Vascular/cardiac Flashcards
Carotid artery stenosis paratmeters. PSV and ICA to CCA ratio.
- <50% stenosis (normal)
- 50-69%
- >70%
- <125. ICA/CCA <2.0
- >125. ICA/CCA>2.0
- >230 cm/sec PSV. ICA/CCA>4.0
If you see Tardus parvus in both Common carotids, where is the stenosis?
Aortic valve
Causes of subclavian steal syndrome?
MCC: athersclerosis.
Less common: Takyasu’s vasculitis, radiation.
Reversal of diastolic flow in Both common carotids - what is diagnosis?
Aortic valve incompetence
ICA vs. ECA
- Resistance, systolic/diastolic, diastolic return to baseline. Continuity of flow
- How can you tell on imaging which is which?
- ICA is low resistance. Low systolic and high diastolic. Diastolic flow will never go to baseline. Continious flow.
- ECA is high resistance at baseline. High systolic and low diastolic. Diastolic flow will drop below baseline. Intermittent flow.
- ICA is low resistance. Low systolic and high diastolic. Diastolic flow will never go to baseline. Continious flow.
- ECA has branches. You can do temporal tap.
What does brain death look like on ICA doppler
- ICA will become high resistance. There will be loss of diastolic flow.
Difference between Stanford A and Stanford B dissection
Stanford A is proximal to left subclavian. This is surgical
Stanford B: dissection is distal to left subclavian. This is medical treatment, unless there is end organ damage
In a normal dissection flap, which lumen is big, which lumen has calcifications, and which lumen contains the takeoff of left renal?
False lumen is usually bigger
True lumen has the calcifications
False lumen frequently contains the takeoff of the left renal artery. Others usually come off the true lumen
Best MR sequence to look for dissection
T1 w/ fat suppression. You would see crescent sign.
What is the pathophys of an acute intramural hematoma?
Rupture of vaso vasorum in media w/o intimal tear. Seen well on noncontrast CT sequence.
- aneurysm mortality predictors
- What is strongest predictor of dissection
Ascending aorta >5cm. Intramural hematoma>2cm. Pericardial effusion
- Size of aneurysm.
What are the 3 Acute aortic sydrome entities, and what is their most common causes?
- Penetrating ulcer: athersclerosis
- Dissection: HTN
- Itramural hematoma: HTN.
3 spots where aorta is injured during trauma (all spots are tethered, which is why they are injured w/ trauma)
- Isthmus
- Aortic root
- By the diaphragm.
Types of graft leaks. Which is most common?
Which are most common vessels involved in Type 2
- Distal or proximal leak (1A is proximal, 1B is distal)
- Feeding vessel (most common). Most common feeding vessels are IMA and lumbar.
- Fracture of the graft itself
- Porous graft. (mneumonic: four Por) - rarely seen with modern grafts.
- Endotention (controversial) - thought to be due to leak below resolution of imaging.
Marfan’s
Classic finding in Marfan’s
Annuloaortic ectasia: tulib Bulb appearance.
Aortic valve insufficiency. High risk for rupture.
Should be repaired early (around 5.5 cm)
Entity with extremely tortuous neck vessels (Marfan’s on steroids)
Loeys Dietz
Unilateral swollen LEFT leg - vascular cause of this
May Thurner syndrome - Left sided iliac vein compressed by right sided iliac artery.
Treatment is thrombolysis and stenting.
Median arcuate ligament syndrome.
Compression of Celiac is worse with what? inspiration or expiration
Compression is worse with expiration (not intuitive).
Popliteal artery aneurysm is a/w what other findings
contralateral popliteal aneurysm, AAA, acute limb thrombosis.
Where are most common locations for fibromuscular disease?
Renal artery, carotid, iliac artery. Treatment is angioplasty without stenting.
- Giant cell arteritis - Demographics. which arteries are effected?
- Takayasu’s - Demographics. which arteries
- Temporal artery, axillary/brachial artery. In old people. (old person needs GIANT crutches, and those crutches mess up the axilary/brachial arteries).
- Young asian girls. Vasculitis involving aorta. Often involves aortic valve and causes aortic insufficiency. (A is for Asian and for Aorta).
Thoracic outlet syndrome.
- what is compressed?
- What muscle is usually the cause?
- What is the name of syndrome when a venous thrombus develops?
- Subclavian vessels, brachial plexus. (Nerve>vein>artery)
- Anterior scalene muscle and cervical ribs are most common cause of compression.
- Paget Schroetter - thoracic outlet syndrome w/ thrombus in subclavian vein.
Aortic occulusion syndrome - Name. Classic Quartet
Leriche syndrome
classical quartet of impotence, buttock claudication, absent femoral pulses, and cold lower extremities.
Aortic coarctation
- Who gets pre-ductal, who gets post-ductal?
- Rib notching involves which ribs?
- What is pseudocoartctation
- Associations?
- Preductal; infants. Postductal: adults
- Rib notching occurs in 4th-8th ribs
- Pseudocoarctation - looks real but there are no collaterals or BP differences.
- Turners. Berry aneurysms.
What is the syndrome name with angiodysplasia and aortic stenosis?
Heyde syndrome
What is correct location for aortic balloon pump?
How does it work?
Balloon tip should be located just distal to the left subclavian artery.
Balloon inflates during diastole, therefore the blood returns up and goes to coronary arteries.
Describe normal branches of aorta
This is seen 66% of the time.
What is this called?
Common brachiocephalic artery artery and left common carotid
Thisi s sometimes incorrectly called “bovine aortic arch”
What is a diverticulum of Kommerel?
Small bulge at oritin of aberrant subclavian artery.
Abberrant subclavian originates from aorta, goes behind esophagus, and may cause dysphagia lusoria
What is a 4 vessel arch?
left vertebral origin off aorta
Acute aortic syndrome
Where is the defect in:
PAU
IMH
Dissection
PAU: defect in intima
IMH: defect in media
Dissection: defect in intima extending into the media.
Risk factors for aortic dissection
Hypertension, connective tissue disorders (Marfan), cocaine, aortopathy, bicuspid aortic valve, weight lifting, sudden deceleration injury.
Intramural hematoma - blood collects in the media w/o an intimal flap to connect the imh and aortic lumen
- What causes IMH?
- Presentation can be similar to dissection with tearing back pain. What is treatment?
- Imaging?
- Thought to be caused by rupture of vasa vasorum
Caused by HTN, like dissection.
- Tx is same as dissection. Surgery for ascending, BP control for descending
- Faint peripheral hyperattenuating (45-50) crescent w/in aorta, best seen on noncontrast CT
Penetratic atherosclerotic ulcer - penetrates intima, allowing blood to extend into media. May lead to aneurysm formation.
- Cause?
- Imaging?
- In contrast to dissection and IMH, this is caused by atherosclerosis, rather than HTN.
- Contrast ulcerating beyond the expected contour of aortic wall.
Traumatic aortic injury
- 3 places that it occurs
- Direct CT signs of traumatic aortic injury
Mediastinal hemorrhage is usually venous, but if the hemorrhage is connected to aortic injury, it will need to be surgically repaired.
- Aortic root, isthmus, hiatus.
Resulting pseudoaneurysm is held in place by surrounding connective tissues.
- Dissection flap, pseudoaneurysm, intramural hematoma.
Thoracic aortic aneurysm
- Diameter parameters
- Name some non-atherosclerotic causes of TAA
- What is annuloaortic ectasia associated with?
Describe it.
- When is surgery recommended for TAA
- What is a sign of impending rupture?
- Complications of TAA treatment?
- Ascending aortic diameter >4cm, or descending thoracic aorta >3 cm.
- connective tissue disorders (marfa, ehlers-danlos), bicuspid aortic valve associated aortopathy, vasculitis (takayasu, GCA, ankylosing spondylitis, relapsing polychondritis), cystic medial necrosis, infectious aortitis.
- It is associated with Marfan and Ehlers Danlos.
Dilated sinuses of valsalva and ascending aorta with effacement of the sinotubular junction, resulting in a tulip bulb-shaped aorta.
- Ascending >5.5 cm or descending > 6 cm. Or growth rate of 5mm/6 months or 1cm/year.
However patients with connective tissue disorders of Bicuspid valve have a lower threshold of >4.5.
- Draped aorta sign
- rupture, dissection, infection, endoleak, paraplegia (artery of adamkiewicz).
Abdominal aortic aneurysm
- Size parameter
- What is the risk of rupture of AAA greather than 7cm
- when is surgery recommended
Mortality of AAA surgery is 3% for elective, 19% for urgent.
- complications of AAA repair
- >3cm
- 32.5%
- >5.5cm or expansion of >mm/year or symptomatic?
- dissection, infection, endoleak, aorto-enteric fistula.
Screening Ultrasound of AAA recommendations on size
- <4cm
- 4-4.5
- 5-5.5 cm
- >5.5 cm
- annual surveillance
- 6 month surveillance
- consider surgery
- surgery recommended
Right or left coronary dominance is determined by what?
which coronary artery is usually dominant?
Artery that gives off PDA (Posterior decending artery), PLA and AV nodal branch is considered dominant.
It is RCA 85% of the time.
7% of time, the left artery is dominant because left circumflex gives off PDA, PLA, AVN
7% of the time it is co-dominant.
