139

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
Phlebitis
Anaphylaxis
C. Catheter:
Cholesterol emboli
Thromboembolism
CVA
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:

Wire Uses/ comments
3J Tortuous/ diseased vessels
15J Large vessels (aorta, IVC, femoral)
Straight Wire Dissection
Rosen Exchanges/ PTA
Amplatz Exchanges, tortuous iliac vessels
Bentson Long, flexible taper (floppy end)
Terumo 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






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B. Catheter types

Type Application
Pigtail Aorta, pulmonary
Cobra (C) Mesenteric, renal, contralateral iliac
Simmons (S) Mesenteric, arch vessels
Headhunter (H) Carotid, arch vessels
Berenstein Carotid
Davis Arch, carotids, upper extremity
Tracker Coaxial subselection
Van Aman/
Grollman
Pulmonary angiography

C. Flow rate injections

Site Catheter Injection
Rate
Abdominal Aorta Pigtail 20/40
Celiac C2, S2 6/60
Renals C2, S2 5/15
SMA S2, C2 6/60
IMA S2, C2 2/20
Splenic/ Hepatic Variable 5/50
Pelvis Pigtail 10/40
Internal iliac C2, S2 5/25
One leg runoff Straight tip 4/48
Two leg runoff Pigtail 6/72
Aortic arch Pigtail 30/60
Pulmonary VA/ Grollman 20/40
CCA Davis A1 7/11
ICA Davis A1 6/8
ECA Davis A1 2/4
Vertebral Davis A1 6/8

4. Pharmacologic intervention:
A. Vasodilators:
Papaverine (= opiate extract): smooth muscle relaxant;
1 mg/min infusion mesenteric ischemia
Tolazoline (= Priscoline): direct muscle relaxant (-blocker);
25 mg IA peripheral spasm
Nitroglycerin: direct muscle relaxant; 100 g 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 g IA; DDX tumor from
normal vessel

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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:

Material Occlusion Primary Use
Temporary Agents
Gelfoam (surgical
gelatin)
Weeks Upper GI bleed; pelvic
trauma; postoperative
Pledgets Weeks Cut to size
Permanent
Ethyl or PVA Permanent Tumors
Steel coils (micro-/
macrocoils)
Permanent Large vessel,
aneurysm, tumor
Balloons Permanent High output AVF
Cyanoacrylate (=glue) Permanent AVM

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)
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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:

Vessel Initial Patency 5-yr Patency
Iliac 95% 70-80%
Fem-Pop 90% 70%
Renal 95% 95% (FMD) >
70-90% (Atherosclerosis)



143
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%
Bleeding
Shunt thrombosis, stenosis
Right heart failure; renal failure



144
11. Lymphangiography:
A. Principles:
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)

12. Conscious sedation:
A. Principles: monitor BP; oxygenation; HR
B. Agents: midazolam (Versed) and fentanyl IV short T
1/2
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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:
Atherosclerosis:
#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:
Marfans: 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


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Mycotic (ascending aorta or isthmus):
Agents: Staphylococcus, Streptococcus, Salmonella
Risk factors =IVDA; endocarditis; postsurgical;
immunocompromised
Inflammatory aortitis:
Takayasus disease
Giant cell arteritis
Collagen-vascular disease (RA; AS)
Behcets: 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: Marfans; Ehlers-Danlos
Congenital: aortic coarctation; bicuspid aortic valve
Pregnancy
C. Classifications:
Stanford:
Type A: involves ascending aorta
Type B: limited to descending aorta
Debakey:
Type I: B: both ascending +descending aorta
Type II: A: ascending aorta
Type III: D: descending aorta
D. Imaging:
Direct signs: 100% specific; near 100% sensitive; 100% PPV
Intimal flap
Pseudoaneurysm
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)




147
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
th
embryonic arch)

Feature Ductus Bump Aortic Tear
Angulation Smooth Sharp
Shape Round Irregular
Neck Broad Narrow
Companion shadow None Present

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







148
7. Takayasus 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; Behcets; Marfans (tulip-bulb);
Ehlers-Danlos; Reiters; psoriasis

9. DDX for aortic stenosis:
Congenital: Williams syndrome
Vasculitis: Takayasus 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
Stenosis:
<75% (1.3%/yr) stroke rate
>75% (10.5%/yr) stroke rate
Studies: NASCET; ACAS; CREST (carotid endarterectomy
revascularization vs. stent trial; underway)
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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
tissue
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 Marfans
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)]



150
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; Williams syndrome;
congenital rubella; NFT
Acquired: Takayasus 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
XRT
Takayasus syndrome
Dissection
Retroperitoneal fibrosis
Marfans
Mucopolysaccharidoses
Hypertonis reflex








151
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
Variants:
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



E. SMA: arises at L1; passes ventral to uncinate process
Branches:
Inferior pancreaticoduodenal artery: 1
st
branch
Middle colic artery: 2
nd
branch
J ejunal and ileal arteries
Ileo-colic and right colic arteries
F. IMA: originates below renal arteries near L3
Branches:
Left colic artery
Sigmoid arteries
Superior hemorrhoidal/ rectal artery
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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)


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)






153
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; Meckels
diverticulum; tumors (metastases; lymphoma; Kaposis)
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)






154
11. Angiodysplasia:
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

12. 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 m
PVA particles embolize both uterine arteries (anterior
division of internal iliacs)
Complications:
Post-embolization syndrome: pain; F; WBC; lasts 3-5
days
Premature ovarian failure: 1-2%; unknown
pathophysiology

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IV. Liver

1. Hepatic tumors:

Lesion Vascularity Features
Hemangioma Normal Dense peripheral stain; multiple
cotton-wool pools
FNH Spoke-wheel appearance
(radiating fibrous septae)
Adenoma Mildly hypervascular;
homogeneous; displaced
vessels
Regenerating
nodules
Associated with cirrhosis;
displaced veins; stretched
arteries
HCC
AV +AP shunt
Portal vein invasion; 75%
hypervascular
Cholangio-
carcinoma
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
Trauma
Budd-Chiari syndrome
Peliosis hepatis: bacillary angiomatosis (Bartonella henselae)

4. Chemoembolization:
A. Indications: HCC; neuroendocrine tumors
B. Agents: Ethidiol; cisplatin; mitomycin-C; adriamycin
B. Contraindications: liver failure; encephalopathy; biliary obstruction
C. Complications:
Abscess
Tumor embolization syndrome: fever; pain; N/V (<3-4 days)
Liver failure: rare
GB ischemia/ cystitis




156
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






157
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)






158
V. Kidneys

1. Anatomy:
A. Normal anatomy: single vessel (65%); anterior +posterior divisions
segmental arteries arcuate interlobar arteries afferent
glomerular arteries; avascular zone = Broedels 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
Tumors
Transplant donors
Veins: renin sampling; thrombosis; tumor extension
B. Interventions: PTA/ stents; embolization (tumor; AVF; trauma)

3. Renal artery stenosis (RAS):
A. Etiologies:
Atherosclerosis:
#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; Takayasus; Wegeners);
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
159
4. Renal arterial aneurysm:
A. Etiologies:
FMD; atherosclerosis; NFT; AML; LAM
Intraparenchymal PAN; Wegeners; 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 =Wegeners 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 (Broedels 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
160
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

Location P
systolic

(mmHg)
P
diastolic

(mmHg)
P
mean

(mmHg)
RA < 5 < 5 0-5
RV 20-30 0-7
PA 15-30 8-12 15
P-wedge < 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
unstable

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:
Pain
Hemoptysis: infarction (<10-15%)

161
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
Aneurysms
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
Iatrogenic
Trauma
Inflammatory:
Behcets 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




162
8. 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; Westermarks sign; Hamptons
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:
Anticoagulation
Filters:

Name Introducer
size
Compound IVC size
Greenfield 8-12 F Titanium <30 mm
Vena Tech 12 F Phynox (8 metal
alloy)
<28 mm
Simon Nitinol 8 F Nickel-titanium <28 mm
Birds Nest 9 F Stainless Steel <40 mm
(extends
over 7 cm)
Trapease 6F Nickel-titanium <30 mm
Gunther-Tulip 8.5 F Non-magnetic <30 mm

Indications: failed anticoagulation; hemorrhage;
prophylaxis (major surgery; etc.)
Contraindications: septic emboli; thrombosis of all access
routes
Procedure:
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
163
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)
Hypotension
Medications: ergots; alkaloids
Neuromuscular/ collagen-vascular disorders
Idiopathic: reflex hypertonis (young patients with psychiatric disorders)

4. Arteriomegaly: diffusely enlarged vessels (aortoiliac +femoral-popliteal
systems); sluggish flow; idiopathic (?)


164
5. Occlusive disease:
A. Etiologies:
Inflammatory
Collagen-vascular diseases; autoimmune disease
Buergers disease
Drugs: amphetamine; ergotism
Vasopasm
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 Ps (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 Ps = 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. Buergers 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

9. Ergotism: symmetric diffuse severe vasospasm; young females with
migraine HA


165
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 Virchows 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:
Anticoagulation
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:
Subtypes:
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

166
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
Syndromes:
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-; laser-/ cryotherapy; surgery
Syndromes:
Kasabach-Merritt syndrome: giant hemangiomata +
PLTs
PHACE: posterior fossa malformations +hemangiomata +
arterial anomalies +coarctation/ cardiac abnormalities
+eye abnormalities
Maffucci syndrome: enchondromatosis +soft tissue
hemangiomata
167
VIII. Differential Diagnoses

1. Aneurysm:
Atherosclerosis
Infection: bacterial; syphilis
Inflammation: Takayasus; giant cell arteritis; PAN
Congenital: Marfans; 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; Buergers disease

4. DDX for emboli:
Cardiac: atrial fibrilllation; MI; ventricular aneurysm; endocarditis
Atherosclerotic emboli: plaque; aneurysm
Paradoxical (shunts)

5. Angiographic tumor features:
B Blush
E Encasement
D Displacement
P Puddling
A Arteriovenous shunting
N Neovascularity

6. DDX for aortic enlargement:
Aneurysm
Dissection
Post-stenotic: coarctation; aortic valve stenosis; sinus of valsalva
aneurysm

7. DDX for aortic stenosis:
Coarctation; pseudocoarctation
Williams syndrome
Rubella (congenital)
Takayasus disease
NFT; XRT

8. DDX for pulmonary artery stenosis:
Williams syndrome (infantile hypercalcemia)
Rubella (congenital)
Takayasus arteritis (type IV)
168
9. Hyper-reninemic HTN:
Atherosclerosis RAS Goldblatt kidney
FMD
Renin-secreting tumors
Renal masses; subcapsular hemorrhage (=Page kidney)

10. DDX for renal tumors:
RCC: 80% hypervascular; neovascular; AV-shunting
AML: aneurysms ( hemorrhage); fat
Oncocytoma: 30% spoke-wheel; hypovascular
Other: metastases; lymphoma

11. DDX for renal artery aneurysm:
A. Main artery:
FMD
Atherosclerosis
NFT
Mycotic
Trauma
Congenital
B. Distal artery:
Vasculitis: PAN; Wegeners
Drug-abuse: amphetamines; cocaine; etc.
Other: post-traumatic; XRT



169
Notes
170
Notes