RVT
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| 1st branch off ascending AO | Coronary Arteries
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| 1st branch of AO arch | Innominate/Brachiocephalic A.
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| Brachiocephalic A divides into which 2 arteries? | RT CCA and RT Subclavian A.
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| 2 branch of AO arch | LT CCA
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| 3 branch of AO arch | Lt Subclavian A
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| Subclavian A becomes | Axillary A
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| Name some branches of the subclavian A | Vertebral, thyrocervical, costocervical
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| Axillary A becomes | Brachial A
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| Brachial A branches into | Radial and Ulnar
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| Brachail A branches at the inner aspect of elbow AKA | antecubital fossa
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| Radial A branches to form | Superficial palmar (volar) arch.
Terminates in deep palmer arch by joining deep branch of ulnar a
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| ulnar A branches to form | deep palmer (volar) arch
terminates in superficial palmer arch
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| Celiac A supplies | stomach, liver, pancreas, duodenum, spleen
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| CA branches into | L. gastric, splenic, common hepatic a
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| SMA supplies | small intestine, cecum, parts of colon
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| SMA is located | about 1cm below CA,
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| T/F: CA and SMA share a common trunk | True
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| Renal A Supplies | kidneys, suprarenal glands,ureters
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| in Trv, a landmark for locating the LRA is, | the LRV. the LRV crosses the AO anteriorly; the artery being just posterior
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| IMA supplies | transverse, decending colon and part of rectum
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| IMA is located | 3-4 cm above AO bifurcation
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| T/F Ima can act as a collateral connection | True
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| Internal iliac A AKA | hypogastric
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| the external A passes under the ___ to become the CFA | inguinal ligament
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| CFA divides into | SFA and DFA
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| SFA passes through an opening in the tendon called _____,______ or____. it enters the pop fossa behind the knee | Adductor hiatus, adductor canal, or Hunters Canal
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| T/F: DFA can act as a collateral conncetion | true
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| Name the 3 arteries in the trifurcation | Anterior tibial, posterior tibial, peroneal
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| 1st branch off distal pop a | ata
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| ata becomes | Dorsalis pedis A (DPA)
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| Major branch of Dpa | deep plantar artery; penetratinf the sole of the foot, it unites with lateral plantar artery to complete plantar arch
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| short segment bt ATA branch and branches of PTA and peroneal A | Tibioperoneal trunk
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| Major branches of PTA | medial and lateral plantar arteries
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| the plantar arch consists of the | deep plantar artery (branch of DPA)
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| the _________ unites with the deep plantar artery | lateral plantar artery (branch of PTA)
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| Arteries: | transport gases, nutrient and other essentials
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| Arterioles: | considered resistance vessels; assist with regulating blood flow through contraction and relaxation
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| capillaries: | nutrients and waste products and exchanged bt the tissue and blood
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| tunica intima/ inner layer | thin, consisting of a surface layer of smooth endothelium, base membrane and connective tissue
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| tunica media/ intermediate layer | thicker, composed of smooth muscle and connective tissue, largely of the elastic type
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| tunica externa/ outter layer (adventitia) | thinner than media, contains fibrous connective tissue, some muscle fibers
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| vasa vasorum: | tiny vessels that carry blood to the walls of the larger arteries
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| which artery layer contains vasa vasorum | adventitial layer (outter)
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| during cardiac contraction pressure in the ______ rises rapidly | lt ventrical
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| pumping action of heart results in high volume of blood in arteries to maintain a high ____ ____ be the arteries and veins | pressure gradient
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| ____ ____ governs th eamount of blood that enters the arterial system | Cardiac output
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| Arterial pressure and ___ ___, determines the amount of blood that leaves arterial lsystem | peripheral resistance
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| each cardiac contractions distends the arteries, which serve as reservoirs to store some blood volume and ____ energy supplie to the system | potential
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| movement of any fluid medium bt 2 points requires 2 things: | 1. a pathway along which fluid can flow
2. difference in energy levels (pressure difference)
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| the amount of flow depends on: | 1.energy difference: includes losses resulting from fluid movement.
2.any resistance which tends to oppose such movement
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| HINT resistance vs flow rate | Lower resistance=higher flow rate;
higher resistance=lower flow rate
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| Pressure (potential)energy: | stored energy and is the major form of energy for circulation of blood; expressed in mmHg
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| Kinetic energy: | fluid density, Velocity measurements
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| gravitational energy: | hydrostatic pressure(HP)weight of the column of blood
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| ex. in a supine pt what is the Hp at ankle level | 0mmHg (HP) against art and veins.
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| when standing, HP increases, adding about ___ mmHg against vessels | 100mmHg
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| a ___ ___ is needed to move blood from one point to another | energy gradient
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| inertia: | relates to the tendency of a fluid to resist changes in its velocity (body at rest tends to stay at rest)
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| A change in __ __ greatly effects vessel resistance | vessel diameter
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| list 2 things that can effect resistance | viscosity, vessel length, and vessel diameter(most dramatic)
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| an elevated hemocratic ___ blood viscosity | increases (thickness of blood)
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| severe anemia ___ blood viscosity | decreases
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| HINT viscosity vs velosity | increased viscosity= decreased velocity
decreased viscosity= increased velocity
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| laminar flow | consists of layers of fluid particles moving against each other
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| Laminar flos is considered stable flow | with fasting moving flow in the center; stationary layer remains at the wall
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| plug flow (blunted) is likely seen at | vessel origin
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| ___ energy loss is due to increased friction bt molecules and layers which ultimately causes energy loss | viscous
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| ___ losses occur with deviations from laminar flow, due to changes in direction and/or velocity | Inertial (prominent cause of energy loss, most significant)
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| what happens with inertial energy loss: | parabolic flow profile is flattened,
disorganized flow,
loss occurs at the EXIT of a stenosis
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| poiseuille's equation defines the relationship bt: | pressure, volume flow, resistance
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| poiseuille's equation helps answer the question of: | howa much fluid moves through the vessel
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| poiseuille's equation | Q=P/R
Q=voulme flow
P=Pressure
R=resistance
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| radius of vessel is ___ proportional to volume flow | directly
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| the law of conservation of mass ezplains the realationship bt velosity and area | Q=AxV
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| velocity changes: area va velocity in a aneurysm= | Area is increased
velocity is decreased
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| Bernoulli; pressure/velocity HINT | increased velocity=decreased pressure
decreased velocity=increased pressure
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| with in a stenosis what is happening with velocity and pressure? | velocity is increased, pressure is decreased
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| what happens post-stenosis with velocity and pressure | velocity is decreased, pressure is increased
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| flow separations occur bc of | geometry changes w/or w/o dz and curves
Know pic on pg 18=curve, and change in color is an expected finding
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| flow separations result in regions with stagnant or little movement. EX: | bypass graft anastamosis site, valve cusp site
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| Reynolds number predicts | when fluid becomes unstable/disturbed.
>2000(unitless number) means laminar flow tends to become disturbed
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| low resistance flow | continuous steady flow, feeding a dilated vascular bed.
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| low resistance flow; EX:arteries | ICA, Vertebral, Renal, Celiac, Splenic, Hepatic.
feeds organs cant be w/o flow
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| High resistance flow | pulsatile nature
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| high resistance flow ex: arteries | ECA, subclavian, AO, extremitys, FASTING sma.
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| doppler flow distal to a significant stenosis is ____resistance | lower
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| doppler flow prox to a significant stenosis is ____ resistance | higher
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| NOTE: as the inflow pressure falls as a result of stenosis, the natural response in periphery is to | vasodilate to maintain flow
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| at rest blood flow may seem normal even in the presence of stenosis/occlusion. why? | Collaterals!
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| exercise should induse ___ which lowers distal ____ and increases blood flow | vasodilation, peripheral resistance
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| vasoconstriction and vasodilation of vessels within skeletal muscles help regulated____ | body temp
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| ____is probably the best single vasodilator of resistance vessles within skeletal muscles | Exercise
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| autoregulation: | ability of most vascularbeds to maintain constant level of blood flow over a wide range of perfusion pressure
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| BP rise=constriction of vessels | BP falls=dilation of resistance vessels
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| T/F mono flow can be a normal finding? | True, may be seen after vigorus exercies
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| a hemodynamically significant stenosis causes a | notable reduction in volume flow and pressure
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| cross sectional area reduction of 75%= | diameter reduction of 50%
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| prox to a stenosis: flow freq are usually ___, with or w/o disturbance | Dampened
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| Entrance to a stenosis an ___ in doppler shift freq (DSF), resulting in ___ and ___ | increased, spectral broadening and elevated velocities
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| list the 3 chronic arterial occlusive dz's | claudication, ischemia rest pain, tissue loss
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| pain in muscles usually occurring during exercise; subsides with rest | Claudication
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| claudication results from | inadequate blood supply to muscles
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| With claudication, the level of dz is usually ___ to location of symptoms | prox
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| pseudo-cladication mimics vascular symptoms but is ____ in origin | Neurogenic or orthopedic
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| ex: pt history of 4 block claudication means what? | pt c/o pain after walking 4 blocks
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| T/F Claudication symptoms are always predictible and reproducable | true!
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| a more severe symptom of diminished blood flow | ischemic rest pain
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| ischemic rest pain occurs when | limb is not dependent; BP decreased (such as when sleeping)
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| Necrosis | death of tissue, tissue loss
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| necrosis is due to | deficient or absent blood supply
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| name the 6 P's (symptoms) of Acute arterial occlusion | pain, pallor, pulselessness , paresthesia, polar
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| acute arterial occlusion may result from ___, ___, or___ | thrombus, embolism, or trauma
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| why is acute arterial occlusion an emergent situation? | since the abrupt onset does not provide for the development of collateral channels
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| pallor: | whiteness, pale skin, result of deficient blood supply
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| cyanosis | bluish, concentration of deoxygenated hemoglobin
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| rubor | dark red, suggest dilated vessels, or vessels dilated secondary to reactive hyperemia
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| Raynaud's phenomenon | condition that exist when symptoms of intermittent digital ischemia occure in response to cold exposure or emotional stress
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| Primary Raynauds | ischemia due to digital arterial spasm (artery is of but stressed)
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| Primary Raynauds symptoms | common in young women, may be hereditary, bilateral, history of symptoms for 2 years w/o progression/ evidence of cause.
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| t/f primary raynauds is a benign condition? | true
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| secandary raynauds AKA | obstructive raynauds syndrome
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| Secondary Raynaud's is where: | normal vasoconstrictive responses of arterioles superimposed on a fixed artery obstruction. (artery is damaged)
ischemia is constantly present
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| secondary Raynauds may be the 1st manifestation of | Buerger's Dz
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| arterial ulcerations are located: | tibial area, foot, toes
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| What is the shape of an arterial ulcer? | deep and more regular in shape
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| are arterial or venous ulcers more painful? | arterial
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| an increase in the capillary refill time denotes ____ arterial perfusion | decreased
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| cadaveric pallor during elevation with ruborous red discoloration with dependency is known as | dependent rubor
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| thrills vs bruits | thrills are palpable (fill the thrill)
bruits are ascultations (heard)
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| a palpable thrill over pulse site may indicate: | fistula, post-stenotic turbulence, or a patent dialysis access site
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| palpable pulses | AO, femoral, pop, DPA, PTA
peroneal is not palpable
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| site you may hear a bruit | carotid, heart, AO,fem, pop
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| name the 5 risk factors for arterial dz | 1. Diabetes-atherosclerosis
2. hypertension
3.hyperlipidemia
4. smoking
5. other (not controllable) age, family history
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| most common arterial pathology | atherosclerosis (obliterans)
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| atherosclerosis is | thickening, hardening, loss of elasticity of the arterial walls
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| atherosclerosis affects which wall layers? | intima and media. does not affect outter
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| what are the 3 major risk factors of atherosclerosis? | smoking, hpyerlipidemia, family history
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| most common site for atherosclerosis | 1.carotid bifurcation
2. vessel orgin
3. infra-renal aorto-iliac system
4. CFA bifurcation
5. SFA at the adductor canal level
6. trifurcation region
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| ____ syndrome is caused by obstruction of the AO, occurs in males | Leriche
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| 4 symptoms of leriche syndrome | 1 Fatigue in hips, thighs, or calves with exercise
2 absence of femoral pulses
3 impotence
4 often times, pallor and coldness of LE
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| obstruction of vessel by foreign substance or blood clot | Embolism
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| most freq cause of embolism | small plaque breaks loose and travels distally until it lodges in small vessel
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| ex of embolism; Blue Toe Syndrome- | toe ischemia
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| a true aneurysm is dilation of which wall layers? | all 3
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| characteristics of Fusiform aneurysm | diffuse, circumferential dilation
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| Characteristics of saccular aneurysm | localized out-pouching
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| a small tear of the inner wall allows blood to form a cavity bt 2 wall layers, is known as | dissecting aneurysm
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| dissecting aneurysm often occurs where? | Thoracic AO
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| a ____ results from a defect (ex: post catheter stick) in the main artery wall | pseudo aneurysm
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| what must be present to confirm a pseudo aneurysm? | a communicating channel (neck) from main artery to the pulsatile structure outside vessel walls
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| the most common location of a true aneurysm is | infra renal
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| locations for an aneurysm include | infra renal, thoracic AO, Abd AO, fem, pop, renal
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| most freq complication of an AAA is | rupture
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| most freq complication of a peripheral aneurysm is | embolization
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| Arteritis affects what arteries | tibial, peroneal. distal/small arteries
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| arteritis is | inflammation of arterial wall, can lead to thrombosis of vessel
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| most common type of arteritis is | Burgers dz
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| burgers dz AKA | thromboangiitis obliterans
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| arteritis is associated with | heavy cigarette smoking
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| arteritis occurs primarily in | young men <40 yrs. old
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| congenital narrowing or stricture of thoracic AO but may affect abd AO | Coarctation of the AO
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| clinical finding of Coarctation | seen in young pediatric pts, with hypertension due to decreased kidney perfusion
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| the distinguishing ultrasound feature of dissection is | a thin membrane dividing the arterial lumen into 2 compartments. tear in the intima causes blood to leak into media (false lumen)
know image pg 29
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| complication of dissection is | stenosis, occlusion, thrombosis
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| PARKS helps confirm diagnosis and | approximate the location of arterial occlusive dz.
indicates severity of occlusive process.
is combined with segmentals
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| PARKS is unable to discriminate stenosis from | occlusion
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| The Doppler effect | when a wave is reflected from a moving target, the freq of the wave received is different (doppler shift) from the transmitted wave.
this effect is relative motion bt the source and the receiver of the sound.
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| Doppler shift EX. | blood is moving target, transducer is stationary source
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| Analog | employs a zero crossing freq meter to display the signals graphically on a strip chart recorder. Paper speed= 25mm/sec
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| zero crossing freq meter | circuitry county each time the input signal crosses through zero(baseline) w/in a time span.
machine estimates freq present in reflected signal & displays them
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| high freq waves have many oscillations; | low freq waves have few
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| Analog | has acceptable accuracy.
Drawbacks include:
noise
less sensitivity
high velocities underestimated
low velocities overestimated
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| Spectral analysis: individual freq displayed by Fast Fourier Transform (FFT) | time is X-axis, freq shifts Y-axis
free of many analog drawbacks
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| PARKS uses what probe | a 8-10 MHz CW
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| With PARKS | audible and wave form qualities are observed, documented, and combined with doppler segmental pressure
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| A monophasic/dampened (pulsatile) signal is often abtained ___to an obstruction | prox
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| Vasodilation of the ____vessel often occur w/ prox obstruction, reducing the pulsatility; causing the signals to have lower resistant steady flow qualities | Distal
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| analog doppler is not capable of portraying velocities of less than ____ | 6 cm/sec
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| Troubleshooting: "60cycle" noise on tracing? | decrease gain, turn system off/on, increase filter,try another plug
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| Pulsatility index calculated by | dividing peak to peak freq difference (P1-P2) by the mean avg.
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| The PI differentiates | inflow dz from outflow
ex. aorto-iliac from femoral
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| Acceleration Time | helps to differentiate inflow dz from outflow
prox art obst results in a slowing of the time interval bt the onset of systole to the point of max peak
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| ex criteria of acceleration time: | an acceleration time of >133 msec suggest presence of prox dz
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| Segmental pressure LE help to | assess presence/ severity of arterial dz.
combined with doppler velocity or volume pulse waveforms
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| t/f segmental pressures can discriminate bt stenosis and occlusion | FALSE segmental cannot distinguish bt stenosis and occulsion or precisely localize area of obstructions
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| when doing segmentals, calcified vessels render falsely ___ pressures | elevated
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| uncompensated CHF may result in ___ abi | decreased
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| when using a narrow cuff on the high thigh will cause | artifactually elevated high thigh pressures
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| how long should a pt rest before starting segmentals? | 20 min
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| HINT: if cuff is too large for a limb segment, BP is falsely lower; | if cuff is too narrow for limb segment, BP is falsely higher
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| width of cuff should be ___% > than diameter of limb | 20%
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| where do you place cuffs for $cuff method | Brachial, high thigh, above knee (AK), below knee (BK), ankle
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| what size cuff is used on thigh for 4 cuff method? | 12's (12x40)
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| where do you place cuffs for 3 cuff method | brachial, thigh, below knee, ankle
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| what sized cuff is placed on knee for 3 cuff method? | 19x40
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| order of segmentals | brachial, ankle, calf, above knee, high thigh
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| NOTE: you must start at ___ and move ___ to eliminate the possibility of underestimating the systolic pressure measurement. | ankle, prox
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| how high do you inflate the cuff during segmentals | 20-30 mmHg beyond last audible signal, OR 20-30mmHg above highest brachial
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| How do you calculate abi's? | divide ankle pressures by HIGHEST brachial
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| A normal ABI calculation is >____ | 1.0
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| an abi of ___-___ may suggest asymptomatic dz or mild arterial dz | >0.9-1.0
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| an ABI of ___-___ suggest Claudication (moderate dz) | 0.5-0.9
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| an abi calculation of ,___ suggest rest pain (severe arterial dz) | 0.5
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| an abi of >1.3-1.5 is considered ____ | incompressible
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| segmential pressure drops of >30mmHg bt 2 consecutive levels suggest ___ dz | Significant
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| a horizontal difference of >20-30 mmHg suggest obstructive dz where? | at or above the level in the leg with the lower pressure
see ex. pg 41
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| in 3 cuff technique, the thigh pressure should be similar to the ___ | highest brachial
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| in the 4 cuff technique the high thigh pressure is normally >30mmHg than ____ | highest brachial
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| toe pressures of ___ are evident in foot and toe ulcers that fail to heal | <30mmHg
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| In diabetic pts, are abi or toe pressures more reliable? | toe pressures due to calcifications
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| contraindications for exercise testing include: | SOB, server hypertension, signif cardiac problems, stroke, walking problems
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| what does pt walk on for exercising exam? | a constant load treadmill at 12% elevation, 1.5 mph, for 5 min or until unbearable
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| what do you document during exercise testing? | duration of walk, MPH, onset, location and progression of symptoms
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| post exercise ABI is normally ___ | increased
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| if post-exercise is ABN, obtain pressures every ___ until pre-exercise pressures are obtained | 2 min
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| Single level Dz take ___-___ for the ABI to increase back to resting levels after they dropped to low levels after exercise | 2-6
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| Multi-level dz takes ___-___ min for the abi to increase back to resting levels after exercise | 6-12 min
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| reactive hyperemia is | an alternative method for stressing the peripherial circulation. used when pts cannot use treadmill testing
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| reactive hyperemia technique: | bilateral thigh cuff (19's) inflated to supersystolic pressure levels (usually 20-30mmHg above the highest brachial) maintain pressure for 3-5 mins
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| reactive hyperemia technique produces: | ischemia and vasodilation distal to the occluding cuffs
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| single level dz ____% drop in ankle pressure w reactive hyperemia | <50%
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| multi level dz ____% anlke pressure drop w reactive hyperemia | >50%
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| UE segmential pressure technique | 12 cuff on upper arm, 10 cuff on forearm
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| allen test evaluates: | patency of palmer arch. determins which artery supplies blood to arch in order to harvest radial artery
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| allen test technique | manual compression of Radial A. my tech, Pt clenches fist 1min, inducing pallor increasing resistance. pt then relaxes hand.
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| normal interpretation for allen test | reappearence of normal color to indicate the ulnar artery is providing flow to the palmer arch
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| ABN interpretation for allen test | color does not reappear to indicate: an ulnar artery occlusion, or palmer arch obstruction
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| documentation for allen test | PPG on index finger to document arterial pulsation
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| a 15-20 mmHg difference bt brachials suggest a >50% stenosis of | subclavian artery
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| a >15-20 mmHg drop from upper arm to forearm suggest: | brachial A obstruction distal to upper cuff,
obstruction of both radial and ulnar A,
obstruction in single forearm artery which has decreased pressure
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| Penile doppler helps determine: | if impotence is related to peripheral vascular insufficiency
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| technique for non imaging penile doppler | doppler CFA,PTA,DPA
calculate ABI
penile pressure obtained w PPG end point detector
cuff size 2.5 cm
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| penile/brachial index: Normal | >0.75
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| penile/ brachial index: Marginal | .65-.74
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| penile/brachial index: ANB | <.65
consistance with vasculogenic impotence
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| reduced pressure highly suggestive of ___ | prox arterial dz(aorto-iliac:internal iliac arteries)
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| technique for penile imaging: which arteries are measured? | cavernosal aeteries measured in trv,
PSV/EDV obtained
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| what freq probe is used for penile imaging | 7-10 MHz
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| medication in injected to induce erection, obtain measurement ___ post injection | 1-2 min
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| which vein velocity is measured during penile imaging? | Dorsal vein velosity
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| if ridgid erection is maintained for up to ___, pt must contact urologist immediatley to reverse the _______ | 3 hrs, priapism
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| penile imaging interpretation: NORMAL | diameter of cavernous arteries should increase post-injection,
PSV should be 30cm/sec higher,
dorsal vein velocity should remain the same(<3cm/sec).
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| dorsal vein veolcity normal vs abn | normal <3 cm/sec
Abn >20 cm/sec
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| combined w/segmentals, Plethysmography helps differentiate ____ | true claudication from non-vascular sources.
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| Plethysmography detects: | presence/absence of arterial dz while defining its functional aspects
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| Plysmography helps ___ the level of obstruction | localize
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| PPG is mainly used for evaluation of ___ and ____ | digits, penile vessels
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| plethysmography is used for ____ treatment | assessment of follow up treatment
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| can plethysmography discriminate between major arteries and collaterals | NO
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| is Plethysmography specific to one vessel | NO
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| volume (air) plethysmography = measurement of | volume change
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| in Volume-PG, a measured about of air is sequentially inflated into a cuff to pressures ranging ____to _____mmHg | 10-65mmHg
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| as arterial flow moves under the cuff , momentary ____ changes in the limb segment occur | volume
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| PPG (photo-phleysmography) detects: | cutaneous blood flow, rather than truly measureing volume change
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| ppg photo cell consists of | light emitting diode and photo-sensor
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| diode transmits ___light into subcutaneous tissue w backscattered light reflected back to the adjacent photo sensor | infrared
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| the ____ determines the reflection | cutaneous blood flow
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| blood attenuates light in proportion to its content in tissue= | increased blood flow results in decreased reflection. HOwever, that is displayed as an increased/positive deflection on the waveform. (alot of blood flow sucks up light, decreasing what is returned= positive deflection which is a good sign)
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| w volume-PG a 3 or 4 cuff method is used. begin w/ ___ part of extremity, moving ___ | upper, distally
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| w PPG abn waveforms always reflect hemo signif dz ____ to level of tracing | Prox
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| what is displacement plethysmography? | any change in volume of the enclosed part will displace an equal amount of water
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|
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