Vascular Technology Registry Review
Limitations of Doppler Segmental Pressures:
-cannot discriminate btwn stenosis and occlusion -cannot discriminate between CFA and External iliac disease -calcified vessels render falsely elevated doppler pressures (diabetics, ESRD) -uncompensated CHF may result in decreased ABI -artifactually elevated high thigh pressures when narrow cuff used on thigh -difficult to interpret in presence of multi-level disease
Cuff artifact:
-cuff too large, BP falsely lower -cuff too narrow, BP falsely higher
Sources of error in Doppler waveform analysis:
-improper probe position -inadvertent probe motion -incorrect angle of incidence -inadequate amount of gel -excessive pressure on the probe tip -insufficient period of rest before testing
A long, bright-echogenic streak noted in CFV, which otherwise patent and compressible. It moves w/ probe compress and appears to move w/ venous flow. This is most likely:
A remnant of recanalized old DVT
Which color Doppler pattern is seen w/ Valvular incompetency***?
A reversal of color seen w/ Valsalva maneuver*** - both proximal compression and Valsalva can be used to rule out valvular incompetency - if a reversal of color is seen (Red to Blue or Blue to Red) w/ either proximal compression or Valsalva, incompetency is suspected!!!
Pt walks on treadmill until forced to stop at 3 mins due to Lt calf & thigh pain. The Rt leg was asymptomatic thru out test. Following results were obtained: Pre-exercise: Rt Arm: 150 Rt PTA: 120 Lt PTA: 120 Postexercise: Rt Arm: 150 Rt PTA: 75 Lt PTA: 50 Which of the following statements is TRUE regarding this test info:
A, B there's arterial disease in both legs, Lt leg worse, severe from pressure decrease
Whats the difference between DC and AC coupling? What type of studies is each used for?
A. DC- Direct current w/ electric voltage being + or -, it only flows in 1 direction, and it detects slow changes in blood content. Its used for venous studies. B. AC- Alternating current that uses reverse polarity (+/-) 60/sec, it flows in both directions and detects fast changes in blood content. Its used for arterial studies.
This waveform was obtained in the ICA. What technical problem is present?
Aliasing is present
Phelgmasia Cerulea Dolens*** is a serious condition associated with:
All - Cyanosis - Iliofermoral DVT - Decreased Arterial inflow due to severely reduced Venous Outflow***
Which of the following accurately describes the Exit effects of flow through a Stenosis**?
All - Flow profile elongates*, eventually reestablishes as parabolic - Boundary layer separation* occurs - Flow near the vessel edges becomes stagnant or Retrograde*
Pt in Hypercoagulable state is seen to have Thrombosis of Rt Renal Vein by Duplex sono. What other findings may be seen in association w/ this?
All - Thrombus w/in IVC - Decreased Diastolic flow in RRA - Poor visualization of Interlobular flow by Color Doppler
Which of the following can result in a loss of the Triphasic Waveform in the Popliteal Artery*?
All - distal vasodilation - proximal occlusion - postexercise
Possible error(s) that can occur when recording a Femoral arterial waveform using continuous-wave Doppler include:
All - insonating artery other than one intended, recording 2 vessels simultaneously, using improper probe freq
The Greater Saphenous Vein:
All - originates along the medial dorsum of the foot - passes superiorly, anterior to the medial malleolous - is accompanied by the saphenous nerve - receives tributaries from all surfaces of the lower extremity
Which is an advantage of Color Doppler imaging over B-mode imaging alone in evaluation of the Venous System?
All - recanalized thrombi readily apparent - partially occluding thrombi better detected - venous collaterals readily visualized
Which of the following arteries arise(s) from the ECA?
All - superior thyroid - lingual - facial - ascending pharyngeal
The symptoms of anterior tibial compartment syndrome are:
All - swelling and/or palpable tenderness over muscle compartment - sensory deficit or parestesias - pain on passive stretch /weakness of the muscles in compartment
Which of the following is a complication of plaque ulceration?
All - thrombosis - intraplaque hemorrhage - embolization
Matching: Proximal vessel: Branch or Continuation of Vessel: A. Innominate 1. ICA B. Subclavian 2. Subclavian C. CCA 3. Basilar D. Vertebral 4. Superficial Temporal E. ECA 5. Vertebral
A. Innominate 2. Subclavian B. Subclavian 5. Vertebral C. CCA 1. ICA D. Vertebral 3. Basilar E. ECA 4. Superficial Temporal
What does the internal iliac arteries supple? External Iliacs?
A. Internal iliacs= pelvic organs B. External iliacs= BLE
Delayed return of the capillary blush after pressure on the pulp of the digit is a sign of:
Advance Ischemia - usually seen after 1-2 sec. In Pts w/ significant ischemia, its delayed for many seconds
Outermost layer of the Arterial wall is the:
Adventitia* - (outer) adventitia, media, intima (innermost layer)
Hyptertension is associated w/ hyperperfusion syndrome
After carotid endarterectomy
Where would the Lowest pressure be found?
B - area of stenosis
Performing US exam on Pt w/ gunshot would involving the Posterior Tibial Artery. What artifact is associated with metallic objects such as bullets?
COMET TAIL - Associated w/ metallic objects such as bullet/surgical clips. Appearance is a series of bands underneath the metallic object. Artifact is caused by multiple reverberations of sound wave w/in the tiny structure
In an Emergency room Pt w/ stroke symptoms, the initial diagnostic exam of choice would likely be
CT
Differentiation b/n Primary Ischemic and Primary Hemorrhagic Stroke* is most readily obtained by which Diagnostic test?
CT of brain
What type of technique uses 2 PZT crystals, one for sending signals and the other for recieving signals, it has no range resolution, and only has 1 fixed sample size? (Spectral analysis, CW Doppler, Pulsed Doppler, or Color Doppler)
CW Doppler
Paraumbilical vein drains into a network of varices that can be seen on the ABD radiating from the umbilicus. These varices are known as:
Caput Medusae*
To evaluate Blood flow BF w/in the Splanchnic arteries, you should examine the following vessels
Celiac artery, SMA, IMA - vessels that supply blood to the gut, stenosis or occlusion involving these vessels can result in chronic ischemia of the bowel, aka MESENTERIC ISCHEMIA
What are the three major branches of the abdominal aorta?
Celiac axis/trunk (Hepatic, splenic, and Lt gastric) SMA, and IMA
The Splenic, Common Hepatic, and Left Gastric arteries arise from this abdominal artery:
Celiac trunk*
Received request to evaluate blood flow w/in SPLANIC Arteries*. Which of the following groups of blood vessels should you examine?
Celiac/SMA/IMA* - Splanic arteries are vessels that supply the GUT. - Stenosis or occlusion involving these vessels can result in Chronic Ischemia of the bowel, known as Mesentric Ischemia***
What is pain in muscles usually occurin during exercise; subsides with rest?
Claudication
PT being evaluated for Portal HTN may have liver-dysfunction symptoms including all of the following EXCEPT:
Claudication - manifestations of hepatic dysfunction: Jaundice, clothing abnormalities, malnutrition, ascites
ABI 0.5-0.9
Claudication (moderate disease)
Early atherosclerosis of the LE will be associated w/:
Claudication* - may be experienced for month/yrs prior to acute arterial occlusion - Acute/late chronic occlusive changes includes: rest pain, blue toe, pregangrene, - swelling, often accompanies Venous thrombosis
The symptoms or sign most likely NOT associated w/ acute arterial occlusion is:
Claudication* - may be experienced for month/yrs prior to acute arterial occlusion - consistent AAO symptoms includes: blue toe, pain of sudden onset, pale/white extremity, paresthesia
Symptoms of Pulmonary Embolization* include all EXCEPT:
Claudication* - venous thrombus that embolizes to lungs is PE - symptoms include: chest pain, dyspnea, tachycardia, tachypnea***
Cramping muscle pain which is induced by exercise and relieved by rest is termed:
Claudication***
Which letter represents Spectral window?
C
Where would a Doppler signal be obtained that showed SPECTRAL BROADENING?
C - area after stenosis, turbulent flow
Where would a Doppler signal show the highest bandwidth?
C - area after stenosis, turbulent/eddie flow
Where would the REYNOLDS number be greatest?
C - area after stenosis, turbulent/eddie flow
Syndrome caused by swelling w/in OSTEOFASCIAL compartments of the leg or arm resulting in Decreased Vascular perfusion is the:
Compartment Syndrome*** - commonly occurs after revascularization following prolonged ischemia, may develope due to External compression or bleeding w/in compartment
What is Compartment Syndrome
Compartment syndrome is a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow.
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:
Compartment syndrome**
A pitfall of MRA is:
All but B - Pts w/ cardiac pacemakers can't be studied - it tends to overestimate the degree of stenosis - it requires a high degree of Pt cooperation
When performing LEV Doppler assessment in normal Pts, cephalad flow diminishes:
All but C: during expiration (decreases pressure in abd, allowing venous outflow from LE to resume*** - during Valsalva maneuver: diminishes venous flow everywhere in body, increases both intraabd and intrathoracic pressure - during inspiration: diminishes venous flow of LE, increases pressure in abd cavity, more pressure on IVC - during proximal compression: diminish venous flow due to pressure on vein***
Some causes of DVT may be:
All except D - trauma, hypercoagulability, extrinsic compression upon deep veins
Pts w/ advanced peripheral arterial vascular occlusive disease exhibit which of the following skin changes?
All except D (stasis pigment) - shiny, scaly skin, dependent rubor, pallor elevation
Where are arterial ulcerations usually seen and how do they look?
Arterial ulcerations are very painful and are often seen in the tibial area, toes, or bony prominences. They are usually seen as deep, regular shaped ("punched out" appearance). The skin of patients with arterial ulcers is dry, scaly, and/or shiny, with loss of hair and toenail thickening.
Which of the following is NOT correct regarding peripheral arterial angiography?
Arteriography is used for routine postoperative follow-up - its invasive, definite risk of complications, adverse reactions less likely w/ newer contrast agents, performed prior to surgery
What is a small terminal artery with muscular walls, that continues into the capillary network called?
Arteriole
Patient presents to the lab w/ HX of recent Brachial Artery Catherization and a palpable thrill over the Brachial Artery. Which diagnosis is most likely?
Arteriovenous Fistula (AVF)*** of the Brachial Artery and Vein - Vascular thrill is a palpable vibration over an artery. Indicates high-flow state w/ turbulence and felt over fistula site - complications of arterial catherization includes: AVF, pseudoaneursyms, hematoma, thrombosis - only fistula and pseudo will produce a palpable thrill!!!
What is an abnormal connection between a high-pressure arterial system and a low-pressure venous system called?
Arteriovenous Fistulae (AVF)
What is a non-atherosclerotic lesion, with Buerger's disease (thromboangitis obliterans) as a form of the condition, which is when LE arterial vessels become inflammed and lead to thrombosis of the vessels
Arteritis
All of the following are causes of or risk factors for acute DVT EXCEPT:
Arthritis - trauma, extrinsic compression on deep veins, hypercoagulability, cancer are
The ability of veins to accommodate large shifts in volume w/ only limited changes in Venous Pressure is known as:
Compliance
In the case of the ICA occlusion, all of the following are potential collateral pathways to perfuse the Ipsilateral Cerebral hemisphere EXCEPT:
Contralateral Subclavian Artery to the Internal Mammary Artery (This is NOT a collateral pathway to the Cerebral hemisphere) - Contralateral ICA thru reversed flow in Ipslateral ACA - VB system thru the PCoA - Ipslateral ECA thru the orbit to the Ophthalmic artery
In case of the Vertebral artery occlusion, which vessel is likely to be enlarged?
Contralateral Vertebral! (compensatory enlargement of the contralateral vertebral is common)
During assessment of ankle pressures, all 3 vessels at the level of the ankle are used to measure pressures. The pressure in both the PTA and Peroneal artery is 40 mmHg & Dorsalis Pedis pressure is 50. Which of the following is TRUE?
Dorsalis pedis artery pressure should be used to calculate the ankle/brachial index - higher ankle pressure is used to calculate the index.
Common sites for auscultatioin of bruits in the LE circulation include all EXCEPT:
Dorsum of foot* - abd, groin, pop space, are common
A PTFE graft can be identified during US imaging by:
Double Line appearance of the graft walls - "GORE-TEX" graft characterized by double line**
What does Diplopia mean?
Double vision or bilateral visual blurring
The greatest pressure of venous hypertension in secondary varicose veins occurs:
During muscle contraction - forces blood out to the superficial veins via incompetent perforating veins
Pt describes a 30 min episode of garbled speech. This is called:
Dysphasia - difficulty w/ speech
Which letter in illustration is pointing to End Diastole?
E
In this cross section of the calf, which letter represents the Interosseous membrane?
E Interosseous septum - next to ATV, Btn Tibia & Fibula
In this cross section of the calf, which letter represents the Posterior Tibial Vessels?
E PTV next to Peroneal veins by GSV - A Peroneal - B LSV - C ATV - D GSV
Which of the following correclty describes an advantage of PW Doppler over CW Doppler***?
Echoes CAN BE received from SPECIFIC Location w/ PW Doppler!!!!*** - Term is called RANGE-GATING, since speed of sound in tissue known 1540 m/s, RT time to specific depth (sample volume location) is easily determined! - System sends a pulse and then waits the calculated time to receive echoes only from desired depth. - CW, echoes are continually received from all moving interfaces in the beam path*
What vessels should be evaluated pre and post operative liver transplants?
Evaluate for patency of: portal vn, hepatic veins, IVC and hepatic artery.
Which of the following is NOT a common feature of renal allograft rejection? - INCREASE allograft size - INCREASE cortical echogenicity - INCREASE prominence of the renal pyramids
DECREASED FLOW RESISTANCE IN PARENCHYMAL ARTERIES is false - resistance tend to INCREASE, manifested as DECREASE in DIASTOLIC FLOW, normal flow is LOW RESISTANCE w/ forward flow thru out cardiac cycle. - DECREASE, ABSENCE OR REVERSAL OF FLOW IN DIASTOLE IS INDICATIVE OF REJECTION!!!!***
The Bernouilli Effect** describes:
DECREASED PRESSURE in regions of high flow speed***
Among the chief limitations of CW Doppler is/are:
DEPTH info isn't possible, precise location of flow pattern can't be determined - 2 xdcr probes for CW are relatively inexpensive, directionality is included, connected to spectrum analyzer, no sample volume as PW does
The 2x2 table box below shows data used to correlate ankle pressure measurement w/ healing in Pts undergoing toe amputation. Not healed Healed <60mmHg 15 3 >60mmHg 5 27 The gold standard is healing of the amputation site. For the purpose of this study, a positive/abnormal ankle pressure was <60mmHg. Which of the following statements is true:
Denominator for calculating PPV is 18
The components of info on the spectral Doppler display include all EXCEPT:
Depth on Y-axis is false - pixel brightness, indicating how many RBC are reflecting at a given freq shift - freq shift on y-axis - time on x-axis
What does Vertigo mean?
Difficulty in maintaining equilibrium
Performing Doppler exam on 32 yo F who was in car accident. She received a blow to the left side of body, presents w/ abdominal bruit, back pain, and HTN. Which of the following conditions is most likely?
Dissection involving the ABD AORTA and possible Renal arteries - only arterial dissection is related to Trauma! Dissection of ABD AO can compromise flow/extend into the Renal Arteries resulting in HTN.
This Doppler waveform was obtained in a stenotic Femoral Artery. Was it most likely taken proximal or distall to the site of stenosis
Distal - demonstrates POSTSTENOTIC TURBULENCE*** - can be seen in the fill-in of the SPECTRAL window and the presence of a small amount of flow below 0 baseline
Of the following vein segments, which is imaged LEAST commonly?
Distal DFV -BC of its depth, the distal deep femoral vein is usually very difficult to image
What if you see fast upstroke and no diastolic flow in CCA, where would you think the disease is located? Proximal or distal to CCA?
Distal disease
Unilateral decrease or absence of diastolic flow in CCA is indicative of:
Distal obstructive disease - most likely occlusion of Cervical ICA or high grade stenosis of Intracranial ICA
Area in the LE where its usually most difficult to bring about vein-wall coaptation w/ probe compression is:
Distal thigh (SFV distal) - Taut bc of adductor muscles, scan more anteriorly, compress w/ non-probe hand behind thigh.
The 2 flow characteristics that define arterial stenosis anywhere in the body include focal accleration of velocities and:
Distal turbulence***
How do you calculate the renal to aorta ratio (RAR)?
Divide the highest renal artery PSV by the aorta PSV.
Which statement is NOT true regarding the Soleal Veins?
Do NOT connect the Superficial Venous System - do empty into Posterior Tibial or Peroneal Veins, found Deep in the calf muscle, do not contain valves
Duplex findings in 58 yo male include a systolic velocity of 58 cm/sec in RCCA and systolic velocity of 92 cm/sec in LCCA. All are potential contributors EXCEPT?
Doppler angle of Incidence was underestimated on LCCA* - most common error, improper measurement of angle of incidence! angle correct cursor, should be 60 or less underestimate of angle of incidence will result in underestimation of the velocity!!!
What occurs when the frequency of the wave received is different from the transmitted wave, which is relative motion between the source (blood) and the receiver of sound (transducer)?
Doppler shift
Venous puncture for introducing contrast in venography to assess for DVT is done at what level?
Dorsal vein on the foot*
Conventional arteriography reveals 30% diameter stenosis in symptomatic Pt w/ severe stenosis by B-mode and PSV of 250 cm/sec in Proximal ICA. Which of the following statements about these findings is TRUE?
Even double-projection may fail to fully determine diameter stenosis, esp. in the event of vessel overlap - main advantage of duplex is ability to visualize in cross section to artery. Vessel overlap is a common problem, a kink would show up on angiography, background noise wouldn't cause accelerated velocities
Pt is referred for Duplex exam to evaluate a prominent pulsatility felt in the base of the Rt neck. What is the most likely etiology of this physical finding?
Excessive CCA turtuosity -Most common etiology of a pulsatile mass in the base of the neck is, by far, excessive tortuosity of proximal CCA. Although an aneurysm would produce the same physical findings, aneurysms of the carotid artery are quite rare.
What is the single best vasodilator of resistance vessels within skeletal muscle?
Exercise
What you exhale where is the pressure increased and where is it decreased?
Exhale forces diaphragm up = increased thoraic pressure and decreased abdominal pressure.
At what point in a stenosis is flow reversals, flow separation, and vortices / eddy currents seen?
Exiting the stenosis, post-stenotic turbulence.
In the Lower Extremity, maximum flow return in the venous system is present w/:
Expiration*** - flow in venous system is diminished or absent during inspiration and maximal during EXPIRATION! - flow may be INCREASED by release of PROXIMAL COMPRESSION or DISTAL AUGMENTATION!!!
Some time after being hit by a car, a Pt has severe pain in the anterior aspect of the Rt Knee and massive Left lower extremity edema. The Pt most likely has:
Extensive left femoropopliteal DVT - massive edema suggests complete outflow obstruction, thus femoropop thrombus, obstruction must be proximal to the edema, the rt knee pain is a bit of a red herring (piece of information is intended to be misleading, or distracting)
Which of the following vessels courses along the medial aspect of the Psoas Muscle*?
External Iliac Artery*
What vessel runs along the medial side of the psoas mucsle and underneath the inguinal ligament?
External Iliac artery
This vessel courses along the medial aspect of the Psoas muscle:
External Iliac artery*
Diastolic reversal of flow is most likely in:
Extremity arteries at REST - Renal/ICA supply low resistance bed, brings increased forward flow during diastole - during exercise, peripheral resistance decreases, diminishing/eliminating diastolic reversal! Diastolic reversal is NOT a characteristic of Venous flow***
If noninvasive test results were positive, but the Gold standard showed normal results, the noninvasive test results are referred to as:
FALSE POSITIVE*** - Noninvasive test results were positive but the Gold standard test results were negative (i.e. normal)
Which of the following does NOT accurately describe events during calf muscle contration and relaxation?
FALSE: Blood flows from the DEEP system INTO the Superficial system via the Perforators during Relaxation - During relaxation, blood flows from the SUPERFICIAL system INTO the DEEP system***
Complications associated w/ hemodialysis access grafts include all of the following EXCEPT:
FALSE: Decreased Distal Venous pressure* - Distal Venous HYPERtension may develop, complication due to reversal of flow in distal vein away from fistula - Distal limb ischemia - pseudoaneurysm - congestive heart failure - increased distal venous pressure*
A Pt relates a 10 min episode of vision loss, he closed each eye and reduction in rt half of visual field was present bilaterally. This pt is describing amaurosis fugax True or False?
FALSE: Homonymous HEMIANOPIA
All of the statements below are accurate regarding an AVFs EXCEPT:
FALSE: Venous Pressure in draining veins is DECREASED True: -There is an increase in the volume of blood flow in the feeding artery - arterial resistance proximal to the fistula is decreased - high output cardiac failure is common in large AVFs* - venous pressure in draining veins is increased
Loss of Spectral Window w/ Pulsed Doppler US occurs with:
FLOW Disturbance - it is filled/lost when turbulent flow creates spectral broadening* - overuse of Doppler gain - incorrect positioning of sample volume outside of center streamline/depicting signals from vessel wall/adjacent slower moving blood flow
In contrast venography* of the LE for diagnosis of DVT*, the radiopaque material is injected into veins in the:
FOOT*
This image is from a 64 yo M w/ back pain. Which term best describes the aortic aneurysm?
FUSIFORM* - circumferential enlargement of a segment of the artery, most common shape - Saccular is focal OUT-POUCHING - Mycotic is infected, no shape - Ectatic is dilated but not aneurysmal by definition
The angular artery is the terminal part of the:
Facial artery
Which of the following is a anterior circulation symptom?
Facial asymmetry - lateralizing weakness is carotid-territory symptom - dizzy, ataxia, bilateral/global is VB
Which statement regarding AVF is NOT True?
False: Blood pressure in Distal Artery is always Increased - BP in distal is DECREASED* - Fistula located close to heart increases potential for Cardiac failure* - Arterial flow Proximal to fistula is markedly Increased* - Thrill may be felt over fistula site
Which of the following would NOT be true regarding the Calf Muscle Pump*?
False: Hydrostatic pressure is increased in the veins at the ankle w/ contraction of the muscle pump - Hydrostatic fluid column is interrupted and pressure is decreased in the veins at the ankle*
Symptoms associated with Thoracic Outlet Syndrome include all EXCEPT:
False: INCREASED Blood pressure on Affected side - Numbness or tingling of the arm - aching of should and forearm - increased discomfort w/ upward arm positions - increased BP on affected side
Which statement is NOT true regarding Intrathoracic pressure*?
False: Intrathoracic pressure INCREASES w/ Inspiration - w/ inspiration, intrathoracic pressure DECREASES, intraabdominal INCREASES*** - this increases venous return from UE & stops venous flow in LE*** - Valsalva maneuver increases both intrathoracic and intraabdominal, which decreases venous return to the heart***
What Doppler findings would NOT be evident in an acute traumatic AVFs?
False: Prominent collateral veins around the fistula - Prominent collateral veins around the fistula would "NOT" be evident in this situation - Increased Diastolic flow in the feeding artery - Increased Systolic velocity in the feeding artery - Pulsatile flow in the draining vein In acute setting, collateral vessels have not had time to develop*
Which of the following would NOT be true regarding the lower extremity veins in an individual who has been standing for a long time?
False: The veins for the LE would collapse under the increased pressure" - Veins in the LE would be DISTENDED as a result of venous pooling and high pressure***
Which is NOT a limitation of CW Doppler*** evaluation for DVT?
False: Venous Incompetence can't be detected* - CW CAN be used to evaluate for venous incompetence! Limitations include: - partial thrombus may not be detected - well-collaterized thrombosis may show normal flow patterns - inaccurate results may be obtained w/ bifid venous system
All of the changes below can be attributed to incompetent venous valves following Venous Thrombosis*** EXCEPT:
False: Venous malformations - TRUE: Edema, venous HTN, varicose superficial veins, cellulitis, brown skin discoloration, and ulcers may develop eventually*** - w/ incompetent valves, hydrostatic pressure column is unterrupted from the RT Atrium to the LE - pressure leads to venous distention, more incompetent superficial veins & perfs. 2ndary varicose veins develop*
Which statement is NOT true regarding AV malformations?
False: they can be defined as a Direct connection b/n artery and vein - AV Fistual is a direct connection - AV Malformations is present at birth - abnormal network which arterial flow directly into venous w/o intervening capillary bed - may be asymtomatic, can occur anywhere in the body
How is anterior compartment syndrome treated?
Fasciotomy, which is a procedure where the fascia is cut to relieve tension or pressure.
The combination of neuropathy and peripherally distributed atherosclerosis makes the diabetic patient especially vulnerable to:
Foot lesions - found in diabetics w/ peripherally neuropathy w/ or w/o peripheral atherosclerosis****
Pts presenting w/ diagnosis of ischemic rest pain may complain of:
Foot pain while in a horizontal position relieved by standing or dangling the foot in a dependent position - rest pain always occurs at night, is relieved by placing leg in dependent position or by exercise, which increases cardiac output, thus BF to periphery
What cranial caviity does the vertebral artery enter through?
Foramen magnum
Where are the Vasa Vasorum found? What do they do?
Found in the adventitial layer. Carry blood to the walls of larger arteries.
Presence of Aliasing* in the Spectral Waveform of the ICA ALWAYS indicates:
Frequency shift greater than 1/2 the PRF* - presence or absence of aliasing in spectral waveform cant be used as indicator of disease - aliasing occurs when recieving freq shift is greater than 1/2 PRF or sampling rate - freq shift may be high bc of small Doppler angles or high flow velocities -aliasing may also be seen at steeper angles of incidence and lower velocities when system PRF is set too low
The type of revascularization surgery that requires the use of valvulatome is:
In situ (in place) saphenous graft - valvulatome disables the valves in the unresituated vein, allowing blood to flow unimpeded from prox to distal
The GSV is left in its normal anatomical position and used to create a diversionary channel for blood flow around an occluded artery.
In situ bypass
What is the effect of Inspiration*** on Venous Flow in the Lower Extremities?
In supine position, venous flow in the lower extremities stops during INSPIRATION, and returns during EXPIRATION***
What vein is most commonly used in the LE as a REVERSED vein bypass graft*?
GREATER SAPHENOUS VEIN*** - if not, cephalic, brachial or lesser saph vein are used
What is the longest vein in the human body?
GSV (greater saphenous vein)
From this cross-sectional diagrahm of the thigh, reading from superficial to deep, identify the vessels marked:
GSV, SFV, PFV* image
Which of the following is NOT one of the commonly assessed characteristics of CW venous Doppler?
Gaiety - characteristic of a cheerful vascular tech Normal venous flow: spontaneity, augmentation, competence, phasicity***
What type of flow occurs when flow moves into a wider portion of the vessel (ex: Carotid Bulb), and the Doppler shift is seen above and below baseline differently?
Helical flow
Which characteristics below are associated w/ Chronic Thrombus***?
Large collateral veins, CONTRACTED vein, BRIGHTLY ECHOGENIC, irregular borders
What kind of flow feeds dilated vascular beds like: ICA, vertebral, renal, celiac, splenic, hepatic?
Low resistance flow, which is continous (steady) flow
This image was taken just distal to the groin, femoral vessels are seen deep in the field of view. The structure w/ the measurement cursors represents:
Lymph node - seen superficial to the femoral vessels, prominent w/ cellulitis
Demonstration of vein-wall coaptation in the extremities is best performed:
In transverse plane w/o color flow - allows visualization of coapting walls as well as multiple vessels - study in gray scale
What is a common landmark for locating the left renal artery?
In transverse, the left renal vein as it crosses the aorta anteriorly, the artery is just posterior
What does Aphasia mean?
Inability to speak
Following exercise, what is a NORMAL response for ankle pressures in comparison w/ resting values?
Increase* - In pt W/O obstructive disease, ankle pressures will increase following exercise. - In the presence of arterial obstructive disease, ankle pressure will decrease immediately after exercise**
Which of the following describes a typical VENOUS Doppler waveform obtained Proximal to an AVF*?
Increased velocity and Pulsatility*
In using Continuous-wave Doppler w/ spectral analysis to assess the ICA, which of the follwoing operator-induced eros would most likely result in a falsely LOW freq shift?
Increasing the beam angle to 70 degrees - this would create lower freq shift than the proper 60 degrees angle/doppler equation* - increase the freq shift by: overdriving the Doppler signal gain, allowing the signal beam to overlap both an artery and vein, changing to higher freq xdcr, leaving the wall filter on
Venous Refill time*** <20 sec w/o tourniquet and < 20 sec w/ tourniquet applied BELOW the knee is consistent w/:
Insufficiency of the DEEP and SUPERFICIAL SYSTEMS*** : Normal VRT is > 20 sec - VRT < 20 sec w/o tourniquent, w/ VRT > 20 sec w/ tourniquet BELOW the knee is consistent w/ REFLUX in LESSER Saphenous Vein - VRT < 20 sec w/o tourniquent, w/ VRT > 20 sec w/ tourniquet ABOVE the knee is consistent w/ REFLUX in GREATER Saphenous Vein
Atherosclerosis is a disease that begins in the:
Intima* - intimal lining of endothelial cells becomes disrupted in 1st stage of process
Which of the following is a late complication of extremity bypass grafts?
Intimal Hyperplasia** - resulting from accumulation of smooth muscle cells, matrix forming a fibrous thickening in the graft. can occur focally or diffusely, lead to stenosis, tends to occur at anastomotic sites, venous valve sites and clamp sites - hematomas & pseudo associated w/ extremity bypass grafts are seen in immediate postop period. - AVFs may spontaneously open or close w/ changing hemodynamics of the graft.
Common feature of Temporal Arteritis* is:
Intimal Thickening* - causes marked thickening* - may be localized, focal or widespread - Pts tend to present w/ severe headache - Other symptoms include scalp tenderness, visual disturbance, joint pain, painful chewing - Blindness can occur as a result of Ischemic Optic neuropathy <20%
What layer of the aortic wall develops a tear, which allows for blood to leak through and form a false lumen?
Intimal layer tears and allows blood to leak into the media layer which weakens the media layers.
Temporal arteritis is commonly characterized by
Intimal thickening!!! - causes marked thickening of the intima*** may be localized, focal or widespread. Pts tend to present w/ severe headache, may have scalp tenderness, visual disturbance, joint pain, painful chewing. Blindness can occur as a result of ischemic optic neuropathy in fewer than 20%
You perform TCD, insonating the left anterior cerebral artery (ACA). The flow is "toward" the beam. This finding suggests:
Ipslateral Carotid obstruction, w/ right to left collateralization* - ACA is normally AWAY from beam, thus this suggests flow coming across from other hemisphere via the ACommA
Decreased radial pulse on 1 arm raises suspicion for:
Ipslateral Subclavian Artery Stenosis*
Pt complains of rest pain. On physical exam, elevation Pallor & Dependent Rubor are present. There are no palpable pulses in the leg. Pressure of 120 mmHg is measured in the ankle. This pressure:
Is HIGHER than expected - might be artifactually higher than normal, due to calcification. Rest pain usually <60 mmHg, ABI <0.30
A Pt w/ mild claudication-like symptoms has an ankle/brachial index for the affected leg of 1.02. This finding:
Is an incomplete evaluation of this Pt - circulation must be challenged by exercise or reactive hyperemia!!! Until test is performed significant vascular disease can't be ruled out***
Amplitude of Arterial volume recording waveforms:
Is only marginally meaningful diagnostically
In a study of the UE, pulse volume recordings show lack of dicrotic notch at all levels of a Pt w/ warm hands and fingers bilaterally. The Pt:
Is vasodilated - loss of dicrotic notch generally 1st abnormality to show up, but its not definitive finding.
Continuous wave Doppler assessment of the Posterior tibial reveals nonspontaneous flow that augments w/ foot compression. This finding:
Is w/in normal limits in cold Pts - not uncommon in either PTV or GSV, if Pt is nervous or cold, vasoconstricted***
A four-level pressure cuff technique is used to assess arterial disease in the legs. The high-thigh pressure is 140 mmHg, w/ an arm pressure of 160mmHg. All of the following lesions can cause this EXCEPT:
Isolated profunda femoral artery disease - any lesion proximal to the cuff can cause abnormally low high-thigh pressure. Usually not detectable by pressure changes
Of the chief advantages of continuous-wave Doppler, which of the following is FALSE?
It allows for more PRECISE RANGE-GATING than PW Doppler is False: CW can't range gate, info is returned from along the entire beam - aliasing can't occur, recording of extremely high freq shifts is possible, signal to noise ratio is inherently greater than PW Doppler systems due to its continuous state of operation, CW Dopplers are less expensive, instrumentation is less complex than in PW Doppler
Which of these is NOT true about superficial thrombophlebitis in the leg?
It can be best diagnosed by PHOTOplethysmography: not useful for this - its usually attributed to a thrombosed saphenous vein - it may result in significant incapacitation for the pt - it usually responds to ambulation, warm soaks, aspirin - its frequently recurrent
What is plethysmography used to help determine?
It helps to differentiate true claudication from non-vascular sources.
Which of the following statements is FALSE regarding smoking:
It increases the oxygen-carrying capacity of blood - Carbon monoxide decreases RBC,
What does an abnormal RI or RAR indicate?
It indicates an increase in distal resistance.
Which of the following statements about the Dorsalis Pedis Artery is NOT correct?
It is a branch of the peroneal artery is false - runs anterior to the medial malleolus - is typically the continuation of the ATA - joins the pedal arch about 1/2 way along dorsum of foot - begins at the bend of the foot & ankle ( Dorsalis pedis continues the ATA to the pedal arch)**
Retrograde flow in the Native artery at the site of Distal anastomosis of a LE Bypass graft is:
NORMAL finding* - Blood flow always courses from high to low pressure direction - in this case, there's higher pressure w/in normal graft and lower pressure w/in native artery - commonly results in some blood coursing up/retro the native artery at distal anastomosis site - retro flow perfuses tissue above the level of the anastomotic site, provides addt'l benefit
Which of the following is NOT a branch of the Subclavian Artery?
NOT Brachial Artery - vertebral/thyrocervical trunk/internal mammary artery
what enhances the sonographers ability to perform a renal doppler
NPO patient, hydrated kidneys, 2.5-5 MHz transducer
The 3 terminal branches of the Opthalmic artery are the:
Nasal, Frontal and Supraorbital arteries
Saphenofemoral Junction*** is identified by Duplex sonography at:
Near the Inguinal Ligament***
What does myopia mean?
Nearsightedness
Which of the following statements about aforementioned calculations is correct?
Neg predicative value is greater than the positive predictive value overall accuracy must fall btn sensitivity as well as positive and negative predictive values. sensitivity = 53/56 (90%) ppv= 53/61 (85%) specificity = 30/38 (70%) npv= 30/33 (91%)
400 PTs underwent noninvasive venous testing w/ subsequent venography. The noninvasive & 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 test is:
Negative predictive value Overall accuracy has denominator: total # of test performed (all 4 boxes) Specificity: total # of normal/neg gold standard studies (True neg + False pos, sum always = # of pos gold standard results) Sensitivity: total # of abnormal/pos gold standard studies (true pos + false neg, sums = # of pos gold standard results) PPV has: total # of abnormal/+ noninvasive studies, whether true or not (true pos + false pos) NPV: total # of normal/neg noninvasive studies, (true neg + false neg)
Where would the Laminar flow be found?
None of the above
ABI >1.0
Normal
Augmentation* of the Doppler signal in the Femoral vein w/ calf compression is indicative of:
Normal
What is a normal PSV range for the cavernous arteries of the penis?
Normal PSV range is approx 30 cm/sec or higher, anything less is often considered abnormal.
This Doppler waveform was obtained in a Posterior Tibial Artery by sweeping the Doppler sample volume from ABOVE (Proximal to) a Graft anastomosis to BELOW (Distal to) the Graft Anastomosis. There is retrograde flow ABOVE the Bypass graft anastomotic site. What is suggested by this finding?
Normal back-flow up the native artery*
Which statement probably does NOT describe aspects of Raynaud's disease:
Normal digital pressures when the hand is immersed in cold water is false! - finger pressures decrease
The examiner listens w/ CW Doppler to the superficial femoral vein at mid thigh and performs a calf compression. The compression maneuver augments the signal. This finding suggests:
Normal finding* - Femoral vein augmentation w/ gentle calf compression suggests probably patency btn the 2 levels.
Helical flow w/ flow separation in the posterolateral aspect of the carotid bulb is a sign of:
Normal flow dynamics
In duplex assessment of the Portal vein, flow
Normally is PHASIC W/ RESPIRATION*
Which is NOT a sono finding associated w/ Portal HTN?
Not Lymphadenopathy* - Splenomegaly, always present in portal HTN*** - GB wall varices, less common feature - Ascites, freq present increase suspicion for PV thrombus*
Information greater than 1/2 PRF that cannot be displayed is called?
Nyquist Limit
Point at which aliasiing occurs is known as the:
Nyquist limit
In conventional transcranial Doppler, the angle of insonation* is assumed to be:
O degrees* - bc actual vessels is not visualized w/ this technique, angle of incidence is assumed to be zero degrees for calculation of velocities
Lymphedema may be caused by all EXCEPT:
Obesity - trauma or surgical excisioni of lymph pathways, infection, inflammation, radiation & chemo
Which branch of the ECA provides a collateral pathway to the Vertebral artery?
Occipital*
A hypertensive, diabetic 65 yo M presents for CerebroVascular testing bc of an asymptomatic bruit on the Rt side. You are considerig all of the following to be potential sources of bruit EXCEPT:
Occlusion of the CCA - stenosis of ECA - stenosis of subclavian artery - Dissection of CCA
What quantitative index is calculated by dividing peak-to-peak frequency difference by the Mean frequency?
PULSATILITY INDEX*
Most common features of Symptomatic Venous Thrombosis* are:
Pain and tenderness
Rest pain is characterized by:
Pain at night in the forefoot or foot that may go away w/ leg dependency - nocturnal forefoot pain relieved by dependency or exercise common complaint
List the deep veins of the lower extremity.
Paired PerV & PTV, ATV, PopV, SFV, CFV, EIV, CIV, IVC
What word (color) results from deficient blood supply; skin pale?
Pallor
What term best describes the Pulse Profile in this image:
Parabolic
Which statement below is NOT true regarding Subclavian Steal***?
Results from Severe Stenosis or Occlusion of the Proximal VA NOT true! - present in Proximal SUBCLAVIAN ARTERY - results in Retrograde flow in Ipslateral VA - flow is "stolen" from Contralateral VA by BA - occurs frequently on left side, if Rt side then its from prox Rt Subcl or Innominate - most are Asymptomatic, associated w/ dizziness, Vertigo, Diplopia, Ataxia, Bilateral Blurred vision, arm claudication/numbess
Major function of the Vasa Vasorum* is to:
Provide nourishment to the Tunica ADVENTITIA***
This waveform was obtained from the Left Vertebral Artery*. From this waveform, it can be determined that there is a stenosis in what vessel?
Proximal Left Subclavian Artery*
Describe the arterial flow seen proximal to an AVF.
Proximal arterial flow has increased diastolic flow because the fistula reduces resistance.
If you see slow upstroke and no diastolic flow in CCA, where would you think the disease is located? Proximal or distal to CCA?
Proximal disease
At what point in a stenosis is the flow frequencies dampened, with or without disturbance?
Proximal to a stenosis
A damped Doppler velocity waveform of the Subclavain artery isolate a significant lesion
Proximal to the Pt. of insonation!!! - damped waveform is result of obstruction damping out energy proximal to probe***
Which of the following describes the ADSON Maneuver* used to diagnosis of Thoracic Outlet Syndrome***?
Pt arms is at a 90 degree angle to the torso w/ head turned toward the affected side and then away from affected side during Deep Inspiration***
Rt arm 180/100 Lt arm 120/60 Rt PTA 100 Lt PTA 90 In consideration of the above pressure findings, which of the following statements is NOT true?
Pt has Renovascular htn not true - Pt has Rt LE/ Lt LE arterial disease, has Lt Subclavian artery disease, arteriography recommended for bypass surgery
Reasons to perform reactive hyperemia instead of treadmill testing include all EXCEPT:
Pt inability to tolerate application of pressure cuffs is FALSE - inability to stand, poor cardiac status, pulmonary issues, severe disease in 1 leg making it difficult to test other leg.
Coaptationn of the Supraclavicular Subclavian Vein* is best performed by:
Pt takes a quick, deep breath* - usually inaccessible, pt can SNIFF, walls are seen too completely coapt that portion of the vein is judged thrombus-free
Demonstration of vein-wall coaptatioin of the subclavian vein is best performed w/
Pt taking a quick, deep breath - difficult to perform compression, big sniff is useful way to assess at subclavian level!
Which bypass Graft has a size discrepancy b/n the Graft and native artery at both Proximal and Distal Anastomotic sites?
REVERSED VEIN GRAFT* - GSV sugicall reversed, venous valves oriented in direction of blood flow - all vein branches are ligated - disadvantage is caliber discrepancy b/n grat and native artery at both sites - GSV normally larger in thigh and smaller at ankle. - Reversing vein results in smaller end being connected to largest part of the native artery and vice versa to native artery.
Evaluate the Segmental Pressures below: The horizontal difference of 28 mmHg at the level BELOW the knee is most likely due to: Rt Segment Lt 155 brachial 151 189 high thigh 192 178 above knee 173 134 BELOW knee 162 97 ankle 152
RT POPLITEAL AND TIBIAL VESSEL DISEASE***
List the deep veins of the upper extremity.
Radial, Ulnar, Brachial, Axillary, Subclavian, Innominate, and SVC
Magnetic resonance angiography (MRA) functions by processing:
Radiofrequency pulses created by tissure and blood flow
What is the effect of massage or pressure on the Carotid Sinus*?
Reflex BRADYCARDIA (SLOW flow)
ABI <0.5
Rest Pain (severe arterial disease)
The most important reason Doppler evaluations should be performed w/ the Pt in basal state & warm temp is:
Results are influenced by the Pt's peripheral resistance - cold room causes vasoconstriction affects resistance and toe pressures
Segmental Pressure measurements listed below were obtained from a 67 yo M w/ symptoms of claudication. What values are used to determin the ABI? Rt Segment Lt 160 brachial 172 189 high thigh 150 161 above knee 126 157 below knee 104 118 ankle 84
Right 118/172, Left 84/172*** - ABIs are right: 0.68, left: 0.48 ankle divided by highest of the 2 brachials
What is the most common anatomic location of Renal Allografts*?
Right Iliac Fossa - located in RT Lower Quadrant
The Right CCA is a branch of the?
Right Innominate
In this B-mode image, name the vessel seen in cross section underneath the IVC
Right Renal Artery*** - passes underneath the IVC as it courses to the Hilum of the kidney
Innominate Artery Occlusion* may result in Reversed Flow in which of the following vessels?
Right Vertebral and Right CCA* - VA will reverse flow to provide BF to the arm - if not, Carotid recovery will occur, VA course to CCA, provide Antegrade flow, thus CCA waveform will be dampened w/ delay in systolic rise time - if no Carotid Recovery, CCA flow will be Bidirectional or completely Retrograde, providing addt'l flow to Rt Sub, thus CCA receives blood from Ipslateral ECA
A "localized" increase in mean velocity from 50 - 150 cm/sec at a depth of 50 mm w/ the TCD xdcr placed in the temporal window probably indicates:
Significant stenosis of the MCA*
What term describes this waveform?
Spectral Broadening***
What Doppler method uses individual frequencies displayed by FFT (Fast Fourier Transform) method?
Spectral analysis
What type of technique uses FFT (Fast Fourier Transform) method to analysis signals and displays the results as freqency shifts; x-axis representing time and the y-axis = velocities? (Spectral analysis, CW Doppler, Pulsed Doppler, or Color Doppler)?
Spectral analysis
Which artery is the Left branch of the Celiac trunk?
Splenic artery
The largest branch of the Celiac Trunk* is the:
Splenic artery*
ECA provides an anastomotic link* to the ICA through the Orbit via which of the following vessels?
Superior Temporal Artery* (ECA can supply ICA thru periorbital circulation. - Ophthalmic artery have anatosmotic links w/ ECA branches, these connections can provide blood flow to the intracranial circulation in cases of ICA occlusion via retrograde flow thru the Ophthmalic. - Surpraorbital and frontal connect ECA thru Superficial temporal. - Nasal becomes angular artery as it descends along lateral border of the nose and connects the ECA via facial artery)
Which of the following arteries does NOT arise from the Subclavian Artery?
Superior Thyroid
1st branch of the External Carotid Artery* is usually the:
Superior Thyroid Artery*
What artery is usally the first branch of the ECA
Superior thyroid artery
Persistent inflammation of the skin around the ankle w/ a tendency toward a BROWN Pigmentation* is known as:
Stasis Dermatitis***
Vichow's Triad* consists of 3 factors that are significant in the development of venous thrombosis are:
Stasis, Hypercoagulability, Trauma
Virchow's triad includes:
Stasis, Increased hypercoagulability, intimal injury
Venous refilling time by photoplethysmography was 10 sec w/o a tourniquet applied and 25 sec w/ tourniquet applies to lower thigh. The diagnosis is:
Superficial valvular insufficiency*** - tourniquet took the superficial system out of the picture, which returned the result to normal. therefore, the superficial system caused the rapid refill
In a PT w/ intestinal ischemia, the cause might be revealed by a duplex scan finding of stenoses in the following arteries:
Superior & inferior mesenteric artery
Small intestine, right colon, transverse colon are supplied by:
Superior Mesentric Artery* (2nd major artery of Abd Ao, arises below origin of Celiac Trunk)*
Edema caused by DVT is characterized by:
Swelling of the ankles and legs BUT NOT the Feet - usually swelling is not found in the feet in venous disease!!!
A common physical finding in Pulmonary Embolism (PE) is:
Tachypnea/tachycardia - rapid respiraction, freq associated with PE
Pt has a 7 cm AAA. The Pt elects NOT to have an operation. Which of the following statements is FALSE:
The risk of death from cardiac disease is greater than the risk of death from rupture of aneurysm is FALSE - Pt w/ aneurysms are followed extensively, most choose surgery to reduce risk of death related to rupture
Which of the followiing is a complication of plaque ulceration?
Thrombosis, Intraplaque hemorrhage, embolization - described as erosion of intimal layer over plaque surface, may progress to deep ulceration w/ embolization of plaque fragments - thrombus formation is initiated by erosion of plaque surface - platelet aggregation occurs forming thrombus directly over ulceration - distal embolization of thrombus fragments may be the source of TIAs* -Intraplaque hemorrhage can occur as leakage of blood into the atherosclerotic plaque thru the ulceration or by rupture of the VASO VASORUM*
Which of the following statements is FALSE regarding the ICA spectrum:
The velocities suggest SEVERE (greater > 80%) stenosis - FALSE*** - this waveform has significantly elevated peak systolic velocity (>125 cm/sec), systolic window is filled in suggesting severe turbulence however, end-diastolic velocities are NOT greatly elevated, NOT approaching 100 cm/sec. Therefore, based on info, stenosis would be hemodynamically signficant BUT NOT severe (ie >50%, but not >80%)
Which one of the following is always TRUE of Pt who suffer from intermittent claudication?
There is pressure drop DISTAL to the obstructed segment AFTER exercise - peripheral flow is generally maintained at rest by compensatory vasodilation distally. Exercise causes pronounced vasodilation, increasing flow. ABIs essentially normal at rest, challenge might be required to provoke pressure drop
54 yo M relates a hx of calf & thigh pain, Rt worse than Lt. Pain resolves sitting down, starts after 1st few steps of walking, but does not limit the Pt's ability to walk 3 blocks. Since he never walks more than this distance, he can't relate that he would have to stop at a greater distance. Some days the pain is quite mild. Etiology of these symptoms can be:
These symptoms are not typical of vascular disease - don't suggest claudication, pain would be consistent, muscle fatigue, extremely limited walking
Regarding capillaries, which is FALSE?
They have only intima & adventitia layers is FALSE - capillaries are made only of endothelial cells - just intima -they measure app 8 microns in diameter - transmit time of blood thru capillaries is app 1 to 3 sec - they lost fluid at arteriolar end - they resorb fluid at the venular end
What is the normal response of the cavernous arteries post-injection? Increase or decrease?
They normally should increase in size.
Which statement best describes these waveforms from the CCA, ICA, ECA?
They suggest Aortic Valve regurgitation - flow during diastole is being pulled RETROgrade by the AO Valve Regurg, this isn't seen in the ICA bc of lower resistance character of distal vascular bed, but there is an abnormal double peak
This image is from the proximal & distal thigh of a Pt a few months following fem-pop Gore-Tex bypass graft surgery. The echoes w/in the graft are from the color flow display, reproduced here in black & white. Which best describes the findings?
They suggest graft infection. Huge area of fluid accumulation around the graft is characteristics of graft infection. Note the double wall echo created by the graft. This appearance is characteristic of Gore tex material
With exercise in patients w/ postphlebitic syndrome, which of the following is FALSE?
They usually have a QUICK DECREASE in venous pressure that takes a min or 2 to return to pre-exercise levels - a prolonged return to pre-exercise pressure would be normal response, return to maximum pressure should take a fairly long time in Pt w/ competent valves preventing reflux. In Pts w/ incomplete recanalization of thrombus, the obstruction may even cause increased pressure w/ exercise bc of congestion. Secondary varices may fill via incompetent perforators during exercise
When nerve fibers release norepinephrine what happens to arterioles?
They vasoconstrict which causes contractile tone of arteriole vessels.
Which of the following are NOT associated with Chronic Venous Disease?
Thickening of toe nails (chronic arterial insufficiency) - pigmentation, brawny edema, subcutaneous fibrosis (scar tissue, thick, and rigid, due to excess accumulation of protein below the skin), cutaneous atrophy (layers of skin get thin)
What is most common arterial pathology?
Thickening, hardening, loss of elasticity of the artery wall
Compared to the arteries, veins have:
Thinner ADVENTITIA & MEDIA intima are the same size in arteries and veins
The examiner uses color flow to assess for competence at the CFV. W/ Valsalva maneuver, there is red flow lasting app 1/2 a sec, then blue flow on release.
This finding is equivocal for significant valvular incompetence. - .5 sec of reflux is often cited as threshold, some labs use a full sec or longer.
Which of the following statements about this figure is TRUE:
This spectrum is characteristic of ECA - prominent dicrotic notch, sharp peak, little diastolic flow
Which of the following statements about this figure is TRUE
This spectrum is characteristic of ICA - Has LOTS of diastolic flow, less prominent dicrotic notch, less distinct peak, feeding low-resistance distal bed (like renal artery)
What is a common location for a dissecting aneurysm to occur?
Thoracic Aorta
The disease/syndrome associated w/ compression of subclavian artery & brachial plexus by the cervical rib is
Thoracic Outlet syndrome***
An occlusive disease of medium & small arteries in the distal upper & lower limbs of primarily young male heavy smokers is:
Thromboangiitis obliterans** - aka Buerger's disease, usually seen in young M addicted to smoking, stumps for hands continue to smoke
You're examining a PT who presents w/ weight loss, postprandial pain, abd bruit. Obstruction of which vessel is most likely to be at least partly responsible:
SMA - chronic mesenteric ischemia results from obstruction of gut arteries, primary vessel is sma, ima/celiac trunk contributes too, symptoms don't occur unless 2 of the 3 arteries are obstructed! rich collateral network exists b/n these 3 vessels, making it a RARE disorder!
Name the vessels labeled A-C
SMA ABD Aorta Left Renal Artery*** (passes above AO)
This Renal Arteries* arise from ABD Ao app. 1cm below:
SMA*
A useful landmark for locating the Renal Arteries is the:
SMA* - Renal - artery origins lie just distal to the origin of the SMA from AO, the Left Renal Vein, which passes across the IVA under the proximal SMA, lies anterior and a bit distal to the renal arteries
Pt presents to lab w/ an ABD BRUIT, weight loss, postprandial pain. Obstruction* of which vessel is most likely responsible?
SMA*** - Chronic Mesenteric Ischemia may result from obstruction of the arteries that supply the GUT!!! - Primary vessel supplying the intestine is SMA*** - IMA and Celiac Trunk may also contribute - Symptoms usually don't occur unless 2 of these 3 arteries are obstructed. - Rich collateral network exists b/n these 3 vessels, making Chronic Mesenteric Ischemia a RARE disorder
Doppler sample volume is usually adjusted:
SMALL, to sample flow only from center stream
The Portal Vein is formed by the junction of the:
SMV & Splenic veins*
The confluence of what 2 veins forms the Portal vein?
SMV and Splenic vein
Which vein located w/in the calf muscle are a common site of Thrombus formation?
SOLEAL VEINS*** - soleal veins are located in Calf w/in soleal muscle are most common thrombus site - don't communicate with superficial venous system, - empty into peroneal or PTA
This Sagittal image was taken from the Mid Calf. The vein seen in this image emptied into a Posterior Tibial Vein*. What vein is being imaged?
SOLEAL Vein*
The ability of a noninvasive test to IDENTIFY disease that NO DISEASE is present is termed:
SPECIFICITY*** - Calculation: TRUE Negatives / TRUE Negatives + False Positives
Which method of Doppler display exhibits a grayscale trace representing the entire range of reflected shifts from the location of the sample volume*?
SPECTRAL ANALYSIS
Which term can best describe this waveform?
SPECTRAL BROADENING**
Protocols for cardiac treadmill testing & claudication treadmill testing differ, the major difference being:
SPEED is varied during cardiac testing
List the superficial veins of the lower extremity.
SSV and GSV
During Expiration***, what is the effect on a Doppler waveform obtained in the Axillary vein?
STOPS!!! - Venous flow from LE INCREASES, whereas venous flow in the UE STOPS!***
56 yo pt reports loss of vision in her left eye 2 days ago, w/ total resolution in 10 mins. Yesterday morning, she developed weakness and numbess in her right hand and was unable to hold her coffee cup. This afternoon her hand strength is about 90% normal, w/ normal sensation. Clinically, she has:
STROKE*** - It persisted longer than 24hrs! Has NOT resolved completely!
What terminates in the right atrium and drains the head and BUE?
SVC
What is formed by the confluence of rigth and left innominate veins?
SVC (Superior Vena Cava), which carries blood to the right atrium
The etiology of arterial aneuryms includes all of the following EXCEPT:
Saccular - is aneurym shape not etiology!
The volume flow rate in a reversed saphenous vein bypass graft should be:
Same thru out graft
This Doppler waveform was obtained in a normal ICA. Which of the following could explain the loss of Spectral window?
Sample volume not centered at artery
A probe in the 7 to 10 MHz range is best used for:
Saphenous vein mapping prior to bypass surgery - best for fairly superficial structures, would be too high a freq for routine LE deep vein assessment
What form of Raynaud's is also known as obstructive Raynaud's syndrome and may be the first manifestation of Buerger's disease?
Secondary Raynaud's
This digital Photoplethysmographic waveform might suggest:
Secondary Raynaud's disease
Which statement is NOT true regarding Varicose Veins?
Secondary Varicose Veins are the most common type of Varicose Veins*! - Primary are the most common type* - Primary occur in the GSV and LSV - Secondary results from obstruction of the Deep system - Stasis in dilated, tortuous varicose veins can lead to thrombosis***
Varices resulting from Deep-venous valvular insufficiency & incompetent perforators are called:
Secondary varices - usually affect GS system and branches, 2ndary result from chronic excessive intravenous pressure transmitted from the incompetent deep system
What can venous hypertension cause?
Venous hypertension can cause excessive fluid to leak out of capillaries and into interstial spaces, causing edema and swelling.
During the duplex venous exam, which of the following findings is the least likely to be associated w/ acute DVT?
Venous reflux - usually chronic condition found after acute event - continuous venous flow, stationary echoes w/in the vein, homogeneous intraluminal echoes, enlarged incompressible vein
A lower extremity has a brownish discoloration, what can that represent?
Venous statis ususally in lower leg-to-ankle area (gaiter zone)
Where are venous ulcerations usually seen and how do they look?
Venous ulcerations are often near the medial malleolus and are shallow, irregular shaped. The skin of these patients: inflammed, infected, and may have presence of variocosities.
Select the best statement regarding comparison of venous and arterial ulcers:
Venous ulcers are usually not painful and are located cephalad to the foot - located proximal to the medial malleolus, venous ulcers are treated w/ Unna boots/compression system w/ medicated dressing not arterial ulcers****
What is a small vein that is continuous with a capillary bed called?
Venule
Name the Vessels of the Circle of Willis*
a) Middle Cerebral Artery b) Anterior Communicating c) Anterior Cerebral d) Internal Carotid e) Posterior Communicating f) Posterior Cerebral g) Basilar h) Vertebral
In reference to stenotic vessels, where is the highest PSV seen? Where is turbulence usually seen?
a. Narrowest part within stenosis will have highest PSV b. Post stenosis will usually have turbulenct waveform
How do you calculate resistive index for kidneys? Whats considered normal vs abnormal?
a. PSV minus EDV divided by PSV b. Normal = <0.8 and Abnormal = > or = to 0.8
What causes fleeting neurologic dysfunction, with symptoms that last less than 24 hrs and are usually caused by embolic from heart or carotid artery? What about if symptoms last more than 24hrs and complete recovery doesnt occur?
a. TIA (Transient Ischemic Attack) b. CVA (Cerebrovascular Accident)
What is the transplanted renal artery, in a renal transplant, anastomosed to? Transplanted renal vein?
a. Tx Renal artery is anastomosed to either EIA or IIA. b. Tx Renal vein is anastomosed to EIV.
What are the reasons for mapping the internal mammary artery (internal thoraic artery)?
a. Utilized as a recipient site for free flaps in breast reconstruction. b. Second important use for this artery is as graft to the left anterior descending (LAD) coronary artery.
what occurs during right atrial diastole in the hepatic veins
acceleration n forward flow from hepatic vein to IVC and slows down as RA begins to fill
what are extrinsic causes of renal vein thrombosis
acute pancreatitis, lymph node enlargement, retroperitoneal fibrosis
where is the origin of the renal arteries
arise laterally from the aorta below SMA origin
what causes mesenteric ischemia
arterial obstruction at the vessels origin (embolus, thrombus, and compression)
What are the vessels of the microcirculation?
arteries, arterioles and capillaries
what are the two main criteria of mesenteric ischemia
assessment of flow patterns (sma and ima are low resistive even in a fasting patient--indicates the capillary beds have vasodilated due to the dx), direct sonographic detection of stenosis or blockage
What is the role of arterioles
assist with regulating blood flow through contraction and relaxation. *considered resistance vessels
what are the clinical presentations of renal vein thrombosis
asymptomatic to pain and hematuria, possible PE
what is the most common site of a stent stenosis
at the hepatic end of the shunt
This image was taken:
at the level of the Inguinal ligament
Unilateral increased Diastolic flow in the ECA* is commonly seen with:
all of the above - ECA stenosis* - Ipslateral ICA occlusion* - Ipslateral CCA occlusion* ECA shows increases in both systolic and diastolic flow w/ stenosis when ECA is used as collateral pathway thru orbit into intracranial circulation, diastolic flow increases can occur w/ extracranial occlusion of ICA/CCA
Regarding venous valves, which is FALSE?
allow flow only away from the heart - allows flow TOWARD heart
what are other modalities for evaluation of the renal arteries
catheter angiography (gold standard), CT angiography, MRA
what effect does tricusid regurge have on the hepatic veins
causes retrograde flow in the hepatic veins during systole
whats the most superior brach of the aorta arising from the anterior surface
celiac artery
What are the branches of the abdominal aorta?
celiac, SMA, renals, IMA, internal and external iliacs
what vessels are splanching or mesenteric arteries
celiac, sma, ima
Which disorder is most likely the cause of the condition in the preceding image?
cellulitis - discrete spaces of collected fluid
how does new thrombus appear sonographically
anechoic--easy to miss without color doppler
Dilatation of all three arterial wall layers:
aneurysm
where does the sma arise?
anterior aorta distal to celiac trunk
where is the IVC located
anterior to the spine and to the right of the aorta
what should a post-op sonogram of a TIPS include
approximately within the first 24 hours of TIPS placement, document the patency of the TIPS and establish baseline velocities
Toe pressures
are falsedly elevated LESS freq than Tibial ankle pressures* - can be useful adjunct in diabetic patients w/ artifactually high ankle pressures
what happens if the celiac occludes
collateralization throught the pancreaticoduodenal arterial arcade-network of small vessels surrounding the pancreas and duodenum (feed into duodenum then into the common hepatic)
what does the eliac artery bif into
common hepatic, splenic, and left gastric
where does the right hepatic vein run
coronal betwen the anterior and posterior segments of the right lobe
What is the first branch of the aortic arch?
coronary artery followed by the innominate/brachiocephalic
The blood supply to vascular tissue is provided by:
Vasa vasorum*
What vessels does the ulnar artery form?
deep palmar (volar) branch and terminates in the superficial palmar arch
What makes up the deep palmar arch?
deep palmar branch of ulnar artery and the distal portion of the radial artery
what should be evaluated with post renal stent protocol
eval aorta, renal artery in its entirety (origin mid and hilum), document stent itself
where is the best place to evaluate the common hepatic artery
eval from anterior abdominal window at the porta hepatis
whats the best way to eval the SMA and IMA
eval in transverse from anterior
what are the normal findings associated with a TIPS
flight protrusion of ends of shunt into portal and hepatic veins, fully filled stent, monophasic slightly pulsatile flow, moderate spectral broadening, PSV from at least 50-60 cm/sec to 90-120 cm/ sec, similar velocities at both ends, hepatopedal flow in portal, increase in portal flow comared to pre shunt status, portal velocity of at least 30 cm/sec with normal range of 37-47 cm/sec
what happens if the IVC is interrupted
flow enters the heart through the azygos and hemiazygos veins and the hepatics drain directly into the right atrium
What is the profile proximal to a stenosis
flow frequencies are dampened, with or without disturbance
What will occur a the exit of stenosis?
flow reversals, flow separations, vortices/eddy currents near edge of flow pattern
Risk of claudication in Diabetic patients is:
greater than 4x general population
Your patient begins to fall while getting off the exam table. You should:
guide the fall, protecting his head - shouldn't try to arrest the fall, you'll simply injure both of you. main thing is to protect the Pt's head
what is the ratio to determine significance of dx?
ratio=peak systolic mesenteric/ peak systolic aorta (1 is normal and 3 is hemodynamically significant)
The most common medical treatment of acute ischemic stroke consists of:
rtPA (recombinant tissue plasminogen activator) is useful in improving outcomes only if administered within 3 hrs of the onset of symptoms
This image was obtained in which scan plane?
sagittal
Flow of a pulsatile nature seen in ECA, sublavian, aorta, iliac, extremity arteries and fasting SMA
high resistance flow
what are the sonographic features of the SMA and IMA in a NPO patient
high resistance flow with low diastolic velocities due to vasoconstriction of mesenteric vessels
what is the normal waveform of the SMA and IMA in a fasting patient
high resistance flow with sharp systolic peaks and absent late diastolic flow
what is a false positive of renal artery occlusion
improper visualization of main RA or if kidney is small due to some other pathology
Systolic thigh pressures could be accurately measure w/ standard (12cm) arm cuff:
in Pts w/ similar thigh & arm diameters - accurate measurement of BP requires cuff be 1.2 x the limb diameter
causes of renal vein thrombosis
intraluminal clot or compression by extrinsic means causing a clot (preexisting renal dx, hypercoaguable state, vena cava or ovarian thrombosis, surgery, trauma dehydration
How is the portal vein characterized
intrasegmental
Contrast venography is:
invasive - very sensitive and specific test, some hazard, diagnostic w/ suspected DVT
An abnormal flow rate for a radial artery/cephalic vein dialysis fistula is
less than 200 ml/min - flow rate of around 300 ml/min is required for dialysis
what must the angle be to allow adequate eval of the vessels
less than 60 degrees
what are the acute symptoms of budd chiari
liver segment enlarges and appears hypoechoic, aschites, pleural effusion, and GB edema-- looks like liver failure with assive ascites and hepatomegally, difficult to see hepatic veins due to this
what are the chronic symptoms of budd chiari
liver segment shrinks and appears echogenic, splenomegally, portosystemic collaterals-- difficult to see hep v's due to fibrosis and reduced liver size
what does direct eval of renal artery stenosis provide
looks at specific peak systolic velocity of the waveform
what is the normal wave form for the common hepatic artery
low resistance continuous forward diastolic flow
what is the normal waveform for the celiac
low resistance flow due to the vascular beds of the liver and spleen with continuous forward flow during diastole
what is the normal waveform for the renal artery
low resistance flow pattern with a rapid systolic upstroke and continuous forward diastolic flow
what are the normal waveforms of the proximal aorta
low resistance flow pattern with continuous forward diastolic flow by the liver spleen, and kidneys (similar to ICA waveform)
What is the normal waveform of the SMA and IMA 30-90 minutes post prandial
low resistance pattern with broad systolic peaks and continuous diastolic flow
what is the normal waveform for the hepatic artery
low resistance profile with a broad systolic peak and gradual deceleration from systole to diastole with continuous diastolic flow
what are the sonographic features of the sma and ima in a post prandial patient
low resistive flow with high systolic and diastolic velocities du to vasodilation of mesenteric vessels
what is the normal renal artery flow
low resistive with continuous systolic and diastolic flow psv- 100+-20 cm/s edv- 30+-5 cm/s RI- less than .75
Higher resistance yields what type of flow rate?
lower flow rate
what is the order of blood flow through the kidney
main renal artery > segmental arery (begin @ hilum) > interlobar arteries (begin at parenchyma) > arcuate arteries (run parallel to cortex surface) >interlobular renal arteries (extend into the cortex)
Pt w/ advanced chronic mesenteric ischemia is most likely to be:
malnourished - eating causes severe ischemic abd pain, pt tend to avoid eating, pronounced weight lost
This ICA waveform has a PSV of 272 cm/sec & EDV of 88 cm/sec is compatible with:
moderately severe 50-80% stenosis - PSV > 125 cm/sec compatible w/ >50% EDV > 100cm/sec to call >80% stenosis
Subclavian steal occurs:
more often on the left side
Brachiocephalic VEIN is found:
on both sides of the neck - formed by the junction of the Subclavian and Internal Jugular Veins
The Pt position for venography is:
on exam table tilted 60 degrees upright
TCD window used for assessing the opthmalmic artery and carotid siphon is:
orbital
what is true of gastric varices
near the stomach in the epigastrium, under the left lobe of the liver near the spleen (cause patient to cough up blood)
where does the left renal vein run
passes anterior to the arta and posterior to sma and enters the left side of the IVC
where does the common hepatic artery turn into the proper hepatic artery
past the GDA
what are the symptoms of acute mesenteric ischemia
patient presents with abdominal cramps and pain after eating, bowel evacuation (diarrhea), distension, fever, dehydration, acidosis, and DEATH---requires surgery (CT)
what are the clinical symptoms of chronic mesenteric ischemia
patient presents with symptoms that are too vague to consider mesenteric ischemia but may describe a fear of food syndrome with weight loss (angiography)
what is 100% positive predictive of an occlusion in the celiac artery
seeing reversal of flow in the GDA or common hepatic arteries
what is the normal size for the IVC
seldom exceeds 2.5 cm but varies with respiration and cardiac cycle (inspirations limit venous return and enlarge IVC)
What happens at the capillary level
nutrients and waste products are exchanged between tissue and blood.
This waveform from the origin of the ICA suggest
occlusion AT the ICA origin - slapping kind of Doppler at the ICA origin, flow is hitting a brick wall. Note simultaneous forward & reverse character of the waveform.
why do common porto-systemic shunts occur
occur as collateral pathways when flow cannot pass through and out of the liver
Pt w/ significant mesenteric artery obstructive disease generally have symptoms of:
postprandial pain - referred to as "bowel claudication", ischemic pain brought on by increased demand for perfusion
what are other causes of Portal HTN
prehepatic obstructions (PV thrombosis, extrinsic compression), intrahepatic obstructions (cirrhosis, hepatic fibrosis, lymphoma), post hepatic (IVC obstruction, hep v obstruction)
what is a false negative of renal artery occlusion
if a collateral artery is seen instead of an occluded main artery (flow may indicate whether there is an occlusion)
when is the coronary (left gastric) vein considered abnormal and indicative of portal HTN
if it exceeds 4 mm and hepatofugal flow indicates abnormal portosystemic pressure
when should you be suspicious of pathology with median arcuate ligament syndrome
if the celiac obstruction disappears with deep inspiration and returns with expiration
In liver transplants, the native common hepatic artery is anastomosed to the donor hepatic artery"
several centimeters PROXIMAL to HEPATIC HILUM*
The digital/brachial systolic pressure ratio in an extremity w/ dialysis fistula usually is:
should NOT be measured* - avoid taking brachial bp in extremity w/ fistula!!!! measure contralateral brachial BP
what is the normal waveform for the IVC
somewhat pulsatile due to the close proximity to the RA
what vesels are joined in a splenrenal shunt
splenic vein to left renal vein
what other than portal HTN may cause splenosystemic collaterals
splenic venous obstruction (find occlusion using color)
what splenic pathology indicates portal HTN
splenomegally
what is the best window to evluate the hepatic veins
sub-xiphoid window
This CW Doppler waveform from a Pop A:
suggests interference from venous flow - since continuous wave analog Doppler displays net/avg freq shifts (ie velocities) of all flow intersecting the beam, venous flow can interfere w/ clear arterial tracings
The following tracing is taken from a Pt w/ Chronic ankle and calf edema. PPG sensor is placed slightly prox to the medial malleolus, Pt dorsiflexes 5x, then relaxes. The tracing: 9 sec to return
suggests significant valvular incompetence*** - PPG should take 20 sec to return to original pressure. A rapid return suggests that blood is refluxing bc of valvular incompetence!!!
what effect does CHF have on the hepatic veins
they become enlarged
what is a TIPS
this is a channel created between the high pressure portal system and the low pressure hepatic veins and installed via the jugular vein
Vibration noted while palpating pulses is called:
thrill* - palpable manifestation of a bruit. both caused by wall vibration
what is the highest risk of stenosis and occlusion in a shunt within the first few weeks
thrombus
Proximal renal artery stenosis >60% is diagnosed when:
systolic renal/aortic velocity ratio is >3.5** - Common method of detecting proximal renal artery stenosis, another method requires localization of the stenosis to see velocity of 100% of more from PREstenotic velocity
what does the common hepatic give rise to
the GDA
what joins to form the MPV
the SMV runs superior from the intestines to join the SV and form the MPV
what is the purpose of evaluating the mesenteric arteries
to look for songraphic signs of mesenteric ischemia (Often prevented due to collateralization)
where does the sma lie in relation to the smv and the left renal vein
to the right of the smv and the left renal vein courses between the sma and aorta
In TCD, the normal direction of flow in the MCA is:
toward the beam
what are pitfalls of portal vein thrombosis
tumor causes it to dilate (greater than 23 mm is indicative of a tumor), anechoic structures are commonly mistaken to be biliary related, low velocities or to and fro flow difficult to detect, inadequate doppler angle which limits detection of PV flow and leads to a false positive
what is the best way to differentiate between thrombus and tumor involvement
tumor involvement will have internal vasculature and and thrombus will not and tumor involvement causes the PV to dilate
Somewhat thinner than media; outer layer of artery; composed of fibrous connective tissue and some muscle fibers.
tunica Externa (Adventicia)
what is the normal splenic artery waveform
turbulent flow due to tortuosity (fig 26-3, 441)
what are the sonographic features of fistulas
turbulent high velocity flow within the renal parenchyma, direct visualization UNCOMMON due to the size of the vessels
The customary format for the 2 x 2 table places the false positive in the:
upper right corner gold standard vas lab true pos false pos false neg true neg True positives (they say pos, you say pos) upper left True neg (they say neg, you say neg) lower right False neg (you say neg, they say pos) lower left False pos ( you say pos, they say neg) upper right
What are the branches of the subclavian?
vertebral, thyrocervical, costocervical
Compared to patency rates in the iliac arteries, patency rates for angioplasty of the infrainguinal arteries are:
worse - latency results of femoral and pop angio have been consistently poorer than iliac arteries
Takayasu's arteritis is most often found in:
young women
In kappa statistics, if there is no relationship b/n the 2 variables being compared, the Kappa value is:
zero
What does dyspnea mean?
Shortness of breath
The primary concern in patients w/ acute DVT is:
PE may occur
Normal waveform of the Renal Vein can be described as:
PHASIC W/ RESPIRATION*
With Duplex sonography, the main purpose of probe compression is to:
Rule out the presence of Thrombus!
The ulnar artery travels distally in forearm to wrist where is becomes what?
Superficial palmar arch
What is the inflammation of the superficial veins, often seen with thrombus called?
Superficial phlebitis.
2 of the major branches of the ECA include the:
Superficial temporal and facial arteries
Intracranial potential collateral arteries include all but the following:
Superficial temporal artery
Which of the following is NOT a condition for which TCD might be useful?
Temporal Arteritis
What causes flow disturbance?
interrupted flow stability with high velocities and eddy currents
What does the politeal artery and its branches supply?
muscles, knee joint and skin
In B-mode imaging of the CFA & its bif into the PFA & SFA, normally the PFA courses:
Posteriorlateral to the SFA - heading toward the femur
Both renal arteries are found anteriorly or posteriorly to the renal veins?
Posteriorly
What does paresthesia mean?
Prickling and tingling of the skin
If your blood pressure falls will your resistance vessels dilate or constrict
dilate
How do you calculate % stenosis a vessel?
Diameter reduction = [1-(d/D)] x 100; where d = narrowest part of stenosis & D = diameter of normal vessel wall
At what point in a stenosis is spectral broadening and elevated velocities seen?
Entering the stenosis, with the high velocity at the narrowest part of the stenosis.
Doppler signal from the subclavian vein is expected normally to be
Pulsatile - reflecting RT Atrial activity, absence may suggest obstruction b/n RT Atrium and Subclavian vein
what are two other possible paths the left renal vein can follow
(1.) circumaortic with separate veins passing anterior and posterior to the aorta (2.)retroaortic passing posterior to the aorta
Match the symptoms w/ the likely ankle/arm index: 1. Claudication a. ABI > 1.30 2. Rest Pain: b. ABI bet. 1.00 - 1.30 c. ABI bet 0.5 - 0.90 d. ABI < 0.50
1-c, 2-d Claudication bet 0.50 - 0.90 Rest pain < 0.50, often < 0.20
What three things have an effect on resistance and which one has the greatest effect?
1-viscosity 2-vessel length 3-change in diameter Change in diameter has the greatest effect
Usual instrumentaton of handheld TCD includes a probe w/ an operatin frequency of:
2 MHz
Frequency most commonly used for Transcranial Doppler is:
2 MHz*
Limitations of handheld CW Doppler venous assessment include all EXCEPT:
*Valvular incompetence can't be assessed w/ CW Doppler: FALSE- can assess venous incompetence - may be bifid Superficial femoral or pop veins - non-occluding thrombus not detected - collateral vein mistaken for vein - exact extent cant be determined for follow-up
How many major branches does the ECA have and what is usually its first branch?
a. 8 Major branches b. Superior Thyroid artery is usually 1st branch
All of the statements below apply to Continuous-wave Doppler EXCEPT?
*Range-gating is applied to Control Vessel Selection* - PW can specify depth to be processed for display -CW requires both transmitting/receiving xdcr - CW shows greater spectral broadening than PW doppler - difference b/n transmitted and received freq. falls w/in audible hearing range for CW
With Transcranial Doppler, which vessel is evaluated from the Foramen Magnum window?
- Basilar artery both VA and BA
Bicuspid Valves of the Venous system are formed by folds of which of the following?
- Intima; venous intimal epithelium
Portal Vein* is formed by the junction of which of the following veins?
- Splenic and SMV***
Signs and symptoms for chronic occlusive disease:
-Claudication, ischemic rest pain, tissue loss,
What conditon exists when symptoms of intermittent digital ischemia occur in response to cold exposure or emotional stress? What skin color changes can occur?
-Raynaud's phenomenon -pallor(whiteness), cyanosis (bluish), rubor (dark red color)
Ischemic rest pain
-a more severe symptom of diminished blood flow -occurs when limb not dependent; BP decreased (such as when sleeping)
Effects of flow abnormality produced by a stenosis depends on factors such as:
-length, diameter, shape, degree of narrowing -multiple obstructions in the same vessel -obstructions in different vessels that are parallel -pressure gradient
Primary Raynaud's
-may be heredity, bilateral; history of symptoms for 2 years without progression/evidence of cause
Tissue loss
-necrosis or death of tissue -Due to deficient or absent blood supply
Secondary Raynaud's
-normal vasoconstrictive responses of arterioles superimposed on a fixed artery obstruction -ischemia constantly present
What might absent Doppler signals suggest post exercise:
-occlusion or a pre-occlusive vessel (string sign)
Claudication
-pain in muscles usually occurring during exercises; subsides with rest -results from inadequate blood supply to muscle -discomfort is predictable and subsides within minutes after exercise -level of disease usually proximal to location of symptoms -pseudo-claudication mimics vascular symptoms but is neruogenic or orthopedic in origin
What would a normal post exercise waveform look like:
-pre-exercise wave form qualities are maintained and/or augmented -no reverse component
Characteristics of biphasic wave form (abnormal):
-rapid upslope -sharp peak -fairly rapid downstroke -flow reversal -no resumption of forward flow -also considered normal in some patients
Characteristics of a triphasic wave form (normal):
-rapid upslope -sharp peak -rapid down-stroke -flow reversal -resumption of forward flow -i.e. UE, LE extremities
Characteristics of monophasic waveforms (abnormal-often obtained proximal to an obstruction):
-slow upslope -rounded peak -slow down stroke -no reversal
What would an abnormal post exercise waveform look like?
-slow upstroke with ore rounded peak -slow down stroke -no reverse component
In handheld TCD, the angle of the beam relative to flow is assumed to be:
0 degrees*
What ABI value is seen in patients with claudication?
0.5 - 0.9
where to 95% of celiac arteries bif
1-3 cm from origin
Major complications of cerebrovascular angiography occur in approximately:
1% of pts
Following cessation of exercise in a normal individual, how long does it take for lowere extremity blood flow to return to resting values?
1-5 mins**
What are somethings you can do to reduce noise on a spectral trace?
1. Decrease gain 2. Increase wall filter 3. Turn machine on/off 4. Try another wall plug
What is an example of something that would increase blood viscosity? Decrease blood viscosity?
1. Elevated hematocrit increases viscosity 2. Severe anemia would decrease viscosity
What are 2 examples of types of true aneurysms?
1. Fusiform 2. Saccular
What two vessels does the popliteal vein recieve?
1. Lesser Saphaneous 2. Gastrocnemius
What 2 things is required for movement of any fluid medium between 2 points?
1. Pathway for fluid to flow 2. Pressure difference / Energy gradient
What 2 things affect the movement of fluid?
1. Physcial properties of the fluid 2. What the fluid is moving through
The total energy contained in moving fluid is the sum of what 3 energies?
1. Potential (Pressure) 2. Kinetic 3. Gravitational
What events lead up to the beginning of cardiac contractions?
1. Pressure in left ventricle begins to rise 2. Left ventricle pressure exceeds that in the aorta 3. Aortic valve opens; blood is ejected, blood pressure rises
What are the 2 most frequent complications of Aneursyms?
1. Rupture of the aortic aneursym 2. Embolization of the peripheral aneurysms
What are the three components to Virchow's Triad?
1. Trauma to vessel 2. Venous stasis 3. Hypercoagulability
What is Virchow's Triad?
1. Venous stasis 2. Hypercoagulability 3. Trauma to a vessel
Pt presents w/ Pseudoaneurysm following arterial puncture. For US guided compression of pseudo, how long would each compression last before checking for cessation of flow into pseudo?
10 mins - apply pressure w/ xdcr over pseudo neck - pressure increased until cessation while maintaining flow w/in native artery - multiple compressions lasting app 10 mins each are usually necessary to obliterate the flow w/in the pseudo and communicating channel
Which of the following imaging xdcr freq could appropriately be used for assessment of the Carotid arteries?
10 or 5 MHz xdcr
Whats the normal length of the kidneys?
10-12cm depending on patients body habitus. `
what are the normal velocities of the sma preprandial
110-180 cm/s
what do you want your sample volume to be for the renal arteries? veins?
2 mm for arteries, 4 mm for veins
2 wks after a fracture of the femur, 33 yo F is seen for swelling of the calf of the same leg. The preliminary diagnosis, prior to performance of any noninvasive testing, should include:
2 of the above - arteriovenous fistula, DVT, Popliteal entrapment
Approximately what percentage of untreated calf-vein thrombosis is thought to propagate to a proximal level (ie pop or above)?
15-20%
What pressure difference from one brachial to the other suggests >50% stenosis of subclavain artery?
15-20mmHg difference
what is the normal velocity of the portal vein
15-40 cm/s
Not healed Healed <60mmHg 15 3 >60mmHg 5 27 On the basis of the info in the 2x2 table, the positive predictive value of the <60mmHg threshold is calculated:
15/18
What is a small blood vessel with only an endothelium membrane where the exchange of nutrients and waste occcurs called?
Capillary
What is an appropriately sized cuff for obtaining pressures in the fingers?
2-2.5 cm
Normal diameter for the ABD Ao is:
2-3cm
what are the correct machine settings to eval the abdominal vessels
2-5 mHZ curved, angle less than 60 degrees, patient NPO,
What is the difference between the 4 cuff method vs the 3 cuff method?
3 cuff method only has one cuff on thigh while the 4 cuff method has 2, high thigh and above knee (low thigh). The 3 cuff method provides more accurate pressure readings.
In performing Reactive Hyperemia testing, the BP cuffs are inflated to suprasystolic pressure levels for:
3-5 mins - alternative method to exercise testing for stressing the peripheral arterial system. - BP cuff is inflated above the highest brachial pressure for 3-5 mins. - Test is very uncomfortable. Ischemia and vasodilation occur distal to the cuff. - Ankle pressure changes are similar to ones obtained after exercise, although transient decrease in pressure of 17-34% may be seen in normal limbs w/ Reactive hyperemia.
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:
30/ 38 Specificity defined as ability to exclude disease & detect normality (# of true neg divided by total # of neg gold standard tests, true neg + false pos) 38 ICAs < 60% stenosis by angiography: denominator. Numerator is # of correctly classified as normal by noninvasive test (true neg agreements)
define portal HTN
elevated pressure in PV system resulting in an impedance of blood flow through the liver
400 PTs underwent noninvasive venous testing w/ subsequent venography. The noninvasive & 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:
375/400 + - + 90 15 Gold Standard - 10 285 Noninvasive test Total 400 exams, 90: True Pos, 285: True Neg Accuracy = all agreements (True pos+ True neg) divided by all tests
Which letter represents Peak Systole?
A
what must occur to diagnose renal vein thrombosis
MUST be able to visualize clot
An aneurysm resulting from infection is termed
MYCOTIC
Where would a DAMPENED Doppler signal be contained?
A -before area of stenosis
What type of technique uses multiple crystals to send out then recieve reflections, has range resolution, and variable sample size? (Spectral analysis, CW Doppler, Pulsed Doppler, or Color Doppler)
Pulsed Doppler
Patients complaining of pain, swelling, and erythema of the lower extremity may have DVT, but the vascular tech knows that diagnosing DVT by these symptoms alone is approximately:
46-62% accurate - clinical diagnosis is only about 50% accurate
The most common anatomic variant of the aortic arch is:
A common origin of the innominate and Lt CCA
Incidence of new strokes per yr is:
500,000
A cross sectional area reduction of 75% will give a diameter reduction of ____%
50
An arterial stenosis that is 75% by cross-sectional area reduction corresponds to a diameter reduction of:
50% A=PieR2
What generates the pressure wave to move the blood?
Pumping Heart
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 Correct calculation for the positive predictive value is:
53/61 PPV is all pos noninvasive test (both true pos + false pos). Numerator is agreement as to positive, you said positive, angio said positive + - gold standard + 53 8 duplex - 3 30
Doppler beam angle considered optimal for standardization of duplex carotid studies at most vascular labs is:
60 degree*
Which of the following is an appropriate angle for Doppler insonation of the Extracranial vasculature?
60 degrees*** - should not exceed 60, as angle of incidence exceeds 60, the accuracy of velocity estimation diminishes - Doppler interrogation should be performed at 60 or less
What is the ideal Angle for Vasucalar studies?
60 degrees, obtained centerstream, parallel to vessel walls
average velocity of the aorta
60-100 cm/s
At any moment, how much of the body's blood volume is found in the veins?
60-75%
Normal values in TcPO2 assessment are
60-80mmHg
A varicose vein is most often:
A dilatation of the GSV or superficial tributary vein
The usual cuff pressure used in Arterial volume recording is:
65mmHg
what are the doppler findings of mesenteric ischemia in a fasting patients SMA
70% stenosis, 275 cm/s - PSV; 45 cm/s- EDV
For Saphenous Vein mapping, which xdcr would be best choice?
7-10 MHz Linear Array
what are the doppler findings of mesenteric ischemia in the celiac
70% stenosis; PSV- 200 cm/s; EDV 55 cm/s
Normal POSTocclusive reactive hypermia PORH velocity response is:
A >100% INCREASE in MEAN velocity
Which of the following is NOT true regarding Bruits***?
A Prominent Bruit will be heard over an Arterial Occlusion is False - Bruit is a vibratory reaction in the tissue distal to a stenosis. It will not be present w/ complete occlusion or trickle flow in High-grade stenosis* - Bruit is a low-frequency sound heard on auscultation - Absence of a bruit can't rule out disease - Bruit persisting thru Diastole is usually associated w/ Severe Stenosis
"Pulsatile" mass in the groin after catherization of cardiac Pt most likely will be:
A Pseudoaneurysms of the femoral artery*** - Femoral artery pseudoaneurysm are often found after catherization. - Hematomas after cardiac catherization are frequent but not pulsatile
Which of these Pts would LEAST likely be considered at high risk for DVT?
75 yo F admitted for TIA
Percentage Diameter Reduction of 50%* in symmetric narrowing of the Carotid artery most closely corresponds to what percentage area reduction?
75% area reduction* - symmetric narrowing, 50% diameter stenosis is approximately the same as 75% area stenosis
Which Doppler frequency would most likely be used to evaluate the Penile artery?
8 MHz
What frequency probe and what Doppler angle should you have for arterial studies?
8-10 MHz probe with a Doppler angle 45-60 degrees to the skin.
What percentage of blood flow is supplied to the liver by the portal vein?
80%
The chance of a patient dying from a rupture of an Abd Ao aneurysm (AAA) averages:
80% -30-50% w/ AAA rupture die before reaching hospital, operative mortality is 40-50%. Best to catch it before rupture!
A stenosis of the SFA showed a PSV of 180 cm/sec and a Prestenotic velocity of 85 cm/sec. What % diameter stenosis* is suggested by these values?
> 50%*** - Ratio is calculated b/n the prestenotic and the PSV w/in stenosis. A 2:1 ratio suggests a greater than 50% diameter stenosis A 4:1 ratio suggests a greater than 75% diameter stenosis
What percentage of Pulmonary Emboli originates from Lower extremity deep venous thrombosis?
> 90% - profound interest in diagnosing and treating DVT before it creates bigger problems
A normal penile/brachial systolic pressure ratio is
>0.75
What value is considered normal for an ABI?
>1.0
Given the following info, overall accuracy can be: Sensivity= 91.3% Specificity= 83.4% Positive predictive value= 94.3% Negative predictive value= 80.7%
85% - overall accuracy MUST fall b/n Sensitivity & Specificity AND b/n PPV & NPV values
What percentage should the width of cuff used in arterial segmentals be greater than the limb?
>20%
In duplex imaging, the best arterial wall image quality is obtained when the beam is at the following angle to the artery walls:
90 degrees* - angle of incidence = angle of reflection, more echoes return to the xdcr w/ 90 degree angle***
400 PTs underwent noninvasive venous testing w/ subsequent venography. The noninvasive & 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. Sensivity is:
90/100 of 100 abnormal venograms, 90 were true positive sensitivity=positive agreements divided by all of the gold standard positives
400 PTs underwent noninvasive venous testing w/ subsequent venography. The noninvasive & 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:
90/105 of 105 abnormal noninvasive exams, 90 were true positives. ppv= positive agreements divided by all of noninvasive positives
For the correlation of carotid angiography & noninvasive carotid testing that specificity was calculated at 94.6% & the sensivity was calculated at 90.3%. The overall accuracy can be:
92.3% must fall btn sensitivity and specificity
An arterial stenosis that is 80% by diameter reduction corresponds to a cross-sectional area reduction of:
96%
The optimal patient position for imaging for the LEV is:
A Semi-Fowlers & C- Reverse Trendelenburg's position - Semi-Fowlers: is raising trunk & head, not knees - Reverse Trendelenburg: Pt supine, head up, feet down
What ABI value is seen in patients with severe arterial disease that have rest pain?
< 0.5
At what toe pressure is it evident that a foot or toe ulcer has failed to heal?
< or = 30mmHg
Which ABI is indicative of Rest Pain*?
<0.5**
In a Pt who wakes up at night w/ pain in the foot & has to drop the foot by side of bed, the Ankle/arm systolic pressure ratio will most likely be:
<0.50 - more likely <0.30, consistent w/ ischemic rest pain
5 yr risk for rupture of AAA of 4 cm is approximately:
<10% - Very small risk w/ 4 cm aneurysm, risk increases to 3-15% per yr at 5-6 cm, 30-50% at >8cm
Rt arm 180/100 Lt arm 120/60 Rt PTA 100 Lt PTA 90 The left ankle/brachial index is:
=0.50 (90/180) use the higher brachial pressure to calculate the index
Segmental pressure drop of what between 2 consecutive levels or horizontal difference, would suggests significant obstruction?
> 30mmHg between 2 consecutive levels and >20-30mmHg of horizontal difference, to suggest significant obstruction
Velocity obtained in the mid Superficial Femoral Artery is 225 cm/sec, while a measurement just proximal to this site gives 90 cm/sec. This suggests:
> 50% SFA stenosis - stenotic velocity that accelerates to double/2x the PREstenotic velocity suggest > 50% stenosis
What are some complications that can follow an angio exam?
Puncture site hematoma, pseudoaneurysm, local arterial occlusion, or possible neurologic complications
Why do collateral vessels ted to have high resistance than normal flow channels?
A & B: SMALL Lumen diameter & Greater Length*
Chronic venous insufficiency frequently leads to ulceration. The vascular tech knows that the Pt can help prevent ulceration by:
A&B, elevating legs above heart level > 4x for 20 mins & using support stockings when ambulatory - decrease venous htn & helps heal ulcers, decrease pain
Assessment of Palmar Arch patency is useful:
A&C, before placement of an AV arm shunt, to evaluate BF to digital arteries
Doppler beam may be attentuated if:
A, B -sound beammust pass thru scar tissue, hematoma, excessive fat - vessel has calcific plaque on the anterior wall - output settings don't affect attenuation, they control size of recording on chart paper
Common signs of advanced arterial insufficiency of the LE include:
A, B, D -loss of hair growth over dorsum of foot/toes - thicken toenails - dependent rubor
Male Pt walks on the treadmill for an evaluation of leg symptoms. During walk he reports both calves & thighs hurt at 10 secs, Rt worse than Lt. Continues to walk for 5 mins, is stopped by tech. Symptoms don't resolve, but don't get worse during exercise. Following pressures are obtained: Pre-exercise: Arm: 130 Rt ankle: 130 Lt ankle: 120 Postexercise: Arm: 160 Rt ankle: 100 Lt ankle: 110 True statements regarding this test is:
A,B,C There is arterial disease on both legs, symptoms aren't due to vascular disease, Rt leg is worse - there is drop in pressure in both legs, thus there's vascular disease in both legs, symptoms don't follow the usual pattern of claudication: they don't progress w/ exercise, pain is not vascular in origin
Explain difference between ascending and descending venography.
A. Ascending venography the contrast is injected into a vein in dorsum of foot w/ a series of x-rays taken. Its used to detect acute and chronic DVT. B. Descending venography the contrast is injected into the CFV w/ a series of x-rays taken. Its used to detect reverse flow from incompetent venous valves.
Segmental pressure readings indicate the following: Rt Brachial: 144 Lt Brachial: 140 Rt high thigh: 110 Lt high thigh: 164 These findings could result from all EXCEPT:
Aortoiliac obstruction - left high thigh is w/in normal limits
Math the following symptoms/signs with likely cause: A. Bruit 1. Aortoiliac + SFA occlusion B. Absent pulse 2. DVT C. Foot rubor 3. Subclavian artery occlusion/acute D. Right sided weakness 4. Left Carotid artery occlusion E. Edema 5. Illiac artery stenosis
A. Bruit 5. Illiac artery stenosis B. Absent pulse 3. Subclavian artery occlusion/acute C. Foot rubor 1. Aortoiliac + SFA occlusion D. Rt side weak 4. Lt Carotid artery occlusion E. Edema 2. DVT
Common radiologic terms, inflow, outflow, runoff, refer respectively to
Aortoiliac, femoropopliteal, trifurcation arteries
Where is the lowest and highest pressure in the vascular system found?
A. Highest-Left Ventricle @ 120mm/Hg B. Lowest-Right Ventricle @ 2-6mm/Hg
What determines the amount of blood that leaves the arterial system?
Arterial pressure and total peripheral resistance
Arteries progressively decrease in size from the largest being __ and the smallest being ___?
A. Largest = Aorta B. Smallest = Arterioles
If a patient comes in for a venous study an there lower extremity has a pallor/whiteness appearance, what could be going on? What if the extremity was bluish/cyanosis color?
A. Pallor color = arterial spasms secondary to extensive, acute iliofemoral thrombosis, also called phlegmasia alba dolens B. Bluish/cyanosis = severly reduced venous outflow from iliofemoral thrombosis markedly reduces arterial inflow as welll; also called phlegmasia cerulea dolens
Will your vessels be constricted or dilated if you scan a cool vs a warm extremity? What type of signal will each have?
A. Warm- Dilated- continuous, steady B. Cool- Constricted- pulsatile
Vascular disease that presents as back, abd, or flank pain is:
AAA - often back pain
A Plug Flow Profile* would most likely be seen in which vessels?
ABD AO - PLUG/BLUNTED is seen in large arteries like ABD Ao and CCA. These arteries central portion of fluid moves together and velocity gradient occurs near the wall***
How is the ankle/brachial index (ABI) or (Ankle/arm pressure API) calculated?
ABI's are calculated by dividing the ankel pressure by the higher of the 2 brachial pressures.
Acceleration time of less than 133 msec obtained in the Femoral Artery suggests:
ABSENCE of significant Iliac Artery Disease - Rapid upstroke in Systole results in a short acceleration time - pattern consistent w/ normal inflow - delayed upstroke occurs w/ significant inflow disease (stenosis proximal to sampling site)*
Correct setting for arterial volume recording is:
AC- coupled output* - DC coupling used for VENOUS recording***
What measurement helps in differentation of inflow vs outflow disease by measuring the time b/n the onset of systole to the max systolic peak?
ACCELERATION TIME*
Which of the following is calculated by dividing the Total Number of CORRECT tests by the Total Number of ALL tests?
ACCURACY*** - Percentage of CORRECT Diagnoses made by the noninvasive test
This image was obtained in the IJV of 34 yo F. What is the most likely diagnosis?
ACUTE Thrombus*
Which is a complication of dialysis access graft:
ALL - Arterial steal - Aneurysm - Venous/arterial stenosis Includes: Graft thrombosis, infection, pseudo formation hematoma**
Increased Diastolic Flow is seen in the SMA* with which of the following?
ALL - Postprandial State* - Stenosis* - Replaced Hepatic Artery*, anatomy variant HA arises from Proximal SMA SMA will show LOW RESISTANCE*** for all the above
Which of the following may be source of emboli?
ALL - Ulcerated Athersclerotic plaque - Mural thrombus w/in an aneurysm - Cardiac Dysrhymias
What is an advantage of using the Radial artery over the Saphenous vein for Coronary Artery Bypass grafts?
ALL - Vessel caliber similar to coronary arteries - thicker vessel wall - longer patency rates Many Pts don't have adequate saph veins for harvesting due to prior thrombus, small size or prior use
Neurologic Exam of a patient suspected of Extracranial Cerebrovascular Disease should include:
ALL -Evaluation of level of consciousness -basic comprehension - orientation to time and place
Which of the following is a limitation of Direct Doppler interrogation of the Renal Arteries*?
ALL 2 methods for detecting stenosis: 1) Direct: Doppler entire length of each artery - Stenosis in accessory renal arteries not detected - Doppler angles <60 difficult to obtain at origin - Body habitus limits access 2) Indirect: Doppler segmental/interlobar w/in kidney, overcomes poor body habitus and angles but limits disguishing b/n stenosis & total occlusion, can't detect <60% diameter reduction stenosis
Pts found to have ulcerating lesions or gangrene may have which of the following diseases:
ALL: - Arterial insufficiency, neuropathy, vasospasm, venous disease
Test used to detect Arterial patency of the PALMAR Arch is termed:
ALLEN's Test*
Power Doppler* encodes which component of reflected signal?
AMPLITUDE*** - colorized amplitude of moving signals - depends on relative number of RBC passing thru beam at any given pt in time - brighter color, greater concentration of RBD - Freq shift is NOT displayed, power Doppler does NOT show flow direction or as much angle dependence as Color Doppler*
What is the most common form of nonsurgical intervention for Focal Atherosclerotic disease in the LE?
ANGIOPLASTY* - aka Balloon angioplasty (PTA), balloon-tipped catheter into artery, slowly inflate and dilate balloon, pushing plaque against the vessel wall, enlarges lumen
In the lower extremity circulation, the most common site of atherosclerosis is:
Arterial segment beginning in HUNTER's canal! - aka adductor canal, located mid-to lower thigh
The proximal CFA has high diastolic flow but the distal CFA has significantly increased reversed flow. The noninvasive study was performed after cardiac cauterization. The likely cause of these findings is:
AVF - abrupt change of flow character, high diastolic flow in prox segment, suggest AV fistula creating localized low resistance pathway
in TCD, the normal direction of flow in the ACA is:
AWAY from the beam*
In TCD, the normal direction of flow in the Vertebral artery is:
AWAY from the beam* - from suboccipital/foramen magnum approach, flow should normally be away
What is formed by the confluence of brachial and basilic(superficial) veins?
Axillary vein
The SMA typically originates from the:
AO b/t celiac trunk & renal arteries
Which bypass graft would most likely be seen in a patient w/ bilateral COMMON ILIAC ARTERY obstruction?
AORTOBIFEMORAL
58 YO M presents to Lab w/ an ABD bruit and bilateral weak LE pulses. Review segmental pressures below and determine the level of disease. Rt Segment Lt 155 brachial 148 101 high thigh 100 98 above knee 98 89 below knee 89 87 ankle 88
AORTOILIAC DISEASE***
What 3 branches is sometimes known as the trifurcation?
APA, PTA, Peroneal Artery
Whats the first branch off distal popliteal artery?
ATA - Anterior Tibia Artery
With inspiration, a Doppler signal from the subclavian vein will usually:
AUGMENT
A normal Doppler response for the Femoral Vein immediately following a Valsalva maneuver* is:
AUGMENTATION*** - Immediately following Valsalva, the Venous flow will be augmented as blood can now course proximal
A connect between an artery and vein that was created as a result of surgery?
AV Fistula
Which of the following does NOT occur as a result of trauma?
AV malformation - present at birth, but may be exacerbated by trauma
What is the most common anomaly of the Circle of Willis?
Absence of Hypoplasia of 1 or both communicating arteries
Which is NOT true regarding Carotid Bruit?
Absence of a bruit rules out signficant stenosis is FALSE - severe stenosis may cause bruit - presence of bruit is significant - cervical bruit might arise from stenosis of the ECA - bruit extending into Diastole suggests SEVERE stenosis
What is the most common anomaly of the Circle of Willis?
Absence or Hypoplasia of 1 or both of the communicating arteries
Doppler waveforem abnormalities in the LE arterial circulation distal to a hemodynamically significant stenosis include:
Absent flow reversal component, blunting of the peak velocity, prolonged upslop and downslope*** - Doppler waveforms distal to a significant stenosis reflect to some degree the lost of energy caused by the stenosis. Stenosis acts as a low-pass filter! tends to filter out the high-freq changes in waveform such as dicrotic notch
This image of the ICA demonstrates
Acoustic shadowing
What arterial condition has symptoms of the 6 P's: pain, pallor (white), pulselessness, paresthesia, paralysis, and polar; it may result from thrombus, embolism, or trauma?
Acute Arterial Occlusion
This image of the popliteal vein from 46 yo F w/ leg swelling. Which of the following correctly describes the US findings:
Acute Thrombus in POP Vein*
Thrombosis that appears on duplex scan to be dark, homogenous, poorly attached to venous wall is:
Acute thrombosis
This image from the Proximal thigh suggests:
Acute venous thrombosis* - echoes are very soft, homogenous, doesn't appear to adhere very well to wall. Chronic would tend to appear brighter, more heterogenous
The SFA passes through an opening in what tendon to enter the popliteal fossa?
Adductor Hiatus (Adductor Canal or Hunter's Canal)
What is the region called where the SFA terminates and the popliteal artery begins?
Adductor Hiatus (Hunter's Canal)
Angle-correct cursor for velocity estimates is best:
Adjusted parallel w/ arterial walls
What test is used to evaluate the patency of the palmar arch?
Allen test
When assessing a digital artery w/ Doppler, patency of the Palmar Arch can be determined by:
Alternately compressing the Radial & Ulnar artery while listening for changes in digital artery signal
All of the following may represent symptoms from the Brain Stem or Posterior Circulation EXCEPT:
Amaurosis Fugax -transient blindness in 1 eye Posterior circulation: dizzy, vertigo, ectasia, syncope
Unilateral temporary vision loss associated w/ Cerebrovascular disease is known as:
Amaurosis Fugax* - shade coming down over 1 eye, due to embolic process from ipsilateral ICA, courses from ICA to Ophthmalic artery usually, CCA or heart
A Pt complains of a temporary shading of the vision of 1 eye. This symptom is called:
Amaurosis fugax - unilateral symptom, curtain/shade that blocks vision temporarily
Chronic deep venous obstruction will increase:
Ambulatory venous pressure - increases dramatically in CVO
Which one of the following conditions will cause an increase in the pulse amplitude of arterial pressure wave?
An increase in peripheral resistance - increase of distal resistance/vasoconstriction reflects more of the pressure-wave energy proximally. This reflected energy sume w/ existing energy in the proximal arteries to increase pulsatility and pressure
What type of error will you get if a patient has a incompressible arterial vessel, when doing an ABI?
An artery with an ABI >1.3-1.5 is considered incompressible and will give a falsely elevated and inaccurate pressures.
A connection created surgically to connect 2 vessels that were not formerly connected?
Anastomosis
While performing a treadmill test, the PT complains of pain in the Lt arm & jaw, but denies any other pain. Examiner should consider that this could be:
Angina - chest pain, radiating to jaw/arm assumption unless proven otherwise
What is the triangular region located anterior to an below th elbow?
Antecubital fossa
The Popliteal Trifurcation is actually a double bifurcation; select the pairs forming these 2 bifurcations.
Anterior Tibial & Tibioperoneal trunk; then Posterior Tibial & Peroneal***
Dorsalis Pedis* is a continuation of which of the following arteries?
Anterior Tibial Artery*
Your segmental pressure readings disclose a 36 mmHg decrease in pressure from the low-thigh to the below the knee ATA, 10mmHg dec from low-thigh-knee PTA. These findings localize obstruction to the:
Anterior Tibial artery (ATA) - significant drop is from low thigh to ATA
What vessel passes through the interosseous membrane, traveling distally between the tibia and fibula to joint the Dorsalis pedis at the ankle?
Anterior Tibial vessels
Give examples of high resistive abdominal vessels?
Aorta, as are a fasting SMA and IMA
Name a few areas where palpable pulses can be felt.
Aorta, femoral, popliteal, DPA, PTA
The Left CCA is a branch off the?
Aortic Arch
Bruits heard bilaterally, loudest low in the neck, are most likely caused by:
Aortic valve stenosis - AO murmurs radiate distally, freq into low carotids
To minimize error during the measurement of the systolic pressures using a manometer having 2 mmHg marks, the deflation rate should be:
Approximately 2 mmHg per HB
What is the name of the tiny intrarenal branches that arise from the interlobar arteries at right angles and course above the renal pyramids?
Arcuate arteries
Tiny IntraRenals branches that arise at the Rt angles from the Interlobar arteries and course above the Renal pyramids are the:
Arcuate arteries* (main renal divides at the Hilum into Segmental renal arteries w/in Renal Cortex, Arcuate give rise to the radially orientated Interlobular artery)
Normal arterial waveforms in the Renal hilum:
Are LOW resistance in character, much diastolic flow
Most often, the settings for venous color flow imaging of the lower extremities:
Are differenct from any of the above - low PRF/scale setting is necessary for slower flow in LE Veins - peripheral arterial studies, abdominal arterial scan, carotid scan, abd venous scan,
Stenting procedures of the ICA:
Are technically less demanding than stenting of coronary arteries
Acute DVT is commonly indicated in venography as:
Area of NO contrast, often w/ "railroad track" lines along walls - filling defect, string of pearls sign w/ FMH - well-developed collaterals suggests chronic
Where does the DFA run?
Arises about 5 cm from the inguinal ligament on the lateral side and can act as collateral
What is pledge position, in reference to upper extremity exams?
Arm is at 45 degree angle from body, & externally rotated.
Presence of a Bruit indicates:
Arterial Stenosis PROXIMAL to the point of auscultation*
VOLUME Plethysmographic waveform* w/ normal amplitude, ROUNDED peak, an ABSENT dicrotic wave is most likely indicative of:
Arterial disease PROXIMAL to the level of the tracing*** - flattened systolic peak and absent dicrotic notch is moderately ABNORMAL, always reflects arterial disease PROXIMAL to the level of the tracing!!!! - other signs of moderate abnormality include: DECREASE in upslope & downslope TIME that is nearly EQUAL b/n upslope and downslope***
This image of CCA from 36 yo F w/ Marfan's syndrome. The linear structure indicated by arrows represents an Intimal Flap*. Which of the following conditions is present?
Arterial dissection*
Where does the common iliac become the CFA?
As it passes under the inguinal ligament.
To optimize carotid vessel image data, lateral resolution should be:
As small as possible, to resolve SIDE by SIDE lesions
All of the following arise from the Intracranial ICA EXCEPT:
Ascending Pharyngeal - MCA - ACA - PCoA
Example of an antiplatelet drug that decreases platelet aggregation resulting in decreased thrombotic activity.
Aspirin
ABI >0.9-1.0
Asymptomatic disease or mild arterial disease
Where does the popliteal artery divide into anterior and posterior branches?
At an interval between the tibia and fibula
Using the 4 cuff technique for segmental pressures, normal high thigh pressures are ____ the Brachial pressure.
At least 30 mmHg greater than Brachial* - High thigh cuff is smaller in diameter compared to limb - this results in artifactually elevated pressure at high-thigh site
A horizontal difference of > or = to 20-30mmHg suggests obstructive disease at or above the level of which leg?
At or above the level in the leg with lower pressure.
Which end of a hemodialysis access graft is stenosis more commonly seen?
At venous anastomosis and outflow vein
Technique in which atherosclerotic plaque is MECHANICALLY removed by cutting or pulverizing it and then extracted by suction or downstream embolization is termed:
Atherectomy
A disease that affects primarily the intima and may extend into the media is:
Atherosclerosis
Which of the following is NOT true regarding atherosclerosis?
Atherosclerosis is a RED Blood Cell is False - starts as breakdown of intima - develops at bifurcation - generalized disease - intimal damage/repair may begin at adolescence
Mechanisms of arterial disease:
Atherosclerosis, embolism, aneurysm, non-atheroslcerotic lesions (arteritis, coarctation of the aorta) dissection, vasospastic disorders, entrapment syndrome
What is the ability of most vascular beds to maintain constant level of blood flow over a wide range of perfusion pressures called?
Autoregulation
Subclavian artery becomes known as what artery after crossing the lateral margin of the 1st rib? *
Axillary Artery
Which of the following statements about Popliteal aneurysms is TRUE:
B (cause symptoms by compressing contiguous structures) & C (pose significant risk of limb loss due to embolism/occlusion) &D (found bilaterally in >10%): - pop have a very low risk of rupture but high risk of embolization/thrombosis leading to limb loss, 50-70% bilaterally, high rate of 40-50% coexisting AAA, claudication rare symptom, coexist stenosis
In this cross section of the calf, which letter represents the Lesser Saphenous Vein?
B LSV smaller of the superficial vein below peroneal, fibula identify which is anterior and which is lateral
In the case described in Budd-chari syndrome, what other vessel(s) should be evaluated for patency?
B&C - Portal Vein - Hepatic Veins
Insufficient veins have the following flow characteristics:
B, C, D - CAUDAL blood flow may be ABNORMAL while patient is quietly STANDING - venous pressure at the ankle in the SUPINE Pt does not differ from that of normal limbs - venous pressure at the ankle in the WALKING pt is markedly INCREASED compared to that of normal limbs
All of the following devices, utilized in a standard fashion, can measure ankle pressures EXCEPT:
B-mode US - doesn't provide hemodynamic info about arteries, only images - others monitors pulses for pressure measurement: Doppler, strain-gauge, photocell, air plethymosgraphy
Probe compression in venous US is best performed in:
B-mode in TRANSVERSE*
Choose the color box that will NOT produce a reasonably good color display for this diving ICA: A. angled Towards B. angled Away C. Square box
B. Angled Away - This position creates angles too close to 90 degrees to create a good color display
Both of these waveforms were obtained from Segmental Renal Arteries** in the Renal Hilum. Which waveform shows a normal Resistance to flow? a) RI=0.82 b) RI=0.53
B. bottom - Normal RI in kidney is <0.7*** - As RI increase, the amount of Diastolic Flow will Decrease - Normal waveforms obtained from the Main Renal Artery or from arteries w/in the Kidney are of LOW RESISTANCE w/ forward flow thru out cardiac cycle - Increased resistance may be seen in cases of: Renal disease, Renal vein thrombosis and hematoma or other mass pressing upon the kidney***
Which vein waveform represents Abnormal Portal Vein* flow?
B. bottom - Normal waveform obtained is mildly undulating signal. Prominent or Bidirectional flow*** in bottom is Abnormal finding indicative of: * Rt Heart Failure, * Tricuspid Regurgitation (TR) * Portal Vein-Hepatic Artery Fistula, * Portal HTN, other abnormalities
Carotid Body Tumor* would be located:
B/n Internal and External Carotid Artery*
Which term can be used to describe this "Pseudoaneurysm" waveform?
BI- Directional
A normal spectral waveform from the Hepatic Veins is
BIDIRECTIONAL*** - result of vessel's proximity to the RT ATRIUM!, reflects RT Atrial pressure changes***
This image is from a 22 yo F w/ abnormal liver function tests and ascites. The thrombus in the IVX is most likely related to which of the following?
BUDD-CHARI syndrome***
Disease involving thrombosis of small or medium sized arteries* of the extremities occuring predominantly in male smokers is:
BUERGER'S DISEASE***
Scans Pt w/ pain, swelling in calf, large dark area noted in the medial popliteal space, no vascular communication found. Most likley:
Baker's cyst
The vertebral arteries branch from the Subclavian arteries to unite and form the:
Basilar artery
The vertebral arteries unite in skull to form what vessel?
Basilar artery
You're examining hardcopy of a TCD exam, 1 printout shows spectral waveform labeled "suboccipital window" and the depth indicated to be 90mm. This is most likely the:
Basilar artery
This TX image was obtained in the Upper arm***. The Brachial Artery is seen w/ a Brachial Vein on each side. The small arrows are pointing to what vessel?
Basilic Vein***
List the superficial veins of the upper extremity.
Basilic and Cephalic veins
Which of the following vessels joins the Brachial Veins to form the Axillary vein?
Basilic vein**
Evaluation of an AAA is faciliated if the study is done:
Before breakfast - AAA/SMA test, first thing in the am if possible, NPO to minimize bowel gas
Whose principle stated that total fluid energy along a streamline of fluid flow is constant?
Bernoulli's Principle
Whose principle states that when a fluid flows without a change in velocity from on point to another, the total energy content remains constant?
Bernoulli's Principle
Where are the Carotid body tumors located:
Between ICA & ECA
Normal flow in the hepatic vein is
Bidirectional - due to proximity to RT Atrium, HV flow reflects RT pressure changes
The "kissing stent" angioplasty/stent technique is useful for:
Bifurcations -method of deploying balloon angioplasty & arranging stents at bifurcations, avoiding occlusion of 1 branch while dilating the other, can be used anywhere including coronary arteries
IVC Thrombosis* most likely results in:
Bilateral Swelling of the LOWER Extremity***
A common manifestation of Portal HTN is
Bleeding esophageal varices - results from abnormally high venous pressures due to Cirrhosis or other liver disorder, esophageal hemorrhage is lethal!
Term cyanosis describes:
Blue color of tissue due to ischemia
This waveform from an ICA is measured at > 273 cm/sex PSV & 125 cm/sec EDV. It suggest:
Borderline for 80%* - EDV is around borderline for calling stenosis greater than 80%, EDV wouldn't be accelerated in a 50% stenosis, would be expected to a good deal higher for 90% stenosis
What does the axillary artery become?
Brachial (after giving off branches)
What artery divides into the radial and ulnar arteries?
Brachial artery
The Axillary artery connects the:
Brachial artery to the Subclavian artery***
Why are blood pressures obtained bilaterally when evaluating a patient for cerebrovascular disease?
Brachial blood pressures are compared to see if they are EQUAL*. - if 1 pressure is 15-20mmHg less than the other, Subclavian stenosis or Steal is suspected on the lower pressure side*
Why are brachial blood pressure obtained bilaterally when evaluating a patient for cerebrovascular disease?
Brachial pressures are compared to see if they are EQUAL - if one pressure is 15-20 mmHg less than the other, Subclavian Steal is suspected on side of lower pressure
This spectral waveform from the distal ICA suggests
Brain death - characteristic to & fro pattern has been shown to suggest brain death in cerebral arteries TCD & also in extracranial ICA
What does the brachial artery become?
Branches into radial and ulnar arteries at the antecubital fossa.
Arterial supply to Carotid Body Tumors is primarily from:
Branches of the ECA***
Signs of duplex venous imaging of acute rather than chronic DVT include all EXCEPT:
Bright intraluminal echoes**: more compatible w/ organized, older thrombus - distended vein, dark intraluminal echoes, slightly compressible (spongy) character to thrombus, presence of "tail" suggesting poor adherence to wall
Abnormal sound heard on Auscultation caused by Flow Disturbulence is a:
Bruit*
A channel that diverts blood flow form 1 artery to another; usually done to shunt flowaround an occluded portion of a vessel?
Bypass
This image is from the Carotid bifurcation. It demonstrates
C, Homogenous plaque that appears to create moderate <50% stenosis
In this cross section of the calf, which letter represents the Fibula?
C Fibula, smaller bone next to Peroneal veins - D Tibia
This femoral artery waveform demonstrates
C&D, turbulent flow at systole & severely elevated PSV - PSV of 500 cm/sex suggest high grade stenosis, turbulent look
Name Branches/vessels of Aortic Arch*
C) Innominate Artery* a) Rt CCA b) Rt Subclavian D) Lt CCA* E) Lt Subclavian*
Typical findings of skin discoloratioin in a Pt w/ chronic venous insufficiency are:
Rusty-brown color at ankles and calves**
At the Inguinal ligament, the External Iliac artery becomes the:
CFA*
What 6 arteries are evaluated on the lower extremities on an arterial study?
CFA, SFA, Popliteal, PTA, DPA, Peroneal (if necessary)
Venous puncture for introducing contrast in venography to assess for Valvular Insufficiency is done at what level?
CFV*
In the preceding question, which disorder would necessitate the TIPS?
CIRRHOSIS** - most common cause of PORTAL HTN in US, everywhere else HEPATITIS is usual cause. TIPS helps relieve the excess pressure!!!!
Most common cause of Portal HTN* in US is:
CIRRHOSIS***
Vertebral Artery enters the Transverse Foramina of the Cervical spine at what level?
C6*
The main power source for Blood Propulsion in the Venous system is:
CALF MUSCLE***
57 YO F w/ Hx of long-term alcohol abuse is referred for a Portal Venous Duplex exam. The Main Portal vein can't be ID at the Porta Hepatis, but instead multiple channels w/ Hepatopetal flow are seen. This is consistent w/:
CAVERNOUS TRANSFORMATION of the Portal Vein*** - in cases of Portal Vein Thrombosis, recanalization may occur, producing an appearance of multiple channels of Hepatopetal flow w/in porta hepatis instead of 1 main Portal Vein*
35 yo F w/ hx of Cystic Medial Necrosis present w/ HORNER'S SYNDROME (disruption of a nerve pathway from brain to face/eye on 1 side of body) and left periorbital headache. Duplex Carotid US reveals 2 channels of flow w/in the LCCA separated by thin echogenic flap. Most likely diagnosis is:
CCA DISSECTION* - Headache behind eye is suggestive of Ipslateral Carotid Dissection - spontaneous dissection of cervical carotid most commonly occurs in young pts - Etiologic factors include FMD, Trauma, Cystic median necrosis, Marfan's syndrome
65 yo male w/ HTN and Diabetes presents to lab for cerebrovascular testing due to a Rt asymptomatic Bruit. All of the following could be considered a potential source of the Cruit EXCEPT:
CCA occlusion - Bruit is a result of vibration in the tissue surrounding a stenosis. A totally occluded vessel will NOT produce a bruit
What abdominal vessel is most commonly compromised by compression of the Median Arcuate Ligament* of the Diaphragm?
CELIAC ARTERY*** - median arcuate ligament of the diaphragm crosses anterior aspect of aorta slightly above celiac trunk!!! - during respiration, this anatomic situation can lead to compression of Celiac Artery and high velocity! - Abnormally high velocity are present during expiration but return to normal during inspiration - Pts may present w/ ABD bruit*
This waveform was obtained from a fasting Pt. Which vessel below is most likely source for this Doppler trace?
CELIAC TRUNK***
Median Arcuate Ligament Syndrome most commonly involves which vessel?
CELIAC TRUNK*** - Rarely compresses SMA too
The usual site of puncture for percutaneous LE angiography is
CFA
Name the vessels labeled A-C
CFA CFV GSV
What are the most common arteries used for an Angio exam?
CFA (safest approach), Axillary, or Brachial arteries
Homan's sign*** is:
Calf discomfort on passive dorsiflexion*** - Homan's sign is a nonspecific and insensitive sign of Venous Thrombosis and should not be used!
You are performing a carotid study on a PT who suffers cardiac arrest. You should first immediately:
Call a code
The drug heparin:
Can cause thrombocytopenia (diminished blood platelet count) - its a protein so it can activate antibodies in sensitive Pts, has significant complication rate and can produce (diminished blood platelet count)
Where does the exchange of nutrients and waste products between blood and tissue take place?
Capillaries
The smallest vessels in the body are:
Capillaries*
Smallest vessels in the body* are termed:
Capillaries*** - arteries divide and shed outermost coat: adventitia - 2 layered known as Arterioles, extend further and shed: tunica media - single-walled vessel: capillaries
Which finding is NOT associated with Venous ULCERS***
SHINY SKIN - Venous tend to have BRAWNY DISCOLORATION, location near medial malleolus, irregular borders*** - Arterial exhibit shiny skin w/ hair loss
If a fistula is found close to the heart, what issue is the patient at an increased risk for?
Cardiac failure
Pitting edema of both lower extremities is likely related to:
Cardiac or systemic origin* - bilateral edema most commonly is cardiac or systemic w/ congestive heart failure as predominant feature***
What governs the amount of blood that enters the arterial system?
Cardiac output
After Carotid Bifurcation disease, the next most common source of stroke symptoms is:
Cardiac-source embolization*** - Atrial fib & myocardial infarction are 2 most common causes or mural thrombus in the heart. - Paradoxical embolization from DVT via PFO remote possibility
Most common location for Atherosclerosis to occur in the Cerebrovascular system is the:
Carotid Bulb!*
24 yo pt w/ hx of recent automobile accident arrives in ICU w/ symptoms of acute Rt side weakness & aphasia. This most likely etiology of these symptoms is:
Carotid DISSECTION* - any kind of severe inertial injury can cause tearing to AO or other arteries!
The circle of Willis receives its blood supply from which combination of arteries?
Carotid and Vertebral arteries* ( remarkable connection of carotid and vertebral arteries: makes possible the ability of the brain to withstand extracranial carotid occlusion w/o significant symptoms)
A duplex image of the Carotid bifurcation that demonstrates a goblet-like configuration of the ICA & ECA branches curving aroudn a highly vascularized mass suggests:
Carotid body tumor*
The NASCET trial indicated that the best treatment for carotid stenosis in the symptomatic patient is:
Carotid endarterectomy for stenosis greater than 70% in diameter
If hyptertensive Pt has experienced multiple TIAs and has a 80% diameter stenosis of the ICA on the side referable to the symptoms:
Carotid endarterectomy is probably recommended
What is the carotid siphon and what artery originates near it?
Carotid siphon is a significant curve of the ICA where the Ophthalmic artery originates
What penile arteries and veins are measured during the imaging technique to determine whether impotence is related to peripheral vascular insufficiency?
Cavernous arteries and Dorsal veins.
Common Hepatic, Splenic, Lt Gastric artery are branches arising from what Abdominal artery? *
Celiac Trunk* (1st major branch of Abd AO, divides into Common Hepatic, Splenic, Lt Gastric arteries)*
Abd vessel that is most commonly compromised by compression of the median arcuate ligament of the diaphragm is the:
Celiac artery*** - median arcuate ligament of the diaphragm crosses anterior aspect of the aorta slightly above celiac trunk. during expiration, this anatomic situation can lead to compression and high velocity. abnormally high velocities are present during expiration but return normal during inspiration. may also present w/ abd bruit
A Pt presents w/acute pronounced bright red discoloration and edema of the skin along the anterior calf. The most likely diagnosis is:
Cellutlitis* - inflammation of the skin and deeper tissues caused by infectious process - common differential diagnosis for DVT
While mapping the Saphenous vein for coronary bypass operation, discover that its not adequate for harvesting. which of the following veins would be best to evaluate as alternative?
Cephalic - lesser saphenous, cephalic, basilic superficial veins may be used when saph vein is too small, diseased or absent
All of the following are Deep Veins of Upper Extremity* EXCEPT:
Cephalic (Superficial: Basilic, median cubital veins not paired) - DEEP veins are Deep Palmar venous arch, Radial, Ulnar, interosseous veins of forearm, Brachial, Axillary usually paired deep veins*
Which of the following is NOT a Deep vein of the upper extremity?
Cephalic vein
UEV most commonly used for arterial bypass in the leg is:
Cephalic vein - cephalic and basilic veins used for arterial bypass
Mapping Saphenous Vein for Coronary Artery bypass surgery, but its inadequate for harvesting. Which of the following veins would be best as alternative graft?
Cephalic vein (CV)* - Lesser Saph V, CV, Basilic V may be mapped as possible conduits for bypass surgery when Saph vein is too small, diseased or absent. - Deep veins (DFV, POP V, AV) are not used.
Which of the following veins is NOT a paired vein*?
Cephalic* (superficial vein not paired) - Deep: Radial, Peroneal, Posterior Tibial
Normal Doppler response for the femoral vein during a Valsalva* maneuver is:
Cessation of flow - Pt takes breath in and bears down like bowel movement - Performed to evaluate valvular competency - Normal flow ceases, if flow persists/increases, valves b/n groin and area of interrogation are incompetent**
In CW Doppler reflux testing, a normal result is:
Cessation of flow PROXIMAL compression, resuming on release*** - augmentation w/ PROX compression or on release of distal compression indicates insufficiency***
Parameters usually assessed in exercise testing include all EXCEPT:
Changes in thigh-to ankle index, not diagnostic in exercise testing - time required for recovery to pre-stress pressure level, pt complaint of pain, length of exercise time, magnitude of pressure drop
Hollenhorst plaques* are:
Cholesterol emboli seen on Ophthalmoscopic exam w/in the Retinal Artery branches
The vascular tech knows that chronic venous insufficiency and ulceration are:
Chronic but controllable
In the US the most common cause of Portal HTN is
Cirrhosis
Scans the femoral veins and notes a very small venous lumen, w/ bright, thickened venous walls along most of the thigh. These findings suggest:
Chronic thrombosis* - bright walls w/ small recanalized lumen is older
Brawyn skin changes at the ankle most likely represent:
Chronic venous insufficiencly - brawny/toughened/swollen changes almost always indicate venous insufficiency
This image is at the Popliteal level, suggests
Chronic venous thrombosis - bright, streaky echo, old reanalyzed thrombus, organized and dense, berating bright echo, will have flow on both sides w/ color flow
The name for the type of graft described in the previous question is:
Cimino-Brescia - flow rates in this type of dialysis fistula are expected to be lower than in "PTFE/synthetic" graft*
What is the largest intra-arterial connection (collaterl pathway) in the human body?
Circle of Willis
Which of the following vessels is NOT found on or near the foot?
Circumflex* (there are "circumflex" arteries, some near or proximal to groin)
12 yo is noted by ped to have decreased femoral artery pulses and is referred to lab. Bilateral arm BP are 210/100, femoral artery pulses bilaterally are indeed diminished, as with ankle pressure. Femoral artery doppler waveforms are abnormal. Diagnosis should be:
Coarctation of the Aorta - coarctation of Ao and renal artery stenosis can cause HTN, but only coarctation will also cause abnormal femoral pulses***
What is a congential anomalie of the arterial system that is seen as congential narrowing or stricture of thoracic aorta called?
Coarctation of the aorta
"Continuous" Venous signal obtained w/ CW Doppler is commonly seen w/:
Collateral Flow*
What type of technique uses assigned colors to diaplay velocities and direction of moving blood? (Spectral analysis, CW Doppler, Pulsed Doppler, or Color Doppler)
Color Doppler
Vascular lab calls a stenosis 60-70% by diameter based on duplex assessment, but angiograph calls it 90% by diameter. Possible reasons for discrepancy include all EXCEPT:
Color flow PRF set too low, creating aliasing, overestimation of velocities is FALSE...it would cause overestimate stenosis, not underestimate it - stenosis is long/smooth, changing its Doppler character compared to shorter lesion - one 1 plane of visualization used for angiography - poor angle-correction, creating artifactually low velocity estimates - acoustic shadowing prevented Doppler assessment of maximal narrowing
Decreased pulse at mid neck is suggestive of:
Common Carotid stenosis if the contralateral pulse is NORMAL
The most common arterial puncture site for all forms of angiography (including cerebral) is the:
Common Femoral Artery
At the Inguinal ligament*, the External Iliac artery becomes what peripheral artery?
Common Femoral Artery*
Most commonly used artery for catheter insertion to perform arteriography of the carotid circulation is the:
Common Femoral Artery*
What vessels are seen w/ Duplex US at the level of the Inguinal Ligament***?
Common Femoral Vein & Artery (CFV/CFA)***
An analog Doppler waveform of the Subclavian or Axillary artery in a normal individual would typically resemble:
Common Femoral or Superficial femoral artery waveform* - UE is high resistance similar to legs
What are the most distal branches of the aorta that supply blood to the pelvis, abdominal wall, and lower limbs?
Common Iliac Arteries (CIA)
At the inguinal ligament, what does the external iliacs turn into?
Common femoral arteries
Most common anatomic variant of the AO Arch* is:
Common origin of the Innominate and Lt CCA*
Pt w/ Hx of Tibial Artery surgical repair now presents with foot drop, muscle necrosis, AND severe pain. What's the diagnosis?
Compartment Syndrome
Aneurysms are most often caused by:
Congential arterial wall weakness* - may be related to trauma, but congential weakness & atherosclerosis are the most common causes for aneurysms
A "Pulsatile" Venous signal is associated with:
Congestive Heart Failure**
Pulsatile LE Venous Doppler signals would be associated w/:
Congestive heart failure** - anything that increases overall venous pressure, like CHF can bring about pulsatility in LE
Proximal to aortic arch, what are the first branches of the ascending aorta?
Coronary Arteries
What does hemoptysis mean?
Coughing up blood.
Pts presenting w/ symptoms of claudication complain of:
Cramping pain in calf, thigh, buttocks w/ exercise & relieved by rest
Which of these conditions is LEAST likely to cause a bruit in the neck?
Critical preocclusive stenosis of the ICA -bruits in the neck disappear when stenosis is very high grade or preocclusive
BC of the location of the IVC, the LRV:
Crosses ANTERIOR to the AO, INFERIOR to the LEFT Renal artery* - AO is to the left of midline, vena cava is to the Rt thus structures located left side of ABD must have their venous outflow across the AO. - The left renal vein is ANTERIOR to the AO, usually INFERIOR to the level of the Renal Artery
The Left Common iliac vein:
Crosses POSTERIOR to the rt common iliac artery just distal to the Ao bifurcation - LT Common Iliac Vein is medial to the artery, The vena cava is to the RT of the AO, thus the Left venous system must cross some arterial structure to communicate w/ the Vena Cava!
What word (color) results from a concentration of deoxygenated hemoglobin, causing bluish discoloration?
Cyanosis
Toe pressure of 30 mmHg or less indicates:
POOR CHANCE OF HEALING FOR FOOT OR TOE ULCER*** - useful in diabetic pts are unreliable bc of arterial calcification - normal toe pressure is 60mmHg! 30 or less is unlikely to heal!!!
Which letter represents Dicrotic Notch?
D*
Normally, venous flow in the calf is from the superficial to the deep veins through perforating veins. However, this flow might be reversed when:
Deep Venous obstruction is present** - congestion, resulting increased deep venous pressure may back out into the perforating veins. with distention, valve leaflets can't coapt, flow can travel abnormally from deep to superficial veins. secondary varicosities may result
Technologist performing a venous study on the LW notes that color Doppler Does NOT fill the calf vein spontaneously. What technical factors could be adjusted to improve color saturation?***
DECREASE color filter, Decrease PRF, Increase color gain*** - flow in calf veins are very slow, both color PRF and wall filter should be DECREASED!!!*** - INCREASING color gain will amplify the signal that's received and increase the color display
The radial artery travels lateral & distally in forearm to wrist where is becomes what?
Deep palmar arch
Wha is a major branch of the DPA (dorsalis pedis artery)?
Deep Plantar Artery- penetrates the sole of foot, it unites with lateral plantar artery to complete plantar arc.
Hemorrhage* w/in the layers of the arterial wall is known as:
DISSECTION*** - Refers to hemorrhage w/in wall of artery! may be localized w/in media b/n intima and media or it may involve adventitia. when extravasated blood elevates intima, an intimal flap results -2 lumen true/false results, separated by intimal flap - usually multiple connections b/n true & false lumen - thrombosis on 1 lumen can occur, narrowing artery - dissections can occu spontaneously (related to systemic HTN, FMD, Cystic Medial Necrosis, Marfan's syndrome, Type IV Ehlers Danlos Syndrome)*** or result of blunt or penetrating trauma* - sono finding include visualization of mobile intimal flap or long, smooth, tapering stenosis suggesting thrombosis - color can delineate flow w/in 2 distinct channels in artery or absence of flow in 1 lumen
This Doppler waveform was obtained in the Femoral Vein. The arrow is pointing to an Augmented portion of the spectrum. This could by caused by:
DISTAL limb compression** :blood is forced rapidly upstream past the pt of Doppler sampling, thereby augmenting flow!!! - wouldn't occur w/ RELEASE of the distal limb compression - flow would cease w/ proximal limb compression or Valsalva maneuver!
What vessel does the ATA become once it crosses the dorsum of the foot?
DPA - Dorsalis Pedis Artery
One complicatioin of Deep vein recanalization is:
Damage to venous valves, allowing reflux
Waveform profile is characteristic of which of the following? a= 29.2 cm/s
Dampened signal obtained PROXIMAL to Arterial OCCLUSION**
If the Greater Saphenous Vein GSV is NOT identified at the appropriate location, the examiner should:
Decrease Probe Pressure - Superficial vein easily collapsible by mistake
What technical parameters should be adjusted to Increase the color Doppler sensivity when the vessel does NOT fill-in well?***
Decrease color PRF and color Filter, Increase color Gain - dec PRF improves sensivity to slow flow by inc time b/n transmitted pulses - dec filter, lower freq shifts can pass thru on display, causes flash artifact from little movement/breathing - inc color gain amplify the return echoes-volume control
Which of the following would NOT correct the technical problem demonstrated in this waveform?
Decrease the Wall Filter***
The plantar arch in foot consists of what branch from DPA?
Deep plantar artery
The following are all possible complications of Heparin EXCEPT:
Decreased activated Partial Thromboplastin time is false - expected to increase, a desired result for therapy - thrombocytopenia/formation of antiplatelet antibody, intraabd bleeding, increased bruising
Which of the following is NOT a common feature of Renal Allograft Rejection***?
Decreased flow resistance in parenchymal arteries - Increased allograft size** - Increased cortical echogencity - Increased prominence of Renal Pyramids ***Renal allograft rejection the flow resistance in parenchymal arteries tend to INCREASE!!! - Leads to Decrease in Diastolic flow - Normal flow is low resistance w/ forward flow thru out cardiac cycle - Decrease, absence or reversal of flow in Diastole is indicative of REJECTION***
What does Homonymous hemianopia mean?
Defective vision or blindness in the right or left halves of the visual field.
More than 90% of infrarenal ABD aneuryms are of:
Degenerative origin - bc of atherosclerosis
What information Can't be determined by cerebrovascular angiography?
Degree of narrowing of ICA by Cross-sectional area
Which of the following determinants dictates xdcr freq selection for optimal carotid B-mode imaging?
Desired beam width, avg & extreme depths of carotid vessels in most subjects to be studies, desired axial resolution - beam width relates to lateral resolution
Transcutaneous partial pressure of Oxygen (TcPO2) studies can be useful for all EXCEPT:
Determination of arterial level of obstruction - can assess only at the site of measurement, can't localize level of proximal obstruction - determine amputation level, assessment of skin-graft viability/foot perfusion/healing of stump
Select the factor least likely to contribute to DVT:
Diabetes - pelvic mass, previous DVT, hip replacement surgery, pregnancy/delivery
Disease in which Segmental pressure studies may show falsely elevated Doppler pressures due to Arterial Wall CALCIFICATION is:
Diabetes Mellitus* - vessels may be incompressible bc of arterial wall calcification leading to falsely elevated pressures
Risk factors for arterial disease:
Diabetes, Hypertension, Hyperlipidemia, Smoking, Other-not controllable: age, family history
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: not healed healed Diabetic <60mmHg 6 1 >60mmHg 4 12 Nondiabetic <60mmHg 9 2 >60mmHg 1 15 According to these data, which of the following statements is NOT true?
Diabetics with >60% mmHg ankle pressures that didn't heal had calcific arteries falsely elevated pressure
This waveform is a typical Ex. of the Doppler signal obtained from a(n): Velocity: 195.3 cm/sec
Dialysis Access Graft* - Dialysis graft forms a direct fistula b/n an artery and vein, arterial signal will have HIGH Diastolic velocities reflecting the LOW resistance in draining the vein* - Typical systolic velocities range b/n 100-400 cm/sec
Brescia-Cimino* Fistula is a type of:
Dialysis Access anastomosis** - AVF b/n Radial Artery & Cephalic Vein is preferred permanent vascular access for hemodialysis due to its fewer complications and greater longevity compared to other types
Brescia-Cimino fistula, straight, & looped synthetic graft are all types of what?
Dialysis access examples
NASCET used the following arteriographic criterion to classify ICA disease:
Diameter % stenosis calculated by dividing the minimal diameter by the diameter of the UN-stenosed Distal ICA
What 2 things predict the resistance an AVF will offer?
Diameter and length of the AVF predict the resistance it offers.
What is PPG used to evaluate mainly?
Digits and Penile vessels
Symptom of Vertebrobasilar insufficiency is:
Diplopia* - double vision symptom
A symptom of Vertebrobasilar insufficiency is:
Diplopia: double vision of VB Insufficiency
Which of the following is NOT true regarding Perforating Veins*?
Direct blood from the Deep system into Superficial system - Perforating veins direct blood flow from Superficial system (GSV/LSV) into Deep system - has 1 valve each, more numerous in the calf than thigh, known as Varicose veins when they are tortuous and dilated due to incompetent valves
When measuring segmental pressures, gradients of 20-30 mmHg b/n corresponding segments of the legs indicate:
Disease AT or ABOVE the level in the leg w/ Lower pressure***
Best method for evaluation of suspected Popliteal Aneurysm is:
Duplex U/S
Which technique is LEAST likely to be used to record digital pulses or changes in arterial volume
Duplex US
In contrast venography is NOT frequently performed today bc:
Duplex exam is accurate, noninvasive alternative - limitations include risk of severe allergic reactions, relatively high expense, pt discomfort
You perform percussion maneuvers on the superficial temporal artery and see oscillations on the Spectral display. The artery being insonated is most likely:
ECA - this percussion maneuver - the "temporal tap"- must be used only cautiously to help identify the ECA in difficult situations.
Which vessel normally supplies blood flow to the face and scalp?**
ECA external carotid artery***
When visualizing the carotid bifurcation using duplex US, MRI or angiography, the best way to determine whether you're looking at the ICA is by the fact that:
ECA has branches near the Bifurcation and ICA does not
This waveform was most likely obtained from which vessel?
ECA*
Manual tapping on the superficial temporal artery will result in the most prominent oscillations on the spectral display of the:*
ECA* Its better to differentiate waveform characteristics, vessel positions, presence of branches
A condition in which the body tissue contains excessive fluid is termed:
EDEMA
Which of the following would be most likely to occur as a result of Increased Portal Venous Pressure in a Pt w/ Portal HTN*?
ENLARGED CORONARY VEIN* - Coronary vein drains into Splenic vein - w/ Portal HTN, the increased portal venous pressure decreases flow into portal system - vessels become enlarged and alternate flow routes - these can break down, causing life threatening bleeding episodes - Cavernous Transformation may occur w/ Pts w/ Portal HTN only in presence of PV thrombosis & recanalization - cavernous transformation of PV most commonly occurs when liver is normal - most pts w/ portal htn have liver cirrhosis! -Ao dissection and hepatic artery aneurysm aren't associated w/ Portal HTN
Pt w/ hx of rest pain, 100 foot calf & thigh claudicatioin, ulcer on great toe of Lt foot, has Lt ankle pressure of >300mmHg. This result is:
ERRONEOUS due to arterial CALCIFICATION!!! - likely due to calcified/incompressible arteries, common in Diabetic Pts***
what is the correct caliper placement on the RA waveform
ESP at the first peak systolic point, mark beginning of acceleration time, then peak of acceleartion time, then at the smae point as peak ESP, velocity at forward systolic point, mark end diastolic velocity
Intraabdominal* Pressure is decreased with:
EXPIRATION*
Elevated peripheral venous pressure results in:
Edema
What is induration of tissue?
Edema, or fluid accumulation
Measurement of a Pt's Abd Ao gives a diameter of 6.5 cm. The probably mgmt of this pt would involve:
Elective repair - risk of rupture increases dramatically as it exceeds >5-6 cm in diameter
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?
Elevated PSV & significant EDV suggest significant ICA Stenosis (>50% by diameter) - PSV of 285 is high >50%, criterion >125 cm/sec threshold, but EDV isn't high enough (100) to call >80%. Systolic window is NOT filled, flow is orderly, but elevated velocities do suggest hemodynamically-significant stenosis
Common evaluation for advanced LE ischemia involves raising the supine Pt's leg and having the Pt sit and dangle the leg. Positive result is described as:
Elevation is pallor, dependent rubor* - Elevation creates negative hydrostatic pressure, decreasing LE perfusion, so foot turns PALE. Having Pt dangle restore perfusion, foot turns very RED.
Which one of the following diagnostic criteria for stenosis would be anticipated in the presence of a 50-60% diameter stenosis of the ICA?
Elevationi of systolic frequency w/ post stenotic turbulence - most sensitive parameter for calling this degree of stenosis is the systolic freq/velocity. Focal accleration w/ distal turbulence is the hallmark of significant stenosis anywhere in the body
How do you differentiate thrombus from embolisms?
Embolism is a piece of thombus that breaks loose and travels distally until it lodges in a small vessle.
Blue Toe Syndrome*** is caused by:
Embolization from Proximal arteries*
The most serious risk from FemoroPopliteal Aneuryms is:
Embolization* - Lower limb ischemia from thrombosis or embolism - most important features are thrombus content and vessel tortuosity - may result in sudden thrombosis and severe ischemia to lower limb - most serious risk of Aortic aneurysms is rupture
Fragment of Atherosclerotic Debris that courses distal thru Vasculature until it lodges in small vessel (n):
Embolus***
Doppler diagnostic criterion that is most important for calling greater than 80% stenosis is:
End-diastolic velocity
Surgical removal of atherosclerotic plaque from an artery is:
Endarterectomy
What is the surgical removal of atherosclerotic material, usually includes portion of intimal lining?
Endarterectomy
What is an endoleak when referring to graft complications?
Endoleak is defined as a persistent blood flow outside the lumen of the endoluminal graft but within an aneurysm sac or adjacent vascular segment being treated by the device. Endoleaks are due to incomplete sealing, or exclusion of the aneurysm sac, and thus cause reflux of blood flow into the sac.
In a Pt w/ PORTAL HTN, the most likely result of increased Portal Venous pressure would be:
Enlarged CORONARY VEIN* - normally drains into the splenic vein, increased pressure decreases flow into portal system, becoming enlarged finding alternative routes of flow, may reverse its flow direction, feed into esophageal varicose, breaks down, causing deadly bleeding episodes***
A Pt is seated w/ legs dangling and Photoplethysmograph sensor placed just above the medial malleolus. After dorsiflexion of the foot 5x, this tracing is made. The tracing is consistent with:
Essentially normal venous refilling time - venous incompetence is illustrated by refill times of < 20 seconds***
Which of the following is NOT considered a risk factor for atherosclerosis?
Female gender - HTN - Diabetes mellitus - Lipoprotein abnormalities - Tobacco/smoking
Which of the following is NOT considered to be a Risk Factor for development of Stroke*?
Female gender - Predisposing factors*: Smoking, Diabetes Mellitus, Cardiac Arrhthmia, Male > 55, Alcohol abuse, HTN, Hyperlipidemia, Carotid Artery Disease (CAD)
What 2 arteries branch anterior-lateral off aorta just below level of renal arteries? Hint: This vessel is different in each gender.
Female its the ovarian arteries and in males its the testicular arteries.
Cerebrovascular fibromuscular dysplasia occurs in:
Females
Computed tomography CT is useful in the LE primarily for detection of:
Femoral or Popliteal Aneurysm*
64 yo M complains for half-block Lt thigh & calf claudication w/o symptoms on the RT. Physical exam reveals that the Lt femoral pulse is absent, pulses on the RT are normal, w/o bruit. Treadmill teasing results are abnormal on Lt, normal on RT. Duplex reveals an occluded iliac artery on the Lt. This Pt may be ideal candidate for:
Femorofemoral bypass - Pt LT iliac artery is totally occluded, no indication for femoropopliteal bypass, lumbar sympathectomy, or balloon angioplasty
A CW Doppler exam of the lower extremities, performed to diagnose DV thrombophlebitis, revealed augmentation upon compression proximal to the probe at all standard levels studied. The diagnosis is:
Femoropopliteal and posterior tibial valvular insufficiency - proximal compression should not elicit flow signals if the valves are competent
What is described as multiple arterial stenoses caused by medial hyperplasia, appearing as "string of beads"?
Fibromuscular Dysplasia
Nonatherosclerotic, noninflammatory, occlusive and aneurysmal disorder that primarily affects woman, referred to "STRING of BEADS"*** is:
Fibromuscular Dysplasia (FMD)*** - Frequently affects RENAL arteries***, carotid being #2 - Renal A may result in RENOVASCULAR HTN***! - Carotid often benign, asymptomatic - Vertebral artery less frequently involved
The conditioin which typically shows up on angiography as "string of pearls" is:
Fibromuscular Dysplasia FMD
In contrast venography*, which finding would indicate the presence of a thrombus?
Filling defect
Which of the following can't be determined from an Arteriogram*?
Flow Turbulence - shows 2D view of anatomy from percentage diameter stenosis can be measured - reversed flow can be detected w/ delayed films - dissection can be seen as well - hemodynamics can't be evaluated
Loss of the Spectral Window w/ Pulsed Doppler US is present with:
Flow Turbulence* - spectral window is blank area underneath systole, its filled in or lost when turbulent flow creates spectral broadening -other reasons for lost include overuse of Doppler gain, incorrect positioning of sample volume outside center of streamline
3 major branches of the Ophthmalmic artery* are:
Frontal Supraorbital Nasal
Symptoms of chronic venous insufficiency might result from all EXCEPT:
Gastrocnemius muscular thrombosis - isolated gastro thrombosis unlikely to create significant chronic venous insufficiency CVI symptoms.
Muscular veins of the calf that empty into the Popliteal vein behind the knees are:
Gastrocnemius veins
Of the following which is NOT one of the main collateral pathways in the event of ICA obstruction?
Genicular to Arcuate branches is FALSE - genicular arteries are around the Knee, arcuate are in Kidneys
Which statement is NOT true regarding Arteriography?
Gives "Functional" info regarding vascular system is FALSE* - Gives Anatomic but not physiologic info*** - requires an intraarterial injection - employs a liquid contrast agent to image arterial lumen
A conduit that can be prosthetic material or autogenous vein used to divert blood flow from one artery to another?
Graft
While monitoring of Femorodistal bypass graft using duplex US, the graft may be at risk of failure if:
Graft velocity has dropped from 70 cm/sec to 30 cm/sec - clear indicator of impending graft failure
What form of energy id equivlent to the weight of the column of blood extending from the heart to the level where pressure is measured?
Gravitational energy or Hydrostatic Pressure (HP)
What is the longest vein in the body?
Greater Saphaneous
The longest vein in the body is the:
Greater Saphenous Vein (GSV)*
Which of the following veins has the greatest number of valves*?
Greater Saphenous Vein (GSV)* has 10-12 valves - LSV 6-12 - Soleal Sinus 0 - Perforator 1 ea - Infrapop/deep 9-12 ea - Pop/femoral 1-3 ea - CFV 1 - External Iliac has only 25% - Common Iliac 0 - Internal/Hypogastic Iliac 0 - IVC 0 - Jugular 1 valve
Peripheral resistance increases with:
Greater length, smaller diameter, higher blood viscosity** (Poiseuille's resistance equation demonstrates influences on resistance of length, viscosity and (inversely & powerful) RADIUS)
Which of the followig is NOT a duplex indication of a totally occluded ICA?
Greatly INCREASED End-Diastolic velocities in CCA spectral display FALSE - High distal resistance created by ICA occlusion would reduce or eliminate diastolic flow in the CCA, NOT increase it - ICA lumen filled w/ heterogenous echoes - NO Doppler or color flow obtainable w/in ICA lumen - Absence of Diastolic flow in CCA spectral display - Drumbeat/slapping Doppler signal at ICA origin
TCD findings consistent w/ vasospasm following subarachnoid hemorrhage would include:
Greatly increased MEAN velocities in MCA - vasospasm causes greatly INCREASED mean velocities in Cerebral arteries
The most common source of lower or upper extremity peripheral arterial embolus is:
HEART* - source of 80-90% of peripheral arterial embolus in extremity - other common source is aneurysmal mural thrombus esp in Ao, iliac, femoral, pop a - most common source of CV embolic activity is atherosclerotic carotid disease*
Which vessel would be imaged in a Pt referred to R/O Budd-Chari syndrome**?
HEPATIC VEIN
Which of the following is a normal finding in a Pt who has a transjugular Intrahepatic Portosystemic shunt TIPS
HEPATOPEDAL FLOW in Main Portal vein* - should be toward the liver!!! Hepatofugal is away from liver, an abnormal finding both the portal & splenic veins
Which of the following describes the classic flow pattern in the NECK of a traumatic Pseudoaneurysm?
HIGH Velocity ANTEgrade flow in Systole WITH RETROgrade flow in Diastole*** - classic pattern is BIDIRECTIONAL* since blood flows from high to low pressure, flows into pseudo in systole, back into native artery during diastole*
Top waveform was obtained from the mid LICA and the bottom waveform from the mid RICA, what is the most likely diagnosis?
HIGH grade stenosis of the Prox LCCA** - w/ significant Prox stenosis, waveforms Distal to disease will show Dampening of Systolic component with delayed Systolic rise time!** - w/ significant disease Distal to site of sampling, Diastolic component will be Dampened bc of Increased Resistance to flow toward the obstruction!***
A traumatic arteriovenous fistula (AVF) produces
HIGH, PULSATILE venous flow in the veins PROXIMAL to the fistula - 4 components of AVF are Proximal/distal artery, proximal/distal vein &- fistula itself. - flow in proximal artery becomes LOW RESISTANCE, lots of diastolic flow - flow in proximal vein INCREASES/HIGH, becomes PULSATILE bc of direct arterial inflow & higher volume
High-pitched signal heard on audible Doppler analysis* always indicates:
HIGH-FREQUENCY SHIFTS* - magnitude of Doppler frequency shift is determined by speed of flow, angle of beam intersects the flow and Doppler frequency - since Dopple freq is constant during given sampling, 2 factors responsible for increased pitch/freq are: high blood flow velocity and decreased angle of incidence, demonstrated by the Doppler equation! Freq shift= 2*f*v*cosO/c
The strongest risk for Stroke is:
HTN*
what can renal artery stenosis cause
HTN, renal insufficiency (damaging parenchyma), narrowing of renal artery, renal ischemia, RAA (vasosuppressor) which leads to HTN, (10% HTN, 3-5% renal dx)
An elderly Pt who presents with localized pain at mid calf has an US exam that reveals a nonocclusive thrombus of the SFV. The calf pain became excruciating after administration of heparin. A second US exam demonstrates:
HYPOechoic mass in shape of an egg mid calf, thought to be hematoma - bleeding complication, hematoma, bc pain closely associated w/ administration of heparin
All of the following parameters may be used to determine the degree of stenosis in the ICA EXCEPT:
Heart Rate - Peak freq shift - PSV - ICA/CCA ratio
The agent of choice in the initial management of PE is:
Heparin*** - drug of choice to initiate treatment
The Budd-Chiari syndrome is a cause of Portal HTN resulting from:
Hepatic VEIN obstruction* - leaves no way for portal venous hepatic arterial blood to be removed, thus hepatic congestion occurs, resulting in ASCITES, progressive Hepatic dysfunction, portal HTN.
Which Abdominal vein normally exhibits a Triphasic* Waveform?
Hepatic Vein** (drains IVC)
This waveform was most likely obtained from which abdominal vessel?
Hepatic Vein***
What vein carries blood FROM the liver to the IVC?
Hepatic vein
Which vessel would be imaged in a Pt referred to rule out R/O Budd-Chiari
Hepatic vein - results from acute obstruction
Which of the following is a Normal finding in a Pt following a Transjugular Intrahepatic Shunt (TIPS)*** procedure?
Hepatofugal flow in INTRAhepatic Portal Radicles - Flow follows the path of least resistance! scarring in liver due to Cirrhosis results in HIGH resistance to flow thru Intrahepatic portal branches. TIPS stent produces a path of LOW resistance so flow in Portal branches reverses and courses toward the stent**
This waveform was obtained at the porta hepatis in a patient with Portal HTN. The signals from both the Portal vein and Hepatic Artery are demonstrated. Which of the following statements is correct?
Hepatofugal flow is present in the Portal Vein*
Which of the following describes Normal flow in the Portal Vein?
Hepatopetal** - toward and into the LIVER. -FUGAL is away, advanced sign Portal Hypertension (HTN)
This is a TX image of the LCCA. Which statement below correctly describes this image?
Hetergeneous plaque w/ questionable intraplaque hemorrhage
What term can be used to describe the Atherosclerotic plaque in this sagittal image of the ICA?
Hetergenous
Which of the following describes this waveform?
High Resistance*
Low resistance yields what type of flow rate?
High flow rate
In duplex assessment of dialysis fistulas (synthetic or native), common abnormalities include all EXCEPT
High flow rates >300ml/min - fistula should have fairly high flow rates to allow for dialysis
If one is listening w/ a continuous-wave Doppler directly over a stenotic lesion, the signal will:
High frequency sound* - accelerated velocities will create high freq directly in the stenotic jet! - just distally there will be turbulent flow, scrambled analog waveform-many velocites/directioins causing many freq shifts!***
Monophasic PTA waveforms, despite normal ankle/arm index in the asymptomatic Pt, indicate that:
High pass filter may be set too HIGH - could clip freq near baseline, leaving only monophasic waveform above baseline in normal arterial signal
The characteristics of flow in the different carotid artery segments are:
High resistance character in ECA, low resistance in ICA and mixed with CCA
Doppler flow proximal to a significant stenosis is higher or lower resistance?
Higher and can have no or minimal diastole
In the calculation of ankle/brachial systolic pressure ratios, the following arm pressure is commonly selected as the denominator
Higher of the RT or LT arm pressures - higher arm pressure used to determine ABI
The velocities measured in a reversed Saphenous vein bypass graft are usually:
Higher proximally and lower distally - lower distally bc of increased sized of graft distally
During ordinary auscultation of Carotid bifurcation, the detection of a bruit that extends into Diastole is:
Highly significant - for carotid artery stenosis or other arterial location, elevated end-diastolic velocities are suggestive of severe stenosis
Maneuvers used to assess the Pt w/ possible thoracic outlet syndrome include all EXCEPT
Hobbs maneuver - Hyperabduction of arms, ADSON maneuver, Costoclavicular maneuver, positioning to reproduce symptoms: may produce diminished or absent distal arterial flow as monitored by PPG, Doppler***
Binocular disturbance that disrupts vision in 1/2 the visual field of both eyes is called:
Homonymous hemianopia
Name the anatomy demonstrated adjacent to the AO in this TX image of ABD AO Aneurysm
Horseshoe Kidneys* - both kidneys connected at lower/rarely upper poles across the midline - complicating factor in AO surgery
Contraindications for Treadmill Stress Testing* include all of the following EXCEPT:
Hx of claudication* - used to help differentiate b/n true and neurogenic claudication to help determine presence or absence of collaterals. Its indicated when resting measurements are not grossly abnormal and/or symptoms don't correlate w/ resting measurements - Contraindications include: SOB, HTN, Cardiac/walking problems, stroke***
Which pressure is greatly influenced by gravity?
Hydrostatic Pressure
What is the pressure within the vascular system due to the weight of a column of blood?
Hydrostatic pressure
What type of pressure is equivalent to the weight of a column of blood pressing against the vessels of the body?
Hydrostatic pressure
An increase in blood flow; this can occur following exercise; it can also occur following restoration of blood flow following periods of ischemia.
Hyperemia
Which one of the following changes occurs in the peripheral blood flow of limbs with obstructive arterial disease in response to lab-induced ischemia/reactive hyperemia procedure or exercise?
Hyperemia is PROLONGED in obstructed limbs in comparison to limbs w/ no obstruction - is prolonged in Pts w/ significant obstruction, decr. peripheral resistance, ie after reactive hyperemia/exercise tend to increase cardiac output
Sign of Chronic Insufficiency* is:
Hyperpigmentation**
Biggest contributing Risk Factor for Stroke* is:
Hypertension (HTN)*** - effective control of HTN can decrease risk of stroke, higher blood pressure, greater risk for stroke
Select the entity that is NOT a risk factor in peripheral arterial occlusive disease:
Hypolipidemia
What is the most prevalent type of Stroke?
ISCHEMIC STROKE*** - app 85%, 15% intracerebral hemorrhage but more fatal
In the normal patient, will the ABI increase or decrease post-exercise?
In a normal patient the ABI's should increase, while in an abnormal patient ABI's will decrease.
What 2 vessels supply blood to the brain?
ICA and Vertebral arteries
Differentiation of the Cervical ICA from the ECA can be accomplished by all of the following EXCEPT*:
ICA is usually located anteromedial to the ECA - ECA gives off multiple branches, - ICA normally no branches, bulbous area seen at origin - ICA usually located lateral and posterior to ECA
Stenosis of the following vessel presents the highest risk for TIA:
ICA***
The following arteries have LOW resistance flow character:
ICA, POSTprandial SMA, Renal arteries*** - after meal sma flows have lower resistance, higher diastolic flow
What two veins unite to form the Innominate/brachiocephalic vein?
IJV and Subclavian vein
What 3 main veins drain the head and neck?
IJV, EJV and vertebral veins
What arises from the abdominal aorta about 3-4 cm above the bifurcation, that can act as a collateral connection?
IMA (Inferior Mesenteric Artery)
Arteriovenous fistula (AVFs) is a complication that most commonly occurs w/:
IN SITU GRAFTS* - AVFs occur when 1 of the venous branches of Saph vein is not ligated, resulting in communication b/n the graft and adjacent vein
According to POISEUILLES LAW**, what would occur to the pressure gradient across an arterial segment in which the radius has been reduced by 1/2?
INCREASE pressure gradient*
The Veins lose their elliptical shape and become more circular w/ which of the following?
INCREASED TRANSMURAL pressure
What changes would be seen in a Doppler waveform of the Femoral Artery that is taken after exercise?
INCREASED flow through out DIASTOLE* - muscles have greater demand for oxygenated blood, arterioles dilate and resistance to flow decreases*, as flow resistance diminishes, the volume of diastolic flow Increases***
Damped waveform demonstrating a delayed accleration time is obtained in the CFA. This is most likely due to which of the following?
INFLOW Disease*
Smooth, painful Ulcer*** located on the DORSUM of the foot is most likely a(n):
ISCHEMIC ULCER*** - most commonly located over PRESSURE POINTS such as the TOE, HEEL, or DORSUM of the foot! - May occur spontaneously or with trauma. - SEVERE PAIN at night and is relieved by placing the extremity in a dependent position - Ulcer base is usually PALE and edge is definitive - Skin around it is Atrophic or Inflamed! - Other trophic changes seen w/ ARTERIAL Insufficiency include hair loss on affected extremity, shiny, SMOOTH skin, thick brittle nails, tapering of toes or fingers*** - STASIS ULCERS are caused by VENOUS stasis in Chronic Venous Insufficiency***. - They tend to occur over the Medial Distal Third of the Leg (GAITER ZONE*) - MILD PAIN, relieved by elevating the discoloration caused by HEMOSIDERIN deposits from breakdown of RBC. - NEUROTROPHIC ULCERS are associated with DIABETES!*** - Occur spontaneously, located on SOLE OF FOOT under calluses or pressure points - NO PAIN - Ulcer edge is definitive and skin around it is CALLOUS
The most prevalent type of stroke is:
ISCHEMIC***
This sagittal abd image shows a Greenfield** filter positioned w/in what vessel?
IVC
What terminates in the right atrium and drains lower half of body?
IVC
Name the vessels labeled A-D
IVC SMA LT Renal Artery* RT Renal artery*
Regarding the IVC, all of the statements below are True EXCEPT:
IVC drains into the Left Atrium of Heart is false -True: IVC is formed by confluence of the Common Iliac veins, has no valves below level of its insertion into the heart, courses to the RT of Abd AO?***
A Pt presents w/ bilateral lower extremity edema and nephrotic syndrome. Thrombus is suspected at which level?
IVC* - to create bilater edema, thrombus would involve either both iliac veins or more likley IVC. might also cause renal dysfunction due to obstructed renal vein outflow
Pt referred to the Vascular Lab presents w/ Bilateral LE Edema and Nephrotic Syndrome***. Thrombus is suspected w/in what vessel?
IVC*** - IVC Thrombus may produce Bilateral Leg Swelling and recurrent PE! - Nephrotic Syndrome occurs if Thrombus is located at the level of the RENAL VEINS!!!
In this same PT who has had 4 episodes of amaurosis fugal in the last week, the most likely course of action would be:
Immediate angiography - repeated TIAx call for action, stenosis falls into somewhat borderline category,
Lymphedema is a result of:
Impaired transport of Lymph
Overestimatation of the degree of stenosis in the ICA may be due to all of the following EXCEPT:
Improper location of sample volume proximal to stenosis - doppler sample obtained prox to stenosis will produce LOWER VELOCITIES than 1 obtained at narrowing, result in underestimation of stenosis. - overestimation of angle result in overestimation of velocity -vessul tortuosity results in overestimation or underestimation of stenosis bc accurate angle is difficult - velocities contralateral to occlusion increase due to compensatory flow. thus, stenosis is likely to be overestimated when it occurs contralateral to an occlusion!****
Major complications of cerebrovascular angiography include all of the following EXCEPT:
Inadvertent venous puncture is False, not major - death, stroke, arterial occlusion at access site, renal failure are serious outcomes
Primary Varicose Veins* form as a result of:
Incompete t or Absent venous valves***
Which statement is TRUE regarding incompetent venous valves?
Incompetent valves may lead to HEMOSIDERIN* deposition - incompetent valves result in increased pressure as blood flows retrograde (away from heart) - this produces stasis and increased development of venous thrombosis - RBC and fibrinogen may leak into the surrounding tissue, leading to Hemosiderin deposition, this causes the BRAWNY SKIN CHANGES ASSOCIATED W/ CHRONIC VENOUS DISEAE (CVD)***
72 yo F referred to lab for evaluation of Rt LE claudication. Brachial pressure are 135 mmHg bilateral, ankle pressures are 300 mmHg. This is most likely related to:
Incompressible arteries due to ARTERIAL CALCIFICATION***
What technical problem is present in this duplex sampling of the CCA?
Incorrect measurement of Doppler angle - should be aligned parallel to the vessel walls at the pt of sampling*
Which of the following is NOT a useful color flow adjustment in an effort to detect slow flow in a possibly occluded ICA?
Increase color flow PRF FALSE - increasing PRF will make the color flow less sensitive to slow flow
A clenched fist will change the following parameter in the brachial artery Doppler
Increase pulsatility index - offers greater distal resistance, doppler waveform expected to become more pulsatile, decrease the diastolic flow
Which of the following is NOT consistent w/ the diagnosis of Rt ICA occlusion?
Increased Diastolic Flow in Ipslateral CCA*** - Findings associated w/ ICA occlusion include: -Dec or absent diastolic flow in Ipslateral CCA -Compensatory Hyperemic flow in Contralateral CCA -Inc diastolic flow in Ipslateral ECA, Ext to Int collateral occurs thru the ORBIT -Debris-fillled ICA -Absence of color fill w/in affected ICA, detect slow flow -Absence of Spectral Doppler signal w/in affected ICA w/ sample volume size includes entire width of vessel -Lack of normal pusatility visible by B-mode in the affected ICA (jerking motion detected instead)
The tendency of objects to maintain their status quo is called:
Inertia
What is the tendency of a fluid to resist changes in its velocity?
Inertia
What type of energy loss occurs with deviation from laminar flow, due to changes in direction and / or velocity?
Inertial energy loss
Diabetic Pt with redness of the skin in the foot and toe probably has:
Infection - can happen w/ or w/o peripheral vascular disease
Hepatic Veins drain into the:
Inferior Vena Cava*
Vessels and structures of the Penis include all of the following EXCEPT:
Inferior Vesicle artery - deep artery of the penis - dorsal artery of the penis - corpus spongiosum - dorsal vein
All of the arteries below demonstrate LOW RESISTANCE*** waveforms in the fasting state EXCEPT:
Inferior mesenteric artery (IMA) - arteries that feed parenchymal organs: celiac, hepatic, splenic and renal in abd demonstrate LOW resistance w/ forward flow present thru-out cardiac cycle!*** - SMA, IMA show little diastolic flow in fasting state* - following meal, diastolic flow in SMA will increase up to 3x its fasting state
What is most common location for a true aneurysm?
Infrarenal
What appear as small confined projections into the vessel lumen made up of a segment of the vessel wall that has separated from the remainder of the wall in a abnormal bypass graft?
Initmal flap
The Term tunica intima denotes:
Inner lining of the arterial wall
The first major arterial branch of the Aorta is the:
Innominate Artery
Which of the following anatomic lesions can produce a vertebral steal?
Innominate artery occlusion & Left subclavian artery origin stenosis - the lesion must be proximal to VA, creating abnormal pressure gradient that pulls blood from the VA to perfuse the arm. Occlusion of the CCA would not creat this gradient, the Axillary artery is too far distal
A left arm blood pressure that is 40mmHg lower than Rt can be result of any of the following EXCEPT:
Innominate artery occlusion is FALSE (if innominate was involved, it would be lower pressure on Right, not left) - Thoracic outlet entrapment - subclavian steal - coarctation of the Aortic arch - axillary artery embolus
Stronger pulse is palpated in the RT neck than the left. This could result from all of the following EXCEPT:
Innominate occlusion - would be expected to make RT Carotid pulse weaker NOT stronger
What is formed by the confluence of subclavian and IJV?
Innominate vein
Which of the following is the most important in Physical Exam of the Venous system?
Inspection* of extremities, limb swelling, ulceration, color changes and cellulitis!!! - venous sounds aren't audible w/ stethoscope - auscultation is not helpful except with AVFs - Palpation only offers minimal info in evaluation
The majority of the CCA's blood, flows into what vessel?
Internal Carotid Artery (ICA)
Opthmalmic Artery is a branch of the:
Internal Carotid artery (ICA)*
What vessel is also referred to as the Hypogastric artery?
Internal Iliac Artery
Another name for the Hypogastric Artery is:
Internal Iliac artery
Hypogastric artery* is another name for the:
Internal Iliac artery*
Image shows a Thrombosed vein adjacent to the CCA. What vein is being imaged?
Internal Jugular vein - courses w/ CCA - External Jugular vein does not accompany artery
What is the intracranial space between the dura mater and periosteum that drains blood into the IJV called?
Intracranial Venous sinuses
During INSPIRATION, what happens to pressure in the ABD and Thorax?
Intrathoracic pressure DECREASES, ABD pressure INCREASES***
During VALSALVA maneuver, what happens to pressure in the ABD and Thorax?
Intrathoracic pressure INCREASES, ABD pressure INCREASES***
Most common cause of upper extremity venous thrombosis is:
Intravenous catheters and lines* - upper extremity venous thrombosis has become common due to increased use of IV lines/catheters during hospital stays
Which of the followig is true regarding Subclavian steal?
It is usually a harmless hemodynamic phenomenon & it is caused by arterial obstruction PROXimal to the Origin of the Vertebral Artery
Which of the following is/are TRUE regarding the clinical detection of a bruit?
It means that turbulent flow exists, it may be indicative of valvular dysfunction in the heart, it may be a normal finding in parts of some vessels & during periods of enhanced flow
A correlation of a noninvasive test to its "gold standard" yields a sensivity of 93%. Which of the following statements is correct:
It must be value from 0-100% sensitivity & specificity are mathematically unrelated. 2 calculations utilize all the data points in the series, both can be any value
Which of the following is NOT correct regarding the GSV?
It passes superiorly on the "Lateral" side of the knee is false. - it passes superiorly on the medial side of the thigh - it enters the femoral vein - it extends distally to the dorsum of the foot - it has more valves in the calf thaan in the thigh
Which statement about Subclavian Steal* is FALSE?
It results from Severe Stenosis or Occlusion of the Proximal VERTEBRAL artery is FALSE (severe stenosis or occlusion is present in Proximal SUBCLAVIAN artery; results in retrograde flow in Ipslateral VA, flow is "stolen" from Contralateral VA by way of basilar artery) - it occurs most commonly on left side - asymptomatic (dizzy, vertigo, diplopia, ataxia, bilat blurred vision) - lower blood pressure on affected side
What is suggested in this spectral display?
It suggest turbulent flow - "shredded" appearance and "filling in defect" in systolic window suggest turbulent flow** There's some low velocities at systole beneath baseline. Since turbulent flow goes many directions, mostly at "lower" velocities, many freq shifts (below baseline)
Which statement about this spectral display from the Superficial femoral artery is TRUE:
It suggests severe velocity increase, compatible w/ approximately 75% PSV this high are compatible w/ high-grade arterial stenosis, note absence of systolic window & low velocities below baseline, suggesting pronounced turbulence!!!
Which of the following is NOT true regarding the ICA?
It supplies high-resistance system is false! (ICA feeds low-resistance system)
Internal friction within a fluid is measured how?
It's measured by its Viscosity
Angiography is generally considered only when the info is necessary for surgery or other urgent Pt management bc of all of these factors EXCEPT:
It's often nondiagnostic
What is a "steal syndrome" in reference to hemodialysis
It's when the distal arterial blood flow is reversed into the lower resistant venous circulation and can cause pain in hand/fingers on exertion, pallor and coolness of the skin distal to the shunt.
What is Klippel-Trenaunay syndrome?
Its a congenital venous disease characterized by multiple varicosities of the superficial system and hypoplastic or absent deep veins.
What is popliteal artery entrapment syndrome?
Its when the popliteal artery can be compressed by medial head of gastronemius muscles, or fibrous bands, which results into claudication or chronic leg ischemia.
Commonly performed methods of Vena Cava Interruption for recurrent PE include all EXCEPT:
Jones Wire arch - Greenfield umbrella filter is oldest, most widely used - Nitinoil is nickel-titanium alloy straigthened for insertion, then resumes shape w/ warmth of BF - bird's nest filter, vena tech filter
The energy of something in motion is termed:
Kinetic Energy
What type of energy is represented by the velocity of moving blood? Potential or kinetic
Kinetic energy
The term LAMINAR FLOW* describes the:
LAYERED manner in which blood flow courses w/in an Arterial Lumen***
Name the structures labeled A-B
LEFT Portal Vein* Ligamentum Teres*
In a cross section of the AO & surrounding regions, the vein that is visualized superficial to the AO & the origins of the Rt & Lt renal arteries & deep to the SMA is the:
LEFT RENAL VEIN* - LRV travels ANTERIOR to AO to reach across to the IVC
Pt in the previous question is Rt handed. Which area of circulation is suspect?
LEFT hemisphere - Speech area of cortex is the temporal lobe of the dominate hemisphere
Which term can be used to describe flow depicted by small sample volume from center of NORMAL Internal Carotid Bulb waveform?
Laminar flow - normal, nonturbulent flow which blood tends to course in layers of decreasing speed from center streamline toward vessel wall. - laminar flow in small vessels assumes parabolic flow profile -larger vessels ie CCA is blunted/plug profile, parabolic at Diastole
Waveforms obtained from an artery supplying an Intracranial Arteriovenous malformation will exhibit?
LOW Pulsatility Index*** - artery that feed an AV malformation will show increased velocities in both systole and diastole - diastolic especialy will be increased! resulting in very LOW Resistance!!! - waveform that exhibits LOW Resistance, will have LOW Pulsatility Index, and LOW Resistive Index measurements***
Which of the following describes a typical ARTERIAL Doppler waveform obtained Proximal to an AVF*?
LOW resistance w/ INCREASED Flow*
These waveforms are obtained from 72 y.o asymptomatic male who was referred for Duplex Carotid US prior to surgery. Waveform at top is of LT CCA, Waveform at bottom is of RT CCA, which diagnosis is most likely considering these findings?
LT ICA Occlusion* -should show similar diastolic flow. - Unilateral decrease in Diastole should increase suspicion for Distal Occlusive Disease on Ipslateral side!
59 yo F presents gradual onset of edema beginning at the DORSUM of the foot, proceeding proximally. Swelling is not relieved by leg elevation. These symptoms most closely relate to which condition?
LYMPHEDEMA*** - may be congential or acquire - acquired involves the entire LE, may be associated w/ minor event such as insect bite, ankle sprain, cutaneous infection - Begins at dorsum of foot, proceeds proximally - Lymphedema can be differentiated from venous edema bc venous edema will improve quickly w/ Leg elevation but not with LYPHEDEMA!!!** - edema usally NOT associated w/ other symptoms - there's no cutaneous pigmentation, dermatitis, or ulceration as in VENOUS edema, long-term cases may show Hyperkeratosis of skin
While performing an ABD US on a kidney transplant, you find that the renal artery and vein are patent, but the arteries of the transplanted kidney don't have diastolic flow. Which statement is true:
Lack of diastolic is ABNORMAL for transplanted kidney - absence of diastolic flow suggests rejection!
The plantar arch in foot consists of what branch from the PTA?
Lateral plantar artery, which unites with the deep plantar artery
The radial artery runs on what side of the forearm?
Lateral side
The Renal arteries arise from the Aorta:
Laterally - RRA usally anterolateral, LRA posterolateral
Using transcranial Doppler, an abnormal flow direction may be detected in the Lt ACA* in cases of:
Left ICA occlusion*** - Crossover collaterization occurs from 1 ACA thru ACoA to contralateral ACA in cases of ICA occlustion on same side as reversed flow*
Pt presents w/ Rt arm numbness and transient loss of vision in Lt eye. What vessel is most likely source of symptoms?
Left ICA* - unilateral eye symptoms are associated w/ Ipslateral ICA, while unilateral symptoms involving the BODY are associated with the CONTRAlateral ICA
What vein normally courses b/n the SMA and Abdominal AO?
Left Renal Vein* -rarely, course behind AO/retroaortic or form ring around AO/circumaortic LRV
TIA of the Rt Anterior hemisphere of the brain will likley affect:
Left side of the body - affect the side of the body opposite ischemic hemisphere
What is May-Thurner Syndrome?
Left sided DVT due to the left common iliac vein passing under the right common iliac artery, which can cause extrinsic pressure.
What syndrome occurs in males and is caused by obstruction of the aorta, resulting in fatigue in the hips, thighs, and calves during exercise, absense of femoral pulse, and impotence?
Leriche Syndrome
Which of the following is TRUE regarding Chronic Venous Ulceration?
Lesions are usually found on the lower third of the leg around the medial aspect of the ankle*** - venous ulcers are caused by venous hypertension during leg dependency, occurs in "GAITER AREA" around medial aspect of the ankle, while arterial ulcers tend to show on toes/foot. - Pain is mild, expect to ooze blood, and exhibit granulation during healing****
What is Auscultation?
Listening through a stethoscope
A dumbbell shaped vein has what type of transmural pressure? low or high?
Low transmural pressure, while a circular shap vein has high transmural pressure.
Distal to an aortoiliac occlusion, the CFA signal is typically:
Low-pitched and monophasic - arterial signal distal to total occlusion represents flow via collaterals, damped out
Is doppler flow distal to a significant stenosis higher or lower resistance?
Lower and it will also be more rounded in appearance and weaker in strength
In the Pt from the previous question, you would expect arm pressures to be:
Lower on the LEFT - lower pressure on the left due to LEFT subclavian obstruction
Exercise should induce peripheral vasodilation, which does what to the distal peripheral resistance? Raise or Lowers?
Lowers the peripheral resistance, increasing blood flow.
48 yr old male presents w/ retrograde flow in Lt Vertbral A. most likely related to occlusion of the:
Lt Subclavian Artery* -prox lt subclavian occlusion, lt VA flow will reverse to -provide BF to the left arm -condition termed SUBCLAVIAN STEAL*** -occurs more commonly on left side
56 yo male presents w/ transient Lt hand numbness in the fingers. Bilateral Brachial Systolic BP are 130mmHg on Rt and 105mmHg on Lt. What is the diagnosis?
Lt Subclavian Stenosis* - Difference of 15-20mmHg b/n Brachial BP suggests Subclavian Stenosis on the lower pressure side.
On CW Doppler assessment, a PT w/ a swollen left leg has loud, continuous flow signals from the Lt GSV. The asymptomatic leg has nonspontaneous flow in the Rt GSV, which augments w/ distal compression. These findings are consistent with:
Lt leg DVT* - greatly increased flow in lt GSV suggests that its acting as major outflow collateral in presence of DVT
Pts with a swollen limb who have just returned from a country where Filariasis is endemic may be suspected of having?
Lymphedema - nematode parasites, causes blockage of the lymphatic channels, leading to swelling
42 yo F presents with a gradual onset of asymptomatic Rt LE swelling which began at the Dorsum of the Foot and gradually included the Whole LEG. These findings are most likely associated with:
Lymphedema** - Gradual onset of swelling over several months is characteristic of Lymphedema!!!! - Acute DVT involving POP V would produce swelling in calf associated w/ pain & tenderness wouldn't be gradual onset - Superficial Venous Thrombosis of GSV would produce pain & tenderness over the thrombosis site - Baker's cyst will not cause swelling of entire LE
Systolic thigh pressures are 180mmHg in both LE, the systolic arm pressure is 170mmHg on the RT, 160 on Lt. Pt complains for buttock claudication:
MAY have aortoiliac occlusive disease -in presence of partially calcified femoral artery wall, can't be ruled out - best/most cautious assessment of this limited info***
Using the temporal window for TCD, you find a strong signal w/ considerable diastolic flow at a depth of 50 mm. This is most likely:
MCA
What vessels are accessed with a unilateral transtemporal approach?
MCA, ACA, PCA, and terminal ICA
Which of the following terms can be used to describe this waveform?
MONOphasic
What type of arterial study uses radio fequency energy and a strong magnetic field to produce images in multiple planes that quantitate blood flow and distinguish it from soft tissue without using contrast agents?
MR Angiography (MRA)
Regarding the use of MRA for evaluation of LEA, which is FALSE?
MRA can't achieve the accuracy of conventional angiography is FALSE - MRA doesn't have the potential side effects that conventional angiography entails, mra is more sensitive in identifying patent runoff arteries, can be used alone before bypass surgery, w/o angio
What is one benefit of performing and MRA study instead of and angiogram?
MRA's dont require contrast agents so patients with renal failure or patients that are allergic to the contrast agents are able to have exam.
What is the function of the Semilunar Valves (Aortic/Pulmonary) of the veins?
Maintain unidirectional flow w/in the Venous System - designed to direct flow of blood Back TOWARD Heart by closing during Retrograde flow
Which statement is correct regarding digital subtraction arteriography DSA?
Mask, often w/o contrast, is selected to be subtracted from the frames obtained during injection of the contrast solution - subtraction technique uses a mask to subtract unnecessary info, such as bony structures from final arteriogram
The infraOrbital artery is a terminal branch of the:
Maxillary artery (infraorbital artery is a terminal branch of the maxillary artery. It creates one of the potential anastomoses w/ orbital branches that can provide collateral pathways in the event of carotid obstruction)
Diastolic flow reversal:
May be absent in VASODILATED limbs* - have low distal resistance & exhibit the reduction or absence of diastolic flow reversal***
In the presence of tibial arterial calcification in the diabetic Pt, the ankle/arm index:
May be in normal range or abnormally decreased, yet falsely elevated - calcification may indicate presence of neg/positive disease.
The Endarterectomy procedure (removal of plaque from an artery):
May be used for obstructed lower extremity arteries
The acoustic windows through which US may pass in performing transcranial Doppler and transcranial imaging exams include all EXCEPT:
Medial part of the Frontal bone
Which vein in the Antecubital Fossa connects the Cephalic and Basilic (superficial) veins?
Median Cubital Vein (not paired)
Extrinsic compression of celiac artery origin by what ligament can cause reversible celiac artery stenosis during expiration?
Median arcuate ligament of the diaphragm
Which vein in the Antecubital Fossa connects the Cephalic and Basilic veins?
Median cubital vein
A patient presents w/ a history of aching and cramping abdominal pain 15-30 minutes after meals. What would you suspect to be the problem?
Mesenteric ischemia or mesenteric angina; which may be due to stenosis or occlusion of the SMA, celiac, or IMA.
The 2 arteries creating the bidirectional signal observed 60-65 mm deep during transcranial insonation of the temporal window are the:
Middle cerebral and ANTERIOR cerebral arteries*
Hemispheric stroke usually affects:
Middle cerebral artery (MCA) distribution & on the Contralateral side of the body***
Which of the following is not an artery in the circle of Willis?
Middle communicating artery
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:
Mild iliofemoral stenosis, severe superficial femoral stenosis/occlusion, severe infrapopliteal occlusive disease** - tracings of mild change/absence of dicrotic notch to most severe/flat progress down the leg
What artifact can be produced from strong reflectors or by having too much gain that results in a Doppler shift above and below the baseline?
Mirror Image Artifact
Carotid Bruit can be detected with color flow and spectral analysis as:
Mosaic of LOW red and blue freq in color flow in tissue lying outside of the lumen, oscillatory waveforms above and below baseline in the Spectral waveform - freq associated w/ bruit are LOW rather than high. low-freq oscillations above and below a spectral baseline that are characteristic of a bruit may also show as low freq red & blue color shifts in adj tissue, often speckled like a mosaic
The most common anatomic variantion of the renal arteries is:
Multipile renal arteries*
Most common anatomic variant of the Renal arteries:
Multiple Renal artery* (commonly originate from Abd Ao or Common Iliac arteries, esp w/ ectopic, horseshoes kidneys)
In this B-mode image, what variant vascular anatomy is present?
Multiple renal arteries*** - there are 2 renal arteries in this image posterior to the IVC - when evaluating the renal arteries for stenosis in renovascular HTN, each renal artery ID must be evaluated throughout its length. - presence of unID accessory or supernumerary renal arteries is a potential pitfull in the US evaluation for Renal artery stenosis***
What does Ataxia mean?
Muscular uncoordination; inability to control gait
Aneurysm resulting from INFECTION is known as:
Mycotic
Rapid proliferation of cells into the intimal layer of the cell wall that can lead to stenosis of a bypass graft?
Myointimal Hyperplasia
Boyd's perforating vein is located:
NEAR the KNEE* *Main ones are Cockett perfs in the mid-distal calf connected by posterior arch vein; Boyd's perfs near the medial Knee, Dodd's perfs above the knee; Hunter's perfs around mid thigh
This waveform profile is characteristic of which of the following?
NECK of Pseudoaneurysm** - to/fro waveform, bidirectional
The proportion of test results that correctly predict NORMALITY is termed:
NEGATIVE PREDICTIVE VALUE*** - Calculation: TRUE Negatives / TRUE Negatives + False Negative
Normal response of ankle pressure to exercise testing/treadmill:
NO CHANGE!!!
With Subclavian artery stenosis on the Rt side:
NONE all false (depends on severity of the stenosis) - flow in RT Vertebral artery will be reversed - pt will have rt arm claudication - arm pressure will be reduced - rt Axillary artery Doppler signal will be monophasic
57 yo M presented to lab for LEA testing. Exercise testing was stopped due to claudication symtoms. Postexercise ankle pressures measured slightly ABOVE resting ankle pressures. What is suspected in this patient?
NONVASCULAR CAUSE of leg pain*** - shows normal ankle pressures after stopping test thus nonvascular cause
Helical flow* with flow separation in the Posterlateral aspect of the Carotid Bulb* is a sign of:
NORMAL Flow Dynamics*** - disrupted by large sinus and sharp curve at bulb
What vessels are accessed with isilateral transorbital approach?
Ophthalmic artery and Carotid siphon
The clinical exam for DVT is:
Neither specific nor sensitive - difficult to call based on signs/symptoms, chronic unilateral edema is the single best indicator***
What is intimal thickening from rapid production of smooth muscle cells in response to vascular injury/reconstruction, such as post carotid endarterectomy?
Neointimal Hyperplasia
Pt undergoes Carotid Endarterectomy. 6 mos later angiography is performed bc of symptoms referable to other side. The angiogram reveals that the operated carotid is significantly narrowed. Most likely cause is:
Neointimal Hyperplasia*
Anterior compartment syndrome is suspected in a trauma patient w/ closed fracture of the fibula. Clinically the calf is tense & tender to palpation, there's decreased sensation in the foot. The dorsal is pedis pulse is present, w/ audible triphasic Doppler signal. The dorsal is pedis pressure is 140mmHg, w/ arm pressure of 130 mmHg. Why is this finding unreliable for ruling out a compartment syndrome?
Nerve and/or motor dysfunction due to compartment syndrome may occur w/o any alteration of arterial hemodynamics - ATA is located in anterior compartment & supplies dorsalis pedis artery, however, increased pressures that can affect ATA nerve & muscle function may be less than those that alter the pressure or audible doppler characteristics of the ATA. Diagnosis of compartment syndrome is made clinically, intracompartment pressures are measured by needle/manometer technique
Possible complications of Vena Cava Interruption for recurrent PE include all EXCEPT:
Night cramps - not symptom of venous disease - dimished cardiac output possible complicatioin to ligation of vena cava - secondary to signficant caval obstruction and elevated venous pressure are: edema, leg ulcers, venous claudication
Is it an uncommon finding to see multiple renal arteries bilaterally?
No it is not uncommon at all.
Analog Doppler are not capable of portraying velocities less than what cm/sec?
No velocities < 6cm/sec
What is thoracic outlet syndrome (arterial component)?
Occurs with neurovascular bundle compression by shoulder structures (cervical rib, clavicle, scalene muscle); occurs in certain arm positions. Most symptoms are due to neurogenic compression of brachial plexus; which cause numbness/tingling of arm or pain/aching of shoulder/forearm.
A correlation of a noninvasive test to its "gold standard" yields a positive predictive value of 86%. This means that:
Of all the PPV, 86% correctly predicted that the Gold Standard would be ABNORMAL/Positive - utilizes only those tests w/ an abnormal result.
The Brachiocephalic vein is found:
On both the right and left
Ulcers due to arterial insufficiency* are found most often:
On toes and distal foot***
The first intracranial branch of the ICA is the:
Ophthalmic artery
In transcranial Doppler, w/ the probe placed over the RT Temporal bone, flow in the RT ACA* will be:
Orientated AWAY from probe*
In the CerebroVascular system, atherosclerosis occurs most commonly in the"
Origin of ICA*
The Term tunica adventitia denotes:
Outer lining of the arterial wall
The 2 x 2 table below correlates arteriographically proven disease in the Lower extremity arteries & significant gradient in systolic pressure b/n segmental pressure cuffs: Present Absent >20mmHg 90 10 <20mmHg 10 90 All of the following are true EXCEPT:
Overall accuracy is calculated by the formula 90/100 overall accuracy: # of correctly classified test results divided by the Total # of tests. 180 correct test results in 200 test performed, correct calculation for overall accuracy is 180/200
Which term describes a PALE skin color due to INSUFFICIENT blood flow?
PALLOR
Which physical finding is more frequently seen w/ arterial insufficiency rather than venous stasis?
PALLOR* more common but may be seen w/ venous stasis due to Arterial SPASM in Acute Iliofemoral DVT! - Venous stasis findings include: red/blue skin, brown skin discoloration, induration***
Which syndrome results in medial displacement of the vessel due to compression by fibrous bands or medial head of the Gastrocnemius muscle?
POPLITEAL ENTRAPMENT SYNDROME* - occurs when artery is compressed by medial head of GAST muscle. - pop a usually dislocated medially more common in young men, occurs bilaterally 1/3 of cases - trauma caused to artery can result in development of aneurym, thrombosis, atherosclerosis, or embolic - symptoms include intermittent claudication - doppler findings include diminished or altered waveforms w/ knee extension, active plantar flexion, passive dorsiflexion of the foot.
28 yo M compalins of exercise induced cramping of RT calf that occurs after walking 6 blocks, is relieved w/in 5 mins of rest. Bounding pedal pulses are noted, resting ankle pressures are normal. Symptoms are reproduced w/ exercise. Ankle pressure remains normal on Lt but drops to 40mmHg on Rt. Signs are consistent w/:
POPLITEAL ENTRAPMENT*** - claudication-like symptoms in young muscular male
Spontaneous SPLENORENAL SHUNT is an abnormal connection b/n the SPLENIC and LEFT RENAL VEIN and is associated with:
PORTAL HTN*
In this image, 48 yo M, large paraumbilical vein is seen exiting the liver. This in indicative of:
PORTAL HTN* - its presence is diagnostic of this disorder - paraumbilical vein is a vestige of the umbilical circulation in the fetus - connects the portal venous system to the systemic venous system, forming a portosystemic shunt
An enlarged CORONARY Vein* w/ Retrograde flow is a sign of:
PORTAL HTN**
Pt you're scanning has an enlarged coronary vein w/ retrograde flow. these findings are a sign of:
PORTAL HTN***
Pulsatile venous Doppler from the Portal Vein may suggest
PORTAL HTN*** - normally gently PHASIC w/ RESPIRATION, not pulsatile
The number of TRUE POSITIVES divided by the number of TRUE POSITIVES + FALSE POSITIVES describe?
POSITIVE PREDICTIVE VALUE*** - Percentage of individuals w/ POSITIVE noninvasive test result who actually HAVE the disease
Palpation of a pulse found in the groove behind the Medial Malleolus* of the ankle corresponds to the:
POSTERIOR TIBIAL ARTERY*
Complaints of chronic unilateral lower extremity swelling, aching, and a sense of heaviness most likely suggest:
POSTphlebitic syndrome
If we increase the Peak systolic velocity value needed to call a carotid test positive for severe ICA stenosis
PPV will INCREASE, NPV will DECREASE, accuracy may increase or decrease - increase of threshold raises the bar, means that more of the PT called positive by duplex do indeed have severe stenosis, means an increase in false neg, since you increase the PSV required to call severe stenosis. - benefit would be making quite sure that someone designated positive- really positive before going to surgery
What is the most common location of Atherosclerotic Disease of the Renal Artery*?
PROXIMAL - tends to affect the BIFURCATIONS of arteries!!! - Renal artery is most commonly affected at its origin from AO! which is considered proximal portion of the vessel - Fibro Muscular Dysplasia (FMD) more commonly affects the Mid to Distal aspect of the Renal artery*
Pt presents w/ swelling around puncture site of arteriography. Duplex sono reveals a high-velocity tract from the artery leading to a large hematoma. This is termed a(n):
PSEUDO*
What type of aneurysm is related to arterial trauma whereby blood escapes through a defect in the vessel and extravasates into the surrounding tissue?
PSEUDO*
Complication following femoral artery catherization in which a characteristic to and fro Doppler waveform is seen w/in a tract leading to a perivascular hematoma is termed a(n):
PSEUDOANEURYSMS - occurs when puncture site fails to close and blood escapes into surrounding tissue forming a perivascular hematoma. - color and spectral Doppler used to confirm mass, id tract/neck - turbulent, classic to and fro pattern w/ high velocities
what are the normal velocities of the celiac arteries
PSV 50-160 cm/s and EDV of less than 50 cm/s
what are the normal velocities of the IMA
PSV 93-189 cm/s
what are the greatest indications of RA stenosis
PSV greater than 200 cm/s, tardus parvus waveforms
The pathology responsible for this abnormal waveform is most likely? RI=0.82
Parenchymal Renal disease**
What route does peroneal artery travel
Passes toward fibula down medial side of that bone to supply structures of the lateral side of the leg/foot
Doppler exam alone, without B-mode, is unlikely to detect the presence of venous thrombosis in:
Peroneal vein* - since calf veins are paired, CW signal may continue to sound normal in 1 branch even if other branch is thrombosed
Which of the following is a significant problem w/ digital substraction angriography
Patient cooperation - patient motion drastically affect ability of DSA to provide adequate images
Auscultation of the Carotid Artery is best performed w/
Patient suspending respiration*
Pulsatility index is defined as:
Peak Systolic to peak end diastolic velocity divided by the mean velocity - aka Gosling's pulsatility index, used w/ Continuous wave Doppler or transcranial, increases w/ distal resistance! Dependent of Doppler angle***
Pulse sites commonly palpated in the LE include all EXCEPT:
Peroneal*
Most common presenting symptoms in acute arterial occlusion include all EXCEPT:
Pedal ulcer - Paralysis, pulselessness, pallor, paresthesias
Which of the following is a TRUE statement regarding impotence?
Penile pressure can decrease after treadmill testing - vascular disease is most common cause but neurogenic and psychosomatic causes are also possible. any vascular lesion at or above the internal iliac artery may be implicated, often erection can be initiated but not sustained, surgical correction done only on selected cases
Which measurement is most commonly used in Angiographic reports of carotid stenosis?
Percentage Diameter Reduction* - easily determined in long on angiography
Blood from the Deep venous system will back up into Superficial system when:
Perforating Veins are Incompetent* - blood will flow retrograde from deep venous system into Superficial venous system, increasing SV pressure
Carrying blood from superficial veins into deep veins is acomplished by what veins?
Perforators
Doppler velocity waveforms from UE vessels may vary slightly from LE waveforms bc:
Peripheral resistance is usually LOWER in the Upper Ext - brachial artery waveform w/o flow reversal is common finding
This Sagittal B-mode image was taken from the probe positioned on the medial aspect of the Mid Calf. What pair of veins is being demonstrated?
Peroneal Veins*
Short segment between ATA branch and branches of PTA and peroneal arteries.
Peroneal trunk
Condition that presents as a severely swollen, blue, cool lower extremity is called:
Phelegmasia cerula dolens***
Condition characterized by severe swelling of the leg w/o redness or cyanosis, Secondary to Acute Iliofemoral DVT is:
Phlegmasia Albe Dolens*** - serious condition caused by arterial spasms secondary to the extensive, Acute Deep Iliofemoral Venous Thrombosis
Of the following techniques, which would be the least effective in detecting significant DVT?
Photoplethysmography - PPG its used for chronic venous insufficiency - IPG, SPG, air are all outflow modalities, tracings essential
Type of Plethysmography that detects cutaneous blood flow by sending INFRARED LIGHT into the tissue is termed:
Photoplethysmography* - detects cutaneous blood flow by sending infrared light into the tissue w/ light-emitting diode - photodetector receives and measures the reflected infrared light
Signs of advanced ischemia in the LE include all of the following EXCEPT:
Pitting Edema - true pitting edema is usually a symptom of systemic disease/CHF, chronic venous disease, lymphedema - slow venous filling after dropping elevated extremity into a dependent position, pallor on elevation, rubor on dependency, ulceration at the dorsum of the foot are signs of adv ischemia***
Best way for a tech to palpate a pulse is to:
Place fingertips over pulse site
The best way to prepare a xdcr for Intraoperative use is:
Place xcdr and acoustic gel w/in sterile sleeve or bag - autoclaviing a xcdr will destroy its piezoelectric properties
What instrument is used for measuring changes in volume within an organ or whole body (usually resulting from fluctuations in the amount of blood or air it contains)?
Plethysmography
A thrombus is found in a soleal vein proximal to mid calf. If this were to propagate proximally, it would next involve:
Posterior tibial veins - soleal veins drain ito the PTA and peroneal. It is thought that this is where much if not most of the DVT begins****
The REYNOLDS* number denotes the:
Point at which flow becomes TURBULENT*
Whose law describe the steady laminar flow of Newtonian fluids or the pressure/flow relationship?
Poiseuille
In a rigid tube, energy losses are mainly viscous; this can be described by whose principles?
Poiseuille's equation
Whose equation define the relationship between: pressure, resistance, and volume flow?
Poiseulle's Equation: Q = P/R (Q=volume flow P=pressure R=resistance); it helps answer the question of how much fluid moves through a vessel
Which characteristics below are associated w/ Acute Thrombus***?
Poorly attached, DILATED vein, HYPOECHOIC, smooth borders** - includes spongy texture and incompressible
This sagittal image was obtained in the POP fossa in a Pt w/ Blue Toe Syndrome. What are the US findings
Popliteal Artery Aneurysm
48 yo M referred to Vascular Lab to R/O presence of Baker's Cyst. What anatomy would be imaged?
Popliteal Fossa* - Baker's cyst is seen as an anechoic or area of mixed echogenicity in the pop fossa. -Its separate from the artery and vein, doesn't fill w/ color - cysts are collections of synovial fluid in a sac posterior to the knee, may dissect down into the calf area, can be painful
Unilateral claudication in the calf & foot of a young individual suggests:
Popliteal artery entrapment* - most common in young person
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:
Popliteal vein - gastroc veins empty into the pop vein, soleal empty into the posterior tibial and peroneal veins
On Duplex exam of 45 yo M, thrombus is seen in 1 of the Gastronemius veins. Progation of this thrombus would most likely involve which vein?
Popliteal* - Gastronemius veins are located around the knee, drains into Popliteal Veins
This image is from a 48 yo M w/ increasing ABD girth and a hx of Alcohol abuse. Which condition is most likely?
Portal HTN
A spontaneous splenorenal shunt- an abnormal connection btn the splenic vein and the Left renal vein LRV- is associated w/:
Portal HTN - 1 of several collateral pathways thru which flow from intestine reaches IVC in event of abnormally increased portal vein resistance/cirrhosis*
What clinical condition is assocated w/ the findings seen in this waveform? "signals from both the Portal vein and Hepatic Artery are demonstrated"
Portal HTN*
Splenic vein drains into which of the following veins?
Portal vein*
All of the following may be found in the clinical presentation of PE EXCEPT:
Positive lower extremity venous US - not a clinical sign, but an exam, not useful with PE - Chest pain, Dyspnea, pleural effusion, tachynea
The probability that a Positive noninvasive test reveals actual disease (as diagnosed by the Gold standard) is called:
Positive predictive value - PPV is ability to predict the presence of disease. ppc of 83% means you can be 83% sure a positive exam indicates presence of disease in a given PT
The superficial vein that sends flow to the 3 main perforating veins of the distal calf is called:
Posterior Arch vein* (it connects the Cockett perfs in the calf, is implicated in the formation of venous stasis ULCERS)
Basilar artery* divides into which artery?
Posterior Cerebral Arteries
This B-mode image was obtained in the Upper calf***. Name the vessels labeled A-F
Posterior Tibia Vein Posterior Tibia Artery Posterior Tibia Vein Peroneal V Peroneal A Peroneal V
Doppler tracing performed at the MEDIAL Malleolus is obtained from what artery?
Posterior Tibial
Boyd's vein* is a Perforating Vein that connects the Gastrocnemius veins to the:
Posterior Tibial Veins* -16 constant perfs - 8 drain PTV known as Boyds/Cockett* - 4 perf drain Peroneal - 4 drain into Soleal and Genicular veins - thigh, 2 constant perf known as Dodd's group/Hunter*
How does the PTA run down the leg?
Posterior and Medial side of leg
What perforators play a major role in development of venous stasis ulcers?
Posterior arch vein, which has 3 perforators
The basilar artery divides into what?
Posterior cerebral arteries
What type of energy is represented by the intravascular pressure, which is supplied by contractions of the heart and is used to distend the vessels? Potential or Kinetic
Potential energy
Regarding lumbar sympathectomy, all are true EXCEPT:
Potentially useful in claudicating patients - is unlikely to help with claudication
This Doppler waveform was obtained from a Segmental artery w/in the KIDNEY in a Pt w/ severe HTN*. Which diagnosis is most likely?
Presence of IPSLATERAL MAIN RENAL ARTERY STENOSIS*** - Delayed Systolic Upstroke and Absence of Early Systolic Peak in waveform indicates PROXIMAL stenosis of greater than 60% in MAIN renal artery*** - waveform is termed TARDUS PARVUS
Presence of Mosaic pattern* in the color Doppler image of the ICA most likely indicates?
Presence of Poststenotic Turbulence* - mosiac pattern alerts of high grade stenosis or aliasing if PRF is set too LOW
Auscultation of the ABD, Aortoiliac, CF areas is important bc:
Presence of a bruit may be first indication of arterial disease** - hearing bruit is more significant than not hearing one
Which of the following conditions is ruled out by this image?
Presence of a paraumbilical vein*
What type of energy is stored energy and is the major form of energy for circulation of blood?
Pressure (Potential) Energy, measured in mmHg.
What can occur due to geometry change with or without intra-luminal disease and becuase of curves in vessels?
Pressure gradients (Flow separation), they occur in areas with stagnant or little movement.
When the valsalva maneuver is perform, what happens to the pressure within the thoracic and abdominal cavity?
Pressure in both cavities is increased causing total hault of venous return.
Where is pressure greatest in the arterial system?
Pressure is greatest at the heart, gradually decreasing as blood moves further away.
The key technology in Arterial Pneumoplethysmography is:
Pressure xdcr monitoring cuff PRESSURE over a limb
What form of Raynaud's is seen as ischemia due to digital arterial spasm and is commonly seen in young women?
Primary Raynaud's
Which artery supplies the small intestine, right colon, and transverse colon?
SMA
What is another name for the deep femoral artery?
Profunda Femoris
Which sign/symptom is least likely to be associated w/ arterial embolization?
Progressive claudication - associated w/ slow progression of atherosclerosis, not w/ embolization
ABD artery that normally demonstrates higher diastolic flow postprandially is:
SMA - after eating/post, vasodilation in the intesting reduces distal resistance
Greatest clinical danger from Venous Thrombosis is:
Pulmonary Embolism***
Gold Standard test for PE, though it carries its own risk for compromised Pts is:
Pulmonary angiography
The most reliable method for establishing the diagnosis of PE is:
Pulmonary angiography* - not taken lightly, but its definitive test
Most widely used interpretive technique for ANALOG Doppler waveform is:
Qualitative approach or pattern recognition* - analog is qualitative: assessing for presence or absence of characteristics, ie reverse-flow component
what is the most common tumor to extend into the renal vein
RCC (others: TCC, wilms, renal lymphoma)
In the situation in the previous question, pressure in the artery distal to the fistula will be
REDUCED!!! - there will be less pressure distally due to the steal across the fistula
53 yo M presents to Lab w/ 6 mo hx of severe HTN and ABD bruit. Which vessel is most likely the source of the Pt's symptoms?
RENAL ARTERY*
Doppler exam on Pt w/ suspected Renovascular HTN. Which diagnostic parameter is the best indicator of Renovascular Disease*?
RENAL/AORTIC RATIO (RAR)*** - Renovascular HTN caused by Renal Artery Stenosis* - Stenosis of the RA can be determined by RAR. - Ratio of the highest velocity in RA to normal velocity of AO obtained at the level of the RA origins. - Ratio of >3.5 is significant RA stenosis*** - Velocity would be 3.5x faster than aorta!
Performing a Doppler study on FMD* Pt, which of the following conditions is most commonly associated w/ this abnormality?
RENOVASCULAR HTN*** - FMD is condition in which artery has a series of small dilatations and narrowings that create the angiographic appearance of STRING of BEADS/PEARLS - FMD tends to affect younger, more females - Can affect renal arteries, tends to be located in Mid to Distal vessel ends. - Splanic vessels are uncommonly affected
What severe symptom of decreased blood perfusion is aggravated by elevation, relieved by dependency, and often occurs when the patient goes to bed at night?
REST PAIN*
Pt complains of digital pallor or cyanosis induced by cold exposure or emotional stimuli. These symptoms are characteristic of:
Raynaud's phenomenon
Syndrome which recurrent digital vasospasm* occurs in response to cold exposure or stress is:
Raynaud's syndrome*** - Vasospastic disorder most commonly occurs in Females following exposure to cold or emotional stress* - characterized by profound skin pallor & numbess - cyanosis occurs w/ warming of digits, then erythema follows, accompanied by burning pain
What's an alternative method for stressing the peripheral circulation, for patients with PVOD, ones that use a cane or walker, have pulmonary problems, or bad heart? An how does it work?
Reactive Hyperemia, which is done by inflating bilateral thigh cuffs to suprasystolic pressure levels and maintianing the pressure for 3-5 minutes. This produces ischemia and vasodilation distal to the occluding cuffs.
This image was obtained just below the Inguinal Ligament in a 37yo F w/ leg swelling. Which of the following accurately describes the US findings?
Reactive Lymph nodes*
Which vessels would be the most difficult to coapt w/ probe compression in cross section?
SFV at the Adductor Canal* - easier to compress with 1 hand behind the leg and press up while pushing down w/ probe - color can confirm patency too
A patient with chronic venous insufficiency complains for sudden onset of edema and pain in the affected leg. This may be related to:
Recurrence of acute DVT - sudden onset of new symptoms must be taken seriously *
What does erythema mean?
Redness seen with an inflammatory process
Audible Doppler venous signals typically are low-freq & vary w/ respiration, whereas normal arterial signals in the legs & arms are:
Relatively high frequency w/ Pulsatile components - do not change w/ respiration
Patients suspected of having venous disease may complain of pain that is:
Relieved by elevation - elevation of extremities decreases venous hypertension and pain
This waveform was most likely obtained from which abdominal vessel?
Renal Vein*
Arteriography is contraindicated in a Pt w/ which condition?
Renal failure
Arteriography would be contraindicated or approached very cautiously in a PT with:
Renal failure*** - contrast can cause severe complications in compromised renal functions
What is the mechanism for hypertension?
Renal ischemia triggers the release of renin and a secondary increase in BP. Renin converts angiotensin I into angiotensin II, which causes severe vasoconstriction.
A validated laboratory index for detection of significant renal artery stenosis is:
Renal stenosis/aorta peak systolic velocity ratio > 3.5 -
Give examples of low resistive abdominal vessels?
Renal, celiac, hepatic, and splenic arteries.
Performing a Doppler exam on a Pt w/ suspected Renovascular HTN. Which diagnostic parameter is the best indicator of Renovascular disease?
Renal/Aortic Ratio RAR*** - renovascular htn is caused by renal artery stenosis. Stenosis of the renal artery can be determined by obtaining a RAR. This is a ratio of the highest velocity obtained in the renal artery to the normal velocity of the AO obtained at the level of the renal artery origins. A ratio of > 3.5 is considered significant renal artery stenosis. this would mean that the velocity in the renal artery is 3.5X faster than the velocity in AO***
Vessels involved in regulating blood flow are called the what vessels, also known as arterioles?
Resistance vessels
If your blood pressure rises, how will your resistance vessels responed?
Resistance vessels will constriction
Which statement is TRUE regarding measurements obtained from this waveform?
Resistive Index would be erroneously high***
Which of the following is/are TRUE regarding AXIAL resolution in Carotid imaging?
Resolves 2 targets positioned 1 in front of another along the axis of beam propagation & improves the observer's abiltiy to estimate vessel wall thickness
Normal arterial VOLUME waveform may have all EXCEPT:
Reverse flow component: is part of arterial Doppler not volume waveform, does NOT have zero baseline! - swift upstroke, sharp peak, rapid downslope bowed toward baseline, dicrotic notch
For Duplex evaluation of the LE veins, the pt should be positioned:
Reversed Trendelenburg*** - bed tiled 10-20 degrees w/ feet lower than head - promotes pooling of blood w/in vein, enlarging them, visualize easier*
What is the most likely explanation for this waveform, which is obtained in prox LICA of 62 y.o?
Reversed flow in stump proximal to ICA occlusion*
Which of the following accurately defines RIND, also called Stroke with recovery?
Reversible ischemic neurologic deficit that completely resolves w/in 24 hrs. - unreversible is CerebroVascularAttack CVA
What predicts when fluid becomes unstable?
Reynolds Number (Re)- >2000 is the point when laminar (stable) flow turns into turbulent (disturbed) flow
A Pt presents w/ swollen rt LE. Duplex imaging demonstrates patency of the femoral, popliteal, calf veins. However, Doppler at the CF level on the Rt is continuous, not changing w/ respiratioin, while Doppler of the Lt CFV is phasic. These findings might suggest:
Rt Iliac thrombosis - if respiratory pressure changes aren't transmitted to the LE venous signals, be suspicious of proximal obstruction*
What vessel courses posterior to the IVC in abdomen?
Right renal artery, which is usually longer and slightly higher than left renal artery.
The Superior Vena Cava is formed by the junction of the:
Rt & Lt Brachiocephalic veins - also called rt & lt innominate veins, brachiocephalic vein turns into the subclavian at the junction of the Internal Jugular vein
Determin the ABIs from the segmental pressure study: Rt Segment Lt 155 brachial 148 101 high thigh 100 98 above knee 98 89 below knee 89 87 ankle 88
Rt 0.56, Lt 0.56*** - 87/155, 88/155
The Rt high-thigh pressure measurement is 108 mmHg, while the Lt high-thigh is 142 mmHg. Brachial pressure is 122 mmHg. Of the following, this most likely suggests:
Rt Femoral Artery obstruction
Rt handed pt presents w/ expressive Aphasia and Left paresis. Obstruction of which vessel most likely responsible?
Rt ICA* - Rt handed, Lt hemisphere is dominant. Lesion in Lt MCA may cause Dysphasia/Aphasia -Lt handed, Rt hemisphere is dominant. Lesion in Rt MCA produce symptoms. -Paresis (weakness/paralysis) on 1 side of Body result from atherosclerotic lesion in OPPOSITE SIDE!*
The great vessels arising from the AO arch include all of the following EXCEPT:
Rt Subclavian artery* - Innominate - Lt CCA - Lt Subclavian
What word (color) suggests dilated vessels secondary to reactive hyperemia; skin is reddened?
Rubor
In normal study, the Ankle Systolic Pressure should be:
SAME or GREATER than the Highest Brachial Pressure*
The ability of a noninvasive test to DETECT disease when it IS PRESENT is termed:
SENSIVITY*** - Calculation: TRUE Positives / True Negatives + False Negatives
What does the CFA divide into?
SFA and DFA (profunda)
Your segmental pressure readings indicate 126 mmHg high-thigh, 144 at low thigh, 120 at below-knee level. These findings might be the result of all EXCEPT:
SFA obstruction - low thigh reading of 144 is reverse gradient!, usually artificat problem: cuff application, incompressible due to calcification - obstruction would expected to decrease low-thigh pressure
Location of the Arterial anastomosis of the Native common hepatic artery to the Donor hepatic artery in Liver transplants is:
Several centimeters PROXIMAL to the HEPATIC HILUM**
Vasospasm* is demonstrated Arteriographically as:
Severe narrowing of the Arterial Lumen*
In B-mode pic, the arrow is pointing to dark area which is caused by?
Shadowing from Calcified Plaque*
Normal Doppler waveform morphology for a peripheral artery includes:
Sharp upslope & downslope & prominent REVERSE flow component***
What is the Tibioperoneal Trunk?
Short segment between ATA branch and branches of PTA and peroneal arteries.
Portal vein carries blood INTO (hepatopetal flow) what exact part of the liver?
Sinusoids
which renal artery branches off the aorta first
right; it also passes posterior to the IVC
Laminar Flow is the even distribution of frequencies at systole: where are lower frequencies found in laminar flow? where is the fastest moving flow?
Slow flow is near vessel walls, with the fastest flow in the centerstream
The Valsalva maneuver:
Slows down or stops venous flow everywhere in the body*** - increases pressure w/in both intraabd and intrathoracic cavity, venous flow everywhere in body diminishes or ceases. This helps to distinguish pulsatile venous signals from arterial signals
The SMA is located 1cm below the celiac trunk and supplies what?
Small Intestines, cecum, and parts of colon,
Which is NOT a risk factor for DVT?
Smoking - cancer, surgery, Age, bed rest are risk factors
Whats some MAJOR risks factors for atherosclerosis?
Smoking, Family history, and hpyerlipidema. (Less impt factors: HTN, diabetes, sedentary (lazy/unhealth) lifestyle, and arterial wall shear/stress.
After the initial dose of Heparin, the current standard of treatment for DVT consists of placing the Pt on the following medication for 3 or more months
Sodium warfarin - COUMADIN is drug of choice for long term anticoagulation after initial treatment of HEPARIN*
In the lower extremity, most common place for thrombus begins in:
Soleal Sinuses*** - soleal veins are located in Calf w/in soleal muscle are most common site, - don't communicate with superficial venous system, - empty into peroneal or PTA
In between what 2 muscles are the lower extremity Venous sinuses located?
Soleal and gastrocnemius muscles
What veins in the body dont have valves?
Soleal sinuses, IVC, SVC, Innominate, Common Iliac, Internal iliac, and the External iliac has valves 25% of the time
Varicose veins are best visualized w/ the patient in which position?
Standing
Which position would result in the Greatest Hydrostatic pressure?
Standing - Varies with position, pressure exerted by fluid w/in a closed system, such as oil in pipeline or blood in circulatory system. - In supine position, there's virtually NO Hydrostatic pressure
What organs does the celiac trunk supply?
Stomach, Liver, Pancreas, Spleen, & Duodenum
The Vertebral artery usually arises from the:
Subclavain artery
Which vessel normally exhibits a Triphasic Waveform*?
Subclavian Artery***
In Transcranial Doppler, w/ the probe placed in the Foramen Magnum window, flow TOWARD the probe in the VA is indicative of:
Subclavian Steal*** -flow in intracranial VA moves AWAY from the probe, this results in a negative Doppler shift
The internal mammary artery is a branch of the
Subclavian artery
The vertebral and internal mammary arteries are branch of what?
Subclavian artery
What event results in retrograde flow in ipsilateral vertebral artery?
Subclavian steal/occlusion
What is formed by the confluence of axillary and cephalic veins?
Subclavian vein
Internal Mammary Artery* is a branch of which of the following arteries?
Subclavian*
What 5 arterial vessels in upper extremities are evaluated in arterial study?
Subclavian, axillary, brachial, radial, and ulnar.
The radial artery branches to form what part of the palmar arch?
Superficial palmar arch
This waveform from the Left Vertebral artery is:
Suggestive of developing Subclavian steal - developing abnormal pressure gradient in the left arm is pulling flow below the baseline at systole, the flow reverts to antegrade in diastole (to/fro pattern) this might be converted to a full steak by performing reactive hyperemia on the left arm or having pt exercise to increase demand
Test on the aforementioned Pt is repeated, this time w/ a tourniquet around leg just below the knee. There is NO appreciable CHANGE in the tracing. Finding:
Suggests DEEP valvular incompetence - tourniquet eliminates the influence of superficial system - if tracing reverted to NORMAL w/ tourniquet, the superficial system would then be implicated
What is represented on this waveform from a Lt Vertebral artery
Suggests Transitional Vertebral STEAL** - Flow is pulled RETROGRADE during systole, then reverts to ANTEgrade during Diastole. This suggests a changing abnormal pressure gradient caused by the progression of PROX Subclavian Artery obstruction.
In a reflux study, the examiner images the Pop V, notes venous color flow display lights up blue w/ calf compression, then RED 2-3 sec on release:
Suggests VENOUS REFLUX*
Which of the following vessels joins the Brachial Veins to form the Axillary Vein*?
Superficial Basilic vein* - begins at Ulnar side of forearm, - crosses ventrally at Antecubital region - lies medial to Brachial in upper arm
The arterial pulsations felt in front of the ear and just above the zygomatic arch are from which artery?
Superficial Temporal
Which superficial vein is NOT commonly used as a bypass graft?
Superficial femoral vein - not superficial, its deep vein
To obtain digital pressures of the toes, how should the pt be positioned:
Supine - head can be elevated 10-20 degrees
When taking ankle pressures, the Pt should be:
Supine - supine in resting state
To obtain Segmental pressures of the LE, the Pt should be positioned?
Supine w/ the LE @ the SAME level as the HEART**
Dysphagia is a:
Symptom associated w/ VB Insufficiency - Difficulty swallowing
A Baker's cyst is a collection of
Synovial fluid from the knee joint
In a waveform, this part of the wave is the upward stroke and represents ; forward flow throughout the periphery
Systole
Arteritis* most commonly affecting the Subclavian, Renal, Carotid, and ascending Aorta in which more than 95% of Females pts:
TAKAYASU'S ARTERITIS* -chronic inflammatory process primary affects aorta & major branches - stenosis tend to be long, tapered/smooth in 2/3rd decade of life - HTN due to involevement of Renal Arteries - Stroke is presenting symptom - US finding include homogenous segmental wall thickening, termed "macaroni" sign in TX - associated w/ increased flow velocity thru affected area - cerebrovascular involvement, homogenous segmental wall thickening limited to CCA and Subclavian arteries - Not uncommon to find occlusion of CCA w/ reversed flow in Ipslateral ECA to patent Ipslateral ICA
What type of velocity is measure with Transcranial Doppler? Peak velocity or Time average maximum velocity (TAMV) or Mean velocity?
TAMV or Mean velocity
Amaurosis Fugax can be interpreted as a:
TIA - TIA of the eye
Neurologic symptoms that are short duration, completely resolving in less than 24hrs are termed?
TIA (Transient Ischemic Attack)* - RIND last longer than 24hr, completely resolves - CVA (cerebrovascular accident) is completed stroke, results permanent damage
what is a method of treating portal HTN
TIPS- transjugular intrahepatic portosystemic shunts
What is the TMVA and the mean velocity for the MCA?
TMVA = 55 +/- with the mean velocity = 12cm/s
What is referred to as the TRAM flap and what is it used for by surgeons?
TRAM- Transverse Rectus Abdominis Myocutaneous Flap, which consist of the rectus abdominis muscle, sub-q fat, arteries, perforators, and overlying skin. Surgeon's use the TRAM flap for autogenous breast reconstruction.
Which set of waveforms is most likely to be obtained w/ a continuous wave doppler when there is a long superficial femoral artery occlusion?
TRIPHASIC waveform at the CFA, SFA Prox with MONOphasic in POP & tibial arteries*** - usually triphasic, occasionally mono, Staccato-type may be seen proximal to occlusion in SFA!!!!
Which term can be used to describe this "Dampened" signal waveform?
TRIPHASIC*
On ophthalmologic exam, bright yellow spot is noted w/in branch artery. This is a Hollenhorst plaque, True or False?
TRUE: these pts have 75% risk of TIA or stroke over the next several yrs
Condition that causes nonatherosclerotic narrowing of Brachiocephalic Arteries in overwhelmingly female PT is called:
Takayasu's arteritis***
How many minutes does it take the ABI's to increase back to resting levels in a patient with single level disease?
Takes 2-6 minutes
How many minutes does it take the ABI's to increase back to resting levels in a patient with Multi-level disease?
Takes 6-12 minutes
Which of the following would alter the freq shift of the ICA Doppler signal?
Tapering of the vessel from the bulb to the distal visualized segment & increasing the transmitted freq - anatomic narrowing can increase the velocity, increasing the operating or transmitted freq will increase the freq shift/doppler equation. - Readjusting angle-correct will change velocity but not shift itself , threshold sensivity doesn't affect freq shift
What term can be used to describe this waveform?
Tardus Parvus*** - delayed systolic upstroke and absence of early systolic peak in waveform, indicated proximal stenosis of greater than 60%
What is the dampened, weak signaled waveform called, that results from renal artery stenosis/occlusion?
Tardus-parvus
How is the Allen test performed?
Tech compresses patients radial artery while the patient clenches fist for at least a minute or until pallor. Then the patient relaxes hand while the tech continues to compress radial artery. A normal finding would be to see color return; an abnormal finding would be for the color not to return which would either mean an ulnar artey occlusion or palmar arch obstruction.
The TCD window used for assessing the MCA is:
Temporal
Amaurosis fugax related to an Internal Carotid lesion will cause:
Temporary blindness or shading of the iplslateral eye
What does Amaurosis fugax mean?
Temporary, partial or total blindness, usually in one eye.
Where does the radial artery terminate? (Just remember that the ulnar branch and termination is opposite of the radial artery)
Terminates in the deep palmar arch
The term PHASICITY**, in reference to the venous system, refers to:
The EBB and FLOW in the VEINS that occurs in response to RESPIRATION***
Ankle/Brachial index is calculated by dividing the ankle pressure by:
The HIGHEST of the 2 Brachial pressures*
Reynolds number*** describes:
The Pt at which FLOW becomes TURBULENT* - Equation RE=Vq2r/ n V=velocity, q=fluid density, r=vessel radius, n=fluid viscosity - Turbulence occurs when RE>2000* since fluid density and viscosity are constant - Velocity and Vessel Radius* are most responsible for Turbulence!!!
All of the following statements apply to Pulsed Wave Doppler EXCEPT:
The beam is continuously transmitted w/ intermittent reception according to vessel depth is FALSE - signal is transmitted in short bursts/pulses, xdcr listens for reflected signal in btn the transmitted pulses
The term MUSCLE PUMP refers to:
The calf muscles
Arterioles are considered what type of vessels and assist in regulating what?
a. Arterioles are considered resistance vessels b. They assist in regulating blood flow through contraction and relaxation.
what waveform is present with RA stenosis
absence of early systolic peak and prolonged acceleration time (tardus parvus)-- dampened PSV distal to site of stenosis
what are the features of renal artery occlusion
absence of visible main renal artery, kidney less than 9 cm, absence of blood flow in the kidney, low amplitude and dampened waveform
What is needed to move blood from one point to another?
an energy gradient
What is one visible sign that you can differentiate a low resistant waveform from a high resistant waveform?
The reversal of flow seen in high resistant waveforms.
Iliac Vein thrombosis* most likely results in:
Unilateral Swelling of the ENTIRE LOWER EXTREMITY***
what occurs in the portal system in a patient with CHF
the main portal vein may demonstrate a doppler waveform that is bidirectional with pulsatile flow
You're using color flow to scan an ICA that dives steeply distally. The color gets much brighter, even aliasing, in the distal portion of the artery. This means:
The freq shifts are changing at different pts in the color box due to the curvature of the artery - One must be constantly on the alert for changing angles, which create potentially misleading color flow changes
What is the key to success when it comes to compression of pseudoaneurysms?
The key to success is whether aneurysm "neck" between native artery and pseudoaneurysm can be Uniformly and Completely compressed.
In this spectral display, the same PT has clenched his fist for 3 mins. What effect has the fist clenching had?
The exercise causes flow to become RETROgrade thru out cardiac cycle - exercise increases the demand in the arm, increasing the ABD pressure gradient, causing flow in the Vertebral artery to flow RETROGRADE thru out cycle. PT will not suffer any symptoms
A Pt presents w/ a unilateral chronic swollen leg and previous diagnosis of DVT 3 yrs ago. Most likely finding would be:
The popliteal is patent and valves are incompetent* - congestive heart failure will cause bilateral edema
What layer of the arterial wall contains the vasa vasorum? What is the vasa vasorum?
The vasa vasorum tiny vessels found in the adventitial layer of the arterial wall, that carry blood to the walls of the largest arteries.
Image of sag view of Rt VA origin (Rt Vertebral Stenosis), both subclavian and prox vertebral artery are demonstrated. the line is pointing to what vessel?
Thyrocervical Trunk* - arises from Subclavian near origin of VA -VA originates from posterior aspect of Subclavian artery, whereas Thyro trunk originates from anterior aspect - follow VA to transverse process* to differentiate since thryo doesn't enter the spine, instead courses medially
The CCA divides into its external and internal branches usually at the level of the upper border of the:
Thyroid cartilage
The prominence of the larynx is form by the
Thyroid cartilage (thyroid cartilage forms a prominenc that is especially visible in tall, thin, socially awkward males)
This is a TX image from the Mid calf. Name the bones labeled A-B
Tibia* Fibula*
Paresthesia refers to:
Tingling sensation
What is Radial artery mapping used for?
To determine suitability for use as graft for coronary artery bypass.
What segmental pressure is more reliable to use than the ankle pressure in diabtetic patients?
Toe pressure
What are some things that can cause falsely elevated velocities during a carotid exam?
Tortuous vessels, cardiac output, compensatory flow, an inappropriate Doppler angle.
Signs that a general practitioner may use in an attempt to diagnose DVT include all of the following EXCEPT:
Tourniquet test (used for superficial venous incompetence) - Homan's sign ( passive dorsiflexion of foot); useless - Bancroft's sign ( anteroposterior calf compression) - Lowenberg's sign (inflating a sphygomomanometer to 80 mmHg on calf - physcial finding of edema; useful finding**
A Popliteal to Dorsal Pedal Lesser Saphenous Reverse Bypass Graft has a peak systolic velocity of 28 cm/sec at the distal anastomosis. Which of the following is true?
Velocity may be normal - 45 cm/sec threshold for graft failure*** - 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
Which testing device would be most useful in evaluation of Arterial Vasospasm following Subarachnoid Hemorrhage*?
Transcranial Doppler* - 1 of the most widespread applications is evaluation of onset, severity and time course of Arterial Vasospasm caused by Subarachnoid Hemorrhage*
The abbreviation TIA stands for:
Transient Ischemic attack
A normal ankle-pressure response to reactive hyperemia is:
Transient decrease of approximately 20% - decrease normally brief, pressures taken immediately on thigh cuff deflation
The pressure within the vein versus pressure outside the vein is called what type of pressure?
Transmural or Distention pressure
What are the three acoustic windows used with transcranial Doppler?
Transtemporal, Transorbital, and Transforaminal (suboccipital)
Percentage Diameter and Area Reduction are most accurate when obtained in which imaging plane?
Transverse - percent stenosis measurement from sag/coronal are easily over/underestimated bc atherosclerotic plaque is typically symmetric. sag slice obtained thru greatest dimenstion of symmetric plaque will overestimate percentage stenosis, whereas sag thru small dimenstion of plaque underestimate
US findings in LE of Pt who has undergone Cardiac Catherization include LOW Resistance, High Velocity flow in CFA and Pulsatile flow in CFV. Prominent Bruit is present, these findings are associated w/?
Traumatic AVFs** - Fistulas occur as complications of Arterial Puncture! - When fistula is present, arterial flow will be preferentially shunted into LOW pressure venous system - This causes pulsatility in downstream component of affected Vein. - Arterial flow is coursing directly into Low resistance venous system - Increased Diastolic flow and high velocity will be seen in artery proximal to fistula
The test of venous incompetence that uses tourniquet and alteration of Pt position is called:
Trendelenburg test
Abnormal Portal Venous waveform* may be indicative of:
Tricuspid Regurgitation (TR)**
Which term or terms can be used to describe the Normal Waveform of the Hepatic Veins*?
Triphasic*
A venule contains which vessel layers?
Tunia adventitia & tunica intima only
Which layer of the arterial wall is made up of fibrous connective tissue?
Tunica externa / outer layer (adventitia)
Thin inner layer of the artery; consists of smooth endothelium, base membrane, connective tissue.
Tunica intima
The layer of arterial or venous wall composed entirely of endothelial cells is the:
Tunica intima*
What is the inner thin layer of the arterial wall called?
Tunica intima, which consists of smooth endothelium and connective tissue
Thicker middle layer of the artery; composed of smooth muscle and connective tissue
Tunica media
What layer of the arterial wall is thickest and made up largely of elastic type of smooth mucsle and connective tissue?
Tunica media / intermediate layer
What error could result from the technical problem shown? (incorrect Doppler angle)
UNDERestimation of Peak Velocity* - misalignment of Doppler angle will result in inaccurate velocity calcs. - if measured angle is smaller than actual angle, velocity will be underestimated - if measured angle is larger than the actual angle, velocity will be overestimated
A 46 yo M comes to vascular lab w/ calf and akle edema, mild discomfort in calf, soft mass behind the knee. CW studies are negative except for some continuous flow over the POPliteal vein. Additional test that might be useful is:
US imaging - PT has classic symptoms of a Baker's cyst! CW signal likely be result of extrinsic compression of the vein***
Angiogram shows an embolus lodged in the RMCA. The source of the embolus could be from:
Ulcerated plaque in RICA and nonvalvular Atrial Fibrillation - ECA doesn't feed MCA* - ulcerated plaque in ipslateral internal/cca may travel into MCA - Cardiac Disease poses risk for embolic stroke, nonvalvular A fib, vegatations on valves can produce emboli****
The brachial veins connect the:
Ulnar & radial to brachial to Axillary veins*
The Deep Palmar arch is a branch of the?
Ulnar artery
What vessel is the predominate source of blood flow to the hand come from?
Ulnar artery
The technical problem demonstrated in this waveform could result in which of the following errors? "aliasing"
Underestimation of PSV***
All of the following are RISK FACTORS for development of Atherosclerotic disease EXCEPT***:
Underweight - Diabetes - Male - HTN - Age, Smoking, Obesity, Family HX
Advantages of angiography over duplex carotid studies include all EXCEPT:
Unlimited repeatability
Most effective lytic treatment for acute arterial thrombosis is:
Urokinase/streptokinase - are thrombolytic agents
Asked to perform Saphenous Vein mapping, which of the following techniques would be most helpful?
Use HIGH Freq probe & "light" probe pressure to track the Saph vein - H.F. Linear array probe bc its very superficial - very light probe pressure bc its easily compressible - veins will be small, hard to see with cold room temps - supine position w/ leg externally rotated, knee slightly bent
Which of the following techniques would be most helpful in mapping the Saphenous vein?
Use HIGH freq probe & Light probe pressure to track saph vein - high freq linear array probe used bc vein is very superficial, easily compressible, room temp warm in supine position
Points of technique to be observed during US guided compression of pseudo aneurysm include all EXCEPT:
Use color flow to confirm that flow remains biphasic w/in the pseudo aneurysm - US guided thrombin injection looks promising at press time & may eventually replace this strenuous procedure - Monitor ankle pressure, use color flow to monitor flow in CFA, release pressure for a short time at 10-15 min intervals, use color flow to confirm that flow is obliterated in pseudo
Radioisotope test for PE that involves both breathing and injection of the isotope, and is usually reported in "high, medium, low probability" of PE is called:
V/Q scan
Peripheral Resistance* is controlled by:
VASOCONSTRICTION & VASODILATION OF THE ARTERIOLES***
Lower extremity ulcers are overwhelmingly the result of:
VENOUS DISEASE*** - 3/4 of LE ulcers are caused by Chronic venous insufficiency!!!
Nuclear medicine screening test that detects perfusion defects of the lungs is known as:
VQ (ventilation quotient, aka ventilation perfusion) scan
The Arrows in this image point to:
Valve leaflets*
What are Avalvular veins?
Valveless veins
Detection of venous flow w/ compression proximal (closer to the heart) to the probe indicates:
Valvular incompetence w/ REFLUX b/n the Augmentation and the Doppler interrogation*** - If augmentation of the Doppler signal occurs w/ proximal limb compression, then blood flow is being forced backward thru the vein under examination. - If there is a valve b/n the 2 pts, valvular incompetence and reflux are indicated!!!
Descending venography is performed to diagnose:
Valvular insufficiency - Ascending defines location and extent of venous obstruction - Descending identifies specific valvular incompetence - trick: IVC has NO valves
As the inflow pressure falls as a result of stenosis, what is the natural response of the periphery vessels? Vasodilate or vasoconstrict?
Vasodilate
In the presence of arterial obstructive disease & distal ischemia
Vasodilation increases, distal resistance decreases - body increases BF by vasodilation, decreasing peripheral resistance. drop in distal pressure is result of increased segmental resistance, stealing of blood to large muscle groups
Uniform forearm cephalic vein measuring 2mm in diameter during US imaging is being considered for a pop tibial bypass:
Vein might be used bc the graft diameter is 2mm & might expand under pressure - surgeon prefer 3mm or larger, but some institution might use 2mm
What vessels are accessed with transforaminal/subocciptal approach?
Vertebral and Basilar arteries
Basilar artery is formed by the confluence of what arteries?
Vertebral arteries
What is firts branch of the subclavian artery?
Vertebral artery
Simultaneous bilateral ocular symptoms in the Pt w/ suspected Cerebrovascular disease generally originate from:
Vertebrobasilar arteries
57 yo female presents w/ Rt Leg and Lt arm numbness. These symptoms are associated with?
Vertebrobasilar* obstruction - BILATERAL symptoms of weakness or numbness are commonly associated with VB disease. - Other symptom include Diplopia, Bilateral visual blurring, hoarseness, Dysarthia, Dysphasia, Ataxia, dizziness, Vertigo, Drop attacks are not considered symptoms of FOCAL VBD unless associated w/ other symptoms.
Which of the following is a Vertebrobasilar symptom?
Vertigo -bilateral or global symptoms are likely from VB system
Ischemic ulcers/lesions*** are:
Very painful & commonly located distally over the dorsum of the foot*** - ulcer found above medial malleolus is venous in origin
What factor has the greatest influence on flow resistance?
Vessel Radius*
The RESISTANCE to FLOW offered by the fluid in motion is termed:
Viscosity
Viscosity measures what of a fluid?
Viscosity measures the thickness of a fluid.
What type of energy loss is due to increased friction between molecules and layers?
Viscous energy loss
What does plethysmography measure?
Volume changes
What 2 things are reduced in a significant stenosis?
Volume flow and Pressure are both significantly reducted
The end diastolic portion of this ECA waveform is not demonstrated on this image bc:
WALL FILTER is set TOO high***
The most common site for bypass graft pseudoaneurysms to occur?
Would be the CFA in the groin at the outflow of a prosthetic aortofemoral or femoro-femoral crossover graft
On the Spectral display, time is displayed on the:
X axis
Performing a CW Doppler on a Pt's LEA. Obtain a signal at the Prox Dorsalis Pedis level. Move proximally, signal becomes higher pitch. This could be result of all EXCEPT:
You have stood the probe up, increasing the angle of incidence - increasing the angle of incidence would lower freq shift
During a cerebrovascular exam, you obtained equal brachial systolic pressures bilaterally. During the scan, you obtain this pulsatile signal from b/n the transverse processes. You move the beam to the CCA, the waveform is below baseline.
You should ask Pt to perfrom Valsalva maneuver - Vertebral venous signals can be quite pulsatile. May help to swing up for CCA signal to establish which directioin is antegrade to make sure
Which of the following describes the Basilic veins*?
a Large Single Vein located near the Brachial Vein - superfical unpaired vein
what is budd chiari syndrome
a hepatic vein obstruction
how is the stenosis visualized within a TIPS
a high velocity flow less than 50-60 cm/s is a clue the shunt is malfunctioning, flow increasing to more than 100 cm/s is indicative of stenosis
what will doppler demonstrate with hep v obstruction
a lack of flow in the hepatic veins at the site of the occlusion and collateral pathways that don't follow the usual vsculature course. A bicolor flow in the hepatic veins (one branch blue and the other red) is a good indication of proximal vein occlusion and distal patency, caudate veins enlarge greater than 3mm (specific to budd chiari in the absence of CHF)
What order is segmental pressures taken?
a. Brachial (upper arm) b. Ankle (use PTA or DPA; peroneal A. only if necessary) c. Calf (BK) (Use PTA or DPA-that had highest pressure) d. Above knee (AK) (Same as above-may need to use pop) e. High Thigh (HT)
What are some things you can do to increase your PRF/Nyquist limit?
a. Decrease baseline b. Increase Doppler scale c. Change transducer to Lower frequency d. Decrease Depth e. Alter angle of insonation or use CW Doppler
What are some indications for preoperative vein mapping?
a. Extremity or coronary artery bypass b. Use in dialysis access/graft
What are the 3 components that are needed to acheive a successful bypass graft?
a. Good Inflow b. Conduit c. Outflow
What are 2 situations that you cannot use the (RAR) renal to aorta ratio?
a. If AAA is present b. If aortic PSV >90cm/s or <40cm/s
What are signs of rejection of a renal transplant?
a. Increased renal transplant size b. Increased cortical echogenicity c. Increased renal arterial resistance
Name the three branches of the aortic arch?
a. Innominate artery/ Brachiocephalic (branches into rt. cca & subclavian) b. Lt CCA c. Lt Subclavian artery
What veins do you map for LE and UE?
a. LE- GSV b. UE- Basilic and Cephalic veins
What are the three branches of the celiac trunk?
a. Left Gastric artery b. Splenic artery c. Common Hepatic artery
What is a PTLA (Percutaneous Transluminal Angioplasty used for and how is it done?
a.Angioplasty is used to dilate focal plaque formation in a vessel. b.Same technque used as arteriography, except a balloon tipped catheter is used under fluoroscopy to region of stenosis, where the balloon is slowly inflated, pushing plaque against walls of vessl, dilating artery lumen.
What type of pharmacologic agents can be used to help treat arterial vessel issues?
a.Any medication that helps decrease blood viscosity, like aspirin, which is an antiplatelet drug that decreases platelet aggregation, resulting in decreased thrombotic activitiy. b. Antihypertensive drugs may serve to decrease shearing forces against vessel walls.
Whats the normal velocity of the SMA? Abnormal?
a.Normal = 110-177 cm/sec b. Abnormal = >or equal 275 cm/sec (> or = 70% diameter reduction)
Whats considered a normal renal to aorta ratio?Abnormal?
a.Normal = < 3.5. b.Abnormal = > or equal to 3.5
What are the 2 branches of the ICA? What type of vascular beds does the ICA feed?
a.Ophthalmic artery and posterior communicating artery b. Low Resistant vascular beds
How is single vs multi-level disease determined with the use of reactive hyperemia?
a.Single level has < or =50% drop in ankle pressure b.Multi-level has >50% drop in ankle pressure. c. Normal limbs may show a transient drop of 17-34%
what is a fistula
abnormal connection between RA's and RV's
what will grey scale indicate with budd chiari
an echogenic intraluminal material possibly a thrombus or tumor invasion (such as a hepatoma)
What does the subclavian artery become?
axillary
what is the origin of the portal vein
begins at junction of splenic and SMV immediately posterior to pancreas neck and courses superior to the right and passes posterior to the first portion of the duodenum and terminates at the porta hepatis
where do most IVC anomalies occur
below the renal veins (duplication, transposition)
what do you want your sweep speed to be for renal doppler
between 2-3 seconds (max of 3 wave forms)
where does the left hep v run
between the medial and lateral segments of the left lobe
where does the middle hep v run
between the right and left lobes
what are causes of PVG
bowel ischemia, diverticulitis, appendicitis, bowel distention, bowel obstruction, ideopathic
what does the sma supply
branches supply the jejunum, ileum cecum, ascending colon, proximal 2/3rds of the transverse colon, portions of the duodenum, and the pancreatic head
what are the normal velocities of the sma postprandial
broad PSV ranges
This US image shows an ICA with:
calcified plaque
what are features of median arcuate ligament syndrome
can be treated surgically with lysis of the arcuate ligament.. patient will present with nausea, abdominal pain, vomiting, and weight loss.
All of the following are consistent w/ total occlusioin of the ICA EXCEPT:
can't be purely RETROGRADE Flow in the Distal ICA, can have eddy currents though - absence of flow in ICA lumen - decreased velocity proximal to occlusion - increase in flow thru collateral pathways - inability to be reconstructed surgically!!!
The absence of a bruit at the Common femoral level:
can't rule out significant stenosis at that level** - bruits heard on physical exam are useful, although absence doesn't rule it out, but does suggest stenosis if present
whats the most common cause of portal HTN in the U.S.
cirrhosis
what causes fibrosis cavernous transformation associated with portal vein thrombosis
complete occlusion of the vessel--appears as a group of tortuous vessels in the porta hepatis 6-20 days after an acute occlusion
what is the sma compression syndrome characterized by
compression of the third or transverse portion of the duodenum against the aorta by the sma which results in chronic, interittent, or acute complete or partial duodenal obstruction (Women age 41)
Which of the following is NOT a predisposiing factor for development of Venous Thrombosis?*
daily use of aspirin - pregnancy - trauma/bone fracture - stasis/long flight - Virchow's triad!*
what effect do collaterals have on portal HTN
decompress the pressure in the liver and allow forward flow in the portal vein. If there are spleno renal collateralys their flow in the portal vein may e reverted. An umbilical vein collateral the splenic and portal vein may show hepatopedal flow. You may also see a reversed flow in the right portal vein with normal flow in the left portal vein
Increasing viscosity
decreases velocity
how does the diameter of the vessel indicate portal HTN
diameter greater than 13 mm, also eval splenic v and SMV (if they increase greater than their normal 70-100% with inspiration) =diagnosis confirmed
what are the 5 things to look for sonographically when detecting Portal HTN
diameter, vasc response to HTN, portal vein flow direction and velocity, size of the spleen, collaterals
Radius of a vessel is ____related to proportional volume flow
directly (remember diameter change has the most dramatic effect on resistance; small changes in radius may result in large changes in volume flow)
What makes up the superficial palmar (volar) arch?
distal portion of the ulnar artery and branch of the radial artery
what should be evaluated with a renal doppler exam
echogenicity, thickness of parenchyma, length, signs of scarring, hyrdro, or masses, a discrepancy of 2 cm or more between the kidneys is significant, eval son app of aorta's entire length for plaque aneurysm and echogenicity, eval each vessel with color and spectral for resistance, stenosis, and occlusions, measure wave form
where does the splenic artery terminate
ends as branches in the splenic hilum
what effect does CHF have on the hepatic veins
engorged with increased pulsatility
what may be mistaken for neoplastic masses if color is not used
esophagogastric junction collaterals
what is the most common location for tumor extension
from the renal vein into the IVC
how does the flow appear in a recannalized paraumbilical vein
hepatofugal (100% indicative of portal HTN)-- should exceed 5 cm/s
what is the normal flow of the hepatic veins
hepatofugal flow that is chaotic pulsatile flow pattern from transmission of RA pulsatations
what are clinical signs of budd chiari
hepatomegally (due to liver congestion), abdominal pain (due to hepatomegally), ascites, Hepaocellular dysfunction (Labs), left and caudate lobes undergo compensatory hypertrophy
what is the normal flow of the PV system
hepatopedal (unidirectional forward flow) with subtle phasic variation produced by respiratory and cardiac hemodynamic effects and unidirectional; sounds like a windstorm
Ankle/arm index is obtained by dividing the:
higher of the 2 brachial pressures by ankle pressure
normal waveforms for distal aorta
higher resistance flow pattern
This US image shows an ICA with:
homogeneous plaque - echoes are soft and gray, same characteristic thru out
Ankle/arm index in claudicating Pts are usually:
in the range of 0.5-0.9
wheredoes the common hepatic artery lay
in the superior border of the pancreatic head, its the right branch of the celiac
what is the best way to evaluate the spenic artery
in the transverse plane from the anterior midline along the tail, eval distal from left lateral window at splenic hilum
what is a long term complication of renal artery stents
in-stent re-stenosis
What is the profile at a stenosis entrance?
increase in Doppler shift frequecies, resulting in spectral brodening and elevated velocities
what are the changes associated with chronic renal vein thrombosis
increased hypocortex, decreased RA size, increased echogenicity
what are flow findings associated with renal tumors
increased neovascularity, low resistance and high velocity waveforms (oncocytoma or RCC)
what is the son app of renal vein thrombosis
increased size, hypocortex and decreased corticomedullary differentiation, possible hypocortex with normal corticomedullary differentiation, mottled echogenicity with loss of normal intrarenal architecture
Diminishing vessel size_____ frictional forces and heat energy loss
increases
decreased viscosity
increases velocity
The incidence of pseudo aneurysm is
increasing - transluminal procedure increases, more iatrogenic pseudo
Locations of aneurysms:
infrarenal aorta (most common), thoracic aorta, femoral, popliteal, renal
what effect does inspiration have on normal hepatic vein flow
it causes a blunted appearance
how does the portal vein lay in relation to the ivc
it crosses anteriorly to the IVC
what occurs after the proper hepatic artery enters the liver
it divides into right and left branches
what is different about the anatomy of the right renal vein
it follows a much shorter course to the IVC with no tributaries
how does the splenic artery run
it follows a tortuous course long the posterior, superior pancreatic body and tail with several pancreatic and gastric branches
what is the course of the SMA
it has a short anterior segment then turns inferiorly and ends near the ileoceccal valve
where does the splenic artery originate
it is a branch off of the celiac axis
how does portal HTN effect the response to respiration
it is lost
what is the function of the portal venous system
it transports nutrient rich blood from the intestines and spleen to the liver
What doe the renal arteries supply?
kidneys, suprarenal glands and ureters
In a waveform, this is where the flow is forward again as reflective wave hits the proximal resistance of the next oncoming wave and reverses
late diastole
In a waveform, this shows temporary flow reversal, due to a phase shifted negative pressure gradient and peripheral resistance causing a reflection of the wave proximally (and it's under the baseline)
late systole/early diastole
Major branches of the PTA:
lateral and medial plantar arteries-branch below the medial malleoulus to supply the sole of the foot.
what is the median arcuate ligament
leaflet of the diaphragm that crosses the anterior aspect of the aorta just cephalic to the celiac axis. It can ompress and partially obstruct the celiac during expiration
which vessel oes retrograde flow occur in in 80-90% of portal HTN
left gastric vein (may cause esophageal varices)
What side of the forearm does the ulnar artery travel down?
medial
what are pitfalls of the mesenteric artery ischemia
median arcuate ligament syndrome (obstruction disappears with inspiration and returns with expiration); SMA compression syndrome
what are the features of a TIPS stent
metallic device used to create shunt or channel and easily visualized
Which of the following statements about Ao aneurysms is FALSE:
most prerupture AAAs are discovered bc of abd symptoms or distal emboli - rarely extend above renal arteries, gold standard is B mode US, CT scan gaining popularity - most are asymptomatic, discovered on routine exams
A congenital AVF involves
multitude of av channels - congenital fistual (aka AV malformation)***, usually has small channels from artery to vein - acquired/traumatic/dialysis fistula is single channel
what is the highest risk of stenosis and occlusion in a shunt later on
neointimal hyperplasia
what does the normal portal vein measure
no larger than 13 mm in diameter but increases with sustained deep inspiration (splenic and SMV can increase 50-100 percent in size with this). this response negates portal HTN
Potential complication of venography include all EXCEPT:
not IATROGENIC CVA, but there's: paradoxical stroke w/ DVT embolizing to arterial side thru patent foramen ovale in Rt atrial wall, thence to brain - allergic reaction to contrast, toxicity to kidneys, AVF, thrombophlebitis
what is the son app of portal vein thrombosis
nonvisualized vein, increased echoes within the vein, absence of flow within the vein
Which of the following represents a normal penile/brachial index (PBI)?
normal PBI is >0.75 based on highest brachial pressure
Which of the following would NOT be associated with Arterial Trauma?
not FibroMuscularDysplasia - FMD is a condition, series of small dilations and narrowings occurs in artery, creating angiographic pattern of "string of pearls" -Dissection: results from intima tear, caused by trauma or FMD, HTN, Marfan's syndrome - Hematoma: swelling caused by clotted blood resulting from blood vessel tear - Pseudoaneurysm: result from trauma, vessel tear w/ blood leaking, not confined by wall, track w/ bidirectional flow leading from artery to pulsing hematoma
Symptoms of acute arterial occlusion:
pain, pallor, pulselessness, paresthesia, paralysis, polar
The term HEMIPARESIS/unilater paresis means:
paralysis of 1 side
what causes the distal aorta to be more high resistive
peripheral resistance and due to the triphasic nature of the aortic branches (reversal during diastole)
what is the normal waveform for the renal veins
phasic flow patern (like IVC) -cardiac pulsatations close to the IVC
The best way to prepare a xdcr for intraoperative use is:
place xdcr & acoustic gel w/in sterile sleeve or bag
what can PVG mimic
poorly defined echogenic areas can look like hemobilia or parenchymal calcifications
what is PVG
portal vein gas - gas in the portal venous system
what does a unilateral finding of pulsatile flow indicate
possible acute renal obstruction or renal vein thrombosis
whats the most common cause of renal vein thrombosis
primary renal disease
This image is from the mid calf suggest
pronounced edema - dark space under skin, probably more chronic
What is the most common location of atherosclerotic disease of the renal artery?
proximal - tends to affect bifurcations of arteries, affected at origin from the aorta, proximal portion of vessel. FMD affects the mid to distal aspect of the renal***
what is the diagnostic criteria of a significant stenosis
psv greater than 180 cm/s, RAR greater than 3.3, damping, AI less than 300 cm/s, AT greater than 100 cm/s, unilateral decreased flow
what does indirect evaluation of renal artery stenosis provide
qualitative data and looks at shape of wave form
Rubor is defined as:
red skin color
what are the positive aspects of a shunt
reduces ascites, prevents collateral hemorrhage, and increased quality of life
What does the dicrotic notch represent?
related to closure of aortic arch and is influenced by peripheral resistance
what are the criteria for a renal artery stenosis
renal PSV divided by Aortic PSV > 3.3, turbulent low post stenosis, low flow velocity in the distal RA, AT > 0.07 sec, missing ESP, tardus parvus waveforms
what is the most correctible cause of HTN
renal artery stenosis
what is a common treatment for renal artery stenosis
renal artery stents
what is the most common cause of acquired fistulas
renal biopsy
what changes occur in the waveform with nonvascular renal disease
renal flow becomes high resistive, renal flow increases in pulsatility
what can renal vein thrombosis cause
renal ischemia, or acute renal failure
what is the most common acute renal finding
renal vein thrombosis
Noninvasive diagnosis of RENAL ARTERY stenosis:
requires duplex system w/ SPECTRAL signal analysis - imaging system is critical to assure that the correct vessel is being sampled
Transient Ischemic Attack:
resolves w/in 24 hrs
A Pt with a Pulmonary Embolus might have any of these EXCEPT:
rest pain (chronic arterial symptom) - chest pain, reduced arterial blood gasses, daiphoresis (sweats), shortness of breath, dyspnea, cough, syncope, tachycardia, cyanosis***
what occurs with azygos and hemiazygos IVC
results from failure of intrahepatic segment of IVC to form, flow is diverted to heart vi the azygos and hemiazygos veins and hep veins drain directly into the rt atrium
What do the common iliacs divide into?
right and left internal (hypogastric) and external iliacs
what should a pre-op sonogram of a TIPS include
should include documentation of flow and patency in the PV, SV, and SMV. Evaluate the liver as well. Location of hepatomas may change the plan for a shunt depending on the tumor's location
Little or no increase of Blood Flow velocity in response to POSTocclusive reactive hyperemia (PORH), using an inflated thigh cuff, would most likely indicate:
significant obstructive disease - normal PORH response is major velocity increase in mean velocity!
what occurs during right atrium diastole in the hepatic veins
slow forward flow from veins to IVC and eventually flow reversal
what are the sonographic features of PVG
small, mobile, echogenic reflections in the lumen of PV and branches, increased doppler signal due to the highly reflective gas bubble compared to a RBC
what aortic pathologies affect the branches
stenosis, aneurysm, plaque
what do the splanching arteries supply
the blood to the bowel
Which lobe do the hepatic veins not drain
the caudate lobe
what is the largest tributary to the IVC
the hepatic veins
why is the proximal aorta more high low resistive
the highly metabolic organs of the abdomen need forward flow in systole and diastole
how does portal flow direction and velocity indicate portal HTN
the increase in pressure in the liver can cause the flow in PV to appear biphasic (TO AND FRO FLOW) or it may reverse completely and become hepatofugal; this may also occur in the splenic vein
what occurs with dupication and transposition
the left sided IVC joins left renal vein and crosses over to join normal right sided IVC
what other vessels does the left renal vein receive blood from
the left suprarenal (adrenal) vein and the left gonadal vein
What do arteries do?
transport gases, nutrients and other essential substances to the capillaries
which pane is the celiac best seen in
transverse
What does the IMA supply?
transverse colon, descending colon and part of the rectum
After walking for 5 mins on the treadmill, Pt experiences decreased in ankle pressure of 40% on Rt, 15% on Lt. these findings:
typical for Pts w/ claudication - can't call occlusion vs stenosis based on info!, decreases suggest mild disease of LT, more pronounced on RT, typical claudication finding
what non vascular diseases cause changes in waveforms
urinary obstruction, acute and chronic disorders
What does paresis mean?
weakness or slight paralysis on one side of body
With severe LE arterial occlusive disease, the Doppler waveform distally:
will appear markedly dampened, making interpretation difficult for distal segments** - damped waveforms distal to prox arterial occlusive disease can make the evaluation of further distal disease difficult
A Pt has a 50% diameter stenosis in LE vein graft. The systolic velocity at the stenosis:
will be 100% greater than the PREstenotic velocity followed by a drop in velocity - usually a 100% increase in velocity followed by distal decrease in velocity is indicative of 50% stenosis
