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Radiology > Vascular > Flashcards

Vascular Flashcards

1
Q

Helpful videos

A

HTN https://www.youtube.com/watch?v=zNmnq2c1i4c

HYPERCHOLESTEROLEMIA https://www.youtube.com/watch?v=AU1yXXktLJI

DVT
https://www.youtube.com/watch?v=YgENAX40DPI

VARICOSE VEINS
https://www.youtube.com/watch?v=hI3O-aPZwk8

VON WILLEBRANDS
https://www.youtube.com/watch?v=EwXVGpBJdlQ

INFLAMMATORY VASCULAR DISEASES
https://www.youtube.com/watch?v=Nu4E6oJAaI8

VASCULITIS
https://www.youtube.com/watch?v=ise3cEqmEqU

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2
Q

Aorta

A

Thoracic aorta into 4 segments

ROOT
Aortic valve annulus to sinotubular junction. DIameter largest here up to 36mm.

ASCENDING AORTA

ARCH

DESCENDING AORTA

Sinuses of Valsalva: 3 outpouchings (right/left/posterior) above annulus that terminate at ST junction. LCA and RCA come off L and R sinuses.

Isthmus: between origin of LSA and ligt arteriosum

Ductus bump: Just distal to isthmus, normal sturcture.

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3
Q

Arch variants

A

NORMAL 75%

BOVINE 15%
Common origin brachiocephalic artery and left common carotid.

LEFT CC OFF BRACHIOCEPHALIC 10%

4 VESSEL L VERT FROM ARCH 5%

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4
Q

Pulmonary sling

A

Abberant LPA from RPA. Only anomaly to indent posterior trachea and anterior esohagous. Only anomaly to cause stridor with normal left arch

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5
Q

Adamkiewicz

A

Great anterior medullary artery which serves as dominant feeder of spinal cord. Usually off left side between T9-12

Classic angiographic appearance of artery is a hairpin turn as its anastomosis with anterior spinal artery

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6
Q

Mesenteric anastomoses

A

ARC OF RIOLAN
Left colic from IMA to middle colic from SMA

MARGINAL ARTERY OF DRUMMOND
Connects colic branches from IMA and SMA. Note watershed zones splenic flexure and at rectosigmoid

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7
Q

Definitions

A

TYPICAL CELIAS AXIS
Artery that gives rise to common hepatic, left gastric and splenic artery

COMMON HEPATIC ARTERY
Artery that gives rise to the right or left hepatic artery and the GDA

REPLACED HEPATIC ARTERY
Hepatic artery that arises from an ectopic location

ACCESSORY HEPATIC ARTERY
Hepatic artery that is duplicated with one vessel from the celiac and the other from another location

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8
Q

Most common variations

A

REPLACED RIGHT HEPATIC 10%
Usually arising from SMA. proper right hepatic is anterior to right portal vein whereas the replaced right hepatic is posterior to main portal vein.. Increased risk of injury in pancreatic surgery

ACCESSORY LEFT HEPATIC 10%
Duplicated left hepatic with one arising normally and the other usually from left gastric

REPLACED LEFT HEPATIC 7%
Left hepatic from ectopic location usually left gastric

Vessel through Strait Sign
If you see a vessel in the fissure from ligamentum venosum, probably replaced left hepatic from left gastric.

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9
Q

Iliac arterial anatomy

A 
ANTERIOR DIVISION
Umbilical
Superior vesicular
Inferior vesicular
Uterine
Middle rectal
Internal pudendal
Inferior gluteal
Obturator

POSTERIOR
Iliolumbar
Lateral Sacral
Superior gluteal

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10
Q

Ovarian artery

A

Arises from anteromedial aorta 90% of time but can arise from internal iliac. Has anastomosis with uterine artery off internal iliac

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11
Q

Persistent sciatic artery

A

Anatomic variant which is a continuation of the internal iliac. Passes posterior to femur in the thigh then anastomoses with distal vasculature. Complications are aneurysms and early atherosclerosis.

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12
Q

CA to SMA

A

Usually Celiac to common hepatic to GDA to Sup pancreaticoduoednal to inf pancreaticoduodenal to SMA

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13
Q

Arc of Buhler

A

Variant anatomy representing collateral pathway from celiac axis to SMA which is independent of GDA and inferior pancreatic arteries.

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14
Q

SMA to IMA

A

Critical for chronic mesenteric ischaemia and access for treating type 2 endoleaks.

ARC OF RIOLAN
Meandering mesenteric artery. Connection between middle colic of SMA and left colic of IMA. Not always present.

MARGINAL ARTERY OF DRUMMOND
SMA to IMA connection always present. Anastomosis of terminal branches of ileocolic, right and middle colic arteries of SMA which form a continuous arterial circleor arcade along inner border of colon.

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15
Q

IMA to internal iliac

A

IMA to superior rectal to inferior rectal to internal pudendal to anterior division of internal iliac.

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16
Q

Winslow pathway

A

Collateral pathway seen in setting or aortoiliac occlusive disease. Can be inadvertently cut during transverse abdominal surgery.

Subclavian arteries to internal thoracic to superior epigastric to inferior epigastric to external iliac

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17
Q

Corona Mortis (Crown of Death)

A

Variant anstomosis between internal iliac (obturator artery) and external iliac artery that can cause massive bleeding after anterior pelvis ring fracture.

Additional pathways exist but any vessel coursing over superior pubic rim can occur.

Significant as injured in pelvic trauma or during surgery and is notoriously difficult to ligate. 6-8% causes of death in pelvic trauma. Can hypothetically cause type 2 endoleak

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18
Q

Subclavian artery

A

Subclavian vein anterior to anterior scalene, artery is in triangle made by ant scalene, mid scalene and first rib

Subclavian has branches including: vertebral, internal thoracic, thyrocervical trunk and dorsal scapular

Axillary artery: begins at first rib
Brachial artery: begins at lower border teres major
Brachial artery: bifurcates into ulnar and radial

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19
Q

Telling radial from ulnar

A

Brachial artery splits around radial head into ulnar and radial

Ulnar artery bigger
Ulnar artery gives off common interosseous
Ulnar artery supplies superficial palmar arch
Radial artery supplies deep palmar arch

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20
Q

Upper extremity variants

A

Anterior interosseuous brachn (median artery) persists and supplies deep palmar arch

High origin of radial artery. Radial artery comes off either the axillary or high brachial

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21
Q

Lower limb

A

Aorta
Common iliac
External iliac
Femoral artery (once inf epigastric given off)
Deep femoral posterolateral
Superficial femoral anteromedial into adductor canal
Popliteal once emerged from adductor canal
Tibioperoneal trunk at distal popliteus
Anterior tibial at distal popliteus

Ant tib goes anterolateral across interosseous membrane and enters foot anterior to lateral malleolus as dorsalis pedis

Tibioperoneal turnk bifurcates into posterior tibial and peroneal.

Post tib goes most medial and enters foot behind medial malleolus to split into medial and lateral plantar arteries

Peroneal continues posteriorly and doesnt enter foot

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22
Q

Gastric varices

A

Portal HTN shunts blood away from liver into systemic venous system. Spontaneous portosystemic collaterals develop to decompress system.

Most gastric varices formed by left gastric (coronary) vein. Isolated gastric varices secondary to splenic vein thrombosis. Gastric varices drain to inferior phrenic and then left renal vein forming gastrorenal shunt

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23
Q

Splenorenal shunt

A

Portal HTN. Collateral between splenic vein and renal vein. Enlarged shunts are also associated with hepatic encephalopathy.

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24
Q

Caval variants

A

LEFT SVC
Most common congenital venous anomaly in the chest. Can result in right to left shunt. Usually duplicated 90%, unilateral 10%. Aunt Minnie appearance. Associated congenital heart defect is ASD. Associated with unroofed coronary sinus. Almost always drains into coronary sinus.

DUPLICATED SVC
As above, duplicated is most common and involves a left SVC as well as normal right SVC. Often left SVC is smaller.

DUPLICATED IVC
Aunt Minnie. Associated with renal anomalies such as Horseshoe and crossed fused ectopia. Also usually have circumaortic renal collars.

CIRCUMAORTIC VENOUS COLLAR
Common variant with an additional left renal vein that passes posterior to aorta. Only matters in renal transplant and IVC filter placement. Anterior limb is superior

AZYGOS CONTINUATION
Absence of hepatic segment of IVC. Hepatic veins drain directly to RA. Usually have duplicate IVC more inferiorly with left terminating into left renal vein. Polysplenia common with this. No IVC in liver, dilated azygos in chest.

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25
Q

Acute aortic syndrome - penetrating ulcer

A

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.

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26
Q

Penetrating ulcer and dissection

A

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

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27
Q

Dissection

A

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

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28
Q

Dissection continued

A

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

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29
Q

Intramural haematoma

A

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

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30
Q

Aneurysm vs pseudoaneurysm

A

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

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31
Q

SVC syndrome

A

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.

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32
Q

Traumatic pseudoaneurysm

A

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.

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33
Q

Ascending aorta calcifications

A

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

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34
Q

Aneurysm

A

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.

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35
Q

Sinus of valsalva aneurysm

A

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.

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36
Q

Rupture/impending rupture.

A

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).

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37
Q

Mycotic aneurysm

A

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.

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38
Q

NF1

A

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.

39
Q

Marfan

A

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

40
Q

Loeys Dietz syndrome

A

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

41
Q

Ehlers Danlos

A

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.

42
Q

Syphilitic (Leutic) aneurysm

A

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.

43
Q

Aortoenteric fistula

A

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.

44
Q

Inflammatory aneurysm

A

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

45
Q

Leriche syndrome

A

Complete occlusion of aorta distal to renal arteries, usually secondary to bad atherosclerosis. May be big collaterals.

Impotence, claudication and absent femoral pulses.

46
Q

Mid aortic syndrome (coarctation of abdominal aorta)

A

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

47
Q

Aortic coarctation

A

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.

48
Q

Pseudocoarctation

A

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.

49
Q

Thoracic outlet syndrome

A

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.

50
Q

Paget Schroetter

A

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

51
Q

Pulmonary artery aneurysm/pseudoaneurysm

A

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.

52
Q

Splenic artery aneurysm

A

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.

53
Q

SMA aneurysm

A

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

54
Q

Hepatic arter aneurysm

A

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

55
Q

Median arcuate ligt (Dunbar) syndrome

A

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

56
Q

Mesenteric ischaemia

A

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

57
Q

Watershed points

A

GRIFFITHS
SMA/IMA watersed at splenic flexure. Most common location for ischaemia

SUDECKS
IMA/Iliac watershed at rectosigmoid. Highly susceptible to ischaemia.

58
Q

Colonic angiodysplasia

A

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).

59
Q

Hereditary Haemorrhagic Telangiectasia (Osler Weber Rendu)

A

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

60
Q

Renal artery stenosis

A

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

61
Q

Fibromusular Dysplasia FMD

A

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.

62
Q

Nutcracker syndrome

A

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.

63
Q

Segmental arterial mediolysis (SAM)

A

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.

64
Q

Pelvic congestion syndrome

A

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

65
Q

Testicular varicocoele

A

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

66
Q

Uterine AVM

A

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.

67
Q

Uterine AVM

A

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.

68
Q

Popliteal aneurysm

A

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.

69
Q

Popliteal aneurysm

A

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

70
Q

Popliteal entrapment

A

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.

71
Q

Cystic adventitial disease

A

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

72
Q

VTE

A

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

73
Q

Peripheral vascular malformations

A

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.

74
Q

Klippel Trenaunay Syndrome

A

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.

75
Q

Intimal hyperplasia

A

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

76
Q

Hypothenar hammer

A

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.

77
Q

Vasculitis

A

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 -

78
Q

Takayasu

A

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.

79
Q

Giant cell arteritis

A

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.

80
Q

Cogan syndrome

A

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

81
Q

Polyarteritis Nodosa PAN

A

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

82
Q

Kawasaki disease

A

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

83
Q

Small vessel ANCA +

A

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.

84
Q

Small vessel ANCA -

A

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

85
Q

Hand angiogram

A

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.

86
Q

Vasculitidies table

A

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

87
Q

Carotid doppler

A

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’.

88
Q

Stenosis

A

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

89
Q

Subclavian steal

A

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

90
Q

Int vs ext carotid

A

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.

91
Q

Aortic regurg

A

Bilateral CCAs with reversal of diastolic flow

92
Q

Brain death

A

Loss of diastolic flow suggests cessation of cerebral blood flow.

93
Q

Intra-aortic balloon pump

A

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.

94
Q

Classic dopplers

A

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.

Radiology (16 decks)

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