Module 3 - Chest

Question 1

On stress echo/MIBI, what are the areas supplied by the

• RCA
• LAD
• circumflex

Answer 1

RCA: inferior and inferolateral
LAD: anterior/anteroseptal
Circumflex: lateral and inferolateral

Question 2

What are some differentials for delayed enhancement on cardiac MRI?

Answer 2

INFARCTION

fibrosis
inflammation
amyloid
sarcoid
tumour

Question 3

Indications for cardiac MRI (3)

Answer 3

Assess patients suspected for CAD and intermedium likelihood of disease
Assess patients with known CAD for revascularisation
Assess patients with inconclusive results from other non invasive testing

Question 4

Indications for CTCA (7)

Answer 4

○ Intermediate pre-test probability: ECG uninterpretable, unable to exercise, acute symptoms
○ Equivocal nuclear study
○ Congenital heart disease/masses
○ New heart failure
○ Poor echo results
○ Redo bypass surgery
○ Aorta/pulmonary artery evaluation

Question 5

In cardiac angiography, what is the FFR and what is its relevance to therapy?

Answer 5

Fractional flow reserve
FFR: extent to which maximal flow is limited
○ Ratio between distal coronary pressure to aortic pressure measured under conditions of maximal hyperaemia
○ Guides revascularisation, if >8, leave it

Question 6

Appearance of ACS on cardiac MRI

Answer 6

• oedema and late enhancement extending from subendocardium to endocardium
• transmural infarction: a small rim, T2 weighted sequences detect oedema
• late enhancement delineates infarcted myocardium

Question 7

What are the indications for lower limb angiographic intervention? (3)

Answer 7

acute limb ischaemia
claudication (<200m)
critical limb ischaemia

Question 8

Contraindications for lower limb angiographic intervention (6)

Answer 8

• Uncorrectable coagulopathy
  
  • Inability to lie supine
  • Severe renal impairment: not yet dialysing
  • Anaphylaxis to contrast: can use alternatives like CO2
  • Extensive pattern of disease
    
    • Pseudoaneurysm, haematoma, infection at access site

Question 9

Describe the de-bakey and stanford classification of aortic dissections

Answer 9

DE BAKEY

• 1: root all the way down
• 2: root to branches
• 3a: subclavian to suprarenal
• 3b: sublclavian past renals

STANFORD
A: involving root
B: not involving root

Question 10

3 subsets of acute aortic syndrome

Answer 10

Dissection: true lumen smaller, false lumen larger
Penetrating ulcer:
Intramural haematoma: crescentic hyperdensity

Question 11

Measurements to classify for aortic aneurysm

• ascending
• thoracic descending
• abdominal

Answer 11

Thoracic Ascending >5cm
Descending >4cm
Abdominal > 3cm

Question 12

Classification of endoleaks

Answer 12

Type 1: leak around graft attachment zone
Type 2: retrograde from aortic branch vessel
Type 3: leakage through graft defects
Type 4: graft wall porosity
Type 5: expansion of sac without demonstrable leak

Question 13

Signs of impending AAA rupture (4)

Answer 13

• Increase in size
• Thrombus to lumen ratio: thrombus is protective, less thrombus increases flow and increases risk of rupture
• Hyperdense crescent size: aorta surrounded by thrombus, hyperdense crescent sign is blood actively bleeding into thrombus (red arrow)
• Contained rupture: aorta drapes over vertebral body

Question 14

What is the imaging characteristic of RV overload on CTPA that confers poor prognosis with PE?

Answer 14

RV : LV diameter >0.9

Question 15

What is the imaging characteristic of pulmonary hypertension on CT Chest?

Answer 15

at level of bifurcation of pulmonary trunk

pulmonary artery trunk > than AA diameter

Question 16

What is the pathophysiology of intramural haematoma?

Answer 16

haemorrhage within aortic media

• spontaneous haemorrhage from vasa vasorum
• penetrating atherosclerotic ulcer