CT and Vascular

Question 1

What are symptoms of vascular rings

Answer 1

1. stridor

2. crowing respiration (baby assumes hyperextended position). If only respiratory Sx then think of tracheomalacia

Question 2

How do you dx vascular rings?

Answer 2

barium swallow and bronchoscopy (rules out tracheomalacia)

Question 3

What is the treatment for vascular rings?

Answer 3

divide smaller of the 2 aortic arches

Question 4

What is the best way to dx morphologic cardiac anomalies?

Answer 4

Echo

Question 5

How do L to R shunts present?

Answer 5

murmur, pulmonary circulation overload, long term damage to pulmonary vasculature

Question 6

Murmur of ASD

Answer 6

systolic flow murmur w/ fixed split 2nd heart sound

Question 7

When is an ASD ususally dxed?

Answer 7

• late infancy. hx of frequent colds is common

Question 8

How do most VSD’s present?

Answer 8

if they high in the membranous septum - they have FTT, loud pansystolic murmur at LSB, increased pulmonary vasculature on CXR
- if the VSD is small and low in muscular septum they ususally close in first 2-3 years of life

Question 9

How do R to L shunts present?

Answer 9

presence of murmur, cyanosis.

Question 10

What is the MC cyanotic anomaly 2/2 to the heart?

Answer 10

TOF

Question 11

How does TOF present?

Answer 11

• small kids, bluish hue in lips, spells of cyanosis relieved by squatting
• systolic ejection murmur in left 3rd ICS

Question 12

CXR findings of TOF

Answer 12

• small heart, diminished pulmonary vascular markings,

Question 13

EKG of TOF

Answer 13

RVH

Question 14

Tell me about TGA

Answer 14

• kept alive by ASD, VSD, or PDA>
• think of this in a 1 or 2 day old baby with cyanosis.
• get ECHO!

Question 15

When to repair aortic stenosis

Answer 15

if gradient or more than 50 mmHg or at first indication of CHF, angina, or syncope

Question 16

When should chronic AR be repaired?

Answer 16

• at first evidence on ECHO of beginning LV diltation

Question 17

When is acute AR seen?

Answer 17

• endocarditis in young drug addcits who develop CHF and new murmur. Replace valve and start long term ABx

Question 18

Associations with Mitral Stenosis

Answer 18

1. think rheumatic fever

2. as it progresses patient become thin and cachectic and get a fib.

Question 19

How is mitral stenosis repaired?

Answer 19

• surgical commissurotomy or balloon valvuloplasty

Question 20

What is the post op care of heart surgery patients?

Answer 20

1. optimize CO. if not normalget PCWP. if Low give IVFs if high it means ventricular failure

Question 21

How does chronic constrictive pericarditis present?

Answer 21

1. DOE, hepatomegaly, ascites

2. equalization of pressures on cardiac cath

Question 22

Workup for suspected cancer of lung?

Answer 22

1. get CXR
2. sputum cytology
3. CT scan for staging

Question 23

How do you dx lung cancer?

Answer 23

1. Cytology of sputum
2. bronchoscopy for central bx
3. percutaneous for peripheral bx
4. if above unsuccessful do VATS and wedge resection

Question 24

How to treat small cell cancer of lung?

Answer 24

chemo and radiation

Question 25

How is operability of lung cancer determines?

Answer 25

on residual function after resection.

• central lesions require pneumonectomy
• peripheral ones can be removed w/ lobectomy
• Minimum FEV1 of 800mL is needed

Question 26

What to do about lung cancer mets?

Answer 26

1. hilar mets can be removed w/ pneumoectomy

2. nodal mets at carina or mediastinum preclude curative resection

Question 27

How to dx lung cancer mets?

Answer 27

1. CT
2. PET
3. endobronchial US - invasive option to sample mediastinal nodes
4. cervical medistainal exploration is rarely needed

Question 28

What is subclavian steal syndrome?

Answer 28

• arteriosclerotic stenotic plaque at origin of subclavian allows enough blood supply to reach the arm for normal activity but doesn’t allow enough to meet higher demands when arm is exercised
• so then arm sucks blood away from the brain by reversing flow in the vertebral artery.

Question 29

What are the Sx of subclavian steal syndrome?

Answer 29

• arm claudication, posterior neurologic signs

- if only vascular Sx were present think of thoracic outlet syndrome.

Question 30

How to dx subclavian steal syndrome?

Answer 30

• duplex scanning. Bypass surgery cures it

Question 31

What to do with the different AAA sizes?

Answer 31

1. < 4 cm, observe
2. 5-6 cm have elective repair
3. if grows 1 cm per year or faster do repair

Question 32

how are most AAA treated now?

Answer 32

endovascular stents. These cases are unruptured and the neck should be at least 2.5 cm

Question 33

What to do in pt w/ excruciating back pain in a patient w a large abdominal aortic anuerysm.

Answer 33

retroperitoneal hematoma is already forming so do emergent surgery.

Question 34

What is the workup of disabling intermittent LE claudication?

Answer 34

1. Doppler students for pressure gradient

2. CT angio or MRI angio to look for stenosis or complete obstruction and to look for a good distal vessel for a graft

Question 35

What is the treatment of stenotic LE vascular segments?

Answer 35

1. short ones - angioplasty and stenting
2. extensive - bypass grafts
3. multiple lesions - repair proximal ones
   - if grafts originate at aortobifemoral do prosthetic. for distal vessels use reversed saphenous grafts

Question 36

Arterial embolization from distant source Rx?

Answer 36

1. early incomplete occlusions - do clot busters
2. embolectomy w/ Fogarthy catheter for complete obstruction
3. Fasciotomy if several hours have passes before revascularization

Question 37

Who gets dissecting aneuryms of thoracic aorta?

Answer 37

poorly controlled HTN

• resembles an MI, pain radiates to back. unequal pules in UE. Xray shows wide mediastinum
• do EKG and cardiac enzymes to r/o MI.
• dx by noninvasive means first. Get spiral CT

Question 38

How to treat aortic dissections?

Answer 38

1. ascending ones - surgery

2. descending ones - control HTN