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146 Cards in this Set

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Before placing a line for pulmonary angiogram what 2 things should be done first
Check for LBBB (need pacer), check Doppler for groin clot (IJV approach)
What type of catheters are used for pulmonary angiography
Use standard diagnostic catheter (pigtail, Grollman) via R femoral vein or R IJ vein
What should be done if the patient has V-tach
If patient has Vtach, reposition catheter/wire
If sustained, 100 mg lidocaine bolus then 2 mg/min
Before injecting contrast what should always be done first
Check PA pressures before injecting
If very high (> 70 mm Hg) decrease contrast dose to lessen risk of right heart failure
What are the 2 MCC of lower GI bleed
diverticular disease, angiodysplasia
What is angiodysplasia
dilated submucosal veins and capillaries in bowel wall. angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places.
What are other less common causes of LGIB
post biopsy or polypectomy, tumors, polyps, IBD, ischemia
If a pt has a positive RBC scan what is the next step
Pts w/positive RBC scan should undergo angio
What is the sensitivity for detection of bleeds for both angios and Tc RBC
Angio can detect 0.5 cc/min
Tc RBC can detect 0.1 cc/min
What is the sequence of injection for suspected LGIB
Suspected LGIB  inject SMA then IMA, and if both negative, celiac
What are the angiographic findings of LGIB
Hallmark is extravasation of contrast into bowel
Occasionally extravasation is curvilinear and mimics a vascular structure (pseudovein sign)
Does diverticula dz have a characteristic bleed
No characteristic appearance unless contrast fills the diverticulum
What are the angiographic findings in a pt with bleeding from angiodysplasia
Bleeding vessel usually not seen
Early venous drainage from one portion of bowel, or tram track sign from simultaneous opacification of feeding artery and draining vein
What is the procedure for using vasopressin to stop a LGIB
Vasopressin: 0.2 U/min  repeat angio after 30 min  if persists, increase to 0.4 U/min and repeat angio in 30 min  if still bleeding, pursue other tx; if working, continue for 12-24 h and taper over 12-48 h
How effective is vasopressin in stopping a LGIB
60-90% effective, rebleeding is common
What are 5 contraindications of LGIB
Contraindications: severe CAD, severe HTN, dysrhythmias, bleeding at sites with dual blood supply, bleeding directly from large artery, after embolotherapy
What are the potential complications of vasopresin therapy
6
bowel ischemia, angina, arrhythmia, HTN, bradycardia, allergy
What is a 2ndary method of treatment for a lower GI bleed
embolectomy
How effective is embolectomy for angiodysplasia
Usually does not work long term for angiodysplasia or AVM (require surgery)
What is the mainstay of embolization of LGIB
Macrocoils, microcoils
Where is the proper placement of coils for LGIB
Coils placed distally in arcades proximal to bleeding vasa recta to minimize intestinal ischemia
How much coiling should be done
Continue embolizing until bleeding stops
Embolize collaterals if contributing to bleeding
How effective is embolization of LGIB
60-100% effective acutely, recurrence is uncommon except with AVM, angiodysplasia
What are the contraindicaitons of LGIB embolization
poor collateral blood flow, prior gastric or bowel surgery or radiation
What is the main complication of LGIB coiling
Complications: bowel infarct < 20%
What are 2 causes of acute SMA occlusion
embolism
thrombosis
Where do embolisms from the heart normally occlude the SMA
Usually from heart, lodge in SMA below origin of middle colic artery
Do SMA embolisms sometimes go into the distal SMA or branches
yes
What sometimes happens to the vessels distal to the SMA occlusion
Arteries beyond occlusion undergo vasoconstriction
What are the angiographic findings of an acute SMA embolus
discrete filling defect, no collaterals
What are the findings of an SMA thombus
Usually involves most proximal portion of SMA and is superimposed on chronic atherosclerotic narrowing
What is a major distinguish feature of an acute and chronic occlusion
Usually well-developed collaterals
The outlined dot marks the sheath entry site into the CFA at the medial aspect
of the femoral head in the midline. (A) Inferior border of the femoral head. (C)
Line demarcating inguinal ligament running from the anterior superior iliac
spine to the pubic symphysis. (D) Bifurcation of CFA into superficial femoral
artery and profunda.
*with permission from Abbott Vascular
The outlined dot marks the sheath entry site into the CFA at the medial aspect
of the femoral head in the midline. (A) Inferior border of the femoral head. (C)
Line demarcating inguinal ligament running from the anterior superior iliac
spine to the pubic symphysis. (D) Bifurcation of CFA into superficial femoral
artery and profunda.
*with permission from Abbott Vascular
What should you suspect if there is retrograde filling of the SMA when injecting the IMA
Sometimes SMA occlusion can be demonstrated on IMA injection when it fills retrograde
What is the tx of an SMA occlusion
: surgical embolectomy for large proximal clot, anticoagulation and vasodilators for distal smaller clots, thrombolysis
What is the indication of percutaneous transhepatic cholaniogram
Used to dx and tx proximal biliary obstruction, and occasionally for nonsurgical tx of bile leaks from duct injury
What should be done 1 hour prior to this procedure
Antibiotics to include gram negative coverage routinely administered one hour prior
What are 4 complications of PTC
sepsis, cholangitis, bile peritonitis, hemorrhage
What is an occasional tx done during PTC
occasionally for nonsurgical tx of bile leaks from duct injury
What are the 2 approaches of PTC
right and left
What is the technique for insertion of the needle during PTC
22G Chiba needle, right lateral midaxillary approach below 10th rib (to avoid pleura) under fluoroscopy
What is a chiba needle
22 gauge thin-walled needle with a sharp inner mandrin originally designed at the University of Chiba, Japan, for fine needle puncture (FNP) and for percutaneous transhepatic cholangiography PTC . Today it is also used for many other access punctures such as percutaneous nephrostomy PCN , fluid collections,
What is the landmark that the chiba needle should be directed toward
Needle passed over rib, directed in a plane parallel to table top aimed toward T11
How far should you advance the chiba needle
Stop advancing needle when you reach midclavicular area
After reaching the midclavicular region what should be done next
Remove stylet and inject 0.1 cc 60% contrast while slowly retracting the needle
How do you know if you are in a bile duct
When contrast fills a tubular structure and stays there, you are likely in a bile duct
What is the next step once you are in the bile duct
Remove 5-10 cc of bile and send for Gram stain and culture
Inject additional 5-10 cc contrast to confirm
What is the region of insertion of the needle for a left sided PTC
Left subcostal approach in the epigastrium
US used to access a bile duct while avoiding artery and portal vein
What is the general difference between benign and malignant biliary strictures
benign strictures tend to taper, where as, malignant will be abrupt
What is the radiographic difference in appearance of AIDS cholangitis and PSC
PSC and AIDS cholangitis are indistinguishable: multifocal strictures with scattered normal areas +/- diverticula
What is the appearance of the biliary ducts in a pt with a klatskin tumor
usually located near hilum (Klatskin), abrupt and possibly nodular, dilated intrahepatic ducts
What is the appearance of the biliary ducts in a patient with pancreatic or ampullary Ca
abrupt occlusion at distal CBD with a beaked appearance
What is the general sequence of exchange of wires in a pt with a stenosis or stricture
Pass 0.018 in wire through Chiba for PTC
Exchange for 0.038 in wire and advance catheter over wire
Dominant proximal stricture can be angioplastied
What type of pts will get biliary stents
Stents can be used for malignancy or nonsurgical candidates
What are 3 ways to drain
3 types of drainage: internal, external, both
What are the surgical options for a traumatic AVF
surgical ligation; catheter embolization.
What is the angiographic findings in a patient with an AVF
on arteriogram, filling of a larger vascular structure, less densely opacified, adjacent to artery
What type vessels are effected by takayasu arteritis
Large artery vasculitis
What specific vessels are effected by takayasu arteritis
Primarily involves aorta, great vessels, pulmonary arteries
What is the demographics that are effected by takayasu
Usually young to middle-aged women
What are the angiographic findings in a patient with takayasuu
Dilation or irregularity of ascending aorta, narrowing of descending aorta, long stenoses or occlusions of arch vessels
What are the findings in a patient with takayasu
CT/MR: enhancement of artery wall in acute phase
When is there enhancement of the arterial wall in takayasu
acute phase
What is the first stage of Takayasu
stenoses of arch and branch vessels
How many stages of takayasu are there
4
What is the second stage of Takayasu
descending thoracic and abdominal aorta + abdominal branches
What is the 3rd stage of takayasu
aortic arch plus abdominal aorta
What is the 4th stage of takayasu
pulmonary artery and aorta
What are the 4 stages of takayasu
1: stenoses of arch and branch vessels
2: descending thoracic and abdominal aorta + abdominal branches
3: aortic arch plus abdominal aorta
4: pulmonary artery and aorta
When is treatment of takayasu delayed until
angioplasty and stent delayed until disease is inactive if possible
What occurs in the 4th stage of takayasu
pulmonary artery and aorta
What demographic is most commonly effected by giant cell arteritis
older women
What artery is giant cell arterititis known for
Usually involves the temporal artery
Takayasu will effect young and middle age women and what age group of women does giant cell arteritis effect
older women
What vessels does giant cell arteritis effect
Involves distal subclavian or axillary arteries,
What do the lesions of giant cell arteritis look like
Lesions are long and smooth
What vessels are not effected by giant cell arteritis
not the brachiocephalic, common carotids, or proximal subclavians
What is the treatment for a staghorn calculus
percutaneous nephrolithotomy
What is done on the first and second day when removing a staghorn calculus
Single or 2-stage (initial access on one day, and then stone extraction on another day)
What is the location of the approach when accessing the kidney for removal of a staghorn calculus
Posterolateral approach below 12th rib
What are 2 potential ways to guide access into the collecting system in a patient with a staghorn calculus
w/US guidance or opacification of collecting system w/fluoro guidance
Once an 18G needle is advanced into the collecting system what is the next step in tx of a patient with staghorn calculus
0.038 in guidewire is advanced to bladder
Why is a nephrostogram done 24-48h after removal of a stone
Nephrostogram 24-48 h after stone extraction to detect residual fragments or obstruction
When is the nephrostomy catheter removed
Only remove percutaneous nephrostomy catheter after documenting forward flow on a gravity nephrogram through the tube
What are potential complications of percutaneous nephrolithotomy
Bleeding, sepsis, perforation of collecting system or ureter (usually heals spontaneously if allowed to drain externally)
Besides the renal arteries where does FMD tend to affect
MC renal arteries, can also involve ICAs, usually mid to distal portion
How often is FMD bilateral
Bilateral in 2/3,
What percent are associated with intracranial aneurysms
25% assoc w/intracranial aneurysms
What are the 5 types of FMD
Medial fibroplasia (MC, 60-70%, string of beads)
Perimedial fibroplasia (15-25%, irregular beaded narrowing)
Medial hyperplasia (5-15%, tubular smooth narrowing)
Intimal fibroplasia (1-2%, focal, smooth)
Adventitial fibroplasia (< 1%, tubular smooth
What is the treatment of FMD
PTA
How big for lithotripsy
How big for percutaneous nephrolithomy
What are the indications for percutaneous lithothomy
THIS IS THE FIRST CHOICE FOR AVF. Hemodialysis access. Endogenous radiocephalic
arteriovenous fistula. Note the inflow radial artery (upper right arrow),
efferent radial artery (arrowhead), and outflow cephalic vein (curved arrow).
YES
What is the preferred type of graft for dialysis
Synthetic loop graft from the distal brachial artery
to the cephalic vein. Crossed catheters are in place for pulse-spray thrombolysis.
radiocephalic AVF
Inflow Vs outflow in radiocephalic AVF
upper ext venous anatomy
upper ext art anatomy
What is the MCC of mesenteric insufficiency
atherosclerotic dz of the mesenteric vessels
What is the MC demographic to have mesenteric ischemia
elderly women
In order for mesenteric ischemia to take place what must occur
2 of the 3 vessels must have significant stenoses or occlusions
What are other causes of mesenteric ischemia
thrombus, embolus, extrinsic compression dissection, vasculitis, vasoconstricting drugs (diffuse stenosis), shock/hypotension (nonocclusive)
What is the tx of mesentric vascular insufficiency
Acute: occlusive  surgery; nonocclusive  papaverine
Chronic: PTA/stent
What are causes of extrinisic compression that may lead to mesenteric ischemia
tumor, inflammatory mass, median arcuate ligament syndrome
What is the typical finding of drug related mesenteric ischemia
diffuse stenosis from vasoconstricting drugs
Can hypotension cause vascular insufficiency
yes
What are the findings of shock or hypotension leading to vascular insufficiency
Diffuse narrowing or segments of alternating spasm and dilation

Poor filling of vasa recta
What is the appearance of the vasa recta in patients with hypotension
`Poor filling of vasa recta
When do you find slow flow w/contrast persisting in intestinal branches for > 2 s after injection has ended
shock/hypotension
What is the work up for a patient with mesenteric insufficiency
What is considered a special case of celiac stenosis
median arcuate ligament syndrome
What is the cause of median arcuate ligament syndrome
Superior aspect of celiac compressed by median arcuate ligament ( which is connected to the crura of the diaphragm)
What is the common demographic and symptoms of median arcuate ligament syndrome
Usually occurs in thin young women

Abdominal pain, weight loss, nausea
When are the symptoms worse in median arcuate ligament syndrome
Symptoms worse during exhalation (may be seen during expiration)
What is another name for leriche syndrome
infrarenal aortic occlusion
What are the SS of leriche syndrome
claudication and impotence
What is a major predisposing factor to leriche syndrome
smoking
What is the tx of leriche syndrome
aortobifemoral graft, endovascular stent graft (possibly subintimal)
What is the ddx of leriche syndrome
Williams syndrome, Takayasu arteritis, giant cell arteritis, dissection, neurofibromatosis
If the aorta is completely occluded in leriche syndrome how does blood get to the lower extremities
collateral circulation
collaterals
collaterals
Where is the arc of riolan
Can williams syndrome, takayasu, and giant cell arteritis affect the aorta and make it appear small
yes
What is the pathway of the internal mammary to the external iliac
internal mammary to the superior epigastric to the inferior epigastric to the external iliac
Intercostals, subcostal, and lumbar arteries  iliolumbar, lateral sacral, and superior gluteal branches of posterior division of internal iliacs
Intercostals and lumbars  deep circumflex iliac  external iliac
SMA  IMA  superior and middle hemorrhoidals  internal iliac  external iliac
Why are the internal iliac arteries prone to transection
Internal iliac artery and branches run close to bones and ligaments of pelvis
What are the branches of the internal iliac arteries
Internal iliac artery: anterior branchesWhat Bill admitted to Hilary: "I Milked Our Insatiable Intern's Udders Under the Desk": Inferior gluteal Middle rectal Obturator Inferior vesical artery Internal pudendal artery Umbilical U/D=Uterine artery (female)/ Deferential artery (male)
What are the common causes of bleeding of the internal iliac arteries
Frequently injured in MVAs, falls, crush injuries
What percent of pelvic fx will have an associated bleed
10% pelvic fxs have bleeds requiring embolization, mostly AP or lateral compression type injuries
What branches MC have bleeding after a fx
MC sources are superior gluteal and internal pudendal
What is the tx of a internal iliac bleed
selective embolization w/Gelfoam, coils
What part of the esophagus will an abberant right subclavian artery be located
posteriorly
What is the MC aortic arch anomaly
the right abberant subclavian (2%)
Does an abberant right subclavian pass behind the trachea and esophagus
yes
What is the dilated portion of the aortic arch arise from
diverticulum of kommerel
If there is a clinical symptom what is the most common SS
dysphagia
Is the abberant vessel in abberant right subclavian artery proximal or distal
distal (more posterior)
What happens to the bronchial arteries in a patient with cystic fibrosis
they will hypertrophy
Do cystic fibrosis patients sometimes have hemoptysis
yes
What artery is most commonly responsible for hemorrhage in patients with CF
the bronchial arteries
What is the common cause of hemoptysis in patients with TB
pulmonary arteries
Besides CF what are some other causes of hemoptysis
Rasmussen aneurysm, AVM, or traumatic PA pseudoaneurysm and TB (other infections)
What are the causes of massive hemopthysis
infection (aspergilloma, TB), bronchiectasis, CF, tumor
What is the definition of massive hemoptysis
over 500ml in 24h