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FRCR 2A > Vascular > Flashcards

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
Q

Corona mortis

A

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.

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26
Q

Positioning of subclavian vessels in neck

A

Subclavian artery runs within the triangle with brachial plexus. Subclavian vein is anterior to triangle.

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27
Q

Subclavian artery branches

A

Vertebral, Internal thoracic, Thyrocervical trunk, Costocervical trunk, dorsal scapular

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28
Q

When does the axillary artery start?

A

Subclavian artery becomes axillary artery after passing under the first rib

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29
Q

When does the brachial artery start?

A

Axillary artery passes under teres major and then becomes brachial artery

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30
Q

How to tell ulnar artery from radial artery?

A
  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
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31
Q

Normal variants in forearm vascular anatomy

A

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

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32
Q

When does the common femoral artery start?

A

After the external iliac artery gives off the inferior epigastric

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33
Q

What is the most medial artery in the leg?

A

Posterior tibial artery

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34
Q

What is the most lateral artery in the leg?

A

Anterior tibial artery

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35
Q

Gastric varices

A

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.

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36
Q

Splenorenal shunt

A

Abnormal collateral between splenic vein and renal vein - desirable shunt as not associated with GI bleeding. Enlarged shunts are associated with hepatic encephalopathy.

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37
Q

Most common congenital venous anomaly in chest

A

Left sided SVC

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38
Q

Most common associated congenital heart disease with left sided SVC

A

ASD

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39
Q

Left sided SVC associated with

A

Unroofed coronary sinus

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40
Q

Left sided SVC drainage

A

92% of the time it drains into the coronary sinus

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41
Q

Duplicated IVC

A

Associated with renal findings - horseshoe or crossed fused ectopic kidneys, often also have circumaortic renal collars

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42
Q

Circumaortic venous collar

A

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

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43
Q

Azygous continuation

A

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

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44
Q

Acute aortic syndromes

A

Aortic dissection, intramural haematoma, penetrating ulcer

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45
Q

Most common cause of acute aortic syndrome

A

Aortic dissection (70%)

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46
Q

Most common cause of aortic dissection

A

Hypertension (70%) - leads to intimal tear resulting in two lumens

47
Q

Stanford A Classification

A

75% of dissections and involve ascending aorta and arch proximal to take off of the left subclavian - treated surgically

48
Q

Stanford B Classification

A

Distal to the take off of the left subclavian and are treated medically unless there are complications

49
Q

Causes of aortic dissection

A

Hypertension, Marfans, Turners (aortic valve defects), infection and pregnancy. Cocaine use in normotensive patients.

50
Q

Aortic dissection findings

A

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
Q

True Lumen in aortic dissection

A

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
Q

False Lumen in aortic dissection

A

“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
Q

Pulmonary sling

A

Aberrant left pulmonary artery coming off the right pulmonary artery

54
Q

First reason why pulmonary sling is unique

A

Only anomaly to create indentations in the posterior trachea and anterior oesophagus

54
Q

Second reason why pulmonary sling is unique

A

Only anomaly that can cause stridor in a patient with a normal left sided arch

55
Q

“Beware the hairpin turn”

A

Classic angiographic appearance of the Artery of Adamkiewicz is the ‘hairpin turn’ as its anastomosis is with the anterior spinal artery

56
Q

Replaced right hepatic artery

A

Arises from the SMA

57
Q

Accessory left hepatic artery

A

Duplicated left hepatic artery, one arising normally from coeliac and the other from left gastric artery

58
Q

Replaced left hepatic artery

A

Arises from left gastric artery

59
Q

Ovarian artery origin

A

Arise from anterior-medial aorta 80-90%, rarely can have a variant origin from he internal iliac

60
Q

Anastomotic connection of ovarian artery

A

With the uterine artery

61
Q

Artery anatomy

A

Intima, media and externa

62
Q

Penetrating ulcer

A

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
Q

Penetrating ulcer #1 risk factor

A

Atherosclerosis

64
Q

Penetrating ulcer clinical history

A

Elderly patient with hypertension and atherosclerosis usually involving the descending thoracic aorta

65
Q

Penetrating ulcer saccular morphology

A

Around the arch

66
Q

Where do penetrating ulcers never occur?

A

In the aortic root, highest flow pressures prevent atherosclerosis

67
Q

Treatment of penetrating ulcer?

A

Medical - similar to type B dissections. if treated tend to do worse than dissections

68
Q

When is treatment for a penetrating ulcer surgical?

A

Haemodynamic instability, pain, rupture, distal emboli, rapid enlargement

69
Q

Pregnancy and dissection

A

Increases risk

70
Q

Cocaine and dissection

A

Cocaine use in young otherwise healthy person is risk of dissection

71
Q

Classic dissection stem contains

A

Patient with “hypertension” and a sub-sternal “tearing sensation”

72
Q

Floating viscera sign

A

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
Q

Static dissection flap in abdomen

A

Dissection flap in the feeding artery - usually treated by stenting

74
Q

Dynamic dissection flap in abdomen

A

Dissection flap dangling in front of ostium - usually treated with fenestration

75
Q

Mural thrombus vs Thrombosed dissection

A

Dissection should spiral, thrombus tends to drop straight down
Intimal calcifications - dissection will displace them

76
Q

Intramural haematoma mechanism flow primary event

A

Seconday to hypertension
HTN -> Blasted vaso vasorum -> intramural haematoma -> serosal rupture // intima tears -> pesudoanurysm // dissection

77
Q

Intramural haematomg mechanism flow seconday event

A

Atherosclerosis -> Focal plaque ruptures -> focal intramural haematoma -> dissection // serosal rupture -> pseudoaneurysm

78
Q

Intramural haematoma on imaging

A

Crescent sign of IMH best seen hyperdense on non-contrast CT
Contrast CT - difficult to distinguish from plaque
T1 bright crescent

79
Q

Intramural haematoma treatment

A

Also uses Stanford A vs B
Controversial opinion of Stanford A = surgery, B = medical

80
Q

Intramural haematoma with worse prognosis

A

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
Q

True aneurysm

A

Enlargement of the lumen of the vessel to 1.5 times its normal diameter - the 3 layers are intact

82
Q

False (pseudo) aneurysm

A

3 layers are NOT intact
Essentially a contained rupture

83
Q

Which type of aneurysm has a higher risk of rupture?

A

Pseudoaneurysm

84
Q

Causes of pseudoaneurysm

A

Trauma
Groin sticks
Infection (mycotic)
Pancreatitis
Some vasculidities

85
Q

Psuedoaneurysm on ultrasound

A

“Yin Yang” sign (although can be seen in true saccular aneurysms) with “to and fro” on pulsed doppler

86
Q

SVC Syndrome

A

Occurs secondary to complete or near complete obstruction of the SVC

87
Q

SVC Syndrome causes

A

External compression - lymphoma, lung cancer
Intravascular obstruction - CVC or pacemaker wire with thrombus
Fibrosing mediastinitis - histoplasmosis

88
Q

Traumatic pseudo aneurysm common location

A

Aortic isthmus (90%) - tethering from ligaments arteriosum

89
Q

Traumatic pseudo aneurysm second and third most common locations

A

Ascending aorta
Diaphragmatic hiatus

90
Q

CXR with traumatic pseudoaneurysm

A

Wide mediastinum, deviation of NG tube to the right, depressed left main bronchus, left apical cap

91
Q

Ascending aortic calcifications causes

A

Takayasu and syphilis
Atherosclerosis typically spares the ascending aorta

92
Q

Aneurysm definition

A

Enlargement of artery to 1.5x its diameter

93
Q

Most common cause of aneurysm

A

Atherosclerosis

94
Q

Most common cause of ascending aorta aneurysm

A

Medial degeneration

94
Q

Cystic medial necrosis

A

Marfans

95
Q

Aneurysms of valsalva sinus

A

More common in Asian men, typically involve right sinus
Congenital or acquired (infectious)

96
Q

Most common cardiac anomaly with aortic sinus aneurysm

A

VSD

97
Q

Aortic sinus aneurysm rupture

A

Can lead to cardiac tamponade

98
Q

Aortic sinus aneurysm repair

A

Surgical repair with Bentall procedure

99
Q

Warning signs of impending rupture

A

Peri-aortic stranding, rapid enlargement (10mm or more per year) or pain

100
Q

Most common imaging finding of aortic rupture

A

Retroperitoneal hematoma adjacent to a AAA

101
Q

Indicator for elective aneurysm repair

A

Maximum diameter of aneurysm - treatment usually around 6cm

102
Q

Protective against aneurysmal rupture

A

Thick circumferential mural thrombus
Enlargement of patent lumen can indicate lysis of thrombus and predispose to rupture

103
Q

Draped aorta sign

A

Posterior wall of the aorta drapes over the vertebral column

104
Q

Findings of impending rupture

A

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
Q

Mycotic aneurysm

A

Most often saccular and most often pseudo aneurysms. Prone to rupture

106
Q

Mycotic aneurysm origin

A

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
Q

Mycotic aneurysm location

A

Most occur in the thoracic or supra-renal aorta

108
Q

Mycotic aneurysm typical findings

A

Saccular shape, lobular contours, peri-aortic inflammation, abscess, peri-aortic gas. Expand faster than atherosclerotic aneurysms

109
Q

Neurofibromatosis 1 vascular findings

A

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
Q

Marfan syndrome gene mutation

A

fibrillin gene

111
Q

Marfan syndrome aneurysm

A

“Annuloaortic ectasia” with dilatation of the aortic root

112
Q
A

FRCR 2A (1 decks)

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