Vascular Flashcards

Question

Acute aortic syndrome - penetrating ulcer

Answer 1

Ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wall. When it reaches media it produces a haematoma within media. Number one RF is atherosclerosis. Elderly patient with HTN and atherosclerosis usually involving descending aorta. Look for gap in intimal calcification. Stanford A or B with regard to takeoff of left subclavian. Sac like aneurysm above diaphragm usually penetrating ulcer, under the diaphragm usually mycotic aneurysm. Medical treatment. If treated surgically usually do worse than dissection. Surgical when haemodynamic instability, pain, rupture, distal emboli or rapid enlargement.

Answer 2

Ulcers caused by atherosclerosis Ulcer can lead to dissection Atherosclerosis does not cause dissection. Dense calcification can stop extension of a tear. Dissections often occur at aortic root where you have highest flow pressures. Ulcers never occur at root as pressure prevents atherosclerosis

Answer 3

Most common cause of acute aortic syndrome 70% HTN main risk factor leads to intimal tear resulting in 2 lumens Marfans, Turners and other connective tissue disorders increase risk. Pregnancy increases risk. Young healthy person using cocaine. 2 theories. HTN kills vasa vasorum which cause haematoma in media which ruptures into media. HTN forces tear in intima. Stanford A before left subclavian takeoff. 75%. Surgical Stanford B after left subclavian takeoff. Medical

Answer 4

TRUE LUMEN Continuity with undissected portion of aorta. Smaller cross sectional area with higher velocity blood. Surrounded by calcs. Usually has origin of CA, SMA and right renal artery FALSE LUMEN Slender linear areas of low attenuation. Larger cross sectional area with slow turbulent flow. Beak sign acute angle edge of lumen. Origin of left renal artery Floating viscera sign on angiography: Opacification of abdominal aortic branch vessels appearing to arise out of nowhere. Little or no antegrade opacification of the aortic true lumen. DISSECTION FLAP Static - stent Dynamic - fenestrated

Answer 5

MECHANISM Primary event secondary to HTN. Secondary event from atherosclerosis. Hyperdense crescent on NON con. Contrast CT difficult to tell from plaque. T1 bright crescent. Also use Stanford classification BAD OUTCOME Haematoma >2cm thickness Association with aneurysmal dilatation of aorta >5cm Progression to dissection or penetrating ulcer IMH and penetrating ulcer has worse outcome than IMH and dissection

Answer 6

ANEURYSM Enlargement of lumen to 1.5x normal diameter. The 3 layers are intact. PSEUDOANEURYSM Contained rupture. 3 layers are not intact. Risk of rupture higher. Trauma, arterial punctures, infection, panreatitis, vasculitidies. Yin yang sign on pulsed doppler

Answer 7

Occurs secondary to complete or near complete obstruction of flow in SVC from external compression (lyphoma, lung cancer) or intravascular obstruction (thrombus, central line) or fibrosing mediastinitis (histoplasmosis). Face neck and bilateral arm swelling.

Answer 8

Contained rupture. Most common place is aoric isthmus 90%. Tethering of ligamentum arteriousum. Ascending aorta and diaphragmatic hiatus next most common. Ascending aorta pseudoaneurysm on CXR would have mediastinal widening, NGT rightward deviation, depressed left main bronchus or left apical cap.

Answer 9

Only a few cause as atherosclerosis spares this area. Takayasu and syphilis. Clampng of aorta in CABG may be difficult.

Answer 10

Arterial enlargement to 1.5x normal diameter. Atheroscelrosis most common cause overall. Medial degeneration most common in ascending aorta. Connective tissue disease tend to have aortic root aneurysm (Marfans, Ehlers Danlos). Most involve infrarenal. General rule is repair over 6cm in chest and 5cm in abdomen.

Answer 11

Sinus of valsalva = aortic sinus. Most common in Asian men and typically involve right sinus. Congenital or acquired (infectious). VSD most common associated anomaly. Rupture can lead to cardiac tamponade. Surgical repair with Bentall procedure.

Answer 12

Most common indicator for repair is max diameter. Drooped aorta sign (posterior wall drapes over vertebral column). Increased aneurysm size 10mm in a year. Focal discontinuity ni circumferential wall calcs. Hyperdense crescent sign (haemorrhage and impending rupture).

Answer 13

Saccular and usually pseudoaneurysm. prone to rupture. Usually haematogenous seeding in setting of endocarditis. Direct seeding via psoas abscess. Usually thoracic or suprarenal aorta. Saccular shape, lobular contour, periaortic inflammation, abscess and periaortic gas.

Answer 14

Neurocutaneous disorder CAFESPOT acronym. Can get aneurysms and stenoses in aorta/large arteries.Renal artery stenosis can occur leading to renovascular HTN. Dysplasia of arterial wall.

Answer 15

Genetic disorder caused by mutations of fibrillin gene. Ectopic lens, tall, pectus, scoliosis, lng fingers. ANEURYSM Annuloaortic ectasia with dilatation of aortic root. Dilatation of aortic root leads to aortic valve insufficiency. Severe aortic regurgitaiton may lead to aortic root dissection or rupture. Disruption of media elastic fibres causes aortic stiffening and predisposed to aneurysm and dissection. Tulip Bulb ascending aneurysm. DISSECTION Recurrent dissections common. PULMONARY ARTERY ENLARGEMENT Also favours root of pulmonary artery

Answer 16

Bad version of Marfans with terrible prognosis and high rate of aortic rupture. Very tortuous vessels. Hypertolerism (frog eyes) Bifid uvula or cleft palate Aortic aneurysm with tortuosity

Answer 17

Disorder in collagen. Strtchy skin, hypermobile joints, blood vessel fragility with bleeding diatheses. Avoid invasive angiography and othe rpercutaneous procedures as high risk dissection. Aneurysms often involve the root.

Answer 18

Rare. Patients with untreated syphilis. Saccular and involves ascending aorta and arch. Saccular asymmetric aortic aneurysm with inolvement of aortic root branches. Heavy calcified tree bark calcs.

Answer 19

PRIMARY Rare. No history of instrumenation. Seen in setting of aneurysm and atherosclerosis. SECONDARY Seen after surgery. Usually 3rd and 4th parts duodenum. Cannot tell between perigraft infection vs AE fistula very well.

Answer 20

Most symptomatic and in young men. Elevated ESR. Not well understood, maybe related to retroperitoneal fibrosis or other automimmune conditions. SMoking is risk factor. Renal failure often also present as retroperitoneal fibrosis involves the ureters

Answer 21

Complete occlusion of aorta distal to renal arteries, usually secondary to bad atherosclerosis. May be big collaterals. Impotence, claudication and absent femoral pulses.

Answer 22

Progressive narrowing of abdominal aorta and major branches. Higher and longer segment than Leriche. Not secondary to atherosclerosis but as result of intrauterine insult HTN, weak/absent femoral pulses, claudication, renal failure

Answer 23

INFANTILE HF in first week of life. Preductal coarctation. Hypoplastic aortic arch. ADULT Leg claudication. BP diffs. Post ductal. Normal aortic arch. Collaterals. Association with Turners. Bicuspic aortic valve most common associated defect. Berry aneurysms. Figure 3 sign CXR. Rib notching 4th - 8th ribs.

Answer 24

Elongation with narrowing and kinking of aorta. No pressure gradient, collaterals or rib notching. Aneurysmal dilatation distal to areas of narrowing in pseudocoarctation which become progressively dilated.

Answer 25

Congenital or acquired compression of subclavian vessels and brachial plexus. Nerve first then vein then artery. Compression by anterior scalene most common. Cervical rib, muscular hypertrophy, fibrous bands Pagets, tumour etc can all cause. Treatment usually surgical. Arms up and down angiography.

Answer 26

Thoracic outlet syndrome with development of venous thrombus in subclavian vein. Effort thombosis as often in athletes with overhead movements.

Answer 27

Iatrogenic from Swan Ganz catheter. Behcets (Turkish descent, mouth and genital ulcers). Chronic PE. Hughes Stovin syndrome: Similar to Behcets. Recurrent thrombophlebitis and pulm art aneurysm and rupture. Rasmussen aneurysm: Pulm art pseudoaneurysm secondary to TB. Upper lobes in reactivation TB TOF gone wrong: patch aneurysm from RVOT repair.

Answer 28

Most common visceral arterial aneurysm. Usually distal artery. False aneurysms associated with pancreatitis. Mimic is islet cell pancreatic tumour which is hypervascular. More common in preg and more likely to rupture in preg. High risk for rupture: Liver transplant. Portal HTN. Pregnancy. Connective tissue disorders. Alpha 1 antitrypsin.

Answer 29

All SMA aneurysms should be treated, High rate of rupure and association with mesenteric ischaemia.

Answer 30

Treated if patient symptomatic or size exceeds 2cm. If patient has FMD or polyarteritis nodosa, treat regardless of size.

Answer 31

Compression of celiac artery by median arcuate ligt (fibrous band that connects diaphragm). Not a syndrome until/unless symptoms of abdominal pain/weight loss. Typical hooked appearance. Worse with expiration. Can lead to collaterals or aneurysm. Treated surgically

Answer 32

CHRONIC Significant stenosis of 2 out of 3 main mesenteric vessels along with symptoms (food fear). Can have bad disease and no symptoms if you have good collaterals. ACUTE ARTERIAL Thin bowel wall, diminished enhancement, bowel not dilated, mesentery not hazy. Occlusive emboli. Vasculitis. SMA most commonly affected. VENOUS Thick bowel wall, variable enhancement, moderate dilation, hazy mesentery. NON OCCLUSIVE Thick bowel wall, variable enhancement, bowel not dilated, mesentery not hazy. Shock or pressors. STRANGULATION Thick bowel wall, variable enhancement, severe dilatation and fluid filled bowel, hazy mesentery with asicites. Usually closed loop. Congested dilated bowel mixed arterial and venous

Answer 33

GRIFFITHS SMA/IMA watersed at splenic flexure. Most common location for ischaemia SUDECKS IMA/Iliac watershed at rectosigmoid. Highly susceptible to ischaemia.

Answer 34

Second msot common cause of colonic arterial bleeding (diverticulosis first). Primarily right sided with angiography showing cluster of small arteries during arterial phase along antimesenteric border of colon. Association with aortic stenosis (Heyde syndrome).

Answer 35

Autosomal dominant multisystem disorder with multiple AVMs. Can have tongue/mouth telengiectasias and history of recurrent blood nose. Can have multiple hepatic AVMs or pulmonary AVMs. If this is suspected, need CT lung and liver and brain MR or MRA

Answer 36

Usually secondary to atherosclerosis 75% and near ostium. Can be stented. FMD is second most common cause and has typical beaded appearance sparing ostium. PAN, Takayasu, NF1 and radiation can also do it

Answer 37

Non atherosclerotic vascular disease primarily affecting renal arteries of young white women. Stricturing and beading. Renovascular HTN in young women is FMD Renal arteries most commonly involved Lower extemity FMD usually ext iliac 3 histological subtypes, medial most common 95% Classification angiographic focal vs multifocal Predisposed to spontaneous dissection Spontaneous Coronary Artery Dissection SCAD String of beads buzzword Can angioplasty, dont stent.

Answer 38

Healthy female 30-40. Left renal vein compressed as it slides under SMA resulting in left flank and abdominal pain and haematuria. Can cause testicle pain in men and LLQ pain in women.

Answer 39

Targets splanchnic arteries in elderly and coronaries in young adults. Not true vasculitis with no inflammation. Media of vessel turns to crap and get multipe aneurysms. Multiple abdominal splanchnic artery saccular aneurysms, dissections and occlusion.

Answer 40

Controversial. Chronic abdominal pain. Depressed multiparous premenopausal women with chronic pelvic pain. Venous obstruction at left renal vein or incompetent ovarian vein valves leads to multiple dilated parauterine veins. Can do ovarian vein embolization

Answer 41

Abnormal dilatation of veins in pampiniform plexus. Usually idiopathic and 98% left sided. Left vein is longer and drains into renal vein at right angle. Can cause infertility. Right sided varicocoele can be sign of malignancy, check for pelvic or abdominal malignancy. Ca also be retroperitoneal fibrosis or adhesions Isolated right side - get CT Non decompressible varicocoele - get CT Bilateral decompressible - might need treatment if infertile but no cancer hunting Isolated left varicocoele - might need treatment if infertile but no cancer hunting

Answer 42

Can present with life threatening massive genital bleeding. Congenital or acquired. Acquired is after D&C, abortion or multiple pregnancies. Serpigenous structures in myometrium with low resistance high velocity - needs embolization. Can look similar to RPOC though this is in endometrium.

Answer 43

Can present with life threatening massive genital bleeding. Congenital or acquired. Acquired is after D&C, abortion or multiple pregnancies. Serpigenous structures in myometrium with low resistance high velocity - needs embolization. Can look similar to RPOC though this is in endometrium.

Answer 44

Most common peripheral arterial aneurysm. Min issue is distal thromboebolism which can be life threatening. Association with AAA. Most dreaded complication is acute ischaemic limb 30-50% of popliteal aneurysms will have AAA 10% of AAA will have popliteal aneurysms 50-70% of popliteal aneurysms are bilateral.

Answer 45

Most common peripheral arterial aneurysm. Min issue is distal thromboebolism which can be life threatening. Association with AAA.

Answer 46

Symptomatic compression or occlusion of popliteal artery due to developmental relationshi with medial head gastroc. Usually young men. Normal pulses that decrease with plantarflexion or dorsiflexion of foot.

Answer 47

Uncommon. Affects popliteal artery of young men. One or more mucoid filled cysts in outer media and adventitia

Answer 48

Blanket term for PE and DVT. more likely to develop of paraplegic vs tetraplegic

Answer 49

40% vascular malformations involve extremities (40% head and neck, 20% thorax). Increse proportionately as child grows. Low flow include venous, lymphatic, capillary and mixes High flow has arterial component.

Answer 50

Often combined with Parkes Weber which is true high flow AVM. KTS has triad of port wine nevi, bony or soft tissue hypertrophy gigantism) and a venous malformation. Persistent sciatic vein often associated. Marginal vein of Servelle (superficial vein in lateral calf and thigh) is pathognomonic and is basically a GSV on wrong side. 20% have GI involvement and can bleed. If system is big enough can eat platelets (Kasabach Merritt) KTS is low flow (venous) Parkes Weber is high flow (arterial) Klippel Trenaunay Weber is blanket term.

Answer 51

Not a true disease but response to blood vessel wall damage. Uxuberant healing response that leads to intimal thickening which can lead to stenosis. Restenosis 3-12 months after angioplasty is probably from intimal hyperplasia. Can grow through bare stent or grow through edges of covered stent

Answer 52

Cause by blunt trauma to ulnar artery and superficial palmar arch. Impact against hook of hamate. Arterial wall damage leads to aneurysm formation with or without thrombosis of vessel. Corkscrew configuration of superficial palmar arch, occlusion of ulnar artery or pseudoaneurysm of ulnar artery.

Answer 53

All vasculitidies look similar. Wall thickening, oclusions, dilatations and aneurysm formation. To tell apart, need age, gender, race and vessels affected. Large vessel Medium vessel Small vessel ANCA + Small vessel ANCA -

Answer 54

Large vessel. Loves young Asian girls 15-30yo. Vasculitis involving aorta with wall thickening and enhancement. Can be occlusion of major aortic branches or dilatation of aorta and its branches. Aortic valve often involved. Pulmonary arteries involved with peripheral pruning.

Answer 55

Large vessel. Most common primary system vasculitis. Loves old men 70-80yo. Involves aorta and major branches, particularly of external carotid (temporal arteritis). USS of temporal artery showng wall thickening or CT/MRA of axilla showing wall thickening, occlusion, dilatation and aneurysm. Places compressed by crutches. ESR and CRP elevated. Responds to steroids. Gold standard is temporal artery biopsy. Clinical connection with polymyalgia rheumatica.

Answer 56

Large vessel vasculitis affecting kids. Rare. Likes eyes (optic neuritis, uveitis and audiovestibular symptoms resembling Menieres). Can get aortitis.

Answer 57

Medium vessel. More common in men (same as Beurgers). PAN more common in MAN. Affects many places including renal 90%, cardiac 70% andGI 50-70%. Microaneurysm formation primarily at branch points followed by infarction. Kidneys with microaneurysms or infarction. Associated with Hep B

Answer 58

Most common vasculitis in kids (HSP also common). Cause of coronary vessel aneurysm. Calcified coronary artery aneurysm on CXR is aunt minnie. Fever for 5 days Strawberry tongue. Neck LNs. Rash of palms/soles. Etiology unknown. Sore throat and diarrhoea

Answer 59

WEGENERS Upper resp tract (sinuses), lower rep tract (lungs) and kidneys. ANCA+ 90% time. Nasal perforation and cavitatory lung lesions CHURG STRAUSS Necrotizing pulmonary vasculitis in spectrum of eosinophilic lung disease. Can have asthma and eosinophilia. Transient peripheral lung consolidation or GGO. Cavitation rare. MICROSCOPIC POLYANGITIS Kidneys and lungs. Diffuse pulmonary haemorrhage.

Answer 60

HENOCH SCHONLEIN PURPURA HSP Most common vasculitis in kids. Systemic disease but GI most common (painful blood diarrhoea). Lead point for intussusception. USS showing doughnut sign or scrotum with wall oedema. BEHCETS Turkish descent with mouth and genital ulcers. Thickening of aorta. Pulmonary artery aneurysm. BEURGERS Vasculitis strongly associated with smokers. Small and medium vessels in arms and legs. Exensive arteril occlusive disease with develoment of corckscrew collaterals. Autoamputation

Answer 61

WIll be hypothenar hammer or Beurgers Ulnar artery involved - HHS. Pseudoaneurysm is giveaway Ulnar artery ok - look at fingers. If fingers our or corkscrew collaterals will be Beurgers.

Answer 62

LARGE VESSEL Takayasu - young Asian female thickened aorta Giant Cell - old guy, crutches region Cogan - kid with eye and ear symptoms and aortitis MEDIUM VESSEL PAN - renal microaneurysm. Associated with Hep B Kawasaki - coronary artery aneurysm SMALL ANCA + Wegeners - nasal septal erosions and cavitatory lung Churg Strauss - transient peripheral lung concolidation Microscopic polyangitis - diffuse pulm haemorrhage SMALL VESSEL ANCA - HSP - Kids, intussusception, scrotal oedema Behcets - pulm art aneurysm Beurgers - Male smoker, finger occlusions

Answer 63

At stenosis UPSTREAM Waveform can be normal, monophasic decreased peak systolic or loss of diastolic. Diastolic flow reduced in severity to stenosis AT STENOSIS Waveform has high velocity jet, might see aliasing. High velocity = low pressure. DOWNSTREAM Waveform can be tardus parvus (prolonged slow systolic acceleration/upstroke and small systolic peak 'rounding of peak'.

Answer 64

Elevated velocity normal is <125cm/s. ICA/CCA ratio normal is <2 ICA end diastolic velocity normal is <40cm/s <50% stenosis will not alter peak systolic velocity 50-69% stenosis PSV 125-230cm/s, ratio 2-4, EDV 40-100 >70% stenosis PSV >230cm/s, ratio >4, EDV >100 Tardus parvus waveform: Unilateral - stenosis Bilateral - aortic stenosis

Answer 65

Stenosis/occlusion at proximal subclavian artery wtith retrograde flow in vertebral.

Answer 66

Brain always 'on' so diastolic needs to always be positive with continuous colour flow through cardiac cycle. Ext carotid feeds face muscles so only on when need to INTERNAL CAROTID Low resistance, low systolic velocity. Diastolic velocity does not return to baseline. Continuous colour flow. EXTERNAL CAROTID High resistance, high systolic velocity, diastolic approaches baseline, colour flow intermittent. Temporal tap on temporal artery will disrupt trace.

Answer 67

Bilateral CCAs with reversal of diastolic flow

Answer 68

Loss of diastolic flow suggests cessation of cerebral blood flow.

Answer 69

Superior balloon is 2cm distal to takeoff of left subclavian artery and inferior aspect of balloon is just above renals. Balloon inflates during early diastole. See extra bump or augmentation as balloon inflates and displaces blood superiorly.

Answer 70

NORMAL CCA Normal peak velocity 60-100cm/s. Continuous diastolic flow NORMAL ICA Lower peak velocity, high velocity continuous diastolic flow NORMAL ECA higher peak velocity, less diastolic flow ICA OCCLUSION CCA trace looks like ECA AORTIC REGURG Classic reversal of diastolic flow, will be shown bilaterally. Can show double systolic peak of hypertrophic obstructive cardiomyopathy ``` AORTIC STENOSIS Tardus parvus (rounded systolic). Shown bilateral. ```