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Question 1

Deep system consists of:

Answer 1

1. IVC: connects CIV to rt atrium
2. CIV: internal and external iliac veins
3. IIV: drains blood from pelvis aka hypogastric vein
4. EIV: extends to inguinal ligament
5. CFV: inguinal ligament to bifurcation
6. FV P,M,D, and PFV
7. Pop V: runs behind knee, connects anterior tibial vein
8. ATV: drains anterior calf and foot, paired veins
9. PTVS: drains medial and posterior calf and foot
10. PER VS: drain medial and posterior calf

Question 2

Superficial system consists of :

Answer 2

GSV and SSV

Question 3

why would we see pulsatility in CFV or POP V?

Answer 3

increased resistance due to CHF causes pulsatility

Question 4

What are the three systems in the leg for a pump?

Answer 4

1. Foot pump: primes the calf pump
2. Calf veno motor pump: major ejection
   3: thigh pump: ejects thigh blood volume

Question 5

What is venous thromboembolism?

Answer 5

Generic term for saying there is a clot in the venous system (superficial, deep, or even PE in lungs)

Question 6

Phlegmasia cerulean dolens

what is it? why does it happen? what do we see?

Answer 6

1. has a high predictive positive value (PPV) for DVT
2. Iliofemoral outflow obstruction presents as massive thigh/calf swelling. blood is trapped so calf swells up
3. pt is in pain, and leg looks purple

Question 7

Superficial thrombophlebitis

Answer 7

Not life-threatening unless thrombus extends into deep system, but its more painful than DVT
Symptoms include:
erythema/ inflammation
tenderness
palpable cord or mass(might be able to feel blood clot)

Question 8

Acute DVT

Answer 8

• happened during a short period of time
• weakly echogenic or partially anechoic thrombus (heterogeneous)
• poorly attached thrombus, spongy texture and dilated vein
• we can get acute DVT if we have a chronic DVT

Question 9

Chronic DVT

Answer 9

• highly echogenic thrombus (hyperechoic)
• well attached thrombus
• rigid/fibrous texture
• vein smaller than artery
• recannalization and or venous webbing (blood is beating down on door of clot so little webs are created to get blood moving again

Question 10

May Thurner Syndrome

what is it? why does it happen? what do we see?

Answer 10

1. thrombosis of left iliac vein
2. caused by compression of the overlying right iliac artery
3. leg is swelling, color change, erythema and warmth

Question 11

What must you compare before ruling out iliac obstruction?

Answer 11

must compare bilateral CFV waveforms to rule out iliac obstruction

Question 12

A) You’re scanning bilateral CFV’s, Lt CFV is a flat line, while Rt CFV shows phasic flow. Where is the clot located?
B) If both waveforms are flat, where is the clot?

Answer 12

A) Clot is in the left CVF

B) Clot is either in both CFV and the IVC, or just IVC

Question 13

a) Having a flat line on venous flow means …

b) Having pulsatile flow in venous flow means…

Answer 13

a) we have a clot

b) we have cardiac influence, could be CHF

Question 14

Spontaneity is

Answer 14

flow within the vein occurs on its own

Question 15

Phasicity is

Answer 15

flow ceases with inspiration, resumes with expiration

Question 16

Augmentation is when

Answer 16

flow increases towards heart when vein is compressed distal to the site

Question 17

Valsalva maneuver

Answer 17

pushing down on pt belly and flow stops

Question 18

Symptoms for UVE

Answer 18

• pain and swelling in arm
• local erythema, palpable cord
• dilated superficial veins of arm/shoulder
• chest pain, SOB (if PE)

Question 19

Deep veins of upper extremity

Answer 19

• SVC (drains blood from arms to rt atrium)
• Innominate (joins to form SVC)
• Subclavian (runs above clavicle from innominate to axillary)
• Axillary (begins at lateral margin of first rib)
• Brachial (usually paired axillary vein to elbow)
• ulnar (brachial wrist to pinky side) and radial (brachial wrist to thumb side)

Question 20

Superficial veins in UE

Answer 20

• basilic (joins brachial v to from axillary {travels medial side)
• Cephalic (from axillary v travels down lateral arm{outer side of arm)
• Median cubital: connects cephalic and basilica at elbow

Question 21

• What is the subclavian vein assessment?

- contralateral assessment?

Answer 21

• Subclavian vein cannot be compressed due to clavicle but we can do sniff test (only if you have reason to) and we must use color and doppler
• its important and required by ICAVL that a comparison be made with the contralateral subclavian vein in the same spot

Question 22

Pulsatility is

Answer 22

related to cardiac nature, arterial waveforms

Question 23

What do you do to look for thrombosis on the upper peripheral veins?
b) what do you do to look for thrombosis in the upper central veins such as clavicle?

Answer 23

a) use compression

b) use grayscale, color and doppler

Question 24

Paget-Schroetter

(what is it? how does it happen? what do we see?0

Answer 24

1. Spontaneous thrombosis of subclavian or axillary vein
2. repeated extrinsic compression of subclavian and axillary vein can lead to this (Sylvester Stallone)
3. veins pop out, looks like Swiss cheese on US

Question 25

Superior vena cava syndrome (what is it? how does it happen? what do we see?)

Answer 25

1. Occlusion or compression of SVC, increasing venous pressure 2. Clot in SVC, blood won't be able to get to heart so it creates buildup and increases venous pressure 3. Edema of neck face and arms usually bilaterally

Question 26

LEA symptoms (6)

Answer 26

- no limb swelling - intermittent pain when walking - foot/limb coolness and pallor - rest pain - gangrene, tissue necrosis

Question 27

What is reflux?

Answer 27

Abnormal reversed flow direction

Question 28

What is tumescence in venous ablation?

Answer 28

Injecting saline and lidocaine to cause local swelling around vein to be "cooked"; acts as heat absorber and prevents burns to underside of skin

Question 29

What is an in situ vein bypass?

Answer 29

GSV remains in place, valves are excised with a valvulatome, perforating veins and tributaries are ligated and cut, and prox GSV is cut and sewn into CFA

Question 30

What factors govern (control) arterial flow?

Answer 30

- cardiac output - intraluminal wall resistance - arterial wall compliance

Question 31

A person who is at rest that has arterial occlusive disease...

Answer 31

do not have a lot of blood getting down to capillary bed being in a resting state

Question 32

What are the 4 indirect physiologic testing (blind testing)?

Answer 32

1. Pressure assessment (ABI/segmental pressures) 2. Plethysmography (PVR and PPG) 3. Doppler waveform analysis 4. Exercise stress testing

Question 33

Pros and Cons of using PPG in segmental pressures

Answer 33

pros: convenient, requires less skill, bilateral capability cons: ambient light interference, no audible pulse, not good for severe disease

Question 34

What is considered normal ABI?

Answer 34

0.9-1.3 >1.3= likely calcified <0.9= abnormal <0.8= probably claudication (pt is limping) <0.5= multilevel disease(more than 1 cuff seperated) or long segmental occlusion (2 or more cuffs back to back) <0.3=ischemic rest pain (pt needs to rest legs off of bed when at rest)

Question 35

What is considered in flow disease?

Answer 35

Aorta to iliac arteries

Question 36

What is considered normal TBI (toe brachial index)?

Answer 36

Normal = >0.75 abnormal= <0.66 in between is inconclusive

Question 37

When do you see calcified arteries show up in indirect testing?

Answer 37

- In diabetic pt - chronic steroid therapy - renal dialysis pt

Question 38

In presence of calcified arteries, what methods must you use instead of segmental pressures?

Answer 38

PVR, CW doppler or even toe pressures (toe pressures will probably be inaccurate)

Question 39

Who do we exercise for stress testing?

Answer 39

- patients that complain when walking (intermittent claudication) - ABI is 0.85-0.4 - if resting study is normal but pt has pain when walking

Question 40

If pt has symptoms occur only at rest and the resting study. is normal, do we exercise the pt?

Answer 40

No bc that is rest pain

Question 41

What are the contraindications for treadmill exercise?

Answer 41

- questionably cardiac status - resting ischemia (ABI <0.3) - ischemic ulceration - poor ambulatory - normal resting study with resting symptoms but no claudication

Question 42

What diameter must the GSV be to have a high graft patency rate?

Answer 42

Greater than or equal to 2.5mm. less than 2.5mm will have high failure rate NOTE: >2mm is too small (unsuitable) and must evaluate contralateral GSV (opposite leg)

Question 43

What is the bypass graft evaluation consist of

Answer 43

1. identify graft type and location 2. perform ABI 3. Use color and spectral to evaluate blood flow

Question 44

You evaluate the entire graft for:

Answer 44

- stenosis - wall irregularity - aneurysms/pseudo - AV fistulas (in situ only) - Partially excised valve leaflets

Question 45

In a 50% graft stenosis what do we have?

Answer 45

PSV is greater than or equal to 150cm/sec and velocity ratio of greater than or equal to 2.0 NOTE: if velocity ratio is >= 3.5 and PSV >300cm/s pt needs intervention to prolong graft latency (its failing)

Question 46

PSV for in stent restenosis for Superficial femoral artery (SFA) for 50%-79% and 80%

Answer 46

- 50-79%: PSV >190 and velocity ratio is 1.5 | - 80%: PSV>275

Question 47

What are is a contraindication for UEA?

Answer 47

Do not perform arm pressure measurement in arm with a graft, use PVR assessment or CW doppler

Question 48

Symptoms of UEA disease?

Answer 48

- arm and or hand weakness - reduced or absent pulses - hand numbness/weakness/pain that is positional - ischemic fingers - cold sensitivity

Question 49

For radial artery harvest (CABG) what must you evaluate?

Answer 49

Palmar arch patency