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80 Cards in this Set
- Front
- Back
Angio complications |
puncture site – hematoma, AVF, pseudoaneurysm, thrombosis, infection
contrast – renal failure, allergic reaction catheter-related – thromboembolism, stroke, dissection therapy-related – hemorrhage |
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Catheters used for: |
*central vessels - hi flow w/ sideholes
*selective vessels - low flow w/ endhole *aorta, PA - pigtail *mesenteric, renal, contralat iliac - Cobra *mesenteric, arch vessels - Simmons *coaxial subselection - Tracker *runoff - straight |
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Flow rates (rate/volume): |
abd aorta/PA 20/40
celiac/SMA 6/60 renals 5/15 IMA 2/20 pelvis 10/40 one leg runoff 4/48 arch 30/60 CCA 8/10 ICA 6/8 ECA 2/4 vertebral 6/8 IVC 15/45 |
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Guidewires: |
standard length - 145
diameters - 0.018 - 0.038 inch Types - Newton J, Rosen, Amplatz, Bentson, Glide |
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Pharmacologic angio therapy:
vasodilator vasoconstrictor |
vasodilators
– papaverine 25-50 mg/hr for mesenteric ischemia, contraind in complete AV block -NTG 100 ug for peripheral spasm vasoconstrictor – vasopressin 0.2-0.4 U/min for GI bleed, contraind in CAD, HTN, arrhythmia |
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Indications for embolization
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*bleed (GI, varices, trauma, bronchial art, tumor, post-op)
*vascular (AVM, AVF, pseudoaneurysm) *pre-op devascularization (RCC, AVM, vascular bone mets) *hepatic chemoembol (palliative, gelfoam + ethiodol + chemo in HCC) |
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Temporary embolization agent
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gelfoam pledgets (for UGIB, pelvic trauma, post-op)
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Permanent embolization agents
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*steel coils (large vessel, aneurysm, tumor)
*PVA (small particles for distal occlusion, tumors, bilateral UFE for fibroids) *ethanol (solid organ necrosis, peripheral AVM) |
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Embolization complications |
postembolization syndrome
infection nontarget embolization |
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Indications for thrombolysis
|
-arterial graft thrombosis
-native acute thrombosis -prior to percutaneous intervention -hemodialysis AVF or graft -venous thrombosis |
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Absolute contraindications to thrombolysis
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active bleed
intracranial lesion (stroke, tumor, recent surgery) pregnant nonviable limb |
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How thrombolysis is performed
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TPA 0.5-1 mg/hr + heparinize, repeat angio in 12 hrs, coaxial dual infusion
always treat underlying lesions Stop if: -no lysis @ 12 hrs infusion -major complication -fibrinogen <100mg/dl |
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Complications of thrombolysis
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major hemorrhage
distal embolization pericatheter thrombosis |
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Success rates for thrombolysis
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90% for grafts
75% for native vessel favorable prognosis if recent clot, good inflow/outflow, positioned in thrombus |
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Indications for angioplasty
|
-claudication or rest pain
-tissue loss -nonhealing wound -establish inflow for distal bypass graft -hemodialysis AVF or grafts |
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Angioplasty technique
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- measure pressure gradients before & after PTA
-heparinize after lesion crossed -piscoline 25 mg IA for vasospasm -balloon sized to adjacent nl artery (exc aorta - undersize) -wire always remains across lesion |
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Success for angioplasty:
fem/pop renal |
fem/pop- 90% initial & 70% @ 5yr
renals- 95% init & - 95% @ 5y for FMD - 70-90% for atherosclerosis ostial lesions poor prognosis |
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Indications for stenting
|
- failed PTA (stenosis > 30%, press gradient > 5 mmHg, large flap, hard calcified plaque)
- recurrent stenosis after PTA - venous obstruct / thrombosis - long segm stenosis / total occlusion - ulcerated plaque - renal ostial lesion - TIPS |
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Indications for TIPS
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portal HTN & variceal bleed failed sclerotherapy,
refractory ascites, Budd-Chiari, pretransplant |
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Contraindications for TIPS
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ABSOLUTE - severe R heart failure, liver failure
RELATIVE – PV thrombosis, hepat encephalopathy, infection, vascular liver tumors, polycystic liver dz - check PV patency - preprocedure paracentesis may help - isolated gastric fundal varices from splenic vein thrombosis not an indication |
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Goal and success rate for TIPS
|
goal:
portosystemic gradient < 12 mmHg decompression of varices patency 50% @ 1 yr |
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Complications of TIPS
|
hepatic encephalopathy
bleeding shunt thrombosis or stenosis R heart failure renal failure |
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Preprocedure meds/prep:
allergy conscious sedation |
contrast allergy – solumedrol 200mg IV + Benadryl 50mg PO or prednisone 40mg 16,8,2 hrs prior + Benadryl 50mg PO 1 hr prior
conscious sedation – Versed 0.5mg, Fentanyl 50 ug increments |
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Thoracic aortic aneurysm:
types and features |
*atherosclerosis– 90% fusiform; most in desc aorta
*cystic medial necr – HTN, Marfan, Ehlers-Danlos, sinus of valsalva aneur (tulip bulb) asc aorta, dissect common, Ca++ rare *syphilis – asymmetric, saccular, tree bark Ca++ *mycotic – saccular @ asc aorta or isthmus, a/w inflamm, immunocomp, IVDA, endocarditis, post-op *posttraumatic pseudoaneurysm *aortitis– Takayasu’s, giant cell, CVD *true aneur usu fusiform, false (posttraum, mycotic, postsurg) usu saccular. |
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Features of aortic dissection: |
*chest / back pain, aortic insuff, BP diff between extremities
*causes – HTN, Marfan, Ehlers-Danlos, coarctation, bicusp valve, preg, trauma *Stanford A – asc aorta, surgery!, beware tamponade, coronary occlusion, aortic insuff *Stanford B – desc aorta only, medical tx *Flap, displaced Ca++, delayed opacif of false lumen, compression of true lumen, occlusion of branch vessels, abnormal catheter position *False lumen larger, slow flow, anterolateral in asc aorta & posterolateral in desc aorta |
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Treatment for urticaria developing following injection
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* Stop injection if not done. No tx needed in most.
* H1 blocker: Benadryl 25-50mg PO/IM/IV or Vistaril 25-50mg PO/IM/IV. May add H2 blocker: Cimetidine 300mg PO/IV or Ranitidine 50mg PO/IV (in 10ml D5W solution) slowly. * If severe: Alpha agonist (art and venous constriction) - Epi SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) if no cardiac contraind. |
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Treatment for Facial or Laryngeal Edema developing following injection
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* Epi SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) or, if low bp Epi (1:10000) slow IV 1.0ml (=0.1mg). Repeat prn, max 1mg.
* O2 6-10 L/m (by mask) * If not responding or obvious laryngeal edema, call code and consider intubation. |
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Treatment for Bronchospasm developing following injection
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* O2 6-10 L/m (by mask).
* Beta-agonist inhalers (e.g. metaproterenol, terbutaline, or albuterol) * Epi SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) or, if low BP, Epi (1:10000) slow IV 1.0ml (=0.1mg). Repeat prn max 1mg * OR, aminophylline 6mg/kg IV, then 0.4-1.0mg/kg/hr, prn (caution: hypotension) or Terbutaline 0.25-0.5mg IM/SC. * Call code team for severe bronchospasm (or O2 sat <88% persists). |
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Patient get contrast for angio
develops hypotension with tachycardia. Treatment? |
* Legs up 60+ degr or T-burg.
* Monitor: EKG, pulse ox, BP. * O2 6-10 L/min (by mask). * Bolus large volumes of NS. * If poor response, Epi (1:10000) slow IV 1.0cc; Repeat prn, max 10cc. * If still crashing, transfer to ICU |
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Treatment for Hypotension with Bradycardia (Vagal Reaction) following injection
|
• Monitor VS.
• Legs up 60+ degr or T-burg • Secure airway; O2 6-10 L/m by mask • IV access; bolus NS. • Atropine 0.6-1.0mg IV slowly. Up to 0.04mg/kg max |
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Treatment for severe hypertension following injection
|
• Monitor EKG, pulse ox, BP
• NTG 0.4mg SL (may rep x 3), or 2% paste, 1” strip • Na nitroprusside- dilute w/ D5W; watch for fast drop in BP • For pheo – phentolamine 5.0mg (1.0mg kids) IV |
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Treatment for seizure following injection
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• O2 6-10 L/m mask
• Consider Valium 5mg or Versed 2.5mg IV. • Neuro consult, consider Dilantin if need longer dur • Monitor VS, airway, consider code |
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Treatment for pulmonary edema following injection
|
• Elevate torso; rotating tourniquets (venous compr)
• O2 6-10 L/m mask • Diurese – Lasix 40mg IV, slow push • Consider morphine, corticosteroids |
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Foreign body retrieval:
what do you use? |
* snare, basket, retractable forceps
* IN heart - pigtail to get out of heart then snare |
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Coagulation correction before procedure when patient is on: |
~heparin – stop 3-6 hrs prior, or protamine IV just pre
~coumadin – vit K for 3 days, or FFP just pre ~aspirin – stop 1 wk, or plts in minutes |
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Traumatic aortic injury
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* isthmus 95%, root, hiatus
* CXR – wide mediast, loss aortic contour, L apical cap, NGT -> R, L bronchus -> down, high rib fxs, hemothorax * CT – mediastinal hematoma gets angio * angio – intimal tear (linear filling def, irreg aortic contour), pseudoaneurysm, ductus diverticulum is smooth & broad-based |
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Takayasu’s arteritis:
-typical patient -what vessels are involved |
* Young females
* stenoses of arch vessels most common, stenosis of aorta, thick aortic wall * PA involv in 50%, abd aortic coarctation and RAS, aneurysms |
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Giant cell arteritis:
-typical pt -how diagnosed -what's involved / spared |
* older pts >50, dx by bx temporal art
* involves ECA branches, aorta and prox brachiocephalic branches usu spared * subclavian, axillary, brachial involv in 15% |
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AAA
|
* 90% infrarenal, diam >3cm
* incr risk rupture >5cm * assoc w/ popliteal aneurysms * Cx – rupture, aortocaval fist, aortoenteric fist, distal embolization, infection |
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Endoleaks
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Type 1 - distal or proximal attachment
Type 2 - (MC) via IMA or lumbar branches Type 3 - Fabric tear/disconnect Type 4 - Graft porosity Type 5 - other/??? |
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Abdominal aortic coarctation
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*young adults / kids
*congenital coarctation, Williams syndr, rubella, NF *acquired – Takayasu’s, FMD, radiation *segmental most common, usu involves renal arteries |
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Williams syndrome
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*supravalvular aortic stenosis
*peripheral PA stenosis *diff coarct of abdominal aorta & stenosis of visceral branches |
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Aortoiliac occlusive disease:
main syndrome collateral pathways |
*Leriche syndr ♂– butt claudication, impotence, weak femoral pulse
*Collaterals -internal mamm -> EIA via sup & inf epigastrics -IMA -> IIA via hemorrhoidal -intercost/lumbar -> EIA by deep circumf iliac -intercost/lumbar -> IIA by iliolumbar & glut |
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Mesenteric collaterals and sources of rectal arteries
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*celiac to SMA – arc of Buehler &pancreaticoduodenal arcade
*SMA to IMA – middle colic -> L colic, arc of Riolan, marg art of Drummond *IMA to IIA – via superior hemorrhoidal *rectal arcades – sup rectal from IMA, mid rectal from IIA, inf rectal from pudendal |
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Median arcuate ligament syndrome
|
* occlusion of prox celiac artery by median arcuate ligament
*accentuated on expiration, best detected on lateral proj |
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Upper GI bleeding:
Sources and tx |
*gastritis most common, PUD, varices, MW tear
*LGA > GDA *tx – vasopressin, gelfoam, PVA or coils for major arterial injury *rich collateral supply |
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Lower GI bleeding:
Sources Treatment How to use vasopressin? |
* Tics most common. Angiodysplasia, colon CA, polyps, IBD, rectal dz
* nucs study to screen * inject SMA, IMA, celiac * tx – gelfoam, vasopressin, coils (used less b/c less collat) *vasopr - 0.2 U/min x 20 min, repeat angio, 0.4 U/min x 20 min if still bleed, repeat angio * embolization or surgery if still bleeding, when bleeding controlled slow taper over 24 hrs |
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Mesenteric ischemia:
Causes Treatment |
*Nonocclusive more common - Atheroscl + low flow state
*Arterial occl- emboli, clot, dissect, vasculitis *Mechanical- hernia, volvulus, intussusc * tx – thrombolysis if acute & no bowel ischemia, surgery if bowel ischemia - nonocclusive - papaverine IA 25-50 mg/hr |
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Angiodysplasia:
-where does it occur -what is seen on angio |
*cecum/R colon
*vascular tuft - antimesent border *early /persist draining vein *active bleeding usu not seen |
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Portal HTN:
Definition Causes Results |
*wedge – IVC pressure > 5mmHg
*causes – PV thromb, Schistosoma, cirrhosis, Budd-Chiari, HV or IVC occlusion, AVM *collat – gastroesoph, mesenteric, perisplenic, periumb, hemorrhoids *ascites, splenomeg, portal collat (cavernous transform), recanalized periumb vein or hepatofugal flow |
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PV thrombosis:
Causes |
idiopathic
HCC, panc CA, mets post-op coagulopathies, sepsis pancreatitis, cirrhosis portal HTN |
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Budd-Chiari syndrome:
Causes and signs |
* HV thrombosis, tumor in HV or IVC (RCC, HCC, adrenal)
* spider web hepatic vns, IVC narrow, stretched straight hepatic art |
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Renal artery stenosis:
Causes Treatment |
* athero > FMD, NF, arteritis (Takayasu, PAN, abd Ao coarct)
* athero - older pt, proximal artery * FMD – medial fibroplasia most comm, mid-dist renals > ICA or vertebrals * PTA success- Ostial 50%, midRA 80% * PTA - control HTN or preserve renal function |
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Renal artery aneursym:
Causes |
* FMD and atherosclerosis common
* Also NF, AML, LAM, mycotic * intraparenchymal – PAN (microaneurysms), speed kidney, IVDA, Wegener's |
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Renal vein thromosis:
Causes |
KIDS – dehydration, sepsis, maternal DM, Wilms
ADULTS – membranous glomerulonephritis, CVD, DM, trauma, thrombophlebitis, RCC |
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Hyperreninemic HTN:
Causes |
Low renal perfusion- athero, FMD
Renin-secreting tumor Renal compression- Mass, cyst, bleed |
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Pulmonary arteriogram: |
Indications:
* PE (int prob V/Q, low prob w/hi clinical susp, contraind to anticoag) PAH, pseudoaneurysm AVM (a/w OWR; feeding art, drain vn, tx coils) *Need pacer if LBBB, Check RA pressur (nl PAsys<30) Cx- acute R ht failure, arrythia, death |
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Bronchial artery angiogram |
*Indic – hemoptysis (TB, CF, CA)
*arise from T4-T7 posterolat *embolize w/ gelfoam, PVA, coils *Cx – spinal artery injury, pain |
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LE atherosclerotic occlusive dz:
where, what's significant |
*sx – pain, pallor, pulseless, paresth, paralysis
*usu symmetric @ bifurc *SFA > iliac > tib > pop > CFA *significant- >50%, collat, >10mm grad |
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LE atherosclerotic aneurysmal dz: |
*pop artery most common
*pop > iliac > femoral *bilateral in 50%, assoc w/AAA *distal emboliz and/or thrombosis |
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Arterial thomboembolism:
|
*cardiac mural thromb (LV aneurysm, Afib, MI)
*aneurysms, iatrogenic *paradoxical (DVT and R-L shunt) *emboli usu lodge @ bifurc, no collaterals, filling defects with menisci |
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Buerger’s dz:
typical pt & presentation? location appearance |
*M smoker 20-40 w/claudication
*calf & foot vessels most common *abrupt segmental arterial occlusions, multiple corkscrew collaterals |
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Popliteal artery entrapment:
who? signs |
*young athletes
*narrowing or occlusion on plantar flexion. |
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May-Thurner syndrome:
|
R common iliac artery compresses L common iliac vein -> DVT
|
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IVC filters:
Indication Size criteria How placed, and where? |
*contraind or failure or complication of anticoag
*Bird’s nest for IVC > 28-40mm *Meditech, Simon nitinol may be placed via brachial vein *place below renal veins *suprarenal if infrarenal clot or pregnancy w/IVC compression *duplication IVCs may need filter in each *retro or circumaortic LRV – place below most inferior renal vein *can do bilat iliac if no room |
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Upper extremity vascular disease:
Causes, what do you see, tx |
* athero, vasculitis, emboli, trauma, iatrogenic, RTX
*thoracic outlet syndrome – compression of brachial plex or subclav vessels, seen w/ hyperabduction *tx is surgical if mechanical compression (e.g. cervical rib) |
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Hypothenar hammer syndrome:
|
*occlusion or pseudoaneurysm of ulnar artery as it crosses over hamate from repetitive trauma
*can result in distal embolic occlus, Raynaud’s phenomenon, improves with priscoline |
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Subclavian steal syndrome:
Causes, signs |
*narrowed / blocked subclavian art. prox to origin of vertebral
*retrogr flow in vertebral, L>R *athero (#1), trauma, aneur, embolism, thor outlet syn, vasculitis, tumor, RTX, congenital * most asx; can get vertebrobasilar insuff or arm claudication |
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Aneurysm:
Causes and types |
*athero – abd aorta most common, desc thoracic Ao, peripheral vasc (pop > iliac > fem)
*infection- mycotic (bacterial), syphilis *inflamm – Takayasu’s, giant cell, PAN *congenital – Marfan, Ehlers-Danlos, FMD, NF |
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Ischemia:
Types and causes |
ARTERIAL- dissect, embo, thrombosis, thromb aneurysm, vasculitis, compression, drugs
VENOUS- thromb (phlegmasia cerulea dolens) LOW-FLOW- Hypovolemia, shock |
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Peripheral vascular disease: |
*athero (occlusive, aneurysmal, small vessel in diabetics)
*embolic (thromboemb, cholesterol emb, plaque emb) *vasculitis *Buerger’s disease *medication |
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Emboli:
Types and causes/sources |
*cardiac – AFib, recent MI, ventric aneur, endocarditis, tumor (myxoma)
*athero – aortoiliac plaque, aneurysm (AAA, popliteal) *paradoxical emboli (R->L shunt) + DVT |
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Angiographic tumor features
|
BEDPAN
Blush Encasement of arteries Displacement of arteries Puddling of contrast A-V shunting Neovascularity |
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Hypervascular lesions:
Distinguish between collaterals, AVM, and tumor neovascularity |
*AVM – early draining vein, no mass effect
*lotsa collaterals – no early draining vein, no mass effect *tumor neovasc – early drain vein in AV shunt, mass effect from tumor |
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Aortic enlargement:
|
*aneurysm
*dissection *poststen dilat due to turbulence (coarctation, Ao valv dz, sinus of valsalva aneur) |
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Aortic stenosis: |
*Congenital – coarct, pseudocoarct
*Williams syndr- supravalvular Ao stenosis *Rubella syndrome *Aortitis – Takayasu’s (most comm aortitis to cause stenosis) *Neurofibromatosis *Radiation |
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Pulmonary artery stenosis:
|
*Williams synd (infantile hypercalcemia)
*Rubella syndrome *Takayasu’s arteritis *Associated with CHD (esp tetralogy) |
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Renal tumors vascular features
|
*RCC – 80% hypervasc, neovascularity, AV shunts, parasitization
*AML – aneurysms, fat content *oncocytoma – spoke wheel in 30%, most hypovascular |
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DDx for suspected angiodysplasia in the bowel
|
* Angiodysplasia
* Hemangioma * Arteriovenous malformation * Hereditary hemorrhagic telangiactasia |
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Causes of splenic artery aneurysm
|
* Pancreatitis
* Pregnancy * Portal HTN * Splenomegaly * Orthotopic liver transplant * Medial fibrodysplasia * PAN * Subacute bacterial endocard |