Angio

Front 1

Angio complications

Back 1

puncture site – hematoma, AVF, pseudoaneurysm, thrombosis, infection; contrast – renal failure, allergic reaction; catheter-related – thromboembolism, stroke, dissection; therapy-related – hemorrhage

Front 2

Catheters

Back 2

high flow with sideholes for central vessels, low flow with endhole for selective vessels, higher flow rate with shorter catheter and larger diameter; pigtail – aorta, PA; Cobra – mesenteric, renal, contralateral iliac; Simmons – mesenteric, arch vessels; Tracker – coaxial subselection; straight – runoff.

Front 3

Flow rates

Back 3

abd aorta/PA 20/40; celiac/SMA 6/60; renals 5/15; IMA 2/20; pelvis 10/40; one leg runoff 4/48; arch 30/60; CCA 8/10; ICA 6/8; ECA 2/4; vertebral 6/8; IVC 15/45.

Front 4

Guidewires

Back 4

145 standard length, 0.018-0.038 inch, Newton J, Rosen, Amplatz, Bentson, Glide.

Front 5

Pharmacologic

Back 5

vasodilator – papaverine 25-50 mg/hr for mesenteric ischemia, contraindicated with complete AV block; NTG 100 ug for peripheral spasm; vasoconstrictor – vasopressin 0.2-0.4 U/min for GI bleeding, contraindicated with CAD, HTN, arrhythmia.

Front 6

Embolization

Back 6

indications – hemorrhage (GI, varices, traumatic organ, bronchial artery, tumor, post-op), vascular (AVM, AVF, pseudoaneurysm), pre-op devascularization (RCC, AVM, vascular bone mets), hepatic chemoembolization (palliative, gelfoam + ethiodol + chemotherapy for HCC, metastatic neuroendocrine tumor); beware of collaterals, use Tracker if possible; temporary agents – gelfoam pledgets (for UGIB, pelvic trauma, post-op); permanent agents – steel coils (large vessel, aneurysm, tumor), PVA (small particles for distal occlusion, tumors, bilateral UFE for fibroids), ethanol (solid organ necrosis, peripheral AVM); Cx – postembolization syndrome, infection, nontarget embolization

Front 7

Thrombolysis

Back 7

indications – arterial graft thrombosis, native acute thrombosis, prior to percutaneous intervention, hemodialysis AVF or graft, venous thrombosis; absolute contraindications – active bleed, intracranial lesion (stroke, tumor, recent surgery), pregnant, nonviable limb; favorable prognosis if recent clot, good inflow/outflow, positioned in thrombus; endpoints – no lysis after 12 hours infusion, major complications, fibrinogen <100mg/dl; always treat underlying lesions; TPA 0.5-1 mg/hr and heparinize, repeat angio in 12 hrs, coaxial dual infusion; success 90% for grafts and 75% for native; Cx – major hemorrhage, distal embolization, pericatheter thrombosis

Front 8

Angioplasty

Back 8

indications – claudication or rest pain, tissue loss, nonhealing wound, establish inflow for distal bypass graft, hemodialysis AVF or grafts; measure pressure gradients before and after PTA, heparinize after lesion crossed; priscoline 25 mg IA for vasospasm; balloon sized to adjacent normal artery except in aorta want to undersize, wire should always remain across lesion; large vessels/proximal lesions > small vessel/distal, stenoses > occlusions, short stenoses > long, isolated disease > multifocal, good inflow/outflow > poor; success for fem/pop PTA is 90% initial and 70% at 5 yrs, renals 95% initial with 95% at 5 yrs for FMD and 70-90% for atherosclerosis, ostial lesions poor prognosis; Cx – groin cx, distal embolization, rupture, renal infarction or failure.

Front 9

Stents

Back 9

indications – unsuccessful PTA, recurrent stenosis, venous obstruction/thrombosis, TIPS, long segment stenosis, total occlusion, ineffective or unsuccessful PTA (residual stenosis > 30%, residual pressure gradient > 5 mmHg, large post-PTA dissection flap, hard calcified plaque), recurrent stenosis after PTA, ulcerated plaque, renal ostial lesions; success in iliac >90% 5 yr patency.

Front 10

TIPS

Back 10

indications – portal HTN and variceal bleeding failed sclerotherapy, refractory ascites, Budd-Chiari, pretransplant; absolute contraindications – severe R heart failure, liver failure; relative – PV thrombosis, hepatic encephalopathy, infection, vascular liver tumors, polycystic liver dz; check PV patency, preprocedure paracentesis may be helpful; goal – portosystemic gradient < 10 mmHg, decompression of varices; patency 50% at 1 yr; Cx – hepatic encephalopathy, bleeding, shunt thrombosis or stenosis, R heart failure, renal failure; isolated gastric fundal varices from splenic vein thrombosis not indication for TIPS.

Front 11

Foreign body retrieval

Back 11

snare, basket, retractable forceps; if in heart use pigtail to get out of heart then snare.

Front 12

Preprocedure

Back 12

premedication for contrast allergy – solumedrol 200mg IV + Benadryl 50mg PO or prednisone 40mg 16,8,2 hrs prior + Benadryl 50mg PO 1 hr prior; conscious sedation – Versed 0.5mg, Fentanyl 50 ug increments.

Front 13

Coagulation correction

Back 13

heparin – stop for 3-6 hrs prior, or protamine IV in minutes; coumadin – vit K x 3 takes days, or FFP in minutes; aspirin – stop aspirin 1 wk, or plts in minutes

Front 14

Thoracic aortic aneurysm

Back 14

atherosclerosis – 90% fusiform, desc aorta more common, rupture uncommon if <5cm; cystic medial necrosis – HTN, Marfan, Ehlers-Danlos, sinus of valsalva aneurysm (tulip bulb) asc aorta, dissection common, calcs rare; syphilis – asymmetric, saccular, tree bark calcs common; mycotic – most are saccular at asc aorta or isthmus, perianeurysmal inflammation, immunocompromised, IVDA, endocarditis, postsurgical; posttraumatic pseudoaneurysm; aortitis – Takayasu’s, giant cell arteritis, CVD; true aneurysm usu fusiform, false aneurysms (posttraumatic, mycotic, postsurgical) usu saccular.

Front 15

Aortic dissection

Back 15

chest or back pain, aortic insufficiency, BP discrepancy between extremities; causes – HTN, Marfan, Ehlers-Danlos, coarctation, bicuspid valve, pregnancy, trauma; Stanford A – asc aortic involvement, surgical tx, beware of pericardial tamponade, coronary artery occlusion, aortic insufficiency; Stanford B – desc aorta only, medical tx; intimal flap, displaced aortic calcs, delayed opacification of false lumen, compression of true lumen by false lumen, occlusion of branch vessels, abnormal catheter position; false lumen larger and slower flow and anterolateral in asc aorta and posterolateral in desc aorta.

Front 16

Traumatic aortic injury

Back 16

aortic isthmus 95%, aortic root, hiatus; CXR – wide mediastinum, loss of aortic contour, L apical cap, NGT displaced to R, L bronchus displaced down, high rib fxs, hemothorax; CT – any mediastinal hematoma should get angio; angio – intimal tear (linear filling defect, irregularity of aortic contour), pseudoaneurysm, ductus diverticulum is smooth and broad-based.

Front 17

Takayasu’s arteritis

Back 17

most pts < 30 and females, stenoses of arch vessels most common, stenosis and occlusion of aorta, thickening of aortic wall, PA involvement in 50%, abd aortic coarctation and RAS, aneurysms.

Front 18

Giant cell arteritis

Back 18

older pts > 50, dx by bx temporal artery, involves ECA branches, aorta and proximal brachiocephalic branches usu spared; subclavian, axillary, brachial involvement in 15%.

Front 19

AAA

Back 19

90% intrarenal, >3cm, increased risk or rupture when >5cm, assoc with popliteal aneurysms; Cx – rupture, aortocaval fistula, aortoenteric fistula, distal embolization, infection.

Front 20

Endoleaks

Back 20

type 2 most common, filling of aneurysmal sac via IMA or lumbar branches.

Front 21

Abdominal aortic coarctation

Back 21

young adults or children; congenital – coarctation, Williams syndrome, rubella, NF; acquired – Mid aortic syndrome, Takayasu’s, FMD, radiation; segmental most common, usu involves renal arteries.

Hint 21

None

Front 22

Williams syndrome

Back 22

supravalvular aortic stenosis, peripheral PA stenosis, diffuse coarctation of abdominal aorta and stenosis of visceral branches.

Front 23

Aortoiliac occlusive disease

Back 23

Leriche syndrome in men – buttocks claudication, impotence, decreased femoral pulses; collaterals – internal mammary -> EIA via sup and inf epigastrics, IMA -> IIA via hemorrhoidal, intercostal/lumbar -> EIA via deep circumflex iliac, intercostal/lumbar -> IIA via iliolumbar and gluteals.

Front 24

Mesenteric collaterals

Back 24

celiac to SMA – arc of Buehler, pancreaticoduodenal arcade; SMA to IMA – middle colic -> L colic, arc of Riolan, marginal artery of Drummond; IMA to IIA – via superior hemorrhoidal; rectal arcades – superior rectal from IMA, middle rectal from IIA, inferior rectal from pudendal.

Front 25

Median arcuate ligament syndrome

Back 25

occlusion of proximal celiac artery from median arcuate ligament, accentuated on expiration, best detected on lateral projection.

Front 26

UGIB

Back 26

gastritis most common, PUD, varices, MW tear; LGA > GDA; tx – vasopressin, gelfoam, PVA or coils for major arterial injury; rich collateral supply.

Front 27

LGIB

Back 27

diverticulosis most common, angiodysplasia, colon CA, polyps, IBD, rectal dz; blood pool study for screening; inject SMA, IMA, celiac; tx – gelfoam, vasopressin, coils (used less due to less collaterals); vasopressin 0.2 U/min x 20 min, repeat angio, 0.4 U/min x 20 min if still bleeding, repeat angio, embolization or surgery if still bleeding, when bleeding controlled slow taper over 24 hrs.

Front 28

Mesenteric ischemia

Back 28

acute or chronic, nonocclusive most common – atherosclerosis and low flow state, arterial occlusion (embolus, thrombus, dissection, vasculitis), mechanical (hernia, volvulus, intussusception); filling defects or occlusion, diffuse vasospasm; tx – thrombolysis if acute and no bowel ischemia, surgery if bowel ischemia, nonocclusive use papaverine IA 25-50 mg/hr.

Front 29

Angiodysplasia

Back 29

cecum/R colon, vascular tuft on antimesenteric border, early or persistent draining vein, active bleeding usu not seen.

Front 30

Portal HTN

Back 30

wedge – IVC pressure > 5mmHg; causes – PV thrombosis, Schistosomiasis, cirrhosis, Budd-Chiari, HV or IVC occlusion, AVM; collaterals – gastroesophageal, mesenteric, perisplenic, periumbilical, hemorrhoids; ascites, splenomegaly, portal collaterals (cavernous transformation), recanalized periumbilical vein or hepatofugal flow.

Front 31

PV thrombosis

Back 31

idiopathic, HCC, panc CA, mets, post-op, coagulopathies, sepsis, pancreatitis, cirrhosis and portal HTN

Front 32

Budd-Chiari

Back 32

HV thrombosis, tumor growth in HV and/or IVC (RCC, HCC, adrenal); spider web hepatic veins, IVC narrowing, stretched straight hepatic arteries.

Front 33

RAS

Back 33

atherosclerosis > FMD, Neurofibromatosis, arteritis (Takayasu’s, PAN, abd aortic coarctation); atherosclerosis – older pts, usu involves proximal artery, ostial stenosis poor PTA response (50%), mid RA stenosis 80% response, PTA to control HTN or preserve renal function; FMD – medial fibroplasia most common followed by perimedial fibroplasia, medial hyperplasia, medial dissection, intimal fibroplasia, adventitial fibroplasia..., mid and distal renal > ICA or vertebrals, string of beads, excellent response to PTA, most common cause of RAS in children, spontaneous RA dissection.

Hint 33

None

Front 34

RA aneursym

Back 34

FMD and atherosclerosis common, NF, AML, LAM; intraparenchymal – PAN, speed kidney.

Front 35

RVT

Back 35

children – dehydration, sepsis, maternal DM, Wilms; adults – membranous glomerulonephritis, CVD, DM, trauma, thrombophlebitis, RCC.

Front 36

PA gram

Back 36

indications – PE, PAH, pseudoaneurysm (trauma or iatrogenic, tx coils), AVM (assoc with OWR, feeding artery draining vein, tx coils); pacer required if LBBB, measure PA pressures (nl PAsys<30mmHg); Cx – acute R heart failure, arrhythmia, death, no absolute contraindications; PE indications – intermediate or indeterminate VQ scan, low prob with high clinical suspicion, contraindication to anticoagulation; acute PE – intraluminal filling defect, tram-tracking of contrast, abrupt cutoff, missing vessels, no collaterals; chronic PE – eccentric filling defects (muralized), smooth cutoffs, missing vessels, synechia or webs, collaterals

Front 37

Bronchial artery

Back 37

indications – hemoptysis (TB, CF, CA); arise from T4-T7 posterolaterally; embolize with gelfoam, PVA, coils; Cx – spinal artery injury, pain.

Front 38

LE atherosclerotic occlusive dz

Back 38

sx – pain, pallor, pulselessness, paresthesias, paralysis; usu symmetric at bifurcations, SFA > iliac > tibial > pop > CFA; significant stenosis - >50% narrowing, collaterals, gradient > 10mmHg.

Front 39

LE atherosclerotic aneurysmal dz

Back 39

pop a most common, bilateral in 50%, assoc with AAA; pop > iliac > femoral; distal embolization and/or thrombosis.

Front 40

Arterial thomboembolism

Back 40

cardiac mural thrombus (LV aneurysm, afib, MI), aneurysms, iatrogenic, paradoxical (DVT and R-L shunt); emboli usu lodge at bifurcations, no collaterals, filling defects with menisci.

Front 41

Buerger’s dz

Back 41

thromboangiitis obliterans, male smoker 20-40 y/o, claudication, calf and foot vessels most common, abrupt segmental arterial occlusions, multiple corkscrew collaterals.

Front 42

Popliteal artery entrapment

Back 42

young athletes, narrowing or occlusion on plantar flexion.

Front 43

May-Thurner syndrome

Back 43

R common iliac artery compresses L common iliac vein -> DVT

Front 44

IVC filters

Back 44

contraindication or failure or complication of anticoagulation; Bird’s nest for mega cava > 28mm up to 40mm, Meditech, Simon nitinol may be placed via brachial vein; IVC gram to document patency and level of renal veins; place below renal veins; suprarenal if infrarenal clot or pregnancy with IVC compression; duplication IVCs may need filter in each; retroaortic or circumaortic LRV – place below most inferior renal vein; if no room infrarenal, can do bilateral iliac vein filters.

Front 45

UE dz

Back 45

atherosclerosis, vasculitis, emboli, trauma, iatrogenic, radiation, thoracic outlet syndrome – compression of brachial plexus or subclavian vessels, seen with hyperabduction, may see subtle subclavian artery aneurysm, tx is surgical if mechanical compression (e.g. cervical rib)

Front 46

Trauma

Back 46

any trauma with abnormal pulse exam; all pts with posterior knee dislocations should get arteriography.

Front 47

Hypothenar hammer syndrome

Back 47

occlusion or pseudoaneurysm formation of ulnar artery as it crosses over hamate from repetitive trauma, can result in distal embolic occlusions, Raynaud’s phenomenon, improves with priscoline.

Front 48

Subclavian steal syndrome

Back 48

narrowed or occluded subclavian artery proximal to origin of vertebral, retrograde flow in vertebral, more common in L, caused by atherosclerosis (#1), also trauma, aneurysm, embolism, thoracic outlet syndrome, vasculitis, extrinsic tumor compression, radiation, congenital anomalies, most are asx but can get vertebrobasilar insufficiency or arm claudication.

Front 49

Aneurysm

Back 49

atherosclerosis – abd aorta most common, desc thoracic aorta, peripheral vasculature (popliteal > iliac > femoral); infection (mycotic) – bacterial, syphilus; inflammation – Takayasu’s, giant cell arteritis, polyarteritis nodosa; congenital – Marfan, Ehlers-Danlos, FMD, NF

Front 50

Ischemia

Back 50

arterial – dissection, embolus, thrombosis, thrombosed aneurysm, vasculitis, extrinsic compression, drugs; venous – thrombosis (phlegmasia cerulea dolens); low flow – hypovolemia, shock, hypoperfusion

Front 51

Peripheral vascular disease

Back 51

atherosclerosis (occlusive, aneurysmal, small vessel in diabetics), embolic disease (thromboembolic, cholesterol emboli, plaque emboli), vasculitis, Buerger’s disease, medication

Front 52

Emboli

Back 52

cardiac emboli – atrial fibrilliation, recent acute MI, ventricular aneurysm, bacterial endocarditis, cardiac tumor (myxoma); atherosclerotic emboli – aortoiliac plaque, aneurysm (AAA, popliteal); paradoxical emboli (R-L shunt) – DVT

Front 53

Angiographic tumor features

Back 53

BEDPAN – blush, encasement of arteries, displacement of arteries, puddling of contrast, arteriovenous shunting, neovascularity

Front 54

Hypervascular lesions

Back 54

AVM – early draining vein, no mass effect; extensive collaterals – no early draining vein, no mass effect; tumor neovascularity – early draining vein in AV shunting, mass effect from tumor

Front 55

Aortic enlargement

Back 55

aneurysm, dissection, poststenotic dilatation due to turbulence (coarctation, aortic valvular disease, sinus of valsalva aneurysm)

Front 56

Aortic stenosis

Back 56

congenital – coarctation, pseudocoarctation, Williams syndrome (supravalvular aortic stenosis), rubella syndrome; aortitis – Takayasu’s disease (most common aortitis to cause stenosis); neurofibromatosis; radiation

Front 57

Pulmonary artery stenosis

Back 57

Williams syndrome (infantile hypercalcemia), rubella syndrome, Takayasu’s, associated with CHD (esp tetralogy)

Front 58

Hyperreninemic HTN

Back 58

decreased renal perfusion – atherosclerosis, FMD; renin-secreting tumors; renal compression – large intrarenal mass (cysts, tumors), subcapsular hemorrhage (Page kidney)

Front 59

Renal tumors

Back 59

RCC – 80% hypervascular, neovascularity, AV shunting, parasitization; AML – aneurysms, fat content; oncocytoma – spoke wheel in 30%, most hypovascular

Front 60

Renal arterial aneurysm

Back 60

main artery aneurysm – FMD (common), atherosclerosis (common), NF, mycotic, trauma, congenital; distal intrarenal aneurysms – PAN, IVDA (septic), vasculitis (Wegener’s, CVD), traumatic pseudoaneurysm, radiation, amphetamine abuse (speed kidney)

Front 61

Replaced hepatics

Back 61

Left hepatic from left gastric. Right hepatic from the SMA.

Front 62

Thoracic outlet syndrome

Back 62

Paget Schroetter syndrome
Evaluate both arms
Up and down position

Front 63

Complications of Fem bypass graft

Back 63

Thrombosis
Femoral Steal
Ansatamostic pseudoaneyrysms
Anastomotic stenosis

Front 64

Pulmonoary AVM

Back 64

Osler Weber Rendu also known as Hereditary hemorrhagic telangectasia.

Front 65

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Back 65

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