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63 Cards in this Set
- Front
- Back
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ddx: hepatic artery aneurysm with vessel narrowing
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iatrogenic
vasculitis - chronic hepatitis - IV drug use - polyarteritis nodosum cryoglobulinemia trauma mycotic |
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what lesions in the lower extremity respond best to angioplasty
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the more proximal the better and the shorter the better
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when should you consider intervening with a stenosis
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for intial angioplasty - pressure gradient measurement readings of >10mm Hg or diameter stenosis over 70% if symptomatic
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when should you think about stenting
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residual gradient > 5mm Hg
residual stenosis > 30% dissection |
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what medicines are used with angioplasty
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heparin - 2000 - 4000 U when the lesion is crossed
verapamil and nitroglycerin for spasm *pearl* remember to check BP after nitro is given |
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what is the expected outcome with angioplasty of the SFA
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lesion shorter than 5cm = 70-80% good outcome at 6 mo
lesion greater than 5cm = < 50% good outcome at 6 mo |
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what is the outcome with angioplasty of the common ileac
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70% 5 year patency with PTA
80-90% 5 year patency with stent |
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what is present with the lumbar arteries are not seen on a midstream aortogram
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AAA
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ddx: popliteal artery occlusion
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trauma
embolism cystic adventitial disease popliteal entrapment syndrome popliteal aneurysm |
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what are the indications for IVC filter placement
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contraindication to anticoagulation
failed anticoagulation complication of anticoagulation large clot burden |
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what are the complications of IVC filter placement
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migration <1%
large, obstructing clot 10% clot distal to filter 10% perforation <1% |
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what is the critical information needed from a cavagram
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to where does clot extend
is the cava larger or smaller than 28mm where are the renal veins |
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what type of filter is used if the cava is over 28mm
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birdsnest filter
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where must IVC filter be placed
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below renal veins
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what are the eponyms for thoracic inlet syndrome
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effort thrombosis
paget-schroeder |
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what are the causes of thoracic inlet syndrome
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only 15% due to cervical rib
most caused by fibrous band or osteophyte |
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how is occlusion due to thoracic inlet syndrome treated
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thrombolyse, wait 6 weeks then perform definitive surgery
-or- thrombolyse and follow with angio q6mo |
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what are the contraindications to thrombolysis of a cold foot
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surgery within 2 weeks (relative, some say 3 days)
craniotoy within 2 months stroke within 3-6 months ongoing GI or GU bleeding any CNS pathology |
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how is thrombolytic administered
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t-PA is delivered via multi-side-hole catheter
initial pulse spray, bolus does of t-PA up to 8mg continuous infusion in ICU, 1mg/hr - 5mg/1hr (some use 0.05mg/kg/hr) recheck q12hr heparin administered at the sheath - 100 U/hr (+/- systemic heparin) |
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how is thrombolysis monitored
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check Hct, PT, PTT, fibrinogen, Plt prior to start
admit to ICU after initial thrombolysis check q6-12hrs for angiographic/clinical change check Plt, PTT, and fibrinogen q4hr fibrinogen < 150mg/dl then cut t-PA dose in half fibrinogen < 100 then d/c maintain PTT 2-3x normal - check for Plt drop due to heparin, d/c as needed |
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what are the endpoints for thrombolysis
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total lysis of clot
antegrade flow hemorrhage lytic stagnation (no change over 12hr) new thrombus |
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what must be evaluated after thrombolysis is completed
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look for the cause, usually in or outflow stenosis
*pearl* there is a worse prognosis if no cause found |
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what is the half-life of t-PA
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6-8 minutes
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what factors predict good thrombolytic outcome
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clot less than 6 weeks of age
ability to pass guidewire (guidewire transit test) ability to imbed catheter in clot occlusion length < 10 cm |
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why is heparin given thru the sheath in thrombolysis
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to avoid back-clotting along the sheath
to decrease clot propagation |
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what must be evaluated prior to starting a PA gram
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in addition to the usual, ECG must be checked fo LBBB - if there then get external pacer
also, if V/Q is indication, check which side is abnormal and start with that |
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what must be checked before and after injection of contrast for a PA gram
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PA pressure
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what is normal PA pressure
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25/10mmHg
*pearl* if elevated check RVEDP/RA pressuer - normal is 0-5mmHg |
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what are the pressures which contraindicate a normal PA injection
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PA systolic > 70mmHg
PA mean > 40mmHg RVEDP > 20mmHg |
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what are the signs of acute clot
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central filling defect
tram-tracking enlarged vessel convexity toward the contrast |
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what are the signs of chronic clot
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concave towards the contrast
recanalization centrally wall irregularity web |
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what are indications for renal PTA
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rising creatinine
worsening hypertension refractory hypertension acute hypertension flash pulmonary edema |
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what is the success of renal PTA for:
- atherosclerosis - FMD |
atherosclerosis:
technical 90% clinical 40% 5 year patency 50% with stent 85% FMD: technical 90% clinical 35% 5 year patency 90% don't stent FMD, it does well without it |
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how do you evaluate for thoracic outlet syndrome
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study in neutral and adson position (abduction/external rotation)
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how do you evaluate for popliteal entrapment syndrome
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A PPD (active plantar, passive dorsi)
study in active plantar and passive dorsiflexion |
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ddx: hemoptysis
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vasculitis
pulmonary AVM rasmussen aneurysm pulmonary embolism iatrogenic cystic fibrosis (common) bronchiectasis (common) sarcoidosis (common) bronchogenic ca |
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how do patients with pulmonary AVM present
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emboli
shortness of breath hemorrhage asymptomatic |
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with what syndrome is pulmonary AVM associated
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85% have osler-weber-rendu
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when should you intervene in pulmonary AVM
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symptomatic AVMs of AVMs with a feeding artery > 3mm
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ddx: young patient with arterial stenosis
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takayasu's
middle-aortic syndrome neurofibromatosis |
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what are the vascular rings
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double aortic arch
right arch with aberrant left subclavian artery |
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what is the post-embolization syndrome
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pain
fever nausea leukocytosis *pearl* symptoms resolve in 72 hours |
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how is portal hypertension evaluated
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place balloon occlusion catheter in hepatic vein
wedge hepatic wedge pressure (HWP) perform venogram with 1-2cc/s for 8-10 sec perform venogram in main hepatic vein, unwedged measure free hepatic venous pressure (FHV) |
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what is the corrected sinusoidal pressure (CSP)?
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the critical measurement for determining degree of portal venous hypertension
CSP = hepatic wedge - free hepatic venous pressures |
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what are normal:
- hepatic wedge pressure - free hepatic pressure - corrected sinusoidal pressure |
HWP < 5
FHV < 6-10 CSP < 5 |
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grade cirrhosis by CSP
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N < 5
mild 6-10 moderate 11-18 severe > 19 |
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what are the steps in biliary drainage or PTC (9 steps)
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1. premedicate with antibiotic
2. approach mid-axillary line between costophrenic angle and inf liver edge 3. use 22 gauge diamond tipped needle 4. advance to mid right lobe and aspirate for blood 5. gentle contrast injection as needle withdrawn 6. make second stick with 21 gauge in straight segment of biliary tree 7. place 0.018 wire and 4-6 french dilators 8. exchange for 0.038 amplatz 9. place 8 french cope biliar tube and upsize as needed *pearl* don't cross stenosis at intial drainage - let it cool off! |
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ddx: aortic dissection
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cystic medial necrosis
hypertension bicuspid valve coarctation pregnancy scoliosis pectus excavatum trauma post surgical |
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how do you tell a ductus diverticulum from a traumatic aortic injury
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ductus has:
smooth transition lack of intimal irregularity absence of delayed contrast washout |
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how do chronic and acute mesenteric ischemia differ
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chronic: weight loss, fear of food, due to stenosis of at lease 2 mesenteric vessels
acute: pain out of proportion to exam, due to acute occlusion or spasm |
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what are the causes of acute mesenteric ischemia
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thrombosis - clot at SMA origin
embolus - clot at branch point (w/in 2-3 cm of origin) non-occlusive ischemia (usually ICU patients) venous thrombosis |
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what are the collateral pathways in aortic occlusion
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THINK:
SKIN: subclavian - IMA - sup epigastric - inf epigastric - common femoral GUT: IMA - sup hemorrhoidal - inf hemorrhoidal - iliac SMA - middle colic - marginal artery of drummond - left colic - hemorrhoidal - iliac SMA - middle colic - artery of riolan - left colic - hemorrhoidal - iliac BACK: lumbars - iliolumbar - int iliac - ext iliac intercostals - lumbars - deep circumflex - iliac |
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how is non-occlusive ischemia managed
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a test injection of papaverine is performed and if it improves flow then a 12-hour infusion is initated
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what are the findings in angio of tumor
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BEDPAN
blush of tumor encasement of vessels displacement of vessels pooling of contrast AV shunting neovascularity |
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what are causes and treatment of upper GI bleed
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duodenal ulcer - treat with embo or vasopressin; neither does well
varices - sclerotherapy and banding, TIPS last resort; both good gastric bleed (gastritis, ulcer) - embo or vasopressin mallory-weiss - embo or vasopressin *pearl* when source unclear empiric therapy in left gastric artery |
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what are angiodysplasia findings
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vascular tuft
early draining vein persistent draining vein |
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what are the rupture risk and surgical indications for AAA
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< 4 cm - 2% rupture risk/lifetime
> 6 cm - 20% risk surgical indications: 5mm growth over 6 months >4.5 cm diameter emboli |
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what are the findings in arterial trauma
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OPEND
occlusion pseudoaneurysm extravasation narrowing dissection |
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how are lower GI bleeds treated
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initial therapy with vasopressin
- 0.2 units/minute for 20 min restudy - stopped: admit to ICU, continue and recheck 12 hours - not stopped: go to 0.4 units/minute for 20 min and recheck restudy - stopped: taper 0.1 U/min/12 hour and then d/c if stopped - not stopped with 0.4 U/min: OR or embo *pearl* 5-25% risk of infarct with embo in lower GI |
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how often is vasopressin effective for lower GI bleed
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90% for tics
60% for angiodysplasia or ca |
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what are contraindications for vasopressin
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severe heart disease
peripheral vascular disease |
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what are indications for TIPS
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upper GI bleed refractory to therapy
multiple failed therapies refractory ascites hydrothorax hepatorenal syndrome |
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what are the contraindications for TIPS
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right heart failure
uncorrectable bleeding diathesis encephalopathy portal vein thrombosis |
