VIQ - CVS and IR

Question 1

@# 57) A 35-year-old man presents following a chest injury. A chest radiograph shows a smooth, curvilinear, tubular opacity adjacent to the right heart border. No other abnormality is seen. The accident and emergency team are requesting a CT of the chest. What is the most likely diagnosis?

a. pulmonary contusion

b. pneumothorax

c. pericardial injury

d. extralobar sequestration

e. partial anomalous pulmonary venous return

Answer 1

e. partial anomalous pulmonary venous return

The appearances are classic of partial anomalous pulmonary venous return, which occurs in 0.3–0.5% of cases of congenital heart disease and is associated with atrial septal defects and hypogenetic lung.

Contusions are seen as illdefined opacities on CT, often with rib fractures.

Anterior pneumothorax would cause increased conspicuity of the heart border.

Pericardial injury produces a thick, irregular, shaggy, soft-tissue density adjacent to the heart border.

Extralobar sequestration produces a triangular-shaped opacity adjacent to the diaphragm.

Question 2

@# 18 A 2 day old neonate presents with difficulty in breathing. On examination there are widespread crepitations. The CXR shows florid pulmonary oedema. Which of the following congenital heart anomalies would be the most likely cause of these appearances?

(a) Atrial septal defect

(b) Hypoplastic Left Heart Syndrome

(c) Pulmonary atresia

(d) Tetralogy of Fallot

(e) Ventricular septal defect

Answer 2

(b) Hypoplastic Left Heart Syndrome

The overall incidence of CHD is 1%, the most common are structural defects bicuspid aortic valve and MVP.

The most common types of CHD presenting in the first month of life are: hypoplastic left heart syndrome (35%), TGA (25%), coarctation (20%), multiple defects (15%), pulmonary atresia/stenosis (10%), severe Tetralogy of Fallot’s (10%).

HLHS describes underdevelopment of LA, LV, MV, AV and aorta, survival requires a large ASD and PDA to allow admixing of the left and right circulations.

CXR shows marked pulmonary oedema and right heart enlargement.

HLHS and the ‘5 Ts’ present at 0-2 days, but HLHS is more common and more likely to produce marked CCF.

Coarctation and AS present at 7-14 days; VSD and PDA presents in infancy and ASD in adulthood.

Question 3

@# Ped) 33 A neonate is cyanosed. A CXR is performed which shows slight cardiac enlargement and oligaemia of the pulmonary vasculature. Which of the following is the most likely diagnosis?

(a) Single ventricle

(b) Total anomalous pulmonary venous connection

(c) Transposition of the great arteries

(d) Tricuspid atresia

(e) Truncus arteriosus

Answer 3

(d) Tricuspid atresia

The list given is that of the ‘5 Ts’ of cyanotic heart disease with increased pulmonary vasculature.

The differential diagnosis for cyanosis and pulmonary oligaemia is tricuspid atresia, Tetralogy of Fallot, Ebstein’s anomaly and pulmonary atresia.

In tricuspid atresia there will only be increased pulmonary flow if there is an associated VSD but no pulmonary stenosis (a frequent association); the majority have reduced pulmonary blood flow.

Question 4

@# Ped) 27 A father of a two-month-old boy is concerned that his son has been getting progressively blue, which becomes more apparent when he cries. On examination he is cyanosed with a pansystolic murmur. A CXR reveals a moderately enlarged heart. What is the likely diagnosis?

a Tetralogy of Fallot

b Corrected transposition of great arteries

C Pulmonary atresia

d Tricuspid atresia

e Patent ductus arteriosus

Answer 4

27 Answer D: Tricuspid atresia

Tricuspid atresia is the second most common cause of neonatal cyanosis after transposition of the great arteries. It is characterised by an absent tricuspid valve, ASD, and a small VSD. Most occur in the absence of transposition (80%), but it may also occur in the setting of transposition. The heart may be normal in size or moderately enlarged with enlargement and hypertrophy of the left ventricle and enlargement of the right atrium.

Question 5

@# 15 A patient undergoing echocardiography for an acyanotic shunt had the following findings on imaging: dilated left atrium and ventricle, dilated right ventricle, undilated right atrium and undilated aorta. What is the most likely cause of the shunt?

a Ostium primum atrial septal defect (ASD)

b Ventricular septal defect (VSD)

c Patent foramen ovale

d Ostium secundum ASD

e Patent ductus arteriosus (PDA)

Answer 5

15 Answer B: Ventricular septal defect (VSD)

The following features can differentiate between the position of acyanotic shunts:.

Question 6

@# Ped) 41 A neonate presents with poor feeding. On examination he is found to be cyanotic, with symptoms of congestive heart failure and a systolic murmur. A CXR shows extreme right atrial enlargement and a hypoplastic aorta and pulmonary trunk. Which of the following is the most likely diagnosis?

a Ebstein’s anomaly

b Eisenmenger’s syndrome

c Transposition of the great arteries

d Patent ductus arteriosus

e Tricuspid atresia

Answer 6

41 Answer A: Ebstein’s anomaly

Ebstein’s anomaly is caused by apical displacement of the posterior and septal tricuspid valve leaflets, leading to part of the right ventricle becoming part of the right atrium.

It is the only cyanotic heart disease to have a hypoplastic aorta and pulmonary trunk.

Question 7

@# 17 The pre-employment chest radiograph of an asymptomatic 32-year-old female shows mild pulmonary plethora. Subsequent investigation with a CT thorax reveals abnormal venous drainage of the right upper lobe. Where is this lobe most likely to drain?

a Right atrium

b Superior vena cava

C Suprahepatic portion of the inferior vena cava

d Coronary sinus

e Portal vein

Answer 7

17 Answer B: Superior vena cava

Partial anomalous pulmonary venous return (PAPVR) is a congenital abnormality, which can be radiologically mistaken for an anomalous SVC. One or more pulmonary veins drain directly into the right atrium or to a systemic vein.

In decreasing order of frequency, the sites of communications are to the SVC, right atrium and IVC.

This results in an extracardiac left to right shunt. The clinical signs and symptoms are related to the degree of left-to-right shunting. Although an isolated PAPVR from a single lobe is usually asymptomatic, individuals with cardiopulmonary disease may develop symptoms.

Question 8

@# 32. Causes of oligaemia (decreased pulmonary blood flow) with cyanosis include: (T/F)

(a) Aortic atresia.

(b) Truncus arteriosus.

(c) Transposition of great vessels.

(d) Total anomalous pulmonary venous return.

(e) Tetralogy of Fallot.

Answer 8

Answers:

(a) Not correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Aortic atresia, Truncus arteriosus, TGA and TAPVR show plethora with cyanosis.

Question 9

@# 49. Which of the following are correct regarding transposition of the great arteries (TGA)? (T/F)

(a) Pulmonary stenosis is an associated feature.

(b) In the D loop of TGA the atria and ventricles have a normal morphological relationship.

(c) Dextrocardia is associated with L loop of TGA.

(d) Chest radiograph shows pulmonary plethora in D loop of TGA.

(e) In the L loop (corrected) transposition there is physiologically corrected circulation.

Answer 9

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Correct

(e) Correct

Explanation:

In the D loop of TGA the aorta arises from the right ventricle and the pulmonary artery from the left ventricle.

A normal relationship exists between the atria and the ventricles.

In the L loop of TGA, there is transposition of the aorta and pulmonary arteries in addition to inversion of the left and right ventricles.

The atria and coronary arteries are associated with their corresponding ventricles.

Question 10

@# 50. Regarding total anomalous pulmonary venous drainage (TAPVD), which of following are correct? (T/F)

(a) The supracardiac type is the most common.

(b) The left atrium is not enlarged.

(c) The infracardiac type may drain into hepatic veins.

(d) There is an association with Scimitar syndrome.

(e) Pulmonary oedema in presence of normal sized heart is a feature of Cardiac type TAPVD.

Answer 10

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Not correct

(e) Not correct

Explanation:

Scimitar syndrome is the association of hypogenetic lung with congenital pulmonary venolobar syndrome where all or part of hypogenetic lung is drained via an anomalous vein into the subdiaphragmatic IVC, hepatic veins, portal vein or coronary sinus.

Pulmonary oedema is a characteristic feature of infracardiac type TAPVD.

Question 11

@# 6. With regards to imaging techniques in the detection of hibernating myocardium, which has the greatest specificity?

A. 2-[18F]-fluoro-2-deoxy-d-glucose positron-emission tomography

B. Thallium-201 rest-redistribution

C. Technetium-99m perfusion imaging

D. Dobutamine stress echocardiography

E. Dobutamine stress magnetic resonance imaging

Answer 11

E. Dobutamine stress magnetic resonance imaging

stress MRI is a well-validated method for the assessment of myocardial hibernation (using a low dose protocol) and ischaemia (using a high-dose protocol). MRI provides superior spatial resolution when compared with echocardiography, and improvement in resting wall motion abnormality is considered a sign of myocardial hibernation.

Question 12

@# 19. A small pericardial metastatic deposit on the Magnetic Resonance Imaging (MRI) of a 55-year-old female demonstrates high-signal intensity on T1-weighted images. Which of the following is the most likely primary tumour?

A. Breast

B. Renal cell carcinoma

C. Colorectal

D. Melanoma

E. Lymphoma

Answer 12

D. Melanoma

Pericardial effusion, thickening or mass may indicate metastatic involvement of the pericardium.

Most neoplasms have a low-signal intensity on T1-weighted images and a high signal intensity on T2-weighted images, with the exception of metastatic melanoma.

The most common tumors to metastasize to the pericardium are breast and lung, followed by lymphomas and melanomas.

Question 13

@# 28. A 65-year-old woman presents with palpitations and a heart murmur. Which of the following features are more in keeping with an atrial myxoma rather than thrombus as demonstrated on CT?

A. Prolapse through the mitral valve on CT

B. The presence of calcification

C. The low attenuation of the lesion

D. A lack of enhancement

E. A smooth surface of the lesion

Answer 13

A. Prolapse through the mitral valve on CT

On CT, prolapse through the mitral valve orifice is the only reliable discriminatory finding indicating myxoma. There is overlap in the features of calcification, mobility, attenuation characteristics, and location between myxoma and thrombus.

Question 14

@# 7- A 32-year-old male patient has a routine CXR for insurance purposes. The film is well centered, the right heart border is indistinct and appears rotated. The lung parenchyma and vasculature appear normal. What is the most likely cause?

(a) Absent left pericardium

(b) Pectus excavatum

(c) Poor patient positioning

(d) Pulmonary artery enlargement

(e) Situs solitus

Answer 14

(a) Absent left pericardium

Congenital absence of the pericardium may be partial (91%) or total (9%).

Large defects can cause strangulation and have the appearance of the large cardiac silhouette seen in pericardial effusions,

small defects are usually asymptomatic.

Partial defects are more common on the left (complete left-sided absence 35%, foraminal defect left side 35%).

In complete left-sided absence, the heart is shifted to the left and rotated, the PA view of the heart mimics an RAO view and the heart is separated from the sternum on the lateral view.

In foraminal left-sided defects, there may only be prominence of the left atrial appendage (appears as left hilar mass, may mimic left PA enlargement). They are associated with bronchogenic cysts (30%), VSD, PDAs, CDHs and mitral stenosis.

Question 15

@# 25. A 54 year old man presents with breathlessness and palpitations. Clinical examination reveals a mid-diastolic murmur with presystolic accentuation. Echocardiography confirms the presence of a mobile intracardiac mass in the left atrium attached to the septum by means of a stalk. Which of the following is the most likely feature of the lesion on MRI?

a. Hypointense relative to myocardium on T1-weighted images

b. Uniform hyperintense to myocardium on T2-weighted images

c. Uniform enhancement following gadolinium

d. Hyperintense to blood pool and hypointense to myocardium on steady-state free precession (SSFP) images

e. Prolapse of the mass through the mitral valve, best demonstrated on the short axis views

Answer 15

25. a. Hypointense relative to myocardium on T1-weighted images

The lesion described is a left atrial myxoma which has a heterogenous appearance on most MRI sequences

and usually demonstrates varying enhancement following gadolinium injection. This is due to varying amounts of myxomatous tissue, fibrous tissue, blood products and tumour necrosis.

The majority of the lesion will be hypointense to myocardium on T1-weighted images.

On SSFP images, it is hypointense to blood pool and hyperintense to myocardium.

The tumour prolapses through the mitral valve and is best seen on cinegradient echo imaging with a four-chambered long axis view

Question 16

@# 36. In the same patient (with cardiomyopathy), which underlying cause and corresponding enhancement pattern are inappropriate?

a. Ischaemic cardiomyopathy – subendocardial pattern in a coronary artery territory

b. Early myocarditis – patchy, focal subendocardial pattern

c. Hypertrophic cardiomyopathy – patchy multifocal changes, commonly the right ventricular free wall and its junction with the interventricular septum

d. Amyloidosis – global and diffuse, commonly subendocardial

e. Dilated cardiomyopathy – midwall myocardial enhancement

Answer 16

36. b. Early myocarditis – patchy, focal subendocardial pattern

In early myocarditis, the enhancement pattern is typically epicardial.

Question 17

@# 73. A 28-year-old patient is admitted from the dermatology clinic where she is being treated for basal cell carcinoma. She suffered an episode of ventricular tachycardia and imaging is requested secondary to the results of echocardiography. CXR reveals bifid ribs. Cardiac MRI reveals a well circumscribed abnormality, which is low signal on both T1WI and T2WI and shows delayed enhancement, within the myocardium of the left ventricular free wall. CT reveals a soft-tissue attenuation mass with calcification. What is the most likely diagnosis?

A. Myxoma.

B. Paraganglioma.

C. Fibroma.

D. Fibroelastoma.

E. Lipoma.

Answer 17

73. C. Fibroma.

This patient has Gorlin’s syndrome (nevoid basal cell carcinoma syndrome, NBCCS).

This may result in abnormalities of the skin (basal cell carcinoma), skeletal (jaw odontogenic keratocysts, bifid, fused, or markedly splayed ribs), and genitourinary (ovarian fibromas) systems, as well as cardiac fibroma (relatively rare) and calcification of the falx. Medulloblastoma is a relatively less common manifestation.

The imaging characteristics of cardiac fibromas reflect their fibrous nature: low signal on T1WI and T2WI with delayed enhancement on MRI.

Most are well circumscribed with a surrounding rim of compressed myocardium.

On CT they manifest as mildly enhancing soft tissue attenuation masses.

Foci of calcification are present in up to 50% of cases.

Although benign they may cause ventricular arrhythmias and even sudden death secondary to interference with conduction pathways.

Atrial myxomas are of mixed signal on T1WI and T2WI sequences. They are most commonly found within the left atrium (80%), with 15% in the right atrium. On CT a low attenuation intracavitary mass with a smooth or slightly villous surface is seen.

Cardiac paragangliomas are well encapsulated, hypervascular (intensely enhancing), and 3–8cm in size. They are isointense to myocardium on T1WI and markedly hyperintense on T2WI. Presentation is with symptoms of catecholamine excess. They are found in the posterior wall of the left atrium, atrioventricular groove, and root of the great vessels.

Fibroelastomas arise from endocardial surfaces, most commonly the aortic and mitral valves. They are a recognized cause of sudden death and immediate resection is warranted. Trans-oesophageal echocardiography is the optimal means of visualization due to their small size and highly mobile nature.

Cardiac lipomas have characteristic imaging features consistent with fat on MRI and CT.

Question 18

@# 8 A 25-year-old male was referred for a routine testicular screening ultrasound. He is known to have a cardiac myxoma and has multiple pigmented lesions on his face and lips. What is the most likely unifying diagnosis?

a Carney’s syndrome

b Peutz Jeghers syndrome

c Waardenburg’s syndrome

d Cronkhite-Canada syndrome

e Gorlin’s syndrome

Answer 18

8 Answer A: Carney’s Syndrome

Carney’s Syndrome or Complex refers to a familial neoplastic lentiginous syndrome consisting of the following:

primary pigmented nodular adrenocortical disease,

lentigines,

ephelides,

blue nevi of the skin and mucosa,

various tumours (including myxomas of the skin, heart and breast)

and Sertoli-cells tumours of the testes.

Question 19

@# 10 A 57-year-old man with diabetes mellitus presented with anterior chest pain on minimal exertion and an exercise tolerance test was positive. Cardiac angiography demonstrated 70% stenosis of the circumflex, 90% stenosis of the left anterior descending and complete occlusion of the right coronary arteries. It was agreed with the patient that coronary artery bypass surgery was appropriate. Which of the following native grafts is most appropriate for bypassing the left anterior descending artery?

a Saphenous vein

b Left internal mammary artery

C Left superior epigastric artery

d Radial vein

e An intercostal artery

Answer 19

10 Answer B: Left internal mammary artery

The distal left anterior descending (LAD) artery lies anteriorly in the chest. The left internal mammary artery (LIMA) lies along the anterior chest wall and passes close to the LAD in the interventricular groove, which makes it an ideal graft. Additionally, arteries make more sustainable graft material.

Question 20

@# 20 A 73-year-old man underwent a contrast-enhanced cardiac MR examination. His ECG had not changed over the last six months and showed Q waves in leads II, III and AT. When would you expect peak differential enhancement of the myocardium in the right coronary artery territory following administration of iodinated contrast?

a No enhancement will occur

b Within 10 seconds

C 20-30 seconds

d 60-90 seconds

e 10-15 minutes

Answer 20

20 Answer E: 10-15 minutes

The ECG findings are consistent with inferior myocardial infarction within the right coronary artery territory.

A perfusion defect will occur within 60-90 seconds after contrast administration.

There will be delayed enhancement of the infarcted tissue, which is most visible at 10-15 minutes.

The size of the enhanced area correlates well with the size of the infarction.

Question 21

@# 6 A45-year-old male with known ischaemic heart disease presented with increasing shortness of breath on exertion and peripheral oedema. Echocardiography showed impaired left ventricular function. A cardiac magnetic resonance study was performed. What finding would be most consistent with hibernating myocardium?

a 75% Subendocardial delayed enhancement

b Normal myocardial contractility at rest

c No myocardial delayed enhancement

d Epicardial hyperenhancement

e Patchy hyperenhancement of myocardium

Answer 21

6 Answer C: No myocardial delayed enhancement

Hibernation describes chronic contractile impairment secondary to chronic hypoperfusion, where the myocardium is still viable.

Delayed hyperenhancement represents infarcted tissue, which is no longer viable.

Question 22

@# 7 A one-year-old male presented to the Emergency Department following a syncopal episode. On clinical examination there was an audible murmur and the child subsequently had an echocardiogram, which demonstrated a solid echogenic mass closely applied to the right ventricular wall. What is the most likely diagnosis?

a Teratoma

b Myxoma

c Rhabdomyoma

d Angioma

e Lymphoma

Answer 22

7 Answer C: Rhabdomyoma

The commonest cardiac tumour in an infant is a rhabdomyoma.

It is a hamartoma and therefore a benign tumour that in 50-80% of patients is associated with tuberous sclerosis.

They are often multiple and usually involve the ventricular free walls or interventricular septum.

They are only managed surgically if they cause obstruction of the outflow tract as they tend to regress over time.

Question 23

@# 11 A 68-year-old male presented to the Emergency Department with shortness of breath. A chest radiograph revealed a pacemaker box lying within the left pectoral pocket with three leads arising from it. The first two leads lie within the right atrial appendage and right ventricle and the distal tip of the third lead is projected over the left ventricle. In which structure is the third lead most likely to be positioned?

a Interventricular septum

b Epicardium

C Coronary sinus

d Cardiac vein

e Persistent left superior vena cava

Answer 23

11 Answer D: Cardiac vein

This appearance describes a cardiac resynchronisation pacemaker, used for cardiac failure in the presence of bundle branch block.

The lead enters the coronary sinus from the right atrium then is placed within an appropriate cardiac vein adjacent to left ventricular myocardium.

If cardiac venous anatomy is not suitable then surgically placed epicardial leads can be used.

Question 24

@# 12 A 24-year-old female was investigated for syncopal episodes. A 24-hour ECG was normal and a coronary angiogram was suspicious for anomalous coronary artery anatomy. A gated coronary artery CT was requested. What arterial course is most likely to cause haemodynamic compromise and therefore require intervention?

a Right coronary artery arising from the left coronary sinus and passing anterior to the aorta

b Right coronary artery arising from the left coronary sinus and passing posterior to the aorta

C Circumflex artery arising from the right coronary sinus passing posterior

d Circumflex artery arising from the left coronary artery and passing into the atrioventricular groove

e Left main stem arising from the non-coronary sinus and passing anteriorly

Answer 24

12 Answer A: Right coronary artery arising from the left coronary sinus and passing anterior to the aorta

This arterial course is between aorta and pulmonary artery, which can compress the vessel causing ischaemia and if symptomatic may require bypass surgery.

The commonest anomalous coronary artery course is an aberrant circumflex arising from the right coronary and passing posteriorly into the left AV groove (option c).

Question 25

@# 20 A 65-year-old woman with a history of an inferior myocardial infarction nine months previously underwent a cardiac MRI. When would you expect peak enhancement of the myocardium in the left ventricular free wall following administration of gadolinium-based contrast? a No enhancement will occur b Within 10 seconds C 20-30 seconds d 5-7 minutes e 10-15 minutes

Answer 25

20 Answer C: 20-30 seconds The left ventricular free wall is unlikely to have been involved in the patient's infarct hence the answer is when normal myocardium enhances.

Question 26

@# 29 A two-year-old child underwent a palliative procedure for a cyanotic congenital heart abnormality. A post-operative CT demonstrated a poly- tetrafluoroethylene (PTFE) graft between the subclavian artery and the ipsilateral branch of the pulmonary artery. What surgical procedure has been performed? a Blalock-Hanlon procedure b Glenn procedure C Rashkind procedure d Norwood procedure e Blalock-Taussig shunt

Answer 26

29 Answer E: Blalock-Taussig shunt The Blalock-Taussig (B-T) shunt is an end-to-side anastomosis between the subclavian and pulmonary arteries performed for Tetralogy of Fallot and tricuspid atresia with pulmonary stenosis.

Question 27

@# 50. A 42-year-old male presents with chest pain, dyspnoea and palpitations. He undergoes cardiac MRI, which reveals extensive scattered delayed enhancement in the anterior, lateral and inferior wall and apex of the left ventricle. This enhancement occurs in the midwall with relative sparing of the subendocardial region. T2WI is unremarkable. What is the most likely diagnosis? A. Acute myocardial infarction. B. Sarcoidosis. C. Myocarditis. D. Hypertrophic cardiomyopathy. E. Amyloidosis.

Answer 27

50. C. Myocarditis. This is defined as inflammation of the heart muscle. A large variety of infections, systemic diseases, drugs, and toxins have been associated with this condition. The diagnosis is based on a combination of clinical and imaging features. The presence of focal delayed enhancement on cardiac MRI in a non-coronary artery distribution, together with wall motion abnormalities, correlates strongly with myocarditis in the correct clinical setting. Many patients present with a nonspecific illness characterized by fatigue, dyspnoea, and myalgia. An antecedent viral syndrome is present in more than 50% of patients. Myocarditis lesions occur typically in the lateral free wall and originate from the epicardial quartile of the ventricular wall. The subendocardial area is spared, a pattern that is otherwise typical for myocardial infarction (in the latter case the lesion would also correspond to a coronary artery territory). In myocarditis the enhancement pattern has been described as becoming less intense and more diffuse over weeks and months. In acute myocardial sarcoidosis, increased focal signal intensity can be observed on T2WI (secondary to oedema due to inflammation) and both early and delayed post-contrast T1 weighted imaging (T1WI). Focal myocardial thickening is often seen due to the oedema and can mimic hypertrophic cardiomyopathy (HCM). HCM will reveal marked hypertrophy of the interventricular septum and left ventricular wall, with associated transmural delayed enhancement in the hypertrophied areas. The latter finding corresponds to the scattered fibrosis present and the amount of enhancement will inversely correlate with regional contractivity. Cardiac amyloidosis leads to a restrictive cardimyopathy. MR imaging shows functional impairment, biventricular hypertrophy, and non-specific inhomogenous gadolinium enhancement.

Question 28

@# 69. A 25-year-old man presents with chest pain on exertion. He is referred for CT coronary angiography. Which of the following findings is most significant? A. The RCA arises from the left coronary sinus and passes between the aorta and pulmonary artery. B. Separate ostia of the LAD and left circumflex (LCx) coronary arteries arise from the left coronary sinus. C. The left main stem (LMS) arises from the right coronary cusp and passes anterior to the pulmonary artery. D. The RCA arises from the right coronary cusp and passes into the right atrioventricular (AV) groove. E. The LMS arises from the left coronary cusp and trifurcates into an LAD, LCx and ramus intermedius branch.

Answer 28

69. A. The RCA arises from the left coronary sinus and passes between the aorta and pulmonary artery. Coronary artery anomalies are rare, but can be a cause of chest pain and sudden cardiac death. Diagnosis can be difficult via conventional catheter angiography due to both difficulty in locating the abnormal ostia and correct interpretation of the vessel course. Cardiac CT is superior in this regard. The anomalies can be malignant or non-malignant depending on the site of origin and course. Option D gives the normal path of the RCA and option E is a common normal variant of the LMS; a bifurcation into LAD and LCx being more usual. In option A the RCA has an anomalous origin from the left coronary cusp and takes a malignant, ‘interarterial’ course, passing between the aorta and pulmonary artery. It is thought that when dilatation of the aorta occurs during exercise, the abnormal slit-like ostium of the RCA becomes narrower, reducing RCA perfusion and causing myocardial infarction. This variant can be associated with sudden cardiac death in 30% of patients. In option C the LMS has an anomalous origin and path, but it is benign as it passes anterior to the pulmonary artery. The multiple ostia in option B are benign and may be beneficial, as disease in one vessel proximally would not compromise the other, as would normally occur in LMS disease. A further malignant coronary anomaly is anomalous origin of the coronary artery from the pulmonary artery (ALCAPA), which is usually symptomatic in childhood. Myocardial bridging, in which a length of coronary artery (usually mid LAD) takes an intramyocardial course & may cause ischaemia, infarction, arrhythmia, and even death, commonly causes no symptoms.

Question 29

@# Ped) 14. A 14 year old patient with Turner syndrome presents with severe headache. Clinical examination confirms upper limb hypertension and a murmur. Which of the following signs is likely on the plain films? a. Boot-shaped heart b. Snowman sign c. Figure-of-three sign d. Egg-on-a-string sign e. Scimitar sign

Answer 29

14. c. Figure-of-three sign The above mentioned are plain radiography signs of various congenital heart diseases. The condition described above is coarctation of the aorta. A boot-shaped heart is a feature of tetralogy of Fallot. Snowman sign or figureof-eight sign is seen in supracardiac TAPVD. Scimitar sign is a feature of partial anomalous pulmonary venous return, and egg-on-astring sign is noted in TGA.

Question 30

@# 16- Regarding congenital abnormality of the IVC. Which of the is most likely be with azygous of the IVC? (a) Asplenia. (b) Total anomalous pulmonary venous connection (TAPVC) (c) Bilateral bilobed lungs (d) Right isomerization (e) Eparterial bronchi

Answer 30

(c) Bilateral bilobed lungs Azygous continuation Of the IVC is congenital absence of the hepatic segment of the IVC with continuation to the right atrium occurring via the azygous or hemi-azygous veins, prevalence = 0.6%. It is often associated with polysplenia syndrome (left isomerization) and only rarely with asplenia syndrome (right isomerization). Polysplenia syndrome is associated with bilateral bi-lobed lungs, partial anomalous pulmonary venous connection (PAPVC), persistent left SVC, situs ambiguous, hyparterial bronchi, atrial septal defects (ASD) and double outlet right ventricle (DORV)

Question 31

@# GIT) 19 A patient is referred for chemo-embolisation of a hepatocellular carcinoma in the right lobe of the liver. The initial angiogram demonstrates that the lesion is supplied from the superior mesenteric artery. What proportion of patients have an arterial supply to liver from the SMA? (a) 7% (b) 14 % (c) 17 % (d) 21 % (e) 25 %

Answer 31

(e) 25 % 14% of patients have an accessory right hepatic artery, 7% have a replaced right hepatic artery and 4% have a totally replaced hepatic artery arising from the SMA.

Question 32

@# 26. A 34 year old IV drug abuser presents with fever, rigors and back pain. Blood cultures reveal staphylococcal septicaemia. CT demonstrates a mycotic aneurysm. Which of the following is the most likely CT feature? a. Fusiform shape b. Perianeurysmal soft-tissue mass c. Pseudoaneurysm d. Periaortic gas collection e. Mural thrombus

Answer 32

26. b. Perianeurysmal soft-tissue mass Mycotic aneurysms are usually saccular true aneurysms. Periaortic soft-tissue mass is a common feature seen in up to 48% of cases. Periaortic gas is an uncommon feature. Mural thrombus and calcification are rare features.

Question 33

@# 28. A 55-year-old man with a recent diagnosis of multifocal hepatocellular carcinoma is referred for transarterial chemoembolisation. Which of the following statements regarding hepatic arterial anatomy is true? A. The classic hepatic arterial anatomy, with the proper and hepatic artery dividing into the right and left hepatic arteries, is seen in approximately 80% of the population. B. Accessory left hepatic artery from left gastric artery is seen in 25% of cases. C. Replaced right hepatic artery commonly arises from the gastroduodenal artery. D. Replaced left hepatic artery commonly arises from the left gastric artery. E. The common hepatic artery is a branch of the superior mesenteric artery.

Answer 33

28. D. Replaced left hepatic artery commonly arises from the left gastric artery. The classic hepatic arterial anatomy, with the proper and hepatic artery dividing into the right and left hepatic arteries, is seen in approximately 55% of the population. Variations in hepatic arterial anatomy are common. A replaced right hepatic artery from the superior mesenteric artery is seen in 11%. A replaced left hepatic artery arising from the left gastric artery is seen in 10%. The entire hepatic trunk may be replaced, which may arise from the superior mesenteric artery (4.5%) or left gastric artery (0.5%). The common hepatic artery is a branch of the coeliac axis.

Question 34

@# 13 A 46-year-old Russian sailor presented with malaise and chest pain. In the course of the investigations he underwent CT scanning of his chest and abdomen. His VDRL and MHA-TP (for Treponerna pallidurn) tests are positive. What is the most likely finding on his CT? a Saccular aneurysm of the ascending aorta with thin, dystrophic wall calcification b Saccular aneurysm of the ascending aorta with interrupted calcification, para-aortic gas collection and adjacent reactive lymph node enlargement C Fusiform aneurysm of the descending aorta with cresenteric mural thrombus. There is ectasia of the remainder of the aorta with heavy atherosclerosis d Fusiform aneurysm of the abdominal aorta demonstrating mural thickening and extensive surrounding fibrosis e Fusiform aneurysm of the descending aorta with an irregular wall and active extravasations of intravenous contrast

Answer 34

13 Answer A: Saccular aneurysm of the ascending aorta with thin, dystrophic wall calcification This is the typical description of a syphilitic aneurysm. Options B, C, D and E are typical of a mycotic aneurysm, an atherosclerotic aneurysm, an inflammatory aneurysm and an actively leaking aneurysm respectively.

Question 35

@# 20. Which of the following are correct regarding fibromuscular dysplasia (FMD): (T/F) (a) Is more common in males. (b) Usually affects the intimal layer. (c) Renal artery FMD is bilateral in 5% of cases. (d) Can occur in veins. (e) May present with a transient ischaemic attack.

Answer 35

Answers: (a) Not correct (b) Not correct (c) Not correct (d) Correct (e) Correct Explanation: FMD is more common in females and presents between 15 to 50 yrs. Medial fibroplasia is more common form of FMD with characteristic ‘strings of beads’ appearance. Intimal fibroplasia occurs in 10% of cases and adventitial hyperplasia is the rarest form. Renal artery FMD is bilateral in approximately 30% of cases.

Question 36

@# 22. Vascular anatomy of the liver: (T/F) (a) The middle hepatic vein divides the liver into anatomical right and left lobes (Couinard classification). (b) At microscopic level, centrilobular veins drain into the portal circulation. (c) The portal vein bifurcation is intrahepatic in 90% of cases. (d) The right hepatic artery arises solely from the superior mesenteric artery in 10-15% of individuals. (e) In the fetus, the ducutus venosus joins the right portal vein to the inferior vena cava.

Answer 36

Answers: (a) Correct (b) Not correct (c) Not correct (d) Correct (e) Not correct Explanation: The hepatic lobule is the basic histological unit. The triads of hepatic arterioles, portal venules and bile duct branches run at the edge of the lobule. Blood flows from periphery inwards via hepatic sinusoids and is drained bycentrilobular veins which in turn drain into hepatic veins. The portal bifurcation is extrahepatic in 40% - 80% cases. Left portal vein is critical to fetal circulation as it receives blood from the placenta via the left umbilical vein and delivers it across the liver to the IVC via ductus venosus.

Question 37

@# 51. Which of the following are correct regarding coarctation of the aorta? (T/F) (a) Adult coarctation is commonly associated with cardiac anomalies. (b) It is a rare cause of infantile heart failure. (c) The ductus arteriosus usually remains patent in adult type coarctation. (d) Rib notching is usually present by 1 yr of age. (e) A short segment of narrowing of ascending aorta is seen in infantile coarctation.

Answer 37

Answers: (a) Not correct (b) Not correct (c) Not correct (d) Not correct (e) Not correct Explanation: Adult coarctation is short narrowing at ligamentum arteriosum. It is rarely associated with cardiac anomalies and the ductus arterosium is usually closed. Aortic coarctation is second most common cause of infantile heart failure (most common is hypoplastic left heart). Rib notching involves 3rd to 8th ribs and in 75% of cases seen in over 6 yrs of age.

Question 38

@# 26- A 66-year-old man presents with right thigh claudication on walking 20 yards. He is referred for an angiogram with a view to possible angioplasty. The angiogram demonstrates a 3-cm focal stenosis of the right extremal iliac artery with no other significant disease seen. What sized balloon would be appropriate for attempted angioplasty? (a) 3 mm (b) 5 mm (c) 7 mm (d) 10 mm (e) 13 mm

Answer 38

(c) 7 mm The more distal the occlusion, the smaller the balloon required for angioplasty, if the balloon is too big there is an increased risk of arterial rupture; if it's too small there is a reduced probability of success. Appropriate balloon sizes include: popliteal artery 3-4 mm, SFA or renal artery 4-6 mm, ElA 6-8 mm, and common iliac 8—10 mm.

Question 39

@# 40 A CT-angiogram in a 67-year-old man a focal 1 cm popliteal occlusion with reconstitution and 3-vessel runoff. Initial sub-intimal angioplasty is successful, but acute thrombosis forms in the peroneal trunk late in the procedure- Thrombolysis rt-PA is considered. Which of the following factors would be an absolute contraindication to thrombolysis? (a) CVA 3 months ago (b) Irreversible ischemia (c) Major abdominal surgery 4 weeks ago (d) Primary cerebral tumor (e) Recent warfarin use

Answer 39

(d) Primary cerebral tumor Absolute contra-indications include major trauma/ surgery/ CPR within 2 weeks, CVA within 2 months, bleeding diathesis, pregnancy, primary or secondary cerebral malignancy and irreversible ischemia (the acute event and normal pre-morbid imaging in this scenario makes this answer wrong in this instance). Relative contra-indications include the other options given, along with cardiac emboli, age > 80 years, and a white limb (surgery would be a better option in this case).

Question 40

@# 10 A diagnostic lower limb angiogram is to be performed. Which of the following guidewires is appropriate in order to site the pigtail catheter in the aorta following a standard retrograde common femoral artery puncture? (a) Aniplatz (b) J-wire (c) Mandrel (d) Straight wire (e) Terumo

Answer 40

(b) J-wire Guidewires have a central stiff steel core with a 'floppy' end; most are coated with Teflon to reduce friction. Wires are sized according to their outer diameter, measured in 1/1000 of an inch (typical measurements are 0.018 - 0.035). 'J' wires are often described in terms of the radius of the curve they form (e.g. 3 mm) and are routinely used for access. The other wires vary in their properties and are useful in different situations.

Question 41

@# 38 Regarding catheters used for interventional angiography. Which of the following catheters is inappropriate for imaging the respective artery? (a) Bernstein - superior mesenteric artery (b) Cobra - renal artery (c) Pigtail - abdominal aorta (d) Sidewinder (Simmons) - coeliac axis (e) Straight catheter - iliac artery

Answer 41

(a) Bernstein - superior mesenteric artery Catheters are sized using the French system: the circumference in mm (diameter is roughly this measurement divided by 3, i.e. 6 Fr has approximately 2 mm diameter). Sheaths are sized in French measurement of their internal diameter (i.e. a 4Fr sheath can hold a 4 Fr catheter). Bernstein catheters are upwards pointed, thus they are ideal for accessing branches of the aortic arch. Access to the downwardly orientated mesenteric vessels would be technically very challenging with a Bernstein catheter - the downward facing sidewinder, or even the sidefacing cobra catheters can be used.

Question 42

@# 13. A 70-year-old male undergoes endovascular stent graft repair of an infrarenal abdominal aortic aneurysm. A follow-up CT at 1 year demonstrates increasing aneurysm sac diameter without any evidence of endoleak. What is the diagnosis? A. Type I endoleak. B. Type II endoleak. C. Type III endoleak. D. Type IV endoleak. E. Type V endoleak.

Answer 42

13. E. Type V endoleak. The main aim of endovascular or surgical treatment of abdominal aortic aneurysm (AAA) is exclusion of the aneurysm sac from the systemic high-pressure circulation. Ongoing leakage of blood into the excluded aneurysm sac after endovascular repair is termed ‘endoleak’. Identification of the type of endoleak and its effect on the aneurysm sac is important for further management. Type I endoleak: Contrast/blood leak at the proximal or distal landing zones of the stent graft is described as type I endoleak. This is due to poor proximal or distal graft apposition, exposing the sac to systemic pressures with significant risk of aneurysm rupture. This type is further subdivided into type IA (proximal aortic attachment) and type IB (distal iliac attachment). These are most commonly seen at the time of the procedure or may develop subsequently due to graft migration. They require urgent treatment. Type II endoleak: This is due to retrograde flow into the aneurysm sac via the inferior mesenteric artery (type IIA) or lumbar arteries (type IIB). Many of these close spontaneously and are managed expectantly. Further treatment is indicated if the sac enlarges or the patient develops symptoms of sac pressurization. Type III endoleak: Leakage of blood through the body of the stent graft due to either poor apposition of graft components or a tear in the graft material is type III endoleak. This requires urgent management due to sac pressurization. Type IV endoleak: Aneurysm sac opacification without an identifiable source intraprocedurally is described as type IV endoleak. These are transient and usually resolve after withdrawal of anticoagulation. Type V endoleak: Continued growth of the sac without radiological evidence of a leak is termed type V endoleak or endotension. Continued growth of the aneurysm sac will require surgical repair due to risk of rupture.

Question 43

@# GIT) 71. A 50-year-old male with a 2.5-cm hepatocellular carcinoma undergoes RFA. Which of the following findings is uncommon in the immediate post-ablation period? A. Transient peri-ablational hyperemia. B. Small number of tiny intra-lesional air bubbles. C. Arterio-portal shunting. D. Ablation zone larger than the primary lesion. E. ‘Mural nodule in cyst’ pattern.

Answer 43

71. E. ‘Mural nodule in cyst’ pattern. RFA produces thermally-induced coagulation necrosis, which manifests usually as an oval or round defect on contrast-enhanced CT. The ablation zone is slightly larger than the actual lesion to achieve curative treatment and prevent local recurrence, which is usually seen at the margins of the ablation zone. The following findings are common in the immediate post ablation period: transient peri-ablational hyperemia, tiny air bubbles, and arterioportal shunting. A ‘mural nodule in cyst’ indicates the development of a bilobar as a complication of RFA. This is usually seen several months after treatment. It is associated with interval enlargement of the RFA zone.

Question 44

@# 66 A 74-year-old man was being investigated by a cardiologist for repeated episodes of `flash' pulmonary oedema. He was hypertensive and echocardiography showed good left ventricular function. Renal artery Doppler and subsequent MR angiography confirmed severe bilateral renal artery stenosis. He was known to have benign prostatic hypertrophy, but there was no renal collecting system dilatation on ultrasound. Following extensive discussion, the decision was made to attempt bilateral renal artery stenting. What benefit over optimal medical therapy is this most likely to result in? a Improve hypertension b Improve renal function C Improve symptoms of prostatism d Reduce episodes of pulmonary oedema e Reduce mortality

Answer 44

66 Answer D: Reduce episodes of pulmonary oedema The role of angioplasty and stenting in renal artery stenosis is controversial. The preliminary results of the ASTRAL (Angioplasty and STent for Renal Artery Lesions) trial show that stenting offers no benefit above medical treatment in terms of hypertension, renal function or mortality. It is likely that in hypertensive patients, with preserved left ventricular function, stenting reduces episodes of `flash' non-cardiogenic pulmonary oedema.

Question 45

@# 67 A 42 -year-old woman with symptoms of dyspareunia and dysmenorrhoea was found to have bulky uterine fibroids on ultrasound. Following discussion with her gynaecologist she was referred for uterine artery embolisation. During the embolisation procedure it is noted that a significant degree of the fibroid blood supply is derived from the ovarian artery. With the aim of temporarily occluding the ovarian artery, what embolic agent is most appropriate? a Cyanoacrylate (glue) b Ethyl alcohol C Gelfoam d Polyvinyl alcohol e Steel coils

Answer 45

67 Answer C: Gelfoam Temporary embolic agents include: autologous blood clot and gelfoam. Permanent agents include: ethyl alcohol, steel coils, polyvinyl alcohol and glue. New embolic agents are frequently being introduced and this is, by no means, an exhaustive list.

Question 46

@# 24. Which of the following are correct regarding bronchial artery embolization (BAE): (T/F) (a) The smallest available polyvinyl alcohol (PVA). (b) Recurrence of haemoptysis after BAE is rare. (c) The bronchial arteries originate directly from the ascending thoracic aorta in 90% of cases. (d) An arch aortogram is usually performed prior to selective bronchial angiography. (e) Chest pain is the most common complication.

Answer 46

Answers: (a) Not correct (b) Not correct (c) Not correct (d) Not correct (e) Correct Explanation: Very small particles can freely flow through the microcirculation and shunts causing infarcts, thus 350 – 500 micro m PVA particles are used. Long term recurrence rates are between 10% - 52% with a mean follow up period of 1 to 46 months. The bronchial arteries originate directly from the descending thoracic aorta most commonly between T5 and T6 vertebrae. The left main bronchus is a useful landmark in angiography, marking the origin of bronchial arteries in most cases. Descending thoracic aortogram is usually performed.