IR Flashcards
femoral arterial access –> needle enter –> at what location on skin?
femoral head –> infmed
femoral arterial access –> needle –> med/lat –> what angle?
45 deg
femoral NAVL –> order?
lat –> med:
- N
- A
- V
- Lymphatic
common femoral A –> begin at what landmark?
inguinal lig
femoral arterial access –> low access –> potential comp?
puncture A & V –> AV fistula
femoral arterial access –> high access –> potential comp?
above pelvic brim –> retroperitoneal hemorrhage
differentiate: pseudoaneurysm –> tx –> watchful wait vs US-guided thrombin injection?
- <1cm: watchful wait
- >1cm: US-guide thrombin inject
AVF –> doppler findings? (3)
- V –> arterial flow
- A –> loss of normal triphasic waveform
- A –> prox to fistula –> inc diastolic flow
venous access procedure –> #1 dangerous part?
catheter –> insert into peel-away sheath
catheter –> insert into peel-away sheath –> pt acute hypoxic –> dx? next step?
air embolism:
- L lat decubitus
- administer 100% O2
lrg air embolism –> possible tx?
aspirate w catheter
angiographic run –> inj rate –> units?
cc/sec for total cc
angiographic run –> inj rate:
- aortic arch
- abd aorta
- IVC
- mesenteric A
- renal A
- distal A
- aortic arch: 20 for 30
- abd aorta: 20 for 20
- IVC: 20 for 30
- mesenteric A: 5 for 25
- renal A: 5 for 15
- distal A: 3 for 12
artery stenosis –> 1st line tx?
perc transluminal angioplasty (PTA)
perc transluminal angioplasty (PTA) –> balloon size –> relative to vessel size?
10-20% lrger than vessel diameter
perc transluminal angioplasty (PTA) –> balloon size –> units?
- diameter (mm)
- length (cm)
perc transluminal angioplasty (PTA) –> comp? (3)
- distal embolus
- vessel rupture
- dissection
stent –> 2 broad types?
- balloon-expandable
- self-expandable
stent –> balloon vs self - expandable –> pro vs con
balloon:
- higher radial force on deploymt
- if crushed –> stay crushed
self:
- more flexible –> more trackable thru vessel
vessels around jts –> preferred stent type?
self-expandable
stent –> what size to use?
- 1-2cm longer than stenosis
- 1-2mm wider than normal vessel lumen
stent size –> oversize by what %?
- arterial stent
- venous
- art –> 10%
- ven –> 20%
stent –> covered –> used for what conditions? (3)
- pseudoaneurysm
- dissection
- TIPS
embolic material –> 2 main categories?
- permanent
- temporary
permanent embolic material? (4)
- coil
- particle
- glue
- sclerosing agent
temporary embolic material? (2)
- gelatin sponge
- autologous clot
embolization coils –> MOA for embolization?
vasc stasis
embolization coils –> pro (2) vs con (1)?
pro:
- precise & quick
- no distal embolization
con:
- lose distal access
bleed –> embolization coils –> general technique? why?
1) coil –> distal to lesion
2) coil –> prox
prevent recurrent bleed from retrograde collaterals
embolic material –> particles –> MOA?
flow distal –> occlude small capillaries
embolization particles (2)?
- trisacyl gelatin microspheres
- polyvinyl alcohol
embolic material –> gelatin sponge (Gelfoam) –> last how long?
2-6wk
embolic material –> gelatin sponge (Gelfoam) –> CT appearance?
embolized organ –> numerous gas locules –> mimic abscess
what is sodium tetradecyl sulfate? use?
sclerosing agent:
- vasc malformation
- varices
what is cyanoacrylate?
glue –> harden when contact blood
embolization –> comp? (2)
- post-embo synd
- non-target embo
what is post-embo synd? when occur after embo?
embo –> tissue infarct –> release endovasc inflamm modulators –> 1day after –> pain, cramp, fever, N/V
post-embo synd –> tx?
- NSAID
- IV fluid
- +/- opioid
what is non-target embolization?
unintentional embo structure other than target
uterine fibroid embo –> non-target embolization site?
ovaries
bronchial A embo –> non-target embolization site? (2)
- brain –> stroke
- spinal A –> paralysis
1 Fr = ? mm
0.33 mm
catheter size –> measured by internal or external diameter?
ext
sheath size –> measured by internal or external diameter?
int (luminal)
catheter –> mult sideholes –> type of catheter?
high flow (flush)
high flow (flush) catheter –> used for what type of angiography?
lrg vessel:
- aorta
- IVC
catheter –> single sidehole –> type of catheter?
- selective
- superselective
catheter –> tip shape?
- C2
- SOS
- Berenstein
- C2: reverse curve
- SOS: reverse curve
- Berenstein: angled
standard wire vs microwire –> size?
- standard –> 0.035”
- micro –> 0.018”
wire –> size? tip type?
- Bentson
- Rosen
- Bentson: standard –> floppy tip
- Rosen: standard –> J-tip
hydrophilic wire –> use? (2)
- cross stenosis
- indwelling device –> routine check & change –> initial cannulation
hydrophilic wire –> 2 examples?
- Roadrunner
- Glidewire
stiff wire –> 1 example?
Amplatz
stiff wire –> use?
require structural rigidity –> ie. dilate subQ tissue:
- sheath
- biliary drain
- nephrostomy tube
giant cell arteritis –> what size vessels are affected?
large & med
giant cell arteritis –> MC location?
UE –> med size A:
- subclavian
- axillary
- brachial
giant cell arteritis –> involve aorta –> T/F?
rarely
giant cell arteritis –> tx?
steroid
SVC –> embryology?
- L ant cardinal V –> regress
- R ant cardinal V –> SVC
L-sided SVC –> embryology?
- L ant cardinal V –> persist
- R ant cardinal V –> regress
L-sided SVC –> drain into –> MC location? rare location?
1 coronary sinus –> RA
rarely: –> LA (R–>L shunt)
duplicated SVC –> embryology?
- L ant cardinal V –> persist
- R ant cardinal V –> persist
SVC synd –> MOA? clinical presentation?
SVC –> acute obstruct – face & UE –> edema, cyanosis
SVC synd –> vasc emergency –> T/F?
T
SVC –> chronic stenosis/occlusion –> ssx?
- asympt
- face edema –> improve w standing
SVC obstruct –> cause? (3)
- thorax malig –> compress SVC
- catheter-assoc thrombosis
- histoplasmosis –> mediastinal fibrosis
SVC obstruct –> CT abd –> classic finding? why?
collateral flow –> vein of Sappey –> hep segmt IVa –> inc enhance
what is V of Sappey?
- region of falc lig –> drain liver
- comm w internal thoracic V (collaterals in SVC occlusion)
pulm angiogram –> pre-proc eval? why?
EKG –> r/o LBBB
pulm A catheter –> can cause temporary RBBB –> LBBB + RBBB –> complete heart block –> can be fatal
pulm angiogram –> pre-proc eval –> EKG –> LBBB –> next step?
place temporary pacer before procedure
normal pressure?
- RA
- RV
- pulm A
- RA: 0-8 mm Hg
- RV: 0-8 dias / 15-30 sys
- pulm A: 3-12 dias / 15-30 sys
mult pulm AVM –> ddx? (1)
hereditary hemorrhagic telangiectasia (HHT) (Osler-Weber-Rendu synd)
hereditary hemorrhagic telangiectasia (HHT) (Osler-Weber-Rendu synd) –> clinical presentation? (3)
- brain abscess
- stroke
- recurrent epistaxis
pulm AVM –> embo –> general procedure?
single feeding A –> coil
limb AVM –> embo –> general procedure?
mult feeding A –> coil entire nidus
pulm AVM –> embo –> contraindicated embo material?
particles –> R-L shunt –> brain emboli –> infarct
pulm AVM –> embo –> indication? (1)
- asympt: feeding A –> >3mm
- sympt –> ie infarct, brain abscess
massive hemoptysis –> definition?
> 300mL/24hr
massive hemoptysis –> prognosis?
very high mortality (asphyxiation)
massive hemoptysis –> 2 MC affected A?
- # 1 bronchial A
- #2 pulm A
massive hemoptysis –> bronchial A normal –> pulm A normal –> next step?
eval:
- subclavian
- internal mamm
- inf phrenic
- celiac
USA –> massive hemoptysis –> MC etiology? (2)
- cystic fibrosis
- thoracic malig
global –> massive hemoptysis –> MC etiology? (2)
- TB
- fungal infx
massive hemoptysis –> MOA?
chronic inflamm –> bronchial A hypertrophy –> hemoptysis
bronchial A –> origin?
thoracic aorta –> T5-6 level
massive hemoptysis –> preferred embo material?
distal embolic agent –> #1 particles
massive hemoptysis –> embo –> general procedure?
- eval for L-R shunt –> prevent inadvertent cerebral embo
- embo to near-stasis
massive hemoptysis –> should not use which embo material? why?
common to rebleed after tx
coils –> prevent repeat access
massive hemoptysis –> embo –> comp?
nontarget embo –> spinal cord:
- ant spinal A –> arise from bronchial A
spine osseous landmark?
- celiac
- SMA
- renal A
- IMA
- celiac: T12
- SMA: T12-L1
- renal A: L1-L2
- IMA : L2-L3 –> L of midline
celiac trunk –> branches?
- L gastric
- common hepatic
- splenic
esophagus –> Mallory-Weiss tear –> possible causative A?
L gastric A
gastroepiploic A –> origin?
- splenic A –> L gastroepiploic
- gastroduodenal A –> R gastroepiploic
what is replaced R hepatic A?
SMA –> R hep A
cystic A –> origin?
R hep A
what is accessory R hep A?
1) proper hep A –> normal R hep A
2) SMA –> access R hep A
replaced R hepatic A –> clinical significance? (3)
- lap chole –> prevent inadvertent A injury
- liver donor –> better anatomosis to recipient
- liver recipient –> small common hep A –> inc arterial comp
replaced L hep A –> origin?
L gastric A
replaced L hep A –> clinical significance? (1)
gastrectomy –> resect replaced L hep A –> predispose to liver injury
SMA –> supplies what?
distal duodenum –> mid-transverse colon
SMA –> branches?
- inf pancreaticoduodenal A
- middle colic A
- R colic A
- ileocolic A
SMA –> R colic A –> supplies what struct?
- R colon
- hep flexure
SMA –> ileocolic A –> supplies what struct?
- terminal ileum
- cecum
- appendix
SMA –> inf pancreaticoduodenal A –> anastomose w what A?
celiac A
SMA –> middle colic A –> anastomose w what A?
marginal A of Drummond
IMA –> branches?
- L colic A
- sigmoid A
- sup rectal (hemorrhoidal) A
internal iliac A –> ant division –> branches?
- inf/middle rectal A
- uterine A
- obturator A
- inf gluteal A
internal iliac A –> post division –> branches?
- lat sacral A
- iliolumbar A
- sup gluteal A
internal iliac A –> ant division –> inf/middle rectal A –> anastomose w what A?
pathway of Winslow –> IMA
internal iliac A –> post division –> iliolumbar A –> anastomose w what A?
deep circumflex iliac A –> external iliac A
ext iliac A –> branches?
- inf epigastric A
- deep circumflex iliac A
- femoral A
ext iliac A –> inf epigastric A –> anastomose w what A?
sup epigastric A
ext iliac A –> deep circumflex iliac A –> anastomose w what A?
iliolumbar A –> int iliac A
what is arc of Buhler?
persistent embryologic remnant –> short segment –> connect celiac & SMA
what is pancreatic cascade?
1) celiac
2) SMA –> inf pancreaticoduodenoal A
collateral network at pancreatic head
what is arc of Barkow?
SMA & celiac anatomosis (via R & L epiploic A)
celiac - SMA anastomoses? (3)
- arc of Butler
- inf pancreaticoduodenal A –> pancreatic cascade
- arc of Barkow
SMA - IMA anastomoses? (3)
- # 1 marginal A of Drummond
- arc of Riolan
- Cannon-Bohn pt
what is Cannon-Bohn pt? clinical sig?
splenic flexure –> pt of transitional blood supply bw SMA & IMA –> watershed zone –> susceptible to ischemia
ext iliac - thoracic aorta anastomosis?
- ext iliac –> inf epigastric A
- thoracic aorta -> internal mammary A
ext iliac - int iliac anastomosis?
- ext iliac –> deep circumflex iliac A
- int iliac –> post div –> iliolumbar A
int iliac - IMA anastomosis?
path of Winslow (rectal arcade)
what is polyarteritis nodosa (PAN)?
systemic necrotizing vasculitis –> small & med A –> mult small visceral aneurysms
mult renal A aneurysms –> ddx? (4)
- polyarteritis nodosa (PAN)
- mult septic emboli
- speed kidney (chronic meth abuse)
- Ehlers-Danlos
polyarteritis nodosa (PAN) –> MC location? (3)
end-arterioles:
- renal
- hep
- mesenteric
polyarteritis nodosa (PAN) –> assoc conditions? (5)
CLASH:
- cryoglobulinemia
- leukemia
- rheum arthritis
- Sjogren synd
- hep B
polyarteritis nodosa (PAN) –> tx?
steroid
MC visceral aneurysm? 2nd MC
#1 splenic A #2 hep A
splenic A aneurysm –> epidemiology? (2)
- multiparous F
- portal HTN
splenic A pseudoaneurysm –> etiology? (2)
- trauma
- pancreatitis
splenic A aneurysm –> indication for tx? (3)
- ssx –> ie. LUQ pain
- > 2.5cm
- expected preg
splenic A aneurysm –> tx?
coil embo
hep A aneurysm –> tx –> embo –> general approach?
embo distal to cystic A
if prox to cystic A –> inc risk for ischemic cholecystitis
liver cirrhosis –> classic IR finding?
hep A branches –> corkscrewing
mesenteric ischemia –> etiology? (4)
- acute A embolus
- chronic A stenosis
- V occlusion
- low-flow state
acute mesenteric ischemia –> MCC?
SMA embolus
acute mesenteric ischemia –> MC tx
surg:
- embolectomy or bypass –> revasc
- direct inspect bowel
- resect necrotic bowel
acute mesenteric ischemia –> SMA embolus –> highest risk of intestinal ischemia –> what location?
distal to middle colic A (few native distal collaterals)
acute mesenteric ischemia –> embolic cause –> no peritoneal signs, no ssx of bowel necrosis –> tx?
endovasc therapy:
- thrombolysis
- suction embolectomy
what is nonocclusive mesenteric ischemia (NOMI)?
mesenteric A –> mult branches –> spasm & narrow –> “intestinal necrosis w patent arterial tree”
nonocclusive mesenteric ischemia (NOMI) –> prognosis?
highly lethal (70-100% mortality)
nonocclusive mesenteric ischemia (NOMI) –> tx?
vasodilator (papaverine) –> direct art infuse
chronic mesenteric ischemia –> MCC?
atherosclerosis
chronic mesenteric ischemia –> how many mesenteric A affected?
at least 2 out of 3
chronic mesenteric ischemia –> tx?
angioplasty & stent
upper GI bleed –> best initial eval?
endoscopy
lower GI bleed –> hemodynamically stable –> best initial eval? why?
localize bleed:
- mesenteric CT angio
- nuc med tagged RBC scan
more sensitive than IR
GI bleed –> detectable bleeding rate?
- tagged RBC scan
- CTA
- IR angiography
- tagged RBC scan: 0.2-0.4 ml/min
CTA: 0.35 - IR angiography: 0.5-1.0
upper GI bleed –> IR –> no visualized extravasation –> next step?
empiric –> embo L gastric A
low GI bleed –> active –> alt IR tx?
vasopressin (antidiuretic hormone) –> intra-art infuse
low GI bleed –> vasopressin (antidiuretic hormone) –> pro vs con?
- useful if bleed from antimesenteric vessels
- stop infuse –> very high rebleed rate
low GI bleed –> vasopressin (antidiuretic hormone) –> AE? (3)
- arrhythmia
- pulm edema
- HTN
low GI bleed –> vasopressin (antidiuretic hormone) –> how long can infuse? why?
24hr
tachyphylaxis (lack of further response)
what is angiodysplasia? clinical sig?
acquired vasc anomaly –> chronic intermittent LGI bleed
angiodysplasia –> MC location? (2)
R colon/cecum
angiodysplasia –> IR appearance?
tangle of vessels –> antimesenteric draining vein –> early fill –> parallel A & V opacify simult –> “tram track” appearance
angiodysplasia –> tx?
endoscopy:
- electrocoag
- laser therapy
- other
older adult –> MCC LGI bleed?
diverticula
differentiate: atherosclerosis –> renal artery stenosis –> tx –> angioplasty + stent vs angioplasty only –> outcome?
angioplasty + stent –> greater long-term patency
what is fibromuscular dysplasia? MC location?
idiopathic –> vasc dz –> renal & carotid A