Mock Exam - Vascular

Question 1

What vessel is most likely affected by right sided heart failure?

A. common carotid artery
B. hepatic veins
C. portal vein
D. aorta

Answer 1

B. hepatic veins

• Rt sided heart failure affects IVC and its branches
• Lt sided heart failure affects Aorta and its branches

Question 2

How is the ECA vessel identification best confirmed?

Answer 2

visualization of branches

• ECA has extracranial branches
• ICA has NO extracranial branches

Question 3

*** What are aneurysms most often caused by?

Answer 3

atherosclerosis

Question 4

What treatment removes plaque?

A. angioplasty
B. stenting
C. embolectomy
D. endarterectomy

Answer 4

D. endarterectomy

Endarterectomy removes the actual plaques and intimal lining of artery.

Angioplasty and Stenting only dilate the vessel size and put a stent in, in order to hold it open, but everything stays in place.

Embolectomy is the removal of embolism, not plaques.

Question 5

What is the significance of a PSV at the proximal SFA of 242cm/s if the distal CFA PSV is 90cm/s?

Answer 5

> /=50% diameter reduction (2:1 ratio)

Since we’re talking about the arterial system in the LE, we’re going to use our velocities stenosis criteria.
2:1 ratio = >/=50% DR
4:1 ration = >/=75% DR

242/90 = 2.68…this is over doubled but not yet quadrupled, so it still falls under 2:1 ratio

Question 6

*** What clinical finding is most indicative for chronic peripheral arterial disease?

A. pain and muscle fatigue w/ activity, relieved with rest
B. Pain in the calf at rest, relieved upon dependency
C. Pain in the limb while dependent, relieved upon elevation
D. Skin discoloration in calf and ankles

Answer 6

A. pain and muscle fatigue w/ activity, relieved with rest

For PAD, we’re looking for clinical findings such as claudication, rest pain, or appropriate descriptions of ulcers or trophic changes. So out of these choices we have here, our correct answer would be “pain and muscle fatigue with activity relieved with rest” because it accurately describes claudication. Other answers are not accurate descriptions of claudication or rest pain.

I picked B and it’s not correct because rest pain is not found in the calf, it’s found in the feet and heels and relieved upon dependent.

Skin discoloration is pale and any ulcers would be found in most distal regions such as tips of the toes, not in the calfs and ankles.

Question 7

Calculate the ABI’s of the following segmental pressure study:

Rt brachial: 140
Lt brachial: 138

Rt ankle: 78
Lt ankle: 106

Answer 7

Rt ABI: 78/140 = 0.5
Lt ABI: 106/140 = 0.7

Use ankle pressure on each leg divide it by the highest brachial pressure.

Question 8

In the lower extremity arterial system, what is the most common site of atherosclerosis for general population?

Answer 8

distal superficial femoral artery (SFA)

Question 9

In the lower extremity arterial system, what is the most common site of atherosclerosis for diabetic patients?

Answer 9

tibial vessels

Question 10

What is the hemodynamic result with an ineffective calf muscle pump?

A. increased venous pressure
B. increased venous return
C. decreased venous volume
D. decreased venous pressure

Answer 10

A. increased venous pressure

Calf muscle pumps that are ineffective have valvular incompetence, which means the venous pressure and volume increases as the patient walks or stands.

So, increasing venous volume, venous pooling, and therefore, increased venous pressure.

Question 11

*** What is the most likely significance of the following doppler waveform?

(image of a flattened peak and slow upstroke waveform of Rt SFA, PSV: -41.3cm/s, EDV: 0cm/s)

A. distal AVF
B. proximal obstruction
C. distal occlusion
D. aneurysmal disease

Answer 11

B. proximal obstruction

The shape of the peripheral arterial waveform is abnormal. It does not have a sharp peak, sharp upstroke, rapid downslope, and diastolic flow reversal.

In the image, the peak is flattened and the upstroke is slow. Whenever that waveform contour shows those findings, that tells us we have a proximal arterial obstruction.

I picked “A: distal occlusion” because I mistakenly read it as high resistance waveform with loss of EDV.

Question 12

Which vessel is most likely to have retrograde flow in the presence of an ICA occlusion?

A. common carotid artery
B. contralateral ICA
C. ophthalmic artery
D. vertebral artery

Answer 12

Retrograde flow in any vessel because of a coexisting ICA occlusion means that that vessel is acting as a collateral vessel.

There are 3 types of collateralization:
1) cross-over
2) external to internal
3) posterior to anterior

Only the two, the cross-over and the external to internal have flow direction changes inside the collateral vessel.
- In cross-over collateralization, it was the ACA that changed the flow direction (retrograde to antegrade)
- In external to internal, it’s the ophthalmic artery that changes the direction (antegrade to retrograde)

So out of the choices we have here, that’s going to be “C: ophthalmic artery”

Question 13

What best explains the findings documented in the image?

Image of the Left Vertebral Artery seen with retrograde flow.

Answer 13

Left subclavian steal

When the vertebral arteries are retrograde, it indicates a subclavian steal on the same side of those vertebral.

So, if retrograde flow is seen in Left Vertebral Artery, it means the patient has Left Subclavian Steal.

Question 14

Where would a dampened waveform be found in the presence of a flow altering stenosis?

Answer 14

distal to the stenosis

“dampened waveform” = tardus parvus (flattened peaks, slow upstroke, rounding of the waveform, low velocity)

tardus parvus indicates stenosis proximal to the waveform.

Question 15

What state is associated with valvular incompetence?

A. decrease venous volume
B. systemic hypertension
C. decrease venous pressure
D. venous hypertension

Answer 15

D. venous hypertension

Valvular incompetence means the patient will experience venous reflux. In other words, the venous blood is not successfully emptying out of the leg. This is going to increase the venous volume and pressure.

Abnormally increased venous volume and venous pressure is termed “venous hypertension”.

Question 16

Where should pressure be applied during a pseudoaneurysm compression procedure?

Answer 16

neck of pseudoaneurysm

During a manual compression procedure, you want to ensure that the neck of the aneurysm can be totally and fully compressed.

Question 17

Where should the needle be placed for thrombin injection is the case of pseudoaneurym?

Answer 17

body of pseudoaneurysm

Question 18

What is the pulsatility index used to calculate?

Answer 18

resistance

Question 19

What vessels form the confluence of the main portal vein?

Answer 19

splenic vein and SMV

Question 20

Where would a tardus parvus waveform most likely be noted in the presence of renal artery stenosis?

Answer 20

segmental artery

Tardus parvus waveform is found distal to stenosis. So, if the stenosis is found at renal artery, tardus parvus has to be found in the vessel segment that is distal to renal artery. Segmental artery is the terminal branches of renal artery and is distal to renal artery.

Question 21

What does it mean if both an arterial and a venous doppler signal are seen on the same side of the baseline at the level of the porta hepatis?

Answer 21

normal finding

Portal vein and hepatic artery both supply blood to the liver (hepatopedal).

Question 22

*** What causes the area of blue in the proximal ICA?

Image of proximal ICA seen with retrograde flow (indicated by red) with some are of antegrade flow (indicated by blue).

A. turbulent flow
B. dissection
C. laminar flow
D. Bernoulli effect

Answer 22

D. Bernoulli effect

According to Bernoulli effect, when we have a lower velocity, we have an increase in pressure and that can momentarily spin our vessel around.

Other correct answers could be:
- flow separation
- increase in pressure due to a decrease in velocity

Question 23

***What best describes the normal peripheral arterial doppler contour?

A. high acceleration time with no diastolic component
B. prominent phasicity with respiration
C. sharp systolic peak and prominent diastolic flow reversal
D. sharp systolic peak, continuous diastolic flow with dicrotic notching

Answer 23

C. sharp systolic peak and prominent diastolic flow reversal

The normal peripheral arterial system is vasoconstricted, meaning higher resistance. So we would expect a nice sharp peak and diastolic flow reversal.

I picked “D” and it’s incorrect because that describes a normal low resistance pattern, not triphasic waveform that should be found in peripheral arterial system.

Question 23

***Where are the terminal branches of the renal artery?

Answer 23

segmental artery

“Terminal” means where the vessel ends. Typically, an artery ends at bifurcation, so the renal artery terminates when it splits into the segmental arteries at the level of the renal sinus.

Question 23

What is documented in the image below?

An image shows a transverse view of a hypoechoic, soft tissue mass located between the ICA and ECA, splitting them apart.

Answer 23

carotid body tumor

Carotid body tumor will always be seen located at the CCA bifurcation and will split the ICA and ECA apart.

Question 24

Detection of a solid mass in the IVC should prompt a thorough investigation of what structure(s)?

Answer 24

kidneys

Question 25

What vessel is deep to the IVC?

Answer 25

right renal artery

The vessel that runs posterior to the IVC is the RRA.

Question 26

What is the best scanning technique for visualization of the distal subclavian artery?

Answer 26

infraclavicular

The subclavian artery is found near the clavicle (collarbone). So depending if we’re above the collarbone or below it, we’ll determine what part of the subclavian artery we’re visualizing.
– Distal subclavian artery would be found infraclavicular.
– Proximal subclavian artery (brachiocephalic artery) would be found supraclavicular.

Question 27

Where is the most common location for venous stasis ulcers?

Answer 27

superior to medial malleolus (AKA lower medial calf, gaiter zone)

Question 28

Based on this table, what values provide the sensitivity?

RUQ: 42
LUQ: 14
LLQ: 61
RLQ: 8

Answer 28

42/50

Question 29

What happens to transmural pressure as venous volume decrease?

Answer 29

decreases

Volume and pressure are directly related in the venous system. So decreased volume means decreased pressure.

Question 30

What waveform abnormality would be documented distal to arterial obstructive disease?

Answer 30

tardus parvus

Question 31

What is the branch of the external carotid artery that is most easily identified by duplex?

Answer 31

superior thyroid artery

This is the 1st branch of the ECA and we often see it traveling back down (caudally) to go towards a thyroid.

Question 32

Where could the disease be located if the CFA demonstrates an acceleration time of 138msec?

A. internal iliac artery
B. deep femoral artery
C. external iliac artery
D. superficial femoral artery

Answer 32

C. external iliac artery

Criteria for acceleration time is if it’s >/= 133msec, then it’s abnormal. In other words, the upstroke is slower and increased acceleration time means we have inflow disease (proximal disease).

The vessel that is proximal to the disease CFA is external iliac artery. Common iliac artery and aorta would also be correct options.

Question 33

What is the hydrostatic pressure at the ankle in a supine patient?

Answer 33

0 mmHg

Question 34

Which of the following is a likely complication of an in situ saphenous vein graft?

A. pseudoaneurysm
B. varicose veins
C. neointimal hyperplasia
D. retained valves

Answer 34

D. retained valves

Since the vein stays in place, we have two possible things that are likely to happen.
1) a valve that’s still there
2) a branch that’s still there
Retained valves can become stenosis. Branches that were not ligated will become arteriovenous fistulas.

Question 35

***What clinical finding best corresponds with decreased arterial perfusion?

A. pain in calf when at rest and supine
B. induced rubor upon elevation and pallor when dependent
C. muscle pain and fatigue upon physical activity
D. brawny discoloration and swelling in lower calf

Answer 35

C. muscle pain and fatigue upon physical activity

Decreased arterial perfusion is just another word for having arterial ischemia or not getting enough blood flow down to the limb. So, we’re looking for a chronic arterial disease symptom.

Out of all the choices, “C” is the correct answer because it gives accurate definition of claudication.

I picked “A” and it’s incorrect because that is not the correct description of rest pain. Rest pain is pain in FEET & HEELS when at rest and supine, not calf.

“B” is incorrect because it’s switched. Poor arterial perfusion will have induced pallor upon elevation and rubor when dependent.

“D” is incorrect because that is an indication of having chronic venous disease, not decreased arterial perfusion.

Question 36

What is a normal response to exercise in the arterial system?

A. decreased resistance, decreased EDV
B. decreased resistance, increased volume flow
C. increased resistance, increased flow volume
D. increased resistance, increased flow velocity

Answer 36

B. decreased resistance, increased volume flow

Exercise is a vasodilator, which means resistance will be decreased.

What is the effect to the volume flow when resistance is decreased? Flow is increased.

When the peripheral system is exercising, the demand for blood supply goes up. So by vasodilating, it can decrease the resistance in the peripheral system and therefore, increase the volume flow.

Question 37

Which scanning technique most accurately describe transcranial doppler?

A. 2MHz PW transducer at 0 degree angle
B. 2MHz CW transducer at 0 degree angle
C 4MHz Phased array at 0 degree angle
D. 8MHz PW transducer at 0 degree angle

Answer 37

A. 2MHz PW transducer at 0 degree angle

Transcranial has to be PW because we need to know range of depth. Also, it has to be low frequency because we need to penetrate. We’re going to assume a 0 degree angle.

Question 38

What is the significance of a peak systolic velocity of 250cm/s found within the celiac artery?

A. >/=60% DR
B. Within normal limits
C. >/=70% DR
D. >/=75% DR

Answer 38

C. >/=70% DR

CRITERIA:
* Celiac artery:
>/= 200cm/s then it has >/=70%DR

• SMA:
  >/=275cm/s then it has >/=70%DR

Since the celiac artery is 250cm/s, it’s greater than 200cm/s. Therefore, this celiac artery is having >/=70%DR.

Question 39

What is the most common vessel in the upper extremity to develop obstructive disease?

Answer 39

left subclavian artery

Most common location for a subclavian steal is on the left upper extremity, so that would also be the most common vessel in the arm to develop stenosis.

Question 40

***What diagnostic test provides the most anatomic information?

A. duplex
B. angiography
C. segmental pressure
D. plethysmography

Answer 40

B. angiography

Angiography would be the best exam to show vessel anatomy.

Question 41

What will cause venous flow in the lower extremities to halt?

A. distal compression
B. inhalation
C. exhalation
D. release of proximal compression

Answer 41

B. inhalation

Anything that’s going to increase the abdominal pressure will make the venous flow from the legs to not flow upwards or it will make them cease/halt momentarily.

Question 42

***What flow patterns would be normally expected in a fasting SMA?

A. low resistance, low velocity
B. high resistance, low velocity
C. high resistance, high velocity
D. low resistance, high velocity

Answer 42

C. high resistance, high velocity

Anything in the abdomen, typically is pretty high velocity. The resistance will change depending on the vessel we’re in, but since we’re talking about the fasting SMA, correct answer is high resistance, high velocity.

I picked “B: high resistance, low velocity” and that’s incorrect because anything in the abdomen is typically pretty high in velocity.

Question 43

What does photoplethysmography document?

A. capillary reflections
B. capillary volume
C. hydrostatic pressure
D. systolic volume

Answer 43

A. capillary reflections

Photoplethysmography is not true photoplethysmography, so it’s not truly documenting volume. Instead, it’s documenting capillary reflections. The PPG sensor sends infrared light and is able to acquire the pulsations of the capillary blood flow.

Question 44

Where is the most common location for renal artery stenosis?

A. proximal renal artery
B. segmental artery
C. distal renal artery
D. mid renal artery

Answer 44

A. proximal renal artery

In general, the most common location for any arterial stenosis is at the proximal artery. So that’s the same for the renal artery.

The only time that goes against the rule is in a lower extremity because the most common location for stenosis in the legs is the distal SFA.

Question 45

***Which of the following is likely to be part of a medical management plan for chronic peripheral arterial disease?

A. hyperbaric chamber
B. exercise
C. oral coumadin
D. elevation of affected limb

Answer 45

B. exercise

The medical management plan for any treatment would be lowering risk factors and increasing the body’s own natural ability to provide solutions. So things like stop smoking, losing weight, controlling diabetes, exercise, all of those are medical management because they don’t require surgery and they’re a little bit less invasive. So out of the choices we have, the correct answer is exercise.

Question 46

***What is consistent with findings of antegrade elevated flow velocities in the PCA as compared to the MCA?

A. external to internal collateralization
B. cross-over collateralization
C. posterior to anterior collateralization
D. basilar artery stenosis

Answer 46

C. posterior to anterior collateralization

The normal PCA should have antegrade flow. The PCA velocities should typically be lower than the MCA velocities. So if the PCA is now elevated, it tells us that the PCA is now acting as a supplying collateral vessel.

Which type of collateralization uses the PCA? Posterior to anterior collateralization. So flow goes from vertebral –> basilar –> PCA –> PcoA –> MCA and ACA

Question 47

Which of the following is considered a primary cause of venous insufficiency?

A. hypoplastic valves
B. obesity
C. previous DVT
D. pregnancy

Answer 47

A. hypoplastic valves

“Primary” are congenital reasons, not acquired reasons. So out of these choices, hypoplastic valves is a congenital cause of venous insufficiency.

All of the three choices are acquired/secondary reasons. Not primary.

Question 48

*** A PVR waveform demonstrates a sharp peak, absent dicrotic notch and a downslope that bows away from the baseline. How would this be interpreted?

A. moderately abnormal
B. severely abnormal
C. mildly abnormal
D. normal

Answer 48

C. mildly abnormal

pg.26 Vascular Study Guide

The normal PVR has a sharp peak with a dicrotic notch. The first thing to go abnormal is the notch. It becomes absent and downslope that goes away from the baseline. So since this waveform still has a sharp peak, this would be mildly abnormal.

Question 49

How would the thigh pressures be interpreted based on this segmental pressure study?

Rt brachial: 133
Lt brachial: 138

Rt hi thigh: 168
Rt lo thigh: 127
Rt calf: 118
Rt ankle: 99

Lt hi thigh: 172
Lt lo thigh: 150
Lt calf: 116
Lt ankle: 94

A. aorta-iliac disease
B. femoral disease
C. internal iliac disease
D. within normal limits

Answer 49

D. within normal limits

This is a 4-cuff method so high thigh pressure must be at least 30mmHg greater than highest brachial.

When comparing vertically, the pressures between each segment should not drop more than 30mmHg (if drop >30mmHg then it indicates disease b/w those segments).

Since the question only ask for thigh pressures, the correct answer is within normal limit.

Question 50

After tourniquet is placed for further testing utilizing venous PPG, what vessel system is considered abnormal if the VRT normalizes?

A. capillaries
B. deep veins
C. superficial veins
D. soleal sinuses

Answer 50

C. superficial veins

The purpose of the tourniquet is to separate the superficial system from the deep system. If the VRT normalizes, that means the deep is normal and superficial is abnormal.

Question 51

What is the normal flow direction of the MCA on TCD?

Answer 51

antegrade

Question 52

What describes acceleration time?

Answer 52

onset systole to peak

Question 53

***What best explains the cause of the higher incidence of the deep venous thrombosis of the left leg rather than the right leg?

Answer 53

venous stasis of left iliac vein due to anatomical location

This happens because the left common iliac vein courses posterior underneath the right common iliac artery. So it’s possible that that vein becomes compressed, causing venous stasis.

Question 54

What can cause transient, elevated velocities of the celiac artery?

Answer 54

median arcuate ligament compression

One of the variants we discussed was celiac band syndrome, and that’s compression of the celiac artery by the median arcuate ligament of the diaphragm. Transient means temporary, so it’s not a permanent stenosis, it’s just means that the velocities are temporarily elevated when the patient is breathing out.

Question 55

What will normally cause venous flow in the lower extremities to augment?

A. inhalation
B. proximal compression
C. release of proximal compression
D. reverse Trendelenburg

Answer 55

C. release of proximal compression

Augment means increase or rush forward. Two things will cause the lower extremities to augment:
1) distal compression
2) release of proximal compression, release of valsalva

Correct answer is “C”. All the other choices would decrease or halt venous flow.

Question 56

What console adjustment can be made to correct aliasing?

A. increasing frequency
B. increase PRF
C. decrease PRF
D. raise baseline

Answer 56

Aliasing is when you have your peak cuts off in spectral waveform, or mosaic pattern in color.
To fix aliasing, we would want to:
- increase the PRF for the velocity scale
- lower the baseline
- decrease the frequency
- increase the angle.

So out of the choices we have here, increase the PRF, which we could also say increase the velocity scale.

Question 57

What is the greatest clinical concern of an abdominal aortic aneurysm greater than 5cm?

A. risk of embolization
B. risk of dissection
C. risk of thrombosis
D. risk of rupture

Answer 57

D. risk of rupture

Most likely complication of a large AAA is risk of rupture.

Question 58

What is considered normal for the resistance index of the renal artery?

A. >1.0
B. >0.65
C. <0.7
D. <0.9

Answer 58

C. <0.7

Renal artery should be low resistance and our correct value is less than 0.7

Question 59

***What is the most common result of deep venous thrombosis?

A. post-phlebitic syndrome
B. pulmonary embolism
C. primary varicose veins
D. distal embolism

Answer 59

A. post-phlebitic syndrome

The most often seen consequence of DVT is valvular damage, therefore, causing post-phlebitic syndrome.

Even though pulmonary embolism can be a result, it’s not the most common result.

Question 60

What is the most dangerous result/consequence of deep venous thrombosis?

Answer 60

pulmonary embolism

Question 61

Which technique would be most informative in a patient complaining of claudication?

Answer 61

treadmill testing

Treadmill testing or exercise testing provides a stress onto the circulation and can reproduce the claudication.

Question 62

***Where is the most common location for obstructive disease of a fistula graft?

Answer 62

venous outflow

AKA venous anastomosis, or distal anastomosis

Question 63

What characterizes a typical doppler waveform distal to a hemodynamically significant stenosis?

A. absent doppler signal
B. loss of end diastolic flow
C. tardus parvus
D. increased pulsatility index

Answer 63

C. tardus parvus

Question 64

How long does it take for thrombin to work for pseudoaneurysm closure?

A. 5-10 minutes
B. 5-10 seconds
C. 5 hours
D. 30 minutes

Answer 64

B. 5-10 seconds

It’s within seconds! You watch it thromboses live as provider is injecting the thrombin.

Question 65

The following patient performs a valsalva during a CW doppler analysis. What does the waveform signify?

Image shows “Rt CFV Val” with flow below the baseline, however, at the point of valsalva, the flow runs above the baseline.

A. arterial incompetence
B. fluid overload
C. distal venous obstruction
D. valvular insufficiency

Answer 65

D. valvular insufficiency

So we notice, there is a retrograde flow during the valsalva. That tells us we have venous reflex or valvular insufficiency.

Competent valves will not show any flow during valsalva. Only shows augmentation after the release of valsalva.

Question 66

Which symptoms is most likely related to vertebrobasilar insufficiency?
A. behavior changes
B. dysphasia
C. syncope
D. vertigo

Answer 66

D. vertigo

VBI symptoms include:
- vertigo
- drop attacks
- bilateral paresthesia
- diplopia

So out of the choice, vertigo is the correct answer.

Syncope is a non-localizing symptom, meaning it’s not specific for either system.

Dysphasia is an specific for ACA.

Behavior changes is specific for MCA.

Question 67

A high resistance waveform is normally documented in which of the following vessels?

A. celiac trunk
B. splenic artery
C. infrarenal aorta
D. post-prandial SMA

Answer 67

C. infrarenal aorta

The branches of aorta inferior to the renal becomes higher resistance because now that part of the aorta is supplying the lower extremities, which is a vasoconstricted vascular system.

Question 68

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

A. hemodialysis access graft
B. in situ saphenous vein graft
C. reversed saphenous vein graft
D. aortic endograft

Answer 68

B. in situ saphenous vein graft

Valvutome is a tool that is used to remove valves and we use them in in situ saphenous vein graft

Question 69

A young, athletic patient complaining of leg pain with exercise is most likely to have what abnormality?

Answer 69

popliteal entrapment

Since patient is young and athletic, even though he has symptoms of claudication, he is not likely to actually have obstructive disease. What they’re more likely to have is the condition called popliteal entrapment, meaning the popliteal artery is wrapped around the fibrous bands or the head of the gastrocnemius muscle. So while they exercise, that artery is being momentarily compressed causing a cutting off of the blood flow and therefore, triggering claudication-like symptoms.

Question 70

Which of the following scenarios could cause of low resistance pattern in the ECA?

A. distal occlusion of the ECA
B. collateralization via the posterior communicating arteries
C. occlusion of the proximal subclavian artery
D. collateralization via the ophthalmic artery

Answer 70

D. collateralization via the ophthalmic artery

Normally the ECA is high resistance. So if the ECA is showing a low resistant pattern, that would be an indication of collateralized flow.

Which collateralization allows the ECA to become the supplying vessel for the ICA? The external to internal collateralization. It uses the ECA branches to go near the eye, the periorbital circulation connects to the ophthalmic artery, and that can go into the carotid siphon.

Question 71

What artifact is most likely to appear similar to a clot in the IVC?

A. reverberation
B. side lobes
C. acoustic enhancement
D. mirror image

Answer 71

A. reverberation

The reverberation echoes might come down from the anterior wall of any vessel and can give a clot like or filled in appearance of any vein or artery.

Question 72

What characteristics should normally be documented within the inflow artery of a hemodialysis access graft?

Answer 72

decreased resistance, increased velocity

Inflow artery is travelling towards a fistula, which is high volume and low resistance. So the inflow artery should also demonstrate low resistance, but higher velocity because of the increased volume of flow throughout the fistula.

Question 73

What is the normal doppler waveform pattern of the post-prandial SMA?

Answer 73

low resistance

After you eat (post-prandial), the vascular system of SMA should vasodilate in the gut, causing a decrease in resistance. So the post-prandial SMA should show low resistance, or in other words, increased EDV.

Question 74

What best describes the etiology of a pulsatile waveform documented at the level of the internal jugular vein?

A. close proximity to the heart
B. fluid overload
C. proximal venous obstruction
D. congestive heart failure

Answer 74

A. close proximity to the heart

Veins that are close to the heart should have pulsatile waveforms: internal jugular, innominate veins, subclavian veins, hepatic veins, IVC.

If the pulsatile waveform was found in a vein that is not close to the heart, then possible options would be fluid overload or CHF.

Question 75

***Which of the following vessels would be a candidate for balloon angioplasty if disease was present?

A. ICA
B. aorta
C. posterior tibial artery
D. renal artery

Answer 75

D. renal artery

Balloon angioplasty works best in focal diseases in medium size vessels. So out of these choices, our best answer is renal artery.

– ICA, even though it’s possible, it’s not likely to undergo a balloon angioplasty. That’s more likely to undergo endarterectomy.

– Aorta is too big.

– Posterior tibial artery is too small.

Question 76

Which of the following values represent a normal ejection fraction of the calf muscle pump?

A. 40%
B. 65%
C. 30%
D. 58%

Answer 76

B. 65%

Normal ejection fraction of the calf muscle pump is >60%.

Question 77

What is the significance of a loss of the end diastolic component in the CCA?

Answer 77

occlusion of ICA

No diastole meaning that is thumping pattern, high resistance. It means we have a distal occlusion. Since most of the blood from CCA goes to ICA, abnormal finding in CCA will most likely result from disease in ICA.

Question 78

***What is the suspicion based on the image below?

Image showing a venous waveform, but we can see that it’s continuous. There’s no phasicity or changes with respiration.

A. valvular incompetence
B. distal thrombosis
C. proximal venous obstruction
D. fluid overload

Answer 78

C. proximal venous obstruction

A continuous venous signal, no phasicity changes with respiration, indicates a proximal venous obstruction.

Question 79

***What type of endoleak is described as retrograde branch leaks?

Answer 79

type II

• Type I: anastomosis sites (attachment sites)
• Type II: branch leaks most common
• Type III: modular connect
• Type IV: transgraft (tears)

pg.40 Vascular Study Guide

Question 80

What is the proximal anastomosis of the autologous fistula graft?

Answer 80

radial artery

Autologous means arising from the own body, so this would be the Brescia-Cimino (radial artery - cephalic vein). Proximal anastomosis of any graft indicates where the blood is coming in from and distal anastomosis is where it’s going out to.

Question 81

What is the normal flow pattern of the portal vein?

A.

Answer 81

hepatopedal, minimally phasic

Question 82

What is the greatest clinical concern of a patient experiencing severe abdominal and back pain?

Answer 82

aortic aneurysm rupture

A patient experiencing abdominal and back pain is most likely to have an aortic aneurysm. Severe abdominal and back pain indicates possible rupture.

Question 83

Which finding requires immediate notification of the physician?

A. portal hypertension w/ splenomegaly
B. total occlusion of the ICA
C. presence of an intimal flap within the aorta
D. saccular aortic aneurysm measuring 5cm

Answer 83

C. presence of an intimal flap within the aorta

These questions were looking for a condition that would require treatment immediately (such as life-threatening conditions, limb-threatening, surgery needed).

Intimal flap indicates dissection, and dissection is very dangerous as the wall is so weakened, it’s possible it could even rupture.

Question 84

What is the most commonly used vein for autologous conduit arterial bypass graft?

Answer 84

greater saphenous vein

• autologous means arising from yourself
• conduit = tube, bypass graft

So in other words, what vein do we usually use for bypass? That’s not synthetic. It’s the most commonly used vein because it’s the longest vein in the body and also, usually has a sufficient diameter.

We would never use a deep vein such as FV, we can only use superficial veins (GSV, SSV, Cephalic, Basilic)

Question 85

Where does the cephalic vein drain into?

Answer 85

subclavian vein

Cephalic vein and axillary vein join together, and both drain into the subclavian vein.

Question 86

***What artery is a landmark for the origination of the external iliac artery?

Answer 86

internal iliac artery (hypogastric artery)

Question 87

What is indicated by ABI’s of 1.4?

Answer 87

medial calcinosis

A very high ABI would be an indication of incompressible vessels (medial calcinosis).

Question 88

What quantitative criteria for the peak systolic velocity of the superior mesenteric artery indicates a >/=70% diameter reduction?

A. >/=180cm/s
B. >/=200cm/s
C. >/=125cm/s
D. >/=275cm/s

Answer 88

D. >/=275cm/s

CRITERIA:
* Celiac artery:
>/= 200cm/s then it has >/=70%DR

• SMA:
  >/=275cm/s then it has >/=70%DR

Question 89

Where is the most common location for thrombus to originate?

Answer 89

valve cusps or sinuses

Thrombus usually originates where the blood is the most stagnant, so that is either at the valve cusp sites or the sinuses.

Question 90

Which of the following can cause an increased resistance doppler signal in a normally low resistance vessel?

A. proximal obstructive disease
B. arteriovenous fistula
C. extrinsic compression
D. distal obstruction

Answer 90

D. distal obstruction

An abnormally increased resistance doppler signal in a vessel that should be low resistance means that the blood is going towards a problem. It’s going towards a blockage, so that’s what’s going to give us our stop-and-go pattern (thumping pattern).

Question 91

What is Budd-Chiari syndrome?

Answer 91

occlusion of hepatic veins

Question 92

What flow patterns are noted proximal to an arteriovenous fistula?

A. bidirectional flow and increased pulsatility
B. increased resistance and increased systolic velocity
C. increased diastolic flow and low resistance
D. decreased systolic flow and increased diastolic velocity

Answer 92

C. increased diastolic flow and low resistance

Proximal to the fistula would be the artery that’s supplying it. That’s going to show a low resistance pattern. Low resistance means high EDV.
Since a fistula also gives us high volume, both the peak and the end are going to have high velocity.

Question 93

Which of the following complications is most likely related to a patient with cirrhosis?

A. portal hypertension
B. chronic mesenteric ischemia
C. renal artery stenosis
D. medial calcinosis

Answer 93

A. portal hypertension

Cirrhosis is the most common cause of portal hypertension.

Question 94

What is the most likely cause of non-pitting calf edema without discoloration or change with limb elevation?

A. acute DVT
B. lymphedema
C. chronic venous insufficiency
D. congestive heart failure

Answer 94

B. lymphedema

Non-pitting edema meant that it does not make an indent inside the edema because the fluid is so engorged inside the calf. This is a classic sign of lymphedema.

If this type of calf edema was related to venous disease such as chronic venous insufficiency, then there was definitely discoloration such as the brawny color around the gaiter zone, possibly even venous ulcers.

Question 95

What vessel is the distal anastomosis of a Brescia-Cimino graft?

Answer 95

cephalic vein

Question 96

What diagnosis is consistent with elevated resistance patterns found in the post-prandial SMA and increased velocity IMA?

Answer 96

chronic mesenteric ischemia

If two out of the three abdominal vessels are abnormal (celiac, SMA, IMA), that gives us chronic mesenteric ischemia.

Normal post-prandial SMA should have low resistance pattern.

Normally, IMA is not be easily seen under ultrasound. If the IMA has a higher velocity and is easily seen, then it indicates that it’s acting as a collateral for the SMA that’s obstructed.

Question 97

Severe occlusive disease of the right ICA could result in which of the following symptoms?

A. right sided paresthesia
B. right amaurosis fugax
C. bilateral paresthesia
D. homonymous hemianopia

Answer 97

B. right amaurosis fugax

Right ICA disease could cause right hemispheric ischemia. That means…
– if the symptoms are found on body, then it would indicate contralateral ICA disease
– if the symptoms are eye-related, then it’s same side ICA (tip: right eye = right Ica)

Question 98

What would most likely cause enlargement of the IVC?

A. splenomegaly
B. portal hypertension
C. chronic liver disease
D. right sided heart failure

Answer 98

D. right sided heart failure

Since the IVC is going into the right atrium, if that side of the heart is congested, the venous blood will back up causing dilatation of the IVC and possibly hepatic veins as well.

Question 99

***Calculate the diameter reduction in a vessel with a lumen of 9mm that demonstrates a narrowing of 2mm?

A. 90%
B. 22%
C. 78%
D. 70%

Answer 99

C. 78%

• Step 1: 2/9=0.22
• Step 2: change to percentage 0.22 –> 22% (this is what left over after the lumen narrowed)
• Step 3: 100% - answer Step 2 = %DR (100%-22%=78%)

Question 100

What patient group is most likely to develop Takayasu arteritis?

A. elderly women
B. young women
C. men that are heavy smokers
D. young athletic men

Answer 100

B. young women

Question 101

***What is occurring in the upper extremity veins during expiration?

A. flow is filling and flowing forwards
B. venous emptying and drainage
C. venous filling and expansion
D. flow is halting and emptying

Answer 101

C. venous filling and expansion

Inhaling
- increased abd pressure
- LE veins stop (filling and expanding)
- arms flow (emptying)

Exhaling
- decreased abd pressure
- LE veins flow (emptying)
- arms stop (filling and expanding)

***I picked D and that’s wrong because when the flow is halting (stop), it’s actually filling, not emptying.

Question 102

What is most likely to cause restenosis of the ICA after endarterectomy?

Answer 102

neointimal hyperplasia

Restenosis caused by neointimal hyperplasia is most likely to be seen 6-24 months after endarterectomy.

Question 103

What will result if a pneumatic cuff is too narrow for the diameter of the limb?

Answer 103

pressure will be falsely high

Question 104

What is the diameter reduction of the finding noted below?

Image of “Lt ICA Mid” with…
- PSV: 479.6cm/s
- EDV: 151.7cm/s

A. >60%
B. 80-99%
C. 50-79%
D. 70-89%

Answer 104

B. 80-99%

CRITERIA:
- PSV: >125cm/s maybe stenosis
- EDV: <140cm/s then it has 50-79% DR
- EDV: >140cm/s then it has 80-99% DR

pg.50 Vascular Study Guide

Question 105

Where is the disease located in the left lower extremity?

Rt brachial: 133
Lt brachial: 138

Rt hi thigh: 168
Rt lo thigh: 127
Rt calf: 118
Rt ankle: 99

Lt hi thigh: 172
Lt lo thigh 150
Lt calf: 116
Lt ankle: 94

Answer 105

femoral-popliteal segment

The question only asks about the LEFT lower extremity, so that’s what we’re going to focus on.

From Lt lo thigh (150) to Lt calf (116), that is a drop of more than 30mmHg.

Question 106

What layer contains the vasa vasorum?

Answer 106

adventitia layer

Question 107

***What clinical factor is related to artificially high segmental pressures?

A. chronic renal disease
B. congestive heart failure
C. high cardiac output
D. smoking

Answer 107

A. chronic renal disease

Artificially high segmental pressures would cause incompressible vessels and that’s related to medial calcinosis. Patients that are at risk for medial calcinosis are diabetics and end-stage renal disease.

Question 108

What disease process would most likely present with an absent bruit?

A. tortuous vessels
B. 75% diameter reduction
C. arterial occlusion
D. arteriovenous fistula

Answer 108

C. arterial occlusion

Bruit is only an indication of having high velocity/ turbulent flow. Bruit is not always a short indicator of the presence of disease. So, a disease could be present and not have a bruit.

A total occlusion would not have a bruit because there’s no high velocity turbulent flow.

All of our other choices would have high velocity turbulent flow and would likely present with the bruit.

Question 109

***In the presence of a renal allograft, the donor renal artery is anastomosed to which vessel?

A. external iliac artery
B. segmental artery
C. aorta
D. internal iliac artery

Answer 109

A. external iliac artery

The renal transplant is placed in the hip within the pelvis, typically the right side and so the donor renal artery and renal vein are connected to the external iliac artery and external iliac vein, simply because they’re the closest vessels.

Question 110

***What is a landmark that can used for proper placement of the radio-frequency electrode catheter?

A. superficial saphenous accessory vein
B. epigastric artery
C. profunda femoris
D. superficial epigastric vein

Answer 110

D. superficial epigastric vein

This type of procedure is the radio-frequency ablations to treat superficial venous insufficiency, so a landmark would be our superficial epigastric vein. It’s the last vein that empties into the greater saphenous vein, right before it meets up at the saphenofemoral junction. That would be a good landmark to make sure that our catheter does not go past that point.

Question 111

These waveform contours depict what pathologic process?

Image shows a “peaked pulse”.

A. arterial obstructive disease
B. Buerger’s disease
C. secondary Raynaud’s
D. primary Raynaud’s

Answer 111

The waveform shape of the pulse is a bit odd. The waveform has a peak at the top, that’s because the dicrotic notch is placed up high on the peak instead of farther down on the downslope. This refers to the peaked pulse and is an indication of having functional Raynaud’s disease.

• Primary Raynaud’s = functional disease
• Secondary Raynaud’s = fixed arterial disease (obstructive)

Question 112

Where does the left subclavian artery originate?

Answer 112

aortic arch

Question 113

***What would make manual compression of the pseudoaneurysm contraindicated?

A. large pseudoaneurysm
B. skin infection
C. multiple communicating channels
D. neck <10mm in diameter

Answer 113

C. multiple communicating channels

Contraindications are reasons that that procedure cannot be performed.

So, what would prevent us from performing manual compression? That would be multiple communicating channels. In order to do manual compression, you must completely and fully compress the neck, if there’s multiple necks, you’re not going to be able to fully compress all of them at the same time.

Question 114

The tardus parvus waveform was obtained at the right proximal subclavian artery. Which of the following vessels is likely to have disease?

A. descending aorta
B. right common carotid artery
C. distal subclavian artery
D. brachiocephalic artery

Answer 114

D. brachiocephalic artery

Question 115

What vessel is most likely to be identified on the lateral side of the upper extremity while performing a duplex exam?

A. cephalic vein
B. basilic vein
C. ulnar artery
D. axillary artery

Answer 115

A. cephalic vein

Question 116

What is Leriche syndrome?

Answer 116

Terminal aorta obstruction in male patients

Leriche causes LE symptoms and also impotence.

Question 117

What vessel is normally documented antegrade at 70mm depth on TCD through the transtemporal approach?

Answer 117

PCA

Question 118

What vein is a tributary to the popliteal vein?

Answer 118

small saphenous vein

The veins that also drain into the popliteal would be the TP trunk and the ATV.

Question 119

***With segmental pressures, a 20 mmHg difference in one brachial pressure to the other suggests a…

Answer 119

> 50% stenosis of the subclavian artery or vessel under the lower cuff

The brachial pressures between both arms should be within 20 mmHg difference. If there are 20 mmHg difference, it means we have disease above the cuff that has the lower brachial pressure.

Remember!! Pressures always drop abnormally when we have disease, and the disease is always above the drop of the pressure.

Question 120

***The PSV is 20cm/s and the EDV is 10cm/s. What is the pulsatility index?

A. 0.5
B. 0.3
C. 0.6
D. 2.0

Answer 120

C. 0.6

(PSV-EDV)/((PSV+EDV)/2)

(20-10)/((20+10)/2) =10/15= 0.6

Question 121

***What vessel is occluded if the bypass graft is placed from the right femoral artery to the left femoral artery?

Drawing shows flow going from right femoral artery to left femoral artery.

A. left external iliac artery
B. right common iliac artery
C. left internal iliac artery
D. right common femoral artery

Answer 121

A. left external iliac artery

This is called a “femoral-to-femoral”, so it’s crossing over from one side to the other. This can be used in cases of unilateral iliac disease. Now, since it’s going from the right to the left, that tells us the right side is the healthy side and the left side is the disease side. Disease would be proximal to left femoral artery.

Question 122

Which of the following may present with residual valve stenosis post-procedurally?

A. hemodialysis access fistula graft
B. reversed saphenous vein graft
C. in situ saphenous vein graft
D. synthetic bypass graft

Answer 122

C. in situ saphenous vein graft

With the in situ saphenous vein graft, the valves must be removed. If you have residual valves, they can become stenosis.

Question 123

Which artery accompanies normally paired deep veins?

A. deep femoral
B. superficial femoral
C. brachial
D. popliteal

Answer 123

C. brachial

Leg: ATV, PTV, PE
Arm: Radial, Ulna, Brachial

Question 124

Upon performance of a modified Allen test, the waveform appears flattened during compression of the radial artery. What is the significance of these findings?

Answer 124

radial artery dependency

This is not a normal finding. We want our waveforms to be maintained throughout all of the compression procedures.

Question 125

What vessels are affected by Buerger’s disease?

Answer 125

digital arteries

Buerger’s disease is found in young men, heavy smokers, and affects the smallest most distal vessel in the digits.

Question 126

What is the significance of a dicrotic notch in a low resistance waveform?

Answer 126

aortic valve closure

Dicrotic notch is normal. It occurs during aortic valve closure.

Question 127

What artifact is most likely to mimic the appearance of an arterial dissection?

A. mirror image
B. posterior enhancement
C. posterior shadowing
D. reverberation

Answer 127

D. reverberation

..because reverberation is going to cause a false echo reverberating or coming down from the real echo, so it could create a linear like object inside of an artery as the anterior wall reverberates into the vessel.

Question 128

What is the first branch of the abdominal aorta?

Answer 128

celiac artery

Question 129

What best explains the most likely source of Blue toe syndrome?

Answer 129

embolic event

Blue toe syndrome is most often caused by embolism and the most likely source of an embolism is the heart.

Question 130

What is the treatment for compartment syndrome?

Answer 130

fasciotomy

Fasciotomy is when physician open the fascia layers to allow the swelling to be relieved and therefore, releasing the pressure on the arterial system.

Question 131

What best describes the result of an effective calf muscle pump?

A. increase venous pressure and decrease venous volume
B. decrease venous pressure and increase venous return
C. decrease venous pressure and increase venous volume
D. increase venous pressure and increase venous pooling

Answer 131

B. decrease venous pressure and increase venous return

Question 132

***What is the normally expected finding after performance of laser ablation for venous insufficiency?

Answer 132

thrombosed superficial vein and patent CFV

The goal of this procedure is to cut off the superficial vein that is being ablated. So, we would expect then that superficial vessel to be completely thrombosed and deep system to be normal.

Question 133

***What occurs in the obstructed limb when reactive hyperemia is performed?

A. hyperemia is improved in the arterial system
B. both arterial and venous hyperemia is obstructed
C. both arterial and venous hyperemia is enhanced
D. hyperemia is delayed in the arterial system

Answer 133

D. hyperemia is delayed in the arterial system

Reactive hyperemia is inducing vasodilation to see if the hyperemia is able to reach the calf quickly. So, in obstructive limb, it’s not, it’s prolonged or delayed.

Question 134

Upon performance of treadmill exercise, which result allows for distinguishing between single level and multilevel disease?

Answer 134

A return to resting pressure within 6 mins indicates single level disease.

Question 135

What is the purpose of the Adson maneuver?

Answer 135

evaluate for arterial compression of thoracic outlet syndrome

Adson maneuver is the exaggerated military stand and chin turn to the tested side to evaluate for thoracic outlet syndrome.

Question 136

A segmental pressure study is ordered for a patient with a bypass graft. If it is uncertain where the bypass is located, what is the most appropriate action?

Answer 136

check with referring physician prior to performing exam

Question 137

A baseball pitcher presents with acute pain and swelling of the right upper extremity. What is the most likely diagnosis?

A. Paget-Schroetter syndrome
B. thoracic outlet syndrome
C. SVC syndrome
D. May-Thurner syndrome

Answer 137

A. Paget-Schroetter syndrome

Paget-Schroetter syndrome is the venous component of TOS. That is repetitive trauma or stress to one of the veins in the right upper extremity near the shoulder, eventually causes an acute DVT.

Question 138

***Which of the following is a contributing factor to thrombus formation?

A. diabetes
B. pregnancy
C. smoking
D. hyperlipidemia

Answer 138

B. pregnancy

All thrombus formation fall under Virchow’s triad.
1) trauma
2) stasis
3) hypercoagulability

Out of all the choices, pregnancy has 2 of the Virchow’s triad.
1) Stasis: due to the compression of the growing fetus and the abdomen
2) Hypercoagulability

Question 139

What is consistent with antegrade doppler signals of the ACA on transcranial imaging?

A. external to internal collateralization
B. posterior to anterior collateralization
C. cross-over collateralization
D. normal finding

Answer 139

C. cross-over collateralization

ACA normally is retrograde. So if we have a change in flow direction of the ACA, it indicates that we have a type of collateralization. That collateralization is the cross-over, where it goes from contralateral ICA –> ACA –> AcoA –> ACA on the side that has occluded ICA

Question 140

What is the most important diagnostic feature of documenting a pseudoaneurysm?

Answer 140

communicating channel (neck of pseudoaneurysm)

Question 141

What term describes temporary monocular vision loss?

Answer 141

amaurosis fugax

Question 142

What is an ascending venogram used for?

Answer 142

rule out obstructive DVT

Question 143

What is an descending venogram used for?

Answer 143

rule out valvular incompetence

Question 144

Which of the following scenarios would the renal artery to aorta ratio not be reliable?

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

Answer 144

B. abdominal aortic aneurysm

Since the aorta is used as the base value, if the aorta is abnormal, we cannot use the ratio:
- AAA
- If aorta <40cm/s or >90cm/s

Question 145

***Which ABI is most consistent with a patient that complains of pain in the feet at night?

A. 0.4
B. 1.3
C. 0.6
D. 0.9

Answer 145

A. 0.4

Rest pain has an ABI <0.5

Question 146

What probe is best for imaging a large abdominal aortic aneurysm on a thin patient?

A. 3MHz curvilinear array
B. 2.5MHz phased array
C. 9MHz linear sequential array
D. 6MHz curvilinear array

Answer 146

D. 6MHz curvilinear array

Question 147

***What info is displayed on the y-axis of the spectral analysis?

A. individual frequency shift
B. estimated frequency shift
C. time
D. volume shifts

Answer 147

A. individual frequency shift

x= time
y= frequency shift (velocity)

Since the spectral analysis displays actual or true frequency shifts, the correct answer would be individual frequency shifts.

Question 148

A patient in the emergency room has a positive D-dimer. What exam will most likely be ordered?

Answer 148

venous duplex

D-dimer indicates thrombolytic activity or the possible presence of thrombosis in the body.

Question 149

What values should be used to calculate accuracy?

RUQ: 42
LUQ: 14
LLQ: 61
RLQ: 8

Answer 149

103/125

Question 150

In color Doppler mode no color signal is detected, what step can you take to improve the sensitivity to the slow flow?

A. lower wall filter
B. decrease transducer frequency
C. increase wall filter
D. increase velocity scale

Answer 150

A. lower wall filter

Improving sensitivity to slow flow is primarily done two ways:
1) lowering the scale
2) lowering the wall filter

Question 151

***What is the critical concern in a patient with an acutely swollen, painful and pale limb?

A. phlegmasia cerulea dolens
B. phlegmasia alba dolens
C. acute DVT
D. acute arterial occlusion

Answer 151

B. phlegmasia alba dolens

This patient has symptom of acute DVT plus acute arterial.
- Acute DVT: pain and swelling
- Acute Arterial: pain and pain

So if you have a combo of acute venous and acute arterial symptoms, that tells you you have a phlegmasia.

Pale = alba
Blue = cerulea

Question 152

In what vessel would the distal anastomosis of a TIPSS be located?

Answer 152

right hepatic vein

Question 153

What is the correct criteria for diagnosing renal artery stenosis?

Answer 153

renal to aorta ratio >/= 3.5 indicates >/=60% stenosis

Question 154

What cardiac event coincides with normal arterial flow reversal?

Answer 154

aortic valve closure

Late systolic aortic valve closure results in a dramatic decrease in pressure energy. The moving blood hits the “wall” of high peripheral resistance resulting in diastolic flow reversal.

Question 155

What describes a decrease in pressure in an area of higher flow speeds?

Answer 155

Bernoulli effect

Bernoulli effect states that pressure and velocity are inversely related.

Question 156

What increases to compensate for a reduction in vessel area?

Answer 156

velocity

According to the Law of Conservation of Mass, when there is a reduction in vessel radius or area, the velocity must increase to maintain the volume.

Question 157

What does the delayed return of the capillary blush after pressure on the pulp of the digit indicate?

Answer 157

advanced ischemia

Normally capillary blushing (flushing pink again) occurs within 3 seconds after pressing the pulp of the digit. Delayed filling would be a sign of very poor arterial perfusion or in other advanced ischemia.