IR Flashcards

Question

Hydrophilic Guidewires next step quiestion 2

Answer 1

Pretty much any situation where you c an ’t get into a tight spot. This could be a stenotic vessel, or even an abscess cavity.

Answer 2

• Remember Diameter is in INCHES, Length is in CENTIMETERS • 180 cm is the standard length • 260 cm is the long one. These are used if you are working in the upper extremity (from a groin access), working in the visceral circulation and need to exchange catheters, using a guide cath that is longer than 90 cm, through-and-through situation (“body flossing”). • Minimal guidewire length = length of catheter + length of the guidewire in the patient.

Answer 3

A lot o f w ires have pointy ends and soft floppy ends. The floppy ends are usually available in different sizes. The testable point is that the shorter the floppy part the greater the chance o f vessel dissection. For example, a 1 cm floppy tip has a greater risk of dissection compared to a 6 cm floppy tip. The practical tip is to choose a wire with a long floppy tip (unless you are trying to squeeze into a really tight spot).

Answer 4

* Bentson (floppy tip) = Classic guidewire test for acute thrombus lysability * Lunderquist (super stiff) = “The coat hanger.” This thing is pretty much only for aortic stent grafting. * Hydrophilic = Trying to get into a tight spot. Yes a Bentson is also an option, but this is more likely the “read my mind” choice.

Answer 5

Least to greatest Noodle like- bentson Normal - hydrophilic, standard 0.035 or j straight supportive - stiff hyrophilic, heavy duty or j straight stiff - flexfinder, amplatzer stiff or extra stiff, 0.018 platinum plus, v18 shapeale tip hulk smash - lunderquist, backup meier

Answer 6

more dissection

Answer 7

Stiff guidewires should NEVER be steered through even the mildest o f curves. You should always introduce them through a catheter (that was originally placed over a conventional guidewire).

Answer 8

A “J Shaped” Tip supposedly has the advantages o f not digging up plaque and o f missing branch vessels. Often you will see a number associated with the J (example 3 mm, 5 mm, 10 mm, 15 mm e tc ...). This number refers to the radius o f the curve. Small curves miss small branch vessels, larger curves miss larger branch vessels. The classic example is the 15mm curve that can be used to avoid the profunda femoris during the dreaded arterial antegrade stick.

Answer 9

the outer diameter size (in French), the inner diameter size (in INCHES), and the length (in CENTIMETERS). Remember that the outer diameter of a catheter defines it’s size (unlike the sheath which is defined by the inner diameter), and that these sizes are given in French. 4F catheters are very commonly used. 110 and 0.035 are not catheter sizes available for humans existing outside of middle earth. Remember that length of the catheter is given in centimeters. The standard lengths vary from about 45 cm to 125 centimeters. Lastly the inner diameter of a catheter is given in inches and will pair up with the size wire. For example, the largest wire a 0.035 catheter will accommodate is a 0.035.

Answer 10

These things are used to inject contrast into medium and large shaped vessels. This is why y o u ” ll hear them called “flush catheters.” pigtail and straight

Answer 11

These things come in a bunch o f different shapes/angles with the goal o f “selecting” a branch vessel (as the name would imply). Endhole only, side + endholes

Answer 12

For larger vessels this is the main workhorse. It’s called a “pigtail” because the distal end curls up as you retract the wire. This curled morphology keeps it out o f small branch vessels. The catheter has both side and end holes. Q: What might happen if you consistently inject through the pigtail like a pussy? A: All the contrast will go out the proximal side holes and not the tip. Eventually, if you keep flushing like a pansy you will end up with a clot on the tip. Q: What should you do prior to giving it the full on alpha male injection ? A: Give a small test injection to make sure you aren’t in or up against a small branch vessel. Pigtails are for use in medium to large vessels. Q: What if the pigtail fails to form as you retract the wire? A: Push the catheter forward while twisting.

Answer 13

This one doesn’t curl up as you retract the wire. Otherwise, it’s the same as a pigtail with side holes and an end hole. The utility o f this catheter is for smaller vessels (with the caveat that they still need decent flow). The classic location is the iliac.

Answer 14

Hand Injection Only *high flow injection can displace the catheter, or cause dissection Utility = Diagnostic Angiograms and Embolization Procedures

Answer 15

Works fine with Pump Injected runs (can handle a rapid bolus without displacing) Utility = Classic would be a SMA Angiogram NEVER use with Embolotherapy. The fucking coils can get trapped in the sideholes or the particulate matter/mush may go out a side hole and go crush the wrong vessel. “Non-targeted” they call it.

Answer 16

Example = Aortic Arch Vessels “Angled Tip Catheter” Berenstein or Headhunter

Answer 17

Example = Renals, Maybe SMA and Celiac “Curved Catheter” “FtDC” Renal Double Curve, or a “Cobra"

Answer 18

Example = Celiac, SMA, IMA “Recurved” Sidewinder (also called a Simmons), or a “Sos Omni”

Answer 19

For whatever reason Academic Angio guys tend to spaz if residents don’t understand why a “recurve” is different than a regular curved catheter. Basically any curved catheter has a “primary” curve and a “secondary” curve. On a regular curved cath both are in the same direction. However, on a recurved cath the primary goes one way, and the secondary goes the other. These catheters are good for vessels with an obtuse angle. You pull the catheter back to drop into them.

Answer 20

Basically one catheter inside another catheter/sheath. The most basic example would be a catheter inside the lumen of an arterial sheath.

Answer 21

These are large catheters meant to guide up to the desired vessel. Then you can swap them for something more conventional for distal catheterization.

Answer 22

This is another name for a long sheath.

Answer 23

These are little (2-3 French). They are the weapon of choice for tiny vessels (example “super-selection” of peripheral or hepatic branches).

Answer 24

a sheath (plastic tube) + hemostatic valve + side-arm for flushing

Answer 25

typical angio lingo for a run at 20cc/sec for a total o f 30cc.

Answer 26

``` For the purpose o f multiple choice, I ’ll ju st say memorize the chart below. In real life you have to consider a bunch o f factors: catheter size, catheter pressure tolerance, flow dynamics, vessel size, volume o f the distal arterial bed (hand arteries can tolerate less blood displacement compared to something like the spleen), and interest in the venous system (a common concern in mesenteric angiography - hence the relatively increased volumes in the SMA, IMA, and Celiac on the chart). ```

Answer 27

You want to try and displace 1/3 o f the blood per second to get an adequate picture.

Answer 28

Bronchial Artery | Intercostal Artery

Answer 29

``` Carotid subclavian renal femoral IMA ``` *IMA are typically given a higher volumes (15-30ml)

Answer 30

Celiac | SMA

Answer 31

aorta aortic arch ivc pulmonary artery *abdominal aorta has a slightly lower rate (15-20ml/sec) as it is smaller htan the thoracic aorta

Answer 32

The se are de te rmined by the IN T ERN A L diame te r, length, and n umb e r o f size holes. In general, each French size g iv e s you a b o u t 8ml/s. These are the n umber s I would gues s i f forced to on multiple choice. In the real world its (a) written on the pa ckage and (b) a range o f number s 3F = 8 ml/s , 4F = 16 ml/s , 5F = 24 ml/s.

Answer 33

This is used in situations where even the smallest thrombus or air bubble is going to fuck with someone’s go lf game (neuro 1R / cerebral angiograms). The technique is to (1) aspirate the catheter until you get blood in the catheter, then (2) you attach a new clean saline filled syringe and flush.

Answer 34

This is used everywhere else (below the clavicles). The technique is to (1) aspirate until you get about 1 drop o f blood in a saline filled syringe, and (2) tilt the syringe 45 degrees and flush with saline only. What i f you accidentally mixed the blood in with the saline? Discard the syringe and double flush

Answer 35

Hopefully you are just jammed against a side wall. Try pulling back or manipulating the catheter. If that doesn’t work then you have to assume you have a clot. In that case your options are to (1) pull out and clear the clot outside the patient, or (2) blow the clot inside the patient - you would only do this if you are embolizing that location anyway (and a few other situations that are beyond the scope of this exam).

Answer 36

next step = stop. resistance is an angio buzzword for something bad. pull hte wire out and confirm pulsatile flow. reposition the needle if necessary.

Answer 37

Next step = flatten the needle agaisnt the skin. you are asssuming the need to negotiate by a plaque.

Answer 38

nest step = look under fluoro to the confirm the carrect anatomic pathway. if it is normal you could put a 4F sheath in and inject some contrast. after that monkeying around with a hydrophilic wire is the ocnventional answer.

Answer 39

Femoral Artery Access - This is the most common arterial access route. Anatomy review = the external iliac becomes the CFA after it gives o ff the inferior epigastric. The ideal location is over the femoral head (which gives you something to compress against), distal to the inguinal ligament / epigastric artery and proximal to the common femoral bifurcation. * If you stick too high (above inguinal ligament): You risk retroperitoneal bleed * If you stick too low, you risk AV Fistula * If you stick at the bifurcation: You risk occluding branching vessels with your sheath.

Answer 40

* Femoral Artery is dead / unaccessible. * The patient’s abdominal pannus, vagina, or ball sack is really stinky. * Upper limb angioplasty is needed

Answer 41

• Holding pressure is often difficult. Even a small hematoma can lead to medial brachial fascial compartment syndrome (cold fingers, weakness) - and is a surgical emergency which may require fasciotomy. • The risk o f stroke is higher (relative to femoral access), if the catheter has to pass across the great vessels / arch. • A sheath larger than a 7F may require a surgical cut down. • The vessel is smaller and thus more prone to spasm. Some people like to give prophylactic “GTN” - glyceryl trinitrate, to prevent spasm.

Answer 42

* Left Side if headed south (abdominal aorta or lower extremity). * Right Side if headed north (thoracic aorta or cerebral vessels). * All things equal = Left side (it’s usually non-dominant, and avoids the most cerebral vessels). * Blood pressure difference greater than 20 Systolic suggest a stenosis (choose the other arm).

Answer 43

This is also a thing. There are two pieces o f trivia that I think are the most testable about this access type. (1) Bedrest is not required after compression. (2) You need to perform an “Allen Test” prior to puncture. The “Allen Test” confirms collateral flow via the ulnar artery to the hand (just in case you occlude the radial artery). The test is done by manually compressing the radial and ulnar arteries. A pulse ox placed on the middle finger should confirm desaturation. Then you release the ulnar artery and saturation should improve, proving the ulnar artery is feeding the hand.

Answer 44

This was more commonly performed in the dark ages / Cretaceous period. You still see them occasionally done during the full-on thrash that is the typical type 2 endoleak repair.

Answer 45

* The patient has to lay on his/her stomach (for hours!) during these horrible thrashes * Hematoma o f the psoas happens pretty much every case, but is rarely symptomatic. * Known supraceliac aortic aneurysm is a contraindication * Typically “high” access - around the endplate of T12 - is done. Although you can technically go “low” - around L3. * The patient “Self compresses” after the procedure by rolling over onto his/her back. * Complaining about a “mild backache” occurs with literally every one of these cases because they all get a psoas hematoma.

Answer 46

Prior to an arterial stick you have to know some anticoagulation trivia. • Stop the heparin 2 hours prior to procedure (PTT 1.2x o f control or less; normal 25-35 sec) • INR o f 1.5 is the number I'd pick if asked (technically this is in flux) • Stop Coumadin at least 5-7 days prior (vitamin K 25-50 mg IM 4 hours prior, or FFP/ Cryo) • Platelet count should be > 50K (some texts say 75) • Stop ASA/Plavix 5 days prior (according to SIR) • Per the ACR - diagnostic angiography, routine angioplasty, and thrombolysis are considered “ clean procedures.” Therefore, antibiotic prophylaxis is unnecessary.

Answer 47

By the book, you want 15 minutes o f compression. You can typically pull a sheath with an ACT o f <150-180. Heparin can get turned back on 2 hours post (assuming no complications). Groin check and palpate pulses should be on the post procedure nursing orders.

Answer 48

Never used if there is a question o f infection at the access site.

Answer 49

Use the non-dominant arm. The preference is basilic > brachial > cephalic. You do n 't place these in patients with CRF, on dialysis, or maybe going to be on dialysis.

Answer 50

The right IJ is preferred. External jugular veins can be used. Subclavian access is contraindicated in patients with a contraindication to PICC lines. Don’t place any tunneled lines/ports in septic patients (they get temporary lines).

Answer 51

Order o f preference for access: RIJ > LIJ > REJ > LEJ. “Fistula First Breakthrough I n i t i a t i v e is the reason you do n ’t place PICCs in dialysis patients.

Answer 52

The right IJ is the preferred access, because it is the shortest route to the preferred location (the cavoatrial junction). It will thrombose less than the subclavian (and even if it does, you d o n ’t lose drainage from the arm - like you would with a subclavian). Femoral approach is less desirable because the groin is a dirty dirty place.

Answer 53

The word “hypotension” in the clinical vignette after an arterial access should make you think about high sticks / retroperitoneal bleeds.

Answer 54

• Placing an angioplasty balloon across the site o f the bleeding (or inflow) vessel.

Answer 55

- Where dat hole b e? The hole in the skin and the hole in the artery don’t typically line up. • Antegrade Puncture = Below the skin entry point • Antegrade Puncture on a Fatty = Well Below the skin entry point • Retrograde Puncture = Above the skin entry

Answer 56

As described in the vascular chapter, you can get a pseudoaneurysm after a visit to the cardiology cath lab (or other rare causes). A lot o f the time, small ones (< 2 cm) will undergo spontaneous thrombosis. The ones that will typically respond to interventional therapy are those with long narrow necks, and small defects. There are 3 main options for repair: (1) open surgery, (2) direct ultrasound compression, or (3) thrombin injection.

Answer 57

Pain disproportionate to that expected after a percutaneous stick = Get an US to look for a pseudoaneurysm

Answer 58

``` Direct compression o f the neck (if possible avoid compression o f the sac). Enough pressure should be applied to stop flow in the neck. ``` Painful for the Patient (and the Radiologist), can take 20 mins to an hour. Don't compress if it’s above the inguinal ligament.

Answer 59

Needle into apex o f cavity (aim towards the inflow defect) - inject 0.5-1.0 ml (500-1000 units). Do NOT aspirate blood into syringe - will clot. ``` Contraindications: Local infection , Rapid Enlargement, Distal Limb Ischemia, Large Neck (risk for propagation), Pseudoaneurysm cavity size < 1cm. ```

Answer 60

May be needed if thrombin injection fails, there is infection, there is tissue breakdown, or the aneurysm neck is too wide.

Answer 61

Probably a covered stent

Answer 62

Thrombin, then repeat US in 2 days, if not better then repeat

Answer 63

probably a covered stent

Answer 64

compression with us, repeat us in 2 days and repeat if not improved. *Might br worth a try but wide neck reduces the success rate. ``` Surgical *if the neck is very wide (15mm or more), you might consider going straight to surgery ```

Answer 65

repeat us in 1 week. if it got bigger then go to neck size algorithm.

Answer 66

The needle should be placed in the apex of the cavity (tip directed towards the inflow defect).

Answer 67

Orthogonal plane to the neck of the | pseudoaneurysm. Pressure is directed to obliterate flow in the neck / sac.

Answer 68

* Anticoagulation has no effect on thrombin injection treatment - primary success** * Anticoagulation does* increase the risk of recurrence (10%?) after thrombin injection treatment * Anticoagulation is NOT a contraindication to attempting direct compression, although it DOES reduce success rate and most people will tell you to stop them prior to the procedure (if possible). * Failure to respond to thrombin = Occult vascular issue (big puncture site laceration, infection) * Untreated Pseudoaneurysm for greater than 30 days tend to resist compression and thrombin therapy to variable degrees. They do best if treated within 2 weeks. * Attempted compression of a Pseudoaneurysm above the inguinal ligament can cause a RP bleed. It is still safe to try and thrombin inject

Answer 69

The balloon should be big enough to take out the stenosis and stretch the artery (slightly). The ideal balloon dilation is about 10-20% over the normal artery diameter. Most IR guys/gals will claim success if the residual stenosis is less than 30%. Obviously you want the patient anticoagulated, to avoid thrombosis after intimal injury. The typical rule is 1-3 months o f anti-platelets (aspirin, clopidogrel) following a stent.

Answer 70

This is angioplasty first, then stent placement. You want to optimize your result. Stenting after angioplasty usually gives a better result than ju st angioplasty alone (with a few exceptions - notably FMD - to which stenting adds very little). An important idea is that a stent c an 't do anything a balloon can’t. In other words, the stent w o n 't open it any more than the balloon will, it ju st prevents recoil.

Answer 71

good for areas that might get compressed (superficial locations). • Classic Examples = Cervical Carotid or SFA.

Answer 72

good for more precise deployment | • Classic Example = Renal ostium

Answer 73

Vascular stent designs may be categorized as (a) closed-cell - where every stent segment is connected by a link (less flexible, with better radial force) or (b) open-cell in which some stent segment connections are deliberately absent (flexible/ conforms to tortuous vessels, less radial force).

Answer 74

Nitinol is said to have a “thermal memory.’’ It is soft at room temperature, but can become more rigid at body temperature. This is exploited for self expanding stents.

Answer 75

These things have been used for CAD for a while. The purpose o f the “drug” is to retard neointimal hyperplasia.

Answer 76

Balloons should be 10-20% larger than the adjacent normal (non-stenotic) vessel diameter. A sneaky move would be to try and get you to measure a post-stenotic dilation. As a general rule, larger balloons allow for more dilating force but the risk of exploding the vessel or creating a dissection is also increased.

Answer 77

``` Aorta -15 mm Common Iliac - 8mm External Iliac - 7mm CFA, Prox SFA - 6mm Distal SFA - 5mm ```

Answer 78

Stents should be 1-2 cm longer than the stenosis and 1-2 mm wider than the unstenosed vessel lumen

Answer 79

The first thing to do (if possible) is to measure a pressure gradient. If there is no gradient across the lesion, you can still stop and claim victory. If there is a gradient you might be dealing with elastic recoil (the lesion disappeared with inflation, but reappeared after deflation). The next step in this case is to place a stent.

Answer 80

Switch balloons to either a higher pressure rated balloon, or a “cutting balloon.”

Answer 81

First do an angiographic run. If the limb / distal vessels look fine then you don’t need to intervene. If you threatened the limb, then obtain ipsilateral access and go after the clot (“aspiration”).

Answer 82

This is why you always leave the balloon on the wire after angioplasty. If you see extravasation get that balloon back in there quickly, and perform a low pressure insufflation proximal to the rupture to create tamponade. You may need to call vascular surgery (“the real doctors”).

Answer 83

Endo Vascular abdominal aortic Aneurysm Repair. These include the bifurcated iliac systems and unilateral aortic + iliac systems.

Answer 84

Thoracic Endo Vascular aortic Aneurysm Repair.

Answer 85

* 30 Day Mortality is LESS for Endovascular Repair (like 30% less) * Long Term Aneurysm Related Mortality (and total mortality) is the SAME for open vs endovascular repair * Graft Related Complications and Re-interventions are HIGHER with Endovascular Repair

Answer 86

(1) AAA larger than 5 cm (or more than 2x the size o f the normal aorta) (2) AAA growing “rapidly” (more than 0.5 cm in 6 months)

Answer 87

* Proximal landing zone must be: * 10 mm long, * Non- aneurysmal (less than 3.2 cm), * Angled less than 60 degrees.

Answer 88

Tortuosity and Vessel Size are issues for device deployment. The general rules are that you have problems if: • Iliac vessels have an angulation > 90 degrees (especially if heavily calcified) • Iliac artery diameters < 7 mm (may need a cut down and the placement o f a temporary conduit).

Answer 89

Landing sites that won’t allow for aneurysm exclusion Covering a critical artery (IMA in the setting o f known SMA and Celiac occlusion. Accessory renals that are feeding a horseshoe kidney, dominant lumbar arteries feeding the cord).

Answer 90

which is an umbrella term for aneurysms near the renals

Answer 91

Aneurysm that has a “short neck” (proximal landing zone < 1 cm) or one that encroaches on the renals.

Answer 92

Aneurysm that involves the renals and extends into the mesenteries.

Answer 93

Aneurysm that extends from the 12th intercostal space to the iliac bifurcation with involvement o f the origins o f the renal, superior mesenteric, and celiac arteries.

Answer 94

``` The most feared/dreaded (testable) complication o f an aortic stent graft is paraplegia secondary to cord ischemia. You see this most commonly when there is extensive coverage o f the aorta (specifically T9- T12 Adamkiewicz territory), or a previous AAA repair. “Beware o f the hair pinned turn” - famously refers to the morphology o f Adamkiewicz on angiogram. ``` Symptoms o f possible / developing paraplegia post procedure. Next Step = CSF d ra in a g e .

Answer 95

Leak at the top (A) or the bottom (B) o f the graft. They are typically high pressure and require intervention (or the sac will keep growing).

Answer 96

Filling o f the sac via a feeder artery. This is the MOST COMMO N type, and is usually seen after repair o f an abdominal aneurysm. The most likely culprits are the IMA or a Lumbar artery. The majority spontaneously resolve, but some may require treatment. Typically, you follow the sac size and if it grows you treat it.

Answer 97

This is a defect/fracture in the graft. It is usually the result o f pieces not overlapping.

Answer 98

This is from porosity o f the graft. ( “4 is from the P o re”). It’s o f historic significance, and doesn’t happen with modem grafts.

Answer 99

This is endotension. It’s not a true leak and it may be due to pulsation o f the graft wall. Some people d o n ’t believe in these, but I’ve seen them. They are real

Answer 100

The endoleaks that must he emergently treated are the high flow ones - Type 1 an d Type 3. Most IR guys / vascular surgeons (real doctors) will watch a Type 2 for at least a year (as long as it’s not enlarging). Most Type 4s will resolve within 48 hours o f device implantation.

Answer 101

coils (lung AVM)

Answer 102

Gelfoam pledget (trauma)

Answer 103

liquid agent (RCC ablation)

Answer 104

PArticles (fibroid embo)

Answer 105

Microshpere (cheo)

Answer 106

coilds Vascular plugs ( amplatzer)

Answer 107

pva - particles (permanenet) Gelfoam (temporary) Autologous (temporary)

Answer 108

sclerosants | non-sclerosants

Answer 109

These are typically used to permanently occlude a large vessel. They come in all kinds o f different sizes and shapes. You can deploy them with a “push” via a coaxial system, or if you do n ’t need exact precision you can “ chase” them with a saline bolus. It gets complicated and beyond the scope o f the exam (probably), but there are a variety o f strategies for keeping these in place. Just know you can pack these things behind an Amplatzer, or you can use scaffolding techniques to hook small coils to a large one

Answer 110

Accurate Deployment’’ = Detachable Coil

Answer 111

Remember never deploy these with a side-hole + end-hole catheter. You want endhole only for accurate deployment

Answer 112

Never pack coils directly into an arterial pseudoaneurysm sac

Answer 113

``` Coils: Deployed via standard 4-7F catheter Micro: Deployed via Micro- Catheter. If you try and deploy them through a standard cath they can ball up inside the thing and clog it. ```

Answer 114

This is a self expanding wire mesh that is made of Nitinol (thermal memory James Bond shit). You mount this bomb on the end of a delivery device/wire. When deployed it shrinks in length and expands in width.

Answer 115

High Flow Situations, when you want to kill a single large vessel. If you are thinking to yourself - I'm gonna need a bunch of coils to take that beast down the answer is probably an amplatzer plug.

Answer 116

* Temporary: Gelfoam, Autologous Blood Clot | * Permanent: PVA Particles

Answer 117

Situations where you want to block multiple vessels. Classic examples would be fibroids and malignant tumors.

Answer 118

An easy way to ask this would simply be “When do | you stop deploying the agent?

Answer 119

The classic teaching is to stop embolization when the flow becomes “to and fro.” If you continue to pile the particulate agent in until you get total occlusion you risk refluxing the agent into a place you don’t want it to go.

Answer 120

``` Powder causes occlusion at the capillary level (tissue necrosis) Pledgets/Sheets cause occlusion at the arteriole or larger level (tissue infarct is uncommon) ```

Answer 121

In many cases if you can use coils, you can also use appropriately sized particles. Size is one way to pick. Coils are good for medium to small arteries. PVA is good for multiple small arteries or capillaries. Smaller particles (less than 300 microns) are going to risk tissue necrosis in many cases - so if you want to preserve the tissue, th a t’s probably the wrong answer. Another tip for picking between the two is the need for repeat Access. The classic example is the bronchial artery embolization. These things tend to re-bleed. So you should NEVER ever use coils (this will block you from re-accessing). Bronchial artery embolization = Particles (> 325 micrometers).

Answer 122

Test injection to confirm adequate occlusion.

Answer 123

* Sclerosants: Absolute Alcohol (the one that hurts) and Sodium Dodecyl Sulfate (SDS) * Non-Sclerosants: Onyx (Ethylene-Vinyl Alcohol Copolymer) , Ethiodol

Answer 124

As would be expected, the sclerosant agents work by producing near immediate thrombosis /irreversible endothelial destruction. As a result, non-targeted embolization can be fairly devastating. There are three main strategies for not causing a major fuck up (i.e. burning a hole in the dude’s stomach, infarcting his bowel, e tc ...). (1) Knowing the anatomy really well through careful mapping (2) Frequent intermittent angiograms during the embolization procedure (3) Use o f Balloon Occlusion to protect non-target sites.

Answer 125

Aggressively aspirate (with a 60 cc syringe) to make sure all the poison is out o f there.

Answer 126

Typically used for neuro procedure s , h ype rva scula r spine tumor s , shit like that. It drys slowly (outside in) and allows for a s lower, more controlled delivery

Answer 127

This is an oil that blocks vessels at the arteriole level ( same as the really small PVA particles). For some reason, h epa tomas love this stuff, and it will preferentially flow to the hepa toma. It is also unique in that it is radio-opaque , which helps decrease non-targeted emboliz a tion and lets you track tumo r size on follow up.

Answer 128

Post-Traumatic High-Flow Priapism (or Priapism induced by the female Brazilian Olympic volleyball team)

Answer 129

ery) = PVA or microspheres 500-1000

Answer 130

Gel Foam in many cases.

Answer 131

Amplatzer plug in the splenic artery proximal to the short gastric arteries. .

Answer 132

PVA Particles (> 325 pm).

Answer 133

Absolute ethanol

Answer 134

Glue (bucrylate-ethiodized

Answer 135

Covered Stent (or coils after bare metal stent)

Answer 136

Endoscopy First (if that fail then in most cases coils)

Answer 137

Usually Microcoils

Answer 138

coils | amplatz occluder

Answer 139

particles liquid scleorsants thrombin ethiodol

Answer 140

gelfoam pledget/sheet autologous clot

Answer 141

microspheres | gelfoam powder

Answer 142

Pain, nausea, vomiting, and low grade fever - is basically an expected finding. You d o n ’t need to order blood cultures - without other factors to make you consider infection. There is a rule o f 3 days - it starts within the first 3 days, and goes away within 3 days o f starting. The vignette is most classic for a large fibroid embolization, but it’s actually common after a solid organ (e.g. liver) - the tumor ju st needs to be big. Some texts suggest prophylactic use o f anti-pyrexial and antiemetic meds prior to the procedure.

Answer 143

Acute limb ischemia can be secondary to thrombotic or embolic events. Frequent sites for emboli to lodge are the common femoral bifurcation and the popliteal trifurcation. You can also get more distal emboli resulting in the so called blue toe syndrome. As crazy as this may sound to a Radiologist, physical exam is actually used to separate patients into 3 categories: viable, threatened, or irreversible. This chart (or something similar) is how most people triage.

Answer 144

Category - Viable Not Threatened capillary return - intact muscle paralysis - none sensory loss - none arterial doppler - + venous doppler - +

Answer 145

Category - Threatened Salvageable capillary return - intact/slow muscle paralysis - none sensory loss - partial arterial doppler - - benous doppler - +

Answer 146

Category - Threatened Salvageable if immediate intervention capillary return - slow/absent muscle paralysis - partial sensory loss - partial arterial doppler - - benous doppler - +

Answer 147

Category -Irreversible NOT Salvageable *Amputation capillary return - absent muscle paralysis - complete sensory loss - complete arterial doppler - - benous doppler - -

Answer 148

h i s is described as

Answer 149

An important point to realize is that lysis o f a clot only re-establishes the baseline (which was likely bad to start with). So after you do lysis, consider additional therapy (angioplasty, surgery, stenting, e tc ...). If there is combined inflow and outflow disease, you should treat the inflow first (they ju st do better).

Answer 150

If it has been occluded for less than 14 days, thrombolysis is superior, if more than 14 days, (surgery is superior).

Answer 151

``` - Isolated suprainguinal embolism probably should be removed surgically. - Fragmented distal emboli should have endovascular thrombolytic therapy ```

Answer 152

The idea behind the ABI is that you can compare the blood pressure in the upper arm, to that of the ankle and infer a degree of stenosis in the peripheral arteries based on that ratio. In a normal person, ratios are usually slightly greater than 1. In patients with occlusive disease, they will be less than that - with a lower number correlating roughly with the extent o f disease.

Answer 153

1.0 Normal No Symptoms 0.75-0.95 Mild Mild Claudication 0.5-0.75 Moderate Claudication 0.3-0.5 Moderate - Severe Severe Claudication < 0.3 Severe or “Critical” Rest Pain

Answer 154

You take blood pressures in both arms, and both ankles. You only use one o f the arm measurements (the higher one). For the actual ratios, opinions vary on this - most people do it by dividing the higher o f either the dorsalis pedis or posterior tibial systolic pressure (at the ankle) by the higher o f either the right or left arm systolic pressure

Answer 155

``` Arterial calcifications (common in diabetics with calcific medial sclerosis) make compression difficult and can lead to a false elevation o f the ABI. This is when you will see ratios around 1.3 — those are bullshit, means the exam is non-diagnostic. ```

Answer 156

As above, diabetics will have noncompressible vessels - which makes ABIs worthless. What you can do is look at the toe pressure. The reason this works is because the digital arteries are not as affected by this disease process. A normal systolic toe pressure is greater than 50 mm Hg, and the ratio (toe-brachial index) should be more than 0.6. The testable trivia is that i f the toe pressures are less than 30 mm ulcers are less likely to heal.

Answer 157

A modification to the standard ABI involves pressures at the thigh, calf, and ankle — if there is a pressure drop o f more than 20-30 you can infer that this is the level of disease. This allows you to sorta sorta sorta guess where the level of disease is.

Answer 158

The normal pulsatile wave is the result o f the pumping action of the left ventricle transmitted to the aortic root and then to the foot. As the LV contracts you have a jet of blood that dynamically expands the aortic root. As the bolus o f blood travels towards the feet the vessels will continue to expand along the path — like a cartoon snake that has eaten a mouse (or your neighbors cat). The wave falls as the cardiac cycle enters diastole. There is a secondary event which is the rebound off the high resistance tibial vascular tree. This is why the normal wave has an up-down-up look to it — “triphasic” they call it. This bounce back or rebound effect demonstrates normal arterial compliance. As the vessel hardens you lose this. With progressive disease there is less and less compliance to the point where the primary wave barely even stretches the vessel.

Answer 159

* Medial Ankle = Venous Stasis * Dorsum o f Foot = Ischemic or Infected ulcer * Plantar (Sole) Surface o f Foot = Neurotrophic Ulcer

Answer 160

These are “useful” categories and classifications o f | signs and symptoms o f peripheral arterial disease.

Answer 161

``` Arterial calcifications (common in diabetics) make compression difficult and can lead to a false elevation o f the AB1 ```

Answer 162

``` Uninterrupted patency o f the graft with no procedure done on the graft itself (repair o f distal vessels, or vessels at either anastomosis does not count as loss o f primary patency) ```

Answer 163

Patency is never lost, but is maintained by prophylactic | interventions (stricture angioplasty etc..).

Answer 164

Graft patency is lost, but then restored with intervention | thrombectomy, thrombolysis, etc..

Answer 165

First Choice - Ipsilateral CFA. If that is down also | (which it often is). I’d pick the contralateral CFA

Answer 166

Contralateral CFA

Answer 167

Ipsilateral CFA

Answer 168

First Choice - Direct Stick. | Second choice-inflow CFA

Answer 169

Ipsilateral CFA

Answer 170

1. The Ipsilateral CFA is occluded. 2. The patient is very very fat. Even fatter than your normal acute leg patient. These are the guys/gals who got the milkshake (instead o f the diet coke) with the baconator. As a point o f gamesmanship, if the question header specifically mentions that the patient is obese they are likely leading you towards contralateral access.

Answer 171

The nomenclature for a downward (towards the toe) access is | “ antegrade.” The terminology is based on the directions o f the arterial flow.

Answer 172

towards the toes

Answer 173

towards the heart

Answer 174

There are a whole bunch of ways to do this. In the most generic terms, you jam the catheter into the proximal clot and infuse TPA directly into the mother fucker. Every 6-8 hours you check to see if you are making progress. People call that “check angiography.”

Answer 175

If they spell that out in the vignette, they are trying to tell you that this clot is organized and probably won’t clear with thrombolysis.

Answer 176

If they specifically state this, they are describing "lytic stagnation, ” which for most reasonable people is an indication to stop the procedure.

Answer 177

Neuro symptoms in a patient getting TPA should make you think head bleed. Next step would be non-con CT head.

Answer 178

This in the setting of TPA means the patient is bleeding out. Next step would be (1) go to the bedside and look at the site. Assuming he/she isn’t floating in a lake of their own blood (2) CT abdomen/pelvis and probably stopping the TPA

Answer 179

Most people will continue treating till the clot clears. Although continuing past 48 hours is typically bad form.

Answer 180

Just know that “tumescent anesthesia” (lots of diluted subcutaneous lidocaine) is provided for ablation of veins. Veins arc ablated using an endoluminal heat source. A contraindication to catheter-based vein ablation is DVT (they need those superficial veins).

Answer 181

The primary complications of DVT are acute PE and chronic post thrombotic syndrome (PTS). There are several clinical predictive models to keep everyone who comes in the ER from getting a CTPA - “Wells Score” is probably the most famous. Recently described is this “Thrombus Density Ratio” as a superior predictor of PE in patients with known DVT on CTV. The density of thrombus on CTV has been shown to be higher in patients with both DVT and PE relative to just DVT. Thrombus Density Ratio of 46.5 (thrombus HU / normal vein HU) = probable PE.

Answer 182

archaic physical diagnosis terms that are high yield for the exam of the future. Phlegmasia alba = massive DVT, without ischemia and preserved collateral veins. Phlegmasia cerulea dolens = massive DVT, complete thrombosis of the deep venous system, including the collateral circulation. These are described as extreme sequella of May-Thurner - but can occur in any situation where you get a punch of DVT (pregnancy, malignancy, trauma, clogged IVC filter, etc..)

Answer 183

This is basically pain and stuff (venous ulcers) after a DVT. Risk factors include being old (>65), a more proximal DVT, recurrent or persistent DVT, and being fat. PTS is usually diagnosed between 6 months and 2 years after DVT. VEINES-QQL is the scoring system used to diagnose and classify severity of PTS. Catheter-directed intrathrombus lysis of iliofemoral DVT is done to prevent post thrombotic syndrome. This is not needed as much with femoropopliteal DVT as it will recanalize more frequently and have less severe post thrombotic syndrome.

Answer 184

• Proven PE while on adequate anticoagulation • Contraindication to anticoagulation with clot in the femoral or iliac veins • Needing to come o ff anticoagulation - complications. There are a few additional indications that are less firm (basically, we think he/she might get a DVT and we c an ’t anticoagulate).

Answer 185

* Permanent Filters: Do Not Come Out * Retrievable Filters: Can Come Out, But Do Not Have To * Temporary Filter: Come out, and have a component sticking outside the body to aide in retrieval

Answer 186

``` Depending on who bought you lunch (gave you a free pen), thrombosis rates vary. In general (for the purpose of multiple choice) about 10% o f the permanent filters thrombose within 5 years. ```

Answer 187

The device is usually placed infrarenal with a few exceptions (see below chart). Why isn i it always ju s t positioned suprarenal? A supra-renal filter has a theoretic increased risk o f renal vein thrombosis. There is zero evidence behind this - like most things in medicine.

Answer 188

Supra-renal To avoid compression

Answer 189

Supra-renal Get above the clot

Answer 190

Either bilateral iliac, or supra-renal (above the bifurcation) Gotta block them both

Answer 191

Below the lowest renal Risk o f clot by passing filter via the renals

Answer 192

If the IVC is less than 28 mm, then any filter can be placed. If it’s bigger than that, you might need to place a b ird ’s nest type o f filter which can be used up to 40 mm. You can also ju st place bilateral iliac filters.

Answer 193

* A “Gunther Tulip” has a superior end hook for retrieval * A “Simon-Nitinol” has a low profile (7F) and can be placed in smaller veins (like an arm vein). * All filters are MRI compatible

Answer 194

You need to do an angiographic run. Where I trained, the classic pimping question for residents on service was to “name the 4 reasons you do an angiogram prior to filter placement!” The only answer that would not result in “additional training” (more weekend PICC workups) was: 1. Confirm patency o f the IVC 2. Measure the size o f the IVC 3. Confirm that you are dealing with 1 IVC 4. Document the position o f the renal veins

Answer 195

The tip o f the filter should be positioned at the level o f the renal vein. If it’s not, honestly it’s not a big deal

Answer 196

The filter can migrate to another part o f the IVC, the heart, or even the pulmonary outflow tract. If it goes to the heart, you need surgery. If it’s ju st superior, you need to snare it out.

Answer 197

Although the incidence o f PE is decreased, the risk o f DVT is increased. Caval thrombosis is also increased, and you should know that clot in the filter is a contraindication to removal (you need to lyse it, before you remove it).

Answer 198

A strut going through the caval wall is common and d oesn’t mean anything. However, aortic penetration, ureteral perforation, duodenal perforation, or lumbar vessel laceration can occur (rarely) from a strut hanging out o f the cava - this is a bigger problem.

Answer 199

A relative contraindication to IVC filter placement is bacteremia

Answer 200

There are two ways to show the renals on an IVC Gram. There is the nice way where they opacify normally and it’s obvious, and there is the sneaky way where you see the "steaming effect ” o f unopacified blood allowing you to infer the position. Obviously the sneaky way is more likely to show up on the exam.

Answer 201

For standard anatomy, the standard answer for a cone shaped fdter is to put the apex at the level o f the renals. Some people think the high flow in this location helps any clot that might get stuck in the filter dissolve.

Answer 202

The filter should be positioned above the most cranial extension o f the clot. As mentioned in my glorious IVC Filter position chart, if the clot extends beyond the renals you need a suprarenal filter.

Answer 203

If it’s retrievable, you may be able to snare it and restart. If it’s permanent you are kind o f hosed. Some people will try and stick a second filter above the retarded one.

Answer 204

The longer these things stay in, the more likely they will thrombose. Prior to removal you should perform an angiogram o f the IVC. The main reason to do this is to evaluate for clot. • More than 1 cm3 o f clot = Filter Stays In • Less than 1 cm-1 o f clot = Filter Comes Out

Answer 205

In the real world, people will yank that mother fucker out o f there. The IVC is the Rodney Dangerfield o f vessels - no respect. For multiple choice? Stop and assume that it can’t be retrieved.

Answer 206

Angiogram should also be done after removal o f the filter to make sure you didn’t rip a hole in the IVC. I f you did rip a hole in it - Next Step - Angioplasty balloon with low pressure insufflation to to create tamponade. If that doesn’t work, most people would try a covered stent graft. If you created a wall injury/dissection ? Again - answers will vary, but the classic answer is systemic anticoagulation

Answer 207

This is a subcutaneous anastomosis between an artery and adjacent native vein (for example the radial artery to the cephalic vein). All things equal, the preferred access (over the graft).

Answer 208

This is also a subcutaneous anastomosis between an artery and adjacent native vein. Except this time the distance between the vessels is bridged with a synthetic tube graft.

Answer 209

- Ready for use in 2 weeks - Easier to declot (clot is usually confined to the synthetic graft)

Answer 210

- Lasts Longer & More Durable - Much less prone to development o f venous neointimal hyperplasia at or downstream from the artery-vein anastomosis. - Fewer infections

Answer 211

-Less overall longevity -Promotes hyperplasia o f the venous intima at or downstream from the graft vein anastomosis, resulting in stenosis and eventual obstruction -More infections (foreign graft material)

Answer 212

-Needs 3-4 Months to “Mature” (vein to | enlarge enough for dialysis)

Answer 213

The primary reason is “slow flows.” It’s important to understand that nephrologists get paid per session o f dialysis. If they can do a session in 1 hour or 4 hours they make the same amount o f money. Therefore they want them running fast. So, really “slow-flow” is referring to slow cash flow in the direction o f the nephrologist’s pocket.

Answer 214

< 600 cc/min for graft = diagnostic fistulogram < 500 cc/min for fistula = diagnostic fistulogram Having said that, you may find different numbers different places - the whole issue is controversial based on the real motivation people have for treating these. Some texts say a fistula can maintain patency with rates as low as 80 cc/min, and grafts can maintain patency with rates as low as 450 cc/min. Also remember medicare won’t pay for two treatments within 90 days, so make sure you treat on day 91

Answer 215

Its a violation o f nature to have a AF Fistula / Graft pulsating in your arm. Your body w o n 't tolerate it forever. Neointimal hyperpasia develops causing an ever-worsening stenosis. If they d o n ’t get treated, they will eventually thrombose. All fistulas/grafts must die.

Answer 216

The only thing worse then actually doing a fistulogram is having to talk with and examine the patient prior to the procedure. Nearly all the IR texts and any program worth its snuff will “work them up” starting with physical exam. Patient arrives in the IR department for “ slow flows.” Next Step = Physical Exam

Answer 217

“Arm Swelling” “Chest Wall Collaterals” “Breast Swelling” Central Venous Stenosis “Discolored Hand” “Pale Colored Hand” “Pallor of the Hand” Dialysis-Associated Steal Syndrome (DASS)

Answer 218

“High-Pitched Bruit” “Bruit in Systole Only” “Discontinuous Bruit” Localized Stenosis

Answer 219

“Water Hammer Pulse” = pre stenosis | “Diminished Pulse” Post Stenosis

Answer 220

A normal graft has an easily compressible p u lse, a low-pitched bruit that is present in both systole + diastole, and a thrill that is palpable with compression only at the arterial anastomosis.

Answer 221

The most common site o f obstruction is venous outflow (usually at or ju st distal to the graft-to-vein anastomosis). This is usually secondary to intimal hyperplasia.

Answer 222

There should be a thrill at the arterial | anastomosis, and a low pitched bruit should be audible throughout the graft.

Answer 223

High Pitch = Stenosis, Low Pitch = Normal

Answer 224

This is classic | for central venous stenosis.

Answer 225

It’s more variable - you are less likely to be asked this. If you are forced - I’d say venous outflow stenosis - typically junta-anastomotic or runoff vein (AV anastomosis stenosis is uncommon).

Answer 226

Nope - they reoccur about 75% o f the | time within 6 months.

Answer 227

Yes - there should be a continuous thrill at the anastomosis. If it is present only with systole then you are dealing with a stenosis. Also, if you can localize a thrill somewhere else in the venous outflow - that is probably a stenosis.

Answer 228

This indicates a more central stenosis - the fistula | should be only slightly pulsatile.

Answer 229

A low pitched bruit in the outflow vein is an expected finding.

Answer 230

The classic story is “cold painful fingers” during dialysis, relieved by manual compression o f the fistula. Too much blood going to the fistula leaves the hand ischemic. The issue is usually a stenosis in the native artery distal to the fistula. Fixing this is typically surgical (DR1L = Distal Revascularization and Interval Ligation o f Extremity, or Flow Reduction Banding).

Answer 231

Infection is the only absolute one. If you fuck with an infected fistula or graft the patient could get endocarditis. If you don’t fuck with it, the patient will probably still get endocarditis but infectious disease will have to blame it on someone else at the QA meeting.

Answer 232

A “relative contraindication” is a new graft or fistula. “New” to most people means less than 30 days. Significant stenosis prior to 30 days strongly suggests a surgical fuck up (“technical problem” they call it). Not to mention that a new dilating anastomosis is high risk for rupture. Those grafts are doomed to never reach long-term patency. Access less than 30 days old with stenosis. Next Step = Send them back to the surgeon.

Answer 233

You will read some places that stenotic segments longer than 7 cm respond poorly to treatment. Some people even consider this a “ relative contraindication.” If the question writer actually spells out the length of the stenosis greater than 7 cm he/she probably wants you to say send them back to surgery. In reality there are plenty of stubborn IR guys that will try and treat multiple long lesions because there is no better way than to prove one’s manhood.

Answer 234

You can use CO2 for runs.

Answer 235

Access is typically directed towards the venous anastomosis - unless you are thinking arterial is the problem (which is much less common). Remember the lingo “antegrade” and “retrograde” refers to the direction of blood flow. Antegrade is the typical route fo r venous problems, and retrograde is the typical route for arterial inflow issues.

Answer 236

The move most places teach is to obstruct the venous outflow (with a clamp, blood pressure cuff, angioplasty balloon, finger - or whatever) which allows the contrast to reflux into the artery.

Answer 237

Give them heparin (3000-5000 units). Exchange your catheter for a 5 or 6 F sheath over a standard 0.035-inch guidewire. Dilate the narrow spot with a 6-8 mm balloon with multiple prolonged inflations. Remember to never take that balloon off the wire when you are doing diagnostic runs - as you might need to rapidly put it back if you caused a tear.

Answer 238

There are two main reasons (1) you arc getting bad elastic recoil, or (2) you have recurrent stenosis within 3 months of angioplasty.

Answer 239

You can use a vasodilator (like nitroglycerin) to distinguish between spasm and stenosis. The spasm should improve. The stenosis will be fixed.

Answer 240

(1) Improved Symptoms (arm swelling better, etc..), or (2) less than 30% residual stenosis.

Answer 241

Small ones get monitored for size increase, but the classic teaching is that these are managed surgically.

Answer 242

Remember that PICC lines should not be put in dialysis (or possible dialysis - CKD 4 or 5) patients because they might need that arm for a fistula.

Answer 243

The portal vein gives you 70-80% o f your blood flow to the liver. The pressure difference between the portal vein and IVC (‘fPSG” , portosystemic gradient) is normally 3-6 mm Hg. Portal HTN is defined as pressure in the portal vein > 10mm Hg or PSG > 5 mm Hg. The most common cause is EtOH (in North America).

Answer 244

``` On ultrasound we are talking about an enlarged portal vein (>1.3-1.5 cm), and enlarged splenic vein (> 1.2 cm), big spleen, ascites, portosystemic collaterals (umbilical vein patency), and reversed flow in the portal vein. ```

Answer 245

* Variceal hemorrhage that is refractory to endoscopic treatment * Refractory ascites. * Budd Chiari (thrombosis o f the hepatic veins) ** most authors will include this

Answer 246

You need two things. (1) An ECHO to evaluate for heart | failure (right or left). (2) Cross sectional imaging to confirm patency o f the portal vein.

Answer 247

First thing you do is measure the right heart pressure. If it is elevated (10-12 mmHg) you stop (absolute contraindication). A normal right heart pressure is around 5 mmHg. If it is normal, you proceed with the procedure. Access the jugular vein on the right, go down the IVC to the hepatic veins, opacify the veins, do a wedge pressure (don’t blow the capsule off), use CO2 to opacify the portal system. Then stick “Crotch to Crotch” from the hepatic veins to the portal vein (usually right to right). Then put a covered stent in and balloon it up. Lastly check pressures and make you sure you didn’t over do it (usually want a gradient around 9-12 “ less th an 12” ).

Answer 248

You want to turn | anterior.

Answer 249

This was initially developed to predict three month mortality in TIPS patients. Now it’s used to help prioritize which drunk driving, Hep C infected. Alcoholic should get a transplant first. MELD is based on liver and renal function - calculated from bilirubin, INR, creatinine. MELD scores greater than 18 are at higher risk o f early death after an elective TIPS.

Answer 250

This is the “old one,” which was previously used to determine transplant urgency prior to the MELD. It works for TIPS outcomes, too, but is "less accurate ” than a MELD. This score assesses the severity o f liver disease by looking at the bilirubin, albumin, PT, ascites, and hepatic encephalopathy. The trivia to know is that class B & C are risk factors o f variceal hemorrhage.

Answer 251

“Simplest prognostic measure” = Serum Bilirubin. > 3 mg/dL is associated with an increase in 30-day mortality after TIPS.

Answer 252

Some sources will say there is no “absolute” contraindication. Others (most) will say severe heart failure (right or left), - but especially right. That the whole reason you check the right heart pressure at the beginning o f the procedure. If you are forced to pick a contraindication and right heart failure is not an option, I would choose biliary sepsis, or isolated gastric varices with splenic vein occlusion. Accepted (by most) “relative” contraindications include cavernous transformation o f the portal vein, and severe hepatic encephalopathy.

Answer 253

Cardiac decompensation (elevated right heart filling pressures), accelerated liver failure, and worsening hepatic encephalopathy.

Answer 254

Because the stent decompresses the portal system, you want to see flow directed into the stent. Flow should reverse in the right and left portal vein and flow directly into the stent. Flow in the stent is typically 90-190 cm/s. Stenosis / Malfunction: * Elevated maximum velocities (> 200 cm/s) across a narrowed segment. * Low portal vein velocity (< 30 cm/s is abnormal). * A temporal increase (or decrease) in shunt velocity by more than 50 cm/s is also considered direct evidence. * “Flow Conversion” with a change o f flow in a portal vein branch from towards the stent to away from the stent. * An indirect sign o f malfunction is new or increased ascites.

Answer 255

These things tend to fail (50% primary patent within 1 year for a bare metal stent), so they need tight follow up. Worsening Ascites, Bleeding, Etc (things that make you think the TIPS isn’t working) Next Step = Venogram with pressures PSG >12 mmHg. Next Step = Treat the stenosis (angioplasty’ + balloon)

Answer 256

The stenosis usually occurs in the hepatic vein, or within the TIPS tract.

Answer 257

Dropping the gradient too low increases the risk o f HE. If the TIPS is too open you may need to tighten it down with another stent.

Answer 258

There is a rarely indicated thing called a “peritoneovenous shunt.” This stupid thing has a high rate of infection and thrombosis, and can even lead to DIC. It’s designed to allow drainage o f the ascites through a tunneled line all the way up to the systemic circulation (jugular).

Answer 259

TIPS and BRTO are brother and sister procedures. Where the TIPS takes blood and steers it away from the liver (to try and help the side effects o f portal hypertension), the BRTO does the opposite - driving more blood into the liver (to try and help with the side effects o f extra hepatic shunting). The inverted indications and consequences are highly testable:

Answer 260

Treat Esophageal Varices Place a shunt to divert blood around liver Complication is worsening hepatic encephalopathy Improves esophageal varices and ascites

Answer 261

Treat Gastric Varices Embolize collaterals to drive blood into liver Complication is worsening esophageal varices and worsening ascites Improves hepatic encephalopathy

Answer 262

The general idea is that you access the portosystemic gastrorenal shunt from the left renal via a transjugular or transfemoral approach. A balloon is used toocclude the outlet o f either the gastrorenal or gastro-caval shunt. Following balloon occlusion, a venogram is performed. A sclerosing agent is used to take the vessels out. After 30-50 minutes you aspirate the remaining sclerosing agent and let down the balloons.

Answer 263

The most common side effect o f BRTO is gross hematuria.

Answer 264

The simple version is at the hilum. There are two main hepatic ducts (right and left) which jo in to make the common hepatic duct. The right hepatic duct is made o f the horizontal right posterior (segment 6 & 7) and vertical right anterior (segment 5 & 8). The left duct has a horizontal course and drains segment 2 and 4.

Answer 265

would know the 2 most common variants. The right posterior segment branch draining into the left hepatic duct is the most common. The second most common is trifurcation o f the intrahepatic radicles (the right anterior duct and right posterior duct and left duct all drain into the common hepatic).

Answer 266

“Normal” Duct Anatomy (57%) right posterior draining into the left (16%) trifucation(12%)

Answer 267

The role o f PTC (Percutaneous Transhepatic Cholangiogram) and PTBD (Percutaneous Transhepatic Biliary Drainage) is centered around situations when ERCP and endoscopy have failed or are not possible (Roux-en-Y).

Answer 268

* Check the coags - correct them if necessary (vitamin K, FFP, e tc ...). * Most institutions give prophylactic antibiotics (ascending cholangitis is bad).

Answer 269

There are two approaches: right lateral mid axillary for the right system, or subxyphoid for the left system. Realistically, diagnostic cholangiogram and PTBD is usually done from the right. The left is more technically challenging (although better tolerated by the patient because the tube isn’t in-between ribs) and usually there is a hilar stricture that wo n ’t allow the left and right system to communicate.

Answer 270

Line up on the patient’s right flank / mid axillary line. Find the 1 Oth rib. Don’t go higher than the 10th rib - always below (avoiding the pleura can save you a ton o f headaches). Prior to jamming the needle in, most reasonable people put metal forceps (or other metal tool) over the target and fluoro to confirm you are over the liver and below the pleural reflection. Now the fun begins. The basic idea is to pretend the patient is a voodoo doll o f the Attending (or childhood tormentor) that you hate the most. Proceed to blindly and randomly jam a chiba needle in and inject slowly under fluoro as you pull back (but not all the way out). Obviously less sticks is better and it’s ideal to do in less than 5 (most places will still consider less than 15 ok). Once you get into a duct the system will opacify. You then can pick your target (posterior is best for best drainage). You stick again, wire in, and place the catheter into the duodenum. A non-dilated system can be very difficult and there is an old school trick where you stick the gallbladder (on purpose) and retrograde fill the system. The problem with that is you have to keep a drain in the gallbladder as well.

Answer 271

This time you use a sub-sternal / subxyphoid approach with ultrasound. Most people aim for the anterior inferior peripheral ducts. Otherwise the moves are pretty much the same.

Answer 272

Most stent placement is preceded by a period o f biliary decompression with an internalexternal drain. Plastic stents are cheaper but have a short patency period. Metal stents will stay patent longer but c an’t be removed. Metal stents are not usually used in benign disease unless the patient has a long life expectancy.

Answer 273

Internal-External drains are the standard for crossing lesions. They have superior stability to a straight drain or pigtail. They offer the advantage o f possible conversion to an internal only drain (save those bile-salts). Some testable trivia is that many centers will manually punch some additional side holes in the proximal portion o f the tube to make sure that drainage adequate. The key is to NOT position any side holes outside the liver (proximal to liver parenchyma).

Answer 274

* Ducts - Flow Towards the Hilum * Vein = Flow Cranially towards the Heart * Artery - Flow Towards the Periphery

Answer 275

``` When I say “Below the 10th Rib,” I mean caudal to the 10th rib, not actually under the rib. Always puncture at the TOP EDGE OF A RIB to avoid the intercostal artery (which runs under the rib). ```

Answer 276

Drain it prior to doing the PTC.

Answer 277

Opinions are like assholes (everyone has one), so y o u ’ll hear different things for this. I think most people would look to make sure the liver still abuts the peritoneum at the puncture site. If it does, then they will do a right sided approach. If it doesn’t then they will use ultrasound and go substemal on the left.

Answer 278

Slowly and carefully roll the patient on their side (right side up). The right ducts are dependent - so this is actually fairly common. Now obviously if there is a known obstruction you d o n ’t need to roll them. The rolling is to prove it’s not a real obstruction.

Answer 279

Place a pigtail drain and let the | system cool down for like 48 hours. Try again when there is less edema.

Answer 280

This is done when you have a super sick patient you c an ’t take to the OR, but the patient has a toxic gallbladder. In cases o f acalculous cholecystitis (with no other source o f sepsis), 60% o f the time cholecystostomy is very helpful. It’s a “temporizing measure.” You have to give pre-procedure antibiotics. There are two approaches

Answer 281

This is preferred by many because it’s a direct approach, and avoids hitting the liver. The major draw back is the wire / catheter often buckles and you lose access (and spill bile everywhere). This is typically not the first choice. However in patients with liver disease or coagulopathy it may be preferred (depending on who you ask). I f the question writer specifically states (or infers) that the patient has an increased risk o f bleeding this is probably the right choice. Otherwise, if forced to choose, pick the Transhepatic route

Answer 282

The major plus here is that when you cross the liver it stabilizes the wire and minimizes th e chan ce o f a bile leak. This is the route most people choose. o Trivia = Typically you go through segments 5 a n d 6 on your way to the gallbladder o Trivia = This route transverse the “bare area” / upper one third o f the gallbladder (hypothetically).

Answer 283

* Prior to the procedure, make sure the bowel isn’t interposed in front o f the liver/ gallbladder. If a multiple choice writer wanted to be sneaky he/she could tell you the patient has "Chilaiditi Syn d rome” - which ju st means that they have bowel in front o f their liver. Some sources will list this as a contraindication to PC. * Even if the procedure instantly resolves all symptoms, you need to leave the tube in for 2-6 weeks (until the tract matures), otherwise you are going to get a bile leak. * After that ‘‘at least 2 week ” period you should perform a cholangiogram to confirm that the cystic duct is patent before you pull the tube. * Most places will clamp the tube fo r 48 hours p rio r to removal. This helps confirm satisfactory internal drainage.

Answer 284

Bile leak is bad as it can lead to massive biliary ascites and chemical peritonitis. Most people will try and place a tube within the bile ducts to divert bile from the location o f the leak (this usually works).

Answer 285

Bile leak is bad as it can lead to massive biliary ascites and chemical peritonitis. Most people will try and place a tube within the bile ducts to divert bile from the location o f the leak (this usually works).

Answer 286

(1) Fine Needle Aspiration — Cytology | (2) Cutting Needle (“Core”) — Biopsy

Answer 287

This is for situations when you only need a few cells. It is typically performed through a 21 or 22G Chiba needle. Vacuum aspiration with a 20 cc syringe is applied as you pass the needle back and forth through the target.

Answer 288

Apply “gentle” suction as you remove the needle. If you suck too hard a tiny sample could get lost in the syringe. If you forget to apply suction the sample will stay in the patient

Answer 289

``` This is for situations when you need a larger sample. There are lots of devices but the most basic mechanism involves a needle with two parts; an outer shaft for cutting, and an inner stylet. ```

Answer 290

For the purpose o f multiple choice, the target is “cut” where the outer shaft is advanced.

Answer 291

The general rule is pick the shortest length needle that will reach the target

Answer 292

“Automated Systems” fire both the inner and outer components to take the sample. The key point is that with these systems the sample is taken from tissue 10-20 mm in front of the needle.

Answer 293

“Automated Systems” fire both the inner and outer components to take the sample. The key point is that with these systems the sample is taken from tissue 10-20 mm in front of the needle.

Answer 294

You can do targeted approaches (for a specific lesion) or you can do non-targeted approaches (sampling). General pearls include: trying to cross the capsule only once, biopsy the subcapsular masses through an area o f uninvolved liver, and avoid the diaphragm. If given the choice, you want to biopsy peripheral lesions through 2-3 cm o f normal liver prior to hitting the target. This is done to avoid a blood bath.

Answer 295

There is ascites = Drain it prior to doing the biopsy

Answer 296

Mild shoulder pain (referred pain) is common after liver biopsy.

Answer 297

Prolonged Shoulder Pain (> 5 mins) = Possible Bleed "Kehr Sign ”.

Answer 298

Prolonged Shoulder Pain (> 5 mins) = Re-evaluation with ultrasound. Always look behind the liver (Morrison’s pouch) to see if blood is accumulating. Bleeding after liver biopsy occurs more from biopsy o f malignant lesions (compared to diffuse disease).

Answer 299

Uncorrectable coagulopathy, thrombocytopenia (< 50,000), infections in the right upper quadrant - are contraindications for a conventional biopsy.

Answer 300

Biopsy o f carcinoid mets is controversial and death by carcinoid crisis has occurred after biopsy.

Answer 301

Massive ascites or severe coagulopathy = Transjugular approach

Answer 302

The rationale is that the liver capsule is never punctured, so bleeding is less o f a risk. Obviously this is a nontargeted biopsy for the diagnosis o f infectious, metabolic, and sometimes neoplastic processes (classic example = grading chronic hep C).

Answer 303

The general technique is to access the hepatic veins via the IVC (via the right ju g u la r vein). Most people will tell you to biopsy through the right hepatic vein while angling the sheath anterior. The reason this is done is to get the biggest bite o f tissue, and avoid capsular perforation (which was the entire point o f this pain in the ass procedure).

Answer 304

* Severe Coagulopathy * Massive ascites * Failure of prior percutaneous liver biopsy * Massive obesity ("Fat Even By West Virginia Standards ”) * Patients on mechanical ventilation * Need for additive vascular procedures like TIPS

Answer 305

Right Sided Jugular Route is the superior route (better than left IJ, or femoral)

Answer 306

Biopsy via the Right Hepatic Vein by angling anterior. Never perform an anterior biopsy from the middle hepatic vein.

Answer 307

``` This procedure has the added benefit o f allowing you to measure hepatic venous pressures - which can guide therapy or assess varix bleeding risk. ```

Answer 308

Embolization is a potential method for dealing with significant trauma to the hepatic or splenic arteries. Opinions on the exact role o f angiography vary between institutions, so “read my mind” questions are likely. I think the most likely type o f indication question might actually be who does NOT go to angio? The most accepted contraindication in a bleeding patient is probably a very busted-up unstable dude who needs to go straight to the OR for emergent laparotomy

Answer 309

*agreed upon by most: • Continuous hemorrhage (active extrav) in a patient who is borderline stable post resuscitation • Early ongoing bleeding after a surgical attempt to gain primary hemostasis • Reblceding after successful initial embolization • Post traumatic pseudo-aneurysm and AVFs (even if they aren’t currently bleeding).

Answer 310

* Gelfoam, pledgets, particles, and/or microcoils are typically used. * Massive non-selective hepatic artery embolization is usually avoided to reduce the risk o f large volume tissue necrosis.

Answer 311

Hepatic abscess development (which is fairly common in a major liver injury anyway).

Answer 312

* Gelfoam, pledgets, particles, and/or microcoils are typically used. * Massive non-selective hepatic artery embolization is usually avoided to reduce the risk o f large volume tissue necrosis.

Answer 313

Hepatic abscess development (which is fairly common in a major liver injury anyway).

Answer 314

``` Coils should NOT be placed in the pseudoaneurysm sac. This can lead to a late rupture. The strategy is to occlude the distal and proximal parent vessels. You'll want to perform “ completion angiography” to prove the thing is occluded prior to catheter removal. ```

Answer 315

Next Step = Gelfoam or particles.

Answer 316

can be treated at the site o f injury (with the sandwich technique) because they are not end arteries (no collaterals). Plus the liver has a dual blood supply.

Answer 317

* Splenic laceration (without active extravasation) is NOT considered an indication to angio (by most people). Remember to use your mind reading powers to confirm the question writer agrees. * The spleen does not have a dual blood supply, and is considered an “end organ” unlike the liver. So if you go nuts embolizing it you can infarct the whole fucking thing.

Answer 318

Next Step = Selective Embolization treatment

Answer 319

Next Step = Use a proximal embolization strategy, and drop an Amplatzer plug into the splenic artery proximal to the short gastric arteries. The idea is to maintain perfusion but reduce the pressure to the spleen (slower blood will clot), with the benefit o f preserved collateral supply and less infarction risk.

Answer 320

Even with this proximal embolization strategy the patient usually does not require vaccination post embolization, as a lot o f functional tissue should remain.

Answer 321

You will read in some sources that transplant is the only way to “cure” an HCC. Others will say transplant, resection, or ablation are “curative” if the tumor is small enough. Arterial embolization (TACE) is typically used in situations where the tumor burden is advanced and the patient cannot undergo surgery.

Answer 322

``` — Transplantation should be considered ONLY in patients < 65 years of age with limited tumor burden (1 tumor < 5 cm or up to 3 tumors < 3 cm). ```

Answer 323

Most people will consider this first line for palliative therapy in advanced cases. The mechanism relies on HCC’s preference for arterial blood. High concentration o f chemotherapy within Lipiodol (iodized oil transport agent) is directly delivered into the hepatic arterial system. The tumor will preferentially take up the oil resulting in a prolonged targeted chemotherapy. The Lipiodol is usually followed up with particle embolization, with the goal o f slowing down the washout o f the agent.

Answer 324

Decompensated (acute on chronic) Liver failure.

Answer 325

Some sources will list portal vein thrombosis as a contraindication (because o f the risk o f liver infarct). Others say portal vein thrombosis is fine as long as an adjustment is made to limit the degree o f embolization and you can document sufficient hepatic collateral flow. Simply read the mind o f the question writer to know which camp they are in.

Answer 326

TACE in Patients with a biliary stent, prior sphinctertomy, or post Whipple are all high risk for biliary abscess.

Answer 327

“Sterile cholecystitis” or “chemical cholecystitis” are buzzwords that when used in the setting of TACE should lead you to believe that the agent was injected into the right hepatic artery’ prior to the takeoff o f the cystic artery (artery to the gallbladder) .

Answer 328

TACE will prolong survival better than systemic chemo

Answer 329

Unfortunately, repeat TACEs can result in a ton o f angio time and therefore a ton o f radiation. Patient do sometimes get skins burns (usually on their left back because o f the RAO camera angle).

Answer 330

Tumor is destroyed by heating the tissue to 60 degrees C (140 F). Any focal or nodular peripheral enhancement in the ablation lesion should be considered residual / recurrent disease. Sometimes, on the immediate post treatment study you can have some reactive peripheral hyperemia - but this should decrease on residual studies. Important trivia is that RF ablation is indicated in patients with HCC and colorectal mets (who can’t get surgery).

Answer 331

As a point o f trivia, it has been shown that TACE + RFA for HCC lesions larger than 3cm, will improve survival (more so than either treatment alone). This is still not curative.

Answer 332

An alternative to TACE is using radioactive embolic materials (Y-90). The primary testable trivia regarding Y-90 therapy is understanding the pre-therapy work up. There are basically two things to know:

Answer 333

You give Tc-99 MAA to the hepatic artery to determine how much pulmonary shunting occurs. A shunt fraction that would give 30 Gy in a single treatment is too much (Y-90 is contraindicated).

Answer 334

The fear is that you get non-targeted poisoning o f the stomach, leading to a non-healing gastric ulcer. To help prevent reflux o f the Y-90 (poison) into places you do n ’t want (basically anywhere th at’s not liver) prophylactic embolization o f the right gastric and the GDA is performed. The right gastric origin is highly variable, and can come o ff the proper hepatic or the left hepatic.

Answer 335

* Shunt Fraction > 30 Gy to the Lungs = No Y-90 * Before you give the poison, embo the right gastric (which has a variable take off) and GDA - so you d o n ’t put a hole in the stomach.

Answer 336

``` Yttrium-90 is a high-energy beta emitter with a mean energy of 0.93MeV. It has no primary gamma emission. Yttrium-90 has a half-life of 64 hours. After administration, 94% of the radiation is delivered over 11 days (4 half-lives). The maximum range of irradiation from each bead is 1.1 cm. ```

Answer 337

• Tumors need to be less than 4 cm or you can’t “cure” them. You can still do RFA on tumors bigger than 4 cm but the buzzword you want for this is “debulking". • You always need a bum margin o f 0.5-1.0 cm around the tumor. So your target is the tumor + another 1 cm o f healthy organ. • A key structure (something you do n ’t want to bum up) that is within 1 cm o f the lesion is considered by most to be a contraindication to RFA. Some people won’t cook lesions near the vascular h ilum , or near the gallbladder. Be on the look out for bowel. It is possible to cook bowel adjacent to a superficial lesion. If they are asking you if a lesion is appropriate for RFA and it’s superficial look for adjacent bowel - that is probably the trick. • RFA requires the application o f a “Grounding pad” on the patient’s leg. Blankets should be jammed between the arms/body and between legs to prevent closed circuit arcs/bums.

Answer 338

supposedly can reduce the risk o f tumor seeding. Basically you leave the cooker on as you remove the probe to burn the tract.

Answer 339

this is a phenomenon described exclusively with RFA. Lesions that are near blood vessels 3mm or larger may be difficult to treat (without getting fancy) because the moving blood removes heat away from the lesion.

Answer 340

Temperatures at 100 C or greater tend to carbonize the tissue near the probe, reducing electrical conductance (resulting in suboptimal treatment). Around 60 C is the usual target.

Answer 341

* Cure = < 4 cm | * Debulk = > 4 cm

Answer 342

Just like a tumor embolization you can get a low grade fever and body aches. The larger the tumor, the more likely the syndrome (just like embolization). • Low Grade Fever and Body Aches Post Ablation. Next Step = Supportive Care • Persistent Fever x 2-3 weeks post ablation. Next Step = Infection workup.

Answer 343

Similar to RFA is that it cooks tumors. The testable differences are that it can generate more power, can cook a bigger lesion, requires less ablation time, it’s less susceptible to heat sink effect, and it does NOT require a ground pad.

Answer 344

Thawing is what actually kills the cancer cells

Answer 345

I f you are planning on treating immediately after biopsy, most sources will advise you to place the probes first, then biopsy, then treat. If you try and place the probes you make a bloody mess then you might not get accurate probe placement. Just do n ’t biopsy the probe. Seriously, if you crack the probe and the high pressure gas leaks out - shit is gonna explode (better have your medical student ready as a shield).

Answer 346

It hurts less than RFA - so patients need less sedation

Answer 347

The risk o f bleeding is higher than with RFA - because you aren’t ablating the small vessels

Answer 348

Instead o f burning the tumors, this technique uses extreme cold in cycles with thawing. The freeze-thaw cycles fuck the cells up pretty good. The cold gun is generated by the compressing argon gas. I actually knew a guy who constructed a similar device shortly after an industrial accident left him unable to survive outside o f subzero environments.

Answer 349

* Week 1-4: It’s ok for the lesion to get bigger. This is a reactive change related to edema, tissue evolution, e tc ... * Month 3: The lesion should be the same size (or smaller) than the pre-treatment study. * Month 6: The lesion should be smaller than pre-treatment.

Answer 350

• Central or Peripheral Enhancement is NEVER normal in the lesion post treatment. • You can have “benign peri-ablational enhancement” - around the periphery o f the ablation zone. This should be smooth, uniform, and concentric. It should NOT be scattered, nodular, or eccentric (those are all words that mean residual tumor).

Answer 351

* Multiphase CT (or MR) at 1 month. If residual disease is present at this time, Next Step = Repeat treatment (assuming no contraindications) * Additional follow up is typically at 3-6 months intervals.

Answer 352

On follow up CT, you need to have pre and post contrast imaging including washout. The iodized oil is going to be dense on the pre-contrast. The more dense oil is in the tumor the better outcome is likely to be. The necrotic tissue should not enhance. If there is enhancement and/or washout in or around the tumor, then you have viable tumor that needs additional treatment. Beam hardening from the iodized oil can cause a problem.

Answer 353

the preferred nomenclature for the post-ablation region on imaging.

Answer 354

Post therapy study is typically performed at 3 months, with additional follow ups at 6 months and 12 months. A good result should be lower in density relative to the adjacent kidney. On MR, a good result is typically T2 dark and T1 iso or hyper.

Answer 355

Just like RFA, ablated lesions can initially appear that they grew in size relative to the pre-treatment study. With time they should progressively shrink (usually faster than with RFA). An increase in size (after the baseline post treatment) should be considered recurrent tumor.

Answer 356

Any nodular enhancement ( >10HU change from pre-contrast run) after treatment should be considered cancer.

Answer 357

“ResiduaI tumor ” or “Incomplete Treatment” = Vocab words used when you see focal enhancement in the tumor ablation zone o f a patient for their first post therapy study. “Recurrent tumor ” = Word used when you see focal enhancement in the tumor ablation zone that is new from the first post therapy study.

Answer 358

Left o f Midline (lateral to the rectus muscle to avoid inferior epigastric) Mid to Distal Body Equal distance from the greater and less curves - to avoid arteries

Answer 359

The cardia o f the stomach is actually the most posterior portion.

Answer 360

There is another method often called a "PIG” because o f the Perioral route. In that version you stab the stomach and tread a wire up the esophagus. Then you grab the wire, slip the tube over it, and advance the tube over the wire into the stomach all the way out the stabbed hole. Then it’s back to the nursing home for Grandma.

Answer 361

Depends on who you ask. Some people will say 12-24 hours fasting post placement. Other people will say use it right away. It depends on the brand and practitioners bias. To know the correct answer for the exam - simply read the mind o f the person who wrote the question.

Answer 362

The basic idea is that you put an NG tube down and pump air into the stomach until it smushes flat against the anterior abdominal wall. Then you spear it and secure it with 4 “T-Tacks” to tack the stomach to the abdominal wall in the gastric body. Then spear it again, wire in and dilate up to the size you want. Typically, the T-Tacks are removed in 3-6 weeks. Other things that you can do is give a cup o f barium the night before to outline the colon. If the patient has ascites. Next Step = Drain that first.

Answer 363

Probably the most common indication for one o f these is esophageal cancer palliation. These are usually placed by Gl, but that doesn’t mean you won’t get asked about them. In the real world, most people do n ’t even size these things. The overwhelming majority o f lesions can be covered by one stent. Having said that, for the purpose o f multiple choice you need a stent with a length at least 2 cm longer than the lesion on each side. You do the procedure through the mouth. I imagine it would be great fun to try and place a stent through the nose - if you really hated the person. You give them some oral contrast to outline the lesion. An amplatz wire is dropped down into the stomach. The stent (usually se lf expanding) is deployed over the wire.

Answer 364

Most people don’t angioplasty after deployment o f the stent. However, if the tumor is bulky and near the carina, some sources will suggest doing a pre-stent angioplasty test up to 20 mm to see if this invokes coughing / stridor. The concern is that a large tumor may get displaced against the carina and cause a respiratory emergency. If the patient doesn’t cough from the test you are safe to deploy the stent (probably).

Answer 365

Most esophageal cancers are in the lower 1/3. If the question specifically tells you it’s higher up (or shows you), they may be leading you towards a “t/o« ’/ cover the larynx dumbass! ” question. The way to avoid this is to have endoscopy do the case so they can identify the cords. If that isn ’t an option then placing a smaller device might be an alternative.

Answer 366

Most people will ju st leave the motherfucker alone. | However, if the patient is symptomatic, endoscopic removal is the textbook answer.

Answer 367

Next Step = Esophagram. The most common cause is food impaction - which sometimes can be cleared with a soda. If that fails, the next step is endoscopy. If it’s not food but instead tumor overgrowth, sometimes you can place a second stent. It depends on a lot o f factors and asking that would be horse shit.

Answer 368

* Acute obstruction is likely food | * Worsening symptoms over time is likely tumor.

Answer 369

* Acute obstruction is likely food | * Worsening symptoms over time is likely tumor.

Answer 370

Some testable trivia is that 85% o f upper GI bleeds are from the left gastric, and often i f a source cannot be identified, the left gastric is taken down prophylactically. If the source o f bleeding is from a duodenal ulcer, embolization o f the GDA is often performed. About 10% o f the time, an upper GI bleed can have bright red blood per rectum.

Answer 371

This is a sign o f active GI bleeding, with the appearance o f a vein created by contrast pooling in a gastric rugae or mucosal intestinal fold. If you aren’t sure if it’s an actual vein, the “pseudo-vein” will persist beyond the venous phase o f injection.

Answer 372

This is a monster artery in the submucosa o f the stomach which pulsates until it causes a teeny tiny tear (not a primary ulcer). These tears can bleed like stink. It’s typically found in the lesser curvature. It’s not exactly an AVM, more like angiodysplasia. Sometimes you can treat it with clips via endoscopy. Sometimes it needs endovascular embolization.

Answer 373

you say celiac artery stenosis. There is a known association with celiac artery compression (median arcuate ligament) and the dilation o f pancreatic duodenal arcades with pseudoaneurysm formation.

Answer 374

``` Retrograde filling of the hepatic artery should make you think about Celiac stenosis (or occlusion) ```

Answer 375

``` It is classically shown with an angiographic run through the SMA, showing a dilated collateral system and retrograde filling o f the hepatic artery. ```

Answer 376

upper gi bleed > endoscopy positive . treat with endoscopy > failed or not possible > angio upper gi bleed > endoscopy negative > three phase CTA > angio (hopefully targeted)

Answer 377

The work-up for lower GI bleeds is different than upper GI bleeds. With the usual caveat that algorithms vary wildly from center to center, this is a general way to try and answer next step type questions regarding the workup.

Answer 378

lower GI bleed > stable > endoscopy lower gi bleed > unstable (tachy and hypotension > three phase cta or RBC scan > no bleed conservative mangeemnt > active bleed > angio

Answer 379

ACR Appropriateness specifically states that in a STABLE patient with lower GI bleeding that endoscopy is first line.

Answer 380

nuclear scintigraphy (RBC bleeding scan) is more sensitive than angiography.

Answer 381

Bleed Scan = 0.1 mL/min CTA = 0.4 ml/min Angiography = 1.0 mL/min

Answer 382

Right Sided Finding. “Early Draining Vein. ” Embolization o f angiodysplasia rarely stops a re-bleed and these often need surgery.

Answer 383

Left Sided Finding (usually). More commonly venous. I f arterial, “filling the diverticulum first ” is classic.

Answer 384

``` Usually shown on Meckles scan (99mTc-Na-pertechnetate). The feeding d artery (vitelline) has a classic look with “extension beyond the mesenteric border, ” “no side branches ” and “a corkscrew appearance” o f the terminal portion. ```

Answer 385

You will want runs o f all 3 vessels (SMA, Celiac, IMA). Some old school guys will say to start with the IMA because contrast in the bladder will obscure that territory as the procedure continues. That’s not really an issue anymore with modem DSA and starting with the SMA will typically be the highest yield. You have to sub select each vessel. Runs in the aorta are not good enough and that would never be the right answer.

Answer 386

You can try “provocative angiography” - which is not nearly as interesting as it sounds. This basically involves squirting some vasodilator (nitro 100-200 meg) or thrombolytic drug (tPA 4 mg) into the suspected artery to see if you can make it bleed for you.

Answer 387

Administer some street justice. Anyone who trained in the last 30 years is going to prefer microcoils and PVA particles. Old guys might use gel-foam. Alcohol should not be used for lower GI bleeds (causes bowel necrosis).

Answer 388

Good because you can see them. Good because you can place them precisely. Bad because they deploy right where you drop them. So you need to go right up next to that bleed to avoid a large bowel infarct. Trivia = Inability to advance the micro-catheter peripherally is the most common cause o f microcoil embo failure say “non-selective embolization o f bowel with microcoils,” you say “bowel infarct”

Answer 389

Good because they are “ flow directed.” So you don’t need to be as peripheral compared to the microcoils. Bad because you have less control. Trivia: Particles must be 300-500 microns. Particles that are smaller will/could cause bowel infarct.

Answer 390

Between me and you this argument was settled in 1986 by a lady named Gomes. Her study showed coils stopped GI bleeds 86% o f the time, compared to 52% for vasopressin and the shit we have today is way better making the disparity even greater. Having said that, some Dinosaurs still do it.

Answer 391

• Vasopressin works as a vasoconstrictor • Vasopressin does not require superselection. You can squirt it right into the main trunk of the artery. • Vasopressin sucks because the re-bleed rates are high (once the drug wears off) • Vasopressin can actually cause non-occlusive mesenteric ischemia (NOMI) • Vasopressin should NOT be used with large artery bleeding (i.e. splenic pseudoaneurysm), bleeding at sites with dual blood supply (classic example is pyloroduodenal bleed), severe coronary artery disease, severe hypertension, dysrhythmias, and after an embolotherapy treatment (risk o f bowel infarct).

Answer 392

You need to do angiography post embolization to look for collateral flow (if there is a dual supply). The classic example is: after performing an embolization o f the GDA (for duodenal ulcer), you need to do a run o f the SMA to look at the inferior pancreaticoduodenal (collateral to the GDA). You might have to take that one out too, but obviously that would increase the risk o f bowel infarct.

Answer 393

— GI Bleeding that continues (or recurs) despite negative upper endoscopy and colonoscopy is described as “obscure GI bleeding. "The actual culprit is often from the small bowel (arteriovenous malformation). — There is no clear consensus on the optimal study to interrogate the small bowel. — ACR Appropriateness Criteria rank CT angiography and capsule endoscopy as the most appropriate choices in this situation. Tc-99m RBC scan is considered as a “reasonable alternative” for localization - but only in the setting of active bleeding. Remember GI bleed scan only works if there is active bleeding.

Answer 394

Risk o f bowel infarct is way lower for upper GI bleeds (because o f the extensive collateral supply), relative to bleeds distal to the ligament o f Trietz.

Answer 395

In general, there are two methods, you can use a trocar or you can use the seldinger technique (wire guided). * Trocar: You nail it with a spinal needle first. Then adjacent to the needle (in tandem) you place a catheter. * Seldinger: One stick with a needle, then wire in, dilate up and place a catheter.

Answer 396

The grosser and thicker stuff will need a bigger tube. If forced I’d go with: • 6-8 F for clear fluid • 8-10 F for thin pus • 10-12 F for thick pus • 12F+ for collections with debris or in collections that smell like a Zombie farted.

Answer 397

You pretty much always use a pigtail. I wouldn’t guess anything else.

Answer 398

• Any “next step” question that offers to turn doppler on p rio r to sticking it with a needle is always the right answer. Trying to trick you into core needling a pseudoaneurysm is the oldest trick in the book. • Decompressing the urinary bladder prior to a pelvic abscess drainage is often a good idea. • Collection has pus. Next step = aspirate all o f it (as much as possible) prior to leaving the drain • You c an’t advance into the cavity because it’s too fibrous/thick walled. Next Step ? I’d try a hydrophilic coated • Family medicine want you to put a 3 way on that 12 F drain. Next step = d o n ’t do that. You are reducing the functional lumen to 6F.

Answer 399

Next step = d o n ’t do that. Antimicrobial therapy should never be withheld because some knuckle head is worried about sterilizing cultures. (1) Cultures almost never change management from the coverage they were on anyway, (2) the trauma of doing the drainage will seed the bloodstream with bacteria and make the sepsis worse.

Answer 400

Remember that “flushing" and “irrigation” are different. Flushing is done to keep the tube from clogging with viscous poop. Irrigation is when you are washing out the cavity (the solution to pollution is dilution) for complete cavity drainage. Going nuts with the irrigation can actually cause a bacteremia. The vignette could say something like “waxing and waning fever corresponding to flush schedule.” The next step would be to train the nurses / family medicine to limit the volume to less than the size of the cavity.

Answer 401

Next Step? Stop irrigating it! You have a big problem. The fluid (which is dirty) is being washed into a location that is not able to be sucked back out by the tube. So you are creating a new pocket o f infection that isn't being drained.

Answer 402

Next Step = (1) confirm that it is in the correct location and not kinked - might need imaging if not obvious at bedside, then (2) try flushing it or clearing an obstruction with a guidewire. If the catheter is clogged for real then y o u ’ll need to exchange it - probably for a larger size. If the tract is mature (older than a week) you can probably get a hydrophilic guidewire through the tract into the collection to do an easy exchange.

Answer 403

(1) drainage is less than lOcc / day, (2) the collection is | resolved by imaging (CT, Ultrasound, e tc ...), and (3) there is no fistula.

Answer 404

The patient should get better pretty quickly after you drain the abscess. If they aren’t getting better it implies one o f two things (1) you did a shitty job draining it, or (2) they have another abscess somewhere else. Either way they need more imaging and probably another drain.

Answer 405

This is a bad sign. In a normal situation the drainage should slower taper to nothing and then once you confirm the abscess has resolved you pull the drain. Spikes in volume (especially on multiple choice exams) suggest the formation o f a fistula. Next step is going to be more imaging, possibly with fluoro to demonstrate the fistula (urine, bowel, pancreatic duct, bile duct, e tc ...).

Answer 406

tubo-ovarian abscess, diverticular abscess, or peri-appendiceal

Answer 407

(1) All things equal, pick the shortest route (2) Avoid bowel, solid organs, blood vessels (inferior epigastrics are classic) , nerves (3) Try not to contaminate sterile areas (4) Choose the most dependent position possible (usually posterior or lateral) to facilitate drainage

Answer 408

Most abscesses in the pelvis are layering in a dependent position so anterior routes are typically not easy. In general there are 4 routes; transabdominal, transgluteal, transvaginal, and transrectal. I’m gonna try and cover the pros/cons and testable trivia for each route.

Answer 409

The pull o f gravity tends to cause infection to layer in the more posterior spaces. As a result transabdominal approaches tend to be long, and therefore violate one o f the 4 general ideas. If you are shown an abscess where this would be the best, shortest route then remember to watch out for the inferior epigastrics. For sure there will be an option to stick the trocar right through one o f them. Make sure you ID them before you choose your answer.

Answer 410

The transgluteal approach is done for a variety o f posterior targets. The patient is positioned prone for targeting.

Answer 411

• Access through the sacrospinous ligament • Medial as possible • Inferior to the piriformis

Answer 412

Legit risk o f artery/ nerve injury. Prone to catheter kinking. Gotta use CT (radiation).

Answer 413

There is a subset o f perverts who prefer to biopsy and drain things through the vagina (tuna purse) and/or the rectum.... Not that there’s anything wrong with that. Well actually the primary disadvantage o f both o f these “endoluminal routes” is catheter stability. Many catheters arc literally pooped out within 3-4 days. Although advocates for these routes will argue that (a) they are more fun to do, and (b) most collections resolve within 3 days.

Answer 414

Biopsy and/or drainage through the vagina (pink taco) has the advantage of providing a very short safe route that can be guided by transvaginal ultrasound, allowing for no radiation and very accurate placement. This was the classic in office route for drainage o f infected gynecologic fluid collections (P1D related). The procedure is done in the lithotomy position. Catheter size is traditionally limited to 12F (or smaller). You should never do this to a patient under the age o f 14 - not even Jared from Subway would try that. Although controversial, it is possible (and well described in the literature) to drain / biopsy adnexa cysts through the vagina (penis fly trap). Vaginal prep / cleansing prior to the procedure is controversial and unlikely to be tested.

Answer 415

Of the three routes (gluteal, vaginal, rectal) transrectal is supposedly the least painful - although in my literature review the psychological pain was not discussed (this kinda thing would really fuck with my machismo). Essentially this route offers all the advantages of the transvaginal route (ultrasound guidance, very short / safe route) plus the added advantage of pre-sacral access. Depending on what you read, people will argue this is first line (over transgluteal) for pre-sacral collection but that is highly variable. Choosing between transgluteal and trans-rectal for a pre-sacral collection would be the worst “read my mind” question ever. If forced into that scenario I would set aside the psychologic trauma to the alpha male ego and use (1) the size of the collection - do you think that will drain before he/she poops the catheter out ?, and (2) is the transgluteal route safe - are the vessels nerves obviously in the way? Prep with a cleansing enema is not controversial and is endorsed pretty much everywhere

Answer 416

The typical threshold for a diverticular abscess to be drained is 2 cm. Anything smaller than that will be more trouble than it is worth.

Answer 417

Remember the grosser and thicker stuff will need a bigger tube. Diverticular abscesses form because o f a perforated diverticulum. Thus, you can come to the logical conclusion that you need a tube capable o f draining shit. For the purpose o f multiple choice, anything smaller than 10F is probable NOT the right answer.

Answer 418

If the abscess is gas producing (they would have to tell you the bulb suction fdls rapidly with gas), the correct next step is to treat the collection like a pleural drain in a patient with an air leak (i.e. put on water seal).

Answer 419

Lots o f etiologies for these, but don’t forget to think about the appendix or diverticulitis. The draining o f these things is somewhat controversial with some authors feeling the risk o f peritoneal spread out weighs the benefits and reserving the drainage for patient’s with a poor prognosis. Other authors say that everyone and their brother should get one, and consider it first line treatment

Answer 420

A pearl to draining these things is to not cross the pleura (you’ll give the dude an empyema). If there is a biliary fistula, prolonged drainage will usually fix it (biliary drainage or surgery is rarely needed).

Answer 421

Biopsy / Aspiration o f Echinococcal cysts can cause anaphylaxis. Surgical removal o f the presumed echinococcal cysts should be discussed with surgery before attempting the procedure in IR (you want to be able to blame it on them, if shit goes bad).

Answer 422

``` Renal abscess is usually secondary to ascending infection or hematogenous spread. The term “perinephric abscess” is used when they perforate into the retroperitoneal space. When they are small (< 3-5 cm) they will resolve on their own with the help o f IV antibiotics. ```

Answer 423

Indications for aspiration or drainage include a large (> 3-5 cm), symptomatic focal fluid collection that does not respond to antibiotic therapy alone.

Answer 424

The strategy is to use ultrasound and stick a pig tail catheter in the thing. After a few days if the thing is not completely drained you can address that by upsizing the tube. If you create or notice a urine leak, you’ll need to place a PCN. There are really only relative contraindication - bleeding risk e tc ..., and the procedure is generally well tolerated with a low complication rate.

Answer 425

This is seen in the setting o f a transplant. When they are small you typically just watch them. However, on occasion they get big enough to cause local mass effect on the ureter leading to hydronephrosis. You can totally aspirate them, but they tend to recur and repeated aspiration runs the risk o f infecting the collection. For multiple choice 1 would say do this: Aspirate the fluid and check the creatinine. If it’s the same as serum it’s probably a lymphocele (if it s more then i t ’s a urinoma). Either way you are going to drain them with a catheter. However, if it’s a lymphocele you might sclerose the cavity (alcohol, doxy, povidine-iodine). *Urinomas (that are persistent) o f any size are drained

Answer 426

Remember that necrotizing pancreatitis is bad, but infected necrotizing pancreatitis is a death sentence. So, be careful draining something that is NOT infected already (otherwise you might make it infected). If you aren’t sure if it’s infected, consider aspirating some for culture (but not placing a tube).

Answer 427

General indications include infected collections or collections causing mass effect (bowel or biliary obstruction).

Answer 428

I f you can get 75% reduction in 10 days, the drain is good enough. If not, the surgeons can use the tract for a video-assisted retroperitoneal debridement (which still avoids open debridement).

Answer 429

Other than pancreatic pseudocysts, most pancreatic collections are either brown or grayish. When the fluid is clear, you should think about pancreatic fluid, and send a sample for amylase to confirm. I f this lasts more than 30 days then you have yourself a “persistent pancreatic fistula. ” Nice jo b idiot... you could have ju st left it alone. That will teach you to let those medicine docs pressure you into doing stuff that’s not indicated. It may be possible to treat that with octreotide (synthetic somatostatin) to inhibit pancreatic fluid, although in these cases extended drainage is usually needed.

Answer 430

General Rule: If the pseudocyst communicates with the pancreatic duct drainage will be prolonged (6-8 weeks in most cases). You can try and use somatostatin to slow it down. Most Cases: Transperitoneal with CT guidance — avoid organs, avoid going through the stomach twice. Can’t Avoid the Stomach or Patient has a known Duct Communication (so they gonna have a tube for a long time) - Transgastric Approach — so it drains into the stomach

Answer 431

Relief o f Urinary Obstruction Urinary Diversion Access for Diagnostic and Therapeutic Procedures

Answer 432

Stones | Cancer

Answer 433

Urine Leak ``` Urine Fistula (for pelvic CA or inflammatory process) ``` ``` Severe Refractory’ Hemorrhagic Cystitis (cyclophosphamide) ```

Answer 434

Whitaker Test (ifit's 1970) Access for Stone Removal (PCNL) Dilation or Stenting o f Stricture

Answer 435

Severe Coagulopathy ► IN R Sh o u ld be le s s than 1.5 P L T > 5 0 K Technically Not P o s s i b l e ► • Approach would c ro ss colon, spleen, or liver

Answer 436

Prior to the procedure, it would be ideal if you normalized the potassium (dialysis). Certainly anything about 7 should be corrected prior to the procedure. Hold anti-platelet drugs for at least 5 days prior to the procedure. The lower pole o f a posteriorly oriented calyx is ideal. The reason you use a posterior lateral (30 degrees) De9 ree s off sagittal (towards the back) approach is to attack along Brodels Avascular Zone (area between the arterial bifurcation). Skin entry site should be 10 cm lateral to the midline (not beyond the posterior axillary line). You don’t want to go too medial unless you want to try and dilate through the paraspinal muscles. You don’t want to go too lateral or you risk nailing the colon. Choosing a lower target minimizes the chance o f pneumothorax. Additional benefit of the posterior calyces approach is that the guidewire takes a less angled approach (compared to an anterior calyces approach). Direct stick into the collecting system without passing through renal parenchyma is NOT a good move (high risk o f urine leak). Dilated System = Single Stick: Ultrasound and stick your ideal target (low and posterior), then use fluoro to wire in, dilate up, and then place the tube. Alternatively you can do the whole thing under CT. Non-Dilated System = Get your partner to do it (these blow). If forced to do = Double Stick. Ultrasound and stick anything you can. Opacify the system. Then stick a second time under fluoro in an ideal position (low and posterior), then wire in, dilate up, and then place the tube. Alternatively you can do the whole thing under CT. The posterior calyces (your target) will be seen “end on’’ if you use contrast. The anterior ones should be more lateral. If you use air, you should just fill the posterior ones (which will be non-dependent with the patient on their belly. Air is useful to confirm. You place the drain and get frank pus back. Next Step = Aspirate the system

Answer 437

The test writer will likely write the question in a way to make you think it’s crazy to try one o f these. Transplant is NOT a contraindication. In fact it’s technically easier than a posterior / native kidney.

Answer 438

* Anterolateral Calyx Should be Targeted (instead o f posterior) * Entry site should be LATERAL to the transplant to avoid entering the peritoneum * Middle to Upper Pole (instead o f a lower pole)

Answer 439

This is done to remove stones in conjunction with urology. The idea is very similar with a few differences. The most testable difference is that the site is often the upper pole (instead o f lower pole) to make stone access easier. The tube / hole is bigger and there is more risk o f bleeding.

Answer 440

The trick to handling these scenarios is the “freshness” o f the tube. If the tract is “fresh, ” which usually means less than 1 week old, then you have to start all over with a fresh stick. If the tract is “mature,” which usually means older than 1 week, you can try and re-access it with a non-traumatic wire

Answer 441

Exchange is required every 2-3 months because o f the crystallization o f urine in the tube. Some hospitals / departments will do exchanges more frequently than 2 months and that is because o f how well this pay s... uh 1 mean they do it for excellent patient care.

Answer 442

``` If this thing gets totally gross it can be very difficult to exchange in the normal fashion. The most likely “next step” is to use a hydrophilic wire along the side o f the tube (same tract) to maintain access. ```

Answer 443

Sometimes urology will request that you ju st kill the ureters all together. This might be done for fistula, urine leak, or intractable hemorrhagic cystitis. There are a bunch o f ways to do it. The most common is probably a sandwich strategy with coils. The sandwich is made by placing large coils in the proximal and distal ends o f the “nest”, and small coils in the middle. Big Coils = Bread, Small Coils = Bacon.

Answer 444

This is used when the patient needs long-term drainage. It's way better than having a bag o f piss strapped to your back. ``` Benign ureter strictures Malignant ureteral obstruction (by fa r the most common indication) Ureteric injury Ureteric calculus undergoing lithotripsy ```

Answer 445

they can be placed in a retrograde (bladder up) or an antegrade (kidney down) fashion. You are going to use the antegrade strategy if (a) y o u ’ve got a nephrostomy tube, or (b) retrograde failed.

Answer 446

Yes, as long as you didn’t fuck them up too bad getting access. If they are bleeding everywhere or they are uroseptic you should wait. Let them cool down, then bring them back to covert to the NUS.

Answer 447

Anyone who doesn’t have a bladder that works (outlet obstruction, neurogenic bladder, bladder tumors, etc..). It makes no sense to divert the urine into a bladder that can’t empty.

Answer 448

This is the ultimate goal for the patient. The testable | stipulation is that this will require the ability to do retrograde exchanges (via the bladder).

Answer 449

A safety PCN - is often left in place after the deployment o f a double J PCN. The point is to make sure the stent is going to work.

Answer 450

1. Place the double J and the safety 2. Cap the safety - so that the internal NUS is draining the patient 3. Bring the patient back in 24-48 hour and “squirt the tube” (antegrade nephrostogram). The system should be non-obstructed. 4. If it’s working you pull the safety. 5. If it’s NOT working you uncap the safety and ju st leave it as a PCN.

Answer 451

Done to either (a) acutely decompress the bladder or (b) decompress long-tenn outflow obstruction (neurogenic bladder, obstructing prostate cancer, urethral destruction, etc..) The best way to do it is with ultrasound in the fluoro suite. The target is midline just above the pubic symphysis at the junction o f the mid and lower thirds o f the anterior bladder wall.

Answer 452

* The low stick avoids bowel and the peritoneal cavity * The low 1/3 and mid 1/3 junction avoids the trigone (which will cause spasm). * The vertical midline is chosen to avoid the inferior epigastric.

Answer 453

* Buncha Pelvic Surgeries - Extensive scar * Being a Big Fat Pig/Cow * Coagulopathy * Inability to distend bladder * Inability to displace overlying small bowel

Answer 454

Use ultrasound and stick it, confirm position with contrast, wire in and then dilate up. Use a small tube for temporary stuff and a larger tube for more long-term stuff. You can always upsize to a foley once the tract is mature. A 16F foley is ideal for long-term drainage.

Answer 455

If you can cross the lesion, and the bladder works then internal Double J NUS is idea

Answer 456

``` This guy has obstruction at the ureter and the bladder. The only option is to divert at the level of the kidney. He gets a PCN. ```

Answer 457

at the bladder. He doesn’t need to cross the ureter. He gets a Cystostomy

Answer 458

(1) renal failure or (2) cancer biopsy.

Answer 459

The renal failure workup “non-focal biopsy” is typically done with a 14 - 18 gauge cutting needle , with the patient either prone or on their side (target kidney up). The most obvious testable fact is that you want tissue from cortex (lower pole if possible) to maximize the yield o f glomeruli on the specimen and minimize complications by avoiding the renal sinus. The complication rate is relatively low, although small AV fistulas and pseudo-aneurysms are relatively common (most spontaneously resolve). Some hematuria is expected. In a high risk for bleeding situation a transjugular approach can be done but that requires knowing what you are doing.

Answer 460

It used to be thought that focal biopsy should NEVER be done because o f the dreaded risk o f upstaging the lesion and seeding the track. This has been shown to be very rare (<0.01%). Having said that I think it’s still the teaching at least in the setting o f pediatric renal masses. This procedure is probably better done with CT. The patient is placed in whatever position is best, but the lateral decubitus with the lesion side down is “preferred” , as it stabilizes the kidney from respiratory motion, and bowel interposition. Just like with ultrasound, not crossing the renal sinus is the way to go. Just put the needle in the tumor. If it’s cystic and solid make sure you hit the solid part. Some texts recommend both fine needle and core biopsy. The core biopsy is going to give a higher yield. A testable pearl is that if lymphoma is thought likely, a dedicated aspirate should be sent for flow cytometry. As with any renal procedure hematuria is expected (not gross - ju st a little). Renal colic from blood clots is rare.

Answer 461

— Renal Bx is a procedure with “ significant bleeding risk, difficult to detect or control.” — SIR guidelines recommend holding aspirin for 5 days prior to the procedure. — Why 5 Days ? Aspirin irreversibly inhibits platelet function and since platelet lifespan is about 8-10 days, patients with normal marrow will replenish 30-50% o f their platelets within 5 days o f withholding the willow bark (aspirin).

Answer 462

Radiofrequency ablation (RFA) is an alternative to partial nephrectomy and laparoscopic nephrectomy. It can be used for benign tumors like AMLs, renal AVMs, and even for RCCs. Angiomyolipomas (AMLs) are treated at 4cm because of the bleeding risk. Sort of a general rule is that things that are superficial you can bum with RFA. Things that are closer to the collecting system it may be better to freeze (cryoablation) to avoid scaring the collecting system and making a stricture. Pyeloperfusion techniques (cold D5W irrigating the ureter) can be done to protect it if you really wanted to RFA. If anyone would ask, RFA has no effect on GFR (it won’t lower the GFR).

Answer 463

( 1) Any increase in the size beyond the acute initial increase, (2) Areas of “nodular” or “crescentic” enhancement, or (3) A new or enlarging bright T2 signal.

Answer 464

that lesions that are < 3cm will appear larger in 1-2 months and lesions >3cm do not grow larger - when successfully treated. So, smaller lesions may initially get bigger but after that - any increase in size should be considered tumor recurrence.

Answer 465

You should always do a nonselective aortogram first to sec how many arteries feed the kidney, where they are , etc. Sometimes the aortogram will show you an obvious ostial problem which you can then select down on and address. Otherwise, you need to do selective angiography and look at each vessel. LAO is the projection of choice for looking at the renals. Sometimes the stenosis is further out, in fact branch artery stenosis is a cause of hypertension in kids.

Answer 466

LA O Minimizes Angiographic | Overlap from the Aorta

Answer 467

Used to treat hypertension caused by atherosclerosis (usually ostial) or FMD. Risks include thrombosis, and vessel spasm. Calcium channel blockers can be given to decrease the risk of spasm. Fleparin should be on board to reduce thrombosis risk. Most people take daily aspirin the day before and every day after for 6 months, to reduce the risk of restenosis.

Answer 468

* Indications for angioplasty = Renal Vascular HTN or Azotemia * Atherosclerosis at the Ostium = Angioplasty + Stent * FMD - usually mid vessel = Angioplasty’ Alone

Answer 469

Don't read the NEJM. The NEJM is run by a bunch of family medicine doctors who hate all procedures. They published a thing called the CORAL trial in 2014, that showed no added benefit from angio + stenting in the setting of renal vascular stenosis compared to high quality medical therapy. This remains controversial and several prominent 1R guys still like to stent, especially if they can measure a pressure gradient in the renal artery. For the purpose of multiple choice, if “high quality medical therapy” is a choice for treated RAS related hypertension, that is probably the right answer — otherwise, pick angio + stent.

Answer 470

Trauma to the kidney (usually iatrogenic from biopsy or diversion procedure) can typically be embolized. The renal arteries are “end arteries,” which means that collaterals are not an issue. It also means that infarction is a legit issue so if you want to salvage the kidney you need to try and get super selective. Having said that, d o n ’t be an idiot and fuck around trying to get super selective while the patient is bleeding to death. Remember most people have two o f these things, plus in a worst case scenario there is always dialysis. Bottom line: if you get into trouble and the patient is crashing, ju st trash the whole thing.

Answer 471

Arterial trauma from the nephrostomy tube placement. Bleeding source is occult on angio. Next step ? Remover the nephrostomy tube (over a guidewire), then look again. Often the catheter tamponades the bleed, making it tougher to see.

Answer 472

Oral boards guys used to be sticklers for the phrase “over a wire. ” In other words if you ju st said “ I’d remove the PCN” they would ding you. You have to say “ I ’d remove the PCN over a wire." The only reason I bring this up is the use o f possible distractors / fuckery.

Answer 473

The highly skilled Interventionalist grants the Fellow the great privilege o f performing a fresh stick nephrostomy. The clumsy, good for nothing Fellow manages to place the tube, but now there is a large volume o f bright red blood in the tube and the Patient’s blood pressure is dropping rapidly. You start fluids and perform an emergent renal arteriography. The source o f bleeding is not seen. What is the best next step?

Answer 474

“Look, man. 1 only need to know one thing: where they are " - Private Vasquez • Small Segmental Arteries = coils • Main Renal Artery’ = Covered Stent to exclude the aneurysm. Alternatively, you could place a bare metal stent across the aneurysm and then pump detachable coils into the sac.

Answer 475

* Remember that you go "above the rib ” to avoid the neurovascular bundle. * If you pull off too much fluid too fast you can possibly get pulmonary edema from re-expansion (this is uncommon). * If it’s malignant you might end up with a trapped lung (lung won’t expand fully)- in other words a thick pleural rind or fibrothorax, can prevent lung reexpansion - makes percutaneous drainage pointless in many cases. A “vacu-thorax” - in the setting o f a trapped lung, does not mean anything, and does not need immediate treatment even if it’s big. If you really need to fix it, y o u ’ll need a surgical pleurectomy / decortication. Pleurodesis (which can be done to patients with recurrent pleural effusions), does NOT help in the setting o f trapped lung. * Pneumothorax is rare but is probably the most common complication (obviously it’s more common when done blind).

Answer 476

* Continuous air bubbles in the Pleur-evac chamber represent an air leak, either from the drainage tubing or from the lung itself. In the setting o f multiple choice - think about a bronchopleural fistula. * INR should generally be < 1.5 prior to placement o f a chest tube. * In the paravertebral region, the intercostal vessels tend to course o ff o f the ribs and are therefore more prone to injury if this route is chosen for chest tube placement

Answer 477

inpatient - 12-14 fr outpatient - 10 fr

Answer 478

inpatietn 14fr | outpatient 15.5 indwelling (pleurX, etc)

Answer 479

Just remember that you can drain an empyema (pus in the pleural space), but you should NOT drain a lung abscess because you can create a bronchopleural fistula (some people still do it).

Answer 480

Radiofrequency ablation o f lung tumors can be performed on lesions between 1.5cm and 5.2cm in diameter. The most common complication is pneumothorax (more rare things like pneumonia, pseudoaneurysm, bronchopleural fistula, and nerve injury have been reported). The effectiveness o f RFA is similar to external beam radiation with regard to primary lung cancer. The major advantage o f lung RFA is that it has a limited effect on pulmonary function, and can be performed without concern to prior therapy.

Answer 481

Imaging (CT and PET) should be performed as a follow up o f therapy. Things that make you think residual /recurrent disease: nodular peripheral enhancement measuring more than 10 mm, central enhancement (any is b a d ) , growth o f the RFA zone after 3 months (after 6 months is considered definite), increased metabolic activity after 2 months, residual activity centrally (at the burned tumor).

Answer 482

The most common complication is pneumothorax, which occurs about 25% o f the time (most either resolve spontaneously or can be aspirated), with about 5% needing a chest tube. The second most common complication (usually selflimiting) is hemoptysis.

Answer 483

* The lower lung zones are more affected by respiratory motion, * The lingula is the most affected by cardiac motion, * Avoid vessels greater than 5 mm, * Try and avoid crossing a fissure (they almost always get a pneumothorax), * Areas lateral to and ju st distal to the tip o f a biopsy gun will be affected by “shock wave injury”, so realize vessels can still bleed from that.

Answer 484

Enter the lung at 90 degrees to pleural surface Avoid interlobar fissures Put the patient puncture side DOWN after the procedure No talking or deep breathing after the procedure (at least 2 hours) If the patient is a cougher, consider postponing the procedure - or giving empiric anti-tussive meds

Answer 485

Repeat the biopsy and / or close follow up. Nonspecific biopsy results don’t mean shit — especially in the lung. Biopsy is only helpful when you get an actual result (cancer, hamartoma, etc...). Otherwise - you could have just missed, or targeted the infection behind the cancer.

Answer 486

pneumo > oxygen via nasal cannula (speeds up resorption of the pneymothorax) > attempt manual aspiration through the introducer needle ([ace a new 16 g needle if you already took it out) use a 50cc syrige and aspirate as you back the needle out and eventually remove it > aspirate more than 650 cc of air> yes>probably should palce a tube > no > CXR at 1 and 3 hours > if pneuomo >2cm, pneumo is enlarging or pat is short of breath > chould place a tube.

Answer 487

You can usually get away with a small-caliber, (6-10 French) catheter. A 10 French Pigtail Catheters would require an 18G needle / 0.035 Amplatz wire. You would need a larger tube if there is fluid (otherwise it will get clogged). You should use CT guidance since you obviously have it available. Most people will tell you to use the so called “ triangle o f safety,” located above the 5th intercostal space, mid-axillary line. This has the thinnest muscle, lets you avoid the breast in females (and fat sloppy dudes) - plus keeps you free of the axillary vasculature, diaphragm, liver, and spleen. Always go along the superior aspect of the rib to avoid the neurovascular bundle along the inferior border of each rib. Heimlich valves will let the patient remain ambulatory, otherwise you can use a conventional water seal device. In most cases, the tube can be removed 1-2 days after the procedure.

Answer 488

Detected by noticing (being told) that the water-seal chamber isn’t fluctuating with respiration or coughing while the drainage system is set to gravity. This means either (1) the lung is fully expanded or (2) the tube is clogged — CXR will tell you the difference. It is controversial to “milk” the tubing - plenty of people still do it. Some people put TPA in the tube - people do lots of crazy shit beyond the scope o f the exam.... probably.

Answer 489

Detected by persistent bubbling within the water seal chamber. Air leak = Air within the pleural space. This is expected after initial insertion of a chest tube, (with an actively resolving pneumothorax). It becomes a problem when it is new or persistent. Next Step: CXR confirm position o f the tube. Inspect the bandage - usually a vaseline bandage covers the insertion site. If everything looks ok - you might be dealing with a bronchopulmonary fistula.

Answer 490

Typically detected by crepitus on physical exam, or shown on chest x-ray. Confirm the tube is in the pleural space. Specially, make sure the side holes are ALL within the pleural space. Look for those fucking side holes. Reposition if needed. If the tube is appropriately positioned, subcutaneousemphysema is self-limited - do nothing.

Answer 491

The primary indications for pulmonary arteriography is diagnosis and treatment o f massive PE or pulmonary AVM.

Answer 492

The “Grollman” catheter, which is a preshaped 7F, is the classic tool. You get it in the right ventricle (usually from the femoral vein) and then turn it 180 degrees so the pigtail is pointing up, then advance it into the outflow tract. Some people will say that a known LBBB is high risk, and these patients should get prophylactic pacing (because the wire can give you a RBBB, and RBBB + LBBB = asystole). An important thing to know is that patients with chronic PE often have pulmonary hypertension. Severe pulmonary hypertension needs to be evaluated before you inject a bunch o f contrast. Pressures should always be measured before injecting contrast because you may want to reduce your contrast burden. Oh, one last thing about angio... never ever let someone talk you into injecting contrast through a swanganz catheter. It’s a TERRIBLE idea and the stupid catheter will blow apart at the hub. I would never ever do that....

Answer 493

Cardiac dysrhythmias (v-tach) during procedure. Next Step ? Re-position the catheter / wire

Answer 494

Patients with PE should be treated with medical therapy (anticoagulation with Coumadin, Heparin, or various newer agents), allowing the emboli to spontaneously undergo lysis. In patients who can’t get anticoagulation (for whatever reason), an IVC fdter should be placed. The use o f transcatheter therapy is typically reserved for unstable patients with massive PE.

Answer 495

Pulmonary HTN with elevated right heart pressures (greater than 70 systolic and 20 end diastolic). If you need to proceed anyway - they get low osmolar contrast agents injected in the right or left PA (NOT the main PA). Left Bundle Branch Block - The catheter in the right heart can cause a right block, leading to a total block. If you need to proceed anyway - they get prophylactic pacing.

Answer 496

Just think lotta PE with hypotension. In those situations, catheter directed thrombolysis, thromboaspiration, mechanical clot fragmentation, and stent placement have all been used to address large clots.

Answer 497

hey can occur sporadically. For the purpose o f multiple choice when you see them think about HHT (Hereditary Hemorrhagic Telangiectasia / Osier Weber Rendu). Pulmonary AVMs are most commonly found in the lower lobes (more blood flow) and can be a source o f right to left shunt (worry about stroke and brain abscess). The rule o f treating once the afferent (feeding) artery is 3mm is based on some tiny little abstract and not powered at all. Having said that, it’s quoted all the time and a frequent source o f trivia that is easily tested. The primary technical goal is to crush the feeding artery (usually with coils) as close to the sac as possible. You do n ’t want that think reperfusing from adjacent branches. Pleurisy (se lf limited) after treatment seems to pretty much always happen.

Answer 498

* HHT Association * Brain Abscess / Stroke - via paradoxical emboli * Treat once the afferent (feeding) artery is 3mm * Coils in the feeding vessel, as close as possible to the sac

Answer 499

This is an aneurysm associated with chronic pulmonary infection, classically TB. The trick on this is the history o f hemoptysis (which normally makes you think bronchial artery). “ It’s a Trap!” - Admiral Gial Ackbar Next Step Strategy to avoid the trap: Patient blah blah blah hemoptysis Next Step? Bronchial Artery Angio • Bronchial Artery Angio is negative, still bleeding. Oh, and his PPD is positive. Next Step ? Pulmonary Artery angio to look for Rasmussen Aneurysms • Rasmussen Aneurysm identified. Next Step ? Coil embolization (yes coils for hemoptysis - this is the exception to the rule).

Answer 500

The primary indication for pulmonary arteriography is diagnosis and treatment o f massive hemoptysis

Answer 501

``` Massive hemoptysis (> 300 cc) can equal death. Bronchial artery embolization is first line treatment (bronchial artery is the culprit 90% o f the time). Unique to the lung, active extravasation is NOT typically seen with the active bleed. Instead you see tortuous, enlarged bronchial arteries. The main thing to worry about is cord infarct. For multiple choice the most likely bad actor is the “hairpin-shaped” anterior medullary artery (Adamkiewicz). Embolizing that thing or anywhere that can reflux into that thing is an obvious contraindication. If present, those bad boys typically arise from the right intercostal bronchial trunk. ```

Answer 502

Particles (> 325 micrometers) are used (coils should be avoided - because if it re-bleeds you ju st jailed yourself out).

Answer 503

``` The vast majority (90%) of bronchial arteries are located within the lucency formed by the left main bronchus. This is right around the T5-T6 Level ``` ``` There is a ton of vascular variation but the pattern of an intercostobronchial trunk on the right and two bronchial arteries on the left is most common (about 40%) ```

Answer 504

In the lower thoracic / upper lumbar region the primary feeding artery o f the anterior spinal cord is the legendary anterior radiculomedullary artery (artery o f Adamkiewicz). This vessel most commonly originates from a left sided posterior intercostal artery (typically between T 9 -T 1 2 ), which branches from the aorta. The distal portion o f this artery, as it merges with the anterior spinal artery, creates the classic (and testable) "hairpin" turn. It is worth noting that Adamkiewicz can originate from the right bronchus (like 5%).

Answer 505

There are a variety o f ways to address occlusion o f the SVC. The goal is to return in line flow from at least one jugular vein down through the SVC. Most commonly thrombolysis is the initial step, although this is rarely definitive. The offending agent (often a catheter) should be removed if possible. If the process is non-malignant, often angioplasty alone is enough to get the job done (post lysis).

Answer 506

* Malignant causes: you should do lysis, then angioplasty, then stent. * Non-malignant causes: may still need a stent if the angioplasty doesn’t remove the gradient (if the collateral veins are still present). * Self-expanding stents should NOT be used, as they tend to migrate. * The last pearl on this one is not to forget that the pericardium extends to the bottom part o f the SVC and that if you tear that you are going to end up with hemopericardium and possible tamponade.

Answer 507

* Acute = No Collaterals * Acute = Emergency * Chronic = Has Collaterals * Chronic = Not an Emergency

Answer 508

Can be used for bleeding or the bulk symptoms of fibroids. Procedure may or may not help with infertility associated with fibroid. If you are paying cash.... it definitely helps.

Answer 509

To do this you need a pre-op MRI/MRA to | characterize the fibroids and look at the vasculature.

Answer 510

• Degenerated leiomyoma are more likely to have a poor response (these are the ones that don’t enhance). • “Cellular” Fibroids - the ones with high T2 signal tend to respond well to embolization. Most fibroids “Flyaline Subtype" are T2 dark. • Smaller lesions do better than larger lesions.

Answer 511

* Submucosal does the best. Intramural does the second best. * Serosal does the third best (it sucks). It speaks the third most Italian - * Cervical fibroids do NOT respond well to UAE — they have a different blood supply.

Answer 512

• Intracavitary Fibroids - Less than 3 cm. O Next Step = GYN referral for hysteroscopic resection • Intracavitary Fibroids - Less than 3 cm , with failed hysteroscopic resection O Next Step = IR Embo • Large Serosal Fibroid, patient wants to be pregnant, no history of prior myomectomy O Next Step = GYN referral for myomectomy • Pedunculated Serosal Fibroid O Next Step = GYN referral for resection • Broad Ligament Fibroid O Next Step = Refer to voodoo priest (these don’t do well with UAE and are technically challenging to operate on).

Answer 513

* Remember fibroids are hormone responsive. They grow with estrogen (and really grow during pregnancy). Gonadotropin-releasing medications are often prescribed to control fibroids by blocking all that fancy hormone axis stuff. * The testable trivia is to delay embolization for 3 months if someone is on the drugs because they actually shrink the uterine arteries which makes them a pain in the ass to catheterize. * The EMMY trial showed that hospital stays with UAE are shorter than hysterectomy * The incidence of premature menopause is around 5% * DVT/ PE is a known risk of the procedure (once pelvic vein compression from large fibroid releases - sometimes the big PE flies up). The risk is about 5%.

Answer 514

Pregnancy. Uterine/Cervical Cancer. Active Pelvic Infection, Prior Pelvic Radiation, Connective Tissue Disease, Prior Surgery with Adhesions (relative)

Answer 515

• Occlusion of small feeding arteries cause fibroid infarction (and hopefully shrinkage). Embolic material is typically PVA or embospheres for fibroids (targeting the pre-capillary level). If ask to choose an agent - I'd say "particles" - don't pick coils, or glue. For postpartum hemorrhage / vaginal bleeding, gel foam or glue is typically used. • Most people will say either 500-700 micro or 700-900 micron particle sizes. As a point of trivia smaller particle size docs not give you a better result for fibroids — but can help with Adenomyosis. • Treatment of adenomyosis with UAE is done exactly the same way, and is an effective treatment for symptomatic relief (although symptoms recur in about 50% of the cases around 2 years post treatment). As above - slightly smaller particles are typically used for this (vs fibroids). • Fibroids should reduce volume 40-60% after the procedure. If you are treating intracavitary fibroids they should turn to mush and come out like a super gross chunky vegetable soup period mix. You actually want that - if they stay (“retained”) inside they can get infected.

Answer 516

• Remember the uterine artery is off the anterior division of the internal iliac • Regardless of the fibroid location, bilateral uterine artery embolization is necessary to prevent recruitment of new vessels • In most cases, branches of the ovarian artery feed the fibroids via collaterals with the main uterine artery. Uterine artery can be identified by the characteristic "corkscrew" appearance of its more disc branches — named the Helicine branches (twisty like a helix)

Answer 517

I mentioned this earlier but just wanted to remind you that it’s classically described with fibroid embolization. Remember you don’t need to order blood cultures - without other factors to make you consider infection. The low-grade fever should go away after 3 days. Some texts suggest prophylactic use of anti-pyrexial and antiemctic meds prior to the procedure. • 3 Days or less with low grade fever = Do nothing • More than 3 Days with fever = “Work it up” , cultures, antibiotics, etc...

Answer 518

I'm 100% certain no one went into radiology to do these things. You do it like a GYN exam. Prep the personal area with betadine, drape the patient, put the speculum in and find the cervix. There are various methods and tools for cannulating and maintaining cannulation of the cervix (vacuum cups, tenaculums, balloons). Insertion of any of these devices is made easier with a catheter and wire. Once the cervix and endometrial cavity have been accessed, the contrast is inserted and pictures are obtained.

Answer 519

Pregnancy, Active Pelvic Infection. Recent Uterine or Tubal Pregnancy

Answer 520

• The ideal time for the procedure is the proliferative phase (day 7-14), as this is the time the endometrium is thinnest (improves visualization, minimizes pregnancy risk). • It’s not uncommon for a previously closed tube to be open on repeat exam (sedative, narcotics, tubal spasm - can make a false positive). • Air bubbles can cause a false positive filling defect. • Intravasation - The backflow of injected contrast into the venous or lymphatic system, used to be an issue during the Jurassic period (when oil based contrast could cause a fat embolus). Now it means nothing other than you may be injecting too hard, or the intrauterine pressure is increased because of obstruction. • The reported risk o f peritonitis is 1%.

Answer 521

``` Tubal factors (usually P1D / Chlamydia) are responsible for about 30% of the cases in female infertility ~ depending on what part of the country you are from sometimes much more (insert joke about your hometown here). Tubal obstruction comes in two flavors; proximal / interstitial, or distal. The distal ones get treated with surgery. The proximal ones can be treated with an endoscope or by poking it with a wire under fluoro. ```

Answer 522

* You should schedule it in the follicular/proliferative phase (just like a HSP) - day 6-12ish. * You repeat the HSG first to confirm the tube is still clogged. If clogged you try and unclog it with a wire ( “selective salpingography ”). * Hydrophilic 0.035 or 0.018 guidewire (plus / minus microcatheter) is the typical poking tool * Repeat the HSG when you are done to prove you did something * Contraindications are the same as HSG (active infection and pregnancy)

Answer 523

Women have mystery pelvic pain. This is a real (maybe) cause o f it. They blame dilated ovarian and periuterine veins in this case, and give it a name ending in the word “syndrome” to make it sound legit. The symptoms o f this “syndrome” include pelvic pain, dyspareunia, menstrual abnormalities, vulvar varices, and lower extremity varicose veins. The symptoms are most severe at the end o f the day, and with standing.

Answer 524

Clinical symptoms + a gonadal vein diameter o f 10 mm (normal is 5 mm).

Answer 525

GnRH agonists sometimes help these patients, since estrogen is a vasodilator. But the best results for treatment o f this “syndrome” are sclerosing the parauterine venous plexus, and coils/plugs in the ovarian and internal iliac veins (performed by your local Interventional Radiologist). This is often staged, starting with ovarian veins plugged first, and then (if unsuccessful) iliac veins plugged second

Answer 526

Most optimal results occur when the entire length o f both gonadal veins are embolized

Answer 527

``` Complications are rare but the one you worry about is thrombosis o f the parent vein (iliac or renal), and possible thrombus migration (pulmonary embolism). ```

Answer 528

The symptoms will classically improve after menopause.

Answer 529

- They are usually left-sided (90%), or bilateral (10%). Isolated right-sided varicoceles should prompt an evaluation for cancer (next step = CT Abd).

Answer 530

There are three indications: (1) infertility, (2) testicular atrophy in a kid, (3) pain.

Answer 531

Remember that multiple venous collaterals “pampiniform plexus” or “spermatic venous plexus” drain the testicles. Those things come together around the level o f the femoral head, forming the internal spermatic vein. The left internal spermatic vein drains into the left renal vein, and the right internal spermatic vein drains into the IVC. Common variants include: multiple veins on the right terminating into the IVC or renal vein, or one right-sided vein draining into the renal vein (instead o f the IVC).

Answer 532

The “primary factor” is right angle entry o f the left spermatic vein into the high pressure left renal vein. Nut-cracker syndrome (compression o f the left renal vein between the SMA and aorta) on the left is another cause (probably more likely asked).

Answer 533

You get into the renal vein and look for reflux into the gonadal vein (internal spermatic) which is abnormal but confirms the problem. You then get deep into the gonadal vein, and embolize close to the varicocele (often with foam), then drop coils on the way back, and often an Amplatzer or other occlusion device at the origin.

Answer 534

There is a paper in the NEJM that says this doesn’t work. Having said that, NEJM doesn’t like any procedures. They’re run by family medicine doctors. They are equally amoral to the person that will do any non-indicated procedure. Regardless o f the actual legitimacy, it’s a big cash cow and several prominent Radiologists have made their names on it... so it will be tested on as if it’s totally legit and without controversy.

Answer 535

• Indications = Acute to subacute fracture with pain refractory to medical therapy or an unstable fracture with associated risk if further collapse occurs. • Contraindications = Fractures with associated spinal canal compression or improving pain without augmentation. • There is a risk o f developing a new vertebral fracture in about 25% o f cases. The literature says you should “counsel patients on the need for additional treatments prior to undergoing vertebroplasty. • The cement can embolize to the lungs. • Risk o f local neurologic complications are about 5%.

Answer 536

1950 called and they want to stage this cancer. Prior to CT, MRI, and US injecting dye into the toes was actually a way to help stage malignancy (mets to lymph nodes, lymphoma, etc..). Another slightly more modem application is to use this process as the first step in the embolization o f the thoracic duct. Why would you take down the thoracic duct? If it’s leaking chylous pleural effusions - status post get hacked to pieces by a good for nothing Surgery Resident.

Answer 537

``` This is done by first injecting about 0.5 cc methylene blue dye in between the toes bilaterally. You then wait half an hour until the blue lymphatic channels are visualized. You then cut down over the lymphatic channels and cannulate with a 27 or 30 gauge lymphangiography needle. An injection with lipiodol is done (maximum 20 ml if no leak). I f you inject too much there is a risk o f oil pneumonitis. You take spot films in a serial fashion until the cistema chyli (the sac at the bottom o f the thoracic duct) is opacified. At that point you could puncture it directly and superselect the thoracic duct to embolize it, typically with coils. ```

Answer 538

Standing waves are an angiographic phenomenon (usually) that results in a ringed layering o f contrast that sorta looks like FMD. A common trick is to try and make you pick between FMD and Standing Waves. Obviously it’s bullshit because in real life standing waves typically resolve prior to a second run through the same vessel, and even if they stayed around they tend to shift position between each run (up or down). FMD on the other hand is an actual physical irregularity o f the vessel wall so it’s fixed between runs and doesn’t go away.

Answer 539

Standing waves are very symmetric and evenlyspaced. FMD is more irregular and asymmetric.

Answer 540

This means a 10 mm diameter x 6 cm length balloon

Answer 541

This means do an angio run at 20 cc/sec for a total o f 30 mL.

Answer 542

An A ngiogram — Oh really? A splenic lac with active extrav? Let’s call IR right away and get him squirted.

Answer 543

A difficult case

Answer 544

I have an admit for you. This lady is a hot mess.

Answer 545

A way o f feigning sympathy.

Answer 546

also, “sick AND stinks” be careful not to mess this up.

Answer 547

C Arm Angulation -70 Degrees LAO Misc - “Candy Cane”

Answer 548

C Arm Angulation - RAO Misc - In the LAO the right subclavian and right common carotid overlap

Answer 549

C Arm Angulation - LAO Misc -

Answer 550

C Arm Angulation - Lateral to Steep RAO Misc -

Answer 551

C Arm Angulation - LAO Misc - Same side as renal

Answer 552

C Arm Angulation -RAO or LAO - depending on who you ask. Misc - This is controversial - a lot o f sources will say you can get away with LAO.

Answer 553

C Arm Angulation - LAO Misc -Opposite side common

Answer 554

C Arm Angulation - LAO Misc -Ipsilateral Oblique

Answer 555

C Arm Angulation - RAO Misc - Ipsilateral Oblique

Answer 556

C Arm Angulation - RAO Misc Opposite side common

Answer 557

Normally, views are defined by the direction of the x-ray beam. However, in Angio it gets a little squirrely. The sidedness refers to the side of the 1.1.

Answer 558

The imaging intensifier is on the right side of the patient. A reasonable person might call this LPO - but they would be wrong.

Answer 559

The imaging intensifier is on the left side of the patient. A reasonable person might call this RPO but they would be wrong.

Answer 560

Sometimes it’s difficult to tell if you are superficial or deep to the lesion you are trying to put a needle in under fluoro. You can problem solve by tilting the 1.1, towards the patient’s head or towards the patient’s feet. If you tilt towards the head, a superficial needle will be shorter but a deep needle will look longer. If you tilt towards the feet, a superficial needle will be longer but a deep needle will look shorter.

Answer 561

* Superficial Needle looks shorter | * Deep Needle looks longer

Answer 562

* Superficial Needle looks longer | * Deep Needle looks shorter

Answer 563

“Sudden onset shortness o f breath’’ “Whoosh sound” or “Sucking sound” during central catheter insertion.

Answer 564

“Durant's maneuver” = left-lateral decubitus + head-down positioning. Other verbiage = “right side up” or “ left side down”, “trendelenburg”

Answer 565

100% Oxygen

Answer 566

* Remember that Platelets Replace Platelets. * Cryoprecipitate is used to correct deficiencies o f fibrinogen. * Heparin: The h a lf life is around 1.5 hours. Protamine Sulfate can be used as a more rapid Heparin Antidote. * Protamine can cause a sudden fall in BP, Bradycardia, and flushing * Coumadin: Vitamin K can be given for Coumadin but that takes a while (25-50mg IM 4 hours prio r to procedure) , more rapid reversal is done with factors (cryoprecipitate). * Remember that patients with “HIT” (Heparin Induced Thrombocytopenia) are at increased risk o f clotting - not bleeding. If they need to be anti-coagulated then they should get a thrombin inhibitor instead (remember those end in “rudin” and “gatran”). * The Life Span o f a Platelet is 8-10 days * IV Desmopressin can increase factor 8 - may be helpful o f hemophilia.

Answer 567

Mechanism - Inhibits thromboxane A2 from arachidonic acid by an irreversible acetylation Trivia - Irreversible - works the life o f the platelet (8-12 days).

Answer 568

Mechanism - Binds antithrombin 3 - and increases its activity. Trivia - Monitored by PTT. Can be reversed with protamine sulfate

Answer 569

Mechanism - Inhibits the binding o f ADP to its receptors - leads to inhibition o f GP Ilb/IIIa Trivia -

Answer 570

``` Mechanism - Inhibits vitamin K dependent factors (2,7,9,10) ``` ``` Trivia - Monitored by INR. Delay in onset o f activity (8-12 hours). Action can be antagonized by vitamin K - but this takes time (4 hours). For immediate reversal give factors (cryopercipitate) ```

Answer 571

Mechanism - Act directly or indirectly to convert plasminogen to plasmin (cleaves fibrin) Trivia - TPA has a very short biologic h a lf life - between 2-10 mins.

Answer 572

— For procedures with a MODERATE risk o f bleeding (liver or lung biopsy, abscess drain placement, vertebral augmentation, tunneled central line placement) — 1NR should be corrected to < 1.5 prior to the procedure. — Aspirin need not be held, — Clopidogrel (plavix) should be held for 5 days. — Platelet count should be more than 50,000.

Answer 573

* “Conscious Sedation” is considered “moderate sedation”, and the patient should be able to respond briskly to stimuli (verbal commands, or light touch). No airway intervention should be needed. * Flumazenil is the antidote for Versed (Midazolam). * Narcan is the antidote for Opioids (Morphine, Fentanyl).

Answer 574

• Maximum Dose is 4-5 mg/kg • A dirty trick would be to say - “Lido with Epi” - in which case it is 7 mg/kg • Some basic scrub nurse math: • 1% Plain Epi - 10 mg per 1 mL • So 1 mg per 0.1 mL • And we said Maximum Dose is 5 mg/kg, so it would be equal to 0.5 mL / kg • Remember that small doses in the right spot can cause a serious reaction. • 150 mg in the thecal sac can cause total spine anesthesia and the need for a ventilator. • Direct arterial injection can cause immediate seizures. • Tinnitus and dizziness are the earliest signs o f toxicity. • Local anesthesia agents have a low potential for allergy - although it can still occur, it’s usually a bogus allergy once a real history is taken. Most “allergies” to lidocaine are actually vaso-vagal, or other CV side effects from epinephrine mixed with lidocaine • There are elaborate mechanisms for testing for a true allergy, or reaction to methylparaben (a preservative). • So what if the allergy is real? or you can’t prove it’s false? - Some texts describe using an antihistamine such as diphenydramine (which can have anesthetic properties).

Answer 575

Indications - Numerous; usually diagnosis o f and treatment o f vascular disease ``` Contraindications - Only one absolute which is an unstable patient with multisystem dysfunction (unless angio is life saving). There are numerous relatives including inability to lay flat, uncooperative patient, and connective tissue diseases ```

Answer 576

Indications - Diagnosis o f DVT, Evaluate Venous malformation or tumor encasement. Contraindications - Contrast Reaction Pregnancy Severely compromised cardiopulmonary status

Answer 577

Indications - Evaluation o f postthrombotic syndrome; valvular incompetence and damage following DVT Contraindications - Contrast Reaction Pregnancy Severely compromised cardiopulmonary status

Answer 578

Indications - Thoracic Outlet Syndrome, Venous Access, Pacer Placement, Eval for fistula Contraindications - Contrast Reaction Pregnancy Severely compromised cardiopulmonary status

Answer 579

``` Indications - Can’t get anticoagulation, Failed anticoagulation (clot progression), Massive PE requiring lysis, Chronic PE treated with thromboendarterectomy. Trauma high risk DVT ``` Contraindications - Total thrombosis o f IVC IVC too big or too small *Sepsis is NOT a contraindication, including septic thrombophlebitis

Answer 580

Indications - Making the nephrologist money (“ slow flows” they call it). Contraindications - Absolute: Right to left cardiopulmonary shunt, Uncorrectable coagulopathy, fistula infection. ``` Relative is significant cardiopulmonary disease (a declot invariably causes PE) ```

Answer 581

Indications - Variceal bleeding refractory to endoscopy. Refractory ascites. Contraindications - Absolute: Heart Failure (especially right heart failure). Severe encephalopathy. Rapidly progressing liver failure.

Answer 582

``` Indications - Performed prior to percutaneous biliary interventions, Choledochojejunostomy patients (liver transplant) with suspected obstruction ``` Contraindications - Absolute: Uncorrectable Coagulopathy, Plavix or other antiplatelet agent Relative: Large Volume Ascites (consider para and left sided approach)

Answer 583

Indications - Basically CBD obstruction (with failed ERCP), cholangitis, bile duct injury/leak. Contraindications - No absolute contraindications Relative: Large Volume Ascites (consider para and left sided approach), Coagulopathy

Answer 584

``` Indications - Cholecystitis in patients who are not surgical candidates, Unexplained sepsis when other sources excluded, Access to biliary tree required and other methods failed ``` Contraindications - No absolute contraindications Relative: Large Volume Ascites (consider para and left sided approach), Coagulopathy

Answer 585

``` Indications - Obstructive Uropathy (Not hydronephrosis), Urinary diversion (leak, fistula), Access for percutaneous intervention ``` Contraindications -Uncorrectable coagulopathy,Contrast Reactions