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Vascular Flashcards

1
Q

Definition of aortic root

A

Portion of aorta extending from aortic valve annulus t the Sino-tubular junction

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2
Q

Largest diameter of aorta

A

Thoracic aorta

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3
Q

Sinsuses of valsalva

A

3 out pouching (right, left, posterior) above the annulus that terminate at the ST Junction. Right and left coronaries come off right and left sinuses. Posterior cusp sometimes called ‘non-coronary’ cusp.

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4
Q

Isthmus

A

Segment of the aorta between the origin of the left subclavian and the ligamentous arteriosum

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5
Q

Ductus bump

A

Just distal to the isthmus is a contour bulge along the lesser curvature, which is a normal structure (not a pseudoaneurysm)

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6
Q

Aortic Arch Variants

A

Normal (75%)
Bovine Arch (15%)
Left CC off Brachiocephalic
4 separate origins

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7
Q

Bovine Arch

A

Common origin of brachiocephalic artery and left common carotid artery

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8
Q

Artery of Adamkiewicz

A

Thoracic aorta gives off important feeders including the great anterior medullary artery (Artery of Adamkiewicz) which serves as dominant feeder of spinal cord - usually comes off on left (70%) between T8-L1 (90%)

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9
Q

First branch of SMA

A

Inferior pancreaticoduodneal

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10
Q

Replaced artery

A

Different origin

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11
Q

Duplicate artery

A

Called accessory

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12
Q

Vessel in fissure of ligamentum venosum

A

Accessory or replaced left hepatic artery arising from the left gastric artery

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13
Q

Positioning of replaced right hepatic artery

A

Replaced right hepatic artery is posterior to the main portal vein - increases risk of injury in pancreatic surgeries. Proper hepatic is normally anterior to main portal vein.

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14
Q

Posterior branches of internal iliac artery

A

“I Love Sex in the butt” - Iliolumbar, Lateral sacral, Superior gluteal

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15
Q

Persistent sciatic artery

A

Continuation of the internal iliac artery, passes posterior to the femur with distal anastomosis

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16
Q

External iliac artery occluded but strong pulse in foot

A

Persistent sciatic artery

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17
Q

Persistent sciatic artery complications

A

Aneurysm formation and early atherosclerosis in vessel

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18
Q

Coeliac axis to SMA arterial collateral pathway

A

Coeliac -> Superior pancreaticoduodenal -> Inferior pancreaticoduodenal -> SMA

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19
Q

Arc of Buhler

A

4% of people, collateral pathway for coeliac-SMA. Can have very rare aneurysm which occurs in association with coeliac axis stenosis

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20
Q

SMA to IMA arterial collateral pathway

A

SMA -> Middle Colic -> Left branch of middle colic -> Arc of Riolan -> Left Colic -> IMA

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21
Q

Arc of Riolan

A

“meandering mesenteric artery” - classically a connection between the middle colic of SMA and left colic of IMA

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22
Q

Marginal artery of Drummond

A

Another SMA to IMA connection - anastomosis of terminal branches of ileocolic, right colic, middle colic of SMA and left colic and sigmoid branches of IMA to form continuous arterial circle along inner border of colon

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23
Q

IMA to iliacs arterial collateral pathway

A

IMA -> Superior rectal -> Inferior rectal -> Internal pudendal -> Anterior branch of internal iliac

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24
Q

Winslow pathway

A

Collateral pathway seen in setting of aorto-iliac occlusive disease, can be accidentally cut during thoracic surgery.

Subclavian -> Internal thoracic -> Superior epigastric -> Inferior epigastric -> External iliac

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25
Corona mortis
Vascular connection between obturator and external iliac. Vessel courses over the superior pubic rim. Can be injured in pelvic trauma or surgery and very hard to ligate. Hypothetically can cause a type 2 endoleak.
26
Positioning of subclavian vessels in neck
Subclavian artery runs within the triangle with brachial plexus. Subclavian vein is anterior to triangle.
27
Subclavian artery branches
Vertebral, Internal thoracic, Thyrocervical trunk, Costocervical trunk, dorsal scapular
28
When does the axillary artery start?
Subclavian artery becomes axillary artery after passing under the first rib
29
When does the brachial artery start?
Axillary artery passes under teres major and then becomes brachial artery
30
How to tell ulnar artery from radial artery?
1. Ulnar artery usually bigger 2. Ulnar artery usually gives off common interosseous 3. Ulnar artery supplies superficial palmar arch and therefore radial supplies deep arch
31
Normal variants in forearm vascular anatomy
Anterior interosseous branch (median artery) persists and supplies the deep palmar arch instead of radial artery High origin of radial artery - comes off axillary or high brachial artery
32
When does the common femoral artery start?
After the external iliac artery gives off the inferior epigastric
33
What is the most medial artery in the leg?
Posterior tibial artery
34
What is the most lateral artery in the leg?
Anterior tibial artery
35
Gastric varices
Portal hypertension shunts blood away from liver into systemic system. Most gastric varices are formed by left gastric vein. 80-85% drain into the inferior phrenic and then into left renal vein.
36
Splenorenal shunt
Abnormal collateral between splenic vein and renal vein - desirable shunt as not associated with GI bleeding. Enlarged shunts are associated with hepatic encephalopathy.
37
Most common congenital venous anomaly in chest
Left sided SVC
38
Most common associated congenital heart disease with left sided SVC
ASD
39
Left sided SVC associated with
Unroofed coronary sinus
40
Left sided SVC drainage
92% of the time it drains into the coronary sinus
41
Duplicated IVC
Associated with renal findings - horseshoe or crossed fused ectopic kidneys, often also have circumaortic renal collars
42
Circumaortic venous collar
Additional left renal vein that passes posterior to the aorta Important in renal transplant and IVC filter placement Anterior limb is superior and posterior limb is inferior
43
Azygous continuation
Absence of hepatic segment of IVC - hepatic veins drain directly into right atrium. IVC duplication often in these patients with left IVC terminating in left renal vein. Associated with POLYSPLENIA
44
Acute aortic syndromes
Aortic dissection, intramural haematoma, penetrating ulcer
45
Most common cause of acute aortic syndrome
Aortic dissection (70%)
46
Most common cause of aortic dissection
Hypertension (70%) - leads to intimal tear resulting in two lumens
47
Stanford A Classification
75% of dissections and involve ascending aorta and arch proximal to take off of the left subclavian - treated surgically
48
Stanford B Classification
Distal to the take off of the left subclavian and are treated medically unless there are complications
49
Causes of aortic dissection
Hypertension, Marfans, Turners (aortic valve defects), infection and pregnancy. Cocaine use in normotensive patients.
50
Aortic dissection findings
Displacement of intimal calcifications on non-contrast Intimal flap in 70% of cases Where there are two lumens seen, they spiral around each other Thrombus located in false lumen
51
True Lumen in aortic dissection
Continuity with undissected portion of aorta Smaller cross sectional areas (with higher velocity blood) Surrounded by calcifications (if present) Usually contains origin of coeliac trunk, SMA and RIGHT renal artery
52
False Lumen in aortic dissection
"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 origin of left renal artery Surrounds true lumen in type A dissection
53
Pulmonary sling
Aberrant left pulmonary artery coming off the right pulmonary artery
54
First reason why pulmonary sling is unique
Only anomaly to create indentations in the posterior trachea and anterior oesophagus
54
Second reason why pulmonary sling is unique
Only anomaly that can cause stridor in a patient with a normal left sided arch
55
"Beware the hairpin turn"
Classic angiographic appearance of the Artery of Adamkiewicz is the 'hairpin turn' as its anastomosis is with the anterior spinal artery
56
Replaced right hepatic artery
Arises from the SMA
57
Accessory left hepatic artery
Duplicated left hepatic artery, one arising normally from coeliac and the other from left gastric artery
58
Replaced left hepatic artery
Arises from left gastric artery
59
Ovarian artery origin
Arise from anterior-medial aorta 80-90%, rarely can have a variant origin from he internal iliac
60
Anastomotic connection of ovarian artery
With the uterine artery
61
Artery anatomy
Intima, media and externa
62
Penetrating ulcer
Ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wall, when it reached the media it produces a haematoma within the media
63
Penetrating ulcer #1 risk factor
Atherosclerosis
64
Penetrating ulcer clinical history
Elderly patient with hypertension and atherosclerosis usually involving the descending thoracic aorta
65
Penetrating ulcer saccular morphology
Around the arch
66
Where do penetrating ulcers never occur?
In the aortic root, highest flow pressures prevent atherosclerosis
67
Treatment of penetrating ulcer?
Medical - similar to type B dissections. if treated tend to do worse than dissections
68
When is treatment for a penetrating ulcer surgical?
Haemodynamic instability, pain, rupture, distal emboli, rapid enlargement
69
Pregnancy and dissection
Increases risk
70
Cocaine and dissection
Cocaine use in young otherwise healthy person is risk of dissection
71
Classic dissection stem contains
Patient with "hypertension" and a sub-sternal "tearing sensation"
72
Floating viscera sign
Classic angiographic sign of abdominal aortic dissection Opacification of abdominal aortic branch vessels during aortography with the branch vessels (coeliac, SMA and RIGHT renal artery) arising out of nowhere Little to no anterograde opacification of the aortic true lumen
73
Static dissection flap in abdomen
Dissection flap in the feeding artery - usually treated by stenting
74
Dynamic dissection flap in abdomen
Dissection flap dangling in front of ostium - usually treated with fenestration
75
Mural thrombus vs Thrombosed dissection
Dissection should spiral, thrombus tends to drop straight down Intimal calcifications - dissection will displace them
76
Intramural haematoma mechanism flow primary event
Seconday to hypertension HTN -> Blasted vaso vasorum -> intramural haematoma -> serosal rupture // intima tears -> pesudoanurysm // dissection
77
Intramural haematomg mechanism flow seconday event
Atherosclerosis -> Focal plaque ruptures -> focal intramural haematoma -> dissection // serosal rupture -> pseudoaneurysm
78
Intramural haematoma on imaging
Crescent sign of IMH best seen hyperdense on non-contrast CT Contrast CT - difficult to distinguish from plaque T1 bright crescent
79
Intramural haematoma treatment
Also uses Stanford A vs B Controversial opinion of Stanford A = surgery, B = medical
80
Intramural haematoma with worse prognosis
Haematoma thickness >2cm Association with aneurysmal dilation of the aorta - 5cm or more Progression to dissection or penetrating ulcer IMH + Penetrating ulcer has a worse outcome compared to IMH + Dissection
81
True aneurysm
Enlargement of the lumen of the vessel to 1.5 times its normal diameter - the 3 layers are intact
82
False (pseudo) aneurysm
3 layers are NOT intact Essentially a contained rupture
83
Which type of aneurysm has a higher risk of rupture?
Pseudoaneurysm
84
Causes of pseudoaneurysm
Trauma Groin sticks Infection (mycotic) Pancreatitis Some vasculidities
85
Psuedoaneurysm on ultrasound
"Yin Yang" sign (although can be seen in true saccular aneurysms) with "to and fro" on pulsed doppler
86
SVC Syndrome
Occurs secondary to complete or near complete obstruction of the SVC
87
SVC Syndrome causes
External compression - lymphoma, lung cancer Intravascular obstruction - CVC or pacemaker wire with thrombus Fibrosing mediastinitis - histoplasmosis
88
Traumatic pseudo aneurysm common location
Aortic isthmus (90%) - tethering from ligaments arteriosum
89
Traumatic pseudo aneurysm second and third most common locations
Ascending aorta Diaphragmatic hiatus
90
CXR with traumatic pseudoaneurysm
Wide mediastinum, deviation of NG tube to the right, depressed left main bronchus, left apical cap
91
Ascending aortic calcifications causes
Takayasu and syphilis Atherosclerosis typically spares the ascending aorta
92
Aneurysm definition
Enlargement of artery to 1.5x its diameter
93
Most common cause of aneurysm
Atherosclerosis
94
Most common cause of ascending aorta aneurysm
Medial degeneration
94
Cystic medial necrosis
Marfans
95
Aneurysms of valsalva sinus
More common in Asian men, typically involve right sinus Congenital or acquired (infectious)
96
Most common cardiac anomaly with aortic sinus aneurysm
VSD
97
Aortic sinus aneurysm rupture
Can lead to cardiac tamponade
98
Aortic sinus aneurysm repair
Surgical repair with Bentall procedure
99
Warning signs of impending rupture
Peri-aortic stranding, rapid enlargement (10mm or more per year) or pain
100
Most common imaging finding of aortic rupture
Retroperitoneal hematoma adjacent to a AAA
101
Indicator for elective aneurysm repair
Maximum diameter of aneurysm - treatment usually around 6cm
102
Protective against aneurysmal rupture
Thick circumferential mural thrombus Enlargement of patent lumen can indicate lysis of thrombus and predispose to rupture
103
Draped aorta sign
Posterior wall of the aorta drapes over the vertebral column
104
Findings of impending rupture
Draped aorta sign Increased aneurysm size Focal discontinuity in circumferential wall calcifications Hyperdense crescent sign - well defined peripheral crescent of increased attenuation on non-con CT
105
Mycotic aneurysm
Most often saccular and most often pseudo aneurysms. Prone to rupture
106
Mycotic aneurysm origin
Most often occur via haematogenous seeding in the setting of septicaemia (endocarditis) Can occur from direct seeding via a psoas abscess or vertebral osteomyelitis
107
Mycotic aneurysm location
Most occur in the thoracic or supra-renal aorta
108
Mycotic aneurysm typical findings
Saccular shape, lobular contours, peri-aortic inflammation, abscess, peri-aortic gas. Expand faster than atherosclerotic aneurysms
109
Neurofibromatosis 1 vascular findings
Aneurysms and stenoses in the aorta and larger arteries Dysplastic features in smaller vessels Renal artery stenosis can occur leasing to renovascular hypertension "Orificial renal artery stenosis presenting with hypertension in teenager/child"
110
Marfan syndrome gene mutation
fibrillin gene
111
Marfan syndrome aneurysm
"Annuloaortic ectasia" with dilatation of the aortic root
112

FRCR 2A (1 decks)

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