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[PBR] Radiology > IR > Flashcards

IR Flashcards

1
Q

What are Category 3 procedures?

A 
TIPS
Renal biopsy
RF ablation
Nephrostomy tube placement
Biliary interventions (new tract)
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2
Q

What are Category 1 procedures?

A 
Non-tunneled venous catheter
Dialysis access interventions
Central line removal 
IVC filter placement
Venography
Catheter exchange
Thoracentesis
Paracentesis
Thyroid biopsy
Joint aspiration/injection
Superficial aspiration, drainage or biopsy
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3
Q

What are Category 2 procedures?

A 
Angiography (access size up to 7-F
Venous interventions
Chemo- or radioembolization
Uterine fibroid embolization
Transjugular liver bx
Tunneled venous catheter
Subcutaneous port placement
Abscess drainage
Biopsy (excluding superficial and renal)
Percutenaous cholecystostomy
Enteric tube placement
Spinal procedures (vertebroplasty, LP, epidural, facet block)
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4
Q

What is the triad of symptoms associated with Leriche syndrome (distal aortic occlusion)?

A

1) Buttock and thigh claudication
2) Absent femoral pulses
3) Impotence

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5
Q

What is the angiographic appearance of Takayasu’s arteritis?

A

-Angiography shows long, smooth stenotic segments of the medium-size and large arteries.

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6
Q

What are the 4 types of Takayasu’s arteritis?

A

type I: classic type involving the solely the aortic arch branches : brachiocephalic trunk, carotid and subclavian arteries
type II:
IIa: involvement of the aorta solely at its ascending portion and/or at the aortic arch +/- branches of the aortic arch
IIb: involvement of the descending thoracic aorta +/ - ascending or aortic arch + branches
type III: involvement of the thoracic and abdominal aorta distal to the arch and its major branches, e.g. descending thoracic aorta + abdominal aorta +/ - renal arteries
type IV: sole involvement of the abdominal aorta and/or the renal arteries
type V: generalised involvement of all aortic segments

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7
Q

What is the typical dose range for catheter-directed tPA?

A

0.25 to 2 mg/hr

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8
Q

When is lytic therapy absolutely contraindicated?

A
  • Prior intracranial hemorrhage
  • Known structural cerebral vascular lesion
  • Known malignant intracranial neoplasm
  • Ischemic stroke within three months (excluding stroke within three hours*)
  • Suspected aortic dissection
  • Active bleeding or bleeding diathesis (excluding menses)
  • Significant closed-head trauma or facial trauma within three months
  • *from Uptodate
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9
Q

What are indications for treatment of abdominal aortic aneurysm?

A

-Diameter of the aneurysm is >=5 cm (with the intro of EVAR, more aneurysms measuring 4.5 cm are being treated)
-Sac grows >0.5 cm within 6 months
-Or if the aneurysm is symptomatic (abdo pain or back pain not explained by any other condition)
(from Radcases)

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10
Q

In celiac artery obstruction, where does collateral flow come from?

A

Collateral supply to celiac branches from the SMA via the pancreaticoduodenal arcade or arc of Buehler

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11
Q

In SMA obstruction, where does collateral flow come from?

A
  • Collateral supply to the SMA branches from the celiac artery via the pancreaticoduodenal arcade or arc of Buehler;
  • Also from IMA via the marginal artery of Drummond or the arc of Riolan
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12
Q

In IMA obstruction, where does collateral flow come from?

A

Collateral supply to the IMA branches from the SMA via the left colic and marginal arteries or arc of Riolan; collateral supply from the internal iliac artery via retrograde flow in the superior rectal artery

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13
Q

What is considered massive hemoptysis?

A

> 500 cc/24 hrs or 100cc 3x/day x 1 week; high risk for death by aspiration.
Sources include bronchial (90%), pulmonary (5%), and systemic arteries (5%)

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14
Q

At what level do the bronchial arteries typically arise from the aorta?
How many bronchial arteries are there?

A
  • Bronchial arteries arise from the thoracic aorta between T3 and T8 (most commonly T5-T6)
  • Typically 2 left bronchial arteries and 1 right bronchial artery
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15
Q

What are complications of bronchial artery embolization?

A
  • bleeding, infection
  • chest pain, dysphagia, dissection, tissue necrosis (lung, bronchi, and esophagus), transient cortical blindness, and paralysis due to spinal artery embolization or injury
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16
Q

What embolic material is usually used for bronchial artery embolization?

A
  • Particles >325 um (stop in the pulmonary bed, ideally 600-700 microns) are used; PVA or tris-acryl microspheres
  • Gelfoam particles are typically NOT used.
  • Coils are avoided except for aneurysms and AVMs
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17
Q

Where does the artery of Adamkewicz usually arise from?

A

The artery of Adamkiewicz has a variable origin but most commonly arises :

  • on the left (~80%)
  • at the level of 9th-12th intercostal artery (~70%)

It arises from the radiculomedullary branch of the posterior branch of the intercostal or lumbar artery, which arise from the thoracic or abdominal aorta respectively. It has a diameter of ~1 mm (range 0.8-1.3 mm).

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18
Q

What are indications for Transjugular Intrahepatic Portosystemic Shunt (TIPS)?

A
  • Variceal bleeding after failed medical mgmt
  • Refractory ascites secondary to portal HTN
  • Refractory hepatic hydrothorax
  • Hepatorenal syndrome
  • Portal gastropathy
  • Budd-Chiari syndrome
  • Veno-occlusive disease
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19
Q

What are absolute contraindications to TIPS?

A
  • Right-sided heart failure
  • Primary pulmonary HTN
  • Polycystic liver disease
  • Severe hepatic failure
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20
Q

What are relative contraindications to TIPS?

A
  • Biliary obstruction
  • Portal vein obstruction
  • Severe encephalopathy
  • Liver or systemic infection
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21
Q

What is post embolization syndrome?

A
  • Fever, leukocytosis, nausea, and vomiting. It may be indistinguishable from infection, and patients may require hospitalization for tx with IV antibiotics.
  • Usually occurs within the first 72 hrs following embolization (liver lesion or uterine fibroids) and then starts to subside after 72 hours
  • more often associated with large fibroids or large tumor embolisation
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22
Q

What are typical US findings of pseudoaneurysm?

A
  • Color Doppler shows the “yin-yang” sign.

- Doppler waveform shows “to-and-from” flow

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23
Q

What are possible treatment options for femoral artery pseudoaneurysm?

A

Treatment options include:

  • surgical repair
  • ultrasound guided compression
  • ultrasound guided thrombin injection
  • endovascular therapy: stent-graft placement

At the time of writing the success rate of thrombin injection (89-96%) is considered to be much higher than with compression (74-78%).

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24
Q

What is the typical dose for percutaneous thrombin injection of a pseudoaneurysm?

A

200 to 1000 IU is injected with a 22-G needle to the apex of the pseudoaneurysm in small increments (100 IU in 0.1 mL) under US monitoring

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25
Q

What are complications of percutaneous thrombin injection?

A

(complications occur in 1% of cases)

  • distal embolization
  • femoral artery thrombosis
  • allergic reaction
26
Q

What is hypothenar hammer syndrome?

A

HHS is occlusive injury to the ulnar artery as it passes over the hamate bone (Guyon’s canal); it is usually caused by repetitive occupational trauma to the hypothenar eminence. Persons whose occupations make them susceptible to HSS include roofers, mechanics, carpenters, and jack hammer operators.

27
Q

What is Paget Schroetter syndrome?

A

aka effort thrombosis of the axillary or subclavian veins at the thoracic inlet.
Narrowing without thrombosis is venous thoracic outlet syndrome. The cause is compression at the thoracic outlet by structures such as the first rib, the anterior scalene muscle, the costclavicular ligament, cervical ribs, and exostoses.

28
Q

What are the different types of endoleak?

A

1) Leak at attachment site
2) Branch leak (retrograde)
3) Graft defect
4) Graft fabric porosity
5) Endotension (no endoleak or sealed endoleak)

29
Q

What is the most common type of endoleak?

A

Type 2 (80%)

30
Q

What embolic agents are typically used for colonic hemorrhage?

A

Embolic agents used include (most commonly) micro coils and Gelfoam. Particles are sometimes used for angiodysplasia.

31
Q

What are the most common anatomic variants of the hepatic arteries?

A

-Replaced right HA off SMA (

32
Q

What is Nutcracker syndrome?

A
  • compression of the left renal vein between the SMA and the aorta that causes increased pressure in the renal even and dilatation of the gonadal and pelvic veins.
  • usually presents in thin, young women, but has been described in children
33
Q

In pelvic trauma, anterior pelvic bleeding often comes from which arteries?

A

internal pudendal artery or obturator artery

34
Q

In pelvic trauma, posterior pelvic bleeding often comes from which arteries?

A

superior gluteal artery (most common) and lateral sacral artery

35
Q

What is considered a “mega cava”?

A

IVC luminal diameter >28 mm

36
Q

What are options for placing an IVC filter in a mega cava?

A

For adequate bilateral caval filtration, this condition requires bilateral placement of common iliac filters or a bird’s nest filter (if the canal diameter is

37
Q

What are indications for an IVC filter?

A
  • DVT/PE and contraindication to anticoagulation
  • DVT/PE and complication of anticoag
  • DVT/PE despite anticoag
  • Free-floating iliofemoral or IVC thrombus
  • Prophylaxis for pts at increased risk for DVT/PE and poor cardiopulmonary reserve
38
Q

What are indications for a suprarenal IVC filter?

A
  • Renal vein, infrarenal or suprarenal caval thrombosis
  • Pregnancy
  • Recurrent PE despite IVC filter

From ACR guidelines:

  1. Presence of IVC thrombus precluding placement of a filter in the infrarenal IVC.
  2. Filter placement during pregnancy. Suprarenal placement is also appropriate in women of childbearing age.
  3. Thrombus extending above previously placed infarenal filter.
  4. Gonadal vein thrombosis.
  5. Anatomic variants: duplication of the IVC, low insertion of renal veins.
  6. Significant extrinsic compression of the infrarenal IVC.
  7. Intrinsic narrowing of the infrarenal IVC.
  8. Patients with an intra-abdominal or pelvic mass who will undergo surgery and in whom operative IVC mobilization is contemplated.
39
Q

When should tPA be held after starting tx?

When should angiographic reassessment be performed after starting catheter-directed thrombolysis?

A
  • tPA is typically infused at 0.5-1 mg/h (0.25-2 mg/h locally);
  • tPA held if fibrinogen drops below 100 mg/dL or if PTT climbs above 60 seconds.
  • Angiographic reassessment usually occurs after 8-20 hours of CDT
40
Q 
A skin entry dose of 2 Gy is the threshold dose for which of the following injuries?
A. Early transient erythema
B. Chronic erythema 
C. Desquamation
D. Telangiectasia
A

A. Early transient erythema.
The threshold dose for early transient erythema is 2 Gy, for chronic erythema 6 Gy, for dry desquamation 13 Gy, for moist desquamation 18 Gy, for teleangiectasia 10 Gy.

41
Q

What is considered a normal resistive index at Doppler US?

A

Normal RI = 0.6-0.7

Abnormal RI = 0.8-1.0

42
Q

DDx for high resistive index in a transplant kidney

A
  • ATN
  • obstruction
  • infection
  • rejection
  • extrinsic compression
  • severe hypotension
43
Q

How do you calculate resistive index?

A

RI = (PSV-EDV)/PSV

44
Q

What is the risk of intracranial hemorrhage during catheter-directed thrombolysis?

A

About 2 in 1000

45
Q

What is adventitial cystic disease?

A

Advential cystic disease is characterized by the accumulation of mucinous material in the adventia compressing the arterial lumen most commonly of the popliteal artery. Standard treatment is surgery. Cyst aspiration fails because the material reaccumulates and the benefits of angioplasty remain unproven.

46
Q

What is the minimal diameter of the external iliac artery to safely accept a delivery sheath for EVAR?

A

equal to or greater than 7 mm

47
Q

What is the typical post-EVAR imaging surveillance regimen?

A

Multiphase (ideally non-contrast, arterial and PVP) contrast enhanced CT scan at 1, 6, and 12 months, then yearly thereafter. If stable, can change frequency of follow-up.

48
Q

What embolic material would you use to embolize a splenic artery aneurysm?

A

Embolization usually performed distally using gel foam or particles. Coil embolization can be used for larger aneurysms.

49
Q

At what size should treatment be considered for a splenic artery aneurysm?

A

If > 2 cm, then consider endovascular tx

If

50
Q

Which types of endoleak can be treated conservatively?

A

Types 2, 4 and 5. If they worsen over time, may eventually require intervention.

51
Q

Which types of endoleak warrant urgent intervention?

A

Types 1 and 3 require urgent intervention

52
Q

What is the eustachian valve?

A

aka valve of the inferior vena cava. It is a valve at the junction of the IVC and right atrium.

53
Q

What is considered “massive hemoptysis”?

A

Usually 300-600 mL/day
-Best defined as any amount that is sufficient to cause hemodynamic instability or imminent or potential airway compromise

54
Q

What is the normal range velocity for a TIPS shunt?

A

90-190 cm/s

55
Q

What is the goal for a TIPS shunt in terms of portosystemic pressure gradient?

A

Aim for protosystemic pressure gradient of

56
Q

What is May-Thurner Syndrome?

A

Left CIV compressed by the R common iliac artery. Presents with DVT.
Treated with stent.

57
Q

How do you do a percutaneous thrombin injection of a pseudoaneurysm?

A
  • Introduce 22 G needle into pseudoaneurysm under imaging guidance
  • 500-1000 units/mL thrombin
  • Risk of rupture
  • Risk of embolization
  • Narrow neck needed
58
Q

What is the threshold for detection of a GI bleed:

  • Tc99m RBC study?
  • Angiography?
  • CT angiogram?
A
  • Tc99m RBC: 0.1 mL/min
  • Angiography: 0.5 mL/min for UGI bleed; 1 mL/min for lower GI bleed
  • CT angio likely comparable to conventional angiography
59
Q

What is the most common cause of LGIB?

A 
Diverticular disease (20-55%)
Angiodysplasia (3-40%)
Neoplasms (8-26%
Colitis (6-22%)
Benign anorectal lesions (9-10%)
-Radiographics 2007
60
Q

Contraindications to pulmonary angiography

A
  • LBBB
  • RVEDP > 20 mmHg
  • PA system pressure >60-70 mmHg
61
Q

What dose for nitroglycerin for angioplasty below the knee?

A

100-300 ug nitro given intra-arterially can help prevent/resolve vasospasm

62
Q

DDx pulmonary artery aneurysm

A
  • Iatrogenic (Swan-ganz catheter placement)
  • TB
  • Syphilis
  • Other bacterial/fungal infection
  • Behcet’s disease
  • PAH
  • Structural vascular abnormalities: Marfan, atherosclerosis

[PBR] Radiology (12 decks)

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