Workbook for Chapter 11&12
What are the main advantages of duplex arteriography, especially as compared to contrast arteriography?
-Avoidance of nephrotoxic agents and radiation -Visualization of low flow arteries -A more expeditious exam -Noninvasive -Can detect occluded arterial aneurysms
What are the characteristic features of intermittent claudication that distinguishes it from other causes of lower extremity pain?
-Cessation of symptoms with quiet standing -Symptoms proximal to disease -Always present w/ exercise -Reproducible results
What are the typical contraindications to exercise in determining the severity of arterial insufficiency in a patient with a relatively normal test at rest?
-Chest pain -Arrhythmia -Post-myocardial infarction/cardiac procedure not cleared by their cardiologist -Unsteadiness -Hypertenion > 180 mmHg
At a measured diameter of 1.1 cm, a common femoral artery would be considered _______, whereas a popliteal artery that measures 1.1 cm would be considered _______
-Normal -Aneurysmal
What are the symptoms associated with acute arterial ischemia?
-Pallor -Pulselessness -Paralysis -Paresthesia -Pain -Polar
A change in ABI of _____ between repeat studies indicates a significant change associated with worsening of PAOD
0.15
The lowest limit of an ABI to be considered within normal range at rest is _____
0.90
A vessel is considered aneurysmal if the diameter is ________ time greater than the more proximal segment
1 1/2
What is the typical protocol used for treadmill exercise testing to assess for claudication symptoms?
1-2 Mph at a 0-10% grade incline Patient is exercised for 5 minutes or until distress is shown, post-exercise ankle pressures are obtained
To ensure accuracy of data, particularly for recording of segmental systolic pressures, how long should the patient be allowed to rest?
10 to 15 minutes
What is the appropriate size for a blood pressure cuff to be used on an extremity to ensure accuracy of data obtained for systolic pressure determination?
20% wider than the diameter of the limb segment and 40% wider than the circumference of the limb segment
An ideal cuff deflation rate for accurately determining the return of Doppler signal when measuring systolic pressure at any segment should be approx. ______
3 mmHg/s
Under normal conditions (absence of disease), the high-thigh pressure using a 4-cuff method will usually be at least _______ greater than normal brachial pressure
30 mmHg
The typical cuff inflation for segmental pulse volume recording (PVR) is:
55-65 Hg
PAOD in the upper extremities occurs in ______ of all cases
< 5%
In the upper extremities, using segmental pressure as diagnostic criteria, significant disease will be most likely when a drop of at least _______ is recorded between two consecutive segments (from proximal to immediately distal segment)
> 20 mmHg
A normal TBI should be at least:
> or equal to 0.8
On a posterior approach of the popliteal fossa, what is the branch identified on the anterior aspect of the image in relation to the popliteal artery?
A gastrocnemius artery
Aneurysm
A localized dilation of an artery involving all three layers of the arterial wall
Using PPG sensor on a digit demonstrating signs of increased vasospasm from primary Raynaud's disease, what characteristic will the waveform typically display?
A peaked pulse on the anacrotic portion
Contrast arteriography
A radiologic imaging technique performed using ionizing radiation to provide detailed arterial system configuration and pathology information
Allen test
A series of maneuvers testing the digital perfusion of the hand while compressing and releasing the radial and ulnar arteries
Which of the following is clear diagnostic criteria to estimate disease between two limb segments when using systolic pressure determination? A) A drop of more than 30 mmHg between the proximal and immediate distal segment B) An increase of more than 30 mmHg between the proximal and immediate distal segment C) A drop of 50 mmHg between the proximal and immediate distal segment D) An increase of 50 mmHg between the proximal and immediate distal segment
A) A drop of more than 30 mmHg between the proximal and immediate distal segment
Which of the following is a main pitfall of duplex ultrasound (in general) in examining arterial disease? A) Flow at velocities less than 20 cm/s B) Flow at velocities over 400 cm/s C) Length of occluded segment D) Collateral vessels
A) Flow at velocities less than 20 cm/s
Severe PAOD can be suspected with all of the following EXCEPT: A) Leg pain while sitting B) Skin discoloration and scaling C) Claudication pain after less than 50 ft walk D) Constant forefoot pain
A) Leg pain while sitting
Thoracic outlet syndrome can include all of the following EXCEPT: A) Pain with arm in neutral position B) Neurologic pain C) Edema of the arm and forearm D) Pain with arm elevated above head
A) Pain with arm in neutral position
The two arteries or arterial segments, which cannot be well examined with duplex ultrasound via a medial approach, are the popliteal artery and _____
ATA
When assessing the appearance of a plaque on a grayscale image, what might an irregular plaque surface indicate?
An area of ulceration
Photoplethysmography
An indirect physiologic test that detects changes in back-scattered infrared light as an indicator of tissue perfusion
Plethysmography
An indirect physiologic test that measures the change in volume or impedance in a whole body, organ, or limb
How is low-resistance blood flow characterized on a Doppler spectrum?
Antegrade flow throughout diastole
On a posterior approach of the upper calf, the artery branching off the popliteal artery deep to the popliteal artery is most likely the _______
Anterior tibial artery
The techniques commonly used for indirect testing of arterial perfusion in the thigh and leg include all of the following EXCEPT: A) Plethysmography B) Photoplethysmography C) Doppler waveforms analysis D) Segmental systolic pressure
B) Photoplethysmography
Which of the following is NOT a consideration when assessing for the possibility of treatment of the arterial lesion by angioplasty or stenting (or both)? A) Size of the artery B) Position of branches C) Length of the stenosis D) Location at the stenosis
B) Position of branches
Which of the following is NOT a potential pathologic finding when the Doppler spectrum of an artery of the lower extremity displays low-resistance characteristics? A) AV fistula B) Post-reactive hyperemia C) Cellulitis D) Trauma
B) Post-reactive hyperemia
Independently of the increasing discussion about the "correct" nomenclature to be used to describe continuous-wave (CW) Doppler waveforms, a normal CW Doppler waveform from an artery of the lower extremity should be:
Bidirectional
Which of the following is NOT a factor typically associated with the need to perform contrast angiography after a limited duplex ultrasound of the arterial system? A) High infrapopliteal vessel calcifications B) Limb-threatening ischemia C) Female gender D) Older age
C) Female gender
The Allen test should be performed before all the following procedures EXCEPT: A) Creation of an AV fistula B) Creation of a dialysis access C) Harvest of the cephalic vein for bypass D) Harvest of the radial artery for coronary bypass
C) Harvest of the cephalic vein for bypass
Which statement regarding the importance of early assessment of the presence of PAD is FALSE? A) Patients are at increased risk for cardiovascular mortality B) Patients are at increased risk for cardiovascular morbidity C) Patients will eventually require an amputation D) PAD is a marker for systemic arterial damage
C) Patients will eventually require an amputation
Thoracic outlet syndrome
Compression of the brachial nerve plexus, subclavian artery, or subclavian vein at the region where these structures exit the thoracic cavity and course peripherally toward the arm
Which statement about intermittent claudication is FALSE? A) Pain with exercise is relieved by rest B) It can be asymptomatic at rest C) ABI values are generally between 0.5 and 1.3 D) ABI value can never be greater than 1.3
D) ABI value can never be greater than 1.3
When using duplex ultrasound to record slow flow (< 20 cm/s) in an arterial segment, which of the following adjustments would NOT be useful? A) Decrease the PRF B) Use a low wall filter C) Increases the persistence of color D) Decrease the Doppler gain
D) Decrease the Doppler gain
Which of the following is NOT one of the main advantages of pulse volume recording (PVR)? A) Records overall segment perfusion B) Can give data even with calcified arteries C) Is easy and quick to perform D) Provides quantitative values
D) Provides quantitative values It actually performs qualitative values because no numbers are used
Which of the following is NOT a common method to induce symptoms with exercise in a patient suspected to have arterial insufficiency but relatively normal results at rest? A) Using a treadmill for walking with a set protocol B) Having the patient walk at own pace until symptoms occur C) Having the patient perform heel raises until symptoms occur D) Raising the limb above the heart while the patient is supine on the exam table
D) Raising the limb above the heart while the patient is supine on the exam table
Progression of PAOD can be established on follow-up of patients by physical examination and clinical history because the patient may describe all of the following EXCEPT: A) Diminution of walking distance B) Increase of recovery time C) Skin and nails changes D) Resolution of pain by changing position
D) Resolution of pain by changing position Consistant with spinal stenosis
All of the following can result in inaccurate systolic pressure measurements in the lower extremities EXCEPT: A) The cuff is too narrow B) The deflation rate is too fast C) The limb segment is elevated above the heart D) The dorsalis pedis artery is used to listen to the signal
D) The dorsalis pedis artery is used to listen to the signal
Doppler spectra with a characteristic low-resistance outline may be seen distal to a hemodynamically significant stenosis. What will the Doppler spectra also display?
Delay on the upstroke in systole
What aspects of duplex ultrasound assessment of the lower extremity arteries allow better estimation of the true hemodynamic significance of an arterial lesion, when compared to contrast angiography?
Doppler spectrum analysis and color Doppler
Most often, symptoms of arterial disease are described as "intermittent" claudication because the symptoms occur ________
During activity
Using duplex ultrasound instead of contrast angiography in patients with severe-to-critical limb ischemia is recommended because the examination with duplex is more _______
Expeditious
The ideal positioning of patients for indirect arterial testing should take great care that all extremities are not elevated above ______
Heart level
When recording pressures from sites proximal to the ankle, the vessel with the ______ pressure is used to obtain the Doppler signal
Higher
The superficial femoral artery typically changes name to become the popliteal artery as the vessel exits the _________
Hunter/adductor canal
The cause of primary Raynaud's disease is ______
Idiopathic
In general, color and power Doppler's primary advantage is for _______ and tracking of the vessels
Localization
As compared to contrast arteriography, duplex ultrasound allows direct visualization of the entire artery and not just the ______
Lumen
Most arteries of the lower extremity can be examined by duplex ultrasound using a ______ approach
Medial
What is the main technical limitation in the routine use of duplex ultrasound instead of contrast angiography to visualize the arteries of the lower extremities due to?
Most plaque will be calcified
ABIs returning to resting values more than 10 minutes post-exercise are a good indication of:
Multilevel disease
Why is the use of contrast angiography in diabetic patients particularly worrisome?
Nephrotoxic agents
What characteristic outline will Doppler spectra in an arterial segment proximal to a hemodynamically significant stenosis or an occlusion have?
No flow in diastole
When assessing the lower extremity arterial system with duplex ultrasound, only the first few centimeters of the _______ are evaluated
PFA
What is the most convenient (and reliable) technique to obtain digital pressures while using a small digital cuff?
PPG
What is the most convenient technique to record changes of arterial insufficiency with thoracic outlet syndrome with a specific (and sometimes tailored) set of maneuvers?
PPG on a digit
How if the velocity ratio (Vr) calculated?
PSV at the stenosis divided by PSV proximal to stenosis
Claudication
Pain in muscle groups brought on by exercise or activity that recedes with cessation of activity; can occur in the calf, thigh, and buttock
Rest pain
Pain in the extremity without exercise or activity, thus, "at rest", can occur in the toes, foot, or ankle area
What is the primary tool to evaluate disease of the lower extremity arteries using duplex ultrasound (at the exception of aneurysm)?
Peak systolic velocity
Why is reporting the presence of a partial thrombus in an aneurysm important?
Pieces of thrombus can embolize
The below-knee segment of the popliteal artery is best examined through a _______ approach
Posterior
Very low flow, particularly to assess the patency of possible outflow vessels, is more easily achieved with duplex ultrasound than with contrast arteriography with the use of _____
Power
To evaluate the dorsalis pedis and distal posterior tibial arteries adequately, a sonographer should be particularly careful with the _______ from the transducer
Pressure
Testing for increased sensitivity to cold using immersion in ice water should one be used in patients with suspected _______
Primary Raynaud's
Symptoms observed or described with intermittent claudication can determine the site of disease because the disease is _______ to the site of symptoms
Proximal
CW Doppler and PVR waveforms analysis are are examples of _______ criteria for the diagnosis of arterial disease
Qualitative
When an occlusion is discovered during duplex assessment of the lower extremity arteries, documentation of where the vessel is ________ by collateral flow is useful to the vascular surgeon
Reconstituted
Using a lower frequency transducer to view the SFA at the adductor canal or the tibioperoneal trunk at the upper calf will reduce _______
Resolution
For recording of accurate segmental systolic pressures, it is important not only to ensure the cuff is appropriate sized for the limb segment but also to allow the patient to _____ before beginning the exam
Rest
Elevation pallor and dependent rubor is usually observed with ______ arterial disease
Severe
Why is it important for the vascular technologist to provide as much information as possible regarding arterial anatomy and disease to the referring physician?
So that all ultrasound data required for patient management decisions can be obtained
Duplex ultrasound is superior to contrast angiography in determining a suitable site for the distal anastomosis of a graft because it can detect the ______ are of the vessel wall
Softest
Lower extremity symptoms that require sitting an/or spinal flexure to relieve is usually associated with ______
Spinal stenosis
Determining/characterizing the "nature" of a plaque or wall thickening is important information a sonographer can convey to a surgeon because _______ through a calcified plaque is almost impossible
Suturing
When can a greater than 70% stenosis in any arteries of the lower extremities be safely inferred?
The Vr is equal to or greater than 3 *When the Vr is equal to or greater than 2 it is a 50-69% stenosis
Plaque
The deposit of fatty material within the vessel walls, which is characteristic of atherosclerosis
Which method is most commonly used to calculate ABI?
The highest pressure at the ankle to the highest systolic pressure of the right or left brachial artery
Which artery is best visualized by a posterolateral approach at the level of the calf?
The peroneal artery
The Allen test is typically performed by placing a PPG sensor on the middle or index finger to record digit perfusion while:
The radial and ulnar arteries are compressed sequentially
Ankle-brachial index
The ratio of ankle systolic pressure and brachial systolic pressure
Conditions and risk factors for which patients are referred for duplex ultrasound of the lower extremity arteries are ______ as those for indirect physiologic testing
The same
Why does duplex ultrasound have an advantage over contrast angiography for the examination of the vessels walls?
The wall thickness can be measured
Distal to a hemodynamically significant stenosis, the Doppler waveform demonstrates poststenotic _______
Turbulence
Duplex arteriography
Ultrasound imaging of the arterial system performed to identify atherosclerotic disease and other arterial pathology, providing a detailed map of the arterial system evaluation
Which method represents good practice to thoroughly evaluate arterial disease in the lower extremities when using B-mode to view the vessel?
Using both transverse and longitudinal planes
Raynaud's disease
Vasospasm of the digital arteries brought on by exposure to cold; can be caused by numerous etiologies
Although the PSV is the primary measurement obtained, stenoses are classified based on ______
Velocity ratio
What will the use of a 4-cuff versus a 3-cuff method to estimate arterial disease in the lower extremities help determine?
Whether disease is present at the iliofemoral level
What is the typical skin color changes (in the hands and fingers) associated with Raynaud's disease from room temperature to exposure to cold temperature and ending with rewarming?
White, blue, red
