7. Which of the following best describes the Doppler effect? (a) Frequency reduces as blood moves faster toward the transducer (b) Frequency becomes louder as blood moves faster toward the transducer (c) Frequency increases as blood moves faster toward the transducer (d) Frequency increases as the angle of the beam approaches 90 degrees (e) No sound is heard at 90 degrees

(c) Frequency increases as blood moves faster toward the transducer

Practice exam Flashcards by Rachel Dimond

An ABI of 0.6 indicates:

(a) mild disease
(b) moderate disease
(c) occlusive disease
(d) a technical aberration due to calcified arteries
(e) no detectable abnormality

(b) moderate disease
Over one you are fine less that one you are not fine
· Reductions in the resting ABI can be grouped as follows:
o mild 0.7-0.9
o Severe 0.5-.7
o rest pain 0.3-0.5
o critical ischemia <0.3

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A critical stenosis of the ICA is one which:
(a) is greater than 1/3 of the bulb diameter
(b) is greater than 90%
(c) affects the volume and pressure of arterial flow
(d) b & c
(e) is greater than 40%

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To increase vascular resistance, which of the following must decrease
(a) pressure gradient
(b) vessel diameter
(c) vessel length
(d) Flow rate
(e) b & c

(b) vessel diameter

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Arteries supplying the sole of the foot are branches of
(a) posterior tibial artery
(b) medial malleolar artery
(c) anterior tibial artery
(d) plantar arterial arch
(e) peroneal artery

(a) posterior tibial artery

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Direct branches of the external carotid artery include which one of the following;
(a) ophalmic artery
(b) posterior cerebral artery
(c) superficial temporal
(d) supra -orbital artery
(e) frontal artery

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Aortic aneurysms that require stenting of the mesenteric arteries are?
(a) Saccular
(b) Infra renal
(c) Fusiform
(d) Supra renal
(e) Type A (dissection)

(b) Infra renal

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Which of the following best describes the Doppler effect?
(a) Frequency reduces as blood moves faster toward the transducer
(b) Frequency becomes louder as blood moves faster toward the transducer
(c) Frequency increases as blood moves faster toward the transducer
(d) Frequency increases as the angle of the beam approaches 90 degrees
(e) No sound is heard at 90 degrees

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A below knee arterial bypass graft is most commonly constructed from
(a) goretex
(b) saphenous vein
(c) dacron
(d) radial artery
(e) giacomini vein

(b) saphenous vein

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An internal carotid artery occlusion may cause retrograde flow in the:
(a) External carotid artery
(b) Superior Thyroid artery
(c) Supra Orbital artery
(d) Vertebral artery
(e) All of the above

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Renal transplant arteries are commonly anastomosed to the:
(a) aorta
(b) common iliac artery
(c) internal iliac artery
(d) hypogastric artery
(e) none of the above

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Describe the physical principles and ultrasound appearance of a:
(a) Mirror artifact

displays objects on both sides of a strong reflector, though they are located only on one side of it.
Eg the diaphragm, pleural surface, or aortic wall
directs some of the echoes to a second reflector before it returns them to the transducer, resulting in a multipath reflection
The resulting artifact shows up as the virtual object, deep to the original image but identical to it-thus the term ‘‘mirror.’’
Mirror images may be produced with gray-scale, color, power, and spectral Doppler.

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Describe the physical principles and ultrasound appearance of a: (b) Twinkle effect from renal calculi

· color Doppler signals that imitate motion or flow behind a stationary strongly reflecting interface
· can be seen behind any granular (irregular or rough) reflecting surface
· Twinkling artifact is believed to be caused by a narrow band of intrinsic machine noise called phase (or clock) jitter
· Similar to an acoustic shadow, twinkling does not occur 100% of the time

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Using Poisuilles equation (assuming other variables remain constant), Describe the change in pressure in an artery: (a) if the radius is reduced (2 marks)

·        P1 – P2 = 8ηLQ/ π r4
o   Where
o   P1 – P2 : Tube Pressure difference
o   η: viscosity of the liquid
o   L: length of the tube
o   r: radius of the tube
o   Q: Flow in the tube
(a) if the radius is reduced (2 marks) 
Pressure will increase by a factor of 4 meaning there will be higher resistance in the artery

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Using Poisuilles equation (assuming other variables remain constant), Describe the change in pressure in an artery: (b) viscosity is reduced (2 marks)

(b) viscosity is reduced (2 marks) 
·        P1 – P2 = 8ηLQ/ π r4
o   Where
o   P1 – P2 : Tube Pressure difference
o   η: viscosity of the liquid
o   L: length of the tube
o   r: radius of the tube
o   Q: Flow in the tube
If viscosity is decreased pressure is decreased as there is less resistance in the artery

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Using Poisuilles equation (assuming other variables remain constant), Describe the change in pressure in an artery: (c) length is increased (2 marks)

(c) length is increased (2 marks) 
·        P1 – P2 = 8ηLQ/ π r4
o   Where
o   P1 – P2 : Tube Pressure difference
o   η: viscosity of the liquid
o   L: length of the tube
o   r: radius of the tube
o   Q: Flow in the tube
If length is increased pressure is increased as there is more total resistance in the artery

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Describe the change in the appearance of the Spectral Doppler after
(a) changing the spectral map setting (2 marks)

Similar to b-mode map
Each map will change the way returning echoes are assigned to a brightness value
Map which gives the greatest contrast is most useful for vascular studies so that the spectral envelope can be measured with greater confidence

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Describe the change in the appearance of the Spectral Doppler after
(b) Increasing the gain (2 marks)

· it will not change the contrast of the spectral waveform but will help show a weak returning signal.
· increasing the gain will bring with it a level of spectral noise and the balance of noise to signal must be judged in each case
· excess gain fills in the tracing as low velocity echoes and mimics turbulent flow

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For a carotid artery velocity of 130cm/s,

a) state the range of stenosis consistent with this velocity (2 marks)

50-69%

<125cm/s is <50%

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For a carotid artery velocity of 130cm/s,

b) three features of the plaque which would make it more likely to produce symptoms (3marks)

Less echogenic than the surrounding muscle or absent B-mode texture (echolucent) with a thin fibrous cap.
Irregular
heterogenous

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For a carotid artery velocity of 130cm/s,

c) three other measurements of the spectral waveform which would support the grading you have chosen (3marks)

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EDV
CCA/ICA psv ratio
Spectral broadening
St marys index ICA psv/Dist CCA EDV

Given complete occlusion of the left popliteal artery

a) Name two graft procedures which may be used to bypass this lesion (2marks)

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Femoral popliteal graft below the knee

Fermorotibial

Given complete occlusion of the left popliteal artery

b) Name the graft material which is most likely to be used for this graft (2marks)

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Vein but synthetic graft can also be used if there is no suitable vein

Given complete occlusion of the left popliteal artery

c) Name two complications of the graft which may occur. (2 marks)

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Stenosis

Occlusion

List 3 genetically inherited clotting disorders that predispose a patient to deep vein thrombosis. (3 marks)

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Protein C deficiency
Protein S deficiency
Anti thrombin 3

7. Briefly describe 3 B mode or Colour Doppler features which would suggest the presence of sub-acute clot. (3 marks)

``` Clot may be isoechoic to surrounding muscle Vein will likely be the same size Non compressible No free floating edge No colour doppler if its occlusive Filling defects if it is non occlusive ```

8. For an infrarenal abdominal aortic aneurysm: | a) List two symptoms which may indicate a ruptured aneurysm (2 marks)

Hypotension pulsatile abdominal mass Sudden Pain in the abdomen or back

8. For an infrarenal abdominal aortic aneurysm: | b) Describe two Bmode features which could indicate the presence of an endoluminal stent leakage. (2 marks)

The stent is identified as a well-defined echogenic circular structure within fluid. The fluid will lie between the stent and the aortic wall

8. For an infrarenal abdominal aortic aneurysm: | c) Following aneurysm repair, list 2 possible complications which can be detected on ultrasound examination (2 marks)

Pseudoaneurysm thrombosis refilling of excluded sac

A 40yo woman presents to your department for a Carotid Duplex scan. She has had headache and dizziness. She has recently been involved in a motor vehicle accident. The examination is commenced. It is immediately evident that she has a high right bifurcation. List 3 strategies that will improve the imaging of this region and how each strategy improves your visualisation. (3 marks)

Turning the head Tilting the head Using different approaches and windows such as moving laterally

A 40yo woman presents to your department for a Carotid Duplex scan. She has had headache and dizziness. She has recently been involved in a motor vehicle accident. The examination is commenced. On the right side, the appearances are typical of a hypoechoic lesion. Describe the main features which are characteristic of this lesion. How do they differ from mixed and calcified lesions? (4 marks)

- Hypoechoic lesion indicates a plaque at high risk - This indicates a significant lipid core or haemorrhage which makes them more vulnerable to rupture and causing symptoms - Mixed lesions contains various levels of echogenicity which may represent highly echogenic calcification or echolucent regions which may represent plaque haemorrhage. - Plaque with echolucent regions are considered at higher risk of symptoms than plaque with calcified regions

A 40yo woman presents to your department for a Carotid Duplex scan. She has had headache and dizziness. She has recently been involved in a motor vehicle accident. The examination is commenced. 3. Describe two possible causes for a hypoechoic lesion in this patient? What Bmode and Colour features would you use to distinguish between these two causes? (6 marks)

Plaque or thrombus Thrombus and plaque will both appear as wall thickening on bmode Both will have colour filling defects and stenose the artery Thrombus will appear more echogenic as it is acute without posterior shadowing Plaque may have a thin fibrous cap or calcific components with posterior shadowing

A 40yo woman presents to your department for a Carotid Duplex scan. She has had headache and dizziness. She has recently been involved in a motor vehicle accident. The examination is commenced. 4. The ICA and the ECA are difficult to differentiate. What sonographic features will identify each artery? (6 marks)

``` ICA is usuall posterolateral ECA is usually anteromedial ECA has branches ICA does not have branches ECA has a larger systolic upstroke ECA has higher resistive index Temporal tap technique ```

A 40yo woman presents to your department for a Carotid Duplex scan. She has had headache and dizziness. She has recently been involved in a motor vehicle accident. The examination is commenced. 5. Describe one cause of dizziness which is related to the arteries of the head and neck. Indicate the ultrasound tests you would perform and the ultrasound features that you would expect to observe. (6 marks)

- Cause - Stenosis of the vertebral artery may result in thrombus formation and occlusion of the artery - Test - Ultrasound of the vertebral artery b-mode, colour, spectral - Cause - Stenosis of the subclavian artery can cause a fall in blood pressure in the subclav artery and vert artery - In severe cases, pressure reduction in the subclav artery is enouigh to cause retrograde flow in the vertebral and basilar arteries = symptoms of ischaemia - Subclavian steal syndrome - Test - Sub clavian and vertebral artery ultrasound bmode, colour, spectral. Reversal of flow for any amount of time indicates potential ischaemia - Cause - Embolic occlusion of the vert or one of its brances accounts for ~30% of vertebrobasilar ischamia - Cannot be seen well on ultrasound - Cause - Compression by osteophytes in the C spine can cause flow disturbances in the post circulation as the head is moved, causing transient and reproducible symptoms with movements of the neck - Test - try recreate the movement that causes the dizziness while scanning.

A 40yo woman presents to your department for a Carotid Duplex scan. She has had headache and dizziness. She has recently been involved in a motor vehicle accident. The examination is commenced. 6. The measured peak systolic velocity is 124cm/s in the ICA. In what stenosis classification would you categorise this lesion? What measurements other than peak systolic velocity would assist your decision? (6 marks)

``` <50% B-mode appearance - presence of plaque If plaque is present estimate of luminal narrowing EDV ICA/CCApsv (psv ratio) ICApsv/CCAedv (st marys index) ```

A 40yo woman presents to your department for a Carotid Duplex scan. She has had headache and dizziness. She has recently been involved in a motor vehicle accident. The examination is commenced. 7. Define the term 'critical' stenosis in the context of a Carotid Duplex examination. (4 marks)

- One which is haemodynamically significant - affects the volume and pressure of arterial flow - When flow is reduced and appreciable pressure drops are seen after a stenosis it is often referred to as critical or hemodynamically significant - Difficult to say exactly in quantitative terms due to varying studies - Usually >70% as graded by a PSV >230cm/s - >50% on bmode - >100cm/s EDV - >4 ICA/CCA ratio - We might expect there to be a certain residual lumen diameter below which a small increase in the degree of the stenosis would result in such a large pressure drop that flow would be effected significantly. - This is near occlusion

A 64yo patient presents with increasing left calf pain. The patient has a history of femoro- popliteal bypass for occlusive disease of the superficial femoral artery. The bypass graft is anastomosed at the common femoral artery and the popliteal artery below the knee. 1. List 3 likely vascular pathologies causing the patient’s symptoms. (3 marks)

Graft stenosis Graft occluson Calf DVT

A 64yo patient presents with increasing left calf pain. The patient has a history of femoro- popliteal bypass for occlusive disease of the superficial femoral artery. The bypass graft is anastomosed at the common femoral artery and the popliteal artery below the knee. 2. What criteria would you use to distinguish each of these pathologies? (3 marks)

Stenosis - colour filling defect. Stenotic jet. High PSV Occlusion - no colour fill beyond occlusion Non compressible thrombus in the vein

A 64yo patient presents with increasing left calf pain. The patient has a history of femoro- popliteal bypass for occlusive disease of the superficial femoral artery. The bypass graft is anastomosed at the common femoral artery and the popliteal artery below the knee. 3. A pulsatile lump is noted in the groin. What are 2 possible causes of this? (2 marks)

pseudoanuerysm at the proximal anastomosis AVM from surgery Ruptured femoral artery

A 64yo patient presents with increasing left calf pain. The patient has a history of femoro- popliteal bypass for occlusive disease of the superficial femoral artery. The bypass graft is anastomosed at the common femoral artery and the popliteal artery below the knee. 4. Assuming the graft was occluded, would you scan the tibial arteries? What are the reasons for your decision? (4 marks)

``` Yes To check they are patent For targets for future grafts In preparation for surgery To make sure the foot is perfused ```

A 64yo patient presents with increasing left calf pain. The patient has a history of femoro- popliteal bypass for occlusive disease of the superficial femoral artery. The bypass graft is anastomosed at the common femoral artery and the popliteal artery below the knee. 5. Would ankle-brachial indices be a useful in diagnosing this patient? Explain how they would assist the diagnosis. (4 marks)

- yes before ultrasound referral - A quick way to assess blood flow for management of suspected occlusion. - To predict the likelihood of future events. - Post-procedure to assess for recannilisation of the limb post-intervention. ABI measurements are less sensitive to the development of stenosis when compared to Duplex scanning in monitoring bypass grafts There would be a reduction in ABI o mild 0.7-0.9 o Severe 0.5-.7 o rest pain 0.3-0.5 o critical ischemia <0.3 The degree of reduction in ABI however, is variable and cannot be related to the degree of stenosis or the claudication distance. So a duplex would be performed if it hadnt already

A 64yo patient presents with increasing left calf pain. The patient has a history of femoro- popliteal bypass for occlusive disease of the superficial femoral artery. The bypass graft is anastomosed at the common femoral artery and the popliteal artery below the knee. 6. Is this graft more likely to be constructed from synthetic material or vein? Briefly explain the reasons for your answer. (4 marks)

- Below the knee femoropopliteal bypass grafts are usually made from the great saphenous vein - However synthetic can be used if there is no suitable veinor if the length of graft is too long (usually made of PTFE) Poly Tetra Fluro Ethylene - This is because in a below the knee fem-pop bypass, veins have a higher patency rate and lower rejection rate

A 37yo woman presents to your department. She has had 4 children and suffers badly from chronic venous insufficiency (CVI) of the legs. Describe 2 non-visual symptoms of a patient who has chronic venous insufficiency. Suggest 2 non surgical methods which might relieve these non visual symptoms

1. Heaviness of the leg and aching | 2. Compression stocking and bandaging and venoactive drugs

A 37yo woman presents to your department. She has had 4 children and suffers badly from chronic venous insufficiency (CVI) of the legs. 2. List the major risk factors associated with chronic venous disease. Which are most likely to relate to this patient? (5 marks)

``` Young Female Pregnancy FHx VV Previous DVT More than 3 kids ```

A 37yo woman presents to your department. She has had 4 children and suffers badly from chronic venous insufficiency (CVI) of the legs. 3. Varices are noted on the inner and posterior thigh which worsens during her menstrual cycle. Where are the most likely proximal sources of these varices? (4 marks)

Left ovarian vein Right ovarian vein External Pudendal vein into the SFJ Postero-medially from the perineum into the posterior branch of the LSV ovarian veins reflux through the veins of the broad ligament to the vulval tributaries and communicate with recurrent or primary varicose veins in the leg.

A 37yo woman presents to your department. She has had 4 children and suffers badly from chronic venous insufficiency (CVI) of the legs. What 2 ultrasound tests could be performed to identify the veins which contribute reflux to these varices? (2 marks)

Ovarian vein Doppler | Lower leg CVI study

A 37yo woman presents to your department. She has had 4 children and suffers badly from chronic venous insufficiency (CVI) of the legs. 4. Will the identification of deep venous obstruction (clot) influence the patient’s management? Explain. (3 marks)

Yes Will have to go on anticoagulants No surgery until off medication Testing for hypercoagulable conditions

A 37yo woman presents to your department. She has had 4 children and suffers badly from chronic venous insufficiency (CVI) of the legs. 5. A reflux duration of 0.7sec was measured in the great saphenous vein. Would you classify this vein as incompetent? List 2 other ultrasound observations that would help you decide if the vein was incompetent or not. (3 marks)

Yes The size of the vein (if it gets bigger) Presence of varicosities Reflux in colour

6. Reflux is noted in the popliteal vein above the saphenopopliteal junction. The short saphenous vein is also incompetent. Is the popliteal reflux a significant clinical finding in this case? Explain. (2 marks)

Significance depends on whether there is reflux at other segments of the popliteal vein Focal reflux at the junction is not significant If the reflux is below the SPJ, this is significant because it is associated with decreased calf muscle pump function and is an important prognostic factor to do with venous ulceration.

6. Reflux is noted in the popliteal vein above the saphenopopliteal junction. The short saphenous vein is also incompetent. Describe 2 possible reasons for reflux in the popliteal vein? (2 marks)

Post thrombotic syndrome Incompetent SSV Incompetent valves

Practice exam Flashcards

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