Vascular Review Starred Questions

Front 1

**What 3 vessels arise from Aortic Arch?

Back 1

Innominate/Brachiocephalic

LCCA

L Subclavian Artery

Front 2

**What does Innominate/Brachiocephalic Artery divide into?

Back 2

RCCA

R Subclavian Artery

Front 3

**Most Common Anomaly of Aortic Arch?

Back 3

Common origin of innominate & L CCA

Front 4

*Subclavian arteries arch _____ the calvicle, ______ apex of lung, and behind the _____ muscle

Back 4

Above

In front of

Scalenus anterior

Front 5

**What are the most important subclavian artery branches?

Back 5

Vertebral (1st branch)

Thyrocervical

Internal thoracic (Internal mammary)

Costocervical Arteries

Front 6

*CCA divides into its external & internal branches usually at level of the upper border of ?

Back 6

Thyroid cartilage which forms the prominence of larynx

Front 7

*Extracranial ICA has ____ branches

Back 7

0/no

Front 8

*Which is larger, ICA or ECA?

Back 8

ICA

Front 9

**1st branch of ECA is _______ artery

Back 9

Superior Thyroid

Front 10

**8 Branches of ECA

Back 10

Superior Thyroid

Ascending pharyngeal

Lingual

Facial (Angular)

Occipital

Posterior Auricular

Maxillary (infraorbital)

Superficial Temporal (STA)

Front 11

Mnemonic for 8 Branches of ECA

Back 11

SUsan ASked LINus For OCtavia's Phone Message Service

Some Aggressive Lovers Find Odd Positions More Stimulating

Front 12

*Angular artery is terminal part of

Back 12

Facial artery

Front 13

*Infraorbital artery is terminal branch of

Back 13

Maxillary artery

Front 14

*What does carotid sinus contain?

Back 14

A chemoreceptor sensitive to changes in O2 tension of blood that then signals necessary changes in respiratory activity to maintain homeostatis & pressoreceptors (baroreceptors) that regular heart rate. Compression can cause an increase pressure which leads to decreased heart rate. Compression can also cause decreased cerebral perfusion &/or distal embolization.

Front 15

**Largest of Intra-arterial connections is?

Back 15

Circle of Willis

Front 16

**What is the Circle of Willis?

Back 16

Hexagonal arrangement of distal ICA, anterior & posterior cerebral arteries, joined together by the anterior & posterior communicating arteries

anterior communicating --> anterior cerebral --> middle cerebral --> ICA --> posterior communicating --> posterior cerebral --> basilar --> vertebral

Front 17

**First branch of ICA

Back 17

Ophthalmic artery

Front 18

**Second & Third ICA branches

Back 18

Anterior Choroidal

Posterior Communicating Arteries

Front 19

**What are the two terminal arteires of ICA?

Back 19

MCA

ACA

Front 20

**How does ICA connect w/ ECA fro collateral flow?

Back 20

3 branches of ophthalmic artery:

Supraorbital

Frontal

Nasal arteries

Front 21

**Describe Periorbital Circulation

Back 21

Ophthalmic artery --> supraorbital artery --> globe to join w/ STA of ECA

Ophthalmic artery --> frontal artery, exits orbit --> forehead to join w/ STA

Ophthalmic artery --> frontal --> nasal artery --> angular --> to join w/ facial artery of ECA

Front 22

*What are some intracranial-extracranial anastomoses?

Back 22

ICA-ECA connections thru ophthalmic & orbital arteries

Meningohypophyseal branches & carotid-tympanic branches

Occipital branch of ECA w/ atlantic branch of vertebral

ECAs across midline

Front 23

**What is the most common anomaly of Circle of Willis?

Back 23

Absence or hypoplasia of one or both of communicating arteries

Front 24

**Why is the MCA not a collateral pathway?

Back 24

It is terminal artery

Front 25

*Why is STA not an intracranial collateral pathway of clinical significance?

Back 25

It not an intracranial artery

Front 26

**What is the tunica intima?

Back 26

Thin & smooth surface inner layer of endothelium, then base membrane, & connective tissue

Front 27

**What is tunica externa/adeventitia?

Back 27

Thin, white fibrous connective tissue & smooth muscle fibers all arranged longitudinally

Front 28

**The blood supply to vascular tissue is provided by ____, tiny layers that carry blood to walls of larger arteries

Back 28

Vaso vasorum located in adventitial layer

Front 29

*What happens in cardiac contraction?

Back 29

Pressure rises in left ventricle & left ventricle pressure exceeds aortic pressure, aortic valve opens, blood is ejected, and blood pressure rises

Front 30

**The heart pump represents what kind of energy?

Back 30

Potential (pressure) energy measure in mmHg

Front 31

*The blood pressure is greatest where and least where in arterial system?

Back 31

Greatest in heart & gradually decreases

Front 32

**What determines the amount of blood leaving arterial system/reservoir What does the amount of flow depend on?

Back 32

The same thing: arterial pressure/energy difference and total peripheral resistance

Front 33

*What stores some of the blood volume and the energy?

Back 33

Distended arteries

Front 34

**The total energy is the sum of

Back 34

Potential (pressure), kinetic (velocity), and gravitational/hydrostatic (HP) energies

Front 35

**In supine PT, there is ____ difference in HP between arteries & veins

Back 35

Negligible (0 mmHg)

Front 36

**What is the dynamic (mean) hydrostatic pressure in supine PT?

Back 36

15 mmHg (negligible)

Front 37

**What is the hydrostatic pressure at ankle of a standing pt?

Back 37

100 to 102 mmHg

Front 38

*The greater the energy difference/gradient, the ____ the flow

Back 38

Higher/great

Front 39

**What is Poiseuille's equation?

Back 39

Pressure = flow X resistance

Front 40

**What two things are required for blood flow (Q)?

Back 40

Pathway & pressure/energy difference (gradient)

Front 41

*Flow is ____ proportional to pressure

Back 41

Directly

Front 42

*Flow is ______ proportional to resistance

Back 42

Inversely

Front 43

*High rsistance = ________ flow rate

Back 43

Low

Front 44

*The lower the resistance, the ____ flow to maintain pressure

Back 44

Higher

Front 45

**What factors affect resistance to flow?

Back 45

Resistance = 8 x n x l / pi x r^4, where n = viscosity, l = length, & r = radius

Front 46

**A change in what has the most affect on resistance?

Back 46

Vessel diameter/radius

Front 47

*Flow is ____ proportional to radius

Back 47

Directly

Front 48

*Longer the vessel, the ___ the pressure required to maintain flow

Back 48

Higher

Front 49

**The radius of a vessel, the blood viscosity, the vessel length is _____ proportional to velocity

Back 49

Inversely

Front 50

**What are the two forms of energy loss?

Back 50

Viscous

Inertial

Front 51

*In a rigid tube, energy losses are mainly

Back 51

Viscous

Front 52

*What is viscous energy loss due to?

Back 52

Increased friction between molecules and laminar layers

Front 53

*Internal friction is measured by its

Back 53

Viscosity (thickness of a fluid)

Front 54

**Energy is expended largely in the form of heat as the eddies and vortices work against the _____ of the blood

Back 54

Viscosity

Front 55

*An elevated hematocrit increases

Back 55

viscosity

Front 56

**What is inertia?

Back 56

The tendency of fluid to resist changes in its velocity in order to help maintain flow

Front 57

**What are inertial losses due to?

Back 57

Deviations from laminar flow as in changes in blood direction &/or velocity (eddy currents, turbulence, and vortices)

Front 58

**What type of energy loss occurs at the exit of a stenosis?

Back 58

Inertial

Front 59

**According to Bernoulli's equation, if kinetic energy (velocity) increaases, pressure energy?

Back 59

Decreases in order to equate the total energy amount

Front 60

*Velocity is ____ to pressure

Back 60

Inversely proportional

Front 61

*Pressure distal to a stenosis is ____ than pressure within a stenosis

Back 61

Higher

Front 62

*Laminar flow has an ____ distribution of frequencies at systole

Back 62

Even

Front 63

*Pressure gradients can be described as flow

Back 63

Separations

Front 64

**Where do flow separations in vessel occur?

Back 64

Geometry changes w/ or w/o disease (carotid bifurcation) & because of curves, and as in a bypass graft anastomosis site

Front 65

*What nonsteady conditions affect fluid behavior?

Back 65

Fluid acceleration, deceleration, & rest

Front 66

**______ results because velocity & area are inversely proportional

Back 66

Acceleration

Front 67

*Flow accelerates ___ a stenosis

Back 67

through

Front 68

*Flow decelerates ____ to a stenosis

Back 68

distal

Front 69

*Laminar flow ____ downstream from a stenosis

Back 69

resumes

Front 70

*Diastolic reversal of flow is most likely in

Back 70

Extremity arteries at rest

Front 71

*How do arterioles assist w/ regulating blood flow?

Back 71

Contraction (constriction) & relaxation (dilation)

Front 72

*Flow reversal increases with

Back 72

Vasoconstriction

Front 73

**What happens during vasoconstriction?

Back 73

Pulsatile changes in small arteries are increased, while these changes are decreased in minute arteries, arterioles, and capillaries

Front 74

*Diastolic flow reversal may be ___ in vasodilated limbs

Back 74

Absent

Front 75

**Describe low resistance flow

Back 75

Continuous (steady) nature feeding a vasodilated vascular bed

Front 76

**What are some examples of vessels with low resistance flow?

Back 76

ICA

Vertebral

Celiac

Post-prandial SMA

Renal

Splenic

Hepatic

Front 77

**What are some examples of vessels w/ high resistance

Back 77

ECA

Subclavian

Aorta

Fasting SMA

Iliac

Extremity arteries

Front 78

*When can a high resistance signal occur?

Back 78

Vasoconstriction at arteriolar level or from distal arterial obstruction

Front 79

**What cannot cause vasodilatation of high resistance bed?

Back 79

Hyperventilation

Front 80

**Why does reversal quality of high resistance signal disappear after a stenosis?

Back 80

Decreased peripheral resistance secondary to ischemia

Front 81

*How may arterial obstruction alter flow in collateral channels?

Back 81

Increased flow

Reversed flow direction

Increased velocity

Waveform pulsatility changes

Front 82

**In presence of total occlusion of main artery, why may there be normal flow?

Back 82

Collateral network & decrease in peripheral resistance

Front 83

**What is most controllable risk factor?

Back 83

Smoking

Front 84

**What does smoking cause?

Back 84

Irritation of endothelial lining

Vasoconstriction

Front 85

*Where is HTN important?

Back 85

Increased incidence of coronary atherosclerosis

Front 86

*What is the most common arterial pathology?

Back 86

Atherosclerosis

Front 87

**What is atherosclerosis?

Back 87

Generalized disease that may begin in adolescence in which there is thickening, hardening, and loss of arterial elasticity beginning in intima & then media layer

Front 88

**What are the three major risk factors for atherosclerosis?

Back 88

Smoking

HLD

Family Hx

Front 89

**What are two less important factors?

Back 89

HTN

DM

Front 90

**What are the most common sites for atherosclerosis?

Back 90

Carotid bifrucation (#1)

Origins of brachicephalic vessel

Origins of visceral vessels

Aorto-iliac bifurcation

CFA birfurcation

SFA at adductor canal (vessel changes course)

Popliteal trifurcation

Front 91

*What is pulsatile mass in neck usually related to?

Back 91

Tortuous common carotid rather than aneurysm

Front 92

**What are five types of atherosclerotic plaque?

Back 92

Fatty streak

Fibrous plaque

Complicated lesion

Ulcerative lesion

Intra-plaque hemorrhage

Front 93

*What is an ulcerative lesion?

Back 93

Deterioration of intimal layer's fibrous cap & may result in intraplaque hemorrhage, thrombosis, embolization

Front 94

*What is dissection?

Back 94

Non-atherosclerotic lesion that results from sudden tear in intima

Front 95

*What can happen to the collected blood on lumen?

Back 95

It may thrombose

Front 96

*What is an embolism?

Back 96

Obstruction of blood vessel by foreign substance or blood clot

Front 97

*What is an embolism composed of?

Back 97

Solid, liquid, or gas

Front 98

**What is most frequent cause of embolism?

Back 98

Part of plaque formation breaks loose (from atherosclerotic lesion, arteritis, or aniographic procedure) and travels distally until it lodges (most common) or may enter from outside body

Front 99

**What is a subclavian (vertebral) steal?

Back 99

Blood flow retrograde down the vertebral artery secondary to ipsilateral subclavian or innominate artery stenosis/occlusion, not secondary to vertebral artery stenosis occlusion

Front 100

**Subclavian steal is usually a ______ hemodynamic phenomenon

Back 100

Harmless

Front 101

*Flow is stolen from the contralateral vertebral artery by way of the ____ artery

Back 101

Basilar

Front 102

*It occurs most commonly on the ____ side

Back 102

Left

Front 103

**Patients are usually ______ meaning there are decreased pulses in affected arm w/ arm claudication being rare

Back 103

Asymptomatic

Front 104

*There is a lower brachial blood pressure difference of _____ in affected arm

Back 104

> 15-20 mmHg

Front 105

*What is a carotid body tumor?

Back 105

Small mass of non-atherosclerotic vascular tissue that adjoins carotid sinus between internal & external carotid arteries

Front 106

*How are tumors fed?

Back 106

Usually through ECA

Front 107

**What is fibromuscular dysplasia (FMD)?

Back 107

Multiple arterial stenosis caused by medical hyperplasia w/ collagen overgrowth

Front 108

**FMD is usually seen in young

Back 108

women

Front 109

**How is FMD diagnosed?

Back 109

"String of beads"

Maybe post stenotic dilatation

Front 110

**What vessels is it seen in ? (FMD)

Back 110

Carotid & renal arteries

Front 111

*A patient undergoes carotid endarterectomy, 6 months later angiography is performed because of symptoms referable to other side. The angiogram reveals that operated carotid is significantly narrowed. The most likely cause is?

Back 111

Neointimal hyperplasia

Front 112

**What is neointimal hyperplasia?

Back 112

Intimal thickening from rapid production of smooth muscle cells (6 to 24 months) as response to vascular injury/reconstruction

Front 113

**What is TIA?

Back 113

Transient Ischemic Attack that lasts a few minutes up to 24 hours

Front 114

*Stenosis of what vessel presents highest risk for TIA?

Back 114

ICA

Front 115

*What does RIND (stroke w/ recovery) mean?

Back 115

Resolving ischemic neurologic deficit

Front 116

*How long does RIND last?

Back 116

More than 24 hours, like a stroke, but there is complete recovery

Front 117

*What is a stroke/CVA?

Back 117

Cerebrovascular accident lasting more than 24 hours w/ permanent neurologic deficit

Front 118

**What are the three classifications of CVA?

Back 118

Acute (sudden onset, unstable)

Stroke in evolution (symtpoms come & go, unstable)

Completed stroke (no progression or resolution, stable)

Front 119

**What is the incidence of new strokes per year?

Back 119

500,000

Front 120

*The strongest risk factor for stroke is

Back 120

HTN

Front 121

*The most prevalent type of stroke is

Back 121

Ischemic (85%)

Front 122

**After carotid bifurcation disease, the next most common source of stroke symptoms is

Back 122

Cardiac-source embolization

Front 123

**The cause of a right hemispheric infarct may be

Back 123

R ICA occlusion

Front 124

**When the source of the lesion is the ICA, the following symptoms are usually seen:

Back 124

Aphrasia

Amaurosis fugax (AF)

Unilateral contralateral paresthesia

Anesthesia or paresis

Front 125

**Amaurosis Fugax (AF) can be interpreted as

Back 125

TIA

Front 126

**What is paresthesia?

Back 126

Pricking/tingling/numb sensation of the skin

Front 127

**What is hemiparesis?

Back 127

Weakness of one side

Front 128

**When the source of the lesion is MCA, the following symptoms are usually seen

Back 128

Aphasia

Dysphagia

More severe contralateral hemiparesis/hemiplegia

Behavior changes

Front 129

*A Patient describes a 30 minute episode of garbled speech. This is called

Back 129

Dysphasia

Front 130

**A binocular distrubance that disrupts vision in half the visual field of both eyes is called

Back 130

Homonymous hemaniopia

Front 131

*When the source of the lesion is ACA, the following symptoms are seen

Back 131

More severe leg hemiparesis or hemiplegia

Incontienence

Loss of coordination

Front 132

*When the source of the lesion is the PCAs, the following symptoms are seen

Back 132

Dyslexia

Coma usually w/o paralysis

Front 133

*When the source of the lesion is in the posterior circulation (Vertebrobasilar arteries), the following symptoms are seen:

Back 133

Bilateral or global symptoms such as vertigo

Bilateral ataxia (muscular incoordination)

Bilateral visual disturbances (blurring, diplopia/double vision)

Bilateral paresthesia or anesthesia

Drop attack

Front 134

**What are four more vertebrobasilar insufficiency (VBI) symptoms?

Back 134

Dizziness

Ectasia

Syncope

Dysphagia (difficulty swallowing)

Front 135

**What are some non-localizing symptoms with a variety of causes?

Back 135

Dizziness (with a tendecy to fall)

Syncope

Speech difficulty (alone)

Headache

Front 136

**Where might a bruit be heard?

Back 136

Stenosis or dissection of carotid, subclavian, aorta, femoral, popliteal arteries

Front 137

*Bruits heard bilaterally, loudest low in neck, are most likely caused by

Back 137

aortic valve stenosis

Front 138

*Why is a bruit not heard with stenosis > 90%?

Back 138

Velocities are slowing in pre-occlusive state, and there is no longer any tissue vibration

Front 139

*The most important reason Doppler evaluations should be performed with patient in a basal state & warm temperature is

Back 139

Results are influenced by pt's peripheral resistance

Front 140

*What are some limitations of periorbital Doppler?

Back 140

Not diagnostic w/ lesions < 50% diameter reduction

Cannot differentiate occlusion from tight stenosis

Cannot establish exact location of disease

Non-diagnostic when collaterals exist

Requires considerable technical skill

Front 141

**How is the frontal artery (of the ophthalmic artery) evaluated?

Back 141

Use 8-10 MHz probe on inner canthus of eye to locate frontal artery

Normal antegrade flow should be noted on recorder

Ipsilateral & contralateral compression manuevers on ECA branches are performed

Front 142

*Flow _____ upon compression of ECA branches or low CCA is evidence of collateral development

Back 142

Reversal

Front 143

**What are some contraindications to OPG-GEE?

Back 143

Allergies to local anesthetics

Eye surgery within the last six months

Past spontaneous retinal detachment

Acute or unstable glaucoma

Front 144

**What are not contradications of OPG-GEE?

Back 144

Myopia

Conjunctivitis

Front 145

*True or false: Plethysmography detects blood volume changes in systole but not diastole

Back 145

False

Front 146

**Standardization deflections should have an amplitude of approximately _____ on the chart recorder paper

Back 146

10 mm above & below the baseline

Front 147

*If the amplitude is not 10 mm, press ____ and adjust GAIN or press STD

Back 147

recaliberate

Front 148

*A pt w/ brachial systolice pressure < 140 mmHg may only require

Back 148

300 mmHg vacuum pressure

Front 149

*A pt w/ brachial systolic pressure > 140 mmHg opr pt w/ ocular pulsations at 300 mmHg may require

Back 149

Max vacuum of 500 mmHg

Front 150

*Pressure in the ophthalmic artery reflects pressure in the

Back 150

distal ICA

Front 151

**Ophthalmic systolic pressures should not differ by more than

Back 151

5 mmHg

Front 152

**A normal ratio of ophthalmic to brachial systolic pressure should be

Back 152

OSP-39/BSP >= .430

Front 153

**What is abnormal OPG-Gee?

Back 153

OSP's that differ by 5 mmHg or more &/or OSP-39/BSP ratio <.43

Front 154

*What is least likely to produce an abnormal indirect cerebrovascular test?

Back 154

Disease in external carotid

Front 155

*What imaging transducer frequencies would appropriately be used for carotid arterial assessment?

Back 155

5, 7.5, or 10 MHz, usually 8-10 MHz

Front 156

*In duplex imaging, the best arterial wall image quality is obtained when beam is at the following angle to artery walls

Back 156

90 degrees where angle of reflection = angle of incidence

Front 157

*What is the biggest limitation to duplex scanning?

Back 157

Acoustic shadowing

Front 158

*What can acoustic shadowing cause?

Back 158

Erroneous calcification of percent stenosis

Front 159

**How is an abnormal B-mode image interpreted?

Back 159

Fatty streaks (hypoechoic & homogenous echoes)

Soft fibrous (homogenous)

Complex plaque (heterogeneous echoes of soft & dense plaque)

Calcification

Thrombosis (same echogenicity of blood)

Surface characteristics (smooth, irregular, crater)

Front 160

**How can overestimation of disease occur?

Back 160

Artifact is mistaken for plaque, accelerated flow due to other causes (tortuous vessel, collateralization for ipsilateral or contralateral disease), inappropriately large doppler angle

Front 161

**What is the most frequent reason for underestimation of the amount of stenosis?

Back 161

Improper placement of the sample volume

Front 162

*What is the Doppler equation?

Back 162

Doppler frequency = 2 X transmit freq X RBC x (cos angle)/(1540m/s)

Front 163

*The reflected frequency is higher or lower depending on

Back 163

Direction of flow

Front 164

**What does the 2 represent (in the Doppler equation)

Back 164

2 Doppler shifts because the RBC is first an observer of an US field, then it acts as a wave source when struck

Front 165

*The angle correct cursor for velocity estimates is best

Back 165

Adjusted parallel w/ arterial walls, not adjusted 60 degrees at all times

Front 166

*What is the greatest source of error?

Back 166

Doppler probe > 60 degree angle

Front 167

*What is continuous wave (CW) DOppler?

Back 167

Two PZT crystals w/o range resolution/range gating & w/ fixed sample size

Front 168

**CW has ____ spectral window

Back 168

Little to No

Front 169

*Why is frequency open window not as apparent with CW?

Back 169

Because it cannot regulate its sample size, there is spectral broadening

Front 170

*In using CW Doppler w/ spectral analysis to assess the ICA, which of the following operator-induced errors would most likely result in falsely low frequency shift?

Back 170

Increasing the beam angle to 70 degrees

Front 171

*Non-imaging CW & PW Doppler provide

Back 171

Only physiologic information

Unable to distinguish tight stenosis from an occlusion

Information from more than one vessel may be included

Collateralized ECA may be mistaken for an occluded ICA

Must be performed by an experienced tech

Front 172

*The __ method allows the individual frequencies that make up the returned signal to be displayed

Back 172

FFT

Front 173

**____ is on the horizontal axis

Back 173

Time

Front 174

**____ are on the vertical axis

Back 174

Various true frequency shifts

Front 175

**Bilateral diminished CCA flow velocities are indicative of

Back 175

Poor cardiac output or stroke volume (cardiac insufficiency)

Front 176

**The waveform of the _____ has a rapid upstroke and down stroke with a strong, high diastolic component

Back 176

ICA

Front 177

*Another name for upstroke is

Back 177

Spectral envelope

Front 178

*A dicrotic notch may ___ evident

Back 178

not be

Front 179

*A high resistance signal is not

Back 179

continuous

Front 180

**The ___ has a rapid upstroke and down stroke with a low, almost no diastolic flow component

Back 180

ECA

Front 181

**How is it best to differentiate ICA from ECA?

Back 181

Waveform characteristics, vessel positions, presence of branches

Front 182

*During a cerebrovascular exam, you obtain equal brachial systolic pressures bilaterally. During the scan, you obtain this pulsatile signal between the transverse processes. You move the beam to the CCA and the waveform is below the baseline. This waveform suggests

Back 182

You should ask patient to perform a Valsalva manuever because it's probably a vertebral venous signal

Front 183

*What is the maximum Doppler shift frequency displayed?

Back 183

1/2 PRF

Front 184

**When might aliasing occur?

Back 184

When PRF is too low

Front 185

**How can PRF be increased and avoid aliasing?

Back 185

Decrease the transducer frequency, increase the angle of insonation closer to 90 degrees to decrease vessel depth, change to CW

Front 186

*What are Doppler shifts above & below the baseline?

Back 186

Mirror image artifact or helical (non-axial corkscrew) flow

Front 187

*What is mirror image artifact caused by?

Back 187

Presence of strong reflectors (B-mode) or utilizing too much gain (doppler)

Front 188

**Why are scan rates lower with Color Doppler?

Back 188

Multiple pulse cycles (7-20) in each color line

Front 189

**What is not a useful color flow adjustment in an effort to detect slow flow in a possibly occluded ICA?

Back 189

Increase color flow PRF because increasing the PRF will make the color flow less sensitive to slow flow

Front 190

*Diameter reduction is a ____ -dimensional measurement

Back 190

One

Front 191

**The two flow characteristics that define arterial stenosis anywhere in the body include focal flow acceleration velocities and

Back 191

Distal turbulence

Front 192

**_______ into the stneosis produced an increase in Doppler shift frequencies resulting in increased velocites

Back 192

Entrance

Front 193

**True spectral broadening & loss of spectral window is consistent with

Back 193

Turbulent flow

Front 194

*What is flow disturbance due to?

Back 194

Interrupted flow stability with high velocities and eddy currents

Front 195

**At stenosis _____, post-stenotic turbulence characterized by flow reversals, flow separations, vortices/eddy currents occur near edge of flow pattern

Back 195

Exit

Front 196

**Where can a jet of elevated velocities be found?

Back 196

Approaching a stenosis

Within a stenosis

Upon leaving the stenosis

Front 197

**What must be considered if there are high resistance flow patterns in the ICA?

Back 197

Disease at the carotid siphon

Front 198

**A low resistance pattern is present in many arteries except

Back 198

Proximal ICA in presence of siphon high-grade stenosis

Front 199

**A hemodynamically significant stenosis usually begins w/ a CSA reduction of ___ which corresponds to a diemter reduction of 50%

Back 199

75%

Front 200

*What diagnostic criterion is anticipated in the presence of a 50-60% diameter stenosis of the ICA?

Back 200

Elevation of systolic frequency w/ post-stenotic turbulence due to pressure & flow gradients

Front 201

**What is the range of Doppler diagnostic guidelines? (stenosis: normal, PSF, EDF, PSV, EDV)

Back 201

PSF: < 4 kHz

EDF:

PSV: < 125 cm/s

EDV

Front 202

**What is the range of Doppler diagnostic guidelines? (stenosis: 1-15%, PSF, EDF, PSV, EDV)

Back 202

PSF: < 4 kHz

EDF:

PSV: < 125 cm/s

EDV

Front 203

**What is the range of Doppler diagnostic guidelines? (stenosis: 16-49%, PSF, EDF, PSV, EDV)

Back 203

PSF: < 4 kHz

EDF:

PSV: < 125 cm/s

EDV

Front 204

**What is the range of Doppler diagnostic guidelines? (stenosis: 50-79%, PSF, EDF, PSV, EDV)

Back 204

PSF: > 4 kHz

EDF: < 4 kHz

PSV: > 125 cm/s

EDV: < 140 cm/s

Front 205

*What does an occluded vessel look like?

Back 205

Varying degrees of echogenic material, vessel completely filled w/ echoes, vessel motion is piston-like or horizontal

Front 206

**The loss of a diastolic component proximally in ipsilateral CCA is consistent w/

Back 206

ICA occlusion

Front 207

*What are some conditions in which TCD might be useful?

Back 207

Vasospasm following subarachnoid hemorrhage

Determination of brain death

Cerebral artery monitoring during surgery

Carotid siphon stenosis

Front 208

**What size transducer is used?

Back 208

2 MHz PW

Front 209

**What angle of insonation is assumed?

Back 209

0 degrees

Front 210

**What are the main three acoustic windows?

Back 210

Transtemporal

Transorbital

Transforaminal/suboccipital

Front 211

*The _____ approach allows for three windows: anterior, middle, and posterior

Back 211

Transtemporal

Front 212

**What is the standard method of quanitfy velocity measurements?

Back 212

Time-averaged maximum velocity (TAMV), not peak velocities

Front 213

**What is the technique for a TCD exam?

Back 213

Unilateral transtermporal approach & identify MCA, ACA, PCA, and terminal ICA (gives most information)

Ipsilateral transorbital approach & identify ophthalmic artery & carotid siphon

Repeat on contralateral side

Foramen magnum/subocciptal approach & identify the vertebral & basilar arteries

Front 214

**What artery is not evaluated?

Back 214

Posterior communicating because of inappropriate Doppler angle

Front 215

**How are the TCD vessels evaluated: MCA (Window, Depth, Direction, Velocity, Angle)

Back 215

Window: transtemp

Depth: 30-60 mm

Direction: antegrade

Velocity: 55 +/- 12 cm/s

Angle: Anterior & Superior

Front 216

**How are the TCD vessels evaluated: Distal ICA (Window, Depth, Direction, Velocity, Angle)

Back 216

Window: Transtemp

Depth: 55-65 mm

Direction: bidirectional

Velocity: 55 +/- 12 cm/s

Angle: Anterior & Superior

Front 217

**How are the TCD vessels evaluated: ACA (Window, Depth, Direction, Velocity, Angle)

Back 217

Window: Transtemp

Depth: 60-80mm

Direction: retrograde

Velocity: 50 +/- 11 cm/s

Angle: anterior & superior

Front 218

**How are the TCD vessels evaluated: PCA (Window, Depth, Direction, Velocity, Angle)

Back 218

Window: Transtemp

Depth: 60-70 mm

Direction: antegrade

Velocity: 39 +/- 10 cm/s

Angle: anterior & superior

Front 219

**How are the TCD vessels evaluated: ICA (Window, Depth, Direction, Velocity, Angle)

Back 219

Window: transorbit

Depth: 60-80 mm

Direction: antegrade/retrograde

Velocity: 47 +/- 14 cm/s

Angle: varies

Front 220

**How are the TCD vessels evaluated: Ophthalmic Artery (Window, Depth, Direction, Velocity, Angle)

Back 220

Window: Transorbit

Depth: 40-64 mm

Direction: antegrade

Velocity: 21 +/- 5 cm/s

Angle: Medial

Front 221

**How are the TCD vessels evaluated: Vertebral Artery (Window, Depth, Direction, Velocity, Angle)

Back 221

Window: Transforam

Depth: 50-90 mm

Direction: retrograde

Velocity: 38 +/- 10 cm/s

Angle: R & L of midline

Front 222

**How are the TCD vessels evaluated: BasilarArtery (Window, Depth, Direction, Velocity, Angle)

Back 222

Window: transforam

Depth: 80-120 mm

Direction: retrograde

Velocity: 41 +/- 10 cm/s

Angle: midline

Front 223

**Using the temporal window, you find a strong signal w/ considerable diastolic flow at a depth of 50mm. This is most likely

Back 223

MCA

Front 224

*If a TCD exam has a spectral waveform labeled "suboccipital window", and depth is 90 mm, this vessel is most likely

Back 224

Basilar artery

Front 225

**What does TCD interpretation incorporate?

Back 225

Flow depth

Flow direction

Flow velocity

Turbulence

Pulsatility

Systolic upstroke

Hemispheric index of MCA/ICA

Front 226

**What is not incorporated in TCD interpretation?

Back 226

The amount of spectral broadening

Front 227

**How does collateralization occur?

Back 227

Antegrade flow in the ACA via the contralateral ACA

Retrograde flow never occurs in MCA

Retrograde flow in the Ophthalmic artery from external-to-internal collateralization through the ipsilateral Ophthalmic artery,

Increased flow velocities in the PCA through posterior-to-anterior collateralization through the ipsilateral PCA

Front 228

*Diagnosis of occlusion is most accurate in

Back 228

ICA & MCA

Front 229

**What is one example that is not a main collateral pathway in the event of ICA obstruction?

Back 229

Genicular to arcuate branches because genicular arteries are around the knee (genuflect), and arcuate arteries are in the kidney

Front 230

*The diagnosis of vasospasm is most accurate in

Back 230

MCA

Front 231

**How is vaospasm diagnosed?

Back 231

Serial recordings of increased mean velocities > 120 cm/s w/ a hemispheric ratio index (MCA TAMV/distal extracranial ICA TAMV) > 3

Front 232

*What does a pinging noise mean?

Back 232

Microembolization

Front 233

*How is an intraoperative TCD interpreted?

Back 233

Decrease in MCA flow during cross-clamping may signal a need for shunting

Front 234

**What are some limitations to an arteriogram?

Back 234

Contrast (iodine) allergy

Renal failure

Inaccurate as a functional (hemodynamic) assessment

Unable to provide multiple images in multiple planes

Front 235

**What are the most common arteries used?

Back 235

CFA

Axillary

Brachial

Front 236

*Which is the safest approach?

Back 236

CFA

Front 237

**How is an arteriogram interpreted?

Back 237

Extent & location of filling defect, aberrant anatomy

Front 238

**What are common locations for atherosclerotic plaque?

Back 238

The adductor canal (#1 location), origins of vessels at arch, other bifurcations

Front 239

**How is diameter reduction calculated?

Back 239

{(1-diameter of residual lumen)/Diameter of true lumen} x 100

D = 5 mm, d = 1.5 mm

1-(1.5/5) x 100

(1-.3) x 100

.7 x 100 = 70%

Front 240

**How is diameter reduction calculated?

Back 240

{(1-diameter of residual lumen)/Diameter of true lumen} x 100

D = 8 mm, d = 2 mm

1-(2/8) x 100

(1-.25) x 100

.75 x 100 = 75%

Front 241

**How is area/cross-sectional reduction calculated?

Back 241

Assuming lesion is symmetrical, {1-(d squared/D squared)} x 100

Ex. 1 -2 squared/8 squared x 100 =

1 - 4/64 x 100 =

1 - .06 x 100 =

.94 x 100 = 94%

Front 242

**What is critical stenosis?

Back 242

50% diameter (75% area) reduction

Front 243

**What are complications of an arteriogram?

Back 243

Puncture site hematoma

Pseudoaneurysm

Local arterial occlusion

Neurologic complications

Front 244

**What is not a common complication of arteriography?

Back 244

Nerve damage

Front 245

*What is unique about digital substraction arteriography (DSA)?

Back 245

A mask, often w/o contrast, is selected to be subtracted from the frames obtained during injection of contrast solution

Front 246

**MR Angiography (MRA) functions by processing

Back 246

Radio frequency pulses/energy created by tissue and blood, and a strong magnetic field

Front 247

*MRA uses ____ radiation

Back 247

Non-ionizing

Front 248

**MRA's are useful for what diagnoses?

Back 248

Abdominal aortic aneurysm (AAA) in determining aortic diameter, & dissection

Front 249

**What are the limitations of MRA?

Back 249

Metalic (surgical) clips

Pacemakers

Monitors

Claustrophobia

Expense

Front 250

**What aren't MRAs able to assess degree of stenosis?

Back 250

Stenosis may be overestimated due to slow flow or turbulence, resulting in loss of magnetic signal

Front 251

*What is CT's most frequent application in CV disease?

Back 251

Evaluate nature of:

cerebral infarctions

Intracranial aneurysms

Hemorrhage

AV malformations

Front 252

*CT is more accurate than what two modalities in diagnosing aneurysms?

Back 252

Arteriography & MRA because the IV contrast allows for more discreet evaluation

Front 253

**The most common medical treatment of acute ischemic stroke consists of

Back 253

Recombinant tissue plasminogen actrivator (rtPA) within three hours of onset of symptoms

Front 254

*What are some lifestyle modifications?

Back 254

Stop smoking

Increase exercise

Control weight

Low-cholesterol diet

Protection to prevent injury/infection

Front 255

**The NASCET trail indicated that the best treatment for carotid stenosis in the symptomatic patient is

Back 255

Carotid endarterectomy for stenosis greater than 70% in diameter

Front 256

**The shape of veins is determined by the

Back 256

Trasmural pressure = pressure within vein minus pressure outside of vein

Front 257

*What caries 2/3 of the blood in the body?

Back 257

Extra-pulmonary veins

Front 258

*What are the components of calf muscle pump?

Back 258

Leg muscles & venous valves

Front 259

**What happens in muscle pump during contraction?

Back 259

The calf ("venous heart") muscle contracts, squeezing blood in soleal sinuses from superficial to deep system resulting in decreaed venous pressure, decreased venous pooling (volume), increased venous return to heart, increased cardiac output

Front 260

**During inspiration, there is venous return from the ___ extremities

Back 260

Upper

Front 261

**What happens during valsava?

Back 261

Both intra-thoracic & intra-abdominal pressures increase, and venous return is halted

Front 262

**What are venae comitantes?

Back 262

Corresponding veins referring to close proximity to its accompanying artery

Front 263

**The radial, ulnar, & brachial veins are

Back 263

Paired venae comitantes

Front 264

**Where do the radial & ulnar veins form the paired brachial veins?

Back 264

Near elbow

Front 265

**The brachial veins become axillary vein at confluence of basilic vein in the

Back 265

axilla

Front 266

*The digital veins form the cephalic vein on the ____ aspect of the forearm

Back 266

Lateral

Front 267

*The digital veins form the basilic vein on the ___ aspect of the forearm

Back 267

medial

Front 268

**The axillary vein becomes the subclavian vein at the confluence of the ___ vein

Back 268

cephalic

Front 269

**The subclavian vein joins the IJV's to form the ____ veins in the neck bilaterally

Back 269

Brachiocephalic/Innominate

Front 270

**What forms the deep venous arches?

Back 270

The deep digital veins that form the metarsal veins

Front 271

*What are the paired veins of the LE?

Back 271

ATVs

PTVs

Peroneal veins

Gastrocnemius veins

Front 272

*Which veins empty the back of the leg?

Back 272

P(osterior)TVs

Front 273

**What are the venous sinuses of the LE?

Back 273

Located in the dilated, saccular muscular (soleal & gastrocnemius) veins that are a major part of the calf-muscle pump, they serve as reservoir spaces and drain blood into the PTVs, peroneal, and popliteal veins

Front 274

**Where does most DVTs begin?

Back 274

The soleal veins

Front 275

**A thrombus is found in a large, muscular soleal vein, a bit proximal to mid calf. If this were to propagate, it would next involve?

Back 275

Posterior tibial &/or peroneal veins, & not popliteal veins

Front 276

*Where are the peroneal veins located?

Back 276

A few cm up calf and deeper than PTVs in lateral leg

Front 277

**A thrombus is found in gastrocnemius vein approximately 1/3 of the way down calf from knee. If this were to propagate proximally, it would next involve?

Back 277

Popliteal vein

Front 278

*The CFV becomes the ___ just above the inguinal ligament

Back 278

EIV (External Iliac Vein)

Front 279

**Why is there more left DVT than right DVT?

Back 279

Left iliac vein passes under left liac artery causing an extrinsic compression point

Front 280

*What is the longest vein in the body?

Back 280

GSV

Front 281

*What is the purpose of perforating veins?

Back 281

To empty blood from superficial system into the deep system

Front 282

*Where is the posterior communicating branch of GSV that is connected to perforator?

Back 282

Medial lower calf

Front 283

**Why are the two perforators of the PTVs at medial malleolus so important?

Back 283

Site of venous stasis ulceration

Front 284

**The superficial vein that receives flow from the three main perforating veins od the distal calf/ankle is called

Back 284

Posterior arch vein

Front 285

**Why is the posterior arch vein important?

Back 285

It is a site for venous ulceration

Front 286

*The aorta is to the ____ of the midline; the IVC is to the ____

Back 286

Left, right

Front 287

**Describe the SVC

Back 287

Formed by confluence of right & left innominate/brachiocephalic veins & drains head & UEs

Front 288

**What are venous valves?

Back 288

Bicuspid extensions of initimal layer

Front 289

**What are some veins without valves?

Back 289

Soleal sinuses

External iliac vein (75% of time)

Common Iliac

Interal Iliac

Innominate

SVC

IVC

Front 290

*What are some veins w/ valves?

Back 290

GSV (10 - 12 below knee)

LSV/SSV (6 - 12)

Perforators (1 each)

Infrapopliteal (7 - 12 each)

Popliteal & SFV (1 - 3 each)

Extenal iliac (25% of time)

CFV (1)

Jugular Vein (1)

Front 291

*Valves of the lower extremity are more susceptan the UE due to

Back 291

Venous thrombosis

Increased ambulatory venous pressure

Increased intra-abdominal pressure &/or venous obstruction

Front 292

**The development of venous thrombosis is based on

Back 292

Virchow's Triad = (Endothelial) trauma, stasis, hypercoagulability

Front 293

**What may venous stasis be caused by?

Back 293

Immobility (bed rest, paraplegia)

MI

CHF

Hypotension

COPD

Obsesity

Pregnancy

Previous DVT

Extrinsic compression

Surgery

Fractured hips

Multiple injuries

Front 294

*What are some causes of hypercoagulability?

Back 294

Pregnancy

Cancer

Hormones (Estrogen)

Myeloproliferative disorders

Front 295

**What are diseases that are not risk factors for DVT?

Back 295

Lymphangitis

Diabetes

Smoking (when not on birth control)

Arthritis

Front 296

**What is the most common sequeala of DVT?

Back 296

Valvular destruction

Front 297

*Approximately what percentage of untreated calf vein DVT is thought to propagate to a proximal level (i.e. popliteal or above)?

Back 297

15-20 or 28%

Front 298

**What are some complications of DVT?

Back 298

Venous insufficiency

Venous hypertension

Pulmonary embolism (PE)

Front 299

*What are the most common findings in chronic venous obstruction?

Back 299

Swelling

Heaviness

Discoloration

Ulcers

Varicosities

Front 300

*Where does chronic venous insufficiency come from?

Back 300

As clot prpagates, flow restrictions cause increased venous pressure, stretching the walls, and damaging the valves

Front 301

**What happens in vavular incompetence?

Back 301

Blood flows antegrade and retrograde (venous reflux)

Increased pressure in the veins

Increased venous pooling

Decreased return to heart

Decreased cardiac output

Front 302

**What is ambulatory venous hypertension?

Back 302

Increased LE venous pressure when pt is standing or walking

Front 303

*The greatest pressure of venous hypertension occurs

Back 303

During muscle contraction

Front 304

**Venous hypertension MOST often results from

Back 304

Deep venous reflux

Front 305

*What can ambulatory venous hypertension result in?

Back 305

Edema

Hyperpigmentation

Ulcer formation

Front 306

**What is the most consistent sign of elevated venous pressure?

Back 306

Edema

Front 307

**Edema from venous disease occurs because of

Back 307

Increased capillary pressure due to an obstructive process

Front 308

*What is a result of incompetent perforators?

Back 308

Blood from deep veins backs up into superficial veins

Front 309

*______ may leak into surrounding tissue secondary to increased pressure

Back 309

Fluid

RBCs

Fibrinogen

Front 310

**What is the result?

Back 310

The increased venous pressure interferes with normal cellular activity resulting in brawny (toughened & swollen) discoloration from the breakdown of stagnant RBCs into hemosiderin, & ulcer formation

Front 311

**What is post-thrombotic syndrome (Post-phlebitic syndrome)?

Back 311

Result of chronic venous hypertension usually secondary to DVT w/ complaints of leg swelling, pain, & hyperpigmentation

Front 312

*What is venous claudication?

Back 312

Complication of post-phlebitic syndrome w/ chronic obstruction of ilio-femoral veins causing severe pressure & thigh pain relieved w/ rest & elevation

Front 313

*The effects of gravity & walking can precipitate

Back 313

Edema

Varicosities (varices)

Ulcer formation

Front 314

*A varicose vein is most often

Back 314

a dilitation of the greater saphenous vein or superficial tributary

Front 315

*________ varicose veins are caused by valvular incompetence of the superficial veins

Back 315

Primary

Front 316

** _____ varicose veins are caused by incompetence of the superficial system resulting from DVT & incompetence of perforators & the deep system

Back 316

Secondary

Front 317

*What are three examples of congenital venous disease?

Back 317

Avalvular veins

AV malformations (AVMs)

3 syndromes

Front 318

** A person with pulm emb might have

Back 318

Chest pain

Reduced arterial blood gasses

Diaphoresis

SOB

Tachypnea

Pleural effusion

Front 319

**What is a lung perfusion scan?

Back 319

A VQ (ventilation quotient/ventilation perfusion) scan to look for Pulm Emb

Front 320

*What are limitations of VQ scan?

Back 320

Other disorders that can cause perfusion defect

Emphysema

Asthma

Pneumonia

Bronchial cancer

CHF

Liver cirrhosis

Radiography

Multiple blood transfusions

Post-operative period

Front 321

**What is better than a VQ scan?

Back 321

Pulmonary angiogram

Front 322

**What is better than a VQ scan?

Back 322

Pulmonary angiogram

Front 323

**What is the "gold standard" for Pulm Emb?

Back 323

Pulmonary angiogram

Front 324

**Pts complaining of pain, swelling, erythema of LE may have DVT, but vascular tech knows that dx DVT by these symptoms alone is approximately

Back 324

46 - 62% accurate

Front 325

**What does the differential diagnosis include?

Back 325

Muscle strain

Direct injury

Muscle tear

Baker's cyst

Cellulitis

Lymphangitis

Extrinsic compression

CHF

Complications of chronic venous insufficiency

Front 326

**What are the most common findings for DVT, in order?

Back 326

Swelling

Pain

Redness

Warmth

Front 327

*Edema caused by DVT is characterized by

Back 327

Swelling in ankles & legs but not the feet

Front 328

*Some time after being hit by a car, pt has severe pain in anterior aspect of right knee & massive left LE edema. The pt most likely has

Back 328

Extensive left fempop DVT

Front 329

*What is a Baker's cyst?

Back 329

Synovial fluid from knee joint

Front 330

*Typical findings of skin discoloration in pt w/ chronic venous insufficiency are

Back 330

Rusty brown color at ankles & calves

Front 331

*Symptoms of chronic venous insufficiency does not result from

Back 331

Gastrocnemius muscular insufficiency

Front 332

*What is pallor due to?

Back 332

Phlegmasia alba dolens

Front 333

*What is phlegmasia alba dolens?

Back 333

Limb-threatening arterial spasms secondary to extensive, acute ilio-femoral thrombosis with leg edema & pain

Front 334

*A condition that presents as severely swollen, blue, cool LE is called

Back 334

Phlegmasia cerulean dolens (venous gangrene) from hypoxia

Front 335

**What is phlegmasia cerulean dolens due to?

Back 335

Limb-threatening severely reduced venous outflow from ilio-femoral thrombosis which reduces arterial inflow

Front 336

**A patient presents with acute pronounced bright red discoloration & edema of skin along anterior calf. The most likely diagnosis is

Back 336

Cellulitis

Front 337

**Patients suspected of having venous disease may complain of pain that is

Back 337

Relieved by elevation

Front 338

*Pitting edema of both LEs is likely related to

Back 338

Cardiac or systemic origin

Front 339

*Complaints of chronic unilateral LE swelling, aching, and a sense of heaviness most likely suggest

Back 339

Postphlebitic syndrome

Front 340

*A pt presents w/ unilateral chronic swollen leg & previous diagnosis of DVT three years earlier. The most likely finding would be

Back 340

The popliteal vein is patent & the valves are incompetent

Front 341

*What is non-pitting edema result of?

Back 341

One cause is lymphedema as a result of obstruction in lymphatic system

Front 342

*What is lymphedema?

Back 342

When lymph nodes &/or lymph vessels are removed (as in cancer surgery) or damaged as in trauma, infection, inflammation, radiation or chemotherapy, and fluid accumulates

Front 343

**How are venous ulcers distinguished from arterial ulcers

Back 343

Venous ulcers are at medial malleolus, have uneven, shallow edges, mild pain, with signs of stasis dermatitis & venous ooze

Arterial ulcers are over a bony prominence (tibia, toes); have regular, well-defined, deep edges; with signs of trophic changes; severe pain

Front 344

*LE ulcers are overwhelmingly the result of

Back 344

Venous disease

Front 345

*A complete venous duplex exam should include

Back 345

Venous compression & Doppler evaluation

Front 346

*The subclavian vein is evaluated from the _____ approach to outer border of the first rib

Back 346

Supraclavicular

Front 347

**What is the most important criterion in identification of deep veins?

Back 347

Adjacent artery

Front 348

**What is preferred method of evaluating vein wall compressibility?

Back 348

Gentle pressure w/ probe, vessel in trv view wo color flow

Front 349

**What are the four main venous blood flow characteristics of LEs?

Back 349

Spontaneity

Phasicity

Augmentation w/ distal compression

Augmentation during proximal release

Front 350

**When is pulsatile venous flow evident?

Back 350

Primarily in pts w/ fluid overload such as CHF

Front 351

**Subclavian venous signals are more

Back 351

Pulsatile

Front 352

**How does the UE signal differ from LE signal?

Back 352

In UE, more limited vessel compressibility, phasicity increases w/ inspiration, and decreases w/ expiration

Front 353

**In LE, phasic venous sound ____ with expiration & decreases w/ inspiration

Back 353

Increases

Front 354

**Augmentation w/ distal compression ____ in the UE veins

Back 354

may not be evident

Front 355

**Normally flow should ______ following Valsalva maneuver

Back 355

Augment

Front 356

**Decreased augmentation following Valsalva indicates

Back 356

Obstruction

Front 357

**What are the characteristics of acute DVT?

Back 357

Dilated vessel

Low echogenicity

Spongy texture

Poor attachment to wall

Lack of collateralization or recanalization

Front 358

*What is least likely to be associated with acute DVT?

Back 358

Probably venous reflux as it is a sequela to acute DVT

Front 359

**What is consistent w/ a proximal iliac obstruction?

Back 359

Diminished velocities

Compressible femoral vein w/ evidence of rouleau formation

Poor augmentaton at CFV w/ release of Valsalva

Front 360

*A pt presents w/ a right swollen extremity, Duplex imaging demonstrates patency of femoral, popliteal, & calf veins. However, Doppler at CFV level on the right is continuous, not changing w/ respiration, while Doppler of left CFV is phasic. These findings might suggest

Back 360

Proximal obstruction: right iliac thrombosis

Front 361

*A ______ color PRF setting is necessary to accommodate slower flow in LE veins

Back 361

lower

Front 362

*Most often, the settings for venous color flow imaging of LEs are ____ those for abdominal venous scanning

Back 362

different from

Front 363

*If there is no color filling of a vein, what must be considered?

Back 363

DVT

Poor angle of insonation

Highpass filter set too high

Front 364

*What is a contraindication to this study?

Back 364

cardiac arrhythmias

Front 365

**What are some limitations to CW evaluation?

Back 365

Difficult to differentiate thrombosis from extrinsic compression (obesity, pt positioning)

Normal flow patterns may be evident w/ partial or well-collateralized thrombosis

Presence of bifed system

Difficult to diagnose calf vein DVT due to presence of paired veins

Severe PAD

Potentiality of false positives

Must be performed by extremely experienced tech

Front 366

*How can tech diminish extrinsic compression?

Back 366

By having pt lay on left side to reduce compression of IVC

Front 367

*In a CW venous Doppler exam, which flow characteristic is least important?

Back 367

Non-pulsatility as pulsatility is related to CHF, not venous disease

Front 368

**How can there be false positives?

Back 368

Extrinsic compression

Pain or anxiety causing muscle contraction

PAD causing decreased venous filling

COPD can elevate central venous pressure

Operator error

Front 369

**How can there be false negatives?

Back 369

Partial thrombosis

Chronic occlusion w/ large collaterals

Presence of bifed system

Front 370

**How long does venous reflux last to be called true venous reflux?

Back 370

Longer than 1 second

Front 371

*The examiner uses color flow to assess for competence at CFV level. With Valsalva maneuver, there is red flow lasting approximately half a second, then blue flow on release of Valsalva

Back 371

This finding is equivocal for significant valvular incompetence as most labs use 1 second rule

Front 372

*Augmentation or flow reversal during Valsalva indicates

Back 372

Reflux secondary to valvular incompetence

Front 373

*In sagittal view, color Doppler shows GSV as blue. During a Valsalva maneuver, the vessel is filled with red. What does this signify?

Back 373

Valvular incompetence

Front 374

*In fact, what is contraindication for PPG study?

Back 374

A pt w/ DVT

Front 375

*What are some limitations to PPG study?

Back 375

Placement of PPG over varicose vein

Thick skin may reduce infrared light penetration

Skin must be intact

Obesity

Front 376

**Light is transmitted/emitted from a

Back 376

Light emitting diode

Front 377

**The backscattered infrared light is received by adjacent

Back 377

Photodetector/photo-sensor/photocell

Front 378

*What is the sensor?

Back 378

The infrared light

Front 379

*Blood ____ light in proportion to its content in tissue

Back 379

Attenuates

Front 380

*A light is emitted & reflected back. Is it absorbed?

Back 380

No

Front 381

*What does the photocell do?

Back 381

Measures the reflection of light qualitatively

Front 382

**What is DC coupling?

Back 382

An electrical voltage that is either positive or negative with current flowing in only one direction to permit slower changes in the blood content to be evaluated in venous studies

Front 383

*Car and flashlight batteries are

Back 383

DC

Front 384

**A short venous refilling time (VRT of 20 seconds) detected by PPG results most commonly from

Back 384

Venous reflux

Front 385

**How is superficial venous insufficiency diagnosed?

Back 385

VRT < 20 seconds w/o tourniquet, & > 20 seconds w/ tourniquet above the knee

Front 386

*What are examples of artifact?

Back 386

Pt mvement

Absent/irregular tracings from system from being on AC

Off-the-scale-deflections that require changes in gain

Front 387

**What is the other test for reflux?

Back 387

Air plethysmorgraph (APG)

Trendelenburg test

Pneumoplethysmography

Front 388

** _____ are usually evident superimposed on the tracing of venous flow

Back 388

Tiny arterial pulsations

Front 389

*What are the physical principles/key technology of APG?

Back 389

Pneumatic cuff is connected to a pressure transducer monitoring cuff pressure over a limb; volume changes amplified & converted to analog

Front 390

*Why are the tip-toe maneuvers performed?

Back 390

To document a decrease in calf venous volume (VV), calculated as the ejection volume (EV) and the venous filling time (VFT)

Front 391

**How is the APG study interpreted?

Back 391

Venous filling index (VFI) = 90% VV/VFT x 90

< or = 2.0 is normal

> or = 10.0 is severe reflux

Front 392

*What is residual fraction volume (RFV)?

Back 392

Ambulatory venous pressure in mmHg

Front 393

*Insufficient veins have the following flow characteristics:

Back 393

Caudal flow may be abnormal while the pt is quietly standing

Venous pressure at ankle in the supine pt does not differ from that of nml limbs

Venous pressure at the ankle in the walking pt is markedly increased compared to that of nml limbs

Front 394

*With exercise in pts w/ post-phlebetic syndrome

Back 394

they have a prolonged return to pre-exercise pressure

Front 395

**(Contrast) venography is still considered to be the ___ for DVT

Back 395

Gold standard

Front 396

*What is ascending venography?

Back 396

Evaluate acute & chronic DVT

Congenital venous disease &/or anomalies

Front 397

**What is descending venography

Back 397

To detect & quantify reversed flow from incompetent valves

Front 398

*Where is the contrast injected for descending venography

Back 398

CFV

Front 399

**What are the advantages of isotope venography w/ I-labeled fibrinogen?

Back 399

Can simultaneously evaluate the pulmonary and peripheral veins

Is highly sensitive to active thrombus

Is extremely accurate in detecting an isolated calf clot

Front 400

*What are some lifestyle modifications to prevent venous disease?

Back 400

Control risk factors related to Virchow's triad:

Decrease venous stasis

Prevent injury/infection

Be aware of hyperocoagulability states/factors

Front 401

*Low dose heparin is administered prophylactically to

Back 401

Slow the conversion of prothrombin to thrombin

Increase the effect of antithrombin III

Decrease platelet adhesiveness to interfere w/ clot

Front 402

*Is low-dose heparin antilytic?

Back 402

No

Front 403

**What does the heparin do?

Back 403

Decrease clot propagation by increasing activated PTT (Partial thromboplastin time)

Front 404

**How is the IV dose regulated?

Back 404

So that the PTT is 1.5 - 2 times normal

Front 405

**Heparin can cause

Back 405

Thrombocytopenia

Formation of platelet antibody

Intraabdominal bleeding

Platelet aggregation

Front 406

**Nearing the end of heparinization, Coumadin (sodium Warfarin) is started for how long?

Back 406

3 to 6 months

Front 407

*What are some vena caval filters called?

Back 407

Greenfield umbrella filter

Bird's nest filter

Nitinol filter

Vena Tech filter

Front 408

*When is a filter used?

Back 408

In those pts at risk for PE and who cannot be anticoagulated

Front 409

**When is ilio-femoral thrombectomy performed?

Back 409

In a pt w/ impending limb loss (phlegmasia cerulean dolens) when urokinase & streptokinase do not work

Front 410

*What is performed for chronic venous insufficiency?

Back 410

Ligation of perforators

Front 411

**What artery becomes axillary artery?

Back 411

Subclavian Artery

Front 412

*How many branches of axillary artery are there before becoming the brachial artery?

Back 412

Seven

Front 413

**The radial artery gives off what branch in the hand?

Back 413

Superficial palmar branch

Front 414

*The radial artery terminates into what artery?

Back 414

Deep palmar arch (by joining deep branch of ulnar artery)

Front 415

**The ulnar artery terminates into what artery?

Back 415

Superficial palmar arch

Front 416

*What is another name for palmar?

Back 416

Volar

Front 417

**The ________ passes under inguinal ligament to become CFA

Back 417

EIA

Front 418

**The SFA passes through what opening?

Back 418

In the tendon of adductor hiatus (adductor canal, Hunter's canal)

Front 419

*What does the popliteal artery give off which can act as collaterals?

Back 419

Genicular branches

Front 420

*What is the first branch of distal popliteal artery?

Back 420

ATA

Front 421

**This artery passes forward above interosseous membrane and distally comes to lie deep on the front of tibia

Back 421

ATA

Front 422

**The short tibio-peroneal trunk divides into what two vessels?

Back 422

Posterior Tibial Artery & Peroneal Artery

Front 423

*What is the largest branch of PTA?

Back 423

Peroneal Artery

Front 424

**The PTA divides into what two vessels below the medial malleolus

Back 424

The medial & lateral plantar arteries

Front 425

**The _______ artery is medial to the fibula

Back 425

Peroneal

Front 426

**The ATA becomes what vessel?

Back 426

The dorsalis pedis artery (DPA)

Front 427

**What is an important branch of DPA?

Back 427

Deep plantar artery

Front 428

**What does the plantar arch consist of?

Back 428

The deep plantar artery which unites w/ lateral plantar artery

Front 429

*What are the smallest vessels in body, the vessels of microcirculation?

Back 429

The capillaries

Front 430

*What is the diameter of a capillary?

Back 430

8-10 microns, about the same as RBC

Front 431

*What are the capillary walls made of?

Back 431

One-cell thick endothelial cells

Front 432

*Capillaries lose fluid through the ______ end and reabsorb fluid through the _______ end

Back 432

Arteriolar, Venular

Front 433

*What is not a risk factor?

Back 433

Hypolipidemia

Front 434

*Why is diabetes important as a risk factor?

Back 434

Increase in atherosclerosis at a younger age, higher incidence of disease in distal popliteal & tibial arteries, medial calcification in LE arteries, higher incidence of gangrenous changes & amputations, neuropathy leading to increased injury

Front 435

*In the presence of arterial obstructive disease & digital ischemia

Back 435

Vasodilatation increases & distal resistance decreases

Front 436

*The most common source of upper or lower extremity peripheral arterial embolus is

Back 436

the heart

Front 437

*What produces "blue toe syndrome"

Back 437

Ulcerated &/or atherosclerotic lesions, embolization, arteritis (which can lead to thrombosis), & some angiographic procedures

Front 438

*What happens w/ blue toe syndrome?

Back 438

The embolic material lodges in digital artery & results in toe ischemia

Front 439

**Where is the most common site of an aneurysm?

Back 439

Infrarenal aorta, then thoracic aorta, femoral, popliteal, & renal arteries

Front 440

**What causes aneurysms?

Back 440

Unknown, may be congenital (#1 reason), atherosclerosis (degenerative), poor arterial nutrition, infection/inflammation (syphillis), or trauma

Front 441

*What is a fusiform aneurysm?

Back 441

Diffuse, circumferential dilatation of arterial segment

Front 442

*What is saccular aneurysm?

Back 442

Localized out-pouching of artery, resulting from wall thinning & stretching

Front 443

**What is dissecting aneurysm?

Back 443

An aneurysm that occurs when small tear of the inner wall allows blood to form a cavity between two layers most often in thoracic aorta

Front 444

**What is the main complication of aneurysm?

Back 444

Rupture of aorta or distal embolization of peripheral aneurysms

Front 445

*With which type of aneurysm, aortic or peripheral, can thrombosis occur?

Back 445

either one

Front 446

**What is arteritis?

Back 446

Inflammation of arterial wall often resulting in thrombosis & sometimes superficial thrombophlebitis

Front 447

**Where does arteritis occur?

Back 447

Capillaries, arterioles, tibial, & peroneal arteries

Front 448

**What is the most common form of arteritis?

Back 448

Buerger's disease (thromboangitis obliterans) & is associated w/ heavy smoking in med < 40 years old

Front 449

*What are some of the symptoms of thromboangitis obliterans?

Back 449

Bilateral rest pain & ischemic ulcerations

Front 450

*A condition that causes nonatherosclerotic narrowing of brachiocephalic arteries in overwhelmingly female Asian patients is called

Back 450

Takayasu's arteries

Front 451

**What is primary Raynaud's syndrome?

Back 451

Raynaud's disease

Spastic Raynaud's syndrome

It is intermittent digital ischemia due to digital arterial spasm in absence of underlying disease

Front 452

*What is secondary Raynaud's syndrome?

Back 452

Raynaud's phenomenon

Obstructive Raynaud's syndrome

Fixed arterial obstruction w/ normal vasoconstrictive responses of arterioles

Front 453

**What is the most common cause of unilateral claudication in a young male?

Back 453

Popliteal artery entrapment syndrome (PAES)

Front 454

*What are the symptoms of PAES?

Back 454

Symptomatic occlusion or claudication following running, not walking

Front 455

*How can symptoms of PAES be elicited in the lab?

Back 455

Active plantar flexion or passive dorsiflexion of foot causing diminished pulses or altered waveforms

Front 456

**What is claudication?

Back 456

Reproducible pain in muscles occurring during exercise whether origin is vascular or not

Front 457

*What three areas are the most frequent sites of claudication?

Back 457

Buttocks, thighs, calves

Front 458

*What levels of occlusive disease are indicated in true claudication?

Back 458

Aorto-iliac, ilio-femoral, femoro-popliteal

Front 459

**A patient presenting w/ ischemic rest pain complains of

Back 459

Foot or forefoot pain at night when supine, relieved by standing or leg dependency

Front 460

*Where does ischemic rest pain occur?

Back 460

Forefoot, heel, toes but not in calf

Front 461

*When does ischemic rest pain occur?

Back 461

When the limb is not in dependent position, and the pt's blood pressure is decreased

Front 462

**Ischemic ulcers are

Back 462

Very painful & commonly located over the tibia, over the dorsum of foot, &/or toes

Front 463

*What are the 6 symptoms of acute arterial occlusion?

Back 463

Pain

Pallor (paleness)

Pulselessness

Paresthesia (Lack of sensation)

Paralysis

Polar (cold)

Front 464

*Why is an acute arterial occlusion an emergency situation?

Back 464

The abrupt onset does not provide fro the development of collateral channels

Front 465

**What are examples of LE arterial insufficiency skin changes?

Back 465

Changes in color, temperature, lesions; trophic changes (dryness, atrophy, shiny skin loss of hair growth over dorsum of toes & feet, thickening of toenails), capillary filling, & elevation/dependency changes

Front 466

**When does cyanosis (blue color due to ischemia) occur?

Back 466

When there is a concentration of deoxygenated hemoglobin

Front 467

*What does rubor suggest?

Back 467

Damaged, dilated vessels, or vessels dilated secondary to reactive hyperemia or infection

Front 468

**Delayed return of capillary blush after pressure on pulp of digit is a sign of ?

Back 468

Decreased arterial perfusion/advanced ischemia

Front 469

*The elevation of the extremity with impaired circulation produces

Back 469

Cadaveric pallor

Front 470

*What is dependent rubor?

Back 470

Lowering the leg causes impaired skin to change from pallid to normal to red discoloration

Front 471

**Why is it when the patient sits up, dependent rubor may occur?

Back 471

Marked increase of blood flow due to collaterals

Front 472

**What extremity artery is NOT palpable/

Back 472

Peroneal

Front 473

*What is a thrill?

Back 473

A palpable bruit

Front 474

**What does a palpable thrill signify?

Back 474

AVF

Post-stenotic turbulence

Patent hemodialysis access graft

Front 475

*Why is there a thrill over a dialysis site?

Back 475

Increased flow volume

Front 476

**What is the Allen test used for?

Back 476

To evaluate the patency of radial artery, ulnar artery, palmar arch

Front 477

What is the limitations of the Allen test?

Back 477

Excessive wrist dorsiflexion or fingers forcibly extended may lead to false positive

Front 478

*How is the Allen test performed?

Back 478

The radial artery is compressed, the hand is clenched then relaxed

Front 479

*What size probe is used for non-invasive testing in both UE & LE?

Back 479

8 - 10 MHz

Front 480

*What are some drawbacks to analog analysis?

Back 480

Signal easily affected by noise, less sensitive than spectral analysis, high velocities underestimated, low velocities overestimated, reverse component may be heard but not seen, uncompensated CHF may result in dampened waveforms, unable to discriminate stenosis from occlusion

Front 481

**Since high velocities are underestimated, analog recordings ______ display amplitudes of all frequencies

Back 481

Do not

Front 482

*The most widely used interpretive technique for analog Doppler waveforms is

Back 482

Qualitative approach or pattern recognition

Front 483

**What are the three types of highly resistant signals?

Back 483

Triphasic

Biphasic

Monophasic

Front 484

*What happens when a waveform goes from triphasic to biphasic?

Back 484

There is no forward flow in diastole

Front 485

**Where might monophasic signals be obtained?

Back 485

Proximal or distal to obstruction

Front 486

*What is autoregulation?

Back 486

The ability of most vascular beds to maintain a constant level of blood flow over wide range of perfusion pressures

Front 487

*In autoregulation, the resistance vessels _____ in response to rise in blood pressure & _______ in response to fall in blood pressure

Back 487

Constrict

Dilate

Front 488

**Flow to a warm (vasodilated) extremity will have _____ signals

Back 488

Continuous, steady

Front 489

*Can a high resistance signal become monophasic proximal to stenosis?

Back 489

Yes, in order for there to be an increase in resistance

Front 490

**How is it possible for a high resistance signal to become monophaisc proximal to stenosis?

Back 490

Vasodilation of distal vessels occur, reducing pulsatility, causing signals to have a low resistance (steady, continuous) flow quality

Front 491

*An analog Doppler waveform of subclavian or axillary artery in normal individual would typically resemble?

Back 491

CFA or SFA waveform

Front 492

*The AV shunts in the skin of fingertips cause flow patterns in the hand to be

Back 492

variable

Front 493

**A dampened Doppler velocity waveform of subclavian artery isolates significant lesion

Back 493

Proximal to point of insonation

Front 494

*Distal to aorto-iliac occlusion, the CFA signal is typically

Back 494

Low-pitched & monophasic

It is distinguished from pulsatile venou signal by having pt perform Valsalva

Front 495

*What set of waveforms is most likely to obtained w/ CW Doppler when there is a long SFA occlusion?

Back 495

Triphasic waveforms at CFA & proximal SFA w/ monophasic waveforms in popliteal & tibial arteries

Front 496

*Monophasic PTA waveforms, despite normal ABI in asymptomatic patient indicate that

Back 496

The high pass filter may be set too high, clipping frequencies near baseline

Front 497

What is the Pulsatility index (PI)?

Back 497

The division of peak to peak frequency by mean frequency

(P1-P2)/mean

Peak systolic to peak end diastolic velocity divided by mean velocity

Peak systole-peak flow reversal/mean

Front 498

*The PI is ______ beam-to-vessel angle

Back 498

independent of

Front 499

*The values of the index ____ from central to peripheral arteries

Back 499

Increase

Ex. CFA > 5.5 & Pop = 8.0

Front 500

**What is the value of acceleration time?

Back 500

Helps to differentiate inflow (aorto-iliac) disease from outflow (SFA) disease

Front 501

*There is _____ prolongation of acceleration time with disease distal to probe

Back 501

No

Front 502

**What are some end-point detectors used to obtain pressure readings?

Back 502

Doppler instrument

Photocell (PPG)

APG

Strain-gauge plethysmography

Stethoscope

Pneumatic cuff

Front 503

**How is the ABI calculated?

Back 503

Divide the ankle pressure by the higher of the two brachial pressures

Front 504

**What is the ABI range for asymptomatic minimal arterial disease?

Back 504

.9 - 1.0

Front 505

**What is the range for claudication, moderate disease?

Back 505

0.5 - 0.9

Front 506

**What is the range for rest pain, severe arterial disease?

Back 506

< 0.5

Front 507

*An ABI , 0.5 may also suggest?

Back 507

Multi-level disease

Front 508

**What are some limitations of Doppler segmental pressure study?

Back 508

Cannot discriminate between stenosis & occlusion, nor precisely locate the area of obstruction, it is difficult to distinguish CFA from EIA disease, & calcified vessels yield falsely elevated Doppler pressures

Front 509

*What size cuffs are used on upper arms & legs?

Back 509

12 x 40

Front 510

*A _______ difference from one brachial pressure to the other suggests a > 50% diameter reduction of subclavian artery &/or vessel under cuff

Back 510

> 15 - 20 mmHg

Front 511

**What suggests a brachial artery obstruction &/or obstruction in both radial & ulnar arteries, &/or obstruction in a single forearm artery?

Back 511

> 15-20 mmHg difference between upper arm & forearm

Front 512

**The width of the cuffs on the legs should be at least _____ greater than the diameter of the limb

Back 512

20%

Front 513

**Is there a disadvantage to using two high cuffs instead of one?

Back 513

Yes, artifically elevated pressures are obtained

Front 514

**Why is one cuff more accurate?

Back 514

At 19 x 40 cm it is so wide that it satisfies the width-girth relationship

Front 515

*In a non-diseased extremity, listening to popliteal artery w/ Doppler velocity detector & inflating thigh cuff, the observer is measuring pressure in which artery?

Back 515

Superficial femoral artery

Front 516

*The cuffs should be inflated ______ beyond the last audible signal or higher than the highest brachial pressure

Back 516

no more than 20-30 mmHg

Front 517

*What are two diseases that may falsely elevate Doppler pressures?

Back 517

Diabetes & ESRF

Front 518

*Too narrow of a cuff may artifically _____ high thigh pressure

Back 518

elevate

Front 519

**The high thigh pressure is at least _____ greater than the brachial pressure

Back 519

30 mmHg

Front 520

*Which pressures should be at least the same as the brachial pressures?

Back 520

AK & BK

Front 521

**If there is a drop in pressure of ______ between two consecutive levels, that is considered significant obstruction

Back 521

30 mmHg

Front 522

*A horizontal difference of _____ suggests obstructive disease in the leg with lower level

Back 522

20-30 mmHg

Front 523

**_______ is probably the best single vasodilator of resistance within skeletal muscle

Back 523

Exercise

Front 524

*What is the purpose of exercise testing?

Back 524

To help differentiate between true claudication & pseudoclaudication, & to determine presence/absence of collaterals

Front 525

**What are the effects of exercise?

Back 525

Vasodilatation causing decreased peripheral resistance & increasing blood flow

Front 526

*What is the technique for using the treadmill?

Back 526

Pt walks at 10% elevation or less, 1.5 mph for up to 5 min or until symptoms are severe; duration of walking, progression of symptoms are documented, post-exercise ABIs are obtained at immediately then once every two minutes up to 20 min until pre-exercise ABIs are reached

Front 527

**Normally, ABIs ____ post exercise

Back 527

Stay the same or slightly increase

Front 528

**Ankle pressures that drop to low levels immediately & increase back to resting levels between 2 & 6 minutes suggest

Back 528

Single-level disease

Front 529

**Why would a monophasic signal appear normally in an extremity artery after exercise?

Back 529

Exercise causes peripheral dilatation & reduced resistance w/ a continuous signal quality

Front 530

*What is an alternative to exercise if the patient cannot walk, has pulmonary problems or poor cardiac status?

Back 530

Post-occlusive reactive hyperemia (PORH)

Front 531

*Which one is preferable, treadmill or PORH?

Back 531

Treadmill because it produces physiologic stress that reproduces ischemic symptoms

Front 532

*What is a contraindication for PORH?

Back 532

Bypass grafts & stents

Front 533

*What is the technique for PORH?

Back 533

Thigh cuffs are inflated to suprasystolic pressures (20-30 mmHg higher) with pressure maintained for 3-5 minutes, & ankle pressures are recorded

Front 534

*Little or no increase of blood flow velocity in response to PORH would most likely indicate?

Back 534

Significant obstructive disease

Front 535

*What is the difference in immediate results between treadmill testing & PORH?

Back 535

Normal limbs do not show an ankle drop post treadmill, but they do PORH

Front 536

**What is the normal ankle pressure transient decrease?

Back 536

17-34%

Front 537

*Patients with single-level disease present with a ______ drop in ankle pressure

Back 537

34-50%

Front 538

*A normal PORH velocity response is

Back 538

a > 100% increase in mean velocity

Front 539

**________ is an electrical voltage that reverses its polarity (positive or negative voltages) at 60 times a second

Back 539

AC coupling

Front 540

**Why is AC required for arterial studies?

Back 540

Relatively intense flow changes are required to produce a measurable signal

Front 541

*Household receptacles deliver 120 volts of

Back 541

AC

Front 542

**What are three capabilities of plethysmography?

Back 542

Can help differentiate between true arterial claudication & non-vascular claudication, help localize level of obstruction, & it can document the functional aspect of disease

Front 543

**What are limitations of plethysmography?

Back 543

It cannot be specific to one vessel nor can it discriminate between major arteries & collaterals, cannot discriminate between stenosis & occlusion. Also, it is difficult to perform on obese patients

Front 544

*Inability to center the stylus may be due to what?

Back 544

Incorrectly selected mode (AC vs DC)

Front 545

*What is another name for volume pulse recording (VPR/PVR)?

Back 545

Air/displacement/volume plethysmography

Front 546

**Momentary volume changes in the limb are converted into _____ within the cuff bladder due to arterial expansion in systole

Back 546

Pulsatile pressure changes

Front 547

**A _______ converts pressure changes into an analog waveform

Back 547

Pressure transducer

Front 548

**The waveform represents how much blood flow is moving via ____ pulsatile vessel

Back 548

every sized

Front 549

*The usual cuff pressure in arterial volume recording is

Back 549

65 mmHg

Front 550

**Qualitative criteria for a normal VPR & PPG waveform is

Back 550

sharp, swift systolic peak, rapid down stroke w/ a prominent reflected (dicrotic notched) wave halfway down

Front 551

*What will often eliminate the dicrotic notch?

Back 551

Vasodilatation

Front 552

*What is VPR artifact typically due to?

Back 552

Improper cuff application (too tight & can diminish/obliterate waveforms)

Front 553

*PVR's demonstrate a lack of dicrotic notch in the recordings at the thigh, decreased pulses at the upper calf, & flat tracings at the ankle. The most likely interpretation of this study is

Back 553

mid ilio-femoral stenosis, severe SFA stenosis/occlusion, & severe infra popliteal disease

Front 554

*The most often used application of PPG is for

Back 554

Evaluation of digits & penile pressures

Front 555

*What can PPG test do?

Back 555

Differentiate fixed arterial obstruction from vasospasm

Front 556

*How is the patient placed for finger evaluation?

Back 556

Sitting with arms resting on a pillow in patient's lap

Front 557

*The width of the cuff should be at least ______ that of digit

Back 557

1.2 times

Front 558

**What size cuff is used for the fingers?

Back 558

2 - 2.5 cm

Front 559

*What size cuff is used for the great toe?

Back 559

2.5 - 3 cm

Front 560

**How high is the cuff inflated?

Back 560

20-30 mmHg above the ankle pressure

Front 561

*What is the paper speed?

Back 561

5 mm/s

Front 562

*Where is peak systole seen?

Back 562

At first significant pulse

Front 563

*What do the rapid fluctuations on plethysmography tracing represent?

Back 563

"Cyclic flow"

Front 564

*What does the upstroke rise on a plethysmography tracing represent?

Back 564

Increase in blood volume secondary to obstruction from venous outflow

Front 565

*Abnormal waveforms always reflect hemodynamically significant disease ____ to the level of tracing

Back 565

Proximal

Front 566

*Reduced amplitude with no changes in the contour is likely to reflect insignificant disease, unless it is

Back 566

unilateral

Front 567

**A mildly abnormal wave has an absent reflected wave (dicrotic notch), & the downslope is bowed away

Back 567

from the baseline

Front 568

**Under what circumstance is there a fair (mildly abnormal) waveform quality but abnormal Doppler pressure?

Back 568

In the presence of collaterals there is a high amplitude signal but no dicrotic notch

Front 569

**A moderately abnormal wave

Back 569

has a flattened systolic peak, upslope & downslope is more delayed, and reflected wave is absent reflecting hemodynamically significant disease

Front 570

**A severely abnormal wave

Back 570

has a low amplitude or is absent

Front 571

**Normally, the UE digits have finger/brachial indices of about

Back 571

0.8-0.9

Front 572

**Normal toe/ankle indices (TAIs) vary from _____ of the ankle pressure

Back 572

60-80%

Front 573

*How do you document the presence/absence of intermittent digital ischemia in response to cold exposure?

Back 573

Perform the resting study, immerse the hands in ice cold water for three minutes, dry the hands, obtain waveforms & pressures immediately & five minutes later

Front 574

**What is the difference between organic (obstructive/fixed) occlusive findings & functional (intermittent) obstructive findings?

Back 574

Organic disease has abnormal Doppler signals, systolic pressures, & PPG tracings. Functional disease has normal Doppler signals, etc but abnormal findings after cold stress test

Front 575

**What is the difference between abnormal obstructive waveform quality & abnormal peaked waveform quality?

Back 575

Both have slow upstrokes, but after cold stimulation the peaked waveform of Raynaud's phenomenon has a sharp anacrotic notch, & the reflected wave is located high as a vasospastic process

Front 576

*Patients with true vasospasm may have a contour that is normal in quality but decreased in

Back 576

amplitude

Front 577

**If you suspect a 50% diameter reduction (75% area reduction), what do you obtain?

Back 577

Pre stenotic PSV, PSV within stenosis, post-stenotic signals

Front 578

*If PSV increases by a 2:1 ratio in any artery, what does this mean?

Back 578

> or = 50% stenosis

Front 579

*How common is UE aneurysm?

Back 579

not common

Front 580

*______ aneurysms often are associated with embolization to digits

Back 580

Subclavian

Front 581

**What are two types of non-synthetic grafts?

Back 581

Reversed saphenous vein graft (RSVG), in situ GSV graft

Front 582

**What are two types of synthetic grafts?

Back 582

Gore-Tex (PTFE), Dacron

Front 583

*What must be done to the GSV prior to use as an in situ graft?

Back 583

Valves are broken up with a valvulatome & branches are ligated

Front 584

*The UE vein most commonly used as a bypass in the leg is?

Back 584

Cephalic vein

Front 585

*For a bypass graft to be successful, what is necessary

Back 585

Good inflow, good conduit, good outflow

Front 586

**Why are anastomosis sites crucial?

Back 586

This is where aneurysms & stenosis occur

Front 587

*The velocities measured in an RSVG are usually

Back 587

Higher proximally in the smaller diameter portion & lower distally

Front 588

**What happens to flow velocity at the large venous end of an RSVG?

Back 588

The large end is anastomosed at the distal artery, and flow velocity is decreased

Front 589

**Is PSV of 45 cm/s anbnormal in the large diameter segmet?

Back 589

Not necessarily

Front 590

**What are other graft complications?

Back 590

CHF caused by increased venous return due to high pressure gradient, a steal syndrome in which distal arterial blood flow is reversed into venous system

Front 591

**What are some abnormal findings in a vein bypass graft?

Back 591

A decrease of 30 cm/s in any graft segment, a change from triphasic to biphasic waveforms, a decrease in ABIs > 0.15, reduced PSVs in the smallest graft diameter to < 45 cm/s, AVF, valve cusp left intact

Front 592

*What is retrograde flow in the native artery evident of?

Back 592

Distal anastomosis of an RSVG

Front 593

**The stenotic & prestenotic PSVs are compared. What would suggest a 50% diameter reduction?

Back 593

A > 100% increase (2:1 ratio) and/or between 200 & 400 cm/s

Front 594

**What would suggest a 75% diameter reduction?

Back 594

4:1 ratio &/or > 400 cm/s PSV

Front 595

**What is Transcutaneous oximetry (TcpO2) used for?

Back 595

Wound healing, amputation level determination, skin graft viability, foot perfusion, healing of a stump

Front 596

*What is Tcp02?

Back 596

Reflects tissue oxygen tension & relies on balance between O2 supply & consumption

Front 597

**What is normal pO2 in mmHg?

Back 597

60-80 mmHg

Front 598

*What is borderline pO2?

Back 598

30-40 mmHg & healing should still occur

Front 599

*What is non-healing pO2?

Back 599

10-15 mmHg

Front 600

*The most effective lytic treatment for acute arterial thrombosis is

Back 600

Urokinase or streptokinase

Front 601

*What is angioplasty?

Back 601

Percutaneous transluminal angioplasty (PTLA, PTA) is used to dilate a precise region of focal plaque in a large vessel (illiac, femoral, popliteal, renal)