• 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

• Aortic root
• Isthmus
• Aortic hiatus

• CT signs of impending rupture
  • high attenuation crescent between intraluminal thrombus and the wall

• 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

• 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

• 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

• Midaortic stenosis
  • noninflammatory nonatheromatous vascular d/o
  • can cause renal artery stenosis
• Takayasu's
• Radiation induced
• Neurofibromatosis

• recent surgery (intracranial, abdominal, or thoracic)
• recent GI bleed
• recent stroke or CNS neoplasm
• recent major trauma
• pregnancy
• severe HTN
• bleeding diathesis
• infected thrombus

• variceal bleeding that cannot be treated medically (acute or chronic)
• intractable ascites

• polycystic liver disease
• severe R heart failure
• severe hepatic failure

• severe hepatic encephalopathy
• hypervascular liver tumor
• portal vein thrombosis
• severe acute infection

• 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• Needle is then withdrawn a bit until you get blood back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

• Best seen w/ provocative maneuver such as hyperabduction

• cervical rib
• congenital fibromuscular bands
• 1st rib anomalies
• muscle hypertrophy
• clavicle fxs

• If severe or pt has embolization, then correction of underlying abnormality is recommended

• 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%

• 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

• 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

• 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 thrombosed
• pregnancy (clot may come from ovarian veins)
  • place suprarenal filter

• 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.

• hair loss
• nail changes
• purple toes
• skin loss
• ulcers

• Cystic Fibrosis
• Infection
• Bronchiectasis
• Tumor

• 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

• 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

• Dose = 0.5 mg/hr infusion
• No bolus needed

• Motor weakness in extremity
  • Do not want to perfuse dead tissue

• 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

• 18G - .035 wire
• 22G - .018 wire

• SFA
• TIPS
• Lacerated vessel

• always use medium size particles
• 500-700 microns

• Done from origin of vessel
• Usually only if embo is not possible

• 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

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