not a useful test for pulmonary embolism in the absence of lower extremity symptoms.

The probability that a positive noninvasive test reveals actual disease (as diagnosed by the gold-standard test) is called: A. accuracy B. sensitivity C. specificity D. positive predictive value E. negative predictive value

D. Positive predictive value. Explanation: The positive predictive value (PPV) of an examination is the ability of a test to predict the presence of disease. A positive predictive value of 83% means that you can be 83% sure a positive examination indicates the presence of disease in a given patient.

Regarding lumbar sympathectomy, all are true EXCEPT: A. potentially useful in patients with Raynaud's disease B. potentially useful in patients with ischemic rest pain C. unlikely to be useful in patients with ischemic ulceration D. potentially useful in claudicating patients E. increases vasodilatation and blood flow primarily in cutaneous vascular beds

D. Potentially useful in claudicating patients. Explanation: Sympathectomy is unlikely to be useful in claudicators.

The superior vena cava is formed by the junction of the: A. inferior vena cava and right innominate vein B. innominate and right subclavian veins C. innominate and left subclavian veins D. right and left brachiocephalic veins E. right and left subclavian veins

D. Right and left brachiocephalic veins. Explanation: Also called the right and left innominate veins. The brachiocephalic vein turns into the subclavian vein at the junction of the internal jugular vein.

Typical findings of skin discoloration in a patient with chronic venous insufficiency are: A. cyanotic (bluish) color in toes and feet B. bright red, mottled skin on anterolateral calf and thigh C. pallor on elevation, rubor on dependency of limb D. rusty brown color at ankles and calves E. bruised-appearing, purple areas on dorsum of feet

D. Rusty-brown color at ankles and calves.

Which is not a risk factor for DVT? A. cancer B. surgery C. age D. smoking E. bed rest

D. Smoking. Explanation: Smoking is not one of the direct risk factors for DVT, although it is implicated when combined with birth control pills.

Edema caused by deep venous thrombosis is characterized by: A. swelling of the feet B. swelling in the ankles and feet C. swelling in the ankles, legs, and feet D. swelling in the ankles and legs but not the feet E. swelling in the groin

D. Swelling in the ankles and legs but not the feet. Explanation: Usually swelling is not found in the feet in venous disease.

Proximal renal artery stenosis greater than 60% is diagnosed when: A. systolic renal velocities are greater than 100cm/sec B. systolic renal velocities are less than 45cm/sec C. systolic renal/aortic velocity ratio is less than 3.5 D. systolic renal/aortic velocity ratio is greater than 3.5 E. stenoses are measured in real-time image, not extrapolated from velocities

D. Systolic renal/aortic velocity ratio is greater than 3.5. Explanation: Renal to aortic ratios that are >3.5 are a common method of detecting proximal renal artery stenosis. Another method, which requires the localization of the stenosis, is to see a velocity increase of 100% or more from the prestenotic velocity.

Which of the following vessels is NOT found on or near the foot? A. the dorsalis pedis B. the posterior tibial C. the peroneal D. the circumflex E. all are found on or near the foot

D. The circumflex. Explanation: There are several "circumflex" arteries, some near or proximal to the groin.

The two flow characteristics that define arterial stenosis anywhere in the body include focal acceleration of velocities and: A. decreased diastolic flow B. decreased resistance proximally C. increase flow reversal D. increased pulsatility distally E. distal turbulence

E. Distal turbulence.

Two weeks after a fracture of the femur, a 33-year-old female is seen for swelling of the calf of the same leg. The preliminary diagnosis, prior to performance of any noninvasive testing, should include: A. arteriovenous fistula B. deep venous thrombosis C. popliteal entrapment D. two of the above E. all three

D. Two of the above. Explanation: The obvious tentative call is deep vein thrombosis; a remoter possibility is traumatic AV fistula, which tends to increase distal venous pressure. Popliteal entrapment is not a likely call.

A 46-year-old man comes to the vascular laboratory with calf and ankle edema, mild discomfort in the calf, and a soft mass behind the knee. Continuous-wave Doppler studies are negative except for some continuous flow over the popliteal vein. An additional test that might be useful is: A. venous reflux plethysmography B. venous outflow C. spectral analysis D. ultrasound imaging E. photoplethysmography

D. Ultrasound imaging. Explanation: Ultrasound imaging may be useful because this patient has the classic symptoms of a Baker's cyst. The continuous CW Doppler signal would likely be the result of extrinsic compression of the vein.

Advantages of angiography over duplex carotid studies include all EXCEPT: A. ability to visualize intracranial collaterals B. superiority at calling ulceration C. ability to visualize the entire cerebral vasculature D. unlimited repeatability E. ability to determine siphon stenosis

D. Unlimited repeatability. Explanation: This is an invasive procedure with a small but definite risk of complication.

Which of the following techniques would be most helpful in mapping the saphenous vein? A. decrease room temperature to dilate the small saphenous vein B. place the patient in an upright position to improve visualization of the saphenous vein C. place the patient in a prone position to improve access to the saphenous vein D. use a high-frequency probe and light probe pressure to track the saphenous vein E. use a lower-frequency probe and firm probe pressure to track the saphenous vein most effectively

D. Use a high-frequency probe and light probe pressure to track the saphenous vein. Explanation: The highest-frequency linear array probe available should be used to track the saphenous vein because it is very superficial. Very light probe pressure should be used since it is easy to compress the vein by resting the probe on the skin. When the vein cannot be visualized, decreasing probe pressure will often help to demonstrate the vein. If the room temperature is too cold, the veins will be small and hard to see. The patient should be placed in a supine position with the leg externally rotated and the knee slightly bent.

In the presence of arterial obstructive disease and distal ischemia: A. vasoconstriction increases, and distal resistance increases B. vasoconstriction increases, and distal resistance decreases C. vasodilatation decreases, and distal resistance decreases D. vasodilatation increases, and distal resistance decreases E. vasodilatation decreases, and distal resistance may either increase or remain the same

D. Vasodilatation increases, and distal resistance decreases. Explanation: The body attempts to increase nutritive blood flow to the extremity by vasodilatation and the subsequent decrease of peripheral resistance. The drop in distal pressure is a result of the increased segmental resistance and "stealing" of blood to the large muscle groups.

During a duplex venous exam, which of the following findings is the least likely to be associated with acute deep venous thrombosis? A. continuous venous flow B. stationary echoes within the vein C. homogeneous intraluminal echoes D. venous reflux E. enlarged incompressible vein

D. Venous reflux. Explanation: Reflux may or may not be associated with deep venous thrombosis, but usually is a chronic condition found after the acute event.

With severe lower extremity arterial occlusive disease, the Doppler waveforms distally: A. will eventually return to a relatively normal waveform pattern once the disease process has stabilized B. will demonstrate flow reversal in the diastolic component C. cannot be distinguished from venous waveforms D. will appear markedly dampened, possibly making interpretation difficult for distal segments E. are almost always absent at the ankle level

D. Will appear markedly dampened, possibly making interpretation difficult for distal segments. Explanation: Damped waveforms distal to proximal arterial occlusive disease can make the evaluation of further distal disease difficult.

A varicose vein is most often: A. a dilatation of a perforating vein B. a dilatation of the small saphenous vein C. a jugular vein aneurysm D. a popliteal vein aneurysm E. a dilatation of the great saphenous vein or superficial tributary

E. A dilatation of the great saphenous vein or superficial tributary. Explanation: Varicose veins usually affect the greater saphenous system and branches, whether they are primary or secondary varicosities.

Color Plate 5 is a transverse image from the abdominal aorta. It demonstrates: A. the right/left iliac bifurcation B. the inferior vena cava to the left of the aorta C. renal artery stenosis D. normal multiphasic flow E. a large aneurysm

E. A large aneurysm. Explanation: This is a big aneurysm, up around 9 to 11cm.

Which of the following determinants dictate(s) XDR frequency selection for optimal carotid B-mode imaging? A. desired beam width B. the average and extreme depths of carotid vessels in most subjects to be studied C. desired axial resolution D. cost E. A, B, and C F. C and D

E. A, B, and C. Explanation: Beam width relates to lateral resolution.

Common signs of advanced arterial insufficiency of the lower extremity include which of the following? A. loss of hair growth over the dorsum of the toes and feet B. thickening of the toenails C. dermatitis with skin pigmentation D. dependent rubor E. A, B, and D

E. A, B, and D. Explanation: Skin pigmentation changes are usually found in patients with chronic venous disease. Dependent rubor as well as thickening of the toenails and hair loss is indicative of chronic arterial insufficiency.

The great saphenous vein: A. originates along the medial dorsum of the foot B. passes superiorly, anterior to the medial malleolus C. is accompanied by the saphenous nerve D. receives tributaries from all surfaces of the lower extremity E. All are correct

E. All are correct. Explanation: The great saphenous vein passes upward on the anteromedial calf and the posteromedial to medial thigh. It ends by passing through the saphenous hiatus in the deep fascia of the proximal thigh to enter the common femoral vein.

When performing lower extremity venous Doppler assessment in normal patients, cephalad flow diminishes: A. during Valsalva maneuver B. during inspiration C. during expiration D. during proximal compression E. all but C

E. All but C. Explanation: Inspiration diminishes venous flow from the lower extremities, because it increases pressure in the abdominal cavity. Proximal compression obviously diminishes venous outflow due to the pressure on the vein. The Valsalva maneuver should diminish venous flow everywhere in the body, as it increases both intraabdominal and intrathoracic pressure. Expiration decreases pressure in the abdomen, allowing venous outflow from the lower extremities to resume.

Patients with advanced peripheral arterial vascular occlusive disease exhibit which of the following skin changes? A. shiny, scaly skin B. dependent rubor C. pallor on elevation D. stasis pigmentation E. all except D

E. All except D. Explanation: Pigmentation is a characteristic symptom of venous rather than arterial insufficiency.

The symptoms of anterior tibial compartment syndrome are: A. swelling and/or palpable tenderness over a muscle compartment B. sensory deficit or paresthesias C. pain on passive stretch of the muscles in the compartment D. weakness of the muscles in the compartment E. all of the above

E. All of the above.

Patients found to have ulcerating lesions or gangrene may have which of the following diseases? A. arterial insufficiency B. neuropathy C. vasospasm D. venous disease E. all of the above

E. All of the above. Explanation: Since the location of the ulcers and gangrene is not specified, any of the causes may be implicated.

Which of the following arteries arise(s) from the external carotid artery? A. superior thyroid artery B. lingual artery C. facial artery D. ascending pharyngeal artery E. All the above

E. All of the above. Explanation: The external carotid artery has eight branches. The following four branches arise in the carotid triangle: the superior thyroid, lingual, facial, and the ascending pharyngeal arteries.

Possible error(s) that can occur when recording a femoral arterial waveform using continuous-wave Doppler include: A. insonating an artery other than the intended one B. recording two vessels simultaneously C. using an improper probe frequency D. B and C only E. all of the above

E. All of the above. Explanation: These errors are less likely using duplex ultrasound.

The optimal patient position for imaging of the lower extremity veins is: A. semi-Fowler's position B. Trendelenburg's position C. Reverse Trendelenburg's position D. supine, leg elevated E. answers A and C

E. Answers A and C. Explanation: Semi-Fowler's position is raising the trunk and head, but not the knees. Reverse Trendelenburg's position is patient supine, head up, and feet down. A combination of these is usually used for venous duplex studies. Trendelenburg's position is patient supine, head down, and feet up--useful for pooling blood in the central circulation in hypotensive patients, but not for venous imaging or Doppler in the lower extremities. Supine, leg elevated is good for venous outflow plethysmography.

The paratibial perforating veins (formerly Boyd's perforator) are located: A. in the lower calf B. in the distal thigh C. in the proximal thigh D. on the dorsum of the foot E. below the knee

E. Below the knee.

The axillary artery connects the: A. radial to the ulnar artery B. ulnar to the brachial artery C. brachial artery to the radial artery D. radial to the subclavian artery E. brachial artery to the subclavian artery

E. Brachial artery to the subclavian artery.

This femoral artery waveform demonstrates: A. normal velocities and flow character B. poor angle correction, precluding accurate velocity estimate C. turbulent flow at systole D. severely elevated peak-systolic velocities E. C and D

E. C and D. Explanation: Once again, peak systolic velocities of 500cm/sec suggest high-grade stenosis; this again looks turbulent.

The drug heparin: A. affects the prothrombin time B. directly attacks formed thrombi C. is reversed by administration of vitamin K D. is safe E. can cause thrombocytopenia

E. Can cause thrombocytopenia. Explanatoin: Heparin is a protein. As such, it can activate antibodies in a sensitized individual. It affects the partial thromboplastin time, but not the prothrombin time. It has no direct actions on clots once they are formed. Protamine is used to reverse the effects of heparin. The drug has a significant complication rate and can produce thrombocytopenia.

The following arteries have low-resistance flow character: A. internal carotid, preprandial superior mesenteric, and renal arteries B. external carotid, preprandial superior mesenteric, and renal arteries C. internal carotid, postprandial superior mesenteric, and renal arteries D. external carotid, postprandial superior mesenteric, and renal arteries E. internal carotid and superior mesenteric arteries

C. internal carotid, postprandial superior mesenteric, and renal arteries. Explanation: postprandial (after a meal) superior mesenteric flows have lower resistance, higher diastolic flow character

A velocity obtained inthe mid superficial femoral artery is 225cm/sec, while a measurement just proximal to this site gives 90cm/sec. This suggests: A. SFA aneurysm B. mild SFA stenosis C. SFA occlusion D. >50% SFA stenosis E. >80% SFA stenosis

D. >50% SFA stenosis. Explanation: A common crieterion for lower extremity arteries (and a good rule of thumb in any arteries): A stenotic velocity that accelerates to double that of the prestenotic velocity suggests >50% stenosis.

This waveform is from a right vertebral artery. Which statement is NOT true? A. flow is antegrade B. there is flow during diastole C. the waveform morphology suggests a developing abnormal pressure gradient proximally D. the waveform suggests subclavian or innominate obstruction E. the waveform suggests distal occlusion

E. This statement--"The waveform suggests distal occlusion"--is NOT true. Explanation: Since there is reasonable diastolic flow, a distal occlusion is unlikely. This is another "transitional" vertebral waveform, with late systole being pulled down briefly by a developing abnormal pressure gradient proximally. This is an early stage; examples of later stages appear elsewhere in this book.

Limitations of handheld CW Doppler venous assessment include all EXCEPT: A. there may be bifid superficial femoral or popliteal veins B. non-occluding thrombus may not be detected C. a collateral vein may be mistaken for the vein of intended assessment D. exact extent cannot be determined for follow-up studies E. valvular incompetence cannot be assessed with CW Doppler

E. Valvular incompetence cannot be assessed with CW Doppler. Explanation: You certainly can assess venous incompetence with hand-held CW. The other items do represent limitations.

A patient has 50% diameter stenosis in a lower extremity vein graft. The systolic velocity at the stenosis: A. will be 50% higher than the prestenotic velocity B. is greater than 150cm/sec, less than 240cm/sec C. is less than 45cm/sec D. is the same as the velocities measured distally in the graft E. will be 100% greater than the prestenotic velocity followed by a drop in velocity

E. Will be 100% greater than the prestenotic velocity followed by a drop in velocity. Explanation: Absolute velocities will differ depending on the size of graft, but usually a 100% increase in velocity followed by a distal decrease in velocity is indicative of a 50% stenosis.

Which of the following accurately defines RIND, also called stroke with recovery? A. a reversible ischemic neurologic deficit that completely resolves within 24 hours. B. a neurologic deficit that does not resolve. C. a neurologic deficit that waxes and wanes. D. an irreversible neurologic deficit. E. a neurologic ischemic deficit that resolves completely after 24 hours.

E. a neurologic ischemic deficit that resolves completely after 24 hours. Explanation: The term reversible ischemic neurologic deficit (RIND) describes an intracranial ischemic event that does not resolve within 24 hours but thereafter completely resolves. An unreversed deficit is a stroke, also called a cerebrovascular accident (CVA).

All of the following may represent symptoms from the brain stem or posterior circulation EXCEPT: A. dizziness B. vertigo C. ectasia D. syncope E. amaurosis fugax

E. amaurosis fugax. Explanation: Amaurosis fugax is transient blindness, usually in one eye. Lateralizing symptoms are usually from the anterior circulation, whereas nonlateralizing ischemic attacks, such as answers A, B, C, and D, are usually from the posterior circulation.

The popliteal trifurcation is actually a double bifurcation; select the pairs forming these two bifurcations: A. posterior tibial and tibioperoneal trunk; then anterior tibial and peroneal B. peroneal and tibioperoneal trunk; then posterior and anterior tibials C. anterior tibial and popliteal; then posterior tibial and peroneal D. posterior tibial and popliteal; then anterior tibial and peroneal E. anterior tibial and tibioperoneal trunk; then posterior tibial and peroneal

E. anterior tibial and tibioperoneal trunk; then posterior tibial and peroneal

Peripheral resistance increases with: A. greater length, smaller diameter, and lower blood viscosity B. greater length, larger diameter, and higher blood viscosity C. shorter length, larger diameter, and lower blood viscosity D. shorter length, smaller diameter, and lower blood viscosity E. greater length, smaller diameter, and higher blood viscosity

E. greater length, smaller diameter, and higher blood viscosity Explanation: Poiseuille's resistance equation demonstrates the influences on resistance of length, viscosity, and inversely, radius. R=8 x L x n / pi x r^4

A patient undergoes carotid endarterectomy. Six months later angiography is performed because of symptoms referable to the other side. The angiogram reveals that the operated carotid is significantly narrowed. The most likely cause is: A. atherosclerotic plaque recurrence B. carotid dissection C. embolic activity D. extrinsic compression E. neointimal hyperplasia

E. neointimal hyperplasia. Explanation: This is a common phenomenon following any trauma to an arterial wall, including endarterectomy and angioplasty. It involves proliferation of smooth-muscle cells in response to the injury.

Which sign or symptom is least likely to be associated with arterial embolization? A. blue toe B. TIA C. popliteal aneurysm D. amaurosis fugax E. progressive claudication

E. progressive claudication. Explanation: Progressive claudication is usually associated with slow progression of atherosclerosis, not with embolization.

A hemispheric stroke usually affects: A. the anterior cerebral artery distribution and the ipsilateral side of the body B. the middle cerebellar artery distribution and the ipsilateral side of the body C. the external carotid distribution, and may affect one or both sides of the body D. the anterior cerebellar artery distribution and the contralateral side of the body E. the middle cerebral artery distribution and the contralateral side of the body

E. the middle cerebral artery distribution and the contralateral side of the body.

Paresthesia refers to: A. dizziness B. disturbance of speech C. loss of function of a limb D. weakness E. tingling sensation

E. tingling sensation.

A male patient walks on the treadmill for an evaluation of leg symptoms. During the walk he reports that both calves and thighs start hurting at 10 seconds, the right worse than the left. He continues to walk for 5 minutes, after which he is stopped by the technologist. The symptoms do not resolve, but do not get worse during exercise. The following pressures are obtained: Before exercise: Arm 130, right ankle 130, left ankle 120 After exercise: Arm 160, right ankle 100, left ankle 110 True statement(s) regarding this test is (are): A. there is arterial disease in both legs B. the symptoms are probably not due to vascular disease C. the right leg is symptomatically worse D. there is evidence of aortoiliac artery disease E. A and B F. A and D G. A, B, and C

G. A, B, and C. Explanation: Since the patient complains of pain in the right leg that is worse than the left, he is ipso facto symptomatically worse in the right leg. There is a drop in pressure in both legs; therefore, there is vascular disease in both legs. As to the symptoms, they do not follow the usual pattern of claudication; they do not progress with the exercise. Therefore, it is likely that at least most of the pain is not vascular in origin.

Which of the following anatomic lesions can produce a vertebral steal? A. innominate artery occlusion B. left subclavian artery origin stenosis C. left vertebral artery stenosis D. right common carotid artery occlusion E. right axillary artery occlusion F. D and E G. A and B

G. A and B Explanation: To produce a vertebral steal, the lesion must be proximal to the vertebral artery, creating an abnormal pressure gradient that pulls blood from the vertebral artery to perfuse the arm. Occlusion of the common carotid artery would not create this gradient, and the axillary artery is too far distal.

Which of the following is true regarding subclavian steal? A. resulting strokes are usually severely disabling. B. it is usually a harmless hemodynamic phenomenon. C. it is caused by arterial obstruction proximal to the origin of the vertebral artery. D. it is caused by arterial obstruction distal to the origin of the vertebral artery. E. A and C F. A and D G. B and C H. B and D

G. B and C. Explanation: subclavian steal is generally a benign disorder. The abnormal flow pattern is caused by arterial obstruction proximal to the origin of the vertebral artery. This creates an abnormal pressure gradient that pulls--or "steals"--flow from the vertebral artery to perfuse the ipsilateral upper extremity.

Match the following symptoms and signs with the likely cause. (Tip: start with the most obvious and work your way in.) A. bruit B. absent pulse C. foot rubor D. right sided weakness E. edema 1. aortoiliac + SFA occlusion 2. deep venous thrombosis 3. subclavian artery occlusion (acute) 4. left carotid artery occlusion 5. iliac artery stenosis

A-5. B-3. C-1. D-4. E-2. Explanation: Some of this is sorted out by elimination. DVT (2) is the obvious choice for edema. A bruit cannot result from total occlusion, which eliminates 1, 3, and 4, leaving iliac artery stenosis (5). There is only aortoiliac/SFA occlusion (1) left to account for the foot rubor; the iliac artery stenosis is unlikely to produce such an advanced symptom anyway. Weakness of the right side most likely results from the left carotid occlusion (4), leaving the subclavian artery occlusion (3) to account for the absent pulse.

Matching: Proximal Vessel: A. innominate B. subclavian C. common carotid D. vertebral E. external carotid Branch or continuation of vessel: 1. internal carotid 2. subclavian 3. basilar 4. superficial temporal 5. vertebral

A. (2); B. (5); C. (1); D. (3); E. (4).

In handheld TCD, the angle of the beam relative to flow is assumed to be: A. 0 degrees B. 30 degrees C. 45 degrees exactly D. 60 degrees E. 90 degrees

A. 0 degrees. Explanation: This appears to work fairly well, even though obviously some of the angles of incidence relative to flow are well away from 0 degrees. (Note that, even with a 30 degrees deviation of angle from 0 degrees, the error in velocity estimate is only approximately 5%).

Right arm 180/100mmHg Left arm 120/60mmHg Right PTA 100mmHg Left PTA 90mmHg The left ankle/brachial index is: A. 0.50 (90/180) B. 0.75 (90/120) C. 0.90 (90/100) D. 1.11 (100/90) E. 1.50 (90/60)

A. 0.50 (90/180). Explanation: You use the higher brachial pressure to calculate the index.

In the image of a radial/ulnar artery bifurcation that appears in Color Plate 9, the ulnar artery, as usual, dives deeper in the field. Which of the following statements are true? 1. the radial artery flow is antegrade 2. the radial artery flow is retrograde 3. the brachial artery flow is antegrade 4. the brachial artery flow is retrograde 5. the ulnar artery flow is antegrade 6. the ulnar artery flow is retrograde A. 1, 3, and 5 B. 1, 3, and 6 C. 2, 3, and 5 D. 2, 3, and 6 E. 2, 4, and 6

A. 1,3, and 5. Explanation: Everything is normal. Red flow away from the beam, so the brachial and ulnar arteries are flowing distally-antegrade. Blue flow is toward the beam, so the radial artery is also flowing distally-antegrade. There is some brachial vein visible above that artery, and some ulnar vein visible above that artery. That blue flow is toward the beam, since that flow is headed cephalad.

A series of carotid duplex studies was correlated to carotid angiography to test a velocity threshold for accuracy in calling >60% vs. <60% stenosis of the internal carotid artery. Of the 56 ICAs called >60% by angiography, 53 were correctly identified by duplex. Of the 38 ICA's called <60% by angiography, 8 were called >60% by duplex. The correct calculation for the positive predictive value is: A. 53/61 B. 30/33 C. 83/94 D. 53/56 E. 53/94

A. 53/61. Explanation: True positive + false positive

The usual cuff pressure used in arterial volume recording is: A. 65mmHg B. 10mmHg C. suprasystolic D. 100mmHg E. dependent on patient size

A. 65mmHg.

In duplex imaging, the best arterial wall image quality is obtained when the beam is at the following angle to the artery walls: A. 90 degrees B. 60 degrees C. 0 degrees D. oblique E. obtuse

A. 90 degrees. Explanation: Since the angle of incidence equals the angle of reflectance, more echoes return to the transducer with a 90 degree angle.

Four hundred patients underwent noninvasive venous testing with subsequent venography. The noninvasive and venographic results were compared. Of the 300 normal venograms, 15 were abnormal by noninvasive testing. Of the 100 abnormal venograms, 90 were abnormal by noninvasive testing. Positive predictive value is: A. 90/105 B. 90/400 C. 100/400 D. 375/400 E. 390/400

A. 90/105. Explanation: Of 105 abnormal noninvasive exams, 90 were true positives. Positive predictive value equals the positive agreements divided by all of the noninvasive positives.

An arterial stenosis that is 80% by diameter reduction corresponds to a cross-sectional area reduction of: A. 96% B. 88% C. 70% D. 60% E. 45%

A. 96%.

What percentage of pulmonary emboli originates from lower extremity deep venous thrombosis? A. >90% B. 75% C. about 50% D. 25% E. 10-15%

A. >90%. Explanation: This explains the profound interest in diagnosing and treating deep venous thrombosis before it creates bigger problems.

A normal postocclusive reactive hyperemia velocity response is: A. a 100% increase in mean velocity B. approximately 50% increase in mean velocity C. any increase in mean velocity D. an 80% decrease in mean velocity E. no increase in mean velocity

A. A >100% increase in mean velocity.

The most common anatomic variant of the aortic arch is: A. a common origin of the innominate and left common carotid arteries B. origin of the left vertebral artery from the aortic arch C. origin of the right subclavian artery from the aortic arch D. origin of the right common carotid artery from the aortic arch E. duplication of the subclavian arteries

A. A common origin of the innominate and left common carotid arteries. Explanation: A common origin of the innominate and left common carotid arteries is by far the most common variant anatomy of the aortic arch, occurring in approximately 22% of individuals.

A carotid bruit can be detected with color flow and spectral analysis as: A. a mosaic of low red and blue frequencies in color flow in tissue lying outside of the lumen, and oscillatory waveforms above and below baseline in the spectral waveform B. a mosaic of high red and blue aliasing frequencies in color flow and oscillatory waveforms above and below baseline in the spectral waveform C. a mosaic of high red and blue aliasing frequencies in color flow; bruits cannot appear on the spectral waveform D. a mosaic of low red and blue frequencies in color flow; bruits cannot appear on the spectral waveform E. high-frequency oscillations in the spectral waveform; bruits cannot appear on color flow

A. A mosaic of low red and blue frequencies in color flow in tissue lying outside of the lumen, and oscillatory waveforms above and below baseline in the spectral waveform. Explanation: The frequencies associated with a bruit are low rather than high. Low-frequency oscillations above and below a spectral baseline that are characteristic of a bruit may also show as low-frequency red and blue color shifts in adjacent tissue, often speckled like a mosaic.

The correct setting for arterial volume recording is: A. AC-coupled output B. DC-coupled output C. 3.5Hz filter setting D. "mean" filter setting E. forward/reverse

A. AC-coupled output. Explanation: AC-coupled amplification is appropriate for arterial plethysmoraphy; DC-coupling is appropriate for venous recording.

The angle-correct cursor for velocity estimates is best: A. adjusted parallel with arterial walls B. adjusted perpendicular to arterial walls C. adjusted zero degrees throughout for maximum frequency shift D. adjusted sixty degrees at all times regardless of vessel direction E. left off to avoid measurement errors

A. Adjusted parallel with arterial walls.

Which one of the following conditions will cause an increase in the pulse amplitude of the arterial pressure wave? A. an increase in peripheral resistance B. a decrease in left ventricular function C. vasodilation secondary to heating D. young age E. mild atherosclerosis

A. An increase in peripheral resistance. Explanation: This question refers to the effects of the arterial pressure wave, an energy wave that travels throughout the arterial tree with each systolic ejection from the heart. This energy is reflected primarily from the arterioles, and the amount of reflection obviously depends on the vasomotor state. A decrease in peripheral resistance and/or vasodilation will cause a decrease in pulse amplitude, since less of the pressure-wave energy is reflected proximally. An increase of distal resistance (vasoconstriction) reflects more of the pressure-wave energy proximally. This reflected energy sums with existing energy in the proximal arteries to increase pulsatility and pressure.

A diabetic patient with redness of the skin in the foot and toe probably has: A. an infection B. emboli C. increased sympathetic tone D. low central temperature E. popliteal aneurysm

A. An infection. Explanation: Diabetic foot infections can happen with or without peripheral vascular disease.

Your segmental pressure readings indicate the following: Rt brachial: 144mmHg Lt brachial: 140mmHg Rt high thigh: 110mmHg Lt high thigh: 164mmHg These findings could result from all EXCEPT: A. aortoiliac obstruction B. right common iliac obstruction C. right external iliac obstruction D. right common femoral obstruction E. right proximal superficial femoral obstruction

A. Aortoiliac obstruction. Explanation: Since the left high-thigh pressure is within normal limits, the aortic segment cannot be included in the diagnosis of obstructon.

What is the name of the tiny intrarenal branches that arise from the interlobar arteries at right angles and course above the renal pyramids? A. arcuate arteries B. segmental arteries C. interlobular arteries D. capsular arteries E. intralobular arteries

A. Arcuate arteries. Explanation: The main renal artery divides at the hilum of the kidney into segmental renal arteries. These in turn give rise to the interlobar arteries, which course alongside the renal pyramids. The arcuate arteries arise at right angles from the interlobar arteries and course on top of the renal pyramids. Within the renal cortex, the arcuate arteries give rise to the radially oriented interlobular arteries.

The term cyanosis describes: A. blue color of tissue due to ischemia B. red color of tissue due to hyperemia C. pale skin due to ischemia D. thickening of toenails due to chronic ischemia E. loss of hair growth due to chronic ischemia

A. Blue color of tissue due to ischemia.

Signs on duplex venous imaging of acute rather than chronic deep vein thrombosis includes all EXCEPT: A. bright intraluminal echoes B. distended vein C. dark intraluminal echoes D. slightly compressible (spongy) character to thrombus E. presence of a "tail" suggesting poor adherence to wall

A. Bright intraluminal echoes. Explanation: Bright intraluminal echoes are more compatible with organized, older thrombus.

Pitting edema of both lower extremities is likely related to: A. cardiac or systemic origin B. deep venous thrombosis C. primary varicose veins D. secondary varicose veins E. lipidemia

A. Cardiac or systemic origin. Explanation: Bilateral edema most commonly is cardiac or systemic in origin with congestive heart failure as a predominant feature.

After carotid bifurcation disease, the next most common source of stroke symptoms is: A. cardiac-source embolization B. paradoxical embolization from DVT via patent foramen ovale C. spinal stenosis D. subclavian stenosis E. aortic dissection

A. Cardiac-source embolization. Explanation: Atrial fibrillation and myocardial infarction are the two most common causes of mural thrombus in the heart. Answer B is a remote possibility; it can happen.

A 64-year-old male complains of half-block left thigh and calf claudication without symptoms on the right. Physical examination reveals that the left femoral pulse is absent; pulses on the right are normal, without bruit. Treadmill testing results are abnormal on the left, normal on the right. Duplex reveals an occluded iliac artery on the left. This patient may be an ideal candidate for: A. femorofemoral bypass B. axillofemoral bypass C. balloon angioplasty D. femoropopliteal bypass E. lumbar sympathectomy

A. Femorofemoral bypass. Explanation: Since this patient's left iliac artery is totally occluded, there is no indication for femoropopliteal bypass, lumbar sympathectomy, or balloon angioplasty. Although axillofemoral bypass is a viable alternative, it is seldom performed in preference to the femorofemoral bypass, which is the procedure of choice for this patient.

In duplex assessment of dialysis fistulas (synthetic or native), common abnormalities include all EXCEPT: A. high flow rates exceeding 300ml/min B. stenosis at the venous anastomosis C. aneurysm of the graft D. false aneurysm caused by needle puncture E. spontaneous thrombosis

A. High flow rates exceeding 300ml/min. Explanation: The fistula should have fairly high flow rates to allow for dialysis. The other answer choices are possible abnormalities to look for when scanning.

The velocities measured in a reversed saphenous vein bypass graft are usually: A. higher proximally and lower distally B. lower proximally and higher distally C. the same throughout the graft D. variable throughout the graft E. inversely proporttional to the diameter of the graft

A. Higher proximally and lower distally. Explanation: The velocities will vary depending on the inflow, size of graft, location of valve cusps, presence of stenoses, and tightness of distal anastomosis. Generally the velocities in a reversed vein graft will be lower distally because of the increased size of the graft distally.

Select the entity that is NOT a risk factor in peripheral arterial occlusive disease: A. hypolipidemia B. smoking C. hypertension D. diabetes E. hyperlipidemia

A. Hypolipidemia. Explanation: Hypolipidemia is not a risk factor for any vascular occlusive disease.

A clenched fist will change the following parameter in the brachial artery Doppler waveform: A. increase the pulsatility index B. decrease the pulsatility index C. increase diastolic flow D. decrease systolic flow E. increase the average velocity

A. Increase the pulsatility index. Explanation: Pulsatility can be informally defined as the degree to which the waveform deviates from the mean. Clenching the fist offers much greater distal resistance, so the Doppler waveform would be expected to become more pulsatile. In addition to increasing the pulsatility index, a closed fist will also decrease the diastolic flow.

The incidence of pseudoaneurysms is: A. increasing B. decreasing C. staying the same D. stabilizing E. not associated with iatrogenic causes

A. Increasing. Explanation: As the number of transluminal procedures increases, we are seeing more iatrogenic pseudoaneurysms.

What is suggested in this spectral display: A. it suggests turbulent flow B. the beam angle suggests that flow is retrograde C. the Doppler beam angle relative to flow is too high for accurate velocity measurement D. the systolic window is clear, suggesting laminar flow E. end-diastolic velocities suggest severe stenosis

A. It suggests turbulent flow. Explanation: The shredded appearance and the filling in of the systolic window suggest turbulent flow. There are also some low velocities at systole beneath the baseline. Since turbulent flow goes many directions, mostly at lower velocities, many frequency shifts are created.

The renal arteries arise from the aorta: A. laterally B. inferiorly to the inferior mesenteric artery C. posteriorly D. superiorly to the superior mesenteric artery E. anteriorly

A. Laterally Explanation: From the lateral aspect. The right renal artery is usually anterolateral, the left renal usually posterolateral.

In a patient who wakes up at night with pain in the foot and has to drop the foot by the side of the bed, the ankle/arm systolic pressure ratio will most likely be: A. less than 0.50 B. between 0.50 and 0.80 C. between 0.80 and 1.00 D. greater than 1.00 E. not measurable

A. Less than 0.50. Explanation: Actually more likely less than 0.30; this is consistent with ischemic rest pain.

In B-mode imaging of the common femoral artery and its bifurcation into the profunda femoris and superficial femoral arteries, normally the profunda femoris artery courses: A. posterolateral to the superficial femoral artery B. anterolateral to the superficial femoral artery C. posteromedial to the superficial femoral artery D. anteromedial to the superficial femoral artery E. lateral to the superficial femoral artery

A. Posterolateral to the superficial femoral artery. Explanation: "Profunda femoris" is Latin for "deep femoral", and the two are used interchangeably; thus, the profunda femoris artery is posterior (deep) to the superficial femoral artery. It usually branches posterolateral to the superficial femoral artery (heading toward the femur).

What is the most common location of atherosclerotic disease of the renal artery? A. proximal B. mid C. distal D. intrarenal E. the disease strikes all of these sites with about the same frequency

A. Proximal. Explanation: Atherosclerotic disease tends to affect the bifurcations of arteries. The renal artery is most commonly affected at its origin from the aorta. This is considered to be the proximal portion of the vessel. Fibromuscular disease more commonly affects the mid to distal aspect of the renal artery.

A patient with chronic venous insufficiency complains of sudden onset of edema and pain in the affected leg. This may be related to: A. recurrence of acute deep venous thrombosis B. elevated right-heart pressures C. failure to wear surgical support stockings D. lymphedema secondary to chronic venous occlusion E. it is probably not vein-related

A. Recurrence of acute deep venous thrombosis. Explanation: Since previous DVT is a risk factor for new DVT, a sudden onset of new symptoms must be taken seriously.

In the situation in the previous question, pressure in the artery distal to the fistula will be: A. reduced B. increased C. variously increased or decreased depending on cardiac output D. unchanged E. immeasurable

A. Reduced. Explanation: There will be less pressure distally due to the steal across the fistula. All of these flow changes will vary with the size of the fistula, proximity to the heart, and time.

The right thigh-pressure measurement is 108mmHg, while the left high-thigh is 142mmHg. Brachial pressure is 122mmHg. Of the following, this most likely suggests: A. right femoral artery obstruction B. left femoral artery obstruction C. aortoiliac obstruction D. left iliac artery obstruction E. right popliteal artery obstruction

A. Right femoral artery obstruction. Explanation: The obstruction must be proximal to the high-thigh cuff, but not as far proximal as the aortic segment, since the left side is within normal limits. (Right iliac artery obstruction is a possibility, of course, but is not of the choices here.)

Your segmental pressure readings indicate 126mmHg at the high thigh, 144 at the low thigh, and 120 at the below-knee level. These findings might be the result of all EXCEPT: A. SFA obstruction B. cuff artifact C. poor cuff application D. calcified arteries in a diabetic patient E. all are possible causes

A. SFA obstruction. Explanation: The low-thigh reading of 144mmHg is a "reverse gradient", usually an artifactual problem: poor cuff application, cuff too narrow, even a partially incompressible artery due to medial calcification. SFA obstruction would be expected to decrease the low-thigh pressure.

A probe in the 7 to 10MHz range is best used for: A. saphenous vein mapping prior to bypass surgery B. routine DVT studies in the lower extremity C. abdominal imaging D. cardiac echo E. this is not a useful probe frequency for vascular studies

A. Saphenous vein mapping prior to bypass surgery. Explanation: This frequency is best for fairly superficial structures; it would be too high a frequency for routine lower extremity deep vein assessment.

This lower extremity angiogram demonstrates: A. severe SFA stenosis on the right B. severe SFA stenosis on the left C. severe CFA stenosis on the right D. severe CFA stenosis on the left E. it is nondiagnostic

A. Severe SFA stenosis on the right. Explanation: You can see some diffuse irregularity along the right superficial femoral artery segment, but there is a focal tight lesion about 3/5 of the way down.

The Doppler sample volume is usually adjusted: A. small, to sample flow only from center stream B. small, to sample flow right against the arterial walls C. big enough to sample flow from the entire lumen of the artery D. big enough to sample flow from a long segment of the artery E. is not an issue with pulsed-wave Doppler

A. Small, to sample flow only from center stream.

Which artery is the left branch of the celiac trunk? A. splenic artery B. hepatic artery C. left gastric artery D. gastroduodenal artery E. the relative size of the branches varies too widely to say with certainty.

A. Splenic artery.

A useful landmark for locating the renal arteries is the: A. superior mesenteric artery B. right renal vein C. celiac axis D. common hepatic artery E. inferior mesenteric artery

A. Superior mesenteric artery. Explanation: The renal--artery origins lie just distal to the origin of the superior mesenteric artery (SMA) from the aorta. The left renal vein, which passes across to the inferior vena cava under the proximal SMA and lies anterior and a bit distal to the renal arteries, can also be a useful landmark.

In this spectral display, the same patient has clenched his fist for three minutes. What effect has the fist clenching had? A. the exercise causes flow to become retrograde throughout the cardiac cycle B. the exercise causes flow to return to antegrade throughout the cardiac cycle C. the exercise has no effect on the vertebral artery D. the patient will suffer posterior-circulation symptoms E. the patient will suffer unilateral visual symptoms

A. The exercise causes flow to become retrograde throughout the cardiac cycle. Explanation: The exercise increases the demand in the arm, increasing the abnormal pressure gradient and causing flow in the vertebral artery to flow retrograde throughout the cardiac cycle. The patient will not necessarily suffer any symptoms at all.

This waveform from an internal carotid artery is measured at >273cm/sec peak systolic velocity and 125cm/sec end-diastolic velocity. It suggests: A. the exercise causes flow to become retrograde throughout the cardiac cycle B. the exercise causes flow to return to antegrade throughout the cardiac cycle C. the exercise has no effect on the vertebral artery D. the patient will suffer posterior-circulation symptoms E. the patient will suffer unilateral visual symptoms

A. The exercise causes flow to become retrograde throughout the cardiac cycle. Explanation: The exercise increases the demand in the arm, increasing the abnormal pressure gradient and causing flow in the vertebral artery to flow retrograde throughout the cardiac cycle. The patient will not necessarily suffer any symptoms at all.

The term tunica intima denotes: A. the inner lining of the arterial wall B. the outer lining of the arterial wall C. transverse arterial muscle fibers D. longitudinal muscle fibers E. the middle layer of the artial wall

A. The inner lining of the arterial wall.

A thrombus is found in a soleal vein, a bit proximal to mid calf. If this were to propagate, it would next involve: A. the posterior tibial veins B. the anterior tibial veins C. the popliteal vein D. the posterior arch vein E. the great saphenous vein

A. The posterior tibial veins. Explanation: Soleal veins drain into the posterior tibial and peroneal veins. It is though that this is where much if not most of deep vein thrombosis begins.

This CW Doppler waveform is from a PTA. The ankle pressure was measured and divided by the higher brachial pressure to arrive at an ankle/arm ratio of 0.56. Which of the following is true? A. there is something wrong here B. this is within normal limits

A. There is something wrong here. Explanation: This is a decidedly normal, triphasic arterial waveform. It does not conform to an A/A ratio of 0.56, where you would expect something damped and monophasic.

Which of the following statements about this figure is TRUE? A. this spectrum is characteristic of an external carotid artery B. this spectrum is characteristic of a common carotid artery C. this spectrum is characteristic of an internal carotid artery D. this spectrum is severely stenotic in character E. this spectrum suggests distal total occlusion

A. This spectrum is characteristic of an external carotid artery. Explanation: This waveform has a prominent dicrotic notch, a sharp peak, and relatively little diastolic flow. We don't know for sure that it is the ECA, but it is characteristic of that artery. The common carotid artery might have similar-appearing peaks, but normally it would have more diastolic flow.

Regarding capillaries, which is FALSE? A. they have only intima and adventitia layers. B. they measure approximately 8 microns in diameter? C. they transit time of blood through capillaries is approximately one to three seconds. D. they lose fluid at the arteriolar end. E. they resorb fluid at the venular end.

A. This statement about capillaries--"They have only intima and adventitia layers"--is false. Explanation: Capillaries are made only of endothelial cells--just intima.

Which of the following is NOT correct regarding the great saphenous vein? A. it passes superiorly on the lateral side of the knee B. it passes superiorly on the medial side of the thigh C. it enters the common femoral vein D. it extends distally to the dorsum of the foot E. it has more valves in the calf than in the thigh

A. This statement above the saphenous vein--"It passes superiorly on the lateral side of the knee"--is NOT correct.

Which statement probably does NOT describe aspects of Raynaud's disease? A. normal digital pressures when the hand is immersed in cold water B. decreased pressures when the hand is immersed in cold water C. normal wrist pressures when the hand is immersed in cold water D. sequential white, blue, then eventually red color changes in fingers when the hand is immersed in cold water E. sequential white, blue, then eventually red color changes in toes when the foot is immersed in cold water

A. This statement--"Normal digital pressures when the hand is immersed in cold water"--probably does NOT describe aspects of Raynaud's disease. Explanation: Finger pressures after cold water immersion decrease in the patient with Raynaud's secondary to vasoconstriction. Indeed, the pulse usually disappears altogether, making pressure measurement impossible until the spasm passes.

A transient ischemic attack: A. resolves within 24 hours B. does not resolve within 24 hours C. resolves within 72 hours D. resolves after 24 hours E. resolves in one week

A. resolves within 24 hours. Explanation: transient ischemic attacks (TIAs), by definition, resolve within 24 hours, although TIAs often last just a few minutes.

A popliteal to dorsal pedal lesser saphenous reverse bypass graft has a peak systolic velocity of 28cm/sec at the distal anastomosis. Which of the following is true? A. this velocity may be normal for this graft B. the graft is failing because the velocity is less than 45cm/sec C. the graft is failing because the graft velocity has increased from 24cm/sec measured in a previous study D. the graft is failing because the graft velocity has decreased from 32cm/sec measured in a previous study E. we must know the diastolic velocity before interpreting this velocity information

A. This velocity may be normal for this graft. Explanation: The 45cm/sec threshold for graft failure has had wide circulation, but other factors may make it invalid. For example, the distal end of the reversed vein graft, being larger in diameter, might be expected to have velocities that are lower than those at the proximal end. The important finding would be significant changes from the baseline exam. Findings suggest criteria for diagnosing impeding graft failure that include mean graft velocity.

The brachial vein connects the: A. ulnar and radial veins to the axillary vein B. ulnar and radial veins to the subclavian vein C. ulnar vein to the cephalic vein D. radial vein to the subclavian vein E. radial vein to the axillary vein

A. Ulnar and radial veins to the axillary vein.

Points of technique to be observed during ultrasound-guided compression of pseudoaneurysm include all EXCEPT: A. use color flow to confirm that flow remains biphasic within the pseudoaneurysm B. monitor ankle pressure C. use color flow to monitor flow in the common femoral artery D. release pressure for a short time at 10 to 15 minute intervals E. use color flow to confirm that flow is obliterated in the pseudoaneurysm

A. Use color flow to confirm that flow remains biphasic within the pseudoaneurysm. Explanation: Ultrasound-guided thrombin injection looks promising at press time and may eventually replace this strenuous procedure.

This angiogram demonstrates: A. vessel overlap, making diagnosis difficult B. moderate ICA stenosis C. severe ICA stenosis D. total occlusion of ICA E. filling defect, suggesting total occlusion of the external branch

A. Vessel overlap, making diagnosis difficult. Explanation: This may indeed be a moderate stenosis, but the overlap of the two branches makes it difficult to say for sure. There is something there; note again the wavy intrusion into the lumen, starting in the distal CCA.

Bruits heard bilaterally, loudest low in the neck, are most likely caused by: A. aortic valve stenosis B. innominate stenosis C. bilateral subclavian stenosis D. aortic arch occlusion E. bilateral CCA obstruction

A. aortic valve stenosis. Explanation: aortic murmurs radiate distally, frequently into the low carotids.

A 24-year old patient with a history of recent automobile accident arrives in the ICU with symptoms of acute right-side weakness and aphasia. The most likely etiology of these symptoms is: A. carotid dissection B. cerebral aneurysm rupture C. severe internal carotid artery stenosis D. embolic activity from cardiac mural thrombus E. thrombocytopenia

A. carotid dissection. Explanation: Any kind of severe intimal injury, as with the sudden and violent movement of a car accident, can cause a tearing injury to the aorta or other arteries. A patient this young is unlikely to have atherosclerotic carotid disease. Cerebral aneurysm is more distantly possible, but the history of automobile accident makes carotid dissection the best answer.

Among the chief limitations of continuous-wave Doppler is (are): A. depth information is not possible; precise location of flow pattern cannot be determined B. the two-transducer system is inherently more expensive C. polarity of the reflected signal frequency shift cannot be determined; direction of blood flow cannot be defined D. FFT spectral analysis cannot be applied to continuous-wave Doppler signal information E. the sample volume is too small to interrogate deeper vessels

A. depth information is not possible, precise location of flow pattern cannot be determined. Explanation: The two-XDR probes for CW Doppler are relatively inexpensive. Directionality is included in most diagnostic-grade CW Doppler systems, and they can be connected to a spectrum analyzer. And of course CW has no sample volume as pulsed Doppler does. (See above).

A patient describes a 30-minute episode of garbled speech. This is called: A. dysphasia B. aphasia C. paresthesia D. dysphagia E. syncope

A. dysphasia. Explanation: "aphasia" is widely used as well, but technically this is incorrect, since it means "absence of speech."

Loss of the spectral window with pulsed Doppler ultrasound occurs with: A. flow turbulence B. parabolic flow C. laminar flow D. all of the above E. none of the above

A. flow turbulence Explanation: the spectral window is the blank area underneath systole on the spectral waveform. It is filled in or "lost" when turbulent flow creates spectral broadening. Other reasons for loss of the spectral window include overuse of Doppler gain and incorrect positioning of the sample volume outside of the center streamline (depicting signals from the vessel wall or adjacent slower moving blood flow).

The usual instrumentation for handheld TCD includes a probe with an operating frequency of: A. 10kHz B. 2MHz C. 5MHz D. 7.5MHz E. 10MHz

B. 2MHz.

The following tracing is taken from a patient with chronic ankle and calf edema. The PPG sensor is placed slightly proximal to the medial malleolus, and the patient dorsiflexes five times, then relaxes. The tracing: A. suggests significant valvular incompetence B. is within normal limits C. is equivocal D. suggests not venous but arterial insufficiency E. suggests acute deep vein thrombosis

A. suggests significant valvular incompetence. Explanation: The PPG tracing is a reflection of intravenous pressure. Following the dorsiflexions, which reduce intravenous pressure to a minimum, the return to original pressure should result only from inflow from capillaries and therefore take at least 20 seconds. A rapid return like this one suggests that blood is refluxing because of valvular incompetence.

In the calculation of ankle/brachial systolic pressure ratios, the following arm pressure is commonly selected as the denominator: A. the higher of the right or left arm pressures B. the lower of the right or left arm pressures C. the right arm pressure D. the left arm pressure E. random selection of the right or left arm pressure

A. the higher of the right or left arm pressures. Explanation: It is very important to remember that the higher arm pressure is the pressure used to determine ankle/brachial systolic pressures.

Simultaneous bilateral ocular symptoms in the patient with suspected cerebrovascular disease generally originate from: A. the vertebrobasilar arteries B. the ophthalmic arteries C. both common carotid arteries D. both internal carotid arteries E. both external carotid arteries

A. vertebrobasilar arteries. Explanation: Bilateral ocular symptoms usually originate in the posterior circulation, as the visual cortex is in the occipital lobe. However, the specific binocular symptom of homonymous hemianopia (see above) results from obstruction of a middle cerebral artery branch, not the vertebrobasilar system.

Choose the color box that will NOT produce a reasonably good color display for this diving internal carotid artery. A B C D. None will produce good color E. All will produce good color.

B. Explanation: This position creates angles too close to 90 degrees to create a good color display.

Major complications of cerebrovascular angiography occur in approximately: A. 10% of patients B. 1% of patients C. 0.1% of patients D. 0.01% of patients E. >20% of patients

B. 1% of patients.

Approximately what percentage of untreated calf-vein thrombosis is thought to propagate to a proximal level (i.e., popliteal or above)? A.3-5% B. 15-20% C. 50-60% D. more than 90% E. all calf-vein thrombosis propagates at least to the popliteal level

B. 15-20%.

Normal diameter for the abdominal aorta is: A. less than 1cm B. 2-3cm C. 3-5cm D. 5-7cm E. approximately 10cm

B. 2-3cm

Conventional arteriography reveals 30% diameter stenosis in a symptomatic patient with severe stenosis by B-mode and peak systolic velocities of 250cm/sec in the proximal ICA. Which of the following statements about these findings is TRUE? A. the high velocities were caused by carotid kinking. B. even double-projection arteriography may fail to fully determine diameter stenosis, especially in the event of vessel overlap. C. arteriography may fail to reveal small "berry" aneurysms in the brain. D. B-mode "plaquing" may have been background ultrasound noise. E. the ultrasound findings are not as important as the findings of an arch study.

B. Even double projection arteriography may fail to fully determine diameter stenosis, especially in the event of vessel overlap. Explanation: One of the main advantages of duplex is the ability to visualize in cross section to the artery. Vessel overlap is a common problem. A kink would show up on angiography. "Background ultrasound noise" would not cause accelerated velocities.

Which of the following is NOT considered a risk factor for atherosclerosis? A. hypertension B. female gender C. diabetes mellitus D. lipoprotein abnormalities E. tobacco use

B. Female gender Explanation: Being female is not considered a risk factor, although postmenopausal females are at greater risk for atherosclerosis than premenopausal females. Indeed, male gender is considered a (minor) risk factor.

Of the following, which is NOT one of the main collateral pathways in the event of ICA obstruction? A. posterior to anterior B. genicular to arcuate branches C. contralateral hemisphere D. ECA branches to ophthalmic branches E. all represent major cerebrovascular collateral pathways

B. Genicular to arcuate branches. Explanation: Genicular arteries are around the knee; arcuate arteries are in the kidneys.

The risk of claudication in diabetic patients is: A. equal to the risk in the general population B. greater than 4 times the risk in the general population C. close to 10% of the risk in the general population D. lower than that in the general population E. claudication is not an ischemic symptom for diabetics

B. Greater than 4 times the risk in the general population. Explanation: Diabetes is a significant risk factor in lower extremity arterial disease.

Which of the following is a normal finding in a patient who has a transjugular intrahepatic portosystemic shunt (TIPS)? A. hepatofugal flow in the MPV B. hepatopetal flow in the MPV C. hepatofugal flow in the splenic vein D. absence of flow in the portal vein E. A, B, and C

B. Hepatopetal flow in the main portal vein. Explanation: Flow should be hepatopetal: toward the liver. Hepatofugal flow, away from the liver, is an abnormal finding in both the portal and splenic veins. No flow is bad too.

The characteristics of flow in the different carotid artery segments are: A. low-resistance character in the ECA, high-resistance in the ICA, with mixed character in the CCA B. high-resistance character in the ECA, low-resistance in the ICA, with mixed character in the CCA C. low-resistance in both the ICA and ECA, with higher-resistance character in the CCA D. high-resistance in both the ICA and ECA, with lower-resistance character in the CCA E. low-resistance character throughout

B. High-resistance character in the ECA, low-resistance in the ICA, with mixed character in the CCA.

Which one of the following changes occurs in the peripheral blood flow of limbs with obstructive arterial disease in response to laboratory-induced ischemia (reactive hyperemia procedure) or exercise? A. flow increases more in obstructed limbs than in limbs with no obstruction B. hyperemia is prolonged in obstructed limbs in comparison to limbs with no obstruction C. flow decreases in order to redistribute blood volume to the central circulation D. cardiac output is reduced E. peripheral resistance is increased due to muscle contraction

B. Hyperemia is prolonged in obstructed limbs in comparison to limbs with no obstruction. A. Hyperemia is prolonged in patients with significant obstruction. Cardiac output is partly a function of how much blood the peripheral circulation is willing to accept. Decreased peripheral resistant, such as after reactive hyperemia or exercise, would tend to increase cardiac output.

This carotid angiogram demonstrates: A. ECA occlusion and moderate ICA stenosis B. ICA occlusion and severe ECA stenosis C. severe stenosis of ICA and ECA D. occlusion of CCA E. the image is nondiagnostic

B. ICA occlusion and severe ECA stenosis. Explanation: The superior thyroid is still there, and some other ECA branches; the ECA itself is a faint shadow, with little contrast making it through. The ICA is gone altogether.

Which of the following describes what is seen on the right lower extremity of patient "Bob"? A. aortoiliac obstruction B. iliac occlusion C. femoral stenosis D. tibial obstruction E. within normal limits

B. Iliac occlusion. Explanation: There is something wrong proximal to that monophasic CFA waveform, but it does not affect the left side, where the CFA is multiphasic. So it can't be aortoiliac; it must be confined to the right iliac level. Mainstream pressure-index criteria suggest occlusion when the high-thigh is less than 0.80.

Which of the following describes what is seen on the right lower extremity of patient "Myra"? A. aortoiliac obstruction B. iliac stenosis C. femoral stenosis D. tibial stenosis E. within normal limits

B. Iliac stenosis. Explanation: Monophasic but still somewhat sharp CFA waveform, but the problem is again confined to the right iliac level since the left CFA is multiphasic. This time the high-thigh index is reduced but not <0.80, so we'll call stenosis rather than occlusion.

Which of the following is NOT a useful color flow adjustment in an effort to detect slow flow in a possibly occluded ICA? A. increase color flow gain B. increase color flow PRF C. decrease color flow PRF D. decrease color flow wall filter E. decrease beam angle relative to the vessel

B. Increase color flow PRF. Explanation: Increasing PRF will make the color flow less sensitive to slow flow.

The most common anatomic variation of the renal arteries is: A. congenital absence of one main renal artery B. multiple renal arteries C. anterocaval course of right renal artery D. retroaortic renal artery E. coarctation of the renal artery

B. Multiple renal arteries. Explanation: Multiple renal arteries are the most common anatomic variant of the renal arteries, occurring in as many as 30% of individuals. Multiple renal arteries may occur unilaterally or bilaterally, and they occur with equal frequency on both the right and left sides. They most commonly originate from the abdominal aorta or common iliac arteries but may arise from the superior and inferior mesenteric, median sacral, intercostal, lumbar, adrenal, inferior French, right hepatic, or right colic arteries. These anomalous origins of the renal arteries are commonly seen in individuals with ectopic or horseshoe kidneys.

The three terminal branches of the ophthalmic artery are the: A. superficial, facial, and frontal arteries B. nasal, frontal, and supraorbital arteries C. basilar, anterior communicating, and posterior communicating arteries D. vertebral, facial, and nasal arteries E. nasal, frontal, and facial arteries

B. Nasal, frontal, and supraorbital arteries. Explanation: These branches are assessed in the periorbital Doppler examination for carotid artery disease. Questions about periorbital Doppler assessment are no longer included on the ARDMS exam.

This lower extremity angiogram demonstrates: A. occlusion of the right superficial femoral artery with distal reconstitution B. occlusion of the left superficial femoral artery with distal reconstitution C. severe stenosis of the right superficial femoral artery D severe stenosis of the left superficial femoral artery E. severe trifurcation disease

B. Occlusion of the left SFA with distal reconstitution. Explanation: Again, having both right and left helps here. This is the distal end of an SFA occlusion, with reconstitution from the deep femoral artery (coming in from the right side of the image).

Rest pain is characterized by: A. upper calf pain B. pain at night in the forefoot or foot that may go away with leg dependency C. pain while walking that goes away with rest D. upper calf pain that goes away with leg dependency E. any calf pain that goes away with leg dependency

B. Pain at night in the forefoot or foot that may go away with leg dependency. Explanation: Nocturnal forefoot pain relieved by dependency or exercise is the most common complaint of patients with rest pain.

Which of the following is a TRUE statement regarding impotence? A. few impotent males have vascular disease as the etiology B. penile pressure can decrease after treadmill testing C. occlusions of the common iliac artery cannot vascular impotence D. vascular impotence is almost always surgically correctable E. erection is impossible if vascular impotence is present

B. Penile pressure can decrease after treadmill testing. Explanation: Vascular disease is the most common cause of impotence, but neurogenic and psychosomatic causes are also possible. Penile pressures can decrease after exercise as a result of a steal to the legs when the lower extremity vascular resistance is reduced. Any vascular lesion at or above the internal iliac artery may be implicated. Often an erection can be initiated but not sustained. Surgical correction of the vascular disease is at this time done only in selected cases, with promising but not absolute results.

A spontaneous splenorenal shunt--an abnormal connection between the splenic vein and the left renal vein--is associated with: A. renovascular hypertension B. portal hypertension C. renal failure D. renal cell carcinoma E. acute IVC thrombosis

B. Portal hypertension. Explanation: This is one of several possible collateral pathways through which flow from the intestine reaches the inferior vena cava in the event of abnormally increased portal vein resistance (cirrhosis).

The superficial vein that sends flow to the three main perforating veins of the distal calf is called: A. small saphenous vein B. posterior accessory vein C. peroneal vein D. perforator trunk vein E. medial malleolar vein

B. Posterior arch vein. Explanation: The posterior accessory vein (formerly "posterior arch vein"), since it connects the Cockett perforators in the calf, is implicated in the formation of venous stasis ulcers.

Auscultation of the abdomen, aortoiliac, and common femoral areas is important because: A. absence of a bruit suggests absence of arterial disease B. presence of a bruit may be the first indication of arterial disease C. abdominal bruits are significant because they are usually radiating from the aortic arch D. only significant stenosis can cause bruits E. B, C, and D

B. Presence of a bruit may be the first indication of arterial disease. Explanation: Again, hearing a bruit may be the first indication of arterial disease.

A damped Doppler velocity waveform of the subclavian artery isolates a significant lesion: A. at or distal to the brachial artery B. proximal to the point of insonation C. near the origin of the subclavian artery D. to the vertebral artery E. to the innominate artery

B. Proximal to the point of insonation. Explanation: This is as specific as you can get with this information. The damped waveform is the result of obstruction damping out energy somewhere proximal to your probe, but you can't yet say exactly where.

Which artery supplies the small intestine, right colon, and transverse colon? A. inferior mesenteric B. superior mesenteric C. left gastric D. right gastric E. gastroduodenal

B. Superior mesenteric. Explanation: The SMA is the second major branch of the abdominal aorta. It arises approximately 1cm below the origin of the celiac trunk. Major branches of the SMA include the inferior pancreaticoduodenal artery, jejunal and ileal branches, ileocolic artery, right colic artery, and the middle colic artery. The IMA feeds the left third of the transverse colon, the sigmoid colon, and part of the rectum. It is usually much smaller than the SMA. It arises on the left ventral aspect of the abdominal aorta a few centimeters before the aortic bifurcation. Its major branches include the left colic artery, sigmoid branches, and superior rectal artery.

What artery is usually the first branch of the external carotid artery? A. inferior thyroid artery B. superior thyroid artery C. supraclavicular artery D. facial artery E. posterior auricular artery

B. Superior thyroid artery.

Which of the following arteries does NOT arise from the subclavian artery? A. vertebral B. superior thyroid C. internal thoracic D. thyrocervical trunk (axis) E. internal mammary

B. Superior thyroid. Explanation: The superior thyroid artery is usually the first branch of the external carotid artery. "Internal mammary" is another name for the "internal thoracic" artery.

When visualizing the carotid bifurcation using duplex ultrasound, magnetic resonance imaging, or angiography, the best way to determine whether you are looking at the ICA is by the fact that: A. the internal carotid has a bulb and the external carotid does not. B. the ECA has branches near the bifurcation and the ICA does not. C. the ICA has branches near the bifurcation and the ECA does not. D. the ECA has a smaller lumen than the ICA. E. the ICA tapers at the bifurcation.

B. The ECA has branches near the bifurcation and the ICA does not.

The test for venous incompetence that uses tourniquets and alterations of patient position is called: A. photoplethysmography B. the Trendelenburg test C. the Hunter's canal test D. the Ferris and Kistener test E. light reflection rheography test

B. The Trendelenburg test. Explanation: This is a venerable test whose accuracy has been called into question.

In the lower extremity circulation, the most common site of atherosclerosis is: A. the arterial segment beginning at the popliteal artery B. the arterial segment beginning in Hunter's canal C. the arterial segment at the iliac bifurcation D. the proximal tibial vessels E. the arterial segment at the popliteal trifurcations

B. The arterial segment beginning in Hunter's canal. Explanation: Another name for Hunter's canal is the adductor canal, located in the mid-to-lower thigh. This is the most common site of atherosclerotic involvement in the lower extremities.

During assessment of ankle pressures, all three vessels at the level of the ankle are used to measure pressures. The pressure in both the PTA and peroneal artery is 40mmHg and the dorsalis pedis pressure is 50mmHg. Which of the following is TRUE? A. The posterior tibial artery pressure should be used to calculate the ankle/brachial index B. the dorsalis pedis artery pressure should be used to calculate the ankle/brachial index C. the peroneal artery pressure should be used to calculate the ankle/brachial index D. there is disease in the tibioperoneal trunk E. there is disease in or above the popliteal artery

B. The dorsalis pedis artery pressure should be used to calculate the ankle/brachial index. Explanation: The higher ankle pressure is used to calculate the index. There may be disease limited t the calf arteries, but there may also be disease above the knee; this information alone does not allow us to say which is the case. Whereas the two branches of the tibioperoneal trunk have equal pressures, each vessel may independently be diseased, and disease in the trunk cannot be diagnosed with this information.

You are using color flow to scan an ICA that dives steeply distally, as shown. The color gets much brighter, even aliasing, in the distal portion of the artery. This probably means: A. the velocities are accelerating as the blood flows downhill. B. the frequency shifts are changing at different points in the color box due to the curvature of the artery. C. there is a significant stenosis distally causing the brighter color and aliasing. D. the color box should be angled in the opposite direction. E. it is not really the internal carotid but the external carotid artery.

B. The frequency shifts are changing at different points in the color box due to the curvature of the artery. Explanation: One must be constantly on the alert for changing angles, which create potentially misleading color flow changes.

The most common source of lower or upper peripheral arterial embolus is: A. ulcerated plaque B. the heart C. aneurysms D. arterial dissections and atherosclerosis E. small vessel arteriosclerosis

B. The heart. Explanation: The heart is the source of 80-90% of peripheral arterial embolic activity in the extremities. The other common source of peripheral arterial emboli is aneurysmal mural thrombus, especially in the aorta, iliac, femoral, and popliteal arteries. On the other hand, the most common source of cerebrovascular embolic activity is atherosclerotic carotid disease.

Monophasic posterior tibial artery waveforms, despite normal ankle/arm indices in the asymptomatic patient, indicate that: A. the low pass filter may be set too low B. the low pass filter may be set too high C. the Doppler gain may be set too high D. the angle of insonation may be too low E. the angle of insonation may be too high

B. The low pass filter may be set too high. Explanation: The high pass filter setting on high could clip frequencies near the baseline, leaving only a monophasic waveform above baseline in the normal arterial signal.

The term tunica adventitia denotes: A. the inner lining of the arterial wall B. the outer lining of the arterial wall C. transverse arterial muscle fibers D. the intimal wall E. the middle layer of the arterial wall

B. The outer lining of the arterial wall.

If we increase the peak systolic velocity value needed to call a carotid test positive for severe ICA stenosis: A. the positive predictive value will decrease, the negative predictive value will increase, and the accuracy may increase or decrease B. the positive predictive value will increase, the negative predictive value will decrease, and the accuracy may increase or decrease C. the positive predictive value and the accuracy will increase, and the negative predictive value will decrease D. the negative predictive value and the accuracy will increase, and the positive predictive value will decrease E. the positive and negative predictive values and the accuracy will remain the same

B. The positive predictive value will increase, the negative predictive value will decrease, and the accuracy may increase or decrease. Explanation: This increase of the threshold raises the bar, as it were, and means that more of the patients called positive by duplex do indeed have severe stenosis. This means an increase in false negatives, since you have increased the PSV required to call severe stenosis. The benefit would be making quite sure that someone designated positive--and perhaps to surgery--really is positive.

The most important reason Doppler evaluations should be performed with the patient in a basal state and warm temperature is: A. the exam will be easier to perform B. the results are influenced by the patient's peripheral resistance C. the results can be expected to vary from day to day D. the results are influenced by the pressure differential found in each vessel E. metabolic activity is increased, making results more reliable

B. The results are influenced by the patient's peripheral resistance. Explanation: Performing the exam in a cold room causes vasoconstriction that may affect peripheral resistance and toe pressures.

Which one of the following is always TRUE of patients who suffer from intermittent claudication? A. peripheral blood flow is reduced at rest B. there is pressure drop distal to the obstructed segment after exercise C. no increase in blood flow occurs through the affected segment during exercise D. marked peripheral vasoconstriction occurs in response to exercise E. there is always a pressure drop distal to the obstructed segment at rest

B. There is pressure drop distal to the obstructed segment after exercise. Explanation: Peripheral flow is generally maintained at rest by compensatory vasodilatation distally. Exercise causes pronounced vasodilatation, greatly increasing flow. Although claudicators usually have a reduced resting pressure, they can sometimes have equivocal or even essentially normal ABIs at rest. Thus some form of challenge (exercise or postocclusive reactive hyperemia) might be required to provoke a pressure drop.

With exercise in patients with postphlebitic syndrome, which of the following is FALSE? A. these patient usually have a small decrease in venous pressure that returns rapidly after ceasing exercise B. they usually have a quick decrease in venous pressure that takes a minute or two to return to pre-exercise levels C. they sometimes have an increase in venous pressure D. they may develop venous claudication E. secondary varices may appear more prominent

B. They usually have a quick decrease in venous pressure that takes a minute or two to return to pre-exercise levels. Explanation: A prolonged return to pre-exercise pressure would be the normal response; return to maximum pressure should take a fairly long time in the patient with competent valves preventing reflux. In patients with incomplete recanalization of thrombus, the obstruction may even cause increased pressure with exercise because of congestion. Secondary varices may fill via incompetent perforators during exercise.

The examiner uses color flow to assess for competence at the common femoral vein level. With Valsalva maneuver, there is red flow lasting approximately half a second, then blue flow on release of Valsalva. A. this finding is within normal limits B. this finding is equivocal for significant valvular incompetence C. this finding confirms significant valvular incompetence D. this finding suggests AV fistula E. this finding confirms deep vein thrombosis

B. This finding is equivocal for significant valvular incompetence. Explanation: 0.5 seconds of reflux is often cited as a threshold for calling incompetence, although some labs use a full second or longer.

Of the chief advantage of continuous-wave Doppler, which of the following is FALSE? A. aliasing cannot occur, recording of extremely high frequency shifts is possible B. it allows more precise range-gating than pulsed-wave Doppler C. the signal-to-noise ratio is inherently greater than pulsed Doppler system due to its continuous state of operation D. continuous-wave Dopplers are less expensive E. the instrumentation is less complex than in pulsed-wave Doppler

B. This statement about CW Doppler--"It allows more precise range-gating than pulse wave Doppler"--is false. Explanation: Continuous-wave Doppler cannot range-gate; information is returned from along the entire beam.

Which of the following is NOT true regarding the internal carotid artery? A. its first major branch is the ophthalmic artery B. it supplies a high-resistance system C. it supplies a low-resistance system D. it is part of the anterior cerebral system E. it originates at the carotid bifurcation

B. This statement about the internal carotid artery--"It supplies a high-resistance system" is false. Explanation: The internal carotid artery feeds a low-resistance system .

Which of these is NOT true about superficial thrombophlebitis in the leg? A. it is usually attributed to a thrombosed saphenous vein B. it can best be diagnosed by photoplethysmography C. it may result in significant incapacitation for the patient D. it usually responds to ambulation, warm soaks, and aspirin E. it is frequently recurrent

B. This statement--"It can best be diagnosed by photoplethysmography"--is NOT true of superficial thrombophlebitis in the leg. Explanation: Photoplethysmography is not a useful modality for this situation.

Which is NOT true regarding carotid bruit? A. severe stenosis may cause a bruit B. the absence of a bruit rules out significant stenosis C. the presence of a bruit is significant D. a cervical bruit might arise from stenosis of the external carotid artery E. a bruit extending into diastole suggests severe stenosis

B. This statement--"The absence of the bruit rules out significant stenosis"--is NOT true. Explanation: Bruits are caused by turbulent flow. Presence of a bruit is significant, since there is turbulent flow for some reason (not always stenosis). The absence of a bruit does not rule out stenosis; severe stenosis may not cause a bruit.

The term hemiparesis means: A. paralysis of one side B. weakness of one side C. numbness/tingling on one side D. spasm of voluntary muscle on one side E. dizziness

B. weakness of one side. Explanation: Hemiparesis is also referred to as unilateral paresis.

A patient has a 7cm abdominal aortic aneurysm. The patient elects not to have an operation, despite the surgeon's recommendation. Which of the following statements is FALSE? A. the mortality of rupture, even with prompt care, is at least 50% B. the risk of death from cardiac disease is greater than the risk of death from rupture of the aneurysm C. there is little risk for distal embolization D. there is little risk for aortic occlusion E. the surgeon's recommendation is sound based on the natural history of AAA

B. This statement--"The risk of death from cardiac disease is greater than the risk of death from rupture of the aneurysm"--is FALSE. Explanation: Despite the association of cardiac disease with other manifestations of atherosclerosis, patients with unrepaired aneurysms of this size have a higher mortality due to rupture than to cardiac disease. Despite the size, the occurrence of other complications is not that common. Before the advent of elective surgical repair, patients with aneurysms were followed extensively in some series, so the natural history of the disease is well known. Most patients choose surgery to reduce their risk of death related to rupture.

Which set of waveforms is most likely to be obtained with a continuous-wave Doppler when there is a long superficial femoral artery occlusion? A. triphasic waveforms from the common femoral to the tibial arteries B. triphasic waveforms at the common femoral and proximal superficial femoral arteries with monophasic waveforms in the popliteal and tibial arteries C. monophasic waveforms throughout D. monophasic waveforms at the popliteal artery and triphasic waveforms at the tibial arteries E. triphasic waveforms at the femoropopliteal arteries and monophasic waveforms at the tibialo arteries

B. Triphasic waveforms at the common femoral and proximal superficial femoral arteries with monophasic waveforms in the popliteal and tibial arteries. Explanation: Usually triphasic, but occasionally monophasic, staccato-type waveforms may be seen proximal to an occlusion in the superficial femoral artery.

Descending venography is performed to diagnose: A. femoral venous thrombosis B. valvular insufficiency C. popliteal venous thrombosis D. superficial venous thrombosis E. inferior vena cava valvular insufficiency

B. Valvular insufficiency. Explanation: Ascending venography defines the location and extent of venous obstruction. Descending venography identifies specific valvular incompetence. Answer choice E is a dirty trick: the IVC has no valves.

Ischemic ulcers (lesions) are: A. completely painless but bleed with manipulation and are located over pressure points or calluses B. very painful and commonly located distally over the dorsum of the foot C. only mildly painful and relieved by elevation D. very painful and are usually located around the malleolus E. caused by pathogenic organisms

B. Very painful and are usually located distally over the dorsum of the foot. Explanation: An ulcer found above the medial malleolus is most likely venous in origin.

You are performing CW Doppler on a patient's lower extremity arteries. You obtain a signal at the proximal dorsalis pedis level. When you move proximally, the signal becomes higher in pitch. This could be the result of all EXCEPT: A. you have moved over a stenotic area B. you have stood the probe up, increasing the angle of incidence C. you have leaned the probe back, decreasing the angle of incidence D. you have moved over a segment of the artery which is going deeper E. you are pushing too hard on the probe, artificially narrowing the artery under it

B. You have stood the probe up, increasing the angle of incidence. Explanation: Increasing the angle of incidence would lower the frequency shift. The other items are possible reasons for an increase of frequency shift. The scenario in answer D would decrease the angle, thereby increasing the frequency shift.

Patients with a swollen limb who have just returned from a country where filariasis is endemic may be suspected of having: A. deep venous thrombosis B. lymphedema C. renal failure D. Klippel-Trenaunay syndrome E. lipidemia

B. lymphedema. Explanation: Filaria ia nematode that takes up residence in the lymph system and can cause lymphedema. This would be a somewhat obscure differential diagnosis for deep venous thrombosis.

Subclavian steal occurs: A. more often on the right side B. more often on the left side C. equally often on both sides D. mainly in young, male smokers E. mainly in females

B. more often on the left side.

Amaurosis fugax related to an internal carotid lesion will cause: A. permanent blindness of the contralateral eye B. temporary blindness or shading of the ipsilateral eye C. permanent blindness of the ipsilateral eye D. temporary blindness or shading of the contralateral eye E. temporary blindness or shading of both eyes

B. temporary blindness or shading of the ipsilateral eye. Explanation: amaurosis fugax affects the same side, since thromboembolic activity from ulcerated ipsilateral carotid atheroma is suspected.

Amaurosis fugax can be interpreted as a: A. stroke of the visual cortex B. transient ischemic attack C. stroke of the eye D. transient ischemic attack of the frontal cortex E. stroke of the parietal cortex

B. transient ischemic attack. Explanation: Since amaurosis fugax is, by definition, transient, it can best be described as a transient ischemic attack of the eye. "Stroke of the eye" would not be accurate, as that would imply tissue necrosis and permanent damage.

Select the best statement regarding comparison of venous and arterial ulcers: A. venous ulcers are usually not painful and are located on the foot B. venous ulcers are usually not painful and are located cephalad to the foot C. venous ulcers are usually painful and are located cephalad to the foot D. venous ulcers are associated with decreased arterial pulses E. arterial ulcers are treated with Unna boots

B. venous ulcers are usually not painful and are located cephalad to the foot. Explanation: Venous ulcers are usually not painful and located proximal to the medial malleolus cephalad to the foot. Venous ulcers are treated with Unna boots (compression system with medicated dressing); arterial ulcers are not.

Which statement about this spectral display from the superficial femoral artery is TRUE? A. it is within normal limits B. it suggests borderline velocity increase, compatible with approximately 50% stenosis C. it suggests severe velocity increase, compatible with >75% stenosis D. it suggests retrograde flow due to collateralization E. it is nondiagnostic

C. It suggests severe velocity increase, compatible with >75% stenosis. Explanation: Peak systolic velocities this high are compatible with high-grade arterial stenosis. Note the absence of systolic window and some low velocities showing below the baseline, both suggesting pronounced turbulence.

On CW Doppler assessment, a patient with a swollen left leg has loud, continuous flow signals from the left great saphenous vein. The asymptomatic leg has nonspontaneous flow in the right great saphenous vein, which augments with distal comrpession. These findings are consistent with: A. normal venous flow B. right-leg DVT C. left-leg DVT D. bilateral DVT E. these findings are not helpful diagnostically.

C. Left-leg DVT. Explanation: The greatly increased flow in the left great saphenous vein suggests that it is acting as a major outflow collateral in the presence of deep vein thrombosis. The character of flow on the right is within normal limits; it is common for flow in the great saphenous vein to be non-spontaneous. Sure, there could be less hemodynamically significant thrombosis on the right, but the saphenous flow does not suggest it.

Which of the following is TRUE regarding chronic venous ulceration? A. lesions are frequently found on the foot. B. pain is severe and is relieved by dependency. C. lesions are usually found on the lower third of the leg around the medial aspect of the ankle. D. lesions do not ooze blood when manipulated. E. granulation tissue is not produced during healing.

C. Lesions are usually found on the lower third of the leg around the medial aspect of the ankle. Explanation: Venous ulcers are partially caused by the venous hypertension that exists during leg dependency. Venous ulceration typically occurs in the "gaiter area" around the medial aspect of the ankle, while arterial ulcers tend to show up on toes and feet. The pain associated with venous ulceration is usually mild. A venous ulcer, not due to arterial insufficiency, would be expected to ooze blood and be able to exhibit granulation.

This carotid angiogram demonstrates: A. normal carotid bifurcation B. preocclusive (>90%) ICA and ECA stenosis C. moderate stenosis of ICA and ECA with probably ulceration D. significant ECA stenosis and normal ICA E. ECA occlusion and moderate ICA stenosis

C. Moderate stenosis of ICA and ECA with probably ulceration.

Anterior compartment syndrome is suspected in a trauma patient with closed fracture of the fibula. Clinically the calf is tense and tender to palpation, and there is decreased sensation in the foot. The dorsalis pedis pulse is present, with an audible triphasic Doppler signal. The dorsalis pedis pressure is 140mmHg, with an arm pressure of 130mmHg. Why is this finding unreliable for ruling out a compartment syndrome? A. dorsalis pedis flow is not via the anterior tibial compartment, thus one would not expect the signal to be altered B. the posterior tibial or peroneal artery may supply collateral flow, such that the dorsalis pedis artery is unaffected C. nerve and/or motor dysfunction due to compartment syndrome may occur without any alteration of arterial hemodynamics D. compartment syndrome is not related to closed fractures E. the noninvasive arterial testing is inadequate. Venous testing would be necessary to make the diagnosis

C. Nerve and/or motor dysfunction due to compartment syndrome may occur without any alteration of arterial hemodynamics. Explanation: The ATA is located in the anterior compartment and supplies the dorsalis pedis artery. However, increased pressures that can affect anterior tibial nerve and muscle function may be less than those that alter the pressure or audible Doppler characteristics of the ATA. The diagnosis of compartment syndrome is made clinically, and if necessary, intracompartment pressures are measured by a needle/manometer technique.

This waveform from the origin of the internal carotid artery suggests: A. severe proximal ICA stenosis B. severe common carotid artery stenosis C. occlusion at the ICA origin D. brain death E. postendarterectomy flow changes

C. Occlusion at the ICA origin.

A correlation of a noninvasive test to its "gold standard" yields a positive predictive value of 86%. This means that: A. of all noninvasive tests performed, 86% correctly classified the disease B. of all gold standard results that were abnormal, the noninvasive test correctly classified 86% C. of all positive noninvasive tests, 86% correctly predicted that the gold standard would be abnormal D. of all noninvasive tests performed, 86% were positive E. of all positive noninvasive tests, 14 incorrectly predicted the gold standard would be abnormal

C. Of all positive noninvasive tests, 86% correctly predicted that the gold standard would be abnormal. Explanation: The calculation of the positive predictive value utilizes only those tests with an abnormal result. Thus any response that utilizes all tests--i.e., responses A and D--cannot be correct. In addition, answer choice B is the definition of sensitivity, since the abnormal "gold standard" results are the denominator of the equation. Thus only responses C and E are potentially correct. Response E states that 14 positive tests were incorrect; this would be true only if a total of 100 positive tests were performed. Since the problem does not state the number of tests performed, there is insufficient data present to derive this answer, and it must be false. The correct definition for the positive value is expressed in answer C.

The brachiocephalic vein is found: A. only on the right side B. only on the left side C. on both the right and left sides D. there is no such vein; it is called "innominate" E. this vein is located centrally in the cranium

C. On both the right and left sides. Explanation: The venous anatomy in the upper torso differs from the arterial anatomy. There are right and left brachiocephalic veins, which receive flow from the internal jugular and subclavian veins, but there is just the right innominate (also called brachiocephalic) artery.

Ulcers due to arterial insufficiency are found most often: A. behind the knee B. in the gaiter area, near the medial malleolus C. on toes and distal foot D. over the lesion, usually along the Hunter's canal E. mid calf

C. On toes and distal foot.

A condition that presents as a severely swollen, blue, cool lower extremity is called: A. stasis dermatitis B. phlegmasia alban dolens C. phlegmasia cerulea dolens D. cellulitis E. lymphedema

C. Phlegmasia cerulea dolens.

A 28-year-old male complains of exercise-induced cramping of the right calf that occurs after walking six blocks and is relieved within 5 minutes of rest. Bounding pedal pulses are noted and resting ankle pressures are normal. The symptoms are reproduced with exercise. The ankle pressure remains normal on the left but drops to 40mmHg on the right. These signs are consistent with: A. occlusion of the superficial femoral artery B. compartment syndrome C. popliteal entrapment D. coarctation of the aorta E. deep venous thrombosis

C. Popliteal entrapment. Explanation: Claudication-like symptoms in a young person, especially a muscular male, are likely due to popliteal entrapment. Atherosclerotic obstruction is very unlikely; Compartment syndrome generally follow injury and/or reperfusion. Coarctation would cause symptoms in both lower extremities. The symptoms of deep venous thrombosis are very different and would not cause a decrease in arterial pressure.

Complaints of chronic unilateral lower extremity swelling, aching, and a sense of heaviness most likely suggests: A. cardiac/systemic origin B. lipidemia C. postphelbitic syndrome D. primary varicose veins E. venous ulceration

C. Postphlebitic syndrome.

Patients with significant mesenteric artery obstructive disease generally have symptoms of: A. preprandial pain, relieved by eating B. preprandial bloating, relieved by eating C. postprandial pain D. postprandial syncope E. postprandial hypertensive state

C. Postprandial pain. Explanation: This is sometimes referred to as "bowel claudication," since it is ischemic pain brought on by increased demand for perfusion.

Audible Doppler venous signals typically are low-frequency and vary with respiration, whereas normal arterial signals in the legs and arms are: A. low-frequency yet pulsatile B. multiphasic and vary with respiration C. relatively high-frequency with pulsatile components D. relatively high-frequency and nonpulsatile E. multiphasic and phasic with respiration

C. Relatively high-frequency with pulsatile components. Explanation: Arterial Doppler signals do not change appreciably with respiration.

Patients suspected of having venous disease may complain of pain that is: A. only during the day B. not constant C. relieved by elevation D. not relieved by elevation E. mostly felt at night

C. Relieved by elevation. Explanation: Elevation of the extremities decreases venous hypertension and pain.

This lower extremity angiogram demonstrates occlusion of: A. right ATA B. left ATA C. right tibioperonenal artery D. left tibioperoneal artery E. right popliteal artery

C. Right tibioperoneal artery. Explanation: Having both right and left images there should help. The right ATA is taking its sharp turn to go anterior, but there is no tibioperoneal trunk. Note all the busy collaterals on this side.

Protocols for cardiac treadmill testing and claudication treadmill testing differ, the major difference being: A. a single, faster speed is used for cardiac testing B. the patient is closely monitored by technologists during cardiac testing C. speed is varied during cardiac testing D. the cardiac risk is greater with claudication testing since few patients are monitored with ECG E. elevation is varied during claudication testing

C. Speed is varied during cardiac testing. Explanation: The standard cardiac treadmill protocol aims to increase the heart rate to a specific target level. This is accomplished by increasing the speed and elevation of the treadmill at specific time intervals during the examination. Treadmill testing for claudication generally uses one unvarying speed and elevation. Both types of exam include blood pressure monitoring, as well as observation by technologists. There is some cardiac risk associated with claudication testing.

This waveform from the left vertebral artery is: A. within normal limits B. suggestive of ICA obstruction C. suggestive of developing subclavian steal D. suggestive of left brachial artery obstruction E. monophasic

C. Suggestive of developing subclavian steal syndrome. Explanation: The developing abnormal pressure gradient in the left arm is pulling flow below baseline at systole; the flow reverts to antegrade in diastole. This might be converted to a full steal by performing reactive hyperemia on the left arm or having the patient exercise the arm to increase demand.

This CW Doppler waveform from a popliteal artery: A. is a normal arterial waveform B. is severely abnormal in character C. suggests interference from venous flow D. suggests femoral artery occlusion E. is monophasic

C. Suggests interference from venous flow. Explanation: Since continuous-wave analog Doppler displays net or average frequency shifts (i.e., velocities) of all flow intersecting the beam, venous flow can interfere with your efforts to get a clear arterial tracing on paper.

Intracranial potential collateral arteries include all but the following: A. anterior communicating artery B. posterior communicating artery C. superficial temporal artery D. leptomeningeal pathways E. rete mirable

C. Superficial temporal artery. Explanation: The superficial temporal artery is not an intracranial vessel. Leptomeningeal collaterals and the rete mirable ("wonderful net") are potential collateral pathways of lesser importance than the circle of Willis arteries.

Venous refilling time by photoplethysmography was 10 seconds without a tourniquet applied and 25 seconds with a tourniquet applied to the lower thigh. The diagnosis is: A. deep and superficial valvular insufficiency B. deep valvular insufficiency C. superficial valvular insufficiency D. superficial venous thrombosis E. deep venous thrombosis

C. Superficial valvular insufficiency. Explanation: The tourniquet took the superficial system out of the picture, which returned the result to normal. Therefore, the superficial system caused the rapid refill.

The portal vein is formed by the junction of the: A. superior mesenteric and colic veins B. inferior mesenteric and splenic veins C. superior mesenteric and splenic veins D. right and left hepatic veins E. right and left portal veins

C. Superior mesenteric and splenic veins. Explanation: The inferior mesenteric vein joins with the splenic vein, which in turn joins with the superior mesenteric vein to become the portal vein.

A condition that causes nonatherosclerotic narrowing of brachiocephalic arteries in overwhelmingly female patients is called: A. compartment syndrome B. Raynaud's syndrome C. Takayasu's arteritis D. FMD E. Buerger's disease

C. Takayasu's arteritis.

The term muscle pump refers to: A. the ventricles of the heart B. the right atrium of the heart C. the calf muscles D. the pulmonary arteries E. the veins in the groin

C. The calf muscles. Explanation: The term "muscle pump" refers to the mechanism of venous return from the lower extremities, which must overcome significant hydrostatic pressure in the upright patient. The veins and sinuses fill during relaxation; then contraction of lower extremity muscles propels blood cephalad.

After completing the study, the authors decided to review their findings to evaluate the role of diabetes in patient outcomes. A review for this variable yielded the following results: According to these data, which of the following statements is NOT true? A. a higher percentage of patients with diabetes did not heal B. an ankle pressure of >60mmHg was a better indication of healing potential than a pressure of <60mmHg for both groups C. diabetics with >60mmHg ankle pressures that did not heal had calcific arteries causing falsely elevated pressure D. about an equal percentage of patients in each group had pressure <60mmHg E. healing of a toe amputation site does occur in some patients with pressures <60mmHg

C. This statement--"Diabetics with >60mmHg ankle pressures that did not heal had calcific arteries causing falsely elevated pressure"--is NOT true based on the data presented.

The ICA waveform below has a peak-systolic velocity of 285 cm/sec, with an end-diastolic velocity of 66 cm/sec. Which of the following is/are true regarding this waveform? A. this is within normal limits B. the open systolic window suggests mild-to-moderate stenosis (<50% by diameter) C. the elevated peak-systolic velocities and significant end-diastolic velocities suggest significant ICA stenosis (>50% diameter) D. the severely elevated peak-systolic velocities and end-diastolic velocities suggest severe ICA stenosis (>80%) E. B and D

C. The elevated PSVs and significant end-diastolic velocities suggest significant ICA stenosis (>50% by diameter). Explanation: The PSV of 285cm/sec is decidedly high enough to call >50%, well over the time-honored and still valid criterion of >125cm/sec for this threshold. On the other hand, nearly all criteria would call for higher PSV and especially higher EDC to call >80%. The systolic window is not filled: flow is still reasonably orderly here, but the elevated velocities do suggest hemodynamically-significant stenosis.

Demonstration of vein-wall coaptation of the subclavian vein is best performed with: A. probe compression (as in the lower extremities) B. firm arm compression C. the patient taking a quick, deep breath D. the Valsalva maneuver E. the subclavian vein cannot be assessed for vein-wall coaptation

C. The patient taking a quick, deep breath. Explanation: Because it is usually difficult to perform compression maneuvers at this level, this big sniff is a useful way to assess at the subclavian level.

A patient presents with a unilateral chronic swollen leg and a previous diagnosis of deep venous thrombosis 3 years earlier. The most likely finding would be: A. the popliteal vein is thrombosed. B. the popliteal vein is patent and the valves competent. C. the popliteal vein is patent and the valves are incompetent. D. venography is necessary to distinguish old from new thrombus. E. the patient has congestive heart failure.

C. The popliteal vein is patent and the valves are incompetent. Explanation: This is the most likely finding, although chronic obstruction is a possibility. Congestive heart failure would cause bilateral--not unilateral--edema.

The volume flow rate in a reversed saphenous vein bypass graft should be: A. higher proximally and lower distally B. lower proximally and higher distally C. the same throughout the graft D. variable throughout the graft E. inversely proportional to the diameter of the graft

C. The same throughout the graft. Explanation: The flow rate must be the same throughout the graft, assuming no leaks, even though the velocities may differ: Q=mean V times CSA.

The image in Color Plate 7 was taken from a supraclavicular approach with the beam aimed inferiorly. Which of the following correctly describes the image? A. this patient has the common anatomic variant of double subclavian arteries B. this patient has retrograde flow in an accessory subclavian vein C. this is an artifactual image D. this patient has the common anatomic variant of double subclavian veins E. there is pronounced aliasing in the artery

C. This is an artifactual image. Explanation: This is the artifact known as "doubling" of an image, caused by a strong reflector--in this case, the pleura near the clavicle. There is only the one subclavian artery, and the deep one is a fake.

Which of the following is true regarding the spectrum below? A. this spectrum is characteristic of an external carotid artery B. this spectrum is characteristic of a common carotid artery C. this spectrum is characteristic of an internal carotid artery D. this spectrum shows total window filling E. this spectrum suggests high distal resistance

C. This spectrum is characteristic of an internal carotid artery. Explanation: This waveform has lots of diastolic flow, a less distinct peak, and a less prominent dicrotic notch. It is characteristic of the ICA or of any artery feeding a low-resistance distal bed, such as a renal artery.

Which of the following is NOT correct regarding peripheral arterial angiography? A. it is frequently used prior to elective operation for peripheral arterial occlusive disease B. there are problems with vessel overlap using angiography C. arteriography is used for routine postoperative follow-up D. contrast reactions are less of a problem than in past years E. digital subtraction angiography may be performed with intravenous or intraarterial injections

C. This statement about peripheral arterial arteriography--"Arteriography is used for routine postoperative follow-up"--is NOT correct. Explanation: Since it is invasive and carries a small but definite risk of complications, arteriography is not used routinely. Adverse reactions are less likely with newer contrast agents, and arteriography is usually performed prior to peripheral arterial surgery.

Which statement about subclavian steal is FALSE? A. it occurs most commonly on the left side. B. most patients are asymptomatic. C. it results from severe stenosis or occlusion of the proximal vertebral artery. D. lower blood pressure is seen in the affected arm. E. All of these statements are false.

C. This statement about subclavian steal--"It results from severe stenosis or occlusion of the proximal vertebral artery"--is NOT true. All other statements are correct. In subclavian steal, a severe stenosis or occlusion is present in the proximal subclavian artery. This results in retrograde flow in the ipsilateral vertebral artery, as illustrated in the drawing below. The flow is "stolen" from the contralateral vertebral artery by way of the basilar artery

Which of the following is NOT true regarding atherosclerosis? A. atherosclerosis starts as a breakdown of the intima. B. atherosclerosis usually develops at bifurcations. C. atherosclerosis is a red blood cell disease. D. atherosclerosis is a generalized disease. E. intimal damage/repair may begin in adolescence.

C. This statement--"Atherosclerosis is a red blood cell disease"--is NOT true. Explanation: Atherosclerosis is a generalized disease that begins most often at bifurcations due to the shear forces generated at the wall surfaces. Patients with atherosclerosis in the periphery will have other atherosclerotic changes in the carotid and coronary vessels even though these may be clinically silent. Disruption of intimal continuity is the primary initial manifestation.

All of the following statements apply to pulsed-wave Doppler EXCEPT: A. aliasing occurs when the frequency shift exceeds 1/2 the pulse repeition frequency B. one transducer is used for both transmission and reception C. the beam is continuously transmitted with intermittent reception according to vessel depth D. a sample volume is used to determine the depth of interest E. all of these statements are true

C. This statement--"the beam is continuously transmitted with intermittent reception according to vessel depth" is false. With pulsed-wave Doppler, the signal is transmitted in short bursts (or pulses), and the transducer "listens" for the reflected signal in between the transmitted pulses.

Why are brachioal blood pressures obtained bilaterally when evaluating a patient for cerebrovascular disease? A. the systolic components from each arm are averaged to determine the likelihood of cerebrovascular disease B. it is necessary to know both brachial pressures to rule out the presence of hypoperfusion syndrome C. the brachial blood pressures are compared to see if they are equal D. both brachial blood pressures must be known to determine if hypertension is present E. there is no value in obtaining bilateral brachial pressures if they are not compared to the ankle pressures

C. the brachial blood pressures are compared to see if they are equal. Explanation: If one pressure is 15-20mmHg less than the other, subclavian steal is suspected on the side of the lower pressure.

On the basis of the information in the preceding 2 x 2 table, the positive predictive value of the <60mmHg threshold is calculated: A. 15/20 B. 27/30 C. 27/32 D. 15/18 E. 42/50

D. 15/18. Explanation: Positive predictive value is calculated by dividing the true positives (agreements) by all of the noninvasive positives (including the false positives).

A series of carotid duplex studies was correlated to carotid angiography to test a velocity threshold for accuracy in calling >60% vs. <60% stenosis of the Internal Carotid artery. Of the 56 ICAs called >60% by angiography, 53 were correctly identified by duplex. Of the 38 ICAs called <60% by angiography, 8 were called >60% by duplex The correct calculation of specificity would be: A. 8/38 B. 30/94 C. 83/94 D. 30/38 E. 30/33

D. 30/38. Explanation: The specificity of a test is defined as its ability to exclude disease and to detect normality, expressed as a percentage (the number of true negative tests divided by the total number of negative gold-standard tests, true negatives + false positives.

An arterial stenosis that is 75% by cross-sectional area reduction corresponds to a diameter reduction of: A. 75% B. 96% C. 60% D. 50% E. 35%

D. 50%.

The Doppler beam angel considered optimal for standardization of duplex carotid studies at most vascular labs is: A. 0 degrees B. 20-40 degrees C. 40-45 degrees D. 60 degrees E. any angle greater than 60 degrees

D. 60 degrees. Explanation: It is generally accepted that, to make consistent velocity measurements, one must be consistent about the Doppler beam angle. Some labs insist on 60 degrees, no more and no less; other labs keep it within the range of 45 degrees or 50 degrees to 60 degrees.

An elderly patient who presents with localized pain at mid calf has an ultrasound exam that reveals a nonocclusive thrombus of the femoral vein. The calf pain became excruciating after administration of heparin. A second ultrasound exam demonstrates: A. progression of deep venous thrombosis to the popliteal and calf veins B. nonocclusive thrombus at the superficial femoral C. a popliteal aneurysm D. a hypoechoic mass in the shape of an egg at mid calf, thought to be a hematoma E. a Baker's cyst in the popliteal fossa

D. A hypoechoic mass in the shape of an egg at mid calf, thought to be a hematoma. Explanation: While a small number of patients will have the complication of thrombocytopenia (reduced platelets) with heparin treatment, a bleeding complication--hematoma--is the most likely answer here because of the pain closely associated with the administration of heparin.

Which statement is correct regarding digital subtraction arteriography? (DSA)? A. the contrast is injected into the veins, not in the arteries B. DSA has a larger field of view than standard angiography C. DSA automatically selects for subtraction two or three frames obtained during injection of contrast solution D. a mask, often without contrast, is selected to be subtracted from the frames obtained during objection of the contrast solution E. in modern instruments, the bony landmarks are lost and not recoverable during subtraction

D. A mask, often without contrast, is selected to be subtracted from the frames obtained during injection of the contrast solution.

Your segmental pressure readings disclose a 36mmHg decrease in pressure from the low-thigh to the below-knee ATA, and a 10mmHg decrease from low-thigh to below-knee PTA. These findings localize obstruction to the: A. distal superficial femoral artery B. popliteal artery C. posterior tibial artery D. anterior tibial artery E. peroneal artery

D. ATA. Explanation: The significant drop is from low thigh to anterior tibial; the drop from low thigh to posterior tibial is within normal limits. This information localizes the obstruction to the proximal anterior tibial segment (i.e., proximal to the below-knee cuff).

What is the most common anomaly of the circle of Willis? A. absence of one of the middle cerebral arteries B. duplication of the posterior communicating arteries C. hypoplasia of the proximal segment of one of the anterior cerebral arteries D. absence or hypoplasia of one or both of the communicating arteries E. duplication of the middle cerebral arteries

D. Absence or hypoplasia of one or both of the communicating arteries.

This image of the internal carotid artery demonstrates: A. probable ulceration in the lesion on the deep wall B. probable ulceration in the lesion on the superficial wall C. total occlusion, with absence of flow distal to the lesion D. acoustic shadowing E. A and B

D. Acoustic shadowing. Explanation: This is a heavily calcified plaque that creates acoustic shadowing. Calling ulceration with duplex is a dodgy in the best of circumstances, and this is not one of those times.

Hypertension is associated with hyperperfusion syndrome: A. of the lower extremities B. prior to a stroke C. after a stroke D. after carotid endarterectomy E. prior to carotid endarterectomy

D. After carotid endarterectomy. Explanation: Hyperperfusion after carotid endarterectomy is a potentially serious complication, one of the most common following carotid endarterectomy.

Which of the following is a complication of plaque ulceration? A. thrombosis B. intraplaque hemorrhage C. embolization D. All of the above E. none of the above

D. All of the above Explanation: Ulceration of atherosclerotic plaque can be described as erosion of the intimal layer over the plaque surface. The erosion may progress to deep ulceration with embolization of plaque fragments. Thrombus formation is initiated by erosion of the plaque surface. Platelet aggregation occurs, forming a thrombus directly over the ulceration. Distal embolization of thrombus fragments may be the source of TIAs. Intraplaque hemorrhage can occur as leakage of blood into the atherosclerotic plaque through the ulceration or by rupture of the vaso vasorum.

A patient complains of a temporary shading of the vision in one eye. This symptom is called: A. subclavian steal syndrome B. dysphasia C. reversible ischemic neurologic event D. amaurosis fugax E. permanent ischemic neurologic event

D. Amaurosis fugax. Explanation: By definition amaurosis fugax is a unilateral symptom that is temporary in nature. It is frequently described by the patient as a curtain or a shade that blocks vision temporarily.

The ankle/arm index is obtained by dividing the: A. higher of the two brachial pressures by ankle pressure B. lower of the two brachial pressures by ankle pressure C. ankle pressure by the lower brachial pressure D. ankle pressure by the higher brachial pressure E. ankle pressure by the average of the two brachial pressures

D. Ankle pressure by the higher brachial pressure.

The patient you are scanning has an enlarged coronary vein with retrograde flow. These findings are a sign of: A. renal parenychmal disease B. thrombosis of the IVC C. iliac vein thrombus D. portal hypertension E. thrombosis of the renal vein

D. Portal hypertension.

The left common iliac vein: A. crosses anterior to the left common iliac artery just distal to the aortic bifurcation B. crosses anterior to the right common iliac artery just distal to the aortic bifurcation C. crosses posterior to the left common iliac artery just distal to the aortic bifurcation D. crosses posterior to the right common iliac artery just distal to the aortic bifurcation E. does not cross either common iliac artery

D. Crosses posterior to the right common iliac artery just distal to the aortic bifurcation. Explanation: The left common iliac vein is medial to the artery. The vena cava is to the right of the aorta. Thus, the left venous system must cross some arterial structure to communicate with the vena cava. Answer D is the usual anatomic relationship.

The components of information on the spectral Doppler display include all EXCEPT: A. pixel brightness, indicating how many red blood cells are reflecting at a given frequency shift B. frequency shift on the y-axis C. time on the x-axis D. depth on the y-axis E. all of the above are components of the spectral Doppler display

D. Depth on the y-axis.

The venous puncture for introducing contrast in venography to assess for deep venous thrombosis is done at what level? A. common femoral vein B. great saphenous vein just distal to the saphenofemoral junction C. popliteal vein D. dorsal vein on the foot E. internal jugular vein, to avoid influencing flower extremity hemodynamics

D. Dorsal vein on the foot.

Common sites for auscultation of bruits in the lower extremity circulation include all EXCEPT: A. abdomen B. groin C. popliteal space D. dorsum of foot E. all are common auscultatory sites

D. Dorsum of foot.

Some time after being hit by a car, a patient has severe pain in the anterior aspect of the right knee and massive left lower extremity edema. The patient most likely has: A. bilateral superficial venous thrombosis B. localized right popliteal deep venous thrombosis C. localized left popliteal deep venous thrombosis D. extensive left femoropopliteal deep venous thrombosis E. extensive right femoropopliteal deep venous thrombosis

D. Extensive left femoropopliteal deep venous thrombosis. Explanation: The massive edema suggests complete outflow obstruction and therefore a femoropopliteal thrombus. The obstruction must be proximal to the edema. The right knee pain is a bit of a red herring.

A continuous-wave Doppler examination of the lower extremities, performed to diagnose deep vein thrombophlebitis, revealed augmentation upon compression proximal to the probe at all standard levels studied. The diagnosis is: A. femoral deep venous thrombosis B. femoropopliteal deep venous thrombosis C. femoropopliteal valvular insufficiency D. femoropopliteal and posterior tibial valvular insufficiency E. femoropopliteal and posterior tibial deep venous thrombosis

D. Femoropopliteal and posterior tibial valvular insufficiency. Explanation: Proximal compression should not elicit flow signals if the valves are competent.

Muscular veins of the calf that empty into the popliteal vein behind the knee are: A. soleal sinuses B. femoral veins C. adductor veins D. gastrocnemius veins E. perforating veins

D. Gastrocnemius vein. Explanation: Gastrocnemius veins are commonly seen on the venous duplex scan and may be thrombosed like other calf veins. They should be distinguished from soleal sinuses, which empty into the posterior tibial and peroneal veins in the calf itself.

Which of the following is NOT a duplex indication of a totally occluded internal carotid artery? A. ICA lumen filled with heterogenous echoes B. no Doppler or color flow obtainable within ICA lumen C. absence of diastolic flow in CCA spectral display D. greatly increased end-diastolic velocities in CCA spectral display E. "drumbeat" or "slapping" Doppler signal at ICA origin

D. Greatly increased end-diastolic velocities in CCA spectral display. Explanation: The high distal resistance created by the ICA occlusion would reduce or eliminate diastolic flow in the CCA, not increase it.

TCD findings consistent with vasospasm following subarachnoid hemorrhage would include: A. absence of diastolic flow in the MCA B. greatly diminished diastolic flow in the MCA C. retrograde flow in the MCA D. greatly increased mean velocities in the MCA E. this is not a condition for which TCD is a useful modality

D. Greatly increased mean velocities in the middle cerebral artery. Explanation: vasospasm causes greatly increased mean velocities in cerebral arteries.

Your patient begins to fall while getting off the examination table. You should: A. catch him under the arms B. catch him around the waist C. let him fall, since you may just hurt him worse by interfering D. guide the fall, protecting his head E. start filling out the incident report

D. Guide the fall, protecting his head. Explanation: You shouldn't try to arrest the fall, since that may simply injure both of you. The main thing to try is to protect the patient's head, guiding the fall if possible.

If one is listening with a continuous-wave Doppler directly over a stenotic lesion, the signal will: A. be comprised of low-frequency flow disturbances B. have a distinct "thumping" sound C. be relatively unchanged from the rest of the vessel D. have a high-frequency sound E. be inaudible

D. Have a high-frequency sound. Explanation: The accelerated velocities will create high-frequency signals directly in the stenotic jet. Just distally there will be turbulent flow and a scrambled analog waveform--many velocities and many directions causing many frequency shifts, which the analog output cannot deal with.

The Budd-Chiari syndrome is a cause of portal hypertension resulting from: A. hepatic artery stenosis B. inferior mesenteric vein thrombus C. superior vena cava thrombus D. hepatic vein obstruction E. a liver tumor

D. Hepatic vein obstruction. Explanation: Hepatic vein obstruction leaves no way for portal venous hepatic arterial blood to be removed. Therefore hepatic congestion occurs, resulting in ascites, progressive hepatic dysfunction, and portal hypertension. In its acute form the disease is rapidly fatal, unless treated surgically. Liver tumors are a separate possible cause of hepatic vein obstruction.

The two arteries creating the bidirectional signal observed 60 to 65mm deep during transcranial insonation of the temporal window are the: A. posterior cerebral and anterior cerebral arteries B. right and left vertebral arteries C. middle cerebral and posterior cerebral arteries D. middle cerebral and anterior cerebral arteries E. right (or left) vertebral and right (or left) posterior inferior cerebral arteries

D. Middle cerebral and anterior cerebral arteries. Explanation: At a depth of approximately 60mm, the internal carotid artery at its distal limit bifurcates into the MCA and ACA. Flow in the MCA is toward the Doppler beam, while flow in the ACA is away from the beam. The TCD sample volume is fairly large, so both arteries appear on the spectral display, above and below baseline, and the question specifies a bidirectional waveform. The MCA/ACA bifurcation waveform is a common reference point that helps the practitioner of blind TCD to be sure of orientation and identification.

Which of the following is not an artery in the circle of Willis? A. anterior cerebral artery B. middle cerebral artery C. anterior communicating artery D. middle communicating artery E. posterior communicating artery

D. Middle communicating artery. Explanation: There are only the anterior and posterior communicating arteries.

Pulse volume recordings demonstrate a lack of dicrotic notch in the recordings at the thigh, decreased pulses at the upper calf, and flat tracings at the ankle. The most likely interpretation of this study is: A. mild iliofemoral, superficial femoral, and tibial artery occlusive disease B. mild iliofemoral, superficial femoral, and severe tibial artery occlusive disease C. severe iliofemoral, superficial femoral, and tibial artery occlusive disease D. mild iliofemoral stenosis, severe superficial femoral stenosis or occlusion, and severe infrapopliteal occlusive disease E. aortic occlusion

D. Mild iliofemoral stenosis, severe superficial femoral stenosis or occlusion, and severe infrapopliteal occlusive disease. Explanation: These waveform tracings range from the mildest change (absence of dicrotic notch) to most severe (flat tracings) as we progress down the leg.

The clinical examination for deep venous thrombosis is: A. specific and sensitive B. not specific but sensitive C. specific but not sensitive D. neither specific nor sensitive E. none of the above

D. Neither specific nor sensitive. Explanation: Deep venous thrombosis is famously difficult to call based on signs and symptoms, although again chronic unilateral edema is the single best predictor.

The patient position for venography is: A. supine, leg elevated B. Trendelenburg's position C. seated, legs dependent D. on an exam table tilted 60 degrees upright E. standing on floor, with weight on the nonsymptomatic leg

D. On an exam table tilted 60 degrees upright.

The first intracranial branch of the internal carotid artery is the: A. superficial temporal artery B. frontal artery C. infraorbital artery D. ophthalmic artery E. middle cerebral artery

D. Ophthalmic artery. Explanation: Even though there is often a branch called the caroticotympanic artery, the ophthalmic artery is regarded as the first major branch of the internal carotid artery. It is central to indirect physiological testing.

Which of the following is a significant problem with digital subtraction angiography? A. longer than normal procedure time B. increase in contrast dosage C. single view filming technique D. patient cooperation E. inability to provide sequential images

D. Patient cooperation. Explanation: Patient cooperation is a significant problem with digital subtraction angiography (DSA), as patient motion can drastically affect the ability of DSA to provide adequate images.

The pulsatility index is defined as: A. peak systolic velocity divided by end diastolic velocity B. peak systolic velocity minus end diastolic velocity divided by systolic velocity C. peak systolic velocity minus mean velocity divided by mean velocity D. peak systolic to peak end diastolic velocity divided by mean velocity E. peak systolic velocity at the internal carotid artery divided by peak systolic velocity at the common carotid artery

D. Peak systolic to peak end diastolic velocity divided by mean velocity. Explanation: This is also known as Gosling's pulsatility index. This index is used mostly with continuous-wave Doppler or transcranial Doppler and increases with increased distal resistance. It is independent of the Doppler angle.

Signs of advanced ischemia in the lower extremity include all of the following EXCEPT: A. slow venous filling after dropping the elevated extremity into a dependent position B. pallor on elevation C. rubor on dependency D. pitting edema E. ulceration at the dorsum of the foot

D. Pitting edema. Explanation: True pitting edema is usually a symptom of systemic disease (such as CHF), chronic venous disease, or lymphedema.

The 2 x 2 table below shows data used to correlate ankle pressure measurement with healing in patients undergoing toe amputation. The gold standard is healing of the amputation site. For the purposes of this study, a positive (abnormal) ankle pressure was <60mmHg. Which of the following statements is true? A. the denominator for calculating sensitivity is 18. B. the denominator for calculating specificity is 32. C. the denominator for calculating overall accuracy is 42. D. the denominator for calculating positive predictive value is 18. E. the denominator for calculating negative predictive value is 30.

D. The denominator for calculating positive predictive value is 18. Explanation: The denominator for overall accuracy is the total number of studies, not the total number of correct studies. The predictive values will derive the denominator from the row totals. Thus only answer choice D is correct.

While monitoring of femorodistal bypass graft using duplex ultrasonography, the graft may be at risk of failure if: A. the graft velocity is more than 45cm/sec B. the graft velocity is 130cm/sec C. the graft velocity has been around 30cm/sec for over three years since its implantation D. the graft velocity has dropped from 70cm/sec, as measured 6 months earlier, to 30cm/sec E. the ankle blood pressure stays the same

D. The graft velocity has dropped from 70cm/sec, as measured 6 months earlier, to 30cm/sec. Explanation: A graft velocity of 30cm/sec that has dropped from 70cmsec is usually a clear indicator of impending graft failure. It is important to remember that the size of the graft affects flow velocities, and that there may be low velocities within a graft that is especially large or has large-diameter segments, so that velocities of 30cm/sec by themselves are not necessarily indicative of graft failure.

A thrombus is found in a gastrocnemius muscular vein approximately a third of the way down the calf from the knee. If this were to propagate proximally, it would next involve: A. the posterior tibial veins B. the anterior tibial veins C. the peroneal veins D. the popliteal vein E. the superficial vein

D. The popliteal vein. Explanation: The gastroc veins empty into the popliteal vein. The soleal veins empty into the posterior tibial and peroneal veins.

Which statement best describes these waveforms from the common carotid, internal carotid, and external carotid arteries? A. they are within normal limits B. they suggest common carotid occlusion C. they suggest aortic valve stenosis D. they suggest aortic valve regurgitation E. they suggest contralateral ICA occlusion

D. They suggest aortic valve regurgitation. Explanation: The flow during diastole is being pulled retrograde by the aortic valve regurgitation. This isn't seen in the ICA because of the lower-resistance character of the distal vascular bed, but there is the abnormal double peak.

Which of the following statements about the dorsalis pedis artery is NOT correct? A. it runs anterior to the medial malleolus. B. it is typically the continuation of the anterior tibial artery. C. it joins the pedal arch about halfway along the dorsum of the foot. D. it is a branch of the peroneal artery. E. it begins at the bend of the foot and ankle.

D. This statement about the dorsalis pedis artery "It is a branch of the peroneal artery"-- is NOT correct. The dorsalis pedis artery continues the anterior tibial artery to the pedal arch.

Regarding venous valves, which is FALSE? A. essential to muscle pump B. bicuspid C. endothelial tissue D. allow flow only away from the heart E. have sinuses to facilitate closure

D. This statement about venous valves--"Allow flow only away from the heart"--is false.

In consideration of the aforementioned pressure findings, which of the following statements is NOT true? A. the patient has right lower extremity arterial disease B. the patient has left lower extremity arterial disease C. the patient has left subclavian artery disease D. the patient has renovascular hypertension E. arteriography would be recommended if bypass surgery is contemplated

D. This statement--"The patient has renovascular hypertension"--is NOT true. Explanation: This patient has bilateral lower extremity obstructive disease based on these pressures and indices. There appears also to be obstruction proximal to the left brachial cuff (60mmHg gradient compared to right arm); this is usually caused by subclavian disease. The patient has hypertension (systemic pressure of 180mmHg), but the reason for this finding cannot be ascertained from this exam. Renovascular hypertension is only one cause of this problem, and is responsible for 3-5% of hypertension cases.

In the same transverse aortic image (Color Plate 5), which is NOT true? A. incomplete filling is due to mural thrombus B. this patient would probably be considered for surgery C. the diameter is larger than 5cm D. this is the preferred plane for diameter measurement E. this is probably from a level inferior to the renal arteries

D. This statement--"This is the preferred plane for diameter measurement"--is NOT true of the image presented. Explanation: The preferred plane for measuring AAA is longitudinal, not short-axis. Aneurysms typically have mural thrombus due to stasis against the wall. Aneurysms larger than 5 to 6cm are usually considered for elective repair, and AAAs are usually infrarenal.

In a reflux study, the examiner images the popliteal vein and notes that the venous color flow display lights up blue with calf compression, then red for 2-3 seconds on release. A. this is within normal limits. B. this confirms deep venous thrombosis. C. this is normal, but the color flow assignment is reversed. D. this suggests venous reflux. E. this is nondiagnostic without probe ccompression to make the walls coapt.

D. This suggests venous reflux. Explanation: This finding suggests significant venous valvular incompetence at this level.

Which of the following describes this image from the common femoral vein? A. the intraluminal echoes are homogeneous in character B. the intraluminal echoes are heterogeneous in character C. it suggests acute thrombosis D. it suggests chronic thrombosis E. A and C F. A and D G. B and C H. B and D

E. A and C. Explanation: This thrombus has the same soft, evenly grainy appearance throughout, compatible with newer thrombus.

During a cerebrovascular exam, you obtain equal brachial systolic pressures bilaterally. During the scan, you obtain this pulsatile signal from between the transverse processes. You move the beam to the CCA, and the waveform is below the baseline: A. this waveform suggests antegrade vertebral flow B. this waveform is suggestive of left-side subclavian steal C. this waveform is suggestive of left ICA obstruction D. you should ask the patient to performa a Valsalva maneuver E. you should change to a lower-frequency transducer

D. You should ask the patient to perform a Valsalva maneuver. Explanation: Vertebral venous signals can be quite convincingly pulsatile. It may help to swing up for a common carotid signal to establish which direction is antegrade if you aren't sure from the display.

Chronic deep venous obstruction will increase: A. venous flow B. arterial inflow C. resting supine venous pressure D. ambulatory venous pressure E. ambulatory residual venous volume

D. ambulatory venous pressure. Explanation: Ambulatory venous pressure increases dramatically in chronic venous obstruction.

The NASCET used the following arteriographic criterion/criteria to classify internal carotid artery disease: A. area and diameter stenoses calculated by dividing the minimal area and diameter at the internal carotid artery by the area and diameter at the common carotid artery. B. area percentage stenosis calculated by dividing the minimal area by the original area at the site of stenosis. C. diameter percentage stenosis calculated by dividing the minimal diameter by the original diameter at the site of stenosis. D. diameter percentage stenosis calculated by dividing the minimal diameter of the un-stenosed distal internal carotid artery. E. area percentage stenosis calculated by dividing the minimal area by the normal area of the distal internal carotid artery.

D. diameter percentage stenosis calculated by dividing the minimal diameter of the un-stenosed distal internal carotid artery. Explanation: Many studies prior to the NASCET study used the maximum diameter of the carotid bulb as the reference. Since an angiogram cannot accurately determine the outer diameter of the bulb, this method has probably caused inaccurate results. On the other hand, our diagnostic velocity criteria were based on the old method, which makes correlation with angiography more complex.

A symptom of vertebrobasilar insufficiency is: A. unilateral paresis B. aphasia C. amaurosis fugax D. diplopia E. none of the above

D. diplopia. Explanation: diplopia-double vision-is a symptom of vertebrobasilar insufficiency.

During ordinary auscultation of a carotid bifurcation, the detection of a bruit that extends into diastole is: A. insignificant B. marginally significant C. moderately significant D. highly significant E. impossible

D. highly significant. Explanation: bruits are not always a reliable indicator of disease, but a bruit that extends into diastole is highly significant for carotid artery stenosis or for any other arterial location. (Perhaps this is related to the fact that elevated end-diastolic velocities are suggestive of severe stenosis).

A binocular disturbance that disrupts vision in half the visual field of both eyes is called: A. hemiplegia B. amaurosis fugax C. dysphagia D. homonymous hemianopia E. hemiparesis

D. homonymous hemianopia

The best way to prepare a transducer for intraoperative use is: A. autoclave it B. immerse it in Cidex solution for 72 hours C. wash it with soap and water D. place transducer and acoustic gel within a sterile sleeve or bag E. microwave it

D. place transducer and acoustic gel within a sterile sleeve or bag. Explanation: Autoclaving a transducer will destroy its piezoelectric properties.

A 56-year old patient reports loss of vision in her left eye two days ago, with total resolution in 10 minutes. Yesterday morning she developed weakness and numbness in her right hand and was unable to hold her coffee cup. This afternoon her hand strength is about 90% normal, with normal sensation. Clinically she has: A. amaurosis fugax B. transient ischemic attack C. migraine D. stroke E. lacunar infarct

D. stroke. Explanation: Because it has persisted longer than 24 hours and has not resolved completely, it is a stroke.

Vessels and structures of the penis include all of the following EXCEPT: A. deep artery of the penis B. dorsal artery of the penis C. corpus spongiosum D. inferior vesicle artery E. dorsal vein

D? Inferior vesicle artery.

In this cross section, which letter represents the interosseous membrane? A B C D E

E

Four hundred patients underwent noninvasive venous testing with subsequent venography. The noninvasive and venographic results were compared. Of the 300 normal venograms, 15 were abnormal by noninvasive testing. Of the 100 abnormal venograms, 90 were abnormal by noninvasive testing. Sensitivity is: A. 15/300 B. 15/400 C. 105/400 D. 375/400 E. 90/100

E. 90/100. Explanation: Of 100 abnormal venograms, 90 were true positives. Sensitivity equals the positive agreements divided by all of the gold standard positives.

A normal penile/brachial systolic pressure ratio is: A. >3.5:1 B. >0.45 C. >1.3 D. >0.5 E. >0.75

E. >0.75. Explanation: Normal penile/brachial index is expressed as greater than 0.75 at rest and not decreasing by more than 0.15 after exercise.

The Doppler beam may be attenuated if: A. the sound beam must pass through scar tissue, a hematoma, or excessive fat B. the vessel has calcific plaque on the anterior wall C. output settings from the Doppler to the recording device are not amplified D. all the above E. A and B only

E. A and B only. Explanation: Output settings do not affect attenuation; they control size of recording on the chart paper.

Which of the following imaging XDR frequencies could appropriately be used for assessment of the carotid arteries? A. 10MHz B. 5MHz C. 2.5MHz D. 0.3MHz E. A and B

E. A and B. Explanation: Both 5MHz and 10MHz transducers can be used to scan the carotids.

Assessment of palmar arch patency is useful: A. before placement of an arteriovenous arm shunt B. when evaluating a patient with suspected subclavian steal C. to evaluate blood flow to the digital arteries D. A and B E. A and C

E. A and C. Explanation: Subclavian steal is a more proximal problem. Evaluation of the palmar arch is useful both before and after the placement of an arteriovenous shunt for digital disease. (A careful Allen test is now being used as well before harvest of the radial artery for coronary artery bypass.)

Which one of the following diagnostic criteria for stenosis would be anticipated in the presence of a 50-60% diameter stenosis of the internal carotid artery? A. poststenotic turbulence only B. blunting of the systolic waveform with absence of a diagnostic frequency, at the site of maximum frequency shift change C. elevation of both systolic and diastolic frequency components, with minimal poststenotic turbulence D. elevation of systolic and diastolic frequency components with no demonstrable poststenotic turbulence E. elevation of systolic frequency with poststenotic turbulence

E. Elevation of systolic frequency with poststenotic turbulence. Explanation: the most sensitive parameter for calling this degree of stenosis is the systolic frequency/velocity. Focal acceleration with distal turbulence is the hallmark of significant stenosis anywhere in the body.

The angular artery is the terminal part of the: A. supraorbital artery B. infraorbital artery C. superficial temporal artery D. transverse facial artery E. facial artery

E. Facial artery. Explanation: The facial artery terminates as the angular artery.

Symptoms of chronic venous insufficiency might result from all EXCEPT: A. calf-vein thrombosis B. popliteal vein thrombosis C. superficial insufficiency D. iliac vein thrombosis E. gastrocnemius muscular thrombosis

E. Gastrocnemius muscular thrombosis. Explanation: Isolated gastrocnemius thrombosis is unlikely to create significant chronic venous insufficiency (CVI) symptoms. It is only fairly recently that we have come to know that even lesser saphenous insufficiency can cause stasis ulcers.

A four-level pressure cuff technique is used to assess arterial disease in the legs. The high-thigh pressure is 140mmHg, with an arm pressure of 160mmHg. All of the following lesions can cause this EXCEPT: A. significant aortic stenosis B. common iliac or external iliac artery disease C. superficial femoral plus profunda artery occlusion D. common femoral artery disease E. isolated profunda femoral artery disease

E. Isolated profunda femoral artery disease. Explanation: Any lesion proximal to the cuff can cause an abnormally low high-thigh pressure. In addition, the equivalent of a common femoral artery lesion, by the presence of disease in both the superficial femoral and profunda arteries, can likewise lower the high-thigh pressure. However, isolated profunda lesions are usually not detectable by pressure changes.

An abnormal flow rate for a radial artery/cephalic vein dialysis fistula is: A. 200 to 400ml/min B. 400 to 900ml/min C. 1000 to 1500ml/min D. greater than 1500ml/min E. less than 200ml/min

E. Less than 200ml/min. Explanation: A flow rate of around 300ml/min is required for dialysis.

This image was taken just distal to the groin; femoral vessels are seen deep in the field of view. The structure with the measurement cursors represents: A. hematoma B. highly-vascularized tumor C. Baker's cyst D. pseudoaneurysm E. lymph node

E. Lymph node. Explanation: This is a lymph node, seen superficial to the femoral vessels, and often prominent in the patients with cellulitis whom we often scan in the ER at 2:30 AM.

Which of the following statements regarding abdominal aortic aneurysms is FALSE? A. AAAs are usually infrarenal B. computerized tomography and MRI are common modalities for the diagnosis of AAA C. ultrasound imaging is the most frequently used modality for diagnosis of AAA D. abdominal aneurysms pose a significant risk of rupture if >6cm in diameter E. most prerupture AAAs are discovered because of abdominal symptoms or distal emboli

E. Most prerupture AAAs are discovered because of abdominal symptoms or distal emboli. Explanation: AAAs rarely extend above the renal arteries. The "gold standard" test has been B-mode ultrasound, although CT scanning is gaining popularity. Arteriograms are obtained prior to operation by some surgeons but may be falsely negative for diagnosing the aneurysm because of laminated clot within the lumen. Most aneurysms are discovered on routine physical examination while the patient is asymptomatic.

Four hundred patients underwent noninvasive venous testing with subsequent venography. The noninvasive and venographic results were compared. Of the 300 normal venograms, 15 were abnormal by noninvasive testing. Of the 100 abnormal venograms, 90 were abnormal by noninvasive testing. The calculation that has as its denominator the total number of normal noninvasive tests is: A. positive predictive value B. sensitivity C. overall accuracy D. specificity E. negative predictive value

E. Negative predictive value. Explanation: Negative predictive value has as its denominator the total number of negative noninvasive studies (true negatives + false negatives).

Possible complications of vena cava interruption for recurrent pulmonary embolism include all of the following EXCEPT: A. diminished cardiac ouput B. edema C. leg ulcers D. venous claudication E. night cramps

E. Night cramps. Explanation: Night cramps usually are not a symptom of venous disease. Diminished cardiac output is a possible complication to ligation of the vena cava. The other symptoms would be secondary to significant caval obstruction and consequently elevated venous pressures.

With a subclavian artery stenosis on the right side: A. the flow in the right vertebral artery will be reversed. B. the patient will have right arm claudication. C. the arm pressure will be reduced. D. the right axillary artery Doppler signal will be monophasic. E. none of the above will necessary be present.

E. None of the above will necessary be present. Explanation: All of the answer choices are possible with right subclavian stenosis, but whether they actually occur depends on the severity of the stenosis

The 2 x 2 table below correlates arteriographically proven disease in the lower extremity arteries and a significant gradient in systolic pressure between segmental pressure cuffs. A. specificity and sensitivity are equal B. positive and negative predictive values are equal C. specificity and positive predictive value are equal D. sensitivity and negative predictive value are equal E. overall accuracy is calculated by the formula 90/100

E. Overall accuracy is calculated by the formula 90/100. Explanation: The overall accuracy is the number of correctly classified test results divided by the total number of tests. In this example there are 180 correct results in the 200 tests performed; thus the correct calculation for overall accuracy is 180/200. The remaining measurements in this problem happen all to be calculated by the formula 90/100.

The most common presenting symptoms in acute arterial occlusion include all EXCEPT: A. paralysis B. pulselessness C. pallor D. paresthesias E. pedal ulcer

E. Pedal ulcer. Explanation: A pedal ulcer would take a bit more time to develop and is more characteristic of chronic rather than acute occlusion. The other of those "five Ps" of acute occlusion is pain. "Polar" (cold extremity--a strenuous effort to use the letter P for all of the symptoms) is sometimes added.

Pulse sites commonly palpated in the lower extremities include all EXCEPT: A. common femoral B. popliteal C. posterior tibial D. anterior tibial E. peroneal

E. Peroneal.

Magnetic resonance angiography (MRA) functions by processing: A. x-ray frequency shifts from moving blood B. x-ray reflections from contrast material in the artery C. isotope radiation using a scintillation camera D. reflections from the hemoglobin in red blood cells E. radiofrequency pulses created by tissue and blood flow

E. Radiofrequency pulses created by tissue and blood flow. Explanation: Magnetic resonance works by sending pulses of radio waves into tissue within a strong magnetic field. The resulting change of spin of the hydrogen protons create a signal that is then processed for image. Different processing methods can create images of blood flow; hence MR angiography or MRA.

A validated laboratory index for detection of significant renal artery stenosis is: A. renal stenosis/aorta peak systolic velocity ratio greater than 1.8 B. renal stenosis/contralateral renal peak systolic velocity ratio greater than 3.5 C. renal stenosis peak systolic frequencies greater than 4.5MHz D. renal stenosis peak systolic velocity greater than 127cm/sec E. renal stenosis/aorta peak systolic velocity ratio greater than 3.5

E. Renal stenosis/aorta peak systolic velocity ratio greater than 3.5. Explanation: Renal to aortic ratios of greater than 3.5 are associated with renal artery stenosis of greater than 60%.

A normal arterial volume waveform may have all EXCEPT: A. swift upstroke B. sharp peak C. rapid downslope bowed toward baseline D. dicrotic notch E. reverse-flow component

E. Reverse-flow component. Explanation: The reverse-flow component is part of an arterial Doppler waveform, not a volume waveform, which does not have a zero baseline.

The abdominal artery that normally demonstrates higher diastolic flow postprandially is: A. celiac axis B. common hepatic C. splenic D. renaal E. SMA

E. SMA. Explanation: After eating, vasodilatation in the intestine reduces distal resistance.

The etiology of arterial aneurysms includes all of the following EXCEPT: A. syphilitic B. degenerative C. inflammatory D. congenital E. saccular

E. Saccular. Explanation: "Saccular describes a shape of aneurysm, not the etiology."

The digital/brachial systolic pressure ratio in an extremity with a dialysis fistula usually is: A. greater than 1.00 B. about 0.80 C. about 0.50 D. less than 0.50 E. should not be measured

E. Should not be measured. Explanation: One avoids taking brachial blood pressure in an extremity with a dialysis fistula. You could measure the contralateral brachial blood pressure, of course.

A localized increase in mean velocity from 50 to 150cm/sec at a depth of 50mm with the TCD XDR placed in the temporal window probably indicates: A. significant stenosis of the ACA B. moderate generalized vasospasm C. significant stenosis of the internal carotid at the siphon D. significant vasospasm of the MCA E. significant stenosis of the MCA

E. Significant stenosis of the middle cerebral artery.

After the initial dose of heparin, the current standard of treatment for deep venous thrombosis consists of placing the patient on the following medication for 3 or more months: A. streptokinase B. urokinase C. tissue plasminogen activator D. vitamin K E. sodium warfarin

E. Sodium warfarin. Explanation: Sodium warfarin or coumadin is the drug of choice for long-term anticoagulation.

A common physical finding in a pulmonary embolism: A. apnea B. bradycardia C. thrombocytopenia D. bradypenia E. tachypnea

E. Tachypnea. Explanation: This is rapid respiration, frequently associated with pulmonary embolism.

Which of the following is NOT a condition for which TCD might be useful? A. vasospasm following subarachnoid hemorrhage B. determination of brain death C. cerebral artery monitoring during surgery D. carotid siphon stenosis E. temporal arteritis

E. Temporal arteritis.

Commonly performed methods of vena cava interruption for recurrent pulmonary embolism include all of the following EXCEPT: A. the bird's nest filter B. the Greenfield umbrella filter C. the nitinol filter D. the Vena Tech filter E. the Jones wire arch

E. The Jones wire arch. Explanation: The Jones wire arch is not a method of interrupting the vena cava. The Greenfield is the oldest and most widely used design. Nitinol is a nickel-titanium alloy that can be straightened for insertion, then resumes its shape on contact with the warmth of blood flow.

Which superficial vein is NOT commonly used as a bypass graft? A. the great saphenous vein B. the small saphenous vein C. the basilic vein D. the cephalic vein E. the femoral vein

E. The femoral vein. Explanation: The femoral vein is not superficial. It is in fact used for autologous vein graft on occasion, however.

A patient relates a 10-minute episode of loss of vision. He closed each eye and the reduction in the right half of his visual field was present bilaterally. This patient is describing amaurosis fugax. True or False?

False: Homonymous hemianopia

A series of carotid duplex studies was correlated to carotid angiography to test a velocity threshold for accuracy in calling >60% vs. <60% stenosis of the Internal Carotid artery. Of the 56 ICAs called >60% by angiography, 53 were correctly identified by duplex. Of the 38 ICAs called <60% by angiography, 8 were called >60% by duplex Which of the following statements about the aforementioned calculations is correct? A. the overall accuracy is less than either the positive or negative predictive values B. the overall accuracy is greater than either the sensitivity or the specificity C. the specificity is greater than the sensitivity D. the specificity is greater than the positive predictive value E. the negative predictive value is greater than the positive predictive value

E. The negative predictive value is greater than the positive predictive value. Explanation: Answer choices A and B can be rejected immediately, since the overall accuracy must fall between the sensitivity and specificity as well as between the positive and negative predictive values. Thus accuracy can be neither lower nor higher than either of the companion measures. Rough calculations can be quickly made for those pertinent measures: Sensitivity= 53/56 (~90%) Positive predictive value= 53/61 (~85%) Specificity= 30/38 (~70%) Negative predictive value= 30/33 (~91%) After making these rough calculations, you can reject answer choices C and D and accept answer choice D.

Systolic thigh pressures are 180mmHg in both lower extremities; the systolic arm pressure is 170mmHg on the right and 160mmHg on the left. The patient complains of buttock claudication. A. the patient does not have significant aortoiliac occlusive disease because the thigh pressures are normal B. the patient does not have unilateral iliac occlusive disease because the thigh pressures are normal and equal C. the patient has bilateral superficial femoral artery occlusion D. thigh pressures are not used to determine the presence of iliac occlusive disease E. the patient may have aortoiliac occlusive disease

E. The patient may have aortoiliac occlusive disease. Explanation: The patient may have aortoiliac disease, although without further information about waveforms in the aortoiliac vessels or at the common femoral level this cannot be precisely determined. Thus, while answer choice A, is possible, E is the best assessment of this limited information.

A uniform forearm cephalic vein measuring 2mm in diameter during ultrasonographic imaging is being considered for a popliteal tibial bypass: A. the vein could not be used because its diameter is less than 4mm B. the vein could not be used because its diameter in the arm is 2mm C. a uniform cephalic vein could not be used as a popliteal tibial bypass D. the vein could be used because the graft diameter must be 4mm E. the vein might be used because the graft diameter is 2mm and might expand under pressure

E. The vein might be used because the graft diameter is 2mm and might expand under pressure. Explanation: Depending on the institution, 2mm veins might be used as grafts, although the surgeon would likely prefer 3mm or larger. Duplex measurements taken with just intravenous pressure may not predict the potential diameter with arterial pressure.

A 54-year-old male relates a history of calf and thigh pain, the right worse than the left. This pain resolves upon sitting down. The patient usually starts after the first few steps of walking, but does not limit the patient's ability to walk three blocks. Since he never walks more than this distance, he cannot relate that he would have to stop at a greater distance. Some days the pain is quite mild. The etiology of these symptoms can be: A. abdominal aortic disease B. bilateral iliac artery disease C. bilateral superficial femoral and profunda disease D. A, B, and C are potential etiologies E. these symptoms are not typical of vascular disease

E. These symptoms are not typical of vascular disease. Explanation: These symptoms do not suggest claudication, symptoms of which are quite consistent. The pain associated with claudication is a muscle fatigue due to anoxia brought on by exercise. Claudication usually does not occur within moments of starting to walk, and, if it does, the distance one can walk is extremely limited.

This image is from the proximal and distal thigh of a patient a few months following fem-pop Gore-Tex bypass graft surgery. (The echoes within the graft are from the color flow display, reproduced here in black and white). Which statement best describes the findings? A. they are within normal limits B. they suggest deep vein thrombosis C. they suggest severe graft stenosis D. they suggest graft occlusion E. they suggest graft infection

E. They suggest graft infection. Explanation: The huge area of fluid accumulation around the graft is characteristic of graft infection. Note the double-wall echo created by the graft. This appearance is characteristic of Gore-Tex material.

Which of the following are NOT associated with chronic venous disease? A. pigmentation B. brawny edema C. subcutaneous fibrosis D. cutaneous atrophy E. thickening of toenails

E. Thickening of toenails. Explanation: Thickening of the toenails is a sign of chronic arterial insufficiently.

Compared to the arteries, veins have: A. thicker, more muscular walls B. thicker intima C. thicker adventitia and media D. thinner intima E. thinner adventitia and media

E. Thinner adventitia and media. Explanation: Intimal linings are the same size in arteries and veins--a layer of endothelial cells.

The examiner listens with CW Doppler to the femoral vein at mid thigh and performs a calf compression. The compression maneuver augments the signal. This finding suggests: A. deep vein thrombosis at the iliac level B. deep vein thrombosis at the femoral level C. deep vein thrombosis in calf veins D. valvular incompetence E. this is a normal finding

E. This is a normal finding. Explanation: Femoral vein augmentation with gentle calf compression suggests probably patency between the two levels. This information can be helpful when the duplex scan is technically difficult.

Which of the following statements is FALSE regarding the ICA spectrum below? A. there is forward flow throughout diastole B. this appears to be from a low-resistance system C. the absence of a systolic window in this spectrum indicates turbulent blood flow D. the velocities indicate a hemodynamically significant stenosis E. the velocities suggest severe (greater than 80%) stenosis

E. This statement--"The velocities suggest severe (greater than 80%) stenosis"--is false. Explanation: This waveform has a significantly elevated PSV (>125cm/sec), and the systolic window is filled in, suggesting fairly severe turbulence. However, the end-diastolic velocities are not greatly elevated, certainly not approaching 100cm/sec. Therefore, based on this information, this stenosis would be called hemodynamically significant but not severe.

A patient walks on the treadmill until forced to stop at 3 minutes due to the left calf and thigh pain. The right leg was asymptomatic throughout the course of the testing. The following results were obtained: Pre-exercise: Right arm 150, right PTA 120, left PTA 120 Postexercise: Right arm 150, right PTA 75, left PTA 50 Which of the following statements is TRUE regarding this information? A. there is arterial disease in both legs B. the left leg has worse disease than the right C. the patient has aortoiliac arterial disease D. retesting the patient in 30 minutes should result in a shorter walking time E. the arm pressure normally increases after treadmill testing, raising questions of the validity of these results F. A and B G. C and D H. C and E I. This question has too many answers

F. A and B. Explanation: Pressure in both legs is reduced, both at rest and after exercise, and the magnitude of the pressure decrease is greater on the left than on the right, suggesting more severe disease on that side. The level of disease cannot be ascertained from these data. The patient should give essentially the same results after recovery. The lack of blood pressure increase in the arm may mean only a relatively healthy systemic-pressure response to exercise. Choice I is possible, but it is not the best answer. The registry exam will not offer this many choices.

A pitfall of magnetic resonance angiography is: A. patients with cardiac pacemakers cannot be studied B. it requires the use of ionizing radiation C. it tends to overestimate the degree of stenosis D. it requires a high degree of patient cooperation E. All but A F. All but B G. All but C.

F. All but B. Explanation: MRA has become an accurate method for assessing carotid stenosis. Patients with pacemakers or other significant bodily metal cannot be subjected to the strong magnetic field this test requires. MRA uses radio waves, not ionizing radiation. It does require the patient to lie quite still for a good while. It does tend to overestimate stenosis, while at least one study demonstrated that angiography often underestimates stenosis. Of course, we duplex users are always right on the money.

Which of the following is (are) true regarding axial resolution in carotid imaging? A. differentiates soft plaque from blood B. resolves two targets positioned one in front of another along the axis of beam propagation C. improves the observer's ability to estimate vessel wall thickness D. determines the absolute depth of penetration of ultrasound beam at a given frequency E. A and D F. B and C G. B and D

F. B and C.

Which of the following is/are TRUE regarding the clinical detection of a bruit? A. a bruit is always an indication of disease B. it means that turbulent flow exists C. it may be indicative of valvular dysfunction in the heart D. it may be a normal finding in parts of some vessels and during periods of enhanced flow E. a bruit is present in >90% of vessels with disease F. B, C, and D G. A, B, and E

F. B, C, and D.

Insufficient veins have the following flow characteristics: A. cephalad blood flow may be normal while the patient is quietly standing. B. caudal blood flow may be abnormal while the patient is quietly standing. C. venous pressure at the ankle in the supine patient does not differ from that of normal limbs. D. venous pressure at the ankle in the walking patient is markedly increased compared to that of normal limbs. E. A, B, and C F. B, C, and D

F. B, C, and D. Explanation: Insufficiency may allow abnormal distal flow in the standing patient. If the patient is supine, hydrostatic pressure is not an issue, so venous pressure at the ankle would not be different from the non-insufficient patient. Walking creates hydrostatic increased pressure as a result of valvular insufficiency, along with a circular venous flow pattern that tends to keep more blood in the leg veins rather than moving it cephalad to the heart.

Which of the following statements about popliteal aneurysms is TRUE? A. they pose a significant risk to the patient due to rupture B. they can cause symptoms by compressing contiguous structures C. they pose a significant risk of limb loss due to embolism or occlusion D. they are found bilaterally in >10% of cases where they exist E. claudication is a rare symptom F. A and D G. B, C, and D

G. B, C, and D. Explanation: Popliteal aneurysms have a very low risk of rupture but a high risk of embolization or thrombosis leading to loss of limb. There are occasional venous or neurologic symptoms due to size. About 50-70% of patients with a popliteal aneurysm have them bilaterally. Additionally, there is a high rate (about 40-50%) of coexisting abdominal aortic aneurysm in these patients. Claudication is a rare symptom and when present is the result of coexistent stenosis, not the aneurysmal process.

On ophthalmologic examination, a bright yellow spot is noted within a branch artery. This is a Hollenhorst plaque. True or False?

True: this is a Hollenhurt plaque. Explanation: These patients have a 75% risk of TIA or stroke over the next several years.