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radiology > IR > Flashcards

IR Flashcards

1
Q

how is size measured for puncture needles, catheters, dilators, sheaths, wires.

A
  • puncture needle- Gauge. Outer
  • catheter/dilator- French. Outer
  • sheath- F. inner (Shy and stays in Shell)
  • wires: outer diam (inch), length (cm). standard=0.035in and 180cm
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2
Q

T or F: larger the gauge, smaller the wire. Larger the F, larger the catheter.

A

True

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3
Q

how many inch = 1 mm. How many F = 1 mm

A
  • 0.039 inch

- 3F

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4
Q

how are wires sized? what is the standard wire size for general purposes

A
  • outer diam=inch. Standard= 0.035 inch

- length =cm, standard=180 cm

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5
Q

size of microwires

A

0.018, 0.014 inches

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6
Q

What size catheter will the standard 0.035 wire fit through?

A

4F (or bigger)

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7
Q

when are sheaths used? How are they sized?

A
  • cases that require exchange of multiple catheters w/o losing access
  • sized via inner lumen. Chosen according to largest catheter they will accommodate
  • outer diameter usually 1.5-2F larger than inner lumen, ieL add 2F for outer diam (if you want to know how big the hole in the skin will be)
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8
Q

some conversions… How many F?

  • 16G needle has outer diam of 1.65 mm
  • 20G needle has outer diam of 0.97 mm
A
  • 5F

- 3F

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9
Q

18G, 19G (seldinger technique) and 21G (micro puncture) needles accept what size guide wire?

A
  • 0.038 in
  • 0.035 in
    0. 018 in (micropuncture)
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10
Q

when is micro puncture good and bad?

A
  • Good-tough access (Ex: antegrade femoral puncture), lack of experience, anatomically sensitive (internal jugular, dialysis access)
  • bad: scarring, obesity, flimsy 0.018 inch guide wire doesn’t give enough support for dilator when upsizing
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11
Q

2 flavors of guidewires

A
  • non-steerable (supportive raises for catheters)

- steerable-tight spots, ex: hydrophilic

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12
Q

“long wire” length and uses

A
  • 260 cm
  • upper extremity from groin access, visceral circulation and need to exchange catheters, guide catheter >90cm, through and through situation (body flossing)
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13
Q

minimal guidewire length

A

-length of catheter + length of guide wire in pt

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14
Q

what’s more likely to cause dissection: short or long floppy tip guidewire

A

shorter

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15
Q

which guide wire for “tight spots”

A

hydrophilic

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16
Q

how should stiff guide wires be introduced?

A

through a catheter

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17
Q

Advantage of J tip guidewires. Significance of number associated with it?

A
  • Don’t dig up plaque and miss branch vessels

- radius of curve (smaller miss small branch vessels, larger miss large branch vessels)

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18
Q

guidewire stiffness: noodle-like, normal, supportive, stiff, hulk smash

A
  • Bentson (floppy tip) (BENdy)
  • hydrophilic (standard 0.35 J or straight)
  • stiff hydrophilic (heavy duty J or straight)
  • flexfinder. Abplatzen stiff or extra stiff. 0.018 platinum plus. V18 shapeable tip
  • hulk smash-lunderquist, back up Meier.)
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19
Q

more guide wire stiffness, more…

A

dissection

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20
Q

use of lunderquist (super stiff) guide wire?

A

-aortic stent grafting

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21
Q

catheter types

A
  • nonselective (medium and large vessels)

- selective (diff shapes/angles for “selecting” branch vessel)

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22
Q

nonselective catheter types

A
  • pigtail

- straight

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23
Q

selective catheter types

A
  • end hole
  • side + end hole
  • acute angle (<60˚), curved (60-120˚), obtuse (>120˚)
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24
Q

what happens if you consistently inject through a pigtail

A

contrast goes out proximal side holes and not the tip –> con’t injection=clot in tip

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25
Q

what should you do before big injection with pigtail Cath?

A

-small test injection-make sure you’re not in a small branch vessel (pigtails are for medium/large vess)

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26
Q

what if pigtail fails to form as you retract the wire?

A

push catheter forward while twisting

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27
Q

morphology and utility of straight catheters

A
  • side holes and end hole

- smaller vessels, classic loc=iliac

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28
Q

end hole vs side & end hole selective catheters

A
  • end hold: hand injection. dx angiograms & embolization procedures
  • side + end hold- pump injection. SMA angiogram. never use in embolization (material can track out side hole)
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29
Q

utility of angled tip, curved, and recurved selective caths

A
  • angled (<60˚)- aortic arch vessels
  • curved (60-120˚)- renal, ?SMA/celiac
  • obtuse (>120˚)- celiac/sma/ima
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30
Q

“recurve”

A

1˚and 2˚ curves

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31
Q
  • co-axial system
  • guide catheter
  • introducer
  • microcatheter
  • vascular sheath
A
  • 1 catheter inside another catheter/sheath. Ex: catheter inside an arterial sheath
  • large catheter guide up to desired vessel then shaped for more conventional distal cath
  • introducer=long sheath
  • microcath-2-3F for tiny vessels (super selection of peripheral or hepatic branches)
  • sheath + hemostatic valve + side arm for flushing
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32
Q

20 for 30

A

20 cc/second for total of 30 s

-bigger artery, higher rate (try to displace 1/3 of blood per second to get adequate picture)

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33
Q

how are maximum flow rates determined and what is flow rate for 3F, 4F, 5F?

A
  • internal diam, length and #side holes

- 8 mL/s, 16, 24 (~8/F)

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34
Q

Double vs single flush techniques

A
  • double: aspirate –> attach new saline syringe (for neuro stuff) –> flush
  • single: aspirate –> tilt 45˚ –> flush w/ SALINE only
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35
Q

what if you accidentally mix blood in with saline on aspiration?

A

discard syringe and double flush

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36
Q

what if you’re unable to aspirate blood?

A

1) jammed against side wall-pull back, manipulate cath

2) clot- pull out/clear clot OR blow clot inside (if embolizing that location anyways)

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37
Q

preference for picc line venous access

A

basilic > brachial > cephalic

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38
Q

preference for central lines/ports

A
  • RIJ > LIJ > REJ > LEJ > Femoral > subclavian
  • subclavian=thrombus, PTX
  • femoral=infection
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39
Q

dose thrombin injection into pseudoaneurysm

A

-0.5-1 mL (500-1000u)

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40
Q

when should you not compress a pseudoaneurysm?

A

above inguinal lig

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41
Q

CI to thrombin injection

A
  • local infection
  • rapid enlargement
  • distal limb ischemia
  • large neck (first for propagation)
  • pseudoaneurysm cavity size <1cm
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42
Q

when is surgery indicated for pseudoaneurysm rx

A
  • thrombin fails
  • inf
  • tissue breakdown
  • aneurysm neck too wide
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43
Q

mc arterial access site

A

femoral

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44
Q

femoral access too high or low

A
  • high (above inguinal lig)-RP bleed

- low: AV fistula

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45
Q

steps when meeting resistance when advancing guide wire during arterial access

A

1) stop, pull wire out and confirm pulsatile flow
2) will not advance beyond top of needle- flatten needle (negotiate plaque)
3) stops after short distance-fluoro to confirm pw. 4F sheet. hydrophilic wire.

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46
Q

when would you want to do brachial access?

A

1) fem a out
2) obesity
3) upper limb angioplasty

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47
Q

risks brachial access

A

1) compartment syndrome
2) stroke if cath passes across GV/arch
3) spasm (small vessel. pox GTN)
* sheat larger than 7F may require surgical cut down

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48
Q

which arm do you use in brachial a access

A
  • left if heading south (abd aorta or LE)
  • right if headed north (thoracic aorta or cerebrum)
  • equal?-left (non dominant, avoid cerebral vess)
  • BP diff >20mmHg systolic sugg stenosis-use other arm
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49
Q

Radial access

A

1) no bedrest

2) allen test

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50
Q

CI to trans lumbar aortic puncture?

A

supra celiac aortic aneurysm

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51
Q

approach to trans lumbar aortic puncture?-pt position, spine level?

A

Prone, left side (avoid IVC)

-high-T12 endplate

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52
Q

mild backache s/p trans lumbar aortic puncture

A

-psoas hematoma (common)

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53
Q

arterial access anticoagulation pre-procedural requirements

A
  • heparin 2 hrs (PTT < 1.2x 25-35s). can turn on 2 hrs after
  • INR 1.5
  • coumadin 5-7 d (vit K 25-50 mg IM 4 hrs, FFP/cryo)
  • PC >50K
  • ASA/plavix 5 d
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54
Q

when do pseudoanuerysms spon’t resolve and resp well to intervention?

A

<2cm

long narrow neck, small defect

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55
Q

ideal degree of balloon dilation

A
  • 10-20% over normal a diameter

- take out stenosis + stretch a slightly

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56
Q

anticoagulation s/p angioplasty

A

-1-3 mo anti-platelets (AsA, clopidogrel)

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57
Q

general indications for angioplasty

A
  • 50% stenosis + syxs
  • a gradient > 10
  • v gradient > 5
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58
Q

where do you not stent

A
  • across joint

- site of possible surgical bypass

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59
Q

exception to angio + stent

A

FMD

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60
Q

stent types

A

1) balloon-precise deployment, ex: renal ostium

2) self-expandable- areas that get compressed (ie: superficial loc, ex: cervical carotid or SFA)

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61
Q

closed vs open cell stents

A
  • closed-every segment connected by link. More radial force, less flexible, greater plaque coverage
  • open= some stent segments deliberately abscenct-flexible/conforms to tortuous vess, less radial F)
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62
Q

ninitol

A

used in self-expanding stents vial thermal memory (soft at room T, more rigid at body T)

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63
Q

drug eluting stents

A

-retard neointimal HP

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64
Q

rough guessing guide for balloon size selecting-aorta, common iliac, ext iliac, CFA/prox SFA, distal SFA

A
  • aorta: 10-15mm
  • CI: 8 mm
  • EI: 7 mm
  • CFA, prox SFA=6mm
  • distal SFA=5mm
  • popliteal=4mm
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65
Q

stent size selection

A
  • 1-2 cm longer than stenosis

- 1-2mm wider than unstenosed vess

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66
Q

next step: >30% residual stenosis

A
  • pressure gradiant-if normal, stop

- if abN-elastic recoil–> stent

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67
Q

next step: waist won’t go away w/ balloon inflation

A

switch balloon to higher P or cutting

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68
Q

next step: distal embo

A
  • angiographic run –> limb perfused? no intervention.

- not perfused? IL access and retrieve clot

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69
Q

next step: extravasation in setting of balloon angioplasty

A

-reinflate balloon

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70
Q

EVAR

A

endovascular abdominal aortic aneurysm repair

-includes iliacs

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71
Q

TEVAR

A

thoracic endovascular aortic aneurysm repair

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72
Q

anatomy criteria for EVAR

A

-proximal landing zone must be 10 mm long, non aneurysmal, <60˚ tortuosity

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73
Q

endograft vs open repair

A
  • endo repair: 30 d mortality less
  • aneurysm related mortality equal
  • graft complications/re-intervention-higher w/ Endo
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74
Q

requirements of iliac vessels in setting of endograft device deployment

A
  • iliac vessels have angulation >90˚ (esp in heavily calcified)
  • iliac a diameter < 7mm -may need to cut down and place temporary conduit
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75
Q

absolute CI to infrarenal EVAR

A
  • landing site won’t allow for aneurysm exclusion
  • covering a critical a (IMA in setting of SMA + celiac occlusion, accessory renal feeding a horseshoe, dominant lumbar arteries feeding the cord)
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76
Q

describing aneurysms near renal

A
  • para-renal-umbrella term near renals
  • juxta renal- short neck (<1 cm) or encroaches on renal
  • suprarenal- involves renal and ext into mesenterics
  • crawford type 4 thoracoabdominal aortic aneurysm-ext from 12th intercostal space to iliac bifurcation w/ involvement of orgs of renal, SMA, and Celiac
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77
Q

crawford type 4 thoracoabdominal aortic aneurysm

A

ext from 12th intercostal space to iliac bifurcation w/ involvement of orgs of renal, SMA, and Celiac

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78
Q

when does paraplegia occ in setting of EVAR. Next step?

A
  • artery of adamkiewicz territory covered (T9-12)

- next step=CSF drainage

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79
Q

vertebral level take off: celiac, sma, renal, ima

A
  • T12
  • L1
  • L2
  • L3
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80
Q

most common type of endoleak

A

type 2

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81
Q

which endoleaks must be treated?

A
  • High flow, emergently: type I and III
  • observe type 2, treat if enlarging
  • type IV resolve ~48 hrs
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82
Q

embolizations options in setting of big vessel

A

permanent: coils (lung AVM)
temporary: gel foam pledget (trauma)

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83
Q

embolization options in setting of small vessel

A
  • permanently kill: liquid (RCC ablation)
  • permanently wound: particles (fibroid embo)
  • temporary: microsphere (chemo)
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84
Q

embo option to slow flow but not occlude

A
  • large proximal embolic (coils, plugs, large particles 500-100µm)
  • ex: GI bleed
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85
Q

embo option to totally infarct

A
  • distal embolic small particle, <250µm

- ex: tumor ablation

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86
Q

coils

A

permanently occlude large vessels

  • diff sizes and shapes
  • push via coaxial system OR chased via saline bolus if exact precision not needed
  • complex: pack behind amplatzer or use as scaffolding to hook small coils to a large one
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87
Q

coil vs microcoil

A
  • deployed via standard 4-7F cath

- micr: deployed via microcath. I f you try to to deploy standard cath and ball up inside thing and clog it

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88
Q

which coil to use in setting of accurate deployment

A

End hole detachable coil

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89
Q

device from which a coil should never be deployed

A

-side hole end hole.

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90
Q

amplatzer vascular plug (AVP)

A
  • self expanding wire mesh made of nitinol mounted at end of delivery device/wire.
  • when deployed: shrinks in length, widens
  • use: high flow station when killing a single large vessel. Going to need a lot of coils to take that beast down.
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91
Q

particulate agents

A
  • temporary- gelfoam, autologous blood clot
  • permanent-PVA particles
  • use: want to block mult vess, ex: fibroids
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92
Q

gel foam powder vs gel foam pledgets/sheets

A

powder- causes occlusion at capillary level (tissue necrosis)
-pledget/sheet-occlusion at arteriole or larger level (infarct less common)

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93
Q

when do you stop deploying deploying particulate agent

A

“to and fro”- if you get total occlusion, you risk refluxing

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94
Q

coils vs PVA particles

A
  • size: coils for medium to small arteries. PVA for small a’s to caps
  • need for repeat
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95
Q

next step: what do you do after placement of occlusion balloon in setting of particle embolization?

A

test injection to confirm adequate occlusion

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96
Q

liquid agents

A
  • sclerosants-absolute EtOH (it hurts) and sodium dodecyl sulfate (SDS)
  • non-sclerosants- onyx (ethylene-vinyl Alocohol copolymer), ethiodol
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97
Q

how do sclerosis agents work?

A

near immediate thrombosis/irreversible endothelial destruction
-nontargeted embo=devastating: know anatomy, f angiograms, balloon occlusion

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98
Q

what do you do prior to deflating occlusion balloon in setting of sclerosing agents?

A

-aggressively aspirate (w/ 60 cc syringe) to make sure all poison is out

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99
Q

onyx

A
  • non sclerosant liquid embo agent used in neuro procedures.

- dries slowly (outside in) allowing for controlled delivery

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100
Q

ethiodol

A
  • non sclerosant liquid embo agent. Oil that blocks vessels at arteriole level (same as small PVA particles)
  • hepatomas love it
  • radio-opaque- decreases non-target embolization, track tumor size on f/u
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101
Q

post-embolization syndrome

A
  • pain/n/vom/low grade fever
  • rule of 3
  • classic for large fibroid
  • ppx w/ anti=pyrexial, antiemetic
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102
Q

frequent limb embolic sites

A
  • CF bifurcation

- popliteal trifurcation

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103
Q

triaging limb ischemia based on physical exam

A
  • category 1 (viable)
  • category 2a (threatened). Salvageable.
  • category 2b-(threatened.) salvageable if immediate intervention
  • category 3 (irreversible)
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104
Q

Category 1 limb ischemia

A

Viable. Not threatened.

  • Capillary return in tact.
  • No m paralysis or sensory loss.
  • a doppler +
  • v doppler +.
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105
Q

category 2a limb ischemia

A

Threatened. Salvageable.

  • cap return intact/slow
  • M paralysis (-)
  • sensory loss-partial
  • arterial doppler (-)
  • venous doppler (+)
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106
Q

category 2b limb ischemia

A

Threatened. Salvageable if immediate intervention

  • cap return slow/absent
  • m paralysis-partial
  • sensory loss-partial
  • a doppler (-)
  • venous doppler (+)
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107
Q

category 3 limb ischemia

A

Irreversible/not salvageable/amputation

  • cap return (-)
  • m paralysis (+)
  • sensory loss (+)
  • arterial doppler (-)
  • venous doppler (-)
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108
Q

“critical limb ischemia”

A

rest pain for 2 wks (or ulceration or gangrene)

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109
Q

treating limb ischemia: inflow vs outflow

A

inflow first

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110
Q

surgery vs thrombolysis limb ischemia

A
  • occluded <14d-thrombolysis
  • occluded > 14d-sx
  • isolated suprainguinal embo-sx
  • fragmented distal emboli-thrombolysis
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111
Q

choosing values for ABI

A
  • BP both arms & ankles. systolic measurement.
  • use higher arm
  • use higher dorsals pedis or pst tibial
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112
Q

categorizing ABI severity:

A
  • N. ø syx
  • 0.75-0.95-Mild. mild claudication.
  • 0.5-0.75-moderate. claudication.
  • 0.3-0.5-moderate/severe. severe claudication.
  • <0.3-severe/critical. rest pain
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113
Q

toe pressure

A
  • distal toe P in diabetics (these a’s not affected)

- N values: systolic >50mmHg, TBI > 0.6

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114
Q

at what toe pressure is ulcer less likely to heal?

A

<30 mmHg

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115
Q

segmental limb P

A
  • modification to standard ABI
  • pressures at thigh, calf, ankle
  • drop of 20-30 mmHg-infer level
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116
Q

what makes limb spectral waveform triphasic?

A

high resistance tibial vascular tree-rebound effect via normal arterial compliance.
-lost in setting of PAD

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117
Q

ulcer location: venous stasis, ischemic/infected ulcer, neurotrophic ulcer

A
  • medial ankle
  • dorsum of foot
  • plantar (sole)
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118
Q

Rutherford and fontaine?

A

categories and classification of sgx and syx PAD

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119
Q

post-op bypass vocab: primary patency

A

uninterrupted latency of graft with no procedure done on the graft itself
-repair of distal vessels or vessels at either anastomosis does not count as loss of primary latency

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120
Q

post-op bypass vocab: assisted primary patency

A

Patency never lost but maintained by ppx (stricture angioplasty, etc)

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121
Q

post-op bypass vocab: secondary patency

A

graft latency lost, then restored with intervention (thrombectomy, thrombolysis, etc)

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122
Q

best route of access for mx threatened limb: iliac

A
  • IL CFA (1st choice)

- CL CFA

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123
Q

best route of access for mx threatened limb: CFA

A

CL CFA

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124
Q

best route of access for mx threatened limb: SFA

A

IL CFA

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125
Q

best route of access for mx threatened limb: fem-pop graft

A

IL CFA

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126
Q

fem-fem cross over

A
  • direct stick (1st choice)

- inflow CFA

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127
Q

best route of access for mx treated limb

A

shortest, most direct

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128
Q

When would you use CL CFA for treating a lesion in setting of threatened leg

A

1) The IL CFA is occluded

- pt fat

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129
Q

antegrade vs retrograde access

A
  • arterial flow
  • antegrade=towards toes
  • retrograde=towards heart
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130
Q

check angiography

A

-infusing TPA directly into clot. Check every 6-8 hrs for progress

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131
Q

what if you can’t cross the clot with a wire

A

it’s organized and probably won’t clear with thrombolysis

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132
Q

lytic stagnation

A
  • clot not clearing during check angiogram

- stop the procedure

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133
Q

what if pt develop confusion in setting of thrombolysis

A

non-con ct

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134
Q

what if the pt level hypoTN and tachycardia in setting of TPA

A
  • bedside eval
  • ct abd/pelvis
  • stop tpa
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135
Q

what’s the end point for tpa?

A

-typically stop after 48 hrs (even if not totally cleared)

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136
Q

varicose v treatment-“tumescent anesthesia”

A
  • lots of diluted subcutaneous lidocaine provided

- ablated via endoluminal heat source

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137
Q

CI to varicose v rx?

A

-DVT

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138
Q

complications dVT

A
  • acute PE

- chronic post thrombotic syndrome

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139
Q

predictive models for CTPA

A
  • wells

- thrombus density ratio

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140
Q

Thrombus density ratio

A

DVT HU : normal v HU > 46.5 ==> likely a PE

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141
Q

phlegmasia alba

A

painful white leg seen in setting of massive DVT

  • ø ischemia
  • preserved collateral v’s
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142
Q

phlegmasia cerulea dolens

A

painful blue leg

-complete thrombosis of deep venous system, including collaterals

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143
Q

when are plegmasia alba and cerulean dolens terminology used?

A
  • extreme sequela of May-Thurner

- any sitch w/ massive DVT, ie: pregnancy, trauma, malignancy, clogged IVC filter

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144
Q

post thrombotic syndrome (PTS)

A

sequelae of DVT.

  • pain, ulcers
  • RFs: >65 yo, prox DVT, recurr/persistent DVT, fat
  • 6 mo-2yrs s/p DVT
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145
Q

what is done to prevent pst thrombotic syndrome

A
  • catheter-directed intrathrombus lysis of iliofemoral DVT

- (not needed for femoropopliteal)

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146
Q

permanent vs retrievable vs temporary filters

A
  • permanent-do not come out (10% thrombus w/I 5 yrs)
  • retrievable-can but don’t have to.
  • temporary-will come out. Component sticks outside body to retrieve
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147
Q

when are suprarenal IVCs placed?

A
  • pregnancy-avoid compression
  • clot in renal or gonads-get above clot
  • duplicated IVCs
  • circumaortic left renal v
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148
Q

risk of suprarenal ivc filter

A

renal v thrombosis (not at all proven)

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149
Q

ivc filter used based on IVC size

A
  • IVC < 28 mm-any

- bird’s nest if bigger, up to 40mm

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150
Q

gunther tulip & Simon nitinol ivc filters

A

GT: superior end hook for retrieval
SN: low profile (7F), placed in smaller v’s (arm)

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151
Q

are IVC filters MRI compatible?

A

yes

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152
Q

check list bf placing filter

A

1) confirm IVC patency
2) measure IVC size
3) confirm 1 IVC
4) document position of renal v’s

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153
Q

complications/risks of ivc filters

A
  • malposition-tip at renal v
  • migration-heart requires sx. otherwise snare
  • thrombosis-caval thrombosis=CI to removal; requires lysis
  • ivc perforation-problem if aortic, ureteral, duodenal, lumbar vessel
  • filter infection-bacteremia=relative CI
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154
Q

steaming effect

A

unspecified blood entering renal v’s let’s you infer correct position of IVC filter

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155
Q

IVC removal-first step

A

angiogram-evaluate for clot

  • > 1 cm3=stays in
  • <1 cm3= comes out
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156
Q

next step: meet resistance when removing IVC filter

A

stop

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157
Q

what should be done after IV filter removal?

A

angiogram-confirm no rupture

  • if rupture: angioplasty–> covered stent
  • if wall injury/dissection–> anticoag
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158
Q

MC dialysis AV fistula

A

radial a – cephalic v

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159
Q

pros of AV graft

A
  • use w/I 2 wks

- easier to declot (thrombus usually confined to graft)

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160
Q

comps of AV graft

A
  • less longevity (only 50% latency at 2 yrs). Require higher flow rates to remain patent
  • HP venous intima or dostreat from graft v anastomosis–> stenosis, obstr
  • inf+ (foreign)
  • 6-10x (+) risk inf, thrombus
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161
Q

pros of AV fistula

A

-last longer, more durable

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162
Q

con’s of AV fistula

A

-3-4 mo maturation

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163
Q

when should you obtain diagnostic fistulogram in setting of AV graft/fistula slow flow?

A
  • graft: <600 cc/min

- fistula: <500 cc/min

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164
Q

why do AV grafts/fistulas fail?

A

hyperplasia –> stenosis/occ/thrombus

*all must die

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165
Q

why’s a normal physical exam for AV graft

A
  • easily compressible pulse
  • low pitched bruit (systole & diastole)
  • thrill-palpable w/ compression only at arterial anastomosis
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166
Q

high pitched bruit

A

stenosis

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167
Q

swollen arm, chest, cw collaterals in setting of av graft/fistula

A

central venous obstruction

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168
Q

where is the problem usually in av grafts?

A

venous outflow

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169
Q

if you fix a stenotic av fistula, they’re good to go, right?

A

reoccur 75%

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170
Q

systolic thrill in av fistula

A

stenotic.

should be con’t at anastomosis

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171
Q

2nd thrill in av fistula

A

another stenosis. should only be 1

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172
Q

steal syndrome in setting of av fistula

A
  • blood preferentially going to fistula due to stenosis in native artery distal to fistula –> cold painful fingers.
  • rx= sx. distal revascularization and interval ligation of extremity (DRIL), or flow reduction banding.
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173
Q

CI to accessing/treating av fistulas/grafts

A
  • infection=absolute
  • <3- d
  • long segm 7 cm stenosis
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174
Q

what dir do you access av graft

A
  • toward venous anastomosis, ie: antegrade

* assuming v is the problem, which it usually is

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175
Q

how do you look at arterial anastomosis

A

obstruct venous outflow –> contrast reflux into artery

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176
Q

what are moves for angioplasty of a narrow spot?

A
  • heparin 3000-5000u
  • exchange cath for 5 or 6F sheath over standard 0.035
  • dilate w/ 6-8 mm balloon
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177
Q

when do you place stent in setting of av fistula/graft stenosis

A

1) bad elastic recoil

2) recurrent stenosis w/I 3 mo angioplasty

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178
Q

role of nitro in av fistula/graft stenosis

A

differentiate spasm vs stenosis

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179
Q

what’s considered a success rx for av fistula/graft stenosis

A

1) improved syxs

2) <30% residual stenosis

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180
Q

av fistula/graft aneurysms

A

surgically fixed

181
Q

portosystemic gradient (PSG)

A

P difference btw portal v and IVC

-3-6 mmHg = N

182
Q

portal HTN

A
  • portal v > 10 mmhg
  • PSG > 5mmHg
  • PV > 1.3-1.5 cm, splenic v >1.2 cm, big spleen, ascites, porosystemic collaterals, slow (<16 cm/s) or reversed PV flow

Portal hypertension: Increased pressure gradient between portal and hepatic veins (> 10 mm Hg)
Portosystemic gradient = direct portal pressure - right atrial pressure
Hepatic vein pressure gradient = wedged hepatic vein pressure - free hepatic vein pressure
Estimate of portosystemic gradient

183
Q

indications for TIPS

A

1) varicocele hemorrhage refractory to endoscopic rx
2) refractory ascites
3) budd chiari

184
Q

preprocedural steps for TIPS

A
  • echo- heart failure

- cross sectional img-confirm patency of portal v

185
Q

ideal pressure s/p TIPS

A

-<12 mmHg is the goal (9-12)

186
Q

TIPS acronym

A

transjugular intrahepatic portosystemic shunt

187
Q

why don’t you turn cath pst in TIPS?

A
  • PTX

- miss PV

188
Q

MELD vs Child Pugh

A
  • Child-Pugh=older. less accurate. eval liver dx severity

- MELD- liver and renal fx

189
Q

MELD

A

-initially developed to predict 3 mo mortality in TIPS. now used to prioritize who gets a tx
-bili, INR, creatinine
>18= high risk early death (even s/p tips)

190
Q

Child Pugh

A
  • initially used to determine tx urgency
  • now can predict TIPS outcomes
  • eval liver dx severity: bili, alb, PT, ascites, hepatic enceph
  • class B & C RFs for vatical hemorrhage
191
Q

absolute CIs to TIPS

A
  • severe heart failure (RHP 10mmHg)
  • severe liver fx (MELD >18, CP B,C), total bilirubin >3mL/dL
  • sev encephalopathy
  • severe ind-uncontrolled systemic inf
192
Q

relative TIPS CIs

A
  • cavernous transformation
  • isolated gastric varicose w/ splenic v occlusion
  • sev hepatic enceph
193
Q

main acute post procedural compl TIPS

A
  • cardiac decomp ((+) RH filling)
  • accelerated liver fx
  • worsening hepatic enceph
194
Q

normal TIPS eval

A

limited 2wks (air bubbles mimic occlusion)

  • 1 mo, 3 mo, 6 mo
  • flow into stent 90-190 cm/s
195
Q

sgx’s of TIPS stenosis/malfucntion

A
  • > 200 cm/s
  • PV < 30 cm/s
  • temporal (+) or (-) >50 cm/s
  • “flow conversion”-PV away from shunt
  • new/increased ascites (indir sgx)
196
Q

where is TIPS stenosis

A
  • usually hepatic v or TIPS tract

- >12 mmHg

197
Q

How to treat TIPS occlusion, flow limited stenosis, severe encephalopathy

A
  • occlusion-thrombolysis + angioplasty
  • flow limited stenosis- angioplasty
  • TIPS reduction
198
Q

TIPS induced hepatic encephalopathy

A
  • gradient too low

- add stent

199
Q

peritoneovenous shunt

A

alternative to TIPS for refractory ascites

  • ascites –> jug v
    • inf, thrombosis
200
Q

balloon occluded retrograde transverse obliteration (BRTO)

A
  • aims to drive blood into liver (to help w/ se’s of extra hepatic shunting)
  • gastro-renal shunt required: access –> venogram –> sclerosed gastric varices
  • improves hepatic encephalopathy
201
Q

mc side effect and compls of BRTO

A
  • MC SE: hematuria

- compl: worsening es varices & ascites

202
Q

biliary duct variants

A
  • right pst duct drains into left duct

- trifurcation

203
Q

where to stick when placing biliary drain/cholangiogramx

A
  • R side: r flank/mid axillary line below 10th rib.

- left: substernal/subxyphoid

204
Q

purpose of punching additional hole in proximal biliary drain

A

ensure drainage

205
Q

benefit of internal/external biliary drain vs straight drain or pigtail

A

cross lesions. stable. conversion to internal

206
Q

benefit of internal biliary drain

A

-save bile salts

207
Q

ascites in setting of biliary drain placement

A
  • excessive: drain

- small: eval with US. If up against peritoneum–> R side. If not, L side

208
Q

Right approach biliary drain w/o filling left ducts

A

R side up (unless known obstruction)

209
Q

full rigor after injection in setting of PTC

A

cholangitis-aggressive resus, place drain, ICU

210
Q

next step: you encounter stones during PTC

A

-dilute to 200-240 mg/mL to avoid obscuring filling defects

211
Q

next step: can’t cross obs in setting of biliary drain

A

-place drain, let cool down (48 hrs)

212
Q

cholecystostmy routes

A
  • transperitoneal-less stable (more spillage)

- transhepatic (segm 5 and 6; transverse the bare area)

213
Q

managing bile leak

A

tube in ducts

214
Q

chilaiditi syndrome

A

bowel interposed in front of liver/gb. ?CI to PC

215
Q

PC length of time

A
  • 2wks (bile leak)
  • cholangiogram to confirm cystic duct patent.
  • clamp 48 hrs
216
Q

fine need aspiration needle size

A

21 or 22G

217
Q

targeting a peripheral liver lesion for bx

A

-2-3 cm normal liver first (bleed)

218
Q

kehr sign

A

shoulder pain >5 mins after liver bx, sugg bleed

219
Q

indication transjug liver biopsy

A
  • severe coagulopathy
  • massive asites
  • massive obesity
  • mechanic ven
  • need for additive vascular procedures (TIPS)
  • failed prior precut attempt
220
Q

added benefit of transjug liver bx

A

-measure hepatic venous P

221
Q

indications hepatic embo in setting of trauma

A
  • con’t hem, borderline stable post resus
  • failed surgical attempt
  • rebleed
  • aneurysm, AVF (don’t have to be actively bleeding!)
222
Q

problem with massive non-selective hepatic a embo?

A

liver abscess (already common after injury)

223
Q

risk of coils in PA sac

A
  • late rupture

- goal: distal and prox parent vess (“sandwich tech”)-distal first!

224
Q

why can hepatic PAs be treated at site of injury

A

bc not end arteries (no collaterals)

-use sandwich tech

225
Q

focal vs mult bleeding sites in setting of splenic rupture

A
  • focal embo

- mult: amplatzer plug in splenic a prox to short gastric a’s (slows flow –> clot)

226
Q

HCC rx

A
  • tace
  • rfa
  • tace + RFA
  • Y90
227
Q

liver tx indications

A
  • <65 yo

- limited tumor burden (1 tumor 5cm(-) or up to 3 tumors < 3cm)

228
Q

TACE composition

A

-chemo + lipiodol. followed w/ particle embo

229
Q

absolute CI to TACE

A

decompensated liver fx

+/- PV thrombosis (if sufficient septic collateral flow)

230
Q

who’s at risk for biliary abscess in setting of tace

A
  • biliary stent
  • px sphincterotomy
  • pst Whipple
231
Q

“sterile cholecystitis” or “chemical cholecysitic” in setting of TACE

A

injected prox to cystic a

232
Q

who does better: tace or systemic chemo

A

TACE

233
Q

where do people get skin burns in setting of TACE

A

left back via RAO camera angle

234
Q

RFA in HCC

A
  • HCC + colorectal mets

- heating to 60˚C

235
Q

TACE + RFA

A

HCC lesions > 3cm do better than either alone

236
Q

prethreapy w/u for Y-90

A

1) Tc-99 MAA to hepatic a –> pulm shunt fraction of >30Gy too much
2) ppx embo R gastric and GDA

237
Q

R gastric a variants

A

proper hepatic or leg heaptic

238
Q

cure vs debulking

A

cure < 4cm

debulking > 4cm

239
Q

RFA target, ie: burn margin size

A

need burn margin 0.5-1 cm

240
Q

CI to RFA

A
  • vascular hilum
  • near gb
  • superficial (near bowel)
241
Q

grounding pad in rfa

A

blanket btw arms/body and btw legs to prevent close circuit arcs/burns

242
Q

hot withdrawal

A

leave rfa probe on while removing probe to burn tract –> decr tumor seeding

243
Q

heat sink

A

lesions near bleed vess 3mm+ treated less bc blood removes heat

244
Q

Temperature limit on RFA

A

100˚C

-if greater: carbonize tissue near probe, reduce electrical conductance

245
Q

post ablation syndrome-when does it start?

A

~2-3 wks after

246
Q

microwave vs RFA

A

microwave. ..
1) generate more power
2) bigger lesions
3) less ablation time
4) less sup to heat sink
5) no ground pad

247
Q

cryoablation

A

compression of argon gas. Thawing is what kills the cancer

-probe placement –> bx –> rx

248
Q

cryoablation vs RFA

A

Cryo…

  • hurts less (less sedation)
  • (+) bleeding-bc not ablating small vess
249
Q

“residual tumor”/”incomplete treatment” vs “recurrent tumor”

A
  • focal enh on 1st post-rx study

- recurrent: new from 1st post rx study

250
Q

expected tumor size change s/p RFA

A
  • 4 wks-bigger (reactive edema, etc)
  • 3 mo-same size
  • 6 mo-smaller
  • if residual: repeat rx (assuming no CI)
251
Q

benign periablational enhacement-what is it, what’s it look like?

A

expected post RFA enh around periphery of ablation zone. Smooth, uniform, concentric

252
Q

TACE post treatment CT

A
  • lipiodiol: denser :). beam hardening a problem.

- zone of ablation

253
Q

cryoablation treatment resp-f/u timeframe, app on CT/MR, size change

A

3 mo, 6 mo, 12 mo

  • ablation spot lower density to kidney OR T2 (-), T1 ~/+
  • size: incr –> same –> smaller
254
Q

methods for G tube placement

A

1) radiographically inserted

2) perioral route

255
Q

radiographically inserted G tube proceure

A
  • cup of barium night before to outline colon
  • drain ascites if present
  • target: left of midline (ie: lat to rectus m to avoid inferior epigastric)
  • mid to distal body. equal distance from greater to lesser curves (avoids Arties)

1) NG tube. inflate until stomach against wall
2) spear, secure gastric body to wall w/ 4 “t-tacks”
3) spear –> wire –> dilate
4) remove t-tacks s/p 3-6 wks

*12-hrs fasting post placement

256
Q

most pst portion of stomach

A

cardia

257
Q

perioral g tube placement

A

stab stomach –> treat wire up es –> grab wire, slip tube over it, advance into stomach all the way out stabbed hole

258
Q

esophageal stent-ideal length

A

length 2 cm longer than lesion on each side

  • oral contrast to outline lesion
  • amplatz sire in stomach
  • pre-stent angioplasty up to 2mm to invoke coughing/stridor if tumor near carina
  • if tumor in upper 1/3-avoid larynx
  • endoscopy or smaller device

-remove stent if dropped into stomach and pt syx

259
Q

esophageal stent occlusion-causes (acute vs chronic), next steps

A
  • acute: food impaction.
  • chronic: tumor progr

-esophagram –> endoscopy –> 2nd stent

260
Q

pseudo v sign

A

active GI bleed

  • angiography appearance of v created by contrast pooling in gastric rug or mucosal intestinal fold
  • persists beyond venous phase
261
Q

Dieulafoys lesion

A

monster artery in submucosa of stomach, tears on pulsation, bleed a lot

  • lesser curvature
  • clips or embo
262
Q

cause of pancreatic arcade bleeding aneurysm

A

celiac artery stenosis

263
Q

celiac a compression (median arcuate lig) association

A
  • pancreatic duodenal arcades via celiac stenosis

- filling of dilated pancreatic duo collateral system and retrograde filing of hepatic a on injection in SMA

264
Q

bleeding rate perceivable by bleeding scan, CTA, angiography

A
  • bleeding scan: 0.1 mL/min
  • CTA: 0.4 mL/min
  • angriography: 1mL/min
265
Q

obscure GI bleed

A

small bowel (AVM)

  • CTA and capsule endoscopy most appropriate
  • Tc-99m RBC scan reasonable alternative (active bleed)
266
Q

left vs right sided lower GI bleed

A
  • left: diverticulosis

- R: angiodysplasia (early draining v)

267
Q

mx angiodysplasia

A

-embo rarely stops it, easily recur. need surgery

268
Q

findings angiodysplasia

A

1) early filling v (45 s)
2) dilated tortuous slow emptying intramural v
3) vascular tufts/nodular opacities on arterial phase

269
Q

meckel’s on Meckel’s scan

A

-feeding artery (vitelline): extension beyond mesenteric border, no side branches, cork screw at terminal portion

270
Q

“provacative angiography”

A

Provocative mesenteric angiography is the use of thrombolytic, vasodilating, and anticoagulation medications to elicit active bleeding from a
source that may have recently ceased
hemorrhaging

nitro 100-200 mcg or tPA 4mg

271
Q

IR rx options for gi bleed

A
  • microcoils- precise and can see them. Inab to advance micro-cash peripherally is mcc fx
  • PVA particles (300-500µm) - flow directed. Less control
  • EtOH for lower GI (bowel necrosis)
272
Q

role of vasopressin in GI bleed

A
  • vasoconstrictor. High re-bleed rates
  • no superselection
  • non-occlusive mesenteric ischemia (NOMI)
273
Q

when to not use vasopressin

A
  • large artery
  • dual blood supply
  • sev CAD, HTN, dysrhythmia
  • s/p embolotherapy rx (risk bowel infarct)
274
Q

purpose of post embo angiography

A
  • collateral flow

ex: SMA run to look at inferior pancreaticoduodenal s/p GDA embo

275
Q

which part of bowel has highest risk bowel infarct s/p embo?

A

after lig of Trietz (extensive collaterals in UGIB)

276
Q

Techniques for abscess drainage

A

1) trocar: spinal needle & cath adj

2) seldinger-needle–> wire –> dilate –> cath

277
Q

drain size for abscess drainage

A
  • 6-8F-clear fluid
  • 8-10F-thin pus
  • 10-12F-thick pus
  • 12+F-v complex/debris/odorous
278
Q

why shouldn’t you 3way a drain?

A

reduce function

279
Q

steps for abscess drainage

A
  • decompress bladder
  • abx first
  • aspirate prior to leaving drain
280
Q

next step: can’t advance drain into abscess

A

hydrophilic coated

281
Q

flushing vs irrigation

A

-flushing-tube

irrigation-cavity

282
Q

risk of aggressive irrigation

A

bacteremia. Limit volume to less than size of cavity

283
Q

next step: irrigate w/ 20 cc, only get 5 back

A

-stop

284
Q

next step: abscess drainage cath no longer draining.

A

1) confirm loc, kinkage
2) flush/clear obstr w/ guidewire
3) exchange-bigger size

285
Q

mature tract

A

1 wk

286
Q

remove drainage cath

A
  • <10cc/d
  • collection resolved by img
  • no fistula
287
Q

persistent fever s/p abscess drainage

A
  • not draining
  • addition abscess
  • more img
288
Q

next step: drainage of abscess spikes

A
  • fistula

- img w/ fluoro

289
Q

routes for pelvic abscess drainage

A
  • most abscesses are dependent
  • shortest, avoid VAN, dependent (pst, lat), don’t contaminate
  • transabd
  • transgluteal
  • endoluminal- transvag, transrectal (least painful)
290
Q

what to watch out for in transabd approach

A

inf epigastric

291
Q

transgluteal approach

A

avoid: sciatic, gluteal a’s

- through sacrospinous lig, medial, inf to piriformis

292
Q

disadvantages of transgluteal approach

A
  • VAN injry
  • catheter kinkage
  • radiation
293
Q

adv/disadv endluminal drains

A
  • faster drainage

- less stable

294
Q

transvag drains

A
  • lithotomy position
  • 12F (-)
  • nevern <14 yo
295
Q

transrectal drainage

A

for pre-sacral

*prep w/ cleansing enema

296
Q

transgluteal vs transrectal drainage caths

A
  • size-will pt poop it out before it drains

- safety of transgluteal route

297
Q

diverticular abscess drain

A

> 2cm

  • 10F+
  • water seal if gas
298
Q

risk of bx/aspiration echinococcal cysts

A

anaphylaxis

299
Q

hepatic abscess drainage

A

controversial

don’t cross pleura

300
Q

renal abscess-causes, mx

A
  • asc inf, hematogenous
  • <3-5cm-IV abx
  • US guided aspirate/drain: >3-5cm, syx, not responding to iv abx
  • urine leak: PCN
  • well-tolerated, low complication rate, only relative CI is bleeding risk
301
Q

perinephric absess

A

perforation of renal abscess into retroperitoneal space

302
Q

mx urinoma

A

drained if persistent

303
Q

perirenal lymphocele vs urinoma

A

-aspirate and check Cr

304
Q

personal lymphocele mx

A
  • recurr (makes aspiration difficult)

- sclerose cavity

305
Q

pancreatic fluid collection drainage-indications

A
  • infected
  • ME
  • never if un-infected
306
Q

when pancreatic fluid colls drainage progress from drain to sx

A

if <75%/10 d. “video assisted retroperitoneal debridement”

307
Q

pancreatic cutaneous fistula

A

compl of pancr drain

  • clear fluid–> amylase+
  • ocreotide (synthetic somatostatin), prolonged drainage
308
Q

pancreatic pseudocyst drainage

A
  • transperitoneal (avoids going through stomach twice).

- can’t avoid stomach or known duct communication (ie: needs drain for awhile)-transgastric (drains into stomach)

309
Q

mx pancreatic pseudocyst communicates with duct

A
  • somatostatin to slow down
  • transgastric approach (drains into stomach)
  • 6-8 wks drain
310
Q

PCN indications

A
  • obstr
  • diversion (leak, fistula, refractory hemorrhagic cystitis)
  • dx or therapeutic access-whitaker test, PCNL, stricture dilation/stent
311
Q

absolute CI to PCN

A
  • coagulopathy
  • approach would cross colon, spleen, liver
  • K <7
312
Q

ideal route PCN

A
  • elevate targeted side
  • lower pole (PTX)
  • pstlat 30˚ (brodel’s avascular zone), less angled
  • enter 10 cm from midline (not beyond pst axillary line-risk colon). too medial=paraspinal
  • parenchyma –> CS (otherwise, urine leak)
  • medial –> lateral (avoid aorta/ivc, spine)
313
Q

sticking a dilated vs non dilated collecting system

A
  • dilated: single stick. US guided stick. Fluoro for wire, dilation, tube plcmt
  • non-dilated: double stick. US guided stick, opacify. Fluoro for 2nd stick, etc
  • whole thing under CT also okay
314
Q

PCN on a transplant

A
  • anterolaateral calyx
  • mid/upper pole
  • enter lat to transplant (avoid peritoneum)
315
Q

PCNL-which pole, risks?

A

upper pole access

-tube/hold bigger, (+) risk bleed

316
Q

PCN catheter maintenance

A

-change q2-3mo

317
Q

encrusted tube

A

-hydrophilic wire along side of tube (ie: same tract) to maintain access

318
Q

when/how do you kill ureters

A
  • fistula, urine leak, intractable hemorrhagic cystitis

- sandwich w/ big coils, small in middle

319
Q

indications nephroureteral stent

A
  • long term drainage
  • ureteral stricture (malignant MCC)
  • injury
  • calc undergoing lithotripsy
320
Q

when to place anterograde NUS

A
  • PCN in place

- retrograde failed

321
Q

who should not get NUS

A

-no functional bladder

322
Q

safety PCN

A

ensures functioning double J PCN

-cap –> bring back after 24-48 hrs –> if not obstructed, pull safety

323
Q

suprapubic cystostomy-location

A
  • midline just above pubic symphysis at junction of mid/lower 3rds ant bladder wall
  • –avoids inf epigastric
  • low stick: avoid peritoneum and bowel
  • junction-avoid trigone (which will cause spasm)
324
Q

ideal foley size for long term drainage

A

16F

325
Q

CI to suprapubic cystostomy

A
  • many sx (Scarring)
  • obesity
  • coagulopathy
  • inab to distend bladder
  • inab to displace overlying small bowel
326
Q

indications renal bx

A
  • cancer

- failure

327
Q

alternative to standard renal bx in setting high risk bleed

A

transjugular

328
Q

types of renal bx

A

1) non focal

2) focal

329
Q

non focal renal bx-approach (position, location), complication rate, expected complication

A
  • prone or targeted kidney up
  • lower pole cortex (maximize glomeruli)
  • low complication rate (small AV fistula’s and PAs common but spon’t resolve)
  • some hematuria expected
330
Q

focal renal bx-risk of seeding, position, what to avoid, what to aim for, what to send if concern for lymphoma

A

risk of seeding < 0.01%

  • lat decub, lesion side DOWN (limits resp motion, bowel interposition)
  • don’t cross renal sinus
  • solid pt
  • send for flow cytometery if lymphoma likely
331
Q

why is ASA held for 5?

A

half life=8-10d

-normal marrow will replenish 30-50% platelets w/I 4 d of withholding

332
Q

indications renal RFA

A
  • RCCs
  • AML
  • AVM
  • superficial lesions (avoid scarring CS). Pyeloperfusion techniques (cold D5W irrigating the ureter) can be done to protect
333
Q

renal cryoablation

A

-lesions close to CS

334
Q

img appearance recurr/residual dx s/p renal RFA

A

1) increased size s/p 1-2 mo (if <3cm, larger should NOT grow)
2) nod/cresc enh
3) new or enlarging T2+

335
Q

renal arteriography projection

A

LAO

-“non selective” to assess number of arteries feeding

336
Q

mx atherosclerosis at renal ostium

A
  • mx-1st line

- angio + stent

337
Q

mx FMD-pressure gradient, when to stent, when to sx, meds

A
  • P gradient distal renal/aorta < 0.9, 10%.
  • angio (no stent). upgrade until P gradient gone
  • stent if complication-dissection, rupture
  • sx-arterial bifurcation, complex aneurysm
  • mx: ASA 75-100mg qd, ace=in/arb
  • walnuts
338
Q

risks and ppx mx of renal angioplasty

A
  • thrombosis (heparin during procedure. ASA day before and qd/6 mo
  • spasm-ccb
339
Q

next step: arterial trauma from nephrostomy tube plcmt

A

remove tube over wire, check again

340
Q

mx renal aneurysms

A
  • small segmental-coil

- main renal-stent

341
Q

complications chest tube

A
  • ptx=mc
  • reexpansion pulm edema
  • bronchopleural fistula-air in pleur-eval chamber
342
Q

choice of chest tube drainage cath size

A
  • empyema: 12-14F inpatient, 10F outpatient

- malignant eff: 14F inpatient, 15.5 pleurx outpatient

343
Q

lung tumor rfa-when, compl, adv

A
  • 1.5-5.2 cm diameter
  • PTX=mc complc
  • reserves pulm function
344
Q

what makes you think cancer after lung RFA

A 
-nodular inch >10 mm
central enh
-growth of RFA zone after 3 mo, (6 mo=definite)
-(+) metabolic act s/p 2 mo
-residual act centrally
345
Q

lung bx-where to avoid

A
  • lower zone (resp motion)
  • lingula (cardiac motion)
  • vess >5mm
  • fissures (PTX)
346
Q

shock wave injury

A

vessels injured just lateral and distal to tip of bx gun

347
Q

how to reduce risk of PTX post bx

A
  • enter lung 90˚ to pleural surface
  • avoid interlobular fissure
  • puncture side down after procedure
  • no talking/deep breathing fo 2 hrs
  • anti-tussive/reschedule if cougher
348
Q

“non-specific lung core bx results”

A

-repeat bx

349
Q

when to place a chest tube after causing a PTX after biopsy

A
  • ptx >2cm
  • ptx enlarging
  • pt short of breath
  • aspirated >650 cc air
350
Q

pigtail placement after causing ptx s/p bx

A
  • 6-10F catheter (larger if fluid)
  • triangle of safety–above 5th intercostal space, mid ax line (thinned m)
  • heimlich valve-ambulatory
  • remove s/p 1-2 d
351
Q

next step: water seal chamber not fluctuating with resp or coughing

A
  • lung fully expanded OR tube clogged

- cxr

352
Q

next step: air bubbles in water seal chamber

A
  • expected after initial insertion w/ resolving PTX
  • new or persistent=problem
  • CXR, check bandage, bronchopleural fistula
353
Q

cause of subq emphysema

A

side holes not all in pleural space

354
Q

indications pulmonary ateriography

A
  • dx/rx PE

- pulm AVM

355
Q

pulm angiography procedure

A
  • grollman catheter=preshaped 7F
  • RV, turn 180˚, adv into outflow tract
  • measure P before injecting contrast (may want to reduce contrast burden)
356
Q

pulm angiography relative Ci

A
  • pulm HTN w/ RHP >70/20. Use low osmolar agent and inject into R or L PA
  • LBBB-ppx pacing
357
Q

next step: heart dysrhythmia during pulm angiograpy

A

reposition catheter/wire

358
Q

mx massive pe (ie: hypoTN)

A
  • thrombolysis
  • thromboaspiration
  • mechanical clot fragmentation
  • stent
359
Q

mc bronchial vascular variation

A

-intercostobronchial trunk on right and two bronchial arteries on L

360
Q

where do most bronchial arteries arise?

A

T5-T6

361
Q

mx rasmussen aneurysm

A

-coils (exception to rule of not using coils on bronchial a’s)

362
Q

where does adamkiewicz org?

A

L pst intercostal a (btw T9-12)

-5% from R bronchus

363
Q

which is emergent?: acute vs chronic SVC occlusion

A

-emergent vs not (collaterals)

364
Q

mx mal vs nonmal causes SVC syndrome

A
  • mal: lyse –> angioplasty –> stent
  • non mal: angioplasty –> stent if P gradient still present, ie: collateral v’s remain
  • no self-expanding stents-will migrate
  • watch pericardium, ext to bottom part of svc
365
Q

which fibroids have poor and good resp to embo

A
  • degenerated: poor
  • cellular: :)

-small > large

submucosal > intramural > serosal > cervical (diff bs)

366
Q

mx: intracavitary fibroids < 3cm

A

GYN hystero resection. IR if fail

367
Q

mx: large serosal fibroid, pt wants to be pregn, no hx of prior myomectomy

A

GYN for myomectomy

368
Q

mx pedunculated serosal fibroid

A

GYN for resection

369
Q

mx broad lig fibroid

A

-don’t do well w/ UAE and technically challenging to operate on

370
Q

what to do in setting of gonadotropic releasing mx

A

-stop for 3 mo (shrink uterine a’s)

371
Q

compls UAE

A
  • premature meno 5%
  • dvt/pe 5%
  • post embo syndrome
372
Q

embo material in UAE

A
  • particles (500-700 µm or 700-900)

- pp hem/vag bleed: gel foam, glue

373
Q

UAE for adenomyosis

A
  • smaller particles
  • good for syx relief
  • recur 50% ~2yrs
374
Q

what’s embolized in setting UAE

A

BL uterine a’s

375
Q

ideal time for hysterosalpingogram

A

proliferative phase (7-14d)-endom thinnest

376
Q

FP hystero

A
  • sedative, narcotic, tubal spasm
  • air bubble (FP filling defect)
  • intravasation-contrast flows into venous or lymphatic system bc you pushed too hard (or obstruction).
377
Q

Fallopian tube recanalization-options

A
  • prox/interstitial-endoscope OR fluoro guided wire

- distal-sx

378
Q

steps for fluoro guided fallopian tube recanalization

A
  • follicular/proliferative phase
  • repeat HSG-confirm tube still clogged
  • selective salpingography. hydrophilic 0.035 or 0.018 wire
  • repeat hsg
379
Q

HSG CI

A

pregn. recent uterine or tubal pregn.

active pelvic inf

380
Q

indications for varicocele rx

A

1) infertility
2) testicular atrophy
3) pain

381
Q

drainage testicles

A

-papiniform plexus/spermatic venous plexus –> internal spermatic v at femoral head –> IVC (if R), left renal (if L)

382
Q

causes of varicocele

A

1) right angle entry of v
2) nutcracker (compression L renal v btw SMA and aorta)
3) obstruction

383
Q

mx varicocele

A

enter renal v, check for reflux

-get in goal v, embolism (foam) close to varicocele, drop coils on way out (amplatzer or occlusion device)

384
Q

lymphangiogram

A
  • 0.5 cc methylene blue dye btw toes BL –> 30 mins –> cannulate 27 or 30 g lymphangiography needle
  • inject lipiodol (only 20 mL otherwise risk oil pneumonitis)
  • spot film until see cisternal chili (sac at bottom of thoracic duct)
  • puncture cc, select thoracic duct, emb w/ coil
385
Q

risk of peritonitis with HSG

A

1%

386
Q

indications vertebroplasty

A
  • acute to subacute fx w/ pain refractory mx

- unstable fx w/ ass risk if further collapse occ

387
Q

CI to vertebroplasty

A
  • fx ass w/ spinal canal compression

- pain improving

388
Q

risk vertebroplasty

A
  • new fx 25%
  • cement embo to lungs
  • local neuro complication 5%
389
Q

standing waves

A

angiographic phenomenon resulting in ringed layering of contrast. symmetric, evenly spaced.
-FMD: irregular, asymm

390
Q

oblique views in IR

A

defined by side of image intensifier (not dir of x ray beam)

  • RAO: II on R ant of pt (not an LPO)
  • LAO: II on L ant of pt
391
Q

durant’s maneuver

A

left lateral decubitus + head down positioning (trendelenburg)
-in setting of air embo

392
Q

how needle will look when tilting table toward head or feet:

A

head: superficial needle looks shorter, deep needle looks longer
feet: vice versa

393
Q

half life tpa

A

2-10 min

394
Q

ideal placement for piccs

A

basilic > brachial > cephalic (Alphabetical order)

395
Q

absolute CI to line placement

A
  • cellulitis, allergy

- Rel CI: coagulopathy, CV/occlusion, PICC in CKD or CRF

396
Q

how many AV fistula’s fail to mature

A

30-50%

397
Q

AV fistula “mature” rule of 6

A 
*Vein big enough/arterialized for high flow P 
> 600 mL/min
>0.6 cm diam
< 0.6 cm depth
6 wks
398
Q

preferred AV fistula sites

A

1) radial a –> cephalic v; preferred. (-) maturation; stenosis @ juxtaanastomotic segm
2) brachial a –> brachiocephalic v- 2nd preferred; (+) DASS; precludes future forearm first
3) brachial a –> brachiobasilic (if cephalic v unsuitable; tech diff (2 stage sz), (+) DASS, stenosis @ prox swing segm)

399
Q

suitable anatomy for AVF

A

a > 2mm diam, v > 2.5 mm

400
Q

when would you use AV graft over fistula

A

-if unsuitable anatomy for AVF

401
Q

where are av grafts placed?

A

forearm > UE > groin

402
Q

mcc fistula non arterialization

A

arterial inflow stenosis (doesn’t allow dilation & arterialization of fistula)

403
Q

pulsatile, ø thrill vs weak pulse, weak thrill vs pulseless

high access recirculation at dialysis

A

venous outflow obstruction
arterial inflow stenosis
thrombosis

venous outflow stenosis

404
Q

outflow vs inflow stenosis

A
  • outflow: aneurysmal dil of access, arm/face swelling, prolonged bleeding, tense/pulsatile access, (+) VP
  • inflow: flat/nonvisualize/easily collapsible fistula; difficult cannulation; no thrill or bruit
405
Q

indications of av fistula repair

A

1) stenosis=MC
2) failed maturation
3) DASS (Grades I, ii)
4) thrombus

406
Q

pre-procedural doppler evaluation

A

1) feeding a-low res
2) arterial anastomosis-N to be turbulent. PSV > 400 cm/s or >3x feeding a=stenosis
3) v OF-pulsatile, low res; 2-3x adj v=stenosis
4) central v

407
Q

when to use abx in ir procedures

A

1) clean contaminated-respiratory, alimentary, GU tract
2) purposeful infarction of tissue
3) sometimes/often new devices (stent grafts, vertebral augmentation.

408
Q

standard doses for moderate sedation. Reversal agents?

A

-midazolam 1g + fentanyl 50µg

Naloxone is the opiate reversal, with a typical first doe of 0.2mg, which can be repeated. Flumazenil reverses benzodiazepine with a typical first dose of 0.2mg.

409
Q

standard injection rate for main PA in pulmonary angiography

A

25cc/s for 50 total

410
Q

“high risk” procedure regarding coagulopathy

A

-new holes in vascular organs, ie: kidney, liver

411
Q

“NPO”

A

clears for 2 hrs

-solids for 6hrs

412
Q

how much epinephrine do you give in anaphylaxis

A

0.3 mL of 1mg/mL IM OR 2mL of 1mg/10mL (0.1mg/mL) IV (slow flush)

413
Q

reason to call on-call attending overnight

A
  • uncontrolled bleeding
  • infected obstructed viscus
  • PIE
414
Q

appearance of various causes GI bleed on angiography

A
  • pool of contrast=active extrav
  • ill defined enhancing lesion= tumor blush
  • tuft of vessels & draining vein= angiodysplasia/AVM
415
Q

wedge hepatic pressure=

A

trans-sinusoidal portal venous pressure

416
Q

definition of portal HTN

A

wedge hepatic P - RA P = > 6mmHg

417
Q

significance of elevated free hepatic P and R atrial P (>5 mmHg)

A

hepatic veno-occlusive dx

418
Q

best mx of iliac and visceral stenoses?

A

-balloon expandable stents

419
Q

basic injection rates and volumes

A 
aortogram: 20 for 30
abdominal aorta: 20 for 20
IVC: 20 for 30
mesenteric a: 5 for 25
renal artery: 5 for 15
distal artery: 3 for 12
420
Q

dilating force/hoop stress (T) equation

A

Diameter x Pressure

421
Q

nominal pressure

A

pressure whereby balloon reaches stated diameter
-non compliant balloons by definition do not dilate significantly beyond their stated diameter (even at pressures much greater than nominal.)

422
Q

common injection rates: thoracic aorta, abdominal aorta, abdominal aortic bifurcation/iliac arteries, femoropopliteal arteries, celiac/SMA, main pulmonary artery, selective right or left pulmonary artery, IVC

A
  • thoracic aorta: 20 mL/s
  • abdominal aorta: 15 mL/s
  • abdominal aortic bifurcation/iliac a’s: 5-10 mL/s
  • femoropopliteal a’s: 4-6 mL/s
  • celeac/SMA: 4-6 mL/s
  • main pulmonary a: 20 mL/s
  • selective R or L pulmonary a: 10 mL/s
  • IVC: 10-20 mL/s
423
Q

when would prolonged power injection be carried out?

A
  • opacify large vascular bed
  • detect small or peripheral bleed
  • study venous outflow of organ
424
Q

empiric vs weight-based heparin dose

A
  • empiric: 5000u –> 1000u after each additional hour

- weight-based: 50-100 u/kg

425
Q

ACT goal for therapeutic anticoagulation

A

1.5-2.5x baseline (if no baseline available, use ACT >200s)

426
Q

What size wire will an 18g and 21g needle accept?

A
  • 21g: 0.018” to 0.021” wire

- 18g: .035” to 0.038” wire

427
Q

When and how much albumin to give during paracentesis

A

6-8 g/L if >5L fluid taken off

428
Q

life expectancy for which external drains may be left in place

A

<3 mo

429
Q

standing waves vs FMD

A

standing wave - long segm and symm/uniform

430
Q

implication of CO2 low viscosity

A
  • rapid diffusion-elucidate subtle findings (small hemorrhages, endoleaks, collateral vessels)
  • retrograde opacify vascular structure across capillary or sinusoidal bed
431
Q

course of uterine a

A
  • internal iliac anterior division –> course medially

- initial descending –> transverse –> ascending

432
Q

when are embolic protection devices used?

A

carotid and lower extremity arteries

433
Q

moderate sedation agents

A
  • opiate (pain)-fentanyl 25-100 mcg
  • benzo (anxiolytic)-midazolam 0.5-2mg
  • short acting ==> 30-60 min procedures
434
Q

best view to evaluate arch and great vessels

A

LAO (patient is RPO)

RAO is good for brachiocephalic bifurcation

435
Q

projections for common iliac and common femoral arterial bifurcations

A

CL oblique

IL oblique

436
Q

vertebral augmentation

A
  • vertebroplasty-percutaneous injection of cement (polymathy methacrylate) into vertebral body
  • kyphoplasty-adjunctive balloon inflation in VB for additional cement injection –> restore height
437
Q

CI to vertebral augmentation

A

bony retropulsion from fracture

438
Q

course of thoracic duct

A

cisterna chyli at thoracolumbar junction (just right of ml) –> ascend thorax just left of ml –> L IJV (where subclavian joins)

439
Q

agents used in thoracic duct embo

A
  • coils

- nBCA glue: lipiodol mixture

440
Q

MC indication thoracic duct embo

A

trauma or iatrogenic duct injury

441
Q

mx thoracic duct embo

A
  • conservative (low fat diet, TPN, ocreotide infusion, tube)
  • percut embo
  • sx
442
Q

ideal arteriotomy site for LE work

A

middle 1/3 femoral head

443
Q

middle colic a course

A

-ext ~cm then branch in a T configuration –> R & L branches along transverse colon –> anastomose w/ R an L colic arteries –> marginal a of colon

444
Q

when is vasopressin used?

A

GI bleed (vasoconstrictor)

445
Q

hepatic a vs portal v vs hepatic v vs bile ducts

A
  • hepatic a: small caliber, tortuous, branch peripherally. Pulsatile forward flow. +/- cystic a
  • portal v: straighter, larger; slow con’t flow. +/- periumbilical v/varix
  • hepatic v: flow toward IVC, RA
  • bd: slow hepatofugal flow toward hilum; non-dev (left lobe) branches fill later) –> bowel.
446
Q

How long do temporary embolic agents last?

A

days-weeks

447
Q

temporary embolic agents and examples of use

A
  • autologous clot-percutaneous biopsy tract
  • gelatin-traumatic hem, precut bx tract
  • thrombin-percut int of PA
448
Q

permanent embolic agents and ex of use

A
  • metallic coils (pushable, detachable), vascular plugs (covered or uncovered): traumatic vessel injury, GIB, aneurysm/PA occlusion, AVF, pulm AVM embo, sm/large vess occlusion, PV embo
  • particles-benign and mal tumor embo, bronchial and GI hem, PV embo, partial splenic embo
  • liquid (nBCA glue, onyx): vascular malform, TD emo, PV emo, small vess hem (GI/bronchia/inf epigastric), partial splenic embo, aneurysm endoleak embo

radiology (31 decks)

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