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During lower extremity venous mapping, the great saphenous vein (GSV) is identified by its characteristic ultrasound appearance within the saphenous compartment. What is this finding called?

Mickey Mouse sign

Egyptian eye sign

Comet tail sign

Twinkle artifact

to track

2026 Statistics

Key Facts: RPhS Exam

100

Practice Questions

OpenExamPrep RPhS bank

0.5 s

Superficial Reflux Threshold

UIP / SVS-AVF consensus

1.0 s

Deep Femoral/Popliteal Reflux Threshold

UIP / SVS-AVF consensus

C0-C6

CEAP Clinical Classes

2020 CEAP revision

Class 1-4

EHIT Surveillance Grades

Kabnick classification

PSI

Test Center / Remote Proctor

CCI testing partner

CCI

Credentialing Body

Cardiovascular Credentialing International

RPhS is a multiple-choice specialty exam administered through PSI for CCI. Verify current question count, exam time, and the application fee in the active CCI RPhS Candidate Handbook because CCI has periodically updated its specialty exam structure. Eligibility includes credentialing and clinical experience pathways tied to phlebology practice. Candidates should master lower-extremity venous anatomy (deep, superficial, perforators), CEAP 2020 classification, current reflux thresholds (>0.5 s superficial, >1.0 s femoral/popliteal), and 2022 SVS/AVF treatment guidelines.

Sample RPhS Practice Questions

Try these sample questions to test your RPhS exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1During lower extremity venous mapping, the great saphenous vein (GSV) is identified by its characteristic ultrasound appearance within the saphenous compartment. What is this finding called?

A.Mickey Mouse sign

B.Egyptian eye sign

C.Comet tail sign

D.Twinkle artifact

Explanation: The Egyptian eye sign (also called saphenous eye) describes the cross-sectional appearance of the GSV bordered superficially by the saphenous fascia and deep by the muscular fascia, forming an oval lid around the round 'pupil' (the vein). This compartmentalization is diagnostic of true GSV versus an accessory or tributary vein lying outside the compartment.

2At the saphenofemoral junction (SFJ), which three structures form the classic 'Mickey Mouse' sign on transverse ultrasound?

A.Common femoral vein, common femoral artery, great saphenous vein

B.Femoral vein, profunda femoris, great saphenous vein

C.Common femoral vein, deep femoral vein, small saphenous vein

D.Popliteal vein, popliteal artery, small saphenous vein

Explanation: At the SFJ in the proximal thigh, transverse imaging shows three round anechoic structures: the common femoral vein (medial, larger 'face'), the common femoral artery (lateral, pulsatile 'ear'), and the great saphenous vein joining anteromedially (the smaller 'ear'). This Mickey Mouse configuration is the standard anatomical landmark for GSV mapping.

3The great saphenous vein originates at which anatomical landmark in the foot?

A.Lateral malleolus

B.Medial malleolus (dorsal venous arch, medial side)

C.Plantar venous plexus

D.First webspace

Explanation: The GSV begins at the medial side of the dorsal venous arch, just anterior to the medial malleolus, and ascends along the medial calf and thigh to terminate at the SFJ in the groin. This medial origin distinguishes the GSV from the small saphenous vein.

4The small saphenous vein (SSV) terminates most commonly at which junction?

A.Saphenofemoral junction at the groin

B.Saphenopopliteal junction (SPJ) in the popliteal fossa

C.Common femoral vein at mid-thigh

D.Posterior tibial vein at the ankle

Explanation: The SSV ascends posterior calf from the lateral malleolus and most commonly terminates at the saphenopopliteal junction (SPJ) in the popliteal fossa, joining the popliteal vein. The exact level of the SPJ varies — about 60-70% terminate within 5 cm of the popliteal crease, but high terminations into the thigh extension (vein of Giacomini) and low terminations occur.

5The vein of Giacomini is best described as which structure?

A.An accessory anterior saphenous vein in the thigh

B.A thigh extension of the small saphenous vein connecting to the GSV via the posterior thigh circumflex vein

C.A perforator at the medial calf

D.A reticular vein on the lateral thigh

Explanation: The vein of Giacomini is a thigh extension of the SSV that ascends in the posterior thigh and typically anastomoses with the GSV via the posterior thigh circumflex vein. It is clinically important because reflux from a high SPJ termination or from the GSV can cross between systems through this vessel and cause atypical varicosity patterns.

6Which perforator group connects the posterior tibial veins to the posterior arch vein at the medial calf and is a frequent source of medial gaiter ulceration when incompetent?

A.Dodd perforators

B.Hunterian perforators

C.Cockett perforators

D.Boyd perforator

Explanation: The Cockett perforators (typically Cockett I, II, III at fixed distances above the medial malleolus) connect the posterior tibial veins to the posterior arch vein (Leonardo's vein) of the medial calf. Cockett incompetence is strongly associated with C5-C6 disease — healed or active venous ulcers at the medial gaiter (lower-third of the calf).

7In the popliteal fossa, which paired veins are the most commonly imaged calf 'sinusoidal' muscle veins implicated in isolated calf DVT?

A.Anterior tibial veins only

B.Soleal and gastrocnemius veins

C.Peroneal veins only

D.Greater saphenous tributaries

Explanation: The soleal and gastrocnemius (medial and lateral) muscular veins are sinusoidal veins within the calf muscle bellies. They are the most common site of isolated calf-vein DVT (especially soleal sinus thrombosis post-immobilization) and should be specifically interrogated with compression and color flow during a complete lower extremity venous duplex.

8The deep femoral vein (profunda femoris vein) joins the femoral vein to form which named vessel?

A.Common femoral vein

B.External iliac vein

C.Popliteal vein

D.Saphenous vein

Explanation: The femoral vein (formerly 'superficial femoral vein' — terminology changed because it is a deep vein) and the deep femoral (profunda femoris) vein converge in the proximal thigh to form the common femoral vein. The CFV continues cephalad and becomes the external iliac vein once it crosses the inguinal ligament.

9Which terminology change has been adopted by major vascular societies (UIP, IUA) to avoid confusion with the superficial venous system?

A.'Superficial femoral vein' renamed to 'femoral vein'

B.'Common femoral vein' renamed to 'iliac vein'

C.'Profunda femoris' renamed to 'lateral femoral vein'

D.'Popliteal vein' renamed to 'tibioperoneal vein'

Explanation: The Union Internationale de Phlebologie (UIP) consensus (2002, reaffirmed in 2018) recommends 'femoral vein' instead of 'superficial femoral vein.' The old name caused dangerous confusion when reports describing 'superficial femoral vein DVT' were dismissed as superficial thrombophlebitis rather than a deep vein thrombosis. RPhS-aligned reporting uses 'femoral vein.'

10On a lower extremity venous duplex, which of the following describes a perforator that should be considered pathologically incompetent and reported pre-procedure?

A.Diameter <2 mm with bidirectional flow <100 ms

B.Diameter >=3.5 mm with outward (superficial-to-deep) reflux >500 ms in association with skin changes (C4-C6)

C.Diameter <1 mm with no detectable flow

D.Any perforator visible on grayscale imaging

Explanation: The 2018 SVS/AVF clinical practice guidelines define a 'pathologic perforator' in patients with healed or active venous ulcers (C5-C6) as outward flow >500 ms duration with diameter >=3.5 mm beneath a healed or open ulcer. Treatment of these perforators is supported in C5-C6 disease but routine ablation in C2-C3 is not recommended.

About the RPhS Exam

RPhS (Registered Phlebology Sonographer) is CCI's specialty credential for sonographers and clinicians who perform venous ultrasound for phlebology practice. Unlike the broader RVS, the RPhS focuses on venous anatomy and physiology, deep vein thrombosis (DVT) diagnosis, CEAP-aligned chronic venous insufficiency (CVI) assessment, reflux mapping, and image guidance for endovenous procedures including thermal ablation (RFA, EVLA), foam sclerotherapy, cyanoacrylate closure (VenaSeal), and post-procedure surveillance for EHIT.

Questions

170 scored questions

Time Limit

3 hours

Passing Score

Scaled passing score (set by CCI)

Exam Fee

$365 (CCI (Cardiovascular Credentialing International))

RPhS Exam Content Outline

15%

Lower Extremity Venous Anatomy

Deep system (CFV, FV, deep femoral, popliteal, peroneal, posterior/anterior tibial, soleal, gastrocnemius), superficial system (GSV, SSV, accessory anterior/posterior saphenous, vein of Giacomini), perforators (Cockett, Boyd, Dodd, Hunterian, paratibial), reticular and telangiectatic veins.

10%

Venous Physiology

Calf muscle pump, valve function, respirophasic flow, venous return, reflux mechanisms, ambulatory venous pressure, and the Trendelenburg/Valsalva/cuff-deflation provocation maneuvers.

15%

Ultrasound Technique for Venous Studies

Transducer selection (linear 5-12 MHz superficial, curvilinear 2-5 MHz deep), patient positioning (standing for reflux, supine for DVT), compression maneuvers, augmentation, color Doppler optimization (low PRF), and reflux measurement (>0.5 s superficial, >1.0 s deep femoral/popliteal).

20%

Acute DVT Diagnosis

Compression ultrasound, lack of compressibility, dilated lumen, echogenic thrombus, color void, proximal vs distal DVT, isolated calf DVT, IVC thrombus, May-Thurner syndrome, recurrent DVT challenges, and differential diagnoses (Baker cyst, hematoma, lymphadenopathy, lipedema).

15%

Chronic Venous Insufficiency

CEAP classification (C0-C6 with C2r, C4c, C6r additions; E congenital/primary/secondary/none; A superficial/deep/perforator/none; P reflux/obstruction/both/none), Venous Clinical Severity Score (VCSS), reflux mapping pre-procedure, perforator incompetence (>=3.5 mm with >500 ms reflux at C5-C6), and venous ulcer evaluation.

10%

Venous Procedures and Post-Procedure Surveillance

Endovenous thermal ablation (RFA ClosureFast, EVLA 810/940/980/1320/1470/1500 nm), non-thermal/non-tumescent (MOCA ClariVein, cyanoacrylate VenaSeal, polidocanol microfoam Varithena), surgical stripping (rare), sclerotherapy (STS, polidocanol), tumescent anesthesia, and EHIT Class 1-4 surveillance.

Upper Extremity and Central Venous

IJ, subclavian, axillary, brachial, basilic, cephalic; line-related thrombosis (PICC, central catheter); Paget-Schroetter (effort) thrombosis; SVC obstruction patterns on IJ Doppler.

Lymphatic and Other Conditions

Lymphedema (post-mastectomy, primary), lipedema differential, AVMs, venous malformations, phleboliths, and pelvic venous reflux contributing to atypical varicosities (vulvar, posterior thigh).

Quality, Ergonomics, and Professional Practice

IAC vascular accreditation requirements, ALARA, transducer disinfection (Spaulding classification), ergonomics to prevent WRMSD, image archiving, RPhS Code of Ethics, scope of practice, and continuing competency.

How to Pass the RPhS Exam

What You Need to Know

Passing score: Scaled passing score (set by CCI)
Exam length: 170 questions
Time limit: 3 hours
Exam fee: $365

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

RPhS Study Tips from Top Performers

1Memorize current reflux thresholds: >0.5 s for saphenous trunks/perforators/calf veins, >1.0 s for femoral and popliteal deep veins

2Master the 2020 CEAP classification with new C2r, C4c (corona phlebectatica), and C6r subclasses

3Know the EHIT (endothermal heat-induced thrombosis) Kabnick Class 1-4 system and management implications

4Distinguish thermal (RFA, EVLA — require tumescent anesthesia) from non-thermal/non-tumescent (MOCA, VenaSeal) techniques

5Drill perforator anatomy: Cockett (medial calf, ulcer), Boyd (proximal calf), Dodd (distal thigh), Hunterian (mid-thigh)

6Practice the SFJ Mickey Mouse sign, GSV Egyptian eye sign, and the vein of Giacomini connection between SSV and GSV

7Recognize bilateral CFV phasicity loss as a flag for IVC pathology

8Review the saphenous and sural nerve risk zones for below-knee thermal ablation

Frequently Asked Questions

What is the CCI RPhS exam?

The RPhS (Registered Phlebology Sonographer) is CCI's specialty credential for sonographers and clinicians performing venous ultrasound in phlebology practice. It validates expertise in venous anatomy, DVT diagnosis, CEAP-aligned CVI assessment, reflux mapping, and pre/post-procedure imaging for endovenous treatments.

How many questions are on the RPhS exam?

Per the CCI RPhS Candidate Handbook, the exam consists of multiple-choice items administered over approximately 3 hours through PSI. Verify the current item count and exam structure in the active handbook, as CCI periodically updates specialty exam parameters.

How much does CCI RPhS cost?

Application fees for CCI specialty exams are set per credential and updated periodically. Verify the current RPhS application fee on the CCI fee schedule before applying. Application fees are non-refundable per the candidate handbook.

How is RPhS different from RVS?

RPhS is a focused phlebology (venous) sonography credential covering venous anatomy, DVT, reflux mapping, and endovenous procedure imaging. RVS (Registered Vascular Specialist) is CCI's broader vascular credential covering arterial, venous, abdominal, and cerebrovascular sonography. RPhS recognizes specialist phlebology practice.

What reflux duration thresholds should I know for RPhS?

Current consensus (UIP and 2018 SVS/AVF criteria) defines pathologic reflux as >0.5 seconds for the saphenous trunks (GSV, SSV), tributaries, calf veins, and perforators, and >1.0 seconds for the femoral and popliteal deep veins. Older texts used 1.0 s for GSV; modern reporting uses 0.5 s for superficial.

What CEAP changes were added in the 2020 revision?

The 2020 CEAP revision added subscript modifiers and three new clinical subclasses: C2r (recurrent varicose veins), C4c (corona phlebectatica), and C6r (recurrent active venous ulcer). It also clarified the 'n' subscript for axes with no findings (En, An, Pn) and the 'r' modifier for recurrence.

Which endovenous procedures are commonly tested on RPhS?

Thermal ablation (RFA ClosureFast and EVLA at 810, 940, 980, 1320, 1470, 1500 nm wavelengths), non-thermal/non-tumescent options (MOCA ClariVein, VenaSeal cyanoacrylate, Varithena polidocanol microfoam), classic sclerotherapy (STS, polidocanol), and ambulatory phlebectomy.