Vascular Interventional Radiology

Indication – nonpalpable peripheral pulses

Preferred – easier to access descending aorta
-left side approach crosses fewer CNS arteries (when going down aorta
-3J wire preferred
Disadvantages:
-difficult to compress
– high incidence of complications
-brachial plexus injury

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)

Low puncture
heparinization
large catheters

Post embolization syndrome (fever, inc WBC) 40%
Infection of embolized area
Reflux of embolic material (nontarget embolization)
Alcohol infarction in the periphery

oxidant production, complement activation, leucocyte-endothelial cell adhesion, platelet-leucocyte aggregation, increased microvascular permeability and decreased endothelium-dependent relaxation

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

Absolute:
active bleeding
pregnancy
intracranial lesion
nonviable limb (revasc –> ARF and myoglobulinuria)
infected thrombus

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

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

Claudication / rest pain
Tissue loss
Non healing wound
Establish inflow for distal bypass graft
Hemodialysis AVF or graft

Long segment stenosis
Total occlusion
Unsuccessful PTA
recurrent stenosis after PTA
Dissection flap
Ulcerated plaque
renal ostial lesions

POrtal hypertension with variceal bleeding
Refractory ascites

Budd Chiari
Pre transplant

<10 mmHg decompression of varices

Absolute
Severe right sided heart failure with elevated CVP
Polycystic liver dz

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

Pneumothorax
Arterial puncture
Hemorrhage
Occlusion
Mechanical problems
Air embolism

Atherosclerosis (most common)
Connective tissue disease (Marfans, Ehlers Danlos)
Syphillis
Post traumatic pseudoaneurysm
Mycotic
Aortitis (Takayasus Giant Cell, Rheumatoid arthritis, Ank Spond)

Degenerative process of aortic muscular layer (media)
-involves sinuses and sinotubular junction
-‘tulip bulb’ aorta

10-30 yrs after primary infection
tree bark calcifications
ascending aorta / arch
assymetrical saccular involvement

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.

Embryonic ventral communication of celiac artery to SMA

SMA – IMA connection

via superior rectal artery –> inferior rectal artery –> pudendal artery –> internal iliac artery

Superior rectal a from IMA
Middle rectal a from internal iliac
Inferior rectal a from pudendal a

spoke wheel appearance

not very vascular

inc vascularity; AV shunting; portal vein invasion

Suspected PE
Dx and tx of pseudoaneurysms and AVM
Work up of pulmonary arterial hypertension

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)

mean PA pressure > 15 mmHg
Systolic > 30 mmHg

No absolute, all relative
Severe pulmonary HTn
LBBB (catheter irritant may induce RBBB –> complete heart block) –> place transvenous pacer
CHF

Internal mammary –> inferior epigastric –> CFA
Lumbar / iliolumbar –> circumflex iliac –> CFA
Lumbar / illiolumbar –> lateral circumflex –> PFA
Gluteal / Obturator –> lateral and medial circumflex –> PFA
Geniculate branches

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

Young:
inflammatory diseases
Takayasus’
Collagen Vascular disease, autoimmune, Buergers disease

Old:
atherosclerosis
embolism

Drugs:
Ergotism (long smooth narrowing)
Amphetamine: speed kidney

Other:
spasm due to trauma (standing waves)
popliteal artery entrapment
radiation

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

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)

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

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

in diabetics; inc calf and foot involvement
high frequency gangrene –> amputation

Microemboli to ischemic digits
Livedo reticularis
Blue toe syndrome

Bilateral, symmetric, diffuse severe vasospasm
Young females on ergot medications for migraines

Compression of left common iliac vein by crossing of the right common iliac artery
Treatment: Stent

DVT and/or PE AND
contraindication to anticoagulation
failure of anticoagulation
complications of anticoagulation
prophylaxis

COmpression of brachial plexus / subclavian vessels
-Scalene triangle
-costoclavicular space
-pectoralis tunnel

“effort thrombosis’ of subclavian vein
-mechanical compression by anterior scalene muscle, first rib, subclavius tendon or costoclavicular ligament

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

PTFE
can be used earlier than fistula; less longevity

Atherosclerosis
Infection (staph, salmonella, syphilis)
Inflammation
Takayasu
Giant cell
Collagen vascular disease (PAN)
Congenital
Collagen dz (Marfan’s, Homocystinuria, Ehlers Danlos)
FMD
NF
Pseudoxanthoma elasticum
Trauma

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.

Atherosclerosis
Small vessel disease (diabetics)
Embolic disease (thromboemboli, cholesterol emboli, plaque emboli)
Vasculitis
Buerger’s disease
Medication

Popliteal aneurysm
Tortuous artery
Popliteal artery entrapment syndrome
Adventitial cystic disease
Baker’s cyst

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.

Congential:
Coarctation
Pseudocoarctation
Williams syndrome
Rubella syndrome
Takayasu’s (most common arteritis to cause stenosis)
NF
Radiation

Williams syndrome (infantile hypercalcemia)
Rubella syndrome
Takayasu’s arteritis
Ass’d with congenital heart disease (esp Tetralogy of Fallot)
Fibrosing mediastinitis
Radiation
PE
Extrinsic mass

Pulmonary valve stenosis
Pulmonary artery aneurysm

congenital narrowing of pulmonary veins
RF ablation
mediastinal fibrosis
left atrial obstruction

Hypoplasia
Interruption of pulmonary artery
Bronchilitis obliterans / Swyer James
PE

Swan-Ganz cath
Infection
TB: Rasmussen’s aneurysm, syphilis, fungus, bacteria
Congenital heart disease
Atherosclerosis
Cystic medial necrosis
Marfan syndrome

Atherosclerosis
Takayasu’s arteritis
Congenital
Postsurgical
Trauma
NF1
Radiation

Decreased renal perfusion (athero, FMD)
Renin secreting tumors
renal compression (intrarenal tumor, Page kidney – subcapsular hemorrhage)

Main:
FMD
athero
NF
mycotic
trauma
congenital

Distal:
PAN
IVDA (septic)
vasculitides (wegeners, collagen vascular)
traumatic
radiation tx
amphetamine abuse (speed kidney)

Hematoma
Rupture / penetrating ulcer
aortitis
mycotic blowout
angiosarcoma