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Interventional Radiology

I. General Principles

1. Angiography complications:

A. Puncture site:

Minor hematoma (5%)

Major hematoma (0.5%)

AVF (0.05%)

Pseudoaneurysm (0.01%)

B. Contrast:

Renal failure

Cardiac failure



C. Catheter:

Cholesterol emboli



Arterial dissection

2. Guidewires:

A. General: central stiff core with distal taper

B. Length: 145 cm up to 250 cm (exchange length); OD = 0.018-0.038 inches; j-tip = radius of curvature

C. Types:


Uses/ comments


Tortuous/ diseased vessels


Large vessels (aorta, IVC, femoral)

Straight Wire



Exchanges/ PTA


Exchanges, tortuous iliac vessels


Long, flexible taper (floppy end)


Slippery hydrophylic coating (torque glide)

3. Catheters:

A. Measurements:

Fr = outer circumference in mm

Inner diameter measured in 1/1000 of an inch

Length: 65 cm for abdominal studies; 100 cm for aortic arch and carotid studies



B. Catheter types






Aorta, pulmonary


Cobra (C)

Mesenteric, renal, contralateral iliac

Simmons (S)

Mesenteric, arch vessels

Headhunter (H)

Carotid, arch vessels





Arch, carotids, upper extremity


Coaxial subselection

Van Aman/

Pulmonary angiography



C. Flow rate injections








Abdominal Aorta






C2, S2




C2, S2




S2, C2




S2, C2


Splenic/ Hepatic








Internal iliac


C2, S2


One leg runoff


Straight tip


Two leg runoff




Aortic arch





VA/ Grollman




Davis A1




Davis A1




Davis A1




Davis A1



Pharmacologic intervention:


A. Vasodilators:

Papaverine (= opiate extract): smooth muscle relaxant; 1 mg/min infusion mesenteric ischemia

Tolazoline (= Priscoline): direct muscle relaxant (α-blocker); 25 mg IA peripheral spasm

Nitroglycerin: direct muscle relaxant; 100 µg IA/ IV peripheral spasm

Nifedipine: Ca 2+ channel blocker; 10 mg SL peripheral spasm

B. Vasoconstrictors:

Vasopressin (= Pitressin): 0.2-0.4 U/min GI bleeding; contraindicated with CAD, HTN, arrhythmias; T 1/2 = 12 min

Epinephrine: renal vasoconstriction; 5 µg IA; DDX tumor from normal vessel

C. Antiplatet agents:


ASA (aspirin)

Clopidigrel (= Plavix): few side-effects; expensive

Ticlodipine (= Ticlid): liver toxicity; expensive

D. Glycoprotein IIb/ IIIa inhibitors: all very potent & expensive

Abciximab (= Reopro)

Eptifibatide (= Integrellin)

Tirofiban hydrochloride (= Aggrastat)

5. Embolization:

A. Indications:

Hemorrhage: GI bleeding; varices; trauma; bronchial arteries; tumors; post-operative

Vascular lesions: AVM, AVF, pseudoaneurysms

Preoperative devascularization: RCC; AVM; vascular bone mets

Other: hypersplenism; hepatic chemoembolization

B. Principles:

Proximal occlusion = surgical ligation control bleeding

Distal occlusion = infarction, necrosis

C. Agents:



Primary Use

Temporary Agents

Gelfoam (surgical gelatin)


Upper GI bleed; pelvic trauma; postoperative



Cut to size


Ethyl or PVA



Steel coils (micro-/ macrocoils)


Large vessel, aneurysm, tumor



High output AVF

Cyanoacrylate (= glue)



D. Complications:

Postembolization syndrome (< 10%): fever, WBC; pain; resolves within 3-4 days

Infection of embolized area

EtOH skin, nerve, and muscle infarction

6. Hepatic chemoembolization:

Palliative only; gelfoam or ethiodol mixed with chemotherapeutic agents (Doxorubicin; Mitomycin; Cisplatin)

Applications: HCC; ocular melanoma; metastatic endocrine tumors

7. Thrombolysis:

A. Indications: arterial graft thrombosis; native vessel thrombosis; HD graft; venous thrombosis (SMV, IMV, portal vein, axillo-subclavian)

B. Principles: obtain diagnostic angiogram prior to thrombolysis; tPA >> urokinase (add heparin for UK)


C. Prognosis: recent clot (< 3 months); good in-/ outflow

D. Endpoints:

No lysis after 12 hrs

Major complication: bleeding

Severe reperfusion syndrome

Progression of ischemia

E. Techniques:

Urokinase (no longer used):

Low dose: 100 x 10 3 U/hr; repeat angiogram in 12 hrs

High dose: 250 x 10 3 U/hr x 4 hrs repeat angio 125 x 10 3 U/hr

Pulse spray ultra-high dose: 600 x 10 3 U/hr in 5000 U boluses (q 30 s)

tPA (tissue plasminogen activator):

Dose: 0.02-0.05 mg/kg/hr or 1.25-2.5 mg/hr (0.5-1.0 mg/hr)

Duration: 12-24 hrs until clot resolves or complications arise

Monitor fibrinogen: > 100 mg/dl

F. Contraindications

Absolute: active bleeding; intracranial lesion (tumor; AVM; aneurysm); pregnancy; non-viable limb

Relative: bleeding diathesis; cardiac thrombus; malignant HTN; recent major surgery; postpartum

G. Complications: hemorrhage; distal embolization; pericatheter thrombosis

8. Angioplasty:

A. Indications: claudication; tissue loss; nonhealing wound/ ulcer; HD- grafts

B. Principles: premedicate with ASA + nifedipine; ipsilateral approach;

heparin (5-10 x 10 3 U after crossing lesion)

C. General balloon size:

Common iliac: 8-10 mm

External iliac: 6-8 mm

SFA: 4-6

Popliteal: 3-4 mm

D. Prognosis: large/ proximal vessel; short/ concentric stenoses; isolated disease; good in-/ outflow

E. Results:


Initial Patency

5-yr Patency









95% (FMD) > 70-90% (Atherosclerosis)

F. Complications:

Intimal hyperplasia: 3 months-1 year

Progression of disease

Distal embolization

Arterial rupture (dissection); renal infarction

9. Intravascular stents:

A. Types:


Balloon expandable: Palmaz; Gianturco zigzag stents

Self-expanding: Wallstent

Covered: Wallgraft

B. Indications: unsuccessful PTA (residual stenosis > 30%; gradient >

5 mm Hg); ulcerated lesions; renal ostial lesions; recurrent stenosis; venous obstruction/ stenosis; TIPS

C. Results:

Iliac: 5-year patency > 90%

Renal: 5-year patency > 80%

10. Transjugular intrahepatic porto-systemic shunt (TIPS):

A. Indications:

Portal HTN with variceal bleeding

Refractory ascites

Possible: Budd-Chiari syndrome; pre-transplant stabilization; hepatic hydrothorax; hepatorenal or hepatopulmonary syndromes

B. Contraindications:

Absolute: severe RHF; severe coagulopathy; multicystic liver disease

Relative: portal vein thrombosis; encephalopathy; LBBB

C. Principles:

Confirm portal vein patency (U/S; MRV)

Right IJ access preferred; obtain wedged hepatic pressure; generate tract from right/ middle hepatic vein to right portal vein; deploy metallic stent (10 mm Palmaz, Wallstent)

Goal: reduce gradient < 12 mm Hg for variceal bleeding (ascites < 15 mm Hg)

Coil embolization of varices

D. Results:

Patency: 50% at 1 year

Recurrent bleeding: 10%

E. Complications:

Hepatic encephalopathy: > 10%


Shunt thrombosis, stenosis

Right heart failure; renal failure







Inject 1 ml of isosulfan blue between 1 st -2 nd and 4 th -5 th toes

Cutaneous cut-down into fascia; isolate lymphatics

Puncture lymphatic vessel with 30-G needle; hook-up to pump and inject contrast (Ethiodol)


Conscious sedation:

A. Principles: monitor BP; oxygenation; HR

B. Agents: midazolam (Versed) and fentanyl IV short T 1/2


II. Thoracic Aorta and Great Vessels

1. Anatomy:

A. Embyologic arches:

1 st maxillary artery

2 nd stapedial artery

3 rd ICA

4 th proximal right portion proximal right SCA; distal portion right-sided AA (remnant = ductus diverticulum along venteromedial descending aorta)

5 th regresses

6 th PA (right); ductus arteriosus (left)

B. Size: ascending > descending diameter

C. Normal configuration (70%): innominate artery; left common carotid; left subclavian artery

D. Variants:

Bovine arch (20%): common origin of innominate and left CCA

Left vertebral artery originates between left CCA and SCA (5%)

Common carotid trunk (1%)

Thyroidea ima to thyroid isthmus

Aberrant right subclavian: persistence of distal right 4 th arch + regression of proximal right 4 th arch

Intercostal arteries: usually paired from 3 rd to 11 th intercostal spaces

Bronchial arteries: usually single right and two left arteries (45%) > single bilateral bronchial arteries (30%)

2. Thoracic aortic aneurysm:

A. Definition:

True aneurysm: contains all three layers of intact arterial wall often fusiform

Pseudoaneurysm: lack one or more layers; often saccular

B. Etiologies:


#1 overall; descending > ascending aorta; concomitant AAA; fusiform >> saccular

Complications: pain; hoarseness; AI; rupture (risk if > 5 cm); impending rupture with focal protuberance (= pointing aneurysm, nipple)

Connective tissue diseases:

Marfan’s: cystic medial necrosis; often involves sinuses (tulip bulb) and sinotubular junction; also MVP

Ehler-Danlos: ascending > descending aorta; ↑↑ dissections

Syphilis: tertiary; long latency (20-30 years); infectious aortitis of vasa vasora; 80% ascending aorta; “tree-bark” Ca 2+ ; rare dissections


Mycotic (ascending aorta or isthmus):

Agents: Staphylococcus, Streptococcus, Salmonella

Risk factors = IVDA; endocarditis; postsurgical; immunocompromised

Inflammatory aortitis:

Takayasu’s disease

Giant cell arteritis

Collagen-vascular disease (RA; AS)

Behcet’s: aortic aneurysm + stenoses of great vessels

Post-traumatic: usually pseudoaneurysm

3. Aortic dissection:

A. Clinical: chest or back pain; AI; discordant BP; neurologic deficits; pulse deficits

B. Etiologies:

HTN: #1

Collagen disorders: Marfan’s; Ehlers-Danlos

Congenital: aortic coarctation; bicuspid aortic valve


C. Classifications:


Type A: involves ascending aorta

Type B: limited to descending aorta


D. Imaging:

B: both ascending + descending aorta

Type I:

A: ascending aorta

Type II:

D: descending aorta

Type III:

Direct signs: 100% specific; near 100% sensitive; 100% PPV

Intimal flap


Contour abnormality; abrupt caliber change

Contrast extravasation

Intramural thrombus

Indirect signs: poor sensitivity and specificity; only 7% PPV

Periaortic hematoma

Mediastinal hematoma

Determine true and false lumina (false lumen usually anterolateral in ascending and posterolateral in descending aorta with delayed opacification; often larger than true lumen and extends into left common iliac artery)

Establish extent, involvement with root, great vessels and coronary arteries

DDX = aortic wall hematoma: intramural bleeding from vasa vasora into media; detect on noncontrast CT (bright wall)

E. Treatment:


Stanford B: medical management unless ischemic, neurologic deficits

Stanford A: surgery (avoid tamponade, AI, coronary artery dissection)

Other: endovascular fenestration (equalize blood flow into true and false lumina); covered stents

4. Traumatic aortic injury:

A. Statistics: > 80% die instantly; < 5% survive at 4 mths; deceleration injury

B. Distribution:

Aortic isthmus: #1 (95%); between left SCA and ligamentum arteriosum

Other sites: proximal ascending aorta, hiatus; associated great vessel injury (< 10%)

C. Radiographic findings:

CXR: widened mediastinum, apical cap, loss of aortic arch contour; displaced bronchus or NG-tube; fracture of 1-4 th ribs

CT: direct (intimal flap, contour abnormality, etc.) and indirect signs (mediastinal hematoma, etc.)

Angiography: intimal tear; pseudoaneurysm; DDX = ductus bump

or diverticulum (remnant of 4


embryonic arch)


Ductus Bump

Aortic Tear










Companion shadow



5. Giant cell arteritis:

A. Clinical: > 50 years; temporal artery biopsy

B. Radiographic: medium-sized arteries (peripheral extremities long, smooth narrowing); aorta (10% aneurysm)

C. Complications: aneurysm, dissection

6. Syphilitic aortitis:

A. Clinical: Treponema pallidum; + FTA-AB; long latency (20-30 years)

B. Radiographic: ascending aorta > aortic arch; tree-bark Ca 2+ ; saccular


C. Complications: aneurysm rupture; AI; coronary artery narrowing; gummatous myocarditis


7. Takayasu’s arteritis:

A. Clinical: marked intimal proliferation and fibrosis; ↑↑ < 30 years; Asian females; CRP/ ESR

B. Types:

Type I: aortic arch + great vessels

Type II: abdominal aorta

Type III: ascending and descending aorta

Type IV: pulmonary arteries (50%)

C. Radiographic:

Stenoses of arch vessels and aorta

Thickened aortic wall

Abdominal coarctation and renal artery stenoses

8. DDX for arterial dilatation (aneurysm):

Trauma: pseudoaneurysm

Infection: Staphylococcus; Salmonella; Syphilis

Connective tissue disorders: RA; AS; Behcet’s; Marfan’s (“tulip-bulb”); Ehlers-Danlos; Reiter’s; psoriasis

9. DDX for aortic stenosis:

Congenital: William’s syndrome

Vasculitis: Takayasu’s or Giant Cell arteritis

XRT (Ca 2+ )

Other: NFT; congenital Rubella

10. Carotid stenosis:

A. Clinical: SXS = TIA; amaurosis fugax; stroke; risks = atherosclerosis

(#1); vasculitis; XRT

B. Radiographic:

U/S + MRA overestimate severe stenoses

CTA: best for “string” sign

Angiography: gold standard; best for tandem lesions; 1% stroke rate


< 75% (1.3%/yr) stroke rate

> 75% (10.5%/yr) stroke rate

Studies: NASCET; ACAS; CREST (carotid endarterectomy revascularization vs. stent trial; underway)

III. Abdomen and Pelvis

1. Vascular anatomy:


A. Embryology: 3 paired cardinal veins: posterior + subcardinal + supracardinal

B. Normal anatomy: aorta/ IVC bifurcate at iliac crest; common iliac vessels bifurcate at pelvic brim; celiac axis originates immediately below the aortic hiatus; SMA originates 1 cm below and renal arteries 2 cm below

C. Anomalies/ variants:

Duplication of IVC: left common iliac vein left renal vein (< 1%)

Left IVC: < 0.2%

Retroaortic (1-2%) or circumaortic (2-5%) left renal vein (retroaortic component lies inferior to the anterior component)

Suprarenal-caval IVC interruption azygos continuation (<1%)

2. Aneurysm:

A. True aneurysm:

A. Definition: all three layers (intima, media, adventitia); saccular, fusiform, or spherical dilatation

B. Criteria:

Aorta > 3 cm; 90% infrarenal; risk of rupture = 5% (< 5 cm), 15% (> 6 cm), and 76% (> 7 cm)

Iliac > 1.5 cm

B. Pseudoaneurysm: hematoma confined within adventitia/ surrounding


Iatrogenic, traumatic

Infectious (mycotic): irregular, saccular contour; without Ca 2+ ; +/- gas, adjacent vertebral osteomyelitis; suprarenal location

Inflammatory (5%): perianeurysmal fibrosis (posterior wall spared); due to autoimmune process; risks = trauma, sepsis, IVDA, endocarditis

Dissecting: true and false lumina separated by intimal flap; thrombosis within false lumen; risk factors include HTN, Ehlers-Danlos, and Marfan’s

Ruptured aortic dissection: mortality > 75%; adjacent retroperitoneal hematoma; dissection into psoas muscle and peritoneal cavity

C. Angiography:

Determine proximal and distal extent

Establish patency of mesenteric and renal arteries

Document aberrant or accessory vessels

D. Treatment: endovascular stents (Ancure; AnneuRx) vs. surgery; complications = endoleaks [I = graft ends; II = retrograde leak via lumbar arteries/ IMA/ etc.; III = graft joints; IV = through graft material (porosity)]


3. Aortoiliac-occlusive disease:

A. Patterns:

Infrarenal aortic occlusion

Distal aortoiliac disease at bifurcation

Small aorta syndrome (= hypoplastic aorta syndrome): focal atherosclerotic stenosis; younger females, TOBA

Multisegment disease: often infra-inguinal

B. Leriche syndrome: triad = buttock claudication + impotence (males) +

diminished femoral pulses

C. Radiographic:

Collateral pathways:

Internal mammary artery (IMA) superior epigastric + inferior epigastric external iliac arteries

IMA hemorrhoidal internal iliac arteries

Intercostal/ lumbar deep circumflex iliac arteries external iliac arteries

Intercostal/ lumbar iliolumbar, gluteal internal iliac arteries

Determine gradients across stenoses

4. Abdominal aortic coarctation:

A. Clinical: renovascular HTN, claudication, abdominal angina

B. Subtypes:

Congenital: thoracic aortic coarctation; William’s syndrome; congenital rubella; NFT

Acquired: Takayasu’s arteritis; FMD; XRT; atherosclerosis (#1)

C. Radiographic:

Segmental coarctation: most common

Often involves renal arteries

IMA = major collateral

5. DDX for diffuse aortic narrowing:

Atherosclerosis: #1

Williams syndrome


Takayasu’s syndrome


Retroperitoneal fibrosis



Hypertonis reflex

6. Aortic surgery:


A. Graft types: bifurcation grafts (end-to-side; end-to-end); endarterectomy; axillo-femoral bypass; femoral-femoral bypass

B. Complications:

Perigraft infection; hematoma

Anastomotic pseudoaneurysm

Aorto-enteric fistula (duodenum = #1 site)

7. Mesenteric vessels:

A. Embryology: celiac trunk (= 10 th vitelline artery); SMA (= 13 th vitelline artery)

B. Celiac axis: arises at T12-L1; 1 st branch = left gastric artery; 2 nd branch = splenic artery; 3 rd branch = common hepatic artery

C. Hepatic artery: proper hepatic artery LHA + RHA + right gastric


RHA from SMA: 15%

LHA from LGA: 10%

Accessory LHA from LGA (8%) or RHA from SMA (5%)

Both RHA and LHA from SMA: 2%

D. Splenic artery:

Branches: dorsal pancreatic artery (40%); pancreatica magna; short gastric arteries; left gastroepiploic arteries

; short gastric arteries; left gastroepiploic arteries E. SMA: arises at L1; passes ventral to uncinate

E. SMA: arises at L1; passes ventral to uncinate process


Inferior pancreaticoduodenal artery: 1 st branch

Middle colic artery: 2 nd branch

Jejunal and ileal arteries

Ileo-colic and right colic arteries

F. IMA: originates below renal arteries near L3


Left colic artery

Sigmoid arteries

Superior hemorrhoidal/ rectal artery


G. Collateral vessels:

Arc of Barkow: collaterals between right (GDA) and left (splenic artery) gastroepiploic arteries

Arc of Buehler: embryonic ventral communication between celiac axis and SMA

Pancreatico-duodenal arcade

Arc of Riolan: direct, short SMA IMA connections (between proximal left (IMA) and middle (SMA) colic arteries)

Marginal artery of Drummond: arcade along mesenteric border of colon (left middle colic arteries)

H. Rectal arteries:

Superior rectal artery: IMA

Middle rectal artery: internal iliac artery

Inferior rectal artery: pudendal artery

I. Median arcuate ligament syndrome: common in young females;

median arcuate ligament compresses celiac trunk + SMA during expiration (counter-intuitive)

celiac trunk + SMA during expiration (counter-intuitive) 8. Upper GI hemorrhage: A. Etiologies: gastritis (#1); PUD

8. Upper GI hemorrhage:

A. Etiologies: gastritis (#1); PUD (#2); varices; Mallory-Weiss tear >> aorto-duodenal fistula; GI malignancy; Dieulafoy disease (erosion into superficial vessel; lesser curvature of stomach); hepatobilia (hepatic tumor/ AVM/ trauma/ etc.)

B. Radiographic:

LGA (80-90%): #1 bleeding site; normal variants (celiac axis > aorta > splenic artery)

RGA (proper hepatic), gastroepiploic (GDA/ splenic) arteries less common

Duodenal bleeding: GDA > pancreaticoduodenal arcade; DDX = hematobilia (AVM; tumor; etc.)

C. Intervention: vasopressin, embolization (coils)

9. Lower GI hemorrhage:


A. Definition: distal to the ligament of Treitz; melena (> 8 hrs) > hematochezia

B. Etiologies:

Large bowel: diverticulosis (#1); angiodysplasia (#2; “tram-track” appearance with early arterial blush + early/ dense/ persistent draining vein); colon CA; polyps; IBD

Small bowel: leiomyoma; AVM; ulcerations; varices; Meckel’s diverticulum; tumors (metastases; lymphoma; Kaposi’s)

C. Radiographic:

Tagged 99m Tc-RBC scan: detects > 0.1 ml/min

Arteriogram: detects > 1 ml/min

Intra-arterial vasopressin: not subselective; (0.2 U/min) x 20 min (0.4 U/min) x 20 min continue for 12-24 hrs and gradually taper (0.1 U/min) q 6 hrs until off

Embolize: avoid distal agents (particles; microspheres; EtOH) ischemia/ infarction

Provocative bleeding study: priscoline (25 mg) + heparin (3,000-10,000 U) + tPA (10-50 mg over 10 min)

D. Complications:

Rebleeding: 30%

Bowel ischemia/ infarction: 25%

Vasopressin: HTN; MI; stroke; mesenteric ischemia; PVD

10. Intestinal Ischemia:

A. Clinical: weight loss; “food-fear” (= sitophobia); post-prandial pain

B. Etiologies:

Arterial: embolization; in situ thrombosis; aortic dissection; vasculitis; atherosclerosis; hypotension

Mesenteric venous thrombosis

Other: incarcerated hernia; volvulus; intussusception

C. Radiographic:

Filling defects: thrombus; embolus

In situ thrombosis proximal (origin of SMA)

Emboli peripheral

Late phase lack of veins; delay; filling defects venous thrombosis

D. Intervention:

Thrombolysis: tPA 1.0-2.0 mg/hr

E. DDX: mesenteric vasospasm (= non-occlusive mesenteric ischemia) scattered stenoses (branch-points) with intervening normal caliber vs. diffuse spasm; absent bowel blush and delayed venous filling; DX/TX = Priscoline or papaverine (1 mg/min)




A. Clinical: acquired; cecum & right colon; association with AS

B. Radiographic:

Vascular tuft on angiography

Early/ dense/ persistent draining vein

C. Treatment:

Gelfoam or pledgets

Avoid particles to prevent ischemia or infarction


Uterine leiomyomata embolization:

A. Clinical: serosal/ submucosal/ intramural; SXS = pain/ menorrhagia

B. Treatment: myomectomy; hysterectomy; embolization; hormonal TX

C. Embolization:

Exclusion criteria: pedunculated fibroids

Technique: 4 French Berenstein/ Roberts catheter; 500-700 µm PVA particles embolize both uterine arteries (anterior division of internal iliacs)


Post-embolization syndrome: pain; F; WBC; lasts 3-5 days

Premature ovarian failure: 1-2%; unknown pathophysiology

IV. Liver

1. Hepatic tumors:







Dense peripheral stain; multiple “cotton-wool” pools



Spoke-wheel appearance (radiating fibrous septae)


Mildly hypervascular; homogeneous; displaced vessels


Associated with cirrhosis; displaced veins; “stretched” arteries



↑↑ AV + AP shunt

Portal vein invasion; 75% hypervascular


Arterial encasement; absent neovascularity; hypovascular


2. Venous imaging:

A. Indications: PV thrombosis; HV thrombosis (Budd-Chiari syndrome); TIPS; hepatic transplants

B. Radiographic:

U/S: screening; velocities & directions

Angiography: arterial portography (late phase celiac/ SMA) vs. transhepatic/ transjugular direct venography

3. DDX for arterioportal shunting:

Cirrhosis: PV-thrombosis; shock; arterial occlusion

Tumors: HCC > metastases; hemangioblastoma; hemangioma; hemangioendothelioma


Budd-Chiari syndrome

Peliosis hepatis: bacillary angiomatosis (Bartonella henselae)

4. Chemoembolization:


Indications: HCC; neuroendocrine tumors


Agents: Ethidiol; cisplatin; mitomycin-C; adriamycin


Contraindications: liver failure; encephalopathy; biliary obstruction




Tumor embolization syndrome: fever; pain; N/V (< 3-4 days)

Liver failure: rare

GB ischemia/ cystitis


5. Portal HTN:

A. Clinical: > 6 mm Hg portal pressure or > 11 mm Hg gradient; variceal bleeding

B. Etiologies:

Presinusoidal: PV obstruction (thrombosis; tumor); Schistosomiasis

Sinusoidal: cirrhosis

Postsinusoidal: Budd-Chiari syndrome; HV or IVC occlusion

High flow states: AVF/ AVM

C. Collaterals:

Esophageal varices: coronary (= left gastric) azygos/ hemiazygos veins

Mesenteric varices: SMV/IMV iliac veins

Caput medusa: umbilical epigastric veins

Gastric fundal varices: splenic azygos

Duodenal/ retroperitoneal varices: splenic retroperitoneal veins

Spontaneous splenorenal shunts

D. Radiographic:

Recanalized umbilical vein (vasa vasora); portal collaterals (cavernous transformation vasa vasora)

Splenomegaly; ascites

Hepatofugal flow in PV; portosystemic collaterals; corkscrew hepatic arteries; “pruned-tree” hepatic veins

Hemorrhoidal varices

E. Treatments:

TIPS: usually middle hepatic vein right PV (10 mm stent)

Indications: gradient > 12 mm Hg with persistent ascites or bleeding (> Budd-Chiari; hepatorenal or hepatopulmonary syndromes)

Contraindications: encephalopathy; severe liver disease; right-sided CHF; coagulopathy; PV thrombosis

Complications: encephalopathy; worsening liver disease (restenosis due to pseudointimal hyperplasia)

Variceal embolization

Suigura procedure (= devascularization procedure):

paraesophageal devascularization + esophageal resection + splenectomy + esophagogastric devascularization + pyloroplasty/ vagotomy; usually reserved for Childs’ A

Surgical shunts:

Portocaval: PV IVC; immediate decompression

Splenorenal shunts: splenic left renal; Warren (distal) + Linton (proximal)

Mesocaval: SMV IVC

6. Portal vein thrombosis:


A. Etiologies: tumor (HCC; pancreatic CA; mets); post-operative; coagulopathies; sepsis; pancreatitis; cirrhosis

B. Radiographic: filling defects; cavernous transformation

C. Splenic vein thrombosis: gastric fundal varices without esophageal varices (coronary vein patent); normal portal-venous pressure

7. Budd-Chiari syndrome:

A. Definition: obstruction of hepatic venous outflow (at hepatic venules/ veins or IVC)

B. Etiologies:

Hepatic vein thrombosis: coagulopathies; OCPs; pregnancy; phlebitis

Tumor growth: RCC; HCC; adrenal carcinoma

Other: IVC membrane/webs; pericarditis; right atrial tumor (myxoma)

C. Radiographic: hepatic venography/ IVC filling defects (“steeple” IVC due to caudate hypertrophy); spiderweb hepatic veins; IVC webs

8. Percutaneous transhepatic cholangiogram (PTC)/ percutaneous biliary drain (PBD):

A. Indications: non-surgical biliary obstruction due to stenosis; compression; stricture [PSC ( intra-/ extrahepatic fibrosis) vs. PBC ( intrahepatic fibrosis)]

B. Contraindications: coagulopathy; ascites

C. Technique: premedicate with ABX

22 gauge Chiba needle opacify ducts 8 F catheter (29/45 side-hole) over guidewire

Start with external drainage internal drainage possible removal of drain

Reserve stents (wallstent; AVE) for palliative treatment of terminal disease (6-9 month survival); avoid for benign disease (thrombosis; lost access)


V. Kidneys

1. Anatomy:

A. Normal anatomy: single vessel (65%); anterior + posterior divisions segmental arteries arcuate interlobar arteries afferent glomerular arteries; avascular zone = Broedel’s line (posterolateral inferior 1/3 of kidney); AP-view posterior calyces en face; anterior calyces in profile

B. Variants: gonadal arteries from renal arteries (20%); inferior phrenic/ adrenal arteries

C. Veins: left = (3 x) right length; left passes anterior to the aorta and receives left adrenal and gonadal veins

2. Renal angiography:

A. Indications:

Renovascular HTN

Trauma: AVF; pseudoaneurysm; bleeding


Transplant donors

Veins: renin sampling; thrombosis; tumor extension

B. Interventions: PTA/ stents; embolization (tumor; AVF; trauma)

3. Renal artery stenosis (RAS):

A. Etiologies:


#1 (70%)

Ostial; bilateral; associated with aortic plaque

Poor PTA response stents

FMD (25%; #1 in children):

5 subtypes (medial fibroplasia >> intimal, perimedial or periadventitial)

Renal arteries (60%) > ICA/ vertebral arteries (35%) >> iliac/ visceral arteries

“String of beads” appearance

Mid- and distal arteries; 50% bilateral

Excellent response to PTA alone (DO NOT overdilate)

Complications = dissection/ rupture; HTN

Other: NFT (proximal); vasculitis (PAN; Takayasu’s; Wegener’s); coarctation; XRT; dissection; pheochromocytoma

B. Radiographic:

Stenosis > 50% (diameter); post-stenotic dilatation

Gradient > 15 mmHg; collaterals

Renin sampling: ratio > (1.5:1)

C. DDX = spasm; standing waves (mimic FMD, but symmetric)

D. Treatment:

PTA +/- stent (ostial lesions always stent); FMD responds well to PTA alone

Results: overall 20% cured, 50% improved, and 30% failure rate

Goal: < 20% residual stenosis; no significant gradient

4. Renal arterial aneurysm:

A. Etiologies:


FMD; atherosclerosis; NFT; AML; LAM

Intraparenchymal PAN; Wegener’s; amphetamine abuse

B. Treatment: embolization if large

5. Polyarteritis nodosa (PAN):

A. Clinical: vasculitis of small-medium arteries; autoimmune process;

HBV; hematuria; HTN; perinephric hematoma

B. Radiographic:

Aneurysms of interlobar and arcuate arteries (more peripheral than FMD)

Renal infarctions

C. DDX = Wegener’s disease; drugs (amphetamines; cocaine)

6. Renal vein thrombosis:

A. Clinical: usually < 2 years old; risks = maternal DM; sepsis; dehydration; GN; DM; trauma; thrombophlebitis; collagen vascular diseases

B. Radiograophic:

Ureteral notching due to venous collaterals

Enlarged kidney with delayed or absent nephrogram

Filling defects

C. Complications: renal failure; pulmonary emboli

7. Percutaneous nephrostomy (PCN):

A. Indications: high-grade obstruction with acute renal failure not amenable to stenting or surgery

B. Contraindications: bleeding diathesis; urosepsis (relative); terminal CA

C. Technique: 22 gauge needle into infero-posterior calyx (Broedel’s line = avascular zone) under U/S-guidance 8-12 F pigtail catheter; prone position posterior calyces en face + anterior calyces in profile

D. Complications: hematuria; pain; sepsis; hemorrhage; PTX; infection; AVM/ pseudoaneurysm

8. Renal AVM:

A. Etiologies: iatrogenic (#1; BX, PCN, etc.); trauma; aneurysm rupture; inflammatory disease; neoplasm

B. Treatment: embolization (distal)

C. Complications: high-output CHF; HTN


VI. Chest

1. Venous anatomy: azygos/ hemiazygos lateral thoracic internal mammary veins; left superior intercostal vein (“aortic nipple”)

2. Catheters:

Pigtail: requires tip-deflecting device; good for high-volume injections

Grollman: multipurpose curvature without tip-deflecting device

NIH catheter: possible perforations

Balloon float catheter: can whip-back during injections

3. Pulmonary angiography:

A. Indications: PE; pseudoaneurysm; AVM; pulmonary HTN

B. Contraindications: LBBB and severe P-HTN (PA sys > 70 mmHg)

C. Pressures













< 5


< 5
















< 12

D. Pearls:

Transvenous pacer for existing LBBB

Pulmonary HTN = (PA Systolic > 30 mmHg) or (PA Mean > 15 mmHg)

Injection: 20 ml/sec for 40 ml total (for normal flow)

E. Complications:

Acute right heart failure

Arrhythmias (RBBB)

Death (0.3%)

F. Treatment: thrombolysis or mechanical thrombectomy if patient is


4. Bronchial arteriography:

A. Indications: evaluate hemoptysis (TB; bronchitis; CA; CF; etc.)

B. Anatomy:

Two left (anterolateral) and one right (posterolateral) bronchial arteries (50%)

Single left and right bronchial arteries (30%)

Originate between T4-T7 antero-/ posterolaterally (90%)

C. Radiographic: selective catheterization with Cobra or Simmons catheters

D. Complications:


Hemoptysis: infarction (< 10-15%)


Spinal cord paralysis: artery of Adamkiewicz originates @ T5-L5 (usually L1-2) >> variants (originating off superior intercostal artery, bronchial artery, or common trunk) with “hair-pin” turn; L > R; supplies inferior 2/3 of spinal cord

5. Bronchial artery embolization:

A. Indication: life-threatening hemoptysis (> 600 ml/ 24 hrs)

B. Technique: Cobra, Simmons or Berenstein catheters; polyvinyl alcohol or Gelfoam preferred for embolization (maintain access for recurrent bleeding)

C. Radiographic:

Contrast extravasation

Hypervascularity/ tortuous vessels


D. Complications:

Spinal artery injury/ paralysis: transverse myelitis; reflux of embolization material

Future rebleeding via collaterals: 30-40%

Bronchoesophageal fistula

Chest pain/ dysphagia

6. Pulmonary AVM/ AVF:

A. Clinical: dyspnea; cyanosis; clubbing; paradoxical emboli

B. Etiologies:

Congenital: isolated or Osler-Weber-Rendu syndrome (= hereditary hemorrhagic telangiectasia)

Acquired: trauma; infection; hepatogenic angiodysplasia (= hepatopulmonary syndrome)

C. Radiographic:

CXR/CT: enhancing mass (lower lobes) with feeding artery and draining vein

Angiography: usually direct AVF; embolize with coils (lesions > 3 mm)

7. DDX for pulmonary aneurysm:

Infection: TB (Rassmusen aneurysm); syphilis; mycotic




Behcet’s disease: aphthous stomatitis + genital ulcerations + iritis; large vein occlusion (SVC syndrome); large artery aneurysms

Hughes-Stovin disease: rare; idiopathic necrotizing vasculitis; pulmonary aneurysms + systemic thrombosis/ pulmonary emboli



Pulmonary thromboembolism:

A. Clinical: many risk factors (postoperative; trauma or burns; malignancy;

prior DVT/PE; immobility; CHF; OCPs; pregnancy; coagulopathy); nonspecific clinical presentation (dyspnea; tachycardia; tachypnea; hemoptysis)

B. Radiographic:

CXR: exclude PTX; pneumonia; Westermark’s sign; Hampton’s hump

V/Q scan: V/Q mismatch; correlate with CXR

CT: identify lobar or segmental thrombi

U/S: rule out DVTs

Pulmonary angiography: gold standard for equivocal CT or V/Q

Acute PE: filling defect; “tram-track” contrast; abrupt cutoff

Chronic PE: eccentric filling defect; webs; smooth cutoff; “missing vessels”; poor prognosis (5-year survival < 10%); PAP MEAN > 50 mmHg

Indications: indeterminate V/Q or CT scan with high clinical suspicion; hemodynamically unstable

C. Treatment:






IVC size



8-12 F


< 30 mm

Vena Tech

12 F

Phynox (8 metal alloy)

< 28 mm

Simon Nitinol

8 F


< 28 mm

Bird’s Nest

9 F

Stainless Steel

< 40 mm

(extends over 7 cm)




< 30 mm


8.5 F


< 30 mm

Indications: failed anticoagulation; hemorrhage; prophylaxis (major surgery; etc.)

Contraindications: septic emboli; thrombosis of all access routes


Venography IVC diameter; ? thrombus; variants (duplicated IVC; circumaortic left renal vein)

Usually place infrarenal, unless > 40 mm, pregnant, or duplicated IVC

Complications: recurrent embolism; filter migration; IVC thrombosis; IVC perforation

VII. Extremities

1. Lower extremity anatomy:

A. Leg:


CFA SFA + profunda ( medial + lateral circumflex and descending branches)

Popliteal artery superior + inferior medial and lateral genicular arteries trifurcation = anterior tibial (1 st branch) + posterior tibial + peroneal arteries

Persistent sciatic artery (= axial artery): rare (1/4000); 20% bilateral; originates off internal iliac artery parallels sciatic nerve; presents with non-palpable femoral pulses

B. Foot:

Dorsal arteries: dorsalis pedis medial + lateral malleolar arcuate metatarsal digital arteries

Plantar arteries: posterior tibial medial + lateral plantar plantar arch metatarsal digital arteries

C. Collaterals:

IMA inferior epigastric external iliac CFA

Lumbar/ iliolumbar circumflex iliac ( CFA) + lateral circumflex PFA

Gluteal/ obdurator circumflex arteries PFA

PFA and geniculate branches

D. Veins:

CFV profunda + SFV ( deep calf system)

Deep calf system: anterior + posterior tibial + peroneal SFV

Superficial calf system: greater (medial CFV) + lesser (posterior popliteal vein) saphenous veins

2. Upper extremity anatomy:

A. Arterial branches:

Subsclavian vertebral + IMA (internal mammary artery) + thyrocervical trunk + costocervical artery

Axillary artery supreme thoracic + thoracoacromial + lateral thoracic + subscapular + humeral circumflex arteries

Brachial artery profunda + radial + ulnar collaterals

Forearm: radial deep arch; ulnar superficial arch

3. DDX for diffuse peripheral arterial narrowing:

Atherosclerotic disease (#1)


Medications: ergots; alkaloids

Neuromuscular/ collagen-vascular disorders

Idiopathic: reflex hypertonis (young patients with psychiatric disorders)


5. Occlusive disease:

A. Etiologies:


Collagen-vascular diseases; autoimmune disease

Buerger’s disease

Drugs: amphetamine; ergotism


Popliteal artery entrapment: due to medial gastrocnemius; exacerbate with active plantar flexion or passive dorsiflexion

Cystic adventitial disease: compression of popliteal artery

Other: atherosclerosis; embolism

B. Atherosclerosis:

Clinical: claudication; hair loss; 5 P’s (pain; pallor; pulseless; paresthesis; paralysis); gangrene

Risk factors: DM; HTN; TOBA; hypercholesterolemia

Radiographic: usually bilateral/ symmetrical involvement (SFA > iliac > tibial > popliteal > CFA); assess for narrowing (> 50%) and gradient (> 10 mm Hg)

Treatment: PTA; stenting; surgery (vein graft; endarterectomy; amputation)

C. May-Thurner syndrome: extrinsic compression of proximal left common iliac vein by proximal right common iliac artery; 75% female; 40 yrs

6. Atherosclerotic aneurysmal disease:

A. Clinical: popliteal > iliac > femoral arteries

B. Location:

Popliteal 50-70% bilateral; distal embolization/ thrombosis

Iliac rupture; associated with AAA

CFA distal embolization; thrombosis

7. Arterial thromboembolism:

A. Clinical: 5 P’s = pain; pallor; pulselessness; paresthesias; paralysis

B. Etiologies: cardiac thrombus; aneurysms; paradoxical embolism

C. Radiographic: emboli lodge at bifurcations; vasospasm; filling defects with menisci

D. Treatment: embolectomy

8. Buerger’s disease:

A. Clinical: non-necrotizing panarteritis (thromboangiitis obliterans); lower > upper extremity; risks = male; TOBA

B. Distribution: calf and foot vessels > ulnar/ radial arteries; palmar/ digital arteries

C. Radiographic: abrupt segmental cutoff; multiple corkscrew collaterals


10. Small vessel atherosclerosis: DM calf/ foot amputation

11. Cholesterol/ atheroma emboli: painful ischemic digits; livido reticularis; blue- toe syndrome

12. Deep venous thrombosis (DVT):

A. Clinical: risk factors Virchow’s triad = stasis + hypercoagulability +

vessel injury

B. Radiographic:

U/S: filling defects; noncompressibility; enlarged vein; absent flow

CT or MRI: filling defect or flow-voids

C. Treatment:


IVC filter: failed or contraindicated anticoagulation; prophylaxis (preoperative)

Filter types:

Birdsnest (= Cook): for mega cava > 28 mm

Greenfield (= Medi-tech)

LGM (= Vena-tech)

Simon nitinol (= Bard): smallest delivery system brachial approach

Complications: migration (< 1%); recurrent PE (3%); IVC thrombosis (10%); IVC perforation (rare)

13. Upper extremity:

A. Thoracic intlet (outlet) syndrome:


Primary axillary-subclavian vein thrombosis (= Paget-von Schroetter syndrome); aka effort-induced (exercise); young males; right > left; TX = primary thrombolysis surgical decompression of thoracic outlet/ inlet (transaxillary 1 st rib resection)

Secondary axillo-subclavian vein thrombosis: due to indwelling catheter or pacing wire; older/ sedentery/ chronically-ill patients

Compression sites = scalene triangle (anterior scalene muscle); costoclavicular space (subclavius muscle); pectoralis tunnel (pectoralis minor muscle)

Clinical: brachial plexus compression ( neuro sxs); SCA claudication; SVC thrombosis

Radiographic: cervical ribs; remote fractures; mural thrombus; aneurysm; arterial stenosis

B. Trauma:

Clinical: abnormal pulse; high velocity or crush injuries; posterior knee dislocations !!

Radiographic: intimal tear; pseudoaneurysm; hematoma; transection/ dissection

DDX = vasospasm/ compartment syndrome


C. Subclavian steal syndrome:

Clinical: visual disturbances; ataxia

Radiographic: L (90%) >> R; proximal SCA stenosis with retrograde flow via ipsilateral vertebral artery towards distal subclavian artery

D. Hypothenar-hammer syndrome:

Clinical: physical laborer with repeated direct trauma

Radiographic: ulnar aneurysm/ occlusion with arterial irregularity and distal digital artery occlusions (embolic events)

14. Vascular anomalies:

A. Vascular malformations:

Clinical: present @ birth + grow with child; enlarge after trauma/ sepsis/ DIC; without involution; normal cell mitosis and mast cells (non-neoplastic)

Treatment: EtOH sclerosis; surgical resection


Klippel-Trenauney syndrome: port-wine nevus + limb overgrowth + varicosities + poly-/ syndactyly; congenital absence of ipsilateral profunda femora vein

Sturge-Weber syndrome: phakomatosis with port-wine nevus

Proteus syndrome (Parkes-Weber): gigantism + macrocephaly + capillary malformations abdomen

+ thorax; cerebri-form thickening of palms + soles

B. Hemangiomata:

Clinical: 30% present @ birth postnatal growth with gradual involution (peak size @ 1 year; involute < 10 years); cell turnover (tumor) + mast cells; facial involvement > extremities

Treatment: steroids; IFN-α; laser-/ cryotherapy; surgery


Kasabach-Merritt syndrome: giant hemangiomata + PLTs

PHACE: posterior fossa malformations + hemangiomata + arterial anomalies + coarctation/ cardiac abnormalities

+ eye abnormalities

Maffucci syndrome: enchondromatosis + soft tissue hemangiomata

VIII. Differential Diagnoses

1. Aneurysm:



Infection: bacterial; syphilis

Inflammation: Takayasu’s; giant cell arteritis; PAN

Congenital: Marfan’s; homocysteinuria; NFT; pseudoxanthoma elasticum

2. Ischemia:

Arterial: dissection; embolus; thrombosis; vasculitis

Venous: thrombosis; hypovolemia; hypoperfusion

3. Peripheral Vascular Disease:

Occlusive atherosclerosis

Aneurysmal atherosclerosis

Small vessel atherosclerosis

Embolic disease: cholesterol; plaque emboli; Buerger’s disease

4. DDX for emboli:

Cardiac: atrial fibrilllation; MI; ventricular aneurysm; endocarditis

Atherosclerotic emboli: plaque; aneurysm

Paradoxical (shunts)

5. Angiographic tumor features:










Arteriovenous shunting



6. DDX for aortic enlargement:



Post-stenotic: coarctation; aortic valve stenosis; sinus of valsalva aneurysm

7. DDX for aortic stenosis:

Coarctation; pseudocoarctation

Williams syndrome

Rubella (congenital)

Takayasu’s disease


8. DDX for pulmonary artery stenosis:

William’s syndrome (infantile hypercalcemia)

Rubella (congenital)



Hyper-reninemic HTN:

Atherosclerosis RAS Goldblatt kidney


Renin-secreting tumors

Renal masses; subcapsular hemorrhage (= Page kidney)


DDX for renal tumors:

RCC: 80% hypervascular; neovascular; AV-shunting

AML: aneurysms ( hemorrhage); fat

Oncocytoma: 30% spoke-wheel; hypovascular

Other: metastases; lymphoma


DDX for renal artery aneurysm:

A. Main artery:







B. Distal artery:

Vasculitis: PAN; Wegener’s

Drug-abuse: amphetamines; cocaine; etc.

Other: post-traumatic; XRT