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48 Cards in this Set

  • Front
  • Back
Replaced RHA

Case findings: right hepatic artery arises from SMA

Replaced artery: vessel supplying an entire lobe arises aberrantly
Accessory artery: portion of a hepatic lobe is supplied by a vessel of normal origin, but an additional vessel of aberrant origin also supplies a portion of the lobe

Replaced RHA: arise from SMA (MC 1st branch from SMA)
Replaced LHA: arise from left gastric artery
Non-occlusive mesenteric ischemia (NOMI)

Case findings: 
Vasoconstriction of the SMA and its branches

Etiology:
Intense mesenteric vasoconstriction in response to a period of mesenteric hypoperfusion
Low flow syndrome of mesenteric circulation fo
Non-occlusive mesenteric ischemia (NOMI)

Case findings:
Vasoconstriction of the SMA and its branches

Etiology:
Intense mesenteric vasoconstriction in response to a period of mesenteric hypoperfusion
Low flow syndrome of mesenteric circulation followed by vasoconstriction

High mortality rate

Angiography:
Constriction of SMA branches
Patch filling of peripheral arcades
Diminished bowel blush
Poor visualization of the SMV

Treatment: papaverine infusion into SMA
If spasm is detected at angiography, a test dose of 30-60 mg of papaverine (or other vasodilator) in the SMA in an attempt to assess reversibility  if response is seen, a 24-hour infusion of papaverine into the SMA

Acute NOMI

SMA injection:
SMA is patent
Diffuse narrowing of the SMA branches
Reflux of contrast into the aorta with the injection

SMA branches
IMA branches
Mesenteric collaterals
Arterial phase
Venous phase
Arterial phase
Venous phase
Angiodysplasia

Case findings:
Vascular tuft or tangle of vessels with early intense filling of draining vein that then slowly empties
Early venous phase displays an early draining vein (arrows)

Telangiectasia: dilations of normal, preexisting structures and NOT true AVM
Cause of chronic intermittent GIB, rarely acute GIB
MC elderly, cecum or proximal ascending colon, multiple
Angiography:
Arterial phase: densely opacified tuft or tangle of vessels
Late arterial phase or early venous phase: early-filling vein that slowly empties
Extravasation of contrast into the colon

Treatment:
Colonic resection curative
Intraarterial administration of vasopressin or embolization

DDX:
Bleeding diverticulum (MC source of GIB in right colon)
Congenital AVM
Carcinoma
Leriche syndrome

Case findings:
Occlusion of infrarenal abdominal aorta
Collateral filling of IMA via the middle colic artery and an arc of Riolan
Early collateral reconstitution of deep iliac circumflex arteries from intercostals and lumbar arteries

Clinical triad:
Buttock and thigh claudication
Absent femoral pulses
Impotence
Etiology:
Thrombosis superimposed on chronic atherosclerotic stenosis
Occlusion of congenitally small aortic bifurcation
Treatment: surgical bypass graft (e.g., aortobifemoral)
Sclerosing cholangitis

Case findings:
PTC: intra and extrahepatic biliary tree including CBD, beaded or pruned tree appearance

Chronic inflammation and progressive fibrosis of intra and extrahepatic biliary system
Associated with:
Autoimmune diseases: IBD (UC, Crohn’s), RPF, mediastinal fibrosis, pancreatitis, Riedel's thyroiditis
DDX:
Cholangiocarcinoma (diffuse)
PBC
Infectious cholangitis (bacterial, viral, parasitic)

Complication: cholangiocarcinoma, acute cholecystitis, biliary cirrhosis with portal hypertension

Treatment: liver transplant, or palliation (percutaneous biliary drainage or hepaticojejunostomy
Caroli’s disease

Case findings: 
Dilated intra- and extrahepatic biliary tree
Walls of the biliary tract are irregular in appearance  as opposed to smoothly marginated (consistent with an inflammatory process)

DDX:
Oriental cholangiohepatitis
S
Caroli’s disease

Case findings:
Dilated intra- and extrahepatic biliary tree
Walls of the biliary tract are irregular in appearance  as opposed to smoothly marginated (consistent with an inflammatory process)

DDX:
Oriental cholangiohepatitis
Severe cholangitis
Choledochal cyst variant (Type V)
Cystic dilatation of intrahepatic ducts is classic, but extrahepatic biliary tree may be involved
Associated with: cirrhosis and portal hypertension, or congenital hepatic fibrosis
Caroli's disease MC involves entire intrahepatic biliary tree  hepatic resection is not practical

Choledochal cyst

Type 1: MC, fusiform dilatation of CBD
Type 2: diverticulum of CBD
Type 3: dilatation of intraduodenal portion of CBD (choledochocele)

Type IV:
Type IV-a: intrahepatic and extrahepatic ductal dilatation
Type IV-b: extrahepatic ductal dilatation

Type V: Caroli’s disease (MC intrahepatic ductal dilatation)
Early arterial injection
Delayed images
Early arterial injection
Delayed images
Left vertebral artery

Bidirectional flow: reversed or retrograde flow away from intracranial circulation throughout diastole

Left brachial artery

Parvus tardus waveform:
Diminished peak systolic velocity 
Long systolic acceleration time

Cons
Left vertebral artery

Bidirectional flow: reversed or retrograde flow away from intracranial circulation throughout diastole

Left brachial artery

Parvus tardus waveform:
Diminished peak systolic velocity
Long systolic acceleration time

Consistent with steno-occlusive disease proximal to the point of interrogation

Right brachial artery (normal)

Normal triphasic Doppler waveform of extremity arteries without proximal disease

Note higher peak systolic velocity and sharp systolic upstroke of short systolic acceleration time

Subclavian steal

Case findings:
Early aortogram reveal patency of the brachiocephalic artery and LCCA, occlusion of the LSA at its origin
Delayed imaging shows retrograde flow in the left vertebral artery  supplying flow to the LSA and LUE

Etiology: MC atherosclerosis, congenital web/absence, dissecting aneurysm, embolism, inflammatory arteritis (Takayasu's)

Clinical: vertebral basilar insufficiency  drop attacks
Treatment
Occlusion of subclavian artery: carotid-to-subclavian bypass
Proximal subclavian stenosis: intravascular stent
AML

Case findings: selective injection of the right kidney reveals two abnormal areas: 
Aneurysm in midpole
Hypervascular exophytic mass extending off lower pole

Angiography:
Hypervascular masses with large tortuous feeding arteries arranged circ
AML

Case findings: selective injection of the right kidney reveals two abnormal areas:
Aneurysm in midpole
Hypervascular exophytic mass extending off lower pole

Angiography:
Hypervascular masses with large tortuous feeding arteries arranged circumferentially
Feeding vessels often distorted and branch vessels may contain aneurysms
AV shunting does NOT commonly occur
DDX: RCC
Complication: hemorrhage (> 4 cm)
Treatment: surgical resection, percutaneous embolization
Early and late images show a large right AML with a bizarre arterial pattern and several aneurysms
Median arcuate ligament syndrome (celiac artery compression syndrome)

Case findings:
Inspiratory: proximal celiac artery displays subtle, superior compression, and the proximal SMA is patent
Expiratory: smooth, superior eccentric narrowing of the celiac artery

Intestinal angina: caused by insufficient blood flow to GI tract
MC visceral arterial compression syndrome
Worsens with expiration (celiac axis moves superiorly and becomes entrapped beneath the ligament of the diaphragm creating a stenosis)
Extrinsic compression of the celiac artery by median crus of diaphragm, and/or celiac neural plexuses and connective tissues
Treatment:
Enlarge diaphragmatic hiatus, resect celiac ganglion
NO response to angioplasty because of external compression
Stenting contraindicated from device fatigue due to external compression

DDX:
Chronic mesenteric ischemia from atherosclerotic disease
Chronic mesenteric ischemia from median arcuate ligament syndrome
Acute mesenteric ischemia from embolus
Fibromuscular dysplasia

2nd MC cause of renovascular hypertension (1st is atherosclerotic RAS)
Angiography:
MC affects mid and distal of main renal arteries
String of beads appearance

DDX:
Atherosclerosis (MC ostial lesions)
Congenital webs

Treatment:
Percutaneous transluminal angioplasty (PTA 5-year patency 90%)
Post thrombolysis image
Prior to thrombolysis, there is left common iliac vein stenosis
Superimposed IVDSA and ascending venogram
Post thrombolysis image
Prior to thrombolysis, there is left common iliac vein stenosis
Superimposed IVDSA and ascending venogram
May-Thurner syndrome (iliac vein compression)

Case findings:
Band-like lucency is seen crossing the left common iliac vein (post-thrombolysis)
Superimposed IVDSA and ascending venogram show the right common iliac artery compresses the vein

Ileofemoral DVT: MC on the left
MC women in 2nd to 4th decades
Etiology: compression of left common iliac vein by crossing right common iliac artery
Differentiated from bland DVT of the LE by the presence of fibrous spur or adhesions in the left common iliac vein represents an inflammatory response to chronic compression of the vein and adjacent arterial pulsations

Treatment: thrombolysis (remove acute thrombus) followed by iliac vein stent placement
Post-thrombotic syndrome: major long-term complication of DVT
Bronchial artery hypertrophy

Findings: hypertrophied and tortuous bronchial arteries 

Etiology: MC worldwide TB, bronchiectasis, CF, bronchogenic carcinoma, Aspergillosis 

Treatment:
Embolize with polyvinyl alcohol (PVA) particles, or Gelfoam
Bronchial artery hypertrophy

Findings: hypertrophied and tortuous bronchial arteries

Etiology: MC worldwide TB, bronchiectasis, CF, bronchogenic carcinoma, Aspergillosis

Treatment:
Embolize with polyvinyl alcohol (PVA) particles, or Gelfoam
Coils are NOT used since they cause proximal occlusion  precluding repeat embolization should hemoptysis recur
Embolization 85-90% effective with a 15% recurrence rate
If recurrence, repeat embolization is usually effective
Presents with massive hemoptysis
Need to identify spinal arteries (spinal artery of Adamkiewicz) that arise from the bronchial and intercostal arteries
Artery of Adamkiewicz: feeds anterior spinal cord, arise between T8 and L2, MC left
Also interrogate anastomosis with bronchial arteries: intercostals, inferior phrenic, internal mammary, branches of the subclavian artery

Angiography:
Need to perform selective injection of LIMA post-treatment  this vessel common source of collateral supply to lungs
Hypertrophied and tortuous bronchial arteries
Pulmonary AV shunting

Subselective cannulation shows a large bronchial artery with areas of increased vascularity

DSA shows significant increased vascularity likely representing inflammation in the area causing the hemoptysis

Spinal artery of Adamkewicz:
Small artery extending to the midline
Has a sharp, hairpin turn
Travels down the center of the anterior aspect of the spinal canal (arrow)
Arms neutral
Arms abducted
Arms neutral
Arms abducted
Thoracic outlet syndrome

Case findings:
Neutral position shows no abnormalities
Arms in abduction shows impingement on bilateral subclavian arteries resulting in significant bilateral subclavian artery stenoses

Etiology: cervical rib, hypertrophie
Thoracic outlet syndrome

Case findings:
Neutral position shows no abnormalities
Arms in abduction shows impingement on bilateral subclavian arteries resulting in significant bilateral subclavian artery stenoses

Etiology: cervical rib, hypertrophied muscles, scalene minimus muscle, clavicle fracture
Complication: distal embolization of thrombus
Treatment: surgical thoracic outlet decompression

Upper extremity arteries
DSV of proximal RUE and central veins
DSV of proximal RUE and central veins
Paget-Schroetter syndrome (primary subclavian-axillary vein thrombosis)

Case findings:
DSV of proximal RUE and central veins shows occlusion of the subclavian vein, intraluminal filling-defect within the axillary vein, and numerous collateral vessels reconstituting the innominate vein
Etiology:
Primary subclavian-axillary vein thrombosis
Secondary MC catheters

Treatment:
Thrombolysis followed by thoracic outlet decompression
Anticoagulation
Stenting NOT an option stent fracture from mechanical compression
Percutaneous transhepatic cholangiography (PTC)
Percutaneous transhepatic cholangiography (PTC)
Cholangiocarcinoma (Klatskin tumor)

Case findings:
PTC: dilated left and right ducts with obstruction at the hilum
CT: mass at confluence of hepatic ducts, causing obstruction

Klatskin tumor: hilar cholangiocarcinoma located at the bifurcation of main biliary ducts
2nd MC primary hepatic tumor (after HCC)
Slow growing, MC adenocarcinoma

Findings
Large mass, hypoattenuating, with irregular margins
CT: delayed enhancement with increasing attenuation (differentiate between HCC which has arterial enhancement)

DDX:
Liver metastasis
HCC
Portal adenopathy
PSC

Risk factors: choledochal cyst, UC, Caroli’s disease, Clonorchis sinensis infection, PSC
Early renal arteriography
Late renal arteriography
Early renal arteriography
Late renal arteriography
Polyarteritis nodosum

Case findings: 
Multiple micro aneurysms involving the segmental and subsegmental branches of the right kidney

DDX:
Polyarteritis nodosum
Diffuse multiple septic emboli, SLE
Necrotizing angiitis (methamphetamine)  speed ki
Polyarteritis nodosum

Case findings:
Multiple micro aneurysms involving the segmental and subsegmental branches of the right kidney

DDX:
Polyarteritis nodosum
Diffuse multiple septic emboli, SLE
Necrotizing angiitis (methamphetamine)  speed kidney

Celiac arteriography reveals multiple micro aneurysms involving the hepatic arteries and GDA

Renal artery aneurysms

Renal artery aneurysms from congenital etiologies

Selective left renal arteriography reveals an aneurysm in the proximal portion of a midpole branch vessel

Methamphetamine abuse necrotizing angiitis (speed kidney)

Renal arteriography reveals multiple micro and macro aneurysms involving the segmental and subsegmental branches of the right kidney

Superior mesenteric arteriography
Replaced RHA arising from the SMA
Multiple areas of micro aneurysms involving the hepatic vasculature and the superior mesenteric vasculature
Chronic mesenteric ischemia

Lateral abdominal aortogram shows occlusion of the celiac and IMA
Severe stenosis of the proximal SMA is present (arrow)
Clinical: postprandial pain  intestinal angina, weight loss 
Angiography: tight origin of the celia
Chronic mesenteric ischemia

Lateral abdominal aortogram shows occlusion of the celiac and IMA
Severe stenosis of the proximal SMA is present (arrow)
Clinical: postprandial pain  intestinal angina, weight loss
Angiography: tight origin of the celiac artery and SMA
Angiographic findings and above clinical findings  pathognomonic

LC than acute mesenteric ischemia
Etiology: MC atherosclerosis (of mesenteric artery ostia)
Treatment: aorto-mesenteric bypass
Renal artery stenosis

Case finding: ostial renal artery stenosis secondary to atherosclerosis

Etiology: MC atherosclerosis, FMD, NF
Treatment: 
Aorto-renal bypass
FMD: PTA (5-year patency 80-90%)  non-ostial lesions
Atherosclerosis: endovascula
Renal artery stenosis

Case finding: ostial renal artery stenosis secondary to atherosclerosis

Etiology: MC atherosclerosis, FMD, NF
Treatment:
Aorto-renal bypass
FMD: PTA (5-year patency 80-90%)  non-ostial lesions
Atherosclerosis: endovascular stent placement  ostial lesions
Diagnosis: Renal artery stenosis secondary to NF1

LAO view shows the proximal stenosis in the left renal artery

Renal artery stenosis, NF1

NF1: stenosis due to direct effect of fibrous proliferation of the intima or the media
Angiography: smooth stenotic segment (usually at orifice) with a tubular segment of dilatation distal to the stenosis, MC bilateral
Appearance differs from FMD where stenosis non-ostial

Treatment: angioplasty can be successful, in general endovascular management has had poor results
NB: hypertension in a child with NF could also be secondary to a pheochromocytoma (NF2)

DDX (RAS in a child): FMD, NF1, Takayasu’s arteritis
Pulmonary AVM

Case finding: single artery connects to a draining pulmonary vein via an aneurysmal sac

PAVM: dilated vascular channels that consist of a direct connection of a pulmonary artery to a pulmonary vein  R-L shunt
Complication: stroke, TIA, brain abscess
Associated with HHT (OWR)

Treatment:
Transcatheter embolotherapy  eliminate arterial inflow (use coils or detachable balloon)
In contrast non-pulmonary (peripheral) AVM  where the goal is to eliminate the nidus
Takayasu’s arteritis

Case findings: 
Tight stenoses of the BCA extending to the carotid-subclavian artery bifurcation 
Tapered stenosis of the left CCA

Granulomatous vasculitis
MC women < 50 year old, elevated ESR

Angiography:
MC affect aorta
Takayasu’s arteritis

Case findings:
Tight stenoses of the BCA extending to the carotid-subclavian artery bifurcation
Tapered stenosis of the left CCA

Granulomatous vasculitis
MC women < 50 year old, elevated ESR

Angiography:
MC affect aorta and large branch vessels (MC LSA)
Smooth concentric narrowing
Classically there is sparing of the distal abdominal aorta above the bifurcation
Pulmonary artery disease is common but frequently asymptomatic

DDX:
Giant cell arteritis (differentiate by age, > 50 year old)
Radiation-induced arteritis

Treatment: PTA (disease should be inactive at the time of intervention as measured by ESR)

Involvement of the subclavian artery  with smooth concentric narrowing
Giant cell arteritis

Case findings: long segment smooth stenosis of axillary artery

MC large vessel involvement is subclavian/axillary arteries, followed by superficial and deep femoral arteries

DDX:
Takayasu's arteritis: angiographically indistinguishable, discriminate by age
Radiation arteritis

Treatment: steroids
Male varicocele

Case findings: 
Distal injection of the left gonadal vein showed collateral veins, with a varicocele (tangle of vessels)
Varicocele:
Dilatation of the pampiniform plexus (MC left)
Infection of left renal vein with reflux into left g
Male varicocele

Case findings:
Distal injection of the left gonadal vein showed collateral veins, with a varicocele (tangle of vessels)
Varicocele:
Dilatation of the pampiniform plexus (MC left)
Infection of left renal vein with reflux into left gonadal vein

Clinical: male infertility, scrotal pain
Treatment:
Surgical ligation
Embolotherapy (coils, sclerosing agent)

Injection in left renal vein showed reflux into the left testicular (gonadal) vein (arrows)
Hepatic vein injection (hepatic venography)
Hepatic vein injection (hepatic venography)
Budd-Chiari syndrome

Case finding: 
Spider-web appearance of intrahepatic collateral veins
Hepatic venography is the gold standard for diagnosis 

Clinical: severe ascites, HSM, hepatic encephalopathy, portal hypertension, hepatic failure 
Etiolog
Budd-Chiari syndrome

Case finding:
Spider-web appearance of intrahepatic collateral veins
Hepatic venography is the gold standard for diagnosis

Clinical: severe ascites, HSM, hepatic encephalopathy, portal hypertension, hepatic failure
Etiology: MC worldwide intrinsic webs, polycythemia vera, PNH, hepatic veno-occlusive disease

Treatment: PTA, stent if stenosis recurs, TIPS

Findings:
CT or MRI: fan-shaped central area of increased attenuation in the liver with IV contrast, enlarged caudate lobe, ascites, cirrhosis
Tc99m sulfur colloid scan: hot caudate lobe sign  decreased activity in the right and left hepatic lobes and increased uptake in the caudate lobe which is usually less affected due to its separate venous drainage into the IVC

DDX: hepatic veno-occlusive disease
BCS is clinically indistinguishable
Endemic in Jamaica due to consumption of the toxic bush tea
Also seen after radiation, chemotherapy and bone marrow transplant

Injection at the junction of the hepatic vein and IVC shows a focal stenosis of the hepatic vein (arrow).
Wedged hepatic injection shows a complex spider-web network of tortuous hepatic venous collateral vessels without filling of the portal vein.
Thoracic aortic aneurysm (tertiary syphilis)

Case findings:
Saccular aneurysm of ascending aorta
Valves of the aorta and sinotubular ridge are not involved
Normal descending aorta

MC saccular (2/3) and LC fusiform
MC ascending aorta

DDX:
Atherosclerosis
Pseudoaneurysm from trauma
Bacterial infection, (tertiary) syphilis
Takayasu's arteritis, giant cell arteritis
Connective tissues disease:
Ehlers-Danlos syndrome
Marfan's syndrome
Splenic artery pseudoaneurysm

Etiology: pancreatitis, pancreatic carcinoma
DDX:
Congenital aneurysm
Mycotic aneurysm

Treatment:
Basic tenant for embolization of pseudoaneurysms is to occlude both proximal and distal to its origin
Proximal embolization alone would allow perfusion to the pseudoaneurysm through collateral pathways
Scleroderma

Case findings:
Segmental occlusions of the lateral proper palmar artery digital arteries of the 2nd – 5th digits

Inflammatory changes involving small vessels and capillary bed
MC UE, including multiple focal stenoses and occlusions involving the ulnar, palmar, and proper digital arteries
Radial artery and commonly digital arteries are rarely involved

Collateral channels are sparse: indicating disease affecting the capillary beds
Majority of theses patients experience Raynaud's phenomenon
DDX:
Collagen vascular disease:
Scleroderma
SLE
Occlusive arterial diseases:
Atherosclerosis
Buerger's disease (thromboangiitis obliterans)
Thromboembolism
Vasospastic diseases:
Raynaud's disease
Raynaud's phenomenon
Early phase of aortogram
Late phase of aortogram
Early phase of aortogram
Late phase of aortogram
Hemangioendothelioma

Case findings:
Aortogram: prominent hepatic artery and diminution of the aortic caliber below the liver
Late phase of aortogram: multiple large vascular spaces within the liver

Benign capillary tumour almost exclusively found in children
Diagnosed first few weeks of life

Undergoes a rapid proliferative phase and then regression
Complications during proliferative phase:
High-output CHF
Kassabach-Merritt syndrome: consumptive coagulopathy, anemia and jaundice
Celiac arteriogram
Arterial phase
Venous phase
Celiac arteriogram
Arterial phase
Venous phase
Insulinoma

Case findings:
Hypervascular mass overlying the region of the body of the pancreas

DDX:
Pancreatic neuroendocrine tumor: insulinoma, glucagonoma, gastrinoma, VIPoma, somatostatinoma
Hypervascular metastasis: melanoma, RCC
Hypervascular gastric tumor: leiomyoma, leiomyosarcoma

Multiple endocrine neoplasia

MEN-I (Wermers syndrome):
Pituitary adenoma
Parathyroid hyperplasia / adenoma
Pancreatic islet-cell tumor
MC gastrinoma (ZE syndrome)
50% of Z-E ==> MEN-1

MEN-IIa (Sipples syndrome)
Medullary thyroid carcinoma
Parathyroid hyperplasia
Pheochromocytoma (MC bilateral)
Celiac arteriography
Arterial phase
Portal venous phase
Celiac arteriography
Arterial phase
Portal venous phase
Splenic vein occlusion

Case findings:
Arterial phase: normal anatomy and no discreet mass or hypervascular region
PV phase: occlusion of splenic vein at its junction with SMV
Large collateral (right gastroepiploic vein) drains the splenic vein, reconstituting the SMV and portal venous system

Etiology:
Pancreatic tumor
Chronic pancreatitis
Hypercoagulable state
Cirrhosis
Carotid body tumor

Case findings:
Hypervascular mass arising between the origins of the right internal and external carotid arteries
Mass splays the bifurcation
MRI: salt and pepper appearance, represent flow voids

Carotid space contains:
Carotid artery, jugular vein, CN X, lymphatic tissue
DDX of carotid space mass:
Vascular: aneurysm, jugular vein thrombosis
Benign: carotid body tumor, schwannoma, neurofibroma
Malignant: metastasis, lymphoma

Paraganglioma (glomus tumor, chemodectoma)

Hypervascular tumor
Originate from extra-adrenal neuroendocrine tissues: have a chemoreceptor function and are located near nerves and vessels

Classified according to site of origin:
Carotid body: CCA bifurcation
Glomus jugulare: jugular foramen (presents with pulsatile tinnitus)
Glomus tympanicum: cochlear promontory
Glomus vagale: carotid space near nodose ganglion of vagal nerve
Marfan’s syndrome

Case findings:
Aortogram: catheter is in true lumen
Dissection flap initiating distal to LSA
Incidentally notes is a bovine arch (common origin of innominate and LCA)
Aortic root is dilated down to aortic valves

Tulip bulb configuration of proximal aorta
Involves sinuses of Valsalva and proximal aortic root
Cystic medial degeneration: aortic dilation, AR, dissection
Aortic dilation starts at aortic annulus
DDX ascending aorta aneurysm:
Marfan's syndrome
Ehlers-Danlos Syndrome, type IV
Homocystinuria
Isolated annuloaortic ectasia with dissection
Sinus of Valsalva aneurysm
Syphilitic aortitis:
Spares annulus and aortic valves, tree-bark calcifications
Choledochal cyst, type 1

DDX: 
Choledochal cyst
Pancreatic pseudocyst
Duplication cyst of the duodenum
Duplicated gallbladder (rare)

Choledochal cyst

Type 1: MC, fusiform dilatation of CBD
Type 2: diverticulum of CBD
Type 3: dilatation of i
Choledochal cyst, type 1

DDX:
Choledochal cyst
Pancreatic pseudocyst
Duplication cyst of the duodenum
Duplicated gallbladder (rare)

Choledochal cyst

Type 1: MC, fusiform dilatation of CBD
Type 2: diverticulum of CBD
Type 3: dilatation of intraduodenal portion of CBD (choledochocele)

Type IV:
Type IV-a: intrahepatic and extrahepatic ductal dilatation
Type IV-b: extrahepatic ductal dilatation

Type V: Caroli’s disease (MC intrahepatic ductal dilatation)

Choledochocele (choledochal cyst, type 3)

Intra-duodenal segment of the CBD demonstrates a small focal bulbous dilatation
ICA PSV: 370 cm/sec
ICA EDV:180 cm/sec
80-99% stenosis
ICA PSV: 370 cm/sec
ICA EDV:180 cm/sec
80-99% stenosis
Carotid artery stenosis

Criteria for CEA:
Stenosis > 70% in symptomatic patients (PSV > 200 cm/sec)
Normal PSV of ICA: < 100 cm/sec

As stenosis increases, PSV increases as follows:
% diameter stenosis PSV
0 - 15 <100
16 - 49 100 - 125
50 - 75 125 - 250
> 75 > 250 and/or 125 (EDV)
Occlusion No Flow
Middle aortic syndrome, NF

Case findings (abdominal aortogram):
Aorta is small in diameter  suggestive of diffuse hypoplasia
Superior left RA has near occlusive ostial stenosis
Middle right RA has a high-grade stenosis
Other renal arteries are also affected
High grade stenosis is present in a hypoplastic left common iliac artery with numerous transpelvic collaterals

DDX:
Severe progressive atherosclerosis
Radiation arteritis
Takayasu's arteritis
Neurofibromatosis
Williams syndrome
Both Takayasu's arteritis and NF involve branch vessels such as the renal artery
Portal venogram
Early phase
Delayed phase
Portal venogram
Early phase
Delayed phase
Gastric and esophageal varices

Case findings (portal venogram):
Numerous tortuous, dilated vessels with retrograde flow in region of the gastric fundus and GEJ
Large collateral vein extending inferiorly from splenic hilum to left renal vein

Gastri
Gastric and esophageal varices

Case findings (portal venogram):
Numerous tortuous, dilated vessels with retrograde flow in region of the gastric fundus and GEJ
Large collateral vein extending inferiorly from splenic hilum to left renal vein

Gastric and esophageal varices  due to portal hypertension with spontaneous splenorenal shunt

Colonic (hemorrhoidal) varices
Spontaneous splenorenal shunt

Recanalized umbilical vein

Large series of abdominal wall collaterals, with a prominent vein the right upper quadrant
Hypothenar hammer syndrome

Case findings:
Diminished ulnar artery flow with occlusion in the carpal area

Caused by chronic trauma or vibration which causes intimal injury, aneurysm formation, emboli, and occlusion
Damage to distal ulnar artery as it runs across the hook of the hamate
Symptoms: digital ischemia, Raynaud’s, pulsatile mass
Obstructive arterial disease of the hand

Raynaud’s disease:
Small artery disorder characterized by intermittent, reversible ischemia
Secondary to vasoconstriction

Buerger’s Disease (thromboangiitis obliterans):
Inflammatory vasculitis of small and medium arteries
Characterized by abrupt occlusions of distal arteries with normal intervening vessels and corkscrew, tortuous collaterals
Emboli:
From cholesterol deposits, endocarditis, thrombosed hemodialysis grafts

Diabetes or chronic renal failure:
Leads to accelerated atherosclerosis of the arteries

Trauma (hypothenar hammer syndrome):
Repetitive trauma

Hypercoagulable conditions (e.g., malignancy)

Collagen vascular disease:
Scleroderma, RA, SLE
Splenic artery aneurysm

Risk factors:
MC pregnancy, portal hypertension, FMD
LC atherosclerosis
Splenic artery pseudoaneurysm:
May be due to pancreatitis, infection, surgery, or trauma

Treatment:
Embolization of the splenic artery both proximal and distal to the aneurysm
Intra-aneurysmal packing with coils

Perfusion to the splenic parenchyma is usually preserved due to collateral blood supply to the distal splenic artery
More recent alternative to embolization is endovascular stent-graft repair using a covered stent  used in patients with favorable arterial anatomy
Traumatic transection of the right axillary artery

Case findings:
Arch aortogram: normal thoracic aorta with abrupt cutoff of contrast at the proximal right axillary artery
Right subclavian arteriogram:
Contrast is seen to the level of the proximal right axillary artery
Evidence of extravasation at this level with possible pseudoaneurysm
Faint reconstitution of the brachial artery from collaterals

DDX arterial occlusion:
Occluding intimal flap
Spasm following complete trasection of the vessel
Extrinsic compression of the vessel due to bone fragments or hematoma
Thromboembolism

Angiography of arterial trauma

Tears in the intima
Extravasation of contrast
Arterial occlusion
Vasospasm
Extrinsic compression
Pseudoaneurysm
A-V fistula
What is the next step?
What is the next step?
Traumatic splenic artery injury

CT: splenic fracture involving the lower pole with active extravasation

Celiac artery angiogram (not shown): pre-embolization show a small focus of extravasation in the lower pole of the spleen

Splenic angiogram: post coil embolization with microcoils demonstrates successful embolization with preservation of greater than 75% splenic parenchyma

Embolization agents

Metallic coils: permanent occlusion
Placed quickly with a high degree of accuracy
Best in single vessel injuries, available in a wide variety if sizes, diameters, lengths, and shapes

Gelatin sponges: temporary occluding agents
Best for single or multiple injuries of smaller arteries
Useful when distal occlusion is necessary or when multiple collateral channels are present

PVA particles

Complications of splenic embolization: inadvertent non-target embolization, splenic infarction, splenic abscess

Organ injury scaling system

Grade I
Hematoma: subcapsular, <10% surface area
Laceration: capsular tear, < 1cm parenchymal depth

Grade II
Hematoma:
Subcapsular, 10-50% surface area
Intraparenchymal, <5cm diameter
Laceration 1-3cm parenchymal depth not involving a parenchymal vessel

Grade III
Hematoma:
Subcapsular, >50% surface area or expanding
Ruptured subcapsular or parenchymal hematoma
Intraparenchymal hematoma >5cm
Laceration: >3cm parenchymal depth or involving trabecular vessels
Grade I
Hematoma: subcapsular, <10% surface area
Laceration: capsular tear, < 1cm parenchymal depth

Grade II
Hematoma:
Subcapsular, 10-50% surface area
Intraparenchymal, <5cm diameter
Laceration 1-3cm parenchymal depth not involving a parenchymal vessel

Grade III
Hematoma:
Subcapsular, >50% surface area or expanding
Ruptured subcapsular or parenchymal hematoma
Intraparenchymal hematoma >5cm
Laceration: >3cm parenchymal depth or involving trabecular vessels
Portal hypertension

Portal pressure > 5-10 mm Hg

Etiology:
MC hepatic cirrhosis
Presinusoidal: PV thrombosis, schistosomiasis
Sinusoidal: cirrhosis
Postsinusoidal: Budd-Chiari, HV or IVC obstruction

Portocaval shunt
Mesocaval shunt
Splenore
Portal hypertension

Portal pressure > 5-10 mm Hg

Etiology:
MC hepatic cirrhosis
Presinusoidal: PV thrombosis, schistosomiasis
Sinusoidal: cirrhosis
Postsinusoidal: Budd-Chiari, HV or IVC obstruction

Portocaval shunt
Mesocaval shunt
Splenorenal shunt (proximal, Litton shunt)
Splenorenal shunt (distal, Warren shunt)
Renal vein thrombosis

Children:
Dehydration
Sepsis
Maternal diabetes

Adult:
Glomerulopathies
CVD
Diabetes
Trauma
Thrombophlebitis
Renal vein thrombosis

Children:
Dehydration
Sepsis
Maternal diabetes

Adult:
Glomerulopathies
CVD
Diabetes
Trauma
Thrombophlebitis
Duplicated IVC
IVC filter, Simon filter
IVC filter, Birdsnest filter
Duplicated IVC
IVC filter, Simon filter
IVC filter, Birdsnest filter
Buerger's disease (thromboangitis obliterans)

Case findings:
Profunda femoris artery is hypertrophied 
Profunda femoris artery provides corkscrew collaterals to reconstitute the popliteal artery 
Corkscrew collaterals also reconstitute the posterio
Buerger's disease (thromboangitis obliterans)

Case findings:
Profunda femoris artery is hypertrophied
Profunda femoris artery provides corkscrew collaterals to reconstitute the popliteal artery
Corkscrew collaterals also reconstitute the posterior tibial artery

Inflammatory arteritis of unknown etiology involving the small and medium-sized arteries of the extremities
MC young males, associated with smoking
Classic:
Occlusion of the one or more arteries of the legs with normal iliac and femoral arteries
Corkscrew collaterals
In contrast to atherosclerosis, high incidence of UE involvement

Lower extremity veins
Lower extremity arteries
Oncocytoma

Case findings:
Angiography:
Central portion of tumor is relatively avascular
Spoke-wheel pattern of hypervascularity that is most intense at the periphery of the mass
CT: renal mass with central scar

Oncocytoma: form of benign renal adenoma
Well encapsulated with dense central fibrous scar

DDX: renal cell carcinoma
Popliteal artery entrapment syndrome

Case findings:
Smooth focal narrowing in mid portion of right popliteal artery
No evidence of an aneurysmal or pseudoaneurysmal change
Medial deviation of the proximal popliteal artery in the stress position
Normal three-vessel runoff (not shown) in RLE

DDX popliteal artery stenosis/occlusion:
Premature accelerated atherosclerosis
Adventitial cystic disease
Entrapment syndromes:
Adductor canal outlet syndrome
Popliteal artery entrapment syndrome
Collagen vascular disease
Takayasu’s arteritis
Thromboangiitis obliterans
Thromboembolism
Rare, but one of the MC cause of intermittent LE claudication in otherwise healthy young adults
Medial deviation of the proximal popliteal artery in the stress position
Persistent sciatic artery

Case findings:
Absent right external iliac artery
Continuation of the internal iliac artery through the sciatic foramen

Uncommon, occurring in 1 in 1000
Embryologic sciatic artery remains dominant inflow vessel to the leg
Due to superficial location in the ischial region, the sciatic artery is prone to intimal injury or aneurysm formation

Aberrant vessel comes off internal iliac artery, passes through the greater sciatic foramen, and runs deep to the gluteus maximus
Above the knee, joins the popliteal artery
SFA is hypoplastic or absent
SVC obstruction (secondary to fibrosing mediastinitis)

Case findings:
CT:
Ill-defined soft-tissue mass encasing and obstructing SVC with extensive collaterals
Superior vena cavogram (simultaneous contrast injection via both arms under fluoroscopy):
Complete obstruction at the level of the brachiocephalic vein confluence with SVC as well as collateral vessels

SVC obstruction

MC due to bronchogenic carcinoma
Fibrosing mediastinitis: due to histoplasmosis
Intraluminal thrombus from indwelling catheter