Pathology Pt 1 Flashcards
If there is a 75% stenosis of the distal axillary artery, which of the following arteries will demonstrate a triphasic waveform? A. subclavian B. brachial C. radial D. ulnar
A
A 75% stenosis is the axillary artery will cause a significant loss of the flow distally. The resistance in the distal vessels will drop and the waveforms will become monophasic. The subclavian artery is proximal to the stenosis and will remain high resistance.
According to the Bernoulli Principle, where will you find the lowest pressure in a vessel with stenosis? A. in the collateral vessels B. proximal to the stenosis C. at the site of the stenosis D. distal to the stenosis
C
Pressure is lowest at the stenotic site which causes an increased pressure gradient from proximal to the stenosis site. This increased gradient leads to increased velocity of flow across the stenotic site.
Unilateral swelling of the lower extremity would be an expected clinical finding with: A. congestive heart failure B. thrombus in the IVC C. lymphedema D. left popliteal DVT
D
Bilateral swelling is associated with renal disease, CHF, lymphedema, and IVC thrombosis. Left popliteal DVT would cause unilateral swelling of the left leg.
Which of the following can lead to systolic flow reversal in the hepatic veins?
A. IVC thrombus at the level of the renal veins
B. Budd Chiari Syndrome
C. significant tricuspid regurgitation
D. portal HTN
C
Tricuspid regurgitation is blood flow that falls back into the right atrium. It can cause the right atrium to dilate and the chamber pressure to increase. If the pressure in the RA increases, inflow from the IVC (and hepatic veins) will be disrupted and flow reversal in systole can occur.
Which of the following factors listed below is NOT a part of the Virchow's triad of symptoms? A. polycythemia vera B. hyperpigmentation C. recent fall D. blood stasis
B
Virchow’s Triad:
1. Blood stasis
2. Trauma
3. Hypercoaguability. Polycythemia vera refers to abnormally thickened blood
Hyperpigmentation is related to chronic vascular disease.
A patient presents for a follow up exam on a lower extremity femoral-popliteal in-situ vein graft that was placed in the right leg 2 weeks ago. He is experiencing pain, pallor and paresthesia in the right foot. Which of the following is not an expected finding on the exam?
A. graft kinking
B. anastomosis narrowed by an aberrant suture
C. extension of atherosclerotic plaque into the graft
D. thrombosis around a valve remnant
C
Atherosclerosis is a chronic disease and would not progress into the area of the graft in such a short time period. The other choices listed are all potential acute complications following graft placement.
When performing a carotid exam, the proximal ICA is limited in color and Doppler evaluation by heavy calcification of the arterial wall. The mid ICA segment demonstrates biphasic flow with the main component of flow moving in a retrograde direction. Which of the following describes the CCA flow pattern that will be identified?
A. increased velocity with decreased resistance
B. triphasic flow with increased velocity
C. triphasic flow with decreased velocity
D. normal appearance due to distal collateral flow in ICA
C
There is most likely an occlusion of the proximal ICA. The retrograde flow in the mid ICA is due to collateralization leading to backfill of the vessel. The CCA will demonstrate a high resistance waveform due to the ICA obstruction.
Which of the following describes abnormal lower extremity venous flow response to distal augmentation?
A. augmentation causes increased flow toward feet followed by flow reversal > 0.5 sec toward the heart
B. augmentation causes increased flow toward feet followed by at least 3 seconds of flow reversal toward the feet
C. augmentation causes increased flow toward heart followed by flow normalization
D. augmentation causes increased flow toward heart followed by flow reversal > 0.5 sec toward the feet
D
<0.5 sec flow reversal with distal augmentation is considered within the normal limits. Reflux is diagnosed when flow reversal exceeds 0.5 sec. > 3 sec flow reversal is considered severe venous reflux. The best answer is augmentation causes increased flow toward the heart followed by flow reversal > 0.5sec toward the feet.
Which of the following can lead to a false negative diagnosis of ICA stenosis? A. anemia B. tortuosity C. increased cardiac output D. congestive heart failure
D
Decreased cardiac output can lead to decreased flow velocities throughout the body. CHF can lead to a false negative diagnosis for stenosis due to abnormally decreased velocities in the carotid system. Anemia causes the blood to thin and flow velocities would increase.
A Greenfield filter is used to prevent which of the following? A. cardiac tamponade B. DVT C. blue toe syndrome D. pulmonary embolism
D
A greenfield filter is inserted into the abdominal portion of the IVC (below the level of the renal veins) to catch embolic material before it reaches the heart and lungs. It does not prevent the formation of DVT, but it does protect the patient from complications related to embolism from a DVT.
A pulsatility index of > 1.2 in the cerebral vessels indicates: A. normal flow resistance B. vasospasm C. mildly decreased resistance D. severely decreased resistance
B
The greater the PI, the greater the variation on velocity throughout the cardiac cycle. The greater the PI, the higher the resistance to flow. Cerebral vessels should normally have a low PI value. Vasospasm causes increased resistance in vessels.
Which vessel can provide a pathway for collateral flow from the vertebral system to the MCA on the same side of the body? A. anterior cerebral artery B. anterior communicator arteries C. basilar artery D. posterior communicator arteries
D
The posterior communicating arteries can provide an avenue for collateral flow from the carotid system to the vertebral system on the same side of the body. If the left ICA is occluded, flow can be redirected to fill the left MCA. Flow in the left vertebral enters the PCA and then the PCoA to provide flow into the left MCA. It is important to note that the flow entering the MCA from the communicating artery will move in the normal direction (toward the transducer) using the temporal window.
Budd Chiari syndrome refers to acute or chronic obstruction of which vessel(s)? A. splenic veins B. splenic artery C. hepatic artery D. hepatic veins
D
Obstruction of hepatic veins by thrombus or tumor is referred to as Budd Chiari syndrome. It can lead to symptoms and complications such as hepatic congestion, hepatomegaly, ascites, RUQ pain and jaundice.
The most common location of a Baker cyst it: A. inguinal canal B. medial antecubital fossa C. medial popliteal fossa D. anterior patellar space
C
The most common location of a Baker cyst is in the medial popliteal fossa. Most are an incidental finding on a lower extremity exam.
Vertigo is a common symptom related to disease of which of the following vessels? A. MCA B. ACA C. ICA D. basilar
D
The cerebellum is responsible for helping to maintain balance and equilibrium. The vertebral and basilar arteries give off branches that supply the cerebellum. If flow is reduced in these arteries, cerebellar ischemia can occur leading to vertigo.
Which of the following is a condition that cannot be evaluated with Transcranial Doppler? A. patent foramen ovale B. MCA disease C. vertebro-basilar disease D. temporal arteries
D
The temporal artery is located extracranially and requires a high frequency probe to evaluate the superficial vessel. A PFO can be evaluated using microbubbles to assess shunt flow in the heart. Microbubbles injected into the venous circulation should not end up in the arterial vessels of the brain. An ASD must be present if the air embolisms are identifies as turbulent spikes in the Doppler tracing of the intracranial arteries.
Which of the following demonstrates the correct calculation for the Hemispheric Index (HI)?
A. MCA mean flow velocity divided by siphon peak systolic velocity
B. ACA peak systolic velocity divided by distal ICA peak systolic velocity
C. siphon peak systolic velocity divided by proximal ICA peak systolic velocity
D. MCA peak systolic velocity divided by distal ICA peak systolic velocity
D
The Hemispheric index is calculated using the MCA peak systolic velocity and dividing it by the distal ICA peak systolic velocity.
The renal-aortic ratio is invalid in patients with: A. abdominal aortic aneurysm B. diabetes C. medullary sponge kidney D. renal vein thrombosis
A
The flow velocity in the aorta will be decreased with the presence of a AAA. A lower aortic velocity will abnormally elevate the RAR.
When evaluating the Doppler waveform at a focal stenosis in the proximal ICA, which of the following Doppler characteristics will be demonstrated?
A. increased peak systolic velocity, increased end diastolic velocity
B. increased peak systolic velocity, increased diastolic flow reversal
C. increased peak systolic velocity, decreased end diastolic velocity
D. decreased peak systolic velocity, increased end diastolic velocity
A
The Doppler waveform at a focal ICA stenosis will demonstrate increased peak systolic velocity and increased end diastolic velocity.
The Valsalva maneuver is most useful when trying to assess which of the following? A. DVT B. median arcuate syndrome C. ECA/ICA differentiation D. venous insufficiency
D
In the lower extremities, the Valsalva maneuver increases intro-abdominal pressure and inhibits normal venous return to the heart. If the venous valves are incompetent, flow reversal will be seen while the maneuver is applied.
Which of the following carries an increased risk of developing varicose veins?
A. wearing compression stockings
B. wearing flat shoes instead of high heels
C. sitting with legs elevated for long periods of time
D. oral contraceptive use
D
Oral contraceptive use will increase the risk of developing varicose veins. Family history, pregnancy and obesity also increase the risk. The other three choices would reduce the risk of developing varicose veins.
Which of the following signs/symptoms is not an expected finding with a carotid sinus massage? A. hypotension B. urticaria C. bradycardia D. dizziness
B
The carotid sinus massage is used to evaluate patient for hypersensitivity of the carotid sinus as the potential cause for the non-specific symptom of syncope. If there is no stenosis identified in the extracranial arteries, this procedure may be performed. The patient is placed on a tilt table and an EKG with blood pressure monitor is used to assess the patient during the procedure. A physician will massage the carotid artery at the level of the cricoid cartilage. An abnormal response will lead to hypotension (>50mmHg drop), bradycardia and feelings of dizziness or syncope. Urticaria refers to the formation of hives which is usually related to an allergic reaction.
Which of the following causes of thrombosis is associated with anatomic variations of the thoracic outlet?
A. radiation therapy treatments to the chest
B. indwelling catheters
C. Paget - Schroetter Syndrome
D. shoulder surgery
C
Paget - Schroetter Syndrome AKA spontaneous effort thrombosis; Most common cause of axillary/subclavian DVT in the ambulatory patient population; Related to the presence of a cervical rib and thoracic outlet syndrome; Higher incidence in the dominant arm.
What is the most common cause of upper extremity DVT in the normal ambulatory patient population?
A. shoulder surgery
B. indwelling catheters
C. radiation therapy treatments to the chest
D. Paget - Schroetter Syndrome
D
Paget - Schroetter Syndrome AKA spontaneous effort thrombosis; Most common cause of axillary/subclavian DVT in the ambulatory patient population; Related to the presence of a cervical rib and thoracic outlet syndrome; Higher incidence in the dominant arm.
Indwelling catheters are a common cause of the upper extremity thrombosis in patients that are ill and require intravenous medication/treatment.
Which of the following measurements is used to differentiate inflow from the outflow disease in the lower extremity arteries? A. acceleration time B. resistive index C. S/D ratio D. pulsatility index
A
Acceleration Time is measured to differentiate inflow from outflow disease in the lower extremity. Measure the time from the onset of systole to the peak of systole on the waveform. >140ms indicates inflow disease. If the AT in the common femoral artery is >140ms, iliac disease is suspected. If the AT in both of the common femoral arteries is >140ms, aortic disease is suspected.
What arteries are most commonly affected by Takayasu arteritis? A. calf B. subclavian and common carotid C. subclavian and brachial D. forearm
B
Takayasu Arteritis causes hypertrophic area(s) of inflamed tissue usually found in the aorta and its branches. It is associated with supravalvular stenosis and aortic coarctation. 90% cases involve the subclavian arteries and over half of the cases involve the common carotid arteries. It can also affect the renal arteries. Most commonly seen in young females (20-40yrs) and more common in Asia and India than the US. Symptoms include absence of peripheral pulse, asymmetric brachial blood pressures, amaurosis fugax, hemiparesis, diplopia, vertigo and upper extremity claudication.
Which type of aortic aneurysm is associated with an infection of the arterial wall? A. mycotic B. saccular C. berry D. ectatic
A
A mycotic aneurysm is caused by infection of the arterial wall which weakens it and allows aneurysm formation.
Which of the following describes collateral flow from the ECA to the ICA on the same side of the body?
A. lingual artery to the MCA
B. superficial temporal artery to the ophthalmic artery
C. posterior communicator to the basilar artery
D. superior thyroidal artery to the ACA
B
Branches of the superficial temporal artery meet with branches of the supraorbital artery. Retrograde flow in the supraorbital artery will enter the ophthalmic artery, reversed flow will be identified in the ophthalmic artery. Flow will be moving back toward the ICA instead of outward toward the eye.
Restenosis of a carotid stent most commonly occurs:
A. in the native artery distal to the stent
B. in the proximal stent
C. in the distal stent
D. at the stent attachment sites
D
Restenosis of a carotid stent most commonly occurs at the attachments sites of the stent. The turbulent flow and vessel healing in these areas will cause plaque formation and the overproduction of normal cells.
A patient presents with left arm paresthesia and intermittent blurring of vision in the right eye. These clinical findings are most consistent with: A. RT ICA stenosis B. LT ICA stenosis C. LT PCA stenosis D. RT PCA stenosis
A
Extremity paresthesia can be a sign of ICA stenosis. The right ICA feeds the part of the brain that controls the left side of the body. Visual symptoms can be a sign of ICA stenosis. The ophthalmic artery is a branch of the ICA and supplies the eye with blood. If the right ICA is blocked, it will affect flow in the right ophthalmic artery and right eye.
Which of the following can lead to an increase in the frequency shift detected in the common femoral artery?
A. proximal superficial femoral artery occlusion
B. 80% stenosis of the superficial femoral artery
C. decreased probe frequency
D. 80% stenosis of the common femoral artery
D
Stenosis in the CFA will increase the detected frequency shift (and calculated velocity). Using a higher frequency probe will increase the detected frequency shift. Significant stenosis or occlusion of the SFA will reduce the detected frequency shift (velocity) in the CFA.
A patient presents for an exam due to a history of Lemierre Syndrome. What vessels should be evaluated for associated findings?
A. bilateral radial and ulnar veins
B. deep veins of the lower extremity
C. superficial veins of the lower extremity
D. bilateral internal jugular veins
D
Lemierre Syndrome refers to thrombophlebitis of the jugular veins with oropharyngeal infection, such as pharyngitis/tonsillitis. Duplex evaluation can demonstrate thrombus within the jugular vein or other neck or facial veins.
\_\_\_\_\_\_\_ is a nonspecific sign of DVT. It is defined as pain experienced upon quick dorsiflexion of the foot. A. Asher Sign B. Allen Sign C. Henderson Sign D. Homan Sign
D
Homan sign is a nonspecific sign of DVT. It is defined as pain experienced upon quick dorsiflexion of the foot. Asher sign refers to enlargement of the spleen that extends across the midline, anterior to the abdominal aorta. The Allen test is used to determine ulnar artery patency related to graft availability for removing the radial artery.
A carotid Doppler exam demonstrates an occlusion of the left ICA, but the distal ICA demonstrates retrograde flow. The ECA demonstrates increased diastolic flow. The ophthalmic artery on the left side demonstrates flow moving away from the transducer. Where is the collateral flow coming from?
A. cross over collateralization through the ACA
B. ophthalmic to ophthalmic collateralization
C. ECA to ICA collateralization
D. vertebrobasilar collateralization
C
Flow reversal in the ophthalmic artery is a key sign of ECA to ICA collateral flow. If the ICA is obstructed proximally, collateral flow can refill the ICA distally. Flow moves from the left ECA - left superficial temporal artery - left supraorbital artery (reversed) - left ophthalmic artery (reversed) - distal left ICA (reversed)
When Thrombin is injected into a pseudoaneurysm, the needle puncture site should be:
A. on the lateral aspect of the groin
B. within 1cm of the neck
C. located as far from the neck as possible
D. within 5mm of the neck
C
When injecting Thrombin, the physician inserts a 21-22g needle into the body of the pseudoaneurysm and confirms the location with 2D ultrasound. Color Doppler should not be used during the procedure because it can obscure the needle position. Thrombin must be injected at a location far from the neck of the pseudoaneurysm to prevent distribution into the arterial system. 0.5 - 1.0mL injected in small increments and thrombosis is monitored on real time imaging. Thrombosis should being immediately (within 5-10 seconds). Once the flow in the pseudoaneurysm has been eliminated, color and Doppler are used to confirm the absence of flow.
If an abnormal transcutaneous oximetry reading is obtained, what should you do next?
A. move the sensor distally
B. report the reading location and end the exam
C. move the sensor proximally
D. turn up the oxygen level entering the patient’s mask
C
TCPO2 is performed to assess tissues to determine the necessary level of amputation. The amputation must be done at an area of tissue that has normal healing capabilities. If an abnormal reading is obtained in transcutaneous oximetry, the sensor should be moved proximally. Keep moving the sensor proximally until a normal reading is obtained and record the location.
Which of the following is a cause for deep venous HTN? A. aortic coarctation B. congestive heart failure C. Klippel Trenaunay Webber Syndrome D. diffuse atherosclerotic disease
B
Venous HTN is described as increased venous volume that causes fluid to leak into interstitial spaces between tissues. Related to thrombus formation, venous insufficiency, CHF, pregnancy.
The string flow sign is associated with which of the following diagnoses? A. critical ICA stenosis B. AV fistula C. fibromuscular dysplasia D. superficial phlebitis
A
The string sign refers to a critical stenosis that only allows a thin string of blood through the tiny opening. The flow velocity will be very low with decreased pulsatility. The risk for total occlusion is extremely high in these cases. FMD causes the appearance of a string of beads.
If there is a left subclavian steal, which brachial artery evaluation will be abnormal?
A. right brachial will have a higher BP and a blunted/monophasic waveform
B. left brachial will have a lower BP and a blunted/monophasic waveform
C. right brachial will have a lower BP and a blunted/monophasic waveform
D. left brachial will have a higher BP and a triphasic waveform
B
If there is a left sided steal, this indicates the left subclavian artery has an occlusion at the origin. The left vertebral artery originates from the left subclavian artery, just distal to its origin from the arch. The left vertebral artery now receives no antegrade flow toward the head, due to the subclavian blockage.
Blood flows toward the head in the right vertebral artery to join the left vertebral artery to form the basilar artery. Some flow from the right vertebral reverses into the left vertebral artery to feed the left subclavian artery and arm.
The BP in the left arm drops due to the blood flow coming in from the low resistance, cerebral circulation. The distal arm pressure will decrease to allow flow to enter the “empty” vessels above, in retrograde fashion.
Vertebral flow is low resistance and monophasic. The Doppler evaluation of the left arm will demonstrate these characteristics which are abnormal for an extremity.
Hemodynamically significant stenosis of the celiac axis is diagnosed with the PSV greater than? A. 1.8 m/s B. 2.0 m/s C. 2.5 m/s D. 2.7 m/s
B
Hemodynamically significant stenosis of the celiac axis is diagnosed with the PSV greater than 2.0 m/s.
A patient presents with a wet ulcer located on the medial calf just above the ankle. What vessel should be evaluated first as the most likely primary cause of the ulcer? A. small saphenous vein B. great saphenous vein C. posterior accessory saphenous vein D. lower extremity arteriesIn
C
Insufficiency of the posterior arch vein (posterior accessory saphenous vein) and perforators is most commonly related to ulcer formation.
Which is the Doppler cursor placed in the aorta to obtain the velocity used in the renal aortic ration?
A. at the level of the renal artery origins
B. at the location of the highest recorded velocity
C. 2 cm above the aortic bifurcation
D. just below the diaphragm
A
The aortic velocity should be obtained at the level of the renal artery origins when evaluating renal arterial flow.
What statement describes a TIA?
A. stroke symptoms lasting 24 - 72 hrs
B. stroke symptoms lasting 24 hrs or less
C. stroke symptoms lasting 2 - 4 weeks
D. stroke symptoms lasting 24 hrs - 2 weeks
B
TIA = stroke symptoms lasting 24 hrs or less
CVA = stroke symptoms lasting more than 24 hrs
Which of the following is related to chronic DVT? A. wet ulceration B. swelling and erythema C. dry ulceration D. engorged, non-compressible vein
A
Ulcerations take time to form. They are a sign of chronic venous disease. Venous ulcers are wet and arterial ulcers are dry.
Which of the following terms is a type of visual disturbance where half of the field of view is disrupted in the eye? A. myopia B. diplopia C. homonymous hemianopia D. ectopia
C
The visual disturbance can be unilateral or bilateral and is commonly caused by ischemia in the occipital lobe of the brain. Medial or lateral half of the field of view in the eye is “absent” while the other half appears normal.
Which of the following correctly describes the symptoms associated with median arcuate ligament syndrome?
A. groin pain that is relieved by placing the legs in the dependent position
B. calf pain relieved by stretching the calf muscles
C. abdominal pain that is relieved by eating a fatty meal
D. abdominal pain that is relieved by deep inspiration
D
The median arcuate ligament compresses the celiac axis on expiration. When the diaphragm moves cephalad, the artery is pinched and abdominal symptoms occur. When the patient inhales, the diaphragm moves caudal and symptoms are relieved.
Which of the following is a characteristic of the Doppler waveform obtained distal to the site of stenosis in an ICA that demonstrates string flow on color Doppler? A. increased diastolic flow B. decreased acceleration time C. blunted waveform D. spectral window
C
Near occlusion of the ICA will lead to low velocity systolic flow with minimal diastolic flow (blunted waveform). Once total occlusion occurs, diastolic flow ceases or flow reversal occurs in the artery just proximal to the occlusion.
Which of the following is a symptom usually related to vertebrobasilar disease? A. expressive aphasia B. unilateral visual disturbances C. dysphagia D. receptive aphasia
C
Dysphagia refers to difficulty swallowing which is controlled by the brain stem. The vertebrobasilar system supplies the brain stem with blood. Unilateral visual disturbances, receptive aphasia, and expressive aphasia are symptoms related to ICA/MCA disease.
When calculating the ICA/CCA peak systolic velocity ratio,
A. use the lowest CCA PSV and the highest ICA PSV obtained
B. use the proximal CCA PSV and the ICA PSV obtained with the highest velocity
C. use the distal CCA PSV and the ICA PSV obtained with the highest velocity
D. use the proximal CCA PSV and the highest ICA PSV obtained from within the first 3cm of the vessel
C
When calculating the ICA/CCA peak systolic velocity ratio, use the distal CCA PSV and the ICA PSV obtained with the highest velocity.
Which of the following describes a positive result from the Adson maneuver?
A. loss of pedal pulses
B. loss of the radial artery pulse
C. increased hydrostatic pressure
D. pain in the foot with quick dorsiflexion
B
The Adson maneuver is a patient position used to evaluate thoracic outlet syndrome. If the radial pulse diminishes or disappears completely during the maneuver, TOS is diagnosed.
If a left ICA occlusion is present, which of the following statements is true?
A. the right MCA flow will be decreased or absent with normal flow in the right internal carotid siphon.
B. the right MCA flow will be decreased or absent with flow reversal in the right internal carotid siphon
C. the left MCA will demonstrate decreased or absent flow.
D. the right ophthalmic artery will demonstrate decreased or absent flow.
C
The ICA supplies the ipsilateral MCA and ophthalmic artery with blood. If the ICA is occluded the flow in these vessels will be absent unless collateral vessels present which would lead to minimal flow in the vessels.
Which of the following is used to determine the capability of healing a wound or identify a site for amputation? A. photoplethysmography B. transcutaneous oximetry C. ascending venography D. sclerotherapy
B
Transcutaneous oximetry evaluates oxygen supply and consumption in the tissues surrounding a wound. The partial pressure of the oxygen is recorded in the tissues around the wound. 70-80mmHg indicates normal pressure, <40mmHg indicates tissue hypoxia. The information is used to determine the healing ability of the wound.
Which renal arteries are evaluated with Doppler in an ultrasound exam that is used to perform an indirect evaluation for renal artery stenosis?
A. main renal artery
B. main renal artery, segmental and parenchymal arteries
C. segmental and parenchymal arteries
D. aorta
C
A direct evaluation uses Doppler to evaluate the velocity in the main renal artery segments. The indirect evaluation uses Doppler to evaluate the flow in the segmental/parenchymal arteries. The RI and AT values are assessed and the shape of the waveform is considered in the diagnosis (not peak velocity). The indirect evaluation looks for signs of stenosis in the main renal artery by looking at the flow in the organ distally. The aorta is not a “renal artery”.
An end diastolic velocity of 160 cm/s is an indication of \_\_\_\_\_\_\_ in the ICA. A. normal flow B. mild stenosis C. moderate stenosis D. severe stenosis
D
The end diastolic velocity (EDV) is a critical component of the evaluation of carotid stenosis. The SRU have established guidelines for possible interventions based of CUS results. According to their trials, a critical stenosis is indicated with an EDV greater than 100 cm/s. Strandness guidelines indicate significant stenosis at an EDV of 140cm/s.
What is the most common lower extremity venous disorder? A. superficial thrombophlebitis B. May Thurner Syndrome C. DVT D. venous insufficiency
D
Venous insufficiency is the most common venous disorder.
You identify flow moving toward the transducer in the left ophthalmic artery and flow moving away from the transducer in the right ophthalmic artery. Which of the following explains these findings?
A. critical stenosis in the left ACA
B. critical stenosis in the right distal ICA
C. critical stenosis in the right ACA
D. critical stenosis in the distal left ICA
B
Flow in the ophthalmic arteries is normally evaluated in the orbital window and demonstrates flow toward the transducer. If the flow is reversed in one of the vessels, this indicates a critical stenosis in the ipsilateral ICA and ECA to ICA collateral flow.
Which of the following correctly describes the symptoms associated with median arcuate ligament syndrome?
A. calf pain relieved by stretching the calf muscles
B. abdominal pain that is relieved by deep inspiration
C. abdominal pain that is relieved by eating a fatty meal
D. groin pain that is relieved by placing the legs in the dependent position
B
The median arcuate ligament compresses the celiac axis on expiration. When the diaphragm moves cephalad, the artery is pinched and abdominal symptoms occur. When the patient inhales, the diaphragm moves caudal and symptoms are relieved.
A patient with aortic coarctation distal to the left subclavian artery origin will demonstrate:
A. systemic HTN with increased brachial pressures
B. increased bilateral ABIs
C. no change in ankle pressures with exercise
D. bounding pedal pulses
A
Coarctation refers to congenital narrowing of the aorta. It most commonly occurs distal to the origin of the left subclavian artery. It causes decreased flow distal to the obstruction and monophasic flow with continuous flow in diastole is identified in the abdominal aorta. Coarctation causes lower extremity ischemia, decreased bilateral pedal pulses, and decreased bilateral ABIs. Because the arch is proximal to the obstruction, flow to the head and neck is usually normal. Systemic HTN is usually present because the coarct causes renal ischemia and the renin-angiotensin system is activated causing increased systemic pressure.
Which of the following is a Doppler indication of acute renal vein thrombosis? A. decreased cortical resistance B. enlarged kidney C. resistive index >0.7 in the cortex D. increased diastolic flow
C
Acute renal vein thrombosis will lead to increased resistance in the arcuate arteries with an RI value >0.7 due to the obstructed outflow. The kidney will enlarge but this is a 2D finding.
Which of the following is a sign of an unstable AAA with an endoleak?
A. echolucent areas within the sac
B. changes in aneurysm shape and/or sac size
C. increased pulsatility of the sac
D. more than one of the above
D
Potential signs of an unstable AAA sac:
echolucent areas within the sac, changes in aneurysm shape and/or sac size, increased pulsatility of the sac.
Which of the following is true regarding the difference between fibromuscular dysplasia (FMD) and atherosclerosis of the internal carotid artery?
A. atherosclerosis forms within the intima of the vessel while FMD is caused by over-proliferation of the adventitia.
B. Atheroma formation usually occurs in the proximal segment while FMD usually affects the more distal segments of the ICA.
C. Atherosclerosis forms within the adventitia of the vessel while FMD is caused by over-proliferation of the intima.
D. FMD usually leads to aneurysm formation while atherosclerosis leads to stenosis.
B
FMD is related to collagen growth in the media layer of the vessel. Atheroma formation involves the media and intimal layer. Atheroma formation usually occurs in the proximal segment while FMD usually affects the more distal segments of the ICA.
A patient presents with a history of trauma to the calf (horse kick). Three days later increasing medial calf pain brings the patient of the US lab. A clot is noted in a soleal vein deep in the calf muscle. Which other calf veins should be evaluated for possible propagation of the clot?
A. posterior tibial and peroneal
B. peroneal, posterior tibial and anterior tibial
C. anterior tibial
D. great saphenous
A
The soleal vessels drain into the peroneal and posterior tibial veins of the calf.
While scanning through the suboccipital window with midline angulation, the mean flow velocity increases from 55sm/s to 145cm/s at 105mm in depth. What do these findings mean?
A. normal velocity for the posterior cerebral artery
B. significant stenosis is present in the MCA
C. significant stenosis is present in the basilar artery
D. normal velocity changes for the tortuous carotid siphon
C
The mean velocity demonstrates a significant increase at a depth of 105mm which is consistent with stenosis in the basilar artery.
Which of the following cardiac abnormalities will have no effect on venous flow characteristics in the lower extremities? A. severe tricuspid stenosis B. premature ventricular contractions C. significant tricuspid regurgitation D. congestive heart failure
B
Premature ventricular contractions are a type of cardiac arrhythmia. A PVC will cause smaller ectopic contractions before a larger compensatory contraction. This abnormality alone will not affect venous flow characteristics in the extremities. The other choices lead to a backlog of flow in the IVC. When the IVC/iliac veins are dilated and engorged with blood, the cardiac pulsatility is transmitted further away from the heart due to the ripple effect.
Which of the following is true regarding scrotal varicoceles?
A. usually occurs on the left side
B. strong association with history of cryptorchidism
C. veins will reduce in size with the Valsalva maneuver
D. usually occurs bilaterally
A
Varicoceles usually form on the left side of the scrotal sac due to the course of the left gonadal vein through the abdomen and the increased risk of compression.
If there is an occlusion at the proximal ICA, what will happen to the flow in the CCA?
A. no effect on the CCA flow until bulb area
B. turbulent with decreased resistance/increased diastolic flow
C. damped with increased resistance/decreased diastolic flow
D. damped with unaffected resistance
C
The ECA normally demonstrates high resistance systolic flow with minimal diastolic flow. The ICA usually demonstrates low resistance systolic flow with increased diastolic flow. The CCA normally demonstrates a combined flow pattern from both of the branches with resistance and diastolic flow at levels between the ECA and the ICA. If the ICA is occluded, the CCA will demonstrate a flow pattern very similar to the ECA because it is now the only CCA branch and resistance too flow is increased.
Which of the following is an autosomal dominant disorder that can lead to arteriovenous AVM or portovenous AVM in the liver? A. Klippel-Trenaunay syndrome B. Paget Schroetter syndrome C. May Thurner syndrome D. Hereditary Hemorrhagic Telangiectasia
D
Hereditary Hemorrhagic Telangiectasia, AKA Osler-Weber-Rendu syndrome, is an autosomal dominant disorder that affects the vasculature of multiple organs. It is characterized by multiple arteriovenous malformations (AVMs). Most commonly the AVMs are superficially located in the skin, but can also occur in pulmonary, cerebral, GI tract, and liver vasculature. Contrast echocardiography can be used to diagnose a suspected pulmonary AVM. The malformations can be arteriovenous or portovenous. Ultrasound evaluation can demonstrate signs of portal HTN due to increased portal flow with abnormal arterial connections. The disorder can cause mesenteric angina from the steal phenomenon.
Which of the following describes cerebral cross-over collateralization?
A. flow form the right MCA to the left MCA through a cross over collateral vessel
B. left ICA flow through posterior communicator to left vertebral
C. flow from the left ACA to the right ACA through the anterior communicating artery
D. flow from the left MCA to the right MCA through cross over collateral vessel
C
Cross over collateralization occurs when flow from the left ACA moves into the right ACA through the anterior communicating artery.
Which of the following is an expected finding in a patient with temporal arteritis?
A. aneurysmal temporal artery with “string of pearls” appearance
B. high velocity, triphasic flow throughout the vessel
C. lower resistance flow throughout the artery
D. plaque filled artery that is palpable on clinical exam
C
Temporal arteritis requires the use of a linear transducer with a 7MHz frequency or higher for proper evaluation with ultrasound. 2D evaluation demonstrates wall thickening and reduced flow through the artery. Doppler evaluation will demonstrate lower resistance flow due to the vessel wall thickening and distal ischemia.
Which of the following Doppler findings would indicate significant venous hypertension?
A. triphasic flow patterns in the lower extremity deep veins
B. continuous flow patterns in the lower extremity deep veins
C. increased systolic velocities with decreased diastolic velocities
D. absence of flow in the deep veins on deep expiration
A
Pulsatile venous flow in the deep veins of the lower extremity indicates increased venous pressures (venous HTN). CHF, electrolyte imbalance and kidney dysfunction can lead to venous HTN. Triphasic flow means the flow has 3 phases of movement in a single cardiac cycle. (The Doppler tracing crosses the baseline 3 times in a cardiac cycle.) The term is not limited to describing arterial flow. Continuous flow patterns in the veins can be a sign of chronic obstruction proximally.
Which of the following scenarios demonstrates the highest risk for embolization?
A. chronic ICA occlusion
B. 40% ICA stenosis with mild, irregular soft atheroma
C. 60% ICA stenosis with moderate, smooth calcific atheroma
D. Buerger disease
B
Stenosis of the internal carotid artery carries the highest risk of TIA. Soft plaque has a much higher risk of embolization than the “fixed” calcific atherosclerosis.
According to the Bernoulli principle, the velocity increases at an area of stenosis. What happens to the pressure at the site of stenosis? A. increases B. decreases C. it increases exponentially D. remains constant
B
The pressure proximal to the stenosis is very high. The pressure at the stenosis is very low causing an increased pressure gradient between the two sites. The higher the pressure gradient, the higher the velocity.
Which of the following defines a stroke?
A. nerve conduction abnormalities within the cerebral tissue
B. acute ischemia in cerebral tissue
C. occlusion of the internal carotid artery
D. mobile piece of plaque or thrombus
B
Loss of blood flow to an area of cerebral tissue causes cerebral ischemia. All strokes are not caused by ICA occlusion and not every patient with an occluded ICA has a stroke.
A patient presents with bilateral distention of the internal jugular veins and arm swelling. The lower extremities are normal on physical examination. These findings are most suggestive of: A. subclavian steal syndrome B. CHF C. SVC Syndrome D. interrupted IVC
C
SVC Syndrome refers to the progressive obstruction of the SVC which causes venous dilatation of the upper extremities and neck. Doppler evaluation of the bilateral internal jugular veins will demonstrate continuous flow patterns. Respiratory phasicity and cardiac pulsatility will be lost.
Increased resistance in a renal artery can indicate: A. normal post-prandial flow B. distal stenosis or kidney disease C. proximal stenosis or kidney disease D. normal pre-prandial flow
B
Increased resistance in a renal artery can indicate distal stenosis or kidney disease. If the renal artery demonstrates increased resistance to flow, there is either a vascular blockage distally or the kidney parenchyma is resisting the arterial inflow because it cannot properly filter the blood. Any kidney disease that affects the filtration system will lead to increased parenchymal resistance to arterial inflow. Normal renal artery flow is low resistance with antegrade diastolic flow.
Which of the following would not result in a carotid bruit? A. 60% ECA stenosis B. 75% ICA stenosis C. 99% ICA stenosis D. aortic valve stenosis
C
99% stenosis will have minimal antegrade flow (string sign) that will not cause an audible bruit. Absence of a bruit does not rule out a critical stenosis. A CCA occlusion will not cause a bruit but an ICA occlusion may demonstrate a bruit. The diversion of all ICA flow into the ECA can cause turbulence and increased velocities.
