RD CVS formatted Flashcards
- A patient is due for a fistula in his left arm, best place for the vascath is
a. Left internal jugular vein
b. Right internal jugular vein
c. Left subclavian vein
d. Right subclavian vein
e. Left femoral vein
b. Right internal jugular vein
- Subclavian arterial thrombosis (LAS – thoracic outlet syndrome), young painter, pain. Which is not associated.
a. Dissection (Subclavian artery dissection)
b. Aneurysm (Subclavian artery aneurysm)
c. Stenosis (Subclavian artery stenosis)
d. Venous thrombosis (Subclavian vein thrombosis)
e. Arterial mural thrombus (Subclavian artery wall haematoma)
a. Dissection (Subclavian artery dissection)
2. Subclavian arterial thrombosis (LAS – thoracic outlet syndrome), young painter, pain. Which is not associated.
a. Dissection (Subclavian artery dissection)
b. Aneurysm (Subclavian artery aneurysm) T – SCA aneurysm
c. Stenosis (Subclavian artery stenosis) T – narrowing of SCA which is positional (abduction)
d. Venous thrombosis (Subclavian vein thrombosis) T – may be occlusive or non-occlusive
e. Arterial mural thrombus (Subclavian artery wall haematoma) T – mural thrombi
StatDx:
• TO consists of interscalene triangle, costoclavicular space, and retropectoralis minor space (subcoracoid tunnel)
o Compression of neural, arterial, or venous structures crossing these tunnels → TOS
o Narrowing of costoclavicular distance may be most important abnormality in symptomatic patients
• Neuropathic TOS: Symptomatology 2° to brachial plexus compression (most symptomatic patients)
o Up to 98% symptomatic patients have plexus compression; minority 2° to arterial or venous impingement
• Vascular TOS: Compression of subclavian vessels o Repetitive arterial trauma → focal stenosis, aneurysm formation, micro-embolization, tissue loss
o Venous compression → SCV thrombosis
- A 45 yo man with intermittent claudication on walking. Angiography showed 3cm long stenosis of less than 50% in the mid SFA. What is the most appropriate treatment:
a. Exercise
b. Angioplasty
c. Bypass graft
d. Stent-graft
a. Exercise Based on AHA/ACC guidelines for peripheral arterial disease 2006:
• Incomplete information – depends on impact on life of disease & comorbidities
• Try supervised claudication exercise therapy & pharmacotherapy first, as well as risk factor modificationTASC-II 2007 guidelines:
- Young man in MVA, CT shows smooth lobulated bulge anteromedial aortic arch near isthmus. No mediastinal blood or other injury. Most likely cause of appearances
a. Ductus diverticulum
b. Pseudo-aneurysm
c. Traumatic aneurysm
d. Acute dissection
e. Injury to the mediastinal veins
Ductus
- AV fistula shows stenosis of arterial anastomosis. Best option for long term patency?
a. Bare metal stent
b. Covered stent
c. Self-expanding stent
d. Angioplasty
d. Angioplasty T angioplasty if upper forearm or upper arm; surgery if lower forearm
- Feature of HOCM:
a. Diastolic dysfunction
b. Aortic level stenosis
c. Interatrial septal thickening
d. Normal mitral valve
a. Diastolic dysfunction T abnormal LV stiffness → impaired LV relaxation → poor early diastolic filling
- Feature of HOCM:
a. Diastolic dysfunction T abnormal LV stiffness → impaired LV relaxation → poor early diastolic filling
b. Aortic level stenosis F subaortic stenosis (septal thickening + SAM)
c. Interatrial septal thickening F asymmetric form (most common) has interventricular septal thickening
- In ‘Power Doppler’ the intensity of colour denotes:
a. Angle of insonation
b. Velocity
c. Amplitude
d. Direction of flow.
c. Amplitude
- Back pain in a 50yo male most likely:
e. Aortic dissection
f. Penetrating atherosclerotic ulcer
g. Aortic aneurysm
e. Aortic dissection peak age 60 years, range 13-87 years (Dahnert)
- Back pain in a 50yo male most likely:
e. Aortic dissection peak age 60 years, range 13-87 years (Dahnert)
f. Penetrating atherosclerotic ulcer elderly with HTN/lipids/atheroma (Dahnert)
g. Aortic aneurysm AAA usually age > 60 years M»F (Dahnert)
colour doppler, coding depends on …. what??
Colour displayed within BVs on colour Doppler function of: • Flow velocity • Doppler angle • Presence of aliasing • Colour map utilized • Phase of cardiac cycle
guy with US with thick walled aneurysm with increased ESR. likely??
a. inflammatory aneurysm
b. mycotic aneurysm
inflammatory A = idiopathic inflammatory aortic aneurysm = dense perianeurysmal fibrosis & a thickened aortic wall; accounts for 5-25% of all AAAs; CECT reveals delayed enhancement of soft tissue component; often fusiform
B = mycotic aneurysm = infected aortic aneurysm = uncommon (0.06-2.6% of all aneurysms); usually saccular rather than fusiform, with perianeurysmal gas, stranding & fluid +/- vertebral body & psoas involvement
which is not associated with azygous continuation of IVC
a. dextrocardia
b. polysplenia
c. left sided SVC
d. gonadal vein into renal vein
e. hepatic vein into RA
E = F hepatic veins drain directly into RA
**LJS - hepatic veins drain into post-hepatic IVC that is still present - into Ra
Young woman with hypertension and narrowing of renal ostia. Most likely
a. FMD
b. Wegners
c. PAN
C = T/F = aneurysms at bifurcation points (up to 1cm); renal infarcts; renal/retroperitoneal haemorrhage; however is listed in StatDx as cause of RAS- Maybe real answer was neurofibromatosis (aneurysm; narrowing of proximal RA) or Takayasu
Causes of RAS
• Atherosclerosis (most common cause, 70%; renal artery ostium or proximal 2cm; elderly)
• FMD (25%; mid-distal RA or hilar branches, may be multifocal; young adults; R>L; bilateral in 2/3)
• Congenital/inheritedo Congenital stenosis (childhood)o Neurofibromatosis (children; proximal renal artery)o Ehlers-Danlos or Williams syndrome
• Arteritiso Takayasuo PANo Buerger disease
• Other
o Abdominal aortic coarctation
o Thromboembolico Radiation therapy
o Aortic dissectiono Phaeochromocytoma
o Infrarenal AAA
o Retroperitoneal fibrosis
- Coronary artery dominance defined by the coronary artery that supplies:
a. The obtuse artery
b. The posterior interventricular artery
c. AV nodal artery
d. The conal artery
b. The posterior interventricular artery T
• Refers to the coronary artery that supplies the diaphragmatic surface of LV & the posterior diaphragmatic portion of the interventricular septum – i.e. the dominant artery gives the posterior interventricular (descending) branch (PDA) & the posterolateral branch (PLB)
• Right dominance denotes RCA origin of flow (80-85%)
• Left dominance denotes LCA origin of flow (15-20%) - in this case the PDA & PLB arise from the LCx artery
• Mixed dominance refers to an intermediate pattern, e.g. PDA comes from RCA & PLB comes from LCx; branches of both arteries run in or near the posterior interventricular groove
• Notes:o The LCA almost always supplies a greater volume of tissueo The non-dominant system is usually smaller in calibre c.f. the dominant system
- 50 female presents with headache and hypertension. Angiography reveals multiple renal aneurysms. Which is MOST likely?
e. Aortic dissection
f. Fibromuscular dysplasia
g. Polyarteritis nodosa
h. Takayasu’s arteritis
i. Wegener’s granulomatosis
c. Polyarteritis nodosa T kidneys involved in 70-80% with multiple peripheral small aneurysms; CNS involved in 10% (microaneurysms; most common systemic vasculitis to affect the CNS)
2. 50 female presents with headache and hypertension. Angiography reveals multiple renal aneurysms. Which is MOST likely?
a. Aortic dissection F no renal aneurysms
b. Fibromuscular dysplasia F can cause hypertension, can also involve craniocervical arteries, but aneuryms usually post-stenotic, although multiple aneurysms can be seen
c. Polyarteritis nodosa T kidneys involved in 70-80% with multiple peripheral small aneurysms; CNS involved in 10% (microaneurysms; most common systemic vasculitis to affect the CNS)
d. Takayasu’s arteritis predilection for aorta esp. AA & its branches (esp. SCA); RAS may occur; can involve proximal carotid arteries; may cause aneurysms
e. Wegener’s granulomatosis F? typically causes GN, but can cause microaneurysms by its small vessel vasculitis; may cause intracerebral & meningeal granulomas or vasculitis
- CXR shows upward bowing of cardiac apex, rib notching and retrosternal mass, most likely? (+ VIC – young male with HTN, indentation of left lateral aortic border)
t. Coarctation of aorta
u. TAPVR
v. Aortic stenosis
w. Dissection
a. Coarctation of aorta T = get rounded elevated apex; rib notching; prominent ascending aorta
23. Old dude with known coronary artery disease. Ovoid mass with areas of calcification adjacent to left sphenoid sinus. Most likely \:i) Fusiform basilar artery aneurysm ii) Fusiform ICA aneurysm iii) CoW berry aneurysm iv) Micotic MCA aneurysm
ii) Fusiform ICA aneurysm T on MR look for pulsation artifact!
- Middle aged woman. End stage renal failure. AV fistula thrombosed and needs access. Decompensating badly with encephalopathy etc. Multiple previous Subclavian, IJ and femoral vascaths/lines. Treating team failed insertion IJ line on ward. Best option:
i) Peritoneal dialysis
ii) Doppler venous mapping
iii) Post con DSA venous mapping
iv) Post con CT venous mapping
v) Post con MR venous mapping
vi) Doppler venous mapping T with aim of doing US/fluoro guided central line insertionv
ii) Post con DSA venous mapping T if planning for new AVFIf in ESRF, further contrast would not be good (e.g. conventional venography) – can use Gadolinium for DSA (although this is against the RANZCR contrast guidelines!). No good evidence as yet for MRA.
Not sure what question means – if put in new AVF, would need to wait until matures anyway. Needs temporary central vein access & would assess with ultrasound in angio suite.If absolutely no access, could plan for peritoneal dialysis.Vascular access society guidelines for pre-op evaluation:
- 30 female left neck pain, 10 hrs of diplopia and dysarthria. Normal non contast CT head and neck. The next investigation should be:
a. Lumbar puncture
b. Contrast enhanced CT head
c. DSA
d. Carotid US
e. MRI brain
e. MRI brain T if with T1 fat sat neck and MRA neck/brain, although according to RG 08 has quite poor sens/spec for vertebral artery dissection. MRI brain to exclude other causes other than dissection.
4. 30 female left neck pain, 10 hrs of diplopia and dysarthria. Normal non contast CT head and neck. The next investigation should be:
a. Lumbar puncture F
b. Contrast enhanced CT head F would be T if CTA head/neck
c. DSA ?F invasive, but “gold standard”
d. Carotid US F
e. MRI brain T if with T1 fat sat neck and MRA neck/brain, although according to RG 08 has quite poor sens/spec for vertebral artery dissection. MRI brain to exclude other causes other than dissection.
50 yo mande, long hx of worsening claudication. 5cm long segment SFA occlusion. Best tx.
a. angioplasty
b. stent graft
c. bypass
d. exercise programme
e. cryotherapy
Still considered limited disease as < 10cm length. Infrainguinal. Best choice is endovascular revascularisation.RCT shows significantly higher patency rates of stenting over angioplasty alone for femoropopliteal artery lesions, however most reserve stent placement for acute failure of PTA. Therefore best answer probably A, angioplasty
.From TASC II 2007 guidelines (JVascSurg 2007)
• Acute limb ischaemia (ALI): Infrainguinal causes of ALI, such as embolism or thrombosis, are often treated with endovascular methods. Initial therapy with catheter-based thrombolysis should be considered in cases of acute thrombosis due to vulnerable atherosclerotic lesions or late bypass graft failures. When thrombolysis reveals underlying localized arterial disease, catheter-based revascularization becomes an attractive option. Stenoses and occlusions are rarely the sole cause of ALI or even severe chronic symptoms but these commonly lead to superimposed thrombosis and, therefore, should be treated to avoid recurrent thrombosis.
- Claudication: The initial approach to the treatment of limb symptoms should focus on structured exercise and, in selected patients, pharmacotherapy to treat the exercise limitation of claudication (risk factor modification and antiplatelet therapies are indicated to decrease the risk of cardiovascular events and improve survival). Failure to respond to exercise and/or drug therapy would lead to the next level of decision making, which is to consider limb revascularization. However, in patients in whom a proximal lesion is suspected (findings of buttocks claudication, reduced or absent femoral pulse) the patient could be considered for revascularization without initially undergoing extensive medical therapy.
- Revascularisation: Endovascular treatment of infrainguinal disease in patients with intermittent claudication is an established treatment modality. The low morbidity and mortality of endovascular techniques such as PTA makes it to the preferred choice of treatment in limited disease such as stenoses/occlusions up to 10 cm in length. For diffuse aortoiliac (suprainguinal) disease, bypass has better long-term patency, however the risks of surgery are greater and patient factors may lead towards PTA which has a 90% success rate
Left SVC drains into
coronary sinus orleft atrium
- Churg Strauss syndrome extrathoracic manifestations include?
a. Renal artery stenosis
b. Cerebral hemorrhage
c. Osteosarcoma
d. Hepatosplenomegaly
e. Mesenteric ischaemia
e. Mesenteric ischaemia T mesenteric vasculitisCSS = triad of asthma, hypereosinophilia & systemic small vessel granulomatous necrotizing vasculitis. Major involvement is of the heart, lungs & skin. (Dahnert – variant of PAN in asthmatic patients). Criteria for Dx (4 of 6) (1) asthma (wheezing, expiratory rhonchi), (2) eosinophilia of more than 10% in peripheral blood, (3) paranasal sinusitis, (4) pulmonary infiltrates (may be transient), (5) histological proof of vasculitis with extravascular eosinophils, and (6) mononeuritis multiplex or polyneuropathy.
- Strong association with allergic rhinitis, asthma, eosinophilia
- Vessels in lung, heart, spleen, peripheral nerves & skin involved by intravascular & extravascular granulomas, with infiltration of vessels & perivascular tissues by eosinophils
- Severe renal disease infrequent
- Coronary arteritis and myocarditis usual cause of morbidity and mortality
- Histologically may be identical to PAN and microscopic angiitis
- Both arteries and veins involved
- p-ANCA present in 40-70%
- Gastrointestinal symptoms (31%) - Symptoms related to GI vasculitis, eosinophilic gastritis, colitis (This includes abdominal pain [59%], diarrhea [33%], and GI bleeding [18%].)
- Which is NOT a recognised cause of Budd-Chiari syndrome
a. Chronic pancreatitis
b. Bone marrow transplantation
c. Chemotherapy
d. Systemic lupus erythematosus
e. Oral contraceptives
a. Chronic pancreatitis F (but does cause PV thrombosis!)
- Regarding tunneled haemodialysis catheters, which is LEAST correct?
a. Femoral catheters can remain in situ for several months
b. Tunneled catheters have a higher rate of infection than non-tunneled catheters
c. Internal jugular vein puncture is preferred to subclavian vein puncture
d. Fibrin sheath is best treated by thrombolysis
e. Optimal tip position is in the upper SVC.
a, c and e…
- Regarding tunneled haemodialysis catheters, which is LEAST correct? SK/Kandarpa p469
a. Femoral catheters can remain in situ for several months F (med comp femoral catheter is intended for use for < 30 days (product info)) Kandarpa – femoral catheters have higher incidence of infection, limits mobility & risk of iliac vein stenosis
b. Tunneled catheters have a higher rate of infection than non-tunneled catheters F non-tunnelled catheters have lower rates of blood flow, a higher incidence of infection & shortened survival c.f. tunneled catheters
c. Internal jugular vein puncture is preferred to subclavian vein puncture T preference is R IJV > L IJV or R EJV – avoid use of subclavian veins (if for later AVF) & avoid insertion on side of maturing AVF
d. Fibrin sheath is best treated by thrombolysis T
e. Optimal tip position is in the upper SVC. (F atriocaval junction or into the RA to ensure optimum flow); red lumen medial & distal (venous/blue) end hole lateral
- The most correct statement about colour Doppler US is?
a. Doppler colour coding depends on the amplitude of flow
b. Doppler colour coding depends on the vessel type
c. Doppler colour coding depends on the velocity of blood flow
d. Doppler colour coding depends on the angle of isonisation
c. Doppler colour coding depends on the velocity of blood flow T brighter colours (or different colour shades) are used to display mean velocities
d. Doppler colour coding depends on the angle of isonisation T in colour Doppler the format of transducer determines direction of Doppler beam. The Doppler angle may change with vessel orientation & produce colour changes related only to changes in the Doppler angle & not to changes in blood flow.Colour displayed within BVs on colour Doppler function of (Brant, US core curriculum) \:• Flow velocity • Doppler angle • Presence of aliasing • Colour map utilized • Phase of cardiac cycle
- Re: lower limb angiography, which is LEAST correct?
a. Peroneal artery terminates above ankle
b. 5Fr catheter adequate for diagnostic studies
c. Adductor canal is in the lower thigh
d. The profunda femoris origin is best seen with leg in external rotation
d. The profunda femoris origin is best seen with leg in external rotation F this will bring the postero lat origin behind the SFA (can’t find a reference)
- Left Atrial enlargement, which is false:
- VSD
- endocardial fibroelastosis
- HOCM
- TOF.
- Atrial myxoma.
4.TOF. F – have small left heart chambers due to ↓ blood returning from lungs (RVOT)
- Left Atrial enlargement which is false (JS)
- VSD - T - Increased pulmonary venous return leads to volume overload of the LA and LV, leading to dilation.
- Endocardial fibroelastosis T – focal or diffuse fibroelastic endocardial thickening of LV +/- LA from deposition of collagen and elastic tissue, causes CHF during first 6mths of life and if diffuse is often fatal by 2 years of age (Dahnert). Get enlarged LA & LV, pulmonary venous congestion. Accompanied by aortic valve obstruction & other CHD in one-third (Robbins). A cause of restrictive cardiomyopathy.
* *LJS opinion: atria dilated due to pressure overload b/c can’t fill ventricles - HOCM. T - LV hypertrophy leads to rapid blood flow through the outflow tract and anterior displacement of the anterior leaflet of the MV causing mitral regurgitation and subsequent LA enlargment (Dahnert)
- TOF. F – have small left heart chambers due to ↓ blood returning from lungs (RVOT)
- Atrial myxoma. T - typically causes enlargement of the LA without enlargement of the atrial appendage
- In lower limb DVT, which is true:
- Isolated calf vein thrombosis in ambulatory patients has an incidence of PE of <5%.
- Approx 40% of calf vein thrombi propagate superiorly to involve at least the popliteal or femoral veins.
- Clinical diagnosis is accurate in 80%.
- Vein diameter typically increases in chronic thrombosis.
- A phasic change with respiration on Doppler of implies thrombosis.
- Isolated calf vein thrombosis in ambulatory patients has an incidence of PE of <5%. - T - risk factors: surgery (esp. legs/pelvis), severe trauma, prolonged immoblisation, malignancy, pregnancy, meds (OCP), previous DVT… UTD: Distal calf vein thrombosis is felt to be of lesser clinical importance than proximal vein thrombosis and its optimal treatment has yet to be defined. If anticoagulation is not administered for isolated asymptomatic distal venous thrombosis, serial noninvasive studies of the lower extremity should be performed over the next 10 to 14 days to assess for proximal extension of the thrombus, which has a higher incidence of pulmonary embolism.
- In lower limb DVT, which is true: (GC) CME00.08 and 03.42 (mixture)
- Isolated calf vein thrombosis in ambulatory patients has an incidence of PE of <5%. - T - risk factors: surgery (esp. legs/pelvis), severe trauma, prolonged immoblisation, malignancy, pregnancy, meds (OCP), previous DVT… UTD: Distal calf vein thrombosis is felt to be of lesser clinical importance than proximal vein thrombosis and its optimal treatment has yet to be defined. If anticoagulation is not administered for isolated asymptomatic distal venous thrombosis, serial noninvasive studies of the lower extremity should be performed over the next 10 to 14 days to assess for proximal extension of the thrombus, which has a higher incidence of pulmonary embolism.
- Approx 40% of calf vein thrombi propagate superiorly to involve at least the popliteal or femoral veins. - F - up to 20% propagate. Serial evaluation every 3-5 days is therefore important in patients who remain symptomatic with conservative therapy to dx clot propagation and prevent PE. [B&H pg 1052]
- Clinical diagnosis is accurate in 80%. - F - The clinical presentation and physical examination findings are unreliable in making the diagnosis [B&H]. 2/3 of DVT are clinically silent and clinically suspected DVT is accurate in only 26-45% [Dahnert].
- Vein diameter typically increases in chronic thrombosis. - F - chronic clot does not expand the lumen of the vein and appears more echogenic than an acute clot. The walls appear thickened, irregular and echogenic and the vein is incompletely compressible. Collaterals can be seen on colour Doppler. [B&H]
- A phasic change with respiration on Doppler of implies thrombosis. - F - normally there is a cyclic variation in flow velocity with respiration - should decrease in expiration and increase in inspiration. Absence of phasicity (ie. continuous venous signal) is suspicious for proximal obstruction. [Dahnert pg 634]
- Vascular US, T/F:
- In the femoral artery a doubling of the peak systolic velocity in a zone of stenosis (cf. the normal vessel proximal to the stenosis) indicates that the stenosis is about 50%.
- 55% reduction in cross sectional area is equivalent to 70% diameter stenosis
- Power Doppler gives information regarding the direction of flow but is less sensitve to low velocities than is colour Doppler.
- Doppler evaluation of renal artery stenosis may be performed by interrogation of the intrarenal (parenchymal) branches.
- Evaluation of the sapheno-femoral junction for venous incompetence is performed with the patient supine
true 1,4
- Vascular US, T/F: (GC/TW)
- In the femoral artery a doubling of the peak systolic velocity in a zone of stenosis (cf. the normal vessel proximal to the stenosis) indicates that the stenosis is about 50%. - T - A ratio of 2 (ie. a doubling of the PSV) represents a hemodynamically significant stenosis with a greather than 50% lumen narrowing (see below about measurements).
- 55% reduction in cross sectional area is equivalent to 70% diameter stenosis. - F - the new remaining radius % squared (ie 70% = 30% radius or 0.3) multipled by the initial CSA = new CSA. Therefore the reduction is (1-remaining radius squared). See below.
- Power Doppler gives information regarding the direction of flow but is less sensitve to low velocities than is colour Doppler. - F - power doppler is more sensitive at detecting flow, particularly slow flow, but is unable to demonstrate direction or velocity of flow.
- Doppler evaluation of renal artery stenosis may be performed by interrogation of the intrarenal (parenchymal) branches. - T - Two approaches are used to detect RAS with Doppler US: direct visualization of the renal arteries and analysis of intrarenal Doppler waveforms. The segmental renal arteries are evaluated by means of a translumbar approach; the different segments must be scanned systematically to detect a stenosis of a segmental or accessory RA. A dampened appearance (pulsus tardus) of an intrarenal Doppler waveform indicates stenosis. The presence of an early systolic peak can be interpreted as a sign of normality; however, its absence does not necessarily indicate stenosis. [Renovascular HTN, RG 2000]
- Evaluation of the sapheno-femoral junction for venous incompetence is performed with the patient supine. - F - examination of the CFV/SFV is performed in the supine postion with a linear 5-7.5MHz transducer in a slight reverse Trendelenburg position. [B&H pg 1051]
- Renal vein thrombosis, not a risk factor:
- Dehydration
- Membranous GN
- Amyloid
- Scleroderma
- Nephrotic syndrome
- Scleroderma - F - Scleroderma affects the renal arterioles and causes cortical necrosis.
- Renal vein thrombosis, not a risk factor: (TW)
- Dehydration - T - Renal vein thrombosis in infants most commonly due to dehydation/sepsis.
- Membranous GN - T - see ans 5.
- Amyloid - T
- Scleroderma - F - Scleroderma affects the renal arterioles and causes cortical necrosis.
- Nephrotic syndrome - T - In adults, most commonly due to nephrotic syndrome (which in turn is most commonly due to membranous glomerulonephritis
- Atrial myxoma, which is false:
- Low T2
- Assoc with Carney’s complex
- Arises left side of the interatrial septum
- Usually pedunculated
- Low T2
* LW –> are variable in T2 signal, calcific components > low signal; myxomatous components > high signal
- Which is true re cardiac MRI:
- Gradient sequences used for dark blood
- Contrast used for cine
- Short anterior oblique (SAO) view shows aortic valve en face
- Retrospective gating better than prospective for diastolic function
- 50% R-R gating for assessing systolic function (this recall a bit hazy)
- Retrospective gating better than prospective for diastolic function - T - although prospective gating is more common, given the trigger window is typically 10-15% of the R-R window, prospective gating sequences will exclude late diastole. Retrospective gaiting is more computationally intensive, but is also helpful in patients with arrhythmias. In retrospective gating there is no trigger window and the whole cardiac cycle is imaged.
- Which is true re cardiac MRI: (TW)
- Gradient sequences used for dark blood - F - T2* weighted coherent GE sequences used so that blood ro CSF appears bright. GE sequences are flow sensitive, as gradient reversl is not slice selective (as in spine echo). Therefore, a flowing nucleus produces signal after gradient rephasing, regardless of its slice location during excitation. T1WI has moving blood produce a signal void.
- Contrast used for cine - F - most cardiac cine acquisitions are generally acquired with gradient echo sequence with retrospective gating techniques. Since cine is performed with a gradient echo sequence, flowing blood appears bright.
- Short anterior oblique (SAO) view shows aortic valve en face - F - horizontal long-axis plane / 4-chamber view. LVOT view used to look at aortic valve in perpendicular plane.
- Retrospective gating better than prospective for diastolic function - T - although prospective gating is more common, given the trigger window is typically 10-15% of the R-R window, prospective gating sequences will exclude late diastole. Retrospective gaiting is more computationally intensive, but is also helpful in patients with arrhythmias. In retrospective gating there is no trigger window and the whole cardiac cycle is imaged.
- 50% R-R gating for assessing systolic function (this recall a bit hazy) - F - peak fo the R wave is used to trigger each pulse sequence because, electrically, it has the greatest amplitude (prospective gating). Retrospective gating (performed during many cardiac cine acquisitions) acquires image data and times to the cardiac cycle during reconstruction (after the scan acquisition). The trigger window is typically 10-15% of the R-R window. The acquisiton window is the duration of the data aquisition (wiht standard trigger window and no trigger delay, this would be 85-90% of the R-R window). Because of the trigger window, prospectively gating sequences will exclude late diastole.
18.Peripheral haemangiomas in infants, which is false:
- More common in premature infants
- Embolism is the most common treatment
- Increased size after 12 months is atypical
- More common in the head and neck
- Sequester platelets
- Embolism is the most common treatment – F – usually require no treatment. Treatment depends on type and sequelae. Embolisation often used pre-resection
- Peripheral haemangiomas in infants, which is false: (TW)
- More common in premature infants – T – hemangiomas are the most common tumor of childhood occurring in 12% of infants. UTD: the incidence of hemangiomas is increased in preterm infants; the most signficiant risk factor appears to be low birth weight.
- Embolism is the most common treatment – F – usually require no treatment. Treatment depends on type and sequelae. Embolisation often used pre-resection
- Increased size after 12 months is atypical - T – characteristically 2-stage process of growth and regression. At birth lesionas are often small and inconspicuous. Shortly after birth, perior of rapi proliferation that lasts several months, and typically, involution begins at approximately 10 months of age. 50% lesions completely resolved by 5yo. UTD: the spontaneous involution phase typically begins in the latter part of the 1st year
- More common in the head and neck – T – have a predilection for head and neck, although they can occur anywhere in the skin, mucous membranes, or internal organs
- Sequester platelets – T – Kasabach-Merritt syndrome = hemorrhagic diathesis due to platelet sequestration by tumor / disseminated intravascular coagulation; characterised by an associateion of hemangioma or hemangioendothelioma, or angiosarcoma with thrombocytopenia and purpura (secondary to increased systemic fibrinolysis). There is an increased incidence of hemangiomas in females and in premature infants weighing less than 1500 grams Over half of all hemangiomas occur in the cervicofacial region
- Renovascular hypertension, which is false:
- Systolic – diastolic / systolic equals resistive index
- Aortorenal ratio of 2.5 means greater than a 70% stenosis
- Hyperpulsatility means a more distant stenosis
- 0.12 sec acceleration time intrarenal arteries indicates proximal stenosis
2.Aortorenal ratio of 2.5 means greater than a 70% stenosis - F - >3.5 for >60% (Dahnert 6) increased renal arterial resistive index (RI): a cut-off value of 0.7 may be a good approximation in clinical practice (RI difference between kidneys > 0.05 - 0.07 )
increased peak systolic velocity (PSV): some advocate 180cm/s 4increased renal-interlobar ratio (RIR): some advocate values greater than 5 3increased renal/aortic ratio (RAR) i.e. PSVrenal/PSVaorta: usually taken as >3.5, although some advocate >3 4turbulent flow in a post-stenotic areapulsus parvus et tardus waveform (slow-rising) due to stenosisintraparenchymal resitive indices > 0.8intraparenchymal acceleration time > 0.07 s
- Regarding TIPS, which is true:
- Ascites is a contraindication
- Increased velocity by 50cm/sec compared with baseline on a follow up study indicates possible stenosis
- Demonstration of flow reversal (ie retrograde flow) in the intrahepatic portal veins indicates stenosis
- Need to have the same pressures as SVC for best results
- Left common femoral approach is best
2.Increased velocity by 50cm/sec compared with baseline on a follow up study indicates possible stenosis - T – a change of >50cm/s (increase or decrease) relative to the baseline study can indicate stenosis. in addition to looking for a narrowing, elevated maximum and depressed minimum stent velocities are signs of stent stenosis (one system uses 90cm/sec and 190cm/sec as the lower and upper limits, of normal stent velocities). Additional signs of dysfunction are low PV velocity, a temporal increase or decrease in max and min stent velocities on sequential examinations, and reversal of flow in the draining hepatic vein (US requisites).
- Regarding TIPS, which is true: (TW)
- Ascites is a contraindication - F - if it was, there probably wouldn’t be many TIPS procedures done. See below for contraindications.
- Increased velocity by 50cm/sec compared with baseline on a follow up study indicates possible stenosis - T – a change of >50cm/s (increase or decrease) relative to the baseline study can indicate stenosis. in addition to looking for a narrowing, elevated maximum and depressed minimum stent velocities are signs of stent stenosis (one system uses 90cm/sec and 190cm/sec as the lower and upper limits, of normal stent velocities). Additional signs of dysfunction are low PV velocity, a temporal increase or decrease in max and min stent velocities on sequential examinations, and reversal of flow in the draining hepatic vein (US requisites).
- Demonstration of flow reversal (ie retrograde flow) in the intrahepatic portal veins indicates stenosis - F - this could potentially be true if saying ‘reversal of flow from the ‘normal’ post TIPS flow’ which itself is reversed. When first placing the TIPS, the stent decompresses the portal system directly into the low pressure hepatic venous system, portal flow in the right and left portal vein usually reverses after stent placement and is directed into the stent instead of into the liver
- Need to have the same pressures as SVC for best results
- Left common femoral approach is best - F - transjugular. Wire through heart into MHV. Then ream through the liver to where you expect the PV to be, and if you miss - try again. Some use a transcutaneous needle into PV and leave a little marker or wire to provide a target for the ‘reaming’, some use US.
- Budd Chiari syndrome, which is true:
- Spider like appearance of portal veins on portal venography is diagnostic
- 70% are idiopathic
- TIPS is not an option for treatment
- Central increased uptake is seen on sulphur colloid scans
- Central increased uptake is seen on sulphur colloid scans - T – (Sulphur-colloid was used previously, but has generally been replaced by other imaging modalities). Hypertrophy of the caudate lobe associated with BCS is demonstrated by its preferential uptake of the radionuclide. However, more than half of patients with BCS do not demonstrate this pattern (UTD). Sulfur colloid liver scan may show a central area of increased activity believed to be secondary to enlargement of the caudate lobe (AJR). See below.
- Budd Chiari syndrome, which is true: (TW)
- Spider like appearance of portal veins on portal venography is diagnostic - F – “Spider web” pattern of hepatic venous collaterals.
- 70% are idiopathic – Previously T, but now is F - in approx 75% of pts, a hematological abnormality or a cause of thrombotic diathesis can be identified that predisposes the patient to the occurrence of BCS (Radiographics 2009). Underlying disorcer can be identified in over 80% of patients with BCS (UTD). (Dahnert says 66% idiopathic)
- TIPS is not an option for treatment - F - TIPS is a good alternative method for relieving liver congestion, with lower mortality and morbidity than those assoc with open surgical procedures. Other options: medical, thrombolysis, angioplasty + stent of stenoses.
- Central increased uptake is seen on sulphur colloid scans - T – (Sulphur-colloid was used previously, but has generally been replaced by other imaging modalities). Hypertrophy of the caudate lobe associated with BCS is demonstrated by its preferential uptake of the radionuclide. However, more than half of patients with BCS do not demonstrate this pattern (UTD). Sulfur colloid liver scan may show a central area of increased activity believed to be secondary to enlargement of the caudate lobe (AJR). See below.
BCS is a heterogeneous group of disorders characterised by hepatic venous outflow obstruction at the level of the hepatic veins, IVC or right atrium. BCS is not a primary condition of the liver parenchyma; it is the result of partial or complete obstruction of hepatic venous outflow.
The “classic” scintigraphic pattern is caudate lobe hypertrophy, at expense of the rest of the liver, in which uptake may be normal, reduced, absent or patchy. Often colloid shift to spleen and bone marrowis seen. Caudate has own venous efferent connections directly with the IVC, so even so maintains good function cf rest of the liver - and maintains good tracer uptake and significant compensatory hypertrophy.This question could be answered as 2. correct (if using old numbers) and 4. incorrect using the argument that there is ‘normal’ (not increased) uptake centrally with relative decreased uptake around it.
- Regarding fibromuscular dysplasia of the renal artery:
- Most common at osteum
- Recurs post dilation
- Osteal stenosis
- Bilateral in 50%
- Intimal fibroplasia is the most common type and causes the classic stenoses alternating with aneurysms
4.Bilateral in 50% - T
- Regarding fibromuscular dysplasia of the renal artery: (JS)
- Most common at osteum - F - most commonly occurs in the middle and distal renal artery, causing “string of beads” appearance.
- Recurs post dilation - F - FMD classically responds well to angioplasty with success rates approaching 98% (B&H). Dahnert mentions 90% success rate with very low restenosis rates. Restenosis 12-25% over 6months to 2y, but restenosis is not necessarily associated with HTN.
- Osteal stenosis - F - more common with atherosclerotic disease
- Bilateral in 50% - T
- Intimal fibroplasia is the most common type and causes the classic stenoses alternating with aneurysms - F - This is Type 2
- AAA stent graft, which is true:
- Kinking = moved
- Not possible if AAA >8cms in length
- Endoleak lumbar artery needs fixing
- Endoleak needs immediate fixing
- Best grade stent with angio catheter and angiogram
- Kinking = moved - T most correct – diminished diameter of the aneurysm after stent – graft implantation also decreases length of aneurysm – associated with distal migration of graft.
- AAA stent graft, which is true: (TW)
- Kinking = moved - T most correct – diminished diameter of the aneurysm after stent – graft implantation also decreases length of aneurysm – associated with distal migration of graft.
- Not possible if AAA >8cms in length - F - for example the Zenith AAA grafts range from 82mm to 149mm in length.
- Endoleak lumbar artery needs fixing -?T (controversial) - = most common endoleak (type II). Significance and management of type II endoleaks is controversial. Some argue that as spontaneous resolution occurs 30-100% of cases, a “wait and see” approach is preferable. UTD recommendations are occluding type II endoleaks that have not spontaneously thrombosed in one month (as systemic pressures have been noted in aneuyrsm sac in the presence of type II endoleaks).
- Endoleak needs immediate fixing - - type I endoleak (ie incompetent seal at either proximal or distal attachment site) must be repaired as soon as possible. Type III endoleaks represtn flow into sac from separation between components of a modular system, or tears in the endograft - these are repaired with an additional endograft. Type IV leaks are due to egress of blood through the pores of the fabric - these heal spontaneously.
- Best grade stent with angio catheter and angiogram
- Carotid Doppler:
- 280cm/sec is >70% stenosis
- Maximal velocity is proximal to stenosis
- Carotid Doppler: (TW)
- 280cm/sec is >70% stenosis - T - >230cm/s equals >70% stenosis, ICA/CCA ratio >4.0. 125-230cm/s equals 50-69% stenosis, ICA/CCA ratio 2.0-4.0. <125cm/s equals <50% stenosis, ICA/CCA ratio <2.0. (US requisites)
- Maximal velocity is proximal to stenosis - F - maximal velocity is at stenosis. Calculating a ratio of PSV at stenosis vs PSV proximal to stenosis is also used as a calculation of % stenosis, where as ratio of 2 (ie., double PSV) equals >50% stenosis.
- Small renal artery aneurysm, which is not true:
- Diabetes
- Polyarteritis Nodosa
- IVDU
- SLE
- RCC
- Diabetes - F - causes diabetic nephropathy (diffuse glomerulosclerosis); other GU manifestations include renal a. stenosis, papillary necrosis, renal/perirenal abscess, emphysematous pyelonephritis/cystitis, XGP, fungal infection.
- Small renal artery aneurysm, which is not true: (GC) CME 03.40
- Diabetes - F - causes diabetic nephropathy (diffuse glomerulosclerosis); other GU manifestations include renal a. stenosis, papillary necrosis, renal/perirenal abscess, emphysematous pyelonephritis/cystitis, XGP, fungal infection.
- Polyarteritis nodosa - T - microaneurysms in 50%, esp. at branch points.
- IVDU - T - drug-abuse vasculitis may be due to immunologic injury from circulating hepatitis Ag-Ab complexes, bacterial endocarditis, direct toxicity, impurity-related. Methamphetamine, heroin, LSD. Mulitple small aneurysms in interlobar branches near corticomedullary jxn.
- SLE - T - aneurysms in interlobar and arcuate aa. (similar to but less frequent than PAN). Kidneys involved in 100% of cases (focal membranoproliferative GN).
- RCC - T - in 14% (also adult Wilm’s). Other neoplasms that may cause RAAs include AML (in 50%), metastatic arterial myxoma.
- Which is false re transjugular intrahepatic portosystemic shunt (TIPS)
- It is a recognized treatment of choice for refractory ascites
- Contraindicated in the presence of right heart failure
- May cause biliary dilatation acutely
- IJV thrombosis precludes performance of TIPS
- IJV thrombosis precludes performance of TIPS - F - RIJV usually used, LIJV can be used if right side can’t be used. Femoral venous approach techniques have also been described, but are used less commonly, and are technically more demanding (eMed).
- Which is false re transjugular intrahepatic portosystemic shunt (TIPS) (TW)
- It is a recognized treatment of choice for refractory ascites - T
- Contraindicated in the presence of right heart failure - T - right-sided heart failure with increased central venous pressure (eMed). Pulmonary HTN and hepatopulmonary syndrome is a contraindication.
- May cause biliary dilatation acutely - T - potential complication of fistula to biliary tree. Studies have also shown biliary epithelial proliferation with creation of large cystlike spaces (but this is not acute).
- IJV thrombosis precludes performance of TIPS - F - RIJV usually used, LIJV can be used if right side can’t be used. Femoral venous approach techniques have also been described, but are used less commonly, and are technically more demanding (eMed).
