IR Flashcards
Arc of Beuhler
collat arter between celiac and SMA
Arc of Barkow
free edge of omentum anast R and L gastroepiploic
Marginal artery of Drummond
anast between SMA and IMA (R, M, and L colic artery)
Large vessel vasculitis with inflamm infiltrates
GCA
- temporal arteries/branches of the ECA.
- headache, scalp tenderness, and jaw claudication.
- Polymyalgia rheumatica: pain and stiffness in the shoulder or pelvic girdle, coexists in up to 40% of cases.
- Females (2:1) males, >age 50.
- GCA also affects noncranial vessels: ascending aorta and its tributaries: brachiocephalic, L CCA, L SCA.
What drug is administered during an adrenal vein sampling procedure?
Cosyntropin.
synthetic subunit of ACTH
What agent is used for embolization for fibroids?
microspheres are used in uterine artery embolization
How common is bovine arch and what does it look like?
15%
common origin of brachiocephalic and L common carotid
Where is most common origine for adamkiewicz?
L (70%) between T8-L1 (90%)
First branch of SMA?
inf. pancreaticoduodenal
Who makes up Arc of Riolan?
L colic (IMA) to middle colic (SMA)
Vessel in the fissure of the ligamentum venosum?
replaced L hepatic artery arising from the L gastric artery
difference in position between proper right hepatic a and replaced right hepatic a?
proper is anterior to the RPV and replaced is posterior to the MPV
which internal iliac branches are part of the posterior division?
iliolumbar, lateral sacral, glueteal
(I like sex in the butt)
from where do the ovarian arteries usually arise?
ant. med. aorta 80-90% of the time
What makes up the corona mortis?
obturator and external iliac- basically any vessel you see coursing over the superior pubic rim
could hypothetically cause a type 2 endoleak.
where does the subclavian vein run in respect to the anterior scalene muscle?
anterior.
SCA runs within the triangle made by the ant scalene and middle scalene muscles
what landmark is the proximal end of the axiallary artery?
1st rib
what landmark is the start of the brachial artery?
lower border of the teres minor
what marks the beginning of the common femoral artery?
onces the external iliac gives off the inferior epigastric
what marks the start of the popliteal artery?
exiting of the SFA from the adducter/Hunter’s canal
what forms most gastic varices?
left gastric (coronary vein)
MC congenital venous anomaly in the chest?
L sided SVC
90% of the time its duplicated
MC assoc CHD is ASD
92% of the time it drains into the coronary sinus
absence of hepatic segment fo the IVC?
azygous continuation: hepatic veins drains directly into RA
also, IVC is usually duplicated with L IVC terminating in L renal vein
think: polysplenia
MC cause of aortic dissection?
HTN (70%)
boundary of stanford A dissection?
proximal to L subclavian
SURGICAL
boundary of Stanford B?
distal to take off of the L subclavian
Name top alt causes of dissection besides HTN.
Marfans, Turners, infxn, pregnancy, coke
circumferential dissection of the intimal layer with subsequnt invagination?
intimo-intimal intussesception
usually tear starts near coronary orifices
strongest predictor for aortic dissection in intramural hematoma?
diameter of 5cm or more
intramural hematoma: T2 bright if acute and T1/T2 bright when subacute
causes of ascending aortic calcs?
Takayasu and syphilis.
athero usually spares ascending
size of “aneurysm” in aorta?
>4 cm ascending
>3.5 descending
>3.0 Abdominal
cystic medial necrosis?
Marfans
buzzwords for sinus of valsalva aneurysms
asian men
right sinus
congenital or acquired
assoc with VSD
rupture -> tamponade
Bentall procedure
warning signs of impending abdominal rupture
peri-aortic stranding, rapid enlargement (10mm+/year), pain, hyperdense crescent sign, draped aorta
Vascular complication of NF-1?
RAS- classicl will be stenosis swith HTN in teen/child
Aneurysm assoc with loss of fibrillin 1 gene?
Annuloaortic ectasia
leads to aortic valve insufficiency
“tulip bulb”
Marfan’s will also get “triple barreled dissection” and pulmonary artery root enlargement
wide eyed shitteir version of Marfan’s?
Loeys Dietz Syndrome
What is the blood supply to carotid body glomus tumors?
typically ascending pharyngeal artey
What qualifies a PE as “massive”?
systemic arterial hypotension
aggressive tx for : hypoTN, RV failure, and need for intubation
In which genetic vascular situation (collagen) should angio and other percutaneous procedures be avoided 2/2 arterial dissection risk?
Ehlers Danlos.
they’ll have aortic aneurysms like Marfans, often involving the aortic root. abdominal visceral artery aneurysms are common as well.
Aneurysm that involves ascending aorta/arch, saccular, heavily calcified “tree bark” intimal calcifications
syphilitic (Luetic) aneurysm
teriary untx syphilis
How can you tell if there is an aorto-enteric fistula?
IV contrast will be in the duodenum
-seen after surg, gas is normally present around graft for 4 weeks
will ask which portion of the duodenum- answer will be 3rd or 4th
Young male has pain, elevated ESR, smokes, and has hydro. Abdominal aorta looks plump
Inflammatory aneurysm: increased risk of rupture, 1/3 cases have hydro because inflammatory process involves ureters, thickening of aortic wall
complete occlusion of the aorta distal to the renal arteries
Leriche Syndrome
bad atherosclerosis
Triad:
ass claudication, absent/decreased fem pulses, limp pene
higher/longer segment of aortic narrowing than Leriche
Mid Aortic syndrome
zebra
young adults
Triad:
HTN, claudication, renal failure
infantile aortic coarc
pre-ductal
have pulm edema
blood supply via PDA
Ductal coarc
adult
not symptomatic until later in childhood
differential arm/leg blood pressures
Coarc assoc with what syndrome?
Turners
Most common assoc card defect of aortic coarc?
bicuspid aortic valve (80%)
CXR “figure 3” sign, rib notching, and berry aneurysms?
aortic coarc
psuedo coarc
looks like coarc, but no pressure gradient, collateral formation, or rib notching
follow the distal dilatation
Thoracic outlet syndrome + venous thrombus in SCV
Paget Schoetter
athletes who raise their arms a lot
What causes pulm art aneurysm/pseudoaneurysm in patient in the ICU?
swan ganz cath
pulm artery aneurysm and mouth and genital ulcers?
Behcets
Turkish descent
Behcets with recurrent thrombophlebitis, pulm art aneurysm and rupture
Hughes-Stovin Syndrome
MC visceral art. aneurysm?
Splenic
assoc. with HTN, portal HTN, pregnancy, cirrhosis, liver transplant
more likely to rupture in pregnancy
features of splenic art aneurysm that would make you treat?
>2cm, false aneurysm (kind assoc with pancreatitis), pregnancy
Median Arcuate Ligament Syndrome/Dunbar Syndrome?
compression of celiac by median arcuate ligament
20-40yo
“hooked appearance”
worse with expiration
tx surg
MC cause of colonic arterial bleeding
diverticulosis
colonic angiodysplasia #2
Angio shows cluster of small arts along border of colon with early opacification of dilated draining veins that persist late
Colonic angiodysplasia
colonic angiodysplasia + aortic stenosis
Heyde syndrome
AD disorder with multiple pulmonary and hepatic AVMs
Osler Weber Rendu (Hereditary Hemorrhagice Telangiectasia
MC cause of RAS?
atherosclerosis
2nd: FMD
string of beads in renal artery in young white woman?
FMD
can also affect carotid and iliac arts.
medial type is most common
spontaneous dissection
tx: balloon WITHOUT stent
smashing of renal vein by SMA
nutcracker syndrome
Right sided varicocele can be caused by__?
pelvic or abdominal malignancy, RCC, retroperitoneal fibrosis, adhesions
Non-compressible= bad
Right = bad
Left = Ok
Bilateral = Ok
Uterine AVM
can be life threatening
after D&C/abortion/multiple pregnancies
DVT of L common iliac 2/2 compression by R common iliac
May Thurner
swollen left leg
thrombolysis and stenting
What is strongly associ with popliteal art aneurysms?
AAA 30-50%
10% of pts with AAA have pop A
50-70% bilat
most dreaded complication of a pop art aneurysm?
acute limb from thrombosis and distal embolization of thrombus pooling in the aneurysm
Young man with normal pulses that decrease with plantar flexion or dorsiflexion of the foot
popliteal entrapment
medial head of gastroc
corckscrew config of superficial palmar arch/occlusion fo the ulanr artery, or PSA off the ulnar artery in manual laborer?
hypothenar hammer- jack hammering against hammate
can cause distal small emoboli which can be confused with Buergers
diff b/w low and high flow peripheral vasc malforms?
low flow: venous, lymphatic, capillary
high flow: arterial
You are shown MRA/MRV of a leg with a bunch of superficial vessels and no deep drainage
Klippel-Trenaunay Syndrom
Parkes-Weber is high flow- often combined
What causes re-stenosis 3-12 months after angioplasty?
intimal hyperplasia
Vasculitis
Large vessel- aorta
Young Asian Girl
Wall thickening and wall enhancement
Takayasu
dick move: MC type 3 with arch and AA involved
Vasculitis
MC
Large vessel- aorta and temporal artery
Old medn (70-80yo)
Wall thickening
Giant Cell
You’ll be shown temporal artery U/S with wall thickening or CTA/MRA of armpit demonstrating wall thickening/occlusions/dilatation/aneurysm
ESR and CRP elevated
gold standard temporal artery biopsy
Vasculitis
zebra
Large vessel
young kids
optic neuritis, uveitis, adiovestibular symptoms, aortitis
Cogan syndrome
Vasculitis
medium vessel- renal, cardiac, GI
man
microaneurysms at brachpoints
PAN polyarteritis nodosa
assoc with Hep B and meth
Vasculitis
MC vasc in children
medium vessel- coronary - can be clac
aneurysms
Kawasaki disease
mucocutaneous lymph node syndrome
“fever for 5 days”
Vasculitis
Small vessel
ANCA+ (c)
nasal perforation
cavitary lung lesions
Granulomatosis with polyangiitis
aka Wegeners
Vasculitis
Small vessel
ANCA+ (p)
necrotizing pulmonary vasculitis
asthma/esosinophilia
transient peripheral lung consolidation
Churg Strauss
Vasculitis
Small vessel
ANCA+ (p)
diffuse pulmonary hemorrhage
Microscopic polyangiitis
Vasculitis
MC in children
Small vessel
ANCA-
GI symptoms most common
HSP (henoch-Schonlein Purpura)
lead point for intussecption, scrotal edema
Vasculitis
Small vessel
ANCA-
mouth and genital ulcers
Turkish descent
pulm art aneurysm
Behcets
You are shown hand angiogram of a smoker with autoamputation
Buergers
more common in legs
arterial occlusive disease
Segmental arterial mediolysis
media of vessel turns shitty and you get a bunch of aneurysms.
abdominal splanchnic artery saccular in elderly and coronaries in young adults
cystic adventitial disease
young man, popliteal artery gets surrounded by mucoid filled cysts -> compression
What carotid waveforms will you see with aortic regurg?
reversal of diastolic flow and pulsus bisferiencs (double systolic peak)
Filling defects in biliary tree after transplant?
Biliary cast syndrome
OR stone
Multiple fusiform aneurysms of the visceral arteries in young patient?
Ehler’s Danlos (type 4)
ddx: PAN, NF-1, and FMD
MC ductal biliary ductal variant anatomy?
right posterior segment branch draining the left hepatic duct
2nd MC is trifurcation of the intrahepatic radicles
1st line in biliary draininge (strictures, sclerosing cholangitis, malignant cbd obstruction, dilated ducts, etc)?
Endoscopic internal biliary catheter draininge
percutaneous is 2nd line. unless a Klatskin tumor?
what should you give before perc chole tube?
abx
pros and cons to transperitoneal and transhepatic perc chole tubes?
transperitoneal: avoids liver, but bile can spill everywehre
transhepatic: less chance of bile leak
How long do you have to leave a perc chole tube in for?
2-6 weeks (until tract matures) because you get bile like otherwise
What is the normal difference (portosystemic gradient) between the portal vein and IVC?
3-6 mmHg
portah HTN: portal vein mmHg > 10 or gradient >6 mmHg
MC cause of portal HTN?
EtOH
What is enlarge diam of MPV?
1.3-1.5 cm
splenic vein 1.2
What are the accepted indications for TIPS?
- variceal hemorrhage refractory to endocopic tx
- MELD score <18 (higher melds die)
What Childs-Pugh scores are at risk for variceal hemorrhage?
B & C
What needs to be done before TIPS?
- ECHO to eval for heart failure
- imaging to eval for portal vein patency
What is a normal right heart pressure? What is the limit for a TIPS?
Normal = 5 mmHg
if elevated to 10-12 mmHg, you stop
What do you want the pressure gradient to be after TIPS?
9-12
What direction do you turn the cather when you are moving from the R hepatic vein to the R portal vein?
anterior
What are the main acute procedural complications of TIPS?
cardiac decompensation (increase R heart filling pressures), accelerated liver failure, and worsening hepatic encephalopathy
What is typical velocity within TIPS?
what are some bad signs on f/u doppler?
90-190 cm/sec
bad if greater than 200 cm/sec
portal vein velocity below 30 cm/sec bad too
increase by more than 50 cm/sec between exams bad
new or increased ascites
what can you do with a TIPS to improve hepatic encephalopathy?
(gradient too low in stent)
tighten stent down with another stent
What are the absolute contraindications for TIPS?
- severe heart failure
- biliary sepsis
- isolated gastic varices with splenic vein occlusion
Relative: cavernous transormation of the portal vein, severe hepatic encephalopathy
What is a peritoneovenous shunt?
Exactly what it sounds like. Gross. Puts ascites back into Jugular.
What is BRTO?
balloon occludd retrograde transverse obliteration
- treats gastric varices (not esophageal like TIPS)
- drives blood into liver (instead of divert like TIPS)
- esophgeal varices and ascites can get worse
- improves hepatic encephalopathy
What is the most common side effect of BRTO?
gross hematuria
What are contraindications for liver biopsy?
uncorrectable coagulopathy, thrombocytopenia (<50,000), RUQ infections
Transjugular approach can b performed if massive ascites or severe coagulopathy
carcinoid bx has caused crisis and death before, otherwise, bleeds are the main prob (check morrison’s pouch)
85% of upper GI bleeds come from what arter?
L gastric
if UGI bleed source is duodenal ulcer, which artery?
GDA
What is dieulafoy’s lesion?
monster artery in submucosa of stomach which can tear lesser curvature mucosa-> bleeds heavy and can be endoscopically clipped or endovascularly embolized
MC cause of lower GI bleed?
diverticulosis - usually L
angiodysplasia will rebleed after embo- will need surgery
1st line tx for lower GI bleed in stable patient?
colonoscopy
reasonable alts:Tc-99 RBC scan and CT angio
Tagged RBC more sensitive than CTA.
0.1 mL/min RBCs vs 1.0 mL/min CTA
1st line therapy in lower GI bleed
vasopressin inj.
contraindicated in large art, severe CAD, severe HTN, dysrhythmias
embos are for failed vasopressin: coils or gelfoam
pancreatic arcade bleeding aneurysm…
celiac artery stenosis
*known assoc of celiac art compression and dilation of pancreatic duodenal arcades-> PSA
How does TACE work?
iodized oil transports anticancer drugs to HCC-> ischemia-> coagulative necrosis
if there is enhancement and/or washout around the treated site, viable tumor present that needs tx
TACE can cause tricky beam hardening
How does RFA work?
tissue heated to 60 deg C.
any focal or nodular peripheral enhancement afterwards is residual or recurrent dz
indicated in HCC and colorectal mets
Which prolongs survival better- TACE or chemo?
TACE
Who is an appropriate candidate for liver transplant?
patient less than 65yrs with small tumor burden:
1 tumor <5cm or 3 less than 3cm
Pre Y90 tx, how do you evaluate the lung shunt fraction?
Tc-99 MAA to hepatic artery. Any fraction that would give 30 Gy to the lungs is too much.
How does Y-90 work?
Yttrium 90 is a high energy B emitter.
energy 0.93 MeV. no gammas
half life 64 hrs
94% of the radiation is delivered over 11 days (4 half-lives). Each bead has a range of 1.1 cm.
What do you embolize pre Y-90?
R gastric and GDA (prevent non-healing ulcers)
In respect to the rib, where do you enter for a thora?
just above
What happens if you pull too much fluid off in a thora?
pulmonary edema fro re-expansion
If the pleur-evac has continuous air bubbles, what’s going on?
Air leak- from draining tube or the lung
“bronchopleural fistula”
What are some pros/cons to lung RFA?
pros: limited effect on pulm fxn, no need to worry about prior radiation therapy
cons: ptx, pna, psa, bronchopleural fistula, nerve injury
How common is ptx after lung bx?
25%
What is a risk factor for thoracic angio?
LBBB because LBBB+iatrogenic RBBB = asytole
pace these patients ahead of time
pulm HTN w/ elevated R heart pressures (greater than 70/20)
can you inject contrast into a swan ganz to eval pulm arteries?
no. it explodes.
When do you treat a pulm AVM?
once afferent vessel is 3 mm
What is first line therapy for massive hemoptysis (>300 mL)?
bronchial artery embolization
*worry about infarcting the cord
particles >325 micrometers, avoid coils
what embolic material is usually used in UAE?
PVA or embospheres for fibroids
Gel foam or glue for post partum hemorrhage/vaginal bleeding
When is the normal post-embolization fever (uterine and hepatic)?
within 1st 3 days
what constitutes pelvic congestion syndrome?
gonadal vein diameter of 10mm (nml 5 mm) + clinical symptoms
What do you do if a thyroid biopsy doesn’t work?
try again in 3 months
indication for emergent perc nephrostomy tube?
sepsis
contraindictions to perc nephrostomy?
bleeding, renal CA
Where are you aiming for a perc nephrostomy?
lower pole posterior oriented calyx- looking to attack Brodel’s Avascular Zone
possible complications from perc nephrostomy?
bleeding and urosepsis
hematuria normal for 24-48 hours, but rapid bleeding abnml
how often do you need to change PNTs?
at least every 2-3 months- urine crystallization
when placing PNT for lithotripsy, how does site differ?
sometimes upper pole instead of lower to make stone access easier
tube is bigger- increased risk of bleeding
where should you stick for suprapubic cath?
just above pubic symph (avoid bowel/peritoneal cavity) and midline (avoid inferior epigastics)
When can you do renal RFA? Cryo?
RFA can be used on AMLs (>4cm), AVMs, and even RCCs.
In general RFA is for superficial stuff and cryo is for stuff near the collecting system.
no effect on GFR
smaller lesions may initially get bigger (<3cm)
what kind of needle is typically used for renal bx?
14-18 gauge cutting needle
avoid renal sinus
small AV fistulas and PSAs are common, but resolve, some hematuria is common
renal mass bx- what special test should you get if you think its lymphoma?
flow cytometry
projection of choice for looking at renal arteries?
LAO
Risks of angioplasty of renal arteries?
- thrombosis
- vessel spasm (can give calcium channgel blockers to decrease risk of spasm)
give heparine to reduce risk of thrombosis
When do you stop heparin prior to a procedure?
2hrs
PTT of 1.2x control or less (nml 25-35 sec)
You need INR of what? for most IR procedures?
1.5
When do you stop coumadin prior to IR procedure?
5-7 days prior
you can also give vitamin K 25-50mg IM 4 hrs prior, FFP/cryo
platelet count should be ___?
>50k (sometimes >75k)
when should you stop ASA or plavix pre procedure?
5 days prior
do you need Abx pre procedure in angio or thrombolysis?
nope. “clean”.
how long do you compress art access site post-procedure?
15 mins
usual wire size?
0.035
micro is 0.018 and 0.014
Type 1 endoleak
type A: coming from top of graft
type B: coming from bottom or graft
Type 2 endoleak
MC
filling of the sac via a feeder artery
IMA or lumbar arts MC
majority spontaneously resolve
how many French in 1 mm?
3
French is a measurement of what?
external diameter of a catheter
How are sheaths sized?
by the largest cather they will accomodate internally.
diameter of a sheath is usually 1.5-2 Fr larger than sheat size
Preference of veins for a PICC?
basilic>brachial>cephalic
don’t place if patient is on or going to be on dialysis
place in non-dominant arm
Pros and cons to grafts and fistulas?
Pro fistula: durable, less neointimal hyperplasia at graft-vein anastomosis
con fistula: 3-4mos to mature
Pro graft: ready to go in 2 wks, easier to declot
con graft: less longevity, more infxns
Normal flow rate in fistula and graft?
700-800 mL/min graft and 500 mL/min fistula
fistula “thrill”, “pulsatile”, “bruit”?
Thrill: normal, but if only in systole, prob a stenosis
pulsatile: central stenosis
bruit: low pitched over outflow is normal
what is the ideal dilation for angioplasty?
10-15% over the normal artery diameter
after placing a stent, what meds are on board?
1-3 months of anti-platelets
adding a stent after balloon angio is helpful except in___?
FMD
Where should self expandable stents go?
areas that might get compressed (carotid, SFA)
Where should a baloon expanding stent go?
places where precise depolyment is important. (renal ostium)
what material is used in self-expanding stents (thermal memory)?
Nitinol
On physical exam of a threatening limb (gasp), what is audible?
only venous doppler… arterial peaces out
what is critical limb ischemia?
rest pain for two weeks
or
ulcer
or
gangrene
how do you decide if you take art. thrombus to surgery or thrombolysis?
less than 14 days better with us, more than 14 days, better with surg
ABI equation
[DP vs PT (whichever mmHg is higher)]/Brachial mmHg
- 3= rest pain
- 5-0.9= claudication
who gets falsely elevated ABIs?
diabetics (art calcs)
what is a contraindication for vein ablation?
DVT
Type 3 endoleak
defect or fracture of the graft - usually failure to overlap
Type 4 endoleak
porosity
“4 is for the pore”
Type 5 endoleak
endotension
30 day mortality is better in which AAA repair?
endovascular
long term mortality difference between endovascular and open AAA repair?
same
graft related complications and reinterventions are higher with which AAA repair?
endovascular
when are some times you would place an IVC filter above the renal veins?
pregnancy
renal or gonadal clot
duplicated IVCs
circumaortic L renal vein
What kind of IVC filter do you place if the cava is bigger than 28mm? (mega cava)
birds nest works up to 40mm
OR bilat iliac
contraindications to vertebroplasty?
fxs with spinal canal compression, pain improving without augmentation
cement can embolize to the lungs
5% risk of local neurologic complications
How many Gy for early transient erythemia?
chronic erythemia?
telengiectasia?
dry desquamation?
moist desquamation?
2 Gy
6 Gy
10 Gy
13 Gy
18 Gy
how do you determine “sidedness” in angio? LAO, RAO etc?
where the image intensifier is. You want aorta LAO etc
what is a rapid heparine antidote?
protamin sulfate
can cause bradycardia and flushing
how should you anticoagulate someone in HIT?
with a thrombin inhibitor (ends in rudin and gatran)
antidote for versed/midazolam?
flumazenil
MOA aspirin?
(-) TXA2
irreversible, works for the lifespan of the platelet
MOA heparin
binds antithrombin 3, increases activity
monitored by PTT
reversed by protamine sulfate
MOA clopidogrel (plavix)
(-) binding of ADP to receptors -> inhibition of GP IIb/IIIa
MOA coumadin/warfarin
(-) vit K dependent facotrs
2,7,9,10
monitored by INR
MOA tPA?
converts plasminogen to plasmin (cleaves fibrin)
short half live 2-10 mins
max doese lido?
4-5mg/kg
Who gets DQ’d from TACE?
- hyperbilirubinemia (> 2 mg/dL)
- liver parenchyma involvement > 50%
- lactate dehydrogenase (LDH) > 425 IU/L
- AST > 100 IU/L
- Child-Pugh Class C liver disease
- hepatic encephalopathy
- refractory ascites
- Eastern Cooperative Oncology Group (ECOG) performance score > 3 which = end-stage disease.
*Treatable hepatic metastasis include melanoma, colorectal, breast neuroendocrine, sarcoma, and renal cell.
What is a therasphere?
Glass microbead containing Y-90
