CVS ِand IR

Question 1

@# 32. Causes of oligaemia (decreased pulmonary blood flow) with cyanosis include: (T/F)

(a) Aortic atresia.

(b) Truncus arteriosus.

(c) Transposition of great vessels.

(d) Total anomalous pulmonary venous return.

(e) Tetralogy of Fallot.

Answer 1

Answers:

(a) Not correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Aortic atresia, Truncus arteriosus, TGA and TAPVR show plethora with cyanosis.

Question 2

41. Causes of inferior rib notching include: ( T/F)

(a) Coarctation of the aorta.

(b) Systemic sclerosis.

(c) Blalock-Taussig shunt.

(d) Superior vena caval obstruction.

(e) Neurofibromatosis Type 1

Answer 2

Answers:

(a) Correct

(b) Not correct

(c) Correct

(d) Correct

(e) Correct

Explanation:

Systemic sclerosis does not cause inferior rib notching.

Question 3

@# 49. Which of the following are correct regarding transposition of the great arteries (TGA)? (T/F)

(a) Pulmonary stenosis is an associated feature.

(b) In the D loop of TGA the atria and ventricles have a normal morphological relationship.

(c) Dextrocardia is associated with L loop of TGA.

(d) Chest radiograph shows pulmonary plethora in D loop of TGA.

(e) In the L loop (corrected) transposition there is physiologically corrected circulation.

Answer 3

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Correct

(e) Correct

Explanation:

In the D loop of TGA the aorta arises from the right ventricle and the pulmonary artery from the left ventricle.

A normal relationship exists between the atria and the ventricles.

In the L loop of TGA, there is transposition of the aorta and pulmonary arteries in addition to inversion of the left and right ventricles.

The atria and coronary arteries are associated with their corresponding ventricles.

Question 4

@# 50. Regarding total anomalous pulmonary venous drainage (TAPVD), which of following are correct? (T/F)

(a) The supracardiac type is the most common.

(b) The left atrium is not enlarged.

(c) The infracardiac type may drain into hepatic veins.

(d) There is an association with Scimitar syndrome.

(e) Pulmonary oedema in presence of normal sized heart is a feature of Cardiac type TAPVD.

Answer 4

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Not correct

(e) Not correct

Explanation:

Scimitar syndrome is the association of hypogenetic lung with congenital pulmonary venolobar syndrome where all or part of hypogenetic lung is drained via an anomalous vein into the subdiaphragmatic IVC, hepatic veins, portal vein or coronary sinus.

Pulmonary oedema is a characteristic feature of infracardiac type TAPVD.

Question 5

6. Which of the following are correct regarding cardiac myxoma: (T/F)

(a) Is the most common primary cardiac tumour.

(b) 80-90% of patients have arrhythmias.

(c) 70-80% are found in the right atrium.

(d) Invasion of the myocardium is seen in >50% at presentation.

(e) Have a low signal on gradient-echo MRI sequences.

Answer 5

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Approximately 75% of myxomas are located in left atrium, 20% in right atrium and rare cases are found in ventricles.

The classical clinical triad of obstructive cardiac symptoms, embolic phenomena and constitutional symptoms has been described and majority of the patients have at least one of these symptoms at presentation.

Cardiac myxomas are endocardial based masses that do not infiltrate the underlying tissues.

Question 6

44. Which of the following are correct regarding pericardial disease: (T/F)

(a) Rheumatoid arthritis is a cause of pericarditis.

(b) Elevation of the jugular venous pressure on inspiration is a sign of chronic pericarditis.

(c) A pericardium of 3mm thickness is normal.

(d) In chronic pericarditis, CT shows curvature of the interventricular septum to the right.

(e) Renal failure is a cause of pericardial effusion.

Answer 6

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Not correct

(e) Correct

Explanation:

Curvature of the interventricular septum to the left is seen in chronic pericarditis on CT.

Question 7

3. Which of the following are correct about thoracic aorta: (T/F)

(a) Stanford type B dissection affects the ascending aorta.

(b) Penetrating aortic ulcers are frequently multiple.

(c) Mycotic aneurysms are usually fusiform in configuration.

(d) Penetrating aortic ulcers usually progress to dissection.

(e) Type A dissection is more common than Type B.

Answer 7

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Dissection affecting ascending aorta is classified as Stanford type A and accounts for 75% of aortic dissection. Acute type A is a surgical emergency to avoid fatal complications. Stanford type B dissection affects the descending aorta.

Mycotic aneurysms are usually saccular and may grow rapidly.

Penetrating atherosclerotic ulcers usually progress to aneurysmal dilatation.

Question 8

@# 20. Which of the following are correct regarding fibromuscular dysplasia (FMD): (T/F)

(a) Is more common in males.

(b) Usually affects the intimal layer.

(c) Renal artery FMD is bilateral in 5% of cases.

(d) Can occur in veins.

(e) May present with a transient ischaemic attack.

Answer 8

Answers:

(a) Not correct

(b) Not correct

(c) Not correct

(d) Correct

(e) Correct

Explanation:

FMD is more common in females and presents between 15 to 50 yrs.

Medial fibroplasia is more common form of FMD with characteristic ‘strings of beads’ appearance. Intimal fibroplasia occurs in 10% of cases and adventitial hyperplasia is the rarest form.

Renal artery FMD is bilateral in approximately 30% of cases.

Question 9

21. Which of the following are correct regarding popliteal artery disease:- (T/F)

(a) The popliteal artery is superficial to the popliteal vein on ultrasound.

(b) Popliteal artery entrapment syndrome (PAES) is a recognized condition in athletes.

(c) Popliteal artery aneurysms are bilateral in 50-70% of cases.

(d) Popliteal artery occlusion is seen in 30-50% of patients with complete knee dislocation.

(e) Balloon mounted stents are usually preferred to self-expanding stents when treating popliteal artery disease.

Answer 9

Answers:

(a) Not correct

(b) Correct

(c) Correct

(d) Correct

(e) Not correct

Explanation:

Popliteal artery lies posterior to the femur and anterior to the vein, thus artery is deep to the vein when scanning the popliteal fossa with ultrasound.

Stent placement in popliteal artery is reserved for cases of failed PTA when limb viability is threatened. Self-expanding stents are preferred because of superficial location of artery and concerns about extrinsic compression.

Question 10

@# 22. Vascular anatomy of the liver: (T/F)

(a) The middle hepatic vein divides the liver into anatomical right and left lobes (Couinard classification).

(b) At microscopic level, centrilobular veins drain into the portal circulation.

(c) The portal vein bifurcation is intrahepatic in 90% of cases.

(d) The right hepatic artery arises solely from the superior mesenteric artery in 10-15% of individuals.

(e) In the fetus, the ducutus venosus joins the right portal vein to the inferior vena cava.

Answer 10

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Correct

(e) Not correct

Explanation:

The hepatic lobule is the basic histological unit. The triads of hepatic arterioles, portal venules and bile duct branches run at the edge of the lobule. Blood flows from periphery inwards via hepatic sinusoids and is drained bycentrilobular veins which in turn drain into hepatic veins.

The portal bifurcation is extrahepatic in 40% - 80% cases.

Left portal vein is critical to fetal circulation as it receives blood from the placenta via the left umbilical vein and delivers it across the liver to the IVC via ductus venosus.

Question 11

23. Which of the following are correct regarding aortic dissection: (T/F)

(a) Type A dissection is usually treated surgically.

(b) Type A dissection involves the ascending aorta.

(c) The true lumen is usually smaller than the false lumen.

(d) Diagnosis is most commonly made by digital subtraction angiography.

(e) Treatment options for type B dissection include stent grafting and balloon fenestration.

Answer 11

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Not correct

(e) Correct

Explanation:

Diagnosis is mostly done by cross sectional imaging (CT or MRI) both of which have high specificity and sensitivityabove 90%.

Question 12

28. Which of the following are correct regarding features of mycotic aneurysms include: (T/F)

(a) Gradual enhancement with contrast.

(b) Fusiform structure.

(c) Adjacent vertebral osteomyelitis.

(d) Adjacent reactive lymph node enlargement.

(e) Tuberculosis is the commonest infective organism.

Answer 12

Answers:

(a) Not correct

(b) Not correct

(c) Correct

(d) Correct

(e) Not correct

Explanations:

Mycotic aneurysms are saccular types showing rapid enhancement and most commonly associated with Staphylococcus aureus (IV drug abuse and subacute bacterial endocarditis).

Question 13

29. Which of the following are correct regarding Buerger’s disease (thrombo-angitis obliterans): (T/F)

(a) Is associated with cigarette smoking in 90-95%.

(b) Initially affects the proximal vessels and progresses distally.

(c) More commonly affects the upper limb.

(d) Has multiple corkscrew-shaped collaterals on angiography.

(e) Has skip lesions as a recognised feature.

Answer 13

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Correct

(e) Correct

Explanations:

Buerger’s disease initially affects the distal vessels and progresses proximally affecting the lower limbs more commonly.

Question 14

30. Which of the following are correct regarding aortic dissection: (T/F)

(a) The Stanford Classification Type B aortic dissection involves the ascending aorta.

(b) Aortic dissections involving the ascending aorta account for 60-70%.

(c) There is an increased risk in Ehlers-Danlos syndrome.

(d) Contrast-enhanced CT is more accurate than transoesophageal echocardiography at identifying aortic dissections.

(e) Displacement of calcification in the aortic knuckle by >10mm is a useful sign.

Answer 14

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Not correct

(e) Correct

Explanations:

Type A dissection involves the ascending aorta.

Ehlers-Danlos syndrome is associated with increased risk of aortic aneurysms and not dissection.

Question 15

31. Which of the following are correct regarding renal artery stenosis: (T/F)

(a) There is an association with neurofibromatosis.

(b) Fibromuscular dysplasia causes stenosis of the proximal renal artery.

(c) There is elevation of the rennin levels on renal vein sampling of the affected kidney by 50%.

(d) Duplex ultrasound is the investigation of choice.

(e) On IVU, there is early appearance of contrast material in the affected kidney.

Answer 15

Answers:

(a) Correct

(b) Not correct

(c) Correct

(d) Not correct

(e) Not correct

Explanations:

In FMD stenosis is more common in mid and distal renal artery.

In atherosclerotic stenosis proximal artery is involved.

MRI is investigation of choice.

Ultrasound is inadequate in 50% cases.

On IVU, there is delay due to reduced glomerular filtration rate.

Question 16

43. Which of the following are correct regarding Takayasu’s arteritis: (T/F)

(a) External carotid artery branches are most commonly affected.

(b) The mean interval between symptom onset and diagnosis is 2-4 months.

(c) It is a recognised cause of fusiform aortic aneurysms.

(d) Stenotic lesions are more commonly seen in the thoracic than abdominal aorta.

(e) Ultrasound of the proximal common carotid artery shows circumferential thickening of the vessel wall.

Answer 16

Answers:

(a) Not correct

(b) Not correct

(c) Correct

(d) Correct

(e) Correct

Explanation:

Takayasu’s arterits mainly affects main aortic branches and pulmonary arteries.

External carotid artery involvement is seen in temporal arteritis.

Internal between symptom onset and diagnosis is 8 yrs.

Question 17

45. Which of the following are correct regarding features of polyarteritis nodosa (PAN) include: (T/F)

(a) Multiple aneurysms.

(b) Luminal irregularities.

(c) Involvement of small veins.

(d) Necrotising vasculitis involving the small and medium sized arteries.

(e) Involvement of kidneys in 70-80%.

Answer 17

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Correct

(e) Correct

Explanation:

PAN is a systemic inflammatory disease, commoner in males and presents around 5th to 7th decade of life. Main differentials include microscopic polyangitis and SLE.

Question 18

46. Regarding aortic transection (traumatic aortic injury), which of the following are correct? (T/F)

(a) The descending aorta is rarely involved.

(b) The most common site is the ascending aorta.

(c) The chest radiograph is normal in 30% of cases at presentation.

(d) The ‘left apical cap’ sign is highly specific for aortic transection.

(e) Chronic false aneurysm develops in 5% of cases.

Answer 18

Answers:

(a) Correct

(b) Not correct

(c) Correct

(d) Not correct

(e) Correct

Explanations:

The most common site is aortic isthmus (95%).

The ascending aorta is involved in 1% of cases.

The ‘left apical cap’ sign refers to mediastinal hematoma with extrapleural extension of blood (only 15% of mediastinal hematomas are due to aortic tear).

Question 19

@# 51. Which of the following are correct regarding coarctation of the aorta? (T/F)

(a) Adult coarctation is commonly associated with cardiac anomalies.

(b) It is a rare cause of infantile heart failure.

(c) The ductus arteriosus usually remains patent in adult type coarctation.

(d) Rib notching is usually present by 1 yr of age.

(e) A short segment of narrowing of ascending aorta is seen in infantile coarctation.

Answer 19

Answers:

(a) Not correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Not correct

Explanation:

Adult coarctation is short narrowing at ligamentum arteriosum.

It is rarely associated with cardiac anomalies and the ductus arterosium is usually closed.

Aortic coarctation is second most common cause of infantile heart failure (most common is hypoplastic left heart).

Rib notching involves 3rd to 8th ribs and in 75% of cases seen in over 6 yrs of age.

Question 20

@# 24. Which of the following are correct regarding bronchial artery embolization (BAE): (T/F)

(a) The smallest available polyvinyl alcohol (PVA).

(b) Recurrence of haemoptysis after BAE is rare.

(c) The bronchial arteries originate directly from the ascending thoracic aorta in 90% of cases.

(d) An arch aortogram is usually performed prior to selective bronchial angiography.

(e) Chest pain is the most common complication.

Answer 20

Answers:

(a) Not correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Very small particles can freely flow through the microcirculation and shunts causing infarcts, thus 350 – 500 micro m PVA particles are used.

Long term recurrence rates are between 10% - 52% with a mean follow up period of 1 to 46 months.

The bronchial arteries originate directly from the descending thoracic aorta most commonly between T5 and T6 vertebrae. The left main bronchus is a useful landmark in angiography, marking the origin of bronchial arteries in most cases.

Descending thoracic aortogram is usually performed.

Question 21

25. Which of the following are correct regarding causes of failure of uterine fibroid embolization (UFE): (T/F)

(a) Failure to catheterize both uterine arteries.

(b) Collaterals supply from ovarian artery.

(c) Use of a micro-catheter for particle delivery.

(d) Embolization particle aggregation.

(e) Use of glycerol trinitrate.

Answer 21

Answers:

(a) Correct

(b) Correct

(c) Not correct

(d) Correct

(e) Not correct

Explanations:

Micro-catheters facilitate ut artery catheterization and may help avoid spasm.

Glycerol trinitrate is a vasodilator.

Question 22

26. Which of the following are correct regarding endoleaks following endovascular abdominal aortic aneurysm (AAA) repair: (T/F)

(a) Type I endoleaks present months or years after AAA repair.

(b) Graft fracture can result in a Type III endoleak.

(c) Type II endoleaks require urgent interventional management.

(d) Type IV endoleaks are the result of graft porosity.

(e) CT demonstrates the cause of Type V endoleak in 20-30% of cases.

Answer 22

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Correct

(e) Not correct

Explanations:

Type I endoleaks usually occur early and may be seen on the on-table angiogram immediately after stent-graft deployment as they occur due to ineffective seal at the graft ends. It has poor prognosis if left untreated.

Type II endoleaks management is controversial, some favouring a conservative approach. Embolization of feeding artery may be performed.

Type V endoleaks refers to endopressure /endotension which is basically aneurysm sac expansion in absence of obvious endoleaks on follow up CT. it has been associated with aneurysm expansion and rupture.