Vascular surgery Flashcards
(93 cards)
1
Q
You are evaluating a liver transplant in a patient that received the organ yesterday. The resistive index (RI) for the hepatic artery is 0.9. Which of the following best describes the findings?
A. the resistive index is abnormally increased and any value greater than 0.6 indicates irreversible rejection
B. the resistive index is abnormally increased and should be reported as a critical finding of suspected rejection
C. the resistive index indicates normal resistance to flow in the liver parenchyma
D. the resistive index is abnormally increased, but this can be a normal finding in immediate post-op patients
A
D
If the immediate post-op patient there can be increased hepatic pressure usually secondary to edema. This can cause the RI values to be elevated. Serial exam should be performed to monitor the expected increase in diastolic flow and decline in RI values. Resistive Index (RI) >0.6-0.8 Normal.
2
Q
A patient presents for a 3 month follow-up on his aortic endograft. The aortic sac has increased in size by 0.8cm since the last ultrasound evaluation performed 2 months ago. No endoleak was detected on ultrasound or CT evaluation. What is the most likely cause for the diameter change? A. endotension B. May Thurner syndrome C. graft migration D. reactive hyperemia
A
A
Endotension - no leak present but there is continued expansion of the aneurysm sac greater than 5mm; sometimes referred to as Type V Endoleak.
3
Q
When performing serial exams on an in situ venous bypass graft, __________ indicates significant graft failure.
A. conversion of the waveform from triphasic to biphasic
B. an increase in end diastolic velocity greater than 30cm/s from the last exam
C. a decrease in peak systolic velocity of 30cm/s from the last exam
D. a decrease in ABI of 0.10 from the last exam
A
C
Serial exams that demonstrate a decrease in the PSV or 30cm/s or more and/or a decrease in the ABI of 0.15 or more indicate poor performance of the graft on the current exam.
4
Q
What native artery is commonly used for the arterial anastomosis in a renal transplant when the external iliac artery is not available? A. internal iliac artery B. common iliac artery C. external iliac vein D. aorta
A
A
The external iliac artery is most commonly used as the arterial anastomosis for the allograft artery. The internal iliac artery is commonly used for the arterial anastomosis when the external iliac artery is not available.
5
Q
What is the most common complication of an in situ vein graft? A. thrombosis B. AV fistula C. infection D. rupture
A
B
An AV fistula is the most common complication of an in situ vein graft. Because the vein is left in its normal position and attached to the arterial system at each end, some side branches persist as residual arteriovenous fistulae.
6
Q
Arterial flow proximal to an AV fistula will be \_\_\_\_\_\_\_\_\_\_. A. phasic B. laminar C. high resistance D. low resistance
A
D
Arterial flow proximal to an AV fistula will be low resistance.
7
Q
Retained valve cusps are a complication of: A. reversed cephalic graft B. in situ saphenous graft C. reversed saphenous graft D. Brescia-Cimino graft
A
B
An in situ saphenous vein graft is performed by disconnecting the proximal GSV from the common femoral vein to connect to the arterial system proximal to an obstruction. The GSV is then ligated distal to the obstruction and the distal end of the in situ graft if attached to the artery just distal to the obstruction. The valves must be removed from the graft or they will prevent arterial blood flow from moving down the leg. Retained cusps can lead to stenosis or thrombosis in the graft.
8
Q
Which of the following will decrease with acute renal allograft rejection?
A. echogenicity
B. diastolic flow in the segmental arteries
C. resistive index from the arcuate arteries
D. kidney size
A
B
Acute renal rejection will result in an enlarged kidney with increased echogenicity of the renal cortex. Doppler evaluation will demonstrate increased resistance in the parenchymal arteries and increased resistive index. This will decrease the amount of diastolic flow in the cortical arteries.
9
Q
Where is the most common location for the surgeon to place a renal allograft? A. 2-4cm below the umbilicus B. right iliac fossa C. left iliac fossa D. 2-4cm above the urinary bladder
A
B
The right iliac fossa is the most common site for placement of a renal allograft.
10
Q
Which of the following is a common occurrence after an endarterectomy? A. neointimal hyperplasia B. congestive heart failure C. intracranial hemorrhage D. intimal dissection
A
A
Neointimal hyperplasia refers to the overgrowth of normal tissue in response to the endarterectomy. This is a common cause of re-stenosis of a vessel that previously underwent endarterectomy.
11
Q
Which of the following techniques is used to monitor flow during a fem-pop bypass procedure? A. duplex ultrasound B. pulse volume recording C. segmental pressures D. B mode ultrasound
A
A
Segmental pressures and PVR exams require the use of pressure cuffs that cannot be used during the surgery. AFTER the surgery would be fine. Intraoperative duplex ultrasound can be used during the procedure to assess flow.
12
Q
Which of the following patients would benefit from intraoperative TCD monitoring of the left MCA? A. right carotid endarterectomy B. left IJV thrombosis C. left carotid endarterectomy D. right ICA stent placement
A
C
Flow from the left ICA enters the left MCA. If a piece of plaque breaks off during the endarterectomy and escapes into the ICA, it can cause stroke symptoms. Monitoring is used to detect emboli.
13
Q
A fem-fem graft is used to treat: A. unilateral femoral stenosis B. bilateral popliteal stenosis C. unilateral iliac stenosis D. bilateral iliac stenosis
A
C
A fem - fem graft can be used to correct unilateral iliac stenosis. Blood is passed from the patent femoral artery through the graft to the contralateral femoral artery at a point distal to the stenosis.
14
Q
Color Doppler evaluation of an aortic endograft:
A. can be limited by twinkle artifact and color flash artifact
B. should be performed with increased wall filter and velocity scale settings with reduced color priority
C. is the most accurate method for diagnosis of an endoleak
D. cannot be performed on patients who are less than 3 months post-op due to the risk of cavitation and graft migration
A
A
Calcification in the aortic wall can cause twinkle artifact on color Doppler evaluation. Because color velocity and filter settings are set to lower levels to detect the lower velocity flow in the aorta, color flash artifact is common with patient movement and respiration. PW Doppler is necessary to confirm the diagnosis of a suspected endoleak seen on color Doppler. Follow up exams for an aortic endograft are usually performed at 1 month post-op, then at 3, 6, 9, 12 and 18 months, followed by annual assessment after the first year.
15
Q
If a patient had surgery to correct an occlusion of the right external iliac vein, which of the following pathways could be used?
A. redirect flow from the right common iliac vein to the right femoral vein
B. redirect flow from the right femoral vein to the left popliteal vein
C. redirect flow from the left femoral vein to the right femoral vein
D. redirect flow from the right femoral vein to the left femoral vein
A
D
Blood is moving cephalad in the venous system. If the right EIV is blocked, flow can be bypassed from the right femoral vein to the left femoral vein.
16
Q
The type of dialysis graft where the cephalic vein is anastomosed to the radial artery is called? A. TIPS graft B. synthetic loop graft C. straight graft D. Brescia-Cimino graft
A
D
The cephalic vein is anastomosed to the radial artery in a Brescia-Cimino graft. Straight Synthetic graft connects from the radial artery at wrist to an antecubital vein. Looped Synthetic graft connects from the brachial artery to antecubital vein. TIPS is a type of shunt used to bypass the liver.
17
Q
Which of the following statements is true regarding Doppler flow evaluation of a rejected renal allograft?
A. rejected allograft waveforms will demonstrate high resistance flow
B. rejected allograft waveforms will demonstrate low resistance flow
C. rejected allograft waveforms will demonstrate low RI and PI values
D. renal allograft waveforms normally demonstrate arterial flow that varies with respiration
A
A
Doppler waveforms from arteries in a rejected allograft will demonstrate high resistance flow. The RI values for the parenchymal vessels will be elevated above 0.70.
18
Q
You are performing an ultrasound on a fem-pop PTFE graft in a lower extremity and you suspect a stenosis at the distal anastomosis. How will you calculate the velocity ration in this patient?
A. divide the velocity in the native popliteal artery by the velocity in the distal graft
B. divide the velocity in the native popliteal artery by the velocity in the native femoral artery
C. divide the velocity at the distal anastomosis by the velocity in the distal graft
D. divide the velocity at the distal anastomosis by the velocity in the proximal anastomosis
A
C
The velocity ratio is calculated by dividing the velocity at the stenosis (distal velocity) by the velocity just proximal to the stenosis.
19
Q
When evaluating a patient for placement of a hemodialysis graft, what is the minimum acceptable diameter for the native artery where the graft will be connected? A. 2mm B. 3mm C. 4mm D. 5mm
A
A
Hemodialysis requires native vein > 2.5mm for AVF; native artery > 2mm; native vein >4mm for synthetic graft.
20
Q
A fem - tib graft is used to treat: A. unilateral distal femoral stenosis B. bilateral popliteal stenosis C. unilateral iliac stenosis D. bilateral iliac stenosis
A
A
A fem - tib graft can be used to correct unilateral distal femoral or popliteal stenosis.
21
Q
A patient presents for evaluation of their hemodialysis graft. The proximal anastomosis demonstrates a velocity of 130cm/s. The mid graft velocity is 275cm/s and the distal anastomosis velocity is 50cm/s. What is your conclusion about the findings on the exam?
A. the venous outflow is most likely thrombosed
B. there is stenosis of the mid graft segment
C. there is stenosis of the proximal anastomosis and the mid graft segment
D. the Doppler evaluation is normal
A
B
Flow velocities that double between segments indicate graft stenosis. The velocity increases by more than 2X at the mid segment. The velocity at the proximal anastomosis is normal as flow within the grafts is usually high velocity.
22
Q
When continuous TCD monitoring is used to assist with a carotid endarterectomy, when is the TCD device first activated to begin monitoring the patient?
A. within 24hrs after the endarterectomy was performed
B. immediately after the endarterectomy was performed but before the wound closure is performed
C. within 1-2 hours after the endarterectomy was performed
D. just before the surgery starts
A
D
The patients intracranial blood flow is monitored closely to identify and count any embolic signatures that may occur during the endarterectomy, and closing phase of the surgery, as well as in the recovery room.
23
Q
How does the imaging protocol differ when evaluating a hemodialysis graft versus a hemodialysis fistula?
A. a graft has two anastomotic sites and the fistula only has one
B. the outflow vein must be evaluated with a graft but is not required for fistula evaluation
C. a graft has one anastomotic site and the fistula has two
D. the outflow vein must be evaluated with a fistula but is not required for graft evaluation
A
A
A hemodialysis graft involves a synthetic graft attached to an artery at one end and a vein at the other end. Both anastomotic sites must be evaluated in a complete exam. The hemodialysis fistula connects a native artery and vein at a single anastomotic site. The standard protocol includes evaluation of the native artery proximal to the anastomosis, the anastomotic site(s) and the outflow vein just distal to the anastomosis.
24
Q
Which of the following describes the importance of the TCD monitoring during a carotid endarterectomy?
A. to evaluate the potential complication of the development of a subarachnoid hemorrhage during the procedure
B. to evaluated the presence of embolic events during the surgery to predict the risk of postoperative stroke
C. the evaluate the presence of associated atherosclerotic intracranial disease
D. to evaluate the potential complication of vasospasm caused by the development of a subarachnoid hemorrhage during the procedure
A
B
The exam performed to evaluate the presence of associated atherosclerotic intracranial disease should be done before the surgery is scheduled. TCD monitoring provides monitoring for emboli and can be used to evaluate collateral formation.
25
Which native vessel is the renal allograft artery commonly attached to?
A. SMA or IMA
B. native ipsilateral renal artery
C. aorta
D. external iliac or internal iliac artery
D
The renal allograft artery is most commonly attached to the native external iliac artery and the internal iliac artery is used as an alternative.
26
```
Which of the following is not an expected complication in a 3 week post-op liver transplant patient?
A. hepatic artery atherosclerosis
B. portal vein thrombosis
C. biloma
D. hepatic vein thrombosis
```
A
Atherosclerosis formation is a chronic process. Thrombosis and biloma formation are acute complications that can be seen with a recent liver transplant.
27
Which of the following is considered a normal finding in a patient with a brachiobasilic hemodialysis graft?
A. continuous flow in the basilic vein proximal and distal to the graft anastomosis
B. triphasic flow in the brachial artery proximal to the graft and monophasic flow in the brachial artery distal to the graft
C. increased resistance and velocity with a loss of flow in diastole in the brachial artery proximal and distal to the graft
D. dilated brachial artery proximal to the graft with low resistance monophasic flow
D
The connection between the artery and the vein will cause the resistance in the brachial artery to decrease and become monophasic. The basilic vein will exhibit pulsatile, high velocity venous flow in the area of the graft due to the arterial inflow.
28
A "snuffbox" fistula connects what two vessels?
A. brachial artery connects to the basilic vein in the upper arm
B. radial artery connects to the basilic vein in the forearm
C. radial artery connects to the cephalic vein in the radial fossa
D. brachial artery connects to the basilic vein at the elbow
C
The anatomical snuffbox is also called the radial fossa. It is a triangular depression on the lateral aspect of the dorsum of the hand. The radial artery, a branch of the radial nerve, and the cephalic vein are found in the snuffbox. Radial artery is connected to the cephalic vein at distal wrist. Because the artery courses directly over the vein in this location, little vessel movement is required during surgery.
29
```
Patient presents 9 months after endarterectomy with an approximate 40% recurrent stenosis. What is the most likely cause?
A. neointimal hyperplasia
B. polycythemia vera
C. lack of Warfarin treatment post op
D. fibromuscular dysplasia
```
A
Neointimal hyperplasia is the most common cause of re-stenosis of a vessel that has a history of the endarterectomy procedure. It can be described as thickening of the vessel wall or over-healing after the procedure. Atherosclerosis can also cause re-stenosis but takes a much longer time to reoccur in the vessel.
30
```
Which of the following vascular complications is treated with a fasciotomy?
A. pseudoaneurysm
B. dissection
C. anterior compartment syndrome
D. popliteal entrapment
```
C
Blood leaks into the muscle compartment of the calf causing increased pressure. If the fasciotomy is not performed to relieve the pressure, damage to the nerves and tissues can occur.
31
A patient presents with a radiocephalic hemodialysis fistula in the left arm. Doppler evaluation of which of the following vessels will be used to rule out steal syndrome?
A. distal inflow artery, within 2cm below the fistula
B. cephalic vein at the wrist
C. proximal inflow artery, within 2cm above the fistula
D. cephalic vein at the shoulder
A
Doppler evaluation of the inflow artery <2cm distal to the fistula is used to diagnose steal syndrome. If flow is moving retrograde in the distal radial (inflow) artery, then flow is moving toward the hand in the ulnar artery, through the palmar arch and then toward the upper arm in the radial artery. Normal flow in the radial and ulnar arteries should move toward the hand and into the palmar arch.
32
After an endarterectomy or carotid stent placement, the first follow up exam should be performed:
A. within one month after the procedure
B. within 5 days of the procedure
C. on the 1 year anniversary date of the procedure
D. immediately following the procedure
A
A patient that has had an endarterectomy or carotid stent placement is usually evaluated within first month following the procedure. If performed too soon after the endarterectomy or other open surgical procedure, artifacts produced by air in the patch or graft may inhibit the exam.
33
You are performing a carotid duplex on a patient that had a carotid endarterectomy 6 years ago. There is homogeneous material lining the ICA and bulb. The Doppler evaluation demonstrates turbulence and elevated velocities. Which of the following is the most likely cause for these findings?
A. intimal flap and dissection
B. progression of atherosclerotic disease
C. residual blockage from suboptimal surgical techniques
D. neointimal hyperplasia
B
Within the first month post-op, restenosis is attributed to suboptimal surgical techniques. Narrowing over the first 24 months after CEA is attributed to neointimal hyperplasia. After 2 years, stenosis occurs due to progression of atherosclerotic disease.
34
You are performing a carotid duplex on a patient that had a carotid endarterectomy 2 weeks ago. There is homogeneous material lining the ICA and bulb and Doppler demonstrates turbulence and elevated velocities. Which of the following is the most likely cause for these findings?
A. neointimal hyperplasia
B. intimal flap and dissection
C. residual blockage from suboptimal surgical techniques
D. progression of atherosclerotic disease
C
Within the first month post-op, restenosis is attributed to suboptimal surgical techniques. Narrowing over the first 24 months after CEA is attributed to neointimal hyperplasia. After 2 years, stenosis occurs due to progression of atherosclerosis disease.
35
In a patient with a patent brachiobasilic AV graft, the axillary vein will:
A. demonstrate a loss of spontaneous and phasic flow and will require distal augmentation to assess patentcy
B. demonstrate biphaisc flow with the majority of antegrade flow occurring during diastole
C. demonstrate high velocity pulsatile flow
D. demonstrate low velocity continuous flow
C
The basilic vein connects to the axillary vein in the upper arm/axilla. The arterial inflow into the basilic vein from the AVG will transmit a pulsatile waveform with high velocities into the axillary vein.
36
```
Which of the following is a normal finding when evaluating a hemodialysis graft?
A. aneurysm
B. thrombosis
C. arteriovenous fistula
D. pseudoaneurysm
```
C
A hemodialysis graft is the surgical creation of an AV fistula (connection of an artery and vein). Complications of a hemodialysis graft include thrombosis of the graft, stenosis/occlusion, aneurysm of the graft, pseudoaneurysm caused by needle puncture for dialysis, CHF due to increased flow in venous return to heat, a and distal ischemia.
37
```
The most common cause of hemodialysis graft failure is __________.
A. acute rejection
B. anastomosis rupture
C. thrombosis formation
D. arterial stenosis
```
C
| The most common cause of hemodialysis graft failure is thrombus formation.
38
```
A patient presents for a stat lower extremity arterial Doppler evaluation following the recent placement of a fem - tib graft in the right leg. The patient complains of significant pain and weakness in the calf muscle with areas of numbness on the anterior aspect of the lower leg. What is the most likely finding on the exam?
A. DVT
B. anterior compartment syndrome
C. phlegmasia alba dolens
D. graft stenosis
```
B
Reperfusion of the leg via bypass graft can lead to anterior compartment syndrome. Symptoms include paresthesia, pain in the calf muscle with foot dorsiflexion, drop foot and calf muscle weakness.
39
```
Which of the following conditions would benefit from intravascular ultrasound with repair?
A. AAA only
B. cerebral artery aneurysm only
C. AAA and renal artery stenosis
D. renal artery stenosis only
```
C
| Intravascular ultrasound can be used in the repair of aortic aneurysms or renal stenosis.
40
```
_____________ refers to when the carotid artery is lacerated and the atheroma formation is scraped for removal.
A. a valvulotome procedure
B. an endarterectomy procedure
C. an atherectomy procedure
D. an angioplasty procedure
```
B
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 ballon 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.
41
Saphenous vein mapping is used to assess the vein for a potential bypass conduit. Which of the following characteristics would still allow the surgeon to use the vein?
A. valvular damage
B. chronic obstruction of the ipsilateral deep system
C. thrombosis
D. lumen <2mm
A
Damaged valves are not a contraindication for venous harvesting. Thrombosis and a small lumen <2mm are contraindications for the use of the vein as a graft. If there is chronic obstruction of the deep veins, the saphenous becomes an integral part of the venous drainage system of the leg and cannot be removed for bypass.
42
You are performing a vein mapping of the cephalic vein in the right arm. The patient is supine and the head of the bed is elevated. The arm is extended and relaxed. The diameter of the vein is 1.5 to 2mm in all segments from the shoulder to the wrist. What should you do next?
A. apply a tourniquet to the forearm and remeasure the cephalic vein segments proximal to the tourniquet
B. report the vein as acceptable for harvest with a maximum diameter of 2mm
C. report the vein as unusable with a diameter at 2mm and select another upper extremity vein to evaluate for a potential graft
D. apply a tourniquet to the upper arm and remeasure the cephalic vein segments distal to the tourniquet
D
>3mm veins are preferred for graft procedures. The basilic and cephalic veins can be acceptable conduits. When performing the exam, the patient is supine with arm extended at side at a level lower than the heart or in a seated position with hand on lap. Tourniquets can be applied to the proximal extremity in cases where the veins are very small. The veins distal to the tourniquet should dilate to provide an accurate maximum diameter.
43
Velocity ratio, volume flow, and peak systolic velocity are measurements that must be reported when evaluating a/an:
A. arteriovenous dialysis graft
B. pseudoaneurysm
C. subclavian steal with vertebral occlusion
D. lower extremity after venous ablation
A
The velocity ratio compares the velocity at a suspected stenosis to the velocity proximal to the stenosis. The volume flow measurement uses a wide Doppler sample volume to assess the amount of flow moving through the graft. The volume flow measurement is specific to hemodialysis grafts. Peal and end diastolic flow velocities are also used to assess the graft.
44
A patient presents for Doppler evaluation after revascularization of the SMA 1 week ago. The study prior to treatment demonstrated a peak systolic velocity of 4.2m/s in the SMA. On today's exam, the velocity in the proximal SMA has reduced to 3.3m/s. How will you report these findings?
A. unable to summarize the results with the end diastolic velocity
B. the SMA flow velocity has decreased, but has not returned to normal levels
C. unable to summarize the results until pre-prandial and post- prandial evaluations are performed
D. the SMA demonstrates normal velocities after the procedure
B
| The normal velocity in the SMA is <2.75m/s.
45
The saphenous vein has already been harvested from both legs for CABG surgery. What other vein could be harvested for an additional bypass graft?
A. internal mammary artery or subclavian
B. subclavian vein or cephalic vein
C. cephalic vein or internal mammary vein
D. cephalic or basilic vein
D
Cephalic and basilic veins can be harvested for use in coronary artery bypass graft surgery. The internal mammary artery can also be used as a bypass graft but the question asks for veins.
46
```
A peak systolic velocity greater than ___________ is consistent with >75% stenosis in a Dacron bypass graft.
A. 250cm/s
B. 175cm/s
C. 300cm/s
D. 400cm/s
```
D
Normal PSV <150cm/s, velocity ratio <1.5.
Less than 49% PSV 150 - 200cm/s, velocity ratio 1.5 - 2.0.
50 - 75% PSV 200 - 400cm/s, velocity ratio 2 - 4.
> 75% PSV >400cm/s, velocity ratio >4.
47
Which of the following statements regarding the radial artery is true?
A. it is the upper extremity artery most commonly affected by atherosclerosis
B. requires normal results from Tinel test prior to harvesting
C. it can be an alternative coronary bypass graft when the great saphenous vein is not an option
D. it supplies the majority of blood to the hand
C
The radial artery is commonly used for CABG surgery. The ulnar artery supplies the majority of blood to the hand. The Tinel test evaluates suspected carpal tunnel syndrome.
48
An in situ vein graft exam must include the evaluation of any patent branches because:
A. they are necessary for proper graft function
B. of increased risk for the formation of an AV malformation
C. of the increased risk of stenosis in the branch
D. of the potential for AV fistula formation
D
In situ and reversed vein grafts should have all branches ligated before being placed as a bypass conduit. This process is more effectively performed on the reversed vein graft because it is removed from the leg before it is placed as a graft. An AV fistula is the most common complication of an in situ vein graft because the venous branches can still be visibly patent. The arterial flow entering the venous branches can cause an AV fistula. An AV malformation is a congenital connection between an artery and vein.
49
Which of the following vessels are a common source for a Type II endoleak?
A. celiac axis and superior mesenteric artery
B. inferior mesenteric artery and lumbar arteries
C. left gastric artery and right hepatic artery
D. common iliac artery and gonadal arteries
B
Type II endoleak: leak at the branch vessels; will see retrograde flow into the aneurysm sac and increase in AAA diameter; inferior mesenteric artery, internal iliac, lumbar arteries and accessory renal arteries are potential sources for the leak.
50
Which of the following would be considered abnormal in the Doppler evaluation of a renal transplant?
A. phasic flow in the renal vein
B. diastolic flow reversal within the parenchymal arteries
C. a resistive index of 0.65 for the arcuate arteries
D. mildly turbulent flow at the arterial anastomosis site
B
Phasic flow in the renal vein, mildly turbulent flow at the arterial anastomosis site and a resistive index of 0.65 for the arcuate arteries are normal findings in a renal allograft. Diastolic flow reversal indicates a significant increase in the resistance of the renal vascular beds which is consistent with rejection.
51
```
An aorto-bifemoral graft is used to treat:
A. unilateral femoral stenosis
B. unilateral iliac stenosis
C. bilateral iliac stenosis
D. bilateral popliteal stenosis
```
C
| An aorto-bifemoral graft can be used to correct distal aortic stenosis or bilateral iliac stenosis.
52
If a patient had surgery to correct an occlusion of the right external iliac artery, what type of graft could be used?
A. right femoral artery to the right popliteal artery
B. right femoral artery to the left femoral artery
C. left femoral artery to the left popliteal artery
D. left femoral artery to the right femoral artery
D
| Arterial flow is shunted from the left femoral artery to the right femoral artery (distal to the obstruction).
53
Which of the following is a sonographic characteristic of a normal renal transplant?
A. decreased parenchymal resistance, RI < 0.70
B. decreased differentiation between renal parenchymal and sinus
C. prominent renal pyramids
D. increased parenchymal resistance, RI > 0.70
A
If the allograft is in rejection, function is significantly decreased. The parenchyma resists the incoming flow due to its inability to filter the blood. This causes increased parenchymal resistance with RI > 0.70. 2D findings of renal allograft rejection include prominent renal pyramids and decreased differentiation between renal parenchyma and sinus.
54
```
A patient presents for an evaluation of a lower extremity synthetic bypass graft for suspected stenosis. What area of the graft should be evaluated first because it is the most common location of graft stenosis?
A. in the proximal graft
B. at the anastomosis sites
C. in the distal graft
D. native artery
```
B
Thrombosis is the most common cause of acute stenosis or occlusion of a graft. Myointimal hyperplasia is the most common cause of chronic stenosis/occlusion of a graft which most commonly occurs due to over-healing of the tissue at the anastomosis sites. The rough surface of the connection and the confluence of the vessel/graft cause increased turbulence of the blood flow. These factors cause an increased incidence of stenosis/thrombosis.
55
All of the following are important parts of evaluating a hemodialysis graft for patency, except:
A. palpation of the graft
B. palpation of the radial and ulnar arteries
C. ipsilateral brachial blood pressure
D. auscultation over the graft
C
Auscultation of a hemodialysis graft is performed to assess patency. Normally turbulent flow will be detected if the graft is patent. A thumping sound can be heard with occlusion. The graft is palpated to assess for the expected thrill over a patent graft. The distal forearm arteries are assessed to confirm blood is reaching the distal arm/hand. NEVER take the blood pressure in an arm with a hemodialysis graft because compressing the graft can cause damage.
56
```
When evaluating a patient for placement of an AV fistula for dialysis, what is the minimum acceptable diameter for the native vein where the graft will be connected?
A. 3.5mm
B. 2.5mm
C. 4.5mm
D. 5mm
```
B
Hemodialysis requires a native vein >2.5mm for AVF; native artery >2mm. A native vein >4mm is required for a synthetic graft.
57
A patient presents for pre-operative arterial mapping for the TRAM flap breast reconstruction procedure. What vessel(s) should be evaluated?
A. radial artery
B. epigastric and internal mammary arteries
C. epigastric arteries and radial artery
D. internal mammary artery and radial artery
B
Internal Mammary Artery: AKA internal thoracic artery originates from subclavian artery; used in breast reconstruction and as coronary graft for left anterior descending (LAD) artery.
Epigastric Arteries: Superior EA originates from internal mammary artery and shares anastomoses with the inferior EA; Inferior EA originates from the external iliac artery; Both vessels supply the rectus abdominis muscle used in TRAM Flap procedure for breast reconstruction; Evaluated to locate the section of muscle with the best perfusion for surgery.
58
```
A patient presents for evaluation of a hemodialysis graft that was inserted 1 week ago. Which of the following is an expected finding on the exam if the graft has failed?
A. myointimal hyperplasia
B. arterial stenosis
C. graft thrombosis
D. graft stenosis
```
C
If the graft was just placed in the arm a week ago, you are looking for an acute cause of failure. The other three choices listed are chronic causes of graft failure.
59
```
Velocities in a reversed vein graft are usually _______ at the __________ anastomosis because it is the smaller end of the vein.
A. higher, proximal
B. lower, proximal
C. higher, distal
D. lower, distal
```
A
Velocities in a reversed vein graft are usually higher at the proximal anastomosis because it is the smaller end of the vein.
60
A patient presents for a follow up of stent placement in the SMA due to stenosis. How will you determine if the procedure was a success?
A. peak velocities should have returned to normal levels related to non-stenotic arterial flow
B. at least a 50% reduction in velocity compared to pre-stented velocities
C. at least a 70% reduction in velocity compared to pre-stented velocities
D. peak velocities should be reduced compared to pre-procedure levels, but will still appear elevated when compared to normal velocities of non-stenotic arterial flow
D
When a stent is used to treat an arterial obstruction it helps to maintain a patent lumen, but will result in elevated velocities compared to expected normal non-stenotic velocities. Follow up exams should demonstrate reasonable velocity reduction compared to pre-stented levels, but normal velocities should not be expected.
61
A venous thrombectomy procedure is usually reserved for which type of patient?
A. patients with phlegmasia alba dolens and phlegmasia cerulean dolens
B. patients with an AV malformation
C. patients with superficial thrombophlebitis
D. patients with extensive venous reflux
A
A venous thrombectomy procedure is usually reserved for patients with phlegmasia alba dolens and phlegmasia cerulean dolens.
62
Which of the following is not a common type of lower extremity graft placement?
A. femoral artery to the PTA
B. popliteal artery to the DPA
C. femoral artery to the femoral artery
D. femoral artery to the popliteal artery
B
A fem - fem bypass graft indicates connection between two segments of the same femoral artery or between the right and left femoral artery. A fem - pop bypass graft connects the femoral artery and popliteal artery in the same leg. A fem - tib graft connects the femoral artery and most commonly the tibial artery. A bypass graft could not be connected to the dorsalis pedis artery because of its size and location.
63
```
What is the name of the vascular device that is placed into the IVC using a catheter?
A. wall filter
B. stent
C. greenfield filter
D. pacemaker
```
C
| A Greenfield filter is placed into the IVC to prevent emboli from the legs from reaching the heart and lungs.
64
Which of the following describes the 2D appearance of acute renal allograft rejection on ultrasound?
A. resistive index over 0.8
B. increased echogenicity and size
C. decreased echogenicity and size
D. increased echogenicity and decreased size
B
2D findings of acute allograft failure include increased echogenicity of the gland, increased size and loss of corticomedullary definition. The RI value will be over 0.8 but this is a Doppler value not a 2D characteristic.
65
Which of the following is part of the standard protocol for evaluating a patient with an aortic endograft?
A. document the location of the proximal attachment site and compare to prior exam to rule out graft migration
B. obtain waveforms in the mesenteric arteries to document flow is unaffected by the graft
C. measure the thickness of the mural thrombus surrounding the graft and compare to the prior exam to rule out increased thrombus formation
D. obtain waveforms in the renal arteries and veins to document flow is unaffected by the graft
A
Graft migration can be a complication of an endograft. On each evaluation, the location of the proximal attachment site should be identified and the level of the attachment in the aorta should be documented. Distal migration can cause kinking, tortuosity or luminal narrowing of the graft.
66
```
Which of the following diagnostic criteria would indicate 50-75% stenosis in a reversed vein bypass graft?
A. peak systolic velocity 250cm/s
B. peak systolic velocity 175cm/s
C. velocity ratio 2.0
D. velocity ratio 4.5
```
A
Normal PSV <125cm/s, velocity ratio <1.4
Less than 49% PSV 125-180cm/s, velocity ratio 1.5 - 2.4
50-75% PSV 180-300cm/s, velocity ratio 2.5 - 4
>75% PSV >300cm/s, velocity ratio > 4
67
Which of the following correctly describes a reversed vein graft?
A. the patient must wait at least 48 hrs after the valvulotome procedure is performed to complete the connection of the graft connection
B. stenosis at the proximal anastomosis is a common complication
C. there is less scarring with a reversed vein graft procedure than an in situ graft procedure
D. commonly used to correct bilateral iliac stenosis
B
The GSV is removed from the leg and replaced in a reversed position. The small distal end of the GSV is attached proximal to the obstruction in the femoral or popliteal vein. For this reason, stenosis of the proximal anastomosis is more common than other complications. The larger proximal end of the GSV is connected distal to the obstruction. Because the GSV is completely removed from the leg, there is more scarring than with an in situ graft where the GSV remains in its natural position. The reversed vein graft is turned upside down, so the valve stay open due to gravity (no valvultome).
68
Volume flow calculations are used to assess hemodialysis graft performance. How is volume flow measured?
A. obtain 3-4 Doppler tracings of the inflow artery and trace the waveforms to obtain the volume flow measurements, then average these numbers
B. obtain 3-4 Doppler tracings and average the peak velocity, then use the Bernoulli equation to calculate the volume flow
C. open the sample volume from wall to wall within a normal segment of the graft and trace the waveforms
D. Doppler US cannot provide the volume flow information and the dialysis machine be used to assess the volume flow through the graft
C
Volume flow calculations are used to assess hemodialysis graft performance. Open the sample volume from wall to wall within a normal segment of the graft and trace the waveform.
69
If a liver transplant patient has a piggyback anastomosis, how does this affect your evaluation?
A. there will be a single anastomosis site in the IVC that must be evaluated
B. the hepatic artery anastomosis will not be able to be visualized because it is located deep within the liver tissue
C. there will be two anastomosis sites in the main portal vein that must be evaluated
D. each hepatic vein is connected to the native IVC separately, so there will be three anastomosis sites in the IVC that must be evaluated
A
Before beginning the exam, the surgical notes should be reviewed to determine if the patient has a full or partial transplant, a piggyback or interposition anastomosis and note the anastomosis sites for all vasculature.
Piggyback - hepatic confluence of transplant liver attached to native IVC; single anastomosis site
Interposition - donor IVC segment replaces a segment of the native IVC; two anastomosis sites
70
```
Venous flow proximal to an AV fistula becomes _________ due to the inflow of arterial flow distally.
A. continuous
B. phasic
C. high resistance
D pulsatile
```
D
| Venous flow proximal to an AV fistula becomes pulsatile due to the inflow of arterial flow distally.
71
Which of the following correctly explains why a surgeon would perform an intravascular ultrasound immediately after stent placement in small artery?
A. to assess the velocity of flow in the stent
B. to confirm that all plaque was removed from the artery
C. to assess the velocity of flow in the artery
D. to evaluate the stent position
D
Intravascular ultrasound uses a 10-30MHz transducer. IVUS allows for 360 degree imaging of the artery lumen. It is used to locate the most narrow segment that would benefit from stent placement, used after angiography to evaluate proper stent placement, used to evaluate coronary artery disease from within the coronary arteries. The transducers allow 2D imaging only, NO Doppler capabilities.
72
Which of the following symptoms would be associated with steal syndrome of a hemodialysis graft?
A. shoulder swelling
B. spontaneous bruising of the neck, arm and hand
C. hand pain that increases with exercise
D. hand pain that is reduced or eliminated during dialysis
C
Steal syndrome most commonly occurs in a radiocephalic graft. The ulnar artery flow will be antegrade and the radial artery flow will be retrograde. Blood travels from the ulnar artery into the hand and moves through the palmar arch to exit the hand in the radial artery. Symptoms include pain, polar sensation, paresthesia, Finger/ Brachial index <0.8, cyanotic finger tips, and diminished radial pulse on palpation. Symptoms can increase with use of the arm (exercise) and during dialysis.
73
```
The TIPS procedure is performed to correct what condition?
A. atherosclerosis
B. AAA
C. portal hypertension
D. pulmonary embolism
```
C
A transjugular intrahepatic porto-systemic shunt is used to bypass the liver and relieve portal HTN. The portal system is directly connected to the IJV or Hepatic veins.
74
The most common site for hepatic artery stenosis in a transplant is ___________.
A. at the native hepatic artery anastomosis site located just inside the liver near the portal bifurcation
B. at the native hepatic artery anastomosis site located just outside the hilum of the liver
C. at the origin of the native hepatic artery from the celiac axis
D. at the common hepatic artery bifurcation located just inside the liver near the portal bifurcation
B
The donor hepatic artery is connected to the native hepatic artery just outside the hilum of the donor liver. The most common site for arterial stenosis is at the anastomosis site. Myointimal hyperplasia can lead to stenosis at the anastomosis site due to "over-healing" of the connection.
75
```
__________ is the most common endoleak and usually does not require intervention, while ________ is most dangerous and requires surgical intervention.
A. Type IV, Type I
B. Type II, Type I
C. Type III, Type IV
D. Type I, Type II
```
B
Type II is the most common endoleak and usually does not require intervention, while Type I is most dangerous and requires surgical intervention.
76
```
Which intracerebral vessel is evaluated on a TCD evaluation performed during a left carotid endarterectomy?
A. ipsilateral MCA
B. ipsilateral ACA
C. contralateral PCA
D. contralateral MCA
```
A
The ipsilateral middle cerebral artery is monitored during carotid endarterectomy for the presence of cerebral emboli and to help determine if a shunt is necessary during the procedure.
77
Which of the following is a sign of a normally functioning hemodialysis graft?
A. presence of a water hammer pulse
B. palpable thrill over the graft
C. absence of a palpable thrill over the graft
D. pain or pallor in the hand
B
A normal AVG should demonstrate a palpable thrill as blood flow moves through it. Absence of the thrill or a water hammer pulse is indicative of an occluded graft. If the graft becomes stenosed or occluded, the distal forearm and hand could become ischemic.
78
A patient presents for Doppler evaluation after revascularization of the SMA 1 week ago. The study prior to treatment demonstrated a peak systolic velocity of 4.2m/s in the SMA. On today's exam, the velocity in the proximal SMA has reduced to 3.3m/s. How will you report these findings?
A. unable to summarize the results until pre-prandial and post- prandial evaluations are performed
B. the SMA demonstrates normal velocities after the procedure
C. the SMA flow velocity has decreased, but has not returned to normal levels
D. unable to summarize the results with end diastolic velocity
C
| The normal velocity in the SMA is <2.75m/s.
79
```
Which of the following requires a 2D and Doppler evaluation for a complete exam?
A. thoracic outlet syndrome
B. raynaud syndrome
C. popliteal entrapment
D. renal or liver transplant
```
D
A renal transplant requires a 2D evaluation to assess renal size and cortical echogenicity related to the renal sinus. Doppler is used to evaluate arterial and venous flow. A liver transplant requires a 2D evaluation to assess liver echogenicity and echotexture. The other abnormalities listed would easily be evaluated with PPG or digit pressures and imaging would not necessarily be required.
80
```
You are performing a follow up exam on a synthetic fem-pop graft that is 2 weeks post-op. The native arteries and graft appear normal on the 2D and color Doppler evaluation. These same segments are evaluated using PW Doppler and monophasic waveforms with mild diastolic flow throughout the cardiac cycle are demonstrated. Which of the following is the most likely reason for the discrepancy in findings?
A. mid graft thrombosis
B. reactive hyperemia
C. stenosis distal to the graft
D. collateral formation
```
B
Reactive hyperemia is the transient increase in blood flow that occurs after a period of ischemia. It commonly occurs following the removal of a tourniquet, unclamping an artery during surgery, bypass graft placement or after vessel recanalization caused by a device or medication. Monophasic flow with increased diastolic flow may still be identified in the first 1-2 months after the procedure due to reactive hyperemia. The body needs time to adjust to the new flow pattern. The waveform should return to a triphasic pattern after 2 month post-op.
81
Which of the following correctly describes steal syndrome in a patient with a Brescia-Cimino graft?
A. a water hammer pulse will be detected
B. pain or pallor in the hand increases with exercise
C. triphasic flow will be identified in the inflow artery
D. it is caused by stenosis in the outflow vein
B
Steal syndrome with an AVF causes blood to travel from the ulnar artery into the hand and move through the palmar arch to exit the hand in the radial artery. It is caused by high volume flow in most cases, but can also occur with inflow stenosis. Both cause pressure changes that lead to blood flow reversal in the radial artery. The arterial flow is diverted from the fingers and back to the outflow vein. Symptoms include pain, pallor, polar sensation, paresthesia, finger/brachial index <0.8, cyanotic finger tips and diminished radial pulse on palpation. Arm exercise can exacerbate the symptoms.
82
```
If both common iliac arteries demonstrate significant stenosis, what type of treatment will most likely be used?
A. right axillary - femoral bypass graft
B. fem - fem bypass graft
C. left axillary - femoral bypass graft
D. kissing stents
```
D
Kissing stents used for stenosis at the origin of the common iliac arteries. Two stents are deployed, one is placed into each iliac artery. Both stents are inflated with the catheter balloon. The proximal end of the stents are touching in the distal aorta (kissing).
83
```
A patient presents for a renal transplant evaluation. Which of the following native vessels will be evaluated during the exam?
A. segmental artery
B. external iliac artery and vein
C. distal renal artery
D. arcuate arteries
```
B
The question asks for native vessels, the external iliac artery and vein are the only native vessels normally evaluated on the exam. The other vessels listed are allograft vessels.
84
Which of the following is an abnormal finding for a hemodialysis graft?
A. inflow artery demonstrates a triphasic waveform
B. volume flow rate 500-1000ml/min
C.. turbulent flow at the anastomosis site
D. high velocity, pulsatile flow in the outflow vein
A
Normal flow velocity within the graft should be >100cm/s. Graft stenosis suspected with velocities greater than 400cm/s. Abnormal flow volume <500ml/min. If the flow velocity doubles (or more) between two points in the graft, significant stenosis is suspected. If the inflow artery demonstrates a triphasic waveform, graft occlusion is suspected. Turbulent flow is normal at the anastomosis site and the venous outflow will also be turbulent and pulsatile.
85
What is the primary reason why dialysis grafts are commonly placed at the antecubital fossa or wrist, and not the shoulder?
A. there is an increased risk of graft thrombosis with the wide range of motion for the normal shoulder
B. there is an increased risk of graft rupture with the wide range of motion for the normal shoulder
C. the shoulder the AV fistula to the heart, the greater the risk of developing heart failure
D. to make it less visible to help with patient privacy related to their dialysis treatment
C
The AV fistula is created in the arm at the furthest point possible where the vessels still meet the minimum size requirements for the procedure. The closer the AVF to the heart, the greater the risk of developing heart failure from reprocessing of the arterial blood that is emptied directly into the venous system.
86
Which of the following correctly describes hemodialysis?
A. An arteriovenous fistula is created by connecting an artery and a vein, usually in the arm
B. contraindications include abdominal wall scarring, hernia, inflammatory bowel disease or diverticulitis
C. a cleaning fluid flows is injected through an intraperitoneal catheter
D. can be performed by the patient at home
A
Hemodialysis requires an arteriovenous fistula. The AVF is created by connecting an artery and a vein, usually in the arm. The dialysis machine is connected to the patient using two separate needles. Blood is removed from the body through the AVF. The treatment requires regular visits to a dialysis center.
87
A patient presents for evaluation of a hemodialysis graft due to suspected stenosis. Considering the most common location of stenosis in an arterio-venous graft, where should you look first for the suspected stenosis?
A. mid graft, especially if it is a looped graft
B. arterial anastomosis and proximal graft
C. inflow artery
D. venous anastomosis and outflow vein
D
| The venous outflow is the most common location of stenosis in an AVG for dialysis.
88
Before performing a liver transplant evaluation, the Sonographer must review the surgical history to determine:
A. the location of all sites of vascular anastomosis
B. if the transplant has a piggyback or interposition anastomosis
C. if the transplant was full or partial
D. more than one of the above
D
Before beginning the exam, the surgical notes should be reviewed to determine if the patient has a full or partial transplant, a piggyback or interposition anastomosis and note the anastomosis sites for all vasculature.
89
```
A patient is undergoing AAA repair in the distal aorta and you are assisting with the ultrasound machine during the exam. The physician places an endovascular graft within the aorta. If the graft placement was successful, how should the ankle pressures change?
A. no change should be seen
B. mild decrease
C. varies with type of graft used
D. mild increase
```
D
The AAA would have caused a reduction in flow moving to the legs. The lower extremities would exhibit decreased resistance in the vascular beds to maintain flow. This would indicate a mild reduction in ankle pressure. When the graft is placed in the aorta, flow to the legs increases and pressure and resistance would both increase at the ankles.
90
Which of the following correctly describes myointimal hyperplasia in an arterial bypass graft?
A. not identified on ultrasound until greater than 3 years post-op
B. most commonly occurs in an in situ vein graft at sites of valve removal
C. easily differentiated from atheroma formation
D. caused by the healing process at the anastomosis sites
D
Myointimal hyperplasia is a common cause of stenosis at the anastomosis sites of a graft. Native tissues proliferate during the healing process after graft placement. It can be identified anytime from 1 month to 2 years post-op. Difficult to differentiate from soft atheroma formation.
91
If a liver transplant patient has an interposition anastomosis, how does this affect your evaluation?
A. there will be two anastomosis sites in the main portal vein that must be evaluated
B. the hepatic artery anastomosis will not be able to be visualized because it is located deep within the liver tissue
C. there will be two anastomosis sites in the IVC that must be evaluated
D. each hepatic vein is connected to the native IVC separately, so there will be three anastomosis sites in the IVC that must be evaluated
C
Before beginning the exam, the surgical notes should be reviewed to determine if the patient has a full or partial transplant, a piggyback or interposition anastomosis and note the anastomosis sites for all vasculature.
Piggyback - hepatic confluence of transplant liver attached to native IVC; single anastomosis site
Interposition - donor IVC segment replaces a segment of the native IVC; two anastomosis sites
92
```
When evaluating a patient with an aortic endograft, what is the minimum increase in aortic sac size that indicates a possible endoleak?
A. 0.2cm
B. 0.9cm
C. 0.5cm
D. 1.5cm
```
C
| An increase in aortic sac diameter of 0.5cm or greater indicates a possible endoleak.
93
A patient presents with a prior history of an isolated focal 75% stenosis of the common femoral artery. He has balloon angioplasty performed 3 months ago. Which of the following describes the expected changes in the extremity flow patterns if the procedure was a success?
A. triphasic flow in the femoral artery is now biphasic
B. increased diastolic flow in the femoral artery and all arteries distally
C. triphasic flow in the femoral artery is now monophasic
D. monophasic flow in the femoral artery is now triphasic
D
Abnormal flow in the lower extremity is demonstrated as a monophasic waveform with increased diastolic flow. After treatment, the flow pattern in the distal arteries should increase in resistance to become biphasic or triphasic.
