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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5775_Библиотеки_им_академика_М_И_Перельмана

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A.Tricuspidregurgitation B.Metastaticinfiltration C.Rightheartfailure D.Portalveinthrombosis
46. Patient A andpatient Bhavethesamelastnames. Patient A wasscheduledfor inferior venacava
filter placement, and patient B was scheduled for transjugular liver biopsy on the same day. The radiologist inadvertently performed the transjugular liver biopsy on patient A. Who is the potential “secondvictim”inthisscenario?
A.PatientA B.Radiologist C.Radiologyinformationsystem D.Ultrasounddepartment
47.Whenhealthcareprofessionalsareawarethattheyarebeingobserved,theyaresignificantlymore
likelytocomplywithhandhygieneguidelines.Thisisanexampleofwhichofthefollowing?
A.Webereffect
B.Hawthorneeffect C.Placeboeffect D.Pygmalioneffect
48.Whichofthefollowingistheprimarydeterminingfactorforgradingcarotidarterystenosis?
A.Internalcarotidartery/commoncarotidarterypeaksystolicvelocity(ICA/CCAPSV)ratio B.Peaksystolicvelocity(PSV) C.Presenceofcalcifiedplaque D.Locationofstenosis
49a.WhatdegreeofICAstenosisisdepictedintheimages?
A.Completeocclusion B.<50% C.50%to69% D.≥70%
49b.Whichvelocityparameterscanbeusedtodiagnosenear-completeocclusionoftheinternalcarotid
artery(ICA)?
A.Peaksystolicvelocity(PSV)>230cm/s B.Peaksystolicvelocity(PSV)<100cm/s C.End-diastolicvelocity(EDV)>100cm/s D.Noneoftheabove
50.Whichofthefollowingcanbecharacterizedasanormalinternalcarotidartery?
A.Peaksystolicvelocity<100cm/swithorwithoutintimalthickeningorvisibleplaque B.Peaksystolicvelocity>80cm/swithoutintimalthickeningorvisibleplaque C.Peaksystolicvelocity<125cm/swithoutintimalthickeningorvisibleplaque D.Peaksystolicvelocity>230cm/swithoutintimalthickeningorvisibleplaque
51a. A65-year-old womanpresents withatransientepisodeofdysarthriaand ataxia.A carotid artery
DuplexUSwasperformed.Theimagesshow:
A.Flowreversalinthevertebralartery B.Internalcarotidarteryocclusion C.Contralateralvertebralarteryocclusion D.Rupturedatheroscleroticplaque
51b.Thepatient’ssymptomsresolveduponarrivingtotheemergencydepartment.Whichmaneuversmay
reelicitthepatient’ssymptoms?
A.Neckflexion B.Neckextension C.Armexercise D.Valsalvamaneuver
52a.WhichspectralDopplerwaveformcharacteristicisdemonstrated?
A.Lossofrespiratoryphasicity B.Lossofaugmentation C.Flowreversal D.Decreasedflowvelocity
52b.  Augmentation during a lower extremity venous examination consists of observing the spectral
Dopplerwaveformwhilecompressingthe:
A.Ipsilateralextremitydistaltothetransducer B.Ipsilateralextremityproximaltothetransducer C.Contralateralextremityatthesamelevelasthetransducer D.Lowerabdomen
52c.Whattypeofvenouswaveformisdepicted?
A.Augmentation B.Monophasic C.Reversed D.Respiratoryphasicity
53a.  A 25-year-old female presents to the emergency department with left lower extremity pain and
swelling.Aperipheralvenousultrasoundwasperformed.Whatisthemostlikelydiagnosis?
A.Deepvenousthrombosis(DVT) B.Inguinallymphadenopathy C.Varicoseveins D.Pseudoaneurysm E.Abscess
53b.Whatimagingfeaturefavorsanacuteversuschronicdeepvenousthrombosis(DVT)?
A.Noncompressibility B.Nocolorflow C.Vesselexpansion D.Hyperechoicthrombus
54.WhatdothecolorDopplerimagesdemonstrateatthelevelofthestenosis?
A.Aliasing B.Flowreversal C.Decreasedflow D.“Twinkle”artifact
AnswersandExplanations
1.AnswerC.Aftertransplantation,thenormalrangeofresistiveindices(RIs)is0.55to0.80.However,
approximatelyhalfofpatientshaveelevatedRIsintheimmediatepostoperativeperiod;theRIstypically normalize within 72 hours. Alternatively, RIs can be transiently low in the immediate postoperative period because of anastomotic edema or hypotension in some patients; persistently low RIs suggest arterialstenosis.
References: Platt JF, et al. Use of Doppler sonography for revealing hepatic artery stenosis in liver transplant recipients. AJR Am J Roentgenol1997;168(2):473–476.
Sanyal R, et al. Orthotopic liver transplantation: reversible Doppler US findings in the immediate post-operative period. RadioGraphics 2012;32:199–211.
2.  Answer C.  Normal diastolic flow is antegrade (above the baseline). The figure shows reversed
diastolic flow (below the baseline), indicating substantially increased vascular resistance in this dysfunctionalrenal transplant.Reversed diastolic flowis animportantbut nonspecific finding in renal transplant patients; differential considerations include external compression of the allograft (e.g., hematoma), renal vein thrombosis, rejection, glomerulosclerosis, and acute tubular necrosis. Although renal vein thrombosis (answer choice A), external compression (answer choice B), and acute tubular necrosis(answerchoiceD)canbeseenintheacuteandsubacutesettings,rejectionisthemostcommon long-termcauseofreverseddiastolicflowinrenaltransplantpatients.
References:BaxterGM.Ultrasoundofrenaltransplantation.ClinRadiol2001;56:802–818.
LockhartME,etal.Reverseddiastolicflowintherenaltransplant:perioperativeimplicationsversustransplantsolderthan1month.AJR AmJ Roentgenol2008;190:650–655.
3.AnswerB.PSV−EDV/PSV.
References:PolakJ,PelleritoJF.Introductiontovascularultrasonography:expertconsult—onlineandprint,6thed.London:Saunders,
2012.ISBN:143771417X.
TublinME,etal.TheresistiveindexinrenalDopplersonography:wheredowestand?AJRAmJRoentgenol2003;180(4):885–892.
4.  Answer C.  Pseudoaneurysm formation is an uncommon complication of orthotopic liver
transplantation but mostcommonlyoccurs at thesite of arterial anastomosis. Pseudoaneurysms in this location can be due to surgical technique, mycotic etiologies, or as a consequence of angioplasty. Pseudoaneurysmsofthemoreperipheral,intrahepaticbranchesofthehepaticarteriesmaydevelopasa consequenceoffocalinfectionorliverbiopsy.
References:BhargavaP.Imagingoforthotopiclivertransplantation.AJRAmJRoentgenol2011;196:WS15–WS25.
CaiadoA,etal.Complicationsoflivertransplantation:multimodalityimagingapproach.RadioGraphics2007;27:1401–1417.
5.AnswerC.TheUSimageshowsheterogeneousperiportalfluidcollections,whereas theCTimage
showsbiliarynecrosismanifestedasperiportalhypoattenuation.
Inthelivertransplantpatient,thehepaticarteryisthesolebloodsupplytothebiliaryepithelium.In thesettingofhepaticarterythrombosis,thebiliaryepitheliumbecomesnecroticandresultsinsloughing ofcellsanddebrisintodilatedbileducts.Venousthrombosis (hepaticveins,portalveins,or IVC) may leadtoareasofinfarctionandalteredenhancement,butdoesnotleadtobiliarynecrosis.Additionally,the portalveinsandIVCareshowntobepatentinthefigure.
References:BhargavaP.Imagingoforthotopiclivertransplantation.AJRAmJRoentgenol2011;196:WS15–WS25.
ItriJN,etal.Hepatictransplantation:post-operativecomplications.AbdomImaging2013;38:1300–1333.
6.AnswerB.Hepaticarterythrombosisisthemostcommonvascularcomplicationaffectingorthotopic
livertransplantandhasbeenreportedtooccurinupto12%ofcases.Theonsetisvariableandcanoccur fromdaystomonthsfollowingthetransplantsurgery.
References:BhargavaP.Imagingoforthotopiclivertransplantation.AJRAmJRoentgenol2011;196:WS15–WS25.
SinghA,etal.Post-operativeimaginginlivertransplantation:whatradiologistsshouldknow.RadioGraphics2010;30:339–351.
7.  AnswerC.  Suboptimal hepatic venous outflow leads to distension of the hepatic veins and IVC,
hepatomegaly, ascites, and pleural effusions. Vena caval or hepatic venous anastomotic stenosis can occasionallybeshownatgray-scaleimagingbutismorecommonlydetectedoncolorDopplerevaluation asafocusofaliasing.SpectralDopplerwillalsoshowaliasingbecauseoftheincreasedvelocitiesatthe siteofstenosisandbluntingoftheupstreamhepaticvenouswaveforms.AnswerchoicesA,B,andDare alsocomplicationsoflivertransplantation,butwouldnotpresentwiththeimagingfindingslistedinthe questionstem.
References:BhargavaP.Imagingoforthotopiclivertransplantation.AJRAmJRoentgenol2011;196:WS15–WS25.
ItriJN,etal.Hepatictransplantation:post-operativecomplications.AbdomImaging2013;38:1300–1333.
8.  Answer A.  Spectral Doppler evaluation demonstrates focal color aliasing at the renal transplant
superior polebiopsysite.Thereis a high-velocity, low-impedance waveform with increased diastolic flow because of an arteriovenous fistula. The majority of arteriovenous fistulas are small, clinically insignificant,andresolvespontaneously.Therefore,short-termfollow-upcanbeperformedtoassessfor resolution.Coil embolization (answerchoiceC) andsurgical repair(answer choiceD)are requiredin onlyaminorityofcases.
References: ElsayesKM, Menias CO,Willatt J, et al. Imaging of renaltransplant: utilityand spectrum of diagnostic findings. Curr Probl DiagnRadiol2011;40(3):127–139.
RajiahP,LimYY,TaylorP.Renaltransplantimagingandcomplications.AbdomImaging2006;31(6):735–746.
9.AnswerA.Theintrarenalsegmentalarterialwaveformshowsaroundedappearanceofthesystolic
peak, consistent with a tardus–parvus pattern. The tardus–parvus pattern gets its name because the systolicpeakisdelayed(accelerationtime>0.08s)andthepeakvelocityisreduced.
A pseudoaneurysm (answer choice B) is characterized by disorganized spectral flow in its neck duringwhichhigh-velocityflowisshownaboveandbelowthebaseline(“to-and-fro”appearance).The spectral waveform of an arteriovenous fistula (answer choice C) is characterized bya low-resistance patternbecauseofhighsystolicvelocityandhighdiastolicvelocityfromtheabnormalshuntingbetween an artery and vein. The spectral waveform of the renal artery in the setting of renal vein thrombosis (answerchoiceD)ischaracterizedbyahigh-resistancepatternbecauseofreversalofdiastolicflow.
References:GranataA,etal.Renaltransplantvascularcomplications:theroleofDopplerultrasound.JUltrasound2014;18(2):101–107.
RodgersSK.Ultrasonographicevaluationoftherenaltransplant.RadiolClinNorthAm2014;52(6):1307–1324.
10.AnswerA.Inordertodetectslowflow,filtersettingsshouldbekeptatthelowestpossiblesetting
(generallyinthe50to100Hzrange).Reducingthewallfiltersettingresultsinfilling-inofthespectral datatowardthebaseline.Inpatientswithslowflow,ahigh-wallfiltersettingmayobscurelow-velocity bloodandleadtoanerroneousinterpretationofvesselocclusion.ThePRFindicatestherate(frequency) at which data are sampled. This variable is directly related to the velocity range (or scale) because higher-flowvelocitiesrequiremorerapidsamplingandalargerscale.IfthePRFissettoohigh,slower moving blood is difficult toappreciate and may be obscured. When the PRF is reduced, the range of depictedvelocitiesisreducedandslowerflowcanbeappreciatedqualitativelyandquantitatively.
References:BooteEJ.DopplerUStechniques:conceptsofbloodflowdetectionandflowdynamics.RadioGraphics2003;23:1315–1327.
KruskalJB,etal.OptimizingDopplerandcolorflowUS:applicationtohepaticsonography.RadioGraphics2004;24:656–675.
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