B P5 C44 Treatment of Noncoronary Obstructive Vascular Disease

Question 1

_____ is a general term that includes pathologic processes affecting arteries, veins, and lymphatics

Answer 1

Peripheral vascular disease

Question 2

_____ PAD may be asymptomatic or may manifest as claudication, critical limb ischemia (CLI), or embolic infarction of a distal organ
(e.g., stroke)

Answer 2

Chronic

Question 3

Asymptomatic disease is common. In the lower extremities, asymptomatic disease occurs in at least half and in as many as 80% of patients with abnormal functional test results indicative of obstructive arterial disease (e.g., abnormal ABI).

Even asymptomatic disease indicates elevated CV risk. These considerations warrant _____ risk factors as a prime goal of therapy to reduce the risk for myocardial infarction (MI) and stroke, the most common causes of death in patients with PAD.

Answer 3

Intensive modification of atherosclerosis

Question 4

_____ classically refers to leg discomfort, weakness, or pain related to exercise and relieved by rest, but it also describes discomfort in the upper limbs caused by effort-related ischemia.

Answer 4

Claudication

Question 5

Supervised exercise training consisting of _____ is particularly useful at improving walking, with or without endovascular intervention

Answer 5

1-hour sessions two to three times a week for 12 weeks

Question 6

_____ strategies aim to improve arterial blood flow in obstructed large- and medium-sized arteries when noninvasive therapies fail.

Answer 6

Revascularization

Question 7

_____, also referred to as critical limb-threatening ischemia, refers to PAD with ischemic pain at rest or tissue loss (e.g., ulcer or gangrene).

This scenario has clinical urgency because of near- term risk for limb jeopardy requiring major amputation

Answer 7

Critical limb ischemia

Question 8

_____ amputation in the lower limbs refers to amputation at or above the level of the ankle and requires a prosthesis for the patient to walk.11 Amputation is disfiguring and at higher levels (above versus below knee amputation) has greater impact on functional independence of the patient

Answer 8

Major

Question 9

_____ amputations (e.g., toe or transmetatarsal) usually have little impact on the patient’s ability to walk. Catheter-based therapies for CLI are used to improve blood flow and heal ischemic tissue, to salvage the limb (prevent major amputation), or to enable a lower level of amputation that might have less impact on the patient’s ability to walk

Answer 9

Minor

Question 10

The risk for major stroke is high shortly after a symptomatic event but declines to the level of asymptomatic disease after approximately _____ months.

Answer 10

3 months

Question 11

_____ remains the mainstay of endovascular intervention for PAD and venous disease

Answer 11

Balloon angioplasty

Question 12

Angioplasty remodels the artery by expansion and accommodates the atherosclerotic plaque to expand the vessel lumen.

This procedure usually causes _____ of the plaque that may or may not impair blood flow.

Answer 12

Dissection

Angioplasty is limited in the short term by acute recoil of the artery and flow-limiting dissections, which may cause abrupt closure of the artery.

Question 13

Angioplasty is limited in the short term by acute recoil of the artery and flow-limiting dissections, which may cause abrupt closure of the artery. In the intermediate time frame, _____ may lead to symptomatic restenosis

Answer 13

Overexuberant neointimal hyperplasia and negative remodeling of the artery

Question 14

Most operators use prolonged inflations (at least ____ minute or more)

Answer 14

1 min or more

Question 15

Bare-metal stents (BMSs) come in two types:

Answer 15

Balloon-expandable stents
Self-expanding stents

Question 16

______ stents have greater radial strength and are less likely to move on deployment, which is important for ostial placement.

Answer 16

Balloon-expandable stents

Such stents can be crushed by external compression and are therefore avoided outside the torso.

They are sometimes used to treat tibial dis- ease, but only for CLI, for which long-term patency may be less of an issue once tissue healing has occurred.

Question 17

_____ stents were originally made of stainless steel but are now usually made of nitinol. Nitinol stents reexpand on compression and are therefore used outside the torso, where external compression is more likely to occur.

Answer 17

Self-expanding stents

They may also be used in tortuous arteries, where they probably conform better than balloon-expandable stents. Their lower radial strength, however, increases the risk for recoil. Con- temporary self-expanding stent designs are more durable and less likely to fracture than older designs.

Question 18

______ stents using a polymer or polymer-free coating of paclitaxel offer lower rates of restenosis than bare-metal self-expanding stents.

Answer 18

Drug coated self-expanding stents

Question 19

In the _____ study, a polymer-coated paclitaxel stent had similar 12 months of efficacy and safety outcomes to a polymer-free paclitaxel stent, and a single-arm cohort study suggested no “catch-up” target vessel revascularization over 3 years with this device.

Answer 19

IMPERIAL

Question 20

The duration of DAPT required for these stents (Drug coated self-expanding stents) is uncertain, but recent randomized trials have generally used _____ months of treatment with an adenosine receptor antagonist.

Answer 20

2-6 months

Question 21

Compared with plain balloon angioplasty, drug- coated balloons have less _____ and repeat in the femoral- popliteal arteries, and similar patency to drug-coated self-expanding stents

Answer 21

Less restenosis and repeat revascularization

Drug-coated balloons also offer a lower risk of restenosis at 1 year compared with plain balloon angioplasty for treating in- stent restenosis lesions

Question 22

The duration of DAPT with drug-coated balloons in the femoral-popliteal arteries is uncertain but varies between _____ months in most randomized trials.

Answer 22

1-6 months

Question 23

However, in 2018 a group-level meta-analysis of randomized trials suggested that patients treated with paclitaxel drug-coated balloons or stents for femoral-popliteal disease had _____ rates of mortality 2 to 5 years after their procedure compared with non-paclitaxel balloons and stents

Answer 23

Higher

Question 23

_____ is a key determinant of restenosis, and a meta-analysis suggests that long lesions have less restenosis and need for target revascularization with paclitaxel drug-coated balloons and stents

Answer 23

Lesion length

Question 24

_____ are very useful for treating perforations related to endovascular treatment or excluding aneurysms

Answer 24

Stents covered with or sandwiching a polymer such as polytetrafluooethylene (PTFE)

Question 25

Potential disadvantages of covered stents include _____.

Answer 25

(1) Unintentional occlusion of important branch vessels
(2) Concerns about the risk for late stent thrombosis
(3) Whether restenosis was merely delayed rather than prevented

Question 26

_____ is an important adjunctive therapy for arterial thrombosis, stent thrombosis, and occlusive thrombotic venous disease.

Answer 26

Catheter-directed thrombolysis

Question 27

Catheter-directed thrombolysis is more effective than intravenous thrombolysis only if an infusion catheter (with multiple infusion holes) is inserted into the thrombosed vessel.

It is also less effective if given more than _____ days after thrombosis.

Typically, the infusion continues for 12 to 24 hours, because treatment over 48 hours is associated with depletion of circulating fibrinogen and a higher risk for major bleeding

Answer 27

> 14 days: Less effective

Question 28

Catheter-based thrombolysis with or without angioplasty or stenting also reduces the incidence of _____ in patients with proximal (iliac) deep venous thrombosis (DVT), and it is used as adjunctive therapy for massive pulmonary emboli

Answer 28

Post-thrombotic syndrome

Question 29

Any thrombolysis regimen increases risk for fatal or major bleeding. Absolute contraindications to thrombolysis include:

Answer 29

(1) a cerebrovascular event less than 2 months previously
(2) active bleeding
(3) gastrointestinal bleeding less than 10 days previously
(4) neurosurgery (intracranial or spinal surgery) or trauma less than 3 months previously.

Question 30

Relative contraindications include:

Answer 30

(1) cardiopulmonary resuscitation less than 10 days previously
(2) nonvascular surgery or trauma less than 10 days previously
(3) uncontrolled hyper- tension (sustained systolic blood pressure [BP] >180 mm Hg or dia- stolic BP >110 mm Hg)
(4) puncture of a noncompressible vessel
(5) intracranial tumor
(6) recent eye surgery

Question 31

The _____ flow retriever system (Inari Medical, Irvine, CA) uses a much larger catheter (up to 24F) and is designed mainly for venous thromboembolism, but case reports show large thrombi extracted with this system.

Answer 31

Inari flow retriever system

Question 32

The _____ aspiration system uses a mechanical aspirator and a range of 3 to 8F catheters to gen- erate a greater suction than manual aspiration catheters

Answer 32

Penumbra Indigo (Penumbra, Almeda, CA)

Question 33

The _____ is primarily a rotational atherectomy device but also aspirates debris and is used for atherectomy and aspiration of a thrombus. M

Answer 33

Jetstream (Boston Scientific, Marlborough, MA)

Question 33

_____ thrombectomy is a more rapid treatment than catheter-directed thrombolysis; embolization can occlude the distal arterial bed and lead to infarction and tissue loss, although combination with an embolic protection device might theoretically reduce this risk.

Answer 33

Mechanical

Question 34

The _____ is generally too small for the larger peripheral arteries, and it is uncertain how a large amount of plaque ablated from a long peripheral lesion would affect the downstream microcirculation. However, for the smaller popliteal artery rotational atherectomy may allow balloon dilation without stenting

Answer 34

Rotablator (Boston Scientific, Marlborough, MA)

Question 35

The _____ (Cardiovascular Systems, Inc., St. Paul, MN) is an orbital atherectomy device.

Answer 35

Diamondback360

Question 36

Directional atherectomy devices include the _____ device

Answer 36

SilverHawk

Question 37

_____ atherectomy uses high-energy monochromatic ultraviolet light to vaporize tissue in contact with the catheter tip and debulk de novo and restenotic lesions in peripheral arteries.

Answer 37

Excimer laser atherectomy

Question 38

_____ involves the use of proprietary balloon and inflation technology to inflate the balloon with nitrous oxide, which chills on expansion to −10°C.

Answer 38

Cryoplasty

Network meta-analyses comparing multiple different therapies suggest cryoplasty is inferior to other technologies with a higher rate of restenosis

Question 39

_____ (Shockwave Medical, Santa Clara, CA) uses a balloon with up to five pressure-emitting nodes along the balloon shaft to generate waves of pressure into the artery wall during a low-pressure balloon inflation

Answer 39

Intravascular lithotripsy

Question 40

_____ is a proven treatment for walking function in patients with claudication. Supervised exercise training after endovascular interventions may also improve maximum walking distance over endovascular interventions alone and should be considered as an adjunctive therapy.

Answer 40

Supervised exercise training

Question 41

_____ is a phosphodiesterase inhibitor that improves walking function in some patients with intermittent claudication

Answer 41

Cilostazol

Small meta-analyses suggest cilostazol used after endovascular therapy may improve walking function and decrease the risk for restenosis, repeat revascularization, and major amputation.

Question 42

In the ______ trial, antithrombotic therapy with low- dose rivaroxaban 2.5 mg twice a day with aspirin decreased the risk of a combined endpoint of vascular, cardiac, and cerebrovascular ischemic events with an increase in major bleeding.54 This regimen may be considered in patients with a favorable balance of bleeding and ischemic risk

Answer 42

VOYAGER

Question 43

_____ is the first stage of planning an endovascular intervention

Answer 43

Vascular imaging

Question 44

_____ angiography images remove bone and soft tissue from the image while leaving the contrast-enhanced image of the artery for more clarity, provided that the limb remains still during acquisition

Answer 44

Digital subtraction

Question 45

_____ using iodinated contrast material provides more rapid imaging, but heavy calcification can mask stenoses and make interpretation of lesion severity more difficult. Iodinated contrast agents can cause adverse reactions or impair renal function.

Answer 45

Computed tomographic angiography (CTA)

Question 46

_____ uses gadolinium or other contrast agents or time-of-flight techniques.

Time of flight relies on laminar blood flow to image arteries and has the advantage of not requiring contrast material, which can rarely cause serious adverse effects in patients with renal insufficiency (e.g., nephrogenic scleros- ing fibrosis)

Answer 46

Magnetic resonance imaging (MRI)

Question 47

MRI cannot be used in patients who have retained ferric metals (e.g., some pacemakers, shrapnel). Most contemporary stents are compatible with MRI but leave a flow void that does not allow interpretation of obstructive disease. _____ offers advantages for assessing stent patency.

Answer 47

High-resolution contrast-enhanced CT scans

Question 48

Typical symptoms of PAD with a normal resting ABI should raise suspicion for iliac or aortic disease, in which case an _____ is generally abnormal

Answer 48

Exercise ABI

Question 49

Aortoiliac disease is approached from the _____.

Answer 49

Ipsilateral femoral artery
Contralateral femoral artery
Radial artery
Brachial artery.

Question 50

In aortoiliac disease, many operators will often use a second arterial access (e.g., contralateral femoral) to provide quick access to the aorta or proximal iliac artery for temporary balloon occlusion in the event of _____.

Answer 50

Perforation and rapid hemorrhage

Question 51

_____stents are useful for treating aneurysms and potentially life-saving for treating vessel rupture or perforation

Answer 51

Covered stents

Question 52

Occlusions involving the _____ aorta often undergo surgical treatment, although percutaneous transluminal angioplasty and stenting offer an option to patients with prohibitive surgical risk.

Answer 52

Distal

Question 53

Obstructive atherosclerosis is more common in the SFA than the popliteal artery or the CFA. Usually, the _____ serves as an important source of collateral blood flow to the leg in patients with obstructive SFA disease

Answer 53

Profunda femoris

Question 53

Even though balloon angioplasty can successfully treat obstructive CFA disease secondary to atherosclerosis or complications of CFA access for other procedures, surgical repair with patch angioplasty is the standard of care for most patients with acceptable surgical risk.

_____ should not be used in this location because of repetitive compression during movement of the hip.

Answer 53

Balloon-expandable stents

Question 54

In patients with a prohibitive surgical risk, _____ is used for CFA lesions, along with bail-out self-expanding stents for flow-limiting dissections.

Answer 54

Balloon angioplasty with or without atherectomy

Question 54

Most percutaneous femoral interventions involve the SFA and popliteal artery, and interventional techniques are similar with both arteries.

The _____ and particularly the ____ are subject to torsion, stretch, and kinking with movement of the leg

Answer 54

Distal SFA

Popliteal artery

For this reason, stents are generally avoided below the level of the top of the patella and above the tibial metaphyseal plate when viewed with the leg straight.

Stenting between this region subjects stents to extreme flexion, compression, and torsion and is associated with stent fracture, restenosis, and poor long-term durability, although specific helical mesh stents may be more durable than other self-expanding stents in this location

Question 55

Acute procedural success rates with catheter-based interventions in femoro-popliteal disease now approach _____%, in part because of a wide variety of wires, crossing catheters, reentry catheters, and combined antegrade and retrograde approaches for difficult total occlusions

Answer 55

90%

Question 56

Restenosis rates are higher than in the _____ artery and may require repeated intervention

Answer 56

Iliac

Question 57

Balloon angioplasty in femoro-popliteal disease alone has durability similar to that of primary stenting for short lesions (<50 to 100 mm in length), and in this setting, provisional stenting for _____ is an acceptable strategy

Answer 57

Abrupt closure,
Fow-limiting dissection
Poor expansion (residual stenosis >50%)

Question 58

For longer femoral-popliteal lesions (>100 mm), _____ stents offer better durability and walking function than balloon angioplasty with provisional stenting

Answer 58

Primary stenting with self-expanding nitinol stents

Question 59

The popliteal artery divides into three tibial arteries:

Answer 59

(1) Anterior tibial, which becomes the dorsalis pedis in the foot

(2) Posterior tibial, which forms the pedal arcade with the anterior tibial artery

(3) Peroneal artery, which usually ends just above the ankle but can be an important collateral to the foot.

In general, claudication is rare with loss of even two of the three tibial arteries

Question 60

Treating severe tibial disease in patients with CLI can promote _____.

Answer 60

Wound healing
Resolve pain at rest
Prevent major amputation

Question 61

A _____ access site for tibial disease may become a nonhealing ulcer if the intervention is unsuccessful

Answer 61

Pedal

Question 61

_____ revascularization refers to revascularization of a tibial artery that supplies the area of a nonhealing ulcer or gangrene

Answer 61

Angiosome-directed

The value of angiosome-directed revascularization versus restoring any straight flow to the foot is debated. In observa- tional studies, wound healing was better and amputation lower with angiosome-directed rather than indirect (nonangiosome) tibial revascularization.

Question 62

Tibial disease is most often treated by _____ balloon inflation, but stents are used as bail-out treatment of flow-limiting dissection

Answer 62

Prolonged

Question 63

Managing CLI with ulceration or gangrene requires close follow-up to _____ in ulcerated areas and aid healing.

Answer 63

Débride dead tissue

Gangrenous toes can be left dry until they mummify and autoamputate or can be surgically amputated once viable and devitalized tissue are clearly demarcated.

Question 64

Infected gangrene does require surgical amputation to avoid _____.

Answer 64

Osteomyelitis

Question 65

_____ are the most important factor related to the risk for disabling stroke and the indication for revascularization.

Answer 65

Symptoms

“Symptomatic disease” refers to patients with a minor stroke or TIA.

Question 66

n the carotid circulation, symptoms are typically dysphasia, contralateral hemipa- resis or hemiparesthesia, or ipsilateral transient monocular blindness (_____)

Answer 66

Amaurosis fugax

Question 67

Symptoms lasting less than ___ hours and without infarction noted on imaging are classified as TIAs.

Answer 67

24 hours

Question 68

Minor strokes are classified as “mild clinical deficits” or “no clinical residual deficits” with evidence of _____ on imaging

Answer 68

Infarction

Question 69

In older trials of endarterectomy versus medical therapy, patients with recent symptoms and a stenosis of ____% had higher risk of stroke and a greater benefit from endarterectomy within the first week after symptoms.

Answer 69

50% to 99%

The risk of stroke declines rapidly after this time, with a smaller net benefit from revascularization especially more than 3 months after symptoms.

Question 70

Compared with carotid endarterectomy, _____ in symptomatic patients is associated with a higher risk of death or stroke over the following 30 days in patients over 70 years of age, but patients younger than 70 years of age had similar outcomes, and the risk of MI and cranial nerve injury was lower with stenting in all age groups.

Answer 70

Carotid stenting

Question 71

Carotid stenting for patients with a 50% to 99% stenosis and recent TIA or minor stroke symptoms may be considered in patients with _____.

Answer 71

Good anatomy for stenting

With high risk of MI or poor surgical outcomes with endarterectomy

Question 72

In asymptomatic patients, the severity of stenosis determines risk, with stenoses greater than ____% increasing the risk of stroke.The reduction in risk with revascularization accrues slowly over the long term and needs to offset the small but important periprocedural/operative risk.

Answer 72

> 80%

Question 73

Factors Associated with Increased Risk for Complications with Carotid Artery Stent Placement

Answer 73

Tortuous aortic arch
Platelet or clotting disorder Difficult vascular access
Lesion or heavy vessel calcification Visible thrombus
Advanced age (>75-80 years)*

• The risk for a cerebrovascular accident (stroke) with carotid artery stent placement is increased, and the risk for myocardial infarction with carotid endarterectomy is increased.

Question 74

Factors Associated with Increased Risk from Carotid Artery Surgery

Answer 74

ANATOMIC CRITERIA
High cervical or intrathoracic lesion
Previous neck surgery or radiation therapy
Contralateral carotid artery occlusion
Previous ipsilateral carotid endarterectomy
Contralateral laryngeal nerve palsy Tracheostomy

MEDICAL COMORBIDITIES
Age >80years*
Class III or IV congestive heart failure
Class III or IV angina pectoris
Left main coronary disease
Two- or three-vessel coronary artery disease Need for open heart surgery
Ejection fraction 􏱦30%
Recent myocardial infarction
Severe chronic obstructive lung disease

Question 74

For asymptomatic patients with carotid disease, indications for carotid stenting include _____% stenosis in those with a periprocedural risk for stroke or death of less than 3%

Answer 74

80% to 99%

Question 75

Carotid stenting starts with access to the common carotid artery with a diagnostic catheter and then a delivery sheath.

Embolic protection consists of distal protection using _____ deployed distal to the carotid stenosis or proximal occlusion devices deployed proximal to the stenosis.

Filters allow blood flow to the brain to continue and theoretically lead to less brain ischemia if the circle of Willis is incomplete.

Answer 75

Filters or obstructive balloons

Question 76

Diagnosis of vertebrobasilar insufficiency is clinical with symptoms affecting the brainstem and cerebellum, including _____.

Answer 76

Dizziness
Ataxia
Diplopia
Syncope

Question 77

Atherosclerosis usually affects the _____ vertebral arteries, but more extensive proximal disease in the subclavian or brachiocephalic arteries can cause vertebrobasilar insufficiency

Answer 77

Proximal

Question 78

Medical treatment of vertebral artery disease includes _____.

Answer 78

Antiplatelet agents and statins

BP control to reduce ischemic stroke requires careful titration to avoid hypotension and hypoperfusion, which can precipitate symptoms.

Question 79

Surgical therapy consisting of vertebral and subclavian disease - ______ entails considerable morbidity, including Horner syndrome, lymphocele, and thrombosis.

Answer 79

Transection and reimplantation into an adjacent subclavian artery

Question 80

_____ percutaneous treatment, particularly with stenting, has much lower morbidity and short-term mortality.

Answer 80

Extracranial

Two randomized trials of intracranial or extracranial vertebral artery stenting for symptomatic vertebral artery disease showed no significant reduction in stroke compared with medical therapy; however, both trials were stopped early.

Question 81

Subclavian stenosis more often affects the _____ subclavian origin than the brachiocephalic or right subclavian arteries

Answer 81

Left

This predilection may result from more disturbed blood flow at the origin of the left subclavian artery

Question 82

Subclavian stenosis usually causes a _____ mm Hg or greater difference in noninvasive brachial BP between the two arms, in the absence of significant bilateral disease

Answer 82

> 15 mm Hg

Question 83

Symptoms from subclavian stenosis include:

Answer 83

(1) Arm claudication with activity
(2) Angina in patients with a left internal mammary/thoracic artery graft from previous coronary artery bypass surgery
(3) VBI with arm activity because of vertebral steal
(4) Ischemic (hand) steal syndrome in patients with a dialysis fistula

Question 84

Because most subclavian disease is proximal or ostial, surgical revascularization usually involves _____ bypass.

Answer 84

Subclavian-to-common carotid

Question 85

More commonly, symptomatic subclavian artery disease is treated with the less morbid procedure of subclavian artery _____. Both treatments have low periprocedural risks of stroke (1% to 2%)

_____ stents are generally used because they allow more precise placement to cover the ostium of the artery and avoid the vertebral and left internal mammary artery origins.

Answer 85

Stenting

Balloon-expandable

Question 86

Embolic stroke is rare in the treatment of subclavian/vertebral artery disease ,possibly because of _____ flow down the vertebral artery during balloon dilation and stenting.

Answer 86

Reverse flow

Thus, embolic protection is infrequently used for vertebral and subclavian artery stenting.

The long-term results of stenting subclavian and brachiocephalic disease are excellent (>80% overall patency).

Question 87

Three arteries supply the mesenteric viscera:

Answer 87

Celiac
Superior mesenteric
Inferior mesenteric.

Although advanced atherosclerosis of the aorta is common, mesenteric angina or infarction is very uncommon, probably because of the multiple collateral networks in the mesentery.

Question 88

Acute mesenteric ischemia with infarction is a surgical emergency because it is usually associated with infarction of the _____.

Answer 88

Small and large intestine

Question 89

An embolus (e.g., from thrombus in the heart associated with atrial fibrillation) is a common cause and typically lodges in the _____ mesenteric artery (usually the superior mesenteric artery)

Answer 89

Proximal

Question 90

Although some cases can be treated by endovascular techniques, ____ indicate bowel necrosis and need for open surgery

Answer 90

(1) Clinical signs of peritonitis or CT findings of pneumatosis

(2) Free intra-abdominal air

(3) Portal venous gas

Question 91

Chronic mesenteric ischemia is a more insidious syndrome that causes abdominal discomfort or pain _____ minutes after eating, early satiety, and substantial weight loss because of food fear or avoidance.

Answer 91

30-60 mins

Classically, more than two mesenteric arteries are stenosed or occluded. The disease is usually adjacent and involves advanced atherosclerosis of the aorta and origins of the mesenteric arteries. Asymptomatic disease of the mesenteric arteries does not require revascularization.

Question 92

_____ revascularization with reimplantation of the arteries (in mesenteric artery disease) has high mortality and morbidity (10% to 15%) because of the advanced age and other vascular comorbid conditions.

Answer 92

Surgical

Question 93

____ in mesenteric artery disease has lower mortality (<5%) and morbidity and achieves good resolution of symptoms in about 70% to 80% of patients over several years.

Answer 93

Percutaneous angioplasty with stenting

Restenosis may require further intervention and can be identified by duplex ultrasound and CTA.

Question 94

Renal artery stenosis can cause secondary hypertension or rapidly deteriorating renal function.

Clinical clues to the diagnosis of renal artery stenosis include _____.

Answer 94

(1) Onset of hypertension before 55 years of age
(2) Resistant or malignant hypertension (particularly in a previously well-controlled patient)
(3) Rapidly increasing creatinine level over a several-month period or earlier
(4) Sudden pulmonary edema without a clear cardiac cause (e.g., because of sudden hypertension with or without acute mitral regurgitation)

Question 95

In the _____ study, even the subgroup of participants with a renal artery stenosis of at least 80% did not benefit from renal artery stenting.

As a result, the enthusiasm for renal artery stenting has waned considerably, although there is still some support for stenting renal artery steno- sis in the presence of “flash” pulmonary edema without cardiac causes, rapidly decreasing renal function, and some cases of accelerating or resistant hypertension, based mainly on case reports and case series

Answer 95

CORAL

Question 96

_____ is a rarer cause of renal artery stenosis and hypertension more often seen in younger patients, with a higher prevalence in women. Although defined histologically in the past, this is now superseded by a classification based on imaging (multifocal “beading” versus focal disease)

Answer 96

Fibromuscular dysplasia (FMD

Question 97

FMD typically involves the _____ renal artery, whereas atherosclerosis usually involves the ostium or proximal renal artery.

Answer 97

Middle or distal

Question 98

Lower extremity DVT is treated primarily medically with anticoagulation, but _____ treatment is an option for patients with proximal venous thrombosis defined as being at the level of the common femoral vein or higher

Answer 98

Endovascular

Question 98

Recognition that the rich plexus of sympathetic nerves in the adventitia of renal arteries may contribute to resistant hypertension led to a number of catheter-based technologies to ablate the sympathetic nerves to lower BP and CV risk

Several randomized sham-controlled trials show on average a modest effect on systolic BP after catheter-based renal sympathetic denervation.

In early studies, this procedure decreased systolic BP by an average _____ mm Hg, with second-generation devices lowering systolic BP by an average of _____ mm Hg

Answer 98

Earlier: 2 mm Hg

2nd Gen: 6 mm Hg

Question 99

Proximal DVT occurs more frequently in the _____ leg as a result of compression of the left iliac vein by the overlying right iliac artery

Answer 99

Left leg

“May-Thurner syndrome”

Question 100

Acute severe proximal deep venous occlusion, characterized by a blue limb, pain, and limb ischemia (_____) is often associated with malignancy.

Answer 100

Phlegmasia cerulea dolens

Question 101

_____ syndrome occurs over several years in about half the patients with iliofemoral DVT and involves limb swelling, heaviness, and pain.

Answer 101

Chronic post-thrombotic

Question 102

Medical treatmen of DVT includes compression stockings and anticoagulation.

Endovascular treatment of proximal DVT by catheter-directed thrombolysis with or without balloon angioplasty and self-expanding stents reduces the incidence of post-thrombotic syndrome by about _____%

Answer 102

30%

Question 103

Upper extremity DVT is related to _____.

Answer 103

• Effort-related proximal vein thrombosis in athletes (Paget-Schroetter syndrome)
• Venous thoracic outlet syndrome
• Catheter-related thrombosis
• Malignancy

Question 104

_____ syndrome is related to compression of the subclavian vein as it exits the thoracic cage between the clavicle, first rib, costoclavicular ligament, and subclavian and anterior scalene muscles.

Answer 104

Venous thoracic outlet

Question 105

______ is the most common treatment of upper extremity DVT, but endovascular therapy can provide relief from post-thrombotic syndrome.

Answer 105

Anticoagulation

Question 106

Endovascular therapy includes catheter-directed thrombolysis and treatment of any precipitating cause.

For example, thoracic outlet syndrome generally requires_____ soon after thrombolysis because stents usually crush or fracture in this location

Answer 106

Surgical decompression (resection of the first rib or other structures) and venoplasty

Question 107

_____ syndrome results from obstruction of the superior vena cava with impairment of venous return from the head and upper limbs

Answer 107

Superior vena cava syndromer

Question 108

Typical causes of SVCS include _____.

Answer 108

(1) External compression
(2) Invasion from a tumor
(3) Thrombosis related to an indwelling central catheter (e.g., for chemotherapy) or leads from pacemakers or defibrillators

Question 109

In SVCS, thrombosis often accompanies stenosis and requires _____ therapy before balloon and stent therapy.

The stent should be oversized and extended well above and partly below the lesion so that it has an _____ shape to help keep it anchored and less likely to embolize

Answer 109

Catheter-directed thrombolytic

Hourglass shaped

Question 110

Anticoagulation is generally prescribed in SVCs, often indefinitely for superior vena cava obstruction or thrombosis associated with malignancy.

Symptoms usually respond rapidly within _____ hours.

Answer 110

24 hours

Question 111

Long-term out- comes depend more on the cause of the superior vena cava obstruction, but in nonmalignant cases, resolution of symptoms occurs in more than _____% of cases.

Answer 111

70%