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Vascular Disease Flashcards

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USMLE® Step 1 flashcards
1
Q

Describe the findings

A

DVT

  • US images:
    • thin walled vein + not collapsible with compression –> DVT
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2
Q

What are other significant doppler/US findings of LE DVT?

A
  • anechoic thrombus
  • increased venous diameter
  • loss of phasic flow with breathing
  • augmentation with calf squeeze
  • absence of color flow
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3
Q

Describe US findings:

  • Baker’s cyst
A

well-circumscribed mass + echolucent center

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4
Q

Describe US findings:

  • arterial stenosis
A
  • atheroma and stenosis are visualized
  • confirmed by spectral Doppler –>
    • significant increase in velocities (flow accelearation)
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5
Q

Describe US findings:

  • Polyarteritis nodosa
A
  • small aneurysms
    • beads of a rosary (“rosary sign”)
    • most commonly involved organ = kidney
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6
Q

How does large artery atherosclerosis lead to cerebral ischemia?

A
  • thromboembolism from the atherosclerotic plaque
  • direct occlusion of the penetrating arteries by the plaque
    • especially in the case of intracranial atherosclerosis
  • hemodynamic perturbations <– plaque related stenosis
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7
Q

What is the Class I indication for carotid endarterectomy?

A

TIA / CVA « 6 months secondary to –>

moderate to severe ( ► 50% stenosis ) extracranial carotid stenosis

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8
Q

What is an alternative to carotid endarterectomy?

  • symptomatic ( CVA / TIA « 6 months)
  • moderate-severe ( ► 50% stenosis)
A

Endovascular stenting (Class IIa)

  • should be reserved for highly selected cases with:
    • extracranial vertebral artery stenosis
    • limited evidence
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9
Q

Describe the difference in treatment and outcomes for intracranial atherosclerotic disease:

  • medical therapy
  • endovascular stenting
A
  • stenting has worse outcomes compared to best medical therapy
  • should only be performed when best medical therapy has failed
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10
Q

What are the recommended first line antiplatelet therapies for secondary prevention of ischemic stroke?

A
  • ASA
  • Clopidogrel
  • ASA/extended-release dipyridamole

****DAPT is not recommended over monotherapy with any of these agents

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11
Q

What is the mortality rate associated with?

  • Type A aortic dissection
  • aortic root / SoV involvement
A
  • Without operation:
    • First 24 hours –> 1-2% / hour
    • First 48 hours –> 50%
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12
Q

What is the mortality associated rate?

  • Type B aortic dissection
A
  • In-hospital –> 8%
  • 5 years –> 60-80%
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13
Q

Describe the initial treatment strategy for acute aortic dissection?

A
  • Decrease wall stress by controlling:
    • HR
    • LV contractility
      • change in pressure / change in time [dP / dT]
  • Beta blockers
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14
Q

What BB’s are utilized in the acute aortic dissection?

A
  • Metoprolol
  • Labetalol
  • Esmolol
  • Propanolol
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15
Q

What are the indications for TEVAR in type B aortic dissection?

A
  • Malperfusion syndrome (end-organ ischemia)
  • Early expansion
  • Rupture
  • Refractory pain
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16
Q

What are the indications for surgery?

  • Acute
  • Type A dissection
A

All patients

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17
Q

What are the indications for surgery?

  • Acute
  • Type B dissection
A
  • Rupture
  • Rapid Aneurysm Expansion
  • Extension
  • Malperfusion syndrome
  • Marfan Syndrome?
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18
Q

What are the indications for surgery?

  • Chronic
  • Type A dissection
A
  • ► 5.5 cm
  • ► 1 cm / year increase in dimension
  • Severe AR
  • Symptoms suggestive of:
    • expansion or
    • compression
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19
Q

What are the indications for surgery?

  • Chronic
  • Type B dissection
A
  • ► 6 cm
  • ► 1 cm / year increase in dimension
  • Symtpoms suggestive of:
    • expansion or
    • compression
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20
Q

What are three genetic risk factors / mutations for aortic aneurysm and dissection?

A
  • FBN1
    • fibrillin-1 gene
    • Marfan’s syndrome
  • TGFB1-2
    • transforming growth factor beta 1 and 2 gene
    • Loeys-Dietz syndrome
  • COL3A1
    • Collagen type 3 alpha 1 gene
    • Vascular Ehlers-Danlos
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21
Q

What patients are at increased risk of PAD?

A
  • Age ► 65 years
  • Age 50-65 years + risk factors (DM, tobacco abuse, dyslipidemia, HTN) or FH PAD
  • Age < 50 years + DM and 1 additional risk factor for atherosclerosis
  • Known ASCVD in another bed
    • coronary, carotid, subclavian, renal, mesenteric artery stenosis, AAA
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22
Q

Describe the diagnostic testing algorithm for suspected PAD?

A
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23
Q

What is the next step?

  • history or PE suggestive of PAD
  • ABI > 1.4 (noncompressible vessels)
A

Toe-brachial index (TBI)

  • « 0.70 = abnormal
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24
Q

What is the mortality associated with a diagnosis of PAD?

A
  • 5- year risk of CV death –> 25-30%
  • Nonfatal MAACE –> 20%
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25
Q

What are the benefits of exercise ABI?

A
  • Diagnosing PAD in patients with:
    • claudication and
    • normal ABI at rest
  • Discriminating claudication from pseudoclaudication
  • Assessing functional capacity
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26
Q

What constitutes further anatomic assessment in PAD?

When should this be performed?

A
  • Duplex US, CTA, MRA or invasive angiography
  • Performed with revasculrization is planned
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27
Q

What patient should be screened for PAD?

  1. 52-year old woman with pale feet when lying in bed, reddish color when standing
  2. 84-year-old woma with a draining ulcer over the medial malleolus
  3. 73-year-old man with pain and tingling in both legs while walking, reduced with bending forward
A

1. - 52-year-old woman with pale feet when lying in bed, reddish color when standing

  • elevation pallor and dependent rubor –> PAD
  • 84 year old with draining ulcer –> venous insufficiency ulcers
    • arterial ulcers tend to be dry
  • 73-year old with tingling in both legs bending over
    • neurogenic claudication –> spinal stenosis
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28
Q

Describe the findings

A

Raynaud phenomenon

  • exaggerated vascular response to cold temperature or emotional stress
  • Secondary RP - triggers:
    • Autoimmune diseases
      • systemic sclerosis
      • SLE
      • mixed connective tissue disease
      • Sjogren syndrome
      • dermatomyositis/polymyositis
    • Drugs / Toxins
      • BB
      • Clonidine
      • Sympathomimetics
      • Stimulants (Methamphetamines)
      • Cyclosporine
      • Cisplatin
      • Bleomycin
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29
Q

What are the indications for carotid duplex prior to CABG?

A
  • > 65 years of age
  • LM stenosis
  • PAD
  • Tobacco abuse (history of)
  • TIA/CVA (history of)
  • Carotid Bruit
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30
Q

Describe the findings

A

Cholesterol emboli syndrome (CES)

  • nonspecific symptoms
  • livedo reticularis
  • renal failure
  • mesenteric ischemia
  • Treatment:
    • supportive
    • increase statin therapy
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31
Q

What is the most common cause of atheroembolism?

A

iatrogenic - > 70%

  • secondary to catheter-based angiography or vascular surgery
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32
Q

What is diagnostic of obstructive PAD on exercise ABI?

A

decrement of > 20%

  • functional testing is important to evaluate for PAD in patients with exertional symptoms (Class I)
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33
Q

What is the BP goal in acute ischemic stroke?

  • no thrombolytics
A

< 220 / 110 mmHg

  • should be tailored based on comorbid conditions
34
Q

What is the BP goal in acute ischemic stroke?

  • thrombolytics given
A
  • prior to administration of thrombolytics = < 180 / 110 mmHg
  • 24 hours post-thrombolysis = < 180 / 105 mmHg
35
Q

What is the window for tpa in acute ischemic stroke?

A

< 4.5 hours

36
Q

Define acute limb ischemia (ALI)

A
  • vascular emergency
  • requires rapid assessment of, to determine limb viability and salvageability:
    • arterial perfusion
    • venous perfusion
    • sensory function
    • motor function
  • revascularization is performed emergently
37
Q

Describe diagnostic testing, findings and treatment of ALI:

  • Category I: Viable limb
A
  • Dopplers:
    • Audible arterial
    • Audible venous
  • Category I: Viable limb
    • Normal motor function
    • No sensory loss
    • Intact capillary refill
  • Urgent (Class I)
    • Anticoagulation
    • Revascularization
38
Q

When should limbs be revascularized in ALI?

A
  • Viable limbs –> within 6-24 hours
  • Threatened limbs –> « 6 hours
39
Q

Describe the diagnostic/treatment algorithm for ALI

A
40
Q

Describe diagnostic testing, findings and treatment of ALI:

  • Category IIa: Marginally threatened
A
  • Dopplers:
    • Inaudibale arterial
    • Audible venous
  • Motor/Sensory function assessment:
    • Intact motor function
    • Sensory loss limited to toes if present
    • slow-to-intact capillary refill
  • Emergent (Class I) - salvageable if treated promptly
    • Anticoagulation
    • Revascularization
41
Q

What is the diagnosis?

  • acute ischemic cerebral syndrome (R hemiparesis)
  • preceded by:
    • neck pain
    • ptosis
    • miosis
A

carotid dissection

  • Horners syndrome –>
    • Ptosis and Miosis
    • symptoms are the result of distension of nerve fibers on the outer surface of the internal CA
    • 25% of cases
42
Q

Describe diagnostic testing, findings and treatment of ALI:

  • Category III: Irreversible
A
  • Dopplers:
    • Inaudibale arterial
    • Inaudible venous
  • Motor/Sensory function assessment:
    • Complete loss of motor function
    • Complete sensory loss
    • Absent capillary refill
  • Emergent (Class I)
    • Primary amputation
43
Q

Describe the findings post-PCI?

What is the best way to confirm the diagnosis?

A
  • Cholesterol Embolization Syndrome (CES)
  • Biopsy
    • only for clinical situations in which diagnosis is unclear
44
Q

What is the appropriate screening recommendation for AAA based on size at diagnosis?

A
  • > 2.5 cm - < 3 cm –> 10 years
  • 3 cm - 3.9 cm –> every 3 years
  • 4 cm - 4.9 cm –> every 12 months
  • 5 cm - 5.4 cm –> every 6 months
45
Q

What are the indications for elective repair of an asymtpomatic AAA?

A
  • > 2.5 cm - « 5.5 cm;
    • ► 5.5 cm –> repair
      • ​women (consider) ► 5.0 cm
  • Rapid expansion; and
  • AAA associated with peripheral arterial aneurysms or PAD
46
Q

What are treatments to improve symptoms of claudication in PAD?

A
  • supervised exercise program
  • Cilostazol
    • contraindicated in heart failure
  • Endovascular therapy
    • effective and reasonable in patients with inadequate response to exercise and medical therapy
47
Q

Describe diagnostic testing, findings and treatment of ALI:

  • Category IIb: Immediately threatened
A
  • Dopplers:
    • Inaudibale arterial
    • Audible venous
  • Motor/Sensory function assessment:
    • Mild or moderate muscle weakness
    • Sensory loss more than toes and with rest pain
    • slow-to-absent capillary refill
  • Emergent (Class I) - salvageable if treated emergently
    • Anticoagulation
    • Revascularization
48
Q

Define critical limb ischemia (CLI)

A
  • chronic ( > 2 week) ischemic rest pain
  • nonhealing wound/ulcers or gangrene in one or both legs
  • attributable to objectively proven arterial occlusive disease
49
Q

What are the requirements to proceed with PFO catheter closure?

A
  • embolic-appearing ischemic stroke
    • without other etiology despite adequate testing
  • 18-60 years of age
50
Q

What is the recommendation for anticoagulation in cryptogenic stroke with presence of PFO?

A

Not recommended (Class III harm)

  • ​unless other indication present (A-fib, h/o DVT, mechanical heart valve)
51
Q

Describe the findings

A
  • Incorrect electrode placement ( +1 )
    • abrupt R-wave increase in lead V2 followed by much smaller R wave in V3
    • V2 is actually V6
  • Atrial tachycardia ( +4 )
    • P-waves of sinus origin should be positive in lead II
  • PVC’s ( +1 )
  • Inferior MI, age indeterminant or probably old ( +1 )
52
Q

Describe the findings

A
  • Atrial flutter ( +4 )
  • LAD ( +1 )
  • LVH ( +1 )
  • RVH ( +1 )
  • RBBB, incomplete ( +1 )
53
Q

Describe the findings

A
  • NSR ( +1 )
  • LAE ( +1 )
  • AV block, second degree, Mobitz I (Wenckebach) ( +4 )
54
Q

Describe the findings

A
  • NSR ( +1 )
  • AV block, second degree, Mobitz I (Wenckebach) ( +4 )
  • LAD ( +1 )
  • IVCD, nospecific type ( +1 )
    • QRS slightly widened (approximately 115 ms) but criteria for LBBB are not met
55
Q

Describe the findings

A
  • NSR ( +1 )
  • PAC’s ( +2 )
    • single dropped beat toward the end of the tracing
    • T-wave preceding this dropped beat has a slightly different morphology
    • PAC burried within the T wave –> dropped beat
56
Q

Define May-Thurner syndrome

A
  • rarely diagnosed condition in which patients develop ileofemoral DVT and recurrent DVTs
  • anatomical defect:
    • the R common iliac artery overlies and compresses
    • the left common iliac vein against the lumbar spine
  • present in > 20% of the population
57
Q

What are common risk factors / presenting symptoms in May-Thurner syndrome?

A
  • scoliosis
  • pregnancy (recent)
  • OCP
  • LLE DVT’s (rather than RLE DVT’s)
  • LLE swelling (in the absece of DVT’s)
  • female sex
58
Q

What is the best method of diagnosis in suspected May-Thurner syndrome?

A

CT or MR venography of the pelvis

  • gold standard –> contrast venography
    • has been replaced due to its invasive nature
59
Q

What is the recommendation for screening in family members of a patient with?

  • bicuspid aortic valve
  • aortic aneurysm
A

CTA or MRA of aorta in first-degree relatives

  • especially when a family history of thoracic aortic aneurysm and/or aortopathy
60
Q

Define critical limb ischemia (CLI)

A

severe PAD associated with:

  • rest pain
  • nonhealin ulcers
  • gangrene
61
Q

What is the recommendation for DAPT in severe PAD (CLI)?

A

not recommended

  • has not been demonstrated to provide incremental benefit
62
Q

What is the diagnosis and next best step?

  • 78 year old woman
  • HA’s, visual disturbances, jaw fatigability with chewing, shoulder stifness
A
  • Giant cell (temporal) arteritis
    • large-vessel vasculitis
  • Temporal biopsy
63
Q

What is the diagnosis and next best step?

  • 38 year old woman
  • tobacco abuse and ulcers on fingertips
A

Buerger’s disease (thromboangitis obliterans)

  • most important therapy = smoking cessation
64
Q

What is the diagnosis and next best step?

  • 28 year old Asian woman
  • mild fevers and arm fatigue when brushing her hair
A

Subclavian stenosis / possible Takayasu arteritis

65
Q

What are the recommendations for surgery for TAA disease based on size and rate of growth of aneurysm?

A
66
Q

What are the recommendations for medical thearpy in TAA?

A
  • BB (atenolol)
  • ARB/ACE (losartan)
67
Q

Describe Takayasu Arteritis

A
  • < 50 years of age
  • 80-90% are women
  • inflammation (thickening) of:
    • aortic arch
    • and stenosis of its branches
68
Q

What laboratory test may help in the diagnosis of cholesterol embolization syndrome?

A

Urine eosinophils

69
Q

When calculating ABI, what brachial BP should be used?

A

higher of the two

  • subclavian stenoses may cause decreases BP in one arm
70
Q

What is the diagnosis and next best step?

  • 75 year old woman with severe substernal chest pain
  • PMH: HTN, dyslipidemia, prior carotid endarterectomy
  • Meds: ASA, Rosuvastatin, Carvedilol, HCTZ
  • VS: HR 98, BP 169/102
  • Labs: Troponin negative
  • CT: crescentic, high attenuation area measuring approximately 3 mm in diameter in the posterior ascending aorta, that does not enhance with contrast. No involvement of the great vessels or arch. No intimal flap or compression of the lumen.
A
  • Type A intramural hematoma (IMH)
  • Emergent surgical consultation
    • ​high risk of rupture
    • mortality with medical therapy alone ~40%
71
Q

What medications are contraindicated in acute aortic syndromes?

A

Vasodilating drugs - Hydralazine

  • should not be given prior to adequate beta-blockers
  • Class III recommendation
72
Q

What are the “5 Ps” of limb ischemia?

A
  • pain
  • pallor
  • paralysis
  • pulselessness
  • paresthesia
73
Q

What are the types of acute aortic syndromes?

A
  • Aortic dissection
  • Intramural hematoma
  • Penetrating aortic ulcer
  • Rapid Aneurysm expansion
  • Aortic Rupture
74
Q

Why is vitamin K not the reversal agent of choice in intracranial hemorrhage?

A
  • slow reversal
  • earliest effect on INR in 2 hours
  • peak effect 6-12 hours
75
Q

What is the agent of choice for reversal?

  • acute cerebral hemorrhage
  • warfarin use
  • INR 3
A

4F-PCC 1500 units

  • contains purified vitamin K-dependent clotting factors
  • do not require ABO compatibility and can be stored at room temperature
  • dosing:
    • INR and
    • bodyweight
76
Q

What is the reversal agent for Dabigitran?

A

Idarucizumab

77
Q

Describe the findings

A
  • NSR ( +1 )
  • AV junctional rhythm / tachycardia ( +1 )
  • AV block, third degree ( +4 )
  • Inferior MI, age recent or probably acute ( +4 )
78
Q

Describe the findings

A
  • NSR ( +1 )
  • LAE ( +1 )
  • AV block, second degree, Mobitz II ( +4 )
  • Nonspecific ST and/or T wave abnormalities ( +1 )
79
Q
A
80
Q

Define posterior reversible encephalopathy syndrome (PRES)

A
  • acute encephalopathy that appers to be related to disordered cerebral autoregulation and endothelial dysfunction
  • acute severe hypertesion (beyond upper limits of cerebral autoregulation) –> Vasogenic edema
  • ​MRI brain
    • focal bilateral areas of cerebral edema
    • posterior portion of the brain (particularly occipital lobes)

Medical (69 decks)

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