Vascular

Question 1

Carotid Triangle

Answer 1

Posterior belly of digastric m.
Anterior belly of omohyoid m.
Sternocleidomastoid m.

Question 2

Internal jugular vein

Answer 2

Lateral to internal carotid artery then lateral to common carotid artery. Facial vein enters IJ at level of carotid bifurcation.
Joins the subclavian vein to form brachiocephalic (innominate) vein.

Question 3

Paget-von-Schroetter syndrome

Answer 3

Venous thoracic outlet syndrome. Effort thrombosis.

thrombosis or severe narrowing of subclavian-axillary vein 2/2 chronic extrinsic mechanical compression w/in thoracic outlet (from cervical rib or muscular tissue b/w head of clavicle and 1st rib)

repetitive injury to subclavian vein at level of costoclavicular space (medial thoracic outlet)

1st rib, clavicle, subclavius muscle, costocoracoid ligament, anterior scalene muscle

Question 4

Cocaine-induced mesenteric ischemia

Answer 4

inhibition of Norepi reuptake at presynaptic terminal –> more NE at postsynaptic rec –> tachycardia, HTN, vasoconstriction

Question 5

NOMI

Answer 5

cocaine, hypovolemia, heart failure

CT: bowel wall thickness, target-like appearance

Question 6

Arterial occlusion MI

Answer 6

Hx PVD, cardiac arrhythmia, valvular disease

CT: bowel wall thickness, filling defect within mesenteric vessels (MC SMA)

Question 7

Venous occlusion MI

Answer 7

Portal HTN, R heart failure, hyper coagulable

CT: wall thickening, decreased attenuation of bowel wall, mesenteric fluid/ascites

Question 8

Mechanical strangulation/MI

Answer 8

Acute onset, malrotation/volvulus, previous abdominal surgery

CT: “whirl sign”, hazy mesentery, bowel dilation, air-fluid levels, venous engorgement (outflow obstruction)

Question 9

Misc causes of MI

Answer 9

Hx vasculitis, trauma, cytotoxic drugs (chemo, radioembolization)

CT: wall thickening, contrast extra or mesentery stranding

Question 10

Mesenteric venous thrombosis tx

Answer 10

resection of non-viable intestine, large vessel venous thrombectomy, admin of anticoagulation

if bowel is dusky -> 2nd look operation to evaluate viability of any marginally perfused bowel

Question 11

AVF maturation failure

Answer 11

Technical failure
Dialysis-associated steal syndrome
aneurysm formation
infection
excess flow -> heart failure
arterial inflow or venous outflow stenosis

Question 12

AVF with poor pulse augmentation

Answer 12

inflow problem

Question 13

AVF without a pulse/thrill

Answer 13

thrombosed or stenotic lesion

outflow problem

Question 14

VTE treatment (provoked vs unprovoked)

Answer 14

Provoked -> RFs: surgery, travel, prolonged immobility, pregnancy, OCPs. Tx: systemic anticoagulation for 12 weeks

Provoked in atypical patients -> RFs: persistent immobility, other persistent reversible RFs, phlegmasia cerulean dolens. Tx: Anticoag for 6-12 months

Unprovoked -> malignancy, inherited thrombophilia. Tx: indefinite anticoagulation

IVC filer - indicated if systemic anticoagulation is contraindicated d/t high bleeding risk (intracranial surgery, spine surgery) or ongoing postop bleeding.

Distal DVTs can be surveilled with serial US.

Question 15

Large PSA distal to L SCA takeoff. CIs to endovascular repair with stent coverage?

Answer 15

Aberrant L vertebral artery
Dominant L vertebral artery
Previous CABG w/ LIMA usage
Functioning AVF in LUE

Question 16

Amaurosis fugax

Answer 16

Emboli to retinal or ophthalmic arteries (branch of ICA) d/t atherosclerotic disease
TIA, “pulling down shade” intermittent vision changes

Question 17

Degree of ICA stenosis by PSV and ICA/CCA PSV ratio

Answer 17

Normal - <50%: <125 cm/s, <2.0
50-69%: 125-230 cm/s, 2.0-4.0
>70%: >230 cm/s, >4.0

Question 18

Indications for CEA

Answer 18

+sxs w/ >50% ICA stenosis

asxs w/ >60% stenosis (if perioperative stroke or death rate <3%)

Question 19

Aortic Dissections

Answer 19

Type A: ascending aorta
Type B: descending aorta

Type B -> uncomplicated vs complicated
Complicated: impending rupture, rupture, malperfusion of aortic branch artery, refractory pain/HTN. Tx: EVAR
Uncomplicated tx: aggressive medical therapy w/ Beta-blocker

Question 20

Activated clotting time (ACT)

Answer 20

Measures intrinsic pathway
Monitors heparin therapy and determines amount of protamine needed to reverse the effects
More accurate for high doses (for CABG cases)

Question 21

Activated Partial Thromboplastin Time

Answer 21

Measures intrinsic pathway
Monitors heparin therapy
Not accurate for high doses of heparin

Question 22

Bleeding Time

Answer 22

Measures effectiveness of platelets

Outdated and time-consuming

Question 23

Prothrombin Time

Answer 23

Measures extrinsic pathway

Question 24

Fibromuscular dysplasia

Answer 24

noninflammatory nonatherosclerotic disorder –> arterial stenosis, aneurysm, dissection, arterial tortuosity

MC involved arteries: renal, ICA, vertebral, iliac, visceral

String of beads = pathognomonic

Tx: balloon angioplasty

Question 25

W/u of deep venous insufficiency from post-thrombotic syndrome

Answer 25

extremity venogram - determine if venous system is chronically occluded or diseased.

tx: recanalization with stenting

Question 26

Classification of peripheral arterial disease (Rutherford)

Answer 26

Class I - viable, intact cap return, MSI, +signals, urgent vascular eval required

Class IIa - threatened (salvageable), slow cap refill, intact or minimal loss of motor and sensation, inaudible signals, urgent revascularization vs thrombolysis

Class IIb - threatened (salvageable w/ immediate recon), slow/absent cap refill, partial paralysis, partial sensory loss + rest pain, absent signals, surgical revascularization

Class III - irreversible, absent cap refill, profound M/S loss, absent signals, amputation

Question 27

Critical limb ischemia

Answer 27

Multi-segment occlusive disease

ABIs <0.4

Question 28

Blue toe syndrome

Answer 28

atheroemboli, originate from aortic plaque, occlude small vessels

P/w: 6 Ps (pallor, pulseless, poikilothermia, paresthesia, paralysis, pain). + strong pedal pulses

Question 29

50% occlusion of ICA correlates to what PSV?

Answer 29

125 cm/sec

Question 30

50-69% occlusion of ICA correlates to what PSV?

Answer 30

125-230 cm/sec

Question 31

> 70% occlusion of ICA correlates to what PSV?

Answer 31

> 230 cm/sec

Question 32

Ischemic monomeric neuropathy

Answer 32

MC in W & +DM
Complication after access surgery
Due to shunting of blood away from nerves of distal upper extremity

Signs/sxs: pain out of proportion, acute sensory and motor deficits after creation of AVF

Dx: clinical, nerve conduction studies show axonal damage

Tx: immediate ligation of AVF, restoration of blood flow to hand

Question 33

Venous hypertension at dialysis access site

Answer 33

Signs/sxs: extremity edema, varicosities, dermatosclerosis, venous ulceration, prolonged bleeding, difficulty with dialysis against high pressure (constant beeping of dialysis machine)

MCC: stenosis, thrombosis of central venous system 2/2 previous catheterization

dx: venogram/fistulogram
tx: end-vascular recanalization of stenotic or occluded veins, or bypass