Vascular Interventional Radiology

Indication – nonpalpable peripheral pulses
Translumbar approach:
Preferred – easier to access descending aorta
-left side approach crosses fewer CNS arteries (when going down aorta
-3J wire preferred
-difficult to compress
– high incidence of complications
-brachial plexus injury
Axillary artery approach
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1. Puncture site complications – groin hematoma, AVF, pseudoaneurysm, vessel thrombosis, neuritis, infection
2. Contrast reaction – anaphylaxis, renal failure, cardiac failure, phlebitis
3. Catheter related complications -dissection, cholesterol emboli, thromboembolism, cerebrovascular accident, arterial dissection
4. Therapy related complications (CNS bleed during thrombolysis)
Angiography complications
Low puncture
large catheters
Risk factors for AVF or pseudoaneurysm
Types of catheters
Types of catheters
Flow rates of injections
Flow rates of injections
Guidewire types
Guidewire types
Angiographic drugs
Angiographic drugs
Post embolization syndrome (fever, inc WBC) 40%
Infection of embolized area
Reflux of embolic material (nontarget embolization)
Alcohol infarction in the periphery
Complications of embolization
oxidant production, complement activation, leucocyte-endothelial cell adhesion, platelet-leucocyte aggregation, increased microvascular permeability and decreased endothelium-dependent relaxation
Reperfusion syndrome
0.001-0.02 mg/kg/hr
t1/2 = 5 minutes
treatment time = 6 hrs
Bleeding – 10%

Arterial: 1mg/hr (total max patient dose = 100mg)
Venous: same
Line clearance: 0.5 mg/hr x 3-4 hours

recombinant TPA dose
active bleeding
intracranial lesion
nonviable limb (revasc –> ARF and myoglobulinuria)
infected thrombus

bleeding diathesis
cardiac thrombus
malignant HTN
recent major surgery

Major hemorrhage needing transfusion / surgery = 7%
minor hemorrhage 7 %
distal emboli
pericatheter thrombosis
termination of therapy required in 10%

Contraindications to tPA
Claudication / rest pain
Tissue loss
Non healing wound
Establish inflow for distal bypass graft
Hemodialysis AVF or graft
Indications for Angioplasty
Long segment stenosis
Total occlusion
Unsuccessful PTA
recurrent stenosis after PTA
Dissection flap
Ulcerated plaque
renal ostial lesions
Indications for stents
POrtal hypertension with variceal bleeding
Refractory ascites

Budd Chiari
Pre transplant

TIPS indications
<10 mmHg decompression of varices
TIPS goal portosystemic gradient
Severe right sided heart failure with elevated CVP
Polycystic liver dz

Active infection
Severe encephalopathy
Portal vein thrombosis
Hepatic hypervascular tumor
hepatic failure

Contraindications to TIPS
Arterial puncture
Mechanical problems
Air embolism
Complications of central venous catheter placement
Atherosclerosis (most common)
Connective tissue disease (Marfans, Ehlers Danlos)
Post traumatic pseudoaneurysm
Aortitis (Takayasus Giant Cell, Rheumatoid arthritis, Ank Spond)
Causes of thoracic aortic aneurysm
Cystic medial necrosis
Degenerative process of aortic muscular layer (media)
-involves sinuses and sinotubular junction
-‘tulip bulb’ aorta
Cystic medial necrosis
Syphilic aneurysms
10-30 yrs after primary infection
tree bark calcifications
ascending aorta / arch
assymetrical saccular involvement
Syphilic aneurysms
Takayasu’s disease (also known as “aortic arch syndrome”, “nonspecific aortoarteritis” and the “pulseless disease”[1]:841) is a form of large vessel granulomatous vasculitis[2] with massive intimal fibrosis and vascular narrowing affecting often young or middle-aged women of Asian descent. It mainly affects the aorta (the main blood vessel leaving the heart) and its branches, as well as the pulmonary arteries. Females are about 8-9 times more likely to be affected than males.Some patients with Takayasu’s arteritis may present with only late vascular changes, without an antecedent systemic illness. In the late stage, weakness of the arterial walls may give rise to localized aneurysms.
Endoleak types
Endoleak types
Celiac axis vessels
Celiac axis vessels
Hepatic artery variants
Hepatic artery variants
SMA anatomy
SMA anatomy
IMA anatomy
IMA anatomy
SMA - IMA collateral pathways
SMA – IMA collateral pathways
Collateral pathways around occluded distal aorta
Collateral pathways around occluded distal aorta
Arc of Buehler
Embryonic ventral communication of celiac artery to SMA
Arc of Buehler
Arc of Riolan; Marginal artery of Drummond
SMA – IMA connection
Arc of Riolan; Marginal artery of Drummond
via superior rectal artery –> inferior rectal artery –> pudendal artery –> internal iliac artery
IMA to internal iliac artery
Superior rectal a from IMA
Middle rectal a from internal iliac
Inferior rectal a from pudendal a
Rectal arcades
Pelvic arteries
Pelvic arteries
FNH arteriogram
spoke wheel appearance
FNH arteriogram
hepatic adenoma
not very vascular
hepatic adenoma
inc vascularity; AV shunting; portal vein invasion
Suspected PE
Dx and tx of pseudoaneurysms and AVM
Work up of pulmonary arterial hypertension
Indications for pulmonary angiography
Psyst/Pdia (mean)
RA (0-5 mmHg)
RV 20-25 / 0-7
PA 20-25 / 8-12

LA (5-10 mmHg)
LV 120 / 10
aorta 120/80 (100)

Normal pressures
mean PA pressure > 15 mmHg
Systolic > 30 mmHg
Definition of pulmonary arterial hypertension
No absolute, all relative
Severe pulmonary HTn
LBBB (catheter irritant may induce RBBB –> complete heart block) –> place transvenous pacer
Contraindications to PA cath
Collaterals in occlusive iliac disease
Internal mammary –> inferior epigastric –> CFA
Lumbar / iliolumbar –> circumflex iliac –> CFA
Lumbar / illiolumbar –> lateral circumflex –> PFA
Gluteal / Obturator –> lateral and medial circumflex –> PFA
Geniculate branches
Collaterals in occlusive iliac disease
Persistent Sciatic artery
Embryonic sciatic artery – off internal iliac, through greater sciatic forament, deep to gluteus maximus –> joins popliteal a above the knee
often bilateral
prone to injury at ischial location
Persistent Sciatic artery
axillary artery anatomy
axillary artery anatomy
Thyrocervical trunk anatomy
Thyrocervical trunk anatomy
Arm veins
Arm veins
inflammatory diseases
Collagen Vascular disease, autoimmune, Buergers disease


Ergotism (long smooth narrowing)
Amphetamine: speed kidney

spasm due to trauma (standing waves)
popliteal artery entrapment

Lower extremity occlusive disease
Dog leg sign
When a popliteal arterial aneurysm is present, a thrombus may prevent contrast material opacification of the entire dilated vessel. Instead, the thrombus may narrow the aneurysmal lumen so that the flowing contrast material simulates the appearance of a dog leg and thus produces the dog leg sign
Dog leg sign
Clinical 5 Ps: pain, pallor, pulselessness, paresthesias, paralysis

Multiple lesions at bifurcations. Lack of collaterals. Severe vasospasm. Menisci filling defects.

Treatment: Surgical embolectomy (*** must differentiate from in situ thrombosis due to different therapy)

Cardiac – mural thrombus, Ventricular aneurysm, MI, Afib
Paradoxical embolus (DVT and L –> R shunt)

Arterial embolism
Buerger's disease
Pan arteritis of unknown etiology
thromboangiitis obliterans
venous involvement in 25%
Nearly all are smokers, 98% male
-Calf and foot vessels most common
-ulnar and radial arteries
-palmar and digital arteries

Abrupt segmental arterial occlusions
intervening normal appearing arteries
corkscrew collaterals
sparing of larger inflow arteries

Buerger’s disease
in diabetics; inc calf and foot involvement
high frequency gangrene –> amputation
Small vessel atherosclerosis
Microemboli to ischemic digits
Livedo reticularis
Blue toe syndrome
Cholesterol emboli
Bilateral, symmetric, diffuse severe vasospasm
Young females on ergot medications for migraines
May Thurner
Compression of left common iliac vein by crossing of the right common iliac artery
Treatment: Stent
May Thurner
Leg veins
Leg veins
DVT and/or PE AND
contraindication to anticoagulation
failure of anticoagulation
complications of anticoagulation
IVC filter indications
COmpression of brachial plexus / subclavian vessels
-Scalene triangle
-costoclavicular space
-pectoralis tunnel
Thoracic outlet syndrome
Paget-Schroetter disease
“effort thrombosis’ of subclavian vein
-mechanical compression by anterior scalene muscle, first rib, subclavius tendon or costoclavicular ligament
Paget-Schroetter disease
AV fistula types
Brescia – Cimino fistula – side to side anastomosis of radial artery and cephalic vein at the wrist
Brachial artery and cephalic vein
Brachial artery and basilic vein
Femoral artery and saphenous vein
AV fistula types
Synthetic graft
can be used earlier than fistula; less longevity
Synthetic graft
Infection (staph, salmonella, syphilis)
Giant cell
Collagen vascular disease (PAN)
Collagen dz (Marfan’s, Homocystinuria, Ehlers Danlos)
Pseudoxanthoma elasticum
DDX Aneurysm
Pseudoxanthoma elasticum
Pseudoxanthoma elasticum (PXE), also known as Grönblad-Strandberg syndrome,[1] is a genetic disease that causes fragmentation and mineralization of elastic fibers in some tissues. The most common problems arise in the skin and eyes, and later in blood vessels in the form of premature atherosclerosis.
Pseudoxanthoma elasticum
Small vessel disease (diabetics)
Embolic disease (thromboemboli, cholesterol emboli, plaque emboli)
Buerger’s disease
Peripheral vascular disease DDX
Popliteal aneurysm
Tortuous artery
Popliteal artery entrapment syndrome
Adventitial cystic disease
Baker’s cyst
Popliteal artery ddx
Supravalvular aortic stenosis****
rare neurodevelopmental disorder characterized by a distinctive, “elfin” facial appearance, along with a low nasal bridge, an unusually cheerful demeanor and ease with strangers; developmental delay coupled with strong language skills; and cardiovascular problems, such as supravalvular aortic stenosis and transient hypercalcaemia.
Williams syndrome
Williams syndrome
Rubella syndrome
Takayasu’s (most common arteritis to cause stenosis)
Aortic stenosis
Williams syndrome (infantile hypercalcemia)
Rubella syndrome
Takayasu’s arteritis
Ass’d with congenital heart disease (esp Tetralogy of Fallot)
Fibrosing mediastinitis
Extrinsic mass
Pulmonary artery stenosis
Pulmonary valve stenosis
Pulmonary artery aneurysm
Assymetric pulmonary artery enlargement
congenital narrowing of pulmonary veins
RF ablation
mediastinal fibrosis
left atrial obstruction
Pulmonary venous hypertension
Interruption of pulmonary artery
Bronchilitis obliterans / Swyer James
Diminished pulmonary artery
Swan-Ganz cath
TB: Rasmussen’s aneurysm, syphilis, fungus, bacteria
Congenital heart disease
Cystic medial necrosis
Marfan syndrome
Pulmonary pseudoaneurysms
Takayasu’s arteritis
Subclavian steal
Decreased renal perfusion (athero, FMD)
Renin secreting tumors
renal compression (intrarenal tumor, Page kidney – subcapsular hemorrhage)
Hyperreninemic hypertension

IVDA (septic)
vasculitides (wegeners, collagen vascular)
radiation tx
amphetamine abuse (speed kidney)

Renal arterial aneurysm
Rupture / penetrating ulcer
mycotic blowout
Soft tissue density around aorta

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