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Richie's Cards: Interventional Radiology
Terms in this set (54)
A. Brachial artery
F. Anterior Interosseous (also a posterior)
C. Deep palmar branch (from radial artery)
D. Superficial palmar (from the ulnar artery)
F. Digital branch
1. Indirect: deep and superficial ring of the inguinal canal->into the scrotom. 5 x more likely to incarcerate than direct types and are usually treated surgically.
2. Direct: through the floor of Hesschels triangle lateral to the lateral rectus and aove the inguinal canal
Indirect versus direct inguinal hernias?
1. The veins are always posterior.
2. For example, the common iliac vein is posterior to the common iliac artery
In the pelvis, are the veins anterior or posterior to the arteries?
1, klippel trenaiuny feil
2, splenic hemangiomas ,vericose veins, hemihypertrophy
what is the standard contrast flow rate for an aortogram?
2. (another option is to place an SVC filter)
best approach for placing IVC filters in a patient with a double IVC?
2. In the acute phase, patient's with Takayasus should recieve immunosuppresive therapy or surgical intervention, not interventional radiology procedures.
1. True or false, a patient should be treated by interventional radiology procedures to open up a stenosis in a patient with ACUTE takayasu's?
1. Arterial angiogram: 20-40 seconds
2. Venous: 180 seconds
1. At what time are images obtained during the arterial angiographic phase?
2. What about the venous phase?
1. lesser: left gastric off the celiac
2. lesser: right gastric off the proper hepatic
2. greater: right gastroepiploic off the GDA
3. Left gastroepiploic off the splenic
1. name the vessels along the lesser and greater curvature of the stomach
1. I like sex:
3. superior rectal
1. name the branches of the posterior division of the internal iliac arter
1. inferior pancraticoduodenal
2 . middle colic
3. right colic
5. duodenal and ileal branches
1. name the branches of the SMA
1. left colic
3. superior rectal
name the branches of the IMA
1. Anterior: vertical
2. Posterior: more horizontal
1. How can you tell the anterior from posterior divisions of the right hepatic duct?
1. Right anterior, right posterior, right main
-more anterior than the right sided ducts
describe the biliary tree anatamy
1. Right posterior can join the left main duct instead of the Right hepatic duct
1. Variant anatamy of the bile ducts
1. 21 or 22 gauge Chiba needle
2. 5-6 french sheath
3. 035 guidewire (need both a soft one and a stiff Amplatz one)
4. 5 french Kumpke catheter
5. 8 french fascial dilator
6. 8 french external drainage catheter (pigtail )or an 8 french internal/external biliary drain (has multiple sideholes)
*radiopaque ring on the biliary drainage cather demarkates the most proximal sidehole
2. type of needle and size of sheath, guidewire, catheter and dilator
1. patient is supine
2. right mid-axillary approach 9-11th intercostal space
3. advance needle parallel to the table and towards T12
*right side is preferred over left but left has a lower risk of biliary leak into peritoneum
1. Patient supine
2. Subxiphoid or subcostal approach
3. Segment 2 duct preferred (forms less of an acute angle with left main duct)
4. segment 3 duct drains more vertically
biliary drain access for the right versus left lobes?
1. Transhepatic (preferred) or trans-peritoneal(preferred if bleeding diathisis or liver disease)
2. transhepatic: right midaxillary line, aim for the bare area of the gallbladder (superior 1/3)-this keeps the catheter extraperitoneal* and limits risk of bile peritoneitis in case of leak
3. transperitoneal: subcostal mid clavicular line->aim towards the gallbladder fundus. takes longer for this approach to have a mature tract
access for percutaneous cholecystostomy
1. bilateral or larger lobe
choice of drainage if there is obstruction at the confluence of the biliary tree
1. tract must have matured (takes 2-3 weeks), longer in transperitoneal approach
2. if you see a leak then it means the tract is not mature
3. patent cystic and common duct
4. clinically improved (decreased WBC, fever)
indications for removal of the GB tube
1. within the GB lumen
optimal placement of the drainage catheter in a cholecystostomy tube placement
1. The needle is initally placed within a peripherally dilated intrahepatic duct
2. Then the guidewire is placed within the bowel securing access
3. lastly the drainage catheter is placed in the bowel
optimal placement of the biliary drain tip for internal drainage?
1. first you must place bilateral biliary drains
2. need bilateral stents which you deploy within the right and left ducts and extend them into the common duct
3. other option is a T congifuration stent that can be placed via unilateral access
Biliary stents procedure when there is blocakage of the confluence
1. dilated ducts: 95-100&
2. non-dilated: 65-80%
Name the technical success rate of the following:
2. PTBD/PTC non--dilated
3. Cholecystostomy tube
Name the complication rate of the following procedures:
1. cholecystostomy tube
1. hemobilia/pseudoaneurysm: most feared
4. dislodged catheter with intraperitoneal bile leak
complications of percutaneous biliary tree procedures
1. bile peritonitis-most common
2. dislodged catheter->obtain CT to assess for biloma.If bile leak or sepsis consider rescue of the tube.
3. bowel perf-most feared (due to interposition of the colon near the liver
4. Injury to hepatic artery, vein, portal vein->subcapsular hematoma
complication of chocystostomy
1. maintain balloon inflation for one minute
2. Perform a total of 3 dilations in each treatment session
3. 3 treatment sessions, each 1-2 weeks apart
describe the following proceedure: baloon dilation of a biliary stricture
1. it should extend 2-3 cm proximal and distal to the stricture
2. it can be placed within the bowel at its distal part
3. these stents will shorten as they are expanded
describe the proper placement of a biliary stent
1. failed ERCP
2. Patient has prior surgery making ERCP not possible
indications for imaging the biliary tree over ERCP
1. acute calculous and acalculous cholecystitis, sepsis of unknown origin, percutaneous biliary access when transhepatic method unsuccessful
indications for placement of a cholecystostomy tube
1. GB tumor that might be seeded
2. GB packed with stones
relative contraindications to performing a cholecystostomy
1. Severe right heart failure
2. Biliary sepsis
3. Gastric varices with an occluded splenic vein
Name the absolute contraindications for TIPS
1. Anterior tibial artery is the most lateral vessel in the leg
2. Lateral at the ankle
3. After crossing the ankle joint it becomes the dorsalis pedis artery
1. Brachiocephalic -> Subclavian
Subclavian -> axillary artery
3. 1st letter- lateral margin 1st rib
Axillary artery->Brachial artery
5. Lateral margin
7. Antecubital fossa: Radial & Ulnar arteries
8. Radial->Deep Palmar Arch
9. Ulnar-> Superficial Palmar Arch
Landmarks for the arteries of the upper extremity
1. Common Iliac -> External Iliac
2. Takeoff of the Internal Iliac
3. External Iliac -> Common Femoral
4. Inguinal Ligament
5. Common Femoral -> Superficial Femoral
6. Profunda Femoris
(has more branches than SFA)
7. Superficial Femoral->Popliteal
8. After leaving the Adductor canal via the adductor hiatus
9. Popliteal->Tibio-peroneal trunk & Anterior Tibial
10. Anterior Tibial is the most lateral (lATeral)
11. Tibioperoneal trunk-> Peroneal artery
12. (*Peroneul-perineum is located in-between your thighs)
13. Posterior tibial is most medial
14. PT travels behind the Medial Malleolus
15. Terminates as the Medial & Lateral Palmar Arteries
Anatomic landmarks for the lower extremity arteries
Tom Dick And Nervous Harry
1. Tibialis Posterior
2. Flexor Digitorum Longus
3. Posterior Tibial Artery
4. Vein, Nerve
5. Flexor Hallicus longus
Contents of the tarsal tunnel from anterior to posterior behind the medial malleolus?
Tom Hates Dick
1. Tibialis Anterior
2. Extensor Hallicus Longus
3. Extensor Digitorum longus
Ligaments of the anterior ankle?
Posterior tibial Artery
1. Profunda Femoris
2. Has more branches than the superficial femoral artery
3. Supplies the femoral head via the circumflex artery.
From Lateral to Medial:
Which arteries in the lower extremity can be found medially and which can be found laterally?
2. Lateral rectus
1. Splenic Artery Embolization
2. Distal to the
3. Gelform of Polyvinyl Alcohol
4. End at 50-70% reduction
5. Pre and post embolization
6. Pneumococcal vaccine
7. Major complication is post-embolization sepsis and infection
1. What is the IR guided treatment for hypersplenism?
1. Type 1A or 1B: Leak is located at the top or the bottom of the graft and is under high pressure requiring intervention
2. Type 3 leak: defect or fracture in the graft
Which types of aortic endovascular graft leaks require urgent repair?
Relative contraindication for IVC filter placement?
1. Type IA (prox) or IB (distal): Due to poor approximation, usually fixed in surgery.
*Type one is in the OR
2. Type 2 is Tributary veins
3. Type three is from a terrible crack
4. Type four is from the pour : Porous graft material
Name the types of endovascular graft leaks
1. Portal venogram via access of a TIPS
2. Right IJV->SVC->RA->Right HepatiC Vein->Right Portal Vein->Splenic Vein
Portal system is made up of the superior mesenteric and splenic veins (S and S)
1. Which vessels contribute to the main portal vein?
1. Branches of the Posterior Division of the Internal Iliac
2. Internal Iliac Anterior Division Branches: I <3 U SUMO
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