Vascular Flashcards

Question

Upper Extremity Anatomy tribia

Answer 1

The subclavian artery runs posterior to the subclavian vein.

Answer 2

the vertebral, the internal thoracic, the | thyrocervical trunk, the costocervical trunk, and the dorsal scapular

Answer 3

* Axillary Artery: Begins at the first rib * Brachial Artery: Begins at the lower border of the teres major (major NOT minor!) * Brachial Artery: Bifurcates to the ulnar and radial

Answer 4

Around the radial head the brachial artery splits into the radial and ulnar arteries. I have three tricks for telling the radial from the ulnar artery apart (in case it’s not obvious). 1. The ulnar artery is usually bigger. 2. The ulnar artery usually gives o ff the common interosseous 3. The ulnar artery supplies the superficial palmar arch (usually), and therefore the radial supplies the deep arch (usually).

Answer 5

* Anterior Interosseous Branch (Median Artery) persists and supplies the deep palmar arch o f the hand. * “High Origin o f the Radial Artery” - Radial artery comes o ff either the axillary or high brachial artery (remember it normally comes off at the level of the radial head).

Answer 6

The nomenclature pearl for the external iliac is that it becomes the common femoral once it gives off the inferior epigastric (at the inguinal ligament). Once the inferior epigastric comes o ff (level o f the inguinal ligament) you are dealing with the common femoral artery(CFA). The CFA divides into the deep femoral (profunda) and superficial femoral. The deep femoral courses lateral and posterior. The superficial femoral passes anterior and medial into the flexor muscle compartment (ADDuctor / Hunter’s Canal). At the point the vessel emerges from the canal it is then the popliteal artery

Answer 7

At the level o f the distal border o f the popliteus muscle the popliteal artery divides into the anterior tibialis (the first branch) and the tibioperoneal trunk. The anterior tibialis courses anterior and lateral, then it transverses the interosseous membrane, running down the front o f the anterior tibia and terminating as the dorsalis pedis.The tibioperoneal trunk bifurcates into the posterior tibialis and fibular (peroneal) arteries.

Answer 8

with the answer being the posterior tibial (felt at the medial malleolus).

Answer 9

As described in more detail in the GI chapter, portal hypertension shunts blood away from the liver and into the systemic venous system. Spontaneous portalsystemic collaterals develop to decompress the system. The thing to know is that most gastric varices are formed by the left gastric (coronary v e in ) . That is the one they always show big and dilated on an angiogram. Isolated gastric varices are secondary to splenic vein thrombosis. Gastric Varices (80-85%) drain into the inferior phrenic and then into the left renal vein, forming a gastro-renal shunt.

Answer 10

Another feature o f portal hypertension, this is an abnormal collateral between the splenic vein and renal vein. This is actually a desirable shunt because it is not associated with GI bleeding. However, enlarged shunts are associated with hepatic encephalopathy (discussed in greater detail in the BRTO section o f the IR chapter). A common way to show this is an enlarged left renal vein and dilatation o f the inferior vena cava at the level o f the left renal vein.

Answer 11

* Most commonly associated CHD is the ASD * Associated with an unroofed coronary sinus * Nearly always (92% o f the time) it drains into the coronary sinus

Answer 12

* Most commonly associated CHD is the ASD * Associated with an unroofed coronary sinus * Nearly always (92% o f the time) it drains into the coronary sinus

Answer 13

“Left Sided SVC” almost never occurs in isolation. Instead, there is almost always a “normal” right sided SVC, in addition to the left sided SVC. It is in this case (which is the majority o f cases o f left sided SVC) that the terminology “duplicated SVC” is used. It is so common that people will use the terms duplicated and left sided interchangeably. But, technically to be duplicated you need a right sided and left sided SVC (even if the right one is a little small - which is often the case in the setting o f a left SVC).

Answer 14

There are two main points worth knowing about this: (1) that the appearance is an Aunt Minnie, and (2) it’s associated with Renal stuff. Renal associations include horseshoe and crossed fused ectopic kidneys. Also these dudes often have circumaortic renal collars

Answer 15

(IVCs are the bread, Aorta is the cheese or peanut butter...or bacon)

Answer 16

Very common variant with an additional left renal vein that passes posterior to the aorta. It only matters in two situations (a) renal transplant, (b) IVC filter placement. The classic question is that the anterior limb is superior, and the posterior limb is inferior.

Answer 17

renal vein is anterior to aorta

Answer 18

Renal vein is posterior to aorta

Answer 19

This is also known as absence o f the hepatic segment o f the IVC. In this case, the hepatic veins drain directly into the right atrium. Often the IVC is duplicated in these patients, with the left IVC terminating in the left renal vein , which then crosses over to join the right IVC.

Answer 20

``` is polysplenia (reversed IVC/Aorta is more commonly associated with asplenia). ```

Answer 21

No IVC in the Liver, Dila ted A z y g o s in the C h e s t

Answer 22

aortic dissection, | intramural hematoma, and penetrating ulcer.

Answer 23

intima media externa

Answer 24

``` 3 AASs can be classified as type A or B Stanford, based on their locations before (type A) or after the takeoff the o f the left subclavian (type B). ```

Answer 25

Atherosclerosis | Delicious Burger King and Tasty Cigarettes

Answer 26

Elderly patient with hypertension and | atherosclerosis usually involving the descending thoracic aorta

Answer 27

Eating like a pig and smoking results in atherosclerosis. Nasty atherosclerotic plaque erodes through the intima. Hematoma forms in the media (intramural hematoma). With severe disease can eventually progress to a pseudo aneurysm (and maybe even rupture)

Answer 28

``` 3 AASs can be classified as type A or B Stanford, based on their locations before (type A) or after the takeoff the o f the left subclavian (type B). ```

Answer 29

These things often result in a saccular morphology around the arch. In general, sac like aneurysm above the diaphragm is related to penetrating ulcer. Sac like aneurysm below the diaphragm is gonna be septic (“mycotic”).

Answer 30

—Controversial (which usually means it won't he tested) - famous last words If forced to answer questions on this relationship, 1 would go with the following: • Penetrating Ulcers are caused by atherosclerosis (this is a fact) • Penetrating Ulcer can lead to Dissection (this is probably true in some cases) • Atherosclerosis does NOT cause Dissection (which is confusing, may or may not be true, and is unlikely to be tested). What is true is that the presence o f dense calcified plaque can stop extension o f a dissection tear. • Dissections often occur in the aortic root - where you have the highest flow pressures • Penetrating Ulcers nearly never occur in the root - as these flow pressures prevent atherosclerosis (wash those cheeseburger crumbs away).

Answer 31

Similar to Type B Dissections. If they do get treated (grafted e tc ...) they tend to do WORSE than dissections (on average)

Answer 32

Hemodynamic instability, Pain, Rupture, Distal Emboli, Rapid Enlargement

Answer 33

* The most common cause o f acute aortic syndrome (70%) * Hypertension is the main factor - leads to an intimal tear resulting in two lumens * Marfans, Turners, and other Connective Tissue Diseases increase risk

Answer 34

* Pregnancy — known to increase risk * Cocaine Use in a young otherwise healthy person * Patient with “Hypertension” and a sub-sternal “Tearing Sensation.”

Answer 35

Some people say that hypertensive pressures kill the vasa vasorum (the little vessels inside the vessel walls) leading to development o f intramural hematoma which then ruptures into the intima. This is the “inside out” thinking. Other people think the hypertensive forces tear the inner layer directly (“outside in” thinking). Honestly... who gives a shit? Not even sure why I mentioned that.

Answer 36

1) Time: Acute (< 2 weeks), or Chronic (2) Location: • Stanford A: Account for 75% of dissections and involves the ascending aorta and arch proximal to the take-off of the left subclavian. These guys need to be treated surgically. • Stanford B: Occur distal to the take-off of the left subclavian and arc treated medically unless there are complications (organ ischemia etc...)

Answer 37

Continuity with undissected portion of aorta Smaller cross sectional areas (with higher velocity blood) Surrounded by calcifications (if present) Usually contains the origin of celiac trunk, SMA, and RIGHT renal artery

Answer 38

“CobWeb Sign” - slender linear areas of low attenuation Larger cross section area (slower more turbulent flow) Beak Sign - acute angle at edge of lumen - seen on axial plane Usually contains the origin of LEFT renal artery Surrounds true lumen in Type A Dissection

Answer 39

This is a classic angiographic sign of abdominal aortic dissection. It is shown as opacification of abdominal aortic branch vessels during aortography (catheter placed in the aortic true lumen), with the branch vessels— ( celiac axis, superior mesenteric artery, and right renal artery) arising out of nowhere. They appear to be floating, with little or no antegrade opacification of the aortic true lumen.

Answer 40

Static = dissection flap in the feeding artery (usually treated by stenting) Dynamic = dissection flap dangling in front of ostium (usually treated with fenestration). It can be hard to tell these apart. I f a sk ed I 'd expect them to ju s t use the vocab words.

Answer 41

* The dissection should spiral, the thrombus tends to drop straight down * Intimal Calcs - the dissection will displace them.

Answer 42

* The dissection should spiral, the thrombus tends to drop straight down * Intimal Calcs - the dissection will displace them.

Answer 43

blasted vaso vasorum > intramural hematoma > intima tears > dissection blasted vaso vasorum > intramural hematoma >serosal rupture > psuedoaneurysm

Answer 44

focal plaque ruptures > focal intramural hematoma > dissection focal plaque ruptures > focal intramural hematoma > serosal rupture > pseudoaneurysm

Answer 45

can occur as - primary event secondary to htn - seconary event usually from atherosclerosis, but also as a focal hematoma on the road to dissection for multible choice the cause is htn

Answer 46

crescent sign hyperdense on noncon contrast CT difficult to distinguish from plaque T1 bright crescent

Answer 47

Also uses the Stanford A vs B idea Some people will say Type A = Surgery, Type B medical • This is controversial and unlikely to be tested

Answer 48

* Most o f these will spontaneously regress. These are the things that make that less likely: * Hematoma Thickness Greater than 2 cm * Association with aneurysmal dilation o f the aorta - 5 cm or more * Progression to dissection or penetrating ulcer * IMH + Penetrating Ulcer has a worse outcome compared to IMH + Dissection

Answer 49

The distinction between a true and false aneurysm lends itself well to multiple choice testing. A true aneurysm is an enlargement o f the lumen o f the vessel to 1.5 times its normal diameter. True = 3 layers are intact. In a false (pseudo) aneurysm all 3 layers are NOT intact, and it is essentially a contained rupture. The risk o f actual rupture is obviously higher with false aneurysm. It can sometimes be difficult to tell, but as a general rule fusiform aneurysms are true, and saccular aneurysms might be false. Classic causes o f pseudoaneurysm include trauma, cardiologists (groin sticks), infection (mycotic), pancreatitis, and some vasculitides. On ultrasound they could show you the classic yin/yang sign, with “to and fro” flow on pulsed Doppler. The yin/yang sign can be seen in saccular true aneurysms, so you shouldn’t call it on that alone (unless th at’s all they give you). To and Fro flow within the aneurysm neck + clinical history is the best way to tell them apart.

Answer 50

Occurs secondary to complete or near complete obstruction o f flow in the SVC from external compression (lymphoma, lung cancer) or intravascular obstruction (Central venous catheter, or pacemaker wire with thrombus). A less common but testable cause is fibrosing mediastinitis (just think histoplasmosis). The dude is gonna have face, neck, and bilateral arm swelling.

Answer 51

Again a pseudoaneurysm is basically a contained rupture. The most common place to see this (in a living patient) is the aortic isthmus (90%). This is supposedly the result o f tethering from the ligamentum arteriosum. The second and third most common sites are the ascending aorta and diaphragmatic hiatus - respectively. Ascending aortic injury is actually probably number one, it ju st kills them in the field so you do n ’t see it. They could show you a CXR with a wide mediastinum, deviation o f the NG Tube to the right, depressed left main bronchus, or left apical cap and want you to suspect acute injury.

Answer 52

There are only a few causes o f ascending aortic calcifications, as atherosclerosis typically spares the ascending aorta. Takayasu and Syphilis should come to mind. The real-life significance is the clamping o f the aorta may be difficult during CABG.

Answer 53

Defined as enlargement o f the artery to 1.5 times its expected diameter (> 4 cm Ascending and Transverse, > 3.5 cm Descending, > 3.0 cm Abdominal). Atherosclerosis is the most common overall cause. Medial degeneration is the most common cause in the ascending aorta. Patients with connective tissue (Marfans, Ehlers Danlos) diseases tend to involve the aortic root. When I say cystic medial necrosis you should think Marfans. Aneurysms may develop in any segment o f the aorta, but most involve the infra-renal abdominal aorta. This varies based on risk factors, rate o f growth, e tc ... but a general rule is surgical repair for aneurysms at 6cm in the chest (5.5 cm with collagen vascular disease) and 5 cm in the abdomen.

Answer 54

Aneurysms o f the valsalva sinus (aortic sinus) are rare in real life, but have been known to show up on multiple choice tests. Factoids worth knowing are that they are more common in Asian Men, and typically involve the right sinus. They can be congenital or acquired (infectious). VSD is the most common associated cardiac anomaly. Rupture can lead to cardiac tamponade. Surgical repair with Bentall procedure.

Answer 55

Peri-aortic stranding, rapid enlargement (10 mm or more per year), or pain are warning signs o f impending rupture. A retroperitoneal hematoma adjacent to an AAA is the most common imaging finding o f actual rupture. The most common indicator for elective repair is the maximum diameter o f the aneurysm , “Sac Size Matters,” with treatment usually around 6 cm (5.5 cm in patients with collagen vascular disease). A thick, circumferential mural thrombus is thought to be protective against rupture. Enlargement o f the patent lumen can indicate lysis o f thrombus and predispose to rupture.

Answer 56

Draped Aorta Sign Posterior wall of the aorta drapes over the vertebral column. Increased Aneurysm Size 10 mm or more increased per year Focal Discontinuity in Circumferential Wall Calcifications Hyperdense Crescent Sign Well-defined peripheral crescent of increased attenuation. One of the most specific manifestations of impending rupture.

Answer 57

These are most often saccular and most often pseudoaneurysms. They are prone to rupture. They most often occur via hematogenous seeding in the setting o f septicemia (endocarditis). They can occur from direct seeding via a psoas abscess or vertebral osteomyelitis (but this is less common). Most occur in the thoracic or supra-renal aorta (most atherosclerotic aortic aneurysms are infra-renal). Typical findings include saccular shape, lobular contours, peri-aortic inflammation, abscess, and peri-aortic gas. They tend to expand faster than atherosclerotic aneurysms. In general small, asymptomatic, and unruptured.

Answer 58

If you see a saccular aneurysm o f the aorta (especially the I f abdominal aorta) you have to lead with infection.

Answer 59

One o f the more common neurological genetic disorders, which you usually think about causing all the skin stuff (Cafe au lait spots and freckling), and bilateral optic gliomas. Although uncommon, vascular findings also occur in this disorder. Aneurysms and stenoses are sometimes seen in the aorta and larger arteries, while dysplastic features are found in smaller vessels. Renal artery stenosis can occur, leading to renovascular hypertension (found in 5% o f children with NF). The classic look is orificial renal artery stenosis presenting with hypertension in a teenager or child. The mechanism is actually Dysplasia o f the arterial wall itself (less common from peri-arterial neurofibroma).

Answer 60

Genetic disorder caused by mutations of the fibrillin gene (step 1 question). There are lots o f systemic manifestations including ectopic lens, being tall, pectus deformity, scoliosis, long fingers etc... Vascular findings can be grouped into aneurysm, dissection, and pulmonary artery dilation:

Answer 61

Dilation with Marfans is classically described as “Annuloaortic ectasia”, with dilatation o f the aortic root. The dilation usually begins with the aortic sinuses, and then progresses into the sinotubular junction, ultimately involving the aortic annulus. Dilatation of the aortic root leads to aortic valve insufficiency. Severe aortic regurgitation occurs that may progress to aortic root dissection or rupture. The mechanism for all this nonsense is that disruption o f the media elastic fibers causes aortic stiffening, and predisposes to aneurysm and dissection. The buzzword for the Marfans ascending aneurysm is “tulip bulb. They are usually repaired earlier than normal aneurysm (typically around 5.5 cm).

Answer 62

Recurrent dissections are common, and even “triple barreled dissection” can be seen (dissections on both sides o f a true channel).

Answer 63

Just like dilation o f the aorta, pulmonary artery enlargement favors the root.

Answer 64

Annuloaortic extasia with dilationof the aortic root

Answer 65

Despite the name, this is actually not a Puerto Rican DJ. Instead think o f this as the really shitty version o f Marfans. They have a terrible prognosis, and rupture their aortas all the time. Vessels are very tortuous (twisty). They also have crazy wide eyes (hypertelorism).

Answer 66

1. Hypertelorism (frog eyes), 2. Bifid uvula or cleft palate 3. Aortic aneurysm with tortuosity

Answer 67

Crazy twisty vertebral arteries

Answer 68

This one is a disorder in collagen, with lots o f different subtypes. They have the stretchy skin, hypermobile joints, blood vessel fragility with bleeding diatheses. Invasive diagnostic studies such as conventional angiography and other percutaneous procedures should be avoided because o f the excessive risk o f arterial dissection. Imaging characteristics o f aortic aneurysms in Ehlers-Danlos syndrome resemble those in Marfan syndrome, often involving the aortic root. Aneurysms o f the abdominal visceral arteries are common as well.

Answer 69

This is super rare and only seen in patients with untreated tertiary syphilis. There is classically a saccular appearance and it involves the ascending aorta as well as the aortic arch. Classic description “saccular asymmetric aortic aneurysm with involvement o f the aortic root branches. ” Often heavily calcified “tree bark” intimal calcifications. Coronary artery narrowing (at the ostium) is seen 30% o f the time. Aortic valve insufficiency is also common.

Answer 70

Very, very, very rare. Refers to an A-E fistula without history o f instrumentation. They are only seen in the setting o f aneurysm and atherosclerosis.

Answer 71

Much more common. They are seen after surgery with or without stent graft placement.

Answer 72

The question is usually what part o f the bowel is involved, and the answer is 3 rd and 4th portions of the duodenum. The second most likely question is A-E fistula vs perigraft infection (without fistula)? The answer to that is unless you see contrast from the aorta into the bowel lumen (usually duodenum), you c an ’t tell. Both o f them have ectopic perigraft gas > 4 weeks post repair, both have perigraft fluid and edema, both lose the fat place between the bowel and aorta (tethering o f the duodenum to the anterior wall o f the aorta), both can have pseudoaneurysm formation.

Answer 73

``` Most are symptomatic, more common in young men, and associated with increased risk o f rupture regardless o f their size. Unlike patients with atherosclerotic AAA, most with the inflammatory variant have an elevated ESR. Their etiology is not well understood but may be related to periaortic retroperitoneal fibrosis or other autoimmune disorders (SLE, Giant Cell, RA). Smoking is apparently a strong risk factor, and smoking cessation is the first step in medical therapy. In 1/3 of cases hydronephrosis or renal failure is present at the time o f diagnosis because the inflammatory process usually involves the ureters. Imaging findings include a thickened wall and inflammatory or fibrotic changes in the periaortic regions. Often there is asymmetrical thickening o f the aorta with sparing o f the posterior wall (helps differentiate it from vasculitis). ```

Answer 74

Refers to complete occlusion o f the aorta distal to the renal arteries (most often at the aortic bifurcation). It is often secondary to bad atherosclerosis. There can be large collaterals.

Answer 75

. Limp Dick (impotence) • Ass claudication • Absence femoral pulses

Answer 76

Refers to progressive narrowing of the abdominal aorta and its major branches. Compared to Leriche, this is higher, and longer in segment. It’s also a total freaking zebra. It tends to affect children / young adults. This thing is characterized by progressive narrowing of the aorta. It is NOT secondary to arteritis or atherosclerosis but instead the result o f some intrauterine insult (maybe) with fragmentation o f the elastic media.

Answer 77

* HTN (most common presenting symptom) - this is the most common cause o f death i f not treated * Weak or Absent Femoral Pulses * Claudication * Renal failure

Answer 78

narrow aorta without arteritis or atherosclerosis

Answer 79

* There are two subtypes * Strong Association with Turners Syndrome (15-20%). * Bicuspid Aortic valve is the most common associated defect (80%). * They have more berry aneurysms. * Figure 3 sign (appearance o f CXR). • Rib Notching: most often involves 4th - 8th ribs. It does NOT involve the l sl and 2nd because those are fed by the costocervical trunk.

Answer 80

Presents with heart failure within the first week of life. Pre-Ductal (Before the left Subclavian A.) Aortic Arch = Hypoplastic

Answer 81

Leg Claudication BP differences between arms and legs. Post-Ductal (Distal to left Subclavian A.) Aortic Arch = Normal Diameter Collateral Formation is More Likely

Answer 82

This is a favorite o f multiple choice writers. You will have elongation with narrowing and kinking o f the aorta. It really looks like a coarctation, BUT there is NO pressure gradient, collateral formation, or rib notching - that is the most likely question. The second most likely question is the area o f aneurysmal dilation may occur distal to the areas o f narrowing in pseudocoarctation, and they may become progressively dilated and should therefore be followed.

Answer 83

Congenital or acquired compression o f the Subclavian vessels (artery and vein), and brachial plexus nerves as they pass through the thoracic inlet. It is a spectrum: Nerve (95%) » » » Subclavian Vein » Subclavian Artery. With symptoms varying depending on what is compressed. Compression by the anterior scalene muscle is the most common cause. However, cervical rib, muscular hypertrophy, fibrous bands, Pagets, tumor e tc ... can all cause symptoms. Treatment is usually surgical removal o f the rib / muscle. The classic way to show this is arms up and arms down angiography (occlusion occurs with arms up).

Answer 84

This is essentially thoracic outlet syndrome, with development of a venous thrombus in the Subclavian vein. It’s sometimes called “effort thrombosis’’ because it’s associated with athletes (pitchers, weightlifters) who are raising their arms a lot. They will use catheter directed lysis on these dudes, and surgical release o f the offending agent as above. Stenting isn’t usually done (and can only be done after surgery to avoid getting the stent crushed).

Answer 85

Think about three things for multiple choice; (1) Iatrogenic from Swan Ganz catheter *most common (2) Behcets, (3) Chronic PE. When they want to lead Swan Ganz they may say something like “patient in the 1CU.” The buzzwords for Behcets are: “Turkish descent”, and “mouth and genital ulcers.”

Answer 86

This is a zebra cause of pulmonary artery aneurysm that is similar (and maybe the same thing) as Behcets. It is characterized by recurrent thrombophlebitis and pulmonary artery aneurysm formation and rupture.

Answer 87

This has a cool name, which instantly makes it high yield for testing. This is a pulmonary artery pseudoaneurysm secondary to pulmonary TB. It usually involves the upper lobes in the setting of reactivation TB.

Answer 88

So another possible testable scenario is the patch aneurysm, from the RVOT repair.

Answer 89

The most common visceral arterial aneurysm (3rd most common abdominal - behind aorta and iliac).

Answer 90

Etiology of these things depends on who you ask. Some source will say arteriosclerosis is the most important cause. However, it seems that most sources will say that arteriosclerosis less important and things like portal hypertension and a history of multiple pregnancy are more important. More common in pregnancy, and more likely to rupture in pregnancy.

Answer 91

* Liver Transplantation * Portal Hypertension * Pregnancy * Connective Tissue Disorders * Alpha 1 Antitrypsin Def

Answer 92

Most are located in the distal artery. False aneurysms are associated with pancreatitis.

Answer 93

An important mimic is the islet cell pancreatic tumor (which is hypervascular). Don’t be a dumb ass and try to biopsy the aneurysm. If you are forced to choose which ones to treat I guess I’d go with: anything over 2 cm, any pseudoaneurysm, and any in a women planning on getting pregnant.

Answer 94

All SMA aneurysms should be treated - as there is a high rate of rupture and association with mesenteric ischemia.

Answer 95

Treated if the patient is symptomatic or size exceeds 2cm (just like the spleen). In patients with FMD or polyarteritis nodosa - typically they are treated regardless of size.

Answer 96

This is compression of the celiac artery by the median arcuate ligament (fibrous band that connects the diaphragm). Most people actually have some degree of compression, but it’s not a syndrome until there are symptoms (abdominal pain, weight loss). Typical age is 20-40 years old. The buzzword is “hooked appearance.” It’s classically shown on angiography and they will want you to know that it gets worse with expiration. It can actually lead to the development of pancreaticoduodenal collaterals and aneurysm formation. It’s treated surgically.

Answer 97

Significant Stenosis o f 2 out o f 3 main mesenteric vessels + symptoms (“ food fear” ) , LUQ pain after eating, pain out o f proportion to exam). Some practical pearls are that you can have bad disease and no symptoms if you have good collaterals. Alternatively if you have bad one-vessel disease you can have symptoms if you have crappy collaterals. Remember that the splenic fle xu re ("Griffith s Point ”) is the most common because it’s the watershed o f the SMA and IMA.

Answer 98

Arterial, Venous, Non-occlussive, and Strangulation.

Answer 99

Occlusive emboli (usually more distal, at branch points), or Thrombus (usually closer to the ostium). Vasculitis can also cause it. The SMA is most commonly affected. Bowel typically has a thinner wall (no arterial inflow), and is NOT typically dilated. After reperfusion the bowel wall will become thick, with a target appearance.

Answer 100

Dilation with wall thickening (8-9mm, with < 5mm being normal) is more common. Fat stranding and ascites are especially common findings in venous occlusion.

Answer 101

Seen in patients in shock or on pressors. This is the most difficult to diagnose on CT. The involved bowel segments are often thickened. Enhancement is variable. Look fo r delayed filling o f the porta! vein at 70 seconds.

Answer 102

This is almost always secondary to a closed loop obstruction. This is basically a mixed arterial and venous picture, with congested dilated bowel. Hemorrhage may be seen in the bowel wall. The lumen is often fluid-filled.

Answer 103

Trivia: Mesenteric Ischemia has a described association with SMA Aneurysm.

Answer 104

thin bowel wall (thick after reperfusion) diminished enhancement bowel not dilated mesentery not hazy (until it infarcts)

Answer 105

thick bowel wall variable moderate dilation hazy with ascites

Answer 106

thick bowel wall variable sever dilation (and fluid filled) hazy with ascites and whirl sign with closed loop

Answer 107

thck bowel wall variable bowel not dilated mesentery not hazy (until it infarcts)

Answer 108

``` • SMA-IMA - Watershed • “Most Common Location for Ischemia” ``` splenic flexure

Answer 109

• IMA - Iliac Watershed • Highly Susceptible to Ischemia sigmoid

Answer 110

Colitis/Enteritis> infection diffuse or TI Colitis/Enteritis > inflammatory (TI) Colitis/Enteritis> ischemic > arterial > occlusive > embolic (branch points) Colitis/Enteritis> ischemic > arterial > occlusive > Thrombotic (closer to ostium) Colitis/Enteritis> ischemic > arterial > non- occlusive > (think hypotension watershed) Colitis/Enteritis> ischemic > venous

Answer 111

This is the second most common cause o f colonic arterial bleeding (diverticulosis being number one). This is primarily right sided with angiography demonstrating a cluster o f small arteries during the arterial phase (along the antimesenteric border o f the colon), with early opacification o f dilated draining veins that persists late into the venous phase. There is an association with aortic stenosis which carries the eponym Heyde Syndrome (which instantly makes it high yield for multiple choice).

Answer 112

This is an AD multi-system disorder characterized by multiple AVMs. On step 1 they used to show you the tongue / mouth with the telangiectasis and a history o f recurrent bloody nose. Now, they will likely show multiple hepatic AVMs or multiple pulmonary AVMs. Extensive shunting in the liver can actually cause biliary necrosis and bile leak. They can have high output cardiac failure.

Answer 113

Most die from stroke or brain abscess.

Answer 114

If the syndrome is suspected, these guys need CT o f the | Lung & Liver (with contrast), plus a Brain MR / MRA

Answer 115

Narrowing o f the renal artery most commonly occurs secondary to atherosclerosis (75%). This type o f narrowing is usually near the ostium, and can be stented. EMD is the second most common cause and typically has a beaded appearance sparing the ostium (should not be stented). Additional more rare causes include PAN, Takayasu, NL-1, and Radiation.

Answer 116

A non-atherosclerotic vascular disease, primarily affecting the renal arteries o f young white women.

Answer 117

- Renovascular HTN in Young Women = LMD - Renal arteries are the most commonly involved (carotid #2, iliac #3) - There are 3 types, but just remember medial is the most common (95%) - They are predisposed to spontaneous dissection

Answer 118

String of beads

Answer 119

Angioplasty WITHOUT stenting. Eating walnuts helps (seriously, there is a paper on it). Eating cashews does not help (same paper), which is too bad because cashews are delicious... and walnuts taste like shit.

Answer 120

Usually a healthy female 30s-40s. The left renal vein gets smashed as it slides under the SMA, with resulting abdominal pain (left flank) and hematuria. The left renal vein gets smashed a lot, but it’s not a syndrome without symptoms. Since the left gonadal vein drains into the left renal vein, it can also cause left testicle pain in men, and LLQ pain in women.

Answer 121

Retrograde venography with renal / caval pressure measurements

Answer 122

Renal Vein, Smashed by SMA. Note the prominent venous collateral (arrow)

Answer 123

multiple abdominal splanchnic artery saccular aneurysms, dissections, and occlusion - Can also be shown as spontaneous intra-abdominal hemorrhage.

Answer 124

Typically the splanchnic circulation o f the GI tract refers to the Celiac, SMA, and IMA.

Answer 125

This is a controversial entity, sometimes grouped in the fibromyalgia spectrum. Patients often have “chronic abdominal pain.” They also often wear a lot o f rings and drink orange soda. The classic demographic is a depressed, multiparous, pre-menopausal women with chronic pelvic pain. Venous obstruction at the left renal vein (nutcracker compression) or incompetent ovarian vein valves leads to multiple dilated parauterine veins. This very “real” diagnosis can be treated by your local Interventional Radiologist via ovarian vein embolization.

Answer 126

Abnormal dilation o f veins in the pampiniform plexus. Most cases are idiopathic and most (98%) are found on the left side (left vein is longer, and drains into renal vein at right angle). They can also occur on the left, secondary to the above mentioned “nutcracker syndrome.” They can cause infertility. “Nondecompressible” is a buzzword for badness. Some sources state that neoplasm is actually the most likely cause o f non-decompressible varicocele in men over 40 years o f age; (left renal malignancy invading the renal vein). Right-sided varicocele can be a sign o f malignancy as well. When it’s new, and on the right side (in an adult), you should raise concern for a pelvic or abdominal malignancy. New right-sided varicocele in an adult should make you think renal cell carcinoma, retroperitoneal fibrosis, or adhesions.

Answer 127

Bad Get an ABD CT (or MR, or US)

Answer 128

Bad Get an ABD CT (or MR, or US)

Answer 129

ok Might need treatment if infertile etc.., but doesn’t need additional cancer hunting imaging.

Answer 130

ok probably Might need treatment if infertile etc.., but doesn’t need additional cancer hunting imaging.

Answer 131

This diagnosis is the classic next step question o f all next step questions because you need to recognize when this common diagnosis is associated with something bad.

Answer 132

This diagnosis is the classic next step question o f all next step questions because you need to recognize when this common diagnosis is associated with something bad.

Answer 133

This can present with life threatening massive genital bleeding. Rarely they can present with CHF. They come in two flavors (a) Congenital, and (b) Acquired. Acquired occurs after D&C, abortion, or multiple pregnancies. They are most likely to show this on color Doppler with serpiginous structures in the myometrium with low resistance high velocity patterns. This one needs embolization. Could look similar to retained products o f conception (clinical history will be different, and RPOC is usually centered in the endometrium rather than the myometrium).

Answer 134

This is the most common peripheral arterial aneurysm (2nd most common overall, to the aorta). The main issue with these things is distal thromboembolism, which can be limb threatening. There is a strong and frequently tested association with AAA. * 30-50% o f patients with popliteal aneurysms have a AAA * 10% o f patients with AAA have popliteal aneurysms * 50-70% o f popliteal aneurysms are bilateral

Answer 135

an acute limb from thrombosis and distal embolization o f thrombus pooling in the aneurysm.

Answer 136

Caused by blunt trauma (history o f working with a jackhammer) to the ulnar artery and superficial palmar arch. The impact occurs against the hook o f the hamate. Arterial wall damage leads to aneurysm formation with or without thrombosis of the vessel. Emboli may form, causing distal obstruction o f digits (this can cause confusion with the main DDx Buergers). Look for corkscrew configuration of the superficial palmar arch, occlusion of the ulnar artery, or pseudoaneurysm of the ulnar artery.

Answer 137

term used to refer to PE and DVT (PE | and DVT are both forms o f VTE).

Answer 138

You are more likely to develop VTE if you are paraplegic vs tetraplegic.

Answer 139

``` VTE is more likely in “motor complete” AIS A patients (those that have lost motor and sensory) vs motor incomplete AIS B,C,D (those with some residual sensory or motor function) -- which is more intuitive. Quad being worse than tetra for VTE risk makes zero sense (and therefore makes a good trivia question). ```

Answer 140

``` VTE is more likely in “motor complete” AIS A patients (those that have lost motor and sensory) vs motor incomplete AIS B,C,D (those with some residual sensory or motor function) -- which is more intuitive. Quad being worse than tetra for VTE risk makes zero sense (and therefore makes a good trivia question). ```

Answer 141

About 40% o f vascular malformations involve the extremities (the other 40% are head and neck, and 20% is thorax). Different than hemangiomas, vascular malformations generally increase proportionally as the child grows. This dude Jackson classified vascular malformation as either low flow or high flow. Low flow would include venous, lymphatic, capillary, and mixes o f the like. High flow has an arterial component. Treatment is basically determined by high or low flow.

Answer 142

This is often combined with Parkes- Weber which is a true high flow AV malformation. KTS has a triad o f port wine nevi, bony or soft tissue hypertrophy (localized gigantism), and a venous malformation. A persistent sciatic vein is often associated. The marginal vein o f Servelle (some superficial vein in the lateral c a lf and thigh) is pathognomonic (it’s basically a great saphenous on the wrong side).

Answer 143

20% have GI involvement and can bleed, if the system is big enough it can eat your platelets (Kasabach Merritt). Basically, if you see a MRA/MRV o f the leg with a bunch o f superficial vessels (and no deep drainage) you should think about this thing.

Answer 144

Low Flow (venous)

Answer 145

High Flow (arterial)

Answer 146

Something people say when they (a) do n ’t know what they are talking about, or (b) do n ’t know what kind o f malformation it is and want to use a blanket term.

Answer 147

So basic familiarity with the so called “Ankle to Brachial Index” can occasionally come in handy, with regard to peripheral arterial disease. This is basically a ratio o f systolic pressure in the leg over systolic blood pressure in the arm. Diabetics can sometimes have unreliable numbers (usually high), because dense vascular calcifications won’t let the vessels compress.

Answer 148

Opinions vary on what the various cut o ff numbers mean. Most people will agree that you can safely deploy the phrase “peripheral arterial disease” if the resting ABI is less than 0.90 You can also deploy the following generalizations: 0.5-0.3 = claudication, < 0.3 = rest pain

Answer 149

“The bane o f endovascular intervention.” This is not a true disease but a response to blood vessel wall damage. Basically this is an exuberant healing response that leads to intimal thickening which can lead to stenosis. You hear it talked about the most in IR after they have revascularized a limb. Re-Stenosis that occurs 3-12 months after angioplasty is probably from intimal hyperplasia. It’s sneaky to treat and often resists balloon dilation and/ or reoccurs. If you put a bare stent in place it may grow through the cracks and happen anyway. If you put a covered stent in, it may still occur at the edges o f the stent. The take home point is that it’s a pain in the ass, and if they show an angiogram with a stent in place, that now appears to be Intimal Hyperplasia losing flow, this is probably the answer.

Answer 150

-dark stuff growing along the inside of the stent walls

Answer 151

This uncommon disorder classically affects the popliteal artery, of young men. Basically you have one or multiple mucoid-filled cysts developing in the outer media and adventitia. As the cysts grow, they compress the artery.This uncommon disorder classically affects the popliteal artery, of young men. Basically you have one or multiple mucoid-filled cysts developing in the outer media and adventitia. As the cysts grow, they compress the artery.

Answer 152

Basically all vasculitis looks the same, with wall thickening, occlusions, dilations, and aneurysm formation. The trick to telling them apart is the age o f the patient, the gender / race, and the vessels affected. Classically, they are broken up into large vessel, medium vessel, small vessel ANCA +, and small vessel ANCA negative.

Answer 153

Takayasu GCA Cpgan

Answer 154

“The pulseless disease.” This vasculitis loves young Asian girls (usually 15-30 years old). If they mention the word “Asian,” this is likely to be the answer. Also, if they show you a vasculitis involving the aorta this is likely the answer. In the acute phase there will be both wall thickening and wall enhancement. There can be occlusion o f the major aortic branches, or dilation o f the aorta and its branches. The aortic valve is often involved (can cause stenosis or AI). In the late phase there is classically diffuse narrowing distally. The pulmonary arteries are commonly involved, with the typical appearance o f peripheral pruning.

Answer 155

If anyone was a big enough jerk to ask, there are 5 types with variable involvement o f the aorta and its branches. Which type is which is beyond the scope o f the exam, ju st know type 3 is most common - involves arch and abdominal aorta.

Answer 156

wall thickening involving the aorta

Answer 157

The most common primary system vasculitis. This vasculitis loves old men (usually 70-80)** although there are a few papers that will say this is slightly more common in women. This vasculitis involves the aorta and its major branches particularly those o f the external carotid (temporal artery). This can be shown in two ways: (1) an ultrasound o f the temporal artery, demonstrating wall thickening, or (2) CTA / MRA or even angiogram o f the armpit area (Subclavian/ Axillary/ Brachial), demonstrating wall thickening, occlusions, dilations, and aneurysm. Think about it as the part o f the body that would be compressed by crutches (old men need crutches).

Answer 158

• ESR and CRP are markedly elevated, • Disease responds to steroids. • “Gold Standard” for diagnosis is temporal artery biopsy (although it’s often negative). • Clinical connection between GCA and polymyalgia rheumatica. (they might be different phases o f the same disease). History might be “morning stillness in shoulders and hips.”

Answer 159

Total Zebra probably not even worth mentioning. It is a large vessel vasculitis that targets children and young adults. It likes the eyes and ears causing optic neuritis, uveitis, and audiovestibular symptoms resembling Menieres. They can also get aortitis, and those that do have a worse prognosis. Basically, kid with eye and ear symptoms + or - aortitis.

Answer 160

PAN | Kawasaki disease

Answer 161

This is one o f two vasculitides (the other being Buergers) that is more common in men. PAN is more common in a MAN. This can effect a lot o f places with the big 3 being Renal (90%), Cardiac (70%), and GI (50-70%). Typically we are talking about microaneurysm formation, primarily at branch points, followed by infarction. I would expect this to be shown either as a CTA or angiogram o f the kidneys with microaneurysms, or a kidney with areas o f infarct (multiple wedge shaped areas).

Answer 162

association with Hep B.

Answer 163

micro-aneurysm formation in the kidney can also be seen in patients who abuse Crystal Meth (sometimes called a “speed kidney”).

Answer 164

Probably the most common vasculitis in children (HSP also common). Think about this as a cause o f coronary vessel aneurysm. A calcified coronary artery aneurysm shown on CXR is a very rare aunt Minnie.

Answer 165

``` “Fever for 5 Days” • Strawberry Tongue • Neck Lymph Nodes • Rash of Palms of Hands / Soles of Feet • Sore Throat Diarrhea • “Etiology Unknown” ```

Answer 166

- Coronary Artery Aneurysms > 8mm are “Giant” and prone to badness including Ml - Coronary Artery Aneurysms < 8mm may regress

Answer 167

Wegeners churg strauss miscroscopic polyangiitis

Answer 168

1 think about upper respiratory tract (sinuses), lower respiratory tract (lungs), and kidneys. cANCA is (+) 90% o f the time. Ways this is shown are the nasal perforation (like a cocaine addict) and the cavitary lung lesions.

Answer 169

This is a necrotizing pulmonary vasculitis which is in the spectrum o f Eosinophilic lung disease. They always have asthma and eosinophilia. Transient peripheral lung consolidation or ground glass regions is the most frequent feature. Cavitation is rare (this should make you think Wegeners instead). They are pANCA (+) 75% if the time.

Answer 170

Affe c ts the kidneys and lungs. Diffuse pulmonary hemorrhage is seen in about 1/3 o f the cases. It is pANCA (+) 80% o f the time.

Answer 171

HSP (henoch schonlein purpura) behcets buergers

Answer 172

The most common vasculitis in children (usually age 4-11). Although it is a systemic disease, G1 symptoms are most common (painful bloody diarrhea). It is a common lead point for intussusception. They could show this two classic ways: (1) ultrasound with a doughnut sign for intussusception, or (2) as a ultrasound o f the scrotum showing massive skin edema. A less likely (but also possible) way to show this case would be multi-focal bowel wall thickening, or a plain film with thumbprinting.

Answer 173

Classic history is mouth ulcers and genital ulcers in someone with Turkish descent. It can cause thickening o f the aorta, but for the purpose o f multiple choice test I expect the question will be pulmonary artery aneurysm.

Answer 174

This vasculitis is strongly associated with smokers. It affects both small and medium vessels in the arms and legs (more common in legs). Although it is more commonly seen in the legs, it is more commonly tested with a hand angiogram. The characteristic features are extensive arterial occlusive disease with the development o f corkscrew collateral vessels. It usually affects more than one limb.

Answer 175

autoamputation

Answer 176

Buuergers or hypothenar hammer syndrome

Answer 177

(1) Ulnar artery involved = HHS. The most helpful finding is a pseudo-aneurysm off the ulnar artery - this is a slam dunk for HHS. (2) Ulnar artery looks ok - then look at the fingers - if they are out, go with Buergers. It sure would be nice to see some “corkscrew collaterals” - to make it a sure thing. Be careful, because the fingers can be out with HHS as well (distal emboli), but the ulnar artery should be fucked. Look at that ulnar artery first.

Answer 178

Think Takayasu

Answer 179

Think Thoracic Syndrome

Answer 180

Think Giant Cell

Answer 181

Young Asian Female - thickened aneurysmal aorta

Answer 182

Old Person with involvement o f the “crutches” / armpit region (Subclavian, axillary, brachial).

Answer 183

Kid with eye and ear symptoms + Aortitis

Answer 184

PAN is more common in a MAN (M > F). Renal Microaneurysm | (similar to speed kidney). Associated with Hep B.

Answer 185

Coronary Artery Aneurysm

Answer 186

Nasal Septum Erosions, Cavitary Lung Lesions

Answer 187

Transient peripheral lung consolidations.

Answer 188

Diffuse pulmonary hemorrhage

Answer 189

Kids. Intussusception. Massive scrotal edema.

Answer 190

Pulmonary artery aneurysm

Answer 191

Male smoker. Hand angiogram shows finger occlusions.

Answer 192

The waveform will go through changes before entering a stenosis, within the stenosis, and after exiting the stenosis.

Answer 193

Waveform can be normal, monophasic decreased peak systolic velocity, or loss of diastolic flow. Diastolic flow is reduced in proportion to the severity of the stenosis.

Answer 194

Waveform usually has a high velocity jet -might see aliasing. High velocity = low pressure (Bernouli’s effect mother fuckers)

Answer 195

``` Waveform can be Tardus Parvus (prolonged “slow” systolic acceleration / upstroke, and small systolic peak - “rounding of the peak”) ```

Answer 196

It would be correct to say that Tardus Parvus is found downstream from a stenosis. It would also be correct to say that Tardus Parvus is the result of upstream stenosis. See what I did right there? I'm not the only one who can pull some shit like th at...

Answer 197

This is discussed in greater detail in the cardiac chapter, but this time lets show it on ultrasound. As a refresher, we are talking about stenosis and/or occlusion of the proximal subclavian artery with retrograde flow in the ipsilateral vertebral artery.

Answer 198

They are going to show two things: (1) Retrograde flow in the left vertebral, and (2) a stenosis of the subclavian artery with a high velocity

Answer 199

They can show this thing called “early steal.” Steal is apparently a spectrum, which starts with midsystolic deceleration with antegrade latesystolic velocities. Some people think the “early steal” waveform looks like a rabbit.

Answer 200

They can show this thing called “early steal.” Steal is apparently a spectrum, which starts with midsystolic deceleration with antegrade latesystolic velocities. Some people think the “early steal” waveform looks like a rabbit.

Answer 201

This really lends itself well to multiple choice test questions. The big point to understand is that the brain is always on. You need blood flow to the brain all the time, which means diastolic flow needs to be present all the time, and thus continuous color flow throughout the cardiac cycle. The external carotid feeds face muscles... they only need to be on when you eat and talk.

Answer 202

low resistance low systolic velocity diastolic velocity does not return to baseline continuous color flow is seen throughout the cardiac cycle

Answer 203

high resistance high systolic velocity diastolic velocity approaches zero baseline color flow is intermittent during the cardiac cycle

Answer 204

It is a technique Sonographers use to tell the external carotid from the internal carotid. You tap the temporal artery on the forehead and look for ripples in the spectrum. The tech will usually write “TT” on the strip - when they do this.

Answer 205

Just like aortic stenosis they are going to show you bilateral CCAs. In this case you are going to get reversal o f diastolic flow.

Answer 206

Apparently in the ever-feuding monarchies o f Europe, ultrasound can be used for brain death studies. A loss o f diastolic flow suggests cessation o f cerebral blood flow.

Answer 207

In case someone asks you, distal formation o f an aneurysm (such as one in the skull) cannot be detected by ultrasound, because proximal flow remains normal.

Answer 208

Remember these guys are positioned so that the superior balloon is 2 cm distal to the take o ff o f the left subclavian artery, and the inferior aspect o f the balloon is ju st above the renals (you d o n ’t want it occluding importing stuff when it inflates). When the balloon does inflate it will displace the blood in this segment o f the aorta - smashing it superior and inferior to the balloon. The balloon will inflate during early diastole (right after the aortic valve closes) because this is when the maximum amount o f blood is available for displacement.

Answer 209

You are going to see an extra | bump or “augmentation” as the balloon inflates and displaces blood superior.

Answer 210

The first one (the one that is not assisted).

Answer 211

The first one (the one that is not assisted).

Answer 212

The Left Ventricular A ssist Device is a surgically implanted device that helps pump blood from the left ventricle to the aorta. It's done in the setting o f severe heart failure, typically as a bridge to cardiac transplantation, or in those who are simply too evil to die o f natural causes (Dick Cheney) and require an intermediate step while the Darth Vader suit is prepped.

Answer 213

LVAD Waveforms will lose the normal high resistance spiked look o f the ICA, CCA, Vertebral Arteries. Instead they are mostly flat, with a tardus parvus look. The flow is continuous through systole and diastole. The little spikes you see during systole are from the small amount o f residual LV function.

Answer 214

LVAD Waveforms will lose the normal high resistance spiked look o f the ICA, CCA, Vertebral Arteries. Instead they are mostly flat, with a tardus parvus look. The flow is continuous through systole and diastole. The little spikes you see during systole are from the small amount o f residual LV function.

Answer 215

Normal Peak Velocity 60-100cm/s Continuous Diastolic Flow

Answer 216

Lower Peak Velocity High Velocity Continuous Diastolic Flow

Answer 217

Higher Peak Velocity | Less Diastolic Flow

Answer 218

-The CCA looks like the E C A , with a highresistance waveform, and loss of diastolic flow

Answer 219

- With Classic Reversal of Diastolic Flow | - Most Likely Shown Bilaterally

Answer 220

-This time showing the "Pulsus Bisferiens" or double systolic peak. This is also seen in hypertrophic obstructive cardiomyopathy.

Answer 221

- Characteristic Tardus Parvus waveform | - This will be shown BILATERAL - to prove it’s the aortic valve. Unilateral will be a more central vascular stenosis.

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