VTR part 4 PAD

E (saccular is a type of aneurysm NOT an etiology)

The etiology of arterial aneurysms includes all of the following EXCEPT: A. Syphilitic B. Degenerative C. Inflammatory D. Congenital E. Saccular

C (pop entrapment) (Claudication-like symptoms in a young person, especially a muscular male, are likely due to popliteal entrapment. Atherosclerotic obstruction is very unlikely; Compartment syndrome generally follows injury and/or reperfusion. Coarctation would cause symptoms in both lower extremities. The symptoms of deep venous thrombosis are very different and would not cause a decrease in arterial pressure)

A 28 year old male complains of exercise-induced cramping of the right calf that occurs after walking six blocks and is relieved within 5 minutes of rest. Bounding pedal pulses are noted and resting ankle pressures are normal. The symptoms are reproduced with exercise. The ankle pressure remains normal on the left but drops to 40 mmHg on the right. These signs are consistent with: 357 A. Occlusion of the superficial femoral artery B. Compartment syndrome C. Popliteal entrapment D. Coarctation of the aorta E. Deep venous thrombosis

E (isolated profundal femora artery disease) (Any lesion proximal to the cuff can cause an abnormally low high-thigh pressure. In addition, the equivalent of a common fem artery lesion, by the presence of disease in both the superficial fem and profundal arteries, can likewise lower the high-thigh pressure. However, isolated profundal lesions are usually not detectable by pressure changes)

A 4-level pressure cuff technique is used to assess arterial disease in the legs. The high-thigh pressure is 140 mmHg, with an arm pressure of 160 mmHg. All of the following lesions can cause this EXCEPT: 363 A. Significant aortic stenosis B. Common iliac or external iliac artery disease C. Superficial femoral plus profundal artery occlusion D. Common femoral artery disease E. Isolated profundal femoral artery disease

E (these symptoms are not typical of vascular disease) (These symptoms do not suggest claudication, symptoms of which are quite consistent. The pain associated with claudication is a muscle fatigue due to anoxia brought on by exercise. Claudication usually does not occur within moments of starting to walk, and, if it does, the distance one can walk is extremely limited.)

A 54- year old male relates a history of calf and thigh pain, the right worse than the left. This pain resolves upon sitting down. The pain usually starts after the first few steps of walking, but does not limit the patient's ability to walk three blokcs. 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. The etiology of these symptoms can be: 321 A. Abdominal aortic disease B. Bilateral iliac artery disease C. Bilateral superficial femoral and profundal disease D. A, B & C are potential etiologies E. These symptoms are not typical of vascular disease

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

A common evaluation for advanced lower extremity ischemia involves raising the supine patient's leg and then having the patient sit and dangle the leg. A positive result is described as: 315 A. Elevation pallor, dependent rubor B. Elevation rubor, dependent pallor C. Elevation paresthesia, dependent pain D. Elevation rubor, dependent cyanosis E. Elevation pallor, dependent cyanosis

C (Takayasu's arteritis causes nonatherosclerotic narrowing of brachiocephalic arteries in mostly females)

A condition that causes nonatherosclerotic narrowing of brachiocephalic arteries in overwhelmingly female patients is called: A. Compartment syndrome B. Raynaud's syndrome C. Takayasu's arteritis D. Fibromuscular dysplasia E. Buerger's disease

B (compartment syndrome)

A condition which might result from reperfusion edema following bypass surgery, causing ischemia due to compression, and which might call for treatment by fasciotomy, is called: 301 A. Marfan's syndrome B. Compartment syndrome C. Raynaud's syndrome D. China syndrome

A (an infection) (diabetic foot infections can happen with or without peripheral vascular disease)

A diabetic patient with redness of the skin in the foot and toe probably has: 322 A. An infection B. Emboli C. Increased sympathetic tone D. Low central temperature E. Popliteal aneurysm

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

A male patient walks on the treadmill for an eval of leg symptoms. During the walk he reports that both calves and thighs start hurting at 10 seconds, the right worse than the left. He continues to walk for 5 minutes, after which he is stopped by the tech. The symptoms do not resolve, but do not get worse during exercise. The following pressures are obtained: Before exercise: Arm 130, Right ankle 130, Left ankle 120 After exercise: Arm 160, Right ankle 100, Left ankle 110 True statement(s) regarding this test is (are): 374 A. There is arterial disease in both legs. B. The symptoms are probably not due to vascular disease C. The right leg is symptomatically worse D. There is evidence of aortoiliac artery disease E. A and B F. A and D G. A, B and C

E (reverse flow component) (The reverse-flow component is part of an arterial Doppler waveform, not a volume waveform, which does not have a zero baseline)

A normal arterial volume waveform may have all EXCEPT: 380 A. Swift upstroke B. Sharp peak C. Rapid downslope bowed toward the baseline D. Dicrotic notch E. Reverse-flow component

A (no change)

A normal response of ankle pressure to exercise testing - such as treadmill - is: 383 A. No change B. A dramatic increase, 50% or more C. A dramatic decrease, at least 50% in normals D. A gradual decrease of 50% over five to ten minutes E. A gradual increase of 50% over five to ten minutes

B (Raynaud's phenomenon) (Raynaud's causes prolonged digital pallor or cyanosis, followed by rubor on reperfusion)

A patient complains of digital pallor or cyanosis induced by cold exposure or emotional stimuli. These symptoms are characteristic of: 340 A. Arterial embolism to the digits B. Raynaud's phenomenon C. Thoracic outlet syndrome D. Carpal tunnel syndrome E. Klippel-Trenaunay-Weber syndrome

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

A patient complains of rest pain. On physical examination, elevation pallor and dependent rubor are present. There are no palpable pulses in the leg. A pressure of 120 mmHg is measured in the ankle. This pressure: 368 A. Is consistent with the patient presentation B. Is lower than expected C. Is higher than expected D. Suggests the physical examination is erroneous E. Obviates the need for arteriography

F (A &B; arterial disease is in both legs & the left leg has worse disease than the right) (Pressure in both legs is reduced, both at rest and after exercise, and the magnitude of the pressure decrease is greater on the left than on the right, suggesting more severe disease on that side. The level of disease can not be ascertained from these data. The patient should give essentially the same results after recovery. The lack of blood pressure increase in the arm may mean only a relatively healthy systemic-pressure response to exercise. - choice I is possible but not the best answer)

A patient walks on the treadmill until forced to stop at 3 minutes due to left calf and thigh pain. The right leg was asymptomatic throughout the course of the testing. The following results were obtained: Pre-exercise: Rt arm 150, Rt PTA 120, Lt PTA 120 Post-exercise: Rt arm 150, Rt PTA 75, Lt PTA 50 Which of the following statements is TRUE regarding this info? 375 A. There is arterial disease in both legs. B. The left leg has worse disease than the right C. The patient has aortoiliac arterial disease D. Retesting the patient in 30 minutes should result in a shorter walking time. E. The arm pressure normally increases after treadmill testing, raising questions of the validity of these results. F. A and B G. C and D H. C and E I. This question has too many answers

B (erroneous due to probable arterial calcification) (The result is likely due to calcified and incompressible arteries. This is very common in diabetic patients, so answer choice A is possible but not proven)

A patient with a history of rest pain, 100 ft calf and thigh claudication, and an ulcer on the great toe of the left foot has a left ankle pressure of >300 mmHg. This result is: 369 A. Diagnostic of a diabetic foot B. Erroneous due to probable arterial calcification C. Consistent with small vessel disease D. Demonstrable of severe hypertension E. Elevated due to a cuff that is too narrow

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

A patient with mild claudication-like symptoms has an ankle/brachial index for the affected leg of 1.02. This finding: 370 A. Indicates the disease is limited to the tibial arteries B. Rules out the presence of any arterial disease C. Is an incomplete evaluation of this patient D. Demonstrates calcific arteries E. Implicates neurogenic claudication as the cause of symptoms

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

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? 353 A. This velocity may be normal for this graft B. The graft is failing because the velocity is less than 45 cm/sec. C. The graft is failing because the graft velocity has increased from 24 cm/sec measured in a previous study. D. The graft is failing because the graft velocity has decreased from 32 cm/sec measured in a previous study E. We must know the diastolic velocity before interpreting this velocity information.

C (a pseudoaneurysm of the femoral artery) (femoral artery pseudoaneurysms are often found after catheterization. Hematomas after cardiac catheterization are also frequent but usually do not pulsate)

A pulsatile mass in the groin after catheterization of a cardiac patient most likely will be: 323 A. A femoral artery aneurysm B. A hematoma C. A pseudoaneurysm of the femoral artery D. A false aneurysm of the femoral vein E. An arteriovenous fistula

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

A 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: 347 A. SFA aneurysm B. Mild SFA stenosis C. SFA occlusion D. >50% SFA stenosis E. >80% SFA stenosis

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

A vibration noted while palpating pulses is called: 330 A. A buzz B. A bruit C. A scintillation D. A pulse E. A thrill

D (are typical for patients with claudication) (One can not call occlusion vs. stenosis based on this info. These decreases suggest mild disease on the left and more pronounced disease on the right, typical findings in a claudicating patient)

After walking for 5 minutes on the treadmill, a patient experiences decreases in ankle pressure of 40% on the right and 15% on the left. These findings: 371 A. Suggest bilateral femoral artery occlusions B. Suggest right femoral artery occlusion C. Are within normal limits D. Are typical for patients with claudication E. Are not diagnostically useful

B (B-mode US) (B-mode US does not provide hemodynamic info about the arteries, only images. All other cited methods can be and have been used to monitor pulses for pressure measurement)

All of the following devices, utilized in a standard fashion, can measure ankle pressures EXCEPT: 360 A. Doppler ultrasound B. B-mode ultrasound C. Strain-gauge plethysmography D. Photocell plethysmography E. Air plethysmography

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

An analog Doppler waveform of the subclavian or axillary artery in a normal individual would typically resemble: 352 A. A common carotid artery waveform B. A vertebral artery waveform C. A common femoral or superficial femoral artery waveform D. None of the above E. A renal artery waveform

B (thromboangiitis obliterans) (Thromboangiitis obliterans, AKA Buerger's disease, is usually seen in young males with a pronounced addiction to cigarette smoking. As legend has it, this addiction is so severe that patients with stumps for hands may continue to smoke)

An occlusive disease of medium and small arteries in the distal upper and lower limbs of primarily young male heavy smokers is: 300 A. Raynaud's syndrome B. Thromboangiitis obliterans C. Atherosclerosis obliterans D. Periarteritis nodosa E. Hyperlipoproteinemia

C (congenital arterial wall weakness) (although aneurysmal disorders may be related to trauma, congenital weakness and atherosclerosis are the most common causes of aneurysmal disease)

Aneurysms are most often caused by: A. Trauma B. Systemic infection C. Pregnancy D. Congenital arterial wall weakness E. Bifurcated laminar flow

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

Ankle/arm indices in claudicating patients are usually: 345 A. Not a useful test for this condition B. In the range of 1.0 - 1.5 C. In the range of 0.5 - 0.9 D. In the range of 0.1 - 0.3 E. Artificially elevated

E (A & C; before placement of an AV arm shunt & to evaluate blood flow to the digital arteries) (Subclavian steal is a more proximal problem. Evaluation of the palmar arch is useful both before and after the placement of an AV arm shunt or for digital disease - a careful Allen test is now being used as well before harvest of the radial artery for coronary artery bypass)

Assessment of palmar arch patency is useful: 351 A. Before placement of an arteriovenous arm shunt B. When evaluating a patient which suspected subclavian steal C. To evaluate blood flow to the digital arteries D. A and B E. A and C

C (relatively high-frequency with pulsatile components) (Arterial Doppler signals do not change appreciably with respiration)

Audible Doppler venous signals typically are low-frequency and vary with respiration, whereas normal arterial signals in the legs and arms are: 394 A. Low-frequency yet pulsatile B. Multiphasic and vary with respiration C. Relatively high-frequency with pulsatile components D. Relatively high-frequency and nonpulsatile E. Multiphasic and phasic with respiration

B (presence of a bruit may be the first indication of arterial disease) (hearing a bruit is more significant than not hearing one)

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

E (A, B, & D; loss of hair growth on feet/toes, thickening of the toenails, & dependent rubor) (Skin pigmentation changes are usually found in patients with chronic venous disease. Loss of hair growth on feet/toes, thickening of toenails, & dependent rubor are indicative of chronic ARTERIAL insufficiency)

Common signs of advanced arterial insufficiency of the lower extremity include which of the following? 312 A. Loss of hair growth over the dorsum of the toes and feet B. Thickening of the toenails C. Dermatitis with skin pigmentation D. Dependent rubor E. A, B, and D

D (dorsum of the foot)

Common sites for auscultation of bruits in the lower extremity circulation include all EXCEPT: 329 A. Abdomen B. Groin C. Popliteal space D. Dorsum of foot E. All are common auscultatory sites

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

Delayed return of the capillary blush after pressure on the pulp of the digit is a sign of: 333 A. Thoracic outlet syndrome B. Venous occlusive disease C. Advanced ischemia D. Hyperlipidemia E. Hypercholesterolemia

C (May be absent in vasodilated limbs) (vasodilated limbs have low distal resistance and exhibit the reduction or absence of diastolic flow reversal)

Diastolic flow reversal: 392 A. Is always present in all abnormal limbs B. Is always present in vasodilated limbs C. May be absent in vasodilated limbs D. Is absent in vasoconstricted limbs E. None of the above

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

Diastolic reversal of flow is most likely in: 355 A. The renal arteries B. The internal carotid artery C. Extremity arteries at rest D. Extremity arteries immediately following exercise E. The vena cava

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

Distal to an aortoiliac occlusion, the common femoral artery signal is typically: 391 A. Multiphasic B. Biphasic C. Low-pitched and monophasic D. Impossible to distinguish from a pulsatile venous signal E. High-pitched

B (peripheral resistance is usually lower in the upper extremity) ( A brachial artery waveform without flow reversal is a common finding)

Doppler velocity waveforms from upper extremity vessels may vary slightly from lower extremity waveforms because: 356 A. The upstroke is not as sharp B. The peripheral resistance is usually lower in the upper extremity C. The peripheral resistance is usually higher in the upper extremity D. There is never a diastolic flow reversal component at rest E. B and D

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

Doppler waveform abnormalities in the lower extremity arterial circulation distal to a hemodynamically significant stenosis include: 377 A. Increased peak-to-peak amplitude B. The presence of a dicrotic notch on the downslope C. An absent flow reversal component, blunting of the peak velocity, and prolonged upslope and downslope D. Absent Doppler signal E. A triphasic waveform

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

During assessment of ankle pressures, all three vessels at the level of the ankle are used to measure pressures. The pressure in both the posterior tibial and peroneal artery is 40 mmHg and the dorsalis pedis pressure is 50 mmHg. Which of the following is TRUE? 365 A. The posterior tibial artery pressure should be used to calculate the ankle/brachial index. B. The dorsalis pedis artery pressure should be used to calculate the ankle/brachial index C. The peroneal artery pressure should be used to calculate the ankle/brachial index D. There is disease in the tibioperoneal trunk E. There is disease in or above the popliteal artery

C (claudication) (all of the rest of the symptoms generally come with acute or late chronic occlusive changes - except for swelling, which often accompanies venous thrombosis)

Early atherosclerosis of the lower extremities will be associated with: 324 A. Rest pain B. Blue toe C. Claudication D. Pregangrene E. Swelling

B (The arterial segment beginning in Hunter's canal) (Hunter's canal is AKA the adductor canal, located in the mid-to-lower thigh. This is the most common site of atherosclerotic involvement in the lower extremities)

In the lower extremity circulation, the most common site of atherosclerosis is: 305 A. The arterial segment beginning at the popliteal artery B. The arterial segment beginning in Hunter's canal C. The arterial segment at the iliac bifurcation D. The proximal tibial vessels E. The arterial segment at the popliteal trifurcations

B (very painful and commonly located distally over the dorsum of the foot) (an ulcer found above the medial malleolus is most likely venous in origin)

Ischemic ulcers (lesions) are: 328 A. Completely painless but bleed with manipulation and are located over pressure points or calluses B. Very painful and commonly located distally over the dorsum of the foot. C. Only mildly painful and relieved by elevation D. Very painful and are usually located around the malleolus D. Caused by pathogenic organisms

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

Match the following symptoms and signs with the likely cause. (Tip: Start with the most obvious and work your way in): 314 A. Bruit B. Absent pulse C. Foot rubor D. Right sided weakness E. Edema 1. Aortoiliac + SFA occlusion 2. Deep venous thrombosis 3. Subclavian artery occlusion (acute) 4. Left carotid artery occlusion 5. Iliac artery stenosis

B (degenerative origin) (most aneurysms, especially in the abdominal aorta, are degenerative because of atherosclerosis)

More than 90% of infrarenal abdominal aneurysms are of: A. Traumatic origin B. Degenerative origin C. Anastomotic origin D. Infectious origin E. Syphilitic origin

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

Normal Doppler waveform morphology for a peripheral artery includes: 382 A. PHASICITY with respiration B. Augmentation with distal compression maneuvers C. A sharp upslope and downslope and a prominent reverse flow component D. A delayed systolic peak with a downslope bowed away from the baseline E. A rounded, extended acceleration with no diastolic wave

B (2-3 cm)

Normal diameter for the abdominal aorta is: 367 A. Less than 1 cm B. 2 - 3 cm C. 3 - 5 cm D. 5 - 7 cm E. Approx. 10 cm

A (Changes in thigh-to-ankle index) (this is not a diagnostic parameter in exercise testing)

Parameters usually assessed in exercise testing include all EXCEPT: 378 A. Changes in thigh-to-ankle index B. Time required for recovery to pre-stress pressure level C. Patient complaint of leg pain during exercise D. Length of time of exercise E. Magnitude of pressure drop

E (all of the above) (Since the location of the ulcers and gangrene is not specified, any of the causes may be implicated)

Patients found to have ulcerating lesions or gangrene may have which of the following diseases? 318 A. Arterial insufficiency B. Neuropathy C. Vasospasm D. Venous disease E. All of the above

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

Patients presenting with a diagnosis of ischemic rest pain may complain of: 317 A. Foot pain at night which occurs on an irregular basis B. Tingling in the foot which is relieved by elevation C. Foot pain while in a horizontal position, relieved by standing or dangling the foot in a dependent position D. A numbing weakness produced by standing E. Pain in feet with walking which is relieved by rest.

B (cramping pain in the calf, thigh, or buttocks with exercise and relieved by rest

Patients presenting with symptoms of claudication complain of: 316 A. Nocturnal muscle cramps B. Cramping pain in the calf, thigh, or buttocks with exercise and relieved by rest C. Numbing weakness in the legs while standing D. Pain in hips or knees not relieved by rest E. Cramping pain in the calf, thigh, or buttocks with exercise not relieved by rest.

E (all except stasis pigmentation- which is a characteristic symptom of VENOUS rather than arterial insufficiency)

Patients with advanced peripheral arterial vascular occlusive disease exhibit which of the following skin changes? 320 A. Shiny, scaly skin B. Dependent rubor C. Pallor on elevation D. Stasis pigmentation E. All except D

E (all of the above - insonating an artery other than the intended one, recording two vessels simultaneously, using an improper probe frequency)

Possible error(s) that can occur when recording a femoral arterial waveform using continuous-wave Doppler include: 385 A. Insonating an artery other than the intended one B. Recording two vessels simultaneously C. Using an improper probe frequency D. B and C only E. All of the above

C (speed is varied during cardiac testing) (The standard cardiac treadmill protocol aims to increase the heart rate to a specific target level. This is accomplished by increasing the speed and elevation of the treadmill at specific time intervals during the examination. Treadmill testing for claudication generally uses one unvarying speed and elevation. Both types of exam include blood pressure monitoring as well as observation by technologists. There is some cardiac risk associated with claudication testing)

Protocols for cardiac treadmill testing and claudication treadmill testing differ, the major difference being: 362 A. A single, faster speed is used for cardiac testing. B. The patient is closely monitored by technologists during cardiac testing C. Speed is varied during cardiac testing. D. The cardiac risk is greater with claudication testing since few patients are monitored with ECG E. Elevation is varied during claudication testing

E (peroneal)

Pulse sites commonly palpated in the lower extremities include all EXCEPT: 335 A. Common femoral B. Popliteal C. Posterior tibial D. Anterior tibial E. Peroneal

A (Patient's inability to tolerate application of pressure cuffs) (One needs to apply cuffs for both exercise and reactive hyperemia testing. Some patients can not tolerate the suprasystolic pressures needed for reactive hyperemia testing)

Reasons to perform reactive hyperemia instead of treadmill testing include all EXCEPT: 379 A. Patient's inability to tolerate application of pressure cuffs B. Patient's inability to stand or walk C. Patient's poor cardiac status D. Patient has pulmonary problems E. Patient has very severe disease in one leg, making exercise assessment of the other leg difficult.

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

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

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

Rubor is defined as: 331 A. Abnormal stiffness of digits B. Small, purple areas of discoloration on the dorsum of the foot C. Thickened, wrinkled skin D. Red skin color E. Slackening of the muscles of the ischemic foot

A (hypolipidemia) (it is not a risk factor for any vascular occlusive disease)

Select the entity that is NOT a risk factor in peripheral arterial occlusive disease: 309 A. Hypolipidemia B. Smoking C. Hypertension D. Diabetes E. Hyperlipidemia

D (pitting edema) (True pitting edema is usually a symptom of systemic disease - such as CHF - chronic venous disease, or lymphedema)

Signs of advanced ischemia in the lower extremity include all of the following EXCEPT: A. Slow venous filling after dropping the elevated extremity into a dependent position B. Pallor on elevation C. Rubor on dependency D. Pitting edema E. Ulceration at the dorsum of the foot

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

Takayasu's arteritis is most often found in: 311 A. Young men B. Middle-aged men C. Elderly men D. Young women E. Elderly women

E (A & B only- the sound beam must pass through scar tissue, a hematoma, or excessive fat. & The vessel has calcific plaque on the anterior wall) (output settings do not affect attenuation; they control size of recording on the chart paper)

The Doppler beam may be attenuated if: 386 A. The sound beam must pass through scar tissue, a hematoma, or excessive fat. B. The vessel has calcific plaque on the anterior wall C. Output settings from the Doppler to the recording device are not amplified D. All the above E. A and B only

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

The absence of a bruit at the common femoral level: 336 A. Rules out significant stenosis at that level B. Cannot rule out significant stenosis at that level C. Suggests stenosis distal to that level D. Suggests total occlusion at that level E. Suggests stenosis proximal to that level

C (is only marginally meaningful diagnostically)

The amplitude of arterial volume recording waveforms: 384 A. Is identical at all four levels B. Is highest distally, where hydrostatic pressure is highest C. Is only marginally meaningful diagnostically D. Is normally approximately one-third the width of the waveform E. Should equal the reverse component

D (Ankle by the higher brachial pressure)

The ankle/arm index is obtained by dividing the: 346 A. Higher of the two brachial pressures by ankle pressure B. Lower of the two brachial pressures by ankle pressure C. Ankle pressure by the lower brachial pressure D. Ankle pressure by the higher brachial pressure E. Ankle pressure by the average of the two brachial pressures.

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

The chance of a patient dying from a rupture of an abdominal aortic aneurysm averages: 303 A. 25% B. 35% C. 45% D. 55% E. 80%

C (foot lesions) (foot lesions are often found in diabetic patients with peripheral neuropathy - with or without peripheral atherosclerosis)

The combination of neuropathy and peripherally distributed atherosclerosis makes the diabetic patient especially vulnerable to: 302 A. Aortoiliac disease B. Popliteal entrapment syndrome C. Foot lesions D. Abdominal aortic aneurysms D. Renal artery lesions

A (AC-coupled output) (AC-coupled amplification is appropriate for arterial plethysmography; DC-coupling is appropriate for venous recording)

The correct setting for arterial volume recording is: 376 A. AC - coupled output B. DC - coupled output C. 3.5 Hz filter setting D. "Mean" filter setting E. Forward/reverse

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

The key technology in arterial PNEUMOPLETHYSMOGRAPHY is: 349 A. Two pairs of electrode bands monitoring impedance changes in a limb segment B. Two photocells monitoring subcutaneous color changes C. A pressure transducer monitoring cuff pressure over a limb D. A silastic tube filled with mercury that changes resistance with changes of limb circumference E. A large air cuff enclosing the entire calf.

E (pedal ulcer is NOT a presenting symptom of acute arterial occlusion) (A pedal ulcer would take a bit more time to develop and is more characteristic of chronic rather than acute occlusion. The other of those "five Ps" of acute occlusion is pain. "Polar" - cold extremity - a strenuous effort to use the letter P for all of the symptoms - is sometimes added)

The most common presenting symptoms in acute arterial occlusion include all EXCEPT: 319 A. Paralysis B. Pulselessness C. Pallor D. Paresthesias E. Pedal ulcer

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

The most common source of lower or upper extremity peripheral arterial embolus is: A. Ulcerated plaque B. The heart C. Aneurysms D. Arterial dissections and atherosclerosis E. Small vessel arteriosclerosis

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

The most important reason Doppler evaluations should be performed with the patient in a basal state and warm temperature is: 393 A. The exam will be easier to perform B. The results are influenced by the patient's peripheral resistance. C. The results can be expected to vary from day to day D. The results are influenced by the pressure differential found in each vessel E. Metabolic activity is increased, making results more reliable

B (a qualitative approach or pattern recognition) (Most analog Doppler analysis is qualitative - assessing for presence or absence of characteristics, such as the reverse-flow component)

The most widely used interpretive technique for analog Doppler waveforms is: 381 A. A quantitative approach evaluating the diagnostic features of the waveform B. A qualitative approach or pattern recognition C. Purely subjective - neither qualitative or quantitative info can be derived from the waveform. D. Spectral analysis of the velocity profiles within a waveform E. B-mode ultrasound evaluation

D (PSV to peak end diastolic velocity divided by mean velocity) (This is AKA Gosling's pulsatility index. This index is used mostly with continuous-wave Doppler or transcranial Doppler and increases with increased distal resistance. It is independent of the Doppler angle)

The pulsatility index is defined as: 341 A. Peak systolic velocity divided by end diastolic velocity B. Peak systolic velocity minus end diastolic velocity divided by systolic velocity C. Peak systolic velocity minus mean velocity divided by systolic velocity D. Peak systolic to peak end diastolic velocity divided by mean velocity E. Peak systolic velocity at the internal carotid artery divided by peak systolic velocity at the common carotid artery

A (right femoral artery obstruction) (The obstruction must be proximal to the high-thigh cuff, but not as far proximal as the aortic segment, since the left side is within normal limits - right iliac artery obstruction is a possibility, but it is not one of the choices)

The right high-thigh pressure measurement is 108 mmHg, while the left high-thigh is 142 mmHg. Brachial pressure is 122 mmHg. Of the following, this most likely suggests: 348 A. Right femoral artery obstruction B. Left femoral artery obstruction C. Aortoiliac obstruction D. Left iliac artery obstruction E. Right popliteal artery obstruction

B (greater than 4x the risk in the gen. pop) (Diabetes is a significant risk factor in lower extremity arterial disease)

The risk of claudication in dibetic patients is: 308 A. Equal to the risk in the general population B. Greater than 4 times the risk in the general population C. Close to 10% of the risk in the general population D. Lower than that in the general population E. Claudication is not an ischemic symptom for diabetics.

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

The symptom or sign most likely NOT associated with acute arterial occlusion is: 327 A. Blue toe B. Pain of sudden onset C. Pale or white extremity D. Claudication E. Paresthesia

E (all; swelling and or palpable tenderness over a muscle compartment, sensory deficit or paresthesias, pain on passive stretch of the muscles in the compartment, and weakness of the muscles in the compartment)

The symptoms of anterior tibial compartment syndrome are: 338 A. Swelling and/or palpable tenderness over a muscle compartment B. Sensory deficit or paresthesias C. Pain on passive stretch of the muscles in the compartment D. Weakness of the muscles in the compartment E. All of the above

A (blue color of tissue due to ischemia)

The term "cyanosis" describes: 313 A. Blue color of tissue due to ischemia B. Red color of tissue due to hyperemia C. Pale skin due to ischemia D. Thickening of toenails due to chronic ischemia E. Loss of hair growth due to chronic ischemia

E (distal turbulence)

The two flow characteristics that define arterial stenosis anywhere in the body include focal acceleration of velocities and: 354 A. Decreased diastolic flow B. Decreased resistance proximally C. Increased flow reversal D. Increased pulsatility distally E. Distal turbulence

A (65 mmHg is normal cuff pressure in arterial VOLUME recording)

The usual cuff pressure used in arterial volume recording is: 389 A. 65 mmHg B. 10 mmHg C. Suprasystolic D. 100 mmHg E. Dependent on patient size

B (AAA) (particularly if rupturing, often present with back, abdominal, or flank pain)

The vascular disease that presents as back, abdominal, or flank pain is: 310 A. Intracranial arterial disease B. Abdominal aortic aneurysm C. Iliofemoral occlusive disease D. Superior mesenteric stenosis E. Renal artery stenosis

C (Suggests interference from venous flow) (Since continuous-wave analog Doppler displays net or average frequency shifts - i.e., velocities - of all flow intersecting the beam, venous flow can interfere with your efforts to get a clear arterial tracing on paper)

This CW Doppler waveform from a popliteal artery: 361 A. Is a normal arterial waveform B. Is severely abnormal in character C. Suggests interference from venous flow D. Suggests femoral artery occlusion E. Is monophasic

B (Secondary Raynaud's disease) (This finding is not universally supported in the literature)

This digital photoplethysmographic waveform might suggest: 390 A. Primary Raynaud's disease B. Secondary Raynaud's disease C. Venous valvular incompetence D. Nerve compression E. This is a normal digital PPG waveform

A (it is NOT USEFUL in determination of arterial level of obstruction) (Like ankle/arm indices, TcPO2 can assess only at the site of measurement; it cannot localize the level of proximal obstruction)

Transcutaneous partial pressure of oxygen (TcPO2) studies can be useful for all EXCEPT: 388 A. Determination of arterial level of obstruction B. Determination of amputation level C. Assessment of skin-graft viability D. Assessment of foot perfusion E. Assessment of healing of stump

C (on toes and distal foot)

Ulcers due to arterial insufficiency are found most often: 332 A. Behind the knee B. In the gaiter area, near the medial malleolus C. On toes and distal foot D. Over the lesion, usually along Hunter's canal E. Mid-calf

A (pop artery entrapment) (Pop artery entrapment is the most common cause of unilateral claudication in a young person)

Unilateral claudication in the calf and foot of a young individual suggests: 339 A. Popliteal artery entrapment B. Anterior tibial compartment syndrome C. "restless leg syndrome" D. Lumbar disc disease E. Arteriosclerosis

A (0.50 - 90/180) (you use the higher brachial pressure to calculate the index)

Using the following information: Right arm 180/100 mmHg Left arm 120/60 mmHg Right PTA 100 mmHg Left PTA 90 mmHg 372 The left ankle/brachial index is: A. 0.50 (90/180) B. 0.75 (90/120) C. 0.90 (90/100) D. 1.11 (100/90) E. 1.50 (90/60)

D (the patient has renovascular hypertension is NOT true) (This patient has bilateral lower extremity obstructive disease based on these pressures and indices. There appears also to be obstruction proximal to the left brachial cuff - 60 mmHg gradient compared to right arm- ; this is usually caused by subclavian disease. The patient has hypertension - systemic pressure of 180 mmHg- but the reason for this finding cannot be ascertained from this exam. Renovascular hypertension is only one cause of this problem, and is responsible for 3-5% of hypertension cases)

Using the following information: Right arm 180/100 mmHg Left arm 120/60 mmHg Right PTA 100 mmHg Left PTA 90 mmHg 373 Which of the following statements is NOT true? A. The patient has right lower extremity arterial disease B. The patient has left lower extremity arterial disease C. The patient has left subclavian artery disease Dl The patient has renovascular hypertension E. Arteriography would be recommended if bypass surgery is contemplated

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

When assessing a digital artery with Doppler, patency of the palmar arch can be determined by: 350 A. Compressing the brachial artery while listening for changes in the digital artery signal B. Compressing the radial artery while listening for changes in the digital artery signal C. Compressing the ulnar artery while listening for changes in the digital artery signal D. Alternately compressing the radial and ulnar arteries while listening for changes in the digital artery signal E. Inflating a digital cuff to suprasystolic pressure

B (It increases the oxygen-carrying capacity of blood is FALSE) (Carbon monoxide is one of many byproducts of smoking. Carbon monoxide decreases the oxygen-carrying ability of red blood cells.)

Which of the following statements is FALSE regarding smoking? 304 A. It accelerates the onset and progression of atherosclerosis B. It increases the oxygen-carrying capacity of blood C. Cigarette smoke contains nearly 5,000 chemicals D. It causes swelling of endothelial cells E. It increases platelet aggregation and adherence

E (most prerupture AAAs are discovered because of abdominal symptoms or distal emboli is FALSE) (AAAs rarely extend above the renal arteries. The "gold standard" test has been B-mode ultrasound, although CT scanning is gaining popularity. Arteriograms are obtained prior to operation by some surgeons but may be falsely negative for diagnosing the aneurysm because of laminated clot within the lumen. Most aneurysms are discovered on routine physical exam while the patient is asymptomatic)

Which of the following statements regarding abdominal aortic aneurysms is FALSE? 307 A. AAAs are usually infrarenal B. Computerized tomography and MRI are common modalities for the diagnosis of AAA C. Ultrasound imaging is the most frequently used modality for diagnosis of AAA. D. Abdominal aneurysms pose a significant risk of rupture if > 6 cm in diameter. E. Most prerupture AAAs are discovered because of abdominal symptoms or distal emboli

G (B, C & D- they can cause symptoms by compressing contiguous structures, They pose a significant risk of limb loss due to embolism or occlusion. and They are found bilaterally in > 10% of cases where they exist) (Popliteal aneurysms have a very low risk of rupture but a high risk of embolization or thrombosis leading to loss of limb. There are occasional venous or neurologic symptoms due to size. About 50-70% of patients with a popliteal aneurysm have them bilaterally . Additionally, there is a high rate (about 40-50%) of coexisting abdominal aortic aneurysm in these patients. Claudication is a rare symptom and wen present is the result of coexistent stenosis, not the aneurysmal process)

Which of the following statements regarding popliteal aneurysms is TRUE? 306 A. They pose a significant risk to the patient due to rupture B. They can cause symptoms by compressing contiguous structures. C. They pose a significant risk of limb loss due to embolism or occlusion D. They are found bilaterally in > 10% of cases where they exist E. Claudication is a rare symptom F. A and D G. B, C, and D

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

Which one of the following changes occurs in the peripheral blood flow of limbs with obstructive arterial disease in response to laboratory-induced ischemia (reactive hyperemia procedure) or exercise? 344 A. Flow increases more in obstructed limbs than in limbs with no obstruction B. Hyperemia is prolonged in obstructed limbs in comparison to limbs with no obstruction C. Flow decreases in order to redistribute blood volume to the central circulation D. Cardiac output is reduced. E. Peripheral resistance is increased due to muscle contraction.

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

Which one of the following conditions will cause an increase in the pulse amplitude of the arterial pressure wave? 343 A. An increase in peripheral resistance B. A decrease in left ventricular function C. Vasodilation D. Young age E. Mild atherosclerosis

B (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, greatly increasing flow. Although claudicators usually have a reduced resting pressure, they can sometimes have equivocal or even essentially normal ABIs at rest. Thus some form of challenge - exercise or postocclusive reactive hyperemia - might be required to provoke a pressure drop)

Which one of the following is always TRUE of patients who suffer from intermittent claudication? 342 A. Peripheral blood flow is reduced at rest B. There is pressure drop distal to the obstructed segment after exercise C. No increase in blood flow occurs through the affected segment during exercise D. Marked peripheral vasoconstriction occurs in response to exercise. E. There is always a pressure drop distal to the obstructed segment at rest.

E (progressive claudication) (progressive claudication is usually associated with slow progression of atherosclerosis, not with embolization)

Which sign or symptom is least likely to be associated with arterial embolization? 325 A. Blue toe B. TIA C. Popliteal aneurysm D. Amaurosis fugax E. Progressive claudication

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

While performing a treadmill test, the patient complains of pain in the left arm and jaw, but denies any other pain. The examiner should consider that this could possibly be: 364 A. Arm claudication B. Angina C. Unimportant symptoms D. Subclavian steal E. Carotid artery disease

D (will appear markedly dampened, possibly making interpretation difficult for distal segments) (Damped waveforms distal to proximal arterial occlusive disease can make the evaluation of further distal disease difficult)

With severe lower extremity arterial occlusive disease, the Doppler waveforms distally: 387 A. Will eventually return to a relatively normal waveform pattern once the disease process has stabilized B. Will demonstrate flow reversal in the diastolic component C. Cannot be distinguished from venous waveforms D. Will appear markedly dampened, possibly making interpretation difficult for distal segments E. Are almost always absent at the ankle level

D (Anterior tibial artery) (The significant drop is from low thigh to anterior tibial; the drop from low thigh to posterior tibial is within normal limits. This information localized the obstruction to the prox. anterior tibial segment - ie, proximal to the below-knee cuff)

Your segmental pressure readings disclose a 36 mmHg decrease in pressure from the low-thigh to the below-knee anterior tibial artery, and a 10 mmHg decrease from low-thigh to below-knee posterior tibial artery. These finding localize obstruction to the: 358 A. Distal Superficial Femoral Artery B. Popliteal artery C. Posterior tibial artery D. Anterior tibial artery E. Peroneal artery

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

Your segmental pressure readings indicate 126 mmHg at the high thigh, 144 at the low thigh, and 120 at the below-knee level. These findings might be the result of all EXCEPT: 359 A. SFA obstruction B. Cuff artifact C. Poor cuff application D. Calcified arteries in a diabetic patient E. All are possible causes

A (Aortoiliac obstruction is NOT indicated) (Since the left high-thigh pressure is WNL, the aortic segment cannot be included in the diagnosis of obstruction)

Your segmental pressure readings indicate the following: Rt. brachial: 144 mmHg Lt. brachial: 140 Rt. high thigh: 110 Lt. high thigh: 164 These findings could result from all EXCEPT: 366 A. Aortoiliac obstruction B. Right common iliac obstruction C. Right external iliac obstruction D. Right common femoral obstruction E. Right proximal superficial femoral obstruction