IR Flashcards
1
Q
Injection rates and total volume of Aortogram (aortic arch)?
A
20 for 30
2
Q
Injection rates and total volume of abdominal aorta?
A
20 for 20
3
Q
Injection rates and total volume of inferior vena cavogram?
A
20 for 30
4
Q
Injection rates and total volume of mesenteric artery?
A
5 for 25
5
Q
Injection rates and total volume of renal artery?
A
5 for 15
6
Q
Injection rates and total volume of distal artery?
A
3 for 12
7
Q
1 Fr = ? mm
A
1 Fr = 0.33 mm
8
Q
Difference between a sheath and catheter?
A
A sheath has a defined luminal diameter; however, the overall diameter of the catheter will be slightly larger
9
Q
Branches of the SMA?
A
Inferior pancreaticoduodenal artery - first branch - forms collaterals with the celiac atery.
Middle Colic Artery - supplies the transverse colon. Anastomoses with the marginal artery of Drummond.
Right Colic Artery - courses retroperitoneally, where it supplies the right colon and hepatic flexure
Ileocolic Artery - terminal artery - sends arterial branches to the terminal ileum, cecum, and appendix.
10
Q
Terminal branch of the SMA?
A
Ileocolic artery - sends arterial branches to the terminal ileum, cecum, and appendix.
11
Q
Branches of the IMA?
A
Left colic artery - supplies the descending colon
Sigmoid arteries- run in the sigmoid mesocolon to supply the sigmoid.
Superior rectal (hemorrhoidal) artery - supplies the upper rectum.
12
Q
Terminal branch of the IMA?
A
Superior rectal (hemorrhoidal) artery - supplies the upper rectum.
13
Q
How to interpret an angiogram?
A
What, where, when, VIA (vessels, interventions, anything else)
What - type of study is it? - DSA, venogram; Flush catheter in a large vessel or selective/superselective angiogram?
Where - in the body is the catheter located and in which vessel?
When - early arterial phase, late arterial phase, parenchymal phase, or venous phase?
Vessels - contrast going where it shouldn’t - active extravasation or neovascularity? Normal vessel contour? - Dissection, irregularity, stenosis, or encasement (external compression)?
Interventions - Any prior stents, grafts, filters, coils, surgical clips, or drains?
Anything else - any other finding on the film? Bony fracture to suggest trauma?
14
Q
What can a low femoral artery stick lead to?
A
AVF due to femoral vein passing posterior
15
Q
How is balloon sized?
A
diameter (mm) x length (cm)
Size 1-2 cm longer than stenosis
10% oversizing of arterial stent
20% oversizing of venous stent.
16
Q
What does balloon noncompliance mean?
A
Fixed diameter that does not expand no matter the air pressure- inflated above, will pop.
Size balloon 10-20% larger than vessel diameter.
17
Q
Difference between self-expandable and balloon-expandable stents?
A
Balloon-expandable = higher radial force upon deployment, but will not rebound if crushed - suboptimal for sites of external compression - joints or adductor canal in the leg.
Self-expandable - more flexible and trackable through vessels - use when lesion is tortuous or when the anatomy is prone to external compression.
18
Q
What is sodium tetradecyl sulfate?
A
Sclerosing agent - vascular malformations and varices.
19
Q
What is cyanoacrylate?
A
glue
20
Q
What are C2 and SOS catheters?
A
Reverse curved-tip catheters
21
Q
What is a Bernstein catheter?
A
Angled-tip catheter
22
Q
A quality of standard wires?
A
Floppy tip or J-tip
23
Q
What is a Bentson wire?
A
Typical floppy tip wire
24
Q
What is a Rosen wire?
A
J-tip wire
25
Where does a left-sided SVC drain?
Coronary sinus to RA
Weak association with CHD. Double SVC has stronger association with CHD.
26
What is the Vein of Sappey?
SVC obstruction - get collateral flow through the vein of Sappey causing increased enhancement of hepatic segment IVa.
Drains the liver in the region of the falciform ligament and communicates with the internal thoracic veins.
27
What do you need to look for prior to pulmonary artery angio?
LBBB.
Can cause temporary RBBB which together can be fatal.
28
What are the normal right-sided pressures?
RA: 0-8 mmHg
RV: 0-8 mmHg diastolic; 15-30 mmHg systolic
PA: 3-12 mmHg diastolic; 15-30 mmHg systolic
29
Patients with what syndrome will have multiple pulmonary AVMs?
Hereditary Hemorrhagic Telangectasia (HTT) - previously known as Osler-Weber-Rendu syndrome.
Can present as brain abscess (R-L shunt), stroke, or recurrent epistaxis (nasal mucosa tenalgectasia).
Coil. No particles b/c of R-L shunt
Treat if symptomatic or if feeding artery >3 mm
30
What is massive hemoptysis?
>300 mL/24 hours
US- cystic fibrosis and thoracic malignancy
Worldwide- TB and fungal infection
31
Where does the Left gastroepiploic artery arise?
Splenic
32
Where does the Right gastroepiploic artery arise?
GDA
33
Where does the cystic artery arise?
R hepatic
34
Where does the Right Gastric Artery arise?
Common/Proper Hepatic
35
Where does the Dorsal Pancreatic Artery arise?
Splenic Artery
36
Where does the Superior Pancreaticoduodenal artery arise?
GDA
37
Branches of the Anterior Division of the Internal Iliac Artery?
Supplies the pelvic viscera
```
Inferior/Middle Rectal
Vesicle
Uterine
Obturator
Inferior Pudendal
Inferior Gluteal
```
38
Branches of the Posterior Division of the Internal Iliac Artery?
Supplies the musculature of the pelvic and gluteal regions.
Superior Gluteal
Iliolumbar
Lateral Sacral
39
Branches of the External Iliac?
Inferior Epigastric
Deep Circumflex Iliac Artery - anastomosis with the internal iliac via the iliolumbar artery.
Femoral Artery
40
What are the Celiac-SMA anastomoses?
Arc of Buhler - Embryologic remnant short-segment direct communication.
Pancreatic Cascade - Inferior pancreaticoduodenal artery - rish collateral network with the celiac about the pancreatic head.
Arc of Barkow - right and left epiploic arteries
41
What is the Arc of Buhler?
Celiac-SMA anastomosis
Embryologic remnant short-segment direct communication.
42
What is the Pancreatic Cascade?
Celiac-SMA anastomosis
Inferior pancreaticoduodenal artery - Forms a rich collateral network with the celiac about the pancreatic head.
43
What is the Arc of Barkow?
Celiac-SMA anastomosis
Via right and left epiploic arteries
44
What are the SMA-IMA anastomoses?
Marginal Artery of Drummond (major) - lateral - lies in the peripheral mesentery of the colon. Ileocolic and R colonic (SMA) to Middle and Left Coloic (IMA)
Arc of Riolan - Medial
45
What is the Cannon-Bohm Point?
Point of transitional blood supply to the colon between the SMA and IMA at the splenic flexure
46
What is the Marginal Artery of Drummond?
Major SMA-IMA anastomosis
Lies in the peripheral mesentery of the colon, adjacent to the mesenteric surface of the colon.
The marginal artery of Drummond is composed of branches from the ileocolic and right (SMA) to middle, and left colic arteries (IMA).
47
Connection between the External Iliac artery and Thoracic Aorta?
Inferior epigastric and superior epigastric from the internal mammary artery.
48
Connection between the External and Internal Iliac Arteries?
Deep circumflex iliac artery from the external iliac anastomoses with the posterior division of the internal iliac artery via the iliolumbar artery.
49
Connection between the Internal Iliac Artery and IMA?
Inferior/Middle rectal arteries from the internal iliac anastomose with the IMA via the superior rectal artery.
Path of Winslow
50
What is the Path of Winslow?
Internal Iliac Artery to IMA.
Inferior/Middle rectal arteries from the internal iliac anastomose with the IMA via the superior rectal artery.
51
What is Polyarteritis Nodosa?
Systemic necrotizing vasculitis - small and medium-sized arterioles.
Causes multiple small visceral aneurysms - renal, hepatic, and mesenteric end-arterioles
P-ANCA positive.
Associated with cryoglobulinemia, leukemia, rheumatoid arthritis, Sjogren syndrome, and hepatitis B (CLASH)
52
Cause of multiple small visceral aneurysms?
Polyarteris Nodosa
Renal, hepatic, and mesenteric end-arterioles.
53
DDx of multiple renal artery aneurysms?
Multiple septic emboli, speed kidney (due to chronic methamphetamine abuse), and Ehlers-Danlos.
54
Polyarteritis Nodosa associated medical conditions?
CLASH
Cryoglobulinemia, leukemia, rheumatoid arthritis, Sjogren syndrome, and hepatitis B
55
MC visceral aneurysm?
Splenic Artery (hepatic artery is 2nd MC).
Multiparous females and patients with portal HTN.
Treated for symptoms, size >2.5 cm, and expected pregnancy.
Pseudoaneurysm = trauma or pancreatitis.
56
What is Nonocclusive Mesenteric Ischemia (NOMI)?
Highly lethal (70-100% mortality) form of acute mesenteric ischemia.
"Intestinal necrosis with a patent arterial tree" and features spasm and narrowing of multiple branches of the mesenteric arteries.
Direct arterial infusion of vasodilator papaverine (60 mg bolus, then 30-60 mg/h)
57
Treatment of Nonocclusive Mesenteric Ischemia?
Direct arterial infusion of vasodilator papaverine (60 mg bolus, then 30-60 mg/h)
"Intestinal necrosis with a patent arterial tree" and features spasm and narrowing of multiple branches of the mesenteric arteries.
58
Sensitivity of angio, CTA, and Tagged RBC scan for GI bleeding?
Angio: 0.5 to 1 mL/min
CTA: 0.35 mL/min
TRBC: 0.2-0.4 mL/min
59
What can be done for empirical treatment of an upper GI bleed if no extravasation found?
Embolize the left gastric- numerous collaterals between celiac and SMA = low risk of infarct.
Can't do for lower bleed b/c collaterals are much less developed = higher risk of infarct.
60
How is Vasopressin given for treatment of GI bleed?
Used for lower GI bleed. High rebleeding rate once stopped. Most useful for antimesenteric vessels.
Directly infused into SMA or IMA.
0.2-0.4 units per minute (100 units mixed in 500 mL saline given at 1 mL/minute) given as continuous infusion for up to 24 hours.
Stopped at 24 hours due to tachyphlaxis (lack of further response).
61
Why is vasopressin for GI bleeds stopped at 24 hours?
Tachyphlaxis - lack of further response
62
What is Angiodysplasia?
Acquired vascular anomaly that is common cause of chronic intermittent lower GI bleeding - typically in the right colon or cecum.
Imaging: tangle of vessels with early filling of an antimesenteric draining vein. Tram-track appearance = simultaneous opacification of the parallel artery and vein.
Treat with endoscopy electrocoagulation, laser therapy, or other techniques. Can do surgery. Embolization or vasopression not effective.
63
MC cause of lower GI bleeding in older adults?
Diverticulosis.
Treat if fail medical management.
64
Name of study that looked at benefit of endovascular revascularization of atherosclerotic renal artery stenosis?
ASTRAL trial.
65
Where is fibromuscular dysplasia found?
Renal and carotid arteries in young and middle-aged women. Mid or distal 1/2 of renal arteries.
MC form is the medial fibroplasia subtype - string of pearls or string of beads appearance.
Less common is intimal fibroplasia in children with smooth stenosis.
Perimedial and adventitial fibroplasia are less common.
Tx is angioplasty alone due to stenting can complicate retreatment with angioplasty and lead to in-stent stenosis due to intimal hyperplasia.
66
Appearance of RCC, Oncocytoma, and AML on angio?
RCC = bizzare neovascularity with AV shunting and venous lakes.
Oncocytoma = spokewheel appearance with peritumoral halo
AML = hypervascular with tortuous feeding arteries which have a sunburst appearance on the parenchymal phase. Small aneurysms. No AV shunting.
Not always possible to differentiate an AML from RCC on angiography.
67
General breakdown of renal injury grading
Grades I-III: Nonexpanding hematomas or parenchymal laceration w/o collecting system injury. Conservative managment.
Grade IV: Deep parenchymal laceration that extends to collecting system or injury to the renal artery or vein with contained hemorrhage.
Grade V: Shattered kidney with avulsion of the renal hilum.
68
Treatment for Median Arcuate Ligament Syndrome?
Surgical release of median arcuate ligament to enlarge the diaphragmatic hiatus.
Angioplasty not effective and stents are controversial due to high risk of device failure.
69
What is Nutcracker Syndrome?
Compression of L Renal Vein between Aorta and SMA.
Can have Posterior Nutcracker - Compression of retroaortic (or circumaortic) renal vein between the aorta and vertebral body.
Can angioplasty and stent.
70
What is May-Thurner syndrome?
Venous thrombosis of the L common iliac vein caused by compression from the crossing right common iliac artery.
Stent.
71
How do you measure portal pressure?
Direct is invasive- use wedged hepatic vein pressure = PV pressure in most patients.
Portosystemic Gradient (aka corrected sinusoidal pressure) = actual sinusoidal resistance to portal flow = wedged hepatic vein pressure - free hepatic vein pressure
Portal HTN = portosystemic gradient > 5 mmHg.
72
What is a Portosystemic Gradient?
Aka corrected sinusoidal pressure = actual sinusoidal resistance to portal flow = wedged hepatic vein pressure - free hepatic vein pressure
73
Pressure considered portal hypertension?
Portosystemic gradient > 5 mmHg.
74
Pathway for Esophageal Varices?
Coronary Vein (PV) --> Azygos/hemiazygos veins (SV)
75
Pathway for Gastric Fundal Varices?
Splenic Vein (PV) --> Azygos Veins (SV)
76
Pathway for Splenorenal Shunt?
Splenic or Short Gastric (PV) --> L Adrenal/Inferior Phrenic (SV) --> L Renal (SV)
77
Pathway for Mesenteric Varices?
SMV or IMV (PV) --> Iliac Veins (SV)
78
Pathway for Caput Medusa?
Umbilical Vein (PV) --> Epigastric Veins (SV)
79
Pathway for Hemorrhoids?
IMV (PV) --> Inferior Hemorrhoidal Veins (SV)
80
Indications for TIPS?
Variceal Hemorrhage
Refractory Ascites
Budd-Chiari
81
What makes up the Child-Pugh Classification?
Lab Values: INR, Bilirubin, and Albumin
| Clinical Assessment: Ascites and Hepatic Encephalopathy
82
What is the goal of TIPS?
Lower portosystemic gradient to <12 mmHg.
Use an 8 mm x 3-4 cm balloon to dilate tract
83
MC complication of IVC filter placement?
Access site thrombosis followed by IVC thrombosis.
IVC perforation is not uncommon but almost always inconsequential.
Filter fracture or embolization is rare.
84
Sizing in IVC filters?
>28 mm = birdnest filter
| >40 = use bilateral common iliac vein filters
85
Sign of a cavagram that there may be a retroaortic renal vein?
Retroaortic renal vein usually joins the IVC markedly inferior to the right renal vein.
86
What is IVC interruption with azygos continuation associated with?
Polysplenia and congenital heart disease.
87
Isolated varicocele on which side is concerning?
Isolated right-sided varicocele is concerning for obstructing retroperitoneal mass.
88
What is sclerosing cholangitis?
Chronic inflammatory and fibrosing process leading to multifocal strictures of the intra and extrahepatic biliary tree.
Obstructive jaundice, malaise, and abdominal pain.
More commonly in men
Associated with IBD (UC)
Biliary cirrhosis and increased risk of cholangiocarcinoma
Liver transplant - PTC can provide relief
Multifocal biliary strictures on cholangiogram.
89
DDx of multifocal biliary strictures?
```
Sclerosing cholangitis
Primary biliary cirrhosis
Multifocal cholangiocarcinoma
Chronic bacterial cholangitis
AIDS cholangitis (usually associated with papillary stenosis)
```
90
What criteria must be met to remove a cholecystostomy tube?
Clinically improved - risk of sepsis if removed prematurely
Cystic and CBD are patent
Six weeks have passed since placement to allow fibrous tract to develop extending from the GB to the skin puncture - risk of bile peritonitis if removed prematurely.
91
Target for percutaneous nephrostomy?
Zone of Brosel - relatively avascular zone, defined as the plane between the ventral and dorsal renal artery branches.
Posterolateral entry directed towards a posterior calyx.
92
Branches of the Femoral Artery?
Deep Femoral Arery - Deep muscles of the thigh
Superficial Circumflex Iliac
Superficial Femoral Artery
93
Branches of the Popliteal Artery?
Posterior Tibial - Medial
Peroneal
Anterior Tibial - Lateral
94
Collaterals from the thoraco-abdominal aorta to the external iliac arteries?
Anterior: Thoracic aorta --> Internal thoracic artery --> superior epigastric artery --> Inferior epigastric --> External Iliac Artery
Middle: Abdominal Aorta --> SMA --> MA --> Superior Rectal Artery (terminal branch of the IMA) --> Middle/Inferior Rectal Arteries (via path of Winslow) --> Retrograde through the internal iliac artery anterior division --> External Iliac Artery
Posterior: Abdominal aorta --> Intercostal and lumbar arteries --> Superior gluteal and iliolumbar arteries (branches of internal iliac artery posterior division) --> Deep circumflex iliac artery --> External Iliac Artery
95
Anterior collateral from the thoraco-abdominal aorta to the external iliac artery?
Anterior: Thoracic aorta --> Internal thoracic artery --> superior epigastric artery --> Inferior epigastric --> External Iliac Artery
96
Middle collateral from the thoraco-abdominal aorta to the external iliac artery?
Middle: Abdominal Aorta --> SMA --> MA --> Superior Rectal Artery (terminal branch of the IMA) --> Middle/Inferior Rectal Arteries (via path of Winslow) --> Retrograde through the internal iliac artery anterior division --> External Iliac Artery
97
Posterior collateral from the thoraco-abdominal aorta to the external iliac artery?
Posterior: Abdominal aorta --> Intercostal and lumbar arteries --> Superior gluteal and iliolumbar arteries (branches of internal iliac artery posterior division) --> Deep circumflex iliac artery --> External Iliac Artery
98
Criteria for treatment of iliac atherosclerotic disease?
<3 cm = PTA
>3 - <10 cm = Surgery or PTA
>10 = Surgery
Stent if >30% residual stenosis or >10 mmHg systolic pressure gradient
99
When do you stent with iliac atherosclerotic disease?
If >30% residual stenosis or >10 mmHg systolic pressure gradient.
100
Size of an iliac artery aneurysm?
>1.5 cm
Repair recommended >3 cm.
Do cross-sectional imaging recommended if iliac stenosis is seen first on angiography. Intra-luminal thrombus can simulate an atherosclerotic stenosis on angiography.
101
What is a Persistent Sciatic Artery?
Fetal sciatic artery persists to supply the majority of blood supply to the leg - femoral artery is usually present, but hypoplastic.
Arises from the internal iliac artery (usually from the internal gluteal artery) and continues as the popliteal artery.
Can predispose to aneurysm formation.
102
What can be done in the setting of life-threatening hemorrhage instead of superselective embolization?
Rapid nonselective gelfoam embolization of either anterior or posterior division of the internal iliac artery.
Done prior to orthopedic surgery.
103
Range of ABIs?
Ratio of systolic BP in the ankles compared to the arms.
<0.9 is abnormal
0.5 - 0.9 = intermittent claudication
<0.4 = rest pain.
104
What does pulse-volume recordings of the arteries tell you?
Can tell you the anatomic location of a lesion by the change from a normal triphasic waveform to a biphasic (moderate stenosis) or flat waveform (severe stenosis/occlusion).
105
Criteria for treatment of femoropopliteal arterial disease?
<10 cm stenosis = Endovascular treatment
Multiple - each less than 5 cm or Single <15 cm = Endovascular treatment preferred
Multiple stenoses or occlusions >15 cm = surtery preferred
106
tPA dose for endovascular thrombolisis of arterial occlusion?
What do you monitor?
0.5 mg/h for 48-72 hours
In ICU, monitor hematocrit and fibrinogen - If fibrinogen decreases to <150 mg/dL and stopped if it reaches <100 mg/dL.
107
Size of a popliteal anerysm?
8 mm or more
Can cause distal ischemia due to embolism
Treat if symptomatic or if >2cm in diameter.
108
What is Buerger Disease?
Medium and small vessel occlusive vasculitis
Lower extermities (most commonly) and the hands (less commonly)
Adult smokers.
Segmental stenosis of the medium and small arteries in the leg with typical corkscrew collaterals in the vasa vasorum.
109
What disease shows corkscrew collaterals in the vasa vasorum?
Buerger Disease
110
What is popliteal entrapment syndrome?
Compression of the popliteal artery by a calf muscle or fibrous band - MC an aberrant medial head of the gastrocnemius.
Important cause of exercise-induced claudication in healthy hound males. Bilateral is common.
Surgical release of the offending muscle.
111
What is Cystic Adventitial Disease?
Mucoid cysts in the adventitia surrounding the popliteal artery - luminal compression.
Surgical resection or bypass.
112
Boundary between the subclavian and axillary arteries?
Lateral margin of the 1st rib
113
Boundary between the axillary and brachial artery?
Inferior margin of the teres major
114
Orientation of the upper extremity veins?
Superficial= Cephalic (lateral) and Basilic (medial)
Deep = Brachial veins
Basilic is 1st choice for PICC, Cephalic is 2nd.
Brachial is avoided due to adjacent median nerve.
115
What is the interscalene triangle?
Space bound by the anterior scalene, middle scalene, and the first rib.
Brachial plexus and subclavian ARTERY pass through
116
What passes through the interscalene triangle?
```
Brachial Plexus
Subclavian ARTERY (vein passes anterior to the anterior scalene)
```
117
MC form of thoracic outlet syndrome?
Neurogenic
118
What is Adson's Maneuver?
Test for subclavian artery compression at the thoracic outlet.
Palpate the radial artery; turn head to contralateral side while they inhale; radial pulse will be reduced.
119
Causes of Subclavian Artery Compression?
70% have a cervical rib
Accessory scalene (scalenus minimus)
Enlargement of the anterior scalene muscle
Well-developed musculature
Complications: Arterial mural thrombus, aneurysm, and distal embolization
Treatment: Surgical thoracic outlet decompression and repair of subclavian artery if aneurysm is present.
120
What is Paget-Schroetter Syndrome?
Subclavan Vein Compression
Compression and thrombosis of the subclavian VEIN as is it enters the thorax, usually in muscular young ment.
Thrombolysis then surgical thoracic outlet decompression.
Stents should generally not be used, especially if there is a mechanical obstruction, due to high risk of device failure.
121
Difference between AVF and AVG?
Grafts require higher flow rates to remain open compared to fistulas.
122
What does a high access recirculation at dialysis suggest?
Venous outflow stenosis.
123
Pulsatile fistula with lack of thrill =
Venous outflow obstruction
124
Weak pulse and poor thrill =
Arterial inflow stenosis
125
Goal measurement after opening venous outflow stenosis?
Restore venous to brachial artery pressure ratio to less than 0.4.
126
What is Hypothenar Hammer?
Injury to ulnar artery as it crosses the hamate bone.
Chronic repetitive trauma - jackhammer operator with ischemia of the fourth and fifth digits.
127
Where does the subclavian artery run in relation to the subclavian vein?
Posterior
128
What are the major branches of the subclavian artery?
Vertebral, internal thoracic, thyrocervical trunk, costocervical trunk and dorsal scapular.
Also have the thoracoacrominal, lateral thoracic, subscapular, and circumflex humeral.
129
Where does the brachial artery start?
Outer edge of the teres major to the bifurcation of the radial and ulnar arteries.
130
Which artery forms the superficial and deep arches in the hand?
Ulnar artery = superficial arch (larger and gives off the common interosseous, which then splits off to form anterior and posterior branches)
Radial artery = superficial arch
Can have an anterior interosseous branch (median artery) that persists and supplies the deep palmar arch.
131
Branches of the posterior division of the internal iliac artery
I Like Sex
Iliolumbar
Lateral Sacral
Superior Gluteal
132
Branches of the anterior division of the internal iliac artery
Umbilical --> Superior vesical branches
Obturator
Male: Inferior vesicular which supplies the base of the bladder and prostate
Female: Uterine Artery --> vaginal artery
Terminal: Middle rectal and internal pudendal artery (which supply the external genitals)
133
What is the most medial artery in the leg?
Posterior tibial
The anterior tibial is lateral
134
What is the most common biliary duct variant?
Right posterior segment branch draining the left hepatic duct
2nd MC is trifurcation of the intrahepatic radicles
135
What segments are drained by the right and left hepatic ducts?
```
Right:
Horizontal posterior (6 and 7)
Vertical Anterior (5 and 8)
```
Left:
Horizontal (2 and 4)
136
What is normal poral systemic gradient?
3-6 mmHg
Difference between the portal vein and IVC
Portal HTN is portal vein >10 mmHg or PSG >6 mmHg
137
What pressure reading is portal hypertension?
Portal vein >10 mmHg or PSG >6 mmHg
138
What is the MELD score cutoff for TIPS?
>18 = higher risk of early death after an elective TIPS.
139
Which direction do you turn the catheter when you are moving from the right hepatic vein to the right portal vein?
Anterior
140
What is an alternative to TIPS for treatment of refractory ascites?
Peritoneovenous shunt
Tunneled line up to the systemic circulation (jugular).
High rate of infection and thrombosis.
141
What is a BRTO?
Balloon-Occluded Retrograde Transverse Obliteration
Used to treat gastric varices.
Access the portosystemic gastrorenal shunt from the L renal vein via transjugular or transfemoral approach.
Balloon is used to occlude the outlet of either the gastrorenal or gastro-caval shunt and sclerosed.
Embolize collaterals drives blood into the liver.
Improves hepatic encephalopathy, can worsen esophageal varices and worsen ascites.
142
Sensitivity of NM and Angio for GI bleeds?
NM: 0.1 mL/min
Angio: 1 mL/min
143
What is a Dieulafoy's Lesion?
Big artery in the submucosa of the stomach which pulsates until it causes a tiny tear that can bleed.
Usually on the lesser curve
Not an AVM, more like angiodysplasia.
Sometimes can clip in endoscopy, sometimes need endovascular embolization.
144
Pancreatic arcade bleed =
Celiac artery stenosis
Can be due to median arcuate ligament
Angiogram of the SMA showing a dilated collateral system and retrograde filling of the hepatic artery.
145
When is RF ablation of liver tumors indicated?
HCC and colorectal mets who can't get surgery
146
What has been proven to improve survival for HCC lesions larger than 3 cm, but not curative?
TACE + RFA
More than either treatment alone
147
What needs to be done before Y-90 embolization?
Lung shunt fraction - 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
Take off of the right gastric- get non-targeted poisoning of the stomach, leading to non-healing gastric ulcer- do prophylactic emolization of the right gastric and GDA.
148
What do you look for in a lung shunt fraction before Y-90?
Give Tc-99 MAA to the hepatic artery to determine how much pulmonary shunting occurs
Shunt fraction that would give 30 Gy in a single treatment is too much.
149
What is done prophylactically before Y-90?
Embolization of the right gastric and GDA
150
What is a Vacu-thorax?
Seen with malignant pleural effusions - can be fixed with surgical pleurectomy/decortication
151
Should you drain a lung abscess?
No - can create a bronchopleural fistula
152
What are findings on CT or PET on f/u of Lung RFA?
Nodular peripheral enhancement measuring >10mm, central enhancement (any is bad), growth of RFA zone after 3 months (after 6 months is considered definite), increased metabolic activity after 2 months, residual activity centrally (at the burned tumor)
153
Contraindications to pulmonary angiography?
Pulm HTN: elevated R heart pressures (greater than 70 systolic and 20 end diastolic)
LBBB: can get total block if you induce a RBBB
154
Multiple pulmonary AVMs =
HHT (Hereditary Hemorrhagic Telangectasia/Osler Weber Rendu)
R to L shunt - stroke and brain abscess
Treat if afferent vessel is 3 mm or symptomatic
155
Which fibroids tend to respond well to embolization?
Submucosal and smaller tumors
Cellular fibroids - densly packed and high T2 signal.
EMMY trial showed that hospital stays with UAE are shorter than hysterectomy.
DVT/PE is known risk of procedure - release compression on pelvic vein.
Contraindications: Pregnancy, active pelvic infection, prior pelvic radiation, connective tissue disease, prior surgery with adhesions
156
When is the ideal time for an HSG?
Proliferative phase - day 6-12 - when endometrium is the thinnest.
157
Where do you want to access for posterior pelvic abscesses?
Transgluteal - avoid sciatic nerves and gluteal arteries by access through the sacrospinous ligament medially (close to sacrum, inferior to piriformis).
158
When do you pull an abscess catheter?
Patient is better (no fever, WBC normal)
Output is <20 cc over 24 hours.
159
Characteristics that make a thyroid nodule more likely cancer
Solid more than cystic
Hypervascular
Blurred margin
Micro calcifications (most important)
Taller than wide.
If path not diagnostic - do not repeat for 3 months as reparative cellular atypia can complicate results.
160
Approach for percutaneous nephrostomy?
Lower pole posteriorly
Brodel's Avascular Zone - between the arterial bifurcation.
161
Can you place a neph tube in a transplant?
YES
162
General rule for renal RFA vs Cryoablation?
Superficial = RFA
Closer to the collecting system = Cryoablation to avoid scarring the collecting system and making a stricture.
No affect on GFR - won't lower
163
Findings of recurrance on RCC after RFA or cryoablation?
Increase in size beyond the acute initial increase
Areas of "nodular" or "crescentic" enhancement
New or enlarging bright T2 signal
Lesions that are <3 cm will appear larger in 1-2 months and lesions >3 cm do not grow larger when successfully treated.
164
Best projection for looking at the renals?
LAO
165
How to tell if something is superficial or deep in fluoro?
Tilt the image intensifier
Tilt toward the head- superficial will be shorter and deep will look longer
Tilt toward the feet- superficial will be longer, but deep will look shorter.
166
When should be checked pre-procedure for an arterial stick?
Stop heparin 2 hours prior to procedure (PTT 1.2x of control or less; normal 25-35 sec
INR of 1.5
Stop coumadin 5-7 days prior (Vitamin K 25-5- mg IM 4 hours prior, or FFP/Cryo)
Platelet count should be >50K
Stop ASA/Plavix 5 days prior
167
What should you do post-procedure for an arterial stick?
15 min of compression
Can pull sheath with an ACT of <150-180
Resume heparin 2 hours post
Groin check and palpate pulses on nursing orders
168
1 mm = ___ inch
1 mm = 0.039 inches
169
0.039 inches = ___ mm
0.039 inches = 1 mm
170
3 French = ___ mm
3 Fr = 1 mm
171
How do you determine the size of French catheter in mm?
Diameter in mm = Fr/3
172
What is the outer size of a sheath?
1.5-2 French larger than the sheath "size"
173
Preference for central lines in dialysis patients?
RIJ > LIJ > REJ > LEJ
Fistula first breakthrough initiative
174
What is the goal of flow and outlet vein diameter in a fistula?
600 cc/min
Outlet vein >6 mm.
175
What is used for self-expanding stents?
Nitinol
Soft at room temp and expands at body temperature.
176
When is surgery preferential over thrombolysis?
<14 days occluded - thrombolysis
>14 days - surgery
177
ABI numbers
Should normally be 1.0 or higher
Claudication: 0.5-0.9
Rest pain: 0.3
178
What is assisted primary patency of a bypass graft?
Patency never lost, but maintained by prophylactic interventions
Primary Patency
Secondary patency - patency lost, but then restored with intervention.
179
When can be done for varicose veins?
Tumescent Anesthesia - lots of diluted SQ lidocaine
Endoluminal heat source
Contraindication is DVT - need the superficial veins.
180
What is post thrombotic syndrome?
Pain and venous ulcers after DVT
>65, proximal DVT, recurrent or persistent DVT, and being fat.
Catheter directed lysis of iliofemoral DVT will prevent.
181
Types of Endoleaks?
I: Top or bottom of the graft - treat
II: MC - feeder artery - IMA or lumbar - may require treatment
III: Defect/fracture in the graft
IV: Porosity of the graft (4 is from the pore) - not in modern grafts
V: Endotension
182
Trivia about endovascular vs open repair?
30 day mortality is LESS for endovascular
Long term aneurysm mortality and total mortality are SAME
Graft related complications and re-interventions are HIGHER with endovascular
183
Indications for suprarenal IVC filter?
Pregnancy - avoid compression
Clot in renals or gonadals
Duplicated IVC - can do bilateral iliac
Circumaortic L renal
Mega-Cava = >28 mm - need a birds nest filter
184
Skin dosage changes
2 Gy - early transient erythema
6 Gy- chronic erythema
10 Gy- Telangectasia
13 Gy- Dry desquamation
18 Gy - Moist Desquamation
185
Position for viewing arteries
```
Arch - 70 degrees LAO
Innominate - RAO
L Subclavian - LAO
L Renal - LAO
R Renal - RAO
L Iliac Bifurcation - RAO
R Iliac Bifurcation - LAO
R SFA/Profundaa - RAO
L SFA/Profunda - LAO
```
186
People with Heparin Induced Thrombocytopenia are at increased risk of what?
Clotting - not bleeding
Get thrombin inhibitor
187
How do ASA, Heparin, Plavix, Coumadin, and TPA work?
ASA: Inhibits thromboxane A2 from arachidonic acid by irreversible acetylation - platelet 8-12 days
Heparin: Binds antithrombin 3 - monitored by PTT - reversed by protamine sulfate
Plavix - inhibits binding of ADP to receptors - leads to inhibition of GP IIb/IIIa
Coumadin - inhibits vitamin K dependent factors (2,7,9,10)
TPA - act directly or indirectly by converting plasminogen to plasmin (cleaves fibrin)
188
First sign of toxicity of lidocaine?
Tinnitus and dizziness
Arterial injection = seizures
189
When is descending venography used?
Evaluation of post-thrombotic syndrome
Valvular incompetence and damage following DVT
190
Is sepsis a contraindication for IVC filter?
No.
Including septic thrombophletibits
191
Contraindication to fistulagram?
Absolute: R-L shunt
Relative: Cardiopulmonary disease (declot causes PE).
192
Where does the artery of Ademkiewicz usually arise?
Left side (70%) between T8-L1 (90%)
193
What is the Arc of Riolan?
Connection between SMA and IMA
Left colic (IMA) to middle colic (SMA)
194
MC variant of hepatic artery branching?
Right hepatic artery replaced off of the SMA.
195
What is the relationship of the R hepatic artery and R portal vein? What about a replaced R hepatic off the SMA?
R proper hepatic is anterior to the R portal vein
Replaced R hepatic is posterior to main portal vein
196
What is the MC hepatic venous variant?
Accessory right inferior hepatic variant - drains segments 6 and 7 into IVC
197
Classic collateral between celiac and SMA?
SMA- inferior pancreaticoduodenal - superior pancreaticoduodenal - GDA
Arc of Buhler is a variant anatomy - collateral independent of the GDA and inferior pancreatic arteries - can cause aneurysm with celiac stenosis
198
What is the Arc of Buhler?
Variant anatomy - collateral between celiac and SMA - independent of the GDA and inferior pancreaticoduodenal arteries
Can cause aneurysm with celiac stenosis.
199
What is the Marginal Artery of Drummond?
SMA to IMA connection - other than Arc of Riolan (Middle colic of SMA to L colic of IMA).
Anastomosis of the terminal branches of the ileocolic, R colic, and middle colic arteries of the SMA, and of the L colic and sigmoid branches of the IMA.
Forms a continuous arterial circle or arcade along the inner border of the colon.
200
What is the Winslow Pathway?
Collateral pathway for aorto-iliac occlusive disease.
Subclavian artery - internal thoracic - superior epigastric - inferior epigastric - external iliac
201
What is the collateral pathway between the IMA and Iliacs?
IMA - superior rectal - inferior rectal - internal pudendal - anterior branch of the internal iliac
202
What is the Corona Mortis?
Vascular connection between the obturator and external iliac
Vessel coursing over the superior pubic rim.
Can be injured in pelvic trauma - difficult to ligate.
Can cause type 2 endoleak
203
What forms most gastric varices?
Left gastric (coronary vein)
Isolated gastric varices are secondary to splenic vein thrombosis
Drain into the inferior phrenic and then into the L renal vein, forming a gastro-renal shunt
204
What causes isolated gastric varices?
Splenic vein thrombosis
205
Where do the left, posterior and short gastric arteries drain?
Left: Cardia
Posterior and Short: Fundus
206
What is an isolated left-sided SVC associated with?
ASD
Drains into coronary sinus
207
What is a duplicated IVC associated with?
Renal stuff- horse shoe and cross fused ectopic kidneys
208
What a Circumaortic L renal vein which is higher?
Anterior limb is higher
209
What is Azygos Continuation associated with?
Polysplenia
Reversed IVC/aorta is more with asplenia.
210
External iliac artery is acutely occluded, but there is a strong pulse in the foot
Persistent Sciatic Artery
211
What is Intimo-intimal intussusception?
Unusual type of dissection - circumferential dissection of the intimal layer which invaginates (windsock).
Intimal tear usually starts near the coronary orifices
Floating viscera sign - opacification of the abdominal aortic branches arising out of nowhere - floating with little or no antegrade opacification of the aortic true lumen
212
Mortality predictors of intramural hematoma?
Max aortic diameter >5 cm is strongest predictor to dissection
Ascending aorta >5 cm
IMH >2 cm
Pericardial effusion
Still use A and B types
IMH maximum diameter of 5 cm is the strongest predictor for dissection.
213
Causes of ascending aortic calcifications?
Rare
Takayasu and Syphilis
214
Cystic Medial Necrosis =
Marfans
Anerysm = 1.5 times its expected diameter
>4 cm of ascending and transverse
>3.5 descending
>3 abdominal
215
Sinus of valsalva aneurysm
Asian Men
Right sinus
216
Arterial findings of NF1
Aneurysms and stenosis seen in aorta and larger arteries. Dysplastic features are found in smaller vessels.
Renal artery stenosis can occur.
Orificial renal artery stenosis presenting with HTN in teenager or child.
Dysplasia of the arterial wall itself - less commonly from peri-arterial neurofibroma.
217
What is Loeys Dietz Syndrome?
Really bad version of Marfans
Rupture of aorta - very tortuous vessels
Wide eyes - hypertelorism
218
Saccular asymmetric aortic aneurysm with involvement of the aortic root branches
Syphilic (Leutic) aneurysm - tertiary syphilis.
Heavily calcified "tree bark" intimal calcifications.
219
What part of the bowel is usually involved with an Aorto-Enteric Fistula?
Usually 3rd and 4th portions of the duodenum.
Can't tell difference between A-E fistula vs perigraft infection without contrast going into the bowel lumen. Both have ectopic perigraft gas >4 week post repair, both have perigraft fluid and edema, both lose fat plane between the bowel and aorta.
Primary vs Secondary - after instrumentation
220
Cause of Inflammatory Aneurysms?
May be related to periaortic retroperitoneal fibrosis or other autoimmune disorders (SLE, Giant Cell, RA).
Typically have hydro or renal failure at time of diagnosis b/c inflammatory process usually involves the ureters
Smoking is big risk factor
221
What is Mid Aortic Syndrome?
Progressive narrowing of the abdominal aorta and its major branches - not secondary to arteritis or atherosclerosis - may be intrauterine insult with fragmentation of the elastic media.
Higher than Leriche and longer segment.
Children and young adults
Classic Triad:
HTN, Claudication, Renal failure
222
What is the spectrum of thoracic outlet syndrome?
Nerve (95%) >>>> SC vein >>> SC artery
Compression of the anterior scalene artery is MC cause.
Can have cervical rib, muscular hypertrophy, fibrous bands, pagets, tumor, etc...
Arms up and arms down angiography - occlusion with arms up.
223
What is Paget Schroetter Syndrome?
Thoracic outlet syndrome with development of venous thrombosis of the subclavian vein- effort thrombosis - athletes who raise arms a lot.
224
Causes of PA artery aneurysm?
Iatrogenic from swan ganz catheter - MC - "patient in ICU"
Behcets - "Turkish descent" - mouth and genital ulcers
Chronic PE
Hughes-Stovin Syndrome- PA aneurysm similar to Behcets - recurrent thrombophlebitis and PA aneurysm formation and rupture.
Rasmussen Aneurysm - PA pseudoaneruysm 2/2 pulmonary TB - upper lobes in setting of reactivation TB.
TOF repair
225
What is Hughes-Stovin Syndrome?
PA aneurysm similar to Behcets
Recurrent thrombophlebitis and PA aneurysm formation and rupture
226
What is Rasmussen Aneurysm?
PA pseudoaneurysm 2/2 pulmonary TB
227
MC visceral arteryal aneurysm?
Splenic - True or False
True: HTN, portal HTN, cirrhosis, liver transplant, and pregnancy - more common in pregnancy and more likely to rupture in pregnancy. Atherosclerosis is not considered the underlying cause
False: Pancreatitis
228
What makes median arcuate ligament syndrome worse?
Expiration
229
What is Heyde Syndrome?
Colonic Angiodysplasia + aortic stenosis
230
Multiple hepatic and pulmonary AVMs?
Osler Weber Rendu (Hereditary Hemorrhagic Telangectasia)
Excessive shunting can cause biliary necrosis and bile leak.
Most die from stroke or brain abscess.
231
What is May-Thurner Syndrome?
DVT of the L Common Iliac Vein from compression by the R iliac artery.
Tx with thrombolysis and stenting.
Swollen left leg.
232
MC perpheral arterial aneurysm?
Popliteal
Can cause distal thromboembolism
Strong association with AAA.
233
What is Popliteal Entrapment?
Symptomatic compression or occlusion of the popliteal artery due to developmental relationship with the medial head of the gastroc - less commonly, the popliteus.
Medial deviation of the popliteal artery is diagnostic.
Normal pulses that decrease with plantar or dorsiflexion.
Young men (<30)
234
What is Klippel-Trenaunay Syndrome?
Often combined with Parkes-Weber which is a true high flow AVM.
Triad of port wine nevi, bony or soft tissue hypertrophy (localized gigantism) and a venous malformation.
Persistent sciatic vein is often associated.
Marginal vein of Servelle - superficial vein in the lateral calf and thigh is pathognomonic - basically the great saphenous on the wrong side.
Can get big enough, can eat platelets - Kasabach Merritt
235
MRA/MRV of the leg with a bunch of superficial vessels (and no deep drainage)
Klippel-Trenaunay Syndrome
236
Large vessel vasculidities
Takayasu
Giant Cell
Cogan Syndrome - children and young adults - eyes and ears causing optic neuritis, uveitis, and audiovestibular syndromes resembling Menieres. Can get aortitis
237
What is Takayasu Arteritis?
Pulse-less disease
Young asian girls
Vasculitis involving the aorta. Wall thickening and enhancement in acute phase. Occlusion of the major aortic branches, or dilation of the aorta and its branches.
Type 3 is MC - involves arch and abdominal aorta
238
What is Giant Cell Arteritis?
MC primary system vasculitis
Old men - 70-80.
Aorta and branches - particularly the external carotid (temporal artery)
CTA/MRA or angiogram of the arm pit showed wall thickening, occlusions, dilations, and aneurysm.
239
What is Cogan Syndrome?
Large vessel vasculitis that affects children and young adults
Eyes and ears causing optic neuritis, uveitis, and audiovestibular symptoms resembling Menieres.
Can also get aortiits
240
What are the medium vessel vasculitidites?
PAN
| Kawasaki
241
What is Polyarteritis Nodosa?
PAN is more common in a MAN
Renal, Cardiac, and GI - microaneurysm formation
Kidney with microaneurysms or multiple infarcts
Association with Hep B
242
What is Polyarteritis Nodosa associated with?
Hep B
243
What is Kawasaki Disease?
MC vasculitis in children (HSP is also common)
Coronary artery aneurysm - calcified coronary artery aneurysm on CXR
Mucocutaneous lymph node syndrome
Fever for five days
244
What are the c-ANCA and p-ANCA positive vasculidities?
c-ANCA: Wegeners
p-ANCA: Churg Strauss and Microscopic Polyangitis
245
What is Wegeners?
cANCA
Upper respiratory tract (sinuses) and lower respiratory tract (lungs), and kidneys
Nasal perforation and cavitary lung lesions
246
What is Churg Strauss?
pANCA
Necrotizing pulmonary vasculitis in the spectrum of eosinophilic lung disease
Asthma and eosinophilia
Transient peripheral lung consolidation or GG regions.
Cavitation is rare
247
What is Henoch-Schonlein Purpura?
MC vasculitis in children (4-11)
GI sx are MC (pain, blood, diarrhea) - common lead point for intussusception
US with doughnut sign for intussusception
US of scrotum showing massive skin edema
248
What is Behcets?
Mouth and genital ulcers in patient with Turkish descent
Can cause thickening of the aorta
Pulmonary artery aneurysm.
249
What is Buergers?
Smokers
Small and medium vessels in the arms and legs - more common in legs, but likely to show hand angiogram
Arterial occlusive disease with development of corkscrew collateral vessels.
Auto-amputation
250
What is Segmental Arterial Mediolysis?
Affects the splanchnic arteries in the elderly and coronary arteries in young adults
Not a true vasculitis with no significant inflammation.
Multiple Aneurysms
251
What is Cystic Adventitial Disease?
Popliteal artery of young men
Multiple mucoid filled cysts in the outer media and adventitia.
Compress artery.
