Chapter 11: Indirect Assessment of Arterial Disease Flashcards
(226 cards)
1
Q
A series of maneuvers testing the digital perfusion of the hand while compressing and releasing the radial and ulnar arteries
A
Allen test
2
Q
The ratio of ankle systolic pressure to brachial systolic pressure
A
ankle-brachial index
3
Q
pain in muscle groups brought on by exercise or activity that recedes with cessation of activity; can occur in the calf, thigh, or buttock
A
claudication
4
Q
An indirect physiological test that detects changes in back-scattered infrared light as an indicator of tissue perfusion
A
photoplethysmography
5
Q
an indirect physiologic test that measures the changes in volume or impedance in a whole body, organ, or limb
A
plethysmography
6
Q
vasospasm of the digital arteries brought on by exposure to cold; can be caused by numerous etiologies
A
Raynaud’s Disease
7
Q
Pain in the extremity without exercise or activity, thus, “at rest”; can occur in the toes, foot, or ankle area
A
Rest pain
8
Q
Compression of the brachial nerve plexus, subclavian artery, or subclavian vein at the region where these structures enter or exit the thoracic cavity
A
Thoracic outlet syndrome
9
Q
Intermittent claudication is located in the _____, _____, _____, _____.
A
buttock, thigh, hip, calf
10
Q
Intermittent claudication and exercise.
A
always
11
Q
Intermittent claudication is relieved by ______.
A
stopping
12
Q
Spinal stenosis is located in the ____, _____, ______, and ____.
A
buttock, thigh, hip, calf
13
Q
Spinal stenosis and exercise.
A
yes, but also with standing
14
Q
Spinal stenosis is relieved by _____.
A
sitting, flexing, and moving spine
15
Q
Herniated disc is located _____.
A
radiates down leg
16
Q
Herniated disc and exercise.
A
variable
17
Q
Herniated disc is relieved by _____.
A
varies; aspirin or anti-inflammatories
18
Q
Osteoarthritis is located in the ____, _____, and _____.
A
hips, knees, ankles
19
Q
Osteoarthritis and exercise.
A
variable; not always produced
20
Q
Osteoarthritis is relieved by _____.
A
varies; aspirin or anti-inflammatories
21
Q
Ankle-Brachial Index >1.30
A
incompressible PAOD
22
Q
Ankle-Brachial index 0.9-1.30
A
normal
23
Q
ABI 0.75-0.89
A
mild paod
24
Q
ABI 0.50-0.74
A
moderate PAOD
25
ABI <0.50
severe PAOD
26
ABI <0.35
tissue threatening PAOD
27
Doppler waveforms proximal to knee are ____.
multiphasic
28
Plethysmography waveforms exhibit a _____.
dicrotic notch
29
Pulse waveforms have a well-defined _____.
peak
30
Resting and postexercise ABIS are _____.
0.90-1.30
31
Single (wide) above knee cuff systolic pressure is ______ higher brachial.
equal to
32
High thigh (narrow) cuff systolic pressure > or equal to _____ abover higher brachial.
30 mm Hg
33
All pulse waveforms have ____ systolic upstroke.
short
34
Difference between adjacent limb segments is < or equal to ____ mm HG.
30
35
Difference between brachial systolic pressures is < or equal to ___ mm Hg.
20
36
Resting and postexercise digit-brachial indices are > or equal to ____.
0.90
37
< or equal to ___ mm Hg systolic pressure between above and below elbows
20
38
Gradient between brachial systolic pressures is < or equal to ___ mm Hg.
20
39
Pulse waveform and temperature normal recovery time < or equal to ___.
10 minutes
40
Peripheral arterial occlusive disease has an ABI less than ___.
0.90
41
Digital ischemia in the lower extremity has a TBI less than ___.
0.80
42
Digital ischemia in the upper extremity has a TBI less than ___.
0.90
43
diminished or flat digital PPG waveforms during provocative arm/shoulder maneuvers and the development of symptoms.
thoracic outlet syndrome
44
Raynaud's disease has a DBI less than ____.
0.90
45
Positive Allen test with diminished digital waveforms during manual compression of radial or ulnar arteries
incomplete palmar arch
(radial/ulnar dependency)
46
Most common symptom of PAOD in the lower extremity
leg discomfort caused by activity
47
fatigue, or as a cramping, aching, or tiredness sensation; usually starts in calf, progressing to thigh and buttocks
intermittent claudication
48
In PAOD symptoms occur ____ to the disease process.
distal
49
correction requiring sitting or spinal flexure
spinal stenosis
50
Claudication distances decrease, symptom recovery time _____ as PAOD progresses.
increases
50
Rest pain
forefoot pain may be constant
51
patient recumbent, raising leg a foot or so above heart level will usually cause blanching of the skin on the foot, becomes red with dependency
elevation pallor/dependent rubor
52
first indication of aneurysmal disease
blueness of the toes
53
most common site for aneurysmal disease
popliteal level
54
___ % of all extrinsic compression-related symptoms in upper extremity.
95
55
Cold sensitivity is generally referred to as ______.
Raynaud's phenomenen
56
Primary Raynaud's origin
idiopathic
57
Secondary Raynaud's origin
underlying disease process
58
coexisting clinical conditions for PAOD exam
stroke/ishemic attack
carotid artery disease
heart attack
coronary artery disease
hypertension
diabetes
lipid disorder
59
symptoms related to positional causes of arm fatigue/numbness/aching and/or symptoms related to cold sensitivity
upper extremity indications
60
How long should patient rest before starting a systolic pressures exam?
10-15 minutes
61
The width of the cuff should be at least __% wider than limb segment.
20
62
If the blood pressure cuff is too narrow:
falsely elevated pressure
63
If the blood pressure cuff is too wide:
falsely lowered pressure
64
Systolic pressure exam cuff should be inflated ___ mm Hg about flat point.
20
65
During systolic pressure exam deflate cuff slowly ___.
3 mm Hg/s
66
indicate overall severity of PAOD between heart and ankle level
ABI
67
calculated by dividing the highest systolic pressure at ankle level by the higher of two brachial systolic pressures
ABI
68
presence of differing ipsilateral resting normal and abnormal ankle pressures; associataion with potential cardiovascular problems
PAOD isolated to a single ipsilateral tibial artery
69
ABI must alter by at least ____ to be significant.
0.15
70
A normal drop of ___ mm Hg as blood flows from heart to distal segments of lower extremity; increase in amplitude of pulses distally
10
71
Normal resting ankle systolic pressure
50 mm Hg
72
Normal resting ABI
0.90
73
indications of calcific vessels
Doppler signal does not reappear at a clearly defined pressure; increases in amplitude with further cuff deflation
74
technique of elevating an extremity; valuable to determine healing potential of pedal lesion
Pole test
75
measuring systolic pressures segmentally at two or three levels more proximally and comparing waveforms
segmental limb systolic pressures
76
Drops greater than 30 mm Hg in distal pressure between adjacent segments indicate:
presence of obstruction proximally
77
In the upper extremity, the most common location for PAOD is:
subclavian level and proximal axillary
78
Lower extremity locations Doppler Waveforms
CFA
SFA
POP
Distal PTA and DPA
79
upper extremity locations Doppler waveforms
subclavian
axillary
brachial
distal radial
distal ulnar
80
exhibit a degree of flow reversal in late systole/ early diastole
bidirectional waveform
81
More reversal in flow relates to ____ resistance to flow.
greater
82
Normal progression of PAOD _____ flow energy distal to lesions
reduces
83
arteriolar bed cannot dilate further and blood flow into affected segment(s) begin to drop
critical stage PAOD
84
PVR inflation of cuff
65 mm Hg
85
relate to moment-to-moment changes in limb volume; difference between arterial inflow and venous outflow
PVR
86
Normal PVR waveform
brisk upstroke with well-defined peak
87
usually shows a "notch" on downstroke in early diastole, which then returns to baseline in a concave manner before onset of next cardiac cycle
dicrotic notch
88
Moderate to severe PAOD waveforms
delayed onset to peak, more rounded
89
Diastolic phase becomes ____ as PAOD progresses
convex
90
Severe PAOD waveforms
waveforms may be virtually flat with very low amplitude
91
operated by transmitting infrared light into tissue and detecting tissue variations in light reflected from underlying blood flow from a depth of 1-3 mm
PPG
92
associated with symptoms involving one or more digits or hand; symptoms or signs asymmetrical; often present with tissue loss; tend to be older; affect both men and women;
Secondary Raynauds
93
Etiology of secondary Raynaud's disease
trauma
94
hands change color when exposed to cold
Primary Raynauds
95
For primary Raynaud's testing the hands should be immersed in ice cold water for __ to __ seconds max.
30-40
96
uses PPG waveforms to indicate adequacy of hand perfusion from radial and ulnar arteries; necessary to establish contribution to digital perfusion before certain surgical procedures
Allen test
97
98
_____ is a valuable asset when examining patients with suspected PAOD.
indirect arterial testing
99
The combination of systolic pressures and pulse waveforms produces both ____ and _____ information on extremity blood flow.
quantitative
qualitative
100
Which statement about intermittent claudication is FALSE?
a. It is generally described as pain with exercise that is relieved by rest
b. It can be asymptomatic at rest
c. ABI values consistent with claudication are generally between 0.5 and 0.8.
d. The amount of activity that produces the symptoms varies from day to day
c
101
Which type of disease is associated with blueness of the toes?
aneurysmal disease
102
Which of the following is associated with vasospasm and digital color changes due to an underlying process such as scleroderma or trauma?
a. primary Raynaud's phenomenon
b. thoracic outlet syndrome
c. secondary Raynaud's phenomenon
d. thromboangiitis obliterans
c
103
Which of the following would be considered risk factors for the development of PAOD?
a. history of smoking
b. coexisting clinical conditions such as TIA, CAD, hypertension, and diabetes
c. family history of cardiac and/or peripheral vascular disease
d. all of the above
d
104
Which method is most commonly used to calculate ABI?
the highest pressure at the ankle divided by the highest systolic pressure of the right or left brachial artery
105
Progression of PAOD can be established on follow up of patients by physical examination and clinical history because the patient may describe all of the following EXCEPT:
a. diminution of walking distance
b. increase of recovery time
c. skin and nail changes
d. resolution of pain by changing position
d
106
Severe PAOD can be suspected with all the following EXCEPT:
a. leg pain while sitting
b. skin discoloration and scaling
c. claudication pain after less than a 50 ft walk
d. constant forefoot pain
a
107
Thoracic outlet syndrome can include all of the following presentations EXCEPT:
a. pain with arm in neutral position
b. neurologic pain
c. edema of the arm and forearm
d. pain with arm elevated above the head
a
108
Which of the following is NOT a method to obtain arterial waveforms from the extremities or digits?
a. plethysmography
b. photoplethysmography
c. CW Doppler
d. segmental systolic pressure
b
109
To ensure accuracy of data, particularly for recording segmental systolic pressures, how long should the patient be allowed to rest?
10-15 minutes
110
What is the appropriate size for a blood pressure cuff to be used on an extremity to ensure the accuracy of data obtained for systolic pressure determination?
20% wider than the diameter of the limb segment
111
All the following can result in inaccurate systolic pressure measurements in the lower extremities EXCEPT:
a. the cuff is too narrow
b. the dorsalis pedis artery is used to listen to the signal
c. the limb segment is elevated above the heart
d. the deflation rate is too fast
b
112
What will the use of a 4-cuff versus a 3-cuff method to estimate arterial disease in the lower extremities help determine?
whether disease is present at the iliofemoral level
113
Which of the following are clear diagnosis criteria to estimate disease between two limb segments when using systolic pressure determination?
a. a drop of more than 30 mm Hg between the proximal and immediate distal segment
b. an increase of more than 30 mm Hg between the proximal and immediate distal segments
c. a drop of 50 mm Hg between the proximal and immediate distal segments
d. an increase of 50 mm Hg between the proximal and immediate distal segments
a
114
Which of the following is NOT a common method to induce symptoms with exercise in a patient suspected to have arterial insufficiency but relatively normal results at rest?
a. using a treadmill for walking with a set protocol
b. having the patient walk at own pace until symptoms occur
c. having the patient perform heel raises until symptoms occur
d. raising the limb above the heart while the patient is supine on the examination table
d
115
Which of the following is NOT one of the main advantages of pulse volume recording (PVR)?
a. records overall segment perfusion
b. can give data even with calcified arteries
c. is easy and quick to perform
d. provides quantitative values
d
116
Which of the following would most likely be used to describe CW Doppler waveforms that occur distal to a hemodynamically significant stenosis?
a. triphasic
b. biphasic; bidirectional
c. monophasic; moderate/severe
d. multiphasic
c
117
When the arteriolar bed cannot dilate further and blood flow to the extremity is reduced due to proximal arterial disease, what symptoms will the patient likely experience?
forefoor pain at rest
118
What is the main pitfall in the interpretation of PVR waveforms and other physiologic data?
inability to differentiate between stenosis and occlusion
119
What is the most convenient (and reliable) technique to obtain digital pressures while using a small digital cuff?
PPG
120
What is the most convenient technique to record changes of arterial insufficiency with thoracic outlet syndrome with a specifiic (and sometimes tailored_ set of maneuvers?
PPG on a digit
121
What is the typical skin color changes (in the hands and fingers) associated with Raynaud's disease from room temperature to exposure to cold temperautre and ending with rewarming?
white, blue, red
122
The Allen test should be performed before all the following procedures EXCEPT:
a. creation on arteriovenous fistula
b. creation of dialysis access
c. harvest of the cephalic vein for bypass
d. harvest of the radial artery for a coronary bypass
c
123
The Allen test is typically performed by placing a PPG sensor on the middle or index finger to record digital perfusion while:
the radial and ulnar arteries are compressed sequentially
124
Using PPG sensor on a digit demonstrating signs of increased vasospasm from primary Raynaud's disease, what characteristic will the waveform typically display?
a peaked pulse on the anacrotic portion
125
Most often, symptoms of arterial disease are described as "intermittent" claudication because the symptoms occur ____.
with activity
126
Symptoms observed or described with intermittent claudication can determine the site of disease because the disease is _____ to the site of symptoms.
distal
127
Lower extremity symptoms that require sitting and/or spinal flexure to relieve is usually associated with _____.
spinal stenosis
128
Elevation pallor and dependent rubor is usually observed with _____ arterial disease.
severe peripheral
129
The cause of primary Raynaud's disease is _____.
idiopathic
130
PAOD in the upper extremities occurs in _____ of all cases.
less than 5%
131
Nonimaging, indirect tests for arterial disease help determine overall limb _____ and serve as an indicator of the functional status of the limb.
perfusion
132
The ideal positioning of patients for indirect arterial testing should take great care that all extremities are not elevated above ____.
the heart
133
For recording of accurate segmental systolic pressures, it is important not only to ensure the cuff is appropriately sized for the limb segment but also to allow the patient to _____ before beginning the exam.
rest
134
An ideal cuff deflation rate for accurately determining the return of Doppler signal when measure systolic pressure at any segment should be approximately ____.
3 mm Hg
135
The lowest limit of an ABI to be considered within normal range at rest is _____.
0.9
136
The presence of differing ipsilateral resting normal and abnormal ankle pressures indicates that PAOD is isolated to ______.
single tibial artery
137
A change in ABI of _____ between repeat studies indicates a significant change associated with worsening of PAOD.
0.15
138
When recording pressures from sites proximal to the ankle, the vessel (PTA or DPA) with the ______ pressure is used to obtain the Doppler signal.
higher systolic
139
Systolic pressures are invalid when the underlying artery is _____ and incompressible.
calcified
140
Under normal conditions (absence of disease), the high-thigh pressure using a 4-cuff method will usually be at least _____ greater than the normal brachial pressures.
30 mm Hg
141
In the upper extremities, using segmental pressure as diagnostic criteria, significant disease will be likely when a drop of at least _____ is recorded between two consecutive segments (from proximal to immediately distal segments)
20 mm Hg
142
ABIs returning to resting values more than 10 minutes postexercise are a good indication of _____.
PAOD at multiple levels
143
Independent of the increasing discussion about the "correct" nomenclature to be used to describe continuous-wave Doppler waveforms, a normal CW Doppler waveform from an artery of the lower extremity should be ______.
bidirectional
144
The typical cuff inflation for segmental pulse volume recording (PVR) is _____.
55-65 mm Hg
145
CW Doppler and PVR waveforms analysis are examples of ______ criteria for the diagnosis of arterial disease.
qualitative
146
An abormal PVR waveform demonstrates delayed onset to peak, rounding and flattening of the peak, and a diastolic component that becomes _____.
convex
147
A normal TBI should be at least ____.
0.8 or greater
148
A positive TOS study will result in the PPG waveform becoming _____ as well as the patient developing systems/.
flattened
149
Testing for increased sensitivity to cold using immersion in ice water should only be used in patients with suspected ____.
primary Raynauds disease
150
A patient with left thigh claudication will most likely have disease present at which of the following levels?
a. aortic occlusive disease
b. left iliofemoral disease
c. aortoiliac occlusive disease
d. left superficial femoral artery disease
b
151
A patient with thigh and calf pain that is associated with exercise and also with standing that can be relieved with sitting or by moving into a different position is most likely due to:
spinal stenosis
152
What is a contraindication to immersing the hands in ice water to detect cold sensitivity?
secondary Raynaud's
153
What is the maximum time for digit temperatures to return to pre-cold water immersion levels, to rule out cold sensitivity?
< 10 minutes
154
A notch on the upstroke (anacrotic) portion of a finger pulse waveform is consistent with which clinical condition?
a. ipsilateral brachial artery occlusion
b. vasospasm
c. ipsilateral dialysis fistula
d. vasodilation
b
155
Measuring the systolic pressure with the point of measurement at the same horizontal level as the heart helps avoid artifacts due to:
hydrostatic pressure
156
What is the normal drop in mean arterial pressure from the heart to the ankle?
10 mm Hg
157
Which of the following statements about the four-cuff versus three-cuff method of determining segmental pressures in correct?
a. the four-cuff method allows the separation of iliofemoral disease from superficial femoral artery disease
b. the four-cuff method allows for separation of superficial femoral from popliteal level disease
c. The four-cuff method allows for lower thigh cuff inflational pressures
d. The four-cuff method allows for more accurate determination of pressure because the narrower cuffs used are the same size as the width of the leg.
a
158
Arterial occlusive disease in the upper extremities is most likely found in which arteries?
subclavian and proximal axillary
159
A brachial blood pressure difference greater than 20 mm Hg is associated with which of the following?
a. A >50% diameter reduction in either the subclavian or proximal axillary arteries
b. A >75% diameter reduction in only the subclavian arteries
c. A >50% diameter reduction in only the subclavian arteries
d. A >75% diameter reduction in either the subclavian or proximal axillary arteries
d
160
A treadmill exercise stress test is typically conducted using the following parameters:
0-10% grade and 1 to 2 mph
161
Contraindications to treadmill exercise include all of the following EXCEPT:
a. arrythmias
b. hypertension with systolic pressures >180 mm Hg
c. Age >75 yeras
d. chest pain
c
162
Which of the following is a technique that can be used to reduce interference from adjacent veins during acquisition of Doppler waveforms?
a. elevate the patient's legs, such that their ankles are higher than the level of their heart
b. Have the patient hold their breath for a few cardiac cycles
c. Inflate a cuff distal to 30 mm Hg to the artery being insonated
d. Have the patient take a long slow inspiration during the capture of the arterial waveforms.
b
163
What is the proper transducer angle to use while obtaining a Doppler waveform?
45 degrees to the skin surface
164
Which of the following statements about flow reversal in a peripheral artery is incorrect?
a. no flow reversal is present in low resistance limbs
b. the greater the resistance to flow, the greater the reverse flow component
c. An incompetent aortic valve may impact flow reversal
d. Flow reversal is maintained in the presence of a functioning dialysis fistula
d
165
Pulse volume recordings reflect:
total perfusion in the underlying segment under the cuff
166
Which of the following statements about photoplethysmography is incorrect?
a. they detect underlying blood flow as 1 to 3 mm depths.
b. they detect total limb blood flow
c. They cannot be calibrated
d. They transmit an infrared light into the tissue
b
167
Which of the following positions is not sued when testing for thoracic outlet syndrome?
a. supine with arms at the side
b. the position that elicitis symptoms
c. the arms abducted rearward
d. the Adson maneuver
a
168
What is the percentage of normal, asymptomatic individuals that can elicit a positive finding on a TOS test?
60%
169
Which of the following is not a possible etiology for secondary Raynaud's?
Takaysu's arteritis
170
Pain in large muscle groups caused by activity; pain may be described as fatigue, cramping, aching, or tiredness; usually occurs in calf, thigh, or buttocks
Intermittent claudication
171
Site of symptoms of intermittent claudication occurs ____ to the site of disease.
distal
172
True claudication symptoms are relieved with _____.
quiet standing
173
Diseases that may mimic claudication include:;
spinal stenosis
herniated disk
osteoarthritis
174
What is rest pain?
pain in foot while patient is lying down; represents increasing severity of disease
175
Thickening of toenails and loss of toe hair
skin discoloration and scaliness
elevation pallor/dependent rubor
ulceration/gangrene
Advanced PAOD
176
Blue toes may indicate:
aneurysmal disease
177
It is important to let the patient rest for ______ minutes before beginning exam.
10-15
178
Cuff width should be ____ wider than the diameter of underlying limg.
20%
179
If the cuff is too narrow:
falsely elevated pressure
180
if the cuff is too wide
falsely lower pressure
181
For ABIs, cuffs are placed at:
upper arm
ankle
182
For multilevel lower extremity pressures, cuffs are placed:
upper arm
thigh
calf
ankles
183
Doppler signal is obtained ____ to the cuff/
distal
184
The cuff should be inflated ___ mm Hg above point where signal disappears.
20
185
Cuff should be deflated at a rate of about ___ mm Hg/s
3
185
Systolic pressure ratios calculated by:
dividing highest systolic ankle pressure by the higher of the two brachial systolic pressures
186
ABI >1.30
incompressible
187
ABI 0.90-1.30
normal
188
ABI 0.75-0.89
mild
189
ABI 0.50-0.74
moderate
190
ABI <0.50
severe
191
ABI <0.35 t
tissue threatening
192
Normal ABI is about ___.
1.0
193
A change of ____ between repeat studies in considered significant.
0.15
194
_____ ABI values correspond to worsening PAOD.
Lower
195
Excessibly high ABI values typically correspond to:
calcified arteries
196
Systolic pressures usually _____ as blood flows distally in the lower extremity.
increase
197
Pressure drop ____ mm Hg indicates presence of proximal obstruction
>30
197
Any reduction is distal pressure should be _______ mm Hg between adjacent segmant.
<30
198
Doppler waveforms proximal to knee are _____.
multiphasic
199
Plethysmography waveforms exhibit a ______.
dicrotic notch
200
Resting and postexercise ABIS are _____.
0.90-1.30
201
Resting and postexercise toe-brachial indices are ____.
>0.80
202
Single (wide) above knee cuff systolic pressure _____ than brachial.
equal to or higher
203
High thigh (narrow) cuff systolic pressure > 30 mm Hg _____ higher brachial.
above
204
Difference between adjacent limb segments is ______ mm Hg.
less than or equal to 30
205
Difference between brachial systolic pressures is _____ mm Hg.
less than or equal to 20
206
ABI that returns to pre-exercise level within ___ minutes associated with single-level disease.
5
207
ABI that returns to pre-exercise level _____ minutes associated with multilevel disease.
>10
208
Normal Doppler waveforms are _____.
multiphasic
209
PAOD reduces flow energy ____ to the lesion.
distal
210
Normal PVR waveforms should include:
Rapid upstroke with well-defined peak
Notch on downstroke in early diastole
return to baseline through remainder of diastole
211
Moderate to severe disease PVR waveforms:
delayed onset to peak
round peak
diastolic phase becomes convex (bows out rather than toward the baseline)
212
Normal TBI
greater than or equal to 0.8
213
Toe pressure of ___ mm Hg indicates adequate pressure for healing.
50
214
PAOD occurs in the upper extremity typicall as _____ and ______.
positional extrinsic compression (TOS syndrome)
cold related vasospasm (Raynaud's disease or phenomenon)
215
Numbness, aching, or tiredness with positional changes of the shoulder
Thoracic outlet syndrome
216
Primary raynaud's has an _____ etioloy.
idiopathic
217
Secondary Raynaud's is associated with:
underlying condition such as scleroderma or trauma
218
If PAOD is found in upper extremity, it is most likely in the _____ and _______ arteries.
subclavian
proximal axillary
219
>___ mm Hg difference in brachial systolic pressures indicates presence of subclavian artery stenosis.
20
220
Normal DBI
> or equal to 0.9
221
Patients with suspected ________ should not have hands immersed in ice water.
secondary Raynaud
222
Used to determine digital perfusion prior to certain surgical procedures
the Allen test
223
