Ir

Front 1

70 year old jaundiced man with recurrent cholangiocarcinoma s/p Whipple with biliary dilatation (and proven recurrent pancreatic cancer). What is next most appropriate step:
a. PTC with biliary drainage (percutaneous transhepatic biliary drainage)
b. Direct puncture of Roux limb with stent placement
c. ERCP with stent placement
d. Percutaneous transjejunal biliary drainage
e. Radiation

Back 1

Percutaneous transhepatic biliary drainage

Front 2

Most important aspect of embolization therapy in peripheral AVMs?
a. Control of arterial feeders
b. Treating the nidus

Back 2

tx nidus

Front 3

Which of the following is TRUE regarding (transcatheter) embolization?
a. Use permanent occlusive devices for varicoceles
b. Coils are the treatment of choice for gastric ulcers
c. Use boiling EtOH for pulmonary AVM

Back 3

Use permanent occlusive devices for varicoceles

Front 4

TRUE regarding varicocele treatment?
a More common on the right
b Efficacy of embolization (with gel-foam) approaches 100% given lack of collaterals
c Surgical tx (sclerotherapy) and catheter embolization have equivalent results
d Sclerotherapy has the best treatment response

Back 4

Surgical treatment (sclerotherapy) and catheter embolization have nearly equivalent results

Front 5

Single best therapy for solitary pulmonary AVM in a child?
a. Coil embolization
b. Alcohol
c. Gel foam
d. IVA particles

Back 5

coil embo

Front 6

All are indications for percutaneous transhepatic biliary drainage EXCEPT:
a. Stone retrieval
b. Relieve obstruction
c. Cholangioplasty
d. Pruritis
e. Cholecystitis

Back 6

Pruritis

Front 7

What artery is a branch off of the anterior division of internal iliac artery?
a. Uterine
b. Iliolumbar
c. Superior gluteal
d. Left coronary
versus

Back 7

uterine

Front 8

Post trauma with splenic injury. What is most indicative of need for intervention:
a. Splenic pseudoaneurysm/aneurysm
b. Peripheral pseudoaneurysms measuring greater than 2 cm
c. Geographic area of nonenhancement (low attenuation wedge defect at edge of spleen)
d. 3 cm perisplenic (subcapsular) hematoma
e. Clotted blood around spleen

Back 8

Splenic pseudoaneurysm

Front 9

Which is true regarding renal artery angioplasty (renal artery stenosis caused by atherosclerosis)?
a. ostial lesions respond the best to angioplasty
b. hypotension is a known complication of angioplasty
c. non lateralization of renin levels is a contraindication to angioplasty
d. 90% can discontinue antihypertensive medication after angioplasty

Back 9

hypotension is a known complication of angioplasty

Front 10

Which is the most accurate regarding renal artery angioplasty for treatment of renal vascular hypertension?
a. ostial lesions have a higher success rate than nonostial lesions
b. renal artery calcs are a contraindication
c. FMD angioplasty has 30% rupture rate
d. severe hypertension is a recognized complication
e. should not be performed if elevated renin levels cannot be localized

Back 10

severe hypertension is a recognized complication

Front 11

Sonographic evaluation of an AV fistula; which is FALSE?
a. may resolve spontaneously
b. proximal artery loses triphasic waveform
c. central vein - pulsatile increased velocity
d. distal artery shows increased velocity
e. speckled echoes in soft tissue at fistula

Back 11

distal artery shows increased velocity

Front 12

All are important in choosing placement of an IVC filter EXCEPT:
a. Location of the thrombus
b. Size of the IVC
c. Size of the thrombus
d. Renal vein location
e. Venous anomaly
f. Presence and extent of IVC thrombus

Back 12

. Size of the thrombus

Front 13

Following endovascular aortic graft placement for aneurysm treatment, which type of endoleak requires immediate open repair?
a IA (proximal)
b IB (distal)
c II (collateral filling sac)
d III
e IV

Back 13

IA (proximal)

Hint 13

Type 1 occurs at the graft insertion site due to an inadequate seal between the stent graft and the aortic wall.
Type 2 occurs when there is retrograde inflow in a patent branch vessel and it is the most common type of endoleak. Small leaks that have a stable or decreasing sac size can be followed with serial CT evaluation as they have a high rate of spontaneous resolution and a low risk of rupture.
Type 3 occurs due to graft degeneration including component disconnection, fabric tears, and disintegration.
Type 4 leaks occur due to transgraft flow due to graft wall porosity.
Another type of leak referred to as "endotension"- no leak is visible radiographically, but the aneurysm continues to grow.

Front 14

Male with pelvic fractures, has IVC filter for prophylaxis; what do you do before you removing the temporary filter?
a. chest xray
b. abdominal film
c. pelvic film healed fracture
d. IVC cavagram to see if there is a clot
e. Renal venogram

Back 14

IVC cavogram to see if there is clot

Front 15

Patient has RLL biopsy and has acute hemetamesis. Do what immediately?
a. Place patient in right lateral decubitis
b. Place patient in left lateral decubitus
c. Sit patient upright
d. Place in Trendelenberg
e. Intubate right mainstem bronchus

Back 15

right lateral decubitus

Front 16

Which of the following regarding the IMA is FALSE:
a. Commonly occluded in people > 50 yo
b. The IMA provides supply to the transverse and descending colon
c. Origin at the level of L3
d. Originates from anterolateral aorta
e. Communicates with internal iliac arteries via collaterals

Back 16

The IMA provides supply to the transverse and descending colon

Hint 16

The superior mesenteric artery supplies the right colon from the cecum to the splenic flexure. The inferior mesenteric artery supplies the left colon from the splenic flexure to the rectum.
The IMA originates at the level of the left pedicle of L3.
Occlusion of the IMA is certainly not unusual—abundant collaterals maintain colonic blood supply. E.g., the IMA is occluded in 80% of AAA. (Dähnert 5th p. 605).
Collateral pathway of IMA is to hemorrhoidal artery to the internal iliac artery to the external iliac arteries.

Front 17

Best indicator of AV graft (forearm dialysis graft failure:
a. Increased venous resistance during dialysis
b. Palpable thrill

Back 17

Increased venous resistance during dialysis

Front 18

S/p coiling of SMA branch for duodenal bleed. Two hours after procedure, patient goes into shock. Likely cause:
a. Acute occlusion of SMA due to intimal flap during cannulation
b. Rupture of coil
c. Groin pseudoaneursym
d. Large retroperitoneal bleed secondary to poor (high) puncture
e. Delayed contrast reaction

Back 18

Large peritoneal bleed secondary to poor (high) puncture

Front 19

What is the blood vessel in May-Thurners syndrome that causes the compression?
A Right common iliac artery
B Left common iliac vein
C Left common iliac artery
D Right common iliac vein

Back 19

right common iliac artery

Front 20

TRUE regarding May-Thurners?
A. Obstruction of the left common iliac vein by the right common iliac artery
B. Chronic leg pain and swelling due to repeated deep venous thrombosis
C. Migratory thrombosis 2° malignancy
D. Chronic leg ulcers related to stasis
E. Chronic thrombosis 2°hypercoagulability

Back 20

Obstruction of the left common iliac vein by the right common iliac artery

Hint 20

May-Thurner syndrome is compression of the left common iliac vein BY the anteriorly crossing right common iliac artery against the lumbrosacral spine. The constant, pulsatile compression is thought to induce intimal scarring and weblike adhesions within the vein, resulting in chronic left leg swelling and risk of DVT. Presents with chronic or acute venous thrombosis. Typically between the 2nd through 4th decade, with F:M ratio of 3:1. Three stages: 1) asymptomatic compression of left common iliac vein without filling of collaterals, pressure gradient < 2 mmHg; 2) intraluminal webs; and 3) thrombosis. Although a trial of thrombolysis may be beneficial, stent placement is considered the primary treatment and is usually attempted before surgery. Surgical treatment options for iliac vein occlusion include femoral to femoral venous or CFV to IVC bypass. Surgical results for May-Thurner are better than those with chronic venous thrombosis.

Front 21

Plain film taken of a patient 24 hours s/p G- tube placement shows pneumoperi-toneum. What should the radiologist do?
A. Inform the clinicians that this is a normal finding and give fluids
B. Confirm the position of the side holes

Back 21

. Inform the clinicians that this is a normal finding and give fluids

Front 22

Which is NOT an indication for urgent nephrostomy tube placement:
A. uremic encephalopathy
B. CHF/CRF
C. pyonephrosis
D. hyperkalemia
E. anuria

Back 22

CHF/CRF

Front 23

After TIPS, what is a normal finding?
a. Hepatopedal flow in main portal vein
b. Pressure gradient >15 mm

Back 23

Hepatopetal flow in MPV

Hint 23

Flow should be hepatopetal in the MPV, but retrograde in the portal vein branches. Successful TIPS placement results in a portosystemic gradient < 12 mm Hg and immediate control of variceal-related bleeding (varices tend not to bleed with gradient < 12 mm Hg). When technical failure occurs, it is usually due to an anatomic situation that prevents acceptable portal venous puncture. Significant reduction in ascites usually occurs within 1 month of the procedure (50-90%).

Front 24

Patient has a TIPS placed from R portal
vein to R hepatic vein. What is the flow
in the L portal vein?
a. Hepatofugal
b. Hepatopetal
c. Biphasic

Back 24

HepatoFUGAL

Hint 24

Hepatofugal flow is frequently seen in the portal vein branches after successful TIPS.
Alteration in flow from hepatofugal to hepatopetal may indicate stent malfunction or occlusion.
Hepatopetal is into the liver (normal), hepatofugal is out of the liver (reversed).
Biphasic flow is seen in arteries with either vasoconstriction or acute occlusion distal to the sampling site.

Front 25

Same about pseudoaneurysm and AVF:
a Associated soft tissue reverberation
b Suitable for treatment by compression and thrombin
c To-and-fro flow
d Decreased diastolic flow proximally

Back 25

a Associated soft tissue reverberation

Hint 25

Both a pseudoaneurysm and an AVF may show soft tissue reverberation. Only a pseudoaneurysm is
suitable for treatment by compression and thrombin. To-and-frow motion is characteristic of a
pseudoaneurysm (only). High velocity flow (not low) is seen proximal to an AV fistula.

Front 26

FALSE regarding varicose veins?
A. Can be caused by reflux from perforating veins
B. Sensitivity of detection is increased with patient in upright position rather than supine
C. Feeders demonstrate reverse flow
D. DVT causes valve dysfunction in 80%
E. Varicose veins have incompetent valves

Back 26

Can be caused by reflux from perforating veins

Front 27

TRUE regarding angiodysplasia?
(a) on angio, multiple AV fistulas (or AVMs) are seen
(b) on angio, early and persistently dense (draining) vein is seen
(c) enlarge supplying artery is seen
(d) only diagnosed by seeing frank extravasation into bowel lumen
(e) IMA > SMA

Back 27

on angio, early and persistently dense (draining) vein is seen

Hint 27

Angiodysplasia rarely shows visible extravasation of contrast and may be found in patients without bleeding or may not be the actual source of bleeding in active hemorrhage. Diagnosis of exclusion. On angiogram, see enlarged arteries on the anti-mesenteric border of the cecum or ascending colon supplying a vascular tuft with an early draining vein that persists throughout most of the filming sequence. Approximately 80% of cases of clinical lower GI bleeding originate from the colon and rectum. 1/3 right colon, 1/3 transvers, 1/3 descending colon and rectum. Most of the acute arterial bleeding sites are of mucosal origin and respond to intra-arterial vasopressin infusions in 95% of cases. Patients treated with intra-arterial vasopressin have a 20% to 25% rebleeding rate.

Front 28

Regarding angiodysplasia of the colon, which of the following is FALSE?
a) Commonly see bleeding with angiography
b) Located on the antimesenteric border
c) Early filling vein

Back 28

a) Commonly see bleeding with angiography

Front 29

Left gastroepiploic artery arises from:
a. splenic
b. hepatic
c. SMA
d. right gastric

Back 29

splenic

Hint 29

The right gastroepiploic artery arises when the gastroduodenal artery bifurcates. The left gastroepiploic artery arises from the splenic artery. The gastroepiploic arteries anastomose to one another on the greater curvature of the stomach.
The word gastroepiploic is derived from gastro (meaning stomach) and epiploic (meaning omentum).

Front 30

The best response from chemo-embolization of hepatic metastases from neuroendocrine tumors occurs with:
a. Asymptomatic patients
b. Patients failing chemotherapy
c. Patients with hormonal symptoms
d. Patients with pain from tumor size
e. Rapidly growing tumors

Back 30

Patients with hormonal symptoms

Front 31

TRUE regarding transrectal/transvaginal drainage EXCEPT?
A Crohn’s disease is relative contraindic.
B Coagulopathy is relative contraindication
C Antibiotics should be withheld until a sample is obtained
D Self-locking catheter should be used
E Medications should be administered for pain and anxiety

Back 31

Antibiotics should be withheld until a sample is obtained

Front 32

NOT true of percutaneous lung biopsy:
A Tumor seeding of needle tract occurs commonly
B Can more easily make definite malignant diagnosis than benign diagnosis
C PTX risk increases with COPD

Back 32

Tumor seeding of needle tract occurs commonly

Front 33

Patient with mechanical mitral valve needs a percutaneous biliary drainage. Appropriate antibiotics:
a None needed since bile is sterile
b Ceftriaxone IV pre, amoxicillin 6 hrs post
c Gentamicin and Ampicillin IV immediately pre and amoxicillin 6 hrs post
d Ampicillin IV immediately pre and amoxicillin 6 hours post

Back 33

c Gentamicin and Ampicillin IV immediately pre and amoxicillin 6 hrs post

Front 34

Absolute contraindication for catheter-directed thrombolysis:
a Pregnancy
b Platelets 125k
c INR 1.4
d Stroke within 2 months
e Guiac positive stool

Back 34

Stroke within 2 months

Hint 34

Answer: Stroke within 2 months

Absolute contraindications include acute or subacute stroke, recent neurological surgery, known CNS neoplasm, and active GI bleeding.
Relative contraindications include recent abdominal or thoracic surgery, uncontrolled HTN, remote history of stroke or GI bleeding.

Front 35

During a long IR procedure, which of the following is LEAST important in reducing risk of dermal radiation injury?
a Variation the imaging angle
b Use of magnification mode
c Use of pulsed fluoroscopy
d Decreasing distance between patient and the image intensifier
e Increasing distance between the patient and the source

Back 35

d Decreasing distance between patient and the image intensifier

Hint 35

Answer: Decreasing distance between patient and the image intensifier (LEAST important)

Assuming the question refers to dermal radiation injury to the patient, decreasing distance between patient and image intensifier only serves to reduce scatter radiation and magnification. The other choices illustrate ways in which radiation exposure to the skin can be reduced. Increasing distance between the patient and the source serves to reduce geometric unsharpness (can also occur with large focal spots), and radiation exposure, which is inversely related to the distance from the focal spot squared. A short focus to skin distance increases the patient’s entrance skin dose. Pulsed fluoroscopy reduces the total amount of radiation utilized for obvious reasons. Use of mag mode and variation of imaging angle reduce the skin surface area exposed and the level of exposure to a particular area, respectively. [Huda first edition p.139]

Front 36

Regarding peripheral venous catheter, which of the following is FALSE:
a. PICC lines used for intermediate access (2-26 weeks)
b. Tunneled catheters - separate skin and vessel entry sites - lower infection rates
c. Central venous line patency can be prolonged using low-dose coumadin
d. The incidence of line infection is higher with TPN than with chemotherapy
e. Line infection rate lower for lines placed in OR than those placed in the angio suite

Back 36

. Line infection rate lower for lines placed in OR than those placed in the angio suite

Front 37

Most accepted indication for percutan-eous, catheter-directed staining, ablation:
a. A patient s/p neck exploration with persistent hyperparathyroidism and a mediastinal parathyroid adenoma
b. Preoperative embolotherapy
c. Functioning parathyroid adenoma
d. Non-functioning parathyroid adenoma

Back 37

Answer: A patient s/p neck exploration with persistent hyperparathyroidism and a mediastinal parathyroid adenoma

Front 38

Which of the following vessels does NOT directly feed into the popliteal vein?
a. Lesser saphenous
b. Gastrocnemius (Sural) vein
c. Soleal vein
d. Tibioperoneal trunk

Back 38

Answer: Lesser saphenous

Hint 38

Deep veins: Ant tib, Post tib, peroneal and calf (Soleal and Gastrocnemius) All drain into the popliteal vein.
The Soleal vein may drain in to the post tibial + peroneal veins or lower part of the popliteal vein.
Superficial veins: Greater/lesser saphenous. The lesser saphenous does drain into the popliteal vein 60% of the time.

Front 39

TRUE regarding GI bleeding:
A. 60% of bleeds represent upper GI bleeds
B. Angiography can demonstrate bleeds of 0.1cc per minute
C. 25% of bleeds are small bowel origin
D. Vasopressin is extremely useful in controlling peptic ulcer bleeds
E. Intra arterial vasopressin may be used to successfully treat esophageal varices

Back 39

60% of bleeds represent upper GI bleeds

Front 40

LEAST likely lesion to respond to percutaneous angioplasty is:
A. 7 cm lesion of the superficial femoral artery
B. Stenosis of infrarenal abdominal aorta
C. Focal calcified iliac artery lesion
D. Fibromuscular dysplasia of renal artery

Back 40

7 cm lesion of the superficial femoral artery