Vascular ARDMS Exam 175 Questions with Verified Answers,100% CORRECT

Vascular ARDMS Exam 175 Questions with Verified Answers Average velocity of the aorta - CORRECT ANSWER 60-100 cm/s what aortic pathologies affect the branches - CORRECT ANSWER stenosis, aneurysm, plaque what are the normal waveforms of the proximal aorta - CORRECT ANSWER low resistance flow pattern with continuous forward diastolic flow by the liver spleen, and kidneys (similar to ICA waveform) normal waveforms for distal aorta - CORRECT ANSWER higher resistance flow pattern what causes the distal aorta to be more high resistive - CORRECT ANSWER peripheral resistance and due to the triphasic nature of the aortic branches (reversal during diastole) why is the proximal aorta more high low resistive - CORRECT ANSWER the highly metabolic organs of the abdomen need forward flow in systole and diastole whats the most superior brach of the aorta arising from the anterior surface - CORRECT ANSWER celiac artery where to 95% of celiac arteries bif - CORRECT ANSWER 1-3 cm from origin what does the eliac artery bif into - CORRECT ANSWER common hepatic, splenic, and left gastric which pane is the celiac best seen in - CORRECT ANSWER transverse what is the normal waveform for the celiac - CORRECT ANSWER low resistance flow due to the vascular beds of the liver and spleen with continuous forward flow during diastole what happens if the celiac occludes - CORRECT ANSWER collateralization throught the pancreaticoduodenal arterial arcade-network of small vessels surrounding the pancreas and duodenum (feed into duodenum then into the common hepatic) how does the splenic artery run - CORRECT ANSWER it follows a tortuous course long the posterior, superior pancreatic body and tail with several pancreatic and gastric branches where does the splenic artery originate - CORRECT ANSWER it is a branch off of the celiac axis where does the splenic artery terminate - CORRECT ANSWER ends as branches in the splenic hilum what is the normal splenic artery waveform - CORRECT ANSWER turbulent flow due to tortuosity (fig 26-3, 441) what is the best way to evaluate the spenic artery - CORRECT ANSWER in the transverse plane from the anterior midline along the tail, eval distal from left lateral window at splenic hilum wheredoes the common hepatic artery lay - CORRECT ANSWER in the superior border of the pancreatic head, its the right branch of the celiac what does the common hepatic give rise to - CORRECT ANSWER the GDA where does the common hepatic artery turn into the proper hepatic artery - CORRECT ANSWER past the GDA what occurs after the proper hepatic artery enters the liver - CORRECT ANSWER it divides into right and left branches what is the normal wave form for the common hepatic artery - CORRECT ANSWER low resistance continuous forward diastolic flow where is the best place to evaluate the common hepatic artery - CORRECT ANSWER eval from anterior abdominal window at the porta hepatis where does the sma arise? - CORRECT ANSWER anterior aorta distal to celiac trunk what is the course of the SMA - CORRECT ANSWER it has a short anterior segment then turns inferiorly and ends near the ileoceccal valve what is the normal waveform of the SMA and IMA in a fasting patient - CORRECT ANSWER high resistance flow with sharp systolic peaks and absent late diastolic flow What is the normal waveform of the SMA and IMA 30-90 minutes post prandial - CORRECT ANSWER low resistance pattern with broad systolic peaks and continuous diastolic flow whats the best way to eval the SMA and IMA - CORRECT ANSWER eval in transverse from anterior what does the sma supply - CORRECT ANSWER branches supply the jejunum, ileum cecum, ascending colon, proximal 2/3rds of the transverse colon, portions of the duodenum, and the pancreatic head where does the sma lie in relation to the smv and the left renal vein - CORRECT ANSWER to the right of the smv and the left renal vein courses between the sma and aorta what is the function of the portal venous system - CORRECT ANSWER it transports nutrient rich blood from the intestines and spleen to the liver what is the normal flow of the PV system - CORRECT ANSWER hepatopedal (unidirectional forward flow) with subtle phasic variation produced by respiratory and cardiac hemodynamic effects and unidirectional; sounds like a windstorm what does the normal portal vein measure - CORRECT ANSWER no larger than 13 mm in diameter but increases with sustained deep inspiration (splenic and SMV can increase 50-100 percent in size with this). this response negates portal HTN what occurs in the portal system in a patient with CHF - CORRECT ANSWER the main portal vein may demonstrate a doppler waveform that is bidirectional with pulsatile flow what is the origin of the portal vein - CORRECT ANSWER begins at junction of splenic and SMV immediately posterior to pancreas neck and courses superior to the right and passes posterior to the first portion of the duodenum and terminates at the porta hepatis what joins to form the MPV - CORRECT ANSWER the SMV runs superior from the intestines to join the SV and form the MPV what is the largest tributary to the IVC - CORRECT ANSWER the hepatic veins what is the normal flow of the hepatic veins - CORRECT ANSWER hepatofugal flow that is chaotic pulsatile flow pattern from transmission of RA pulsatations what effect does CHF have on the hepatic veins - CORRECT ANSWER they become enlarged Which lobe do the hepatic veins not drain - CORRECT ANSWER the caudate lobe where does the right hepatic vein run - CORRECT ANSWER coronal betwen the anterior and posterior segments of the right lobe where does the middle hep v run - CORRECT ANSWER between the right and left lobes where does the left hep v run - CORRECT ANSWER between the medial and lateral segments of the left lobe where is the IVC located - CORRECT ANSWER anterior to the spine and to the right of the aorta what is the normal size for the IVC - CORRECT ANSWER seldom exceeds 2.5 cm but varies with respiration and cardiac cycle (inspirations limit venous return and enlarge IVC) what is the normal waveform for the IVC - CORRECT ANSWER somewhat pulsatile due to the close proximity to the RA where do most IVC anomalies occur - CORRECT ANSWER below the renal veins (duplication, transposition) what happens if the IVC is interrupted - CORRECT ANSWER flow enters the heart through the azygos and hemiazygos veins and the hepatics drain directly into the right atrium what occurs with dupication and transposition - CORRECT ANSWER the left sided IVC joins left renal vein and crosses over to join normal right sided IVC what occurs with azygos and hemiazygos IVC - CORRECT ANSWER results from failure of intrahepatic segment of IVC to form, flow is diverted to heart vi the azygos and hemiazygos veins and hep veins drain directly into the rt atrium where is the origin of the renal arteries - CORRECT ANSWER arise laterally from the aorta below SMA origin which renal artery branches off the aorta first - CORRECT ANSWER right; it also passes posterior to the IVC what is the normal waveform for the renal artery - CORRECT ANSWER low resistance flow pattern with a rapid systolic upstroke and continuous forward diastolic flow where does the left renal vein run - CORRECT ANSWER passes anterior to the arta and posterior to sma and enters the left side of the IVC what are two other possible paths the left renal vein can follow - CORRECT ANSWER (1.) circumaortic with separate veins passing anterior and posterior to the aorta (2.)retroaortic passing posterior to the aorta what other vessels does the left renal vein receive blood from - CORRECT ANSWER the left suprarenal (adrenal) vein and the left gonadal vein what is different about the anatomy of the right renal vein - CORRECT ANSWER it follows a much shorter course to the IVC with no tributaries what is the normal waveform for the renal veins - CORRECT ANSWER phasic flow patern (like IVC) -cardiac pulsatations close to the IVC what is the best window to evluate the hepatic veins - CORRECT ANSWER sub-xiphoid window what effect does inspiration have on normal hepatic vein flow - CORRECT ANSWER it causes a blunted appearance what occurs during right atrium diastole in the hepatic veins - CORRECT ANSWER slow forward flow from veins to IVC and eventually flow reversal what occurs during right atrial diastole in the hepatic veins - CORRECT ANSWER acceleration n forward flow from hepatic vein to IVC and slows down as RA begins to fill what effect does CHF have on the hepatic veins - CORRECT ANSWER engorged with increased pulsatility what effect does tricusid regurge have on the hepatic veins - CORRECT ANSWER causes retrograde flow in the hepatic veins during systole How is the portal vein characterized - CORRECT ANSWER intrasegmental what is the normal velocity of the portal vein - CORRECT ANSWER 15-40 cm/s how does the portal vein lay in relation to the ivc - CORRECT ANSWER it crosses anteriorly to the IVC what is the normal waveform for the hepatic artery - CORRECT ANSWER low resistance profile with a broad systolic peak and gradual deceleration from systole to diastole with continuous diastolic flow define portal HTN - CORRECT ANSWER elevated pressure in PV system resulting in an impedance of blood flow through the liver what are the 5 things to look for sonographically when detecting Portal HTN - CORRECT ANSWER diameter, vasc response to HTN, portal vein flow direction and velocity, size of the spleen, collaterals whats the most common cause of portal HTN in the U.S. - CORRECT ANSWER cirrhosis what are other causes of Portal HTN - CORRECT ANSWER prehepatic obstructions (PV thrombosis, extrinsic compression), intrahepatic obstructions (cirrhosis, hepatic fibrosis, lymphoma), post hepatic (IVC obstruction, hep v obstruction) how does the diameter of the vessel indicate portal HTN - CORRECT ANSWER diameter greater than 13 mm, also eval splenic v and SMV (if they increase greater than their normal 70-100% with inspiration) =diagnosis confirmed how does portal HTN effect the response to respiration - CORRECT ANSWER it is lost how does portal flow direction and velocity indicate portal HTN - CORRECT ANSWER the increase in pressure in the liver can cause the flow in PV to appear biphasic (TO AND FRO FLOW) or it may reverse completely and become hepatofugal; this may also occur in the splenic vein what splenic pathology indicates portal HTN - CORRECT ANSWER splenomegally what effect do collaterals have on portal HTN - CORRECT ANSWER decompress the pressure in the liver and allow forward flow in the portal vein. If there are spleno renal collateralys their flow in the portal vein may e reverted. An umbilical vein collateral the splenic and portal vein may show hepatopedal flow. You may also see a reversed flow in the right portal vein with normal flow in the left portal vein which vessel oes retrograde flow occur in in 80-90% of portal HTN - CORRECT ANSWER left gastric vein (may cause esophageal varices) how does the flow appear in a recannalized paraumbilical vein - CORRECT ANSWER hepatofugal (100% indicative of portal HTN)-- should exceed 5 cm/s what vesels are joined in a splenrenal shunt - CORRECT ANSWER splenic vein to left renal vein what is true of gastric varices - CORRECT ANSWER near the stomach in the epigastrium, under the left lobe of the liver near the spleen (cause patient to cough up blood) why do common porto-systemic shunts occur - CORRECT ANSWER occur as collateral pathways when flow cannot pass through and out of the liver when is the coronary (left gastric) vein considered abnormal and indicative of portal HTN - CORRECT ANSWER if it exceeds 4 mm and hepatofugal flow indicates abnormal portosystemic pressure what other than portal HTN may cause splenosystemic collaterals - CORRECT ANSWER splenic venous obstruction (find occlusion using color) what may be mistaken for neoplastic masses if color is not used - CORRECT ANSWER esophagogastric junction collaterals what is the son app of portal vein thrombosis - CORRECT ANSWER nonvisualized vein, increased echoes within the vein, absence of flow within the vein what causes fibrosis cavernous transformation associated with portal vein thrombosis - CORRECT ANSWER complete occlusion of the vessel--appears as a group of tortuous vessels in the porta hepatis 6-20 days after an acute occlusion what are pitfalls of portal vein thrombosis - CORRECT ANSWER tumor causes it to dilate (greater than 23 mm is indicative of a tumor), anechoic structures are commonly mistaken to be biliary related, low velocities or to and fro flow difficult to detect, inadequate doppler angle which limits detection of PV flow and leads to a false positive how does new thrombus appear sonographically - CORRECT ANSWER anechoic--easy to miss without color doppler what is the best way to differentiate between thrombus and tumor involvement - CORRECT ANSWER tumor involvement will have internal vasculature and and thrombus will not and tumor involvement causes the PV to dilate what is PVG - CORRECT ANSWER portal vein gas - gas in the portal venous system what are causes of PVG - CORRECT ANSWER bowel ischemia, diverticulitis, appendicitis, bowel distention, bowel obstruction, ideopathic what are the sonographic features of PVG - CORRECT ANSWER small, mobile, echogenic reflections in the lumen of PV and branches, increased doppler signal due to the highly reflective gas bubble compared to a RBC what can PVG mimic - CORRECT ANSWER poorly defined echogenic areas can look like hemobilia or parenchymal calcifications what is budd chiari syndrome - CORRECT ANSWER a hepatic vein obstruction what are clinical signs of budd chiari - CORRECT ANSWER hepatomegally (due to liver congestion), abdominal pain (due to hepatomegally), ascites, Hepaocellular dysfunction (Labs), left and caudate lobes undergo compensatory hypertrophy what are the acute symptoms of budd chiari - CORRECT ANSWER liver segment enlarges and appears hypoechoic, aschites, pleural effusion, and GB edema-- looks like liver failure with assive ascites and hepatomegally, difficult to see hepatic veins due to this what are the chronic symptoms of budd chiari - CORRECT ANSWER liver segment shrinks and appears echogenic, splenomegally, portosystemic collaterals-- difficult to see hep v's due to fibrosis and reduced liver size what will grey scale indicate with budd chiari - CORRECT ANSWER an echogenic intraluminal material possibly a thrombus or tumor invasion (such as a hepatoma) what will doppler demonstrate with hep v obstruction - CORRECT ANSWER a lack of flow in the hepatic veins at the site of the occlusion and collateral pathways that don't follow the usual vsculature course. A bicolor flow in the hepatic veins (one branch blue and the other red) is a good indication of proximal vein occlusion and distal patency, caudate veins enlarge greater than 3mm (specific to budd chiari in the absence of CHF) what is a method of treating portal HTN - CORRECT ANSWER TIPS- transjugular intrahepatic portosystemic shunts what are the normal findings associated with a TIPS - CORRECT ANSWER flight protrusion of ends of shunt into portal and hepatic veins, fully filled stent, monophasic slightly pulsatile flow, moderate spectral broadening, PSV from at least 50-60 cm/sec to 90-120 cm/ sec, similar velocities at both ends, hepatopedal flow in portal, increase in portal flow comared to pre shunt status, portal velocity of at least 30 cm/sec with normal range of 37-47 cm/sec what is a TIPS - CORRECT ANSWER this is a channel created between the high pressure portal system and the low pressure hepatic veins and installed via the jugular vein what are the features of a TIPS stent - CORRECT ANSWER metallic device used to create shunt or channel and easily visualized what should a pre-op sonogram of a TIPS include - CORRECT ANSWER should include documentation of flow and patency in the PV, SV, and SMV. Evaluate the liver as well. Location of hepatomas may change the plan for a shunt depending on the tumor's location what should a post-op sonogram of a TIPS include - CORRECT ANSWER approximately within the first 24 hours of TIPS placement, document the patency of the TIPS and establish baseline velocities what is the most common site of a stent stenosis - CORRECT ANSWER at the hepatic end of the shunt how is the stenosis visualized within a TIPS - CORRECT ANSWER a high velocity flow less than 50-60 cm/s is a clue the shunt is malfunctioning, flow increasing to more than 100 cm/s is indicative of stenosis what are the positive aspects of a shunt - CORRECT ANSWER reduces ascites, prevents collateral hemorrhage, and increased quality of life what is the highest risk of stenosis and occlusion in a shunt within the first few weeks - CORRECT ANSWER thrombus what is the highest risk of stenosis and occlusion in a shunt later on - CORRECT ANSWER neointimal hyperplasia what do the splanching arteries supply - CORRECT ANSWER the blood to the bowel what vessels are splanching or mesenteric arteries - CORRECT ANSWER celiac, sma, ima what is the purpose of evaluating the mesenteric arteries - CORRECT ANSWER to look for songraphic signs of mesenteric ischemia (Often prevented due to collateralization) what are the normal velocities of the celiac arteries - CORRECT ANSWER PSV 50-160 cm/s and EDV of less than 50 cm/s what are the normal velocities of the sma preprandial - CORRECT ANSWER 110-180 cm/s what are the normal velocities of the sma postprandial - CORRECT ANSWER broad PSV ranges what are the normal velocities of the IMA - CORRECT ANSWER PSV 93-189 cm/s what are the sonographic features of the SMA and IMA in a NPO patient - CORRECT ANSWER high resistance flow with low diastolic velocities due to vasoconstriction of mesenteric vessels what are the sonographic features of the sma and ima in a post prandial patient - CORRECT ANSWER low resistive flow with high systolic and diastolic velocities du to vasodilation of mesenteric vessels what are the symptoms of acute mesenteric ischemia - CORRECT ANSWER patient presents with abdominal cramps and pain after eating, bowel evacuation (diarrhea), distension, fever, dehydration, acidosis, and DEATH---requires surgery (CT) what are the clinical symptoms of chronic mesenteric ischemia - CORRECT ANSWER patient presents with symptoms that are too vague to consider mesenteric ischemia but may describe a fear of food syndrome with weight loss (angiography) what causes mesenteric ischemia - CORRECT ANSWER arterial obstruction at the vessels origin (embolus, thrombus, and compression) what are the two main criteria of mesenteric ischemia - CORRECT ANSWER assessment of flow patterns (sma and ima are low resistive even in a fasting patient--indicates the capillary beds have vasodilated due to the dx), direct sonographic detection of stenosis or blockage what are the doppler findings of mesenteric ischemia in a fasting patients SMA - CORRECT ANSWER 70% stenosis, 275 cm/s - PSV; 45 cm/s- EDV what are the doppler findings of mesenteric ischemia in the celiac - CORRECT ANSWER 70% stenosis; PSV- 200 cm/s; EDV 55 cm/s what is 100% positive predictive of an occlusion in the celiac artery - CORRECT ANSWER seeing reversal of flow in the GDA or common hepatic arteries what must the angle be to allow adequate eval of the vessels - CORRECT ANSWER less than 60 degrees what are the correct machine settings to eval the abdominal vessels - CORRECT ANSWER 2-5 mHZ curved, angle less than 60 degrees, patient NPO, what is the ratio to determine significance of dx? - CORRECT ANSWER ratio=peak systolic mesenteric/ peak systolic aorta (1 is normal and 3 is hemodynamically significant) what are pitfalls of the mesenteric artery ischemia - CORRECT ANSWER median arcuate ligament syndrome (obstruction disappears with inspiration and returns with expiration); SMA compression syndrome what is the median arcuate ligament - CORRECT ANSWER leaflet of the diaphragm that crosses the anterior aspect of the aorta just cephalic to the celiac axis. It can ompress and partially obstruct the celiac during expiration what are features of median arcuate ligament syndrome - CORRECT ANSWER can be treated surgically with lysis of the arcuate ligament.. patient will present with nausea, abdominal pain, vomiting, and weight loss. when should you be suspicious of pathology with median arcuate ligament syndrome - CORRECT ANSWER if the celiac obstruction disappears with deep inspiration and returns with expiration what is the sma compression syndrome characterized by - CORRECT ANSWER compression of the third or transverse portion of the duodenum against the aorta by the sma which results in chronic, interittent, or acute complete or partial duodenal obstruction (Women age 41) what is the order of blood flow through the kidney - CORRECT ANSWER main renal artery > segmental arery (begin @ hilum) > interlobar arteries (begin at parenchyma) > arcuate arteries (run parallel to cortex surface) >interlobular renal arteries (extend into the cortex) what is the normal renal artery flow - CORRECT ANSWER low resistive with continuous systolic and diastolic flow psv- 100+-20 cm/s edv- 30+-5 cm/s RI- less than .75 what are other modalities for evaluation of the renal arteries - CORRECT ANSWER catheter angiography (gold standard), CT angiography, MRA what enhances the sonographers ability to perform a renal doppler - CORRECT ANSWER NPO patient, hydrated kidneys, 2.5-5 MHz transducer what should be evaluated with a renal doppler exam - CORRECT ANSWER echogenicity, thickness of parenchyma, length, signs of scarring, hyrdro, or masses, a discrepancy of 2 cm or more between the kidneys is significant, eval son app of aorta's entire length for plaque aneurysm and echogenicity, eval each vessel with color and spectral for resistance, stenosis, and occlusions, measure wave form what do you want your sample volume to be for the renal arteries? veins? - CORRECT ANSWER 2 mm for arteries, 4 mm for veins what do you want your sweep speed to be for renal doppler - CORRECT ANSWER between 2-3 seconds (max of 3 wave forms) what are the criteria for a renal artery stenosis - CORRECT ANSWER renal PSV divided by Aortic PSV > 3.3, turbulent low post stenosis, low flow velocity in the distal RA, AT > 0.07 sec, missing ESP, tardus parvus waveforms what is the correct caliper placement on the RA waveform - CORRECT ANSWER ESP at the first peak systolic point, mark beginning of acceleration time, then peak of acceleartion time, then at the smae point as peak ESP, velocity at forward systolic point, mark end diastolic velocity what can renal artery stenosis cause - CORRECT ANSWER HTN, renal insufficiency (damaging parenchyma), narrowing of renal artery, renal ischemia, RAA (vasosuppressor) which leads to HTN, (10% HTN, 3-5% renal dx) what is the most correctible cause of HTN - CORRECT ANSWER renal artery stenosis what waveform is present with RA stenosis - CORRECT ANSWER absence of early systolic peak and prolonged acceleration time (tardus parvus)-- dampened PSV distal to site of stenosis what is the diagnostic criteria of a significant stenosis - CORRECT ANSWER psv greater than 180 cm/s, RAR greater than 3.3, damping, AI less than 300 cm/s, AT greater than 100 cm/s, unilateral decreased flow what does indirect evaluation of renal artery stenosis provide - CORRECT ANSWER qualitative data and looks at shape of wave form what does direct eval of renal artery stenosis provide - CORRECT ANSWER looks at specific peak systolic velocity of the waveform what are the greatest indications of RA stenosis - CORRECT ANSWER PSV greater than 200 cm/s, tardus parvus waveforms what non vascular diseases cause changes in waveforms - CORRECT ANSWER urinary obstruction, acute and chronic disorders what changes occur in the waveform with nonvascular renal disease - CORRECT ANSWER renal flow becomes high resistive, renal flow increases in pulsatility what does a unilateral finding of pulsatile flow indicate - CORRECT ANSWER possible acute renal obstruction or renal vein thrombosis what are flow findings associated with renal tumors - CORRECT ANSWER increased neovascularity, low resistance and high velocity waveforms (oncocytoma or RCC) what are the features of renal artery occlusion - CORRECT ANSWER absence of visible main renal artery, kidney less than 9 cm, absence of blood flow in the kidney, low amplitude and dampened waveform what is a false positive of renal artery occlusion - CORRECT ANSWER improper visualization of main RA or if kidney is small due to some other pathology what is a false negative of renal artery occlusion - CORRECT ANSWER if a collateral artery is seen instead of an occluded main artery (flow may indicate whether there is an occlusion) what are the clinical presentations of renal vein thrombosis - CORRECT ANSWER asymptomatic to pain and hematuria, possible PE causes of renal vein thrombosis - CORRECT ANSWER intraluminal clot or compression by extrinsic means causing a clot (preexisting renal dx, hypercoaguable state, vena cava or ovarian thrombosis, surgery, trauma dehydration whats the most common cause of renal vein thrombosis - CORRECT ANSWER primary renal disease what are extrinsic causes of renal vein thrombosis - CORRECT ANSWER acute pancreatitis, lymph node enlargement, retroperitoneal fibrosis what can renal vein thrombosis cause - CORRECT ANSWER renal ischemia, or acute renal failure what is the most common acute renal finding - CORRECT ANSWER renal vein thrombosis what are the changes associated with chronic renal vein thrombosis - CORRECT ANSWER increased hypocortex, decreased RA size, increased echogenicity what is the son app of renal vein thrombosis - CORRECT ANSWER increased size, hypocortex and decreased corticomedullary differentiation, possible hypocortex with normal corticomedullary differentiation, mottled echogenicity with loss of normal intrarenal architecture what must occur to diagnose renal vein thrombosis - CORRECT ANSWER MUST be able to visualize clot what is the most common tumor to extend into the renal vein - CORRECT ANSWER RCC (others: TCC, wilms, renal lymphoma) what is the most common location for tumor extension - CORRECT ANSWER from the renal vein into the IVC what is a fistula - CORRECT ANSWER abnormal connection between RA's and RV's what is the most common cause of acquired fistulas - CORRECT ANSWER renal biopsy what are the sonographic features of fistulas - CORRECT ANSWER turbulent high velocity flow within the renal parenchyma, direct visualization UNCOMMON due to the size of the vessels what is a common treatment for renal artery stenosis - CORRECT ANSWER renal artery stents what is a long term complication of renal artery stents - CORRECT ANSWER in-stent re-stenosis what should be evaluated with post renal stent protocol - CORRECT ANSWER eval aorta, renal artery in its entirety (origin mid and hilum), document stent itself