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IR Flashcards

1
Q

Injection rates and total volume of Aortogram (aortic arch)?

A

20 for 30

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2
Q

Injection rates and total volume of abdominal aorta?

A

20 for 20

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3
Q

Injection rates and total volume of inferior vena cavogram?

A

20 for 30

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4
Q

Injection rates and total volume of mesenteric artery?

A

5 for 25

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5
Q

Injection rates and total volume of renal artery?

A

5 for 15

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6
Q

Injection rates and total volume of distal artery?

A

3 for 12

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7
Q

1 Fr = ? mm

A

1 Fr = 0.33 mm

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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

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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.

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10
Q

Terminal branch of the SMA?

A

Ileocolic artery - sends arterial branches to the terminal ileum, cecum, and appendix.

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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.

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12
Q

Terminal branch of the IMA?

A

Superior rectal (hemorrhoidal) artery - supplies the upper rectum.

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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?

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14
Q

What can a low femoral artery stick lead to?

A

AVF due to femoral vein passing posterior

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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.

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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.

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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.

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18
Q

What is sodium tetradecyl sulfate?

A

Sclerosing agent - vascular malformations and varices.

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19
Q

What is cyanoacrylate?

A

glue

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20
Q

What are C2 and SOS catheters?

A

Reverse curved-tip catheters

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21
Q

What is a Bernstein catheter?

A

Angled-tip catheter

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22
Q

A quality of standard wires?

A

Floppy tip or J-tip

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23
Q

What is a Bentson wire?

A

Typical floppy tip wire

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24
Q

What is a Rosen wire?

A

J-tip wire

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25
Q

Where does a left-sided SVC drain?

A

Coronary sinus to RA

Weak association with CHD. Double SVC has stronger association with CHD.

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26
Q

What is the Vein of Sappey?

A

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.

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27
Q

What do you need to look for prior to pulmonary artery angio?

A

LBBB.

Can cause temporary RBBB which together can be fatal.

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28
Q

What are the normal right-sided pressures?

A

RA: 0-8 mmHg
RV: 0-8 mmHg diastolic; 15-30 mmHg systolic
PA: 3-12 mmHg diastolic; 15-30 mmHg systolic

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29
Q

Patients with what syndrome will have multiple pulmonary AVMs?

A

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

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30
Q

What is massive hemoptysis?

A

> 300 mL/24 hours

US- cystic fibrosis and thoracic malignancy
Worldwide- TB and fungal infection

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31
Q

Where does the Left gastroepiploic artery arise?

A

Splenic

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32
Q

Where does the Right gastroepiploic artery arise?

A

GDA

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33
Q

Where does the cystic artery arise?

A

R hepatic

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34
Q

Where does the Right Gastric Artery arise?

A

Common/Proper Hepatic

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35
Q

Where does the Dorsal Pancreatic Artery arise?

A

Splenic Artery

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36
Q

Where does the Superior Pancreaticoduodenal artery arise?

A

GDA

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37
Q

Branches of the Anterior Division of the Internal Iliac Artery?

A

Supplies the pelvic viscera

Inferior/Middle Rectal
Vesicle
Uterine
Obturator
Inferior Pudendal
Inferior Gluteal
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38
Q

Branches of the Posterior Division of the Internal Iliac Artery?

A

Supplies the musculature of the pelvic and gluteal regions.

Superior Gluteal
Iliolumbar
Lateral Sacral

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39
Q

Branches of the External Iliac?

A

Inferior Epigastric
Deep Circumflex Iliac Artery - anastomosis with the internal iliac via the iliolumbar artery.
Femoral Artery

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40
Q

What are the Celiac-SMA anastomoses?

A

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

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41
Q

What is the Arc of Buhler?

A

Celiac-SMA anastomosis

Embryologic remnant short-segment direct communication.

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42
Q

What is the Pancreatic Cascade?

A

Celiac-SMA anastomosis

Inferior pancreaticoduodenal artery - Forms a rich collateral network with the celiac about the pancreatic head.

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43
Q

What is the Arc of Barkow?

A

Celiac-SMA anastomosis

Via right and left epiploic arteries

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44
Q

What are the SMA-IMA anastomoses?

A

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

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45
Q

What is the Cannon-Bohm Point?

A

Point of transitional blood supply to the colon between the SMA and IMA at the splenic flexure

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46
Q

What is the Marginal Artery of Drummond?

A

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).

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47
Q

Connection between the External Iliac artery and Thoracic Aorta?

A

Inferior epigastric and superior epigastric from the internal mammary artery.

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48
Q

Connection between the External and Internal Iliac Arteries?

A

Deep circumflex iliac artery from the external iliac anastomoses with the posterior division of the internal iliac artery via the iliolumbar artery.

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49
Q

Connection between the Internal Iliac Artery and IMA?

A

Inferior/Middle rectal arteries from the internal iliac anastomose with the IMA via the superior rectal artery.

Path of Winslow

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50
Q

What is the Path of Winslow?

A

Internal Iliac Artery to IMA.

Inferior/Middle rectal arteries from the internal iliac anastomose with the IMA via the superior rectal artery.

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51
Q

What is Polyarteritis Nodosa?

A

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)

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52
Q

Cause of multiple small visceral aneurysms?

A

Polyarteris Nodosa

Renal, hepatic, and mesenteric end-arterioles.

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53
Q

DDx of multiple renal artery aneurysms?

A

Multiple septic emboli, speed kidney (due to chronic methamphetamine abuse), and Ehlers-Danlos.

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54
Q

Polyarteritis Nodosa associated medical conditions?

A

CLASH

Cryoglobulinemia, leukemia, rheumatoid arthritis, Sjogren syndrome, and hepatitis B

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55
Q

MC visceral aneurysm?

A

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.

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56
Q

What is Nonocclusive Mesenteric Ischemia (NOMI)?

A

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)

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57
Q

Treatment of Nonocclusive Mesenteric Ischemia?

A

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.

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58
Q

Sensitivity of angio, CTA, and Tagged RBC scan for GI bleeding?

A

Angio: 0.5 to 1 mL/min
CTA: 0.35 mL/min
TRBC: 0.2-0.4 mL/min

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59
Q

What can be done for empirical treatment of an upper GI bleed if no extravasation found?

A

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.

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60
Q

How is Vasopressin given for treatment of GI bleed?

A

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).

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61
Q

Why is vasopressin for GI bleeds stopped at 24 hours?

A

Tachyphlaxis - lack of further response

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62
Q

What is Angiodysplasia?

A

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.

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63
Q

MC cause of lower GI bleeding in older adults?

A

Diverticulosis.

Treat if fail medical management.

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64
Q

Name of study that looked at benefit of endovascular revascularization of atherosclerotic renal artery stenosis?

A

ASTRAL trial.

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65
Q

Where is fibromuscular dysplasia found?

A

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.

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66
Q

Appearance of RCC, Oncocytoma, and AML on angio?

A

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.

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67
Q

General breakdown of renal injury grading

A

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.

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68
Q

Treatment for Median Arcuate Ligament Syndrome?

A

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.

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69
Q

What is Nutcracker Syndrome?

A

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.

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70
Q

What is May-Thurner syndrome?

A

Venous thrombosis of the L common iliac vein caused by compression from the crossing right common iliac artery.

Stent.

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71
Q

How do you measure portal pressure?

A

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.

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72
Q

What is a Portosystemic Gradient?

A

Aka corrected sinusoidal pressure = actual sinusoidal resistance to portal flow = wedged hepatic vein pressure - free hepatic vein pressure

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73
Q

Pressure considered portal hypertension?

A

Portosystemic gradient > 5 mmHg.

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74
Q

Pathway for Esophageal Varices?

A

Coronary Vein (PV) –> Azygos/hemiazygos veins (SV)

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75
Q

Pathway for Gastric Fundal Varices?

A

Splenic Vein (PV) –> Azygos Veins (SV)

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76
Q

Pathway for Splenorenal Shunt?

A

Splenic or Short Gastric (PV) –> L Adrenal/Inferior Phrenic (SV) –> L Renal (SV)

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77
Q

Pathway for Mesenteric Varices?

A

SMV or IMV (PV) –> Iliac Veins (SV)

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78
Q

Pathway for Caput Medusa?

A

Umbilical Vein (PV) –> Epigastric Veins (SV)

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79
Q

Pathway for Hemorrhoids?

A

IMV (PV) –> Inferior Hemorrhoidal Veins (SV)

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80
Q

Indications for TIPS?

A

Variceal Hemorrhage
Refractory Ascites
Budd-Chiari

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81
Q

What makes up the Child-Pugh Classification?

A

Lab Values: INR, Bilirubin, and Albumin

Clinical Assessment: Ascites and Hepatic Encephalopathy

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82
Q

What is the goal of TIPS?

A

Lower portosystemic gradient to <12 mmHg.

Use an 8 mm x 3-4 cm balloon to dilate tract

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83
Q

MC complication of IVC filter placement?

A

Access site thrombosis followed by IVC thrombosis.

IVC perforation is not uncommon but almost always inconsequential.

Filter fracture or embolization is rare.

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84
Q

Sizing in IVC filters?

A

> 28 mm = birdnest filter

>40 = use bilateral common iliac vein filters

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85
Q

Sign of a cavagram that there may be a retroaortic renal vein?

A

Retroaortic renal vein usually joins the IVC markedly inferior to the right renal vein.

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86
Q

What is IVC interruption with azygos continuation associated with?

A

Polysplenia and congenital heart disease.

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87
Q

Isolated varicocele on which side is concerning?

A

Isolated right-sided varicocele is concerning for obstructing retroperitoneal mass.

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88
Q

What is sclerosing cholangitis?

A

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.

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89
Q

DDx of multifocal biliary strictures?

A 
Sclerosing cholangitis
Primary biliary cirrhosis
Multifocal cholangiocarcinoma
Chronic bacterial cholangitis
AIDS cholangitis (usually associated with papillary stenosis)
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90
Q

What criteria must be met to remove a cholecystostomy tube?

A

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.

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91
Q

Target for percutaneous nephrostomy?

A

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.

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92
Q

Branches of the Femoral Artery?

A

Deep Femoral Arery - Deep muscles of the thigh

Superficial Circumflex Iliac

Superficial Femoral Artery

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93
Q

Branches of the Popliteal Artery?

A

Posterior Tibial - Medial

Peroneal

Anterior Tibial - Lateral

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94
Q

Collaterals from the thoraco-abdominal aorta to the external iliac arteries?

A

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

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95
Q

Anterior collateral from the thoraco-abdominal aorta to the external iliac artery?

A

Anterior: Thoracic aorta –> Internal thoracic artery –> superior epigastric artery –> Inferior epigastric –> External Iliac Artery

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96
Q

Middle collateral from the thoraco-abdominal aorta to the external iliac artery?

A

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

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97
Q

Posterior collateral from the thoraco-abdominal aorta to the external iliac artery?

A

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

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98
Q

Criteria for treatment of iliac atherosclerotic disease?

A

<3 cm = PTA
>3 - <10 cm = Surgery or PTA
>10 = Surgery

Stent if >30% residual stenosis or >10 mmHg systolic pressure gradient

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99
Q

When do you stent with iliac atherosclerotic disease?

A

If >30% residual stenosis or >10 mmHg systolic pressure gradient.

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100
Q

Size of an iliac artery aneurysm?

A

> 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.

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101
Q

What is a Persistent Sciatic Artery?

A

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
Q

What can be done in the setting of life-threatening hemorrhage instead of superselective embolization?

A

Rapid nonselective gelfoam embolization of either anterior or posterior division of the internal iliac artery.

Done prior to orthopedic surgery.

103
Q

Range of ABIs?

A

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
Q

What does pulse-volume recordings of the arteries tell you?

A

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
Q

Criteria for treatment of femoropopliteal arterial disease?

A

<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
Q

tPA dose for endovascular thrombolisis of arterial occlusion?

What do you monitor?

A

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
Q

Size of a popliteal anerysm?

A

8 mm or more

Can cause distal ischemia due to embolism

Treat if symptomatic or if >2cm in diameter.

108
Q

What is Buerger Disease?

A

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
Q

What disease shows corkscrew collaterals in the vasa vasorum?

A

Buerger Disease

110
Q

What is popliteal entrapment syndrome?

A

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
Q

What is Cystic Adventitial Disease?

A

Mucoid cysts in the adventitia surrounding the popliteal artery - luminal compression.

Surgical resection or bypass.

112
Q

Boundary between the subclavian and axillary arteries?

A

Lateral margin of the 1st rib

113
Q

Boundary between the axillary and brachial artery?

A

Inferior margin of the teres major

114
Q

Orientation of the upper extremity veins?

A

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
Q

What is the interscalene triangle?

A

Space bound by the anterior scalene, middle scalene, and the first rib.

Brachial plexus and subclavian ARTERY pass through

116
Q

What passes through the interscalene triangle?

A 
Brachial Plexus
Subclavian ARTERY (vein passes anterior to the anterior scalene)
117
Q

MC form of thoracic outlet syndrome?

A

Neurogenic

118
Q

What is Adson’s Maneuver?

A

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
Q

Causes of Subclavian Artery Compression?

A

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
Q

What is Paget-Schroetter Syndrome?

A

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
Q

Difference between AVF and AVG?

A

Grafts require higher flow rates to remain open compared to fistulas.

122
Q

What does a high access recirculation at dialysis suggest?

A

Venous outflow stenosis.

123
Q

Pulsatile fistula with lack of thrill =

A

Venous outflow obstruction

124
Q

Weak pulse and poor thrill =

A

Arterial inflow stenosis

125
Q

Goal measurement after opening venous outflow stenosis?

A

Restore venous to brachial artery pressure ratio to less than 0.4.

126
Q

What is Hypothenar Hammer?

A

Injury to ulnar artery as it crosses the hamate bone.

Chronic repetitive trauma - jackhammer operator with ischemia of the fourth and fifth digits.

127
Q

Where does the subclavian artery run in relation to the subclavian vein?

A

Posterior

128
Q

What are the major branches of the subclavian artery?

A

Vertebral, internal thoracic, thyrocervical trunk, costocervical trunk and dorsal scapular.

Also have the thoracoacrominal, lateral thoracic, subscapular, and circumflex humeral.

129
Q

Where does the brachial artery start?

A

Outer edge of the teres major to the bifurcation of the radial and ulnar arteries.

130
Q

Which artery forms the superficial and deep arches in the hand?

A

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
Q

Branches of the posterior division of the internal iliac artery

A

I Like Sex

Iliolumbar
Lateral Sacral
Superior Gluteal

132
Q

Branches of the anterior division of the internal iliac artery

A

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
Q

What is the most medial artery in the leg?

A

Posterior tibial

The anterior tibial is lateral

134
Q

What is the most common biliary duct variant?

A

Right posterior segment branch draining the left hepatic duct

2nd MC is trifurcation of the intrahepatic radicles

135
Q

What segments are drained by the right and left hepatic ducts?

A 
Right:
Horizontal posterior (6 and 7)
Vertical Anterior (5 and 8)

Left:
Horizontal (2 and 4)

136
Q

What is normal poral systemic gradient?

A

3-6 mmHg

Difference between the portal vein and IVC

Portal HTN is portal vein >10 mmHg or PSG >6 mmHg

137
Q

What pressure reading is portal hypertension?

A

Portal vein >10 mmHg or PSG >6 mmHg

138
Q

What is the MELD score cutoff for TIPS?

A

> 18 = higher risk of early death after an elective TIPS.

139
Q

Which direction do you turn the catheter when you are moving from the right hepatic vein to the right portal vein?

A

Anterior

140
Q

What is an alternative to TIPS for treatment of refractory ascites?

A

Peritoneovenous shunt

Tunneled line up to the systemic circulation (jugular).

High rate of infection and thrombosis.

141
Q

What is a BRTO?

A

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
Q

Sensitivity of NM and Angio for GI bleeds?

A

NM: 0.1 mL/min

Angio: 1 mL/min

143
Q

What is a Dieulafoy’s Lesion?

A

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
Q

Pancreatic arcade bleed =

A

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
Q

When is RF ablation of liver tumors indicated?

A

HCC and colorectal mets who can’t get surgery

146
Q

What has been proven to improve survival for HCC lesions larger than 3 cm, but not curative?

A

TACE + RFA

More than either treatment alone

147
Q

What needs to be done before Y-90 embolization?

A

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
Q

What do you look for in a lung shunt fraction before Y-90?

A

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
Q

What is done prophylactically before Y-90?

A

Embolization of the right gastric and GDA

150
Q

What is a Vacu-thorax?

A

Seen with malignant pleural effusions - can be fixed with surgical pleurectomy/decortication

151
Q

Should you drain a lung abscess?

A

No - can create a bronchopleural fistula

152
Q

What are findings on CT or PET on f/u of Lung RFA?

A

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
Q

Contraindications to pulmonary angiography?

A

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
Q

Multiple pulmonary AVMs =

A

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
Q

Which fibroids tend to respond well to embolization?

A

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
Q

When is the ideal time for an HSG?

A

Proliferative phase - day 6-12 - when endometrium is the thinnest.

157
Q

Where do you want to access for posterior pelvic abscesses?

A

Transgluteal - avoid sciatic nerves and gluteal arteries by access through the sacrospinous ligament medially (close to sacrum, inferior to piriformis).

158
Q

When do you pull an abscess catheter?

A

Patient is better (no fever, WBC normal)

Output is <20 cc over 24 hours.

159
Q

Characteristics that make a thyroid nodule more likely cancer

A

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
Q

Approach for percutaneous nephrostomy?

A

Lower pole posteriorly

Brodel’s Avascular Zone - between the arterial bifurcation.

161
Q

Can you place a neph tube in a transplant?

A

YES

162
Q

General rule for renal RFA vs Cryoablation?

A

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
Q

Findings of recurrance on RCC after RFA or cryoablation?

A

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
Q

Best projection for looking at the renals?

A

LAO

165
Q

How to tell if something is superficial or deep in fluoro?

A

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
Q

When should be checked pre-procedure for an arterial stick?

A

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
Q

What should you do post-procedure for an arterial stick?

A

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
Q

1 mm = ___ inch

A

1 mm = 0.039 inches

169
Q

0.039 inches = ___ mm

A

0.039 inches = 1 mm

170
Q

3 French = ___ mm

A

3 Fr = 1 mm

171
Q

How do you determine the size of French catheter in mm?

A

Diameter in mm = Fr/3

172
Q

What is the outer size of a sheath?

A

1.5-2 French larger than the sheath “size”

173
Q

Preference for central lines in dialysis patients?

A

RIJ > LIJ > REJ > LEJ

Fistula first breakthrough initiative

174
Q

What is the goal of flow and outlet vein diameter in a fistula?

A

600 cc/min

Outlet vein >6 mm.

175
Q

What is used for self-expanding stents?

A

Nitinol

Soft at room temp and expands at body temperature.

176
Q

When is surgery preferential over thrombolysis?

A

<14 days occluded - thrombolysis

> 14 days - surgery

177
Q

ABI numbers

A

Should normally be 1.0 or higher

Claudication: 0.5-0.9

Rest pain: 0.3

178
Q

What is assisted primary patency of a bypass graft?

A

Patency never lost, but maintained by prophylactic interventions

Primary Patency

Secondary patency - patency lost, but then restored with intervention.

179
Q

When can be done for varicose veins?

A

Tumescent Anesthesia - lots of diluted SQ lidocaine

Endoluminal heat source

Contraindication is DVT - need the superficial veins.

180
Q

What is post thrombotic syndrome?

A

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
Q

Types of Endoleaks?

A

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
Q

Trivia about endovascular vs open repair?

A

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
Q

Indications for suprarenal IVC filter?

A

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
Q

Skin dosage changes

A

2 Gy - early transient erythema

6 Gy- chronic erythema

10 Gy- Telangectasia

13 Gy- Dry desquamation

18 Gy - Moist Desquamation

185
Q

Position for viewing arteries

A 
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
Q

People with Heparin Induced Thrombocytopenia are at increased risk of what?

A

Clotting - not bleeding

Get thrombin inhibitor

187
Q

How do ASA, Heparin, Plavix, Coumadin, and TPA work?

A

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
Q

First sign of toxicity of lidocaine?

A

Tinnitus and dizziness

Arterial injection = seizures

189
Q

When is descending venography used?

A

Evaluation of post-thrombotic syndrome

Valvular incompetence and damage following DVT

190
Q

Is sepsis a contraindication for IVC filter?

A

No.

Including septic thrombophletibits

191
Q

Contraindication to fistulagram?

A

Absolute: R-L shunt

Relative: Cardiopulmonary disease (declot causes PE).

192
Q

Where does the artery of Ademkiewicz usually arise?

A

Left side (70%) between T8-L1 (90%)

193
Q

What is the Arc of Riolan?

A

Connection between SMA and IMA

Left colic (IMA) to middle colic (SMA)

194
Q

MC variant of hepatic artery branching?

A

Right hepatic artery replaced off of the SMA.

195
Q

What is the relationship of the R hepatic artery and R portal vein? What about a replaced R hepatic off the SMA?

A

R proper hepatic is anterior to the R portal vein

Replaced R hepatic is posterior to main portal vein

196
Q

What is the MC hepatic venous variant?

A

Accessory right inferior hepatic variant - drains segments 6 and 7 into IVC

197
Q

Classic collateral between celiac and SMA?

A

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
Q

What is the Arc of Buhler?

A

Variant anatomy - collateral between celiac and SMA - independent of the GDA and inferior pancreaticoduodenal arteries

Can cause aneurysm with celiac stenosis.

199
Q

What is the Marginal Artery of Drummond?

A

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
Q

What is the Winslow Pathway?

A

Collateral pathway for aorto-iliac occlusive disease.

Subclavian artery - internal thoracic - superior epigastric - inferior epigastric - external iliac

201
Q

What is the collateral pathway between the IMA and Iliacs?

A

IMA - superior rectal - inferior rectal - internal pudendal - anterior branch of the internal iliac

202
Q

What is the Corona Mortis?

A

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
Q

What forms most gastric varices?

A

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
Q

What causes isolated gastric varices?

A

Splenic vein thrombosis

205
Q

Where do the left, posterior and short gastric arteries drain?

A

Left: Cardia

Posterior and Short: Fundus

206
Q

What is an isolated left-sided SVC associated with?

A

ASD

Drains into coronary sinus

207
Q

What is a duplicated IVC associated with?

A

Renal stuff- horse shoe and cross fused ectopic kidneys

208
Q

What a Circumaortic L renal vein which is higher?

A

Anterior limb is higher

209
Q

What is Azygos Continuation associated with?

A

Polysplenia

Reversed IVC/aorta is more with asplenia.

210
Q

External iliac artery is acutely occluded, but there is a strong pulse in the foot

A

Persistent Sciatic Artery

211
Q

What is Intimo-intimal intussusception?

A

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
Q

Mortality predictors of intramural hematoma?

A

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
Q

Causes of ascending aortic calcifications?

A

Rare

Takayasu and Syphilis

214
Q

Cystic Medial Necrosis =

A

Marfans

Anerysm = 1.5 times its expected diameter

> 4 cm of ascending and transverse
3.5 descending
3 abdominal

215
Q

Sinus of valsalva aneurysm

A

Asian Men

Right sinus

216
Q

Arterial findings of NF1

A

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
Q

What is Loeys Dietz Syndrome?

A

Really bad version of Marfans

Rupture of aorta - very tortuous vessels

Wide eyes - hypertelorism

218
Q

Saccular asymmetric aortic aneurysm with involvement of the aortic root branches

A

Syphilic (Leutic) aneurysm - tertiary syphilis.

Heavily calcified “tree bark” intimal calcifications.

219
Q

What part of the bowel is usually involved with an Aorto-Enteric Fistula?

A

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
Q

Cause of Inflammatory Aneurysms?

A

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
Q

What is Mid Aortic Syndrome?

A

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
Q

What is the spectrum of thoracic outlet syndrome?

A

Nerve (95%)&raquo_space;» SC vein&raquo_space;> 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
Q

What is Paget Schroetter Syndrome?

A

Thoracic outlet syndrome with development of venous thrombosis of the subclavian vein- effort thrombosis - athletes who raise arms a lot.

224
Q

Causes of PA artery aneurysm?

A

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
Q

What is Hughes-Stovin Syndrome?

A

PA aneurysm similar to Behcets

Recurrent thrombophlebitis and PA aneurysm formation and rupture

226
Q

What is Rasmussen Aneurysm?

A

PA pseudoaneurysm 2/2 pulmonary TB

227
Q

MC visceral arteryal aneurysm?

A

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
Q

What makes median arcuate ligament syndrome worse?

A

Expiration

229
Q

What is Heyde Syndrome?

A

Colonic Angiodysplasia + aortic stenosis

230
Q

Multiple hepatic and pulmonary AVMs?

A

Osler Weber Rendu (Hereditary Hemorrhagic Telangectasia)

Excessive shunting can cause biliary necrosis and bile leak.

Most die from stroke or brain abscess.

231
Q

What is May-Thurner Syndrome?

A

DVT of the L Common Iliac Vein from compression by the R iliac artery.

Tx with thrombolysis and stenting.

Swollen left leg.

232
Q

MC perpheral arterial aneurysm?

A

Popliteal

Can cause distal thromboembolism

Strong association with AAA.

233
Q

What is Popliteal Entrapment?

A

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
Q

What is Klippel-Trenaunay Syndrome?

A

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
Q

MRA/MRV of the leg with a bunch of superficial vessels (and no deep drainage)

A

Klippel-Trenaunay Syndrome

236
Q

Large vessel vasculidities

A

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
Q

What is Takayasu Arteritis?

A

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
Q

What is Giant Cell Arteritis?

A

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
Q

What is Cogan Syndrome?

A

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
Q

What are the medium vessel vasculitidites?

A

PAN

Kawasaki

241
Q

What is Polyarteritis Nodosa?

A

PAN is more common in a MAN

Renal, Cardiac, and GI - microaneurysm formation

Kidney with microaneurysms or multiple infarcts

Association with Hep B

242
Q

What is Polyarteritis Nodosa associated with?

A

Hep B

243
Q

What is Kawasaki Disease?

A

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
Q

What are the c-ANCA and p-ANCA positive vasculidities?

A

c-ANCA: Wegeners

p-ANCA: Churg Strauss and Microscopic Polyangitis

245
Q

What is Wegeners?

A

cANCA

Upper respiratory tract (sinuses) and lower respiratory tract (lungs), and kidneys

Nasal perforation and cavitary lung lesions

246
Q

What is Churg Strauss?

A

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
Q

What is Henoch-Schonlein Purpura?

A

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
Q

What is Behcets?

A

Mouth and genital ulcers in patient with Turkish descent

Can cause thickening of the aorta

Pulmonary artery aneurysm.

249
Q

What is Buergers?

A

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
Q

What is Segmental Arterial Mediolysis?

A

Affects the splanchnic arteries in the elderly and coronary arteries in young adults

Not a true vasculitis with no significant inflammation.

Multiple Aneurysms

251
Q

What is Cystic Adventitial Disease?

A

Popliteal artery of young men

Multiple mucoid filled cysts in the outer media and adventitia.

Compress artery.

IR (1 decks)

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