Nesvs 2013 Postgraduate Course Self-assessment Exam

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| By Angela Wetherbee
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Angela Wetherbee
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Quizzes Created: 2 | Total Attempts: 177
Questions: 18 | Attempts: 65

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Nesvs 2013 Postgraduate Course Self-assessment Exam - Quiz

The 2013 Postgraduate Course of the New England Society for Vascular Surgery has been assigned 4.00 self-assessment credits. In order to receive these self-assessment credits, a minimum performance level of 75% must be attained. Multiple attempts are permitted, but all exams must be completed within 10-days of the conclusion of the course (Friday, October 11, 2013). There are no exceptions to this deadline.


Questions and Answers
  • 1. 

    Which of the following trials does not support the use of CEA for the management of asymptomatic carotid artery stenosis?

    • A.

      ACAS

    • B.

      ACST

    • C.

      CREST

    • D.

      NASCET

    Correct Answer
    D. NASCET
    Explanation
    The correct answer is NASCET. NASCET (North American Symptomatic Carotid Endarterectomy Trial) was conducted to evaluate the effectiveness of carotid endarterectomy (CEA) in patients with symptomatic carotid artery stenosis, not asymptomatic carotid artery stenosis. Therefore, it does not support the use of CEA for the management of asymptomatic carotid artery stenosis. ACAS (Asymptomatic Carotid Atherosclerosis Study), ACST (Asymptomatic Carotid Surgery Trial), and CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) are trials specifically designed to assess the use of CEA in asymptomatic carotid artery stenosis.

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  • 2. 

    Under current CMS reimbursement guidelines all of the following treatment scenarios is eligible for reimbursement from Medicare except?

    • A.

      Carotid angioplasty and stenting for 80% stenosis in an asymptomatic low risk patient outside of a clinical trial

    • B.

      CEA for symptomatic high risk patients with 80% stenosis

    • C.

      CEA for asymptomatic patients with 80% stenosis

    • D.

      Carotid angioplasty and stenting with any approved CAS system for symptomatic high risk patients with 80 % stenosis

    Correct Answer
    A. Carotid angioplasty and stenting for 80% stenosis in an asymptomatic low risk patient outside of a clinical trial
    Explanation
    The given correct answer is "Carotid angioplasty and stenting for 80% stenosis in an asymptomatic low-risk patient outside of a clinical trial." This treatment scenario is not eligible for reimbursement from Medicare under current CMS reimbursement guidelines. The guidelines specify that carotid angioplasty and stenting are only eligible for reimbursement in symptomatic high-risk patients or in asymptomatic patients with contralateral carotid occlusion. Asymptomatic low-risk patients do not meet the criteria for reimbursement in this scenario.

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  • 3. 

    In the United States which of the statements concerning the management of carotid artery disease is TRUE?

    • A.

      CEA is performed more frequently for symptomatic carotid artery disease than asymptomatic disease

    • B.

      CAS is performed more frequently by vascular surgeons than by cardiologists

    • C.

      Significant regional variation exists in the use of CAS and CEA to manage carotid artery stenosis

    • D.

      Carotid angioplasty and stenting comprises 50% of the intervention for carotid artery disease in the United States

    Correct Answer
    C. Significant regional variation exists in the use of CAS and CEA to manage carotid artery stenosis
    Explanation
    There is significant regional variation in the use of CAS (carotid angioplasty and stenting) and CEA (carotid endarterectomy) to manage carotid artery stenosis in the United States. This means that different regions in the country have different preferences and practices when it comes to these treatments. The statement does not provide information about the frequency of CEA for symptomatic or asymptomatic carotid artery disease, the frequency of CAS performed by vascular surgeons or cardiologists, or the percentage of carotid artery interventions that are comprised of carotid angioplasty and stenting.

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  • 4. 

    The potential benefits of using a flow reversal system for CAS compared with distal filters include all of the following except:

    • A.

      Decreased risk of microemboli to the brain

    • B.

      Lower profile devices and smaller sheath size

    • C.

      Ability to have cerebral protection in place before crossing the stenosis with a guide wire

    • D.

      The ability to use any FDA approved carotid stent

    • E.

      Active aspiration of debris or in line flow reversal to minimize the risk of atheroembolization

    Correct Answer
    B. Lower profile devices and smaller sheath size
    Explanation
    Using a flow reversal system for CAS offers several potential benefits. These include decreased risk of microemboli to the brain, the ability to have cerebral protection in place before crossing the stenosis with a guide wire, the ability to use any FDA approved carotid stent, and active aspiration of debris or in line flow reversal to minimize the risk of atheroembolization. However, it does not provide the benefit of lower profile devices and smaller sheath size.

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  • 5. 

    Upcoming or current carotid stent trials in the United States involving CAS include the following:

    • A.

      ROADSTER Trial using direct cervical carotid access and flow reversal

    • B.

      CREST II trial to prospectively evaluate CAS vs. CEA vs. best medical therapy for carotid stenosis

    • C.

      Bioabsorbable drug eluting stent trial to treat carotid stenosis

    • D.

      A and B

    Correct Answer
    D. A and B
    Explanation
    The correct answer is A and B. The explanation for this answer is that the question is asking for the upcoming or current carotid stent trials in the United States involving CAS (carotid artery stenting). The ROADSTER trial involves the use of direct cervical carotid access and flow reversal, while the CREST II trial aims to evaluate CAS versus CEA (carotid endarterectomy) versus best medical therapy for carotid stenosis. Therefore, options A and B are the correct choices as they both involve carotid stent trials in the United States.

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  • 6. 

    Potential high risk criterion for inclusion in ongoing carotid angioplasty and stenting trials include all of the following except:

    • A.

      History of previously treated coronary artery disease with normal ejection fraction

    • B.

      Previous CEA

    • C.

      Prior neck irradiation

    • D.

      High bifurcation with difficult to access distal endpoint

    • E.

      Contralateral ICA occlusion

    Correct Answer
    A. History of previously treated coronary artery disease with normal ejection fraction
    Explanation
    The potential high risk criteria for inclusion in ongoing carotid angioplasty and stenting trials include previous CEA (carotid endarterectomy), prior neck irradiation, high bifurcation with difficult to access distal endpoint, and contralateral ICA (internal carotid artery) occlusion. However, a history of previously treated coronary artery disease with normal ejection fraction is not considered a high-risk criterion for inclusion in these trials.

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  • 7. 

    Which of the following criterion are listed as potential requirements when applying to become a CMS approved center to perform and be reimbursed for CAS?

    • A.

      Participation in an ongoing outcome data collection with regular reporting of outcomes to CMS and recertification every two years

    • B.

      Evidence of prior participation in carotid stenting clinical trials

    • C.

      Attestation by the facility that high quality imaging and advanced physiologic monitoring exists to perform CAS in the angio suite

    • D.

      Attestation that CAS interventionalists undergo a specific credentialing process with ongoing assessment of individual and institutional outcomes

    • E.

      Attestation that all patients are seen by a vascular surgeon who determines that they are too high risk for an open procedure

    Correct Answer
    E. Attestation that all patients are seen by a vascular surgeon who determines that they are too high risk for an open procedure
    Explanation
    The correct answer is "Attestation that all patients are seen by a vascular surgeon who determines that they are too high risk for an open procedure." This criterion is listed as a potential requirement when applying to become a CMS approved center to perform and be reimbursed for CAS. It ensures that patients who undergo CAS have been evaluated by a vascular surgeon and deemed too high risk for an open procedure. This helps to ensure patient safety and appropriate selection of candidates for CAS.

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  • 8. 

    Which of the following results of the CREST trial are true?

    • A.

      The rate of stroke/death and MI was not different between CAS and CEA

    • B.

      The rate of stroke/death for all patients was higher in CAS vs. CEA

    • C.

      Only asymptomatic patients were treated in the CREST trial

    • D.

      Only A and B

    Correct Answer
    D. Only A and B
    Explanation
    The CREST trial, a study comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA), found that the rate of stroke/death and myocardial infarction (MI) was not different between the two procedures. This means that the risk of these complications was similar whether patients underwent CAS or CEA. Additionally, the trial did not exclusively include asymptomatic patients, as indicated by the statement that the rate of stroke/death for all patients was higher in CAS compared to CEA. Therefore, the correct answer is "Only A and B."

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  • 9. 

    Which of the following statements concerning the 2011 SVS Guidelines concerning the management of extracranial carotid disease is not true?

    • A.

      CAS is indicated in symptomatic patients who are high risk for CEA

    • B.

      CEA is the first line treatment for symptomatic patients with 60-99% stenosis

    • C.

      CAS is indicated in some asymptomatic low risk patients outside of clinical trials

    • D.

      CEA is indicated in selected asymptomatic patients with 60-99% stenosis

    • E.

      Statin therapy should be implemented along with antiplatelet therapy in patients undergoing carotid intervention

    Correct Answer
    C. CAS is indicated in some asymptomatic low risk patients outside of clinical trials
    Explanation
    The 2011 SVS Guidelines state that CAS is not indicated in asymptomatic patients outside of clinical trials. Therefore, the statement "CAS is indicated in some asymptomatic low risk patients outside of clinical trials" is not true.

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  • 10. 

    Which of the following statements concerning the ACC/AHA carotid guidelines is not true?

    • A.

      Simultaneous Carotid revascularization (CEA/CABG) is supported by Level 1 evidence for asymptomatic patients with 80% stenosis undergoing coronary revascularization

    • B.

      CEA should be considered for high risk symptomatic patients with 80% stenosis

    • C.

      CAS should be considered for high risk surgical patients with 80% stenosis

    • D.

      Vascular surgeons, cardiologists and vascular medicine specialists participated in writing these guidelines

    Correct Answer
    A. Simultaneous Carotid revascularization (CEA/CABG) is supported by Level 1 evidence for asymptomatic patients with 80% stenosis undergoing coronary revascularization
    Explanation
    Simultaneous Carotid revascularization (CEA/CABG) is not supported by Level 1 evidence for asymptomatic patients with 80% stenosis undergoing coronary revascularization.

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  • 11. 

    In patients with non-obstructive atherosclerotic disease and TIA’s preferred on no prior antiplatelet therapy, initial antithrombotic treatment may include all of the following except:

    • A.

      Aspirin 81 mg

    • B.

      Plavix 75 mg in aspirin intolerant patients

    • C.

      Aspirin 325 and Plavix 75 mg

    • D.

      Aspirin and dipyridamole combination

    • E.

      Aspirin 325 mg

    Correct Answer
    C. Aspirin 325 and Plavix 75 mg
    Explanation
    The combination of Aspirin 325 and Plavix 75 mg is not preferred as an initial antithrombotic treatment in patients with non-obstructive atherosclerotic disease and TIA's who have no prior antiplatelet therapy. The other options listed, such as Aspirin 81 mg, Plavix 75 mg in aspirin intolerant patients, Aspirin and dipyridamole combination, and Aspirin 325 mg, may be considered as initial antithrombotic treatments in these patients.

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  • 12. 

    The CREST trial did not demonstrate which of the following:

    • A.

      Higher incidence of cranial nerve injury for patients undergoing CEA

    • B.

      Higher incidence of MI in patients undergoing CEA

    • C.

      The lowest incidence of Stroke in both the CEA and the CAS group of any prospective multicenter randomized carotid trial

    • D.

      No difference in the outcomes of CAS for Vascular surgeons compared to cardiologists in the Pivotal arm of the trial

    • E.

      A lower overall incidence of stroke for CAS than with CEA

    Correct Answer
    E. A lower overall incidence of stroke for CAS than with CEA
    Explanation
    The CREST trial did not demonstrate a lower overall incidence of stroke for CAS (carotid artery stenting) compared to CEA (carotid endarterectomy).

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  • 13. 

    Which of the following statements concerning the use of TCD is true?

    • A.

      Transcranial Doppler is performed using an ultrasound probe to insonate the intracerebral vessels through the frontal bone window

    • B.

      Directionality of flow may be assessed in the middle cerebral artery

    • C.

      Microemboli from either air or plaque may be detected only during CEA and not CAS

    • D.

      A and C

    Correct Answer
    B. Directionality of flow may be assessed in the middle cerebral artery
    Explanation
    Transcranial Doppler (TCD) is a procedure that uses an ultrasound probe to assess blood flow in the intracerebral vessels through the frontal bone window. It can be used to determine the directionality of flow in specific arteries, such as the middle cerebral artery. This means that TCD can help identify the direction in which blood is flowing in the middle cerebral artery, which is important for evaluating blood flow patterns and detecting any abnormalities. The statement is true because TCD can indeed assess the directionality of flow in the middle cerebral artery.

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  • 14. 

    The different types of embolic protection used during carotid angioplasty and stenting trials have included:

    • A.

      Distal filters or baskets placed in the distal internal carotid artery in the neck

    • B.

      Distal filters or baskets placed in the intracerebral carotid artery

    • C.

      Proximal occlusion with flow reversal systems placed in the common carotid artery

    • D.

      A and C

    Correct Answer
    D. A and C
    Explanation
    The correct answer is A and C. During carotid angioplasty and stenting trials, two types of embolic protection methods have been used. One method is the use of distal filters or baskets placed in the distal internal carotid artery in the neck, which helps to catch any emboli that may be released during the procedure. The other method is proximal occlusion with flow reversal systems placed in the common carotid artery, which redirects blood flow away from the carotid artery during the procedure to prevent emboli from reaching the brain. Therefore, options A and C are the correct choices as they describe the different types of embolic protection used during carotid angioplasty and stenting trials.

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  • 15. 

    Which of the following statements concerning data supporting medical management of asymptomatic carotid stenosis is not TRUE?

    • A.

      A recent metaanalyses published in Stroke in 2009 suggested that medical intervention alone was the best method to prevent stroke in asymptomatic patients

    • B.

      This article suggests that the rate of stroke with medical intervention has fallen over the past 2 decades

    • C.

      In these studies only patients with severe (70-89%) and critical (> 90%) stenoses were included

    • D.

      A recent study from the MGH demonstrated that asx patients with severe or critical stenoses on optimal medical therapy had a 25% incidence of neurologic symptoms at 5 years

    Correct Answer
    C. In these studies only patients with severe (70-89%) and critical (> 90%) stenoses were included
    Explanation
    The given statement that is not true is "In these studies only patients with severe (70-89%) and critical (> 90%) stenoses were included". This is because the previous statements mention that medical intervention alone is the best method to prevent stroke in asymptomatic patients and that the rate of stroke with medical intervention has fallen over the past 2 decades. Therefore, it implies that these studies included patients with various degrees of carotid stenosis, not just severe and critical stenoses.

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  • 16. 

    Which of the following statements concerning diffusion weighted MRI after carotid intervention is not true:

    • A.

      New bright areas on diffusion weighted MRI have been detected after all types of carotid intervention

    • B.

      It is thought that these areas correlate with new areas of microemboli to the brain

    • C.

      Long-term decline in neurocognitive functioning has been hypothesized to correlate with new areas of microemboli

    • D.

      New bright areas on diffusion weighted MRI only occur on the same side of the carotid intervention

    Correct Answer
    D. New bright areas on diffusion weighted MRI only occur on the same side of the carotid intervention
    Explanation
    The given correct answer states that new bright areas on diffusion weighted MRI only occur on the same side of the carotid intervention. This means that after carotid intervention, the new bright areas on diffusion weighted MRI are not observed on the opposite side of the intervention. This statement suggests that the microemboli causing these new bright areas are localized to the same side of the carotid intervention and do not spread to the other side.

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  • 17. 

    A 69 year old female in presents with peripheral arterial disease and asymptomatic recurrent carotid stenosis after a previous Right CEA x 2. Optimal medical management for this patient would include all of the following except:

    • A.

      Aspirin as an antiplatelet agent

    • B.

      Smoking cessation

    • C.

      Coumadin for anticoagulation for her PAD and carotid stenosis

    • D.

      Atorvastatin for management of cholesterol

    Correct Answer
    C. Coumadin for anticoagulation for her PAD and carotid stenosis
    Explanation
    The correct answer is Coumadin for anticoagulation for her PAD and carotid stenosis. Coumadin (warfarin) is not typically used for anticoagulation in peripheral arterial disease (PAD) and carotid stenosis. Instead, antiplatelet agents like aspirin are commonly used to prevent clot formation. Smoking cessation is important to reduce the risk of further arterial disease progression. Atorvastatin is a statin medication used to manage cholesterol levels, which is beneficial in reducing the risk of cardiovascular events in patients with PAD and carotid stenosis.

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  • 18. 

    This patient has asymptomatic recurrent stenosis in the RICA with 50-69% stenosis by carotid duplex examination which has been stable for the past two years. The best therapy for treating her carotid stenosis would be optimal medical therapy and:

    • A.

      Redo carotid endarterectomy

    • B.

      Carotid Angioplasty and stenting from a transfemoral approach

    • C.

      Carotid angioplasty and stenting from a direct transcervical approach

    • D.

      Optimal medical therapy alone and continued surveillance

    Correct Answer
    D. Optimal medical therapy alone and continued surveillance
    Explanation
    The patient has asymptomatic recurrent stenosis in the RICA with 50-69% stenosis, which has been stable for the past two years. In this case, the best therapy would be optimal medical therapy alone and continued surveillance. This means that the patient should receive medication and lifestyle changes to manage their condition, without any invasive procedures such as redo carotid endarterectomy or carotid angioplasty and stenting. Since the stenosis has been stable and the patient is asymptomatic, the risk of complications from invasive procedures outweighs the potential benefits. Regular monitoring and medical management are sufficient in this case.

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