The following is a content outline for each examination administered by the AAVR for the RVMS Certification Program. The percentage ranges that are shown are an indication of approximately how many questions on the exam may be included from that section of the outline.

The AAVR does not endorse any specific source of information for education programs, nor does it sponsor or endorse any registry review course. No attempt is made to list literature references because of the multiplicity of such information and to avoid the implication that listed works are in any way used as a basis for the examination.

- Sonography Principles and Instrumentation
- Abdomen
- Echocardiography
- Cardiovascular Principles
- Neurosonology
- Ultrasound Physics/ Instrumentation
- Vascular Principles/ Instrumentation

I. Patient care, safety and communication [8-12%]
A. Patient identification / documentation
B. Patient interaction
C. Verification of requested examination
D. Emergency situations
E. Universal precautions
F. Bioeffects and ALARA

II. Physics principles [18-22%]
A. Properties of ultrasound waves
B. Interactions of sound with tissue
C. Power, intensity, and amplitude
D. Units of measurement

III. Ultrasound transducers [15-20%]
A. Transducer construction and characteristics
B. Transducer types (sector, linear, phased arrays, etc.)
C. Spatial resolution
D. Transducer selection

IV. Pulse-echo instrumentation [25-30%]
A. Display modes and their formation (A-mode,B-mode, M-mode, 3-D, etc.)
B. Transmission of ultrasound
C. Reception of ultrasound (preprocessing)
D. Beam former
E. Postprocessing of ultrasound signals
F. Pulse-echo imaging artifacts
G. Tissue harmonic imaging
H. Realtime ultrasound instrumentation
I. Recording and storage devices

V. Doppler instrumentation and hemodynamics [15-20%]
A. Doppler effect
B. Factors influencing the magnitude of the Doppler shift frequency
C. Continuous wave and pulsed wave Doppler
D. Doppler PRF, Nyquist limit and aliasing
E. Color flow imaging
F. Power Doppler imaging
G. Duplex Doppler imaging
H. Spectral analysis
I. Doppler artifacts
J. Hemodynamics (laminar and turbulent flow, velocity profiles, energy, etc.)

VI. Quality assurance / quality control of equipment [8-12%]
A. Preventive maintenance
B. Malfunctions Abdomen Outline

I. Liver (16%-24%)
A. Anatomy
B. Technique
C. Laboratory values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Parenchymal disease
     1. Focal and Diffuse abnormalities
     2. Acute and Chronic processes
F. MassesBenign and Malignant
G. Cysts
     1. Simple and Complex      2. Benign and Malignant
H. Infection-Focal and Diffuse abnormalities

II. Gallbladder and Biliary Tree (10%-18%) A. Anatomy
B. Technique
C. Laboratory values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Biliary dilatation
F. MassesBenign and Malignant
G. Cholelithiasis-choledocholithiasis
H. Cholecystitis (Acute and Chronic)

III. Pancreas (6%-14%)
A. Anatomy
B. Technique
C. Laboratory values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Parenchymal disease
     1. Focal and Diffuse abnormalities
     2. Acute and Chronic processes
F. Masses-Benign and Malignant
G. Cysts-Simple and Complex, including Pseudocysts

IV. Kidneys and Urinary Tract (16%-24%)
A. Anatomy
B. Technique
C. Laboratory values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Renal Parenchymal Disease
     1. Focal and Diffuse abnormalities
     2. Chronic and Acute processes
F. Masses-Benign and Malignant, including Pseudomasses
G. Cysts
     1. Simple and complex
     2. Benign and Malignant
H. Infection
I. Calculi
J. Urinary tract obstruction
K. Ischemia
L. Anomalies
M. Kidney Transplants Pre-surgical and Post-surgical evaluation
N. Urinary BladderMasses, Calculi, and Inflammatory processes (including evaluation of the ureters, urethra, and urachal anomalies)

V. Scrotum (3%-7%)
A. Anatomy
B. Technique
C. Laboratory Values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Parenchymal Disease
     1. Focal and Diffuse abnormalities
      2. Chronic and Acute processes, including Testicular Torsion
F. Masses-Benign and Malignant, including Cryptorchidism
G. Cysts and Fluid Collections-Acute and Chronic
H. Infection (Acute and Chronic)

VI. Prostate (1%-2%)
A. Anatomy
B. Technique
C. Laboratory Values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Parenchymal Disease
     1. Diffuse and Focal abnormalities
     2. Acute and Chronic processes
F. Masses
G. Cysts
H. Infection

VII. Spleen (1%-5%)
A. Anatomy
B. Technique
C. Laboratory Values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Parenchymal Disease Focal and Diffuse abnormalities
F. Masses (Benign and Malignant)
G. Cysts
H. Infection
I. Hematoma
J. Infarction

VIII. Retroperitoneum (3%-7%)
A. Anatomy
B. Technique
C. Laboratory Values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Masses and Lymphdenopathy (Benign and Malignant)
F. Hematoma
G. Adrenal Gland
     1. Normal sonographic appearance
     2. Benign and Malignant abnormalities

IX. Abdominal Vascular (7%-15%)
A. Anatomy
B. Technique (including Color Doppler, Power Doppler and duplex Doppler)
C. Laboratory values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Aneurysm
F. Thrombosis (including Portal Vein, Splenic Vein and Renal Vein Thrombosis)
G. Shunts Arteriovenous, Porto-systemic, Surgical and Radiological H. Doppler Spectral Waveform Analysis (including Stenosis, Thrombosis, Portal Hypertension, and Direction of flow)
I. Color Doppler and Power Doppler (including Stenosis, Thrombosis, Portal Hypertension, and Direction of flow)

X. Gastrointestinal Tract (1%-5%)
A. Anatomy
B. Technique
C. Laboratory Values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Infection (including Acute Appendicitis and Abscess)
F. MassesBenign and Malignant
G. ObstructionSmall Bowel and Colon obstruction
H. HerniaI. Peritoneal Fluid (including Inflammatory Fluid Collections)

XI. Neck (1%-3%)
A. Anatomy
B. Technique
C. Laboratory values
D. Indications (including clinical symptoms, clinical correlation and associated complications)
E. Thyroid and parathyroid parenchymal disease
     1. Focal and Diffuse abnormalities
     2. Chronic and Acute processes
F. Thyroid masses (Benign and Malignant)
G. Thyroid cysts
     1. Simple and Complex
     2. Benign and Malignant
H. Parathyroid masses
I. Infection
J. Lymph nodes  (Benign and Malignant)
K. Carotid Artery and Jugular VeinIncluding Sonographic Identification

XII. Abdominal wall, superficial and muscular structures(1%-5%)

A. Anatomy

B. Techniques

C. Laboratory Values

D. Indications (including clinical symptoms, clinical correlation and associated complications)

E. Masses

F. Cysts and Fluid Collections

G. Infection

H. Hematomas

I . Vessels (including Iatrogenic Vascular Injuries)

J. Musculoskeletal (including Normal and Ruptured tendons, such as Patellar and Achilles tendons, and Foreign Bodies)

K. Non-echocardiography Chest (including Pleural and Pericardial Effusions and Masses)

 

 

XIII. Instrumentation (1%-2%)

A. Techniques

B. Transducers

C. Machine settings

D. Image recording

E. Artifacts

F. Quality Assurance

G. Harmonic Imaging

• 1. Physics and clinical applications

 

XIV. Invasive Procedures (1%-2%)

A. Pre-procedure preparation

B. Procedural related issues

C. Indications (including clinical symptoms, clinical correlation and associated complications)

Echocardiography Content Outline

I. Anatomy and Physiology (5%-10%)

 A. Ventricular Wall Segments

B. Nomenclature 

• 1. Subdivisions of ventricles
  
• 2. Valves
  
• 3. Great vessels

C. Coronary Sinus (vs. Descending Aorta)

 D. Coronary Arteries  

E. Normal Pressures (in All Four Cardiac Chambers and Great Vessels)

•  1. Phases of cardiac cycle
  

a. electrical/mechanical systole  

b. filling phases of diastole   

• 2. Timing of events (relative to ECG)

F. Pulmonary Veins  

G. Miscellaneous

 

II. Technique (10%-20%)  

A. Use of Equipment Controls  

B. Recognition of Technical Artifacts  

C. Recognition of Setup Errors  

D. Use of Contrast Agents

 E. Provocative Maneuvers  

F. Best Approach for Doppler Studies  

G. Miscellaneous  

H. Two-dimensional Study I

. M-mode Patterns

 

III. Valvular Heart Disease (15%-25%)

A. Mitral Valve

• 1. Physiology/hemodynamics
• 2. Mitral stenosis

a. M-mode

b. two-dimensional study

c. Doppler study

d. effects on:(1) atria(2) ventricles(3) cardiac vessels ])

• 3. Mitral regurgitation

a. M-mode

b. two-dimensional study

c. Doppler study

d. effects on:(1) atria (2) ventricles (3) cardiac vessels (4) pulmonary veins

e. mitral prolapse

f. chordae rupture

g. flail leaflet

h. mitral annular calcification

i. mixed mitral valve disease )(MS/MR)

B. Aortic Valve

• 1. Physiology/hemodynamics
• 2. Aortic stenosis

a . M-mode

b. two-dimensional study

c. Doppler study

d. effects on:(1) atria(2) ventricles(3) cardiac vesselse. etiologies(1) congenital(2) degenerative(3) endocarditis

e. mixed lesions (AS/AR)

f. aortic stenosis

• 3. Aortic regurgitation

a. M-mode

b. two-dimensional study

c. Doppler study

d. effects on:(1) atria(2) ventricles(3) cardiac vessels

e. etiologies(1) congenital(2) infectious(3) secondary (e.g., aortic root abnormality)(4) flail

f. mixed (AS/AR)

C. Tricuspid Valve

• 1. Physiology/hemodynamics
• 2. Tricuspid stenosis/ regurgitation

a. M-mode

b. two-dimensional study

c. Doppler study

d. effects on:(1) atria(2) ventricles(3) cardiac vesselse. etiologies

f. with mixed lesions

• 3. Tricuspid regurgitation

a. M-mode

b. two-dimensional Study

c. Doppler Study

d. effects on:(1) atria(2) ventricles(3) cardiac vessels

e. etiologies(1) degenerative(2) tricuspid prolapse (3) chordal rupture(4) flail leaflet

D. Pulmonary Valve

• 1. Physiology/hemodynamics
• 2. Pulmonary stenosis

a. M-mode

b. two-dimensional study

c. Doppler study

d. effects on:(1) atria(2) ventricles(3) cardiac vessels

e. etiologies(1) congenital

• 3. Pulmonary regurgitation

a. M-mode

b. two-dimensional study

c. Doppler study

d. effects on:(1) atria(2) ventricles(3) cardiac vesselse. etiologies(1) pulmonary hypertension 

f. mixed PS/PIE.

Endocarditis

• 1. Physiology/hemodynamics
• 2. Involvement of adjacent cardiac structures
• 3. M-mode patterns
• 4. Two-dimensional study

 

 

IV. Pericardial Disease (2%-8%)

 

A. Constrictive

• 1. Physiology/hemodynamics
• 2. Etiologies
• 3. Echocardiographic manifestations

B. Effusion

• 1. Physiology/hemodynamics a. tamponade
• 2. Etiologies
• 3. Differentiation from pleural effusion

C. Tumor

• 1. Primary
• 2. Metastatic

D. Miscellaneous

• 1. Adhesions
• 2. Nonspecific thickening

3. False positives

 

V. Systemic & Pulmonary Hypertensive Heart Disease (1%-3%)

A. Systemic

• 1. Physiology/hemodynamics
• 2. Echocardiographic findings

B. Pulmonary

• 1. Physiology/hemodynamics
• 2. Doppler assessment a. from tricuspid regurgitant jet b. from pulmonary artery acceleration time
• 3. Image findings

 

 

VI. Cardiomyopathies (5%-15%)

A. Hypertrophic

• 1. With/without dynamic obstruction
• 2. Associated abnormalities

a. mitral regurgitant/left atrial enlargement

B. Dilated

• 1. Etiologies
• 2. Associated findings

a. mitral regurgitation

b. other chamber enlargement

c. thrombus

C. Restrictive

• 1. Etiologies

2. Diastolic dysfunction

 

VII. Ventricular Function (10%-20%)

A. Wall Motion Abnormalities

B. Associated Findings

• 1. Thrombi
• 2. Changes in appearance of involved myocardium
• 3. Valve dysfunction
• 4. Pericardial effusion
• 5. Cardiomyopathy
• 6. Right ventricular involvement

C. Diastolic Function

D. Normal LVF

 

VIII. Cardiac Tumors (2%-5%)

A. Primary vs. secondary (metastatic)

B. Pericardial Involvement

C. Differentiation from Other Masses or Artifacts

D. Complications

 

IX. Miscellaneous (5%-10%)

A. Arrhythmias and Conduction Disturbances

• 1. Effect on valve motion
• 2. Production of wall motion abnormalities
• 3. Effect on Doppler flow velocity waveforms

B. Parameters of Left Ventricular Function

C. Right Side Volume Overload

D. Other

 

X. Congenital Heart Disease in the Adult (3%-7%)

 

A. Categories

• 1. Aortic valve

a. bicuspid

b. supravalvular/subvalvular stenosis

• 2. Pulmonic stenosis
• 3. Mitral valve dysplasia
• 4. Atrial septal defecta. typesb. means of assessing(1) contrast(2) Dopplerc. physiology/hemodynamics(1) associated chamber enlargement(2) direction for shunt flow
• 5. Ventricular septal defect

a. types

b. means of assessing(1) contrast(2) Dopplerc. physiology/hemodynamics(1) associated chamber enlargement(2) directions for shunt flow

• 6. Endocardial cushion defect
• 7. Ebstein’s anomaly
• 8. Patent ductus arteriosus
• 9. Tetralogy of Fallot
• 10. Status, postoperative congenital heart disease
• 11. Coarctation of the aorta

 

XI. Doppler (3%-7%)

A. General Information

B. Formulas for Measurement

• 1. Modified Bernoulli equation
• 2. Pressure half-time formula
• 3. Doppler formula

C. Color Flow Mapping

Neurosonology Content Outline

I. Physics & Instrumentation (1%-5%)

A. Effects of Bone on Ultrasonic Energy

B. Effect of Transducer Frequency on Image Quality

C. Bone Induced Artifacts

D. Effect of Instrument Controls on Image Quality

 

II. Technique in Neurosonography (10%-20%)

A. Rationale for Selection of Modality, Instrument, and Transducer for a Specific Examination

B. Scan-Plane Selection and Identification

C. Adjustment of Instrument Controls

D. Recognition of Normal Anatomic Structures and Landmarks

• 1. Cerebellum
• 2. Cerebrum
• 3. Brain stem
• 4. Ventricular system

E. Examination Protocol

F. Normal Dimensions and Measurement Techniques

G. Sterile Technique in Intraoperative Examination

H. Transcranial Doppler Techniques

 

III. Anatomy & Physiology (30%-40%)

A. Bones of the Os Cranium

B. Fontanelles and External Landmarks

C. Gross Topographical Anatomy

• 1. Cerebellum
• 2. Cerebrum
• 3. Brain stem
• 4. Spinal cord

D. Membranous Partitioning of the Intracranial Space

E. Intra- and Extracranial Vascular Structures

• 1. Normal vascular structures

F. Gray/White Matter Organization of the Brain and Cord

G. The Ventricular System

H. Origin, Flow, and Reabsorption of the Cerebrospinal Fluid

I. Principal Functional Tracts of the Central Nervous System

 

IV. Recognition of Pathology and Differential Diagnosis (40%-50%)

A. Midline Displacements

B. Space-occupying Lesions and Mass Effects in the Brain

C. Inflammatory Lesions

D. Ventricular Enlargement

E. Intra- and Extracranial Hemorrhage

F. Trauma

Ultrasound Physics and Instrumentation Content Outline

I. Elementary Principles (8%-12%)

A. Nature of Ultrasound

• 1. Definition of sound

a. propagation of vibration(1) compression(2) rarefaction

• 2. Differentiation between audible sound and ultrasound

B. Frequency, Wavelength, Propagation Speed

• 1. Definition of terms
• 2. Relationships

C. Properties of Ultrasound Waves

• 1. Amplitude
• 2. Pressure
• 3. Power
• 4. Intensity

D. Decibels

• 1. Definition

a. related to intensity

b. related to amplitude

• 2. Numerical examples

E. Physical Units

• 1. Scientific notation
• 2. Metric notation (e.g., micro, Mega)
• 3. Common units

F. Measurement Dimensions

• 1. Distance

a. Linear

b. Circumference

• 2. Area
• 3. Volume

 

II. Propagation of Ultrasound through Tissues (10%-14%)

A. Speed of Sound

• 1. Average speed of sound in tissues
• 2. Range of propagation speeds in the body

a. air

b. soft tissue (average)

c. soft tissue: specific tissues (e.g., muscle, fat, parenchyma)

d. bone

B. Reflection

• 1. Characteristic of acoustic impedance - definition
• 2. Reflection and transmission at specular interfaces

a. interface size and contour (smooth or irregular)

b. dependence on angle

c. dependence on acoustic impedance mismatch

• 3. Scattering

a. definition of scattering

b. frequency dependence (Rayleigh scattering)

c. Interface contour (smooth or irregular)

d. contrast media

e. harmonics

C. Refraction

• 1. Definition of refraction
• 2. Dependence of angle
• 3. Dependence of velocity mismatch
• 4. Numerical example

D. Attenuation

• 1. Definition and sources of attenuation

a. Scattering

b. Absorption

• • 1. heat
  • 2. Measurement

c. Reflection

• 2. Typical values in soft tissue
• 3. Variation with frequency - numerical example
• 4. Effects on images

E. Useful Diagnostic Frequency Range

• 1. Numerical values
• 2. Tradeoff: penetration vs. spatial resolution

F. Terminology Associated with Image Characteristics

• 1. Echogenic (e.g., hyperechoic, hypoechoic, anechoic, isoechoic, etc.)
• 2. Homogeneity, Heterogeneity, etc.

3. Other

 

III. Ultrasound Transducers (17%-25%) 

A. The Piezoelectric Effect 

• 1. Definition and concept
• 2. Curie point
• 3. Piezoelectric materials

B. Transducer Construction and Characteristics 

• 1. Thickness resonance of crystal
• 2. Operating (resonance) frequency

a. Crystal thickness 

b. Speed of sound in crystal material 

• 3. Frequency characteristics (spectrum)

a. Bandwidth

1. Quality factor

 2. Effect of damping

 b. Multi-Hertz1. Harmonics 

• 4. Damping
• 5. Matching layer-numerical example

C. Sound Beam Formation - Near Field and Far Field (Fresnel and Fraunhofer Zones) 

• 1. Interference phenomena

a. Huygen's principle

 b. diffraction (divergence)  

c. Bandwidth 

• 2. Length of near field (focal distance)
• 3. Shape of near field and far field

a. Beam width

 b. Natural focus 

• 4. Dependence on frequency and crystal or aperture size

D. Axial Resolution 

• 1. Dependence on spatial pulse length/ pulse duration
• 2. Numerical example
• 3. Effect of damping
• 4. Transducer frequency spectrum-relation to pulse duration
• 5. Bandwidth

E. Lateral Resolution 

• 1. Dependence on beam width
• 2. Frequency
• 3. Transducer size and focal characteristics
• 4. Range

F. Slice Thickness Resolution (Elevational Resolution) 

• 1. Dependence on beam width
• 2. Transducer array and focal characteristics
• 3. Frequency
• 4. Lateral and axial resolution relationship

G. Focusing 

• 1. Methods of focusing

a. Mechanical (internal and external) 

b. Electronic (transmit and receive) 

• 2. Focal zone characteristics

a. Focal distance (length) 

b. Focal zone region 

• 1. Maximum intensity

H. Transducer Arrays and Image Appearance

• 1. Mechanical and/or electronic construction
• 2. Multiple element construction

a. Linear array 

b. Curved array 

c. Annular array 

d. Multi-dimensional array

• 3. Multiple element operation

a. Sequenced 

b. Phased 

c. Annular  

d. Vectore. Multi-dimensional 

• 4. Beam Steering

a. Transmission time delays 

b. Reception time delays 

• 5. Beam focusing

a. Time delays 

b. Dynamic reception focus

 c. Multiple transmission foci 

d. Apodization 

e. Subdicing

 f. Dynamic aperture

 

I. Transducer Care and Maintenance

 

IV. Pulse Echo Instruments (6%-10%

 A. Range Equation - General Concepts 

B. Pulsing Characteristics 

• 1. Pulse repetition frequency
• 2. Pulse repetition period
• 3. Pulse duration
• 4. Spatial pulse length
• 5. Duty factor

C. Transmitter (Output) 

• 1. Effect of transmitter voltage on penetration
• 2. Effect of transmitter voltage on intensity and on patient exposure

D. Receiver

• 1. Amplification (overall gain)
• 2. Compensation (swept gain-TGC or DGC)

a. Attenuation with range 

b. Effects on return signal and display

 c. Dynamic frequency tuning

 d. Harmonic processing

• 3. Compression

a. Dynamic range 

1. Definition 

2. Dynamic range (receiver) 

a. Compare to other system components 

b. Numerical values (dB) 

• 4. Demodulation

a. Rectification

 b. Smoothing (enveloping)

 

• 5. Rejection

 

V. Principles of Pulse Echo Imaging (6%-10%) 

A. Principal Display Modes (A-mode, B-mode, 3-D, M-mode) 

• 1. Definition of each mode
• 2. Information displayed on each mode
• 3. Advantages and disadvantages of each mode

B. Principles of Real-time, B-Mode Image Formation

•  1. Relationship between echo amplitude and B-mode display
• 2. Positioning of echoes
• 3. Harmonics

C. Scanning Speed Limitations 

• 1. Applications of range equation and relationship to pulsing characteristics
• 2. Real-time systems-relationships between

a. Pulsing characteristics

 b. Frame rate and time required to generate one frame 

c. Number of lines per framed. Number of focal regionse. Field of view (e.g., sector angle)f. Image depth (penetration)

 

• 3. Temporal resolution, ability to evaluate rapid motion

VI. Images, Storage, and Display (10%-14%) 

A. Role of scan converter 

• 1. Image storage
• 2. Scan Conversion

B. Digital Devices 

• 1. Binary system

a. Terminology (bits, bytes, pixels) 

b. Discrete nature of binary numbers 

• 2. Steps in processing echo information

a. Analog-to-digital converterb. Digital memory 

1. Spatial resolution 

a. pixels

 b. matrix 

c. Field of view 

2. Contrast resolution

 a. Size of memory

 b. Digital-to-analog converter

 c. Display devices 

C. Preprocessing versus Postprocessing

•  1. Definition
• 2. Preprocessing functions

a. Time (depth) gain compensation

 b. Logarithmic compression

 c. write magnification 

• 3. Postprocessing function

a. Freeze frame

 b. Black/white inversion 

c. Read magnification 

d. Contrast variation

• 4. Preprocessing or postprocessing functions (equipment manufacturers' discretion)

a. Persistence 

b. Frame averaging

 c. Edge enhancement 

d. Smoothing 

e. Fill-in interpolation

D. Display devices 

• 1. TV monitors
• 2. High resolution monitors

a. Lines and spatial resolution

 b. Brightness 

c. Contrast 

d. Frame rate 

E. Recording and Archiving Techniques 

• 1. Video Format

a. Display (monitors) 

b. Single or multi-image cameras and laser imagers 

1. Photographic film

 2. Emulsion film

 c. Recorders 

1. Fiber-optic 

2. Videotape cassette 

d. Printer 

1. Thermal 

2. Laser  

• 2. Digital format

a. Magneto-optical disc (digital still recorder)

 b. PACS  (Picture Achiving and communication systems) 

• 3. Contrast and brightness control adjustments

 

• 4. Advantages and limitations of each type

VII. Hemodynamic, Doppler, Color Flow, and Color Power Imaging (10%-14%) 

A. Hemodynamics 

• 1. Energy gradient
• 2. Effects of viscosity, friction, inertia
• 3. Pressure/flow relationships
• 4. Velocity
• 5. Steady flow vs pulsatile flow
• 6. Laminar versus turbulent flow
• 7. Effects of stenosis on flow characteristics
• 8. Venous resistance
• 9. Hydrostatic pressure
• 10. Pressure/volume relationship
• 11. Effects of respiration (phasicity)

B. Doppler Physical Principles 

• 1. Doppler Effect

a. Principle as related to sampling red blood cell movement 

b. Doppler equation

• 2. Factors influencing the magnitude of the Doppler shift frequency

a. Range of the Doppler shift frequency 

b. Effects of beam angle, transmitted frequency, flow velocity, and flow direction 

C. Doppler Instruments 

• 1. Continuous wave and pulsed wave Doppler

a. Differences 

b. Advantages and disadvantages of each 

1. Aliasing (Nyquist criteria) 

2. Range ambiguity 

c. Instrumentation

 1. Receiver 

2. Demodulater3

. Wall filter for clutter rejection 

4. Directional devices 

• 2. Duplex instruments-definition and basic principles
• 3. Spectral analysis

a. Purpose 

1. Direction 

2. Velocity 

3. Duration

 4. Character 

5. Magnitude

 b. Fast Fourier transform (FFT) 

c. Diagnostic measurements (indices-i.e., pulsatility, resistive) 

D. Color Flow Imaging 

• 1. Basic Principles

a. Sampling methods 

b. Display of Doppler information 

1. Reflector direction 

2. Average velocity 

3. Velocity variance 

c. Advantages and limitations 

• 2. Instrumentation

a. Autocorrelation 

b. Time domain processing 

c. Color field size and frame rate 

1. Ensemble length (packet size, pulse packet) 

2. Line density 

3. Maximum depthd. Color maps, assignment, or coding

 1. Hue 

2. Saturation 

3. Luminance (significance, brightness, intensity) 

e. Artifacts (see section VIII)

E. Color Power (Energy) Mode

• 1. Displayed information

 

• 2. Advantages and limitations

VIII. Artifacts (6%-10%)

A. Definition of Artifacts

B. Artifact Recognition in Performing and Interpreting Examinations

• 1. Echoes not representing actual interfaces
• 2. Missing echoes
• 3. Misrepresented interface location
• 4. Misrepresented interface amplitude

C. Artifacts Associated with Resolution and Propagation (Axial Resolution, Lateral Resolution, Section Thickness, Acoustic Speckle)

• 1. Definitions
• 2. Mechanisms of Production
• 3. Appearance

D. Artifacts Associated with Propagation (Reverberation, Comet-tail, Ring-down, Mirror Image, Multipath, Side Lobes, Grating Lobes, Refraction, Speed Error; and Range Ambiguity)

• 1. Definitions
• 2. Mechanisms of Production
• 3. Appearance

E. Artifacts Associated with Attenuation (Shadowing, Enhancement, and Focal Enhancement or Focal Banding)

• 1. Definitions
• 2. Mechanisms of Production
• 3. Appearance

F. Artifacts Associated with Doppler and Color Flow Instrumentation (Aliasing, Slice Thickness, Reverberation, Mirror Imaging, Ghosting or Flash, Registration, Incident Beam Angle, and Clutter)

• 1. Definitions
• 2. Mechanisms of Production
• 3. Appearance

G. Other (Electronic Noise, Equipment Malfunction)

• 1. Definitions
• 2. Mechanisms of Production
• 3. Appearance

 

H. Artifact Effects on Measurements (velocity or speed error and range ambiguity)

 

IX. Quality Assurance of Ultrasound Instruments (4%-8%)

A. General Concepts Regarding the Need for and Nature of a Quality Assurance Program

B. Methods for Evaluating Instrument Performance

• 1. Test objects
• 2. Phantoms (tissue, Doppler, flow)

C. Parameters to Be Evaluated

• 1. Test object

a. Dead zone

b. Axial resolution and lateral resolution (beam width)

c. Depth calibration accuracy

d. TGC characteristics

e. Uniformity

f. System sensitivity

• 2. Tissue equivalent (mimicking) phantom

a. Dead zone

b. Depth calibration accuracy

c. Lateral (horizontal) distance measurement accuracy

d. Axial, lateral, and section thickness (elevational) resolution

e. TGC characteristics

f. System sensitivity

g. Dynamic range

h. Contrast resolution

i. Lesion detection

• 3. Doppler flow, string, or belt phantomsa

a. Maximum depth

b. Pulsed Doppler sample volume alignment (gate position accuracy)

c. Velocity accuracy

d. Color flow penetration

e. Image congruency test

D. Preventive Maintenance

• 1. Standard precautions

a. Equipment

1. Cleaning

2. Disinfecting

3. Sterilization

E. Record Keeping

F. Statistical Indices

• 1. Sensitivity/specificity
• 2. Negative/positive predictive value

 

• 3. Accuracy

 

X. Bioeffects and Safety (6%-10%)

A. Acoustic Output Quantities

• 1. Pressure

a. Units (MPa, mmHg)

b. Peak pressures (compression, rarefaction)

c. Methods of determining pressure (miniature hydrophone)

• 2. Power

a. Units (mW)

b. Methods of determining power (radiation force, hydrophone)

• 3. Intensity

a. Units (mW/cm², W/cm²)

b. Spatial and temporal considerations

c. Average and peak intensities

d. Methods of determining intensity (hydrophones)

e. Common intensities(1) SATA(2) SPTA(3) SPPA(4) SPTP

• 4. Intensity and power values for different operating modes

B. Acoustic Output Labeling Standard

• 1. Thermal index

a. TIS

b. TIB

c. TIC

• 2. Mechanical index

C. Acoustic Exposure

• 1. Definition and concepts of prudent use (ALARA)
• 2. Methods of reducing acoustic exposure

D. Primary Mechanisms of Biologic Effect Production

• 1. Cavitation mechanisms: relevant acoustic parameters
• 2. Thermal mechanisms: relevant acoustic parameters

E. Experimental Biological Effect Studies

• 1. Animal studies
• 2. In vitro studies
• 3. Epidemiologic studies

a. Limitations

 

 

 

 

 

 

 

Vascular Physical Principles and Instrumentation Content Outline

I Ultrasound Physics (35%-45%)

A. Definition of Sound (6%-10%)

• 1. Sound vs. ultrasound
• 2. Propagation velocity
• 3. Frequency
• 4. Wavelength
• 5. Frequency vs. depth
• 6. Frequency ranges

B. Propagation of Sound in Tissue (6%-10%)

• 1. Speed of sound through tissue: air, bone, soft tissue
• 2. Speed of sound through blood
• 3. Acoustic impedance
• 4. Reflection
• 5. Refraction
• 6. Absorption
• 7. Attenuation

C. Transducers: Ultrasound (6%-10%)

• 1. Piezoelectric effect
• 2. Transducer characteristics
• 3. Sound beam characteristics

a. effect of beam diameter on resolution

b. effect of transducer frequency on beam characteristics

c. beam focusing

d. near field

e. far field

• 4. Lateral resolution
• 5. Axial resolution
• 6. Mechanical transducers
• 7. Electronic transducers

D. Doppler Signal Processing (6%-10%)

• 1. Doppler effect
• 2. Doppler frequency shift
• 3. Effect of transmitting frequency on Doppler frequency shift
• 4. Effect of insonation angle on Doppler frequency shift
• 5. Reflector speed (velocity)
• 6. Extracting the Doppler signal
• 7. Audible Doppler signal analysis
• 8. Analog Doppler waveform generation
• 9. Spectral display characteristics
• 10. Sample volume size
• 11. Aliasing

E. Doppler Instruments (6%-10%)

• 1. Continuous wave instruments
• 2. Pulsed wave instruments
• 3. Bidirectional Doppler
• 4. Unidirectional Doppler
• 5. Color flow

 

• 6. Transcranial

II. Ultrasonic Imaging (15%-25%)

A. Imaging Principles (10%-14%)

• 1. A-mode: definition
• 2. B-mode: definition
• 3. Real-time: definition
• 4. Gray scale display
• 5. Dynamic range
• 6. Frame rate
• 7. Scan converter
• 8. Gain
• 9. Time gain compensation
• 10. Recording techniques

a. multi-imaging camera

b. video tape

c. thermal video printer

d. digital storage

• 11. Duplex instrumentation
• 12. Image resolution

B. Imaging Artifacts (6%-10%)

• 1. Artifact: definition
• 2. Origin of artifacts: technique
• 3. Origin of artifacts: instrumentation
• 4. Enhancement
• 5. Multiple reflections
• 6. Reverberation
• 7. Shadowing

 

• 8. Refraction

III. Physiology & Fluid Dynamic (10%-20%)

A. Arterial Hemodynamics (7% -11%)

• 1. Energy gradient
• 2. Effects of viscosity, friction, inertia
• 3. Pressure/flow relationships

a. Poiseuille’s law

b. Bernoulli’s principle

• 4. Velocity
• 5. Steady flow vs. pulsatile flow
• 6. Effects of stenosis on flow characteristics

a. direction, turbulence, disturbed flow

b. velocity acceleration

c. entrance/exit effectsd. diameter reduction

e. peripheral resistance

f. collateral effects

g. effects of exercise

h. occlusion

B. Venous Hemodynamics (4%-8%)

• 1. Venous resistance
• 2. Hydrostatic pressure
• 3. Pressure/volume relationship
• 4. Effects of edema
• 5. Effects of muscle pump mechanism

a. at rest

b. contraction

c. relaxation

C. Other (0%-3%)

• 1. Arteriovenous fistula (traumatic, congenital, access dialysis)

 

• 2. Trauma (pseudoaneurysm)

 

IV. Ultrasound Safety & Quality Assurance (3%-7%)

A. Instrument Performance (2%-6%)

• 1. Evaluation of image quality
• 2. Evaluation of Doppler quality
• 3. Preventive maintenance

B. Biological Effects (0%-3%)

• 1. Minimizing exposure time
• 2. Mechanisms of production
• 3. Scientific data

• 4. Preventing electrical hazards

AAVR-"Certifying Responsible Imaging"

One of the following options must be met in order for an applicant to be considered for the RVMS certification:

(I) ACVR or ACVIM-cardiology certfication in good standing

or

(II) An ARDMS certification and (1) necessary clinical ultrasound (minimum five years in human sonography), and (2) clinical ultrasound training for a minimum of six months under the supervision of a board-certified veterinary cardiologist and/or radiologist.

 

Renewal Prerequisites

If you are applying for certification renewal, you must submit:

1. An original completed AAVR Clinical Verification (CV) form
2. Letter from a sponsoring board-certified veterinary cardiologist or radiologist
3. Proof of attendance to the ACVR annual meeting within the past two years

Please include your AAVR number on all supporting documentation.·

 

1.1. Review of Credentials, Applicants, Candidates, Registrants and Other Individuals

1.1.1. AAVR conducts a certification program; however, AAVR does not express an opinion on competence or warrant the job performance of anyone. AAVR examinations and their content are the property of AAVR. AAVR examinations are available only to those persons who desire in good faith to become certified by meeting AAVR requirements and successfully completing AAVR examinations. AAVR examinations and their content are not available to any other individual, and may not be used by anyone for any other purpose. In applying for certification or recertification, an applicant or registrant agrees that:
(A) The individual complies and will comply with all AAVR rules and standards in place now and in the future and bears the burden for showing and maintaining compliance at all times.
(B) The examinations, certificates, cards, logos, patches and emblems of AAVR, the name American Association of Veterinary Radiology AAVR®, Registered Veterinary Medical Sonographer , RVMS and abbreviations relating thereto are all the exclusive property of AAVR, and may not be used in any way without the express written consent of AAVR; registrants are permitted to use AAVR property only in accordance with AAVR rules. AAVR does not recognize or authorize theterm “Registry-eligible” as it pertains to AAVR.
(C) The individual shall immediately relinquish, refrain from using and correct at the individual's expense any outdated or other inaccurate use of any AAVR certificate, card, logo, patch, emblem, and AAVR name and other designations and abbreviations (such as those mentioned in Section 2.6.1 (B) above) in case of suspension, limitation, revocation, failure to meet AAVR requirements, or as otherwise requested by AAVR.
(D) If the individual refuses to relinquish immediately, refrain from using and correct at his or her expense any misuse or misleading use of any of the above items when requested, the individual agrees that AAVR shall beentitled to obtain injunctive relief, damages costs and attorney's fees incurred in obtaining any such or other relief.

1.1.2. Eligibility for Certification or Recertification

(A) No individual is eligible to apply for certification or recertification unless incompliance with all AAVR rules and standards. AAVR may deny, revoke, suspend, or otherwise act upon certification or recertification, or eligibility toapply or sit for AAVR examinations, where an individual is not in compliance with AAVR rules and standards.
(B) The individual must truthfully complete and sign an application in the form provided by AAVR and shall provide additional information as requested. The individual must notify AAVR of any change of address, telephone number, and any other facts bearing on eligibility, certification, continued certification or recertification within thirty (30) days of such an occurrence. All documents, communications or other information provided to AAVR are the property of AAVR and will not be returned.
(C) Applicants for initial certification, registrants, and applicants for recertificationare required to notify AAVR immediately of any conviction, guilty plea, or nolo contendere plea or any disciplinary action taken by a state licensing board, state or Federal agency, or national professional association related to the public health or the provision of diagnostic medical sonography or vascular technology services.
(D) An individual may request a pre-application interpretation of AAVR eligibility rules pertaining to criminal matters upon submission of a completed form provided by AAVR for this purpose, compliance with AAVR rules posted on the AAVR website and/or available in print, and payment of a nonrefundable review fee. AAVR may grant, deny or hold in abeyance a determination on such request.
(E) In order to apply for AAVR certification or recertification or to maintain current certification, applicants, candidates and registrants agree that they waive all claims against and will hold harmless AAVR, its staff, volunteersand agents, which arise out of or relate to AAVR' assessment and communication concerning certification and recertification application review,examination administration, certification and recertification decisions, the furnishing or inspection of documents, records and other information, and/orAAVR investigation and review of eligibility or alleged violations of AAVR standards (Section 2.6.4).

1.1.3. Score Reports

AAVR is concerned with reporting only valid scores. On rare occasions, misconduct or circumstances beyond the individual's control may render a scoreinvalid. If doubts are raised about a score because of these or other circumstances,

AAVR Disciplinary Policies Administration

AAVR expects all individuals to cooperate in any AAVR investigation. AAVR reserves the right to cancel any exam score if, in the sole opinion of AAVR, there is adequate reason to question its validity. AAVR in its discretion will (i) offer the individual an opportunity to retake the examination again at no additional fee; (ii) offer the individual an opportunity to retake the examination again in ordinary course,including payment of all fees; or (iii) proceed as described in Section 2.6.4, Review of Applicants and Certificants, below. For administrative exam irregularities (not processed under Section 2.6.4. of these Policies), the Executive Director, on advice from the Director of Testing, will review the matter and decide whether to cancel the exam scores, and whether the candidate may be offered a retest (i) at AAVRexpense, or (ii) at the candidate's expense.

1.1.4. Review of Applicants and Certificants 1.1.4.1 Grounds for Discipline

The following may provide grounds for sanction:
(A) Engaging in fraud, misrepresentation, deception, or concealment of a materialfact in connection with obtaining or renewing AAVR certification on one's own behalf or that of another;
(B) Having been convicted of, plead guilty to, or plead nolo contendere to a misdemeanor or felony related to the public health or the provision ofdiagnostic medical sonography services ;
(C) Having had disciplinary action taken by a state licensing board, state orfederal agency, or national professional association on grounds that related to the public health or the provision of diagnostic medical sonography services; and
(D) Failure to cooperate with AAVR concerning investigations of alleged grounds for discipline under Section 2.6.4.1, including the collection ofrelevant information.

1.1.4.2 Sanctions

Violations may result in one or more of the following sanctions:
(A) Revocation, meaning the permanent loss of certification;
(B) Suspension, meaning the loss of certification for a specified period, afterwhich the individual may be required to apply for reinstatement;
(C) Probation, meaning that continued certification is subject to fulfillment ofspecified conditions, including, without limitation, reexamination, educational requirements, monitoring, supervision, counseling, participation in the impaired provider process, reports to AAVR, and/or other appropriateconditions;
(D) Censure, meaning a formal expression of disapproval that is publicly announced; (E) Reprimand, meaning a formal expression of disapproval addressed to the individual, but which is not publicly announced; and (F) Ineligibility for Certification, meaning that the individual is barred from becoming certified, either indefinitely or for a specific period.

1.1.4.3 Initial Investigation and Action

(A) Investigation. Upon the receipt of information indicating that an individual applicant or a certificant ("subject") may be subject to discipline for violations of Section 2.6.4.1, AAVR staff shall investigate the allegations and to reportits findings and recommendations to the AAVR council. In conducting its investigation, the staff shall send a letter to the subject requesting his or her response to the allegations.
(B) AAVR council. The AAVR council shall oversee the certification process and consist of three members: the Chair of the Board, the Chair ofthe Certification process, and a third person appointed by the Chair of theBoard.
(C) Action. After reviewing the staff's findings and recommendations, the AAVR council shall determine whether to: (i) dismiss the complaint due to insufficient evidence concerning grounds for discipline under Section 2.6.4.1, the matter being insufficiently serious, or for other appropriate reasons; or (ii) agree with staff findings and recommendations; or (iii) make alternative disciplinary recommendations.
(D) Charging Letter. If disciplinary action is recommended, the subject shall besent a letter that sets forth the alleged facts and grounds for discipline under Section 2.6.4.1. The letter shall inform the subject of his or her right torequest a hearing within 30 days of receiving the letter. Pursuant to Section2.6.4.7, the AAVR council also may include a proposed settlement agreement with the charging letter.

1.1.4.4 Hearing

(A) Notice of Hearing. If a subject requests a hearing, AAVR staff shall arrangea meeting of a AAVR council and send a hearing notice to the subject. The notice shall state the time and place of the hearing. Hearings will either beheld telephonically or in-person at a time and place determined by AAVR.
(B) Hearing Panel Composition. The Chair of the Board shall appoint a Hearing Panel consisting of three AAVR members. Those appointed shall not have any prior involvement in the case, nor shall they have any personal or professional conflicts of interest with regard to the subject.
(C) Subject's Representation and Expenses. The subject may be represented atthe hearing by his or her legal counsel. The subject shall be solely responsible for all of his or her own expenses related to the hearing.
(D) Evidence. The Hearing Panel may consider any evidence which it deems appropriate and relevant.
(E) Standard of Proof. The Hearing Panel shall sanction a subject only when there is clear and convincing evidence of grounds for sanction under Section 2.6.4.1.
(F) Procedure When No Hearing Requested. If the subject did not respond to the charging letter, the Hearing Panel shall review the matter, but is not required to conduct an in-person hearing.
(G) Hearing Panel Decision. The Hearing Panel shall render its decision bymajority vote and shall issue a written opinion within 30 days of the hearing. The opinion shall describe its findings of fact, application of Section 2.6.4.1's standards to the facts, any sanctions imposed on the subject, and requirements for reinstatement.

1.1.4.5 Appeal

(A) Request for Appeal. A subject must make a request for an appeal in writing within 30 days following receipt of the decision of the Hearing Panel. If no appeal is made, the matter is considered final upon issuance of the Hearing Panel's opinion.
(B) Appeal Panel Composition. The Chair of the Board shall appoint three Board members to serve as the Appeal Panel. Those appointed shall not have any prior involvement in the case, nor shall they have any personal or professionalconflicts of interest with regard to the subject.
(C) Time in Which Appeal Must Be Decided. The appeal normally shall be shall be heard within 120 days of the appeal request, unless the Appeal Panel determines that cause exists for extending that time limit.
(D) Appeal Procedure. The appeal shall consist of a review of the written record developed by the Hearing Panel and any additional materials submitted by the subject. The appeal shall not consist of an in-person hearing.
(E) Standard of Review. The Appeal Panel may overturn or modify the Hearing Panel's decision only if it determines by majority vote that the Hearing Panel's decision was arbitrary and capricious. Otherwise, it must affirm the Hearing Panel's decision.
(F) Appeal Panel Decision. The Appeal Panel shall issue a written opinion within 30 days that sets forth the basis for its decision. Upon the issuance of the opinion, the matter is considered final.

1.1.4.6 Reinstatement

If permitted under a subject's sanctions, the subject may request reinstatement. The subject must submit a written request that sets forth the grounds which the subject believes justifies reinstatement. In its discretion, the staff may request additiona linformation and documentation concerning the grounds for reinstatement. The subject's request shall be considered generally in accordance with Sections 2.6.4.4 and 2.6.4.5. Requests for reinstatement will be heard before the Disciplinary Reinstatement Panel. Reinstatement hearings may be held in-person ortelephonically. If the subject's request for reinstatement is granted, the individualshall apply as a first-time applicant.

1.1.4.7 Settlement

Informal dispositions may be made of any contested case by settlement or by another method agreed upon by the subject and the AAVR council, without prejudice to the AAVR's ability to institute disciplinary proceedings based upon the same or related material if circumstances so warrant.

1.1.4.8 Notification

All notifications referred to in these procedures shall be in writing and shall be by certified, return receipt mail or commercial delivery service that tracks delivery.

1.1.5. Non-Disciplinary Appeals Policy

AAVR initial staff decisions denying applications based on ineligibility to take an examination or recertification, and disruptive examination conditions, may be appealed to AAVR council. The grounds for appeal to the AAVR council are only those statedabove. An appeal to the AAVR council must be made in writing and received byAAVR within 30 days of (i) the date on which AAVR mailed the notice denying eligibility to take the examination or recertification; or (ii) the date on which a disruptive examination condition occurred. The written appeal must identify the precise factual basis, applicable rules or examination conditions which are the basis for the appeal. The AAVR council shall be composed of two or more AAVR registrants who have at least 5 years previous experience in ultrasound and/or testing. Upon receipt of an appeal, the Chair shall appoint qualified registrants to serve on an Appeal Panel. If an Appeal Panel is appointed, the Appeal Panel members shall serve on the Appeal Panel for one year. An Appeal Panel may hear more than one appeal and more than one Appeal Panel may be convened in the discretion of the Chair. The Appeal Panel shall review the written appeal and all supporting documentation. The Appeal Panel shall reasonably attempt to decide any appeal of an eligibility denial prior to the examination date for which the applicant originally applied. In the discretion of the Appeal Panel, if additional information is necessary, the Appeal Panel may schedule a telephone conference and/or request additional documentation from the individual requesting the appeal or any other individuals who may have knowledge of facts relevant to the appeal. The Appeal Panel shall by majority vote make one of the following recommendations: 1. To reverse the decision denying eligibility to take the examination or recertification; 2. To affirm the decision denying eligibility to take the examination or recertification; or3. If the Appeal Panel finds that examination conditions may have impaired the validity of an examination score, that the candidate be given a retest at no charge to thecandidate. The recommendation of the Appeal Panel, along with all documentation relating to the appeal, shall be submitted to the AAVR council for a final vote on the appeal. The council shall review the appeal and the Appeal Panel's recommendation and shall render a decision on the appeal by majority vote of the council members. The decision of the AAVR council shall be final.

1.1.5 Documentation

AAVR shall make available to the public by electronic and/or print means a list with appropriate definitions or explanation of: (a) AAVR Directory of Registrants; (b) Persons Currently Under AAVR Sanction; and (c) Persons No Longer Certified.