Vascular CORE - Sheet1 Flashcards
Average size of aortic root
3.6cm
Average size of distal descending aorta
2.4cm
Bovine arch
common origin of brachiocephalic artery and left CCA (15%)
What is the 3rd most common arch variant?
left CCA coming off the brachiocephalic proper (10%)
What is the 4th most common arch variant?
4 separate origins (left vert off of arch) (5%)
What side does the Artery of Adamkiewicz arise?
Left (70%) between T8-L1 (90%) aka great anterior medullary a.
First branch off the SMA
inferior pancreaticoduodenal
What makes the Arc of Riolan?
left colic (from IMA) to the middle colic (from SMA)
Branches of the SMA
inferior pancreaticoduodenal, middle colic, right colic, ileo-colic (appendicular)
Branches of the IMA
left colic, sigmoid branches, superior rectal (marginal artery)
2 most common hepatic artery variants
right hepatic replaced off the SMA and left hepatic replaced off the left gastric
Is there normally a vessel in the ligamentum venosum?
No, it’s an accessory or replaced left hepatic arising from the left gastric
How do you tell if it’s a replaced right hepatic?
Proper right hepatic is anterior to right portal vein. Replaced right hepatic is posterior to the main PV
Most common hepatic venous variant
Accessory right inferior hepatic vein (drains seg 6/7 into IVC)
Branches of internal iliac artery (posterior division)
Iliolumbar, Lateral Sacral, Superior Gluteal (I Love Sex) + Inferior gluteal (sometimes)
Branches of internal iliac artery (anterior division)
Umbilical, Obturator, Inf. vesicular/uterine, middle rectal, internal pudendal
What is the first branch off the popliteal artery?
Anterior tibialis
When does the CFA start?
inguinal ligament
When does the SFA start?
once the CFA gives off the profunda femoris
When does the popliteal artery start?
as the SFA exits the adductor canal
When the popliteal artery end?
terminates as the ant tibial and tibioperoneal trunk
When does the axillary artery start?
at the first rib
When does the brachial artery start?
as it crosses the teres major
When does the brachial artery end?
bifurcates tot he ulnar and radial arteries
What hand arch does the ulnar artery supply?
superficial arch
What hand arch does the radial artery supply?
deep arch
What supplies to the intraosseous branch?
ulnar artery (usually)
Arc of Buhler
collateral pathway from celiac to SMA (independent of GDA and inf. pancreatic)
Normal collateral pathway from celiac to SMA
celiac - GDA - sup pancreatic duodenal - inf pancreatic duodenal - SMA
Marginal artery of Drummond
SMA to IMA connection, continuous arterial circle/arcade along the inner border of the colon
IMA to Iliac normal collateral pathway
IMA - superior rectal - inferior rectal - internal pudenal - anterior branch of internal iliac
Winslow pathway
IMA to iliac collateral pathway seen in aorto-iliac occlusive dz (subclavian - int. thoracic/mammary - sup. epigastric - inf. epigastric - extenal iliac)
what vessels does the corona mortis connect?
obturator and ext. iliac
what abnormal vessel courses over the superior pubic rim?
corona mortis (injured during surgery or pelvic trauma)
Most gastric varices are formed by which vein?
left gastric/coronary
What vein drains the gastric cardia?
left gastric/coronary
What vein drains the gastric fundus?
posterior and short gastric
enlarged splenorenal shunts are associated with?
hepatic encephalopathy
where does a left SVC drain?
coronary sinus (92%) or left atrium (8%)
duplicated IVC associations
renal stuff - horse shoe and crossed fused ectopic + circumaortic renal collars
which limb is superior in circumaortic venous collar?
anterior limb
other name for azygous continuation
absence of the hepatic segment of the IVC
where do hepatic veins drain in azygous continuation?
directly into right atrium
azygous continuation association
polysplenia
persistent sciatic artery
continuation of the internal iliac
what abnormal vessel passes posterior to femur in the thigh?
persistent sciatic artery
external iliac is acutely occluded, but there’s still a strong pulse in the foot
persistent sciatic artery
most common cause of aortic dissection + intramural hematoma
hypertension (70%)
floating viscera sign
IR sign in AA dissection, catheter placed in true lumen with branch vessels arising out of nowhere
most common cause of penetrating ulcer
atherosclerosis
IMH progression to dissection?
max diam of 5cm is strongest predictor for dissection
true aneursym size
1.5 x normal diam
how can histoplasmosis cause SVC syndrome?
fibrosing mediastinitis
most common location of traumatic pseudoaneursym?
aortic isthmus (90%)
ascending aortic calcification
Takayasu and Syphilis
Size cut-offs of aorta
> 4cm ascending and transverse, >3.5 cm descending, > 3cm abd
Most common cause of aortic aneursym
atherosclerosis
cystic medial necrosis
Marfan
size for surgical repair of AAA
6cm
who gets sinus of valsalva aneurysm
Asian Men, usually right sinus
vascular findings in NF-1
aneurysms/stenosis lg vessels, renal artery stenosis/renovascular HTN (5% of NF1 kids)
vascular findings in NF-1
annuloaortic ectastia - aortic valve insufficiency, recurrent dissection, PA enlargement
tulip bulb
Marfan ascending aneursym
orbital finding in Loeys Dietz
hypertelorism (crazy wide eyes)
what procedures should be avoided in Ehlers Danlos
angio + percutaneous b/c of arterial dissection risk
vascular findings in Ehlers Danlos are similar to?
Marfan
“tree bark” intimal calcfications
syphilitic, saccular ascending aorta aneursym
what part of the bowel is involved in aortic-enteric fistula?
3rd and 4th portion of duodenum
AAA + increased ESR
inflammatory aneurysm
who gets inflammatory aneurysm?
young men who smoke
inflammatory aneursym spares the?
posterior wall
leriche syndrome
complete occlusion of the aorta
triad of leriche
ass claudication, absent femoral pulses, impotence
triad of mid aortic syndrome
HTN, claudication, renal failure
who gets mid aortic syndrome
children, young adults (intrauterine insult with fragmentation of the elastic media)
infantile aortic coarctation
pre-ductal, blood supply to descending aorta is PDA
how does adult aortic coarctation present?
(Ductal), differential arm/leg BP
association of aortic coarctation
Bicuspid aortic valve (80%), Turners (15-20%)
pseudocoarctation
looks like coarc, but NO pressure gradient, collateral formation, or rib notching
order of involvement in thoracic outlet syndrome
nerve (95%) - subclavian vein - subclavian artery
most common cause of thoracic outlet syndrome
compression by anterior scalene muscle
paget schroetter
thoracic outlet syndrome + subclavian vein thrombosis
who gets paget schroetter
athletes (pitchers, weightlifters)
can you stent the subclavian vein in paget schroetter?
no, it gets crushed. you have to do surgery.
3 causes of PA aneursyms/psa
iatrogenic/swan ganz, Behcets, Chronic PE
hughes-stovin
recurrent thrombophlebitis + PA aneursym formation/rupture
rasmussen aneursym
PA pseudoaneursym 2/2 pulmonary TB
PA aneursym in a congenital heart kid
patch aneursym from RVOT repair in TOF
most common location of chronic mesenteric ischemia
splenic flexure (watershed of SMA and IMA)
arterial vs. venous acute mesenteric ischemia
arterial = thin wall, non-dilated, diminished enhancement; venous = thick wall, dilation, fat stranding
true splenic artery aneursyms
HTN, portal HTN, cirrhosis, liver tx, pregnancy
false splenic artery aneuryms
pancreatitis
mimic of splenic a. aneursym
islet cell pencreatic tumor (hypervascular). don’t biopsy!
median arcuate ligament syndrome
compression of celiac a. by median arcuate ligament
how to treat median arcuate ligament syndrome?
surgical release
typical presentation for median arcuate ligament?
20-40 years old, worse with expiration
Heyde syndrome
colonic angiodysplasia + aortic stenosis
other name for osler weber rendu
hereditary hemorrhagic telangiectasia
common imaging for osler weber rendu
multipic hepatic and pulmonary AVMs
how to osler weber rendu patient die?
stroke or brain abscess (pulmonary AVM)
most common cause of renal artery stenosis
atherosclerosis (75%)
2nd most common cause of renal artery stenosis
FMD
renovascular HTN in young women
FMD
string of beads
FMD
treatment for FMD
angioplasty WITHOUT stenting
nutcracker syndrome
smashing left renal vein as it slides under the SMA
nutcracker syndrome
left flank/abd pain and hematuria
what other vein is involved in nutcracker (besides left renal)
left gonadal vein (drains into left renal), left testicle pain in men, LLQ pain in women
testicular varicocele side
LEFT 98% (left vein is longer and drains into renal vein at acute angle)
what is the bad buzzword for varicocele?
“non-decompressible”, can be related to neoplasm in men >40
which side is the bad side of varicocele?
RIGHT, raises concern for RCC, retroperitoneal fibrosis, or adhesions if new in adult
2 kind of uterine AVMs
congenital and acquired
how do you treat aquired uterine AVM?
embolization
May Thurner
DVT of L CIV 2/2 compression of the left common iliac vein by the overlying right common iliac artery
presentation of May Thurner
swollen left leg (L CIV DVT)
most common peripheral arterial aneursym
popliteal
association of popliteal artery aneursym
30-50% will have AAA
how often is popliteal artery aneursym bilateral?
50-70%
most dreaded complciation of popliteal artery aneurysm?
acute limb from thrombosis and distal embolization
what causes popliteal entrapment?
compression by medial head of the gastrocnemius (less common the popliteus)
presentation of popliteal entrapment
normal pulses that decrease with plantar flexion or dorsiflexion of foot
3 presentations of hypothenar hammer
corkscrew configuration or superficial palmar arch, occlusion of ulnar artery, or pseuodaneursym off the ulnar artery
klippel-trenaunay triad
port wine nevi, bony or soft tissue hypertrophy (local gigantism), and a venous malformation
what abnormal vessel is pathognomic of klippel-trenaunay
marginal vein of Servelle (superficial vein in the lateral calf and thigh)
Kasabach Merritt
infant with a rapidly growing vascular tumor is responsible for thrombocytopenia, microangiopathic hemolytic anemia and consumptive coagulopathy.
How is Parkes-Weber different from Klippel-Trenaunay?
In contrast to children who have Klippel-Trenaunay syndrome, kids with PWS have arteriovenous malformationsthat can cause heart failure.
Normal ABI + abnormal values
1 = normal, 0.5-0.3 = claudication, <0.3 = rest pain
re-stenosis of stent 3-12 months after angioplasty
probably from intimal hyperplasia (the bane of endovascular intervention)
who gets Takayasu
young Asian girls (15-30)
vasculitis involving the aorta
Takayasu
what happens to the aortic wall in Takayasu
wall thickening + wall enhancement (acute phase)
what vasculitis love old men?
Giant Cell
vessels involved in giant cell?
temporal artery and arm pit vessels
cogan syndrome
kid with eye and ear sx +/- aortitis
is polyarteritis nodosa more common in men or women?
PAN is more common in a MAN
most common vessels involved in PAN
renal (90%), cardiac (70%), GI (50-70%)
most common imaging of PAN
kidneys with microaneurysms or kidney with areas of infarct
association of polyarteritis nodosa (PAN)
Hep B
kidney abnormality in meth users?
“speed kidney”, renal microaneursyms similar to PAN
Kawasaki
calcified coronary artery aneursym (shown on CXR)
most common vascultitis in children
Kawasaki (HSP also common)
3 ANCA + vasculitides
Wegeners, Churg Strauss, Microscopic polyangiitis
4 ANCA - vasculitides
HSP, Behcets, Buergers
Wegeners
nasal septum erosions, cavitary lung lesions
Churg Strauss
transient peripheral lung consolidations
microscopic polyangiitis
diffuse pulmonary hemorrhage
HSP
kids, intussusception, massive scrotal edema, MF bowel wall thickening
Behcets
PA aneursyms (Turkish, mouth and genital ulcers)
Buergers
male smoker. hand angio showing finger occlusions.
buzzword for buergers
“auto-amputation”
Segmental arterial mediolysis
multiple abdominal splanchnic artery saccular aneurysms
cystic adventital disease
multiple mucoid filled cysts develop in the outer media and adventitia in the pop artery of young men
normal ICA/CCA ratio
2
normal ICA end diastolic velocity
<40
normal carotid artery velocity
125 cm/s
PSV + EDV in 50-69% ICA stenosis
PSV = 125-230 cm/s, EDV = 40-100, ICA/CCA PSV ratio = 2-4
PSV + EDV in >70% ICA stenosis
PSV = > 230 cm/s, EDV = > 100, ICA/CCA PSV ratio = >4
unilateral tardus parvus carotid artery
innominate artery stenosis
bilateral tardus parvus cardotid artery
aortic stenosis
loss of diastolic flow in the CCA
ICA occlusion, high resistance waveform like ECA
bilateral CCA reversal of diastolic flow
aortic regurgitation
pulsus bisferiens
double systolic peak in the CCA seen in aortic regurgitation
classic doppler finding in aortic stenosis
bilateral tardus parvus waveform in the CCAs
temporal tap
method for sonographers to tell the external from internal carotid artery
