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
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
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
4
Q
Vasopressin for GI bleeding
A
vasoconstrictor, infused directly into SMA or IMA; high re-bleeding rates; may cause NOMI
5
Q
Complications of vasopressin
A
arrhythmia, pulmonary edema, hypertension, NOMI; tachyphylaxis develops after 24 hours
6
Q
Papaverine dose for NOMI
A
30-60 mg/hr direct arterial infusion
7
Q
Heparin reversal
A
protamine; 1 mg IV per 100 units active heparin
8
Q
Side effects of protamine
A
sudden drop in BP, bradycardia, flushing
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
10
Q
1 Fr = ___ mm
A
0.33 mm; also 1 mm = 0.038”
11
Q
Microwire sizes
A
0.018” and 0.014”; micropuncture technique refers to a 21G needle and 0.018” diameter wire
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
13
Q
Standard 0.035” wire will fit through what size sheath?
A
4 Fr or larger
14
Q
Wire diameters are in ______ and lengths are in ______
A
diameter in inches, length in cm
15
Q
Standard wire length (cm)
A
180 cm (long wire is 260 cm)
16
Q
Wire tips - floppy, J-tip, hydrophilic, and stiff
A
floppy = Bentson; J-tip = Rosen; hydrophilic = Glidewire, Roadrunner; stiff = Amplatz, Lunderquist
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
18
Q
Uses for hydrophilic wires
A
cross a stenosis, cannulate an indwelling device, enter abscess cavity
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)
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
21
Q
Selective catheters
A
end hole only; used for selection and embolization; contrast administered via hand injection only (no pump runs)
22
Q
Catheter flow rates (by Fr)
A
3 Fr = 8 ml/s; 4 Fr = 16 ml/s; 5 Fr = 24 ml/s
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)
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
25
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
26
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
27
Indications for brachial artery access
upper limb angioplasty or femoral artery is out; risk of stroke if catheter has to cross aortic arch
28
Which side for brachial artery access?
left brachial if headed "south", right brachial if headed "north"
29
Important points of radial artery access (2)
bedrest not required; need to perform Allen test prior to puncture
30
Contraindication to translumbar aortic puncture
known supraceliac aortic aneurysm
31
Risk of translumbar aortic puncture
psoas hematoma; used for type 2 endoleak; stick at T12; "self compress" by rolling on back
32
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
33
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
34
Balloon nomenclature
[diameter in mm] x [length in cm], e.g. "10 x 6" = "10 mm in diameter, 6 cm in length"
35
Balloon-expanding stents
higher radial force, better for more precise deployment; will not rebound if crushed; do not use around joints
36
Self-expanding stents
more flexible; preferred in tortuous route to lesion or areas prone to external compression
37
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
38
Indications for covered stents (no fenestrations)
treatment of pseudoaneurysm, dissection, and TIPS
39
Primary stenting definition
angioplasty followed by stenting
40
Particle size for bronchial artery embolization (hemoptysis)
>325 um; particles <300 um may cause tissue necrosis; NEVER coils
41
Particle size for UAE
500-700 um
42
Particle size for GI bleed
300-500 um; particles <300 um may cause bowel infarct
43
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)
44
CO2 contrast
negative contrast agent often used in patients with renal insufficiency or severe contrast allergy, also in TIPS
45
Swollen left leg
May-Thurner; treatment is thrombolysis + stenting
46
Splenic artery aneurysm associations
pregnancy, portal HTN, HTN, cirrhosis, liver transplant; pseudoaneuryms classically assoc. with pancreatitis
47
Increased risk of splenic artery aneurysm rupture
during pregnancy
48
Indications for splenic artery aneurysm treatment
symptomatic, aneurysm size >2 cm, prior to expected pregnancy
49
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)
50
Dialysis access: arm swelling, chest wall collaterals, and/or breast swelling
central venous stenosis
51
Dialysis access: pale, discolored, and/or cold hand
dialysis-associated steal syndrome
52
Dialysis access: high pitched, discontinuous, and/or systolic only bruit
localized stenosis; normal bruit is low-pitched during systole and diastole
53
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
54
Dialysis access: water hammer pulse + no thrill (at fistula)
venous outflow stenosis
55
Dialysis access: diminished pulse + poor thrill (at fistula)
arterial inflow stenosis
56
Contraindications to fistulography
infected graft/fistula (absolute), <30 days old (relative), stenosis >7 cm long (relative); send latter two back to surgery
57
Right posterior bile duct drainage
drains segments 6 and 7 - horizontal course
58
Right anterior bile duct drainage
drains segments 5 and 8 - vertical course
59
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
60
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)
61
Criteria for portal HTN
PV pressure >10 mmHg, PSG >6 mmHg (normal is 3-6 mmHg)
62
Imaging findings in portal HTN
PV >13-15 mm, splenic vein >12 mm, splenomegaly, ascites, varices, reversal of flow in PV
63
Indications for TIPS
refractory variceal hemorrhage, refractory ascites, Budd-Chiari; MELD >18 has higher risk of death post-TIPS
64
Pre-TIPS evaluation (2)
echo to assess for heart failure, CT abdomen to assess for PV patency
65
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)
66
Acute complications post-TIPS
cardiac decompensation, accelerated liver failure, worsening hepatic encephalopathy
67
Goal PSG post-TIPS
4-12 mmHg; <4 mmHg results in increased risk of encephalopathy; >12 mmHg leads to refractory ascites and variceal bleeding
68
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
69
Treatment of TIPS stenosis
measure pressure; >12 mmHg => angioplasty
70
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
71
Normal PV velocity
16-40 cm/s
72
Child-Pugh
INR, bilirubin, albumin + ascites and hepatic encephalopathy; classes B and C are higher risk for variceal bleeding
73
MELD (Model End-stage Liver Disease)
INR, bilirubin, Cr; higher MELD = higher post-TIPS mortality
74
Indication for BRTO
treatment of gastrorenal shunt (to improve hepatic encephalopathy); diverts blood to portal system
75
Complications of BRTO
worsening ascites and esophageal varices (basically makes portal HTN worse)
76
Landing zone criteria (EVAR)
10-15 mm proximal landing zone, non-aneurysmal, angled <60 degrees
77
EVAR deployment issues
iliac artery angulation >90 degrees, iliac artery diameter <7 mm
78
Adrenal vein sampling
used to guide treatment of primary hyperaldosteronism; cosyntropin may be administered during sampling
79
Unilateral adenoma treatment
surgical excision
80
Bilateral adrenal hyperplasia treatment
oral spironolactone
81
Most common biliary ductal variants
right posterior to left > trifurcation
82
PTC, PTBD, biliary stenting, or cholecystostomy prophylaxis
antibiotics (usually levofloxacin for gram negative coverage)
83
PTC/PTBD approaches
right mid-axillary (fluoro-guided) or left sub-xyphoid (US-guided)
84
Ideal biliary drain for crossing lesions
internal-external drain; may be converted to internal only
85
Cholecystostomy approaches
transhepatic (preferred; segments 5/6 => bare area of GB) or transperitoneal (if significant bleeding risk)
86
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
87
Management for bile leak
can place biliary drain to divert bile from location of leak
88
Metallic stent placement
only in patients with life expectancy less than 6 months (median patency of 6-8 months and cannot be removed)
89
Liver biopsy technique
choose path to ideally biopsy lesion through at least 2 cm of normal liver tissue (don't biopsy the capsule)
90
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
91
Rotation of sheath/cannula for transjugular liver biopsy
rotate anteriorly if in right hepatic vein and posteriorly if in middle hepatic vein
92
Kehr sign
prolonged shoulder pain post-liver biopsy; may represent bleeding (need to check with US)
93
Contraindications to liver biopsy
uncorrectable coagulopathy, plt <50, RUQ infection
94
Varicose vein treatment + contraindication
endoluminal heat source (tumescent anesthesia is used); DVT is a contraindication
95
Spider web appearance (hepatic venogram)
Budd-Chiari
96
Most common complication of popliteal artery aneurysm
distal thromboembolism
97
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
98
Post-arterial access management
compression for 15 minutes, can resume heparin in 2 hours, groin checks and pulses on nursing orders
99
Contraindication to arterial closure device
suspected infection at access site
100
PICC access vessel preference
basilic > brachial > cephalic; use non-dominant arm
101
Tunneled lines in septic patients
NO; place a temporary line
102
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
103
Central line vessel preference
RIJ > LIJ > REJ > LEJ; RIJ is also preferred site for a dialysis catheter
104
Spiral appearance of wire while attempting to cross a tight stenosis
dissecting wire
105
Injection rate: aortogram (aortic arch)
20 for 30
106
Injection rate: abdominal aorta
20 for 20
107
Injection rate: IVC
20 for 30
108
Injection rate: mesenteric arteries
5 for 25
109
Injection rate: renal arteries
5 for 15
110
Injection rate: distal arteries
3 for 12
111
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
112
Treatment of post-embolization syndrome
NSAIDs, IVFs, +/- opioids
113
EVAR and TEVAR (acronyms)
EVAR = EndoVascular Aortic Repair (includes abdominal aorta and iliacs); TEVAR = Thoracic-EVAR
114
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
115
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
116
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
117
Crawford type 4 thoracoabdominal aortic aneurysm
aneurysm extending from 12th intercostal space to iliac bifurcation, with involvement of mesenteric and renal arteries
118
Type 4 and 5 endoleaks
4 = porous graft (most resolve within 48 hours); 5 = endotension
119
Permanent embolization agents
coils, plugs, particles, sclerosing agents (alcohol or SDS), glue
120
Temporary embolization agents
gelfoam (2-6 weeks), autologous clot; gelfoam may appear as locules of gas on CT
121
Strategy for embolizing a specific lesion
coil distal to lesion, then proximal to lesion (prevents collateral flow); cannot use for "end" arteries
122
Coils vs. particles
coils can be placed precisely (no distal embolization); particles flow distally to occlude small capillaries
123
Vessel to embolize: uterine fibroids
bilateral uterine arteries; particles
124
Vessel to embolize: varicocele
gonadal vein (a.k.a. testicular or spermatic vein)
125
Vessel to embolize: diffuse splenic trauma
proximal splenic artery (before short gastrics); Amplatz plug; short gastrics maintain some splenic perfusion
126
Vessel to embolize: hemoptysis
bronchial artery; particles (NOT coils)
127
Signs of irreversible limb ischemia
complete muscle paralysis, complete sensory loss, no venous flow on Doppler (loss of arterial flow may still be salvageable)
128
Cause of acute limb ischemia
thrombotic and/or embolic events; most common source is a left atrial thrombus (Afib) => echo to identify source
129
5 P's of acute limb ischemia
pain, pallor, pulseness, paresthesias, poikilothermia (cold); emergency
130
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)
131
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
132
ABI: normal
1.0-1.4; >1.4 is non-compressible due to calcification; ABI = ankle SBP / brachial SBP
133
ABI: borderline
0.9-0.99
134
ABI: abnormal
<0.9; claudication at 0.5-0.9, rest pain at 0.3
135
Foot ulcers: medial ankle, dorsal foot, plantar foot
medial ankle = venous stasis; dorsal foot = infection/ischemic; plantar foot = neuropathic (diabetes)
136
Risk factors for peripheral vascular disease (chronic)
smoking, diabetes, HTN, hyperlipidemia, no exercise, family history; claudication => rest pain => tissue loss
137
Classification systems for peripheral vascular disease
Rutherford and Fontaine
138
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
139
Lower extremity arterial access: access for fem-fem bypass
direct stick > inflow CFA
140
tPA patient with new confusion - NEXT STEP
stop tPA + head CT
141
tPA patient with hypotension and tachycardia - NEXT STEP
stop tPA + check site +/- CT abdomen/pelvis (patient is bleeding out)
142
Post-thrombotic syndrome
pain and venous ulcers after DVT; prevent with catheter-directed thrombolysis of iliofemoral DVTs
143
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
144
Most common complication of IVC filter placement
access site thrombosis > IVC thrombosis
145
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
146
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)
147
Risk of suprarenal IVC filter
renal vein thrombosis
148
Indications for suprarenal IVC filter placement
prengnacy (avoid compression), clot in renal or gonadal veins, duplicated IVC (may also be bilateral iliac filters)
149
IVC filter placement with circumaortic left renal vein
below lowest renal vein (usually circumaortic vein); retroaortic renal vein may insert low on the IVC
150
Nitroglycerin - spasm vs. stenosis
spasm will improve with nitroglycerin, while stenosis will not
151
Successful angioplasty
<30% residual stenosis
152
Treatment for hepatic pseudoaneurysm (post-traumatic)
embolize distally, then embolize proximal
153
Treatment for focal splenic abnormality (post-traumatic)
selective embolization (not the same as treatment for diffuse splenic trauma)
154
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)
155
Contraindications to TACE
decompensated liver failure (absolute); PV thrombosis may be a relative contraindication
156
Indications for RFA (liver)
patients with HCC or colorectal mets who are not surgical candidates; 60 degrees C is ideal temperature
157
Risk of Y-90 radioembolization
gastric ulceration/necrosis (via right gastric a.); may embo right gastric and GDA prior to Y-90
158
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)
159
Higher bleeding risk with RFA or cryoablation
cryoablation
160
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)
161
Lesion size increase after initial post-treatment scan (hepatic mass)
concerning for recurrent tumor
162
Ideal target for G-tube placement
mid-to-distal gastric body (lateral to rectus to avoid inferior epigastric a.)
163
Division of upper vs. lower GI bleeds
ligament of Treitz
164
Most common source of upper GI bleed
left gastric artery; may be embolized prophylactically if no source can be identified
165
Vessel to embolize: bleeding duodenal ulcer
GDA
166
Pancreatic arcade bleeding aneurysm
celiac artery stenosis; shown as an SMA run with dilated collaterals and filling of hepatic artery
167
Management: upper GI bleed with positive endoscopy
should treat with endoscopy; if endoscopic treatment fails => angio
168
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
169
Management: lower GI bleed in stable patient
endoscopy (1st line per ACR appropriateness criteria)
170
Management: lower GI bleed in unstable patient
3-phase CTA or RBC scan => angio; if positive (otherwise conservative management)
171
Management: obscure GI bleeding (negative endoscopy and colonoscopy)
suggests small bowel source; CTA or capsule endoscopy (per ACR appropriateness criteria)
172
Detectable bleeding rates - RBC scan vs. CTA vs. angiography
RBC scan = 0.1 cc/min; CTA = 0.4 cc/min; angio = 1 cc/min
173
Angio with early draining vein (in GI bleed)
angiodysplasia; usually right-sided
174
Angio with corkscrew vessel (in GI bleed)
vitelline artery (bleeding Meckel's)
175
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
176
When to remove abscess drainage catheter? (3)
drainage <10 cc/day, collection resolved by imaging, no fistula
177
Spike in output volume from abscess drain - NEXT STEP
suggests fistula formation; next step is imaging to identify source
178
Route considerations for pelvic abscess drainage
shortest route possible; avoid bowel, blood vessels, nerves (especially inferior epigastric a.)
179
Transgluteal approach (pelvic abscess drainage)
access through sacrospinous ligament, as medial as possible, inferior to piriformis
180
Transvaginal and transrectal approaches (pelvic abscess drainage)
transvaginal for gynecolgic collections (PID); transrectal is an option for pre-sacral collections; both use US guidance
181
Size criteria for renal abscess drainage
>3 cm; if <3 cm, treat with antibiotics
182
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
183
Indications for pancreatic collection drainage
infected collection or causing mass effect on bowel/CBD
184
Pancreatic fluid collection with amylase
pancreatic fistula (fluid is usually clear)
185
Indications for percutaneous nephrostomy
urinary obstructions (stones or cancer), urinary diversion (leak or fistula), access for procedures
186
Contraindications to PCN
INR >1.5, plt <50; potassium needs to be correct to <7
187
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
188
Target for PCN (transplant kidney)
anterior-lateral calyx, mid-to-upper pole, lateral approach
189
PCN maintenance
catheter exchange q2-3 months (due to urine crystallization)
190
Contraindications to nephroureteral stent
bladder outlet obstruction, neurogenic bladder, obstructing bladder tumor
191
Indications for suprapubic cystostomy
acute bladder decompression; or bladder outlet obstruction, neurogenic bladder, obstructing bladder tumor
192
Target for suprapubic cystostomy
midline, lower-to-mid anterior bladder wall
193
Indication for targeted and non-targeted renal biopsy
targeted for renal mass; non-targeted for native or transplant renal failure (biopsy renal cortex)
194
Complications of renal biopsy
hematuria, AVF, pseudoaneurysm; latter two are usually small and resolve without treatment
195
Renal RFA
alternative to partial or total nephrectomy for AML, AVM, and RCC
196
Treatment threshold for renal AML
>4 cm (increased bleeding risk)
197
Management after renal angioplasty
aspirin day before procedure and for 6 months after
198
Complication of removing too much pleural fluid
re-expansion pulmonary edema
199
Continuous air bubbles in pleur-evac chamber (chest tube)
bronchopleural fistula; could also represent leak in tube
200
Empyema vs. pulmonary abscess drainage
empyema is ok to drain; pulmonary abscess is NOT (risk of BPF)
201
Most common complication of lung biopsy
pneumothorax > hemoptysis
202
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
203
Pneumothorax on post-lung biopsy radiograph - NEXT STEP
serial radiographs; chest tube indicated if patient is symptomatic or pneumothorax is enlarging
204
Lung zones most affected by respiratory and cardiac motion
lower lungs are most affected by respiratory motion; lingula is most affected by cardiac motion
205
Size criteria for pulmonary RFA
1.5-5.2 cm
206
Indications for pulmonary angiography
diagnosis/treatment of massive PE, treatment of pulmonary AVM
207
Prior to injecting contrast for pulmonary angiography you must...
measure pulmonary/right heart pressures
208
Relative contraindications to pulmonary angiography
LBBB (need prophylactic pacing), pulmonary HTN (systolic PAP >70 mmHg or RVEDP >20 mmHg)
209
Cardiac dysrhythmia during pulmonary angiography - NEXT STEP
reposition catheter/wire
210
Indication for interventional treatment of PE
unstable patient with massive PE (hypotensive)
211
Criteria for treatment of pulmonary AVM
symptomatic or afferent vessel >3 mm; must use coils (particles would just embolize through the shunt)
212
Hemoptysis + positive PPD
rasmussen aneurysm (TB); occurs in pulmonary arteries; coil embolization
213
Massive hemoptysis definition + NEXT STEP
>300 cc/hour; bronchial artery angio; seen as tortuous enlarged bronchial arteries (not extravasation usually)
214
Most common configuration of bronchial arteries
intercostobronchial trunk on right, two bronchial arteries on left; arise at T5-6 level
215
Treatment of acute SVC obstruction
acute = emergency; thrombolysis => remove offending agent (catheter usually) => angioplasty +/- stent
216
Do NOT use _______ stents in the SVC
self-expanding stents (tend to migrate)
217
Hot quadrate sign
SVC obstruction; via vein of Sappey
218
Hot caudate sign
Budd-Chiari
219
Indications for UAE
uterine bleeding (e.g. postpartum hemorrhage), symptomatic fibroids (from mass effect), symptomatic adenomyosis
220
Location of fibroids responding best to UAE
submucosal > intramural > serosal; small fibroids and fibroids with high T2 signal respond well also
221
Contraindications to UAE
pregnancy, uterine or cervical cancer, active pelvic infection, prior pelvic radiation, connective tissue disease, prior surgery with adhesions (relative)
222
Indications for gyn referral for fibroid removal
intracavitary fibroid <3 cm, pedunculated serosal fibroid, large serosal fibroid + patient wants to become pregnant
223
UAE for patient on GnRH
must discontinue for 3 months prior to UAE
224
Risk of PE with UAE
5%; thrombus in compressed pelvic vein embolizes when pressure from fibroid is released
225
Complications of UAE
PE, premature menopause
226
Contraindications to HSG
pregnant, active pelvic infection, recent uterine or tubal pregnancy
227
Ideal timing of HSG
days 6-12 of menstrual cycle; thinnest endometrium (better visualization), minimizes risk of pregnancy
228
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
229
Diagnosis for pelvic congestion syndrome
symptoms (pain, dyspareunia, menstrual issues) + gonadal vein diameter >10 mm; symptoms worse at end of day and with standing
230
Vessel to embolize: pelvic congestion syndrome
both gonadal (ovarian) veins; GnRH agonists are an alternative; symptoms improve with menopause
231
Complications in pelvic congestion syndrome
thrombosis of parent vein (iliac or renal), PE (from thrombus migration)
232
Indications to treat varicocele
infertility, testicular atrophy, pain
233
Causes of varicocele
right angle of entry of the spermatic vein into the left renal vein, nutcracker syndrome
234
Indications for vertebroplasty
acute to subacute fracture with pain refractory to medical therapy, unstable fracture with risk of further collapse
235
Contraindications to vertebroplasty
fractures with associated spinal canal compression, improving pain without augmentation
236
Complications of vertebroplasty
new vertebral fracture (25% of cases), embolization of cement, local neurologic complications (5%)
237
Standing waves
symmetric and evenly space; resolve on subsequent runs
238
Oblique views - relative to source or detector in IR?
relative to the detector
239
Oblique view for aortic arch
LAO (70 degrees) - "candy cane"
240
Oblique view for innominate artery
RAO
241
Oblique view for left subclavian artery
LAO
242
View for mesenteric arteries
lateral (or steep RAO)
243
Oblique view for left renal artery
LAO
244
Oblique view for right renal artery
RAO
245
Oblique view for left iliac bifurcation
RAO
246
Oblique view for right iliac bifurcation
LAO
247
Oblique view for left CFA bifurcation
LAO
248
Oblique view for right CFA bifurcation
RAO
249
Cryoprecipitate is used to correct...
low fibrinogen (e.g. from tPA)
250
How to: correct INR
FFP or vitamin K; alternatively discontinue coumadin and wait
251
Heparin-induced thrombocytopenia (HIT) causes increased or decreased clotting
increased clotting (thrombosis); can anticoagulate with fondaparinux, argatroban, or -rudin drugs
252
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
253
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
254
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
255
High risk bleeding procedures (5)
TIPS, PCN (new), renal biopsy, biliary interventions (new), RFA (complex)
256
Antidotes for midazolam and opioids
flumazenil and narcan, respectively
257
Early signs of lidocaine toxicity
tinnitus and dizziness; occurs from direct arterial injection; may cause immediate seizures
258
Desmopressin
increases von Willebrand factor (factor VIII); 0.3 mcg/kg IV over 30 min; used for von Willebrand disease or hemophilia
259
Left SVC drainage
coronary sinus > LA (right-to-left shunt); most common congenital venous anomaly in the chest
260
Left SVC + associations
persistent left anterior cardinal vein; assoc. with unroofing of the coronary sinus, ASD
261
Normal right atrial pressure
<5 mmHg
262
Normal right ventricular pressure
25/5 mmHg
263
Normal pulmonary artery pressure
<25/10 mmHg
264
Corkscrewing of hepatic artery branches
cirrhosis
265
Position of GDA relative to CBD
GDA is anterior to CBD (e.g. on transverse US image)
266
Tram track appearance (angiogram)
angiodysplasia (common right sided GI bleed); simultaneous opacification of parallel artery and vein
267
Bizarre neovascularity (angiogram)
renal cell carcinoma
268
Spoke wheel appearance with peritumoral halo (angiogram)
renal oncocytoma
269
Wilkie syndrome
a.k.a. SMA syndrome; compression of duodenum by SMA (thin children, burn victims, patients who have lost weight)
270
Iliac artery aneurysm
>1.5 cm; repair at >3.0 cm (stent graft)
271
Popliteal artery aneurysm
>8 mm; 20% have aortic aneurysms, 50% have bilateral popliteal aneurysms
272
Treatment of poplilteal artery aneurysm
>2 cm or symptomatic; endovasclar stent-graft or surgical bypass
273
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.
274
Size threshold for treatment of renal or splenic artery aneurysms
>2 cm
275
Persistent sciatic artery
arises from internal iliac artery, usually from the inferior gluteal artery; courses posterior to femoral head
276
Tortuous arteries and aneurysms (syndrome)
Loeys-Dietz ("Marfan's on steroids"); aortic aneurysms often rupture; also have hypertelorism
277
Non-decompressible varicocele - NEXT STEP
abdominal imaging; same for isolated right-sided varicocele
278
Most common hepatic venous variant
accessory right inferior hepatic vein
279
Most common pediatric vasculitis
Henoch-Schonlein purpura
280
Significant arterial stenosis
>10 mmHg drop at rest
281
Increased risk of splenic artery aneurysm
pregnancy, multiparous females, patients with portal hypertension, after liver transplantation
282
Increased risk of splenic artery aneurysm rupture
during pregnancy
283
Indications for splenic artery aneurysm treatment
symptomatic, aneurysm size >2 cm, prior to expected pregnancy
284
Most common site for visceral aneurysms
splenic > hepatic
285
At what MELD score is TIPS not recommended
>25; consider transplant, BRTO, banding or sclerotherapy, or repeat paracentesis
286
Length of imaging follow-up after EVAR
remainder of life (for graft evaluation)
287
Multiple renal artery aneurysms DDx
PAN, septic emboli, speed kidney, Ehlers-Danlos
288
PAN associations
CLASH = Cryoglobulinemia, Leukemia, Arthritis (rheumatoid), Sjogren's, Hepatitis B; treat PAN with steroids
289
Do IVC filters increase or decrease the risk of caval thrombosis and DVTs?
increase (for both)
290
Is sepsis a contraindication to IVC filter placement?
no
291
Klatskin tumor (hilar neoplasm)
may require separate biliary drains in the right and left ducts
292
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.
293
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.
294
Relationship of replaced right hepatic artery to portal vein
posterior to PV (normal RHA is anterior to PV)
295
First branch off SMA
inferior pancreaticoduodenal artery
296
Superior vesicular artery origin
umbilical artery (most commonly)
297
Inferior rectal artery origin
internal pudendal artery (most commonly)
298
Corona mortis
variant anastomosis between obturator a. and EIA or inferior epigastric a.; courses superior to pubic rim
299
Artery supplying superficial palmar arch
ulnar artery
300
Artery supplying deep palmar arch
radial artery; may also be supplied by a persistent anterior interosseous branch (median artery)
301
Isolated gastric varices
splenic vein thrombosis; gastric varices drain into inferior phrenic v. => left renal v.
302
Duplicated IVC associations
horseshoe kidney, cross-fused renal ectopia
303
Azygous continuation association
polysplenia
304
Absence of the intrahepatic IVC
azygous continuation; hepatic veins drain directly to RA
305
Most common acute aortic syndrome
aortic dissection
306
Risk factors for aortic dissection
hypertension, Marfan's, bicuspid AV, aortic coarctation, pregnancy, cocaine, syphilitic aortitis
307
Displacement of intimal calcifications on NECT
aortic dissection
308
Left renal artery usually arises from the true or false lumen?
false lumen (enhances later and is usually larger than the true lumen)
309
Floating viscera sign
aortic dissection
310
Rupture of vasa vasorum
intramural hematoma; may progress to dissection; also classified as Stanford A or B
311
Mortality predictors in IMH (and PAU)
ascending aorta >5 cm, IMH >2 cm, pericardial effusion; maximum aortic diameter is strongest predictor
312
Cause of penetrating atherosclerotic ulcers
atherosclerosis (not HTN as with other acute aortic syndromes)
313
Most common location for traumatic pseudoaneurysm
aortic isthmus (from tethering of ligamentum arteriosum)
314
Apical cap in the post-traumatic setting
suspect aortic injury
315
Ascending aortic calcifications
Takayasu arteritis, syphilis (tree bark intimal calcifications)
316
Aortic aneurysm sizes
ascending >4 cm, descending >3.5 cm, abdominal >3 cm
317
Child with hypertension and orificial renal artery stenosis
NF1
318
Annuloaortic ectasia ("tulip bulb")
Marfan's, Ehlers-Danlos; increased risk of aortic dissection and aortic regurgitation; can also involve pulmonary artery
319
Sinus of Valsalva aneurysm association + treatment
associated with VSD; treatment is Bentall procedure; rupture may cause cardiac tamponade
320
Leutic aneurysm
from syphilis (tertiary); saccular, involves ascending aorta; coronary narrowing in 30%
321
Location for mycotic aneurysms
most occur in thoracic or supra-renal aorta; most often via hematogenous seeding from endocarditis
322
Aortoenteric fistula vs. perigraft infection
can only differentiate if there is IV contrast in the bowel; fistula involves 3rd/4th segments of duodenum
323
Mid-aortic syndrome
progressive narrowing of the abdominal aorta; triad of claudication, HTN, and renal failure in children/young adults
324
Most common cause of thoracic outlet syndrome
compression by anterior scalene muscle; from most to least affected, nerve > vein > artery
325
Effort thrombosis
a.k.a. Paget-Shroetter; TOS + SCV thrombosis; often seen in pitchers and weightlifters; Tx thrombolysis + angioplasty + surgical release (NO stenting)
326
Pulmonary artery aneurysm/pseudoaneurysm
iatrogenic (Swan-Ganz), Behcet's, chronic PE, Rasmussen aneurysm
327
Hughes-Stovin syndrome
recurrent thrombophlebitis and pulmonary artery aneurysms; similar to Behcet's
328
Heyde syndrome
aortic stenosis, colonic angiodysplasias
329
Segmental arterial mediolysis
coronaries in young adults, splanchnic arteries in elderly; classically multiple splanchnic saccular aneurysms
330
Medial deviation of popliteal artery
popliteal entrapment (due to relationship of medial head of gastrocnemius)
331
Pulses decrease with plantarflexion or dorsiflexion
popliteal entrapment; may see occlusion on MRA or angiography with plantar or dorsi-flexion
332
Marginal vein of Servelle
large vein in superficial lateral calf; assoc. with Klippel-Trenaunay syndrome
333
Klippel-Trenaunay syndrome triad
port-wine nevi, localized bony or soft tissue hypertrophy, venous malformation
334
c-ANCA+
granulomatosis with polyangiitis (Wegener's)
335
p-ANCA+
Churg-Strauss, microscopic polyangiitis, PAN
336
Auto-amputation of digits
Buerger disease; distal occlusions and/or corkscrew collaterals
337
Pseudoaneurysm of ulnar artery (hand)
hypothenar hammer syndrome; may also see ulnar artery or more distal occlusions
338
Hand angiogram with finger occlusions
Buerger's or HHS; ulnar artery involvement suggests HHS
339
Henoch-Schoenlein purpura
palpable purpura, GI bleeding, intussusception; bowel wall thickening, scrotal edema; non-ANCA
340
50-69% carotid stenosis
ICA PSV 125-230 cm/s or ICA/CCA PSV ratio 2.0-4.0
341
>70% carotid stenosis
ICA PSV >230 cm/s or ICA/CCA PSV ratio >4.0
342
Temporal tap
to identify the ECA (from the ICA)
343
Bilateral carotid reversal of flow
aortic regurgitation
344
Loss of diastolic flow in ICAs
brain death
345
CCA waveform looks like ECA waveform
ICA occlusion (loss of diastolic flow in CCA)
346
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
347
Pulsus bisferiens
two peaks; seen in aortic regurgitation, severe HOCM, dissection, severe COPD
348
Vertical vein
in supracardiac TAPVR; pulmonary veins converge to form a vertical vein which drains into SVC, BCV, or azygous vein
349
Takayasu treatment
steroids; angioplasty is NOT performed in the acute setting
350
Fibrin sheath
contrast flows retrograde away from tip; "line flushes, but does not aspirate"
351
Celiac, SMA, IMA, and renal arteries arise at what spinal levels
celiac = T12, SMA = T12-L1, renal arteries = L1-2, IMA = L3-4
352
Source of bleeding in Mallory-Weiss tear
left gastric artery often; partial thickness tear
353
Vessel in the fissure of the ligamentum venosum
replaced/accessory left hepatic artery
354
Meandering mesenteric artery
arc of Riolan; connection between middle colic a. and left colic a.
355
Vessel within scalene triangle
subclavian artery (with brachial plexus); vein runs anterior to the anterior scalene muscle
356
Borders of scalene triangle
anterior scalene m., middle scalene m., first rib
357
Branches of subclavian artery
vertebral a., internal mammary a., thyrocervical trunk, costocervical trunk, dorsal scapular a. (from proximal to distal)
358
Landmarks for beginning and end of axillary artery
distal margin of first rib to lower border of teres major
359
Ulnar vs. radial artery
ulnar artery is bigger, gives off common interosseous branch, and supplies superficial palmar arch
360
Lower leg arteries (from lateral to medial)
anterior tibial a., peroneal a., posterior tibial a.
361
Most gastric varices are formed by which vessel?
left gastic vein (coronary vein)
362
True aneurysm definition
enlargement of lumen 1.5x its normal diameter
363
Leriche syndrome
infrarenal aortoiliac occlusion; triad of impotence, buttock/thigh claudication, absent femoral pulses
364
Blood supply to descending aorta in pre-ductal aortic coarctation
PDA
365
Dunbar syndrome
a.k.a. median arcuate ligament syndrome; worse with expiration; surgical treatment
366
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
367
Suspected HHT - NEXT STEP
CTA of liver and lungs + MRA brain
368
Most common location for FMD
renal aa. > carotid aa. > iliac aa.; most common type is medial
369
Most common peripheral arterial aneurysm
popliteal artery aneurysm
370
Most common type of Takayasu arteritis
type 3 (involves aortic arch and abdominal aorta)
371
Most common sites of involvement in PAN
renal > cardiac > GI; microaneurysm formation; more common in males
372
Cogan syndrome
aortitis + vertigo, tinnitus, and/or inflammatory eye disease
373
Most common cause of acute mesenteric ischemia
SMA embolus
374
Treatment for non-enhancing uterine fibroids
do not embolize
375
Intra-procedural heparinization
angioplasty, any dialysis intervention, neuro IR
376
Portal vein embolization
used to increase remnant liver size prior to partial hepatectomy
