Ouhsc - Vascular Test 3

Front 1

What does the pulmonary trunk originate from, and what does it bifurcate into?

Back 1

Originates @ pulmonary valve
Bifurcates into L & R pulmonary arteries

Front 2

How many zones is pulmonary circulation divided into?

Back 2

3

Front 3

What affects the pressure within the zones?

Back 3

Gravity (upright vs. supine) [plays large role, can enable tech to image a certain part of the lung], pulmonary A & V pressure, alveoli, & interstitial pressures

Front 4

Indications for Pulmonary Angiography

Back 4

AVM (arteriovenous malformations)
PDA (Patent ductus arteriosus)
PE (pulmonary embolus)

Front 5

Contraindications for Pulmonary Angiography

Back 5

- recent MI
- pulmonary hypertension (MAP > 60 mmHg) [mean arterial pressure]

Front 6

Most common approach for pulmonary angiography

Back 6

Femoral vein (can be contraindicated when PE is suspected)

Alternative method --> brachial vein

Front 7

What kind of catheters are used in pulmonary angiography?

Back 7

Pigtail, close-end, multi-sidehole

ex. Grollman, Van Aman
Advantage --> reduction in catheter whipping

Front 8

How quickly should the contrast media be injected in pulmonary angio?

Back 8

1-2 seconds

Front 9

How should contrast be injected for a patient w/ pulmonary hypertension?

Back 9

Never directly into artery; should be pushed from R atrium to avoid side effects (arrhythmias, pulmonary edema)

Front 10

Supine Imaging - Pulmonary Angio

Back 10

Used to evaluate symmetric flow of arteries, size of vessel, etc.

Front 11

Oblique Imaging - Pulmonary Angio
[Patient position based on II, not table]

Back 11

RAO position (LPO on table)
- 10-15 degree RAO shows R pulmonary artery
LAO position (RPO on table)
- 30-45 degree LAO shows L main pulmonary artery

Front 12

Serial Imaging vs. Digital Subtraction Angio

Back 12

- DSA preferred b/c can record emboli as small as 2 mm
- DSA has more motion artifacts (breathing, heart beat)

Front 13

Complications of Pulmonary Angio

Back 13

PVCs, perforation, arrhythmias, twisted catheter, severe bradycardia

Front 14

Pulmonary Angiographic Findings

Back 14

- PE (filling defect, complete occlusion)
- Pulmonary stenosis
- Vascular changes in lung fields (ex. AVM)
- Coarctation of pulmonary A
- PDA
- Tumors

Front 15

What's the largest artery in the body?

Back 15

Aorta

Originates --> aortic valve
Ends --> bifurcation of common iliacs (L4)

Front 16

Segments of Aorta

Back 16

- thoracic aorta = aortic valve to T12
- above aortic valve = aortic bulb or root

Front 17

Which ostia of the "great vessels" is contained in the aortic arch?

Back 17

Innominate artery (R brachiocephalic artery)
L common carotid A
Left subclavian A

Front 18

Indications for Thoracic Angio

Back 18

Abnormalities undeterminable / PDA / aneurysm / coarctation / aortic insufficiency (AI) / aortic stenosis (valvular gradient)

Front 19

Equipment used for Thoracic Angio

Back 19

- Electromechanical injector (pushes large amounts of CM quickly enough to fill vessel of interest)
- Cineradiographic equipment
- Emergency equipment

Front 20

Thoracic Angio Pre-Procedural Care & Safety

Back 20

- thorough patient history
- premedication
- any previous images (can help decide type of equipment to use)

Front 21

Thoracic Angio Forward Approach

Back 21

- rarely used; antegrade approach (with the flow)
- catheterization of femoral VEIN, puncture through septum of heart (Brockenbrough needle set)
- limited to cases w/ severe aortic stenosis & when retrograde is contraindicated

Front 22

Risks of Forward Approach

Back 22

- needle and/or wire could puncture aorta
- possible perforation of myocardium allowing access to pericardium, causing tamponade

Front 23

Thoracic Angio Retrograde Approach

Back 23

- femoral approach preferred (can be contraindicated due to distal stenoses or tortuosity)
- can use left brachial approach if femoral is contraindicated

Front 24

Most common catheter for Thoracic Angio

Back 24

Pigtail b/c of end hole & sideholes (large bolus)
- may use angled one if also performing LHC
- w/ known disease, "marked" pigtail used

Front 25

How much contrast media is needed to image aortic arch?

Back 25

Up to 600 mL

Front 26

Optimal concentration of Contrast for Thoracic Angio

Back 26

70%

Can cause cerebral damage if brain accumulates significant amounts

Front 27

Where is the catheter tip positioned in thoracic angio?

Back 27

Mid-ascending aorta

Can be placed close to root if AI is suspected
Selective angio --> tip in ostium of vessel

Front 28

Thoracic Angio Positioning & Imaging

Back 28

- most often used = PA & lateral
- also used = LAO, RAO

AP & LAO sufficient for thoracic anatomy

Front 29

Death Rate for Thoracic Angio

Back 29

1.7%

Higher concentration of CM, higher risk
Largest % of death due to cerebral damage

Front 30

An increased risk of complications for thoracic angio is seen in patients...

Back 30

On anticoagulants, hypertension, arteriosclerosis, AI

Front 31

Aortic Insufficiency (AI)

Back 31

- seen on CXR as downward, lateral, posterior displacement of cardiac apex
- pronounced L ventricular dilation
- seen in angio as regurgitation of CM into LV when injected from aortic root

Front 32

Implications of AI

Back 32

- increased LV pressures --> leads to mitral valve insufficiency & failure
- leads to LV & LA hypertrophy --> leads to CHF

Front 33

Thoracic Angio Positional Abnormalities

Back 33

- variations in shape of arch and/or position of great vessel origins
- "Bovine" arch: R brachicephalic & LCCA share common ostium (20% of patients) [also a version w/ L vertebral ostium originating from arch]
- R subclavian is retro-esophageal (distal to L sub)

Front 34

Thoracic Aneurysms

Back 34

- Ascending 22%, Arch 12%, Descending 7%, rest associated w/ AAA
- Fusiform (blobby, not uniform, unpredictable path)
- Saccular (spherical shape, looks like a big ball)
- Dissecting

Front 35

3 Layers of Lumen Wall

Back 35

Adventitia, Media, Intima

Dissection occurs when blood is allowed through intima into medial layer w/o rupturing adventitia

Front 36

False Lumen (FL) & True Lumen (TL)

Back 36

- created by dissection
- if FL blocks flow to TL, ischemia occurs & morbidity advances quickly

Front 37

Risk of Death in untreated aortic dissection

Back 37

25% first 24 hours
50% in first week
75% in first month
90% in first year

Front 38

Patent Ductus Arteriosus (PDA)

Back 38

- in unborn child, ductus arteriosus allows blood to bypass high resistance fluid-filled compressed lungs; blood flows from RV to PA through DA into aorta
- if DA fails to close after birth, PDA allows oxygenated blood to flow back through PA into lungs (should close 12-24 hours)

Front 39

Coarctation

Back 39

- narrowing between vasculature going into upper extremity & down to lower extermity
- best visualized in AP or LAO position

Front 40

Indications for Cerebral Angio

Back 40

- previous positive studies
- Gold Standard

Front 41

Contraindications for Cerebral Angio

Back 41

- CM sensitivity
- advanced arteriosclerosis
- very ill/comatose patients
- severe hypertension
- severe subarachnoid or intracerebral hemorrhage

Front 42

Most common method of vessel access for cerebral angio...

Back 42

transfemoral artery

alternate methods = direct carotid, brachial a

Front 43

Catheters & Contrast Rate for Cerebral Angio

Back 43

- Berenstein / Headhunter / Simmons / Newton / Manj / Bentson

- 2 mL/kg/hr

Front 44

Positioning in Cerebral Angio

Back 44

- for AP position (PA Axial projection) & lateral, interpupillary line is perpendicular to table (IOML 20 degree angle)

Front 45

Difference in tube angles in cerebral angio btw. carotid arteriography or vertebral angiography

Back 45

Carotid Arteriography = 15 caudal
Vertebral Angiography = 25 caudal

Front 46

Complications from Cerebral Angio

Back 46

- contrast allergic reactions
- mechanical injuries (ruptured vessel, hemorrhage, etc.)
- physiologic complications (stroke, TIA, etc.)

Front 47

Findings in Cerebral Angio

Back 47

Atherosclerosis / Aneurysms / Traumatic Intracranial Hemorrhage / AV Malformations / Tumors / Evidence of Stroke

Front 48

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Back 48

- ballooning causes controlled injury by tearing intima & media (stretches adventitia past point of recoil)

Front 49

Indications of PTCA

Back 49

Atherosclerosis / Clots (unstable angina) / Previous Coronary Artery Bypass Graft (CABG)

Front 50

Contraindications of PTCA

Back 50

- L Main CAD (going to have CABG if stenosis is severe)
- excessive heart dependency on 1 artery alone
- poorly functioning heart
- multi-vessel disease

Front 51

The "Widow Maker"

Back 51

Severe blockage within the LMA

Front 52

Overall occurrence rate of complications from PTCA is approx....

Back 52

4-5%

After 2-5 years, 70-75% are still patent

Front 53

Major Complications from PTCA

Back 53

Coronary A occlusion / MI / Neurologic deficit / Renal failure / death

Front 54

Recoil Factor

Back 54

- balloons don't compress all areas of vessel the same b/c of varying degree of hardness throughout the plaque
- may cause lumen size to become smaller

Front 55

Coronary Stents

Back 55

- expandable metal device that presses against lumen wall to keep it open
- first one placed = 1986 in France
- US first stent = 1994

Front 56

Methods of Coronary Stenting

Back 56

Direct
- stent placed directly into stenosis as soon as its positioned properly & inflated
Angioplasty plus Stenting
- angio performed using regular balloon, then stent is placed

Front 57

Indications for Coronary Stenting

Back 57

- angioplasty alone is unsuccessful (lesion keeping recurring)
- uncontrolled dissection in artery

Front 58

Contraindications for Coronary Stenting

Back 58

- acute angles in vessel @ location of stenosis
- less than 2 mm vessel size

Front 59

Acute Complications of Coronary Stenting

Back 59

- artery may abruptly close
- thrombus from elsewhere becoming embolus
- incomplete stent apposition

Front 60

Long Term Complications of Coronary Stenting

Back 60

- after receiving stent, it's recommended to take a platelet inhibitor (Coumadin) for 4-6 months
- anticoagulant therapy may become lifelong, especially for bare-metal stents
Death Rate = 0.1%

Front 61

Bare Metal Stent

Back 61

- multiple stent designs, all made of stainless steel
- 4-15% of re-stenosis

Front 62

Drug Eluting Stent

Back 62

- have polymer coating which chemically houses drug; released uniformly within stent
- 3% chance of re-stenosis
- can have (rare) allergic reactions to polymer coating

Front 63

Cypher Drug Eluting Stent

Back 63

- 1st one released in US in 2003
- Sirolimus (originally used to prevent rejection of transplanted organs)

Front 64

Taxus Drug Eluting Stent

Back 64

- released in US in 2004
- Paclitaxil (originally marketed as cancer drug)

Front 65

Xience V Drug Eluting Stent

Back 65

- released in US in 2008
- Everolimus: derivative of sirolimus

Front 66

Directional Atherectomy

Back 66

- method of removal --> mechanically driven catheter shaves off plaques (stores in collection chamber within catheter)
- higher risk of MI
- 33% recurrence of re-stenosis

Front 67

Rotational Atherectomy

Back 67

- high speed burr coated w/ microscopic diamond particles; rotates up to 200,000 rpm
- breaks thrombus into smaller than RBC pieces
- 30-50% re-stenosis rate

Front 68

Thrombolysis

Back 68

- IV or IA infusion of anticoagulation meds are used (t-PA [tissue plasminogen activator], streptokinase, urokinase)
- may use as pulse spray or infusion drip
- Risks: increased bleeding/hemorrhage risk

Front 69

Thrombectomy

Back 69

Mechanical
- catheter advanced to lesion, wire used to mechanically "grab" the clot
Aspiration
- heparinized saline pumped @ high pressure, dissolves clot which is simultaneously aspirated

Front 70

Coronary Artery Bypass Graft (CABG)

Back 70

- 1-2% of patients come from previous angio procedures
- typically use saphenous vein grafts (SVG) to bypass lesion (vein turned inside out)

Front 71

"Mapping" CABG

Back 71

- one on right usually is RCA
- on left side: lowest one LAD / next up Diagonal / next up Marginal (OM) / next up Circumflex (CX) or another Marginal

Front 72

Modified Seldinger Percutaneous Approach (Non-Vascular Angio)

Back 72

- needle w/ stylet, advanced through skin to anatomy of interest; stylet removed, reflux of fluid determines proper location
- wire advanced into selected area
- needle removed, catheter inserted over wire

Front 73

Nephrostomy

Back 73

- posterior approach on patient (prone w/ side of interest elevated)
- needle puncture 2-3 cm below 12th rib
- catheter should enter in middle/lower calyx, advancing through renal pelvis; dilators widen tract

Front 74

What is an exception to the posterior approach to nephrostomy?

Back 74

Transplanted kidney requires supine positioning w/ anterior approach

Front 75

Where should the catheter enter in the kidney for stone removal?

Back 75

Superior Calyx

Front 76

A renal stent can be placed 2 ways...

Back 76

1) Pigtail looped in renal pelvis, body of stent exits posteriolaterally through skin
2) Stent advanced & 1 pigtail end placed within renal pelvis, body of stent travels through ureter, other pigtail end placed in bladder

Front 77

Indications for Nephrostomy

Back 77

- drain obstructed kidney/ureter
- remove a stone
- infuse drugs

Front 78

Complications with Nephrostomy

Back 78

- about 4% of the time
- 2 most frequent = hemorrhage & infection
- sepsis other major complication (occurs w/ infected stone or urine, bacteria gets into blood stream)

Front 79

Percutaneous Biliary Drainage

Back 79

- antibiotics given 1 hr prior to exam
- supine w/ right arm raised above head
- needle inserted into R lateral superior abdomen below 10th rib
- internal or external drainage placed

Front 80

Indications for Percutaneous Biliary Drainage

Back 80

- un-resectable malignant disease (pancreatic CA) [palliative]
- biliary obstruction
- post-op biliary leakage
- stone removal

Front 81

Contraindications for Percutaneous Biliary Drainage

Back 81

- asymptomatic jaundice
- ascites
- advanced liver cirrhosis
- defuse hepatic mets or liver failure (life expectancy = less than 1 month)

Front 82

Complications from Percutaneous Biliary Drainage

Back 82

Sepsis / Hemobilia / Catheter Obstruction/Displacement / Cholangitis / Bile peritonitis / Pneumo/Hemothorax

Front 83

Percutaneous Abscess Drainage - Needle Aspiration

Back 83

- performed if abscess < 5 cm in diameter
- 22 G needle, can use 18 G if it's viscous
- small amt of fluid is aspirated & tested (if infected, antibiotics inserted directly into abscess; if not, abscess drained)

Front 84

Percutaneous Abscess Drainage - Catheter Drainage

Back 84

- similar to localizing abscess w/ needle
- wire introduced, needle removed, catheter inserted (single-lumen), CM injected (sinogram), catheter left in place for days to drain
- when output measurements reach zero, catheter removed
-

Front 85

Indications for Percutaneous Abscess Drainage

Back 85

Abscess (localized collection of pus, most likely from infection)

"Walled Off" by body, continue to grow & can become serious

Front 86

Complications from Percutaneous Abscess Drainage

Back 86

- septic shock
- fistula formation (abnormal connection btw 2 organs)
- bleeding

Front 87

Percutaneous Needle Biopsy

Back 87

.- special needles w/ collecting chamber are used to take tissue sample
- sample is gram stained or put into formalin for culture assessment

Front 88

Indications/Contraindications for Percutaneous Needle Biopsy

Back 88

Indications: samples tissue for mets or not (most common areas = lungs, kidneys, pancreas, & liver)

Contraindications: patients w/ vascular lesions or AVMs in ROI

Front 89

Complications from Percutaneous Needle Biopsy

Back 89

- Lungs: pneumothorax, hemothorax, air emboli, hemoptysis
- Kidneys: hematuria, hematoma, ureter obstruction

Front 90

Gastrostomy Tube Placement

Back 90

- NPO 8 hours before
- ID liver & colon to ensure no overlap of stomach prior to puncture
- NG tube placed to inflate stomach; percutaneous puncture; dilators used up to 24 Fr; wire inserted, dilator removed; tube threaded over wire to location; anchored by balloon & rubber disc

Front 91

Indications for Gastrostomy Tube Placement

Back 91

- long term feeding (patient unable to eat/swallow of own accord)
- those suffering from strokes, cancer in esophagus/tongue

Front 92

Complications from Gastrostomy Tube Placement

Back 92

- puncture of liver, colon, or posterior wall of stomach
- improper tube placement into abdomen instead of into stomach/GI tract as well

Front 93

At what spine level does the celiac trunk originate?

Back 93

Anterior to L1

Common iliacs @ L4

Front 94

Abdominal Aortogram

Back 94

- includes entire abdominal aorta from diaphragm down
- catheter placed in most superior part of abdominal aorta (requires more CM, gives great pics)

Front 95

Celiac & Mesentery Angiogram

Back 95

- flow can experience ischemia through...embolism (most common) / thrombosis (highest mortality rate [90%]) / non-occlusive ischemia

Front 96

Renal/Adrenal Angiogram - Renal Artery Stenosis (RAS)

Back 96

- 2 main causes: fibromuscular dysplasia (FMD) & atherosclerotic RAS (ARAS) [most common form]
- FMD can affect all 3 lumen layers, often seen as medial FMD
- RAS usually requires stent placement for best results (only 50% effective w/o stent, 95% with)

Front 97

Stenosis is clinically significant at....

Back 97

50-70% stenosis

Front 98

Extremity Venograms

Back 98

Upper
- puncture site distal, CM is antegrade
Lower
- puncture site distal (ex. femoral vein)

Front 99

AFR (Aortofemoral Runoff) [Extremity Arteriogram]

Back 99

- femoral approach most often used (utilize descending aorta to access great vessels on arch)
- on lower ext, femoral approach can be contraindicated w/ previous bypass, occlusion, etc
- can use up to 60 mL of CM for bilateral imaging

Front 100

Thromboendarterectomy (TEA)

Back 100

Surgical procedure involving excision of thrombus by removing it from intimal lining of vessel (cut into vessel through surface of skin)

Front 101

Mechanical Atherectomy/Rotational Atherectomy

Back 101

- similar procedure to endarterectomy, but plaque is removed via catheter from vessel
- indicated for fibrocalcific lesions (stent-mal-expansion & fxs more common) & for femoropopliteal segments that are difficult to stent

Front 102

Aortofemoral Bypass Grafts (AFB)

Back 102

- more common than TEA
- used for patients w/ diffuse or multifocal disease
- may use an "axillofemoral bypass" if distal aorta is compromised

Front 103

Angioplasty/Stenting

Back 103

- proven successful for more focal lesions
- self-expanding stents preferred to avoid "crush injuries" due to natural body mvmt

Front 104

Covered Stents/Stent Grafts

Back 104

- covered material allows for treatment of inadvertent punctures, traumatic AV fistulae, vessel ruptures, & small vessel aneurysms
- usually made of PTFE (polytetrafluoroethylene)

Front 105

Cutting Balloon

Back 105

- longitudinally mounted microsurgical blades on balloon; as balloon is inflated, atherotomes are deployed into vessel walls
- reduces elastic recoil & allows for lower balloon pressures

Front 106

Cryotherapy

Back 106

- nitrous oxide fills balloon, causes it to cool to -10 degrees C
- causes less pressure to open artery, more uniform dilation of vessel b/c plaque cracks when frozen
- rapid cooling causes cellular apoptosis