Chapter 1 1. b. Vascular smooth muscle cells (not endothelial cells) migrate into the intima during atherosclerosis initiation. Endothelin is primarily a vasoconstrictor via the endothelin A receptor on vascular smooth muscle. Endothelin can act on endothelin B receptors on endothelial cells to increase nitric oxide (a potent vasodilator), but the net effect of endothelin on arteries is dominated by the vasoconstrictor effect on endothelin A receptors. The smaller muscular arteries (rather than elastic arteries) regulate resistance. The adventitia contains connective tissue, but the media contains abundant smooth muscle and connective tissue. 2. e. HDL is considered the main transport lipoprotein for reverse cholesterol transport, which removes cholesterol from peripheral tissues. 3. c. Nitric oxide tends to prevent activation of NF-κB. The selectins are most responsible for monocyte rolling, whereas the CAMs are most responsible for monocyte arrest and recruitment into the artery wall. MCP-1 enhances (not blocks) monocyte recruitment. 4. e. All are found in advanced plaques. 5. b and e. Monocytes and leukocytes are more characteristic of atheroma than are neutrophils. Therapies that lower LDL levels usually do not decrease plaque size. Most human studies (intravascular ultrasonographic and angiographic) suggest intensive lipid lowering is associated with small changes in plaque size (generally less than 5%) compared with the large decrease in the risk of clinical events. Calcification is an active (not passive) process that in some cases mimics construction and destruction processes seen in bone. 6. b. Compensatory enlargement refers to the enlargement of the whole artery to accommodate the athero© 2007 Society for Vascular Medicine and Biology
sclerotic plaque to preserve the lumen size. Over time this process is thought to be overwhelmed and the lumen decreases in size. Negative remodeling refers to a decrease in size of the whole artery segment; this tends to contribute to lumen narrowing and the development of stenoses. Metalloproteases are more often found in positively remodeled arterial segments and are thought to contribute to the growth of the artery.
Chapter 2 1. d 2. b 3. c 4. b 5. b
Chapter 3 1. c 2. a 3. d 4. d 5. a 6. d 7. f 8. a
Chapter 4 1. c. The calf pump failure syndrome is caused by either retrograde flow through incompetent perforator veins during calf muscle contraction or ineffective muscle contraction, both of which result in secondary varicose veins. 313
2. c. May-Thurner syndrome is caused by compression of the left iliac vein by the right iliac artery as the vein crosses over to the left leg. The term “May-Thurner syndrome” is only used when significant venous obstruction is produced by the overlying artery. During pregnancy, an otherwise normal woman may have symptoms of this condition, due to increased intra-abdominal pressure. 3. c. The Trendelenburg test is a simple bedside test that can help distinguish primary from secondary varicose veins and should be performed before consideration of sclerotherapy. She had no symptoms or history of DVT, and duplex ultrasonography would be the preferred diagnostic test to exclude DVT rather than venography. The veins will decompress with elevation, but neither bed rest nor analgesics will resolve her condition in the long term. 4. b. Reducing edema is the most important element of CVI treatment and decreases cutaneous complications. Diuretics only help edema minimally. Small ulcers should be treated first with aggressive medical therapy before consideration of skin grafting. In the SEPS procedure, ligation of perforator veins is performed under endoscopic guidance. 5. c. Filariasis is the most common cause of lymphedema worldwide and is especially prominent in Africa, India, and South America. Lymphedema sometimes secondarily complicates CVI. Milroy disease is a form of familial primary lymphedema. 6. d. This patient has lymphedema praecox, which typically presents during puberty. The patient has swelling that extends into the feet and toes with cutaneous fungal infection, which are characteristics of lymphedema. Stemmer sign is positive if the skin at the base of the toes cannot be pinched. Swelling from lymphedema usually progresses slowly up the leg over time.
Chapter 5 1. e 2. c 3. a 4. d 5. d 6. b
Chapter 6 1. e 2. c 3. c 4. f 314
5. e 6. d
Chapter 7 1. c. Both PW and CW Doppler instruments can detect forward and reverse flow, but CW Doppler instruments are less costly and simpler to use. The penetration of ultrasound in tissue is primarily dependent on transmitting frequency (with lower frequencies penetrating to deeper depths) and is the same for PW and CW Doppler. Only PW Doppler can distinguish between flow at different sites or depths in tissue. 2. a. Compressibility (or stiffness) should not affect pneumatic cuff pressure measurements in normal tibial and brachial arteries. However, if calcification or atherosclerotic occlusive disease is present in the tibial arteries, they may be less compressible, which leads to erroneously high cuff pressure measurements. The mean arterial pressure decreases as the pulse moves distally, whereas the systolic pressure increases and the diastolic pressure decreases (so the pulse pressure widens). Because the brachial artery site of pressure measurement is closer to the heart, this augmentation or increase in systolic pressure makes the normal ankle pressure greater than the arm pressure and the ABI greater than 1.0. Cuff artifacts should not be significant at the brachial and ankle sites. 3. b. The digital arteries are not affected by medial calcification, even if the tibial arteries are heavily calcified. Toe-brachial indices are in the range of 0.80 to 0.90 in normal persons. It is often difficult to obtain Doppler flow signals from the toes, and PPG is easier to use for this purpose. Although patients with diabetes mellitus are especially prone to medial calcification in the tibial arteries, the digital arteries are not involved, so toe pressure measurements are not different in diabetic and non-diabetic patients. 4. d. The normal segmental plethysmographic waveform is characterized by a rapid steep upstroke, a sharp systolic peak, and a more prolonged downslope that bows toward the baseline. Changes in amplitude alone generally have little diagnostic significance. A prominent dicrotic wave is normally seen on the downslope of the waveform and represents the reverse-flow phase of the arterial flow pulse. Significant arterial occlusive disease proximal to the recording cuff is excluded by the presence of a dicrotic wave. 5. c. The maximum change in ankle pressure after treadmill exercise occurs immediately after walking, so it is important to measure pressures as quickly as possible. A slight increase in ankle pressure after treadmill exercise is often seen in normal persons. Patients with signifi-
cant arterial occlusive disease typically have symptoms within 5 minutes of walking at 2 mph up a 12% grade, and more prolonged exercise times are rarely necessary. Some mild-to-moderate arterial lesions are not hemodynamically significant at resting flow rates, but they become flow limiting when flow rates are increased by exercise.
3. d 4. d 5. c 6. b 7. a
Chapter 11 Chapter 8 1. b 2. e 3. d 4. a 5. d
1. e 2. d 3. d 4. e 5. d 6. e 7. b
1. c. This patient has intermediate risk factors and is scheduled to undergo a high-risk vascular operation. β-Blockers decrease the risk of adverse preoperative cardiovascular events; this medical management in this situation would result in an outcome similar to coronary revascularization before vascular surgery. 2. a. This patient has an impending rupture of an abdominal aortic aneurysm and requires urgent surgery. Performance of any cardiac tests would delay the operation. 3. d. This patient has a symptomatic carotid stenosis. Carotid endarterectomy, an intermediate-risk procedure, should be performed. She has excellent functional capacity and minimal risk factors. She can proceed directly to surgery with perioperative administration of β-blockers and aspirin because she is at low risk for an adverse cardiovascular event. 4. a. This patient likely has three-vessel coronary artery disease, left ventricular dysfunction, and angina. The popliteal artery aneurysm repair is elective. Regardless of the popliteal artery aneurysm, he should be referred for cardiac catheterization as a prelude to a coronary revascularization procedure. 5. a. According to the ACC/AHA practice guidelines, the presence of symptomatic aortic valvular stenosis, even in the absence of a critical stenosis (<1.0 cm2), indicates a very high risk that should prompt aortic valve replacement before planned elective vascular surgery.
1. c 2. b 3. d 4. a 5. b
Chapter 13 1. e. Although increased levels of LDL are associated with an increased incidence of lower extremity PAD, diabetes mellitus and cigarette smoking are more strongly associated with PAD. Obesity is not as strong a risk factor for PAD as diabetes and cigarette smoking. 2. b. Patients with PAD have a 3.0- to 4.0-fold increased risk of cardiovascular disease mortality compared with patients without PAD. 3. c. Most epidemiologic studies show the sensitivity of the intermittent claudication questionnaire for the diagnosis of PAD to be approximately 10% to 25%. 4. d. Cigarette smoking and diabetes mellitus are the two most important predictors of critical limb ischemia among PAD patients with intermittent claudication. 5. b. Patients with PAD who have rest pain are less likely to require amputation than those who have gangrene or an ulcer.
Chapter 14 Chapter 10 1. a 2. c
1. a 2. c 3. b 4. c 315
5. c 6. c 7. a
Chapter 15 1. b. Arterial emboli usually lodge at or proximal to arterial bifurcations and predominantly affect the lower extremities. About three-fourths of all cases occur between the aortic and popliteal bifurcation, with the rest affecting the upper limbs and the cerebral and visceral circulation. 2. d. Most patients with clinical atheromatous embolism are men aged 60 years or older. Whites are affected more frequently than blacks. 3. e 4. b. Acute compartment syndrome is especially common in patients with combined arterial and venous injury, due to the added venous hypertension.
Chapter 16 1. b. The most common complication of a fusiform popliteal artery aneurysm is formation of a thrombus, which can embolize to distal vessels. Thrombotic occlusion of the popliteal artery and emboli may cause acute limb ischemia. 2. b. Increased concentration of MMPs has been observed in experimental models of aortic aneurysm and in tissues excised from human aortic aneurysms. 3. d. This aneurysm has expanded 1 cm over the course of 1 year and meets one criterion for repair. 4. d. Of the factors listed, only diabetes mellitus is not associated with aneurysm formation. 5. a. The risk of rupture of TAA increases progressively with expansion, and most studies recommend repair of a descending TAA with a diameter of 6.5 to 7.0 cm. Similar to AAAs, TAAs should be imaged every 6 to 12 months to determine whether the size has increased considerably.
3. a. This is a type A IMH in the ascending aorta. The proper management is blood pressure control and rapid repair. 4. c. The factors that most strongly predict need for aneurysm repair are an aortic diameter ≥4.0 cm and a patent false lumen. 5. d. For patients with a type A aortic dissection, pericardiocentesis is associated with higher rates of mortality, and catheterization has not been shown to provide benefit. β-Blockers would be contraindicated in a hypotensive patient.
Chapter 18 1. a. Bilateral RAS is a volume-mediated form of hypertension. Thus, many of these patients have low renin levels and are not angiotensin dependent for filtration. If a diuretic was added, the blood pressure would probably decrease but at the risk of acute renal failure developing. 2. b. Typical medial fibroplasia should be treated with PTA alone. There is no reason for a stent. Branch involvement does not contraindicate PTA. Although the blood pressure may be normalized with medications, the patient is young and may not require any blood pressure medications after PTA. 3. d. The renal-aortic ratio is 5.5 on the right side, and the PSV is greater than 200 cm/s. This indicates a 60%-99% stenosis. The RRIs are normal. 4. c. Answers a, b, and d are not correct because patients with FMD do not require stenting; a creatinine value of 3.5 mg/dL cannot be explained by unilateral RAS; and 40%-60% stenosis is not enough to cause severe hypertension. 5. c. The patient has non-occlusive mesenteric ischemia. This is due to hypoperfusion and not to a fixed obstruction. The diagnosis is made angiographically and the initial treatment is infusion of vasodilators. If peritoneal signs develop, exploration would be the next step, but only after vasodilator infusion.
Chapter 19 Chapter 17 1. a. Because aortic dissection cannot be excluded, an imaging test must be ordered. The carotid artery and aorta may be imaged well with MRI but not with ultrasonography. 2. d. Pulse deficits are associated with a marked increase in the risk of death for patients with a type B dissection.
1. c. The most common cause of cerebral ischemia is atherosclerotic thrombosis, likely as a result of longstanding hypertension involving the lenticulostriate arteries deep in the brain. CT will show classic abnormalities of a lacunar infarct. The erythrocyte sedimentation rate is an acute-phase reactant used to identify cerebral vasculitis, a rare cause of cerebral ischemia. Transcranial Doppler ultrasonography is useful for de-
termining intracranial collateral pathways in the brain in a patient with extracranial carotid stenosis. Transesophageal echocardiography is used to determine aortic arch atherosclerosis, patent foramen ovale, valvular heart disease, and cardiac chamber thrombi, which are all sources of emboli. Hemoglobin A1c will only identify diabetes mellitus and will not determine the cause of cerebrovascular ischemia. 2. d. The most important clinical clue is clear evidence of a symptom attributable to a moderate or severe carotid artery stenosis. Cervical bruits are markers of atherosclerosis but do not predict the severity of carotid stenosis or indicate the need for revascularization. The absence of a temporal artery pulse suggests clinically significant disease at the carotid artery bifurcation but may represent stenosis of the external carotid artery only. Dermatologic manifestations of familial hypercholesterolemia suggest the need for aggressive lipid-lowering therapy; however, they do not suggest significant carotid stenosis or the need for carotid revascularization. Tobacco use is a risk factor for atherosclerosis, but it does not define the severity of carotid stenosis or the need for revascularization. 3. b. The basic diagnostic algorithm for carotid artery stenosis is a thorough history and physical examination followed by CDUS. If duplex ultrasonography shows severe carotid stenosis in a patient who would benefit from revascularization, digital subtraction arteriography would be the next step. Digital subtraction arteriography should rarely, if ever, be the initial diagnostic test. Diffusion-weighted magnetic resonance imaging is used to evaluate the brain. MRA is an excellent test but requires use of a contrast agent. The two-dimensional time-of-flight images cannot be used alone because the severity of carotid artery stenosis is often overestimated. MRA and multidetector CTA are rarely used together because of the cost. 4. e. A systolic and diastolic cervical bruit caused by extracranial carotid artery stenosis suggests critical bilateral disease. The cardiac valvular pathology that could result in a systolic/diastolic bruit is aortic insufficiency. Impaired left ventricular function and jugular vein thrombosis are unrelated to this physical finding. 5. c. Carotid revascularization is indicated for patients with symptomatic and severe carotid artery stenosis. CAS placement is recommended as an alternative to CEA for patients with high-risk anatomic or medical comorbid conditions. This patient has a severe symptomatic carotid artery stenosis and an anatomic factor (contralateral internal carotid artery occlusion) that places him at high risk with CEA. Combination antiplatelet therapy has not been shown to offer benefit over aspirin alone as the primary medical therapy or after CEA. However, combination antiplatelet therapy is critical for patients
who undergo CAS placement to prevent early stent thrombosis.
Chapter 20 1. a 2. b 3. c 4. d 5. b
Chapter 21 1. c. This patient has right subclavian disease involving the ostium. The right subclavian typically projects posteriorly, and the true ostium of the right subclavian artery is frequently eclipsed by the carotid in the LAO and AP views. This anatomy varies depending on the tortuosity and redundancy of the great vessels, particularly in elderly patients, but an RAO view usually provides the best definition of the subclavian ostium. 2. d. CH (Charriere) is synonymous with French size (F). 6F=0.33×6=1.98 mm. 1.98/2.54=0.78 in. 3. c. Shaping the Simmons sidewinder catheter in the aortic arch can put the patient at risk for atheroembolization. Aggressive maneuvers to shape the catheter in the ascending aorta should be avoided. It is generally recommended to first gently advance the catheter over a wire into the left subclavian artery. The wire is then retracted into the secondary curve to provide rigidity at the point of the secondary bend, improving the ease of prolapse as the catheter is advanced forward and assumes its preformed shape. The Simmons sidewinder is the carotid-selective catheter of choice for many operators, but its use has a learning curve and aggressive manipulation in the aortic arch must be avoided. 4. e. The only incorrect answer is increasing the psi threshold and proceeding with an injection. The typical diagnostic catheter has a rated burst of 1,050 to 1,200 psi. By simply increasing the psi threshold of the injector, the catheter could rupture, and the risk is increased of dislodging a thrombus or occlusive material from the catheter into the artery or vein of interest. 5. b. Typically, shaped catheters should be removed over a wire. However, advancing a wire into a diagnostic catheter that has no blood return could result in embolization of the occlusive material through the tip of the catheter as the wire is advanced. If blood cannot be withdrawn from a catheter stationed in a vessel, an attempt should first be made to reposition and make certain the catheter tip is not against the vessel wall or in a small side branch or plaque. After these maneuvers, if the catheter still will 317
not flush and there is no evidence of a kink, attempts to clear the catheter while inside the body using a power injection, forward flush, or guidewire are ill advised. 6. f. Typically, a 65-cm pigtail catheter has a maximal flow rate of 33 mL/s. All of the choices listed would be appropriate on the basis of Poiseuille’s law. 7. e. This is the most feared catastrophic complication of simple abdominal angiography. The complication is less common now that image quality has improved and fewer end-hole catheters are being used for non-selective angiography. The complication occurs by inadvertent injection of contrast into a thoracic branch that happens to provide circulation to the anterior spinal artery. The rapid high-pressure injection of contrast is associated with barotrauma to the spinal cord and immediate paralysis. There is some theoretical benefit from venting of the spinal fluid immediately after this complication, but no controlled studies have confirmed change in outcome after venting. 8. d. This is a fairly common normal variant and would not be considered a pathologic finding. If the right subclavian artery originates distal to the left subclavian or contiguous with the left subclavian, this is considered an anomalous origin that can be associated with aneurysmal change or the so-called Kommerell diverticulum (marked by dysphagia and tracheal encroachment). 9. c. This case illustrates the importance of meticulous imaging and of preprocedural physical examination when making decisions within the angiographic suite. Unilateral absence of pedal pulses cannot be explained with the “normal” angiographic findings reported. This patient had an occult popliteal stenosis that was eclipsed by the prosthetic knee. This type of lesion is frequently missed without appropriate image intensifier angulation.
Chapter 22 1. c 2. d 3. b 4. b 5. c
Chapter 23 1. d 2. b 3. b 4. a 5. a
Chapter 24 1. c 2. d 3. c 4. b 5. b 6. a 7. a
Chapter 25 1. c 2. b 3. d 4. a 5. b
Chapter 26 1. c 2. e 3. a 4. c 5. a 6. d
Chapter 27 1. c. On the basis of the MRA, the patient most likely has giant cell arteritis. Because she presented more than 6 hours after symptom onset, immediate intervention with local thrombolytic or angioplasty and stenting would increase the patient’s risk of hemorrhagic conversion. Lesions in patients with giant cell arteritis result from inflammation, not atherosclerosis. Thus, atherectomy would not be beneficial. Treatment with corticosteroids should be initiated. Aorta-to-carotid bypass in 5 to 7 days would provide the best revascularization option (Figure). 2. a. In the vast majority of patients, occlusion of the subclavian artery does not lead to serious clinical consequences. If the endograft procedure requires covering the left subclavian artery, preoperative imaging with CTA, MRA, or 4-vessel cerebral angiography is warranted to verify patency of the innominate and right subclavian arteries, assess the size of the vertebral arteries, and determine whether the circle of Willis is intact.
3. c 4. a 5. c
Figure for Answer 1.
3. b. The right aortic arch with aberrant left subclavian artery is the most common form of right aortic arch. It is one of the most common causes of symptom-producing vascular ring. 4. a. Based on results of the WASID study, patients with symptomatic intracranial stenosis should be treated with aspirin. Patients randomly assigned to aspirin (as opposed to warfarin) tolerated the medication better, had a lower incidence of hemorrhage, and had a lower mortality rate. 5. a. CT shows dissection of the left vertebral artery. Most vertebral artery dissections heal spontaneously. Anticoagulation is recommended to decrease the potential for secondary thromboembolic complications. Catheterbased intervention is reserved for patients with ongoing symptoms despite maximal anticoagulation or the presence of an aneurysm causing recurrent thromboembolism or with impending rupture.
Chapter 28 1. c 2. e
1. b. The most common cause of acute limb ischemia is thromboembolism (75% of cases). The most common source is the left atrial appendage in atrial fibrillation or the left ventricle after an anterior wall myocardial infarction. In some cases, atheromatous material can embolize from the aorta. Typically, patients with an embolic etiology of ischemia have abrupt onset of pain, a recent cardiac event, and no history of claudication. If the etiology is clearly embolic and the site of occlusion can be identified (e.g., the popliteal artery), the patient should undergo surgical embolectomy. Systemic thrombolysis is rarely used. Catheter-directed thrombolysis would be appropriate for patients with thrombosis in situ. Neither intravenous heparin nor a glycoprotein IIb/IIIa inhibitor will dissolve the clot, and amputation is reserved for non-viable limbs. 2. a. Several factors predict successful outcome, including graft occlusion <14 days, ability to traverse the lesion with a guidewire, and two- or three-vessel runoff. Catheter-directed thrombolysis can unmask the etiology underlying the graft failure. Unless the underlying lesion is treated (angioplasty, stenting, or surgical revision), the graft is likely to reocclude. 3. d. Adjunctive use of mechanical thrombectomy devices may avert the need for thrombolysis or permit lower doses of thrombolytic drugs. Low-dose heparin and shorter catheter dwell times decrease bleeding rates. Fibrinogen levels should be checked approximately every 6 hours because levels <100 mg/dL are associated with systemic fibrinolysis. 4. d. In assessing patients with acute limb ischemia, the degree of limb ischemia can be categorized as Category I (viable), IIa (marginally threatened) or IIb (immediately threatened), or III (irreversible). Revascularizing a nonviable limb leads to profound metabolic acidosis, hyperkalemia, myoglobinuria, acute renal failure, and death. 5. a. The TOPAS study compared rUK with primary surgery in patients with acute lower extremity arterial ischemia. The increase in ankle-brachial index was similar in the surgery and thrombolysis arms. There was no difference in the rate of either major amputation or death between the groups within 1 year of followup. The TOPAS trial established equivalency of the two treatment arms.
1. d 2. b 3. e 4. d 5. e 6. e
1. d 2. c 3. d 4. b 5. a 6. c 7. a, b, and d