Non-imaging Testing - Vascular Ultrasound

Question 1

How can the normal Doppler morphology of a peripheral artery be described?
1. delayed systolic peak and bowing of downslope away from baseline
2. phasicity with respiration
3. Sharp upslope and downslope with prominent diastolic flow reversal

Answer 1

3. Sharp upslope and downslope with prominent diastolic flow

The extremities are normally vasoconstricted vascular beds causing the arterial waveforms to be high resistance. The normal flow pattern in this system would be described as triphasic or biphasic, meaning there is a sharp peak and a diastolic flow reversal. Rounded peaks and slower upstrokes are never a normal finding.

Question 2

What is true regarding CW doppler analysis?
1. It cannot provide spectral analysis display
2. It has a higher Nyquist limit than PW doppler
3. The signal depth allows for vessel identification
4. It does not provide range resolution

Answer 2

4. It does not provide range resolution

CW doppler uses two crystal side by side and continuously transmits and receives. Without pulses it cannot determine the location or range of a signal. It also does not have a Nyquist limit since there are no pulses and no PRF.

Question 3

Which would be an example of an abnormal accelertion time at the groin?
1. 133 msec
2. 110 msec
3. 138 msec
4. 125 msec

Answer 3

3. 138 msec

Abnormal acceleration time is > 133 msec and would be an indication of inflow disease

Question 4

What would be the appearance of a doppler waveform in the presense of a distal occlusion?

1. increased resistance
2. absent doppler signal
3. tardus parvus
4. normal waveform contour

Answer 4

1. Increased resistance

Distal occlution means the obstruction is ahead of us and we are dopplering proximal to it. Since the blood is approaching a blockage, it will demonstrate higher resistance and little or no diastolic flow.

Question 5

What waveform characteristics would be most likely documented distal to the site of a stenosis?

1. decreased diastolic velocity
2. aliasing
3. tardus parvus
4. increased resistance

Answer 5

3. tardus parvus

Tardus parvus is always seen downstream or distal to an arterial obstruction. Documenting this type of waveform means there is a proximal stenosis, and the waveform is documented distal to it.

Question 6

Calculate the pulsatility index: PSV 60 cm/sec and EDV 20 cm/sec
1. 1.5
2. 0.5
3. 1.0
4. 3.0

Answer 6

3. 1.0

Pulsatility Index= Peak to Peak / Mean
Peak to Peak = 60-20
Mean (average) = (60+20)/2 = 80/2 = 40
PI = 40/40 = 1

Question 7

What is the most important basis of interpretaton for CW doppler analysis?
1. waveform amplitude
2. peak systolic velocity
3. wave contour
4. quantitative criteria

Answer 7

3. wave contour

CW doppler is primarily a qualitative exam. Waveform shape or contour is the most important to interpret this study

Question 8

What would be a means of interpretive criteria that is considered quantitative?
1. accelertion time
2. waveform amplitude
3. turbulance
4. waveform contour

Answer 8

1. Acceleration time

Quantitative means something we can measure. Qualitative means shapes and qualities that are not measurable but can be interpreted such as waveform contour.

Question 9

How would a continuous wave doppler audible signal sound when placed directly over a stenotic lesion?
1. Distinct thumping sound
2. Inaudible
3. low frequency disturbances
4. High frequency sounds

Answer 9

4. High frequency sounds

A stenotic region causes a focal increase in PSV. Increased velocities means the frequency shift would also be elevated, producing a higher piched sound. Thumping sounds would be heard proximal to an occulsion, inaudible would be directly over the occulsion and low frequency disterbances would be found when there is a turbulent flow.

Question 10

What would be the expected doppler findings at the location of a bruit?
1. High velocity, turbulent flow
2. total occlusion, absent doppler signal
3. Loss of end diastolic flow
4. Tardus Parvus waveform

Answer 10

1. High velocity, turbulent flow

A bruit is an audible sound you can hear upon auscultation and is caused by high velocity turbulent flow.

Question 11

What is the significance of a monophasic continuous waveform at the level of the groin?
1. inflow disease
2. distal obstruction
3. within normal limits
4. unable to determine

Answer 11

1. Inflow disease

Monophasic and continuous means we have a proximal disease

Question 12

What does pulsatility index measure?
1. velocity ratio
2. resistance
3. turbulance
4. volume

Answer 12

2. resistance

Question 13

Disease in which of the following vessels would cause and acceleration time of 142msec in the CFA?
1. Internal iliac
2. Deep femoral artery
3. Superficial femoral artery
4. Common iliac artery

Answer 13

4. Common iliac artery

Normal acceration time= <133msec
abnormal means a slower upstroke and would indicate a proximal disease.

Question 14

What interpretative description is considered a qualitative assessment?
1. Normal acceleration time <133 cm/sec
2. Pulsatility index normally increases distally
3. Triphasic contour has forward, reversed and return to forward flow
4. Perform continuous wave analysis in segments in each leg.

Answer 14

3. Triphasic contour has forward, reversed and return to forward flow

4. is only a description of a technique and 1 and 2 can be calculated quantitiatively.

Question 15

A biphasic waveform is documented in the left CFA and a monophasic waveform is documented at the levele of the popliteal. At what level is the disease located?
1. iliofemoral
2. infrapopliteal
3. tibial
4. femoral

Answer 15

4. femoral

Question 16

When is the systolic pressure recorded during deflation?
1. When the last audible signal disapears
2. when the first audible signal returns
3. 3 seconds after the return of the first audible signal

Answer 16

2. When the first audible signal returns

To appropriately take a systolic pressure reading: inflate the cuff to suprasystolic pressures (30mmhg higher than the last audible signal), then slowly deflate. Record pressure when the first audible signal returns.

Question 17

Calculate the ABI’s based on the following information:
RT brachial: 130
Left Brachial: 134
RT ankle : 148
Left ankle: 82

1. Rt: 1.2, Lt 0.8
2. Rt: 1.1, Lt 0.6
3. Rt: 0.9, Lt 0.6
4. Rt: 0.9, Lt 1.6

Answer 17

2. Rt. 1.1, Lt 0.6

Rt: 148/134 = 1.1
Lt: 82/134 = 0.6
Remember that if the ankle pressure is greater than the brachial, the answer will be greater than 1. If the ankle is less than the brachial then the answer will be less than 1.
Ankle pressure goes inside the box.

Question 18

What best describes the purpose of the Allen test?
1. Test the Reynauds phenomenon
2. evaluates the patency of the palmer arch
3. evaluate for upper extremity disease
4. Test the patency of the radial artery.

Answer 18

2. evaluate the patency of the palmer arch

The Allen tests allows us to see if both the radial and ulnar arteries supply the entire pulmar arch. If the arch is incomplete or in the presense of disease the palmer arch will depend on just one of the vessels.

Question 19

The ankle pressure of 120 mmhg is documented in a patient complaining of rest pain and evidence of color dependency changes. This pressure seems to be….
1. higher than expected
2. consistent with patient presentation
3. within normal limites ruling out vascular disease
4. lower than expected

Answer 19

1. higher than expected

The patients symptoms are consistent with severe arterial disease. We would expect the ankle pressures to be severely low in comparrison to the brachial. And ankle pressures of 120mmhg would be close to the normal range.

Question 20

Patient has symptoms of claudication but initial segmental pressure values are within normal limits. What step would be the most appropriate?
1. Perform exercise testing
2. Perform reactive hyperemia
3. complete the exam and read as normal
4. Perform CW doppler analysis

Answer 20

1. perform exercise testing

Patients with true claudication may have normal resting values. Exercise testing provides a physiological stress on the circulation and allows us to see if there is evidence of vascular claudication caused by arterial disease.

Question 21

What happens to segmental systollic pressures in the presense of hemodynamically significant arteral obstruction?
1. Increases proximally
2. Increases distally
3. Decreases distally
4. Decreases proximally

Answer 21

3. decreases distally

Due to energy losses and volume flow interruptions, the pressures always decrease
after or distal to a diseas.

Question 22

If performing a segmental pressure exam and it is unclear where the bypass graft is, what is the most appropriate action?
1. Cancel the order and perform a duplex
2. Change an order to an ABI and CW doppler analysis
3. Speak to referring physician
4. Ask the supervising sonographer

Answer 22

3. Speak to referring physician

Question 23

With segmental pressure studies of the upper extremities, a 20mmhg difference in one brachial pressure to the other suggests which of the following?
1. Total occlusion of the vessel under the cuff on the side of the higher pressure
2. Within normal limits
3. More than 50% stenosis in the subclavian or auxillary artery in the arm with the lower pressure
4. Severe radial and ulnar artery obstruction disease on the same side of the lower pressure reading

Answer 23

3. More than 50% stenosis in the subclavian or auxillary artery in the arm with the lower pressure

Normal brachial pressures should be less than 20mmhg difference. A significant difference between arms indicates arterial disease proximal to the arm with the lower pressure.

Question 24

In a 4 cuff method pressure study the normal high thigh pressure should be 30 greater than the highest brachial. True or False?

Answer 24

True

If the high thigh pressure is abnormal bilaterally then there is a problem in the common trunk. This would be most likely considered aortoiliac disease.

Question 25

What is the purpose of exercise testing?
1. Produce ischmia and vasodilation
2. Stress the circulation
3. Increase stroke volume
4. to confirm chronic vs acute

Answer 25

2. Stress the circulation

Question 26

Calculate the ABI of an ankle pressure of 88mmhg and highest brachial of 132mmHg.
1. 0.6
2. 0.4
3. 1.5
4. 0.8

Answer 26

1. 0.6

132/88 = 0.6

Question 27

Which of the following would be considered a normal ankle pressure in a patient with a brachial pressure of 120mmHg?
1. 60
2. 120
3. 160
4. 200

Answer 27

2. 120

Question 28

What would be the significance of bilateral ankle pressures of 240 in a patient with systolic pressure of 120?
1. Study within normal limits
2. Severe hypertention
3. Bilateral arterial occlusive disease
4. Medial calcinosis

Answer 28

4. Medial calcinosis

Severe hypertension would be seen from a brachial pressure. Occlusive disease will always decrease the pressures never increase the pressures.