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CORE: IR > Abdominal/Pelvic Angiography > Flashcards

Abdominal/Pelvic Angiography Flashcards

1
Q

Osseous landmarks for major aortic vessels

A

Celiac: T12
SMA: T12-L2
Renal: L1-L2
IMA: L2-L3, left of midline

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2
Q

Celiac axis anatomy

A

ceiliac trunk&raquo_space; left gastric, common hepatic, splenic artery

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3
Q

left gastric bleeds?

A

esophageal Mallory-Weiss tear

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4
Q

vessels along greater curvature of stomach

A

right and left gastroepiploic arteries

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5
Q

where does right gastroepiploic arise from

A

GDA

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6
Q

common hepatic arteries

A

common hepatic –> GDA and proper hepatic –> L/R hepatic

cystic artery arises from R hepatic artery

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7
Q

replaced right hepatic artery; significance

A

arises from SMA; significant during SMA disease or during abdominal surgery

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8
Q

accessory right hepatic artery

A

normal right hepatic artery and one off SMA

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9
Q

replaced left hepatic artery arises from?

A

left gastric artery

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10
Q

accessory left hepatic artery?

A

arises from left gastric artery and supplies left lobe; normal left hepatic artery too

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11
Q

SMA branches

A

inferior pancreaticoduodenal artery, middle colic –>marginal artery of Drummond, right colic artery, ileocolic artery

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12
Q

IMA branches

A

left colic, sigmoid, superior rectal

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13
Q

Internal iliac branches

A

Anterior division: pelvic viscera (inferior/middle recal, uterine, obturator, inferior gluteal)

Posterior: lateral sacral, iliolumbar, superior gluteal

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14
Q

External iliac

A

inferior epigastric, deep circumflex, femoral

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15
Q

Anastamoses

-celiac-SMA

A

arc of Buhler (celiac/SMA)
pancreatic cascade (inferior pancreaticoduodenal artery)
arc of Barkow (right/left epiploic arteries)

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16
Q

Anastamoses

SMA-IMA

A

marginal artery of Drummond (lateral); peripheral mesentery of colon

arc of Riolan (medial)

Cannon-Bohm point (splenic flexure)

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17
Q

Iliac artery anastamoses

A

external iliac - thoracic aorta (internal mammary)

external iliac- internal iliac (deep circumflex iliac artery)

internal iliac - IMA (path of Winslow/rectal arcade)

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18
Q

polyarteritis nodosa

A

P-ANCA + ; systemic necrotizing vasculities of small to medium sized arteries (renal, hepatic, mesenteric)

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19
Q

Ddx for multiple renal artery aneurysms

A

multiple septic emboli, speed kindey (meth use), Ehlers-Danlos, PAN

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20
Q

Polyarteritis nodosa associations? CLASH

A 
CLASH
cryoglobulinemia
leukemia
rheumatoid arthritis
Sjogren syndrome
hepatitis B
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21
Q

Treatment PAN

A

steroids

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22
Q

most common visceral aneurysm?

A

splenic aneurysm

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23
Q

who develops splenic artery aneurysms vs pseudoaneurysms

A

multiparous femsles (can rupture during pregnancy); portal hypertension

pseudoaneurysm from trauma/pancreatitis

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24
Q

indication for splenic aneurysm treatment; treatment

A

> 2.5 cm, LUQ pain;
prior to expected pregnancy

endovascular coil embolization distal to aneurysm neck and then proximally

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25
Q

how is hepatic artery embolization achieved?

A

distal to cystic artery to avoid ischemic cholecystitis

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26
Q

cirrhosis angiogram sign

A

corkscrewing of hepatic artery branches from fibrosis

hypervascular mass in cirrhotic liver suggestive CHC

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27
Q

cause of acute mesenteric ischemia

A

SMA embolus
-lactic acidosis elevated

nonocclusive mesenteric ischemia (NOMI)
-intestinal necrosis with patent arterial tree from spasm/narrowing of multiple branches

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28
Q

treatment for acute mesenteric ischemia

A

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)

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29
Q

cause of chronic mesenteric ischemia

A

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

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30
Q

treatment of chronic mesenteric ischemia

A

angioplasty/stenting

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31
Q

tx for acute upper GI bleeding

A

endoscopy

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32
Q

localizing lower GI bleeding

A

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)

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33
Q

dose of vasopressing in SMA/IMA

A

0.2-0.4 units/minut over 24 hrs

can be used for 24 hrs before tachyphylaxis develops

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34
Q

angiodysplasia

A

acquired vascular anomaly with intermitted chronic RLQ bleeding (right colon/cecum)

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35
Q

angiodysplasia on imaging

A

tangle of vessels with early filling of antimesenteric draining vein; tram-track appearance

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36
Q

most common cause of lower GI bleed

A

diverticulosis

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37
Q

most common cause of renal artery stenosis

A

atherosclerosis, usually at ostia of renal arteris

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38
Q

treatment for renal artery stenosis (atherosclerotic)

A

controversial

angioplasty + stenting

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39
Q

fibromuscular dysplasia? population?

A

idioathic vascular disease of renal/carotid arteries; usulaly bilateral

common in young/middle aged women

afects mid to distal third fo renal arteries

40
Q

radiographic findings fibromuscular dysplasia

A

string of pearls/beaded appearance on angiography

smooth stenosis seen in intimla fibroplasia (seen in kids)

41
Q

treatment for fibromuscular dysplasia

A

angioplasty (improves BP) to disrupt fibrous tissue but can have restenosis

stenting not recommended due to intimal hyperplasia

42
Q

cause of renal artery stenosis in kids

A

NF

43
Q

bizarre neovascularity?

A

RCC hypervascular tumors with AV shunting and venosu lakes

44
Q

oncocytoma angiogram findings

A

benign renal mass, similar to RCC on imaging

spokewheel apperance with peritumoral halo; no bizarre neoplastic vessels

45
Q

hypervascular hamartoma in the kidney? angiogram findings

A

renal AML

tortuous feeding arteries with sunburst appearance on parenchymal phase

46
Q

hematuria present with renal trauma T/F

A

T

47
Q

AAST renal injury scale

A 
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

48
Q

cause of renal AVF, complications

A

aquired; trauma vs renal biopsy

hematuria, less commonly high output cardiac failure or retroperitoneal hemorrhage

49
Q

treatment of renal AVF/malformations

A

embolization (coil, glue, alcohol)

50
Q

medial arculate ligament syndrome; patient population?

A

celiac artery compresion by median arcute ligament (diaphgragmatic crura)

thin young women

51
Q

treatment of median arcuate ligament syndrome

A

surgical release of median arcuate ligament to enlarge diaphgragmatic hiatus

52
Q

SMA syndrome aka Wilki syndrome

A

compression of duodenum between aorta/SMA

53
Q

nutcracker syndrome

A

compression left renal vein between aorta/SMA; left renal venous outflow obstruction

54
Q

posterior nutcracker, presentation

A

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

55
Q

treatment of nutcracker syndrome

A

angioplasty/stenting; hematuria tends to resolve within 2 years

56
Q

May Thurner syndrome

A

venous thrombosis of left common iliac from compression from crossing right common iliac

57
Q

treatment may thurner

A

endovascular thrombolysis and stenting

58
Q

portal hypertension definition

A

portosystemic gradient > 5 mm Hg (wedged hepatic vein pressure vs free hepatic vein pressure)

wedged hepatic vein pressure measured via IJ

59
Q

collateral vessels in portal hypertension

A
  • 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
60
Q

TIPS stands for?

A

transjugular intrahepatic portosystemic shunt (TIPS) creats connection between portal and hepatic vein

usually right hepatic vein connected to right portal vein with covered stent

61
Q

indication for TIPS

A

variceal hemorrhage unamenable to endoscopy; refractor ascities, Budd Chiari (hepatic vein thrombosis)

62
Q

assessment of hepatic dysfunction scales

A

Child Pugh: lab values and clinical assessment (INR, bilirubin, albumin, ascites, hepatic encephalopathy)

MELD: INR, bilirubin, Cr; higher score = higher post TIPS mortality

63
Q

contraindications to TIPS

A

right sided heart failure, severe active hepatic failure, severe hepatic encephalopathy

64
Q

how is pressure measured?

A

right hepatic vein wedged balloon CO2 occlsion venography

65
Q

TIPS pressure aim

A

portosystemic gradient <12 mm Hg

66
Q

followup with TIPS

A

doppler ultrasound for patency

67
Q

goal of IVC filter placement

A

reduce risk of PE from DVT in pts who can’t be anticoagulated (trauma pt, recurrent PE)

68
Q

complication of IVC filter placement

A

access site thrombosis, IVC thrombosis;

rare IVC perforation, filter fracture or embolization

69
Q

IVC filter steps

A

IVC cavogram with pigtail high flow cathether

place below renal arteries but above IVC confluence

70
Q

precautions if IVC is large

A

> 28-40 mm requires birds nest filter

>40 mm, use separate filters in common iliac vein

71
Q

renal vein variants

A

circumaortic: left renal vein passes anterior and retroartic
retroaortic: single renal vein posterior to aorta

interruption of IVC with azygos continuation

72
Q

interruption of IVC with azygos continuation associations

A

polysplenia, congenital heart disease

embryologic failure of right subcardinal vein to joint intrahepatic venous complex

73
Q

dilation of pampiniform venous plexus

A

varicocele

74
Q

primary vs secondary varicocele

A

primary: absent/incompetent valves in proximal gonadal vein causing reflux
secondary: mass obstructing venous return

75
Q

concern for right sided varicocele

A

obstructing retroperitoneal mass

76
Q

diagnosis of varicocele

A

dilated >2mm venous plexus with bag of worms appearance, worsens on Valsalva

77
Q

treatment varicocele

A

coil embolization or surgical ligation of gonadal vein

78
Q

indication for percutaneous transhepatic cholangiography

A

relief of biliary obstruction, biliary diversion in case of ductal injury, treatment of biliary calculi (usually endoscopy), adjunctive presurgical treatment prior to biliar anastamosis

79
Q

access for right biliary tree, left biliary tree

A

right midaxillary line over ribs (avoid neurovascular bundle) ; 2 needle approach

left subxiphoid approach

80
Q

when is biliary stent placed

A

metallic stent for stricture when life expectancy < 6 mo, cant be removed

plastic stents placed endoscopically can be replaced/exchanged

81
Q

complications from percutaneous biliary drain

A

sepsis, hemorrhage, bile leak, hemobilia, abscess

82
Q

contraindications to PTC

A

intrahepatic tumor, ascietes (but ok after therapeutic paracentesis)

83
Q

bile duct injury causes

A

iatrogenic from laparoscopic cholecystectomy, orthotopic liver transplant

treat with biliary diversion

84
Q

sclerosing cholangitis

A

chronic inflammation of intra/extrahepatic biliary tree with multifocal strictures

obstructive jaundice, malaise, abdominal pain

associated with inflammatory bowel disease (UC)

85
Q

treatment of sclerosing cholangitis

A

liver transplant; percutaneous biliary drain can provide palliative relief

86
Q

DDx for multifocal biliary strictures

A 
Sclerosing cholangitis.
Primary biliary cirrhosis.
Multifocal cholangiocarcinoma.
Chronic bacterial cholangitis.
AIDS cholangitis (usually associated with papillary stenosis)
87
Q

malignant biliary obstruction

A

metastatic disease or primary malignancy of bile ducts (hilar obstruction/Klatskin tumor)

88
Q

indication for percutaneous gallbladder drainage

A

acute calculous or acalculous cholecystitis who are not surgical candidates

89
Q

approaches for percutaneous gallbladder

A

transhepatic: decreased risk of bile leak, increases risk of liver laceration (more common)
transperitoneal: penetration of gallbladder fundus

90
Q

how long to keep percutaneous tube in place?

A
  • 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
91
Q

indication for percutaneous nephrostomy tube

A

urinary diversion of an obstructed kidney to stone, malignancy, stricture

pyonephrosis

place anterograde uretero stent if retrograde stent can’t be placed cystoscopically

92
Q

zone of Brodel

A

avascular zone between the ventral and dorsal renal arteries; posterolateral kidney towards posterior calyx

93
Q

complications of PCN

A

bleeding, infection, transient hematuria, risk of sepsis

94
Q

indications for gastrostomy tube

A

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

95
Q

contraindications to gastrostomy

A

colonic interposition, extensive gastric varices, uncorrectable coagulopathy

96
Q

how long to leave G tube in place for mature transperitoneal tract

A

1 month

CORE: IR (5 decks)

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