Chest Wall, Pleura and Mediastinum (TCVS) Flashcards
All of the following increase the risk or tracheal stenosis EXCEPT
A. Age over 70years
B. Radiation
C. Male gender
D. Excessive corticosteroid therapy
Answer: C
Intubation-related risk factors include:
1) prolonged intubation;
2) high tracheostomy through the first tracheal ring or cricothyroid membrane;
3) transverse rather than vertical incision on the trachea;
4) oversized tracheostomy tube;
5) prior tracheostomy or intubation; and
6) traumatic intubation.
Stenosis is also more common in older patients, in females, after radiation, or after excessive corticosteroid therapy, and in the setting of concomitant diseases such as autoimmune disorders, severe reflux disease, or obstructive sleep apnea and the setting of severe respiratory failure.
However, even a properly placed tracheostomy can lead to tracheal stenosis because of scarring and local injury.
Mild ulceration and stenosis are frequently seen after tracheostomy removal.
Use of the smallest tracheostomy tube possible, rapid downsizing, and a vertical tracheal incision minimize the risk for post-tracheostomy stenosis.
(See Schwartz 10th ed., p. 607.)
Adenoid cystic carcinomas
A. Spread submucosally
B. Exhibit aggressive growth
C. Are not radiosensitive
D. Have a 5-year survival rate of >50%
Answer: A
Squamous cell carcinomas often present with regional lymph node metastases and are frequently unresectable at presentation.
Their biologic behavior is similar to that of squamous cell carcinoma of the lung. Adenoid cystic carcinomas, a type of salivary gland tumor, are generally slow-growing, spread submucosally, and tend to infiltrate along nerve sheaths and within the tracheal wall.
Although indolent in nature, adenoid cystic carcinomas are malignant and can spread to regional lymph nodes, lung, and bone.
Squamous cell carcinoma and adenoid cystic carcinomas represent approximately 65% of all tracheal neoplasms.
The remaining 35% comprises small cell carcinomas, mucoepidermoid carcinomas, adenocarcinomas, lymphomas, and others.
Postoperative mortality, which occurs in up to 10% of patients, is associated with the length of tracheal resection, use of laryngeal release, the type of resection, and the histologic type of the cancer.
Factors associated with improved long- term survival include complete resection and use of radiation as adjuvant therapy in the setting of incomplete resection.
Due to their radiosensitivity, radiotherapy is frequently given post-operatively after resection of both adenoid cystic carcinomas and squamous cell carcinomas.
A dose of 50 Gray or greater is usual. Nodal positivity does not seem to be associated with worse survival.
Survival at 5 and 10 years is much better for adenoid cystic (73 and 57%, respectively) than for tracheal cancers (47 and 36%, respectively; P <0.05).
For patients with unresectable tumors, radiation may be given as the primary therapy to improve local control, but is rarely curative.
For recurrent airway compromise, stenting or laser therapies should be considered part of the treatment algorithm.
(See Schwartz 10th ed., pp. 610–611.)
Which of the following is NOT a non-small-cell tumor of the lung?
A. Squamous cell carcinoma
B. Adenocarcinoma
C. Carcinoid tumor
D. Large-cell carcinoma
Answer: C
The term non–small-cell lung carcinoma (NSCLC) includes many tumor cell types, including large cell, squamous cell, and adenocarcinoma.
Historically, these subtypes were considered to be a uniform group based on limited understanding of the distinct clinical behaviors of the subtypes as well as the act that there were few treatment options available.
With increasing understanding of the molecular biology underlying these tumor subtypes, however, the approach to diagnosis and management and the terminology used in describing these tumors is evolving rapidly.
(See Schwartz 10th ed., p. 614.)
The most common pattern of benign calcifcation in hamartomas is
A. Solid
B. Diffuse
C. Central
D. Popcorn
Answer: D
Computed tomography (CT) indings characteristic of benign lesions include small size, calcification within the nodule, and stability over time.
Four patterns of benign calcification are common: diffuse, solid, central, and laminated or “popcorn.”
Granulomatous infections, such as tuberculosis, can demonstrate the first three patterns, whereas the popcorn pattern is most common in hamartomas.
In areas of endemic granulomatous disease, differentiating benign versus malignant can be challenging.
Infectious granulomas arising from a variety of organisms account for 70 to 80% of this type of benign solitary nodules; hamartomas are the next most common single cause, accounting or about 10%.
(See Schwartz 10th ed., p. 622.)
For an adenocarcinoma that has pleural invasion, tumor necrosis, and has lymphovascular invasion the correct subtype is
A. Minimally invasive adenocarcinoma (MIA)
B. Lepidic predominant adenocarcinoma (LPA)
C. Invasive adenocarcinoma
D. Adenocarcinoma in situ
Answer: B
If lymphovascular invasion, pleural invasion, tumor necro- sis, or more than 5 mm of invasion are noted in a lesion that has lepidic growth as its predominant component, minimally invasive adenocarcinoma (MIA) is excluded, and the lesion is called lepidic predominant adenocarcinoma (LPA), and the size of the invasive component is recorded for the T stage.
(See Schwartz 10th ed., p. 615.)
The grade of neuroendocrine carcinoma (NEC) that is associated with hemoptysis, pneumonia, and tumor cells arranged in cords and clusters is
A. Grade VI NEC
B. Grade IV NEC
C. Grade II NEC
D. Grade I NEC
Answer: D
Grade I neuroendocrine carcinoma (NEC) (classic or typical carcinoid) is a low-grade NEC; 80% arise in the epithelium of the central airways.
It occurs primarily in younger patients. Because of the central location, it classically presents with hemoptysis, with or without airway obstruction and pneumonia.
Histologically, tumor cells are arranged in cords and clusters with a rich vascular stroma. This vascularity can lead to life-threatening hemorrhage with even simple bronchoscopic biopsy maneuvers.
Regional lymph node metastases are seen in 15% of patients, but rarely spread systemically or cause death.
(See Schwartz 10th ed., p. 617.)
Which of the following is NOT a known predictive or prognostic tumor marker for adenocarcinoma?
A. EGFR
B. KRAS
C. AFP
D. EML4-ALK
Answer: C
Establishing a clear histologic diagnosis early in the evaluation and management of lung cancer is critical to effective treatment.
Molecular signatures are also key determinants of treatment algorithms or adenocarcinoma and will likely become important for squamous cell carcinoma as well.
Currently, differentiation between adenocarcinoma and squamous cell carcinoma in cytologic specimens or small biopsy specimens is imperative in patients with advanced stage disease, as treatment with pemetrexed or bevacizumab-based chemotherapy is associated with improved progression-free survival in patients with adenocarcinoma but not squamous cell cancer.
Furthermore, life-threatening hemorrhage has occurred in patients with squamous cell carcinoma who were treated with bevacizumab.
Finally, EGFR mutation predicts response to EGFR tumor kinase inhibitors and is now recommended as first-line therapy in advanced adenocarcinoma.
Because adequate tissue is required for histologic assessment and molecular testing, each institution should have a clear, multidisciplinary approach to patient evaluation, tissue acquisition, tissue handling/processing, and tissue analysis.
In many cases, tumor morphology differentiates adenocarcinoma rom the other histologic subtypes. If no clear morphology can be identified, then additional testing or one immunohistochemistry marker for adenocarcinoma and one for squamous cell carcinoma will usually enable differentiation.
Immunohistochemistry for neuroendocrine markers is reserved for lesions exhibiting neuroendocrine morphology.
Additional molecular testing should be performed on all adenocarcinoma specimens for known predictive and prognostic tumor markers (eg, EGFR, KRAS, and EML4-ALK fusion gene).
Ideally, use of tissue sections and cell block material is limited to the minimum necessary at each decision point.
This emphasizes the importance of a multidisciplinary approach; surgeons and radiologists must work in direct cooperation with the cytopathologist to ensure that tissue samples are adequate or morphologic diagnosis as well as providing sufficient cellular material to enable molecular testing.
(See Schwartz 10th ed., p. 627.)
Desmoid tumors
A. Arise from the periosteum of the rib
B. Are treated with wide local excision with a 2- to 4-cm margin
C. Require radical excision (sacrificing neurovascular structures) to obtain 4-cm margins
D. Require chemotherapy to treat or prevent metastatic disease
Answer: B
Because the lesions have low cellularity and poor yield with fine needle aspiration (FNA), an open incisional biopsy or lesions over 3 to 4 cm is often necessary.
Surgery consists of wide local excision with a 2- to 4-cm margin and intraoperative frozen section assessment of resection margins.
Typically, chest wall resection, including the involved rib(s) and one rib above and below the tumor with a 4- to 5-cm margin of rib, is required.
A margin of less than 1 cm results in much higher local recurrence rates.
If a major neurovascular structure would have to be sacrificed, leading to high morbidity, then a margin of less than 1 cm would have to suffice.
Survival after wide local excision with negative margins is 90% at 10 years.
(See Schwartz 10th ed., p. 666.)
A 57-year-old non-small-cell lung cancer patient with a potentially resectable tumor found on computed tomography (CT) scan who can walk on a flat surface indefinitely without oxygen or stopping to rest, secondary to dyspnea will most likely tolerate
A. Lobectomy
B. Pneumonectomy
C. Single-lung ventilation
D. Wedge resection
Answer: A
Patients with potentially resectable tumors require careful assessment of their functional status and ability to tolerate either lobectomy or pneumonectomy.
The surgeon should first estimate the likelihood of pneumonectomy, lobectomy, or possibly sleeve resection, based on the CT images.
A sequential process of evaluation then unfolds.
A patient’s history is the most important tool for gauging risk. Specific questions regarding performance status should be routinely asked. If the patient can walk on a flat surface indefinitely, without oxygen and without having to stop and rest secondary to dyspnea, he will be very likely to tolerate lobectomy.
If the patient can walk up two lights of stairs (up two standard levels), without having to stop and rest secondary to dyspnea, he will likely tolerate pneumonectomy.
Finally, nearly all patients, except those with carbon dioxide (CO2) retention on arterial blood gas analysis, will be able to tolerate periods of single-lung ventilation and wedge resection.
(See Schwartz 10th ed., pp. 635–636.)
An “onion-peel” appearance of a rib on CT is suggestive of
A. Chondroma
B. Ewing sarcoma
C. Plasmacytoma
D. Osteosarcoma
Answer: B
Primitive neuroectodermal tumors (PNEs) (neuroblastomas, ganglioneuroblastomas, and ganglioneuromas) derive from primordial neural crest cells that migrate from the mantle layer of the developing spinal cord.
Histologically, PNEs
and Ewing sarcomas are small, round cell tumors; both possess a translocation between the long arms of chromosomes 11 and 22 within their genetic makeup.
They also share a consistent pattern of proto-oncogene expression and have been found to express the product of the MIC2 gene.
Ewing sarcoma occurs in adolescents and young adults who present with progressive chest wall pain, but without the presence of a mass.
Systemic symptoms of malaise and fever are often present.
Laboratory studies reveal an elevated erythrocyte sedimentation rate and mild white blood cell elevation.
Radiographically, the characteristic onion peel appearance is produced by multiple layers of periosteum in the bone formation. Evidence of bony destruction is also common.
The diagnosis can be made by a percutaneous needle biopsy or an incisional biopsy.
(See Schwartz 10th ed., p. 669.)
Pancoast tumors are identified as involving all of the following except:
A. The chest wall at or below the second rib.
B. Tumors of the parietal pleura or deeper structures overlying the first rib.
C. The superior sulcus.
D. The extreme apex of the chest.
Answer: A
Carcinoma arising in the extreme apex of the chest with associated arm and shoulder pain, atrophy of the muscles of the hand, and Horner syndrome presents a unique challenge to the surgeon.
Any tumor of the superior sulcus, including tumors without evidence for involvement of the neurovascular bundle, is now commonly known as Pancoast tumors, after Henry Pancoast who described the syndrome in 1932.
The designation is reserved for tumors involving the parietal pleura or deeper structures overlying the first rib.
Chest wall involvement at or below the second rib is not a Pancoast tumor.
Treatment is multidisciplinary; due to the location of the tumor and involvement of the neurovascular bundle that supplies the ipsilateral extremity, preserving postoperative function of the extremity is critical.
(See Schwartz 10th ed., p. 642.)
The most likely cause of aspiration pneumonia is
A. A mixture of aerobes and anaerobes
B. Aerobes only
C. Anaerobes only
D. Gram-negative bacteria
Answer: C
Normal oropharyngeal secretions contain many more Streptococcus species and more anaerobes (approximately 1 × 108 organisms/mL) than aerobes (approximately 1 × 107 organisms/mL).
Pneumonia that follows from aspiration, with or without abscess development, is typically poly- microbial.
An average of two to four isolates present in large numbers have been cultured from lung abscesses sampled percutaneously.
Overall, at least 50% of these infections are caused by purely anaerobic bacteria, 25% are caused by mixed aerobes and anaerobes, and 25% or fewer are caused by aerobes only.
In nosocomial pneumonia, 60 to 70% of the organisms are gram-negative bacteria, including Klebsiella pneumoniae, Haemophilus influenzae, Proteus species, Pseudomonas aeruginosa, Escherichia coli, Enterobacter cloacae, and Eikenella corrodens.
Immunosuppressed patients may develop abscesses because of the usual pathogens as well as less virulent and opportunistic organisms such as Salmonella species, Legionella species, Pneumocystis carinii, atypical mycobacteria, and fungi.
(See Schwartz 10th ed.,p.650.)
Laboratory evaluation of a chest wall mass showing elevated erythrocyte sedimentation rates indicates
A. Osteosarcoma
B. Plasmacytoma
C. Ewing sarcoma
D. Multiple myeloma
Answer: C
Laboratory evaluations are useful in assessing chest wall masses or the following:
- Plasmacytoma: Serum protein electrophoresis demonstrates a single monoclonal spike, which is measuring the overproduction of one immunoglobulin rom the malignant plasma cell clone.
- Osteosarcoma: Alkaline phosphatase levels may be elevated.
- Ewing sarcoma: Erythrocyte sedimentation rates may be elevated.
(See Schwartz 10th ed., able 19-18, p. 665.)
The most common benign chest wall tumor is
A. Chondromas
B. Osteochondromas
C. Desmoid tumors
D. Fibrous dysplasia
Answer: A
Chondromas, seen primarily in children and young adults, are one of the more common benign tumors of the chest wall.
They usually occur at the costochondral junction anteriorly and may be confused with costochondritis, except that a painless mass is present.
Radiographically, lesion is lobulated and radiodense; it may have diffuse or focal calcifications; and it may displace the bony cortex without penetration.
Chondromas may grow to huge sizes if left untreated.
Treatment is surgical resection with a 2-cm margin.
Large chondromas may harbor well-differentiated chondrosarcoma and should be managed with a 4-cm margin to prevent local recurrence.
(See Schwartz 10th ed., p. 666.)
Which of the following is an indication for surgical drainage of a lung abscess?
A. Abscess >3 cm in diameter.
B. Hemoptysis.
C. Failure to decrease in size after 1 week of antibiotic therapy.
D. Persistent ever.
Answer: B
Surgical drainage of lung abscesses is uncommon since drainage usually occurs spontaneously via the tracheobronchial tree.
Indications for intervention are:
- Failure of medical therapy
- Abscess under tension
- Abscess increasing in size during appropriate treatment
- Contralateral lung contamination
- Abscess >4–6 cm in diameter
- Necrotizing infection with multiple abscesses, hemoptysis, abscess
rupture, or pyopneumothorax - Inability to exclude a cavitating carcinoma
What percentages of chest wall masses are malignant?
A. 10–20%
B. 20–30%
C. 50–80%
D. 40–50%
Answer: C
Patients with chest wall tumors, regardless of etiology, typically complain of a slowly enlarging palpable mass (50–70%), chest wall pain (25–50%), or both.
Interestingly, growing masses are often not noticed by the patient until they suffer a trauma to the area.
Pain from a chest wall mass is typically localized to the area of the tumor; it occurs more often and more intensely with malignant tumors, but it can also be present in up to one-third of patients with benign tumors.
With Ewing sarcoma, fever and malaise may also be present.
Benign chest wall tumors tend to occur in younger patients (average age 26 years), whereas malignant tumors tend to be found in older patients (average age 40 years).
Overall, between 50 and 80% of chest wall tumors are malignant.
(See Schwartz 10th ed., p. 665.)
The population most at risk for developing active tuberculosis is
A. Elderly
B. Minorities
C. Urban residents
D. Human immunodeficiency virus (HIV) infected
Answer: D
Tuberculosis is a widespread problem that affects nearly one-third of the world’s population. Between 8.3 and 9 million new cases of tuberculosis and 12 million prevalent cases (range 10–13 million) were estimated worldwide in 2011 according to the World Health Organization. Only 10,521 new cases were reported to the World Health Organization in the United States in 2011.
Human immunodeficiency virus (HIV) infection is the strongest risk factor for developing active tuberculosis. The elderly, minorities, and recent immigrants are the most common populations to have clinical manifestations of inection, yet no age group, sex, or race is exempt from infection.
In most large urban centers, reported cases of tuberculosis are more numerous among the homeless, prisoners, and drug-addicted populations.
Immunocompromised patients additionally contribute to an increased incidence of tuberculosis infection, often developing unusual systemic as well as pulmonary manifestations.
(See Schwartz 10th ed., p. 654.)
The fungi associated with the highest mortality rate due to invasive mycoses in the United States is
A. Aspergillus
B. Cryptococcus
C. Candidia
D. Mucor
Answer: A
The genus Aspergillus comprises over 150 species and is the most common cause of mortality due to invasive mycoses in the United States.
It is typically acute in onset and life-threatening and occurs in the setting of neutropenia, chronic steroid therapy, or cytotoxic chemotherapy.
It can also occur in the general intensive care unit population of critically ill patients, including patients with underlying chronic obstructive pulmonary disease (COPD), postoperative patients, patients with cirrhosis or alcoholism, and post-inluenza patients, without any of these factors present.
The species most commonly responsible for clinical disease include A. fumigatus, A. flavus, A. niger, and A. terreus.
Aspergillus is a saprophytic, filamentous fungus with septate hyphae.
Spores (2.5–3 μm in diameter) are released and easily inhaled by susceptible patients; because the spores are microns in size, they are able to reach the distal bronchi and alveoli.
(See Schwartz 10th ed., p. 655.)
A patient presenting with a history and findings of dyspnea, wheezing, hemoptysis, and a mediastinal mass in the visceral compartment yields a diagnosis of
A. Lymphoma
B. Thymoma with myasthenia gravis
C. Mediastinal granuloma
D. Germ cell tumor
LYMPHOMA
- Hx/PE: Night sweats, weight loss, fatigue, extrathoracic adenopathy, elevated erythrocyte sedimentation rate or C-reactive protein level, leukocytosis
- Location: Any compartment
THYMOMA WITH MYASTHENIA GRAVIS
- Hx/PE: Fluctuating weakness, early fatigue, ptosis, diplopia
- Location: Anterior
MEDIASTINAL GRANULOMA
- Hx/PE: Dyspnea, wheezing, hemoptysis
- Location: Visceral (middle)
GERM CELL TUMOR
- Hx/PE: Male gender, young age, testicular mass, elevated levels of human chorionic gonadotropin and/or α- fetoprotein
- Location: Anterior
A patient with an anterior mediastinal mass and elevated serum α- etoprotein (AFP) most likely has
A. A teratoma
B. A nonseminomatous germ-cell tumor
C. A seminomatous germ-cell tumor
D. Metastatic hepatocellular carcinoma
Answer: B
The use of serum markers to evaluate a mediastinal mass can be invaluable in some patients. For example, nonseminomatous and seminomatous germ-cell tumors can frequently be diagnosed and often distinguished from one another by the levels of α- etoprotein (AFP) and human chorionic gonadotropin (hCG).
In over 90% of nonseminomatous germ-cell tumors, either the AFP or the hCG level will be elevated. Results are close to 100% specificic if the level of either AFP or hCG is greater than 500 ng/mL.
Some centers institute chemotherapy based on this result alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than 100 ng/mL.
Other serum markers, such as intact parathyroid hormone level or ectopic parathyroid adenomas, may be useful for diagnosing and also for intraoperatively confirming complete resection.
After successful resection of a parathyroid adenoma, this hormone level should rapidly normalize.
(See Schwartz 10th ed., p. 672
The primary site for male patients with malignant pleural effusions is
A. Gastrointestinal tract
B. Lung
C. Genitourinary tract
D. Melanoma
Answer: B
Malignant pleural effusions may occur in association with a number of different malignancies, most commonly lung cancer, breast cancer, and lymphomas, depending on the patient’s age and gender.
(p. 132 Schwartz ABSITE)
Eosinophilic granulomas are associated with
A. Langerhans cell histiocytosis (LCH)
B. Parasitic infections
C. Crohn disease
D. Gardner syndrome
Answer: A
Eosinophilic granulomas are benign osteolytic lesions. Eosinophilic granulomas of the ribs can occur as solitary lesions or as part of a more generalized disease process of the lymphoreticular system termed Langerhans cell histiocytosis (LCH).
In LCH, the involved tissue is infiltrated with large numbers of histiocytes (similar to Langerhans cells seen in skin and other epithelia), which are often organized as granulomas.
The cause is unknown. Of all LCH bone lesions, 79% are solitary eosinophilic granulomas, 7% involve multiple eosinophilic granulomas, and 14% belong to other forms of more systemic LCH.
Isolated single eosinophilic granulomas can occur in the ribs or skull, pelvis, mandible, humerus, and other sites. They are diagnosed primarily in children between the ages of 5 and 15 years.
Because of the associated pain and tenderness, they may be confused with Ewing sarcoma or with an inflammatory process such as osteomyelitis.
Healing may occur spontaneously, but the typical treatment is limited surgical resection with a 2-cm margin.
(See Schwartz 10th ed., p. 666.)
A chylothorax is likely to be present in a patient whose pleural fluid analysis results show a triglyceride level of
A. 80mg/100mL
B. 100mg/100mL
C. 45mg/100mL
D. 130mg/100mL
Answer: D
Laboratory analysis of the pleural fluid shows a high lymphocyte count and high triglyceride levels.
If the triglyceride level is greater than 110 mg/100 mL, a chylothorax is almost certainly present (a 99% accuracy rate).
If the triglyceride level is less than 50 mg/mL, there is only a 5% chance of chylothorax.
(See Schwartz 10th ed., p. 686.)
Osteosarcoma of the rib
A. Is considered nonoperable if pulmonary metastases are present
B. Is treated with radiation therapy before resection
C. Is treated with adjuvant chemotherapy before resection
D. Requires excision with a 6-cm margin
Answer: C
While osteosarcomas are the most common bone malignancy, they represent only 10 to 15% of all malignant chest wall tumors.
They primarily occur in young adults as rapidly enlarging, painful masses; however, osteosarcomas can occur in older patients as well, sometimes in association with previous radiation, Paget disease, or chemotherapy.
Radiographically, the typical appearance consists of spicules of new periosteal bone formation producing a sunburst appearance.
Osteosarcomas have a propensity to spread to the lungs, and up to one-third of patients present with metastatic disease.
Osteosarcomas are potentially sensitive to chemotherapy. Currently, preoperative chemotherapy is common. After chemotherapy, complete resection is performed with wide (4-cm) margins, followed by reconstruction.
In patients presenting with lung metastases that are potentially amenable to surgical resection, induction chemotherapy may be given, followed by surgical resection of the primary tumor and of the pulmonary metastases.
Following surgical treatment of known disease, additional maintenance chemotherapy is usually recommended.
(See Schwartz 10th ed., p. 667.)
Excisional biopsy of a chest wall mass is allowed if
A. Needle biopsy was nondiagnostic.
B. Imaging reveals classic appearance of a chondrosarcoma.
C. It is >3cm.
D. None of the above.
Answer: B
- Needle biopsy: Pathologists experienced with sarcomas
can accurately diagnose approximately 90% o patients using FNA cytology. A needle biopsy (FNA or core) has the advantage of avoiding wound and body cavity contamination (a potential complication with an incisional biopsy). - Incisional biopsy: If a needle biopsy is nondiagnostic, an incisional biopsy may be performed, with caveats. First, the skin incision must be placed directly over the mass and oriented to allow subsequent scar excision; skin laps and drains should be avoided. However, if the surgeon believes a hematoma is likely to develop, a drain is useful for limiting soft tissue contamination by tumor cells. At the time of definitive surgical resection, the en bloc resection includes the biopsy scar and the drain tract along with the tumor.
- Excisional biopsy: Any lesion less than 2.0 cm can be excised as long as the resulting wound is small enough to close primarily. Otherwise, excisional biopsy is performed only when the initial diagnosis (based on radiographic evaluation) indicates that the lesion is benign or when the lesion has the classic appearance of a chondrosarcoma (in which case, definitive surgical resection can be under- taken).
(See Schwartz 10th ed., p. 666.)
A 77-year-old male who is a former smoker (quit 10
years ago; smoked 1 pack per day for 50 years) with
COPD, type 2 diabetes mellitus, and CAD status post
CABG x 3 10 years ago, presents with a 4 month history of a non-productive cough and 10 pound weight loss in the past 3 months. A CXR and CT chest demonstrate a 2 x 3.1 cm mass in his right upper lung that was not present on a CXR taken 5 years earlier.
What is the best appropriate next step in the management of this patient?
A. Positron emission tomography (PET) scan
B. Cervical mediastinoscopy
C. Right upper lobectomy
D. Right upper lobectomy with mediastinal lymph
node sampling
E. Bone scan and abdominal CT scan
A. PET scanning uses fluorodeoxyglucose (FDG)
with radiolabeled fluorine to help detect malignant cells. Malignant cells metabolize glucose at a higher rate than normal cells, resulting in a radiolabeled metabolite of FDG, which results in a visual marker to help identify malignant cells, nodal stage, and metastases.
Surgical resection without any attempt at preoperative staging is not appropriate.
Although cervical mediastinoscopy may be an important step in assessing the stage of thÿs patients lung cancer, PET scanning may identify suspicious nodes and
distant metastasis and helps guide the surgeon on where to obtain the appropriate tissue for diagnosis.
Assuming this patient was diagnosed with a primary
non-small cell lung cancer (NSCLC) in the right upper lobe of his lung, which of the following is an absolute contraindication to surgical resection?
A. A post-operative predicted FEV1 of 45%
B. A malignant pleural effusion in the right chest
C. Tumor directly invading the chest wall
D. Tumor directly invading the right main bronchus 0.5 cm away from the carina
E. Tumor directly invading the mediastinal pleura
B. Surgery is contraindicated for Stage IIIB and IV lung cancer.
T4 lesions are classified as stage IIIB if they are associated with N2 disease.
Tumors of any size are T4 if they invade the heart, great vessels, trachea, esophagus, vertebral body, or carina. Tumors associated with malignant pleural or pericardial effusions are considered to have MIA disease, which precludes
surgical intervention.
T3 tumors include tumors of
any size that directly invade any of the following: diaphragm, chest wall, mediastinal pleura, parietal pericardium, or a tumor invading the main bronchus less than 2 cm from the carina (without involvement of the
carina).
Depending on nodal and metastatic involvement, T3 tumors may not result in a staging level of
IIIB or IV. Thus, surgery may be appropriate in select
patients presenting with T3 tumors.
Preoperative testing of pulmonary functional
reserve is essential prior to determining whether a
patient is a candidate for surgical resection. In gen¬
eral, a predicted post-operative FEVj less than 40% is thought to be a contraindication to surgical resection.
Although a post-operative predicted FEV1 of 45% is
not an absolute contraindication to surgical resection, it certainly merits thorough preoperative patient
assessment (including evaluation of comorbidities,
and predicted lung diffusion capacity). It is also important to remember that if the lung to be resected is not actually functional (secondary to collapse or bronchial
obstruction) than the post-operative predicted FEV,
should not be expected to change significantly from the preoperative FEV1.
Conversely, if the lung to be
resected happens to be functional, but the patient has
other areas of lung that are non-functional, than the
FEV1 will actually decrease more dramatically when
this functional lung is resected.
When performing a right upper lobectomy, after the pleura overlying the anterior hilum are divided from anterior to posterior, what is the order o structures that would need to be divided?
A. Superior pulmonary vein/Upper lobe bronchus/
Truncus anterior
B. Truncus anterior/Superior pulmonary vein/
Upper lobe bronchus
C. Superior pulmonary vein/Truncus anterior/
Upper lobe bronchus
D. Upper lobe bronchus/Truncus anterior/Superior
pulmonary vein
E. Truncus anterior/Upper lobe bronchus/Superior
pulmonary vein
C. Structures that would be need to be divided for a
right upper lobectomy from anterior to posterior are
the superior pulmonary vein, truncus anterior, and
upper lobe bronchus.
This is a simplified description of the most commonly encountered anatomy for the main structures seen.
During dissection the surgeon must be mindful of aberrant anatomy (often noted on preoperative imaging) and more commonly branching vessels, which may appear in different planes than listed above.
After resection of his tumor by a right upper lobectomy, pathology demonstrated squamous cell
carcinoma with negative margins. Lymph nodes sampled were also negative for malignancy. Which
of the following is true?
A. The patient will not need any further surveillance.
B. The only surveillance needed will be a repeat CT
chest in 2 years.
C. The most common site of relapse for NSCLC is
bone.
D. The patient will require radiation therapy for
6 months post-operatively.
E. Most recurrences occur within the first two years
after surgery.
E. NSCLC is most likely to relapse within the first two
years after resection (over 60%).
Thus, oncologic surveillance should be done every 3 to 4 months during this time.
Though there is no single recommendation for surveillance beyond 2 years, coordinated oncologic
surveillance should be performed long-term.
Though relapse of NSCLC is common in the bone, the most
common site of relapse for all stages of NSCLC is the
brain. Other sites of relapse include the lung (ipsilateral or contralateral), liver, and adrenal glands. There is
no indication for radiation therapy post-operatively.
If another patient presented with significant hyponatremia and seizures and was incidentally found to have similar sized lung mass in the right upper lobe, the patient would most likely benefit
from which of the following treatment modalities?
A. Surgical resection of the tumor alone
B. Single agent chemotherapy
C. Radiation therapy alone
D. Combination chemotherapy alone
E. Combination chemotherapy and radiation therapy
E. Paraneoplastic syndromes develop in as many as 40% of patients with newly diagnosed lung cancers.
Significant hyponatremia in the setting of a newly diagnosed lung mass is highly suspicious of syndrome of inappropriate antidiuretic hormone (SIADH). It is important to recognize that SIADH is most commonly associated with small cell lung cancer (SCLC).
In addition to hyponatremia, the diagnosis of SIADH is confirmed by demonstrating a
serum osmolarity <275mOsm/kg, urine osmolarity > serum osmolarity, and urine sodium > 25 meq/L.
Associated symptoms may include lethargy, nausea,
vomiting, altered mental status, and seizures.
SCLC account for D20% of all lung cancers. These tumors are known for rapid growth, and thus often present with necrosis. They commonly invade vascular and lymphatic tissue, and metastasize early.
Up to 70% of patients present with metastasis at the time of diagnosis. Given that SCLC is a systemic disease, chemotherapy is the primary medical treatment.
Combination chemotherapy with the addition of radiotherapy for locorégional control has been shown to improve survival. Additional prophylactic cranial irradiation has been shown to decrease the incidence brain metastasis, but has not been shown
to improve overall survival.
Other paraneoplastic syndromes associated with
hormone alterations should also be recognized.
Often Patients with SCLC may exhibit elevations in adrenocorticotropic hormone (ACTH). This may manifest with hypokalemia, hyperglycemia, and metabolic alkalosis.
Diagnosis can be confirmed by
measuring elevated ACTH in the blood or elevated
17-hydroxycorticosteroid levels in the urine.
- A 14-year-old boy is seen by a pediatric cardiologist because of increasing shortness of
breath. Studies reveal increased pulmonary
vascular resistance, left axis deviation on
Electrocardiogram (ECG), and mitral regurgitation murmur. What is the most likely
diagnosis?
(A) Ostium primum defect
(B) Tetralogy of Fallot
(C) Right aortic arch
(D) Ostium secundum defect
(E) Atrioventricular canal
- (A) Ostium primum. Typically ostium primum
in an adolescent would be diagnosed by
increasing symptoms, increased pulmonary
resistance, left axis on ECG, and a mitral regurgitation murmur due to a cleft mitral valve.
Ostium secundum would cause increased pulmonary resistance later in life, not at age 14. AV
canal is seen most commonly in Down syndrome. Right aortic arch and tetralogy of Fallot
do not have this symptom complex.
- A cyanotic female neonate is born with transposition of the great arteries. Metabolic acidosis and hypoxemia are present and are life
threatening. Which of the following is the best
initial treatment?
(A) Urgent Mustard operation
(B) Prostaglandin E1
(C) Atrial septotomy
(D) Pulmonary artery banding
(E) Prostaglandin E1 and atrial septotomy
- (E) Prostaglandin E1 and Aterial septotomy.
Prostaglandin E1 is used to keep the ductus
arteriousus open in transposition. Desaturated
“systemic” blood can pass through the pulmonary circulation to be oxygenated. The aterial septotomy creates an ASD, which aids in
saturated blood being pumped peripherally,
decreasing the cyanosis. The mustard operation is not commonly done as the arterial
switch operation is most common in this era,
and in this acutely ill neonate definitive operation would not be the best initial treatment.
Pulmonary artery banding does not apply.
- A 65-year-old man undergoes cardiac surgery
for triple vessel coronary artery disease. What
can he anticipate?
(A) 95% chance his grafts will occlude after
12 months.
(B) 5% chance of living for 5 years.
(C) If the internal mammary artery is used
as a conduit, patency is increased.
(D) Mortality if 10–20% in most centers.
(E) Functional improvement with the
saphenous vein graft is better than
internal memory artery.
- (C) Internal thoracic artery. The internal thoracic artery is the conduit of choice especially
for grafting the left anterior descending (LAD)
artery. Arterial and venous grafts 95% of the
time do not occlude after 12. Seventy-five percent of patients under coronary artery bypass
graft (CABG) survive 5 years. Mortality is 2%
or lower in most centers.
- Three months after aortic valve replacement
with a mechanical prosthesis, a 60-year-old
man describes malaise, and increasing shortness of breath. Examination reveals pulsus
paradoxus. ECG shows low voltage precordially. What test is most useful for making the
diagnosis?
(A) Stress thallium exam
(B) Computer Tomography (CT)
examination of chest
(C) Coronary angiography
(D) Echocardiography
(E) Serum creatinine phosphokinase (CPK)
- (D) Echocardiography. This patient has a pericardial effusion. Echocardiography is the most
useful in making the diagnosis. CAT scan of the
chest can be used but is not the best exam. The
other choices do not apply.
5. In the patient described above urine output decreases to 20 cc/h. Studies reveal paradoxical septal motion. What is the next course of therapy? (A) Expectant medical therapy (B) Redo aortic valve surgery (C) Left chest tube (D) Ontra-aortic balloon (E) Pericardial window
- (E) Pericardial window. The patient developed
decreased cardiac output (decreasing urine
output,)and cardiac tamponade. Emergent
pericardial window is the treatment of choice.
Medical therapy will result in the patient’s
death. The other choices do not apply.
- A 58-year-old man is in cardiogenic shock in
the emergency department after sustaining an
acute myocardial infarction (MI). An intraaortic balloon pump (IABP) is inserted. Which
statement is TRUE about IABP?
(A) The balloon increases coronary
perfusion during diastole.
(B) The balloon increases coronary
perfusion during systole.
(C) The balloon increases peripheral
resistance.
(D) The balloon is inflated in systole and
diastole.
(E) The pump must be removed after
24 hours.
- (A) IABP increases coronary perfusion during
distole. The IABP inflates during diastole and
propels blood into the coronary circulation.
IABP decreases peripheral resistance and
decreases afterload on the heart. The IABP can
stay in the patient for longer than 24 hours.
- A 66-year-old female has had two MIs in the
past. She is admitted to the emergency department in congestive heart failure. After admission and appropriate therapy her Holter
monitor shows frequent PVCs and her ejection
fraction is found to be 35%. Appropriate treatment would include which of the following?
(A) Single chamber pacemaker
(B) Cardioversion
(C) Dual chamber pacemaker
(D) Internal cardiac defibrillator (ICD)
(E) Greenfield filter
- (D) ICD. In a patient with history of MI, congestive heart failure, and decreased ejection
fraction coupled with frequent premature ventricular beats studies have shown that this
subset of patient benefits from internal cardiac
defibrillators, as the most frequent cause of
death in these patients is sudden cardiac death
from ventricular fibrillation. Single and dual
chamber pacemakers are used for bradyarrythmias. The other choices do not apply.
- During a routine examination of a 30-year-old
female actuary seeking life insurance, she is
found to have a ventricular septal defect (VSD).
She undergoes subsequent studies including
ECG, chest x-ray, echocardiography, and
Doppler ultrasound. What is the major determinant of operability in VSD?
(A) Age of patient
(B) Pulmonary vascular resistance
(C) Size of the VSD
(D) Location of the VSD
(E) Presence of cyanosis
- (B) Increase in pulmonary vascular resistance
causes an increased cardiac output. Small shunts
(with a pulmonary/systemic flow ratio >1.5) do
not require surgery but must be treated with
prophylactic antibiotics. Larger shunts should be
repaired, because the mortality rate exceeds 50%
when severe pulmonary pressure (>85 mm Hg)
occurs. Closure of the VSD in the presence of
cyanosis with established reversal of the direction of flow (right to left) would be detrimental, carrying a very high mortality.
- At the age of 3 years, a child with a VSD
becomes progressively short of breath and
requires urgent surgery. What is the most
common type of VSD (Fig. 4–1)?
(A) Defect anterior to the crista
supraventricular
(B) Membranous septal defect
(C) Posterior septal defect
(D) Low muscular defect
(E) Right-to-left shunt
- (B) VSD is the most common cardiac congenital abnormality and results from failure of
fusion of the uppermost part of the interventricular septum with the aortic septum.
Membranous septal defects account for 90% of
VSDs. There is usually a left-to-right shunt and
cyanosis does not occur until pulmonary
hypertension is severe enough to reverse flow
across the VSD. Surgery is indicated in large
shunts only when symptoms occur and pulmonary hypertension is evident. Forty percent
will close spontaneously in childhood.
- A 1-year-old girl is found to have a posterior
membranous VSD. Peripheral resistance of the
pulmonary system is 40% that of the systemic.
How should you proceed?
(A) Observe the child, because most VSDs
close spontaneously.
(B) Band the pulmonary artery and fix the
defect at age 6.
(C) Repair electively at age 14.
(D) Repair electively between ages 4 and
6 years.
(E) Repair immediately as an emergency.
- (D) Increase in pulmonary resistance would
require more urgent intervention. Because
nearly half the cases of VSD in childhood will
close spontaneously, elective surgery is deferred
to late childhood. Banding procedures are used
less frequently today because of the high mortality rate. If symptoms increase in severity and
pulmonary pressure is high, more urgent intervention is indicated. If the pulmonary systolic
pressure is over 85 mm Hg and the left-to-right
shunt is small, surgical mortality exceeds 50%.
- At birth, the 6 weeks premature infant is
noted to have progressive dyspnea. There is a
continuous murmur in the pulmonic area (second left intercostal space), and cyanosis is
absent. ECG findings are normal. An x-ray of
the heart shows cardiomegaly, and the pulse
is bounding. Patent ductus arteriosus (PDA)
is diagnosed. What does treatment include?
(A) Immediate surgical correction
(B) Administration of indomethacin
(C) Administration of cortisone
(D) Renal dialysis
(E) Endotracheal intubation in all cases
- (B) Management of compromised respiratory
status in the premature infant with PDA
includes fluid restriction, adequate oxygenation, attempted closure by medication with
indomethacin, and surgical ligation (undertaken when indomethacin is contraindicated).
Good results can be anticipated in the absence
of other serious complications.
- During a routine preschool physical examination, the physician notes that a 3-year-old girl
has a machinery-type murmur on auscultation
of the chest. The pulse is bounding and palpable in the femoral and radial region of both
sides of her body. There were no symptoms,
and she has excellent exercise performance.
Persistent PDA is confirmed on subsequent
examination. The parents should be advised
that the girl requires which of the following:
(A) Surgical correction and closure of the
PDA
(B) Indomethacin
(C) Coronary angiography
(D) No treatment unless symptoms occur
(E) CT scan of the heart
- (A) In full-term infants born with persistent
PDA, the anomaly must be closed or excised
between 6 months and 3 years of age to avoid
cardiac complications, including endocarditis.
In PDA, persistence of the communication
between the pulmonary trunk and aorta
increases pulmonary blood flow, left atrial
flow, left ventricular flow, and ascending aorta
flow. PDA accounts for 15% of all congenital
cardiac abnormalities. Cyanosis does not occur
initially, because oxygenated blood is shunted
from the aorta to the pulmonary trunk. The
murmur is continuous (sounds like machinery)
and has harsh features. Its intensity is maximum over the left second intercostal space but
radiates to the chest wall and the neck.
- At the age of 34 years, a female long-distance
runner notes increasing dyspnea after running
more than 10 mi. On inspection and palpation,
a prominent right ventricular heave is noted.
There is a loud systolic murmur in the left third
interspace. The ECG shows right-axis deviation with right bundle branch block. An x-ray
of the chest shows a small aortic knob. What
sign or test will most likely reveal the cause of
the congenital heart abnormality thought to be
atrial septal defect?
(A) Beading (scalloping) of the ribs on x-ray
(B) Decreased carotid pulse
(C) Left ventricular hypertrophy on ECG
(D) Elevated sedimentation rate
(E) Increased oxygen saturation gradient
between the superior vena cava and the
right ventricle
- (E) Cardiac catheterization is the definitive test
for confirming the diagnosis of ASD. It quantifies the size of the shunt and confirms the
increase in oxygen saturation between the right
ventricle and the superior vena cava. Beading
of the ribs is seen in coarctation, and a
decreased carotid pulse is found in aortic stenosis. An elevated sedimentation rate occurs in
the presence of infection such as bacterial
endocarditis.
- The only son of a physiology instructor dies
suddenly at the age of 12 years following worsening symptoms of tetralogy of Fallot. What
would an autopsy reveal?
(A) Dextroposition of the appendix
(B) Brachiocephalic vein draining into the
right renal vein
(C) Inferior vena cava (IVC) draining to the
superior mesenteric vein
(D) Atrial Septal Defect (ASD)
(E) Decreased vascularity of the lung field.
- (E) There is decreased vascularity of the lungs
seen on chest x-ray. Tetralogy of Fallot includes
VSD, right ventricular outflow obstruction,
dextroposition of the aorta, and right ventricular hypertrophy. Tetralogy of Fallot accounts
for over one-half the cases of congenital cyanotic heart disease.
- After suffering a streptococcal throat infection,
a 12-year-old immigrant boy develops cardiac
symptoms that are attributed to rheumatic
fever. Years later, at the age of 34 he is admitted
to the hospital with pulmonary edema. Further
examination reveals a diastolic murmur at the
apex and mitral stenosis is diagnosed. Before
surgical evaluation, which of the following
findings can be attributed to mitral stenosis?
(A) Large left ventricle
(B) Indentation of the middle third of the
esophagus by an enlarged left atrium
(C) Notching of the ribs
(D) Bounding, full pulse
(E) Angina pectoris
- (B) Dilation of the left atrium is the obvious complication following long-standing mitral stenosis.
Echocardiography is the simplest and most precise method of showing enlargement of the left
atrium. Frequently, there is a latency period of
15–20 years before symptoms become evident.
Important complications of mitral stenosis
include exertional dyspnea caused by an increase
in left atrial pressure and backup of blood with
possible pulmonary edema, decreased cardiac
output, atrial fibrillation, emboli (15%), and pressure in the intermediate third of the esophagus as
seen on an esophogram after barium swallow.
The pulse in mitral or aortic stenosis is reduced.
- A 23-year-old ballet dancer is concerned about
the recent sudden death of a young famous
Russian dancer on a New York stage. The
patient seeks advice about his own risk for
developing cardiac disease. His father died
suddenly from ischemic heart disease at the
age of 40. What is the most important risk
factor that would further indicate the possibility of coronary artery heart disease?
(A) Diabetes mellitus
(B) Personality type
(C) Elevated high-density lipoprotein
(D) Elevation of total cholesterol/
high-density lipoprotein ratio
(E) Obesity
- (D) Elevation of total cholesterol/high-density
lipoprotein is a useful predictor of coronary
artery disease (CAD). Other known main risk
factors include genetic predisposition, high
cholesterol level, arterial hypertension, and cigarette smoking. Obesity, diabetes mellitus, and
personality type are of probable importance as
independent risk factors. The presence of
elevated high-density lipoprotein is a favorable factor.
- In evaluating the risk factors involved in advising elective cholecystectomy in a 52-year-old
man with heart disease, which of the following
conditions should alert the surgeon to avoid
an elective procedure?
(A) MI 9 months earlier
(B) Persistent nonspecific changes on ECG
(C) Increased frequency and severity of
attacks of angina
(D) Elevated alkaline phosphatase levels
(E) Hypertension controlled with diuretics
- (C) Changes in the nature of angina should alert
the physician to the possible progression of the
underlying cardiac status. The pain may become
more severe and more frequent, may last longer,
and may occur with a lesser degree of exertion.
Nocturnal pain should likewise signal concern.
In the face of unstable angina, 30% of patients are
likely to develop MI within a 3-month period.
- After his first heart attack 3 years ago, a 63-
year-old painter complained of central chest
pains that radiated to the left arm after exercise.
The pain was alleviated by nitroglycerin.
Recently, he fell on a steel object and severed
the median nerve and flexor tendons at the
wrist. The skin was sutured but he is now
scheduled to have a second operation that will
require anesthesia. What is the best method to
diagnose angina pectoris?
(A) Cholesterol/high-density lipid ratio
(B) Isoenzymes
(C) Stress electrocardiography
(D) Echocardiography
(E) Chest x-ray
- (C) In about one-quarter of patients with angina
pectoris, the ECG findings will be normal.
Exercise electrocardiography will reveal STsegment depression and possibly precipitate
symptoms if angina pectoris is present. There is
a risk of myocardial death in patients tested, and
patients with symptoms after minimal exertion
and/or unstable angina are at particular risk
with this procedure. If hypotension, ventricular
arrhythmia, and supraventricular arrhythmia
occur or if the ECG shows a fall in segment ST of
over 3 mm, the test should be discontinued.
In these cases, 201Tl scintigraphy would be
used to detect cardiac ischemia or infarction.
Echocardiography during supine exercise may
be a helpful test in selected circumstances.
- Eight days after undergoing a hysterectomy, a 64-year-old woman complains of chest pain.
After 12 hours, the internist orders tests to
exclude MI. Which test will most likely support
this diagnosis?
(A) Serum glutamic oxaloacetic
transaminase (SGOT) elevation
(B) Increased sedimentation rate
(C) 99mTc pyrophosphate scintigraphy
showing a “hot spot”
(D) Thallium 201 (201Tl) scintigraphy
showing a (“hot spot”)
(E) Dimethyliminodiacetic acid (HIDA) scan
- (C) 99mTc pyrophosphate scintigraphy showing a
“hot spot.” Following injection of 99mTc pyrophosphate, scintigraphy may show a hot spot in the
infarcted area. The hot spot is developed as the
radiotracer forms a complex with calcium in
necrotic tissue. The test should be requested
within the first 18 hours following the onset of
acute MI. It is not sensitive enough to detect
small infarctions. Following 201Tl scintigraphy, a
“cold spot” occurs because of hypoperfusion.
The test is performed where exercise or dipyridamole (Persantine) injection can be given.
SGOT levels are elevated in liver disease. The
HIDA scan is used to exclude gallbladder disease. Cardiac enzyme levels and ECG findings
are useful to establish a diagnosis of MI.
- After undergoing repair of a left indirect
inguinal hernia, a 72-year-old obese man is
admitted to the emergency department with
severe retrosternal pain of 1-hours duration.
The pain radiates to the medial aspect of the left
hand. The ECG shows Q waves and an elevated ST-segment. A diagnosis of acute MI is
established 1 hour after admission. Immediate
management should include which of the
following?
(A) Thrombolytic therapy with tissue
plasminogen activator (tPA)
(B) Vitamin K
(C) Ampicillin, 2 mg tid PO
(D) Hydrochlorthiazide, 50 mg/d
(E) Sodium, nitroprusside 0.5 mg/kg/min
- (A) Thrombolytic therapy intravenously with
streptokinase, urokinase, or tPA is indicated
in most patients with MI presenting early for
treatment. This therapy, however, is effective
only if initiated within 6 hours after the onset
of pain in patients with acute MI. These drugs
are fibrinogenolytic, and aspirin and heparin
are frequently included in the anticoagulant
protocol. Reperfusion rates of 60% can be
anticipated; reocclusion rates of 15% usually
occur. Vitamin K is not indicated, because it
would increase the coagulability of blood. If
a diuretic, such as hydrochlorothiazide, 25–50
mg/d is indicated to treat milder hypertension, hypokalemia must be avoided.
- Following recovery from an acute MI, a 44-
year-old embryology lecturer is discharged
from the hospital with what instructions?
(A) Angiogram every 3 months to evaluate
the degree of atherosclerosis
(B) Nitroglycerin three times a day
(C) Digoxin
(D) 325 mg of aspirin on alternate days
(E) Pacemaker insertion
- (D) Studies have shown that in men over the
age of 50, taking 1 tablet of aspirin (325 mg) on
alternate days reduces the incidence of subsequent CAD complications. Nitroglycerin is prescribed if angina pectoris develops, and
digoxin would be indicated if congestive heart
faliure (CHF) is evident. Progression of atherosclerosis should be minimized by appropriate
diet and exercise. The intake of excess of cholesterol and saturated fats in the diet causes
changes in the vascular endothelium and
smooth muscle proliferation, with subintimal
fat and fibrous tissue accumulation leading to
occlusion of the coronary arteries, their
branches, and other arteries.
- A 63-year-old woman fell while crossing the
street after her Thursday afternoon bridge
game. Attempts at resuscitation for cardiac
arrest by the emergency medical service (EMS)
team were unsuccessful. The woman had previously been diagnosed as having aortic stenosis and left ventricular hypertrophy. In addition
to these factors, which of the following predisposes to sudden cardiac death?
(A) Split first heart sound
(B) Hypokalemia
(C) Soft murmur at left of sternum that
varies with inspiration
(D) Failure of the central venous pressure
(CVP) to rise more than 1 cm H2O with 30-second pressure on the liver (hepatojugular reflux)
(E) CVP of -1 cm H2O
- (B) Sudden cardiac death is defined as an unexpected death occurring within 1 hour after the
beginning of symptoms in a patient who was
previously hemodynamically stable. In asymptomatic patients presenting initially with cardiac disease, 20% will die within the first hour
of symptoms. Electrolyte imbalance, hypoxia,
and conduction system defect are additional
factors that increase the risk of sudden death
syndrome. Split first heart sound accentuated
on inspiration occurs in normal individuals. In
CHF, the CVP changes more than 1 cm when
pressure is applied below the right costal
margin to the liver (hepatojugular reflex) for a
30-second period.
New York Classification of Functional
Changes in Heart Disease
Class Limitation of Physical Activity
I None
II Slight
III Marked
IV Complete (even at rest)
- Three days after a patient underwent hip
replacement for a fracture of the neck of the
femur, the resident is called to examine the
patient and notes hypotension ( 85/60 mm Hg)
and a pulse rate of 104 beats per minute (bpm).
Fluids are administered, but there is no improvement. The ECG shows peaked T waves
and ST-elevation. Bedside monitoring reveals a
cardiac index (CI) of 1.7 L/min/m2 (normal
>2.2), stroke work index of 16 g/m2 (normal
>30), and a pulmonary artery wedge pressure
(PAWP) of 22 mm Hg (normal <15). Urgent
treatment should involve which of the
following?
(A) Rapid hypertonic saline solution
administration
(B) Adrenaline
(C) Inotropic agents and, if necessary,
intra-aortic balloon counterpulsation
(D) Indomethacin
(E) Atropine
- (C) The patient described has cardiogenic
shock due to postoperative MI. The mortality
rate for patients who develop MI is increased to
more than 60% if hypotensive cardiogenic
shock also supervenes. Pathology studies of
patients dying after such episodes reveal that
more than 40% of the heart will have infarcted.
Inotropic drugs such as dobutamine are used.
If a rapid response is not obtained, intra-aortic
balloon tamponade is provided to unload the
left ventricle during systole and increase diastolic coronary arterial flow. Hypertonic solutions in graded amounts would be given only
if hypovolemia is evident. Atropine and adrenaline would be contraindicated.
- A 58-year-old neurologist is admitted to the
emergency department with persistent hypotension and shock following an acute MI. He is
placed on an IABP. Which following statement is
true about IABP?
(A) The balloon is inflated during systole.
(B) The balloon is inflated during diastole
and systole.
(C) The pump must be removed after
10 minutes.
(D) The balloon usually is inserted via the
femoral artery.
(E) Use of an IABP worsens diastolic
coronary blood flow.
- (D) The balloon usually is inserted via the
femoral artery. The balloon is inflated during
diastole and deflated during systole. It is
important that the balloon be adequately
deflated during systole to avoid damage to the
left ventricle. The pump can be used for a few
days if required.
- While lying on the examining table before
colonoscopy, a 68-year-old electrician notes palpitations. The colonoscopy was scheduled as a
routine procedure following removal of a
benign polyp 1 year earlier. He had rheumatic
fever in infancy. His atrial rate on ECG is 450
bpm, and his ventricular rate is 160 bpm. His
pulse rate is 88 bpm. The left atrium is enlarged.
Similar findings were noted 1 year ago, but he
declined to take any medication. Treatment
should entail which of the following?
(A) Continue with colonoscopy
(B) Continue with colonoscopy after
administration of parenteral antibiotics
(C) Immediate administration of antibiotics
and follow-up colonoscopy at a later date
(D) Immediate administration of
anticoagulation and digoxin and
follow-up colonoscopy at a later date
(E) Immediate electrocardioversion with a
current of 300–400 J
- (D) The major complications occurring in
atrial fibrillation are cardiac failure, coronary
ischemia, and emboli. Emboli may lead to
stroke. Urgent cardioversion is required in
patients with auricular fibrillation if heart failure, hypotension, or angina are also present.
Immediate cardioversion is indicated in ventricular tachycardia or ventricular fibrillation. If
treatment with lidocaine is ineffective, electrocardioversion with 100–200 J for ventricular
tachycardia or 300–400 J for ventricular fibrillation is urgently indicated.
- During routine clinical examination of a 23-
year-old seeking consultation to remove a mole
on her left cheek, she develops tachycardia
with a pulse rate of 186 bpm. Her pulse is regular and is otherwise asymptomatic. An ECG
reveals supraventricular tachycardia. What
should the treatment be?
(A) Alternate pressure on the right and left
carotid sinus
(B) Bilateral simultaneous pressure over
right and left carotid sinus
(C) Deep eyeball pressure
(D) Morphine sulfate, 4–8 mg IV, given
cautiously
(E) Electrical cardioversion
- (A)Alternate pressure over the carotid sinus
for 20 seconds will end an attack of paroxysmal
tachycardia in nearly one-half of cases. The
procedure is contraindicated in patients who
have had a cerebral TIA or those who have a
carotid bruit. Bilateral simultaneous pressure
on the carotid sinus carries an additional risk of
stroke and must be avoided. The common
carotid artery usually divides at the level of
the upper border of the thyroid cartilage or
hyoid bone (C3). The carotid sinus may be
located either on the proximal internal carotid
artery or distal common carotid bifurcation.
Eyeball pressure may be effective but carries
the risk of retina detachment. If initial measures
are unsuccessful, the arrhythmia is treated with
intravenous administration of verapamil or a
similar drug. Electrocardioversion is indicated
in severe cases, particularly if there are adverse
symptoms caused by the tachycardia.
- After experiencing progressive chest pain for
2 months, a surgical-supply store owner undergoes a CT scan that reveals a space-occupying
lesion of the wall of the left atrium, which was
confirmed to be a myxoma. There is no evidence of disease elsewhere. What would the
next line of treatment be?
(A) Excision of a myxoma performed with a
bypass procedure
(B) Excision of a myxoma performed
without a bypass procedure
(C) Insertion of a pacemaker
(D) Chemotherapy
(E) Radiotherapy
- (A) Myxomas constitute more than 50% of all
primary cardiac tumors. They are usually polypoid and attached to the septum. Sarcomas
constitute 20–25% of primary cardiac tumors.
Cardiac metastases are seen in patients with
metastatic disease.
- During examination of a 49-year-old male
schoolteacher who presents with a swelling in
the neck, palpation by a bounding pulse. Which
test would be most likely to establish a possible
cause of the underlying condition?
(A) Funduscopic eye examination
(B) Liver–spleen scan
(C) Thyroid function studies
(D) X-ray of the chest and cervical spine
(E) Carotid sinus pressure
- (C) The pulse is bounding when the pulse pressure is magnified because of a wide difference
between the systolic and diastolic pressure. It
may be due to aortic incompetence, PDA, or
noncardiac causes that result in increase in cardiac output and decreased peripheral resistance (e.g., hyperthyroidism, peripheral AV
fistula, or anemia).
- Following a car accident, a 52-year-old lawyer
complains of pain in the left abdomen and
back. After arrival of the EMS team, her pulse
rate is 84 bpm, but of small volume. She states
that she has some cardiac condition but is
uncertain of its nature. Which is the most likely
cause of the small pulse volume?
(A) Aortic stenosis
(B) Syphilis
(C) Hyperthyroidism
(D) Carcinoid syndrome
(E) Aortic incompetence
- (A) A small pulse occurs when the cardiac
output is decreased and/or the peripheral
resistance is increased. The pulse is reduced in
aortic stenosis, heart failure, pulmonary hypertension, pulmonary incompetence, mitral
stenosis, and pericardial effusion. The typical
cardiac lesion in syphilis is aortic incompetence, which results in a forceful bounding
pulse with a wide pulse pressure. Other noncardiac conditions that result in an increased
pulse pressure include hyperthyroidism, carcinoid syndrome, and aortic incompetence.
- Stenosis of which of the following vessels is
associated with the highest patency rates following angioplasty or stenting?
(A) Medial circumflex artery
(B) Iliac artery
(C) Superficial femoral artery
(D) Popliteal artery
(E) Tibial arteries
- (B) Angioplasty and stenting of the iliac vessels
has a patency rate of 75% at 5 years; PTA and
stenting of all other vessels has a much lower
patency than bypass procedures. The FDA has
only approved illiac artery stenting.
Question 31
(A) History of angina and prior MI
(B) Left ventricular ejection fraction of
over 50%
(C) Aortic stenosis
(D) Signs of left ventricular failure
(E) Lowered jugular venous distension
(F) Minimal decrease in hematocrit
(G) Presence of groin hernia
(H) Decreased bowel motility
31. A 83-year-old retired navy general shows
improvement in claudication following aortoiliac bypass surgery. What is the factor that
would cause the greatest concern over the
possibility of developing cardiac complications? SELECT ONE.
- (D) The single most serious prognostic sign for
adverse changes after vascular surgery is the
presence of CHF. Every effort must be made to
correct pulmonary congestion and improve left
ventricular function before undertaking elective procedures. MI occurring within 3 months
before operation carries a high mortality rate that will be reduced by delaying surgery for
3–6 months when possible.
(A) A double aortic arch (B) Tetralogy of Fallot (C) PDA (D) Coarctation of the aorta (E) Tricuspid atresia (F) Umbilical caput medusa (G) Neurofibromatosis (von Recklinghausen’s disease) (H) Noncyanotic ASD (I) Spider nevi (J) Femoral AV fistula (K) Beading (notching) of the ribs
- Cerebrovascular accident occurs most often in
which? SELECT ONE.
- (B) Cerebrovascular accident is the most important cause of death during the first year of life
in patients with tetralogy of Fallot. Over 65% of
patients with the tetralogy have cyanosis before
1 year of age. These patients have more severe
polycythemia and are particularly liable to
develop cyanotic spells of unconsciousness,
cerebral thrombosis, hemiplegia, and death.
Brain abscess may develop subsequent to
infarction and bacteria’s entering the systemic
circulation via a right-to-left shunt.
(A) A double aortic arch (B) Tetralogy of Fallot (C) PDA (D) Coarctation of the aorta (E) Tricuspid atresia (F) Umbilical caput medusa (G) Neurofibromatosis (von Recklinghausen’s disease) (H) Noncyanotic ASD (I) Spider nevi (J) Femoral AV fistula (K) Beading (notching) of the ribs
- Dyspnea and dysphagia occur with what?
SELECT ONE.
- (A) A double aortic arch implies that there are
two arches of the aorta; one passes posterior to
the esophagus and the other anterior to the trachea. The right side is more common than the
left side, and usually one of the arches is
smaller than the other. Respiratory difficulty
with a labored type of respiration (often precipitated by feeding) usually occurs within the
first few months of life. Dysphagia occurs less
frequently. Treatment is required only if symptoms are troublesome.
(A) A double aortic arch (B) Tetralogy of Fallot (C) PDA (D) Coarctation of the aorta (E) Tricuspid atresia (F) Umbilical caput medusa (G) Neurofibromatosis (von Recklinghausen’s disease) (H) Noncyanotic ASD (I) Spider nevi (J) Femoral AV fistula (K) Beading (notching) of the ribs
- Differential pressure in right arm and right leg
indicates what? SELECT ONE.
- (D) Coarctation of the aorta is a relatively
common anomaly and accounts for approximately 15% of all congenital anomalies. The
most common site of coarctation is immediately distal (within 3–4 cm) to the origin of the
left subclavian artery. Normally, pressure in
the lower extremity is higher than that in the
upper extremity, but in coarctation of the aorta,
the femoral pulses are absent or markedly
reduced. Magnetic resonance imaging (MRI)
(cine) of chest shows coarctation (Fig. 4–2).
(A) A double aortic arch (B) Tetralogy of Fallot (C) PDA (D) Coarctation of the aorta (E) Tricuspid atresia (F) Umbilical caput medusa (G) Neurofibromatosis (von Recklinghausen’s disease) (H) Noncyanotic ASD (I) Spider nevi (J) Femoral AV fistula (K) Beading (notching) of the ribs
- A child was born with congenital heart disease.
The mother had rubella during pregnancy. The
child has what? SELECT ONE.
- (C) In the fetus, the sixth left aortic arch diverts
blood in the pulmonary artery away from the
undeveloped lungs. After birth, the channel
closes and becomes the ligamentum arteriosum.
In rubella, a PDA may be associated with
mental retardation and cataracts. Most cases
of PDA occur without a clear-cut cause.
(A) A double aortic arch (B) Tetralogy of Fallot (C) PDA (D) Coarctation of the aorta (E) Tricuspid atresia (F) Umbilical caput medusa (G) Neurofibromatosis (von Recklinghausen’s disease) (H) Noncyanotic ASD (I) Spider nevi (J) Femoral AV fistula (K) Beading (notching) of the ribs
- Notching of ribs occurs in what? SELECT
ONE.
- (D) In the presence of coarctation of the aorta,
left ventricular enlargement, hypertrophy, and
failure to develop occur. As the child grows,
collaterals develop between the subclavian
artery and the aorta via the intercostal and
internal thoracic vessels. In children older than
8 years of age, the intercostal arteries cause typical notching on the inferior margin of the ribs.
(A) A double aortic arch (B) Tetralogy of Fallot (C) PDA (D) Coarctation of the aorta (E) Tricuspid atresia (F) Umbilical caput medusa (G) Neurofibromatosis (von Recklinghausen’s disease) (H) Noncyanotic ASD (I) Spider nevi (J) Femoral AV fistula (K) Beading (notching) of the ribs
- Hypoplasia of the right ventricle occurs in
what? SELECT ONE
- (E) Tricuspid atresia accounts for 5% of cyanotic
heart disease. Blood to the lungs is maintained
by a PDA.
A 62-year-old black physician complains of headache,
nocturia, and dysuria of 3 weeks duration. Rectal
examination reveals a palpable mass in the prostate,
and a biopsy confirms the presence of prostatic carcinoma. He is advised to undergo prostatectomy. His
blood pressure is 160/105 mm Hg.
(A) Verapamil
(B) Propanalol (inderal)
(C) Deep eyeball pressure
(D) Hydrochlorthiazide diuretic
(E) Calcium phosphate
(F) Digoxin
(G) Cardiac catheterization
(H) Repeat blood pressure assessment in the
supine position
(I) Antihistamine
- The next step in management is which?
SELECT ONE
- (H) Repeat blood pressure assessment in the
supine position. Hypertension can be defined as
a diastolic pressure above 90 mm Hg or systolic
pressure above 160 mm Hg. Anxiety in an office
setting may provide a false high reading of
blood pressure. The pressure usually decreases
when the individual remains seated and still for
a short while. Essential hypertension implies
that there is no clear associated cause to explain
the hypertension. Approximately 10–15% of
white adults and 20–30% of black adults in the
United States suffer from hypertension.
A 62-year-old black physician complains of headache,
nocturia, and dysuria of 3 weeks duration. Rectal
examination reveals a palpable mass in the prostate,
and a biopsy confirms the presence of prostatic carcinoma. He is advised to undergo prostatectomy. His
blood pressure is 160/105 mm Hg.
(A) Verapamil
(B) Propanalol (inderal)
(C) Deep eyeball pressure
(D) Hydrochlorthiazide diuretic
(E) Calcium phosphate
(F) Digoxin
(G) Cardiac catheterization
(H) Repeat blood pressure assessment in the
supine position
(I) Antihistamine
- The patient’s blood pressure remains elevated
when assessment is repeated on several occasions. Investigations fail to reveal an underlying cause of hypertension. Before surgery, he
should receive what? SELECT ONE.
- (D) Diuretics and angiotensinogen-converting
enzyme (ACE) inhibitors are more likely to
be effective in elderly black men presenting
with hypertension. ACE inhibitors inhibit the renin–angiotensin–aldosterone system,
sympathetic nervous system activity, and
bradykinin degradation and cause an increase
in prostaglandin (vasodilator) synthesis. PBlockers (e.g., propanalol) and calcium channel
blockers (e.g., verapamil, nifedipine) are the
first line of drugs chosen for young white men
presenting with hypertension.
While undergoing a physical examination for life
insurance purposes, a 46-year-old executive is noted
to have a harsh systolic murmur in the left third and
fourth parasternal area. Further evaluation, including echocardiography, reveals pulmonary stenosis.
(A) Right ventricular/pulmonary artery
gradient of 20 mm Hg
(B) Right ventricular/pulmonary artery
gradient of 65 mm Hg
(C) Left ventricular hypertrophy
(D) Right ventricular hypoplasia
(E) Absence of symptoms
(F) Hyperbaric oxygen
(G) Surgical correction
(H) Outflow tract (tunnel) to divert blood
from the aorta to the right ventricle
(I) Percutaneous balloon valvuloplasty
- The indication for surgery in pulmonary stenosis is what? SELECT ONE.
- (B) The presence of mild stenosis (valve gradient/right ventricular pulmonary artery <30
mm Hg) in asymptomatic patients does not
require surgical correction; such patients can
anticipate a normal life expectancy. Moderate
to severe stenosis (right ventricular/pulmonary
artery gradient of 50–80 mm Hg) requires surgical correction.
While undergoing a physical examination for life
insurance purposes, a 46-year-old executive is noted
to have a harsh systolic murmur in the left third and
fourth parasternal area. Further evaluation, including echocardiography, reveals pulmonary stenosis.
(A) Right ventricular/pulmonary artery
gradient of 20 mm Hg
(B) Right ventricular/pulmonary artery
gradient of 65 mm Hg
(C) Left ventricular hypertrophy
(D) Right ventricular hypoplasia
(E) Absence of symptoms
(F) Hyperbaric oxygen
(G) Surgical correction
(H) Outflow tract (tunnel) to divert blood
from the aorta to the right ventricle
(I) Percutaneous balloon valvuloplasty
- The appropriate treatment for significant pulmonary stenosis involves which? SELECT TWO
- (G, I) Percutaneous balloon valvuloplasty is
now used in many centers as an initial
approach to correct pulmonary stenosis. Right
ventricular hypertrophy accounts for the
parasternal heave noted on examination. Left
ventricular hypertrophy does not occur consequent to pulmonary stenosis. Pulmonary stenosis was once considered rare but now accounts
for 10% of cases of congenital heart disease.
On the day of admission for elective cataract surgery, an 84-year-old retired bus driver is noted to
have a blood pressure of 255/120 mm Hg.
(A) Undergo cataract surgery after oral diuretic therapy (B) Undergo cataract surgery without general anesthesia (C) Be given a discharge order and referred to the cardiology clinic (D) Undergo electrocardioversion (E) Be given sodium nitroprusside intravenously (F) Undergo a CT scan of the head (G) Undergo central venous pressure monitoring (H) Undergo arterial blood gas (ABG) measurement 42. Blood pressure assessment is repeated on two occasions, and the same measurements are obtained. What should he do? SELECT ONE.
- (E) Sodium nitroprusside, 0.5–10 mg/kg/min
IV, is given to patients (such as the one here)
presenting as an urgent hypertensive emergency (e.g., symptomatic hypertension with
systolic blood pressure >200 mm Hg, or asymptomatic with systolic pressure >240 mm Hg).
Sodium nitroprusside lowers blood pressure
by causing arteriolar and venous dilation.
Untreated hypertension may lead to cardiovascular, cerebrovascular, and renal disease. Other
complications of hypertension include pulmonary edema, aortic dissection, progressive
atherosclerosis, accelerated (malignant) hypertension, and, in pregnant patients, eclampsia.
- A 61-year-old man with a long history of heavy
smoking shows on computed axial tomography (CAT) scanning a right upper lobe tumor
and enlarged paratracheal nodes. The tumor
has been diagnosed as malignant by bronchoscopy. Your next move should be:
(A) Esophagoscopy to rule out invasion of
the esophagus.
(B) Proceed with lobectomy and
paratracheal node dissection.
(C) Begin radiation of the tumor and
paratracheal area.
(D) Perform a mediastinoscopy for staging.
(E) Wait 3 months and repeat CAT scan to
evaluate further disease progression.
- (D) Next move should be sampling of mediatinal nodes to stage this carcinoma of the lung. If
the nodes are positive, the patient is not a surgical candidate. He needs chemo-radiotherapy.
Radiation to the mediastinal nodes should not
begin without pathologic confirmation of nodal
metastasis. Waiting constitutes malpractice.
- A young man is shot at the level of the right
sternoclavicular joint. His blood pressure is
80/60 mm Hg, pulse 120 bpm, and a chest xray shows a right hydropneumothorax. The
first step should be:
(A) Insert a chest tube and observe for
drainage.
(B) Perform an immediate right thoracotomy.
(C) Perform an angiogram to rule out great
vessels injury.
(D) Perform median sternotomy with
extension along with right anterior
boarder of the sternocleidomastoid
muscle.
(E) Perform a CAT scan with contrast, to
evaluate extent of injury.
- (D) This patient has probably suffered a penetrating injury to the vessels of the thoracic outlet
and/or superior mediastinum. Immediate operation is needed. This incision gives excellent
exposure on the right and also gives access to
both chest cavities.
- A patient with a long history of smoking, diabetes, and hypertension develops a carcinoma
of the right lung. Along the staging process he
presents enlarged right mediastinal (paratracheal) nodes that, upon biopsy, are found to
contain cancer cells. He is at stage:
(A) IA N0 M0
(B) IA N1 M1
(C) IA N1 M0
(D) IIIA
(E) IV
- (D) Positive ipsilateral parathracheal nodes
defines stage IIIA.
- During a car crash a young man suffers bilateral
multiple fracture ribs. He is alert and presents
shortness of breath. His blood pressure is
100/60 mm Hg and chest is unstable. Treatment
for this is:
(A) Prolonged intubation and ventilatory
support until rib fractures heal along
with aggressive bronchial toilette.
(B) Once the patient is stable, open rib fracture
reduction and stabilization with plates.
(C) Fracture stabiliztion, with towel clips on
ribs and attached to weights (external
fixation).
(D) Avoid intubation, control pain, and
perform aggressive bronchial toilette.
(E) Temporary extracorporeal circulation to
allow fractures to heal.
- (D) In the past, prolonged intubation (internal
fixation) was performed with enthusiasm
because the pulmonary failure was thought to
be secondary to chest wall instability. Today is
known that pulmonary failure and breathing
problems are due to lung contusion and pain,
respectively. Avoiding intubation, controlling
pain, and performing aggressive bronchial toilette yield better results.
- Immediately following a bout of pneumonia, a
young woman develops a large pleural effusion. A chest tube is inserted and 600 mL of
thin pus is obtained. A CAT scan shows incomplete drainage and multiple intrapleural loculations. Management of this empyema requires:
(A) Insertion of multiple chest tubes under
CAT guidance to drain either most or all
loculations.
(B) Treat the patient with antibiotics and
continue single chest tube drainage.
(C) Treat patient with antibiotics and continue
single chest tube drainage waiting for a
thick peel to develop and then proceed
with open total lung decortication.
(D) Proceed with thoracoscopy and
intrapleural toilette. Break the
loculations and place drains.
(E) A thorough open total lung
decortication immediately.
- (D) During the early period of the fibrinopurulent stage of empyema, thoracoscopy is the
standard of care.
- A 40-year-old woman treated for many years
for gastroesophageal reflux develops dysphagia and weight loss. Previous esophagoscopy
has revealed cellular atypia. An esophagoscopy
is about to be performed. What is it most likely
to reveal?
(A) Leiomyoma arising from the long
esophageal muscular layer
(B) Squamous cell carcinoma arising from
esophageal mucosal lining
(C) Adenocarcinoma originated from
islands of Barrett’s esophagus
(D) Adenocarcinoma extending from the
stomach
(E) A large ulcer at the gastroesophageal
junction
- (C)Adenocarcinoma, originated from islands of
Barrett’s esophagus, is today the most common
cancer of the esophagus in the United States.
49. A young woman has suffered severe achalasia of the lower most esophagus. Attempted dilations have failed. The best treatment is: (A) Left thoracotomy and extensive myotomy (B) Resection of the gastoesophageal junction and reanastomosis Questions: 44–54 87 (C) Left thorcotomy, myotomy, and stomach wrap (fundoplication) (D) Laparoscopic myotomy and partial fundoplication (E) Transthoracic esophagogastrostomy (side-to-side) anastomosis to avoid disrupting the gastroesophageal sphincter
- (D) Today, the standard of care for classic achalasia is laparoscopic myotomy and partial
fundoplication.
- Shortly after an esophagoscopy, the patient
develops shortness of breath, chest pain, and
fever. A contrast study shows extravasation of
contrast into the left chest cavity. You should:
(A) Perform a cervical esophagostomy,
gastrostomy, insert a chest tube and
begin high dose antibiotic therapy
(B) Insert a nasogastric tube and begin high
dose antibiotic therapy
(C) Perform immediate left thoracotomy
and repair the esophageal tear
(D) Depoly an endoscopic intraesophageal
stent to “plug the hole”
(E) Stop all ingestion of food, insert a chest
tube and begin high dose antibioic
therapy
- (C) Perforation of the esophagus is associated
with serious complications and death. Earliest
repair is mandatory. Antibiotics would also be
given. The other choices allow an on-going leak.
- An 80-year-old woman walks into the emergency room complaining of vomiting and
severe retrosternal pain. This has happened
many times in the past. A nasogastric tube is
inserted and there is immediate clinical
improvement. On chest x-ray the tube is found
looped in the chest. This patient has:
(A) A large diveticulum of the
mid-esophagus
(B) The tube perforated the esophagus
(C) Achalasia
(D) A short esophasus
(E) A gastric volvulus
- (E) The esophagus is not perforated because of
the patient’s dramatic improvement. Achalasia
is usually accompanied by chronic dysphagia.
Short esophagus does not present with severe
retrosternal pain. The nasogastric tube is
looped inside the intrathoracic, volvulated
stomach and the patient has improved because
of decompression.
- The best treatment of this 80-year-old woman
with vomiting retrosternal pain and a looped
nasogastric tube in her left chest is:
(A) Remove the tube because the patient is
now well and discharged.
(B) Evaluate the esophageal myotomy to
treat achalasia.
(C) Immediate left thoracotomy to treat
perforation.
(D) Consider surgical reduction of volvulus
and diaphragmatic repair.
(E) Do not consider any surgical repair
because the patient is too old.
- (D) Recurrent volvulus of the stomach into the
chest is a serious condition that can lead to incarceration and gangrene. Every attempt should
be made to repair this diaphragmatic hernia.
- While landing at the end of flight a young
woman develops shortness of breath and rightsided pressure chest pain. She is tall and thin.
The pain, although less in intensity, occurs
during her menstrual periods. She has not previously consulted a doctor. A chest film is likely
to show?
(A) Left pleural effusion
(B) Pneumothorax
(C) Dilated stomach
(D) Widening of the mediastinum
(E) Cardiomegaly
- (B) The presentation itself should alert the clinician to the possibility of a pneumothorax (Fig
4–3). This condition is seen quite frequently with
patients that are thin and tall. This lady presents
with a catamenial pneumothorax syndrome.
54. And the treatment is: (A) Insertion of a chest tube (B) Immediate cardiology consult (C) Thoracentesis (D) Insertion of a nasogastric tube (E) A CAT scan
- (A) This is the first documented pneumothorax
on this patient. The treatment of choice is insertion of a chest tube. If the air leak persists for
more than 3 days or if she develops a recurrence after discharge, a thoracoscopy, resection
of bullae and pleurodesis becomes the treatment of choice.
(A) Transvalvular gradient of 50 mm or more (B) History of congestive heart failure (C) Transient ischemic attacks (TIA) (D) Angina (E) Aortic insufficiency (F) Aortic dissection (G) Ventricular fibrillation (H) Mitral insufficiency (I) Acute MI
- A 50-year-old man has a systolic heart murmur
best heard in the second interspace on the right
side. He is increasingly short of breath. Which
of the above clinical settings would determine
the decision to operate? SELECT ONE.
- (A) The decision to operate in patients with
aortic stenosis is based on transvalvular
gradient. 50-mm gradient is termed critical
aortic stenosis and the valve should be replaced
in a symptomatic patient.
(A) Transvalvular gradient of 50 mm or more (B) History of congestive heart failure (C) Transient ischemic attacks (TIA) (D) Angina (E) Aortic insufficiency (F) Aortic dissection (G) Ventricular fibrillation (H) Mitral insufficiency (I) Acute MI
- A 68-year-old female with aortic stenosis needs
a valve replacement. Which of the above might
result in a poor result for this patient? SELECT
ONE.
- (B) Congestive heart failure. In patients with
aortic stenosis, risk factors include a history of
agina, stroke or TIAs, and a history of congestive heart failure, which indicates a compromised left ventricle. Of the three, congestive
heart failure is the factor which is the greatest
risk factor for patients undergoing surgery.
(A) Transvalvular gradient of 50 mm or more (B) History of congestive heart failure (C) Transient ischemic attacks (TIA) (D) Angina (E) Aortic insufficiency (F) Aortic dissection (G) Ventricular fibrillation (H) Mitral insufficiency (I) Acute MI
- A 55-year-old man with a diastolic murmur
heard in the second interspace on the right that
radiates toward the apex of the heart. The cardiac
index is normal at rest but decreases with exercise. The most likely diagnosis is? SELECT ONE.
- (E) Aortic insufficiency. This is the murmur of
a patient with aortic insufficiency. Typically,
these patients will be well compensated at rest
but will have decreased cardiac output with
exercise. These patients should be operated on.
(A) Transvalvular gradient of 50 mm or more (B) History of congestive heart failure (C) Transient ischemic attacks (TIA) (D) Angina (E) Aortic insufficiency (F) Aortic dissection (G) Ventricular fibrillation (H) Mitral insufficiency (I) Acute MI
- A 45-year-old tall, thin, male has acute onset of
chest pain radiating into the back. In the emergency room his right radial pulse is bounding
but his femoral pluses are absent. The most
likely diagnosis is? SELECT ONE.
- (F) Aortic dissection. This describes a patient
with Marfan syndrome, who are typically at
risk for aortic dissection. With dissection you
may preserve right radial pulse but lose
femoral pulses.
- A 56-year-old male has history of leg pain at
rest. Patient also has history of severe coronary
artery diseases. He cannot walk two flights of
steps without getting short of breath. He underwent evaluation and was noted to have complete aortoiliac occlusive disease. He needs
surgery. Which one of the following options is
acceptable?
(A) Aortobililiac bypass
(B) Aortobifemoral bypass
(C) Aortoiliac angioplasty and stent
placement
(D) Axillobifemoral bypass
(E) Axilloiliac
- (D) The treatment goal in these patients is to
reestablish blood flow to the lower extremity.
The treatment is based on the findings at
angiogram. All the treatment options are valid
and are used in treatment of the aortoocclusive
disease. Patients with short-segment (TASCA)
stenosis in common iliac artery are treated with
angioplasty and/or stent placement and the
patency results are expected to be comparable to
surgery. In patients with long-segment stenosis
and good risk patient treatment options would
include aortobifemoral bypass. These procedures
are long lasting. The long-term patency rates are
reported to be 65–90%. Axillobifemoral bypass is
utilized in patients with high risk and poor general condition. The patency rates for this group
vary between 50–85% in 5 years. The patient
described would be an ideal candidate for axillobifemoral bypass.
- A 65-year-old female on her routine examination was noted to have a pulsatile abdominal
mass. She has been otherwise healthy with history of hypertension with no other history,
except family history of father dying of ruptured abdominal aortic aneurysm. What are
the acceptable reasons to operate on abdominal
aortic aneurysms in 65-year-old female with
5-cm infrarenal aneurysm?
(A) Presence of aneurysm
(B) Aneurysm with intramural thrombus
(C) Asymptomatic aneurysm 5.5 cm
(D) Associated 2-cm iliac aneurysm
(E) Patient with splenic artery aneurysm
1.5 cm
- (C) The current indication for repair of abdominal aortic aneurysm in female includes
aneurysm size 5 cm in acceptable risk patient. A
United Kingdom small aneurysm study has
increased the size that could be observed to
5.5 cm in male while in female it is acceptable
to treat aneurysm at 5 cm size for acceptable
risk. Any aneurysm with associated complication should be treated; just the presence of
intramural thrombus does not justify repair.
Asymptomatic 5.5-cm aneurysm should be
treated in all patients, male or female, at acceptable cardiac risk. Patients with 2-cm aneurysm
of iliac artery without any symptoms and complications should be observed; as the risk of surgery is higher than risk of observation till they
reach to 4 cm. In patients, not in child-bearing
age, 1.5-cm splenic aneurysm could be observed.
- An 89-year-old male presents with asymptomatic 8-cm abdominal aneurysm. He has a
recent history of myocardial infarction (MI) and
is not a candidate for coronary artery bypass.
What should the treatment options include?
(A) Conservative treatment observation
(B) Computerized axial tomography (CAT)
scan to evaluate eligibility for
endovascular repair
(C) Open repair without any further
workup
(D) Axillofemoral bypass and coil
embolization of aneurysm
(E) b-blocker therapy
- (B) An 8-cm aneurysm carries significant
mortality which exceeds 50% in 1 year from
aneurysm related death if observation or medical management is chosen as treatment option.
It would be appropriate, if the neck size is
greater than 1.5 cm and diameter is less than
26 mm, without any significant thrombus or
calcification in the neck. This patient does well
at least on mid term follow-up. They have
lower perioperative morbidity compared to traditional open repair. Open repair with given
cardiac history would carry high morbidity
and morotality. b-blocker therapy would be
indicated for his cardiac condition but is not a
standard therapy for aneurysm.
- A 70-year-old male underwent an open abdominal aortic aneurysm repair for ruptured
aneurysm. He was stable during the procedure.
In intensive care unit he was noted to have no
urine output and was also noted to have large
bloody bowel movement on first postoperative
day. The next step for investigation includes:
(A) Reexploration
(B) Arterial blood gas evaluation for acidosis
(C) CAT scan abdomen
(D) Sigmoidscopy/colonoscopy
(E) Antibiotics and hydration
- (D) Mortality associated with aortic aneurysm
is usually around 0–3%. A ruptured AAA carries mortality in range of 60–80% depending on
presentation. Risk of large-bowel ischemia with
ruptured AAA is about 10%. The first investigation with patients where colonic ischemia is
suspected is to perform sigmoidoscopy. All
other investigations may be done but none of
them would be the primary investigation for
the suspected pathology.
- A 69-year-old man was noted to have abdominal pain in left flank with severe hypotension
and pulsatile mass in abdomen. He was taken
to the operating room after he coded in the
emergency room. Which of the following statements regarding ruptured abdominal aortic
aneurysm is TRUE?
(A) 10% of patient with ruptured aneurysm
reach the Hospital.
(B) Mortality is about 10%.
(C) Aortic control is usually obtained by
thoracotomy.
(D) It cannot be treated by endovascular
means.
(E) Mortality following a code for ruptured
AAA is 100%.
- (E) Ruptured AAA carries a mortality of
40–50%. It is true that only 50% of all ruptured
AAA reaches the hospital. Free peritoneal rupture carries a very high mortality. Thoracotomy
is not the standard approach for proximal aortic
control. Ruptured AAA can be treated with
endovascular grafts. Preoperative hypotension
is a good predictor of poor outcome but cardiac arrest is associated with 100% mortality in
most of the studies.
Answers and Explanations
- A 82-year-old female presented with history of
loss of vision in right eye for about 15 minutes
and it cleared up. She has a history of diabetes
and hypertension. She had which showed old
infarct on right side. Carotid duplex showed
that patient had 99% carotid artery stenosis.
Which one of the following statements is
TRUE?
(A) 60% chance that extra cranial carotid
artery stenosis is the cause of transient
ischemic attack (TIA).
(B) It is always due to platelet emboli.
(C) 25% may be intracranial bleed.
(D) 0.5 to 10% may have cardiac and other
causes of TIA.
(E) It is always due to thrombosis.
- (A) Neurological events are associated with
extracranial carotid artery in about 60%. Fourty
percent may have extracranial/intracranial
cause for neurological events, which includes
cardiac emboli, arch of aorta as source of emboli;
intracranial bleed may be more than just a TIA.
It is not always that platelet emboli are the cause
of TIA, it could be due to atheroma. It is not
always attributed to thrombus.
- A 63-year-old male was noted to have a recent
TIA. Patient was having recurrent episodes of
TIA despite of being on aspirin and clopidogrel
bisulfate. He does have a history of unstable
angina. His workup includes magnetic resonance angiography (MRA) and carotid duplex.
What are the appropriate treatment options?
(A) Carotid endarterectomy for 50% carotid
stenosis on MRA
(B) Carotid endarterectomy for 60% stenosis
on MRA without any treatment of
unstable angina
(C) Carotid endarterectomy for 90% stenosis
with coronary artery bypass graft
(CABG) at the same time
(D) Start patient on heparin therapy and
treat conservatively for carotid stenosis
of 80%
(E) Coronary angiogram with possible
coronary intervention and simultaneous
carotid angiogram and angioplasty and
stenting
- (D) Asymptomatic carotid artery stenosis is only
treated surgically if it is greater than 70% stenosis. The risk reduction with surgical treatment is
favorable with 70% stenosis when compared
to nonoperative treatment. Any symptomatic
stenosis is an indication for surgical intervention
including ulcerated plaque. Any amount of
stenosis with unstable angina would need appropriate workup for cardiac risk prior to carotid
intervention. Carotid endarterectomy and CABG
are viable options if they are left main disease
and have undergone coronary angiogram. In this
patient the most appropriate treatment is option
to perform coronary angiogram and possible
carotid stenting if feasible. Role of anticoagulation to prevent recurrent TIA is not well established. Aspirin and clopidogrel bisulfate are
appropriate options for TIA.
- A 62-year-old man had right carotid endarterectomy 7 years ago. Now he has presented with
80% stenosis on the same side. He has no symptoms from the stenosis. He has carotid artery
stenosis on the opposite side of 80%. He does
not have any history of TIA. What is the appropriate treatment for the patient?
(A) Medical management with aspirin
(B) Carotid artery redo surgery and patch
angioplasty
(C) Angiogram and angioplasty and stenting
(D) Left carotid endarterectomy
(E) Antiocoagulation of the patient to
prevent stroke
- (D) Recurrent stenosis is secondary to intimal
hyperplasia but it occurs in first two years. If
more than two years, it is progression of disease and it does not carry high risk for
embolization, so it is reasonable to observe it. It
is also a surgery which carries higher stroke
rate and morbidity with nerve injury which
is in range of 7%. Patient is treated with
antiplatelet therapy which includes aspirin and
clopidogrel bisulfate. Anticoagulation with
warfarin is not a standard therapy. It is appropriate to treat the opposite side with 80%
carotid stenosis. Angiogram and angioplasty
is an option but if the stenosis is significant
and symptomatic. Priority in this case would be
to treat the opposite side.
- A 60-year-old male patient with bilateral carotid
artery stenosis 90%, with history of right-sided
weakness with resolution of symptoms in 15
minutes. How would you treat the patient?
(A) Right carotid endarterectomy
(B) Left carotid endarterectomy
(C) Right carotid angioplasty and stenting
(D) Start patient on aspirin
(E) Start patient on heparin
- (B) The treatment for symptomatic carotid
artery stenosis greater than 70% is carotid
endarterectomy. Since patient has left cerebral
symptoms, it would be appropriate to treat that
side first. Patient would need bilateral carotid
endarterectomy but symptomatic side would
be the first one to be operated. Heparin has no
significant role in preventing stroke. Aspirin is
a part of therapy but would not constitute a primary modality for treatment.
10. A 72-year-old patient is noted to have neurological deficit following elective carotid endarterectomy in recovery room. What is the most appropriate treatment at this time? (A) Carotid duplex (B) CAT scan of brain (C) Angiogram of cerebral vessels (D) Heparin drip (E) Exploration of the same side
- (E) In recovery room, the immediate approach
would be to explore the patient. The cause for
immediate stroke is usually technical and is
most likely reversible if treated early on. All
investigations are valid options once the technical cause is addressed and it would not be a
primary option.
- A 63-year-old man has had a cyanotic painful
left fourth toe for 2 days. The dorsalis pedis
and posterior tibial arteries are palpable on both
sides. There is no history of cardiac or vascular
disease. What is the most likely diagnosis?
(A) Cardiac embolus
(B) Atheroembolism
(C) Lupus vasculitis
(D) Digital atherosclerosis
(E) Raynaud’s syndrome
- (B) All the listed conditions may result in
isolated digital ischemia. In this age group,
atheroembolism is the most likely diagnosis in a
man. The atheroma is derived from an occult
aortic aneurysm or a proximal ulcerative atherosclerotic lesion. This plaque or ulcer can be any
part of the vascular tree proximal to the ischemic
toe. Cardiac emboli also are common in this
age group but are a less likely cause in the
absence of previous MI, arrhythmia, or valvular disease.
- A 40-year-old chronic smoker presents with
ulceration of the tip of the right second, third,
and fourth toes. He gives a history of recurrent migratory superficial phlebitis of the feet
occurring a few years ago. Physical examination findings are remarkable for absent bilateral
posterior tibial and dorsalis pedis pulses with
palpable popliteal pulses. What is the single
most important step in management?
(A) Multiple toe amputations
(B) Long-term anticoagulant therapy
(C) Immediate operative intervention
(D) Angiography followed by bypass surgery
(E) Cessation of smoking
- (E) This patient suffers from thromboangiitis
obliterans (Buerger’s disease), a disease found
most frequently in white men between 20 and
40 years of age. It is a form of panvasculitis
involving the artery, vein, and nerve. Heavy
tobacco smoking is strongly associated with
this disease. Early in the course of the disease,
there is involvement of the superficial veins,
producing recurrent migratory superficial
phlebitis. The distribution of arterial involvement is usually segmental, involving the
peripheral arteries. In the lower extremities,
the disease occurs generally beyond the
popliteal arteries and distal to the forearm in
the upper extremities. As long as ulceration or
gangrene is confined to a digit, amputation
should be postponed as long as possible unless
rest pain or infection cannot be otherwise controlled. Bypass surgery is rarely indicated, and
long-term anticoagulation has not been of
much benefit. The most important aspect of
treatment is cessation of smoking, which can
halt progression of the disease.
228 10: Vascular
- A middle-aged man is found to have a small
pulsating mass at the level of the umbilicus
during a routine abdominal examination. What
is the best initial test to establish the diagnosis?
(A) Aortography
(B) Ultrasound
(C) Computed tomography (CT)
(D) Magnetic resonance imaging (MRI)
(E) Plain films of the abdomen
- (B) Although aortography, CT, and MRI can
all establish the diagnosis of abdominal aortic
aneurysm, ultrasound remains the best screening test. It is the preferred method for making
the initial diagnosis, because it is reliable, inexpensive, and noninvasive. Aortography is used
infrequently because of the small but definite
risk it entails and because diagnosis can be
made by other means. Once the aneurysm
meets the criteria for repair, then a CT scan is
done preoperatively to establish the true size
and to delineate the aneurysm more accurately.
Plain films of the abdomen are inaccurate in
establishing the diagnosis.
- A 58-year-old woman is found to have a right
carotid bruit on routine examination. She is
completely asymptomatic. A carotid duplex
scan and carotid arteriogram (Fig. 10–1) reveal
a right carotid stenosis. Which of the following
statements is true?
(A) Operative treatment is indicated if the
stenosis is greater than 80%, even if the
patient is asymptomatic.
(B) The incidence of stroke can be decreased
by prophylactic carotid endarterectomy
in patients with as little as 40% stenosis.
(C) Aspirin is always a superior treatment
to surgery regardless of the degree of
stenosis.
(D) If symptoms eventually develop, they
are invariably TIAs, not stroke.
(E) Neither surgery nor aspirin is indicated,
because the patient is asymptomatic.
- (A) Operative treatment is indicated if the diameter of the stenosis is greater than 60%, even if
the patient is asymptomatic. The value of prophylactic carotid endarterectomy, for hemodynamically significant carotid stenosis, decreases
the incidence of subsequent cerebral ischemic
events if performed with morbidity and mortality rates under 4%. Several studies including
asymptomatic carotid artery surgery (ACAS)
have shown that surgical treatment is superior
to medical management if the stenosis is 60% or
greater. The ACAS trial has shown the benefits
of surgical treatment over medical management
if the stenosis is greater than 60%. However,
there are no data to support the use of carotid
endarterectomy in asymptomatic patients with
stenosis of less than 60%. If ischemic events
eventually develop, stroke can be the presenting
symptom.
- A 57-year-old male smoker is referred to you
because of two episodes of right upper extremity weakness over the past 6 months, each lasting for 10–15 minutes. Findings on CT scan of
the head are negative. An angiogram shows a
75% stenosis of the left carotid artery. What is
the most appropriate treatment?
(A) Antiplatelet therapy
(B) Oral anticoagulants
(C) Carotid endarterectomy
(D) Carotid artery bypass to vertebral system
(E) Surgery only if a stroke develops
- (C) This patient is experiencing recurrent left
hemispheric TIA with a hemodynamically significant stenosis of the left carotid artery. This
is clearly an indication for surgery because
operative management is superior to aspirin
in symptomatic carotid bifurcation disease with
stenosis greater than 70%. Oral anticoagulants
may decrease the incidence of TIAs but not of
completed strokes, and they are associated with
a considerable risk of hemorrhage. Carotid
endarterectomy, and not carotid artery bypass,
is the surgical procedure of choice. Surgical
treatment must be performed before and not
after major neurologic deficits are produced
from cerebral infarction.
- A 24-year-old man complains of progressive
intermittent claudication of the left leg. On
examination, the popliteal, dorsalis pedis, and
posterior tibial pulses are normal; but they disappear on dorsiflexion of the foot. What is the
most likely diagnosis?
(A) Embolic occlusion
(B) Thromboangiitis obliterans
(C) Atherosclerosis obliterans
(D) Popliteal artery entrapment syndrome
(E) Cystic degeneration of the popliteal
artery
- (D) Popliteal artery entrapment syndrome consists of intermittent claudication caused by an
abnormal relation of that artery to the muscles,
usually the medial head of the gastrocnemius
muscle. As a consequence of developmental
abnormalities, the popliteal artery may be compressed by the medial head of the gastrocnemius muscle, resulting in ischemia of the leg at
an unusually early age. On examination, the
pulses may be diminished or absent, but they
may also be normal and be made to disappear
on dorsiflexion of the foot. Angiography is
essential to establish the diagnosis.
- Four days after undergoing hysterectomy, a 30-
year-old woman develops phlegmasia cerulea
dolens over the right lower extremity. What is
the most appropriate treatment?
(A) Bed rest and elevation
(B) Systemic heparinization
(C) Venous thrombectomy
(D) Prophylactic vena caval filter
(E) Local urokinase infusion
- (C) Phlegmasia cerulae (blue) dolens, indicates
that major venous obstruction has occurred.
The standard treatment for postoperative
thrombosis includes bed rest and anticoagulation. Venous thrombectomy may be indicated
when impending gangrene is noted. Vena caval
filters are inserted in patients with established pulmonary emboli, but they may be
considered as a prophylactic measure when
iliofemoral thrombosis is massive. They are
also inserted as an adjunct to venous thrombectomy along with creation of an arteriovenous
fistula to prevent the venous system from
rethrombosing. Thrombolysis of major venous
thrombi requires placement of a multihole
pigtail catheter inside the thrombus and
administration of tPA, including systemic
heparinization and is therefore contraindicated
postoperatively.
- A 21-year-old woman is referred to your office
because of multiple lower extremity varicose
veins. She has large varicosities in the distribution of the long saphenous vein. What is the
next step in management?
(A) A ligation and stripping operation
(B) Ligation of both the long and short
saphenous system
(C) Sclerotherapy
(D) Duplex evaluation along with clinical
correlation as an essential initial step
(E) Compression stockings and
anticoagulation therapy
- (D) A through clinical evaluation followed by
a venous duplex examination are the two most
important steps in managing varicose vein of
the lower extremity. An asymptomatic patient
without complications of phlebitis, ulceration,
or hemorrhage should be treated with compression stocking. Duplex evaluation will help
map the valvular incompetence of the superficial and deep system including the perforators
that guide the extent of the initial surgical intervention, and also investigate if these are primary or secondary varicosities. Sclerotherapy is
an alternative to surgery but in the presence of
saphenofemoral, saphenopopliteal, or perforator reflux is associated with a high incidence of
recurrence and complications.
Answers: 6–18 229
- A 45-year-old woman undergoes cardiac
catheterization through a right femoral approach.
Two months later, she complains of right lower
extremity swelling and notes the appearance of
multiple varicosities. On examination, a bruit is
heard over the right groin. What is the most
likely diagnosis?
(A) Femoral artery thrombosis
(B) Superficial venous insufficiency
(C) Arteriovenous (AV) fistula
(D) Pseudoaneurysm
(E) Deep vein insufficiency
- (C) A traumatic AV fistula results from a penetrating injury to adjacent artery and vein, permitting blood flow from the injured artery
into the vein. The iatrogenic injury in this
case occurred during cardiac catheterization.
Femoral artery thrombosis results in signs of
limb ischemia. A bruit is usually not heard
with venous insufficiency. Traumatic pseudoaneurysm presents as an enlarging pulsating
mass. Once the diagnosis of AV fistula is made,
an angiogram is performed, and surgical repair
(division of the fistula and reconstruction of
the artery and preferably of the injured vein as
well) is carried out.
- A young basketball player develops an acute
onset of subclavian vein thrombosis (effort
thrombosis) after heavy exercise. What is the
next step in management?
(A) Active exercise of the limb
(B) Anti-inflammatory drugs
(C) Thrombolytic therapy
(D) Antibiotics
(E) First-rib resection
- (C) Effort thrombosis, also called Paget-von
Schroetter syndrome, is the development of
thrombosis of the axillary-subclavian vein as a
result of injury or compression. It occurs primarily in young athletes and is disabling.
When these patients are seen early, thrombolytic therapy is the first step in management
and is followed by a venogram to detect correctable lesions. If effort thrombosis is associated with thoracic outlet syndrome, then
thrombolytic therapy should be followed by
cervical rib resection. If the condition is chronic,
thrombolytic therapy might not be successful;
these patients usually respond to limb elevation and anticoagulation.
- A middle-aged man undergoes a left belowknee amputation for left-foot gangrene secondary to arterial occlusive disease. Which of
the following statements is true after the belowknee amputation?
(A) There is less efficient function than after
a through-knee amputation.
(B) Stump prognosis can be judged by
transcutaneous oxygen monitoring.
(C) Poor prognosis is inevitable if Doppler
fails to record a pulse at that level.
(D) The fibula and tibia are of equal length.
(E) The level of transection is 5 cm above
the medial malleolus.
- (B) Stump prognosis can be judged by transcutaneous oxygen monitoring. Doppler is not
fully reliable to select the level of transection,
because it cannot calculate the quantity of vascular flow. Transcutaneous oxygen (PO2 >40
mm Hg) offers a fairly accurate prediction of a
favorable result; although, Doppler fails to confirm a patient pulse at the level of transection.
On the other hand, a duplex evaluation with
blood flow of more than 50 cm/s is also a fairly
accurate predictor for stump prognosis. The
level of transection is 13–15 cm below the level
of the medial condyle of the tibia.
22. A 72-year-old retired banker complains of leftleg intermittent claudication while playing golf. An angiogram shows occlusion of the superficial femoral artery and reconstitution of the popliteal artery below the knee. What is the treatment of choice? (A) A vigorous exercise program (B) Endarterectomy of the superficial femoral artery (C) Femoropopliteal bypass with expanded polytetrofluoroethylene (PTFE) graft (D) In situ femoropopliteal bypass (E) Femoropopliteal bypass with reversed saphenous vein graft
- (A) If claudication is the only symptom, elective vascular reconstruction is considered only if
claudication is disabling and interferes with dayto-day activity. Because the risk of gangrene,
occurring in a patient who has only claudication,
is small, this alone does not constitute a clear-cut
indication for operation. Vigorous exercise programs have resulted in marked improvement
in claudicants. Revascularization surgery is usually reserved for rest pain or tissue loss (nonhealing ulcer, gangrene). Addition of a
phosphodiastraze inhibitor, cilostazol (pletal),
or pentoxiphyline (trental) can help increase the
claudication distance. It should also be kept in
mind that an angiogram is not indicated for
claudication. An initial evaluation with noninvasive vascular studies is the investigation of
choice. Angiogram is only requested if the decision is made to intervene surgically.
- A 40-year-old patient undergoes a CT scan of
the abdomen for nonspecific abdominal pain. A
splenic artery aneurysm is incidentally identified. What is true of the splenic artery aneurysm?
(A) It requires splenectomy for optimal
treatment.
(B) It is more common in men.
(C) It is caused by atherosclerosis in most
cases.
(D) It may rupture during pregnancy.
(E) It is rarely calcified on an abdominal
x-ray.
- (D) Splenic artery aneurysms are rare and are
most frequently caused by medial necrosis.
Small asymptomatic aneurysms caused by atherosclerosis are more commonly incidental
findings at autopsy. Larger (>3 cm) aneurysms
predominate in women and characteristically
may rupture during late pregnancy. Rupture
may be preceded by an initial warning bleed
into the retroperitoneum, with massive bleeding following after 1 or 2 days.
- A 70-year-old man with a long-standing history
of diabetes develops gangrene of the right
second toe. What is true of his diabetic foot?
(A) Dorsalis pedis and posterior tibial
arteries are always absent.
(B) Gangrene of the toe always requires
urgent below-knee amputation.
(C) Arterial reconstruction is invariably
required.
(D) His right femoral artery is most probably occluded or stenosed.
(E) Trophic ulcers are sharply demarcated.
- (E) Patients with a diabetic foot may have localized arterial occlusion involving the popliteal
artery and its branches, usually sparing the
femoral artery. Although patients have gangrene
of the toes, there may be a palpable pulse in the
foot. In the presence of localized disease, trophic
ulcers and even gangrene of the toes may
respond to local foot care, and major vascular
reconstruction or amputations are not required.
The trophic ulcers have punched sides. Patients
may not realize the gravity of localized gangrene with spreading cellulitis, which develops
because of the neurotropic nature of the lesions
with the absence of pain sensation.
- Eleven years after undergoing right modified
radical mastectomy, a 61-year-old woman
develops raised red and purple nodules over
the right arm. What is the most likely diagnosis?
(A) Lymphangitis
(B) Lymphedema
(C) Lymphangiosarcoma
(D) Hyperkeratosis
(E) Metastatic breast cancer
- (C) Lymphangiosarcoma is a rare complication of
long-standing lymphedema, most frequently
described in a patient who has previously undergone radical mastectomy (Stewart-Treves syndrome). It usually presents as blue, red, or purple
nodules with satellite lesions. Early metastasis,
mainly to the lung, may develop if it is not recognized early and widely excised. Lymphedema
is a complication of radical mastectomy and presents as diffuse swelling and nonpitting edema of the limb. Lymphangitis and hyperkeratosis are complications of lymphedema.
- Four days after undergoing subtotal gastrectomy for stomach cancer, a 58-year-old woman
complains of right leg and thigh pain, swelling
and redness, and has tenderness on examination. The diagnosis of deep vein thrombosis is
entertained. What is the initial test to establish
the diagnosis?
(A) Venography
(B) Venous duplex ultrasound
(C) Impedance plethysmography
(D) Radio-labeled fibrinogen
(E) Assay of fibrin/fibrinogen products
- (B) The most accurate method of confirming the
diagnosis of venous thrombosis is the injection
of contrast material to visualize the venous
system (venography). However, this method is
invasive and time-consuming and must be done
in the radiology suite. Venous duplex ultrasound is noninvasive, can be done bedside, and
has a sensitivity and specificity of 96 and 100%,
respectively. The other methods listed are used
less often in certain selected patients.
- A middle-age woman has right leg and foot
nonpitting edema associated with dermatitis
and hyperpigmentation. The diagnosis of
chronic venous insufficiency is made. What is
the treatment of choice?
(A) Vein stripping
(B) Pressure-gradient stockings
(C) Skin grafting
(D) Perforator vein ligation
(E) Valvuloplasty
- (B) The mainstay of treatment of chronic venous
insufficiency and its complication, venous stasis
ulceration, is conservative management. Elastic
stocking support, frequent elevation of the legs,
and avoidance of prolonged sitting and standing is used for venous insufficiency in the
absence of ulceration. If venous stasis ulcers
develop, then paste boots (e.g., Unna’s boots)
are used along with appropriate bed rest and
foot elevation until the ulcer heals. Patients
whose ulcers fail to heal after such conservative
management may need perforator vein ligation. Skin grafting should be considered for
chronic stasis ulcers that are large, and perforator incompetance has been treated. Venous
reconstruction procedures, including valvuloplasty, can be useful for a selected group of
patients, especially those with venous claudication to less than half a block, that have been
treated with all the procedures above, including
stripping and ligation. Unlike previous opinions, superficial venous stripping and ligation
is not always contraindicated in the presence of
chronic venous insufficiency and even previous history of deep vein thrombosis.
- A 55-year-old woman has bilateral leg edema
associated with thick, darkly pigmented skin. A
Trendelenburg’s test is done, and results are
interpreted as positive/positive. What does
this patient have?
(A) Competent varicose veins/competent
perforators
(B) Competent varicose veins/incompetent
perforators
(C) Deep vein thrombosis (DVT)
(D) Incompetent varicose veins/competent
perforators
(E) Incompetent varicose veins/incompetent
perforators
- (E) The Trendelenburg’s test is a two-part test
used to access the competency of the superficial
and perforating veins. The legs are elevated to
evacuate the veins, and pressure is applied to
the saphenofemoral junction either by hand or
tourniquet. The four possible results are: (a) negative/negative response if there is gradual filling
of veins from below and continued slow filling
after release of pressure, indicating absence of
incompetent superficial and perforating veins;
(b) negative/positive response if there is gradual
filling of veins from below while there is rapid
retrograde filling after release of pressure, indicating incompetent superficial veins only; (c)
positive/negative response if there is rapid initial filling of the veins from below while only
continued slow filling after the release of pressure, indicating incompetent perforators only;
and (d) positive/positive response if there is
rapid filling of the saphenous vein before and
after release of pressure, indicating incompetent
superficial and perforating veins.
- A middle-aged man known to have peptic
ulcer disease is admitted with upper gastrointestinal (GI) bleeding. During his hospital stay,
he develops DVT of the left lower extremity.
What is the most appropriate management?
(A) Anticoagulation
(B) Observation
(C) Thrombolytic therapy
(D) Inferior vena cava (IVC) filter
(E) Venous thrombectomy
- (D) The main treatment of DVT is adequate anticoagulation. However, if pulmonary embolism
develops during anticoagulant therapy or if there
is contraindication to anticoagulation, the insertion of an IVC filter is indicated either to prevent
occurrence of or to offer prophylaxis against
recurrence of pulmonary embolism (Fig. 10–4).
Observation alone leaves the patient unprotected
against pulmonary embolism, and operative
thrombectomy is reserved for limb salvage in
the presence of impending venous gangrene.
Obviously, if anticoagulation is contraindicated
(as in the patient presented), thrombolytic therapy cannot be used.
- A 70-year-old executive is complaining of
three-block intermittent claudication of both
legs. What is the percentage chance of his
developing limb-threatening gangrene?
(A) Less than 10%
(B) 20%
(C) 45%
(D) 60%
(E) More than 75%
- (A) The relatively benign course of intermittent claudication has been well established. The
risk of gangrene developing within 5 years in
an extremity with claudication as the only
symptom is only about 5%. The patient must be
encouraged to stop smoking, to exercise, and be
placed on a diet that lowers cholesterol.
31. Thirty-six hours after undergoing an abdominal aortic aneurysm repair, a 70-year-old woman develops abdominal distension associated with bloody diarrhea. What is the most likely diagnosis? (A) Aortoduodenal fistulas (B) Diverticulitis (C) Pseudomembranous enterocolitis (D) Ischemic colitis (E) Acute hepatic failure
- (D) The occurrence of bowel movements
during the first 24–72 hours after repair of an
abdominal aortic aneurysm (especially if the
hemoccult test is positive), should raise suspicion for ischemic colitis. It may develop as a
result of interruption of flow to the inferior
mesenteric artery with inadequate collateral
circulation from either the superior mesenteric
artery or the iliac arteries. Aortoduodenal fistula is a late complication of aneurysm repair.
Pseudomembranous enterocolitis occurs late
in the postoperative course.
32. A 65-year-old man is referred to you because of an incidental finding of a 3-cm left popliteal aneurysm (Fig. 10–2). The patient is completely asymptomatic and has normal pulses. How should the aneurysm be treated? (A) It should be observed. (B) It should be repaired because it may lead to spontaneous rupture. (C) It should be repaired only if it is larger than 5 cm. (D) It should be repaired because of its tendency to either undergo thrombosis or embolize distally. (E) It should be repaired because of its tendency to cause nerve compression if it enlarges.
- (D) Popliteal aneurysms are usually arteriosclerotic and are bilateral in at least 50% of
cases. Any popliteal aneurysm twice the size of
the normal artery is an indication for surgical
repair. Although often asymptomatic and
small, they should be treated surgically because
of their propensity to produce limb-threatening
ischemia related to thrombosis or embolism.
Spontaneous rupture and/or nerve compression are rare complications of a popliteal
aneurysm. The ideal repair consists of ligation
of the aneurysm, including its branches and a
bypass to the open distal vessels.
- A 72-year-old woman falls at home after an
episode of dizziness. She had been complaining
of low-back pain for 3 days before the fall. In the
emergency department, she is hypotensive and
has cold, clammy extremities. A pulsating
mass is palpable on abdominal examination.
Following resuscitation, the next step in the management should involve which of the following?
(A) Peritoneal lavage
(B) Immediate abdominal exploration
(C) CT scan of the abdomen
(D) Abdominal aortogram
(E) Abdominal ultrasound
- (B) The presence of acute vascular collapse with
history of abdominal or flank pain and associated pulsating abdominal mass is characteristic
of a ruptured abdominal aneurysm. Operation
should be performed as quickly as possible,
because the first priority is to control the hemorrhage. No time should be lost in obtaining
diagnostic studies, because these patients often
crash in the radiology suite. These patients
should not be resuscitated aggressively, because
an increase in systolic pressure will only cause
more intra-abdominal hemorrhage.
34. A 60-year-old man complains of dizziness, vertigo, and mild right-arm claudication. On physical examination, there is decreased pulse and blood pressure of the right upper extremity. What is the treatment of choice? (A) Anticoagulation (B) Repair of coarctation of the aorta (C) Ligation of vertebral artery (D) Carotid endarterectomy (E) Carotid subclavian bypass
- (E) The clinical picture presented is that of a subclavian artery stenosis resulting in subclavian
steal syndrome, represented by vertebrobasilar
symptoms and extremity ischemia. The symptoms are due to a decrease of posterior circulation
(vertebral artery) blood flow. Claudication occurs
more commonly than ischemic findings. Most
patients have no triggering events, and the
symptoms are not readily reproducible. Carotid
subclavian bypass restores the circulation
beyond the stenotic area and corrects the steal
syndrome. Ligation of the vertebral artery will
correct the steal syndrome but will not improve
the circulation of the arm. Anticoagulation has no
role in the treatment of this entity. Other treatment options include subclavian artery transposition, axilloaxillary bypass, and subclavian
artery angioplasty. Coarctation of the aorta
results in pulse and pressure difference between
the upper and lower extremities.
- An 18-year-old man develops a painful, swollen
leg while training for the New York Marathon.
There is tenderness in the calf and ecchymosis
is present. What is the most likely diagnosis?
(A) Cellulitis
(B) DVT
(C) Superficial thrombophlebitis
(D) Tear of the plantaris muscle
(E) Medical lemniscus tear
- (D) Spontaneous thrombophlebitis in this age
group is unlikely. Plantaris or gastrocnernius
tear may occur during physical exertion involving running or walking, causing a sharp pain in
this region. After resolution of a hematoma in
this region, it may be difficult to exclude cellulitis if there is any question that the integrity
of the skin has been damaged. In superficial
thrombophlebitis, there is tenderness along the
distribution of the long or short saphenous
veins. A tear of the medial lemniscus of the knee
joint is detected by tenderness over the medical
aspect of the knee joint during flexion and internal rotation of the knee joint (McMurray sign).
Four days after suffering MI, a 78-year-old woman
suddenly develops severe diffuse abdominal pain.
Her electrocardiogram (ECG) shows atrial fibrillation. On examination, the abdomen is soft, minimally
tender, and slightly distended. Hyperactive bowel
sounds are present.
36. What is the most likely diagnosis? (A) Mesenteric embolus (B) Nonocclusive ischemic disease (C) Perforated peptic ulcer (D) Congestive heart failure (CHF) (E) Digoxin toxicity
- (A) Patients with atrial fibrillation are more
likely to develop emboli to different sites
throughout the body. Nonocclusive ischemic
disease is characterized by spasm of the major
mesenteric arterial vessels, with a characteristic beading effect. Early recognition may result
in improvement with direct intra-arterial infusion of papaverine (which causes vasodilation),
thus avoiding operative intervention.
Four days after suffering MI, a 78-year-old woman
suddenly develops severe diffuse abdominal pain.
Her electrocardiogram (ECG) shows atrial fibrillation. On examination, the abdomen is soft, minimally
tender, and slightly distended. Hyperactive bowel
sounds are present.
37. The most appropriate initial examination consists of which of the following?
(A) Gastrografin upper GI series
(B) White blood cell (WBC) counts and serial
abdominal examination
(C) Colonoscopy
(D) Diagnostic peritoneal lavage
(E) Angiography
- (E) Clinical findings of peritoneal irritation and
leukocytosis in patients with suspected visceral
ischemia indicate necrosis of ischemic bowel.
Immediate arteriography is required to establish
the diagnosis and initiate treatment to restore
circulation before massive bowel infarction,
232 10: Vascular
acidosis, and possible perforation occur. The
most likely diagnosis is a mesenteric embolus
arising from the heart, especially in the presence of atrial fibrillation. The catheter should be
left in place to allow papaverine infusion to an
area of borderline ischemic bowel.
- A 28-year-old woman has new-onset hypertension and a bruit on abdominal examination.
An arteriogram shows fibromuscular dysplasia
(FMD) of the right renal artery. What is the best
treatment option?
(A) Aortorenal saphenous vein bypass
(B) Patch angioplasty of the renal artery
(C) Percutaneous transluminal angioplasty
(PTA)
(D) Transaortic renal endarterectomy
(E) Hepatorenal bypass
- (C) Among all causes of renovascular hypertension, FMD responds best to angioplasty.
Intermediate results of PTA for FMD are similar
to those of bypass. PTA has lower morbidity,
causes less discomfort, and is less expensive.
Recurrence can be treated by repeated PTA.
A 60-year-old man with a history of atrial fibrillation is found to have a cyanotic, cold right lower
extremity.
39. The embolus is most probably originating from which of the following? (A) An atherosclerotic plaque (B) An abdominal aortic aneurysm (C) Heart (D) Lungs (E) Paradoxical embolus
- (C) The heart is the origin of about 90% of
lower extremity emboli. The causes are usually mitral stenosis, atrial fibrillation, or MI. A
rare source of left atrial emboli is a left atrial
myxoma. The remaining 10% arise from ulcerated plaques in the aorta or peripheral arteries.
Paradoxical emboli arising from the venous
system may reach the arterial circulation through
a patent foramen ovale.
A 60-year-old man with a history of atrial fibrillation is found to have a cyanotic, cold right lower
extremity.
40. Which is the most common site at which an arterial embolus lodges? (A) Aortic bifurcation (B) Popliteal artery (C) Tibial arteries (D) Common femoral artery (E) Iliac artery
- (D) Arterial emboli usually lodge proximal to
bifurcations, the most common site being the
common femoral artery.
A 60-year-old man with a history of atrial fibrillation is found to have a cyanotic, cold right lower
extremity.
41. What is the most appropriate management? (A) Embolectomy (B) Lumbar sympathectomy (C) Bypass surgery (D) Amputation (E) Arteriography
- (A) Once the diagnosis is made clinically,
heparin is administered intravenously to prevent the development of thrombi distal to
the embolus. Then embolectomy can be done
in most instances under local anesthesia.
Arteriography to confirm what is already clinically apparent only delays the needed surgical
procedure. If there is a doubt, duplex evaluation will help confirm the diagnosis. Lumbar
sympathectomy locks are of dubious value. In
patients who have known occlusive disease,
absent pulses in the contralateral extremity,
absence of clinical features of hyperacute
ischemia would be best managed by an angiogram and thrombolytic infusion.
- An elderly patient with ischemic rest pain is
found to have combined aortoiliac and
femoropopliteal occlusive disease. What is the
treatment of choice?
(A) Aortofemoral bypass
(B) Femoropopliteal bypass
(C) Aortofemoral and femoropopliteal bypass
(D) Lumbar sympathectomy
(E) Vasodilator therapy
- (A) Patients with combined segmental occlusive disease require correction of proximal
hemodynamically significant disease before
distal (infrainguinal) bypass. Only about 20%
of patients undergoing aortofemoral reconstruction in the presence of superficial femoral
artery occlusion will subsequently require
femoropopliteal bypass. Combined procedures
should be reserved for patients with severe lifethreatening ischemia. Lumbar sympathectomy
and vasodilator therapy are ineffective in treating severe arterial occlusive disease.
- A 66-year-old woman has a 5.5-cm infrarenal
abdominal aortic aneurysm. What is the most
common manifestation of such an aneurysm?
(A) Abdominal or back pain
(B) Acute leak or rupture
(C) Incidental finding on abdominal
examination
(D) Atheroembolism
(E) Spontaneous thrombosis
- (C) Most patients are unaware of their abdominal
aneurysm until it is incidentally discovered by
their physician. The importance of careful deep
palpation of the abdomen cannot be overemphasized. On occasion, these aneurysms may
expand, causing abdominal or back pain, and
may even leak or rupture, mimicking other acute
intra-abdominal conditions. Signs and symptoms
of acute ischemia in the lower extremities are rare
and usually follow thrombosis or embolization
from an abdominal aneurysm.
- A 72-year-old man complains of bilateral thigh
and buttock claudication of several months
duration. He was told by his physician that the
angiogram revealed findings indicating that he
has Leriche syndrome. What does this patient
have?
(A) Abdominal aortic aneurysm
(B) Aortoiliac occlusive disease
(C) Iliac artery aneurysm
(D) Femoropopliteal occlusive disease
(E) Tibial occlusive disease
- (B) Leriche syndrome consists of the manifestations of aortoiliac occlusive disease and includes
thigh and buttock claudication, atrophy of the
leg muscles, diminished femoral pulses, and
impotence in men.
- A young woman develops a left femoral arteriovenous fistula a few months after a stab
wound to the groin. Which of the following
physiological changes (Nicoladoni-Branham
sign) is elicited on physical examination?
(A) Appearance of CHF when the artery
proximal to the fistula is compressed
(B) Slowing of the pulse rate when the
fistula is compressed
(C) A rise in the pulse rate when the artery
distal to the fistula is compressed
(D) A bruit heard only after the fistula is
occluded
(E) Absent dorsalis pedis after leg is elevated
- (B) The Nicoladoni-Branham sign can be elicited
in some patients with an AV fistula. Occlusion of
the fistula or the artery proximal to the fistula
may result in slowing of the heart rate. By
this compression, the peripheral resistance is
increased, venous return is decreased, and the
pulse rate falls.
- A young patient sustains blunt trauma to his
right knee that results in acute thrombosis of
his popliteal artery. Which tissue is most sensitive to ischemia?
(A) Muscle
(B) Nerve
(C) Skin
(D) Fat
(E) Bone
- (B) Peripheral nerve endings are the tissues most
sensitive to anoxia in the extremity. Therefore,
paralysis and paresthesia are most important
when evaluating an extremity with acute arterial
occlusion. The second most sensitive tissue is
the muscle. This is why an extremity with paralysis and paresthesia will develop gangrene if
circulation is not restored. Gangrene is less likely
to occur if signs of ischemia are present, but
motor and sensory functions are intact.
- Seven years after undergoing resection of an
abdominal aortic aneurysm and repair with a
Dacron graft, a 65-year-old man develops an
aortoenteric fistula. What would be the safest
method to treat this patient?
(A) Administration of a prolonged course of
antibiotics
(B) Removal of the Dacron graft, closure of
the enteric defect, and the insertion of a
new aortic graft
(C) Closure of the enteric fistula, removal of
the Dacron graft, ligation of the infrarenal
aorta, and insertion of an extra-anatomic
axillobifemoral bypass graft
(D) Division of the fistula, closure of the
aortic and enteric defects, and
interposition of omentum in between
(E) Closure of the enteric fistula, removal of
the Dacron graft, ligation of the infrarenal
aorta, and insertion of an extra-anatomic
bypass at a later date
- (E) The use of an extra-anatomic bypass (axillobifemoral) is indicated in the presence of
“hostile” abdomen (infection, dense and severe
adhesions, tumors) or if the patient is too sick to
undergo an abdominal operation. If a previously placed graft is contaminated (infection,
Answers: 30–47 233
aortoenteric fistula), the graft must be removed,
and the enteric defect must be closed. Although
some surgeons advocate removing the infected
graft and replacing it in situ with a new graft, the
safest approach remains the extra-anatomic
route to restore circulation to the lower extremities (axillobifemoral bypass).
- A 24-year-old male cyclist undergoes repair of
both popliteal artery and vein following a gunshot wound to the right knee. Thirty-six hours
postoperatively, there is increasing swelling of
the leg and foot, and the patient complains of
increasing foot pain and inability to move his
toes. His pedal pulses are palpable. What is the
most immediate next step that should be
undertaken?
(A) Arteriography
(B) Leg and foot elevation
(C) Fasciotomy
(D) Venography
(E) Immediate reexploration of the popliteal
space
- (C) Compartment syndrome can occur following repair of vascular injuries, especially if
ischemia time is more than 6 hours or if there
have been substantial periods of shock. Other
instances include the combination of arterial
and venous injury and the presence of concomitant soft-tissue crush injury or bone fracture. Compartment swelling and tenderness,
pain disproportionate to the physical findings,
paresthesia, and weakness are all clinical signs
of compartment syndrome and require urgent
surgical decompression. A palpable pulse does
not rule out the presence of a compartment
syndrome, because compartment pressures are
high, even before loss of a palpable pulse.
- A homeless elderly man is brought to the emergency department after sustaining frostbite to
both feet. What is the most appropriate immediate management?
(A) Slow rewarming at room temperature
(B) Amputation of the gangrenous toes
(C) Rapid rewarming with warm water
(D) Rapid rewarming with hot water or dry
heat
(E) Thorough debridement of blisters and
devitalized tissue
- (C) Rapid warming of the injured tissue is the
most important aspect of treatment. The frozen
tissue should be placed in warm water, with a
temperature in the range of 408–448ºC. Dry
heat or hot water carries the risk of thermal
injury because of decreased sensation in the
injured part. Opening of blisters and debridement of devitalized tissue are contraindicated.
Demarcation of gangrenous areas should be
carefully observed, often for several weeks,
before amputation is performed. The extremity
should be elevated, tetanus prophylaxis should
be administered as indicated, and antibiotics
should be given in the presence of open wounds.
- A 55-year-old woman who comes from a highaltitude location is diagnosed as having a
carotid body tumor (Fig. 10–3). What is true of
these tumors?
(A) They most frequently present as a
painless neck mass.
(B) They arise from endothelial cells.
(C) They are usually hypovascular.
(D) They frequently manifest with a stroke.
(E) They are usually treated by embolization.
- (A) Carotid body tumors are usually 3–4 mm in
size and are located at the carotid bifurcation.
They arise from nests of chemoreceptor cells
of neuroectodermal origin (carotid body). In
normal individuals, the carotid body responds
to a fall in PO2 and pH and to a rise in PCO2 and
temperature to cause an increase in cardiac contraction, heart rate, and respiratory rate. Carotid
body tumors are uncommon, slow growing, and
highly vascular. Although large tumors may
cause compression of the vagus or hypoglossal
nerves, most tumors present as a palpable painless mass at the carotid bifurcation. The treatment is definitely excision whenever possible.
- A middle-aged man complains of shortdistance claudication in the right thigh. The
angiogram shows a right common iliac artery
stenosis of 90% over a short segment. What is
the treatment of choice?
(A) Aortofemoral bypass
(B) Left-to-right fermorofemoral bypass
(C) Iliofemoral bypass
(D) PTA and stent placement
(E) Axillofemoral bypass
- (D) PTA is technically successful in approximately 90% of iliac lesions with good patency
rates. It is more successful for single short
stenoses rather than multiple long stenosis or
occlusions. The advantages of PTA is that it is
less invasive than surgery, has a lower initial
cost, has a shorter hospital stay, and lower morbidity, enables an earlier return to full activity,
and the procedure can be repeated without an
increase in morbidity or a decrease in clinical
result. It is particularly useful for patients who
are at high operative risks. The ideal procedure
would be and angioplasty and stent placement.
52. A 65-year-old man with hypertension and a blood pressure of 190/105 mm Hg has unilateral renal artery stenosis. What is the best diagnostic test to determine the physiologic significance of the lesion? (A) Aortography (B) Renal scan (C) Renal ultrasound (D) Renal vein renin assay (E) Rapid-sequence intravenous pyelogram
- (D) Aortography and renal ultrasound can detect
the presence of renal artery stenosis, but they do
not determine the functional significance of the
lesion. IVP is not a sensitive enough test to detect
the presence of renal artery stenosis. Arenal scan
can show decreased flow (uptake) or decreased
function of the affected kidney, but it, too, lacks
sensitivity. The assessment of renal vein renin
levels is a good diagnostic test to determine the
physiologic significance of renal artery stenosis.
It indicates whether the stenosis is significant
enough to decrease the glomerular filtration rate
and cause the release of renin. In addition, the
opposite kidney should have suppression of
renin secretion.
- A young college student injures his left knee
while playing football and is unable to bear
weight. The provisional x-ray report indicates
that there are no fractures seen. He is discharged home but presents the next morning to
the emergency department with a severely
swollen, painful left knee and severe pain in the
foot. On examination, the foot is pale, cold, and
pulseless. What is the most likely diagnosis?
(A) Traumatic deep vein thrombosis
(B) Gastrocnemius muscle tear
(C) Traumatic arteriovenous fistula
(D) Posterior knee dislocation with
thrombosed popliteal artery
(E) Traumatic sciatic neuropathy
- (D) Normal radiographic findings in the presence of severe knee trauma should raise suspicion for posterior dislocation of the knee, which
is often associated with popliteal artery thrombosis. A careful vascular examination should,
therefore, be made in such a situation. The presence of pain, pallor, and pulselessness (three of
the five p’s) is indicative of severe ischemia. This
patient should undergo urgent exploration for
vascular repair. The other options are unlikely to
cause the signs and symptoms presented.
- An elderly patient complains of recurrent
episodes of amaurosis fugax. This is attributable
to microembolization of which of the following?
(A) Facial artery
(B) Retinal artery
(C) Occipital artery
(D) Posterior auricular artery
(E) Superficial temporal artery
- (B) Amaurosis fugax, one type of TIA, is a manifestation of carotid bifurcation atherosclerotic
disease. It is manifested by unilateral blindness,
being described by the patient as a window
234 10: Vascular
shade across the eye, lasting for minutes or
hours. It is caused by microemboli from a carotid
lesion lodging in the retinal artery, the first intracerebral branch of the internal carotid artery.
- A 65-year-old woman television technician
undergoes femoral embolectomy and leg fasciotomy. Following surgery, she is noted to
have oliguria, and her urine is red. What is the
most probable diagnosis?
(A) Hematuria secondary to heparin
(B) Embolus of the renal artery
(C) Myoglobinuria
(D) Retroperitoneal hematoma
(E) Hemoglobinuria
- (C) Patients with sudden severe ischemia are
prone to “ischemia-reperfusion” syndrome. With
revascularization, there is sudden release of the
accumulated products of ischemia into the circulation; namely, potassium, lactic acid, myoglobin, and cellular enzymes. Hyperkalemia,
metabolic acidosis, and myoglobinuria (red
urine, clear plasma) are the key features of
the syndrome. Renal tubular acidosis results
in myoglobin deposition in the renal tubules.
Anticipation and early recognition require the
induction of diuresis with mannitol, alkalinization of the urine to avoid precipitation of myoglobin in the renal tubules, and correction of
hyperkalemia.
56. A 24-year-old woman on oral contraceptive pills develops an episode of deep vein thrombosis that is adequately treated with anticoagulation. She is at increased risk of developing which of the following? (A) Recurrent foot infections (B) Claudication (C) Pulmonary embolism (D) Postphlebetic syndrome (E) Superficial varicose veins
- (D) Despite receiving optimal treatment for
DVT, approximately 50% of the patients will
develop the post-thrombotic syndrome. The
recanalization of the deep veins will result in
deformity and subsequently incompetence of
the affected venous valves. Although patients
with DVT can develop infections secondary to
edema, these are usually located about the
ankle and resolve with adequate treatment.
Patients adequately treated for DVT are not at
increased risk of developing pulmonary embolus. Neither the arterial circulation nor the
superficial venous system are affected by the
development of DVT. Young patients with
iliofemoral thrombosis are best managed by
thrombolytic infusion, which has been shown
to preserve valvular function and decrease the
incidence of postphlebitic syndrome.
- A72-year-old businessman undergoes a femoralto-posterior tibial in situ bypass graft for a
nonhealing foot ulcer. During routine follow-up
examination 4 years later, the graft is found to be
occluded. The cause of his graft failure is most
probably secondary to which of the following?
(A) Progression of atherosclerosis
(B) Technical error
(C) Retained valve in the conduit
(D) Venous aneurysm
(E) Intimal hyperplasia
- (A) The causes of graft failure can be divided
into early and late. Although early failure of
vein grafts is usually attributed to either technical error or inadequate outflow tract, late failure is usually related to progressive proximal
or distal atherosclerotic disease. Other less
common causes of late graft failures include—
local stenotic areas from trauma or endothelial
damage, valve stenosis from fibrosis, and venous
aneurysms and subsequent thrombosis. Intimal
hyperplasia is a rare cause of late failure.
- A60-year-old woman has an asymptomatic right
carotid bruit. A carotid duplex scan shows no
evidence of significant carotid bifurcation disease but reveals reversal of flow in the right vertebral artery. What is the most likely diagnosis?
(A) Stenosis of the origin of the common
carotid artery
(B) Stenosis of the vertebral artery
(C) Stenosis of the subclavian artery
(D) Stenosis of the external carotid artery
(E) Stenosis of the intracranial portion of
the internal carotid artery
- (C) Occlusion or stenosis of the subclavian
artery proximal to the origin of the vertebral
artery results in the “subclavian steal” syndrome. In response to decreased pressure in the
distal subclavian artery, especially in instances
in which increased perfusion is needed, there is
reversal of flow in the vertebral artery. The clinical picture is that of vertebrobasilar symptoms
in association with upper extremity exercise.
Although this phenomenon is sometimes seen
on duplex scanning or angiography, evolution
into a clinical syndrome is relatively rare. The
other mentioned options do not result in retrograde flow in the vertebral artery.
- A newborn girl with family history of lymphedema is noted to have bilateral lower
extremity swelling. What is the diagnosis?
(A) Secondary lymphedema
(B) Lymphedema praecox
(C) Milroy disease
(D) Lymphedema tarda
(E) Meigs’s syndrome
- (C) Lymphedema is classified by etiology—primary versus secondary. Primary lymphedema
is divided into congenital, praecox, and tarda,
depending on the age of onset. The diagnosis of
Milroy disease is reserved for patients with
familial lymphedema in which clinical factors
are present at birth or noticed soon thereafter.
Lymphedema is classified as praecox if the age
of onset is between 1 and 35 years. Meigs’
disease is the familial form of primary lymphedema praecox. If the onset of primary lymphedema is after 35 years of age, it is called
lymphedema tarda. Secondary lymphedema
usually results from a disease process that
causes obstruction of the lymphatic system.
