III. Peripheral Arterial (vascular semester 3)

Common signs of advanced arterial insufficiency of the lower extremity include which of the following?

A, B, and D. (A. Loss of hair growth over the dorsum of the toes and feet, B. Thickening of the toenails, D. Dependent rubor)

Referring to the readings below, the left ankle/brachial index is:

A. 0.50 (90/180)

The usual cuff pressure used in arterial volume recording is:

A. 65mmHg

A normal postocclusive reactive hyperemia velocity response is:

A. A>100% increase in mean velocity

The correct setting for arterial volume recording is:

A. AC-coupled output

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

Your segmental pressure readings are indicated below. These findings could result from all EXCEPT:

A. Aortoiliac obstruction

The term cyanosis describes:

A. Blue color of tissue due to ischemia

The upper extremity vein most commonly used for an arterial bypass in the leg is the:

A. Cephalic vein

Parameters usually assessed in exercise testing include all EXCEPT:

A. Changes in thigh-to-ankle index

Transcutaneous partial pressure of oxygen (tcPO2) studies can be useful for all EXCEPT:

A. Determination of arterial level of obstruction

A common evaluation for advanced lower extremity ischemia involves raising the supine patient's leg and then having the patient sit and dangle the leg. A positive result is described:

A. Elevation pallor, dependent rubor

A 64yr 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

The velocities measured in a reversed saphenous vein bypass graft are usually:

A. Higher proximally and lower distally

Select the entity that is NOT a risk factor in peripheral arterial occlusive disease:

A. Hypolipidemia

The type of revascularization surgery that requires the use of a valvulatome is:

A. In situ saphenous graft

A clenched fist will change the following parameter in the brachial artery Doppler waveform:

A. Increase the pulsatility index

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

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

A normal response of ankle pressure to exercise testing (such as treadmill) is:

A. No change

Which statement probably does NOT describe aspects of Raynaud's disease?

A. Normal distal pressures when the hand is immersed in cold water

Reasons to perform reactive hyperemia instead of treadmill testing include all EXCEPT:

A. Patient's inability to tolerate application of pressure cuffs

Unilateral claudication in the calf and foot of a young individual suggests:

A. Popliteal artery entrapment

The right high-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

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

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

A popliteal to dorsal pedal small saphenous reverse bypass graft has a peak systolic velocity of 28cm/s at the distal anastomosis. Which of the following is true?

A. This velocity may be normal for this graft

A diabetic patient with redness of the skin in the foot and toe probably has:

A. an infection

Normal diameter for the abdominal aorta is:

B. 2-3cm

Normal values in tcPO2 assessment are:

B. 60-80mmHG

A PTFE graft can be identified during ultrasonographic imaging by:

B. A double-line appearance of the graft walls

The most widely used interpretive technique for analog Doppler waveforms is:

B. A qualitative approach or pattern recognition

Match the following symptoms and signs with the likely cause (Tip: Start with the most obvious and work your way in) Symptoms A. Bruit B. Absent pulse C. Foot rubor D. Right sided weakness E. Edema Signs 1. Aortoiliac + SFA occlusion 2. Deep venous thrombosis 3. Subclavian artery occlusion (acute) 4. Left carotid artery occlusion 5. Iliac artery stenosis

B. A-5, B-3, C-1, D-4, E-2

The vascular disease that presents as back, abdominal, or flank pain is:

B. Abdominal aortic aneurysm

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:

B. Angina

Toe pressures:

B. Are falsely elevated less frequently than tibial ankle pressures

All of the following devices, utilized in a standard fashion, can measure ankle pressures EXCEPT:

B. B-mode ultrasound

The absence of a bruit at the common femoral level:

B. Cannot rule out significant stenosis at that level

A 12yr 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:

B. Coarctation of the aorta

The usual site of puncture for percutaneous lower extremity (or any) angiography is:

B. Common femoral artery

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:

B. Compartment syndrome

Patients presenting with symptoms of claudication complain of:

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

More than 90% of infrarenal abdominal aneurysms are of:

B. Degerative origin

Which technique is LEAST likely to be used to record digital pulses or changes in arterial volume?

B. Duplex sonography

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 left ankle pressure of >300mmHg. This result is:

B. Erroneous due to probably arterial calcification

A 36yr old female comes to the vascular lab because of a nonhealing ulcer on the medial aspect of the right malleolus. In addition to the ulcer, a brownish discoloration is evident in the area from the right ankle to the lower calf. With reference to these figures, the PPG tracing most likely to be seen is:

B. Figure B

The risk of claudication in diabetic patients is:

B. Greater than 4 times the risk in the general population

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?

B. Hyperemia is prolonged in obstructed limbs in comparison to limbs with no obstruction

Which of the following statements is FALSE regarding smoking?

B. It increases the oxygen-carrying capacity of blood

Rest pain is characterized by:

B. Pain at night in the forefoot or foot that may go away with leg dependency

Auscultation of the abdomen, aortoiliac, and common femoral areas is important because:

B. Presence of a bruit may be the first indication of arterial disease

A dampened Doppler velocity waveform of the subclavian artery isolates a significant lesion:

B. Proximal to the point of insonation

A patient complains of digital pallor or cyanosis induced by cold exposure or emotional stimuli. These symptoms are a characteristic of:

B. Raynaud's phenomenon

Arteriography would be contraindicated or approached very cautiously in a patient with:

B. Renal failure

This digital photoplethysmographic waveform might suggest:

B. Secondary Raynaud's disease

Little or no increase of blood flow velocity in response to postocclusive reactive hyperemia (PORH), using an inflated thigh cuff, would most likely indicate:

B. Significant obstructive disease

In the lower extremity circulation, the most common site of atherosclerosis is:

B. The arterial segment beginning in Hunter's Canal

During assessment of ankle pressures, all three vessels at the level of the ankle are used to measure pressures. The pressure in both the posterior tibial and peroneal artery is 40mmHg and the dorsalis pedis pressure is 50mmHg. Which of the following is TRUE?

B. The dorsalis pedis artery pressure should be used to calculate the ankle/brachial index

Monophasic posterior tibial artery waveforms, despite normal ankle/arm indices in the asymptomatic patient, indicate that:

B. The low pass filter may be set too high

Doppler velocity waveforms from upper extremity vessels may vary slightly from lower extremity waveforms because:

B. The peripheral resistance is usually lower in the upper extremity

The most important reason Doppler evaluations should be performed with the patient in a basal state and warm temperature is:

B. The results are influenced by the patient's peripheral resistance

Which one of the following is always TRUE of patients who suffer from intermitten claudication?

B. There is pressure drop distal to the obstructed segment after exercise

An occlusive disease of medium and small arteries in the distal upper and lower limbs of primarily young male heavy smokers is:

B. Thromboangiitis obliterans

Which set of waveforms is most likely to be obtained with a continuous-wave Doppler when there is a long superficial femoral artery occlusion?

B. Triphasic waveforms at the common femoral and proximal superficial femoral arteries with monophasic waveforms in the popliteal and tibial arteries

Ischemic ulcers (lesions) are:

B. Very painful and commonly located distally over the dorsum of the foot

Compared to patency rates in the iliac arteries, patency rates for angioplasty of the infrainguinal arteries are:

B. Worse

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:

B. You have stood the probe up, increasing the angle of incidence

The most common source of lower or upper extremity peripheral arterial embolus is:

B. the heart

Match the symptoms with the likely ankle/arm index:

C. 1-c and 2-d

An analog Doppler waveform of the subclavian or axillary in a normal individual would typically resemble:

C. A common femoral or superficial femoral artery waveform

The key technology in arterial pneumoplethysmography is:

C. A pressure transducer monitoring cuff pressure over a limb.

A pulsatile mass in the groin after catheterization of a cardiac patient most likely will be:

C. A pseudoaneurysm of the femoral artery

Normal Doppler waveform morphology for a peripheral artery includes:

C. A sharp upslope and downslope and a prominent reverse flow component

A normal ankle-pressure response to reactive hyperemia is:

C. A transient decrease of approximately 20% (This decrease is normally quite brief and may not be registered unless pressures are taken immediately on thigh-cuff deflation)

Delayed return of the capillary blush after pressure on the pulp of the digit is a sign of:

C. Advanced ischemia

Doppler waveform abnormalities in the lower extremity arterial circulation distal to a hemodynamically significant stenosis include:

C. An absent flow reversal component, blunting of the peak velocity, and prolonged upslope and downslope

Which of the following is NOT correct regarding peripheral arterial angiography?

C. Arteriography is used for routine postoperative follow-up

Diastolic reversal of flow is most likely in:

C. Extremity arteries at rest

Computed tomography is useful in the lower extremities primarily for detection of:

C. Femoral or popliteal aneurysm

The combination of neuropathy and peripherally distributed atherosclerosis makes the diabetic patient especially vulnerable to:

C. Foot lesions

Patients presenting with a diagnosis of ischemic rest pain may complain of:

C. Foot pain while in a horizontal position, relieved by standing or dangling the foot in a dependent position

A traumatic arteriovenous fistula produces:

C. High, pulsatile venous flow in the veins proximal to the fistula

Systolic thigh pressures could be accurately measured with standard (12 cm wide) arm cuffs:

C. In patients with similar thigh and arm diameters

Ankle/arm indices in claudicating patients are usually:

C. In the range of 0.5-0.9

A patient with mild claudication-like symptoms has an ankle/brachial index for the affected leg of 1.02. This finding:

C. Is an incomplete evaluation of this patient

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:

C. Is higher than expected

The amplitude of arterial volume recording waveforms:

C. Is only marginally meaningful diagnostically

In at study of upper extremities, pulse volume recording shows lack of dicrotic notch at all levels of a patient with warm hands and fingers bilaterally. The patient:

C. Is vasodilated

Distal to an aortoiliac occlusion, the common femoral artery signal is typically:

C. Low-pitched and monophasic

Diastolic flow reversal:

C. May be absent in vasodilated limbs

In the presence of tibial arterial calcification in the diabetic patient, the ankle/arm index:

C. May be in the normal range or abnormally decreased, yet falsely elevated

Ulcers due to arterial insufficiency are found most often:

C. On toes and distal foot

A 28yr 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 by drops to 40mmHg on the right. These signs are consistent with:

C. Popliteal entrapment

Audible Doppler venous signals typically are low frequency and vary with respiration, wheras normal arterial signals in the legs and arms are:

C. Relatively high frequency with pulsatile components

Protocols for cardiac treadmill testing and claudication treadmill testing differ, the major difference being:

C. Speed is varied during cardiac testing.

This CW Doppler waveform from a popliteal artery:

C. Suggests interference from venous flow

A condition that causes nonatherosclerotic narrowing of brachiocephalic arteries in overwhelmingly female patients is called:

C. Takayasu's arteritis

The volume flow rate in a reversed saphenous vein bypass graft should be:

C. The same throughout the graft

Early atherosclerosis of the lower extremities will be associated with:

C. claudication

A velocity obtained in the mid superficial femoral artery is 225cm/s, while a measurement just proximal to this site gives 90cm/s. This suggests:

D. >50% SFA stenosis

A patient walks on the treadmill until forced to stop at 3 minutes due to left calf and thigh pain. The right leg was asymptomatic throughout the course of the testing. Referring to the results below, which of the following statements is TRUE?

D. A & B (A. There is arterial disease in both legs, B. The left leg has worse disease than the right)

Which statement is correct regarding ditial subtraction arteriography (DSA)?

D. A mask, often without contracts, is selected to be subtracted from the frames obtained during injection of the contrast solution

When assessing a digital artery with Doppler, patency of the palmar arch can be determined by:

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

Your segmental pressure readings disclose a 36mmHg decrease in pressure from the low-thigh to the below-knee anterior tibial artery, and a 10mmHg decrease from low-thigh to below-knee posterior tibial artery. These findings localize obstruction to the:

D. Anterior tibial artery

The common radiologic terms "inflow," and "runoff" refer respectively to:

D. Aortoiliac, femoropopliteal, and trifurcation arteries

To minimize error during the measurement of the systolic pressures using a manometer having 2 mmHg marks, the deflation rate should be:

D. Approximately 2mmHg per heartbeat

After walking for 5 minutes on the treadmill, a patient experiences decreases in ankle pressure of 40% on the right and 15% on the left. These findings:

D. Are typical for patients with claudication

Aneurysms are most often caused by:

D. Congenital arterial wall thickness

All of the following can apply to a high-resistance signal EXCEPT:

D. Continuous

Common sites for auscultation of bruits in the lower extremity circulation include all EXCEPT:

D. Dorsum of foot

If one is listening with a continuous wave Doppler directly over a stenotic lesion, the signal will:

D. Have a high frequency sound

Pulse volume recordings demonstrate a lack of dicrotic notvh 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:

D. Mild iliofemoral stenosis, severe superficial femoral stenosis or occlusion, and severe infrapopliteal occlusive disease

Which of the following is a significant problem with digital subtraction angiography?

D. Patient cooperation

The pulsatility index is defined as:

D. Peak systolic to peak end diastolic velocity divided by mean velocity

Signs of advanced ischemia in the lower extremity include all of the following EXCEPT:

D. Pitting edema

Regarding lumbar sympathectomy, all are true EXCEPT:

D. Potentially useful in claudication patients

Rubor is defined as:

D. Red skin color

While monitoring of femorodistal bypass graft using duplex ultrasonography, the graft may be at risk of failure if:

D. The graft velocity has dropped from 70cm/s, as measured 6 months earlier, to 30cm/s.

In consideration of the pressure findings below, which of the following statements is NOT true? (Right arm 180/100mmHg, Left arm 120/60mmHg, Right PTA 100mmHg, Left PTA 90mmHg)

D. The patient has renovascular hypertension

In the presence of arterial obstructive disease and distal ischemia:

D. Vasodilation increases, and distal resistance decreases

With severe lower extremity arterial occlusive disease, the Doppler waveforms distally:

D. Will appear markedly dampened, possibly making interpretation difficult for distal segments

Takayasu's arteritis is most often found in:

D. Young women

The ankle/arm index is obtained by dividing the:

D. ankle pressure by the higher brachial pressure

The symptom or sign most likely NOT associated with acute arterial occlusion is:

D. claudication

The chance of a patient dying from a rupture of an AAA averages:

E. 80%

The five year risk for rupture of AAA of 4cm is approximately:

E. <10%

The Doppler beam may be attenuated if:

E. A & B only (A. The sound beam must pass through scar tissue, a hematoma, or excessive fat, B. The vessel has plaque on the anterior wall)

Assessment of palmar arch patency is useful:

E. A & C (A. Before placement of an arteriovenous arm shunt, C. To evaluate blood flow to the digital arteries)

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 10seconds, the right worse than the left. He continues to walk for 5 minutes, after which he is stopped by the tech. The symptoms do not resolve, but do not get worse during exercise. Considering the pressures obtained below, true statements regarding this test is (are): (Before exercise, arm 130, right ankle 130, left ankle 120) (After exercise arm 160, right ankle 100, left ankle 100)

E. A, B, & C (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)

Patients with advanced peripheral arterial vascular occlusive disease exhibit which of the following skin changes?

E. All except D (A. Shiny, scaly skin, B. Dependent rubor, C. Pallor on elevation)

Patients found to have ulcerating lesions or gangrene may have which of the following diseases?

E. All of the above (A. Arterial insufficiency, B. Neuropathy, C. Vasospasm, D. Venous disease, E. All of the above)

The symptoms of anterior tibial compartment syndrome are:

E. All of the above (A. Swelling and/or palpable tenderness over a muscle compartment, B. Sensory deficit or parasthesias, C. Pain on passive stretch of the muscles in the compartment, D. Weakness of the muscles in the compartment, E. All of the above)

Which of the following statements about popliteal aneurysms is TRUE?

E. B, C, & D. (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)

The "kissing stent" angioplasty/stent technique is useful for:

E. Bifurcations

The two flow characteristics that define arterial stenosis anywhere in the body include focal acceleration of velocities and:

E. Distal turbulence

The condition that typically shows up on angiography as a "string of beads" is:

E. Fibromuscular dysplasia

A four-level pressure cuff technique is used to assess arterial disease in the legs. A high-thigh pressure is 140mmHg, with an arm pressure of 160mmHG. All of the following lesions can cause this EXCEPT:

E. Isolated profunda femoral artery disease

Which of the following statements regarding abdominal aortic aneurysms is FALSE:

E. Most prerupture AAAs are discovered because of abdominal symptoms or distal emboli

The most common presenting symptoms in acute arterial occlusion include all EXCEPT:

E. Pedal ulcer

Pulse sites commonly palpated in the lower extremities include all EXCEPT:

E. Peroneal

Which sign or symptom is least likely to be associated with arterial embolization?

E. Progressive claudication

A normal arterial volume waveform may have all EXCEPT:

E. Reverse-flow component

The etiology of arterial aneurysms includes all of the following EXCEPT:

E. Saccular

Which superficial vein is NOT commonly used as a bypass graft?

E. The femoral vein

Systolic thigh pressures are 180mmHg in both lower extremities; the syst0lic arm pressure is 170mmHg on the right and 160mmHg on the left. The patient complains of buttock claudication.

E. The patient may have aortoiliac occlusive disease

A 54yr old male relates a history of calf and thigh pain, the right worse than the left. This pain resolves upon sitting down. The pain 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:

E. These symptoms are not typical of vascular disease

A vibration noted while palpating pulses is called a:

E. Thrill

A patient has a 50% diameter stenosis in a lower extremity vein graft. The systolic velocity at the stenosis:

E. Will be 100% greater than the prestenotic velocity followed by a drop in velocity

Possible error(s) that can occur when recording a femoral arterial waveform using continuous wave Doppler include:

E. all of the above (A. insonating an artery other than the intended one, B. Recording two vessels simultaneously, C. Using an improper probe frequency, D. B & C only, E. All of the above)