Indication for treatment of AVF in pregnant pt
Bleed
High flow cardiac failure
Indications for treatment of visceral artery aneurysm
larger than 2 cm in diameter
demonstrate rapid growth
when patients present with symptoms attributable to the aneurysm
therapy is often advocated for VAAs in women of childbearing age, pregnant women, and liver transplant recipients irrespective of their size and presence of symptoms
Indications for uterine embolization in post partum hemorrhage
Uterine atony refractory to medical treatment
Cervical uterine hemorrhage
Vaginal thrombus
Cervical vaginal tear after failed surgical repair
Pseudoaneurysm
Persistent bleed post hysterectomy
What is minimum size of particles when embolizing bronchial art. circulation
325microns
If you use smaller, risk of distal embolization with complications such as tracheal and pericardial necrosis
Why shouldn’t you embolize with particles a pulmonary AVF in HHT?
NEVER use particles in this situation as they will go into the systemic circulation with high risk of stroke
What type of ablation technique could you use if you want to treat a tumor surrounding a vessel or duct that you want to preserve?
Irreversible electroporation.
Structures surrounded by collagen are preserved.
Particularly useful for pancreas tumor ablation. Other ablation techniques cause pancreatitis
What is the largest tumor size amenable to tumor ablation?
Maximum number?
4cm
If it’s larger, ablation is non curative and not indicated
No more than 5 lesions
What is the major complication of an intra-atrial central line placement in neonates?
Cardiac tamponnade (0.1-0.18% incidence in NICU PICCs)
What is the reversal agent for opiate overdose?
Naloxone 0.4-0.8mg IV
What is the reversal agent for benzodiazepine overdose?
Flumazenil 0.2mg IV
Why is it not recommended to use a glidewire (terumo) as an initial wire after arterial puncture?
When doing a single wall puncture, if there is intima tenting at the tip of the needle, using a glidewire as an initial wire can cause a dissection. Other wires have a lower risk of causing arterial dissection in these situations.
What are the contraindications for the use of an arterial closure device?
Puncture too high/low Femoral artery too small <5mm Patient too thin/too heavy Severe atherosclerosis at the site of puncture Multiple prior punctures at access site Allergy Double wall puncture
At what size should you treat a postprocedure femoral pseudoaneurysm? How?
> 1cm in diameter
Ultrasound-guided thrombin injection is the treatment of choice
What type of femoral puncture increases the risk of retroperitoneal hemorrhage?
A high arterial puncture, above the pelvic brim
What type of femoral puncture increases the risk of AVF?
Low femoral arterial puncture, because the femoral vein often times passes posterior to the artery distally.
In comparison, at the inferomedial aspect of the femoral head, the standard puncture site, the vein passes medial to the artery.
If an air embolism is suspected, what are the necessary steps for treatment?
Position patient in left lateral decubitus (left side down).
100% oxygen administration, stimulates resorption of air
If air bubble is large, catheter aspiration can be attempted.
In conventional angiography, what is the typical injection rate (cc/sec) of these vessels:
1- Aorta 2- IVC 3- Mesenteric artery 4- Renal artery 5- Peripheral arteries
1- 20cc/sec (arch: 20 for 30, abdo: 20 for 20) 2- 20cc/sec (20 for 30) 3- 5cc/sec (5 for 25) 4- 5cc/sec (5 for 15) 5- 3cc/sec (3 for 12)
(cc/sec for total cc)
When performing percutaneous transluminal angioplasty, what should the balloon size be?
10-20% larger than the vessel diameter.
TRUE OR FALSE
Anticoagulation should always be used with angioplasty
TRUE
What is the difference in radial force and flexibility (rebound) between balloon-expandable and self-expandable stents?
Balloon-expandable stents have a higher radial force but will not rebound if crushed.
Self-expandable stents are more flexible and trackable through vessels.
In what situations are self-expandable stents preferred over ballon-expandable stents?
Because self-expandable stents are more flexible, their use is favored when:
- The route to the lesion is tortuous
- The anatomy is prone to external compression (creases in the body)
What is the general approach to choosing a stent size for the treatment of a stenosis?
Stent should be 1-2cm longer than the stenosis
Diameter should be 1-2mm wider than the unstenosed vessel lumen
10% oversizing of arterial stent
20% oversizing of venous stent
In what situations should you use a covered stent instead of a fenestrated stent?
Pseudoaneurysm
Dissection
TIPSS
What are the permanent embolic materials?
coils
particles
glue
sclerosing agent
What are the temporary embolic materials?
absorbable gelatin sponge
autologous clot
When embolizing with coils, what technique should be used to prevent recurrent bleeding?
When using coils, distal access is sacrificed. You must therefore first coil distal to the site of bleed, then proximal. This prevents recurrent bleeding from retrograde collaterals.
What is the duration of absorbable gelatin sponge (gelfoam)?
2-6 weeks
If a patient has had a recent procedure and appears to have an abscess within the procedure site on imaging, what clinical information is needed to avoid false positive diagnosis of infection?
If absorbable gelatin sponges were used, as they can show numerous gas locules and mimic the appearance of an abscess.
What is post-embolization syndrome?
Post-embolisation syndrome is one of the commonest side effects of transarterial embolisation and chemoembolisation.
The patient develops fever, nausea/vomiting, and pain within the first 72 hours after embolisation and then starts to subside after 72 hours.
Thought to be due to release of endovascular inflammatory modulators by infarcted tissue.
What is the treatment of post-embolization syndrome?
NSAID
Opioid when appropriate
IV fluids
TRUE OR FALSE
Post-embolization syndrome is a predictor of post-operative infection.
FALSE
In the absence of other factors, blood cultures are not necessary.
1 French is equal to what size in mm?
1 Fr = 0.33mm
Is the size (in french) of a catheter measured based on the outer diameter or inner lumen? How is a sheath measured?
A catheter is measured based on its external diameter, with the lumen being slightly smaller.
A sheath is measured based on its inner lumen, with the external diameter being slightly larger.
Therefore, a 6Fr catheter can be inserted through a 6F sheath.
What kind of guidewire is Amplatz? What is its use?
Stiff wire
Used when structural rigidity is required.
TRUE OR FALSE
In giant cell arteritis, the aorta is rarely involved, whereas involvement is common in Takayasu arteritis
TRUE
In left-sided SVC, where does the SVC drain?
- It usually drains directly into the coronary sinus and then right atrium.
- Rarely drains directly into left atrium causing right to left shunt
What is the prevalence of left-sided SVC in the general population? In patients with CHD?
It is weakly associated with CHD.
Left-sided SVC present in 0.5% of genreal population, 4% of patients with CHD.
Facial edema that improves when standing is characteristic of what disease?
Chronic SVC obstruction/stenosis
What are the most common causes of SVC obstruction?
Compression by thoracic malignancy
Catheter associated thrombosis
Mediastinal fibrosis (post histoplasmosis exposure)
Why should an EKG be performed prior to conventional pulmonary angiogram?
To assess for the presence of a left bundle branch block.
If the pulmonary artery catheter were to cause temporary RBBB in the presence of a LBBB, it can cause complete heart block.
A temporary pacer is required prior to pulmonary angiogram
What are the normal right sided pressures in a pulmonary angiogram?
Right atrium: 0-8mm Hg Right ventricle: - 0-8mm Hg diastolic - 15-30mm Hg systolic Pulmonary artery - 3-12mm Hg diastolic - 15-30mm Hg systolic
What embolization material should be used in the treatment of a pulmonary AVM?
Coils.
Particles are contraindicated as the right to left shunt would cause brain emboli and infarction
What are the indications for treatment of a pulmonary AVM?
- Asymptomatic lesion with feeding artery >3mm diameter
- Symptomatic lesion
What embolization material is commonly used in bronchial artery embolization for hemoptysis?
Particles
Because rebleeding post treatment is common in patients with hemoptysis, coils are rarely used because they prevent repeated access.
The presence of absence of a branch of which artery arising from the bronchial/intercostal arteries should be documented prior to attempting a bronchial artery embolization?
Anterior spinal artery.
If it is present, there is a risk of non-target embolization of the spinal cord which can lead to paralysis.
It must be identified to ensure the tip of the catheter is distal to this branch and there is no reflux within it.
What are the potential complications of bronchial artery embolization?
NON-TARGET EMBOLIZATION
- anterior spinal artery, paralysis
- Chest wall, intercostal artery, chest pain
- Esophageal arterial branches, dysphagia
ACCESS SITE COMPLICATIONS
- Hematoma
- Pseudoaneurysm
- AV fistula
CONTRAST REACTION/NEPHROPATHY
DELAYED COMPLICATIONS
- Bronchial necrosis
- Pulmonary infarction
The celiac trunk arises from the aorta at the level of which vertebral body?
T12
The SMA arises from the aorta at the level of which vertebral body?
T12-L1 disc space
The renal arteries arise from the aorta at the level of which vertebral body?
L1-L2 disc space
The IMA arises from the aorta at the level of which vertebral body?
L2-L3 disc space, left of midline
What is the origin of the right gastroepiploic artery?
It arises from the gastroduodenal artery
What is the origin of the left gastroepiploic artery?
It arises from the splenic artery
What is the origin of the gastroduodenal artery?
It arises from the common hepatic artery, which becomes the proper hepatic artery distal to the origin of the GDA.
What is the origin of the cystic artery?
It arises from the right hepatic artery
What is the origin of the dorsal pancreatic arteries?
They arise from the splenic artery along the course of the pancreas
What is the origin of the superior pancreaticoduodenal artery?
It arises from the gastroduodenal artery.
What is the origin of the inferior pancreaticoduodenal artery?
It arises from the SMA
What is paget-schrotter syndrome
Effort induced thrombosis of the axillary-subclavian vein.
Thought to be due to compression of the subclavian vein when it passes through the costoclavicular space. Associated with forced abduction of the upper limb.
What is most frequent cause of post partum hemorrhage
Uterine atony 70%)
What is fibromuscular dysplasia? 2 most commonly affected vessels?
idiopathic, non-inflammatory and non-atherosclerotic angiopathy of small and medium sized arteries. Due to fibrous or fibromuscular thickening of the arterial wall (any layer, but media most common).
FMD most commonly causes small stenoses along a vessel with intervening areas of dilatation (small aneurysms), creating “string of beads” appearance.
Renal arteries most common, followed by extracranial ICA
What is buerger disease? (also give other name)
thromboangiitis obliterans
non-necrotising arteritis found predominantly in young male smokers. Medium and small vessels of distal extremities.
What is takayasu arteritis (also distribution and typical pt)
granulomatous large vessel vasculitis that predominantly affects the aorta and its major branches. may also affect pulmonary arteries.
strong female predominance, mostly in asians, younger pts
What is kawasaki disease
Small to medium vessel vasculitis. Predominantly affects coronary vessels in young children.
It can cause coronary arterial aneurysm.
What is the most common condition to affect the small to medium sized renal arteries?
Also name 3 other vasculitides that affect the renal arteries and give 4 other etiologies
Polyarteritis nodosa
other 3:
Wegener vasculitis
Churg-Strauss Syndrome
Takayasu arteritis
Mycotic/septic emboli
Trauma
Ehlers-danlos syndrome
Speed kidney (chronic amphetamines)
What is glomangioma and give MRI appearance
Benign vascular tumour typically at the distal extremities. AKA glomus tumour (different from paraganglioma).
T1 low to intermediate
T2 high
T1 C+ uniform enhancement
Name the syndrome:
chronic compression of the left common iliac vein against the lumbar vertebrae by the overlying right common iliac artery with or without to deep venous thrombosis
May-Thurner syndrome
What are the potential complications of a dialysis fistula?
Thrombosis Infection (2nd most common cause of death in dialysis patients) Prolonged bleeding times Tortuous fistula difficult to cannulate Stenoses Aneurysm Steal phenomenon High rate flow AVF
How do you determine severity of stenosis with doppler imaging of carotid arteries?
Severity of stenosis determined by measuring peak systolic velocity:
50%-70%: velocity 125 to 250cm/sec
70%-90%: velocity 250 to 400cm/sec
>90%: velocity >400cm/sec>95% may result in decreased velocity
What are the criteria for proper maturation of a dialysis fistula? (Rule of 6)
> 600cc/min flow in upper arm, less than 6mm from skin, above 6mm in diameter
In what situations do patients with an aberrant left subclavian artery (right aortic arch) have a complete vascular ring?
Tight left ductus arteriosus
Diverticulum of kommerell (bulbous origin of the aberrant left subclavian artery)
Most common symptomatic vascular ring?
Double aortic arch
What tracheal and esophageal findings can you see in double aortic arch
Posterior and bilateral lateral impressions on the esophagus
Bilateral impressions on the trachea
The right lateral impression will be superior to the left lateral impression (right arch is higher than left arch)
What is a pulmonary sling? What is its course?
The left pulmonary artery originates from the posterior wall of the right pulmonary artery.
It courses superior to the right main bronchus and between the trachea and esophagus.
What is compressed in a pulmonary vascular sling?
The right mainstem bronchus can be compressed.
Normal bronchial artery anatomy (origins)
The bronchial arteries typically arise from the thoracic aorta at the T3-T8 levels with ~ 70% (range 64-80%) arising from the T5-T6 level.
Left bronchial arteries
There are usually two bronchial arteries on the left that arise directly from the anterior surface of the thoracic aorta:
superior left bronchial artery: arises from the anteromedial surface of the aortic arch, lateral to the carina and posterior to the left main bronchus
inferior left bronchial artery: also arises from the aorta and is parallel to the superior artery, but inferior to the left main bronchus
Right bronchial artery:
The right bronchial artery has a common origin with an intercostal artery and this is called the intercostobronchial trunk (ICBT) and arises from the right posterolateral aspect of the thoracic aorta.
Variant bronchial artery anatomy?
Ectopic origin is present in ~20% of patients, from the aorta outside of the level from superior endplate of T5 to inferior endplate of T6.
Possible origins:
aortic arch internal thoracic artery thyrocervical trunk subclavian artery coronary arteries
common bronchial artery trunk (i.e. for both left and right bronchial arteries)
single bronchial artery bilaterally (i.e. one left and one right)
single bronchial artery on the left and two bronchial arteries on the right (one ICBT)
left bronchial artery less commonly has its origin from an ICBT
Name the branches of internal iliac artery
I Love Going Places In My Very Own Underwear!
I: iliolumbar artery L: lateral sacral artery G: gluteal (superior and inferior) arteries P: (internal) pudendal artery I: inferior vesical artery (there's also superior and middle) M: middle rectal artery V: vaginal artery O: obturator artery U: uterine artery
Also, the first three arteries (iliolumbar, lateral sacral and superior gluteal arteries) are all branches of the posterior trunk of the internal iliac artery, whilst the remainder are branches of the anterior trunk.
umbilical artery no longer patent in adults.
Name the 3 arteries that feed the uterus
Uterine artery
Ovarian artery
Round ligament artery
Ovarian artery origin and course
Origin
The ovarian artery arises anterolaterally from the aorta just inferior to the renal arteries and superior to the inferior mesenteric artery.
Course
Descends caudally in the retroperitoneum on psoas major with the gonadal vein and ureter. Passes into the pelvis anterior to the iliac vessels. In the pelvis it takes a medial path through the suspensory towards the uterus. Anastomoses with the ovarian branch of the uterine artery at the uterus.
What are the Course and branches of SMA
Courses anteroinferiorly, behind the neck of pancreas and splenic vein, crossing anterior to the left renal vein. It emerges anterior to the uncinate process of the pancreas and crosses anterior to the third part of duodenum. It then enters the upper portion of the small bowel mesentery and runs along the root of the mesentery downwards to the right. Branches to the jejunum and ileum are given off to the left, and branches to the proximal and mid colon are given off to the right.
Branches
inferior pancreaticoduodenal artery
Left-sided
jejunal branches
ileal branches
Right-sided
ileocolic artery
right colic artery
middle colic artery
What is the marginal artery of drummond?
The terminal branches of the ileocolic, right colic and middle colic arteries of the SMA - along with the terminal branches of the left colic artery and sigmoid branches of the IMA - form a continuous arterial circle or arcade along the inner border of the colon known as the marginal artery of Drummond. From this marginal artery, straight vessels (also known as vasa recta) pass to the colon.
How many distal branches of bronchial arteries are present per lung?
3, 1 per lobe (including lingula)
If you do not see 3 distal branches per lung, there is probably a bronchial artery that you have not found
At what level is the aortic arch? (Vertebra)
starts at the level of the plane of Ludwig, a horizontal plane from the sternomanubrial angle to the T4 vertebral body
On imaging, typically seen at level of T4
Origin of internal mammary artery?
Subclavian artery
What spinal cord levels are typically covered by the artery of adamkiewicz?
T7-T11 (forghani) or T8 to conus (radiopedia)
Arises from radiculomedullary branch of the posterior branch of the intercostal or lumbar artery, which arise from the thoracic or abdominal aorta.
It anastomoses with the anterior spinal artery.
What are the branches of the inferior mesenteric artery?
left colic artery
sigmoid arteries (2-4)
superior rectal artery
Most common aortic vascular anomaly?
Aberrant right subclavian artery - incident 0.5%
Not a vascular ring, it is a normal variant
Arises distal to the left subclavian artery and travels to the right. Indents the esophagus.
True or false
A right aortic arch can descend on either side of the thorax
True
A right aortic arch can descend either on the right or left, but a left aortic arch never descends on the right
Which aortic vascular abnormality has the highest association with CHD?
Mirror image right arch, 98% association with congenital heart disease
True or false: Right arch mirror branching pattern is not a vascular ring
True
What is the order of the neurovascular bundle in the inguinal region?
From lateral to medial (NAVL): Nerve Artery Vein Lymphatics
What is the origin of a replaced left hepatic artery?
left gastric artery, present in 11-12% of patients
What is the origin of the inferior rectal artery?
It arises from the internal pudental artery, which is a branch of the internal iliac artery.
What is the arc of riolan?
Artery that connects the proximal SMA or one of its primary branches to the proximal IMA or one of its primary branches.
It is classically described as connecting the middle colic branch of the SMA with the left colic branch of the IMA. It forms a short loop that runs close to the root of the mesentery.
Plays important role in the setting of arterial occlusion, providing collateral flow.
What is the pathway of Winslow?
Collateral arterial pathway present in certain patients:
subclavian->internal mammary->superior epigastric->inferior epigastric->external iliac
The iliolumbar artery anastomoses with the external iliac artery via which branch?
Via the deep circumflex iliac artery
What are the branches of the external iliac artery?
Inferior epigastric artery
Deep circumflex iliac artery
Femoral artery
What is the origin of the superior epigastric artery?
Internal thoracic (mammary) artery
What is the arc of Buhler?
Persistent embryologic connection between the celiac artery and SMA, travels vertically anterior to the aorta.
Present in 1-4% of the general population.
What are the branches of the GDA?
The right gastroepiploic artery
The superior pancreaticoduodenal artery - anterior and posterior divisions.
It also gives off a few small branches prior to these.
What is the arc of Barkow?
The arc of Barkow is formed by the anastomosis of the right gastroepiploic and left gastroepiploic arteries.
The arc of Barkow supplies the transverse colon with multiple ascending branches.
What is the Cannon-Bohm point?
The Cannon–Böhm point is the point of transitional blood supply to the colon between the SMA (proximal) and IMA (distal), at the splenic flexure.
This watershed zone is susceptible to ischemia in case of systemic arterial insufficiency.
The internal iliac and inferior mesenteric arteries anastomose through which pathway?
The inferior and middle rectal arteries connect the internal iliac artery to the inferior mesenteric artery via the superior rectal artery.
What medical conditions is polyarteritis nodosa associated with?
CLASH
Cryoglobulinemia Leukemia Rheumatoid arthritis Sjogren syndrome Hepatitis B
What is the treatment of polyarteritis nodosa?
steroids
What are the 2 most common visceral artery aneurysms?
1- splenic artery
2- hepatic artery
Embolism/thrombosis in which segment of the SMA carries the highest risk of intestinal ischemia?
Distal to the middle colic artery, as there are few native distal collaterals.
The middle colic artery anastomoses with the IMA via the marginal artery of Drummond and the arc of Riolan.
What is the primary treatment of nonocclusive mesenteric ischemia?
Ischemia with a patent arterial tree, secondary to arterial spasm with narrowing.
The primary treatment is direct arterial infusion of a vasodilator (papaverine 60mg bolus then 30-60mg/hr).
Which anatomic landmark seperates upper from lower GI bleed?
Ligament of Treitz
What is the bleeding rate required for a GI bleed to be positive on conventional angiography?
Tagged RBC scan?
CT angiogram?
conventional angio: 0.5-1.0 mL/min.
Tagged RBC: 0.2-0.4 mL/min
CTA: 0.35 mL/min
TRUE OR FALSE
A CTA should be performed before conventional angiogram in all cases of GI bleeding.
FALSE
In a hemodynamically unstable patient with clinical evidence of current GI bleeding, the CTA is not necessary and the patient can go straight to angiography.
When performing an angiogram in cases of upper GI bleed, if no active extravasation is identified, which artery can be empirically embolized?
Left gastric.
There are multiple collaterals between the celiac axis and SMA, risk of ischemia minimal.
What are the potential major complications of intraarterial infusion of vasopressin?
Arrhythmia
Pulmonary edema
Hypertension
What are the imaging features of gastrointestinal angiodysplasia?
CT:
Focal area of contrast enhancement in the bowel wall (tangle of vessels).
Early filling of antimesenteric draining vein.
The simultaneous opacification of parallel artery and vein gives a “tram-track” appearance.
On conventional angiogram, there is early venous enhancement (AV shunting) and ectatic vessels without a mass.
TRUE OR FALSE
Endovascular treatments are ineffective for GI angiodysplasia
TRUE
Vasopressin/embolization are generally not effect due to the abnormal vessels of angiodysplasia.
What is the most common cause of lower GI bleeding in older adults?
Diverticulosis
What is the role of angioplasty and stenting in the treatment of fibromuscular dysplasia?
FMD responds well to angioplasty alone, with improved blood pressure control in 97% of patients, with 90% 5 year patency.
Stenting of FMD is not recommended. Can lead to in-stent stenosis and complicate future angioplasty.
Name this disease:
Venous thrombosis of the left common iliac vein caused by compression from the crossing right common iliac artery.
May-Thurner syndrome
What is the typical treatment of May-Thurner syndrome?
Endovascular thrombolysis + stenting
What is the portosystemic gradient and what is the value for the diagnosis of portal hypertension?
The portosystemic gradient represents the sinusoidal resistance to portal flow and is calculated as the wedged hepatic vein pressure minus the free hepatic vein pressure.
Portal hypertension is defined as a portosystemic gradient >5mm Hg.
Name the collateral pathways seen in portal hypertension (6)
Esophageal varices gastric fundal varices Splenorenal shunt Mesenteric varices Caput medusa Hemorrhoids
In esophageal varices, which portal vein is connected to which systemic vein?
Coronary vein connected to azygos/hemiazygos veins
In gastric fundal varices, which portal vein is connected to which systemic vein?
Splenic vein connected to azygos vein
In splenorenal shunt, which portal vein is connected to which systemic vein?
Splenic or short gastric is connected to left adrenal/inferior phrenic, which leads to the left renal vein.
In mesenteric varices, which portal vein is connected to which systemic vein?
SMV/IMV is connected to the iliac veins
In caput medusa, which portal vein is connected to which systemic vein?
Umbilical vein is connected to the epigastric veins
In hemorrhoids, which portal vein is connected to which systemic vein?
IMV is connected to the inferior rectal veins
What are the indications for TIPSS?
- Variceal hemorrhage that cannot be controlled endoscopically
- Refractory ascites
- Budd-Chiari
What is the use of the Child-Pugh and MELD scores in the pre-TIPSS assessment?
They help predict post-TIPSS mortality (higher score = higher mortality)
What are the contraindications to a TIPSS procedure?
- Right sided heart failure
- Severe active hepatic failure
- Severe hepatic encephalopathy
All of these conditions can be exacerbated by a TIPSS procedure
What are the preferred vessels to be used during a TIPSS? Why?
Right portal vein connected to the right hepatic vein via a covered stent.
The right hepatic vein has a relatively constant anatomy and tends to be larger than the left.
What are the indications for IVC filter placement?
Contraindication to anticoagulation
Recurrent PE while anticoagulated
High risk for developping DVT/PE in patient with contraindication to anticoagulation (ex. multitrauma)
What are the contraindications for IVC filter placement?
Complete IVC thrombosis
IVC too small/too large for safe filter placement
Septic thromboembolism
What are the indications for suprarenal IVC filter placement?
- Duplicated infrarenal IVC
- Left IVC
- Low insertion of renal veins
- Pregnancy
- Pelvic mass compressing infrarenal IVC
- Presurgical placement followed by surgery in which IVC manipulation may occur
- Thrombus in gonadal/renal veins
- IVC thrombosis extending above renal veins
What are the potential complications of IVC filter placement?
IMMEDIATE COMPLICATIONS Contrast reaction Incomplete delivery, opening, excessive tilting Thrombosis of venous access site PE Pneumothorax
DELAYED COMPLICATIONS
DVT, PE, IVC thrombosis
Filter migration (>2cm position change)
Filter fracture/penetration
On scrotal ultrasound, what is the size criteria for the diagnosis of a varicocele?
Pampiniform venous plexus >2mm in diameter.
Bag of worms appearance
Worsens on valsalva maneuver
What is the treatment of varicoceles?
If symptomatic (ex. infertility) and requiring treatment:
Coil embolization or surgical ligation of the gonadal vein have equal outcomes.
What are the advantages/disadvantages of transhepatic vs transperitoneal percutaneous cholecystostomy?
Transhepatic:
- Decreased risk of peritoneal bile leak
- Increased risk of liver laceration
Transperitoneal:
- Decreased risk of liver laceration
- Increased risk of peritoneal bile leak
- Necessitates penetration of the gallbladder fundus, the most mobile portion.
What are the necessary criteria prior to removal of a cholecystostomy tube?
- Clinical improvement
- Cystic and common bile ducts patent on cholangiogram
- At least 6 weeks post placement to allow development of fibrous tract from GB to skin puncture, otherwise there is risk of bile peritonitis.
What is the zone of Brodel and why is it important?
It is the relatively avascular zone between the ventral and dorsal renal artery branches.
It is the preferred access site during a percutaneus nephrostomy to minimize vascular complications.
The optimal entry plane is the posterolateral kidney directed towards the posterior calyx.
TRUE OR FALSE
There is evidence for improvement of quality of life post gastrostomy placement in elderly patients with dementia.
FALSE
Strong evidence that it does NOT improve survival or quality of life in this patient population
What are the contraindications to percutaneous gastrostomy?
Lack of appropriate window (colonic interposition)
Extensive gastric varices
Uncorrectable coagulopathy
What are the branches of the common femoral artery?
Deep femoral artery
Superficial femoral artery
superficial epigastric artery
superficial circumflex iliac artery
superficial external pudendal artery
deep external pudendal artery
What are the branches of the popliteal artery?
Posterior tibial
Tibioperoneal trunk
- Peroneal
- Anterior tibial
What is Leriche syndrome?
Chronic occlusive atherosclerotic disease of the distal abdominal aorta with impotence, buttock claudication, absent femoral pulses and cold lower extremities.
What are the TASC-II recommendations for treatment of aortoiliac atherosclerotic flow-limiting disease? (type A-D, PTA vs surgery)
Type A (<3cm length): PTA preferred
Type B/C (3-10cm): Surgery preferred
Type D:(>10cm): Surgical, PTA has limited role.
What are the TASC-II recommendations for stenting of aortoiliac atherosclerotic flow-limiting disease post PTA?
Stenting is indicated if there is >30% residual stenosis or >10mmHg systolic pressure gradient at rest.
At what diameter is repair of an iliac artery aneurysm recommended?
> 3cm diameter
If mass effect from an iliac artery aneurysm is causing neurologic or urologic symptoms, what is the preferred treatment method?
Surgical treatment, leads to faster decreased in size of aneurysm.
What is a persistent sciatic artery?
A persistent sciatic artery is a rare vascular anomaly where there is the continuation of the internal iliac artery into the thigh through the greater sciatic notch. It may be the dominant artery supplying the leg, in which case the superficial femoral artery may be small.
What are the branches of the external iliac artery?
Femoral artery
inferior epigastric artery
deep circumflex iliac artery
What ankle-brachial index (ABI) value is considered abnormal?
<0.9
What are the TASC-II recommendations for treatment of femoropopliteal atherosclerotic flow-limiting disease? (type A-D, PTA vs surgery)
Type A (single stenosis <10cm length): PTA treatment of choice Type B (multiple <5cm, single >15cm): PTA preferred. Type C (multiple >15cm): Surgery preferred Type D:(chronic total occlusion): Surgical treatment of choice.
What is the size criteria for popliteal artery aneurysm?
Popliteal artery diameter 8mm or more.
In what situation is treatment of popliteal artery aneurysm recommended?
Symptomatic
Asymptomatic and >2cm in diameter
TRUE OR FALSE
In Buerger disease, the large vessels are typically spared.
TRUE
In lower extremity involvement, the common femoral, superficial femoral and popliteal artery are typically spared.
What are the 6 subtypes of popliteal artery entrapment syndrome?
Type 1: Popliteal artery has aberrant medial course along medial head of gastrocnemius
Type 2: Normal position of the popliteal artery, the MHG inserts more lateral than usual; the artery passes medial and beneath the muscle.
Type 3: an accessory slip of MHG slings around the artery
Type 4: artery lies deep in popliteal fossa entrapped by popliteus or fibrous band.
Type 5: Any of the aforementioned abnormalities with both artery and vein entrapment.
Type 6: normal anatomy (typically athletes with hypertrophy).
What are the most common subtypes of popliteal artery entrapment syndrome?
Type 1 and 2
What is cystic adventitial disease? Most common region of involvement?
A collection of mucinous material (mucous cysts) within adventitial wall of an affected vessel (arterial ++), usually presents in young males, causing compression of the vessel with claudication.
85% of cases involve the popliteal artery.
Which type of vascular access should be avoided in a patient with chronic renal failure who may need a fistula in the future?
PICC LINE. Central access should be attained through an internal jugular vein approach.
Name this space:
The ______________ is the space bounded by the anterior scalene muscle, the
middle scalene muscle, and the first rib
Interscalene triangle
What are the neurovascular structures that pass through the interscalene triangle?
The brachial plexus and subclavian artery.
In contrast, the subclavian vein does not pass through the interscalene triangle but instead runs anterior to the anterior scalene muscle.
What are the causes of subclavian artery compression?
Cervical rib (present in 70% of cases)
Accessory scalene muscle (scalenus minimus)
Enlargement of the anterior scalene muscle
Well-developed musculature
What percentage of surgical AV fistulas fail to mature?
30%
A fistula is mature when the veins have enlarged sufficiently to allow the high flow rates for dialysis.
What is the long term patency of a surgical AV fistula?
85% at 2 years
What are the 2 most common locations for a surgical AV fistula?
Radial artery to cephalic vein at the wrist
Brachial artery to variable veins in the forearm
What are the advantages and disadvantages of a PTFE graft as opposed to a surgical AV fistula?
only 50% patency at 2 years but able to be used sooner.
Grafts also require higher flow rates to remain patent.
What is the most common origin of the right gastric artery?
Proper hepatic artery (~50%)
Common hepatic and left hepatic are less likely.
What is the arterial supply of the anal canal?
Above dentate line:
Superior and middle rectal artery
Median sacral arteries
Below dentate line:
Inferior rectal artery
What is the venous supply of the anal canal?
Above dentate line: Superior rectal vein
Below dentate line: Inferior and middle rectal veins
When should you proceed to stent insertion after angioplasty of an iliac artery stenosis?
greater than 30% residual stenosis
residual systolic pressure gradient of >10mmHg at rest
residual systolic pressure gradient of >20mmHg after vasodilator
Hemodynamically significant dissection
Late restenosis at angioplasty site
What is the diameter of a megacava? What type of IVC filter should be used in these patients?
28mm
TrapEase or Bird’s nest filters can be used, or 2 filters can be inserted into the CIVs.
What are the indications for percutaneous gallbladder drainage?
- Acute calculous or acalculous cholecystitis
- Access for percutaneous stone dissolution or removal
- Diagnostic cholangiography
- Drainage of the biliary system when the CBD is obstructed
What is the primary treatment for fibromuscular dysplasia with renal artery stenosis?
Percutaneous transluminal angioplasty.
No place for stenting unless angioplasty fails
What is the 5 year patency rate following angioplasty for renal artery FMD?
90%
What % of patients treated with angioplasty for renal artery FMD have improved/cured hypertension?
40% cured
40% improved blood pressure
What is the most common angiographic finding in acute traumatic aortic injury? How often is free extravasation seen at angiography?
Pseudoaneurysm.
Free extravasation is rarely seen.
What are the complications of femorofemoral bypass placement?
Graft thrombosis
Femoral steal phenomenon
Anastomotic pseudoaneurysms
Anastomotic stenoses
What is the embolization material of choice for pulmonary arteriovenous malformation?
Coils
When treating pulmonary AVMs, what is the goal of therapy (in contrast to AVMs in the rest of the body)?
The majority of pulmonary AVMs have a single feeding artery and a single draining vein, with an intervening thin-walled aneurysm. Because of this configuration, the goal of therapy is to eliminate arterial inflow.
This is in contrast to peripheral AVMs where the goal of therapy is to eliminate the nidus.
What are the main collaterals between the celiac and SMA circulations?
Pancreaticoduodenal arteries
Gastroduodenal arteries
What are the major indications for invasive treatment of lower-extremity atherosclerotic disease?
Limb-threatening rest pain
Lifestyle-limiting intermittent claudication
Presence of a lesion that is suspected of being a source of distal embolization
What is the 5 year patency of a femoropopliteal bypass graft?
What are the 2 and 5-year patency of a superficial femoral artery angioplasty procedure?
Femoropopliteal bypass graft: 50-80% 5-year patency
Superficial femoral artery angioplasty:
50-70% 2-year patency
<50% 5-year patency
What are the findings of GI angiodysplasia on conventional angiogram?
vascular tuft/tangle of vessels
Ectatic vessels
early, intense filling of the draining vein from AV shunting
“tram-track” appearance of artery and vein
Which part of the esophagus is affected in patients with esophageal varices secondary to portal hypertension, and why?
Lower third, because the esophageal veins in this segment drain into the left gastric vein which drains into the portal vein.
The esophageal veins in the upper two thirds of the esophagus drain into the azygos -> SVC
Give 4 potential etiologies for renal artery stenosis
Atherosclerosis (by far most common)
FMD
Aortic dissection
NF1
What imaging findings help you distinguish FMD from atherosclerosis when assessing renal artery stenosis?
- Atherosclerosis typically at ostial/periostial portions of main renal artery. FMD in mid/distal portion.
- FMD has “beading” appearance: multiple areas of arterial dilatation
- In atherosclerosis there will be atherosclerotic disease in remainder of vessels. In FMD the aorta and other branches are usually normal.
What is the most common upper-extremity arterial variant?
High radial artery origin (from the brachial)
You can also have high ulnar artery origin, from the brachial. Also, both these arteries can arise from the axillary artery, less commonly.
What are the most common causes of massive hemoptysis?
Cystic fibrosis Bronchogenic carcinoma Bronchiectasis Aspergillosis Tuberculosis
TRUE OR FALSE
Massive hemoptysis rarely presents with active extravasation on bronchial artery angiogram
TRUE
Name this pathology:
Compression of the brachial plexus or subclavian vessels as they pass through the superior thoracic aperture
Thoracic outlet syndrome
If there is compression of the subclavian vein with venous thrombosis, it is called paget-schroetter syndrome
Name some causes of thoracic outlet syndrome
- Abnormal insertion of scalenus anterior onto 1st rib (scalenus anticus syndrome, commonest cause)
- Congenital cervical rib
- 1st rib or clavicle bone abnormality
- Elongated C7 transverse process
- Muscle hypertrophy (beef cake)
- Fibrous bands
- Supraclavicular tumour
- Lymphadenopathy
What are the 3 common sites of compression in Thoracic outlet syndrome?
1- Scalene triangle: between scalenus anterior and scalenus medius muscles
2- Costoclavicular space: between clavicle and 1st rib
3- Subpectoral space: between pectoralis minor and coracoid process
Name 3 indications for TIPS
Refractory ascites
Bleeding varices with failure of endoscopic management
Hepatic hydrothorax
Name 4 contraindications to TIPS
All relative contraindications:
Hepatic encephalopathy
Hepatic failure
Uncorrected coagulopathy
Active infection
Name some early complications of TIPS
Intraperitoneal hemorrhage
Worsening of hepatic encephalopathy
Stent infection
Early TIPS occlusion
What is the 1 year patency rate for TIPS?
50%
What is the most common cause of long-term TIPS failure?
Development of stenosis along the course of the TIPS, most commonly at the hepatic vein end but also at the portal vein end or within the stent
IR
What are the contraindications to vasopressin infusion?
Severe CAD
Dysrhythmia
Cerebrovascular disease
Severe hypertension
What are the indications for uterine artery embolization?
1- Control postpartum bleeding refractory to medical or surgical management
2- Treat trauma-related pelvic hemorrhage
3- Improve symptoms in patients with uterine leiomyoma
4- Palliate bleeding pelvic malignancies (bleeding commonly recurs after embolization)
What is the success rate of uterine fibroid embolization?
85-90% success in producing significant improvement in symptoms or menorrhagia or pelvic pain
If a patient with a central venous catheter has a clinical finding of impaired ability to aspirate blood but preserved ability to inject, what is the most likely diagnosis?
Pericatheter fibrin sheath
TRUE OR FALSE
Catheter exchange over a guidewire for treatment of pericatheter fibrin sheath is unlikely to produce long-term improvement
TRUE
The new catheter is typically reinserted into the existing fibrin sheath
What are the 3 most common types of dialysis AVFs?
brachiocephalic
radiocephalic
brachial artery to transposed basilic vein
Among the hemodialysis delivery options, which one has the highest rate of thrombosis and infection?
Central venous hemodialysis catheters
