1. Vascular p104-116 (Anatomy)

Question 1

Aorta - regions (4)

Answer 1

Root (Aortic valve annulus to sino-tubular junction),
Ascending aorta,
Transverse aorta/arch,
Descending aorta.

Question 2

Aorta - diameter (2)

Answer 2

Average is 3.6cm at root (largest point) and 2.4cm in distal descending.

Question 3

Sinuses of Valsalva (3)

Answer 3

3 outpouchings above the annulus (right, left, posterior) which terminate at the ST junction.
Right and left coronaries come off right and left sinuses.
Posterior is often called non-coronary cusp

Question 4

Aortic isthmus

Answer 4

Segment between left subclavian and ligamentous arteriosum

Question 5

Ductus bump (2)

Answer 5

Contour bulge along the lesser curvature, distal to isthmus.
NORMAL structure, not a pseudoaneurysm.

Question 6

Aortic arch variants (4)

Answer 6

Normal (75%)
Bovine (15%) - common origin of brachiocephalic artery and left common carotid.
Left common carotid coming off the brachiocephalic (10%)
4 separate origins (left vertebral artery originates separately from the arch, rather than the left subclavian)

Question 7

Artery of Adamkiewicz (3)

Answer 7

Great anterior medullary artery (Artery of Adamkiewicz) comes off thoracic aorta.
Dominant feeding artery of spinal cord.
Comes off left side (70%) between T8-L1 (90%)

Question 8

Inferior pancreatoduodenal artery comes off the…

Answer 8

…SMA (first branch of SMA)

Question 9

Arc of Riolan

Answer 9

Made up from anastamosis of the left colic artery (comes off IMA) and middle colic artery (comes off SMA)

Question 10

Marginal artery of drummond

Answer 10

Formed from terminal branches of SMA and IMA

Question 11

Coeliac axis branches (5)

Answer 11

Coeliac axis branches into:
- Common hepatic artery
- Left gastric artery
- Splenic artery
Common hepatic artery
- Becomes proper hepatic artery after GDA (gastroduodenal artery)
This traditional anatomy only seen in 55%

Question 12

Variant hepatic artery anatomy (3)

Answer 12

Right or left hepatic arteries may be replaced (come from other than proper hepatic) or accessory (duplicated).
Replaced - usually off left gastric or SMA.
Accessory - duplication of vessel, spare usually from left gastric or SMA.

Question 13

Vessel in the ligamentum venosum?

Answer 13

Usually an accessory or replaced left hepatic artery (arising from left gastric)

Question 14

Proper vs replaced right hepatic artery

Answer 14

Proper right hepatic artery is anterior to right portal vein.
Replaced right hepatic artery is posterior to main portal vein.
This positioning increases risk of injury in pancreatic surgeries.

Question 15

Internal Iliac Artery Branches - posterior (4)

Answer 15

Iliolumbar,
Lateral sacral,
Superior gluteal,
Inferior gluteal (sometimes)

Question 16

Internal Iliac Artery Branches - Anterior (8)

Answer 16

Umbilical (gives off superior vesicular),
Inferior vesicular
Obturator
Uterine (female),
Middle rectal,
Internal pudendal,
Inferior gluteal,

Question 17

Ovarian artery origin

Answer 17

80-90% arise from anterior-medial aorta

Question 18

Persistent sciatic artery (4)

Answer 18

Anatomic variant, continuation of internal iliac.
Passes posterior to femur and anastamoses with distal vasculature.
Complications include aneurysms and early atherosclerosis.
Acute occlusion of external iliac, but still has foot pulses, think persistent sciatic artery.

Question 19

Coeliac to SMA - collateral pathways (3)

Answer 19

Conventional is Coeliac > Superior pancreatic duodenal > Inferior pancreatic duodenal > Gastroduodenal
Arc of Buhler (anatomic variant collateral from coeliac to SMA): Arch between SMA and Coeliac, independent of inferior pancreatic duodenal or gastroduodenal.
- This rare (4%) collateral can have an aneurysm, associated with coeliac axis stenosis.

Question 20

SMA to IMA collaterals (3)

Answer 20

Conventional: SMA > Middle colic > Left branch of middle colic > arc of Riolan > Left colic > IMA
- Arc of Riolan (aka meandering mesenteric artery): connects middle colic (SMA) and left colic (IMA)
- Marginal artery of drummond: Anastamosis of terminal branches of ileocolic, right colic and middle colic arteries of SMA with left colic and sigmoid branches of IMA, forms a continuous arterial circle along the inner border of the colon

Question 21

IMA to Ilaics - collaterals

Answer 21

Conventional: IMA > Superior rectal > Inferior rectal > Inferior pudendal > Anterior branch of internal iliac

Question 22

Winslow pathway - anatomy (3)

Answer 22

Seen in aorto-occlusive disease.
Subclavian artery > internal thoracic(mammary) artery > superior epigastric artery > inferior epigastric artery > external ilac artery.
Can be inadvertantly cut during transverse abdominal surgery.

Question 23

Corona mortis - anatomy/trivia (4)

Answer 23

Vascular connection between obturator and external ilaic.
Any vessel coursing over the superior pubic rim.
Can be injured in pelvic trauma or during surgery (notoriously difficult to ligate).
Can hypothetically cause a type 2 endoleak.

Question 24

Neck/Subclavian anatomy (3)

Answer 24

Sagittal view:
Scalene muscles make a triangle in the neck (triangle between anterior and middle scalene).
Subclavian vein runs anterior to said triangle.
Subclavian artery runs IN the triangle.

Question 25

Branches of the subclavian artery (5)

Answer 25

Vertebral,
Internal thoracic,
Thyrocervical trunk,
Costocervical trunk,
Dorsal scapular

Question 26

Continuation of subclavian artery (3)

Answer 26

Axillary artery: begins at first rib
Brachial artery: begins at lower border of teres major
Brachial artery: bifurcates to become ulnar and radial arteries

Question 27

Ulnar vs Radial artery on imaging (3)

Answer 27

Ulnar artery is usually bigger.
Ulnar artery usually gives off common interosseous.
Ulnar artery usually supplies the superficial planar arch, while the radial usually supplies the deep arch.

Question 28

Normal variants of upper extermety vasculature (2)

Answer 28

Anterior interosseous branch (median artery) persists and supplies deep palmar arch of hand.
High origin of radial artery - radial artery comes off either axillary or high brachial artery (normally comes off at level of radial head)

Question 29

External iliac becomes common femoral once…

Answer 29

…it has given off inferior epigastric artery (at the inguinal ligament)

Question 30

Common femoral artery - bifurcation (3)

Answer 30

Becomes superficial femoral and profunda femoris.
Profunda femoris courses posterior and lateral.
Superficial passes anterior and medial into adductor canal. When it emerges, it becomes popliteal artery

Question 31

Popliteal artery - continuation (3)

Answer 31

At level of distal border of popliteus muscle, popliteal artery becomes anterior tibial and tibioperoneal trunk.
Anterior tibial runs anterior and lateral, traverses interosseous membrane, down front of anterior tibia and terminates as dorsalis pedis.
Tibioperoneal trunk bifurcates into posterior tibial (most medial artery in leg, felt at medial malleolus) and peroneal (fibular) arteries.

Question 32

Venous collaterals - Gastric varices (5)

Answer 32

Portal HTN shunts blood away from liver and into systemic venous system.
Spontaneous portal-systemic shunts develop to decompress the system.
Most gastric varices formed by left gastric vein (coronary vein).
Isolated gastric varices are secondary to splenic vein thrombus.
Gastric varices (80-85%) drain into inferior phrenic vein, then left renal vein, forming gastro-renal shunt.

Question 33

Stomach venous supply (2)

Answer 33

Left gastric (coronary) vein = cardia
Posterior and short gastric = fundus

Question 34

Spleno-renal shunt (4).

Answer 34

Feature of portal HTN.
Abnormal collateral between splenic vein and renal vein.
Not associated with GI bleed, however, enlarged shunts associated with hepatic encephalopathy.
Imaging: Enlarged left renal vein with enlarged IVC at the level of the left renal vein.

Question 35

Caval variants (3)

Answer 35

Left SVC.
Duplicated SVC.
Duplicated IVC.

Question 36

Left sided SVC - features (3)

Answer 36

Can (rarely) result in right to left shunt.
Only seen in isolation in 10% (90% it’s duplicated).
Usually drains into the coronary sinus.

Question 37

Left SVC - trivia (3)

Answer 37

Commonest congenital venous anomaly in the chest.
Most common associated CHD is ASD.
Associated with unroofed coronary sinus.

Question 38

Duplicated SVC

Answer 38

Usually seen in scenario of left SVC with smaller, duplicated right SVC

Question 39

Duplicated IVC

Answer 39

2 IVCs seen either side of aorta.
Associated with renal pathology:
- Horseshoe and crossed fused ectopic kidneys
- Circumaortic renal collars

Question 40

Circumaortic venous collar (3)

Answer 40

Additional left renal vein that passes posterior to aorta.
Anterior limb is superior, posterior limb is inferior.
Important for renal transplant or IVC filter placement.

Question 41

Azygos continuation (5)

Answer 41

aka absence of hepatic segmen of IVC.
Hepatic veins drain straight into right atrium.
IVC often duplicated, left IVC terminates in left renal vein, which then crosses over to join right IVC.
Azygos vein is dilated.
Associated with polysplenia