A. Correct. Buerger’s disease should be suspected in any patient presenting with peripheral vascular disease before the age of 45. There is a strong association with cigarette smoking and male gender. Migratory thrombophlebitis is also a feature of the disease.

A. The most common location for shunt stenosis is in the hepatic vein end of the shunt. Shunt stenosis can be identified by ultrasound by localized high velocity flow and turbulence. This associated with incomplete filling of the hepatic vein end of the shunt with color flow makes this the most likely diagnosis.

A. One of the primary considerations includes lymphoma when a mediastinal mass is encountered. A large amount of tissue is required for accurate characterization and diagnosis of lymphoma and thus a core biopsy is required. Fine needle aspiration is not adequate for making accurate diagnosis of lymphoma.

Findings: The chest radiograph demonstrates a normal sized heart and normal left hemithorax, including pulmonary vasculature. The angiogram confirms a small right pulmonary artery. The right main pulmonary artery is small and the right lung is hyperlucent due to a diffuse decrease in pulmonary vascularity.

A. Osler-Weber-Rendu Syndrome, also known as hereditary hemorrhagic telangiectasia, is an autosomal dominant disorder resulting in diffuse vascular dysplasia. The dysplasia is manifested as arteriovenous malformations (small ones are called telangiectasias), and aneurysms. Pulmonary arteriovenous malformations occur in 5-15% of patients. This disease does not result in diffuse hypoplasia of a vascular bed.
B. Swyer James Syndrome is the result of acute viral bronchiolitis in infancy or early childhood that prevents further normal lung development. Symptoms include cough, dyspnea on exertion, hemoptysis, and recurrent lower respiratory infections. Radiographic abnormalities may be present even in asymptomatic individuals. Pathologic findings include a small hemithorax, diffuse bronchiectasis, emphysematous changes in the lung parenchyma, and a diffusely small pulmonary arterial tree. The findings usually involve one lung, but may be restricted to a single lobe, or involve both lungs. Ventilation perfusion scanning demonstrates air trapping and diffusely decreased perfusion in the affected region. Bronchiectasis is evident on high resolution CT. The pulmonary arterial tree is intrinsically normal but is small because it subserves a decreased amount of lung parenchyma.
C. Chronic pulmonary embolism can cause the pulmonary arteries to be small and the arterial tree to have a pruned appearance. Chronic PE, however, does not affect a single lung; abnormalities will be evident in both lungs. In addition, the arteries are intrinsically abnormal; findings include abrupt occlusion of vessels, irregularity of the vessel wall, and intravascular webs. These abnormalities are the result of clot retraction and fibrosis. Finally, in chronic PE, the central pulmonary arteries can be quite large due to the pulmonary arterial outflow obstruction.
D. Isolated valvular pulmonic stenosis is one of the most common congenital heart diseases diagnosed in adulthood. It may require no treatment or may lead to clinically significant right ventricular outflow obstruction. The most common presenting symptoms are due to exercise intolerance, and may include fatigue, dyspnea, chest pain and syncope. Pathologic findings resulting from the narrowed valve orifice include right ventricular hypertrophy and post stenotic dilation of the main pulmonary artery. Because of the direction of the jet effect, the left pulmonary artery may also be dilated. The right pulmonary artery and peripheral arterial tree are usually normal. In this case, there is no evidence of right ventricular hypertrophy or enlargement of the main pulmonary artery on the chest radiograph. In addition, the right pulmonary arterial tree is clearly hypoplastic.
E. Takayasu arteritis is a granulomatous inflammation affecting the aorta, its major branches, and the pulmonary arteries. It is of unknown etiology and usually presents in patients younger than age 50. Radiographic findings include systemic arterial stenosis and occlusions, although regions of vascular dilation can occur. The pulmonary arteries may be involved. Pulmonary arterial abnormalities include multiple segmental stenoses and occlusions that mimic chronic pulmonary embolism. Because of the diffuse nature of the disease, both lungs are typically. Due to outflow obstruction, the central pulmonary arteries may be enlarged. As is seen in the systemic circulation, affected pulmonary arteries are thick-walled on cross-sectional imaging.

Findings: The abdominal aorta and its major visceral branches are normal. There is a large filling defect at the aortic bifurcation extending across the origins of both common iliac arteries. The iliac arteries beyond their origins are normal.

A. Except for the filling at the aortic bifurcation, the arteries here are normal. They have smooth margins, they are of normal caliber, and they taper gradually as they course peripherally. The iliac arteries are diffusely small, but this can be explained by the obstruction to inflow by the large filling defect at the aortic bifurcation. Atherosclerotic changes include vessel wall calcifications, marginal irregularity of vessels, and segmental stenosis that may be concentric or eccentric. The aortic bifurcation is a common site for atherosclerotic stenosis or occlusion to occur – especially in elderly smokers. However, it would not against in a background of otherwise normal vessels. Other vessels would demonstrate changes of atherosclerosis. In addition, atherosclerotic occlusions occur gradually, allowing collateral vessels to develop. Collaterals that result from atherosclerotic occlusion of the distal aorta typically arise from lumbar arteries. The lumbar arteries here are of normal caliber and course.
B. Correct. This is a classic appearance of an embolus: a filling defect with menisci at its borders with patent lumen. In addition, emboli typically lodge at bifurcation points, as is the case here. Other vessels are normal. The patient’s history in this case suggest that the source of the embolus may be bacterial endocarditis.
C. A dissection occurs when a partial thickness tear occurs in the arterial wall, allowing blood to flow within a channel that develops in the medial layer. The classic arteriographic finding is a liner filling defect within the artery that spirals along the course of the artery. Re-entry tears occur at branch points. The false channel can thrombose; when that happens the arteriogram demonstrates smooth narrowing of the residual true lumen. An abrupt short occlusion with menisci is not characteristic of a dissection.
D. Coarctation is a congenital narrowing or occlusion of the aorta. Coarctation of the thoracic aorta typically presents in childhood. Congenital abdominal aortic coarctation is rare, and may present in young adults. Its etiology is poorly understood; it may be the result of incomplete fusion of the two embryonic dorsal aortas. Congenital abdominal aortic coarctation appears as a smooth tapered narrowing of the vessel. It may involve the origins of one or more visceral vessels. Coarctation at or above the level of the renal arteries usually presents with hypertension.. Coarctation of the infrarenal aorta may present with claudication. Large collateral channels are invariably present. With infrarenal coarctation, collateral supply to the legs arises from the lumbar and inferior mesenteric arteries, and possibly the internal mammary arteries.
E. A transsection is a circumferential laceration of the vessel wall. Aortic transsection is invariably the result trauma, typically deceleration injury. Aortic transsection usually occurs as a result of high speed motor vehicle accident. The common locations for this injury are the aortic root, the aortic isthmus, and the aorta at the level of the diaphragm. Of these, root injuries are the most common in autopsy series; isthmus injuries are most common among patients who live long enough to reach medical care. Abdominal aortic transsection is relatively rare but may occur. In small peripheral arteries, transsection may result in arterial occlusion at the site of injury. This is not the case in the large caliber, high flow aorta. With aortic transsection, the classic angiographic finding is extravasation of contrast from the vessel lumen into an irregular but contained vascular space commonly called a pseudoaneurysm. The pseudoaneurysm is contained by the connective tissue surrounding the aorta. Free extravasation of contrast is rare and when it occurs is a premorbid event.

"Findings: This is a normal celiac arteriogram. The labeled artery is the gastro-epiploic artery, the terminal branch of the gastro-duodenal artery. It courses along the greater curvature of the stomach. The major branches of the celiac axis are the splenic, left gastric and common hepatic arteries. In about 50% of people, including this patient, the inferior phrenic arteries also arise from the celiac axis. This patient's hepatic arterial supply is non-standard: the left hepatic artery arises from the left gastric artery, this occurs in about 25% of patients.

A. The right gastric artery is a small vessel that is frequently not seen on celiac arteriography. It usually arises from the proper hepatic artery or the proximal left hepatic artery. It courses along the lesser curvature of the stomach to anastomose with terminal branches of the left gastric artery.
B. The dorsal pancreatic artery is a large short vessel that courses vertically from the celiac axis or splenic artery to provide blood supply to the body of the pancreas. It gives off the transverse pancreatic artery which courses along the long axis of the pancreas. It also anastomoses with branches of the pancreatico-duodenal arcade. Although its origin can be variable, it does not arise from the gastroduodenal artery and does not have the long course demonstrated by the gastroepiploic artery.
C. The inferior pancreatico-duodenal artery arises from the proximal superior mesenteric artery (SMA) or from a jejunal branch of SMA. It branches into anterior and posterior divisions that wrap around the head of the pancreas to anastomose with the superior pancreatico-duodenal branches of the gastroduodenal artery. You can fill this vessel on a celiac arteriogram but you would expect to see contrast reflux from it into SMA.
D. The labeled artery is the gastroepiploic artery. This terminal branch of the gastroduodenal artery runs along the greater curvature of the stomach, supplying branches to the stomach as well as to the omentum. The gastroduodenal artery is one of two major branches of the common hepatic artery. The other is the proper hepatic artery. The arteries can be named correctly by assessing where they arise and where they travel.
E. The middle colic artery arises from the proximal superior mesenteric artery and has a typical branching pattern. It branches in a ""T""-like fashion into right and left branches which course along the mesenteric border of the transverse colon. Rarely, this vessel can arise from the celiac axis or from the dorsal pancreatic artery. It does not arise from the gastroduodenal artery.

Findings: There is dense opacification of veins throughout the mesentery. In the periphery of the mesentery, the veins have a normal course and location. In the region of the root of the mesentery, there is a tangle of varicosities which course along the expected location of the main superior mesenteric vein and main portal vein. In the right upper quadrant, the varicosities drain into a vein that could be mistaken for the main portal vein. However, it is small and irregular; it terminates in a tangle of small vessels in the liver hilum. Normal intrahepatic portal vein branches can be seen in the periphery of the liver. The splenic vein is not seen.

A. An arteriovenous malformation in the superior mesenteric circulation could cause dense venous opacification. It could also be the source of recurrent GI hemorrhage. It could cause varicosities to develop due to high flow. However, you would expect to see simultaneous opacification of arteries and veins. An AVM would not lead to portal vein occlusion. Therefore, you would expect to see varices in addition to a large portal vein.
B. Pancreatic cancer can cause encasement, invasion, compression, and occlusion of the superior mesenteric and portal veins. However, because pancreatic cancer is typically an aggressive disease, these changes occur relatively rapidly. Varicosities do not develop, presumably due to concurrent invasion of potential collateral channels and because of lack of time prior to the patient’s death.
C. Correct. The superior mesenteric, and portal veins do not fill on this superior mesenteric arteriogram. Large varicosities replace them. This is the classic appearance of “cavernous transformation of the portal vein”, or chronic portal venous occlusion. In this case the central right and left portal vein branches are involved as is the superior mesenteric vein. The central venous occlusion is most likely the result of chronic pancreatitis. The splenic vein is also probably occluded, at least centrally. The varicosities arise from small periportal and peribiliary veins that dilate over time. Chronic portal vein occlusion can occur following sepsis or pancreatitis, or as a result of cirrhosis. It can occur in infants after umbilical vein catheterization.
D. Budd-Chiari syndrome is the result of obstruction to hepatic venous outflow – due either to thrombosis of peripheral intrahepatic vein branches; central hepatic vein webs, or IVC obstruction. There is no association with pancreatitis. The portal system is normal, although the portal pressures are high and flow in the portal vein may be reversed.
E. A spontaneous spleno-renal shunt occurs as a natural decompression pathway in patients with portal hypertension and a patent splenic vein. The angiographic appearance includes filling, from the splenic vein, of a large cluster of varicosities in the left upper quadrant of the abdomen that drains caudally into the inferior vena cava via the left renal vein. This arteriogram demonstrates none of the findings of spleno-renal shunt.

Findings: There is a focal dilatation of the proximal descending aorta, with linear defects projecting transversely across the aorta at the proximal and distal aspects of the focal dilatation.  An endotracheal tube, a left chest tube, and a nasogastric tube are present.

A. The aorta and proximal great vessels appear normal with the exception of the findings described. Atherosclerotic disease is usually extensive and affects multiple vessels. It also usually affects older individuals.
B. A Type aortic dissection involves the ascending aorta, which is normal in this case. Aortic dissection usually develops after age 50,  and is more common in males.
C. Syphilitic aneurysms more commonly affect the ascending aorta or arch. They are typically saccular in appearance and are a late complication of syphilis, occurring 10 to 30 years after the primary infection.
D. Correct. The proximal descending aorta is the most common location of a traumatic false, or pseudoaneurysm, of the aorta. The presence of a chest tube, an endotracheal tube, and a nasogastric tube support the diagnosis of a traumatic injury. It most commonly occurs in young adults or adults, with a mean reported age of 35 in one large study.
E. A penetrating ulcer is usually an eccentric, focal outpouching of the aorta.  It occurs in older age groups and is associated with underlying atherosclerotic disease

"Findings: The films demonstrate that the aorta is normal – straight and smooth. There are high-grade orificial stenoses of both the right and the left renal arteries. The main renal arteries and renal artery branches are otherwise normal.

A. This patient is too young to have atherosclerosis this advanced. In addition, the aorta and peripheral renal arteries are normal. Hemodynamically-significant atherosclerotic stenosis does not occur against a background of completely normal vessels. If you look, you will always see further evidence of arterial disease – such as irregular walls, mild stenosis, and pruning of peripheral branches.
B. Medial fibroplasia is the most common type of fibromuscular dysplasia. It typically occurs in the mid renal arteries sparing the vessel origins in almost all cases. The classic angiographic appearance is a “string of beads”, with multiple webs alternating with short areas of vessel dilatation. The abnormality in this angiogram doesn’t look like medial fibroplasia.
C. Polyarteritis Nodosa is a systemic necrotizing inflammation of medium-sized and small muscular arteries. The disease is typically associated with fever, arthralgias, myalgias, and an elevated sedimentation rate. It is more common in men than in women. The primary angiographic manifestation of the disease is demonstration of multiple small saccular aneurysms of medium and small arterial branches. The renal arteries are most commonly involved. Branch arterial stenosis and occlusions can also occur. Isolated stenosis of the main renal artery does not occur.
D. Granulomatous arteritis is an infiltrative granulomatous process in the arterial wall that can progress to fibrosis and vessel occlusion. It is typically associated with a flu-like prodrome, and is invariably associated with an elevated erythrocyte sedimentation rate. It is morphologically indistinguishable from Takayasu arteritis. It occurs typically in adults over age 50, peaking at ages 65 – 75. It causes long segment stenosis and occlusions. The classic site of involvement is the temporal artery.
E. Correct. Orificial renal artery stenosis is a classic finding in patients with neurofibromatosis and hypertension. The renal artery involvement is typically found in childhood due to the associated hypertension. The stenosis may be due to either dysplasia of the arterial wall itself (most common), or due to narrowing of the vessel by a periarterial neurofibroma (rare). The primary differential diagnostic possibility in this case is congenital renal artery stenosis. Renal artery stenosis due to neurofibromatosis can narrow the renal arteries a bit more peripherally than is seen in this case. When that happens, the differential diagnosis must also include the smooth forms of fibromuscular disease (such as intimal fibroplasia).

Findings: There is irregularity of the left main renal artery, extending to the main bifurcation, with alternating areas of aneurysm and narrowing. The aorta and other opacified visceral vessels appear normal.

A. While the vessel appears irregular, there is no filling defect to suggest acute thrombus. Therefore, thrombolysis is not indicated.
B. Correct. The alternating aneurysms and narrowing is characteristic of the “string of beads” appearance of fibromuscular dysplasia (medial fibroplasia type). It usually affects the mid and distal segments of the main renal arteries, and is usually bilateral.  Stenoses due to fibromuscular dysplasia of the renal artery respond favorably to percutaneous transluminal angioplasty (PTA), which is the treatment of choice. Five-year patency rates are approximately 90%.
C. While angioplasty with stent placement is typically necessary in patients with an atherosclerotic etiology of renovascular hypertension, angioplasty alone is highly effective for the treatment of the medial fibroplasia type of fibromuscular dysplasia. Stent placement following angioplasty in patients with fibromuscular dysplasia should be reserved for use in treating a hemodynamically significant dissection as a complication of angioplasty.
D. Surgical aortorenal vein bypass is an effective treatment for severe, long segment  stenoses of the main renal artery causing renovascular hypertension. These stenoses usually result from  atherosclerotic disease. Angioplasty with stenting is less effective with long segment stenoses.
E. Renal vein renin sampling is performed to evaluate for a renovascular cause for hypertension. In hypertensive patients with a documented  unilateral etiology for the hypertension, as in the present patient, there is no additional information gained by performing renal vein renin sampling. The hypertension is presumed to be caused by the severe narrowing caused by the fibromuscular disease, and balloon angioplasty is indicated.

"Findings: The inferior vena cava is patent. The infrarenal segment is narrowed for the entire length. There is an absence of inflow artifact from the left iliac vein. There is a large inflow artifact from the left renal vein, and the inferior vena cava becomes much larger in diameter cephalad to the renal vein level.

A. The vena cava appears patent and in the normal location. The azygous vein would be located more medially. There would also likely be large collateral veins present.
B. Left renal vein tumor thrombus would be possible if the filling defect in the inferior vena cava cephalad to the renal vein was an isolated finding. However given the other associated findings described above, this is less likely. Another cause of thrombus in the IVC would be extension from a lower extremity deep venous thrombosis. However, filling defect would be evident extending cephalad from an iliac vein.
C. Correct. All of the described findings are seen with a duplication of the inferior vena cava, with insertion of the duplication into the left renal vein. This explains the absence of inflow from the left iliac vein, and the larger than normal inflow artifact from the left renal vein.
D. Hypovolemic shock can cause a diffuse decrease in the diameter of the inferior vena cava. However, the vena cava cephalad to the renal vein level appears normal. Common etiologies of hypovolemic shock are trauma or sepsis, and the patient has associated clinical findings of tachycardia and hypotension.
E. The inferior vena cava appears normal in contour, and without filling defects. A venacaval occlusion with recanalization would result in an irregular vena caval contour, and chronic coaptations or filling defects. Collateral veins would also likely be present.

Findings: Figure 4A is a selective superior mesenteric arteriogram. There is a large vessel arising from the proximal portion of the superior mesenteric artery which course towards the right upper quadrant. The branching pattern of this vessel is consistent with a hepatic artery. Figure 4B is a selective celiac arteriogram. Left gastric, left hepatic, gastroduodenal, and splenic arteries are identified.

Findings: Selective left pulmonary angiogram with multiple filling defects in the left main pulmonary artery and in the lobar and segmental branches.

A. Recent major abdominal, thoracic, or neurological surgery is risk factors for hemorrhage with anticoagulation therapy. Central nervous system events in the prior 6 months are also considered a contraindication to anticoagulation. Other contraindications include recent or ongoing hematuria, or gastrointestinal bleeding.
B. There is no proven benefit to thrombolytic therapy or to mechanical thrombectomy compared with anticoagulation therapy in hemodynamically stable patients. However, in patients with hemodynamic instability or patients with poor cardiopulmonary reserve, more aggressive therapy such as thrombolysis or thrombectomy may be indicated.
C. Incorrect.  As noted above, there is no proven benefit to percutaneous thrombectomy in hemodynamically stable patients.
D. The pulmonary angiogram is the gold standard imaging modality for the diagnosis of pulmonary embolism. A contrast enhanced CT scan would not add any additional useful information. At this point, a therapeutic decision is required.
E. Correct. The standard therapy for deep venous thrombosis and its major complication, pulmonary embolus, is anticoagulation. Placement of an inferior vena caval filter is preferred if anticoagulation is contraindicated. It protects the patient from further pulmonary emboli while the body autolyses the existing pulmonary thrombi. Contraindications for anticoagulation are noted above in option A. The recent stroke in this patient is a contraindication to anticoagulation and thus, the best alternative therapy is an inferior vena caval filter.

Findings: The angiographic image demonstrates occlusion of the left common femoral artery.

A. Dislocation of the femoral head could potentially occlude the common femoral artery, but the femoral head appears to be in good position, no fractures are present, and there is no history of recent trauma.
B. The intimal flap, characteristic of an arterial dissection, is not seen.
C. There is no evidence of irregular atherosclerotic plaques in the other visualized arterial segments, so an occlusion secondary to atherosclerotic disease is unlikely.
D. Extrinsic compression by solid mass, such as hematoma or tumor, may occlude an artery, but the vessel would typically be bowed or displaced from its expected course. In addition, extrinsic compression would not normally cause an abrupt occlusion of an artery; it would usually be a more tapered occlusion.
E. Correct. In the test case, the artery is abruptly cut off, a typical appearance of an acute embolic occlusion. Although there are several collateral vessels around the femoral head, the adjacent superficial femoral artery is not visualized, which also suggests an acute event. An intraluminal meniscus, a classic finding in an embolic occlusion, can be seen on close inspection of the image. In this case, the collateral vessels do not reconstitute the superficial femoral artery, and one can understand why the leg is acutely ischemic, cyanotic, and painful. Surgical thrombectomy is commonly done.

Findings: Hepatic rupture represents approximately 50% of the deaths from abdominal trauma. Indications for angiography include evaluation of bleeding from pseudoaneurysms, transected arteries with development of expanding subcapsular hematoma, and hemobilia. In the setting of trauma and the presence of a persistent and irregular contrast collection, pseudoaneurysm is the most likely diagnosis.

A. Correct.
B. Mycotic aneurysms of the hepatic artery are uncommon, especially with the current use of antibiotics. They should be considered as a possible cause in febrile patients who have the rapid development of an aneurysm.
C. Atherosclerotic aneurysms of the hepatic artery are rare, with approximately 200 reported in the literature. Eighty percent of these aneurysms are extrahepatic. The aneurysm seen in this study is intrahepatic.
D. Polyarteritis nodosa usually presents with multiple aneurysms. The liver is involved in two-thirds of patients.
E. Congenital aneurysms are associated with connective tissue disorders such as Marfan’s or Ehlers-Danlos syndromes, or other conditions such as focal medial agenesis, tuberous sclerosis, gonadal dysgenesis, and Menkes kinky-hair syndrome. These etiologies are not associated with aneurysms in the liver.

"Findings: There is a prominent arterial communication in the lower abdomen between the left colic and middle colic arteries running along the border of the large bowel.

A. The arc of Buehler is a short artery bridging the celiac and superior mesenteric arteries in the upper abdomen. It is a persistent remnant of the ventral aorta.

B. The arc of Barkow is an arcade running in the free edge of the omentum, anastomosing the right and left gastroepiploic vessels.
C. Correct. The marginal artery of Drummond runs along the mesenteric border joining the right, middle, and left colic arteries. This is an important anastomotic pathway between the superior and inferior mesenteric arteries. It will supply blood to the descending colon when the inferior mesenteric artery is occluded at its origin. In this case, it hypertrophied to supply the right side of the colon and small bowel because the superior mesenteric artery was occluded at its origin.
D. The pancreaticoduodenal arcades, located near the head of the pancreas, are the major collateral pathways between the celiac and superior mesenteric arteries.
E. Spontaneous splenorenal shunts are venous collateral pathways between the portal and systemic circulation that typically enlarge with portal hypertension.

Findings: The catheter has entered a left-sided superior vena cava.

A. Perforation of the left subclavian/innominate vein is a potential complication of placement of peripherally inserted central catheters. Since these small catheters are advanced over flexible guide wires, perforation would be unlikely. An extraneous placement would be suspected by a course separate from the great veins and their branches. This may be difficult to detect clinically, since catheters that have perforated the vein may be within a pseudoaneurysm, and since blood may be aspirated from them. Administration of intravenous contrast using fluoroscopic guidance can confirm an extravascular catheter position.
B. Passage of a peripherally inserted central catheter into the left internal mammary vein can occur. In such a case, the catheter would course just lateral to the sternum and would have a more vertical course than in this patient. A lateral view would confirm a retrosternal location.
C. Clearly, the catheter in this patient does not extend into the descending aorta. A catheter entering the aorta would imply that the entry site in the arm was into an artery, rather than a vein - an unlikely scenario.
D. Correct. A persistent left superior vena cava is the most common congenital vascular anomaly of the thorax, occurring in approximately 0.3% of the population. Embryologically, this anomaly results from a communication of the left anterior and common cardinal veins. The left superior vena cava drains caudally into the oblique vein of the left atrium, the great cardiac vein, and the coronary sinus, which then enters the right atrium. Its cephalad connection is with the left innominate vein. Eighty percent of patients with a left-sided superior vena cava have a right-sided superior vena cava. Sixty percent have a left brachiocephalic vein, which connects with both superior vena cava.
E. Passage of a catheter into the pericardium would not be expected to occur from the position in the superior mediastinum where this catheter begins to descend. The cephalic extent of the pericardium is to the mid portion of the ascending aorta, the distal superior vena cava, and the mid portion of the pulmonary trunk.

Findings: The aortogram demonstrates several faint areas of focal vascular blush, consistent with tiny aneurysms. These are in the pancreatic bed and the bowel, better seen on the selective injections in the splenic artery and the superior mesenteric artery.

A. Correct. Polyarteritis nodosa typically manifests itself as small aneurysms (1-5 mm) of the small and medium sized arteries. Irregularities with stenoses and occlusions (infarction) can be seen. The most frequently involved organs are kidneys (85%), heart (65%), liver (50%), bowel, and pancreas.
B. Necrotizing angiitis with microaneurysm formation is seen in amphetamine abuse with intracranial hemorrhage. It demonstrates irregularity and beading of intracranial vessels.
C. Angiodysplasia of the colon involves the right colon. The angiographic appearance is of enlarged arteries on the antimesenteric border of the cecum or ascending colon supplying a vascular tuft with an early draining vein (ileocolics vein) that persists throughout most of the filming. It may involve the small bowel.
D. Hereditary hemorrhagic telangiectasia or Osler-Weber-Rendu disease is an autosomal dominant disorder. It is manifested by telangiectasias (capillary angiomas) of multiple organs (skin, mucous membranes, intestines, stomach, liver, kidneys, and the nervous system). Vascular problems with bleeding (epistaxis, hematuria, GI bleeding) can occur.
E. Klippel-Trenaunay syndrome consists of cutaneous hemangiomas, bone, and soft tissue hypertrophy of the lower extremity and congenital superficial venous varicosities. Venous malformation of the pelvis may be seen in children. Colonic angiomatosis (dilated tortuous veins) do not have arteriovenous shunting, nor are the feeding arteries dilated.

Findings: On the right side, the popliteal artery is obstructed. On the left side there is opacification of a long fusiform popliteal artery aneurysm.

A. Correct. All 4 possible answers are associated with occlusions of the popliteal artery. Popliteal artery aneurysms are bilateral in the majority of cases and much more frequent in men than woman. Arterial occlusive symptoms result either from thrombosis of the aneurysm, as in this case, or from distal embolization.
B. Diabetes is a common condition, certainly associated with arterial occlusive disease, but is not the best choice in the face of the contralateral aneurysm.
C. Typically popliteal artery entrapment presents in young athletes with a pathognonomic finding of medial deviation of the popliteal artery. Although aneurysms may rarely develop, they would be an unusual complication of an unusual condition.
D. Adventitial cystic disease is a rare condition characterized by the extrinsic compression of the popliteal artery by a mucinous filled cyst.

A. Res ipsa loquitur.
B. The purpose of the imaging is to confirm the diagnosis of leiomyomata, exclude other pelvic pathology and provide baseline measurements to assess the effects of treatment.
C. Successful treatment of uterine leiomyomata requires distal occlusion of all branches feeding the uterine leiomyomata. Proximal occlusion of larger arteries with coils would not be expected to provide clinical success.
D. A pain management strategy is required for all patients.

A. Urinary tract obstruction is the most frequent indication for percutaneous nephrostomy.
B. These patients are at high risk for gram-negative sepsis. Emergency drainage is indicated.
C. Correct. Life threatening hyperkalemia is NOT an indication for nephrostomy. It is true that patients in renal failure will elevate their potassium and that percutaneous nephrostomies will reverse renal failure when the cause is urinary tract obstruction. However, severe hyperkalemia is actually a contraindication to percutaneous nephrostomy because of the risk of cardiac arrest. The emergency treatment is hemodialysis.
D. Access for stone removal is one example of an indicated endoscopic procedure that requires a preliminary percutaneous nephrostomy.

D. Correct.

A. Fistulas have superior longevity in comparison to bridge grafts. But they take several weeks for the access to mature, for the egress veins to enlarge sufficiently to provide adequate blood flow and become large enough to accept large bore needles. They may never mature. Synthetic grafts are ready for use in two weeks. Tunneled catheters are available for use immediately following placement. Further, tunneled catheters are the most easily accessed. The patient doesn't have to be stuck. But tunneled catheters are not recommended for long-term hemodialysis because of the risk of infection and early failure rate. Bridge grafts are easier to declot than native fistulas because the clot is usually confined to the synthetic graft, the grafts are superficial and the anatomy straightforward.

A. Heavy beam filtration, such as 0.1-0.9 mm copper, reduces lower energy x-rays that are absorbed in patient tissue contributing to patient dose.
B. Correct. The dose rate to the image receptor is maintained at a constant level so increasing the distance between the patient and the image receptor increases the fluoroscopic dose rate.
C. Dose is inversely proportional to the square of the distance from the focal spot, so increasing the distance results in a lower fluoroscopic dose rate.
D. Pulsed fluoroscopy operating at low frames results reduces the fluoroscopic dose rate.

C. The advantage of a bird’s nest filter is that it can be safely placed in a vena cava with a diameter as large as 40 mm. The maximum cava diameter for most other filters is 28 or 30 mm.

B. The advantage of the transjugular approach is a diminished risk of bleeding because hopefully bleeding will follow the needle tract into the hepatic vein and be harmless. But with this technique you cannot reliably direct the needle into a discrete lesion whether near or remote from the hepatic vein. Transjugular biopsy is indicated for patients with diffuse parenchymal disease who are at increased risk for bleeding.

C. Radiofrequency along with microwave, laser and high-intensity focused sonography are all thermal ablation techniques used to destroy the tumor. The mechanism of ablation, of cellular death, is coagulation necrosis, achieved by raising the temperature in the treated tissue to between 50 and 100 degrees Celsius. Thus, the most important parameter governing tissue destruction is temperature. The number of probes, the tissue vascularity, even perhaps the radiofrequency (more so for microwave ablation) certainly do have bearing, but only to the extent they contribute to the distribution of heat throughout the lesion.

A. The danger is a preexisting left, not right bundle branch block, because while passing the catheter through the right ventricle the procedure it can cause a right bundle branch block. This may then result in complete heart block. Even in these patients the procedure may safely proceed if a temporary pacing wire is placed first.
B. Correct. Severe pulmonary hypertension is dangerous. The pulmonary vascular bed may be largely obliterated. In such cases the amount of contrast that can be safely injected, if any, is markedly reduced.
C. There is too much dilution of the contrast by non opacified blood to obtain high quality images with the catheter in the right atrium. The catheter tip should be positioned selectively in each the right and left pulmonary arteries.
D. Don’t try it. The catheter will blow apart at the hub.

A. Size does matter. Acute elastic recoil is a potential cause of treatment failure, as is a residual stenosis. Thus the balloon should be large enough to both obliterate the stenosis and stretch the artery slightly beyond the vessel’s elastic limit. Over dilation by 10-15% usually is considered to be optimal. Haphazard choice of balloon size can lead to anything from early failure secondary to elastic recoil or residual stenosis if the balloon is sized too small; to arterial rupture were the balloon size too large.

A. Correct. Gelfoam pledgets are absorbed by the body over 4-6 weeks and are very useful when temporary occlusion is desired. Gelfoam powder is of course also absorbed by the body, but because the powder particles are so small they often infarct tissue which is of course permanent.
B. Absolute alcohol is a powerful sclerosant, destroying any tissue it comes in contact with. On or off target it does permanent damage.
C. Polyvinyl alcohol, despite the name is solid particulate matter. It is considered a permanent agent, but occluded arteries sometimes do recanalize, perhaps because of the tendency of the material to clump.
D. N-Butyl cyanoacrylate, a glue, polymerizes into a permanent contour-filling solid upon contact with blood.

Findings: Multiple intraluminal filling defects are seen within the princeps pollicis artery and proper palmar digital arteries to the index digit. In addition, there is occlusion of the proper palmar digital arteries to the thumb and middle digit as well of the deep palmar branch of the radial artery.

A. Hypothenar hammer syndrome typically affects the ulnar artery. Here the radial artery is occluded.
B. Raynaud's disease is characterized by vasospasm. Angiographic findings include attenuation of the arteries of the hand with incomplete visualization of the digital arteries.
C. Emboli account for 50% of cases of acute upper extremity arterial occlusion. Although most originate within the heart, additional sources of emboli include atherosclerotic plaque in the aorta or proximal upper extremity arteries, thrombus from subclavian artery aneurysms, endocarditis, and paradoxical emboli from the venous circulation.
D. Scleroderma is characterized by multiple stenoses and occlusions of the small arteries of the hand.

Findings: There is duplication of the inferior vena cavae. There is a filter in the right-sided inferior vena cava and clot in the left-sided inferior vena cava.

A. The patient already has a filter in the right-sided infra renal venacava, but the clot is on the left.
B. The ideal location for a filter is in the infra renal vena cava, as shown on the right. There is room in this patient to place a second filter above the clot in the left-sided inferior vena cava just below the left renal vein.
C. Although this is a potential solution for a patient with duplicated inferior vena cavae and clot coming from the legs, this patient already has a right-sided filter and more importantly clot in the left vena cava above the iliac veins.
D. Although a potential solution, placing a filter above the renal veins is associated with renal vein thrombosis and should be avoided if possible.

"Findings: There is an eccentric defect along the superior margin of the proximal celiac artery with the remainder of the examination normal.

B. The median arcuate ligament connects the crura of the diaphragm anterior to the aorta, often just superior to the origin of the celiac artery. This ligament frequently compresses the superior surface of the celiac artery.

Findings: There are stones within the proximal ureter causing hydronephrosis. There is a droplet of gas in an anterior calyx and inflammatory stranding of the perinephric fat.

D. Here is a patient with an obstructed and infected kidney. Pus under pressure is dangerous. It is necessary to communicate to the ER doctors that this patient requires an emergency nephrostomy.

A. Although high velocities are the hallmark of arterial flow through a stenosis, increased velocities also occur as a compensatory mechanism for occlusive disease elsewhere.
B. The reversal of flow on the left is typical for a subclavian steal.
C. Hypoplastic or distally occluded vertebral arteries will have a high resistance pattern with absent flow in diastole.
D. Compensatory increased flow may develop in a collateral pathway with arterial occlusion. But a better explanation for the increased flow in the right vertebral artery here is the reversal of flow in the left vertebral artery rather than an occluded carotid artery.

"B. Type 2 endoleaks represent the majority of early and late causes of continued perfusion of the aneurysm sac.

Type I Endoleak (Graft-Related Endoleak)
Inadequate seal at proximal or distal landing zones of graft
Type 1A. Proximal
Type 1B. Distal
Type 1C. Iliac occluder (aorto-uni-iliac EVAR)

Type II Endoleak (Nongraft-Related Endoleak)
Persistent collateral blood perfusing aneurysm sac by flowing retrograde from lumbar arteries, inferior mesenteric arteries, other collateral vessels
Type 2A. Single vessel (simple)
Type 2B. Two or more vessels creating a circuit (complex) architecture, often compared to arteriovenous malformation (sac being nidus fed by inflow and outflow vessels)

Type III Endoleak (Device Failure)
Leakage of contrast through defect in graft fabric
Leakage between segments of modular graft
Mechanical failure of graft
Type 3A. Junctional separation of modular devices
Type 3B. Endograft fracture or holes

Type IV Endoleak (Graft Porosity)
Minor blush of contrast through graft material
Seen in early phase of commercial development of stent grafts, fabric leakage now rarely seen

Type V Endotension
Continued aneurysm expansion in absence of confirmed endoleak

A. For those x-rays scattered toward the direction indicated by 1, the intervening body will attenuate a larger fraction of the scattered x-rays.
B. Towards direction 2, the x-ray scatter will also be less because of more intervening body tissue between the scatter direction exit and the majority of the scattering sites.
C. At 90 degrees, there will be a slightly less probability of scatter, but the major reason why scatter isn’t as great in this direction is the lintervening body tissues.
D. This is the correct answer because in the diagnostic energy range, the propensity for an x-ray to be backscattered is similar to forward scatter (or essentially at any direction, within small variations). Since there is much less tissue between the scattering sites that receive the greatest x-ray fluence, a much greater amount of scattered radiation will be present at 135 degrees (if 0 degrees is forward-directed scatter). Thus, over-table x-ray fluoroscopy units will have much greater scatter towards the eye of the fluoroscopist, and laterally positioned fluoroscopy beams will have much greater scatter towards the user on the entrance side of the patient.

A. Representing the second most common cause of acute lower GI bleeding in patients over the age of 50, angiodysplasia or vascular ectasia is an aquired anomaly of submucosal veins primarily involving the ascending colon. It is angiographically characterized by an abnormal vascular tuft or tangle with early and persistent opacification of a draining vein.
B. Representing the most common etiology of acute lower GI bleeding in patients over the age of 50, diverticular bleeding arises from a branch of the vasa recta communicating with the bleeding diverticulum. Although colonic diverticulosis most often involves the descending and sigmoid colon, massive diverticular bleeding occurs within the ascending colon in 50% or more of cases.
C. Bleeding peptic ulcers is clearly upper gastrointestinal hemorrhage, hemorrhage proximal to the Ligament of Treitz. But the point is that upper gastrointestinal hemorrhage can be so brisk as to present as bright red blood per anum.
D. Certainly a cause of lower GI hemorrhage, it is not as common as diverticular bleeding. History is important.

A. Nonenhancement of tissue has been shown to be a reliable sign of non viable tumor and has been the traditional way tumors have been followed after treatment with radiofrequency energy.
B. The appearance of non-viable post ablation lesions on MRI are typically T-2 dark.
C. Gas within a lesion can be seen immediately post procedure and does not correlate with tumor viability.
D. Fat stranding is not associated with tumor viability. A halo may be seen in lesions immediately post RF and may represent an area of inflammation that will resolve over time.

C. Boland and associates showed a dramatic response in a previously reported series. The response usually occurs within 24-48 hours and is evidenced by a decrease in white cell count, normalization of body temperature, and reduced dependence on vasopressor support.

C. An aortoenteric fistula is a late complication of aortic surgery, usually the open repair of an abdominal aortic aneurysm. Most frequently it develops between the proximal anastomosis of a synthetic graft and the overlying duodenum.  

A. In addition to puncturing the stomach it is necessary to pass a tube through the pylorus. This can be difficult and time consuming.
B. Gastrostomy feedings can be prepared at home and given as a bolus. Jejunal feedings need be prepared in the pharmacy and require prolonged infusions.
C. There may be more and certainly aren’t fewer complications placing gastrojejunostomy tubes.
D. The chief reason for a gastrojejunostomy is to prevent reflux with aspiration.

B. It is the position of the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurological Surgeons/Congress of Neurological Surgeons and the American Society of Spine Radiology that vertebral augmentation with vertebroplasty or kyphoplasty is a medically appropriate therapy for the treatment of painful vertebral compression fractures refractory to medical therapy. There are no studies to demonstrate the benefits of kyphoplasty to vertebroplasty or vice versa.

A. The right internal jugular vein provides the shortest and most direct intravascular route to the desired location of the catheter at the right cavoatrial junction. The jugular vein is less likely to thrombose than the subclavian vein and should the jugular vein thrombose or stricture it will not impede blood return from an upper extremity graft or fistula. The femoral approach has the added drawbacks of poor hygiene and a tendency for the catheter to back out of the tunnel.

A. Although intracranial bleeding is a devastating complication, its likelihood is about 2 in 1000.
B. The natural history of isolated femoropopliteal DVT is different from iliofemoral DVT. Recanalization of the veins below the inguinal ligament is frequent and the likelihood and severity of postthrombotic syndrome small compared with the more central veins.
C. Catheter directed intrathrombus thrombolysis has significant potential to prevent postthrombotic syndrome and offers distinct advantages compared with surgical venous thrombectomy or anticoagulation alone.
D. Practice has shown no increase in symptomatic pulmonary emboli resulting from catheter directed intrathrombus thrombolysis.

Post thrombotic syndrome: Sequelae of DVT resulting from chronic venous obstruction and/or acquired incompetence of valves resulting in chronic leg swelling, ankle pigmentation, ulceration in lower calf and ankle (gaiter zone).

A. Hypoventilation is a slowly developing problem usually the result of over sedation, with time for the dedicated sedation observer to observe and correct.
B. Correct.
C. Bronchospasm develops uncommonly, in our practice often an idiosyncratic reaction to contrast media.
D. Adequate fasting and the maintenance of the patient’s protective reflexes should prevent most aspiration complications.

A. To date all cases of NSF have been discovered in patients with impaired renal function.
B. Gadolinium is highly toxic. The principle of contrast media is its physical, not chemical properties. The purpose of chelation is to surround the toxic gadolinium with a chemically inert barrier.
C. Interventional radiologists have been using gadolinium for arteriography to avoid nephrotoxicity in patients with impaired renal function. This is an off label use.
D. The danger of gadolinium is not nephrotoxicity, but this newly discovered disease, NSF.

A. Correct. Although all four conditions may be associated with aneurysm formation, coronary artery aneurysms are a frequent serious complication of Kawasaki disease.

"B. One anatomic variant is a right-sided aortic arch with an aberrant left subclavian artery. Frequently the aberrant subclavian artery will then arise from a saccular dilation at the junction of the aorta and the left subclavian artery, called the Diverticulum of Kommerell.

"D. Correct. Adventitial cystic disease is characterized by the accumulation of mucinous material in the adventitia compressing the arterial lumen most commonly of the popliteal artery. Standard treatment is surgery. Cyst aspiration fails because the material reaccumulates and the benefits of angioplasty remain unproven.

A. This geometry is poor because the source to object (patient) distance (SOD) is closer than C or D; also the source to image distance (SID) is larger than necessary (II is not as close to the patient as possible), resulting in magnification and a greater SID, resulting in greater exposure to the patient.
B. This geometry is poor because of the relatively short SID and SOD, although the geometry of the II is OK (close to the patient). This is the “second-best” geometry.
C. The problem with this geometry, although the SOD is relatively large, is that the SID is also very large, causing a large decrease in x-ray photons getting to the detector, with a commensurate increase in the dose to the patient.
D. This is the best geometry for reducing dose to the patient, as the SOD is large and the SID is at a minimal distance from the source. Inverse square law provides the best dose sparing in this situation.

A. Increase in the output after 3-4 days of drainage indicates a probable fistula.
B. When drains are dislodged or clogged output diminishes.
C. It is an uncommon mistake to drain a necrotic tumor and it is unlikely for the output to increase without a fistula.
D. Despite the improving white count and fever, persistent and increasing drainage indicates you have not cured the patient.

"C. Associated with aortic stenosis, angiodysplasia is the most common vascular abnormality of the gastrointestinal tract. A developmental lesion, angiodysplasia is characterized by dilatation and ectasia of mucosal arteries and veins. It is a common cause of chronic occult low grade gastrointestinal bleeding.

  

Colonic Angiodysplasia
Tend to be small lesions of vascular ectasia that occur in the cecum, ascending or proximal transverse colon
Symptoms of intermittent low-grade bleeding, but occasionally have episodes of massive rectal bleeding
Visible on colonoscopy and selective arteriography
Angiographically a cluster or tangle of small arteries is seen in arterial phase, with early filling and delayed emptying of dilated veins
Decision to surgically resect ascending and proximal transverse colon in these patients made on basis of colonoscopy and occasionally angiography

A. Ovarian arteries represent the most common source of collateral blood supply to the uterus in the setting of failed uterine artery embolization.

A. The contrast outside the aorta on both the CT image and the aortogram should not be mistaken for a penetrating ulcer within the wall of the aorta.

D. The beaded appearance depicted here, alternating segments of strictures with some focal bile duct dilatation between, affecting the intra and extra hepatic bile ducts, is classic for primary sclerosing cholangitis. There is a differential diagnosis including chemotherapy cholangitis, AIDS cholangiopathy among others, but these choices were not offered.

A. A saccular aneurysm of the abdominal aorta has an infectious etiology until proven otherwise. The most common offending pathogen is Salmonella. This pathogen has particular propensity toward invasion of diseased, atherosclerotic aortas. Other pathogens include staphylococci, streptococci and E coli. Staph aureus tends to occur in the setting of endocarditis related to intravenous drug abuse, whereas Strep viridans if not drug abusers.

A. The history and CT are highly suggestive of an hepatic abscess. The best treatment is image guided percutaneous drainage.

A. The problem here is to recognize that a catheter has been positioned in the left adrenal vein.  This is not a common procedure. Adrenal vein sampling and venography are usually performed to isolate the source of hyperaldosteronism in patients with hypertension suggestive of hyperaldosteronism.

D. It is not merely that there are strongly held conflicting opinions regarding the optimal location, but that an accurate assessment of the location of the junction of the superior vena cava and the right atrium is not easily determined by the operator using fluoroscopy at the time of placement.

A. Unlike the left gonadal vein which drains into the left renal vein in excess of 99% of the time, the right gonadal vein drains directly into the inferior vena cava in about 90% of patients. Veins however intercommunicate freely in the retroperitoneum, so that duplicated channels on occasion communicate directly with the paravertebral veins. Under pathological circumstances with normal drainage blocked, by a tumor for example, the drainage may be redirected into the pelvic veins.

A. The Rutherford categories and the Fontaine classification describe the clinical signs and symptoms of peripheral arterial disease.

D. Most patients with HCC are not candidates for curative procedures, resection or liver transplantation; but both TACE and RF ablation, although not curative procedures, do prolong survival. Rather than being contraindicated, a recent publication in JAMA showed that TACE followed by RF ablation to treat HCC lesions greater than 3 cm in size will improve survival compared to either modality alone. The risk of liver failure was not increased.

C. The procedure usually can be accomplished more easily than for a native kidney, because of the superficial location of the transplanted kidney.

B. Of the three hepatic veins, right, middle and left, the right hepatic vein is most often the largest. Under these circumstances, the right portal vein will be the closest at hand.

C. Heparin induced thrombocytopenia is a hypercoaguable state. The risks to the patient are primarily from thrombosis rather than hemorrhage. Treatment consists of stopping any form of heparin and substituting a direct thrombin inhibitor for purposes of anticoagulation. The condition cannot be corrected rapidly. An indicated procedure, an emergency cholecystostomy perhaps, should be performed.

A. Preliminary to thermo ablation of lower extremity veins, copious quantities of dilute lidocaine (100-200 mL of .2% lidocaine) are injected along the perivenous space under ultrasound guidance. This provides effective local anesthesia, compresses the vein about the endoluminal heat source and provides a protective barrier between the treated vein and adjacent tissues.

A. French is a scale used for denoting the size of catheters and other tubular instruments. Each unit is roughly equivalent to .33 mm. Three French indicates a diameter of 1 mm.

C. This is desirable. As per the Modified Ramsay scale, moderate procedural sedation (conscious sedation) is characterized by: Purposeful response to verbal commands or light tactile stimulation. No airway intervention is required. Adequate spontaneous ventilation. Cardiovascular function is usually maintained.

D. All three of these occur when using magnification mode. In order to keep the skin dose on the lower end of a typical range when using fluoroscopy, limited use of the magnification mode is advised.

B. The posterior tibial artery is located medially in the calf. You can palpate your own posterior tibial artery behind the medial malleolus at the ankle.

A. The common femoral artery offers the safest arterial access. It is a large, superficially located artery that, following catheter removal, can be compressed against the femoral head to achieve hemostasis.

A high puncture, above the inguinal ligament into the external iliac artery increases the risk of inadequate compression and uncontrolled bleeding, which may be intraperitoneal in location and escape ready detection.

Low punctures increase the risk of thrombosis, pseudoaneurysm and arteriovenous fistula.

Thrombosis because the superficial femoral artery is of smaller diameter and usually more atherosclerotic than the common femoral artery. Pseudoaneurysms and arteriovenous fistulas for a number of reasons. There are many more crossing arteries and veins below the bifurcation of the common femoral artery into superficial and deep branches. Following inadvertent puncture of the deep femoral artery or a narrow caliber, diseased superficial femoral artery it may be difficult to thread the guidewire through the needle so that the artery has to be repunctured, sometimes more than once. Further there is a tendency to become increasingly impatient as more arterial punctures are required. Sufficient time to achieve hemostasis may be neglected. Also it may be difficult to adequately compress a low puncture against the femoral head. Unlike uncontrolled hemorrhage from a high puncture, bleeding from a low puncture is usually walled off in the musculature of the thigh forming a pseudoaneurysm.

C. It is the consensus opinion of the Society of Radiologists in Ultrasound that a less than 50% stenosis will not alter the peak systolic velocity. A peak systolic velocity between 125-230 cm/sec is characteristic of a 50 to 69% stenosis. A peak systolic velocity greater than 230 cm/sec is characteristic of a 70 to 99% stenosis. There is of course no flow through an obstruction.

"Findings: There are normal caliber, not enlarged, feeding arterial branches of the left hepatic artery. There is early appearance of numerous and variably sized spots of contrast. There is delayed visualization of these spots during the venous phase. There is no arteriovenous shunting.

A. This is not the typical appearance of a primary hepatic malignancy. The feeding arterial branches would be enlarged and there may be arteriovenous shunting. Venous invasion may also be present.

"Findings: There is contrast enhancement of the medial segment of the left lobe of the liver (segment IV or quadrate lobe). There is opacification of superficial veins in the right abdominal wall (right arm injection), and azygous vein collaterals.

A. The presence of multiple collateral veins and the characteristic enhancement pattern of segment IV of the liver is diagnostic of SVC syndrome. None of the three other choices would explain the collateral veins. Liver lacerations are typically more linear in configuration and do not enhance to the degree seen on the image depicted. Focal nodular fatty sparing occurs in the setting of  a fatty liver and the area of the enhancement here is not really nodular to consider a regenerating nodule or fat sparing.

Findings: Web-like stenoses alternating with small aneurysms affect segments of the left subclavian and brachial arteries.

A. Although subclavian, axillary and brachial arteries are frequently affected by giant cell arteritis, the characteristic appearance is long irregular stenoses.
B. Alternating webs and aneurysms are the characteristic appearance of fibromuscular dysplasia. Although renal artery involvement is commonest, fibromuscular dysplasia may affect any medium sized artery. Taken together, brachial, axillary and subclavian arteries are the fifth most common location. The pathogenesis of the disease is unknown, but it is not an atherosclerotic or inflammatory process.
C. Resembling giant cell arteritis in both pathological and angiographic appearance, long, tapered, nonostial common carotid and subclavian stenoses are common findings.
D. Polyarteritis nodosa is a systemic necrotizing arteritis characterized by multiple small aneurysms adjacent to the arteries, or arterial occlusions, in either case caused by destruction of the wall of the artery by the disease process.

Most common upper extremity artery: Brachial; also seen in subclavian, and axillary arteries
Most common lower extremity artery: External iliac; also seen in femoral, popliteal, and tibial arteries

Findings: There is a hypertrophied bronchial artery. Contrast injected into the bronchial artery opacifies the pulmonary artery.

A. Chronic lung inflammation, tuberculosis, cystic fibrosis, in this case sarcoidosis, regardless of the cause leads to occlusion of the pulmonary arterioles. This results in hypertrophy of the bronchial circulation in the respiratory mucosa. These hypertrophied vessels under systemic arterial pressure have the propensity to rupture causing massive hemoptysis.
B. Pulmonary AVMs are communications between pulmonary arteries and veins, not, as shown here, between systemic and pulmonary arteries.
C. A single pseudoaneurysm is the expected angiographic abnormality from hemoptysis caused by rupture of a pulmonary branch artery from inflation of the balloon of a Swan-Ganz catheter.
D. Certainly neoplasia can cause hemoptysis, but there is no mass to be seen, nor is a cancer likely to cause bronchial artery hypertrophy and shunting to the pulmonary arteries.

"Findings: There is medial calcific sclerosis - Monckeberg's arteriosclerosis - forming calcified tubular casts of the major arteries in the leg.

A. The arrow is below the knee, at a level where the popliteal artery has already divided into the trifurcation vessels.
B. The anterior tibial artery is usually the first of the trifurcation vessels to arise from the popliteal artery below the knee. It traverses the intraosseous membrane and runs down the lateral aspect of the leg along the medial margin of the fibula.
C. The posterior tibial artery, as suggested by its name, runs posteriorly in the calf. Maybe I will put the arrow on this artery, or the peroneal artery in a future quiz.
D. Usually the smallest of the three arteries, it is located posterior to the anterior tibial artery.

"Findings: There is a catheter placed in the superior mesenteric artery via a left axillary approach. There are two collateral pathways depicted here. The arrow is on the larger of  the two, the arc of Riolan. More laterally located, and in this patient the smaller of the two, is the marginal artery of Drummond. Both collateral pathways connect the middle colic to the left colic artery.

A. This is an anastomotic pathway between  the superior mesenteric artery and either the celiac trunk, the hepatic or splenic arteries.
B. Arc of Barkow, truncus epiploicus magnus of Barkow, as the long name implies, is a long collateral pathway between the right epiploic and left epiploic arteries in the posterior layer of the greater omentum.
C. See description of findings.
D. See description of  findings.

Findings: The aortogram shows no abnormalities. Specifically the artery supplying the upper pole of the left kidney is normal. The selective left renal arteriogram shows a tapered narrowing of the artery supplying the left upper pole.

A. There is more than one subtype of  fibromuscular dysplasia that will not display the  typical string of beads appearance, but rather a tapered narrowing that resembles the appearance shown here on the selective renal arteriogram. But the fact that this artery is normal before the catheter is placed indicates that this is catheter spasm, and not a fixed deformity.
B. Catheter induced vasospasm is produced by mechanical stimulation of a muscular artery or coronary artery by poking or prodding these vessels with a guidewire or catheter. The fact that the artery here is normal on the mid stream aortogram and narrowed after selective catheterization indicates it is an iatrogenic abnormality.
C. In addition to subtypes of fibromuscular dysplasia, other conditions including neurofibromatosis, Takayasu's arteritis, even encasement of the left renal artety by a pancreatic carcinoma may cause narrowing of  the renal artety. But the fact that the artery was normal on the aortogram and constricted after catheterization indicates that this is catheter spasm.

Findings: Contrast injected into the femoral vein shows narrowing of the left common iliac vein just before its confluence with the right iliac vein. There is thrombus filling the iliac veins upstream from the stenosis. The vena cava is free of clot downstream from the obstructing lesion, as is a portion of the opacified right iliac vein.

A. There is no filter, nor thrombus shown in the portion of the IVC included in the image.
B. Alternatively called Cockett's syndrome or perhaps best named the iliac vein compression syndrome, this entity stems from the compression of the left common iliac vein between the right common iliac artery and the vertebral column. Chronic arterial pulsations lead to intimal hypertrophy and stenosis of the compressed vein. Thrombus formation occurs upstream as a result of venous stasis.
C. Although very likely the femoral vein is thrombosed, the thrombus shown on this image involves the iliac veins. And to select this response is to overlook the stenosis of  the proximal common iliac vein responsible for the disease.
D. Superficially the contrast tracking around the thrombus in the iliac veins might resemble contrast opacification of a false channel of an iliac artery dissection, perhaps the complication of an endovascular procedure gone awry. But then why would the vena cava opacify?

"Findings: In addition to the dialysis catheter, there is an infusion port, an NG tube and an endotracheal tube. There is opaque material in the pulmonary arteries. There is opaque material in two adjacent vertebral bodies.

A. Percutaneous vertebroplasty involves the injection of acrylic cement (polymethylmethacrylate) into a diseased vertebral body. It is now well recognized that the cement can intravasate into the perivertebral venous plexus and migrate to the pulmonmy arteries.
B. It is unusual to repair pulmonary AVMs with glue rather than coils, and then there is the cement in the vertebral bodies to account for.
C. The branching nature of the opacities should indicate that they are in tubular structures and are not calcified granulomas.
D. Lymphangiography is very rarely performed nowadays. Lymhangiographic contrast material, Ethiodol, will embolize to the pulmonary arteries, but it will be distributed more peripherally and difusely than cement and can best be appreciated at the base of  the lungs.

A. Aortocaval fistulas are rare. Most develop as a consequence of  an aortic aneurysm eroding into an adjacent venous structure, the vena cava, an iliac or a renal vein.
B. There are two opacified approximately parallel structures, in the abdomen. The one on the patient's right should be recognized as the inferior vena cava. The one on the left containing the catheter is in the normal position for the aorta, has the shape of a fusiform aneurysm, and the direction of flow is peripheral, not towards the heart.
C. This would be a very unusual location.
D. Duplicated aortic arches and duplicated vena cavae do exist, but not to my knowledge duplicated abdominal aortas.

A. The procedure, bilateral uterine artery embolization with particles, does not differ from that for symptomatic uterine fibroids.
B. The dose to the ovary is in the range of 100 to 200 mGy.
C. Effectiveness of the procedure does not rely on the presence or absence of fibroids.
D. Reported clinical success rates for uterine artery embolization for the treatment of adenomyosis range from 73% to 92%. Symptoms do tend to recur in up to 44% of patients two years following the procedure.

C. Correct.

The rationales for this answer did not match the question. They were deleted and edited as above.

A. Venous diseases (occlusion and varix formation) are more common than arterial system involvement in Behcet's disease. Arterial complications are found in 7% of cases, with aneurysm formation and occlusive disease being most common. Aneurysm of the thoracic and abdominal aorta is rarely seen.
B. Polyarteritis nodosa is a small and medium-sized vessel arteritis. Arteries most commonly affected are the renal and visceral arteries. Microaneurysm formation in these arterial distributions represents the arterial hallmark of this disease. Vascular pruning and narrowing are less common features.
C. Patients with thromboangiitis obliterans, Buerger's disease, have segmental thrombotic occlusions of small- and medium-sized arteries in lower and upper extremities. Aortic involvement is not a manifestation of this disorder.
D. Also named nonspecific aortoarteritis, Takayasu's arteritis is a large-vessel vasculitis. The thoracic or/and abdominal aorta can be affected as well as their branches, especially the subclavian arteries. Granulomatous inflammatory infiltration of the media leads to vessel wall thickening, with eventual stenoses and occlusions.

Takayasu
General Features
Best diagnostic clue: Smooth narrowing of aorta and major vessels

Late phase occlusive or pulseless
Follows early phase by 5-20 years
Type 1: Involves arch vessels and is classic pulseless disease
Type 2: Involves aorta and arch vessels
Type 3: Involves aorta and may produce coarctation
Type 4: Involves aortic dilatation
Type 3 is most common (65% of patients)

"A. Access via the right internal  jugular vein, in contrast to the left internal jugular vein or more rarely the external jugular veins, offers the straightest line through the superior vena cava and right atrium to the ostia of the hepatic veins in the intrahepatic inferior vena cava.
B. The fact is, that owing to the increased risk of hemorrhage with percutaneous liver biopsy in the setting of ascites, the presence of ascites is an indication for this technique.
C. Due to the increased risk of hemorrhage with percutaneous liver biopsy, transvascular biopsy is often performed in coagulopathic patients. By avoiding needle puncture of the liver capsule, the risk of catastrophic intraperitoneal bleeding is decreased. In addition, intraparenchymal bleeding may communicate with the hepatic veins, in essence ""bleeding into the vessel"" and thus of no consequence.
D. There is no directionality to the needle. The technique is used for diffuse liver disease in patients at risk for hemorrhage.

A. There are 360,000 patients in the United States that suffer symptomatic pulmonary emboli and 240,000 deaths from this disease each year. The mortality if untreated or inadequately treated may be in the 60 to 70% range. Following filter placement there is a 2 to 5% rate of recurrent PE, and less than 1% of patients will die from this disease. Absolute indications for filters include proven venous embolic disease where anticoagulation fails to prevent recurrent PE, or when anticoagulation results in hemorrhage, or if anticoagulation is contraindicated.

A. Arteriovenous fistulas have superior longevity compared to synthetic grafts. 85% versus 50% at two years. Longevity is the key. Excluding a successful transplant, these patients will require dialysis for the rest of their lives. And access sites are limited. Infection and central vein thrombosis preclude a policy of long-term maintenance dialysis through tunneled central vein catheters.
B. Following the creation of a fistula, it usually requires three or four months, if it happens at all, for the egress vein to enlarge sufficiently for efficient dialysis. This compares to a perhaps two week period after a synthetic graft is bridged between the brachial artery and vein. A straight or tunneled dialysis catheter can be used immediately.
C. Unlike the fistula, a patient doesn't have to get stuck three days a week with a temporary central vein catheter.
D. A temporary dialysis catheter can be quickly placed, and at the bedside if necessary.

C. Nephrostomy tubes do not last forever. Despite diligent irrigation the tubes become encrusted with particulate matter which over time will both obstruct the tubes and prevent their ready exchange. The patient should be instructed to return every two to three months and have new tubes exchanged for the old ones. If the patient begins to leak urine onto their skin, they should come in immediately for a tube check.

"D. ""It is the position of the Society of lnterventional Radiology that percutaneous RF ablation of hepatic tumors is a safe and effective treatment for selected patients with HCC and colorectal carcinoma metastases."" Patients eligible for cure should undergo surgical resection of colorectal metastases or orthotopic liver transplantation for HCC.

B. When angiography was used as the reference standard for setting Doppler criteria for internal carotid artery stenoses, the degree of stenosis was determined by comparing the narrowest diameter of the residual lumen to an estimate of the diameter of the original lumen in the same location.

"C. A peritoneovenous shunt is designed to provide continuous drainage of ascites into the systemic circulation as a treatment for refractory ascites.  It can be placed surgically or percutaneously.

C. Correct. The expected outcome is that the procedure can be accomplished with immediate pain relief for about 95% of patients. The risks of local neurological complications are about 5%. But it has been well documented that after treatment the risk of developing new vertebral fractures is approximately 25%. All patients should be counseled regarding this and the potential need for additional treatment prior to undergoing vertebroplasty.

"A.  Incorrect. Necrosis of the skin has dose threshold of  >16 Gy.
B. The dose threshold for main erythema is 6 Gy.
C. Desquamation occurs above 14 Gy.
D. Correct. This effect has a lower dose threshold of 2 Gy.  It may begin within hours after irradiation and peak at about 24 hour.

C. Correct. The cholecystostomy tube must remain in place until a mature tract develops, usually somewhere between 2 to 6 weeks.  If the tube is removed too early bile may spill from the gallbladder into the peritoneal cavity, causing bile peritonitis

A. Correct. Medial arterial calcification is commonly found in diabetics with peripheral arterial disease. These heavily calcified vessels are frequently not compressible. This may lead to falsely elevated ankle brachial index measurements.

"A. Correct. The ovarian arteries arise anteromedially from the abdominal aorta inferior to the renal arteries in 80%-90% of cases.  Other origins, adrenal, renal, lumbar, iliac arteries are rare. In about 4% of cases the uterine arteries alone supply the ovaries.

"A. Correct. The Gunther Tulip Filter has a hook on its superior end for transjugular retrieval.
B. The Simon-Nitinol Filter has a low profile (7 French) delivery system, allowing placement via small veins such as the basilic vein.
C. The Bird’s Nest filter has two V-shaped struts connected by four stainless steel wires. It can be safely deployed in vena cavae measuring up to 38 cm, about 10 cm greater than for most other filters.
D. All filters are compatible with a magnetic resonance scanner.

A. Blunt trauma to the liver, or for that matter the spleen or kidney, often cause multiple arterial injuries. But the blunt trauma will tear arteries, causing pseudoaneurysms, whereas true aneurysms, the fusiform aneurysms depicted here are characteristic of arteritities.
B. Most iatrogenic trauma is caused by needle sticks, penetrating trauma. But needle sticks could not create the fusiform aneurysms imaged here.
C. A systemic process, an arteritis will damage and weaken the wall of numerous arteries leading in this case to the fusiform aneurysms. If sufficiently weakened the arterial wall may rupture. A contained rupture is a pseudoaneurysm, as also illustrated here.
D. There is no mass and no tumor neovascularity. This is a bad choice.

"A. For an accessory right hepatic artery to be the correct answer, there must be a dual blood supply to the right liver, i.e. from both the celiac axis and the superior mesentic artery, or occasionally directly from the aorta. Here, the entire right liver is supplied from a single branch of the superior mesenteric artery.
B. Digital subtraction angiography of the superior mesenteric artery shows a replaced right hepatic artery as the single arterial supply to the right liver. There is flow of contrast only to the right liver and none to the left. Whereas digital subtraction angiography of the celiac axis shows the left hepatic artery with no contribution to the right liver.
C. The left hepatic artery in this case is supplied directly from the celiac axis. The gastroduodenal artery originates from the left hepatic artery. Therefore, this is not a replaced left hepatic artery.
D. Although a common hepatic artery may arise from the superior mesenteric artery, a common hepatic artery will supply the right and the left liver as well as the gastroduodenal artery. But here the blood supply from the superior mesenteric artery is only to the right liver.

A. The tip of the catheter observed fluoroscopically would be somewhat near the expected location of the pulmonic valve. But the diagonal course of the catheter is not correct for the pulmonary outflow tract. Efforts to advance the catheter will of course fail. Fortunately the operator was advancing a shepherd crook leading edge which will make it difficult to perforate the heart. Injected contrast instead of flowing antegrade into the pulmonary artery, flows in the opposite direction back into the right atrium. The catheter is in the coronary sinus
B. The pulmonary outflow has a much broader diameter, a different course and the direction of flow is opposite that of the coronary sinus.
C. It is possible to pass a catheter through a patent foramen ovale or atrial septal defect into a pulmonary vein, but then the injected contrast would enter the left atrium, not track back along the course of the catheter into the right atrium.
D. Incorrect.

"A. Cystic advential disease is an unusual disease most frequently seen in darkened hotel rooms in Louisville, Kentucky. The condition most commonly affects young men, and is always found near a joint, most frequently the knee. The cyst within the wall of the artery may be a developmental manifestation of mucin-secreting cells.  
B. Buerger disease is characterized by occlusion of all the named arteries of the lower extremities with the development of extensive arterial collateral formation.
C. There is a single smooth wall stenotic lesion affecting only one location. Atheromatous plaque is bilateral and multifocal with numerous irregular projections into the lumen of the arteries rather than the extrinsic appearance of this lesion.
D. This is a stenosis, not an occlusion. Also, there is no appearance of aneurysmal dilatation of the ipsilateral or contralateral popliteal artery. In fact, no imaged arterial segment is the slightest bit increased in diameter.

A. To arrive at the correct answer, the first hurdle is to recognize the abnormality, the amorphous collection of contrast. Second is to appreciate that this represents active hemorrhage, as opposed to an aneurysm or pseudoaneurysm. Third is to appreciate the bleeding is coming from a branch of the gastroduodenal artery and likely from the duodenum. Finally it would be helpful to know that a peptic ulcer is the most likely cause of hemorrhage in this location.
B. Aortic enteric fistulae do bleed into the duodenum. But in aortic enteric fistulae, the bleeding originates from the aorta not from a branch of the gastroduodenal artery.
C. Although colonic diverticulae, more often arising from the right colon, are the commonest source of lower GI bleeding, this is upper GI bleeding into the duodenum, not the colon.
D. Depicted here is arterial, not venous bleeding.

A. This is inadequate treatment, especially for an athlete. This treatment will not lyse the clot. This treatment will not address an intrinsic stenosis or extrinsic compression.
B. Stenting should be avoided. One theory of the thrombosis is irritation of the vein by extrinsic compression during exercise. In addition to not addressing the extrinsic compression, the motion can fatigue and fracture the stent.
C. Appropriate treatment includes more than angioplasty. The clot must be lysed. Angioplasty is performed to relieve an intrinsic vascular stenosis, often followed by surgery to relieve an extrinsic compression.
D. The best diagnosis is Paget-Schroetter syndrome. Other names for the condition are effort thrombosis and venous thoracic outlet syndrome. The clot must be lysed. Any intrinsic stenoses most be dilated and surgery is usually subsequently necessary to relieve an extrinsic compression of the subclavian vein.

D. There is agreement that if an intervention is required for FMD, the appropriate therapy is angioplasty alone. But the trick here is to recognize that in addition to the medial fibromuscular dysplasia, there is also a renal carcinoma requiring surgery. This is also "a satisfaction of search case."

A. The two chief indications for a TIPS are variceal bleeding or ascites. There are varices. There is no ascites.
B.
C. It would be a mistake to misinterpret this procedure as a gastrostomy. During a gastrostomy the stomach is inflated with gas. Here there is a balloon inflated with gas within the stomach. And what then is the explanation for all that activity in the liver.
D. The indication for a transjugular liver biopsy is to evaluate the nature of diffuse parenchymal disease in a patient with a bleeding diathesis. Although, some of the apparatus used for a transjugular liver biopsy is similar to that used for a TIPS. But the opacification of the portal venous system including the varices, and the balloon catheter in the stomach indicate that this is a TIPS.

A. Correct. Compression of the left common iliac vein by the right common iliac artery is iliac vein compression syndrome, May-Thurner syndrome. This patient went on to thrombose the compressed left iliac vein.
B. The simultaneous imaging of the artery and the vein on the first coronal MR image does not imply an abnormal communication between the two.
C. As it turned out the history did suggest this diagnosis to the referring clinicians, and the patient did indeed have left femoral popliteal clot that I had diagnosed one day earlier on a duplex ultrasound examination. But that condition cannot be diagnosed from the included images.
D. There is no clot imaged in the ovarian veins.

"A. A type I endoleak is an attachment leak, a lack of seal between the endograft and the wall of the artery.
B. A type II endoleak, the commonest, results from retrograde flow from a collateral source, with filling of the aneurysmal sac via a branch artery.
C. A type III endoleak is the result of a disruption of the integrity of the graft, perhaps a rent in the lining, or as shown here a separation of the modular elements.  
D. A type IV endoleak is caused by porous graft material. This is usually a transient phenomenon, not requiring treatment.

A. First, a significant stenosis would cause the fistula to function poorly. More importantly, the problem here is that too much blood is being diverted through the fistula leaving the hand ischemic, unlikely in the face of a stenosis.
B. A cold painful hand, with symptoms exacerbated during dialysis, relieved by manual compression of the fistula, most often results from a steal syndrome. An elderly, diabetic patient, with stenoses in her native artery distal to the fistula, is likely to experience this ischemic side effect.  
C. Hand pain and cold fingers are consistent with diabetic neuropathy. But exacerbation of symptoms during dialysis relieved by manual compression makes steal a better choice.
D. Pseudoaneurysm do develop from repeated venipunctures for dialysis, but even were they a source for emboli, such emboli would travel to the lungs, not to the hand.

"A. According to NKF K/DOQI Guidelines ""In patients with CKD stage 4 or 5, forearm and upper-arm veins suitable for placement of vascular access should not be used for venipuncture or for the placement of intravenous (IV) catheters, subclavian catheters, or peripherally inserted central catheter lines (PICCs)."" The idea is to preserve the veins for future dialysis access.
B. The concern with a left bundle branch block is related to passing a catheter through the pulmonary outflow tract into the pulmonary artery and in doing so causing a right bundle branch block. This will result in complete heart block. But under usual circumstances, no wire enters the right ventricle when placing a PICC.
C. A PICC after all is a PERIPHERALLY inserted central catheter and not much more traumatic than a venipuncture. Patients on Coumadin with elevated bleeding factors are routinely monitored with blood draws.
D. Although indwelling lines do promote venous thrombosis, cephalic vein thrombosis is not a contraindication to a PICC line insertion. Both the basilic and the brachial veins may be used. Basically, the only contraindication to a PICC is concern for preserving upper extremity veins for access in patients requiring chronic hemodialysis

C. The ankle brachial index is calculated by dividing the higher of the dorsalis pedis or posterior tibial artery systolic blood pressure measurements at the ankle by the higher of the systolic blood pressure measurements in the right or left arm.

D. Modern fluoroscopy systems (manufactured after June 10, 2006) are required to display the air kerma rate and cumulative air kerma measured at the “interventional reference point” defined by IEC standard 60601-2-43 as a point along the central ray of the x-ray beam 15 cm from the isocenter toward the x-ray source.

A. Ischemic or infected ulcers are a better choice for this location.
B. The characteristic location for neurotrophic ulcers.
C. A venous stasis ulcer is usually located above the medial malleolus and has an indolent appearance with granulation tissue at the base.
D. I do not know what type of ulcer has a predisposition for this location.

"A. Greenfield is the father of inferior vena caval filters. In the minds of many referring physicians the term ""Greenfield"" remains synonymous with filter. Actually there have been several revisions of the original Greenfield filter as the manufacturer attempted to compete with rival products. Regardless, the maximum safe diameter for this filter is 28 mm.
B. The unique design of the Bird's Nest filter allows effective deployment in vena cavae as large as 40 mm. The limit for most other filters are a maximum caval diameter not to exceed 28 or 30 mm.
C. This is a retrievable filter. The maximum allowed caval diameter is 30 mm.
D. When first marketed, the unique feature of this filter was the small diameter of the delivery system. The maximum safe diameter for the filter is 28 mm.

A. Pneumothorax is the most common complication of a percutaneous lung biopsy. Depending upon the diligence with which they are searched for, the incidence is in the range of 10 to 30%. Most do not require chest tubes.
B. This is the second most common complication. It usually is self limited, but on occasion can be life threatening.
C. This is a rare complication. The thorax is under negative pressure and an open needle with its tip in a vessel may suck air.
D. This is more a complication of a biopsy of the mediastinum. If the aorta or great vessels are nicked beneath the pericardial reflection, this may result in a pericardial tamponade. I have also seen pericardial tamponade develop as the result of a misguided liver biopsy.

A. 0.5-1.0 Gy. The threshold for cataracts from an acute exposure is ~0.5 Gy (50 rads). Cataracts will develop over 20 years after the acute exposure.

A. Midazolam (Versed), a benzodiazepine, is an ideal agent for moderate sedation.
B. Flumazenil is a diazepine antagonist, and will have the opposite of the desired effect.
C. This is an opioid antagonist.
D. Succinylcholine is a muscle relaxant, not what you want.

C. Rutherford et al, developed very strict criteria regarding the measurement of the longevity of arterial bypass grafts. The following is taken directly from their 1997 recommended reporting standards (J Vasc Surg 1997; 26:517-538): 1. Primary patency refers to uninterrupted patency with either no procedure performed on the graft, or a procedure performed to deal with disease progression in the adjacent native artery. In other words, the only exceptions that do not disqualify the graft for primary patency are procedures performed for disease beyond the graft and its two anastomoses. 2. Assisted primary patency was a modification of the original definition to describe the situation where the patency of the graft was never lost, but maintained by prophylactic intervention; an anastomotic stricture angioplasty is the example given here. 3. Secondary patency refers to the situation where graft patency had been lost and then restored after occlusion by thrombectomy, thrombolysis or other intervention. In this question, the primary patency is one year, the assisted primary patency is three years and the secondary patency is five years, at which point the graft failed.

C. Three papers and an editorial in the May 20, 2010 NEJM emphasize that although the 30 day mortality is less for an endovascular repair, this advantage is lost by two years, and that the long-term aneurysm related mortality and total mortality for an endovascular or open repair are the same. The rates of graft-related complications and reinterventions are higher with an endovascular repair.

B. Correct. On Valsalva maneuver there is retrograde flow in the great saphenous vein indicating venous valvular insufficiency with reflux.

A. Correct. The frontal aortogram shows no functioning left kidney, no filling of the splenic artery and collateral flow from the left colic branch of the inferior mesenteric artery into the mid colic artery. The lateral shows the superior mesenteric artery to be occluded at its origin and an all but occluded celiac trunk. These findings are sufficient to cause chronic intestinal ischemia.

A. Correct. Intravenous administration of heparin is the initial therapy of choice to treat all forms of pulmonary thromboemboli. More aggressive therapy is reserved for hemodynamically unstable patients.

C. Correct. The image shows a biliary drainage catheter passing from the right hepatic duct through the common hepatic duct. There is contrast in the dilated obstructed left hepatic duct. Unlike pancreatic carcinoma that typically obstructs the common bile duct, the usual point of biliary obstruction with cholangiocarcinoma is at the confluence of the right and left hepatic ducts as demonstrated here.

A. Correct. Midazolam is a commonly used short acting benzodiazepine. The antidote for an overdose of midazolam (or any other benzodiazepine) is flumazenil.

"C. Correct. The left colic artery is the first branch of the inferior mesenteric artery. It courses superiorly to supply the descending colon. At Griffiths point, in the region of the splenic flexure, it anastomoses with the middle colic artery a branch of the superior mesenteric artery.

D. The waveforms for both the right and left common carotid arteries show two systolic peaks. The first peak represents the left ventricular contraction. The second peak is cause by inflation of the intra-aortic balloon. As the downward pointing peak illustrates, late in diastole there is retrograde flow in both the right and left carotid arteries caused by deflation of the balloon.

C. Correct. A contraindication to great saphenous vein ablation is dependency on the saphenous system for venous drainage because of significant deep vein obstruction.

A. Correct. There is a partially occlusive filling defect or defects within the contrast opacified superior mesenteric artery characteristic for a thromboembolus.

B. Correct.

A. Correct. The characteristic finding for this entity is compression of the celiac artery by the median arcuate ligament of the diaphragm. 

B. Correct.