Vascular Flashcards
Define pseudocoarctation:
This is elongation and narrowing and kinking of aorta. No pressure gradient, collateral formation or rib notching.
Define thoracic outlet syndrome:
Clue?
This is congenital or acquired compression of SCA and vein and brachial plexus as they pass through thoracic inlet. It is a spectrum:
Nerves (95%) –> SCV–> SCA
Clue: Arms up ( there will be an occlusion) and down angio.
Define Paget Schroetter
Also known as effort syndrome- seen in athletes:
This is thoracic outlet syndrome AND SCV thrombosis
What are the causes of PA aneurysm? (3)
- Iatrogenic
- Behcet
- Chronic PE.
What are the types pf PA aneurysm? (3)
- Hughes Stovin syndrome- PAA similar to Behcet , recurrent thrombophlebitis , PAA and rupture
- Rasmussen: PAA 2 to TB
- TOF repair
Define mid aortic syndrome:
This is progressive narrowing of abdominal aorta and its major vessels without arteritis or atherosclerosis.
What is triad of mid aortic syndrome?
- HTN
- Claudication
- Renal failure
What are the different types of coarctation?
a) infantile (pre ductal)- pulmonary oedema
b) adult type (ductal)
What are the association with coarctation? (3)
- Turner’s syndrome
- Berry’s aneurysm
- Bicuspid aortic valve.
What are the signs of coarctation?
Figure 3 on CXR
Rib notching
What are the findings of inflammatory aneurysm?
- 1/3 hydronephrosis/renal failure
- Thickened wall with peri-aortic fibrotic changes with sparring of the posterior wall.
Name a sign that is associated with dissection:
Floating viscera sign
RF for dissection: (5)
- Marfans
- Turners
- Infection
- Pregnancy
- Cocaine
Re Marfans syndrome:
which gene is affected?
Mutation of Fibrillar gene
Re Marfans syndrome:
Vascular findings?
Body features?
Vascular: - Aneuryms -Dissection - PAA
Body features: ectopic lens, tall, Pectus deformity, Scoliosis and long fingers
Re Marfans syndrome:
- What are the associations?
Congenital heart disease
Coarctation
ASD
Myxomatous degeneration of aortic wall leads to dilatation and AR
Re mycotic aneurysm
- What type?
- Findings?
- This is a saccular pseudo-aneurysm
- Septicaemia ( endocarditis), psoas abscess and osteomyelitis.
- Affecting the thoracic and suprarenal aorta.
Re NF1
- Findings?
- Vascular findings?
- Cafe au last spots, freckling and bilateral optic glioma.
- aneurysm/Stenosis in aorta/Large arteries
- renal artery stenosis__ renovascular hypertension in paeds.
Re Takayasu
Affecting young Asian girls (15-30yrs)
Acute: Wall thickening and enhancement, affecting the aorta.
Re Cogans syndrome
- Which vessels are affected?
- Which parts?
- Large vessel vasculitis (aortitis), Affecting children and young adults.
- likely affecting ears (audio vest symptoms) and eyes (optic neuritis and uveitis).
Re Giant cell
- Which vessels?
- Tx?
- Gold standard?
- Vasculitis involving the aorta and its major branches especially External carotid artery (Temp a)
- Raised ESR/CRP - Tx: steroid
- Gold standard: TA Biopsy
- ** Vessels crushed by crutches ***
Re Takayasu
Which valves are most commonly affected?
Aortic valve is usually involved resulting in AS and AI.
PA are involved.
Re Good pastures syndrome:
Autoimmune pulm Renal syndrome [pulm haem and Glomeronephritis], affecting young male
- Bilateral coalescent airspace opacity ~ haemorrhage- resolve quickly- 2 weeks
- Pulm haemosiderosis from recurrent bleeding episodes.
- Fe Deposition - small ill defined nodules
Re PAN
PAN is more common in a MAN
- RENAL 90% - Cardiac 70% - GI 50-70%
Micro aneurysm formation and infarction.
It is associated with Hep B. Patients who abuse crystal meth- Speed kidney
Re Kawasaki Disease
Coronary vessel aneurysm- might be calc on CXR
“Mucocutaneous lymph node syndrome “
“ fever for 5 days “
Re SSS
This is stenosis/occlusion of SCA with retrograde flow in ipsilateral VA.
Re Segmental arterial mediolysis- SAM
This affect the splanchnic arteries in elderly and coronaries in young patients.
- This is not a true vasculitis, ++++ aneurysm
- Multiple abdo splanchnic artery saccular aneurysm
Re internal vs external carotid
Internal:
- Low resistance
- Low systolic velocity
- Diastolic velocity does NOT return to baseline
- Continuous colour flow throughout cardiac cycle.
External:
- High resistance
- High systolic velocity
- Diastolic velocity approaches zero base line
- Color flow is intermittent during cardiac cycle.
Cystic adventitial disease
Pop a of young men- there will be multiple mucoid filled cysts in the outer media and adventitia.
As the cysts grow they compress the artery.
Indications for cholecystostomy
- Sick patients you cannot take to OR
2. Acalculus cholecystitis with no other source of sepsis
What are the two approaches for cholecystectomy?
- Tranhepatic- minimises the risk of bile leak.
- Transperitoneal- , risk of losing access- bile leak
Need to leave the tube in for 2-6 weeks, until tract matures- otherwise bile leak
Define Portal HTN:
Pressure in the PV > 10 mmHg or
Portal systemic gradient > 6 mmHg
What does PHTN look like?
- Enlarged PV >1.3-1.5cm and enlarged splenic vein >1-2cm
- Splenomegaly
- Ascites
- Collaterals
- Reversed flow in the PV.
Indications for TIPS
- Varicael haemorrhage that is refractory to endoscopic treatment
- Refractory ascites
MELD score (bilirubin, INR and Creatinine) score, if >18: at increased risk of early death after elective TIPS
What is needed prior to performing TIPS
- Echo to evaluate heart failure (right or left)
2. Cross sectional imaging to confirm patency of the portal vein
How is TIPS done?
Measure the right heart pressure if elevated STOP (Normal 5)
Rt Jugular vein –> IVC –> HV (measure the pressure)–> stent HV to PV (usu R-R)
Measure the pressure again.
In TIPS what do you use to opacify the portal system?
CO2
Which direction do you turn the catheter when you are moving from the right HV to the right PV?
Anterior
What are the complications of TIPS
Cardiac decompensation- elevated right heart filling pressure
Accelerated liver failure
Worsening hepatic encephalopathy
Evaluation of a normal
TIPS
Because the stent decompresses the portal system- the flow is directed into the stent. Flow should reverse in the right and left portal vein and flow directly into the stent.
Flow in the stent is typically 90-190cm
What are the signs associated with stenosis/malfunction?
- Elevated max velocities: >200 cm/s across the narrowed segment.
- Low PV velocity <30 cm/s is abnormal
- A temporal increase or decrease in shunt velocity by more than 50 cm/s is also abnormal
- Flow conversion with a change of flow in a portal vein branch towards the stent to away from the stent.
- indirect sign: new or increased asciteds
What would happen if the gradient is too low in TIPS?
There will be risk of Hepatic encephalopathy.
What are the # for TIPS?
- Severe heart failure- right or left
- Biliary sepsis
- isolated gastric varices with splenic vein occlusion
Relative #:
cavernous transformation of PV and severe hepatic encephalopathy.
What is alternative method to TIPS for refractory ascites?
Peritoneovenous shunt- high rate of infection and thrombosis, can lead to DIC.
TIPS vs BRTO(Balloon occluded Retrograde Transverse Obliteration)
TIPS: - Treat oesophageal varices. - Shunt to divert blood around liver - Complication: worsening HE. 0- Improves oesophageal varices and ascites
BRTO:
- Treat gastric varices
- Embolise collaterals diverts blood to liver.
- Complication: worsening oesophageal varices and ascites
- Improves HE.
What happens in BRTO?
Balloon occluded Retrograde Transverse Obliteration
You access the portosystemic gastrorenal shunt from left renal vein via trans-jugular or transfemoral approach.
A balloon is then used to occlude the outlet of either gastro-renal or gastrocaval shunt.
Following balolon occlusion, a venogram is performed. A sclerosing agent is used to to take the vessel out.
After 30-50 minutes aspirate the remaining sclerosing agent and let the balloon down.
The most common side effect of BRTO?
Gross haematuria.
What is the alternative to liver biopsy in severe coagulopathy or massive ascites?
Transjugular approach.
to vasopressin injection in acute GI bleed?
- Large artery bleeding.
- Bleeding at sites with dual blood supply
- Severe coronary artery disease
- Severe HTN.
- Dysrhythmias
- After embolotherapy Treatment- risk of bowel infarct
What is a Dieulafoy’s lesion?
This is angiodysplasia in the submucosa of stomach usually in the lesser curvature.
can cause massive GI bleed. Can get clipped in endoscopy.
When I say pancreatic arcade bleeding aneurysm, you say…
Coeliac artery stenosis.
There is a known associated with coeliac artery compression (median arcuate ligament) and dilatation of the pancreatic duodenal arcades with pseudoaneurysm formation.
What are the two main indications for RF ablation of the liver?
HCC and colorectal mets.
What does the pre therapy work up involve for radioembolisation?
- Lung shunt fraction- give Tc 99 MAA to hepatic artery and determine how much pulm shunting occurs. Shunt fraction >30 Gy is too much and is #
- Take off the right gastric artery and GDA.
The right gastric artery can come off proper hepatic or left hepatic.
What can be done to reduce the risk of pneumothorax post biopsy? (3)
- Avoid interlobar fissures
- Put the puncture side down after the procedure
- No talking or deep breathing or coughing for 2 hours
When would you put in a chest drain post biopsy?
if pneumothorax is symptomatic or if it is getting larger on serial radiographs.
Which lung tumours are suitable for RFA?
Lesions between 1.5 -5.2cm in diameter
What is the major advantage of lung RFA ?
It has limited effect on pulmonary function and can be performed without prior concern to prior therapy.
Which findings would make you think residual/recurrent disease?
- Nodular peripheral enhancement > 10mm
- Central enhancement
- Growth of RFA zone after 3 months
- Increased metabolic activity after 2 months.
- Residual activity centrally
Which type of heart block can thoracic angio produce?
RBBB
People with LBBB should get prophylactic pacing
What are the two main contraindications to pulmonary angio?
- Pulmonary HTN, if need to proceed, inject inthe right or left PA and not the main PA.
- LBBB, the wire can give you RBBB, combine together: asystole
Pulmonary AVM
Think of HHT
Usually in the lower lobes. Can cause Right to Left shunt (stroke and brain abscess)
When to treat pulmonary AVM?
when the afferent vessel is > 3mm
What is usually the source of haemoptysis?
Bronchial arteries
How would active bleeding look like on imaging?
NO active contrast extravasation
Instead there will be going to be enlarged turtuous vessels.
Which vessels should be avoided in lung emb?
Avoid hairpin shaped vessels, risk of transverse myelitis from accidental plugging of anterior spinal artery feeder.
What are the embolic materials used in :
- Fibroid embolisation
- PPH and vaginal bleeding?
Fibroid: PVA or embospheres
PPH: Gel foam and glue.
Which medication should be stopped 3 months prior to fibroid embolisation?
Gonadotropin releasing medication
Where does uterine artery arise from?
anterior division of the internal iliac artery
Which fibroids tend to respond better to embolisation?
Cellular fibroids which are densely packed smooth muscle and high T2 SI tend to respond better.
Submucosal location.
to UAE
- Pregnancy
- Active pelvic infection
- Prior pelvic radiation
- Connective tissue disease
- Prior surgery with adhesions (relative)
What is post embolisation syndrome?
Pain, nausea, vomiting, and low grade fever
When is the ideal time for HSG?
During proliferative phase (day 6-12)- when endometrium is the thinnest- improves visualisation and min pre risk
Indications for treating varicocele (3)
- Infertility
- Pain
- Testicular atrophy in a kid
Why varicocele happen?
Primary factor is the right angle entry of left spermatic vein.
Nut cracker syndrome on the left.
What is the general rule regarding transgluteal abscess drainage?
Avoid sciatic nerves and gluteal arteries by access through sacrospinous ligament medially.
What is the treatment for pancreatic cutaneous fistula?
Octreotide- synthetic somatostatin to inhibit pancreatic fluid
What makes thyroid nodules suspicious for cancer?
1- solid more than cystic
2- hypervascular
3- blurred margin
4- micro calcification
What projection is best to look at the renals?
LAO
True or false?
RFA reduces GFR
False
RFA has no effect on GFR
What is the preferred access for a dialysis catheter?
Right IJ
What are the pros and cons of AV fistula?
Pros AV Fistula:
- Lasts longer and more durable.
- Less prone to neointimal hyperplasia
- Fewer infection
Cons of fistula:
- Needs 3-4 months to mature
What are the pros and cons of AV graft?
Pros:
- Ready for use in 2 weeks
- Easier to declot- usually confined to synthetic graft.
Cons:
- Less overall longevity
- Promotes hyperplasia leading to stenosis and obstruction
- More infection.
What flow rate do you need in AV graft?
600 cc/min flow with outlet vein >6mm.
Where is the problem in grafts?
The most common site of obstruction is venous outflow - usually at or just distal to graft to vein anastomosis. This is usually secondary to intimal hyperplasia.
What is the ideal dilatation in angioplasty?
General rule re anticoagulation.
Ideal dilation is 10-15% over the normal artery diameter.
1-3 months of anti platelets (aspirin and clopidogrel) following a stent.
One exception where angioplasty alone is preferred without stenting?
FMD- stent adds very little
Define critical limb ischaemia:
Rest pain for two weeks. (or ulceration gangrene)
Surgery vs thrombolysis in acute limb ischaemia
< 14 days: thrombolysis
> 14 days: surgery
What is ABPI?
Dorsalis pedis or posterior tibial systolic pressure (at the ankle) : Right or left arm systolic pressure
Normal value > 1
What does ABPI mean?
Normal > 1
Rest pain 0.3
Claudication 0.5-0.9
What does the ulcer location mean?
Medial ankle: Venous stasis
Dorsum of foot: Ischaemic or infected ulcer
Plantar surface of foot: Neurotrophic ulcer
False positive of ABPI?
Arterial calcification common in diabetic make compression difficult and can lead to false elevation of ABPI.
What is post thrombotic syndrome?
This is pain and venous ulcer after DVT.
RF: age > 65, proximal DVT, obesity , recurrent or persistent DVT
What are the indications for IVC filter?
- Proven PE while on adequate anticoagulation
- # to anticoagulation with clot in femoral or iliac veins
- Needing to come off anticoagulation- complications
Where is the IVC filter usually placed?
Usually Infrarenal
Suprarenal may cause renal vein thrombosis
Pregnancy and if there is a clot in renal or gonadal : suprarenal
Location of IVC filter in duplicated IVC:
Either bilateral iliac or suprarenal
What are the complications of IVC filter:
- Malposition- should be placed at the level of the renal vein
- Migration = if in heart - surgery
- Thrombosis = reduces PE but increases DVT
- IVC perforation
- Infection
Is the IVC filter MRI compatible
Yes, all are compatible
Which types of endoleak are considered high pressure?
type 1 and 3- because they communicate directly with systemic blood flow.
Define type 1 endoleak:
Leak at the top (A) or the bottom (B) of the graft
Define type 2 endoleak:
Filling of the sac via a feeder artery- most common.
Usually involves the IMA or lumbar artery
Usually self limiting.
Define type 3 endoleak:
This is a defect/fracture in the graft. It is usually the result of pieces not overlapping
Define type 4 endoleak:
This is from the porosity of the graft (4 is from the pore)
Does not happen with modern grafts.
Define type 5 endoleak:
Endotension- not a true leak and maybe due to pulsation of the graft wall.
What is the chance of developing new fracture post vertebroplasty?
Complication?
25%
The cement can embolize to the lungs.
What are the treatment option for pseuodoaneurysm?
- Direct compression: Direct compression of the neck
- thrombin injection: # local infection, rapid enlargement, distal limb ischaemia.
- surgery: if thrombin injection fails, infection, tissue breakdown, too wide neck aneurysm
What are the patients with heparin induced thrombocytopenia at increased risk of?
They are at increased risk of clotting and NOT bleeding
If they need to be anti coagulated then they should get thrombin inhibitor instead
What is the half life of:
- heparin
- platelets
- heparin: 1.5 hours
- platelets: 8-12 days
What is the antidote for Midazolam?
Flumazenil
What is the max dose for Lidocaine?
4-5mg/kg
Re testicular varicocele:
- Define
- Causes?
- When concerning for malignancy?
D: abnormal dilatation of veins in the pampiform plexus, most are idiopathic. 98% are on the left. can cause infertility.
Non decompressione varicocele - CT AP/ USS/MR
Left: Left renal malignancy invading Renal vein.
Right: Pelvic/abdo malignancy. ? RCC, ?RPF or ?adhesions
Uterine AVM
- causes/types
- Appearance
- Management?
- Ddx
causes: congenital or acquired after D&C/abortion or multiple pregnancy.
Doppler: Serpinginous structure in myometrium with low resistance and high flow velocity pattern.
Tx: embolisation
Ddx: Retained product of conception ( this will be in the endometrium rather than myometrium.
May Thurner?
- What is it? Pathology?
- Treatment?
Syndrome from DVT in LCIV
This is compression of LCIV by RCIA, resulting in DVT in LCIV
Tx: Thrombolysis and stenting.
Popliteal aneurysm
- Asso
- % of AAA have pop a and vice versa
- % bilateral
- Complication?
- Strong association with AAA
- Distal thromboembolism , limb threatening
- 30-50% with pop A have AAA
- 10% its with AAA have pop A
- 50-70% are bilateral
- Complication: Acute limb from thrombosis.
Popliteal artery entrapment syndrome
Diminished Doppler of popliteal artery during muscle contraction(Stressed).
Angiography: medial deviation of the popliteal artery, popliteal stenosis and post stenotic dilatation.
Bronchial artery embolisation:
- What do you do first?
- How to inject contrast, pump or manual?
- What materials are used?
- A preliminary descending thoracic aortogram is performed to identify the number and site of origin of bronchial arteries.
- Manual injection of contrast
- PVC are used.
In bronchial artery embolisation:
Where would you position the catheter for embolisation
Safe positioning distal to origin of spinal cord branches to avoid spinal cord ischaemia.
What are the complications in bronchial artery embolisation?
Most common complication: chest pain, dysphagia, dissection of bronchial artery or aorta and spinal cord ischaemia.
