I want to thank all our speakers for really phenomenal talks. Um really appreciate all the knowledge you gave us today. I'm gonna invite dr hearth up so that we can do our mock RPV eye exam and um I'm just gonna go ahead and get started with a question um and anybody can feel free to blurt out an answer. Um So what is suggested by this image? Is it a stenosis of a vertebral artery, a retrograde vertebral artery, stenosis of a subclavian artery or a complete subclavian steal. So you probably saw this waveform earlier today? Maybe not this exact picture. What's going on with that vertebra? Shall we vote? Go ahead. Yeah. Okay. Yeah. So what do we see there? We see that bunny rabbit sign so that um systolic retraction that's consistent with a pre steel wave form. Um So uh hemo dynamically significant stenosis of the subclavian artery. You wanna take that 1? Oh you can't see him. I'm gonna I'll just read it. So we're too short for the podium. What's suggested by this image? So is this a a mirror image artifact, be a more distal occlusion CIA stenosis or D. A dissection here in the common carotid artery at mid, I heard B. D. I heard D. I heard d correctly, sorry I'm losing my hearing too much loud rock music. Yeah so a dissection. So we see those two flow channels. Why is it not a mirror image artifact? Exactly. So you'd probably see the same direction also. This is not a place where there's a strong reflector. Unlike in the subclavian um more distal occlusion. It is a high resistive waveform. But the key is those two flow channels. Alright so uh what do we see in this image? Um so we have an I. c. a velocity of 46.9 cm/s. So is this 0-49% stenosis? 50-69%,, 70-99%. Or is this a string sign? Think we need more caffeine. B. I. So what I did I hear B. D. D. I. Can't D. As in dog. Right string sign. Okay. A nearer occlusion. Exactly. So we've fallen off our spencer. Reid curve here. Our velocities have gone way down because we have such a tight critical stenosis. You wanna do some questions? All right. Okay so this is the first image you see on a dialysis access study. And so what does it suggest? As we just heard dr Wong described a normal fistula. Be a V. Fistula. Steel C. Occluded fistula or D. Pseudo aneurysm. But this is at the mid breaking artery before and access. What would you expect to see? So this is a really normal looking artery I heard C. Over here. Okay so this is an occluded fistula suggestive of an included fish. So this looks like a high resistive regular arterial duplex. For an arm without an access what you'd expect to see in an open fistula is a low resistive persistent and diastolic flow because of that low resistant bed. Um So that's why it is not a normal fistula as the answer. So the answer is C. So this way form is seen throughout the bilateral carotid systems. What is suggested? What is the suggested diagnosis And nominate stenosis? Aortic insufficiency, aortic stenosis or normal artery? This is the right mid common carotid artery. See by her charlie. C. As in charlie. He isn't charlie is what I heard B. B. As in boy. Alright. We have A. B. And we have A. C. And the answer is B. So there's a little bit of reversal of flow. See if you could see um consistent with the presence of an aortic insufficiency, What is the most likely diagnosis based on this image? This is the left right. Common core auditory. So is it aortic stenosis? A left. I see A Occlusion. Right. I see occlusion, oreo, arctic insufficiency. And if you can't see that? That is the right common carotid. What's the wave form look like? It's high resistive. So we have a C. Correct. So this is as dr. Gornick showed us earlier an example where you have an occlusion distantly of the I. C. And you lose that low resistive bed giving you this particular waveform. If we had a left. I see a occlusion. No I'm not going to ask that question. Watch it, Do it. Alright. Some basic math as dr leers educated us on earlier. How is the A. B. I calculated on this patient the options as listed A. Three D. Which is the right one Or the correct one. So what is it not? Which number combination is accurate? So just a reminder. So this is definitely going to be on your exam. We calculate the A. B. I. By taking the higher of the two break. He'll pressures and then the higher and we use that throughout and then the higher ankle pressure on each side. So we can eliminate A. And D. We're talking correct. It's just looking at the numbers and assuring that you've used the higher of the two break yields as part of the A. B. Calculation and we could have been more clear by saying how the left A. B. I calculated on this patient. Okay what is the interpretation of this? PVR I'll let you take a look for a minute here. So options are normal on the right. Non compressible on the right bilateral distal pop disease. Distal aortic or bilateral iliac disease or un interpreter. You have the pressure. Is there non compressibility and A. B. I. As best as you've been given charlie don't have highway form. Bye. Right. Right exactly. So we can look at this and we see so if you look at the right side there's a normal A. B. I. But when we look at the wave forms they're very clearly abnormal. So we've ruled out a uh it is interpreted ble. Um And so of the two remaining choices. Disloyal arctic or bilateral iliac disease would fit best based on those highest the high thigh wave forms. What is the interpretation of this PVR? Is there a horrific disease? Bilateral femoral disease left this philosophy pop little disease or no significant change in pressure or A. B. I. After exercise. You can kind of eliminate some see you here, see. Okay correct. So so if you look at the the right side, you have all the way down to the metatarsal. Have a nice day, chronic notch, brisk upstroke. Very normal. Looking away forms of the normal A. B. I. On the left side. You have a pressure gradient drop across the levels consistent with S. F. A. Pop Little disease and a bit of blunting and the loss of that democratic notch at the ankles with the rust. So what is shown in these images? Is it a median rQ? It ligament syndrome? Be a non fasting patient, De fibra muscular dysplasia or d superior mesen terek artery stenosis And velocities. If you cannot see them peak systolic velocity of 339 on the left and 143 on the right. With a maneuver. It's A. So this is median RQ. At ligament syndrome. Alright, what is the interpretation of this PVR? Is it normal? A. B. I. S. And a patient with severe aortic insufficiency be normal. A. B. Is with more proximal disease. See normal A. B. I. S. In a patient with an intra aortic balloon pump or d. Not enough information. I'm looking at the lab techs because I know they do these studies go for it. It's C. Right. So it's important to this patient has a normal A. B. I. Um And you'll see these a lot in pre op patients. Um And so we need to be able to recognize um when someone has an intra aortic balloon pump it will have an augmented wave. Um You'll also see that a lot of times on characters that have some implications for how we diagnose carotid stenosis. What is shown in these images? Is it a 0 to 49% stenosis? B 50 to 69%. C. 70 to 99% or D. A. String sign six. I think I heard B. And C. So by current criteria. So we have a approximate I. C. F. 3 31 with an end diastolic velocity of 1 37. So we are We are firmly in the 70-99% stenosis category. And also the I. C. A two CC. A ratio is way more than four. So what is suggested by this image is this a normal celiac artery? Is this a 70-99% celiac artery stenosis. Is this a non fasting patient or do we need more information? Mhm. Peak systolic velocity of 336. We have a little bit of diastolic flow. We're in the celiac artery D. D. I heard. Need more information. Right? So we can't diagnosis celiac artery stenosis without those conspiratorial maneuvers. Because this could be um esoteric artery ligament syndrome. Uh Sorry median rQ. It ligaments syndrome. So we have a lot of abdominal questions. What is suggested by this image? Is this a median RQ It ligament syndrome? Be a non fasting patients? The fibrosis, killer dysplasia or d superior mesen terek artery stenosis, B. B. B. As in bravo. The non fasting art of patients. All right. We should be looking for a high resistive waveform in the S. M. A. Um in a fasted patient. And so we see some diastolic flow. So this is probably somebody who had breakfast. What is suggested by this image? Is it a a popular till artery occlusion. Be common femoral artery, critical stenosis. See a normal common femoral artery? Or D. A common femoral artery dissection. So is this is there um is there a pop little artery occlusion? How would we know that or moving through our other choices? Is this a common femoral artery? Critical stenosis. So what makes you say that? Okay thank you. So there's not. Maybe not a great picture. There's probably disease in multiple parts of this limb. Um I think the issue here is that we're getting toward that kind of blunted um Pre exclusive waveform in the distal common femoral artery. Yes we we looked at this question. It's not a great not a great question. Not a great question because you still have a fund in sf a open. So not a great question. We're gonna kind of move along. You want to take this one. Um So what is suggested by this image? It's the right vertebral Velocities are 1 27. And so is there a stenosis of the proximal right vertebral artery stenosis of the distal right vertebral artery? Retrograde flow on the right vert or are normal right vertebral artery. This is about interpreting the waveform. Want to give it a stab at interpreting. So what does the upstroke look like anybody? Very sharp. Sharp, Good. Okay. What is the outflow look like? Low but not throughout. Okay. So of the choices. What is that most consistent with? Interestingly though, it also has that mid systolic retraction. And so you have to wonder what's going on in the subclavian as well. But we didn't get it's hard to it's hard to have get your rabbits on this. No cardiac. Exactly. Um I think it's important. So on the R. P. V. I. Um I think the questions are less ambiguous. Um The real world a lot of times people have disease in multiple places. So you may see tandem lesions, you may see people with um uh you know, multiple things going on. I think so. Um It is 11 55. We have um promised to stop at noon. Um We have a big bank of questions and I think if it's okay with our cmi folks we will provide those in pdf format to anyone who wants them who's studying for the R. P. V. I. Um I want to thank everybody for attending today and for all of the wonderful um speakers and uh who we had um giving us just phenomenal pearls about interpretation. Um and I just really appreciate everybody coming and I hope you'll give everyone a round of applause and then um I'll remind our vascular lab folks um we're gonna be sticking around at noon um for lunch in to do some quality improvement and and other items. One quick thing about the upcoming Q. I. For the vascular lab members, it's gonna start at noon and we have till 1 30 so we'll grab lunch and start Kind of chatting during lunch so we can keep to the time we have here and it'll adjourn promptly at 1:30. Um I think it's in here. Thank you very much.