CCI - Cardiovascular Credentialing International Peripheral Arterial Evaluation Questions and Answers — Questions and Answers
Question 1: A 68-year-old male complains of pain in his left calf after walking two blocks, which is relieved by rest. His right brachial pressure is 140 mmHg and his left is 136 mmHg. Ankle pressures are 126 mmHg on the right and 82 mmHg on the left. What is the correct interpretation of his left Ankle-Brachial Index (ABI)?
- Normal
- Mild arterial disease
- Severe arterial disease (rest pain)
- Moderate arterial disease (claudication) (Correct answer)
Correct answer: Moderate arterial disease (claudication)
The ABI is calculated by dividing the ankle systolic pressure by the highest of the two brachial systolic pressures. In this case, Left ABI = 82 mmHg (left ankle) / 140 mmHg (highest brachial) = 0.58. An ABI value between 0.41 and 0.90 is indicative of mild-to-moderate peripheral arterial disease, which is consistent with the patient's symptoms of claudication.
Question 2: While performing a lower extremity arterial duplex exam, the technologist obtains a triphasic Doppler waveform in the common femoral artery. Distally, in the popliteal artery, the waveform is monophasic with a delayed systolic upstroke. What does this change in waveform most likely indicate?
- An arteriovenous fistula
- A hemodynamically significant stenosis between the two sample sites (Correct answer)
- Normal distal vasodilation after exercise
- A pseudoaneurysm in the distal SFA
Correct answer: A hemodynamically significant stenosis between the two sample sites
A normal, high-resistance peripheral artery will exhibit a triphasic or biphasic waveform. A hemodynamically significant stenosis will dampen the flow distal to the lesion, causing a loss of the reverse flow component and a delayed systolic peak. This results in a monophasic, 'tardus parvus' waveform, which is indicative of significant proximal disease.
Question 3: A duplex ultrasound of the superficial femoral artery (SFA) reveals an area of plaque with spectral broadening and elevated velocities. The peak systolic velocity (PSV) within the stenosis is 250 cm/s. The PSV in the SFA segment just proximal to the stenosis is 100 cm/s. Based on the velocity ratio, how would this stenosis be graded?
- Normal; <50% stenosis
- Severe; >75% stenosis
- Moderate; 50-74% stenosis (Correct answer)
- Mild; <50% stenosis
Correct answer: Moderate; 50-74% stenosis
The velocity ratio (VR) is calculated as PSV at stenosis / PSV proximal to stenosis. Here, VR = 250 cm/s / 100 cm/s = 2.5. A velocity ratio of 2.0 or greater (specifically a range of approximately 2.0-4.0) is a widely accepted criterion for a hemodynamically significant stenosis of 50% or greater. A ratio of 2.5 falls into the moderate, or 50-74%, stenosis category.
Question 4: Which of the following findings on a Pulse Volume Recording (PVR) is most consistent with hemodynamically significant arterial disease at or proximal to the level of the tracing?
- A sharp systolic peak with a prominent dicrotic notch
- A delayed upstroke, rounded peak, and loss of the dicrotic notch (Correct answer)
- An abnormally increased amplitude compared to the adjacent segment
- A rapid systolic upstroke with a brisk downstroke
Correct answer: A delayed upstroke, rounded peak, and loss of the dicrotic notch
A normal PVR waveform has a sharp systolic upstroke and a prominent dicrotic notch on the downstroke. Significant proximal occlusive disease dampens the pressure wave, resulting in a delayed systolic upstroke, a rounded or flattened peak, and a complete loss of the dicrotic notch. The amplitude of the waveform is also typically reduced.
Question 5: A 55-year-old male patient presents with bilateral buttock and thigh claudication and erectile dysfunction. Physical examination reveals absent femoral pulses. These findings are most suggestive of occlusive disease in which arterial segment?
- Popliteal arteries
- Superficial femoral arteries
- Aortoiliac segment (Correct answer)
- Tibioperoneal trunk
Correct answer: Aortoiliac segment
The combination of bilateral buttock/thigh claudication, absent femoral pulses, and erectile dysfunction is the classic triad for Leriche syndrome, which is caused by severe stenosis or occlusion of the aortoiliac segment. The location of claudication symptoms typically points to occlusive disease at or proximal to that level.
Question 6: A patient with suspected peripheral arterial disease is unable to perform a treadmill exercise test due to poor ambulatory status. Which alternative physiologic test can be used to induce peripheral vasodilation and assess for significant arterial disease?
- Allen's Test
- Thoracic Outlet Maneuver
- Post-Occlusive Reactive Hyperemia (PORH) (Correct answer)
- Adson's Maneuver
Correct answer: Post-Occlusive Reactive Hyperemia (PORH)
Post-Occlusive Reactive Hyperemia (PORH) is a technique used to create vasodilation when exercise is not possible. Pneumatic cuffs are inflated on the limbs to a suprasystolic pressure for 3-5 minutes, inducing ischemia. Upon release, a normal response is a brief, transient drop in ankle pressure followed by a quick return to baseline. A significant drop that is slow to recover indicates occlusive disease.
CCI - Cardiovascular Credentialing International Peripheral Arterial Evaluation Questions and Answers
A 68-year-old male complains of pain in his left calf after walking two blocks, which is relieved by rest.
His right brachial pressure is 140 mmHg and his left is 136 mmHg.
Ankle pressures are 126 mmHg on the right and 82 mmHg on the left.
What is the correct interpretation of his left Ankle-Brachial Index (ABI)?