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48 Cards in this Set
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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 |
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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 |
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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 |
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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) |
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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 |
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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) |
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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 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 |
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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 |
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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 |
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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%) |
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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 |
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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) |
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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, hypertrophied muscles, scalene minimus muscle, clavicle fracture Complication: distal embolization of thrombus Treatment: surgical thoracic outlet decompression Upper extremity arteries |
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DSV of proximal RUE and central veins
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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 |
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Percutaneous transhepatic cholangiography (PTC)
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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 |
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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 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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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Hepatic vein injection (hepatic venography)
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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. |
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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 |
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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 |
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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 |
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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 |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 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 |
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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 |
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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 |
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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 |
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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 |
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What is the next step?
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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 |
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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) |
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Renal vein thrombosis
Children: Dehydration Sepsis Maternal diabetes Adult: Glomerulopathies CVD Diabetes Trauma Thrombophlebitis |
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Duplicated IVC
IVC filter, Simon filter IVC filter, Birdsnest filter |
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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 |
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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 |
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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 |
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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 |
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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 |