Vascular 2

Question 1

Gangrenous Ischemic colitis

severe acute ischemia of the large bowel resulting in ___

Answer 1

infarction

Question 2

Nongangrenous Ischemic colitis

hypoperfusion of the large bowel

Management?

Answer 2

Conservative

Mostly transient and self-limiting

Question 3

Acute mesenteric ischemia

acute inadequate blood flow to the ___ bowel (arterial or venous) that can result in bowel infarction

Answer 3

small

Question 4

Chronic mesenteric ischemia

constant OR episodic hypoperfusion of the small intestine, usually due to

Answer 4

atherosclerosis

Question 5

Causes of Ischemic colitis:

1. Thromboembolism (a-fib, IE)
2. Hypovolemia (dehydration, hemorrhage)
3. Vasoconstrictive drugs
   4.

Answer 5

Cardiovascular surgery
(Aortic repairs & cardiac bypass)

Question 6

Sites at High risk for compromise in Ischemic colitis (2)

because they are “watershed areas”

Answer 6

Splenic flexure

Rectosigmoid junction

Question 7

Clinical features of Ischemic colitis:

1. Hyperactive phase
   - Sudden onset of ___ abdominal pain
   - ____ stools
2. Shock phase (rare)
   - _____

Answer 7

Crampy
Loose, Bloody

Peritonitis
(rebound/guarding)

Question 8

In severe ischemic colitis labs can show:
↑ ___, ___, Creatinine Kinase
Leukocytosis

Answer 8

Lactate

LDH

Question 9

Imaging for suspected Ischemic colitis

First line:

Confirmatory:

Answer 9

KUB: abdominal x-ray
(air-filled, distended bowel)

CT scan
(wall thickening, air in intestine walls)

Thumbprint sign: edematous thickening of the mucosa causes indentations in the large bowel wall

Question 10

Mild-Moderate Ischemic colitis

• No specific laboratory finding
• Procedure of choice in moderate cases =
  Colonoscopy ( edema, cyanosis, +/- ulceration)

Management of mild-moderate sxs:

Answer 10

Conservative:
IVF, NPO, +/- NGT
Antiplatelet +/- Anticoagulation therapy

Question 11

Definitive management of Ischemic colitis with signs of sepsis and peritoneal irritation?

Answer 11

Ex-lap

Question 12

postprandial mismatch between splanchnic blood flow and intestinal metabolic demand → postprandial pain
Diagnosis:

Answer 12

Chronic Mesenteric Ischemia

Question 13

Clinical features
Crampy abdominal/intestinal angina
Recurrent, dull, postprandial epigastric pain ~within the first hour after eating
a fear of eating → weight loss
Diagnosis:

Answer 13

Chronic Mesenteric Ischemia

Question 14

Chronic Mesenteric Ischemia
Imaging:
Treatment:

Answer 14

CT-Angiography

Frequent, small low-fat meals 
Revascularization surgery (if severe)

Question 15

Acute Mesenteric Ischemia typically caused by what

Answer 15

Atrial Fibrillation → arterial embolism

SMA (∼ 90% of cases)

Question 16

A patient with ____ typically presents with severe abdominal pain (usually periumbilical) fever, +/-bloody diarrhea, leukocytosis, ↑ Lactate.

Typically h/o a-fib

Answer 16

Acute Mesenteric Ischemia

Question 17

A patient with ____ typically has a known cardiovascular or peripheral vascular disease and/or symptoms of chronic mesenteric ischemia in addition to the acute symptoms.

Answer 17

Acute arterial thrombosis

Question 18

confirmatory test for Acute Mesenteric Ischemia

Answer 18

CT-Angiography

• wall thickening
• distended bowel with black flecks and stripes aka Pneumatosis Intestinalis (suggests transmural ischemia or infarction)

Question 19

Treatment of Acute Mesenteric Ischemia
1. Bowel rest +

Definitive management:

1. hemodynamically unstable: ___
2. hemodynamically stable patients w/o signs of advanced ischemia: ___

Long-term measures:
Statin therapy
____ therapy

Answer 19

IVFs, NGT, NPO + ABxs

1. Ex-Lap for (unstable, peritonitic, or septic)
   - Embolectomy mechanically
   - Bypass of artery
2. Endovascular revascularization (stable)
   - Angioplasty + Stenting
   - Catheter-based Heparin (thrombolytics) or mechanical thrombectomy

Anticoagulation (for long-term)

Question 20

Bilaterally absent femoral, popliteal, and ankle pulses
Pain in both legs and the buttocks
Erectile dysfunction

Answer 20

Leriche syndrome (aortoiliac occlusive disease)

Question 21

Leriche syndrome (aortoiliac occlusive disease)
sxs (3)

Answer 21

bilateral absent LE pulses
pain in legs/butt
erectile dysfunction

Question 22

Acute limb ischemia
Best initial test: ____
Confirmatory test: ____

Answer 22

Doppler U/S (arterial & venous)

Angiography (CTA, MRA, DSA*)

*Digital subtraction angiography

Question 23

Treatment of Acute limb ischemia due to thromboembolism:

Answer 23

IV heparin bolus followed by continuous infusion

Question 24

Treatment of Acute limb ischemia s/p anticoagulation:

Answer 24

Angiography → Revascularization

Question 25

Treatment of Acute limb ischemia s/p HEPARIN ANTICOAGULATION : 1. Threatened limb Emergent (w/in 6hr) ____ 2. Non-viable limb Limb amputation

Answer 25

Revascularization via Catheter-directed Thrombolysis *(or percutaneous Thromboembolectomy)

Question 26

Contraindication to cardiac catheterization

Answer 26

Acute renal failure

Question 27

Risk factors for Thoracic aortic aneurysm: [PMH] Smoking Trauma [Congenital] [s/t obliterative endarteritis in vasa vasorum] Connective tissue diseases (Marfan syndrome, Ehlers-Danlos syndrome)

Answer 27

Arterial HTN Bicuspid aortic valve (Turner syndrome) Tertiary syphilis

Question 28

Descending thoracic aortic aneurysm: typically 2/2 ____

Answer 28

atherosclerosis

Question 29

Pt presents with raspy voice and feeling like food gets stuck in his chest causing pressure & now back pain. Suspected Diagnosis?

Answer 29

Thoracic aortic aneurysm +/- sxs of mediastinal compression/obstruction: - Difficulty swallowing (esophagus) - Upper venous congestion (SVC syndrome) - Hoarseness (recurrent laryngeal nerve)

Question 30

Best confirmatory test for Thoracic aortic aneurysm

Answer 30

CT angiography chest | initial CXR may show widened mediastinum

Question 31

Conservative management for Thoracic aortic aneurysm (3)

Answer 31

Antihypertensives Smoking cessation Statins

Question 32

Clinical features of ruptured TAA: __ rupture → Severe chest pain __ rupture →Possible loss of consciousness

Answer 32

Contained Free

Question 33

Procedure Indications: | Degenerative or traumatic descending aortic aneurysms

Answer 33

Thoracic endovascular aneurysm repair (TEVAR)

Question 34

Type of surgery for: 1. Ascending Thoracic Aortic Aneurysm or Aortic Arch Aneurysm: 2. Descending Thoracic Aortic Aneurysm or Abdominal Aortic Aneurysm:

Answer 34

1. Open surgical repair (OSR) | 2. Thoracic endovascular aneurysm repair (TEVAR)

Question 35

Complications of Thoracic aortic aneurysm: 1. Left-sided ____ 2. ____ s/t bleeding into the mediastinum

Answer 35

1. Hemothorax 2. Cardiac Tamponade ( s/t bleeding into the mediastinum)

Question 36

most important risk factor in Abdominal Aortic Aneurysms

Answer 36

Smoking

Question 37

Lower back pain Pulsatile abdominal mass Bruit on auscultation Diagnosis:

Answer 37

Abdominal Aortic Aneurysm | Infrarenal Aortic Aneurysm

Question 38

Best initial and confirmatory test for: 1. Abdominal Aortic Aneurysm 2. Thoracic Aortic Aneurysm

Answer 38

1. Abdominal ultrasound (Unless pt Obese → CTA or MRA) 2. CXR → CTA chest

Question 39

Indications for repair of Abdominal Aortic Aneurysms: Diameter: ≥ __ cm Expansion rate: ≥ _ cm/year Symptomatic aneurysm Has ruptured

Answer 39

5. 5 | 1. 0

Question 40

Indications for repair of Thoracic Aortic Aneurysms Diameter AScending aneurysm ≥ __ cm DEscending aneurysm ≥ __cm

Answer 40

5. 5 | 6. 5

Question 41

How do you surveillance an un-repaired AAA of 5.0–5.4 cm [imaging] q [timing]

Answer 41

Ultrasound every 6 months

Question 42

Pt presents with Sudden onset of severe, tearing back & abdominal pain with radiation to the flank, buttocks, legs, or groin. Vitals show tachycardia & 90/40 (narrowed PP) (Hypovolemic shock) Painful pulsatile mass on abdominal exam. Diagnosis?

Answer 42

Ruptured AAA

Question 43

Unstable patients with suspected Abdominal aortic aneurysm rupture management:

Answer 43

Surgery (ideally within 90 minutes): EVAR or OSR (diagnosis is clinical)

Question 44

stable patients with suspected Abdominal aortic aneurysm rupture management:

Answer 44

CTA Thorax, Abdomen, and Pelvis (for surgical planning) (Black crescent within mural thrombus + extravasation of contrast)

Question 45

1 x Screening for AAA with abdominal U/S In men aged __ years with any h/o smoking

Answer 45

65–75

Question 46

``` Risk Factors for Aortic Dissection: ___ (most common risk factor) Trauma ( ____ injury) Vasculitis (syphilis) ____ use [congenital] Connective tissue disease (Marfan syndrome, Ehlers-Danlos syndrome) ```

Answer 46

Hypertension deceleration injury Amphetamines and cocaine Bicuspid aortic valve (Turner syndrome)

Question 47

Clinical features: - Sudden and severe tearing/ripping pain in anterior chest (ascending) or back (descending) - Interscapular or retrosternal pain - Hypertension - Asymmetrical blood pressure and pulse readings between limbs - Syncope, diaphoresis, confusion Diagnosis

Answer 47

Aortic Dissection

Question 48

Normal ___ findings do not rule out aortic dissection.

Answer 48

CXR If clinical suspicion for acute aortic dissection persists, perform a CT C/A/P

Question 49

In STABLE pt with suspected aortic dissection what imaging is best:

Answer 49

CTA | chest, abdomen, and pelvis

Question 50

In UN-stable pt with suspected aortic dissection what imaging is best: (Or if pt has renal insufficiency or contrast allergy)

Answer 50

Transesophageal echocardiography (TEE) | CXR if TEE not available

Question 51

Classic CXR finding of aortic dissection:

Answer 51

Widened mediastinum | initial test, but is negative get CTA

Question 52

Treatment Stanford A dissection: ____ Stanford B dissection: ____

Answer 52

Ascending = surgical emergency! | Conservative = Anti-hypertensives, Telemetry unless complications occur

Question 53

In patient with suspected aortic dissection what management do you want to start first then second?

Answer 53

FIRST: Beta Blocker (BP control prevents progression) Second: VASODILATOR (IV sodium nitroprusside) *Avoid thrombolytic therapy & Inotropes