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67 Cards in this Set
- Front
- Back
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Occlusion of fem-pop graft
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-no opacification of SFA
-circular graft marker -filling of proximal stump Tx: -cannulate the graft with wire -place multisidehole infusion catheter -infusion of TPA at 1mg/hr overnight -if patent, but proximal stenosis, then angioplasty |
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Thoracic outlet syndrome
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-positional compression of left subclavian artery (abduction)
-stenosis accentuated by hyperabduction Tx: arterial - surgical decompression by resection of 1st rib |
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Paget-Schroetter syndrome (venous thoracic outlet syndrome)
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-narrowing/thrombosis of axillary/subclavian vein
-extensive venous collaterization Tx: -thrombolysis (tPA - 1mg/hr for 36hrs + heparin) -surgical decompression + intraoperative angioplasty -subclavian vein stenting (last resort) Tx complications: bleeding, arterial injury, PTX, phrenic nerve injury, infection |
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Subclavian Steal Syndrome
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Early:
-Left subclavian artery occlusion Late: -Retrograde vertebral artery flow with transient neurologic symptoms -Reconstitution of flow in left subclavian artery Tx: -percutaneous angioplasty for non-occlusive lesions -bypass surgery for complete occlusion |
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Budd-Chiari Syndrome
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Clinical triad:
RUQ pain ascites hepatomegaly Findings: -hepatic vein outflow obstruction -"spider web" intrahepatic venous collaterals Tx: -angioplasty or stent -TIPS |
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May-Thurner Syndrome
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-compression of left common iliac vein by right common iliac artery
-left common iliac vein stenosis (due to crossing right iliac artery) -females>males -thin body habitus Tx: -thrombolysis -venous stenting |
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Duplicated IVC
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Tx options:
-two filters below confluence -single suprarenal filter |
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Cather to left of mediastinum
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DDx:
-Left-sided SVC (drains into coronary sinus) -Duplicated SVC -Catheter in chest wall collateral |
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Fragmented catheter
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-endovascular retrieval
-sheath in the groin and use a snare to retrieve |
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Pulmonary AVM
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-pulmonary artery dilation
-aneurysm -early draining pulmonary vein Tx: -coil embolization (large coils) Dreaded complication is emoblization into pulmonary veins - compress carotid arteries if this happens |
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Malignant biliary obstruction treatment
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-metallic wall stent (Wallstent) - palliation
For malignant obstruction only because metal stents do not stay open past 6 months No metal stents for tx of benign disease or curable malignancy Tx for benign ds: -balloon dilation -percutaneous biliary drainage if needed -surgical revision as last resort |
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Chest tube drainage
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-parapneumonic effusion success rate 70%
-typical duration 5-10 days Inadequate drainage: lytics, larger drain -tPA 5mg in 50cc sterile saline; clamp tube for 4 hours -pigtail chest tubes: 8F to 24F -at least 12F recommended |
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Left varicocele
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-left (83%), infiertility (85%)
-retrograde filling of left testicular vein on selective left renal venogram Tx: -coil entire vein to just below the renal vein as incompetent venous valve often close to renal vein Analogous condition in women: Pelvic congestion syndrome -ovarian vein obstruction |
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Percutaneous abscess drainage
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-shortest route
-antibiotics Approach: -transabdominal -transgluteal (as medial and caudal to sacrum as possible to avoid injury to sciatic nerve and pelvic vessels) for deep pelvic collections -trans - rectal/vagnial (not thru bowel) -transhepatic if collection deep to liver -small bore (12F) pigtail catheter -straight sumps (12-24F) -large bore (22-30F) -tube check 1 week following drainage - inject contrast through draing -exchange tube over a wire if there is still a collection and depending on output Check for fistulization with bowel - takes longer to resolve |
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Renal transplant hydronephrosis due to ureteral stricture
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-antegrade nephrostogram
-needle inserted into an upper pole calyx -contrast injected into collecting system to find location of stricture Tx: -Nephrostomy and external drainage and -Balloon dilation of stricture and double J stent placement |
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AML
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(assoc with TS)
Endovascular treatment: ->4cm due to bleeding reisk -angiogram, selective embolization with Embospheres |
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Acute calculous cholecystitis
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-U/S and fluorscopically guided percutaneous cholecystostomy tube placement
-Transhepatic drain for 6 weeks (cross liver parenchyma to reduce risk of lead and peritonitis) |
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Popliteal artery entrapment syndrome
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Findings:
-Occlusion or near occlusion of popliteal artery - may become evident with plantar or dorsiflexion of foot -Impingement of popliteal artery by medial head of gastrocnemius Tx: -No angioplasty/stent -Surgical bypass, surgical release of muscle or tendon Other conditions involving popliteal artery: -emboli -atheroscleroic ds -cystic adventitial disease -aneurysm -trauma -XRT |
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Traumatic thoracic aortic injury
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Traumatic pseudoaneurysm
-intimal tear -indistinct borders, acute margins -delayed washout of contrast -location at aortic isthmus, just distal to left subclavian artery (ascending aorta is fixed and decelarates more rapidly than descending) Ddx: Ductus diverticulum (9%) -remnant of ductus arteriosum -smooth anteromedial outpouching of the aortic isthmus Look for other injuries - arch vessels or diaphragmatic aorta Tx: Surgical repair Endovascular repair |
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Thoracic aortic aneursm
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DDx:
Post-traumatic Atherosclerotic Mycotic Congenital Syphilitic Higher rate of rupture than AAA Tx: Observation - small, non-operable Surgery - expanding Endovascular stent-grafts |
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Aortic dissection
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-Narrow true lumen (compression of true lumen by false lumen)
-Delayed filling of false lumen -Intimal tear |
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Type 2 endoleak
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-contrast enhancement within endosac, best seen on delayed imaging (90 sec)
-retrograde filling of the endosac from a vessel (IMA or lumbars) coming from the excluded aneurysm Coil embolization: -catheterization of endosac from IMA (via SMA) -deploy coils soaked in thrombin to fill endosac and proximal IMA |
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Acute SMA embolus causing visceral ischemia
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Selective SMA angio
-abrupt occlusion of the main SMA with visible meniscus -no collaterals Tx: operative embolectomy Visceral iscemia: Acute - embolic, thrombotic (hypercoagulable) Chronic - atherosclerosis, median arcuate ligament syndrome, FMD |
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Chronic visceral ischemia
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-occlusion of celiac, SMA, and IMA
-collateral flow via marginal artery Tx: surgical bypass Anatomy: -pancreaticoduodenal arteries connect the celiac to the proximal SMA -marginal artery of Drummon and the paracolic arcades run between SMA and IMA -if IMA occluded, may have systemic vessels from internal iliac arteries feeding IMA via retrograde flow |
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Fibromuscular dysplasia
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1/3 of renovascular hypertension
mid-distal renal artery (20% branches) 2/3 bilateral (unilateral R>L) Types: Medial (85%) - "string of beads" Perimedial (10%) - irregular stenosis Intimal (5%) - web-like stenosis, post-stenotic dilation, young man Tx: Balloon angioplasty DDx: Connective tissue disease Inflammatory vasculitis |
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Bleeding right colon
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-extravasation from right colic artery
Tx: -microcatheterization with coil embolization -correct coagulopathy |
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Bilateral renal artery stenosis due to atherosclerosis
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-Bilateral balloon expandable stents
-Anticipate improvement in control of HTN in >60% -Anticipate improvement in renal fxn in >20% |
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Inflammatory vasculitides
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Mycotic aneursym
-eccentric Kawasaki's -children -coronary and systemic arterial aneurysm Radiation Arteritis -focal stenosis in unusual location |
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Idiopathic arteritides
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Polyarteritis nodosa
-microaneurysms -kidney and pancreas Temporal arteritis (Giant cell arteritis) -stenosis or occlusion -upper extremity or arch vessels -dx: temporal artery biopsy Takayasu's -stenosis or occlusion -aorta, arch vessels, PA Buerger's -segmental occlusions, cork screw collaterals (dilated vaso vasorum) -peripheral vasculature |
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Hereditary Vascular Disorders
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Connective Tissue Disorders
-Marfan's and Ehlers-Danlos -young patient with dissection and diffuse vasculopathy |
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Percutaneous transluminal angioplasty (PTA)
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-non-compliant balloon (compared to occlusion or embolectomy balloon)
-will not expand beyond stated diameter -patient must be symptomatic (claudication, rest pain, HTN, renal failure) -focal, short, non-calcified lesions respond well to PTA -long, diffuse, calcified lesions DO NOT respond well to PTA (high recurrence) -tibial TPA has greater risks so restricted indications (at risk of losing limb, graft salvage to maintain patency) |
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Hemodynamic assessment for PTA
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-50% stenosis is hemodynamically significant (corresponds to 75% reduction in cross sectional diameter)
-10mmHg systolic pressure gradient is significant at rest -if on vasodilators (nitroglycerin), 20mmHg systolic pressure gradient is significant -indirect size - collaterals, kidney size -hemodynamically significant stenosis usually occurs at DISTAL aspect of a fem-pop graft and requires PTA |
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PTA balloon specifications
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Optimal diameter:
10% larger than the normal, unaffected vessel Optimal length spans the lesion and does not extend more than 1cm on either side Standard balloons -0.035 inch guidewire -5-7 French -renal (6mm), SFA (6mm), common iliac (10mm), external iliac (8mm), popliteal (5mm) Small ballons -0.018 inch guidewire -used in coronary arteries or tibial vessels (3-4mm) |
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Pharmacologic adjuncts to PTA
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prevents vasospasm and thrombosis
Heparin (4,000-10,0000 units) Nitroglycerine (50-100 micrograms) Lytics (tPA) |
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PTA success rate: peripheral vascular disease
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long-term = 3-5year patency
Infrarenal 80% Iliac 70% Femoropopliteal 50% Infrapopliteal 40-80% |
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PTA success rate: renovascular HTN
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FMD 85%
Atherosclerosis non-ostial stenoses 70% ostial stenoses 60% |
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PTA complications
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Puncture site
-hematoma 5% -pseudoaneurysm <1% PTA site -acute thrombosis 5% -rupture <1% Distal complication -thromboembolism <5% -cholesteral embolus rare Intimal flap is NOT a complication unless it's causing a reduction in flow. |
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Stent placement
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Rationale
-better immediate result -better long-term patency Deployment -Primarily - iliacs, renal, heart -Secondarily - if PTA result is suboptimal (e.g. SFA) Stent design -Balloon expandable (Palmaz): iliacs, renals -Self-expanding (Wallstent, Nitinol): extremities (SFA) -Stent graft: infrarenal AAA (metallic stent covered with fabric - gortex, dacron) -Zenith has 2cm of uncovered stent proximally deployed in a suprarenal position - gives superior stability -Wallgraft (covered stent): iliacs when stenting a common iliac to external iliac, important to embolize the internal iliac or you will get a type 2 endoleak |
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Endoleak
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leak into endosac
Type 1: Proximal and distal attachment Type 2: Collaterals (IMA, lumbar) Type 3: Modular junction points Type 4: Directly through graft material (porosity) |
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Fibrinolysis (aka thrombolysis)
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Indications:
-acute or sub-acute thrombus in native vessels or grafts (<2wks old) -clotted grafts (dialysis) Tissue Plasminogen Activator (tPA) -1mg/hr -adjuncts: heparin, plavix (antiplatelet agent) -multi-side hole catheter lodged into thrombus -ICU observation -Fibrinogen >150 (reduce tPA dose <150. stop immediately at <100) -lysis expected in 24-48hrs Contraindications: -recent surgery, GI bleeding, recent stroke, brain mets, threatened limb Complications: -bleeding: puncture site, systemic (rare) -distal emboli (usually resolve spontaneously with the tPA) |
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Therapeutic embolization
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Indications:
-control of GI bleeding -tx of fibroids -palliate malignancy -traumatic injury Particulates: -gelfoam (very temporary) -polyvinyl alcohol (PVA -Embospheres Coils |
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GI blood supply
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Upper GI tract
-Celiac: left gastric, hepatic, gastroduondenal, splenic -SMA: pancreatico-duodenal Lower GI tract -SMA: jejunal, ileal, ileocolic, ight colic, middle colic -supplies small bowel and proximal 2/3 of tx colon - branches go to right and left -origin at pedicle of L1 -IMA: left colic, superior hemorrhoidal -supplies lateral 1/3 of tx colon, descending, sigmoid colon and superior rectum - branches go to left abdomen -origin at left pedicle of L3 |
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Embolization of GI bleed
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Upper GI bleed
-often tx with endoscopy -selective catheterization and coils Lower GI -vasopressin (ADH) infusion -0.2 units/min x 24-36hrs -angio at 20min - increase or decrease dose 0.1-0.4 units/min -microcoils Results: Mallory-Weiss/gastric 80% Duodenal 60% (due to collaterals) Lower GI ?75% |
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Uterine Artery Emobilzation (UAE)
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-fibroids (dysfxnal bleeding, pain)
-post-partum, post-surgical bleeding Particulate: Embospheres (500-750microns) Collaterals exist so don't need uterine artery |
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TIPS (transjugular intrahepatic portosystemic shunt)
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Normal portal-venous anatomy: SMV, IMV, splenic vein
Pathologic portal-venous anatomy: filling of portosystemic collaterals umbilical, hepatofugal flow in IMV, coronary vein, and short gastrics Indications: -Variceal bleeding - refractory to endoscopic therapy -Ascites - refractory to medical therapy -Hepatohydrothorax (side-use) - holes in diaphragm Jugular vein to hepatic vein to liver parenchyma to portal vein Target PSG < or = 12mmHg TIPS Stent: -right heptaic vein to right portal -Viatorr - 2cm uncovered portion protrudes into PV and covered portion extends through intrahepatic tract to jxn of hepatic vein and IVC -8-12mm Immediate complications: -Bleeding (intraabdominal, hemobilia, subcapsular) -Liver failure -Renal failure -Stent migration MELD score -model of end-stage liver disease -natural logarithmic function of the serum bilirubin, INR, and serum creatinine -used to predict who will survive -want those with a score of 18 or less Stops rebleeding better than endoscopic sclerotherapy, but comes at a cost of encephalopaty (mortality is similar in both) |
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DVT
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Causes:
Advanced age, contraceptives, CHF, obesity, recent surgery Indications for thrombolysis: -LE DVT in young patinet -Phlegmasia Cerulea Dolens (emergent indication of profound thombus on venous side that it prevents arterial inflow) -Severe pain and morbidity from DVT -Preservation of femoral venous access site Technique: -Popliteal access (U/S) -tPA thrombolysis -mechanical thrombectomy as indicated -venous PTA and stenting as indicated (May-Thurner) |
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Superior vena cava syndrome
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Partial or complete obstruction of SVC
(can be occluded from the brachiocephalic vein and blood flow is through azygous and up through IVC) Etiologies -bronchogenic CA (80%), lymphoma -histo/cocci fibrosing mediastinitis -chronic central venous access catheters -dialysis through AVF Symptoms: -facial edema and flushing, upper extremity edema Tx: -anticoagulate, diuretics -PTA (+ or - metallic stent) Complications: -vein rupture, bleeding -part of SVC is in pericardial so can have tampanode |
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IVC filter indications
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-pt with PE or iliofemoral DVT with a contraindication, complication, or failure of anticoagulation
-massive acute PE in a pt with ongoing DVT -free-floating IVC thrombus -DVT is setting of severe cardiopulmonary disease Relative indications: -prophylactic placement for trauma pts -"high risk" patients (long term immobilization or hypercoagulable) -short-term protection during fibrinolysis |
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IVC filter types
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Greenfield filter
-deployment over wire helps decrease tilting Bird's Nest -for large diameter IVCs (28-40mm) Vena Tech -vertical struts to keep it straight (coaxial) in IVC Simon Nitinol -two tiered configuation Opt Ease: -retreivable (femoral vein access for retreival) Gunther Tulip -retrievable |
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Suprarenal IVC filter indications
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-renal vein thrombosis
-IVC thrombus above renal veins -thrombus extending above previously placed infrarenal filter -filter placed during pregnancy -anatomic variants: duplicated IVC Left circumaortic left renal vein - place filter below left retroaortic vein component |
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IVC filter complications
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-caval thrombosis
tx: suprarenal filter, thrombolysis -recurrent PE |
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Hemodialysis arteriovenous fistulas and grafts
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1 yr primary patency: 70%
2 yr primary patency: 60% Direct AVFs - 25% -better durability, less infection -radial artery - cephalic vein (wrist) -antecubital fossa (brachiocephalic & brachiobasilic) Grafts - 75% -PTFE -brachial artery - basilic vein -radial artery - cephalic vein -axillary artery - axillary vein |
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AVF and graft complications
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Nonhemodynamic complications:
-infection -CHF Flow-related (hemodynamic) complcations: -stenosis (most common) -thrombosis (most common) -venous aneurysms -venous or graft pseudoanerusyms -arterial steal Graft stenosis occurs at venous anastomosis AVF stenosis -radiocephalic - occurs at AV anastomosis just distal to radial artery -brachiocephalic- uniform stenosis throughout the vein |
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AVF and graft stenosis treatment
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-PTA at least as good as surgical revision
Primary patency after PTA: -radiocephalic AVFs - 20months -brachiocephalic AVFs - 7 months Secondary patency with PTA (elevated pressures) - 6 years AVF stenting indications: -resistant to AVF -venous dissection / rupture -exclusion of pseudoaneurysms |
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AVF and graft thrombosis treatment
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-surgical thrombectomy
-surgical creation of new AVF -percutaneous fibrinolysis, thrombectomy Fibrinolysis - tPA (1mg/hr) + heparin Post-fibrinolysis balloon dilation / clot maceration (with Amplaz clot buster) -exchanged catheter for balloon catheter -dilate and sweep debris towards venous outflow -dilate any stenoses |
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Biliary anatomy
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Right posterior segmental duct may insert on the left hepatic duct, the common hepatic duct, or cystic duct
Insertion of this duct is crucial during lap choly because mistaking this for a cystic duct could cause severe bile duct injury |
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Percutaneous Transhepatic Cholangiography
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-22 gauge needle into liver parenchyma and contrast is administered as needle is slowly withdrawn
-right transhepatic, intercostal approach Findings: -bile duct obstruction -bile duct leak/stones |
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Location of malignant biliary strictures
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Location of malignant obstruction:
-hilum: gallbladder ca, mets, HCC -distal CBD: ampullary ca, pancreatic ca, -cholangio ca can occur anywhere along course of bile ducts |
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Benign vs malignant biliary strictures
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Benign (smooth tapering ducts)
-post-operative strictures -sclerosing cholangitis -pancreatitis -stone related obstruction (recurrent pyogenic cholangitis, Mirizzi syndrome) Malignant -abrupt ending ducts |
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Percutaneous Transhepatic Biliary Drainage (PTBD)
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Indications:
-palliation (malignant obstruction - symptomatic with pruritis, jaundice) -biliary stricture / leak -access for stone retrieval Contraindications: -unfavorable anatomy - ascites, colonic interposition, liver cysts -coagulopathy or thrombocytopenia Technique: -PTC -Catheterization -Tract dilation -Catheter (8-12F) insertion (external or internal/external drainage) Complications: -biliary sepsis (2.5%) -arterial injury (2.5%) |
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Percutaneous Cholecystostomy
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Indications:
-acalculous cholecystitis (15% ICU pts) -calculous chloleystitis (non-surgical candidate) Technique -needle advanced into GB under U/S -wire advanced through needle into GB -tract is dilated -drain is placed High technical success (95%) Complications: -hemorrhage -bile perotinitis Tube removal vs. cholecystecomy -removal in 6wks ; wait for fibrous tract to form |
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Nephrostomy
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Indications:
-obstruction - pain, sepsis, renal failure causing hydro due to stones / scar / tumor -leak - non-dilated system Technique: -prone, 4 finger breadths away from midline below the costal margin -needle placed under U/S into posterior calyx -catheter (8-12F) is placed into renal pelvis Central puncture - more likely to injure arterial structures Complications rare: -urosepsis 4% -bleeding |
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Ureteral stents
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stents placed from renal pelvis to urinary bladder (double J stent)
-sometimes placed in conjunction with percutaneous nephrostomy tube) -obstruction -leak |
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Splenic abscess treatment
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-higher risk of bleeding
-usually respond to antibiotics alone -if abx fail, drainage can be performed |
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Pancreatic fluid collection treatment
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Percutaneous drainage if:
-infection most common indication and must be suscpected -pt must be symptomatic -acute fluid collection -pseudocyst - if infected -pancreatic abscess - usually viscous so multipl tube changes and long-term drainage |
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Liver abscess treatment
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-defined well density fluid collection likely to respond to percutaneous abscess drainage
-septated, necrotic filled collection will not respond well to PAD Infected liver mets will not heal -requires drainage for life |
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Enteric fistulae
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Length of tx - 6 wks
Determinants of success Small bowel (80% success) Colon (50% success) Output volume is high (>200ml/day) or intrinsic bowel disease (distal bowel obstruction of inflammatory ds - unlikely to respond to drainage |
