Interventional radiology Flashcards
What are the branches of the celiac artery?
Left gastric, common hepatic, splenic
What is the collateral flow to the spleen?
Short gastrics (via left gastroepiploic)
where does the GDA originate and what does it become?
Originates from common hepatic (which becomes proper hepatic beyond that) and branches into right gastroepiploic and superior pancreaticoduodenal
what connects the SMA and celiac?
Pancreaticoduodenal arcade: superior pancreaticoduodenal artery comes from GDA, inferior pancreaticoduodenal artery comes from SMA
(Dorsal pancreatic artery: splenic artery to superior pancreaticoduodenal a)
Give two routes to access a lesion in the gastroepiploic artery
From the right: celiac -> GDA -> gastroepiploic, from the left: celiac -> splenic -> left gastroepiploic
What do you have to remember when treating an upper GI bleed?
Bracket the bleed because of collateral supply
In any patient with GI bleed, including BRBPR, especially if shocky, what should you ask?
Has an NG tube been placed (to check for upper GI blood)?
What agents can be used for upper GI bleeds?
gelfoam, coils - rich vascular supply
what agents can be used for lower GI bleeds?
Coils (no gelfoam, no particles, would lead to necrosis)
What causes hemobilia s/p ERCP?
extrav from injury to (right) hepatic artery
Bronchial artery bleeds - causes?
Bronchiectasis (many causes, including CF), fungus/TB, tumor
What material is used to embolize bronchial artery bleeding?
particles (not coils)
What are the risks to remember before doing bronchial artery embo?
Paralysis from anterior spinal artery embo, also remember to go past the takeoff of intercostal branches
What is a Rassmusen’s aneurysm?
A pulmonary artery aneurysm in or adjacent to a tuberculous cavity
What do you do when there’s a lot of hematuria following perc nephrostomy tube placement?
1st upside the tube to tamponade. If still bleeding, do renal arteriogram to look for fistula
How large do visceral aneurysms (e.g. splenic or renal) need to be before most people would treat them?
2 cm
What’s the cause of diffusely small, abnormal mesenteric vessels?
Shock/hypotension (everything is vasoconstricted), pt may be “bleeding on the bed”
What’s the first vital sign to check to evaluate for blood-loss/pt becoming unstable
Heart rate (blood pressure only drops after tachycardia cannot compensate)
What material to embolize an AML?
Particles (you want necrosis), or glue
Why are AMLs prone to bleeding?
Abnormal arteries, prone to aneurysm formation
What patients get aortoenteric fistulas? How are they treated?
S/p aortic endograft or open AAA repair. Rx is surgery.
GI bleeding arteriogram - blush but it washes out rather than persisting indicates what?
Tumor
How many types of endoleak are there and what are they?
1a - Leak from top of graft 1b - leak from bottom of graft 2 - retrograde flow from a collateral vessel 3 - fabric tear or at overlap points 4 - porosity of the material 5 - "endotension" aka "we have no idea"
Where do type 2 leaks usually come from?
Type 2 is retrograde flow from a collateral, usually the IMA or a lumbar artery originating from the internal iliac
How can you identify CO2 angiograms?
sometimes they are white, in general lower resolution, don’t travel very far, always below diaphragm
Contraindications to CO2 angiography?
Anything above the diaphragm, L->R shunt
How to treat bilateral common iliac artery stenoses?
Kissing stents, deployed simultaneously to avoid embo from one side to the other
Why would you see celiac filling on an SMA injection?
Backfilling due to proximal celiac occlusion
What are the conditions necessary for chronic mesenteric ischemia?
2 of 3 mesenteric vessels must be occluded or severely stenosed
Treatment for acute femoral artery occlusion
Lysis with tPA (1mg/hr in ICU), then angioplasty
How do you treat distal emboli caused by treating a proximal lesion?
Options include suction thrombectomy and tPA
Where does stenosis occur in a native dialysis fistula?
proximal and distal ends
What are “safe” coags for most procedures?
INR of less than 2, platelets of at least 50
What’s the (theoretical) reason for placing a perc chole tube transhepatic?
Prevent intraperitoneal bile leak
What should you reflexively look for/ask for when you see a popliteal artery aneurysm
Aortic aneurysm - high association
What should the portal vein pressure be after TIPS
5-10 mmHg
Long segment, smooth narrowing of arch vessels = ?
Takayasu’s arteritis (Sx diplopia, dizziness, syncope)
What is the treatment for vessels affected by Takayasu’s arteritis?
angioplasty and stent
What vessels are affected by Takayasu’s? Who does it typically affect?
Aorta, it’s branches (esp arch vessels and renals) and pulmonary arteries. Young asian women
Giant cell arteritis manifests how? Who does it typically affect?
aka temporal arteritis, most commonly temporal artery, but any medium to large artery, esp aorta and it’s branches. Tends to affect older people, esp women. More distal disease (eg subclavian arteries but not carotids) and older patients than Takayasu’s.
Numerous intrarenal aneurysms = ?
PAN - polyarteritis nodosa
or chronic amphetamine abuse, SLE
What arteries are affected in PAN?
Renal arteries, coronary, GI tract, liver, spleen, pancreas
How do you treat a side-by-side AV fistula (e.g. subclavian to subclavian)?
Covered stent
How do you treat a (nonpulmonary) AVM?
Glue (not coils, since it will just reconstitute)
How do you treat a pulmonary AVM?
Coils (they’re really fistulas and not like AVMs in the rest of the body)
How do you treat a venous malformation (formerly known as a hemangioma)?
Direct puncture and EtOH. Multiple sessions may be needed.
What is Paget-Schroetter syndrome?
primary thrombosis of the subclavian vein due to mechanical compression, usually in the costoclavicular space. Also known as effort thrombosis, it is associated with forced abduction of the upper limb and most commonly seen in young athletes who use repetitive shoulder-arm motions such as weight-lifters, wrestlers, baseball pitchers or tennis player
How do you treat subclavian artery thrombosis?
Thrombolysis, angioplasty if needed, surgery in 1-8 weeks. No stenting unless you really have to.
What is thoracic outlet syndrome?
Compression of the brachial plexus, subclavian artery, and/or subclavian vein by anterior scalene, 1st rib or cervical rib, or generalized muscle hypertrophy
How do you treat Budd-Chiari if it’s acute? Chronic?
Acute - single, gross vessel occlusion -> thrombolysis. Chronic = TIPS then transplant
Steps in a TIPS
Cath subclavian, SVC, IVC, Hepatic vein, portal vein, measure pressures in both, balloon the tract, place covered stent (to avoid biliary fistula).
What is the first and most common dialysis fistula created?
Radial artery to cephalic vein
Pt with cirrhosis, arterially enhancing lesion with washout. What do you do?
Treat for HCC as appropriate, no need for biopsy, it’s an imaging dx in that circumstance
Rx for HCC less than 3cm, 3-6cm, and greater than 6cm
less than 3cm: RFA, 3-6: chemoembo then RFA, greater than 6: chemoembo
Which is better in the liver - RFA or cryoablation?
RFA - cryo is not used due to concern for shock liver
Risk of draining lesser sac/pancreatic collection?
Interruption of panc duct, Rx with stent
Where to place drainage catheter for perirectal abscess?
inferior and medially as close to sacrum as possible, through sacrospinous ligament
Treatment for SVC syndrome
Immediate: stent, Later: rad/chemo
how do you size a snare
based on size of blood vessel
What history and labs before a procedure?
Cr, coags, CBC, allergies
Where does the uterine artery originate?
Anterior division of internal iliac artery
What’s a Klatskin tumor?
Hilar cholangiocarcinoma obstructing the hepatic ducts
You’re about to start a biliary drainage on a pt with a klatskin tumor - what should you do?
Give antibiotics - even without Sx, 1/3 chance of infection in a collection with stasis
Risks/complications of perc biliary drainage
Infection, hepatic artery injury, bile duct injury
Rx bile obstruction from Klatskin tumor
Perc biliary drainage, may need to do both sides separately, though usually relief with at least one. Try to place stent, but may need to retry in a couple days after everything is decompressed
How long do dialysis fistulas take to mature?
3-4 months, could use in 2 if essential
Indications for placement of IVC filter
Failure of anticoag, unable to anticoag (eg recent surgery, active bleeding), massive clot burden (can’t tolerate any more), pt won’t comply with meds
What’s the maximum IVC caliber for a regular filter?
28mm
What kind of filter do you use for a mega-cava?
Bird’s nest
IVC venogram before filter placement checks for what?
Vessel diameter, presence of clot, duplicated IVC, circumaortic left renal vein
Rx for pseudoaneurysm (eg in groin)
Inject thrombin under US visualization, tiny amounts, backing out
Rx for splenic lac that needs treatment
Selective embo (coils), but nonselective if you can’t get there - spleen has collaterals through short gastrics
Where do you perform a nonfocal renal Bx? What size needle?
Lower pole, through Brodel’s line (avascular plane). 17-18 coaxial system
Beaded appearance of the renal artery = ?
FMD (fibromuscular dysplasia)
FMD: pts affected, vessels affected, most common subtype
Young women. Renal arteries, extracranial ICA, vertebrals, iliacs, mesenteric.
Most common subtype is medial fibroplasia
Rx for FMD renal artery stenosis?
Angioplasty. DO NOT stent
Where to access if going to mesenteric arteries/renals from upper extremity?
LEFT arm. Catheter should not cross arch vessels.
How do you measure pressure gradient? What’s significant?
Simultaneously, one through sheath, one through catheter.
20mmHg.
Rx for AVF in uterus (s/p D&C)
glue (just like any other nonpulmonary AVF)
What kind of stent for Rx atherosclerotic stenosis?
Balloon expandable
Ddx for proximal celiac stenosis
Median arcuate ligament syndrome - rule out by seeing if it disappears when the patient is in full inspiration
What should you be past before starting UFE embolization?
the cervical-vaginal branch
Ddx for popliteal artery occlusion
Acute: Embolus, chronic: in situ thrombosis (atherosclerosis), popliteal aneurysm thrombosis, popliteal entrapment, trauma, cystic adventitial disease (men)
What is the risk associated with popliteal aneurysm? How is it treated?
Thrombosis (which propogates, embolizes). Thrombolysis of vessel, possibly bypass, then surgery for aneurysm.
What descriptors should be used when describing stenosis?
Degree: mild, moderate, severe
Length: focal, long-segment
What does rest pain in a limb indicate?
In the leg, it means more than just e.g. the common iliac is occluded, there’s SFA occlusion/multifocal disease
With multiple stenoses, what do you treat first?
Proximal first, always get inflow before outflow
What does proximal iliac disease imply about the patient?
Smoker
What’s present if there’s arterial occlusion?
Thrombus.
Rx renal artery ostial stenosis
Balloon expandable stent
Pt has traumatic aortic injury - Rx/next step?
Transfer to center with cardiopulmonary bypass for surgery
Rx pelvic artery traumatic injury
Gelfoam (also for proximal femoral branch injury e.g. from hip fracture)
What is a diverticulum of Kommerell? What’s it associated with?
Bulbous origin of the subclavian artery, either an aberrant left from a right arch or aberrant right from a left arch
Stenosis and occlusion of the digital arteries, esp of 4th and 5th digits = ?
Hypothenar hammer syndrome (repetative blunt trauma to hand).
Pulmonary AVM - what disease do you suspect? How likely is it?
HHT (aka Osler-Weber-Rendu. 33-50% chance they have the disease, about 20% of those with it have PAVMs.
Name of subclavian vein thrombosis?
Paget-Schroetter Syndrome aka effort thrombosis
Ddx for bile duct filling defect:
air bubble, calculus, thrombus, tumor, inspissated bile, pus
Causes of broncial artery bleed:
bronchiectasis (e.g. CF), TB cavity, sarcoid, cancer
Causes of biliary stenosis at the common duct or confluence:
Malignant: cholangio ca, GB ca, HCC, Mets
Benign: sclerosing cholangitis, mirrizzi’s syndrome, ischemia, iatrogenic
Causes of mid CBD stricture:
Malignant: Pancreatic ca, cholangio ca, lymphoma, mets
Benign: iatrogenic, inflammatory (post calculus, pancreatitis), calculus
Causes of distal CBD stricture:
Malignant: Pancreatic ca, cholangio ca, ampullary neoplasm, duodenal neoplasm
Benign: iatrogenic, inflammatory (post-calcluus, pancreatitis), calculus, spasm, choledochocele
Causes of intrahepatic biliary strictures:
sclerosing cholangitis, primary biliary cirrhosis, cholangiocarcinoma, ischemia, radiation, infection (AIDS), hepatic artery embo
Name and describe the types of choledochal cysts
Type 1 (80-90%): cystic dilatation of CBD Type 2: diverticulum of CBD Type 3: intraduodenal cyst or choledochocele Type 4: multiple extrahepatic cysts, maybe also multiple intra as well Type 5: multiple intrahepatic cysts = Caroli's disease
Locations for aortic injury/rupture:
Root (usually swiftly fatal), ligamentum arteriosum (most commonly seen in hospital), diaphragmatic hiatus
Ddx of vascular stenosis:
atherosclerosis, thrombus, vasculitis, compression syndrome (e.g. median arcuate ligament), encasement (e.g. malignancy), FMD, spasm, radiation
Collaterals from SMA to IMA:
from middle colic: Meandering artery / Arc of Riolan (relatively central), Marginal artery of Drummond (parallels the colon)
complete occlusion of distal aorta:
Leriche syndrome - sx buttock claudication, absent femoral pulses, impotence in males, Rx surgical bypass
What’s a crazy-looking aneurysm often due to?
Mycotic aneurysm (infectious)
What’s the diangosis for squiggly intrahepatic arteries?
cirrhosis
What’s the vascular supply to HCC? To hepatic mets?
HCC: hepatic artery
Mets: portal vein
Classification of aortic dissection (2 methods)
Stanford: A and B
Debakey: Type 1 (both), Type 2 (ascending), Type 3 (descending)
Ddx for renal artery stenosis in children:
FMD, NF1, arteritis, congenital, muscular bands
Dds for renal artery aneurysm in adult:
atherosclerosis, FMD, congenital, traumatic, inflammatory (mycotic, arteritis), neoplastic
Popliteal artery entrapment: who? cause? diagnosed how?
Young males.
Abnl insertion of gastrocnemius or popliteus m. with medial deviation of popliteal artery. Worse with passive dorsiflexion or active plantarflexion
Cystic adventitial disease - who? what is it? How does it look? How diagnosed?
Young males with claudication
Mucinous cysts in wall
smooth luminal narrowing
Dx with cross-sectional imaging
Ddx for vacular abnl of hand:
emboli, trauma (including hypothenar hammer), arteritis (Buerger’s), collagen vascular dz (scleroderma, SLE), hypercoag, drugs, hypersensitivity angitis, atherosclerosis, raynaud’s, thermal inj.
What are the most common anatomical variants of the celiac artery?
- Replaced R hepatic from SMA
2. Replaced L hepatic from left gastric
Hepatic artery to portal vein fistula - what caused it?
HCC
Where does the bronchial artery typically originate?
Anteriorly around the level of the carina/upper thoracic
Thrombin injection (e.g. for psuedoaneurysm): Dose and amount
1000u/cc, use less than 1cc
Lateral deviation of the popliteal artery - what’s the concern?
Popliteal artery aneurysm
calf arteries- describe anatomy on frontal and lateral projections
Pop gives off anterior tibial (hockey stick) and tibioperoneal trunk
Lateral to medial: Anterior tibial, peroneal, posterior tibial
Anterior to posterior: anterior tib (becomes dorsalis), peroneal (Y), posterior tib
How big does an artery have to be to be aneurysmal?
1.5x normal diameter
what are contraindications to vertebroplasty
Old fracture, not significant pain, fracture compressing cord or nerve root (these need surgery)
Why do patients with coarctation get hypertension?
Renal hypoperfusion
What other cardiovascular abnormalities are associated with aortic coarctation?
Bicuspid aortic valve
intracranial aneurysms
what gets compressed in hypothenar hammer syndrome?
Ulnar artery as it passes over the hook of the hamate
When should renal artery stenosis be treated (endovascularly or surgically)
If the patient is not controlled on at least 3 antihypertensive medications
What’s the short-term treatment for Takayasu’s arteritis?
Steroids (only Rx surg. or endovasc. later)
What do “cobwebs” refer to regarding aortic dissection?
strands of tissue visible in the false lumen (helps distinguish it from true lumen)
What are complications of vertebroplasty?
cement extrusion - anteriorly - not much consequence
laterally - root compression
posteriorly - cord compression
disc - increased risk of fx at adjacent vertebral body
What are complications of vertebroplasty?
cement extrusion - anteriorly - not much consequence
laterally - root compression
posteriorly - cord compression
disc - increased risk of fx at adjacent vertebral body
What are signs it’s too late to salvage a limb?
White, cold, *insensate, *paralyzed
isolated gastric varices =
splenic vein thrombosis
abnormal large artery off the iliac going to the thigh - what is it? What’s the problem?
Persistent sciatic artery (goes through sciatic notch)
Prone to injury, especially at ischial tuberosity, may get aneurysm or thrombosis
What’s the normal velocity of blood in the portal vein?
30-40cm/s
What’s the problem with hemangiomas?
Platelet sequestration, called Kasabach-Merritt
How do you convert catheter size in French to mm?
French/3 = mm
e.g. 9Fr = 3mm
