Post-Test Questions

Article 1 (3–10)

1. Direct acting oral anticoagulants are best avoided in which of the following populations:

   • Young patients with venous thromboembolism.

   • Patients with unprovoked venous thromboembolism.

   • Patients after bariatric surgery.

   • Patients with estrogen-associated DVT.

2. Which of the following drugs is not dependent on renal function for elimination?

   • Low-molecular-weight heparin.

   • Dabigatran.

   • Warfarin.

   • ivaroxaban

3. The anticoagulant of choice for the treatment of cancer-associated venous thromboembolism is:

   • Vitamin K antagonists (e.g., warfarin).

   • Low-molecular-weight heparins (e.g., dalteparin, enoxaparin).

   • Rivaroxaban.

   • Apixaban.

   Article 2 (11–15)

4. A 70-year-old woman with a PE has a blood pressure of 120/80, heart rate of 115 beats/minute, RV strain on echocardiography, and an elevated troponin. This PE qualifi es as a:

   • High-risk PE.

   • Massive PE.

   • High-risk intermediate PE.

   • Low-risk intermediate PE.

   • Low-risk PE.

5. The ULTIMA trial randomizing 59 patients to receive CDT versus heparin alone had this/these key fi ndings:

   • Mortality reduction in patients receiving CDT.

   • Reduction in the rate of clinical deterioration in patients receiving CDT.

   • Higher intracranial bleeding in the CDT group.

   • Signifi cant reduction in right heart dilation at 24 hours in the CDT group compared to heparin group, with no diff erence in bleeding rates.

6. The single-arm SEATTLE II trial of 150 CDT-treated patients had this (these) key fi ndings:

   • Signifi cant reduction in right heart dilation at 48 hours, but with 11% major bleeds.

   • Multiple intracranial bleeds.

   • Signifi cant reduction in right heart dilation at 3 months.

   • Improvement in long-term quality of life.

   Article 3 (16–24)

7. Which of the following treatments for PE do the majority of patients treated by a PERT receive?

   • Anticoagulation alone.

   • Catheter-directed thrombolysis.

   • Surgical thromboembolectomy.

   • Inferior vena cava fi lter.

   • Systemic thrombolysis.

8. Which of the following best describes the main benefit of a PERT?

   • Creation of a treatment algorithm that incorporates data comparing diff erent treatments for PE.

   • Multidisciplinary discussion of cases by specialists with diff erent perspectives.

   • Increased use of thrombolysis over time.

   • More effi cient billing for consultations.

   • Direction of procedures to a single group.

9. In order to be sustainable, a PERT should ensure different procedural specialists on the team:

   • Perform all procedures exactly the same way.

   • Have similar thresholds for performing an intervention.

   • Distribute nonprocedural work equitably and fairly.

   • Unanimously agree prior to performing any procedure.

   • Are from the same department.

   Article 4 (25–34)

10. Compared to systemic thrombolysis, catheter-directed thrombolysis is associated with:

    • Higher incidence of bleeding

    • Same incidence of PE

    • Increased administration of lytic agent

    • More rapid and complete thrombolysis

11. A 27-year-old woman presents with an acute extensive inferior vena cava thrombosis and unilateral left leg swelling. She is admitted to the hospital and initiated on systemic anticoagulation. However, her symptoms persist while still in the hospital. The patient is being considered for percutaneous pharmaco-mechanical catheter-directed thrombolysis. Which of the following would discourage this treatment option?

    • Recent obstetrical delivery.

    • Known seizure disorder.

    • Recent ovarian mass biopsy.

    • All of the above.

12. A 76-year-old man with history of DVT had a right hip replacement 5 days ago. Postoperatively he develops progressive bilateral lower extremity edema. CT venogram demonstrates complete thrombosis of his bilateral common iliac veins and inferior vena cava, up to the level of a previously placed retrievable inferior vena cava fi lter. Which treatment modality would be most reasonable?

    • Systemic thrombolysis.

    • Catheter-directed thrombolysis.

    • Catheter-directed suction thrombectomy.

    • Open surgical thrombectomy of iliocaval venous system.

    Article 5 (35–49)

13. The fi rst-line anticoagulation agents for the management of pediatric VTE are:

    • Unfractionated heparin, direct thrombin inhibitors, and direct oral anticoagulants.

    • Low-molecular-weight heparin, vitamin K antagonists, and direct thrombin inhibitors,

    • Unfractionated heparin, low-molecular-weight heparin, and vitamin K antagonists.

    • Direct oral anticoagulants, low-molecular-weight heparin, unfractionated heparin.

14. Which of the following is CORRECT regarding the placement of inferior vena cava fi lters in pediatric patients:

    • Permanent devices are preferred and are predominately used in adolescent patients for primary prophylaxis (i.e., after severe trauma, malignancy, or orthopedic surgery).

    • Retrievable devices are preferred and are predominately used in adolescent patients for primary prophylaxis (i.e., after severe trauma, malignancy, or orthopedic surgery).

    • Permanent devices are preferred, and are predominately used in adolescent patients with lower extremity DVT and contraindications for anticoagulation.

    • Retrievable devices are preferred, and are predominately used in adolescent patients with lower extremity DVT and contraindications for anticoagulation.

15. Which of the following multimodal treatment strategy is recommended for the management of pediatric venous thoracic outlet syndrome:

    • Conventional anticoagulation therapy and prompt catheter-based thrombolytic therapy, followed by surgical thoracic outlet decompression.

    • Conventional anticoagulation therapy and prompt catheter-based thrombolytic therapy followed by long-term arm activity restrictions.

    • Prompt systemic thrombolytic therapy, followed by surgical thoracic outlet decompression and long-term arm activity restrictions.

    • Prompt catheter-based thrombolytic therapy, followed by surgical thoracic outlet decompression and long-term arm activity restrictions

    Article 6 (50–53)

16. Why is low-molecular-weight heparin (LMWH) considered the treatment of choice for patients with cancer-related DVT?

    • LMWH has been shown to reduce recurrent thrombosis compared with warfarin therapy in randomized trials.

    • LMWH cannot cause heparin-induced thrombocytopenia.

    • LMWH has been shown to reduce recurrent thrombosis compared with new oral anticoagulants in randomized trials.

    • Bleeding with LMWH occurs with 50% reduced frequency compared to warfarin and new oral anticoagulants.

17. Which patient is the most appropriate candidate for catheter-directed thrombolysis?

    • An 84-year-old man with prostate cancer who underwent surgical prostatectomy 5 days ago and developed an acute left femoral DVT.

    • A 55-year-old man with abdominal lymphoma and acute DVT of the right iliac and common femoral veins.

    • A 44-year-old woman with acute iliofemoral DVT who is chronically bedridden from widely disseminated breast cancer.

    • A 35-year-old man with glioblastoma and acute left iliofemoral DVT.

18. Which of the following is a true statement about cancer-related DVT?

    • Cancer patients do not develop postthrombotic syndrome.

    • Cancer patients are more likely to experience bleeding from treatment.

    • Cancer patients with isolated calf DVT should undergo ultrasound surveillance without anticoagulation.

    • The presence of cancer is a contraindication to performance of catheter-directed thrombolysis.

    Article 7 (54–60)

19. What is the most common cause of upper extremity deep vein thrombosis?

    • Cancer.

    • Presence of a central venous catheter.

    • Paget-Schroetter syndrome (eff ort thrombosis).

    • Coagulopathy.

    • None of the above.

20. What is the optimal timing for fi rst-rib resection following thrombolysis for Paget-Schroetter syndrome?

    • As soon as possible, during the same hospitalization as thrombolysis.

    • 3-12 weeks after thrombolysis.

    • First-rib resection should not be routinely performed, except in cases of recurrent PSS.

    • There is insuffi cient evidence to determine a single, optimal timing for fi rst-rib resection.

    • None of the above.

21. Which of the following is an indication for peripherally inserted central catheter (PICC) removal in the setting of upper extremity deep vein thrombosis?

    • The patient has a line infection.

    • The PICC is functional.

    • The PICC is positioned at the cavoatrial junction.

    • The patient requires continued central venous access.

    • The patient has an asymptomatic UEDVT associated with the PICC.

    Article 8 (61–67)

22. A 45-year-old woman visits her primary care doctor after an episode of proximal deep vein thrombosis after an elective knee surgery. She has read about postthrombotic syndrome on the Internet and is concerned about her risk of developing this condition in the next few months. The most appropriate answer to her question is:

    • Less than 1%.

    • More than 95%.

    • 20–50%.

    • 75–90%.

    • 5–25%.

23. A 35-year-old man visits his vascular specialist for established postthrombotic syndrome after a provoked extensive DVT. He is compliant with elastic compression stockings, but still has symptoms of heaviness, swelling, and pain after standing for his job as a cook at a vegan restaurant. He has heard from a friend that there are herbs and supplements that might help his condition and would like a treatment recommendation. Which of the following may be effi cacious in reducing his symptoms and signs of postthrombotic syndrome?

    • Ginkgo biloba.

    • Horse chestnut seed extract.

    • Garlic.

    • Black cohosh.

    • Cranberry.

24. 35-year-old woman comes to your clinic after being referred to you by her primary care physician. She had extensive iliac, proximal, and calf vein DVT after a car accident 1 year ago. At that time, she underwent thrombolysis and left iliac stent placement. She completed a year of treatment with a DOAC still has leg pain, swelling, and has now developed lipodermatosclerosis, which is evident on exam. She has a past medical history of diabetes and is a longtime smoker. In this visit, which therapy may be most important to emphasize in counseling this patient?

    • Leg elevation.

    • Compliance with medication.

    • Skin care.

    • Compliance with compression.

    • Smoking cessation.

    Article 9 (68–72)

25. Which of the following is true about the postthrombotic syndrome (PTS)?

    • PTS can include lower extremity symptoms and signs in patients with previous DVT.

    • Typical features of PTS include chronic pain, swelling, heaviness, edema, and skin changes in the aff ected limb.

    • PTS is a leading determinant of long-term quality of life in DVT patients.

    • All of the above.

26. Which of the following therapies is not appropriate for patients with mild symptoms of PTS?

    • Elastic compression stockings.

    • Common femoral vein stent placement.

    • Structured exercise therapy.

    • Weight loss, if overweight or obese.

27. Which of the following is an important evidence gap for PTS?

    • Randomized trials evaluating stent placement against conservative therapy.

    • Randomized trials evaluating the use of compression therapy for venous ulcer.

    • Prospective pilot study evaluating structured exercise therapy for mild-moderate PTS.

    • Proof-of-concept studies to prove that stents can reopen occluded iliac veins.

    Article 10 (73–80)

28. Active targeting of nanoparticle therapy is defi ned as:

    • Binding of a specifi c targeting molecule to the nanoparticle, to direct the particle to the site of desired action.

    • Accumulation of nanoparticles within a desired location due to mechanical eff ects.

    • Delivery of nanoparticles to the site of desired action surgically or endovascularly.

    • The use of masking molecules to decrease clearance of nanoparticles from the circulation.

    • None of the above.

29. P-selectin is a promising target for nanoparticle therapies because:

    It is present on almost all tissues within the body.

    It is present constitutively on endothelium.

    40Anti-p-selectin nanoparticles may have on-target, secondary eff ects on the development of postthrombotic syndrome.

    It is not expressed on platelets, even when activated.

    None of the above.

30. On-target, secondary eff ects are:

    • Inhibition of the action of nanoparticles by circulating molecules.

    • Eff ects of the nanoparticle therapy on areas of mechanical accumulation.

    • Never desirable in nanoparticle therapies.

    • An action of the therapeutic at other than the site of desired action.

    • None of the above.