vascular board questions numbered
TRANSCRIPT
Vascular Board Questions
1. Name 4 Vascular Emergencies: Torsion: Ovarian & Testicular
Pulsatile Vascular massesDVT: UE’s & LE’sAcute changes in Neurologic symptoms
2. Predisposing Factors for DVT: (Causes) CHF
Pelvic & lower abd. surgeryCoagulopathy Birth controlParaplegia trauma
Prolonged bedrest
3. Valsalva results in stasis of blood flow & venous dilatation.
4. Inspiration results in a decreased Doppler signal and Expiration results in increase visualized flow.
5. With unilateral swelling the most common diagnosis is DVT.
6. With unilateral swelling the least common diagnoses would be:Ruptured baker’s cystCompartment syndromeMusculoskeletal injury
7. With bilateral swelling most common diagnosis is CHF & least common diagnoses are: Bilateral DVT or renal disease.
8. Predisposing Factors of UE DVT: Central venous cath’s & PICC line
Hypercoaguable stateIV drug use, or trauma or surgery in armCancer
9. Axillary & Subclavian veins are usually anterior to arteries.
10. For subclavian artery to compress try sniffing maneuver.
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11. Testicular torsion is most common in infants & adolescent boys.
12. Ovarian Torsion may occur in a normal ovary or ovary with pre- existing ovarian cyst or benign mass. Occurs more on the right and
there is an increased risk with pregnancy.
13. Symptoms of Ovarian Torsion:Pelvic pain
N&V
14. Aortic dissection is considered a vascular emergency caused by a defect in the intima but is usually asymptomatic and caused by trauma, HTN, pregnancy & Marfan’s Syndrome.
15. 4 types of Arterial Testing: Doppler Plethysmography
ABI’s/Pressures (PVR’s) ABI’s w/exercise Testing
16. When performing PVR’s, always evaluate the height, amplitude, & shape of the waveform. (HINT: HAS)
17. A normal PVR waveform has a sharp upstroke, & reflected wave.
18. Severe arterial disease shows a rounded waveform that eventually becomes flat.
19. Patients who are symptomatic but have normal PVR’s need exercise testing.
20. When performing a carotid study, the head is to the left of the screen.
21. When performing a carotid study, with an anterior approach the ECA is at the top of the screen and with a posterior approach the ECA is at the bottom of the screen.
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22. Clinical Indications for Carotids: CVA or TIA Amarousis Fugax Pre-op for CABG Post-endarterectomy F/U stenosis Bruit
23. The thicker the fibrointimal hyperplasia along the post wall, the higher the risk for heart disease.
24. The ECA has an early diastolic notch and a deflection in diastoleduring temporal tapping.
25. If a patient has a normal PVR and is symptomatic and cannot do exercise testing, have pt. do toe raises for 1 min. and do post
pressures.
26. If you get a high PSV and see no stenosis, other things to think of: Tortuous vessel stenosis/occlusion on contralateral side.
27. If you see lots of plaque and the PSV is not as high as you’d expect, Think of: Tandem lesions (lesions in a row) FMD Long segment stenosis >95% stenosis
28. Proximal to a high-grade stenosis or occlusion, you may see a low PSV with little or no diastolic flow representing a “knocking”
waveform.
29. A delayed upstroke with a rounded systolic peak distal to a high grade stenosis/occlusion is known as tardus parvus.
30. Decreased PSV’s in the CCA’s bilaterally think of:Decreased cardiac output
Cardiac diseases Aneurysm of ascending aorta
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31. The CCA’s & Subclavian on the right branch from the innominate Artery and on the left the CCA’s & Subclavian branch from the
Aorta.
32. Increased PSV’s bilaterally in the CCA’s think of: Aortic Regurgitation Bradycardia Thyrotoxicosis (hypermetabolic condition assoc. with
hyperthyroidism) HINT: I have this
33. When you see a decreased PSV with a more pronounced flow reversal in diastole throughout CCA that worsens as you reach the distal CCA & eventually becomes a “knocking” waveform, think of: High grade stenosis or obstructing lesion in ICA
34. If you see a tardus parvus waveform in the CCA’s bilaterally, most likely Aortic stenosis.
35. If you see tardus parvus waveform throughout RT. CCA & ICA with reversed flow in the vert. this is most likely stenosis of Innominate Artery, & if you see the same on the lt. it is most likely stenosis of the Subclavian Artery.
36. If you see a bilateral “knocking waveform” in CCA’s and it gets worse in the ICA’s, then most likely Intracranial stenosis.
37. If you see a waveform that look like the ICA (low-resistant) in the ECA then you know this is an occluded ICA.
38. If you see reversed diastolic flow in the proximal CCA’s bilaterally, think of: Aortic Regurgitation.
39. If you are doing a caroitid on a young patient with a stroke and no obvious neurologic symptoms are present ad you see a bizarre, variable waveform with a decreased PSV, think of: Aortic Dissection.
40. Subclavian Steal is more common on the lt. side and there is lower blood pressure in that affected arm.
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41. A common phenomenon following any injury to an arterial wall, including endarterectomy or angioplasty, involving proliferation
of smooth muscle in response to injury is called dissection.
42. Temporary shading of the vision of one eye is called amaurosis fugax, while double vision is known as diplopia and is a symptom
of vertebrobasilar insufficiency.
43. Increased PSV in the proximal subclavian with a tardus parvus in the Distal subclavian, most likely vertebral steal.
44. If you see a sharp systolic peak with a more rounded second peak in the vertebral artery with preservance of the antegrade flow, this is known as the pre-bunny waveform.
45. Arteritis of the Carotids with cocentric thickening of the wall can be caused by: Radiation therapy FMD Takayasu’s Arteritis Temporal arteritis
46. With Carotids we use the equation for Flow: Q=VxA
47. When you see a decreased PSV (30-40cm/sec) in any artery or graft, this is most likely due to a nearly occluded vessel.
48. When you see a “bisferiens” waveform when doing carotids, most likely a diagnosis of: Aortic Regurgitation.
49. If a patient present with vertebrobasilar symptoms and arm ischemia, Subclavin steal is most suspected and most commonly occurs in the left vert and it is larger than the right.
50. Vertigo or bilateral ocular symptoms are related to the
Vertebrosbasilar system.
51. Induced Hyperemia on the ipsilateral side with a pre-bunny waveform can convert an incomplete steal to a complete steal.
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52.A neurologic ischemic deficit that resolves completely after 24 hours is known as RIND (reversible ischemic neurologic deficit) stroke.
53. A “to and fro” waveform in the vert. represents a significant steal while a reversed flow signal represents a complete steal.
54. Condition caused by restricted blood flow to the heart causing edema to the face & arms is referred to as: SVC Syndrome
55. Catheter Angiography is considered the Gold Standard method for evaluating disease of great vessels including subclavian steal.
56. Atherosclerosis is the most common cause of subclavian steal.
57. Symptomatic patients with a greater than 70 % stenosis is warrant consideration for carotid endarterectomy.
58. Carotid endarterectomy or stenting is done for pts. with Carotid stenosis or more conservatively, antiplatelets, are given to the patient.
59. Symptoms of ICA lesion: amarousis fugax aphasia paresis (unilateral) paresthesia (unilateral)
60. The carotid siphon is the most common place for ICA stenosis.
61. Risk Factors for ICA disease: smoking RAY_RAY hyperlipidemia DM HTN
62. Bilateral blood pressure difference of >30 mmHg suggests stenosis of >50% of subclavian or axillary artery.
63. The proximal end of this very superficial vein is at about the level
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of the very distal axillary artery: Basilic v.
64. This artery is found just superior to the left renal vein: SMA
65. This artery runs post. to the tibia along most of its course.(Who’s buried in Grant’s tomb?) Post. tib artery
66. Compression of the neurovascular bundle which may contain brachial plexus, subclavian artery & subclavian vein is called
Thoracic Outlet Syndrome.
67. When doing penile plethysmography, Doppler velocity signals are taken of the CFA, PTA, and DPA.
68. Poor arterial inflow to LE due to proximal obstruction may affect penile arterial flow.
69. Congenital narrowing or stricture of the thoracic Aorta is known as Coarctation of the Aorta.
70. This calf artery is found along the soleal muscular septum near the tibia: PTA
71. The proximal limit of this vein is the popliteal vein: LSV
72. This calf artery is found along the intersosseous membrane between the tibia and the fibula: ATA’s
73. The renal arteries are posterior to the lt. renal vein.
74. A normal Penile/Brachial Index is > or equal to 0.75 & <0.65 is consistent with vasculogenic incompetence.
75.Most common location of true aneurysm is infrarenal aorta.
76. An increase in dorsal vein velocity could suggest a venous leak.
77. PPG’s are mainly used for the digits and penile vessels.
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78.Plethysmography, in combination with Doppler segmental pressures, helps differentiate between true claudication from
pseudoclaudication.
79. Large, sinusoid, saccular veins that drain into the post. tibial and peroneal veins and located deep within the calf muscles are called: venous sinuses
80. Plethysmography cannot differentiate b/t major arteries and collateral branches and tracing reflects all arterial flow beneath cuff.
81. Both volume and photo plethysmograpy are evaluated using qualitative criteria and not quantitative.
82. Volume changes beneath cuff are converted to pulsatile pressure changes within the air-filled cuff bladder.
83. The venous sinuses are dilated vessels in the soleal & gastrocnemius muscles of the calf that serve as reservoirs for venous blood.
84. Photo-plethysmography (PPG) measures the change in skin blood volume using a small light probe placed on the skin just above the ankle and used measurement of the efficiency of the calf pump of the lower leg. (venous insufficiency)
85. PPG detects cutaneous blood flow rather than truly measuring volume changes.
86. Diode transmits infrared light into subcutaneous tissue with backscattered light reflected back to the adjacent photo-sensor
87. With Photo PPG’s, the cutaneous blood flow determines the reflection. Increased blood flow results in decreased reflection.
88. With volume (air) plethysmography, as arterial flow moves under the cuff, momentary volume changes in the limb segment occur.
89. Photo-plethysmography (PPG), uses a photocell that consists of a
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light-emitting diode and photo-sensor.
90. Air plethysmography is the same as PVR’s.
91. With PPG’s, blood attenuates light in proportion to its content in tissue.
92. With PVR’s, machine performs a self-calibration when activated.
93. PPG’s are used for venous reflux testing and consists of a transducer, amplifier, and strip-chart recorder.
94. PPG’s measure cutaneous blood flow while PVR’s measure volume changes.
95. Abnormal waveforms on PPG’s and PVR’s always reflect significant disease proximal (above) to level of tracing .
96. Ascends medially following the tibia bone and along the medial surface of the thigh: GSV
97. The more significant the disease on PVR’s, the more rounded the
waveform until it eventually becomes flattened.
98. A normal PVR wavefrom displays a fairly rapid upstroke, sharp systolic peak with reflected wave.
99. With mild and moderate arterial disease, PVR displays an absentreflected wave (notch).
100. An almost normal waveform quality may accompany abnormal segmental pressures because collaterals can underestimate significance of obstruction.
101. When performing PVR’s, AC mode is used for arterial studies & DC mode is used for venous studies.
102. Blood flow in the body starts at the lt. ventricle and ends at the rt. atrium.
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103. Expect to see Spectral Broadening at these sites: HINT: FEAT AV fistula Endarterectomy site Focal atherosclerosis ( a high stenosis) Tortuous and small vessels
104. Name 4 types of emergency vascular masses: (HINT: APAP) AAA AV Fistula Pop Artery aneurysm Palpable groin mass: PSA (pseudoaneurysm), hematoma, aneurysm
105. 2nd largest artery in the body: pulmonary artery
106. LE Arterial Duplex Criteria for ≥ stenosis: Doubling of PSV (at site of max stenosis compared to prx. to stenosis) Triphasic (normal) to biphasic to monophasic
107. A Hemispheric Index of _>3 and a PSV of > 120 cm/sec. indicates vasospasm of the MCA.
108. Water displacement plethysmograpy is accurate for detecting changes in limb volume and is measured by the height of the water
in the chimney.
109. Hydrostatic Pressure as well as the water surface are measured and used for calculation of transient changes in limb volume when performing water displacement plethysmography.
110. With volume plethysmography, cuffs applied too tightly, can obliterate or diminish the pulse wave forms. With photo
plethysmography improper contact with skin surface will cause
poor results.
111. Digital plethysmography differentiates between fixed arterial obstruction from vasospasm and is used to detect Raynaud’s disease following cold immersion.
112. With digital plethysmography, a photocell is placed on the plantar
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side of toe using double-stick tape or velcro and pulses are recorded on paper.
113. Following cold immersion, abnormal cold sensitivity is likely if the amplitude fails to return to baseline level with 5 minutes.
114. The presence of artifactually high ankle pressures from arterial calcinosis usually requires a toe/brachial index,
115. Normal UE digit Finger/brachial indices should be 0.8-0.9 Normal LE digit Toe/brachial indices should be 0.6-0.8.
116. Transcutaneous Oximetry (TcPO2) determines wound healing & amputation level by measuring the oxygen level of tissue beneath the skin.
117. The oxygen that escapes through the skin is measured by a sensor in an electrode affixed to a fixation ring when performing TcPO2 .
118. The electrode converts a chemical reaction to a “current” reading which is converted to pO2 (partial pressure of oxygen in blood) reading in mmHg.
119. TcPO2 readings: Healing should occur with a pO2 reading of 70-80 mmHg. Non-healing levels are _10-15___ mmHg.
120. Arteries are larger in diameter than veins. Arteries are more elastic & muscular.
121. Contraction or relaxation of a muscle changes the size of the lumen
& controls blood pressure in a vessel.
122. Organic disease is Fixed obstructive disease & Functional disease is Intermittent disease.
123. A Transcranial Doppler study utilizes Pulsed Doppler.
124. “ Peaked ” pulse is a characteristic seen in digit pulse contours in patients with Raynaud’s phenonema.
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125. Evaluate UE Dialysis grafts as follows: Inflow artery
Arterial anastamosis Body of graft
Venous anastamosis Outflow vein
126. Artifact displayed as on Spectral Analysis as above & below the baseline cause by very strong reflectors, e.g. (bone), or from too much gain: Mirror-Image
127. 2 types stents: which is self employed and which is balloon
expandable? Palmaz-balloon expandable Wall-self expanding
128. A TIPS shunt in the liver is created b/t the PV & HV with the hepatic v. end being the outflow end & Portal v. being the
inflow end.
129. Other causes than DVT for leg swelling: lymphedema cellulitis CHF Baker’s cyst rupture liver failure renal failure
130. 3 types of AV Fistulas: (Hint: CAT) Congentital
Acquired Theraputic
131. Iatrogenic means cause by trauma, medical exam (post biopsy) or treatment.
132. Straight grafts include Brachial artery to: (Hint: JAC) Jugular v Axillary v Cephalic v
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133. Synthetic grafts can be used immediately after implantation whereas natural grafts take 3-4 wks to mature before you can
use it.
134. U-Shaped synthetic grafts are established as loops from brachial artery at elbow to basilic or brachial vein. (HINT: 3 B’s)
135. Theraputic grafts are used for: dialysis after thrombectomy for pelvic vein thrombosis
136. An AV fistula is a direct communication b/t an artery and vein that bypasses the capillary bed.
137. Under-estimation of disease process may include: low cardiac output long, smooth plaque formation inappropriate Doppler angle stenosis at area of dilatation (bulb)
138. Suitable volume for hemodialysis fistula’s is 300-1200 ml. in.
139. Other factors that can cause ↑ flow other than a stenosis: tortuous vessel
↑ cardiac output inappropriate Doppler angle collaterals
140. A Brescia-Cimino graft is the connection of the cephalic v. to the radial artery.
141. Shunt flow is determined by the diameter of the feeding artery and it’s mean flow velocity by using equation Q=VxA.
142. Perivascular vibration artifact and mosaic pattern are common artifacts in shunts/fistulas.
143. Feeding artery of dialysis graft has monophasic flow with a large
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diastolic component. 144. The draining vein of a dialysis graft displays an arterialized profile with pronounced turbulence.
145. In a dialysis graft, if arterial flow is >400 cm/sec, there is a > 75% diameter reduction.
146. Ischemia is a sign of reduced shunt flow.
147. Vasospastic disorder occurring in women approx 20-50 and is brought on by emotional stress and cold weather and causes cyclic color changes in the hand/digits is called Raynaud’s Syndrome.
148. Excessive shunt flow, >1200 ml/min. can lead to steal phenomenon causing ischemia in the hand digits.
149. Stenosis in a graft predominantly develops in the venous anastamotic area or along the access vein.
150. If stenosis is excluded in a graft and there is inadequate flow, look for venous collaterals that reduce fistula flow rate and need to be ligated surgically.
151. Stenosis/Obstruction or compression of venous outflow,
monophasic flow becomes pulsatile, high resistant with loss of diastolic component.
152. Direct criteria for shunt stenosis: volume flow rate <250 ml/min. focal flow acceleration turbulent flow perivasular tissue vibration doubling of velocity compared to adjacent graft segment PSR>2
153. The Allen test is used to detect patency of the radial artery for use as a coronary artery bypass graft.
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154. We do ultrasound of fistula’s/graft to determine flow rate and look for complications such as: (HINT:STAPHS)
stenosis/occlusion PSA thrombosis hematoma
155. Inverse damping factor should always be close to 1.0 for each segment of the limb and if less than significant disease is present.
156. Use a high PRF for high velocities in fistula and a lower gain to prevent vibration artifacts.
157. Most perforating veins are found in the medial inner aspect of the leg.
158. Hemodynamic complications of excessive fistula flow, over 1600 ml/min. are: an increased risk of cardiac insufficiency or steal syndrome (ischemia dst. to shunt.)
159. The most accurate method for determining the shunt volume is to calculate the difference of flow rates of feeding artery upstream and
downstream of the shunt which is the same as before anastamosis & after anastamosis.
160. Most common sites of stenosis in a hemodialysis access graft? venous anastamosis outflow vein
161. Retrograde arterial flow is often observed in the native artery at the distsal anastamosis of a bypass graft.
162. Successful bypass grafts include: (HINT:GOD) Good inflow Optimal conduit (passageway) Good outflow
163. 7 types of LE bypass grafts: aorto-fem axillo-fem
aorto-bi-fem axillo fem/bi-fem
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fem-fem fem-fem fem-pop
164. Low PSV obtained in access graft could indicate arterial inflow problems. (HINT: think volume flow & measured in art seg.)
165. A false aneurysm is a typical graft puncture complication that develops as a result of blood escaping into a subcutaneous hollow space.
166. A suture aneurysm, especially common after infection, is a type of false aneurysm that appears on US as a perivascular space with pulsatile flow.
167. The right vertebral is usually smaller than the left.
168. Occurs only with LE in-situ bypass grafts: AV Fistula
169. In almost completed thrombosed graft will have a reduced, triphasic waveform with a low PSV presented on US as a “knocking” waveform.
170. Caused by a fracture of the penis where fibrous tissue develops
under the skin causing curvature of the penis is called: Peyronie’s Disease
171. A TRAM flap consists of rectus abdominus muscle, sub-q fat, arteries, perforators & overlying skin & is used for breast reconstruction.
172. 4 Complications that can occur after an angiographic procedure: hematoma pseudoaneurysm neurolocgic complications arterial occlusion
173. Cerebrovascular collaterals: Contralateral hemisphere Posterior to anterior
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ECA to ICA branches
174. A varicocele occurs when veins of the pampiniform plexus become extremely enlarged.
175. A normal Penile/Brachial Index (PBI) is between 0.7-1.0 and <0.6 is considered abnormal.
176. After full erection is achieved, diastolic velocities should decrease significantly & sometimes even reverses in direction.
177. Arterioles have the highest resistance in the Circulatory system.
178. In the arterial system, total blood flow may be normal in an extremity at rest, even when there is a significant stenosis or
occlusion of a vessel, due to collaterals.
179. Vasoconstriction causes arterioles to be high-resistant & triphasic at rest.
180. The Pulsatility Index should be >5.0 in a healthy blood vessel.
181. Name the 4 main visceral arterial branches: Celiac IMA SMA Renals
182. The celicac artery branches: splenic, hepatic & lt. gastric
183. The SMA supplies: (HINT: Remember CATS) cecum ascending colon transverse colon small intestine
184. The celiac supplies: (HINT: Pan lives splendid stomaches duo) Pancreas Liver Spleen Stomach
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duodenum
185. What branches form the palmar arch? Radial artery teminates into the Deep Palmar arch
Ulnar artery terminates into the Superficial Palmar arch
186. What branches form the plantar arch? (HINT: DP-DP) Deep plantar artery & lateral plantary artery
187. The dorsalis pedis artery originates from the anterior tibial artery.
188. The deep and lateral plantar artery arise from the posterior tibial artery.
189. Calf artery medial to the fibula? Peroneal
190. The EIA travels along the medial side of the psoas major muscle.
191. The vasa vasorum are tiny vessels that carry blood to the walls of the larger arteries.
192. A contralateral pathway in the Circle of Willis is retrograde flow in the ECA along branches of the ophthalmic artery.
193. The anterior tibial arteries & veins are paired and anterior to the tibia.
194. The post. tibial arteries & veins are paired and post. to the tibia.
195. Pseudo-claudication mimics vascular symptoms and is usually orthopedic or neurogenic in origin.
196. If bilateral buttock pain then most likely there is aorto-iliac disease but if unilateral then iliac artery occlusive disease.
197. If calf pain only then most likely there is femoro-pop occlusive disease.
198. If there is thigh disease then most likely there is Iliac &/or femoral occlusive disease.
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199. With Primary Raynaud’s disease, intermittent digital ischemia occurs due to digital arterial spasm brought on by emotional stress, exposure to cold or other factors. (vasospasm)
200. Secondary Raynaud’s suggested to be the 1st manisfestation of Buerger’s disease and happens when the normal
vasoconstrictive responses of the arterioles are superimposed on an already fixed arterial obstruction.
201. The waveform qualities of PPG’s help to distinguish between intermittent and fixed claudication.
202. Vasospastic disorders are considered intermittent while arterial obstruction is considered fixed.
203. 3 major risk factors of Atherosclerotic disease: (HINT: FSH) Family Hx Other Factors: DM & HTN Smoking Hyperlipidemia
204. A fusiform aneurysm is diffuse circumferential dilatation whereas a sacular aneurysm is a localized outpouching.
205. Name 3 Collagen Vascular diseases: Sclerodoma Lupus RA FMD
206. 4 places that can be auscultated with a stethoscope: aorta femoral carotid popliteal
207. Pallor is paleness (white) Rubor is redness Cyanosis is bluish
208. The analog Doppler is easily affected by noise and is less sensitive
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than spectral analysis.
209. Arteries that carry low resistant blood flow are those that provide blood to a continuously dilated arterial vascular bed.
210. The thickest layer of the wall of the veins is the tunica media .
211. As blood travels from the aorta to the capillaries resistance increases.
212. Difference b/t the systolic and diastolic pressures is known as the pulse pressure.
213. The tunica media contains concentric layers of smooth muscle.
214. As depth of respiration increases, venous return increases.
215. As heart rate decreases, diastolic pressure will decrease.
216. 65% of the blood volume is contained within the veins.
217. Atherosclerosis is not a red blood cell disease.
218. A hemispheric stroke is usually affects the middle cerebral artery and the contralateral side of the body.
219. Veins carry deoxygenated blood back to the heart.
220. As resistance of blood flow through the artery increases, the pressure drop across the artery will increase. HINT:
(stenosis)
221. The vessel diameter (radius) is the principal determinant of resistance.
222. When performing a preoperative scan of the radial artery for a CABG, another test must be performed: Allen Test
223. The flow rate within vessel in is affected by 3 things:
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(Same as factors affecting blood flow within the body) vessel length viscosity velocity
224. Fluid along the tube is proportional to the 4 th power of the vessel radius.
225. When there is a pressure gradient along the length of an artery, there is a corresponding loss of energy.
226. There is more energy lost when the vessel is longer, velocity is higher and blood is more viscous.
227. Flow rate is proportional to the pressure gradient (pressure drop).
228. Flow characteristics of pulsatile flow reveal a sharp rise in velocity during systole which is the ejection phase and a decrease in velocity during diastole which is the relaxation phase.
229. Upon inspiration, the diaphragm descends causing an UE veins to distend and LE veins to collapse.
230. The end point of venous flow is at the right atrium.
231. Vein walls have more collagen fibers than arteries.
232. Arteries control oxygen to the legs and veins control the rate of blood return back to the heart thereby regulating cardiac
output.
233. Pressure increases when either flow or resistance increases. (THINK OF A HOSE)
234. In the vascular system, an increase in volume results from an increase in cardiac output.
235. When collateral blood flow develops resistance at the level will decrease. (HINT: think occlusion, velocity decreases).
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236. When a patient with a stenotic lesion is exercised, the pressure gradient at the site of a stenosis will increase.
237. Total volume of blood in the circulatory system, of an average person, is 5 liters.
238. Pseudoaneurysm is the most common complication of catheterization or iatrogenic trauma to a vessel. Other complications include:
AV fistula dissection perforation thrombus occlusion
239. Leg pain upon elevation is intermittent arterial claudication and pain when legs are dependent because of blood pooling at ankles is
venous claudication.
240. Name some symptoms of PVD: Pain gangrene Claudication hardened toe nails rest pain hair loss on legs non healing wounds over pressure points (heels & ankles) 241. Venous ulcers are a result of high blood pressure in the veins of your legs caused by venous insufficiency. 242. With arterial insufficiency you must NEVER elevate the legs or
use compression hose as you would with venous insufficiency.
243. An artery with a larger pulse wave amplitude means that it has a high systolic peak.
244. A pulse with a rapid upstroke, rapid downstroke, high amplitude and short duration is known as a “water hammer” pulse and seen with aortic incompetence.
245. Arterial ulcers form between the toes and outer ankles while venous ulcers occur above the ankle on the side of the leg or shin.
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246. Almost always there will be edema with venous ulcers and is usually the 1st thing you will find. (HINT: why legs must be elevated).
247. Arterial ulcers are much deeper and irregular than venous ulcers which makes them more severe.
248. Venous ulcers “ooze” while arterial ulcers cause little bleeding.
249. An anacrotic pulse is prolonged with a low amplitude and prolonged duration usually seen in aortic stenosis.
250. Dicrotic means twice beating meaning that this phase of the arterial pressure pulse should have a 2nd smaller wave or notch.
251. Pulsus bisferiens is a pulse with two peaks where upstroke is sharp and rises high to the 1st peak, falls again & rises to a 2nd
peak.
252. Heat causes vasodilation of vessels and cold & stress causes vasoconstriction of vessels. (THINK: Raynaud’s)
253. Risk factors for AAA: smoking HTN male family hx Marfan’s syndrome
254. Arteries used for a TRAM flap for breast reconstruction are: internal mammary artery (internal thoracic art.)
epigastric artery
255. Portal vein is formed by the splenic vein & SMV.
256. Portal Hypertension is caused by an increased impedance of flow through the liver.
257 A measurement of >13 mm. of the portal vein diameter with
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hepatofugal flow indicates portal hypertension.
258. When evaluating liver for portal hypertension, you must also evaluate the IVC for obstruction and the hepatic veins for Budd Chiari syndrome.
259. Stenosis or obstruction of hepatic veins may be caused by: hepatomegaly (HINT: HAS) ascites splenomegaly 260. When performing the Allen test for palmar arch if flow reverses
after radial artery compression then it is a(n) complete arch, if flow does not reverse after compression then a(n) incomplete arch.
261. Intraoperative US is performed to direct hepatic resection in an avascular plane during donor hepatectomy.
262. Injuries unique to balloon angioplasty/stenting include: arterial rupture & dissection.
263. MCA lesions affect the arms while ACA lesions affect the legs.
264. A stenosis that reduces the vessel diameter by 50% is equivalent to a 75% area reduction.
265. The Adson maneuver is performed for assessment of thoracic outlet syndrome.
266. When evaluating a bypass graft an abnormal flow pattern is from triphasic to biphasic.
267. Takayasu’s disease is known as the “pulseless” disease of the aorta and it’s branch arteries & also affects the CCA & subclavian
arteries.
268. If intraluminal pressure exceeds tissue pressure then vein dilates.
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269. Transmural pressure is the difference between intramural & tissue pressure.
270. An indirect sign of severe significant transplant renal artery stenosis displaying a delayed increase of systolic signal is called a “tent” sign.
271. A renal transplant ultrasound cannot exclude rejection.
272. Most common complication post biopsy is : AV fistula.
273. After renal transplantation normal flow is triphasic, if biphasic then there is atherosclerosis.
274. When evaluating bypass grafts, compare results with previous studies & observe for changes such as:
reduced PSV’s in smallest graft diameter that were previously higher decrease of 30 cm/sec in any graft segment decrease in ABI of 0.15
275. Intraoperative monitoring of grafts is done to check patency of anastomotic sites, valve cusp sites, & any suspicious stenotic or
turbulent areas.
276. In a reversed vein bypass graft branches are ligated.
277. The Doppler Equation:
Df =2 Fo V Cos Ø C
278. Propagation speed in equation above (in soft tissue) is 1540 m/s.
279. In reversed LE vein bypass graft velocity will be higher proximally because vein is reversed and small end is proximal.
280. In an in-situ LE bypass graft, valves are broken up and branches are ligated.
281. Venous hypertension is the predominant underlying factor that leads to chronic venous insufficiency.
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282. MRI is currently the GOLD STANDARD for diagnosis of aortic dissection.
283. If you see a tardus parvus waveform in the distal vert., then there is stenosis where: proximal vert.
284. Other branches of ECA: lingual facial occipital maxillary temporal
285. When standing, normal venous pressure in the deep veins in the legs is 80 mmHg and 20 mmHg in the superficial veins.
286. First branch of ECA is Superior Thyroid artery.
287.Name the different types of ICA plaque: Calcified Fibrotic Soft
Complicated
288. Complicated plaque has the highest potential for embolism in the ICA while calcified plaque has the lowest potential.
289. With increasing arterial disease, the waveform loses amplitude & reflected wave. (also known as dicrotic notch)
290. Aortic dissection is considered a vascular emergency caused by a defect in the intima but is usually asymptomatic and caused by trauma, HTN, pregnancy & Marfan’s Syndrome.
291. Evaluate Dialysis grafts as follows: Inflow artery Arterial anastamosis Body of graft Venous anastamosis Outflow vein
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292. Rule of thumb; open sample volume gate 1/3 the size of the vessel.
293. Thrombangitis obliterans is also known as Buerger’s Disease.
294. Retrograde flow in rt. vertebral usually indicates innominate artery obstruction.
295. Retrograde flow in left vertebral artery usually indicates CCA obstruction.
296. Subclavian steal is more common in the left (larger) vertebral.
297. With subclavian steal, there is a 15-20 mmHg difference in BP and the side with the lower BP is the affected side.
298. When significant disease is present in proximal subclavian or brachiocephalic artery, blood must course up the contralateral vert., cross the basilar artery, cross down vert of affected side to
subclavian to perfuse arm.
299. With subclavian steal you will see retrograde flow in ipsilateral vert. & ↑ resistance in contralateral vert.
300. In a partial steal you will see bi-directional flow can be converted to a complete steal by having patient exercise hand or placing a blood pressure cuff on arm for few minutes and releasing.
301. With severe CCA disease, flow not only in vert. may reverse but also in basilar artery.
302. Thoracic Outlet Syndrome is caused by an extra rib in thorax or scalene muscles causing extrinsic compression on distal subclavian or proximal axillary arteries.
303. Testing for TOS consists of recording waveform in radial artery in different positions using these maneuvers:
Costoclavicular (military position) Hyperabduction (arms out, palms up) Causative (hand on lap, 90 or 120 degrees)
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304. The subclavian artery is imagined for TOS in the supraclavicular & infraclavicular positions and flow velocities recorded.
305. With vertebral disease, tardus parvus is consistent with proximal vert. artery obstruction and an ↑resistance seen with distal vertebral or basilar obstruction. (Opposite than normal arterial obstruction).
306. Peripheral artery aneurysm › 2cm. usually requires surgery.
307. Thickest layer of the walls of veins is the tunica media.
308. As blood flows from the aorta to the capillaries, its velocity of flow will decrease.
309. Surgical procedures for PVD: Embolectomy PTA (balloon angioplasty) Vein ligation (stripping) Endarterectomy
310. Risk factors for DVT: Virchow’s Triad Prolonged bed rest Birth control Obesity Pregnancy
311. 3 things associated with Virchow’s Triad: (HINT: SHE) stasis (alterations in normal flow) hypercoaguability (alterations in consistency of blood) endothelial injury (trauma)
312. The tunica media is composed of concentric layers of smooth muscle. (HINT: middle-muscle)
313. The tunic intima is composed of endothelial cells. (HINT: endo means within)
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314. The tunica externa is composed of collagenous & elastic fibers. (HINT: ouside layer most elasticity)
315. Network of mīnute (my nute) blood vessels that perfuse tissues is called vaso vasorum.
317. An exchange of nutrients & waste products b/t blood & cells of tissue takes place in the capillaries.
318. Arterioles account for ½ of the total resistance to blood flow.
319. Blood Pressure ~ Blood Flow
320. Poiseuille’s Law demonstrates that a change in diameter of a blood vessel affects resistance the most.
321. When collaterals develop gradually, there is less resistance across the region of stenosis.
322. Resistance to flow across the acute stenosis or occlusion will be higher than resistance to flow across a chronic stenosis or
occlusion.
323. The vessel radius is the most principal determinant to control resistance.
324. Cardiac output is the principal factor for determining arterial blood pressure.
325. Resistance in the blood vessels is affected by three parameters: length of a vessel viscosity of blood radius of vessel
326. Bernoulli Equation describes the relationship between pressure & velocity.
327. The volume of blood moving through a given area in a given time is the blood flow.
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328. Also called the fibular artery: peroneal artery.
329. The proximal limit of the axillary artery is the thoracic outlet.
330. The brachial artery originates at the insertion of the teres major muscle in the proximal arm.
331. The peroneal artery is medial to the fibula.
332. The CFA begins at the inguinal ligament and the EIA ends at the inguinal ligament.
333. The SMA is just superior to the left renal vein.
334. Calf artery found along the intersosseous membrane between the tibia & fibula is the anterior tibial artery.
335. First 3 main branches off the aortic arch: Innominate artery Lt. CCA Lt. subclavian
336. A true aneurysm involves all 3 layers of the wall of an artery while pseudoaneurysm does not primarily involve such distortion of the vessel.
337. Blood flow is proportional to the 4th power of the vessel radius.
338. PTA (Percutaneous Transluminal Angioplasty) is a procedure done by passing a balloon catheter into a vessel and inflated
pressing outward against vessel walls to relieve arterial stenosis.
339. Prominent medullary pyramids post renal transplant usually indicates acute renal failure.
340. Biphasic flow in the iliac artery post renal transplant is normal.
341. RAS is an important cause of hypertension in transplant patients.
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342. An acute emergency post renal transplantation is acute venous thrombosis.
343. You will see pendle flow in a pt. with acute venous thrombosis post renal transplantation.
344. A PSV of >250cm/sec in the renal artery post transplant indicates a >50% stenosis.
345. If the transplant is from a live donor there is no aortic patch.
346. A RAR (renal artery ratio) of >3.5 indicates RAS.
347. An acceleration time of 0.07 in renal artery is considered normal.
348. Upon reaching renal hilum, main renal artery branches into segmental arteries which in turn give rise to the interlobar arteries.
349. The interlobar arteries branch into the arcuate arteries at the cortico-medullary junction.
350. Interlobar arteries course alongside the renal pyramids toward periphery of kidney while the arcuate arteries travel across the top of the renal pyramids.
351. When scanning longitudinally, the head is always to the left of the screen & when transverse, head is on top of screen.
352. Claudication results from inadequate blood supply to the muscles.
353. Diagnostic Criteria for stenosis of LE’s: Doubling of velocities ↑ PSV’s to 200 cm/sec ↑ EDV’s over 100 cm/sec Ratio: ≥ 2 but < 4 =50% ≥ 4 = >75%
354. Re= vq2r q stands for density n n stands for viscosity
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355. 2 types of Autologous vein grafts: Reversed saphenous graft “In-situ” graft
356. Brownish skin discoloration occurs with venous disease.
357. In an autologous vein graft, a change in flow from triphasic to monophasic and a change in the shape of the high resistant waveform signals impending failure or occlusion.
358. Occlusions in post-op bypass grafts are caused by: Immediate: technical inadequate surgical technique (poor
outflow tract or anastamoses) Within 1st year: neointimal hyperplasia
Later: atherosclerosis
359. In an “in-situ” graft, there is a possibility of non-ligated side branches being left in which leaves a risk of an AV fistula
forming. (because they can communicate with the deep system).
360. Plegmasia alba dolens, also known as milk leg, and common in pregnant women due to compression of the iliofemoral v.
361. Main complication of endovascular intervention, following trauma, or vascular surgery is development of a(n) pseudoaneurysm.
362. The dicrotic notch represents the interruption of smooth flow due to the brief backflow of blood that closes the aortic semilunar valve.
363. Tests to diagnose venous incomptetence: Doppler US Plethysmography Lower limb venography
364. Klippel-Trenaunay-Weber Syndrome is congenital absence or artresia of deep veins.
365. May-Thurner Syndrome is when the lt. common iliac vein courses posterior to rt. CIA.
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366. Most severe form of limb thrombosis (DVT), usually in the upper leg, caused by occlusion of the major and collateral veins
and is known as “blue leg” is called plegmasia cerulea dolens.
367. Plegmasia alba dolens comes before plegmasia cerulea dolens.
368. Plegmasia alba dolens is distinguished clinically from plegmasia alba dolens in that there is no ischemia with alba dolens.
369. If no spontaneous flow, & only augmented flow, at CFV, FV or pop v, obstruction at or distal to site you are evaluating.
370. If no augmented flow with distal compression, obstruction at site you are evaluating or more proximal.
371. Photoplethysmography is a non-invase test used to diagnose venous insufficiency.
372. Photo PPG uses transducer that transmits, receives, and quantitates light.
373. Analog Doppler is displayed on a strip chart recorder that incorporates a zero-crossing detector.
374. With increasing proximal stenosis of the lower extremity the reverse flow component is lost.
375. The medial malleolus to mid calf is known as the “gaitor” zone.
376. Cardiac output, radius & resistance all have a directly proportional relationship with blood pressure.
377. With renal transplant rejection, you might see hypoechoic areas in the parenchyma.
378. A renal transplant is preferred more on the rt. than the left due to the longer renal vein.
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379. With renal transplantation, often with cadaveric donors a Carrell patch (small portion of surrounding aorta), is acquired and
anastamosed to the External Iliac artery.
380. Post renal transplant fluid collections may contain urine, blood, lymph or pus. (HINT: plub)
381. Acute Tubular Necrosis (ATN) occurs in the immediate post renal transplant period as a result of ischemia and more commonly seen in
cadaveric transplants.
382. Signs & Symptoms of IVC obstruction: (HINT:HAP) Hepatomegaly Ascites Pain (abd.) Most severe: LE edema
383. The normal response of a vein below the point of obstruction will be dilatation, but above the obstruction the vein should remain normal
in diameter.
384. An IVC filter is made of nickel titanium (nitinol).
385. With deep inspiration, venous blood flow decreases and the IVC dilates.
386. When performing PVR’s, the 4-cuff method is better at differentiating inflow disease from fem. artery disease.
387. The most common cause of IVC obstruction is right-sided heart failure.
388. Bad plaque is hetergenous & echolucent.
389. Normal Transcutaneous Oximetery readings are between 70-80 mmHg and non-healing is 10-15 mmHg.
390. When performing a Valsalva maneuver, venous return is blocked & flow temporarily reverses in the IVC causing it to bulge.
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391. Sonographically, an enlarged renal vein is >1.5 cm.
392. Reactive Hyperemia is the transient increase in organ blood flow that occurs following a brief period of ischemia.
393. The ability of most vascular beds to maintain a constant level of blood flow over a wide range of perfusion pressures is known
as Autoregulation.
394. In genereal, the ability of an organ to display reactive hyperemia, is similar to its ability to display autoregulation.
395. Hyperemia occurs during the period of occlusion & tissue hypoxia (no oxygen to tissues) dilates arterioles (causing vasodilation) and
decreases vascular resistance.
396. After reactive hyperemia, when perfusion pressure is restored (occlusion released), flow becomes elevated because of the
reduced vascular resistance. (↓ resistance = ↑ blood flow).
397. In Portal HTN, there is isolated LRV involvement.
398. When does an AV malformation occur? trauma biopsy complications iatrogenic tumor involvement 399. Reactive hyperemia produces ischemia and vasodilation distal to the occluding cuffs.
400. A normal toe-brachial-index falls between 0.6-0.8. Significant disease: < 0.5 Normal finger indexes are 0.8-0.9.
401. Symptoms seen with an ICA lesion: (HINT: U- PAPA?) paresis symptoms are unilateral amaurosis Fugax parethesia (numbness & tingling)
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aphasia
402. Post exercise ABI’s should _↑_abnormal if _↓_.
403. Bad plaque is hetergenous & echolucent
404. Only eye symptom associated with ICA disease is amarousis fugax.
405. MCA lesions affect the arms and ACA lesions affect the legs.
406. Symptoms seen in MCA lesion: (HINT: BAD CHAF) behavioral changes aphasia dysphasia contralateral hemiparesis arm & face
407. Symptoms with ACA lesion: (HINT: MIL) More severe hemiparesis and hemilplegia Incontinence Loss of Coordination
408. Symptoms seen with a PCA lesion: (HINT: DC)dyslexia
coma
409. Resistance is proportional to pressure and inversely proportional to radius.
410. Blood volume is proportional to blood pressure, therefore, hemorrhage causes a ↓ in blood volume so blood pressure ↓.
411. Bernoulli equation states velocity & pressure are inversely proportional so therefore as velocity ↑ pressure ↓.
412. Horner’s Syndrome is ptosis (drooping) of the upper eyelid with sinking in of the orbit & constriction of the pupil.
413. A normal TcPo2 reading is 70-80 mmHg and non-healing
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levels are 10-15 mmHg.
414. Dorsal vein velocities should not increase post paparavine injection in penis for vasculogenic impotence.
415. A PSV of ≥ 200 cm/sec & a RAR of > 3.5 indicates a RAS of >60% . 416. Posterior circulation consists of the verts. & PCA. 417. Diameter of cavernous arteries should increase post-injection.
418. Dorsal vein velocities should not increase post paparavine injection in penis for vasculogenic impotence.
419. If dorsal vein velocities increase post injection, indicates venous leak.
420. Endarterectomy vein patches are susceptible to rupture while prosthetic patches are susceptible to infection.
421. Diagnostic test that overestimates stenosis: MR Angiography
422. CT is most frequently used in cerebrovascular disease.
423. Intraoperative monitoring to monitor the MCA during cerbrovacular & cardiovascular surgeries.
424. The MCA is 30-60 mm deep.
425. When doing TCD’s. what angle of insonation is used? ZERO
426. TCD’s: transtemporal window used for : MCA, ACA, PCA & Term. ICA
427. TCD’s: transorbital window used for: Opthalmic & ICA at siphon
428. TCD’s: transforaminal (transoccipital) window used for: Vertebral & Basilar
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429. What vessels exhibit antegrade flow in the brain? (HINT: MOP) MCA, Opthalmic & PCA
430. What vessels exhibit retrograde flow in the brain? (HINT:VBA)Vert., Basilar & ACA
431. Systolic pressure is the maximum amount of pressure exerted by the blood against the artery walls.
432. Air Plethysmography is a technique that allows the measurement of limb volume changes with different maneuvers.
433. Diastolic pressure is the result of ventricular relaxation and systolic pressure is the result of ventricular contraction.
434. Pulse pressure is the difference between systolic & diastolic pressure.
435. 2 limb-threatening colors associated with venous disease: whitish & bluish
436. These tests are used to diagnosis venous insufficiency by quantitating venous reflux.
437. PPG’s APG’s • photo cell w/light emitting • pressure transducer diode & photo sensor limb volume changes • diode transmits infrared • analog strip chart recorder light into tissue • electrical coupling (AC or DC)
438. With PPG’s, increased blood flow results in decreased reflection.
439. PPG’s cannot be calibrated volumetrically like APG’s.
440. AC coupling detects fast changes in blood content & is used for arterial studies.
441. With PPG’s, the normal VRT is ≥ 20 sec. without tourniquet.
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442. If VRT is < 20 sec. it means that it is filling too quick because the valves are not working.
443. A VRT of < 20 sec. without tourniquet signifies Superficial system incompetence.
444. A VRT of < 20 sec. with & without tourniquet signifies Deep system incompetence.
445. The strip chart runs at a slow speed of 5 mm/sec. and uses heat sensitive paper.
446. The Asymptomatic Carotid Atheroscleosis Study determined that the therapeutic benefit of endarterectomy in symptomatic patients with > 60% diameter reduction of the ICA.
447. Diagnostic Interpretation of APG’s consist of using 3 things: (VFI) Venous Filling Index want number to be low (EF) Ejection Fraction want high % (RVF) Residual Volume Fraction want low %
448. Contrast venography is considered to be the “gold standard” for evaluation of acute & chronic DVT & other venous anomalies.
449. 2 types of Contrast Venography: Ascending: for DVT & other venous anomalies Descending: to quantify reversed flow from incompetent venous
valves
450. For Ascending venography, contrast media is injected into the dorsum of foot.
451. For Descending venography, contrast media is injected into the
CFV.
452. Pharmacologic (anticoagulant) treatment for DVT: Heparin Coumadin Lytic therapy: urokinase & streptokinase
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453. Surgical & Endovascular treatment for DVT: IVC Filter Iliofemoral thrombectomy
454. For chronic venous insufficiency, a vein ligation of incompetent perforators is performed or valvular reconstruction.
455. Varicose vein treatment: Sclerotherapy Phlebectomy (vein stripping) Laser ablation & radio frequency ablation Endovenous procedure using heat (causing vein to shrink) Valvular resconstruction
456. Specifity is the ability of a test to identify normalcy.
457. Sensitivity is the ability of a test to detect disease.
458. Accuracy tells how good a test is.
459. Negative Predictive Value tells how often negative study is correct.
460. Positive Predictive Value tells how often a positive study is correct.
461. Specifity: # of true negative tests (HINT: too specific can # of all negative diagnoses be negative)
462. Sensitivity: # of true positive tests (HINT: sensitive people # of all positive diagnoses are positive)
463. Approach for inserting TIPS is into the Rt. IJV to IVC to rt. hepatic vein.
464. In a TIPS shunt, the hepatic end is the outflow end & the portal vein is the inflow end.
465. A- True Positive B- False Positive C- False Negative D- True Negatives
40
HINT: TF (Tommy Fallon) FT (Fallon, Tommy)
466. Accuracy = A+D_____ A+B+C+D
467. Sensitivity A______ A+C 468. Normal flow through a TIP should not have a PSV of higher than 90 cm/sec.
469. An Inverse Damping Factor should be close to 1.0 for each segment of the limb & the Pulsatility Index should be >5.0 in a healthy
vessel
470. In LE’s during Resting blood vessel is vasoconstricted & should exhibit triphasic flow and after exercise blood vessel is
vasodilated and should exhibit monophasic flow.
471. Normal toe pressures are between 0.6-0.8 and < 0.5 indicates significant occlusive disease.
472. Fistula’s/Grafts: PSV > 250 cm/sec = > 50% stenosis PSV > 400 cm/sec = > 75% stenosis
473. Sensitivity & Specifity are vertical
474. Pos. Predictive Value & Neg. Predictive Value are horizontal 475. With Analog Doppler, the vertical axis (y) represents amplitude while the horizontal axis represents (x) time.
476. Limitations of Analog Doppler: amplitude dependent background noise does not display 2 peak frequencies causes venous & arterial signals to be added together
477. Spectral Analysis uses FFT method & makes it possible to display individual frequencies.
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478. Spectral Analysis displays information related to the intensity of a spectrum with a narrow spectrum for laminar flow and
spectral broadening for turbulent flow with wide range of frequencies.
479. Most common variant of the Circle of Willis is a hypoplastic ACA.
480. A PI of >5.0 and an Inverse Damping Factor of 1.0 indicates a healthy vessel.
481. Gastrocnemius vein drains into the popliteal vein.
482. The GSV drains into the femoral v. & the LSV drains into the popliteal v.
483. The GSV is medial and the LSV is lateral in the leg.
484. When doing ABI’s/PVR’s, the 1st sign of abnormality is absence of the dicrotic notch.
485. Distal to more significant occlusions, the slope of both the ascending & descending segments of the trace decreases and
rounding of the systolic peak is noted. As obstruction increases, waveforms become flatter.
486. When there is stenosis in the LE’s, exercising can help form collaterals.
487. Treatment options for LE arterial disease: exercise bypass graft angioplasty 488. Nonlateralizing and less specific carotid symptoms: headaches vertigo dizziness
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489. Long term consequences of varicose veins: (HINT: PUBE) pigmentation ulceration bleeding excema
490. The most important diagnostic criteria during duplex examination of the lower extremity arterial system is:
spectral Doppler waveform
491. The normal Doppler spectral arterial waveform of the lower arterial system does not include a dicrotic notch.
492. Utrasound compression therapy of a pseudoaneuryms usually requires 30-60 minutes to be successful.
493. Surveillance programs of lower extremity bypass graft will benefit by beginning it within days after the operation.
494. What is the best benefit of using arterial duplex imaging to evaluate the arterial stenosis of the lower extremity? Distinguishing b/t stenosis versus occlusion
495. Digit plethysmography differentiates fixed arterial obstruction from vasospasm.
496. Plethysmography is done to measure gas volume changes in the lungs and to determine if there is pulmonary artery obstruction.
497. Diastolic pressure is the lowest pressure in the artery.
498. Laminar flow is caused by the friction (resistance) between the blood & the vessel walls.
499. Autoregulation is the process by which organs & tissues of the body self-regulate blood delivery.
500. The exchange of materials (nutrients) between tissue cells & the blood take place in the capillaries.
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501. A false negative ABI result can be due to 2 things? Calcified arteries: DM End stage renal disease
502. Pts. with moderate disease of the infrarenal aorta or iliac artery may have normal arterial circulation at rest but when exercised demonstrate a decrease in ankle pressures.
503. A normal PVR waveform exhibits a rapid upstroke, rapid downstroke and prominent dicrotic notch.
504. With increasing severity of PAD, the waveforms become more attenuated and virtually absent waveforms.
505. A treadmill exercise test following PVR’s requires walking at a speed of 2 mph, at a 12% incline at a max of 5 minutes.
506. A > 50 % stenosis in the lower extremities will show a doubling (>100%) of PSV compared to the proximal segment & reduced systolic velocity distal to the stenosis.
507. The tunic adventita (outermost layer) of a vein is composed of connective tissue.
508. The tunica media (middle layer) of a vein is made of smooth muscle.
509. The tunica intima (innermost layer) is made up of endothelial cells.
510. The greater saph vein has its own “hidden” fascial compartment In the thigh and exits the fascia only near the knee.
511. Veins are also called capacitance vessels.
512. The superficial veins are the ones affected by varicosities.
513. Varicose vein symptoms: (HINT: HALTS) heaviness
44
achiness leg cramps throbbing swelling
514. Lifestyle Causes of varicose veins: (anything that puts pressure one the LE’s from the abdomen down): obesity aging pregnancy prolonged sitting & standing constipation birth control lack of exercise hormone replacement 515. Veins are known as blood reservoirs.
516. If venous return decreases, heart will not be able to pump blood.
517. The EIA turns into the femoral artery from the groin.
518. The PTA divides into the medial & lateral plantar arteries & the ATA branches into the DPA.
519. When evaluating bypass grafts, if the ratio of the PSV within a stenotic segment relative to the normal segment proximal to a stenosis is >2, this suggests a 50%-75% diameter reduction & and EDV >100 cm/s suggests a >75% stenosis.
520. The “Gold Standard” for carotids is cervical angiography.
521. Surveillance of bypass grafts should be done within 7 days of formation, then again in 1 month, then at 3-month intervals.
522. The development of a stenosis on a graft surveillance study should prompt consideration of arteriography.
523. Complications of arteriography include: (HINT: DNR@HR) hematoma at puncture site dissection arterial wall rupture
45
nephrotoxicity due to IV contrast material radiation exposure
524. The tunica intima’s smooth surface decreases its resistance to blood flow.
525. IMA supplies distal half of large intestine.
526. SMA supplies most of small intestine.
527. CIV’s join to form the IVC.
528. The splenic vein supplies what 3 organs? Spleen, pancreas & greater curvature of stomach
529. A triphasic waveform is displayed in a well-functioning in-situ bypass graft.
530. Pseudoaneurysms are commonly found involving the CFA.
531. A normal, well-functioning LE synthetic bypass graft displays a biphasic waveform (no 3rd forward component-just the 1st 2 of a triphasic waveform on a picture) or triphasic waveform.
532. A PTFE (Gore) graft is currently the graft of choice for femoro- popliteal bypass grafts.
533. A vein patch is a small piece of vein that is used to patch or expand a biologic graft in an area of anatomic narrowing or at the site of a focal stenosis.
534. The GSV drains into the femoral vein & the LSV drains into the popliteal vein.
535. The most common cause of CCA/ICA disease is atherosclerosis & the 2 most common symptoms are TIA & amarousis fugax. (whichever one is an answer on the boards)
536. ICA divides into the MCA & ACA.
46
537. The systemic arterial pressure waveform results from the ejection of blood from the left ventricle into the aorta during systole.
538. Subclavian artery occlusive disease is the most commonly treated of the great vessel lesions with common carotid artery occlusive disease the least encountered.
539. Takayasu’s arteritis is the 2nd most encountered great vessel occlusive disease in the U.S.
540. Lateralizing symptoms of carotid artery disease: TIA CVA Amarousis fugax
541. Non-lateralizing symptoms of carotid artery disease: bilateral visual disturbances headaches ataxia aphasia vertigo
542. Subclavian (or innominate) artery occlusive disease symptoms: upper extremity ischemic pain with use arm fatigue ALL SIGNS OF generalized aching CLAUDICATION digital ischemia č microemboli or ulcerations 543. “Inverted champagne bottle” refers to what disease? Venous Insufficiency
544. Compression stockings will help to reduce the risk of further ulcers from venous insufficiency.
545. The presence of perforator venous reflux represents a significant factor in the development of venous reflux disease in the GSV.
546. The gaiter areas in the leg are the areas where skin changes & venous stasis ulcers are more likely to occur.
547. Perforator veins & their locations: Dodd’s- thigh & along Hunter canal
47
Boyd’s- just below pop fossa (below knee) Cockett’s- just above the ankle (3 sets)
548. Lateral calf perforators called the peroneal perforators connect the LSV’s to the peroneal veins & are also called Bassi’s veins.
549. Clinical indications for Mesenteric Arterial Duplex: abdominal pain & cramping after eating significant unexplained weight loss unexplained GI symptoms diarrhea abdominal bruit
550. Clinical indications for Venous Duplex of UE’s & Le’s: swelling prior DVT pain vein mapping suspected PE chronic leg ulcerations discoloration
551. Clinical indications for Renal Duplex US: HTN RAS renal failure post renal transplant pts. too young for HTN
552. Clincal indications for Peripheral Arterial Study: Claudication Rest pain Ulcerations Ischemia Decreased pedal pulses Limb pain
553. Medial calf perforating veins are commonly associated č severe chronic venous insufficiency (ulcerations)
554. Photoplethysmography is a non-invasive test used to diagnose pulmonary artery obstruction.
48
555. Toe pressures & Tcp02 non-invasive tests are particularly impt. in performing in pts. with falsely elevated ABI’s due to calcified vessels.
556. Clinical Indications for performing Arterial Plethysmography rather than Duplex Doppler examination:
Raynaud’s disease Medical calcinosis Ischemia
557. Normal toe pressures are ≥ 50 mmHg and <30 mmHg it is unlikely that the ulcer will heal.
558. If patient has an ankle pressure <55 mmHG it is unlikely that the foot/ankle ulcer will heal.
559. If there is a ≥ 0.15 difference b/t indices compared to previous study this indicates significant change.
560. On PVR studies, the shape of the wave is more reliable than the amplitude of the wave.
561. Tests for lower extremity PAD & GOLD STANDARD (in Italics) PVR’s (segmental pressures) CTA ABI’s MRA Duplex Doppler angiography ABI’s with exercise
562. Tests for Carotid Artery Disease & GOLD STANDARD (in Italics) Ultrasound carotid angiogram CTA MRA cerebral angiogram 563. For possible pseudoclaudication ABI’s with exercise is done.
564. Tests for AAA & GOLD STANDARD (in Italics) Abdominal US Ultrasound CTA
49
MRA
565. Tests for Cerbrovascular disease & GOLD STANDARD (in Italics) Transcranial ultrasound cerebral angiogram
566. Tests for Venous Insufficiency & GOLD STANDARD (in Italics)
Doppler US AVP (Ambulatory venous pressure) venography air & photo plethysmography
567. Tests for DVT & GOLD STANDARD (in Italics) Ultrasound venography
CT MRI D-dimer blood test
568. 2nd largest vein in the body is the : SVC
569. With venous Plethysmography normal venous filling times should be >20 sec. 570. With Arterial Plethysmography, cuffs are inflated to 65 mmHg.
571. With Venous Plethysmography, the effects of respiration on venous volume are evaluated.
572. Absence of changes during respirations with Venous Plethy. testing indicates thrombotic occlusion.
573. Venous Plethysmography is used for the diagnosis of valvular incompetence & varicose veins.
574. The number of venous valves decrease in the veins from proximal to distal.
575. APG measurements includes:
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(VFI) venous filling index (want low) (EF) Ejection Fraction (want high) (RVF) Residual Volume Fraction (want low)
576. Venae Comitantes means corresponding veins which are paired, deep veins of the calf that follow their corresponding arteries.
577. Major part of calf muscle pump & drains blood into the PTV & peroneal veins are called the Soleal sinuses.
578. Empites the lateral hand & forearm: Radial veins
579. Formed by the digital veins: Basilic vein
580. Superficial venous incompetence is the most common form of of venous disease.
581. Veins without valves: (HINT: ICES) Internal Iliac v Common Iliac External Iliac Soleal Sinuses
582. Paget-Schroetter Syndrome is stress effort thrombosis & involves the axillary or subclavian vein.
583. With SVC syndrome flow to the UE remains the same during inspiration (remains continuous).
584. Rouleau formation is RBC’s arranged like rolls or coins& moving very sluggish very likely meaning an outflow problem.
585. Phasic, bi-directional (pulsatile) Doppler signals are seen in these abdominal veins: (HINT: HIR) Hepatic IVC Renal
586. If there is no augmentation with proximal release, consider a more proximal obstruction.
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587. Ascites related to Budd Chiara syndrome is caused by occluded or thrombosed hepatic veins. 588. Hetergenous plaque can cause a TIA which is considered a vascular emergency.
589. Resistance is proportional to pressure and inversely proportional to radius.
590. The SMA turns immediately to course parallel to the Aorta.
591. The proximal limit of the pop. artery is at the adductor hiatus.
592. Symptoms frequently seen with vertebrobasilar lesion: ( HINT: Villian Audrey Did Perform Daring Acts) vertigo ataxia diplopia parasthesia drop attack
amnesia
593. Dorsal vein velocities should not increase post paparavine injection in penis for vasculogenic impotence.
594. Penile plethysmography is performed to determine whether impotence is related to peripheral vascular insufficiency.
595.Doppler velocities are obtained of the CFA, PTA & DPA to calculate penile-brachial index.
596. The dorsal arteries supply the skin of the penis and the glans.
597. ABI ratio: Ankle pressure ÷ highest brachial pressure.
598. Any drop in pressure after exercise testing indicates significant arterial disease.
599. Low ABI pressures before and after exercise testing are abnormal
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600. Post exercising ABI’s for single level & multi-level disease: Single level Disease takes 2-6 min. to increase back to resting state
Multi-level Disease takes 6-12 min. to increase back to resting state
601. If Reactive Hyperemia done instead of exercise testing with ABI’s, Single level disease shows ≤ 50% drop in ankle pressures Multi-level disease shows › 50% drop in ankle pressures
602. When performing TCD’s, diagnosis of vasospasm is most accurate in the MCA and occlusion is most accurate in the ICA & MCA.
603. Severe vasospasm in the MCA is indicated with a PSV of
>200cm/sec.
604. 4 causes of impotence in men: psychogenic neurogenic arteriogenic venogenic
605. LE Arterial Duplex Criteria for ≥ 60% stenosis: Doubling of PSV (at site of max stenosis compared to prx. to stenosis) Triphasic (normal) to biphasic to monophasic ≥ 50% but < 75% = RATIO ≥ 2-4 ≥ 75% but < 100% = RATIO ≥ 4
606. An analog display employs a zero-crossing frequency meter to display signals graphically on a strip chart recorder.
607. The rt. & lt. innominate veins unite to form the: SVC
608. If overall graft velocity is <45 cm/sec, signifies impending graft failure.
609. When comparing ABI indices to a previous study, if ≥ 0.15 then this indicates a significant change.
610. Amplitude of PVR waveform is a less reliable indicator of vascular disease than the shape of the wave.
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611. Hemodialysis access can be performed through either a synthetic graft or surgically created AVF and can be straight or looped.
612. A synthetic graft matures quicker than an AVF graft and has fewer initial complications, however, once an AVF graft matures, lasts longer.
612. Graft failure < 1month is usually due to surgical complications and >1month most commonly occurs secondary to progressive stenosis from neointimal hyperplasia.
613. Treatment for stenosis in a graft or AVF: angioplasty/stenting surgical revision
614. Indications for graft failure: decreased flow volume poor perfusion decreased thrill
615. Also known as the “pulseless” disease: Takayasu’s disease 616. A Carotid Body Tumor helps control respiration by sensing changes in oxygen tension of blood.
617. A reasonable guideline is that a 2-3 fold increase in graft velocities suggests a 50% stenosis and a 3-4 fold increase suggests a >75% stenosis.
618. Graft Complications: Pseudoaneurysm’s Hematoma’s Absesses thrombus steal
619. Normal dialysis graft waveforms in the supplying arteries are monophasic, and low-resistant with PSV’s from 100-400
cm/sec. and EDV’s of 60-200 cm/sec.
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620. The draining veins in a graft have arterial pulsations with PSV’s of 30-100 cm/sec.
621. With PTFE grafts, stenosis and subsequent thrombosis usually occur at the venous anasamosis site.
622. Arterial steal is defined as retrograde flow in the native artery distal to the graft anastomosis.
623. Posterior circulation of the brain is mainly supplied by the Rt. & Lt. verts via the basiliar artery and the anterior circulation is fed by the ICA’s.
624. Thrombangitis obliterans is caused by inflammation of the arteries and always starts in the plantar or palmar vessels & proceeds
centrally and prevents collaterals from forming.
625. Occurs from increased pressure in the calf due to DVT, hemorrhage, or serous fluid not allowing the fascia to expand: Compartment Syndrome
626. MRA overestimates stenosis & angio has a risk of stroke.
627. Anterior Circulation of the brain consists of the ICA’s, MCA, & ACA while the Verts, basilar & PCA involves the Posterior Circulation of the brain.
628. Clinically, shunts are recognized by a palpable thrill and a more or less persistent high frequency bruit present throughout the cardiac cycle.
629. In a graft/fistula, normal flow is monophasic in the feeding artery & the draining vein shows an arterialized flow pattern with pronounced turbulence. 630. Determination of flow rate in the feeding artery has been found to be the most reliable measure for estimating the fistula flow rate.
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631. The volume flow rate is calculated from the mean velocity & the cross-sectional area of the vessel.
632. The fistula flow rate is determined by comparing the value measured in the feeding artery with the same name artery on the contralateral side or by subtracting the blood flow in the artery the blood flow in the artery distal to the shunt.
633. Clinical Indication for Hemodialysis Graft/Fistula Exam: (HINT: 5 P’s & LI) Pre-op Assesment limb ischemia puncture problems poor dialysis ↑ pressures during dialysis perigraft fluid collection
634. The Lesser Saph. vein continues up the thigh as the Giacomini vein & terminates into the mid/dst SFV.
635. A frequent complication of AAA aneurysm is rupture & a frequent complication of peripheral artery aneurysm is distal embolization.
636. When doing PVR’s the 3 cuff method is more accurate.
637. When doing PVR’s, the width of cuff should be 20 % greater then diameter of limb.
638. When doing PVR’s, with 3-cuff technique, the high thigh pressure should be similar to the highest brachial pressure & the 4-cuff technique pressure should be > 30 mmHg to the highest brachial pressure.
639. Exercise testing is better than Reactive hyperemia testing in that it helps to differentiate between true & pseudo claudication.
640. The Acceleration Time is based on the fact that the arterial obstruction prox. to the Doppler probe results in a slowing of the time between the onset of systole & the point of max. systolic peak.
641. The AT & PI helps differentiate inflow from outflow disease.
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642. Resting PPG waveforms & cold immersion testing is done on pts., who present with cold sensitivity of fingers, for vasospastic disease.
643. Organic obstructive disease has abnormal tracings while functional obstructive disease has normal Doppler, pressures, & PPG tracings.
644. Plethysmography helps differentiate true claudication from neurogenic (false) claudication and also locate the level of obstruction.
645. Photoplethysmography does not actually record flow volume changes rather it detects cutaneous blood flow.
646. When taking simultaneous blood pressures at 4 different sites, this must involve a subsequent cuff on the same extremity.
647. When collateral vessels are present and plethysmography is used alone, the degree of obstructive disease may be underestimated.
648. An “end-point” detector is a device that can monitor a signal distal to a pressure cuff in order to obtain a pressure reading.
649. Name 4 such devices: photocell stethoscope pneumatic cuff Doppler instrument
650. Limitations of Plethysmography (air or photo): cold room too tight improper contact with skin pt. has tremors 651. A slower than normal upslope culminating in a sharp anacrotic notch is seen in patients with Raynaud’s disease.
652. The 2 main capabilities of TcP02 are to determine whether healing can occur at a wound site or amputation level.
653. The unique step for setting up TcP02 test is Manual Calibration.
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654. 2 most common sites for stenosis in a Dialysis graft are: venous anastomosis outflow vein 655. Sites above are so vulnerable to stenosis due to the introduction of increased arterial pressure into the outflow vein.
656. CHF can occur due to placement of a hemodialysis graft due to increased venous return to the heart. (The closer the access to the heart the access graft, the higher the likelihood).
657. When comparing 2 VEIN bypass graft studies, you must check to see if flow in any graft segment has decreased by 30 cm/sec or if the ABI’s have decreased more than 0.15.
658. Intraoperative monitoring during a LE vein graft is very useful in order to check patency of anastamotic sites & evaluate suspicious stenotic or turbulent areas.
659. Indirect criteria for dialysis shunt stenosis are triphasic flow in the feeding artery & a decrease in shunt flow to <250 ml/min.
660. RAR for >60% stenosis: ≥ 3.5 PSV >180 cm/sec.
661. With proximal high grade stenosis or occlusion, the distal Doppler signal does not change its resistance, just its strength.
662. The 2 main criteria used to determine whether resistance has ↑ in the kidney &/or renal artery are the: Parenchymal Resistance Ratio (PR) Resistive Index (RI)
663. Most common complications after liver transplantation: (4) Hepatic artery occlusion pseudoaneurysm PV thrombosis IVC thrombosis 664. The number 2 in the Doppler equation represents that RBC is 1st an “observer” of a stationary US field then it acts as a
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wave source when wave scatter from its surface.
665. Other conditions that can cause Renal Artery Resistance other than after Renal transplantation: renal vein thrombosis Infection Tubular Necrosis
666. The Superior Epigastric artery branches off the Internal Mammaryartery & the Inferior Epigastric artery branches off the External Iliac
artery.
667. The “watershed area” is where the Superior Epigastric & Inferior Epigastric artery anastamose.
668. 4 arteries that are preoperatively mapped using Duplex Doppler: Superior Epigastric Inferior Epigastric Internal Mammary Radial Artery
669. Blue Toe Syndrome is caused by: (4 things) (HINT: 4 A’s) Aneursymal disease Arteritis Athersosclerotic lesions &/or ulcerations Angio procedures 670. 3 veins often mapped for bypass grafts: GSV Cephalic Basilic
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