IR CORE - Sheet1 Flashcards
(231 cards)
1
Q
Which is anterior? Subclavian artery vs. vein
A
Subclavian vein is anterior to artery
2
Q
Major branches of subclavian artery
A
Vertebral, Internal thoracic, Thyrocervical trunk, Costocervical trunk, dorsal scapular
3
Q
Extent of subclavian artery?
A
brachiocephalic to the first rib (outer edge)
4
Q
Extent of axillary artery?
A
from the first rib (outer edge) to teres major (outer edge)
5
Q
Extent of brachial artery?
A
from teres major (outer edge) to bifurcation of the radial and ulnar arteries
6
Q
which gives off interosseous artery?
A
usually ulnar, which is also usually bigger
7
Q
normal variant that can supply the deep palmar arch of the hand
A
persistent anterior interosseous branch (median artery)
8
Q
high origin of the radial artery
A
radial a. comes off either the axillary or brachial a.
9
Q
when does the external iliac become the CFA?
A
once it gives off the inferior epigastric (at the inguinal ligament)
10
Q
CFA bifurcates into these 2 vessels
A
deep femoral (profunda) and superficial femoral
11
Q
superficial femoral turns into the popliteal after?
A
after emerging from Hunter’s canal
12
Q
popliteal artery divides when?
A
at the distal border of the popliteus muscle
13
Q
popliteal artery divides into?
A
anterior tibial and tibial peroneal trunk
14
Q
what is the most medial artery in the leg?
A
posterior tibial (felt at medial malleolus)
15
Q
most common biliary duct variant?
A
right posterior segment draining the left hepatic duct
16
Q
2nd most common biliary duct variant
A
trifurcation of the intrahepatic radicles
17
Q
how many times can you try a PTC before quitting?
A
15-20
18
Q
what happens if you inject contrast forcefully during a PTC?
A
ICU visit for cholangitis
19
Q
what is the benefit of a transhepatic cholecystostomy?
A
minimizes chance of bile leak c/w transperitoneal approach
20
Q
when can you pull a cholecystostomy tube?
A
2-6 weeks after placing (have to wait for tract to mature) or else leak
21
Q
how do you manage an accidental bile leak?
A
place a tube in the bile ducts to divert bile from location of leak
22
Q
what % of blood flow to liver comes from PV?
A
70-80%
23
Q
normal pressure gradient between PV and IVC
A
3-6 mmHg
24
Q
define portal HTN (mmHg)
A
PV > 10 mmHg or PSG > 6 mmHg (portal systemic gradient)
25
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
26
2 reasons for TIPS
variceal hemorrhage refractory to endoscopy + refractory ascites
27
no TIPS above this MELD score
18 - higher risk of early death after elective TIPS
28
2 pre-procedural steps for TIPS
Echo to eval for heart failure + cross sectional imaging to demonstrate patency of PV
29
normal right heart pressure
5 mmHg
30
value of right heart pressure that precludes a TIPS
10-12 mmHg
31
what to what for a TIPS
IVC to hepatic veins to PV (usually right to right)
32
ideal PSG (portal systemic gradient) after TIPS
9-12 mmHg (remember normal = 3-6 mmHg)
33
which direction to you turn the catheter when moving from the right HV to the right PV?
turn needle anterior
34
3 main post-TIPS complications
cardiac decompensation (elevated right heart pressure), accelerated liver failure, worsening encephalopathy
35
typical velocity of TIPS stent
90-190 cm/s
36
what TIPS stent velocity is too high?
>200 cm/s (stenosis)
37
what PV velocity is too low s/p TIPS
< 30 cm/s abnormal
38
indirect sign of TIPS malfunction
new or increased ascites
39
3 absolute contraindications to TIPS
severe heart failure + biliary sepsis + isolated gastric varices with splenic v. occlusion
40
2 relative contraindications to TIPS
cavernous transformation of the PV + severe hepatic encephalopathy
41
alternative to TIPS for refractory ascites
peritoneovenous shunt (Denver shunt)
42
major risks of Denver shunt
high rate of infection and thrombosis (even DIC)
43
BRTO
balloon-occluded retrograde transverse obliteration
44
what does BRTO treat?
gastric varices
45
major complication of BRTO
worsening esophageal varices and ascites
46
how does BRTO affect hepatic encephalopathy
improves it
47
2 reasons for doing transjugular liver biopsy
massive ascites + severe coagulopathy
48
first line treatment for GI bleeds
vasopressin
49
which is more sensitive for GI bleed: nuclear scintigraphy or angiography?
RBC bleeding scan
50
rate of bleeding detected on RBC scan
0.1 mL/min
51
rate of bleeding detected on angiography
1 mL/min (10x less sensitive than RBC scan)
52
most common embolization agents for GI bleed
coils or gelfoam
53
3 contraindications to GI bleed embolization
prior stomach or bowel surgery, prior radiation, or inadequate collateral circulation
54
why do angiography after you embolize?
look for collateral flow (after you embolize GDA, look at SMA to at inf. pancreaticoduodenal)
55
most common source of upper GI bleed
left gastric (85%)
56
what do you embolize if it's a duodenal ulcer bleed?
GDA
57
most common cause of lower GIB
diverticulosis (on the left)
58
does embolization help with angiodysplasia?
no, usually re-bleeds and need surgery
59
"pseudo-vein" sign
sign of acitve GIB, appearance of vein created by contrast pooling in gastric rugae or intestinal fold
60
dieulafoy's lesion
monster artery in the submucosa of the stomach which pulsates until it causes a teeny tiny tear
61
pancreatic arcade bleeding
celiac artery stenosis (dilation of pancreatic duodenal arcades + pseudoaneurysms)
62
what is the only cure for HCC?
transplant
63
better survival: TACE or systemic chemo?
TACE
64
contraindication to TACE
PV thrombosis (risk of infarcting liver)
65
"zone of ablation"
preferred nomenclature for post-ablation region s/p TACE/RFA
66
nucs study you do before a Y-90 radioembo
lung shunt fraction using Tc-99 MAA
67
lung shunt fraction that precludes Y-90 tx
fraction that would give >30 Gy in a single treatment
68
what artery do you embolize before Y-90 tx?
right gastric and GDA (prevent reflux of Y-90)
69
above or below rib for thora?
above! (avoid neurovascular bundle)
70
how to position patient post-lung biopsy to reduce risk of pneumo
puncture side DOWN
71
2 reasons to place a chest tube post biopsy
symptomatic pneumothorax or enlarging pneumo or serial CXR
72
better to drain an empyema or lung abscess?
empyema (draining an abscess can create bronchopleural fistula)
73
who should get prophylactic pacing prior to pulmonary angio?
LBBB
74
when should you measure pressures on pulmonary angio?
BEFORE injecting contrast (may need to decrease volume in pulm HTN)
75
2 contraindications to pulmonary angio
pulmonary HTN (right heart pressure > 70 systolic and 20 ED) + LBBB
76
major risks of AVMs
right to left shunt = stroke and brain abscess
77
from what does the uterine artery arise?
anterior division of the internal iliac
78
embolize unilateral or bilateral?
always bilateral (too many collaterals)
79
what meds do you stop before UAE?
gonadotropic-releasing meds (3 months prior, they constrict the uterine a.)
80
which location of fibroids responds best to UAE?
submucosal
81
which trial showed the hospital stay are shorter for UAE than hysterectomy?
EMMY trial
82
incidence of premature menopause following UAE
5%
83
risk of peritonitis following HSG
1%
84
what time of cycle is best for HSG
proliferative phase (days 6-12)
85
3 reasons to treat varicocele
infertility, testicular atrophy, pain
86
left internal spermatic (gonadal) vein drains into the...
left renal vein
87
right internal spermatic (gonadal) vein drains into the...
IVC
88
2 reasons varicoceles occur
right angle entry of the left spermatic v into left renal v. + nut-cracker syndrome on the left
89
how to treat varicocele
mad embolization of the gonadal vein - foam, coils, amplatzer, all of it
90
try to avoid these on transgluteal drainage
sciatic nerves and gluteal arteries (access through the sacrospinous ligament medially)
91
when to pull an abscess catheter
patient is better + output < 20 mL over 24 hrs
92
pancreatic cutaneous fistula
pancreatic drain with clear fluid > 30 days
93
4 reasons to biopsy a thyroid nodule
solid > cystic, hypervascular, blurred margin, microcalcs (most important)
94
what if path is non-diagnostic
don't repeat for 3 months
95
Brodel's Avascular Zone
posterior lateral LP target of PCN placement (btw arterial bifurcation)
96
can you do a perc neph on a transplant kidney?
of course + it's easier
97
2 risks of perc neph
bleeding + urosepsis
98
how often should you exchange perc neph tubes?
every 2-3 months (b/c of crystallization)
99
2 indications for renal abscess drainage
large (>3-5 cm) + symptomatic that does not respond to abx alone
100
what part of the kidney do you want for random renal biopsy?
cortex (to get the glomeruli)
101
positioning for focused renal biopsy?
lesion side DOWN (stabilizes kidney from motion/bowel)
102
3 things that we do renal RFA for
AMLs, AVMs, RCCs
103
treatment for atherosclerosis at ostium of renal arteries
angioplasty + stent
104
treatment for FMD renal arteries
angioplasty only
105
medial brachial fascial compartment syndrome
cold fingers + weakness 2/2 hematoma from brachial artery stick
106
when to stop heparin before arterial stick
2 hours prior to procedure
107
INR for arterial procedure
1.5
108
when to stop coumadin before arterial stick
5-7 days prior
109
platelet count for arterial stick
> 50 K (some texts say 75)
110
when to stop ASA/plavix prior to arterial stick
5 days prior
111
how long to I have to stand here and hold compression after an arterial stick
15 min
112
when can I turn heparin back on after arterial stick
2 hours
113
0.039 inch (in mm)
1mm
114
0.035 inch (in mm)
considered 1 mm for usual purposes (actually 0.039)
115
what's a microwire in inches
0.018 + 0.014
116
what's a glide wire
hydrophilic coated wire, easier passage
117
3 F (in mm)
1mm
118
6 F (in mm)
2mm
119
9 F (in mm)
3mm
120
diameter in mm = F/x
F/3
121
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
122
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
123
catheter size
outer lumen
124
sheath size
inner lumen (+ 2 for outer diameter)
125
standard size for routine vascular work
6-8 F
126
standard size for a filter
6-9 F (8.5 for Tulip)
127
standard size for stent graft
15-20 F
128
standard size of abdominal drains
12 F
129
standard size of PEG tube
24 F
130
standard guide wires
0.035-0.038 inches = 3 F = 1mm
131
preferred vein for PICC
basilic > brachial > cephalic
132
preferred vein for central line/port
right IJ
133
order of preference for dialysis access
RIJ > LIJ > REJ > LEJ
134
do we place PICCs in dialysis patients?
NO
135
how long does an AV fistula take to mature?
3-4 months
136
how long until you can use an AV graft?
2 weeks
137
which lasts longer AV fistula vs. graft
AV fistula lasts longer
138
which gets more infections: AV fistula vs. graft
AV grafts get more infections (synthetic graft material)
139
goal flow of AV fistula/graft
600 mL/min with outlet vein > 6mm
140
most common complication of AV grafts
venous outflow obstruction (2/2 intimal hyperplasia)
141
most common complication of AV fistula
more variable than in grafts (venous outflow obstruction), not gonna be asked
142
"steal syndrome" (AV fistula)
"cold painful fingers" during dialysis relieved by manual compression of fistula (stenosis in native a. distal to fistula)
143
meds after stent placement
1-3 months of anti-platelets (aspririn, plavix)
144
drug eluting stents
try to prevent neointimal hyperplasia
145
critical limb ischemia
rest pain for 2 weeks (or ulceration or gangrene)
146
surgery for thrombolysis for ischemia
thrombolysis for occlusions < 14 days
147
ulcer on medial ankle
venous stasis
148
ulcer on dorsum of foot
ischemic or infected ulcer
149
ulcer on plantar surface of foot
neuropathic ulcer
150
false elevation of ABI
arterial calcification in diabetics
151
contraindication to varicose vein treatment
DVT (need those superficial veins)
152
anesthesia for varicose vein treatment
"tumescent anesthesia" lots of dilute SQ lidocaine
153
post-thrombotic syndrome
pain + venous ulcers after a DVT
154
Type 1 endograft leak
leak at top or bottom of graft
155
Type 2 endograft leak
filling of sac via feeder artery
156
Type 3 endograft leak
defect/fracture in graft
157
Type 4 endograft leak
porosity of graft (4 is from the pore)
158
Type 5 endograft leak
endotension (pulsation of graft wall?)
159
most common endoleak type
2 - filling of sac via feeder artery (IMA or lumbar)
160
30-day mortality: endograft vs. open repair
less for endograft
161
long term aneurysm related mortality: endograft vs. open repair
same
162
graft related complications: endograft vs. open repair
high with endograft
163
why don't we place IVC filters supra-renal
theoretical risk of renal vein thrombosis
164
when do we place supra-renal IVC filters (2)
pregnancy + clot in renals or gonadals
165
what do you do if the IVC is huge?
bird's nest type filter up to 40 mm (normal <28mm) or bilateral iliac filters
166
what happens to DVT risk with IVC filter?
goes UP (risk of PE goes down)
167
gunther tulip
IVC filter with superior end-hook for retrieval
168
simon-nitinol
low profile (7 F) filter, can be placed in small veins (arm)
169
are IVC filters MRI compatible?
yes, duh
170
2 bad complications of vertebroplasty
new vertebral fracture (25%) + cement can embolize to lungs
171
Dose (Gy) for early transient erythema
2 Gy
172
Dose (Gy) for chronic erythema
6 Gy
173
Dose (Gy) for telangiectasia
10 Gy
174
Dose (Gy) for dry desquamation
13 Gy
175
Dose (Gy) for moist desquamation
18 Gy
176
3 ways to repair groin stick pseudoaneursym
open surgery, direct ultrasound compression, thrombin injection
177
best projection for aortic arch
70 degrees LAO (candy cane)
178
best projection for innominate a.
RAO
179
best projection for left SCV
LAO
180
best projection for left renal
LAO (same as renal)
181
best projection for right renal
RAO (same as renal)
182
best projection for left iliac bifurc
RAO (opposite side)
183
best projection for right iliac bifurc
LAO (opposite side)
184
Right SFA/profunda
RAO (same side SFA)
185
Left SFA/profunda
LAO (same as SFA)
186
what replaces platelets?
more platelets
187
what reverses heparin
protamine sulfate
188
what reverses coumadin
Vit K (25-50 mg IM 4 hrs prior), more rapid with cryoprecipitate
189
half life of a platelet
8-12 days
190
antidote for versed (midazolam)
flumazenil
191
antidote for opioids
narcan
192
half life of TPA
2-10 min (very short)
193
max dose of local anesthesia (lido)
4-5 mg/kg
194
complication of lidocaine in thecal sac
total spine anesthesia + need for vent
195
complication of direct arterial injection of lido
immediate seizures
196
early signs of lido toxicity
tinnitus and dizziness
197
is sepsis a contraindication to IVC filter placement?
NO, not even septic thrombophlebitis
198
Y-90: high, medium, or low energy?
high. mean energy of 0.93 MeV
199
Y-90: what kind of emitter?
high-energy beta emitter
200
Half life of Y-90
64 hours. 94% of radiation delivered in 11 days (4 half-lives)
201
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.
202
embolic agent for UAE
particles in the range of 500-700 µm
203
rate of infection following non-tunneled line
5.3% per 1000 catheter days
204
single high risk vascular procedure
TIPS
205
4 high risk non-vascular procedures
biliary procedures (new tract), nephrostomy tube placement, renal biopsy, ablation
206
INR for high risk procedures
> 1.5, correct with FFP or vit K
207
INR for low risk procedures
> 2, correct with FFP or vit K (only need to check for patients on warfarin or with liver dz)
208
INR for moderate risk procedures
> 1.5, correct with FFP or vit K (same as high risk)
209
platelet count for high risk procedure
< 50K, transfuse
210
platelet count for moderate risk procedure
< 50K, transfuse
211
platelet count for low risk procedure
< 50K, transfuse (not routinely required to check)
212
what to do with aspirin for low risk procedure?
do not hold
213
what to do with aspirin for moderate risk procedure?
81mg ok, 325-->81mg for 5 day prior
214
what to do with aspirin for high risk procedure?
hold 5d
215
what to do with LMWH for low risk procedure?
hold 12h
216
what to do with LMWH for moderate risk procedure?
hold 12h
217
what to do with LMWH for high risk procedure?
hold 24h
218
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
219
hairpin turn during bronchial angiography
anterior medullary (spinal cord) artery
220
fever, WBC, Nausea + vomiting after UAE
post-embolization syndrome (or all of our patients)
221
most feared complication of bronchial artery embo
spinal cord infarct
222
3 things we don't drain
tumors, acute hematoma, things associated with acute bowel rupture/peritonitis
223
above this Cr, renal artery stenting doesn't work
Cr > 3
224
most common side effect of BRTO
gross hematuria
225
should you use a swan ganz for a thoracic angio
NO
226
procedure for acute Budd Chiari with fulminant livery failure
TIPS
227
treatment for pancreatiduodenal pseuodaneurysm
"sandwich technique" distal and proximal segments must be embolized
228
what size particles for embolizing mass hemoptysis
bronchial artery, particle > 325 um
229
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
230
what if you accidentally stick a drain in the colon?
wait 4 weeks for tract to mature, then remove
231
DVT + severe sx + no response to systemic anticoagulation
catheter directed thrombolysis
