Cardiology Intensive Board Review, 3th Edition

Chapter 7 - Peripheral Vascular Disease

Douglas E. Joseph, Hemantha K. Koduri

QUESTIONS

1.A 53-year-old man with a history of obesity, obstructive sleep apnea, hypertension, and hypercholesterolemia presents to the clinic complaining of a nonhealing ulcer on his left ankle present for the past month. His blood pressure is 160/78 mmHg. His physical examination is remarkable for mild bilateral lower leg edema as well as lipodermatosclerosis and hyperpigmentation around the ankles. A mildly tender, superficial ulceration is observed with an irregular pink base above his medial malleolus. His feet and toes are warm, pink, and have 2-second capillary refill and intact sensation. Laboratory tests on this patient include a random blood sugar of 160 mg/dL, creatinine of 1.1 mg/dL, calcium of 10.4 mg/dL, phosphorus of 4.4 mg/dL, and serum intact parathyroid hormone level of 50 pg/mL. What is the most likely etiology of the ulceration?

a.Diabetes mellitus

b.Chronic venous insufficiency

c.Peripheral arterial disease (PAD)

d.Calciphylaxis

e.Brown recluse spider bite

2.A 49-year-old woman with a 60-pack per year history of smoking presents to the emergency department (ED) with complaints of constant, worsening right foot pain and tingling in the toes for several hours. She denies a history of trauma. On examination, she is in moderate distress from pain and has a regular cardiac rhythm at a rate of 104 bpm. Her right lower extremity has a palpable femoral pulse and cool, pale foot with nonpalpable pedal pulses. There is a faint dorsalis pedis arterial signal with continuous-wave handheld Doppler evaluation. Strength is intact in the foot and toes, but she reports pain during examination. What is the most appropriate next step?

a.Admit to the hospital; begin a heparin infusion and antiplatelet therapy. Obtain an urgent echocardiogram to identify the source of embolism.

b.Obtain urgent ankle–brachial indices (ABIs) and pulse volume recordings to determine the severity of disease and begin aggressive risk-factor–modifying medical therapy.

c.Admit to the hospital for an urgent diagnostic abdominal aortogram with runoff and potential endovascular revascularization.

d.Admit to the hospital for pain control and obtain a lumbar magnetic resonance imaging to evaluate for lumbar canal stenosis and pseudoclaudication.

e.Obtain ABIs at rest and with exercise to assess for lower extremity PAD and a venous plethysmography of the lower extremities with exercise to evaluate for venous claudication.

3.A 65-year-old man presents with progressive, short-distance, intermittent claudication in his right leg and a declining ABI. He undergoes an abdominal aortic angiogram with runoff demonstrating a discrete 90% stenotic lesion of the superficial femoral artery. Percutaneous transluminal angioplasty followed by placement of a self-expanding nitinol mesh stent is performed with good post-procedural angiographic results. Which of the following is the most appropriate post-procedure surveillance program for this patient?

a.Regular visits with assessment for interval change in symptoms, vascular examination, and ABI measurement beginning in the immediate post-procedure period and at intervals for at least 2 years

b.Regular visits with assessment for interval change in symptoms, vascular examination, and arterial duplex at 1 month, 3 months, and at month 12

c.Regular visits with assessment for interval change in symptoms, vascular examination, and ABI measurement at 3 months, 6 months, 9 months, and at month 12

d.Regular visits with assessment for interval change in symptoms, vascular examination, and arterial duplex at 3 months, 6 months, 12 months, and 2 years

e.Annual visits with assessment for interval change in symptoms, vascular examination, ABI measurement, and arterial duplex

Case 1 (Questions 4 and 5)

A 59-year-old morbidly obese woman is admitted for cholecystectomy and postoperatively is placed on deep venous thrombosis (DVT) prophylaxis with mini-dose subcutaneous heparin. On hospital day 2, a peripherally inserted central venous catheter is placed in the right arm. The patient is discharged to a rehabilitation facility on hospital day 5 after removal of the venous catheter. Two days later she presents to the emergency room with right upper extremity pain and swelling. She reports she has not felt well enough to participate with physical therapy since being discharged from the hospital. Venous duplex of the right arm demonstrates acute thrombosis of the right cephalic vein. Complete blood count (CBC) and chemistries are within normal range with a platelet count of 180 K/μL.

4.What is the most appropriate management of this patient?

a.Admit to the hospital and start on intravenous (IV) anticoagulation with heparin or a direct thrombin inhibitor (DTI).

b.Prescribe enoxaparin 1 mg/kg every 12 hours and coumadin. Admit for 4 to 5 days of overlap and discontinue enoxaparin once the international normalized ratio (INR) is within therapeutic range for 2 consecutive days. Continue anticoagulant therapy for 3 months.

c.Prescribe enoxaparin 1 mg/kg every 12 hours and coumadin. Discharge with instructions for 4 to 5 days of overlap and discontinue enoxaparin once the INR is within therapeutic range for 2 consecutive days. Continue anticoagulant therapy for 6 months.

d.Prescribe enoxaparin 1 mg/kg every 12 hours and coumadin. Discharge with instructions for 4 to 5 days of overlap and discontinue enoxaparin once the INR is within therapeutic range for 2 consecutive days. Continue anticoagulant therapy for 12 months.

e.Warm compresses and nonsteroidal anti-inflammatory drugs for pain.

5.What should the target activated partial thromboplastin time (aPTT) be to achieve optimal efficacy and safety if anticoagulation with a DTI were to be initiated in this patient?

a.An aPTT of 3.0 to 4.0 times the baseline value

b.An aPTT of 2.5 to 3.0 times the baseline value

d.An aPTT of 2.0 to 3.0 times the baseline value

e.An aPTT of 1.5 to 2.0 times the baseline value

Case 2 (Questions 6 to 8)

A 15-year-old man presents to the clinic accompanied by his mother for evaluation of “red hands.” He earned money last winter clearing sidewalks of snow and plans to do so again in the upcoming weeks. He reports developing red discoloration of his hands after returning home from the cold. The discoloration persisted for a few minutes until his hands were rewarmed. He denies weakness, paresthesia, pain, or skin lesions. He is otherwise healthy. At the time of consultation, inspection of his hands is unrevealing. Radial and ulnar pulses are 2+/2 bilaterally. The Allen test and reverse Allen test reveal return of color to the hands in 7 seconds bilaterally. His mother reports that she and her mother both have Raynaud phenomenon. The patient’s mother expresses concern that her son may have systemic lupus and she requests further testing.

6.What is the most likely diagnosis?

a.Raynaud disease

b.Raynaud phenomenon

c.Normal physiologic cold response

d.Acrocyanosis

e.Thermal injury

7.Of the following, which is the most appropriate next step to objectively evaluate this patient?

a.Obtain an upper extremity angiogram with selective imaging of the digital vessels and before and after administration of nitroglycerin.

b.Obtain digital pulse volume recordings and transcutaneous partial pressure of oxygen measurements of the digits.

c.Order a C-reactive protein level, erythrocyte sedimentation rate, and perform nailfold capillaroscopy.

d.Order a C-reactive protein level, erythrocyte sedimentation rate, and plasma homocysteine level.

e.Order antinuclear antibodies, erythrocyte sedimentation rate, and perform nailfold capillaroscopy.

8.When would be the most appropriate time to schedule a follow-up appointment?

a.5 years

b.3 years

c.2 years

d.1 year

e.As needed

Case 3 (Questions 9 and 10)

A 49-year-old man presents to the clinic with complaints of progressive exertional dyspnea for several weeks. His speech is mildly breathless. Neck veins are distended bilaterally and there is moderate lower extremity edema. He denies chest pain. Electrocardiogram (ECG) shows sinus tachycardia without ST-segment abnormality. Physical examination reveals a parasternal heave and systolic ejection murmur. Past medical history is significant for splenectomy after a car accident several years ago.

9.Which of the following will most accurately confirm the underlying cause of this patient’s symptoms?

a.Chest computed tomography (CT) with IV contrast

b.Transthoracic echocardiogram

c.Transesophageal echocardiogram

d.Pulmonary arteriogram

e.Ventilation–perfusion scan

10.Which of the following statements is most accurate concerning this patient’s underlying diagnosis?

a.Inflammatory mechanisms have not been implicated in the pathogenesis.

b.Patients should be anticoagulated with a vitamin K antagonist and target INR of 2.5 to 3.5.

c.IV epoprostenol is an effective therapy in patients with advanced disease.

d.Inhaled iloprost has been demonstrated to improve exercise capacity.

e.Bosentan has been shown to improve exercise capacity in patients with mild-to-moderate liver disease.

11.You are consulted for recommendations regarding a deep vein thrombosis in a patient who is status post aortic valve replacement with a bioprosthetic valve 4 days prior. Earlier on the day of consult he complained of pain and was diagnosed with a partially occlusive left femoral vein thrombosis. His postoperative course has been otherwise uncomplicated. On examination, the patient is tender around the surgical site. There is moderate pitting edema in the legs bilaterally. He has palpable pulses in all extremities. What do you recommend?

a.Bolus subcutaneous low-molecular-weight heparin (LMWH) 80 mg/kg, then dose at 1 mg/kg subcutaneously every 12 hours

b.Placement of a retrievable inferior vena cava filter

c.Catheter-directed thrombolysis

d.Begin a DTI

e.Begin a weight-based unfractionated heparin infusion

12.A patient with a history of heparin-induced thrombocytopenia (HIT) 8 years ago presents to your office for preoperative evaluation for bioprosthetic aortic valve replacement and coronary artery bypass grafting. He requires anticoagulation while on cardiopulmonary bypass pump during surgery. A recent ELISA (enzyme-linked immunosorbent assay) antiplatelet factor-4 antibody test is negative (<0.400 optical density). He has had no subsequent heparin exposures over the last 8 years. What is the most appropriate anticoagulation regimen you should recommend for this patient?

a.Administration of IV fondaparinux intraoperatively with subsequent daily monitoring of platelet counts

b.Administration of IV LMWH intraoperatively with subsequent daily monitoring of platelet counts

c.Administration of IV argatroban intraoperatively with subsequent daily monitoring of platelet counts

d.Administration of IV hirudin intraoperatively with subsequent daily monitoring of platelet counts

e.Administration of IV unfractionated heparin intraoperatively with subsequent daily monitoring of platelet counts

13.A patient comes to your office 1 month after a hospital stay for gastric bypass surgery. She was diagnosed with a mesenteric vein thrombosis postoperatively. She denies a prior history of venous thromboembolism (VTE). She and her husband have questions about the duration of anticoagulant therapy. They bring copies of laboratory results showing she was checked for a hypercoagulable condition. One laboratory test indicates she is heterozygous for a mutation of the methylenetetrahydrofolate reductase (MTHFR) enzyme. All other laboratory tests are within normal range. She asks you how these results impact duration and intensity of anticoagulation. The most accurate reply is

a.all first-episode DVTs are treated similarly; thus, the discovery of this genetic mutation is of doubtful clinical significance.

b.given the clinical circumstances the laboratory finding is of doubtful clinical significance and you advise she should be anticoagulated with a vitamin K antagonist for 3 months with a target INR of 2.0 to 3.0.

c.she should be anticoagulated with a vitamin K antagonist for 3 months with an increased target INR of 2.5 to 3.5 because of increased thrombogenicity induced by the genetic mutation.

d.she should be anticoagulated with a vitamin K antagonist with a target INR of 2.0 to 3.0 for an extended duration of therapy to 6 months because of increased thrombogenicity induced by the genetic mutation.

e.she should be anticoagulated with a vitamin K antagonist with an INR target of 2.0 to 3.0 indefinitely because of the high rate of recurrent VTE associated with the heterozygous form of this genetic mutation.

14.A 34-year-old woman with a history of deep vein thrombosis who is chronically anticoagulated with warfarin discovers she is pregnant. Her due date is 34 weeks from now. Currently, she is on warfarin and has an INR of 2.2. She presents to the clinic for recommendations regarding her anticoagulation management. Which of the following is true regarding venous thromboembolic disease, anticoagulation therapy, and pregnancy?

a.When deep vein thrombosis of the lower extremities complicates a pregnancy, the right leg is affected significantly more often than the left, presumably because of exaggeration of the compressive effects of the left iliac artery compressing on the right iliac vein during pregnancy.

b.The incidence of teratogenic complications of pregnancy caused by warfarin, including nasal hypoplasia and stippled epiphyses, is greatest if warfarin exposure occurs during weeks 14 through 24.

c.Warfarin is contraindicated in the nursing mother because of a high incidence of inducing an anticoagulant effect in the infant fed with breast milk from a mother on warfarin therapy.

d.Fatal pulmonary embolism is a leading cause of maternal mortality in the Western world.

e.LMWHs have been proven safe and efficacious in pregnant woman with prosthetic heart valves, and supplanted unfractionated heparin as the standard of care in this setting.

Case 4 (Questions 15 and 16)

A 65-year-old man presents to the clinic with complaints of episodic burning pain involving the soles of his feet and toes. He reports symptoms are most severe when the weather becomes hot and generally occurs when he is outside in the heat. His feet and toes turn red and feel hot to touch during episodes. When he returns to an air-conditioned area, symptoms begin to dissipate or some episodes may take hours for complete resolution. Elevating his legs relieves symptoms as does walking barefoot on cold tile floors. His past medical history includes hypertension, well controlled with atenolol, and he takes once daily low-dose aspirin for primary prevention.

Physical Examination

Blood pressure is 120/70 mmHg and pulse is 84 bpm.

The cardiac and lung examinations are normal.

The abdomen is soft and nontender with a normal-sized palpable aortic pulsation.

No bruit can be heard over the neck, abdomen, or either groin.

Radial, dorsalis pedis, and posterior tibial pulses are 2+/2 bilaterally.

A mild erythema and increased warmth are noted in toes and soles of the feet.

15.Which of the following is the most likely diagnosis?

a.Heat urticaria

b.Erythromelalgia

c.Chilblains (perniosis)

d.Raynaud phenomenon

16.What laboratory values should be followed serially in patients with this condition?

a.Electrolytes, blood urea nitrogen, and creatinine

b.Erythrocyte sedimentation rate

c.Ionic calcium

d.Complete blood count with differential (CBC with diff)

17.A 17-year-old boy was involved in a motor vehicle accident, which resulted in multiple fractures as well as internal injuries that necessitated multiple abdominal surgeries over a 2-week period. He is expected to recover fully. An intraluminal filling defect was incidentally identified consistent with DVT of the right external iliac vein on a contrast-enhanced abdominal CT scan. Anticoagulation was contraindicated because of a retroperitoneal hemorrhage. It was determined that placement of an inferior vena cava filter was necessary. Of the following types of filters, which filter is most appropriate in this case?

a.Bird’s Nest vena cava filter

b.Gunther Tulip retrievable vena cava filter

c.TrapEase inferior vena cava filter

d.Greenfield vena cava filter

e.Simon Nitinol inferior vena cava filter

Case 5 (Question 18)

You are called to the bedside of a 68-year-old man in mild distress who underwent cardiac catheterization earlier in the day. He is complaining of increasing right groin pain. He complains of weakness and tingling in his foot and toes. He is presently on a heparin infusion because of atrial fibrillation. On inspection you note a large area of skin in his right groin and proximal thigh to be dark blue and there is a large, palpable, hard pulsatile mass. With ultrasound using color Doppler you note an irregular shaped area of flow measuring 4.0 cm × 3.3 cm near the common femoral artery, approximately 4.0-cm deep and connected to the artery by a 0.5-cm neck. There is surrounding hematoma observed. Spectral waveform analysis of the neck demonstrates a to-and-fro pattern.

18.What is the best treatment option for management of this patient’s condition?

a.Placement of a femoral compression device overnight and analgesics for pain

b.Injection of thrombin by ultrasound guidance

c.Ultrasound-guided compression for 30 minutes

d.Surgical evacuation of the hematoma and suture repair of the artery

e.Placement of a compression dressing with snugly applied bandages around the leg and serial duplex scans to monitor for resolution

19.A 74-year-old man is in the ICU (intensive care unit) recovering from coronary artery bypass surgery and has developed a hemorrhagic pericardial effusion. He is currently stable, but has noted swelling and pain in his left leg. An ultrasound is ordered and reveals acute thrombus in the left peroneal vein. Which of the following is the best management option?

a.No action is required because calf vein thrombus is not clinically important

b.Pneumatic compression stockings and enoxaparin 40 mg every 24 hours

c.Follow up with serial duplex ultrasound scans

d.Initiate a continuous unfractionated heparin infusion

e.Proceed with placement of an inferior vena cava filter

Case 6 (Questions 20 and 21)

A 25-year-old man presents to the clinic with complaints of pain in his feet with walking. He reports this has been going on for several months and has progressively worsened in the past few weeks. He is beginning to develop symptoms in his right calf and earlier this week noticed a black area on his great toe. He has no medical problems, takes no medications, and is in good health overall. He is a smoker and works as a computer salesman. He reports a family history of VTE; his mother had a pulmonary embolism at the age of 50 and was diagnosed with the antiphospholipid antibody syndrome.

20.What is the most likely cause of his symptoms?

a.Elevated anticardiolipin antibodies

b.Thromboangiitis obliterans (TAO, Buerger disease)

c.Takayasu arteritis

d.Premature atherosclerosis

e.Livedoid vasculitis (atrophie blanche)

21.What is the most important aspect of therapy for this patient?

a.Anticoagulation with a vitamin K antagonist

b.Cessation of exposure to all forms of tobacco

c.Initiate immunosuppressive therapy with glucocorticoids

d.Antiplatelet therapy with aspirin

e.Admit to the hospital to begin tissue plasminogen activator therapy

Case 7 (Questions 22 and 23)

A 24-year-old woman presents with complaints of a swollen, painful left leg. She has a history of two episodes of deep vein thrombosis in the past. She recalls that they were both on the left side, but is unsure of which veins were involved. She was on warfarin in the past but discontinued it when she began attempting to conceive. Venous duplex demonstrates an acute deep vein thrombosis of the left femoral vein.You initiate treatment with LMWH.

22.What is the most likely diagnosis?

a.Heterozygous prothrombin gene mutation

b.Heterozygous factor V Leiden mutation

c.May-Thurner syndrome

d.Klippel-Trenaunay syndrome

e.Klippel-Trenaunay-Weber syndrome

23.Which of the following is the best management option?

a.Indefinite anticoagulant therapy with warfarin

b.Indefinite monotherapy with enoxaparin

c.Venography for thrombus removal and stent placement

d.Placement of an inferior vena cava filter and discontinue anticoagulants

e.Anticoagulate with either warfarin or enoxaparin for 6 months

24.A 68-year-old gentleman underwent coronary artery bypass surgery using the saphenous vein harvested from his left leg. He has done well postoperatively except for failure of the left leg incision to heal completely. Four months after surgery, his leg is still not fully healed and a peri-incisional ulcer is now present. He has significant edema in his leg, which was present prior to surgery. There are no symptoms or physical findings suggestive of infection. His ABI is 0.94 on the right and 0.89 on the left. You order an ultrasound, which is negative for acute thrombus but does reveal significant venous valvular incompetence in the deep veins. Which of the following is most likely to improve this patient’s wound healing?

a.Whirlpool therapy

b.Antibiotics and topical steroids

c.Compression stockings

d.Plastic surgery consult

e.Revascularization

25.You are providing postoperative care for a patient who is in the cardiovascular surgery postoperative ICU, status post coronary artery bypass surgery. A venous duplex ultrasound was performed to evaluate for new-onset bilateral leg swelling. Results are reported as negative for DVT, but with monophasic flow noted within the bilateral common femoral veins. Which of the following is the next best step?

a.CT venogram of the lower extremities

b.CT venogram of the abdomen and pelvis

c.Enoxaparin therapy 1 mg/kg subcutaneous injections every 12 hours

d.Enoxaparin therapy 40 mg subcutaneous injections every 24 hours

Case 8 (Questions 26 and 27)

A 39-year-old man presents to the ED with shortness of breath and tachycardia. He eventually develops hypotension with a systolic blood pressure of 80 mmHg. A stat CT scan of the chest reveals a saddle pulmonary embolism involving the main pulmonary artery trunk.

26.Which of the following is the next most appropriate step?

a.Begin an IV unfractionated heparin infusion at 18 U/kg/h

b.Begin alteplase 100 mg IV over 2 hours

c.Begin enoxaparin subcutaneous injections 1 mg/kg every 12 hours

d.Insert an inferior vena cava filter

27.Which of the following findings or laboratory values could be used to predict his prognosis?

a.C-reactive protein

b.Atrial arrhythmia

c.Left ventricular dysfunction

d.Prolonged QT interval

e.Elevated serum myoglobin

28.A 52-year-old man with metastatic prostate cancer has developed left lower extremity swelling. You order an ultrasound and a left acute external iliac deep vein thrombosis is visualized. You hospitalize the patient and his initial labs reveal hemoglobin 14.5 g/dL and creatinine 1.0 mg/dL. Which of the following treatment options is most appropriate?

a.Begin a weight-based unfractionated heparin infusion and bridge to warfarin.

b.Begin enoxaparin 1 mg/kg subcutaneous injections every 12 hours.

c.Place an inferior vena cava filter.

d.Begin unfractionated heparin 5,000 units subcutaneous injections every 8 hours.

29.A 55-year-old man is admitted to the hospital with upper gastrointestinal bleeding. He is transfused with 2 units of packed red blood cells and undergoes esophagogastroduodenoscopy. A bleeding gastric ulcer is discovered and treated with epinephrine injection. Several days into his admission he begins complaining of right calf discomfort. Venous duplex ultrasound is performed demonstrating acute deep vein thrombosis of the popliteal and posterior tibial veins. What is the next appropriate step in the management of this patient?

a.No action is required because calf vein thrombus is not clinically important.

b.Pneumatic compression stockings and enoxaparin 40 mg every 24 hours.

c.Follow up with serial duplex ultrasound scans.

d.Initiate a continuous unfractionated heparin infusion.

e.Proceed with placement of an inferior vena cava filter.

30.A 58-year-old man presents to the clinic with a complaint of bilateral lower extremity cramping muscular pain with exertion relieved after a few minutes of rest. His medical history includes coronary artery disease status post left anterior descending artery stent 2 years ago, diabetes mellitus type 2, and essential hypertension. An ABI is performed in your office demonstrating a right ABI of 1.10 and left ABI of 1.04. What is the most appropriate next step in the evaluation of this patient?

a.Reassurance and suggest low-impact exercise, i.e., swimming

b.Referral to a peripheral vascular interventionalist for lower extremity angiogram

c.Order bilateral ABI measurements in the vascular laboratory at rest and following an exercise protocol

d.Order magnetic resonance imaging of the lumbosacral spine to confirm the likely diagnosis of pseudoclaudication

e.Have him return in 6 months and repeat the resting ABI measurements

31.A 68-year-old woman recently diagnosed with PAD presents to the clinic for follow-up. A fasting lipid profile obtained prior to the appointment demonstrates a low-density lipoprotein (LDL) level of 145 mg/dL. You decide to initiate therapy with a hydroxymethyl glutaryl coenzyme-A reductase inhibitor (statin). Which of the following LDL target levels is most appropriate?

a.Less than 150 mg/dL

b.Less than 130 mg/dL

c.Less than 100 mg/dL

d.Less than 50 mg/dL

e.There is no defined LDL target

32.A 52-year-old woman with a history of PAD, diabetes mellitus type 2, and active smoking presents to the clinic with a blood pressure of 150/95 mmHg. What blood pressure target should you recommend for this patient?

a.Less than 150/90 mmHg

b.Less than 140/90 mmHg

c.Less than 130/80 mmHg

d.Less than 120/75 mmHg

e.Less than 100/70 mmHg

33.For the above patient you decide to start her on a new antihypertensive medication. Which of the following class of medications are contraindicated?

a.β-Adrenergic blockers

b.Thiazide diuretics

c.Angiotensin-converting enzyme inhibitors

d.Angiotensin II receptor blockers

e.None of the above

Case 9 (Questions 34 and 35)

A 68-year-old man with a 30 pack-year history of smoking is seen in the clinic for follow-up after a non-ST-elevation myocardial infarction (NSTEMI). Because of his smoking history and age you order an ultrasound of his abdomen to rule out abdominal aortic aneurysm (AAA). He is discovered to have an infrarenal AAA measuring 5.0 cm × 4.9 cm.

34.After this initial baseline study, how often should you repeat the ultrasound of the abdomen?

a.Every 3 months

b.Every 3 to 6 months

c.Every 6 to 12 months

d.Every 12 months

e.Every 24 months

35.At what size measurement should you refer a patient for repair of an asymptomatic infrarenal AAA?

a.4.0 to 5.0 cm

b.4.5 to 5.0 cm

c.5.0 to 5.4 cm

d.5.5 cm or greater

e.6 cm or greater

36.Which of the following population groups is it appropriate to do a screening ultrasound of the abdomen for an AAA?

a.Men >60 years of age with a first-degree relative with an AAA

b.Women >60 years of age with a first-degree relative with an AAA

c.Men 65 to 75 years of age with a smoking history

d.Women 65 to 75 years of age with a smoking history

e.All of the above groups are appropriate to screen for an AAA

Case 10 (Questions 37 and 38)

A 70-year-old man presents for follow-up in the clinic 1 month after undergoing right internal carotid artery stenting.

37.When should you get a post-procedure baseline carotid duplex ultrasound?

a.Four weeks after the intervention

b.Six weeks after the intervention

c.Two months after the intervention

d.Six months after the intervention

e.Twelve months after the intervention

38.A baseline carotid duplex ultrasound demonstrates patency of the stent and no evidence of residual stenosis or restenosis of the right internal carotid artery after the procedure. One year after the carotid intervention, how often is it recommended to perform repeat carotid ultrasound surveillance in an asymptomatic patient?

a.Every 6 months

b.Every 12 months

c.Every 18 months

d.Every 24 months

e.Every 36 months

Case 11 (Questions 39 to 42)

A 65-year-old man presents for a routine physical examination. During the interview he complains about swelling behind his right knee. You order an ultrasound of the area (findings illustrated in Fig. 7.1).

Figure 7.1

39.What is the most likely diagnosis?

a.Abscess

b.Baker cyst

c.Popliteal artery aneurysm

d.Enlarged lymph node

e.Lipoma

40.What percentage of patients with a popliteal artery aneurysm have concomitant AAA?

a.10%

b.20%

c.40%

d.50%

e.60%

41.After finding the results illustrated in Figure 7.1 you refer the patient for ultrasound of the abdomen and contralateral popliteal artery. No additional abnormalities are discovered. What is the next appropriate step in his management?

a.The finding is benign and no intervention is indicated.

b.Repeat the ultrasound in 3 months.

c.Repeat the ultrasound in 6 months.

d.Repeat the ultrasound in 1 year.

e.Refer for the repair of the aneurysm.

42.What is the most common complication of untreated, symptomatic popliteal artery aneurysms measuring more than 2.5 cm in greatest dimension?

a.Rupture

b.Thromboembolism

c.Infection

d.No complications

e.Popliteal vein thrombosis

43.During rounds in the telemetry unit you evaluate a 55-year-old woman 1 day after she underwent a left heart catheterization. She complains of right groin pain and swelling at the vascular access site. You order a duplex ultrasound of the right groin. Findings of the ultrasound are illustrated in Figure 7.2A and B. What is your diagnosis?

a.Hematoma

b.Arteriovenous fistula

c.Abscess

d.Pseudoaneurysm

e.Enlarged lymph node

Figure 7.2

44.A 64-year-old woman presents to the clinic for evaluation prior to coronary artery bypass surgery. She underwent carotid duplex ultrasound demonstrating normal bilateral internal carotid arteries. Images from her scan are illustrated in Figure 7.3. What unexpected condition is demonstrated by her ultrasound images?

a.Subclavian artery aneurysm

b.Subclavian artery thrombosis

c.Subclavian artery stenosis

d.Subclavian vein thrombosis

e.Hematoma surrounding the subclavian artery

45.A 55-year-old woman with a history of deep vein thrombosis 2 months ago for which she was on warfarin was admitted to the hospital for chest pain. She underwent chest CT angiography which was negative for pulmonary embolism. She underwent a left heart catheterization after her INR normalized. During her procedure she received IV heparin. Her coronary arteries were free of disease. Following the procedure she was prescribed 10 mg of warfarin daily for 3 days. During this time her CBC was monitored and her hemoglobin and platelet counts showed minor fluctuations. A day later she developed a lesion on her abdomen illustrated in Figure 7.4. What is the likely cause of the skin lesion?

a.Heparin-induced skin necrosis

b.Vasculitis

c.Warfarin skin necrosis

d.Eczema

e.Allergic reaction

Figure 7.3

Figure 7.4

46.A 70-year-old man is admitted to the telemetry unit for workup of dizziness of 2 days’ duration. He denies chest pain or shortness of breath. His heart rate is 60 bpm and blood pressure is 130/50 mmHg. On physical examination, a systolic murmur is heard over the left sternal border. Carotid duplex ultrasound is performed demonstrating the spectral waveforms of the bilateral internal carotid and vertebral arteries illustrated in Figure 7.5. Which of the following conditions is suggested by the carotid duplex waveforms?

a.Pulmonary valve stenosis

b.Systolic heart failure

c.Pericardial tamponade

d.Aortic valve stenosis

e.Mitral regurgitation

Figure 7.5

47.A 55-year-old woman presents to the ED with precordial chest discomfort and shortness of breath. Her body mass index is 34. Her medical history includes essential hypertension, diabetes mellitus type 2, and a 30 pack-year smoking history. Laboratory results include a troponin of 2.4 mg/mL and a B-type natriuretic peptide of 840 pg/mL. An ECG reveals no ST-segment elevation and nonspecific ST-T wave changes. The ED physician requests cardiology consultation for an NSTEMI. When you arrive to see the patient you order an IV contrast-enhanced chest CT scan of the lungs. Findings are demonstrated in Figure 7.6. What is the diagnosis?

a.Type A aortic dissection

b.Myocarditis

c.Pneumonia

d.Saddle pulmonary embolism

e.Interstitial lung fibrosis

48.Which of the following cardiovascular risk factor assessment tools has not been demonstrated to be useful in the risk assessment for a first atherosclerotic cardiovascular event?

a.High-sensitivity C-reactive protein

b.Coronary artery calcium score

c.Carotid intima-media thickness

d.ABI

e.Family history of premature coronary vascular disease

Figure 7.6

ANSWERS

1.b. Chronic venous insufficiency. This patient has no history of neuropathy and has intact sensation, making a neurotrophic ulcer often associated with diabetes unlikely. While his glucose is elevated, inadequate information is provided to make the diagnosis of diabetes mellitus. Bilateral leg edema, hyperpigmentation of the ankles, and the location of the ulcer over the medial malleolus (“gaiter distribution”) are findings consistent with a venous stasis wound. Ulcers secondary to arterial disease are usually painful, involve the toes, and are well circumscribed. The information provided suggests adequate arterial supply. Wounds associated with calciphylaxis may be anywhere. They are usually very painful, involve large areas of skin, and are associated with black eschar formation. These wounds are most often seen in patients with renal impairment and hyperparathyroidism, neither of which is true in this case. Nothing in the clinical vignette is suggestive of a brown recluse spider bite.11

2.c. Admit to the hospital for an urgent diagnostic abdominal aortogram with runoff and potential endovascular revascularization. The patient described is suffering from acute critical limb ischemia. The hallmarks of acute limb ischemia are the five “P’s”, which are suggestive of impending tissue necrosis. They are pain, paralysis, paresthesia, pulseless, and pallor and some add poikilothermia (coldness) for a sixth “P.” Our patient exhibits all but paralysis. Based on the Society for Vascular Surgery/International Society for Cardiovascular Surgery classification scheme for clinical categories of acute limb ischemia, her limb is marginally to intermediately threatened. Acute limb ischemia requires prompt diagnosis and intervention to avoid limb loss and life-threatening systemic illness resulting from tissue gangrene.12

3.a. Regular visits with assessment for interval change in symptoms, vascular examination, and ABI measurement beginning in the immediate post-procedure period and at intervals for at least 2 years. Unlike follow-up of autologous vein bypass grafts, well-established evidence-based guidelines for surveillance of post-endovascular revascularization patients do not exist. However, it is considered standard of care to evaluate these patients with interval history, examination, and measurement of the ABI regularly for at least 2 years after their percutaneous revascularization procedure.13

4.e. Warm compresses and nonsteroidal anti-inflammatory drugs for pain. Empiric anticoagulation, including outpatient anticoagulation, for superficial vein thrombosis is not routinely recommended. The clinical scenario may represent HIT and she should have a follow-up platelet count in 2 days. Her prior platelet counts from her recent hospitalization should be evaluated for a drop in platelets of ≥50% from baseline.15

5.e. An aPTT prolongation of 1.5 to 2.0 times the baseline value. Although the recommended range for therapeutic anticoagulation for VTE with a DTI is 1.5 to 2.5 times the baseline, which is not given as an option, published data indicate that anticoagulation with a DTI target aPTT of 1.5 to 2.0 times the baseline is just as efficacious and is associated with less bleeding risk.16

6.c. Normal physiologic cold response. This patient is exhibiting a normal response to prolonged exposure to cold. The diagnosis of Raynaud phenomenon is clinical and includes the presence of pallor or acrocyanosis and pain with cold exposure. Redness of the hands with warming after prolonged cold exposure, without concomitant pain, may be a normal response in a healthy young individual. He should be counseled to wear gloves and report any change in his symptoms, as his family history does predispose him to development of Raynaud phenomenon.17

7.e. Order antinuclear antibodies, erythrocyte sedimentation rate, and perform nailfold capillaroscopy. If all these tests are normal, it is very unlikely that this patient has secondary Raynaud phenomenon and no further testing is necessary.18

8.e. As needed. Although the patient does not have Raynaud phenomenon, he should be encouraged to follow up as needed because of his family history. Patients who have primary Raynaud phenomenon should have clinical follow-up for a minimum of 2 years after diagnosis.17

9.d. Pulmonary arteriogram. An arteriogram is the test most likely to confirm pulmonary artery hypertension in this patient presenting with cor pulmonale, although a right heart catheterization is usually done first. This patient most likely has chronic thromboembolic pulmonary hypertension (CTEPH), a condition seen in otherwise healthy postsplenectomy patients. Other predisposing conditions include history of pulmonary embolism, myeloproliferative disorders, and chronic inflammatory conditions.19

10.c. IV epoprostenol is an effective therapy in patients with advanced disease. Patients with CTEPH may be bridged to pulmonary endarterectomy with IV epoprostenol. The other answers are incorrect. Anticoagulation with a vitamin K antagonist is indicated; however, the INR target of 2.0 to 3.0 is recommended. The Aerosolized Iloprost Randomization (AIR) study did not demonstrate improved exercise capacity with inhaled iloprost. Bosentan does improve exercise capacity and decreases pulmonary vascular resistance, but is not advocated for use in patients with moderate-to-severe hepatic dysfunction.19

11.e. Begin a weight-based unfractionated heparin infusion. Although LMWH may be appropriate as the initial anticoagulant of choice for the treatment of an acute DVT in the ambulatory as well as hospitalized patient, it does not require a bolus. In the setting of the postoperative state where rapid reversal of anticoagulation may be required, unfractionated heparin is favored. An inferior vena cava filter would be an appropriate recommendation if anticoagulation could not be administered at therapeutic levels. Thrombolytic therapy is contraindicated in the setting of recent open heart surgery. Use of a DTI is not indicated for routine anticoagulation.22

12.e. Administration of IV unfractionated heparin intraoperatively with subsequent daily monitoring of platelet counts. The nature of immune response to heparin is anamnestic; this means a second exposure in the absence of positive antibodies is not associated with the development of a clinical hyperacute immune response. Perioperatively, heparin products should be avoided in patients with a history of HIT even with undetectable antiplatelet antibodies prior to cardiac surgery or vascular surgery. Nevertheless, heparin is favored over DTIs in cardiac and vascular surgery because of its reversibility and relative ease of use. Acute HIT is unlikely to occur even in patients who have a remote history of HIT as long as there has been no heparin exposure within the previous 100 days. This recommendation is based on expert opinion (level 1C) and not on randomized controlled trials.15

13.b. Given the clinical circumstances the laboratory finding is of doubtful clinical significance and you advise she should be anticoagulated with a vitamin K antagonist for 3 months with a target INR of 2.0 to 3.0. While the site of thrombosis is somewhat out of the ordinary, it was in the setting of abdominal surgery and was her first episode; therefore, a routine course of 3 months of anticoagulation with a vitamin K antagonist and an INR target of 2.0 to 3.0 is appropriate. All first-episode venous thrombotic events are not treated the same. Patients with malignancy-related thrombosis, idiopathic events, and those with certain thrombophilic conditions such as the antiphospholipid antibody syndrome require a longer duration of therapy relative to patients with transient risk factors for VTE. The MTHFR genetic mutation in the absence of hyperhomocysteinemia is not associated with increased risk of recurrence after discontinuation of anticoagulant therapy and has not been shown to increase thrombogenicity requiring a higher than usual INR target.23

14.d. Fatal pulmonary embolism is a leading cause of maternal mortality in the Western world. Thromboembolism is clearly the leading direct cause of maternal mortality according to the Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. The May-Thurner syndrome involves compression of the left iliac vein by the right iliac artery. The greatest teratogenicity of warfarin is seen during weeks 6 through 12. Use of LMWH in pregnant women who have prosthetic heart valves is highly controversial and certainly not the standard of care.24

15.b. Erythromelalgia. The name of this condition is based on three Greek words: erythro meaning red, melos meaning extremity, and algos meaning pain. It is uncommon, affecting about 1 in 40,000. It may be primary or secondary. Primary erythromelalgia is usually bilateral, not associated with gangrene, and patients have normal pulses. Secondary erythromelalgia is often unilateral, can be associated with gangrene, and patients have variable pulses. Secondary erythromelalgia can be associated with medications including bromocriptine, nifedipine, nicardipine, and verapamil. It may also herald the onset of a myeloproliferative disease such as polycythemia vera or essential thrombocythemia.24

16.d. Complete blood count with differential (CBC with diff). Patients with this condition should have a CBC with diff checked periodically for at least 2 to 3 years. It is important for treating physicians to recognize that erythromelalgia can precede the laboratory manifestations of a myeloproliferative disorder by up to 2 to 3 years.28

17.b. Gunther Tulip retrievable vena cava filter. This patient is young and his deep vein thrombosis is situational. He is expected to recover fully with no sequelae; thus he does not require placement of a permanent inferior vena cava filter. Proximal iliac thrombus in the setting of a hospitalized trauma patient following multiple abdominal surgeries is a very high-risk scenario for development of serious, life-threatening VTE. Anticoagulation is the treatment of choice when it can be safely administered; however, when contraindicated an inferior vena cava filter should be placed without delay. Patients with a temporary contraindication for anticoagulants should be reassessed at short intervals and, if circumstances permit, anticoagulants should be instituted for treatment of their VTE and to prevent recurrence. Of the filter types listed, only the Gunther Tulip is approved in the United States for retrieval. The OptEase is also approved for retrieval. The Bird’s Nest filter is the only filter available for use in patients with a so-called megacava (vena cava greater than 28 mm). The Bird’s Nest filter can be placed into an inferior vena cava of up to 42 mm in diameter. The TrapEase, Greenfield, and Simon Nitinol filters were not designed to have the option of retrieval.25

18.d. Surgical evacuation of the hematoma and suture repair of the artery. The patient complains of developing numbness in the setting of developing a large hematoma and pseudoaneurysm. To relieve the compressive effect of the hematoma, prevent irreversible injury, and relieve pain, the most appropriate method of repair in this patient is to evacuate the hematoma. Most small to moderately sized pseudoaneurysms can be treated with either ultrasound-guided compression, thrombin injection, or when very small may be observed for spontaneous resolution. Placement of a femoral compression device (Fem-Stop) is not appropriate in this setting, and bandages should not be wrapped proximally around the thigh as this will cause worsening swelling and pain.26

19.c. Follow up with serial duplex ultrasound scans. The peroneal vein is a calf vein with less propensity for clinically significant sequelae. Anticoagulant therapy for calf vein DVT is controversial. However, in this setting there is a clear contraindication to anticoagulate. Even prophylactic doses of anticoagulants are not advisable in patients with hemorrhagic pericardial effusions status post open heart surgery. Serial ultrasound scans have been studied as an alternative to anticoagulant therapy. If no propagation after several weeks, no anticoagulant therapy is necessary. If propagation occurs, then anticoagulation versus placement of an inferior vena cava should be considered.27

20.b. Thromboangiitis obliterans (TAO, Buerger disease). TAO classically manifests in young, male patients with a recent history of heavy tobacco use. The clinical presentation is consistent with ischemia, beginning distally and involving the small- and medium-sized arteries. Usually the lower extremities are involved, with ischemia or claudication of the feet or legs. Foot or arch claudication is typical. Occasionally, the hands are involved. If the disease progresses with continued exposure to tobacco, patients are at significant risk for progressive ischemia, ulceration, gangrene, and eventually amputation. Antiphospholipid antibody syndrome is certainly possible, but it is not a hereditary condition and most often manifests with venous thrombosis. Takayasu arteritis does not usually present in this way. Nothing is suggestive of atrophie blanche, and premature atherosclerosis presenting in a 25-year-old man with claudication and ischemia would be highly unusual.28

21.b. Cessation of exposure to all forms of tobacco. The strong link between tobacco abuse and TAO is well recognized. There have been suggestions that some patients may demonstrate an abnormal sensitivity to a component of tobacco, which leads to small vessel occlusive disease. It has been shown that patients with TAO have higher tobacco consumption as well as higher carboxyhemoglobin levels than do patients with atherosclerosis.28

22.c. May-Thurner syndrome. Also known as iliac vein compression syndrome, Cockett syndrome, or iliocaval compression syndrome, May-Thurner syndrome is caused by compression of the left common iliac vein by the right common iliac artery and the underlying vertebral body. A history of chronic left lower extremity edema with or without the presence of DVT is suggestive of May-Thurner syndrome, especially in a female population. This phenomenon causes a partial obstruction caused by physical entrapment of the vein under the artery as well as by repetitive pulsatile force resulting in intimal hyperplasia of the vein. It has been estimated that this condition occurs in 2% to 5% of patients who are evaluated for lower extremity venous problems.29

23.c. Venography for thrombus removal and stent placement. May-Thurner syndrome is an anatomical anomaly that results in repeated venous trauma and often subsequent thrombus formation. Removal of thrombus followed by angioplasty, if needed, and placement of a stent is a potentially definitive treatment that could avoid the need for indefinite anticoagulant therapy in the young woman presented in this case.29

24.c. Compression stockings. The importance of edema control is often underestimated for wound healing. This patient has deep system venous reflux. He has no signs of infection complicating the healing of his incision, so antibiotics are unlikely to be helpful. Topical steroids offer no benefit in this case. His ABIs suggest adequate arterial inflow for wound healing. Whirlpool therapy is helpful in select cases, most often when multiple small wounds are present, which need cleansing and gentle debridement. Although the size of the wound is not clearly stated, these wounds are most often small and referral for skin grafting is not indicated.30

25.b. CT venogram of the abdomen and pelvis. Monophasic (loss of respiratory phasicity) flow is suggestive of proximal venous obstruction, especially in a patient with swollen limbs and under high-risk circumstances for VTE. Monophasicity is not specific to thrombosis. Other potential causes include obesity, pregnancy, and a pelvic mass. Respiratory or cardiac dysfunction may also produce an abnormal venous flow pattern.31

26.b. Begin alteplase 100 mg IV over 2 hours. The patient presented has a clinically massive pulmonary embolism with hemodynamic compromise; thus thrombolytic therapy is indicated.32

27.b. Atrial arrhythmia. There have been many laboratory, ECG, and echocardiogram findings shown to be predictive of mortality and prognosis. Right ventricular dysfunction, particularly when accompanied by hypotension, is predictive of pulmonary embolism–related hospital mortality. Elevated serum troponin and elevated brain natriuretic peptide have also been shown to predict an increased risk of death. Additional findings associated with a poorer prognosis include atrial arrhythmia, right bundle branch block, inferior Q waves and precordial T-wave inversions, and ST-segment changes. The other distracters have not been shown to predict prognosis.

28.b. Begin enoxaparin 1 mg/kg subcutaneous injections every 12 hours. Cancer patients are at a sixfold increased risk of developing VTE. Patients with active cancer make up about 20% of all new VTE diagnosed in the community. The risk, however, varies somewhat with cancer type, and those that incur a higher risk include malignant brain tumors and adenocarcinoma of the ovary, pancreas, colon, stomach, lung, prostate, and kidney. Several studies have demonstrated a benefit to treatment with LMWH when compared with coumadin in this patient population. One study, which compared dalteparin with coumadin, reported 27 of 336 patients in the LMWH group had recurrent VTE when compared with 53 of 336 in the coumadin group in a 6-month follow-up period. There was no increased risk of bleeding in the LMWH group.33,34

29.e. Proceed with placement of an inferior vena cava filter. The patient has a proximal DVT with a contraindication for anticoagulation. This scenario represents an absolute indication for the placement of an inferior vena cava filter. Pneumatic compression stockings are indicated for the prevention of VTE but not for treatment. Serial duplex ultrasound scans may be an acceptable strategy for management of isolated acute calf vein thrombosis but not for proximal DVT. IV unfractionated heparin or enoxaparin 1 mg/kg subcutaneous injections would be appropriate treatment options if the patient did not have a recent gastrointestinal bleed requiring transfusion.35

30.c. Order bilateral ABI measurements in the vascular laboratory at rest and following an exercise protocol. The patient in the clinical vignette presented with classic intermittent claudication symptoms suggestive of PAD. A normal resting ABI does not rule out PAD in a patient presenting with ambulatory symptoms.36 Performing the test following exercise often unmasks significant disease revealing markedly lower ABI values. Exercise may be an appropriate suggestion but it will not help to establish the diagnosis of this patient’s presenting problem. It would be premature to refer this patient for intervention. Pseudoclaudication may present similarly, but this patient has risk factors for PAD; therefore, a post exercise ABI would be the most appropriate next step in their workup. Repeating the resting ABI in 6 months is not likely to provide new information.

31.c. Less than 100 mg/dL. The most recent practice guidelines for the management of PAD, updated in March 2013, recommend a target LDL of less than 100 mg/dL for patients with an established diagnosis of PAD.36

32.c. Less than 130/80 mmHg. The most recent practice guidelines for the management of PAD, updated in March 2013, recommend a target blood pressure of less than 140/90 mmHg for patients with PAD. The guidelines recommend a lower target, less than 130/80 mmHg, for patients with PAD and concomitant diabetes mellitus or renal insufficiency.36

33.e. None of the above. Thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and β-adrenergic blockers are all acceptable medications to achieve blood pressure targets in patients with PAD.36

34.c. Every 6 to 12 months. According to the appropriate use criteria published by the intersocietal committee on peripheral vascular testing and the American College of Cardiology Foundation/American Heart Association practice guidelines for PAD, patients with an asymptomatic AAA measuring 4.0 to 5.4 cm should have surveillance imaging every 6 to 12 months in the first year.36,37

35.d. 5.5 cm or greater. The patient should be referred for repair once the infrarenal AAA reaches a diameter of 5.5 cm or greater due to an increased risk of spontaneous rupture.36 Surveillance imaging is advised at regular intervals for aneurysms less than 5.5 cm.

36.e. All of the above groups are appropriate to screen for an AAA. According to the appropriate use criteria published by intersocietal committee on peripheral vascular testing all of the groups listed are appropriate for AAA screening.37

37.a. Four weeks after the intervention. All patients should get a baseline carotid duplex ultrasound within 4 weeks after a carotid artery stenting or endarterectomy procedure.37

38.b. Every 12 months. It is recommended to repeat carotid duplex ultrasound every 12 months after the first year following carotid artery stenting to assess for evidence of in-stent restenosis.37

39.c. Popliteal artery aneurysm. Shown is a transverse and longitudinal image of a large popliteal artery aneurysm containing mural thrombus. The appearance is not suggestive of an abscess, Baker cyst, lymph node, or lipoma.

40.d. 50%. A large number of patients with a popliteal artery aneurysm will also have an AAA. Furthermore, 50% of patients with a popliteal artery aneurysm will have an aneurysm of the contralateral popliteal artery.38

41.e. Refer for repair of the aneurysm. Popliteal artery aneurysms measuring greater than 2.5 cm are at risk for thrombosis, embolism, or rupture and therefore should be repaired.36 Popliteal artery aneurysms measuring less than 2.5 cm are imaged at regular intervals.

42.b. Thromboembolism. Popliteal artery aneurysms most commonly cause thromboembolism that can lead to popliteal artery occlusion or painful distal embolic lesions. Rupture of popliteal artery aneurysms occurs infrequently.38,39

43.d. Pseudoaneurysm. The spectral Doppler waveform shown is a typical to-and-fro signal seen within the neck of the pseudoaneurysm. The incidence of pseudoaneurysm complicating percutaneous arterial procedures ranges between 0.2% and 0.5%. Patients typically present post catheter-based procedure with a painful pulsatile mass. When small these may resolve spontaneously, while others require intervention such as ultrasound-guided thrombin injection or surgical repair.5

44.c. Subclavian artery stenosis. Color Doppler imaging shows significant color aliasing, spectral broadening, and turbulent high-velocity flow within the subclavian artery. It is important to recognize severe subclavian artery stenosis prior to coronary artery bypass surgery in which the internal mammary artery may be utilized. Severe subclavian artery stenosis can lead to retrograde flow in the internal mammary artery predisposing to early graft failure. In an aneurysm usually the velocities are decreased.

45.c. Warfarin skin necrosis. Pictured is a large erythematous lesion with surrounding violaceous borders. Given the history of several days of high doses of warfarin without parental anticoagulation makes warfarin skin necrosis the most correct response. Heparin skin necrosis has been described but usually occurs at the site of subcutaneous injections.

HIT can rarely be associated with necrotic skin lesions but in this case her platelets remained stable. A vasculitis can cause skin necrosis but is unlikely in the given scenario.

46.d. Aortic valve stenosis. The waveforms in the bilateral internal carotid and vertebral arteries have a Tardus-Parvus morphology. They have a blunted and slow upstroke, suggesting more proximal or central narrowing. In this patient, these findings along with a systolic murmur are suggestive of aortic valve stenosis.

47.d. Saddle pulmonary embolism. This patient has a pulmonary embolism involving both main pulmonary arteries. Massive and submassive pulmonary embolism can cause an increase in troponin and B-type natriuretic peptide as seen in acute myocardial infarction. The image shown illustrates a filling defect within the main pulmonary artery at the bifurcation. There are no findings suggestive of aortic dissection, pneumonia, or interstitial fibrosis.

48.c. Carotid intima-media thickness. According to the latest American College of Cardiology/American Heart Association cardiovascular risk assessment guidelines, there is insufficient evidence available to recommend use of carotid intima-media thickness, ApoB, albuminuria, glomerular filtration rate, or cardiorespiratory fitness in cardiovascular risk assessment. There is adequate evidence to recommend use of high-sensitivity C-reactive protein, ABI, coronary artery calcium score, and a family history of premature cardiovascular disease for refinement of cardiovascular risk assessment.40

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