Rivaroxaban 2.5 + ASA vs DAPT PAD?
Inferior
Superior MALE
Equal bleed
MACE worse
Explanation: Better limb outcomes COMPASS/VOYAGER.
Complex polyvascular atherosclerosis patient with borderline ABI, elevated ABI in one leg from calcification, low TBI. Illustrates need for?
Multimodal assessment (ABI + TBI + duplex) in high-risk
Invasive angiography first
Single-test reliance
No testing
Explanation: Guidelines advocate complementary tests in diabetes/CKD where ABI limited by calcification.
A 38-year-old female with May-Thurner anatomy (left CIV stenosis 65%) develops acute DVT post- partum (day 5). After catheter-directed thrombolysis (CDT) with tPA 0.5 mg/hr x 24 hrs reducing clot burden >90%, venogram shows residual 50% recoil stenosis. IVUS confirms post-balloon area 55 mm². What is the primary risk if stenting is deferred, and the most evidence-based anticoagulation duration post- stenting?
Pulmonary embolism (25% risk); indefinite LMWH
Chronic PTS (50% risk); 6-12 months anticoagulation
Recurrent ipsilateral DVT (40% risk); 3 months DOAC
Stent fracture (15% risk); 1 month warfarin
Explanation: Untreated residual iliofemoral stenosis >50% post-DVT predicts chronic PTS in 50% at 2 years due to ambulatory venous hypertension; stenting reduces this to <20%. Guidelines recommend 6-12 months therapeutic anticoagulation post-venous stenting in provoked DVT with thrombophilia, transitioning to DOAC; indefinite only if unprovoked/recurrent. PE risk is mitigated by filter if needed, but not primary here; fracture rare with proper sizing.
A 50-year-old with leg ulcers painful punched stellate atrophie blanche white ivory plaques medial ankles surrounded telangiectasia livedo reticularis broken net irregular persistent cold-aggravated, non-pitting edema mild Stemmer negative arms normal, pulses normal no bruits abdominal silent. Skin finding vasculitis subtype?
Lymphedema Stemmer positive
Livedoid vasculopathy livedo racemosa
Physiologic cutis marmorata
FMD string beads palpable
Explanation: Livedoid vasculopathy (livedo racemosa irregular + painful ulcers atrophie blanche) thrombophilic arteritis microvessels fibrin thrombi, antiphospholipid common; vs physiologic regular transient.
Post-thrombolysis for Rutherford IIb ALI (motor deficit onset 6 hours), tPA at 0.75 mg/hr x 18 hours lyses 80% SFA thrombus. Labs: D-dimer 4500 ng/mL, platelets 95k/μL, no bleeding. Angiogram shows residual thrombus with poor runoff. Optimal adjunct?
Extend tPA to 36 hours
Percutaneous mechanical thrombectomy (PMT)
Balloon maceration alone
Systemic heparin 18 units/kg/hr
Explanation: For Rutherford IIb (irreversible risk if delayed), hybrid CDT+PMT (e.g., AngioJet) clears
residual thrombus in 95% cases, shortening lysis time/reducing tPA dose (bleeding OR 0.4 vs CDT alone). High D-dimer/platelets signal ongoing thrombosis; balloon risks distal embolization without extraction.
2024 guidelines Class I for hybrid in <14-day onset.
Elderly man with polymyalgia rheumatica develops vision loss. ESR 105. TA biopsy: giant cells, elastic disruption. MRA: vertebral stenosis causing vertebrobasilar ischemia. What MMP-driven process affects intracranial vessels?
Distal corkscrew recanalization
Lymphocyst compression
Giant cell elastolysis and intimal hyperplasia extending intracranially
Popliteal myofibroblast entrapment
Explanation: Giant cell arteritis intracranial extension (5-10%) involves granulomatous inflammation with MMP-9/granzyme from CD68+ macrophages destroying internal elastic lamina, leading to stenosis/thrombosis; endovascular balloon angioplasty/stenting for refractory vertebrobasilar. Temporal artery classic; PET differentiates mimics. High-dose steroids urgent.
A 70-year-old male with erectile dysfunction and bilateral buttock claudication undergoes CTA showing bilateral common iliac artery occlusions with reconstitution of external iliac arteries and infrarenal aortic stenosis of 70%. This lesion pattern is classified as TASC II.
Type B suitable for endovascular as preferred
Type C with endovascular feasible in experienced centers
Type A recommending endovascular therapy
Type D traditionally favoring open surgical reconstruction
Explanation: TASC II classification for aortoiliac lesions describes Type D as extensive disease including bilateral common iliac occlusions, diffuse aortic involvement, or complex bilateral iliac occlusions requiring reconstruction. These are traditionally recommended for open surgical repair (aortobifemoral bypass) due to superior long-term patency. However, advancements in endovascular techniques (covered stents, re- entry devices) have expanded feasibility for Type D in high-surgical-risk patients, though open surgery remains the durability standard in good-risk candidates. The described bilateral occlusions with aortic
involvement fits classic Type D morphology.
Rutherford 6 CLI diabetic, AT/PTA CTOs diffuse, angiosome direct revascularization anterior wound. 2026 BTK strategy maximizes wound healing?
Loop technique AT-PTA
Single runoff vessel
Angiosome indirect
Above-ankle only
Explanation: Infrapopliteal CLI, loop revascularization AT/PTA restores foot arch, healing >80% vs single vessel; angiosome adjunct.
Acute thromboembolism iliac stent thrombosis. Virchow?
Injury metal
Hypercoag clopi resist
Stasis stent
All
A 48-year-old female post-iliac vein stenting for chronic occlusion develops acute calf pain 6 hours later, anterior compartment pressure 42 mmHg (diastolic BP 85 mmHg), CK 8,500 U/L rising, no arterial injury on angiogram. Scenario confirms reperfusion after 14-day occlusion. Intervention?
Leg elevation and mannitol
Hyperbaric oxygen therapy
Four-compartment fasciotomy
CDT of venous thrombus
Explanation: Atypical compartment syndrome from reperfusion injury post-venous recanalization occurs via edema from oxygen free radicals and neutrophil activation in ischemic tissue, indicated by delta pressure <20 mmHg; emergent fasciotomy decompresses all four compartments to halt myonecrosis progression, with 80% limb salvage if <12 hours delay. Supportive alkalinization prevents AKI from myoglobin.
Thrombosis on DES: malapposition gap 0.3 mm. Cause?
Hypersensitivity polymer
Positive remodeling recoil
Stent underexpansion
Neoatherosclerosis lipid ingress
Explanation: Underexpansion <80% area creates flow disturbance.
A 65-year-old male with PAD and recent endovascular iliac stenting is on aspirin. He develops atrial fibrillation requiring anticoagulation.
Switch to rivaroxaban 2.5 mg twice daily plus aspirin
Continue aspirin, add full-dose DOAC without overlap
Add warfarin, discontinue aspirin
Initiate apixaban full dose plus aspirin
Explanation: In PAD patients requiring anticoagulation for separate indications (e.g., atrial fibrillation), full- dose direct oral anticoagulant (preferably reduced-dose if eligible) combined with single antiplatelet therapy balances thromboembolic protection without excessive bleeding compared to triple therapy or vascular- dose regimens designed for atherothrombotic prevention alone.
2026 WHO projections estimate LMIC PAD doubling by 2045 driven by smoking epidemic. A 51-year- old Chinese male 22 pack-year smoker, abdominal obesity, fasting glucose 118 mg/dL, ABI 0.93. What risk transition predominates emerging economies?
Diabetes predominance
Hypertension control improvement
Aging demographics
Smoking prevalence decline
Explanation: Westernization produces diabetes epidemic preceding obesity/smoking as dominant PAD driver in urbanizing LMICs. Insulin resistance accelerates atherogenesis 8-12 years premature versus Caucasians. Impaired fasting glucose 100-125 mg/dL triples risk with HbA1c >6.0% predicting conversion. Metformin initiation age <55 years reduces microvascular progression 37%.
Aortic saccular coil jail cuff?
Rupt
Fail
Mig
Shrink no EL
Explanation: Unconventional success.
A 65-year-old female presents with a 3 cm shallow ulcer over the medial malleolus, granulating base, surrounding stasis dermatitis, hyperpigmentation, and moderate edema worse with dependency. Pulses are palpable, no elevation pallor. Duplex shows great saphenous reflux >4 seconds standing. Per latest guidelines, which physical finding best differentiates pure venous from mixed arterial-venous ulcer?
Pain worsening with leg dependency
Granulating base with moderate exudate
Palpable pedal pulses without ischemic signs
Shallow irregular shape with sloping edges
Explanation: Palpable pedal pulses without ischemic signs (prolonged elevation pallor, rubor delay) strongly favor pure venous etiology, as arterial/mixed ulcers often have diminished pulses or ABI <0.9. Shallow irregular ulcers with granulation are classic venous; dependency worsening relates to venous hypertension; sloping edges typical venous vs punched-out arterial.
A 70-year-old male with 35 pack-year history has AAA ultrasound showing 3.1 cm diameter. His calculated AAA growth rate from prior study (2 years ago) was 0.2 cm/year.
According to 2026 SVS surveillance guidelines, what is the appropriate follow-up interval?
No further imaging needed
Every 3 years
Every 6 months
Annually
Explanation: The 2026 SVS guidelines recommend ultrasound surveillance every 3 years for AAA 3.0-3.9 cm, every 12 months for 4.0-4.9 cm, and every 6 months for 5.0-5.4 cm. Growth rate <0.5 cm/year does not alter these intervals unless size thresholds are met.
In MESA study 2025 update, asymptomatic 60-year-olds screened ABI<0.9. Multivariate model: diabetes OR 2.8, CKD eGFR<60 OR 3.2. Calculate combined relative risk (assume independence) for PAD if both present vs neither.
8.96-fold
No multiplicative
2.8-fold
5.9-fold
Explanation: Multiplicative risk: diabetes OR 2.8 × CKD OR 3.2 = 8.96; CKD+PAD doubles amputation/mortality vs single. eGFR<45 OR>5; diabetes duration >15 years triples. Intensive glycemic/BP control slows progression 25%.
GCA temporal biopsy + PET aorta SUV 6.2 active vision loss ESR 95.
Entrapment
Venography
Duplex carotid
PET systemic
Explanation: PET GCA.
A 65-year-old male with cancer-associated PE and thrombocytopenia (platelets 60 x10^9/L).
Transfuse platelets then anticoagulate
Full-dose DOAC
Hold anticoagulation
Reduced-dose LMWH with monitoring
Explanation: Mild-moderate thrombocytopenia allows cautious reduced-dose LMWH.