1
Q
A 37 year old female patient presents with mild discomfort from a moderately edematous left foot and leg. She has no Hx of any previous trauma. List 5 possible causes of edema.
A
- CHF
- Nephritis
- Nephrosis
- Hypervolemic
- Hepatic disease
2
Q
A 74 year old patient presents with a painless chronic and recurrent ulceration and edema of the medial aspect of the lower leg about 9 cm above the medial malleolus. There was no previous Hx of accident or injury. Which of the following is the most probable cause of this ulceration?
A
Chronic venous insufficiency
3
Q
0% of all cases of chronic occlusive disease of the lower extremities are
A
Arteriosclerosis Obliterans (ASO)
4
Q
A 95 year old patient presents to your office for routine foot care and has a Hx of chronic multi-segmental occlusive disease but without gangrene or open wounds. He does have 3 block claudication and mild rest pain. List 8 recommendations you could make for conservative management of this patient.
A
- Stop smoking
- Exercise “walk-through” claudication 4-5 X/d
- Reverse Trendelenburg bed position 6- 8”
- Tx for hyperlipidemia if it exists
- Tx control DM if it exists
- Sheepskin blanket??
- Rx: vasodialators; sympatholytics; persantine; ASA; pentoxiphylline calcium channel blockers
- Sympathectomy
5
Q
An ABI of 1.4 is normal. (True or False?)
A
- False
- Normal is 0.9 - 1.0
- Greater than 1.3 is abnormally high and indicates disease
6
Q
An ABI of _____ is the threshold for critical limb ischemia (CLI)
A
Less than 0.5
7
Q
The angiokeratomas of Fabry’s disease is due to an accumulation of _____ due to a deficiency of _____
A
- Sphingolipids
- Alpha galactosidase
8
Q
ApoB-100 apoprotein is found in
A
- VLDLs
- LDLs
9
Q
ApoE protein is found in
A
IDLs
10
Q
At the level of the ankle Anterior tibial artery, lies between what two tendons?
A
EHL and EDL
11
Q
At what level does the aorta bifurcate into the common iliac?
A
L4
12
Q
At what stage in RSDS does one find “spotty osseous demineralization” as an x-ray finding?
A
- Stage II
- RSDS stages:
- Stage 1 = acute or disuse syndrome
- Stage 2 = dystrophic stage (no sympathetic overactivity)
- Stage 3 = atrophic stage
13
Q
Be able to Identify the four part of the analog Doppler waveform
A
- Sharp Upstroke
- Dicrotic Notch
- Diastolic Flow
- Reversal
- Vessel Wall
- Rebound
14
Q
“Blue toe syndrome” is actually due to
A
Atheromatous emboli from surgery proximal vascular interventional procedures
15
Q
Cold Agglutinin disease is due to high concentrations of circulating antibodies, usually IgM, directed against which of the follow cells of tissue?
A
RBCs
16
Q
Cutaneous atrophy is generally associated with _____?
A
Chronic ischemia
17
Q
Define claudication time and how it is quantified?
A
- The amount of time spent in motion until you feel the cramps
- Quantified by minutes on a treadmill, or distance walked
18
Q
Define CREST syndrome
A
C = calcinosis R = Raynaud's E = esophageal dysmotility S = sclerodactyly T = telangiectasias
19
Q
Define what is meant by “the rule of the artery”
A
“The rule of the artery must be absolute, universal and unobstructed, or disease will be the result.” - A.T. Still
20
Q
Describe anatomically, the cause of thoracic outlet syndrome?
A
- Compression at the superior thoracic outlet
- Excess pressure placed on a neurovascular bundle passing between the anterior/middle scalene muscles
21
Q
Describe the anatomical landmarks for palpation of the common femoral artery.
A
- Just below the Ilio-Inguinal Ligament (Poupart’s)
- In the femoral triangle
- Between the Sartorius and the Adductor Longus
22
Q
Describe the theory of how a Doppler works
A
Ultrasound beam is shifted proportionally to the speed of the moving target (blood cells) that it hits
23
Q
Describe what is meant by the” triphasic sequence “ of Raynaud’s phenomenon
A
- Pallor
- Cyanosis
- Reactive hyperemia
24
Q
Diatrizoate (water soluble for peripheral angiography) is contraindicated in
A
- Renal insufficiency
- Lactic acidosis (METFOMRIN)
25
Eyelid xanthelasma is a sign of
| possible _____?
Dyslipidemia
26
For RSD involving the foot, what is the appropriate level to perform a surgical sympathectomy?
Lumbar sympathectomy (L1/L2)
27
The Greater Saphenous Vein (GSV) travels distally along what structure?
Ascends in front of the tibial malleolus and along the medial side of the leg in relation with the saphenous nerve
28
How do you diagnose Buerger's disease
Arteriogrpahy shows multiple occluded segments
29
Irreversible cell death happens in _____ hours of occlusion
6
30
Largest in size but lowest in density of all lipoproteins
Chylomicrons
31
The lesser or small saphenous vein (SSV) travel distally along with which nerve?
- Lower third of the leg, close relation with the sural nerve
- Upper two-thirds with the medial sural cutaneous nerve
32
List 5 risk factors for the development of atherosclerosis
1. Hyperlipidemia
2. Hypertension
3. Smoking
4. Diabetes Mellitus
5. Age
6. Sex
7. Obesity
8. Hyperhomocystinemia
33
List collagen vascular diseases that have vasculitis as a secondary manifestation?
- Systemic lupus erythematosus (SLE)
- Rheumatoid arthritis (RA)
- Relapsing polychondritis
- Behçet's disease
34
List five treatments for the treatment of symptomatic vasospastic disease
- Calcium channel blockers
- Alpha adrenoreceptor antagonists
- Nitrates
- Local anesthetic blocks
- Surgical sympathectomy
35
List four characteristics that describe the clinical picture unique to Berger's disease (aka TAO, aka thromboangiitis obliterans)
- Young males who smoke
- Ages 25-40
- Prevalent among Jews
- HLA positive
36
List ten potential causes of Raynaud's phenomenon
1. Scleroderma (PSS) 90%
2. SLE
3. RA
4. Dermatomyositis (children) and Polymyositis
5. Fabry's Disease (angiokeratoma corporis diffisum)
6. Cryoglobulinemia
7. Cold Agglutinin Disease
8. Sjorgen's Syndrome
9. Mixed Connective Tissue Disease (Sharp's Syndrome, overlap syndrome) 80%
10. Myxdema
37
List the 7 P's of ischemia
1. Pain (50%)
2. Poikilothermia (cold)
3. Pallor
4. Pulseless
5. Paresthesias (numbness, tingling)
6. Paresis (partial loss of motor function)
7. Paralysis
38
"Meltzer's triad" of cryoglobulinemia consists of what three elements?
- Purpura
- Arthralgia
- Myalgia
39
The most common site of a high-grade stenotic lesion in the lower extremity is?
Superficial femoral artery (at the adductor hiatus)
40
The most common site of high-grade stenotic lesions in a diabetic patient is?
Carotid artery
41
The pain associated with claudication closely resembles which of the following?
Leg cramps
42
Painless persistent coldness and cyanosis of distal parts of extremities, cold induced mottling of skin
Acrocyanosis
43
Palmar and tuberous xanthomas are found in what Frederickson Phenotype
Type 3: broad beta disease or dysbetalipoproteinemia
44
Poiseuille's Law of abnormal hemodynamics associated with stenotic vessels states flow is proportional to _____ and inversely proportional to _____
- The pressure difference (pre- stenotic vs post-stenotic) times the fourth power of the radius of the vessel
- The length of the stenotic segment
45
Proteins A1 and A2 responsible for "reverse cholesterol transport" (scavenger function) is found in
HDLs
46
Raynaud's phenomenon is characterized by which of the following?
A triphasic color change in hands and feet in response to cold
47
String of beads sign, mural aneurysms, young females
Fibromuscular displasia
48
A surgical sympathectomy above the level of L1 could cause what possible negative complication?
Recurrence of the original symptoms due to nerve regeneration or nerve sprouting can occur within the first year post surgery
49
A systolic toe Pressure _____ mm Hg is indicative of Chronic Limb Ischemia (CLI)
< 30
50
T/F: A systolic BP taken at the level of the ankle is 90% that of the arm systolic pressure is considered normal
True
51
Transcutaneous oxygen tension (TcPO2) detects oxygen that diffuse through skin in response to temp. How many mmHg necessary for healing?
35 mmHg
52
The triad of Sjogrens syndrome- or "Sicca syndrome" consists of?
1. Xerostomia (dry mouth)
2. Keratoconjunctivitis sicca (dry eyes)
3. Bilateral parotid enlargement
53
What are the boundaries of the femoral triangle?
- Inguinal ligamen (sup.)
- Sartorius (inf.)
- Adductor longus (med.)
- Pectineus and Ilio-psoas (floor)
54
What are these changes called?
reflect the nutritional status of the tissues. Alteration or cessation of growth of skin or appendages due to arterial insufficiency, edema, or venous congestion.
Trophic changes
55
What are the stages of a stroke?
1. TIA - reversible, brief, RINDS
2. progressing stroke
3. completed stroke
56
What are three diagnostic clues to diagnosis of vasculitis?
↑ erythrocyte sedimentation rate (ESR)
↑ C-reactive protein (CRP),
↑ white blood cell count and eosinophilia, anemia, hematuria
57
What does the two phase Trendelenburg test measure?
- 2 phase venous test
- Retrograde filling test: tests the efficacy of the saphenofemoral valve and the competence of the valves of the perforators, between the superficial and deep venous systems
58
What has anti- centromere antibody
Scleroderma (PSS)
59
What has anti-SS-A and anti-SS-B and anti-DNA antibody
Sjogrens
60
What is a device utilized to record minute changes in the volume of the limb in response to changes in blood volume or stoke volume. It measures large and medium sized vessels
Plethysmography
61
What is a HTN ulcer called and where is it found
- Martorells Ulcer
- Painful, begin as blisters
- Ant/Lat leg or post. calf, achilles
62
What is a markedly dilated tortuous vessel called?
Aneurysmal varix
63
What is a ratio expressed as the difference between the peak systolic and peak diastolic
Normal is > 6.0
Pulsatility index
64
What is characterized by the following features/keywords: necrotizing, small & medium vessels, aka allergic granulomatosis, nasal polyps, extravascular granulomas, eosinophilia, adult onset asthma
- EGPA (eosinophilic granulomatosis with polyangiitis)
| - Formerly called Churg-Strauss syndrome
65
What is the difference between pitting and indurated edema?
- Soft: pitting edema (water)
| - Hard: indurated edema
66
What is the MOA of the Fogarty catheter?
Inflate balloon distal to thrombus, pull balloon proximal over and over until bleeding occurs and thrombus is removed
67
What is the normal range for a CRP?
0-1.0 mg/dL or less than 10 mg/L
68
What is the normal range of a sed
| rate?
- Male: 12-14mm/hr
| - Female: 6-20mm/hr
69
What is the triad of buergers disease?
- Phlebitis
- Atherosclerosis
- Thrombosis
70
What is this? Aortoiliac disease, inflow obstruction, gradual occlusion of the terminal aorta
6 symptoms: disabling claudication, rest pain, gangrene or ulceration, atrophy of leg muscles, impotence, pallor of legs.
Leriche's syndrome
71
What is this called?
Burning pain. This indicates a local increase in body temperature (often by exercise or entering a warm room)
Characterized by widening of the vessel
Erythromelagia
72
Inflammation of a lymph node
Lymphadenitis
73
Inflammation of lymph channels
Lymphangitis
74
Swollen or enlarged lymph nodes; often due to infection, auto-immune disease, or malignancy
Lymphadenopathy
75
Syndrome in which someone has an enlarged spleen and chronic low white cell count and occurs with RA.
Felty's Syndrome
76
What is unique to polyarteritis nodosa?
- Vasculitis of medium sized vessels, and is necrotizing
- Affected are 30-49 (young) and lungs are spared
- 20% have Hep B or C
- No involvement of postcapillary venules like most
- No granulomas and a "rosary sign"
77
What occurs at postcapillary venules and is clinically observed as purpura, petechiae, and shallow ulcers. Since it affects small or medium sized vessels, the observations are superficial and palpable by touch, as opposed to large vessel vasculitide that are not palpable and located more deep.
Cutaneous small vessel vasculitis
78
What of the following collagen vascular diseases has the characteristic Anti Jo antibodies?
- Dermatomyositis (children) and polymyositis
| - Anti Jo antibodies in > 65% of patients
79
What Rutherford criteria class: Pain, No paralysis or sensory loss
Class 1: viable
80
What Rutherford criteria class: Profound neurologic deficit, absent capillary flow, skin marbling, absent arterial & venous signal
Class 3: non-viable
81
What Rutherford criteria class: Sensory and Motor loss > Needs immediate treatment
Class 2B: threatened but salvageable
82
What Rutherford criteria class: Some sensory loss, No paralysis > No immediate threat
Class 2A: threatened but salvageable
83
What stage of CRPS (RSDS) is there allodynia muscle atrophy, increased osseous demineralization and sympathetic overactivity
Stage 2: dystrophic stage
84
What stage of CRPS (RSDS) is there irreversible changes in skin, severe pain, muscle atrophy and weakness, severely limited mobility and sympathetic overactivity
Stage 3: atrophic
85
What stage of CRPS (RSDS) is there no sympathetic overactivity
Stage 1: acute or disuse syndrome stage
86
When taking segmental BP at different levels of the lower extremity, a pressure drop of ______ mm Hg is an indicator of a clinically significant stenosis.
> 20
87
Which of the follow are true about rest pain?
It seems to be worse at night
88
Which of the following autoimmune conditions has the characteristic antibodies to citRullinAted peptide (ACPA, anti-CCP)?
RA
89
Which of the following collagen vascular diseases has the characteristic of proximal muscle weakness causing difficulty in ascending stairs and rising from a seated position, dysphagia and elevation of CPK, EMG? anti-Jo antibodies
- Dermatomyositis (children)
| - Polymyositis (adults)
90
Which of the following conditions has the characteristic antiphosphlipid antibody?
- SLE
| - Also ANA, anti-dsDNA, anti-histone, anti-SM, anti-RNP
91
Which of the following conditions is characterized by painless but persistent coldness and cyanosis of the distal parts of the extremities?
- Acrocyanosis
| - Note: in acrocyanosis, no trophic changes occur and pulses are normal
92
Which of the following degenerative arteriopathies has characteristic degeneration of smooth muscle and elastic followed by hemorrhage "leakage" and calcium deposition in the vessel walls often seen in diabetes and renal failure.
Mockenberg's medial calcific sclerosis
93
Which of the following degenerative arteriopathies has characteristic nonatheromatous "mural aneurysms" seen on x-rays of large arteries, often in young females that predisposes to aneurysm.
Fibromuscular dysplasia
94
Which of the following degenerative arteriopathies often associated with Marfan's syndrome
predisposes to aortic aneurysms.
Cystic medial necrosis
95
Which of the following forms of livido reticularis is cold induced, but disappears when the patient is brought into a warm environment?
- Cutis marmorata
96
3 types of livido reticularis
1. cutis marmorata
2. livido reticularis idiopathica = mottling persists despite changes in temp
3. livido reticularis symptomatica = some other vascular disease is occuring concomitantly
97
Which of the following Frederickson phenotypes is characterized by tendinous xanthomas, elevated LDL; family Hx of hyperchol and CHD
II familial hypercholesterolemia (FH)
98
Which of the following Frederickson phenotypes is characterized increased chylomicrons causing fasting hypertriglyceridemia with levels of 1500 mg/dl , milky serum and cutaneous xanthomas.
- I exogenous hypertriglyceridemia
| - Type 1: cholesterol is normal, decreased VLDL, decreased IDL, decreased LDL
99
Which of the following Frederickson phenotypes is common and frequently seen in diabetics with normal total cholesterol and elevated triglyceraides.
- IV endogenous hypertriglyceridemia
| - Type 4: familial form
100
Which of the following is also called "mucocutaneous lymph node syndrome" and is characterized by abnormal erythema of lips, pharynx or tongue and erythema and edema of palms/soles?
- Kawasaki Disease
- Keywords for Kawasaki's: strawberry tongue, fatal coronary artery aneurysms, fever longer than 5 days, cervical lymphadenopathy, asian children.
101
Which of the following is the classic finding of diabetic retinopathy?
Microaneurysms and neovascularization
102
Which of the following is the most common type of vasculitis?
- Giant Cell Arteritis: most common vasculitis in adults
| - Henoch-Schonlein: most common vasculitis in children
103
Which of the following is the most common vasculitis in children and is distinguished by prominent deposits of IgA, purpura and bowel angina?
Henoch-Schonlein purpura
104
Which of the following is the most diagnostic test in the conformation of vasculitis?
- The definite diagnosis of vasculitis is established after a biopsy of involved organ or tissue, such as skin, sinuses, lung, nerve, and kidney
- The biopsy elucidates the pattern of blood vessel inflammation
105
Which of the following is true about blood?
it follows non-neutonian fluid dynamics because it is 92% water
106
Which of the following lipoproteins contain the highest proportion of protein mass, contains the proteins A-1 and A-2 and have an anti- atherogenic effect.
HDL
107
Which of the following NIVA tests is best to assess capillary bed perfusion?
Photoplethysmography
108
Which of the following vasculitides generally affects the aorta or its large branches?
Takayasu artertitis (aka aortic arch syndrome)
109
Which of the following vasculitides generally affects the temporal or cranial arteries?
Giant cell/temporal arteritis
110
Which of the following vasculitides is characterized by a saddle-nose deformity?
Wegner's granulomatosis
111
Which of the following vessels have the greatest autoregulatory effect on blood pressure?
Arterioles
112
Which of the following vessels serves as "capacitance vessels" in the vascular tree?
Veins
113
Which of the following vessels serves as "resistance vessels" the vascular tree?
Muscular arteries
114
Which of the following would be the most effective in the Tx of high serum LDLs?
Atorvastatin (Lipitor)
115
You are a first year resident in the ER and a patient presents with what you suspect is an acute arterial occlusion. List five test that you will order to help confirm your Dx.
- Segmental BPs
- MRA/CTA
- Contrast arteriogram
- Serum enzymes
116
Kawasaki's triad
1. Cervical adenopathy
2. Eye infection (red eye, lips, palms, and soles)
3. Sore throat
117
T/F: A systolic BP taken at the level of the ankle is 90% that of the arm systolic pressure is considered normal.
True
118
Classic finding of diabetic neuropathy
Microaneurysms and neovascularization
119
NIVA test to best assess capillary bed perfusion
Photoplethysmography
120
Three diagnostic clues to diagnosis of vasculitis
- Increased: ESR, CRP, ANCA, WBCC, eosinophils
- Anemia
- Hematuria
121
Triad of Buerger's
- Phlebitis
- Atherosclerosis
- Thrombosis
122
Three elements of cryoglobulinemia (Meltzer's triad)
- Purpura
- Arthralgia
- Myalgia
123
Blood flow form aorta to big toe
1. Left ventricle
2. Ascending aorta
3. Arch of aorta
4. Descending aorta
5. Thoracic aorta
6. Abdominal aorta
7. Common iliac
8. External iliac
9. Femoral artery
10. Deep femoral
11. Popliteal
12. Anterior tibial
13. Dorsalis pedis
14. Dorsal metatarsal
15. Dorsal digital
Peripheral Vascular Disease
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