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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
*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
one leg runoff
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
standard length
standard length - 145
diameters - 0.018 - 0.038 inch
Types - Newton J, Rosen, Amplatz, Bentson, Glide
Pharmacologic angio therapy:
– 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
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)
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
Indications for TIPS
portal HTN & variceal bleed failed sclerotherapy,
refractory ascites,
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
shunt thrombosis or stenosis
R heart failure
renal failure
Preprocedure meds/prep:
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
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.

* 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 – 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%
* 90% infrarenal, diam >3cm
* incr risk rupture >5cm
* assoc w/ popliteal aneurysms
* Cx – rupture, aortocaval fist, aortoenteric fist, distal embolization, infection
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
-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
*tx – vasopressin, gelfoam, PVA or coils for major arterial injury
*rich collateral supply
Lower GI bleeding:
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:
*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
-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:
*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:
HCC, panc CA, mets
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:
* 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:
* FMD and atherosclerosis common
* Also NF, AML, LAM, mycotic
* intraparenchymal – PAN (microaneurysms), speed kidney, IVDA, Wegener's
Renal vein thromosis:
KIDS – dehydration, sepsis, maternal DM, Wilms
ADULTS – membranous glomerulonephritis, CVD, DM, trauma, thrombophlebitis, RCC
Hyperreninemic HTN:
Low renal perfusion- athero, FMD
Renin-secreting tumor
Renal compression- Mass, cyst, bleed
Pulmonary arteriogram:

indications and cautions
* 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
-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:
-associated with?
*pop artery most common
*pop > iliac > femoral
*bilateral in 50%, assoc w/AAA
*distal emboliz and/or thrombosis
Buerger’s dz:
typical pt & presentation?
*M smoker 20-40 w/claudication
*calf & foot vessels most common
*abrupt segmental arterial occlusions, multiple corkscrew collaterals
Popliteal artery entrapment:
*young athletes
*narrowing or occlusion on plantar flexion.
May-Thurner syndrome:
R common iliac artery compresses L common iliac vein -> DVT
IVC filters:
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
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
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)
*Buerger’s disease
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
Encasement of arteries
Displacement of arteries
Puddling of contrast
A-V shunting
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:
*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)
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
* Subacute bacterial endocard

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