US Guided Procedures

Question 1

A patient presents for a follow up after a mesenteric stent placement for a 75% SMA stenosis. Which of the following describes the findings in the SMA that indicate a successful procedure?

a) Change from monophasic to peaked triphasic
b) Increased resistance and decreased diastolic flow
c) Decreased resistance and increased diastolic flow
d) Change from peaked triphasic to monophasic

Answer 1

b) Increased resistance and decreased diastolic flow

Question 2

A patient is undergoing balloon angioplasty of the left common femoral artery. The physician just completed the first expansion of the balloon and asks you to check the
flow with Doppler. Where is the preferred location to evaluate flow?
a) Dorsalis pedis or PTA
b) Distal superficial femoral artery
c) Proximal superficial femoral artery
d) Popliteal artery

Answer 2

a) Dorsalis pedis or PTA

Question 3

Which of the following is a responsibility of a Sonographer when assisting with a radiofrequency ablation of the great saphenous vein?
a) To operate the US machine controls and/or the probe, as directed by the physician
b) To send the US catheter for sterilization after the procedure
c) To advance the US catheter during the procedure
d) To perform initial puncture for the catheter prior to the vascular surgeon entering the room

Answer 3

a) To operate the US machine controls and/or the probe, as directed by the physician

Question 4

Which of the following is true regarding compression techniques used to treat a pseudoaneurysm of the femoral artery in the groin?
a) Pressure equivalent to 100mmHg should be performed in three ten-minute
intervals and if this does not close the stalk, alternative treatment must be considered
b) Blood pressure evaluation cannot be performed anywhere on the legs until the stalk to the pseudoaneurysm is closed
c) Thrombin injection is more effective than compression techniques in pseudoaneurysms with large diameter stalks
d) Compression should be performed in 30-second intervals with color Doppler evaluation in between compressions

Answer 4

c) Thrombin injection is more effective than compression technique in pseudoaneurysms with large diameter stalks

Question 5

Which of the following is true regarding the initial post-op examination of a transjugular intrahepatic portosystemic shunt placement?

a) It should be performed within 30 days following the procedure
b) CTA is most commonly performed for the initial evaluation of a TIPS procedure
c) It helps to establish baseline velocities for upcoming follow up exams
d) Marked ascites is a common finding for the initial post-op exam on a TIPS patient

Answer 5

c) It helps to establish baseline velocities for upcoming follow up exams

Question 6

Which of the following is a contraindication for endovenous laser ablation of the GSV?
a) Baker’s cyst in the ipsilateral popliteal fossa
b) Valvular incompetence in the great saphenous vein
c) Chronic obstruction of the femoral vein
d) Chronic obstruction of the peroneal veins

Answer 6

c) Chronic obstruction of the femoral vein

Question 7

If the physician is having trouble visualizing the needle on the US screen during a thrombin injection, how can you help to improve the visualization of the needle?
a) Use electronic steering to reduce the incident angle between the US beam and the long axis needle to a value closer to 0 degrees
b) Use a lower frequency probe
c) Use electronic steering to increase the incident angle between the US beam and the long axis needle to a value closer to 90 degrees
d) Increase the output power to the maximum setting

Answer 7

c) Use electronic steering to increase the incident angle between the US beam and the long axis needle to a value closer to 90 degrees

Question 8

Which of the following correctly describes how to prepare for an intra-operative vascular US?
a. Gather extra packets of sterile gel to be used on the outside of the sterile sheath
b. Use sterile gloves to open the packaging for supplies used in the procedure
c. Cover a high frequency transducer with a sterile sheath that contains gel
d. Cover a low frequency transducer with a sterile sheath that contains gel

Answer 8

c. Cover a high frequency transducer with a sterile sheath that contains gel

Question 9

Which of the following describes the sonographic appearance of a transjugular intrahepatic portosystemic shunt?

a. Strongly reflective curved structure connecting the right portal vein and right hepatic vein
b. Anechoic tube, without distinctive wall reflection, that connects the right hepatic vein to the right portal vein
c. Shunts are not easily evaluated sonographically and CTA is the preferred method for evaluation
d. Requires color Doppler evaluation for visualization of the graft within the liver

Answer 9

a) Strongly reflective curved structure connecting the right portal vein and right hepatic vein

Question 10

A physician orders a vein mapping of the left upper extremity for potential arterial bypass harvesting but does not indicate which vessel he plans to use. Which vein should you evaluate because it is the most commonly used for bypass?
a. Antecubital vein
b. Brachial vein
c. Cephalic vein
d. Radial vein

Answer 10

c) Cephalic vein

Question 11

Which of the following is an advantage of intraoperative vascular US compared to intraoperative angiography?
a. Technique does not require vessel puncture to obtain flow information
b. Provides real time flow evaluation
c. Can be performed during the surgical procedure
d. Can assess flow in all branches of the intracerebral vessels

Answer 11

a. Technique does not require vessel puncture to obtain flow information

Question 12

Which of the following describes a difference between endovenous ablation of the great saphenous vein and of the small saphenous vein?
a. The catheter is inserted at the groin for the treatment of the GSV and at the dorsum of the foot for the treatment of the SSV
b. The catheter is inserted at the groin for the treatment of the GSV and at the popliteal fossa for the treatment of the SSV
c. The SSV cannot be treated by endovenous ablation techniques
d. At the start of the procedure, the patient is placed in the supine position for the GSV treatment and in the prone position for the SSV treatment

Answer 12

d. At the start of the procedure, the patient is placed in the supine position for the GSV treatment and in the prone position for the SSV treatment

Question 13

A patient presents for a follow up exam after radiofrequency ablation of the GSV. What is the purpose of the exam?
a. To evaluate thrombus formation in the GSV
b. To confirm the patency of the GSV and thrombosis of its branches
c. To confirm the contraction of the GSV and absence of thrombus in the deep system
d. To assess the valvular motion in the GSV

Answer 13

c. To confirm the contraction of the GSV and absence of thrombus in the deep
system

Question 14

If the GSV is being used to create an in-situ vein graft:

a. The diameter will be greatest at the distal end of the graft
b. All perforator veins must be evaluated for patency because the graft will not
function properly with obstructed perforator veins
c. All perforator veins must be marked on the vein mapping so they can be closed
d. The valves will remain in place and provide little resistance to arterial flow

Answer 14

c. All perforator veins must be marked on the vein mapping so they can be closed

Question 15

At ______ post-injection, __________ should be performed to determine the success of a Thrombin injection for pseudoaneurysm treatment.

a. 1 hour, CW Doppler evaluation
b. 20 minutes, color Doppler and ABI evaluation
c. 5 minutes, PPG and ABI evaluation
d. 24-48 hours, color Doppler and ABI evaluation

Answer 15

b. 20 minutes, color Doppler and ABI evaluation

Question 16

A patient presents for US evaluation of a PICC line. The findings on the image are most suggestive of:

a. Thrombus formation around the catheter in the left IJV
b. Thrombus formation around the catheter in the right IJV
c. Normal catheter demonstrated in the right IJV
d. Thrombus formation around the catheter in the right subclavian vein

Answer 16

b. Thrombus formation around the catheter in the right IJV

Question 17

Which of the following is a contraindication for harvesting of the great saphenous vein?
a. Baker’s cyst in the ipsilateral popliteal fossa
b. Chronic obstruction of the peroneal veins
c. Chronic obstruction of the femoral vein
d. Valvular incompetence in the GSV

Answer 17

c. Chronic obstruction of the femoral vein

Question 18

Which of the following correctly describes a pre-procedure vein mapping?
a. A permanent marker or carbol fuchsin stain is used to create the markings
b. Keep the transducer perpendicular to the skin surface and use very light transducer pressure
c. The diameter of the vein is usually written on the arm/leg at the location it was taken
d. More than one of the above

Answer 18

d) More than one of the above ?

Question 19

Which of the following statements best describes the Doppler in the stalk of a PSA?
a. Low resistance to and fro flow
b. Phasic forward flow
c. High resistance to and fro flow
d. Continuous forward flow

Answer 19

c) High resistance to and fro flow

Question 20

Which of the following requires the use of sterile technique?
a. Laser ablation for telangiectasia
b. Vein mapping
c. Sclerotherapy
d. Radiofrequency venous ablation

Answer 20

d. Radiofrequency venous ablation

Question 21

Prior to any invasive procedure, the patient should be educated about the procedure, expected outcomes and any possible complications. The patient will be required to sign a document stating their understanding of these topic in order to proceed with the procedure. This form is called:

a. Litigation waiver
b. Health insurance waiver
c. Patient acceptance form
d. Informed consent form

Answer 21

d) Informed consent form

Question 22

Which of the following is a treatment for a PSA?
a. Compression stockings
b. Thrombin injection
c. Coumadin
d. IV heparin

Answer 22

b) Thrombin injection

Question 23

You are evaluating a patient that had a balloon angioplasty on the proximal superficial femoral artery 3 years ago. The AT in the CFA is 230ms. This finding is most suggestive of:
a. Normal arterial flow
b. Obstruction in the distal superficial femoral artery
c. Iliac artery stenosis
d. Recurrence of stenosis in the proximal superficial femoral artery

Answer 23

c) Iliac artery stenosis

Question 24

Which of the following is not an expected finding with an AV fistula caused by an interventional procedure?
a. Pulsatile venous outflow
b. Low resistance arterial inflow
c. Direct connection between a single artery and vein
d. Dilated venous collaterals adjacent to the fistula

Answer 24

d. Dilated venous collaterals adjacent to the fistula

Question 25

When thrombin is injected in a PSA, the clotting should begin: a. Within 5-10 seconds post-injection b. Within 5-10 minutes post-injection c. After 1 minute of manual compression following the injection d. Within 24hrs

Answer 25

a. Within 5-10 seconds post-injection

Question 26

Why is the distance from the most proximal point of the contracted GSV to the SFJ measured in a post-ablation exam? a. To document the lack of thrombus propagation into the deep system b. To assess the length of the segment that still requires treatment c. To document that the procedure was unsuccessful d. All of the above

Answer 26

a. To document the lack of thrombus propagation into the deep system

Question 27

A patient presents for a follow up exam after a recent endarterectomy that was performed 3 days ago. The intraoperative report indicates a possible self lesion in the ICA. How will this be demonstrated on today’s exam? a. Hypoechoic plaque in the vessel lumen with an abrupt edge b. <3mm intimal flap demonstrates a false lumen with turbulent flow c. >3mm intimal flap that causes turbulence and increased velocity d. <3mm intimal flap that causes turbulence and increased velocity

Answer 27

a. Hypoechoic plaque in the vessel lumen with an abrupt edge

Question 28

Which of the following procedures allows patients to continue their normal course of anticoagulant therapy before and after the procedure? a. Ascending venography b. Carotid endarterectomy c. Compression therapy of pseudoaneurysm d. Percutaneous transluminal angioplasty

Answer 28

a. Ascending venography

Question 29

Which of the following correctly describes sclerotherapy procedures? a. Physicians may inject saline into the superficial veins of the extremity in order to improve circulation by thinning the blood, which in turn reduces varicosity size b. Physicians may inject saline into the superficial veins of the extremity in order to cause increased viscosity and promote the formation of thrombus, which in turn reduces varicosity size c. Physicians may inject saline into the deep veins of the extremity in order to increase viscosity and promote the formation of thrombus, which in turn reduces varicosity size d. Physicians may inject saline into the superficial veins of the extremity in order to cause the vessel to contract and cause fibrosis, which in turn reduces varicosity size

Answer 29

d. Physicians may inject saline into the superficial veins of the extremity in order to cause the vessel to contract and cause fibrosis, which in turn reduces varicosity size

Question 30

Which of the following is a contraindication for US guided compression therapy for a PSA at the groin? a. Patient that stopped taking Coumadin 3 days ago b. A PSA that measures 3.2cm in diameter c. Infection at the puncture site d. A PSA that has been present for more than 72hrs

Answer 30

c. Infection at the puncture site

Question 31

A common complication of cardiac catheterization is the formation of: a. Pseudoaneurysm b. Arterial dissection c. DVT d. Fusiform aneurysm

Answer 31

a. Pseudoaneurysm

Question 32

Which of the following techniques cannot be used to monitor distal flow in the leg while compression therapy for a PSA is performed? a. Doppler evaluation of the PTA or DPA b. Pressure monitor on the great toe c. PPG sensor on the ankle d. PPG sensor on the great toe

Answer 32

c. PPG sensor on the ankle

Question 33

A patient is referred to the vascular lab to evaluate the placement of a Greenfield filter. Where will you look for this? a. Abdominal aorta b. Subclavian or IJV c. IVC d. Right or left groin

Answer 33

c. IVC

Question 34

A patient is scheduled for a stab phlebectomy. What is being treated for this patient? a. DVT removal b. Varicose veins c. Carotid stenosis d. PSA

Answer 34

b. Varicose veins

Question 35

Why did the technologist steer the 2D image while scanning during the thrombin injection? a. To improve the color flow demonstration b. To make the US beam more perpendicular to the long axis of the needle c. To make the US beam more parallel to the long axis of the needle d. To provide a better view of the posterior enhancement from the PSA

Answer 35

b. To make the US beam more perpendicular to the long axis of the needle

Question 36

Which of the following statements is false regarding intraoperative duplex evaluation during a carotid endarterectomy? a. Due to the increased attenuation of sound caused by air in the extracranial vessels, the lowest probe frequency available is preferred for the exam b. The technique is used to assess the immediate flow changes within the vessel undergoing the endarterectomy c. The highest probe frequency available is preferred for intraoperative duplex evaluation d. The probe is placed in direct contact on the vessel that is being evaluated so sterile technique is required.

Answer 36

a. Due to the increased attenuation of sound caused by air in the extracranial vessels, the lowest probe frequency available is preferred for the exam

Question 37

At the start of an endovenous ablation procedure for the GSV, the catheter is inserted _________ and advanced to a position ________ before activating the device. a. Into the distal GSV, 2cm distal to the SPJ b. Into the GSV at the groin, at the most distal point of reflux c. Into the GSV at the groin, 2cm below the knee d. Into the distal GSV, 2cm distal to the SFJ

Answer 37

d. Into the distal GSV, 2cm distal to the SFJ

Question 38

Which of the following is NOT a part of the information required on an informed consent form for an interventional vascular procedure? a. Signature line to indicate patient consent b. Percentage of patients that have experienced complications after the sameprocedure at the facility c. Possible complications that the patient may experience d. Description of the procedure

Answer 38

b. Percentage of patients that have experienced complications after the same procedure at the facility

Question 39

Which of the following is an absolute contraindication to an endovenous ablation? a. Hx of diabetes mellitus b. Current antibiotic use c. Uncooperative patient d. Daily aspirin use

Answer 39

c. Uncooperative patient

Question 40

A patient presents for a pre-procedure scan for placement of a central venous catheter in the IJV. In order to avoid potential hematoma or AV fistula formation, the relationship of the vein to the ____________ must be documented on today’s exam. a. CCA b. ICA c. EJV d. SCM

Answer 40

a) CCA

Question 41

If the peak velocity in a transjugular intrahepatic portosystemic shunt at the portal vein anastomosis is 50cm/s, and the mid graft velocity is 25cm/s, what is indicated? a. The mid-graft velocity is very low and indicates impending failure of the shunt b. The velocities indicate normal flow within the shunt c. There is most likely an occlusion in the graft at the proximal end d. There is approximately a 50% stenosis at the portal anastomosis

Answer 41

a. The mid-graft velocity is very low and indicates impending failure of the shunt

Question 42

What is an absolute contraindication for sclerotherapy? a. Patient allergy to injectate b. Vein location above the inguinal ligament c. Polycythemia vera d. Vein location immediately over a bony prominence

Answer 42

a. Patient allergy to injectate

Question 43

Which of the following measurements should be obtained to evaluate the success of a percutaneous angioplasty performed on the left SFA? a. AT and PI b. PSV and velocity ratio c. FA diameters proximal to the treated area, the treated area and distal to the treated area d. More than one of the above

Answer 43

d. More than one of the above

Question 44

Endovenous heat induced thrombosis is a complication of: a. Microphlebectomy b. Chemical ablation c. Sclerotherapy d. Radiofrequency ablation

Answer 44

d. Radiofrequency ablation

Question 45

All of the following correctly describe proper behavior related to a sterile field, except: a. When in doubt about sterility, discard the potentially contaminated item and begin again b. Sterile individuals must pass each other back-to-back when moving around the procedure room c. Hands and elbows must be kept above the level of the table d. Sterile gloves must be used to open the procedure tray

Answer 45

d. Sterile gloves must be used to open the procedure tray

Question 46

A patient presents for a follow up for the TIPS located between the right portal vein and right hepatic vein. The chart indicates an abnormal bruit and stenosis is suspected.Where should you look first for the stenosis because it is the most common site of stenosis in a TIPS? a. Portal vein anastomosis b. Biliary anastomosis c. Hepatic vein anastomosis d. Hepatic artery anastomosis

Answer 46

c. Hepatic vein anastomosis

Question 47

What is the best sonographic technique to use to evaluate the status of a PSA after 10-min of compression therapy is applied? a. CW doppler b. Color doppler c. PW doppler d. Tissue doppler

Answer 47

b. Color doppler

Question 48

What effect does a warm exam room have on a vein mapping procedure performed for coronary bypass surgery? a. Reduced compressibility of superficial veins b. Contracted veins with reduced diameters c. Normal venous diameters will be documented d. Increase in tissue edema and reduced image resolution

Answer 48

c. Normal venous diameters will be documented

Question 49

Which of the following statements correctly describes an endovenous laser ablation of the GSV? a. The procedure is considered a success if thrombus fills the GSV from the ankle to the SFJ b. Intravascular US is performed after the procedure to confirm success c. The procedure is much more easily performed if the patient already has a DVT d. The physician injects a halo of anesthesia medicine around the GSV

Answer 49

d. The physician injects a halo of anesthesia medicine around the GSV

Question 50

What is the preferred patient position during catheter retraction in an endovenous laser ablation treatment? a. Trendelenburg b. Standing c. Seated with legs dangling d. Reverse Trendelenburg

Answer 50

a. Trendelenburg

Question 51

In most cases, a peripherally inserted central catheter (PICC) line is inserted in the basilic vein exam and advanced until the tip reaches: a. Proximal subclavian vein b. Axillary vein c. Brachiocephalic vein d. Atriocaval junction

Answer 51

d. Atriocaval junction

Question 52

Which of the following indicates a balloon angioplasty of an 80% stenosis of the SFA was a success? a. A decrease in the PI distal to the treated segment b. Velocity ratio greater than 2.0 c. Increased damping in the inflow artery d. An increase in the ABI of at least 0.15

Answer 52

d. An increase in the ABI of at least 0.15

Question 53

In most patients with a central venous catheter, the tip is positioned in the: a. Distal subclavian vein b. Proximal subclavian vein c. Distal 1/3 of the SVC d. IJV

Answer 53

c. Distal 1/3 of the SVC

Question 54

When evaluating the left arm for potential placement of a central venous catheter, you identify multiple small venous collaterals surrounding the subclavian vein, what would you do next? a. Evaluate the collaterals for patency b. Evaluate the venous system in the right arm c. Measure the largest collateral for potential pathway for the catheter d. More than one of the above

Answer 54

b. Evaluate the venous system in the right arm

Question 55

When preparing the sterile tray for an invasive procedure, the cover on the tray should be opened: a. No more than 2 hours before the procedure begins b. By pulling the far corner of the wrapper toward you c. While wearing sterile gloves d. By the radiologist

Answer 55

b. By pulling the far corner of the wrapper toward you

Question 56

Which of the following is not part of the sonographer’s responsibilities when assisting with an endovenous ablation? a. Give the pt compression stockings and confirm the pt understands the aftercare instructions b. Performing the groin puncture and inserting the proximal end of the catheter into the vein that will be treated by the physician c. Map the position of the vein and determine the area of catheter access d. Review pt records and US images to confirm the diagnosis and the leg that will be treated

Answer 56

b. Performing the groin puncture and inserting the proximal end of the catheter into the vein that will be treated by the physician