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106 Cards in this Set
- Front
- Back
What does the pulmonary trunk originate from, and what does it bifurcate into?
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Originates @ pulmonary valve
Bifurcates into L & R pulmonary arteries |
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How many zones is pulmonary circulation divided into?
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3
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What affects the pressure within the zones?
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Gravity (upright vs. supine) [plays large role, can enable tech to image a certain part of the lung], pulmonary A & V pressure, alveoli, & interstitial pressures
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Indications for Pulmonary Angiography
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AVM (arteriovenous malformations)
PDA (Patent ductus arteriosus) PE (pulmonary embolus) |
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Contraindications for Pulmonary Angiography
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- recent MI
- pulmonary hypertension (MAP > 60 mmHg) [mean arterial pressure] |
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Most common approach for pulmonary angiography
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Femoral vein (can be contraindicated when PE is suspected)
Alternative method --> brachial vein |
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What kind of catheters are used in pulmonary angiography?
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Pigtail, close-end, multi-sidehole
ex. Grollman, Van Aman Advantage --> reduction in catheter whipping |
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How quickly should the contrast media be injected in pulmonary angio?
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1-2 seconds
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How should contrast be injected for a patient w/ pulmonary hypertension?
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Never directly into artery; should be pushed from R atrium to avoid side effects (arrhythmias, pulmonary edema)
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Supine Imaging - Pulmonary Angio
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Used to evaluate symmetric flow of arteries, size of vessel, etc.
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Oblique Imaging - Pulmonary Angio
[Patient position based on II, not table] |
RAO position (LPO on table)
- 10-15 degree RAO shows R pulmonary artery LAO position (RPO on table) - 30-45 degree LAO shows L main pulmonary artery |
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Serial Imaging vs. Digital Subtraction Angio
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- DSA preferred b/c can record emboli as small as 2 mm
- DSA has more motion artifacts (breathing, heart beat) |
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Complications of Pulmonary Angio
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PVCs, perforation, arrhythmias, twisted catheter, severe bradycardia
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Pulmonary Angiographic Findings
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- PE (filling defect, complete occlusion)
- Pulmonary stenosis - Vascular changes in lung fields (ex. AVM) - Coarctation of pulmonary A - PDA - Tumors |
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What's the largest artery in the body?
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Aorta
Originates --> aortic valve Ends --> bifurcation of common iliacs (L4) |
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Segments of Aorta
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- thoracic aorta = aortic valve to T12
- above aortic valve = aortic bulb or root |
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Which ostia of the "great vessels" is contained in the aortic arch?
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Innominate artery (R brachiocephalic artery)
L common carotid A Left subclavian A |
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Indications for Thoracic Angio
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Abnormalities undeterminable / PDA / aneurysm / coarctation / aortic insufficiency (AI) / aortic stenosis (valvular gradient)
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Equipment used for Thoracic Angio
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- Electromechanical injector (pushes large amounts of CM quickly enough to fill vessel of interest)
- Cineradiographic equipment - Emergency equipment |
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Thoracic Angio Pre-Procedural Care & Safety
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- thorough patient history
- premedication - any previous images (can help decide type of equipment to use) |
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Thoracic Angio Forward Approach
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- rarely used; antegrade approach (with the flow)
- catheterization of femoral VEIN, puncture through septum of heart (Brockenbrough needle set) - limited to cases w/ severe aortic stenosis & when retrograde is contraindicated |
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Risks of Forward Approach
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- needle and/or wire could puncture aorta
- possible perforation of myocardium allowing access to pericardium, causing tamponade |
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Thoracic Angio Retrograde Approach
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- femoral approach preferred (can be contraindicated due to distal stenoses or tortuosity)
- can use left brachial approach if femoral is contraindicated |
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Most common catheter for Thoracic Angio
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Pigtail b/c of end hole & sideholes (large bolus)
- may use angled one if also performing LHC - w/ known disease, "marked" pigtail used |
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How much contrast media is needed to image aortic arch?
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Up to 600 mL
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Optimal concentration of Contrast for Thoracic Angio
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70%
Can cause cerebral damage if brain accumulates significant amounts |
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Where is the catheter tip positioned in thoracic angio?
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Mid-ascending aorta
Can be placed close to root if AI is suspected Selective angio --> tip in ostium of vessel |
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Thoracic Angio Positioning & Imaging
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- most often used = PA & lateral
- also used = LAO, RAO AP & LAO sufficient for thoracic anatomy |
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Death Rate for Thoracic Angio
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1.7%
Higher concentration of CM, higher risk Largest % of death due to cerebral damage |
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An increased risk of complications for thoracic angio is seen in patients...
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On anticoagulants, hypertension, arteriosclerosis, AI
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Aortic Insufficiency (AI)
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- seen on CXR as downward, lateral, posterior displacement of cardiac apex
- pronounced L ventricular dilation - seen in angio as regurgitation of CM into LV when injected from aortic root |
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Implications of AI
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- increased LV pressures --> leads to mitral valve insufficiency & failure
- leads to LV & LA hypertrophy --> leads to CHF |
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Thoracic Angio Positional Abnormalities
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- variations in shape of arch and/or position of great vessel origins
- "Bovine" arch: R brachicephalic & LCCA share common ostium (20% of patients) [also a version w/ L vertebral ostium originating from arch] - R subclavian is retro-esophageal (distal to L sub) |
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Thoracic Aneurysms
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- Ascending 22%, Arch 12%, Descending 7%, rest associated w/ AAA
- Fusiform (blobby, not uniform, unpredictable path) - Saccular (spherical shape, looks like a big ball) - Dissecting |
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3 Layers of Lumen Wall
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Adventitia, Media, Intima
Dissection occurs when blood is allowed through intima into medial layer w/o rupturing adventitia |
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False Lumen (FL) & True Lumen (TL)
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- created by dissection
- if FL blocks flow to TL, ischemia occurs & morbidity advances quickly |
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Risk of Death in untreated aortic dissection
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25% first 24 hours
50% in first week 75% in first month 90% in first year |
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Patent Ductus Arteriosus (PDA)
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- in unborn child, ductus arteriosus allows blood to bypass high resistance fluid-filled compressed lungs; blood flows from RV to PA through DA into aorta
- if DA fails to close after birth, PDA allows oxygenated blood to flow back through PA into lungs (should close 12-24 hours) |
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Coarctation
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- narrowing between vasculature going into upper extremity & down to lower extermity
- best visualized in AP or LAO position |
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Indications for Cerebral Angio
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- previous positive studies
- Gold Standard |
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Contraindications for Cerebral Angio
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- CM sensitivity
- advanced arteriosclerosis - very ill/comatose patients - severe hypertension - severe subarachnoid or intracerebral hemorrhage |
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Most common method of vessel access for cerebral angio...
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transfemoral artery
alternate methods = direct carotid, brachial a |
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Catheters & Contrast Rate for Cerebral Angio
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- Berenstein / Headhunter / Simmons / Newton / Manj / Bentson
- 2 mL/kg/hr |
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Positioning in Cerebral Angio
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- for AP position (PA Axial projection) & lateral, interpupillary line is perpendicular to table (IOML 20 degree angle)
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Difference in tube angles in cerebral angio btw. carotid arteriography or vertebral angiography
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Carotid Arteriography = 15 caudal
Vertebral Angiography = 25 caudal |
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Complications from Cerebral Angio
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- contrast allergic reactions
- mechanical injuries (ruptured vessel, hemorrhage, etc.) - physiologic complications (stroke, TIA, etc.) |
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Findings in Cerebral Angio
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Atherosclerosis / Aneurysms / Traumatic Intracranial Hemorrhage / AV Malformations / Tumors / Evidence of Stroke
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Percutaneous Transluminal Coronary Angioplasty (PTCA)
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- ballooning causes controlled injury by tearing intima & media (stretches adventitia past point of recoil)
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Indications of PTCA
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Atherosclerosis / Clots (unstable angina) / Previous Coronary Artery Bypass Graft (CABG)
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Contraindications of PTCA
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- L Main CAD (going to have CABG if stenosis is severe)
- excessive heart dependency on 1 artery alone - poorly functioning heart - multi-vessel disease |
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The "Widow Maker"
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Severe blockage within the LMA
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Overall occurrence rate of complications from PTCA is approx....
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4-5%
After 2-5 years, 70-75% are still patent |
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Major Complications from PTCA
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Coronary A occlusion / MI / Neurologic deficit / Renal failure / death
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Recoil Factor
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- balloons don't compress all areas of vessel the same b/c of varying degree of hardness throughout the plaque
- may cause lumen size to become smaller |
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Coronary Stents
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- expandable metal device that presses against lumen wall to keep it open
- first one placed = 1986 in France - US first stent = 1994 |
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Methods of Coronary Stenting
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Direct
- stent placed directly into stenosis as soon as its positioned properly & inflated Angioplasty plus Stenting - angio performed using regular balloon, then stent is placed |
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Indications for Coronary Stenting
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- angioplasty alone is unsuccessful (lesion keeping recurring)
- uncontrolled dissection in artery |
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Contraindications for Coronary Stenting
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- acute angles in vessel @ location of stenosis
- less than 2 mm vessel size |
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Acute Complications of Coronary Stenting
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- artery may abruptly close
- thrombus from elsewhere becoming embolus - incomplete stent apposition |
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Long Term Complications of Coronary Stenting
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- after receiving stent, it's recommended to take a platelet inhibitor (Coumadin) for 4-6 months
- anticoagulant therapy may become lifelong, especially for bare-metal stents Death Rate = 0.1% |
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Bare Metal Stent
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- multiple stent designs, all made of stainless steel
- 4-15% of re-stenosis |
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Drug Eluting Stent
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- have polymer coating which chemically houses drug; released uniformly within stent
- 3% chance of re-stenosis - can have (rare) allergic reactions to polymer coating |
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Cypher Drug Eluting Stent
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- 1st one released in US in 2003
- Sirolimus (originally used to prevent rejection of transplanted organs) |
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Taxus Drug Eluting Stent
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- released in US in 2004
- Paclitaxil (originally marketed as cancer drug) |
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Xience V Drug Eluting Stent
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- released in US in 2008
- Everolimus: derivative of sirolimus |
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Directional Atherectomy
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- method of removal --> mechanically driven catheter shaves off plaques (stores in collection chamber within catheter)
- higher risk of MI - 33% recurrence of re-stenosis |
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Rotational Atherectomy
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- high speed burr coated w/ microscopic diamond particles; rotates up to 200,000 rpm
- breaks thrombus into smaller than RBC pieces - 30-50% re-stenosis rate |
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Thrombolysis
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- IV or IA infusion of anticoagulation meds are used (t-PA [tissue plasminogen activator], streptokinase, urokinase)
- may use as pulse spray or infusion drip - Risks: increased bleeding/hemorrhage risk |
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Thrombectomy
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Mechanical
- catheter advanced to lesion, wire used to mechanically "grab" the clot Aspiration - heparinized saline pumped @ high pressure, dissolves clot which is simultaneously aspirated |
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Coronary Artery Bypass Graft (CABG)
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- 1-2% of patients come from previous angio procedures
- typically use saphenous vein grafts (SVG) to bypass lesion (vein turned inside out) |
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"Mapping" CABG
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- one on right usually is RCA
- on left side: lowest one LAD / next up Diagonal / next up Marginal (OM) / next up Circumflex (CX) or another Marginal |
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Modified Seldinger Percutaneous Approach (Non-Vascular Angio)
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- needle w/ stylet, advanced through skin to anatomy of interest; stylet removed, reflux of fluid determines proper location
- wire advanced into selected area - needle removed, catheter inserted over wire |
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Nephrostomy
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- posterior approach on patient (prone w/ side of interest elevated)
- needle puncture 2-3 cm below 12th rib - catheter should enter in middle/lower calyx, advancing through renal pelvis; dilators widen tract |
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What is an exception to the posterior approach to nephrostomy?
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Transplanted kidney requires supine positioning w/ anterior approach
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Where should the catheter enter in the kidney for stone removal?
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Superior Calyx
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A renal stent can be placed 2 ways...
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1) Pigtail looped in renal pelvis, body of stent exits posteriolaterally through skin
2) Stent advanced & 1 pigtail end placed within renal pelvis, body of stent travels through ureter, other pigtail end placed in bladder |
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Indications for Nephrostomy
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- drain obstructed kidney/ureter
- remove a stone - infuse drugs |
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Complications with Nephrostomy
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- about 4% of the time
- 2 most frequent = hemorrhage & infection - sepsis other major complication (occurs w/ infected stone or urine, bacteria gets into blood stream) |
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Percutaneous Biliary Drainage
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- antibiotics given 1 hr prior to exam
- supine w/ right arm raised above head - needle inserted into R lateral superior abdomen below 10th rib - internal or external drainage placed |
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Indications for Percutaneous Biliary Drainage
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- un-resectable malignant disease (pancreatic CA) [palliative]
- biliary obstruction - post-op biliary leakage - stone removal |
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Contraindications for Percutaneous Biliary Drainage
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- asymptomatic jaundice
- ascites - advanced liver cirrhosis - defuse hepatic mets or liver failure (life expectancy = less than 1 month) |
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Complications from Percutaneous Biliary Drainage
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Sepsis / Hemobilia / Catheter Obstruction/Displacement / Cholangitis / Bile peritonitis / Pneumo/Hemothorax
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Percutaneous Abscess Drainage - Needle Aspiration
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- performed if abscess < 5 cm in diameter
- 22 G needle, can use 18 G if it's viscous - small amt of fluid is aspirated & tested (if infected, antibiotics inserted directly into abscess; if not, abscess drained) |
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Percutaneous Abscess Drainage - Catheter Drainage
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- similar to localizing abscess w/ needle
- wire introduced, needle removed, catheter inserted (single-lumen), CM injected (sinogram), catheter left in place for days to drain - when output measurements reach zero, catheter removed - |
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Indications for Percutaneous Abscess Drainage
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Abscess (localized collection of pus, most likely from infection)
"Walled Off" by body, continue to grow & can become serious |
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Complications from Percutaneous Abscess Drainage
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- septic shock
- fistula formation (abnormal connection btw 2 organs) - bleeding |
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Percutaneous Needle Biopsy
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.- special needles w/ collecting chamber are used to take tissue sample
- sample is gram stained or put into formalin for culture assessment |
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Indications/Contraindications for Percutaneous Needle Biopsy
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Indications: samples tissue for mets or not (most common areas = lungs, kidneys, pancreas, & liver)
Contraindications: patients w/ vascular lesions or AVMs in ROI |
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Complications from Percutaneous Needle Biopsy
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- Lungs: pneumothorax, hemothorax, air emboli, hemoptysis
- Kidneys: hematuria, hematoma, ureter obstruction |
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Gastrostomy Tube Placement
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- NPO 8 hours before
- ID liver & colon to ensure no overlap of stomach prior to puncture - NG tube placed to inflate stomach; percutaneous puncture; dilators used up to 24 Fr; wire inserted, dilator removed; tube threaded over wire to location; anchored by balloon & rubber disc |
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Indications for Gastrostomy Tube Placement
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- long term feeding (patient unable to eat/swallow of own accord)
- those suffering from strokes, cancer in esophagus/tongue |
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Complications from Gastrostomy Tube Placement
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- puncture of liver, colon, or posterior wall of stomach
- improper tube placement into abdomen instead of into stomach/GI tract as well |
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At what spine level does the celiac trunk originate?
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Anterior to L1
Common iliacs @ L4 |
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Abdominal Aortogram
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- includes entire abdominal aorta from diaphragm down
- catheter placed in most superior part of abdominal aorta (requires more CM, gives great pics) |
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Celiac & Mesentery Angiogram
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- flow can experience ischemia through...embolism (most common) / thrombosis (highest mortality rate [90%]) / non-occlusive ischemia
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Renal/Adrenal Angiogram - Renal Artery Stenosis (RAS)
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- 2 main causes: fibromuscular dysplasia (FMD) & atherosclerotic RAS (ARAS) [most common form]
- FMD can affect all 3 lumen layers, often seen as medial FMD - RAS usually requires stent placement for best results (only 50% effective w/o stent, 95% with) |
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Stenosis is clinically significant at....
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50-70% stenosis
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Extremity Venograms
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Upper
- puncture site distal, CM is antegrade Lower - puncture site distal (ex. femoral vein) |
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AFR (Aortofemoral Runoff) [Extremity Arteriogram]
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- femoral approach most often used (utilize descending aorta to access great vessels on arch)
- on lower ext, femoral approach can be contraindicated w/ previous bypass, occlusion, etc - can use up to 60 mL of CM for bilateral imaging |
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Thromboendarterectomy (TEA)
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Surgical procedure involving excision of thrombus by removing it from intimal lining of vessel (cut into vessel through surface of skin)
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Mechanical Atherectomy/Rotational Atherectomy
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- similar procedure to endarterectomy, but plaque is removed via catheter from vessel
- indicated for fibrocalcific lesions (stent-mal-expansion & fxs more common) & for femoropopliteal segments that are difficult to stent |
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Aortofemoral Bypass Grafts (AFB)
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- more common than TEA
- used for patients w/ diffuse or multifocal disease - may use an "axillofemoral bypass" if distal aorta is compromised |
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Angioplasty/Stenting
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- proven successful for more focal lesions
- self-expanding stents preferred to avoid "crush injuries" due to natural body mvmt |
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Covered Stents/Stent Grafts
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- covered material allows for treatment of inadvertent punctures, traumatic AV fistulae, vessel ruptures, & small vessel aneurysms
- usually made of PTFE (polytetrafluoroethylene) |
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Cutting Balloon
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- longitudinally mounted microsurgical blades on balloon; as balloon is inflated, atherotomes are deployed into vessel walls
- reduces elastic recoil & allows for lower balloon pressures |
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Cryotherapy
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- nitrous oxide fills balloon, causes it to cool to -10 degrees C
- causes less pressure to open artery, more uniform dilation of vessel b/c plaque cracks when frozen - rapid cooling causes cellular apoptosis |