Alternative Diagnostic Tests and Therapeutic Interventions Flashcards
1
Q
what is arteriography?
A
xray imaging of the arteries that uses contrast medium
2
Q
2 types of arteriography
A
intra-arterial injection
digital subtraction angiography (DSA)
3
Q
how does digital subtraction angiography (DSA) work?
A
uses real-time digital video processing to detect small amounts of radiopaque contrast medium within vessels
removes bones and other static structures that could limit visualization of the vessels
4
Q
what is the purpose of arteriography?
A
evaluate peripheral and abdominal arteries in patients with suspected vascular disorder
5
Q
4 limitations of arteriography
A
- allergy to contrast (iodine)
- cannot provide multiple images in multiple planes in real time
- good images of lumen, but not the vessel wall
- poor kidney function to excrete contrast agent
6
Q
5 complications of arteriography
A
puncture site hematoma
localized numbness at puncture site
pseudoaneurysm
local arterial occlusion
renal dysfunction
7
Q
arteriography intra-arterial injection uses the ___ technique
A
Seldinger technique
percutaneous puncture of a superficial artery and insertion of a very thin catheter
8
Q
the most commonly used arteries for an arteriography are (3)
A
CFA
axillary
brachial
9
Q
arteriography
when removing the catheter, hemostasis is achieved with (2)
A
manual compression
vascular closure device
10
Q
T/F: arteriography is a functional study
A
FALSE
it is NOT a functional study
11
Q
arteriography
normal anatomy of vessel
A
contrast medium will completely fill the vessel
12
Q
arteriography interpretation is based on ___
A
how much (if any) of the artery does not fill with the contrast agent
13
Q
arteriography
atherosclerosis appearance (2)
A
plaque appears as irregular or smooth negative images
collaterals are usually present in cases of long-standing occlusion
14
Q
arteriography
aneurysm appearance (2)
A
thrombus may develop along the dilated wall creating the appearance of a straight tube
lack of arterial branches, elongation, and tortuosity
15
Q
arteriography
fibromuscular dysplasia appearance
A
appear as a “string of beads”
16
Q
fibromuscular dysplasia more often is located in the ___
A
mid to distal renal artery
17
Q
___ and ___ both use radiofrequency energy and a strong magnetic field to produce multiplanar images
A
magnetic resonance imaging (MRI)
magnetic resonance angiography (MRA)
18
Q
MRI is excellent for evaluating ___
A
anatomic structures
19
Q
MRA can quantify ___ and construct images that look like angiograms
A
blood flow
20
Q
MRA without contrast agents can distinguish ___ from ___
A
blood flow from soft tissue
21
Q
purpose of MRI and MRA is to evaluate (3)
A
AAA
dissection
peripheral arterial disease
22
Q
MRI and MRA limitations (6)
A
- pacemakers, monitoring equipment, metallic objects
- degree of stenosis is difficult to assess
- stenoses may be overestimated
- more expensive than ultrasound
- claustrophobia
- interpretation requires considerable skill
23
Q
computed tomography (CT) uses ___ to obtain cross-sectional images of anatomic structures with or without contrast agents
A
ionizing radiation
24
Q
computed tomography angiography (CTA) provides better visualization of ___
A
vasculature
25
CT and CTA purpose (3)
1. help define the relationship of the aorta to RA origins
2. determine whether an aortic aneurysm is present
3. assess for presence/location of dissection
26
CT and CTA limitations (4)
1. images are degraded with patient motion and presence of surgical clips
2. requires more time and is expensive
3. limited application in peripheral arterial disease
4. renal insufficiency
27
CT and CTA
3D reconstruction provides the exact ___ and ___ of vessels related to the aneurysm
contour and measurement
28
relationship of ___ to AAA is critical in planning surgical or endovascular intervention
renal arteries
29
Medical management includes ___ and ___
behavioral and drug therapy
30
8 examples of medical therapy
1. Cessation of smoking
2. Exercise
3. Weight control
4. Statins
5. Aspirin
6. Blood thinners
7. Blood pressure meds
8. Protection and prevent injury and/or infection
31
The decision to operate depends on the ___ and ___ of disease and the patient's ___
Extent and severity of disease
Patient's symptoms
32
What is endarterectomy?
Surgical removal of atherosclerotic material from the arterial lumen
33
Bypass grafts provide an alternate pathway for ___
Distal blood flow
34
Bypass grafts require (3)
Good arterial flow
Patient conduit
Patent distal runoff
35
6 common bypass grafts
Aorta to both iliac arteries
Aorta to bifemoral
Femoral to popliteal
Femoral to PTA, ATA, or Per A
Femoral to femoral
Axillary to femoral
36
2 types of vein-harvesting methods for reversed saphenous vein bypass graft
Open saphenous vein harvesting (OVH)
Endoscopic vein harvesting (EVH)
37
Open saphenous vein harvesting (OVH) method
GSV is surgically removed through a long incision down the length of the leg
38
Endoscopic vein harvesting (EVH) method
Through a 1 inch incision, the surgeon will use a small endoscope/dissector with a tiny camera on the end
39
angiosome concept
optimize ____ in plastic surgery
tissue transfer procedures
40
angiosome concept
applied to patients with ___ in order to enhance the potential for limb salvage when planning revascularization distally
critical limb ischemia (CLI)
41
angiosome concept
is based on the idea that ____
if direct arterial flow to an ischemic region is established, it will provide the best chance for wound healing and limb salvage
42
angiosome concept
surgeon must decide between what 2 procedures
direct revascularization (DR)
indirect revascularization (IR)
43
direct revascularization (DR) consists of ___
endovascular therapy or surgical bypass graft to angiosome of the ulcer
44
indirect revascularization (IR) consists of ___
bypass graft to the adjacent artery, relying on collateral flow
45
source artery = PTA
angiosome supplied =
1. medial to the ankle
2. plantar surface of foot
46
source artery = Per A
angiosome supplied =
1. anteriolateral aspect of ankle
2. lateral aspect of heel
47
source artery = ATA
angiosome supplied =
1. dorsum of foot
2. anterior surface of ankle
48
ulcer location = diabetic pressure ulcer (plantar foot wound)
angiosome supplied by =
PTA
49
ulcer location = dorsal foot wound
angiosome supplied by =
ATA
50
ulcer location = lateral ankle wounds
angiosome supplied by =
Per A
51
what is endovascular therapy?
therapeutic procedures performed by insertion of a catheter into the vessel at a site that is distant from the site of the procedure
52
endovascular therapy
thrombotic component of any occlusion must be managed before ___ or ___ is performed
angioplasty or atherectomy
53
endovascular therapy
serious complications occur in less than ___% of cases
5%
54
what is angioplasty?
mechanical widening of narrowed or obstructed arteries by means of a balloon catheter
55
___ is used to precisely dilate the segment of a vessel that contains a focal atherosclerotic lesion
percutaneous transluminal angioplasty (PTLA)
56
angioplasty
cannot be applied to all vessels or all types of lesions
usually performed in what (3) arteries?
iliac
femoral
popliteal
57
angioplasty
uses ___ guidance and injection of small amounts of contrast media
fluoroscopic guidance
58
angioplasty
the tip of the catheter is positioned within the ___
stenotic segment
59
what is subintimal angioplasty?
minimally invasive endovascular procedure that may be used in some patients who are not candidates for traditional surgical or endovascular treatment
60
subintimal angioplasty
provides blood flow around a ___
creates a channel between ___ and ___
provides blood flow around a totally occluded artery
creates a channel between the intima and media
61
subintimal angioplasty
prox to occlusion, guide wire and catheter are used to create an ____ followed by angioplasty
prox to occlusion, guide wire and catheter are used to create an "intentional dissection" followed by angioplasty
62
what is intravascular ultrasound (IVUS)?
procedure that utilizes ultrasound to see inside the blood vessel
63
intravascular ultrasound (IVUS)
provides a more detailed visualization of the ___ and any ___ formation
more detailed visualization of intima and any plaque formation
64
intravascular ultrasound (IVUS)
determines where ___ should be placed
identify whether there is a ___ present
assess effects for treatment of ___
determines where stent should be placed
identify whether there is a dissection present
assess effects for treatment of stenosis
65
intravascular ultrasound (IVUS)
done at the end of angioplasty with stent placement or after ___
coronary catheterization
66
stent and stent grafts are wire mesh tubes designed to ___
maintain the intraluminal structure and patency of an artery
67
3 types of stents
balloon-expandable
self-expandable
thermal-expandable
68
3 types of stent grafts/covered stents that are used to repair specific types of aneurysmal disease
tube grafts
bifurcated grafts
aortoiliac grafts
69
3 limitations of stents/stent grafts
course and size of vessel
abdominal gas
patient's inability to lie flat
70
5 complications of stents/stent grafts
intimal hyperplasia
stent migration
twisting
dislodgement
leaks
71
endovascular aortic stent complications (6)
1. LE ischemia secondary to embolization
2. graft infection
3. delayed rupture of the aortic aneurysm
4. bleeding
5. pseudoaneurysm at the insertion site
6. hematoma
72
___ is the postinterventional evaluation of stents
computed tomographic angiography (CTA)
73
___ is the noninvasive technique to evaluate stents
color duplex ultrasound
74
renal artery restenosis criteria (3)
elevated PSVs ≥ 180cm/sec
elevated renal-to-aortic ratio (RAR) > 4
poststenotic turbulence
75
SMA stent restenosis criteria (1)
PSVs approach 500 cm/sec = in-stent stenosis (ISS)
76
Type I endoleak
Attachment endoleak
Proximal and/or distal attachment sites
Considered the most dangerous and should be repaired
77
Type II endoleak
Branch leak
Most common
Originated from native vessels normally branching off the aorta, allowing retrograde flow into the residual aneurysmal sac
78
Type III endoleak
Modular connect endoleak
Leaks from connections of modular components
Considered dangerous and should be repaired
79
Type IV endoleak
Transgraft endoleak
Very rare
Occurs from minute tears in the fabric or from changes in wall porosity
80
Type V endoleak
Continued expansion of aneurysm sac without demonstrable leak on imaging (endotension)
81
Ultrasound evaluation of endoleak (6)
1. Residual thrombus - heterogeneous "spongey" texture
2. Hypoechoic areas with residual AAA sac
3. Asymmetry of the sac
4. Attachment endoleak
5. Branch endoleak
6. If there is a suspected endoleak, turn patient to the flank position and rescan
82
Attachment endoleak or branch endoleak?
Spectral waveforms similar to that within the graft
Attachment endoleak
83
Attachment endoleak or branch endoleak?
Different spectral waveforms from that within the graft
Branch endoleak
84
What is embolectomy?
Emergency procedure that removes embolus that is blocking blood circulation
85
What is a thrombectomy?
Procedure to remove a blood clot
86
Embolectomy/Thrombectomy are similar to ___
Balloon angioplasty
Catheter is inserted into artery and passed down so the top is beyond the area of thromboembolism and balloon is inflated
87
What is atherectomy?
Alternative to percutaneous transluminal angioplasty that removes atherosclerotic plaque from a large blood vessel
88
atherectomy
may be used as a complement to ___ or ___ in order to remove the more hardened plaque
angioplasty or stenting
89
atherectomy limitations (3)
1. heat generation from some rotational devices may limit the amount of plaque that can be safely removed
2. lack of a guide wire
3. microembolization of pulverized particles can occur
90
atherectomy
types of catheters used (4)
rotating
orbital
directional
laser
91
___ therapy is for patients who have critical limb ischemia (CLI) and have run out of options
investigational therapy
92
investigational therapy
increase ___ and ___
enhance ___ and ___
modulation of ___
increase angiogenesis (growth of new vessels in capillary circulation) and microcirculation
enhance collateral development (arteriogenesis) and tissue remodeling
modulation of inflammatory response
93
3 examples of investigational therapy
1. bone marrow aspirate - injected into the gastrocnemius at multiple locations
2. vascular endothelial growth factor (VEGF) - injected into the calf muscle at multiple locations
3. intramuscular gene transfer - multiple injections into the calf muscle
94
pseudoaneurysm treatment options (4)
1. do nothing
2. manual compression
3. ultrasound-guided thrombin injection
4. surgery
95
pseudoaneurysm treatment option 2 - manual compression
is dependent on (2)
size & location of pseudoaneurysm
location of its communicating channel to the native artery
96
pseudoaneurysm treatment option 2 - manual compression
contraindications (3)
1. anticoagulation therapy
2. inability to uniformly compress pseudoaneurysm and multiple communicating channels
3. presence of infection
97
pseudoaneurysm treatment option 3 - ultrasound-guided thrombin injection
contraindications (5)
allergy to thrombin or bovine materials
ischemia of overlying skin
groin infection
distal limb ischemia
very wide or short neck
98
pseudoaneurysm treatment option 4 - surgery
3 situations to perform surgery
1. neck of the pseudoaneurysm cannot be sufficiently compressed
2. pseudoaneurysm is too large to be closed by manual compression
3. thrombin injection is too risky for patient to undergo
