Dave: Ir Board Review 4

Front 1

What is the treatment of a traumatic pseudoaneurysm

Back 1

coil or gelfoam

Front 2

Can a traumatic AVF be coiled sometimes

Back 2

yes, this may be coiled sometimes

Front 3

What is the general cutoff where long segment stenosis will not do well with percutaneous therapy

Back 3

> 10 cm, do not do well with percutaneous intervention

Front 4

What is the treatment for long segment stenosis

Back 4

if greater than 10cm then surgery

Front 5

What is the treatment for stenosis less than 10 and greater than 3 cm

Back 5

For obstructions < 10 cm but > 3 cm, not involving SFA origin or distal popliteal, can thrombolyse and then balloon

Front 6

What is done is the stenosis is less than 3cm

Back 6

For < 3 cm, can balloon angioplasty alone

Front 7

What is the ddx of no flow to the renal artery

Back 7

embolus (usually from heart), thrombus superimposed on stenosis, dissection, traumatic injury or avulsion, iatrogenic

Front 8

How long can the kidney tolerate total ischemia before it becomes non-viable

Back 8

Kidney can tolerate total ischemia for 90 min before it becomes nonviable

Front 9

When is embolectomy performed on a renal emboli

Back 9

There is increased morbidity with embolectomy of the kidney therefore conservative management is preferred unless there is bilateral emboli or emboli of a solitary kidney

Front 10

What is the conservative treatment for emboli of the kidney

Back 10

percutaneous catheter-directed thrombolysis (< 3 h), anticoagulation,

Front 11

Superficial lower extremity veins

Back 11

Deep lower extremity veins

Front 12

superficial

Back 12

deep

Front 13

What is the location of the greater saphaneous vein

Back 13

The greater saphenous vein continues along the medial aspect of the thigh and drains into the common femoral vein (CFV) at the saphenofemoral junction (SFJ).

Front 14

What is the MCC of AVF in the lower extremities

Back 14

usually traumatic

Front 15

If there is a traumatic AVF can it be coiled

Back 15

yes, can occasionally be coiled if there is a long fistula

Front 16

When do you drain a pancreatic pseudocyst

Back 16

drain if symptomatic
infected
greater than 4-5cm

Front 17

What is the technique for drainage of a pancreatic pseudocyst

Back 17

Most can be drained via transabdominal or retroperitoneal approach but
can also drain transgastric and transhepatic

Front 18

What are the complications of pancreatic pseudocyst

Back 18

bleeding, infection, pneumothorax, empyema

Front 19

Last slide was complication of treatment

Back 19

yes

Front 20

Is it possible to get a pancreatic fistula with a pseudocyst

Back 20

yes, if there is continued drainage despite

Front 21

What is the treatment of a pancreatic pseudocyst fistula

Back 21

Can give octreotide 100 ug SC TID

Front 22

What is the technique for drainage of a pancreatic pseudocyst

Back 22

Seldinger technique with US or CT guidance
18G Chiba needle into collection, 0.038 wire
Check wire placement with US or CT
Progressively dilate tract
10 Fr catheter inserted over guidewire, form pigtail
Drain as much fluid as possible by aspiration
Attach 3-way stopcock and irrigate with saline until fluid is clear
Attach to drainage bag or suction

Front 23

Do you leave the catheter in for drainage of a pseudocyst

Back 23

yes, and leave suction on

Front 24

Do you irrigate with the pseudocyst with saline

Back 24

yes

Front 25

When do you remove the pseudocyst catheter

Back 25

Catheter removal
Improvement in clinical symptoms (afebrile)
Decreasing or normal WBC count
Drainage from catheter < 10 mL or stopped

Front 26

If there is persistance of drainage from a pseudocyst after 4 wks what should be suspected

Back 26

Persistence despite drainage for > 4 w = persistent pancreatic fistula

Front 27

What is the ddx of a splenic artery aneurysm
3

Back 27

pancreatitis
infection
atherosclerosis

Front 28

When is a splenic artery aneurysm at higher risk of rupture

Back 28

Frequency of rupture is increased with liver transplantation, portal hypertension, and pregnancy

Front 29

What is the mortality of rupture of a splenic artery aneurysm

Back 29

Rupture carries mortality risk between 20% and 36%

Front 30

What is the treatment of a splenic artery aneurysm

Back 30

Embolization is the primary approach to treatment. Embolization and/or stent-graft placement may be used also to exclude splenic artery aneurysms from the normal vessel lumen and thereby prevent aneurysm rupture.

Front 31

How is embolism of a splenic artery aneursym accomplished

Back 31

Packing of the aneurysmal sac with embolic agents (most commonly with coils, but also with detachable balloons and inert particles) and exclusion of the aneurysmal neck with the “sandwich” method are the recommended techniques for treating splenic artery aneurysms

Front 32

What is the sandwhich technique of embolizing a splenic artery aneurysm

Back 32

coil the aneurysm first and then proximal and distal with in the splenic artery

Front 33

Back 33

Front 34

interlobar arteries

Back 34

interlobary arteries

Front 35

If there are chronic PEs what is the typical measurement of main PA pressure

Back 35

35-60mmhg (nl is 9-18)

Front 36

Classification for leg ischemia

Back 36

Classification for leg ischemia

Front 37

What is a normal ABI

Back 37

greater than 0.9 is normal

Front 38

What is the treatment for an ABI less than 0.9 and asymptomatic

Back 38

smoking cessation, exercise, HbA1c < 7, statin, antihypertensive (thiazide, ACEI), antiplatelet (ASA, Plavix)

Front 39

What is the treatment for an ABI of 0.5-0.8 with symptoms

Back 39

Claudication (ABI 0.5-0.8)  medical tx + Pletal (cilostazol) + walking regimen
1-3% require amputation over 5 y period

Front 40

What is the treatment of rest pain, non-healing ulcer, gangrene and ABI less than 0.4

Back 40

revascularization (endovascular, surgical bypass)  > 70% limb salvage

Front 41

What is the prognosis of severe stenosis of lower extremity vessels

Back 41

Without tx, 20% dead, 35% amputated, 45% alive w/o amputation in 1 y

Front 42

When is PTA for leg ischemia indicated

Back 42

Flow limiting, short, single or multiple stenoses

Front 43

What are the contraindications of PTA for leg ischemia

Back 43

diffuse disease, long occlusions, severe arterial calcification

Front 44

Is it possible to PTA infrapopiteal arteries

Back 44

yes, PTA of infrapopliteal arteries made feasible by low profile balloon catheters delivered through 4 or 5 Fr sheath and thin steerable guidewires

Front 45

What is the approach of PTA of a ischemic vessel of the leg

Back 45

Antegrade puncture of ipsilateral CFA

Front 46

Is anticoagulation used in conjunction with tibial artery PTA

Back 46

yes, Anticoagulation important for reducing risk of thrombus in tibial vessels
Aspirin prior to angioplasty
Heparin during the procedure
Vasodilators (NTG) extremely helpful in preventing arterial spasm

Front 47

What are the potenital complications of PTA of the tibial arteries

Back 47

Complications: thrombosis, distal embolization, intimal dissection

Front 48

What is the treatment of bilateral common iliac artery stenosis

Back 48

simultaneous “kissing” angioplasty + stent placement

Front 49

Do common iliac stenosis do well with percutaneous therapy

Back 49

yes, 1 y and 3 y patencies of 90% and 85% for stents and 80% and 70% for PTA alone

Front 50

What is the MC congenital cause of pulmonary AVMs

Back 50

Osler-Weber-Rendu (hereditary hemorrhagic telangiectasia)

Front 51

What are the findings of osler weber rendu

Back 51

Autosomal dominant w/incomplete penetrance
Telangiectasias of nasal mucosa ( epistaxis), mouth, GI tract, brain, lung
Multiorgan AVMs

Front 52

Do most pulmonary AVMs of osler weber rendu have a single feeding artery

Back 52

90% have a single feeding artery and draining vein (simple), other 10% complex w/multiple feeders

Front 53

What is a feared complication of pulmonary AVMs

2

Back 53

R to L shunt w/possible stroke, brain abscess

Front 54

What are 3 clinical signs of pulmonary AVMs

Back 54

Dyspnea, fatigue, hemoptysis (rare)

Front 55

What are the plain film findings of a patient with AVMs

Back 55

Nodule or multiple nodules with tubular structures leading to them (vessels)

Front 56

What are the angiographic findings in a patient with AVMs

Back 56

One or more dilated arteries feeding an aneurysmal dilated sac, rapid venous outflow

Front 57

What are the indications of treating a pulmonary AVM

Back 57

Indications: arterial feeder ≥ 3 mm, symptomatic

Front 58

Is embolization successful in treatment of pulmonary AVMs

Back 58

yes, Embolization successful long term in > 90%

Front 59

What is the procedure for treateing pulmonary AVMs

Back 59

Coils placed proximal to nidus, should be 1-2 mm larger than artery being embolized

Front 60

What screening of the brain should occur in pt with known or suspected osler weber rendu

Back 60

Brain AVM: MR, once in childhood, once as an adult (brain AVMs thought to be congenital)

Front 61

What screening of the lungs should occur in pt with known or suspected osler weber rendu

Back 61

Pulmonary AVM
In childhood, O2 saturation every 1-2 y
Contrast (bubble) echocardiogram in adults
If positive, chest CT

Front 62

What screening of the liver should occur in pt with known or suspected osler weber rendu

Back 62

Doppler US

Front 63

If a pt has osler weber rendu and has AVM in the liver when are they treated (what is the treatment)

Back 63

Only treated if signs of liver or heart failure, severe portal HTN  liver transplantation

Front 64

Can the AVMs of osler weber rendu within the liver be treated with embolization

Back 64

no, embolization (severe complications: parenchymal, biliary necrosis  sepsis)

Front 65

What are the 2 major causes of dissections of the vessels of the lower extremities

Back 65

Dissections in lower extremities most often from either extension of aortic dissection or iatrogenic/catheter-related

Front 66

What is the pathophysiology of a dissection

Back 66

Dissection = separation b/w intima and media or within the media

Front 67

What are 2 potential major complications of dissections

Back 67

ischemia and rupture

Front 68

What is the treatment of a dissection

Back 68

stent

Front 69

Back 69

Front 70

Back 70

Front 71

What is a consideration when analyzing a horseshoe kidney

Back 71

Usually supplied by 3 or more arteries arising from the aorta, iliac arteries, or both

Front 72

What are the blood supplies to an adrenal tumors

Back 72

Usually 3 blood supplies to adrenal
Superior adrenal artery from inferior phrenic artery
Middle adrenal artery from suprarenal aorta
Inferior adrenal artery from proximal renal artery

Front 73

What is the ddx of malignant tumors of the adrenal gland

Back 73

adrenal cortical tumor
pheo
mets

Front 74

What is a consideration when treating a patient a pheochromocytoma

Back 74

For pheochromocytoma, pretreat for 3 d prior to angio w/phenoxybenzamine and use phentolamine as needed during procedure to avoid a hypertensive crisis

Front 75

What percent of pheochromocytoma are in the adrenal medulla

Back 75

90%

Front 76

What syndromes is pheochromocytoma associated with

Back 76

men 2a and 2b

Front 77

What is an important consideration when obtaining angiographic images of a pheochromocytooma

Back 77

The angio is usually delayed until hypertension is controlled by a combination of α-blockers and β-blockers (usually phenoxybenzamine and propanalol
. β-Blockers should not be used until adequate α-blockade has been achieved

Front 78

Alpha 1

Back 78

vasoconstricts

Front 79

Beta 1

Back 79

increase heart rate

Front 80

Beta 2

Back 80

dilates

Front 81

Alpha vasonstricts blood vessels and beta 2 will dilate so you stop alpha first because you dont want unopposed alpha if beta 2 is blocked first

Back 81

yes

Front 82

Do aortocaval fistulas commonly occur

Back 82

no, rare (4% of ruptured AAA) other causes are trauma, and iatrogenic.