1
Q
Indications for transarterial thrombolysis
A
- acute (<14 days) native arterial thrombosis
- acute (<14days) graft thrombosis
- acute emboli
- NOTE: Chronic occlusion is probably better served by surgical correction.
2
Q
Dropped emboli post transarterial thrombolysis
A
- After the 12-hour infusion of reteplase, however, the runoff has been adversely affected with the evidence of abrupt cutoff of the dominant runoff vessels, the peroneal and anterior tibial arteries, suggesting “dropped” emboli from the graft lysis.
- When this happens, need to continue with transcatheter thrombolysis.
3
Q
FNH feeding vessel
A
- FNH is well-circumscribed, hypervascular
- feeding vessels are enlarged, and usually in the periphery
- no AV shunting, no pooling or puddling of contrast
4
Q
Transplant renal artery stenosis
A
Delayed time-to-peak, retention of contrast
Undistinguishable from
- RAS
- ATN
- Rejection
5
Q
When to treat splenic artery aneurysm
A
- Ruptured and symptomatic SAAs
- In pregnant women or women of childbearing age
- Patients with portal hypertension or who undergo liver transplantation
- Enlarging aneurysms
- Aneurysms 2.5–3 cm or more in diameter
6
Q
Splenic artery pseudoaneurysm from pancreatitis
A
- Soft tissue mass on CT with an “onion-layered” pattern and with the adjacent area that enhances similar to the aorta is a classic CT pattern for a partially thrombosed pseudoaneurysm
- Vascular injury from pancreatitis
- venous thrombosis/occlusion
- arterial pseudoaneurysm
- Rx for splenic artery pseudoaneurysm - embolization
- need to occlude the vessel both proximal and distal to its origin
- proximal embolization alone would allow perfusion to the pseudoaneurysm through collateral pathways
7
Q
IR Rx of traumatic thoracic duct transectionn
A
- lymphangiography
- thoracic duct embolization
8
Q
Hepatic tumor chemoembolization
A
- High density contrast material - Lipoidol (Ethiodol: brandname is US)
- poppyseed oil
- radiodense contrast material
9
Q
Hepatic subcapsular hematoma
A
- Liver subcapsular hematomas often occur when the parenchyma of the liver is disrupted by blunt trauma, but Glisson’s (liver) capsule remains intact.
- It is usually secondary to hepatic arterial hemorrhage.
- Typically, the finding is a lenticular-shaped low-density area beneath the liver capsule that may compress the hepatic parenchyma.
10
Q
IR Rx for biliary stenosis
A
- PTC (percutaneous transhepatic cholangiogram) should be performed to delineate biliary anatomy
- Prophylactic antibiotics should be give 1 hour before the procedure to prevent biliary sepsis.
- A 10-Fr or larger internal/external biliary drainage catheter should be placed across the stricture and left to drain bile into the small bowel.
- If the anastomotic stricture cannot be transversed at the initial setting, an external drainage catheter should be placed and a second attempt made a day or two later.
- Internal drainage is important to avoid loss of bile salts and to secure the drainage catheter*.
- Percutaneous balloon dilatation of benign biliary strictures is another option. Following dilatation, a large (12-Fr or greater) biliary catheter should be left across the stricture to prevent restenosis. Patients should return every 2-3 months for routine biliary catheter exchanges and repeated angioplasty if necessary.
11
Q
IR Rx for biliary leak from cystic duct
A
- PTC
- Percutaneous biliary drainage until the cystic duct heals on its own
12
Q
Post renal transplant lymphocele
A
- Present with swelling over the transplant, unilateral leg edema secondary to iliac vein compression, or increased creatinine and hydronephrosis secondary to ureteral compression.
- Diagnosis of lymphoceles can be confirmed by simple aspiration.
- high protein content
- creatinine concentration equal to that of the serum
- The treatment of lymphocele in the acute phase includes percutaneous drainage and monitoring.
- In cases resistant to this therapy, sclerosis of the cyst cavity can be considered (using povidone-iodine or tetracycline).
- The definitive and preferred therapy is surgical unroofing of the lymphocele wall to allow drainage into the peritoneal cavity (peritoneal window).
- It should be noted that small asymptomatic lymphoceles don’t require treatment.
13
Q
Traumatic ICA dissection
A
- Risk of thrombosis and embolization
- Rx - anticoagulation +/- antiplatelet
- May use endovascular stent
14
Q
MR appearance of fibroids
A
- iso to hypo intense on T1 and T2
- enhance on post gad images
- if no enhancement - spontaneous infarct
- Rx - uterine artery embolization
15
Q
Percutaneous cholecystostomy
A
- Indications: calculous and calculous cholecystitis, access for stone fragmentation and removal and sometimes for decompression of both the gallbladder and the biliary system if a transhepatic route is not feasible.
- Access to the gallbladder is frequently performed using ultrasound guidance.
- Access routes include transhepatic and subhepatic
- For the transhepatic route, advantages include an easily visible window through the liver with ultrasound guidance, the tamponade effect of the intervening liver for catheter placement, a more readily established tract between the gallbladder and the skin, and entry to the gallbladder at a fixed point. Disadvantages include liver injury from placing a catheter through the parenchyma.
- The single most notable advantage to a subhepatic or transperitoneal approach is the avoidance of traversing the liver and all its potential complications. A major disadvantage of the subhepatic or transperitoneal approach is the possibility of gallbladder laceration with bile peritonitis secondary to the mobility of this portion of the gallbladder.
- In general, the catheter must remain in place for six weeks to allow for the establishment of a connecting tract.
- Inflammation of the gallbladder must resolve and the patency of the cystic duct must be demonstrated. The catheter can then be removed after an established tract between the gallbladder and the skin has been demonstrated as well.
16
Q
Primary Subclavian-Axillary Vein Thrombosis
(Paget-Schroetter Syndrome)
A
- Primary SAVT is idiopathic or related to physical activity or arm positioning;
- All other causes (usually central venous catheters) are referred to as secondary SAVT.
- Primary SAVT accounts for less than 2% of all cases of deep vein thrombosis and is frequently associated with an extrinsic compression of the subclavian-axillary vein due to narrowing of the costoclavicular space by bony and/or soft-tissue structures.
- In the majority of cases, the clinical presentation is that of a young, active, healthy male who rapidly develops swelling of his dominant arm.
17
Q
Iliac artery occlusion
A
- Iliac artery occlusion may be acute or chronic
- The presence of well-developed collaterals –> chronic occlusion
- Lumbar artery is an important collateral
*
18
Q
Carcinoid tumor
A
- CT - mesenteric mass, radiating vessels, dysplastic reaction, mesentery being “pulled in” towards the mass; 70% has calcifiations
- NOTE: fibrosing mesenteritis can have a very similar appearance
- Angiography - primary carcinoid tumor and carcinoid metastases are very different!
- carcinoid tumor - avascular; with associated arterial and venous occlusion
- liver carcinoid metastases - hypervascular like any other neuroendocrine tumors
19
Q
Vertebroplasty
A
- Indications: compression fractures and clear association of pain onset and fracture, painful tumor (including metastases, hemangiomas, and myeloma), and occasionally traumatic fractures.
- Contraindications: coagulopathy, inability to lie prone, unclear etiology of back pain, severe compression fracture, or comminuted burst fracture. There is a relative contraindication if the fracture line extends to the posterior wall of the vertebral body or if there is fear of cement going into the canal.
20
Q
Hilar Cholangiocarcinoma
Klatskin tumor
A
- Risk factors: PSC, choledochal cysts, familial polyposis, congenital hepatic fibrosis, and infection with the liver fluke Clonorchis sinensis.
- CT: delayed enhancement of tumor
- Rx: perc external/internal drain; if life expectancy < 1 year, metallic stent can be placed
21
Q
Renal angiomyolipoma
A
- CT/MR - fat content
- Angiography - enlarged, distorted feeding vessels, may contain aneurysm
- NOTE: hypervascular AML may be fat poor and do not have fat content visible
- can be differentiated from RCC by the lack of calcifications
- >4cm is usually the threshold for Rx
22
Q
Hypothenar hammer syndrome
A
- An abnormality of the ulnar artery caused by repetitive, blunt trauma to the hypothenar area.
- HHS is most prevalent in men with occupations that require repetitive hammer-like motion
- The mechanism of injury is repetitive injury of this arterial segment as it courses around the hamate bone.
- Characteristic “corkscrew” or “beaded” appearance to the effected artery, and the segment can serve as a source of emboli to the digital arteries.
- Other angiographic findings include aneurysm and thrombosis of the ulnar artery.
23
Q
Budd-Chiari syndrome
A
- Hepatic vein or IVC occlusion or stenosis.
- The syndrome is idiopathic in 2/3 of cases. Maybe associated with
- OCP, neoplasms, congenital disorders, polycythemia rubra vera, chronic leukemia or trauma.
- Hepatic venoocclusive disease - Jamaican toxic bush tea
- CT - nutmeg liver
- NM (Tc99m sulfur colloid)- hot caudate lobe (separate venous drainage into IVC)
- Angio - “spider web appearance” of intrahepatic collateral veins
24
Q
Leriche syndrome
A
- chronic occlusion of the abdominal aorta
- form collateral pathways
- triad
- buttock and thigh claudication
- absent femoral pulses
- impotence
25
Branches of posterior division of the internal iliac artery
* iliolumbar artery
* superior gluteal artery
* lateral sacral artery
26
Popliteal artery occlusion post knee posterior dislocation
* thrombogenic response post intimal injury
*
27
Popliteal artery entrapment syndrome
Can be elicited by plantar flexion of foot
28
Mesenteric ischemia
Classification of mesenteric ischemia
* occlusive
* embolus
* thrombosis
* non-occlusive
* low flow status - sepsis, shock, heart failure
29
Fibrin sheath formation
* Fibrin is thought to begin forming within hours at the site of catheter insertion. It is composed of fibronectin, laminin, collagen and immunoglobulins.
* Fibrin sheath can form a tail or flap extending from the catheter tip and is responsible for persistent withdrawal occlusion.
* Upon infusion, this flap opens and allows fluid flow, while upon aspiration, this flap is pulled over the catheter lumen occluding the backflow of blood.
* Treatment Options include intraluminal thrombolytic infusion, fibrin sheath stripping using a snare, and catheter exchange over a guidewire.
30
Most common cause of colonic bleed?
1. diverticular disease
2. angiodysplasia
31
Angiodysplasia
* common cause of colonic bleeding
* more properly termed "telangiectasia", as angiodysplasias are dilatations of normal, pre-existing blood vessels
* \>60 yo
* almost always occur in cecum and right colon
* colonoscopy - the only way to clinical Dx
* angiography
* a densely opacified tuft or tangle of vessels best seen in the arterial phase
* an early-filling vein that can either be seen in the late arterial phase or early venous phase
* extravasation of contrast into the colon
* Rx: endovascular vasopressin injection and embolization; surgical resection
32
Page kidney
* renin-dependent hypertension due to renal ischemia caused by external renal compression without evidence of renal artery stenosis
* causes of renal compression
* Most commonly, trauma causing either subcapsular or perinephric hematoma.
* intrarenal or splenic cyst
* renal rhabdomyosarcoma
* infectious urinoma
* pararenal lymphatic cysts
* peritransplant hematoma
* retroperitoneal paraganglioma
* Rx: Observation with blood pressure therapy; Percutaneous drainage; Capsulectomy; Nephrectomy.
33
Venous rupture following angioplasty of hemodialysis graft stenosis
Treatment options
* (1) manual compression of the injured area
* (2) reinflation of the angioplasty balloon across the site of injury to provide endovascular tamponade
* (3) deployment of an endovascular stent across the damaged vascular segment
* If all of these methods fail to control bleeding from the rupture site than the final alternative may be to occlude the hemodialysis graft
34
Right sided aortic arch
2 patterns
* most common branching pattern - aberrant left subclavian artery
* travels posterior to the esophagus
* dysphagia lusoria
* 12% risk of congenital heart disease
* second most common branching pattern - mirror image
* 98% congenital heart disease
35
Adventitial cystic disease
* an uncommon cause of intermittent claudication
* mucin-filled cysts originate within the arterial adventitia and progressively enlarge, leading to extrinsic compression and focal stenosis and even occlusion of affected vessel
* most common occurs in popliteal artery
* typically young male
* Rx: medical, percutaneous, surgical
36
Median arcuate ligament syndrome
* gold standard - lateral angiography
* exacerbation of stenosis on expiration
* Rx: surgery; endovascular is less long-lasting
37
Cavernous venous malformation
* mature age, lack AV communication
* lesion is more extensive on venogram than on MRI
* NOTE: capillary hemangioma on the other hand, will involute as the baby grows
* characteristic Dx findings are
* dilated venous spaces that fill slowly on a diagnostic venogram, and late in the late phase of an arteriogram
* poor communication with normal venous channels
* no arterial abnormalities
* calcified phleboliths
* lesions usually more extensive on venogram than on CT/MR
* Rx: direct puncture of the venous malformation, and injection of sclerosant
38
Portal vein thrombosis
* Etiologies for portal vein thrombosis
* idiopathic
* malignancy - HCC, pancreatic carcinoma, metastatic carcinoma
* coagulable state
* cirrhosis
* pancreatitis
* sepsis
* Rx: systemic anticoagulation, catheter-directed thrombolysis
* Complications - can lead to pre-sinosoidal portal hypertension
39
Pancreatic pseudocyst
* DDx
* pancreatic pseudocyst
* pancreatic/peripancreatic abscess
* pancreatic cystic neoplasm
* enteric or mesenteric duplication cyst
* lymphangioma
* As the fluid can track a variety of places before formation of a wall, pseudocysts can be identified in the paracolic gutter, the pararenal spaces, the lesser sac, or even the mediastinum
* Indications for drainage
* compression of adjacent organs, superimposed infection, significant pain
* Rx
* percuataneous drainage if a safe route is available
* transgastric drainage
* surgical - cyst-gastrostomy
* If output is high through the drainage tube
* may have developed a pancreatic ductal fistula
* Rx - TPN, bowel rest, and octreotide to decrease pancratic secretions to allow fistula to heal
* when puncturing the stomach, try to avoid the lesser and greater curvatures
* to avoid gastric and gastroepiploic areries, respectively
40
Splenic artery aneurysm
* 60% of all splanchnic artery aneurysm
* causes - medial degeneration and fibrodysplasia, portal hypertension, hormone/pregnancies, infection, pancreatitis
* majority are true aneurysms
* rupture rate 2%
* NOTE: most of splenic artery aneurysms discovered during pregnancy rupture! 95%! high maternal and fetal mortality!
* Rx recommonded if
* \>2cm
* growing
* symptomatic
* pragnant
* if associated with inflammation/infection - pseudoaneurysm
* Percutaneous embolization
* Occlusion the splenic artery itself, as close as possible to the splenic artery aneurysm, is preferable and safer in comparison to the more risky aneurysmal cavity embolization
* also need embolization of all outflow tracts to prevent retrograde collateral flow into the aneurysm
* Post-embolization syndrome: LUQ pain, fever. Rarely, splenic infarct, with or without abscess formation, can occur after splenic artery embolization
41
Hepatocellular carcinoma
* can be solitary, multicentric, or diffuse
* angiographic findings
* enlarged arterial feeders
* neovascularity
* vascular lakes and puddles
* dense tumor stain
* arterial-portal shunting
* invasion of hepatic veins and bile ducts
* NOTE: hepatic adenoma and FNH may also show enlarged feeding vessels and neovascularity, but no tumor staining or venous puddling/lake!
42
* white arrow - left main renal artery
* yellow arrow - anterior and posterior division
* blue arrow - segmental artery
* green arrow - interlobar artery
* dividing further - arcuate artery
* smallest branch - interlobular artery
43
Polyarteritis nodosa
* panarteritis of small to medium sized arteries
* multiple foci of fibrinoid necrosis beginning in the media of the vessels with subsequent inflammation spreading to involve with intimia and adventitia
* periarterial inflammation and destruction of the elastic lamina that leads to the formation of small aneurysms, local thrombosis, and vessel rupture
* involvement
* renal 80-100%
* cardiac 70%
* liver 40-60%
* gastrointestinal 30-50%
* angiography findings
* multiple small aneurysms - 100% specific!
* stretching and attenuation of the peripheral intrarenal vessels
* decrease number of vessels from multiple thromboses
* patchy nephrograms secondary to small subsegmental infarcts
44
Chronic mesenteric ischemia
* classic surgical teaching requires at least 2 of 3 mesenteric vessels to be compromised by a stenosis or occlusion
* not always the case though
* median arcuate ligament syndrome - only celiac is compromised but symptomatic
* some patients with 3 vessel occlusion but asymptomatic from good collaterals
45
Subclavian steal syndrome
* subclavian artery stenosis or obstruction near its origin, with reversal of flow in the ipsilateral vertebral artery at the expense of the cerebral circulation
* occlusion has to be more proximal to the takeoff of the vertebral artery
* male:female = 3:1
* vertebrobasilar insufficiency - syncopal episodes, particularly upon exercising the ischemic arm, headaches, vertigo, and ataxia. Additionally, there may be signs of left arm claudication.
*
46
AV fistulas for hemodialysis
* Several types
* direct arteriovenous fistulas
* synthetic and nonsynthetic interposition grafts
* polytetrafluoroethylene
* (PTFE)
* stenosis of arterial inflow is very rare
* more often on the venous side
47
Contrast agent choice
* if worried about esophageal perforation
* use Gastrografin/soluble contrast agent
* barium can cause mediastinitis
* if worried about aspiration
* use Barium
* Barium is well tolerated in the airways and is used in bronchography
* Gastrografin will cause pulmonary edema/inflammatory pneuomonitis
48
Since the liver receives about 75% of its blood supply from the portal vein, unless the patient has underlying severe liver disease, hepatic artery embolization is rarely complicated by liver failure.
49
Rasmussen aneurysm
TB pulmonary artery mycotic aneurysm
* mass hemoptysis \> 300cc/24hours
* most common cause - bleeding from bronchial arteries
* percutaneous transcatheter embo with balloon or coils
50
Caroli's disease
Choledochal cyst variant type V
* choledochal cyst type V
* autosomal recessive
* cystic dilatation of the intrahepatic biliary ducts is the hallmark of the disease, but the extrahepatic biliary tree may also be involved
* may be associated with cirrhosis, portal hypertension, or congenital hepatic fibrosis
* complications
* pain, infection, bacteremia and/or sepsis, and stone formation
* Rx: PTC drainage, stent placement in CBD, partial hepatectomy (if only part of the liver is involved)
51
* Large cavernous hemangiomas or hemangioendotheliomas may cause hyperkinetic heart failure in young neonates plus potential coagulation disturbances
* Rx: embo, surgical resection
52
Polyarteritis nodosa vs Kawasaki disease
* PAN - small aneurysms in kidneys
* Kawasaki's - coronary artery and brachial artery aneurysms
53
Angiographically, temporal arteritis is indistinguishable from Takayasu's arteritis. Both share the same basic pathology, with the major difference being the age of onset.
Takayasu's arteritis is seen in much younger patients (age \<50), while temporal arteritis in seen in older (age \>50) patients.
54
Fibrolamellar hepatocellular carcinoma
* NOT associated with cirrhosis or other known risk factors
* alpha-fetoprotein levels are typically NOT elevated in fibrolamellar HCC
* mean age 23 yo
* better survival than other HCC
* angiography - like HCC
* neovascularity
* enlarged arteries
* venous puddling/lake
* AV shunting
55
Scleroderma
* intimal proliferation and medial hypertrophy with concentric narrowing progressing to occlusion
* multiple focal stenoses and occlusions involving the ulnar, palmar, and proper digital arteries
* radial artery is rarely involved
56
Bacillary angiomatosis
* acquired by inoculation with gram negative bacterial Bartonella henselae and Bartonella quintana after traumatic contact with a cat
* an opportunistic infection and an AIDS-defining illness
* cutaneous and subcutaneous firm and non-blanching nodules that are usually purplish to bright red in color
* also: pulmonary nodules; lytic bone lesions
* Rx: oral clarithromycin until the lesions resolve
57
Coronary subclavian steal syndrome
Coronary-subclavian steal syndrome refers to decreased or reversed left internal mammary artery (LIMA) flow, which causes angina related to severe subclavian steno-occlusive disease in patients with in situ internal mammary-to-coronary artery graft.
58
Carotid body tumor
Carotid body tumor
AKA
Carotid body paraganglioma
Glomus tumor
59
Contrast agent in patients with renal insufficiency
* CO2
* gadolinium
60
Pre-operative embolization of RCC
* Pre-op embolization should be performed within 24 hours of surgery
* Post-embolization syndrome will be seen in the majority of patients who do not proceed immediately to surgery. This syndrome consists of fever, pain, and white blood cell count elevation
61
Acute nonocclusive mesenteric ischemia secondary to vasospasm
* The etiology of acute, non-occlusive mesenteric ischemia is intense mesenteric vasoconstriction in response to a period of mesenteric hypoperfusion.
* Angiography - constriction of the SMA branches, patch filling of peripheral arcades, diminished bowel blush and poor visualization of the superior mesenteric vein.
* If spasm is detected at angiography, a test dose of 30-60 mg of papaverine (or other vasodilator) can be administered into the SMA in an attempt to assess reversibility.
* Should a response be seen, a 24-hour infusion of papaverine into the SMA at a dose of 0.5 to 1.0 mg per minute (at a concentration of 1mg per ml) can be initiated.
* Following the 24-hour infusion, normal saline should be infused for 30 minutes, followed by a repeat angiography to assess for long-term benefit.
62
Mesenteric collaterals
* between SMA and IMA
* if the major collateral courses along the margin of the colon, it is called the Marginal Artery of Drummond
* if it runs in the mesentery, it is called the Arc of Riolan
* between celiac and SMA
* pancreaticoduodenal arcades
* between IMA and systemic (internal iliac)
* middle and inferior hemorroidal to supply superior hemorroidal
63
Renal artery aneurysm
* atherosclerotic or congenital renal artery aneurysm
* usually single
* can become quite large
* typically involving main renal artery and its main branches
* renal artery aneurysm related to polyarteritis nodosa
* usually multiple
* often small
* typicall involving the segmental renal arteries and its smaller branches
64
Iliac artery aneurysm
* aneurysm if \>1.5 cm
* surgical repair if \> 3.0 cm
65
Severe stenotic aortoiliac artery disease in a young patient
* atherosclerotic disease in a patient with genetic hyperlipidemia and hypercoagulability
* radiation arteritis
* Takayasu arteritis
* neurofibromatosis
66
Neurofibromatosis and vessel stenosis
* Due to the mesenchymal abnormalities in neurofibromatosis, there is abnormal vascular development resulting in hypoplasia with stenosis caused by abnormal proliferation of elastic fibers and smooth muscle cells derived from the mesenchyma.
* Can have thoracic or abdominal aortic stenosis
67
Renal oncocytoma
* The key feature of this entity is that an oncocytoma cannot be reliably distinguished from renal cell carcinoma on the basis of imaging characteristics. Need Bx for definitive diagnosis.
* Although the cross-sectional imaging characteristics of this tumor are atypical for renal cell carcinoma, a lesion with this appearance is more likely to be renal cell carcinoma, as the latter is much more prevalent.
* CT: an ovoid or round well-circumscribed shape, homogeneous contrast enhancement and a stellate central scar.
* Angio: a mass with relative hypovascularity, homogeneous tumor contrast during the capillary phase, spoke-wheel arrangement of tumor vessels (especially in larger tumors), peri-tumoral halo, sharp demarcation from the kidney and surroundings and linear course of vessels.
68
Ostial renal artery stenosis
* OSTIAL renal artery stenoses are most commonly caused by large aortic plaques that form at the origins of the renal arteries.
* Surgical bypass for ostial lesions is the primary treatment of choice for ostial renal artery stenoses, secondary to its proven long-term primary patency.
* However, for patients who are poor surgical candidates, intravascular stent placement is a good alternative.
* Due to the large concentric forces of the overgrown aortic plaque in these ostial-type lesions, primary stent placement is more successful than angioplasty alone.
69
Common sclerosants
* absolute alcohol
* Sodium tetradecyl sulfate (STS)
70
Buerger's disease
Thromboangiitis obliterans
* a nonnecrotizing vasculitis affecting small and medium-sized arteries
* young, male, smokers
* 40-45 yo
* classic symptom: a peripheral burning sensation at rest - differs from the claudication syndrome of atherosclerotic disease
* may progress to ischemic ulcerations of the toes, feet, or finger
* NOTE: the vessel wall, unlike arteriosclerosis and other systemic vasculitides, remains intact
* angiography
* proximal arteries are normal
* with abrupt segmental occlusions of the popliteal, crural, and plantar arteries.
* "corkscrew collaterals" that follow the course of the normal arteries - Martorell's sign - pathognomonic
* Rx: cessation of smoking
71
Diabetic vasculopathy
Atherosclerotic lesions of the lower extremities tend to affect the proximal vessels, especially the superficial femoral artery (in the region of the adductor canal) and the popliteal artery in non-diabetic patients.
In the diabetic patient, the distal vessels are more commonly affected. As illustrated in this case, "diabetic vasculopathy" can decimate the runoff vessels, making treatment very difficult. If the runoff is limited, neither percutaneous nor surgical intervention will be very useful and amputation is frequently the outcome.
72
Vasa vasorum
The smaller blood vessels known as vasa vasorum penetrate the arterial wall and provide nutritional supply to the artery itself.
73
Pulmonary sling
* A pulmonary sling can be differentiated from the majority of vascular rings on the lateral view of a barium swallow.
* Vascular rings (aberrant subclavian artery) typically indent the esophagus posteriorly
* While pulmonary slings lie between the trachea and esophagus.
74
Popliteal artery aneurysm
* Popliteal aneurysms are significant because of the high incidence of associated distal thromboembolization and limb loss.
* The popliteal artery is the most common site of aneurysm formation in the peripheral circulation and is second only to the abdominal aorta as a site of aneurysm formation anywhere in the body.
* \> 2.0 cm
* Due to the high rate of complications and the associated high incidence of amputation after the onset of symptoms, most surgeons recommend operative repair of asymptomatic popliteal aneurysms except in high-risk patients.
75
Carotid Duplex data
Duplex data have been correlated with angiographic findings. The following correlations exist:
* Peak systolic velocity \< 130 cm/sec = 40-59 % diameter stenosis.
* Peak systolic \> 130 cm/sec = 60-79 % diameter stenosis.
* Peak systolic velocity \> 250 cm/sec and Peak diastolic velocity \> 100 cm/sec = 80-99 % diameter stenosis.
76
"hard" findings of arterial injury
* "hard" findings of arterial injury
* physical evidence of arterial occlusion (loss of pulses, pallor, etc)
* active arterial bleeding
* rapidly expanding hematoma
* and palpable thrill of audible bruit indicating the presence of an arteriovenous fistula
77
How to "open up" the aortic arch?
LAO projection
78
Traumatic carotid cavernous fistula
* 2 shunting pathways
* superior ophthalmic vein --\> facial vein
* inferior petrosal sinus --\> jugular vein
* etiology
* most often: closed head injury in MVC
* iatrogenic - pituitary surgery
* spontaneous - rupture of intracavernous carotid aneurysm
79
JNA
or any nosebleed
which vessel bleeds?
internal maxillary artery
80
Massive epistaxis
* can treat with empiric embolization of the distal internal maxillary artery
* be aware of two potential collateral pathways from internal maxillary artery (external carotid) to the intracranial circulation (internal carotid) - be careful not to embo ICA branches!
* internal maxillary a. --\> middle meningeal a. --\> ICA
* internal maxillary a. --\> ophthalmic a. --\> ICA
81
Venous aneurysm
* rare
* have the potential to thrombose and lead to PE
82
Hepatic hydrothorax
* a pleural effusion in a cirrhotic patient in the absence of cardiopulmonary disease
* usually right sided
* results from a defect in the diaphragm resulting in a patent pleuro-peritoneal communication
* can be confirmed by injecting technetium-99m sulphur colloid into the peritoneal cavity and demonstrating its movement into the chest
83
TIPS
* indications: refractory ascites and variceal bleeding despite maximal medical therapy
* goal: portosystemic gradient \<12 mmHg
* if overshunting, worsening hepatic encephalopathy and hepatic failure
* need regular US surveillance to ensure patency
84
Alternative route for central venous acess
* translumbar placement into the infrarenal IVC
* transhepatic catheter via the hepatic vein
* inguinal approaches (using access via femoral, saphenous, or external iliac vein)
* via collateral veins
* other enlarged veins (azygous/hemiazygous system, intercostal, and internal mammary veins to enter the SVC; inferior epigastric, lumbar or gonadal veins to enter the IVC)
85
May-Thurner Syndrome
* right common iliac artery compresses the left common iliac vein
* needs systemic anticoagulation long term, or stent placement
* post thrombotic syndrome
* venous claudication, venous stasis ulcers, valvular incompetency, and chronic leg edema
86
Duplicated IVC
* failure of regression of the embryologic left-sided supracardinal vein --\> persistence of a left-sided parallel venous conduit as far proximally as the left renal vein
* the 2 IVCs join at the level of the left renal vein and ascend as a right-sided suprarenal IVC
* need to place 2 IVC filters in this case
* other IVC anomaly: right sided IVC
87
Portosystemic shunts
* left gastric vein/coronary vein --\> gastroesophageal varices --\> submucosal venous channels in the lower 1/3 of the esophagus --\> azygoz vein
* splenorenal, mesenteric-renal
*
* normal portosystemic gradient \< 5mmHg
* portal hypertension \>= 6mmHg
* goal of TIPS \< 12mmHg
88
Isolated gastric varices
* isolated gastric varices WITHOUT esophageal varices
* be aware of splenic vein thrombosis
* splenorenal shunt in case of splenic vein thrombosis may course through the gastric fundus to give isolated gastric varices
* in this case, TIPS will not help
89
Good and Bad splenorenal shunts
* Good splenorenal varices - course through the retroperitoneum to the left renal vein, as they are not associated with a risk of bleeding.
* Bad splenorenal varices - cross the gastric fundus en route to the left renal vein, can be associated with gastric variceal bleeding despite normalized portosystemic gradient (\<12mmHg) post TIPS creation.
* Rx - embolization of the splenorenal shunts
90
Chronic portal vein thrombosis and cavernous transformation
* etiology: HCC, pancreatitis, cirrhosis, liver transplantation, and splenectomy
* chronic portal vein thrombosis --\> will open up multiple collateral veins in the hepatoduodenal ligament and porta hepatis --\> cavernous transformation of the portal vein
* flow remains hepatopetal --\> acts as a portoportal shunt, although there may be some shunting to the systemic circulation
91
Pelvic congestion syndrome
Female varicocele
* dilated gonadal/ovarian veins
* can cause pelvic pain
* Rx - embolization
92
Where does umbilical vein drain into?
Left portal vein
93
Renal artery stenosis in childhood
* Main renal artery stenosis in childhood is an uncommon disorder
* The most common etiologies of renal artery stenosis in childhood are
* fibromuscular dysplasia (non-ostial)
* NF-1 (ostial)
* Takayasu arteritis
94
Causes of hypertension in kids
* renal artery stenosis
* pheochromocytoma
95
SMV thrombosis
* etiology: pancreatitis, diverticulitis, sepsis, malignancy, trauma, hyper-coagulability
*
96
Which type of Ehler-Danlos Syndrome most often affects vascular structures?
* Ehler-Danlos Type IV
* often die \< 40 yo from aortic rupture
97
Lower GI bleed
* nuclear imaging is more sensitive, detecting 0.05-0.1mL/min bleeding
* versus 0.5-1 mL/min bleeding required for detection by angiography
* Typical angiographic findings
* diverticulum bleed - contrast extravasation in the diverticulum and subsequent extravasation into the colonic lumen
* angiodysplasia bleed - tuft of arterioles, large early draining vein, active contrast extravasation
* Rx
* transcatheter vasopressin injection
* embolization
98
Pinch off syndrome
* Catheter fracture (pinch-off) is caused by the pinching and kinking of the catheter (inserted via subclavian approach) between the first rib and the clavicle, particularly when a patient is upright and the weight of the shoulder narrows this space
* Repetitive kinking and compression of the catheter during ordinary movement can cause the catheter to fatigue with subsequent partial or complete fracture
* Infusion attempts through the venous access device after a partial or complete fracture will result in localized swelling and/or pain
* A complete fracture is complicated by embolization of the distal catheter to the right heart or pulmonary artery causing sudden onset chest pain. The free fragment after catheter fracture can be retrieved using a snare device
* Rx: insert the catheter more laterally
99
Splenic vein thrombosis
* well-recognized sequelae of chronic pancreatitis
*
100
Subclavian vein thrombosis
* hemodialysis related SVT - neointimal hyperplasia
* catheter-associated thrombosis from an indwelling infusion catheter
* effort thrombosis - Paget-Schroetter Synrdome (thoracic outlet syndrome)
101
Most common cause of bronchial artery hypertrophy
and secondary hemoptysis
* chronic TB
* bronchiectasis
* cystic fibrosis
102
Massive hemoptysis
\> 300cc / 24hour
103
Bronchial artery embolization for hemoptysis
* most often configuration: 1 right, 2 left
* if injection of the bronchial arteries does not directly produce evidence of the source of hemoptysis, other arteries, which form anastomoses with the bronchial arteries must be interrogated
* the intercostals
* the inferior phrenic
* the internal mammaries
* the subclavian artery
* Artery of Adamkiewicz - small artery which feeds the anterior spinal cord
* arise between T8 and L2
* is located on the left ~80% of the time
* a small artery extending to the midline and with a sharp, hairpin turn, travels down the center of the anterior aspect of the spinal canal
104
Rx for renal artery fibromuscular dysplasia
angioplasty
105
Main DDx in hand ischemia
* vasculitis/vasospastic disorder
* embolic or atherosclerotic process
106
Esophageal stent for malignant esophageal stricture
* best when the stent is placed in the middle third of the esophagus.
* should not be placed over the cricopharyngeal muscle in the upper 1/3 or over the cardia in the lower 1/3. Placement in one of these two areas may produce severe odynophagia or gastroesophageal reflux respectively
*
107
Choledochal cyst
* congenital anomalies of the biliary tract
* "common channel" theory: an abnormally long distal common bile duct, below the union of the bile duct and pancreatic duct, allows for chronic reflux of pancreatic enzymes, common bile duct wall injury, and cystic dilatation
* complications
* bile stasis
* stone formation
* infection
* malignancy 3-30%
* Rx: int/ext PTC drain, surgery definitive
108
* Type 1B choledochal cyst
* Note the pancreatic duct arising from the common bile duct, and long "common channel" of the CBD distal to the insertion of the pancreatic duct
109
Necrotizing angiitis
* a result of drug abuse, particularly methamphetamine abuse
* strikingly similar to polyarteritis nodosa with severe renal, gastrointestinal, cardiac, and neurologic involvement
* may show attenuation of the peripheral intrarenal vessels, decrease number of vessels from multiple thromboses, aneurysms of varying size in the intralobar and ocular arteries, and patchy nephrograms secondary to small subsegmental infarct
110
Persistent sciatic artery
* persistent sciatic artery (as the terminal branch of the internal iliac artery) passes through the sciatic notch and courses POSTERIORLY to the femur
* superior femoral artery is extremely small
* prone to aneurysm formation
111
persistent sciatic artery
with aneurysm formation
112
Popliteal entrapment syndrome
* anatomical vs functional
* anatomical
* medial diviation of the popliteal arteries due to an aberrant course of the artery around the medial head of the gastrocnemius muscle
* functional
* worsened by foot PLANTAR flexion!
113
* abnormal medial course of the popliteal arteries
* occlusion upon plantar flexion of feet
114
Most common cause of dysfunction of PTFE loop grafts placed for hemodialysis
* VENOUS anastomotic stenosis; stenosis in the venous outflow
* due to neointimal hyperplasia
115
The proper selection of embolic agent
* The proper selection of embolic agent is crucial in the treatment of gastrointestinal bleeding. The following are general guidelines for embolic agents based on location of the bleeding:
1. left gastric artery embolization: Gelfoam
2. gastroduodenal artery: coils and Gelfoam
3. bleeding aneurysm: coils
4. bleeding diverticulum: (a) surgery if possible, (b) if not surgical candidate, vasopressin infusion, (c) if a specific site of bleeding is seen and is technically amenable to percutaneous intervention, consider small microcoils.
116
Ergotism
* Ergotism: generalized vasoconstriction/vasospasm caused by the ingestion of ergot containing medications or foods
* most common manifestation is acute peripheral ischemia
* meds used in treatment of migraine headaches may cause ergotism when taken at supratherapeutic doses
* Rx: catheter directed vasodilator infusions, IV infusions, or oral systemic tratments
117
Thoracic outlet syndrome
* spectrum of symptoms
* brachial plexus (95%)
* subclavian vein (4%)
* subclavian artery (1%)
* etiology
* cervical ribs
* fibromuscular bands
* anomalies of the 1st rib
* muscular hypertrophy
* clavicular fracture
* 3 common sites of vascular compression
* scalene triangle
* costoclavicular space
* retropectoral space
* Rx: surgery to remove extrinsic compression
118
Types of balloon
* non-compliant balloon
* angioplasty balloon
* graded to certain pressure
* compliant balloon
* can be inflated to variable pressures
119
Types of stent
* balloon-expandable
* self-expanding
120
Types of choledochal cysts
* Type I - most common (80-90%); saccular or fusiform dilatation of the CBD; normal IH ducts
* Type II - isolated diverticulum of the CBD
* Type III - also called choledochocele; arise from dilatation of the duodenal portion of CBD or where pancreatic duct meets
* Type IV - intra and extra-hepatic duct dilatation
* Type V - also called Caroli's disease; cystic dilatation of the intrahepatic ducts only
121
Primary sclerosing cholangitis
PSC
* associated with ulcerative colitis, retroperitoeneal fibrosis, Riedel's thyroiditis
* 50-70% of UC pts develop PSC
* complications
* cirrhosis
* cholangiocarcionma
* Rx: balloon, stent, Roux-en-Y hepaticojejunostomy, liver transplant
122
Terumo
Terumo Glidewire
123
How to treat iatrogenic biliary duct laceration
* to place a drainage catheter across the transection
* to allow the laceraton to heal
124
Collateral supply to the lower extremity
* The systemic-systemic network constitutes
* lumbar-iliolumbar-superior and inferior gluteal-external iliac artery pathway;
* subcostal, intercostal, lumbar-deep circumflex iliac and superficial circumflex iliac-external iliac/common femoral artery pathway;
* intercostal/internal mammary-inferior epigastric-external iliac artery (Winslow) pathway.
* The visceral-systemic network constitutes inferior mesenteric artery-superior hemorrhoidal branches-middle and inferior hemorrhoidal branches-internal iliac artery.
* If the stenosis is above the inferior mesenteric origin, the visceral pathway includes the superior mesenteric artery-middle colic-left colic-inferior mesenteric-hemorrhoidal-internal iliac arteries.
125
Percutaneous treatment of common iliac artery origin stenoses
Percutaneous treatment of common iliac artery origin stenoses is complicated by the possibility that a dissection or dislodged plaque may compromise the origin of the other common iliac artery. Simultaneous "kissing" angioplasty or stent placement to protect (or treat) the other common iliac artery origin has been advocated to prevent this possibility.
126
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