====== Post-Traumatic Vascular Injury ====== ===== CXR Signs ===== * wide mediastinum * filling in of AP window * depressed L mainstem * rightward displacement of trachea or NG tube * L apical cap * L effusion * L upper rib fxs ===== Most Common Locations for TAI ===== * Aortic root * Isthmus * Aortic hiatus ===== Classification of Dissections ===== | |{{db1.png}}|{{db2.png}}|{{db3.png}}| | Percentage | 60% | 10-15% | 25-30% | | DeBakey | I | II | III | | Stanford | A || B | | | Proximal || Distal | ====== Aortic Aneurysms ====== * CT signs of impending rupture * high attenuation crescent between intraluminal thrombus and the wall ====== Types of Endoleaks ====== * Type 1 - bad seal @ prox/distal end * treatment is emergent * Type 2 - endoleak via IMA or lumbar collaterals * Type 3 - leak thru internal seal * Type 4 - porosity of graft * resolves spontaneously * Type 5 - endotension * sac not getting smaller, but no leak ====== Takayasu's ====== * dilation or irregularity of the ascending aorta * narrowing of the descending artery * long stenoses or occlusions of arch vessels (especially the subclavian) * CT/MR show enhancement of the artery wall in the acute phase * angioplasty and stent should be delayed until the disease is inactive if possible * Type 1 -> stenoses of aortic arch and branch vessels * Type 2 -> descending thoracic and abdominal aorta + abdominal branches * Type 3 -> aortic arch plus abdominal aorta * Type 4 -> pulmonary artery and aorta ====== Giant Cell Artieritis ====== * affects older women, and usually involves the temporal artery * involves the distal subclavian or axillary arteries, but not the brachiocephalic, common carotids or proximal subclavians * lesions are long and smooth ====== DDx Midaortic Stenosis ====== * Midaortic stenosis * noninflammatory nonatheromatous vascular d/o * can cause renal artery stenosis * Takayasu's * Radiation induced * Neurofibromatosis ====== Aortic Occlusion ====== ===== Collateral Pathways ===== ===== Contraindications ===== * recent surgery (intracranial, abdominal, or thoracic) * recent GI bleed * recent stroke or CNS neoplasm * recent major trauma * pregnancy * severe HTN * bleeding diathesis * infected thrombus ====== TIPS ====== ===== Indications ===== * variceal bleeding that cannot be treated medically (acute or chronic) * intractable ascites ===== Contraindications ===== ==== Absolute ==== * polycystic liver disease * severe R heart failure * severe hepatic failure ==== Relative ==== * severe hepatic encephalopathy * hypervascular liver tumor * portal vein thrombosis * severe acute infection ===== Technique ===== * Do u/s first to assess PV patency, flow direction, status of hepatic veins, degree of ascites, and eval for liver tumor * Check coags and correct w/ FFP * Broad spectrum antibiotics * 10Fr sheath RIJ and assess RA and IVC pressures * Measure wedged hepatic vein pressure which will equal PV pressure, subtract the IVC pressure to get gradient * Insert needle * Opacify the portal vein via a wedged contrast injection * Stick the needle anteromedially into the right portal vein * Needle is then withdrawn a bit until you get blood back * Inject contrast to check your position * Advance a guidewire into the PV and then to the splenic vein or SMV * Dilate the parenchymal track with a 10mm balloon * Place 10 or 12 mm Wallstent so that one end is within 3 cm of the portal bifurcation, and the other within 3cm of the IVC * Dilate tract with a 10mm balloon * If gradient remains (>12mm Hg), redilate w/ 12mm balloon * If gradient persists, can employ parallel stent or embolize varices ====== Paget-Schroetter Disease ====== * Best seen w/ provocative maneuver such as hyperabduction ===== Causes ===== * cervical rib * congenital fibromuscular bands * 1st rib anomalies * muscle hypertrophy * clavicle fxs ===== Management ===== * If severe or pt has embolization, then correction of underlying abnormality is recommended ====== Colonic bleed ====== * Causes of lower GI bleed: * diverticular dz * angiodysplasia (dilated submucosal veins and capillaries in the bowel wall) * post biopsy or polypectomy * tumors * polyps * IBD * ischemia * Patients with a positive Tc RBC or SC scan should undergo angio * Sensitivity: * angio - 0.5cc/min * Tc RBC - 0.1cc/min * Most likely vessel, based on nucs scan, should be injected 1st * Otherwise SMA then IMA, and if both negative, then celiac * In angidysplasia, a bleeding vessel is usually not seen * instead, you see early venous drainage from one portion of the bowel, or a tram track sign from simultaneous opacification of a feeding artery and draining vein * Treatment: * vasopressin - 0.2 units per minute * after 30 minutes a repeat angiogram is done, the infusion is continued at that rate with the pt in ICU * if persists, increase to 0.4u/min and repeat angio in 30 minutes * if still bleeding, need to pursue other methods * rebleeding is common * Contraindications: severe coronary artery dz, severe HTN, dysrhythmias, bleeding at sites with a dual blood supply, bleeding directly from a large artery (eg spl artery aneurysm) and after embolotherapy * Side effects: bowel ischemia, angina, arrythmia, HTN, bradycardia, and allergy * embo - performed with macrocoils or microcoils and gelfoam * embo usually does not work long term for angiodysplasia or AVM, these will require surgery * placed distally in the arcades proximal to the bleeding vasa recta to minimize intestinal ischemia * inject the proximal vessel to make sure there is no bleeding thru collaterals * complictions include bowel infarct <20% ====== Pulmonary Embolism ====== * Primary finding - intraluminal filling defect at least partly surrounded by contrast * Secondary signs - vessel cutoff, regional hypoperfusion, pruning of vessels, slow flow, and filling of collaterals ===== Technique ===== * check for LBBB & use pacer if present * also check u/s for groin clot * check PA pressures before injecting main PA; cut back on injection if pressures are elevated ====== Transhepatic Cholangiogram ====== ===== Procedure ===== * Start w/ antibiotics to include gram negative coverage - one hour prior to any biliary work * Right sided approach: * 22G Chiba needle is placed in the midaxiallry line below the 10th rib (to avoid the pleura) * fluoro is used to check the position of the pleura in full inspiration, so that it may be avoided * needle is passed over a rib, to avoid injury to the nerves and vessels which run on the undersurface * needle is directed toward a plane parallel to the table top aimed toward T11 * remove the stylet and inject 0.1cc of 60% strength contrast while slowly retracting the needle * when contrast fills a tubular structure and stays there, you are likely in a bile duct, and you should remove 5-10 cc of bile and send for gram stain and culture * then inject an additional 5-10cc contrast to confirm and determine duct diameter and location relative to porta hepatis * Left sided access: * from a left subcostal approach in the epigastrium * US is used to access a bile duct while avoiding artery and portal vein * Treatment: * pass a 0.018 wire thru the chiba needle you used for the THC, then exchange for a .038 wire, and advance a catheter over that wire * a dominant proximal stricture can be angioplastied * stents can be used for malignancy b/c the pts life expectancy is short and the stent will likely last as long as the pt needs * for benign dz, stents should only be used for pts who are not operative candidates and who failed angioplasty * a wallstent is the stent of choice ====== IVC Filter ====== * ===== Contraindications ===== * IVC thrombosed * pregnancy (clot may come from ovarian veins) * place suprarenal filter ====== Nephrostomy ====== ===== Technique ===== * check labs; stop anticoagulants * prophylactic antibiotics 1hr preprocedure (ancef 1g and gentamycin 80mg or specific to the organism) * place pt prone and select puncture site (4 fingers from midline, just below 11th rib) * start by puncturing collecting system with a 22G Chiba needle and opacifying collecting system * aspirate urine for culture and remove urine before injecting contrast to minimize sepsis risk * choose best entry site under fluoro: * for simple decomression, it is safest to puncture a lower pole calyx b/c that has the lowest risk for PTX * if ureteral stent placement is planned, then go for an interpolar calyx to get an easier angle to get the catheter down the ureter * puncture at least 12 cm lateral to midline in order to avoid going thru paraspinal muscles * puncture a posterior calyx (know posterior b/c seen en face in AP plane, or can inject air) with an 18G needle * posterolateral approach, with needle angled 40 degress from vertical is best (Brodel’s avascular line) * if infected, initially just decompress, do not manipulate more until infection is treated * place a stiff amplatz .035 down into ureter * the tract is dilated, and a 10 fr pigtail is placed over the .035 wire and locked into position by forming the pigtail * secure to skin with adhesive dressing or suture. ====== Signs of Leg Ischemia ====== * hair loss * nail changes * purple toes * skin loss * ulcers ====== Sources of Hemoptysis ====== ===== Bronchial Artery ===== * Cystic Fibrosis * Infection * Bronchiectasis * Tumor ==== Technique ==== * place the catheter deep into the abnormal bronchial artery * if you can not get deep with your initial catheter, place a coaxial microcath thru it to go out deeper * findings in pts with a bronchial artery bleed include eenlarged bronchial artery, hypervascularity, parenchymal stain, amd bronchial to pulmonary artery shunting * contrast extrav is not usually seen, and is not necessary for treating * look for the small branches to the anterior spinal artery which arise form the proximal portion of the vessel and take a hairpin turn going 1st superior and then inferior toward midline * if there is a spinal artery branch, some people wont embolize, but some will embo if they can get the catheter well beyond the branch * embo agent is PVA (medium sized particles) or gelfoam * if no bronchial or collateral bleeding source is found, then you have to inject the pulmonary arteries ===== Pulmonary Artery ===== * Rasmussen Aneurysm * Pulmonary AVM * Unlike other AVM's, as there is no real nidus * Therefore, it is the only AVM where you embolize the feeding vessel * Use coils! * PA Pseudoaneurysm ====== TPA Thrombolysis ====== * Dose = 0.5 mg/hr infusion * No bolus needed ===== Contraindications ===== * Motor weakness in extremity * Do not want to perfuse dead tissue ====== Popliteal Artery Disease (ABCDE) ====== * Atherosclerotic disease / Aneurysm * Buerger's disease * corkscrew vessels * Baker's cyst * Cystic adventitial disease * cysts in vessel wall on IVUS * Dissection * Entrapment * induced by plantarflexion or forced dorsiflexion of foot * caused by abnormal relationship with medial head of gastrocnemius ====== General Technique ====== ===== Seldinger ===== * 18G - .035 wire * 22G - .018 wire ===== Stenting ===== ==== Good Locations for Covered Stents ==== * SFA * TIPS * Lacerated vessel ===== Embolization ===== * always use medium size particles * 500-700 microns ===== Vasopressin ===== * Done from origin of vessel * Usually only if embo is not possible ===== TPA Infusion ===== * place multisidehole catheter across occlusion * 2mg initial TPA bolus * then infuse 1mg/hour * f/u angiogram in 12hrs * treat residual stenosis w/ angioplasty * give heparin prior to thrombolysis * 5000U bolus then 1000U/hr infusion ====== Anatomy ====== ===== Celiac ===== {{celiac.gif}} ===== SMA ===== {{sma.jpg}} ===== Adrenal ===== {{adrenalbs.jpg|Three blood supplies to the adrenal: * superior adrenal artery from the inferior phrenic artery * middle adrenal artery form the aorta above the renal artery * inferior adrenal artery from the proximal renal artery}} Hover over image for info ===== Run-off ===== {{antro.gif|Anterior View}}{{postro.gif|Posterior View}}