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IR > IR > Flashcards

IR Flashcards

1
Q

‘Usual’ wire size?

A

.035 inch

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2
Q

‘Microwire’ size

A

.018 and .014 inches

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3
Q

‘Glide’ = ?

uses

A

hydrophilic coated

easier passage of occlusions, stenosis, small or tortuous vessels

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4
Q

Catheter French

measured where

A

External diameter, NOT lumen

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5
Q

Sheaths

Measured how?

A

sized according to largest catheter they’ll hold

INNER DIAMETER

ADD 2F for outer diameter and how big hole in patient will be

6F sheath will hold a 6F catheter, 8F hole in patient

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6
Q

Puncture needles, Guide wires, Dilators

sized how

A

OUTER d

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7
Q

SHEATHS

A

INNER D

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8
Q

Wire diameter

Wire length

units

A

DIAMETER = INCHES .035, .014, .018

LENGTH = CM

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9
Q

16G needle outer diameter? catheter?

20G needle outer diameter? catheter?

A

16G = 1.65 mm = 5F catheter

20G = 0.97 = 3F catheter

Remember 16G 5F

20G 3F

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10
Q

Needle and Wire rules

18G

19G

A

18G .038 inch

19G .035 inch

19 main one, 035 MC wire

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11
Q

Micropuncture

size

pros cons

A

21G = .018 wire

dilate up to 4-5F for .035 wire

Good for tough access, sensitive anatomy

Bad for fat, scars, hard to upsize from .018

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12
Q

Wire length

standard?

long one?

A

180cm = standard

260 cm = long

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13
Q

Floppy tips

risk of short vs long floppy

A

shorter floppy end = higher risk of dissection

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14
Q

Classic wires stiffness scenarios

Bentson

Lunderquist

Hydrophilic

A

Bentson = “noodle” classic guidewire test for lysable thrombus

Lunderquist = SUPER stiff, coat hanger, aortic stent grafting

Hydrophilic = tight spot

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15
Q

Stiffness chart

A

CTC pg 452

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16
Q

J tip terminology

purpose

A

measurement = radius of the J

Bigger J’s miss bigger branch vessels (3, 5, 10, 15)

15mm curve will miss profunda femoris during an antegrade fem stick

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17
Q

Catheter labeling

3 numbers

A

“OUTER DIAMETER (F), INNER DIAMETER (inch), LENGTH (cm)”

“Size” = outer diameter (F)

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18
Q

Non Selective

Pigtail

design

A

Distal end curls as u retract wire

curl keeps it out of small branch vessels

BOTH SIDE AND END HOLES

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19
Q

Pigtail Q

continuous injection can lead to ?

A

clot at end hole

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20
Q

Pigtail Q

Prior to full force injection?

A

puff to make sure you’re not in a small side branch

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21
Q

Straight (vs pigtail) catheter

use?

A

smaller vessels (iliac classic)

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22
Q

Maximum flow rates

determined by

estimates based on F

3F?

4F?

5F?

A

INTERNAL DIAMETER, length, number of side holes

3F 8 ml/s

4F 16 ml/s

5F 24 ml/s

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23
Q

Selective catheters

End hole only vs Side + End holes

A

END ONLY - HAND INJ ONLY, USED IN DX ANGIOS AND EMBOS

SIDE PLUS END - can use pump injector, SMA ANGIO, NEVER WITH EMBOS

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24
Q

SIDE BRANCH Q’s

(angle measured on opposite side from approach, angle of turn the cath has to make. 179 would be a U, OBTUSE)

Acute?

example

common name

specific

A

Arch vessels

“angled tip catheters”

berenstein or Head hunter

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25
Q

SIDE BRANCH Q’s

(angle measured on opposite side from approach, angle of turn the cath has to make. 179 would be a U, OBTUSE)

60-120

ex

common

specific

A

Renals, SMA, celiac maybe

“Curved cath”

Renal double curve or COBRA

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26
Q

SIDE BRANCH Q’s

(angle measured on opposite side from approach, angle of turn the cath has to make. 179 would be a U, OBTUSE)

obtuse

>120

ex

common name

specific types

A

Celiac, SMA, IMA

“Recurved”

Sidewinder, Sos Omni

Recurve = second curve in opposite direction (for dropping into obtuses)

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27
Q

random vocab

“introducer guide”

“microcatheter”

“vascular sheath”

A

“introducer guide” A long sheath

“microcatheter” 2-3 F

“vascular sheath” Sheath + hemostatic valve + side-arm for flushin

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28
Q

Flushing

Double flush

sitch, technique

Single

sitch, technique

A

Double flush

AIR A PROBLEM, brain. aspirate blood, attach a clean one, flush

Single

aspirate tiny bit of blood, tilt, flush

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29
Q

Arterial access next steps

resistance?

wire wont advance beyond top of needle?

Wire stops after short distance?

A

resistance?

STOP, pull out and confirm pulsey flow

wire wont advance beyond top of needle?

Flatten needle (prob against a plaque)

Wire stops after short distance?

fluoro, inject contrast with a 4F sheath, use something hydrophilic

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30
Q

Fem art access

anatomy? (origin, branches)

ideal spot?

risks of high, low sticks?

A

External iliac > CFA after inferior epigastric, at inguinal lig

Too high, above inguinal lig > retroperitoneal hematoma

Too low > AV fistula (fem vein right there)

Too low (at bifurcation), sheath can occlude branch vessels

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31
Q

Brachial access?

WHY?

A

Dead/cant get fem

pannus

upper limb angioplasty

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32
Q

Brachial access probs/risks

?larger sheath needed

A

Diff to hold pressure, hematoma easily > medial brachial fascial compartment syndrome

Higher risk of stroke if passing arch

Larger than 7F requires cut down

smaller vessel prone to spasm, prophylactic = GTN glycerine trinitrate

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33
Q

Which arm to access?

Headed south?

headed north?

all things equal?

BP diff?

A

LEFT if LE or AA

lower left

RIGHT if NORTH

All the same = LEFT (non dom, avoids most cerebrals)

BP diff >20 suggest stenosis, use other

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34
Q

Radial access

factoids

A

NO bedrest

Allen test beforehand, confirms Ulnar hand collats

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35
Q

Translumbar aortic stick

when?

position?

hematoma?

contraindication?

compression?

A

when? 2 endoleak repair

position? Stomach

hematoma? Psoas > back pain

contraindication? known supraceliac aneurysm

compression? roll onto back

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36
Q

Pre IR procedure stuff

Heparin timing?

INR?

Coumadin?

Plt?

ASA/Plavix?

abx proph?

A

Heparin timing? - 2hrs, PTT 1.2 x control, nml 25-35 sec

INR? 1.5

Coumadin? 5-7 days (25-50 Vit K IM 4 hrs prior, or FFP/cryo

Plt? >50k

ASA/Plavix? 5 days

abx proph? IR = clean procedure, no abx

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37
Q

Post procedure

timing of compression?

ACT to pull sheath?

turn hep back on?

A

timing of compression? 15 minutes

ACT to pull sheath? <150-180

turn hep back on? 2 hours post

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38
Q

PICC access order of pref

A

Basilic > Brachial > Cephalic

picture on 461

Lat to med

Basilic Brachial Cephalic

BBC

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39
Q

Central line pref

A

R IJ

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40
Q

Order of pref for DIALYSIS

A

RIJ > LIJ > REJ > LEJ

right over left, IJ over EJ

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41
Q

Pseudoaneurysm treatment

3 options

A

Direct compression

Thrombin injection

Surgery

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42
Q

Pseudoaneurysm treatment

Direct compression

where, how long?

A

neck, 20-60 minutes, painful

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43
Q

Pseudoaneurysm treatment

Thrombin inj

how?

contrainx

A

needle into apex

0.5 - 1.0 ml

500-1000 units

infection, rapid enlargement, limb ischemia, large neck, cavity size < 1cm

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44
Q

Pseudoaneurysm treatment

Surgery

A

If thrombin fails, infection, neck too wide

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45
Q

Pseudoaneurysm

spontaneous thrombosis size?

Which will respond to IR tx?

A

<2cm may thrombose

Respond to IR tx = long necked with small defects < 2mm

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46
Q

PTA and stents

ideal balloon dilatation?

success?

anticoag post plasty?

A

ideal balloon dilatation? 20% larger than normal diameter

success? residual stenosis < 30%

anticoag post plasty? 1-3 months ASA/Plavix

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47
Q

Balloon vs self expanding stents

why ?

classic locales ?

A

Balloon good for PRECISE PLACEMENT

RENAL ostia

Self expanding good for areas that might get compressed (superficial)

CERVICAL CAROTID, SFA

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48
Q

Nitinol

A

soft at room temp, more rigid at body temp

useful for self expanding

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49
Q

Rough balloon sizes (10-20% greater than normal D)

Aorta?

Common iliac?

External iliac?

CFA/Prox SFA?

Distal SFA?

Popliteal?

A

Aorta? 10-15 mm

Common iliac? 8mm

External iliac? 7mm

CFA/Prox SFA? 6mm

Distal SFA? 5mm

Popliteal? 4mm

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50
Q

Stent selection

length?

diameter?

A

1-2 cm longer than stenosis

1 - 2 mm wider than unstenosed lumen

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51
Q

Success alternate

A

>30% stenosis still but no pressure gradient

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52
Q

balloon doesnt fix waist

A

use a higher pressure one or a ‘cutting’ one

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53
Q

distal embo?

A

do a run

distal vessels fine, its ok

not, get ipsi access and try to aspirate it

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54
Q

exploded the vessel

A

inflate balloon with low pressure proximal to extrav to create tamponade

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55
Q

crossing tight stenosis, funny looking wire?

A

classic “spiral” of a dissecting wire

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56
Q

Endo vs open repair

30 day mortality

long term aneurysm related mortality (and total)

Graft compx and re-interventions

A

30 day mortality - LESS for endo

long term aneurysm related mortality (and total)- SAME

Graft compx and re-interventions - HIGHER for endo

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57
Q

EVAR (aaa)

indications?

anatomic criteria?

A

AAA larger than 5cm (or double normal size)

prox landing zone

> 1cm

non - aneurysmal (<3.2 cm)

angled less than 60 degrees

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58
Q

Iliac reqs for evar

A

> 90 degree angles

<7mm iliac diameter may require cut down and conduit

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59
Q

Absolute infrarenal EVAR contraindx

A

bad landing site

Covering a CRITICAL ARTERY

IMA with known sma and celiac occlusion

accessory renals feeding a horseshoe

dominant lumbars feeding the cord

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60
Q

renal related AAA vocab

para renal

juxta renal

supra renal

Crawford type 4 thoracoabdominal AA

A

para renal - near renals

juxta renal - landing zone <1cm, encroaches on renals

supra renal - involves renals and extends to mesenterics

Crawford type 4 thoracoabdominal AA - 12th IC space to iliac bifurcation involving renals, SMA and celiac

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61
Q

EVAR compx

A

paraplegia

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62
Q

Type 1

A

A top

B bottom

high pressure and require intervention

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63
Q

Type 2

A

Feeder

MC type

IMA or lumbar

majority resolve

follow sac size and tx if growing

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64
Q

Type 3

A

Defect/fracture

overlapping components

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65
Q

Type 4

A

4 from pore

porosity

doesn’t happen with modern grafts

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66
Q

type 5

A

endotension, not a real leakcould be 2/2 pulsation

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67
Q

Coils

A

accurate deployment = detachable coil

pushed or chased with saline (not precise)

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68
Q

Amplatzer plug

made of ?

sitch?

A

Nitinol

high flow situations, killing a single large vessel

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69
Q

Particulates

Permanent or Temporary

A

Temporary = gelfoam, autologous blood clot

Permanent = PVA particles

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70
Q

Particulates

when

when to stop

A

To block multiple vessels

fiibroids and malig tumors

Stop when flow becomes to and fro (avoid reflux)

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71
Q

Gelfoam powder vs pledgets

A

powder goes to capillaries, necrosis

pledgets cause occlusion at arteriole or larger, no necrosis

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72
Q

Coils vs particles

size?

need for re access

A

Coils medium to small, PVA multiple small or capillaries

<300 micrometer particles cause necrosis

Coils, can’t re access

classic is bronchial artery embo, they rebleed

BAE, particles >325 micrometers

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73
Q

Liquid agents

Sclerosants

Non-sclerosants

A

Sclerosants = alcohol (ouch) and Sodium tetradecyl sulfate SDS

Non sclerosants = ONYX, ethiodol

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74
Q

Classic embo scenarios

Priapism (post traumatic high flow)

A

Autologous blood clot

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75
Q

Classic embo scenarios

UFE (bilat uterine artery)

A

PVA or microspheres (500- 1000 microspheres)

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76
Q

Classic embo scenarios

Generic trauma

A

Gel foam in many cases

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77
Q

Classic embo scenarios

DIFFUSE splenic trauma

A

(proximal embo) Amplatzer plug in splenic artery, proximal to short gastrics

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78
Q

Classic embo scenarios

Pulmonary AVM

A

coils

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79
Q

Classic embo scenarios

BAE (hemoptysis)

A

PVA particles (>325 microm)

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80
Q

Classic embo scenarios

spinal tumors (vascular)

A

Onyx

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81
Q

Classic embo scenarios

total renal embo

A

Absolute ethanol

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82
Q

Classic embo scenarios

Selective renal embo

A

GLUE (bucrylate-ethiodized oil)

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83
Q

Classic embo scenarios

segmental renal artery aneurysms

A

COILS

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84
Q

Classic embo scenarios

Main renal artery aneurysm

A

COVERED STENT

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85
Q

Classic embo scenarios

Peripartum hemorrhage

A

Gel Foam

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86
Q

Classic embo scenarios

Upper GI bleed

A

ENDO first then prolly coils

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87
Q

Classic embo scenarios

Lower GI bleed

A

Usually microcoils

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88
Q

Post embo syndrome

A

Pain, n/v, low grade fever

characteristic after UFE, but also big liver tumors

don’t cx

starts within and goes away within 3 days

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89
Q

Acute limb

surgery vs thrombolysis

A

<14 days lysis

>14 days surgery

above inguinal isolated = surgically

fragmented distal = endo lytics

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90
Q

Ulcer trivia

Medial ankle?

Dorsum of foot?

Plantar foot?

A

Medial ankle? VENOUS STASIS

Dorsum of foot? ISCHEMIC OR INFX ULCER

Plantar foot? NEUROTROPHIC ULCER

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91
Q

Bypass vocab

Primary

Primary assisted

Secondary

A

Primary = uninterrupted, nothing done to graft itself (repair of distal vessels or vessels at either anastamosis ok)

Assisted primary = Patency NEVER LOST, but maintained with prophylaxis (plasty)

Secondary = patency lost then restored with ectomy, lysis etc

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92
Q

Next step extremity clot stuff

can’t cross clot with wire

A

won’t clear with thrombolysis

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93
Q

Generic procedure for lysis

A

jam cath in clot, infuse tpa directly, check q6-8 hours

“check angiography”

94
Q

Next step extremity clot stuff

NO clearing during a check angiogram

A

“lytic stagnation”

stop procedure

95
Q

Next step extremity clot stuff

“confusion”

96
Q

Next step extremity clot stuff

Tachy and hypoTN

A

look at site, CT abd/pelvis, stop tpa

97
Q

Next step extremity clot stuff

end point?

A

clot clears or 48 hours

98
Q

Varicose vein treatment

A

tumescent anesthesia, lots of dilute subq lido

ablated using endoluminal heat source

contraindx = DVT

99
Q

Post thrombotic syndrome

demo

RF

tx/prophylx

A

Pain and ulcers after a DVT

OLD, proximal DVT, fat

catheter lyis of iliofemoral DVT will prevent, not needed as much with femoropop DVT

100
Q

Filter indications

A

PE on anticoag

contra to anticoag with CLOT IN FEMORAL OR ILIACS

101
Q

AV fistula vs graft

pros cons

A

Fistula, vein plugged into artery (cephalic into radial)

FISTULA

Pros- Longer, durable, less neointimal hyperplasia, fewer infx

Cons- Needs 3-4 months to mature

GRAFT (uses a synthetic tube)

Pros- Ready in 2 weeks, easier to declot (in graft)

Cons- less longevity, more hyperplasia stenosis obstrx, INFX

102
Q

normal graft PE

A

Easily compressible pulse

low pitched bruit in systole and diastole

palpable thrill with compressoin only at the arterial anastamosis

103
Q

MC site of obstrx

A

venous outflow, at or just distal to graft to vein anastamosis

104
Q

fistula stenosis reoccurence

A

75% of the time within 6 months

105
Q

FISTULA THRILL

?only in systole

A

should be continuous at anastamosis

only in systole = stenosis

106
Q

Fistula, cold hand during HD

A

Steal syndrome, distal native artery stenotic

tx = surgical

107
Q

Def of portal HTN

A

Pressure in portal vein > 10 mm Hg

or PSG > 6 mm Hg

Normal PSG, diff bt PV and IVC is 3-6 mm Hg

108
Q

Portal HTN US look

A

Enlarged PV > 1.3-1.5 cm

Enlarged Splenic vein > 1.2 cm

Big spleen

ascites

patent umbilical

reversed PV flow

109
Q

TIPS indx

A

variceal hem refractory to endoscopic tx

Refractory ascites

Budd (hepatic vein thrombosis)

110
Q

TIPS w/u?

A

ECHO- evaluate for HF

CT to confirm patency of portal vein

111
Q

TIPS steps…

A

Measure R heart pressure - if elevated 10-12 mmHg, STOP

Jug access, down IVC to hepatics, get wedge pressure

use CO2 to opacify portals

Right hepatic to Right portal stick

covered stent in, balloon up.

Check pressures, want gradient of 9-12

112
Q

Hepatic to portal stick move in TIPS?

A

turn catheter ANTERIOR

113
Q

MELD

A

Transplant score

based on liver and renal fx

bili

inr

creatinine

Greater than 18 = higher risk of early death after elective TIPS

114
Q

Childs Pugh

A

Prior to MELD

less accurate

assesses severity of liver disease

bili

PT

albumin

ascites, hepatic encephalopathy

B and C are high risk

115
Q

SImplest prognostic measure with liver

A

Serum bili > 3mg/dl = increase in 3 day mortality afer TIPS

116
Q

TIPS contraindx

A

MC Severe HF (right more)

biliary sepsis

isolated gastric varices with splenic vein occlusion

relative

cav transformation of PV, encephalopathy

117
Q

Main acute TIPS complx

A

cardiac decompensation (elevated RH pressure)

accelerated liver failure

worsening encephalopathy

118
Q

Evaluation of a ‘normal TIPS’

A

Normal = flow into stent, reversed in R and L portal veins

in stent flow 90-190

Stenosis/malfx

  • >200cm/s across a narrowing
  • Low PV velocity <30cm/s
  • indirect = new or increased ascites
119
Q

TIPS F/U

A

50% primary patency at 1 year

signs of failure ascites, bleeding etc

Do venogram

PV >12 bad

next step treat stenosis plasty + balloon

120
Q

MC TIPS stenosis site

A

hepatic vein and within TIPS tract

121
Q

Worsening encephalopathy

A

TIPS too open, tighten with another stent

122
Q

BRTO

Balloon occluded retrograde transverse obliteration

BRTO treats

what is it

complx

helps

A

Treats GASTRIC varices

transjug, balloon used to occlude outlet of either gastrorenal or gastrocaval shunt. sclerosing agent used to take vessels out

30-50 minutes later, aspirate remaining sclerosant and let down balloon

Embolized collaterals > more blood to liver vs away in TIPS

WORSENS ESOPH VARICES and ASCITES

IMPROVES ENCEPHALOPATHY

123
Q

MC BRTO SE

A

gross hematuria

124
Q

Biliary ductal anatomy

A

Right hepatic duct

posterior - 6 and 7

anterior - 5 and 8

Left hepatic duct

2 and 4

125
Q

Ductal variants

A

MC Right posterior drains left hepatic duct

2nd MC Trifurcation of Right anterior, right posterior and left ducts

126
Q

Biliary drainage

pre procedure

A

abx and coags

127
Q

biliary drainage approaches

A

Right lateral mid axillary for right system

SUBXYPHOID for left

128
Q

Right PTC approach

A

BELOW 10th rib (TOP EDGE)

stick blindly and inject while pulling back, try for posterior, wire in, cath into duodemum

In the duct?

flow to hilum

veins flow to heart, arteries to periphery

129
Q

PTC next steps

ascites?

Don’t see left system?

Rigor?

stones?

can’t cross an obstrx with a wire?

A

Drain them

Roll patient right side up

RIGOR = forceful injection and instant cholangitis, biliary sepsis

Stones, dilute contrast to avoid obscuring defects

obstrx, place pigtail and try again 48 h later

130
Q

ccy ostomy

approaches

Coagulopathic?

Main route?

A

Transperitoneal

avoids liver in bleeders, risks big bile spill

Transhepatic

liver stabilizes wire

usually through 5 and 6

131
Q

managing GB tube

leave in?

before pulling?

A

leave in 2-6 weeks

confirm patent cystic duct prior to pulling

clamp 48 hours prior to pulling

132
Q

Liver FNA

A

cytology

21 or 22G chiba, vacuum aspirate

133
Q

biopsy a liver lesion

course?

Shoulder pain?

contraindx?

A

traverse 2-3 cm of normal liver first to avoid big bleed

Mild shoulder pain normal, prolonged = possible bleed, US behind liver, morry’s pouch

contra = RUQ infx, coagulopathy

carcinoid met bx can kill 2/2 carcinoid crisis

coag or ascites can do TRANSJUG

134
Q

TRANSJUG Bx

path?

A

through R hepatic vein while angling ANTERIOR (biggest bite and avoids capsular perf)

135
Q

Angio for hepatic/splenic trauma

indications?

contraindx?

A

continuous bleeding in a stable patient

ongoing bleeding after surgery to obtain hemostasis

rebleeding after initial embo

post traumatic pseudoan or AVF

CONTRAINDX

unstable pt needs lap

136
Q

Hepatic embo

what’s usually used?

selective or non?

Tx for pseudoan?

Hepatic surface bleeding?

A

what’s usually used? Gelfoam pledgets/particles or microcoils

selective or non? avoid massive non-selctive. necrosis and abscess

Tx for pseudoan? sandwich. ok to take these

Hepatic surface bleeding? usually more than one source, so gelfoam or particles

137
Q

Splenic embo

indx?

strategies, focal vs diffuse

A

laceration without active extrav NOT an indication

focal abn = selective embo

multiple sites = proximal embo

drop amplatzer plug into splenic artery PROXIMAL to short gastrics (preserved collateral supply)

138
Q

HCC

?transplant appropriate

A

<65, limited tumor burden

139
Q

TACE

indx

mechanism

agent

chemo followed with

absolute contraindx

A

First line for palliative

Tumors love arterial blood

high [] chemo in Lipiodol (oil)

followed with particle embo, slows down washout of agent

CONTRA = Decompensated, acute on chronic, liver failure

140
Q

TACE in pt with biliary stent, prior sphincterotomy, post WHIPPLE risk?

A

biliary abscess

141
Q

RISK to GB?

A

Agent injected into R hepatic artey, prior to cystic artery origin

sterile or chemical cholecystitis

142
Q

repeat TACE risk

A

burns, left back 2/2 RAO position

143
Q

RFA

temp?

residual tumor = ?

indx?

TACE + RFA ?

A

60C

Peripheral enhancement after tx = residual or recurrent

INDICATED for HCC and COLORECTAL METS that can’t get sx

TACE + RFA for lesions bigger than 3 cm improve survival more than either alone. not curative

144
Q

Y90

Pre-tx w/u

A

Shunt fx

Tc-99 MAA in hepatic artery

30Gy to lungs = contraindx

Take off of right gastric (proper or left hepatic)

prophylactic embo of R gastric and GDA

145
Q

Ytrium facts

? emitter, energy

half life?

range of rad from each bead?

A

Beta emitter

mean energy of 0.93MeV

half life 64 hours

1.1 cm maximum bead range

146
Q

RFA trivia

size for ‘cure’ vs ‘debulk’?

burn margin?

Patient precautions?

Hot withdrawal?

Heat sink?

A

size for ‘cure’ vs ‘debulk’? >4cm, just debulked

burn margin? 1.0 cm

Patient precautions? grounding pad on leg, blankets in gooch and armpits

Hot withdrawal? prevents seeding

Heat sink? adjacent vessels can remove heat

147
Q

Post ablation syndrome

A

can get fever and aches

>2-3 weeks, infx w/u

148
Q

Microwave diffs from RFA

A

More power

cooks bigger stuff

less ablation time

less susceptible to heat sink

no grounding pad

149
Q

Cryoablation

trivia

A

thawing kills cells

hurts less

higher risk of bleeding than RFA, small vessels aren’t cauterized

150
Q

RFA tx response

week 1-4?

month 3?

month 6?

A

week 1-4? OK to get bigger

month 3? same size or smaller

month 6? should be smaller

151
Q

Post RFA enhancement

benign vs residual/recurrent

A

Benign = peripheral, smooth, uniform, concentric

f/u at 1 month, residual enhancement = disease = repeat tx

152
Q

TACE f/u CT

A

tx oil = dense, more = better

enhancement or washout = tumor

“zone of ablation”

153
Q

Cryo tx response

CT at?

good post tx look?

A

3 months, 6 months, 12 months

Good CT = lower density than adjacent kidney

Good MRI = T2 dark, T1 iso or hyper

154
Q

G tube

ideal target

A

Left of midline

Mid to distal body

between greater and lesser curvatures to avoid vessels

155
Q

GI bleed

upper vs lower

A

ligament of Treitz

156
Q

Upper GI bleed

MC vessel

duodenal ucler vessel

A

Left gastric

GDA

157
Q

parcreatic arcade bleeding aneurysm = ?

look?

A

Celiac compression (median arcuate)

dilation of pancreatic duodenal arcades with PSEUDOAN, bleed

Shown with SMA run, dilated collateral system and retrograde filling of hepatics

158
Q

Angio vs RBC scintigraphy sensitivity

A

NUCS 0.1 ml/min

CTA 0.4 ml/min

Angio 1ml/min

159
Q

GI bleeding buzzwords

Angiodysplasia

Diverticulosis

Meckles

A

Right sided. early draining vein. NEED SURGERY

LEFT sided. usually venous. If arterial, fills tic first

Feeder = Vitelline “extension beyond mesenteric border”, “no side branches”, “corkscrew appearance”

160
Q

Provocative angio looking for bleeding

if you see bleeding?

A

nitro and tPa

microcoils and PVA particles

161
Q

PVA vs coils

A

coils have to get right up to bleed. more proximal will cause bowel infarct

PVA flow directed, don’t need to be as peripheral. Less control

300-500 microns

162
Q

Post embo?

Classic dual supply question

A

angio post embo to look for collaterals

GDA embo for duoy ulcer, do SMA run for inferior pancreaticoduodenal, take if bleeding but increase risk of infarct

Higher riks of infarct with lower GI bleeds in general. Above Treitz = more collaterals

163
Q

tube size for abscess drainage

clear

thin pus

thick pus

debris

A

clear 6-8 F

thin pus 8-10 F

thick pus 10-12 F

debris 12+ F

164
Q

Paths to drain pelvic absceses

Transabdominal

A

Usually a long course

Watch out for INFERIOR EPIGASTRIC

165
Q

Paths to drain pelvic absceses

Transgluteal

access, what to avoid

A

Avoid gluteal arteries and sciatic nerves

access through sacrospinous ligament

medial as possible

inferior to piriformis

166
Q

Indication for renal abscess drainage

A

large >3-5 cm, doesn’t respond to abx

167
Q

Indications for PCN

A

Obstrx

Diversion- leak, fistula, severe hemorrhagic cystits (cyclophosphamide)

Access for a procedure

168
Q

PCN contraindx

A

coagulopathy 1.5, 50k

colon, spleen, liver in way

169
Q

Prior to PCN

A

K < 7

antiplatelets held for 5 days

170
Q

PCN target stuff

where

A

Lower pole of a posteriorly oriented calyx

30 degree to hit brodel avascular zone

10 cm from midline (spine)

171
Q

Approach to PCN a transplant

A

anterolateral calyx

lateral to avoid peritoneum

172
Q

PCN exchange

A

q 2-3 months

173
Q

Long term drainage (urinary)

A

nephroureteral stent

174
Q

Suprapubic cystostomy

target

contraindx

A

Midline above symphysis, mid and lower thirds of anterior bladder wall- avoids bowel, avoids trigone (spasm), avoids inferior epigastrics

Contraindx- scar, fat, caogulopath, inability to distend bladder, overlying small bowel

175
Q

Renal biopsy

RF or cancer

A

Non focal (RF)

14-18 G cutting needle, tissue from lower pole cortex

Focal

better with CT, some risk of seeding, lesion side down decub stabilizes kidney

176
Q

Renal ablation RFA

A

can be used for AML’s (at 4cm for bleeding risk), AVM’s, even RCC’s

closer to collecting system, better to freeze

RFA no effect on GFR

177
Q

Renal arteriography

to start?

position?

A

Aortogram to define arteries (can be multiple)

LAO

178
Q

Renal artery stenting

risks

drugs

A

Thrombosis and spasm

heparin then ASA x 6 months

dont stent FMD

179
Q

Renal aneurysms

small vs main

A

Small segmental tx = COILS

Main renal artery = covered stent or bare stent and coil thru

180
Q

Pleural drainage

paravertebral risk?

A

intercostal vessels are off the ribs, more prone to injury

181
Q

Lung abscess

A

DONT DRAIN

BRONCHOPLEURAL FISTULA

182
Q

Lung bx

complx

A

MC = PTX, 25%, 5% need tube

hemoptysis

183
Q

Avoiding PTX with lung bx

when to CT

kind of CT

A

90 degress to pleura

AVOID FISSURES

Puncture side down after procedure

Treat coughers before, don’t talk or deep breath x 2 hours

CT for symptomatic, enlarging

CT usually 10F pigtail, 18G needle, 0.035 amplatz

184
Q

RFA of lung tumors

size?

effectiveness?

benefit?

A

1.5 - 2.5 cm

comparable to external beam RT with limited effect on pulmonary function

185
Q

Thoracic angio

types, big indx

A

Pulmonary artery

PE or AVM

Bronchial artery

hemoptysis

186
Q

PA angio

catheter?

risk?

pre-eval?

A

GROLLMAN catheter, 7F, pre-shaped

catheter can cause RBBB, so LBBB is high risk, prophylactic pacing needed

eval for pulm HTN (chronic PE)

>70 systolic, >20 diastolic

if you hafta, low osmolar agents into RIGHT OR LEFT, NOT MAIN PA

187
Q

Pulm angio

Vtach during?

A

Re-position catheter/wire

188
Q

Pulm angio for PE

indx

A

1st tx - anticoag

can’t? filter

unstable with massive PE? catheter therapy (lysis, aspiration, fragmentation, stent)

189
Q

Pulm avm’s

a/w?

where?

complx?

tx when and how?

A

HHT/OWR

MC in lower lobes

Brain abscess/stroke

Tx at 3mm afferent

Coils in feeder

190
Q

rasmussen tx

A

coils

hemoptysis with negative bronchial artery angio

191
Q

bronchial artery angio

hemoptysis

look

BIG risk

tx

A

won’t see extrav

tortuous, enlarged bronchial arteries

vessel with hairpin turn = anterior medullary, embo this or near this > paralysis

PARTICLES >325, no coils, can’t get back in if rebleed

192
Q

SVC syndrome

tx steps

malig vs non malig

risk of tamponade

A

Malig = LYSIS, PLASTY, STENT

Non Malig = MAY OR MAY NOT NEED STENT

Dont use self expanding, they migrate

pericardium extends to bottom of SVC, so if you tear there > big problem

193
Q

UAE

size and location?

A

submucosal best

Intramural second

serosal worst

small do better

194
Q

UAE

Cellular fibroids

look

response to embo

A

T2 bright

respond well

195
Q

Intracavitary fibroids- less than 3cm?

A

GYN for hysteroscopic rsxn

196
Q

Intracavitary fibroids - less than 3cm, failed rsxn

197
Q

LARGE, serosal, patient wants to remain fertile, never had a myomectomy

A

GYN for myomectomy

198
Q

pedunculated serosal fibroid

A

GYN for resection

199
Q

Broad ligament fibroid

A

can’t embo, hard to operate on

200
Q

Fibroid medical tx

A

Grow in pregnancy, hormone responsive, GnRH meds

201
Q

Patient on hormone meds for fibroids, want UAE?

A

delay 3 months off meds, meds shrink uterine arteries, harder to cath

202
Q

UAE risks

A

5% premature menopause

DVT/PE 5% (large fibroid compression released, DVT flies up)

203
Q

UAE contraindx

A

PREG

Cancer

PID

prior radiation

CTD

204
Q

UAE tx trivia

anatomy?

which to tx?

material vs post partum hem?

adenomyosis tx?

volume reduction?

A

anatomy? UA branch of ANTERIOR DIV of INTERNAL ILIAC

which to tx? BOTH

material vs post partum hem? Fibroids PVA or embospheres, PP hem tx = gelfoam or glue

adenomyosis tx? SAME, symp tend to recur

volume reduction? Fibroids down 40-60%

205
Q

HSG trivia

best time?

closed tube?

false positives?

A

DAYS 6-12 PROLIFERATIVE (thinnest endometrium)

Previously closed tube can be open on repeat exam, narcotics, tubal spasm

air bubbles can mimic filling defect

206
Q

Fallopian tube recanalization

prox, interstitial, distal tx?

A

Distal = surgery

Proximal = endo or wire under fluoro

207
Q

Tube recanalization

timing?

poking tool?

contraindx?

A

DAY 6-12, PROLIFERATIVE, thin endometrium

Hydrophilic .035 or .018

Repeat HSG when finished

PID and PREG

208
Q

PELVIC CONGESTION SYNDROME

dx?

Tx?

A

clinical symptoms + gonadal vein > 10mm

medical = GnRH

IR = sclerosing parauterine veins, coils/plugs in ovarian and internal iliac veins

209
Q

Varicoceles

when to tx?

A

tx for infertility, atrophy in a kid, pain

210
Q

heparin half life

211
Q

Protamine SE

A

sudden drop in BP, BRADY and FLUSHING

212
Q

HIT

risk

tx

A

RISK OF CLOTTING NOT BLEEDING

If they need to be anticoag, use thrombin inhibs (rudin and gatrans)

213
Q

Abdominal aorta injection rate

214
Q

Takayasu look

A

Smooth, non-ostial

215
Q

CTA timing

arterial

venous delay

A

20-40 seconds

180 seconds

216
Q

Timing, location of graft/fistula complx

A

First six months arterial inflow

Past 1 year out, venous outflow

217
Q

RFA contraindx/ideal lesion

A

1 2 3

<1cm from capsule

<2cm from major vessel

<3cm in size

>3cm TACE

218
Q

General rate for ‘selective’ angios (SMA etc)

219
Q

Angiodysplasia look, tx

A

tuft of vessels

super selective coil

(also for pseudoan and extrav)

220
Q

Median arcuate lig

worse w/?

Tx?

A

EXPIRATION

Surgery

221
Q

UFE embo material =

A

particles >350 microns

222
Q

Secondary supply to fibroids leading to recurrent symptoms =

A

ovarian arteries

Right off aorta

Left off renal

223
Q

embo material for tic bleed

A

selective coiling

particles > infarcts

224
Q

Indirect portal venogram?

A

delayed SMA injection

celiac vs SMA by presence/absence of splenic blush

225
Q

PCN tube size pussy vs non pussy

A

pyonephrosis = 10F for pus

routine PCN = 8F

226
Q

occluded aorto question, origin of superior epigastric

A

INTERNAL MAMMARY

anastamoses with inferior epigastric at umbilicus

227
Q

TIPS contraindx

A

CHILD C

MELD >18

encephalopathy

elevated PAP

228
Q

TIPS stent =

A

Covered, self expanding

229
Q

PE findings with fistula complx

outflow stenosis?

Arterial stenosis?

A

Outflow stenosis = increased back pressure and increased pulsatility

Arterial stenosis = weak or absent thrill

230
Q

threshold for visceral/renal artery aneurysm intervention?

231
Q

number of bronchial arteries

A

MC one on right two on left

IR (1 decks)

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