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AJT CORE > CORE - Vascular_IR > Flashcards

CORE - Vascular_IR Flashcards

1
Q

Femoral pseudoaneurysm treatment

A

direct compression of PSA neck, thrombin injection, or surgery (3 cm or greater); can watch if 1 cm or less

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2
Q

How much thrombin to inject into pseudoaneurysm

A

500-1000 units (or 0.5 to 1.0 mL); thrombin injection is the preferred method if possible

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3
Q

Contraindications to thrombin injection (for femoral PSA)

A

local infection, rapid enlargement, distal limb ischemia, large neck, PSA <1 cm; inject APEX of cavity

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4
Q

Vasopressin for GI bleeding

A

vasoconstrictor, infused directly into SMA or IMA; high re-bleeding rates; may cause NOMI

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5
Q

Complications of vasopressin

A

arrhythmia, pulmonary edema, hypertension, NOMI; tachyphylaxis develops after 24 hours

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6
Q

Papaverine dose for NOMI

A

30-60 mg/hr direct arterial infusion

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7
Q

Heparin reversal

A

protamine; 1 mg IV per 100 units active heparin

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8
Q

Side effects of protamine

A

sudden drop in BP, bradycardia, flushing

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9
Q

Wire size for 18G and 19G needles

A

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

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10
Q

1 Fr = ___ mm

A

0.33 mm; also 1 mm = 0.038”

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11
Q

Microwire sizes

A

0.018” and 0.014”; micropuncture technique refers to a 21G needle and 0.018” diameter wire

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12
Q

Sheaths sizes are designated by inner or outer diameter

A

inner diameter (add 2 Fr for outer diameter); everything else is by outer diameter

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13
Q

Standard 0.035” wire will fit through what size sheath?

A

4 Fr or larger

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14
Q

Wire diameters are in ______ and lengths are in ______

A

diameter in inches, length in cm

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15
Q

Standard wire length (cm)

A

180 cm (long wire is 260 cm)

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16
Q

Wire tips - floppy, J-tip, hydrophilic, and stiff

A

floppy = Bentson; J-tip = Rosen; hydrophilic = Glidewire, Roadrunner; stiff = Amplatz, Lunderquist

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17
Q

Size in mm associated with J-tip wires refers to what?

A

radius of curvature (of the ‘J’); small curves miss small branch vessels, large curves miss large branch vessels

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18
Q

Uses for hydrophilic wires

A

cross a stenosis, cannulate an indwelling device, enter abscess cavity

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19
Q

Catheter numbers - e.g. 4, 180, 0.035

A

refers to outer diameter (in Fr), length (in cm), and inner diameter (in inches)

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20
Q

Non-selective (high flow) catheters - pigtail vs. straight

A

pigtail for injecting medium-to-large vessels; straight for injecting small vessels; both have side and end holes

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21
Q

Selective catheters

A

end hole only; used for selection and embolization; contrast administered via hand injection only (no pump runs)

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22
Q

Catheter flow rates (by Fr)

A

3 Fr = 8 ml/s; 4 Fr = 16 ml/s; 5 Fr = 24 ml/s

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23
Q

Angle of catheter for selecting celiac, SMA, or IMA

A

obtuse angle (>120 degrees); a.k.a. recurve catheter (sidewinder, C2, or sos)

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24
Q

Ideal location for femoral arterial stick

A

inferomedial margin of femoral head; needle angled 45 degrees cranially for retrograde access and 45 degrees caudally for anterograde access

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25
Q

Location of femoral vein relative to femoral artery just inferior to femoral head

A

femoral vein is deep to the femoral artery; risk of AVF with low puncture

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26
Q

Treatment for suspected air embolism

A

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

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27
Q

Indications for brachial artery access

A

upper limb angioplasty or femoral artery is out; risk of stroke if catheter has to cross aortic arch

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28
Q

Which side for brachial artery access?

A

left brachial if headed “south”, right brachial if headed “north”

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29
Q

Important points of radial artery access (2)

A

bedrest not required; need to perform Allen test prior to puncture

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30
Q

Contraindication to translumbar aortic puncture

A

known supraceliac aortic aneurysm

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31
Q

Risk of translumbar aortic puncture

A

psoas hematoma; used for type 2 endoleak; stick at T12; “self compress” by rolling on back

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32
Q

Anticoagulation during + after angioplasty

A

should be anticoagulated during procedure to avoid thrombosis from intimal injury (typically with heparin); ASA + plavix for 1-3 months after stenting

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33
Q

Balloon size

A

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

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34
Q

Balloon nomenclature

A

[diameter in mm] x [length in cm], e.g. “10 x 6” = “10 mm in diameter, 6 cm in length”

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35
Q

Balloon-expanding stents

A

higher radial force, better for more precise deployment; will not rebound if crushed; do not use around joints

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36
Q

Self-expanding stents

A

more flexible; preferred in tortuous route to lesion or areas prone to external compression

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37
Q

Stent size

A

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

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38
Q

Indications for covered stents (no fenestrations)

A

treatment of pseudoaneurysm, dissection, and TIPS

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39
Q

Primary stenting definition

A

angioplasty followed by stenting

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40
Q

Particle size for bronchial artery embolization (hemoptysis)

A

> 325 um; particles <300 um may cause tissue necrosis; NEVER coils

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41
Q

Particle size for UAE

A

500-700 um

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42
Q

Particle size for GI bleed

A

300-500 um; particles <300 um may cause bowel infarct

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43
Q

IR procedures with antibiotic prophylaxis

A

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)

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44
Q

CO2 contrast

A

negative contrast agent often used in patients with renal insufficiency or severe contrast allergy, also in TIPS

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45
Q

Swollen left leg

A

May-Thurner; treatment is thrombolysis + stenting

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46
Q

Splenic artery aneurysm associations

A

pregnancy, portal HTN, HTN, cirrhosis, liver transplant; pseudoaneuryms classically assoc. with pancreatitis

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47
Q

Increased risk of splenic artery aneurysm rupture

A

during pregnancy

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48
Q

Indications for splenic artery aneurysm treatment

A

symptomatic, aneurysm size >2 cm, prior to expected pregnancy

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49
Q

Slow flow rates for AV graft and fistula

A

<600 cc/min (graft), <500 cc/min (fistula); indication for diagnostic fistulogram; grafts require high flow rates to maintain patency (relative to fistulas)

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50
Q

Dialysis access: arm swelling, chest wall collaterals, and/or breast swelling

A

central venous stenosis

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51
Q

Dialysis access: pale, discolored, and/or cold hand

A

dialysis-associated steal syndrome

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52
Q

Dialysis access: high pitched, discontinuous, and/or systolic only bruit

A

localized stenosis; normal bruit is low-pitched during systole and diastole

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53
Q

Dialysis access: palpable thrill along venous outflow or systolic only thrill

A

venous stenosis; normall thrill is palpable at arterial anastomosis only during systole and diastole

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54
Q

Dialysis access: water hammer pulse + no thrill (at fistula)

A

venous outflow stenosis

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55
Q

Dialysis access: diminished pulse + poor thrill (at fistula)

A

arterial inflow stenosis

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56
Q

Contraindications to fistulography

A

infected graft/fistula (absolute), <30 days old (relative), stenosis >7 cm long (relative); send latter two back to surgery

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57
Q

Right posterior bile duct drainage

A

drains segments 6 and 7 - horizontal course

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58
Q

Right anterior bile duct drainage

A

drains segments 5 and 8 - vertical course

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59
Q

Treatment of iliac atherosclerotic disease

A

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

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60
Q

Treatment of femoropopliteal atherosclerotic disease

A

PTA +/- stenting preferred for single lesion <15 cm in length or multiple lesions each <5 cm in length (TASC-II)

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61
Q

Criteria for portal HTN

A

PV pressure >10 mmHg, PSG >6 mmHg (normal is 3-6 mmHg)

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62
Q

Imaging findings in portal HTN

A

PV >13-15 mm, splenic vein >12 mm, splenomegaly, ascites, varices, reversal of flow in PV

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63
Q

Indications for TIPS

A

refractory variceal hemorrhage, refractory ascites, Budd-Chiari; MELD >18 has higher risk of death post-TIPS

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64
Q

Pre-TIPS evaluation (2)

A

echo to assess for heart failure, CT abdomen to assess for PV patency

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65
Q

Relative contraindications for TIPS

A

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)

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66
Q

Acute complications post-TIPS

A

cardiac decompensation, accelerated liver failure, worsening hepatic encephalopathy

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67
Q

Goal PSG post-TIPS

A

4-12 mmHg; <4 mmHg results in increased risk of encephalopathy; >12 mmHg leads to refractory ascites and variceal bleeding

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68
Q

Findings suggestive of TIPS stenosis

A

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

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69
Q

Treatment of TIPS stenosis

A

measure pressure; >12 mmHg => angioplasty

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70
Q

Shunt fraction to reduce dose or contraindicate Y-90

A

<10% is normal, 10-20% needs a decreased Y-90 dose, >20% is at risk for radiation pneumonitis

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71
Q

Normal PV velocity

A

16-40 cm/s

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72
Q

Child-Pugh

A

INR, bilirubin, albumin + ascites and hepatic encephalopathy; classes B and C are higher risk for variceal bleeding

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73
Q

MELD (Model End-stage Liver Disease)

A

INR, bilirubin, Cr; higher MELD = higher post-TIPS mortality

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74
Q

Indication for BRTO

A

treatment of gastrorenal shunt (to improve hepatic encephalopathy); diverts blood to portal system

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75
Q

Complications of BRTO

A

worsening ascites and esophageal varices (basically makes portal HTN worse)

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76
Q

Landing zone criteria (EVAR)

A

10-15 mm proximal landing zone, non-aneurysmal, angled <60 degrees

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77
Q

EVAR deployment issues

A

iliac artery angulation >90 degrees, iliac artery diameter <7 mm

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78
Q

Adrenal vein sampling

A

used to guide treatment of primary hyperaldosteronism; cosyntropin may be administered during sampling

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79
Q

Unilateral adenoma treatment

A

surgical excision

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80
Q

Bilateral adrenal hyperplasia treatment

A

oral spironolactone

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81
Q

Most common biliary ductal variants

A

right posterior to left > trifurcation

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82
Q

PTC, PTBD, biliary stenting, or cholecystostomy prophylaxis

A

antibiotics (usually levofloxacin for gram negative coverage)

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83
Q

PTC/PTBD approaches

A

right mid-axillary (fluoro-guided) or left sub-xyphoid (US-guided)

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84
Q

Ideal biliary drain for crossing lesions

A

internal-external drain; may be converted to internal only

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85
Q

Cholecystostomy approaches

A

transhepatic (preferred; segments 5/6 => bare area of GB) or transperitoneal (if significant bleeding risk)

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86
Q

How long to leave cholecystostomy in?

A

2-6 weeks (tract must mature to avoid bile leak); do cholangiogram prior to removal to ensure cystic duct is patent

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87
Q

Management for bile leak

A

can place biliary drain to divert bile from location of leak

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88
Q

Metallic stent placement

A

only in patients with life expectancy less than 6 months (median patency of 6-8 months and cannot be removed)

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89
Q

Liver biopsy technique

A

choose path to ideally biopsy lesion through at least 2 cm of normal liver tissue (don’t biopsy the capsule)

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90
Q

Approach for liver biopsy in patient with severe coagulopathy or massive ascites

A

transjugular (avoids capsule => less bleeding); assuming ascites cannot be drained for some reason

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91
Q

Rotation of sheath/cannula for transjugular liver biopsy

A

rotate anteriorly if in right hepatic vein and posteriorly if in middle hepatic vein

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92
Q

Kehr sign

A

prolonged shoulder pain post-liver biopsy; may represent bleeding (need to check with US)

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93
Q

Contraindications to liver biopsy

A

uncorrectable coagulopathy, plt <50, RUQ infection

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94
Q

Varicose vein treatment + contraindication

A

endoluminal heat source (tumescent anesthesia is used); DVT is a contraindication

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95
Q

Spider web appearance (hepatic venogram)

A

Budd-Chiari

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96
Q

Most common complication of popliteal artery aneurysm

A

distal thromboembolism

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97
Q

Pre-arterial access management

A

stop heparin 2 hours before, stop coumadin 5 days before, stop aspirin/plavix 5 days prior; INR >1.5, plt >50, normal PTT

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98
Q

Post-arterial access management

A

compression for 15 minutes, can resume heparin in 2 hours, groin checks and pulses on nursing orders

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99
Q

Contraindication to arterial closure device

A

suspected infection at access site

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100
Q

PICC access vessel preference

A

basilic > brachial > cephalic; use non-dominant arm

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101
Q

Tunneled lines in septic patients

A

NO; place a temporary line

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102
Q

Relative contraindications for PICC placement

A

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

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103
Q

Central line vessel preference

A

RIJ > LIJ > REJ > LEJ; RIJ is also preferred site for a dialysis catheter

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104
Q

Spiral appearance of wire while attempting to cross a tight stenosis

A

dissecting wire

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105
Q

Injection rate: aortogram (aortic arch)

A

20 for 30

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106
Q

Injection rate: abdominal aorta

A

20 for 20

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107
Q

Injection rate: IVC

A

20 for 30

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108
Q

Injection rate: mesenteric arteries

A

5 for 25

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109
Q

Injection rate: renal arteries

A

5 for 15

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110
Q

Injection rate: distal arteries

A

3 for 12

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111
Q

Post-embolization syndrome

A

pain, cramping, fever, and/or nausea/vomiting; starts within 3 days, goes away within 3 days; similar symtpoms may occur post-ablation

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112
Q

Treatment of post-embolization syndrome

A

NSAIDs, IVFs, +/- opioids

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113
Q

EVAR and TEVAR (acronyms)

A

EVAR = EndoVascular Aortic Repair (includes abdominal aorta and iliacs); TEVAR = Thoracic-EVAR

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114
Q

Endograft vs. open repair

A

EVAR has lower 30-day mortality; graft complications and re-interventions are higher with EVAR; long-term aneurysm-related mortality is the same

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115
Q

Indications for EVAR

A

AAA >5 cm, or growing at >1 cm/year (0.5 cm per 6 months), or symptomatic; may be 5.5 cm

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116
Q

Indications for TEVAR - ascending and descending thoracic aorta

A

> 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

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117
Q

Crawford type 4 thoracoabdominal aortic aneurysm

A

aneurysm extending from 12th intercostal space to iliac bifurcation, with involvement of mesenteric and renal arteries

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118
Q

Type 4 and 5 endoleaks

A

4 = porous graft (most resolve within 48 hours); 5 = endotension

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119
Q

Permanent embolization agents

A

coils, plugs, particles, sclerosing agents (alcohol or SDS), glue

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120
Q

Temporary embolization agents

A

gelfoam (2-6 weeks), autologous clot; gelfoam may appear as locules of gas on CT

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121
Q

Strategy for embolizing a specific lesion

A

coil distal to lesion, then proximal to lesion (prevents collateral flow); cannot use for “end” arteries

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122
Q

Coils vs. particles

A

coils can be placed precisely (no distal embolization); particles flow distally to occlude small capillaries

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123
Q

Vessel to embolize: uterine fibroids

A

bilateral uterine arteries; particles

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124
Q

Vessel to embolize: varicocele

A

gonadal vein (a.k.a. testicular or spermatic vein)

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125
Q

Vessel to embolize: diffuse splenic trauma

A

proximal splenic artery (before short gastrics); Amplatz plug; short gastrics maintain some splenic perfusion

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126
Q

Vessel to embolize: hemoptysis

A

bronchial artery; particles (NOT coils)

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127
Q

Signs of irreversible limb ischemia

A

complete muscle paralysis, complete sensory loss, no venous flow on Doppler (loss of arterial flow may still be salvageable)

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128
Q

Cause of acute limb ischemia

A

thrombotic and/or embolic events; most common source is a left atrial thrombus (Afib) => echo to identify source

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129
Q

5 P’s of acute limb ischemia

A

pain, pallor, pulseness, paresthesias, poikilothermia (cold); emergency

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130
Q

Endovascular treatment of acute thromboembolism (technique)

A

cross lesion with hydrophilic wire; infuse tPA via multi-sidehole catheter (0.5 mg/hr for 48-72 hours)

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131
Q

When to slow and stop intra-arterial tPA

A

slow if fibrinogen decreases to <150 mg/dL; stop if fibrinogen <100 mg/dL; patient should be monitor in ICU during infusion

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132
Q

ABI: normal

A

1.0-1.4; >1.4 is non-compressible due to calcification; ABI = ankle SBP / brachial SBP

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133
Q

ABI: borderline

A

0.9-0.99

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134
Q

ABI: abnormal

A

<0.9; claudication at 0.5-0.9, rest pain at 0.3

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135
Q

Foot ulcers: medial ankle, dorsal foot, plantar foot

A

medial ankle = venous stasis; dorsal foot = infection/ischemic; plantar foot = neuropathic (diabetes)

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136
Q

Risk factors for peripheral vascular disease (chronic)

A

smoking, diabetes, HTN, hyperlipidemia, no exercise, family history; claudication => rest pain => tissue loss

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137
Q

Classification systems for peripheral vascular disease

A

Rutherford and Fontaine

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138
Q

Lower extremity arterial access: when to access via contralateral CFA

A

ipsilateral CFA lesion or EXTREMELY obese; iliac, SFA, and fem-pop graft lesions are all accessed via ipsilateral CFA

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139
Q

Lower extremity arterial access: access for fem-fem bypass

A

direct stick > inflow CFA

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140
Q

tPA patient with new confusion - NEXT STEP

A

stop tPA + head CT

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141
Q

tPA patient with hypotension and tachycardia - NEXT STEP

A

stop tPA + check site +/- CT abdomen/pelvis (patient is bleeding out)

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142
Q

Post-thrombotic syndrome

A

pain and venous ulcers after DVT; prevent with catheter-directed thrombolysis of iliofemoral DVTs

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143
Q

Indications for IVC filter placement

A

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

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144
Q

Most common complication of IVC filter placement

A

access site thrombosis > IVC thrombosis

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145
Q

Indication for bird’s nest IVC filter

A

28-40 mm IVC diameter; if >40 mm, separate IVC filters can be placed in the common iliacs

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146
Q

IVC filter retrieval

A

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)

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147
Q

Risk of suprarenal IVC filter

A

renal vein thrombosis

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148
Q

Indications for suprarenal IVC filter placement

A

prengnacy (avoid compression), clot in renal or gonadal veins, duplicated IVC (may also be bilateral iliac filters)

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149
Q

IVC filter placement with circumaortic left renal vein

A

below lowest renal vein (usually circumaortic vein); retroaortic renal vein may insert low on the IVC

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150
Q

Nitroglycerin - spasm vs. stenosis

A

spasm will improve with nitroglycerin, while stenosis will not

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151
Q

Successful angioplasty

A

<30% residual stenosis

152
Q

Treatment for hepatic pseudoaneurysm (post-traumatic)

A

embolize distally, then embolize proximal

153
Q

Treatment for focal splenic abnormality (post-traumatic)

A

selective embolization (not the same as treatment for diffuse splenic trauma)

154
Q

ACR appropriateness criteria for liver transplantation

A

patient <65 y/o with limited tumor burden (1 tumor <5 cm, or up to 3 tumors <3 cm each)

155
Q

Contraindications to TACE

A

decompensated liver failure (absolute); PV thrombosis may be a relative contraindication

156
Q

Indications for RFA (liver)

A

patients with HCC or colorectal mets who are not surgical candidates; 60 degrees C is ideal temperature

157
Q

Risk of Y-90 radioembolization

A

gastric ulceration/necrosis (via right gastric a.); may embo right gastric and GDA prior to Y-90

158
Q

Size criteria for RFA (liver)

A

lesion <4 cm (larger lesions require debulking); need a “burn margin” of 0.5-1 cm (includes vascular hilum and adjacent bowel)

159
Q

Higher bleeding risk with RFA or cryoablation

A

cryoablation

160
Q

Post-treatment changes - RFA/TACE/cryo (hepatic mass)

A

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)

161
Q

Lesion size increase after initial post-treatment scan (hepatic mass)

A

concerning for recurrent tumor

162
Q

Ideal target for G-tube placement

A

mid-to-distal gastric body (lateral to rectus to avoid inferior epigastric a.)

163
Q

Division of upper vs. lower GI bleeds

A

ligament of Treitz

164
Q

Most common source of upper GI bleed

A

left gastric artery; may be embolized prophylactically if no source can be identified

165
Q

Vessel to embolize: bleeding duodenal ulcer

A

GDA

166
Q

Pancreatic arcade bleeding aneurysm

A

celiac artery stenosis; shown as an SMA run with dilated collaterals and filling of hepatic artery

167
Q

Management: upper GI bleed with positive endoscopy

A

should treat with endoscopy; if endoscopic treatment fails => angio

168
Q

Management: upper GI bleed with negative endoscopy

A

3-phase CTA (dry, arterial, delayed); if positive for source => angio; can consider non-targeted angio if negative

169
Q

Management: lower GI bleed in stable patient

A

endoscopy (1st line per ACR appropriateness criteria)

170
Q

Management: lower GI bleed in unstable patient

A

3-phase CTA or RBC scan => angio; if positive (otherwise conservative management)

171
Q

Management: obscure GI bleeding (negative endoscopy and colonoscopy)

A

suggests small bowel source; CTA or capsule endoscopy (per ACR appropriateness criteria)

172
Q

Detectable bleeding rates - RBC scan vs. CTA vs. angiography

A

RBC scan = 0.1 cc/min; CTA = 0.4 cc/min; angio = 1 cc/min

173
Q

Angio with early draining vein (in GI bleed)

A

angiodysplasia; usually right-sided

174
Q

Angio with corkscrew vessel (in GI bleed)

A

vitelline artery (bleeding Meckel’s)

175
Q

Angio technique (in GI bleed)

A

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

176
Q

When to remove abscess drainage catheter? (3)

A

drainage <10 cc/day, collection resolved by imaging, no fistula

177
Q

Spike in output volume from abscess drain - NEXT STEP

A

suggests fistula formation; next step is imaging to identify source

178
Q

Route considerations for pelvic abscess drainage

A

shortest route possible; avoid bowel, blood vessels, nerves (especially inferior epigastric a.)

179
Q

Transgluteal approach (pelvic abscess drainage)

A

access through sacrospinous ligament, as medial as possible, inferior to piriformis

180
Q

Transvaginal and transrectal approaches (pelvic abscess drainage)

A

transvaginal for gynecolgic collections (PID); transrectal is an option for pre-sacral collections; both use US guidance

181
Q

Size criteria for renal abscess drainage

A

> 3 cm; if <3 cm, treat with antibiotics

182
Q

Post-renal transplant persistent urinoma vs. lymphocele

A

check fluid for Cr; if Cr is same as serum => lymphocele; if Cr > serum => urinoma; both need drain placement

183
Q

Indications for pancreatic collection drainage

A

infected collection or causing mass effect on bowel/CBD

184
Q

Pancreatic fluid collection with amylase

A

pancreatic fistula (fluid is usually clear)

185
Q

Indications for percutaneous nephrostomy

A

urinary obstructions (stones or cancer), urinary diversion (leak or fistula), access for procedures

186
Q

Contraindications to PCN

A

INR >1.5, plt <50; potassium needs to be correct to <7

187
Q

Target for PCN (native kidney)

A

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

188
Q

Target for PCN (transplant kidney)

A

anterior-lateral calyx, mid-to-upper pole, lateral approach

189
Q

PCN maintenance

A

catheter exchange q2-3 months (due to urine crystallization)

190
Q

Contraindications to nephroureteral stent

A

bladder outlet obstruction, neurogenic bladder, obstructing bladder tumor

191
Q

Indications for suprapubic cystostomy

A

acute bladder decompression; or bladder outlet obstruction, neurogenic bladder, obstructing bladder tumor

192
Q

Target for suprapubic cystostomy

A

midline, lower-to-mid anterior bladder wall

193
Q

Indication for targeted and non-targeted renal biopsy

A

targeted for renal mass; non-targeted for native or transplant renal failure (biopsy renal cortex)

194
Q

Complications of renal biopsy

A

hematuria, AVF, pseudoaneurysm; latter two are usually small and resolve without treatment

195
Q

Renal RFA

A

alternative to partial or total nephrectomy for AML, AVM, and RCC

196
Q

Treatment threshold for renal AML

A

> 4 cm (increased bleeding risk)

197
Q

Management after renal angioplasty

A

aspirin day before procedure and for 6 months after

198
Q

Complication of removing too much pleural fluid

A

re-expansion pulmonary edema

199
Q

Continuous air bubbles in pleur-evac chamber (chest tube)

A

bronchopleural fistula; could also represent leak in tube

200
Q

Empyema vs. pulmonary abscess drainage

A

empyema is ok to drain; pulmonary abscess is NOT (risk of BPF)

201
Q

Most common complication of lung biopsy

A

pneumothorax > hemoptysis

202
Q

Increased risk of pneumothorax in lung biopsy

A

lesion size <2 cm, depth >4 cm, COPD, non-perpendicular pleural entry site, multiple pleural punctures, crossing fissures

203
Q

Pneumothorax on post-lung biopsy radiograph - NEXT STEP

A

serial radiographs; chest tube indicated if patient is symptomatic or pneumothorax is enlarging

204
Q

Lung zones most affected by respiratory and cardiac motion

A

lower lungs are most affected by respiratory motion; lingula is most affected by cardiac motion

205
Q

Size criteria for pulmonary RFA

A

1.5-5.2 cm

206
Q

Indications for pulmonary angiography

A

diagnosis/treatment of massive PE, treatment of pulmonary AVM

207
Q

Prior to injecting contrast for pulmonary angiography you must…

A

measure pulmonary/right heart pressures

208
Q

Relative contraindications to pulmonary angiography

A

LBBB (need prophylactic pacing), pulmonary HTN (systolic PAP >70 mmHg or RVEDP >20 mmHg)

209
Q

Cardiac dysrhythmia during pulmonary angiography - NEXT STEP

A

reposition catheter/wire

210
Q

Indication for interventional treatment of PE

A

unstable patient with massive PE (hypotensive)

211
Q

Criteria for treatment of pulmonary AVM

A

symptomatic or afferent vessel >3 mm; must use coils (particles would just embolize through the shunt)

212
Q

Hemoptysis + positive PPD

A

rasmussen aneurysm (TB); occurs in pulmonary arteries; coil embolization

213
Q

Massive hemoptysis definition + NEXT STEP

A

> 300 cc/hour; bronchial artery angio; seen as tortuous enlarged bronchial arteries (not extravasation usually)

214
Q

Most common configuration of bronchial arteries

A

intercostobronchial trunk on right, two bronchial arteries on left; arise at T5-6 level

215
Q

Treatment of acute SVC obstruction

A

acute = emergency; thrombolysis => remove offending agent (catheter usually) => angioplasty +/- stent

216
Q

Do NOT use _______ stents in the SVC

A

self-expanding stents (tend to migrate)

217
Q

Hot quadrate sign

A

SVC obstruction; via vein of Sappey

218
Q

Hot caudate sign

A

Budd-Chiari

219
Q

Indications for UAE

A

uterine bleeding (e.g. postpartum hemorrhage), symptomatic fibroids (from mass effect), symptomatic adenomyosis

220
Q

Location of fibroids responding best to UAE

A

submucosal > intramural > serosal; small fibroids and fibroids with high T2 signal respond well also

221
Q

Contraindications to UAE

A

pregnancy, uterine or cervical cancer, active pelvic infection, prior pelvic radiation, connective tissue disease, prior surgery with adhesions (relative)

222
Q

Indications for gyn referral for fibroid removal

A

intracavitary fibroid <3 cm, pedunculated serosal fibroid, large serosal fibroid + patient wants to become pregnant

223
Q

UAE for patient on GnRH

A

must discontinue for 3 months prior to UAE

224
Q

Risk of PE with UAE

A

5%; thrombus in compressed pelvic vein embolizes when pressure from fibroid is released

225
Q

Complications of UAE

A

PE, premature menopause

226
Q

Contraindications to HSG

A

pregnant, active pelvic infection, recent uterine or tubal pregnancy

227
Q

Ideal timing of HSG

A

days 6-12 of menstrual cycle; thinnest endometrium (better visualization), minimizes risk of pregnancy

228
Q

Fallopian tube recanalization

A

for proximal tubal obstruction (distal gets surgery); do HSG => poke with hydrophilic wire => repeat HSG to demonstrate patency; contraindications are same as HSG

229
Q

Diagnosis for pelvic congestion syndrome

A

symptoms (pain, dyspareunia, menstrual issues) + gonadal vein diameter >10 mm; symptoms worse at end of day and with standing

230
Q

Vessel to embolize: pelvic congestion syndrome

A

both gonadal (ovarian) veins; GnRH agonists are an alternative; symptoms improve with menopause

231
Q

Complications in pelvic congestion syndrome

A

thrombosis of parent vein (iliac or renal), PE (from thrombus migration)

232
Q

Indications to treat varicocele

A

infertility, testicular atrophy, pain

233
Q

Causes of varicocele

A

right angle of entry of the spermatic vein into the left renal vein, nutcracker syndrome

234
Q

Indications for vertebroplasty

A

acute to subacute fracture with pain refractory to medical therapy, unstable fracture with risk of further collapse

235
Q

Contraindications to vertebroplasty

A

fractures with associated spinal canal compression, improving pain without augmentation

236
Q

Complications of vertebroplasty

A

new vertebral fracture (25% of cases), embolization of cement, local neurologic complications (5%)

237
Q

Standing waves

A

symmetric and evenly space; resolve on subsequent runs

238
Q

Oblique views - relative to source or detector in IR?

A

relative to the detector

239
Q

Oblique view for aortic arch

A

LAO (70 degrees) - “candy cane”

240
Q

Oblique view for innominate artery

A

RAO

241
Q

Oblique view for left subclavian artery

A

LAO

242
Q

View for mesenteric arteries

A

lateral (or steep RAO)

243
Q

Oblique view for left renal artery

A

LAO

244
Q

Oblique view for right renal artery

A

RAO

245
Q

Oblique view for left iliac bifurcation

A

RAO

246
Q

Oblique view for right iliac bifurcation

A

LAO

247
Q

Oblique view for left CFA bifurcation

A

LAO

248
Q

Oblique view for right CFA bifurcation

A

RAO

249
Q

Cryoprecipitate is used to correct…

A

low fibrinogen (e.g. from tPA)

250
Q

How to: correct INR

A

FFP or vitamin K; alternatively discontinue coumadin and wait

251
Q

Heparin-induced thrombocytopenia (HIT) causes increased or decreased clotting

A

increased clotting (thrombosis); can anticoagulate with fondaparinux, argatroban, or -rudin drugs

252
Q

AC management for low risk bleeding procedures

A

INR <2.0, plt >50; stop plavix 5 days prior, hold LMWH for 1 dose; aspirin is ok to continue; no PTT consensus

253
Q

AC management for moderate risk bleeding procedures

A

INR <1.5, plt >50; stop plavix 5 days prior, hold LMWH for 1 dose; aspirin is ok to continue; no PTT consensus

254
Q

AC management for high risk bleeding procedures

A

INR <1.5, plt >50, PTT >1.5x control; stop aspirin/plavix 5 days prior, hold LMWH for 2 doses or 24 hours

255
Q

High risk bleeding procedures (5)

A

TIPS, PCN (new), renal biopsy, biliary interventions (new), RFA (complex)

256
Q

Antidotes for midazolam and opioids

A

flumazenil and narcan, respectively

257
Q

Early signs of lidocaine toxicity

A

tinnitus and dizziness; occurs from direct arterial injection; may cause immediate seizures

258
Q

Desmopressin

A

increases von Willebrand factor (factor VIII); 0.3 mcg/kg IV over 30 min; used for von Willebrand disease or hemophilia

259
Q

Left SVC drainage

A

coronary sinus > LA (right-to-left shunt); most common congenital venous anomaly in the chest

260
Q

Left SVC + associations

A

persistent left anterior cardinal vein; assoc. with unroofing of the coronary sinus, ASD

261
Q

Normal right atrial pressure

A

<5 mmHg

262
Q

Normal right ventricular pressure

A

25/5 mmHg

263
Q

Normal pulmonary artery pressure

A

<25/10 mmHg

264
Q

Corkscrewing of hepatic artery branches

A

cirrhosis

265
Q

Position of GDA relative to CBD

A

GDA is anterior to CBD (e.g. on transverse US image)

266
Q

Tram track appearance (angiogram)

A

angiodysplasia (common right sided GI bleed); simultaneous opacification of parallel artery and vein

267
Q

Bizarre neovascularity (angiogram)

A

renal cell carcinoma

268
Q

Spoke wheel appearance with peritumoral halo (angiogram)

A

renal oncocytoma

269
Q

Wilkie syndrome

A

a.k.a. SMA syndrome; compression of duodenum by SMA (thin children, burn victims, patients who have lost weight)

270
Q

Iliac artery aneurysm

A

> 1.5 cm; repair at >3.0 cm (stent graft)

271
Q

Popliteal artery aneurysm

A

> 8 mm; 20% have aortic aneurysms, 50% have bilateral popliteal aneurysms

272
Q

Treatment of poplilteal artery aneurysm

A

> 2 cm or symptomatic; endovasclar stent-graft or surgical bypass

273
Q

Adson’s maneuver

A

Test for subclavian artery compression - palpate radial artery in neutral position, patient turns head to contralateral side and inhales. Radial pulse reduces in TOS.

274
Q

Size threshold for treatment of renal or splenic artery aneurysms

A

> 2 cm

275
Q

Persistent sciatic artery

A

arises from internal iliac artery, usually from the inferior gluteal artery; courses posterior to femoral head

276
Q

Tortuous arteries and aneurysms (syndrome)

A

Loeys-Dietz (“Marfan’s on steroids”); aortic aneurysms often rupture; also have hypertelorism

277
Q

Non-decompressible varicocele - NEXT STEP

A

abdominal imaging; same for isolated right-sided varicocele

278
Q

Most common hepatic venous variant

A

accessory right inferior hepatic vein

279
Q

Most common pediatric vasculitis

A

Henoch-Schonlein purpura

280
Q

Significant arterial stenosis

A

> 10 mmHg drop at rest

281
Q

Increased risk of splenic artery aneurysm

A

pregnancy, multiparous females, patients with portal hypertension, after liver transplantation

282
Q

Increased risk of splenic artery aneurysm rupture

A

during pregnancy

283
Q

Indications for splenic artery aneurysm treatment

A

symptomatic, aneurysm size >2 cm, prior to expected pregnancy

284
Q

Most common site for visceral aneurysms

A

splenic > hepatic

285
Q

At what MELD score is TIPS not recommended

A

> 25; consider transplant, BRTO, banding or sclerotherapy, or repeat paracentesis

286
Q

Length of imaging follow-up after EVAR

A

remainder of life (for graft evaluation)

287
Q

Multiple renal artery aneurysms DDx

A

PAN, septic emboli, speed kidney, Ehlers-Danlos

288
Q

PAN associations

A

CLASH = Cryoglobulinemia, Leukemia, Arthritis (rheumatoid), Sjogren’s, Hepatitis B; treat PAN with steroids

289
Q

Do IVC filters increase or decrease the risk of caval thrombosis and DVTs?

A

increase (for both)

290
Q

Is sepsis a contraindication to IVC filter placement?

A

no

291
Q

Klatskin tumor (hilar neoplasm)

A

may require separate biliary drains in the right and left ducts

292
Q

High flow priapism (from Alan)

A

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.

293
Q

Low flow priapism (from Alan)

A

Painful, venous. SCD, venous thrombosis. Considered a true vascular emergency. Have to stick needles in the corpora for direct pressure measurement. Managed by urology.

294
Q

Relationship of replaced right hepatic artery to portal vein

A

posterior to PV (normal RHA is anterior to PV)

295
Q

First branch off SMA

A

inferior pancreaticoduodenal artery

296
Q

Superior vesicular artery origin

A

umbilical artery (most commonly)

297
Q

Inferior rectal artery origin

A

internal pudendal artery (most commonly)

298
Q

Corona mortis

A

variant anastomosis between obturator a. and EIA or inferior epigastric a.; courses superior to pubic rim

299
Q

Artery supplying superficial palmar arch

A

ulnar artery

300
Q

Artery supplying deep palmar arch

A

radial artery; may also be supplied by a persistent anterior interosseous branch (median artery)

301
Q

Isolated gastric varices

A

splenic vein thrombosis; gastric varices drain into inferior phrenic v. => left renal v.

302
Q

Duplicated IVC associations

A

horseshoe kidney, cross-fused renal ectopia

303
Q

Azygous continuation association

A

polysplenia

304
Q

Absence of the intrahepatic IVC

A

azygous continuation; hepatic veins drain directly to RA

305
Q

Most common acute aortic syndrome

A

aortic dissection

306
Q

Risk factors for aortic dissection

A

hypertension, Marfan’s, bicuspid AV, aortic coarctation, pregnancy, cocaine, syphilitic aortitis

307
Q

Displacement of intimal calcifications on NECT

A

aortic dissection

308
Q

Left renal artery usually arises from the true or false lumen?

A

false lumen (enhances later and is usually larger than the true lumen)

309
Q

Floating viscera sign

A

aortic dissection

310
Q

Rupture of vasa vasorum

A

intramural hematoma; may progress to dissection; also classified as Stanford A or B

311
Q

Mortality predictors in IMH (and PAU)

A

ascending aorta >5 cm, IMH >2 cm, pericardial effusion; maximum aortic diameter is strongest predictor

312
Q

Cause of penetrating atherosclerotic ulcers

A

atherosclerosis (not HTN as with other acute aortic syndromes)

313
Q

Most common location for traumatic pseudoaneurysm

A

aortic isthmus (from tethering of ligamentum arteriosum)

314
Q

Apical cap in the post-traumatic setting

A

suspect aortic injury

315
Q

Ascending aortic calcifications

A

Takayasu arteritis, syphilis (tree bark intimal calcifications)

316
Q

Aortic aneurysm sizes

A

ascending >4 cm, descending >3.5 cm, abdominal >3 cm

317
Q

Child with hypertension and orificial renal artery stenosis

A

NF1

318
Q

Annuloaortic ectasia (“tulip bulb”)

A

Marfan’s, Ehlers-Danlos; increased risk of aortic dissection and aortic regurgitation; can also involve pulmonary artery

319
Q

Sinus of Valsalva aneurysm association + treatment

A

associated with VSD; treatment is Bentall procedure; rupture may cause cardiac tamponade

320
Q

Leutic aneurysm

A

from syphilis (tertiary); saccular, involves ascending aorta; coronary narrowing in 30%

321
Q

Location for mycotic aneurysms

A

most occur in thoracic or supra-renal aorta; most often via hematogenous seeding from endocarditis

322
Q

Aortoenteric fistula vs. perigraft infection

A

can only differentiate if there is IV contrast in the bowel; fistula involves 3rd/4th segments of duodenum

323
Q

Mid-aortic syndrome

A

progressive narrowing of the abdominal aorta; triad of claudication, HTN, and renal failure in children/young adults

324
Q

Most common cause of thoracic outlet syndrome

A

compression by anterior scalene muscle; from most to least affected, nerve > vein > artery

325
Q

Effort thrombosis

A

a.k.a. Paget-Shroetter; TOS + SCV thrombosis; often seen in pitchers and weightlifters; Tx thrombolysis + angioplasty + surgical release (NO stenting)

326
Q

Pulmonary artery aneurysm/pseudoaneurysm

A

iatrogenic (Swan-Ganz), Behcet’s, chronic PE, Rasmussen aneurysm

327
Q

Hughes-Stovin syndrome

A

recurrent thrombophlebitis and pulmonary artery aneurysms; similar to Behcet’s

328
Q

Heyde syndrome

A

aortic stenosis, colonic angiodysplasias

329
Q

Segmental arterial mediolysis

A

coronaries in young adults, splanchnic arteries in elderly; classically multiple splanchnic saccular aneurysms

330
Q

Medial deviation of popliteal artery

A

popliteal entrapment (due to relationship of medial head of gastrocnemius)

331
Q

Pulses decrease with plantarflexion or dorsiflexion

A

popliteal entrapment; may see occlusion on MRA or angiography with plantar or dorsi-flexion

332
Q

Marginal vein of Servelle

A

large vein in superficial lateral calf; assoc. with Klippel-Trenaunay syndrome

333
Q

Klippel-Trenaunay syndrome triad

A

port-wine nevi, localized bony or soft tissue hypertrophy, venous malformation

334
Q

c-ANCA+

A

granulomatosis with polyangiitis (Wegener’s)

335
Q

p-ANCA+

A

Churg-Strauss, microscopic polyangiitis, PAN

336
Q

Auto-amputation of digits

A

Buerger disease; distal occlusions and/or corkscrew collaterals

337
Q

Pseudoaneurysm of ulnar artery (hand)

A

hypothenar hammer syndrome; may also see ulnar artery or more distal occlusions

338
Q

Hand angiogram with finger occlusions

A

Buerger’s or HHS; ulnar artery involvement suggests HHS

339
Q

Henoch-Schoenlein purpura

A

palpable purpura, GI bleeding, intussusception; bowel wall thickening, scrotal edema; non-ANCA

340
Q

50-69% carotid stenosis

A

ICA PSV 125-230 cm/s or ICA/CCA PSV ratio 2.0-4.0

341
Q

> 70% carotid stenosis

A

ICA PSV >230 cm/s or ICA/CCA PSV ratio >4.0

342
Q

Temporal tap

A

to identify the ECA (from the ICA)

343
Q

Bilateral carotid reversal of flow

A

aortic regurgitation

344
Q

Loss of diastolic flow in ICAs

A

brain death

345
Q

CCA waveform looks like ECA waveform

A

ICA occlusion (loss of diastolic flow in CCA)

346
Q

Carotid waveform with IABP

A

normal peak + assisted peak; ideal IABP position is superior balloon 2 cm distal to LSCA and inferior balloon is just above renals

347
Q

Pulsus bisferiens

A

two peaks; seen in aortic regurgitation, severe HOCM, dissection, severe COPD

348
Q

Vertical vein

A

in supracardiac TAPVR; pulmonary veins converge to form a vertical vein which drains into SVC, BCV, or azygous vein

349
Q

Takayasu treatment

A

steroids; angioplasty is NOT performed in the acute setting

350
Q

Fibrin sheath

A

contrast flows retrograde away from tip; “line flushes, but does not aspirate”

351
Q

Celiac, SMA, IMA, and renal arteries arise at what spinal levels

A

celiac = T12, SMA = T12-L1, renal arteries = L1-2, IMA = L3-4

352
Q

Source of bleeding in Mallory-Weiss tear

A

left gastric artery often; partial thickness tear

353
Q

Vessel in the fissure of the ligamentum venosum

A

replaced/accessory left hepatic artery

354
Q

Meandering mesenteric artery

A

arc of Riolan; connection between middle colic a. and left colic a.

355
Q

Vessel within scalene triangle

A

subclavian artery (with brachial plexus); vein runs anterior to the anterior scalene muscle

356
Q

Borders of scalene triangle

A

anterior scalene m., middle scalene m., first rib

357
Q

Branches of subclavian artery

A

vertebral a., internal mammary a., thyrocervical trunk, costocervical trunk, dorsal scapular a. (from proximal to distal)

358
Q

Landmarks for beginning and end of axillary artery

A

distal margin of first rib to lower border of teres major

359
Q

Ulnar vs. radial artery

A

ulnar artery is bigger, gives off common interosseous branch, and supplies superficial palmar arch

360
Q

Lower leg arteries (from lateral to medial)

A

anterior tibial a., peroneal a., posterior tibial a.

361
Q

Most gastric varices are formed by which vessel?

A

left gastic vein (coronary vein)

362
Q

True aneurysm definition

A

enlargement of lumen 1.5x its normal diameter

363
Q

Leriche syndrome

A

infrarenal aortoiliac occlusion; triad of impotence, buttock/thigh claudication, absent femoral pulses

364
Q

Blood supply to descending aorta in pre-ductal aortic coarctation

A

PDA

365
Q

Dunbar syndrome

A

a.k.a. median arcuate ligament syndrome; worse with expiration; surgical treatment

366
Q

Most common site affected by chronic mesenteric ischemia

A

splenic flexure of colon (watershed region); chronic usually requires stenosis of at least 2 of the 3 main mesenteric arteries

367
Q

Suspected HHT - NEXT STEP

A

CTA of liver and lungs + MRA brain

368
Q

Most common location for FMD

A

renal aa. > carotid aa. > iliac aa.; most common type is medial

369
Q

Most common peripheral arterial aneurysm

A

popliteal artery aneurysm

370
Q

Most common type of Takayasu arteritis

A

type 3 (involves aortic arch and abdominal aorta)

371
Q

Most common sites of involvement in PAN

A

renal > cardiac > GI; microaneurysm formation; more common in males

372
Q

Cogan syndrome

A

aortitis + vertigo, tinnitus, and/or inflammatory eye disease

373
Q

Most common cause of acute mesenteric ischemia

A

SMA embolus

374
Q

Treatment for non-enhancing uterine fibroids

A

do not embolize

375
Q

Intra-procedural heparinization

A

angioplasty, any dialysis intervention, neuro IR

376
Q

Portal vein embolization

A

used to increase remnant liver size prior to partial hepatectomy

AJT CORE (12 decks)

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