Angiography/Cardiovascular/Interventional Section

The following are True/False questions:

1992
Regarding bronchial artery embolization:
1. it is successful for treatment of bleeding in patient with cystic fibrosis
2. one complication is spinal cord infarct
3. gelfoam or small particles are the method of choice
4. often cause pulmonary infarct
5. is successful in the treatment of AVM
*
Bronchiectasis may result in life-threatening hemoptysis in CF. Bronchial arteries
may be markedly enlarged. Bronchial artery embolization may successfully treat such
episodes of hemoptysis but may be complicated by spinal cord infarct, as spinal arteries
may arise from the intercostals. Particles or gelfoam should be employed, as larger
and/or more permanent agents such as coils may preclude future access to bleeding
vessels and hemoptysis tends to be a recurrent problem in CF. Alcohol is contraindicated
because of resultant cell necrosis
Bronchial artery embolization only rarely results in pulmonary infarct (e.g.,
concurrent pulmonary artery occlusion).
Pulmonary AVMs result from defects in the terminal capillary loops of the
pulmonary vessels, not bronchial vessels.
References: Kadir, pp. 197-200; baby Fraser and Pare p. 278; M. Soulen
*
Answer: 1. True 2. True 3. True 4. False 5. False

1994, 1992, 1990, 1989, 1988

Regarding the clotting cascade:
6. plasmin destroys fibrinogen
7. heparin destroys fibrinogen
8. aspirin activates prothrombin to thrombin
9. urokinase converts plasminogen to plasmin
10. fibrin is soluble
*
Plasmin degrades fibrinogen; it also degrades fibrin to FSPs.
Heparin binds to and potentiates the action of antithrombin III, thereby blocking
the conversion of prothrombin to thrombin. It does not destroy fibrinogen, nor does it
have anything to do with clotting factors.
Fibrin clot is not soluble. Fibrin monomers (which are cross-linked to form the
fibrin clot) are soluble.

Thrombolytic therapy is based on the activation of plasminogen to plasmin, which

is a nonspecific proteolytic agent that has an affinity for fibrin.
 Urokinase is a protease that converts plasminogen to plasmin (like t-PA and
streptokinase). Being a product of human kidney cell culture, it is not antigenic. Though
it has less selective affinity for fibrin-bound plasminogen than t-PA, is has less of a
systemic effect than streptokinase.
Streptokinase is produced by group C beta-hemolytic streptococci. It binds to
plasminogen, forming a combined molecule which activates circulating plasminogen and,
to a lesser degree, plasminogen which has already bound to fibrin in clot. At high doses,
a systemic lytic state is rapidly produced. In local infusions, a systemic effect is not
usually achieved for 10-12 hours. Because humans often have had exposure to
streptococcal organisms, many have antibodies to streptokinase.
Aspirin inhibits platelet aggregation.
References: Goodman and Gilman, Ch. 58; Robbins, p. 69
*
Answer: 6. True 7. False 8. False 9. True 10. False

1992
Correct relationships include:
11. SVC is anterior to the right pulmonary artery
12. Common iliac artery is posterior to the common iliac vein
13. Testicular vein is posterior to the ureter
14. left renal vein is anterior to the aorta
15. Gastroduodenal artery is posterior to the portal vein
*
Answer: 11. True 12. False (anterior) 13. False (anterior) 14. True (usually)
15. False (anterior)

1995, 1992
Regarding pulmonary AVMs:
16. gelfoam and Ivalon are the agents of choice (95, 92)
17. pulmonary infarct is most common complication of embolization (95, 92)
18. treatment success is the same as with peripheral AVMs (95, 92)
19. they are associated with cutaneous telangiectasia (92)
20. they are supplied by bronchial arteries (92)
21. they commonly drain into the azygous vein (95)
22. often seen in patients with buccal telangiectasia (95)
*

Answer: 16. False 17. False 18. False 19. True 20. False 21. ?false 22.
?false (? often = >50%)

Permanent agents, such as coils, not gelfoam or Ivalon, are the agents of choice
for embolization.
 Systemic complications of embolization occur more frequently than pulmonary
infarcts. Hemoptysis, cyanosis, clubbing, and bleeding from other sites are common
complications of pulmonary AVMs.
40-65% of pulmonary AVMs are associated with Osler-Weber-Rendu (autosomal
dominant)
AVMs occur most commonly in the lower lobes and are twice as common in
women. They occur most often in the third and fourth decade.
They are defects in the terminal capillary loops of the pulmonary arteries. They
are not supplied by the bronchial arteries.
Reference: baby Fraser and Pare, p. 278

15% of pt w/ Osler Weber Rendu have Pulm AVMs.

vs 60% of pt w/ Pulm aVM have Osler Weber Rendu
40-50% of pt with diffuse pulm teleangiectasia have teleangietatic lesions of the
skin, mucous mem, parenchymal and hollow organs
ref: Kadir, dx angio p. 603
AVM is abnormal connection between pulm. artery and pulm. vein. Defect in
terminal capillary loops with formalion of a thin vascular sac. Pulm v. drains into the left
atrium..
ref.: AFIP notes 1995 Philip Templeton section L-3.
*

1995
Which of the following are true regarding chronic lower extremity arterial insufficiency?
23. patients have paresthesias, paralysis, pulselessness
24. claudication is an independent risk factor for coronary artery disease
25. only 10% of patients with claudication will show improvement with smoking
cessation and an exercise program
26. the 5-year risk of amputation is greater in smokers versus diabetics
another question here???
*

Answer: ???
23. false ( only in acute occlusion get paralysis)
24. true 25. ??? false 26.false ( greater in DM)

Insufficiency Sx are secondary to ischemia: claudication, impotence, parethesia,

ischemic neural pain, and limb weakness. In acute occlusion ( secondary to trauma,
thromboembolism, aneurysm occlusion, thrombosis superimposed on atherosclerotic
disease), sx include 5 P's -- pulselessness, pain, pallor, paresthesias, paralysis.
pt with DM have higher incidence and severity of PVD with premature onset of
disease. In a large autopsy study, 0.66% NON-diabetics vs 24.9% of DM had gangrene
of the extremities.
ref: Kadir dx angio p. 222, 225, 228,
 risk factors for atheroscllerotic disease: male, FHx of premature ischemic heart
disease, hyperlipidemia, cigarette, HTN, low HDL, DM, Personal hx of cerebral vascular
or peripheral vasc. disease, sever obesity, high lipoprotein.
ref: Harrison's 12th ed, p 996 table 195-4
In ischemic heart disease, smoking has been definitively shown that when
eliminated, clearly decreases the risk of atherosclerotic disease. Physical training has been
shown to improve the exercise performance fo pt with heart dis and angina .
No percentage given.
ref. p.999 Harrison's 12th ed.

1995
Regarding primary pulmonary hypertension:
27. PCWP can be normal
28. COPD is the most common cause
29. calcification in dilated pulmonary arteries indicates long-standing pulmonary
hypertension
30. more common in women (another question here???)
*

Answer: 27. false 28. false ( secondary) 29. ??true 30. true
primary pulm HTN is characterized by increased pulm arterial pressure and
vascular resistence w/o obvious cause. Dx can be made only after other etiologies of pulm
htn have been excluded
women>ment 1.7:1
average survival from time of dx is 2-3 yrs. occasional pt live longer than 10 yr
ref: Harrison's 12th ed p.1087

1995
Regarding thrombolytic agents such as tissue plasminogen activator (tPA):
31. bleeding complications are rare
32. urokinase is prepared from cultured human kidney cells
33. bleeding complications within the brain are more common in patients with
hypertension
34. tPA is useless in a thrombus which has been present for 14 weeks
35. tPA is more effective in activating plasminogen which is bound to fibrin (wording???
- this was a true statement on the test)
*

Answer: 31. false 32. true 33. ??? 34. ???true 35. true
urokinase is from human kidney cell culture
Incidence of major bleeding complications is no higher than for heparin but bleed
ing from puncture sight, trauma or recent wounds is more likely. tPA trials, hematoma at
site was common, GI bleed 6% with tPA, and 10% with streptokinase (p. 624)
tPA has high affinity for fibrin and activates fibrin - bound plasminogen to
plasmin to a greater extent than it activates plasminogen.
ref: DE6 by AMA p.621-624
clear contraindication to thrombolytic therapy is marked HTN 180/100., stroke
within 2 wks.
ref.: Harrison's 12ed, p. 956
Fibrin clot is not soluble. Fibrin monomers (which are cross-linked to form the
fibrin clot) are soluble.??At 14 wks, the clot is most likely going to be mostly organized
fibrin and thromblytics won't be effective at this point.

1995
Regarding abdominal interventional procedures:
36. a catheter draining an abscess should be removed immediately after drainage stops
37. manipulation of the catheter can result in sepsis and disseminated intravascular
coagulation
38. the ideal location for puncture of the biliary tree is centrally within the right hepatic
duct from a right lateral approach
39. abdominal abscess drainage catheters should always be placed to suction
*

Answer: 36. false 37. true 38. false ( want peripheral) 39. false
PTC can be performed either ant. or laterally. Anterior approach has increased
radiation to hands. Lateral is used more frequently to access the rt or lt ducts.
Puncture of the biliary tree should be peripheral as central puncture poses
increased risk of bleeding because of the larger central portal and hepatic vasc. system.
Removal of drainage catheters depends on - amount and character of drainage, pt's
clinical status, decrease in abscess cavity, <20cc/day output, pus>>clear. When the
catheter is withdrawn, it's done gradually several cm/day.
Complications of catheter placement include MINOR: bacteremia, superficial skin
infection, minor bleed, and MAJOR complications: massive hemmorage, septicemia,
empyema, bowel perforation. Major complications occur <5% and death <1%.
There are two types of drainage catheters. Non-sump catheter which is put to
gravity drainage. Sump catheter which is put to low continuous suction. ( At HUP,
fellows are trained to put fistulous tracts to suction).
ref: Kadir, Interventional Rad, p. 576, 574

1995
Regarding a patient who is status post orthotopic liver transplant:
40. stenosis in the common bile duct on cholangiography indicates ischemia
41. extravasation on cholangiography indicates infarct
42. Doppler ultrasound of the common hepatic artery which shows no evidence of flow is
indicative of hepaic artery thrombosis
43. because CT scan is diagnostic of transplant rejection, biopsy is rarely indicated
44. transjugular biopsy of the liver is contraindicated in a patient with coagulopathy
*
Answer: 40. false (can have other etiologies) 41. false as worded but true if not at
anastomosis 42. ???false( suggests but does not indicate; may be low/slow flow)
43. false 44. false

Indications for transjugular bx are usually contraindications for percutaneous bx.

Indications include: coagulopathy, significant ascites, benign and vascular liver tumors,
obesity, failed perc, amyloid, concomitant dx procedure from venous approach, peliosis
hepatitis.
ref Kadir, Interventional Rad, p.109
Clinical presentation of vascular insult post txp include nonanastomotic bile
leaks, septicemia, hepatic dysfuntion, hepatic ischemia. p. 2070.
On US, patency of flow is easier to dx than abscence. ID obstruction: echogenic
thrombus, turbulence, high velocity is partial obstruction, secondary parenchymal or
biliary abnormalities can provide corroborative data. Can have slow or low flow. Need
low freq doppler, low wall filters.
Biliary obstruction is 2x as common as bile leak.Hepatic art. thrombosis
predisposes to nonasnastomotic biliary strictures and leaks. causes of biliary obsruction
include, infection ,rejection, ischemia, recurrence of sclerosing cholangitis or malignancy,
mucoceles of the cystic duct. Multiple biliary stricures are secondary to hepatic arterial
supply compromise or recurrent sclerosing cholangitis.
Value of rad. examinations in dx of acute or chronic rejection or infection is less
clear. Findings of rejection primarily reflect edema, lymphedema and cellular infiltrate
which can also be seen in viral infection ,kpreservation injury, ischemia, cholangitis,
chronic rejection.
ref ; Gore, Levine, Laufer p. 2070-2072

1994, 1992, 1989

A catheter can be inserted from the IVC into the aorta without going through the left
ventricle in which of the following conditions?
45. truncus arteriosus
46. tetralogy of Fallot
47. transposition
48. hypoplastic left heart
49. DORV
*

Answer: 45. True 46. True 47. True (best answer if this question is not T/F)
48. False 49. True

The central anatomic feature of hypoplastic left heart syndrome is serve aortic
valve hypoplasia or, more often, aortic valve atresia. As a consequence of limited
outflow, the left ventricle develops abnormally and is hypoplastic or virtually absent.
There is associated mitral valve hypoplasia or atresia. 25% of children have either
double-outlet right ventricle with aortic valve atresia and left ventricular hypoplasia or
complete common atrioventricular canal malaligned over the right ventricle and
associated left ventricular hypoplasia and aortic valve atresia with or without double-
outlet right ventricle. Systemic blood flow is provided virtually in its entirety from the
right ventricle through a patent ductus arteriosus (therefore, the neonate needs a
continuous infusion of prostaglandin E1 to maintain patency).
Hypoplastic left heart syndrome (underdevelopment of the left side of the heart) is
secondary to severe combined aortic valve and mitral valve atresia or mild stenosis of
both or isolated severe atresia of one or the other or hypoplasia of the ascending and
transverse aorta. Nevertheless, the catheter will travel from the IVC through the right
atrium through the patent foramen ovale through the left atrium through the left ventricle
and on to the aorta.
In transposition of the great vessels, the catheter travels from the IVC to the right
atrium through the right ventricle and into the aorta. The classic chest X-ray description
is "egg on a string." due to overlap of the aorta and pulmonary artery and an ovoid,
malpositioned heart. If there has been congenital "correction, the description is a
"waterfall" appearance.
In truncus arteriosus (single great vessel drains both ventricles and supplies
systemic, pulmonary, and coronary circulation) the catheter travels the same route as in
transposition.
In double outlet right ventricle, the catheter leaving the right ventricle may go into
the pulmonary artery or the aorta - it doesn't need to go through the left ventricle to get to
the aorta.
Since there is an overriding aorta in tetralogy of Fallot, the catheter leaving the
right ventricle may go into either the stenotic pulmonary artery or into the overriding
aorta. Tetralogy of Fallot consists of:
1. infundibular pulmonic stenosis
2. right ventricular hypertrophy
3. a large membranous VSD
4. an aortic arch which straddles the VSD
The degree of pulmonic stenosis affects the amount of shunting. Chest radiographs
reveal the classic "boot-shaped" heart (coeur-en-sabot), which is caused by the prominent,
hypertrophied right ventricle. In 25% of patients there is a right aortic arch, which
typically has mirror-image branching.
*

1994
Causes of pulmonary edema in the immediate neonatal period include:
50. cor triatriatum
51. TAPVR below the diaphragm
52. hypoplastic left heart
53. tricuspid atresia
54. transposition
*
Answer: 50. True 51. True 52. True 53. False 54. False
Reference: Dahnert, Gedgaudas
*

1994
Regarding embolization:
55. small particles are used to prevent tissue necrosis
56. coils are used in diverticular disease
57. coil use and permanent occlusion of varicoceles is desirable
58. the goal in treating AVMs is to embolize the feeding arteries
59. in bronchial artery occlusion coil embolization is used instead of particles because the
particles are too large
*

Answer: 55. False 56. False 57. True 58. False 59. False

Smaller particles occlude the capillary bed, therefore are more likely to produce
infarction and necrosis.
Coils can be used in diverticular hemorrhage but usually aren't. It is better to use
a temporary agent like gelfoam pledgets since diverticular hemorrhage at the same site
rarely recurs.
Coils are used for varicoceles because permanent occlusion is desired (make sure
to block the front door and the back door!)
The nidus of the AVM must be treated with particles, alcohol, or glue. If you just
treat the feeding arteries, they will recur.
The issue regarding bronchial embolization is not whether particles are too large
(they aren't) - it is that you don't want to use particles that are too small and this cause
occlusion at the capillary level and subsequent infarction and death of tissues. Dr.
Pentecost says particles should always be used for bronchial embolization due to
collateral circulation. Permanent occlusion is not desired; therefore, avoid coils.
*

1991, 1988
Regarding peripheral angioplasty:
60. common iliac artery angioplasty is initially successful in greater than 90% of cases
61. balloon size considerations are made based on the diameter of the stenosis
62. the major complication is intimal dissection
63. anticipated 3 year patency is approximately 30% in femoropopliteal atheromatous
disease
*

Answer: 60. True 61. False 62. False 63. False

In percutaneous transluminal angioplasty (PTA), one hopes to create a

"controlled" injury to the wall of a stenotic artery. The fracture may be superficial and
penetrate only through an atherosclerotic plaque, or it may extend to involve the intima
and media. The degree of penetration appears to be related to the incidence of restenosis;
deeper tears elicit a more vigorous hyperplastic response.
The result of PTA can be immediately assessed by changes in the patient's
symptoms and measurement of pressure gradients before and after treatment. Adjuvant
administration of a vasodilator is often necessary to realize the full impact of a lesion. A
systolic gradient of greater than 15% or a residual stenosis of greater than 30% is thought
to be a significant risk for restenosis.

Complications occur in 7-12%. The major complications are thrombosis,

hematoma, and distal emboli. Controlled intimal tear is desired with angioplasty.
Chose balloon size based on the size of the native vessel.

Technical success has been reported in nearly 90% of femoropopliteal

angioplasties. The patency at both 2- and 5-year follow-up is 67%. Therefore, following
uncomplicated treatment, the patient can anticipate a 3-year patency of around 70% (in
the iliac artery, the number is closer to 60%).
Initial technical success rates for PTA of femoropopliteal atherosclerotic lesions
range from 90-95%. The type of lesion (stenosis or occlusion) and indication for
procedure (claudication or limb salvage) are two factors important in determining
successful outcomes soon (1 month) after PTA. However, angiographic runoff and type
of lesion are more significant factors for predicting long-term success.
Therefore, in patients with femoropopliteal atheromatous disease, long-term
success rates are optimal when the patient presents with claudication, focal stenosis, and
good distal runoff. As these parameters change for the worse, the long-term success of
PTA is diminished, and surgical revascularization offers improved long-term success
rates. PTA would be an option for those patients for whom there is a limited life
expectancy, a high surgical risk, or insufficient bypass material.
An important limitation of PTA is post-PTA restenosis. One-third of
atherosclerotic small- to medium-sized arteries will restenose in 1 year, though most of
these respond well to a second dilatation. Restenosis following PTA can be divided into
three types: acute, early, and late. Acute failures occur during or immediately following
PTA, and are the result of dissection, elastic recoil, and/or spasm, which may be
complicated by thrombosis. Endovascular stenting and thermal welding are currently
being investigated as therapies for dissection. Spasm and thrombosis are treated
intravenously with nitroglycerin and/or nifedipine, and heparin and/or urokinase,
respectively.
Early stenosis occurs between 1 month and 1 year following PTA. It is thought to
be caused by a fibrocellular response by myocytes which are exposed as the intima and
media are injured during PTA.
Late restenosis, occurring more than 1 year after PTA, is most often due to
progression of the patient's underlying atherosclerotic disease.

References: Becker, Radiology 170:921-940, 1989; Johnston, Radiology 183:767-771,

1992
*

1991
Peripheral vasodilation is seen with:
64. epinephrine
65. tolazoline
66. papaverine
67. aspirin
*
Answer: 64. False 65. True (=priscoline) 66. True 67. False

1994, 1989
Which of the following drugs can be used to treat arterial spasm induced during
angioplasty?
68. papaverine
69. nitroglycerin
70. tolazoline (priscoline)
71. lidocaine
*

Answer: 68. False 69. True 70. True 71. True

Nitroglycerin, a direct smooth muscle relaxant, is probably the best answer (Duke
review book). The biological half-life is short.
Alpha adrenergic blockers, such as tolazoline (priscoline) may also be used. Its
half-life is several hours.
Calcium channel blockers such as nifedipine (SL) can also be used.
Kirks says peri-arterial injections of lidocaine around the artery puncture site can
reduce local spasm.
Papaverine, which is a direct smooth muscle relaxant, similar to nitroglycerine,
also could be used. However, it is rarely used in reaction to spasm because of its long
biological half-life (several hours).
Reference: Kadir, Current Practice of Interventional Radiology, 1991, pp. 370-372
*

1991
Renin:
72. causes vasoconstriction
73. is formed when standing erect
*

Answer: 72. True (through angiotensin) 73. True

 Renin is a proteolytic enzyme that is synthesized, stored, and secreted mainly in
the kidney, but also in brain and blood vessel walls. Renin cleaves angiotensinogen to
produce angiotensin I. Renin is secreted by the granular cells of the JGA in response to
reductions in renal perfusion pressure or in effective circulating volume. The release of
renin is stimulated by lowering the blood pressure, assumption of the erect posture, salt
depletion, beta-adrenergic or CNS stimulation, and certain prostaglandins. Its plasma
half-life is around 15 minutes.
Reference: Cecil 1988, p. 278, 503, 1345
*

1991
Angiotensin II:
74. is formed in the lung
75. causes thirst
76. is a stimulus to aldosterone secretion
*

Answer: 74. True 75. True 76. True

Angiotensin II is formed in the lung by proteolysis with angiotensin converting
enzyme. Its half-life is 1-2 minutes. It has three major effects on volume conservation:
1. It is a potent pressor agent. It has direct action on arterioles.
2. It is the major stimulus to aldosterone secretion and consequently is a key factor
modultating renal sodium conservation.
3. The angiotensin II formed in the CNS is a potent stimulus to thirst.
Reference: Cecil 1988, p. 530, 1345
*

1991
Major complications of aortic aneurysm include:
77. dissection
78. perforation
79. intimal tear
80. clot
81. distal embolization
*

Answer: 77. False 78. True (MAJOR) 79. False 80. True 81. True

1994
Patients with aortic stenosis have:
82. cerebral emboli
83. angina
84. left ventricular dilatation
85. aortic knob prominence
86. increased systolic pressure in the left ventricle
*

Answer: 82. False 83. True 84. True (but occurs late) 85. True 86. True

Angina occurs secondary to LVH and subendocardial ischemia and infarcts. The
classic triad is angina, syncope, and dyspnea.
Left ventricular dilatation can occur as a late complication (LV failure).
Post-stenotic dilatation of the aorta can occur (ascending aorta). ???knob
Harrison's makes no mention of cerebral emboli. Left ventricular pressures are
probably increased.
Reference: W. Miller, Sr.
*

1994, 1991
On apical lordotic views of the chest:
87. there is increased transverse diameter of the heart
88. the aorta is more prominent relative to the pulmonary artery
89. the pulmonary valve is seen en face
90. there is elevation of the cardiac apex
91. the right atrial contour appears more curvilinear
*
Reference: W. Miller, Sr.
*
Answer: 87. True 88. True 89. True 90. True 91. True

1994
Regarding cardiac surgery:
92. mitral annuloplasty reverses the effect of calcific mitral stenosis
93. coronary ostial markers are not necessary when the coronary ostia are occluded
94. in restrictive VSD, the patches are on the high pressure left ventricular side
95. the Jantene or the switch operation for transposition involves switching of the venous
inflow to the atria
*

Answer: 92. False 93. False 94. False 95. False

Mitral annuloplasty is not used for MS. Mitral stenosis is treated with
cimmussurotomy of the valve or replacement. Annuloplasty is used for mitral
regurgitation.
Coronary ostial markers are used to mark the site of bypass grafts (for future
catheterizations), not to mark native coronaries.
VSDs are usually approached through the low pressure right ventricle and the
patch is on the right ventricle side.
 The Jantene procedure is an arterial switch procedure with reimplantation of the
coronaries. The Mustard procedure uses an intra-atrial baffle to redirect venous return.
*

1994
Regarding common AV canal:
96. the tricuspid valve could be normal
97. septum primum is absent
98. the gooseneck deformity is due to a hypertrophied ventricular septum
99. tricuspid valve is posterior to the mitral valve
100. there is a supracristal VSD
*

Answer: 96. True 97. True 98. False 99. False 100. False

In partial AV canal (a minor variant) there may be only an ostium primum ASD
and a mitral valve cleft and the tricuspid valve may be normal.
The septum primum is absent, giving an ostium primum ASD.
The gooseneck results from downward attachment of the anterior mitral valve
leaflet to the lower margin of the endocardial cushion defect.
The tricuspid valve is not posterior to the mitral valve.
There is a membranous VSD, not a supracristal defect.
*

1991, 1988
Regarding portosystemic collaterals:
101. may involve the retroperitoneum
102. never seen in normal people
103. may go from the coronary vein to the IVC
104. may involve the IMA to the iliac artery
*
In c., the coronary vein drains above the diaphragm, into the azygous vein and
very infrequently into the IVC.
*
Answer: 101. True 102 False??? 103. False 104. False

1992
Which of the following can cause life-threatening hemoptysis?
105. cystic fibrosis
106. pulmonary AVM
107. Scimitar syndrome
108. sequestration
109. TB
*
Hemoptysis in CF is associated with bronchiectasis and may be treated with
bronchial artery embolization.
In TB there may be persistent cough which may be mildly productive and can
occasionally be associated with hemoptysis. There can also be erosion into the aorta. (J.
Aronchick) Tb is associated with Rasmusen's aneurysm which can bleed. (AFIP notes,
1995)
*
Answer: 105. True 106. True? 107. True? 108. False 109. True

1993
The following can cause microaneurysms in the renal artery:
110. Lupus
111. Takayasu's
112 Wegener's
113. IV amphetamine abuse
114. polyarteritis nodosa
*
Reference: Dahnert, p. 434
*
Answer: 110. True 111. False (large artery disease) 112. True 113. True 114.
True

1993
Calcifications of the mitral valve annulus ?? are associated with:
115. calcification of the aortic valve annulus
116. often seen in elderly patients
117. associated with mitral stenosis
118. associated with rheumatic heart disease
*
Calcification of the aortic valve nearly always signifies significant aortic stenosis.
The most common symptoms are angina (50-70%), CHF, and syncope.
Although calcification commonly develops in the mitral valves in the elderly
(there is not a similar annulus to calcify), the incidence of significant valvular disease is
quite low. When mitral valve calcification is present in known rheumatic heart disease,
there is no correlation with the degree of stenosis.
*
Answer: 115. False 116. True 117. False 118. False (Ca++ of leaflets, not
annulus)

1992
Regarding aortic trauma:
119. typically involves only the intima
120. most occur at the ligamentum arteriosum
121. when supravalvular, death is due to acute aortic insufficiency
122. invariably fatal with complete transection of the intima and media
*

Answer: 119. False 120. True 121. False 122. False

Aortic trauma generally involves complete transection (80%). Most tears occur at
the ligamentum arteriosum with the second-most common site being the ascending aorta.
Death is commonly secondary to pericardial tamponade or exsanguination, not acute AI.
Death is the rule if untreated, but occasionally (2-5%) tears may be contained by the
adventitia, resulting in pseudoaneurysm formation. This generally happens in young,
otherwise healthy patients.
References: Elliot, p. 309; Higgins, p. 195
*

1992
Regarding cardiac MR:
123. turbulence on gradient echo images results in signal loss
124. images can be obtained on the basis of flow direction and velocity
125. the pericardium can be low signal because of fibrous tissue
126. phosphorous spectroscopy is useful to map the extent of a myocardial infarction
*
Images can be obtained on the basis of flow direction and velocity through the use
of phase contrast technique.
The pericardium (or any fibrous tissue) may exhibit low signal intensity.
Phosphorous spectroscopy may help to map the extent of MI; phosphorous
spectroscopy does provide information about the metabolic state of cells.
*
Answer: 123. True 124. True 125. True 126. True

1994, 1992
Contraindications to MR include:
127. hip prosthesis
128. Starr-Edwards valve
129. demand pacemaker
130. coronary ostial marker
131. cochlear implant
132. metallic foreign body in eye
133. atrial fibrillation
134. cardiac surgery within the past 7 days
135. ?prosthetic mitral valve?
*
Answer: 127. False 128. True 129. True 130. False 131. True 132. True 133.
False 134. True??? 135. ???

Contraindications to MR include Starr-Edwards valve, demand pacemaker, and

cochlear implant, and metallic foreign body in the eye (usually from welding without a
protective mask).
Starr-Edwards valves are controversial - some models have been shown to deflect
at high field strengths, others have not. Some which have deflected are felt to be subject
to higher deflection forces by the beating heart. The published position is that all valves
are safe except for Type I of Starr-Edwards.
Pacemakers may move, may undergo programming changes, or may conduct
current while under the influence of strong magnetic fields.
Hip prostheses and coronary ostial markers do not deflect and hence are safe.
Reference: Atlas pp. 91-101.
*

1994 ITE
Concerning hypoplastic left heart syndrome:
136. most infants are symptomatic within 6 days after delivery
137. the heart is usually small
138. pulmonary undercirculation is generally present
139. the papillary muscles are underdeveloped
140. angiography is required for diagnosis
*

Answer: 136. True 137. false 138. false 139. true 140.false

Hypoplastic left heart syndrome generally becomes symptomatic within 12-24

hours after birth.
left sided structures are underdeveloped. Papillary muscles go to the mitral valve.
The left ventricle is usually underdeveloped in size and the mitral valve and ring are
small.
The size of the heart is normal to mildly enlarged.
Pulm. vascularity is variable. Not uncommon to have pulm. edema but can have
near normal CXR.
Cath is no longer necessary because Echo can establish the dx.
ref: Kirks p.505
*

1992 ITE
Concerning tricuspid atresia:
141. obstruction to pulmonary flow is caused by restrictive VSD
142. when associated with transposition of the great arteries, pulmonary overcirculation is
present
143. fibrous continuity is present between the mitral valve and the aortic valve
144. increased pulmonary resistance is mandatory for a Fontan operation
145. indomethacin (Indocin) is administered before surgery if pulmonary blood flow is
inadequate
*

Answer: 141. true 142. ??true 143. ??? 144. false 145.false

Intrapulmonary vasculature may be present in one of four ways:

1. normal
2. decreased, as in right-to-left shunt, pt will be cyanotic, DDX "PUPETT"
P = pulmonary stenosis with TA or TOGA or DORV or Single Ventricle
U = Uhl's Dz (large thin walled hypoparistaltic RV)
P = Pulmonic Atresia
E = Ebstein's Anomaly (deformed tricuspid valve and atrialization of RV)
T = Tetrology of Fallot (TOF) with pulmonic atresia (psuedotruncus)
T = Tricuspid atresia (TA) with pulmonic stenosis

- seen in tetralogy of Fallot, tricuspid atresia, and at times in transposition of the great
vessels
3. arterial engorgement, as in left-to-right shunt

without cyanosis DDX = "PAVES" and others

P= PDA
A = ASD
V = VSD
E = ECD
S= Systemic AVF

with cyanosis DDX = "D 5T's"

D= DORV without Pumonic stenosis (PS)
T = TOGA (D-Loop) without PS
T= Truncus arteriosis = single large vessel leaving the heart
T= TA without PS
T = Taussing Bing Complex = partial transposition (a.k.a. DORV type II) Aorta
to RV, PA from RV and LV with a supracristal VSD
T = Total Anom. Pulmonary VenousReturn (TAPVR)
S = single atrium, single ventricle

- generally, a left-to-right shunt of at least two to one is required

4. lymphatic and pulmonary venous congestion

- obstructing lesions on the left side of the heart
- failure of the left ventricle

Frequently, a VSD is present that may progressively decrease in size, reducing

pulm blood flow.
Fontan is performed in older pt. Pt must have good LV function, no evidence of
pulmonary vascular obstructive disease.
In newborns w severe cyanosis, pulmonary blood flow may be dependent on PDA.
Vasodilatation of PDA with prostaglandin increases pulm blood flow. Indomethicin
closes PDA.
ref: Kirks, p. 457-459

1994 ITE
Concerning a patent ductus arteriosus:
146. as an isolated defect, it accounts for 20% of all congenital heart disorders
147. there is a high incidence in low-birth-weight infants
148. there is right atrial enlargement on chest radiography
149. prostaglandin synthetase inhibitors dilate an isolated ductus arteriosus
150. the incidence is higher in babies born at high altitudes
*
Answer: 146. false (10%; #1 = bicuspid aortic valve) 147. true (and maternal rubella)
148. False (nl early, eventual enlarged LA, LV, aorta, engorged pulm vasc.) 149. False
(indomethacin - inhibits PGE1 which is a potent dilator of the duct , works in 60% of
infants) 150. true (also female > male)

In patent ductus arteriosus, blood from the proximal aorta goes through the patent
ductus arteriosus to the pulmonary arteries - thus blood recirculates through the left heart
(enlarging the left atrium and ventricle).
Incidence of PDA is 1:3000. The frequency of CHD is in order : Bicuspid Ao
valve 2% population and 30% of CHD; VSD= 25% congenital heart disease; Tetrology
(3rd most common)= 11% p.454; then PDA, ASD, pulm valve stenosis, coarct.... p.
441
Wiessleder's Diag Rad Primer states that ASD is most common, VSD is 2nd.

There is a high incidence of PDA in low birth wt infants. 43% of <1750gm infants
and 80% of <1200g infants have PDA.
There is a higher incidence of PDA in trisomy 21, 18 , rubella, born at high
altitude, and infants with birth asphyxia.
Prostaglandin E1 and E2 dilate an isolated ductus arteriosus. Prostaglandin
Inhibitors , indomethicin, constrict the ductus arteriosus and causes closure.
Small PDA have normal CXR. Mod to large PDA, increased vascularity,
enlarged left main pulm artery, pulm veins, left atrium, left ventricle, and transverse
portion of Ao arch because increased blood flow to these areas.
ref: Kirks, P. 448-9, 441, 454.
*

1992 ITE
Concerning dextrotransposition of the great arteries:
151. there is atrioventricular concordance and ventriculoarterial discordance
152. it has a strong female predominance
153. fibrous continuity is present between the pulmonary and mitral valves
154. the aortic arch is left-sided in greater than 80% of the cases
155. anterior, superior, and right-sided position of the aortic valve are characteristic
*

Answer: 151. true 152. false 153. ??? 154. false 155.true

Complete transposition is also known as d-transpostion. Incidence is 19-

33:100,000 live virths with strong male predominance.
discordant ventricular arterial connection.. In d-transposition, the rt atrium faces
systemic vascular resistence.
CXR-- both the aorta and the main pulmonary artery are rightward in position.
Figure 5-37 p. 465 , shows the Ao valve to be anterior and the right of the pulm valve.In a
normal heart the pulm valve is superior to the Ao valve. The pulmonary valve is superior
to the Ao because of the presence of the infundibulum. When there is transposition of the
great vessels the right ventricular outflow tract ,aka infundibulum, connects to the Ao
and Aoric valve. So the AoV is supeior in position to the pulmonary valve. ref: Dr. Ken
Fellows lecture on congenital heart disease- conf 6/24/96
ref; Kirks
*

1993
Which of the following cause decreased PaO2 in the blood?
156. intralobar sequestration
157. pulmonary AVM
158. PDA
*
Answer: 156. False 157. True 158. False

1988
Which of the following are true if there is SVC obstruction below its junction with the
azygous vein?
159. there is retrograde flow in the azygous
160. there is anterograde flow in the hemiazygous vein
161. there are varices in the inferior esophagus
162. there is increased flow in the IVC
*
 Downhill varices usually involve the proximal half of the esophagus
*
Answer: 159. True 160. False 161. False 162. True

1988
Which of the following cause severe cardiomegaly in the newborn?
163. transposition
164. tricuspid atresia
165. peripheral AVM
166. pulmonary stenosis with intact interventricular septum
*
Answer: 163. False 164. False 165. True 166. True

1989
Regarding patent ductus arteriosus:
167. calcification means pulmonary hypertension
168. indomethacin closes the patent ductus arteriosus
169. prostaglandins close the patent ductus arteriosus
170. associated with increased pulse pressure in the aorta
*
It is not too uncommon to have calcification in the ductus after ductal closure.
This normally disappears over a few years in a child. Indomethacin blocks the effects of
prostaglandins which keep the patent ductus arteriosus open.
*
Answer: 167. False 168. True 169. False 170. True

1989
Regarding IHSS:
171. there is increased left ventricular ejection fraction
172. there is increased end diastolic volume in the left ventricle
173. there is anterior motion of both leaflets of the mitral valve
*
IHSS is secondary to assymetric septal hypertrophy with the septal wall being
approximately 1.3 times thicker than the free wall of the left ventricle. Also, there is
anterior motion of the anterior leaflet of the mitral valve, but not of both leaflets. Since
stroke volume remains within normal limits and there is decreased end diastolic volume,
the ejection fraction would increase. The left ventricle hypertrophies, but there should
not be increased end diastolic volume unless failure has superceded.
*
Answer: 171. True 172. False 173. False
1989
Regarding left atrial myxoma:
174. it most commonly arises from the mitral valve
175. it has increased echogenicity on ultrasound
176. it can embolize
177. it mimics aortic stenosis clinically
*
Left atrial myxomas most commonly arise from the septal wall of the left
ventricle. Due to the systolic murmur and episodes of blackouts, myxomas can mimic
aortic stenosis clinically.
*
Answer: 174. False 175. True 176. True 177. True

1989
Which of the following have valves?
178. cephalic veins
179. spermatic veins
180. coronary sinus veins
181. pulmonary veins
182. portal vein
*
Both the superficial and deep cephalic veins are valveless.
The right spermatic vein enters the IVC and the left spermatic vein enters the left
renal vein. These veins have valves, but they are often imperfect and scantly organized.
The thesbian valve is a valve within the coronary sinus as the coronary terminates
in the right atrium. The coronary sinus is at the posterior part of the left AV groove. All
veins joining the coronary sinus except the oblique vein have valves.
The pulmonary veins are valveless. There are also no valves within the portal
vein or its branches.
*
Answer: 178. False 179. True 180. True 181. False 182. False

1994
Associated with ASD:
183. enlarged LA
184. enlarged aorta
185. enlarged PA
*
Answer: 183. False 184. False 185. True

1994
Coronary artery calcification:
186. is always indicative of atherosclerosis, regardless of age
187. is more accurate than stress or EKG testing
188. is found in high grade stenosis
189. is in equal frequencies in all coronary arteries
190. is a contraindication to angioplasty
*
Coronary artery calcification is more common in the LAD and left main.
Coronary artery calcification is more sensitive for atherosclerotic disease
compared to nuclear medicine imaging and EKG.
Reference: G. Holland
*
Answer: 186. True 187. True 188. False 189. False 190. False
ITE
Concerning single ventricle:
191. right ventricular type is the most common
192. fibrous continuity is present between the A-V valves and the semilunar valves
193. the septal notch noted on chest X-ray is formed by the septum between the main
chamber and the outlet chamber
194. the great arteries are usually normally related
195. it is one of the malformations occuring with the asplenia syndrome
*
Answer: 191. false 192. ??? 193. ??? false 194. false 195. True

Hypoplastic left heart sydrome is a spectrum fo cardiac anomalies of varying

degrees of under development of the Ao, Ao valve, LV, MV, LA. Accounts for 10% of
infants dying with structural congenital heart lesions.p.504
Asplenia is associated with sever cyanotic complex congenital heart disease
characterized by decreased pulmonary vascularity.p.435.
Most commonly, the right ventricle is underdeveloped. Anomalies associated
with with monoventricle include transposition, VSD, venous anomalies, and lt or rt sided
isomerism. single ventricle is rare 1% and is a malformation in which the septum is
missing.p. 473-4
ref, Kirks, p. 504, 435, 473-4

1991
Which of the following can give volume overload but normal PCWP in a child?
196. hypoplastic left heart
197. pulmonary atresia with intact septum
198. tricuspid atresia with small VSD
199. tetralogy of Fallot
200.Wilson- Mikity
*

Answer: 196. false 197. true 198. true 199. true 200. ???false
 Pulmonary venous HTN will give increased PCWP. On Table 5-10 in Kirks, of
lesions causing pulmonary venous HTN, only hypoplastic left heart is listed. Tetrology,
tricuspic atresia, pulmonary atresia have decreased pulmonary blood flow.
ref: Kirks, p.442
Wilson-Mikity syndrome was first described, it was when ventilator therapy had
just been invented. So pt with this disease had to struggle to breathe on their own.
stronger infants would breath but whould get uneven alveolar aeration and bubbly lungs
that look like bronchopulmonary dysplasia. Rare disease now because of ventilators. It is
pulmonary damage secondary to room air.
ref.Kirks, p. 608. AJR, April 1996 p. 917- Swischuk
? Even though these pt w/ Wilson-mikity have a primary pulm. problem, if they are
volume overload, would expect pulm edema/ CHF; therefore, giving increased PCWP

Angiography/Interventional/Congenital Heart Disease

Select the single best answer:

1995
1. Regarding the popliteal artery entrapment syndrome, at angiography, if initial images
are normal, to further test for presence of this condition, which one of the following
maneuvers should be perfomed:
a. extreme inversion of the foot
b. plantar flexion of the foot
c. flex the knee
d. inflate a blood pressure cuff on the calf
e. elevate the leg

Answer: b
If the arteriogram is normal, should repeat with the foot in dorsal / plantar flexion which
results in extrinsic compression of the pop artery in pt with entrapment.
ref. Kadir Dx Rad p. 303

1994
2. A 7 y/o has inspiratory and expiratory stridor. There is hoarseness and dyspnea when
flexing the neck towards the chest. The most likely diagnosis is:
a. pulmonary sling
b. double aortic arch
c. cervical aortic arch
d. left arch with aberrant right subclavian
*
Answer: a or b

1994
3. Bleeding from a Mallory Weiss tear is usually from:
a. left gastric vein
b. azygous vein
c. gastroepiploic artery
d. inferior esophageal artery
*
a. left gastric vein

1995
4. A 45 y/o male is immediately S/P aortography utilizing a right axillary approach. In
the recovery area he complains of right forearm and hand numbness and tingling. He has
axillary pain. Pulses are intact. Which one of the following is the most likely cause of
the above findings?
a. dissection of the axillary artery
b. hemorrhage from the arterial puncture site
c. occlusion of the axillary artery
d. axillary artery spasm
*
Answer: b. hemorrhage from the arterial puncture site

1995
5. Which agents should be used in the percutaneous embolization of a Blalock-Taussig
shunt?
a. Ivalon particles
b. gelfoam
c. autologous clot
d. glue
e. coils
*
Ivalon is polyvinyl alcohol
Answer: ???
e . coils

1995
6. A 50 y/o male is S/P single-vessel CABG. Pre-surgery cardiac catheterization at that
time revealed a non-right-dominant coronary circulation with significant occlusion of the
RCA. 5 years later the patient has chest pain and undergoes stress thallium imaging
which reverse a large reversible posterior wall defect. Which of the following is most
likely?
a. ischemia in the right coronary artery distribution secondary to graft occlusion
b. ischemia in the right coronary artery distribution secondary to stenosis in the native
artery distal to the graft insertion site
c. occlusion of the graft
d. stenosis of the left anterior descending artery resulting in inferior ischemia
e. ???
*
lt circumflex feeds posterior left ventricle. RCA feeds the inferior and posterior
septal segments. Decreased activity in the apical and posterior segments aren't reliably
correlated with disease of any vessel. Dominance is what supplies the crux and the
posterior descending artery.
Ref: Danhert
In a LCA dominant system, very little contribution of the blood form the RCA to
the posterior wall of the LV. Posterior supply comes from the LCA as a continuation of
the enlarged circumflex branch. So the lesion has to be a L circumflex lesion.
ref: Clemente, anatomy. fig 198.

Answer: ???
The lesion is not a RCA lesion as it doesn't supply any to the posterior circulation
in this left dominant system. LAD stenosis would cause only inferior ischemia. The
lesion has to be LCA or Lt circ.

1995
7. Regarding percutaneous transluminal angioplasty, which of the following is associated
with the lowest success rate?
a. a single stenotic segment in the infrarenal abdominal aorta
b. a nonostial renal artery segment which is caused by fibromuscular dysplasia
c. stenosis in the superficial femoral artery 7 cm in length caused by atherosclerosis
d. a nonostial renal artery segment which is caused by atherosclerosis
e. a single short segment of 95% stenosis in the common iliac artery
*
In Aortic and iliac angioplasty, the intial success rate varied form 83-100%.
Usually greater success because the vessel is larger.
Carefully planned and appropriately conducted PTA is femoral arteries is
successful in over 96%. initially. Overall cumulative patency is 80% 1 yr, 70-75% 2 yr,
70% 3 yrs, 60% 5yrs. Long stenosis up to 10cm can also be treated although not ideal..
Long segment dilatation can have a high rate of sucess. p. 318., 312
Iliac artery stenosis PTA-- 94%success. Rates declined to apprx 80% over years.
p. 299
RAS secondary to fibromuscular dysplasia would expect 100% sucess post
angioplasty.Only slightly less benefit if stenosis were secondary to atherosclerotic
disease. failed 64% long term sucess for athersclerotic disease. 75% success for FMD. p
610.
reference: Kadir, Interventional Rad p. 318, 312, 299, 610
Answer: ???d?? strictly based on % verses ??c?? because of such a long segment.
1995
8. Regarding traumatic aortic dissection:
a. mortality from transection of the ascending aorta is usually secondary to acute aortic
insufficiency
b. untreated tears usually result in death from rupture and exsanguination
c. greater than 50% of the tears result in dissection of the descending aorta
d. the most common cause is lateral trauma to the chest
*

Answer: b
Ao lac results form sudden horzontal deceleration injuries usually with MVA.
Vertical decel injuries can also injure the Ao, usually the descending thoracic Ao.
If only Ao trauma, only 20% of these pt survive the initial episode. In 80% of pt,
the laceration is at the Ao isthmus just distal to the ligamentum arteriosum. 2nd most
frequent site is the prox ascending aorta. ref: Kirks p 151.
High velocity deceleration injury in MVA or from a fall with the victim landing
prone.
Ao rupture involves full thickness tear and pt exanguinate. 15-20% who survive
have partial tears with intact adventitia. Of the pt who survive to the hospital, 49%
exsanguinate w/in 1st 24hrs, 80% by 1st week, and 95% 4 months post injury.
Remaining 2-4% who survive may live a normal lifespan. The most common site is the
proximal descending Ao. Injuries at the root of the Ao, including those of the A valve are
usu acutely fatal with only 7% reaching the hospital.
Pathology of aortic injury of the pt who succumb at the time of injury is complete
tear in which the pt exsanguinates.
ref. Harris and Harris p. 536-7

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
1995
9. The finding on PA chest radiograph which is most sensitive for detection of aortic
transection following trauma:
a. apical pleural cap
b. fractures of the first three ribs
c. nasogastric tube deviated to the right
d. inferior deviation of the left mainstem bronchus
e. abnormal contour of the aortic knob
*
Superior mediastinal widening only signifies presence of mediastinal hematoma.
53% sensitive and 59% specific for Ao rupture.
 p. 550 Mirvis related apicla pleural cap to rupture but with a low degree
sensitivity and specificity. Mirvis reported that never saw apical pleural cap as a sole
indicator for ao rupture. Apical pleural cap is a sign of mediastinal hematoma.
Many plain radiograph signs of Ao rupture have been described bu none are
sensitive or specific. Some may be specific for mediastinal hematoma. Approximately
20% of pt with signs of mediastinal hematoma will have Ao rupture. p, 538 Therefor, the
most reliable signs of mediastinal hematoma are abnormal superior mediastinum, left
mediastinal sripe above the aortic arch, left apical pleural cap, abnormal right paratracheal
stripe.
NGT position may be either false positive or false negative. It is not a sign of Ao
rupture.
There is not pathologic basis of lt mainstem bronchial depression.
ref : Harris and Harris, p. 558, 538, 550.
Answer: ???a or e (most likely e)

1995
10. A patient with a known Mallory Weiss tear undergoes embolization of the left gastric
and gastroepiploic arteries with no effect. Bleeding is likely arising from which of the
following?
a. anterior superior pancreaticoduodenal artery
b. transverse pancreatic artery
c. hepatic artery
d. inferior phrenic artery
e. SMA
*
Usually lt gastric supplies the bleeding site 85% of the time. Can rarely be from
the short gastric arties from the splenic, or the left phrenic artery.
ref. Kadir, Interventional Rad p. 413
Answer: d

1995, 1993, 1990

11. Two days after orthopedic surgery for a hip replacement, an elderly man develops
thigh swelling. The most specific finding for the confirmation of acute deep venous
thrombosis is:
a. non-compressibility of the vein
b. echogenic thrombus within the vessel
c. tenderness over the vessel
d. non-augmentation of flow
e. venous stasis dermatitis
*

Answer: a. non-compressibility of the vein

None of the other possibilities have been shown to increase the sensitivity or specificity
for detecting DVT compared to compressibility
Reference: Mittelstadt, p. 1179
*

1992
12. Which of the following is the least likely to be embolized?
a. esophageal varices
b. hemorrhagic gastritis
c. Mallory-Weiss tear
d. bleeding duodenal ulcer
e. Boerhaave syndrome
f. gastric ulcer
*

Answer: b. hemorrhagic gastritis???or e, Boerhaave's ( needs to go to the OR

immediately and is unlikely to have time for angiographic embolization) .

Boerhaave syndrome is caused by severe vomiting, and patients develop

immediate and severe epigastric pain. Death often occurs unless the rupture is repaired.
This is rapidly fatal. Results in sepsis, mediastinitis, and shock if left untreated
surgically. (ref: Gore, Levine, Laufer) The tear almost always occurs along the left
posterior esophageal wall near the left diaphragmatic crus, usually resulting in a left
hydropneumothorax and pneumomediastinum. Gastrograffin should be used for the
esophagram, to minimize the risk of mediastinitis if there is extravasation.
Hemorrhagic gastritis is a diffuse process; therefore, it usually is not amenable to
embolization. Hemorrhagic gastritis is managed with intravenous vasopressin.
embolotherapy for Mallory Weiss is to control bleeding. Only embo if identify
the source of bleeding. Since it is a self healing lesion, non-permanent embolic material is
preferred. Embolize the left gastric .
The most common cause of gastric bleeding is acute hemorrhagic gastritis and
doesn't demonstrate focal contrast extravasation. To treat with embo, need to ID bleed
first. Only treat without ID bleed for DU. For Gastric bleeding, can treat with
embolization or vasopressin. Use vasopresion if prior hx of gastric surgery(increased
risk of necrosis) or CV disease or HTN. Usually the Lt gastric is embolized. Usually use
gelfoam.
Duodenal ulcer, embolize with gelfoam in GDA. Also asses the inferior
pancreatoduodenal artery.
Esophageal varices can be treated with a portacaval shunt or with coronary v
embolization with splenic artery occlusion. Embolize with Etoh, gelfoam , coils.
ref: Kadir, Interventional, p 394-423, 439
*

1992
13. Drainage of the glans penis: (best answer)
a. central vein
b. superficial dorsal vein
c. deep dorsal vein
*
The superficial dorsal vein drains the skin
Reference: Pollock, p. 479
*
Answer: c. deep dorsal vein

1993, 1991
14. In cirrhosis (patient with portal hypertension) on ultrasound, one must image the:
a. ligamentum teres
b. falciform ligament
c. coronary ligament
d. sinus venosis
e. ligamentum venosum
*

Answer: b. falciform ligament

The normal pressure in the portal vein is 5-10 mm Hg. When the pressure in the
portal vein is more than 5 mm Hg above IVC pressure, portal hypertension is present.
The periumbilical vein classically shunts blood from the left portal vein into the
periumbilical venous network. With a high-frequency (7.5 MHz) transducer, it is easily
seen sonographically beneath the skin near the umbilicus. It follows a vertical, right
paramedian course to enter the falciform ligament through the left lobe of the liver, where
it joins the left portal vein.
Reference: Rumack 1991, pp. 1131-1135
*

1995, 1991
15. That structure seen under the aortic knob:
a. left recurrent laryngeal nerve
b. vagus nerve
c. phrenic nerve
d. brachial plexus
*
Answer: a. recurrent laryngeal nerve

1991
16. The cause of acute flank pain in a patient with mitral stenosis and atrial-fibrillation is:
a. embolus to the renal artery
b. bradycardia
c. CVA
d. hypotensive ischemia to the gut
*
Answer: a. embolus to the renal artery

1991
17. On spin-echo cardiac gated MR of the heart, signal of the blood versus the
myocardium:
a. higher
b. isointense
c. lower
*
Answer: c. lower

1994
18. A 40 y/o man was in an MVA and hit the steering wheel with his chest. He has
multiple contusions and presents with chest pain and a holosystolic murmur. What is the
most likely cause?
a. aortic laceration
b. papillary muscle rupture
c. traumatic VSD
d. aortic valve rupture
*
Rupture of the chordae tendinae would give a holosystolic murmur, but this is
extremely uncommon.. A new murmur or changing murmur has been reported as a
clinical sign of aortic laceration.
*
Answer: a. aortic laceration

1991
19. In occluding a pulmonary AVM, one would use:
a. Gianturco coils
b. gelfoam
c. alcohol
d. autologous clot
*
For AVMs you can use coils.
*
Answer: a. Gianturco coils

1993, 1991
20. A left-sided SVC drains into the:
a. coronary sinus
b. left atrium
c. brachiocephalic vein
d. right atrium
e. space of Retzius
f. right superior vena cava
*
Answer: a. coronary sinus

1993
21. In order to have a 75% stenosis (area), the diameter of the vessel must be decreased
by:
a. 10%
b. 25%
c. 50%
d. 66.7%
e. 90%
*
The formula is Area =Pi(dia)2 , so the new area is 0.25 of the original and the new
diameter would be the square root of that value, which is 0.50 - therefore there has been
50% narrowing of the diameter.
*
Answer: c. 50%

1993
22. The most common cause of renal artery stenosis (renal hypertension) in a child:
a. Takayasu arteritis
b. neurofibromatosis
c. FMD
d. previous abdominal radiation
e. iatrogenic secondary to catheters in the umbilical artery
*

Answer: c. FMD

Others are rare in comparison

Reference: Barbaric, p.232
*

1994
23. On echocardiography, the four chamber view of the heart is best to diagnose which
one of the following anomalies?
a. coarctation of the aorta
b. DORV
c. common AV canal
d. high outlet VSD
*

Answer: c. common AV canal

Four chamber view is also called the subcostal view. It can only tell atrioventricular
connection defects. To look at areas such as the root of the aorta the transducer needs to
be rotated 90 degrees.
In coarctation of the aorta, there is extreme narrowing of a portion of the aorta,
usually just distal to the origin of the left subclavian artery. Impressions on the barium-
filled esophagus by the small aortic knob above the coarctation and the dilatation of the
aorta below the coarctation produce the classic reverse "3" sign. Notching of the ribs is a
valuable clue, and on occasion, the dilated and tortuous internal mammary artery may be
appreciated anteriorly on the lateral chest X-ray.
Reference: Gedgaudas, p. 93
*

1993, 1988
24. Which cardiac anomaly is most associated with Kawasaki's disease?
a. coronary artery aneurysm
b. PDA
c. pulmonary artery thrombosis
d. coronary artery thrombosis
e. aortitis
*

Answer: a. coronary artery aneurysm

Kawasaki's disease is also called mucocutaneous lymph node syndrome. It
presents with fever, rash, conjunctivitis, inflammation of the lips and oral cavity, cervical
adenopathy, myocarditis, and vasculitis of medium to large arteries. This leads to
coronary artery aneurysm in proximal portions of the right and left coronary arteries.
Coronary stenosis can also develop. The heart abnormalities can then lead to MI (1/3 of
which are asymptomatic). Therapy consists of IgG and ASA with CABG as needed.
EKG is the best screening test.
Reference: Kirks, p. 485
*

1993
25. All of the following could be associated with aortic insufficiency except:
a. anomalous origin of the left coronary artery
b. ankylosing spondylitis
c. Marfan's syndrome
d. sinus of Valsalva aneurysm
*

Answer: a. anomalous origin of the left coronary artery

Aortic insufficiency is associated with:

- cong. bicuspid valve - rheumatic endocarditis
- bacterial - cystic medial necrosis
- prosthesis - trauma
- hypertension - dilatation of annulus
- syphilis
- ank spon
- Reiter's
- RA
- Marfan's
*

1993
26. What is the interval for peak diastolic filing measured from the R peak?
a. 15 msec
b. 25 msec
c. 50 msec
d. 75 msec
e. 100 msec
*
Answer: ???

1993
27. What is the positive predictive value to giving a test dose of non-ionic contrast to
determine patients at risk for contrast reaction?
a. <5%
b. 10%
c. 20%
d. 30%
e. 50%
*
No information is available on test doses of non-ionic contrast. Test doses of
ionic contrast to determine risk of subsequent reaction with full dose ionics have been
unpredictable. (29/32 patients with no reaction to an ionic test dose died with a full dose
of ionic contrast (Lalli, 1980).)
 Of interest, a prior reaction to ionic contrast carries a 20% risk of subsequent
reaction to ionic contrast. A prior reaction to ionic contrast carries a 4% risk of
subsequent reaction to non-ionic contrast.
References: Dunnick 1991, pp. 85-87; M. Banner; Z. Haskel
*
Answer: don't know ???

1993
28. Which of the following tumors are not detected with venous sampling?
a. parathyroid adenoma
b. Graves' disease
c. pancreatic islet cell tumors
d. Cushing's disease
e. Conn's syndrome
*
Angiographic procedures exist for venous sampling of parathyroid disease,
pancreatic islet cell tumors, Cushing's disease and Conn's syndrome but there are plasma
detectable abnormalities in all these diseases (i.e., don't need sample from a selective
vein)
*
Answer: don't know???but likely Graves'

1993
29. Concerning tetralogy of Fallot without cyanosis:
a. pulmonary stenosis
b. overriding aorta
c. VSD
d. PDA
*
The presence of a PDA is why in the 1st 3-4 months of life, tetralogy of Fallot
patients are not cyanotic. Pulmonary stenosis, overriding aorta, and VSD are features of
tetralogy of Fallot with or without cyanosis. "Pink" tets have infundibular hypertrophy
and VSD and are 3% of all tetralogies.
Reference: Dahnert
*
Answer: d. PDA

1992, 1988
30. Myocardial ischemia/infarction with an aberrant left coronary artery is due to:
a. deoxygenated blood from the pulmonary arteries
b. "steal"
c. spasm/intermittent flow
d. small caliber of the vessel
e. abnormal distribution of the left coronary artery.
*
In aberrant left coronary artery, usually the entire left coronary artery arises from
the pulmonary artery (Blabd-White-Garland syndrome), but sometimes only a branch of
the left coronary arises from the pulmonary artery. Hemodynamic changes and injury
depend on collateral flow from normal coronary arteries. ??? Steal from right coronary
artery???
Reference: Swischuk, p. 289
Ischemic symptoms don't develop until the pulmonary artery pressures drop at
around 7 days old. The low pulmonary pressures preferentially drive blood to the lungs
away from the abberant coronary artery. Right coronary artery enlarges and feills the
LCA retrograde through coronary collaterals. But the blood in the LCA goes
preferentially into the low pressure pulmonary system creating a small l-to-rt shunt. The
main significance is the steal of blood from the left myocardium.
ref: Kirks p. 484
*
Answer: b. steal

1992
31. A 60 y/o male has shortness of breath and syncope when lying on left. Best exam:
a. echocardiography
b. cardiac catheterization
c. Doppler of the L carotid
d. selective right ventriculogram
e. selective left ventriculogram
*
A non-invasive study is first indicated. Cardiac tumors, such as atrial myxoma
may cause syncope through outflow obstruction. Signs and symptoms tend to be highly
dependent on position, intermittent, and sudden in onset.
Reference: Harrison's pp. 64-68 and 1004-1005
*
Answer: a. echocardiography

1992
32. Which artery supplies the AV node?
a. proximal segment of RCA
b. conus branch of RCA
c. distal RCA
d. circumflex
e. diagonal branches of LAD
*
 Usually, the vessels supplying the SA and AV node arise from branches of the
RCA distally. 20% of the time the vessel to the AV node is from the Left atrioventricular
branch off the circumflex branch of the LCA -- this is true in left dominant systems.
ref: Clemente ,fig 196- 199
Answer: c

1993
33. Pulmonary varix is seen with which of the following:
a. mitral stenosis
b. aortic stenosis
c. VSD
d. pulmonary outlet obstruction
*
Pulmonary varix is an abonrmal tortuosity and dilatation of the pulmonary vein
just before the entrance into the left atrium. It is congenital and associated with
pulmonary venous hypertension. It changes in size during the Valsalva and Mueller
manuevers.
Reference: Dahnert 1993, p. 323
*
Rarely congenital . associated with acquired heart disease, left atrial enlargement,
pulm venous HTN.
ref. AFIP notes 1995, Templeton L-9
Answer: a. mitral stenosis???

1988
34. Which of the following is the best way to diagnosis constrictive pericarditis?
a. pericardial calcifications
b. by catheter with typical pulse patterns in the right ventricle
c. fluoroscopy
d. small heart with ascites
*
By definition, constrictive pericarditis is a physiologic condition of impaired right
heart filling. This can be diagnosed interventionally with pressure measurements in the
right heart. Plain films and fluoroscopy can at best detect conditions which correlate with
the physiologic state, without confirming the correct physiology.
*
Answer: b. by catheter with typical pulse patterns in the right ventricle

1993
35. A patient with an ankle/arm index of 0.4 is likely to have:
a. normal finding
b. venous insufficiency
c. stasis dermatitis
d. ischemic ulcers
*
Typically, in the range of 0.15-0.20 there will be tissue loss.
ankle/ arm index of 0.4-0.5 associated with rest pain. A/A index of <0.3 associated with
ulcer/ gangrene. Table 5-3, p. 87. Normal Ankle / Arm index is greater than 1.0. table 5-
2.
venous insufficiency is secondary to venous obstruction. p 574.
ref: Kadir p 87, 574
*
Answer: c. stasis dermatitis???

1993, 1990, 1989, 1988

36. The minimal pulmonary capillary wedge pressure at which vascular redistribution can
be seen is (best answer):
a. 10 mm Hg
b. 15 mm Hg
c. 25 mm Hg
d. 30 mm Hg
*
PCWP: 8-12 normal
12-18 redistribution
19-25 interstitial pulmonary edema
> 25 alveolar flooding
Above answers are in mm Hg (1.3 cm water = 1 mm Hg).
Reference: Brant p. 426-427
*
Answer: b. 15 mm Hg

1988
37. Of the following, which is the most common congenital heart disease?
a. transposition
b. truncus arteriosus
c. tetralogy of Fallot
*
Answer: c. tetralogy of Fallot
From Robbins Pathology % CHD top ten (not including bicuspid AoValve or MV prolapse)
1 VSD 30
2 PDA 10
3 ASD 10
4 PULM STEN 7
5 COARCT AO 7
6 AO STEN 6
 7 TET OF F 6
8 TOGA 4
9 TRUNCUS 2
10 TRICUS ATR 1.5
*

1988
38. Of the following, which is the most common congenital heart disease?
a. membranous VSD
b. tetralogy of Fallot
c. ASD
d. bicuspid aortic valve
*
Answer: d. bicuspid aortic valve

1994
39. Azygous vein enlargement is maximal with:
a. supine position and Valsalva maneuver
b. upright position with Valsalva maneuver
c. supine position with Mueller maneuver
d. upright position with Mueller maneuver
*
Answer: c. supine position with Mueller maneuver

1994
40. A patient is 2 days S/P MI with tachypnea and no rales. The most appropriate test
would be:
a. EKG
b. CXR
c. pulmonary angio
d. echocardiography
e. V/Q scan
f. Doppler examination of the heart
*
Possible causes of tachypnea in this patient include acute mitral regurgitation,
cardiac rupture, septal perforation, and PE. Causes other than PE should produce rales on
exam. Complications of ventricular aneurysm usually do not occur for weeks to months
following MI. PE complicates approximately 10-45% of all MIs. Risk of PE increases
with heart failure and with shock. LLL atelectasis may be seen with this entity and may
not produce rales.
Although arrhythmias are relatively common following MI, an arrhythmia severe
or chronic enough to cause tachypnea should also cause rales.
*
Answer: b. CXR followed by e. V/Q scan if CXR doesn't satisfy clinical concerns

1992
41. A 65 y/o male is 3 days S/P MI and develops SOB but no rales on exam. CXR will
likely reveal:
a. diffuse haze obscuring distinct pulmonary vessels
b. dilated pulmonary vessels
c. LLL atelectasis
d. aneurysmal configuration of the LV
e. bilateral patchy densities
*
Answer: c. LLL atelectasis (see above discussion)

1994, 1992
42. A patient is brought to the ER with left rib fractures. BP drops to 80/60 when patient
is rolled onto the left side and patient is difficult to ventilate. The most likely diagnosis
is:
a. tension pneumothorax
b. PE
c. fat embolus
d. pneumomediastinum
e. pericardial tamponade
*
Symptoms of fat embolus usually occur 1-2 days after injury and are unlikely to
give hypotension.
Reference: W. Gefter
*
Answer: a. tension pneumothorax

1994
43. The number of bronchial arteries is:
a. 1
b. 2
c. 3
d. 4
e. 5
*
There usually (45%) are three bronchial arteries (2 on one side and one on the
contralateral side). Single bronchial arteries (To each side???) occur in 30%.
There are usually 2 pulmonary arteries and 4 pulmonary veins.
Reference: Kadir, p. 49
*
Answer: c. 3

Angio/Interventional, including congenital heart disease

The following are matching questions:

1993 c PreTest
1. ventral communication between celiac axis and superior mesenteric artery
2. vessel in root of mesentery linking superior and inferior mesenteric arteries
3. omental vessel which parallels the gastroepiploic artery
4. common alternate blood supply to lower body in aortic occlusion

a. arc of Riolan
b. path of Winslow
c. arc of Buehler
d. marginal artery of Drummond
e. arc of Barkow
*

Answer: 1. c 2. a 3. e 4. b

The arc of Buehler represents persistence of the ventral anastomosis, which is a

longitudinal vessel that parallels the embryonic aorta anteriorly. Each visceral artery can
be thought of as rungs in a ladder, with the aorta and ventral anastomosis forming the
siderails. The tenth, eleventh, and twelfth rungs will coalesce to form the celiac axis and
the thirteenth rung will become the SMA. Just as with formation of the aortic arch, as the
ventral anastomosis regresses, the point at which it ultimately breaks determines the final
branching pattern. For instance, the common or right hepatic artery may be on the SMA
side when the break occurs, giving rise to "replaced" arteries. When the ventral
anastomosis persists, the vestige is referred to as the arc of Buehler.
The arc of Riolan lies in the mesentery. It is a connection between branches of the
middle and left colic arteries that permits collateral flow between the SMA and the IMA.
The marginal artery of Drummond lies more peripherally in the mesentery and runs along
the length of the colon connecting the distal arcades.
The arc of Barkow is located in the greater omentum, paralleling the
gastroepiploic artery. It may provide an alternative pathway for flow in the case of
splenic artery occlusion. It also supplies small ascending branches in the transverse
colon.
In the case of abdominal aortic occlusion, the path of Winslow becomes an
important source of collateral blood flow to the lower abdomen, pelvis, and legs. Blood
flows from the internal mammary and intercostal arteries through the anterior abdominal
wall to reach the inferior epigastric branches of the common femoral arteries.
*
1994, 1992
5. tamponade
6. LV aneurysm
7. dilated cardiomyopathy

a. LV systolic dysfunction
b. LV diastolic dysfunction
c. RV systolic dysfunction
d. RV diastolic dysfunction
e. LV systolic and diastolic dysfunction
*

Answer: 5. d 6. a 7. a
Tamponade impairs filling of the heart. This may occur with as little as 250 cc of
fluid. Common causes include trauma, surgery, Dressler's syndrome (an uncommon
constellation of signs and symptoms occurring weeks to months following MI -
characteristically, patients have fever and pain, with a pericardial friction rub and left
pleural effusion discovered on examination. Its etiology is unknown, but it may be an
autoimmune disorder), tumor, infection (e.g. TB), radiation, and uremia.
LV aneurysm implies paradoxical motion of the LV wall. The wall is composed
of scar tissue. The aneurysm occurs weeks to months following MI and may result in
CHF, dysrhythmias, and emboli.
In dilated cardiomyopathy the LV systolic function is predominantly impaired.
LVEF and RVEF are reduced. Diastolic dysfunction may also be present, but this is a
more common feature of hypertrophic and restrictive cardiomyopathies.
References: Harrison's p. 992, 999-1000, and 1010; Mettler, pp. 139-140
*

1995
8. dilated cardiomyopathy
9. restrictive cardiomyopathy
10. hypertrophic cardiomyopathy

a. familial (hereditary)
b. alcohol
c. methotrexate
d. amyloid
*

Answer: 8. b 9. d 10. a

Dilate cardiomyopathy may be secondary to viral, selenium, hypophosphate,

hypocalcium, and a small number have familial forms-- x-linked inheritance.
 Alcoholic cardiomyopathy is the major form of secondary dilated cardiomyopathy
in the western world. Ceasing alcohol can stop progression or can lead to improvement.
Amyloid is a common cause of secondary restrictive cardiomyopathy.
About half of all cases of hypertophic cardiomyopathy appear to be transmitted as
autosomal dominance with a variable degree of expression and penetrance.
ref: Harrison's
Methotrexate adverse reactions include: stomatitis, hemorrhagic enteritis,
myelosupression, renal tox, hepatic dysfunction, alopecia dermatities, patchy pulmonary
infiltrates. CNS toxicity( intrathecal administration). Cardiac side effects are not listed.
ref: DE6 p 1193
*
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

1994, 1989
11. Rastelli
12. Fontan
13. Norwood
14. Pulmonary artery banding
15. pulmonary artery to RV shunt/baffle

a. transposition with VSD and pulmonic stenosis

b. tricuspid atresia
c. tetralogy of Fallot with left main from right coronary ostia
d. multiple small VSDs and pulmonic stenosis
e. Hypoplastic left heart syndrome
*

Answers: 11. a 12. b 13. e 14. d 15. c

Procedures:
Rastelli is RV to PA via an external conduit. It is used for dextroposition,
pulmonic stenosis, or pulmonary atresia. (Kirks, p. 501)
In the Fontan procedure, an atretic tricuspid valve is bypassed with a right atrial to
pulmonary outflow tract conduit. The conduit alternatively can go from the right atrium
to the left pulmonary artery. Pressure in the right atrium is higher postoperatively.
The Jatene procedure is used for transposition of the great vessels - it involves
switching the great arteries and placing them over their proper ventricles. The coronary
arteries must be transplanted as well.
The Mustard procedure is a corrective procedure for transposition of the great
arteries. A Rashkind procedure is initially done. The intraatrial septum is excised and an
artificial baffle is inserted to direct blood flow. The right ventricle now becomes the
systemic ventricle. A late complication is arrhythmia.
 The Rashkind procedure is a balloon septostomy. A balloon-tipped catheter is
inflated in the left atrium and pulled through the foramen ovale, thus causing a huge
ASD.

Shunts:
The Blalock-Taussig shunt is a palliative shunt in which a brachiocephalic artery
(usually the subclavian) is anastomosed to the pulmonary artery through a synthetic graft,
thus effectively bypassing the right heart. It is usually performed on the side opposite the
aortic arch. There is rib notching on the side of the procedure only if the subclavian
artery was divided and the distal portion was ligated (not usually done now).
The Waterson-Cooley shunt is a connection between the posterior ascending aorta
and the adjacent right pulmonary artery. It is no longer used.
The Glenn shunt anastomosis the SVC to the right pulmonary artery, thus
bypassing the right heart. It was devised for the treatment of pulmonary atresia. It is
reserved for only those cases in which definitive surgery cannot be performed, because
once created, it is nearly impossible to reverse.
The Potts procedure (shunt) connects the descending aorta to the left pulmonary
artery.

Reference: Gedgaudas
*

1995
16. impression on posterior esophagus only
17. impression on the anterior trachea and posterior esophagus
18. impression on the posterior trachea and anterior esophagus

a. right aortic arch with congenital heart disease

b. right aortic arch without congenital heart disease
c. double aortic arch
d. pulmonary sling
*

Answer: 16. b 17. c, and possibly a 18. d

Common vascular rings fig. 5-61 , p 490.

Impression on the posterior esophagus only is a right ao arch with an aberrant lt
subclavian artery OR lt ao arch with aberrant right subclavian artery. The incidence of
intracardiac defects is 5-12%.
If there is congenital heart disease in rt -ao-arch, w./ abberant left subclavian,
lesions include Tet, ASD/VAD, coarct. Only 5%of these pt develop a tight ring with sx.
These pt also have large ao diverticulm and tight left sided ligamentum arteriosum AND
by conventional radiography are difficult to differentiate from double aortic arch. Need
MR or angio to differentiate.
 impression onthe ant trachea and posterior esoph is double ao arch OR right ao
arch with aberrant lt suclavian artery, aortic diverticulum and lt ligamentum arteriosum.
impression on posterior trach, and ant esophagus is pulmonary sling.
ref: Kirks, p 490

1994
Regarding the motion of the mitral valve on echocardiography:
19. Systolic anterior motion
20. accentuated posterior motion in systole
21. decreased motion of the anterior leaflet during diastole

a. IHSS
b. mitral prolapse
c. ruptured papillary muscle
d. left atrial myxoma
e. mitral stenosis
*
Answers: 19. a??? 20. b 21. e???

1994, 1992, 1989

Matching:
22. splenic
23 hypogastric
24. SMA
25. celiac artery.
26. right hepatic artery
27. gastroduodenal

a. gastroduodenal
b. left colic
c. short gastrics
d. inferior pancreaticoduodenal
e. middle rectal
f. cystic artery
g. right gastroepiploic artery
*

Answers: 22. c 23. e 24. d 25. a (by way of common hepatic artery) 26. f
27. g

vessels on the bottom arise from choices on the top.

The internal iliac artery supplies the middle and inferior rectal arteries.
The left gastroepiploic artery arises from the splenic artery.
*

1992, 1989
Matching
28. abdominal aorta to azygous (eventually)
29. left renal vein to azygous
30. splenic vein to left renal vein

a. extralobar sequestration
b. intralobar sequestration
c. polysplenia
d. cirrhosis
e. asplenia
*

Answers: 28. a 29. c 30. d

Extralobar sequestrations have systemic arterial supply (usually from the aorta) as
well as systemic drainage (usually into the IVC, azygous, hemiazygous, or the portal
vein), thus creating a L--->R shunt (functionally it is an AVF). 90% are related to the left
hemidiaphragm. It possesses its own pleural investment and 30% are associated with
diaphragmatic hernias. They may also communicate with the GI tract. They are
congenital
Intralobar sequestrations occur most commonly in the lower lobes (usually the
left) and are infrequently associated with other anomalies. Their arterial supply is via
systemic circulation (usually the aorta or a branch) but their drainage is via the pulmonary
veins, creating a L---->L shunt. There is some controversy on whether these are
congenital or acquired.
In asplenia there is a tendency for bilateral right sidedness (more severe than
polysplenia). There is almost always severe complex congenital heart disease (most often
cyanotic). There is often a single atrium with two right atrial appendages. There is an
ASD in all cases (since there are "two right atria" and the septum primum is a "left-sided
structure."). The liver is symmetric and the stomach is midline. There are two right (i.e.,
trilobed) lungs (therefore, there are bilateral eparterial bronchi). Since there is no spleen
there are Howell-Jolly/Heinz bodies. The stomach and gallbladder can be anywhere. The
SVC is often duplicated but the IVC is usually single.
In polysplenia there is bilateral left sidedness. There is azygous continuation of
the IVC (which means that the IVC is interrupted, usually in the hepatic segment), and
venous return to the heart is via the azygous system. There are bilateral SVCs.
Congenital heart disease is less severe, less common, and usually acyanotic. There is a
single atrium with two left atrial appendages. The gall bladder is absent and there is
hepatic symmetry. There are bilateral left (bilobed) lungs with bilateral hyparterial
bronchi.
Spontaneous spleno-renal shunts may occur in cirrhosis/portal hypertension.
References: Dahnert p. 309, 356; baby Fraser and Pare pp. ??
*

1992
Match the reaction with the treatment:
31. vasovagal reaction
32. acute hypertension
33. bleeding due to heparin

a. atropine
b. benadryl
c. nifedipine
d. prednisone
e. protamine
*
Answers: 31. a 32. c 33. e

1994, 1992, 1989, 1988

Match the parameter to the correct number:
34. mean pulmonary artery pressure
35. plasma oncotic pressure

a. 5 mm Hg
b. 10 mm Hg
c. 15 mm Hg
d. 20 mm Hg
e. 25 mm Hg
*
Answers: 34. c 35. e

1993
36. Overdose of morphine
37. hypertension in pheochromocytoma
38. coumadin overdose

a. naloxone
b. vitamin K
c. phentolamine
*
Answers: 36. a 37. c 38. b

1992, 1989
39. tricuspid atresia
40. supravalvular aortic stenosis
41. pseudocoarctation of the aorta

a. transposition of the great vessels

b. multiple pulmonary coarctations
c. bicuspid aortic valves
d. right aortic arch
*

Answer: 39. a 40. b 41. c

Tricuspid atresia is usually associated with pulmonary stenosis but no
transposition (no transposition in 80%).???
Pseudocoarctation of the aorta is elongation of the thoracic aorta with redundancy
and kinking just distal to the left subclavian artery origin. There is no pressure gradient
through this area; therefore, there is no rib notching or increase in left ventricle size. It is
associated with bicuspid aortic valve, patent ductus arteriosus, aortic/subaortic stenosis,
single ventricle, ASD, and anomalies of the aortic arch and branches.
Williams syndrome is elfin facies, hypercalcemia, and retardation - seen with
supravalvular aortic stenosis and multiple pulmonary coarctations.
References: Dahnert, p. 388, 406, 413; Swischuk, p. 285, 293
*

1993
42. Cardiac fluoroscopy for ventricular aneurysm
43. MR for detection of aortic dissection
44. enlarged heart for pericardial effusion

a. high sensitivity and specificity

b. low sensitivity, high specificity
c. low sensitivity, low specificity
*

Cardiac fluoroscopy is 50% sensitive for detection of ventricular aneurysms.

MR is highly sensitive and specific for aortic dissection.
Cardiomegaly (on CXR) is neither sensitive nor specific for detection of
pericardial effusion.
References: Dahnert; W. Miller, Jr.
*
Answers: 42. b 43. a 44. c

1991
45. normal
46. angioplasty
47. surgery

a. 24 y/o with chest pain

b. 63 y/o with prior MI; 53% EF at rest, 37% with exercise
c. 57 y/o shortly after inferolateral MI now with inferolateral EKG changes
*
Answers: 45. a 46. c 47. b

1993
48. overdose of morphine
49. bleeding in a patient on coumadin
50. acute hypertension during angiogram

Use:
a. naloxone
b. vitamin K
c. propranolol
d. papaverine
*
Answer: 48. a 49. b 50. d

1991
51. tetralogy of Fallot with pulmonary atresia
52. transposition of the great arteries
53. Ebstein's anomaly with a large ASD
54. absent left pulmonary artery

a. neonatal death
b. pulmonary vascular prominence
c. neither
d. both
*

Answer: 51. a 52. d 53. c ,??a 54. c

Nine lesions causing sever congenital heart disease during the neonatal period can
cause cyanosis or respiratory distress in the 1st few days of life. Transposition,
pulmonary atresia, tricuspid atresia, TAPVR, hypoplastic left heart, Ebstein, truncus,
coarct.
Tetrology, Ebstein has decreased pulm vasc. Transposition has shunt vascularity
with active congestion.p 502 Kirks
Ebstein anomaly is a congenital displacement of the posterior and septal leaflets
of the tricuspid valve downward, into the right ventricular chamber. As a result, a portion
of the ventricle is "atrialized" and the remaining ventricular chamber is small. Forward
flow is reduced, and depending on the degree of tricuspid insufficiency, a right to left
shunt is almost always present through a patent foramen ovale or ASD. The anomaly is
found more frequently in infants whose mothers were receiving lithium during pregnancy.
Conduction disturbances are common. Most typically, the EKG shows giant peaked P
waves and a right bundle branch block. About 10% of patients have Wolff-Parkinson-
White syndrome. Although the most common symptom is dyspnea on exertion,
palpitations from episodes of supraventricular tachyarrhythmia are not uncommon. The
chest X-ray often reveals marked cardiomegaly and decreased pulmonary vasculature.
Although half of those with Ebstein malformation will present with cyanosis and
congestive heart failure in infancy, the remainder who do not have associated anomalies
may not present until early adulthood. Occasionally, cyanosis that is present at birth will
disappear as pulmonary vascular resistance falls, but, eventually, almost all patients come
to medical attention. The RV is small and contracts out of phase with the atrialized
portion, producing a "paradoxical" motion. The regurgitant tricuspid valve and right-to-
left shunt are also evident.
*

1993 c PreTestv
55. cavernous hemangioma
56. focal nodular hyperplasia
57. hepatocellular carcinoma

a. "spoke-wheel" pattern of vessels during arterial phase

b. retention of contrast material into and usually well beyond the venous phase
c. hypervascular with dilated hepatic arterial supply and extensive neovascularity
*

Answer: 55. b 56. a 57. c

Cavernous hemangiomas are benign tumors of the liver and have a characteristic
appearance on angiography. In the late arterial phase, small groups of dilated amorphous
vascular spaces fill with contrast. They are well-defined, but have irregular walls. Since
blood flow through a hemangioma is very slow, there is retention of contrast material into
and usually well beyond the venous phase.
Focal nodular hyperplasia is usually a hypervascular mass with a definable arterial
supply that breaks up into small branches which permeate the mass. As a result, one can
see a reticular or "spoke-wheel" pattern of vessels during the arterial phase. Focal
nodular hyperplasia does not usually have irregular, dilated vascular spaces. In further
distinction, the hepatogram phase in cases of focal nodular hyperplasia often reveals fine
granular appearance to the lesion.
Hepatocellular carcinoma is typically hypervascular, with a dilated hepatic arterial
supply and extensive neovascularity. However, the abnormal vascular spaces (or vessels)
seen in hepatoma do not retain the contrast nearly as long as those of hemangiomas, and
typically wash out during the venous phase.
*