Point Q's Test 2

A treadmill exercise stress test is typically conducted using the following parameters:

0% to 10% grade and 1 to 2 mph A typical treadmill workload ranges from level to 10% grade and 1 to 2 mph, for a maximum of 5 minutes

What is the normal drop in mean arterial pressure from the heart to the ankle?

10 mm Hg There is a normal drop of approximately 10 mm Hg in mean artery pressure as blood flows from the heart to distal segments of the lower extremity

What is the appropriate percentage of peripheral arterial disease (PAD) that is not caused by atherosclerosis?

10%

Provocative maneuvers used to detect thoracic outlet syndrome can reveal positive findings in what percent of normal patients?

20% These provocative maneuvers are not specific, and subclavian artery occlusion can be demonstrated in up to 20% of normal individuals

During an ultrasound examination, the following velocities are obtained: proximal to a stenosis PSV = 98, at the stenosis PSV = 233, distal to the stenosis PSV = 76. What is correct velocity ratio, Vr, for this stenosis?

233/98 = 2.4 The PSV at the stenosis is divided by the PSV just proximal to the stenosis to calculate the velocity ratio (Vr).

What is the proper transducer angle to use while obtaining Doppler waveforms?

45 degrees to the skin surface The transducer is then adjusted, so that an approximately 45-degree angle with the skin is achieved. This is varied slightly to improve the Doppler shift, so that an accurate waveform with a maximum deflection is achieved

What is the percentage of normal, asymptomatic individuals that can elicit a positive finding on a TOS test?

60% Up to 60% of persons can demonstrate a compression without necessarily developing symptoms. For a TOS study to be reported as positive, the systolic pressures/pulse waveforms must be significantly affected by the maneuvers-plus the patient must develop symptoms

What is the maximum time for digit temperatures to return to pre-cold water immersion levels, to rule out cold sensitivity?

< 10 minutes Normal digital tracings and/or temperatures should return to pre-immersion status within 10 minutes to be categorized as normal, with > 10 minutes being consistent with cold sensitivity

What waveform type presents proximal to an occlusion or near occlusion?

A high resistance pattern with only antegrade flow during systole and no flow during diastole When scanning vessels proximal to an occlusion or near occlusion, the spectral waveforms can display a very high resistance pattern with only an antegrade flow component during systole and no flow during diastole

Examination of the femoral, popliteal, and tibial vessels generally is best performing using:

A linear array transducer with imaging frequencies between 4 and 7 MHz Curvilinear 5-2 MHz and phased array 3-2 MHz probes are typically used for aortoiliac scanning, but these lower frequency probes may be needed to insonate deeper lower extremity vessels in heavier limbs. Linear 7-4 MHz transducers are used for visualization of the femoral, popliteal, and tibial vessels. High resolution of compact linear 15-7 MHz transducer allows better visualization of superficial arteries on the ankle and foot

A 75 year old patient presents with headaches, visual disturbances, and asymmetrical brachial blood pressures. Which of these diseases is most likely the cause? A) Giant cell arteritis B) Raynaud's disease C) Takayasu's arteritis D) Buerger's disease

A) Giant cell arteritis Giant cell arteritis or temporal arteritis is an inflammatory vasculitis seen in elderly patients. The average age of onset is 70 years and rarely occurs in people younger than 50 years of age. Patients are frequently referred to the vascular laboratory because of asymmetrical upper extremity blood pressures. Patients may also typically present with temporal headaches, tenderness over the superficial temporal artery (a branch of the external carotid artery), decreased pulse, or a cord-like structure over the superficial temporal artery. Other symptoms may include aching or stiffness in the neck, headaches, jaw claudication, and visual disturbances

Which statement correctly describes the standard approach to scanning the deep femoral or profunda artery (PFA)? A) Only the first few centimeters of the PFA is scanned B) The PFA is followed through the entire length of the thigh C) The PFA is not routinely included in the lower extremity protocol D) The PFA is followed to the adductor canal

A) Only the first few centimeters of the PFA is scanned Most laboratory protocols require only the first few centimeters of the of the PFA to be scanned. After a short distance, the PFA courses deeper in the thigh, giving rise to multiple branches

If digital symptoms are the result of suspected disease more central to the level of the wrist, ultrasound can be used to look for all of these most common sources EXCEPT: A) Vasospasm B) Plaque formation C) Thrombus D) Aneurysmal disease

A) Vasospasm Typically occurs within the small vessels distal to the wrist level. Other sources of digital ischemia in more proximal vessels include aneurysmal disease, thrombus, or plaque formation, which may give rise to distal embolization

An anatomic variant where the right subclavian artery arises directly off the aorta is called:

Aberrant subclavian artery The right subclavian artery may originate directly from the aorta distal to the left subclavian artery in what is known as a retroesophageal subclavian artery, or an aberrant subclavian artery

Sensitivity measures the:

Ability to find disease when disease is present Sensitivity measures the proportion of actual positives studies, which are correctly identified. It is the ability to identify disease when disease is present

This is a measure of how "close" something is to the actual value and is calculated as a percentage of correct results

Accuracy

Continuous, antegrade flow through diastole in a peripheral artery can normally be observed proximal to:

An arteriovenous fistula In the cases of a distal arteriovenous fistula, trauma, or cellulitis or in the post exercise patient, antegrade flow will be observed throughout diastole

The majority of the anterior tibial artery can be followed using what approach?

Anterolateral As the anterior tibial artery courses lower in the calf, it can be followed with an anterolateral approach

Which is the most common underlying disease seen as a source of cardiac emboli?

Atrial fibrillation Thrombus forms in the left atrial appendage due to stagnation of blood, then embolizes to a distal site

When scanning an artery that appears aneurysmal, what is the most accurate transducer orientation or scanning plane that should be used?

Axial to the vessel When an aneurysm is encountered, measurements are obtained in the transverse view in both the anteroposterior (AP) and lateral orientations. It is important to visualize the vessel in a true axial plane so as not to falsely overestimate aneurysm diameter with an oblique view

When examining a patient for suspected Takayasu's arteritis with ultrasound, which of the following would be most consistent with this disease? A) Irregular long segments of heterogeneous plaque with stenosis on spectral analysis B) Concentric, homogeneous wall thickening associated with stenosis on spectral analysis C) Focal, heterogeneous plaque usually at branch points with stenosis on spectral analysis D) Focal, homogeneous plaque with an irregular surface with stenosis on spectral analysis

B) Concentric, homogeneous wall thickening associated with stenosis on spectral analysis Unlike eccentric plaques produced by atherosclerotic disease, vascular arteritis typically has the ultrasound appearance of being concentric around the entire vessel. In addition, the ultrasound appearance of the diseased wall is homogeneous

Which of the following is not commonly observed with a pseudoaneurysm? A) Red-blue color swirling pattern within the pseudoaneurysm sac B) Dampened flow within the proximal segment of the feeding artery C) A to-and-fro Doppler pattern within the segment leading into the sac D) A neck or track that connects the blood vessel with the sac

B) Dampened flow within the proximal segment of the feeding artery There is color outside the vessel wall with a neck or tract that connects to the vessel with the pseudoaneurysm sac. The color demonstrates a red-blue swirling pattern consistent with a pseudoaneurysm. Spectral Doppler patterns within the neck of the pseudoaneurysm will demonstrate a flow into the sac as well as flow out of the sac, which is referred to as a to-and-fro Doppler pattern.

There are several characteristic ultrasound findings associated with an arteriovenous fistula (AVF). Which of the following are not seen with an AVF? A) Increased velocity and turbulent flow in the vein near and central to the AVF B) Prolonged acceleration times in the artery proximal to the AVF C) High diastolic flow in the artery proximal to the AVF D) A color bruit at the site of the fistula connection

B) Prolonged acceleration times in the artery proximal to the AVF The characteristic findings on ultrasound include all those listed except and increased acceleration time. Normal acceleration times should be seen in the artery proximal to the AVF

Which of the following is not an advantage of duplex ultrasound over contrast angiography? A) Can detect flow in very low-flow states B) Provides better visualization of collateral network C) Allows for plaque characterization D) Waveform analysis provides a better estimation of hemodynamic significance of a stenosis

B) Proves better visualization of collateral network

The examination of a patient with suspected popliteal entrapment must include which of the following? A) Digital photplethysmographic recordings both supine and standing B) Provocative maneuvers of active plantar flexion or dorsiflexion C) Treadmill exercise for 3-5 minutes at a 10% to 12% grade D) Volume flow measurements at the popliteal artery

B) Provocative maneuvers of active plantar flexion or dorsiflexion Clinical examination typically reveals that distal pulses are present at rest with the ankle in the neutral position. Pulses disappear with active plantar or dorsiflexion. Ultrasound can be employed to image the popliteal artery at rest and with active plantar flexion. Normal velocities at rest will become altered during the maneuver and demonstrate diminished or no flow

Which of the following positions is not used when testing for thoracic outlet syndrome? A) The Adson maneuver B) Supine with arms at the side C) The position that elicits symptoms D) The arms abducted rearward

B) Supine with arms at the side Patients are examined sitting with their arms resting in their lap. The following positional changes are then performed: elbows to the rear and arms almost upright; arms elevated above the head; arms abducted rearward; the Adson maneuver; and any other positions that elicit symptoms

Which of the following statements about the four-cuff versus three-cuff method of determining segmental pressures is correct? A) The four-cuff method allows for more accurate determination of pressure because the narrower cuffs used are the same size as the width of the leg B) The four-cuff method allows the separation of iliofemoral disease from superficial femoral artery disease C) The four-cuff method allows for separation of superficial femoral from popliteal level disease D) The four-cuff method allows for lower thigh cuff inflation pressures

B) The four-cuff method allows the separation of iliofemoral disease from superficial femoral artery disease The higher thigh cuff will reflect flow through the iliofemoral vessels. The thigh cuff placed just above the knee will reflect the flow through the superficial femoral artery

Which if the following statements about photoplethysmography is incorrect? A) They cannot be calibrated B) They detect total limb blood flow C) They transmit an infrared light into the tissue D) They detect underlying blood flow at 1-3 mm depths

B) They detect total limb blood flow Photoplethysmographs are not true plethysmographic instruments because they cannot be calibrated in volume terms, but they are convenient for recording arterial pulses. They operate by transmitting infrared light into tissue and detecting variations in the light reflected from underlying blood flow, from a depth of 1-3 mm

In addition to assessing the degree of narrowing, which of the following is least helpful prior to angioplasty and/or stent placement? A) Length of stenosis B) Vessel depth C) Plaque characteristics D) Artery size

B) Vessel depth A precise evaluation of arterial size, length, and degree of narrowing as well as plaque characteristics is performed for a single focal lesion or sequential lesions suitable for balloon angioplasty and/or stent placement

Velocities in the radial and ulnar arteries are:

Between 40 and 60 cm/s and usually similar

A brachial blood pressure difference greater than 20 mm Hg is associated with which of the following? A) A > 75% diameter reduction in only the subclavian arteries B) A > 50% diameter reduction in either the subclavian or proximal axillary arteries C) A > 75% diameter reduction in either the subclavian or proximal axillary arteries D) A > 50% diameter reduction in only the subclavian arteries

C) A > 75% diameter reduction in either the subclavian or proximal axillary arteries A > or equal to 75% diameter reduction in either the subclavian or proximal axillary arteries will cause a > 20 mm Hg difference between brachial systolic pressures

Normal lower extremity arterial waveforms have all of the characteristics EXCEPT: A) A reflected wave displayed as retrograde flow in early diastole B) A sharp acceleration to peak systole C) An early systolic peak slightly before the highest peak velocity D) A rapid deceleration

C) An early systolic peak slightly before the highest peak velocity An early systolic peak is not often present within peripheral arterial waveforms. Normal lower extremity waveforms have a sharp upstroke to peak systole, a rapid deceleration, a reflected wave displayed as retrograde flow below the baseline, and often a small brief wave of antegrade flow in diastole

Which of the following statements about flow reversal in a peripheral artery is incorrect? A) No flow reversal is present in low resistance limbs B) The greater the resistance to flow, the greater the reverse flow component C) Flow reversal is maintained in the presence of a functioning dialysis fistula D) An incompetent aortic valve may impact flow reversal

C) Flow reversal is maintained in the presence of a functioning dialysis fistula Other than from an artery feeding a well-functioning dialysis fistula or graft, flow reversal indicates the level of peripheral resistance (PR) in the arteriolar bed, where more reversal relates to greater resistance to flow (ignoring the effects of flow reversal through an incompetent aortic valve) and less (or no) reversal relates to lower resistance

Methods that can be employed to overcome the technical challenges of vessel calcification include all of the following EXCEPT: A) Using multiple insonation planes increasing persistence B) Increasing power Doppler gain C) Increasing PRF D) Using multiple insonation planes

C) Increasing PRF Increasing the PRF will not aid to fill a vessel in areas of calcification. Some techniques can be used to obtain the necessary information even within severely calcified vessel, such as using multiple insonation planes, increasing color and power Doppler gain, sensitivity, and persistence or using SonoCT imaging mode

All of the following are associated with a stenosis EXCEPT: A) Color aliasing B) The color flow channel will be reduced C) The color will appear uniform D) A color bruit may be present

C) The color will appear uniform Normal color flow imaging will completely fill the vessels. With proper equipment settings of gain and scale, the color will appear uniform and be limited to just the lumen. In areas of disease, color aliasing will be apparent, the color flow channel within the lumen will be reduced, and a color bruit may be present within the surrounding tissue

Which of the following statements concerning arterial closure devices is incorrect? A) They may only present as a small wall defect with a slight change in echogenicity B) They may cause weak popliteal and femoral pulses on a physical examination C) They are easily identified on ultrasound as a bright reflector causing an acoustic shadow D) They may cause partial or complete vessel thrombosis

C) They are easily identified on ultrasound as a bright reflector causing an acoustic shadow Depending on the composition of the closure device and when it was placed, it may be difficult to identify. Occasionally only a small defect may be present in the vessel wall or a slight change in echogenicity way noted at the site of the closure device

The presence of which of the following most increases the embolic risk for an aneurysm? A) Calcification in the aneurysm walls B) Length of the aneurysm C) Thrombus within the aneurysm D) Size of the aneurysm

C) Thrombus within the aneurysm

Contraindications to treadmill exercise include all of the following EXCEPT: A) Hypertension with systolic pressures > 180 mm Hg B) Chest pain C) Arrhythmia D) Age > 75 years

D) Age > 75 years Contraindications for treadmill exercise testing include chest pain, arrhythmia, post-myocardial infarction/cardiac procedure and not cleared by their cardiologist, unsteadiness, and hypertension > 180 mm Hg

The use of color during arterial ultrasound examinations can do all of the following EXCEPT: A) Guide the placement of the Doppler sample volume in the area of the greatest velocity shift B) Assist with tracking the course of a vessel C) Rapidly assess flow dynamics D) Determine the percent stenosis

D) Determine the percent stenosis Color can assist with localization and tracking the course of the vessels. Color can provide a rapid assessment of the flow dynamics. Color is very useful in identifying flow abnormalities associated with arterial plaque but alone cannot be used to determine the percent stenosis. Color is also helpful in placing the Doppler sample volume at the area of the greatest velocity shift

The ultrasound appearance of temporal arteritis includes all of the following EXCEPT: A) Thickening over a long segment of the vessel B) Concentric wall thickening C) Anechoic area surrounding the vessel D) Hyperechoic wall thickening

D) Hyperechoic wall thickening Giant cell arteritis often appears as a concentric wall thickening, which is hypoechoic. This thickening can occur over a long segment of the vessel and lead to a tapering of the arterial lumen. Additionally, an anechoic area may be present surrounding the vessel producing a "halo" around the vessel

A patient with left thigh claudication will most likely have disease present at which of the following levels? A) Aortoiliac occlusive disease B) Left superficial femoral artery disease C) Aortic occlusive disease D) Left iliofemoral disease

D) Left ilifemoral disease The site of the symptoms indicate the site(s) of the disease, because they occur distal to the disease process, so claudication limited to the thigh symptoms is likely associated with iliofemoral artery disease

All of the following can cause symptoms related to arterial disease EXCEPT: A) Thoracic outlet obstruction B) Embolism C) Trauma D) Paget-Schroetter disease

D) Paget-Schroetter disease It is compression of the subclavian vein at the thoracic outlet and does not produce arterial symptoms. Causes of upper extremity symptoms related to arterial disease include mechanical obstruction at the thoracic outlet, embolism, trauma, digital artery vasospasm, and digital artery occlusion

A patient with chronic arterial ischemia will have the following symptoms except: A) Skin changes B) Hair loss C) Nail thickening D) Paralysis

D) Paralysis Paralysis is consistent with an acute arterial occlusions not chronic disease

Which of the following is not a possible etiology for secondary Raynaud's? A) Scleroderma B) Frostbite C) Prior use of jackhammers or other pneumatic vibratory tools D) Takayasu's arteritis

D) Takayasu's arteritis The etiology of secondary Raynaud's is trauma from the use of vibratory tools or equipment (jackhammers, riding motorcycles, etc.); injury such as using the hand as a hammer (ulnar hammer syndrome); or severe frostbite. Other cause may include underlying medical problems such as scleroderma

Which of the statements about Buerger's disease is correct? A) It usually involves the fingers or toes but not both B) The typical age of onset is over 50 C) It only occurs in men D) Tobacco abuse is always present

D) Tobacco abuse is always present

Which of the following is least likely to result in compression of structures in the thoracic outlet? A) Cervical ribs B) Hypertrophy of the scalene muscles C) Abnormal fibrous bands D) Tumor at the apex of the lung

D) Tumor at the apex of the lung Compressions of structures in the thoracic outlet may be secondary to cervical ribs, abnormal fibrous bands, and possibly hypertrophy of the scalene muscles. Very rarely a Pancoast tumor at the apex of the lung can cause compression

Which of the following are not standard windows of insonation for the subclavian artery? A) Infraclavicular B) Supraclavicular C) Sternal notch D) Via the axillary fat pad

D) Via the axillary fat pad The axillary fat pad is seen while examining the axillary artery. The windows for insonation of the origin of the subclavian artery include the steal notch and supraclavicular or infraclavicular approaches

If a venous ultrasound fails to show a thrombosis and is read as normal but a venogram indicates a popliteal DVT, this ultrasound would be an example of a

False negative

If an ultrasound demonstrates elevated velocities in a renal artery, which is interpreted as a stenosis but angiography shows no disease present, the ultrasound finding would be called a:

False positive

The most common site for embolization outside the cerebrovascular system is:

Femoral Embolization to the femoral level occurs in 36% of cases. The next most frequent location accounting for 22% of cases is the aortoiliac system

Which of the following is a technique that can be used to reduce interference from adjacent veins during acquisition of Doppler waveforms? A) Inflate a cuff distal to 30 mm Hg to the artery being insonated B) Have the patient take a long slow inspiration during the capture of the arterial waveform C) Elevate the patient's legs, such that their ankles are higher than the level of their heart D) Have the patient hold their breath for a few cardiac cycles

Have the patient hold their breath for a few cardiac cycles The Doppler beam is positioned to exclude interference from an adjacent vein; however, this is largely subjective. The patient can be requested to hold the breath for a few cardiac cycles to reduce venous flow and thus venous interference

Measuring the systolic pressure with the point of measurement at the same horizontal level as the heart helps avoid artifacts due to:

Hydrostatic pressure Be careful not to elevate areas above heart level. To avoid artifacts from the effect of hydrostatic pressure, systolic pressures should be measure with the point of measurement at the same (horizontal) level as the heart

Traumatic injury to the ulnar artery at the level of the hamate bone is called:

Hypothenar hammer syndrome The ulnar artery courses toward the wrist adjacent to the flexor carpi ulnaris tendon before crossing the wrist where it then passes deep to the hook of the hamate bone. It terminates as the superficial palmar arch. The hamate is an important landmark. Traumatic injury to the ulnar artery in this region can lead to arterial degeneration, thrombus formation, and potential occlusion. This describes the hypothenar hammer syndrome

A true positive finding is:

If an ultrasound shows a deep venous thrombosis (DVT) at the common femoral vein and a venogram demonstrates a common femoral vein thrombosis True positives (TP) are the number of studies performed by ultrasound, which state that disease is present and the gold standard agrees with the ultrasound findings. For example, an ultrasound shows a dilated non compressible femoral vein with no flow, the venogram demonstrates an occluded femoral vein and the physician's diagnosis is a DVT. All are in agreement that disease is present: a true positive

A true negative finding is:

If an ultrasound shows a normal internal carotid artery and an angiogram demonstrates no disease present within the internal carotid artery True negatives (TN) are the number of negative findings reported by ultrasound that were also reported negative by the gold standard. For example, the ultrasound indicates no evidence of echogenic plaque and normal flow velocities in the proximal internal carotid artery, an arteriogram does not identify any disease, and the physician's interpretation is not internal carotid artery disease

Why is an angiogram considered to be a "gold standard"?

It has a long history of accuracy The angiogram has a long history of accuracy, and therefore, all newer types of vascular imaging must be compared to it to determine the presence or absence of disease and the extent to which it presents

Takayasu's arteritis commonly results in:

Long segment occlusions

Intermittent digital ischemia is a characteristic of which disease?

Raynaud's disease

What is a contraindication to immersing the hands in ice water to detect cold sensitivity?

Secondary Raynaud's When secondary Raynaud's is suspected, the patient should not have their hands immersed in ice water, to avoid causing increased injury

The ability of a test to say something is normal is a measure of:

Specificity

A patient with thigh and calf pain that is associated with exercise and also with standing that can be relieved with sitting or by moving into a different position is most likely due to:

Spinal stenosis Cessation of symptoms with quiet standing corresponds to true ischemic intermittent claudication, whereas correction requiring sitting and/or spinal flexure is more associated with spinal stenosis

A 35 year old Asian woman with symmetrical brachial blood pressures may likely have symptoms that are the result of:

Takayasu's arteritis The disease is most common in Southeast Asia. There is an eight-to-one female-to-male prevalence with greater than 80% of affected individuals being younger than 40 years. The presenting symptom of patients is often an absent peripheral pulse. There may be a brachial blood pressure gradient of greater than 30 mm Hg

Duplex ultrasound findings of a thickened hypoechoic arterial wall are consistent with:

The acute phase of Giant cell arteritis

Which feature should be closely examined to aid in assessing the age of an occlusion?

The adjacent vessel walls Duplex arteriography (DA) has the ability to more accurately assess the age of the occlusion. It is possible to differentiate between an isolated chronic SFA occlusion and an acute embolism with little underlying disease or acute thrombosis with severe underlying atherosclerotic disease. The adjacent vessel walls should be closely examined to determine if atherosclerotic disease is present

This is the most common site for a pseudoaneruysm:

The common femoral artery

Reliability is:

The consistency of obtaining similar results under similar circumstances It is accuracy over a period of time

The Chi square test compares:

The difference between what you expect and what you actually observe

Which of the symptoms are suggestive of popliteal entrapment?

The onset of claudication in a young patient after exercise

Giant cell arteritis commonly impacts which arteries?

The ophthalmic, subclavian, and axillary

Arterial occlusive disease in the upper extremities is most likely found in which arteries?

The subclavian and proximal axillary arteries PAOD is less common in the upper extremity compared with the lower but, when present, it is found most likely in the subclavian and proximal axillary arteries

What is found to be a frequent cause of subclavian artery aneurysm?

Thoracic outlet syndrome Accounting for 16/38 (42%) of subclavian artery aneurysms in one series

Pulse volume recordings reflect:

Total perfusion in the underlying segment under the cuff A pulse volume recording reflects the total perfusion in the underlying segment of the extremity, because the cuff encircles the whole limb but, unlike Doppler ultrasound, this testing modality does not identify specific arteries

Positive predictive value (PPV) is calculated by:

True positives divided by the sum of true positives plus false positives The PPV is the proportion of patients with positive test results that are correctly identified

A notch on the upstroke (anacrotic) portion of a finger pulse waveform is consistent with which clinical condition?

Vasospasm The digital pulse waveform may appear normal or exhibit a "peaked pulse" on the anacrotic (systolic) portion in patients with primary Raynaud's

The first event that occurs with Raynaud's disease is:

Vasospasm with the fingers demonstrating pallor

With vascular arteritis, what is the end result to the vessel wall?

Weakening of the blood vessel and necrosis within the vessel wall The inflammatory process of arteritis is associated with the media of the cell wall becoming infiltrated with a variety of white blood cells. Muscular and elastic portions of the wall are eroded and fibrosis develops. The end result is an overall weakening of the blood vessel and necrosis within the vessel wall