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Most common arch anomaly
Left arch with aberrant right subclavian artery. 2% of population.
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Two congenital aorta arch anomalies seen in an adult vascular radiology practice:
Left-sided (normal) arch with aberrant right subclavian artery. Pseudocoarctation (aortic kink) of thoracic aorta.
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Diverticulum of Kommerell?
"Dilation at origin of aberrant right subclavian artery. May impress esophagus, resulting in dysphagia."
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Pseudocoarctation (aortic kink)?
"Mild form of coarctation, hemodynamically insignificant stenosis. Infolding occurs near ligamentum arteriosum. Pressure gradient across the kink less than 10 mmHg."
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Traumatic aortic injury sites
Proximal ascending aorta. Just beyond left subclavian (aortic isthmus). Just above the level of the diaphragm.
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Evidence of mediastinal hemorrhage includes
Poorly defined fat planes. Mediastinal hemorrhage. Perivascular hematoma. Periaortic hematoma. Contrast extravasation.
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Direct signs of aortic injury include
Abnormal contour of aorta. Change in caliber. Intraluminal irregularity (intimal flap).
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Keys to distinguishing a ductus bump from a contour abnormality at the aortic isthmus?
Ductus bump is very smooth and convex without acute margins. Aortic tear has acute margins and irregularly shaped. May have associated Luminal narrowing. Persistence of contrast in the outpouching. Double densities. Intimal flap.
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Ascending aortic aneurysm causes:
Cystic medial necrosis. Marfan syndrome. Ehlers-Danlos syndrome. Syphilis.
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"Aneurysms of the arch and descending aorta, causes:"
Atherosclerosis.
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Posttraumatic thoracic aortic aneurysms most often occur at
Aortic isthmus.
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Major complications of thoracic aortic aneurysms
Rupture. Acute dissection.
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Takayasu arteritis
Granulomatous (giant cell) inflammation of media and adventitia of large elastic arteries. IAsian women. Female-to-male ratio of 10:1. Most often affects thoracic aorta and its proximal branches and pulmonary arteries.
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Aortic infection is usually divided into two types based on the causative microorganism:
Syphilitic. Mycotic (nonsyphilitic).
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"Mycotic nonsyphilitic aortitis, the most common organisms are:"
Staphylococci. Streptococci. Salmonella.
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Very large aneurysmal aortic root with sinotubular ectasia (tulip bulb appearance)
Marfan syndrome.
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Stanford classification for aortic dissection?
Type A involves ascending aorta. Type B does not involve ascending aorta.
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Differential diagnosis of aortic dissection
Intramural hematoma. Penetrating aortic ulcer. Together these constitute the acute aortic syndrome.
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Diagnosis of chronic PE by pulmonary angiography is based on the identification of
Webs. Luminal irregularities. Abrupt vessel narrowing and/or obstruction. Dilated central pulmonary arteries.
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Most common complaint in symptomatic patients with PAVM
Epistaxis from hereditary hemorrhagic telangiectasia.
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PAVMs categories
Simple: One artery to one vein. Complex: Multiple feeding arteries and/or draining veins.
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Indications for transcatheter embolotherapy of PAVMs include
Exercise intolerance. Prevention of neurologic complications. Prevention of lung hemorrhage (hemoptysis).
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PAVMs are usually treated when the feeding artery is at least
3 mm in size.
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Most common indication for bronchial arteriography
Hemoptysis.
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Common anatomic variants of peripheral arterial system.
Absence of anterior or posterior tibial arteries (5% of individuals). High origin of radial artery from the axillary or brachial artery (17% of patients). Persistent sciatic artery (normal fetal branch of internal iliac artery that continues into lower etremity).
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"In general, a normal ABI should be greater than"
1
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An ABI between _____ and _____ signifies intermittent to severe claudication.
0.95 and 0.5
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The angiographic appearance of diabetic vascular disease differs from typical atherosclerosis in two main ways:
"Vascular calcification involving arteries of all sizes. Disease involvement is more distal, often sparring large proximal vessels."
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Most common site for upper-extremity atherosclerotic involvement is the
Proximal left subclavian artery. Can result in subclavian steal.
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"In acute peripheral thrombosis or embolism, what clinical findings steer toward an endovascular approach versus open surgery."
"In general, patients with pain and pallor are embolic candidates. Sensory and motor deficits are treated surgically."
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"Exclusive of Takayasu arteritis, what two main vasculitides occur in the peripheral arterial system?"
Giant cell arteritis. Buerger disease.
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Giant cell arteritis typically involves the
"Medium to large blood vessels supplying head (Temporal arteries), neck (Carotid arteries), and arms (Axillary and brachial arteries). Most common in women greater than 60 years. Smooth, long segment narrowing."
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Angiographic hallmark of Buerger disease is
Corkscrew appearance of arteries. Collaterals around areas of occlusion (most often at wrists and ankles). Absence of atherosclerotic findings.
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Buerger disease (thromboangiitis obliterans)
Acute inflammation and thrombosis of arteries and veins. Primarily affects hands and feet. Typically young heaving smoking males.
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Range of angiographic findings of trauma include
Vasospasm. Intimal irregularity. Pseudoaneurysm. Extravasation. Arteriovenous fistula.
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Hypothenar hammer
"Repetitive palmar trauma. Injury of ulnar artery adjacent to hook of hamate. Ulnar artery can be aneurysm, thrombosed, or send emboli to digital arteries."
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Which peripheral arteries can be sacrificed (embolized) without consequence?
Branches of internal iliac. Branches of profunda femoris. Geniculate branches. Subclavian/axillary/brachial artery branches (except vertebral).
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Fibromuscular disease (FMD) has been described in what arteries
Upper extremity: Subclavian artery. Axillary artery. Brachial artery. Lower extremity: Iliac artery. Femoral artery. Popliteal artery.
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Thoracic outlet syndrome
Compression syndrome of upper limb neurovascular bundle at the level of scalene muscles and first rib. 70% with arterial injury have a cervical rib.
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Popliteal entrapment
Popliteal artery and or vein deviate around medial head of gastrocnemius.
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Adventitial cystic disease
Mucin collects in adventitial layer. May lead to narrowing or obstruction. Most commonly in popliteal artery.
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Arteriomegaly
"Unusual manifestation of aneurysmal disease. Diffuse, generalized dilation of aortoiliac and femoral vessels."
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Elective repair of an asymptomatic AAA is when the diameter exceeds
5.0 cm.
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Endoleaks are categorized into four types:
Type 1: Leak at superior or inferior attachment site. Type 2: Patent side branch filling grafted aneurysm sac (Lumbar or Inferior mesenteric artery). Type 3: Loss of stent graft integrity. Type 4: Leak through porous graft material.
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Commonest pathogen of mycotic aneurysms or pseudoaneurysms of abdominal aorta?
"Salmonella species, up to 74%."
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Leriche syndrome
"Bilateral buttock claudication, impotence, and absent femoral pulses. Aortic occlusion."
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"Aortoiliac occlusive disease can be caused by inflammatory diseases, in particular"
"Takayasu arteritis. Long segment, smooth narrowing of abdominal aorta. May extend into branch vessels."
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Hypoplastic aortic syndrome
Congenital long segment narrowing of aorta. Usually seen in young females.
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"There are a number of etiologies for renal artery occlusive disease, including"
Two most common: Atherosclerosis. Fibromuscular dysplasia (FMD). Others: Dissection. Vasospasm. Vasculitis. Coarctation syndromes. Neurofibromatosis.
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Neurofibromatosis causes renal artery stenosis by
Extrinsic compression of renal artery by neurofibromata. Disorganized intimal and medial proliferation at renal artery orifice or proximal renal artery.
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Hypertension secondary to neurofibromatosis is seen mainly in
Children.
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"Renal artery aneurysms, outside of trauma, are basically of two types:"
"Extrarenal: Atherosclerosis. FMD. Intrarenal: Polyarteritis nodosa (PAN, small and multiple)."
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"PAN is a rare necrotizing vasculitis that affects small and medium-sized arteries of multiple organs, most commonly"
"Kidney (85%). Liver (65%). Multiple, small, saccular microaneurysms, occlusions, and irregular stenoses throughout abdominal viscera."
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Differential diagnosis of microaneurysms includes
PAN. Wegener granulomatosis. Systemic lupus erythematosus. Rheumatoid vasculitis. Drug abuse.
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most common aneurysm outside of aorta and iliac arteries.
Splenic artery aneurysm.
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"Hepatic neoplasms (mets included), which are responsive to embolization?"
Hepatocellular carcinoma. Neuroendocrine tumors. Melanoma. Sarcoma. Colorectal metastases.
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Tumor replacement of greater than _____% of normal liver is a contraindication to embolization.
50% to 75%.
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three collateral communications of mesenteric arteries.
"Marginal artery of Drummond: Anastomosis between right colic, right and left branches of middle colic, and left colic arteries. Found along mesenteric border of colon. Important collateral supply in IMA occlusions. Arc of Riolan: Variable communication between SMA and IMA. Located more centrally than marginal artery. Arc of Buehler: Short, ventral artery between main celiac and SMA. Persistent fetal communication."
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Causes of acute mesenteric ischemia.
Arterial embolism and thrombosis. Nonocclusive ischemia. Mesenteric venous thrombosis.
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"A left SVC occurs in 0.3% of the population and descends through the left mediastinum anteriorly to join the _______, which drains into the RA"
coronary sinus
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Azygos continuation of the IVC is caused by
Absence of intrahepatic portion of the IVC. Failure of right subcardinal vein to anastomose with hepatic veins. Hepatic veins drain into RA. Renal and iliac veins drain via azygos and hemiazygos veins into SVC.
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"Retroaortic left renal vein, circumaortic left renal vein?"
Retroaortic left renal vein (2%) crosses behind aorta. Both retroaortic and preaortic renal veins form the circumaortic left renal vein (8%).
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The femoral vein is a continuation of the popliteal vein at the ______.
Adductor hiatus
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Contraindications for peripheral thrombolysis:
Internal bleeding. Stroke within past 6 months. Cranial or spinal surgery within past 2 months. Intracranial neoplasm. Bleeding diathesis. Uncontrolled hypertension. Contraindication to anticoagulation.
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Complications of venous thrombolysis include:
Pulmonary embolus. Bleeding: At access site. Hemorrhagic stroke. GI bleeding. Retroperitoneal hematoma.
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Phlegmasia cerulea dolens
Limb arterial compromise caused by massive acute venous thrombosis. Thrombosis involves both main and collateral venous drainage. Causes swelling and severe elevations in vascular resistance resulting in ischemia.
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Paget-von Schrötter syndrome
"Compression of subclavian vein by a cervical rib, soft tissue anomaly, or scar tissue after clavicle fracture. Results in thrombosis and arm swelling."
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SVC syndrome is caused by
"SVC stenosis and or thrombosis. Extrinsic compression: Bronchogenic carcinoma (up to 82%). Granulomas (histoplasmosis and tuberculosis). Lymphoma. Intrinsic: Intravascular foreign bodies (pacemaker leads, central venous catheters), Venous stenoses caused by chronic dialysis and venous hypertension."
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May-Thurner syndrome
"Compression of left iliac vein by crossing right iliac artery. This is normal anatomy. Arterial pressure on vein results in wall thickening, narrowing, and thrombosis. "
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Budd-Chiari syndrome
Occlusion of hepatic veins. Result of hepatic venous or IVC outflow obstruction.
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Coronary vein portosystemic shunt pathway
Communicates with azygos system in submucosa of distal esophagus and gastric cardia.
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Contraindications to TIPS
Hepatic failure. Severe right heart failure.
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