vascular Flashcards
lateral and medial margins axillary v
- lateral=teres major
- medial-bx SCV at 1st rib lateral margin
where does cephalic v drain?
into SCV
how is pelvic venography obtained?
- prone from popliteal access
- check IVC rel to spine
which renal v is higher
left
breakdown of ascending aorta
- aortic valve annulus
- aortic root (from AV to sinotubular junction)
- sinus of valsalva
- sinotubular junction
isthmus
segment of aorta btw org L SCA and lig arteriosum
ductus bump
just distal to isthmus; contour along lesser curvature.
aortic variant percentage bd
normal 75%
bovine 15%
sep org left vert 5%
branches of SMA
- inferior pancreaticoduo
- ileocolic
- middle colic
- right colic
arc of riolan (meandering mesenteric a)
anastomoses btw middle colic and left colic
*not always present
how often is traditional celiac anatomy seen? BD of variants
60%
- replaced RHA-10%
- accessory LHA 10%
- replaced LHA 7%
why care about variant celiac anatomy
- partial hepatectomy
- course through Calot’s triangle + short cystic a (lap cholecystectomy)
- pancreatic surgery (replaced RHA)
“vessel through straight” sign
vess through lig venous
Posterior division internal iliac artery
I Love Sex
Iliolumbar
Superior gluteal
lateral sacral
Ant division int iliac a
- umbilical
- sup vesicular
- inferior vesicular
- uterine
- middle rectal
- int pudendal
- inf gluteal
- obturator
I Love Going
Places In My Very Own Underwear!
- Pudendal
- Inf gluteal
- middle rectal
- inf Vescicular
- Obturator
- Uterine/umbilical
persistent sciatic a
continuation of internal iliac passing pst to femur and anastomose with distal vasculature
- aneurysm, early athero
- “ext iliac occluded but strong pulse in foot”
Internal iliac artery continues as sciatic artery and then as popliteal artery
Hypoplastic external iliac, common femoral, and superficial femoral arteries (SFA)
2 types based on degree of SFA hypoplasia
Aneurysms in 25%, typically under gluteus maximus due to compression of artery by greater trochanter
arc of buhler
-4% variant collateral pw Celiac – SMA
anastomoses SMA-IMA
- chr mesenteric isch, treating type 2 endoleak
- arc of riolan-not always present
- marginal of Drummond-always present
mc loc penetrating ulcer
desc thoracic aorta
-high flow at aortic root prevents formation of athero
anastamoses btw IMA and int iliacs
- sup rectal (From IMA)
- inf rectal (From int pudendal)
Winslow pathway
- sup epigastric (from internal thoracic)
- inf epigastric (From EIA)
corona mortis/crown of death
- variant anastomosis btw obturator and EIA coursing over sup pubic bone–> sev bleed in trauma (6-8% deaths?)
- theoretical cause of type 2 endoleak
orientation SCA and SCV
- SVA pst to SVC.
- SVA in scalene triangle (w/ brachial plexus), SVC ant to triangle
branches of subclavian
- vertebral
- internal thoracic
- thyrocervical
- costocervical
- dorsal scapular
subclavian –> brachial
- ax at 1st rib
- brachial at lower border tires MAJOR
- radial at radial head
ulnar vs radial a on angiogram/cta
- ulnar bigger, gives off common interosseous
- ulnar supplies superficial palmar arch
- radial appear at radial head. supplies deep arch
“high org radial a”
from ax or high brachial a
anterior interosseous branch (median artery)
upper extremity variant
-persistence of branch supplying deep palmar arch
The anterior interosseous artery is one of the two branches of the short common interosseous artery (from the ulnar artery). The artery courses deep in the anterior compartment of the forearm on the anterior surface of the interosseous membrane along with the anterior interosseous nerve (from the median nerve). It runs between flexor digitorum profundus (medially) and flexor pollicis longus (laterally) muscles supplying both. It gives off several small branches that pierce the interosseous membrane, supplying the deep extensor muscles within the posterior compartment of the forearm. Small nutrient vessels also supply the radius and ulna. At the upper border of pronator quadratus, the artery:
gives off a small branch to anastomose with the palmar carpal arch and,
pierces the interosseous membrane to enter the posterior compartment of the forearm and anastomoses with the posterior interosseous artery which continues distally to join the dorsal carpal arch.
when does EIA bc CFA?
-once it gives off inf epigastric at ing ligament
course of deep femoral artery
lateral, pst.
course SFA
anterior, medial into flexor m compartment (adductor/hunter’s canal)
-popliteal once emerge from canal
popliteal branches
- ant tib (1st branch)
- tibioperoneal trunk
- at level of distal popliteus m
adductor/hunters canal
The adductor canal extends from the apex of the femoral triangle to the adductor hiatus. It is an intermuscular cleft situated on the medial aspect of the middle third of the anterior compartment of the thigh, and has the following boundaries:
Anteromedial wall - sartorius.
Posterior wall - adductor longus and adductor magnus.
Laterally - vastus medialis.
course of ant tibialis
anterolat through interosseous membrane
-dorsalis pedis at angkle
most medial a in leg?
-pst tibial (felt at medial malleolus)
isolated gastric varies-cause and drainage
- splenic v thrombus
- –> inf phrenic v –> renal v –> gastrorenal shunt
splenorenal shunt
- collateral btw splenic and renal v
- not ass w/ GI bleed!!!
- but is ass w/ hepatic encephalopathy
left SVC ass
- ASD (mc)
- unroofed coronary sinus
duplicated IVC ass
- renal stuff
- horseshoe
- cross fused ectopic kidneys
- circumaortic renal collars
circumaortic venous collar/renal vein-when it matters and loc of limbs
- renal tx, ivc filter
- ant=sup, pst=inf
azygos continuation of ivc ass
- duplicated IVC
- polysplenia
- dilated azygos in chest
MC cong venous anomaly in chest
left SVC
sac like aneurysm above vs below diaph
- above=penetrating ulcer
- below=mycotic aneurysm
path of penetrating ulcer
atherosclerotic –> erosion of intimal –> hematoma in media –> pseudoaneursym, rupture
mcc acute aortic syndrome
dissection 70%
who’s at risk of dissection
- htn #1
- CT do
- preg
- cocaine
ascending aorta Ca
takayasu
syphilis
*matters during clamping for CABG
acute dissection by week
<2wks
contents of true vs false lumens
true: celiac trunk, SMA, right renal
false= left renal
aneurysm with mural thrombus vs thromboses dissection
diss should spiral and displace intimal calcs
predictors of shitty outcome in intramural hematoma
- > 2 cm thickness
- 5cm+ aneurysm
- +diss/penetrating ulcer (PU worse than diss)
true vs false aneurysms shape
- true=fusiform
- false=saccular
causes of aortic pseudoaneurysm
trauma iatrogneic inf pancreatitis vasculitides
sinus of valsalva aneurysm-who, which sinus, causes, ass, compl, mx
- asian men
- R sinus
- cong or acquired (inf)
- VSD
- cardiac tamp
- bentall procedure
MCC ascending aortic aneurysm
medial degeneration
sgx’s of impending aortic aneurysm rupture
- draped aorta
- growth 10mm+/yr
- focal discon’t in circumferential wall calcs
- hyperdense crescent sax-hemorrhage. One of most spec manifestations of impending rupture
- periarotic stranding
- pain
MC img finding of aortic rupture
RP hematoma
embolic vs thrombotic colitis/enteritis
- embolic=branch points
- thromboic=otsteium
what protects against aneurysm rupture?
circumferential mural thrombus
mycotic aneurysm-how, app, where, mx
- seeding from endocarditis
- SACCULAR, PA, inflamm, gas. Expand faster than athero
- thoracic or suprarenal abd
- small, asyx and enruptured.
where are most atherosclerotic AAA
infrarenal
joeys Dietz syndrome-triad
hypertelorism
bifid uvula or cleft palate
-aortic aneurysm with tortuosity
*shitty version of marfans
pathophy marfans vs ehlers danlos
- marfans=fibrillin gene.
- ehlers-danlos-collagen
marfans systemic findings
- ectopic lens
- tall
- pectus deformity
- scoliosis
- long fingers
- vascular-aneurysm, diss, pulm a dilation
Ehlers danlos systemic findings
- many subtypes
- stretchy skin, hypermobile joints, bv fragility w/ bleeding diatheses
- vascular issues-aortic root, abd visceral a’s
who should you avoid precut on?
Ehlers danlos-excessive risk arterial dissection
syphilitic leutic aneruysm
untreated tertiary syph
- saccular, asc aorta and arch + root branches
- heavily “tree bark” intimal ca
- 30% CA ostium narrowing
- AV insufficiency
aortoenteric fistula-types, where
- 1˚ and 2˚ (mc)
- 3rd, 4th pts duo
inflammatory aneurysms
- young men
- often syx. rupture risk ind of size
- RF= smoking-smoking cessation; periarotic RP fibrosis, AI (SLE, GC, RA)
- 1/3 hydro/renal fx
- ESR+
- sparing pst wall (diff from vasculitis)
how to differentiate inflamm aneurysm from vasculitis
-sparing pst wall
leriche syndrome
-compl occlusion aorta distal to renal a’s (MC at aortic bifurcation.) 2/2 athero
+ collateral
-triad: impotence, claudication, ø femoral pulse
mid aortic syndrome (CoA of abd aorta)-how, triad
- absolute zebra off children/young adults 2/2 intrauterine insult w/ fragmentation of elastic media
- narrowed long segm aorta w/o arteritis or atherosclerosis
Triad:
- htn-mc presenting sx and cause of death
- weak/ø fem pulse
- claudation
- renal fx
CoA vs pseudocoA
-pseudo=no P gradient, collateral formation, rib notching
what a supplies 1st and 2nd rib
costocervical trunk
thoracic outlet syndrome-how, order of spectrum, causes, mx, img
- cong or acquired compression SC vess and brachial plexus passing through inlet
- spectrum (N 95%»_space;»»» SCV > SVA)
causes:
- compression by ant scalene (MC)
- cervical rib
- muscular HTr
- firous bands
- pagets
- tumors, etc
mx:
sx removal rib/m
img:
occlusion w/ arms up on angiogram
paget schroetter
- TOS + venous thrombus in SCV
- athletes
- mx: lysis + sx removal offending agent
pulm a aneurysm
- swan ganz
- behcets
- chronic PE
- rasmussen
- TOF repair gone wrong
- Hughes-stovin syndrome
splenic artery aneurysm-high risk rupture
- liver tx
- portal htn
- pregnancy
- ct do
- alpha 1 antitrypsin def
spelnic a aneurysm-rx
->2cm
pseduoanerusym
woman planning to get pregnant
splenic a aneurysm mimic
-islet cell pancreatic tumor-ie: don’t bx an aneurysm
causes splenic a aneurysm
- portal htn
- mult pregn
- pancreatitis (false aneurysms)
MC loc splenic a aneurysm
distal
SMA aneurysm-mx, ass
treat all (high rate of rupture) -ass w/ mes ischemia
hepatic a aneurysm-mx
- syx or >2cm
- FMD, PAN-treat regardless of size.
median arcuate lig syndrome (dunbar syndrome)
- compression celiac a by medical arcuate lig
- worse on expiration
- 20-40 yo
- “hooked appearance”
- –> pancreaticoduonenal collaterals and aneurysm
- sx
griffith’s point
SMA-IMA watershed.
MC loc for ischemia
Sudeck’s point
IMA-iliac watershet
-highly susceptible to ischemia
mcc death HHT
-stroke, brain abscess
problem with HHT in liver
-shunting –> biliary necrosis –> bile leak
uterine avm vs RPOC
myometrial
renal artery stenosis causes
- athero 75%
- FMD- 2nd MCC
- PAN, takayasu, NF1, radiation
next step: CTA+ or high susp FMD
1) angio w/ P measurements
AND
2) CTA head to toe (look for occult aneurysms)
FMD locs
renal-mc
- carotid 2nd mc
- vertebral 3md
- lower extrem=EIA (BL and MF)
FMD types and classification
- 3 histo types (medial mc (95%))
- classification=angiographic (focal vs MF)
Segmental arterial mediolysis
abN medial layer –> aneurysms (mult, saccular, diss, occlusion). Spon’t intraabdominal hemorrhage.
- splanchnic in elderly
- coronaries in young
FMD ass
- spon’t dissection
- spon’t coronary artery dissection (SCAD)
FMD mx
-mx but if pressure gradient: angio (no stent)
nutcracker syndrome vs SMA syndrome
- nutcracker=renal v compressed by sma
- SMA syndrome= duo compressed by SMA
nutcracker syndrome-who, syx
- health female 30s-40s
- left flank pain, hematuria, llc pain/testicular pain if gonad v involved
splanchnic a’s
Celiac, SMA, IMA
pelvic congestion syndrome
chronic pelvis pain via venous obstruction at left renal v (nutcracker) or income ovarian vein
- mul dilateer parauterine v’s
- mx: ovarian v embo
branches of IMA
Left colic
Sigmoid
Superior rectal arteries
testicular varicocele-which are bad
- non decompressible
- right sided
uterine AVM causes
- cong
- acquired (D&C, abortion, mult pregs
mx uterine AVM
-embo
May Thurner
compression left common iliac v by right common iliac a
popliteal aneurysm ass, main concern, bilaterality
- mc peripheral arterial aneurysm (2nd to aorta)
- BL 50-70%
ass:
- AAA (30-50%)
- 10% AAA have popliteal aneurysm
concern: acute limb from thromb/distal embo
popliteal entrapment
symptomatic compression/occlusion popliteal a via medial head gastrocnemius (less commonly popliteus)
- men <30 yo
- normal pulse that decrease w/ doors/plantar flexion of foot
- dx: medial deviation of pop a
cystic adventitial dx
- multiple mucoid-filled cysts in outer media and adventitia of popliteal a –> compr popliteal arter
- uncommon disorder
- young men
who’s more likely to dev VTE: paraplegic or tetraplegic?
para (doesn’t make sense)
Klippel Trenaunay Syndrome (KTS)-what, ass, dx
low flow (venous) AV malformations
- port wine nevi
- bony/soft tissue HTr (gigantism)
- venous malform
- ass: -peristent sciatic v
- gi involvement/bleed 20%
- margincal v of servelle=pathognomonic. superficial v in lateral calf and thigh. ie: great saphenous on wrong side
think of this when you see MRA/MRV of leg w/ bunch of superficial vessels (and no deep drainage)
*often linked with Parkes-weber (high flow arterial AVM)
ABI for claudication?
- 0.75-0.9=mild
0. 5-0.75-claudication
0. 3-0.5=severe
ABI for rest pain?
<0.3
intimal HP
- recurr stenosis after revascularization
- can grow through stent (if fenestrated) or at tips (if covered)
hypothenar hammer
blunt trauma to ulnar a and superficial palmar arch
- aneurysm +/- thrombosis
- corkscrew or pseudoaneurysm app
takayasu types
-5 total, #3 MC (involving aortic arch and abd aorta
takayasu vessel involvement
-aorta and branches, pulm a’s (“pruning”)
MC primary system vasculitis?
Giant cell
GCA ass
polymyalgia rheumatica (morning stillness in shoulders/arms)
location strategy: central chest, mid clay, armpit
central=takayasu
-mid clavicle=thoracic syndrome
=armpit=gca
cogan syndrom
-kid with eye and ear syx’s + aortitis
vasculitides based on vessel size
- large-takayasu, GCA, Cogan
- medium-PAN, Kawasaki
- small, ANCA+: granulomatosis w/ polyangiitis, churg-strauss, microscopic polyangiitis
- small ANCA-: HSP, Behcets, Beurgers
PAN- involved organs, app, ass
- renal (90%), cardiac (70%), GI (50-70%)
- microaneurysm (typically at branch points) –> infarction (wedge shaped)
- hep B
which vasculitides are MC in men?
- PAN (MAN)
- beurgers
when is a CA aneurysm ass with Kawasaki not good?
> 8mm (risk MI) (smaller may regress)
clinical sequelae of kawasaki
- 5 day fever
- strawberry tongue
- neck LAD
- sore throat/diarrhea
- palm/sole feet
ways of showing henoch schonlein purpura
intuss
massive scrotal edema
behcets
mouth/genical ulcers
aortic thickening, pulm artery aneurysm
beugers
smokers
- legs> hand, more than one limb
- BW: “auto amputation”
mc vasculitis in children
-henoch schonlein purpura
corkscrew angiogram of hand
ulnar=hhs
finger=buergers
what’s considered narrow neck in pseudo aneurysm?
-neck:PA <1/2
where do superior & inferior epigastric anastomose?
umbilicus
how common is the 3 vessel L aortic arch?
-70-80%
most common arch variation and how common?
common trunk of brachiocephalic and L common carotid (21-27%)
congenital vascular anomolies ass w/ aberrant right subclavian?
PDA
ACoA
VSD
carotid/vertebral anomolies
Complications of a kommerell diverticulum?
dissection, rupture
“significant carotid stenosis”
PSV > 230 cm/s in ICA
OR
ICA/CCA ratio > 4
*suggest 70% stenosis –> intervention required
Aortic arch types
1-3 based on degree of elongation (origin brachiocephalic to cephalic portion of arch)
HU normal bf
40-50
Monckenberg calcification-what, vs atheromatous Ca
- calcification within media of vessels
- diabetes, elderly
- no luminal narrowing
- vs: atheromatous plaque: intermittent, nonuniform calcification of atheromatous plaques, which is associated with luminal narrowing, ischemic symptoms, and aneurysmal development.
