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63 Cards in this Set

  • Front
  • Back
ddx: hepatic artery aneurysm with vessel narrowing
- chronic hepatitis
- IV drug use
- polyarteritis nodosum
what lesions in the lower extremity respond best to angioplasty
the more proximal the better and the shorter the better
when should you consider intervening with a stenosis
for intial angioplasty - pressure gradient measurement readings of >10mm Hg or diameter stenosis over 70% if symptomatic
when should you think about stenting
residual gradient > 5mm Hg
residual stenosis > 30%
what medicines are used with angioplasty
heparin - 2000 - 4000 U when the lesion is crossed
verapamil and nitroglycerin for spasm

*pearl* remember to check BP after nitro is given
what is the expected outcome with angioplasty of the SFA
lesion shorter than 5cm = 70-80% good outcome at 6 mo
lesion greater than 5cm = < 50% good outcome at 6 mo
what is the outcome with angioplasty of the common ileac
70% 5 year patency with PTA
80-90% 5 year patency with stent
what is present with the lumbar arteries are not seen on a midstream aortogram
ddx: popliteal artery occlusion
cystic adventitial disease
popliteal entrapment syndrome
popliteal aneurysm
what are the indications for IVC filter placement
contraindication to anticoagulation
failed anticoagulation
complication of anticoagulation
large clot burden
what are the complications of IVC filter placement
migration <1%
large, obstructing clot 10%
clot distal to filter 10%
perforation <1%
what is the critical information needed from a cavagram
to where does clot extend
is the cava larger or smaller than 28mm
where are the renal veins
what type of filter is used if the cava is over 28mm
birdsnest filter
where must IVC filter be placed
below renal veins
what are the eponyms for thoracic inlet syndrome
effort thrombosis
what are the causes of thoracic inlet syndrome
only 15% due to cervical rib
most caused by fibrous band or osteophyte
how is occlusion due to thoracic inlet syndrome treated
thrombolyse, wait 6 weeks then perform definitive surgery
thrombolyse and follow with angio q6mo
what are the contraindications to thrombolysis of a cold foot
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
how is thrombolytic administered
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)
how is thrombolysis monitored
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
what are the endpoints for thrombolysis
total lysis of clot
antegrade flow
lytic stagnation (no change over 12hr)
new thrombus
what must be evaluated after thrombolysis is completed
look for the cause, usually in or outflow stenosis

*pearl* there is a worse prognosis if no cause found
what is the half-life of t-PA
6-8 minutes
what factors predict good thrombolytic outcome
clot less than 6 weeks of age
ability to pass guidewire (guidewire transit test)
ability to imbed catheter in clot
occlusion length < 10 cm
why is heparin given thru the sheath in thrombolysis
to avoid back-clotting along the sheath
to decrease clot propagation
what must be evaluated prior to starting a PA gram
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
what must be checked before and after injection of contrast for a PA gram
PA pressure
what is normal PA pressure

*pearl* if elevated check RVEDP/RA pressuer - normal is 0-5mmHg
what are the pressures which contraindicate a normal PA injection
PA systolic > 70mmHg
PA mean > 40mmHg
RVEDP > 20mmHg
what are the signs of acute clot
central filling defect
enlarged vessel
convexity toward the contrast
what are the signs of chronic clot
concave towards the contrast
recanalization centrally
wall irregularity
what are indications for renal PTA
rising creatinine
worsening hypertension
refractory hypertension
acute hypertension
flash pulmonary edema
what is the success of renal PTA for:
- atherosclerosis
technical 90%
clinical 40%
5 year patency 50%
with stent 85%

technical 90%
clinical 35%
5 year patency 90%
don't stent FMD, it does well without it
how do you evaluate for thoracic outlet syndrome
study in neutral and adson position (abduction/external rotation)
how do you evaluate for popliteal entrapment syndrome
A PPD (active plantar, passive dorsi)

study in active plantar and passive dorsiflexion
ddx: hemoptysis
pulmonary AVM
rasmussen aneurysm
pulmonary embolism
cystic fibrosis (common)
bronchiectasis (common)
sarcoidosis (common)
bronchogenic ca
how do patients with pulmonary AVM present
shortness of breath
with what syndrome is pulmonary AVM associated
85% have osler-weber-rendu
when should you intervene in pulmonary AVM
symptomatic AVMs of AVMs with a feeding artery > 3mm
ddx: young patient with arterial stenosis
middle-aortic syndrome
what are the vascular rings
double aortic arch
right arch with aberrant left subclavian artery
what is the post-embolization syndrome

*pearl* symptoms resolve in 72 hours
how is portal hypertension evaluated
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)
what is the corrected sinusoidal pressure (CSP)?
the critical measurement for determining degree of portal venous hypertension
CSP = hepatic wedge - free hepatic venous pressures
what are normal:
- hepatic wedge pressure
- free hepatic pressure
- corrected sinusoidal pressure
HWP < 5
FHV < 6-10
CSP < 5
grade cirrhosis by CSP
N < 5
mild 6-10
moderate 11-18
severe > 19
what are the steps in biliary drainage or PTC (9 steps)
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!
ddx: aortic dissection
cystic medial necrosis
bicuspid valve
pectus excavatum
post surgical
how do you tell a ductus diverticulum from a traumatic aortic injury
ductus has:
smooth transition
lack of intimal irregularity
absence of delayed contrast washout
how do chronic and acute mesenteric ischemia differ
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
what are the causes of acute mesenteric ischemia
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
what are the collateral pathways in aortic occlusion

subclavian - IMA - sup epigastric - inf epigastric - common femoral

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

lumbars - iliolumbar - int iliac - ext iliac
intercostals - lumbars - deep circumflex - iliac
how is non-occlusive ischemia managed
a test injection of papaverine is performed and if it improves flow then a 12-hour infusion is initated
what are the findings in angio of tumor

blush of tumor
encasement of vessels
displacement of vessels
pooling of contrast
AV shunting
what are causes and treatment of upper GI bleed
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
what are angiodysplasia findings
vascular tuft
early draining vein
persistent draining vein
what are the rupture risk and surgical indications for AAA
< 4 cm - 2% rupture risk/lifetime
> 6 cm - 20% risk

surgical indications:
5mm growth over 6 months
>4.5 cm diameter
what are the findings in arterial trauma

how are lower GI bleeds treated
initial therapy with vasopressin
- 0.2 units/minute for 20 min
- stopped: admit to ICU, continue and recheck 12 hours
- not stopped: go to 0.4 units/minute for 20 min and recheck
- 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
how often is vasopressin effective for lower GI bleed
90% for tics
60% for angiodysplasia or ca
what are contraindications for vasopressin
severe heart disease
peripheral vascular disease
what are indications for TIPS
upper GI bleed refractory to therapy
multiple failed therapies
refractory ascites
hepatorenal syndrome
what are the contraindications for TIPS
right heart failure
uncorrectable bleeding diathesis
portal vein thrombosis