Abdominal/Pelvic Angiography Flashcards
Osseous landmarks for major aortic vessels
Celiac: T12
SMA: T12-L2
Renal: L1-L2
IMA: L2-L3, left of midline
Celiac axis anatomy
ceiliac trunk»_space; left gastric, common hepatic, splenic artery
left gastric bleeds?
esophageal Mallory-Weiss tear
vessels along greater curvature of stomach
right and left gastroepiploic arteries
where does right gastroepiploic arise from
GDA
common hepatic arteries
common hepatic –> GDA and proper hepatic –> L/R hepatic
cystic artery arises from R hepatic artery
replaced right hepatic artery; significance
arises from SMA; significant during SMA disease or during abdominal surgery
accessory right hepatic artery
normal right hepatic artery and one off SMA
replaced left hepatic artery arises from?
left gastric artery
accessory left hepatic artery?
arises from left gastric artery and supplies left lobe; normal left hepatic artery too
SMA branches
inferior pancreaticoduodenal artery, middle colic –>marginal artery of Drummond, right colic artery, ileocolic artery
IMA branches
left colic, sigmoid, superior rectal
Internal iliac branches
Anterior division: pelvic viscera (inferior/middle recal, uterine, obturator, inferior gluteal)
Posterior: lateral sacral, iliolumbar, superior gluteal
External iliac
inferior epigastric, deep circumflex, femoral
Anastamoses
-celiac-SMA
arc of Buhler (celiac/SMA)
pancreatic cascade (inferior pancreaticoduodenal artery)
arc of Barkow (right/left epiploic arteries)
Anastamoses
SMA-IMA
marginal artery of Drummond (lateral); peripheral mesentery of colon
arc of Riolan (medial)
Cannon-Bohm point (splenic flexure)
Iliac artery anastamoses
external iliac - thoracic aorta (internal mammary)
external iliac- internal iliac (deep circumflex iliac artery)
internal iliac - IMA (path of Winslow/rectal arcade)
polyarteritis nodosa
P-ANCA + ; systemic necrotizing vasculities of small to medium sized arteries (renal, hepatic, mesenteric)
Ddx for multiple renal artery aneurysms
multiple septic emboli, speed kindey (meth use), Ehlers-Danlos, PAN
Polyarteritis nodosa associations? CLASH
CLASH cryoglobulinemia leukemia rheumatoid arthritis Sjogren syndrome hepatitis B
Treatment PAN
steroids
most common visceral aneurysm?
splenic aneurysm
who develops splenic artery aneurysms vs pseudoaneurysms
multiparous femsles (can rupture during pregnancy); portal hypertension
pseudoaneurysm from trauma/pancreatitis
indication for splenic aneurysm treatment; treatment
> 2.5 cm, LUQ pain;
prior to expected pregnancy
endovascular coil embolization distal to aneurysm neck and then proximally
how is hepatic artery embolization achieved?
distal to cystic artery to avoid ischemic cholecystitis
cirrhosis angiogram sign
corkscrewing of hepatic artery branches from fibrosis
hypervascular mass in cirrhotic liver suggestive CHC
cause of acute mesenteric ischemia
SMA embolus
-lactic acidosis elevated
nonocclusive mesenteric ischemia (NOMI)
-intestinal necrosis with patent arterial tree from spasm/narrowing of multiple branches
treatment for acute mesenteric ischemia
surgical revascularization, bowel resection if necrotic
select patients: endovascular thrombolysis/suction embolectomy
NOMI: -arterial infusion of papaverine (60 mg bolus then drip 30-60 mg/hr)
cause of chronic mesenteric ischemia
postprandial abdominal pain out of proportion to exam
ostial narrowing of mesenteric vessels with post stenotic dilation (lateral aortagram)
2/3 mesenteric arteries must be diseased to produce symptoms in chronic disease
treatment of chronic mesenteric ischemia
angioplasty/stenting
tx for acute upper GI bleeding
endoscopy
localizing lower GI bleeding
hemodynamically stable: mesenteric CT angiogram, NM tagged RBC scan to localize bleed
hemodynamically unstable: angiography, empiral embolization of left gastric artery in upper GI bleeding due to collateralsand intraarterial infusion of ADH (although high rebleeding rate once transfusion stops)
dose of vasopressing in SMA/IMA
0.2-0.4 units/minut over 24 hrs
can be used for 24 hrs before tachyphylaxis develops
angiodysplasia
acquired vascular anomaly with intermitted chronic RLQ bleeding (right colon/cecum)
angiodysplasia on imaging
tangle of vessels with early filling of antimesenteric draining vein; tram-track appearance
most common cause of lower GI bleed
diverticulosis
most common cause of renal artery stenosis
atherosclerosis, usually at ostia of renal arteris
treatment for renal artery stenosis (atherosclerotic)
controversial
angioplasty + stenting
fibromuscular dysplasia? population?
idioathic vascular disease of renal/carotid arteries; usulaly bilateral
common in young/middle aged women
afects mid to distal third fo renal arteries
radiographic findings fibromuscular dysplasia
string of pearls/beaded appearance on angiography
smooth stenosis seen in intimla fibroplasia (seen in kids)
treatment for fibromuscular dysplasia
angioplasty (improves BP) to disrupt fibrous tissue but can have restenosis
stenting not recommended due to intimal hyperplasia
cause of renal artery stenosis in kids
NF
bizarre neovascularity?
RCC hypervascular tumors with AV shunting and venosu lakes
oncocytoma angiogram findings
benign renal mass, similar to RCC on imaging
spokewheel apperance with peritumoral halo; no bizarre neoplastic vessels
hypervascular hamartoma in the kidney? angiogram findings
renal AML
tortuous feeding arteries with sunburst appearance on parenchymal phase
hematuria present with renal trauma T/F
T
AAST renal injury scale
Grades I–III include nonexpanding hematomas or parenchymal laceration without collecting system injury. These injuries are usually managed conservatively. Grade IV includes a deep parenchymal laceration that extends to the collecting system, causing the CT finding of extravasation of opacified urine on delayed imaging. Injury to the renal artery or vein with contained hemorrhage is also OIS grade IV, and is often treated with endovascular coil embolization as in the case above. Grade V (most severe) injury is a shattered kidney with avulsion of the renal hilum. Treatment is usually surgical.
also look for renal artery thrombosis and renal artery pseudoaneurysm
cause of renal AVF, complications
aquired; trauma vs renal biopsy
hematuria, less commonly high output cardiac failure or retroperitoneal hemorrhage
treatment of renal AVF/malformations
embolization (coil, glue, alcohol)
medial arculate ligament syndrome; patient population?
celiac artery compresion by median arcute ligament (diaphgragmatic crura)
thin young women
treatment of median arcuate ligament syndrome
surgical release of median arcuate ligament to enlarge diaphgragmatic hiatus
SMA syndrome aka Wilki syndrome
compression of duodenum between aorta/SMA
nutcracker syndrome
compression left renal vein between aorta/SMA; left renal venous outflow obstruction
posterior nutcracker, presentation
compression of retroaortic renal vein between aorta and vertebral body
variable clinical symptoms including pain, hematuria, orthostatic proteinuria, pelvic congestion, and varicocele (in a male
treatment of nutcracker syndrome
angioplasty/stenting; hematuria tends to resolve within 2 years
May Thurner syndrome
venous thrombosis of left common iliac from compression from crossing right common iliac
treatment may thurner
endovascular thrombolysis and stenting
portal hypertension definition
portosystemic gradient > 5 mm Hg (wedged hepatic vein pressure vs free hepatic vein pressure)
wedged hepatic vein pressure measured via IJ
collateral vessels in portal hypertension
- Esophageal varices: Coronary vein g azygos/hemiazygos veins
- Gastric fundal varices: Splenic vein g azygos veins
- Splenorenal shunt: Splenic or short gastric g left adrenal/inferior phrenic g left renal vein
- Mesenteric varices: SMV or IMV g iliac veins
- Caput medusa: Umbilical vein g epigastric veins
- Hemorrhoids: IMV g inferior hemorrhoidal veins
TIPS stands for?
transjugular intrahepatic portosystemic shunt (TIPS) creats connection between portal and hepatic vein
usually right hepatic vein connected to right portal vein with covered stent
indication for TIPS
variceal hemorrhage unamenable to endoscopy; refractor ascities, Budd Chiari (hepatic vein thrombosis)
assessment of hepatic dysfunction scales
Child Pugh: lab values and clinical assessment (INR, bilirubin, albumin, ascites, hepatic encephalopathy)
MELD: INR, bilirubin, Cr; higher score = higher post TIPS mortality
contraindications to TIPS
right sided heart failure, severe active hepatic failure, severe hepatic encephalopathy
how is pressure measured?
right hepatic vein wedged balloon CO2 occlsion venography
TIPS pressure aim
portosystemic gradient <12 mm Hg
followup with TIPS
doppler ultrasound for patency
goal of IVC filter placement
reduce risk of PE from DVT in pts who can’t be anticoagulated (trauma pt, recurrent PE)
complication of IVC filter placement
access site thrombosis, IVC thrombosis;
rare IVC perforation, filter fracture or embolization
IVC filter steps
IVC cavogram with pigtail high flow cathether
place below renal arteries but above IVC confluence
precautions if IVC is large
> 28-40 mm requires birds nest filter
>40 mm, use separate filters in common iliac vein
renal vein variants
circumaortic: left renal vein passes anterior and retroartic
retroaortic: single renal vein posterior to aorta
interruption of IVC with azygos continuation
interruption of IVC with azygos continuation associations
polysplenia, congenital heart disease
embryologic failure of right subcardinal vein to joint intrahepatic venous complex
dilation of pampiniform venous plexus
varicocele
primary vs secondary varicocele
primary: absent/incompetent valves in proximal gonadal vein causing reflux
secondary: mass obstructing venous return
concern for right sided varicocele
obstructing retroperitoneal mass
diagnosis of varicocele
dilated >2mm venous plexus with bag of worms appearance, worsens on Valsalva
treatment varicocele
coil embolization or surgical ligation of gonadal vein
indication for percutaneous transhepatic cholangiography
relief of biliary obstruction, biliary diversion in case of ductal injury, treatment of biliary calculi (usually endoscopy), adjunctive presurgical treatment prior to biliar anastamosis
access for right biliary tree, left biliary tree
right midaxillary line over ribs (avoid neurovascular bundle) ; 2 needle approach
left subxiphoid approach
when is biliary stent placed
metallic stent for stricture when life expectancy < 6 mo, cant be removed
plastic stents placed endoscopically can be replaced/exchanged
complications from percutaneous biliary drain
sepsis, hemorrhage, bile leak, hemobilia, abscess
contraindications to PTC
intrahepatic tumor, ascietes (but ok after therapeutic paracentesis)
bile duct injury causes
iatrogenic from laparoscopic cholecystectomy, orthotopic liver transplant
treat with biliary diversion
sclerosing cholangitis
chronic inflammation of intra/extrahepatic biliary tree with multifocal strictures
obstructive jaundice, malaise, abdominal pain
associated with inflammatory bowel disease (UC)
treatment of sclerosing cholangitis
liver transplant; percutaneous biliary drain can provide palliative relief
DDx for multifocal biliary strictures
Sclerosing cholangitis. Primary biliary cirrhosis. Multifocal cholangiocarcinoma. Chronic bacterial cholangitis. AIDS cholangitis (usually associated with papillary stenosis)
malignant biliary obstruction
metastatic disease or primary malignancy of bile ducts (hilar obstruction/Klatskin tumor)
indication for percutaneous gallbladder drainage
acute calculous or acalculous cholecystitis who are not surgical candidates
approaches for percutaneous gallbladder
transhepatic: decreased risk of bile leak, increases risk of liver laceration (more common)
transperitoneal: penetration of gallbladder fundus
how long to keep percutaneous tube in place?
- patient clinically improved (risk of sepsis if removed prematurely)
- cystic/CBD demonstrated patent on cholangiogram
- 6 weeks since placement to allow fibrous tract to develop extending from gallbladder to skin puncture; risk of bile peritonitis if removed prematurely
indication for percutaneous nephrostomy tube
urinary diversion of an obstructed kidney to stone, malignancy, stricture
pyonephrosis
place anterograde uretero stent if retrograde stent can’t be placed cystoscopically
zone of Brodel
avascular zone between the ventral and dorsal renal arteries; posterolateral kidney towards posterior calyx
complications of PCN
bleeding, infection, transient hematuria, risk of sepsis
indications for gastrostomy tube
esophageal, H&N, neurologic disease ; bowel decompression (palliation of malignant bowel obstruction, ileus)
no strong evidence improves QOL for elderly demented patients with decreased oral intake
contraindications to gastrostomy
colonic interposition, extensive gastric varices, uncorrectable coagulopathy
how long to leave G tube in place for mature transperitoneal tract
1 month
