Vascular

Question 1

Presentations of AAA

Answer 1

Incidental
Pain (abdo, flank, chest, thigh, groin or scrotum)
syncope
Hemorrhagic shock
Abdominal mass / fullness
Ureteral Colic
Upper or lower GI bleed - fisutla
High output CHF - Aortovenous or aortocaval fistula

Question 2

Physical Findings of AAA

Answer 2

Pulsatile mass
Triad: pain, mass, hypotension
Distended, large, tender, guarded abdo (blood-induced ileus)
More rare: Bruits, most have normal femorals,
VTE possible - blue toe syndrome, acute lower extremity occlusions

Question 3

Aneurysm vs Pseudoaneurysm Def’n

Answer 3

Aneurysm: Dilation of all three layers (intima, media and adeventitia)
Pseduo: Arterial wall defect that is in communication but can be walled off from true lumen

Question 4

AAA Common Misdiagnoses

Answer 4

mechanical LBP
renal colic
acute MI
prevorated viscous
Acute abdomen (pancreatitis, diverticulitis, cholecystitis, appendicitis, obstruction)
Intestinal ischemia

Question 5

3 complications of AAA repair

Answer 5

Infection
Aortoenteric fistula
Pseudoaneurysm with anastomotic leak

Question 6

Common complications of endovascular AAA repair

Answer 6

Femoral pseudoaneurysm
Infection
Ischemia - spinal cord, gut, renal, extremity
AEF
Chylothorax
Leak

Question 7

AAA - size criteria

Answer 7

< 3 cm normal
> 5 cm - risk of rupture.

Question 8

AAA Management

Answer 8

Surgical Repair is ruptured.
MOVIE - At least 6U immediately available
OR stat
Mortality with rupture is 30-40%

Question 9

Etiologies of HTN

Answer 9

Primary - Idopathic / Essential
Secondary:
*Endo:
- Hyperaldo / Cushings
- Hyperthyroid
- OCP Use
- Pheochromocytoma
*Pulmonary:
- OSA
*Renal:
- RAS
- Nephrotic / Nephritic
- DM nephropathy
- PCKD
*Toxic / Metabolic:
- Sympathomimetic
- EtOH use chronic
*Vascular
- Atherosclerosis
- Coarctation of Aorta

Question 10

Aortic Dissection Risk Factors

Answer 10

Family Hx (3x)
Bicuspid Valve
Connective tissue
Male
Hx of CV Surgery

Question 11

Classifications for AD

Answer 11

DeBakey
- Type I - Arises in ascending and includes descending
- Type II - Ascending only
- Type III - Descending only
Standford
- Type A - Ascending
- Type B - Descending (Below)
* Below the L subclavian

Question 12

AD Presentation and Signs

Answer 12

Tearing pain (Thunderclap ~ 50%)
Radiation to back
New neuro deficit
Migratory (only 17%)
Evolving symptoms

Signs:
New aortic regurg
Pulse deficit
BP discrepancy
Signs of tamponade (Beck’s: Hypotension, distended neck veins, muffled heart sounds)
Neuro findings - stroke, peripheral deficits
Widened mediastinum
Inferior or RV/posterior MI (Dissection in RCA)

Question 13

Aortic dissection Investigations

Answer 13

Trop
D-Dimer
CXR
ECG
Advanced imaging

CT-A Diagnostic Gold standard
TEE good sensitivity
TTE / POCUS less sensitive

Question 14

CXR Findings of AD

Answer 14

Wide mediastinum
Loss of PA window
Loss of Aortic knuckle
Esophagus displaced to R.
Trachea to R
L mainstem down
Pleural effusion
Apical Cap
NG deviated to R

Question 15

Role of D-Dimer in Aortic Dissection

Answer 15

94-99% sensitive
False negative: false lumen, intramural hematoma, chronic, young age

96% sensitive with cut-off of 500

Question 16

Aortic Dissection Pathway for Testing

Answer 16

High-risk physical exam findings
Risk factors
High-risk pain features
AAS most likely dx

Low - no testing
Moderate - D-Dimer
High Risk - CT-A

Practical Steps:
1. Get hx to rule out high risk features
2. Examine for new murmurs, neurodeficits, pulse deficits
3. Check BP for hypotension
4. POCUS
5. XR
6. ECG and Trop

STEMI - angio
Stroke - CT/CTA
Calculate risk based on findings.

Question 17

Aortic Dissection Treatment

Answer 17

Pain - Fentanyl
HR - Labetalol or Esmolol. If asthma can give Diltiazem or Verapamil
Then Nitroprusside or IV Ace inhibitor (Enaliprilat)

Type A: emergent surgery. med mgmt in ED. May need pericardiocentesis.
Type B: Medical management in ICU. Vasc Sx Consultation.

Question 18

5 Causes of Hypotension in AD

Answer 18

Pseudo hypotension.
Tamponade / Pericardial Effusion
STEMI
Aortic regurg
Aortic Wall Rupture (no chest tube)

Question 19

AAA leaks - 5 types

Answer 19

1 - At waist or ankles
2 - Branch vessel
3 - Leakage at anastomosis between stent components
4 - Leakage through graft material
5 - NYD

Question 20

Differential for DVT

Answer 20

Venous insuffiency
Baker’s Cyst / Rupture
Cellulitis
SVT
Vasculitis
Fracture
Lymphedema
Hematoma
Calf Strain

Question 21

Causes of elevated D-Dimer

Answer 21

Trauma
Sepsis
VTE
Aging
Recent Sx
Stroke
MI
Bed Rest / casting
Malignancy
Pregnancy

Question 22

Wells’ Criteria DVT

Answer 22

PE:
Pitting edema to symptomatic leg only
Tender to palpation
Entire leg swollen
Superficial non-varicose
Calf Swelling > 3 cm

Hx:
Previous DVT
Recent Sx / Bedridden
Active cancer
Plaster Immobilization

Question 23

Risk Factors for PE

Answer 23

Inherited thrombophilia
Cancer
Pregnancy
Prior DVT/PE

Surgery or trauma

Dsypnea
Hemoptysis
Pulse > 100
O2 < 95%
Unilateral limb swelling

Question 24

Types of PE

Answer 24

Low risk - labs and vitals normal
Non-massive - BP > 90, elevated trop/dimer, RV dysfunction, SpO2 < 94%
Submassive - Moderate distress, new RBBB, Sp)2 < 90%
Massive - Hypotension < 90 sBP for > 15 minutes, distress, cardiac arrest

Question 25

ECG and CXR Findings of PE

Answer 25

New RBBB, A. Fib, Sinus tach, Symmetric TWI in V1-V4, S1Q3T3 Unilateral basilar atelectasis, Hampton's Hump, Westmark sign (decreased BV on affected side)

Question 26

Wells PE

Answer 26

Hx: Past PE/DVT, recent Sx or immobilization, active Ca Physical: Signs of DVT, hemoptysis, HR > 100 Gestalt: Most likely Dx

Question 27

PERC

Answer 27

Cannot rule rule out if: Age > 50 OCP HR > 100 O2 sat < 95% on room air Hemoptysis Unilateral leg Hx of DVT/PE Recent Trauma / Sx

Question 28

What are Phlegmasia Cerulea Dolens and alba dolens

Answer 28

Blue leg due to massive iliofemoral DVT. (Alba - white)

Question 29

Year's Criteria

Answer 29

Signs of DVT Hemoptysis PE most likely If none of above D-Dimer < 1000 Rule out If any of signs above - D-Dimer 500 If signs of DVT - US. - If normal Dimer < 500 - If abnormal - Treat

Question 30

Differential for peripheral arterial insufficiency

Answer 30

Venous insufficieny Neuropathic ulcers Nocturnal muscle cramps Aorto-occlusive disease Vasculitis Spinal stenosis

Question 31

3 Disorders of Abnormal Vasomotor Response

Answer 31

Reynauds Disease (Phenomenon when 2nd disease present) Benign Livedo Reticularis Acrocyanosis Primary Erythromelalgia

Question 32

Reynaud's Disease Characteristics

Answer 32

Cold or emotional upset Bilateral symptoms No / minimal tissue loss No systemic disease for Reynaud's Phenomenon 2 years of Symptoms Classics - White - Purple - Red Tx: CCB for symptomatic relief

Question 33

3 Types of Visceral Aneurysms

Answer 33

Splenic Artery: (most common in young pregnant females) - Should be coiled - 70% mortality if rupture Hepatic Artery: Stem from atherscerosis, infection, post trauma, polyarteritis - Men > 60 - Usually asymptomatic - need to be treated when found SMA: 60% by non-hemolytic strep from infective endocarditis - Usually < 50, IV drug users - Upper abdo angina

Question 34

3 Types of Thoracic Outlet Syndrome

Answer 34

1) Compression of brachial plexus 2) " " subclavian artery 3) " " " vein Or all of the above 95% with compression of plexus

Question 35

Types of Infective Aneurysm

Answer 35

Mycotic - Endocarditis, strep usually or staph Atherosclerotic Pre-existing aneurysm Post-traumatic