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ABIM update2018-2019 > PAD vasc boards ACC-SAP and Cath-SAP > Flashcards

PAD vasc boards ACC-SAP and Cath-SAP Flashcards

1
Q

atypical claudication sx

A

heaviness or weakness with stairs/ ambulation (this is seen in ~30%)

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2
Q

definition of intermittent claudication (4 parts)

A

discomfort cramping or aching in calves, thighs buttox that

  • comes on with exertion
  • improves with rest
  • reproducible
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3
Q

ddx (4) of acute onset leg pain

A
  1. athero/thromboemboli (AF,AAA)
  2. plaque ruputure
  3. dissection
  4. other embolic conditions –> infectious, metastatic
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4
Q

hx signaling location of PAD lesion

A

isolated calf? –> SFA

Buttox and calf –> aorto iliac

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5
Q

How do ABI

A

higher DP or PT over higher arm right or left

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6
Q

when do TBI

A

abi > 1.4

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7
Q

when do exercise

A

0.9 to 1.4 with sx’s

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8
Q

what direction is arterial flow shown in ultrasound

A

R to L (higher to lower)

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9
Q

abn u/s findings the basics (4) and examples

A
  1. easiest increased systolic velocity (ie > 125 cm/s)
  2. increased end diastolic velocity (ie > 40 in ICA) off baseline
  3. Aliasing
  4. smaller diameter
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10
Q

65% stenosis in the CIa which is a class 1 indication –> asx

A

statin

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11
Q

PAD recommendations for antiplt rx guildlines (give level of recommendations I, IIa, IIb)

A

1a. ASA alone or plavix alone class Ia in symptomatic pts with PAD (monotherapy)
IIa - asx patients with PAD antiplt (ASA or plavix is reasonable) < 0.9)
IIb. asx with b/l abi 0.91-0.99 uncertain benefit ot antiplatelet

statins also Ia

Note riva 2.5 bid + asa will be IIa soon likely! given compass pad

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12
Q

data for Ia recommendation for statins

A

heart protection study in lancet 2002 24% RR reduciton < 0.00001 for patients with mi, chd, pad, stroke or dm (note DM data was extremely powerful)

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13
Q

what was the heart protection study.

A

simvastatin in patients with some form of vascular dz (MI, HF, CVD, DM) and showed a 24% relative risk reduction

it was in lancet in 2002.

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14
Q

NOACs or coumadin in PAD?

A

III? what about compass? –> now showing benefit. eickelboom JW

Compass PAD –> riva 2.5 bid + asa 81with HR of 0.72 p0.005. this is going to change everything. patients with pad will be on riva +asa as a class I however there is a price of excess bleeding. This will change how we manage PAD (compass PAD lancet 2018)

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15
Q

compass pad

A

asa + riva 2.5 in secondary prevention of PAD with HR of 0.72 and p of 0.0005 vs asa alone.

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16
Q

what about rx to reduce claudicatoin

A 
cilostazole (cant use with CHF) class I. 
pentofxifyline is class III
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17
Q

moa of cilosazole

grade of recommmendation

warning

who would you use it in?

A

phospdiaesterase III inhibitor

class I

cant use in CHF.

no one.

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18
Q

class I recs for sx pad (claudication)

A 
statin
asa or clopidogrel (riva may be coming)
cilostazole although we dont use it
structured exercise (supervised over unsupervized when availibe class Ia vs. IIa)
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19
Q

when is an endovascular intervention Ia?
IIa?
IIb?

A

Ia? lifestyle limiting aorto-iliac claudication
IIa? fempop
infrapop

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20
Q

class III recommendatio regarding endovascular intervention in claudicaiton

A

class III - endovascular procedures should not be performed in patients with pad soley to prevent progression to CLI

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21
Q

grade this statement “endovascualr procedures should not be performed in patients with PAD soley to prevent progression to CLI

A

class III harm.

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22
Q

surgery for claudication when class I, IIa, III (2)

A

I vein over prostethic dacron grafting ehn feasible
IIa. surgical procedures are reasonable as revasc option for patients with lifestyly limiting claudication with inadequate response to GDMT and technical factors suggesting advantages over endovascular procedures.
III. harm femoral tibial a. bypass with prosthetic grafts should NOT BE USED FOR CLUAIDICATION
III surgical procedures for claudication shouldbt be performed to prevent progressoin to CLI

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23
Q

5 year patecy for aortoilica or aortofemoral bypasses

A

90%

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24
Q

CLI endovascular rx recs if have nonhealing wounds or gangrene

what about CLI 2/2 rutherford IV (rest pain)

angiosome directed endovascualr rx in patients with CLI and nonhealing wounds/ gangrene

A

Class I,

IIa

IIb -

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25
Q

medical therpay with heparin with ALI

A

class I for acute limb ischemia.

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26
Q

ALI cathereter based thrombolysis

A

Ia! catheter directed throbmolysis and limb salvage.

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27
Q

if fempop aneursysms have a 20% incidence of also having this

A

20%

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28
Q

surgery is recommended for pop aneursysms > ___ cm ?

A

2 cm

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29
Q

5 way ddx of upper ext PAD

A
  1. atherosclerosis duh.
    2 vasculitis - takayasu’s young and gca old with pmr
    3 compression syndroms - arterial or venous, thoracic outlet
    4 embolic
    5 vasc malformaitons
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30
Q

for each of the follwing conditoins name the arterial/venous beds that are possibly involved

  1. GCA
  2. TA
  3. PAN
  4. KD
  5. BD
A
  1. GCA - thoracic aorta, abd aorta, carotids, UEs,
  2. TAs - throacic, abdominal, pa, carotid, ue
  3. PAN Mesenteric, renals
  4. KD - cors
  5. BD -Upper ext LE ext
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31
Q

for each vascular bed distribution name thevasculitic dz
1. Upper and LE only
2. pa, carotids, thoracic ao, abd, aor, upper ext
3. mesenteric and renal a
4. carotids thoracic ao, abd ao, UEs
.5 coronaries

A
  1. Bergers
  2. TA (takayasu)
  3. PAN
  4. GCA or TA (young TA old GCA) similar arteries except TA can involve pa as well.
  5. Kawaskai
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32
Q

bergers dz men or woment

A

men&raquo_space;» women

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33
Q

bergers triad

A

raynauds, cluadication superfical thromboplebitis

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34
Q

claudication, raynauds, superfical thrombophlebitis

A

buergers dz

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35
Q

bergers upper vs lower ext

biggest risk factor

angiogram two findings

A

classically upper ( more common)

Heavy heavy smoking 2-3 ppd x 10 years of morec

spasm in distal ext (usual hand -> fing lost of flow and spasm with “cork screw collaterals”

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36
Q

buergers aka

A

thromboangitis obliterans

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37
Q

thromboangitis obliterans

A

buegers

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38
Q

angiogram of hand with corkscrew collaterals

A

“buergers”

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39
Q

when consider renal a dz? 5 times for boards

A
  1. flash
  2. early (< 30) or late accellerated htn (> 55 yo)
  3. resistant htn
  4. kiney size discrepancy
  5. azotemia with ace
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40
Q

kidney size discrepancy c/w ras

A

1.5 cm

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41
Q

what velocities in renal a are consistent with RAS

A

> 200 cm/s systolic
150 cm /s
post stenotic turbulent flow

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42
Q 
class I rec for stenting with RAS?
IIa?
A 
class I flash edema
hemodynamic signficant RAS with malignant and resistant htn or htn with unexplained small kiney, or cKD with bilateral dz /affecting solitary kindey, RAS and stable anginga.
43
Q

abd pain acute onset out of proportion to exam

A

acute mesenteric ischemia. mortality is >50% and 30 % in venous thrombosis,

44
Q

chronic mesentic ischemia

A

chronic post prandial d/c and wieght loss

note need 2/3 mesentic vessels and treatment is revasc.

45
Q

def TIA

TIA over 3 months in TIA

A

< 24 hrs usually < 15 min WITHOUT EVIDICNE OF STROKE ON DWI MRI!

25% adverse vents and 10% stroke

46
Q

time windown for acute stroke tpa

thrombectomy comined with thrombolystic

A

4.5 hrs.

ranikin scale improved for TPA+ mech thrombectomy SAVR JL NEJM 2015usual mca or ACA

now 5 studies (halperin jacc 2016)

47
Q

AF is the cause of __% of cryptogenic stroke

A

15%

48
Q

R to L on Us

A

caudal to cranial direction

49
Q

stenosis estimates based on velocity !!

A

200 cm/sec -50%
250 cm/sec 70%
300 cm/ sec 80%
400 cm/sec 90%

50
Q

250 cm/sec on carotid us

A

~70% stenosis

51
Q

antithrombotic rx in carotid dz

A 
obstructive 
class I-asa alone or clopidogrel alone or asa  
class I +diparamidole 81 +200

BUT (2013 weng in china, dapt is better after minor stroke) ? so many centers do dapt for 21 days. (not us)

lacunar strokes no role for dapt and risk is hemorrhage. I feel like we just do asa here

52
Q

TIA, and carotid dz is found… how quickly do you need to decide to go aheah

A

within 2 weeks IIa

53
Q

what is current recommendations for carotid revsac - havent been updated since the 90s

A
  1. 50% on angiogram with stroke sx or 70% on dopplar or CT CEA as long as anticipated risk of perioperative stork or mort is < 6%
54
Q

CREST stupid conclusion from Brott NEJM

A

older pts better CEA 70-75 (well thats fucking everyone man)

55
Q

one of best current roles for stenting

A

CAD needing bypass, stent then send for surgery

56
Q

rutherford and fontaine classifications

A 
fontaine I asx
IIa mild
IIb mod-severe
III ischemic res p[ain
IV rest pain
rutherford
0 asx
1 mild
2 mod 
3 severe
4 ischemic 
5 minor tissue loss
6 gangrene
57
Q

Where does VTE rank in terms of CV death

A

3rd
CAD
CHF
VTE

58
Q

First step in treatment of any pert case

A

start heparin, can be imitated even before confirmation of dx if clinical suspicion is high

59
Q

Who should get Catheter directed thrombolysis

A
  1. intermediate risk PE with risk for clinical deterioration and without an abs ci to thrombolysis
  2. high risk PE
60
Q

when does the PERT consensus recommend Surgical embolectomy

A
  1. high risk PE with failure of Systemic or Catheter directed lysis.
  2. mainly 2/2 RV thrombus in transit or thrombus in transit in a pfo
61
Q

When to consider ECMO

A

patients with clinical deterioration with significant PE and refractory shock

62
Q

PERT team 2 times of IVC filter

A
  1. cannot systemically anticoagulant
  2. pre CTEPH or Surgerical embolectomy
  3. large free floating proximal DVT is seen (although one could argue to do angiovac from above here….
63
Q

PERT follow up

A

w/in 2 weeks post pe

64
Q

PERT pager goes off major things want to assess

A
  1. hx, pe, labs, imaging BLEEDING RISK!!!!
65
Q

5 abs and 5 relative CI to thrombolysis

A 
5 abs:
1. Active bleeding
2. Any Hx of ICH
3. Stroke within 3 mo
4. suspected ao dissection
5 (3). Recent brain or spin surgery, recent head trauma, or active intracranial neoplasm, Vasc malformation, aneurysm or other structuralbrain dz

Relative CI -5

  1. age >75
  2. Wt < 60 kg
  3. known bleeding do
  4. INR > 1.7
  5. BP > 180 /DBP >110
  6. recent bleeding (non ICH within a month),
  7. current or recent pregnancy (w/in a week)
  8. remote ischemic stroke
66
Q

Give pert consensus def of high risk, intermediate risk and low risk

A

High risk- SBP < 90 or a drop in SBP of 40 from baseline , or pressors or hemodynamic support

Intermediate risk PESI III/VIor RV dilation or dysfunction. by cta and echo, + tn, elevated NTp probrnp

intermediate high risk - RV dysfunction + tn pos,

intermediate low risk (either but not both RV dysfunction and tn elevation)

67
Q

3 biomarkers should check with every PE

A
  1. Tn
  2. NT probnping
  3. lactate

-if all 3 pos there is an almost a 20% chance of mortality or hemodynamic collapse with medical rx.

68
Q

When do we do catheter directed thrombolysis?

A

High risk or intermediate high risk (PESI III./IV, sPESI >=1, biomarker + esp if lactate too, and signs of rv strain).

69
Q

VTE epi key points

A

1 million per year. 100,000 deaths. <10% have a genetic risk

70
Q

acquired risk factors for VTE (6)

A
  1. cancer
  2. age related VTE
  3. obesity
  4. varicose veins
  5. hormone rx.
  6. preg
71
Q

wells score helpful use?

A

score greater than 4 start treatment prior to scan if bleeding risk is acceptable.

72
Q

unprovoked VTE how long AC

A

indefinite with reassessment of bleeding risk.

73
Q

calf DVT

A

pt preference, usually do 2 week follow up scan if still there or progressed then use usual recs

74
Q

PE 2/2 factor V leiden, while on apixiban, what should we do?

A

LMWH chest 2016. If on LMWH increase dose on it. Get heme c/s. (cancer pts).

75
Q

when consider op chemoprophylaixs ?

A

only cancer + additoinal risk factor.

76
Q

simple way to destinguish takayasu vs. giant cell aortitis

A

older in giant cell young in takayasu. Both have fever but takayasu higher? left subclavian is class location for takasysu

77
Q

subclavian stenosis after a “funky febrile illness”

A

Takaysu endartitis (classic)

78
Q

bifid uvula

A

loeys-dietz syndrome, ehlers-danlos

79
Q

name the 4 important aortic genetic dz assoc with aneursyms and tell at least 2 common clinical features and their genetic defect

A
  1. marfans - ectopia lentis, AVMs brain, skeltal features, fibrillin (FBN-1)
  2. Loeys-Dietz bifid uvula, hypertelorism TGF-B
  3. Ehlers-Danlos - tranulscent skin and corea, rupture of a gravid uterus and gi rupture –> Col3A1
  4. Turners - primary aamenorrheam BAV, coarctation, short, webbed neck 45 X karyotype
80
Q

bifid uvula / cleft palate

A

Loeys-Deitz (bad news)

81
Q

clubbed feet

A

marfans

82
Q

FH questions for aortopathy?

A

TAA, Ao dissection, Bicuspid Ao Valve, cerebral aneurysm

83
Q

bicusp ao valve

A

remeber can get aortopathy.

84
Q

When do we operate

A

5.5 cm ascending ao, 6.5 desc before the hinge point. b
asc beyond 6 cm 30% risk of rupture lifetime
desc beyond 7 mc 40% lifetime risk of rupture.

85
Q

when to operate on Asc and desc ao aneursyms

A

5.5 and 6.5 cm or change in > .5 cm in a year.

86
Q

when have a marfan patient look up this?

A

ghent criteria

87
Q

cut point for genetic dz asc ao

A

5.0 marfans (could be even smaller if FH of AoD at a smaller diameter or rapily expanding). If she is preggo and has marphans need 4. (treat familial asc like marfans). Loeys Dietz 4.2, CT 4.5, Ehlers danlos 5 bc they dont survive.

88
Q

FH of ASc Ao key question

A

if family member dissected, what size ao was before it disseected.

89
Q

ao replacement main concern

A

lower ext paresis (csf drainage, LE hypothermia, reimplanation of thoracic branches. )

90
Q

Thoracic Ao how often to image

A

yearly but when approaching 5 go to q 6 mo.

91
Q

Mort with type A

A

20% at 24 hrs, 50% at 1 month.

92
Q

post dissection repair follow up imaginga

A

1, 3 6 12 mo

93
Q

thoracic dissection

A

at site of ligamentamentum atriuosum.

94
Q

2 classifications systemts of Ao dissection

A

type A (asc,) type B desending (stanford)

Type 1 the entire ao
Type II just the top
type III just the descending.

95
Q

crescent moon sign on CT or mri ao

A

inta-mural hematoma.

96
Q

if AAA ruprtures mort rate

A

90%

97
Q

biggest RFs for developing AAA

A

age and smoking

98
Q

chichester screening study what size was operated on

A

6.0 mm (study showed 65 yo man had

99
Q

females with AAA things to know

A

more likely to rupture.

100
Q

who gets AAA screening?

A

smoking and > 65

101
Q

viva study

A

vascular screening or nothing. 3% had a triple A. Men > 65 in denmakr 3.3% with triple A. 0.93 HR and cost reductions

102
Q

endoleaks 4 types

A 
type I leak at marging of a stented cuff
type II retrograde flow through branch vessels excuded from lumen
type III blood leaks through graft matieral
type IV (stupid)
103
Q

abd ao repair threshold for repair

A

men 5.5 and women 5.0 (lower for women)

ABIM update2018-2019 (3 decks)

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