Vascular System

Question 1

List 8 risk factors for aortic dissection

Answer 1

1. Age
2. Male
3. HTN
4. Cardiac surgery
5. Bicuspid valve
6. FHx
7. Ehlers-Danlos
8. Marfan’s
9. Cocaine use
10. Trauma
11. Exertion
12. IABP insertion
13. Congenital heart disease

Question 2

List 2 classification systems for aortic dissection

Answer 2

Stanford (2 syllables)

• Type A - ascending
• Type B - descending

DeBakey (3 syllables)

• Type I - ascending + descending
• Type II - ascending
• Type III - descending

Question 3

List 10 findings on CXR for aortic dissection.

Answer 3

1. Wide mediastinum
2. Abnormal aortic contour
3. Calcium sign
4. Double egg sign
5. Loss of PA window
6. Loss of aortic knob
7. Apical cap
8. Pleural effusion
9. Displacement of NG right
10. Right mainstem displaced right
11. Left mainstem displaced down

Question 4

What is your HR and BP target in aortic dissection? Which do you get first?

Answer 4

• HR < 60 bpm
• sBP <110 mmHg

Achieve HR goal first to avoid reflex tachycardia

Question 5

List 2 reasons why NIFEDIPINE should not be used in aortic dissection.

Answer 5

1. Reflex tachycardia
2. Doesn’t slow HR

Question 6

List 4 risk factors for AAA. What is the most important risk factor for the risk of rupture?

Answer 6

1. Age
2. Male
3. FHx
4. HTN
5. Smoking
6. DLD

Rate of size increase is most concerning

Size >5.5 cm = surgery

Question 7

List 7 complications that can arise from an INTACT AAA

Answer 7

1. Rupture
2. Aortic thrombosis
3. Embolization
4. Paralysis
5. AKI
6. Limb ischemia
7. Aortocaval fistula
8. Aortoenteric fistula

Question 8

List 4 late complications of AAA repair

Answer 8

1. Endoleak
2. Infection
3. Aortoenteric fistula
4. Pseudoaneurysm

Question 9

Explain the 4 types of endoleak

Answer 9

Type I

• Leak from end of graft

Type II

• Leakage into aneurysm sac from branch vessels

Type III

• Leak between stent components

Type IV

• Leak through graft material

Question 10

How is arterial embolism best managed?

Answer 10

Embolism

• Fogarty Catheter Embolectomy

Thrombus

• Fogarty Catheter Embolectomy
• Bypass Graft

Non-Limb Threatening

• Heparin
• Intra-arterial tPA

Amputate if irreversible ischemia

Question 11

What is Buerger’s sign?

Answer 11

• Patient supine, raise leg 45 degrees
• When feet have pallor, sit with hanging over edge
• Normal if colour returns in 10-15s
• Advanced ischemia if >20s
• Ischemic if cyanotic first, then red

Question 12

How do you differentiate embolus from thrombosis?

Answer 12

Embolus

• Usually have afib
• Other leg is normal, no claudication
• Sharp demarcation of ischemia
• Few collaterals

Thrombus is opposite

Question 13

What are the 5 diagnostic criteria of Buerger’s disease? What is the only treatment?

Answer 13

1. Smoker
2. Absence of atherosclerotic risk factors
3. Onset <50 yo
4. Infrapopliteal arterial occlusions
5. Upper limb involvement

Treatment

• Stop smoking

Question 14

Differentiate phlegmasia cerulea dolens & phlegmasia alba dolens

Answer 14

Phlegmasia cerulea dolens

• Massive iliofemoral DVT
• Cyanotic leg

Phlegmasia alba dolens

• Arterial insufficiency from massive iliofemoral DVT
• White leg

Question 15

List 5 diagnostic criteria for Raynaud’s disease.

Answer 15

1. Symptoms >2yr
2. Worse in cold/emotion
3. Bilateral
4. No gangrene
5. No disease that causes Raynaud’s phenomenon
6. Scleroderma, SLE, RA

White –> Blue –> Red

Question 16

22 yo male with months of severe pain in the ulnar distribution of his left arm. Worse at work (stocks overhead shelves). Diagnosis? Best test?

Answer 16

Thoracic Outlet Syndrome

Elevated Arm Stress Test (EAST)

• Most reliable screening test
• Abduct arm and elbow to 90 degrees
• Open/close fists for 3 min
• Positive if:
• Early fatigue
• Numb hand
• Progressive aching to top of arm/shoulder

Question 17

List 8 DDx for DVT

Answer 17

1. Muscle strain, hematoma
2. Baker’s cyst
3. Lymphedema
4. Cellulitis
5. Vasculitis
6. Fracture
7. Superficial phlebitis
8. Chronic venous insufficiency
9. Proximal venous compression (pregnancy, tumour)
10. CHF
11. Hypoalbuminemia

Question 18

What are the 10 components of the Well’s Score for DVT?

Answer 18

C3P3O R2D2 - note it is not C3PO

1. Cancer
2. Collateral superficial veins
3. Calf swelling >3 cm larger than other
4. Pitting edema
5. Previous DVT
6. Pain along the deep venous system
7. Oedema of the entire leg
8. Recent immobilization
9. Recent surgery (3mo)
10. Different diagnosis more likely (-2)

If 2+, get U/S. If 0/1, get D-dimer

Question 19

List the dose of the following mediations in treatment of DVT:

• UFH
• Enoxaparin
• Dalteparin
• Rivaroxaban

Answer 19

• UFH 80 units/kg IV bolus, then 18 units/kg IV infusion
• Enoxaparin 1 mg/kg SC BID
• Dalteparin 100 units/kg SC BID
• Rivaroxaban 15 mg PO BID

Question 20

Name 3 absolute contraindications for treating a proximal DVT.

Answer 20

1. Active bleeding
2. Bleeding diathesis
3. PLT <20
4. Intracranial bleed
5. Recent NSx/Ocular Sx

Question 21

What are the 7 components of the Well’s Score for PE?

Answer 21

Don’t Die Tell Team To Calculate Criteria

1. DVT symptoms (3)
2. Diagnosis most likely PE (3)
3. Tachycardia (1.5)
4. Three days immobilized/30 days surgery (1.5)
5. Thromboembolism in the past (1.5)
6. Cancer (1)
7. Coughing blood (1)

If score >4, CT. If score 4 or less, D-dimer

Question 22

What are the 8 criteria in the PERC rule?

Answer 22

HAD CLOTS

1. Hormones
2. Age >50
3. DVT/PE history
4. Coughing blood
5. Leg swelling
6. Oxygen >95%
7. Tachycardia
8. Surgery in last month

Question 23

What are 5 CXR findings of PE?

Answer 23

1. Hampton’s hump
   * Wedge-like opacity at the edge (infarct)
2. Westermark’s sign
   * Unilateral lung oligemia
3. Fleischner’s sign
   * Enlarged pulmonary artery
4. Pleural effusion
5. Unilateral basal atelectasis

Question 24

List 5 ECG findings that can occur with PE

Answer 24

1. Sinus tachycardia
2. TWI V1-V4
3. RBBB
4. RAD
5. S1Q3T3
6. ST changes
7. Afib

Question 25

What are 6 treatments available in massive PE?

Answer 25

1. Anticoagulation 2. Fluid resuscitation 3. Vasopressors/Inotropes 4. tPA 5. Catheter-directed tPA 6. Embolectomy

Question 26

What is the dose of tPA in massive PE? How do you give it?

Answer 26

Dose = 0.9 mg/kg The administration is contentious. * If dead, 50% upfront, 50% over 1 hr * If not dead, perhaps 15% upfront, 85% over 1 hr

Question 27

Define massive PE

Answer 27

* Cardiac arrest * Profound hypotension (sBP \<90) * Bradycardia \<40 bpm

Question 28

List 3 indications for tPA in massive PE

Answer 28

1. Cardiac arrest 2. Persistent hypotension 3. Cardiogenic shock These are basically the definition of massive PE

Question 29

List 8 absolute contraindications for tPA

Answer 29

**Absolute** 1. Active bleeding 2. AVM 3. Brain cancer 4. ICH 5. Aortic dissection 6. Severe hypertension 7. Closed head injury within 3 months 8. Stroke within 3 months 9. Brain/Spine Sx within 2 months

Question 30

List 8 relative contraindications for tPA

Answer 30

**Relative** 1. Severe hypertension 2. Other intracranial diseases 3. CPR \>10 min 4. Surgery within 3 weeks 5. GI bleed within 3 weeks 6. Plt \<100 7. Non-compressible vascular access 8. Pregnancy 9. OAC