Arterial Module Final Exam

Question 1

A low resistance waveform pattern is expected in which of the following vessels?

A. post-prandial SMA
B. pre-prandial SMA
C. subclavian artery
D. CFA

Answer 1

A. post-prandial SMA

Vessels that are supplying vasodilated vascular beds will show low resistance patterns. So typically, our organ vessels (hepatic artery, renal artery, splenic artery) will all show low resistance waveforms.

All of our peripheral vessels are showing high resistance waveforms because the peripheral system is vasoconstricted.

Question 2

Upon renal duplex to rule out reno-vascular hypertension, what would be the significance of the following findings: Aorta PSV 80cm/s and 240cm/s in the proximal left renal artery?

Answer 2

within normal image, because the RAR is 3.0

abnormal RAR is >/=3.5 which indicates >/=60% DR

Question 3

Upon penile doppler, what is indicated by an increase to the dorsal venous flow velocity?
A. arteriovenous fistula
B. rules out vasculogenic impotence
C. venous leak
D. venous reflux

Answer 3

C. venous leak

The dorsal venous flow should not increase, it should stay the same. So if it increases, that means we have a venous leak.

Question 4

What are the 2 reasons for having vasculogenic impotence?

Answer 4

1) venous leak (increase dorsal venous flow)
2) arterial insufficiency (decrease PBI)

Question 5

Where is the level of obstructive disease based on the segmental pressure study?

Rt brachial: 143
Lt brachial: 146

R hi thigh: 178
R low thigh: 157
R calf: 119
R ankle: 98

L hi thigh: 182
L low thigh: 159
L calf: 140
L ankle: 144

Answer 5

R femoral popliteal

This is a 4 cuff method. Normal result would be hi thigh 30mmHg or high than greatest brachial.

Question 6

Which finding would confirm the diagnosis of a >/= 75% diameter reduction of the distal SFA which has a PSV of 320cm/s?

A. a proximal PSV of approx 160cm/s
B. a PSV of 78cm/s proximal to the site of elevated velocities
C. an ABI of 0.4
D. a proximal PSV 4 times greater than the stenotic PSV

Answer 6

B. a PSV of 78cm/s proximal to the site of elevated velocities

2:1 ratio double (>/=50%DR)
4:1 ratio quadruple (>/=75%DR)
If the 320cm/s is quadrupled velocity, then the proximal segment would be 1/4 of 320cm/s.

Question 7

What hemodynamic changes occur in the distal limb due to arterial obstructive disease?

A. vasoconstriction and increased resistance
B. vasoconstriction and lower resistance
C. vasodilation and decreased resistance
D. vasodilation and increased resistance

Answer 7

C. vasodilation and decreased resistance

When we have arterial obstructive disease, you have an abnormal loss in energy and abnormal decrease in volume flow. Because of that, the body tries to increase the volume flow by vasodilation. So the result of that will always be “vasodilation occur distal to arterial obstructive disease”.

Vasodilation always decrease the resistance by increasing the size of the arteries.

Question 8

Ankle/brachial indices found in the patients with claudication are…

A. unreliable due to incompressibility
B. >1.3
C. 1.0-1.3
D. 0.5-0.8

Answer 8

D. 0.5-0.8

Claudication indicates moderate disease.

> 1.3 = medical calcinosis
0.9-1.0 = normal
0.8-0.9 = mild, minimal
0.5-0.8 = moderate, claudication
<0.5 = severe, rest pain

Question 9

Which of the following most accurately describe ischemic ulcers?

A. painless but oozing on site
B. mildly painful and relieved by elevation
C. very painful and most likely seen superior to medial malleolus
D. very painful and most commonly located on dorsum of foot or bony regions

Answer 9

D. very painful and most commonly located on dorsum of foot or bony regions

Ischemic ulcers are caused by arterial insufficiency and so, since the lack of blood flow is worse in the most distal parts of the limb, we’re going to see these on the tips of the toes and maybe the tops of the feet. They are very painful, regular in shape, and deep.

Question 10

How would this finding be interpreted?

An image of the SMA with spectral broadening and turbulent flow waveform. The PSV of the waveform is 509cm/s and the EDV is 49cm/s.

A. near total occlusion
B. >/= 80% DR
C. >/= 70% DR
D. >/= 60% DR

Answer 10

C. >/= 70% DR

The SMA if >/= 275cm/s means we have a >/= 70% DR. This is clearly abnormal. This would be a stenosis at the proximal SMA. We only have criteria for >/= 70% DR in SMA.

Question 11

Takayasu’s arteritis is most commonly found in…

A. elderly men
B. young women
C. young men
D. elderly women

Answer 11

B. young women

Takayasu’s arteritis is also called “pulselessness disease”. Because the arteritis effects the most larger vessels, such as the aorta, the aortic arch, subclavian, and so because of that your distal pulses will be diminished or close to absent.

Question 12

Which of the following can be used as a landmark for the left renal artery?

A. right renal vein
B. IVC
C. aorta
D. SMA

Answer 12

D. SMA

The SMA and left renal veins are the two best vessels to use as landmarks for the left renal artery.

Question 13

A patient presenting with ischemic rest pain would complain of…

A. pain upon exercise and relieved upon rest
B. pain upon dependency and relief when elevated
C. foot pain when elevated and relieved when dependent
D. pain when foot is still and relieved upon movement

Answer 13

C. foot pain when elevated and relieved when dependent

When the limb is elevated or the same level as the heart (supine), there’s no gravity pulling that blood down. So they experience the pain and in most distal part of the limb.

When they hang the foot off the side of the bed, the gravity helps pull that arterial blood down and so the pain is relieved.

Question 14

What is celiac band syndrome?

Answer 14

compression of the celiac artery by the median arcuate ligament of the diaphragm

This type of compression change with respiration. Since the diaphragm moves when you breathe, sometimes it will compress the celiac artery based on respiration and sometimes it will be relieved. So if you’re getting high velocity flow in the celiac artery in a young, especially athletic woman, you would Doppler it during inspiration and also during expiration. So if the velocities go back to normal during one of those moments, then you know that this is what they have…median arcuate ligament compressing the celiac artery.

Question 15

Which treatment option for pseudoaneurysm is most accurately described below?

A. immediate surgical intervention is needed for all patients
B. under ultrasound guidance, thrombin injection into the body of the pseudoaneurysm
C. the patient’s hands could apply pressure to the pulsating mass for periods of 10-15 mins and repeated until pulsating is no longer felt
D. thrombin injection under ultrasound guidance into the neck of the pseudoaneurysm

Answer 15

B. under ultrasound guidance, thrombin injection into the body of the pseudoaneurysm

There are two main treatment options for pseudoaneurysm:
1) manual compression: compresses the neck
2) thrombin injection: injects into the body

Question 16

Angiography reveals an occluded right iliac artery. Which treatment would most likely be performed?

A. balloon angioplasty with stent
B. axilo-femoral bypass
C. femoral-femoral bypass
D. femoral-popliteal bypass

Answer 16

C. femoral-femoral bypass

In the presence of a unilateral iliac occlusion, the best treatment would be the femoral-femoral bypass. They’ll use the normal iliac artery to take the blood down that limb. So in this case, the left iliac artery would be clean. It would go down towards the femoral, then with the femoral to femoral bypass, it will cross over to the other limb and then we’ll able to supply that right lower extremity with blood flow.

Balloon angioplasty with stent is only for focal stenosis, it’s not going to work with occlusion.

Axilo-femoral bypass is possible, but it’s kind of extreme to go from the axillary artery to the femoral artery. You’re only going to do something so drastic when the others cannot be performed.

Femoral-popliteal bypass would not help us at all because that would be bypassing part of the distal femoral artery, not the iliac at all.

Question 17

What is the difference between analog and spectral analysis display of CW doppler analysis?

A. analog estimates frequency shift info
B. analog uses spectral analysis to display true frequency shifts
C. spectral Doppler uses a zero-crossing frequency meter
D. spectral analysis displays frequency shift info on the x-axis

Answer 17

A. analog estimates frequency shift info

• Analog: estimates the frequency shift
• Spectral analysis display: shows true frequency shift
  So the analog is not as sensitive. The spectral analysis would have a higher sensitivity.

Question 18

What is the area reduction of a 50% diameter reduction?

Answer 18

75%

Question 19

Calculate the ABIs

Rt Brachial: 132
Rt PTA: 128

Lt Brachial: 108
Lt PTA: 70

Answer 19

Rt 0.9 and Lt 0.5

Rt: 128/132 = 0.9
Lt: 70/108 = 0.5
Always use only highest brachial pressure

Question 20

Which transducer would you most likely choose to rule out abdominal aortic aneurysm on an overweight male patient?

A. 7 MHz linear array
B. 10 MHz linear array
C. 5 MHz curvilinear array
D. 3 MHz curvilinear array

Answer 20

D. 3 MHz curvilinear array

Question 21

What is the significance of monophasic, high-resistance, and absent diastolic flow?

Answer 21

distal stenosis

Monophasic, high resistance, and absent diastolic flow are characteristics of “thumping waveform”.

Question 22

What statement best describes a thrill?

A. a vibration felt in response to high velocity turbulent flow
B. a defect in the heart causing an auditory murmur
C. a stimulating event that triggers symptoms
D. a bounding pulse often due to aneurysmal dilatation

Answer 22

A. a vibration felt in response to high velocity turbulent flow

ex: hemodialysis access graft

The thrill and the bruit are caused by the same thing (high velocity turbulent flow). The only difference is that the bruit is something you hear and thrill is something you feel.

Question 23

In the presence of an AV fistula, the proximal artery would demonstrate what type of flow patterns?

A. low resistance with increased diastolic flow
B. low resistance with decreased diastolic flow
C. high resistance with diastolic flow reversal
D. increased resistance with constant forward flow

Answer 23

A. low resistance with increased diastolic flow

Question 24

Atherosclerosis affects which layer(s) of the artery?

Answer 24

intimal and medial layers

Question 25

What best describes the technique for accurately obtaining a systolic pressure?

Answer 25

inflate cuff to suprasystolic pressures (30 more after disappearance of last audible signal), slowly deflate until pulsation returns, record pressure

Question 26

Fasciotomy is the treatment for what disease?

A. anterior compartment syndrome
B. fibromuscular dysplasia
C. thoracic outlet syndrome
D. popliteal entrapment syndrome

Answer 26

A. anterior compartment syndrome

Fasciotomy treats compartment syndromes. In this case, the choice is anterior compartment syndrome. With compartment syndrome, there’s swelling and a lot of pressure within the fascial layers causing a compression of the vascular structures. So the fasciotomy opens up the fascial layers to allow things to be relieved of their pressure until the swelling goes down. When it goes down, things can be closed up again.

Question 27

What vessel is seen crossing posterior to the SMA and anterior to the aorta?

Answer 27

left renal vein

Question 28

If scanning medially along the forearm, what vessel is most likely to be visualized?

A. ulnar artery
B. cephalic vein
C. radial artery
D. brachial artery

Answer 28

A. ulnar artery

The brachial artery is also found medially, but that would be the upper arm, not forearm.

Question 29

In this angiogram, what finding is indicated by the arrow?

A pinching or a thinning of the radiopaque dye in the left common iliac artery.

A. common iliac occlusion with collaterals
B. common iliac stenosis
C. CFA occlusion
D. proximal SFA stenosis

Answer 29

B. common iliac stenosis

Based on the angiogram, we have common iliac stenosis, specifically that would be the left common iliac because it’s on the left side.

Question 30

What are the main layers of the arteries from inner to outer?

Answer 30

intima, media, adventitia

Question 31

Patient has a fistula graft in the upper extremity and is now experiencing symptoms of tingling in the arm. What would this most likely be caused by?

A. fistula occlusion
B. graft aneurysm
C. graft embolism
D. steal syndrome

Answer 31

D. steal syndrome

The complications of fistula graft could be any of these: occlusion, aneurysm, embolism, or steel syndrome. But if the patient is experiencing symptoms of tingling, that would sound like ischemia of the hand, in other words, the distal hand is not getting enough blood flow. This would indicate that the fistula graft is stealing or taking the blood away from the hand. Sonographic finding of steal syndrome would be retrograde flow in the distal artery to the fistula, so perhaps if this was a Brescia-Cimino graft (cephalic v. - radial a.), then the radial artery in the forearm would have retrograde flow (flow going to the fistula instead of distal hand)

Question 32

Which of the following bypasses require the use of a valvutome?

A. gore-tex graft
B. PTFE graft
C. reversed GSV graft
D. in situ GSV graft

Answer 32

D. in situ GSV graft

Valvutome is a tool that they use to remove the vales in the autologous saphenous vein graphs. Now the reverse saphenous vein graft, you don’t need to remove the valves because you’re going to flip the whole vein upside down and so the valves just stay open. However, in the case of the in situ GSV graft, everything is kept in place, so the valves must be removed in order to allow blood to now go distally towards the limb.

Question 33

The tardus parvus waveform is obtained at the distal anterior tibial artery. The posterior tibial arteries demonstrate triphasic waveform patterns. Which condition could explain this appearance?

Answer 33

stenosis of the proximal anterior tibial artery

The disease cannot be at popliteal artery. If it is at popliteal artery, the it would also affect everything distal to that including PTA.

Question 34

A patient presents with back and abdominal pain. What is the most likely vascular disease process?

A. renal artery stenosis
B. abdominal aortic aneurysm
C. iliac disease
D. aortic stenosis

Answer 34

B. abdominal aortic aneurysm

• AAA: back & abd pain, bounding abd pulse
• renal artery stenosis: present with hypertension
• iliac disease & aortic stenosis: lower limb ischemia –> hip/thigh claudication, other chronic PAD symptoms

Question 35

What would be an indication of liver transplant rejection?

A. hepatopedal flow in the PV
B. absent end diastolic flow in the HA
C. hepatofugal flow in the HV
D. elevated end diastolic velocity in the HA

Answer 35

B. absent end diastolic flow in the HA

Any type of organ transplant, our main focus is going to be the supplying artery as well as the vein. Possible vascular complications including thrombosis of the vessel, or just abnormal waveforms in the artery.

Question 36

What type of waveform would indicate the presence of a proximal arterial obstruction?

A. absent diastolic component
B. bidirectional
C. pulses bisferiens
D. tardus parvus

Answer 36

D. tardus parvus

• absent diastolic component: indicates distal arterial obstruction
• bidirectional: seen in the case of pseudoaneurysm
• pulses bisferiens: this means we have a double peak pulse that’s found when we have aortic regurgitation

Question 37

The renal to aorta velocity ratio cannot be used when there is which of the following?

A. fibromuscular dysplasia
B. AAA
C. renal artery PSV >400cm/s
D. nephrosclerosis

Answer 37

B. AAA

We cannot use the RAR when the aorta is abnormal. So in the presence of AAA or when aorta is <40cm/s or >90cm/s, we have to rely our criteria solely on the renal velocities alone.

Question 38

What clinical finding is most pertinent in a patient with suspected Buerger’s disease?
A. diabetic
B. hypertension
C. smoker
D. absent pulses

Answer 38

C. smoker

• diabetic: chronic PAD
• hypertension: chronic PAD
• absent pulses: chronic PAD, acute arterial occlusion, takayasu arthritis

Question 38

A 32 yo male patient with a history of alcohol abuse and heavy smoking presents. to the ultrasound department with pain at night bilaterally and gangrenous ulcers on the feet. What disease process is suspected?

A. atherosclerosis
B. thromboangitis obliterans
C. arteritis
D. phlegmasia cerulea dolens

Answer 38

Patient profile: young, male, alcohol abuse, heavy smoker. The young age rules out atherosclerosis and chronic PAD. This most likely fits a very specific category of Buerger’s Disease (AKA thromboangitis obliterans).

Patient profile of Buerger’s disease: young, heavy smoker, rest pain, ulcers.

Question 38

Which of the following would be a likely indication to performing an Allen test?

A. ruling out Raynaud’s phenomenon
B. pre-op for TRAM flap breast reconstruction
C. evaluate radial artery for hemodialysis access graft
D. evaluate ulnar artery as possibility for lower extremity bypass graft

Answer 38

C. evaluate radial artery for hemodialysis access graft

Allen test is used to evaluate the patency of the Palmer Arch. One of the reasons we could do this, especially the modified Allen test, is if we’re looking to harvest or use the radial artery for other things such as coronary bypass or hemodialysis. access graft.
- We don’t use Allen test for Raynaud’s. We would need cold stress for that.
- TRAM flap breast reconstruction uses epigastric and internal membrane
- We never use the ulna artery for anything.

Question 39

During the angiography a focal stenotic lesion is found, what would most likely be the course of treatment?

A. Gore-Tex graft
B. balloon angioplasty
C. fem-pop bypass
D. in situ GSV graft

Answer 39

A good course of treatment for focal stenotic lesion is balloon angioplasty, where they would also put in a stent.

Bypass and graft are most likely to be used for more extensive disease and total occlusions. So if they’re doing the angiography and they just see a focal small lesion, they’re just going to do the angioplasty right then in there.

Question 40

The total sum of energy contained in moving blood is equal to what?

Answer 40

the sum of pressure, gravitational, and kinetic energies

Question 41

What should be done in the presence of a pulsating hematoma post catheterization?

A. duplex exam to rule out the presence of an AVF
B. duplex exam to rule out total occlusion of native artery
C. nothing, this is normal post procedure
D. duplex exam to investigate for a possible pseudoaneurysm

Answer 41

D. duplex exam to investigate for a possible pseudoaneurysm

One of the risk factors of post catheterization would be a pseudoaneurysm . We could also have an AVF or native artery occlusion. However, a pulsating hematoma most likely fits a pseudoaneurysm. So then, we’ll have to perform a duplicate exam looking just for that, a pseudoaneurysm.

Question 42

What findings would confirm the presence of extrinsic compression of the artery with thoracic outlet syndrome?

Answer 42

Normal resting PPG waveforms that flatten as the patient’s arm is in different positions

If the artery is being compressed with thoracic outlet syndrome, it’s going to pinch or shut off the artery when the arm is in different positions or specific positions. So the resting PPG waveform would be normal because it’s not compressing it, so they’re going to have the nice sharp peak and dicrotic notch. If it’s being compressed in a specific position, then we’re going to see the waveform flattening.

Not compressed =normal
Compressed = flattened

Question 43

Which of the following vessels would be most likely used as an arterial bypass?

A. 2.5mm small saphenous vein
B. 2.0mm ulnar artery
C. 2.5mm brachial vein
D. 1.5mm GSV

Answer 43

A. 2.5mm small saphenous vein

A vessel needs to have both categories correct in order to be used as arterial bypass:
1) correct vessel
2) at least 2mm

Choices for arterial bypass are superficial veins, GSV, small saphenous vein, cephalic, and basilic, and radial artery.

The minimum size is 2mm. We never use any other artery and any deep vein.