Vascular Technology Review

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

What vessels do NOT arise from subclavian artery?

Back 6

Those that arise from ECA like Superior Thyroid

Front 7

What is the anterior circulation?

Back 7

ICA

ECA

Branches of ECA

Front 8

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

Back 8

Thyroid cartilage which forms the prominence of larynx

Front 9

What does ICA supply?

Back 9

Anterior portion of brain, eyes, forehead, and nose

Front 10

ICA carries how much of CCA blood?

Back 10

90%

Front 11

*Extracranial ICA has ____ branches

Back 11

0/no

Front 12

What is carotid siphon?

Back 12

S-curve of ICA

Front 13

*Which is larger, ICA or ECA?

Back 13

ICA

Front 14

What does ECA supply?

Back 14

Neck, face, Scalp

Front 15

ECA has ____ branches

Back 15

8

Front 16

**1st branch of ECA is _______ artery

Back 16

Superior Thyroid

Front 17

**8 Branches of ECA

Back 17

Superior Thyroid

Ascending pharyngeal

Lingual

Facial (Angular)

Occipital

Posterior Auricular

Maxillary (infraorbital)

Superficial Temporal (STA)

Front 18

Mnemonic for 8 Branches of ECA

Back 18

SUsan ASked LINus For OCtavia's Phone Message Service

Some Aggressive Lovers Find Odd Positions More Stimulating

Front 19

*Angular artery is terminal part of

Back 19

Facial artery

Front 20

*Infraorbital artery is terminal branch of

Back 20

Maxillary artery

Front 21

Arterial pulsations felt in front of ear & just above zygomatic arch are from which artery?

Back 21

STA (Superficial Temporal Artery)

Front 22

*What does carotid sinus contain?

Back 22

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 23

What is the posterior circulation?

Back 23

Vertebrals & Basilar Artery

Front 24

The vertebrals pass through the ____ of cervical vertebrae

Back 24

Transverse foramina

Front 25

Right & Left Vertebrals unite for form ____ artery

Back 25

Basilar

Front 26

**Largest of Intra-arterial connections is?

Back 26

Circle of Willis

Front 27

The Circle receives its blood supply from which combination of connecting arteries to provide collateral pathways?

Back 27

Carotid (anterior system) & Vertebral (posterior system)

Front 28

The carotid & vertebral arteries are connected through?

Back 28

Anterior & Posterior Communicating Arteries

Front 29

The Circle also connects the?

Back 29

Right & Left Hemispheres

Front 30

**What is the Circle of Willis?

Back 30

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 31

**First branch of ICA

Back 31

Ophthalmic artery

Front 32

**Second & Third ICA branches

Back 32

Anterior Choroidal

Posterior Communicating Arteries

Front 33

**What are the two terminal arteires of ICA?

Back 33

MCA

ACA

Front 34

Mnemonic for 5 branches of ICA

Back 34

OPportunities Are Probably MIles Away

Front 35

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

Back 35

3 branches of ophthalmic artery:

Supraorbital

Frontal

Nasal arteries

Front 36

**Describe Periorbital Circulation

Back 36

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 37

What three pathways does the Circle of Willis provide

Back 37

External to internal collateralization via ophthalmic artery, crossover collateralization via ACA, posterior to anterior collateralization via posterior communicating artery

Front 38

*What are some intracranial-extracranial anastomoses?

Back 38

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 39

What are some small intra-arterial communications?

Back 39

Transdural anastomoses & leptomeningeal collaterals that form meningeal border-zone network

Front 40

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

Back 40

Absence or hypoplasia of one or both of communicating arteries

Front 41

**Why is the MCA not a collateral pathway?

Back 41

It is terminal artery

Front 42

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

Back 42

It not an intracranial artery

Front 43

What are the three coats of arteries?

Back 43

Tunica intima

Tunica media

Tunica adventitia

Front 44

What may the coats be separated by?

Back 44

Internal & External elastic membranes

Front 45

**What is the tunica intima?

Back 45

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

Front 46

What is the tunica media?

Back 46

Thick, circularly arranged smooth muscle & elastic connective tissue

Front 47

**What is tunica externa/adeventitia?

Back 47

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

Front 48

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

Back 48

Vaso vasorum located in adventitial layer

Front 49

*What happens in cardiac contraction?

Back 49

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

Front 50

Every heart beat pumps about ____ liters of blood into aorta causing a blood pressure pulse

Back 50

.07

Front 51

**The heart pump represents what kind of energy?

Back 51

Potential (pressure) energy measure in mmHg

Front 52

What governs amount of blood that enters arterial reservoir?

Back 52

Cardiac output

Front 53

Heart pump generates pressure to move blood resulting in

Back 53

Pressure (energy) wave

Front 54

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

Back 54

Greatest in heart & gradually decreases

Front 55

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

Back 55

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

Front 56

There is a _____ pressure gradient between the arteries and the veins

Back 56

High

Front 57

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

Back 57

Distended arteries

Front 58

What is responsible for continuation of flow during diastole?

Back 58

The blood volume & energy in distended arteries

Front 59

**The total energy is the sum of

Back 59

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

Front 60

Kinetic energy is expressed in terms of

Back 60

Fluid density & velocity

Front 61

HP (Hydrostatic Pressure)

Back 61

Specific gravity of blood X gravitational acceleration X distance from heart

Front 62

When supine, HP is ____ at heart level

Back 62

zero

Front 63

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

Back 63

Negligible (0 mmHg)

Front 64

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

Back 64

15 mmHg (negligible)

Front 65

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

Back 65

95 mmHg

Front 66

When standing, anything above heart is measured at ___ mmHg

Back 66

zero

Front 67

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

Back 67

100 to 102 mmHg

Front 68

When standing, ankle pressure =

Back 68

Circulatory pressure + 100 to 102 mmHg

Front 69

How is energy continually restored?

Back 69

Pumping action of the heart

Front 70

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

Back 70

Higher/great

Front 71

The greater the energy losses, the ____ the flow

Back 71

Lower

Front 72

Poiseuille's law describes flow as being ____ or parabolic

Back 72

Laminary/stable

Front 73

**What is Poiseuille's equation?

Back 73

Pressure = flow X resistance

Front 74

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

Back 74

Pathway & pressure/energy difference (gradient)

Front 75

If there is no change in pressure, there is _____ change in flow

Back 75

no

Front 76

*Flow is ____ proportional to pressure

Back 76

Directly

Front 77

*Flow is ______ proportional to resistance

Back 77

Inversely

Front 78

*High rsistance = ________ flow rate

Back 78

Low

Front 79

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

Back 79

Higher

Front 80

**What factors affect resistance to flow?

Back 80

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

Front 81

Flow =

Back 81

Differences in pressure x pi x r^4/8 x n x L

Front 82

Peripheral resistance increases w/

Back 82

Smaller diameter

Greater length

Higher blood viscosity

Front 83

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

Back 83

Vessel diameter/radius

Front 84

*Flow is ____ proportional to radius

Back 84

Directly

Front 85

Small changes in the radius result in ___ changes in flow

Back 85

Large

Front 86

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

Back 86

Higher

Front 87

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

Back 87

Inversely

Front 88

A ____ flow profile is common for smaller vessels

Back 88

Parabolic

Front 89

A profile approximating _____ flow is characteristic for larger vessels

Back 89

Plug

Front 90

Where does steady flow occur?

Back 90

Where there is steady driving pressure

Front 91

**What are the two forms of energy loss?

Back 91

Viscous

Inertial

Front 92

*In a rigid tube, energy losses are mainly

Back 92

Viscous

Front 93

*What is viscous energy loss due to?

Back 93

Increased friction between molecules and laminar layers

Front 94

*Internal friction is measured by its

Back 94

Viscosity (thickness of a fluid)

Front 95

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

Back 95

Viscosity

Front 96

*An elevated hematocrit increases

Back 96

viscosity

Front 97

**What is inertia?

Back 97

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

Front 98

**What are inertial losses due to?

Back 98

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

Front 99

Blood must change ___ as the flow stream narrows

Back 99

direction

Front 100

Diminishing vessel size ___ frictional forces & heat losses

Back 100

Increases

Front 101

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

Back 101

Inertial

Front 102

What word is actually better than "stenosis"?

Back 102

Obstruction

Front 103

Is nonlaminar flow abnormal?

Back 103

No

Front 104

What does Q = P/R mean?

Back 104

Flow = Pressure/Resistance

Front 105

Flow : Current as Pressure : ?

Back 105

Voltage

Front 106

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

Back 106

Decreases in order to equate the total energy amount

Front 107

*Velocity is ____ to pressure

Back 107

Inversely proportional

Front 108

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

Back 108

Higher

Front 109

*Laminar flow has an ____ distribution of frequencies at systole

Back 109

Even

Front 110

The ___ layer has lower frequencies distributed at the walls

Back 110

Boundary

Front 111

*Pressure gradients can be described as flow

Back 111

Separations

Front 112

Flow separations are regions of ____ movement

Back 112

Little

Front 113

**Where do flow separations in vessel occur?

Back 113

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

Front 114

Helical flow w/ flow separation in posterolateral aspect of disease-free carotid bulb is a sign of

Back 114

Normal Flow Dynamics

Front 115

Why does flow separation occur?

Back 115

Beacuse linear momentum of flow is distrupted by large sinus & sharp curve at bulb

Front 116

*What nonsteady conditions affect fluid behavior?

Back 116

Fluid acceleration, deceleration, & rest

Front 117

**______ results because velocity & area are inversely proportional

Back 117

Acceleration

Front 118

Acceleration causes increased

Back 118

Energy losses

Front 119

*Flow accelerates ___ a stenosis

Back 119

through

Front 120

*Flow decelerates ____ to a stenosis

Back 120

distal

Front 121

*Laminar flow ____ downstream from a stenosis

Back 121

resumes

Front 122

Describe Pulsatile Flow

Back 122

During systole there is fluid acceleration

During diastole there is temporary flow reversal

During late diastole there is flow forward again

Front 123

Why is there a temporary flow reversal during diastole?

Back 123

Negative phase-shifted pressure gradient & peripheral resistance causing proximal reflection of wave

Front 124

*DIastolic reversal of flow is most likely in

Back 124

Extremity arteries at rest

Front 125

Why is flow forward again during late diastole?

Back 125

Reverse reflective wave hits proximal resistance of next oncoming wave

Front 126

Diastolic flow reversal is present in vessels that apply ___ peripheral resistance vascular beds

Back 126

high

Front 127

*How do arterioles assist w/ regulating blood flow?

Back 127

Contraction (constriction) & relaxation (dilation)

Front 128

*Flow reversal increases with

Back 128

Vasoconstriction

Front 129

**What happens during vasoconstriction?

Back 129

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

Front 130

What happens during vasodilatation?

Back 130

Opposite of vasoconstriction

Front 131

*Diastolic flow reversal may be ___ in vasodilated limbs

Back 131

Absent

Front 132

**Describe low resistance flow

Back 132

Continuous (steady) nature feeding a vasodilated vascular bed

Front 133

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

Back 133

ICA

Vertebral

Celiac

Post-prandial SMA

Renal

Splenic

Hepatic

Front 134

Describe high resistance flow

Back 134

Pulsatile flow w/ flow reversals & no flow in diastole

Front 135

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

Back 135

ECA

Subclavian

Aorta

Fasting SMA

Iliac

Extremity arteries

Front 136

*When can a high resistance signal occur?

Back 136

Vasoconstriction at arteriolar level or from distal arterial obstruction

Front 137

**What cannot cause vasodilatation of high resistance bed?

Back 137

Hyperventilation

Front 138

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

Back 138

Decreased peripheral resistance secondary to ischemia

Front 139

Proximal & Distal pulsatility changes ____ precisely differentiate between severe stenosis & occlusion

Back 139

do not

Front 140

*How may arterial obstruction alter flow in collateral channels?

Back 140

Increased flow

Reversed flow direction

Increased velocity

Waveform pulsatility changes

Front 141

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

Back 141

Collateral network & decrease in peripheral resistance

Front 142

If good collaterization is present, prox or distal waveform qualities ____ be altered

Back 142

may not

Front 143

What are mechanisms of cerebrovascular disease?

Back 143

Stenosis

Embolization

Thrombosis

Fribromuscular dysplasia

Carotid body tumor

Trauma

Neointimal hyperplasia

Front 144

What are some risk factors for arterial disease?

Back 144

DM

HTN

HLD

Smoking

Increased age

Family Hx

Male gender

Front 145

**What is most controllable risk factor?

Back 145

Smoking

Front 146

**What does smoking cause?

Back 146

Irritation of endothelial lining

Vasoconstriction

Front 147

*Where is HTN important?

Back 147

Increased incidence of coronary atherosclerosis

Front 148

What is frequent cause of HLD?

Back 148

Diet high in animal fat & heredity that may cause metabolic problems

Front 149

What are some uncontrollable risk factors?

Back 149

Age

Family Hx

Male gender

Front 150

*What is the most common arterial pathology?

Back 150

Atherosclerosis

Front 151

**What is atherosclerosis?

Back 151

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 152

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

Back 152

Smoking

HLD

Family Hx

Front 153

**What are two less important factors?

Back 153

HTN

DM

Front 154

What may be the least risk factor?

Back 154

Premenopausal female

Front 155

**What are the most common sites for atherosclerosis?

Back 155

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 156

What does atherosclerosis rarely cause?

Back 156

Carotid aneurysm

Front 157

Aneurysm is ___ seen in carotid arteries

Back 157

rarely

Front 158

*What is pulsatile mass in neck usually related to?

Back 158

Tortuous common carotid rather than aneurysm

Front 159

What is atherosclerotic plaque?

Back 159

Form of arterosclerosis in which there is accumulation of lipid-containing material (atheroma), smooth muscle cells, collagen, fibrin, & platelets w/in or beneath intima

Front 160

**What are five types of atherosclerotic plaque?

Back 160

Fatty streak

Fibrous plaque

Complicated lesion

Ulcerative lesion

Intra-plaque hemorrhage

Front 161

What is a fatty streak?

Back 161

Thin layer of lipid material on intimal layer

Front 162

What is fibrous plaque?

Back 162

Accumulation of lipids that are covered by more lipid material, collagen, and elastic fibers

Front 163

What is a complicated lesion?

Back 163

Fibrous plaque that includes fibrous tissue, more collagen, calcium, and cellular debris

Front 164

*What is an ulcerative lesion?

Back 164

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

Front 165

How does intraplaque hemorrhage occur?

Back 165

Leakage of blood into plaque through ulceration or by rupture of vaso vasorum

Front 166

What does intraplque hemorrhage look like?

Back 166

Sonolucent area w/in plaque

Front 167

*What is dissection?

Back 167

Non-atherosclerotic lesion that results from sudden tear in intima

Front 168

*What can happen to the collected blood on lumen?

Back 168

It may thrombose

Front 169

What is a thrombus?

Back 169

Structure composed of large amounts of RBC's within a fibrin network (blood clot); clumps of platelets may be evident

Front 170

How is thrombus formation initiated?

Back 170

Erosion of plaque surface w subsequent platelet aggregation

Front 171

*What is an embolism?

Back 171

Obstruction of blood vessel by foreign substance or blood clot

Front 172

*What is an embolism composed of?

Back 172

Solid, liquid, or gas

Front 173

**What is most frequent cause of embolism?

Back 173

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 174

**What is a subclavian (vertebral) steal?

Back 174

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

Front 175

**Subclavian steal is usually a ______ hemodynamic phenomenon

Back 175

Harmless

Front 176

What happens during a subclavian (vertebral) steal?

Back 176

An abnormal pressure gradient pulls blood from vertebral artery to perfuse the arm

Front 177

Why is flow resistance in vertebral artery higher during a subclavian (vertebral) steal?

Back 177

Because it is feeding a high resistance bed

Front 178

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

Back 178

Basilar

Front 179

Why can't axillary artery occlusion cause a subclavian (vertebral) steal?

Back 179

It is far too distal

Front 180

Reversed vertebral flow in systole is not suggestive of?

Back 180

Brachial arterial obstruction

Front 181

*It occurs most commonly on the ____ side

Back 181

Left

Front 182

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

Back 182

Asymptomatic

Front 183

What is subclavian steal syndrome?

Back 183

Dizziness

Vertigo

Ataxia

Bilateral blurred vision

In 1/3 of pts:

Arm claudication

Numbness

Front 184

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

Back 184

> 15-20 mmHg

Front 185

Reversed vertebral flow in systole & antegrade flow in diastole is suggestive of

Back 185

Developing subclavian steal

Front 186

How can it be converted to full steal?

Back 186

Reactive hyperemia or have pt exercise affected arm

Front 187

How is subclavian steal treated?

Back 187

Bypass graft or endarterectomy

Front 188

*What is a carotid body tumor?

Back 188

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

Front 189

What does it look like?

Back 189

Goblet-like configuration of internal & external branches curving around highly vascular mass

Front 190

*How are tumors fed?

Back 190

Usually through ECA

Front 191

Surgical excision of tumor may require

Back 191

Ligation of ICA &/or ECA

Front 192

**What is fibromuscular dysplasia (FMD)?

Back 192

Multiple arterial stenosis caused by medical hyperplasia w/ collagen overgrowth

Front 193

**FMD is usually seen in young

Back 193

women

Front 194

**How is FMD diagnosed?

Back 194

"String of beads"

Maybe post stenotic dilatation

Front 195

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

Back 195

Carotid & renal arteries

Front 196

*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 196

Neointimal hyperplasia

Front 197

**What is neointimal hyperplasia?

Back 197

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

Front 198

What happens in neointimal hyperplasia?

Back 198

Endothelium denuding leads to platelet aggregation, endothelium regeneration, and smooth muscle cells proliferation

Front 199

What are the two types of cerebrovascular disease that involve transient symptoms?

Back 199

TIA

RIND

Front 200

**What is TIA?

Back 200

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

Front 201

What is the etiology of TIA?

Back 201

Cardiac or carotid artery embolism

Front 202

*Stenosis of what vessel presents highest risk for TIA?

Back 202

ICA

Front 203

On ophthalmologic exam, a bright yellow spot is noted w/in branch artery. This is ____ plaque

Back 203

Hollenhorst

Front 204

Patients w/ Hollenhorst plaque have a ______ risk of TIA or stroke over next several years

Back 204

75%

Front 205

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

Back 205

Resolving ischemic neurologic deficit

Front 206

*How long does RIND last?

Back 206

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

Front 207

*What is a stroke/CVA?

Back 207

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

Front 208

**What are the three classifications of CVA?

Back 208

Acute (sudden onset, unstable)

Stroke in evolution (symtpoms come & go, unstable)

Completed stroke (no progression or resolution, stable)

Front 209

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

Back 209

500,000

Front 210

*The strongest risk factor for stroke is

Back 210

HTN

Front 211

*The most prevalent type of stroke is

Back 211

Ischemic (85%)

Front 212

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

Back 212

Cardiac-source embolization

Front 213

Most stroke fatalities are caused by

Back 213

Hemorrhage

Front 214

56-year old patient reports loss of vision in her left eye two days ago, with total resolution in 10 minutes. Yesterday morning she developed weakness and numbness in her right hand and was unable to hold her coffee cup. This afternoon her hand strength is about 90% normal, with normal sensation. Clinically she has

Back 214

Stroke (because she has loss of hand strength more than 24 hours)

Front 215

**The cause of a right hemispheric infarct may be

Back 215

R ICA occlusion

Front 216

A TIA of right hemisphere of brain will likely affect

Back 216

left side of body

Front 217

Left hemispheric CVA results in neurological deficits on the ____ side of the body

Back 217

right

Front 218

What is one symptom of anterior circulation system?

Back 218

Facial asymmetry because it is laterizing, non-global symptom

Front 219

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

Back 219

Aphrasia

Amaurosis fugax (AF)

Unilateral contralateral paresthesia

Anesthesia or paresis

Front 220

What is aphasia?

Back 220

Absence of speech

Front 221

When is aphasia present?

Back 221

When dominant hemisphere is affected

Front 222

**Amaurosis Fugax (AF) can be interpreted as

Back 222

TIA

Front 223

Why can Amaurosis Fugas be interpreted as TIA?

Back 223

Thromboembolic activity from ulcertated ipsilateral carotid atheroma is suspected

Front 224

**What is paresthesia?

Back 224

Pricking/tingling/numb sensation of the skin

Front 225

What is paresis?

Back 225

Loss of sensation

Front 226

**What is hemiparesis?

Back 226

Weakness of one side

Front 227

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

Back 227

Aphasia

Dysphagia

More severe contralateral hemiparesis/hemiplegia

Behavior changes

Front 228

A Hemispheric stroke usually affects

Back 228

MCA distribution and the contralateral side of the body

Front 229

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

Back 229

Dysphasia

Front 230

The patient with the 30 minute episode of garbled speech is right handed. Which area of circulation is suspect?

Back 230

Left hemispheric

The speech area of the cortex is in the temporal lobe of the dominant hemisphere

Front 231

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

Back 231

Homonymous hemaniopia

Front 232

What is homonymous hemaniopia caused by?

Back 232

Obstruction of a MCA branch

Front 233

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

Back 233

More severe leg hemiparesis or hemiplegia

Incontienence

Loss of coordination

Front 234

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

Back 234

Dyslexia

Coma usually w/o paralysis

Front 235

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

Back 235

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 236

What is vertigo?

Back 236

Difficulty in maintaining equilibrium/"room spinning"

Patients have a sense of either moving around or being surrounded by moving objects

Front 237

What is ataxia?

Back 237

Muscular incoordination characterized by inability to control one's gait or other body movements

Front 238

Why do bilateral visual disturbances occur?

Back 238

The visual cortex is in the occipital lobe

Front 239

What is drop attack?

Back 239

Falling to the ground without loss of consciousness

Front 240

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

Back 240

Dizziness

Ectasia

Syncope

Dysphagia (difficulty swallowing)

Front 241

What is syncope?

Back 241

Transient loss of consciousness

Front 242

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

Back 242

Dizziness (with a tendecy to fall)

Syncope

Speech difficulty (alone)

Headache

Front 243

What is a term for the speech difficulty?

Back 243

Dysarthria

Front 244

What does palpation include?

Back 244

Heart

CCA

Superior Thyroid

Subclavian

Axillary Arteries

Front 245

A decreased pulse at mid neck suggests

Back 245

Common carotid stenosis if contralateral pulse is decreased

Front 246

What is "wall noise"?

Back 246

A bruit

Front 247

**Where might a bruit be heard?

Back 247

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

Front 248

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

Back 248

aortic valve stenosis

Front 249

During auscultation of a carotid bifurcation, the detection of a bruit that extends into diastole is

Back 249

Highly significant bc elevated end-diastole velocities suggest severe stenosis

Front 250

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

Back 250

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

Front 251

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

Back 251

Results are influenced by pt's peripheral resistance

Front 252

Doppler US is good at detecting & quantifying the presence, direction, speed, and _____ of blood flow

Back 252

character

Front 253

How does Perorbital Doppler detect lesions of ICA?

Back 253

By evaluating flow to some of its terminal branches around the eye

Front 254

*What are some limitations of periorbital Doppler?

Back 254

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 255

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

Back 255

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 256

What vessels are compressed when evaluating frontal artery?

Back 256

Facial artery (under chin bone)

Superior temporal

Infraorbital artery

Low CCA

Front 257

Why must compression of CCA be done with great care?

Back 257

To prevent stimulation of carotid sinus & resultant alteration in heart rate/rhythm

May also cause decreased cerebral perfusion & distal embolization

Front 258

Compression of these vessels (Facial artery, Superior Thyroid, Infraorbital; not low CCA) should result in ____ of flow

Back 258

No diminution or reversal

Front 259

Ipsilateral compression of low CCA should result in ____ frontal artery flow

Back 259

Diminution

Front 260

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

Back 260

Reversal

Front 261

If left frontal artery flow is obliterated during compression of the ipsilateral Superior Thyroid Artery, what does this mean?

Back 261

The ipsilateral ECA and its branches are serving as external-to-internal collateral pathways via the Occipital Artery

Front 262

If compression of ipsilateral Superficial Thyroid Artery may be a

Back 262

Collateral

Front 263

If compression of the ipsilateral facial artery causes flow dimuntion, the ____ may be the source of collateral flow

Back 263

Nasal artery branch

Front 264

What is OPG-Gee?

Back 264

OcularPneumoplethysmoGraphy that detects hemodynamically significant lesions of ICA by evaluating flow in one of its branches

Front 265

**What are some contraindications to OPG-GEE?

Back 265

Allergies to local anesthetics

Eye surgery within the last six months

Past spontaneous retinal detachment

Acute or unstable glaucoma

Front 266

**What are not contradications of OPG-GEE?

Back 266

Myopia

Conjunctivitis

Front 267

What are the limitations of OPG-GEE?

Back 267

Same as periorbital doppler plus determination of ocular systolic pressure may not be possible in pts w/ severe HTN, nor is it useful for documenting disease progression

Front 268

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

Back 268

False

Front 269

What does OPG-GEE technique include?

Back 269

Bilateral brachial pressures

EKG leads

Local anestheic applied to eyes

Front 270

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

Back 270

10 mm above & below the baseline

Front 271

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

Back 271

recaliberate

Front 272

Why is caliberation critical with OPG-GEE?

Back 272

Signifcant reduction in size of tracing reflects signficant reduction in blood volume

Front 273

What is the paper speed for OPG-GEE?

Back 273

5 mm/sec

Front 274

What is physiologic basis for OPG-GEE?

Back 274

Ophthalmic systolic pressure (OSP) is measured by applying a vacuum to the eye. As the vacuum distorts the shape of the globe, the intraocular pressure increases, thereby obliterating opthalmic artery inflow. As the vacuum is decreased, the changes in pressure are documents. When the opthalmic artery pressure exceeds the intraocular pressure, a pulse waveform appears.

Front 275

A reduction in the size of tracing represents a ____ in blood volume

Back 275

Significant loss

Front 276

Eye cups are placed on the sclera and not on the ____

Back 276

Corneas

Front 277

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

Back 277

300 mmHg vacuum pressure

Front 278

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

Back 278

Max vacuum of 500 mmHg

Front 279

The pulsed wave form appears when the ___ pressure exceeds the intra-ocular pressure

Back 279

Ophthalmic

Front 280

*Pressure in the ophthalmic artery reflects pressure in the

Back 280

distal ICA

Front 281

What technique is repeated upon removal of the eye cups?

Back 281

Brachial pressure on the higher side

Front 282

How are eyes pulses distinguished from blinking?

Back 282

The eye pulse should coincide w T wave on EKG

Front 283

**Ophthalmic systolic pressures should not differ by more than

Back 283

5 mmHg

Front 284

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

Back 284

OSP-39/BSP >= .430

Front 285

**What is abnormal OPG-Gee?

Back 285

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

Front 286

If either OSP > 140 mmHg, the difference in amplitude of the two tracings should be less than?

Back 286

2 mm

Front 287

What are some examples of artifact?

Back 287

Blinking (resolved by applying more anesthetic)

Cardiac arrythmias

Cardiomyopathy (causes bilateral diminished tracings)

Front 288

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

Back 288

Disease in external carotid

Front 289

What are some of the determinants that dictate transducer frequency selection for otpimal carotid B-imaging?

Back 289

Desired beam width

Average & extreme depths of carotid vessels

Desired axial resolution

Front 290

To optimize carotid vessel image data, lateral resolution should be

Back 290

As small as possible, to resolve side by side data

Front 291

What is true regarding axial resolution?

Back 291

Resolves two targets positioned one in front of another along the axis of beam propagation, and improves observer's ability to estimate vessel wall thickness

Front 292

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

Back 292

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

Front 293

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

Back 293

90 degrees where angle of reflection = angle of incidence

Front 294

5 factors that may limit carotid duplex scanning?

Back 294

Presence of dressings, Skin staples, Sutures

Soft tissue abnormalities (edema, hematoma)

Abnormal neck size or contour

Vessel depth or course

Acoustic shadowing caused by calcification

Front 295

*What is the biggest limitation to duplex scanning?

Back 295

Acoustic shadowing

Front 296

*What can acoustic shadowing cause?

Back 296

Erroneous calcification of percent stenosis

Front 297

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

Back 297

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 298

**How can overestimation of disease occur?

Back 298

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

Front 299

How can underestimation of disease occur?

Back 299

Low-level echoes of soft plaque not appreciated

Jet of accelerated flow missed

Carotid bulb stenosis

Cardiac myopathy causes decreased velocity

Inappropriate doppler angle

Front 300

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

Back 300

Improper placement of the sample volume

Front 301

What is the approximate sample size?

Back 301

1 - 1.5 mm

Front 302

Doppler information is evaluated for phase. What is phase?

Back 302

Direction toward or away from the transducer

Front 303

*What is the Doppler equation?

Back 303

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

Front 304

Doppler effect is a change in frequency or ____ of a wave due to motion

Back 304

Wavelength

Front 305

*The reflected frequency is higher or lower depending on

Back 305

Direction of flow

Front 306

The Doppler _____ in the receiver is generally a phase-quadrature detector

Back 306

Demodulator

Front 307

The demodulator has ____ output channels representing forward and reverse flow

Back 307

two

Front 308

Doppler shift (in the Doppler equation) is

Back 308

measured

Front 309

RBC velocity & cosine of the angle (in the Doppler equation) are

Back 309

calculated

Front 310

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

Back 310

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

Front 311

*The angle correct cursor for velocity estimates is best

Back 311

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

Front 312

*What is the greatest source of error?

Back 312

Doppler probe > 60 degree angle

Front 313

Does readjusting the angle-correct cursor alter the frequency shift of the ICA Doppler signal?

Back 313

It changes the velocity element but not the shift itself

Front 314

*What is continuous wave (CW) DOppler?

Back 314

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

Front 315

Among the chief limitations of CW Doppler is

Back 315

Depth information is not possible

Precise location of flow pattern cannot be determined

Front 316

**CW has ____ spectral window

Back 316

Little to No

Front 317

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

Back 317

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

Front 318

*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 318

Increasing the beam angle to 70 degrees

Front 319

What is pulsed wave (PW) Doppler?

Back 319

One crystal w/ range resolution, variable sample size, and well-defined spectrum

Front 320

CW & PW Instruments provide ______ Doppler info

Back 320

One-dimensional

Front 321

The signal-to-noise ratio is greater in ___ Doppler than ___ Doppler

Back 321

CW, PW

Front 322

*Non-imaging CW & PW Doppler provide

Back 322

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 323

The _____ the sample volume (Doppler gate) the better the signal-to-noise ratio

Back 323

Smaller

Front 324

How is the pulse-echo system of PW Doppler similar to sonography?

Back 324

The voltage generator provides voltage pulses of several cycles in length

Front 325

How are pulse-echo systems of PW Doppler & sonography different?

Back 325

Longer pulses are used in PW Doppler than for imaging

Front 326

What are three differences between gray scale & Doppler?

Back 326

Gray scale has short US pulse

High spatial resolution

Fast frame rates

Front 327

The PW Doppler uses how many pulse cycles per scan line?

Back 327

256

Front 328

The ____ detects & presents Doppler shift information audibly & visually

Back 328

receiver

Front 329

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

Back 329

FFT

Front 330

**____ is on the horizontal axis

Back 330

Time

Front 331

**____ are on the vertical axis

Back 331

Various true frequency shifts

Front 332

Spectral analysis is ____ of analog recording drawbacks

Back 332

Free

Front 333

What happens during autocorrelation?

Back 333

Each echo is correlated w/ the corresponding one from the previous pulse, thus determining that motion has occured

Front 334

What does autocorrelation yield?

Back 334

The direction (sign), mean & variance around the mean Doppler shift

Front 335

Representation of the normal blood flow pattern is dependent upon

Back 335

Diameter of the artery

Vascular resistance of the end-organ

Size of the sample volume

Front 336

**Bilateral diminished CCA flow velocities are indicative of

Back 336

Poor cardiac output or stroke volume (cardiac insufficiency)

Front 337

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

Back 337

ICA

Front 338

*Another name for upstroke is

Back 338

Spectral envelope

Front 339

*A dicrotic notch may ___ evident

Back 339

not be

Front 340

The ICA is slightly more ___ and ___ than the ECA

Back 340

High pitched, continuous

Front 341

*A high resistance signal is not

Back 341

continuous

Front 342

The ECA signal is more

Back 342

Pulsatile

Front 343

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

Back 343

ECA

Front 344

A ___ is clearly seen with ECA waveform

Back 344

dicrotic notch

Front 345

Tapping of a ___ causes oscillations of the ECA waveform

Back 345

Superficial Temporal Artery (STA)

Front 346

Can you get oscillations in ICA with temporal tap?

Back 346

Yes

Front 347

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

Back 347

Waveform characteristics, vessel positions, presence of branches

Front 348

*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 348

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

Front 349

*What is the maximum Doppler shift frequency displayed?

Back 349

1/2 PRF

Front 350

**When might aliasing occur?

Back 350

When PRF is too low

Front 351

**How can PRF be increased and avoid aliasing?

Back 351

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

Front 352

What are two examples in which it is hard to detect PW aliasing in continuous signals?

Back 352

AVF

Venous signals

Front 353

*What are Doppler shifts above & below the baseline?

Back 353

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

Front 354

*What is mirror image artifact caused by?

Back 354

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

Front 355

What is one way of decreasing artifical spectral broadening?

Back 355

Defocus the beams

Front 356

Ghost artifact comes from

Back 356

not using a wall filter

Front 357

What is color Doppler?

Back 357

Assigns color to display average frequencies and direction of moving bloodH

Front 358

How is color flow analogous to pulse-echo sonography?

Back 358

Both produce real-time information

Front 359

In color Doppler, every color has three components:

Back 359

Hue

Saturation

Brightness

Front 360

___Is our subjective interpretation of the frequency of light we see (red, green, blue)

Back 360

Hue

Front 361

____ is the concentration of the hue mixed with white (pale, deep, etc.)

Back 361

Saturation

Front 362

____ is the amount of light emitted per unit are (lightness, lumonisoity, intensity, value)

Back 362

Brightness

Front 363

What does the color map show?

Back 363

Color assignment for the mean Doppler frequencies at any given PRF

Front 364

What is ensemble length/color sensitivity?

Back 364

Number of pulses per scan line

Front 365

**Why are scan rates lower with Color Doppler?

Back 365

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

Front 366

Increased color sensitivity ____ frame rate

Back 366

Decreases

Front 367

Frame rate depends on

Back 367

PRF

Imaging depth

Width of color box

Ensemble length

Front 368

What does PW & color Doppler aliasing have in common?

Back 368

Diastolic portion of waveform does not alias

Front 369

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

Back 369

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

Front 370

A carotid bruit can be detected with color flow and spectral analysis as

Back 370

A mosasic of low red and blue frequencies in color flow in tissue lying outside of the lumen, and oscillatory waveforms above & below baseline in spectral waveform

Front 371

Color Doppler displays a mean frequency shift whereas Powr Doppler _____ frequency shift

Back 371

total

Front 372

Power Doppler is ___ sensitive than color Doppler

Back 372

More

Front 373

Does power doppler display aliasing?

Back 373

No

Front 374

The degree & occurence of flow abnormality produced by a stenosis depends upon

Back 374

Length & diameter of narrowing

Roughness of endothelial surface

Shape & degree of narrowing

Ratio of area of reduction to nml vessel

Rate of flow

AV pressure gradient

Peripheral resistance beyond the stenosis

Front 375

Stenosis should be visible from at least ___ projections

Back 375

two

Front 376

*Diameter reduction is a ____ -dimensional measurement

Back 376

One

Front 377

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

Back 377

Distal turbulence

Front 378

What does flow acceleration result from?

Back 378

The fact that velocity and area are inversely proportional

Front 379

What does flow acceleration involve?

Back 379

Elevated velocity & elevated frequency shifts

Front 380

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

Back 380

Entrance

Front 381

What does flow acceleration cause?

Back 381

Increased energy loss

Front 382

What does turbulence result from?

Back 382

Blood changing direction as the flow stream enters and leaves the stenosis

Front 383

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

Back 383

Turbulent flow

Front 384

What is another reason for loss of spectral window?

Back 384

Overuse of Doppler gain & incorrect positioning of the sample volume outisde the center of the stream

Front 385

*What is flow disturbance due to?

Back 385

Interrupted flow stability with high velocities and eddy currents

Front 386

What does turbulence cause?

Back 386

Energy loss because of inertia

Front 387

Why does the waveform of stenotic vessel have a higher than normal amplitude?

Back 387

It corresponds to flow acceleration

Front 388

____, the flow frequencies are usually dampened, with or without disturbance

Back 388

Proximal to a stenosis

Front 389

The speed of blood is essentially ____ across a tube

Back 389

Constant

Front 390

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

Back 390

Exit

Front 391

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

Back 391

Approaching a stenosis

Within a stenosis

Upon leaving the stenosis

Front 392

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

Back 392

Disease at the carotid siphon

Front 393

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

Back 393

Proximal ICA in presence of siphon high-grade stenosis

Front 394

A hemodynamically significant stenosis causes a notable reduction in ___ and flow

Back 394

pressure

Front 395

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

Back 395

75%

Front 396

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

Back 396

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

Front 397

What is unlikely to produce an abnormal indirect cerebrovascular test?

Back 397

50% diameter reduction of ECA

Front 398

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

Back 398

PSF: < 4 kHz

EDF:

PSV: < 125 cm/s

EDV

Front 399

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

Back 399

PSF: < 4 kHz

EDF:

PSV: < 125 cm/s

EDV

Front 400

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

Back 400

PSF: < 4 kHz

EDF:

PSV: < 125 cm/s

EDV

Front 401

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

Back 401

PSF: > 4 kHz

EDF: < 4 kHz

PSV: > 125 cm/s

EDV: < 140 cm/s

Front 402

is the range of Doppler diagnostic guidelines? (stenosis: 80-99%, PSF, EDF, PSV, EDV

Back 402

PSF: > 4 kHz

EDF: > 4 kHz

PSV: > 125 cm/s

EDV: > 140 cm/s

Front 403

When is disease in the ICA 50-79% stenosed?

Back 403

When the PSV is > 125 cm/s, but the EDV is still less than 140 cm/s

Front 404

When is disease in the ICA 80-90% stenosed?

Back 404

When the EDV is > 140 cm/se

Front 405

*What does an occluded vessel look like?

Back 405

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

Front 406

The proverbial "thump" appears ____ to an occlusion

Back 406

Proximal

Front 407

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

Back 407

ICA occlusion

Front 408

An absent signal may suggest

Back 408

Occlusion

Difficult-to-detect flow stream

Tight stenosis w/ blood flow < 6 cm/s

Front 409

Can there be retrograde flow in the distal ICA in presence of total occlusion of carotid artery?

Back 409

No. It can have eddy currents, but not pure retrograde flow

Front 410

The best way to prepare a transducer for intraoperative use is to

Back 410

Place transducer & acoustic gel w/in sterile sleeve or bag

Front 411

What are some defects secondary to endarterectomy?

Back 411

Stricture of suture line, intimal flaps, areas of platelet aggregation, residual plaque

Front 412

Why is gray-scale important?

Back 412

Detecting subtle wall defects

Front 413

Why must a carotid duplex scan be performed first?

Back 413

CCA compression & oscillations are contraindicated w/ low carotid bifurcation, high grade stenosis, occlusion of ICA, or presence of complicated plaque formation

Front 414

What is the compression technique?

Back 414

Palpate CCA

Apply slow downward pressure

Hold compression for 2-4 cardiac cycles

Slowly release

Note changes in blood flow

Front 415

What is the oscillation technique?

Back 415

Palpate the CCA

Apply series of short & rapid compressions

Note oscillatory patterns transmitted

Front 416

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

Back 416

Vasospasm following subarachnoid hemorrhage

Determination of brain death

Cerebral artery monitoring during surgery

Carotid siphon stenosis

Front 417

What is an example of one condition in which TCD is not useful?

Back 417

Temporal arteritis

Front 418

What are some limitations of the TCD?

Back 418

Recent eye surgery (may limit orbital approach)

Hyperostosis of temporal bone

Inaccurate vessel identification

Front 419

**What size transducer is used?

Back 419

2 MHz PW

Front 420

**What angle of insonation is assumed?

Back 420

0 degrees

Front 421

**What are the main three acoustic windows?

Back 421

Transtemporal

Transorbital

Transforaminal/suboccipital

Front 422

What can be a foruth window?

Back 422

Submandibular

Front 423

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

Back 423

Transtemporal

Front 424

Accurate vessel identification requires

Back 424

Depth of sample volume

Direction of blood flow

Velocity of blood flow

Relationship of flow patterns to one another

Front 425

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

Back 425

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

Front 426

**What is the technique for a TCD exam?

Back 426

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 427

**What artery is not evaluated?

Back 427

Posterior communicating because of inappropriate Doppler angle

Front 428

What factors may alter intracranial blood flow?

Back 428

Age

Sex

Hematocrit

Blood gasses

Metabolism

Front 429

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

Back 429

Window: transtemp

Depth: 30-60 mm

Direction: antegrade

Velocity: 55 +/- 12 cm/s

Angle: Anterior & Superior

Front 430

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

Back 430

Window: Transtemp

Depth: 55-65 mm

Direction: bidirectional

Velocity: 55 +/- 12 cm/s

Angle: Anterior & Superior

Front 431

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

Back 431

Window: Transtemp

Depth: 60-80mm

Direction: retrograde

Velocity: 50 +/- 11 cm/s

Angle: anterior & superior

Front 432

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

Back 432

Window: Transtemp

Depth: 60-70 mm

Direction: antegrade

Velocity: 39 +/- 10 cm/s

Angle: anterior & superior

Front 433

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

Back 433

Window: transorbit

Depth: 60-80 mm

Direction: antegrade/retrograde

Velocity: 47 +/- 14 cm/s

Angle: varies

Front 434

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

Back 434

Window: Transorbit

Depth: 40-64 mm

Direction: antegrade

Velocity: 21 +/- 5 cm/s

Angle: Medial

Front 435

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

Back 435

Window: Transforam

Depth: 50-90 mm

Direction: retrograde

Velocity: 38 +/- 10 cm/s

Angle: R & L of midline

Front 436

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

Back 436

Window: transforam

Depth: 80-120 mm

Direction: retrograde

Velocity: 41 +/- 10 cm/s

Angle: midline

Front 437

Retrograde flow as in ACA is the same thing as flow ____ the transducer

Back 437

away from

Front 438

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

Back 438

MCA

Front 439

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

Back 439

Basilar artery

Front 440

**What does TCD interpretation incorporate?

Back 440

Flow depth

Flow direction

Flow velocity

Turbulence

Pulsatility

Systolic upstroke

Hemispheric index of MCA/ICA

Front 441

**What is not incorporated in TCD interpretation?

Back 441

The amount of spectral broadening

Front 442

What is the TAMV of the anterior vessels?

Back 442

About 55 cm/s

Front 443

A localized increase in mean velocity from 50 to 150 cm/s at a depth of 50 mm with the TCD transducer placed in the temporal window probably indicates

Back 443

Significant stenosis of MCA

Front 444

What is the TAMV of the posterior vessels?

Back 444

About 40 cm/s

Front 445

The left vertebral artery may be dominant and demonstrate

Back 445

Greater mean velocities

Front 446

Which vessel has the lowest TAMV?

Back 446

Ophthalmic artery at 21 +/- 5 cm/s

Front 447

Hyperventilation ___ mean flow velocity and ____ pulsatility

Back 447

Decreases, increases

Front 448

**How does collateralization occur?

Back 448

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 449

You perform TCD, insonating the left ACA. The flow is toward the beam. This finding suggests

Back 449

Ipsilateral carotid obstruction w/ right-to-left collateralization through the right ACA because flow in ACA is normally away from beam

Front 450

*Diagnosis of occlusion is most accurate in

Back 450

ICA & MCA

Front 451

How is occlusion diagnosed?

Back 451

Absence of signal

Low diastolic component just proximal to suspected occluded segment

Evidence of collateralization

Front 452

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

Back 452

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

Front 453

*The diagnosis of vasospasm is most accurate in

Back 453

MCA

Front 454

**How is vaospasm diagnosed?

Back 454

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

Front 455

How are AV malformation diagnosed?

Back 455

Increased systolic & diastolic velocities w/ very low pulsatility indices. There is also reductionof flow in adjacent arteries

Front 456

What are the six stages of cerebral perfusion deterioration?

Back 456

1) Reduction in diastolic velocity w/ increased pulsatility indices

2) End diastolic velocity approaching zero

3) Reversal of diastolic flow

4) Reverberatory flow

5) Low velocity, systolic-spike waveform

6) Absence of flow

Front 457

For what two procedures does TCD aid in the OR?

Back 457

Carotid endarterectomy & coronary artery bypass

Front 458

*What does a pinging noise mean?

Back 458

Microembolization

Front 459

*How is an intraoperative TCD interpreted?

Back 459

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

Front 460

What is the Seldinger technique?

Back 460

Percutaneous puncture & superficial arterial injection of a radio-opaque substance into a catheter

Front 461

**What are some limitations to an arteriogram?

Back 461

Contrast (iodine) allergy

Renal failure

Inaccurate as a functional (hemodynamic) assessment

Unable to provide multiple images in multiple planes

Front 462

**What are the most common arteries used?

Back 462

CFA

Axillary

Brachial

Front 463

*Which is the safest approach?

Back 463

CFA

Front 464

The dye gives a picture of the lumen not the

Back 464

wall

Front 465

A _____ technique is used to expose films sequentially

Back 465

Rapid film changer

Front 466

Using ____, digital information may be obtained and stored

Back 466

Fluoroscopy

Front 467

How long is the patient on bed rest after fluoroscopy?

Back 467

6-8 hours

Front 468

How is hemorrhage avoided?

Back 468

Sandbag

Front 469

**How is an arteriogram interpreted?

Back 469

Extent & location of filling defect, aberrant anatomy

Front 470

What does a filling defect indicate?

Back 470

Presence, location, extent of disease

Front 471

The common radiologic terms "inflow, outflow, runoff" refer respectively to?

Back 471

Aorto-iliac

Femoro-popliteal

Trifurcation arteries

Front 472

**What are common locations for atherosclerotic plaque?

Back 472

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

Front 473

What is NASCET?

Back 473

North American Symptomatic Carotid Endarterectomy Trial

Front 474

The NASCET used the following arteriographic criteria to classify ICA disease

Back 474

Diameter percentage of stenosis calculated by dividing the minimal diamter by diameter of un-stenosed distal ICA

Front 475

**How is diameter reduction calculated?

Back 475

{(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 476

**How is diameter reduction calculated?

Back 476

{(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 477

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

Back 477

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 478

Calculate the area reduction for an asymmetric lesion where the true area = 18 mm squared & residual area = 4 mm squared

Back 478

{(A-a)/A x 100 =

18-4/18 x 100

12/18 x 100

.78 x 100 = 78% area reduction

Front 479

**What is critical stenosis?

Back 479

50% diameter (75% area) reduction

Front 480

A vascular lab calls a stenosis 60-70% by diameter based on its duplex assessment, but angiography the next day calls it 90% by diameter. What is one example that is not a cause for the discrepancy?

Back 480

Color flow PRF set too low, creating aliasing & overestimation of velocities

Front 481

Conventional arteriography reveals 30% diameter stenosis in a symptomatic pt w/ severe stenosis by B-mode and peak systolic velocities of 150cm/s in proximal ICA. Why?

Back 481

Even double-projection arteriography may fail to fully determine diameter stenosis, especially in the event of vessel overlap

Front 482

Identification of an embolic source may be

Back 482

Difficult

Front 483

Can vasospasm be seen on arteriogram?

Back 483

Yes, as a narrowing w/o occlusion

Front 484

**What are complications of an arteriogram?

Back 484

Puncture site hematoma

Pseudoaneurysm

Local arterial occlusion

Neurologic complications

Front 485

**What is not a common complication of arteriography?

Back 485

Nerve damage

Front 486

Major complications of cerebrovascular angiography occur in approximately

Back 486

1% of patients

Front 487

What are major complications of a cerebral angiogram?

Back 487

Death

Stroke

Arterial occlusion at the access site

Renal failure

Front 488

What is not a major complcation of a cerebral angiogram?

Back 488

Inadvertent venous puncture

Front 489

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

Back 489

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

Front 490

What is an example of unneccesary information?

Back 490

Bony structures

Front 491

What is a significant problem w/ DSA (digital substraction arteriography)?

Back 491

Patient cooperation as motion can affect the ability of DSA (digital substraction arteriography) to provide adequate images

Front 492

**MR Angiography (MRA) functions by processing

Back 492

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

Front 493

Flowing blood is ____ from soft tissue

Back 493

Well distinguished

Front 494

*MRA uses ____ radiation

Back 494

Non-ionizing

Front 495

**MRA's are useful for what diagnoses?

Back 495

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

Front 496

**What are the limitations of MRA?

Back 496

Metalic (surgical) clips

Pacemakers

Monitors

Claustrophobia

Expense

Front 497

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

Back 497

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

Front 498

What is CT?

Back 498

Computerized tomography

Front 499

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

Back 499

Evaluate nature of:

cerebral infarctions

Intracranial aneurysms

Hemorrhage

AV malformations

Front 500

What else is CT used for?

Back 500

Determining size of aorta

Dissection

Location & amount of mural thrombosis

True from false lumen

Renal artery origins & other aorta branches

Front 501

In an ER patient w/ stroke symptoms, the initial diagnostic exam of choice would likely be

Back 501

CT

Front 502

CT usually requires the use of

Back 502

IV contrast

Front 503

CT angio is better than MRA's for what?

Back 503

Distinguishing arteries from veins

Front 504

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

Back 504

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

Front 505

What are limitations of CT?

Back 505

Patient motion

Metallic clips resulting in lost detail

Time consumption

Expense

Views are in one plane

Not good for extremity small vessels

Front 506

What are advantages of spiral CT over CT angio?

Back 506

Conventional CT limitations avoided, quicker, uses less radiation

Front 507

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

Back 507

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

Front 508

What are some pharmacological forms of treatment?

Back 508

Aspirin

Medications that decrease blood viscosity (Trental)

Antihypertensive drugs

Front 509

How does aspirin help?

Back 509

Decreased platelet aggregation which causes decreased thrombotic activity

Front 510

How do antihypertensive drugs help?

Back 510

Decreased shearing forces on the endothelial cells

Front 511

*What are some lifestyle modifications?

Back 511

Stop smoking

Increase exercise

Control weight

Low-cholesterol diet

Protection to prevent injury/infection

Front 512

Weight control & a low-cholesterol diet may ___ metabolism

Back 512

Enhance normal endothelial cell

Front 513

What can a stent be compared to?

Back 513

A scaffold

Front 514

What are three types of stents?

Back 514

Balloon-expandable

Self-expanding

Stent grafts

Front 515

What are some stent complications?

Back 515

Induced intimal hyperplasia causes re-stenosis

Stent migration

Twisting

Dislodgement

Leaks

Front 516

What is a "kissing stent" angioplasty/stent technique used for?

Back 516

Bifurcations

Front 517

What is endarterectomy?

Back 517

Surgical removal of atherosclerotic material, usually including a portion of intimal lining

Front 518

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

Back 518

Carotid endarterectomy for stenosis greater than 70% in diameter

Front 519

When is hypertension associated w/ hyperperfusion syndrome?

Back 519

After carotid endarterectomy

Front 520

When will a surgeon perform surgery on an occluded artery?

Back 520

Rarely and only a focal occlusion

Front 521

Because veins are seldom completely full, their flattened shape offers ______ resistance than circular shape

Back 521

Greater

Front 522

Venous resistance _____ arterial resistance

Back 522

Approximates

Front 523

**The shape of veins is determined by the

Back 523

Trasmural pressure = pressure within vein minus pressure outside of vein

Front 524

When the veins first expan there is ____ increase in pressure & resistance is decreased

Back 524

No

Front 525

______ pressure changes are required to change the vein from its normal shape to a circular shape

Back 525

Small

Front 526

_____ pressure changes are required to accomodate further increases

Back 526

Large

Front 527

When distended, the cross-sectional area of the veins is about ___ that of the corresponding area

Back 527

3-4 times

Front 528

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

Back 528

Extra-pulmonary veins

Front 529

*What are the components of calf muscle pump?

Back 529

Leg muscles & venous valves

Front 530

**What happens in muscle pump during contraction?

Back 530

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 531

What happens during muscle relaxation?

Back 531

Blood from superficial system travels to deep system to reduce peripheral venous pressure

Front 532

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

Back 532

Upper

Front 533

During inspiration, intra-thoracic pressure is

Back 533

decreased

Front 534

During inspiration, intra-abdominal pressure is

Back 534

Increased

Front 535

This increase in presure _____ the outflow of peripheral veins to abdomen

Back 535

reduces

Front 536

**What happens during valsava?

Back 536

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

Front 537

Augmentation of venous signal should be ___ as pt releases deep breath and stops bearing down

Back 537

evident

Front 538

The maneuver ____ performed in pts w/ severe CAD, acute MI, or moderate to severe hypovolemia

Back 538

should not be

Front 539

What is the opposite of confluence?

Back 539

Bifurcation

Front 540

What forms the palmar arches of the hands?

Back 540

Deep digital veins

Front 541

**What are venae comitantes?

Back 541

Corresponding veins referring to close proximity to its accompanying artery

Front 542

**The radial, ulnar, & brachial veins are

Back 542

Paired venae comitantes

Front 543

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

Back 543

Near elbow

Front 544

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

Back 544

axilla

Front 545

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

Back 545

Lateral

Front 546

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

Back 546

medial

Front 547

The medial forearm veins empty into the axillay vein by way of the ___ vein

Back 547

basilic

Front 548

The vein in the antecubital fossa that connects the cephalic & basilic veins is the ____

Back 548

Median cubital vein

Front 549

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

Back 549

cephalic

Front 550

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

Back 550

Brachiocephalic/Innominate

Front 551

**What forms the deep venous arches?

Back 551

The deep digital veins that form the metarsal veins

Front 552

*What are the paired veins of the LE?

Back 552

ATVs

PTVs

Peroneal veins

Gastrocnemius veins

Front 553

The peroneal veins and the _____ empty into the tibio-peroneal trunk at the insertion of the ATVs

Back 553

PTVs

Front 554

*Which veins empty the back of the leg?

Back 554

P(osterior)TVs

Front 555

Where are the PTVs located?

Back 555

Between the medial malleolus & Achilles' tendon

Front 556

The _____ & the tibio-peroneal trunk form the popliteal vein

Back 556

ATVs

Front 557

The ATVs empty what?

Back 557

The front of the leg

Front 558

What are the venous sinuses of the brain?

Back 558

Spaces between dura mater & periosteum that receive venous return & terminate in IJV

Front 559

**What are the venous sinuses of the LE?

Back 559

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 560

**Where does most DVTs begin?

Back 560

The soleal veins

Front 561

**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 561

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

Front 562

*Where are the peroneal veins located?

Back 562

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

Front 563

**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 563

Popliteal vein

Front 564

*The CFV becomes the ___ just above the inguinal ligament

Back 564

EIV (External Iliac Vein)

Front 565

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

Back 565

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

Front 566

*What is the longest vein in the body?

Back 566

GSV

Front 567

What is the course of the GSV?

Back 567

GSV passes upward on the anteromedial calf and the posteromedial to medial thihg. It ends by passing through the spahenous hiatus in the deep fascia of proximal thigh to enter CFV

Front 568

*What is the purpose of perforating veins?

Back 568

To empty blood from superficial system into the deep system

Front 569

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

Back 569

Medial lower calf

Front 570

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

Back 570

Site of venous stasis ulceration

Front 571

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

Back 571

Posterior arch vein

Front 572

**Why is the posterior arch vein important?

Back 572

It is a site for venous ulceration

Front 573

Boyd's perforating vein is located

Back 573

near the knee

Front 574

Dodd's perforator is located

Back 574

Above the knee

Front 575

The LSV/SSV has an important ___ perforating branch

Back 575

Lateral

Front 576

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

Back 576

Left, right

Front 577

Thus structures located in the left side of abdomen must have their venous outflow ___ the aorta to get to the IVC

Back 577

cross

Front 578

**Describe the SVC

Back 578

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

Front 579

Describe IVC

Back 579

Formed by confluence of common iliac veins

Front 580

True or False: The veins are completely passive structures

Back 580

False

Front 581

The venous element of reactivity is also known as

Back 581

Venomotor tone

Front 582

How are the vein walls the same as arteries?

Back 582

They have same three layers

Front 583

How are the vein walls different from arteries?

Back 583

The medial & adventitial layers are much thinner

Front 584

**What are venous valves?

Back 584

Bicuspid extensions of initimal layer

Front 585

What do valves have to facilitate closure?

Back 585

Sinuses

Front 586

**What are some veins without valves?

Back 586

Soleal sinuses

External iliac vein (75% of time)

Common Iliac

Interal Iliac

Innominate

SVC

IVC

Front 587

*What are some veins w/ valves?

Back 587

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 588

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

Back 588

Venous thrombosis

Increased ambulatory venous pressure

Increased intra-abdominal pressure &/or venous obstruction

Front 589

**The development of venous thrombosis is based on

Back 589

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

Front 590

**What may venous stasis be caused by?

Back 590

Immobility (bed rest, paraplegia)

MI

CHF

Hypotension

COPD

Obsesity

Pregnancy

Previous DVT

Extrinsic compression

Surgery

Fractured hips

Multiple injuries

Front 591

*What are some causes of hypercoagulability?

Back 591

Pregnancy

Cancer

Hormones (Estrogen)

Myeloproliferative disorders

Front 592

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

Back 592

Lymphangitis

Diabetes

Smoking (when not on birth control)

Arthritis

Front 593

Where are thrombi formed?

Back 593

They frequently begin at the cusps of the valves or in soleal sinuses secondary to stagnation

Front 594

Thrombi as a reuslt of traum occur at ___ site

Back 594

any

Front 595

**What is the most common sequeala of DVT?

Back 595

Valvular destruction

Front 596

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

Back 596

15-20 or 28%

Front 597

**What are some complications of DVT?

Back 597

Venous insufficiency

Venous hypertension

Pulmonary embolism (PE)

Front 598

Can a patient w/ isolated calf DVT go on to have Pulm Emb?

Back 598

Yes

Front 599

Normally, venous flow in the calf is from superficial to deep veins through perforating veins. However, this flow might be reversed when ____ is present

Back 599

Deep Venous Obstruction

Front 600

Chronic deep venous obstruction will increase

Back 600

Ambulatory venous pressure

Front 601

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

Back 601

Swelling

Heaviness

Discoloration

Ulcers

Varicosities

Front 602

One complication of deep venous recanalization is

Back 602

Damage to venous valves, allowing reflux

Front 603

*Where does chronic venous insufficiency come from?

Back 603

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

Front 604

**What happens in vavular incompetence?

Back 604

Blood flows antegrade and retrograde (venous reflux)

Increased pressure in the veins

Increased venous pooling

Decreased return to heart

Decreased cardiac output

Front 605

**What is ambulatory venous hypertension?

Back 605

Increased LE venous pressure when pt is standing or walking

Front 606

*The greatest pressure of venous hypertension occurs

Back 606

During muscle contraction

Front 607

What happens during muscle contraction?

Back 607

Muscle contraction forces blood out to superficial veins via incompetent perforating veins

Front 608

**Venous hypertension MOST often results from

Back 608

Deep venous reflux

Front 609

*What can ambulatory venous hypertension result in?

Back 609

Edema

Hyperpigmentation

Ulcer formation

Front 610

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

Back 610

Edema

Front 611

**Edema from venous disease occurs because of

Back 611

Increased capillary pressure due to an obstructive process

Front 612

Where does this increased capillary pressure come from?

Back 612

Incompetent perforators

Front 613

*What is a result of incompetent perforators?

Back 613

Blood from deep veins backs up into superficial veins

Front 614

*______ may leak into surrounding tissue secondary to increased pressure

Back 614

Fluid

RBCs

Fibrinogen

Front 615

**What is the result?

Back 615

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 616

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

Back 616

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

Front 617

*What is venous claudication?

Back 617

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

Front 618

*The effects of gravity & walking can precipitate

Back 618

Edema

Varicosities (varices)

Ulcer formation

Front 619

*A varicose vein is most often

Back 619

a dilitation of the greater saphenous vein or superficial tributary

Front 620

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

Back 620

Primary

Front 621

What are two aggravating factors for primary varicose veins?

Back 621

Obesity

Pregnancy

Front 622

What is an example of superficial venous incompetence?

Back 622

Congenital absence of valves

Front 623

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

Back 623

Secondary

Front 624

*What are three examples of congenital venous disease?

Back 624

Avalvular veins

AV malformations (AVMs)

3 syndromes

Front 625

What are the three syndromes?

Back 625

Kleppel-Trenaunauy (hypoplastic/absent deep veins)

Sturge-Weber (hypoplastic/absent deep veins w/ cerebral AVMs)

Kasabach-Merritt (capillary hemangiomas)

Front 626

What percentage of pulmonary emboli originates from LE DVT?

Back 626

> 90%

Front 627

** A person with pulm emb might have

Back 627

Chest pain

Reduced arterial blood gasses

Diaphoresis

SOB

Tachypnea

Pleural effusion

Front 628

What is not found in clinical presentation of Pulm Emb?

Back 628

Positive LE venous US as it is a test not a sign

Front 629

Is venous duplex useful to rule out Pulm Emb in the absence of LE symptoms?

Back 629

No

Front 630

**What is a lung perfusion scan?

Back 630

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

Front 631

*What are limitations of VQ scan?

Back 631

Other disorders that can cause perfusion defect

Emphysema

Asthma

Pneumonia

Bronchial cancer

CHF

Liver cirrhosis

Radiography

Multiple blood transfusions

Post-operative period

Front 632

**What is better than a VQ scan?

Back 632

Pulmonary angiogram

Front 633

**What is better than a VQ scan?

Back 633

Pulmonary angiogram

Front 634

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

Back 634

Pulmonary angiogram

Front 635

What is used next if not pulmonary angio?

Back 635

Spiral CT

Front 636

Signs that a general practitioner may use in an attempt to dx DVT thrombosis include

Back 636

Homan's sign

Bancroft's sign (anteroposterior calf compression)

Lowenberg's sign (Inflating a sphygmomanometer to 80 mmHg)

Front 637

A general practitioner would not use

Back 637

A tourniquet test as it is meant to rule out insufficiency

Front 638

**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 638

46 - 62% accurate

Front 639

The clinical exam for DVT is

Back 639

Neither specific nor sensitive

Front 640

**What does the differential diagnosis include?

Back 640

Muscle strain

Direct injury

Muscle tear

Baker's cyst

Cellulitis

Lymphangitis

Extrinsic compression

CHF

Complications of chronic venous insufficiency

Front 641

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

Back 641

Swelling

Pain

Redness

Warmth

Front 642

*Edema caused by DVT is characterized by

Back 642

Swelling in ankles & legs but not the feet

Front 643

Two weeks after fracture of femur, 33 y/o female is seen for swelling of calf of same leg. The preliminary dx, prior to performance of any noninvasive testing, should include:

Back 643

DVT

AVF

Front 644

A patient presents w/ bilateral LE edema & nephritic syndrome. Thromus is suspected at what level?

Back 644

IVC

Front 645

*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 645

Extensive left fempop DVT

Front 646

*What is a Baker's cyst?

Back 646

Synovial fluid from knee joint

Front 647

What kind of skin changes occur?

Back 647

Tissue induration due to fluid accumulation, rubor, brawny discoloration/pigmentation, pallor, cyanosis, subcutaneous fibrosis, cutaneous atrophy

Front 648

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

Back 648

Rusty brown color at ankles & calves

Front 649

What is not a finding?

Back 649

Thickening of toenails

Front 650

Symptoms of chronic venous insuffiency might result from

Back 650

Calf vein DVT

Popliteal vein DVT

Iliac vein thrombosis

Superficial insufficiency

Front 651

*Symptoms of chronic venous insufficiency does not result from

Back 651

Gastrocnemius muscular insufficiency

Front 652

A pt w/ chronic venous insufficiency complains of sudden onset of edema & pain in affected leg. This may be related to

Back 652

Recurrence of acute DVT

Front 653

*What is pallor due to?

Back 653

Phlegmasia alba dolens

Front 654

*What is phlegmasia alba dolens?

Back 654

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

Front 655

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

Back 655

Phlegmasia cerulean dolens (venous gangrene) from hypoxia

Front 656

**What is phlegmasia cerulean dolens due to?

Back 656

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

Front 657

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

Back 657

Cellulitis

Front 658

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

Back 658

Relieved by elevation

Front 659

What is pitting edema a result of?

Back 659

Fluid retention subq

Electrolye imbalance

Renal dysfunction

CHF

Front 660

*Pitting edema of both LEs is likely related to

Back 660

Cardiac or systemic origin

Front 661

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

Back 661

Postphlebitic syndrome

Front 662

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

Back 662

The popliteal vein is patent & the valves are incompetent

Front 663

*What is non-pitting edema result of?

Back 663

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

Front 664

*What is lymphedema?

Back 664

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 665

Patients w/ swollen limb who have just returned from a country where filariasis is endemic may be suspected of having

Back 665

Lymphedema

Front 666

Patients found to have ulcerating lesions or gnagrene may have which diseases?

Back 666

Arterial insufficiency, neuropathy, vasospasm, venous disease

Front 667

What are venous stasis ulcers caused by?

Back 667

Venous hypertension resulting from valvular incompetence. The antegrade & retrograde blood flow causes edema & primary varicosities as well as leakage of fluid, RBCs, & fibrinogen into surrounding tissues, & the tissues do not receive proper oxygen & nutrients

Front 668

Where are these lesions found?

Back 668

On the lower third of the leg around medial aspect of ankle

Front 669

The vascular technologist knows that chronic venous insufficiency & ulceration are

Back 669

Chronic but controllable

Front 670

**How are venous ulcers distinguished from arterial ulcers

Back 670

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 671

*LE ulcers are overwhelmingly the result of

Back 671

Venous disease

Front 672

Why is pt placed supine?

Back 672

To facilitate venous filling & enhance Doppler signal

Front 673

How should a patient be positioned for imaging LE veins is

Back 673

Supine or Low Fowlers

Front 674

Arms are in what position

Back 674

Pledge

Front 675

The optimal patient position for imaging LE veins is?

Back 675

Semi-Fowler's position & reverse Trendelenburg

Front 676

What is semi-Fowler's position?

Back 676

Raising the trunk & head but not knees

Front 677

The extremities should be ____ than heart by 30 degrees

Back 677

Lower

Front 678

What position is this called when combined with legs externally rotated & hips & knees flexed?

Back 678

Reverse Trendelenburg

Front 679

*A complete venous duplex exam should include

Back 679

Venous compression & Doppler evaluation

Front 680

What are some capabilities of venous duplex scanning?

Back 680

Evaluate non-occluding/partial thrombus

distinguish between extrinsic & intrinsic compression

evaluate soft tissue masses

assist w/ documenting an elevated systemic venous pressure

assess portocaval shunts

evaluate some liver diseases

Front 681

Which two views are necessary to ensure adequate information?

Back 681

Transverse & sagittal

Front 682

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

Back 682

Adjacent artery

Front 683

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

Back 683

Supraclavicular

Front 684

The subclavian vein may be evaluated from subclavicular approach if probe is angled into the _____ triangle

Back 684

Delto-pectoral

Front 685

In transverse view the subclavian vein is _____ and _______ than subclavian artery

Back 685

Medial, more superficial

Front 686

The axillary vein is more ______ and _____ than the axillary artery

Back 686

Medial, more superficial

Front 687

The paired brachial veins are ____ than the brachial artery

Back 687

Deeper

Front 688

The CFV is _____ and ____ than CFA

Back 688

Medial, Deeper

Front 689

The popliteal vein is _____ and _____ than popliteal artery

Back 689

Medial, more Superficial

Front 690

The peroneal vein is ______ and ______ than PTVs

Back 690

Medial, Deeper

Front 691

Evaluation for other abdominal vessels begin in trv view at

Back 691

Xiphoid process

Front 692

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

Back 692

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

Front 693

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

Back 693

Spontaneity

Phasicity

Augmentation w/ distal compression

Augmentation during proximal release

Front 694

**When is pulsatile venous flow evident?

Back 694

Primarily in pts w/ fluid overload such as CHF

Front 695

**Subclavian venous signals are more

Back 695

Pulsatile

Front 696

With inspiration, a Doppler signal from subclavian vein will usually

Back 696

Augment

Front 697

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

Back 697

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

Front 698

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

Back 698

Increases

Front 699

When performing LE venous Doppler assessment in normal pts, cephalad flow diminishes

Back 699

During inspiration

Front 700

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

Back 700

may not be evident

Front 701

Why is augmentation reduced in UE?

Back 701

There is not as much blood volume as in the lower extremity

Front 702

**Normally flow should ______ following Valsalva maneuver

Back 702

Augment

Front 703

**Decreased augmentation following Valsalva indicates

Back 703

Obstruction

Front 704

**What are the characteristics of acute DVT?

Back 704

Dilated vessel

Low echogenicity

Spongy texture

Poor attachment to wall

Lack of collateralization or recanalization

Front 705

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

Back 705

Probably venous reflux as it is a sequela to acute DVT

Front 706

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

Back 706

Diminished velocities

Compressible femoral vein w/ evidence of rouleau formation

Poor augmentaton at CFV w/ release of Valsalva

Front 707

*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 707

Proximal obstruction: right iliac thrombosis

Front 708

How do you maximize color?

Back 708

Adjust color scale to detect slower velocities

Change wall filters

Increase color gain

Front 709

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

Back 709

lower

Front 710

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

Back 710

different from

Front 711

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

Back 711

DVT

Poor angle of insonation

Highpass filter set too high

Front 712

An elderly pt who presents w/ localized pain at mid calf has US exam that reveals nonocclusive thrombus of SFV. The calf vein became excruciating after administration of heparin. A second US exam demonstrates:

Back 712

Hypoechoic mass in shape of egg at mid calf, thought to be hematoma, a side effect of heparin

Front 713

CW is used to evaluate

Back 713

deep venous obstruction

venous incompetence

Front 714

*What is a contraindication to this study?

Back 714

cardiac arrhythmias

Front 715

What size probe should be used?

Back 715

5 MHz

Front 716

**What are some limitations to CW evaluation?

Back 716

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 717

*How can tech diminish extrinsic compression?

Back 717

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

Front 718

Doppler exam alone, w/o B mode, is unlikely to detect presence of venous thrombosis in

Back 718

a Peroneal vein as it is a paired vein

Front 719

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

Back 719

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

Front 720

CW Doppler assessment of PTVs reveals nonspontaneous flow that augments w/ foot compression. This finding is abnormal in a _____ patient

Back 720

warm

Front 721

On CW Doppler assessment, a pt w/ a swollen left leg has loud, continuous flow signals from left GSV. The asymptomatic right leg has nonspontaneous flow in GSV, which augments w/ distal compression. These findings are consistent w/

Back 721

Left leg DVT as left GSV is acting as collateral

Front 722

**How can there be false positives?

Back 722

Extrinsic compression

Pain or anxiety causing muscle contraction

PAD causing decreased venous filling

COPD can elevate central venous pressure

Operator error

Front 723

**How can there be false negatives?

Back 723

Partial thrombosis

Chronic occlusion w/ large collaterals

Presence of bifed system

Front 724

In CW Doppler reflux testing, a normal result is

Back 724

Cessation of flow w/ proximal compression, resuming on release

Front 725

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

Back 725

Longer than 1 second

Front 726

*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 726

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

Front 727

In a reflux study, the examiner images the popliteal vein & notes that venous color display lights up blue w/ calf compression, the red for 2 - 3 seconds on release. This suggests

Back 727

venous reflux

Front 728

*Augmentation or flow reversal during Valsalva indicates

Back 728

Reflux secondary to valvular incompetence

Front 729

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

Back 729

Valvular incompetence

Front 730

A CW Doppler exam of LEs, performed to diagnose deep vein thrombophlebitis, revealed augmentation upon compression proximal to probe at all standard levels studied. The diagnosis is

Back 730

Fempop & PT valvular insufficiency

Front 731

An older clot's vessel is non-compliant & ______ over time, and the vessel is smaller than normal

Back 731

retracts

Front 732

In an older clot there is _________ attachment of thrombus to vessel wall

Back 732

firm

Front 733

A long, brightly echogenic streak is noted in CFV, which is otherwise patent & compressible. It moves w/ probe compression & appears to move w/ venous flow. This is most likely

Back 733

A remnant of recanalized old DVT

Front 734

What does a PPG exam consist of?

Back 734

A transducer, amplifier, & strip-chart recorder

Front 735

Why is PPG not true plethysmography?

Back 735

It does not measure volme changes

Front 736

PPG determines microcirculation which reflects

Back 736

intravenous pressure

Front 737

Can superficial thrombophlebitis best be diagnosed w/ PPG?

Back 737

No

Front 738

*In fact, what is contraindication for PPG study?

Back 738

A pt w/ DVT

Front 739

*What are some limitations to PPG study?

Back 739

Placement of PPG over varicose vein

Thick skin may reduce infrared light penetration

Skin must be intact

Obesity

Front 740

Is PPG calibrated the same as in air plethysmography?

Back 740

No

Front 741

**Light is transmitted/emitted from a

Back 741

Light emitting diode

Front 742

**The backscattered infrared light is received by adjacent

Back 742

Photodetector/photo-sensor/photocell

Front 743

*What is the sensor?

Back 743

The infrared light

Front 744

*Blood ____ light in proportion to its content in tissue

Back 744

Attenuates

Front 745

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

Back 745

No

Front 746

*What does the photocell do?

Back 746

Measures the reflection of light qualitatively

Front 747

The difference between transmitted & reflected light is _______ and converted into a waveform

Back 747

amplified

Front 748

**What is DC coupling?

Back 748

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 749

*Car and flashlight batteries are

Back 749

DC

Front 750

How is the patient positioned for reflux plethysmography? Why?

Back 750

In a non-wt bearing position: seated with legs dangling

To facilitate venous emptying & refilling

Front 751

How is the PPG study for venous reflux performed?

Back 751

The PPG sensor is placed 5-10 cm above the medial malleolus. Run the chart recorder at 5 cm/s. The pt performed adequate dorsiflexions

Front 752

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

Back 752

Venous reflux

Front 753

A tourniquet is inflated to ____ and placed at the ankle, below the knee, and above the knee

Back 753

50 mmHg

Front 754

How is deep system incompetence diagnosed?

Back 754

VRT < 20 seconds w/o torniquet & VRT < 20 seconds w/ tourniquet at ankle or below knee

Front 755

**How is superficial venous insufficiency diagnosed?

Back 755

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

Front 756

*What are examples of artifact?

Back 756

Pt mvement

Absent/irregular tracings from system from being on AC

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

Front 757

**What is the other test for reflux?

Back 757

Air plethysmorgraph (APG)

Trendelenburg test

Pneumoplethysmography

Front 758

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

Back 758

Tiny arterial pulsations

Front 759

Why does this happen?

Back 759

Plethysmography measures volume changes of all vessels under sensor

Front 760

Why is it important to maintain the same gain through the study?

Back 760

To ensure that a significant difference in the tracing can be interpreted as significant difference in blood volume

Front 761

What does the APG test use?

Back 761

Tourniquets & alternations of pt position

Front 762

What is an important limitation of APG?

Back 762

Will not diagnosis incompetent perforators or distal veins

Front 763

How is the patient positioned for an APG study?

Back 763

Study started w/ pt supine

Pt then assumes variety of standing positions

Front 764

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

Back 764

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

Front 765

What is the technique of APG?

Back 765

Leg is passively elevated, and zero venous volume is documented

Pt stands on contralateral leg, and the increased venous volume is documented

Pt stands on both legs and performed tip-toe maneuvers.

Pt is supine, and test leg is elevated to empty veins.

If findings are abnormal, test is repeated with a tourniquet to eliminate influence of superficial system

Front 766

*Why are the tip-toe maneuvers performed?

Back 766

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

Front 767

**How is the APG study interpreted?

Back 767

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

< or = 2.0 is normal

> or = 10.0 is severe reflux

Front 768

What is ejection fraction? (EF)

Back 768

The measure of calf muscle pump function

Front 769

EF=EV/VV x 100 or

Back 769

= 60% is normal

Front 770

*What is residual fraction volume (RFV)?

Back 770

Ambulatory venous pressure in mmHg

Front 771

RFV = RV/VV and

Back 771

< 35% is normal

Front 772

*Insufficient veins have the following flow characteristics:

Back 772

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 773

*With exercise in pts w/ post-phlebetic syndrome

Back 773

they have a prolonged return to pre-exercise pressure

Front 774

If the recorder stylus fails to document any plethysmographic waveform, what is the first thing to do?

Back 774

See if the controls have been set for the appropriate type of plethysmography (photo vs air)

Front 775

What do you do if the stylus "wanders"?

Back 775

Activate the re-set, and make certain the correct function is selected

Front 776

What do you do if you are unable to obtain a clean waveform?

Back 776

Reapply the PPG

Front 777

What do you do if there is no tracing?

Back 777

Check the exam mode, paper, paper speed, pause button, connection points

Front 778

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

Back 778

Gold standard

Front 779

The patient position for venography is

Back 779

on exam table tilted 60 degrees upright

Front 780

How is invasive venography performed?

Back 780

Serial x-rays are taken as radio-opaque injected material passes

Front 781

What does the radiologist look for?

Back 781

Filling defects

Collaterals

Incompetent valves

Front 782

*What is ascending venography?

Back 782

Evaluate acute & chronic DVT

Congenital venous disease &/or anomalies

Front 783

Wheere is the contrast injected to assess for DVT?

Back 783

Dorsal vein of foot

Front 784

**What is descending venography

Back 784

To detect & quantify reversed flow from incompetent valves

Front 785

*Where is the contrast injected for descending venography

Back 785

CFV

Front 786

What are some limitations of venography?

Back 786

Adverse effect of contrast media extravasation

Contraindicated in pts w/ severe peripheral venous obstructive disease

Expensive

Highly technical

May cause an allergic reaction

Front 787

What are some complications of venography?

Back 787

Allergic reaction to contrast

Toxicity to kidneys

AVF

Thrombophlebitis

Front 788

What is not a common complication?

Back 788

Iatrogenic CVA though a patent foramen ovale

Front 789

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

Back 789

Can simultaneously evaluate the pulmonary and peripheral veins

Is highly sensitive to active thrombus

Is extremely accurate in detecting an isolated calf clot

Front 790

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

Back 790

Inability to detect established clot

Sensitive to clinically insignificant clot

Difficult in documenting thrombosis in pelvis or upper thigh due to background activity

Front 791

*What are some lifestyle modifications to prevent venous disease?

Back 791

Control risk factors related to Virchow's triad:

Decrease venous stasis

Prevent injury/infection

Be aware of hyperocoagulability states/factors

Front 792

How is venous stasis decreased?

Back 792

Limit long periods of inactivity/bed rest & promote venous drainage

Front 793

How is venous drainage promoted?

Back 793

Wear support hose/elastic stocking

Elevate legs

Intermittent calf compression during/after surgery

Front 794

What is the drug of choice for initial DVT therapy?

Back 794

Heparin

Front 795

*Low dose heparin is administered prophylactically to

Back 795

Slow the conversion of prothrombin to thrombin

Increase the effect of antithrombin III

Decrease platelet adhesiveness to interfere w/ clot

Front 796

*Is low-dose heparin antilytic?

Back 796

No

Front 797

What is recommended for acute DVT &/or PE?

Back 797

A loading dose of heparin followed by 5 - 10 days of IV heparin

Front 798

**What does the heparin do?

Back 798

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

Front 799

**How is the IV dose regulated?

Back 799

So that the PTT is 1.5 - 2 times normal

Front 800

**Heparin can cause

Back 800

Thrombocytopenia

Formation of platelet antibody

Intraabdominal bleeding

Platelet aggregation

Front 801

Heparin does not cause

Back 801

Decreased activated PTT

Front 802

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

Back 802

3 to 6 months

Front 803

How is the Coumadin dose regulated?

Back 803

PT (Prothrombin time) is 1.5 -2 times normal

Front 804

How can an acute ilio-femoral clot by lysed?

Back 804

Urokinase or streptokinase

Front 805

*What are some vena caval filters called?

Back 805

Greenfield umbrella filter

Bird's nest filter

Nitinol filter

Vena Tech filter

Front 806

*When is a filter used?

Back 806

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

Front 807

How is it inserted?

Back 807

Under fluroscopy, a filter is palced in IVC via jugular or femoral vein

Front 808

A vena cava interruption device is usually placed ___ and may be echogenic

Back 808

below renal veins

Front 809

What is not used to vena cava interruption?

Back 809

Jones wire arch

Front 810

When is an external caval (around IVC) clip used?

Back 810

During abdominal surgery to reduce the incidence of PE

Front 811

Treatment includes limited bed rest, elevating legs, intermittent pneumatic calf compression during & after surgery, and _________ to prevent thrombosis

Back 811

wearing support hose

Front 812

The patient can help prevent ulceration by

Back 812

Elevating legs above heart level more than 4 times a day for 20 minutes & using support stockings when ambulatory

Front 813

How are venous ulcers treated?

Back 813

A medicated compression dressing called an unna boot

Front 814

**When is ilio-femoral thrombectomy performed?

Back 814

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

Front 815

*What is performed for chronic venous insufficiency?

Back 815

Ligation of perforators

Front 816

What is the sclerosing agent for varicose veins

Back 816

Sodium tetradecyl sulfate injected into varix

Front 817

How often are valvular reconstructions & valve transplantations performed?

Back 817

Infrequently

Front 818

The ascending aorta arises from the left ventricle & has what two branches?

Back 818

Right & Left Coronary Arteries

Front 819

The descending aorta extends from the aortic arch to what point?

Back 819

The diaphgram

Front 820

**What artery becomes the axillary artery?

Back 820

The subclavian artery

Front 821

At what rib does the subclavian artery become the axillary artery?

Back 821

The outer border of the first rib

Front 822

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

Back 822

Seven

Front 823

What is the name of the seventh axillary artery branch?

Back 823

Thoraco-dorsal

Front 824

Where does the ulnar artery originate?

Back 824

Brachial artery

Front 825

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

Back 825

Superficial palmar branch

Front 826

*The radial artery terminates into what artery?

Back 826

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

Front 827

The ulnar artery gives off what branch in the hand?

Back 827

Deep plamar branch

Front 828

**The ulnar artery terminates into what artery?

Back 828

Superficial palmar arch

Front 829

The superficial palmar arch is compromised of what arteries?

Back 829

Superficial palmar branch of the radial artery & the distal portion of the ulnar artery

Front 830

The deep palmar arch is comprised of what arteries?

Back 830

Deep palmar branch of the ulnar artery & distal portion of the radial artery

Front 831

*What is another name for palmar?

Back 831

Volar

Front 832

The digital arteries divide into what?

Back 832

The lateral & medial branches

Front 833

**The _______ passes under the inguinal ligament to become the CFA

Back 833

EIA

Front 834

The deep femoral artery (profunda femoris) arises how far from the inguinal ligament?

Back 834

About 5 cm

Front 835

Normally the profunda femoris courses

Back 835

posterolateral to SFA

Front 836

What is unique about the profunda femoris?

Back 836

It can act as a collateral

Front 837

The superficial femoral artery (SFA) is also known as

Back 837

Femora Artery

Front 838

**The SFA passes through what opening?

Back 838

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

Front 839

Where is the termination of SFA & the beginning of popliteal artery?

Back 839

The adductor hiatus

Front 840

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

Back 840

Genicular branches

Front 841

**The popliteal artery divides into what two arteries?

Back 841

The anterior tibial artery (ATA) & tibio-peroneal trunk

Front 842

Where does the popliteal artery divide?

Back 842

At the interval between the tibia & fibula

Front 843

*What is the first branch of the distal politeal artery?

Back 843

ATA

Front 844

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

Back 844

ATA

Front 845

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

Back 845

The posterior tibial artery (PTA) & peroneal artery

Front 846

*What is the largest branch of the PTA?

Back 846

Peroneal artery

Front 847

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

Back 847

The medial & lateral plantar arteries

Front 848

**The _______ artery is medial to the fibula

Back 848

Peroneal

Front 849

The peroneal artery supplies what?

Back 849

The lateral side of the foot & the calcaneal region of the foot

Front 850

**The ATA becomes what vessel?

Back 850

The dorsalis pedis artery (DPA)

Front 851

The DPA _______ a branch of the peroneal artery

Back 851

is not

Front 852

**What is an important branch of the DPA?

Back 852

Deep plantar artery

Front 853

**What does the plantar arch consist of?

Back 853

The deep plantar artery which unites with the lateral plantar artery

Front 854

What vessels distribute blood into the digits?

Back 854

The plantar arch & dorsal metatarsals

Front 855

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

Back 855

The capillaries

Front 856

How long are the capillaries?

Back 856

About 1 mm

Front 857

*What is the diameter of a capillary?

Back 857

8 - 10 microns, about the same as RBC

Front 858

*What are the capillary walls made of?

Back 858

One-cell thick endothelial cells

Front 859

What is the total surface area of the capillaries?

Back 859

6000 sq meters

Front 860

What is the transmit time of blood through capillaries?

Back 860

1 - 3 seconds

Front 861

*Capillaries lose fluid through the ____ end and reabsorb fluid through the _____ end

Back 861

Arteriolar, venular

Front 862

A venule contains which vessel layers?

Back 862

Tunica media & tunica intima

Front 863

What are risk factors for peripheral arterial disease (PAD)?

Back 863

Diabetes

Smoking

HTN

Hyperlipidemia

Front 864

*What is not a risk factor?

Back 864

Hyperlipidemia

Front 865

*Why is diabetes important as a risk factor?

Back 865

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

Front 866

The combination of neuropathy and peripherally distributed atherosclerosis makes the diabetic pt especially vulnerable to

Back 866

Foot lesions

Front 867

*In the presence of arterial obstructive disease & digital ischemia

Back 867

Vasodilatation increases & distal resistance decreases

Front 868

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

Back 868

The heart

Front 869

What is an example of a reversible embolic condition?

Back 869

Blue toe syndrome

Front 870

*What produces "blue toe syndrome?"

Back 870

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

Front 871

*What happens with blue toe syndrome?

Back 871

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

Front 872

What is a true aneurysm?

Back 872

Dilatation of all three layers of arterial wall

Front 873

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

Back 873

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

Front 874

True or False: Patients w/ one aneurysm have a higher incidence of two

Back 874

True

Front 875

**What causes aneurysms?

Back 875

Unknown. May be congenital (#1 reason), atherosclerosis (degenerative), poor arterial nutrition, infection/inflammation (syphilis) or trauma

Front 876

What are not causes of aneurysms?

Back 876

Any of the terms that are used to describe the types of aneurysms

Front 877

*What is a fusiform aneurysm?

Back 877

Diffuse, circumferential dilatation of an arterial segment

Front 878

*What is a saccular aneurysm?

Back 878

A localized out-pouching of an artery, resulting from wall thinning & stretching

Front 879

**What is a dissecting aneurysm?

Back 879

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

Front 880

**What is the main complication of an aneurysm?

Back 880

Rupture of the aorta or distal embolization of peripheral aneurysms

Front 881

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

Back 881

Either one

Front 882

What is true about popliteal aneurysms?

Back 882

They can cause symptoms by compression; they pose a significant risk of limb loss due to embolism or occlusion; they are found bilaterally in 10% of cases

Front 883

What else is true about popliteal aneurysms?

Back 883

They do not pose a significant risk to the patient due to rupture; claudication is common

Front 884

**What is arteritis?

Back 884

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

Front 885

**Where does arteritis occur?

Back 885

Capillaries, arterioles, tibial & peroneal arteries

Front 886

**What is the most common form of arteritis?

Back 886

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

Front 887

Where does the disease (arteritis) occur?

Back 887

Medium & small arteries of distal upper & lower limbs

Front 888

*What are some of the symptoms of thromboangitis obliterans?

Back 888

Bilateral rest pain & ischemic ulceration

Front 889

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

Back 889

Takayasu's arteritis

Front 890

A patient complains of digital pallor cyanosis induced by cold exposure or emotional stimuli. These symptoms are characteristics of

Back 890

Raynaud's phenomenon

Front 891

**What is Raynaud's phenomenon?

Back 891

Condition when symptoms of intermittent digital ischemia occur in response to cold or emotional stress

Front 892

**What is primary Raynaud's syndrome?

Back 892

Also called Raynaud's disease & spastic Raynaud's syndrome, it is intermittent digital ischemia due to digital arterial spasm in absence of underlying disease

Front 893

*What is secondary Raynaud's syndrome?

Back 893

Also known as secondary Raynaud's phenomenon & obstructive Raynaud's syndrome, there is a fixed arterial obstruction with normal vasoconstrictive responses of arterioles

Front 894

_______ may be the first manifestation of a collagen disorder or Buerger's disease

Back 894

Secondary Raynaud's

Front 895

Where does dissection occur?

Back 895

In the aorta & peripheral arteries

Front 896

What is the distinction on duplex?

Back 896

Thin membrane dividing the lumen into two compartments

Front 897

Where is the false lumen?

Back 897

In the media

Front 898

Are the flow velocities similar in each lumen?

Back 898

No

Front 899

What is a complication of dissection?

Back 899

Stenosis/occlusion of branches

Front 900

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

Back 900

Popliteal artery entrapment syndrome (PAES)

Front 901

What is PAES?

Back 901

Compression of the popliteal artery by the medial head of the gastrocnemius muscle or fibrous bands (#1), or an abnormally located popliteal artery

Front 902

*What are the symptoms of PAES?

Back 902

Symptomatic occlusion or claudication following running, not walking

Front 903

How often is PAES bilateral?

Back 903

1/3 of the time

Front 904

What can PAES result in?

Back 904

Aneurysm, thrombosis, emboli

Front 905

*How can the symptoms be elicited in the lab?

Back 905

Active plantar flexion or b of the foot causing diminished pulses or altered waveform

Front 906

A 28 year old male complains of exercise-induced cramping of the right calf that occurs after walking six blocks and is relieved within five minutes of rest. Bounding pedal pulses are noted and resting ankle pressures are normal. The symptoms are reproduced with exercise. The ankle pressure remains normal on the left but drops to 40 mmHg on the right. These signs are consistent with

Back 906

PAES

Front 907

Early atherosclerosis of the LEs is associated with

Back 907

Claudication

Front 908

**What is claudication?

Back 908

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

Front 909

What is the differential diagnosis for claudication?

Back 909

Neurogenic or musculoskeletal (aka pseudoclaudication)

Front 910

The level of disease is usually _______ to location of symptoms

Back 910

proximal

Front 911

This means the vessel blockage appears ____ the pain

Back 911

above

Front 912

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

Back 912

Buttocks, thighs, calves

Front 913

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

Back 913

Aorto-iliac, ilio-femoral, femoro-popliteal

Front 914

The risk of claudication in diabetic patients is

Back 914

> 4x the risk in general population

Front 915

A 54-year old male relates a history of calf & thigh pain, the right worse than the left. This pain resolves upon sitting down. The pain usually starts after the first few steps of walking, but does not limit the patient's ability to walk three blocks. Since he never walks more than this distance, he cannot relate that he would have to stop at a greater distance. Some days the pain is quite mild. The etiology of these symptoms can be

Back 915

Not typical of vascular disease

Front 916

**A patient presenting with ischemic rest pain complains of?

Back 916

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

Front 917

*Where does ischemic rest pain occur?

Back 917

Forefoot, heel, toes but not in calf

Front 918

*When does ischemic rest pain occur?

Back 918

When the limb is not in a dependent position and the patient's blood pressure is decreased

Front 919

Why does ischemic rest pain improve in the dependent position?

Back 919

Hydrostatic pressure

Front 920

*Ischemic ulcers are

Back 920

Very painful and are commonly located over the tibia, over the dorsum of the foot, and or toes

Front 921

*What are six symptoms of acute arterial occlusion?

Back 921

Pain

Pallor (paleness)

Pulselessness

Paresthesia (lack of sensation)

Paralysis

Polar (cold)

Front 922

What is not a symptom of acute arterial occlusion?

Back 922

Claudication

Front 923

Why is claudication not a symptom of acute arterial occlusion?

Back 923

Claudication is associated with a progressive, chronic disease

Front 924

*Why is an acute arterial occlusion an emergency situation?

Back 924

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

Front 925

Changes in skin color may include

Back 925

Pallor

Cyanosis

Rubor

Front 926

What is pallor due to?

Back 926

Deficient blood supply

Front 927

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

Back 927

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 928

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

Back 928

When there is a concentration of deoxygenated hemoglobin

Front 929

*What does rubor suggest?

Back 929

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

Front 930

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

Back 930

Decreased arterial perfusion/advanced ischemia

Front 931

*The elevation of the extremity with impaired circulation produces

Back 931

Cadaveric pallor

Front 932

Why does cadaveric pallor occur when elevating extremity with impaired circulation?

Back 932

Negative hydrostatic pressure

Front 933

*What is dependent rubor?

Back 933

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

Front 934

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

Back 934

Marked increase of bloow flow due to collaterals

Front 935

**What extremity artery is not palpable?

Back 935

Peroneal

Front 936

Auscultation is important because

Back 936

Presence of bruit may be first indication of arterial disease

Front 937

Do abdominal bruits usually radiate from the aortic arch?

Back 937

No

Front 938

Common sites for bruits in the LE circulation include

Back 938

Abdomen

Groin (Aorto-iliac, CFA)

Popliteal space

Front 939

What is an example of an area not auscultated?

Back 939

Dorsum of foot

Front 940

Do only significant stenoses cause bruits?

Back 940

No

Front 941

*What is a thrill?

Back 941

A palpable bruit

Front 942

**What does a palpable thrill signify?

Back 942

AVF

Post-stenotic turbulence

Patent hemodialysis access graft

Front 943

*Why is there a thrill over a dialysis site?

Back 943

Increased flow volume

Front 944

It is essential that the patient has rested _____ minutes prior to the test (Allen test)

Back 944

20

Front 945

Assessment of the palmar arch is useful for

Back 945

Before placement of AV shunt, to evaluate blood flow to the digital arteries

Front 946

*What is the limitations of Allen test?

Back 946

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

Front 947

*How is the Allen test performed?

Back 947

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

Front 948

When assessing a digital artery with Doppler, patency of the palmar arch can be determined by

Back 948

Alternately compressing the radial and ulnar arteries while listening for changes in the digital arterial signal

Front 949

What is the simplest way to display Doppler frequencies?

Back 949

Audible sound

Front 950

*What size probe is used for Doppler evaluation?

Back 950

8-10 MHz

Front 951

What does analog Doppler velocimetry employ?

Back 951

A zero crossing frequency meter

Front 952

Displaying the Doppler-shifted frequencies on a strip-chart recorder is available using

Back 952

A Zero-crossing detector

Front 953

The zero-crossing detector ______ the frequencies present in reflected signal

Back 953

estimates

Front 954

High frequency waves have ____ oscillations (many, few)

Back 954

many

Front 955

Low frequency waves have _____ oscillations (many, few)

Back 955

few

Front 956

When is self-calibration done?

Back 956

Every time system is activated

Front 957

**What are some drawbacks to analog analysis?

Back 957

Signal easily affected by noise

Less sensitive than spectral analysis

High velocities understimated

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 958

**Since high velocities are underestimated, analog recordings _____ display amplitudes of all frequencies. (do, do not)

Back 958

Do not

Front 959

What are some examples of graphical errors?

Back 959

Recorder stylus not recording

60 Hz noise on tracing

Stylus is stuck

Audible signal but no tracing

Front 960

How are these errors fixed?

Back 960

Check for proper test/probe selection

Decrease gain

Reboot system

Increase filter

Change outlets

Reset stylus to re-center

Unpause/unfreeze recorder

Front 961

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

Back 961

a qualitative approach or pattern recognition

Front 962

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

Back 962

Triphasic

Biphasic

Monophasic

Front 963

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

Back 963

There is no forward flow in diastole

Front 964

Biphasic waveforms may be ______ in some patients

Back 964

Normal

Front 965

Describe a monophasic waveform

Back 965

Slow upslope

Rounded peak

Slow down stroke

No flow reversal

Non pulsatile