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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
• Phlebitis
• Anaphylaxis
C. Catheter:
• Cholesterol emboli
• Thromboembolism
• 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

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/
Pulmonary angiography

C. Flow rate injections

Site Catheter Injection
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 (α-blocker);
25 mg IA peripheral spasm
• Nitroglycerin: direct muscle relaxant; 100 µg IA/ IV peripheral
• Nifedipine: Ca
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
=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:

Material Occlusion Primary Use
Temporary Agents
Gelfoam (surgical
Weeks Upper GI bleed; pelvic
trauma; postoperative
Pledgets Weeks Cut to size
Ethyl or PVA Permanent Tumors
Steel coils (micro-/
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)
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
U/hr; repeat angiogram in 12 hrs
• High dose: 250 x 10
U/hr x 4 hrs repeat angio 125 x
• Pulse spray ultra-high dose: 600 x 10
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
• 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

8. Angioplasty:
A. Indications: claudication; tissue loss; nonhealing wound/ ulcer; HD-
B. Principles: premedicate with ASA +nifedipine; ipsilateral approach;
heparin (5-10 x 10
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)

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
B. Contraindications:
• Absolute: severe RHF; severe coagulopathy; multicystic liver
• 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

11. Lymphangiography:
A. Principles:
• Inject 1 ml of isosulfan blue between 1
and 4
• 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
II. Thoracic Aorta and Great Vessels

1. Anatomy:
A. Embyologic arches:
• 1
maxillary artery
• 2
stapedial artery
• 3
• 4
proximal right portion proximal right SCA; distal portion
right-sided AA (remnant =ductus diverticulum along
venteromedial descending aorta)
• 5
• 6
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
arch +
regression of proximal right 4
• Intercostal arteries: usually paired from 3
to 11
• 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:
• 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”
; rare dissections

• Mycotic (ascending aorta or isthmus):
• Agents: Staphylococcus, Streptococcus, Salmonella
• Risk factors =IVDA; endocarditis; postsurgical;
• 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
B. Etiologies:
• HTN: #1
• Collagen disorders: Marfan’s; 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)

E. Treatment:
• Stanford B: medical management unless ischemic, neurologic
• Stanford A: surgery (avoid tamponade, AI, coronary artery
• 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
B. Distribution:
• Aortic isthmus: #1 (95%); between left SCA and ligamentum
• 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
• CT: direct (intimal flap, contour abnormality, etc.) and indirect
(mediastinal hematoma, etc.)
• Angiography: intimal tear; pseudoaneurysm; DDX =ductus bump
or diverticulum (remnant of 4
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
; 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
• 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
• Stenosis:
• <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 +
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
• 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
+/- 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
• 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
• Dissection
• Retroperitoneal fibrosis
• Marfan’s
• Mucopolysaccharidoses
• 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
vitelline artery); SMA (=13
B. Celiac axis: arises at T12-L1; 1
branch =left gastric artery; 2
=splenic artery; 3
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
• Middle colic artery: 2
• 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
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
• 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) >
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
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
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)

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

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
↓ Associated with cirrhosis;
displaced veins; “stretched”
HCC ↑↑
AV +AP shunt
Portal vein invasion; 75%
↓ 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;
• 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

5. Portal HTN:
A. Clinical: >6 mm Hg portal pressure or >11 mm Hg gradient; ↑ variceal
B. Etiologies:
• Presinusoidal: PV obstruction (thrombosis; tumor);
• 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

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;
• Tumor growth: RCC; HCC; adrenal carcinoma
• Other: IVC membrane/webs; pericarditis; right atrial tumor
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
• 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
• 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
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
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
> 70 mmHg)
C. Pressures

Location P



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
> 30 mmHg) or (PA

> 15
• 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
D. Complications:
• Pain
• 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
• 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:
• Behcet’s disease: aphthous stomatitis + genital ulcerations +
iritis; ↑ large vein occlusion (SVC syndrome); ↑ large artery
• Hughes-Stovin disease: rare; idiopathic necrotizing vasculitis;
pulmonary aneurysms + systemic thrombosis/
pulmonary emboli

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;
B. Radiographic:
• CXR: exclude PTX; pneumonia; Westermark’s sign; Hampton’s
• 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
>50 mmHg
• Indications: indeterminate V/Q or CT scan with high clinical
suspicion; hemodynamically unstable
C. Treatment:
• Anticoagulation
• Filters:

Name Introducer
Compound IVC size
Greenfield 8-12 F Titanium <30 mm
Vena Tech 12 F Phynox (8 metal
<28 mm
Simon Nitinol 8 F Nickel-titanium <28 mm
Bird’s Nest 9 F Stainless Steel <40 mm
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
• 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
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
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
• 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 (?)

5. Occlusive disease:
A. Etiologies:
• Inflammatory
• Collagen-vascular diseases; autoimmune disease
• Buerger’s 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 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;
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
C. Radiographic: abrupt segmental cutoff; multiple corkscrew collaterals

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

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:
• Anticoagulation
• IVC filter: failed or contraindicated anticoagulation; prophylaxis
• Filter types:
• Birdsnest (=Cook): for mega cava >28 mm
• Greenfield (=Medi-tech)
• LGM (=Vena-tech)
• Simon nitinol (=Bard): smallest delivery system brachial
• 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
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
• 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
• 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 >
• Treatment: steroids; IFN-α; 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
VIII. Differential Diagnoses

1. Aneurysm:
• Atherosclerosis
• Infection: bacterial; syphilis
• Inflammation: Takayasu’s; giant cell arteritis; PAN
• Congenital: Marfan’s; homocysteinuria; NFT; pseudoxanthoma

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:
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

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)
• Takayasu’s arteritis (type IV)
9. Hyper-reninemic HTN:
• Atherosclerosis RAS Goldblatt kidney
• 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:
• Atherosclerosis
• Mycotic
• Trauma
• Congenital
B. Distal artery:
• Vasculitis: PAN; Wegener’s
• Drug-abuse: amphetamines; cocaine; etc.
• Other: post-traumatic; XRT