CORE - Vascular_IR Flashcards
Femoral pseudoaneurysm treatment
direct compression of PSA neck, thrombin injection, or surgery (3 cm or greater); can watch if 1 cm or less
How much thrombin to inject into pseudoaneurysm
500-1000 units (or 0.5 to 1.0 mL); thrombin injection is the preferred method if possible
Contraindications to thrombin injection (for femoral PSA)
local infection, rapid enlargement, distal limb ischemia, large neck, PSA <1 cm; inject APEX of cavity
Vasopressin for GI bleeding
vasoconstrictor, infused directly into SMA or IMA; high re-bleeding rates; may cause NOMI
Complications of vasopressin
arrhythmia, pulmonary edema, hypertension, NOMI; tachyphylaxis develops after 24 hours
Papaverine dose for NOMI
30-60 mg/hr direct arterial infusion
Heparin reversal
protamine; 1 mg IV per 100 units active heparin
Side effects of protamine
sudden drop in BP, bradycardia, flushing
Wire size for 18G and 19G needles
18G needle can fit an 0.038” wire, 19G needle can fit an 0.035” wire; a 19G needle CANNOT fit an 0.038” wire
1 Fr = ___ mm
0.33 mm; also 1 mm = 0.038”
Microwire sizes
0.018” and 0.014”; micropuncture technique refers to a 21G needle and 0.018” diameter wire
Sheaths sizes are designated by inner or outer diameter
inner diameter (add 2 Fr for outer diameter); everything else is by outer diameter
Standard 0.035” wire will fit through what size sheath?
4 Fr or larger
Wire diameters are in ______ and lengths are in ______
diameter in inches, length in cm
Standard wire length (cm)
180 cm (long wire is 260 cm)
Wire tips - floppy, J-tip, hydrophilic, and stiff
floppy = Bentson; J-tip = Rosen; hydrophilic = Glidewire, Roadrunner; stiff = Amplatz, Lunderquist
Size in mm associated with J-tip wires refers to what?
radius of curvature (of the ‘J’); small curves miss small branch vessels, large curves miss large branch vessels
Uses for hydrophilic wires
cross a stenosis, cannulate an indwelling device, enter abscess cavity
Catheter numbers - e.g. 4, 180, 0.035
refers to outer diameter (in Fr), length (in cm), and inner diameter (in inches)
Non-selective (high flow) catheters - pigtail vs. straight
pigtail for injecting medium-to-large vessels; straight for injecting small vessels; both have side and end holes
Selective catheters
end hole only; used for selection and embolization; contrast administered via hand injection only (no pump runs)
Catheter flow rates (by Fr)
3 Fr = 8 ml/s; 4 Fr = 16 ml/s; 5 Fr = 24 ml/s
Angle of catheter for selecting celiac, SMA, or IMA
obtuse angle (>120 degrees); a.k.a. recurve catheter (sidewinder, C2, or sos)
Ideal location for femoral arterial stick
inferomedial margin of femoral head; needle angled 45 degrees cranially for retrograde access and 45 degrees caudally for anterograde access
Location of femoral vein relative to femoral artery just inferior to femoral head
femoral vein is deep to the femoral artery; risk of AVF with low puncture
Treatment for suspected air embolism
left side down and 100% oxygen +/- catheter aspiration if large; insertion of catheter into peel-away sheath is highest risk part of procedure for air embolism
Indications for brachial artery access
upper limb angioplasty or femoral artery is out; risk of stroke if catheter has to cross aortic arch
Which side for brachial artery access?
left brachial if headed “south”, right brachial if headed “north”
Important points of radial artery access (2)
bedrest not required; need to perform Allen test prior to puncture
Contraindication to translumbar aortic puncture
known supraceliac aortic aneurysm
Risk of translumbar aortic puncture
psoas hematoma; used for type 2 endoleak; stick at T12; “self compress” by rolling on back
Anticoagulation during + after angioplasty
should be anticoagulated during procedure to avoid thrombosis from intimal injury (typically with heparin); ASA + plavix for 1-3 months after stenting
Balloon size
10-20% greater than the normal vessel diameter; aorta is 10-15 mm, CIA is 8 mm, EIA is 7 mm, CFA/proximal SFA is 6 mm, distal SFA is 5 mm
Balloon nomenclature
[diameter in mm] x [length in cm], e.g. “10 x 6” = “10 mm in diameter, 6 cm in length”
Balloon-expanding stents
higher radial force, better for more precise deployment; will not rebound if crushed; do not use around joints
Self-expanding stents
more flexible; preferred in tortuous route to lesion or areas prone to external compression
Stent size
1-2 cm longer than stenosis, diameter 1-2 mm wider than unstenosed vessel lumen; 10% oversizing for arterial stents, 20% oversizing for venous stents
Indications for covered stents (no fenestrations)
treatment of pseudoaneurysm, dissection, and TIPS
Primary stenting definition
angioplasty followed by stenting
Particle size for bronchial artery embolization (hemoptysis)
> 325 um; particles <300 um may cause tissue necrosis; NEVER coils
Particle size for UAE
500-700 um
Particle size for GI bleed
300-500 um; particles <300 um may cause bowel infarct
IR procedures with antibiotic prophylaxis
endograft (IV cefazolin 1g), TACE, UAE, TIPS, “pull” gastrostomy (IV cefazolin 1g), PTC/PTBD, cholecystostomy, liver/GU procedures, percutaneous abscess drainage, transrectal percutaneous biopsy, percutaneous vertebroplasty (IV cefazolin 1g)
CO2 contrast
negative contrast agent often used in patients with renal insufficiency or severe contrast allergy, also in TIPS
Swollen left leg
May-Thurner; treatment is thrombolysis + stenting
Splenic artery aneurysm associations
pregnancy, portal HTN, HTN, cirrhosis, liver transplant; pseudoaneuryms classically assoc. with pancreatitis
Increased risk of splenic artery aneurysm rupture
during pregnancy
Indications for splenic artery aneurysm treatment
symptomatic, aneurysm size >2 cm, prior to expected pregnancy
Slow flow rates for AV graft and fistula
<600 cc/min (graft), <500 cc/min (fistula); indication for diagnostic fistulogram; grafts require high flow rates to maintain patency (relative to fistulas)
Dialysis access: arm swelling, chest wall collaterals, and/or breast swelling
central venous stenosis
Dialysis access: pale, discolored, and/or cold hand
dialysis-associated steal syndrome
Dialysis access: high pitched, discontinuous, and/or systolic only bruit
localized stenosis; normal bruit is low-pitched during systole and diastole
Dialysis access: palpable thrill along venous outflow or systolic only thrill
venous stenosis; normall thrill is palpable at arterial anastomosis only during systole and diastole
Dialysis access: water hammer pulse + no thrill (at fistula)
venous outflow stenosis
Dialysis access: diminished pulse + poor thrill (at fistula)
arterial inflow stenosis
Contraindications to fistulography
infected graft/fistula (absolute), <30 days old (relative), stenosis >7 cm long (relative); send latter two back to surgery
Right posterior bile duct drainage
drains segments 6 and 7 - horizontal course
Right anterior bile duct drainage
drains segments 5 and 8 - vertical course
Treatment of iliac atherosclerotic disease
PTA +/- stenting for non-calcified stenosis <3 cm in length (TASC-II); 3-10 cm may be PTA or surgical; stent if >30% residual stenosis or >10 mmHg pressure gradient after angioplasty
Treatment of femoropopliteal atherosclerotic disease
PTA +/- stenting preferred for single lesion <15 cm in length or multiple lesions each <5 cm in length (TASC-II)
Criteria for portal HTN
PV pressure >10 mmHg, PSG >6 mmHg (normal is 3-6 mmHg)
Imaging findings in portal HTN
PV >13-15 mm, splenic vein >12 mm, splenomegaly, ascites, varices, reversal of flow in PV
Indications for TIPS
refractory variceal hemorrhage, refractory ascites, Budd-Chiari; MELD >18 has higher risk of death post-TIPS
Pre-TIPS evaluation (2)
echo to assess for heart failure, CT abdomen to assess for PV patency
Relative contraindications for TIPS
elevated right or left heart pressures, heart failure or valvular insufficiency, rapidly progressive liver failure, severe hepatic encephalopathy, sepsis, unrelieved biliary obstruction; there are no absolute contraindications (per SIR/ACR)
Acute complications post-TIPS
cardiac decompensation, accelerated liver failure, worsening hepatic encephalopathy
Goal PSG post-TIPS
4-12 mmHg; <4 mmHg results in increased risk of encephalopathy; >12 mmHg leads to refractory ascites and variceal bleeding
Findings suggestive of TIPS stenosis
TIPS velocity <90 cm/s or >190 cm/s; interval change +/- 50 cm/s; MPV velocity <30 cm/s; flow away from TIPS; new or increased ascites
Treatment of TIPS stenosis
measure pressure; >12 mmHg => angioplasty
Shunt fraction to reduce dose or contraindicate Y-90
<10% is normal, 10-20% needs a decreased Y-90 dose, >20% is at risk for radiation pneumonitis
Normal PV velocity
16-40 cm/s
Child-Pugh
INR, bilirubin, albumin + ascites and hepatic encephalopathy; classes B and C are higher risk for variceal bleeding
MELD (Model End-stage Liver Disease)
INR, bilirubin, Cr; higher MELD = higher post-TIPS mortality
Indication for BRTO
treatment of gastrorenal shunt (to improve hepatic encephalopathy); diverts blood to portal system
Complications of BRTO
worsening ascites and esophageal varices (basically makes portal HTN worse)
Landing zone criteria (EVAR)
10-15 mm proximal landing zone, non-aneurysmal, angled <60 degrees
EVAR deployment issues
iliac artery angulation >90 degrees, iliac artery diameter <7 mm
Adrenal vein sampling
used to guide treatment of primary hyperaldosteronism; cosyntropin may be administered during sampling
Unilateral adenoma treatment
surgical excision
Bilateral adrenal hyperplasia treatment
oral spironolactone
Most common biliary ductal variants
right posterior to left > trifurcation
PTC, PTBD, biliary stenting, or cholecystostomy prophylaxis
antibiotics (usually levofloxacin for gram negative coverage)
PTC/PTBD approaches
right mid-axillary (fluoro-guided) or left sub-xyphoid (US-guided)
Ideal biliary drain for crossing lesions
internal-external drain; may be converted to internal only
Cholecystostomy approaches
transhepatic (preferred; segments 5/6 => bare area of GB) or transperitoneal (if significant bleeding risk)
How long to leave cholecystostomy in?
2-6 weeks (tract must mature to avoid bile leak); do cholangiogram prior to removal to ensure cystic duct is patent
Management for bile leak
can place biliary drain to divert bile from location of leak
Metallic stent placement
only in patients with life expectancy less than 6 months (median patency of 6-8 months and cannot be removed)
Liver biopsy technique
choose path to ideally biopsy lesion through at least 2 cm of normal liver tissue (don’t biopsy the capsule)
Approach for liver biopsy in patient with severe coagulopathy or massive ascites
transjugular (avoids capsule => less bleeding); assuming ascites cannot be drained for some reason
Rotation of sheath/cannula for transjugular liver biopsy
rotate anteriorly if in right hepatic vein and posteriorly if in middle hepatic vein
Kehr sign
prolonged shoulder pain post-liver biopsy; may represent bleeding (need to check with US)
Contraindications to liver biopsy
uncorrectable coagulopathy, plt <50, RUQ infection
Varicose vein treatment + contraindication
endoluminal heat source (tumescent anesthesia is used); DVT is a contraindication
Spider web appearance (hepatic venogram)
Budd-Chiari
Most common complication of popliteal artery aneurysm
distal thromboembolism
Pre-arterial access management
stop heparin 2 hours before, stop coumadin 5 days before, stop aspirin/plavix 5 days prior; INR >1.5, plt >50, normal PTT
Post-arterial access management
compression for 15 minutes, can resume heparin in 2 hours, groin checks and pulses on nursing orders
Contraindication to arterial closure device
suspected infection at access site
PICC access vessel preference
basilic > brachial > cephalic; use non-dominant arm
Tunneled lines in septic patients
NO; place a temporary line
Relative contraindications for PICC placement
CKD patients, patients on dialysis, patients that may be going on dialysis; “Fistula First Breakthrough Initiative”; these are also CIs for subclavian central line placement
Central line vessel preference
RIJ > LIJ > REJ > LEJ; RIJ is also preferred site for a dialysis catheter
Spiral appearance of wire while attempting to cross a tight stenosis
dissecting wire
Injection rate: aortogram (aortic arch)
20 for 30
Injection rate: abdominal aorta
20 for 20
Injection rate: IVC
20 for 30
Injection rate: mesenteric arteries
5 for 25
Injection rate: renal arteries
5 for 15
Injection rate: distal arteries
3 for 12
Post-embolization syndrome
pain, cramping, fever, and/or nausea/vomiting; starts within 3 days, goes away within 3 days; similar symtpoms may occur post-ablation
Treatment of post-embolization syndrome
NSAIDs, IVFs, +/- opioids
EVAR and TEVAR (acronyms)
EVAR = EndoVascular Aortic Repair (includes abdominal aorta and iliacs); TEVAR = Thoracic-EVAR
Endograft vs. open repair
EVAR has lower 30-day mortality; graft complications and re-interventions are higher with EVAR; long-term aneurysm-related mortality is the same
Indications for EVAR
AAA >5 cm, or growing at >1 cm/year (0.5 cm per 6 months), or symptomatic; may be 5.5 cm
Indications for TEVAR - ascending and descending thoracic aorta
> 5.5 cm and >6.5 cm, respectively (or >5 cm and >6 cm, respectively, for Marfan’s, familial disease, or bicuspid valve); also if growing at >1 cm/year or symptomatic
Crawford type 4 thoracoabdominal aortic aneurysm
aneurysm extending from 12th intercostal space to iliac bifurcation, with involvement of mesenteric and renal arteries
Type 4 and 5 endoleaks
4 = porous graft (most resolve within 48 hours); 5 = endotension
Permanent embolization agents
coils, plugs, particles, sclerosing agents (alcohol or SDS), glue
Temporary embolization agents
gelfoam (2-6 weeks), autologous clot; gelfoam may appear as locules of gas on CT
Strategy for embolizing a specific lesion
coil distal to lesion, then proximal to lesion (prevents collateral flow); cannot use for “end” arteries
Coils vs. particles
coils can be placed precisely (no distal embolization); particles flow distally to occlude small capillaries
Vessel to embolize: uterine fibroids
bilateral uterine arteries; particles
Vessel to embolize: varicocele
gonadal vein (a.k.a. testicular or spermatic vein)
Vessel to embolize: diffuse splenic trauma
proximal splenic artery (before short gastrics); Amplatz plug; short gastrics maintain some splenic perfusion
Vessel to embolize: hemoptysis
bronchial artery; particles (NOT coils)
Signs of irreversible limb ischemia
complete muscle paralysis, complete sensory loss, no venous flow on Doppler (loss of arterial flow may still be salvageable)
Cause of acute limb ischemia
thrombotic and/or embolic events; most common source is a left atrial thrombus (Afib) => echo to identify source
5 P’s of acute limb ischemia
pain, pallor, pulseness, paresthesias, poikilothermia (cold); emergency
Endovascular treatment of acute thromboembolism (technique)
cross lesion with hydrophilic wire; infuse tPA via multi-sidehole catheter (0.5 mg/hr for 48-72 hours)
When to slow and stop intra-arterial tPA
slow if fibrinogen decreases to <150 mg/dL; stop if fibrinogen <100 mg/dL; patient should be monitor in ICU during infusion
ABI: normal
1.0-1.4; >1.4 is non-compressible due to calcification; ABI = ankle SBP / brachial SBP
ABI: borderline
0.9-0.99
ABI: abnormal
<0.9; claudication at 0.5-0.9, rest pain at 0.3
Foot ulcers: medial ankle, dorsal foot, plantar foot
medial ankle = venous stasis; dorsal foot = infection/ischemic; plantar foot = neuropathic (diabetes)
Risk factors for peripheral vascular disease (chronic)
smoking, diabetes, HTN, hyperlipidemia, no exercise, family history; claudication => rest pain => tissue loss
Classification systems for peripheral vascular disease
Rutherford and Fontaine
Lower extremity arterial access: when to access via contralateral CFA
ipsilateral CFA lesion or EXTREMELY obese; iliac, SFA, and fem-pop graft lesions are all accessed via ipsilateral CFA
Lower extremity arterial access: access for fem-fem bypass
direct stick > inflow CFA
tPA patient with new confusion - NEXT STEP
stop tPA + head CT
tPA patient with hypotension and tachycardia - NEXT STEP
stop tPA + check site +/- CT abdomen/pelvis (patient is bleeding out)
Post-thrombotic syndrome
pain and venous ulcers after DVT; prevent with catheter-directed thrombolysis of iliofemoral DVTs
Indications for IVC filter placement
DVT with contraindication to AC, recurrent PE while on AC, need to discontinue AC due to complications, high risk of developing DVT/PE with contraindication to AC
Most common complication of IVC filter placement
access site thrombosis > IVC thrombosis
Indication for bird’s nest IVC filter
28-40 mm IVC diameter; if >40 mm, separate IVC filters can be placed in the common iliacs
IVC filter retrieval
clot in filter needs to be lysed prior to removal; may retrieve while the patient is anticoagulated; cavogram should be performed after removal (assess for tear)
Risk of suprarenal IVC filter
renal vein thrombosis
Indications for suprarenal IVC filter placement
prengnacy (avoid compression), clot in renal or gonadal veins, duplicated IVC (may also be bilateral iliac filters)
IVC filter placement with circumaortic left renal vein
below lowest renal vein (usually circumaortic vein); retroaortic renal vein may insert low on the IVC
Nitroglycerin - spasm vs. stenosis
spasm will improve with nitroglycerin, while stenosis will not
Successful angioplasty
<30% residual stenosis
Treatment for hepatic pseudoaneurysm (post-traumatic)
embolize distally, then embolize proximal
Treatment for focal splenic abnormality (post-traumatic)
selective embolization (not the same as treatment for diffuse splenic trauma)
ACR appropriateness criteria for liver transplantation
patient <65 y/o with limited tumor burden (1 tumor <5 cm, or up to 3 tumors <3 cm each)
Contraindications to TACE
decompensated liver failure (absolute); PV thrombosis may be a relative contraindication
Indications for RFA (liver)
patients with HCC or colorectal mets who are not surgical candidates; 60 degrees C is ideal temperature
Risk of Y-90 radioembolization
gastric ulceration/necrosis (via right gastric a.); may embo right gastric and GDA prior to Y-90
Size criteria for RFA (liver)
lesion <4 cm (larger lesions require debulking); need a “burn margin” of 0.5-1 cm (includes vascular hilum and adjacent bowel)
Higher bleeding risk with RFA or cryoablation
cryoablation
Post-treatment changes - RFA/TACE/cryo (hepatic mass)
may be transient size increased at 1-4 weeks => same size or smaller 3 months => smaller at 6 months; post-treatment enhancement should be peripheral, smooth, and uniform (any nodular enhancement suggests residual tumor)
Lesion size increase after initial post-treatment scan (hepatic mass)
concerning for recurrent tumor
Ideal target for G-tube placement
mid-to-distal gastric body (lateral to rectus to avoid inferior epigastric a.)
Division of upper vs. lower GI bleeds
ligament of Treitz
Most common source of upper GI bleed
left gastric artery; may be embolized prophylactically if no source can be identified
Vessel to embolize: bleeding duodenal ulcer
GDA
Pancreatic arcade bleeding aneurysm
celiac artery stenosis; shown as an SMA run with dilated collaterals and filling of hepatic artery
Management: upper GI bleed with positive endoscopy
should treat with endoscopy; if endoscopic treatment fails => angio
Management: upper GI bleed with negative endoscopy
3-phase CTA (dry, arterial, delayed); if positive for source => angio; can consider non-targeted angio if negative
Management: lower GI bleed in stable patient
endoscopy (1st line per ACR appropriateness criteria)
Management: lower GI bleed in unstable patient
3-phase CTA or RBC scan => angio; if positive (otherwise conservative management)
Management: obscure GI bleeding (negative endoscopy and colonoscopy)
suggests small bowel source; CTA or capsule endoscopy (per ACR appropriateness criteria)
Detectable bleeding rates - RBC scan vs. CTA vs. angiography
RBC scan = 0.1 cc/min; CTA = 0.4 cc/min; angio = 1 cc/min
Angio with early draining vein (in GI bleed)
angiodysplasia; usually right-sided
Angio with corkscrew vessel (in GI bleed)
vitelline artery (bleeding Meckel’s)
Angio technique (in GI bleed)
should subselect celiac, SMA, and IMA and do runs (to look for collateral flow to site of bleeding); may try injecting nitroglycerin or tPA to “provoke” bleeding
When to remove abscess drainage catheter? (3)
drainage <10 cc/day, collection resolved by imaging, no fistula
Spike in output volume from abscess drain - NEXT STEP
suggests fistula formation; next step is imaging to identify source
Route considerations for pelvic abscess drainage
shortest route possible; avoid bowel, blood vessels, nerves (especially inferior epigastric a.)
Transgluteal approach (pelvic abscess drainage)
access through sacrospinous ligament, as medial as possible, inferior to piriformis
Transvaginal and transrectal approaches (pelvic abscess drainage)
transvaginal for gynecolgic collections (PID); transrectal is an option for pre-sacral collections; both use US guidance
Size criteria for renal abscess drainage
> 3 cm; if <3 cm, treat with antibiotics
Post-renal transplant persistent urinoma vs. lymphocele
check fluid for Cr; if Cr is same as serum => lymphocele; if Cr > serum => urinoma; both need drain placement
Indications for pancreatic collection drainage
infected collection or causing mass effect on bowel/CBD
Pancreatic fluid collection with amylase
pancreatic fistula (fluid is usually clear)
Indications for percutaneous nephrostomy
urinary obstructions (stones or cancer), urinary diversion (leak or fistula), access for procedures
Contraindications to PCN
INR >1.5, plt <50; potassium needs to be correct to <7
Target for PCN (native kidney)
Brodel’s avascular zone; lower pole, posterior calyx, posterior-lateral approach (30 degree angle), 10 cm lateral to midline; side of target should be slightly elevated (use a wedge); upper pole site if for lithotripsy access
Target for PCN (transplant kidney)
anterior-lateral calyx, mid-to-upper pole, lateral approach
PCN maintenance
catheter exchange q2-3 months (due to urine crystallization)
Contraindications to nephroureteral stent
bladder outlet obstruction, neurogenic bladder, obstructing bladder tumor
Indications for suprapubic cystostomy
acute bladder decompression; or bladder outlet obstruction, neurogenic bladder, obstructing bladder tumor
Target for suprapubic cystostomy
midline, lower-to-mid anterior bladder wall
Indication for targeted and non-targeted renal biopsy
targeted for renal mass; non-targeted for native or transplant renal failure (biopsy renal cortex)
Complications of renal biopsy
hematuria, AVF, pseudoaneurysm; latter two are usually small and resolve without treatment
Renal RFA
alternative to partial or total nephrectomy for AML, AVM, and RCC
Treatment threshold for renal AML
> 4 cm (increased bleeding risk)
Management after renal angioplasty
aspirin day before procedure and for 6 months after
Complication of removing too much pleural fluid
re-expansion pulmonary edema
Continuous air bubbles in pleur-evac chamber (chest tube)
bronchopleural fistula; could also represent leak in tube
Empyema vs. pulmonary abscess drainage
empyema is ok to drain; pulmonary abscess is NOT (risk of BPF)
Most common complication of lung biopsy
pneumothorax > hemoptysis
Increased risk of pneumothorax in lung biopsy
lesion size <2 cm, depth >4 cm, COPD, non-perpendicular pleural entry site, multiple pleural punctures, crossing fissures
Pneumothorax on post-lung biopsy radiograph - NEXT STEP
serial radiographs; chest tube indicated if patient is symptomatic or pneumothorax is enlarging
Lung zones most affected by respiratory and cardiac motion
lower lungs are most affected by respiratory motion; lingula is most affected by cardiac motion
Size criteria for pulmonary RFA
1.5-5.2 cm
Indications for pulmonary angiography
diagnosis/treatment of massive PE, treatment of pulmonary AVM
Prior to injecting contrast for pulmonary angiography you must…
measure pulmonary/right heart pressures
Relative contraindications to pulmonary angiography
LBBB (need prophylactic pacing), pulmonary HTN (systolic PAP >70 mmHg or RVEDP >20 mmHg)
Cardiac dysrhythmia during pulmonary angiography - NEXT STEP
reposition catheter/wire
Indication for interventional treatment of PE
unstable patient with massive PE (hypotensive)
Criteria for treatment of pulmonary AVM
symptomatic or afferent vessel >3 mm; must use coils (particles would just embolize through the shunt)
Hemoptysis + positive PPD
rasmussen aneurysm (TB); occurs in pulmonary arteries; coil embolization
Massive hemoptysis definition + NEXT STEP
> 300 cc/hour; bronchial artery angio; seen as tortuous enlarged bronchial arteries (not extravasation usually)
Most common configuration of bronchial arteries
intercostobronchial trunk on right, two bronchial arteries on left; arise at T5-6 level
Treatment of acute SVC obstruction
acute = emergency; thrombolysis => remove offending agent (catheter usually) => angioplasty +/- stent
Do NOT use _______ stents in the SVC
self-expanding stents (tend to migrate)
Hot quadrate sign
SVC obstruction; via vein of Sappey
Hot caudate sign
Budd-Chiari
Indications for UAE
uterine bleeding (e.g. postpartum hemorrhage), symptomatic fibroids (from mass effect), symptomatic adenomyosis
Location of fibroids responding best to UAE
submucosal > intramural > serosal; small fibroids and fibroids with high T2 signal respond well also
Contraindications to UAE
pregnancy, uterine or cervical cancer, active pelvic infection, prior pelvic radiation, connective tissue disease, prior surgery with adhesions (relative)
Indications for gyn referral for fibroid removal
intracavitary fibroid <3 cm, pedunculated serosal fibroid, large serosal fibroid + patient wants to become pregnant
UAE for patient on GnRH
must discontinue for 3 months prior to UAE
Risk of PE with UAE
5%; thrombus in compressed pelvic vein embolizes when pressure from fibroid is released
Complications of UAE
PE, premature menopause
Contraindications to HSG
pregnant, active pelvic infection, recent uterine or tubal pregnancy
Ideal timing of HSG
days 6-12 of menstrual cycle; thinnest endometrium (better visualization), minimizes risk of pregnancy
Fallopian tube recanalization
for proximal tubal obstruction (distal gets surgery); do HSG => poke with hydrophilic wire => repeat HSG to demonstrate patency; contraindications are same as HSG
Diagnosis for pelvic congestion syndrome
symptoms (pain, dyspareunia, menstrual issues) + gonadal vein diameter >10 mm; symptoms worse at end of day and with standing
Vessel to embolize: pelvic congestion syndrome
both gonadal (ovarian) veins; GnRH agonists are an alternative; symptoms improve with menopause
Complications in pelvic congestion syndrome
thrombosis of parent vein (iliac or renal), PE (from thrombus migration)
Indications to treat varicocele
infertility, testicular atrophy, pain
Causes of varicocele
right angle of entry of the spermatic vein into the left renal vein, nutcracker syndrome
Indications for vertebroplasty
acute to subacute fracture with pain refractory to medical therapy, unstable fracture with risk of further collapse
Contraindications to vertebroplasty
fractures with associated spinal canal compression, improving pain without augmentation
Complications of vertebroplasty
new vertebral fracture (25% of cases), embolization of cement, local neurologic complications (5%)
Standing waves
symmetric and evenly space; resolve on subsequent runs
Oblique views - relative to source or detector in IR?
relative to the detector
Oblique view for aortic arch
LAO (70 degrees) - “candy cane”
Oblique view for innominate artery
RAO
Oblique view for left subclavian artery
LAO
View for mesenteric arteries
lateral (or steep RAO)
Oblique view for left renal artery
LAO
Oblique view for right renal artery
RAO
Oblique view for left iliac bifurcation
RAO
Oblique view for right iliac bifurcation
LAO
Oblique view for left CFA bifurcation
LAO
Oblique view for right CFA bifurcation
RAO
Cryoprecipitate is used to correct…
low fibrinogen (e.g. from tPA)
How to: correct INR
FFP or vitamin K; alternatively discontinue coumadin and wait
Heparin-induced thrombocytopenia (HIT) causes increased or decreased clotting
increased clotting (thrombosis); can anticoagulate with fondaparinux, argatroban, or -rudin drugs
AC management for low risk bleeding procedures
INR <2.0, plt >50; stop plavix 5 days prior, hold LMWH for 1 dose; aspirin is ok to continue; no PTT consensus
AC management for moderate risk bleeding procedures
INR <1.5, plt >50; stop plavix 5 days prior, hold LMWH for 1 dose; aspirin is ok to continue; no PTT consensus
AC management for high risk bleeding procedures
INR <1.5, plt >50, PTT >1.5x control; stop aspirin/plavix 5 days prior, hold LMWH for 2 doses or 24 hours
High risk bleeding procedures (5)
TIPS, PCN (new), renal biopsy, biliary interventions (new), RFA (complex)
Antidotes for midazolam and opioids
flumazenil and narcan, respectively
Early signs of lidocaine toxicity
tinnitus and dizziness; occurs from direct arterial injection; may cause immediate seizures
Desmopressin
increases von Willebrand factor (factor VIII); 0.3 mcg/kg IV over 30 min; used for von Willebrand disease or hemophilia
Left SVC drainage
coronary sinus > LA (right-to-left shunt); most common congenital venous anomaly in the chest
Left SVC + associations
persistent left anterior cardinal vein; assoc. with unroofing of the coronary sinus, ASD
Normal right atrial pressure
<5 mmHg
Normal right ventricular pressure
25/5 mmHg
Normal pulmonary artery pressure
<25/10 mmHg
Corkscrewing of hepatic artery branches
cirrhosis
Position of GDA relative to CBD
GDA is anterior to CBD (e.g. on transverse US image)
Tram track appearance (angiogram)
angiodysplasia (common right sided GI bleed); simultaneous opacification of parallel artery and vein
Bizarre neovascularity (angiogram)
renal cell carcinoma
Spoke wheel appearance with peritumoral halo (angiogram)
renal oncocytoma
Wilkie syndrome
a.k.a. SMA syndrome; compression of duodenum by SMA (thin children, burn victims, patients who have lost weight)
Iliac artery aneurysm
> 1.5 cm; repair at >3.0 cm (stent graft)
Popliteal artery aneurysm
> 8 mm; 20% have aortic aneurysms, 50% have bilateral popliteal aneurysms
Treatment of poplilteal artery aneurysm
> 2 cm or symptomatic; endovasclar stent-graft or surgical bypass
Adson’s maneuver
Test for subclavian artery compression - palpate radial artery in neutral position, patient turns head to contralateral side and inhales. Radial pulse reduces in TOS.
Size threshold for treatment of renal or splenic artery aneurysms
> 2 cm
Persistent sciatic artery
arises from internal iliac artery, usually from the inferior gluteal artery; courses posterior to femoral head
Tortuous arteries and aneurysms (syndrome)
Loeys-Dietz (“Marfan’s on steroids”); aortic aneurysms often rupture; also have hypertelorism
Non-decompressible varicocele - NEXT STEP
abdominal imaging; same for isolated right-sided varicocele
Most common hepatic venous variant
accessory right inferior hepatic vein
Most common pediatric vasculitis
Henoch-Schonlein purpura
Significant arterial stenosis
> 10 mmHg drop at rest
Increased risk of splenic artery aneurysm
pregnancy, multiparous females, patients with portal hypertension, after liver transplantation
Increased risk of splenic artery aneurysm rupture
during pregnancy
Indications for splenic artery aneurysm treatment
symptomatic, aneurysm size >2 cm, prior to expected pregnancy
Most common site for visceral aneurysms
splenic > hepatic
At what MELD score is TIPS not recommended
> 25; consider transplant, BRTO, banding or sclerotherapy, or repeat paracentesis
Length of imaging follow-up after EVAR
remainder of life (for graft evaluation)
Multiple renal artery aneurysms DDx
PAN, septic emboli, speed kidney, Ehlers-Danlos
PAN associations
CLASH = Cryoglobulinemia, Leukemia, Arthritis (rheumatoid), Sjogren’s, Hepatitis B; treat PAN with steroids
Do IVC filters increase or decrease the risk of caval thrombosis and DVTs?
increase (for both)
Is sepsis a contraindication to IVC filter placement?
no
Klatskin tumor (hilar neoplasm)
may require separate biliary drains in the right and left ducts
High flow priapism (from Alan)
Non emergent, painless, arterial. Most of the time you leave them alone and they improve. May perform superselective embolization if they do not improve with conservative therapy. Erection should resolve within 24 hours, if not, you may have to reembolize.
Low flow priapism (from Alan)
Painful, venous. SCD, venous thrombosis. Considered a true vascular emergency. Have to stick needles in the corpora for direct pressure measurement. Managed by urology.
Relationship of replaced right hepatic artery to portal vein
posterior to PV (normal RHA is anterior to PV)
First branch off SMA
inferior pancreaticoduodenal artery
Superior vesicular artery origin
umbilical artery (most commonly)
Inferior rectal artery origin
internal pudendal artery (most commonly)
Corona mortis
variant anastomosis between obturator a. and EIA or inferior epigastric a.; courses superior to pubic rim
Artery supplying superficial palmar arch
ulnar artery
Artery supplying deep palmar arch
radial artery; may also be supplied by a persistent anterior interosseous branch (median artery)
Isolated gastric varices
splenic vein thrombosis; gastric varices drain into inferior phrenic v. => left renal v.
Duplicated IVC associations
horseshoe kidney, cross-fused renal ectopia
Azygous continuation association
polysplenia
Absence of the intrahepatic IVC
azygous continuation; hepatic veins drain directly to RA
Most common acute aortic syndrome
aortic dissection
Risk factors for aortic dissection
hypertension, Marfan’s, bicuspid AV, aortic coarctation, pregnancy, cocaine, syphilitic aortitis
Displacement of intimal calcifications on NECT
aortic dissection
Left renal artery usually arises from the true or false lumen?
false lumen (enhances later and is usually larger than the true lumen)
Floating viscera sign
aortic dissection
Rupture of vasa vasorum
intramural hematoma; may progress to dissection; also classified as Stanford A or B
Mortality predictors in IMH (and PAU)
ascending aorta >5 cm, IMH >2 cm, pericardial effusion; maximum aortic diameter is strongest predictor
Cause of penetrating atherosclerotic ulcers
atherosclerosis (not HTN as with other acute aortic syndromes)
Most common location for traumatic pseudoaneurysm
aortic isthmus (from tethering of ligamentum arteriosum)
Apical cap in the post-traumatic setting
suspect aortic injury
Ascending aortic calcifications
Takayasu arteritis, syphilis (tree bark intimal calcifications)
Aortic aneurysm sizes
ascending >4 cm, descending >3.5 cm, abdominal >3 cm
Child with hypertension and orificial renal artery stenosis
NF1
Annuloaortic ectasia (“tulip bulb”)
Marfan’s, Ehlers-Danlos; increased risk of aortic dissection and aortic regurgitation; can also involve pulmonary artery
Sinus of Valsalva aneurysm association + treatment
associated with VSD; treatment is Bentall procedure; rupture may cause cardiac tamponade
Leutic aneurysm
from syphilis (tertiary); saccular, involves ascending aorta; coronary narrowing in 30%
Location for mycotic aneurysms
most occur in thoracic or supra-renal aorta; most often via hematogenous seeding from endocarditis
Aortoenteric fistula vs. perigraft infection
can only differentiate if there is IV contrast in the bowel; fistula involves 3rd/4th segments of duodenum
Mid-aortic syndrome
progressive narrowing of the abdominal aorta; triad of claudication, HTN, and renal failure in children/young adults
Most common cause of thoracic outlet syndrome
compression by anterior scalene muscle; from most to least affected, nerve > vein > artery
Effort thrombosis
a.k.a. Paget-Shroetter; TOS + SCV thrombosis; often seen in pitchers and weightlifters; Tx thrombolysis + angioplasty + surgical release (NO stenting)
Pulmonary artery aneurysm/pseudoaneurysm
iatrogenic (Swan-Ganz), Behcet’s, chronic PE, Rasmussen aneurysm
Hughes-Stovin syndrome
recurrent thrombophlebitis and pulmonary artery aneurysms; similar to Behcet’s
Heyde syndrome
aortic stenosis, colonic angiodysplasias
Segmental arterial mediolysis
coronaries in young adults, splanchnic arteries in elderly; classically multiple splanchnic saccular aneurysms
Medial deviation of popliteal artery
popliteal entrapment (due to relationship of medial head of gastrocnemius)
Pulses decrease with plantarflexion or dorsiflexion
popliteal entrapment; may see occlusion on MRA or angiography with plantar or dorsi-flexion
Marginal vein of Servelle
large vein in superficial lateral calf; assoc. with Klippel-Trenaunay syndrome
Klippel-Trenaunay syndrome triad
port-wine nevi, localized bony or soft tissue hypertrophy, venous malformation
c-ANCA+
granulomatosis with polyangiitis (Wegener’s)
p-ANCA+
Churg-Strauss, microscopic polyangiitis, PAN
Auto-amputation of digits
Buerger disease; distal occlusions and/or corkscrew collaterals
Pseudoaneurysm of ulnar artery (hand)
hypothenar hammer syndrome; may also see ulnar artery or more distal occlusions
Hand angiogram with finger occlusions
Buerger’s or HHS; ulnar artery involvement suggests HHS
Henoch-Schoenlein purpura
palpable purpura, GI bleeding, intussusception; bowel wall thickening, scrotal edema; non-ANCA
50-69% carotid stenosis
ICA PSV 125-230 cm/s or ICA/CCA PSV ratio 2.0-4.0
> 70% carotid stenosis
ICA PSV >230 cm/s or ICA/CCA PSV ratio >4.0
Temporal tap
to identify the ECA (from the ICA)
Bilateral carotid reversal of flow
aortic regurgitation
Loss of diastolic flow in ICAs
brain death
CCA waveform looks like ECA waveform
ICA occlusion (loss of diastolic flow in CCA)
Carotid waveform with IABP
normal peak + assisted peak; ideal IABP position is superior balloon 2 cm distal to LSCA and inferior balloon is just above renals
Pulsus bisferiens
two peaks; seen in aortic regurgitation, severe HOCM, dissection, severe COPD
Vertical vein
in supracardiac TAPVR; pulmonary veins converge to form a vertical vein which drains into SVC, BCV, or azygous vein
Takayasu treatment
steroids; angioplasty is NOT performed in the acute setting
Fibrin sheath
contrast flows retrograde away from tip; “line flushes, but does not aspirate”
Celiac, SMA, IMA, and renal arteries arise at what spinal levels
celiac = T12, SMA = T12-L1, renal arteries = L1-2, IMA = L3-4
Source of bleeding in Mallory-Weiss tear
left gastric artery often; partial thickness tear
Vessel in the fissure of the ligamentum venosum
replaced/accessory left hepatic artery
Meandering mesenteric artery
arc of Riolan; connection between middle colic a. and left colic a.
Vessel within scalene triangle
subclavian artery (with brachial plexus); vein runs anterior to the anterior scalene muscle
Borders of scalene triangle
anterior scalene m., middle scalene m., first rib
Branches of subclavian artery
vertebral a., internal mammary a., thyrocervical trunk, costocervical trunk, dorsal scapular a. (from proximal to distal)
Landmarks for beginning and end of axillary artery
distal margin of first rib to lower border of teres major
Ulnar vs. radial artery
ulnar artery is bigger, gives off common interosseous branch, and supplies superficial palmar arch
Lower leg arteries (from lateral to medial)
anterior tibial a., peroneal a., posterior tibial a.
Most gastric varices are formed by which vessel?
left gastic vein (coronary vein)
True aneurysm definition
enlargement of lumen 1.5x its normal diameter
Leriche syndrome
infrarenal aortoiliac occlusion; triad of impotence, buttock/thigh claudication, absent femoral pulses
Blood supply to descending aorta in pre-ductal aortic coarctation
PDA
Dunbar syndrome
a.k.a. median arcuate ligament syndrome; worse with expiration; surgical treatment
Most common site affected by chronic mesenteric ischemia
splenic flexure of colon (watershed region); chronic usually requires stenosis of at least 2 of the 3 main mesenteric arteries
Suspected HHT - NEXT STEP
CTA of liver and lungs + MRA brain
Most common location for FMD
renal aa. > carotid aa. > iliac aa.; most common type is medial
Most common peripheral arterial aneurysm
popliteal artery aneurysm
Most common type of Takayasu arteritis
type 3 (involves aortic arch and abdominal aorta)
Most common sites of involvement in PAN
renal > cardiac > GI; microaneurysm formation; more common in males
Cogan syndrome
aortitis + vertigo, tinnitus, and/or inflammatory eye disease
Most common cause of acute mesenteric ischemia
SMA embolus
Treatment for non-enhancing uterine fibroids
do not embolize
Intra-procedural heparinization
angioplasty, any dialysis intervention, neuro IR
Portal vein embolization
used to increase remnant liver size prior to partial hepatectomy
