Lange Review Ultrasonography Examination, 4th Edition

Answers and Explanations

At the end of each explained answer, there is a number combination in parentheses. The first number identifies the reference source; the second number or set of numbers indicates the page or pages on which the relevant information can be found.

1. (A) All deep veins of the lower leg contain at least ten valves. As many as 10–15 may be present in each vein. They are usually paired and communicate with the superficial system. (Study Guide)

2. (C) The longest vein in the body is the great saphenous vein located in lower extremities. The largest vein in the body is the inferior vena cava (IVC) located in the abdomen. (Study Guide)

3. (B) The popliteal vein extends upward through the adductor (Hunter’s) canal to become the femoral vein. The flexor hallucis longus are tendons in close proximity to the interosseous membrane in the distal third of the lower leg. The femoral vein ascends into Scarpa’s triangle, then crosses behind the artery to assume a more medial position. (Study Guide)

4. (B) The femoral vein located in the lower extremities, is part of the deep venous system. The great and short saphenous veins are also in the lower extremities. The basilic vein is found in the upper extremity. (Study Guide)

5. (C) Normally the veins are not pulsatile. Exceptions include cardiac disease, extreme bradycardia and overtransfusion, which can cause pulsatility. Variations in the diameter of veins are caused by respiration, rather than the cardiac cycle. (Study Guide)

6. (D) Seventy-five to 80% of the blood volume is contained within the venous system. The ability of the veins to adjust shape and size makes it ideally suited for the storage of blood. (Study Guide)

7. (A) Veins have thinner walls with very little muscle, resulting in their being both distensible and collapsible. They can also be divided into deep and superficial systems, unlike arteries. (Study Guide)

8. (B) The primary clinical concern in DVT is the complication of pulmonary embolism. Claudication is an arterial disease. Valvular incompetence frequently results from a DVT. (Study Guide)

9. (B) Duplex scanning of the deep vein system of the lower extremities is usually performed with the patient supine and the leg externally rotated. It is important that the leg also be relaxed for ease of blood flow. The popliteal vein can be visualized with the patient in a prone position. (Study Guide)

10. (C) The tunica adventitia, the outer layer, is the strongest part of the vein wall. It is composed of collagen fibers. Tunica media is the middle layer. Tunica intima is the inner layer that contains the venous valves. (Study Guide)

11. (B) A spontaneous venous signal may not be heard at the posterior tibial vein at the ankle. In this location, the blood flow rate may be below the sensitivity of the Doppler velocity detectors. Most Doppler velocity detectors cannot detect movement below 6 cm/s. (Study Guide)

12. (B) A normal venous signal is phasic and spontaneous. A continuous venous signal indicates either internal obstruction of flow or external compression of the vein proximal to the position of the transducer. (Study Guide)

13. (D) Phlegmasia cerulea dolens produces a clinical pattern of tight leg edema, severe pain, and cyanotic mottled skin when extensive iliofemoral thrombosis occurs. Raynaud’s syndrome is a functional vasospastic disorder affecting the small arteries and arterioles of the extremities. (Study Guide)

14. (A) In patients who have had previous episodes of deep vein thrombosis the vessel walls are thickened not thinned. Post-phlebitic syndrome often leads to chronic induration, stasis dermatitis, and ulcers in later years. Symptoms of this condition appear between 18 months and 10 years after the thrombotic event. (Study Guide)

15. (B) Respiration causes the diaphragm to descend. This increases intra-abdominal pressure, decreasing blood flow from the lower extremities while increasing the flow from the upper part of the body. (Study Guide)

16. (D) CT scan cannot evaluate chronic venous insufficiency. Photoplethysmography, Doppler, ultrasound, descending contrast venography, ascending contrast venography, and ambulatory venous pressure can evaluate chronic venous insufficiency. (Study Guide)

17. (C) Immobility of extremity is not one of the categories of “Virchow’s triad.” Rudolf Virchow was the German pathologist who introduced the theory between 1845 and 1856. There are many risk factors that may increase a patient’s chances of developing thrombosis, but all factors should fit into one of the three categories. (Study Guide)

18. (B) The posterior tibial veins’ distal landmark is the area between the medial malleolus and the Achilles tendon. After identifying the vessels, they can be followed up the medial surface of the calf. The veins are paired, one vein on either side of the posterior tibial artery. (Study Guide)

19. (B) The tunica intima (inner layer) is the thin layer of endothelial cells that contains the venous valves. The valves consist of two leaflets that maintain the blood flow in one direction, toward the heart. (Study Guide)

20. (B) The filter is placed in the inferior vena cava (via the jugular or femoral approach) to prevent the upward extension of clot to the lung. The Greenfield filter consists of a small cone-shaped filter that is placed usually below the levels of the renal veins in the IVC. (Study Guide)

21. (D) As soon as the subclavian vein branch of the cephalic vein, its name change to the axillary vein. This happens at the outer border of the first rib. Usually, only one valve is found in the axillary vein. (Study Guide)

22. (C) The gastrocnemius plexus empties into the popliteal vein. The soleus plexus veins empty into the posterior tibial vein. (Study Guide)

23. (C) The right atrium pressure is normally 0 mm Hg and is termed central venous pressure. When it measures 0 mm Hg, the blood flows from the systemic veins into the right atrium. (Study Guide)

24. (C) Varicose veins cannot compromise the flow of a vessel by external compression. Baker’s cyst, tumors, or hematomas often produce external compression that can compromise the flow. (Study Guide)

25. (E) Vein characteristics include phasicity, spontaneity, compressibility, and augmentation. They do not have a continuous signal without respiratory motion; this is characteristic of collateral venous flow. (Study Guide)

26. (A) There are no valves in the innominate veins. Valves are present in the external and internal jugular veins, axillary veins, and the subclavian vein. (Study Guide)

27. (A) The superficial veins of the lower extremities lie within 1–2 cm of the skin surface within the subcutaneous fat. The system consists of dorsal venous arch, marginal veins, and lesser and greater saphenous veins. (Study Guide)

28. (B) The Brescia–Cimino fistula is created surgically between the cephalic vein and the radial artery at the wrist. It has a 3-year patency rate of 80–90%, and is the most durable dialysis access. It requires 3 to 6 weeks to mature. (Study Guide)

29. (D) Deep vein thrombosis is occurring more frequently due to the increased use of central venous catheters. (Study Guide)

30. (A) The veins of the lower extremity flow from the superficial veins through the perforators(communicating veins) to the deep veins. Valves maintain the flow in one direction. Flow in the opposite directions is abnormal. (Study Guide)

31. (B) The anterior tibial vein is a continuation of the dorsalis pedis and lies between the tibial and fibula, located in the anterior compartment just on top of the interosseous membrane. In the upper part of the calf, they join the popliteal vein. (Study Guide)

32. (C) Outflow vein stenosis. (Study Guide)

33. (C) Sclerotherapy is the injection of a sclerosing agent into the superficial veins to damage the endothelium and cause thrombosis which organizes and closes the veins. (Study Guide)

34. (B) Surgery. Some of the causes of chronic venous insufficiency are varicose veins, chronic recurrent thrombosis, and post-thrombotic syndrome. Venous stasis, the result of the failure of the venous pump mechanism, reflects chronic venous insufficiency. (Study Guide)

35. (D) Compression of the vein with the transducer probe is a maneuver used to confirm patency and rule out the presence of clot. It is not the maneuver used for augmentation. Distal compression, Valsalva, or cough maneuvers are the methods for augmenting the veins. (Study Guide)

36. (B) Venous thrombus or clot obstructs the draining vein and creates a filling defect on the venogram. (Study Guide)

37. (A) Chronic thrombus is not compressible to any extent. (Study Guide)

38. (A) Absence of leg pain. Venous stasis is characterized by chronic swelling of the leg, malleolar ulceration, cutaneous hyperpigmentation, varicose veins, and leg pain. Venous stasis leads to chronic venous insufficiency. (Study Guide)

39. (C) Small not large arteriovenous fistulas have been suggested as a possible contributing factor to primary varicose veins. Other factors are abnormal wall weakness, increased distending force, and multiple arteriovenous fistulas. Primary varicose veins are associated with venous valvular incompetency. (Study Guide)

40. (A) Ascending venography cannot assess the function of the proximal valves in the lower extremity. Only descending venography can offer that capability. Ascending venograph can offer the location of incompetent perforators; localize recanalized channels indicating previous thrombophlebitis and the absence or presence of varicosities. (Study Guide)

41. (B) Varicose veins with competent deep vein valves and incompetent superficial veins are termed primary varicose veins. Veins with both incompetent superficial and deep vein valves are termed secondary varicose veins. (Study Guide)

42. (B) The posterior tibial veins arise from and drain the plantar venous arch and superficial venous net of the foot. They also receive the peroneal veins farther up the calf. (Study Guide)

43. (D) The subclavian vein receives both the superficial and deep venous system of the upper extremity. An occlusion of this vein blocks both these major systems. Acute pain, swelling, and edema of the entire upper extremity can occur. (Study Guide)

44. (A) The feet contain 60–80% smooth muscle. Veins consist largely of smooth muscle and have relatively little elastin. (Study Guide)

45. (B) The dorsal digital and plantar veins unite to form the dorsal metatarsal veins that join to form the superficial dorsal venous arch. The plantar cutaneous arch eventually drains into the greater and lesser saphenous veins. (Study Guide)

46. (C) Normally, there are more than 100 communicating veins located throughout most limbs. They are mainly <2 mm in diameter and are usually described in groups. (Study Guide)

47. (D) The hydrostatic indifferent point (HIP) is just below the diaphragm. It is the only point that remains constant. (Study Guide)

48. (C) Generally about 5 days after the thrombus fills the vein, it will start to contract. The next step is recanalization. Valves within the thrombus are usually destroyed. (Study Guide)

49. (C) The significant causes for DVT are multiple: Surgery, oral contraceptive pills, smoking, prolonged bed rest, pregnancy and obesity. Diabetes is not among the most significant risk factor for DVT. (Study Guide)

50. (A) The soleal sinusoids are the most common site to develop a DVT according to recent studies. DVTs can originate any place with the venous system. (Study Guide)

51. (A) The plantar cutaneous arch empties into the great and short saphenous veins. The superficial dorsal venous arch also ends up at the great and short saphenous veins. (Study Guide)

52. (B) The descending venography offers the ability of assessing valvular functions. It directly visualizes the venous valves. (Study Guide)

53. (C) The renal system does not go through the portal vein. The spleen, stomach, pancreas, gallbladder, and intestines do send their blood to the liver by way of the portal vein. (Study Guide)

54. (A) The inherent semilunar venous valves are found in the tunica intima; the innermost lining of the vein. (Study Guide)

55. (D) The left ovarian vein drains into the left renal vein. The right empties directly into the inferior vena cava. (Study Guide)

56. (C) Valves are competent if they do not allow reversal of flow. The valves ensure flow in the forward direction toward the heart. (Study Guide)

57. (A) Popliteal vein (Study Guide)

58. (B) Great saphenous vein (Study Guide)

59. (C) Femoral vein (Study Guide)

60. (F) Profunda (deep) femoral vein (Study Guide)

61. (E) Internal iliac vein (Study Guide)

62. (H) Common femoral vein (Study Guide)

63. (D) Distal inferior vena cava (Study Guide)

64. (G) External iliac vein (Study Guide)

65. (H) Great saphenous vein (Study Guide)

66. (F) Peroneal veins (Study Guide)

67. (D) Plantar digital veins (Study Guide)

68. (G) Popliteal vein (Study Guide)

69. (E) Plantar metatarsal veins (Study Guide)

70. (B) Posterior tibial veins (Study Guide)

71. (A) Anterior tibial veins (Study Guide)

72. (C) Soleal vein (Study Guide)

73. (D) Posterior enhancement (Study Guide)

74. (B) common femoral vein (Study Guide)

75. (A) Great saphenous vein (Study Guide)

76. (C) Femoral vein (Study Guide)

77. (B) Thrombosed common femoral vein (Study Guide)

78. (C) Normal response to distal compression (Study Guide)

79. (A) Normal phasic flow (Study Guide)

80. (D) The splenic vein and the superior mesenteric vein posterior to the neck of the pancreas to form the portal vein. The main portal vein courses toward the right, superiorly, and anteriorly. (Study Guide)

81. (M) Ulna vein (Study Guide)

82. (J) Left subclavian vein (Study Guide)

83. (G) Vertebral vein (Study Guide)

84. (D) Cephalic vein (Study Guide)

85. (H) External jugular vein (Study Guide)

86. (C) Axillary vein (Study Guide)

87. (N) Basilic vein (Study Guide)

88. (E) Radial vein (Study Guide)

89. (H) Internal jugular vein (Study Guide)

90. (B) Brachiocephalic vein (Study Guide)

91. (L) Brachial vein (Study Guide)

92. (F) Inferior thyroid vein (Study Guide)

93. (A) Right subclavian vein (Study Guide)

94. (K) Internal thoracic vein (Study Guide)

95. (D) About 80% of patients with deep vein thrombosis will be likely to develop venous insufficiency in the next 5–10 years. The incidence of serious venous problems is increasing in the United States according to recent studies. (Study Guide)

96. (B) Baker’s cyst is a pathological condition that can mimic a deep vein thrombosis. It can also be easily demonstrated by ultrasound, along with the patency of the deep veins. (Study Guide)

97. (B) An opened valve (Study Guide)

98. (B) Incompressibility of a vein segment (Study Guide)

99. (A) Normal respiratory movement. It is phasic with respiration and controlled by intra-abdominal pressure. (Study Guide)

100. (C) Fig. 13–41 is a gray-scale image of the common femoral vein at the saphenous-femoral junction, with an arrow pointing to open valves at the junction. The margins of the valves are positioned in the direction of blood flow, and lie flat against the wall as long as the flow is going toward the heart. The valves close when the flow reverses. (Study Guide)

101. (D) The spectral analysis of the portal vein in Fig. 13–42 show normal respiratory movements and blood flow toward the liver. This is called hepatopetal flow. (Study Guide)

102. (A) The image in Fig. 13–43 is of the common femoral vein with a Doppler waveform demonstrating normal augmentation distal to the transducer. Squeezing the distal portion of the extremity forces the flow of the blood to increase at a rapid speed. (Study Guide)

103. (A) Augmentation demonstrating reflux (Study Guide)

104. (D) Fig. 13–45 is an image of a sapheno-femoral junction. (Study Guide)

105. (B) Fig. 13–46 pictures occlusion of the great saphenous vein. (Study Guide)

106. (C) Deep vein thrombosis results in the post-phlebitic syndrome and venous incompetency. The venous valves are destroyed with deep vein thrombosis leading to venous incompetency. In later years, there will be chronic induration, stasis, dermatitis, and ulceration associated with venous incompetency. (Study Guide)

107. (C) Fig. 13–47 represents thrombus in the proximal great saphenous vein.

108. (C) Fig. 13–48 represents multiple veins in the calf (posterior tibial and peroneal veins)

109. (D) Fig. 13–49 shows retrograde internal jugular vein flow.

110. (B) Fig. 13–50 shows occluded, varicose superficial vein.

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