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■ Case 4
1. The concept of chronic cerebrospinal venous
insuciency was rst described by…
a) Zamboni
b) Zivadinov
c) Haacke
d) Sclafani
e) None of the above
The correct answer is (a). Dr. Paolo Zamboni, an Italian
vascular surgeon, is the physician who coined the term
“chronic cerebrospinal venous insuciency,” or CCSVI.
2. The entity known as CCSVI is characterized by which
of the following?
a) Renal artery stenosis
b) Bilateral carotid artery stenosis
c) Stroke symptoms
d) Venous obstruction aecting mainly internal
jugular veins and the azygos vein
e) Stenosis of the mesenteric arteries
The correct answer is (d). CCSVI is an entity described by
Dr. Zamboni. In its original description, CCSVI is a vascular
condition characterized by obstructive lesions involving
the main extracranial outow pathways—mainly, both
jugular veins and the azygos vein.
■ Case 5
■ Case 6
1. All of the following statements regarding the Essure
system are true except…
a) It is a device for permanent sterilization.
b) The ideal location is within the body of the uterus.
c) The ideal location is within the fallopian tubes.
d) Complications have included unintended
pregnancies.
e) The device is made of nitinol.
The correct answer is (b). The Essure system is a nitinolbased permanent sterilization device. It is placed under
hysteroscopy and the intended site for placement is within
the fallopian tubes. Unintended pregnancy is one of the
described complications of this device.
2. Reported complications related to the Essure system
include which of the following?
a) Tubal perforations
b) Unintended pregnancies
c) Bleeding
d) Pain
e) All of the above
The correct answer is (e); all of the complications
mentioned have been reported with the Essure system.
Approved by the U.S. Food and Drug Administration in
2002 with minimal background research, the device is
now being reevaluated because multiple complications
associated with its use have been reported.
1. The rst report of the use of carbon dioxide as an
angiographic contrast agent was published by…
a) Dr. Kurt Amplatz
b) Dr. Itsvan Seldinger
c) Dr. Irvin Hawkins
d) Dr. James Caridi
e) Dr. Charles Dotter
The correct answer is (c); Dr. Irvin Hawkins published the
rst article on the use of carbon dioxide as a contrast agent
for digital subtraction angiography in 1982.
2. All of the following characteristics of carbon dioxide
as a contrast agent are considered to be advantageous
except…
a) It is non-nephrotoxic.
b) It is nonallergenic.
c) It has very low viscosity and can be injected
through small catheters.
d) It is cheap.
e) It can be safely used in cerebral angiography.
The correct answer is (e). Carbon dioxide is contraindicated
in arteries above the diaphragm. There is a potential risk for
cerebral embolism with signicant clinical consequences.
■ Case 7
1. Regarding spinal osteomyelitis and diskitis, which of
the following is true?
a) The most common underlying infection is
tuberculosis.
b) The most common mechanism of infection is a
surgical complication.
c) Empiric antibiotic therapy is the treatment of
choice.
d) Diagnosis should be established with image-guided
needle aspiration.
e) None of the above
The correct answer is (d). The Infectious Diseases Society
of America guidelines recommend image-guided aspiration
of areas suspicious of osteomyelitis and diskitis. Empiric
antibiotic treatment is not recommended.
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2. Regarding spinal osteomyelitis and diskitis, which of
the following is true?
a) Diagnostic sensitivity of needle aspiration is
75 to 90%.
b) Cultures need to be obtained for possible fungal
infections.
c) Fungal infections are the cause in , 5% of cases.
d) Needle aspiration should not be obtained if blood
cultures are positive.
e) Both a and b are true.
The correct answer is (e). Diagnostic sensitivity of needle
aspiration varies depending upon the series reviewed.
Sensitivities range between 75 and 90%. Cultures for
possible fungal infections need to be obtained, although
sensitivity of needle aspiration for fungal infection is
lower. Even if blood cultures are positive, needle aspiration
is still indicated if imaging studies are suggestive.
■ Case 8
1. The May–Thurner anatomy is which of the following?
a) The compression of the right iliac artery by the
right iliac vein
b) The compression of the left iliac artery by the left
iliac vein
c) The compression of the left common iliac vein by
the right common iliac artery
d) The compression of the left renal vein by the
superior mesenteric artery
e) None of the above
The correct answer is (c). In its classic description,
May–Thurner anatomy is the compression of the left
iliac vein by the right common iliac artery. This anatomic
relationship, in the appropriate clinical scenario, makes
the patient prone to iliofemoral venous thrombosis.
2. Regarding the management of symptomatic May–
Thurner syndrome, which of the following is true?
a) No treatment is necessary.
b) Conservative therapy with compression hose is
accepted as a rst step.
c) In patients who present with left iliac vein
thrombosis, catheter-directed thrombolysis
followed by stent placement is an accepted
treatment.
d) Balloon angioplasty is enough to treat the problem.
e) Answers b and c are correct.
The correct answer is (e). Many patients with symptomatic
May–Thurner syndrome seek management. An accepted
rst step is the continuous and regular use of compression
hose. In general, 3 to 6 months of conservative therapy
is recommended. If patients do not respond, then stent
placement is accepted as a therapeutic option. In patients
who present with left iliofemoral deep venous thrombosis,
catheter-directed thrombolysis followed by stent placement is the standard of care. Although some authors have
claimed that balloon angioplasty is enough to treat this
problem, it is generally accepted that stent placement is
the best endovascular option.
■ Case 9
1. Regarding the management of renal artery aneurysms,
all of the following are true except…
a) Treatment is indicated if the aneurysm is , 1 cm in
size in an asymptomatic patient.
b) Treatment is indicated if there is growth over time.
c) Treatment is indicated if the patient presents with
back pain.
d) Treatment is indicated if the aneurysm is larger
than 2 cm.
e) Treatment is indicated if the patient presents with
hematuria.
The correct answer is (a). The treatment of renal artery
aneurysms based only on size is controversial. In general,
it is accepted that if the aneurysm is larger than 2 cm,
treatment is indicated even if the patient is asymptomatic.
In the presence of symptoms (back pain, hypertension, or
hematuria), treatment is indicated regardless of its size.
Treatment is not indicated if the patient is asymptomatic
and the aneurysm is smaller than 1 cm.
2. Regarding the management of renal artery aneurysms,
which of the following is true?
a) Treatment is indicated to prevent rupture.
b) Treatment is indicated to cure hypertension.
c) Treatment is indicated to prevent renal failure.
d) Treatment is indicated to prevent infection.
The correct answer is (a). The main reason to treat a renal
artery aneurysm is the risk of rupture with signicant
bleeding. Women of childbearing age are at particularly
higher risk because rupture has been described during
pregnancy, posing a risk to the mother and the fetus. Most
series have reported an improvement in hypertension after
treatment; however, this is a secondary goal.
■ Case 10
1. Regarding postsurgical renal artery pseudoaneurysm,
which of the following is true?
a) It is a very uncommon complication (, 2%).
b) It may be completely asymptomatic.
c) High clinical suspicion is essential for diagnosis.
d) Contrast-enhanced CT is the best diagnostic
imaging method.
e) All of the above are true.
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The correct answer is (e). Postsurgical renal artery pseudoaneurysms are uncommon. The bleed is contained
within the renal capsule. Some patients may be completely
asymptomatic. Contrast-enhanced CT is the cross-sectional
image of choice for diagnosis. Symptoms include back pain,
dysuria, and hematuria.
2. Regarding postsurgical renal artery pseudoaneurysms,
which of the following is true?
a) Endovascular management should be the rst line
of treatment.
b) Superselective coil embolization is the
management of choice.
c) Thrombin injection should be superselective and
carefully injected.
d) Parenchyma preservation is a therapeutic goal.
e) All of the above are true.
The correct answer is (e). Endovascular management is
the treatment of choice. Minimally invasive endovascular
management oers eective therapy and renal parenchymal preservation. Thrombin injection is eective to cause
thrombosis of the pseudoaneurysm, but administration
of thrombin carries the risk of non-target administration,
resulting in renal infarction. Thrombin injection, if
performed, should be conducted with extreme care.
The correct answer is (c). Embolization of the midsegment
of the splenic artery is eective to control bleeding from
splenic artery injuries. In case of splenic trauma, embolization of the midsegment of the splenic artery is comparable
to superselective embolization. Coiling of the midsegment
of the splenic artery is not associated with splenic infarc-
tion as the ow to the spleen is preserved via short gastric
collaterals and gastroepiploic artery collaterals.
■ Case 12
1. Regarding the recognition of a vascular injury after
a percutaneous procedure, which of the following is
true?
a) Identication requires a high degree of suspicion.
b) Prompt recognition is imperative.
c) Prompt action upon recognition is life-saving.
d) Delay in treatment may result in a fatal outcome.
e) All of the above are true.
The correct answer is (e). Vascular injuries after percutaneous procedures may be life threatening. Prompt recognition is imperative, but a high clinical suspicion is necessary
to be fully aware of the early clinical signs. Immediate
action is important as a delay in treatment may result in a
fatal outcome.
■ Case 11
1. The segment of the pancreas removed during a Whipple
surgery is which of the following?
a) The tail of the pancreas
b) The body and tail of the pancreas
c) The entire pancreas
d) The head of the pancreas
e) None of the above
The correct answer is (d). The head of the pancreas is
resected during Whipple surgery. The surgery includes
removal of the duodenum, creation of a Roux-en-Y,
anastomosis of the body and tail of the pancreas to the
aerent limb, and a bilioenteric anastomosis to the
aerent limb.
2. Regarding coil embolization of the splenic artery,
which of the following is true?
a) It is contraindicated in the central segment of the
splenic artery.
b) It is eective for bleeding from a gastroduodenal
arterial source.
c) In splenic trauma, proximal embolization is
comparable to superselective embolization.
d) The splenic artery should never be coiled.
e) Coiling of the midsegment of the splenic artery will
cause splenic infarction.
2. Vascular injuries after percutaneous procedures
include all of the following except…
a) Pseudoaneurysms
b) Lacerations
c) Arteriovenous stula
d) Dissections
e) Low-ow vascular malformations
The correct answer is (e). Low-ow vascular malformations
are congenital. Vascular injuries secondary to percutaneous
procedures are usually clinically signicant. Some of these
injuries may be fatal, and prompt recognition and treatment
are essential.
■ Case 13
1. The types of endoleak that need emergent treatment
include which of the following?
a) Type I endoleak
b) Type II endoleak
c) Type III endoleak
d) Type IV endoleak
e) Answers a and c
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The correct answer is (e). Types I and III endoleaks are
active leaks into the aneurysmal sac, are associated with a
signicant increase in sac pressure, and are associated with
a high risk of rupture. These types of endoleak require
emergent treatment.
2. Type I-B endoleak is an endoleak from which of the
following?
a) Collaterals from the iliolumbar artery
b) Aortic attachment site
c) Collaterals from the inferior mesenteric artery
d) Iliac attachment site
e) Perforation of the graft material
The correct answer is (d). Type I-B endoleaks are endoleaks
arising from the iliac attachment site.
■ Case 14
1. All of the following are true about type II endoleaks
except…
a) Type II endoleak is the most common type of
endoleak.
b) Type II endoleaks need immediate treatment.
c) Type II endoleaks need to be treated if there is sac
growth.
d) Type II endoleaks arise from collateral arteries that
communicate with the aneurysmal sac.
e). Some type II endoleaks are associated to the
inferior mesenteric artery.
The correct answer is (b). Type II endoleaks arise from
collaterals either from the iliolumbar system or the inferior mesenteric artery. Type II endoleaks can be followed
clinically and only need to be treated if there is sac growth
or if the patient experiences symptoms related to sac
growth.
2. Regarding the management of type II endoleaks, which
of the following is correct?
a) Embolization of the internal iliac artery is eective
to treat type II endoleaks.
b) Embolization of the sac is of extreme importance.
c) All type II endoleaks need to be treated.
d) Direct access to the sac is contraindicated.
e) Answers c and d are correct.
The correct answer is (b). Embolization of the sac and, if
possible, the arteries feeding the sac in a type II endoleak is
of extreme importance. Embolization of proximal arteries
(i.e., internal iliac artery main branches) is ineective
and should be avoided. Direct sac puncture is a valuable
option for treatment.
■ Case 15
1. Regarding type III endoleaks, which of the following is
the true statement?
a) Type III endoleaks arise from the aortic attachment
site.
b) Type III endoleaks arise from collaterals.
c) Type III endoleaks are secondary to a rupture of the
graft material.
d) Type III endoleaks are not associated with sac
growth.
e) None of the above
The correct answer is (c). Type III endoleaks are associated
with rupture of the graft material or a rupture of the
endostent. These leaks are associated with sac growth and
increased sac pressure and need to be assessed as soon as
they are identied. These leaks are associated with a high
risk of sac rupture.
2. Regarding the management of type III endoleaks, which
of the following is true?
a) Management is elective.
b) Management requires embolization of collaterals.
c) Placement of an aortic cu at the aortic attachment
usually solves the leak.
d) Treatment usually requires placement of a new
graft within the existing endograft.
e) No management is necessary.
The correct answer is (d). Management of type III endoleaks is emergent and should not be postponed. These
leaks are associated with high sac pressure and high risk
of sac rupture. They should be treated as soon as they are
identied. These leaks are usually at the limb junction,
and treatment requires insertion of additional limbs.
■ Case 16
1. Regarding pseudoaneurysms of dialysis arteriovenous
(AV) grafts, which of the following is true?
a) They are related to infected needles.
b) They appear suddenly as an acute complication.
c) They are multifactorial, and evolution is usually
chronic and slowly progressive.
d) They may result in massive bleeding.
e) Answers c and d are correct.
The correct answer is (e). Pseudoaneurysms in AV grafts
are usually slowly progressive. These lesions are thought
to be multifactorial, but repeat needle punctures for dialysis sessions are thought to be an important participating
factor. These lesions need to be addressed promptly
because they may result in fatal blood loss, especially in
older patients.
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2. Regarding the treatment of a bleeding pseudoaneurysm
in an AV graft, which of the following is true?
a) Surgical correction is the only therapeutic option.
b) Ligation of the graft with catheter placement is the
treatment of choice.
c) Placement of a stent graft is feasible and eective.
d) These lesions should not be treated because they
resolve spontaneously.
e) None of the above
The correct answer is (c). Bleeding pseudoaneurysms in an
AV graft are lesions that can be potentially fatal. Treatment
is necessary, and if active bleeding is detected, the patient
needs to be treated immediately. Surgical revision used to
be the only option for the management of these lesions, but
with the development of stent grafts, placement of stent
grafts is feasible and eective to manage them.
■ Case 17
1. All of the following are indications for inferior vena
cava (IVC) lter placement except…
a) Patient with deep venous thrombosis (DVT) and
contraindication to anticoagulation
b) Patient with DVT who is therapeutically
anticoagulated and presents with pulmonary
embolism
c) Patient with history of DVT who will undergo hip
surgery
d) Patient with a free-oating thrombus in the iliac
vein who is therapeutically anticoagulated
e) Patient with DVT who is therapeutically
anticoagulated and suddenly develops hematuria
■ Case 18
1. Regarding the Hemodialysis Reliable Outow (HeRO;
Merit Medical, South Jordan, UT) device, which of the
following is true?
a) It is the rst line of treatment for patients who
need dialysis.
b) It is a peritoneal dialysis device.
c) It is a hybrid arteriovenous (AV) dialysis access
system with a graft segment and an outow
stent-graft segment.
d) The stent segment should be placed in the
innominate veins.
e) It is contraindicated in patients with allergy to
iodinated contrast.
The correct answer is (c). The HeRO graft system is a
hybrid system for hemodialysis. This device is used as a
“last-ditch” eort in patients who have failed AV stulae
or AV grafts because of stenotic lesions in the central veins.
The correct placement of the outow segment is within
the right atrium.
2. All statements regarding the HeRO device are true
except…
a) It is a hybrid AV dialysis access system with a graft
segment and an outow stent graft segment.
b) It is indicated as a “last-ditch” eort in dialysis
patients with previously failed access.
c) The placement of this device is contraindicated in
patients with central vein occlusion.
d) The placement of this device is contraindicated in
patients with allergy to iodinated contrast.
e) Answers c and d
The correct answer is (d). The presence of a free- oating
thrombus in a patient who is anticoagulated and tolerating
anticoagulation without complications is not a formal
indication for IVC lter placement. In some cases, physicians
taking care of such patients may decide to insert an IVC lter,
but it is not considered to be a strong indication for IVC lter
placement. Prophylactic IVC lter insertion is controversial;
however, orthopedic surgeons do use prophylactic IVC lters
in patients with a history of DVT and undergoing a major
orthopedic surgery such as knee replacements or hip surgery.
2. All of the IVC lters in the list are retrievable lters
except…
a) Greeneld (Boston Scientic, Quincy, MA) lter
b) OptEase (Cordis/Cardinal Health, Milpitas, CA)
IVC lter
c) Option (Argon Medical, Plano, TX) IVC lter
d) Denali (Bard, Tempe, AZ) IVC lter
e) Günther Tulip (Cook Medical, Bloomington, IN)
IVC lter
The correct answer is (a). Out of this list, the permanent
lter is the Greeneld lter. All the other lters in the list
are retrievable lters.
The correct answer is (e). The HeRO device is a hybrid
dialysis access stent graft system. HeRO placement is
indicated in patients who have previous AV stula or graft
access failed secondary to venous outow problems. It is
considered to be as a device of “last-ditch” eort. Central
venous occlusion and contrast allergy are not contraindications to placement of this device.
■ Case 19
1. Regarding venous occlusion attributed to dialysis
catheter insertion, which of the following is true?
a) The occlusion is immediate, shortly after
hemodialysis catheter insertion.
b) Occlusion of central veins is always attributed to
catheter insertion.
c) The incidence of occlusion is higher in patients
who undergo subclavian catheter insertion as
opposed to jugular vein insertion.
d) The incidence of occlusion is higher in patients
who undergo jugular catheter insertion as opposed
to subclavian vein insertion.
e) None of the above
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The correct answer is (c). It has been well described that
the incidence of central venous occlusion is higher in
patients who underwent subclavian vein catheters as
opposed to jugular vein catheters. Occlusion is usually a
chronic process, not acute.
2. Regarding initiation of hemodialysis in patients
with end-stage renal disease with tunneled dialysis
catheters, which of the following is true?
a) It is the method of choice.
b) Catheter insertion is safe and free of complications.
c) Initiation of hemodialysis with tunneled catheters
should be discouraged.
d) Hemodialysis using a tunneled catheter is the least
desirable method to start dialysis.
e) Answers c and d are true.
The correct answer is (e). Tunneled dialysis catheters
are the least desirable method to start hemodialysis in
patients with end-stage renal disease. The use of tunneled
dialysis catheters as the rst method of treatment has been
reduced; however, still, 80% of patients starting hemodialysis are started with a tunneled catheter insertion. It is
calculated that 100,000 tunneled dialysis catheters are
inserted in the United States each year.
■ Case 20
1. Regarding Mirizzi’s syndrome, which of the following
is true?
a) It is a very common complication of biliary stone
disease.
b) It is always associated with upper gastrointestinal
bleeding.
c) It is the obstruction of the common hepatic duct
secondary to inammation caused by gallstone
impaction in the gallbladder neck.
d) It is always associated to gallbladder carcinoma.
e) None of the above
The correct answer is (c). The classic description of
Mirizzi’s syndrome is the benign obstruction of the common hepatic duct secondary to gallstone impaction in the
gallbladder neck or cystic duct, resulting in local inammation and bile duct spasm. This scenario is sometimes
complicated with a stula to the common hepatic duct
(Mirizzi’s syndrome type II). It is uncommon; the incidence ranges between 1 and 5%. It can be associated with
gastrointestinal bleeding, but this is a rare occurrence.
Gallbladder carcinoma can also cause Mirizzi’s syndrome–
type clinical presentation, but the original description is
that of a benign entity.
2. Regarding bilioenteric stulas secondary to stone
disease, which of the following is true?
a) They are benign and do not require treatment.
b) The therapy of choice is laparoscopic repair.
c) Most of these patients need open surgery because
the anatomy is distorted.
d) There is minimal inammation in the area,
facilitating the laparoscopic approach.
e) Answers b and d are true.
The correct answer is (c). The therapy of choice is open
surgery. These stulas are usually associated with an
intense inammatory reaction at the hepatic hilum,
and surgery is dicult. Most reports indicate that open
surgery is better than laparoscopic surgery.
■ Case 21
1. Regarding splenic abscesses, which of the following
is true?
a) It is a very common entity.
b) Parasitic infections are the most common.
c) It is a rare entity seen mainly in
immunosuppressed individuals.
d) Treatment is splenectomy.
e) Percutaneous drainage is contraindicated.
The correct answer is (c). The presence of a splenic abscess
is a rare entity. The incidence of splenic abscess is reported
to be , 0.4%. These abscesses are more common in immunosuppressed individuals; mainly, patients with HIV,
leukemia, and diabetes. Percutaneous drainage has become
an excellent therapeutic alternative because it may avoid
splenectomy. Splenectomy is indicated in patients who
do not have success with percutaneous drainage and
antibiotic therapy.
2. Regarding percutaneous drainage of splenic abscesses,
which of the following is true?
a) It is contraindicated.
b) The risk of bleeding is extremely high.
c) It should only be performed in stable patients.
d) If carefully performed, it is safe and eective,
regardless of the possible diagnosis.
e) It should not be performed if echinococcal disease
is suspected.
The correct answer is (d). Percutaneous drainage of splenic
abscesses has gained popularity. If properly performed,
the procedure is safe and potentially eective. The risk of
bleeding is not higher than with any other percutaneous
procedure. Echinococcal splenic cysts can be successfully
drained percutaneously.
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■ Case 22
1. The prevalence of residual common bile duct (CBD)
stones after laparoscopic cholecystectomy is which of
the following?
a) 50%
b) Over 30%
c) Approximately 15 to 20%
d) 1 to 2%
e) None of the above
The correct answer is (d). The incidence of residual stones
within the CBD ranges between 1 and 2%. The incidence
of recurrent stones is quite similar, ranging between 1 and
3%. Management highly depends on the local available
services and expertise. Options are repeat laparoscopic
surgery, endoscopic manipulation, or percutaneous stone
manipulation.
2. Regarding CBD stones in patients with previous gastric
surgery, which of the following is true?
a) Most surgeons will avoid repeat CBD exploration.
b) Endoscopic retrograde cholangiopancreatography
(ERCP) is technically dicult.
c) In some centers, ERCP for CBD stone management
is contraindicated in patients with previous gastric
bypass surgery.
d) Percutaneous bile stone manipulation is safe and
eective in patients with previous gastric bypass
surgery.
e) All of the above
The correct answer is (e). In general, surgeons avoid open
reexploration of the biliary system in patients who have
residual or recurrent CBD stones, especially if they are
morbidly obese. ERCP is technically dicult. Some skilled
endoscopists will take the challenge, but for the most part,
in this group of patients, the percutaneous approach is
safe, eective, and probably the rst option.
obstruction or a combination of both. Successful treatment
of these complications requires a multidisciplinary team
that includes biliary endoscopists, interventional radiologists, and hepatobiliary surgeons. Endoscopic treatment
is the main option for a biliary leak. Percutaneous inter-
ventions are the second option and should be oered
promptly after endoscopic failures.
2. The most common etiology of bile duct leak is which of
the following?
a) Laparoscopic cholecystectomy
b) Liver transplantation
c) Liver resection
d) Trauma
e) Percutaneous drainage procedures
The correct answer is (a). In a large retrospective series
including 518 patients, laparoscopic cholecystectomy was
the cause of iatrogenic bile leaks in 70% of the patients,
liver transplantation 11%, liver resection 14%, and trauma
2.5%. Early recognition of the leak is imperative to estab-
lish treatment. Failure to recognize a major bile leak may
result in bile peritonitis, sepsis, and death.
■ Case 24
1. The most common urgent causes of acute lower
abdominal pain in young women are all of the
following except…
a) Pelvic inammatory disease
b) Ovarian torsion
c) Ruptured ovarian cyst
d) Appendicitis
e) Diverticulitis
The correct answer is (e). Diverticulitis is not common in
the younger population; it is usually seen in older people.
All other options are frequent causes of acute lower
abdominal pain in young women.
■ Case 23
1. The main therapeutic option for the management of
iatrogenic bile duct injuries is which of the following?
a) Open surgical revision
b) Percutaneous drainage of the biliary system
c) Endoscopic stent placement
d) Laparoscopic surgical revision
e) None of the above
The correct answer is (c). Bile duct injuries are considered
serious complications after hepatobiliary surgery. These
complications are associated with high morbidity and
mortality. The incidence of iatrogenic injuries of bile ducts
has increased after the advent of laparoscopic cholecystectomy. These injuries present with biliary leaks or biliary
2. An indicator of poor prognosis in a patient with tuboovarian abscess is which of the following?
a) Smoking history
b) High C-reactive protein levels
c) Leukocytosis
d) Abscess larger than 6 cm
e) High fever
The correct answer is (d). In a large retrospective series
by Topcu and colleagues, the authors found that a signicant poor prognostic factor in patients with tubo-ovarian
abscess was the presence of a large abscess that is . 6 cm
in diameter.
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■ Case 25
1. The most common complication after percutaneous
lung biopsy is which of the following?
a) Patient discomfort
b) Pneumothorax
c) Hemothorax
d) Pulmonary hemorrhage
e) None of the above
The correct answer is (b). By far the most common complication of percutaneous lung biopsies is pneumothorax.
This is seen in approximately 20 to 30% of cases. Not all
patients who develop a pneumothorax after percutaneous
lung biopsy will require chest tube insertion. Approximately 20 to 30% of patients with a pneumothorax will
require a chest tube insertion (this is 4–5% of all lung
biopsy procedures).
2. A potentially fatal complication of image-guided
percutaneous lung biopsy is which of the following?
a) 20% pneumothorax
b) Mild pulmonary hemorrhage
c) 5% hemothorax
d) Air embolism
e) None of the above
The correct answer is (d). Air embolism is an uncommon
but potentially fatal complication after percutaneous
image-guided biopsy of the lung. The air disseminates into
the systemic circulation through the pulmonary veins. The
most aected vessels are the coronary arteries and the
cerebral circulation. Even as little as 2 mL of air within
the cerebral circulation is enough to have a fatal eect. All
other complications are usually managed successfully.
■ Case 26
1. The theory of a crossing vessel as a cause of
ureteropelvic junction (UPJ) obstruction is
controversial; a crossing vessel is found in
approximately what percentage of patients?
a) 5%
b) 80%
c) 60%
d) 15–40%
e) A crossing vessel is never seen.
The correct answer is (d). Although the theory of a crossing
vessel as the cause of UPJ obstruction is controversial, studies report the presence of an accessory renal artery crossing
the ureter in 15 to 40% of patients with documented UPJ
obstruction.
2. Imaging studies useful in the detection of an accessory
artery crossing the UPJ include all the following except…
a) Helical CT scan
b) MRI with urographic protocol (MRU)
c) Intra-arterial angiography
d) Color Doppler
e) CT angiography
The correct answer is (d). Color Doppler will depict vessels,
but it will be very dicult for this technique to pinpoint
accessory vessels compressing the UPJ. This is the least
useful imaging modality for this diagnosis.
■ Case 27
1. Techniques to improve function of a nonmaturing
arteriovenous (AV) stula include which of the
following?
a) Arterial angioplasty
b) Venous angioplasty
c) Coiling of collateral veins
d) Stent placement
e) All of the above
The correct answer is (e). Techniques used to improve s-
tula function include arterial and venous angioplasty, stent
placement, thrombectomy, venous branch ligation, stula
supercialization, and banding, among other techniques.
2. The preferred method to start hemodialysis in a patient
with chronic renal failure is which of the following?
a) Temporary catheter
b) Tunneled catheter
c) Peritoneal dialysis
d) AV graft
e) AV stula
The correct answer is (e). Of all these methods, the
preferred method to start dialysis is via an AV stula. All
other methods are used; however, if properly created and
matured, an AV stula is a reliable access for dialysis, with
very good patency rates and low infection rates.
■ Case 28
1. The most common cause of arteriovenous (AV) stula
declot failure is which of the following?
a) Fistula anatomy
b) Location of the AV stula
c) Operator inexperience
d) Time of stula use
e) Patient age
The correct answer is (c). Previous publications have
reported that operator inexperience is the most common
cause for AV stula declot failure.
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2. The contraindication to perform a declot in an AV
stula is which of the following?
a) Patient age older than 85
b) Immature stula that has never been used
c) Fistula infection
d) Clotted stula for 48 hours
e) None of the above
The correct answer is (c). The only contraindication to
declot an AV stula is the presence of an infected stula.
Declotting an infected stula poses a high risk of systemic
infection and, furthermore, a chronic systemic infection.
■ Case 29
1. Regarding neck paragangliomas, which of the following
statements is false?
a) They are neuroendocrine tumors.
b) The tumors arise from the carotid body.
c) They contain lymph tissue.
d) These tumors are usually unilateral.
e) They are more frequent in women.
The correct answer is (c). Paragangliomas are also known
as chemodectomas or carotid body tumors. They arise
from the carotid body and are considered to be neuroendocrine tumors. Usually unilateral, these tumors are more
frequent in women.
2. Regarding the blood ow to these tumors, which of the
following statements is true?
a) Most of the blood ow is from branches of the
internal carotid artery.
b) The lingual artery supplies most of the blood ow.
c) Preoperative embolization is mandatory.
d) The ascending pharyngeal artery is the main source
of blood.
e) The meningeal arteries are the main source of blood.
The correct answer is (d). The ascending pharyngeal
artery is the main source of blood to these tumors. It has
a characteristic hook appearance and may be enlarged in
patients with paragangliomas. Preoperative embolization
is possible; however, it is not standard practice and may
be associated with complications.
■ Case 30
The correct answer is (d). Knowledge of nerve anatomy is
useful for all the reasons mentioned. Numerous references
now exist describing ultrasound-guided interventional
procedures to treat nerve problems.
2. A small, noncompressible structure is identied below
the knee in a patient who underwent trauma. All other
veins are normal and compressible. The correct action
is which of the following?
a) Establish the diagnosis of DVT and treat with
anticoagulants.
b) Place an inferior vena cava lter.
c) Describe it as a nerve; no follow-up required.
d) Describe it as a noncompressible structure.
Follow-up ultrasound in 48 hours.
e) Ignore the nding because it is not important.
The correct answer is (d). The patient described here is at
risk to develop DVT. If a noncompressible structure is identi-
ed below the knee, it could be a thrombosed soleal vein. If
all other veins are normal, it is unlikely that it will be a DVT;
however, in a patient at high risk, it is reasonable to follow
up in 48 hours.
■ Case 31
1. Vascular access site–related complications are common.
The reported rate is which of the following?
a) 50–60%
b) 20–30%
c) 1–9%
d) 15%
e) None of the above
The correct answer is (c). The reported rate of vascular
complications is 1 to 9%.
2. Important high-risk factors for vascular access site
complications include which of the following?
a) Use of anticoagulants
b) Obesity
c) Atherosclerosis
d) Advanced age
e) All of the above
The correct answer is (e). All of these factors are high-risk
factors for vascular access site–related complications. The
use of ultrasound decreases the risk of complications.
1. Knowledge of nerve anatomy is useful for which of the
following?
a) Nerve block procedures
b) Avoiding nerve injuries with interventional
procedures
c) Avoiding false diagnosis of deep venous thrombosis
(DVT)
d) All of the above
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■ Case 32
1. Therapeutic options for the management of prehepatic
portal hypertension include which of the following?
a) Portal vein recanalization
b) Splenic vein recanalization
c) Occlusion of portosystemic collaterals
d) Splenic artery embolization
e) All of the above
The correct answer is (e). Examples of prehepatic portal
hypertension include portal vein thrombosis, splenic vein
thrombosis, and arteriovenous stulas. Described therapeutic options to manage prehepatic portal hypertension
include recanalization of portal vein and splenic vein, with
stent placement, balloon-occluded retrograde transvenous
obliteration (BRTO), occlusion of varices, and embolization
of stulas.
2. Regarding the hemodynamic evaluation of patients
with prehepatic portal hypertension, which of the
following is true?
a) The wedge hepatic vein pressure is normal.
b) The free hepatic vein pressure is normal.
c) The hepatic vein gradient is normal.
d) All of the above
e) None of the above
The correct answer is (d). Patients with prehepatic portal
hypertension will have normal hepatic vein, wedge hepatic
vein, and hepatic vein gradient pressures. The high pressure is found in the varices, shunts, or any area proximal to
the occlusion site.
■ Case 33
1. Regarding percutaneous transhepatic variceal
embolization, which of the following is true?
a) Described in 1974 by Lunderquist and Vang
b) Originally described to treat intractable variceal
bleeding
c) Successful embolization controls acute bleeding in
70–90% of patients
d) Successful embolization may improve
encephalopathy
e) All of the above
2. Regarding spontaneous portosystemic shunts in
cirrhosis, which of the following is true?
a) Left gastric veins connect to the azygos system
through esophageal varices.
b) A recanalized paraumbilical vein shunt
communicates with the right portal vein.
c) The splenorenal shunts communicate to the right
renal vein.
d) Embolization of spontaneous portosystemic shunts
may improve encephalopathy.
e) Answers a and d are correct.
The correct answer is (e). Options a and d are correct.
The paraumbilical vein is the recanalization of the ductus
venosus and connects to the left portal vein. The splenorenal shunts drain into the left renal vein via the left adrenal
vein. Embolization of spontaneous portosystemic shunts
may improve encephalopathy.
■ Case 34
1. The only U.S. Food and Drug Administration (FDA)–
approved stent graft for transjugular intrahepatic
portosystemic shunt (TIPS) insertion is…
a) Wallgraft
b) Fluency
c) Viabahn
d) WALLSTENT
e) VIATORR
The correct answer is (e). The VIATORR is a stent graft that
is approved by the FDA for tracheobronchial application.
It is the only stent graft approved for application in TIPS
procedures. It was approved in 2004.
2. The best imaging method with which to do TIPS
surveillance is which of the following?
a) MRI
b) CT angiography
c) Noncontrast CT scan
d) Doppler ultrasound
e) None of the above
The correct answer is (d). Doppler ultrasound is the best
imaging method for TIPS surveillance. It allows assessment
of shunt patency, ow velocities, ascites, and so forth.
The correct answer is (e). Embolization of esophageal
varices using a percutaneous transhepatic approach was
described by Lunderquist and Vang in 1974. It was initially
popular as the technical success rate was high (70–90%
success rate in the control of variceal bleed). Unfortunately,
the recurrent bleeding rate was also high (10–60%) and
this technique lost popularity.
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