IR

Question 1

GU) 1. A 55-year-old man begins to feel unwell after RFA to his right kidney. Considering post-RFA syndrome, which is the single best answer?

A. Flu-like symptoms and myalgia 10 days postprocedure

B. Haemorrhage is the most common major complication

C. Urinomas from urine leaks are common

D. Cell death occurs at temperatures higher than 40 °C with complete tumour necrosis at 50-60°C

E. Involves conversion of high-pressure argon gas to cold low-pressure liquid by using the Joule-Thomson effect

Answer 1

B. Haemorrhage is the most common major complication

Post-RFA syndrome occurs 24-48 hours post-ablation. It is a likely inflammatory response to tumour necrosis or cytokine production. Persistence of fever beyond day 10 should be evaluated for infection.

Haemorrhage is most commonly seen in central tumours.

Ureteral strictures and urinomas are rare.

Question 2

4. Which of the following features would be an indication for transarterial catheter ablation of a pulmonary Arteriovenous Malformation (AVM)?

A. A feeding vessel diameter of 3mm

B. The absence of a filtering capillary bed

C. Patchy enhancement on CT

D. Previous stroke

E. Size of lesion on CXR greater than 1.5cm

Answer 2

A. A feeding vessel diameter of 3mm

CT angiography is an accurate means of diagnosis, with PAVMs appearing as enhancing nodules or serpiginous masses connected with blood vessels. A feeding vessel diameter of 3mm or more is considered an indication for transarterial embolization.

Question 3

10. When considering a request for inferior vena cava (IVC) filter insertion, which of the following is an absolute rather than relative indication?

A. Free-floating proximal DVT

B. DVT/PE and limited cardiopulmonary reserve

C. Massive PE treated with thrombolysis/thrombectomy

D. Iliocaval DVT treated with thrombolysis/ thrombectomy

E. PE with inability to achieve or maintain therapeutic anticoagulation

Answer 3

E. PE with inability to achieve or maintain therapeutic anticoagulation

Other absolute indications include PE/DVT with contraindication to anticoagulation, PE/DVT and complications of anticoagulation and recurrent DVT/PE despite anticoagulation.

Ref: Hammond CJ et al. Audit of the use of IVC filters in the UK: experience from three centres over 12 years.

Question 4

13. A 67-year-old obese man develops a left groin swelling one day post-coronary intervention. Ultrasound (US) reveals a 3cm left femoral pseudoaneurysm. He is currently haemodynamically stable. Although he is being anticoagulated with heparin, Hb is stable. What is the most appropriate management option?

A. Conservative management, recommending repeat US in 48 hours

B. US-guided compression

C. US-guided thrombin injection

D. Percutaneous injection with the additional measure of inflating a balloon or across the pseudoaneurysm neck

E. Surgical repair

Answer 4

C. US-guided thrombin injection

There are several advantages of ultrasound-guided thrombin injection over ultrasound-guided compression. These include the technique being effective in patients on heparin or warfarin, greater technical success, shorter procedure duration and suitability for pseudoaneurysms arising above the inguinal ligament. Balloon inflation may have a potential role when the aneurysm neck is unfavourably short or wide to prevent escape of thrombin and downstream thrombosis, but has not gained wider acceptance due to increased complexity and invasiveness.

Question 5

9) A 28-year-old female presents with menorrhagia and dysmenorrhea. An ultrasound scan shows a large fibroid in the uterus measuring 7 cm. An MR scan confirms an intramural fibroid which enhances vividly. The patient undergoes uterine artery embolization. What is the commonest complication occurring in the first 12 months following this procedure?

a. premature ovarian failure

b. failure of therapy with need for re-embolization or hysterectomy

c. hysterectomy for uterine infection or pain

d. persistent non-offensive vaginal discharge

e. post-embolization syndrome

Answer 5

e. post-embolization syndrome

Post-embolization syndrome occurs in up to 52% of patients and is characterized by a flu-like illness with malaise and fever. This is self-limiting and lasts for up to 10 days.

Failure of therapy with the need for re-embolization or hysterectomy occurs in 10% within the first 12 months, but increases to 20–25% at 5 years.

A persistent nonoffensive discharge per vaginum, which is negative on bacterial culture, occurs in 7–14% of patients and appears to be more common with submucosal fibroids.

Hysterectomy for uterine sepsis or intractable pain is required in 2.9% in the first year.

Premature ovarian failure is seen in approximately 1–2% of patients, but this increases with age, rising to 25% in the over-45 age group.

Question 6

GIT) A transjugular intrahepatic portosystemic shunt lies between the portal vein and which vessel?

A. hepatic vein

B. inferior vena cava

C. aorta

D. common hepatic artery

E. left gastric vein

Answer 6

A. hepatic vein

A transjugular intrahepatic portosystemic shunt (TIPSS) is an endovascular procedure performed to create a portosystemic shunt between the portal venous and hepaticvenous systems, for decompression of portal hypertension, particularly in patients with variceal bleeding uncontrollable by endoscopic management.

The shunt is normally formed between the right hepatic vein and right portal vein. The right internal jugular vein is accessed, and via this the right hepatic vein.

Curved needle passes are made in an anterior direction to access the right portal vein.

The portosystemic pressure gradient is measured and portal venography is performed to enable planning of stent placement.

A stent is deployed following balloon dilatation of the stent tract.

The goal is to decrease the portosystemic gradient to below 12 mmHg and to see no significant filling of varices.

Portosystemic shunts require close follow-up, as there is a high incidence of shunt stenosis and occlusion.

Question 7

33) A 42-year-old female with tuberous sclerosis presents with flank pain. Ultrasound scan and CT demonstrate a 7 cm renal angiomyolipoma, with multiple similar smaller lesions in both kidneys. No evidence of acute hemorrhage is seen. She undergoes embolization with polyvinyl alcohol particles. After 48 hours, she presents again with flank pain and is found to have a large perinephric haematoma on the side of the embolization. What is the most likely cause?

a. vascular trauma during embolization

b. spontaneous hemorrhage from non-embolized lesion

c. post-embolization rupture

d. revascularization of embolized lesion

e. inadequate embolization material used

Answer 7

c. post-embolization rupture

Following embolization of an angiomyolipoma, there is propensity to rupture, which appears to be more common if particulate embolization material is used alone without coiling of the feeding vessels. This latter procedure is therefore recommended by some practitioners.

Vascular trauma from the original procedure may have a delayed presentation, but this is rarely seen.

Spontaneous rupture of another lesion would remain a possibility, but, given the recent embolization, cause of haematoma would be more likely to be related to this.

Question 8

74) A 48-year-old female patient presents with right upper quadrant discomfort. She has previously had a liver biopsy for deranged liver function tests, which was normal. Ultrasound scan shows a rounded, 2 cm, lowechogenicity lesion related to a branch of the hepatic artery. This shows arterial-type flow throughout on Doppler. Which minimally invasive treatment option should be offered?

a. injection of thrombin

b. transcatheter coil embolization

c. transcatheter placement of covered stent

d. embolization of hepatic artery

e. no endovascular treatment

Answer 8

b. transcatheter coil embolization

The most likely diagnosis here is pseudoaneurysm following the biopsy.

Visceral artery aneurysms, in general, affect the splenic artery most commonly, followed by the hepatic artery.

They are usually solitary. Intrahepatic branch aneurysms are usually a result of trauma, infection or vasculitis, or are iatrogenic (biopsy).

These are usually treated by coil embolization, although some advocate injecting thrombin into small peripheral lesions.

Stent insertion is not often used, as deploying stents in the smaller branch arteries is technically difficult and the stents do not allow sufficient flow and thrombose.

Embolization of the hepatic artery carries a significant risk of liver ischemia and is not advisable.

Question 9

82) A 78-year-old patient who had an endovascular aortic aneurysm repair undergoes a routine 6-month followup scan. This shows that the aneurysm sac has increased in size compared with the 1-month follow-up scan. On the delayed-phase part of the scan, there is contrast seen in the periphery of the aneurysm sac, not in contact with the stent. What is the most likely diagnosis?

a. type I endoleak

b. type II endoleak

c. type III endoleak

d. type IV endoleak

e. type V endoleak

Answer 9

b. type II endoleak

Endovascular aortic aneurysm repair (EVAR) procedures require lifelong follow-up imaging – 6-monthly CT scans are recommended.

Complications include expansion and rupture of the sac, or endoleak.

The latter has five described types:

type I – leak from stent–graft attachment, which can be subdivided into subtypes a and b, corresponding to leaks at proximal and distal attachments respectively;

type II (commonest) – retrograde flow through aortic branches, usually inferior mesenteric artery or lumbar arteries;

type III – structural failure of stent–graft;

type IV – due to porosity of the graft;

type V endotension, which is expansion of the sac without obvious cause, although it may be due to an occult type I, II or III.

Question 10

GU) 10 With regards to embolisation treatment of varicocoeles, which of the following statements is false?

(a) The right side is easier to embolise than the left

(b) Coils are the embolisation material of choice

(c) The internal spermatic vein is occluded

(d) Testicular venous rupture is a recognized complication

(e) Bilateral varicocoeles can be approached through the same puncture site

Answer 10

(a) The right side is easier to embolise than the left

The right renal vein drains directly into the IVC thus making it harder to approach. A right internal jugular approach may help in this situation.

Question 11

GIT) 20 A patient with liver disease is referred for US assessment of their TIPS stent which has been in situ for 3 months. The Doppler study a rate of 2.3 m/s. What is this most likely to represent?

(a) Normal flow

(b) Arterio-venous fistula

(c) Stent stenosis

(d) Stent fracture

(e) Stent occlusion

Answer 11

(c) Stent stenosis

This is a jet phenomenon at a narrow stenosis. Normal flow rates are 0.5-1.9 m/s but may vary with respiration.

Question 12

21- A 56-year-old smoker without pre-existing lung disease is found to have a suspicious peripheral 2cm mass in the middle lobe. Which of the following statements is false ‘with regards to CT guided percutaneous biopsy of this mass?

(a) The patient should be consented for a risk of pneumothorax of 40%

(b) Oxygen saturation during the procedure is mandatory

(c) If uncomplicated, biopsy could be performed as a day case

(d) The patient should be encouraged to breath hold during imaging

(e) The horizontal fissure should not be traversed if possible

Answer 12

(a) The patient should be consented for a risk of pneumothorax of 40%

The risk of pneumothorax is 15-20%, depending on location and the presence of bullae. Only 2—5% require formal drainage. The patient should be warned that minor hemoptysis can occur. If multiple passes are required a co-axial system is usually employed. The patient is usually asked to hold their breath during inspiration in an attempt to reduce the degree of movement of the lesion between scans.

Question 13

@# 26- A 66-year-old man presents with right thigh claudication on walking 20 yards. He is referred for an angiogram with a view to possible angioplasty. The angiogram demonstrates a 3-cm focal stenosis of the right extremal iliac artery with no other significant disease seen. What sized balloon would be appropriate for attempted angioplasty?

(a) 3 mm

(b) 5 mm

(c) 7 mm

(d) 10 mm

(e) 13 mm

Answer 13

(c) 7 mm

The more distal the occlusion, the smaller the balloon required for angioplasty, if the balloon is too big there is an increased risk of arterial rupture; if it’s too small there is a reduced probability of success. Appropriate balloon sizes include:

popliteal artery 3-4 mm,

SFA or renal artery 4-6 mm,

ElA 6-8 mm,

and common iliac 8—10 mm.

Question 14

33- A 55-year-old man presents with chest pain radiating to the back, the arm pulses are unequal, but the patient is hemodynamically stable. CXR shows a widened mediastinum, and non-contrast CT demonstrates crescentic high attenuation material along the outer wall of the distal descending thoracic aorta. Which of the following subclassifications most accurately describes this dissection?

(a) Stanford A and DeBakey I

(b) Stanford A and DeBakey II

(c) Stanford B and DeBakey I

(d) Stanford B and DeBakey II

(e) Stanford B and DeBakey Ill

Answer 14

(e) Stanford B and DeBakey Ill

Thoracic aortic dissections are classified by either the DeBakey or Stanford systems-

DeBakey has 3 subdivisions:

I involve ascending and descending aorta,

II ascending only,

III descending only.

Stanford has 2 subdivisions:

A: ascending +/- descending thoracic aorta,

B: descending only (NOT ascending)-

Thus, Stanford A incorporates DeBakey types I and II,

and Stanford B is equivalent to DeBakey III-

Question 15

@# 40 A CT-angiogram in a 67-year-old man a focal 1 cm popliteal occlusion with reconstitution and 3-vessel runoff. Initial sub-intimal angioplasty is successful, but acute thrombosis forms in the peroneal trunk late in the procedure- Thrombolysis rt-PA is considered. Which of the following factors would be an absolute contraindication to thrombolysis?

(a) CVA 3 months ago

(b) Irreversible ischemia

(c) Major abdominal surgery 4 weeks ago

(d) Primary cerebral tumor

(e) Recent warfarin use

Answer 15

(d) Primary cerebral tumor

Absolute contra-indications include major trauma/ surgery/ CPR within 2 weeks, CVA within 2 months, bleeding diathesis, pregnancy, primary or secondary cerebral malignancy and irreversible ischemia (the acute event and normal pre-morbid imaging in this scenario makes this answer wrong in this instance).

Relative contra-indications include the other options given, along with cardiac emboli, age > 80 years, and a white limb (surgery would be a better option in this case).

Question 16

46- Which of the following is not a recognized indication for a trans jugular intrahepatic porto-systemic shunt (TIPS) procedure?

(a) Budd-Chiari syndrome

(b) Hepatic encephalopathy

(c) Hepato-pulmonary syndrome

(d) Refractory ascites

(e) Uncontrolled variceal bleed

Answer 16

(b) Hepatic encephalopathy

Refractory ascites and variceal bleeding uncontrolled by endoscopic and medical therapy account for 99% of TIPS cases. Other indications include hepatorenal syndrome, hepatopulmonary syndrome, hepatic hydrothorax and Budd-Chiari. Hepatic encephalopathy is a relative contra-indication to a TIPS procedure.

Question 17

10 A diagnostic lower limb angiogram is to be performed. Which of the following guidewires is appropriate in order to site the pigtail catheter in the aorta following a standard retrograde common femoral artery puncture?

(a) Aniplatz

(b) J-wire

(c) Mandrel

(d) Straight wire

(e) Terumo

Answer 17

(b) J-wire

Guidewires have a central stiff steel core with a ‘floppy’ end; most are coated with Teflon to reduce friction. Wires are sized according to their outer diameter, measured in 1/1000 of an inch (typical measurements are 0.018 - 0.035). ‘J’ wires are often described in terms of the radius of the curve they form (e.g. 3 mm) and are routinely used for access. The other wires vary in their properties and are useful in different situations.

Question 18

15 A man with a long smoking history is found to have a subpleural 2.5 cm lesion in the left lower lobe. His FEV1 is 1.5 L and clotting is normal. He is consented for a CT-guided biopsy of the lesion. What is the commonest occurring complication from this procedure?

(a) Air embolism

(b) Haemoptysis

(c) Infection

(d) Pneumothorax

(e) Tumour seeding

Answer 18

(d) Pneumothorax

Published complication rates vary widely, and technique and practice differs according to the centre. The below study showed that small pneumothoraces are common but rarely require treatment (overall rate 16.4%); the number requiring chest drain was only 2.4%. Haemoptysis occurred in 4.8%, but major haemoptysis requiring blood transfusion was only 0.15%. Further rare complications include death (0.15% ) , air embolism (0.02%) and tumour seeding (0.02%).

Question 19

GU) 18 A 38 year old man presents with an infected, hydronephrotic kidney secondary to an impacted 9 mm distal ureteric calculus. The decision is made to proceed to percutaneous nephrostomy. Which of the following sites would be best approached for initial puncture?

(a) Renal pelvis

(b) Anterior approach to upper pole calyx

(c) Posterior approach to upper pole calyx

(d) Anterior approach to lower pole calyx

(e) Posterior approach to lower pole calyx

Answer 19

(e) Posterior approach to lower pole calyx

The upper pole is best avoided due to the risk of pneumothorax.

Renal pelvis punctures increase the risk of vascular damage and persistent urine leaks.

Generally, anterior punctures are regarded as unfavourable as there is a risk of damage to anterior structures such as bowel, liver or spleen

Question 20

GU) 27 A 32 year old woman presents with dysmenorrhoea and menorrhagia. MRI confirms the presence of a large fibroid. Which of the following statements is true regarding· uterine fibroid embolisation (UFE)?

(a) Uterine artery is usually embolised on one side

(b) The uterine artery is a branch of the posterior division of the internal iliac artery

(c) An 8 Fr catheter should be used to catheterize the uterine artery

(d) Embolisation is best achieved with coils

(e) UFE is generally not preferred for pedunculated fibroids

Answer 20

(e) UFE is generally not preferred for pedunculated fibroids

Bilateral uterine artery embolisation with particulate (PVA or microspheres) are required for satisfactory treatment.

A 4Fr catheter is a suitable size to reach the uterine artery.

The uterine artery is a branch of the anterior division of the llA.

Pedunculated fibroids may necrose their stalk and fall into the uterine or abdominal cavity, therefore UFE is not the treatment of choice.

Question 21

35 Which of the following is considered an absolute indication for an IVC filter?

(a) DVT/PE and limited cardiopulmonary reserve

(b) lliocaval DVT

(c) High risk of DVT/PE in peri-operative setting

(d) High risk of DVT/PE following trauma

(e) PE/DVT and complication of anticoagulation

Answer 21

(e) PE/DVT and complication of anticoagulation

The Society of lnterventional Radiology consensus statement indications for IVC filter insertion classify the indications as being prophylactic, ansvJ~rs (c) and (d), absolute, or relative.

Other absolute indications include a contraindication to anticoagulation, inability to achieve/maintain therapeutic anti-coagulation or recurrent DVT /PE despite anti-coagulation.

Relative indications include answers (a) and (b), also free-floating proximal DVT, massive PE/ileocaval DVT treated with thrombolysis/thrombectomy, high risk of complications from anticoagulation, or likely poor compliance with anti-coagulation.

Question 22

@# 38 Regarding catheters used for interventional angiography. Which of the following catheters is inappropriate for imaging the respective artery?

(a) Bernstein - superior mesenteric artery

(b) Cobra - renal artery

(c) Pigtail - abdominal aorta

(d) Sidewinder (Simmons) - coeliac axis

(e) Straight catheter - iliac artery

Answer 22

(a) Bernstein - superior mesenteric artery

Catheters are sized using the French system: the circumference in mm (diameter is roughly this measurement divided by 3, i.e. 6 Fr has approximately 2 mm diameter).

Sheaths are sized in French measurement of their internal diameter (i.e. a 4Fr sheath can hold a 4 Fr catheter).

Bernstein catheters are upwards pointed, thus they are ideal for accessing branches of the aortic arch.

Access to the downwardly orientated mesenteric vessels would be technically very challenging with a Bernstein catheter - the downward facing sidewinder, or even the sidefacing cobra catheters can be used.

Question 23

54 During a CT-guided lung biopsy the patient becomes acutely dyspnoeic with a ‘gasp’ reflex and retrosternal chest pain; the ECG monitor shows dysrythymias. An air embolism is suspected. Which position should the patient be placed in immediately for treatment?

(a) Erect

(b) Left lateral decubitus

(c) Prone

(d) Right lateral decubitus

(e) Supine

Answer 23

(b) Left lateral decubitus

VAE is a rare complication of lung biopsy. VAE can only occur if there is direct communication between air and the circulation and a pressure gradient favouring passage into the circulation.

‘Gasp’ reflex is described as a gasp induced when a bolus of air enters the pulmonary circulation causing acute hypoxia.

Treatment is to place the patient in the left lateral decubitus (Durant manoeuvre) and Trendelenburg (head down) positions, which helps prevent air travelling through the right heart into the pulmonary arteries, which can lead to right ventricular outflow obstruction (air lock).

100% 0 2 is also given to try and reduce the size by decreasing the nitrogen content of the air bubble.

Question 24

58 A 36 year old man has recurrent episodes of haemoptysis. Investigations reveal a solitary pulmonary AVM in the right lower lobe. An elective embolisation procedure is planned. What is the most appropriate embolisation agent to use?

(a) Autologous blood clot

(b) Coils

(c) Ethyl alcohol

(d) Gelfoam

(e) Polyvinyl alcohol

Answer 24

(b) Coils

Pulmonary AVMs may be multiple if associated with Osler-WeberRendu syndrome, and they are more common in the lower lobes (70%). Symptoms are rare, but they are an indication for treatment, and include epistaxis, dyspnoea, and cyanosis.

There is a theoretical risk of embolisation material particles passing into the systemic circulation, thus large materials such as coils or detachable balloons are used when embolisation is attempted (NB: in the USA only coils are licensed by the FDA, balloons are yet to gain approval).

Question 25

64 Which of the following statements is most accurate regarding IVC filters?

(a) Bilateral iliac vein thrombosis is a contraindication

(b) Cannot be placed above the renal veins

(c) Filter migration is common

(d) Post-procedural anti-coagulation is required for 6 weeks

(e) Retrieval is performed via the SVC

Answer 25

(e) Retrieval is performed via the SVC

Retrieval is performed via the SVC (left or ideally right IJV approach) to snare the retrieval hook at the top of the filter.

IVC filters should be sited below the renal veins to reduce the chance of renai· vein thrombosis, however, they can be sited supra-renally if the DVT extends above the renal veins.

Filter migration is very rare (0.2% of patients in the below study).

Post-procedural anticoagulation is not necessary as the filter is expecting to be effective immediately.

Bilateral iliac vein thrombosis is a contraindication to a femoral approach for filter placement, but they can still be placed in the IVC via a superior approach (IJV and SVC).

Question 26

66 Regarding a trans-jugular intrahepatic porto-systemic shunt procedure. Which of the following is incorrect?

(a) A 10 mm x 6 cm stent is appropriate

(b) A cobra catheter is used to select the hepatic vein

(c) C02 angiography is an accepted technique to outline the portal vein

(d) Portal vein patency should be demonstrated before the procedure

(e) The preferred route is via the left hepatic vein

Answer 26

(e) The preferred route is via the left hepatic vein

Access is ideally via the right IJV to the right (or middle) hepatic vein, with the shunt running from the RHV to the right portal vein; this may not be possible in conditions such Budd-Chiari syndrome where the RHV may be thrombosed.

Stents are typically of 8-12 mm diameter, length 6 cm.

Portal vein patency should be confirmed preprocedure by US, CT or angiography.

Portal vein position and patency can be demonstrated during the procedure, co2 may be used for this, as its lower viscosity allows for easier diffusion (and reduces iodinated contrast burden).

Question 27

74 A follow-up CT is performed in a patient 12 months after an endovascular aneurysm repair (EVAR) stenting for an enlarged AAA. There is enlargement of the aneurysm sac, with retrograde blood flow entering the sac via lumbar arteries, but with a complete seal around the graft attachment zones. What sub-type of endoleak does this represent?

(a) Type I

(b) Type II

(c) Type III

(d) Type IV

(e) Type V

Answer 27

(b) Type II

There are 4 types of endoleak.

Type II is also termed ‘retrograde’ or ‘non-graft related’ endoleak. Type I is due to inadequate or ineffective seal at the graft ends.

Type Ill is due to a defect in the graft fabric (mechanical graft failure).

Type IV is a minor blush of contrast due to contrast diffusion across the pores of the graft fabric; it is usually an inherent part of the graft design.

Question 28

7. A 67 year old man presents with abdominal discomfort three months after endovascular repair of an abdominal aortic aneurysm. The patient undergoes a non-contrast CT followed by an arterial phase study. There is high attenuation on the non-contrast study between the stent and the aortic wall, which enhances further in the arterial phase. The graft itself is intact, as are the attachment sites. Which of the following is the most likely cause for the appearance?

a. Type I endoleak

b. Type II endoleak

c. Type III endoleak

d. Graft infection

e. Dissection

Answer 28

7. b. Type II endoleak

Type II endoleaks are due to retrograde flow from the small branches of the aorta such as the lumbar arteries. A Type I endoleak is due to a seal failure at either end, type III is due to a defect in the graft and type IV is due to graft porosity.

Question 29

15. A 58 year old man with pancreatic cancer presents with recurrent pulmonary emboli despite adequate anticoagulation. He is shown on this admission to also have a right femoral DVT. He subsequently undergoes an IVC filter placement. Following a flus injection in the IVC, injecting contrast at which of the following site is essential prior to stent placement?

a. Right hepatic vein

b. Left renal vein

c. Right common iliac vein

d. Right renal vein

e. Left common iliac vein

Answer 29

15. e. Left common iliac vein

The presence of the renal veins will be demonstrated on the flush IVC injection, and selective injection into the renal veins is not usually necessary. However, it is mandatory to exclude a double IVC. A second IVC originates from the left iliac vein and can be a cause for failure of the filter despite good positioning.

Question 30

30. A 36 year old female with history of pelvic pain and severe dysmenorrhoea undergoes a pelvic ultrasound examination which reveals uterine fibroid disease. Which of the following imaging features would be associated with the best outcome following uterine artery embolisation?

a. Submucosal location

b. Subserosal location

c. Associated adenomyosis

d. Calcification

e. Multiple fibroids

Answer 30

30. a. Submucosal location

Subserosal fibroids, especially pedunculated ones, may often draw their blood supply from adjacent viscera, which may be a cause of failure of the procedure. They are also associated with a higher incidence of complications.

Calcific fibroids are less vascular and may not respond well to embolisation.

Bulky and multiple fibroids may need multiple interventions or surgery. Adenomyosis is a known cause for failure of the procedure.

Question 31

41. A 60 year old man who recently suffered a haemorrhagic stroke develops pulmonary emboli. He is referred for an IVC filter insertion and angiography is performed prior to this. The usual reasons for doing so would be all of the following except:

a. To identify the renal veins

b. To identify the hepatic veins

c. To size the IVC

d. To rule out the presence of a left IVC

e. To evaluate for the presence of an IVC thrombus

Answer 31

41. b. To identify the hepatic veins

The hepatic veins do not need to be identified routinely prior to filter insertion. Most filters are deployed in an infrarenal position, unless there is IVC thrombus which would preclude this, in which case the filter is positioned in suprarenal position. A left iliac injection is performed to rule out a IVC, which could be a cause of filter failure.

Question 32

52. A 36 year old female awaiting liver transplantation undergoes routine pre-operative planning ultrasound examination of the abdomen. Whilst the rest of the abdomen is normal, a 4 cm splenic artery aneurysm is seen, which is subsequently confirmed on CT. Which of the following would be the preferred course of action?

a. Follow-up ultrasound scan in a year’s time

b. Referral to the surgeons for a splenectomy

c. Thrombin injection of the aneurysm

d. Endoscopic ligation of the aneurysm

e. Coil embolisation of the aneurysm

Answer 32

52. e. Coil embolisation of the aneurysm

This patient was discovered to have an incidental asymptomatic aneurysm. Prophylactic embolisation is generally offered to three groups of patients:

1. Those who have aneurysms greater than 2.5 cm in size.
2. Those with portal hypertension.
3. Those awaiting liver transplantation.

Percutaneous splenic artery aneurysm embolisation using coils is the preferred treatment. Thrombin injection is usually preferred in cases where embolisation has failed. Aneurysms with wider necks often need additional measures such as a detachable balloon.

Question 33

GU) 54. A 47 year old with an obstructed urinary system is advised to have a percutaneous nephrostomy. Which of the following is appropriate?

a. Persistent post-procedural haematuria usually needs a nephrectomy

b. If appropriate, the preferred site of puncture on the renal surface is just anterior to the convex lateral margin

c. A lower pole calyx is preferred when ureteral intervention is planned

d. There is a 10% chance of developing haematuria post-procedure

e. In an obstructed infected system, further imaging and manipulation are usually delayed after establishing drainage

Answer 33

54. e. In an obstructed infected system, further imaging and manipulation are usually delayed after establishing drainage

The most common reasons for persistent haematuria are traumatic arteriovenous fistula, pseudoaneurysm or vascular injury, all of which are usually managed endovascularly.

Brodel’s avascular plane is just posterior to the convex lateral margin.

Whilst an easily accessible lower pole calyx is usually the target for a simple nephrostomy drainage, for ureteral interventions, a posterior calyx in the mid or upper polar region may be better.

Almost all patients develop haematuria, but 1–3% may need transfusion or further intervention.

Question 34

56. A 45 year old woman with severe portal hypertension and variceal bleeding is referred for a trans-jugular intrahepatic porto-systemic shunt (TIPSS) procedure following the failure of endoscopic procedures in controlling the bleeding. Which of the following is the most appropriate regarding TIPSS?

a. The middle hepatic vein is the preferred route of access to the portal vein

b. The right portal vein is usually posterior to the right hepatic vein

c. Flow of contrast towards the porta hepatis usually indicates puncture of the biliary tree

d. The gradient across the shunt should be less than 20mmHg

e. Stenosis tends to occur in the portal vein

Answer 34

56. c. Flow of contrast towards the porta hepatis usually indicates puncture of the biliary tree

Usually the right hepatic vein (RHV) is the preferred route of access to the right portal vein, which lies anterior to the RHV.

Flow of contrast towards the porta, and especially if it remains there, usually indicates biliary puncture.

Puncture of portal vein and hepatic artery usually result in contrast flowing to the periphery.

The shunt gradient should be < 12mm of mercury.

Stenoses usually tend to occur in the hepatic vein or the shunt itself.

Question 35

QUESTION 12 A 58-year-old woman suffers a left ureteric injury during a total abdominal hysterectomy. Postoperatively, she develops left loin pain and a fever, and ultrasound demonstrates a moderate left hydronephrosis. The clinical team are concerned that she has an infected, obstructed left kidney and request a nephrostomy. Which one of the following statements is correct regarding percutaneous nephrostomy?

A A 4 French nephrostomy catheter is adequate to drain an infected collecting system likely to contain pus.

B If the renal pelvis is punctured with the wire during a successful procedure, the patient will always require surgical repair.

C It is best to dilate the tract 1 French size bigger than the size of the intended nephrostomy catheter (eg 8F for a 7F catheter).

D It is best to directly puncture the renal pelvis.

E It is usually best to aim to puncture an upper pole calyx.

Answer 35

C It is best to dilate the tract 1 French size bigger than the size of the intended nephrostomy catheter (eg 8F for a 7F catheter).

Puncture of posterior calyces in the mid- and lower poles is optimal.

Upper pole puncture increases the risk of pneumothorax

whilst direct puncture of the pelvis increases the risk of major vascular injury and persistent urinaty leak.

If the renal pelvis is inadvertently punctured with the guidewire, once adequate drainage is obtained, this usually settles with observation.

Question 36

QUESTION 21 A 41-year-old woman is diagnosed with significant right renal arteiy stenosis and referred for angioplasty. Regarding this procedure, which one of the following statements is correct?

A Angioplasty of ostial lesions has a poorer prognosis than angioplasty of more distal lesions.

B Intra-arterial GTN to treat vasospasm is contraindicated during the procedure.

C Stenoses due to fibromuscular dysplasia don’t respond well to angioplasty

D Stenoses due to fibromuscular dysplasia tend to involve the renal artery

E The majority of renal artery stenoses are due to fibromuscular dysplasia

Answer 36

A Angioplasty of ostial lesions has a poorer prognosis than angioplasty of more distal lesions.

Ostial and proximal lesions are usually due to atherosclerotic disease.

Ostial stenoses are due to aortic wall atheroma and are prone to elastic recoil; therefore they have poor results with angioplasty alone.

As a result, many radiologists will opt for angioplasty and primary stenting in patients with ostial stenoses.

Fibromuscular dysplasia typically affects the mid-distal renal artery and responds well to angioplasty alone.

Question 37

@# 13. A 70-year-old male undergoes endovascular stent graft repair of an infrarenal abdominal aortic aneurysm. A follow-up CT at 1 year demonstrates increasing aneurysm sac diameter without any evidence of endoleak. What is the diagnosis?

A. Type I endoleak.

B. Type II endoleak.

C. Type III endoleak.

D. Type IV endoleak.

E. Type V endoleak.

Answer 37

13. E. Type V endoleak.

The main aim of endovascular or surgical treatment of abdominal aortic aneurysm (AAA) is exclusion of the aneurysm sac from the systemic high-pressure circulation.

Ongoing leakage of blood into the excluded aneurysm sac after endovascular repair is termed ‘endoleak’.

Identification of the type of endoleak and its effect on the aneurysm sac is important for further management.

Type I endoleak: Contrast/blood leak at the proximal or distal landing zones of the stent graft is described as type I endoleak. This is due to poor proximal or distal graft apposition, exposing the sac to systemic pressures with significant risk of aneurysm rupture.

This type is further subdivided into type IA (proximal aortic attachment) and type IB (distal iliac attachment). These are most commonly seen at the time of the procedure or may develop subsequently due to graft migration. They require urgent treatment.

Type II endoleak: This is due to retrograde flow into the aneurysm sac via the inferior mesenteric artery (type IIA) or lumbar arteries (type IIB). Many of these close spontaneously and are managed expectantly. Further treatment is indicated if the sac enlarges or the patient develops symptoms of sac pressurization.

Type III endoleak: Leakage of blood through the body of the stent graft due to either poor apposition of graft components or a tear in the graft material is type III endoleak. This requires urgent management due to sac pressurization.

Type IV endoleak: Aneurysm sac opacification without an identifiable source intraprocedurally is described as type IV endoleak. These are transient and usually resolve after withdrawal of anticoagulation.

Type V endoleak: Continued growth of the sac without radiological evidence of a leak is termed type V endoleak or endotension. Continued growth of the aneurysm sac will require surgical repair due to risk of rupture.

Question 38

14. A patient is referred to radiology with a diagnosis of a mass in the lung which is adjacent to, but not overtly invading, the pleura. The clinical team need a tissue type to decide on treatment. There is a history of colorectal carcinoma. You are undecided as to whether to carry out a core biopsy with a coaxial system or a fine needle aspiration (FNA). Which of these factors should have the greatest influence on your decision?

A. Pneumothorax risk.

B. Availability of a cytopathologist.

C. Tumour seeding risk.

D. Suspected cell type of the lesion.

E. Risk of air embolism.

Answer 38

14. B. Availability of a cytopathologist.

Contrary to expectations, core biopsy is not associated with a higher rate of pneumothorax as compared to FNA, especially when used to sample peripheral lesions.

Overall complication rates for the two procedures are similar.

The chance of tumour seeding is low and is postulated to be lower when coaxial systems are used.

Air embolism is also rare, although it is more common in core biopsies and when a central lesion is being sampled.

The main drawback of FNA is inadequate sampling, which frequently occurs, requiring a repeat procedure. Thus the availability of a cytopathologist to review the sample at the time, to ensure an adequate number of cells have been obtained, is essential to this being a cost-effective procedure.

Question 39

23. A 40-year-old male presents with a history of severe epigastric pain and raised amylase. CT demonstrates acute pancreatitis complicated by a 2.5- cm pseudoaneurysm of the gastroduodenal artery (GDA). Embolization of the GDA is requested. What is the accepted method of embolization?

A. Coil embolization proximal to the pseudoaneurysm.

B. Coil embolization distal and proximal to the pseudoaneurysm.

C. Embolization with polyvinyl alcohol (PVA) particles.

D. Amplatzer plug occlusion of common hepatic artery.

E. Embolization with gelfoam.

Answer 39

23. B. Coil embolization distal and proximal to the pseudoaneurysm.

Coil occlusion is the commonly used method for embolization of GDA.

GDA territory is a classic example for the concept of occluding ‘front door’ and ‘back door’. If only proximal occlusion is carried out then retrograde flow via the pancreatico-duodenal arcade will re-perfuse the pseudoaneurysm. It is therefore essential to embolize GDA proximal (inflow) and distal (outflow)to the pseudoaneurysm.

Gelfoam is a temporary embolic agent and is not used in GDA embolization.

Particles are not used in this territory.

For aneurysms of smaller arteries, branch vessel occlusion may be carried out with particles, followed by coil embolization of the proximal parent artery.

Question 40

24. A 73-year-old male diabetic patient, with poorly controlled hypertension, is referred for renal Doppler ultrasound due to an episode of flash pulmonary oedema. He has a history of stage 3 chronic kidney disease. The ultrasound shows a small left kidney, which measures 5 cm in bipolar diameter. The right kidney is also small, measuring 6 cm. The resistive indices measure 0.9 on both sides. The peak systolic velocity is 130 cm/s on the left and 150 cm/s on the right. Which interventional treatment would be recommended for this patient?

A. Renal artery angioplasty on left side.

B. Renal artery stenting on left side.

C. Renal artery stenting on right side.

D. Bilateral renal artery stenting.

E. No intervention.

Answer 40

24. E. No intervention.

The factors described are all indicators of poor outcome following renal artery intervention. Reduced renal size bilaterally indicates advanced bilateral renal disease, unlikely to respond to intervention.

The renal ultrasound Doppler patterns are also not suggestive of renal artery stenosis, which is indicated by a peak systolic velocity of greater than 180 cm/s. Resistive indices of greater than 0.7 indicate a likelihood of improvement after intervention.

Question 41

29. You are the interventional radiology fellow in your hospital. A nephrologist has asked you for an opinion on four patients they feel require renal arterial intervention.

Patient A is a 68-year-old male who has had a catheter angiogram which showed a 60% narrowing in the right renal artery. This patient has refractory hypertension.

Patient B is a 42-year-old female, also with refractory hypertension. She has had an MR angiogram, which has shown a number of stenoses, with intervening mild aneurysm formation, in the proximal right renal artery.

Patient C is a 72-year-old female with impaired renal function, who underwent captopril renal scintigraphy. On the baseline study, there was a similar appearance of the kidneys. On the captopril study, there was a differential split of renal function of 15% between the right and left kidney, with a decrease of time to peak activity of 320 seconds. The final

patient D had a renal Doppler ultrasound, which showed a biphasic flow pattern in the segmental arteries, with a slow upstroke. Which of these patients has significant atherosclerotic renal artery stenosis?

A. Patients A and B.

B. Patients C and D.

C. Patients A, C, and D.

D. Patients B, C, and D.

E. All of them.

Answer 41

29. B. Patients C and D.

A 70% stenosis is taken as the cut-off for significant stenosis.

Patient B is atypical in their age. They also have imaging characteristics typical of fibromuscular dysplasia.

Patients C and D have classical imaging features of renal artery stenosis (RAS). With regard to ultrasound diagnosis using Doppler, this is made by either showing flow acceleration immediately distal to the site of stenosis or showing dampened flow in the segmental arteries.

In the renal artery, a peak systolic velocity of over 180 cm/s combined with a renal/aortic velocity ratio of over 3 is reported as being the most sensitive method of detecting RAS.

Question 42

33. A 70-year-old man undergoes a trans-femoral angiogram as a day procedure. Haemostasis is achieved by manual compression to the puncture site for 15 minutes. The next day he returns to A&E with a history of pain and swelling in the groin. On examination a tender, pulsatile swelling is noted in the groin at the site of femoral puncture. Doppler ultrasound confirms a femoral artery pseudo-aneurysm. Which of the following statements regarding iatrogenic femoral artery pseudoaneurysm is false?

A. It is contained only by the haematoma and surrounding tissues.

B. Patients undergoing haemodialysis are at increased risk of developing pseudoaneurysm.

C. Low femoral puncture is associated with a higher risk of developing pseudoaneurysm.

D. Ultrasound is the diagnostic method of choice.

E. Ultrasound-guided compression is the treatment of choice.

Answer 42

33. E. Ultrasound-guided compression is the treatment of choice.

Femoral artery pseudoaneurysm has been reported to occur in 0.2% of diagnostic and 8% of interventional procedures.

Femoral pseudoaneursym is contained only by the haematoma and the pressure of the surrounding tissues. It is therefore at a high risk of rupture.

A number of risk factors for pseudoaneurysm formation have been identified. Patient factors include obesity, anticoagulation, haemodialysis, and calcified arteries.

Procedural factors include low femoral punctures, superficial femoral or profunda punctures, and inadequate compression post procedure.

Doppler ultrasound is the diagnostic method of choice.

A fluid collection adjacent to femoral artery puncture site with ‘yin yang’ internal flow is diagnostic.

Ultrasound guided thrombin injection is the treatment method of choice.

Question 43

GU) 42. A 35-year-old female presents with a history of menorrhagia. MRI of pelvis demonstrates a fibroid uterus for which treatment with high-intensity focused ultrasound (HIFU) is proposed. What is the principle mechanism of action of HIFU?

A. Coagulation necrosis.

B. Apoptosis.

C. Cavitation.

D. Microstreaming.

E. Radiation forces.

Answer 43

42. A. Coagulation necrosis.

HIFU is a non-invasive method to treat solid tumours or haemorrhage.

As HIFU is essentially ultrasound, it requires an acoustic window to transmit ultrasound energy and is subject to similar artefact.

The principle effect of HIFU is heat generation from absorption of acoustic energy.

This causes coagulation necrosis within seconds.

Hyperthermia also induces apoptosis, which can be an important delayed effect in tissue exposed to lower energy HIFU.

This mechanism is also a potential limitation of HIFU as adjacent tissue may be at risk.

Mechanical effects such as cavitation and microstreaming are also seen with the use of higher ultrasound intensity

Question 44

GU) 47. A 46-year-old female with pressure symptoms related to uterine fibroids is referred for fibroid embolization. Which of the following complications is the patient at increased risk of?

A. Uterine sepsis.

B. Fibroid passage.

C. Fibroid regrowth.

D. Ovarian dysfunction.

E. Hysterectomy

Answer 44

47. D. Ovarian dysfunction.

Ovarian dysfunction is a known complication of fibroid embolization. The exact mechanism is not known, but inadvertent embolization of the ovaries via a uterine–ovarian anastomosis has been suggested. There is a higher prevalence of uterine–ovarian anastomosis in women over 45 years of age and that puts them at increased risk.

Question 45

54. A 25-year-old with a history of cystic fibrosis presents with massive haemoptysis. Bronchial artery embolization is requested. Which of following statements regarding bronchial artery embolization is false?

A. A descending thoracic aortogram is performed prior to selective bronchial angiography.

B. Bronchial angiography is performed with manual injection of contrast medium.

C. The abnormal bronchial artery is embolized at its origin.

D. Polyvinyl alcohol particles (diameter of 350–500 μm) may be used as the embolic material.

E. Chest pain is the most common complication.

Answer 45

54. C. The abnormal bronchial artery is embolized at its origin.

Bronchial artery embolization (BAE) is an established procedure in the management of massive haemoptysis.

Knowledge of the bronchial artery anatomy and its variations is essential in carrying out the procedure safely.

A preliminary descending thoracic aortogram is performed to identify the number and site of origin of the bronchial arteries.

Abnormal bronchial arteries are visualized on the preliminary thoracic aortogram in the majority of affected patients.

Selective bronchial angiography is performed with manual injection of contrast.

Selective bronchial artery catheterization and safe positioning distal to the origin of spinal cord branches is essential to avoid spinal cord ischaemia/infarction.

Polyvinyl alcohol particles (350–500 μm diameter) are the most frequently used embolic agent.

Smaller particles can freely flow via the intrapulmonary shunts, causing pulmonary or systemic infarcts.

Chest pain is the most common complication (24–91%). Other complications include dysphagia (due to embolization of oesophageal branches), dissection of the bronchial artery or aorta (usually self-limited), and spinal cord ischaemia.

Question 46

60. A 58-year-old smoker with a history of hypertension and diabetes presents with chest pain typical of angina and is referred for CT coronary angiography. This reveals soft plaque in the proximal left anterior descending (LAD) artery, which is causing a 40% stenosis by area and calcified plaque in the right coronary artery (RCA), which is causing a 50% stenosis by area. Which of the following is the most appropriate next step?

A. Percutaneous coronary intervention (PCI) to the LAD.

B. PCI to the RCA.

C. PCI to both vessels.

D. Exercise stress testing.

E. Lifestyle and risk factor modification.

Answer 46

60. E. Lifestyle and risk factor modification.

A stenosis is suitable for PCI when it is greater than 75% and may be suitable when it lies between 50 and 75%, depending on the minimal luminal area (MLA) and functional significance.

Those stenoses less than 50% are not generally suitable for intervention and require medical management only (however, the minimal luminal area of the LMS and proximal main vessels are also taken into account by some authors).

Unfortunately the blooming artefact caused by calcium will cause overestimation of the size of a calcified plaque on CT coronary angiography and this remains a great limitation of the technique.

In some cases this will make a vessel appear completely occluded by calcium when it is not and an alternative investigation, e.g. catheter angiography, is required.

In this question, the calcified plaque will appear to cause a 50% stenosis, when in fact the stenosis is much smaller, certainly less than 50%.

The LAD stenosis is too small to require treatment (assuming the vessel is of adequate size).

Exercise stress testing is not of any particular use, as we have shown no need for revascularization and it would not alter management, which should be aggressive treatment of hypertension, hyperlipidaemia, diabetes, and lifestyle modification

Question 47

GU) 62. A 28-year-old male with a history of von Hippel Lindau disease and a 3-cm renal cell carcinoma undergoes cryo-ablation. Which of the following is suggestive of incomplete treatment/recurrence?

A. Hypodense ablation zone larger than the original tumour.

B. Lack of enhancement in the ablation zone.

C. Ablation zone unchanged in size over time.

D. Peripheral ring enhancement.

E. Perinephric fat-stranding post procedure.

Answer 47

62. C. Ablation zone unchanged in size over time.

Following ablation the treatment zone is larger than the original lesion, as a margin of normal tissue is intentionally ablated to prevent recurrence.

This should reduce in size/involute over time.

If the ablation zone remains the same or increases in size, recurrence should be suspected.

Lack of enhancement is a reliable indicator of successful treatment.

It is not uncommon to find peripheral enhancement in the immediate post-treatment period due to reactive hyperaemia.

Any nodular or central enhancement indicates incomplete treatment or recurrence.

Question 48

71. A 50-year-old male smoker presents with a history of right-sided calf claudication. The symptoms are not settling with best medical therapy. The magnetic resonance angiogram (MRA) shows occlusion of the right common and external iliac arteries. He is otherwise well and has normal calf veins. What is the recommended treatment for this type of lesion?

A. Symptomatic relief.

B. Continue modification of risk factors and exercise therapy.

C. Percutaneous angioplasty.

D. Percutaneous stenting.

E. Surgical bypass.

Answer 48

71. E. Surgical bypass.

According to the trans-Atlantic intersociety consensus (TASC) for management of peripheral arterial disease, aorto-iliac lesions are classified into four groups: A, B, C, and D.

The MR angiography findings in this case fall into group D.

For TASC A lesions (generally short stenosis) endovascular therapy is the treatment of choice

and for TASC D lesions (complex/long occlusions) surgical bypass is the treatment of choice.

For TASC B and C lesions, the patient’s co-morbidities, patient preference, and local operator’s long-term success rates should be considered.

TASC recommends endovascular treatment for type B lesions and surgery for goodrisk patients with type C lesions.

Question 49

@# GIT) 71. A 50-year-old male with a 2.5-cm hepatocellular carcinoma undergoes RFA. Which of the following findings is uncommon in the immediate post-ablation period?

A. Transient peri-ablational hyperemia.

B. Small number of tiny intra-lesional air bubbles.

C. Arterio-portal shunting.

D. Ablation zone larger than the primary lesion.

E. ‘Mural nodule in cyst’ pattern.

Answer 49

71. E. ‘Mural nodule in cyst’ pattern.

RFA produces thermally-induced coagulation necrosis, which manifests usually as an oval or round defect on contrast-enhanced CT.

The ablation zone is slightly larger than the actual lesion to achieve curative treatment and prevent local recurrence, which is usually seen at the margins of the ablation zone.

The following findings are common in the immediate post ablation period: transient peri-ablational hyperemia, tiny air bubbles, and arterioportal shunting.

A ‘mural nodule in cyst’ indicates the development of a bilobar as a complication of RFA. This is usually seen several months after treatment. It is associated with interval enlargement of the RFA zone.

Question 50

19 A 32-year-old man with known hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) was admitted for elective embolisation of a pulmonary arteriovenous malformation. What would be the most appropriate material with which to embolise this lesion?

a Coils

b PVA particles

c Glue

d Lipidol

e Alcohol

Answer 50

19 Answer A: Coils

Pulmonary arteriovenous malformation can be embolised with coilsiballoons. There is a risk of embolisation to the systemic circulation with the other options

Question 51

MSK) 39 You are preparing the equipment required to perform a bone biopsy. When would a coaxial (introducersheathed) needle offer an advantage?

a To biopsy a deep lesion

b To biopsy a superficial lesion

C To biopsy a large, easy to target lesion

d To obtain a larger specimen

e To reduce cost

Answer 51

39 Answer A: To biopsy a deep lesion

Although more expensive, introducer-sheathed biopsy needles have the advantage of allowing deeper biopsies to be taken.

They are often used for smaller, more difficult to target biopsies.

Smaller specimens are taken with introducer-sheathed needles.

Question 52

63 An 82-year-old man with worsening symptoms of lower limb arterial insufficiency underwent MR angiography which demonstrated a short superficial femoral artery stenosis. On transfer to the intervention suite an 18-gauge intravenous cannula was sited in his antecubital fossa and he was given 2 L per minute oxygen via nasal cannulae. A femoral catheter was inserted and shortly after the first diagnostic images he complained of feeling unwell and developed facial swelling and an audible wheeze. What should be your first action?

a Call for the resuscitation team

b Give intravenous adrenaline

C Give intravenous hydrocortisone

d Remove the femoral arterial catheter

e Site a large-bore intravenous cannula

Answer 52

63 Answer A: Call for the resuscitation team

Reactions to iodinated contrast include: nausea/vomiting, bronchospasm, laryngeal oedema, hypotension, generalised anaphylactoid reaction, contrast medium extravasation and delayed skin reactions. The symptoms described are of a generalised anaphylactoid reaction. Royal College of Radiologists. Standards for Iodinated Intravascular Contrast Agent Administration to Adult Patients.

Question 53

66 When planning an endovascular stenting procedure, the internal luminal diameter of the common femoral artery is measured at 6 mm. Assuming that this measurement is accurate and that the vessel will not stretch, what is the largest size vascular catheter that could theoretically be introduced into this vessel?

a 2 Fr

b 6 Fr

c 12 Fr

d 18 Fr

e 24Fr

Answer 53

66 Answer D: 18 Fr

The French Catheter Scale is used to grade the circumference of catheters. The French size is equivalent to three times the diameter in millimetres. Thus a 6-mm lumen will accept an 18 Fr catheter.

Question 54

70 A patient underwent endovascular repair of an abdominal aortic aneurysm. After the endograft had been successfully sited a check angiogram showed opacification of the aneurysm sac by retrograde flow through the inferior mesenteric artery. What type of endoleak is this?

a Type I endoleak

b Type II endoleak

C Type III endoleak

d Type IV endoleak

e Type V endoleak (endotension)

Answer 54

70 Answer B: Type II endoleak

Endoleaks are common immediately post EVAR and most resolve spontaneously. They are classified as follows: I Leak from proximal or distal graft attachment site II Retrograde filling of sac from persistent collateral vessel III Leak from midgraft/component junction IV Leak through porous graft material V Endotension

Question 55

5 A patient with extensive, multi-system arterial disease was scheduled for a lower limb vascular study and intervention. Due to their comorbidities carbon dioxide was considered as a contrast agent rather than iodinated contrast. When should carbon dioxide not be used?

a Intra-arterially below the diaphragm

b Intra-arterially in suspected arteritis

c Intravenously in the presence of an inferior vena cava filter

d Intravenously in Eisenmenger’s syndrome

e Intravenously in the presence of a deep venous thrombosis

Answer 55

Answer D: Intravenously in Eisenmenger’s syndrome

Carbon dioxide is a useful negative vascular contrast agent in situations where iodinated contrast is contraindicated. The main risk is cerebral toxicity and it should therefore be avoided intra-arterially above the diaphragm and intravenously in patients with a right-to-left shunt.

Question 56

24 An individual underwent a stent graft repair of an infra-renal aneurysm a day prior. He presents for a followup CT aortogram. A blush of contrast is seen near the end of the stent graft. Which type of endoleak is most compatible with the CT aortogram finding?

a Type I

b Type 11

C Type III

d Type N

e This is a normal finding within 24-48 hours after stent grafting

Answer 56

24 Answer A: Type I

In a type I endoleak, there is blood flow into the aneurysm sac due to incomplete seal or ineffective seal at the end of the graft. This type of endoleak usually occurs in the early course of treatment, but may also occur later.

Question 57

GU) 26 A 40-year-old woman with menorrhagia is referred for possible uterine artery embolisation. Which type of fibroid would put her at highest risk of surgical intervention following the procedure?

a Submucosal fibroid

b Pedunculated submucosal fibroid

C Subserosal fibroid

d Pedunculated subserosal fibroid

e Intramural fibroid

Answer 57

26 Answer D: Pedunculated subserosal fibroid

Uterine artery embolisation is recommended only in symptomatic patients (pain, bleeding and pressure symptoms). Subserosal pedunculated fibroids are a relative contraindication as the risk of detachmen from the uterus is high, which would require surgical treatment.

Question 58

63 A patient is due for an angiographic examination but is concerned due to a previous complication following angiography. On his previous admission he developed a femoral pseudoaneurysm (false femoral aneurysm) which required surgical exploration. He asks you how likely this is to happen again. What would make another false femoral pseudoaneurysm more likely?

a Catheterisation of the common femoral artery

b Diagnostic angiography

C High femoral puncture

d Obesity

e Overly vigorous post-procedure compression

Answer 58

63 Answer D: Obesity

There are a number of factors that increase the risk of femoral pseudoaneurysm formation:

Procedural factors: interventional rather than diagnostic procedures, catheterisation of artery and vein and catheterisation of SFA or profunda.

Poor technique: low femoral puncture and inadequate compression post procedure.

Patient factors include: obesity, anticoagulation, haemodialysis and calcified arteries.

Question 59

GIT) 37 A 37-year-old male with known alcoholic liver disease causing severe cirrhosis and multiple previous admissions for gastrointestinal haemorrhage was recently treated with a transjugular intrahepaticporto-systemic shunt (TIPS). Unfortunately, he has developed encephalopathy as a result of decompensated liver disease and the gastroenterologist would like to know if the TIPS is patent. What is the most appropriate first-line investigation to determine this?

a Ultrasound of the liver with Doppler

b Triple-phase intravenous contrast-enhanced CT

C Time of flight gadolinium-enhanced MR

d Fluoroscopy with venous catheter-based contrast injections

e Double-phase intravenous contrast-enhanced CT

Answer 59

37 Answer A: Ultrasound of the liver with Doppler

Doppler ultrasound is a reliable, non-invasive method in assessing shunt patency.

Question 60

GU) 62 A 79-year-old male has locally advanced prostate cancer causing left distal ureteric obstruction and retrograde stent insertion has failed. You are to perform an emergency percutaneous nephrostomy to relieve the acute obstruction and you plan to replace this electively with an anterograde ureteric stent. What is the ideal site of puncture into the collecting system?

a Anterior upper pole calyx

b Posterior upper pole calyx

c Anterior lower pole calyx

d Posterior interpolar calyx

e Renal pelvis

Answer 60

62 Answer D: Posterior interpolar calyx

The posterior approach is associated with less bleeding complications. Either an interpolar or lower pole calyx may be used for percutaneous nephrostomy, but the angle made from an interpolar entry site facilitates ureteric stent insertion.

Question 61

64 A cardiology inpatient underwent an ultrasound examination of the groin that showed a 5-cm lesion immediately superficial to the proximal superficial femoral artery. On colour duplex this lesion demonstrated turbulent flow. There was no evidence of communication with the venous system. There was no evidence of infection. What is the most appropriate treatment?

a Observation and routine ultrasound at four weeks

b Application of a manual compression device

C Ultrasound-guided compression

d Percutaneous thrombin injection

e Surgical exploration

Answer 61

64 Answer D: Percutaneous thrombin injection

It is likely the patient has a false femoral aneurysm following a percutaneous intervention.

Question 62

65 An 82-year-old female patient was undergoing a percutaneous transhepatic cholangiogram and biliary stent insertion to relieve jaundice related to a hilar cholangiocarcinoma. She was anxious and found the procedure painful so was given several intravenous boluses of midazolam and fentanyl during the procedure. After 45 minutes she had received a total of 12 mg of midazolam. Her respiratory rate was noted to be low and she became less responsive. What is the most appropriate flumazenil regime in this situation?

a 200 mg IV bolus over 15 seconds followed by 100 mg at 1-minute intervals up to a maximum of 1000 mg

b 500 mg N bolus over 15 seconds followed by 250 mg at 1-minute intervals up to a maximum of 5 000 mg

C 1000 mg bolus

d 100-400 mg/hr infusion

e 1000-4000 mg/hr infusion

Answer 62

65 Answer A: 200 mg IV bolus over 15 seconds followed by 100 mg at oneminute intervals up to a maximum of 1000 mg

Midazolam is a short-acting benzodiazepine and is widely used in interventional procedures. It should be used with particular caution in the elderly, where it is more likely to cause respiratory depression and agitation. Flumazenil (Anexate®) reverses the action of midazolam and other benzodiazepines. An infusion of 100-400 mg/hr can be used for longer-acting benzodiazepines but, for rapid reversal, an initial 200-mg bolus is most appropriate.

Question 63

@# 66 A 74-year-old man was being investigated by a cardiologist for repeated episodes of `flash’ pulmonary oedema. He was hypertensive and echocardiography showed good left ventricular function. Renal artery Doppler and subsequent MR angiography confirmed severe bilateral renal artery stenosis. He was known to have benign prostatic hypertrophy, but there was no renal collecting system dilatation on ultrasound. Following extensive discussion, the decision was made to attempt bilateral renal artery stenting. What benefit over optimal medical therapy is this most likely to result in?

a Improve hypertension

b Improve renal function

C Improve symptoms of prostatism

d Reduce episodes of pulmonary oedema

e Reduce mortality

Answer 63

66 Answer D: Reduce episodes of pulmonary oedema

The role of angioplasty and stenting in renal artery stenosis is controversial. The preliminary results of the ASTRAL (Angioplasty and STent for Renal Artery Lesions) trial show that stenting offers no benefit above medical treatment in terms of hypertension, renal function or mortality. It is likely that in hypertensive patients, with preserved left ventricular function, stenting reduces episodes of `flash’ non-cardiogenic pulmonary oedema.

Question 64

67 A 42 -year-old woman with symptoms of dyspareunia and dysmenorrhoea was found to have bulky uterine fibroids on ultrasound. Following discussion with her gynaecologist she was referred for uterine artery embolisation. During the embolisation procedure it is noted that a significant degree of the fibroid blood supply is derived from the ovarian artery. With the aim of temporarily occluding the ovarian artery, what embolic agent is most appropriate?

a Cyanoacrylate (glue)

b Ethyl alcohol

C Gelfoam

d Polyvinyl alcohol

e Steel coils

Answer 64

67 Answer C: Gelfoam

Temporary embolic agents include: autologous blood clot and gelfoam.

Permanent agents include: ethyl alcohol, steel coils, polyvinyl alcohol and glue. New embolic agents are frequently being introduced and this is, by no means, an exhaustive list.

Question 65

GU) 67 A 50-year-old patient is undergoing investigations for acute renal failure. Which is the following is a contraindication to renal biopsy?

a Warfarin therapy

b Presence of large renal cysts

C Hydronephrosis

d Platelet count of 150 000/mL

e Single kidney

Answer 65

67 Answer E: Single kidney

The main complication to renal biopsy is haemorrhage and thus the presence of a single kidney is a contraindication in case of catastrophic bleeding, although fortunately this is uncommon. Less than 5% of patients require transfusion or surgery and mortality is 1 in 1000.

Question 66

68 A 53-year-old alcoholic was admitted with oesophageal variceal bleeding and decompensated alcoholic liver disease. Repeated endoscopy with attempted sclerotherapy and banding was unsuccessful in resolving the bleeding and a transjugular intrahepatic portosystemic shunt (TIPS) procedure was considered. What would be an absolute contraindication to TIPS?

a Ascites

b Budd-Chiari syndrome

C Hepatic encephalopathy

d Hepatic failure

e Severe right-sided heart failure

Answer 66

68 Answer E: Severe right-sided heart failure

The only absolute contraindications to TIPS are severe right-sided heart failure with elevated central venous pressure and polycystic liver disease. Relative contraindications include active infection, severe encephalopathy, portal vein thrombosis, hypervascular liver tumours and hepatic failure.

Question 67

70 You are undertaking a lower limb angiogram in a patient with an acutely ischaemic limb and are considering using intra-arterial thrombolysis. In which of the following situations would you be happy to administer rtPA?

a The patient underwent cardiopulmonary resuscitation one week ago

b The patient is known to have cerebral metastases

c The patient reported an episode of haematemesis

d The patient is pregnant

e The patient received streptokinase 10 years ago

Answer 67

70 Answer E: The patient received streptokinase 10 years ago

Contraindications to thrombolysis include: recent trauma, surgery or CPR (within two weeks), brain tumour or CVA within two months, bleeding tendency, irreversible limb ischaemia and pregnancy.

Question 68

5 A patient was due to have an aortic stent graft. The native artery measured 28-30 mm in diameter. What diameter of stent would be most appropriate?

a 25mm

b 28mm

c 30mm

d 33 mm

e 36mm

Answer 68

Answer D: 33 mm

Usually a stent is oversized by approximately 10% to ensure a seal.

Question 69

GU) 44 A 21-year-old man presented with a dull ache in the left side of his scrotum and was found to have a varicocele. He is considering embolisation as a treatment. What should be discussed during the process of obtaining consent?

a Risk of testicle infarction in 3%

b Infertility risk

C No symptom improvement in approximately 10%

d Sedation as it is usually required

e Need for three weeks of prophylactic antibiotics post procedure

Answer 69

44 Answer C: No symptom improvement in approximately 10%

This is usually due to unseen vein duplication or the symptoms not being related to the varicocele.

Question 70

GU) 52 A 52-year-old woman underwent radiofrequency (RF) ablation of a small renal tumour three months previously and has a follow-up CT scan. What are the expected findings?

a Low attenuation central mass with peripheral nodular enhancement

b An enhancing mass of similar appearance to before ablation

c Bull’s-eye appearance of central treated tumour surrounded by a thin soft-tissue rim, with thin halo of fat separating the two

d Non-enhancing central mass with a thin uniform rim of enhancement

e No detectable ablated mass

Answer 70

52 Answer C: Bull’s-eye appearance of central treated tumour surrounded by a thin soft tissue rim, with thin halo of fat separating the two

The typical appearance of RF-ablated renal tumours is of a central non-enhancing mass, clearly demarcated from normal enhancing renal parenchyma.

Peripheral or exophytic tumours additionally have a thin double halo of outer soft-tissue density and inner normally appearing fat. This finding is likened to a bull’s-eye appearance, and is seen on CT and MR.

The central ablation zone is typically hypointense on T2-weighted images.

Any nodular enhancing tissue is likely to represent residual or recurrent disease.

Cryoablated renal tumours often show a thin rim of enhancement, however, and are often not detectable at two years, unlike RF-ablated lesions when a mass is invariably still present

Question 71

61 A patient with lower limb ischaemia underwent diagnostic angiography. Therapeutic options including angioplasty, stent insertion, thrombolysis and surgery were considered. When is thrombolysis most appropriate?

a Acute limb ischaemia

b Chronic limb ischaemia

C Claudication

d Irreversible ischaemia

e `White limb’

Answer 71

61 Answer A: Acute limb ischaemia

Indications for thrombolysis include: acute or acute-on-chronic ischaemia, graft thrombosis, thrombosed popliteal aneurysm and periprocedural thrombolysis.

Question 72

62 An 82-year-old arteriopath patient was found to have a palpable pulsatile abdominal mass and ultrasound confirmed an abdominal aortic aneurysm. He was fit enough for either open or endovascular repair and an abdominal CT angiogram was performed to assess suitability for EVAR (endovascular aortic repair). What would make EVAR unfavourable?

a Extension of aneurysm into one common iliac artery

b Infra-renal aneurysm

C Long aneurysmal neck (>15 mm)

d Narrow iliac arteries (<8 mm)

e Neck angulation of 30 degrees

Answer 72

62 Answer D: Narrow iliac arteries (<8 mm)

Although the exact measurements vary between EVAR systems, the principles are the same. Relativecontraindications include:

narrow (<8 mm) or angulated iliac arteries,

short (<15 mm), angulated (>60 degrees) or tapering proximal neck

or if the graft is likely to occlude visceral arteries.

Graft technology is constantly evolving and new developments (e.g. fenestrated grafts) may overcome some of these issues.

Question 73

63 An individual underwent a stent graft repair of an infra-renal aneurysm and was followed up with CT aortography the next day. A blush of contrast was seen within the aneurysm sac close to the origin of a small branch from the aorta. What is the next appropriate step in management?

a Prompt surgical correction

b Reduce the systemic blood pressure to less than 120/70

c No immediate intervention: follow up but may be self-limiting

d Reimage only if the patient becomes symptomatic

e Normal finding

Answer 73

63 Answer C: No immediate intervention: follow up but likely to be self-timing

Type II endoleaks may cease if the aneurysm sac thromboses and the flow stops. If they persist, the aneurysmal sac may continue to expand.

Question 74

10. A patient with history of underlying heart condition was diagnosed with a liver lesion. Which of the following is a contraindication for ultrasound-guided liver biopsy?

(a) HIV positive patient

(b) INR 1.5

(c) Suspected metastasis

(d) Suspected haemangioma

(e) Obesity

Answer 74

10. (d) Suspected haemangioma

Other options are not contraindications for biopsy.

Question 75

24. Which of the following are correct regarding bronchial artery embolization (BAE): (T/F)

(a) The smallest available polyvinyl alcohol (PVA).

(b) Recurrence of haemoptysis after BAE is rare.

(c) The bronchial arteries originate directly from the ascending thoracic aorta in 90% of cases.

(d) An arch aortogram is usually performed prior to selective bronchial angiography.

(e) Chest pain is the most common complication.

Answer 75

Answers:

(a) Not correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Very small particles can freely flow through the microcirculation and shunts causing infarcts, thus 350 – 500 micro m PVA particles are used.

Long term recurrence rates are between 10% - 52% with a mean follow up period of 1 to 46 months.

The bronchial arteries originate directly from the descending thoracic aorta most commonly between T5 and T6 vertebrae. The left main bronchus is a useful landmark in angiography, marking the origin of bronchial arteries in most cases.

Descending thoracic aortogram is usually performed.

Question 76

25. Which of the following are correct regarding causes of failure of uterine fibroid embolization (UFE): (T/F)

(a) Failure to catheterize both uterine arteries.

(b) Collaterals supply from ovarian artery.

(c) Use of a micro-catheter for particle delivery.

(d) Embolization particle aggregation.

(e) Use of glycerol trinitrate.

Answer 76

Answers:

(a) Correct

(b) Correct

(c) Not correct

(d) Correct

(e) Not correct

Explanations:

Micro-catheters facilitate ut artery catheterization and may help avoid spasm.

Glycerol trinitrate is a vasodilator.

Question 77

26. Which of the following are correct regarding endoleaks following endovascular abdominal aortic aneurysm (AAA) repair: (T/F)

(a) Type I endoleaks present months or years after AAA repair.

(b) Graft fracture can result in a Type III endoleak.

(c) Type II endoleaks require urgent interventional management.

(d) Type IV endoleaks are the result of graft porosity.

(e) CT demonstrates the cause of Type V endoleak in 20-30% of cases.

Answer 77

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Correct

(e) Not correct

Explanations:

Type I endoleaks usually occur early and may be seen on the on-table angiogram immediately after stent-graft deployment as they occur due to ineffective seal at the graft ends. It has poor prognosis if left untreated.

Type II endoleaks management is controversial, some favouring a conservative approach. Embolization of feeding artery may be performed.

Type V endoleaks refers to endopressure /endotension which is basically aneurysm sac expansion in absence of obvious endoleaks on follow up CT. it has been associated with aneurysm expansion and rupture.