Peripheral InterventionalProcedures

Question 1

What procedure has shown noninferiority to traditional surgical carotid endarterectomy in high-risk populations?

Answer 1

Carotid artery stenting

Supported by several registries and the SAPPHIRE trial.

Question 2

What was the primary endpoint of the SAPPHIRE trial?

Answer 2

Composite of death, stroke, and MI within 30 days

Results showed a 39% reduction in this endpoint for stenting.

Question 3

What were the results regarding 1-year event-free survival in the SAPPHIRE trial?

Answer 3

88% for stenting vs. 79% for endarterectomy

Statistically significant with p = 0.048.

Question 4

What are some criteria for high-risk candidates for carotid artery stenting?

Answer 4

• Age >80 years
• CHF III to IV
• EF < 30%
• Recent MI
• Unstable angina
• Severe pulmonary disease
• Contralateral laryngeal nerve palsy

These criteria were established based on clinical and anatomic considerations.

Question 5

What did a recent meta-analysis conclude about stenting for symptomatic carotid stenosis in older patients?

Answer 5

Should be avoided in patients age ≥70 years

Stenting might be safe for younger patients.

Question 6

What is the incidence of stroke post carotid artery stenting in high-risk patients?

Answer 6

Approaches 3%

Primary mechanism is distal embolization of atheromatous debris.

Question 7

What complication can occur due to distention of the carotid sinus mechanoreceptors during stenting?

Answer 7

Hypotension and bradycardia

Occurs in up to 40% of procedures involving internal carotid lesions.

Question 8

What was the incidence of MI within 30 days of carotid stenting in the SAPPHIRE trial?

Answer 8

1.9%

Significantly lower than after carotid endarterectomy.

Question 9

What is the compensatory response of cerebral vessels to carotid occlusive disease?

Answer 9

Compensatory vasodilation

Aims to maintain adequate blood flow to the brain.

Question 10

What are symptoms of hyperperfusion following carotid artery intervention?

Answer 10

• Throbbing headache
• Nausea
• Vomiting
• Visual changes
• Focal motor deficits
• Seizures

Symptoms can occur due to sudden increase in blood flow to dilated vasculature.

Question 11

What is the initial test of choice for diagnosing PAD according to AHA Guidelines?

Answer 11

Resting ABI

ABI is calculated by dividing the highest dorsalis pedis or posterior tibial pressure by the highest arm pressure.

Question 12

What is considered an abnormal ABI value indicating PAD?

Answer 12

ABI <0.9

Diagnosis is confirmed in symptomatic patients with this ABI.

Question 13

What medications are FDA-approved for relief of claudication due to PAD?

Answer 13

• Pentoxifylline
• Cilostazol

Cilostazol is a type III phosphodiesterase inhibitor.

Question 14

What was the result of cilostazol in a meta-analysis for patients with moderate to severe claudication?

Answer 14

Increased maximal walking distances by 50% and pain-free walking distances by 67%

Based on eight randomized trials.

Question 15

What is the normal range for ABI?

Answer 15

1.00 to 1.40

Values above 1.40 suggest a noncompressible artery.

Question 16

What is the recommendation for patients with claudication symptoms and abnormal ABI?

Answer 16

Undergo diagnostic testing for PAD

Patients with risk factors should also be tested.

Question 17

What are the independent predictors of increased walking distances in exercise rehabilitation for PAD?

Answer 17

• Use of claudication endpoint
• Program length
• Mode of exercise

These factors were identified in a meta-analysis of 33 trials.

Question 18

What is the significance of the Heart Protection Study regarding PAD?

Answer 18

Reduction in all-cause mortality by 13% and major vascular events by 24%

Study involved 20,536 patients with CAD, diabetes, or PAD.

Question 19

What is the complication rate of PTA in the infrapopliteal vascular bed?

Answer 19

Not prohibitively high

Clear indications for PTA exist despite potential risks.

Question 20

What are the lifestyle modifications recommended for patients with PAD?

Answer 20

• Aggressive management of diabetes
• Cessation of tobacco use

These modifications are essential alongside medical therapy.

Question 21

What is the risk of limb loss for smokers with claudication symptoms?

Answer 21

20% risk of limb loss

Smokers have increased rates of disease progression.

Question 22

What were the major adverse events reported in the studies?

Answer 22

No major adverse events such as death, MI, or limb loss were reported

MI stands for myocardial infarction.

Question 23

What was the p-value indicating the increase in ABIs after intervention?

Answer 23

p = 0.0001

Question 24

What is the recommended therapy for patients with PAD who smoke?

Answer 24

Pharmacologic therapy with varenicline, bupropion, and/or nicotine replacement

Referral to a smoking cessation program is also recommended.

Question 25

What type of exercise program is recommended for patients with PAD?

Answer 25

Supervised exercise programs performed for 30 to 45 minutes three times per week for a minimum of 12 weeks

Question 26

What is the effect of statin medications in patients with PAD?

Answer 26

Decrease major adverse cardiovascular and cerebrovascular events (MACCE), mortality, and major amputation or death

Question 27

Which medication has been shown to improve PAD symptoms and increase walking distance?

Answer 27

Cilostazol

Question 28

What are the mostly ineffective treatments for claudication?

Answer 28

Pentoxifylline, iron chelation with ethylenediaminetetraacetic acid, or B-complex vitamin supplementation

Question 29

What is the primary aim of revascularization in chronic limb ischemia?

Answer 29

Decreasing limb pain and improving wound healing

Question 30

What is favored in patients with high surgical risk for revascularization?

Answer 30

Endovascular revascularization

Question 31

What percentage of patients experience restenosis after balloon angioplasty within one year?

Answer 31

Approximately 60%

Question 32

What was the primary endpoint of the LEVANT 2 trial?

Answer 32

Freedom from restenosis or repeat revascularization of the target lesion at 12 months

Question 33

What are the two main causes of renal artery stenosis?

Answer 33

Atherosclerotic disease and fibromuscular dysplasia (FMD)

Question 34

What is the characteristic appearance of FMD on angiography?

Answer 34

String of beads

Question 35

What is recommended for patients with unilateral renal artery stenosis who have hypertension?

Answer 35

Treatment of renal artery stenosis may benefit patients

Question 36

What factors guide the management strategy for asymptomatic aneurysms?

Answer 36

Risk of rupture, size of aneurysm, and rate of aneurysm expansion

Question 37

What is the recommended treatment for aneurysms larger than 5.5 cm?

Answer 37

Surgical repair

Question 38

What does renal denervation target to address resistant hypertension?

Answer 38

The autonomic nervous system, particularly the sympathetic nervous system

Question 39

What was the outcome of the SIMPLICITY HTN-3 trial regarding renal denervation?

Answer 39

Renal denervation did not provide better blood pressure control than medical therapy alone

Question 40

What are the common complications associated with renal arteriography?

Answer 40

Atheroembolism, renal artery ostial trauma, dissection, and contrast nephrotoxicity

Question 41

What is the technical success rate of percutaneous revascularization in patients with FMD?

Answer 41

88.2%

Question 42

What is the combined complication rate for surgical revascularization in FMD?

Answer 42

16.9%

Question 43

What is the combined complication rate for patients who underwent surgical revascularization?

Answer 43

16.9% ## Footnote The majority of complications were defined as major (15.4%) with a perioperative mortality of 1.2%

Question 44

What is the hypertension cure rate with surgery?

Answer 44

57.5% ## Footnote This indicates the effectiveness of surgical intervention in treating hypertension.

Question 45

What is the most critical component of a technically successful endovascular AA repair?

Answer 45

Preprocedural planning ## Footnote CT provides the backbone for evaluating patient candidacy.

Question 46

What anatomic criteria must patients fulfill for EVAR?

Answer 46

Patients must have: * Iliofemoral access vessels that allow safe insertion and deployment of the device * An infrarenal aortic neck of adequate length, limited angulation, and appropriate diameter

Question 47

What was the significant finding of the EVAR-1 trial regarding 30-day mortality?

Answer 47

Endovascular repair group had 1.6% mortality compared to 4.7% in surgical group ## Footnote p = 0.007 indicates statistical significance.

Question 48

What were the long-term follow-up results of the EVAR-1 trial regarding all-cause mortality?

Answer 48

Similar all-cause mortality between endovascular and surgical repair groups ## Footnote Endovascular repair group had higher overall rates of complication.

Question 49

What was the complication rate in the endovascular group of the EVAR-1 trial?

Answer 49

17.6/100 person years ## Footnote Compared to 3.3/100 person years in the surgical group.

Question 50

What do the results of the DREAM trial indicate about endovascular vs. open surgical repair?

Answer 50

Similar long-term cumulative survival rates ## Footnote A significant reduction in aneurysm-related mortality was noted in the endovascular group.

Question 51

What is the five-year and nine-year rupture-free survival rate observed after EVAR?

Answer 51

>97% for 5-year and >94% for 9-year ## Footnote Indicates the long-term effectiveness of EVAR.

Question 52

What are independent risk factors for AA rupture?

Answer 52

* COPD * Hypertension * Female gender * Smoking * Symptoms like abdominal tenderness or back pain * Expansion >0.6 cm in 1 year

Question 53

What is the most common serious perioperative complication of EVAR?

Answer 53

Cardiac complications ## Footnote These complications are also the most common cause of late death.

Question 54

What is subclavian steal syndrome?

Answer 54

A group of symptoms due to vertebrobasilar insufficiency from proximal subclavian stenosis ## Footnote Symptoms can include upper extremity claudication, paresthesia, and visual symptoms.

Question 55

What are the indications for revascularization of the subclavian artery?

Answer 55

* Symptomatic steal syndrome * Disabling upper extremity weakness * Vertebrobasilar insufficiency * Preservation of flow to in situ internal mammary grafts * Evidence of embolic phenomenon

Question 56

What is the most efficient and precise strategy to diagnose and treat subclavian steal syndrome?

Answer 56

Angiography ## Footnote While ultrasound and MRA can help, angiography is preferred.

Question 57

What is the most commonly seen variation of right-sided aortic arch?

Answer 57

Left carotid as the first branch and left subclavian as the last branch ## Footnote Understanding this requires familiarity with embryology.

Question 58

What characterizes Takayasu’s arteritis?

Answer 58

Inflammation of the aorta and its main branches ## Footnote It primarily affects females, is more common in Asians, and has a mean age presentation of 25 years.

Question 59

What were the most common presenting symptoms in patients with Takayasu’s arteritis?

Answer 59

* Arm claudication * Light-headedness * Visual changes * Constitutional complaints (weight loss, fever)

Question 60

What is the treatment for Takayasu’s arteritis?

Answer 60

Oral steroids at 1 mg/kg for up to 3 months; cytotoxic agents if steroids can't be weaned ## Footnote Surgical treatment is indicated for refractory hypertension or severe stenosis.

Question 61

What branches does the celiac artery divide into?

Answer 61

* Left gastric artery * Hepatic artery * Splenic artery

Question 62

What is the function of the left gastric artery?

Answer 62

Provides blood flow to portions of the esophagus and the cardiac portion of the stomach ## Footnote It anastomoses with the right gastric artery.