Interventional Radiology Recertify Board Reviews

Front 1

Malignant Neoplasm of the Vein

Back 1

Very Rare
2 major types: Leiomyosarcoma
Epithelioid hemangioendotheliomas
Centrally: IVC most frequent site,
Peripherally: GSV>CFV>EIV>Pop Vein
5x more common than arterial

Front 2

Leiomyosarcoma of the Vein

Back 2

Cause venous obstruction > DVT > collateral masked venous obstruction >Delayed in Dx up to 2yrs
Slow Growth
Poor Prognosis
Metastasize early particularly to lung and liver

Front 3

Epithelioid Hemangioendotheliomas

Back 3

commonly in iliac and femoral veins
slow grow
Asx venous obstruction
Mets uncommon

Front 4

Treatable cause of HTN

Back 4

Renal Arterial Stenosis (ASVD, FMD)
Renal Arterio-Venous Fistula
Coarctation of the Aorta
Primary hyperaldosteronism
Cushing's syndrome
Pheochromocytoma
Hyperthyroidism
Hyperparathyroidism
Sleep apnea
Drug effect

Front 5

Clinical feature of treatable HTN

Back 5

Severe HTN (>180 sys / >110 dia)
onset below the age of 20 y.o. or above 50y.o.
Lack of Fam Hx
Poor response to therapy
Positive lab test or Physical Exam

Front 6

Fibromuscular Dysplasia (FMD)

Back 6

75-80%
Most common: medial fibroplasia, string of beads
-5-10%-intimal fibroplasia,
-30-40%- bilateral
-ICA and Vert. art.-25-30% of FMD pt, assoc. with 7-50% intracranial aneurysm

Front 7

Pheochromocytoma

Back 7

Rules of 10: 10% bilateral
10% malignant
10% extraadrenal
higher risk for extraadrenal in women, and younger age
Rx: alpha blocker must be started before beta blocker

Front 8

Pheo continue

Back 8

Okay to give nonionic contrast, even b4 alpha blocker

Glucagon is contraindicated, known to induce catecholamine release

Hypertensive crises: Trauma, Exercise, Anesthesia,
Manipulation at surgery, Micturition,
percutaneous needle biopsy, angiography

Front 9

Meandering Mesenteric Artery

Back 9

a.k.a. Arc of Riolan
Enlarge branch of Left Colic artery
More common with SMA occlusion
Would cause bowel ischemia if occluded with EVAR

Front 10

Popliteal Entrapment Syndrome

Back 10

3 types : 1) Medial to medial head of Gastroc, most common, compression
b/w muscle & medial femoral condyle
2) Normal or near normal course, atypical positioned muscles fibers or tendons cause it to be compressed.
3) Combo of the 2 above

Front 11

Popliteal Entrapment Syndrome

Back 11

Calf claudication w/ strenous exercise
0.5% of cases of claudication, 40% in < 30y.o.
♂ > ♀ 6.5:1
Bilateral in up to 1/4 of the cases, Sx tend to be unilateral
Presentation: Claudication, acute ischemia, distal emboli, Aneurysm, or DVT (if pop. v. entrapment )
DDx: Adventitial Cystic Disease

Front 12

Popliteal Entrapment Syndrome

Back 12

Pop. Artery and Vein course through popliteal fossa in close proximity, separated by small amount of fat.

If there is an interruption at any point by soft tissue band, entrapment is present. This is not apply when art. and vein are trap together.

US may not be helpful in cases of thin
musculotendinous band.

Rx: Stent and balloon angioplasblasty has no role.

Thrombolysis would be helpful to delineate underlying pathology of popiteal occlusion.

Front 13

Segmental arterial mediolysis

Back 13

- rare
- vacuolization and lysis of arterial smooth muscle -> aneurysm
-? variant of FMD
-Abdominal SAM: Elderly, multiple arterial involvement
-Coronary SAM: Neonates, children and young adults.
Rx- Fusiform aneurysm of SMA, IMA or renals require surgical intervention.

Front 14

Pancreaticoduodenal Artery Aneurysm

Back 14

Etiology
ASVD
Septic Emboli
Trauma
Pancreatitis
Vsculitis

Front 15

Pancreaticoduodenal Artery Aneurysm

Back 15

- Prone to rupture
- Rarely present with GI bleed
- Presentation: abd. pain and catastrophic retroperitoneal bleed
-Rx: Ligated, resected, or embolized even if Asx, regardless of size.

Front 16

May-Thurner Syndrome (Cockett syndrome, Iliac Vein Compression Syndrome)

Back 16

- Asx venous compression -> endothelial adhesions and webs -> superimposed thrombosis

Front 17

SVC syndrome

Back 17

-15,000 Americans per year
-Non-malignant causes, 35% of cases
-Malignant: Rx- external beam radiation and endovascular stenting. Lymphoma-systemic chemotherapy

Front 18

Aberrant Coronary Arterial Vasculature

Back 18

-anomalous origin of Lt circumflex artery, most common
(arising from right sinus of Valsalva)
-anomalous origin of Rt coronary artery ( from Lt sinus of
Valsalva) 2nd most common

Front 19

Aberrant Coronary Artery

Back 19

1) Retroaortic- anomalous artery crosses the base of the heart posterior to aorta
2) b/t ascending aorta and pulmonary trunk
3) Anterior to pulmonary trunk

Front 20

Patent Ductus Arteriosus

Back 20

-10-12% of all congenital heart anomalies
-Symptomatology usually depends on the size of the PDA
-Presentation: Fatigue, dyspnea, palpitations and exercise intolerance, infective endocarditis, Pulm HTN, CHF

Front 21

Angiomyolipoma

Back 21

-Lesion >4cm should be treated, 80-90% Symptomatic
- 50-60% will have retroperitoneal bleed
-Rx: Embolized with ETOH to ethiodol ( ratio 3:1 mixture)

Front 22

Varicocele Embolization

Back 22

-technical failure 5-12 %
- partially competent valve, vessel tortuosity, vein spasm
-spasm Rx: NTG could help
- spermatic vein is fragile -> extravasate during firm injection or coil placement
- Failure of embolization is due to collaterals around embolized vessels, aberrant vessels to the varicocele (17-19%)
-Collateral can arise from renal vein branches near hilum, directly off the IVC or from retroaortic renal vein.

Front 23

Uterine Fibroid Embolization

Back 23

-85% clinical response rates
-MRA - 100% sensitive, 77% specific for detecting ovarian artery supply
- Aortic flush to detect ovarian branch feeding fibroid is controversial
- Some recommend ovarian artery embo as a second procedure after seeing response to UFE alone and after appropriate conseling for possible ovarian dysfunction

Front 24

Hereditary Hemorrhagic Telangectasia (HHT)

aka Rendu-Osler-Weber Disease

Back 24

-Autosomal dominant disorder
-Mucocutaneous telangiectasia
-AV Malformation (nose, skin, lungs, brain, liver and GI tract) , incidence highest in lung, 15-20% of HHT pt.
-Recurrent epistaxis

Front 25

Simple AVMs

Back 25

-80-90%
-Single pulmonary artery branch and single efferent pulmonary vein, connected through a thin walled aneurysm

Front 26

Complex AVMs

Back 26

-Less common
- 2 or 3 feeding arteries and 2 or more draining veins
-Multiple, bilateral and predilection for lower lobe
-Capillary free communications b/t lung and systemic circulation -> AV shunt (Right to Left shunt) ->TIA, CVA, brain abscesses

Front 27

Pulmonary AVMs

Back 27

-Increase Mortality with size
-Rx: Treatment should be offered to all Sx and Asx pt with lesions wider than 2 cm or with feeding artery bigger than 3mm

Front 28

Transcatheter Embolotherapy (TCE) for Pulm. AVMs

Back 28

-The definitve Rx of HHT (PAVM)
-Surgical intervention -> high mortality and post op complications
-Most common complication of TCE: Pleurisy can develop in 24-48 hrs due to thrombosis of large aneurysmal sac near pleura and pulm. infarct. Delayed pleurisy up to 4-6 wks w/ fever and infiltrate
-Less common: air embolism (related to manipulation of embo materials) -> angina, bradycardia and perioral paresthesias

Front 29

Laparoscopic Partial Nephrectomy

Back 29

-33% of pt
-urine leak and hemorrhage ( av fistula, pseudoaneurysm)
-exophytic mass has less complication than hilar mass /central

Front 30

Upper GI bleed

Back 30

-Incidence: acute non-variceal GI bleed with normal angiogram 30-80%
-Helpful: CO2 angio,
Rx: prophylactic embo of left gastric after endoscopic localization

Front 31

Renal Arterial Stenting

Back 31

-17% stent restenosis in 6mos.

Front 32

Renal Arterial Stenting
Risk factor for restenosis

PT RELATED FACTOR

Back 32

-older pt age
-DM
-female gender
-chronic renal insufficiency
-continued tobacco use
-poorly controlled hyperlipidemia
-homocysteinemia
-genetic predisposition

Front 33

Renal Arterial Stenting
Risk factor for restenosis

VESSEL RELATED FACTOR

Back 33

-less than 6mm (best predictor)
-Total renal reocclusion
-Longer length lesion
-Intrarenal small vessel disease

Front 34

Renal Arterial Stenting
Risk factor for restenosis

PROCEDURE RELATED FACTOR

Back 34

-polishing and integrity of stent surface
-coating of stent surface
-the number of stents used
-how well stent opposed the wall
-amount of traum to vessel beyond edges of stent
-use of prei-procedural antiplatelet agents.

Front 35

TASC II

Back 35

TYPE A: Rx-endovascular repair
-less than 5cm occlusions or less than 10 cm stenosis

TYPE B and C: Rx- endovascular or surgery depending on operator experience, type B favoring endovascular repair and C favoring surgery repair.

TYPE D: Rx-Surgery
-occlusion of CFA,
-or occlusion greater than 20cm involve popliteal artery
-or occlusion of popliteal artery that involve all 3 trifurcation vessels.

Front 36

Neurovacular TPA (systemic, IV)

Back 36

-0.9 mg/kg of TPA with a max. of 90 mg) within 3 hrs of CVA and without exclusion criteria
-Recannalization rate less than 30%
-High rate of re-Occlusion
-No association with early CT changes and hemorrhage

Front 37

Merci Retriever ( clot remover)

Back 37

- Recannalization rate of 53% if use alone and 63% with additional measures (TPA , average 6mg , up to 20mg)
- Complication rate of 7%
-FDA approved
-can be use for unresponsiveness to IV TPA
-No increase rate of hemorrhage after full dose of IV TPA

Front 38

Post traumatic epistaxis

Back 38

-Presentation: 5 days to 9 wks post-trauma
-less than 5% of facial trauma
-rarely require more than conservative measures
-traumatic pseudoaneurysm : thin walled
-other treatment to consider-> carotid occlusion
-cover stenting: Jostent coronary stent graft (require a straight artery and antiplatelet therapy which may not be suitable to post traumatic pt.

Front 39

Intra-Arterial TPA after IV TPA for CVA

Back 39

-up to TPA 20mg into thrombus
-no significant improvement in clincial outcomes
-increase in rate of symptomatic or potentially life threatening bleed when using combo IV and IA

Front 40

IVC FILTER retrieval

Back 40

-85% success rate
-Failure (1/2 due to thrombus, 1/2 filter tilt and embedded tip)
- tilted tip w/o imbedded tip can be retrieval beyond 180 days
-embedded tip can be disssected with bronchoscopy forcep as long as 245 days out.

Front 41

IVC anomalies

Back 41

-Circumaortic left renal vein (1.5%-8.7%)
-Azygous and hemiazygous continuation of IVC 0.2%-4.3%)
-Retroaortic left renal vein (1.2%-2.4%)
-IVC duplication (0.2%-3%)
-Isolated left-sided IVC (0.2-0.5%)

Front 42

Suprarenal IVC filter placement

Back 42

-Caval thrombus extending to renal vein
-Renal vein thrombus
-Recurrent PE following infrarenal filter palcement
-PE after ovarian vein thrombosis
-Duplicated IVC
-Placement of a prior malpositioned infrarenal filter
-pregnant pt

Front 43

Upper Extremity DVT

Back 43

Etiology: Central line, pacer leads

Presentation:
1) Risk of Sx and/or fatal PE
2) Acute phase limb pain, swelling, and functional limitations
3) Long-term disability due to post-thrombotic syndrome

Rx: 1) Anticoagulant therapy is the mainstay of treatment for upper and lower DVT
2) Sx duration less than 2-3 weeks with low risk of bleeding, adjunctive catheter directed thrombolysis, faster relieve of Sx and reduce risk of PTS.
3) Treat underlying cause, balloon angio, no stent, or rib resection (primary DVT:Paget-Schroetter syndrome

Front 44

Post-Thrombotic Syndrome (PTS)

Back 44

-25-50% risk of pt with Proximal DVT

Presentation: pain, swelling, paresthesias, stasis dermatitis, venous claudication, and/or venous ulcer

-inadequate anticoagulation-> increase up to 3x of developing PTS

-knee-high compression stocking markedly reduced PTS

-catheter directed thrombolysis probably reduces PTS (best for pt with DVT of iliac vein and/or common femoral vein)

Front 45

Balloon Occluded Retrograde Transvenous Obliteration (BTRO)

Back 45

-usually emergently perform
-pt w/ esophago-gastric varices and pts w/ isolated gastrice varices
- pt w/ massive, acute gastric variceal bleed
- pt w/ splenic vein thrombosis and isolated gastric variceal bleed
-pt who is not good candidate for TIPS

ONLY USEFUL in pt with splenorenal or gastro-renal shunts.

Front 46

BTRO

Back 46

Technique: femoral vein access ->select Lt renal vein ->select Lt adrenal vein ->venogram to document gastro-renal or splenorenal shunt-> 20mm or larger balloon to occlude vessel -> inject sclerosing agent (Ethanolamine Oleate and Iopamido, Maintained in the embolized vein for several hours. Could modified with coil partial embo. of splenic artery and then complete with BTRO and use Dehydrated ETOH in vein for 5-10 minutes.

Front 47

Downhill Esophageal Varices (DEV)

Back 47

-Very rare esophageal variceal bleed
-0.1% of all variceal hemorrhage
-SVC obstruction ->blood back into Rt atrium using collateral mediastinal pathways -> IVC (retrograde flow)
-Associate: Thyroid Ca, Lung Ca, Chronic Mediastinal Fibrosis, Medastinal masses
-Normal Portal pressure

Front 48

Upper Esophagus Venous drainage

Back 48

Innominate veins through inferior thyroid bronchial and superior intercostal veins

Front 49

Mid thoracic Esophagus Venous drainage

Back 49

Azygous and Hemi-azygous venous systems

Front 50

Lower thoracic Esophagus Venous drainage

Back 50

Portal system via left gastic vein

Front 51

Portal Vein Thrombosis (Post transplant)

Back 51

-occur immediate post-op
-incidence: 2.7%
-maybe catastrophic leading to re-transplantation
-Rx: initiation of anticoagulation therapy -> complete or partial success in 40-50% pt
-catheter directed thrombolysis

Front 52

Transarterial Catheter Embolization (TACE) follow by Portal Vein Embolization (PVE)

Back 52

-Greater Future Liver Remnant (FLR) volume
-Tumor necrosis higher (83%) vs 6% with PVE alone
-Recurrence free rate higher with both vs PVE alone
(83,54,and 43 vs 72,31,and 31% in 1, 3, and 5 yrs)
-Survival rates was also higher (93,37,and 37 vs 63, 19,and 19% for 1,3 and 5 yrs)
-Rec: 3 wks b/t embo, result in less liver damage especially in Cirrhotic pt. ,
-Particle (cyanoacrylate or microparticles as opposed to Ethanol)

Front 53

PVE complications

Back 53

-9-12% Rt PVE regardless of segment 4
-Subcapsular hematoma
-Hemoperitoneum
-Hemobilia
-Pseudoaneurysm
-Arteriovenous fistula
-Arterio-portal shunts
-Portal Vein thrombosis
-Transient liver failure
-Pneumothorax
-Sepsis

Front 54

TIPS

Back 54

Complication: 5% of pt

Hepatic artery pseudoaneurysm- estimated to be 1%
Arterioportal fistula
Arteriovenous fistula
Portal Vein laceration
Portal vein thrombosis
Hepatic vein injuries

Front 55

Hodgkin's Lymphoma

Back 55

-Large cells were noted :classic Reed-Sternberg cells diagnostic of H. lymphoma.
-Nodular Sclerosing type: fibrosis
-FDG-PET help decide the best site for bx
-FNA should be avoided, 25% sensitive
-"B" symptoms: skin rash, fever, night sweats and wt loss

Front 56

Whitaker Test

Back 56

-placement of a double lumen catheter (4 or 5 fr) into the pelvis and then bladder. Measurement of pressure when infusion of fluid has reached equilibrium.
- Pressure of less than 15cm of H20 is normal
- Pressure of greater than 22 cm are abnormal, indicated obstruction

Front 57

Priapism

Back 57

-Low flow: result from venous outflow obstruction
-Imagings: low to normal flow in cavernosum artery
-painful ischemic state -> if untreated ->may result in corporal smooth muscle fibrosis, cavernosal artery thrombosis and ultimately irreversible impotence.
-true emergency
-Rx- corporal aspiration and alpha adrenergic irrigation
-Sickle cell : 2/3 of cases

-High flow: Excessive arterial flow
Imagings: US normal to high flow of cavernosum artery
Etiology- trauma to perineum or penis -> fistula b/t cavernosal artery and carvernosum
-No ischemia therefore painless
-not an emergency
-Rx: observe for potential spontaneous closure, if intervention is require -> superselective embo

Front 58

Varicocele Embo

Back 58

- Circumaortic renal vein : 4-11%, may drain into upper or lower retroaortic limb or common trunk at the renal hilum
- Success rate 94%
- Recurrence rates greater in embo that does not include caudal segment of spermatic vein near or within inguinal canal
- Most commonly drain into Lt renal vein.
- Lt spermatic vein may communicate with lumbar veins, internal and external iliac veins, saphenous vein and portal system

Front 59

Pediatric cause of Liver Cirrhosis

Back 59

-Langerhan Cell Histiocytosis
-Biliary atresia
-Infectious and autoimmune hepatitis
-Cystic Fibrosis
-Alpha 1-antitripsin defiency
-RX: TIPS can be done using 6mm stent

Front 60

Catastrophic Antiphospholipid Syndrome (CAS)

Back 60

- Multiorgan involvement over a brief period of time with histopathologic evidence of small vessel occlusions.
- can lead to multiorgan failure -> lethal
-portal venous thrombosis- can be Rx with thrombolysis and rheolytic

Front 61

Pediatric Pancreatic Pseudocyst

Back 61

-Traumatic: RX conservative
-Non-traumatic : more likely require and benefit from intervention (surgical, endoscopic, or percutaneous)

-Initial Rx :fasting, then if increasing Sx, increasing PP size, infection or hemorrhage -> intervention (endoscopic guided sphincterotomy and stenting, endoscopic cystgastrostomy, surgical cystgastrostomy/cystojejuonostomy and other less common procedures)

-percutaneous drainage

-choices: depends on general condition of child, size, number, and location of PP, communication w/ duct and expertise.

Front 62

Liver abscess

Back 62

-Etiology:
post TACE and RFA 0.1-0.5 %
Stent placement, sphincterotomy, or Whipple procedure or sphincter of oddi intervention
-Bacteria: E. Coli > Enterococci > Klebsiella > Streptococcus Viridans
-Presentation: 2-4 wks post treatment

Front 63

Liver abscess

Back 63

-Prophylactic Abx:
Levofloxacin 500mg QD and Flagyl 500mg BID 48 hrs preprocedure

Neomycin 1 gm and Erythromycin 1 gm base at 1pm,2pm and 11pm on the day before procedure

Levofloxacin and metronidazole IV continued throughout hospital stay.

Same meds continue for 2 wks after discharge

or
diffferent regimen ( more aggressive)
Tazobactam/piperacillin for 24-36 hrs on inpt plus bowel prep with neomycin,erythromycin and bisacodyl sodium

Front 64

Tumor Lysis Syndrome (TLS)

Back 64

-associated with treatment for blood borne malignancies (lymhoma and leukemia)
-can occur following: chemotherapy, radiation therapy, interferon, surgery, and IR procedure (RFA and chemo-embo {relatively uncommon})
-hallmark: disturbance of electrolyte values, ↑K, ↑Phosphate, ↓Ca, and Hyperuricemia, Renal failure and acidosis

-Rx: Aggressive hydration (standard practice), Allopurinol (neurtralize uric acid)

Front 65

Transcatheter Arterial ChemoEmbo
(TACE)

Extrahepatic arterial feeding of Anterior liver (therefore, if there is a mass in ventral aspect (regardless of size) , suspect extrahepatic blood supply)

Back 65

-Extra-hepatic arterial supply: Internal Mammary Artery -> supply far anterior aspect of diaphragm and gives off anterior intercostal branches, pericardiophrenic artery, anterior mediastinal arteries, pericardial branches, and sternal branches.

-Pericardiphrenic artery typically anastomoses with inferior phrenic artery
-IMA (@6th intercostal space) → Musculophrenic artery and Superior Epigastric artery

-Musculophrenic ⟶ Anterior intercostal branches (7,8,and 9Th IC branches) and anastomose w/ Inferior phrenic artery

-Superior Epigastric Artery ⟶ branches to diaphragm and extend into falciform ligament of liver and anastomose with hepatic artery.

Front 66

Hypervascular HCC

Arterio-Portal shunt

Back 66

-Shunting incidence: 31 - 63%

-Hepatic Arteriogram ⟶ if there is evidence of shunting (Arteriaoportal) at level of the tumor, need to occlude shunt using PVA , gelfoam slurry or coil

Front 67

HCC

Back 67

- 8th leading cause of death in USA
-Incidence: ↑ 80% over the past 15-20 yrs
-Presentation: unresectable, multi-drug resistant, radiation resistant (relative to liver parenchyma)

-Rx: local and regional therapies (RFA, cryoablation, ETOH ablation, microwave ablation, bland embo, Chemo-Embo, and Radio-Embo

Front 68

HCC : Radio-Embo

Back 68

- Yttrium-90 (90-Y) - catheter based therapy that delivers internal radiation to tumors
- 90-Y: pure beta emitter ( 2.5mm tissue penetration)
- dose : 50 - 150 Gy as oppose to external radiation (30 Gy)
- Good for large mass
-External beam radiation have little proven benefit for unresectable HCC
-RFA or microwave Ablation is not indicated in pt w/ portal vein thrombosis
-Bland and ChemoEmbo is effective in treating unresectable HCC but with Portal Vein thrombosis ⟶ can lead to ischemic hepatitis and liver necrosis ( esp. in cirrhotic and altered hepatic function)

Front 69

Colorectal Ca

Back 69

-3rd most common cancer in men and women
-liver most frequent site of metastases
-Rx: Surgery as treatment of choice for eligible pt (< 20% )
-Rx: Unresectable pt ➙ conformal radiation, Yttrium 90, Hepatic arterial infusion chemotherapy, TACE or RFA
-90 Y- FDA approve
-Other vessels of concern: Rt gastric artery, Accessory/Left gastric, Falciform, supra duodenal, left inferior phrenic and inferior esophageal

Front 70

NeuroEndocrine Tumors (NET)

Back 70

-uncommon
-slow growing
-often refer to as Carcinoid
-derived from enterochromaffin or Kulchitsky cells
-Incidence : 2-3 cases per 100,00
-Primary: most commonly develop in foregut, midgut, and hind gut

Front 71

Midgut NET

Back 71

-Small intestine and appendiceal carcinoids (40-70%)
-Mostly located in Ileum and mets to liver > lung > peritoneum > pancreas
-Excessive secretion of Serotonin ➙ Carcinoid Syndrome: diarrhea, flush, bronchoconstriction (wheezing) and right valvular heart failure. Occur in 20% of pt with midgut NET.
- 5yrs survival rate <20% when mets to liver
-Rx: ChemoEmbo (most common), RFA, RadioEmbo, BlandEmbo.