IR Flashcards
1 mm = ? Fr
- For hole created add 2Fr.
Of all the variables in the equation, the radius (r) has the greatest impact on the flow. Doubling the internal diameter of the sheath will obviously double its radius. and the flow ir proportional to R to the what power?
r^4
1 mg of protamine sulfate will inactivate approximately
100 units of active heparin
“Five for fifteen” is an injection of
5 mL/s for a total volume of 15 mL.
Common injection rates that one should be familiar with include
Thoracic aorta Abdominal aorta Abdominal aortic bifurcation/iliac arteries Femoropopliteal arteries Celiac/SMA Main pulmonary artery Selective right or left pulmonary artery Inferior vena cava 10 to 20 mL/
Thoracic aorta 20 mL/s
Abdominal aorta 15 mL/s
Abdominal aortic bifurcation/iliac arteries 5 to 10 mL/s
Femoropopliteal arteries 4 to 6 mL/s
Celiac/SMA 4 to 6 mL/s
Main pulmonary artery 20 mL/s***
Selective right or left pulmonary artery 10 mL/s
Inferior vena cava 10 to 20 mL/s
ACT value to define therapeutic anticoagulation
> 200 sec
American Association for the Study of Liver Diseases) recommends an infusion of albumin of ______ of ascites removed for large-volume paracentesis
6 to 8 g/L
large-volume paracentesis is defined as
> 5 L
uncontrolled postpartum hemorrhage can be tx w
catheter-directed particle or gelfoam embolization (avoiding the morbidity of a hysterectomy)
What is a reasonable starting dose for moderate sedation?
Fentanyl 50 mcg; Midazolam 1 mg
Although asymptomatic in most patients, a Kommerell diverticulum has been associated with
dissection and rupture.
Typical indication for vertebroplasty or kyphoplasty. Goal of procedure:
symptomatic compression fracture(s) from underlying osteoporosis or neoplasm.
Pain relief.
Marrow displacement during the procedure can result in
fat emboli syndrome.
Initial conservative management for chyle leak
low-fat diet or total parenteral nutrition, octreotide infusion, and tube drainage of the leak
If the chyle leak is of high output or refractory to conservative measures what can you do?
- Surgical ligation of the thoracic duct (traditional)
- Percutaneous transcatheter embolization of the thoracic duct (and other chyle leaks) (more recent)
To opacify the draining branches to the superior mesenteric vein and subsequently the main portal vein, a delayed image from injection to ____ should be obtained
SMA
superior hemorrhoidal artery is a branch of the
IMA
After wire and catheter manipulation into a right hepatic artery branch, angiography shows spasm. Appropriate nxt step?
Nitroglycerin infusion
portal vessels tend to be _____ compared to hepatic arteries arteries which are _____
straighter and larger; smaller in caliber and more tortuous as they branch peripherally
Preferred access for PA angio
Venous access via the internal jugular or common femoral veins is preferred.
Normal main pulmonary artery pressure (PAP)
25/10 mmHg with a mean around 15 mmHg.
Pulmonary hypertension is defined as resting mean PAP
> 25 mmHg
Tx for hemangioma to regress
Propanolol
Terms used for hemangiomas that are
fully grown at birth:
appear/grow after birth:
Congenital
Infantile
Characteristics of Venous malformations
- usually a child
- phleboliths
- enlarge over time
- fluid fluid levels
- increased enhacement over time
- Dark on T1 FS
high T2 signal intensity mass with large cystic spaces and thin internal septations. CE images show enhancing thin septations and enhancing periphery
lymphatic malformation
- may grow after birth
- flow voids
- homo enhancement
- T1 iso
what am I?
hemangioma
The most accepted indication for the treatment of a type 2 endoleak is
growth by 5mm
Failure of the stent graft to achieve a circumferential seal. This can occur at the proximal attachment site or distal attachment sites . What type of endoleak?
1a and 1b
Retrograde collateral arterial flow to the aneurysm sac by branch vessels. Most commonly the inferior mesenteric artery or a lumbar artery. What type of endoleak?
2
Leak or separation between stent graft components. Less commonly tear or hole in the stent graft fabric. What type of endoleak?
3 slit
Graft porosity. Identified immediately after stent graft deployment. What type of endoleak?
4 for pores.
Graft porosity. Identified immediately after stent graft deployment. Resolves on its own. What type of endoleak?
4 for pores.
Unknown. By definition, an enlarging aneurysm sac without a demonstrable endoleak. What type of endoleak
five for why?
diminished or absent common femoral artery pulses, buttock claudication, and impotence from severe aortoiliac arterial occlusive disease
Leriche Syndrome
An abrupt onset of pain in a pulseless leg is consistent with
acute limb-threatening ischemia (ALI). This can be due to in situ disease with thrombosis or distant embolus occluding otherwise normal arteries in the leg.
long-segment occlusion, chronic in appearance, with reconstitution distally. Most likely pts presenting symptoms?
Intermittent claudication in the left calf
the time from the original intervention performed to restore vessel patency (SFA recanalization with stenting) until the time that a second intervention is required to treat thrombosis or stenosis.
Primary patency
time from the original intervention performed to restore vessel patency plus additional time gained from a second intervention to keep the vessel patent, such as balloon angioplasty or atherectomy.
Primary assisted patency
Acute limb ischemia symptoms
absent pulse. cool to the touch, pale, and rigid.
Mesenteric arterial pseudoaneurysms management:
Tx: Urgent treatment of any size.
Coil embo prox and distal to pseudoA or stent if seal can be achieved.
PSV of ____ has a high risk of graft thrombosis and requires immediate intervention
> 300cm/sec
When evaluating a patient with symptomatic arterial blockages from Takayasu, which is the most useful piece of info in determining the next step in treatment?
Erythrocyte sedimentation rate (ESR). Avoid intervention w active inflammation.
typically affects younger patients with a history of heavy smoking and involves the small- to medium-sized arteries and veins of the upper and lower extremities. In the lower extremities, the tibial arteries are often affected with multifocal occlusions and formation of collateral arteries with a characteristic “corkscrew” appearance.
Thromboangiitis obliterans or Buerger disease
Provides flow to all three arterial branches through SMA in case of Celiac artery occlusion
GDA
persistent embryonic connection between the celiac and SMA.
The Arc of Buhler
When evaluating a patient with suspected median arcuate ligament syndrome (MALS), which technique will help discern the etiology of the celiac artery stenosis?
Angiogram in lateral view with separate inspiration and expiration injections
the middle and inferior rectal arteries, which are branches from the
ant division of int iliac a.
The rectum receives its blood from the ____ via the superior rectal artery
IMA
contraindication to percutaneous thrombin injection?
infxn of the overlying skin, concomitant arteriovenous fistula, inability to visualize the needle, and/or a short wide neck.
Tx for symptomatic popliteal artery entrapment syndrome (PAES)
surgical reconstruction
Although there is evidence of vascular injury on the initial angiogram in this case, one should not clear the pelvis with
nonselective angiography alone. Bilateral selective internal iliac angiography in multiple obliquities should be performed with quality power injections to completely evaluate the vasculature for injury.
The artery of Adamkiewicz MC arises from ________ in the lower thoracic region.
left intercostal artery
MC involved artery in FMD? Second?
Renal; Extracranial carotid arteries
MC presenting symptom of FMD?
renovascular hypertension**
MC type of FMD
medial fibroplasia
Tx for FMD?
angioplasty alone (responds well) w stents reserved for complications and refractory lesions. **
post traumatic arterial phase images show abnormal round and linear contrast enhancement within the splenic parenchyma with gradual washout w/o pooling or spreading of the abnormal contrast
intra splenic pseudoaneursym**
active bleeding would show increasing accumulation and intrasplenic hematoma
Tx for a hemodynamically stable adult patient with blunt splenic injury and intrasplenic pseudoaneurysm formation?
Proximal main splenic artery embolization with coils** Diminished arterial pressure beyond the embolization site promotes hemostasis and healing of splenic injuries, whereas collateral arterial pathways (pancreatic and gastric) reconstitute the distal splenic artery, maintaining viable perfusion to the splenic parenchyma.
After prox splenig a embo it is (common/uncommon) to see persistent pseudoaneurysm filling after embolization, particularly on early follow-up examinations. No further treatment.
Common
Discrete terminus to the normal-looking artery, with an abnormal wire-thin lumen beyond. On the delayed phase image, there is contrast retention in a relatively larger distal artery segment. This appearance is classic for ….
arterial dissection with dyssynchronous filling of the true (smaller) and false (larger) lumen.
DSA w early arterial filling with lesion being perfused before parenchyma
HCC
densely calcified atherosclerotic plaque throughout the proximal to mid common femoral artery that appears occlusive
Vascular surgery…surgical endarterectomy
most important treatment strategy for Buerger Dx
Cessation of smoking
An abdominal aortic aneurysm is most commonly defined as
aortic diameter >3.0 cm or diameter 1.5x normal.
Prophylactic vs therapeutic contraindications to PE
Pro: Pt has no DVT or prior PE but is at inc risk for many reasons.
Therapeutic: Contraindication to AC, has DVT or has had prior PE.
most common renal venous anomaly (reported prevalence up to 17% of patients)
Circumaortic left renal vein
duplicated IVC is in need of filter placement
suprarenal IVC filter or two IVC filters
Implanting physicians should consider removing retrievable IVC filters when they are no longer medically needed for protection from PE. Ideally between
29-54 days
A chronically occluded jugular vein is_____ in size, often difficult to find, and tends to have a______ thrombus. Also, prominent collaterals are often seen elsewhere.
diminutive; hyperechoic
The echotexture of the vein is heterogeneous with a swirled appearance. This appearance is seen with
slow flow
acute clot would cause what in a vein? And would be?
distention
hypoechoic
prolonged bleeding after needle decannulation,
reduced flow in the circuit and high return pressures on the dialysis machine
inc in pressure 2ndary to outflow obstruction.
May-Thurner tx
angioplasty and self expanding stent
symptomatic left great saphenous venous insufficiency tx
Closure of the left great saphenous vein with endovenous ablation
in the setting of large gauge needle access multiple times a week on a graft what can happen?
graft degeneration with focal contained outpouchings**
focal rupture of the outflow vein with active extravasation after angioplasty management…
angioplasty to obstruct defect, serial angioplasties, stent
Following a period of maturation (typically ____), the fistula venous outflow should have a flow rate of _____mL/min, achieve a diameter of _____ mm, and travel _____ mm from the skin surface.
6-8 wk; >600 mL/min; >6 mm; <6 mm
The rule of 6.
If graft stent is too deep. Management?
surgical revision
Best initial option for cuffed tunneled central venous catheter for hemodialysis
right internal jugular vein (2) left internal jugular vein (3) right external jugular vein (4) left external jugular vein
MegaCava diameter
28mm
just cephalad to the right mainstem bronchus, the catheter deviates medially rather than straight down the SVC to the right atrium. This course is classic for
azygos vein positioning. A lateral image can demonstrate the classic posterior deviation of the catheter.
initial treatment of dialysis access stenosis (minimum stenosis of 50%) is
balloon angioplasty.
severe acute thrombosis with complete blockage of venous drainage and almost a compartment syndrome
Phlegmasia Cerulea Dolens
Tx for phlegmasia cerulea dolens in addition to beginning anticoagulation….
prompt endovascular venous thrombectomy
Paget-Schroetter syndrome management?
- catheter-directed thrombolytic therapy 2. Once venous patency is restored, surgical decompression of the thoracic outlet is performed
Avoid stents***
An alternative approach with similar outcomes is anticoagulation alone followed by surgical decompression of the thoracic outlet, avoiding the risks of tPA.
Once HIT is suspected, providers should ___. How do you confirm this?
discontinue all forms of heparin and switch to an alternative anticoagulation such as bivalirudin.
Confirm with antibody test
Massive hemoptysis
at least 300 mL blood in 24 hours.
Initial management of massive hemoptysis
airway protection with dependent positioning of the bleeding lung, and often intubation and placement of a bronchial blocker on the affected side.
most commonly used first-line embolic agent in bronchial artery embolization for hemoptysis
Permanent particles. They can be sized accordingly, delivered in precise amounts, and mixed with iodinated contrast for visualization.
Active bleeding is virtually never seen angiographically, and embolization should not/should be performed in its absence.
SHOULD
most common etiology for pulmonary artery pseudoaneurysm.
Pulmonary artery catheterization for the purposes of physiologic monitoring and cardiopulmonary evaluation
pulmonary artery pseudoaneurysm management
Coils or plugs prox and distal to pseudoaneu
Patients with cardiac tamponade demonstrate which of the following on echo
cardiac chamber collapse
Clinical practice guidelines from the Society of Vascular Surgery recommend TEVAR over open surgery and over expectant medical management for aortic injury grades…?
II through IV.
Management when pinch-off is identified.
Portacath revision
Catheter-associated fibrin sheath formation can be treated in several ways.
short-duration tPA infusion through the catheter, catheter stripping, and balloon fragmentation of the sheath to be effective in restoring catheter function.
Anything ___ is considered right heart strain.
> 0.9
Hemodynamically unstable patients with a acute PE are considered
high risk. Options for treatment include systemic fibrinolysis with intravenous tPA (or its equivalent), catheter-directed intervention, or surgical embolectomy.
urrent recommendations for PAVM embolization in adults?
When feeding artery diameter is > 2-3mm or pts w smaller but symptomatic.
Both symp and asymp in HHT
Which of the following is the preferred embolic agent for the treatment of PAVM?
Fibered coil
acute SVC thrombosis mayor concern
airway compromise
treatment for malignant SVC syndrome
often external radiation therapy, chemotherapy, and/or endovascular recanalization with stenting.
“vascular blowout” from the left axillary artery management?
the operator must consider whether flow preservation is necessary. If it is… stent
This condition typically affects patients with advanced malignancies that have been previously treated with surgery, radiation, and/or chemotherapy.
Indications to treat a left subclavian artery stenosis?
Symptoms such as arm claudication or vertebrobasilar insufficiency are indications for intervention
ALso, Planning for a left coronary artery bypass graft using the internal thoracic artery
what are manifestations of a complicated aortic dissection?
those with impending rupture or malperfusion of organs such as the spinal cord, viscera, kidneys, or lower extremities.
also refraactory chest pain
It also crosses the pleural surface at an oblique angle, which increases the risk of ____
Other factors are: operator inexperience, lesion size <2 cm, and the presence of underlying chronic obstructive pulmonary disease.
PTX
Indications for chest tube after pneumothorax
symptomatic or growing PTX
There is a real risk of ________ with percutaneous drainage of a lung abscess
bronchopleural fistula. preprocedural consultation with thoracic surgery is strongly recommended.
The mortality rate for reexpansion pulmonary edema
20%
pulmonary artery pseudoaneurysm arising specifically in the setting of a mycobacterial cavitary lesion.
Rasmussen aneurysm
pulm mycotic aneurysm may be treated with
coil
The best initial step if hemoptysis after lung bx->
position the patient biopsy side down.
This position will spare the contralateral lung from aspirated blood, which could further compromise lung aeration and gas exchange.
Cryo, radiofrequency, and microwave thermal ablation have all been utilized in practice. Complication rates vary, with ____ bien a regular ocurrence
PTX
MC presenting symp for air embolism
AMS
Nxt step after air is seen in the ventricle
abort procedure, remove needle, trendelemburg, ( or theoretically R lat decubitus)
