Post-Test Questions

Article 1 (65–70)

1. A 70-year-old man admitted with an acute hemorrhagic stroke is found to have an acute right lower extremity iliofemoral DVT. The most appropriate management of the patient's VTE is:

   • Therapeutic anticoagulation alone

   • IVC filter placement alone

   • Therapeutic anticoagulation and IVC filter placement

   • Catheter-directed thrombolysis

2. A 23-year-old woman is brought to the emergency department following a motor vehicle accident with severe closed head injury and multiple long bone fractures. She is not placed on prophylactic anticoagulation for VTE because of her increased bleeding risk and impending surgeries. Which of the following is most appropriate:

   • Consider prophylactic placement of a permanent IVC filter

   • Consider prophylactic placement of an optional IVC filter

   • Only place an IVC filter if the patient develops iliocaval DVT

   • Only place an IVC filter if the patient develops massive PE

3. Extended indications for IVC filter placement include all of the following EXCEPT:

   • Poor compliance with anticoagulation

   • VTE with limited cardiopulmonary reserve

   • Large, free-fl oating proximal DVT

   • Complication of anticoagulation resulting in cessation of therapy

   Article 2 (71–74)

4. Anticoagulation poses a unique challenge in cancer patients due to the possibility of major bleeding events. Which of the following are contributing risk factors for bleeding in this patient population?

   • Surgery

   • Drug interactions

   • Nutritional status

   • Intracerebral metastases

   • All of the above

5. Regarding “absolute” and “extended” (or “relative”) indications for inferior vena cava filter placement, which of the following grouping of indications most accurately encompasses “absolute” indications?

   • Contraindication to anticoagulation, massive pulmonary embolism, inability to achieve or maintain therapeutic anticoagulation, or poor compliance with anticoagulation

   • Contraindication to anticoagulation, complication of anticoagulation, inability to achieve or maintain therapeutic anticoagulation, or recurrent venous thromboembolism on adequate anticoagulation

   • Massive pulmonary embolism, limited cardiopulmonary reserve, free-floating inferior vena cava thrombus, or poor compliance with anticoagulation

   • Massive pulmonary embolism, contraindication to anticoagulation, free-floating inferior vena cava thrombus, or recurrent venous thromboembolism on adequate anticoagulation

   • None of the above

6. Which of the following is CORRECT regarding inferior vena cava filter retrieval rates in patients with cancer?

   • Patients with cancer have a significantly lower retrievable inferior vena cava filter retrieval rate than patients without cancer. The retrieval rate is even lower in patients with metastatic cancer.

   • Patients with cancer have a significantly higher retrievable inferior vena cava filter retrieval rate than patients without cancer. The retrieval rate is even higher in patients with metastatic cancer.

   • Patients with cancer have a retrievable inferior vena cava filter retrieval rate that is similar to rates observed in patients without cancer.

   • Patients with metastatic cancer have a retrievable inferior vena cava filter retrieval rate that is higher than rates observed in patients without cancer.

   • None of the above

   Article 3 (75–78)

7. A 38-year-old woman with no past medical history on oral contraceptives presents with left leg pain and swelling. She also reports pleuritic chest pain. A CT scan reveals acute pulmonary embolism. Which of the following treatments is most appropriate?

   • Systemic anticoagulation

   • IVC filter placement

   • IVC filter placement and systemic anticoagulation

   • Intravenous lytic therapy

8. What is the most common complication associated with long-term retrievable filter use?

   • Caval thrombosis

   • Filter migration

   • Filter fracture

   • Perforation of caval wall by filter component(s)

9. Which of the following parameters is NOT associated with an optional filter being declared permanent?

   • Female gender

   • Advanced age

   • History of malignancy

   • History of anticoagulation failure

   Article 4 (79–87)

10. Regarding current vena cava filters that can be removed or converted:

    • All must be removed or converted

    • Some must be removed or converted

    • Some can be either removed or converted

    • All can be permanent or nonconverted

11. Of the filters first approved in the United States for retrieval in 2003 and 2004, which of the following devices are still available:

    • Recovery, Option Elite

    • Günter Tulip, Celect Platinum

    • Günther Tulip, OptEase

    • Recovery, OptEase

12. Materials used in the construction of currently available retrievable and convertible filters include:

    • Aluminum

    • ePTFE

    • N-butyl cyanoacrylate

    • Copper

    Article 5 (88–92)

13. Which of these is NOT an indication for suprarenal filter placement?

    • Anatomic variant preventing placement in infrarenal IVC

    • Thrombus in infrarenal IVC

    • Enlarged infrarenal IVC

    • Pregnant patient

14. Which set of embryological veins does NOT develop normally in an interrupted IVC (lack of suprarenal IVC)?

    • Vitelline veins

    • Supracardinal veins

    • Subcardinal veins

    • Posterior cardinal veins

15. When normal anatomy is encountered, which of the following vessels have the highest rate of filter tilt when used for deployment?

    • Right internal jugular vein

    • Left internal jugular vein

    • Right femoral vein

    • Left femoral vein

    Article 6 (93–100)

16. Which filter design is associated with the highest reported risk of penetration?

    • Purely conical

    • Conical with umbrella

    • Conical with cylindrical element

    • Biconical with cylindrical element

17. Which conical filter types are associated with the highest reported rates of filter fracture?

    • Günther-Tulip

    • ALN

    • Bard Recovery and G2

    • Option

18. All of the following are defined as insertional issues except:

    • Tilting of the filter

    • Incomplete opening

    • Filter migration

    • Prolapse of filter components

19. Filter migration is defined as movement of an IVC filter:

    • >1 cm along the IVC beyond the initial placement position

    • >2 cm along the IVC beyond the initial placement position

    • >3 cm along the IVC beyond the initial placement position

    • >5 cm along the IVC beyond the initial placement

    Article 7 (101–104)

20. Which of the following are possible complications of IVC thrombosis?

    • Renal failure

    • Chronic lower extremity pain

    • Pulmonary embolism

    • All of the above

21. What modality would be most useful to evaluate for IVC thrombosis in an obese patient with equivocal ultrasound and a glomerular filtration rate (GFR) of 12 mL/hour?

    • CT venogram with iodinated contrast

    • Conventional venography

    • Noncontrast MR venogram with steady-state free precession sequences

    • MR venogram with gadolinium

22. Which of the following statements is TRUE regarding endovascular therapy for recurrent DVT or IVC thrombosis with an IVC filter in place?

    • Balloon venoplasty and stenting are often indicated in the setting of chronic thrombosis.

    • Anticoagulation has been proven to significantly decrease clot burden in the majority of patients.

    • Follow-up venography is not necessary after catheter-directed thrombolysis.

    • Success rates for thrombolysis with an IVCF in place are lower than those reported for iliofemoral DVT therapy in the absence of a filter

    Article 8 (105–108)

23. Which of the following has been shown to dramatically increase retrieval rates of IVC filters?

    • Allowing referring services to follow and refer patients back for retrieval when indicated

    • Providing patient education, a tracking system to minimizing patient loss, and dedicated personnel to oversee the process

    • Providing information to patients at the time of filter placement to contact their referring doctor about timing of retrieval

    • Placing information about the filter placement and need for timely retrieval on inpatient discharge notes

24. How can prospective consultation prior to filter placement improve filter utilization?

    • Allows for referring services to choose if a permanent or retrievable IVC filter should be placed

    • Contributes to low follow-up and retrieval rates

    • Can decrease the elevated risk of complications with rIVCF

    • Allows optimization of resource allocation, but decreases patient safety

25. In which of the following ways can a dedicated IVCF service line improve patient safety?

    • Allows for the establishment of a robust database from which research can be performed to further optimize IVC filter clinical practice

    • Allows referring services to monitor patients after filter placement and refer them back for retrieval

    • Allows all patients to receive rIVCF safely because they are tracked by a dedicated tracking system

    • Decreases the risk of complications related to IVC filters for patients lost to follow-up

    Article 9 (109–121)

26. All of the following are limitations to ultrasound in the evaluation of venous thrombosis EXCEPT:

    • Thrombus is isoechoic to blood

    • Overlying bowel gas

    • Tenderness

    • Edema

    • None of the above

27. To perform direct computed tomographic venography (CTV), all of the following should be performed EXCEPT:

    • An IV should be started in the dorsum of the foot

    • Full strength contrast should be used

    • A tourniquet should be used above the level of interest

    • The patient should be placed in a supine position

    • None of the above

28. Which of the following MR agents is a strictly bloodpool agent?

    • Gadoversetamide

    • Gadopentetate dimeglumine

    • Gadoterate meglumine

    • Gadoteridol

    • Godogosveset trisodium

    Article 10 (122–131)

29. The novel oral anticoagulants showed lower rates of bleeding in all of the following categories EXCEPT:

    • Clinically relevant nonmajor bleeding

    • Intracranial bleeding

    • Gastrointestinal bleeding

    • Fatal bleeding

30. The novel oral anticoagulants have not become standard of care for the treatment of acute venous thromboembolism in cancer patients because:

    • In the relevant phase III studies, the NOACs were not as effective as LMWH.

    • To date, there have been no studies comparing the NOACs to LMWH.

    • Cancer patients experienced an excessive rate of bleeding with the NOACs compared to bleeding rates with warfarin or LMWH.

    • The NOACs have too many drug–drug interactions with the most common chemotherapy regimens.

31. Which of the following NOACs is most dependent on renal clearance?

    • Dabigatran

    • Betrixaban

    • Rivaroxaban

    • Apixaban

    Article 11 (132–136)

32. What did the U.S. Judicial Panel on Multidistrict Litigation recently decide regarding cases involving Bard's G2 IVC filter?

    • These cases should be argued separately due to their distinct questions of facts.

    • These cases should be centralized due to their common question of facts.

    • These cases should be argued separately because the discovery period has not been reopened in more than 2 years in any of the cases.

    • These cases should be centralized due to a recent FDA warning letter issued to Bard.

33. What were the three types of product defects considered in the Tillman case under Florida law?

    • Marketing, design, manufacturing

    • Structural, conceptual, advertisement

    • Minor, moderate, severe (resulting in death or serious injury)

    • Development, marketing, performance

34. Which of the following best characterizes the current protection off ered to medical device firms by the 1976 Medical Device Amendments?

    • Complete: If the FDA has approved the device, the firm is immune.

    • Partial: Regulations are viewed as a minimum; firms are still liable if the plaintiff can prove that a reasonable firm would have done more.

    • None: The 1976 MDAs removed the legal protection offered to firms by FDA approval.

    • None: The 1976 MDAs originally offered protection, but this was repealed by the Medical Device Safety Act of 2009.

35. Why was the Johnson v. Kokemoor case significant for physician liability regarding informed consent?

    • It strengthened past case law suggesting physicians are only required to disclose general risks.

    • It set a binding precedent that relevant information be determined by what a reasonable physician would disclose in a similar situation.

    • It held a physician liable for not disclosing his unique characteristics which would have caused a reasonable patient to choose a different course.

    • It set a persuasive precedent that written documentation of consent off ers physicians little protection if the patient felt important information was not disclosed.

    Article 12 (137–143)

36. Mobile apps can assist healthcare providers with various tasks including:

    • Health record maintenance and access

    • Information gathering

    • Clinical decision making

    • Medical education

    • All of the above

37. Since 1980, IVC filter use in the United States has:

    • Increased

    • Decreased

    • Remained stable

    • Initially decreased, then plateaued

38. Which organization released a Safety Alert on IVC filters in 2010 recommending that “implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVC filters consider removing the filter as soon as protection from pulmonary embolism is no longer needed.”

    • Food and Drug Administration

    • American Heart Association

    • American Board of Medical Specialties

    • The Joint Commission

    Article 13 (144–148)

39. Which of the following are commonly associated with retrievable inferior vena cava filters with prolonged dwell time?

    • Advanced techniques frequently fail to retrieve filters with prolonged implantation.

    • Prolonged dwell inferior vena cava filters have higher rates of device-related complications.

    • Standard techniques are usually sufficient to retrieve devices that have been in place for an extended period of time.

    • Caval thrombosis rates are greater than 50%.

40. A 68-year-old man presents for removal of a retrievable inferior vena cava filter that was placed 8 months ago. Inferior vena cavography demonstrates no evidence of thrombus in the filter; however, the filter appears tilted with the apex within a dense fibrin cap. Which of the following advanced techniques would NOT be appropriate for its removal?

    • Endobronchial forceps

    • Loop wire

    • Curved sheath

    • Laser sheath

    • C and D

41. Regarding the 2010 FDA safety communication, which of the following is CORRECT?

    • It is safe for all retrievable inferior vena cava filters to remain in place indefinitely.

    • Only permanent inferior vena cava filters should be placed.

    • CRetrievable inferior vena cava filters should be removed once no longer indicated, if clinically appropriate.

    • It is the responsibility of the patient to seek follow-up care to have their filter retrieved.