1. Vascular (Non-aortic pathology)

Question 1

Thoracic outlet syndrome - definition (2)

Answer 1

Congenital or acquired compression of subclavian vessels and brachial plexus as they pass through thoracic outlet.
Spectrum: Nerve (95%) > Vein > Artery

Question 2

Thoracic outlet syndrome - features/cause (6)

Answer 2

Symptoms depend on what’s being compressed.
Compression by anterior scalene muscle is most common.
Other causes include:
- Cervical rib,
- Muscular hypertrophy,
- Fibrous bands
- Pagets
- Tumour
Will be shown angio with arms up/down, occlusion occurs with arms up

Question 3

Thoracic outlet syndrome Rx

Answer 3

Surgical removal of the causative rib/muscle

Question 4

Paget Schroetter - features/Rx (3)

Answer 4

Thoracic outlet syndrome with development of thrombus in subclavian vein.
Sometimes called “effort thrombus” - occurs in weightlifters who lift arms a lot.
Rx: Catheter directed lysis and surgical removal of extra rib/muscle.

Question 5

Pulmonary artery aneurysm - Causes (6)

Answer 5

Iatrogenic (swan ganz catheter) is most common. “Pt in ITU”
Behcets. “Turkish, mouth and genital ulcers”
Chronic PE.
Hughes-stovin syndrome
Rasmussen aneurysm.
Tetralogy of Fallow repair.

Question 6

Hughes-stovin syndrome (2)

Answer 6

Similar to Behcets.
Recurrent thrombophlebitis and pulmonary artery aneurysm formation & rupture.

Question 7

Rasmussen aneurysm (2)

Answer 7

Pulmonary artery pseudoaneurysm secondary to TB.
Involves upper lobes in setting of reactivation TB.

Question 8

Tetralogy of Fallow repair - pulmonary artery aneurysm

Answer 8

Patch aneurysm from RVOT repair.

Question 9

Splenic artery aneurysm - trivia (5)

Answer 9

Commonest visceral arterial aneurysm.
Can be true or false.
True are more common in pregnancy, more likely to rupture in pregnancy.
Most located in distal artery.
Atherosclerosis is NOT underlying cause.

Question 10

Splenic artery aneurysm - Causes

Answer 10

True ones associated with
- HTN
- Portal HTN
- Cirrhosis
- Liver transplant
- Pregnancy
False aneurysms associated with pancreatitis

Question 11

Splenic artery aneurysm - mimic

Answer 11

Islet cell tumour (hypervascular)

Question 12

Dubnar syndrome - features (5)

Answer 12

aka median arcuate ligament syndrome
Compression of coeliac artery by the median arcuate ligament (fibrous band connecting diaphragm).
Most people have some degree of compression, not syndrome until symptoms
- Pain
- weight less
Typically 20-40 years old

Question 13

Dunbar syndrome - imaging (2)

Answer 13

“Hooked appearance” classically.
Worse with expiration on angio.

Question 14

Dunbar syndrome - Rx (2)

Answer 14

Can lead to pancreaticoduodenal collaterals and aneurysm formation. Therefore treated surgically.

Question 15

Mesenteric ischaemia - Causes (5)

Answer 15

Chronic: Stenosis of 2 of 3 main mesenteric vessels + symptoms
Acute: 4 main causes
- Arterial
- Venous
- Non-occlusive
- Strangulation

Question 16

Chronic mesenteric ischaemia (5)

Answer 16

Symptoms include
- Food fear
- LUQ pain after eating
- Pain out of proportion to exam
Can have bad disease but no symptoms due to good colaterals, or can have opposite
Commonest site is splenic flexure (watershed between SMA and IMA)

Question 17

Acute mesenteric ischaemia - arterial (4)

Answer 17

Due to occlusive emboli (more distal, at branch points) or thrombus (closer to ostium) or vasculitis.
SMA most commonly affected.
Arterial has thinner wall (no arterial inflow) and not typically dilated. Reduced enhancement.
Bowel will become thick walled with target appearance after reperfusion.

Question 18

Acute mesenteric ischaemia - venous (2)

Answer 18

Dilatation with wall thickening, 8-9mm (<5mm is normal) and moderate dilatation.
Fat stranding and ascites especially common in venous occlusion.

Question 19

Acute mesenteric ischaemia - non-occlusive (3)

Answer 19

Seen in shock or pt on pressors. Hardest to diagnose on CT.
Involved segments are thickened. Enhancement is variable.
Delayed filling of portal vein at 70 seconds.

Question 20

Acute mesenteric ischaemia - strangulation (4)

Answer 20

Usually due to closed loop obstruction.
Mixed arterial and venous picture, congested dilated bowel.
Haemorrhage may be seen in bowel wall.
Lumen usually fluid filled and dilated.

Question 21

Colonic angiodysplasia - features (4)

Answer 21

2nd commonest cause of colonic arterial bleeding (diverticulosis is no.1),
Primarily right sided.
Angio shows cluster of small arteries during arterial phase (along antimesenteric border of colon), with early opacification of draining veins that persists into late venous stage.
Association with aortic stenosis (Heyde syndrome)

Question 22

Osler Weber Rendu- features (5)

Answer 22

aka hereditory haemorrhagic telangiectasia
AD, multi-system disorder characterised by multiple AVMs (hepatic or pulmonary).
Extensive shunting in the liver can cause biliary necrosis and bile leak.
Can have high output cardiac failure.
Most die from stroke or brain abscess.

Question 23

Imaging needed for suspected HHT

Answer 23

CT lung and liver with contrast.
MRA brain.

Question 24

Renal artery stenosis - Causes (6)

Answer 24

most commonly due to atherosclerosis (75%).
- Usually near the ostium, can be stented.
FMD (Fibromuscular dysplasia) is no.2 cause
- Usually beaded appearance, sparing the ostium (should NOT be stented)
Other rare causes
- Takayasu, PAN, NF-1 and radiation

Question 25

FMD - Fibromuscular dysplasia - trivia (7)

Answer 25

Non-atherosclerotic vascular disease, primarily affecting renal arteries of young, white women.
Commonest cause of renovascular HTN in young women.
Renal arteries most commonly involved, then carotids, then iliac
3 types, medial is most common.
Predisposed to spontaneous dissection.
Buzzword - String of beads
Rx: Angioplasty WITHOUT stent.

Question 26

Nutcracker syndrome (3)

Answer 26

Left renal vein compressed between SMA and aorta.
Causes left flank pain and haematuria.
Left gonadal veins drain into left renal vein, so this can also cause left testicular pain in men and LLQ pain in women.

Question 27

Pelvic congestion syndrome (4)

Answer 27

Sometimes grouped in fibromyalgia spectrum.
Multiparous or pre-menopausal women with chronic pelvic pain.
Venous obstruction at left renal vein or incompetent ovarian vain leads to multiple dilated parauterine veins.
Rx: ovarian vein embolisation

Question 28

Testicular varicocele (4)

Answer 28

Abnormal dilatation of pampiniform plexus.
Most are idiopathic. Can be secondary to nutcracker syndrome.
98% left sided (left vein is longer, drains in renal vein at right angle).
Can cause infertility.

Question 29

Isolated right varicocele Ix

Answer 29

CT AP - raises concerns for pelvic or abdominal malignancy.
RCC, retroperitoneal fibrosis or adhesions.

Question 30

Non-compressible varicocele Ix

Answer 30

CT AP - is a bad sign, suggests malignancy (left renal Ca invading renal vein)

Question 31

Bilateral decompressible varicocele Ix

Answer 31

No cancer hunting needed, might need treated if infertile

Question 32

Isolated left varicocele Ix

Answer 32

No cancer hunting needed, might need treated if infertile

Question 33

Uterine AVM - features (6)

Answer 33

Can present with life threatening massive bleed. Rarely presents with CHF.
Congenital and Acquired.
Acquired occurs after D&C, abortion or multiple pregnancies.
Doppler: serpiginous structures in the myometrium with low resistance, high velocity patterns.
Rx: embolisation.
Can look similar to retained products of conception, hx will be different.

Question 34

May Thurner

Answer 34

DVT of left common iliac vein, due to compression of left common iliac vein by right common iliac artery.
Rx: Thrombolysis and stenting.
Swollen left leg, it’s probably May Thurner.

Question 35

Popliteal aneurysm - trivia (5)

Answer 35

Commonest peripheral arterial aneurysm.
Biggest issue is distal thromboembolism, can be life threatening.
30-50% have AAA.
10% of AAA patients have popliteal artery aneurysm.
50-70% of popliteal artery aneurysms are bilateral.

Question 35

Popliteal entrapment - features (4)

Answer 35

Symptomatic compression or occlusion of popliteal artery due to developmental relationship with medial head of gastrocnemius (less commonly popliteus).
Medial deviation of popliteal artery is diagnostic.
Occurs in young men <30.
Normal pulses that decrease with plantar flexion or dorsiflexion of the foot. artery will correspondingly occlude on angio.

Question 36

Hypothenar hammer - (4)

Answer 36

Blunt trauma to ulnar artery and superficial palmar arch, impact against hook of hamate.
Arterial wall damage > aneurysm +/- thrombosis.
Emboli can form, causing distal obstruction of digits (Causes confusion with Buergers).
Corkscrew configuration of superficial palmar arch, occlusion of ulnar artery, or pseudoaneurym off ulnar artery,

Question 37

Peripheral vascular malformations (5)

Answer 37

40% of vascular malformations involve extremeties, other 40% head and neck, 20% thorax.
They increase proportionally as child grows.
Low flow: Venous, lymphatic, capillary, mixes of these.
High flow: has an arterial component.
Rx determined by high or low flow

Question 38

Klippel-Trenaunay Syndrome (KTS) - triad

Answer 38

Triad:
- Port wine nevi
- Bony or soft tissue hypertrophy (localized gigantism)
- Venous malformation

Question 39

KTS - features (5)

Answer 39

Associated with persistent sciatic vein.
Marginal vein of Servelle (superficial vein in the lateral calf and thigh) is pathognomonic (great saphenous vein on wrong side).
20% can have GI involvement and bleed. If system is big enough, can consume platelets (Kasaback Merritt).
IF MRV shows a bunch of superficial vessels with no deep drainage, think of this.
Parks Weber is the high flow variant.

Question 40

ABIs (Ankle to Brachial Index) - (2)

Answer 40

aka ABPI.
Can be unreliable in diabetics, dense calcifications make vessel harder to compress.
1 = normal. 0.3-0.5 = claudication. <0.3 = rest pain

Question 41

Intimal Hyperplasia (8)

Answer 41

Response to blood vessel wall damage.
Exuberant healing process leading to intimal thickening, can lead to stenosis.
Common after IR procedure to revascularise a limb.
Common cause of re-stenosis 3-12 months after angioplasty.
Often sneaky and resists balloon dilatation or reoccurs.
Can even grow through the cracks of a bare stent.
May still occur at the edges of a covered stent.
Angiogram with stent in situ, losing flow, it’s probably this.