Vascular Flashcards
GU) 25. A 30-year-old man with known Hep B surface Antigen (HBsAg), abdominal pain, malaise and weight loss is diagnosed with Polyarteritis nodosa (PAN). Which of the following is true?
A. Affects small arteries only
B. Causes aneurysms which are usually 5-10mm in size
C. Produces moth-eaten nephrograms after thrombosis of the microaneurysms
D. Angiography has signifcantly higher sensitivity than specifcity in diagnosis
E. Angiography has a much higher positive predictive value (PPV) compared with negative predictive value (NPV)
C. Produces moth-eaten nephrograms after thrombosis of the microaneurysms
Affects medium and small arteries.
Aneurysms are 2-3cm in size,
which when thrombosed produce moth-eaten nephrogram.
Angiography has high sensitivity and specificity
but a much higher negative than positive predictive value in diagnosis.
Diagnosis is often made with clinical features and angiography.
GU) 26. A 29-year-old female with new onset hypertension has normal renal tract ultrasound. Magnetic resonance Angiography (MRA) is performed which demonstrates narrowing at the distal right main renal artery. Which is the most likely diagnosis?
A. Renal artery stenosis
B. Fibromuscular dysplasia
C. Arteriosclerotic RA disease
D. Neurofbromatosis
E. Polyarteritis nodosa
B. Fibromuscular dysplasia
FMD accounts for 35% of RAS. It is more common in children and young adults, affecting a greater amount of females than males.
It is associated with hypertension and progressive renal insuffciency.
FMD occurs bilaterally in 2⁄3 of cases and R > L 4:1.
It usually affects the mid distal renal artery and there can be a beaded appearance of artery
- A 30-year-old male being investigated for progressive intermittent left calf claudication presents. Doppler waveforms of the popliteal artery are noted to be diminished during muscle contraction. Angiography reveals medial deviation of the popliteal artery, popliteal stenosis and post-stenotic dilatiation. Which is the most likely diagnosis?
A. Popliteal aneurysm with thrombosis
B. Ruptured Baker’s cyst
C. Popliteal artery entrapment syndrome
D. Buerger’s disease
E. Cystic adventitial disease of the popliteal artery
C. Popliteal artery entrapment syndrome
Stress angiography shows a normal arterial lumen with the foot in the relaxed position, with narrowing of the lumen during stress manoeuvres
- Which of the following features distinguishes coarctation from pseudocoarctation of the aorta?
A. Associated hypertension
B. Bicuspid aortic valve
C. Asymptomatic history
D. Indentation of the left lateral margin of the aortic arch in the region of the aortopulmonary window
E. Rib notching
E. Rib notching
The following features are not present in pseuocoarctation: rib notching, dilatation of the brachiocephalic arteries, LV enlargement and post-stenotic dilatation.
5) A 28-year-old male with known Marfan’s syndrome presents with chest pain and shortness of breath. An echocardiogram is performed. What are the most likely findings?
a. aortic regurgitation and dilatation
b. pulmonary stenosis
c. aortic stenosis and post-stenotic dilatation
d. global myocardial wall thickening
e. ventricular septal defect
a. aortic regurgitation and dilatation
Marfan’s syndrome is an autosomal dominant connective tissue disorder.
It predominantly affects the musculoskeletal system but 60–98% of patients have cardiovascular manifestations.
There is myxomatous degeneration of the aortic wall, leading to dilatation of the aortic root and aortic regurgitation.
There is an association with congenital heart disease, incomplete coarctation and atrial septal defects.
18) A right-sided aortic arch with mirror-image branching is most frequently associated with which congenital cardiac abnormality?
a. pulmonary atresia and ventricular septal defect
b. truncus arteriosus
c. uncomplicated ventricular septal defect
d. Fallot’s tetralogy
e. corrected transposition of the great vessels
d. Fallot’s tetralogy
There is a 98% incidence of associated congenital heart disease with a right-sided aortic arch with mirror-image branching.
Nearly all of these cases will be tetralogy of Fallot.
All of the given options are associated with rightsided aortic arch, as well as dextrocardia with situs inversus and double-outlet right ventricle.
Right-sided aortic arch with left subclavian artery is associated with only a 12% incidence of congenital heart disease, again with Fallot’s tetralogy being the most commonly associated abnormality
GU) 18) A 55-year-old, hepatitis B-positive male under investigation for painless haematuria is admitted as an emergency with unilateral loin pain and hypotension. A renal arteriogram shows multiple, bilateral, small, renal artery branch aneurysms. Which of the following antibody titres is most likely to be positive?
a. anti-double-stranded DNA
b. anti-basement membrane
c. anti-Ro
d. anti-immunoglobulin G
e. perinuclear anti-neutrophil cytoplasmic
e. perinuclear anti-neutrophil cytoplasmic
While several forms of arteritis can cause multiple small renal aneurysms, it is polyarteritis nodosa that does so most commonly, affecting men more than women with a mean age of 55 years, the range being 18–81 years.
It is associated with HIV and hepatitis B infection, and pANCA is usually positive.
Systemic lupus erythematosus is associated with anti-double-stranded DNA antibodies,
Goodpasture’s disease with anti-basement membrane antibodies,
Sjogren’s syndrome with anti-Ro and anti-La antibodies
and rheumatoid arthritis with antiimmunoglobulin G (anti-IgG), also known as rheumatoid factor.
21) A 32-year-old male presents with headaches and bilateral lower limb claudication. He is noted to have weak pulses in the lower limbs. A chest radiograph shows a ‘figure-3’ indentation of the aorta and inferior rib notching. The cardiac apex is elevated. There is no previous medical history. What is the most likely diagnosis?
a. superior vena caval obstruction
b. aortic dissection
c. coarctation of the aorta
d. aortic thrombosis
e. transposition of the great vessels
c. coarctation of the aorta
Adults presenting with coarctation usually have headaches (due to hypertension) and claudication (due to hypo perfusion).
The chest radiograph shows an indentation on the lateral margin of the aorta (‘figure-3’ sign) and elevation of the cardiac apex due to left ventricular hypertrophy.
Rib notching is seen in adults, usually over 20 years, and affects the third to eighth ribs.
Superior vena caval obstruction may cause rib notching but also causes a ‘nipple’ on the side of the aorta due to dilated collaterals (accessory hemizygous).
Aortic thrombosis may present similarly to coarctation, but the ‘figure-3’ sign is not seen.
Transposition presents in the first 2 weeks of life.
23) A 40-year-old female presents with a stroke, which is confirmed on CT of brain. She gives a history of worsening claudication of the limbs and a long history of fever and myalgia. CT of the neck and thorax shows thickening of the arterial walls of the aorta and major vessels with irregular stenotic lesions throughout the aorta, with focal areas of dilatation and stenosis in the brachiocephalic arteries and carotid arteries. What is the most likely diagnosis?
a. fibromuscular dysplasia
b. syphilis
c. atherosclerosis
d. Marfan’s syndrome
e. Takayasu’s arteritis
e. Takayasu’s arteritis
Takayasu’s arteritis is a granulomatous inflammatory condition of unknown cause.
It is the only aortitis to cause stenosis/occlusion of the aorta.
It produces irregular short or long stenotic lesions within the aorta.
Involvement of the great vessels usually produces multisegmental dilatation with segmental septation.
Atherosclerosis tends to occur in older patients.
Syphilis produces aneurysms of the ascending aorta with extensive calcification.
Marfan’s syndrome produces aneurysms and occasionally is associated with aortic coarctation.
25) A patient with known polyarteritis nodosa presents with acute left loin pain. Which of the following is most likely to be seen on ultrasound scan?
a. hydronephrosis
b. a solid mass with a perinephric collection
c. multiple renal artery aneurysms and perinephric collection
d. crossed fused ectopia
e. small kidneys with increased echogenicity
c. multiple renal artery aneurysms and perinephric collection
Polyarteritis nodosa is a systemic necrotizing inflammation of mediumsized and small muscular arteries.
No glomerulonephritis (small, echogenic kidneys) is present.
The condition most commonly affects the kidneys (85%) and is usually seen as multiple small intrarenal aneurysms, which may disappear due to thrombosis.
Recognized complications are perinephric or subcapsular hemorrhage due to aneurysm rupture.
Crossed fused ectopia and hydronephrosis are not recognized features of polyarteritis nodosa.
42) A 28-year-old male is involved in a road traffic accident and sustains chest trauma. He has chest pain and bruising over the chest with reduced blood pressure. A chest radiograph shows a shift of the trachea to the right at T3–4 level with depression of the left main bronchus and loss of clarity of the aortic knuckle. Which diagnosis should be considered?
a. bronchial rupture
b. superior vena caval laceration
c. azygos vein injury
d. aortic rupture
e. internal mammary artery injury
d. aortic rupture
Aortic injury is usually fatal, though some patients survive to reach hospital. A chest radiograph may show a variety of features including deviation of the trachea and esophagus (position of nasogastric tube) to the right, depression of the left main bronchus, apical pleural cap and left pleural effusion.
The presence of a mediastinal haematoma following trauma is more likely due to azygos or hemizygous vein injury or possibly internal mammary or intercostal artery injury.
Superior vena caval injury tends to cause right-sided mediastinal and lung changes.
Bronchial rupture may be accompanied by vascular injury but would tend to present with pneumomediastinum and pneumothorax with or without collapsed lung.
45 A 28 year old man has a Barium swallow to investigate dysphagia. The RAO views show a ‘reverse 3’ indentation in the mid oesophagus. Which of the following features would make the diagnosis of true coarctation more likely than pseudocoarctation?
(a) Ejection systolic murmur
(b) His lack of symptoms
(c) Inferior rib notching
(d) No gradient on pressure studies
(e) Widening of the superior mediastinum
(c) Inferior rib notching
Pseudocoarctation is an acute kink/ anterior buckling just distal to the left SCA origin. Patients are asymptomatic and there is no pressure gradient (hence collateral vessels with subsequent rib-notching are not seen). There is an ESM on auscultation and the superior mediastinum appears widened due to elongated, redundant ascending aorta and elongated aortic arch. Both true and pseudocoarctation produce the ‘figure 3’ sign on angiogram (‘reverse 3’ on RAO projections at Barium swallow) due to notching at the ligamentum arteriosum.
GIT) A 65-year-old man presents with a several-week history of lower abdominal pain and diarrhoea. On examination he has tenderness and guarding in the left lower quadrant. On contrast-enhanced CT, the inferior mesenteric vein is dilated, with a thin rim of enhancement around a central area of low density. What is the most likely additional pathology demonstrated on the CT?
A. sigmoid diverticulitis
B. appendicitis
C. Crohn’s disease
D. pancreatitis
E. caecal malignancy
A. sigmoid diverticulitis
The inferior mesenteric vein provides venous drainage for the rectum, sigmoid and descending colon, and is a potential route of spread of neoplastic and inflammatory conditions. Inferior mesenteric vein thrombosis may occur secondary to an inflammatory process, most commonly diverticulitis, or malignancy. Other potential causes include hypercoagulable states, surgery, trauma and bowel obstruction. Appearances are of an enlarged vein with rim enhancement surrounding central low density thrombus. Superior mesenteric vein thrombosis is much more common (95% of mesenteric venous thrombosis) and may follow an inflammatory or neoplastic process affecting the small intestine, caecum, and ascending and transverse colon.
29) A 64-year-old man presents with pain in the left arm when exercising, associated with a headache. The clinical team suspect subclavian steal syndrome. Ultrasound scan, however, shows normal flow in the carotid and vertebral arteries bilaterally. What is most likely to happen to the flow in the vessels during patient exercise to reproduce the pain?
a. reversal of flow in the right carotid artery
b. reversal of flow in the left carotid artery
c. reversal of flow in the right vertebral artery
d. reversal of flow in the left vertebral artery
e. no change
d. reversal of flow in the left vertebral artery
In subclavian steal syndrome (SSS), there is a stenosis in the subclavian artery proximal to the vertebral artery origin. This causes reversal of flow in the ipsilateral vertebral artery to maintain blood supply to the upper limb. If the stenosis is not severe, there is normal flow at rest, but exercise aggravates this by increasing the blood supply to the limb. As the stenosis is unable to accommodate the increased flow, the flow in the ipsilateral vertebral artery is reversed. This is termed ‘occult SSS’.
GIT) A 70-year-old man presents with fresh bleeding per rectum. He undergoes resuscitation, receiving 5 units of blood over the following 24 hours. Colonoscopy is unsuccessful in detecting the source of the bleeding, and he continues to pass fresh blood, although he remains haemodynamically stable. What is the most appropriate next investigation?
A. 99m Tc-labelled red blood cell radionuclide imaging
B. CT angiography
C. repeat colonoscopy
D. digital subtraction mesenteric angiography
E. abdominal ultrasound scan
B. CT angiography
Several imaging methods are available for use in those patients in whom endoscopy fails to detect the source of bleeding in gastrointestinal haemorrhage.
Radionuclide imaging is non-invasive and very sensitive, detecting bleeding rates as low as 0.1–0.5 ml/min. Images are acquired over several hours, enabling detection of intermittent and venous bleeding, but anatomical localization can be insensitive and variable.
Conventional angiography is invasive and requires active bleeding at the time of both imaging and contrast injection. Higher bleeding rates of 0.5–1 ml/min are required, and motion artefact from bowel peristalsis may be problematic, but it provides superior localization of the bleeding site and options for therapeutic intervention.
CT angiography is advocated as the most appropriate investigation, due to its wide availability, minimal invasiveness and high sensitivity, detecting bleeding rates as low as 0.3 ml/min in animal models. In addition, it enables assessment of a pathological lesion causing bleeding, which may be helpful in planning further management.
45) A 42-year-old female patient presents with a swollen calf, and deep venous thrombosis is suspected clinically. The D-dimer is elevated. Doppler ultrasound scan shows no thrombus in the thigh or calf veins. Spectral Doppler shows continuous signal with no respiratory variation. Which further investigation may be of value?
a. no further investigation – normal findings
b. pelvic ultrasound
c. CT pulmonary angiogram
d. chest radiograph
e. echocardiogram
b. pelvic ultrasound
Even with no clot seen, the loss of respiratory variation with continuous flow suggests a more proximal occlusion. As the limb swelling is unilateral, the most likely site of occlusion would be in the pelvic veins.
58) In multidetector CT angiography of the lower limbs, the effects of calcification on the images can be reduced by the use of which post-processing technique?
a. curved planar reformat
b. maximum-intensity projection
c. minimum-intensity projection
d. volume rendering
e. digital subtraction of pre- and post-contrast studies
a. curved planar reformat
The effects of vessel calcification can be difficult to remove from CT angiogram, and ultimately axial data may be the only method to assess the vessels accurately.
Curved planar reformat images may be helpful to show the lumen. This can be more problematic in small vessels.
Maximum-intensity projections can be severely affected by calcification, which ‘hides’ the lumen.
Digital subtraction CT is feasible but has not yet been adequately proven to be of value.
Minimum-intensity projections are of no value.
60) A 74-year-old male presents with low back pain. MRI shows some degenerative changes but no disc protrusion or neural compromise. A 6 cm, abdominal aortic aneurysm is seen, which has an irregular wall, with patchy high signal within mural thrombus and in the wall on T1W images. No perianeurysmal fluid to suggest leak is seen. What advice should be given regarding the aneurysm?
a. follow-up with ultrasound scan
b. follow-up with CT
c. follow-up with MRI
d. routine referral to vascular surgeon
e. emergency assessment by vascular surgeon
e. emergency assessment by vascular surgeon
The patchy high T1 signal in the mural thrombus and wall is suggestive of hemorrhage and the aneurysm is therefore unstable.
Impending rupture should be considered and urgent surgical assessment should be sought.
64) A 33-year-old female with renal failure has an indwelling right internal jugular venous catheter. She presents with swelling of the right arm. Ultrasound Doppler scan of the neck and arm veins is performed. Which feature would suggest occlusion of the right brachiocephalic vein?
a. collapse of right internal jugular vein on sniffing
b. variation of flow with respiration in right subclavian vein
c. variation with cardiac cycle in right subclavian vein
d. continuous monophasic flow in the right subclavian vein
e. collapse of the left internal jugular vein on sniffing
d. continuous monophasic flow in the right subclavian vein
Ultrasound evaluation of the central veins is difficult, as the brachiocephalic veins and superior vena cava cannot be directly visualized. Secondary features to confirm patency can be seen, such as collapse of the internal jugular veins on sniffing (Valsalva manoeuvre), and variability of flow with respiration and the cardiac cycle. A continuous monophasic flow with loss of variability suggests a proximal occlusion or stenosis.
GIT) A 45-year-old man presents with dysphagia and undergoes a double-contrast barium swallow. This demonstrates a smooth oblique indentation on the posterior wall of the oesophagus. What is the most likely cause of these appearances?
A. enlarged left atrium
B. aberrant right subclavian artery
C. aberrant left pulmonary artery
D. right-sided aortic arch
E. coarctation of the aorta
B. aberrant right subclavian artery
A number of anomalies of the major vessels can cause extrinsic impressions upon the oesophagus.
The commonest aortic anomaly is a right-sided aortic arch, which produces an indentation on the right lateral oesophageal wall in the absence of the normal left aortic arch impression.
An aberrant right subclavian artery originates from the aortic arch just distal to the left subclavian artery, and passes upwards and to the right, behind the oesophagus, giving rise to an oblique posterior oesophageal indentation.
In aortic coarctation, the pre- and post-stenotic dilatations of the aorta produce a characteristic reversed-3 impression upon the left wall of the oesophagus.
An enlarged left atrium andan aberrant left pulmonary artery both cause anterior indentations upon the oesophagus.
- A 16 year old with headache and hypertension has a chest radiograph which demonstrates plain radiographic signs of coarctation of the aorta. Further investigations reveal anomalous post-coarctation origin of the right subclavian artery. The ribs most likely to demonstrate inferior rib notching would be:
a. Left third to ninth ribs
b. Bilateral third to ninth ribs
c. Right third to ninth ribs
d. Bilateral first and second ribs
e. Left first and second ribs
- a. Left third to ninth ribs
Due to the anomalous origin of the right subclavian artery from the post-coarctation segment, there is no collateral flow to the intercostal arteries on the right. Subsequently, there is no right-sided rib notching.
@# Ped) 14. A 14 year old patient with Turner syndrome presents with severe headache. Clinical examination confirms upper limb hypertension and a murmur. Which of the following signs is likely on the plain films?
a. Boot-shaped heart
b. Snowman sign
c. Figure-of-three sign
d. Egg-on-a-string sign
e. Scimitar sign
- c. Figure-of-three sign
The above mentioned are plain radiography signs of various congenital heart diseases.
The condition described above is coarctation of the aorta.
A boot-shaped heart is a feature of tetralogy of Fallot.
Snowman sign or figureof-eight sign is seen in supracardiac TAPVD.
Scimitar sign is a feature of partial anomalous pulmonary venous return,
and egg-on-astring sign is noted in TGA.
96) A 35-year-old female who smokes presents with hypertension and renal impairment. Ultrasound scan shows normal appearance of the kidneys. Doppler of the renal arteries demonstrates a peak velocity of 180 cm/s and no diastolic flow. Angiography shows multiple stenosis of the renal arteries bilaterally with a normal aorta. Which therapeutic option should be offered?
a. angiotensin-converting enzyme inhibitors
b. other antihypertensive
c. angioplasty
d. surgical correction
e. no definitive therapy is of value
c. angioplasty
The appearances are suggestive of fibromuscular hyperplasia, which is the commonest cause of renovascular hypertension in young patients and causes 35% of all renal artery stenosis. It affects the aortic branches, but not the aorta itself. Complications include giant aneurysm and arteriovenous fistula. Angioplasty has a 90% success rate with a low restenosis rate and is the treatment of choice. Surgical correction can be performed (end-to-end anastomosis, vein grafts) but is usually reserved for refractory cases or where there is involvement of the segmental vessels rather than the main renal arteries.
GU) 4 A 56 year man presents with hypertension and headache. He undergoes renal investigations which show a small right kidney on US and prolonged nephrogenic phase on contrast enhanced CT. MRA shows a 50% stenosis in the right main renal artery 1 cm from the ostium. What is the most likely diagnosis?
(a) Atherosclerosis
(b) Fibromuscular dysplasia
(c) lnfrarenal aortic aneurysm
(d) Buerger’s disease
(e) Polyarteritis nodosa
(a) Atherosclerosis
Overall, atherosclerosis is the commonest cause of RAS. It has a particular tendency to involve the proximal 2 cm of the main renal artery in contradistinction to fibromuscular dysplasia, the seeond most common cause.
6 Which of the following is not an accepted indication to choose C02 angiography?
(a) EVAR stent procedure
(b) Fluoroscopic angiography where DSA unavailable
(c) IVC filter placement
(d) Previous anaphlaxis post-IVU
(e) Serum creatinine of 190 μmol/L
(b) Fluoroscopic angiography where DSA unavailable
The main advantages of C02-angiography is its use in patients where iodinated agents are contraindicated, e.g. renal failure or previous contrast reaction,
or for long procedures in order to limit contrast burden (e.g. EVAR placement).
C02 is not diluted by blood thus can opacify central veins more readily from a peripheral approach, which is advantageous when placing IVC filters.
The overall quality of C02 images is reduced as there is decreased density compared to Iodine, thus DSA is essential.
Additionally, multiple injections are usually required, thus radiation exposure may be increased.
MSK) 10 In the evaluation of a splenic injury following trauma, which of the following features favours pseudoaneurysm over active extravasation?
(a) Less apparent on delayed imaging
(b) Layering
(c) Ill-defined
(d) Increased size on delayed imaging
(e) Jet of contrast medium
(a) Less apparent on delayed imaging
Pseudoaneurysms are typically well-defined, rounded and may be seen to have a neck adjoining an adjacent vessel.
They are more difficult to detect on delayed images and there is no change in the haematoma.
Management may be by embolisation or surgery depending on the clinical condition of the patient.
Ped) 11 An infant presents within the first few weeks of life with stridor, respiratory distress, and wheezing. CXR shows left deviation of the trachea, the lateral view reveals increased density in the region of the hilum. A pulmonary sling is suspected and a CT chest is arranged for further evaluation. Which of the following findings is most likely to be seen?
(a) Anterior trachea and anterior oesophageal compression
(b) Anterior trachea and posterior oesophageal compression
(c) No compression
(d) Posterior trachea and anterior oesophageal compression
(e) Posterior trachea and posterior oesophageal compression
(d) Posterior trachea and anterior oesophageal compression
A ‘pulmonary sling’ refers to an aberrant left PA, which arises from the right PA and passes between the trachea and oesophagus, resulting in posterior compression of the trachea and anterior compression of the oesophagus.
It may lead to tracheo-bronchiomalacia or stenosis in up to 50% patients.
12- A 27-year-old man under investigation for suspected liver disease has his venous pressures measured and is found to have a hepatic venous wedge gradient of 3 mmHg. What does this indicate?
(a) There is no liver disease
(b) Pre-sinusoidal cause of portal venous hypertension
(c) Sinusoidal cause of portal venous hypertension
(d) Post-sinusoidal cause of portal venous hypertension
(e) There is Insufficient data to draw a conclusion
(e) There is Insufficient data to draw a conclusion
These are normal physiological measurements (1—4 mmHg), but may be seen in normal patients, extra hepatic portal hypertension and some cases of pre—sinusoidal portal hypertension.
Elevation in sinusoidal disease is seen and correlates with Child score and risk of esophageal variceal hemorrhage
13- When optimizing a CT study of the aorta, which of the following would not improve arterial enhancement?
(a) Increasing the injection flow rate.
(b) Increasing the iodine concentration.
(c) Increasing the duration of the injection
(d) Increasing the cardiac output
(e) Increasing the volume of the contrast medium
(d) Increasing the cardiac output
Cardiac output is inversely proportional to arterial opacification. The other 4 techniques are used to increase arterial opacification- Rates above 8 ml/s offer no incremental value, whilst matching dose to bodyweight will give more uniform enhancement across a patient group.
14- A 76-year-old man injection flow rate Iodine concentration duration of the injection cardiac output volume of contrast medium presents with central chest pain- He is hemodynamically stable and undergoes a thoracic CT study which demonstrates a hyperdense crescent in the wall of the descending thoracic aorta on the unenhanced study, which does not change following the administration of IV. contrast medium. What is the most likely diagnosis?
(a) Aortic dissection
(b) Atherosclerosis
(c) Intramural hematoma
(d) Vasculitis
(e) Mediastinal fibrosis
(c) Intramural hematoma
This results from the rupture of the vasa vasorum and hemorrhage in to the arterial media. It is associated with hypertension (50%, is more common in men (60%) and presents in the same manner as aortic dissection, with most (> 90%) cases non—traumatic. It has a mortality rate of around –
15- A 67-year-old patient with cardiac risk factors presents with left calf claudication on walking 30 yards. An MR angiogram is performed and a focal stenosis of the right popliteal artery. The vascular surgeons discuss further management. What is the best approach for subsequent catheter angiography?
(a) Antegrade, left common femoral artery
(b) Antegrade, right common femoral artery
(c) Retrograde, left common femoral artery
(d) Retrograde, left popliteal artery
(e) Retrograde, right common femoral artery
(b) Antegrade, right common femoral artery
The likely location and extent of the lesion is known. As intervention is likely, the antegrade (‘down the leg’) approach should be adopted on the symptomatic side. A diagnostic run should be performed to confirm disease extent as MR can over-estimate it, alliteratively there may have been disease progression depending on the elapsed time-interval
@# 16- Regarding congenital abnormality of the IVC. Which of the is most likely be with azygous of the IVC?
(a) Asplenia.
(b) Total anomalous pulmonary venous connection (TAPVC)
(c) Bilateral bilobed lungs
(d) Right isomerization
(e) Eparterial bronchi
(c) Bilateral bilobed lungs
Azygous continuation Of the IVC is congenital absence of the hepatic segment of the IVC with continuation to the right atrium occurring via the azygous or hemi-azygous veins, prevalence = 0.6%.
It is often associated with polysplenia syndrome (left isomerization) and only rarely with asplenia syndrome (right isomerization).
Polysplenia syndrome is associated with bilateral bi-lobed lungs, partial anomalous pulmonary venous connection (PAPVC), persistent left SVC, situs ambiguous, hyparterial bronchi, atrial septal defects (ASD) and double outlet right ventricle (DORV)
19- A 29-year-old active man presents with slowly progressive intermittent unilateral claudication brought on by exercise or standing. He has never smoked and has never family history. On examination, plantar flexion against resistance resistance reproduces the What is the likely diagnosis?
(a) atherosclerosis
(b) burger’s disease.
(c) Cystic adventitial disease of the popliteal
(d) Popliteal artery entrapment syndrome
(e) Ruptured Achilles tendon
(d) Popliteal artery entrapment syndrome
PAES is most common in young active male patients (60% are < 30 yrs.) and must be considered in an individual of this demographic who develops calf claudication on exercise.
It is bilateral in up to 67% and usually results from an anomalous course of the medial head of gastrocnemius which causes compression of the popliteal artery.
It can rarely be caused by a fibrous band, or muscle hypertrophy in athletes.
Surgical release of the muscle or tendon is the optimal treatment, there is no role for angioplasty/ stenting.
GU) 41 A 53 year old asymptomatic man is discovered to have a 1.5 cm unilateral, calcified, extrarenal solitary renal artery aneurysm. Which of the following statements is incorrect?
(a) The lesion should be treated surgically
(b) 2/3 of renal artery aneurysms are extrarenal
(c) The likeliest cause is atherosclerosis
(d) Ehlers-Danlos syndrome is a cause
(e) It is more common in women
(a) The lesion should be treated surgically
A small (< 2 cm) renal artery aneurysm which is well calcified may be treated conservatively.
Indications for surgery include being a woman of childbearing age (due to the increased risk of rupture in p’regnancy), interval growth, emboli to kidney or diminishing renal function.
lntrarenal aneurysms are most commonly congenital; true extra-renal aneurysms are caused by fibromuscular dysplasia, pregnancy and mesenchymal disease such as NF and Ehlers-Danlos, in addition to atherosclerosis.
42- Following a prolonged angioplasty procedure is noted to have a swelling at the CFA puncture site. US confirms a 4-cm pseudo aneurysm- The patient is hemodynamically stable. What is the most appropriate immediate treatment?
(a) Conservative ‘management
(b) Manual compression
(c) Stent—graft placement
(d) Surgical repair
(e) US-guided thrombin injection
(e) US-guided thrombin injection
Femoral artery pseudoaneurysms occur in 0.2% of diagnostic and 8% of interventional procedures; compression of adjacent structures or rupture are potential complications.
Risk factors include 10’” puncture, larger catheter size, lengthy procedures, and peri-procedural anti- coagulation-
Treatment can be conservative for small aneurysms < 2 cm.
US-guided thrombin injection has replaced US-guided compression as the treatment of choice in uncomplicated cases due to greater success rate, reduced procedural time and better patient tolerance-
Stentgrafts are more commonly used in larger diameter arteries and have a lower complication rate compared to surgery.
Surgery is reserved for cases of rapid aneurysm expansion, rupture, infection, or failure of other treatments.
49- A 53-year-old man presents with abdominal pain. A post- contrast injection CT examination is performed in the portal phase which reveals an enlarged aorta ‘With an eccentric thrombosed channel, extending over 8 cm. Which of the following features makes a thrombosed aneurysm more likely than a chronic dissection?
(a) Involvement of the SMA
(b) Small aortic lumen
(c) Mural calcification displaced outwards
(d) Thrombus extending over 6 cm cranio-caudally
(e) Total aortic diameter > 5 cm
(c) Mural calcification displaced outwards
A thrombosed aneurysm and thrombosed blood within the false lumen of a chronic dissection can have similar appearances.
In thrombosed aneurysm, the calcium is typically displaced outwards, thus appears to be pushed outside from the aortic lumen (in dissection any calcium, if present would be displaced medially, ‘inside’ the lumen),
in addition there is likely to be extensive calcification seen elsewhere in the wall.
Dissection usually extends over a longer (> 6 cm) cranio-caudal distance and, although the overall aortic size is normal in the acute phase, it can be very large (> 5 cm) in the chronic phase.
The aortic lumen is likely to be normal or small in dissection, but is expected to be large with an aneurysm.
Involved vessels are not a reliable guide, but an aneurysm tends to involve the lumbar branches, a dissection of the renal arteries and the SMA.
Pd) 49 A 10 year old boy presents to his GP with back-pain. He is found to have a scoliosis, but is also noted to be tall for his age and rather thin. Which of the following supports the diagnosis of Marfan’s syndrome over homocystinuria?
(a) Aortic aneurysm
(b) Lens dislocation
(c) Mental retardation
(d) Osteoporosis
(e) History of pulmonary emboli
(a) Aortic aneurysm
The conditions have a similar phenotype. In Marfan’s there is MV prolapse, aortic regurgitation, coarctation, and dissecting aneurysm of the ascending aorta; lens dislocation is upwards and outwards (down/ inward in homocystinuria).
Homocystinuria is an enzyme deficiency disorder, leading to homocystine build-up which causes a defect in collagen structure.
Features which help distinguish it from Marfan’s include the propensity for thrombo-emboli disease and osteoporosis (osteopaenia in Marfan’s).
GIT) 19 A patient is referred for chemo-embolisation of a hepatocellular carcinoma in the right lobe of the liver. The initial angiogram demonstrates that the lesion is supplied from the superior mesenteric artery. What proportion of patients have an arterial supply to liver from the SMA?
(a) 7%
(b) 14 %
(c) 17 %
(d) 21 %
(e) 25 %
(e) 25 %
14% of patients have an accessory right hepatic artery, 7% have a replaced right hepatic artery and 4% have a totally replaced hepatic artery arising from the SMA.
Ped) 20 A 4 year old boy presents following a recent history of a fever, cervical lymphadenopathy, and a rash around both elbows and conjunctivitis. What is the most likely diagnosis?
(a) Fibromuscular dysplasia
(b) Giant cell arteritis
(c) Henoch Schonlein purpura
(d) Kawasaki’s disease
(e) Takayasu’s disease
(d) Kawasaki’s disease
Kawaski’s disease is an idiopathic acute febrile, multisystem vasculitis.
It is usually self-limiting, with peak presentation at 1-2 years.
Complications include coronary artery aneurysms, myocarditis, and acute Ml.
Treatment is with aspirin and gamma globulins.
23 A 53 year old man presents with right calf swelling. He had a previous right leg DVT treated 5 years previously at another hospital and describes the current symptoms as being similar. US shows echoic material extending 5 cm within the mid right SFV. What feature most strongly supports a diagnosis of acute DVT over chronic changes from his previous DVT?
(a) Enlarged vein diameter
(b) Hyperechoic material in the vein
(c) Non-corrlpressible vein
(d) Presence of collateral veins
(e) Vein wall thickening
(a) Enlarged vein diameter
It may be difficult to distinguish acute from chronic DVT, and previous imaging if available can be helpful. Signs more in keeping with chronic DVT include wall thickening, collateral vessels, and echogenic material of the same or increased echoreflectivity as compared to surroundingtissue; vein diameter is often reduced.
Acute thrombus is of lucent-tointermediate echogenicity as compared to surrounding tissues, is seen to expand the vein, is often ‘free-floating’ within the lumen in the first week, and may be compressible in the early stages.
GU) 25 A 30 year old woman presents with a history of hypertension and headache. She undergoes renal angiography which demonstrates alternating areas of stenosis and ectasia in the distal third of both main renal arteries. What is the likeliest diagnosis?
(a) Atherosclerosis
(b) Takayasu’s arteritis
(c) Polyarteritis nodosa
(d) Fibromuscular dysplasia
(e) Buerger’s disease
(d) Fibromuscular dysplasia
Overall, the commonest cause of renal artery stenosis is atherosclerosis, but FMD accounts for up to 30% of all cases, and is commoner in young patients. It typically affects the mid and distal portion of the artery and a ‘string of beads’ appearance is often seen
27 A 68 year old man presents with a lower GI haemorrhage. He is fluid resuscitated and an angiogram is performed to localise the site of bleeding. Initial selective angiogram of the IMA shows a distal bleeding point within the pelvis. Which of the following arteries is the more likely source of the bleed?
(a) Median sacral
(b) Middle rectal
(c) Sigmoid
(d) Inferior epigastric
(e) Internal pudendal
(c) Sigmoid
Branches of the IMA include left colic, sigmoidal branches, superior rectal, and marginal arteries. Medial sacral comes directly off the aorta; middle rectal and internal pudendal arteries are branches of the IIA; the inferior epigastric arteries are branches of the EIA.
44 Which of the following conditions is not associated with Raynaud’s phenomenon?
(a) Atherosclerosis
(b) Rheumatoid arthritis
(c) Sarcoid
(d) Takayasu disease
(e) Trauma
(c) Sarcoid
Raynaud’s disease is the primary form of vasospasm induced digital ischaemia following cold or emotional stimuli. The colour changes typically seen are pallor, cyanosis, then eventually redness with reperfusion. Raynaud’s phenomenon is secondary vasospasm with obstruction, causes include atherosclerosis (most frequent; either in situ or due to emboli), arterial trauma, Buerger’s, Takayasu’s, drugs (ergot), and collagen vascular diseases (RhA, scleroderma, SLE). Radiological investigations include angiograms performed at ambient temperatures, followed by ‘stress angiogram’ performed after immersing the hand in ice water for 20 seconds. Sarcoidosis is not associated.
52 A 29 year old women presents with pain in her left forearm. She has previous been investigated for hypertension, arthralgias, and weight loss. The arm BPs are unequal. Aortic angiogram reveals long-segment smooth stenoses at the origin of the left subclavian artery, within the abdominal aorta and in the right renal artery. What is the most likely diagnosis?
(a) Buerger’s disease
(b) Giant cell arteritis
(c) Polyarteritis nodosum
(d) Syphilitic aortitis
(e) Takayasu disease
(e) Takayasu disease
Takayasu (‘pulseless’) disease is a granulomatous inflammation of unknown aetiology affecting mainly elastic arteries, i.e. aorta and its major branches and the pulmonary arteries causing stenoses and occasionally aneurysms.
It is more common in female patients (x 8) and presents at a young age (90% < 30 years).
In up to 50% the early phase is marked by systemic symptoms such as fever, weight loss, night sweats, arthralgia; mean time from disease development to diagnosis is 8 years.
Ped) 69 What is the most common cause of renal artery stenosis in a child?
(a) Fibromuscular dysplasia
(b) Middle aortic syndrome
(c) Neurofibromatosis
(d) Takayasu’s arteritis
(e) William’s syndrome
(a) Fibromuscular dysplasia
All are causes of RAS, other causes include polyarteritis nodosa, postrenal transplantation and post-radiotherapy. FMD is the most common, the other conditions are rare. In adults, the majority of cases of RAS is secondary to atherosclerosis.
75 A 63 year old man previously treated for lung cancer presents with a gradual onset of dyspnoea, headache and facial swelling with prominent veins over the preceding weeks. A CT is requested.
Which of the following collateral veins are least likely to be enlarged?
(a) Azygous vein
(b) Hemiazygous veins
(c) Internal thoracic veins
(d) Lateral thoracic veins
(e) Pericardial Veins
(e) Pericardial Veins
The extent and location of collateral opacification in SVCO at CT depends on the location/ degree of obstruction and the site/ timing of contrast injectiop.
Major collateral pathways include the azygous, hemiazygous, internal thoracic, lateral thoracic veins, and the thoraco-acromioclavicular venous complex.
Minor collateral pathways include the anterior jugular, the pericardia! and umbilical veins; the parascapular, pericardia! superficial, thoracoabdominal and epigastric veins may also be opacified.
