IR Flashcards
(232 cards)
1
Q
‘Usual’ wire size?
A
.035 inch
2
Q
‘Microwire’ size
A
.018 and .014 inches
3
Q
‘Glide’ = ?
uses
A
hydrophilic coated
easier passage of occlusions, stenosis, small or tortuous vessels
4
Q
Catheter French
measured where
A
External diameter, NOT lumen
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
6
Q
Puncture needles, Guide wires, Dilators
sized how
A
OUTER d
7
Q
SHEATHS
A
INNER D
8
Q
Wire diameter
Wire length
units
A
DIAMETER = INCHES .035, .014, .018
LENGTH = CM
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
10
Q
Needle and Wire rules
18G
19G
A
18G .038 inch
19G .035 inch
19 main one, 035 MC wire
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
12
Q
Wire length
standard?
long one?
A
180cm = standard
260 cm = long
13
Q
Floppy tips
risk of short vs long floppy
A
shorter floppy end = higher risk of dissection
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
15
Q
Stiffness chart
A
CTC pg 452
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
17
Q
Catheter labeling
3 numbers
A
“OUTER DIAMETER (F), INNER DIAMETER (inch), LENGTH (cm)”
“Size” = outer diameter (F)
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
19
Q
Pigtail Q
continuous injection can lead to ?
A
clot at end hole
20
Q
Pigtail Q
Prior to full force injection?
A
puff to make sure you’re not in a small side branch
21
Q
Straight (vs pigtail) catheter
use?
A
smaller vessels (iliac classic)
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
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
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
25
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
Renals, *SMA, celiac maybe*
"Curved cath"
Renal double curve or COBRA
26
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
Celiac, SMA, IMA
"Recurved"
Sidewinder, Sos Omni
Recurve = second curve in opposite direction (for dropping into obtuses)
27
random vocab
"introducer guide"
"microcatheter"
"vascular sheath"
"introducer guide" A long sheath
"microcatheter" 2-3 F
"vascular sheath" Sheath + hemostatic valve + side-arm for flushin
28
Flushing
**Double flush**
sitch, technique
**Single**
sitch, technique
**Double flush**
AIR A PROBLEM, brain. aspirate blood, attach a clean one, flush
**Single**
aspirate tiny bit of blood, tilt, flush
29
Arterial access next steps
resistance?
wire wont advance beyond top of needle?
Wire stops after short distance?
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**
30
Fem art access
anatomy? (origin, branches)
ideal spot?
risks of high, low sticks?
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**
31
Brachial access?
WHY?
Dead/cant get fem
pannus
upper limb angioplasty
32
Brachial access probs/risks
?larger sheath needed
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
33
Which arm to access?
Headed south?
headed north?
all things equal?
BP diff?
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
34
Radial access
factoids
NO bedrest
Allen test beforehand, confirms Ulnar hand collats
35
Translumbar aortic stick
when?
position?
hematoma?
contraindication?
compression?
when? **2 endoleak repair**
position? **Stomach**
hematoma? **Psoas \> back pain**
contraindication? **known supraceliac aneurysm**
compression? **roll onto back**
36
Pre IR procedure stuff
Heparin timing?
INR?
Coumadin?
Plt?
ASA/Plavix?
abx proph?
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**
37
Post procedure
timing of compression?
ACT to pull sheath?
turn hep back on?
timing of compression? 15 minutes
ACT to pull sheath? \<150-180
turn hep back on? 2 hours post
38
PICC access order of pref
Basilic \> Brachial \> Cephalic
picture on 461
Lat to med
Basilic Brachial Cephalic
BBC
39
Central line pref
R IJ
40
Order of pref for DIALYSIS
RIJ \> LIJ \> REJ \> LEJ
right over left, IJ over EJ
41
Pseudoaneurysm treatment
3 options
Direct compression
Thrombin injection
Surgery
42
Pseudoaneurysm treatment
Direct compression
where, how long?
neck, 20-60 minutes, painful
43
Pseudoaneurysm treatment
Thrombin inj
how?
contrainx
needle into apex
0.5 - 1.0 ml
500-1000 units
infection, rapid enlargement, limb ischemia, **large neck**, cavity size \< 1cm
44
Pseudoaneurysm treatment
Surgery
If thrombin fails, infection, neck too wide
45
Pseudoaneurysm
spontaneous thrombosis size?
Which will respond to IR tx?
\<2cm may thrombose
Respond to IR tx = long necked with small defects \< 2mm
46
PTA and stents
ideal balloon dilatation?
success?
anticoag post plasty?
ideal balloon dilatation? **20% larger than normal diameter**
success? residual stenosis \< **30%**
anticoag post plasty? **1-3 months ASA/Plavix**
47
Balloon vs self expanding stents
why ?
classic locales ?
Balloon good for PRECISE PLACEMENT
RENAL ostia
Self expanding good for areas that might get compressed (superficial)
CERVICAL CAROTID, SFA
48
Nitinol
soft at room temp, more rigid at body temp
useful for self expanding
49
Rough balloon sizes (10-20% greater than normal D)
Aorta?
Common iliac?
External iliac?
CFA/Prox SFA?
Distal SFA?
Popliteal?
Aorta? 10-15 mm
## Footnote
**Common iliac? 8mm**
**External iliac? 7mm**
**CFA/Prox SFA? 6mm**
**Distal SFA? 5mm**
**Popliteal? 4mm**
50
Stent selection
length?
diameter?
1-2 cm longer than stenosis
1 - 2 mm wider than unstenosed lumen
51
Success alternate
\>30% stenosis still but no pressure gradient
52
balloon doesnt fix waist
use a higher pressure one or a 'cutting' one
53
distal embo?
do a run
distal vessels fine, its ok
not, get ipsi access and try to aspirate it
54
exploded the vessel
inflate balloon with low pressure proximal to extrav to create tamponade
55
crossing tight stenosis, funny looking wire?
classic "spiral" of a dissecting wire
56
Endo vs open repair
30 day mortality
long term aneurysm related mortality (and total)
Graft compx and re-interventions
30 day mortality - **LESS for endo**
long term aneurysm related mortality (and total)- **SAME**
Graft compx and re-interventions - **HIGHER for endo**
57
EVAR (aaa)
indications?
anatomic criteria?
**AAA larger than 5cm** (or double normal size)
prox landing zone
\> 1cm
non - aneurysmal (\<3.2 cm)
angled less than 60 degrees
58
Iliac reqs for evar
\> 90 degree angles
\<7mm iliac diameter may require cut down and conduit
59
Absolute infrarenal EVAR contraindx
bad landing site
Covering a CRITICAL ARTERY
**IMA with known sma and celiac occlusion**
**accessory renals feeding a horseshoe**
**dominant lumbars feeding the cord**
60
renal related AAA vocab
para renal
juxta renal
supra renal
Crawford type 4 thoracoabdominal AA
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
61
EVAR compx
paraplegia
62
Type 1
A top
B bottom
high pressure and require intervention
63
Type 2
Feeder
MC type
IMA or lumbar
majority resolve
follow sac size and tx if growing
64
Type 3
Defect/fracture
overlapping components
65
Type 4
4 from pore
porosity
doesn't happen with modern grafts
66
type 5
endotension, not a real leakcould be 2/2 pulsation
67
Coils
accurate deployment = detachable coil
pushed or chased with saline (not precise)
68
Amplatzer plug
made of ?
sitch?
Nitinol
high flow situations, killing a single large vessel
69
Particulates
Permanent or Temporary
Temporary = gelfoam, autologous blood clot
Permanent = PVA particles
70
Particulates
when
when to stop
To block multiple vessels
fiibroids and malig tumors
Stop when flow becomes to and fro (avoid reflux)
71
Gelfoam powder vs pledgets
powder goes to capillaries, necrosis
pledgets cause occlusion at arteriole or larger, no necrosis
72
Coils vs particles
size?
need for re access
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
73
Liquid agents
Sclerosants
Non-sclerosants
**Sclerosants** = **alcohol** (ouch) and Sodium tetradecyl sulfate **SDS**
**Non sclerosants** = **ONYX, ethiodol**
74
Classic embo scenarios
Priapism (post traumatic high flow)
Autologous blood clot
75
Classic embo scenarios
UFE (bilat uterine artery)
PVA or microspheres (500- 1000 microspheres)
76
Classic embo scenarios
Generic trauma
Gel foam in many cases
77
Classic embo scenarios
DIFFUSE splenic trauma
(proximal embo) Amplatzer plug in splenic artery, proximal to short gastrics
78
Classic embo scenarios
Pulmonary AVM
coils
79
Classic embo scenarios
BAE (hemoptysis)
PVA particles (\>325 microm)
80
Classic embo scenarios
spinal tumors (vascular)
Onyx
81
Classic embo scenarios
total renal embo
Absolute ethanol
82
Classic embo scenarios
Selective renal embo
GLUE (bucrylate-ethiodized oil)
83
Classic embo scenarios
segmental renal artery aneurysms
COILS
84
Classic embo scenarios
Main renal artery aneurysm
COVERED STENT
85
Classic embo scenarios
Peripartum hemorrhage
Gel Foam
86
Classic embo scenarios
Upper GI bleed
ENDO first then prolly coils
87
Classic embo scenarios
Lower GI bleed
Usually microcoils
88
Post embo syndrome
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
89
Acute limb
surgery vs thrombolysis
\<14 days lysis
\>14 days surgery
above inguinal isolated = surgically
fragmented distal = endo lytics
90
Ulcer trivia
Medial ankle?
Dorsum of foot?
Plantar foot?
Medial ankle? VENOUS STASIS
Dorsum of foot? ISCHEMIC OR INFX ULCER
Plantar foot? NEUROTROPHIC ULCER
91
Bypass vocab
Primary
Primary assisted
Secondary
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
92
Next step extremity clot stuff
can't cross clot with wire
won't clear with thrombolysis
93
Generic procedure for lysis
jam cath in clot, infuse tpa directly, check q6-8 hours
"check angiography"
94
Next step extremity clot stuff
NO clearing during a check angiogram
"lytic stagnation"
stop procedure
95
Next step extremity clot stuff
"confusion"
CT head
96
Next step extremity clot stuff
Tachy and hypoTN
look at site, CT abd/pelvis, stop tpa
97
Next step extremity clot stuff
end point?
clot clears or 48 hours
98
Varicose vein treatment
tumescent anesthesia, lots of dilute subq lido
ablated using endoluminal heat source
contraindx = DVT
99
Post thrombotic syndrome
demo
RF
tx/prophylx
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
Filter indications
PE on anticoag
contra to anticoag with CLOT IN FEMORAL OR ILIACS
101
AV fistula vs graft
pros cons
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
normal graft PE
Easily compressible pulse
low pitched bruit in systole and diastole
**palpable thrill with compressoin only at the arterial anastamosis**
103
MC site of obstrx
**venous outflow, at or just distal to graft to vein anastamosis**
104
fistula stenosis reoccurence
75% of the time within 6 months
105
FISTULA THRILL
?only in systole
should be continuous at anastamosis
only in systole = stenosis
106
Fistula, cold hand during HD
Steal syndrome, distal native artery stenotic
tx = surgical
107
Def of portal HTN
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
Portal HTN US look
Enlarged PV \> 1.3-1.5 cm
Enlarged Splenic vein \> 1.2 cm
Big spleen
ascites
patent umbilical
reversed PV flow
109
TIPS indx
variceal hem refractory to endoscopic tx
Refractory ascites
Budd (hepatic vein thrombosis)
110
TIPS w/u?
ECHO- evaluate for HF
CT to confirm **patency of portal vein**
111
TIPS steps...
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
Hepatic to portal stick move in TIPS?
turn catheter **ANTERIOR**
113
MELD
Transplant score
based on liver and renal fx
bili
inr
creatinine
Greater than 18 = higher risk of early death after elective TIPS
114
Childs Pugh
Prior to MELD
less accurate
assesses severity of liver disease
bili
PT
albumin
ascites, hepatic encephalopathy
B and C are high risk
115
SImplest prognostic measure with liver
Serum bili \> 3mg/dl = increase in 3 day mortality afer TIPS
116
TIPS contraindx
MC Severe HF (right more)
biliary sepsis
isolated gastric varices with splenic vein occlusion
relative
cav transformation of PV, encephalopathy
117
Main acute TIPS complx
cardiac decompensation (elevated RH pressure)
accelerated liver failure
worsening encephalopathy
118
Evaluation of a 'normal TIPS'
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
TIPS F/U
50% primary patency at 1 year
signs of failure ascites, bleeding etc
Do venogram
PV \>12 bad
next step treat stenosis plasty + balloon
120
MC TIPS stenosis site
hepatic vein and within TIPS tract
121
Worsening encephalopathy
TIPS too open, tighten with another stent
122
BRTO
Balloon occluded retrograde transverse obliteration
BRTO treats
what is it
complx
helps
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
MC BRTO SE
gross hematuria
124
Biliary ductal anatomy
Right hepatic duct
posterior - 6 and 7
anterior - 5 and 8
Left hepatic duct
2 and 4
125
Ductal variants
MC Right posterior drains left hepatic duct
2nd MC Trifurcation of Right anterior, right posterior and left ducts
126
Biliary drainage
pre procedure
abx and coags
127
biliary drainage approaches
Right lateral mid axillary for right system
SUBXYPHOID for left
128
Right PTC approach
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
PTC next steps
ascites?
Don't see left system?
Rigor?
stones?
can't cross an obstrx with a wire?
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
ccy ostomy
approaches
Coagulopathic?
Main route?
Transperitoneal
avoids liver in bleeders, risks big bile spill
Transhepatic
liver stabilizes wire
usually through 5 and 6
131
managing GB tube
leave in?
before pulling?
leave in 2-6 weeks
confirm patent cystic duct prior to pulling
clamp 48 hours prior to pulling
132
Liver FNA
cytology
21 or 22G chiba, vacuum aspirate
133
biopsy a liver lesion
course?
Shoulder pain?
contraindx?
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
TRANSJUG Bx
path?
through R hepatic vein while angling ANTERIOR (biggest bite and avoids capsular perf)
135
Angio for hepatic/splenic trauma
indications?
contraindx?
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
Hepatic embo
what's usually used?
selective or non?
Tx for pseudoan?
Hepatic surface bleeding?
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
Splenic embo
indx?
strategies, focal vs diffuse
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
HCC
?transplant appropriate
\<65, limited tumor burden
139
TACE
indx
mechanism
agent
chemo followed with
absolute contraindx
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
TACE in pt with biliary stent, prior sphincterotomy, post WHIPPLE risk?
biliary abscess
141
RISK to GB?
Agent injected into R hepatic artey, prior to cystic artery origin
sterile or chemical cholecystitis
142
repeat TACE risk
burns, left back 2/2 RAO position
143
RFA
temp?
residual tumor = ?
indx?
TACE + RFA ?
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
Y90
Pre-tx w/u
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
Ytrium facts
? emitter, energy
half life?
range of rad from each bead?
Beta emitter
mean energy of 0.93MeV
half life 64 hours
1.1 cm maximum bead range
146
RFA trivia
size for 'cure' vs 'debulk'?
burn margin?
Patient precautions?
Hot withdrawal?
Heat sink?
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
Post ablation syndrome
can get fever and aches
\>2-3 weeks, infx w/u
148
Microwave diffs from RFA
More power
cooks bigger stuff
less ablation time
less susceptible to heat sink
no grounding pad
149
Cryoablation
trivia
thawing kills cells
hurts less
higher risk of bleeding than RFA, small vessels aren't cauterized
150
RFA tx response
week 1-4?
month 3?
month 6?
week 1-4? OK to get bigger
month 3? same size or smaller
month 6? should be smaller
151
Post RFA enhancement
benign vs residual/recurrent
Benign = peripheral, smooth, uniform, concentric
f/u at 1 month, residual enhancement = disease = repeat tx
152
TACE f/u CT
tx oil = dense, more = better
enhancement or washout = tumor
"zone of ablation"
153
Cryo tx response
CT at?
good post tx look?
3 months, 6 months, 12 months
Good CT = lower density than adjacent kidney
Good MRI = T2 dark, T1 iso or hyper
154
G tube
ideal target
Left of midline
Mid to distal body
between greater and lesser curvatures to avoid vessels
155
GI bleed
upper vs lower
ligament of Treitz
156
Upper GI bleed
MC vessel
duodenal ucler vessel
Left gastric
GDA
157
parcreatic arcade bleeding aneurysm = ?
look?
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
Angio vs RBC scintigraphy sensitivity
**NUCS 0.1 ml/min**
CTA 0.4 ml/min
**Angio 1ml/min**
159
GI bleeding buzzwords
Angiodysplasia
Diverticulosis
Meckles
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
Provocative angio looking for bleeding
if you see bleeding?
nitro and tPa
microcoils and PVA particles
161
PVA vs coils
**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
Post embo?
Classic dual supply question
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
tube size for abscess drainage
clear
thin pus
thick pus
debris
clear 6-8 F
thin pus 8-10 F
thick pus 10-12 F
debris 12+ F
164
Paths to drain pelvic absceses
Transabdominal
Usually a long course
## Footnote
**Watch out for INFERIOR EPIGASTRIC**
165
Paths to drain pelvic absceses
Transgluteal
access, what to avoid
Avoid gluteal arteries and sciatic nerves
access through sacrospinous ligament
medial as possible
inferior to piriformis
166
Indication for renal abscess drainage
large \>3-5 cm, doesn't respond to abx
167
Indications for PCN
Obstrx
Diversion- leak, fistula, severe hemorrhagic cystits (cyclophosphamide)
Access for a procedure
168
PCN contraindx
coagulopathy 1.5, 50k
colon, spleen, liver in way
169
Prior to PCN
K \< 7
antiplatelets held for 5 days
170
PCN target stuff
where
Lower pole of a posteriorly oriented calyx
30 degree to hit brodel avascular zone
10 cm from midline (spine)
171
Approach to PCN a transplant
anterolateral calyx
lateral to avoid peritoneum
172
PCN exchange
q 2-3 months
173
Long term drainage (urinary)
nephroureteral stent
174
Suprapubic cystostomy
target
contraindx
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
Renal biopsy
RF or cancer
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
Renal ablation RFA
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
Renal arteriography
to start?
position?
Aortogram to define arteries (can be multiple)
LAO
178
Renal artery stenting
risks
drugs
Thrombosis and spasm
heparin then ASA x 6 months
dont stent FMD
179
Renal aneurysms
small vs main
Small segmental tx = COILS
Main renal artery = covered stent or bare stent and coil thru
180
Pleural drainage
paravertebral risk?
intercostal vessels are off the ribs, more prone to injury
181
Lung abscess
DONT DRAIN
BRONCHOPLEURAL FISTULA
182
Lung bx
complx
MC = PTX, 25%, 5% need tube
hemoptysis
183
Avoiding PTX with lung bx
when to CT
kind of CT
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
RFA of lung tumors
size?
effectiveness?
benefit?
1.5 - 2.5 cm
comparable to external beam RT with limited effect on pulmonary function
185
Thoracic angio
types, big indx
Pulmonary artery
PE or AVM
Bronchial artery
hemoptysis
186
PA angio
catheter?
risk?
pre-eval?
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
Pulm angio
Vtach during?
Re-position catheter/wire
188
Pulm angio for PE
indx
1st tx - anticoag
can't? filter
unstable with massive PE? catheter therapy (lysis, aspiration, fragmentation, stent)
189
Pulm avm's
a/w?
where?
complx?
tx when and how?
HHT/OWR
MC in lower lobes
Brain abscess/stroke
Tx at 3mm afferent
Coils in feeder
190
rasmussen tx
coils
hemoptysis with negative bronchial artery angio
191
bronchial artery angio
hemoptysis
look
BIG risk
tx
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
SVC syndrome
tx steps
malig vs non malig
risk of tamponade
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
UAE
size and location?
**submucosal best**
Intramural second
**serosal worst**
**small do better**
194
UAE
Cellular fibroids
look
response to embo
T2 bright
respond well
195
Intracavitary fibroids- less than 3cm?
GYN for hysteroscopic rsxn
196
Intracavitary fibroids - less than 3cm, failed rsxn
IR embo
197
LARGE, serosal, patient wants to remain fertile, never had a myomectomy
GYN for myomectomy
198
pedunculated serosal fibroid
GYN for resection
199
Broad ligament fibroid
can't embo, hard to operate on
200
Fibroid medical tx
Grow in pregnancy, hormone responsive, GnRH meds
201
Patient on hormone meds for fibroids, want UAE?
delay 3 months off meds, meds shrink uterine arteries, harder to cath
202
UAE risks
5% premature menopause
DVT/PE 5% (large fibroid compression released, DVT flies up)
203
UAE contraindx
PREG
Cancer
PID
prior radiation
CTD
204
UAE tx trivia
anatomy?
which to tx?
material vs post partum hem?
adenomyosis tx?
volume reduction?
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
HSG trivia
best time?
closed tube?
false positives?
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
Fallopian tube recanalization
prox, interstitial, distal tx?
Distal = surgery
Proximal = endo or wire under fluoro
207
Tube recanalization
timing?
poking tool?
contraindx?
DAY 6-12, PROLIFERATIVE, thin endometrium
Hydrophilic .035 or .018
Repeat HSG when finished
PID and PREG
208
PELVIC CONGESTION SYNDROME
dx?
Tx?
clinical symptoms + gonadal vein \> 10mm
medical = GnRH
IR = sclerosing parauterine veins, coils/plugs in ovarian and internal iliac veins
209
Varicoceles
when to tx?
tx for infertility, atrophy in a kid, pain
210
heparin half life
l.5 hrs
211
Protamine SE
sudden drop in BP, BRADY and FLUSHING
212
HIT
risk
tx
RISK OF CLOTTING NOT BLEEDING
If they need to be anticoag, use thrombin inhibs (rudin and gatrans)
213
Abdominal aorta injection rate
20cc/sec
214
Takayasu look
Smooth, non-ostial
215
CTA timing
arterial
venous delay
20-40 seconds
180 seconds
216
Timing, location of graft/fistula complx
First six months arterial inflow
Past 1 year out, venous outflow
217
RFA contraindx/ideal lesion
1 2 3
\<1cm from capsule
\<2cm from major vessel
\<3cm in size
\>3cm TACE
218
General rate for 'selective' angios (SMA etc)
5cc/sec
219
Angiodysplasia look, tx
tuft of vessels
super selective coil
(also for pseudoan and extrav)
220
Median arcuate lig
worse w/?
Tx?
EXPIRATION
Surgery
221
UFE embo material =
particles \>350 microns
222
Secondary supply to fibroids leading to recurrent symptoms =
ovarian arteries
Right off aorta
Left off renal
223
embo material for tic bleed
selective coiling
particles \> infarcts
224
Indirect portal venogram?
delayed SMA injection
celiac vs SMA by presence/absence of splenic blush
225
PCN tube size pussy vs non pussy
pyonephrosis = 10F for pus
routine PCN = 8F
226
occluded aorto question, origin of superior epigastric
INTERNAL MAMMARY
anastamoses with inferior epigastric at umbilicus
227
TIPS contraindx
CHILD C
MELD \>18
encephalopathy
elevated PAP
228
TIPS stent =
Covered, self expanding
229
PE findings with fistula complx
outflow stenosis?
Arterial stenosis?
Outflow stenosis = increased back pressure and **increased pulsatility**
Arterial stenosis = **weak or absent thrill**
230
threshold for visceral/renal artery aneurysm intervention?
\>2cm
231
number of bronchial arteries
MC one on right two on left
232
