Pathology Pt 2 Flashcards
(188 cards)
1
Q
Hemodynamically significant stenosis of the SMA is diagnosed when the peak systolic velocity is greater than? A. 1.0 m/s B. 1.75 m/s C. 2.0 m/s D. 2.75 m/s
A
D
Hemodynamically significant stenosis of the SMA is diagnosed with the PSV greater than 2.75 m/s.
2
Q
What is the most common location of an intracranial aneurysm? A. internal carotid artery siphon B. middle cerebral artery C. anterior communication artery D. posterior communicating artery
A
C
The anterior communication artery is the most common location for a berry or saccular intracranial aneurysm.
3
Q
An acute occlusion occurs in the common iliac artery on the left side. Which of the following vessels will also have absent flow?
A. external iliac artery only
B. common femoral artery and saphenous artery
C. internal iliac artery and gonadal artery
D. common femoral, external iliac and internal iliac artery
A
D
The external iliac and internal iliac arteries are branches of the common iliac artery. The external iliac artery becomes the common femoral artery once it crosses beneath the inguinal artery.
4
Q
Which of the following patients would benefit from a Percutaneous Transluminal Angioplasty?
A. patient with chronic iliac DVT
B. patient with recurrent pulmonary embolism
C. patient with 80% stenosis in proximal SFA
D. patient with left ICA occlusion
A
C
Percutaneous Transluminal Angioplasty is used to open areas of stenosis in an artery. This intervention cannot be performed on a fully occluded vessel.
5
Q
What is the purpose of performing periorbital Doppler?
A. detect severe distal ECA disease
B. detect flow reversal in the frontal artery signifying ICA disease
C. to evaluate the ophthalmic artery using Doppler
D. evaluate the integrity of the retina
A
B
Periorbital Doppler is used to assess flow direction in the frontal artery. If flow is moving away from the transducer, ipsilateral ICA disease is present. TRANSorbital Doppler is performed to evaluate the ophthalmic artery.
6
Q
Which of the following procedures can be performed on a patient in renal failure? A. Duplex ultrasound B. MRA exam with contrast C. CT scan with contrast D. Angiography
A
A
Renal disease or failure is a contraindication for the use of radiology imaging contrast.
7
Q
Significant atherosclerotic disease found in which artery could lead to male impotence? A. common iliac or internal iliac B. common iliac or external iliac C. common femoral or profunda femoral D. external iliac or common femoral
A
A
Disease in the common iliac and internal iliac artery can lead to ischemia of the penile tissues.
8
Q
Which of the following is a long term treatment for DVT? A. venous ligation B. Lovenox C. Warfarin D. Heparin
A
C
Treatment for Acute DVT:
Subcutaneous shot of Lovenox immediately.
Heparin administered for 5-10 days to stop the progression of the clot, but does not have a clot lysing properties to decrease the clot that has already formed.
After Heparin dosage completed and recanalization has occurred. Warfarin is administered to prevent future clot formation. First DVT occurrence - Warfarin prescribed for 3 months
Recurrent DVT - Warfarin prescribed for 6+ months
9
Q
Which of the following is a symptom related to giant cell arteritis? A. asymmetric brachial blood pressures B. jaw claudication C. headaches and neck pain D. more than one of the above
A
D
Temporal arteritis is associated with headaches and tenderness over the artery. Asymmetric brachial blood pressures are seen in patients with arteritis in extremities. Other symptoms include pain and/or stiffness in the neck, jaw claudication, and visual disturbances.
10
Q
Which of the following causes flow reversal in venous perforators?
A. superficial thrombosis
B. deep vein thrombosis
C. compression stockings
D. combination of superficial and deep thrombosis
A
B
DVT in the deep system forces any remaining flow into areas of lower pressure, the perforators. Flow exits the deep system through the perforators to try to “escape” into the patent superficial system.
11
Q
Which of the following is not an expected characteristic of flow proximal to an ICA occlusion? A. increased diastolic flow B. triphasic C. increased diastolic flow reversal D. increased resistance
A
A
The occlusion causes increased resistance in the flow proximally. There will be a loss of diastolic flow and reversal of diastolic flow causing a biphasic or triphasic waveform.
12
Q
Which of the following is a sonographic finding of acute DVT?
A. incomplete compressibility of the vein
B. engorged vein with increased echogenicity in the lumen
C. valvular insufficiency
D. flattened, collapsed vessel with increased echogenicity of the wall
A
B
Chronic thrombus will demonstrate as echogenic material lining a partially collapsed vein. Acute thrombus causes the vein to grow in size and appear engorged with blood/debris.
13
Q
A patient presents for a lower extremity arterial exam with mild bilateral leg pain. The 2D evaluation demonstrates minimal diffuse atherosclerosis bilaterally. The Doppler waveforms from the arteries of both legs demonstrate biphasic waveforms with increased acceleration time. Which of the following could explain these findings? A. bilateral popliteal entrapment B. cardiac ejection fraction 85% C. cardiac ejection fraction 30% D. systemic hypertension
A
C
Bilateral decrease in lower extremity velocities can indicate a cardiac issue, especially in the absence of aortic or bilateral iliac disease. Popliteal entrapment syndrome is a functional issue where the artery becomes compressed with contraction of the calf muscles, usually seen in runners. Symptoms of this disorder would be related to activity and would not normally produce constant mild pain. An exercise arterial exam would be necessary to diagnose this issue.
14
Q
What critical finding is associated with calf paresthesia, localized muscle weakness, pain when stretching calf muscles, and drop foot? A. popliteal entrapment B. anterior compartment syndrome C. peripheral arterial disease D. post-phlebitic syndrome
A
B
Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury and without intervention, it can lead to permanent muscle damage. Symptoms of compartment syndrome include paresthesia, localized muscle weakness, pain when stretching calf muscles, and drop foot.
15
Q
The ______ on the foot is used as the dye injection site for ascending venography, while the _______ is used as the dye injection site for lower extremity arteriography.
A. dorsal vein, common femoral artery
B. dorsal vein, common femoral artery
C. common femoral vein, common femoral artery
D. tibial vein, superficial femoral artery
A
A
The dorsal vein on the foot us used as the dye injection site for ascending venography. Contrast material ascends through patent veins of the extremity. The common femoral artery is used as the dye injection site for lower extremity angiography. Contrast fills the arteries as blood moves distally into the leg.
16
Q
Warfarin is administered to a patient:
A. to assist in clot lysis and recanalization
B. to prevent thrombus propagation
C. to increase platelet aggregation
D. to assist in atheroma lysis and recanalization
A
B
Warfarin is administered to a patient to prevent thrombus propagation and reduce platelet aggregation. Streptokinase is used for clot lysis in phlegmasia patients. Increased platelet aggregation would cause clot propagation.
17
Q
\_\_\_\_\_\_\_\_ uses a balloon tipped catheter to compress the atheroma and expand the vessel lumen. A. an angioplasty procedure B. an endarterectomy procedure C. a valvulotome procedure D. an atherectomy procedure
A
A
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.
18
Q
A patient complains of bilateral pain and color changes in the legs. When he lies down, both legs become pale. When he sits up on the edge of the bed, both legs become reddened. These clinical findings are most suggestive of: A. significant aortic stenosis B. deep venous reflux C. significant venous obstruction D. normal arterial flow
A
A
Pallor and dependent rubor are indications of significant arterial disease. The bilateral presentation indicates the obstruction is blocking flow to both legs = aorta.
19
Q
Which of the following is associated with CREST syndrome? A. superficial phlebitis B. secondary Raynaud phenomenon C. primary Raynaud disease D. aortic aneurysm
A
B
In contrast to Raynaud disease, Raynaud phenomenon presents concurrently with CREAST syndrome, in which tissue necrosis results from spastic and occlusive disease. CREST syndrome involves symptoms of generalized calcinosis, Raynaud phenomenon, esophageal dysfunction, scleroderma, and telangiectasia.
20
Q
A patient is referred for an arterial duplex exam for leg pain. The chart describes brown discoloration of the calves and prominent pedal pulses. Which of the following is an expected finding on today's exam? A. medial calcification B. normal arterial flow C. popliteal aneurysm D. Raynaud syndrome
A
B
Brawny discoloration of the calf is usually a sign of venous disease. Prominent pedal pulses indicate strong arterial flow in the tibial arteries. The patient will most likely demonstrate normal arterial flow.
21
Q
Arterial claudication occurs: A. while the legs are in the dependent position B. distal to the obstruction C. while the patient is resting D. proximal to the obstruction
A
B
Arterial claudication occurs distal to the hemodynamically significant obstruction.
22
Q
Which of the following abnormalities would be best evaluated by asking the patient to hyperextend the leg and point the toes? A. popliteal entrapment B. May Thurner syndrome C. Paget-Schreotter syndrome D. Raynaud syndrome
A
A
Popliteal entrapment occurs when the artery is compressed with contraction of the calf muscle. When the patient hyperextends the leg and points the toes, the calf muscle will contract. PPG or PW Doppler can be used to assess changes in flow during the maneuver.
23
Q
Venous ulcers are normally located on the \_\_\_\_\_\_\_\_, while arterial ulcers are normally found on the \_\_\_\_\_\_\_\_. A. calf, thigh B. heel, toes C. distal calf, toes and heel D. toes and heel, distal calf
A
C
Venous ulcers are normally located on the distal calf, while arterial ulcers are normally found on the toes and heel.
24
Q
When scanning a patient with a history of renal cell carcinoma, you identify a hypoechoic mass within the IVC lumen near the renal veins. What is the best way to determine if this is tumor invasion or thrombus formation?
A. evaluate the iliac veins for thrombus
B. evaluate the aorta for tumor invasion.
C. roll the patient into the decubitus position to evaluate the possible mobility of the mass.
D. apply color doppler to assess internal vascularity of the mass.
A
D
The mass should be evaluated for internal vascularity that would indicate tumor invasion. If there is not internal vascularity, the obstruction is most likely a thrombus. The iliac veins should be evaluated if the mass causes IVC obstruction, but the question refers to mass characterization.
25
All of the following correctly describe compartment syndrome, except:
A. all forms of compartment syndrome are considered an emergency
B. can occur in the leg or arm
C. most commonly occurs due to trauma
D. prevents blood flow in and out of surrounding tissues
A
26
```
You are performing a renal artery Doppler exam for renal stenosis. The mid aortic peak velocity is 70cm/s. The RRA peak velocity is 140cm/s and the LRA peak velocity is 240cm/s. What is the RAR for the right kidney?
A. 0.3
B. 3.4
C. 2
D. 0.5
```
C
| RRA 140cm/s / aorta 70cm/s = 2; LRA 240cm/s / aorta 70cm/s = 3.4
27
Which of the following would lead to overestimation of stenosis in the internal carotid artery?
A. reduced systemic blood pressure
B. significant aortic valve stenosis
C. tandem stenosis
D. compensatory flow due to stenosis on the other side
D
Overestimation of stenosis in the ICA can be seen with:
Systemic HTN
Compensatory flow due to stenosis on the other side
Short area of focal stenosis
Smaller vessel size
Elevated heart rate
Measuring a compensatory heart beat with arrhythmias
28
```
Which of the following describes chronic lower extremity DVT?
A. echogenic vein walls
B. varicocele formation
C. vein is completely non-compressible
D. pulsatile flow pattern
```
A
Chronic thrombus formation can cause the vein walls to appear thickened and echogenic. It can also lead to partial compressibility on the vein and continuous flow in the vessel.
29
A patient presents with a script that requests an aortic Doppler evaluation due to Leriche syndrome. What are you looking for on the exam?
A. the formation of multiple aneurysms of the aortic segments
B. extensive diffuse atherosclerotic disease causing obstruction of the distal aorta
C. monophasic flow in all segments of the aorta due to coarctation of the aorta in the chest
D. agenesis of the anterior branches of the aorta
B
Leriche syndrome refers to extensive diffuse atherosclerotic disease causing obstruction of the distal aorta and bilateral lower extremity symptoms.
30
```
Treatment for internal carotid artery occlusion includes which of the following?
A. stent placement
B. endarterectomy
C. angioplasty
D. none of the above
```
D
Occlusions in the carotid arteries are usually not invasively or surgically treated. There is limited benefit to attempting to revascularize the vessel and the risk of stroke/death is quite significant. Critical stenosis can be treated, occlusions cannot!
31
```
What is the most common cardiac disorder associated with arterial embolism?
A. cardiomyopathy
B. Marfan syndrome
C. atrial fibrillation
D. myocardial infarction
```
C
80-90% of arterial emboli are from a cardiac source. Atrial fibrillation can lead to clot formation in the left atrium. If the clot breaks of, it can travel anywhere in the systemic arterial system. If the foramen ovale is patent, the clot could also travel into the right heart and the pulmonary arteries.
32
```
Which of the following is a congenital vascular abnormality that commonly causes decreased ankle pressures bilaterally?
A. coarctation of the aorta
B. thoracic outlet syndrome
C. congestive heart failure
D. Budd Chiari syndrome
```
A
Coarctation causes a ridge of tissue that blocks flow, usually in the descending aorta. This causes monophasic flow with increased antegrade diastolic flow. Brachial pressures will be normal but the bilateral ankle pressures will be decreased.
33
The most common reason for underestimation of arterial stenosis is:
A. insonation of a vein and artery simultaneously
B. insonation of a vein instead of an artery
C. improper sample volume angle
D. improper sample volume location
D
The most common reason for underestimation of arterial stenosis is improper sample volume location. Anytime stenosis is suspected, the cursor should be walked through the area of stenosis to locate the area of highest velocity. Lack of proper sample placement can cause you to miss the area of highest velocity and therefore underestimate the stenosis.
34
```
Most lower extremity thrombosis begins in the __________.
A. soleal sinuses
B. tibial veins
C. femoral vein in the adductor canal
D. peroneal vein
```
A
| Most lower extremity thrombosis begins in the soleal sinuses and propagates into the PTA and/or peroneal veins.
35
```
A patient presents with a history of right hip and thigh pain with numbness when he walks. Sometimes he walks only a short distance before the pain starts and sometimes he can walk for 20-30 minutes before the pain starts. There are no symptoms in his lower leg. The pain is reduced by sitting down. These findings are most suggestive of?
A. peripheral arterial disease
B. Raynaud's disease
C. chronic venous disease
D. neurogenic cause
```
D
| The leg pain is not consistent and reproducible which are key components of claudication related to vascular disease.
36
```
Which of the following will be administered to a patient with extensive DVT to cause lysis of the clot?
A. Heparin or Coumadin
B. Streptokinase
C. Heparin
D. Coumadin
```
B
Heparin, Coumadin and Warfarin are medications that reduce the viscosity of blood to prevent propagation of the clot but they have no clot lysing properties. Streptokinase and Urokinase are used to dissolve the thrombus in cases with significant thrombosis of the venous system.
37
```
The type of plaque that carries the greatest risk of embolization is _________.
A. soft
B. complex
C. calcific
D. soft and complex
```
A
Soft plaque has the greatest risk of embolization due to its composition and decreased adhesive levels. Complex and calcific plaque have become increasingly fibrous and more easily adheres to the vessel wall.
38
Carotid body tumors are more common in:
A. men and people with Buerger disease
B. women and people living at sea level
C. men and people with Ehler-Danlos syndrome
D. women and people living at high altitudes
D
CBT is more common in females. Living at higher altitudes means less oxygen in the air. Chronic hypoxia leads to an overactive and enlarged CBT.
39
A patient presents for a carotid ultrasound. The chart state there is a history of myocardial infarction and a left ventricular assist device is present. Which of the following describes the expected flow pattern in the normal common carotid artery?
A. antegrade flow in systole and retrograde flow in diastole
B. high-velocity flow with accelerated upstroke
C. triphasic waveform with increased systolic velocity
D. low-velocity flow with delayed upstroke and loss of pulsatility
D
Left Ventricular Assist Device (LVAD) causes CCA Doppler waveforms with low-velocity flow, delayed upstroke and loss of pulsatility. Carotid Doppler waveform morphology is highly variable among patients with LVADs and is very dependent on pump settings. It is very important to document the presence of a left ventricular assist device or intra-aortic balloon pump on the preliminary report. The waveform contour cannot be evaluated in the patients.
40
```
Amaurosis fugax in the right eye indicates potential disease in what vessel?
A. right ICA
B. left ICA
C. right ECA
D. left ECA
```
A
Amaurosis fugax refers to an intermittent black shade covering the eye and can indicate a blockage in the orbital supply. The eyes are supplied with blood by branches of the distal ICA. The affected eye will be on the same side as the disease in the ICA.
41
Post-phlebitic Syndrome:
A. refers to valve damage in the veins after thrombus formation
B. will usually resolve within 2 weeks after treatment for DVT
C. refers to black discoloration of the toes caused by embolism from a AAA
D. will usually resolve within 6-8 weeks after treatment for DVT
A
| Post-phlebitic Syndrome refers to valve damage in the veins after thrombus formation.
42
```
Blue Toe Syndrome can be a complication of which of the following?
A. abdominal aortic aneurysm
B. deep venous thrombosis
C. thoracic outlet syndrome
D. Raynaud phenomenon
```
A
Blue Toe Syndrome is caused by emboli reaching the small digital arteries and causing obstruction/ischemia. The ischemic toe tissue becomes discolored and cyanotic in appearance. AAA formation usually leads to thrombus accumulation in the affected area of the vessel. This thrombus poses a risk of emboli formation and distal ischemia.
43
```
An abnormal renal-aortic ratio would be a ratio _______.
A. <3.5
B. >1.8
C. <1.8
D. >3.5
```
D
The renal aortic ratio is calculated by dividing the peak renal artery velocity by the peak velocity in the aorta. A value <3.5 indicates a normal exam.
44
A patient presents with gangrene of the foot and toes. The most likely cause of these symptoms is:
A. extensive deep and superficial vein thrombosis
B. chronic occlusion of the popliteal artery
C. coarctation of the aorta
D. a 5cm aortic aneurysm with mural thrombus
A
| Venous gangrene usually involves the foot and all toes, while arterial gangrene usually involves one or two toes.
45
```
Which of the following terms would be used to describe flow identified just proximal to a 95% ICA stenosis?
A. tardus parvus
B. damped
C. laminar
D. low resistance
```
B
Pre-stenotic Zone: Increased resistance and resistive index, flow velocity may be dampened with loss of diastolic flow, short acceleration time.
46
The Bernoulli principle explains the:
A. increase in pressure seen with increased blood flow velocity
B. decrease in pressure seen with decreased blood flow velocity
C. decrease in pressure seen with increased blood flow velocity
D. decrease in resistance seen with increased blood flow velocity
C
| The Bernoulli principle explains the decrease in pressure seen with increased blood flow velocity.
47
```
A patient presents with intermittent left lower leg swelling for several months. The popliteal vein demonstrates a collapsed appearance with echogenic, thickened walls. These findings are most consistent with:
A. proximal venous stenosis
B. chronic popliteal DVT
C. vasculitis of the popliteal vein
D. acute femoral DVT
```
B
Chronic DVT will become echogenic as it becomes more fibrous while attached to the vein wall. The fibrous material limits the pliability of the walls leading to a semi-collapsed appearance. Acute femoral DVT would cause a dilated popliteal vein.
48
```
Lower extremity ulcers are most commonly caused by ________.
A. chronic arterial disease
B. chronic venous disease
C. acute venous disease
D. recurrent cellulitis
```
B
| Lower extremity ulcers are most commonly caused by chronic venous disease (75%).
49
```
_________ is the "gold standard" exam technique for diagnosis of venous disease in the lower extremities.
A. arteriography
B. venography
C. Doppler ultrasound
D. MR Angiography (MRA)
```
C
| Doppler ultrasound has surpassed venography as the gold standard for evaluation of the veins in the lower extremities.
50
Which renal arteries are evaluated with Doppler in an ultrasound exam that is used to perform a direct evaluation for renal artery stenosis?
A. main renal artery, segmental and arcuate arteries
B. aorta
C. segmental and arcuate arteries
D. main renal artery
D
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.
51
Patients with lower extremity venous insufficiency may describe pain:
A. that is relieved by walking
B. that is relieved by lying down
C. that is relieved by elevating the legs
D. that is relieved by placing legs in a dependent position
C
The dependent position helps blood to reach the lower legs more quickly. Walking and elevating the legs would increase the flow toward the heart and reduce blood pooling in the calves. With venous insufficiency venous system. This can lead to increased pooling in the lower leg with swelling and pain.
52
```
Pulsus bisferiens in the carotid arteries is a sign of:
A. mitral stenosis
B. mitral regurgitation
C. aortic regurgitation
D. pulmonary regurgitation
```
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).
53
A patient presents with a script for a "vascular ultrasound" due to a history of Paget Schroetter syndrome. What type of exam should be performed for this patient?
A. lower extremity venous Doppler exam
B. upper extremity venous Doppler exam
C. arterial PPG of the toes
D. segmental pressures on the lower extremities
B
Paget Schroetter Syndrome refers to the formation of upper extremity DVT due to excessive motion. It is usually associated with thoracic outlet syndrome.
54
```
Which of the following treatments would not be recommended for chronic peripheral arterial disease?
A. Angioplasty
B. Thrombolytic therapy
C. Coumadin therapy
D. Bypass graft
```
B
| Thrombolytic therapy is used to treat DVT or acute arterial occlusion by thrombus.
55
Congestive heart failure is more commonly seen with __________, while distal ischemia is more commonly seen with ___________.
A. AV malformation, AV fistula
B. distal AV fistula, proximal AV fistula
C. AV fistula, hemodialysis
D. proximal AV fistula, distal AV fistual
D
Congestive heart failure is more commonly seen with a proximal AVF, while distal ischemia is more commonly seen with distal AVF.
56
```
If the left proximal CCA demonstrates a PSV of 35cm/s and the right proximal CCA demonstrates a PSV of 115cm/s, which of the following could explain the findings?
A. congestive heart failure
B. decreased hematocrit
C. left ICA occlusion
D. aortic valve stenosis
```
C
If a single CCA demonstrates elevated velocity = tortuosity on that side or compensatory flow due to obstruction in the other carotid system. If the left ICA is occluded, flow in the CCA will be low velocity with a quick upstroke and little to no diastolic flow. The right CCA velocity can increase as it tries to provide the additional cerebrovascular flow needed. The left vertebral artery may also demonstrate elevated velocity as it tries to compensate for the ipsilateral ICA occlusion. The other choices would cause bilateral hemodynamic changes.
57
```
Which of the following is related to the appearance of Rouleaux formation on the image?
A. intracranial collateral flow
B. thoracic outlet syndrome
C. DVT
D. Raynaud Syndrome
```
C
Proximal to a DVT the flow may be very slow and visible on 2D imaging, the RBCs appear lined up or stacked in rolls similar to coin rolls from your bank which is called the Rouleaux Formation.
58
Aneurysm formation affects the __________, while atherosclerotic disease affects the __________.
A. intimal layer of the vessel wall, media and adventitia layers of the vessel wall
B. extracranial arteries, intracranial arteries
C. media and adventitia layers of the vessel wall, intimal layer of the vessel wall
D. proximal arteries, distal arteries
C
Aneurysm formation is caused by a breakdown of the media and adventitia layers of the vessel wall. Atherosclerotic disease causes formation of plaque within the intimal layer of the vessel wall. Both disorders can be found in any artery in the body.
59
```
Which cardiac abnormality usually has NO effect in the peak systolic velocities in the carotid arteries?
A. cardiomyopathy
B. mitral valve regurgitation
C. coronary artery disease
D. aortic valve stenosis
```
B
Cardiac structure and function should be considered on all vascular evaluations. Changes in cardiac function can effect the velocities in the arterial system and change the flow characteristics of the venous system. Mitral regurgitation does NOT affect the systolic velocities in the arterial system. Aortic stenosis, mitral stenosis, CHF, diastolic dysfunction, dilated cardiomyopathy and CAD can reduce the PSV in the arterial system. Systemic HTN, aortic regurgitation, hypertrophic cardiomyopathy and compensatory heart beats with arrhythmias can falsely elevate the PSV.
60
A patient presents with leg pain 2 days after a coronary artery catheterization. All of the following are an important part of the physical evaluation of the patient, except:
A. evaluation of the lower leg for loss of hair, dry skin and thick toenails
B. evaluation of the groin for a bruit
C. evaluation of the leg for signs of pallor
D. evaluation of the toes for blue discoloration
A
Loss of hair, dry skin and thick toenails are symptoms of chronic disease that would not really be important to the acute onset of the new symptoms. Angiography procedures have a risk of related pseudoaneurysm, AV fistula (bruit), distal embolization (blue toes) and acute occlusion from the puncture.
61
```
Lymphedema is commonly related to:
A. peripheral arterial disease
B. a pulmonary embolism
C. Leriche syndrome
D. a history of radiation therapy or cancer
```
D
Lymphedema occurs due to an obstructed lymphatic system. It can be caused by many things, but is commonly seen with infection, injury, trauma, or cancer that affects the lymphatic system. Radiation therapy or removal of lymph nodes related to cancer can also cause lymphedema.
62
Which of the following is not an expected finding with a positive evaluation for thoracic outlet syndrome?
A. low amplitude PPG digit tracings on the affected side with arm adduction
B. decreased flow velocity in the distal arm on the affected side with arm adduction
C. decreased blood pressure on the affected side with Adson's maneuver
D. decreased resistance in the proximal subclavian artery on the affected side with arm abduction
D
Due to compression of the distal subclavian with TOS, the flow in the proximal subclavian artery will demonstrate increased resistance.
63
```
An aortic aneurysm is diagnosed when the diameter of the aorta exceeds _______ and a popliteal aneurysm is diagnosed when the diameter of the popliteal artery exceeds ________.
A. 3.5cm, 2cm
B. 3.5cm, 1 cm
C. 3cm, 3cm
D. 3cm, 1cm
```
D
An aortic aneurysm is diagnosed when the diameter of the aorta exceeds 3cm and a popliteal aneurysm is diagnosed when the diameter of the popliteal artery exceeds 1cm.
64
```
Bilateral bruits are detected in the proximal neck. This finding is most suggestive of:
A. CHF
B. Subclavian steal
C. Polycythemia vera
D. Aortic valve stenosis
```
D
Bilateral carotid bruits and changes in both carotid flow patterns can be related to aortic stenosis. If the aortic valve is stenotic causing increased flow velocity and turbulence, flow in both carotids will reflect this change and may demonstrate bilateral bruits. CHF would lead to decreased flow through both carotids but a bruit would most likely NOT be identified due to slow moving flow.
65
```
Which of the following portions of the leg would be swollen with chronic insufficiency?
A. calf only
B. ankle and calf, but not the foot
C. foot and ankle, but not the calf
D. calf, foot, ankle
```
B
| Swelling of the feet normally does not occur with venous disease (systemic or cardiac disease, yes)
66
Which of the following is a potential symptom caused by a subclavian steal?
A. HTN
B. syncope
C. unilateral amaurosis fugax
D. syncope and unilateral amaurosis fugax
B
Vertebrobasilar disease is associated with syncope. Amaurosis fugax is a visual disturbance than can be related to ICA stenosis. HTN is a risk factor for developing vascular disease.
67
```
Aspirin would be the preferred treatment for which of the following patients?
A. 60% ICA stenosis
B. presence of significant venous reflux
C. compartment syndrome
D. total occlusion of an ICA
```
A
Aspirin prevents platelet aggregation in the arteries which reduces the ability of plaque to form. Patients with mild to moderate carotid stenosis can benefit from an aspirin each day.
68
A 60yr old male presents for a carotid ultrasound due to two recent episodes of syncope. He also has a history of CHF. Which of the following statements describes the Doppler waveforms you expect to see on this exam?
A. bilateral CCA waveforms will demonstrate decreased resistance and velocity
B. bilateral CCA waveforms will demonstrate increased resistance and velocity
C. the right CCA waveform will be damped and the left CCA waveform will be increased in velocity and resistance
D. the left CCA waveform will be damped and the right CCA waveform will be increased in velocity and resistance
A
CHF = congestive heart failure
Any abnormality that causes a decrease in cardiac output will result in damped CCA waveforms bilaterally. Severe aortic valve stenosis can also lead to damped CCA blood flow bilaterally.
69
```
A patient presents for a carotid Doppler exam due to left sided amaurosis fugax. These findings are most suggestive of stenosis in:
A. left ICA
B. right ICA
C. right vertebral artery
D. left vertebral artery
```
A
| Visual symptoms occur on the same side as the stenosis because the ophthalmic artery is a branch of the distal ICA.
70
```
Bilateral homonymous hemianopia is most commonly seen with:
A. internal carotid artery stenosis
B. subclavian vein thrombosis
C. vertebrobasilar disease
D. abdominal aortic aneurysm
```
C
Bilateral visual symptoms are most commonly related to verterbrobasilar disease and reduced flow to the occipital lobes of the brain. Unilateral visual symptoms are most commonly related to ICA disease and decreased flow to the ophthalmic artery.
71
```
Proximal to a DVT in the femoral vein, the flow appears very slow and visible on 2D imaging. The red blood cells appear lined up or stacked in rolls. What is this phenomenon called?
A. Rouleaux Formation
B. May-Thurner Syndrome
C. Phlegmasia cerulea dolens
D. Raynaud phenomenon
```
A
Proximal to a DVT in the superficial femoral vein, the flow appears very slow and visible on 2D imaging. The red blood cells appear lined up or stacked in rolls. This phenomenon is called Rouleaux formation.
72
```
A patient presents 3 days after left hip surgery for a DVT evaluation. There is severe edema from the hip to the ankle and the leg has a mild cyanotic appearance. You identify acute thrombus from the common femoral vein through the calf veins. The great saphenous vein is also occluded by thrombus. What is the diagnosis for this condition?
A. Phlegmasia Alba Dolens
B. Acute arterial occlusion
C. Phegmasia Cerulea Dolens
D. Budd Chiari syndrome
```
C
Phlegmasia Cerulea Dolens refers to extensive DVT occluding deep system and superficial system. Arterial inflow is significantly affected. Severe limb edema and mottled skin are noted with cyanosis due to high concentration of deoxygenated blood. Tip for remembering the difference between Cerulea Dolens and Alba Dolens, "C"erulea causes "C"yanosis of the leg, while Alba Dolens results in pallor.
73
Which of the following will result in a low resistance external carotid artery waveform with increased antegrade flow in diastole?
A. contralateral subclavian stenosis
B. ipsilateral mid common carotid artery stenosis
C. contralateral internal carotid artery occlusion
D. temporal arteritis
B
The ECA normally demonstrates a high resistance flow pattern with minimal antegrade diastolic flow. Stenosis proximal to the ECA (in the CCA) or in the proximal ECA will cause lower resistance ECA flow with increased antegrade flow in diastole. If the ipsilateral ICA is occluded, these same changes will occur.
74
If you detect flow toward the transducer in the right ACA while using the temporal window,
A. there is probably a left MCA occlusion
B. there is probably an occlusion of the right ICA
C. the flow direction is normal
D. there is probably an occlusion of the left ICA
B
If flow direction is reversed in one of the anterior cerebral arteries, the change can be caused by cross-over collateralization. An ICA occlusion should be suspected on the same side.
75
Patients with lower extremity arterial disease may describe pain
A. that is relieved by walking
B. that is relieved by elevating the legs
C. that is relieved by placing legs in a dependent position
D. that is relieved by lying down
C
The dependent position helps blood to reach the lower legs more quickly. Walking and elevating the legs would increase the pain. Lying down would provide minimal relief due to the loss of gravity's assistance with the flow.
76
When performing an upper extremity venous Doppler evaluation for thrombosis, which of the following veins should be evaluated on the exam?
A. cephalic, basilic and brachial veins
B. axillary, cephalic, basilic and brachial veins
C. subclavian, axillary, cephalic, basilic and brachial veins
D. axillary, brachial and deep forearm veins
C
When performing an upper extremity venous Doppler evaluation for thrombosis, the subclavian, axillary, cephalic, basilic and brachial veins should be evaluated on the exam.
77
Which of the following conditions would cause an increase in the systemic BP in just the right arm?
A. right subclavian artery stenosis
B. aortic coarctation just distal to the origin of the left common carotid artery
C. right subclavian steal
D. thoracic outlet syndrome of the right arm
B
If aortic coarctation occurs just distal to the origin of the left common carotid artery, BP will be reduced in the left arm and increased in the right arm. BP will be reduced in the right arm with the other choices.
78
Which of the following is most suggestive of renal transplant rejection?
A. urinary frequency and urgency
B. hyperbilirubinemia
C. oliguria
D. reduced serum levels of BUN and creatinine
C
Oliguria or anuria are important clinical indications for renal transplant failure. If the kidney is not prducing urine, it is failing. Other signs include elevated BUN and creatinine levels, hematuria and new onset of HTN.
79
Why would exposure to cold increase symptoms of lower extremity arterial stenosis?
A. increased resistance due to vasoconstriction
B. increased resistance due to vasodilation
C. increased resistance due to vasoconstriction and blood becomes less viscous with cold exposure
D. blood becomes less viscous with cold exposure
A
Cold exposure can cause the smaller vessels on the hand/foot to constrict which increases resistance to flow. This effect could further exacerbate symptoms of ischemia in the extremity.
80
Which of the following is not part of the standard TCD protocol for vasospasm?
A. measure any anechoic spaces around the brain that could indicate a hemorrhage
B. report all mean flow velocities in the MCA that are greater than 120cm/s
C. perform serial exams to evaluate flow velocity in the MCA
D. calculate the hemispheric index
A
A TCD exam for vasospasm involves performing serial evaluations of the MCA velocities. Report all mean flow velocities in the MCA that are greater than 120cm/s because this indicates a positive exam. The hemispheric index is calculated by dividing the peak MCA velocity by the peak ICA velocity. An HI > 3 indicates a positive exam. There is no 2D imaging in the TCD exam, therefore the cerebral tissue cannot be evaluates.
81
Which of the following correctly describes an IVC aneurysm?
A. Must be associated with interrupted IVC to be considered a true IVC aneurysm
B. rarely leads to thrombus formation
C. most IVC aneurysms are saccular
D. commonly associated with blue toe syndrome
C
IVC aneurysms can be saccular or fusiform, but the saccular formation is slightly more common. Aortic aneurysms are more commonly fusiform.
Anatomic classification system:
Type I: occurs in the suprahepatic IVC without venous obstruction
Type II: associated with interruption of the IVC above or below the hepatic veins
Type III: occurs in the infrarenal IVC without associated venous anomaly
Type IV: a left-sided IVC with an aneurysm at the confluence of the left internal and external iliac veins. Can lead to thrombus formation and increases risk of embolism to the lungs.
82
Venous gangrene usually involves ___________, while arterial gangrene usually involves ________.
A. all the toes and foot, just one or two toes
B. just one or two toes, all the toes and foot
C. the foot but no toes, the toes but not the foot
D. right foot, left foot
A
| Venous gangrene usually involves the foot and all toes, while arterial gangrene usually involves one or two toes.
83
```
If a patient has a history of ________, they have an increased risk for carotid dissection.
A. Budd Chiari
B. Thoracic outlet syndrome
C. Raynaud syndrome
D. Marfan syndrome
```
D
Marfan syndrome is a connective tissue disorder that affects the heart and blood vessels. It it often associated with dilatation and/or aneurysm of the aorta, which can lead to intimal dissection.
84
Which of the following correctly describes DVT in the lower extremity?
A. Chronic thrombus will demonstrate complete coaptation of the venous walls upon compression
B. Recanalization of a thrombus usually occurs around 5 days after formation occured
C. acute thrombus will be completely non-pliable upon compression
D. Heparin is used to treat a DVT due to its clot lysing properties
B
Recanalization of a thrombus usually occurs around 5 days after formation occured. Heparin is used to treat a DVT because it thins the blood and prevents further propagation of the clot. It does not have clot lysing properties. Acute thrombus will be somewhat pliable upon compression. Chronic thrombus will be non-pliable upon compression.
85
```
Which of the following is the most common site for atherosclerosis formation in the lower extremity?
A. popliteal artery
B. calf trifurcation
C. SFA in Adductor canal
D. CFA bifurcation
```
C
| The most common site for atherosclerosis formation in the lower extremity is in the SFA in the adductor canal.
86
Why would bilateral brachial blood pressure (BP) assessment assist in the diagnosis of a subclavian steal?
A. the highest brachial pressure is needed to calculate the ABI
B. the systolic BP will be lower on the affected side
C. the systolic BP will be higher in the affected side
D. to evaluate the potential for future limb amputation
B
For example: If the left subclavian artery is occluded proximal to the origin of the left vertebral artery, flow from the right vertebral artery will fill the left vertebral artery in a retrograde fashion. This blood will then fill the distal subclavian artery and enter the arm. The reduced flow into the left arm will demonstrate reduced pressure.
87
Which of the following are collagen disorders that have increased risk for arterial dissection?
A. Paget Schroetter syndrome and Raynaud syndrom
B. Shone complex and Blue Toes syndromd
C. Marfan syndrome and Polycythemia vera
D. Marfan syndrome and Ehler-Danlos syndrome
D
Marfan syndrome and Ehler-Danlos syndrome are collagen disorders that can lead to the formation of arterial aneurysm or dissection. Shone complex is a group of cardiac defects and defects of the aortic arch and valve. Blue Toe syndrome is caused by emboli from an AAA with mural thrombus, Paget Schroetter syndrome affects the upper extremity veins. Raynaud syndrome is a collagen disorder that reduces floe to the hands/feet. Polycythemia vera is a rare cancer that causes blood thickening.
88
```
What is the minimum amount of diameter stenosis in the internal carotid artery that will demonstrate hemodynamic significance?
A. 25%
B. 75%
C. 50%
D. 95%
```
C
Hemodynamic significance refers to the appearance of signs and symptoms related to the compromised blood flow. 50% diameter or 75% area stenosis of a vessel is described as hemodynamically significant.
89
```
The most common complication of lower extremity DVT is:
A. phlegmasia cerulea dolens
B. phlegmasia cerulea alba
C. pulmonary embolism
D. valvular incompetence
```
D
The presence of DVT damages venous valvular structure and motion and venous insufficiency is the most common sequela seen with DVT. Pulmonary embolism is the most critical complication of DVT.
Phlegmasia alba dolens is an extensive iliofemoral thrombosis, usually due to stasis of uterine blood with recent pelvic surgery or pregnancy. It presents as painful swelling and pallor of the entire leg (milk leg).
Phlegmasia cerulea dolens is an uncommon severe form of DVT which results from extensive thrombotic occlusion of the veins of an extremity. It presents as painful "blue" swollen leg. Milk leg becomes blue leg if untreated.
90
```
Patients with this risk factor have a greater incidence of atherosclerotic disease in walls of the vessels in the calf.
A. Buerger disease
B. systemic HTN
C. Raynaud syndrome
D. diabetes
```
D
Diabetic patients suffer from medial calcification of the blood vessel walls. This leads to increased resistance in the vessels and decreased flow.
91
```
A patient presents with a diminished pulse in the right radial artery and a normal pulse in the ulnar artery. These findings are most suggestive of:
A. right subclavian artery stenosis
B. proximal right radial artery stenosis
C. right brachial artery stenosis
D. innominate artery stenosis
```
B
Reduced flow in a single forearm artery would indicate a stenosis in the proximal segment of the affected artery. The other choices would reduce flow to both forearm arteries.
92
A patient presents with a script that states "2yr hx of Budd Chiari Syndrome." What are you looking for on the exam?
A. atrophied liver with nonvisualization of the hepatic veins
B. enlarged liver with marked ascites and nonvisualization of the hepatic veins
C. bilateral renal artery stenosis
D. dilated IVC
A
| Chronic obstruction of the hepatic veins will cause the liver to atrophy and fibrosis to occur.
93
An aortic dissection most commonly originates:
A. in the infrarenal descending aorta
B. in the ascending aorta
C. in the descending thoracic aorta, just distal to the origin of the left subclavian artery
D. in the aortic root
C
Aortic dissection most commonly occurs in the descending thoracic aorta, just distal to the origin of the left subclavian artery. The ascending aorta and arch are the second most common sites for dissection.
94
Adventitial cysts:
A. most commonly affect the popliteal artery
B. are a normal variant that can be seen in up to 10% of patients
C. are more common in women
D. are usually treated with bypass graft placement
A
Adventitial cysts are a rare condition that involves the collection of mucinous material within the adventitial wall layer of the affected vessel. They predominantly affect the peripheral arteries with the popliteal artery most commonly affected. The cysts are most common in young to middle-aged men. They can be treated by ultrasound guided cyst aspiration.
95
What causes thoracic outlet syndrome?
A. extrinsic compression of the subclavian artery from bony and muscular structures
B. focal inflammation of the proximal subclavian artery
C. viral infection of the intimal layer of the arteries in the upper extremity
D. medial calcification of the arteries of the upper extremity
A
TOS is caused by extrinsic compression of the subclavian artery from bony and muscular structures. The compression causes ischemia and symptoms in the affected arm/hand. Changes in flow will be detected with patient arm movement.
96
Why does blood move into smaller collateral vessels when a larger vessel is occluded?
A. because of the significant drop in venous pressure
B. the resistance to flow in the smaller collateral is lower than the resistance in the occluded vessel
C. to compensate for loss of blood flow proximal to the obstruction
D. the resistance to flow in the smaller collateral is higher than the resistance in the occluded vessel
B
Collateral flow around an occlusion develops to compensate for the reduction in flow to the distal tissues. When the native artery is patent, the resistance to flow is greater in the smaller arteries. When the larger artery is occluded, the resistance to flow in the smaller collateral is lower than the resistance in the occluded vessel. Blood flow moves into the vessel with the least resistance.
97
Which of the following is not an expected finding with a left subclavian steal?
A. right vertebral artery increases in size
B. flow reversal in the left vertebral artery
C. increased flow volume and velocity in the right vertebral artery
D. increased resistance in the left axillary artery
D
If the left subclavian artery is obstructed, flow will move from the right vertebral into the left vertebral artery. Flow in the right vertebral artery will increase with increased velocity as it tries to meet the increased demands. This usually causes the artery to dilate. Flow in the left vertebral artery is revered and the flow enters the left subclavian artery distal to the obstruction. The flow in arteries of the left arm will demonstrate reduced resistance and a monophasic flow pattern.
98
```
Which of the following conditions is usually related to cardiac pulsatility in the leg veins?
A. bradycardia
B. congestive heart failure
C. DVT
D. tachycardia
```
B
As the heart moves in the chest it causes the ripple effect in the venous system. Normally, the upper IVC and Hepatic veins demonstrate this ripple effect as flow reversal during cardiac systole. The "ripples" of cardiac pressure/motion usually dissipate as they reach the mid abdomen area. In patients with CHF, the venous blood volume is increased throughout the system. The cardiac pulsatility will extend further into the lower extremities due to the increased blood volume.
99
Thoracic outlet syndrome occurs when the _______ is compressed by the ________.
A. brachial plexus, scalene muscle or cervical rib
B. renal artery, diaphragm crura
C. superior mesenteric artery, median arcuate ligament of the diaphragm
D. celiac axis, median arcuate ligament of the diaphragm
A
Thoracic outlet syndrome occurs when the brachial plexus is compressed by the scalene muscle or cervical rib. Because the nerves are also compressed with the lymph and blood vessels, numbness and tingling are common symptoms of TOS.
100
Which of the following describes the path of an embolus?
A. a small piece of soft plaque breaks off from the carotid bulb and floats toward the lungs
B. a small piece of soft plaque breaks off from the carotid bulb and floats toward the brain
C. a small piece of thrombus breaks off from a thrombus in the right ventricle and floats toward the brain
D. a small piece of thrombus breaks off from a thrombus in the left ventricle and floats toward the lungs
B
An embolus is a floating piece of debris, air bubble, thrombus or plaque that moves distally until it lodges in a small vessel. Thrombus in the right ventricle will be sent to pulmonary artery and the lungs = pulmonary embolism. Thrombus in the left ventricle can be sent to the brain through the aorta = stroke. An embolus in the carotid system will go to the brain.
101
When compared to the normal left CCA, the right CCA demonstrates reduced velocity, slower upstroke and holodiastolic flow. These findings are most consistent with:
A. elevated hematocrit levels
B. congestive heart failure
C. decreased hematocrit levels
D. stenosis proximal to the point of insonation
D
If a single CCA demonstrates reduced velocity, slower upstroke and holodiastolic flow = stenosis proximal to the point of insonation. The vessel demonstrates the characteristics of flow distal to a stenosis. The other choices would cause hemodynamic changes in both carotid arteries.
102
```
What term refers to the phenomenon of a PW Doppler tracing displaying a wider distribution of the velocity of blood cells with varying degrees of arterial blockage?
A. spectral broadening
B. turbulence
C. laminar flow
D. occlusion
```
A
Spectral broadening refers to PW Doppler tracing displaying a wider distribution of the velocity of blood cells with varying degrees of arterial blockage. Laminar flow refers to the slight difference in speed in the layers of blood velocity on a PW Doppler tracing. Turbulence refers to the distribution of laminar flow causing eddy currents within the vessel. Turbulence is displayed as spectral broadening on a PW Doppler tracing.
103
If the tibioperoneal trunk is occluded, flow in which calf vessel(s) will demonstrate increased flow?
A. anterior tibial artery
B. posterior tibial artery
C. peroneal artery
D. posterior tibial artery and peroneal artery
A
The popliteal artery bifurcates into the anterior tibial artery and tibioperoneal trunk just outside the popliteal artery. Slight distal to that bifurcation the trunk splits into the posterior tibial artery and peroneal artery.
104
Bilateral leg and foot edema are present. What is the most common cause for this?
A. chronic insufficiency in the superficial system
B. lymphedema
C. chronic insufficiency in deep system
D. congestive heart failure
D
Cardiac and systemic problems lead to bilateral swelling of the lower extremities, including the feet. Lymphedema can cause bilateral leg and foot swelling, but it is less common than CHF. Chronic venous disease does not normally cause swelling of the feet and is most commonly unilateral.
105
A patient presents for a venous insufficiency exam, but is unable to stand for the exam. How will this affect your exam?
A. no change as long as they can move their feet to perform the heel raises
B. the PPG tracings will be increased in amplitude
C. the segmental pressures will be falsely elevated
D. venous reflux may not be demonstrated in veins where it is actually present
D
Because the patient knees and hips are bent in the sitting position flow will be slowed in these areas which would reduce the appearance of reflux. Standing increases hydrostatic pressure to better demonstrate the reflux.
106
A patient presents for a carotid ultrasound for pre-op testing for an aortic valve replacement surgery. The echo report in their chart indicates the stenosis is severe. What is the best way to determine if carotid stenosis is present in the patient?
A. calculate the ICA/CCA systolic and diastolic velocity ratios
B. unable to evaluate carotid stenosis in patients with known heart disease
C. using the peak systolic and end systolic velocity of the CCA
D. using the peak systolic and end systolic velocity of the ICA
A
With aortic valve stenosis, blood flow increases in velocity as it moves through the narrowed valve. The flow into the ascending aorta will be turbulent. Characteristics of post-stenotic flow can be transmitted to the carotid arteries: lower resistance, turbulence and reduced velocity. Brachial pressures may also be lower than normal. The ICA/CCA systolic and diastolic velocity ratios should be used to assess the patient for carotid stenosis because peak velocities may be diminished.
107
```
Thrombolytic therapy is used to treat:
A. chronic deep vein thrombosis
B. acute arterial occlusion caused by thrombus
C. venous insufficiency
D. chronic venous disease
```
B
Thrombolytic drugs are used in medicine to dissolve blood clots. Thrombolytic therapy is used to treat extensive acute DVT and acute arterial obstruction by thrombus.
108
```
A patient complains of the right leg pain and color changes in the leg. When he lies down, the right calf and foot become pale. When he sits up on the edge of the bed, the right calf and foot become reddened. The left leg is asymptomatic. These findings are most suggestive of:
A. deep venous reflux
B. significant right iliac stenosis
C. significant aortic obstruction
D. right popliteal stenosis
```
D
Pallor and dependent rubor are indications of significant arterial disease. The unilateral presentation indicates the obstruction is blocking flow to just the right leg. Only the lower leg experiences the color change, so the blockage must be at the level of knee = right popliteal stenosis is the most likely cause.
109
```
A 56yr old female presents with mild calf pain that is caused by dorsiflexion of the foot. The symptoms began after she returned from vacation in France. Yesterday she noticed a sudden red color change and edema, localized to the lower leg. These clinical findings are most suggestive of:
A. chronic insufficiency
B. pseudoaneurysm
C. cellulitis
D. acute DVT
```
D
The patient noticed the problem after a vacation in France = long plane ride = venous stasis. The sudden onset of additional symptoms indicates propagation of a clot in the calf.
110
You are performing a venous Doppler exam due to the recent onset of swelling in the left calf. The mid left femoral vein appears to be occluded by hypoechoic, non-compressible. Which of the following Doppler waveform characteristics is expected from the popliteal vein?
A. increased pulsatility
B. decreased response to distal augmentation of calf muscle
C. loss of respiratory phasicity
D. normal response to distal augmentation of calf muscle
C
The flow response to the distal augmentation would most likely be decreased but NEVER augment a patient's calf when an acute DVT is diagnosed. The best answer is loss of respiratory phasicity because continuous flow is expected with the proximal obstruction.
111
```
Which of the following symptoms is most commonly seen with peripheral arterial disease?
A. absent pedal pulses
B. dry ulcerations
C. phlegmasia dolens
D. claudication
```
D
Claudication is defined as pain in muscles that subsides w/ rest. The pain will be predictable and reproducible at the same level of exercise. EX: calf cramping occur every time the patient walks for 5 mis.
112
```
A 65yr old female presents with left leg swelling for over one year. Mild hyperpigmentation is present in the distal calf and ankle area. These clinical findings are most suggestive of:
A. chronic insufficiency
B. superficial phlebitis
C. cellulitis
D. Acute DVT
```
A
Chronic swelling and brown discoloration are characteristics of venous stasis. This is most commonly associated with chronic insufficiency. Acute DVT would result in acute swelling with a red discoloration.
113
```
What is the normal value for a transcutaneous oximetry exam?
A. <40mmHg
B. 2.0 (unitless)
C. 70-80mmHg
D. 3.5 (unitless)
```
C
Transcutaneous Oximetry determines capability of healing a wound or specific site for amputation; Evaluates oxygen supply and consumption in tissues surrounding the wound; Measures the oxygen partial pressure in adjacent areas of a wound; cannot evaluate the wound itself, only the surrounding tissues; Normal TcPO2 levels 70-80mmHg; <40mmHg indicates tissue hypoxia.
114
```
______________ refers to a collection of mucinous material within the adventitial wall layer of the affected vessel.
A. mucinous dissection
B. adventitial cyst
C. vasa vasorum
D. Baker cyst
```
B
Adventitial cysts are a collection of mucinous material within the adventitial wall layer of the affected vessel. The cysts predominantly form in the walls of the peripheral arteries, with the popliteal artery most commonly affected. It is most common in young to middle-aged men with no other vascular disorders. Usually presents as multiple anechoic or hypoechoic areas within the wall. No blood flow is detected in the areas. The cysts can cause narrowing of the vessel lumen and stenosis.
115
```
A patient complains of the right leg pain and color changes in the leg. When he lies down, the entire right leg become pale. When he sits up on the edge of the bed, the entire right leg becomes reddened. The left leg is asymptomatic. These findings are most suggestive of:
A. right popliteal stenosis
B. significant right iliac stenosis
C. deep venous reflux
D. significant aortic obstruction
```
B
Pallor and dependent rubor are indications of significant arterial disease. The unilateral presentation indicates the obstruction is blocking flow to just the right leg. The entire leg experiences the color change, so the blockage must be at the groin = right iliac.
116
```
The most common color change demonstrated in a lower extremity with an acute arterial occlusion is:
A. brawny
B. rubor
C. pallor
D. cyanosis
```
```
C
Six "P's" of Acute Occlusion:
1. pain
2. pallor
3. pulselessness
4. paresthesia
5. paralysis
6. polar sensation (cold)
***Caused by embolism, thrombus formation or trauma
```
117
```
If a patient is diagnosed with a pulmonary embolism, what should be the next step in their patient care?
A. IV Heparin
B. pulmonary angiography
C. V/Q scan
D. lower extremity venous Doppler exam
```
A
If the patient has been diagnosed with a PE, additional exams may or may not be required to locate the source of the embolism. Immediate IV Heparin therapy should be administered.
118
Which of the following would lead to underestimation of stenosis in the internal carotid artery?
A. significant aortic valve stenosis
B. short area of focal stenosis
C. elevated heart rate
D. compensatory flow due to stenosis on other side
A
Underestimation of stenosis in the ICA can be seen with:
Reduced systemic blood pressure
Proximal stenosis - such as significant aortic valve stenosis
Long area of focal stenosis
Tandem stenosis or eccentric stenosis
Critical stenosis (string flow)
Reduced cardiac output - CHF, coronary artery disease, dilated cardiomyopathy
119
```
What type of carcinoma is commonly related to tumor infiltration causing obstruction of the IVC?
A. splenic
B. pancreatic
C. gastric
D. renal
```
D
Renal carcinoma cases have demonstrated tumor invasion into the renal vein and IVC. The infiltrated mass leads to venous outflow obstruction and possibly thrombosis which leads to an increased risk of pulmonary embolism. The other types of cancer listed are in organs that are connected to the portal venous system. If a cancer develops in the pancreas, spleen or stomach, venous infiltration would progress into the portal system.
120
If flow in the left ophthalmic artery is revered in a transorbital evaluation, what is the expected flow pattern in the right ophthalmic artery?
A. increased pulsatility
B. increased systolic and diastolic velocities
C. reduced systolic and diastolic velocities
D. flow moving away from the transducer
B
Normal flow in the ophthalmic artery should be moving toward the transducer in the transorbital window. If flow is reversed in the left ophthalmic artery, the right ophthalmic artery will demonstrate increased antegrade flow volume and velocities with decreased pulsatility.
121
```
While scanning the popliteal artery, you notice a thrombus in the popliteal vein. Which vein(s) should be evaluated next for ascending propagation of the clot?
A. common femoral vein
B. distal femoral vein
C. GSV
D. ATA and tibioperoneal trunk
```
B
If a clot is identified in the popliteal vein, the distal femoral vein should be evaluated next for propagation of the thrombus.
122
Secondary Raynaud phenomenon:
A. is a functional vasospastic disorder that occurs due to kidney disease
B. occurs in patients with severe venous disease
C. is a functional vasospastic disorder which occurs in patients with an unobstructed vascular system
D. occurs in patients with an obstructed vascular system
D
Primary - Normal vascular system, intermittent bilateral digital arterial spasm, excellent prognosis; Raynaud syndrome or disease.
Secondary - Abnormal obstructed system with vasoconstriction causes constant ischemia, may be unilateral, Raynaud phenomenon.
123
```
Which of the following is not a common symptom of chronic venous disease?
A. varicosities
B. pitting edema
C. pallor
D. brawny discoloration
```
C
| Pallor is most commonly a sign of arterial disease.
124
What structure compresses the artery in popliteal entrapment?
A. lateral meniscus
B. medial meniscus
C. medial head of the gastrocnemius muscle
D. patella
C
Popliteal entrapment is the compression of the artery by the medial head of the gastrocnemius muscle. It is commonly found in runners and athletes and is the most common cause of unilateral claudication in young patients.
125
________ cause primary varicose veins, while _______ cause secondary varicose veins.
A. incompetent valves, incompetent perforators
B. elevated deep venous pressures, incompetent valves
C. incompetent valves, elevated deep venous pressures
D. elevated deep venous pressures, elevated arterial pressures
C
Incompetent valves cause primary varicose veins, while elevated deep venous pressures in a diseased deep system (hx of DVT or abnormal valves) cause secondary varicose veins. Primary varicose veins are much more common than secondary.
126
What is caput medusa?
A. tortuous vessels around the umbilicus caused by portal HTN
B. lower extremity varicosities on the anterior thigh
C. formation of gastroesophageal varices caused by portal HTN
D. lower extremity varicosities on the anterior knee
A
| Caput medusa refers to dilated, tortuous vessels around the umbilicus caused by portal HTN.
127
A patient presents with a swollen left leg from hip to ankle and the right leg is normal. An US exam shows compressible vessels bilaterally. Doppler demonstrates normal flow in the right leg but there is loss of phasicity of flow and decreased augmentation of the left common femoral vein and proximal femoral vein. These findings are most suggestive of:
A. left ovarian mass or left external iliac thrombosis
B. right external iliac thrombosis or IVC thrombosis
C. bilateral external iliac or internal iliac thrombosis
D. IVC thrombosis
A
A left ovarian mass could compress the iliac vein to cause the swelling. Left external iliac thrombosis could also cause unilateral swelling of the entire leg. IVC thrombosis or bilateral external iliac thrombosis could cause flow abnormalities in both extremities. Internal iliac thrombosis will not affect the venous outflow of the legs.
128
Which of the following describes an AV malformation?
A. can be treated using Thrombin injection
B. direct connection between a single artery and vein
C. dilated venous collaterals adjacent to the area of interest
D. caused by trauma or surgical procedures
C
An AVM is a congenital malformation with multiple connections between the arterioles and venules without a capillary bed in between. Venous collateral will develop and dilate over time. An AVF is an acquired condition that is caused by trauma or invasive procedures. Because it is an acute complication, no collateral vessels form. The arterial inflow and venous outflow will demonstrate the same hemodynamic characteristics for an AVM and and AVF, low resistance arterial inflow and pulsatile, turbulent venous outflow. Thrombin cannot be used to treat and AVM or AVF because it could occlude the arterial system.
129
All of the following describe a transcutaneous oximetry exam of the lower extremity, except:
A. readings are taken in the toes, lower leg and thigh
B. the electrodes heat the tissues to 45 degrees Celsius to release oxygen
C. it takes approximately 3 minutes to obtain a reading
D. a baseline reading is obtained first on the crest
C
Transcutaneous Oximetry determines capability of healing of a wound or specific site for amputation. The sensor evaluates oxygen supply and consumption in tissues surrounding the wound. Electrodes head the skin to 45 degrees Celsius and oxygen escapes from the tissue to be measured by the sensor. It takes approximately 15-20 minutes to obtain a reading. System calibration is REQUIRED!!!! First, obtain a reading on the chest as a baseline, then obtain readings of the toes, lower leg and thigh. Normal TcPO2 levels 70-80mmHg; <40mmHg indicates tissue hypoxia.
130
```
What penile structure is usually fractured with penile trauma?
A. corpus carvernosum
B. glans penis
C. pampiniform plexus
D. corpus spongiosum
```
A
| The corpus cavernosum on one or both sides can be fractured causing subcutaneous bleeding and significant pain.
131
```
Fibromuscular dysplasia most commonly affects which portion of the carotid arteries?
A. bulb and proximal ICA
B. CCA bifurcation
C. proximal ECA
D. mid segment of the ICA
```
D
FMD usually occurs in the mid or distal segment of the ICA, while atherosclerosis most commonly affects the proximal ICA.
132
If significant disease is identified on the arterial duplex evaluation, but 4 minutes of exercise has little effect on the ankle pressures:
A. there are collateral pathways present
B. digital pressures must be recorded to diagnose disease in this patient
C. post-occlusive reactive hyperemia should be performed
D. service should be scheduled for the ultrasound unit
A
If significant disease identified on the ultrasound evaluation, but exercise has little effect on the ankle pressures, collateral pathways are present that are maintaining the required flow volume. Digit pressures would also be normal due to the collateral flow. Post-occlusive reactive hyperemia is reserved for those patients that cannot exercise. If it was performed, it would provide the same results as exercise.
133
What is the most common indication for an upper extremity arterial Duplex exam?
A. arterial stenosis due to atherosclerosis
B. Raynaud Phenomenon
C. evaluate hemodialysis graft performance
D. Thoracic Outlet Syndrome
C
Raynaud Phenomenon and TOS are best evaluated with PVR or PPG techniques. Atherosclerosis formation is uncommon in the upper extremities.
134
```
It is not possible to evaluate and document valvular insufficiency with only:
A. color Doppler evaluation
B. 2D real time imaging
C. plethysmography
D. PW Doppler evaluation
```
B
The black and white 2D images are not capable of demonstrating blood flow characteristics. Venous valve movement may be assessed in 2D but this does not help quantify valvular incompetence.
135
```
When evaluating a liver transplant, you must use angle correction during Doppler evaluation of:
A. hepatic arteries and portal veins
B. hepatic arteries only
C. portal veins only
D. hepatic arteries and veins
```
A
When evaluating the velocity in a vessel using PW Doppler, angle correction must be used to obtain an accurate velocity. All arterial evaluations with Doppler require angle correction because velocity is not evaluated, the portal vein velocity is measured to assess a liver transplant and angle correction is necessary.
136
```
Which of the following risk factors has the highest incidence of lower extremity thrombus formation?
A. rotator cuff repair
B. polycythemia vera
C. recent hip surgery
D. diabetes
```
C
Patients who have undergone any type of lower extremity surgery are at the greatest risk of DVT. Usually these patients are confined to a bed for several days/weeks which leads to stasis. There are significant limitations with using blood thinners immediately following surgery because it would prevent the healing of the surgery and could lead to hemorrhage.
137
```
Which of the following describes the proper way to measure an abdominal aortic aneurysm?
A. inner wall to inner wall
B. outer wall to outer wall
C. inner wall to outer wall
D. outer wall to inner wall
```
B
The aortic should be measured from outer wall to outer wall. The AP dimension is considered the most reliable dimension for assessing a possible AAA.
138
A patient presents with a prior history of popliteal DVT and a recent history of intermittent mild leg pain with increasing appearance of small varicosities on the calf. Which statement below best describes his condition?
A. the patient is suffering from secondary varicose vein formation
B. the patient most likely has a recurrent acute DVT
C. there is most likely a Baker's cyst in the popliteal fossa causing extrinsic compression
D. there is most likely a clot in the gastrocnemius veins of the calf
A
Primary varicosities form due to abnormal valves in the superficial venous system. Secondary varicosities form if there is an associated problem in the deep system, such as previous DVT.
139
```
The profunda artery demonstrates a 75% stenosis. Which of the following arteries will demonstrate monophasic flow due to the stenosis?
A. popliteal
B. posterior tibial
C. anterior tibial
D. none of the above
```
D
The femoral artery supplies the popliteal and calf vessels with blood. A stenosis in the profunda artery will not cause decreased resistance in the vessels of the lower leg.
140
Which of the following correctly describes an aortic aneurysm?
A. patients with a popliteal artery aneurysm rarely have an associated AAA
B. the AP diameter is considered the most reliable dimension for diagnosis of AAA
C. AAA with a diameter of 4.5cm or greater will require surgical intervention
D. the most common complication of a AAA is thrombus formation in the IVC
B
The AP diameter is considered the most reliable dimension for diagnosis of a AAA. AAA with a diameter of 5.5cm or greater will require surgical intervention. The most common complication of a AAA is rupture. >60% of patients that have a popliteal artery aneurysm also have a AAA.
141
```
A patient presents with splenomegaly and multiple, small, tortuous vessels are visualized in the porta hepatis area of the liver. These vessels most likely represent:
A. cavernous transformation
B. dilated extrahepatic biliary system
C. duplicated hepatic artery
D. portal aneurysm
```
A
Cavernous transformation of the vessels at the porta hepatis refers to the formation of varices from the increased portal pressure with portal HTN. Accessory veins dilate at the porta hepatis due to the backlog of blood flow. These vessels are small and tortuous. Splenomegaly is another sign of portal HTN and a backlog in the blood flow in the portal system.
142
```
A patient presents for a carotid ultrasound due to recent episodes of near syncope. Other symptoms include shortness of breath and pedal edema. Noticeable respiratory variation in the peak velocities of the carotid arteries is present. What cardiac complication should be suspected?
A. tricuspid stenosis
B. mitral stenosis
C. cardiac tamponade
D. low cardiac output
```
C
Cardiac tamponade is a critical finding that requires pericardiocentesis. Severe pericardial effusion within the fibrous pericardium causes extrinisic compression of the right heart chambers. Respiratory variation in arterial flow velocities will occur. Flow diminishes with inspiration and normalizes with expiration. Another sign of cardiac tamponade is pulsus alterans. Pulsus alterans - the peak systolic velocity alternates between two levels with each beat. Pulsus alterans is also associated with dilated cardiomyopathy and constrictive pericarditis.
143
Which of the following vessels will be abnormally dilated with significant portal HTN?
A. main portal vein and hepatic veins
B. hepatic veins only
C. left gastric vein and hepatic veins
D. main portal vein and left gastric vein
D
The left gastric vein (AKA coronary vein) dilates with significant portal HTN. It normally drains into the splenic vein near the portal confluence and is best evaluated in sagittal plane near the porta hepatis. A dilated, patent umbilical vein is also a sign of significant portal HTN. It is best evaluated in the sagittal plane to the left of midline at the level of the ligamentum teres. It acts as a reservoir for portal blood with nowhere to go.
144
What is the best quantitative parameter to use to estimate internal carotid artery stenosis in patients with severe aortic valve stenosis?
A. velocity ratio
B. peak systolic and end diastolic velocities
C. end diastolic velocity
D. acceleration time
A
Flow in the carotid arteries will be diminished in patients with significant aortic valve stenosis. When cardiac output is reduced, the flow velocities in the carotid systems will be reduced. This can lead to underestimation of ICA stenosis. The velocity ratio is used to provide a more accurate of estimate stenosis in these patients.
145
A patient in the ER has just been diagnosed with acute DVT of the popliteal vein. What would be the physicians preferred treatment plan?
A. perform sclerotherapy to resolve the clot
B. begin the use of compression stockings and perform a follow up exam in 30 days
C. insert a valvulotome into the popliteal vein and recnalize the lumen
D. immediate IV treatment with Heparin and begin in 90 days of Warfarin pills once released from the hospital
D
Acute DVT is usually initially treated with IV Heparin followed by at least 90 days of Warfarin/Coumadin therapy once the patient is out of the hospital.
146
```
If there is an acute occlusion of the proximal femoral artery, what will the Doppler waveform look like in the mid femoral artery?
A. varies with collateral formation
B. blunted
C. high resistance
D. absent
```
D
There will be no flow in the mid femoral artery with an acute obstruction because there has not been time for collaterals to form.
147
```
Which of the following would cause flow in the left ECA to reverse direction during systole?
A. right CCA occlusion
B. left CCA occlusion
C. left vertebral artery occlusion
D. left proximal ICA occlusion
```
B
Ipsilateral CCA occlusion can cause ECA flow reversal so that it can supply the ICA with flow. Collateral flow from the contralateral cerebral system will back fill the ECA. Reversed flow in the ECA will fill the left ICA with blood because the CCA is occluded.
148
```
Which of the following is not considered a risk factor for peripheral arterial disease?
A. pregnancy
B. diabetes
C. systemic HTN
D. smoking
```
A
Pregnancy can lead to an increase in venous blood volume and stasis but has no effect on the formation of arterial disease.
149
During a color evaluation of the common femoral vein, the patient is asked to perform the Valsalva maneuver. The blue color in the CFV changes to red for approximately 3 seconds before returning to blue. What do these color Doppler findings indicate?
A. the CFV has minimal venous insufficiency
B. superficial venous insufficiency is present
C. there is most likely an occlusive DVT in the superficial femoral vein causing the venous turbulence proximally
D. a significant level of insufficiency is present and should be further evaluated with PW or CW Doppler techniques.
D
0.5 seconds or less of flow reversal is considered normal in the superficial veins. 1 sec or less of flow reversal is considered normal in the deep veins. 3 seconds or greater of flow reversal indicates significant venous reflux.
150
Which of the following describes Takayasu Arteritis?
A. most commonly affects the ascending aorta
B. strongly associated with stasis dermatitis
C. more common in males
D. most commonly found in patients that smoke
A
Takayasu Arteritis presents as hypertrophic area(s) of inflamed tissue found in the aorta and its branches. It is commonly associated with supravalvular aortic stenosis and aortic coarctation. It can also affect the renal and subclavian arteries. Most commonly seen in young females.
151
A venous insufficiency exam is performed for a patient with multiple varicosities. The deep system is found to be competent, but there is insufficiency present in the great saphenous vein. Which of the following statements regarding the findings is true?
A. there are secondary varicosities present but compression stockings are not an option for treatment for this patient
B. there are primary varicosities present
C. there are secondary varicosities present
D. compression stockings are not an option for treatment for this patient
B
Varicosities with superficial venous insufficiency related to deep venous system disease = secondary varicosities. Varicosities with incompetent valves causing superficial venous insufficiency and normal deep system = primary varicosities. Compression stockings are usually the first step in treatment for all varicosities.
152
```
Which of the following vessels supplies blood to a carotid body tumor?
A. subclavian
B. MCA
C. ICA
D. ECA
```
D
| Branches of the ECA supply blood to a carotid body tumor.
153
```
Which of the following conditions would be treated with streptokinase?
A. 70-90% carotid stenosis
B. partial DVT
C. phlegmasia cerulea dolens
D. venous insufficiency
```
C
Streptokinase is only used to break up a clot in patients with phlegmasia due to risk of emboli formation. The benefits of the drug outweigh the risk of embolism in phlegmasia because it is a critical finding.
154
Which of the following Doppler characteristic will be identified at a 70% femoral artery stenosis?
A. loss of the retrograde flow component in diastole
B. decreased acceleration time
C. increased diastolic flow reversal
D. prominent spectral window
A
The diastolic flow reversal will become continuous antegrade flow throughout the cycle (triphasic to monophasic). The acceleration time will decrease as the stenosis increases. The flow will reach the peak velocity faster at stenosis than in a normal vessel.
155
Which of the following statements is true regarding the signs and symptoms of lower extremity arterial disease?
A. Significant ischemia disease in the leg will lead to pallor with dependency
B. significant ischemia disease in the leg will lead to rubor with elevation
C. significant ischemia disease in the leg will lead to cyanosis upon elevation
D. significant ischemia disease in the leg will lead to pallor upon elevation and rubor with dependency
D
| Significant ischemia disease in the leg will lead to pallor upon elevation and rubor with dependency.
156
An AV fistula is present connecting the femoral artery and vein at the right groin. The Doppler evaluation of the common femoral artery will demonstrate what flow pattern?
A. biphasic flow with increased diastolic flow reversal
B. monophasic with increased diastolic flow
C. peaked, triphasic waveform
D. monophasic with minimal diastolic flow
B
| The low resistance venous connection causes decreased resistance and monophasic flow proximal to the fistula.
157
A patient that is currently on Heparin therapy for a recent pulmonary embolism is referred for a carotid Duplex exam. The prior carotid exam from last year demonstrated mild plaque with normal flow velocities. On today's exam, the velocities in both carotid systems are elevated to an abnormal level, but the plaque formation appears unchanged. What could explain the change on today's exam?
A. decreased hematocrit levels in the blood
B. increased viscosity of the blood
C. congestive heart failure has manifested
D. intracranial occlusion causing collateral flow compensation from the extracranial arteries
A
Heparin is a blood thinner that will reduce the hematocrit (viscosity) levels of the blood. Decreased viscosity = increased velocity.
158
A patient presents for a carotid Doppler exam due to bilateral diplopia and dizziness. These findings are most suggestive of stenosis in:
A. left ICA
B. vertebral arteries
C. bilateral proximal common carotid arteries
D. right ICA
B
| Bilateral visual symptoms are most commonly associated with vertebrobasilar disease.
159
```
A damped waveform with low velocity turbulent systolic flow will be found:
A. in a normal PTA tracing
B. proximal to a significant stenosis
C. distal to a significant stenosis
D. at the stenosis site
```
C
Distal to the site of stenosis, the blood flow will be lower velocity than at the stenosis. Turbulence will also cause spectral broadening.
160
Thromboangiitis obliterans involves inflammation of:
A. intimal wall layer
B. all vessel walls with no effect on connective tissue
C. intimal and media wall
D. all vessel walls and surrounding connective tissue
D
Thromboangiitis refers to diffuse inflammation of the intimal wall layer. Thromboangiitis obliterans refers to inflammation of all vessel walls and surrounding connective tissue.
161
Which of the following correctly describes the effects of walking on the deep venous pressure in the lower extremity in a patient with post phlebitic syndrome?
A. walking has little to no effect on the deep venous pressure, only the arterial pressure is affected by exercise
B. walking causes a significant drop in deep venous pressure that takes several minutes to return to pre-exercise levels once the patient stops walking
C. walking causes a gradual decrease in pressure during the first 1-2 minutes of exercise that quickly returns to pre-exercise levels once the patient stops walking
D. walking causes an immediate, quick drop in pressure in the deep veins at the onset of exercise that quickly returns to pre-exercise levels once the patient stops walking.
D
Valvular insufficiency in the deep system commonly occurs after an episode of DVT and is a key characteristic of post-phlebitic syndrome. Normal deep veins will only allow flow toward the heart. As the leg veins empty and pressure quickly drops with muscle contraction, the arterial inflow is the only source of blood to refill the veins and pressure rises slowly upon stopping. In order to refill the veins and increase deep venous pressure to pre-exercise levels, the patient will need to stand for several minutes (>5min). Venous refill time is very fast if the deep veins contain incompetent valves. The pressure will drop quickly at the start of exercise but will quickly return to pre-exercise levels upon standing. The deep veins are refilled by arterial inflow and retrograde flow in the veins.
162
The bilateral proximal common carotid arteries demonstrate normal velocity and systolic upstroke. Diastolic flow reversal is present and continues throughout diastole. These findings are most consistent with:
A. mild to moderate aortic valve stenosis
B. mid CCA occlusion
C. proximal ICA occlusion
D. significant aortic valve regurgitation
D
Significant aortic valve regurgitation will cause flow to move from the ascending aorta/arch into the left ventricle during diastole. This can cause flow reversal that lasts throughout diastole in the branches of the arch. Both CCA can be affected. If there was an ICA occlusion, the CCA velocity would be reduced with minimal diastolic flow reversal in early diastole.
163
```
Which of the following is a common infection that causes skin discoloration in patients with venous insufficiency?
A. staphylococcus aureus
B. stasis dermatitis
C. staphylococcus epidermidis
D. arteritis
```
B
Stasis dermatitis is a common inflammatory skin disease. It is usually the earliest cutaneous sequela of chronic venous insufficiency with venous hypertension and causes discoloration of the ankle and calf.
164
Which of the following patients has the lowest risk of upper extremity venous thrombosis?
A. polycythemia vera
B. recent shoulder surgery
C. central venous catheter for chemotherapy
D. hemophilia
D
| Hemophilia refers to a condition causing abnormally thin blood and would be a contraindication to clot formation.
165
Which of the following correctly describes thoracic outlet syndrome?
A. the Homan's sign indicates a positive test result for TOS
B. patients commonly experiencing dull, aching pain and paresthesia in the affected knee and ankle
C. PPG or PVR tracings can be used to evaluate a patient with suspected TOS
D. the Tinel test is used during assessment for TOS
C
Homan's sign refers to pain in the calf with quick dorsiflexion of the foot, seen with DVT. The Tinel sign indicates a damaged nerve at the wrist and is associated with hypothenar hammer syndrome. Patients with TOS commonly experiencing dull, aching pain and paresthesia in the affected shoulder/arm. PPG or PVR tracings can be used to evaluate a patient with suspected TOS using specific maneuvers during testing.
166
```
The Scimitar sign is associated with:
A. adventitial cysts
B. femoral to femoral bypass graft
C. median arcuate ligament syndrome
D. bovine arch
```
A
The Scimitar sign is associated with adventitial cyst formation. The arterial lumen is compressed by the cyst and is said to look like a scimitar (type of curved sword).
167
```
Which of the following is the second most common site for atherosclerosis formation in the lower extremity?
A. distal SFA in Adductor canal
B. popliteal trifurcation
C. origin of the common iliacs
D. CCA bifurcation
```
C
| The distal SFA in the adductor canal is the most common site of atherosclerosis formation in the legs.
168
```
Which of the following is the most accurate way to measure diameter and area stenosis in the carotid arteries?
A. transverse view of ultrasound
B. longitudinal view on ultrasound
C. CT without contrast
D. angiography
```
A
Using US, diameter and area stenosis can be measured on the transverse view. The longitudinal view is used in ultrasound is not as accurate for diameter stenosis as a transverse view because of the possibility of off axis images and plaque distribution in the artery. The longitudinal view cannot be used to assess area stenosis. Angiography only allows for estimation of diameter stenosis. Contrast is necessary to visualize blood vessels and assess stenosis on CT exams.
169
At the start of an arterial Duplex exam you identify monophasic flow in the left common femoral artery. What should you evaluate next to explain these findings?
A. stop the exam and start a PPG evaluation instead
B. stop the exam and start a PVR evaluation instead
C. evaluate the groin for a mass pressing on the common femoral artery bifurcation
D. evaluate proximal arteries feeding the CFA, such as the aorta and iliac bifurcation
D
Monophasic flow in an extremity artery indicates a proximal obstruction. If the CFA demonstrates monphasic flow, you should evaluate the vessels proximal to the CFA for stenosis.
170
```
Which of the following provides the greatest risk for peripheral arterial disease?
A. excessive sitting
B. hyperlipidemia
C. polycythemia vera
D. excessive standing
```
B
Hyperlipidemia refers to high cholesterol which is a risk factor for arterial disease. Excessive sitting or standing can lead to venous stasis and thrombus formation. Polycythemia vera causes thickening of the blood which can lead to venous stasis and thrombus formation.
171
Which of the following lower extremity vessels would most likely be occluded in a patient with Phlegmasia Alba Dolens?
A. femoral vein, deep calf veins, popliteal vein
B. saphenous veins only
C. common femoral artery
D. deep veins, superficial veins and common femoral artery
A
Phlegmasia Alba Dolens refers to a condition where all deep venous vessels are occluded in the extremity causing reduced arterial inflow. The superficial veins are usually patent. The leg las a milky white appearance due to severe outflow obstruction and markedly reducing arterial inflow. Leads to ischemia in entire extremity with severe pain.
172
```
Which of the following is an expected finding with Hypothenar Hammer Syndrome?
A. Ulnar artery stenosis or occlusion
B. negative Tinel sign
C. negative Allen test
D. compartment syndrome
```
A
Hypothenar Hammer Syndrome can be caused by repetitive compression or blunt trauma. The ulnar artery is commonly affected because it crosses over the hook of hamate bone. It is associated with Raynaud syndrome and most commonly causes ischemia of fourth and fifth fingers.
Positive Tinel sign = distal parethesia induced by compression of the affected portion of the entrapped ulnar nerve
Positive Allen test = demonstrates occlusion of the distal ulnar artery
Ultrasound may also demonstrate irregular contour or aneurysm of the ulnar artery.
173
Which of the following correctly describes Hollenhorst plaques?
A. heavily calcified plaque that forms in the aortic arch
B. usually seen on optometry exams
C. most patients experience intermittent periods of unilateral blindness
D. heavily calcified plaque that forms in the distal aorta
B
Hollenhorst plaques are cholesterol emboli that originate from atherosclerotic lesions in the ipsilateral carotid artery or aorta and lodge in the small branches of the retinal artery. They are usually identified by an optometrist on a standard vision exam because the patient is asymptomatic.
174
A 30yr old male who smokes 2-3 packs per day is referred for an arterial evaluation for pain and pallor of both forearms and hands. The bilateral radial and ulnar arteries demonstrate diffuse, homogeneous intimal thickening and monophasic flow. The arterial lumen characteristics and flow in the upper arms and shoulders are normal. These findings are most consistent with:
A. Takayasu Arteritis
B. Atherosclerosis causing tunnel stenosis
C. medial calcification
D. Buerger disease
D
The patient most likely has Buerger disease which refers to arteritis of the smaller arteries that is usually associated with males who are heavy smokers. Takayasu Arteritis normally affects the aorta, subclavian and renal arteries.
175
All of the following correctly describes Buerger disease, expect?
A. most commonly presents as multiple painless, wet, oozing ulcers of the feet and ankles
B. commonly associated with collagen disease
C. associated with males that are heavy smokers
D. also known as thromboangiitis obliterans
A
Buerger Disease/Thromboangiitis Obliterans is an occlusive disease of SMALL to MEDIUM size arteries caused by inflammation of arterial wall and surrounding connective tissue. It is always associated with heavy smoking. It is most common in men, age 20-30 years. Collagen disease, such as lupus, is usually associated with Buerger disease. The disease first affects the plantar or palmar arteries then moves centrally. Common symptoms include ischemic rest pain and distal dry, painful ulcers. Evaluation can be performed by Duplex and PPG techniques.
176
A patient is referred for an ultrasound of the aorta due to a history of Ehler-Danlos syndrome. What are you looking for on the exam?
A. aneurysm
B. significant soft plaque formation in the distal aorta and proximal iliac arteries
C. significant fibrous tissue formation surrounding the distal aorta that is compressing the vessel
D. absence of all anterior branches
A
Ehler-Danlos syndrome is a genetic disorder that negatively affects collagen formation. The reduction in collagen will result in less rigid arteries and increased risk of aneurysm formation.
177
A varicose vein is usually:
A. a dilated vessel of the perforator system
B. a dilated tributary of the deep system
C. a dilated lesser saphenous vein
D. a dilated tributary of the greater saphenous vein
D
| The greater saphenous vein and associated tributaries are most commonly associated with varicosity formation.
178
Patients with venous disease may describe leg pain that is:
A. relieved by elevating the legs
B. relieved by placing the legs in a dependent position
C. relieved by resting/sitting
D. very painful and accompanied by paresthesia
A
Venous disease symptoms will be relieved by elevating the legs to "empty" the calves. Arterial disease symptoms will be relieved by standing still or placing the legs in a dependent position.
179
```
If a patient suffers from ischemic rest pain in the feet, what maneuver can relieve the pain?
A. standing
B. sitting with legs elevated
C. walking
D. valsalva maneuver
```
A
Ischemic rest pain is described as burning pain in the ball of the foot and toes that is worse at night when the patient is in bed. Standing STILL or hanging the legs in a dependent position would use gravity to assist the arterial flow in entering the feet at a faster rate. Walking and elevating the legs would continue to increase the need for arterial inflow and exacerbate the symptoms.
180
While performing an aortic duplex exam, you identify an intimal flap that begins just below the renal arteries and measures 2.5cm in length. According to the Stanford Classification, this is a:
A. juxtarenal dissection
B. type B dissection
C. type A dissection
D. normal variant in patients over 70yrs of age
B
Stanford Classification:
Type A: dissections that involve the ascending aorta and arch
Type B: dissections that involve the aorta from the left subclavian artery to the iliac bifurcation.
181
```
Which of the following will not demonstrate a bruit on auscultation?
A.stenosis
B. pseudoaneurysm
C. occlusion
D. AV fistula
```
C
| An occlusion will not demonstrate a bruit because no flow is moving under the stethoscope.
182
Posterior to anterior collateralization with a left ICA occlusion will cause:
A. increased velocity in the right PCA P1 segment
B. reduced right vertebral velocity
C. increased velocity in the left PCA P1 segment
D. increased left MCA velocity
C
Posterior to anterior collateralization with a left ICA occlusion will cause increased velocity in the left PCA P1 segment. Flow moves from the P1 segment of the PCoA and into the MCA on the affected side. This can cause a reduction in flow into the P2 segment also.
183
```
A bilateral decrease in the femoral pulses can be related to:
A. DVT formation
B. aortic coarctation
C. occlusion of the deep femoral artery
D. occlusion of the popliteal artery
```
B
Aortic coarctation refers to the overgrowth of normal tissue in the aorta causing obstruction. It most commonly occurs in the arch just distal to the origin of the left subclavian artery. If the coarctation occurs distal to the origin of the left subclavian artery, both arms will demonstrate normal systolic BP and the legs will demonstrate significantly lower pressures. If the coarctation occurs proximal to the origin of the left subclavian artery, the right arm will demonstrate a much higher pressure than the left arm and the legs.
184
The carotid compression test is used to ________, while the carotid sinus massage is used to ________.
A. stimulate TIA symptoms, reduce TIA symptoms
B. reduce the heart rate, evaluate the presence of collateral flow
C. increase flow in the vertebral arteries, decrease flow in the vertebral arteries
D. evaluate the presence of collateral flow, reduce the heart rate
D
The carotid compression test is used to evaluate for the presence of collateral flow, while the carotid sinus massage is used to reduce the heart rate to diagnose/treat certain arrhythmias.
185
Paresthesia is defined as:
A. an abnormal skin sensation, such as numbness or tingling
B. dizziness related to change in patient position
C. loss of vision in one eye for a short period of time
D. loss of ability to move an extremity to move an extremity or other body part
A
Paralysis is defined as loss of ability to move an extremity or other body part. Paresthesia refers to an abnormal skin sensation, such as numbness or tingling.
186
```
Aside from the carotid artery, what other vessels are commonly affected by fibromuscular dysplasia (FMD)?
A. jugular veins
B. renal and mesenteric arteries
C. small arteries of the foot and ankle
D. small arteries of the hand and wrist
```
B
If FMD is identified in the carotid arteries, the renal and mesenteric arteries should also be evaluated for FMD. Stenosis caused by atherosclerosis usually affects the origin of the artery, while FMD usually causes stenosis in the mid/distal artery.
187
```
A 72yr old female presents for an upper extremity arterial Doppler exam due to asymmetric brachial pressures. The right axillary artery demonstrates a circumferential halo of thickened vessel wall tissue and increased wall vascularity. These findings are most consistent with:
A. giant cell arteritis
B. Kawasaki disease
C. temporal arteritis
D. Buerger disease
```
A
Giant Cell Arteritis usually presents in the cranial arteries (temporal arteritis), but can be seen in the extremities. It is usually seen in patients 70-80 years of age and is more common in women. Associated with elevated erythrocyte sedimentation rate (how quickly the red blood cells fall to the bottom of the blood sample) and C-reactive protein (CRP) levels. Asymmetric brachial blood pressures are seen in patients with arteritis in extremities. Arteritis causes diffuse or focal thickening of the muscle layer with increased vascularity in the wall of the inflamed segment. Halo Sign - a ring of thickened vessel wall tissue surrounding the vessel.
Doppler findings similar to stenosis.
Temporal arteritis is associated with headaches and tenderness over the artery as it courses extracranially. Buerger disease affects the small to medium arteries of the extremity. It is most commonly seen in males 20-30yrs of age that are heavy smokers.
188
A 55yr old with a history of alcoholism, jaundice and cirrhosis is referred for a liver Doppler exam. Which of the following is an expected abnormal finding?
A. respiratory phasicity in portal vein flow
B. multiphasic flow in the hepatic veins
C. dilated IVC
D. increased resistance in the hepatic artery
D
Resistance in the hepatic artery will increase with the increase in resistance to flow in the cirrhotic liver tissue. The coronary vein (AKA left gastric vein) and the umbilical vein will dilate with significant portal HTN. The IVC is not usually affected by isolated cirrhosis. The hepatic vein flow will be multiphasic in the normal patient. Normal portal venous flow demonstrates mild respiratory phasicity.
