IR CORE - Sheet1 Flashcards
Which is anterior? Subclavian artery vs. vein
Subclavian vein is anterior to artery
Major branches of subclavian artery
Vertebral, Internal thoracic, Thyrocervical trunk, Costocervical trunk, dorsal scapular
Extent of subclavian artery?
brachiocephalic to the first rib (outer edge)
Extent of axillary artery?
from the first rib (outer edge) to teres major (outer edge)
Extent of brachial artery?
from teres major (outer edge) to bifurcation of the radial and ulnar arteries
which gives off interosseous artery?
usually ulnar, which is also usually bigger
normal variant that can supply the deep palmar arch of the hand
persistent anterior interosseous branch (median artery)
high origin of the radial artery
radial a. comes off either the axillary or brachial a.
when does the external iliac become the CFA?
once it gives off the inferior epigastric (at the inguinal ligament)
CFA bifurcates into these 2 vessels
deep femoral (profunda) and superficial femoral
superficial femoral turns into the popliteal after?
after emerging from Hunter’s canal
popliteal artery divides when?
at the distal border of the popliteus muscle
popliteal artery divides into?
anterior tibial and tibial peroneal trunk
what is the most medial artery in the leg?
posterior tibial (felt at medial malleolus)
most common biliary duct variant?
right posterior segment draining the left hepatic duct
2nd most common biliary duct variant
trifurcation of the intrahepatic radicles
how many times can you try a PTC before quitting?
15-20
what happens if you inject contrast forcefully during a PTC?
ICU visit for cholangitis
what is the benefit of a transhepatic cholecystostomy?
minimizes chance of bile leak c/w transperitoneal approach
when can you pull a cholecystostomy tube?
2-6 weeks after placing (have to wait for tract to mature) or else leak
how do you manage an accidental bile leak?
place a tube in the bile ducts to divert bile from location of leak
what % of blood flow to liver comes from PV?
70-80%
normal pressure gradient between PV and IVC
3-6 mmHg
define portal HTN (mmHg)
PV > 10 mmHg or PSG > 6 mmHg (portal systemic gradient)
ultrasound findings of portal HTN
large PV (>1.3-1.5 cm), large splenic v. (>1.2cm), big spleen, ascites, collaterals, reversed flow in PV
2 reasons for TIPS
variceal hemorrhage refractory to endoscopy + refractory ascites
no TIPS above this MELD score
18 - higher risk of early death after elective TIPS
2 pre-procedural steps for TIPS
Echo to eval for heart failure + cross sectional imaging to demonstrate patency of PV
normal right heart pressure
5 mmHg
value of right heart pressure that precludes a TIPS
10-12 mmHg
what to what for a TIPS
IVC to hepatic veins to PV (usually right to right)
ideal PSG (portal systemic gradient) after TIPS
9-12 mmHg (remember normal = 3-6 mmHg)
which direction to you turn the catheter when moving from the right HV to the right PV?
turn needle anterior
3 main post-TIPS complications
cardiac decompensation (elevated right heart pressure), accelerated liver failure, worsening encephalopathy
typical velocity of TIPS stent
90-190 cm/s
what TIPS stent velocity is too high?
> 200 cm/s (stenosis)
what PV velocity is too low s/p TIPS
< 30 cm/s abnormal
indirect sign of TIPS malfunction
new or increased ascites
3 absolute contraindications to TIPS
severe heart failure + biliary sepsis + isolated gastric varices with splenic v. occlusion
2 relative contraindications to TIPS
cavernous transformation of the PV + severe hepatic encephalopathy
alternative to TIPS for refractory ascites
peritoneovenous shunt (Denver shunt)
major risks of Denver shunt
high rate of infection and thrombosis (even DIC)
BRTO
balloon-occluded retrograde transverse obliteration
what does BRTO treat?
gastric varices
major complication of BRTO
worsening esophageal varices and ascites
how does BRTO affect hepatic encephalopathy
improves it
2 reasons for doing transjugular liver biopsy
massive ascites + severe coagulopathy
first line treatment for GI bleeds
vasopressin
which is more sensitive for GI bleed: nuclear scintigraphy or angiography?
RBC bleeding scan
rate of bleeding detected on RBC scan
0.1 mL/min
rate of bleeding detected on angiography
1 mL/min (10x less sensitive than RBC scan)
most common embolization agents for GI bleed
coils or gelfoam
3 contraindications to GI bleed embolization
prior stomach or bowel surgery, prior radiation, or inadequate collateral circulation
why do angiography after you embolize?
look for collateral flow (after you embolize GDA, look at SMA to at inf. pancreaticoduodenal)
most common source of upper GI bleed
left gastric (85%)
what do you embolize if it’s a duodenal ulcer bleed?
GDA
most common cause of lower GIB
diverticulosis (on the left)
does embolization help with angiodysplasia?
no, usually re-bleeds and need surgery
“pseudo-vein” sign
sign of acitve GIB, appearance of vein created by contrast pooling in gastric rugae or intestinal fold
dieulafoy’s lesion
monster artery in the submucosa of the stomach which pulsates until it causes a teeny tiny tear
pancreatic arcade bleeding
celiac artery stenosis (dilation of pancreatic duodenal arcades + pseudoaneurysms)
what is the only cure for HCC?
transplant
better survival: TACE or systemic chemo?
TACE
contraindication to TACE
PV thrombosis (risk of infarcting liver)
“zone of ablation”
preferred nomenclature for post-ablation region s/p TACE/RFA
nucs study you do before a Y-90 radioembo
lung shunt fraction using Tc-99 MAA
lung shunt fraction that precludes Y-90 tx
fraction that would give >30 Gy in a single treatment
what artery do you embolize before Y-90 tx?
right gastric and GDA (prevent reflux of Y-90)
above or below rib for thora?
above! (avoid neurovascular bundle)
how to position patient post-lung biopsy to reduce risk of pneumo
puncture side DOWN
2 reasons to place a chest tube post biopsy
symptomatic pneumothorax or enlarging pneumo or serial CXR
better to drain an empyema or lung abscess?
empyema (draining an abscess can create bronchopleural fistula)
who should get prophylactic pacing prior to pulmonary angio?
LBBB
when should you measure pressures on pulmonary angio?
BEFORE injecting contrast (may need to decrease volume in pulm HTN)
2 contraindications to pulmonary angio
pulmonary HTN (right heart pressure > 70 systolic and 20 ED) + LBBB
major risks of AVMs
right to left shunt = stroke and brain abscess
from what does the uterine artery arise?
anterior division of the internal iliac
embolize unilateral or bilateral?
always bilateral (too many collaterals)
what meds do you stop before UAE?
gonadotropic-releasing meds (3 months prior, they constrict the uterine a.)
which location of fibroids responds best to UAE?
submucosal
which trial showed the hospital stay are shorter for UAE than hysterectomy?
EMMY trial
incidence of premature menopause following UAE
5%
risk of peritonitis following HSG
1%
what time of cycle is best for HSG
proliferative phase (days 6-12)
3 reasons to treat varicocele
infertility, testicular atrophy, pain
left internal spermatic (gonadal) vein drains into the…
left renal vein
right internal spermatic (gonadal) vein drains into the…
IVC
2 reasons varicoceles occur
right angle entry of the left spermatic v into left renal v. + nut-cracker syndrome on the left
how to treat varicocele
mad embolization of the gonadal vein - foam, coils, amplatzer, all of it
try to avoid these on transgluteal drainage
sciatic nerves and gluteal arteries (access through the sacrospinous ligament medially)
when to pull an abscess catheter
patient is better + output < 20 mL over 24 hrs
pancreatic cutaneous fistula
pancreatic drain with clear fluid > 30 days
4 reasons to biopsy a thyroid nodule
solid > cystic, hypervascular, blurred margin, microcalcs (most important)
what if path is non-diagnostic
don’t repeat for 3 months
Brodel’s Avascular Zone
posterior lateral LP target of PCN placement (btw arterial bifurcation)
can you do a perc neph on a transplant kidney?
of course + it’s easier
2 risks of perc neph
bleeding + urosepsis
how often should you exchange perc neph tubes?
every 2-3 months (b/c of crystallization)
2 indications for renal abscess drainage
large (>3-5 cm) + symptomatic that does not respond to abx alone
what part of the kidney do you want for random renal biopsy?
cortex (to get the glomeruli)
positioning for focused renal biopsy?
lesion side DOWN (stabilizes kidney from motion/bowel)
3 things that we do renal RFA for
AMLs, AVMs, RCCs
treatment for atherosclerosis at ostium of renal arteries
angioplasty + stent
treatment for FMD renal arteries
angioplasty only
medial brachial fascial compartment syndrome
cold fingers + weakness 2/2 hematoma from brachial artery stick
when to stop heparin before arterial stick
2 hours prior to procedure
INR for arterial procedure
1.5
when to stop coumadin before arterial stick
5-7 days prior
platelet count for arterial stick
> 50 K (some texts say 75)
when to stop ASA/plavix prior to arterial stick
5 days prior
how long to I have to stand here and hold compression after an arterial stick
15 min
when can I turn heparin back on after arterial stick
2 hours
0.039 inch (in mm)
1mm
0.035 inch (in mm)
considered 1 mm for usual purposes (actually 0.039)
what’s a microwire in inches
0.018 + 0.014
what’s a glide wire
hydrophilic coated wire, easier passage
3 F (in mm)
1mm
6 F (in mm)
2mm
9 F (in mm)
3mm
diameter in mm = F/x
F/3
what is the size of a puncture hole in mm of a 6 F sheath?
(6 + 2)/3 = 2.7 mm –> add 2 to estimate the outer diameter
what is the size of a puncture hole in mm of a 6 F sheath, placed coaxially into a short access sheath
6 F sheath will need a 8 F inner diameter, which will be a 10 F outer diameter: 10/3 = 3.3 mm
catheter size
outer lumen
sheath size
inner lumen (+ 2 for outer diameter)
standard size for routine vascular work
6-8 F
standard size for a filter
6-9 F (8.5 for Tulip)
standard size for stent graft
15-20 F
standard size of abdominal drains
12 F
standard size of PEG tube
24 F
standard guide wires
0.035-0.038 inches = 3 F = 1mm
preferred vein for PICC
basilic > brachial > cephalic
preferred vein for central line/port
right IJ
order of preference for dialysis access
RIJ > LIJ > REJ > LEJ
do we place PICCs in dialysis patients?
NO
how long does an AV fistula take to mature?
3-4 months
how long until you can use an AV graft?
2 weeks
which lasts longer AV fistula vs. graft
AV fistula lasts longer
which gets more infections: AV fistula vs. graft
AV grafts get more infections (synthetic graft material)
goal flow of AV fistula/graft
600 mL/min with outlet vein > 6mm
most common complication of AV grafts
venous outflow obstruction (2/2 intimal hyperplasia)
most common complication of AV fistula
more variable than in grafts (venous outflow obstruction), not gonna be asked
“steal syndrome” (AV fistula)
“cold painful fingers” during dialysis relieved by manual compression of fistula (stenosis in native a. distal to fistula)
meds after stent placement
1-3 months of anti-platelets (aspririn, plavix)
drug eluting stents
try to prevent neointimal hyperplasia
critical limb ischemia
rest pain for 2 weeks (or ulceration or gangrene)
surgery for thrombolysis for ischemia
thrombolysis for occlusions < 14 days
ulcer on medial ankle
venous stasis
ulcer on dorsum of foot
ischemic or infected ulcer
ulcer on plantar surface of foot
neuropathic ulcer
false elevation of ABI
arterial calcification in diabetics
contraindication to varicose vein treatment
DVT (need those superficial veins)
anesthesia for varicose vein treatment
“tumescent anesthesia” lots of dilute SQ lidocaine
post-thrombotic syndrome
pain + venous ulcers after a DVT
Type 1 endograft leak
leak at top or bottom of graft
Type 2 endograft leak
filling of sac via feeder artery
Type 3 endograft leak
defect/fracture in graft
Type 4 endograft leak
porosity of graft (4 is from the pore)
Type 5 endograft leak
endotension (pulsation of graft wall?)
most common endoleak type
2 - filling of sac via feeder artery (IMA or lumbar)
30-day mortality: endograft vs. open repair
less for endograft
long term aneurysm related mortality: endograft vs. open repair
same
graft related complications: endograft vs. open repair
high with endograft
why don’t we place IVC filters supra-renal
theoretical risk of renal vein thrombosis
when do we place supra-renal IVC filters (2)
pregnancy + clot in renals or gonadals
what do you do if the IVC is huge?
bird’s nest type filter up to 40 mm (normal <28mm) or bilateral iliac filters
what happens to DVT risk with IVC filter?
goes UP (risk of PE goes down)
gunther tulip
IVC filter with superior end-hook for retrieval
simon-nitinol
low profile (7 F) filter, can be placed in small veins (arm)
are IVC filters MRI compatible?
yes, duh
2 bad complications of vertebroplasty
new vertebral fracture (25%) + cement can embolize to lungs
Dose (Gy) for early transient erythema
2 Gy
Dose (Gy) for chronic erythema
6 Gy
Dose (Gy) for telangiectasia
10 Gy
Dose (Gy) for dry desquamation
13 Gy
Dose (Gy) for moist desquamation
18 Gy
3 ways to repair groin stick pseudoaneursym
open surgery, direct ultrasound compression, thrombin injection
best projection for aortic arch
70 degrees LAO (candy cane)
best projection for innominate a.
RAO
best projection for left SCV
LAO
best projection for left renal
LAO (same as renal)
best projection for right renal
RAO (same as renal)
best projection for left iliac bifurc
RAO (opposite side)
best projection for right iliac bifurc
LAO (opposite side)
Right SFA/profunda
RAO (same side SFA)
Left SFA/profunda
LAO (same as SFA)
what replaces platelets?
more platelets
what reverses heparin
protamine sulfate
what reverses coumadin
Vit K (25-50 mg IM 4 hrs prior), more rapid with cryoprecipitate
half life of a platelet
8-12 days
antidote for versed (midazolam)
flumazenil
antidote for opioids
narcan
half life of TPA
2-10 min (very short)
max dose of local anesthesia (lido)
4-5 mg/kg
complication of lidocaine in thecal sac
total spine anesthesia + need for vent
complication of direct arterial injection of lido
immediate seizures
early signs of lido toxicity
tinnitus and dizziness
is sepsis a contraindication to IVC filter placement?
NO, not even septic thrombophlebitis
Y-90: high, medium, or low energy?
high. mean energy of 0.93 MeV
Y-90: what kind of emitter?
high-energy beta emitter
Half life of Y-90
64 hours. 94% of radiation delivered in 11 days (4 half-lives)
Max penetration of Y-90
maximum range of irradiation from each bead is 1.1 cm, while the average soft tissue penetration is 2.5 mm.
embolic agent for UAE
particles in the range of 500-700 µm
rate of infection following non-tunneled line
5.3% per 1000 catheter days
single high risk vascular procedure
TIPS
4 high risk non-vascular procedures
biliary procedures (new tract), nephrostomy tube placement, renal biopsy, ablation
INR for high risk procedures
> 1.5, correct with FFP or vit K
INR for low risk procedures
> 2, correct with FFP or vit K (only need to check for patients on warfarin or with liver dz)
INR for moderate risk procedures
> 1.5, correct with FFP or vit K (same as high risk)
platelet count for high risk procedure
< 50K, transfuse
platelet count for moderate risk procedure
< 50K, transfuse
platelet count for low risk procedure
< 50K, transfuse (not routinely required to check)
what to do with aspirin for low risk procedure?
do not hold
what to do with aspirin for moderate risk procedure?
81mg ok, 325–>81mg for 5 day prior
what to do with aspirin for high risk procedure?
hold 5d
what to do with LMWH for low risk procedure?
hold 12h
what to do with LMWH for moderate risk procedure?
hold 12h
what to do with LMWH for high risk procedure?
hold 24h
what to do with argatroban before procedures?
don’t hold for low risk, defer non-emergent procedures, hold 4h for mod-high risk emergent procedures
hairpin turn during bronchial angiography
anterior medullary (spinal cord) artery
fever, WBC, Nausea + vomiting after UAE
post-embolization syndrome (or all of our patients)
most feared complication of bronchial artery embo
spinal cord infarct
3 things we don’t drain
tumors, acute hematoma, things associated with acute bowel rupture/peritonitis
above this Cr, renal artery stenting doesn’t work
Cr > 3
most common side effect of BRTO
gross hematuria
should you use a swan ganz for a thoracic angio
NO
procedure for acute Budd Chiari with fulminant livery failure
TIPS
treatment for pancreatiduodenal pseuodaneurysm
“sandwich technique” distal and proximal segments must be embolized
what size particles for embolizing mass hemoptysis
bronchial artery, particle > 325 um
2 ways to fix hepatic encephalopathy after TIPS
place a new stent inside the TIPS to make it smaller or place two new stents parallel to each other
what if you accidentally stick a drain in the colon?
wait 4 weeks for tract to mature, then remove
DVT + severe sx + no response to systemic anticoagulation
catheter directed thrombolysis
