VASCULAR ARDMS BOARDS DAVIES TERMS AND EXAM QUESTIONS

VASCULAR ARDMS BOARDS DAVIES TERMS AND EXAM QUESTIONS VASCULAR ARDMS BOARDS DAVIES TERMS AND EXAM QUESTIONS What's the first major arterial branch of the aorta is the? Innominate artery or brachiocephalic artery The vertebral artery usually arises from the: Subclavian Artery The incidence of new strokes per year is: from 500,000 to 700,000 The abbreviation TIA stands for: Transient Ischemic Attack A TIA of the right anterior hemisphere of the brain will likely affect: The left side of the body - affects the side of the body opposite that of the ischemic hemisphere Amaurosis Fugax related to an internal carotid lesion will cause: Temporary blindness or shadowing of the ipsilateral eye. affects same side since thromboembolic activity from ulcerated ipsilateral carotid atheroma is suspected A transient ischemic attack: Resolves within 24 hours. TIA often last just a few minutes Simultaneous bilateral ocular symptoms in the patient with suspected cerebrovascular disease generally originate form: The vertebrobasilar arteries . usually originate in the posterior circulation , as the visual cortex is in the occipital lobe. The specific binocular symptom of homonymous hemianopia results from obstruction of a middle cerebral artery branch, not the vertebrobasilar system What are symptoms when vertebrobasilar circulation is effected? Vertigo, dizziness, ataxia, or other bilateral or global symptoms . What are symptoms when anterior circulation is effected? Facial Asymmetry, unilateral What accurately defines RIND also called stroke with recovery? A neurologic ischemic deficit that resolves completely after 24 hours. Describes an intracranial ischemic event that does not resolve within 24 hours but thereafter completely resolves. A 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: Stroke because it has persisted longer than 24 hours and has not resolved completely The infraorbital artery is a terminal branch of the: Maxillary Artery . It creates one of the potential anastomoses with orbital branches that can provide collateral pathways in the even of carotid obstruction Amaurosis Fugax can be interpreted as a: Transient Ischemic Attack of the eye. Dysphagia is : Difficulty swallowing. Symptom associated with vertebrobasilar insufficiency. A binocular disturbance that disrupts vision in half the visual field of both eyes is called: Homonymous Hemianopia Paresthesia refers to: tingling sensation A patient describes a 30-minute episode of garbled speech. This is called: Dysphasia . Aphasia is widely used as well but technically this is incorrect, since it means "absence of speech." A right-handed patient experiences a 30-minute episode of dysphasia. Which area of circulation is suspect? Left hemisphere . The speech area of the cortex is in the temporal lobe of the dominant hemisphere What is true regarding subclavian steal? It is usually a harmless hemodynamic phenomenon. It is caused by arterial obstruction proximal to the origin of the vertebral artery. This creates an abnormal pressure gradient that pulls or "steals" flow from the vertebral artery to perfuse the ipsilateral upper extremity. Subclavian steal occurs: more often on left side . A hemispheric stroke usually affects: The middle cerebral artery distribution and the contralateral side of the body Stenosis of the following vessel presents the highest risk for a TIA: Internal Carotid Artery The vertebral arteries branch from the subclavian arteries to unite and form the: Basilar Artery . This system is called the vertebrobasilar system and is responsible for the circulation to the posterior portion of the brain . A decreased pulse at mid neck is suggestive of: Common Carotid stenosis if the contralateral pulse is normal. Sometimes the right neck pulse can feel reduced because of the larger muscles overlying the carotid. Occasionally the right neck feels stronger due to tortuosity of the common carotid Artery. What is NOT true regarding carotid bruit? The absence of a bruit rules out significant stenosis. What are bruits caused by? Turbulent flow. Presence of a bruit is significant, since there is turbulent flow for some reason. The absence of a bruit does not rule out stenosis; severe stenosis may not cause a bruit. Bruits heard bilaterally, loudest low in the neck, are most likely caused by: Aortic Valve Stenosis. Aortic murmurs radiate distally, frequently into the low carotids. A stronger pulse is palpated in the right neck than on the left. This could result from all the following except: Innominate occlusion which would be expected to make the right carotid pulse weaker, not stronger. What is true regarding the clinical detection of a bruit? It means that turbulent flow exists. It may be indicative of valvular dysfunction in the heart. This finding may be normal in parts of some vessels and during periods of enhanced flow. During ordinary auscultation of a carotid bifurcation, the detection of a bruit that extends into diastole is: Highly significant for carotid artery stenosis or for any other arterial location. Perhaps this is related to the fact that elevated end-diastolic velocities are suggestive of severe stenosis. Which of these conditions is least likely to cause a bruit in the neck? Critical preocclusive stenosis of the internal carotid artery. Bruits often disappear when the stenosis is very high-grade or preocclusive. Why are brachial blood pressures obtained bilaterally when evaluating a patient for cerebrovascular disease? The brachial blood pressures are compared to see if they are equal. If one pressure is 15-20mmHg less than the other, subclavian steal is suspected on the side of the lower pressure. All of the following statements apply to pulsed-wave Doppler Except: The beam is continuously transmitted with intermittent reception according to vessel depth. How is the signal transmitted with pulsed-wave Doppler? In short bursts or pulses, and the transducer "listens" for the reflected signal in between the transmitted pulses. Loss of the spectral window with pulsed Doppler ultrasound occurs with: Flow turbulence What is the spectral window? Is the blank area underneath the systolic peak on the spectral waveform. It is filled in or "lost" when turbulent flow creates spectral broadening. Other reasons for loss of the spectral window include overuse of Doppler gain and incorrect positioning of the sample volume outside of the center streamline (depicting signals from the vessel wall or adjacent slower moving blood flow). The first intracranial branch of the internal carotid artery is the: Ophthalmic artery. Even though there is often a branch called the caroticotympanic artery, the ophthalmic artery is regarded as the first major branch of the internal carotid artery. It is central to indirect physiological testing. A duplex image of the carotid bifurcation that demonstrates a goblet-like configuration of the internal and external branches curving around a highly vascularized mass suggests: Carotid body tumor In duplex imaging, the best arterial wall image quality is obtained when the beam is at the following angle to the artery walls: 90 degrees. More echoes return to the transducer with 90 degrees Transcranial findings consistent with vasospasm following subarachnoid hemorrhage would include: Greatly increased mean velocities in the middle cerebral artery. In TCD, the normal direction of flow in the vertebral artery is: away from the beam . From the suboccipital, foramen magnum, approach, flow should normally be away from the beam. What is a condition that TCD might not be useful for ? Temporal Arteritis The Doppler beam angle considered optimal for standardization of duplex carotid studies at most vascular labs is: 60 degrees. It is generally accepted , to make consistent velocity measurements, one must be consistent about the Doppler beam angle. Some labs insist on 60 degrees , no more and no less; other labs keep it within the range 45 degrees to 60 degrees. The usual instrumentation for handheld TCD includes a probe with an operating frequency of: 2 MegaHertz In Transtemporal window of TCD, the normal direction of flow in the anterior cerebral artery is: Away from the beam A localized increase in mean velocity from 50 to 150 cm/sec at a depth of 50 mm with the TCD transducer placed in the temporal window probably indicates: Significant stenosis of the middle cerebral artery In handheld Transcranial Doppler, the angle of the beam relative to flow is assumed to be: 0 degrees. The circle of Willis receives its blood supply from which combination of arteries? Carotid and Vertebral arteries. This makes possible the ability of the brain to withstand sometimes extracranial carotid occlusion without significant symptoms You perform TCD, insonating the left anterior cerebral artery. The flow is toward the beam. This finding suggests: Ipsilateral carotid obstruction, with right- to- left collateralization. It suggests flow coming across from the other hemisphere via the anterior communicating artery. What would alter the frequency shift of the internal carotid artery Doppler signal? Anatomic narrowing or tapering of an artery can increase the velocity; increasing the operating or transmitted frequency shift. Readjusting the angle-correct cursor will change the velocity estimate for a given frequency shift, but won't change the shift itself. The threshold sensitivity does not affect the frequency shift. What diagnostic criteria for stenosis would be anticipated in the presence of a 50% - 60% diameter stenosis of the internal carotid artery? Elevation of systolic frequency with poststenotic turbulence. The most sensitive parameter for calling this degree of stenosis is the systolic frequency/velocity. Focal acceleration with distal turbulence is the hallmark of significant stenosis anywhere in the body. The best way to prepare a transducer for intraoperative use is: Place transducer and acoustic gel within a sterile sleeve or bag. What would autoclaving a transducer do ? Destroy transducers piezoelectric properties In using continuous-wave Doppler with spectral analysis to assess the internal carotid artery, what operator induced errors would most likely result in a falsely LOW frequency shift? Increasing the beam angle to 70 degrees. This would create a lower frequency shift than the proper 60 degrees angle . In continuous- wave Doppler , What would falsely higher frequency shift? Overdriving the Doppler signal gain. Allowing the signal beam to overlap both an artery and a vein. Changing to a higher-frequency transducer. Leaving the wall filter on. Of the chief advantages of continuous-wave Doppler, what is FALSE ? It allows more precise range-gating than pulsed-wave Doppler. Among the chief limitations of continuous-wave Doppler is (are): Depth information is not possible; precise location of flow pattern cannot be determined. What does the spectrum's characteristics of the external carotid artery? Has a prominent dicrotic notch, a sharp peak , and relatively little diastolic flow. What does the spectrum's characteristics of the internal carotid artery? Has lots of diastolic flow, a less distinct peak, and a less prominent dicrotic notch. True or False: The velocities greater than 80% in ICA suggest severe stenosis? False The three terminal branches of the ophthalmic artery are the: Nasal , Frontal , and supraorbital arteries. An ICA waveform has a peak-systolic velocity of 285cm/s and end diastolic velocity of 66cm/s . What is the problem? The elevated peak-systolic velocities and significant end-diastolic velocities suggest significant ICA stenosis greater than 50% by diameter In Transcranial Doppler using transtemporal window , the normal direction of flow in the middle cerebral artery is : Towards the beam . What determinants dictate transducers frequency selection for optimal carotid B-mode imaging? Desired beam width, the average and extreme depths of carotid vessels in the most subjects to be studied. What is the appropriate frequency to use when assessing the carotid arteries? 5 - 10 Megahertz What is true regarding axial resolution in carotid imaging? Resolves two targets positioned one in front of another along the axis of beam propagation. Improves the observer's ability to estimate vessel wall thickness. Using the temporal window for TCD, you find a strong signal with considerable diastolic flow at a depth of 50mm. This is most likely: Middle Cerebral Artery. 30-60mm is the depth with a velocity of 43-67cm/s . To optimize carotid vessel image data, lateral resolution should be: As small as possible , to resolve side by side lesions The TCD window used for assessing the middle cerebral artery is: Temporal A carotid bruit can be detected with color flow and spectral analysis as: A mosaic of low red and blue frequencies in color flow in tissue lying outside of the lumen, and oscillatory waveforms above and below baseline in the spectral waveform. What isn't consistent with total occlusion of the internal carotid artery ? Retrograde flow in the distal internal carotid artery Two of the major branches of the external carotid arteries include the: Superficial temporal and facial arteries. Characteristic of calcified plaque on B-mode image: Brightly echogenic plaque and acoustic shadowing What does homogenous plaque look like? Echoes are soft and gray and have essentially the same character throughout. The TCD window used for assessing the ophthalmic artery and carotid siphon is: Orbital The Doppler diagnostic criterion that is most important for calling greater than 80% stenosis is: End-diastolic velocity. An arterial stenosis that is 75% by cross-sectional area reduction corresponds to a diameter reduction of: 50% An arterial stenosis that is 80% by diameter reduction corresponds to a cross-sectional area reduction of: 96% Stenosis 10% by diameter reduction corresponds to a cross-sectional area reduction of: 19% Stenosis 20% by diameter reduction corresponds to a cross-sectional area reduction of: 36% Stenosis 30% by diameter reduction corresponds to a cross-sectional area reduction of: 51% Stenosis 40% by diameter reduction corresponds to a cross-sectional area reduction of: 64% Stenosis 50% by diameter reduction corresponds to a cross-sectional area reduction of: 75% Stenosis 60% by diameter reduction corresponds to a cross-sectional area reduction of: 84% Stenosis 70% by diameter reduction corresponds to a cross-sectional area reduction of: 91% Stenosis 80% by diameter reduction corresponds to a cross-sectional area reduction of: 96% Stenosis 90% by diameter reduction corresponds to a cross-sectional area reduction of: 99% A vascular lab calls a stenosis 60-70% by diameter based on its duplex assessment, but angiography the next day calls it 90% diameter. Possible reasons for this discrepancy might include: The stenosis is long and smooth, changing its Doppler character compared to that of a shorter lesion. Only one plane of visualization was used for angiography. Poor angle- correction with the duplex, creating artificially low velocity estimates. Acoustic shadowing prevented Doppler assessment of the maximal narrowing You are examining hardcopy of a TCD exam. One printout shows a spectral waveform labeled "suboccipital window", and the depth is indicated to be 90mm. This is most likely the: Basilar artery The characteristics of flow in the different carotid artery segments are: High-resistance character in the ECA, low-resistance in the ICA, with mixed character in the CCA The Doppler sample volume is usually adjusted: Small, to sample flow only from center stream What intracranial collateral pathways are clinically significant ? Circle of Willis, Trigeminal arteries, Hypoglossal arteries, and Pial branches of the Middle Cerebral arteries The angle-correct cursor for velocity estimates is best: Adjusted parallel with arterial walls The components of information on the spectral Doppler display include: Pixel brightness, indicating how many red blood cells are reflecting at a given frequency shift. Frequency shift on the y-axis. Time on the x-axis. Is depth on the y-axis shown on Doppler spectrum ? No You are using color flow to scan an internal carotid artery that dives steeply distally, as shown. The color gets much brighter, even aliasing, in the distal portion of the artery. The probably means: The frequency shifts are changing at different points in the color box due to the curvature of the artery. One must be constantly on the alert for changing angles, which create potentially misleading color flow changes. You perform percussion maneuvers on the superficial temporal artery and see oscillations on the spectral display. The artery being insolated is most likely: External Carotid Artery. What is not a useful color flow adjustment in an effort to detect slow flow in a possibly occluded internal carotid artery? Increase color flow Pulse repetition frequency, makes less sensitive to slow flow. What is not a duplex indication of a totally occluded internal carotid artery? Greatly increased end-diastolic velocities in CCA spectral display What are duplex indications of a totally occluded internal carotid artery? ICA lumen filled with heterogeneous echoes. NO Doppler or color flow obtainable within ICA lumen. Absence of diastolic flow in CCA spectral display. "Drumbeat" or "slapping" Doppler signal at ICA origin. During a cerebrovascular exam, you obtain equal brachial systolic pressures bilaterally and this pulsatile signal from between the transverse processes. You move the beam to the common carotid artery, and the waveform is below the baseline: You should ask the patient to perform a Valsalva Maneuver. Vertebral venous signals can be quite convincingly pulsatile. It may help to swing up for a common carotid signal to establish which direction is antegrade if you aren't sure from the display. The acoustic windows through which ultrasound may pass in performing transcranial Doppler and transcranial imaging examinations include: The Temporal bone, the orbit of the eye, the suboccipital window, and the submandibular area . What is not true regarding the internal carotid artery? It supplies a high-resistance system What are the main collateral pathways in the event of ICA obstruction? Posterior to Anterior. Contralateral hemisphere. ECA branches to ophthalmic branches . When visualizing the carotid bifurcation using duplex ultrasound, magnetic resonance imaging, or angiography, the best way to determine whether you are looking at the internal carotid is by the fact that: The external carotid has branches near the bifurcation and the internal carotid does not. Conventional angiography reveals 30% diameter stenosis in a symptomatic patient with severe stenosis by B-mode and peak systolic velocities of 250cm/sec in the proximal internal carotid artery. What is a true finding? Even double-projection arteriography may fail to fully determine diameter stenosis, especially in the event of vessel overlap. What is the main advantage of duplex ? The ability to visualize in cross section to the artery What are the major complications of cerebrovascular angiography? Death, stroke, arterial occlusion at the access site, and renal failure. What's not a major complication of cerebrovascular angiography? Inadvertent venous puncture. Major complications of cerebrovascular angiography occur in approximately: 1% of patients What information CANNOT be determined by cerebrovascular angiography? Degree of narrowing of ICA by cross-sectional area. (angiograms are longitudinal pictures of vessels; they cannot provide cross-sectional information) Angiography is generally considered only when the information is necessary for surgery or other urgent patient management because of all these factors: It carries a risk of stroke. It carries a risk of anaphylactic complications. It is expensive. It is an invasive procedure. The most common arterial puncture site for all forms of angiography, including cerebral, is the: Common Femoral artery. Advantages of angiography over duplex carotid studies include: Ability to visualize intracranial collaterals. Superiority at calling ulceration. Ability to visualize the entire cerebral vasculature. Ability to determine siphon stenosis. In an emergency room patient with stroke symptoms, the initial diagnostic exam of choice would likely be: CT - Computer tomography is the usual first choice exam, since it can distinguish hemorrhagic stroke from ischemic infarction and is usually more readily available. In addition, it is better tolerated because examination time is shorter. The other exams are quite possible as well, but less likely for initial evaluation. The two arteries creating the bidirectional signal observed 60 to 65 mm deep during transcranial insonation of the temporal window are the: Middle cerebral and anterior cerebral arteries Magnetic resonance angiography (MRA) functions by processing: Radiofrequency pulses created by tissue and blood flow. How does MRA work? works by sending pulses of radio waves into tissue within a strong magnetic field. The resulting change of spin of the hydrogen protons create a signal that is then processed for image. Different processing methods 'time of flight" technique can create images of blood flow; hence MR angiography A pitfall of magnetic resonance angiography is: Patients with cardiac pacemakers cannot be studied. It tends to overestimate the degree of stenosis. It requires a high degree of patient cooperation. The endarterectomy procedure (removal of plaque from an artery): May be used for obstructed lower extremity arteries. Are endarterectomy procedures most often performed on carotids? Most often performed on carotid arteries and has been largely superceded in the lower extremity arteries by the use of bypass grafts, it is still sometimes useful option for revascularization of iliac or femoral arteries. New Techniques have improved the outcomes for this procedure in the lower extremity arteries. Stenting procedures of the internal carotid artery: Are technically less demanding than stenting of coronary arteries If a hypertensive patient has experienced multiple TIAs and has an 80% diameter stenosis of the internal carotid artery on the side referable to the symptoms: Carotid endarterectomy is probably recommended. Symptomatology of a patient with any stenosis of the internal carotid artery makes it likely that endarterectomy recommended. The NASCET trial indicated that the best treatment for carotid stenosis in the symptomatic patient is: Carotid Endarterectomy for stenosis greater than 70% in diameter The most common medical treatment of acute ischemic stroke consists of: rtPA - Recombinant tissue plasminogen activator is useful in improving outcomes only if administered within three hours of the onset of symptoms. Hypertension is associated with hyperperfusion syndrome: After carotid endarterectomy . It's a potentially serious complication Which of these patients would least likely be considered at high risk for deep venous thrombosis? A 75-year-old woman admitted for transient ischemic attack. Individuals with cancer, fractured hips, multiple injuries, congestive heart failure, and obesity are at greater risk. The primary concern in patients with acute deep venous thrombosis is: Pulmonary embolism may occur. Which arteries do NOT arise from the subclavian artery? Superior Thyroid artery What's another name for "internal mammary" artery? "Internal thoracic" artery What is the most common anomaly of the circle of Willis? Absence of hypoplasia of one or both of the communicating arteries. Some causes of deep venous thrombosis may be: Trauma, Hypercoagulability, and Extrinsic compression upon deep veins. The greatest pressure of venous hypertension in secondary varicose veins occurs: During muscle contraction. Forces blood out to the superficial veins via incompetent perforating veins. What factor is least likely to contribute to deep venous thrombosis? Diabetes - is a risk factor for atherosclerosis , not DVT Virchow's Triad includes: Stasis, Hypercoagulability, and intimal injury What is NOT a risk for DVT? Smoking . It is only a risk factor if patient is taking birth control pills and smoking. What percentage of pulmonary emboli originate from lower extremity deep venous thrombosis? greater than 90% The vascular technologist knows that chronic venous insufficiency and ulceration are: Chronic but controllable . This explains the profound interest in diagnosing and treating deep venous thrombosis before it creates bigger problems. 543 What can lymphedema by caused by? Trauma or surgical excision of lymph pathways . Infection. Inflammation. Radiation and chemotherapy. NOT obesity. A varicose vein is most often: A dilation of the greater saphenous vein or superficial tributary. Varices resulting from deep venous valvular insufficiency and incompetent perforators are called: Secondary varices. may be from chronic excessive intravenous pressure transmitted from the incompetent deep system. A baker's cyst is a collection of: Synovial fluid from the knee joint. A thrombus is found in a gastrocnemius muscular vein approximately a third of the way down the calf from the knee. If this were propagate proximally, it would next involve: The popliteal vein - gastroc veins empty into the popliteal vein. A thrombus is found in a soleal vein, a bit proximal to mid calf. If this were to propagate, it would next involve: The posterior tibial viens - The soleal veins empty into the posterior tibial and peroneal veins Approximately what percentage of untreated calf-vein thrombosis is thought to propagate to a proximal level (i.e. , popliteal or above)? 15-20% -( Zweibel says up to 28%. Perhaps about 1/2 of DVT does not involve the calf. Many patients with isolated calf-vein thrombosis go on to have significant problems with chronic venous insufficiency and pulmonary. ) One complication of deep venous recanalization is: Damage to venous valves, allowing reflux. (In more than half 60% of cases of recanalization, the venous walls and valves are permanently damaged, and the valves are stuck to the wall of the vein and unable to close. The result is venous incompetence, and reflux occurs when the individual stands.) Two weeks after a fracture of the femur, a 33-year-old female is seen for swelling of the calf of the same leg. The preliminary diagnosis, prior to performance of any noninvasive testing, should include: Deep Vein Thrombosis; a remoter possibility is traumatic Arteriovenous fistula, which tends to increase distal venous pressure. Popliteal entrapment is NOT a likely call. Symptoms of chronic venous insufficiency might result from what? Calf-Vein thrombosis, popliteal vein thrombosis, superficial insufficiency, Iliac vein thrombosis. Isolated gastrocnemius thrombosis unlikely to: create significant chronic venous insufficiency symptoms. It is only fairly recently that we have come to know that even lesser saphenous insufficiency can cause stasis ulcers. Patients suspected of having venous disease may complain of pain that is: Relieved by elevation -Elevation of the extremities decreases venous hypertension and pain. Patients complaining of pain, swelling, and erythema of the lower extremity may have deep venous thrombosis, but the vascular technologist knows that diagnosing DVT by these symptoms alone is approximately: 46-62% accurate Edema caused by deep venous thrombosis is characterized by: Swelling in the ankles and legs but not the feet. (Usually swelling is not found in the feet in venous disease. ) Helical flow with flow separation on the wall away from the flow divider is a sign of: Normal flow dynamics. (Flow separation at the posterior wall of the carotid bulb occurs because the linear momentum of the flow is disrupted by the large sinus and sharp curve at the carotid bulb. Flow separation depends on a relatively disease-free bulb. ) What is not a risk factor for acute deep venous thrombosis ? Arthritis -is the least likely cause of DVT Complaints of chronic unilateral lower extremity swelling, aching, and a sense of heaviness most likely suggest: Postphlebitic syndrome A patient with chronic venous insufficiency complains of sudden onset of edema and pain in the affected leg. This may be related to: Recurrence of acute deep venous thrombosis. (A sudden onset of new symptoms must be taken seriously) Pitting edema of both lower extremities is likely related to: Cardiac or systemic origin. with congestive heart failure as a predominant feature. Insufficient veins have the following flow characteristics : Caudal blood flow may be abnormal while the patient is quietly standing. Venous pressure at the ankle in the supine patient does not differ from that of normal limbs. Venous pressure at the ankle in the walking patient is markedly increased compared to that of normal limbs. With exercise in patients with postphlebitic syndrome, what is not true? They usually have a quick decreased in venous pressure that takes a minute or two to return to pre-exercise levels. Patients with a swollen limb who have just returned from a country where filariasis is endemic may be suspected of having: Lymphedema - (Filaria is a nematode that takes up residence in the lymph system and can cause lymphedema. This would be a somewhat obscure differential diagnosis for deep venous thrombosis.) A patient presents with bilateral lower extremity edema and nephrotic syndrome. Thrombus is suspected at which level? Inferior Vena Cava. (To create bilateral edema, thrombus would have to involve either both iliac veins or , more likely, the IVC. This situation might also cause renal dysfunction due to obstructed renal vein outflow.) Lower extremity ulcers are overwhelmingly the result of: Venous Ulcers . (Three -quarters of lower extremity ulcers were caused by chronic venous insufficiency) Normally, venous flow in the calf is from the superficial to the deep veins through perforating veins. However, this flow might be reversed when: Deep venous obstruction is present. The most common anatomic variant of the aortic arch is: A common origin of the innominate and left common carotid arteries. occurring approximately 22% of individuals. A patient presents with acute pronounced bright red discoloration and edema of the skin along the anterior calf. The most likely diagnosis: Cellulitis (inflammation of skin and deeper tissues caused by an infectious process is one of the common differential diagnoses for deep venous thrombosis. ) A patient with a pulmonary embolus might have any of these : Chest Pain, reduced arterial blood gasses, diaphoresis, shortness of breath. (quite similar symptoms of myocardial infarction.) Typical findings of skin discoloration in a patient with chronic venous insufficiency are: Rusty brown color at ankles and calves. A condition that presents as a severely swollen, blue, cool lower extremity is called: Phlegmasia cerulea dolens The clinical examination for deep venous thrombosis is: Neither specific nor sensitive. (Deep venous thrombosis is famously difficult to call based on signs and symptoms, although again chronic unilateral edema is the single best predictor.) What is associated with chronic venous disease? Pigmentation, brawny edema, subcutaneous fibrosis, & cutaneous atrophy. What is TRUE regarding chronic venous ulceration? Lesions are usually found on the lower third of the leg around the medical aspect of the ankle. Some time after being hit by a car, a patient has severe pain in the anterior aspect of the right knee and massive left lower extremity edema. The patient most likely has: Extensive left femoropopliteal deep venous thrombosis. Massive edema suggests complete outflow obstruction or femoropopiteal thrombus. An elderly patient who presents with localized pain at mid calf has an ultrasound exam that reveals a nonocclusive thrombus of the superficial femoral vein. The calf pain became excruciating after administration of heparin. A second ultrasound exam shows: A hypoechoic mass in the shape of an egg at mid calf, thought to be a hematoma. A patient presents with a unilateral chronic swollen leg and a previous diagnosis of deep venous thrombosis 3 years earlier. The most likely finding would be: The popliteal vein is patent and the valve are incompetent. The greater saphenous vein: Originates along the medial dorsum of the foot. Passes superiorly, anterior to the medial malleolus. Is accompanied by the saphenous nerve. Receives tributaries from all surfaces of the lower extremity. Chronic deep venous obstruction will increase: Ambulatory venous pressure. (increases dramatically in chronic venous obstruction) Brawny skin changes at the ankle most likely represent: Chronic venous insufficiency Select the best statement regarding comparison of venous and arterial ulcers: Venous ulcers are usually not painful and are located cephalad to the foot. (venous ulcers treated with Unna boots -compression system with medicated dressing ) Signs that a general practitioner may use in an attempt to diagnose deep venous thrombosis include : Pain on passive dorsiflexion of foot -Homans' sign . Anteroposterior calf compression-Bancroft's sign. Inflating a sphygmomanometer to 80mHg on calf -Lowenberg's sign . Physical findings of edema. A common physical finding in pulmonary embolism is: Tachypnea - Rapid respiration What is NOT a clinical presentation of pulmonary embolism ? Positive lower extremity venous ultrasound What venous issue cannot be diagnosed by photoplethysmography ? Superficial thrombophlebitis in the leg The most reliable method for establishing the diagnosis of pulmonary embolism is: Pulmonary angiography. (not undertaken lightly, but it is the definitive test for pulmonary embolism) Doppler examination alone, without B-mode, is unlikely to detect the presence of venous thrombosis in: A peroneal vein. (calf veins are paired continuous-wave flow signals may continue to sound normal in one branch even if the other branch is thrombosed. ) A patient is seated with legs dangling and a photoplethysmograph sensor placed just above the medial malleolus. After dorsiflexion of the foot five times, this tracing is made. The tracing is consistent with: Essentially normal venous refilling. (venous incompetence is illustrated by refill times of less than 20 seconds. This well exceeds that refill time.) True or False : The greater saphenous vein passes superiorly on the lateral side of the knee. False A 46-year-old man presents with calf and ankle edema, mild calf discomfort, and a soft mass behind the knee. Continuous Wave Doppler studies are negative except for some continuous flow over the popliteal vein. An additional test that might be useful is: Ultrasound imaging. In continuous - wave Doppler reflux testing, a normal result is: Cessation of flow with proximal compression, resuming on release. (augmentation with proximal compression or on release of distal compression indicates insufficiency. ) The test for venous incompetence that uses tourniquets and alterations of patient position is called: The Trendelenburg test. (this is a venerable test whose accuracy has been called into question. ) A continuous-wave Doppler examination of the lower extremities, performed to diagnose deep vein thrombophlebitis, revealed augmentation upon compression proximal to the probe at all standard levels studied. The diagnosis is: Femoropopliteal and posterior tibial valvular insufficiency. (proximal compression should not elicit flow signals if the valves are competent. ) Venous refilling time by photoplethysmography was 10 seconds without a tourniquet applied and 25 seconds with a tourniquet applied to the lower thigh. The diagnosis is: Superficial valvular insufficiency . (the tourniquet took the superficial system out of the picture, which returned the result to normal. Therefore, the superficial system caused the rapid refill.) The examiner listens with continuous wave Doppler to the superficial femoral vein at mid thigh and performs a calf compression. The compression maneuver augments the signal. This finding suggests: This is a normal finding. (femoral vein augmentation with gentle calf compression suggests probable patency between the two levels. This information can be helpful when the duplex scan is technically difficult. ) During a duplex venous exam, Is venous reflux least likely to be associated with acute deep venous thrombosis? Yes it is least likely. May or may not be associated with deep venous thrombosis, but usually is a chronic condition found after the acute event. What is the least effective technique in detecting significant deep venous thrombosis? Photoplethysmography. Most often, the settings for venous color flow imaging of the lower extremities: A low PRF scale setting is necessary for the slower flow . When performing lower extremity venous Doppler assessment in normal patients, cephalad flow diminishes: During Valsalva maneuver. During inspiration. During proximal compression. The superficial vein that sends flow to the three main perforating veins of the distal calf -Cockett perforators is called: Posterior arch vein. On continuous wave Doppler assessment, a patient with a swollen left leg has loud, continuous flow signals from the left greater saphenous vein. The asymptomatic leg has nonspontaneous flow in the right great saphenous vein, which augments with distal compression. These findings are consistent with: Left leg Deep vein thrombosis The Valsalva maneuver: Slows down or stops venous flow everywhere in the body (Valsalva maneuver increases pressure within both thoracic and abdominal cavities) Is Gaietiness a commonly assessed characteristics of Continuous wave venous Doppler? No it is not. A patient presents with a swollen right lower extremity. Duplex imaging demonstrates patency of the femoral, popliteal, and calf veins. However, Doppler at the common femoral level on the right is continuous, not changing with respiration, while Doppler of the left common femoral vein is phasic. These findings might suggest: Right iliac thrombosis. (If respiratory pressure changes are not transmitted to the lower extremity venous signals, the technologist should be suspicious of proximal obstruction.) The optimal patient position for imaging of the lower extremity vein is: Semi-Fowler's position -raising the trunk and head but not the knees, and Reverse Trendelenburg's position- patient supine, head up, and feet down. Demonstration of vein-wall coaptation in the extremities is best performed: In transverse plane without color flow. ( allows careful visualization of the coapting walls as well as of multiple vessels. This part of the study in grey-scale procedure; color flow should be left off to allow scrutiny of walls) The examiner uses color flow to assess for competence at the common femoral vein level. With Valsalva maneuver, there is red flow lasting approximately half a second, then blue flow on release of Valsalva. This finding is equivocal for significant valvular incompetence. 0.5 seconds of reflux ( is often cited as a threshold for calling incompetence, although some labs use a full second or longer) Signs on duplex venous imaging of acute rather than chronic deep vein thrombosis include: Distended vein , dark intraluminal echoes, slightly compressible (spongy) character to thrombus, presence of a "tail" suggesting poor adherence to wall. Limitations of handheld continuous wave Doppler venous assessment include : There may be bifid superficial femoral or popliteal veins. Non-occluding thrombus may not be detected. A collateral vein may be mistaken for the vein of intended assessment. Exact extent cannot be determined for follow-up studies. What is not a limitation of handheld Continuous wave Doppler venous assessment? Valvular incompetence cannot be assessed with continuous wave Doppler. The examiner scans the femoral veins and notes a very small venous lumen , with bright, thickened venous walls along most of the thigh. These findings suggest: Chronic thrombosis Boyd's perforating vein is located: Near the knee. Thrombosis that appears on duplex scan to be dark, homogeneous in character, and poorly attached to the venous wall suggests: Acute thrombosis The examiner scans a patient with pain and swelling in the calf. A large, dark area is noted in the medial popliteal space, and no vascular communication to it is found. This most likely represents: Baker's cyst In a reflux study, the examiner images the popliteal vein and notes that the venous color flow display lights up blue with calf compression, then red for 2-3 seconds on release. You know that: This suggests venous reflux. (suggests significant venous valvular incompetence at this level. ) The area in the lower extremity where it is usually most difficult to bring about vein-wall coaptation with probe compression is: The distal thigh A long, brightly echogenic streak is noted in the common femoral vein, which is otherwise patent and compressible. It moves with probe compression and appears to move with venous flow. This most likely: A remnant of recanalized old Deep venous thrombosis. Pulsatile lower extremity venous Doppler signals would be associated with: Congestive heart failure. Continuous-wave Doppler assessment of the posterior tibial levels reveals nonspontaneous flow that augments with foot compression. This finding: Is within normal limits in a cold patient. The following tracing is taken from a patient with chronic ankle and calf edema. The PPG sensor is placed slightly proximal to the medial malleolus, and the patient dorsiflexes five times, then relaxes. The tracing: Suggests significant valvular incompetence. ( This PPG result from a patient with chronic calf and ankle edema is repeated, this time with a tourniquet round the leg just below the knee. There is no appreciable change in the tracing. This finding: Suggests deep venous valvular incompetence. Descending venography is performed to diagnose: Valvular insufficiency. (it checks valve function) The left common iliac vein: Crosses posterior to the right common iliac artery just distal to the aortic bifurcation Contrast venography: Invasive (very sensitive and specific test) The venous puncture for introducing contrast in venography to assess for deep venous thrombosis is done at what level? Dorsal vein on the foot The venous puncture for introducing contrast in venography to assess for valvular insuffiency is done at what level? Common femoral vein. The patient position for venography is: On an exam table tilted 60 degrees upright What is a potential complications of venography? Allergic reaction to contrast. Toxicity to kidneys. Arteriovenous fistula. Thrombophlebilitis. Is Iatrogenic cerebrovascular accident a potential complications of venography? NO Acute deep venous thrombosis is commonly indicated in venography as: Area of no contrast, often with "railroad track" lines along walls. The "gold standard" test for pulmonary embolus, though it carries its own risk for compromised patients, is: Pulmonary angiography A radiosctope test for pulmonary embolism that involves both breathing and injection of the isotope, and is usually reported in "high, medium, or low probability" of pulmonary embolus, is called: V/Q scan - ventilation/perfusion lung scan The drug heparin: can cause thrombocytopenia Heparin: is a protein. As such, it can activate antibodies in a sensitized individual. It affects the partial thromboplastin time, but not the prothrombin time. It has no direct actions on clots once they are formed. Protamine is used to reverse the effects of heparin. The drug has a significant complication rate and can produce thrombocytopenia (diminished blood platelet count). Chronic venous insufficiency frequently leads to ulceration. The vascular technologist knows that the patient can help prevent ulceration by: Elevating the legs above hear level more than 4 times a day for 20 minutes. Using support stockings when ambulatory. From this cross-sectional diagram of the thigh, reading from superficial to deep, identify the vessels marked: Greater saphenous vein, superficial femoral vein, profunda femoris vein. What are possible complications of heparin? Thrombocytopenia. Formation of antiplatelet antibody. Intraabdominal bleeding. Platelet aggregation. Is decreased activated partial thomboplastin time a possible complication of herparin? NO - it would be expected to increase. After the initial dose of heparin, the current standard of treatment for deep venous thrombosis consists of placing the patient on the following medication for 3 or more months: Sodium Warfarin or Coumadin - drug for long term anticoagulation Commonly performed methods of vena cava interruption for recurrent pulmonary embolism is: The bird's nest filter. The Greenfield umbrella filter . The nitinol (nickel- titanium alloy) filter. The vena Tech filter. The etiology of arterial aneurysms includes all of the following : Syphilitic, degenerative, inflammatory, congenital. More than 90% of infrarenal abdominal aneurysms are of: Degenerative origin . (because of atherosclerosis) A condition that causes nonatherosclerotic narrowing of brachiocephalic arteries in overwhelmingly female patients is called: Takayasu's arteritis. The most common source of lower or upper extremity peripheral arterial embolus is: The heart, 80-90% What is another common source of peripheral arterial emboli? aneurysmal mural thrombus, especially in the aorta, iliac, femoral, and popliteal arteries. What is the most common source of cerebrovascular embolic activity ? Atherosclerotic carotid disease. Aneurysms are most often caused by: Congenital arterial wall weakness and atherosclerosis . The angular artery is the terminal part of the: Facial artery The brachial veins connect the: Ulnar and radial veins to the axillary vein An occlusive disease of medium and small arteries in the distal upper and lower limbs of primarily young male heavy smokers is: Thromboangiitis obliterans or Buerger's disease. A condition which might result from reperfusion edema following bypass surgery, causing ischemia due to compression, and which might call for treatment by fasciotomy, is called: Compartment syndrome. The combination of neuropathy and peripherally distributed atherosclerosis makes the diabetic patient especially vulnerable to: Foot lesions. The chance of a patient dying from a rupture of an abdominal aortic aneurysm averages: 80% TRUE or FALSE : Does smoking increase the oxygen-carrying capacity of blood ? FALSE . the carbon monoxide byproduct of smoking decreases the oxygen-carrying ability of red blood cells. In the lover extremity circulation, the most common site of atherosclerosis is: The arterial segment beginning in Hunter's canal or adductor canal. What is true about popliteal aneurysms ? They can cause symptoms by compressing contiguous structures. They pose a significant risk of limb loss due to embolism or occlusion. They are found bilaterally in greater than 10% of cases where they exist. Are most preruptured Abdominal aortic aneurysms discovered because of abdominal symptoms or distal emboli? NO . AAAs rarely extend above the renal arteries. The risk of claudication in diabetic patients is: Greater than 4 times the risk in the general population. Is hypolipidemia a risk factor in peripheral arterial occlusive disease? No . Is the distal deep femoral vein imaged often? No its the least commonly imagined because its depth and is usually very difficult to image. The vascular disease that presents as back, abdominal, or flank pain is: Abdominal aortic aneurysm Takayasu's arteritis is most often found in: Young Women - in the second or third decade of life. most frequently in Asian women Common signs of advanced arterial insufficiency of the lower extremity include which of the following? Loss of hair growth over the dorsum or the toes and feet. Thickening of the toenails. Dependent rubor . The term cyanosis describes: Blue color of tissue due to ischemia. Symptoms : A. Bruit B. Absent pulse C. Foot rubor D. Right sided weakness E. Edema Signs: 1. Aortoiliac & SFA occlusion - C 2. Deep venous thrombosis -E 3. Subclavian artery occlusion -acute -B 4. Left carotid artery occlusion -D 5. Iliac artery stenosis -A A common evaluation for advanced lower extremity ischemia involves raising the supine patient's leg and then having the patient sit and dangle the leg . A positive result is described as : Elevation pallor, dependent rubor. Patients presenting with symptoms of claudication complain of: Cramping pain in the calf , thigh , or buttocks with exercise and relieved by rest. Patients presenting with a diagnosis of ischemic rest pain may complain of: Foot pain while in a horizontal position, relieved by standing or dangling the foot in a dependent position. Patients found to have ulcerating lesions or gangrene may have which of the following diseases? Any of the following are possible: Arterial insufficiency. Neuropathy. Vasospasm. Venous disease. The most common presenting symptoms in acute arterial occlusion include: The five Ps: Paralysis. Pulselessness. Pallor. Paresthesias. Pain. The term "muscle pump" refers to: The calf muscles - (mechanism of venous return from the lower extremities, which must overcome significant hydrostatic pressure in the upright patient. The veins and sinuses fill during relaxtion; Then contraction of lower extremity muscles propels blood cephalad. ) Patients with advanced peripheral arterial vascular occlusive disease exhibit which of the following skin changes? Shiny, scaly skin, dependent rubor, pallor on elevation. A 54-year old male relates a history of calf and 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. These symptoms are not typical of vascular disease. (These symptoms do not suggest claudication, symptoms of which are quite consistent. The pain associated with claudication is a muscle fatigue due to anoxia brought on by exercise. Claudication usually does not occur within moments of starting to walk, and , if it does , the distance one can walk is extremely limited. ) A diabetic patient with redness of the skin in the foot and toe probably has: An infection (can happen with or without peripheral vascular disease.) Early atherosclerosis of the lower extremities will be associated with: Claudication Which sign of symptom is least likely to be associated with arterial embolization? Progressive claudication (usually associated with slow progression of atherosclerosis, not with embolization. ) Rest pain is characterized by: Pain at night in the forefoot or foot that may go away with leg dependency. (Nocturnal forefoot pain relieved by dependency or exercise is the most common complaint of patients with rest pain. ) The symptom or sign most likely NOT associated with acute arterial occlusion is: Claudication - (may be experienced months or years prior to an acute arterial occlusion, or it may not be felt at all prior to the episode. The other symptoms are consistent with an acute event. ) Ischemic ulcers (lesions) are: Very painful and commonly located distally over the dorsum of the foot. (ulcer found above the medial malleolus is most likely venous in original) Common sites for auscultation of bruits in the lower extremity circulation include all: Abdomen, Groin, popliteal space. Is dorsum of foot a common site for auscultation of bruits in the lower extremity circulation ? No A vibration noted while palpating pulses is called a: Thrill Rubor is defined as: Red skin color. (examples are the cherry-red color of digits in a Raynaud's patient when the digital arteries reopen after prolonged spasm, or the bright red foot in dependency after elevation in a patient with advanced arterial occlusive disease.) Ulcers due to arterial insufficiency are found most often: On toes and distal foot. Delayed return of the capillary blush after pressure on the pulp of the digit is a sign of: Advanced ischemia. (capillary blush usually is seen after 1-2 seconds. In patients with significant ischemia, it may be delayed for many seconds. ) Signs of advanced ischemia in the lower extremity include all of the following: Slow venous filling after dropping the elevated extremity into a dependent position. Pallor on elevation. Rubor dependency. Ulceration at the dorsum of the foot. What is pitting edema? Usually a symptom of systemic disease such chronic heart failure, chronic venous disease, or lymphedema. Pulse sites commonly palpated in the lower extremities include : Common femoral. Popliteal. Posterior tibial. Anterior tibial. The absence of a bruit at the common femoral level: Cannot rule out significant stenosis at that level. (Bruits heard on physical examination are useful: Although the absence of a bruit does not rule out significant arterial obstruction, the presence of a bruit does suggest stenosis.) Auscultation of the abdomen, aortoiliac, and common femoral areas is important because: Presence of a bruit may be the first indication of arterial disease. The symptoms of anterior tibial compartment syndrome are: Swelling and/or palpable tenderness over a muscle compartment . Unilateral claudication in the calf and foot of a young individual suggests: Popliteal artery entrapment. (Is the most common cause of unilateral claudication in a young person.) A patient complains of digital pallor or cyanosis induced by cold exposure or emotional stimuli. These symptoms are characteristic of: Raynaud's phenomenon. (causes prolonged digital pallor or cyanosis followed by rubor or reperfusion.) The pulsatility index is defined as: Peak systolic to peak end diastolic velocity divided by mean velocity. (This is also known as Gosling's pulsatility index. This index is used mostly with continuous- wave Doppler or transcranial Doppler and increases with increased distal resistance. It is independent of the Doppler angle. ) Which is always TRUE of patients who suffer from intermittent claudication? There is pressure drop distal to the obstructed segment after exercise. vasodilation, greatly Which one of the following conditions will cause an increase in the pulse amplitude of the arterial pressure wave? An increase in peripheral resistance Which change occurs in the peripheral blood flow of limbs with obstructive arterial disease in response to laboratory-induced ischemia (reactive hyperemia procedure or exercise? Hyperemia is prolonged in obstructed limbs in comparison to limbs with no obstruction. Ankle/brachial indices in claudicating patients are usually: In the range of 0.5-0.9 The ankle/brachial index is obtained by dividing the: Ankle pressure by the higher brachial pressure. A velocity obtained in the mid superficial femoral artery is 225cm/sec, while a measurement just proximal to this site gives 90cm/sec. This suggests: greater than 50% superficial femoral artery stenosis. (stenotic velocity accelerates to double that of a prestenotic velocity suggest greater than 50% stenosis. ) The right high-thigh pressure measurement is 108mmHg, while the left high-thigh is 142mmHg. Brachial pressure is 122mmHg. Of the following, this most likely suggests: Right femoral artery obstruction. The key technology in arterial penumoplethysmography is: A pressure transduced monitoring cuff pressure over a limb. When assessing a digital artery with Doppler, patency of the palmar arch can be determined by: Alternatively compressing the radial and ulnar arteries while listening for changes in the digital artery signal Assessment of palmar arch patency is useful: Before placement of an ateriovenous arm shunt. Evaluating a patient with suspected subclavian steal. An analog Doppler waveform of the subclavian or axillary artery in a normal individual would typically resemble: A common femoral or superficial femoral artery waveform. A popliteal to dorsal pedal lesser saphenous reverse bypass graft has a peak systolic velocity of 28cm/sec at the distal anastomosis. Which of the following is true? This velocity may be normal for this graft. The two flow characteristics that define arterial stenosis anywhere in the body include focal acceleration of velocities and: Distal turbulence. Diastolic reversal of flow is most likely in: Extremity arteries at rest. Doppler velocity waveforms from upper extremity vessels may vary slightly from lower extremity waveforms because: The peripheral resistance is usually lower in the upper extremity. A 28-year-old male complains of exercise-induced cramping of the right calf that occurs after walking six blocks and is relieved within 5minutes 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 40mmHg on the right. These signs are Popliteal entrapment. ( claudication-like symptoms in a young person, especially a muscular male, are likely due to popliteal entrapment.) Your segmental pressure readings disclose a 36 mmHg decrease in pressure from the low-thigh to the below-knee anterior tibial artery, and a 10mmHg decrease from low-thigh to below-knee posterior tibial artery. These findings localize obstruction to the: Anterior tibial artery. Your segmental pressure readings indicate 126 mmHg at the high thigh, 144 at the low thigh, and 120 at the below-knee level. These findings might be the result of : Cuff artifact, poor cuff application, calcified arteries in a diabetic patient. All of the following devices, utilized in a standard fashion, can measure ankle pressures : Doppler ultrasound, strain-gauge plethysmography, photocell plethysmography, air plethysmography. This continuous wave Doppler waveform from a popliteal artery: Suggests interference from venous flow. Protocols for cardiac treadmill testing and claudication treadmill testing differ, the major difference being: Speed is varied during cardiac testing. (The standard cardiac treadmill protocol aims to increase the heart rate to a specific target level. ) A four-level pressure cuff technique is used to assess arterial disease in the legs. The high-thigh pressure is 140mmHg, with an arm pressure of 160mmHg, All of the following lesions can cause: Significant aortic stenosis , common iliac or external iliac artery disease, Superficial femoral plus profunda artery occlusion, common femoral artery disease. While performing a treadmill test, the patient complains of pain in the left arm and jaw, but denies any other pain. The examiner should consider that this could possibly be: Angina During assessment of ankle pressures, all three vessels at the level of the ankle are used to measure pressures. The pressure in both the posterior tibial and peroneal artery is 40mmHg and the dorsalis pedis pressure is 50mmHg. Which pressure should be used? The dorsalis pedis artery pressure should be used to calculate the ankle/brachial index. Your segmental pressure readings are indicated below. These findings could result from: Right common iliac obstruction, Right external iliac obstruction, Right common femoral obstruction, Right proximal superficial femoral obstruction. Normal diameter for the abdominal aorta is: 2-3cm A patient complains of rest pain. On physical examination, elevation pallor and dependent rubor are present. There are no palpable pulses in the leg. A pressure of 120mmHg is measured in the ankle. This pressure: Is higher than expected. (Due to the physical examination this pressure is much higher than suggested & would lead one to think that the pressures might be artificially higher than normal, perhaps due to calcification. ) A patient with a history of rest pain, 100-foot calf and thigh claudication, and an ulcer on the great toe of the left ankle pressure of greater than 300mmHg. This result is: Erroneous due to probable arterial calcification . (The result is likely due to calcified incompressible arteries. This is very common in diabetic patients) Which vein in the antecubital fossa connects the cephalic and basilica veins? Median cubital vein A patient with mild claudication-like symptoms has an ankle/brachial index for the affected leg of 1.02. This finding: Is an incomplete evaluation of this patient. After walking for 5 minutes on the treadmill, a patient experiences decreases in ankle pressure of 40% on the right and 15% on the left. These findings: Are typical for patients with claudication. (one cannot call occlusion vs. stenosis based on this info. These decreases suggest mild disease on the left and more pronounced disease on the right, typical findings in a claudicating patient) Referring to the readings below , Right arm 180/100mmHg Left arm 120/60 Right PTA 100mmHg Left PTA 90mmHg. The left ABI index is: 0.50 -90/180 In consideration of the pressure findings below, Right arm 180/100mmHg Left arm 120/60 Right PTA 100mmHg Left PTA 90mmHg, What is true and what is false? True - The patient has right lower extremity arterial disease. The patient has left lower extremity arterial disease. The patient has left subclavian artery disease. Arteriography would be recommended if bypass surgery is contemplated. False statement - The patient has renovascular hypertension. A male patient walks on the treadmill for an evaluation of leg symptoms. During the walk he reports that both calves and thighs start hurting at 10 seconds, the right worse than the left. He continues to walk for 5 minutes, after which he is stopped by the technologist. The symptoms do not resolve, but do not get worse during exercise. Considering the pressures obtained before exercise: Arm 130, Right ankle 130, Left ankle 120, and obtained after exercise: Arm 160, Right ankle, Left ankle 100. What is true? There is arterial disease in both legs. The symptoms are not due to vascular disease. The right leg is symptomatically worse. A patient walks on the treadmill until forced to stop at 3 minutes due to left calf and thigh pain. The right leg was asymptomatic throughout the course of the testing. Referring to the results below: Pre-exercise: Right arm 150, Right PTA 120, Left PTA 120 Post-exercise: Right arm 150, Right PTA 75, Left PTA 120, which of the following statements is TRUE? There is arterial disease in both legs. The left leg has worse disease than the right. The correct setting for arterial volume recording is: AC-coupled output, Amplification is appropriate for arterial Plethysmography. Doppler waveform abnormalities in the lower extremity arterial circulation distal to a hemodynamically significant stenosis include: An absent flow reversal component, blunting of the peak velocity, and prolonged upslope and downslope. Parameters usually assessed in exercise testing includes: Time required for recovery to pre-stress pressure level. Patient complaint of leg pain during exercise. Length of time of exercise. Magnitude of pressure drop. Reasons to perform reactive hyperemia instead of treadmill testing includes: Patient's inability to stand or walk. Patient's poor cardiac status. Patient has pulmonary problems. Patient has very severe disease in one leg, making exercise assessment of the other leg difficult. Which are not part of the deep veins of the upper extremity? cephalic vein, basilica vein , median cubital vein. A normal arterial volume waveform may have all except: Reverse- Flow component. ( May have all of these though swift upstroke, sharp peak, rapid downslope bowed toward baseline, dicrotic notch) The most widely used interpretive technique for analog Doppler waveforms is: A qualitative approach or pattern recognition. Normal Doppler waveform morphology for a peripheral artery includes: A sharp upslope and downslope and a prominent reverse flow component. A normal response of ankle pressure to exercise testing (such as treadmill) is: No change The amplitude of arterial volume recording waveforms: Is only marginally meaningful diagnostically Possibl