Vascular Town

Perfuse the Brain

100

All of the following are true except: a. a normal carotid artery has continuous forward flow b. the MC site carotid stenosis is the bifurcation of internal and external carotid arteries c. a healthy 60 yo M with TIAs and a carotid stenosis of 80% should receive medical therapy ASA D. PTA is generally the best Tx for sx carotid stenosis from fibromuscular dysplasia

C. pts w/ sx from carotid disease and stenosis >60-70 should have CEA, asx pts and stenosis >70-80 should have CEA

200

All of the following are true except: a. the vagus is the MC injured nerve with CEA and results in hoarseness b. the MCC of death after CEA is myocardial infarction c. the facial vein can be routinely ligated d. CEA involves removing the intima only

D. CEA involves removing the intima and part of medial layers, the vagus is the MC injured n w/ CEA and results in hoarseness

300

A 56 yo F is suffering from vertigo, syncope and frequent falls. You get a duplex US which shows minimal carotid stenosis bilaterally (0-46%) and reversal of flow in left vertebral artery and antegrade flow in the right vertebral artery. When of the following is the most appropriate in this patient a. left carotid endarterectomy b. left vertebral artery stent c. left subclavian stent d. basilar artery stent

C. pt has subclavian seal syndrome from subclavian artery stenosis as evidenced by the retrograde flow through the left vertebral artery. Tx is left subclavian stent or carotid to subclavian artery bypass

400

All of the following are true regarding carotid artery aneurysms except: a. almost never include carotid bulb b. May be mycotic from staph or syphilis c. are almost always bilateral d. presentation is pulsatile neck mass

a. almost always include carotid bulb, ~12% b/l, rupture rare, may be secondary to infection or injury

500

What is Moya Moya Disease?

a consequence of inadequate cerebral circulation within the brain causing the formation of collateral blood flow through the brainstem - looks like "puff of smoke" on imaging. Increased risk of stroke. May been seen in children w/ HgbSS

Abdomen

100

A 22 y.o. F is evaluated in ED for vague sx’s of abd pain and is found to have 2.5 cm splenic artery aneurysm. The most appropriate next step is: a. Coumadin b. careful follow-up c. exclusion with covered stent placement or open procedure d. splenectomy

c. all visceral artery aneurysms (>2cm, >1.5cm for renal) need repair except for splenic. The rupture rate for visceral a aneurysms is 50% for those other than splenic. The majority of these are repaired using covered stents. Women in child bearing age should have splenic artery aneurysms repaired due to specific risk of rupture w/ pregnancy

200

6 wks after an ARF for an AAA your pt returns to clinic w/ mild pain in his left groin. His femoral artery tissue was poor on that side and you are worried about a pseudoaneurysm. The study of choice for this is: a. MRI b. abd CT c. duplex u/s d. angio

C. color flow duplex u/s is most cost effective option to study post-op AAA repairs, also best method for peripheral bypass graft surveillance

300

346. All of the following are true except: a. the right renal artery MC goes posterior to the IVC b. the left renal vein MC goes anterior to the aorta c. renal fibromuscular dysplasia (FMD) is best treated w/ open bypass d. isolated iliac artery stenosis is best treated w/ PTA and stent

C. renal FMD is best treated w/ PTA and stent, the right renal artery most commonly goes posterior to IVC, left renal vein MC goes anterior to aorta, ex isolated iliac artery stenosis is best tx w/ PTA and stent (80% patent at 5 years)

400

All of the following are true except: a. maintenance of flow to at least one hypogastric a is indicated for both open and endovascular aorto-bifemoral repairs b. AAA’s measuring 4.9cm should be repaired c. hematemesis 6 months after open AAA repair is worrisome for aorto-enteric fistula (MC aorto-duodenal) d. chylous ascites following open AAA repair is best tx initially w/ a drainage catheter and if that fails ligation of cysterna chyli

C. AAA 4.9cm should be observed, >5.5 is an indication for repair. Maintenance of flow to at least one hypogastric a (internal iliac) is indicated for both open and endo aorto-bifem repairs to prevent pelvic ischemic cx’s. hematemesiss 6mo out after open AAA repair worrisome for aorto-enteric fistula dx w/ CT, tx w/ graft resection and extra-anatomic bypass. Chylous ascities s/p open AAA tx initially w/ drainage catheter and if that fails, ligation of cistern chili. Bloody diarrhea after AAA repair worrisome for ischemic colitis (dx w/ colonoscopy)

500

"Dunbar syndrome" is: a. mesoaortic compression of left renal vein b. compression of the celiac by median arcuate ligament c. congenital absence of extrahepatic IVC d. bovine arch with stenosis at bifurcation

b. patients present w/ abdominal pain, weight loss, and sometimes an abdominal bruit. a=Nutcracker syndrome. c=one of our patients had so we couldn't place an IVC filter. d=I made up

Extremities

100

344. All of the following are true except: a. ASA is the tx of choice for improving long term vascular graft patency b. best predictor of long term patency in extremity vein grafts is surgical technique c. duplex u/s is the best technique for surveillance of bypass grafts d. rest pain typically begins w/ an ABI <0.5

B. the best predictor of long term patency in the extremity vein bypass grafts in vein quality

200

A 55 yo golfer presents w/ 40 pack year smoking hx and pain in his calves after walking 150 ft. the most appropriate next step in management is : a. angio and PTA b. Coumadin c. smoking cessation and exercise therapy d. angiogram and bypass

C. medical tx is the initial tx for intermittent claudication

300

2 years after an aorto-bifemoral graft (ABF) for AAA your pt presents w/ an acutely painful right groin. u/s shows a pseudoaneurysm and a large fluid collection. What is the most likely cause of this pt’s problem? a. trauma b. infection c. poor surgical technique d. graft thrombosis

B. Fast-growing pseudoaneurysm after vascular bypass graft is most consistent w/ graft infection, MC organism is staph epidermidis

400

a 62 M s/ severe T2DM presents w/ heal ulcer. There is a skin breakdown but it does not seem to be involving the bone. X-ray shows no signs of osteomyelitis. All of the following are appropriate for this patient except: a. aggressive wound care b. debride c. keep wound moist d. patient will likely need a BKA

d. b/c the bone is not involved the heel can be potentially salvaged

500

the MC injured nerve w/ lower extremity calf faschiotomy for compartment syndrome is a. superficial peroneal b. common peroneal c. tibial d. peroneal

A. superficial peroneal nerve is very superficial at area b/w anterior and lateral compartments near the prox fibula. When performing 2 incision technique the lateral incision comes very close to superficial peroneal n

AVF/G

100

All of the following suggest venous outflow obstruction for an AVF except: a. increase in returning line pressure b. acute hand ischemia early following AVF placement c. high outflow pressure >200 d. increase in re-circulation

B. acute hand ischemia following avf placement suggests inflow obstruction. Late venous outflow obstruction can present w/ increase in pressure in returning line, high outflow pressure >200 or increased recirculation. Tx is placement of a venous stent at the obstruction or redo the venous anastomosis depending on the level of obstruction (venogram)

200

You perform a lower arm brachial artery to cephalic vein PTFE loop fistula in a 65 M w/ established CKD. There is palpable thrill and Doppler signal at the end of the case. On POD 1 you inspect the graft and there is a poor thrill and poor dopper signal. The most appropriate next step in this patient’s management is: a. heparin b. fistulogram c. graft ligation d. graft excision

b. take pt back to OR, de-clot graft and perform a fistulogram

300

In the above pt you place a PTFE hood patch at the site of the PTFE-venous anastomosis and the flow through the graft improves. Two days later your pt starts to develop arm swelling. Initially you try conservative tx (elevation) the arm continues to swell. The most appropriate next step is a. heparin b. compressive wraps c. re-do the venous anastomosis d. angiogram and shoot run-off

D. arm swelling after AVF/AVG placement is due to venous HTN. Initial tx is arm elevation, as collaterals develop the swelling goes down. If swelling persists it suggests major outflow obstruction – get angio and look at shunt run off, tx for stenotic area is PTA and stent

400

A 21 M is shot in the leg. Five years later he presents to your clinic w/ right groin discomfort and a vibration felling in his groin. All of the following are true of this patient’s most likely condition except: a. mild left ventricle hypertrophy b. a thrill over groin likely present c. this is best dx w/ u/s d. he will likely need a femoral to pop bypass

D. open repair is indicated for acquired AVF w/ primary closure of vein w/ lateral venous suture, patch for artery, interpose some Sartorius mm b/w vein and artery so fistula does not recur

500

Name either the 7 stages of man or the 7 stages in the Rutherford Classification.

Stage 0 – Asymptomatic Stage 1 – Mild claudication Stage 2 – Moderate claudication – The distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters. Stage 3 – Severe claudication Stage 4 – Rest pain Stage 5 – Ischemic ulceration not exceeding ulcer of the digits of the foot Stage 6 – Severe ischemic ulcers or frank gangrene

Rando

100

All of the following are true of thromboangitis obliterans (Buerger’s) except a. MC in young men b. characterized by thrombotic occlusions of small and medium sized vessels, resulting in severe rest pain +ulcerations/gangrene of digits c. curable with nicotine cessation d. involves major occlusions proximal to brachial and pop arteries

D the major vessels proximal to the brachial and pop arteries are normal. Sm to medium sized aa are affected

200

All of the following are true of pseudoaneurysms except: a. initial treatment for a femoral artery pseudo following angio is u/s guided thrombin injection b. tx for femoral pseudo following an aortic bifemoral graft is open repair c. there are no collateral vessels around the knee d. tx for a distal femoral artery pseudo in an IVDA pt is ligation without bypass

C. geniculate collaterals exist around knee. IVDA pts w/ distal femoral pseudo can undergo simple ligation of SFA as profunda has collateral circulation to LL through geniculate

300

all of the following are contraindication to vein stripping except a. dvt b. sapheno-femoral and sapheno-pop valve incompetence c. venous outflow obstruction d. varicosities with pregnancy

b. sapheno-fem and sapheno-pop valve incompetence are indications for vein stripping

400

all of the following are true of thrombophlebitis except: a. a palpable cord is consistent w/ superficial thrombophlebitis b. staph aureus is the MCC of bacterial thrombophlebitis c. removal of any intravenous catheter is the 1st step in tx of thrombophlebitis d. continued bacteremia or purulence at the site indicates need for vein resection

a. palpable cord is consistent w/ suppurative thrombophlebitis, continued bacteremia or purulence at site is indication for vein resection

500

which organ does not contain lymphatics a. lung b. liver c. spleen d. muscle

d. mm does not contain lymphatics