What are Category 3 procedures?
TIPS Renal biopsy RF ablation Nephrostomy tube placement Biliary interventions (new tract)
What are Category 1 procedures?
Non-tunneled venous catheter Dialysis access interventions Central line removal IVC filter placement Venography Catheter exchange Thoracentesis Paracentesis Thyroid biopsy Joint aspiration/injection Superficial aspiration, drainage or biopsy
What are Category 2 procedures?
Angiography (access size up to 7-F Venous interventions Chemo- or radioembolization Uterine fibroid embolization Transjugular liver bx Tunneled venous catheter Subcutaneous port placement Abscess drainage Biopsy (excluding superficial and renal) Percutenaous cholecystostomy Enteric tube placement Spinal procedures (vertebroplasty, LP, epidural, facet block)
What is the triad of symptoms associated with Leriche syndrome (distal aortic occlusion)?
1) Buttock and thigh claudication
2) Absent femoral pulses
3) Impotence
What is the angiographic appearance of Takayasu’s arteritis?
-Angiography shows long, smooth stenotic segments of the medium-size and large arteries.
What are the 4 types of Takayasu’s arteritis?
type I: classic type involving the solely the aortic arch branches : brachiocephalic trunk, carotid and subclavian arteries
type II:
IIa: involvement of the aorta solely at its ascending portion and/or at the aortic arch +/- branches of the aortic arch
IIb: involvement of the descending thoracic aorta +/ - ascending or aortic arch + branches
type III: involvement of the thoracic and abdominal aorta distal to the arch and its major branches, e.g. descending thoracic aorta + abdominal aorta +/ - renal arteries
type IV: sole involvement of the abdominal aorta and/or the renal arteries
type V: generalised involvement of all aortic segments
What is the typical dose range for catheter-directed tPA?
0.25 to 2 mg/hr
When is lytic therapy absolutely contraindicated?
- Prior intracranial hemorrhage
- Known structural cerebral vascular lesion
- Known malignant intracranial neoplasm
- Ischemic stroke within three months (excluding stroke within three hours*)
- Suspected aortic dissection
- Active bleeding or bleeding diathesis (excluding menses)
- Significant closed-head trauma or facial trauma within three months
- *from Uptodate
What are indications for treatment of abdominal aortic aneurysm?
-Diameter of the aneurysm is >=5 cm (with the intro of EVAR, more aneurysms measuring 4.5 cm are being treated)
-Sac grows >0.5 cm within 6 months
-Or if the aneurysm is symptomatic (abdo pain or back pain not explained by any other condition)
(from Radcases)
In celiac artery obstruction, where does collateral flow come from?
Collateral supply to celiac branches from the SMA via the pancreaticoduodenal arcade or arc of Buehler
In SMA obstruction, where does collateral flow come from?
- Collateral supply to the SMA branches from the celiac artery via the pancreaticoduodenal arcade or arc of Buehler;
- Also from IMA via the marginal artery of Drummond or the arc of Riolan
In IMA obstruction, where does collateral flow come from?
Collateral supply to the IMA branches from the SMA via the left colic and marginal arteries or arc of Riolan; collateral supply from the internal iliac artery via retrograde flow in the superior rectal artery
What is considered massive hemoptysis?
> 500 cc/24 hrs or 100cc 3x/day x 1 week; high risk for death by aspiration.
Sources include bronchial (90%), pulmonary (5%), and systemic arteries (5%)
At what level do the bronchial arteries typically arise from the aorta?
How many bronchial arteries are there?
- Bronchial arteries arise from the thoracic aorta between T3 and T8 (most commonly T5-T6)
- Typically 2 left bronchial arteries and 1 right bronchial artery
What are complications of bronchial artery embolization?
- bleeding, infection
- chest pain, dysphagia, dissection, tissue necrosis (lung, bronchi, and esophagus), transient cortical blindness, and paralysis due to spinal artery embolization or injury
What embolic material is usually used for bronchial artery embolization?
- Particles >325 um (stop in the pulmonary bed, ideally 600-700 microns) are used; PVA or tris-acryl microspheres
- Gelfoam particles are typically NOT used.
- Coils are avoided except for aneurysms and AVMs
Where does the artery of Adamkewicz usually arise from?
The artery of Adamkiewicz has a variable origin but most commonly arises :
- on the left (~80%)
- at the level of 9th-12th intercostal artery (~70%)
It arises from the radiculomedullary branch of the posterior branch of the intercostal or lumbar artery, which arise from the thoracic or abdominal aorta respectively. It has a diameter of ~1 mm (range 0.8-1.3 mm).
What are indications for Transjugular Intrahepatic Portosystemic Shunt (TIPS)?
- Variceal bleeding after failed medical mgmt
- Refractory ascites secondary to portal HTN
- Refractory hepatic hydrothorax
- Hepatorenal syndrome
- Portal gastropathy
- Budd-Chiari syndrome
- Veno-occlusive disease
What are absolute contraindications to TIPS?
- Right-sided heart failure
- Primary pulmonary HTN
- Polycystic liver disease
- Severe hepatic failure
What are relative contraindications to TIPS?
- Biliary obstruction
- Portal vein obstruction
- Severe encephalopathy
- Liver or systemic infection
What is post embolization syndrome?
- Fever, leukocytosis, nausea, and vomiting. It may be indistinguishable from infection, and patients may require hospitalization for tx with IV antibiotics.
- Usually occurs within the first 72 hrs following embolization (liver lesion or uterine fibroids) and then starts to subside after 72 hours
- more often associated with large fibroids or large tumor embolisation
What are typical US findings of pseudoaneurysm?
- Color Doppler shows the “yin-yang” sign.
- Doppler waveform shows “to-and-from” flow
What are possible treatment options for femoral artery pseudoaneurysm?
Treatment options include:
- surgical repair
- ultrasound guided compression
- ultrasound guided thrombin injection
- endovascular therapy: stent-graft placement
At the time of writing the success rate of thrombin injection (89-96%) is considered to be much higher than with compression (74-78%).
What is the typical dose for percutaneous thrombin injection of a pseudoaneurysm?
200 to 1000 IU is injected with a 22-G needle to the apex of the pseudoaneurysm in small increments (100 IU in 0.1 mL) under US monitoring
