Pathology Pt 1

Question 1

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

Answer 1

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.

Question 2

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

Answer 2

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.

Question 3

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

Answer 3

D
Bilateral swelling is associated with renal disease, CHF, lymphedema, and IVC thrombosis. Left popliteal DVT would cause unilateral swelling of the left leg.

Question 4

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

Answer 4

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.

Question 5

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

Answer 5

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.

Question 6

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

Answer 6

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.

Question 7

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

Answer 7

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.

Question 8

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

Answer 8

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.

Question 9

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

Answer 9

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.

Question 10

A Greenfield filter is used to prevent which of the following?
A. cardiac tamponade
B. DVT
C. blue toe syndrome
D. pulmonary embolism

Answer 10

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.

Question 11

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

Answer 11

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.

Question 12

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

Answer 12

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.

Question 13

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

Answer 13

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.

Question 14

The most common location of a Baker cyst it:
A. inguinal canal
B. medial antecubital fossa
C. medial popliteal fossa
D. anterior patellar space

Answer 14

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.

Question 15

Vertigo is a common symptom related to disease of which of the following vessels?
A. MCA
B. ACA
C. ICA
D. basilar

Answer 15

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.

Question 16

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

Answer 16

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.

Question 17

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

Answer 17

D
The Hemispheric index is calculated using the MCA peak systolic velocity and dividing it by the distal ICA peak systolic velocity.

Question 18

The renal-aortic ratio is invalid in patients with:
A. abdominal aortic aneurysm
B. diabetes
C. medullary sponge kidney
D. renal vein thrombosis

Answer 18

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.

Question 19

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

Answer 19

A
The Doppler waveform at a focal ICA stenosis will demonstrate increased peak systolic velocity and increased end diastolic velocity.

Question 20

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

Answer 20

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.

Question 21

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

Answer 21

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.

Question 22

Which of the following signs/symptoms is not an expected finding with a carotid sinus massage?
A. hypotension
B. urticaria
C. bradycardia
D. dizziness

Answer 22

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.

Question 23

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

Answer 23

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.

Question 24

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

Answer 24

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.

Question 25

``` 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 ```

Answer 25

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.

Question 26

``` What arteries are most commonly affected by Takayasu arteritis? A. calf B. subclavian and common carotid C. subclavian and brachial D. forearm ```

Answer 26

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.

Question 27

``` Which type of aortic aneurysm is associated with an infection of the arterial wall? A. mycotic B. saccular C. berry D. ectatic ```

Answer 27

A | A mycotic aneurysm is caused by infection of the arterial wall which weakens it and allows aneurysm formation.

Question 28

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

Answer 28

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.

Question 29

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

Answer 29

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.

Question 30

``` 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 ```

Answer 30

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.

Question 31

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

Answer 31

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.

Question 32

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

Answer 32

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.

Question 33

``` _______ 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 ```

Answer 33

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.

Question 34

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

Answer 34

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)

Question 35

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

Answer 35

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.

Question 36

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

Answer 36

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.

Question 37

``` 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 ```

Answer 37

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.

Question 38

``` 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 ```

Answer 38

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.

Question 39

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

Answer 39

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.

Question 40

``` 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 ```

Answer 40

B | Hemodynamically significant stenosis of the celiac axis is diagnosed with the PSV greater than 2.0 m/s.

Question 41

``` 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 ```

Answer 41

C Insufficiency of the posterior arch vein (posterior accessory saphenous vein) and perforators is most commonly related to ulcer formation.

Question 42

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

Answer 42

A | The aortic velocity should be obtained at the level of the renal artery origins when evaluating renal arterial flow.

Question 43

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

Answer 43

B TIA = stroke symptoms lasting 24 hrs or less CVA = stroke symptoms lasting more than 24 hrs

Question 44

``` Which of the following is related to chronic DVT? A. wet ulceration B. swelling and erythema C. dry ulceration D. engorged, non-compressible vein ```

Answer 44

A Ulcerations take time to form. They are a sign of chronic venous disease. Venous ulcers are wet and arterial ulcers are dry.

Question 45

``` 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 ```

Answer 45

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.

Question 46

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

Answer 46

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.

Question 47

``` 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 ```

Answer 47

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.

Question 48

``` Which of the following is a symptom usually related to vertebrobasilar disease? A. expressive aphasia B. unilateral visual disturbances C. dysphagia D. receptive aphasia ```

Answer 48

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.

Question 49

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

Answer 49

C When calculating the ICA/CCA peak systolic velocity ratio, use the distal CCA PSV and the ICA PSV obtained with the highest velocity.

Question 50

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

Answer 50

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.

Question 51

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.

Answer 51

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.

Question 52

``` 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 ```

Answer 52

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.

Question 53

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

Answer 53

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".

Question 54

``` 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 ```

Answer 54

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.

Question 55

``` What is the most common lower extremity venous disorder? A. superficial thrombophlebitis B. May Thurner Syndrome C. DVT D. venous insufficiency ```

Answer 55

D | Venous insufficiency is the most common venous disorder.

Question 56

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

Answer 56

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.

Question 57

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

Answer 57

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.

Question 58

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

Answer 58

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.

Question 59

``` 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 ```

Answer 59

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.

Question 60

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

Answer 60

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.

Question 61

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.

Answer 61

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.

Question 62

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

Answer 62

A | The soleal vessels drain into the peroneal and posterior tibial veins of the calf.

Question 63

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

Answer 63

C The mean velocity demonstrates a significant increase at a depth of 105mm which is consistent with stenosis in the basilar artery.

Question 64

``` 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 ```

Answer 64

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.

Question 65

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

Answer 65

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.

Question 66

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

Answer 66

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.

Question 67

``` 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 ```

Answer 67

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.

Question 68

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

Answer 68

C Cross over collateralization occurs when flow from the left ACA moves into the right ACA through the anterior communicating artery.

Question 69

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

Answer 69

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.

Question 70

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

Answer 70

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.

Question 71

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

Answer 71

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.

Question 72

``` 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 ```

Answer 72

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.

Question 73

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

Answer 73

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.

Question 74

``` 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 ```

Answer 74

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.

Question 75

``` 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 ```

Answer 75

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.

Question 76

``` 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 ```

Answer 76

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.

Question 77

A patient presents for a carotid ultrasound. The chart states there is a history of dilated cardiomyopathy and an intra-aortic balloon pump is present. Which of the following correctly describes how to evaluate the patient for carotid stenosis? A. the patient should be rescheduled until after the pump is removed because there is no way to evaluate carotid stenosis while a pump is active B. waveforms from the common carotid artery will have two systolic peaks and the first one should be measured to determine the peak velocity C. the peak systolic velocity is invalid, but the end diastolic velocity should be measured D. waveforms from the common carotid artery will have two systolic peaks and the second one should be measured to determine the peak velocity

Answer 77

B IABP assisted waveforms have 2 systolic peaks for each pulse. The first peak indicates the left ventricular contraction. The second peak indicates the balloon inflation. EDV cannot be determined in the patients with an IABP because flow reversal is commonly seen after the balloon deflation. If possible, turn off the IABP during carotid evaluation. If this is not possible, velocity from the first peak should be used as the PSV.

Question 78

``` Flow distal to a significant stenosis will exhibit which of the following characteristics? A. higher resistance flow B. lower resistance flow C. increased velocity D. increased resistive index ```

Answer 78

B | Flow distal to a significant stenosis will demonstrate reduced velocity and resistance.

Question 79

The most common location of valvular insufficiency is: A. great saphenous and common femoral vein junction B. superficial and deep femoral vein junction C. short saphenous vein D. calf vein confluence

Answer 79

A The most common location of valvular insufficiency is at the SFJ (junction of great saphenous and common femoral vein junction).

Question 80

How do the microbubbles in an ultrasound contrast agent change the image? A. microbubbles cannot be used to evaluate arterial flow due to embolism risk B. increase the reflectivity of flowing blood C. increase the resistance to flowing blood to make it more visible D. increase vasodilation to move the bubbles more quickly so they are visible to ultrasound

Answer 80

B | Microbubbles in an ultrasound contrast agent increase the reflectivity of flowing blood.

Question 81

A patient presents for a lower extremity venous Doppler exam due to a history of Klippel-Trenaunay-Weber Syndrome. What are the expected findings on the exam? A. extensive acute DVT causing volume overload of the superficial venous system B. extensive chronic DVT causing volume overload of the superficial venous system C. extensive atherosclerosis of the arterial system causing volume overload of the superficial venous system D. absence of the deep veins in the leg with multiple dilated varicosities present

Answer 81

D Klippel-Trenaunay-Weber Syndrome refers to congenital absence of the deep veins which causes numerous prominent superficial varicosities.

Question 82

``` When a water hammer pulse is identified in the carotid arteries, what cardiac complication should be suspected? A. severe mitral stenosis B. severe mitral regurgitation C. severe aortic regurgitation D. severe tricuspid regurgitation ```

Answer 82

C Blood moves back through the aortic valve into the left ventricle during diastole. It is usually caused by diseased valve, congenital defects and chamber or aortic dilatation. Significant regurgitation results in volume overload in the chamber receiving the retrograde blood flow. With aortic regurgitation, volume overload occurs in the left ventricle. Pulsus bisferiens can occur in the carotid arteries. The waveforms will demonstrate double systolic peaks. Severe regurgitation is associated with diastolic flow reversal in the carotid arteries (Water Hammer Pulse).

Question 83

``` Which of the following is not a common risk factor for varicose vein formation? A. smoking B. post-phlebitic syndrome C. pregnancy D. standing for long periods daily ```

Answer 83

A | Smoking is a risk factor for atherosclerotic disease.

Question 84

You receive an order for an upper extremity arterial exam to rule out Buerger disease. What is the preferred method of evaluation? A. evaluate the smaller arteries of the arm with Duplex and PPG techniques B. evaluate the hands for vascular changes with cold sensitivity testing C, evaluate the arterial flow at rest and with exercise D. evaluate the arteries of the shoulder for extrinsic compression with movement

Answer 84

A Buerger disease refers to obstruction of the smaller arteries in the hands and feet. It is more common in males and smokers.

Question 85

What is the most accurate sonographic indicator for the presence of DVT? A. flow abnormalities found with PW Doppler B. loss of augmentation response C. lack of compressibility D. flow abnormalities found with Color Doppler

Answer 85

C | The most accurate sonographic indicator for the presence of DVT is non-compressibility of the vein.

Question 86

Which of the following describes the correct protocol for evaluating suspected popliteal entrapment? A. use Doppler to evaluate the flow in the distal femoral artery at rest and with plantar extension B. evaluate the toe pressures at rest and during plantar extension C. use Doppler to evaluate the flow in the popliteal vein at rest and with plantar flexion D. use Doppler to evaluate the flow in the popliteal artery at rest and with plantar flexion

Answer 86

D Popliteal entrapment involves the intermittent compression of the popliteal artery with flexing of the calf muscle. Arterial inflow is reduced causing pain in the calf muscle and foot due to ischemia. The velocity of the flow in the vessel is important to evaluate the degree of stenosis that is caused by movement. PPG is the preferred method of evaluation but Doppler evaluation can also be used.

Question 87

``` If greater saphenous venous flow velocity is approximately 20cm/s and appears continuous, which other vessel should be evaluated for a cause for the flow abnormality? A. internal iliac vein B. profunda vein C. short saphenous vein D. femoral and popliteal vein ```

Answer 87

D Venous perforators normally send flow from the superficial system into the deep system. If the deep system of the thigh/popliteal fossa has occlusive thrombus, the flow in the GSV will be rerouted to the groin to enter the common femoral vein. The increased flow will increase the velocity in the GSV and cause a continuous flow pattern.

Question 88

``` A clot is identified in two of the gastrocnemius veins. The physician recommends warm compresses, leg elevation and a follow up exam in 2 weeks. The follow up exam is ordered to ensure the clot does not propagate up the leg. What vessel should be carefully evaluated on the follow up exam? A. anterior tibial vein B. popliteal vein C. peroneal vein D. deep femoral vein ```

Answer 88

B | Gastrocnemius thrombosis will first extend into popliteal vein.

Question 89

Which of the following carries an increased risk of pulmonary embolism? A. portal vein thrombosis B. thrombus accumulation in an aortic aneurysm C. renal vein thrombosis D. common femoral artery thrombosis

Answer 89

C A clot in the systemic venous system can break loose and travel to the lungs. The renal veins drain into the IVC. The portal system does not directly communicate with the systemic veins, so a clot in the portal vein cannot lead to pulmonary embolism. An embolus in the arterial system will only travel until it becomes lodged in a smaller distal artery and cause ischemia.

Question 90

A tardus parvus waveform is the result of: A. significant proximal arterial stenosis B. distal arterial obstruction C. <50% proximal arterial stenosis D. partial venous obstruction

Answer 90

A A. tardus parvus waveform is associated with significant stenosis that severely decreases flow through an artery. This waveform is described as low velocity and resistance with a late systolic peak.

Question 91

``` The most common location of atherosclerotic formation in the cerebrovascular system? A. carotid bifurcation B. vertebrobasilar system C. circle of Willis D. ophthalmic and orbital arteries ```

Answer 91

A | The most common location of atherosclerotic formation in the cerebrovascular system occurs at the carotid bifurcation.

Question 92

``` A patient with RUQ abdomen pain and bloating is referred to rule out Budd Chiari syndrome. What vessels will be evaluated for this diagnosis? A. hepatic veins B. renal veins C. renal arteries D. aorta, SMA and celiac axis ```

Answer 92

A Budd Chiari syndrome refers to chronic obstruction of the hepatic veins. It can be related to thrombus formation and extrinsic compression of the vessels.

Question 93

If an acute left ICA occlusion is present, which of the following statements is true? A. the right MCA flow will be decreased or absent with flow reversal in the right internal carotid siphon B. the right MCA will demonstrate decreased or absent flow C. the left ophthalmic artery will demonstrate decreased or absent flow D. the right ophthalmic artery will demonstrate decreased or absent flow

Answer 93

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.

Question 94

``` Which of the following has no effect on the severity of an arterial stenosis? A. valvular competence B. vessel radius C. polycythemia vera D. peripheral resistance ```

Answer 94

A | The veins contain valves, not the arteries. Valvular incompetence will not affect arterial stenosis.

Question 95

``` _________ uses a catheter with a rotating head to break up the plaque and suction capabilities to remove it from the artery. A. an angioplasty procedure B. an endarterectomy procedure C. a valvulotome procedure D. an atherectomy procedure ```

Answer 95

D Atherectomy uses a catheter with a rotating head and suction capabilities to break up the plaque and remove it from the artery. Angioplasty uses a balloon tipped catheter to compress the atheroma and expand the vessel lumen. An endarterectomy refers to when the carotid artery is lacerated, and the atheroma formation is scraped for removal. A valvulotome procedure is used to remove valves from inside a vein.

Question 96

``` Which intracranial artery is most commonly associated with stroke? A. PCA B. ACA C. basilar D. MCA ```

Answer 96

D The MCA is a continuation of the distal ICA. Embolism from an ICA stenosis will most likely lodge in the MCA unless it is small enough to pass through into the circle of Willis.

Question 97

A patient presents for an upper extremity venous Doppler evaluation due to bilateral arm and face swelling. There are also varicosities visible on the upper chest wall. These symptoms are most consistent with: A. congestive heart failure and venous stasis B. occlusive thrombus in the superior vena cava C. occlusive thrombus in the internal jugular vein D. more than one of the above

Answer 97

B Chest wall varices, facial and bilateral arm swelling are indicative of SVC thrombosis. IJV thrombosis can be related to facial swelling but the arm would not be affected. CHF usually causes swelling in the legs.

Question 98

A patient presents with persistent calf pain after a recent biking accident and spending a few days on bed rest. After visual inspection of the right leg (image of swollen right leg), what type of vascular exam should be performed? A. lower extremity venous Doppler B. lower extremity arterial Doppler C. soft tissue exam to rule out hematoma formation D. segmental pressure exam

Answer 98

A The significant difference in size demonstrates fluid accumulation in the swollen leg. The recent trauma and few days of stasis while on bed rest most likely caused a DVT to form in the leg.

Question 99

``` Amaurosis fugax can be described as: A. CVA of the eye B. CVA of the frontal lobe C. TIA of the frontal lobe D. TIA of the eye ```

Answer 99

D | Because the symptom of amaurosis fugax is usually fleeting, it is termed a transient ischemic attack of the eye.

Question 100

A patient presents for a lower extremity venous Doppler to rule out venous insufficiency. Which vessels should be completely evaluated for the exam? A. femoral and popliteal veins B. great and short saphenous veins C. iliac, femoral and great saphenous veins D. femoral, popliteal, short saphenous and great saphenous veins

Answer 100

D The deep veins should be evaluated for thrombus before the reflux exam is performed. The deep veins should also be evaluated for reflux along with the superficial veins.

Question 101

``` The images displayed are from a renal Doppler exam on a 15 year old female with significant HTN. What is the most likely cause for the abnormality demonstrated (increased velocity seen in renal arteries)? A. fibromuscular dysplasia B. atherosclerotic disease C. infrarenal AAA D. suprarenal AAA ```

Answer 101

A The bilateral presentation of renal stenosis in a pediatric patient is most likely due to a diffuse disorder of congenital or idiopathic nature. Atherosclerosis formation is a chronic disease. Suprarenal AAA would reduce the blood flow to the kidneys increasing the BP but would not cause the increase in velocity in the arteries.

Question 102

Why is the carotid compression technique performed? A. to evaluate the carotid as a potential arterial graft B. to evaluate the effects of vasospasm C. to evaluate the presence of intracranial collateral formation D. to evaluate the venous outflow of the intracranial vessels

Answer 102

C Carotid Compression Test is performed by a PHYSICIAN ONLY! Used to evaluate the risk for carotid treatment; compress unilateral CCA for approximately 5 minutes, if no symptoms occur, collateral are present that are compensating for reduced flow.

Question 103

Which of the following describes an abnormal response to proximal augmentation? A. flow reversal begins upon release of the augmentation maneuver B. no flow reversal occurs with proximal augmentation, but will occur with distal augmentation C. flow reversal begins at the onset of the augmentation maneuver D. long venous refill time

Answer 103

C If the proximal thigh is squeezed while evaluating the distal GSV, flow reversal will occur as soon as you start to squeeze. The Valsalva maneuver can also be used for proximal augmentation. Flow reversal begins at the start of the Valsalva strain.

Question 104

``` How is Heparin administered to a patient with DVT? A. orally B. intravenous C. intra-arterial D. subcutaneous injection ```

Answer 104

B DVT treatment can include 5-10 day dose of intravenous Heparin to prevent clot extension but it does not lyse current thrombus.

Question 105

``` What is the minimum % ICA stenosis that is considered hemodynamically significant and treatment is recommended? A. 95% B. 75% C. 70% D. 80% ```

Answer 105

C | A hemodynamically significant stenosis requiring intervention is defined as 70-99% blockage of the ICA.

Question 106

Wernicke aphasia is defined as: A. inability to speak but can understand others B. inability to understand speech, speak, or follow directions C. inability to swallow liquids D. inability to swallow solid foods

Answer 106

``` B Wernicke aphasia (AKA receptive aphasia) is defined as the inability to understand speech, speak, or follow directions. ```

Question 107

Congestive heart failure causes increased pulsatility in the: A. iliac veins and portal veins B. bilateral carotid arteries C. bilateral superficial femoral arteries D. renal arteries and veins

Answer 107

A CHF causes reduced cardiac output and a backlog of flow in the venous system. The systemic and portal venous system can demonstrate increased pulsatility with CHF. The decreased cardiac output can reduce pulsatility in the distal arterial system.

Question 108

``` Which of the following arteries are evaluated during a penile duplex exam for erectile dysfunction? A. dorsal B. cavernosal C. ventral D. urethral ```

Answer 108

B A penile duplex exam can be performed to evaluate a vascular cause of the erectile dysfunction. The cavernosal artery diameters and velocities are evaluated before and after an injection of vasoactive substance. The dorsal vein is also evaluated.

Question 109

``` Renal artery stenosis is considered hemodynamically significant when it is greater than ______. A. 50% B. 60% C. 70% D. 80% ```

Answer 109

B | Renal artery stenosis is considered hemodynamically significant when it is greater than 60%.

Question 110

If there is a 90% stenosis in the left carotid siphon, which of the following is true? A. left MCA flow will be high resistance B. left vertebral flow will be high resistance C. left ICA flow will be high resistance D. right MCA will be high resistance

Answer 110

C | Distal stenosis will lead to high resistance flow proximally = ICA high resistance with siphon stenosis.

Question 111

``` An AV malformation is most commonly caused by: A. recent angiography procedure B. trauma C. a congenital defect D. hemodialysis access ```

Answer 111

C | An AVM is a congenital defect. An AVF is caused by trauma or an interventional procedure.

Question 112

A 32yr old construction worker fell 15ft at work. He was treated and released by the ER 36hrs prior. He now presents with acute hemiparesis and dysphasia. These clinical findings are most suggestive of: A. basilar artery rupture B. spontaneous intracerebral aneurysm rupture C. polycythemia vera D. carotid dissection

Answer 112

D A carotid dissection should be suspected with trauma. Spontaneous intracerebral aneurysm rupture and basilar artery rupture would cause critical loss of blood within the cranium. In most cases death would be eminent within hours. At 36hrs post trauma, these two diagnoses are very unlikely.

Question 113

``` Which of the following symptoms would most be suggestive of significant disease in the middle cerebral artery (MCA)? A. ipsilateral face and arm paresis B. contralateral face and arm paresis C. contralateral leg paresis D. ipsilateral leg paresis ```

Answer 113

B The MCA feeds the portions of the brain responsible for the face and arm motion. The right side of the brain controls the motor functions of the contralateral (left) side of the body and vice versa. MCA disease will cause symptoms in the contralateral arms and face. The ACA is responsible for supplying the brain tissue that controls the motor functions of the legs.

Question 114

``` Which of the following terms would be used to describe flow within an abdominal aortic aneurysm? A. triphasic flow B. non-laminar flow C. high resistance flow D. plug flow ```

Answer 114

B Flow within the AAA will be decreased in resistance and turbulent due to the swirling effect. Normal aortic flow is called plug flow. Flow in a AAA would be of many different velocities and is considered non-laminar.

Question 115

``` The Doppler tracing of the flow in a vessel just distal to a stenosis will demonstrate _______ than at the stenosis. A. greater bandwidth B. greater resistance C. more laminar flow D. greater Doppler shift ```

Answer 115

A Turbulence will cause a large range of different velocities (frequency shifts). The increased bandwidth is displayed as spectral broadening and irregular waveform contour (post stenotic turbulence).

Question 116

``` The diagnosis of the AAA is made once the aorta AP or width dimension exceeds ______. A. 2.5cm B. 3.0cm C. 3.5cm D. 4.0cm ```

Answer 116

B | The diagnosis of AAA is made once the aorta AP or width dimensions exceeds 3.0cm.

Question 117

``` A peak systolic velocity of 100cm/s is an indication of _______ in the ICA. A. normal flow B. mild stenosis C. moderate stenosis D. severe stenosis ```

Answer 117

A | The peak systolic flow velocity in the ICA is normal when it is less than 125cm/s.

Question 118

You are performing a TCD exam to assess collateral flow with a right ICA occlusion. You identify flow moving away from the transducer at 90cm/s with decreased pulsatility in the right ophthalmic artery. The left ophthalmic artery demonstrates flow moving toward the transducer with a velocity of 45cm/s. What is indicated by these findings? A. cross over collateralization B. ECA to ICA collateralization C. posterior to anterior collateralization D. normal flow parameters, no collateralization present

Answer 118

B The superficial temporal artery and the inferior maxillary artery are branches of the ECA that communicate with branches of the ophthalmic artery. Flow moves from the ECA to these branches and refills the ophthalmic artery to send flow back into the areas affected by the ipsilateral ICA occlusion.

Question 119

``` Which of the following is a sign or symptom of chronic DVT? A. positive Homan's sign B. warmth C. redness D. brawny discoloration ```

Answer 119

D Hyperpigmentation refers to brawny discoloration of the distal 1/3 of the calf. It is caused by cell debris and waste accumulating in the tissues outside the veins. Homan's sign refers to calf pain with quick dorsiflexion of the foot. This can be a sign of a DVT with the calf pain relating to the inability to pump out the blood when the muscle is quickly contracted. Swelling, warmth and redness are all related to venous stasis in the vessels below the area of DVT.

Question 120

``` Which of the following is NOT a potential acute complication of a liver transplant? A. portal vein stenosis B. cirrhosis C. portal thrombosis D. hepatic artery thrombosis ```

Answer 120

B Cirrhosis is a chronic liver disease. Thrombosis and extrinsic vessel narrowing/compression are acute complications that can occur in a liver transplant.

Question 121

``` Venous perforators with a diameter of _______ or greater will usually demonstrate reflux. A. 2mm B. 4mm C. 6mm D. 2cm ```

Answer 121

B | Normal perforator diameter is 2mm.

Question 122

Significant valvular disease in the right heart usually leads to: A. biphasic flow in the carotid arteries B. pulsatile flow in the lower extremity veins C. exaggerated respiratory phasicity in the portal vein D. tardus parvus waveforms in the carotid arteries

Answer 122

B Significant valvular disease in the right heart usually leads to pulsatile flow in the lower extremities, IVC and portal veins. Significant aortic disease can cause changes to the carotid artery flow. Aortic Stenosis - turbulent flow, post-stenotic flow changes. Aortic Regurgitation - pulsus bisferiens

Question 123

Which of the following describes symptoms of a patient with lymphedema? A. unilateral non-pitting edema that is unaffected by leg elevation B. warm, red calf with significant swelling C. unilateral left leg swelling that is relieved by elevating the legs for 30 minutes D. bilateral calf swelling with severe pitting edema

Answer 123

A Lymphedema does not normally cause skin discoloration, while acute DVT can be associated with warmth and redness. Lymphedema causes non-pitting edema, DVT causes pitting edema. Elevating the leg will have no effect on the swelling, but can reduce swelling associated with DVT. Lymphedema and DVT formation can affect one or both legs.

Question 124

Localized redness and warmth of the distal calf is most commonly associated with: A. anterior compartment syndrome B. cellulitis C. acute DVT formation in the popliteal vein D. acute arterial occlusion of the popliteal artery

Answer 124

B | Redness and warmth are most commonly seem with cellulitis but can be a symptom of acute DVT.

Question 125

Which of the following indicates a significant SMA stenosis? A. PSV > 200cm/s B. mesenteric - aortic ration > 2.5 C. pain in the abdomen when hungry that is relieved by eating/digestion D. dilated inferior mesenteric artery that is easily visualized sonographically

Answer 125

D The IMA is usually very tough to find in most patients with ultrasound. If the artery is visible and easily evaluated, it usually means it is dilated due to compensatory flow related to an SMA stenosis. A PSV greater than 2.75cm/s indicates significant stenosis. If the mesenteric - aortic ration exceeds 3.0, a significant stenosis is present.

Question 126

Which of the following is a characteristic of an ICA waveform with 50-69% stenosis? A. increased peak systolic and end diastolic velocity B. clear spectral window C. decreased diastolic flow with EDV less than 20cm/s D. diastolic flow reversal

Answer 126

A Stenosis in the ICA leads to increased systolic and diastolic flow velocities. Spectral broadening occurs with stenosis. Diastolic flow reversal in the ICA is identified with an occlusion distal to the Doppler sample.

Question 127

``` Which of the following is associated with spectral broadening? A. pulsatile flow B. blunted waveform C. laminar flow D. increased bandwidth ```

Answer 127

D Bandwidth refers to the difference between the highest and lowest frequencies in the pulse. Laminar flow has a narrow bandwidth of reflected signals because the blood cells are all moving at relatively the same speed. This allows for the display of a spectral window on the tracing. With turbulent flow, the blood cells are moving at many different velocities. This produces a wide bandwidth of reflected signals and the spectral window fills in.

Question 128

``` What is the main risk factor for a stroke? A. diabetes B. systemic HTN C. hyperlipidemia D. smoking ```

Answer 128

B | Systemic HTN is the main risk factor for stroke.

Question 129

Which of the following is not a characteristic of a high-grade stenosis? A. extremely high velocity signals at the site of stenosis B. spectral broadening just distal to the site of stenosis C. loss of pulsatility of waveform distally D. laminar flow just distal to the site of stenosis

Answer 129

D Turbulent flow is demonstrated distal to a stenosis of the vessel. Spectral broadening occurs due to the variety of blood cell velocities present and this results in the non-laminar flow patterns.

Question 130

``` Which of the following would be used to describe a Doppler waveform taken in the mid ICA with a critical stenosis of the proximal segment? A. peaked B. damped C. increased resistive index D. increased pulsatility index ```

Answer 130

B The Doppler waveform will be blunted and significantly damped downstream with a significant obstruction proximal to the point of insonation. There will be minimal diastolic flow, but no flow reversal.

Question 131

``` Elevated erythrocyte sedimentation rate and C-reactive protein (CRP) levels are associated with which of the following? A. fibromuscular dysplasia B. marfan syndrome C. giant cell arteritis D. Klippel Trenaunay syndrome ```

Answer 131

C | Giant cell arteritis is associated with elevated erythrocyte sedimentation rate and C-reative protein (CRP) levels.

Question 132

Which of the following statements is true regarding a partial venous obstruction? A. may cause continuous flow B. may cause phasic flow C. usually results in significant flow reversal during Valsalva maneuver D. May cause increased volume of flow seen with distal augmentation

Answer 132

A Partial DVT will decrease the flexibility of the venous wall causing a more continuous/less phasic flow pattern. Insufficiency is assessed using the Valsalva maneuver. The maneuver does not provide pertinent information related to the diagnosis of a partial DVT.

Question 133

``` An abnormality in all of the following vessels could potentially be related to vasculogenic impotence, except? A. external iliac artery B. common iliac artery C. aorta D. internal iliac artery ```

Answer 133

A The external iliac artery supplies blood to the leg. The internal iliac artery supplies blood to the branches that supply the penis. If there are flow abnormalities in the aorta, internal iliac artery or common iliac artery, this can lead to vasculogenic impotence.

Question 134

Schlerotherapy: A. is used to treat incompetent deep veins B. refers to the treatment of veins using a radiofrequency catheter C. involves the injection of saline into superficial varocosities D. refers to the treatment of deep venous reflux with compression stockings

Answer 134

C Sclerotherapy refers to the injection of saline or other sclerosing agent that damages the vein and causes fibrosis to occur. Ablation can be used to avoid surgical intervention in some cases, catheter based radiofrequency application can occlude the vessels leading to overall atrophy of the vessels.

Question 135

Which of the following correctly describes the standard protocol for performing cerebral angiography? A. the Seldinger technique is used to puncture the brachial artery in order to insert a catheter that will be advanced to the left ventricle for contrast administration B. the Seldinger technique is used to puncture the common carotid artery and inject contrast through a catheter C. the Seldinger technique is used to puncture the common femoral artery in order to insert a catheter that will be advanced to the left ventricle for contrast administration D. the Seldinger technique is used to puncture the common femoral artery in order to insert a catheter that will be advanced to the aortic arch for contrast administration

Answer 135

D The Seldinger technique is used to puncture the common femoral artery in order to insert a catheter that will be advanced to the aortic arch for contrast administration.

Question 136

Which of the following sonographic characteristics is most suggestive of renal vein thrombosis? A. reduced diastolic flow in the renal arteries B. prominent flow in the segmental and intralobar arteries C. turbulent venous flow within the kidney D. low resistance flow in the intrarenal arteries

Answer 136

A Renal vein thrombosis will demonstrate increased kidney size, hypoechoic renal cortex, decreased corticomedullary differentiation, mottled echogenicity, dilated renal vein and no intrarenal venous flow, and increased resistance in renal arteries. Diastoic flow is reduced in the segmental and intralobar arteries due to increased parenchymal resistance.

Question 137

While scanning a patient following a recent car accident you identify an arteriovenous connection in the left groin. How can you determine if this finding is related to the recent trauma or it is a congenital abnormality? A. Evaluate the deep veins for associated thrombus B. Perform a Doppler evaluation of flow within the connected vessels C. Locate the number of connections between the artery and the vein D. Determine the location of the arteriovenous connection

Answer 137

C A Congenital malformation (AVM) will usually have multiple connections between the artery and the vein. An AV fistula (AVF) caused by trauma is usually a single connection between the artery and vein. The other items listed would be possible exam techniques used to evaluate the patient, but they will not differentiate a congenital AVM from a traumatic AVF.

Question 138

``` If a patient complains of a recent onset of uncontrollable systemic HTN with average BP readings exceeding 170/90mmHg, what vascular cause should be suspected? A. subclavian stenosis B. portal HTN C. hepatic congestion D. renal artery stenosis ```

Answer 138

D A sudden increase in systemic BP with no response to medication is usually associated with renovascular HTN caused by renal artery stenosis.

Question 139

Which of the following is the most common cause of venous stasis ulcer formation on the distal medial calf? A. insufficiency in the paratibial perforators and the posterior arch vein B. insufficiency in the distal thigh perforators and the great saphenous vein C. insufficiency in the posterior tibial perforators and the posterior arch vein D. insufficiency in the proximal thigh perforators and the great saphenous vein

Answer 139

C Insufficiency in the posterior tibial perforators and the posterior arch vein most commonly leads to venous stasis ulcer formation on the distal medial calf.

Question 140

``` The most significant complication seen with DVT is __________. A. pulmonary embolism B. incompetent valves C. cardiac tamponade D. varicose veins ```

Answer 140

A Varicose vein formation is the most common complication of DVT and pulmonary embolism is the most significant complication of DVT. A pulmonary embolism occurs when a piece of thrombus breaks off and travels to the lungs. This occludes the bronchial artery and leads to the inability of the lungs to replace the oxygen in the blood. 15% of all cases of sudden death are PE related.

Question 141

``` Which of the following is least likely to be associated with renal artery stenosis? A. fibromuscular dysplasia B. scleroderma C. CREST syndrome D. May Thurner syndrome ```

Answer 141

D May Thurner syndrome involves the compression of the left common iliac vein against the lumbar vertebrae by the overlying right common iliac artery. Scleroderma and CREST syndrome involve systemic sclerosis of multiple vessels. Fibromuscular dysplasia is also associated with stenosis of the renal arteries.

Question 142

A patient presents for a 6 month follow up carotid ultrasound exam. The prior report states that there is an occlusion of the left ICA and internalization of the left ECA flow. What do you expect to see on today's exam? A. The left ECA will have a low resistance Doppler flow pattern similar to the waveform in a normal ICA B. Anatomic variation of the ECA where it is found within the cerebral tissues and connects to the circle of Willis, similar to the distal ICA. C. The right ECA will have a high resistance Doppler flow pattern similar to the ICA D. The ECA and ICA are transposed anatomically. The ICA has many branches with a smaller caliber and the ECA is larger with no visible branches

Answer 142

A The conversion of the ECA flow to more of an ICA flow pattern can occur with ICA occlusion and ECA collateral formation. If the ECA takes over the supply of the cerebral tissues, the flow within becomes low resistance with increased diastolic flow to accommodate the new organ that is now being supplied.

Question 143

``` A critical ICA stenosis will have what effect on the ipsilateral MCA flow? A. increased diastolic flow B. decreased diastolic flow C. no effect D. increased systolic flow ```

Answer 143

B A waveform distal to a critical stenosis will demonstrate a blunted monophasic waveform with minimal or absent diastolic flow.

Question 144

Why is aspirin prescribed for patients with atherosclerotic arterial disease? A. to reduce blood viscosity B. to increased blood volume in the venous system C. to increase platelet production D. to increase hemoglobin levels

Answer 144

A Aspirin reduces the risk of thrombus formality by inhibiting platelet aggregation. It thins the blood and allows it to move more freely through a narrowed vessel.

Question 145

``` The most accurate Doppler predictor of ICA stenosis is: A. the systolic ratio (ICAs/CCAs) B. the peak systolic velocity C. the end diastolic velocity D. the diastolic ratio (ICAd/CCAd) ```

Answer 145

C | The most accurate Doppler predictor if ICA stenosis is the end diastolic velocity.

Question 146

``` In the circle of Willis, if a difference _______ is present between the velocities taken in the same vessel on both sides, this can indicate intracerebral disease. A. >20% B. >30% C. >40% D. >50% ```

Answer 146

B Blood flow velocities in the vessels of the circle of Willis should be similar between the vessels on the left and right sides. A difference >30% between the velocities taken in the same vessel on both sides can indicate intracerebral disease is present.

Question 147

``` Median arcuate ligament syndrome involves compression of which vessel during respiration? A. main portal vein B. celiac axis C. superior mesenteric artery D. inferior mesenteric artery ```

Answer 147

B The median arcuate ligament connects the right and left crura of the diaphragm across the anterior proximal abdominal aorta. The celiac axis origin is very close to the diaphragm and in some patients the median arcuate ligament crosses anterior to the celiac origin. Median arcuate ligament syndrome is caused by the ligament compressing the celiac axis with respiration. The aorta and branches move superiorly upon expiration. If the media arcuate ligament is compressing the celiac axis, symptoms will be emphasized upon expiration.

Question 148

``` A patient presents for a carotid Doppler exam due to left arm and leg paresthesia. Which vessel should be closely evaluated for a potential vascular cause of the symptom? A. left ICA B. right ICA C. left vertebral D. right vertebral ```

Answer 148

B Symptoms of stroke that occur in the body are associated with ICA disease on the contralateral side. Left extremity paresthesia would be associated with right ICA disease.

Question 149

Which of the following changes in flow can be seen with a Baker cyst? A. pulsatile flow in the popliteal vein B. continuous flow in the popliteal vein C. continuous flow in the popliteal artery D. pulsatile flow in the superficial femoral vein

Answer 149

B A Baker cyst can cause extrinsic compression of the popliteal vein which leads to a loss of phasicity and a continuous waveform.

Question 150

Which of the following vessels can provide a collateral pathway to redistribute flow from one side of the brain to the other side? A. middle cerebral artery only B. posterior communicator artery only C. anterior communicating artery only D. anterior communicator and basilar artery

Answer 150

D The anterior communicating arteries can allow flow to move from one ACA into the other. If the left ICA is occluded, flow from the right ICA enters the brain and travels to the right ACA. Flow then moves through the communicator to fill the left ACA in a retrograde fashion. The cerebellum is supplied by blood from branches of the vertebral arteries and basilar artery. If the left vertebral is occluded proximally, flow moves cephalad toward the brain in the right vertebral artery and then some of this flow is redirected caudally into the left vertebral (retrograde filling).

Question 151

``` All of the following terms refer to the areas of flow separation seen distal to a stenosis, except: A. eddy currents B. post stenotic turbulence C. autoregulation D. flow vortices ```

Answer 151

C | Eddy currents are also known as flow vortices. These areas of flow separation are seen with post-stenotic turbulence.

Question 152

``` A bilateral visual symptom, such as diplopia, is commonly associated with disease in which artery? A. posterior cerebral B. vertebral C. innominate D. anterior cerebral ```

Answer 152

B In reference to symptoms related to cranial vessel disease, unilateral visual disturbances are most commonly associated with disease in the ICA. Bilateral visual disturbances are most commonly associated with vertebrobasilar disease.

Question 153

Which of the following describes the abnormal response to papaverine injection during a penile impotence exam? A. the PSV and EDV of the arterial inflow will decrease B. decreased dorsal venous outflow C. the PSV and EDV will increase post injection but dorsal venous flow will remain unchanged D. increased reflux in the veins in the scrotal varicocele

Answer 153

A Doppler evaluation includes assessment of the cavernous arteries with Doppler pre- and post- medication injection (papaverine most common); normally the PSV and EDV will increase post injection but dorsal venous flow will remain unchanged.

Question 154

If the external iliac artery is occluded, what vessels provide the potential for collateral flow to the extremity? A. inferior epigastric artery and deep circumflex artery B. medial and lateral plantar arteries C. internal thoracic artery and lumbosacral artery D. genicular arteries

Answer 154

A Lateral branches of the EIA include the inferior epigastric artery and deep circumflex artery that supply the abdominal wall muscles/skin. They also provide potential for collateralization with obstruction of the EIA.

Question 155

Which of the following is most suggestive of a subclavian steal? A. amaurosis fugax B. systemic HTN C. difference in brachial pressures > 20 mmHg D. congestive heart failure

Answer 155

C Amaurosis fugax is usually related to ICA stenosis. HTN is a non-specific symptom and not a complication of a subclavian steal. Because the blood flow to the affected arm is being "pulled" from the brain, the pressure in the arm is much lower than the unaffected side. BP levels in both arms that differ more than 15mmHg are highly suspicious for the presence of a subclavian steal.

Question 156

The most common site for renal artery stenosis is: A. in the segmental artery of the upper pole B. at the origin of the renal artery C. in the segmental artery of the lower pole D. at the renal hilum

Answer 156

B | The most common site for renal artery stenosis is at the renal artery origin.

Question 157

``` An acute, occlusive thrombus is identified in the femoral vein in the adductor canal. Which of the following veins will demonstrate related blood stasis? A. great saphenous B. small saphenous C. common femoral D. proximal femoral vein ```

Answer 157

B The DVT in the femoral vein will cause a backlog of blood in the popliteal vein. The SSV empties into the popliteal vein and will become dilated with an obstruction in the femoral vein. The proximal femoral vein will still demonstrate normal flow due to the perforators in the thigh filling the vein with blood from the superficial system.

Question 158

``` Which of the following vessels are evaluated in a Doppler evaluation for erectile dysfunction? A. internal pudendal artery B. cavernous arteries and dorsal veins C. cavernous veins and dorsal arteries D. common femoral artery ```

Answer 158

B Doppler evaluation of erectile dysfunction includes assessment of the cavernous arteries and dorsal veins with Doppler pre- and post- medication injection (papaverine most common); Normally the PSV and EDV of the arteries will increase post injection but dorsal venous flow will remain unchanged; PSV > 30cm/s considered normal.

Question 159

``` Which of the following calculations is necessary to accurately diagnose renovascular HTN? A. parenchymal index B. renal-aortic ratio C. systolic / diastolic ratio D. peak pressure gradient ```

Answer 159

B The renal-aortic ratio compares the velocities in the renal artery with the velocity of the aorta in the mid-segment. >3.5 indicates renal artery stenosis.

Question 160

Broca aphasia can be defined as: A. inability to understand speech, speak, or follow directions B. inability to swallow liquids C. inability to speak but can understand and follow directions D. inability to swallow solid food

Answer 160

``` C Broca aphasia (AKA expressive aphasia) can be defined as the inability to speak but can understand and follow directions. ```

Question 161

``` Which of the following would be the most likely cause of a false positive diagnosis of ICA stenosis? A. improper Doppler angle B. decreased cardiac output C. tortuosity D. CHF ```

Answer 161

C A curved vessel will cause increased velocities at the "kinked" location(s). This can cause a false positive diagnosis of stenosis. CHF, decreased cardiac output, or an improper Doppler angle can lead to a false negative for ICA stenosis.

Question 162

``` Which of the following is a characteristic of the Doppler waveform obtained at the site of stenosis in an ICA with > 70% stenosis? A. blunted waveform B. increased diastolic flow C. decreased acceleration time D. spectral window ```

Answer 162

B As stenosis increases, peak systolic and end diastolic velocities increase. Acceleration time increases as stenosis increases. As the vessel nears 99% stenosis, systolic and diastolic flow may be significantly reduced. Occlusion will lead to increased resistance in the proximal vessel.

Question 163

``` The majority of aortic aneurysms form in what part of the vessel? A. suprarenal B. infrarenal C. arch D. juxtarenal ```

Answer 163

B Juxtarenal and suprarenal AAA can cause serious complications related to blood flow to the kidneys and renal induced HTN. These types of AAA are considered a critical finding at any size. Infrarenal AAA formation is the most common AAA location. Fortunately this type of AAA can be monitored over time until it reaches 5.5-6cm in size when surgical intervention is necessary.

Question 164

``` If the distal femoral artery demonstrates a peak velocity of 3.2m/s, the waveform in the posterior tibial artery will most likely be _________. A. triphasic B. absent C. monophasic D. biphasic ```

Answer 164

C Normal flow in the PTA would be triphasic. A 3.2m/s PSV in the femoral artery indicates a hemodynamically significant stenosis which would cause decreased resistance distally. The popliteal and calf arterial waveforms will most likely be monophasic.

Question 165

Which of the following is not an expected complication caused by a Baker cyst? A. pain B. thrombosis due to valvular insufficiency C. swelling D. thrombosis due to extrinsic compression

Answer 165

B | A Baker cyst does not directly affect the valvular competence and will not usually lead to insufficiency.

Question 166

``` A patient presents for a lower extremity venous Doppler exam due to a history of May-Thurner Syndrome. What vessel should you closely evaluate for related findings? A. bilateral popliteal veins B. left iliac vein C. bilateral distal femoral veins D. right iliac vein ```

Answer 166

B | May-Thurner Syndrome refers to increased incidence of left DVT due to extrinsic compression by RIGHT iliac artery.

Question 167

When evaluating a focal stenosis of the femoral artery, where should you place the cursor to obtain the highest velocity related to the stenosis? A. at the narrowest point in the vessel or immediately distal to the focal point of the stenosis B. immediately proximal to the focal point of the stenosis C. 1-2cm distal to the focal point of the stenosis D. 1-2cm proximal to the focal point of the stenosis

Answer 167

A When evaluating a focal stenosis of an artery, you should place the cursor at the narrowest point in the vessel or immediately distal to the focal point of the stenosis to obtain the highest velocity related to the stenosis. It is important to move the Doppler cursor through the stenotic area and out the other side to locate the peak velocity.

Question 168

Which of the following patients has the lowest risk of a future stroke that affects the right side? A. 60% left ICA stenosis caused by heterogeneous calcific plaque B. no appreciable plaque identified in the left ICA C. 20% left ICA stenosis caused by smooth, soft plaque D. total occlusion of the left ICA

Answer 168

D A stenosis on the left internal carotid artery will cause symptoms on the right side of the body. The risk of a future stroke on that side drops significantly when the internal - carotid artery is totally occluded. If a stroke would occur, it would have happened at the time the occlusion occurred.

Question 169

Which of the following vessels are a common source for a Type II endoleak? A. inferior mesenteric artery and lumbar arteries B. celiac axis and superior mesenteric artery C. left gastric artery and right hepatic artery D. common iliac artery and gonadal arteries

Answer 169

A Type II endoleak: leak at the branch vessels; will see retrograde flow into the aneurysm sac and increase in AAA diameter; inferior mesenteric artery, internal iliac, lumbar arteries and accessory renal arteries are potential sources for the leak.

Question 170

``` The external carotid artery normally demonstrates a velocity below: A. 100cm/s B. 80cm/s C. 150cm/s D. 230cm/s ```

Answer 170

C | the ECA normally demonstrates a velocity below 150cm/s.

Question 171

``` The following velocities are obtained in the left carotid system. The CCA PSV is 100cm/s, the ICA PSV is 255cm/s with an EDV of 75cm/s, what will be the recommended treatment for this patient? A. 6 mo F/U exam B. angiography C. endarterectomy D. stent ```

Answer 171

A The velocities indicate a 50-69% stenosis. The ICA PSV is just above the 230cm/s minimum for a >70% diagnosis. Both the EDV and the SVR indicate 50-69% stenosis.

Question 172

Which of the following is NOT a pathway for ECA to ICA collateralization? A. superficial temporal artery to frontal artery B. angular artery to facial artery C. superficial temporal artery to supraorbital artery D. angular artery to the frontal artery

Answer 172

B The facial artery is a branch of the ECA. The angular artery is a terminal branch of the facial artery. Angular to facial arterial flow would indicate retrograde flow toward the ECA.

Question 173

``` Which of the following is not an expected clinical finding in a patient with a venous stasis ulcer? A. discoloration of the affected area B. severe pain C. located at the medial malleoulus D. oozing ```

Answer 173

B | Venous ulcers are usually mildly painful. Arterial ulcers usually cause significant pain.

Question 174

``` Which cerebral vessel is most commonly involved in an acute cerebral ischemia? A. PCA B. ACA C. MCA D. basilar ```

Answer 174

C | The MCA is most commonly involved in an acute occlusion and cerebral ischemia due to its connection to the ICA.

Question 175

``` A patient presents with diminished pulses in the right radial and ulnar arteries. All of the following could cause this symptom, except: A. right brachial artery stenosis B. right subclavian artery stenosis C. right lateral palmar arch stenosis D. innominate artery stenosis ```

Answer 175

C Reduced flow in the forearm arteries indicates a proximal stenosis. The palmar arch is in the hand, distal to the radial and ulnar arteries.

Question 176

Nutcracker syndrome is defined as: A. entrapment of the popliteal artery seen most commonly in runners B. entrapment of the subclavian artery by structures in the shoulder/neck C. abnormal compression of the left renal vein by the SMA and aorta D. abnormal compression of the celiac axis with respiration

Answer 176

C Nutcracker syndrome is defined as abnormal compression of the left renal vein by the SMA and aorta. It can lead to renal vein congestion and thrombosis.

Question 177

A patient presents for a carotid ultrasound. The chart states a history of 2 recent episodes of amaurosis fugax. Which statement best describes amaurosis fugax? A. spots flashing in front of eyes B. monocular blindness C. dizziness upon standing D. bilateral blindness for more than 24 hrs

Answer 177

B It occurs when a piece of plaque in the carotid artery breaks off and travels to the retinal artery in the eye. In people with amaurosis fugax, vision loss continues as long as the blood supply to the retinal artery is blocked. This usually only lasts seconds but may last several minutes. Some patients describe the loss of vision as a black shade coming down over their eye.

Question 178

Which of the following correctly describes carotid dissection? A. dissection is more common in the Circle of Willis than the extracranial arteries B. dissection is more common in the extracranial ICA than the intracranial ICA C. always associated with trauma D. commonly associated with Paget - Schroetter syndrome

Answer 178

B | Dissection is more common in the extracranial ICA than the intracranial ICA.

Question 179

``` The common femoral artery velocity is 0.8m/s and the proximal femoral artery demonstrates atherosclerosis formation causing an increase in the velocity to 3.2 m/s. This indicates what level of stenosis? A. 75% B. 100% C. 25% D. 50% ```

Answer 179

A When the velocity between two extremity arterial segments doubles, this indicates at least a 50% stenosis. When the velocity between two extremity arterial segments quadruples, this indicates at least a 75% stenosis.

Question 180

``` A velocity is recorded in the distal femoral artery of 2.75m/s, what hemodynamic changes will be seen in popliteal artery? A. decreased acceleration time B. increased diastolic flow reversal C. high velocity, peaked waveform D. increased acceleration time ```

Answer 180

D The resistance distal to the stenosis will be decreased and flow will become monophasic. Acceleration time is prolonged with lower resistance flow.

Question 181

Which of the following statements is true regarding the aorta? A. rupture is the most common complication of an aortic aneurysm B. suprarenal AAAs normally do not affect the arterial flow to the kidneys C. the most common location for an aortic dissection is at the iliac bifurcation D. the majority of the aortic branches that lead to abdominal organs are lateral branches

Answer 181

A The most common location for an aortic dissection is in the thoracic segment. The majority of the aortic branches that lead to abdominal organs are anterior branches. Infrarenal AAAs normally do not affect the arterial flow to the kidneys.

Question 182

``` Which of the following describes the appearance of a waveform distal to a critical carotid stenosis? A. increased diastolic flow B. increased systolic flow C. large spectral window D. decreased diastolic flow ```

Answer 182

D The waveform of the flow distal to a critical ICA stenosis will be blunted, low systolic and diastolic peaks and turbulent flow with loss of the spectral window.

Question 183

``` Which of the following describes the most common flow pattern seen in a Type II endoleak? A. continuous, phasic flow B. monophasic retrograde flow C. bidirectional D. monophasic, low resistance ```

Answer 183

C Flow within a Type I leak resembles the flow within the graft. Flow in a Type II leak usually demonstrates a bidirectional flow pattern because the Doppler waveform morphology reflects the end source resistance. A single branch vessel entering the sac will demonstrate bidirectional flow.

Question 184

``` What is the most common cause of cerebrovascular disease? A. stroke B. atherosclerosis C. embolism D. vasospasm ```

Answer 184

B Atherosclerosis formation is the most common cause of cerebrovascular disease. Embolism formation is much less common and is usually a complication of atherosclerosis formation. A stroke is a potential complication with all types of cerebrovascular disease.

Question 185

When using the suboccipital window for TCD evaluation with left lateral angulation, you detect low resistance flow moving toward the transducer with a mean flow velocity of 40cm/s at a depth of 60mm. These findings are most suggestive of: A. abnormal left vertebral velocity and flow direction B. normal left vertebral flow C. normal right vertebral flow D. normal left vertebral velocity with abnormal flow direction

Answer 185

D The flow in the left vertebral is reversed but normal in velocity. A blockage in the proximal left subclavian artery can cause left vertebral flow reversal as the distal left subclavian "steals" blood from the cerebral vessels.

Question 186

Which of the following is an abnormal flow change caused by congestive heart failure? A. increased velocities in the bilateral common carotid arteries B. pulsatile flow in the proximal hepatic veins C. monophasic portal flow D. decreased ankle pressures

Answer 186

D The hepatic veins normally demonstrate pulsatile or triphasic flow due to the ripple effect from cardiac motion. CHF reduces cardiac output that leads to biphasic portal vein flow, decreased velocities in the bilateral common carotid arteries, and reduced ankle pressures.

Question 187

``` All of the following describes vascular compression syndromes, except: A. PHACE syndrome B. Hypothenar hammer syndrome C. Eagle syndrome D. Thoracic outlet syndrome ```

Answer 187

A PHACE syndrome involves congenital malformations of arterial vasculature. Eagle syndrome involves compression of the carotid artery. TOS involves compression of the vessels in the thoracic outlet. Hypothenar hammer syndrome involves compression of the ulnar artery.

Question 188

``` Bilateral tardus parvus waveforms in the carotid arteries can indicate: A. mitral regurgitation B. pulmonary regurgitation C. pulmonary stenosis D. mitral stenosis ```

Answer 188

D Significant stenosis can cause left atrial pressure overload and reduced cardiac output. The carotid arteries will demonstrate low resistance, low velocity flow with reduced cardiac output. Bilateral tardus parvus waveforms in the carotid arteries can indicate severe mitral stenosis.

Question 189

If the P1 segment of the PCA is occluded on the left side, how will flow reach the P2 segment of the PCA? A. flow reversal within the left posterior communicator artery B. flow reversal within the right posterior communicator artery C. flow reversal in the basilar artery D. cross over flow through the branches of the MCA

Answer 189

A | Flow in the left posterior communicator artery will travel posterior from the left distal ICA to reach the P2 segment.

Question 190

``` The common femoral artery velocity is 0.8m/s and the proximal femoral artery demonstrates atherosclerosis formation causing an increase in the velocity to 2.2 m/s. This indicates what level of stenosis? A. 25% B. 50% C. 75% D. 80-99% ```

Answer 190

B When velocity between two extremity arterial segments doubles, this indicates at least a 50% stenosis. When the velocity between two extremity arterial segments quadruples, this indicates at least a 75% stenosis.