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Potential aortic abnormalities
- •Trauma (Penetrating, blunt with transection, flap tear, hematoma)
- •Vasculitis (Takaysu's, infection, Giant cell arteritis)
- •Aneurysm (Atherosclerotic, infection-syphillis-higher up, CVD-Marfan's-base of aorta)
- •Dissection (Ehlers-Danlos, ASVD)
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Most common places to get traumatic aortic injuries
- 1. Isthmus - arch just past left subclavian takeoff
- 2. Hiatus - desc aorta as it goes through the diaphragm
- 3. Ascending aorta
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DDx: Thickening of the aorta
- Vasculitis - TIGeR is the main
- T
akayasu’s arteritis - Infection
- Giant cell (temporal) arteritis
- Radiation
- Beçhet’s disease
- Connective tissue disorders
- -Rheumatoid arthritis
- -Ankylosing spondylitis
- -Reiter’s syndrome
- -Psoriatic arthritis
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Sinotubular aneurysm of the aorta
Marfan's Syndrome
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Infections of the aorta
- Syphillis = eggshell calcs, ascending aorta not affecting sinotubular portion like Marfan's
- Salmonella = mycotic
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Treatment for aortic dissection
- Ascending - surgery
- Descending - medical usually, but occ stent grafting
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Potential pulmonary artery problems
- •Embolism - Tx prefered medical and IVC filter/ sometimes need catheter-direct thrombolysis if hemo unstable
- •Arteriovenous malformation - Tx coil - Assoc. with OWR/HHT - can result in abscess
- •Aneurysm - TB, Iatrogenic, Behcet's
- •Stenosis
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Indication for bronchial artery embolization
- HEMOPTYSIS
- -CF
- -Lung Cancer
- -TB
Rarely acutally see a bleeding site
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During bronchial artery embolization you see a fine hairpin turn vessel
Anterior spinal artery - injecting particles if this is seen can cause paralysis
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Management for type II endoleak
- Surveilance
- 75% will resolve on their own
- If not, then need embolized
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Management of type I, III or IV endoleak
- Cannot use surveilance,
- Either reline the graft or open surgical repair
- I and III are high pressure and need urgent repair
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If you see a AAA repair graft, a leak and the kidneys in the same image?
Most likely a type I endoleak
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Odd saccular aneurysm at aortic bifurcation to iliacs is what until proven otherwise?
Mycotic
- DDx:
- –Inflammatory
- –Chronic pseudoaneurysm
- –Radiation therapy
- –Surgical
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Indications for stent placement
- A.Greater than 30% residual stenosis after angioplasty
- B.Flow limiting dissection flap
- C.Residual pressure gradient > 5 mm
- D.Eccentric lesion
- E.Calcified lesion
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58 yo male with impotence and bilateral hip and thigh claudication, impotence.
Abd aortagram shows abrupt cutoff of infrarenal aorta with extensive collaterals.
- Leriche’s syndrome
- Tx - surgical bypass
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Treatment of a pseudoaneurysm of the common iliac?
Covered stent angioplasty
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Treatment of pelvic fx bleed
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Do not embolize intracavitary fibroid over what diameter?
3cm
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One thing that can lead to failure of UAE
Collateral supply from the ovarian artery
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Marginal artery of Drummond seen?
Either SMA or IMA is occluded and MAD is the collateral pathway
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Opacified vessel seen in anterior abdomen?
Recanalized umbilical vein due to portal HTN
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Small or nonvisible splenic vein with gastric wall varices
SVT/occlusion from pancreatic process (i.e. cancer or pancreatitis)
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Treatment for bleeding diverticulum
microcatheter embolization
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If GI bleed is present and angiodysplasia is seen in the IMA territory, what must also be assessed?
Celic and SMA must also be assessed for involvement
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Tx for pseudoaneurysm of splenic or intraabdominal vessel
Coils
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Diffuse small nodular aneurysms usually in kidneys, but can involve liver and other
polyarteritis nodosum
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corkscrew small artery extending beyond normal SMA blood supply
Meckel's diverticulum
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GI bleed with history of AAA repair
Think of aortoenteric fistula
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Where should you coil for GI bleed?
Proximal AND distal to the bleed
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Treatment for young post-partum female with NOMI of SMA distribution
Papavarine infusion into SMA
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Treatment of splenic vessel bleed
- +Acute setting with diffuse injury.–Proximal Occlusion (main splenic artery emb.)
- •Acute setting with focal extravasation.–Target Occlusion.
- •Delayed setting with focal abnormality.–Target Occlusion.
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Treatment for hypersplenism with tortuosity of the splenic vessels
- Particle embolization placing catheter distal to dorsal pancreatic artery and pancreatic magna arteries to avoid non-target embolization
- 50% reduction in flow is goal
- Potentional complication later = infection with encapsulated organsims
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Tx of choice for splenic artery aneurysm
- Coil into aneurysm
- Trap the aneurysm
Only trap a pseudoaneurysm
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Potential abn if splenic artery seen
"THAT"
- Trauma
- Hypersplenism
- Aneurysm
- Tumor
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Treatment for hepatoma (HCC)
Particles or particles and cytotoxic agent into the target vascular bed
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Things to do prior to embolization of liver lesion
- Ensure portal vein is patent
- Avoid cystic artery
- Avoid gastroduodenal artery
- Analagesia
- Antiobiotics
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Indications for transjugular biopsy status post liver transplant
rOACH
- -rejection
- –Obesity
- –Ascites
- –Coagulopathy
- –Hepatic venous pressures
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Which directions to do transjugular biopsy for liver with which vessel?
"RAMP"
- Right HV Anterior
- Middle HV Posterior
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"Aunt minnie" spider vessels related to occlusion of hepatic vein seen on angiogram
Budd-Chiari
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Indications for TIPS
- Refractory ascites
- Bleeding varices
- Hepatorenal syndrome
- Cirrhotic hydrothorax
- Budd chiari
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Contraindications for TIPS
- Severe Hepatic Failure
- Right Heart Failure
- Encephalopathy
- Portal Vein Thrombosis
- Hepatic Neoplasm
- Polycystic Liver
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Goal for TIPS procedure
Get the PV-RA pressure gradient above 4mm Hg and less than 12mm Hg
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Interventional management of a pancreatic psuedocyst
- Should resolve spontaneously
- Only drained if very large or symptomatic
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Common ablative therapies
- •Heat: RF, microwave, laser
- –Hepatic tumors
- –Osteoidosteoma
- •Cold: Cryoablation
- –Enhancing renal tumors
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Where to target for percutaneous nephrostomy?
Lower pole posterior calyx (less chance of bleeding or PTX)
Ideally at “Brodel’s bloodless line” (junction between medial 1/3 and lateral 2/3)
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