Vascular/cardiac

Question 1

Carotid artery stenosis paratmeters. PSV and ICA to CCA ratio.

1. <50% stenosis (normal)
2. 50-69%
3. >70%

Answer 1

1. <125. ICA/CCA <2.0
2. >125. ICA/CCA>2.0
3. >230 cm/sec PSV. ICA/CCA>4.0

Question 2

If you see Tardus parvus in both Common carotids, where is the stenosis?

Answer 2

Aortic valve

Question 3

Causes of subclavian steal syndrome?

Answer 3

MCC: athersclerosis.

Less common: Takyasu’s vasculitis, radiation.

Question 4

Reversal of diastolic flow in Both common carotids - what is diagnosis?

Answer 4

Aortic valve incompetence

Question 5

ICA vs. ECA

1. Resistance, systolic/diastolic, diastolic return to baseline. Continuity of flow
2. How can you tell on imaging which is which?

Answer 5

1. • ICA is low resistance. Low systolic and high diastolic. Diastolic flow will never go to baseline. Continious flow.
     - ECA is high resistance at baseline. High systolic and low diastolic. Diastolic flow will drop below baseline. Intermittent flow.
2. ECA has branches. You can do temporal tap.

Question 6

What does brain death look like on ICA doppler

Answer 6

1. ICA will become high resistance. There will be loss of diastolic flow.

Question 7

Difference between Stanford A and Stanford B dissection

Answer 7

Stanford A is proximal to left subclavian. This is surgical

Stanford B: dissection is distal to left subclavian. This is medical treatment, unless there is end organ damage

Question 8

In a normal dissection flap, which lumen is big, which lumen has calcifications, and which lumen contains the takeoff of left renal?

Answer 8

False lumen is usually bigger

True lumen has the calcifications

False lumen frequently contains the takeoff of the left renal artery. Others usually come off the true lumen

Question 9

Best MR sequence to look for dissection

Answer 9

T1 w/ fat suppression. You would see crescent sign.

Question 10

What is the pathophys of an acute intramural hematoma?

Answer 10

Rupture of vaso vasorum in media w/o intimal tear. Seen well on noncontrast CT sequence.

Question 11

1. aneurysm mortality predictors
2. What is strongest predictor of dissection

Answer 11

Ascending aorta >5cm. Intramural hematoma>2cm. Pericardial effusion

2. Size of aneurysm.

Question 12

What are the 3 Acute aortic sydrome entities, and what is their most common causes?

Answer 12

1. Penetrating ulcer: athersclerosis
2. Dissection: HTN
3. Itramural hematoma: HTN.

Question 13

3 spots where aorta is injured during trauma (all spots are tethered, which is why they are injured w/ trauma)

Answer 13

1. Isthmus
2. Aortic root
3. By the diaphragm.

Question 14

Types of graft leaks. Which is most common?

Which are most common vessels involved in Type 2

Answer 14

1. Distal or proximal leak (1A is proximal, 1B is distal)
2. Feeding vessel (most common). Most common feeding vessels are IMA and lumbar.
3. Fracture of the graft itself
4. Porous graft. (mneumonic: four Por) - rarely seen with modern grafts.
5. Endotention (controversial) - thought to be due to leak below resolution of imaging.

Question 15

Marfan’s

Classic finding in Marfan’s

Answer 15

Annuloaortic ectasia: tulib Bulb appearance.

Aortic valve insufficiency. High risk for rupture.
Should be repaired early (around 5.5 cm)

Question 16

Entity with extremely tortuous neck vessels (Marfan’s on steroids)

Answer 16

Loeys Dietz

Question 17

Unilateral swollen LEFT leg - vascular cause of this

Answer 17

May Thurner syndrome - Left sided iliac vein compressed by right sided iliac artery.

Treatment is thrombolysis and stenting.

Question 18

Median arcuate ligament syndrome.

Compression of Celiac is worse with what? inspiration or expiration

Answer 18

Compression is worse with expiration (not intuitive).

Question 19

Popliteal artery aneurysm is a/w what other findings

Answer 19

contralateral popliteal aneurysm, AAA, acute limb thrombosis.

Question 20

Where are most common locations for fibromuscular disease?

Answer 20

Renal artery, carotid, iliac artery. Treatment is angioplasty without stenting.

Question 21

1. Giant cell arteritis - Demographics. which arteries are effected?
2. Takayasu’s - Demographics. which arteries

Answer 21

1. Temporal artery, axillary/brachial artery. In old people. (old person needs GIANT crutches, and those crutches mess up the axilary/brachial arteries).
2. Young asian girls. Vasculitis involving aorta. Often involves aortic valve and causes aortic insufficiency. (A is for Asian and for Aorta).

Question 22

Thoracic outlet syndrome.

1. what is compressed?
2. What muscle is usually the cause?
3. What is the name of syndrome when a venous thrombus develops?

Answer 22

1. Subclavian vessels, brachial plexus. (Nerve>vein>artery)
2. Anterior scalene muscle and cervical ribs are most common cause of compression.
3. Paget Schroetter - thoracic outlet syndrome w/ thrombus in subclavian vein.

Question 23

Aortic occulusion syndrome - Name. Classic Quartet

Answer 23

Leriche syndrome

classical quartet of impotence, buttock claudication, absent femoral pulses, and cold lower extremities.

Question 24

Aortic coarctation

1. Who gets pre-ductal, who gets post-ductal?
2. Rib notching involves which ribs?
3. What is pseudocoartctation
4. Associations?

Answer 24

1. Preductal; infants. Postductal: adults
2. Rib notching occurs in 4th-8th ribs
3. Pseudocoarctation - looks real but there are no collaterals or BP differences.
4. Turners. Berry aneurysms.

Question 25

What is the syndrome name with angiodysplasia and aortic stenosis?

Answer 25

Heyde syndrome

Question 26

What is correct location for aortic balloon pump? How does it work?

Answer 26

Balloon tip should be located just distal to the left subclavian artery. Balloon inflates during diastole, therefore the blood returns up and goes to coronary arteries.

Question 27

Describe normal branches of aorta

Answer 27

This is seen 66% of the time.

Question 28

What is this called?

Answer 28

Common brachiocephalic artery artery and left common carotid Thisi s sometimes incorrectly called "bovine aortic arch"

Question 29

What is a diverticulum of Kommerel?

Answer 29

Small bulge at oritin of aberrant subclavian artery. Abberrant subclavian originates from aorta, goes behind esophagus, and may cause dysphagia lusoria

Question 30

What is a 4 vessel arch?

Answer 30

left vertebral origin off aorta

Question 31

Acute aortic syndrome Where is the defect in: PAU IMH Dissection

Answer 31

PAU: defect in intima IMH: defect in media Dissection: defect in intima extending into the media.

Question 32

Risk factors for aortic dissection

Answer 32

Hypertension, connective tissue disorders (Marfan), cocaine, aortopathy, bicuspid aortic valve, weight lifting, sudden deceleration injury.

Question 33

Intramural hematoma - blood collects in the media w/o an intimal flap to connect the imh and aortic lumen 1. What causes IMH? 2. Presentation can be similar to dissection with tearing back pain. What is treatment? 3. Imaging?

Answer 33

1. Thought to be caused by rupture of vasa vasorum Caused by HTN, like dissection. 2. Tx is same as dissection. Surgery for ascending, BP control for descending 3. Faint peripheral hyperattenuating (45-50) crescent w/in aorta, best seen on noncontrast CT

Question 34

Penetratic atherosclerotic ulcer - penetrates intima, allowing blood to extend into media. May lead to aneurysm formation. 1. Cause? 2. Imaging?

Answer 34

1. In contrast to dissection and IMH, this is caused by atherosclerosis, rather than HTN. 2. Contrast ulcerating beyond the expected contour of aortic wall.

Question 35

Traumatic aortic injury 1. 3 places that it occurs 2. Direct CT signs of traumatic aortic injury Mediastinal hemorrhage is usually venous, but if the hemorrhage is connected to aortic injury, it will need to be surgically repaired.

Answer 35

1. Aortic root, isthmus, hiatus. Resulting pseudoaneurysm is held in place by surrounding connective tissues. 2. Dissection flap, pseudoaneurysm, intramural hematoma.

Question 36

Thoracic aortic aneurysm 1. Diameter parameters 2. Name some non-atherosclerotic causes of TAA 3. What is annuloaortic ectasia associated with? Describe it. 4. When is surgery recommended for TAA 5. What is a sign of impending rupture? 6. Complications of TAA treatment?

Answer 36

1. Ascending aortic diameter \>4cm, or descending thoracic aorta \>3 cm. 2. connective tissue disorders (marfa, ehlers-danlos), bicuspid aortic valve associated aortopathy, vasculitis (takayasu, GCA, ankylosing spondylitis, relapsing polychondritis), cystic medial necrosis, infectious aortitis. 3. It is associated with Marfan and Ehlers Danlos. Dilated sinuses of valsalva and ascending aorta with effacement of the sinotubular junction, resulting in a tulip bulb-shaped aorta. 4. Ascending \>5.5 cm or descending \> 6 cm. Or growth rate of 5mm/6 months or 1cm/year. However patients with connective tissue disorders of Bicuspid valve have a lower threshold of \>4.5. 5. Draped aorta sign 6. rupture, dissection, infection, endoleak, paraplegia (artery of adamkiewicz).

Question 37

Abdominal aortic aneurysm 1. Size parameter 2. What is the risk of rupture of AAA greather than 7cm 3. when is surgery recommended Mortality of AAA surgery is 3% for elective, 19% for urgent. 4. complications of AAA repair

Answer 37

1. \>3cm 2. 32.5% 3. \>5.5cm or expansion of \>mm/year or symptomatic? 4. dissection, infection, endoleak, aorto-enteric fistula.

Question 38

Screening Ultrasound of AAA recommendations on size 1. \<4cm 2. 4-4.5 3. 5-5.5 cm 4. \>5.5 cm

Answer 38

1. annual surveillance 2. 6 month surveillance 3. consider surgery 4. surgery recommended

Question 40

Right or left coronary dominance is determined by what? which coronary artery is usually dominant?

Answer 40

Artery that gives off PDA (Posterior decending artery), PLA and AV nodal branch is considered dominant. It is RCA 85% of the time. 7% of time, the left artery is dominant because left circumflex gives off PDA, PLA, AVN 7% of the time it is co-dominant.