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Son5025 Vasc > Likely pathologies > Flashcards

Likely pathologies Flashcards

1
Q

What is sub clavian steal phenomenon?

A

steno-occlusive disease of the proximal subclavian artery with retrograde flow in the ipsilateral vertebral artery.

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2
Q

What is sub clavian steal syndrome?

A

the same as subclavian steal phenomenon with the addition of cerebral ischaemic symptoms.

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3
Q

What is an early sign of subclavian steal in the vertebral?

A

Bunny ears

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4
Q

How can patients with sub clavian steal present?

A
  • usually an incidental finding during carotid and vertebral examination.
  • Patients are usually asymptomatic, but five percent will exhibit signs of ischaemia, such as pain, weakness, cold arm, and decreased pulse
  • Clinically, the affected arm will demonstrate a decreased brachial and radial pulse.
  • Patients will report difficulties with blood pressure measurements on the affected arm.
  • There also may be decreased strength and pallor of the hand.
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5
Q

What is vertebrobasilar insufficiency?

A

identifies a number of conditions which impair the posterior circulation

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6
Q

What can cause vertebrobasilar insufficiency?

A

embolic occlusion
external compression
Stenosis
for example
arteriosclerosis causing stenosis, occlusion, aneurysm;
cervical trauma causing arterial dissection;
subclavian steal syndrome;
cardiac dysfunction;
haemodynamic effects of carotid artery disease;
vertebral artery ectasia; and
vertebral artery impingement.

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7
Q

What are some symptoms of vertebrobasilar insufficiency?

A

dizziness and vertigo to diplopia, paresthesias, tinnitus or drop attacks.

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8
Q

Ways to determine whether the patient’s symptoms of vertebrobasilar insufficiency are related to carotid artery or vertebral artery disease:

A

not possible to be certain clinically - there is an overlap of symptoms;
vertebral impingement - try to reproduce the patient’s symptoms, scan the vertebrals;
ultrasound examination of the carotid and vertebral arteries; and
transcranial examination of the vertebral and basilar arteries.

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9
Q

What is thoracic outlet syndrome?

A

Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed.

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10
Q

What are some symptoms of thoracic outlet syndrome?

A

Neck, shoulder, arm pain
Numb, cold arm and hand
Pallor of the hand
Decreased hand strength

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11
Q

What are some causes of thoracic outlet syndrome?

A

Cervical rib
Fibrous bands
Trauma to shoulder region causing compression

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12
Q

Outline Assessment for outlet syndrome entrapment of the subclavian artery

A

The patient is often best sat in a chair.
Prior to scanning, the position of the arm in 0 deg, 45 deg, 90 deg. and 110deg. is explained. This is shown to them.
Spectral waveforms are then recorded just lateral to the clavicle in th subclavian artery in each position.
If there is a velocity increase or cessation of flow, the arm in moved to determine exactly what angle the entrapment occurs at.
The venous system in then assessed for thrombosis. It is also observed through this range of movement.
As this is often a bilateral anomaly, the contralateral side is also scanned.
The diagnosis in generally a clinical one. Careful discussion with the patient about their symptom will assist you in determining the likelihood of this pathology.

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13
Q

How can you identify an AAA using ultrasound

A

the aorta normally decreases in diameter as it approaches its bifurcation
an increase in diameter compared to the proximal artery can be considered as either ectatic or aneurysmal
an aortic diameter of 3cm or greater is also used as a good guide to classifying an aorta as aneurysmal
a focal enlargement of 1.5times the proximal diameter of the artery can be used as a more quantitative guide.
If the aortic diameter is greater than 5cm, it is usually considered for surgical or endoluminal repair
Iliac arteries are usually less than 1cm in diameter and diameters above this can be considered as either ectatic or aneurysmal.

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14
Q

What are some complications of AAA surgical repair?

A 
haematoma
·        pseudoaneurysm at anastomosis
·        thrombosis
·        refilling of excluded sac via branch arteries (often lumbar arteries)
·        adjacent aneurysm development
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15
Q

What are some EVAR (Endovascular Aneurysm Repair) complications?

A

· endograft leak
· thrombosis
· stent migration

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16
Q

What are the different types of endoleaks?

A

· A type I endoleak is defined as direct flow into the aneurysmal sac related to the incomplete sealing of the stent-graft to the aortic wall.
· A type II endoleak is the retrograde filling of the aneurysm mainly from the lumbar arteries and the inferior mesenteric artery.

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17
Q

What can be a consequence of endoleak?

A

Endoleaks can lead to aneurysmal growth and rupture

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18
Q

Why would ultrasound be used over ct to assess endoleak?

A

· it is less expensive
· widely available
· does not require iodine contrast medium injection or radiation

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19
Q

What are some risk factors for AAA?

A 
•	Family history of aneurysm
•	male gender
•	smoking
•	Increasing age
Less association is seen with:
•	Hypertension
•	Peripheral artery disease
•	Coronary disease
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20
Q

When an aneurysm is identified what should you measure?

A
  • Maximum diameter in the A-P and coronal planes.
  • Diameter of the aorta at the renal arteries
  • Length of the aneurysm
  • Distance from the aortic bifurcation to the end of the aneurysm
  • Size of the patent lumen if mural thrombus is present
  • Diameter of iliac artery dilatation
  • Location in terms of infra-renal or supra-renal.
  • Other diameters and velocities recorded as described in examination techniques
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21
Q

What is acute ischaemia of the leg?

A 
Acute ischemia is not just a recent and severe onset of claudication or diffuse leg pain. Acute ischemia is defined by the presence of six features which include:
•	Pulselessness
•	Pallor
•	Paraesthesia
•	Paralysis
•	Poikilothermia (Cold)
•	Pain
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22
Q

What is chronic ischaemia of the leg?

A
  • Usually the results of atherosclerosis.
  • Worsens over time
  • Progressing claudication and critical limb ischaemia
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23
Q

What is critical limb ischaemia?

A
  • occurs when the level of ischemia causes tissue loss in the extremity
  • usually associated with extensive ischemic changes and often with severe claudication and rest pain.
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24
Q

What is rest pain?

A
  • Rest Pain refers specifically to ischemic pain when there is insufficient pressure to adequately supply the leg while at rest (while supine).
  • Rest pain usually occurs in the toes and foot but may at times be experienced in the region of the ankle.
  • The characteristic features of rest pain are usually experienced while supine and relieved by hanging the leg over the side of the bed.
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25
Q

What is a false aneurysm?

A
  • A ‘false aneurysm’ or pseudoaneurysm is a collection of arterial blood which ‘leaks’ from an artery and is constrained by the adventitia and fibrous tissue adjacent to its source artery.
  • These often result from leakage from a needle puncture which does not seal, but may occur with other causes of trauma of the arterial wall.
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26
Q

What are the three causes of AVF?

A

Klippel Trenaunay syndrome
Parkes Webber syndrome
A-V fistula

27
Q

Name lower limb grafts

A 
o	Femoro-popliteal (Fem-Pop) , Above knee Fem-Pop,
o	Femoro-distal or femoro- tibial,
o	Aorto-bifemoral,
o	aorto-iliac
o	femoral to femoral cross-over
28
Q

When are synthetic grafts used?

A

• Grafts bypassing proximal disease
• such as the aorto-bifemoral or axillo-bifemoral graft
• made of synthetic tube since vein is not considered large enough to cope with the high flow rates
• typically made of Dacron.
• The above knee Fem-Pop graft is also synthetic but is not a proximal inflow graft.
• Synthetic grafts are used for this bypass as they have a higher patency rate than vein.
- Extra anatomic bypass grafts
• grafts which are positioned outside the normal anatomic region of the arteries being bypassed.

29
Q

When are vein grafts used?

A
  • Grafts from arteries above the knee to the popliteal or tibial arteries are usually constructed of vein
  • A synthetic graft may be used if there is no suitable vein available or if the length of graft is too long and these are usually made of Poly Tetra Fluro Ethylene (PTFE).
30
Q

A patient presents to her general practitioner with pain in the right calf after playing four holes of golf. The pain decreases with rest but returns after playing two more holes. Describe the physical examination her doctor should perform and any diagnostic tests that should be requested.

A
  • Assess pulses, colour, temperature, region of pain, health of skin, duration of pain, any recent injury, or arthritis of knee (Baker’s cyst).
  • Treadmill exercise testing would determine if there were arterial causes for calf pain, may proceed to ultrasound Doppler to assess level and extent of arterial disease.
31
Q

Consult a department’s protocol for lower extremity Doppler. List the important information you would need to demonstrate during the examination.

A
  • peak systolic velocity (PSV);
  • AP diameter;
  • aneurysmal dilation;
  • level and length of stenosis or occlusion;
  • PSV ratio before and at stenosis;
  • spectral broadening; and
  • collateral vessels.
32
Q

What is the objective of ultrasound in TIPS evaluation?

A
  • Despite adequate initial shunting, some patients present with recurrence of gastrointestinal bleeding, new onset or reappearance of ascites, or hepatic failure
  • each of these problems can result from progressive liver disease, they may also result from hemodynamic failure (stenosis) or occlusion of the portosystemic shunt.
  • objective of the ultrasound examination is to identify this situation.
33
Q

What should the initial TIPS scan image and what should it demonstrate?

A
  • Image flow in the PV, SMV and SV
  • Show patency of the hepatic veins
  • Image the shunt
  • Perform spectral analysis throughout the length of the shunt

The scan should demonstrate:
• the ends of the shunt in the native vessel at either end
• good colour fill
• low impedence waveform with some pulsatility acceptable
• PSV 50-60cm/s
• similar velocities at either end of the shunt
• hepatopedal flow in the PV
• PV > 30 cm/s (NR 37-47 cm/s)

34
Q

Adter TIPS An initial gray scale evaluation should be performed to look for

A
  • the presence of ascites
  • intrahepatic hematomas
  • bile collections
  • Measurement of the size of the spleen
  • a search for any known varices or new portosystemic collaterals
  • A careful assessment should also be made of the size, configuration, and position of the stent with respect to the portal branch and draining hepatic vein.
  • The diameter of the stent should be measured along its entire length to assure that the device has properly expanded.
35
Q

The initial hemodynamic assessment of TIPS should include

A 
o	extrahepatic portal vein
o	right and left portal vein,
o	SMV
o	splenic vein at the confluence of the SMV
o	multiple sites from within the stent
o	all three main hepatic veins
o	the intrahepatic IVC. 
o	To assess the arterial response to the TIPS and to avoid missing an arterial injury, a quick survey of the hepatic artery with a calculation of the systolic and diastolic velocity and resistance index is encouraged.
36
Q

What are to two ways of assessing RAS?

A

Direct and indirect

37
Q

What is the criteria for RAS direct assessment?

A

Direct assessment:

renal artery: aorta (RAR) ratio > 3.5:1, PSV > 180cm/s

38
Q

What are the criteria for indirect RAS assessment?

A
  • pattern recognition: normal, equivocal, abnormal
  • loss of early systolic peak and flattening of the systolic upstroke is a marker for abnormality
  • resistive index: variation of > 0.05 (marker for abnormality)
  • resistive index: < 0.8 suitable for intervention
39
Q

What are renal allograft complications involving perinephric fluid collections?

A

Lymphocele
Urinoma
Haematoma
Post surgical seroma

40
Q

How can you differentiate perinephric fluid collections of the renal allograft using location?

A
  • Urinomas will emanate from a ureter.
  • Lymphoceles will be seen arising from the renal hilum.
  • Seromas tend to be anterior.
  • Haematomas can be anywhere and look like anything.
41
Q

How can you differentiate perinephric fluid collections of the renal allograft using shape?

A
  • Lymphoceles are wedge-shaped when small and tend to be thin-walled.
  • Seromas tend to be tubular and follow tissue planes (rarely large).
42
Q

How can you differentiate perinephric fluid collections of the renal allograft using internal echoes?

A
  • There are very few echoes except that septations tend to represent a lymphocele.
  • Urinomas are also without echoes but can have thick walls.
  • Seromas are usually septated.
  • Haematomas are variable.
43
Q

How can you differentiate perinephric fluid collections of the renal allograft using clinical indicators?

A
  • Hematomas, urinomas and seromas are lesions identified in the first couple of weeks.
  • Haematomas and urinomas are painful, unlike seromas and lymphoceles.
  • Hydronephrosis is associated with lymphoceles and urinomas.
44
Q

What are potential vascular complications of the renal allograft?

A

RAS
Renal artery thrombosis
Renal vein thrombosis
AVM

45
Q

Criteria for RAS in the renal allograft?

A

The criteria used to be suspicious of a RAS is > 200cm/s. This figure varies in the literature.
The site of anastomosis is most important to examine.
should be suspected in cases of severe hypertension refractory to medical therapy
1. Color aliasing at the stenotic segment
2. Distal turbulent flow
3. Peak systolic velocity > 250 cm/sec
4. Velocity gradient between the renal artery and external iliac artery greater than 1.8:1

46
Q

What does renal artery thrombosis of the allograft indicate?

A
  • It places the kidney at risk of overall demise.
  • It is often a complication of rejection.
  • Rejection must be suspected when there is an identified occlusion of the renal artery
47
Q

What is post thrombotic syndrome?

A

• The resolution of clot and associated vein wall remodelling resulting in some severe consequences in the longer term.
• Incomplete resolution of the clot or inadequate revascularisation will promote the formation of collateral veins to bypass the obstructed venous segment. (varicose veins)
- OR damages the walls causing inffufficiency
- OR both
• where the alternate collateral pathways cannot drain the limb effectively, venous pressure will increase below the level of the obstruction.

48
Q

What are some complications of post thrombotic syndrome?

A
  • This increase in venous pressure over time can result in chronic limb swelling and skin changes including ulceration.
  • In severe cases of obstruction the raised venous pressure will impair capillary flow and may even reduce arteriolar inflow, causing ischemia and venous gangrene.
49
Q

What is Phlegmasia Alba Dolens?

A

describes the patient with swollen and white leg because of early compromise of arterial flow secondary to extensive DVT. This condition is also known as “milk leg,”

50
Q

How does phlegmasia alba dolens present?

A
  • presents as a triad of edema, pain, and white blanching skin without cyanosis.
  • As the venous thrombosis progresses, it develops into phlegmasia cerulea dolens, which is characterized by edema, worsening pain, and cyanosis from ischemia.
51
Q

What are the common causes of phlegmasia alba dolens?

A
  • In cases of pregnancy most often seen during the third trimester, resulting from a compression of the left common iliac vein against the pelvic rim by the enlarged uterus.
  • Today, this disease is most commonly (40% of the time) related to some form of underlying malignancy
52
Q

At what stage does phlegmasia alba dolens become phlegmasia cerulea dolens?

A

• begins with a deep vein thrombosis that progresses to total occlusion of the deep venous system.
• It is at this stage that it is called phlegmasia alba dolens.
The next step in the disease progression is occlusion of the superficial venous system, thereby preventing all venous outflow from the extremity. At this stage it is called phlegmasia cerulea dolens.

53
Q

What are the risk factors for phlegmasia cerulea dolens?

A
  • malignancy
  • prothrombotic state
  • inferior vena cava filter
  • trauma
  • venous stasis
54
Q

What is the clinical presentation of phlegmasia cerulea dolens?

A

It is characterised by a clinical triad of acute limb swelling, cyanosis and severe acute pain.

55
Q

What are the complications of phlegmasia cerulea dolens?

A

• significant risk of massive pulmonary embolism, even with anticoagulation
• 40-60% develop gangrene of the periphery
o due to increased compartmental pressures from severe venous congestion and oedema
• 20-50% mortality
• amputation rate as high as 25% in survivors

56
Q

How are pelvic veins and varicose veins of the leg sometimes related?

A
  • The presence of vulval or peri-vulval varices is frequently associated with pelvic congestion syndrome and can be associated with incompetence of the left and right ovarian veins.
  • In these cases the ovarian veins reflux through the veins of the broad ligament to the vulval tributaries and communicate with recurrent or primary varicose veins in the leg.
57
Q

How is the patient set up to assess ovarian vein incompetence?

A

• This is a procedure that must be done with the patient at > 60 degrees to the supine position

58
Q

Which veins are assessed in an ovarian vein incompetence study?

A
  • Para-ovarian/uterine veins
  • Right and left ovarian veins
  • Left renal vein
  • Right and left internal iliac veins
59
Q

What ultrasound measurements are made in an ovarian vein incompetence study?

A 
Measurements: B-mode
•	Para-uterine veins: supine and > 60 degrees
•	Left ovarian vein: superior (AP diam)
•	Right ovarian vein: superior (AP diam)
Measurements: Spectral
•	Left ovarian vein
•	Right ovarian vein
•	Right internal iliac spectral trace
•	Left internal iliac spectral trace
60
Q

How do patients with ovarian vein incompetence often present?

A

• Often, these patients present to the vein clinic with recurrent varicose veins, because the standard procedures have failed and the pelvic origin was not recognised.

61
Q

How is diagnosis established in relating recurrent varicose vein to pelvic vein incompetence?

A

• To establish diagnosis, the communication from the atypical varicose veins in the legs to the ovarian veins must be shown and incompetence of one or both ovarian veins must be demonstrated

62
Q

What are the two most common pathways between the ovarian vein and leg veins?

A
  1. Postero-medially from the perineum into the posterior branch of the LSV
  2. Via the Ext pudendal V into the SFJ.
63
Q

What size ovarian vein indicates reflux?

A

A measurement of 1.0cm is considered conclusive of LOV reflux

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