Youtube

Question 1

Definition of vascular compression syndrom

Answer 1

Vascular compression syndromes are a group of conditions compression resulting from mechanical compression of blood vessels by adjacent structures leading to compromised of blood flow.

Question 4

Cas #1:
▫️22 y old female reffered for symptomatic right subclavian artery stenosis
▫️ Absence of significant medical or surgical past history
▫️ Clinical examination , a hard mass in the right basal neck , reduced brachial artery pulsation and right cervical murmur
▫️echo :Calibre reduction and aneurysmal dilation of subclavian artery .
Deviation of right subclavian artery on color flow Doppler.
Intermittent Irregular flow of right subclavian artery on supine position whe any motion of the arm ( no irregular rythm , nor ectopic beat ).

🔶️Wich examination is needed to make and confirm the diagnosis of the anomaly ?and what is the diagnosis

Answer 4

🔷️anterior Cervical X Ray :Cervical ribs (right C7): vertèbre cervicale en contacte avec la 1ere cote
🔷️CT angiography :thight stenosis of the right subclavian artery
the mobility of the artery and compression during breathing explains the am of intermittent subclavian flow.
Left subclavian artery : dilatation post stenotique

🔸️Diagnosis:
Bilateral thoracic outlet arterial syndrome with cervical ribs .

Question 5

Why should we not misdiagnosing TOS ?thorasic outlet syndrom

Answer 5

• Arterial lesion can be dramatic and can lead to severe ischemia ( possible limb amputation !!)
• Venous complication need urgent treatment (effort thrombosis Schratter ) to prevent PE.
• Nervous symptoms are the main clinical presentation and need early diagnosis.(amyotrophie de la loge thenar ++ )

Question 6

Quatre zones de compression potentielle dans le défilé thoracobrachial

Answer 6

1 Le défilé inter-costo- scalénique
2 Le canal costoclaviculaire
3 Le tunnel sous- pectoral
4 Le billot huméral

Question 7

Pathology of TOS

Answer 7

• Muscle hypertrophy due to sport activity in specific sports: basket ball, hand ball, shot put , body building , javelin , weightlifting
• Bones anomaly causing vascular compression : Cervical rib , apophysomegaly ,agenesis of first thoracic rib

Question 8

Diagnosis of TOS

Answer 8

• Clinical examination +++
• Cervical XR, Chest XR : cervical rib, agenesia of first rib.
• Electromyography.
• Color Doppler ultrasound with dynamic maneuvers
• CT angiography , 3D angiography , Catheter based angiography.
• CT venography

Question 9

Clinical diagnosis of TOS :ROOS Test

Answer 9

Dynamic maneuver :
• ROOS Test or elevated arm stress test ( EAST ) : The patient has both arms in the 90° abduction-external rotation`position
• Test : the patient is to open and close the hands slowly over a 3 minutes
• Results : gradual increase in pain at neck and shoulder, progressing down the arm
• Venous compression: cyanosis , swelling
• Arterial compression : pallor , reactive hyperemia

Question 10

TOS clinical presentations

Answer 10

• Neurogenic (n TOS) :nerve compression C5-D1 (95%)
• Venous (v TOS):effort DVT (3%)
• Arterial (a TOS ): acute or subacute ischemia ( 1%).

Question 11

What is n TOS ?

Answer 11

• Clinical examination and medical history are essentials for diagnosis +++:
🔹️ • neurologic symptomd depends of levels of compression
🔹️ • High level compression : C5,C6,C7 ou low level :C7,C8,D1
🔹️• Pains and paresthesias: neck, shoulder, arm, fore arm anterior wall of chest, between shoulder and chest.
🔹️ • May be associated with ulnar nerve compression at elbow and median nerve at wrist

Exemple : PE and Superior vena cava thrombus in a patient with n TOS.

Question 12

V TOS ?

Answer 12

• Oedema , cyanosis, fore arm fatigability
• Superficial venous circulation
• Effort thrombosis ( Paget-Schroetter )
• Pulmonary embolism ( 2 to 35 %)

Exemple :
●Chronic Thromboembolic Pulmonary Hypertension Due to Upper-Extremity Deep Vein Thrombosis Caused Thoracic Outlet Syndrome

Question 13

A 36-year-old woman presented with a 3-week history of swelling and bluish discoloration of her left arm The symptoms started after she had spent 10 days typing at a desk. Venography was performed: veinal stenosis
Diagnostic ?

Answer 13

Venous Thoracic Outlet Syndrome

Question 14

A 36-year-old woman presented with a 3-week history of swelling and bluish discoloration of her left arm The symptoms started after she had spent 10 days typing at a desk. Venography was performed: veinal stenosis
Diagnostic ?

Answer 14

Venous Thoracic Outlet Syndrome

Question 15

On voit quoi sur l’echo de Artère sous Clavière gauche au repos et après manæuvre dynamique en cas de sd de defilé thoraco brachial ?

Answer 15

Réduction de Calibre

Question 16

On voit quoi sur l’echo de Artère sous Clavière gauche au repos et après manæuvre dynamique en cas de sd de defilé thoraco brachial ?

Answer 16

Réduction de Calibre

Question 17

On voit Quoi à l’echo de v TOS in a body builder young man with Paget Schroetter syndrome ( Effort DVT)?

Answer 17

Thrombus et un contraste spontanée par exemple

Question 18

What we see in Dynamic color Doppler ultrasound of compression of right subclavian artery?

Answer 18

Arrêt de flux artérielle
Doppler pulsé : Augmentation de vitesse puis un arrêt puis la réapparition de flux

Question 19

Exemples of à TOS

Answer 19

●Subclavian artery aneurysm thrombus causing hand ischemia. Flux pulpaire amorti jusqu’à gangrène
●A TOS with aneurysm dilation

Question 20

Non operative treatment of nTOS:

Answer 20

• Physiotherapy : Initial treatment
Life style modification ( limiting exacerbating activity ).
2 to 3 times per week ( protocol of 8 to 12 weks )
60% to 90% with n TOS can ovoid surgery ( Novak 1995, Lindgren 1997).

• Lidocaine injection into scalene muscles ( potential response to rib resection ).

• Botulin toxin injection ( relax the scalene muscle and decreasing nerve compression ).

Question 21

Non operative treatment of v TOS:

Answer 21

• LMWH treatment of choise
• 50% to 85% of patients treated with anticoagulation alone will have residuel symptoms.
• Compression therapy with elastic bandages and sleeve.
• Pharmacologic and mechanical thrombolytic therapy with success rate reported at 100%
• Any benefit is negligible if performed > 14 days after symptom onset

Question 22

Treatment of aTOS:stages

Answer 22

Scher class fication of surgical treatment for subclavian artery pathology
🔺️ Stage 0: Asymptomatic subclavan artery
No surgical treatment except for high-performance athletes or patients compression required to perfom repetitive movements wth a fected ar: monitor for arterial wal degeneraton
🔺️Stade 1: Subclavian artery stenosis with mild
Decompress thoracic outlet and reimage subclavan artery
dlation but no intimal injury
🔺️stage 2 : Subclavian artery aneurysm wth mural
Decompress thoracic outlet and reconstruct subc lavian artery thrombus
🔺️Stage 3 :Arterial thrombasis or distal embolization with occlusion
Thrombectomy vs thrombolysis : decompress thoracic outlet and reconstruct subclavan arter

Question 23

A 20 Y old man refered for evaluation of a lower limb arterial disease
• Negative medical past history, tobacco use
• Recent intermittent of R limb during walking , estimation of distance near to 500 meters aggravation when walking through slope
• Previous Doppler ultrasound shows abnormal flow in arterial R leg
•doppler flow : Right popliteal artery and vein were separated at the leve knee and upper knee ( by muscular band).
Doppler flow of L popliteal artery during dynamic maneuver ( use plantar flexion ) resulting of flow disappearence due to complete shum compression of the artery
Right popliteal artery : linear echoic defect in the lumen
B mode ultrasonography : Effects of dynamic maneuver on left popliteal artery ( plantar flexion muscle contraction )=>réduction de Calibre au moment de flexion
●COMPIL RENDU DE_L’EXAMENECHOGBAPHIE DOPPLERCOULEUB_DES_ARIERES_DES MEMBRES_INEERIEURS:
L’aorte abdominale est de calibre normal Les artères iliaques communes et externes sont perméables Les bifurcations fémorales sont perméables. Les artères témorales auperficielles sont Raukabisa. A droite Thrombose entendue de l’artère poplité supra-articulaire jusqu’a son segment inter-acticulairs. qul est perméable et re: iolestee par la collateralite.. i existe une dissection au niveau do la thrombose mis en Gvidence par la présence d’un lambeau intimale au niveau de la lumière ) on note une séparation de la veine et de l’artére poplité par une bandelette musculaire L’artère tibiale antédeurs.. postérieure et péronière sont de la cheville est de 85 mm Hg perméables mais de flux amortl La pression systolique au niveau A gauche On note une stenose tres courte et moderée au niveau de l’artere poplité intersacticulairs qul présente un epaississement iatimals lors de la mancouvre d hyperextension du pied on note un écrasement de fartere poplité avec arret du flux circulatoire On note une potite dilatation de lartére poplité en aval de la sténose (diamétre de l’artére poplité de 5,5 mm et 8 mm en aval de la sténose) Les arteres jambieres sont paucables La pression systolique au niveau de la cheville est de 85 mm Hg.
CONCLUSION
Thrombose de Fartère poplité droite sus articulaire associée a une sténose trés courte de Fartére poplité gauche sus articulaire Laxeg legere dilatation de l’artere poplité en aval de la sténose ) en rapport avec un syndrome de l’artère poplité plégée bilatéral.

• Angio-CT performed latter (occlusion de l’artère poplitée droite et Sténose de l’art poplitée gauche)
• Planned to be operated abroad by endovascular surgery.

What is your diagnosis ?
1. Premature atherosclerosis.
2. Buerger’s disease.
3. Thrombophilia or sytemic immune disease .
4. Cystic degeneration of popliteal artery
5. opliteal artery entrapment

Answer 23

5

Question 24

Sd de l’artere poplitée piégée classification

Answer 24

Type 1 The poplieal artery is abeormally nanning medial to the medial head of the gastrocnenius,which has a normal insertion.
Type2 Entrapment results from an aberant insertion of’the medial head of the gastrocnemius muscle
Type 3 Entrapment results from an accessory slip from the medial head of the gastrocnemius muscle.
Type 4 The popliteal artery is compressed when passing under the popliteal muscle or under a fibrous web.

Autre :
Type I Popliteal artery displaced medially by the medial head of the gastrocnemius muscle
Type ll Medial head of the gastrocnemius head attached laterally tio the popliteal artery
Type lll Accessory muscle strings/hibrous bands arising from the medial head of the gastrocnemius muscle
type 4 Popliteal artery compressed by muscle strings/fibrous bands arising from the popliteal muscke
Type 5 Entrapment of the popliteal vein
Type 6 Other variants
Type F Functional entrapment

Question 25

Exemples de popliteal artery entrapment

Answer 25

1 young hand baller with bilateral popliteal aneurysms with PAE operated 2 A 16 y old boy with severe bilateral lower arterial disease due to thromboembolism from bilateral popliteal artery aneurysms complicating PAES. 3 21 y old lady volley ball player with past history of bilateral claudication of lower limbs during 3 years Duplex ultrasound : dynamic compression of bilateral popliteal in favour of popliteal entrapment syndror 2 Angio-CT Scan reveal no compression of popliteal arteries I! Conclusion Absence de syndrome de l'artère ou de veines piégées poplitées décelables. Cenchesion: Absence de signes de sténose des artéres des membres Inferleurs piège dans l' évaluation de l' artère poplitée piégée I Dynamic Doppler ultrasound L'aorte abdominale est de calibre normal. Les artéres iiaques communes et externes sont perméables. Les bifurcafons témorales sont permeables. Les anteres lemorales supericieles e popites sont permeables Les arteres obiales anhérieures, tbiales poshérieures sont perméables a noter que Tartere poplité ne présente pas d anomalie de trajet et n'est pas séparée par une bandelete musculaire avec la veine poglte. Lors.de la posion debaut. on pralique un enregistrement du fux au miveau des artéres tiiales antérieures au miveau de leur crosses , lors du passage vers T'atftude en extension des pieds ( pafiente se tenant sur la pointe des pieds ), on obtient wn abolition du signal Doppler des 2 cotis ,les artères poplités sont comprimés par les structures musculaires au niveau des creux popiwis ce quiest en laveur d un piege a ce niveau. 4 Jogging Disease It Affect Healthy Athletes

Question 26

• 18 old female , preparing graduating high school , referred for < chronic left lumbar pain and hematuria • Disabling pains evolving for 3 years , high intensity , use of Tramadol* tablets (morphinic analgesic ). • Macro and microscopic hematuria • Abdominal CT scan : no significant anomaly. At this age what is the probable origin of left lumbar pains? 1. Renal lithiasis 2. Pancreatitis 3. Psychosomatic ( preparing high school diploma ) . 4. Left renal vein elevated pressure Wich is your first examination to perform on your patient ? 1. Abdominal CT-Angiography . 2. Doppler ultrasound 3. Magnetic angiography. 4. Uretro-cystoscopy.

Answer 26

Dc 4 Examination 2

Question 27

At this age what is the probable origin of left lumbar pains? 1. Renal lithiasis 2. Pancreatitis 3. Psychosomatic ( preparing high school diploma ) . 4. Left renal vein elevated pressure

Question 28

What is the nutcracker syndrom

Answer 28

Nutcracker syndrome is one of the abdominal venous entrapments, aused by compression of the left renal vein between the superor mesenteric artery and the abdominal aorta. Ocasionally a retro-aortic left renal vein is compressed between the aorta and the vertebral body (postericr nutcracker symdrome)_ The renal vein distl to the compression is dilated and renal venous flow can be diverted toward the pevis through an incompetent,refuxine left wvarian or spermatic vein,in addidion to dninage through retroperitoneal venous colaterals. In this article, we describe the diffrent surgical and endovascular techniques that are used to treat ths syndrome

Question 29

Computed Tomography au cours de nutcracker syndrom

Answer 29

• CT scan with 3 dimensional reconstruction imaging is considered of great value in diagnosing nutcracker syndrome including: • Beak sign: triangular shape of narrowing of the left renal vein at the aortomesentéric portion.This represents severe form of narrowing.the sensitivity of this sign is reported to be 91,7% ans the specificity is 88,9%. • Left renal vein diameter ratio ( hilar-aortomesenteric) cut-off of 4,9. • Angle between the superior mesenteric artery and the aorta cut-off value of 41". • Well-developed collateral veins in the retroperitoneum and around the renal hilum.

Question 30

Nutcracker Syndrome---A Rare but Important Cause of Varicocele in Adolescent Boys is ?

Answer 30

Nutcracker syndrome is a complex of clinical symptoms due to compression of the left renal vein between abdominal aorta and superior mesenteric artery. Hematuria and pelvic or back pain are the most common presenting symptoms with varicocele being an uncommon clinical finding in these patients especially in children. Doppler ultrasound, computed tomography and selective left renal vein phlebography are useful to confirm the diagnosis. Treatment can be conservative or surgical depending on the severity of symptoms. Here, we report a 13 year-old boy with left flank pain and varicocele on examination who on evaluation was found to have nutcracker syndrome as the etiology.

Question 31

Nutcracker surgical treatment

Answer 31

Reimplatntation de l'art rénal plus bas pour afin d'éviter la compression par l'art mésentérique sup

Question 32

Nutcracker endovascular stenting

Answer 32

Stent entre l'art mésentérique sup et l'aorte

Question 33

C quoi le nutcracker posterieur

Answer 33

C une compression de la veine qui passe entre l'aorte abdominale et le rachis lombaire

Question 34

Difference entre syndrome de natcracker et phénomène de nutcracker

Answer 34

Phénomène de nutcracker :30%de population Syndrome : Augmentation de pression au niveau de volume ovarienne ou de la veine spermatique surtout avec la congestion pelvienne

Question 35

• Frequent in female (4:1). • Age:30y-40y. • Symptoms: epigastric pain,nausea,vomiting, weight loss, post prandial pain ,exercice induced abdominal pain. • Diagnosis : exclusion diagnostic +++ • Duplex ultrasound :deflection angle >50 betwen inspiration and expiration ) and expiration PSV>350 cm/sec ( $s:83% Sp:100%) CTA: proximal celiac stenosis with hook appearance wich make difference with atherosclerotic lesions. What is it ?

Answer 35

Median arctuate ligament syndrome MAEs

Question 36

Presenting symptoms for patients with median arcuate ligament syndrome (MALS) in published series

Answer 36

Weight loss Diarrhea Postprandial/epigastric pain Nausea Abdominal bruit

Question 37

Origins of pains in MALS:

Answer 37

• Neurogenic component ( neuropathic pain). • Arterial ischemic component ( post prandial ischemic pain )

Question 38

Quels sont les critères échographiques évocateurs du MALS ?

Answer 38

Vitesse du flux dans l’artère cœliaque > 200 cm/sec Vélocité télédiastolique > 55 cm/sec Vitesse accrue en expiration profonde (compression dynamique) Angle de déflexion > 50° entre inspiration expiration

Question 39

Q : Quel est le mécanisme du MALS et quel test le confirme ?

Answer 39

R : Mécanisme : compression de l’artère cœliaque par le ligament arqué médian Test clé : Doppler mésentérique montrant une augmentation du flux en expiration

Question 40

61 k old lady referred for recent left leg edema with calf pain with restricted walking distance • Medical past history : multinodular goitre , normocalcic hyperparathyroidism • Clinical examination left calf augmentation volume with > 1 cm calf circumferentiel size than right calf • Normal lower limbs pulses palpation • Absence of varicose veins , collaterals veins circulation (-) COMPTE RENDU DE L'EXAMEN ECHOGRAPHIEDOPPLERCOULEURDESVEINES_ETDES ARTERES_DES MEMBRES INERIEURS: Sur le plan veineux La veine cave inferieure est perméable. Les axes veineux ifaques sont perméables. on note cependant une compression dynamique de la veine liaque commune gauche (en décubitus dorsale) par Tartére Wiaque commune droite qui disparait en décubitus latéral droit. En décubitus dorsal, E veine hypogastrique gauche est le siege dune inversion du flux en rapport avec la compression dynamique de la veine iliaque commune gauche, son flux est restaure lors du passage en décubitus latéral droit. Par ailleurs les veines des membres intérieurs sont perméables, on note cepondant une perte de la rythmicité respiratoire tant au niveau de la veine iiaque externe que de la veine fémorale superficielle et poplitée gauches. Sur le plan artériel ^ 'aorte abdominale est de calibre normal. Les antdres iliaques. les bilurcations fémorales. les axes fémoro-poplités et jambiers sont perméables. CONCLUSION: Artères et veines des membres inférieurs peungables, Exploration veineuse en faveur d'une compression de la veine Maque comiune gauche par l'artère iliaque commune droite en faveur d'un syndrome de COCKET ou MAY-TÚRNER. Du fait des symptômes sur le plan cinique un phléboscanner est indiqué. What is the right answer? 1. Lymphedema. 2. Post phlebitic syndrome 3. Lipedema. 4. Vein compression edema

Answer 40

4

Question 41

Clinical case : 2 45+ 1ll .tl 27%- • A 39 y old man presented an acute ischemic pain of the right calf necessated an hospital admission • The next day an Angio- CT scan was performed , a right stenosis of right popliteal artery was diagnosed , an anticoagulant treatment was started with LWMH ( enoxaparin ), the patient was discharged with a treatment combination of clopidogrel and statins • Past medical history : orthepedic surgery for cross ligament of right knee ( 15 y before • next angio-CT scan of lower limb arteries performed 3 months later revealed no significant abnormality of right popliteal artery. • A3rd angio-CT scan realised 4 months after confirm the presence of right popliteal stenosis !!. Duplex ultrasound of the right artery : Hypoechoic mass ( cystic structure ) of anterior wall of the right popliteal artery 21mmx5mm) What is your diagnostic? 1. Dissection. 2. Thrombus. 3. Synovial cyst 4. Cyst adventitial disease of the popliteal artery .

Answer 41

4

Question 42

What is Adventicial cystic desease

Answer 42

• Adventitial cystic disease is rare ( 0,1% of all vascular diseases ). • Atkins and Key first described the lesion ( 1947 ). • Others locations ( external iliac, common femoral , radial and ulnar ) •80% are men • Symptoms :ischemic pain , claudication • Diagnosis: Duplex ultrasound , CT scan , MRAngiography. • Treatment:aspiration,removal of the cyst and graf interposition

Question 43

• 23 y old female , 7th month pregnancy , presented a convulsive seizure during sleeping with loss of consciousness • Referred to emergency unit ( admitted while unconscious) • Cerebral MRA reveals cereberal stroke • Reffered to a cardiologist for cardiac evaluation. Echo: Vertebrals arteries hypoplastic left vertebral artery ( diameter measuring 2,3 mm ) Dynamic Duplex of right vertebral artery ( red vessel ) with left rotation of the head abolition en tournant la tête COMPTE RENDU DE L'EXAMEN EGHOGRAPHIE DOPPLER DES TRONCS SUPRA-AORTIQUES: Le tronc artériel brachio-céphalique est perméable. Les artères sous claviéres sont perméables. Les artères vertébrales sont perméables cependant lors de la rotation de la téte ( rotation gauche pour Fartére vertébrale droite et droite pour Tartère vertébrale gauche ) ainsi que lors de l'extension de la téte vers le haut on observe un arrét du flux au niveau de chaque artère vertébrale ce qui est en faveur dun syndrome de compression bilatérale des artères vertébrales C Bow hunter syndrome ), cette compression n' est pas observée en position d'orthostatisme ( patiente assise ) au niveau des artères vertébrales intracrâniennes ( usage du Doppler transcrânien) Les carotides communes sont lbres de plaque d'athérome et sont perméables Au niveau des bifurcations carotidiennes Absence de mise en évidence d'anomalie pariétale au niveau des bifurcations carotidiennes. CONCLUSION: Examen en faveur d'un syndrome de compression bilatérale des artères vertébrales lors des mouvements de rotation de la tête LEasx hunter syndrome ) pouvant expliquer éventuellement lischémie cérébelleuse

Answer 43

Bow hunter syndrome or rotational vertebral artery syndrom

Question 44

What is bow hunter syndrom

Answer 44

The bow hunter's syndrome occurs when there is ver- tebral artery stenosis or occlusion from compression during head rotation that results in vertebrobasilar insuffcieny • Symptoms can range in severity from transient vertigo to posterior circulation stroke. • Diagnosis requires dynamicimaging during head rotation,and the gold standard is digital subtraction angiography. • Management is often conservative with antithrombotic medications and behavioral modification to limit head rotation, but sometimes surgical resection of the com- pressing structure is necessary.

Question 45

How to explain seizure? In bow hunter syndrome

Answer 45

• To best of our knowledge , seizures are very are symptoms in patients with BHS, seizures occur in patients with cortical infarcts in the anterior circulation. • The vertebrobasilar insufficiency was due to compression of the vertebral artery, while the dilated posterior communicating artery was speculated to steal the blood flow from the internal carotid artery to compensate for the posterior circulation , this compensation would reduce the blood flow of the anterior circulation and result in cerebral metabolic and perfusion disorders L

Question 46

• A 25 old man volley ball player sport referred for right hand ischemia < • Clinical examination: palor and coldness of the right hand and fingers. • Duplex ultrasound: mobile thrombus in distal right brachial artery partial occlusion with total occlusion of right ulnar artery ( incompressible ). Echo : Right brachial artery: mobile thrombus Right radial artery flow , and incompressible right ulnar artery Occluded branch of right axillary artery: Is there a cause and effect relationship between occlusic. deep brachial artery and thrombosis of brachial artery? COMPTE RENDU DE L'EXAMEN ECHOGRAPHIE DOPPLER_DU MEMBRE_SUPERIEURDROIT_: Le tronc brachio-céphalique est perméable € artere sous slaxiece est Rsrmsabis absence de dilatatign ou d anemalie caretale niveau L'artére humérale superficielle est perméable, occlusion de l'artére humérale profonde. Présence d'un thrombus partiellement occlusif imesurant 30 mim de bawuieuure, mooio stue au niveau de la partie distale de l'artére humérale juste en amont de sa bifurcation L'artère ulnaire est occluse le long de tout son trajet. L'artére radiale est perméable. Par ailleurs il n' pas été mise en évidence de compression artérielle au niveau du défilé thoraco-brachial. CONCLUSION: Thrombus mobile et partiellement occlusif au niveau de la partie distale de l'artère humérale droite avec occlusion de l'artère ulnaire Prescription ce jour de l'enoxaparine 0.8x2 Where is your diagnosis ? 1. Raynaud syndrome 2. aTOS 3. Quadrilateral space syndrome 4. Hypothenar hammer syndrome ( syndrome du marteau piqueur )

Answer 46

3

Question 47

34- rear-old male pabent voleybal player, exhibted aneurysm the posterio circumfex humera emboilizaton artery (PCHA: white asterisk). Since te patent insaly presented weh acute ischemia of the hand, surgical treatment by means C embolectomy was necessary. Athough PCHA aneurysms are on the whole extremely they are typical in overhead athletes, such as voleyball players. rare. Tne most hkely pathomechanism involves hyperabduction, extemal rotation, and extension Or the shoulder in the above-mentioned group. leading to artery compression and potenbally to subsequent aneurysm lormabon superrposed thrombus may be "miked out" and embolize. For the young. active patient. the decision was taken to perform open surgical aortc repair by proximalidistal ligation The pabent was discharged 5 days postoperatively and has since resumed regular sports actvites

Answer 47

"Volleyball" Aneurysm of the Posterior Circumflex Humeral Artery

Question 48

• A 70 yo lady is referred for echocardiography ( preoperative assessement before valvular surgery ) for significant tricuspid regurgitation with atrial fibrillation, presents clinical signs of right heart failure , with isolated dilation of right external jugular vein • Medical past history of rheumatic heart disease • She is symptomatic with dyspnea on exertion classe NYHA Il,with past history of lower limb edema'treated with frusemide 40mg tablet daily • Echocardiography: severe tricupid regurgitation with dilation of right atrial with surface area of 28 cm² with right ventricular dilation and distension with minimun collapse of inferieur vena cava. • The right internal jugular vein is dilated with, reflux, the ffus for not dilated with no reflux with significant reduction of venous veineuse flow Why the left internal jugular vein is not dilated? 1. Left superior vena cava. 2. Left internal jugular hypoplasia. 3. Compression of left innominate vein 4. Effort thrombosis ( Paget-Schroetter ).

Answer 48

3 !

Question 49

• 65 years lady reffered for suspicion of left internal jugular thrombosis. • Clinical examination : distension of left external jugular vein • Medical past history of ascendant aortic aneurysm What is the right answer? 1. Anticoagulant therapy with apixaban 2,5 mg BID. 2. LWMH with full dose curative therapy. 3. Left internal jugular vein compression by ascendant aortic aneurysm 4. Aorto-sternal venous compression