Dave: Ir Board Review 1

Front 1

What is the normal platelets and acceptable levels for patients prior to IR procedurs

Back 1

Platelet count: 150,000-450,000/uL (> 50,000/uL sufficient for procedures)

Front 2

What are the normal PT/INR and acceptable levels for patients prior to IR procedurs

Back 2

PT (INR): 11-14 s (0.9-1.1) (PT < 1.5x midpoint of nl range sufficient for procedures)

Front 3

What is the normal level of PTT

Back 3

Activated PTT: 25-35 s

Front 4

When should Antiplatelet agents (ASA, Plavix) be stopped

Back 4

5-7d

Front 5

When should lovenox be stopped

Back 5

12-24h

Front 6

When should heparin be stopped

Back 6

less than 6 h

Front 7

When should coumadin be stopped

Back 7

7 days

Front 8

How much FFP is needed to reverse an INR of 2.5

Back 8

in general, 2 units FFP will reverse INR 2.5

Front 9

How are platelets usually dosed

Back 9

often dosed as 4-6 units (random donors) or as one single donor unit

Front 10

What is the dosage of protamine to reverse heparin

Back 10

: 50 mg slow IV push dose will reverse common intraprocedural doses of heparin (3,000-5,000 IU

Front 11

What is given to reverse INR

Back 11

vit k and FFP

Front 12

Should INR be measured in all patients with on warfarin or liver disease

Back 12

yes

Front 13

When is PTT definitely measured

Back 13

pts recieving heparin

Front 14

What procedures have a low risk of bleeding

Back 14

Front 15

What procedures have a high risk of bleeding

Back 15

Front 16

What are the major differences in high risk bleeding pts meds and labs

Back 16

INR threshold is <1.5 (2 in low risk)
plavix should be withheld in high risk

Front 17

What procedures have a significant risk of bleeding

Back 17

Front 18

What should be known about anticoagulation meds for significant risk of bleeding

Back 18

Front 19

What is the only categories of risk of bleeding that aspirin is held

Back 19

significant

Front 20

What is the general rule of thumb for injection rate into an artery

Back 20

the diameter of the artery

Front 21

What is the general rule for filming rate

Back 21

the larger the vessel the faster the filming rate

Front 22

What is the injection and filming rates for various blood vessels

Back 22

Front 23

What vessels tend to get fast film rates

Back 23

aorta, pulm art, renal artery, carotid artery, IVC

Front 24

General diameters of various vessels

Back 24

Front 25

General diameters of various vessels

Back 25

Front 26

What 2 types of vasodilators are used and what are the doses

Back 26

Nitroglycerin: 100 ug doses
Papaverine: 30-60 mg/h IA

Front 27

What type of vasoconstrictor is used and what is the dose

Back 27

Vasopressin: 0.1-0.4 U/min

Front 28

What 3 analgesics are used and what are the doses

Back 28

Morphine: 1 mg bolus, 1 mg maintenance
Versed (midazolam): 1 mg bolus, 1 mg maintenance
Fentanyl: 50 ug bolus, 50 ug maintenance

Front 29

What are the drugs used for reversal
2

Back 29

Naloxone (opioid antagonist): 1 mg IV
Flumazenil (benzodiazepine antagonist): 0.2 mg IV

Front 30

What is the most common cause of an aortic pseudoaneurysm

Back 30

deceleration injury from MVA

Front 31

What are the 3 MC sites for traumatic pseuodaneurysm

Back 31

MC at ligamentum arteriosum, next MC aortic root and diaphragm level

Front 32

What are 6 cxr findings of traumatic pseudoaneurysms

Back 32

Wide mediastinum
Indistinct arch contour
Filling in of AP window
Depressed L main stem bronchus
Rightward shift of trachea or NG tube
Left apical cap
Left pleural effusion
Upper rib fxs

Front 33

Where is the AP window

Back 33

Front 34

What does digital subraction imaging look like

Back 34

case of brachiocephalic artery injury

Front 35

What is a common cause of intramural hematoma

Back 35

Usually elderly hypertensive pt

Front 36

Can a intramural hematoma progress to a dissection

Back 36

yes

Front 37

What is an intramural hematoma

Back 37

Thought to represent a rupture of vasa vasorum resulting in hematoma within aortic media. I have read it could also be a dissection without a entery point seen

Front 38

What are the indications for TIPS

Back 38

Refractory variceal hemorrhage despite adequate endoscopic treatment
Refractory ascites
Hepatic hydrothorax
Budd-Chiari

Front 39

What are the absolute contraindications for TIPS

Back 39

Primary prevention of variceal hemorrhage
Congestive heart failure
Severe pulmonary hypertension
Severe tricuspid regurgitation
Active biliary obstruction
Sepsis
Multiple hepatic cysts or Caroli disease

Front 40

If a pt has severe tricuspid regurgitation should a TIPS procedure be done

Back 40

no

Front 41

Should a TIPS ever be done for primary prevention of variceal bleeding

Back 41

no

Front 42

What is the first step in performing a TIPS procedure

Back 42

Preprocedure US, coags checked and corrected, broad spectrum antibiotics

Front 43

After obtaining venous access through the right jugular what is the next step for TIPS

Back 43

Place small catheter into RHV and obtain wedged HV pressure (= PV pressure)

Front 44

After venous access and wedge pressure what is the next step

Back 44

Perform venogram: opacify portal vein via wedged contrast injection
(they can also inject CO2 to make a roadmap)

Front 45

What to vessels is the puncture suppose to connect

Back 45

Using direct puncture, create a connection between RHV and RPV and place a wire into the portal system

Front 46

Once the parenchymal tract is created what is the next step

Back 46

Dilate parenchymal tract with 10 mm balloon angioplasty

Front 47

What is correct placemtn of the viatorr stent

Back 47

Place Viatorr stent so that one end is within 3 cm of portal bifurcation, and other within 3 cm of IVC

Front 48

What r 2 things to be sure to do before finishing a TIPS procedur

Back 48

Completion portal venogram, determine postprocedure gradients

Front 49

What is the appropiate gradient for after TIPS

Back 49

Completion portal venogram, determine postprocedure gradients

Front 50

What is a Viator Stent

Back 50

Expanded polytetrafluoroethylene (ePTFE)-covered nitinol stent-graft consisting of two parts: a distal 2-cm-long uncovered portion that lies in the portal vein and an inner covered portion (4-8 cm long) for the tract and hepatic side of the TIPS

Front 51

Does a Viator stent have a covered and uncovered portion

Back 51

yes

Front 52

What does a viator stent look like

Back 52

the uncovered portion lies in the portal vein

Front 53

What is the effectiveness of a TIPS

Back 53

TIPS patency is 50% at 1 y, 30% at 2 y

Front 54

What is the primary assisted patency

Back 54

this is the patency after a procedure

Primary assisted patency 90% at 1 y, 87% at 3 y

Front 55

What percent will have recurrent variceal bleeding

Back 55

Rebleeding in 15% at 6 m, 30% later

Front 56

Is TIPS effective for treating ascites

Back 56

Cures ascites in 50-75%

Front 57

Where does most stensosis occur

Back 57

Most stenoses occur at hepatic venous outflow or within stent

Front 58

What is the survellaince regime for TIPS

Back 58

Requires surveillance with US at 1 day post procedure, 1 m, 3 m intervals in 1st year, 6-12 m subsequent

Front 59

What are the signs of failure of TIPS on US

Back 59

No flow
Rise or fall > 50 cm/s c/w postprocedure study
Peak < 90 cm/s, > 190 cm/s
Return of antegrade flow in intrahepatic PVs and reversed flow in draining hepatic vein

Front 60

What are the signs of restenosis on angiograms

Back 60

Gradient > 12
Stenosis > 50%
Variceal filling

Front 61

What is the tx of TIPS failure

Back 61

balloon angioplasty +/- additional stent

Front 62

What does MELD stand for

Back 62

Model for End-Stage Liver Disease

Front 63

What parameters does a MELD score measure

Back 63

Scoring system for assessing severity of chronic liver disease
Serum bilirubin
Serum creatinine
INR

Front 64

Why was the MELD score developed

Back 64

Initially developed to predict death within 3 m of surgery in pts undergoing TIPS

Front 65

When are you considered to have a poor outcome

Back 65

Poor outcomes for MELD > 24

Front 66

What is the MELD score now used for

Back 66

Also used for prioritizing allocation of liver transplants

Front 67

What is a penetrating aortic ulcer

Back 67

Ulceration of atherosclerotic plaque into the media

Front 68

What demographic MC gets penetrating aortic ulcers

Back 68

Usually elderly hypertensive pt w/marked atherosclerotic disease

Front 69

What a re the CT findings for penetrating aortic ulcers

Back 69

CT: contrast material-filled outpouching in aorta in absence of dissection flap or false lumen, often extensive aortic calcification, frequently assoc w/intramural hematoma

Front 70

What are 3 potential serious outcomes that may result from a penetrating aortic ulcers

Back 70

May precipitate localized intramedial dissection, may break through into adventitia to form a pseudoaneurysm, or may rupture completely into right or left hemithorax

Front 71

What is a bovine arch

Back 71

Bovine arch: common origin of brachiocephalic and L CCA

Front 72

What is a ductus diverticulum

Back 72

Ductus diverticulum: occurs at same place as a tear, but is smooth, has continuous edges with the aorta, no flap and rapid (normal) washout of contrast

Front 73

How often does an abberant right subclavian vessel occur

Back 73

Ductus diverticulum: occurs at same place as a tear, but is smooth, has continuous edges with the aorta, no flap and rapid (normal) washout of contrast

Front 74

What is a diverticulum of Kommerel

Back 74

Often arises from a dilated portion called the diverticulum of Kommerell

Front 75

If the right subclavian branch is aberrant where does it arise

Back 75

it is the last branch off the aorta

Front 76

is an abberant right subclavian posterior to the trachea

Back 76

yes

Front 77

Abberant right subclavian

Back 77

Front 78

Vessels of the leg

Back 78

Front 79

where do most arterial vessel emboli lodge

Back 79

Most macroemboli lodge in femoral or popliteal arteries

Front 80

What is the MCC of embolus

Back 80

a-fib

Front 81

What are the findings specific to acute emboli

Back 81

Creates a meniscus
Minimal or no vascular disease
No contralateral leg abnormalities
Poorly developed collaterals
Other emboli elsewhere

Front 82

What are the findings of acute limb ischemia

Back 82

Pain, pulselessness, pallor, paresthesia, paralysis

Front 83

What are 5 causes of acute limb ischemia

Back 83

native/graft thrombosis, embolism(a-fib), trauma, peripheral aneurysm w/embolus or thrombosis

Front 84

Is heparin indicated for acute limb ischemai

Back 84

Immediate parenteral anticoagulant therapy (heparin) indicated in all pts with ALI

Front 85

What are the classes of ischemia

Back 85

Front 86

What are the treatment guidelines for the classes of limb ischemia

Back 86

Front 87

What is the difference in management between 2a and 2b ALI

Back 87

Category I, IIA: catheter-directed thrombolysis +/- percutaneous aspiration/mechanical thrombectomy
Category IIB: immediate revascularization (surgical, endovascular)

Front 88

What are the indications of thrombolysis

Back 88

Acute or subacute (< 2 w) thrombus in native vessels or grafts
Clotted grafts (dialysis)
Embolic occlusions (alternative is surgical embolectomy

Front 89

What is the the first step in the procedure for thrombolyisis

Back 89

contralateral femoral access

Front 90

After obtaining femoral access what is the next step

Back 90

cross the occlusion with a guidewire

Front 91

Are there cases where you are unable to get the guidewire across

Back 91

yes, and this is a bad prognostic indicator

Front 92

What type of catheter is used across the occlusion

Back 92

Place multisidehole catheter across occlusion

Front 93

What is the dosing regime for heparin in a patient undergoing thrombolysis

Back 93

Heparin given before thrombolysis, 5,000 U bolus, then low dose (100 U/hr) during tPA infusion

Front 94

What is the dosage of TPA

Back 94

2 mg initial bolus tPA, followed by infusion of 0.5-1 mg/h (average total dose 10-20 mg; do not exceed 40 mg)

Front 95

Where does the patient go after the catheter is placed

Back 95

Pt monitored in ICU, f/u angiogram at 12 h

Front 96

What is done for lysis of a clot that is not complete

Back 96

When lysis complete or near complete (~24-48 h), tx any remaining stenosis with angioplasty

Front 97

What happens when the fibrinogen level drops below 150

Back 97

Risk of hemorrhage increases when fibrinogen level drops below 100-150 mg/dL

Front 98

What is fibrinogen

Back 98

Fibrinogen (factor I) is a soluble plasma glycoprotein, synthesised by the liver, that is converted by thrombin into fibrin during blood coagulatio

Front 99

What are the complications of thrombolysis

Back 99

Bleeding (10%)
Distal embolization of clot (advance infusion catheter to level of distal clot)
Revascularization syndrome: necrotic tissue revascularized and lactic acid/myoglobin released

Front 100

What is revascularization syndrome

Back 100

: necrotic tissue revascularized and lactic acid/myoglobin released

Front 101

What are the absolute contraindications to thrombolysis

Back 101

Absolute: active internal bleeding, irreversible limb ischemia, recent stroke, brain tumor, left heart thrombus

Front 102

What are the relative contraindications to thrombolysis

Back 102

Relative: h/o GI bleeding, major surgery within 10 d, diabetic hemorrhagic retinopathy, coagulopathy, embolus of cardiac source

Front 103

Are the result good when trying to open up a long segment femoropoptieal occlusion with tpa

Back 103

no, For long segment fem-pop occlusions, percutaneous tx results not good

Front 104

What is the treatment for shorter segment occlusions (less than 10cm

Back 104

Short occlusions < 10 cm
< 3 cm, may be able to do PTA w/o thrombolysis
For longer occlusion, thrombolysis prior to PTA

Front 105

What are the findings in a pt with portal htn on an SMA/celiac angiogram

Back 105

Hepatic arteries have corkscrew appearance because of increased arterial flow and liver shrinkage
Enlarged spleen and splenic artery
Arterioportal shunting may be seen
Flow in GDA may be reversed

Front 106

Normal flow in portal system

Back 106

Front 107

Flow in portal hypertension

Back 107

Front 108

Sites of collateral circulation in portal htn

Back 108

Front 109

Is aterioportal shunting often seen in phtn

Back 109

Arterioportal shunting may be seen

Front 110

portal htn

Back 110

reverse flow in the GDA

Front 111

What are the collateral vessels seen in portal htn

Back 111

Left gastric (coronary) to azygous through esophagogastric varices
Left PV to abdominal wall via paraumbilical
Inferior mesenteric to internal iliac via hemorrhoidal
Splenic to left renal through retroperitoneal veins (splenorenal shunt

Front 112

What are the indications for transjugular liver biopsy

Back 112

Indication: diffuse liver disease + contraindication to percutaneous biopsy (massive ascites, coagulopathy)

Front 113

What is the technique for a transjugular liver biopsy

Back 113

Right IJ vein access
Catheter in right hepatic vein
Obtain sample directing anteriorly

Front 114

What are te 3 types of TOS

Back 114

neurologic
arterial
venous

Front 115

What is the MC type of TOS

Back 115

neurologic (95%)

Front 116

What is compressed in neurologic type of TOS

Back 116

Compression of brachial plexus at point where nerves pass b/w anterior and middle scalene muscles

Front 117

What is compressed in venous TOS

Back 117

Subclavian or axillary vein compressed

Front 118

What is another name of venous TOS

Back 118

Paget-Schroetter disease

Front 119

What is the treatment of TOS

Back 119

thrombolysis, balloon angioplasty residual stenoses, anticoagulation and delayed surgery to correct anatomic cause

Front 120

What is the cause of arterial TOS

Back 120

Chronic compression leads to intimal and medial injury, can lead to occlusion or aneurysm
Mostly affects young adults

Front 121

What are the findings of arterial TOS during angiogram

Back 121

Angio: normal or minimal stenosis in adduction, narrowing evident with provocative maneuver such as hyperabduction

Front 122

What is the tx of arterial TOS

Back 122

conservative if mild, surgical correction of anatomic abnormality if severe or complicated, thrombolysis if completely occluded

Front 123

Vessesl of upper arm

Back 123

Front 124

Anatomy of thoracic outlet

Back 124

Front 125

Can thoracic outlet syndrome occur becaue of an cervical rib

Back 125

yes

Front 126

What is the cause of VENOUS TOS

Back 126

Graphic shows the subclavian vein (black open) crossing over anterior scalene muscle (white curved) and being compressed between the 1st rib (white arrow) and the clavicle (white open). The subclavian artery (black arrow) and brachial plexus (black curved)

Front 127

Venous TOS

Back 127

clavicle and first rib

Front 128

Arterial TOS

Back 128

scalene muslce and 1st rib or cervical rib (elongated transverse process)

Front 129

What is the protocol for CT Chest Angio

Back 129

120 cc Omnipaque 350 at 3 cc/s via antecubital vein
30 s delay
Slice thickness 3 mm with reconstruction interval of 2 mm

Front 130

What are secondary findings for a PE with angiograpy

Back 130

abrupt vessel cutoff, regional hypoperfusion, pruning of vessels, slow flow, filling of collaterals

Front 131

What are the 3 medications used for tx of PE

Back 131

TPA, heparin and coumadin

Front 132

When is fibrinolytic therapy used

Back 132

Almost always. Fibrinolytic therapy (tPA 100 mg IV over 2 h) has replaced surgical embolectomy as primary tx for hemodynamically unstable pts (hypotension, significant hypoxemia, evidence of right heart strain)

Front 133

When is embolectomy used

Back 133

Surgical thromboembolectomy now reserved for pts in whom fibrinolysis has failed or cannot be tolerated

Front 134

Another way of naming the pulmonary arteries

Back 134