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chest FRCR > Vascular > Flashcards

Vascular Flashcards

1
Q

Define pseudocoarctation:

A

This is elongation and narrowing and kinking of aorta. No pressure gradient, collateral formation or rib notching.

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2
Q

Define thoracic outlet syndrome:

Clue?

A

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.

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3
Q

Define Paget Schroetter

Also known as effort syndrome- seen in athletes:

A

This is thoracic outlet syndrome AND SCV thrombosis

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4
Q

What are the causes of PA aneurysm? (3)

A
  1. Iatrogenic
  2. Behcet
  3. Chronic PE.
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5
Q

What are the types pf PA aneurysm? (3)

A
  1. Hughes Stovin syndrome- PAA similar to Behcet , recurrent thrombophlebitis , PAA and rupture
  2. Rasmussen: PAA 2 to TB
  3. TOF repair
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6
Q

Define mid aortic syndrome:

A

This is progressive narrowing of abdominal aorta and its major vessels without arteritis or atherosclerosis.

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7
Q

What is triad of mid aortic syndrome?

A
  1. HTN
  2. Claudication
  3. Renal failure
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8
Q

What are the different types of coarctation?

A

a) infantile (pre ductal)- pulmonary oedema

b) adult type (ductal)

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9
Q

What are the association with coarctation? (3)

A
  1. Turner’s syndrome
  2. Berry’s aneurysm
  3. Bicuspid aortic valve.
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10
Q

What are the signs of coarctation?

A

Figure 3 on CXR

Rib notching

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11
Q

What are the findings of inflammatory aneurysm?

A
  • 1/3 hydronephrosis/renal failure

- Thickened wall with peri-aortic fibrotic changes with sparring of the posterior wall.

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12
Q

Name a sign that is associated with dissection:

A

Floating viscera sign

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13
Q

RF for dissection: (5)

A
  1. Marfans
  2. Turners
  3. Infection
  4. Pregnancy
  5. Cocaine
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14
Q

Re Marfans syndrome:

which gene is affected?

A

Mutation of Fibrillar gene

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15
Q

Re Marfans syndrome:
Vascular findings?
Body features?

A

Vascular: - Aneuryms -Dissection - PAA

Body features: ectopic lens, tall, Pectus deformity, Scoliosis and long fingers

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16
Q

Re Marfans syndrome:

  • What are the associations?
A

Congenital heart disease
Coarctation
ASD

Myxomatous degeneration of aortic wall leads to dilatation and AR

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17
Q

Re mycotic aneurysm

  • What type?
  • Findings?
A
  • This is a saccular pseudo-aneurysm
  • Septicaemia ( endocarditis), psoas abscess and osteomyelitis.
  • Affecting the thoracic and suprarenal aorta.
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18
Q

Re NF1

  • Findings?
  • Vascular findings?
A
  • Cafe au last spots, freckling and bilateral optic glioma.
  • aneurysm/Stenosis in aorta/Large arteries
  • renal artery stenosis__ renovascular hypertension in paeds.
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19
Q

Re Takayasu

A

Affecting young Asian girls (15-30yrs)

Acute: Wall thickening and enhancement, affecting the aorta.

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20
Q

Re Cogans syndrome

  • Which vessels are affected?
  • Which parts?
A
  • Large vessel vasculitis (aortitis), Affecting children and young adults.
  • likely affecting ears (audio vest symptoms) and eyes (optic neuritis and uveitis).
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21
Q

Re Giant cell

  • Which vessels?
  • Tx?
  • Gold standard?
A
  • 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 ***
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22
Q

Re Takayasu

Which valves are most commonly affected?

A

Aortic valve is usually involved resulting in AS and AI.

PA are involved.

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23
Q

Re Good pastures syndrome:

A

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
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24
Q

Re PAN

A

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

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25
Q

Re Kawasaki Disease

A

Coronary vessel aneurysm- might be calc on CXR

“Mucocutaneous lymph node syndrome “
“ fever for 5 days “

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26
Q

Re SSS

A

This is stenosis/occlusion of SCA with retrograde flow in ipsilateral VA.

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27
Q

Re Segmental arterial mediolysis- SAM

A

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
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28
Q

Re internal vs external carotid

A

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.
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29
Q

Cystic adventitial disease

A

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.

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30
Q

Indications for cholecystostomy

A
  1. Sick patients you cannot take to OR

2. Acalculus cholecystitis with no other source of sepsis

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31
Q

What are the two approaches for cholecystectomy?

A
  1. Tranhepatic- minimises the risk of bile leak.
  2. Transperitoneal- , risk of losing access- bile leak

Need to leave the tube in for 2-6 weeks, until tract matures- otherwise bile leak

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32
Q

Define Portal HTN:

A

Pressure in the PV > 10 mmHg or

Portal systemic gradient > 6 mmHg

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33
Q

What does PHTN look like?

A
  • Enlarged PV >1.3-1.5cm and enlarged splenic vein >1-2cm
  • Splenomegaly
  • Ascites
  • Collaterals
  • Reversed flow in the PV.
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34
Q

Indications for TIPS

A
  1. Varicael haemorrhage that is refractory to endoscopic treatment
  2. Refractory ascites

MELD score (bilirubin, INR and Creatinine) score, if >18: at increased risk of early death after elective TIPS

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35
Q

What is needed prior to performing TIPS

A
  1. Echo to evaluate heart failure (right or left)

2. Cross sectional imaging to confirm patency of the portal vein

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36
Q

How is TIPS done?

A

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.

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37
Q

In TIPS what do you use to opacify the portal system?

A

CO2

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38
Q

Which direction do you turn the catheter when you are moving from the right HV to the right PV?

A

Anterior

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39
Q

What are the complications of TIPS

A

Cardiac decompensation- elevated right heart filling pressure
Accelerated liver failure
Worsening hepatic encephalopathy

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40
Q

Evaluation of a normal

TIPS

A

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

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41
Q

What are the signs associated with stenosis/malfunction?

A
  1. Elevated max velocities: >200 cm/s across the narrowed segment.
  2. Low PV velocity <30 cm/s is abnormal
  3. A temporal increase or decrease in shunt velocity by more than 50 cm/s is also abnormal
  4. Flow conversion with a change of flow in a portal vein branch towards the stent to away from the stent.
  5. indirect sign: new or increased asciteds
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42
Q

What would happen if the gradient is too low in TIPS?

A

There will be risk of Hepatic encephalopathy.

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43
Q

What are the # for TIPS?

A
  1. Severe heart failure- right or left
  2. Biliary sepsis
  3. isolated gastric varices with splenic vein occlusion

Relative #:
cavernous transformation of PV and severe hepatic encephalopathy.

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44
Q

What is alternative method to TIPS for refractory ascites?

A

Peritoneovenous shunt- high rate of infection and thrombosis, can lead to DIC.

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45
Q

TIPS vs BRTO(Balloon occluded Retrograde Transverse Obliteration)

A 
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.
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46
Q

What happens in BRTO?

Balloon occluded Retrograde Transverse Obliteration

A

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.

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47
Q

The most common side effect of BRTO?

A

Gross haematuria.

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48
Q

What is the alternative to liver biopsy in severe coagulopathy or massive ascites?

A

Transjugular approach.

49
Q

to vasopressin injection in acute GI bleed?

A
  • Large artery bleeding.
  • Bleeding at sites with dual blood supply
  • Severe coronary artery disease
  • Severe HTN.
  • Dysrhythmias
  • After embolotherapy Treatment- risk of bowel infarct
50
Q

What is a Dieulafoy’s lesion?

A

This is angiodysplasia in the submucosa of stomach usually in the lesser curvature.
can cause massive GI bleed. Can get clipped in endoscopy.

51
Q

When I say pancreatic arcade bleeding aneurysm, you say…

A

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.

52
Q

What are the two main indications for RF ablation of the liver?

A

HCC and colorectal mets.

53
Q

What does the pre therapy work up involve for radioembolisation?

A
  1. 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 #
  2. Take off the right gastric artery and GDA.
    The right gastric artery can come off proper hepatic or left hepatic.
54
Q

What can be done to reduce the risk of pneumothorax post biopsy? (3)

A
  1. Avoid interlobar fissures
  2. Put the puncture side down after the procedure
  3. No talking or deep breathing or coughing for 2 hours
55
Q

When would you put in a chest drain post biopsy?

A

if pneumothorax is symptomatic or if it is getting larger on serial radiographs.

56
Q

Which lung tumours are suitable for RFA?

A

Lesions between 1.5 -5.2cm in diameter

57
Q

What is the major advantage of lung RFA ?

A

It has limited effect on pulmonary function and can be performed without prior concern to prior therapy.

58
Q

Which findings would make you think residual/recurrent disease?

A
  • Nodular peripheral enhancement > 10mm
  • Central enhancement
  • Growth of RFA zone after 3 months
  • Increased metabolic activity after 2 months.
  • Residual activity centrally
59
Q

Which type of heart block can thoracic angio produce?

A

RBBB

People with LBBB should get prophylactic pacing

60
Q

What are the two main contraindications to pulmonary angio?

A
  1. Pulmonary HTN, if need to proceed, inject inthe right or left PA and not the main PA.
  2. LBBB, the wire can give you RBBB, combine together: asystole
61
Q

Pulmonary AVM

A

Think of HHT

Usually in the lower lobes. Can cause Right to Left shunt (stroke and brain abscess)

62
Q

When to treat pulmonary AVM?

A

when the afferent vessel is > 3mm

63
Q

What is usually the source of haemoptysis?

A

Bronchial arteries

64
Q

How would active bleeding look like on imaging?

A

NO active contrast extravasation

Instead there will be going to be enlarged turtuous vessels.

65
Q

Which vessels should be avoided in lung emb?

A

Avoid hairpin shaped vessels, risk of transverse myelitis from accidental plugging of anterior spinal artery feeder.

66
Q

What are the embolic materials used in :

  • Fibroid embolisation
  • PPH and vaginal bleeding?
A

Fibroid: PVA or embospheres
PPH: Gel foam and glue.

67
Q

Which medication should be stopped 3 months prior to fibroid embolisation?

A

Gonadotropin releasing medication

68
Q

Where does uterine artery arise from?

A

anterior division of the internal iliac artery

69
Q

Which fibroids tend to respond better to embolisation?

A

Cellular fibroids which are densely packed smooth muscle and high T2 SI tend to respond better.
Submucosal location.

70
Q

to UAE

A
  1. Pregnancy
  2. Active pelvic infection
  3. Prior pelvic radiation
  4. Connective tissue disease
  5. Prior surgery with adhesions (relative)
71
Q

What is post embolisation syndrome?

A

Pain, nausea, vomiting, and low grade fever

72
Q

When is the ideal time for HSG?

A

During proliferative phase (day 6-12)- when endometrium is the thinnest- improves visualisation and min pre risk

73
Q

Indications for treating varicocele (3)

A
  1. Infertility
  2. Pain
  3. Testicular atrophy in a kid
74
Q

Why varicocele happen?

A

Primary factor is the right angle entry of left spermatic vein.
Nut cracker syndrome on the left.

75
Q

What is the general rule regarding transgluteal abscess drainage?

A

Avoid sciatic nerves and gluteal arteries by access through sacrospinous ligament medially.

76
Q

What is the treatment for pancreatic cutaneous fistula?

A

Octreotide- synthetic somatostatin to inhibit pancreatic fluid

77
Q

What makes thyroid nodules suspicious for cancer?

A

1- solid more than cystic
2- hypervascular
3- blurred margin
4- micro calcification

78
Q

What projection is best to look at the renals?

A

LAO

79
Q

True or false?

RFA reduces GFR

A

False

RFA has no effect on GFR

80
Q

What is the preferred access for a dialysis catheter?

A

Right IJ

81
Q

What are the pros and cons of AV fistula?

A

Pros AV Fistula:

  • Lasts longer and more durable.
  • Less prone to neointimal hyperplasia
  • Fewer infection

Cons of fistula:
- Needs 3-4 months to mature

82
Q

What are the pros and cons of AV graft?

A

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.
83
Q

What flow rate do you need in AV graft?

A

600 cc/min flow with outlet vein >6mm.

84
Q

Where is the problem in grafts?

A

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.

85
Q

What is the ideal dilatation in angioplasty?

General rule re anticoagulation.

A

Ideal dilation is 10-15% over the normal artery diameter.

1-3 months of anti platelets (aspirin and clopidogrel) following a stent.

86
Q

One exception where angioplasty alone is preferred without stenting?

A

FMD- stent adds very little

87
Q

Define critical limb ischaemia:

A

Rest pain for two weeks. (or ulceration gangrene)

88
Q

Surgery vs thrombolysis in acute limb ischaemia

A

< 14 days: thrombolysis

> 14 days: surgery

89
Q

What is ABPI?

A

Dorsalis pedis or posterior tibial systolic pressure (at the ankle) : Right or left arm systolic pressure

Normal value > 1

90
Q

What does ABPI mean?

A

Normal > 1
Rest pain 0.3
Claudication 0.5-0.9

91
Q

What does the ulcer location mean?

A

Medial ankle: Venous stasis
Dorsum of foot: Ischaemic or infected ulcer
Plantar surface of foot: Neurotrophic ulcer

92
Q

False positive of ABPI?

A

Arterial calcification common in diabetic make compression difficult and can lead to false elevation of ABPI.

93
Q

What is post thrombotic syndrome?

A

This is pain and venous ulcer after DVT.

RF: age > 65, proximal DVT, obesity , recurrent or persistent DVT

94
Q

What are the indications for IVC filter?

A
  1. Proven PE while on adequate anticoagulation
  2. # to anticoagulation with clot in femoral or iliac veins
  3. Needing to come off anticoagulation- complications
95
Q

Where is the IVC filter usually placed?

A

Usually Infrarenal
Suprarenal may cause renal vein thrombosis

Pregnancy and if there is a clot in renal or gonadal : suprarenal

96
Q

Location of IVC filter in duplicated IVC:

A

Either bilateral iliac or suprarenal

97
Q

What are the complications of IVC filter:

A
  1. Malposition- should be placed at the level of the renal vein
  2. Migration = if in heart - surgery
  3. Thrombosis = reduces PE but increases DVT
  4. IVC perforation
  5. Infection
98
Q

Is the IVC filter MRI compatible

A

Yes, all are compatible

99
Q

Which types of endoleak are considered high pressure?

A

type 1 and 3- because they communicate directly with systemic blood flow.

100
Q

Define type 1 endoleak:

A

Leak at the top (A) or the bottom (B) of the graft

101
Q

Define type 2 endoleak:

A

Filling of the sac via a feeder artery- most common.
Usually involves the IMA or lumbar artery
Usually self limiting.

102
Q

Define type 3 endoleak:

A

This is a defect/fracture in the graft. It is usually the result of pieces not overlapping

103
Q

Define type 4 endoleak:

A

This is from the porosity of the graft (4 is from the pore)

Does not happen with modern grafts.

104
Q

Define type 5 endoleak:

A

Endotension- not a true leak and maybe due to pulsation of the graft wall.

105
Q

What is the chance of developing new fracture post vertebroplasty?

Complication?

A

25%

The cement can embolize to the lungs.

106
Q

What are the treatment option for pseuodoaneurysm?

A
  1. Direct compression: Direct compression of the neck
  2. thrombin injection: # local infection, rapid enlargement, distal limb ischaemia.
  3. surgery: if thrombin injection fails, infection, tissue breakdown, too wide neck aneurysm
107
Q

What are the patients with heparin induced thrombocytopenia at increased risk of?

A

They are at increased risk of clotting and NOT bleeding

If they need to be anti coagulated then they should get thrombin inhibitor instead

108
Q

What is the half life of:

  • heparin
  • platelets
A
  • heparin: 1.5 hours

- platelets: 8-12 days

109
Q

What is the antidote for Midazolam?

A

Flumazenil

110
Q

What is the max dose for Lidocaine?

A

4-5mg/kg

111
Q

Re testicular varicocele:

  • Define
  • Causes?
  • When concerning for malignancy?
A

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

112
Q

Uterine AVM

  • causes/types
  • Appearance
  • Management?
  • Ddx
A

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.

113
Q

May Thurner?

  • What is it? Pathology?
  • Treatment?
A

Syndrome from DVT in LCIV
This is compression of LCIV by RCIA, resulting in DVT in LCIV

Tx: Thrombolysis and stenting.

114
Q

Popliteal aneurysm

  • Asso
  • % of AAA have pop a and vice versa
  • % bilateral
  • Complication?
A
  • 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.
115
Q

Popliteal artery entrapment syndrome

A

Diminished Doppler of popliteal artery during muscle contraction(Stressed).

Angiography: medial deviation of the popliteal artery, popliteal stenosis and post stenotic dilatation.

116
Q

Bronchial artery embolisation:

  • What do you do first?
  • How to inject contrast, pump or manual?
  • What materials are used?
A
  • 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.
117
Q

In bronchial artery embolisation:

Where would you position the catheter for embolisation

A

Safe positioning distal to origin of spinal cord branches to avoid spinal cord ischaemia.

118
Q

What are the complications in bronchial artery embolisation?

A

Most common complication: chest pain, dysphagia, dissection of bronchial artery or aorta and spinal cord ischaemia.

chest FRCR (3 decks)

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