Differential Angio

Front 1

Before procedures:

Back 1

OFF ASA for at least 5 days (plt fxn affected)
OFF Plavix for one week
OFF Lovenox for 24-48 hrs; does not necessarily affect PTT
STOP heparin 4-6 hrs prior; PTT must be < 40
Protamine can be used to counter heparin or lovenox

Front 2

Coagulation correction:

Back 2

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 3

Thrombolysis treatment:

Back 3

Always start tPA at 1 mg/hr; fibrinogen followed q8hrs along with H/H, platelets, and K+; if fibrinogen falls <150 cut infusion rate in ½; if it falls <100 stop infusion.TPA 0.5-1 mg/hr and heparinize, repeat angio in 12 hrs, coaxial dual infusion

Front 4

Thrombolysis treatment: Indications

Back 4

arterial graft thrombosis, native acute thrombosis, prior to percutaneous intervention, hemodialysis AVF or graft, venous thrombosis;

Front 5

Thrombolysis treatment:absolute contraindications

Back 5

active bleed, intracranial lesion (stroke, tumor, recent surgery), pregnant, nonviable limb

Front 6

Thrombolysis treatment:favorable prognosis

Back 6

if recent clot, good inflow/outflow, positioned in thrombus

Front 7

Thrombolysis treatment: endpoints

Back 7

endpoints – no lysis after 12 hours infusion, major complications, fibrinogen <100mg/dl

Front 8

Thrombolysis treatment:success

Back 8

90% for grafts and 75% for native

Front 9

Thrombolysis treatment:Cx

Back 9

major hemorrhage, distal embolization, pericatheter thrombosis

Front 10

Treatment:Proximal subclavian stenosis:

Back 10

carotid-subclavian bypass = 90-96% long term patency

Front 11

Treatment:Common iliac stenosis:

Back 11

PTA with stent placement (kissing stents if bilateral) = 80-90% at 4 yrs
Aortofem bypass = 90% at 5 yrs

Front 12

ABI

Back 12

ABI 0.5-0.9: claudication
ABI 0.2-0.4: rest pain

Front 13

Reasons for hepatic venogram:

Back 13

measure wedge pressure (often with balloon dilated), to perform carbon dioxide portography, to perform TIPS, to diagnose Bud Chiari.

Front 14

methods of portal venography:

Back 14

hepatic vein wedge via CO2, delayed SMA injection

Front 15

TIPS: indications

Back 15

portal HTN and variceal bleeding failed sclerotherapy, refractory ascites, refractory hepatic hydrothorax, Budd-Chiari

Front 16

TIPS: absolute contraindications

Back 16

severe R heart failure, liver failure (MELD >26)

Front 17

TIPS: relative contraindications

Back 17

PV thrombosis, hepatic encephalopathy, infection, vascular liver tumors, polycystic liver dz

Front 18

TIPS: GOAL

Back 18

portosystemic gradient < 12 mmHg, decompression of varices; patency 50% at 1 yr;

Front 19

TIPS COMPLICATIONS

Back 19

major complication early is intraperitoneal hemorrhage due to transcapsular needle puncture, hepatic encephalopathy, shunt thrombosis or stenosis, R heart failure, renal failure.

Front 20

Normal portal vein - systemic vein pressure:

Back 20

< 6 mm Hg; > 12 = risk of variceal bleeding;

Front 21

PV thrombosis

Back 21

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

Front 22

PORTAL VEIN COLLATERALS

Back 22

gastroesophageal, mesenteric, perisplenic, periumbilical, hemorrhoids;

Front 23

findings in PV thrombosis

Back 23

splenomegaly, portal collaterals (cavernous transformation), recanalized periumbilical vein or hepatofugal flow.

Front 24

Types of biliary drains:

Back 24

external, internal-external, and internal

Front 25

2 major complications of PTC/PBD
percutaneous transhepatic cholangiography; percutaneous biliary drainage

Back 25

(1) HA pseudoaneurysm (tampanode bile tract with balloon and coil artery) and (2) biliary sepsis (premed with abx)

Front 26

Budd-Chiari:

Back 26

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

Front 27

HCC: findings on angio

Back 27

arterial-portal venous shunting and portal vein invasion and thrombosis are findings nearly pathognomonic for HCC; increased tumor vascularity is also noted;

Front 28

Chemo embo for HCC

Back 28

hepatic chemoembolization can be performed if tumor does not occupy >50-75% of liver; Hepatic arterial supply chiefly to tumor so can embolize without concern for infarct since most of hepatic supply is by portal vein. Use PVA particles, CTX, contrast, ethiodol. CT immed post-procedure.

Front 29

HCC post embo syndrome

Back 29

A condition that includes pain, nausea, vomiting and low-grade fever

Front 30

Things to know prior to chemo embo HCC

Back 30

Before TACE, must know if portal vein patent and direction of flow. Late phase celiac and SMA injection will give you the answer.

Front 31

Liver chemo embo common tumors

Back 31

HCC, neuroendocrine tumors, melanoma, sarcoma, colon

Front 32

Porta Hepatis Biliary Obstruction:

Back 32

Klatskins tumor, HCC, gallbladder CA, Metastatic LAD at porta hepatic, Mirizzis

Front 33

Microaneurysma in Liver:

Back 33

PAN, necrotizing angiitis secondary to drug abuse (methamphetamine), mycotic aneurysms

Front 34

Axillosubclavian vein occlusion:

Back 34

thoracic outlet obstruction (Paget-Schroetter syndrome) versus indwelling catheter

Front 35

Thoracic Outlet obstruction:

Back 35

exacerbated by shoulder abduction or Adson’s maneuver (hyperextend neck with head rotated to ipsilateral side and inspire deeply); may cause subclavian vein occlusion and/or subclavian artery occlusion/thrombosis (with emboli!)/aneurysm; causes include cervical rib, muscular habitus with enlargement of the anterior scalene muscle or pec minor, scalenus minimus muscle, anomalous 1st rib that narrows the costoclavicular space, healed fracture deformity of 1st rib or clavicle. Tx: surgical decompression with possible arterial embolectomy.

Front 36

Lower GI Bleed:

Back 36

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 continue for another 12 hrs and then slow taper over 12-24 hrs (persistent abdominal pain may indicate ischemia); recurrent bleeding occurs in 40% patients. Vasopressin NOT used for UGI bleed; contraindication to vasopressin = CAD, CV disease, severe HTN.

Front 37

Mesenteric ischemia:

Back 37

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 38

Right arch with mirror image branching:

Back 38

98% association with CHD (TOF and Truncus)

Front 39

Takayasu’s arteritis:

Back 39

most pts < 30 and females, THE classic large vessel arteritis; pathologically indistinguishable from giant cell arteritis, but the latter affects medium-size arteries, typically ECA branch such as superficial temporal artery; 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 40

Giant cell arteritis:

Back 40

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

Front 41

SVC Syndrome:

Back 41

Most common cause is bronchogenic carcinoma in USA. Other causes can include long-term catheters or pacemaker leads, granulomatous mediastinitis, radiation-induced fibrosing mediastinitis (this case); Radiation therapy may be considered first line for malignant SVCS; for palliation may perform thrombolysis and stenting; may have downhill varices

Front 42

Hypothenar hammer syndrome:

Back 42

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. peripheral vasodilator

Front 43

Subclavian steal syndrome:

Back 43

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

Front 44

Splenic artery aneurysm:

Back 44

Most common aneurysm of visceral arteries; next in abd after AAA and iliacs; Females 4:1. Multiparity and portal htn risk factors. Preg increases rx risk; Tx rec’d when > 2 cm size, women who may become preg or inflamm etiology – can embolize or stent graft; Need prox and distal embo to prev collateral filling. Other options incl surg ligation or splenectomy; Complications of embolization include splenic infarction, embolization of other arteries, abscess formation, incomplete occlusion, and recanalization.

Front 45

Causes of popliteal artery stenosis or occlusion:

Back 45

atheroscerosis, cystic adventitial dz, thromboemb
popliteal aneurysm, popliteal entrapment, posterior knee dislocation/relocation

Front 46

Popliteal artery aneurysm:

Back 46

Diffuse or focal enlargement of the popliteal artery with thrombosis; sx of distal ischemia may be secondary to emboli (20%) or more commonly thrombosis (40%). Significant % are bilateral. Assoc with aneurysm elsewhere (usually AAA or common femoral artery aneurysm); Rupture is very uncommon (<5%); tx is surgical resection with bypass

Front 47

Popliteal artery entrapment:

Back 47

young athletes, narrowing or occlusion on plantar flexion.

Front 48

Buerger’s dz:

Back 48

thromboangiitis obliterans, Inflammatory arteritis of unknown etiology affecting medium size arteries of upper and lower extremities ; male smoker 20-40 y/o, claudication, calf and foot vessels most common, Multiple abrupt segmental occlusions of the small and medium-sized vessels; background of otherwise relatively normal vasculature; Hallmark feature is distinctive CORKSCREW collaterals

Front 49

IVC filters:

Back 49

contraindication or failure or complication of anticoagulation; Bird’s nest for mega cava > 28mm up to 40mm, Simon nitinol filter (9F system) may be placed via brachial vein!; Standard Greenfield filter is a 14F system; 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 50

Bronchial artery embolization:

Back 50

Massive hemoptysis = 300 cc/day; bronchial artery angiogram shows tortuous tangle of vessels (neovasculairy 2o inflammation) vessels…active extrav very rare; originate from descending aorta at T5-6; spinal arteries may airse from bronchial arteries!!!; typically use polyvinyl alcohol.

Front 51

Uterine artery embolization

Back 51

Effective in reducing menorrhagia as well as pressure symptoms related to the bulky fibroids in more than 90% of patients; Selectively embolizing the uterine arteries with polyvinyl alcohol particles bilaterally; Ovarian artery collaterals prevent uterine infarct; Embolization may play a role in the management of uncontrolled post-partum hemorrhage using absorbable Gelfoam pledgets so that the uterine arteries will eventually recanalize, leaving open the possibility of future pregnancies.

Front 52

Thoracic aortic aneurysm:

Back 52

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 53

Aortic dissection:

Back 53

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 54

Traumatic aortic injury:

Back 54

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 55

AAA:

Back 55

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

Front 56

Endoleaks:

Back 56

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

Front 57

Abdominal aortic coarctation:

Back 57

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

Front 58

Williams syndrome:

Back 58

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

Front 59

Aortoiliac occlusive disease:

Back 59

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 60

Mesenteric collaterals:

Back 60

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 61

Median arcuate ligament syndrome:

Back 61

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

Front 62

UGIB:

Back 62

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

Front 63

Angiodysplasia:

Back 63

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

Front 64

RAS:

Back 64

atherosclerosis > FMD, NF, 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, mid and distal renal > ICA or vertebrals, string of beads, excellent response to PTA, most common cause of RAS in children, spontaneous RA dissection.

Front 65

RA aneursym

Back 65

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

Front 66

RVT:

Back 66

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

Front 67

PA gram:

Back 67

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 68

LE atherosclerotic occlusive dz:

Back 68

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

Front 69

LE atherosclerotic aneurysmal dz:

Back 69

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

Front 70

Arterial thomboembolism:

Back 70

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 71

May-Thurner syndrome:

Back 71

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

Front 72

UE dz:

Back 72

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 73

Trauma indications for angio.

Back 73

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

Front 74

Aneurysm:

Back 74

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 75

Ischemia:

Back 75

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

Front 76

Peripheral vascular disease:

Back 76

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

Front 77

Emboli:

Back 77

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 78

Angiographic tumor features

Back 78

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

Front 79

Hypervascular lesions:

Back 79

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 80

Aortic enlargement:

Back 80

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

Front 81

Aortic stenosis:

Back 81

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

Front 82

Pulmonary artery stenosis:

Back 82

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

Front 83

Hyperreninemic HTN:

Back 83

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

Front 84

Renal tumors:

Back 84

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

Front 85

Renal arterial aneurysm:

Back 85

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 86

Angio complications:

Back 86

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

Front 87

Catheters:

Back 87

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 88

Flow rates:

Back 88

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 89

Guidewires:

Back 89

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

Front 90

Pharmacologic:

Back 90

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 91

Embolization:

Back 91

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 92

Angioplasty:

Back 92

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 93

Stents:

Back 93

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 94

Foreign body retrieval:

Back 94

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

Front 95

Urticaria

Back 95

1. Discontinue injection if not completed. No treatment needed in most cases.
2. H1-receptor blocker: Benadryl 25-50mg PO/IM/IV or Vistaril 25-50mg PO/IM/IV. H2-receptor blocker may be added: Cimetidine 300mg PO/IV or Ranitidine 50mg PO/IV (diluted in 10ml D5W solution) slowly.
3. If severe or widely disseminated: Alpha agonist (arteriolar and venous constriction) - Epinephrine SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) if no cardiac contraindications.

Front 96

Facial or Laryngeal Edema

Back 96

1. Epinephrine SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) or, if hypotension evident, Epinephrine (1:10000) slowly IV 1.0ml (=0.1mg). Repeat as needed up to a maximum of 1mg.
2. O2 6-10liters/min (via mask).
3. If not responsive to therapy or obvious acute laryngeal edema, seek appropriate assistance (eg code team) and consider intubation.

Front 97

Bronchospasm

Back 97

1. O2 6-10liters/min (via mask).
2. Beta-agonist inhalers (bronchiolar dilators, such as metaproteronol, terbutaline, or albuterol)
3. Epinephrine SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) or, if hypotension evident, Epinephrine (1:10000) slowly IV 1.0ml (=0.1mg). Repeat as needed up to a maximum of 1mg.
4. Alternatively, aminophylline 6mg/kg IV in D5W over 10-20 minutes (loading dose), the 0.4-1.0mg/kg/hr, as needed (caution: hypotension) or Terbutaline 0.25-0.5mg IM or SC.
5. Call for assistance (eg code team) for severe bronchospasm (or if O2 sat <88% persists).

Front 98

Hypotension with Tachycardia

Back 98

1. Legs elevated 60 degrees or more (preferred) or Trendelenburg position.
2. Monitor: EKG, pulse ox, BP.
3. O2 6-10liters/min (via mask).
4. Rapid administration of large volumes of normal saline.
5. If poorly responsive, Epinephrine (1:10000) slowly IV 1.0ml (=0.1mg). Repeat as needed up to a maximum of 1mg.
6. If still poorly responsive, transfer to ICU for further treatment.

Front 99

Hypotension with Bradycardia (Vagal Reaction)

Back 99

1. Monitor vital signs.
2. Legs elevated 60 degrees or more (preferred) or Trendelenburg position.
3. Secure airway: give O2 6-10liters/min (via mask).
4. Secure IV access: rapid fluid replacement with normal saline.
5. Atropine 0.6-1.0mg IV slowly.
6. Repeat atropine up to a total dose of 0.04mg/kg (2-3mg in adult).

Front 100

Hypertension, Severe

Back 100

1. Monitor EKG, pulse ox, BP.
2. Nitroglycerine 0.4mg tablet, sublingual (may repeat x 3), or, topical 2% ointment, apply 1 inch strip.
3. Sodium nitroprusside; solution must be further diluted with 5% Dextrose before infusion; must maintain proper monitoring for potential precipitous decreases in BP; review complete dosage and administration instructions prior to use; infusion pump necessary to titrate.
4. For pheochromocytoma – phentolamine 5.0mg (1.0mg in children) IV.

Front 101

Seizures or Convulsions

Back 101

1. O2 6-10liters/min (via mask).
2. Consider Valium 5mg or Versed 2.5mg IV.
3. If longer effect needed, obtain consultation; consider Dilantin infusion 15-18mg/kg at 50mg/min.
4. Careful monitoring of vital signs required.
5. Consider code team for intubation if needed.

Front 102

Pulmonary Edema

Back 102

1. Elevate torso; rotating tourniquets (venous compression).
2. O2 6-10liters/min (via mask).
3. Diuretics – Lasix 40mg IV, slow push.
4. Consider morphine. Corticosteroids optional.