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VIR notes for oral boards

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Angio complications
puncture site – hematoma, AVF, pseudoaneurysm, thrombosis, infection
contrast – renal failure, allergic reaction
catheter-related – thromboembolism, stroke, dissection
therapy-related – hemorrhage
Catheters used for:
central vessels
selective vessels
aorta, PA
mesenteric, renal, contralat iliac
coaxial subselection
runoff
*central vessels - hi flow w/ sideholes
*selective vessels - low flow w/ endhole
*aorta, PA - pigtail
*mesenteric, renal, contralat iliac - Cobra
*mesenteric, arch vessels - Simmons
*coaxial subselection - Tracker
*runoff - straight
Flow rates (rate/volume):
abd aorta/PA
celiac/SMA
renals
IMA
pelvis
one leg runoff
arch
CCA
ICA
ECA
vertebral
IVC
abd aorta/PA 20/40
celiac/SMA 6/60
renals 5/15
IMA 2/20
pelvis 10/40
one leg runoff 4/48
arch 30/60
CCA 8/10
ICA 6/8
ECA 2/4
vertebral 6/8
IVC 15/45
Guidewires:
standard length
diameters
types
standard length - 145
diameters - 0.018 - 0.038 inch
Types - Newton J, Rosen, Amplatz, Bentson, Glide
Pharmacologic angio therapy:
vasodilator
vasoconstrictor
vasodilators
– papaverine 25-50 mg/hr for mesenteric ischemia, contraind in complete AV block
-NTG 100 ug for peripheral spasm

vasoconstrictor – vasopressin 0.2-0.4 U/min for GI bleed, contraind in CAD, HTN, arrhythmia
Indications for embolization
*bleed (GI, varices, trauma, bronchial art, tumor, post-op)
*vascular (AVM, AVF, pseudoaneurysm)
*pre-op devascularization (RCC, AVM, vascular bone mets)
*hepatic chemoembol (palliative, gelfoam + ethiodol + chemo in HCC)
Temporary embolization agent
gelfoam pledgets (for UGIB, pelvic trauma, post-op)
Permanent embolization agents
*steel coils (large vessel, aneurysm, tumor)
*PVA (small particles for distal occlusion, tumors, bilateral UFE for fibroids)
*ethanol (solid organ necrosis, peripheral AVM)
Embolization complications
postembolization syndrome
infection
nontarget embolization
Indications for thrombolysis
-arterial graft thrombosis
-native acute thrombosis
-prior to percutaneous intervention
-hemodialysis AVF or graft
-venous thrombosis
Absolute contraindications to thrombolysis
active bleed
intracranial lesion (stroke, tumor, recent surgery)
pregnant
nonviable limb
Complications of thrombolysis
major hemorrhage
distal embolization
pericatheter thrombosis
Success rates for thrombolysis
90% for grafts
75% for native vessel

favorable prognosis if recent clot, good inflow/outflow, positioned in thrombus
Indications for angioplasty
-claudication or rest pain
-tissue loss
-nonhealing wound
-establish inflow for distal bypass graft
-hemodialysis AVF or grafts
Angioplasty technique
- measure pressure gradients before & after PTA
-heparinize after lesion crossed
-piscoline 25 mg IA for vasospasm
-balloon sized to adjacent nl artery (exc aorta - undersize)
-wire always remains across lesion
Indications for stenting
- failed PTA (stenosis > 30%, press gradient > 5 mmHg, large flap, hard calcified plaque)
- recurrent stenosis after PTA
- venous obstruct / thrombosis
- long segm stenosis / total occlusion
- ulcerated plaque
- renal ostial lesion
- TIPS
Indications for TIPS
portal HTN & variceal bleed failed sclerotherapy,
refractory ascites,
Budd-Chiari,
pretransplant
Contraindications for TIPS
ABSOLUTE - severe R heart failure, liver failure
RELATIVE – PV thrombosis, hepat encephalopathy, infection, vascular liver tumors, polycystic liver dz

- check PV patency
- preprocedure paracentesis may help
- isolated gastric fundal varices from splenic vein thrombosis not an indication
Complications of TIPS
hepatic encephalopathy
bleeding
shunt thrombosis or stenosis
R heart failure
renal failure
Preprocedure meds/prep:
allergy
conscious sedation
contrast allergy – solumedrol 200mg IV + Benadryl 50mg PO or prednisone 40mg 16,8,2 hrs prior + Benadryl 50mg PO 1 hr prior

conscious sedation – Versed 0.5mg, Fentanyl 50 ug increments
Features of aortic dissection:
clinical present
causes
classification
imaging features
*chest / back pain, aortic insuff, BP diff between extremities
*causes – HTN, Marfan, Ehlers-Danlos, coarctation, bicusp valve, preg, trauma
*Stanford A – asc aorta, surgery!, beware tamponade, coronary occlusion, aortic insuff
*Stanford B – desc aorta only, medical tx
*Flap, displaced Ca++, delayed opacif of false lumen, compression of true lumen, occlusion of branch vessels, abnormal catheter position
*False lumen larger, slow flow, anterolateral in asc aorta & posterolateral in desc aorta
Treatment for urticaria developing following injection
* Stop injection if not done. No tx needed in most.
* H1 blocker: Benadryl 25-50mg PO/IM/IV or Vistaril 25-50mg PO/IM/IV. May add H2 blocker: Cimetidine 300mg PO/IV or Ranitidine 50mg PO/IV (in 10ml D5W solution) slowly.
* If severe: Alpha agonist (art and venous constriction) - Epi SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) if no cardiac contraind.
Treatment for Facial or Laryngeal Edema developing following injection
* Epi SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) or, if low bp Epi (1:10000) slow IV 1.0ml (=0.1mg). Repeat prn, max 1mg.
* O2 6-10 L/m (by mask)
* If not responding or obvious laryngeal edema, call code and consider intubation.
Treatment for Bronchospasm developing following injection
* O2 6-10 L/m (by mask).
* Beta-agonist inhalers (e.g. metaproterenol, terbutaline, or albuterol)
* Epi SC (1:1000) 0.1-0.3ml (=0.1-0.3mg) or, if low BP, Epi (1:10000) slow IV 1.0ml (=0.1mg). Repeat prn max 1mg
* OR, aminophylline 6mg/kg IV, then 0.4-1.0mg/kg/hr, prn (caution: hypotension) or Terbutaline 0.25-0.5mg IM/SC.
* Call code team for severe bronchospasm (or O2 sat <88% persists).
Patient get contrast for angio
develops hypotension with tachycardia.

Treatment?
* Legs up 60+ degr or T-burg.
* Monitor: EKG, pulse ox, BP.
* O2 6-10 L/min (by mask).
* Bolus large volumes of NS.
* If poor response, Epi (1:10000) slow IV 1.0cc; Repeat prn, max 10cc.
* If still crashing, transfer to ICU
Treatment for Hypotension with Bradycardia (Vagal Reaction) following injection
⬢ Monitor VS.
⬢ Legs up 60+ degr or T-burg
⬢ Secure airway; O2 6-10 L/m by mask
⬢ IV access; bolus NS.
⬢ Atropine 0.6-1.0mg IV slowly. Up to 0.04mg/kg max
Treatment for severe hypertension following injection
• Monitor EKG, pulse ox, BP
• NTG 0.4mg SL (may rep x 3), or 2% paste, 1” strip
• Na nitroprusside- dilute w/ D5W; watch for fast drop in BP
• For pheo – phentolamine 5.0mg (1.0mg kids) IV
Treatment for seizure following injection
⬢ O2 6-10 L/m mask
⬢ Consider Valium 5mg or Versed 2.5mg IV.
⬢ Neuro consult, consider Dilantin if need longer dur
⬢ Monitor VS, airway, consider code
Treatment for pulmonary edema following injection
• Elevate torso; rotating tourniquets (venous compr)
• O2 6-10 L/m mask
• Diurese – Lasix 40mg IV, slow push
• Consider morphine, corticosteroids
Foreign body retrieval:
what do you use?
* snare, basket, retractable forceps
* IN heart - pigtail to get out of heart then snare
Coagulation correction before procedure when patient is on:
-heparin
-coumadin
-aspirin
~heparin – stop 3-6 hrs prior, or protamine IV just pre
~coumadin – vit K for 3 days, or FFP just pre
~aspirin – stop 1 wk, or plts in minutes
Traumatic aortic injury
* isthmus 95%, root, hiatus
* CXR – wide mediast, loss aortic contour, L apical cap, NGT -> R, L bronchus -> down, high rib fxs, hemothorax
* CT – mediastinal hematoma gets angio
* angio – intimal tear (linear filling def, irreg aortic contour), pseudoaneurysm, ductus diverticulum is smooth & broad-based
Takayasu’s arteritis:
-typical patient
-what vessels are involved
* Young females
* stenoses of arch vessels most common, stenosis of aorta, thick aortic wall
* PA involv in 50%, abd aortic coarctation and RAS, aneurysms
Giant cell arteritis:
-typical pt
-how diagnosed
-what's involved / spared
* older pts >50, dx by bx temporal art
* involves ECA branches, aorta and prox brachiocephalic branches usu spared
* subclavian, axillary, brachial involv in 15%
AAA
* 90% infrarenal, diam >3cm
* incr risk rupture >5cm
* assoc w/ popliteal aneurysms
* Cx – rupture, aortocaval fist, aortoenteric fist, distal embolization, infection
Endoleaks
Type 1 - distal or proximal attachment
Type 2 - (MC) via IMA or lumbar branches
Type 3 - Fabric tear/disconnect
Type 4 - Graft porosity
Type 5 - other/???
Abdominal aortic coarctation
*young adults / kids
*congenital coarctation, Williams syndr, rubella, NF
*acquired – Takayasu’s, FMD, radiation
*segmental most common, usu involves renal arteries
Williams syndrome
*supravalvular aortic stenosis
*peripheral PA stenosis
*diff coarct of abdominal aorta & stenosis of visceral branches
Aortoiliac occlusive disease:
main syndrome
collateral pathways
*Leriche syndr ♂– butt claudication, impotence, weak femoral pulse
*Collaterals
-internal mamm -> EIA via sup & inf epigastrics
-IMA -> IIA via hemorrhoidal
-intercost/lumbar -> EIA by deep circumf iliac
-intercost/lumbar -> IIA by iliolumbar & glut
Mesenteric collaterals and sources of rectal arteries
*celiac to SMA – arc of Buehler &pancreaticoduodenal arcade
*SMA to IMA – middle colic -> L colic, arc of Riolan, marg art of Drummond
*IMA to IIA – via superior hemorrhoidal
*rectal arcades – sup rectal from IMA, mid rectal from IIA, inf rectal from pudendal
Median arcuate ligament syndrome
* occlusion of prox celiac artery by median arcuate ligament
*accentuated on expiration, best detected on lateral proj
Upper GI bleeding:
Sources and tx
*gastritis most common, PUD, varices, MW tear
*LGA > GDA
*tx – vasopressin, gelfoam, PVA or coils for major arterial injury
*rich collateral supply
Lower GI bleeding:
Sources
Treatment
How to use vasopressin?
* Tics most common. Angiodysplasia, colon CA, polyps, IBD, rectal dz
* nucs study to screen
* inject SMA, IMA, celiac
* tx – gelfoam, vasopressin, coils (used less b/c less collat)
*vasopr - 0.2 U/min x 20 min, repeat angio, 0.4 U/min x 20 min if still bleed, repeat angio
* embolization or surgery if still bleeding, when bleeding controlled slow taper over 24 hrs
Mesenteric ischemia:
Causes
Treatment
*Nonocclusive more common - Atheroscl + low flow state
*Arterial occl- emboli, clot, dissect, vasculitis
*Mechanical- hernia, volvulus, intussusc
* tx – thrombolysis if acute & no bowel ischemia, surgery if bowel ischemia
- nonocclusive - papaverine IA 25-50 mg/hr
Angiodysplasia:
-where does it occur
-what is seen on angio
*cecum/R colon
*vascular tuft - antimesent border
*early /persist draining vein
*active bleeding usu not seen
Portal HTN:
Definition
Causes
Results
*wedge – IVC pressure > 5mmHg
*causes – PV thromb, Schistosoma, cirrhosis, Budd-Chiari, HV or IVC occlusion, AVM
*collat – gastroesoph, mesenteric, perisplenic, periumb, hemorrhoids
*ascites, splenomeg, portal collat (cavernous transform), recanalized periumb vein or hepatofugal flow
PV thrombosis:
Causes
idiopathic
HCC, panc CA, mets
post-op
coagulopathies, sepsis
pancreatitis, cirrhosis
portal HTN
Budd-Chiari syndrome:
Causes and signs
* HV thrombosis, tumor in HV or IVC (RCC, HCC, adrenal)
* spider web hepatic vns, IVC narrow, stretched straight hepatic art
Renal artery stenosis:
Causes
Treatment
* athero > FMD, NF, arteritis (Takayasu, PAN, abd Ao coarct)
* athero - older pt, proximal artery
* FMD – medial fibroplasia most comm, mid-dist renals > ICA or vertebrals
* PTA success- Ostial 50%, midRA 80%
* PTA - control HTN or preserve renal function
Renal artery aneursym:
Causes
* FMD and atherosclerosis common
* Also NF, AML, LAM, mycotic
* intraparenchymal – PAN (microaneurysms), speed kidney, IVDA, Wegener's
Renal vein thromosis:
Causes
KIDS – dehydration, sepsis, maternal DM, Wilms
ADULTS – membranous glomerulonephritis, CVD, DM, trauma, thrombophlebitis, RCC
Hyperreninemic HTN:
Causes
Low renal perfusion- athero, FMD
Renin-secreting tumor
Renal compression- Mass, cyst, bleed
Pulmonary arteriogram:

indications and cautions
Indications:
* PE (int prob V/Q, low prob w/hi clinical susp, contraind to anticoag)
PAH, pseudoaneurysm
AVM (a/w OWR; feeding art, drain vn, tx coils)
*Need pacer if LBBB, Check RA pressur (nl PAsys<30)
Cx- acute R ht failure, arrythia, death
Bronchial artery angiogram
-Indications
-Anatomy
-materials used to embolize
-Cx of embolization
*Indic – hemoptysis (TB, CF, CA)
*arise from T4-T7 posterolat
*embolize w/ gelfoam, PVA, coils
*Cx – spinal artery injury, pain
LE atherosclerotic aneurysmal dz:
-where?
-associated with?
-Cx?
*pop artery most common
*pop > iliac > femoral
*bilateral in 50%, assoc w/AAA
*distal emboliz and/or thrombosis
Buerger’s dz:
typical pt & presentation?
location
appearance
*M smoker 20-40 w/claudication
*calf & foot vessels most common
*abrupt segmental arterial occlusions, multiple corkscrew collaterals
Popliteal artery entrapment:
who?
signs
*young athletes
*narrowing or occlusion on plantar flexion.
May-Thurner syndrome:
R common iliac artery compresses L common iliac vein -> DVT
IVC filters:
Indication
Size criteria
How placed, and where?
*contraind or failure or complication of anticoag
*Bird’s nest for IVC > 28-40mm
*Meditech, Simon nitinol may be placed via brachial vein
*place below renal veins
*suprarenal if infrarenal clot or pregnancy w/IVC compression
*duplication IVCs may need filter in each
*retro or circumaortic LRV – place below most inferior renal vein
*can do bilat iliac if no room
Upper extremity vascular disease:
Causes, what do you see, tx
* athero, vasculitis, emboli, trauma, iatrogenic, RTX
*thoracic outlet syndrome – compression of brachial plex or subclav vessels, seen w/ hyperabduction
*tx is surgical if mechanical compression (e.g. cervical rib)
Hypothenar hammer syndrome:
*occlusion or pseudoaneurysm of ulnar artery as it crosses over hamate from repetitive trauma
*can result in distal embolic occlus, Raynaud’s phenomenon, improves with priscoline
Subclavian steal syndrome:
Causes, signs
*narrowed / blocked subclavian art. prox to origin of vertebral
*retrogr flow in vertebral, L>R
*athero (#1), trauma, aneur, embolism, thor outlet syn, vasculitis, tumor, RTX, congenital
* most asx; can get vertebrobasilar insuff or arm claudication
Aneurysm:
Causes and types
*athero – abd aorta most common, desc thoracic Ao, peripheral vasc (pop > iliac > fem)
*infection- mycotic (bacterial), syphilis
*inflamm – Takayasu’s, giant cell, PAN
*congenital – Marfan, Ehlers-Danlos, FMD, NF
Ischemia:
Types and causes
ARTERIAL- dissect, embo, thrombosis, thromb aneurysm, vasculitis, compression, drugs
VENOUS- thromb (phlegmasia cerulea dolens)
LOW-FLOW- Hypovolemia, shock
Peripheral vascular disease:
Types and causes
*athero (occlusive, aneurysmal, small vessel in diabetics)
*embolic (thromboemb, cholesterol emb, plaque emb)
*vasculitis
*Buerger’s disease
*medication
Emboli:
Types and causes/sources
*cardiac – AFib, recent MI, ventric aneur, endocarditis, tumor (myxoma)
*athero – aortoiliac plaque, aneurysm (AAA, popliteal)
*paradoxical emboli (R->L shunt) + DVT
Angiographic tumor features
BEDPAN
Blush
Encasement of arteries
Displacement of arteries
Puddling of contrast
A-V shunting
Neovascularity
Hypervascular lesions:
Distinguish between collaterals, AVM, and tumor neovascularity
*AVM – early draining vein, no mass effect
*lotsa collaterals – no early draining vein, no mass effect
*tumor neovasc – early drain vein in AV shunt, mass effect from tumor
Aortic enlargement:
*aneurysm
*dissection
*poststen dilat due to turbulence (coarctation, Ao valv dz, sinus of valsalva aneur)
Aortic stenosis:
*Congenital – coarct, pseudocoarct
*Williams syndr- supravalvular Ao stenosis
*Rubella syndrome
*Aortitis – Takayasu’s (most comm aortitis to cause stenosis)
*Neurofibromatosis
*Radiation
Pulmonary artery stenosis:
*Williams synd (infantile hypercalcemia)
*Rubella syndrome
*Takayasu’s arteritis
*Associated with CHD (esp tetralogy)
Renal tumors vascular features
*RCC – 80% hypervasc, neovascularity, AV shunts, parasitization
*AML – aneurysms, fat content
*oncocytoma – spoke wheel in 30%, most hypovascular
DDx for suspected angiodysplasia in the bowel
* Angiodysplasia
* Hemangioma
* Arteriovenous malformation
* Hereditary hemorrhagic telangiactasia
Causes of splenic artery aneurysm
* Pancreatitis
* Pregnancy
* Portal HTN
* Splenomegaly
* Orthotopic liver transplant
* Medial fibrodysplasia
* PAN
* Subacute bacterial endocard

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