VIR Flashcards

Question

Dake's Zilver PTX (Paclitaxil) studies (fempop)

Answer 1

DES superior to BMS with respect to patency and freedom from TLR. Clinical metrics (The Rutherford classification, ABI, and WIQ scores) improved in both the DES and PTA groups from pre-procedure to 2 years with no significant differences between the groups. Patients in the provisional DES group also sustained greater clinical benefit through 2 years compared with the provisional BMS group (83.9% vs. 68.4%). Provisional group had stents placed after acute PTA failure.

Answer 2

Self expanding BMS vs PTA as primary treatment of moderate-length lesions in the SFA and proximal popliteal artery. BMS associated with better angiographic results and improved clinical outcomes compared vs PTA. Rate of stent fracture was low and was not associated with any adverse clinical sequelae.

Answer 3

Background: The management of acute DVT by medical therapy with anticoagulation has long been supported by evidence-based clinical practice guidelines outlined in the American College of Chest Physicians supplement. Early thrombus removal in patients with iliofemoral DVT has been reported to lead to improved venous valve function, improved quality of life, and decreased incidence of postthrombotic syndrome over anticoagulation alone. The ATTRACT trial will randomize patients to medical management with standard anticoagulation versus catheter-directed thrombolysis in addition to standard anticoagulation after stratification to iliofemoral versus femoropopliteal DVT in order to determine the primary outcome of postthrombotic syndrome over a 24-month follow-up. Assessed clinical outcomes include 2-year PTS rates, health-related quality of life, relief of pain and swelling, safety, and cost effectiveness.

Answer 4

Covered vs SE BMSs stents for the treatment of aortoiliac occlusive disease. Result: in pts with aorta iliac occlusive disease, there is decreased restenosis and occlusion with covered stents vs BMS at 12 & 18 months.

Answer 5

I, “Viable": intact motor/sensory; audible arterial and venous Doppler in ankles. IIA, “Marginally Threatened”: no sensory loss or limited to the toes; inaudible ankle arterial Doppler (motor and venous Doppler WNL) IIB, “Immediately Threatened": sensory loss above level of toes; detectable muscle weakness; probable continuous rest pain. III, “Irreversible”: profound motor and sensory loss; inaudible arterial and venous Doppler. Can still occasionally be treated if able to treat within 1-2 hours of onset (emboli event). SENSORY FIRST TO GO.

Answer 6

I, “Viable": - Heparin and obs if multiple co-morbidities; - Endovascular (CDT & mech thrombectomy + tx of underlying lesion) if few co-morbidities. IIA, “Marginally Threatened”: Endovascular (CDT & mech thrombectomy + tx of underlying lesion). IIB, “Immediately Threatened": Surgery or Endovascular depending on available capabilities. Note, perceptible improvement in limb perfusion with CDT typically occurs well before complete thrombus removal and angiographic demonstration of a widely patent arterial lumen. III, “Irreversible”: Amputation. Co-morbidities generally treated first.

Answer 7

Embolism (75%): dramatic, immediate onset. Heart is most common source of emboli. Thrombosis (25%): gradual with collateral formation. Progressive ATH with ultimate plaque rupture and thrombosis.

Answer 8

1) Access 2) 9 sheath (use 45 cm is support needed) 3) 7 Fr Van Aman catheter to MPA & RPA 4) Rosen inserted through Van Amen 5) Van Aman exchanged for a 7 Fr White Lumax catheter system (7 Fr guide sheath and 5 Fr Tapered tip catheter like a Berenstein) which is used to sub select with either a Bentson or Glidewire or the 5 Fr tapered tip catheter. 6) Intervention then performed. Coiling, plugs and glue can be performed through the White Set. Alternatively, the tapered tip catheter in the white set can be exchanged for a 5 Fr pigtail for mechanical thrombolysis and tPA.

Answer 9

1) Ti: seen in submissive and massive when there is enough RV stain to cause leakage from myocytes. 2) BNP: Elevated with ventricular stretching as with PE, CHF and other causes of pulmonary HTN. 3) d-Dimer: measures a fibrin derivative. Superior sensitivity but alone is non specific. Positive also in pts with CA, infection, injury, inflammation. When d-Dimer negative in setting of low protest probability, imaging not necessary.

Answer 10

SBP < 90 mmHg (signifies cardiogenic shock)

Answer 11

1) Heparin 2) Systemic thrombolysis: 100 mg IV tPA over 2 hours. Must have no contraindications. Still carries 20% risk of major hemorrhage and 3-5% risk hemorrhagic stroke. 3) CDT with no or low-dose tPA (< 30 mg): when contraindications to systemic tPA or insufficient time to infuse full dose IV thrombolytics. Rate of major complications only 2.4% b

Answer 12

50-100 U/kg or 3000 U for small women, 5000 U for small man. ACT checked at baseline (nl 80-120s) with goal of 2.5x increase. Sheaths removed when ACT at baseline or < 200s.

Answer 13

Inactivates factor Xa. 5-7 hours. Can monitor anti-Xa levels.

Answer 14

1.0 - 1.5 mg protamine sulfate IV for every 100 IU of ACTIVE heparin, not to exceed 50 mg. OR As a general rule, 10 mg of protamine will neutralize 1000 units of heparin; the dose should be halved every 30 minutes after heparin administration. Example: Start with 50 mg protamine if 5000U Heparin given <15m, give 50 mg. At 30m, halve dose to 25 mg. At 60m, halve dose to 12.5 mg. At 90m, halve dose to 6.25 mg.

Answer 15

1) Catheter directed mechanical fragmentation: rotating pigtail fragmentation (can result in distal embolization and elevation of PAP requiring adjunctive aspiration thrombectomy to complete tx), mechanical devices (just know Angiojet can cause bradycardia and heart block and and has a black box warning). 2) Intraclot administration of tPA. Note if tPA given proximal to thrombus, currents will direct it away from the clot.

Answer 16

PE causing right heart strain without systemic hypotension. Right heart strain can be demonstrated via cardiac Biomarkers, EKG findings (ie. T wave inversions in leads 1-4), clinical findings (JVD), imaging findings (RV:LV > .9, tricuspid regurg).

Answer 17

1) Systemic tPA (100 mg/2 hours): off label for submissive PE; decrease in hospital death, clinical deterioration and development of chronic pulmonary artery HTN in patients with submissive PE treated with systemic tPA vs heparin alone. 2) Catheter placement and overnight thrombolytic infusion (total dose 1-2 mg/hr or 0.5-1 mg/hr each side) as mechanical debulking may not be necessary given hemodynamic stability.

Answer 18

1gm Ampicillin 80mg Gentamicin (check renal fx) 500 mg Flagyl * Then get ID approval for more long term treatment. If outpatient and just a fever, can give 10 days cipro 500mg BID.

Answer 19

1) 4 mg tPA in 50 cc NS over 1 hour 2) 4 mg in 10 cc NS to dwell 3) Venogram to look for sheath/kink, strip it

Answer 20

4 mg tPA/20 cc NS for 2-4 hours, roll pt, then open.

Answer 21

Triglycerides Lymphocytes Cholesterol

Answer 22

Reglan 10mg QID Or Thorazine 10mg TID (hallucinations)

Answer 23

Ice and Bactroban ointment.

Answer 24

30 mg IV q6h

Answer 25

AVFs: best patency rates although PTFE grafts outnumber AVFs 2:1.

Answer 26

Tunneled: 1) Exit site infection with (-)BCx, (-) systemic, (-) tunnel d/c: Topical Abx and local care or oral Abx. If tunnel drainage, Cx and administer IV Abx based on C&S. 2) Bacteremia in stable pt: Overwire exchange and retunnel. 3) Catheter related bacteremia, unstable pt: Remove. 3) Catheter related bacteremia in patient who is afebrile w/in 48h and is clinically stable: can attempt catheter salvage with interdialytic Abx lock solution and 3w IV Abx. Temporary: Remove if catheter related bacteremia.

Answer 27

1) PTA 2) Elastic central vein stenosis that does not respond to larger balloon or prolonged PTA or if stenosis recurs in 3 months.

Answer 28

- Determine RCC subtype. - Dx lipid poor AML. - Improved efficacy calculation for academic purposes.

Answer 29

The edges of the visible ice ball represents the 0 degree isotherm and is not lethal. As such the margins of the ice ball should extend 5-6 mm (optimal 1 cm) beyond the margins of the tumor. This ensures that the tumor is frozen to at least -25 degrees Celsius.

Answer 30

10 minute freeze 8 minute thaw 10 minute refreeze

Answer 31

- Elderly or those with increased bleeding risk. | - Large masses requiring multiple cryo probes.

Answer 32

TOP 3: Hemorrhage, Nerve Injury, Hematuria 1) Hemorrhage is MC (can restart anticoag 2 days after RFA but Coumadin should be held for 2 weeks due to risk of delayed bleeding - bridge with Lovenox) 2) Nerve Injury (in 15%): intercostal and genito-femoral. Usu self limiting. 3) Hematuria (10-20%): Self limiting. Make sure pt can void. Bladder irrigation prn. 4) PTX when the probes cross the pleura. 5) Urethral injury (can place double-J pre procedure for 4-6 weeks). 6) Adrenal crisis if the lesion is close to the adrenals: Premed with alpha and beta blockers for at lease a week.

Answer 33

Contrast enhanced MRI or CT at 1, 3, 6, 12, 18, and 24 months, and annually thereafter. 15-20% of cases show some persistent, peripheral enhancement in the ablation zone without residual tumor in the first few months; nodular or central enhancement or an increased size of the lesion is not normal and suggests residual or recurrent tumor, potentially requiring retreatment.

Answer 34

Comparable to surgery with early stage disease.

Answer 35

Demerol 25 mg slow IV push every 20 minutes until controlled. Up to 2 doses then try Dilaudid. Dilaudid 1 mg IV

Answer 36

NV-H Intra-arterial: 200 mcg Nitroglycerin, 2.5 mg Verapamil, 3000 units Heparin given directly into the sheath post placement. EMLA cream 30 to 60 min before procedure.

Answer 37

1) Patient instructed to clench fist for 30 seconds. 2) Examiner then compresses the RADIAL and ULNAR arteries simultaneously. 3) Patient asked to open 4) ULNAR artery is released. 5) Time needed for maximal palmar blush to return is recorded. Normal time for return of palmar blush: 5–10 seconds is typically considered normal (ie, a positive modified Allen test) and indicates adequate collateral circulation.

Answer 38

Often first branch off anterior division or may share common trunk with the superior vesicle artery. Had descending, transverse and ascending segments which allows it to be distinguished from the SVA or inferior gluteal aa which descend distally.

Answer 39

1) Gastric varices have a higher flow rate and mortality vs. esophageal varices. 2) < 8 mmHg for refractory ascites; < 12 mmHg for esophageal varices. 3) No, gastric varices still demonstrate a high rate of bleeding post TIPSS even at pressure gradients < 12 mm Hg. 4) Venous access into the gastro-renal shunt via the L renal and adrenal veins. Occlusion of the outflow veins using an occlusion balloon followed by the injection of a sclerosing agent directly into the varix endovascularly.

Answer 40

Inject saline or 100 ug nitroglycerine.

Answer 41

At 2 years: stent grafts proved as safe as balloon angioplasty and more effective in terms of treatment area and overall access patency (decreased need for repeat intervention and longer time to subsequent intervention).

Answer 42

1) ~75% on the left 2) ~75% at level of 9th-12th intecostal artery 3) From the radiculomedullary branch of the posterior branch of the intercostal or lumbar arteries. 4) 1mm NOTE: Bronchials most commonly have have 2L, 1R and occur at T5-6.

Answer 43

The superimposition of a stored image over a live fluoroscopic image.

Answer 44

Technique to catheterize ipsilateral uterine artery. GS uses a 5F Cobra 2 glide catheter.

Answer 45

1) 5d to INR

Answer 46

1) 5 days | 2) Not held

Answer 47

1) 2-4 hrs and check aPTT to goal <1.5x | 2) On call to IR

Answer 48

1) 2 doses or 24h 2) 1 dose or 12 hours 3) Immediately with lowest risk procedures once hemostasis achieved. 24-72 hours for highest risk procedures.

Answer 49

5d in general. If high priority low risk (venous interventions, IVC filter, tube changes), can hold 0-5d.

Answer 50

1) 2 to 5 days based on CrCl (2-3d if CrCl > 50, 3-5d if

Answer 51

1) Based on NSAID half-life. Ibuprofen (short t 1/2) held for 24 hours). Naproxen & Celecoxib (intermediate t 1/2) held 2-3 days). Meloxicam (long t 1/2) held 10d. 2) Not held

Answer 52

1) Defer until off medication. If emergent, try and hold for 2-3h for CrCl > 50, 3-5h for CrCl

Answer 53

1) 4 hours | 2) Held until just before punctur

Answer 54

1) Flush microcatheter with D5W 2) Administer lipiodol:glue suspension (we used 3:1 for renal paeudoaneurysm - more glue = more viscous/thicker) 3) Follow with D5W flush 4) Remove microcatheter

Answer 55

1) SE BMS (e-Luminexx to 14 mm, Zilver Vena to 16 mm). 2) No consensus. - JHH: one month if no DVT. - (+)DVT, 3 month recommended provoked tx. - Chronic DVT or aggressive stenting (ie. to lesser troch): AC for up to 1 year may be required.

Answer 56

Self-expanding stents: SMART (Cordis), eLuminexx (Bard), Zilver PTX drug eluting (Cook), Zilver Vena (up to 16 mm diameter), Life stent (Bard), Wallstent (Boston Scientific). Self-expanding stent grafts: Viabahn (Gore), Fluency (Bard), Wallgraft (Boston Scientific). Balloon-expandable stents: Palmaz (Cordis), Express (Boston Scientific) Balloon-expandable stent grafts: I-cast (Atrium Medical)

Answer 57

Because even with an extended L hepatectomy (2,3,4,5,8) and caudate lobectomy, we are still left with a FLR of 33%. Future Liver Remnant

Answer 58

20% if normal function to 60% with cirrhosis.

Answer 59

Contralateral (access L to embo R): risks damaging FLR and thrombosing good PV. Ipsilateral approach: access R to embo R.

Answer 60

1) n-butyl cyanoacrylate (NBCA) and lipiodol, 2) Fibrin glue, 3) Ethanol, 4) Microparticles such as PVA or trisacryl gelatin.

Answer 61

1) FLR growth rate > 2%/wk post embolization associated with lower complication rates than <2%. 2) 4 weeks post PVE

Answer 62

- n-BCA (glue) w/ piercing cap - Tantalum Powder (gray metallic to opacity) - Ethiodized oil

Answer 63

3 months AC for provoked DVT - Initiation with Heparin, LMWH or Fondaparinux (days 1-7, minimum 5 days or INR > 2.0 for 24h) - Acute phase tx: Oral AC (d1-m3) Then stop, or Secondary Prevention phase: targets new clot. Only needed if high enough risk for new clot formation.

Answer 64

- Serial US (qw x 2w) if no severe sxs. OR - Anti coagulation if severe sxs or risk factors (Dd, CA, prior clot)

Answer 65

1) When clot is proximal to the axillary vein? 2) Same as LE DVT - minimum duration 3m. If catheter-associated (ie. PICC): Can AC for 1 wk to stabilize clot, then remove. Or can leave in place during AC tx if access required.

Answer 66

Choose initiation dose: warfarindosing.org (complex calc)

Answer 67

- AC contraindicated - Failed AC - Low CPR

Answer 68

1) 3 months | 2) Workup required with possible secondary prevention AC beyond 3 months.

Answer 69

ASA 81 mg qd | Plavix 75 mg qd

Answer 70

1) ASA 81 mg qd AND Plavix 75 mg qd | 2) 300 mg procedural loading dose OR start 75 mg day prior

Answer 71

Covered stents don't influence patient survival but do demonstrate superior primary patency, decreased tumor in-growth and require fewer re-interventions, thereby affording a QOL.

Answer 72

Injection of cement under high pressure into a VB compression fx.

Answer 73

- Wallflex (covered and uncovered with retrieval loop) - Viabil - E-Luminexx BMS (done x1)

Answer 74

Injection of cement into a VB compression fx following ballooning of the fx.

Answer 75

5 - 5.5 cm

Answer 76

Falsely elevates it.

Answer 77

- >1.4: sig arterial wall Ca (DM, CRF) - Normal: 1 - Intermittent claudication: < 0.6 - Ischemic rest pain: < 0.4 - Impending tissue necrosis: < 0.1

Answer 78

Elevate them.

Answer 79

1) 4 cuffs used - prox thigh, above knee, below knee and above malleolus. 2) Gradient should drop no more than 10-12 mm between each level. 3) Cuffs should be 20% wider than diameter of limb at that level. 4) Falsely elevated.

Answer 80

1) DDx - PAD - Venous claudication - Spinal stenosis - Neurogenic claudication - Chronic exercise induced compartment syndrome 2) Pain with standing and coughing, relieved by leaning forward, takes a long tim to abate post cessation of exercise.

Answer 81

Triphasic with brisk systolic upstroke, reverse flow component early in diastole and low end-diastolic forward flow. This reflects high end organ resistance to flow in the resting extremity.

Answer 82

1) A decrease in the absolute ankle pressure of 20mm Hg or 20% Or 2) A decrease in the ABI of 0.2 in the symptomatic extremity after exercise testing.

Answer 83

1) Reverse flow component is lost first. 2) Rise in systolic upstroke decreases. 3) The amplitude of the waveform decreases. 4) Diastolic flow increases relative to the systolic flow.

Answer 84

Combines grey scale (B-mode) and color Doppler. B-mode allows plaque visualization and localization of the artery which permits precise placement of the Doppler sample volume at a known angle (60 degrees best) to the artery being examined. Knowing the angle allows for calculation of frequently shifts, velocities and degree of stenoses.

Answer 85

Spectral broadening and elevated PSVs.

Answer 86

Generally 5 days. Can be adjusted based on risk of procedure and need.

Answer 87

DCB: - Fewer TLRs vs PTA - Better 12m primary patency (82% vs 52% w PTA)

Answer 88

Sheaths should receive continuous infusion of NS at 30 mL/hour to prevent sheaths from clotting. Heperanized saline should be given through infusion catheters if tPA is stopped for any reason.

Answer 89

1) Use Ropivicaine (longer acting) or Lidocaine ( shorter acting) to confirm location. 2) No, Bupivacaine is chondrotoxic. 3) Bicarbonate will precipitate.

Answer 90

Oxycodone Zofran prn Pantoprozole 40 mg 4 weeks

Answer 91

Stage 1 & 2: surgery Stage 3a: surgery, chemo & RT Stage 3b: chemo & RT Stage 4: palliative chemo Surgery dropped first then RT

Answer 92

Has not been investigated but could potentially be used to treat limited peripheral Stage 1 SCLC.

Answer 93

Stage 1 & 2 NSCLC in inoperable candidates (do not meet pulmonary criteria for lobar or sublobar resection - FEV & DLCO > 60%).

Answer 94

1) Non surgical candidates | 2) Pts with recurrent or residual disease after surgery, chemo or RT.

Answer 95

1) Solitary 2) Completely intra-parenchymal 3) < or equal to 3 cm (best rate of necrosis - else use multiple probes) Also: < 6 lesions in the case of multifocal disease, no continuity with the hilum or vital mediastinal structures, such as the trachea, esophagus, heart, aorta, and great arteries.

Answer 96

At least 5 mm rim of ground glass around lesion through 1 cm+ is preferred.

Answer 97

At least 1. 2 if multiple probes.

Answer 98

Advantages: 1) No grounding pads/skin burns, 2) No nerve pain, 3) Quicker (probes heat faster), 4) Less heat sink (probes heat faster). Disadvantages: 1) Higher cost, 2) Less predictable ablation pattern, 3) Interference with PMs and AICDs (will need cardiology to reprogram/disable or externally pace)

Answer 99

Electrodes should be placed no further than 2 cm apart and no further than 1 cm from the margin of the tumor (on the inside). Kelvin ablation article pg 242 fig 2.

Answer 100

Stimulation of the intercostal nerves.

Answer 101

Proper hepatic aa (post GDA) Less commonly the common hepatic.

Answer 102

1) > 6h 2) Patients initially improve post intervention but a few hours later deteriorate 3) Fasciotomy

Answer 103

``` 6 Ps Pain Pallor Parenthesis Paralysis Poikilothermia (impaired temp regulation) Pulselessness ```

Answer 104

Universally reproducible: occurs when walking X distance (vs OA pts have good and bad days) Relieved by rest: not necessarily sitting (as seen with spinal stenosis, sitting alleviates pain) Pain located within muscular bed, not joint.

Answer 105

Smoking cessation Can improve walking distance and decrease progression to rest pain. Also decreases cardiac and cerebrovascular related mortality.

Answer 106

Smoking cessation: Can improve walking distance and decrease progression to rest pain. Also decreases cardiac and cerebrovascular related mortality.

Answer 107

1) 3-6 months 2) No clear guidelines to define failure. Based on lack of enough sx improvement or sx progression. 3) Inflow dz (ie. aortoiliac, femoral, SFA, profunda). Sxs will resolve in 85%. If poor response then address multilevel disease.

Answer 108

``` ABCD A: ASA B: Beta-blockers C: Cholesterol lowering meds D: Diabetes regimen ``` -target LDL t get into managing these meds.

Answer 109

1) Clinical staging system for describing PAD. 2) Based on presence of claudication, rest pain, tissue loss. ``` 3) 7 Stages (0-6): Stage 0 – Asymptomatic Stage 1 – Mild claudication Stage 2 – Moderate claudication Stage 3 – Severe claudication Stage 4 – Rest pain Stage 5 – Ischemic ulceration not exceeding ulcer of the digits of the foot Stage 6 – Severe ischemic ulcers or frank gangrene ``` The distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.

Answer 110

Fibrous tumors: best treated with the innermost -40 degree isotherm Water-containing tumors: can be treated using the -20 degree isotherm.

Answer 111

Advantages: 1) Doesn't interference with PMs and AICDs 2) Lower subjective pain especially with subpleural or juxtapleural lesions 3) Spares collagenous structures and safer to nerves and bronchi Disadvantages: 1) Poor visualization of ice ball in lung 2) Increased risk of hemorrhage

Answer 112

1) Electrodes should be placed no further than 2 cm apart and no further than 1 cm from the margin of the tumor (on the inside). 2) Edge of ice ball is 0 degree isotherm and does not kill tumor. Goal is to have edge of ice ball 5-10 mm beyond tumor margin, which represents -20 degree isotherm.

Answer 113

Cough, hemoptysis (62%), fever, and HTN. Pulmonary hemorrhage: Occurs during thaw cycle and on repositioning of the cryoprobe after the initial ablation cycle. Don't reposition. This is why Coumadin held for 2 weeks with cryo. Hemoptysis: seen with greater frequency in cryo than the other 2 modalities (62%). Typically, self-limiting. HTN: Unique to cryo. If preexisting HTN, ensure proper blood pressure control.

Answer 114

- PTX - Post ablation syndrome - Pleural effusions - Hemothorax - Hemptysis - Nerve pain - Bronchopleural fistula PTX: Seen in 25%-35% of patients of RFA pts. 10%-20% of these patients require chest tube. Rates similar in microwave and lower with cryoablation. Postablation syndrome: mild fever, cough with rust colored sputum, chills, pain, nausea, and malaise. Can last 1-7 days. Can be seen in 36% of RF pts, 2% of microwave pts. Not seen in cryo pts. Tax with antipyretics, pain control, antitussives. Pleural effusion: seen in all 3 ablation modalities. Hemothorax less common but can be fatal. Hemoptysis: most common with cryoablation. Bronchopleural fistulas: seen in 0.6% of patients. Tx includes pleurodesis, endobronchial mgmt or surgical repair.

Answer 115

Patients with COPD retain CO2. High CO2 normally stimulates breathing. This is blunted in COPD pts and instead low O2 drives respiration. When supplemental oxygen is given to a COPD pt, they are at risk for respiratory depression.

Answer 116

1) Painful lesions (pleura, chest wall) 2) Can't lie flat 3) Lung disease/breathing problems

Answer 117

Monitoring in PACU. CXR at 2 hours and 4 hours post procedure. D/C with Ibuprofen or other anti-inflammatory x5 days to reduce inflammation, pain, pleural effusions, and systemic inflammatory response. NOTE: postprocedural low-grade fever for 2-3 days is not uncommon. No air travel for 3 weeks as cabin pressure can predispose to PTX.

Answer 118

1) A coagulopathy associated with large and/or deep venous malformations that affect any location. 2) Lesions with elevated D-dimer and low fibrinogen levels (severe LIC) have the highest risk of hemorrhage. 3) Presence of a palpable phlebolith increases the risk of LIC. 4) LMWH can be used both to treat the pain caused by LIC and to prevent decompensation of severe LIC to DIC.

Answer 119

1) Treatment can be curative with stage 1a and 1b NSCLC. 2) Range: 70-90% for early stage NSCLC or recurrent NSCLC and mets. 3) Determinants of survival for mets: - Baseline tumor size and type, - # of mets (pulmonary and non) and size - Control of the primary 4) Comprable.

Answer 120

Formed by the union of the pancreatic duct and the common bile duct. Above sphincter of oddi.

Answer 121

1) Use a scapel to open the veno tommy site at the neck. 2) Grab the catheter with a clamp. 3) Cut catheter on tunnel side of clamp. 4) Stabilize venous side of device while removing over wire. 5) Place appropriately sized peel away sheath. 6) Remove tunneled portion of old catheter. 7) Retunnel new device.

Answer 122

1) Who: All HBV pts and HCV patients with cirrhosis or fibrosis. 2) AFP and US 3) q6m

Answer 123

Fibrin degradation product present in the blood after a blood clot is degraded by fibrinolysis. Comprised of two crosslinked D fragments of the fibrin protein. Fibrinogen is fibrin precursor. It is decreased when the clotting cascade is activated.

Answer 124

PREPIC 1: RCT in pts with proximal DVT showing that permanent vena cava filters reduced the incidence of PE but increased that of DVT at 2 and 8 years. The filters had no effect on survival. PREPIC 2: study of retrievable filters of which 92% were successfully retrieved at 3 months.

Answer 125

Posterior division: Iliolumbar artery Lateral sacral artery Superior gluteal artery

Answer 126

Inferior and superior EPIGASTRIC ARTERIES: arise from external iliac artery just above inguinal ligaments and ascends medially. Ascending branch of DEEP CIRCUMFLEX ILIAC ARTERY: arise from external iliac artery just above inguinal ligaments and ascends laterally.

Answer 127

1) Continuation of the IAA into the thigh through the greater sciatic notch. It can be bilateral in up to 25% of cases. 2) Buttock aneurysms, ischemic embolic disease, early atherosclerosis.

Answer 128

1) Iliac PTA or Stenting. DAT Duration? - Lifelong ECASA - 1m DAT for PTA or stent (>1m it poor inflow/outlfow, CLI.) **COBEST recommended minimum 1m. We did 3m DAT in COBEST kissing stent pt given signs of CLI and also because covered stents warrant longer AC. COBEST showed covered stents are better vs. BMS for TASC C/D Aortoiliac lesions in terms of patency and clinical outcomes. 2) Fempop PTA/stent. DAT Duration? - Lifelong ECASA - 1-3m with PTA or BMS if stent > 7 mm * **Consider >3 months if: - poor runoff (would apply to BK interventions) - CLI - long occlusion - Tasc C/D - High risk of stent fracture - > 6m with covered stent or with stent lumen <7 mm

Answer 129

Looks at max linear dimension of lesion on imaging to determine if a cancer patient responded to treatment (Categories: "respond", "stable" or "progression").

Answer 130

- Barbeau D waveform - Small radial artery - Pts w AVF or those nearing dialysis Barbeau D: loss of tracing without recovery within 2 minutes)

Answer 131

3 Fr = 1 mm

Answer 132

1) Primary and secondary endpoints: In-office and 24h ambulatory BP at 6m. 2) No. SBP decreases were only in the order of 2 mmHg. 3) 3 year data showed a statistically significant decreases in SBP of -33 and DBP of -14 mmHg.

Answer 133

1) 2-6 mmHg 2) 25/5 3) 25/10, mean < 15 4) 4-12 5) 70-105 2-6, 25/5, 25/10, 4-12, 70-105

Answer 134

1) True 2) Must differentiate gastric wall stain from tumor blush within the left hepatic lobe when injecting LHL vessels. Inadvertent delivery of chemo into an accessory LGA can cause gastric ulceration and necrosis.

Answer 135

1) Test used to assess dual hand circulation. Uses plethysmography (venous waveforms) and pulse ox to improve on the sensitivity of the modified Allen test. 2) Steps: 1) Pulse Ox placed on ipsilateral thumb and morphology of tracing noted. 2) examiner then occludes RADIAL aa, noting any change in tracing and SO2. 3) Grades Type A: no change in height of tracing even after 2 minutes. Type B: dampening of the pulse tracing. Type C: loss of tracing followed by recovery within 2 minutes, representing the recruitment of collaterals. Type D: loss of tracing without recovery within 2 minutes. 4) Only Type D is a contraindications to the procedure.

Answer 136

From the proximal segments of multiple hepatic arteries including the PHA, main LHA, main RHA.

Answer 137

1) PHA, then LHA 2) Descends to PYLORUS then runs R to L along lesser curve to anastamose with the LGA. 3) GD ulceration and necrosis. Prophylactic embolization should be considered.

Answer 138

Aorta, just above the celiac trunk. Directly from the celiac trunk as common trunk.

Answer 139

1) Compared bypass-surgery to PTA in patients with severe infrainguinalischemic disease. Outcomes: Short-term: surgery is more expensive and has higher morbidity. Medium term: outcomes similar with respect to amputation-free survival, all- cause mortality and HRQL. Long term (>2y): surgery may be more durable.

Answer 140

1) Replaced RHA from the SMA (12%) - mC than accessory | 2) Replaced = Accessory LHA from the LGA (8%)

Answer 141

1) A hilar artery that primarily supplies hepatic segment 4. 2) Arises from the RHA or LHA in 80%. **In livers w/ replaced LHA, the MHA originates from the RHA; in livers that had a replaced RHA, it originates from the LHA.

Answer 142

1) Arises as terminal branch from LHA or MHA. 2) Courses rightward over short segment, then leftward over longer segment towards the umbilicus. Communicates with branches of the IMA and Superior Epigastric Arteries.

Answer 143

RHA. Less commonly from the replaced/accessory RHA, the LHA, CHA, GDA. Has two branches.

Answer 144

From microscopic biliary plexus that is seldom visualized angiographically. Arises from corresponding hepatic artery branches. May dilate when supplying tumor invading the biliary tree or portal vein.

Answer 145

RHA. Less commonly from a replaced/accessory RHA, the LHA, CHA, GDA. Has two branches.

Answer 146

1) Arises from GDA branches, specifically the anterior superior pancreaticoduodenal artery and the posterior superior pancreaticoduodenal artery. 2) Components: - Anterior PDA: formed by anterior superior pancreaticoduodenal artery, the smaller of the two end branches of the GDA. - Posterior PDA: formed by posterior superior pancreaticoduodenal artery, usually the first branch off the GDA. 3) Supplies head of pancreas and duodenal C loop. 4) The most common collateral pathway from the SMA to the celiac. The two arcades either unite with the SMA via a separate inferior PDA given off by the SMA or end in a common inferior PDA.

Answer 147

1) Runs along anterior margin of liver, dividing the LHL into medial and lateral segments. 2) In cirrhosis, the position of the ligament is shifted to the right pulling the artery with it.

Answer 148

Both contain 15 cm access needles, 0.018 wires and three part introducers (inner stiffening cannula, introducer and outer sheath). Jeffrey: 8 Fr sheath can accommodate two 0.038 wires or a 5 Fr catheter and 0.018 wire. Neff: 6 Fr sheath and can accommodate one 0.038 wire or a 4 Fr catheter.

Answer 149

6 Fr peel away for a Hohn.

Answer 150

Closing of the aortic valve.

Answer 151

1) Radial-cephalic at wrist or brachial-antecube, cephalic or transposed basilic in upper arm. 2) 85% patency at 2y vs 50% grafts. 3) Require serval months to mature with 30% fail rate.

Answer 152

An anastamotic stenosis.

Answer 153

A venous stenosis along the outflow limb.

Answer 154

A central stenosis.

Answer 155

True and the bruit becomes high pitched in the presence of a stenosis.

Answer 156

1) Venogram from access through micro-puncture directed towards venous outflow with imaging from the arterial anasatmosis to the RA. 2) Heparinize, then upsize to 5 or 6 Fr sheath over a 0.035 wire. 3) Yes. Apply gentle pressure or purse string.

Answer 157

6-8 mm high pressure ballon depending on the known diameter of the graft.

Answer 158

6-8 mm or whatever is appropriate visually.

Answer 159

Multiple, slow, prolonged inflations.

Answer 160

Cutting balloons.

Answer 161

1) Stent them 2) No, due to fracture. Stent grafts improve patency of venous anastamotic stenosis in AVGs and may have advantages in central veins as well.

Answer 162

1) No 2) 30% at 12m 3) 90%

Answer 163

1) Acute thrombosis: responds to pharmachomechanic thrombectomy. 2) Dissection: prolonged balloon inflation or stent placement. 3) Rupture: 10-15 minutes of manual compression, else prolonged balloon inflation or stent placement across the site.

Answer 164

A stenotic lesion (must ID and address).

Answer 165

To prevent reflux of thrombus into the arterial circulation.

Answer 166

True. This can be determined by advancing a 5 Fr catheter centrally while injecting contrast until patent vessels are found.

Answer 167

1) Patients with a suspected graft infection 2) Severely limited cardiac reserve (2/2 small PEs that result) 3) Patients with R to L shunts due to risk of paradoxical emboli. 4) Severe pulm HTN 5) Patients emergently requiring HD 6) Two declots in previous month - refer for revision 7) Clotted fistula with cannula site ulcer (eschar can rupture giving fatal hemorrhage) 8) Enlarged aneurysmal fistula with extensive clot burden (could give fatal PE) 9) Clotted fistula in presence of known Distal Hypoperfusion Ischemic Syndrome (DHIS - when high flow through AVF/AVG steals flow from hand).

Answer 168

Heparinize FIRST! Pulse spray: involves forcefully injecting tPA through two multi-sidehole catheters one in each direction. The jets fragment the clots while the tPA lyses. Progress checked via small contrast injections. Once adequate lysis, PTA venous anastamosis and pull plug through arterial. Lyses and wait: Insert small access in direction of venous outflow. Compress proximal and distal ends of access (arterial and venous anastamosis in graft or arterial anastamosis and distal venous outflow limb in AVF) while slowly injecting 5 mg tPA (5 ml). Wait 15-30 minutes. Upsize to 5-6 Fr sheaths in both directions in order to PTA venous anastamosis and pull plug through arterial. Angiojet

Answer 169

1) A network of veins parallel to skin surface (between the saphenous fascia and dermis) that drain the lower extremity skin and SQ tissue though saphenous tributaries or deep veins via perforators. 2) Dilated, nonpalpable, blue dermal veins,

Answer 170

1) Arises from medial aspect of dorsal pedal venous arch, ascends anterior to the medial malleolus, crossing the tibia at the mid calf, passing posteromedial to the knee. Ascends medially in the thigh to perforate the deep fascia and join the common femoral vein 3 to 4 cm inferior and lateral to the pubic tubercle. 2) Bordered superficially by the saphenous fascia and deep by the muscular fascia. Lies within a subcompartment referred to as the 'Egyptian eye'. 3) Anterior to the GSV in the calf and may be injured by procedures extended into the calf. 4) Yes. It is identified by splitting of the vein into two channels, both lying on the muscular fascia and which later rejoin. Present in the thigh in 8% and in the calf in 25% of cases. 5) True. Lack of fascia support in these areas has been suggested as a cause of varicose veins, which most frequently occur above the level of the superficial fascia.

Answer 171

1) Anterior branch (of the GSV or GSV proper) and the posterior arch (Leonardo’s vein) 2) Begins behind the medial malleolus and joins the GSV just distal to the knee. 3) Drains a network of medial ankle veins and is important in that the posterior tibial perforators join this vein rather than the main trunk of the great saphenous vein. Procedures directed toward the greater saphenous vein in the calf will not address these perforators.

Answer 172

Anterior and posterior accessory saphenous veins. Ascend parallel to the great saphenous vein, external to the saphenous fascia.

Answer 173

Superficial external pudendal, circumflex iliac, and epigastric veins. Join the GSV near the saphenofemoral junction.

Answer 174

Yes, in 94%-100% of individuals. Yes, The main trunk of the GSV usually has at least six valves. Varicosed GSVs have slightly fewer valves although the relevance of this observation is unclear.

Answer 175

1) Arises from the dorsal pedal arch, ascends posterior to the lateral malleolus ultimately joining the popliteal vein within 8 cm of the knee joint (~60%). In the remainder of pts, 20% join the GSV via the anterior and posterior accessory saphenous veins in the thigh and 20% join the deep venous system. 2) Yes, 7 to 10 closely spaced valves. 3) The sural nerve.

Answer 176

A cranial extension of the small saphenous vein that ascends posteriorly in the thigh to communicate with the great saphenous vein through the posterior thigh circumflex vein.

Answer 177

The major deep veins of the lower extremity follow the course of the associated arteries and, with the exception of the femoral vein, are named accordingly. External iliac vein - inguinal ligament - common femoral vein - SFJ - femoral vein, popliteal vein, AT/PT/peroneal veins. The deep vein extending from the popliteal vein to the common femoral vein is now referred to as the femoral vein rather than the superficial femoral vein. The phrase ‘‘superficial femoral vein’’ has been abandoned in current nomenclature.

Answer 178

1) Greater than 60 perforators between the ankle and the groin. 2) Direct: Empty into deep veins; Indirect: Empty into venous sinuses of the calf. 3) Superficial to deep via valve directed flow? Foot perforators which drain deep to superficial. 4) Calf perforators: 1. Paratibial perforators: connect GSV and PTV. 2. Posterior tibial perforators: connect post arch and PTV. 3. Lateral perforators. 4. Anterior perforators. The medial calf perforators, including the paratibial and posterior tibial perforators, are clinically most important. Eponyms Sherman, Boyd, Cockett no longer used. Many paratibial perforators may not be accessible with subfascial endoscopic perforator ligation unless the fascia between the superficial and deep posterior compartments is incised. 5. An ~3-cm wide imaginary lane ascending the medial calf along which the majority of the medial calf perforators (para and posterior) exist. 6. The perforators of the femoral canal (hunterian perforators) connect the GSV and the distal femoral or proximal popliteal vein. These perforators may give rise to medial thigh varicosities in the presence of a competent proximal great saphenous vein.

Answer 179

The muscular venous sinuses are the principal collecting system of the calf muscle pump. There are soleal and gastrocnemial intramuscular venous sinus networks which communicate with the PTV and pop.

Answer 180

Clinical Etiology Anatomic distribution Pathophysiology 1) 7 Clinical disease classes based on objective signs from asymptomatic to active ulcers. C0: no visible or palpable signs of venous disease. C1: telangiectasies or reticular veins. C2: varicose veins. C3: edema. C4: skin changes without ulcerations. C4a: pigmentation and eczema (stasis dermatitis). C4b: lipodermatosclerosis and atrophie blanche. C5: healed venous ulcer. C6: active venous ulcer. S: symptoms including ache, pain, tightness, skin irritation, heaviness, muscle cramps, as well as other complaints attributable to venous dysfunction. A: asymptomatic. 2) Etiology: Congenital, Primary, or Secondary. Congenital causes include things like absent valves. Primary venous disorders are not associated with an identifiable mechanism of venous dysfunction (likely just degenerative). In contrast, secondary venous disorders result from an antecedent event, usually an episode of acute deep venous thrombosis (DVT). 3) Anatomic distribution: 18 venous segments. 4) Pathophysiology: whether related to reflux or obstruction.

Answer 181

- Degenerative processes (primary venous disease). - DVT (secondary venous disease). - Absent valves (congenital).

Answer 182

Dilated, palpable, tortuous, > 4 mm, do not discolor the overlying skin. The major saphenous trunks are often incompetent with varicose veins. vs. Reticular (Dilated, nonpalpable, blue dermal veins, < 4 mm, without saphenous trunk abnormalities).

Answer 183

1) 50% 2) Leg pain, heaviness, itching, swelling, redness, and ulcers (sores). Approximately 2/3 of pts with ulcers have multi segmental disease (involving the deep, superficial, and perforating veins). 3) DVT causes obstruction, pressure buildup, valve damage, resultant reflux, delayed venous filling and pooling of blood. 4) Treatment: anti coagulation, compression stockings, wound care.

Answer 184

Used to assess the prognosis of chronic liver disease and cirrhosis. BA-PEA: - BIli - Ascites - PT - Encephalopathy - Albumin Points Class 1y surv 2y surv 5-6 A 100% 85% 7-9 B 81% 57% 10-15 C 45% 35%

Answer 185

ABSOLUTE: - Severe pulmonary HTN (> 40 mm Hg) - Acute PNA. RELATIVE: - Inability to lie flat and breath hold (use GA) - Coagulation disorders - Pacemakers/AICD - Prior pneumonectomy (OK if RAPID chest tube can be placed).

Answer 186

Heparin held on call for low/moderate. Integrilin stopped at time of puncture for low risk. Bival not held for lowest. All held 2-4 hours for highest risk procedures.

Answer 187

HTN Also consider hemorrhage/hemoptysis as this also occurs with greater frequency in cryo patients.

Answer 188

1) Pushable and detachable. 2) 2-20 mm and straight for tiny vessels. 3) 35-5-10: will pass through a catheter that will accept a 0.035-inch guidewire; total extended length 5 cm; formed coil diameter will be 10 mm. 4) STEPS: - Position catheter. Advance guide or pusher wire to its tip to ensure stability. NOTE: micro catheters require a special pusher wire that is softer and flexible at the tip. - Load coil. Use hard end of pusher wire to advance coil well into catheter. Then flip wire and push with soft end. - Use smaller, shorter coils at the end to prevent covering vital branches.

Answer 189

Individuals who are hemodynamically stable (unstable = surgery) and who meet one of three criteria: 1) Active extravasation on CT, 2) Grade 3-5 with decreasing H/H, 3) Visualized vascular injury (ie. paeudoaneurysm, AVF) and decreasing H/H. AGAIN: Extrav is not required for SAE. A grade 3 or higher injury is sufficient.

Answer 190

1) Active bleeding and vessel injury (pseudoaneurysm, AVF). 2) Some authors recommend embolization based empirically on the CT findings (ie. grade III to V injury without angiographic evidence of extra or vascular injury). Others base the embolization more on the angiographic findings and clinical evidence for active hemorrhage. Note, the discrepancy may be due to cessation of bleeding which can recur or vasospasm so don't rule out prophylactic embolization.

Answer 191

1) Micropuncture access. 2) Celiac arteriogram through Sim 1 with particular attention paid to splenic artery and collaterals including the left gastric artery. 3) Splenic artery catheterization and splenic arteriogram. 4) Embolization - proximal vs distal.

Answer 192

1) Sub-selective embolization as close to the site of injury/etrav as possible utilizing a non high flow micro-catheter and wire combination (ie. Renegade STS catheter and Fathom 0.016). 2) Coils, glue, gelfoam, medium-size particles (300–500 μm).

Answer 193

1) Decrease perfusion pressure of the spleen while allowing splenic flow via collateral pathways. 2) Short gastric arteries, pancreatic arteries, gastroepiploic arteries (from GDA and splenic), splenic capsular arteries. 3) Just distal to the dorsal pancreatic artery origin (typically in proximal 1/3 of splenic artery). This allows for perfusion of the spleen via the dorsal pancreatic–transverse pancreatic–arteria pancreatica magna–splenic artery pathway (pathway may be more evident immediately after the embolization). 4) Complete absence of opacification of the splenic artery distal to the coils.

Answer 194

5 - 7 small gastric arteries arising from end of splenic artery.

Answer 195

Advantages? 1) Quicker 2) Less radiation 3) Less risk for infarction 4) Lower secondary splenectomy rate vs observation alone Disadvantage? 1) Can't re-intervene if coil pack placed proximally. Equal efficacy. As such, authors of this paper prefer to perform proximal embolization in trauma patients in nearly all circumstances.

Answer 196

Due to the risk of infection including fatal postsplenectomy sepsis.

Answer 197

1) Infarct 2) Infection/abscess 3) Splenic artery dissection

Answer 198

1) Active extravasation 2) Vessel injury 2) Pelvic fractures with hemodynamic instability and no clear source for the hemorrhage.

Answer 199

1) Multiple bleeding sites OR hemodynamically unstable patients with fxs in whom a source of bleeding cannot be ID'd. 2) Because of extensive collateral arterial circulation that is normally present within the pelvis. 3) In hemodynamically stable patients. 4) Selective embolization (occurring in 5-25%).

Answer 200

Artery, vein, bone Venous!

Answer 201

Administered to near-stagnation with resultant “pruned-tree” endpoint.

Answer 202

1) No 2) Buttock, thigh, and perineal paresthesia. Short term complications studied include: skin necrosis, sloughing, pelvic perineal infection, nerve injury. Long term complications studied include: claudication, skin ulceration, regional pain.

Answer 203

1) Active arterial extravasation. 2) Vascular injury (ie. pseudoaneurysm, AVF). 3) High grade organ injury with decreasing H/H.

Answer 204

In the setting of a pelvic fractures without a clear abdominal source for the bleed as deep pelvic bleeding is difficult to localize in the OR.

Answer 205

1) Coils, gel foam or glue. 2) Proximal gel foam embolization, especially in unstable patients. 3) Proximal and distal to the PA. 4) No. Increased pressure can lead to rupture. 5) Re-bleeding, infarction (rare in setting of patent portal vein), infection/abscesses, biliary/GB necrosis.

Answer 206

The posterior branches and the two terminal branches of the anterior IIA. In descending order: - Superior gluteal, - Internal pudendal, - Lateral sacral, - Iliolumbar, - Inferior gluteal arteries.

Answer 207

1) Contralateral IIA 2) IMA 3) Lumbar arteries 4) Median sacral 5) Inferior epigastric (from EIA) 6) Circumflex vessels - medial, lateral and deep (from EIA) 7) Variants

Answer 208

Variant obturator arising from either the EIA, inferior epigastric or CFA.

Answer 209

Compliance: the ability of a structure to stretch or increase in size with increasing pressure. Compliant balloons continue to increase in size with inflations.

Answer 210

Inject around a 0.018 guidewire using a Tuohy-Borst adaptor and 0.035-inch lumen guide catheter.

Answer 211

- Contained saccular out pouching of vessel - Equal density to the adjacent vessel - No evidence of extravasation - Washes out on parenchymal phase imaging.

Answer 212

1) Cessation of bleeding, vasospasm, venous bleed | 2) Provocative angiography with Nitro (OK in trauma b/c short t 1/2 of 3min) OR prophylactically embolize.

Answer 213

Temporary vs. Permanent Mechanical: coils, vascular plugs Particulate agents: PVA, Gelfoam Liquid agents: sclerosants (doxy, bleo), adhesives (glue)

Answer 214

1) Dorsal pancreatic artery arising from the celiac artery in 10%. 2) Replaced RHA from SMA (12%). 3) Corona mortis: obturator from the EIA, inferior epigastric artery (from EIA) or CFA.

Answer 215

1) Midline 2) Below the symphysis 3) Washes out (extrav persists)

Answer 216

1) Coils or glue (Get sub-selective) | 2) Infarction, abscess

Answer 217

DEB advantages in the PRECISION trial: - Decreased systemic and hepatic toxicity. - Superior overall response rates and disease control rates in the DEB group though differences not statistically significant. - The improved safety and tolerability profile allowed treatment to be repeated in more advanced cases where cTACE could not. NOTE: A recent case-control study conducted by Song in Asian patients with HCC confirmed higher ORR and DCR for DEB compared with cTACE

Answer 218

1) Tumor localization with a microcatheter. 2) Pretreatment DP-CBCT (early arterial and delayed phases in a single contrast injection - 5 sec manual delay at start). 3) Infusion: - 50 mg Doxorubicin/10 mg of Mitomycin-C in 10 mL + 10 mL Lipiodol in a 1:1 ratio (total 20 mL) - 20 cc of 1% Lidocaine - 100-300u Embospheres 4) Post treatment SP-CBCT to see distribution of lipiodol.

Answer 219

1) Tumor localization with a microcatheter. 2) Pretreatment DP-CBCT 3) Infusion: 100 mg of Doxorubicin loaded 100-300u beads suspended in contrast (2:1 - 4:1 contrast to DEBs). 4) Post treatment SP-CBCT to see distribution of contrast. NOTE: You can also follow treatment with a DP-CBCT and look for enhancement defects which prove those portions of the tumor were embolized.

Answer 220

- 10 mg Dexamethasone - 50 mg Benadryl - 8 mg Zofran - Antibiotic prophylaxis and PPIs at discretion of MD.

Answer 221

1) Gelfoam embolization. | 2) Procedure cannot be performed.

Answer 222

1) Slow (some advocate 1 cc DEB/contrast mix/minute. 2) Continue until near stasis in the feeding artery. Contrast column should clear within 2 to 5 heartbeats. 3) Bland embolization until injection end point reached OR schedule patient for repeat treatment.

Answer 223

1) Failure to achieve objective response in targeted tumor after two treatments. 2) Clinical deterioration to ECOG > 2 3) Hepatic decompensation (CP B8 or higher).

Answer 224

1) Decompensated cirrhosis - Child-Pugh B8 or higher (jaundice, clinical encephalopathy, refractory ascites, hepatorenal syndrome) 2) Massive tumor replacement of both lobes 3) Severely reduced portal vein flow 4) Untreatable AVF 5) Renal insufficiency (Cr > 2, CrCl < 30)

Answer 225

Yes. Studies have shown that time to progression (TTP) for cTACE/DEB plus Sorafenib was longer than the TTP seen in patients treated with TACE and placebo.

Answer 226

Identified based on branching pattern, no course. Three groups: First: - Uterine: desc, trans, ascending (deferential in males) - Superior vesicle: descending only - Obturator artery: thru obturator foramen Mid: - Inferior vesicle artery in males (prostate vessels) versus vaginal in females - Middle rectal artery Terminal branches: - Inferior gluteal artery: exits pelvis via greater sciatic foramen. - Internal pudendal artery: supplies genital branches including the dorsal aa of penis and scrotal vessels. Gives rise to the inferior rectal artery.

Answer 227

1) Doses in excess of 30 Gy can be toxic to adjacent liver parenchyma. 2) Pure B-emitter. 3) 2.5 mm (11 mm max). Yes, permits higher dosing of 100-150 Gy. 4) >70 Gy

Answer 228

``` SIR-Spheres (SRC-50): Composition: Resin Approved use: Colorectal mets Sphere diameter: 22u Dose/sphere: 50 Bq ``` ``` TheraSpheres: Composition: Glass Approved use: Unresectable HCC Sphere diameter: 32u Dose/sphere: 2500 Bq ``` Given the smaller per-sphere dose of SIR-Spheres, a significantly larger number of spheres must be administered to reach the intended dose. It is not uncommon for the entire vascular bed to become saturated with microspheres and an embolic state reached prior to delivering the entire dose. This also increases the risk of reflux, requiring prophylactic embolization of the RGA/GDA.

Answer 229

>30 Gy 50 Gy

Answer 230

- Aortogram - SMA angio w/ portal eval - Celiac angio - Prophylactic vessel embo (GDA/RGA) w/ SIR - 5 mCi Tc99m MAA administered into the vessel being treated (image within 1 h) NOTE: Unilobar or whole liver injection of MAA may be performed. Irrespective of the location of MAA injection, it is imperative that the MAA be delivered with flow rates and catheter position that mimic the anticipated Y90 infusion rate.

Answer 231

"Whole liver delivery": treating both lobes in one setting vs "Sequential or lobar delivery": treating one lobe, then the other after a 4-6 week interval.

Answer 232

1) Least intense of all the intra-arterial loco-regional therapy options. 2) Side effects: - Fatigue and abdominal pain (seen in 25%) - Radiation pneumonitis (at doses > 30 Gy) - Radiation gastritis (<8%) - GB wall edema not requiring cholecystectomy - RILD (Radiation induced liver disease)

Answer 233

1) Pretreatment MAA scan demonstrating >30 Gy radiation exposure to the lung. Lifetime limit 50 Gy. 2) Pretreatment MAA scan demonstrating flow to the GI tract that cannot be corrected by catheter embolization techniques 3) Pregnancy/Breastfeeding 4) Capecitabine therapy

Answer 234

1) Avoid close contact (<1m) with others for one week. 2) 24h fluid precautions with SirSpheres only (double flush, sit to urinate), not with Theraspheres. 3) Patient is able to get urgent medical treatment as needed. Medical staff can contact RSO with questions.

Answer 235

CP > B-8 is an absolute contraindication. ECOG > 2 is contraindication as progression to liver failure likely. BCLC for TACE says ECOG 0. But patients should be independently assessed. Y90 has less toxicity and may be safer in borderline patients.

Answer 236

RESILIANT BMS vs. PTA: BMS associated with better angiographic results and improved clinical outcomes compared vs PTA in tx of moderate-length lesions in the SFA and proximal popliteal artery. VIASTAR GRAFT vs. BMS Fempop: SE heparin bonded Stent Grafts better than BMS in tx of long fem-pop lesions. COBEST GRAFT vs. BMS Aortoiliac: SE covered stents better than BMS in tx of Aortoiliac dz. ATTRACT PTS at 2Y POST DVT: Looking at PTS rates post LE DVT in patients randomized to AC alone or AC in combo with pharmachomechanical thrombolysis. INPACT SFA Trial DCB vs. PTA: Compared the InPact DCB (Paclitaxel) to standard PTA. DCB REQUIRED fewer TLRs vs PTA and demonstrated better primary patency at 12m (82% vs 52% w PTA) ZILVER PTX DES vs. BMS: DES (Paclitaxel) superior to BMS with respect to patency and freedom from TLR. BASIL BYPASS vs. PTA: Bypass-surgery vs PTA in patients with severe infrainguinal ischemic disease. Short-term: surgery is more expensive and has higher morbidity. Medium term: outcomes similar with respect to amputation-free survival, all-cause mortality and HRQL. Long term (>2y): surgery may be more durable.

Answer 237

1) Classification scheme for describing atherosclerotic disease patterns in the lower extremities. Based on anatomic distribution, # of lesions and lesion characteristics (stenosis, occlusion). 2) A-D, describing Aortoiliac and Fempop disease patterns. None define tibial disease. Type A lesions: Aortoiliac: - Short CIA or EIA stenoses (≤3 cm) Femoropopliteal: - Single stenosis ≤10 cm or single occlusion ≤5 cm Type B lesions: Aortoiliac: - Short (≤3 cm) stenosis of the infrarenal aorta - UL CIA occlusion - Single or multiple EIA stenoses (3-10 cm) not involving the CFA - UL EIA occlusion not involving the origins of the IIA or CFA Femoropopliteal: - Multiple stenoses or occlusions, each ≤5 cm - Stenosis or occlusion ≤15 cm not involving the infra-geniculate popliteal artery - Single or multiple lesions in the absence of continuous tibial vessels to improve inflow for a distal bypass - Heavily calcified occlusion ≤5 cm - Single popliteal stenosis Type C lesions: Aortoiliac: - BL CIA occlusions - BL EIA stenosis (3-10 cm) not involving the CFA - UL EIA stenosis extending into the CFA - UL EIA occlusion involving the origin of the IIA or CFA - Heavily calcified UL EAI occlusion with or without involvement of the origins of the IIA or CFA Femoropopliteal: - Multiple stenoses or occlusion totaling >15 cm (+/-) heavy calcification - Recurrent stenoses/occlusion post two endovascular interventions Type D lesions: Aortoiliac: - Infrarenal aortoiliac occlusion - Diffuse disease of the aorta and both iliac arteries - Diffuse multiple stenoses involving the UL CIA, EIA and CFA - UL occlusions of both the CIA and EIA - BL occlusions of EIA - Iliac stenoses in patients with AAA not amenable to endograft placement Femoropopliteal: - CTO of the CFA or SFA (>20 cm, involving the popliteal artery) - CTO of the popliteal artery and proximal trifurcation vessels 3) Outcomes data recommends endovascular for A & B, surgical for C & D.

Answer 238

1) IV furosemide and a 250 mL normal saline bolus to temporary dilate calyces for US guided access. 2) Administration of 50-80 cc IV contrast to opacify the renal collecting system for fluoroscopically guided calyceal access. Note contrast will wash out quickly so many use contrast for the two-stick technique. 3) Two-stick technique (with or with our IV contrast). 4) Combined procedure with retrograde ureterography.

Answer 239

Two-stick technique: 1) 21G needle is placed directly into the renal pelvis from a straight PA approach. 50-80 cc IV contrast can be used to guide initial needle placement. Alternatively, fluoroscopic guidance can be based on the renal shadow or osseous landmarks (2 cm lateral to transverse process of L2). If no urine is aspirated after the first needle pass, change the approach angle by 10 degrees in one direction or another (operator choice). NOTE: After administration of IV contrast, using a straight PA approach, the posterior calyces are typically seen en face, whereas the anterior calyces are visualized longitudinally. 2) Once access is obtained in the renal pelvis, 10 cc of 50% contrast is injected to confirm adequate placement of the renal pelvis needle. 3) Air is then injected while watching under fluoroscopy. Gas will rise to the nondependent calyces, in which a prone patient is the posterior calyces complex. This represents the target calyx for puncture. You must watch or you will be unable to distinguish the air from bowel gas. 4) Once the appropriate posterior calyx is identified, chose an exit site (hands breadth medial to the posterior axillary line). Place hemostat at the exit site and angle the X-ray tube in both the mediolateral and craniocaudal projection allowing superimposition of the hemostat and the targeted calyx, facilitating a “down the barrel” approach for the catheter placement. 5) Once the calyx is accessed, standard technique is performed for final tube placement.

Answer 240

1) Naloxone | 2) 0.1–0.2 mg slow IVP at 2–3-minute intervals until desired degree of reversal is achieved.  

Answer 241

1) Flumazenil | 2) 200ug over 15 seconds. Repeated doses may be necessary; maximum total dose  is 3 mg.

Answer 242

1) VK (used in patients with synthetic liver dysfuntion) and FFP 2) FFP: Used for transient reversal of warfarin. Lasts six hours. A minimum dose of at least 2 units is usually required with one of the units given at the start of the procedure. 3) 12h 4) Following VK, it may take 2–3 weeks to reestablish anticoagulation with warfarin. Do not use vitamin K1 when continued anticoagulation is desired!

Answer 243

1) 1% contains 10 mg/mL. Do not exceed 20 mL or 200 mg. 2% contains 20 mg/mL (do not exceed 10 mL). 2) 1% Prilocaine (can give up to 40 mL or 400 mg. 3) Bupivacaine: Not used for induction because it takes up to 30 minutes to reach full effect. And Ropivocaine.

Answer 244

1) 1 mg in elderly, 2.5 mg in normal adult. | 2) 4–6 hours.

Answer 245

1) 0.6 mg IVP. Max dose 3 mg. 2) Dose-related anticholinergic effects: dry mouth, urinary retention, blurred vision. 3) Closed angle glaucoma.

Answer 246

- Hydralazine - Labetalol - Enalaprilat (IV Enalapril) - Oral clonidine - Oral captopril - Nifedipine (AVOID) Hydralazine: Initial dose 10 mg IV, with max dose 20 mg IV. Labetalol: - PO: 100 mg po bid - IVP: bolus 20 mg initially, followed by 20 to 80 mg q10m to a total dose of 300 mg. - Infusion: 0.5 to 2 mg/min Enalaprilat: 0.625 mg IV initial dose (up to 5 mg q6h). 1.25 mg IV equal to 5 mg PO. Can elicit hypotensive response hypovolemic patients with high plasma renin. Oral clonidine: 0.2 mg (not intended as long-term therapy) Oral captopril: 6.25 or 12.5 mg (if the patient is not volume depleted) Nifedipine (CCB): AVOID. There are some issues with the sublingual type.

Answer 247

MAP should not decrease by more than 25-30% in first few hours.

Answer 248

Avoid adhesives as possible. Allow adhesives and EKG pads to fall off naturally.

Answer 249

Clean: A procedure is regarded as clean if the GI, GU or respiratory tract is not entered, if inflammation is not evident, and if there is no break in aseptic technique. Example: routine diagnostic angiography. Clean-contaminated: A procedure is regarded as clean-contaminated if the GI, biliary, or GU tract is entered but there is no break in aseptic technique. Example: nephrostomy tube placement in a patient with sterile urine. Contaminated: A procedure is regarded as contaminated if there is entry into an inflamed or colonized GI or GU tract without frank pus, or if a major break in aseptic technique occurs. Dirty: A procedure is regarded as dirty if it involves entering an infected purulent site such as an ab- scess, a clinically infected biliary or GU site, or perforated viscus. Antibiotic prophylaxis for IR procedures is generally recommended for procedures that are not clean, or for procedures that are considered clean but, as a result of which, a potentially significant volume of necrotic tissue is generated in potentially contaminated areas, eg, embolization with intent to create infarction.

Answer 250

Antibiotic prophylaxis for IR procedures is generally recommended for procedures that are not clean, or for procedures that are considered clean but, as a result of which, a potentially significant volume of necrotic tissue is generated in potentially contaminated areas, eg, embolization with intent to create infarction. ``` Aortic eddografts Peripheral endografts Dialysis access endografts Ports in IC pts Embolization/chemoembolization (2/2 infarction) UFE (2/2 infarction) PEG (pull technique, not push; check JHH) Biliary drainage (1 gm Ceftriaxone: 3G w enhanced biliary excretion vs 2G Cefotetan) Percutaneous Nephrostomy Tube Placement Tube Exchange (only if infected) Ureteral Stents Percutaneous abscess drainage Verteboplasty/Kyphoplasty ```

Answer 251

Trauma, portal HTN complications, and hypersplenism (plt < 75K) due to various etiologies

Answer 252

To levels above 100K

Answer 253

Yes (pneumococcal, H influenza & meningococcal vaccine).

Answer 254

The middle or lower pole splenic branches due to lower risk of pain and pulmonary complications such as atelectasis, pneumonia and pleural effusion which are more common with upper lobe embolization.

Answer 255

Embospheres (300-500 & 500-700 μm). It can be mixed with 80 mg of gentamycin and injected slowly. Other agents include Gelfoam, nBCA and coils.

Answer 256

1) 30% to 40% (lifetime 70%) | 2) 70%

Answer 257

After 1 month if adequate therapeutic response has not been achieved.

Answer 258

1) Admit patients for management of postembolization syndrome (fever, LUQ pain, NV, anorexia) and PCA. 2) Antibiotic prophylaxis with 250 to 500 mg per day of amoxicillin x 10d OR 1 gm Cefaperazone q12h x 5d OR suspend beads in Gentamycin. 3) CTAP with contrast after one day to evaluate extent of infarction.

Answer 259

If the drain has been in for > 1 week, the tract is well-established. The catheter can be removed, a hydrophilic guidewire can be passed into the collection and a new drain can be placed over the wire. Alternatively, cut the hub off the catheter, pass a sheath over the outside of the catheter, remove the catheter, pass a guidewire into the collection through the sheath, then remove the sheath and place a new catheter over the wire.

Answer 260

Posterior transgluteal route traversing the sacrosciatic notch. The sciatic nerve and gluteal vessels pass through the anterior portion of the notch. To avoid them, the tract should pass as close to the sacrum as possible.

Answer 261

USAT regimen superior to heparin alone in reversing RV dilatation at 24 hours. No increase in bleeding complications. There was also a statically significant decrease in right heart pressures in the USAT group.

Answer 262

In patients with intermediate-risk pulmonary embolism, fibrinolytic therapy prevented hemodynamic decompensation but increased the risk of major hemorrhage (11.5% vs. 2.4%) and stroke (2.4% vs. 0.2%).

Answer 263

Upper 2/3 is the LIGAMENTOUS portion? Lower 1/3 is the SYNOVIAL portion lined by hyaline cartilage?

Answer 264

Epidural blocks: 3-10 ml (LS) 3-6.5 (CS) Nerve root blocks: 2-4 ml (0.5 cc Depo-Medrol [40 mg/ml] & 1 cc 0.25% Bupivicaine) Facet joints: 1–2 ml (0.5 cc Depo-Medrol [40 mg/ml] & 1 cc 0.25% Bupivicaine)

Answer 265

No. Because saturation is less likely to occur given the higher per bead dose.

Answer 266

Comes in 200u increments (ie. 100-300u) as a dry plastic and is mixed with contrast prior to administering. Use one class smaller versus the Embospheres you would normally use. So if Embospheres were 300-500, you would use 100-300 PVA. Clumping and size irregularity with the potential to occlude more proximally then expected.

Answer 267

Type I: around the graft anchorage points (not a snug fit!). • Type II: via collateral vessels, lumbar arteries and IMA. • Type III: limb dislocation. Insert another limb to bridge the gap. • Type IV: leakage through the graft material due to porosity; this will settle when the heparin wears off.

Answer 268

- Pregnancy - Severe renal artery stenosis - Severe hyperkalemia

Answer 269

``` Common femoral - Femoral (more medial) - Profunda - Medial & Lateral Circumflex (asc/desc branches) ```

Answer 270

Ansel 1, 2 and 3: each have a curved tip curved tip with the angle becoming more acute from 1 to 3. Ansel also makes a straight tip. Destination: various shapes (RDC has 2 curves; also available as straight tip, hockey stick etc).

Answer 271

1) RCFA Access 2) 5 Fr sheath 3) Omniflush aortogram from arch 4) 5 Fr Mickleson, SOS Select, non-glide C2, Sim1 to select bronchials (anterolateral at level of carina) with contrast limit of 5 cc/kg. 5) Renegade high flow and .016 Fathom to achieve purchase in bronchials. 6) Embolize with 0.2cc alloquats of Embospheres (>250u decreases risk of tissue necrosis and spinal artery delivery). Follow with slow saline flush to push beads out of catheter.

Answer 272

- 21g needle access - Contrast to confirm position - Mandrel wire - Aprima set (remove inner metal once accessed) - 4 Fr tapered glide cath and glide wire to access bladder. - Measure from UVJ to renal pelvis with glide to determine NUS length leaving catheter in bladder. - Amplatz through catheter into bladder. - NUS over Amplatz

Answer 273

- 5 Fr Micropuncture - 9 Fr 11 cm Vascular sheath - 8 Fr Hopkins Hook to select LRV and LGV - 5 Fr 100 cm glide JB1 catheter and Bentson wire to get down the LGV (or 6 Fr MPC if >= 1cm plug to be used) - Regular Renegade and 0.018 shapeable straight tip GT for coiling (above inguinal ligament) - Sim1 or 2 formed in LRV through Hopkins Hook then used to select RGV Pelvic congestion can be checked post embolization by using the Hopkins catheter and JB1 to select the left internal iliac vein and perform venography with and without balloon occlusion with Behrman wedge. The right internal iliac vein can be selected with the Sim 2.

Answer 274

The Curacao criteria, published in 2000, remain the mainstay of HHT clinical diagnosis: - Recurrent, spontaneous nosebleeds - Mucocutaneous telangiectases at characteristic sites (fingertips, lips, oral mucosa, tongue) - Visceral AVMs (gastrointestinal, pulmonary, hepatic, cerebral, or spinal) - Family history (first-degree affected relative)

Answer 275

1) Sotradecol foam preparation of 1 mL 3% STS mixed with 4 mL of air (improves endothelial surface contact, slows or stops flow allowing for extended periods of contact). Foam injected while withdrawing catheter. Dose avg 0.5 - 2 ml (up to 6 ml use reported). 2) Sandwhich technique: coil-Sotradecol-coil (first coil pack just above inguinal ligament).

Answer 276

8 mm; 1 cm plugs require a 6 Fr catheter.

Answer 277

- Incision sites in RUQ below costochondrol jx - Introducer and wire inserted at oblique angle - Anesthetize 5-8 cm track - Tunnel so cuff is 1 cm from superior incision - Insert peel away then remove wire and insert catheter

Answer 278

Dorsal and ventral ducts. The ventral duct which is oriented towards the skin surface is accessed subxiphoid.

Answer 279

3-6m, followed by 2w clinical trial (cut short) and Whittaker? 90% 1y patency with clinical trial and Whittaker vs. 70% with just clinical trial.

Answer 280

- Bentson - 9 Fr sheath - Inter abdominal IVC, intra IVC, and RA pressure - 5 Fr curved tip catheter (MPA) to select RHV - Lateral - Behrmann over a Rosen - Free, retired and wedges pressure - Sheath advanced over Rosen and Behrmann - Rosen and Behrmann out - Biopsy introducer in so it just pokes out tip of sheath - Torque anterior - Advance needle to black line - Push cocked needle forward and sample - Venography post bx to r/o leak

Answer 281

No, unless there are signs and sxs of pheochromocytoma or biochemical abnormalities.

Answer 282

Celect: - 9 Fr 45 cm sheath over Bentson - 5 Fr flush run below filter - 15 mm gooseneck snare of filter hook - 9 Fr sheath down over top of filter Denali: - 11 Fr 35 cm sheath over Bentson - 5 Fr flush run below filter - 9 Fr 45 cm sheath through 11 - 15 mm gooseneck snare of filter hook - 9 Fr sheath down over filter to leg hooks - Sheath filter with 9 Fr - Once filter covered pull up through 11 Fr

Answer 283

Loop snare technique using a revere curve catheter to displace embedded hook on tilted filter. Balloon displacement technique to displace penetrating filter strut. Endobronchial forceps technique to grasp embedded filter hook.

Answer 284

1) Age of thrombus: acute/subacute (4w). 2) Extent of thrombus: if all infrainguinal, US imaging sufficient; if BL leg involvement, then pelvic vein or IVC is involved and CTV or MRV needed. 3) Co-morbidities: renal insufficiency, contraindications to thrombolysis, contrast allergies, thrombocytopenia, coagulopathies.

Answer 285

1) Popliteal access 2) Initial venogram 3) Cross the clot all the way to central aspect 4) Put in 8 Fr sheath. 5) Coaxially place 8 Fr hockey stick guide catheter, through which we put AngioJet catheter with tPA (10 of tPA in 500 NS or 25 of tPA 1000 NS). Perform the spiraling technique (rotate the guide catheter rather than the AngioJet catheter) while slowly retracting both through the clot burden with the Angiojet vacuum on (vs. Angiojet power-pulse technique where you are pulsing tPA while moving forward thru the clot over a wire, waiting, then withdrawing with vacuum on). Rotating the hockey stick allows for wall to wall circumferential apposition. 6) Treat 10-15 cm segments followed by venography through Angiojet sideport. Then treat more peripheral segment.

Answer 286

Afferent: duodenum and proximal jejunum Efferent (roux limb): from GJ to JJ.

Answer 287

nl PV >30 cm/s TIPS v: 90-190, difference no greater than 100 Fugal in R and L PV towards TIPS

Answer 288

``` T12: Celiac L1: SMA L2: Renals L3: IMA L4: Bifurcation ```

Answer 289

nl PV >30 cm/s TIPS v: 90-190, difference no greater than 100 Fugal in R and L PV towards TIPS

Answer 290

``` T12: Celiac L1: SMA L2: Renals L3: IMA L4: Bifurcation ```

Answer 291

Both variations involve the removal of the gallbladder, CBD, duodenum and head of the pancreas. In the Classic Whipple, a 30-40% distal gastrectomy or stomach resection is preformed. In the pylorus preserving Whipple (Mini-Whipple) the stomach is preserved and the GI tract is transected 1 inch past the stomach leaving a small segment of duodenum. The jejunum gets pulled up and anastamosed to the pancreas (pancreaticojejunostomy) most proximally, then the hepatic duct (hepaticojejunostomy) and then the stomach (gastrojejunostomy).

Answer 292

True (can be beneficial in cardiac patients)

Answer 293

100 mg in 7 cc Dilute with 3:1 contrast Total volume 28 cc

Answer 294

1) Micropuncture access into the popliteal vein. 2) Gentle contrast injection to confirm intraluminal position. 3) 6 Fr sheath 4) Glide wire and glide catheter to access IVC (can periodically check position with gentle contrast admin) 5) Amplatz wire into IVC 6) Unifuse catheter placement with infusion of 0.5 mg tPA hour through each catheter. 7) Sheaths continuously flushed with 1000U Heparin in 500cc saline run at 30cc/hr. 8) After 12 hours, remove occlusion wires and place Amplatz wires through Unifuse catheters. 9) Perform venography through sheaths. 10) 10 tPA in 50 cc saline pulsed using Angiojet from filter to below level of clot (if BL, do 1/2 on each side). Allow to dwell for 20 minutes. 11) Rheolytic thrombectomy from filter to below level of clot. 12) Upsize sheaths as necessary to perform PTA (we used Atlas balloons 12 x 4).

Answer 295

Scleroses and occludes hepatic arterioles and enters portal venules through AV shunts. This results in reflux of lipiodol into portal veins. We want to see this.

Answer 296

L GONADAL - Bentson into IVC - 8 Fr sheath - 7-8 Fr Hopkins Hook pulled down into L renal vein - L Renal Venogram - Push Hopkins forward while injecting contrast and rotating catheter tip towards the anterior and posterior aspects of the vessels. Pull back and push up as needed until catheter seated in L gonadal vein. - L Gonadal Venogram - Glide wire and 5 Fr tapered tip glide catheter to pelvic brim - Pelvic Venogram - note outflow rate, central vein drainage and contrast volume - Sotrodecol foam (1:4 Sotrodecol:air) - Rosen wire through glide catheter to stiffen system. Then advance Hopkins Hook down gonadal to pelvic brim. - Amplatzer plug deployment through HH (plug to tip of HH, then pin and pull until distal plug marker at tip of HH; rotate 6 turns counterclockwise, repeat) R GONADAL - Sim 2 to end of HH in proximal L gonadal vein; pin-pull HH back into IVC, then push up to form Sim (May need to rotate Sim slightly) - Sim 2 to select R Gonadal usually just below R renal. May need to pull down into vessel especially in setting of competent valve. - Repeat above steps on R if necessary. ILIAC - HH to iliac bifurcation - Glide wire and glide catheter into L internal iliac vein - L internal iliac Venogram - Balloon occlusion when........

Answer 297

At risk when going through psoas. Patients get thigh numbness. Usually transient.

Answer 298

DVT < 1% | Nerve injury 2% with 90% resolving

Answer 299

True If stockings completely relieve pain, there is no data to show that RFA will benefit, though Heller frequently has seen benefit. May not be able to get insurance to cover this though.

Answer 300

Plavix or Xarelto x 2 weeks

Answer 301

C2: discontinue if asx at 2 week visit C4+: continue longer, duration TBD

Answer 302

Vein or branches still fill distally resulting in sx accessory branches.

Answer 303

Opening FA/SFA: ipsilateral Opening internal/external iliacs: contralateral Opening anterior/posterior branches of iliacs: ipsilateral

Answer 304

DC for pts with sx relief and CEAP 2 or less. CEAP 3+ should continue wearing. C2: discontinue if asx at 2 week visit C4+: continue longer, duration TBD

Answer 305

Level 1: closure with thrombus below the level of the epigastric vein. Level 2: closure with thrombus extension flush with the orifice of the epigastric vein. Level 3: closure with thrombus extension flush with the saphenofemoral junction. Level 4: closure with thrombus bulging into the common femoral vein (CFV). Level 5: closure with proximal thrombus extension adherent to the adjacent wall of the CFV past the saphenofemoral junction (SFJ). Level 6: closure with proximal thrombus extension into the CFV, consistent with a DVT.

Answer 306

Perifibroid plexus: ~500u in diameter. Use of particles

Answer 307

Duplex US performed 48-72h postprocedure after removal of all dressings. No further dressing was used in most patients. If US abnormal (level 3-6), treatment was initiated and repeat duplex US performed weekly until the thrombus retracted and stabilized at a level 2 to 3. No further imaging was performed after this finding and discontinuation of anticoagulation. Management of levels of closure: Patients with level 1 or 2 closure 48 to 72 hours postprocedure had no further management of their GSV, although they were instructed to return for a final evaluation of their venous disease 6 weeks postprocedure. Patients with level 3 closure were managed with both observation and repeat duplex ultrasound to assess for progression of thrombus, or with low molecular weight heparin (LMWH) as an outpatient. The LMWH was discontinued when the thrombus had retracted to a level 2 or 3. No further anticoagulation was recommended or used. Patients with level 4 closures were treated with LMWH uniformly, until the thrombus retracted flush with or into the saphenous vein. No further anticoagulation was used after clot retraction. Patients with level 5 closures were treated with outpatient LMWH, which was used until the thrombus retracted to level 3 and then discontinued. Although no patient had a level 6 closure, it would have been treated with LMWH and coumadin for 3 months.

Answer 308

No. No symptoms, no stocking.

Answer 309

72h post op US and appt w nurse 1-2w post w doc Compression stockings: - C2: discontinue if asx at 2 week visit - C4+: continue longer, duration TBD

Answer 310

< 0.5% PE < 1% DVT 2% nerve injury

Answer 311

Walk for 5 minutes every hour post op

Answer 312

One of the largest branches of the splenic artery Chief blood supply of the distal body and tail of the pancreas. If this artery is singular, it usually arises from the midportion of the splenic artery.67 Van Damme and Bonte68 described in detail the confusion involved in the naming of the arteries which supply the bod

Answer 313

Iliopubic Ilioischial

Answer 314

True Extraperitoneal rupture is more common (85% of major bladder injuries) and can usually be managed nonoperatively with Foley catheter drainage. Intraperitoneal bladder ruptures must be repaired surgically.

Answer 315

Retrograde cystography was, until recently, the standard diagnostic test. The bladder is filled with 250–300 mL of water- soluble contrast material. When a urethral injury is suspected, a retrograde urethro- gram should be performed prior to Foley catheter insertion

Answer 316

CT cystography entails repeating the pelvic CT after a delay of 5–7 minutes to allow filling of the bladder with contrast (the Foley catheter, if present, should be clamped). Alternatively, 250–300 mL of contrast can be instilled into the bladder through the Foley catheter. (Standard abdominal CT is performed 90 seconds after the start of the intravenous contrast bolus and contrast is not present in the urinary tract or bladder.)

Answer 317

10 mL total 8 mL Bupivicaine 0.25% 2 mL Kenalog 40 (40 mg/mL - total dose 80 mg)

Answer 318

Kinase inhibitor | Inhibits angiogenesis which is increased in setting of tumor hypoxia which occurs post TAE

Answer 319

Looks at maximum dimension of lesion to assess treatment response. Single lesion: multiply the longest diameter by the greatest perpendicular diameter Multiple lesions: sum the products of all measured lesions Complete Response: Disappearance of all lesions Partial Response: >30% decrease Stable: No change Progression: > 20% increase

Answer 320

RECIST criteria does not accurately assess anti-tumor therapies which do not result in tumor shrinkage but rather influence tumor enhancement. mRECIST looks at maximum dimension of lesion to assess treatment response Complete Response: Absent intratumoral arterial enhancement Partial Response: >30% decrease in viable enhancing tumor Stable: No change Progression: > 20% increase in viable enhancing tumor

Answer 321

Deploy IVC Filter Short 6 Fr sheath into RIJV 6 Fr Berman catheter was advanced through the sheath RA and RV Pressures Berman to MPA MPA pressure Berman to RPA Rosen into RPA 136 cm EKOS into RPA Second access into RIJV 6 Fr sheath placed 6 Fr Berman advanced into MPA and LPA selected with glide wire Glide exchanged for Rosen 106 cm EKOS into LPA EKOS catheters secured to sheaths using silk and sheaths secured to pt using nylon Pressures: RA, RV, PA, BP Drip Rates: TPA: 0.5 mg/hour through the EKOS port marked “DRUGS”. NS: 35 cc/hour through the EKOS port marked “COOLANT”. Low dose heparin continuous infusion should be initiated through a peripheral IV with goal aPPT of 50- 65 units.  SHEATH: Heparinized saline: 1000U in 500 ml at 25 ml/hr Fibrinogen levels q4h:

Answer 322

Uncontrolled HTN despite 3 meds Flash pulmonary edema or recurrent CHF Loss of renal function or renal mass while on antihypertensives Hypertension with unexplained unilateral small kidney

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