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■ Case 35
1. Regarding chronic portal vein thrombosis, which of the
following is true?
a) It is common in patients with cirrhosis.
b) It is a frequent complication after endoscopic
banding/sclerotherapy.
c) It is an uncommon nding in patients with cirrhosis.
d) Catheter-directed thrombolysis is the rst line of
treatment.
e) None of the above
The correct answer is (c). Portal vein thrombosis is an
uncommon nding. Etiology is multifactorial. Treatment
options vary depending on the clinical presentation and
gravity of the case.
2. Regarding chronic portal vein thrombosis, which of the
following statements is false?
a) Abdominal pain is a common clinical presentation.
b) Anticoagulation is an accepted therapeutic option.
c) These patients should not be treated unless
bleeding occurs.
d) Recanalization and stent placement are useful to
palliate symptoms.
e) The nding is relatively more common in patients
with pancreatic malignancies.
The correct answer is (c). Portal vein thrombosis is uncommon. It is relatively more frequently seen in patients with
pancreatic malignancies, and it may present with upper
gastrointestinal bleeding. Reconstruction with guidewire
recanalization and stent placement is a feasible option.
■ Case 36
1. Regarding transjugular liver biopsy (TJLB), which of the
following is true?
a) The diagnostic yield is lower compared to that of
percutaneous biopsy.
b) The diagnostic yield is comparable to that of
percutaneous liver biopsy.
c) The only advantage of the procedure is that it can
be performed in patients with ascites.
d) Complication rates are higher than those seen with
percutaneous biopsy.
e) None of the above
The correct answer is (b). TJLB is a safe procedure. Complication rates are similar to those seen with percutaneous
liver biopsy, although TJLB is usually performed in patients
who are at higher risk of a complication, so TJLB is considered to be safer than percutaneous biopsy. The diagnostic
yield is comparable to that of percutaneous biopsy.
2. The indications for TJLB include which of the
following?
a) Patient with ascites
b) Patient with coagulopathy
c) Evaluation of portal hypertension
d) Assessment of hepatitis C
e) All of the above
The correct answer is (e). All of the above-mentioned indications are valid indications for TJLB.
■ Case 37
1. True or false: Larger angiographic catheters are less
traumatic than smaller catheters when high-ow
contrast injections are performed.
a) True
b) False
The correct answer is (a). Larger diameter catheters for
high-ow angiographic studies are less traumatic than
smaller, more exible catheters.
2. Examples of vascular injury associated with highpressure contrast injections include which of the
following?
a) Subintimal extravasation
b) Dissection
c) Perforation
d) Vessel rupture
e) All of the above
The correct answer is (e). Subintimal extravasation,
dissection, perforation, and vessel ruptures are examples
of vascular injuries after high-pressure contrast injection.
In extreme cases, these complications may result in
patient death.
■ Case 38
1. Superior vena cava (SVC) syndrome can be secondary
to which of the following possibilities?
a) Mediastinal brosis
b) Lung cancer
c) Pacemaker leads
d) Central catheters
e) All of the above
The correct answer is (e). All of the stated problems or
circumstances can be associated with SVC syndrome.
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2. Regarding the endovascular management of SVC
syndrome, which of the following is true?
a) Balloon-expandable, noncovered stents should be
used.
b) Anticoagulation will be necessary after stent
placement.
c) Self-expandable, noncovered stents should be used.
d) Covered self-expandable or balloon-expandable
stents can be used.
e) All of the above are viable options.
The correct answer is (e). Balloon-expandable and selfexpandable, covered or noncovered, stents can be used to
treat SVC syndrome with endovascular techniques. Once
placed, the patient will have to be on some sort of blood
thinner; either platelet aggregation–inhibiting drugs or
formal anticoagulation should be used. Surgical correc-
tion is dicult and is best avoided in these patients. The
technical success rate for stent placement is high (close
to 95%); the clinical success rate is lower and is mainly
limited by stent occlusion or thrombosis. Endovascular
option is the rst line of treatment for the management of
SVC syndrome.
■ Case 39
1. True or false: The cost of placing chest ports is higher
in the interventional radiology (IR) suite when
compared to the surgical suite.
a) True
b) False
The correct answer is (b). Costs are lower for chest ports
placed in the IR suite. It is more expensive to place them in
an operating room. Outcomes and complication rates are
not signicantly dierent.
2. Some useful pointers when placing chest ports include
which of the following?
a) In obese patients, it is useful to x the port to the
fascia to prevent migration.
b) In active patients, it is useful to x the port to
prevent ipping.
c) IV antibiotics should always be used as a
prophylactic measure.
d) All of these cases should be done under general
anesthesia.
e) Only a and b are true.
The correct answer is (e). Obese and active patients are at a
slightly higher risk to have chest port migration or ipping.
Suturing the chest port to the underlying fascia is very
useful to prevent ipping or migration in obese and active
patients. The use of prophylactic antibiotics has not been
proven to be eective to prevent infections. It is entirely up
to the operator to use or not use prophylactic antibiotics,
and either practice cannot be criticized. The great advantage of placing ports in the IR suite is the ability to do this
with patients under conscious sedation.
■ Case 40
1. Regarding inferior vena cava (IVC) lter placement in
the United States, which of the following is true?
a) There was an increase in IVC lter use in 2000
compared to 1979.
b) The use of IVC lters in the United States is 25 times
higher than their use in Europe.
c) The approval of retrievable IVC lters has further
increased the use of IVC lters.
d) Answers a and b are correct.
e) Answers a, b, and c are correct.
The correct answer is (e). There has been a signicant
increase in the use of IVC lters in the United States. Approximately 2000 lters were placed in 1979, compared to
a calculated total of 50,000 in 1999. The use of IVC lters
is much higher in the United States when compared to all
European countries together. The approval of retrievable
lters has further increased the use of IVC lters.
2. Regarding IVC thrombosis in patients with IVC lters:
a) The TrapEase IVC lter has the lowest rates of IVC
thrombosis.
b) The Option retrievable lter has the highest
incidence of IVC thrombosis.
c) The TrapEase lter has a caval occlusion rate of 25%
or higher.
d) The Greeneld IVC lter has not been reported to
be associated with caval thrombosis.
e) None of the above options is correct.
The correct answer is (c). The TrapEase IVC lter has the
highest reported incidence of IVC thrombosis, ranging up
to 25% or higher. All other lters are reported to have a 10
to 15% incidence of IVC thrombosis.
■ Case 41
1. In current practice, the imaging modality of choice for
the diagnosis of pulmonary embolism (PE) is which of
the following?
a) CT pulmonary angiography
b) Nuclear medicine ventilation/perfusion scan
c) Pulmonary angiography
d) Chest CT scan
e) None of the above
The correct answer is (a). CT pulmonary angiography is the
imaging modality of choice for the diagnosis of PE.
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2. Indications for pulmonary artery thrombolysis include
all of the following except…
a) Oxygen saturation of 96% on room air
b) Intubation requirement
c) Hypotension
d) Right-to-left ventricular (RV/LV) ratio of 1.5
The correct answer is (a). Indications for thrombolytic
therapy (systemic or catheter-directed) are hemodynamic
or respiratory instability secondary to PE. The need for
intubation indicates respiratory compromise, and hypotension and an RV/LV ratio . 1 indicate heart strain with
hemodynamic compromise. These factors are strong indicators for aggressive management of PE.
■ Case 42
1. True or false: Varicocele is considered to be the most
common cause of male infertility.
a) True
b) False
The correct answer is (a). The statement is true. Varicocele
is a set of pathologically enlarged tortuous veins of the
pampiniform plexus, leading to an increased testicular
temperature. The presence of a varicocele can impair spermatogenesis and is considered the most common cause of
male infertility.
The correct answer is (e). Radiation of head and neck tumors
may result in damage to the vasa vasorum of the carotid
arteries. This damage may result in weakening of the carotid
artery wall and may participate as a contributing factor in
CBS. Infection and previous surgery are other factors that
have been considered as participating factors in this entity.
2. All of the following statements are true regarding CBS
except…
a) The 1-year survival rate is close to 90%.
b) Coil embolization is an accepted therapeutic
approach.
c) Endovascular stent graft placement is an accepted
therapeutic approach.
d) The risk of perioperative stroke is 10%.
e) The risk of recurrent bleeding at 30 days is 25
to 30%.
The correct answer is (a). CBS is a disease process that carries a poor prognosis. With the advent of the multidisciplinary approach, surgical reconstruction, bypass, endovascular stent graft placement, and coiling have achieved a
high therapeutic success rate for the acute event. However,
the 1-year survival after an episode of CBS is only 36%.
The risk of perioperative stroke is 10%, and the risk of
rebleeding at 30 days is 25 to 30%.
■ Case 44
2. True or false: Varicocele is much more common on the
left side.
a) True
b) False
The correct answer is (a). Left-sided varicocele is much
more common than right-sided (. 80% of cases). The predominance for the left side may be related to the anatomy
of the left spermatic vein. The left testicular vein runs in a
vertical direction and enters the left renal vein almost at
a straight angle, and this anatomic relationship appears to
create ow turbulence that may cause reux. Additional
problems include the compression of the left renal vein by
the superior mesenteric artery (“nutcracker eect”) and,
nally, the incompetence of the valve at the junction of
the spermatic vein and the left renal vein (or the complete
lack of this valve).
■ Case 43
1. Participating factors in carotid blowout syndrome
(CBS) include which of the following?
a) Radiotherapy
b) Infection
c) Previous surgery
d) Damage to the adventitial layer of the carotid artery
e) All of the above
1. True or false: Surgical bypass is the preferred
therapeutic option for limb salvage in elderly patients
with critical limb ischemia.
a) True
b) False
The correct answer is (b). The high technical success and
good outcomes reached with endovascular techniques has
made the endovascular approach the option of choice in the
management of critical limb ischemia in elderly patients.
In recent years, device companies have invested money and
eort in the development of ne recanalization tools. With
the use of these devices, the technical and clinical success
rate of endovascular techniques has increased signicantly.
2. Complications during arterial recanalization
procedures include which of the following?
a) Vessel rupture
b) Dissection
c) Unintentional subintimal angioplasty
d) Hematoma
e) All of the above
The correct answer is (e). Arterial recanalization is dicult
from the technical standpoint. Some of these occlusions
are heavily calcied and dicult to traverse. In certain
instances, the guidewire will advance in a subintimal location and reenter the true lumen. High technical success has
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been described with intentional subintimal angioplasty.
However, the use of certain devices is limited if a subintimal
dissection has occurred.
■ Case 45
1. Regarding acute embolic occlusion of peripheral
arteries, which of the following is true?
a) There is preference for the mesenteric circulation.
b) The renal arteries are at higher risk of embolism.
c) The internal iliac arteries are the most aected.
d) The embolus distribution is unpredictable.
e) None of the above
The correct answer is (d). The distribution of the embolus
during an embolic episode is unpredictable. There is no
literature indicating that any of the above-mentioned
arteries is at a particularly higher risk. When evaluating a
CT scan with evidence of embolic occlusion in one of the
arteries, all other arteries should be carefully reviewed.
2. In a case of acute arterial embolism, which of the
following is true?
a) The therapy of choice is catheter-directed
thrombolysis.
b) The therapy of choice is surgical embolectomy.
c) Anticoagulation is the treatment of choice.
d) Warfarin should be started immediately.
e) None of the above
The correct answer is (b). In cases of acute embolic occlusion, surgical embolectomy is the main treatment. In some
cases, endovascular thromboaspiration may be indicated,
but for the most part, treatment is surgical.
■ Case 46
1. The most common cause of nonvariceal upper
gastrointestinal (GI) bleed is which of the following?
a) Ulcers related to peptic disease
b) Use of nonsteroidal anti-inammatory drugs (NSAIDs)
c) Anticoagulation
d) Mallory–Weiss tears
e) Vascular ectasia
The correct answer is (a). Nonvariceal upper GI bleed is
secondary to peptic ulcer disease in 50 to 60% of cases, and
this is the most common etiologic factor.
The correct answer is (e). Nonvariceal upper GI bleed may
be associated with multiple factors. All factors mentioned
may cause nonvariceal upper GI bleed.
■ Case 47
1. True or false: The Angio-Seal (Terumo, Somerset, NJ)
closure device closes the arterial puncture by a suture
mechanism.
a) True
b) False
The correct answer is (b). Angio-Seal has a polymer anchor
(footplate) that is absorbable. This anchor is deployed
within the arterial lumen and secures the device. Then, a
collagen plug seals the tract. Angio-Seal is not a suturebased device.
2. Major complications of Angio-Seal include all of the
following except…
a) Vasovagal reaction
b) False aneurysm requiring intervention
c) Arteriovenous stula requiring intervention
d) Retroperitoneal bleed
e) Infection of the puncture site, with hospitalization
The correct answer is (a). Vasovagal reaction is considered
a minor complication after Angio-Seal use. All others are
major complications. The incidence of a major complication after Angio-Seal use ranges between 3 and 5%.
■ Case 48
1. True or false: Small (, 3 cm) renal masses are
increasingly detected incidentally by cross-sectional
imaging studies done for other reasons.
a) True
b) False
The correct answer is (a). The increasing use of abdominal
cross-sectional imaging for dierent diagnostic purposes
has increased the detection of small, asymptomatic renal
masses.
2. True or false: Thermal ablation of small kidney tumors
is an excellent therapeutic option.
a) True
b) False
2. Causes of nonvariceal upper GI bleed include:
a) Mallory–Weiss tears
b) Vascular ectasia
c) Complications of pancreatitis
d) Tumors
e) All of the above
The correct answer is (a). Thermal ablation of small
(, 3 cm) kidney tumors is an excellent approach and
substitutes for partial nephrectomy in patients who are
not good surgical candidates. Cryoablation is an even
better option because it is essentially a painless procedure,
requiring only minimal conscious sedation.
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■ Case 49
1. Causes of pneumothorax include which of the
following?
a) Spontaneous
b) Secondary to lung biopsy
c) Secondary to central venous access attempts
d) Secondary to neck biopsy procedures
e) All of the above
The correct answer is (e). All of the options mentioned are
recognized causes of pneumothorax.
2. True or false: Large chest tubes are more eective to
treat pneumothoraces than small-bore chest tubes.
a) True
b) False
The correct answer is (b). Previous reports have shown
that small-bore catheters are as eective to treat pneumothoraces as are large-bore chest tubes. Smaller diameter
chest tubes should be tried rst.
■ Case 50
1. True or false: Uterine broids are more common in
African American women than in Caucasian women.
a) True
b) False
The correct answer is (a). The incidence of uterine broids
is close to 60% among African American women compared
to 40% in Caucasian women in the age group between
5 and 40 years of age.
■ Case 51
1. Regarding lymphatic malformations (LMs), which of
the following is true?
a) They are classied in the same category as
hemangiomas.
b) They contain cystic spaces that enhance with
gadolinium injection.
c) They demonstrate low ow on Doppler imaging.
d) They contain spaces lined by a single layer of
endothelium.
e) They are neoplasms.
The correct answer is (d). Unlike hemangiomas and
other neoplasms, LMs are classied as low-ow vascular
malformations. No ow is detectible by Doppler imaging,
and no enhancement within the cystic spaces is detectible
by gadolinium-enhanced MRI, although septations may
enhance in a pattern of rings and arcs.
2. Regarding treatment of LMs, which of the following is
false?
a) Injected sclerosant should roughly match cyst volume.
b) OK-432 and bleomycin are common sclerosing agents.
c) Clinical success is achieved for 50% of macrocystic
LMs.
d) Not all LMs require interventional treatment.
e) Monthly imaging is recommended after treatment
to rule out residual LMs.
The correct answer is (c). Clinical success is achieved most
of the time (75–100%) for macrocystic LMs, although lower
success rates are reported for sclerotherapy of microcystic
LMs in limited studies. Options a, b, d, and e are all true.
2. Treatment options for uterine broids include which of
the following?
a) Medical treatment including hormone modulators
b) Endovascular broid embolization
c) High-frequency ultrasound
d) Surgery
e) All of the above
The correct answer is (e). All the above-mentioned options
are accepted in the management of uterine broids. Hormone modulators have gained popularity because of their
noninvasiveness. Uterine broid embolization continues
to be an excellent alternative in women who want to
preserve the uterus. It has few major complications;
the risk of hysterectomy after endovascular broid
embolization is low.
■ Case 52
1. What is the most common etiology of ureteral stulas
and leaks?
a) Surgery
b) Radiation therapy
c) Trauma
d) Malignancy
e) Infection
The correct answer is (a). The majority are caused by surgical
procedures—most commonly, hysterectomy. The remainder
of the options are possible causes but are not as common.
2. Which of the following is an option for inoperable,
malignant vesicovaginal stula?
a) Bladder catheterization
b) Radiation therapy
c) Percutaneous nephroureterostomy placement
d) Retrograde ureteral stent placement
e) Coil embolization of the ureters
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The correct answer is (e). Permanent coil embolization of
the ureters, coupled with permanent percutaneous nephrostomy catheter placement, treats incontinence associ-
ated with vesicovaginal stula. Options a, c, and d allow
continued lling of the urinary bladder, which facilitates
continued leakage through the stula. Radiation therapy
causes rather than treats urinary tract stulas.
■ Case 53
1. Which of the following best describes primary
sclerosing cholangitis (PSC)?
a) The majority of patients with PSC have ulcerative
colitis.
b) The majority of patients with PSC will end up with
cholangiocarcinoma.
c) Biopsy results are quite specic for PSC.
d) Diuse intrahepatic PSC usually requires
percutaneous biliary drainage.
e) Onset is typically during childhood.
The correct answer is (a). Up to 70% of patients with PSC
have ulcerative colitis, but only 10-to 15% of PSC patients
will end up with cholangiocarcinoma. Biopsy excludes
alternative causes for biliary obstruction like malig-
nancy; results in PSC cases show nonspecic inammatory features. Diuse intrahepatic PSC may worsen with
catheter or stent placement and transplantation should be
considered. Onset may be in childhood, but average onset
actually occurs in the fourth decade.
2. For extrahepatic PSC, which of the following is most
accurate?
a) Surgical choledochoenterostomy is typically avoided.
b) Catheter drainage or plastic stent placement is
typically avoided.
c) Ascending cholangitis may be a complicating factor.
d) Balloon dilatation is contraindicated because of the
risk of infection.
e) Imaging ndings are quite specic.
The correct answer is (e). Branch-point involvement is
atypical, which distinguishes SAM from mycotic aneurysms. Elevated ESR and response to steroid treatment are
not seen with SAM, but are typical of inammatory vasculitis. Patients are typically older and aortic involvement is
not common.
2. Outcomes of SAM may include all of the following
except…
a) Spontaneous repair and remodeling
b) High mortality rate
c) Aneurysmal rupture
d) Intestinal ischemia
e) Low recurrence after angioplasty
The correct answer is (e). Unlike bromuscular dysplasia,
angioplasty is typically not performed for SAM because
the risk of rupture is high. The rest of the options are all
outcomes of SAM.
■ Case 55
1. Which of the following is the strongest indication for
revascularization of complete portal vein thrombosis
(PVT)?
a) Acute PVT after liver transplantation
b) Acute PVT prior to scheduled liver transplantation
c) Chronic PVT before liver transplantation
d) Acute PVT related to coagulopathy in an otherwise
healthy patient
e) Acute PVT related to ongoing abdominal infection
The correct answer is (a). Acute PVT after liver transplantation is the strongest indication since it results in graft loss;
revascularization by endovascular or surgical methods is
commonly indicated. Options b, c, and d are softer indications and may preserve the candidacy and potential ease
of liver transplantation as well as treat rapid clinical pro-
gression. Option e is a poor candidate for revascularization
since PVT is related to ongoing abdominal infection.
The correct answer is (c). Even though instrumentation
can increase the risk of superimposed ascending cholangitis, balloon dilatation or the use of catheters and plastic
stents may buy patients with extrahepatic strictures more
time prior to liver transplantation. Imaging ndings show
annular strictures and are nonspecic.
■ Case 54
1. Which of the following is common with segmental
arterial mediolysis (SAM)?
a) Elevated erythrocyte sedimentation rate (ESR)
b) Tendency to occur in younger patients
c) Aortic involvement
d) Responds to high-dose steroid treatment
e) Not associated with branch points
2. In symptomatic cirrhotic patients with complete, acute
PVT, endovascular revascularization typically involves
all of the following except:
a) Anticoagulation
b) Thrombolysis
c) Thrombectomy
d) Transjugular intrahepatic portosystemic shunt (TIPS)
e) Balloon-occluded retrograde transvenous
obliteration (BRTO)
The correct answer is (e). BRTO is contraindicated in
the setting of complete, acute PVT because of the risk of
causing mesenteric venous thrombosis and ischemia. Options a, b, and c are indicated to treat symptoms, prevent
progression, and improve or preserve candidacy for liver
transplantation. TIPS is often used after recanalization of
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acute PVT to prevent recurrence resulting from sluggish
portal vein ow. TIPS is also used to preserve candidacy for
liver transplantation in patients with chronic PVT.
■ Case 56
1. Treatment options for peripheral artery pseudoaneurysms
(PSAs) include all of the following except…
a) Physical compression
b) Thrombin injection
c) Coil embolization
d) Stent graft placement
e) Sclerotherapy
The correct answer is (e). Sclerotherapy is used for uid
collections and vascular malformations, but not for PSAs.
2. Which of the following is most accurate regarding the
treatment of peripheral artery pseudoaneurysms?
a) They can be followed by imaging surveillance.
b) They can cause death.
c) Typical thrombin dose for treatment ranges from
2000 to 3000 IU.
d) Ultrasound-guided compression results in low
recurrence rates, even for anticoagulated patients.
The correct answer is (a). SMA aneurysms are often
mycotic, and up to 50% present with rupture with a high
mortality rate.
■ Case 58
1. Which of the following is not a common component of
hypothenar hammer syndrome (HHS)?
a) Raynaud’s disease
b) Emboli to digital arteries
c) Fibromuscular dysplasia
d) Corkscrew conguration of the ulnar artery
e) Ulnar artery aneurysms
The correct answer is (a). Raynaud’s phenomenon, or secondary Raynaud’s, is a common component. The rest of the
options are known associations or complications of HHS.
2. HHS can be described most accurately as what type of
disorder?
a) Environmental exposure
b) Occupational exposure
c) Congenital
d) Vasculitis
e) Embolic
The correct answer is (b). Rupture can case compartment
syndrome and massive hemorrhage. Small PSAs can be followed with imaging and sometimes thrombose spontaneously. Thrombin dosages range from 200 to 750 IU in most
cases. Recurrence is common after ultrasound-guided
compression of PSAs in anticoagulated patients.
■ Case 57
1. Ongoing infection in a ruptured, visceral aneurysm is
best managed by which of the following?
a) Antibiotic therapy alone
b) A full course of antibiotics followed by coil
embolization
c) Surgical options
d) Stent graft placement
e) Imaging surveillance to determine stability
The correct answer is (c). Ruptured, infected aneurysms
are a surgical emergency. Occasionally, presurgical embolization is performed to buy time to surgical candidacy.
2. Compared to other visceral artery aneurysms, superior
mesenteric artery (SMA) aneurysms are which of the
following?
a) More prone to rupture
b) Larger
c) Usually followed with serial imaging studies
d) Usually missed on imaging
e) Usually related to atherosclerosis
The correct answer is (b). Repeated trauma causes HHS,
although the idiopathic condition of bromuscular dysplasia is a predisposing factor. “Environmental” is a less
specic term that includes conditions such as temperature,
electrical, and chemical injury.
■ Case 59
1. Which of the following is true regarding renal cell
carcinoma (RCC)?
a) The rising incidence of RCC is most likely the result
of environmental exposure.
b) Patients with von Hippel–Lindau syndrome are
poor candidates for thermal ablation.
c) Thermal ablation is avoided in patients with
solitary kidneys.
d) Thermal ablation is avoided in patients with poor
renal function.
e) Nephrectomy is the preferred treatment option for
early lesions.
The correct answer is (e). Nephrectomy is still considered
the best chance for cure for early RCC, although limited
evidence suggests that outcomes of thermal ablation are
comparable to outcomes of surgical resection for lesions
, 2 cm in diameter. The rising incidence of RCC is most
likely the result of more numerous and improved imaging
studies. Patients with von Hippel–Lindau syndrome, solitary kidneys, and poor renal function are strong candidates
for thermal ablation to preserve renal function.
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2. Which of the following is true regarding thermal
ablation for renal cell carcinoma?
a) Cryotherapy results in better margin detection than
radiofrequency ablation.
b) Enhancement surrounding the ablation zone
indicates recurrence or residual tumor in all cases.
c) Serial cross-sectional imaging after thermal
ablation is performed every 6 months.
d) Exophytic tumors are more dicult to treat than
tumors in other locations.
e) The ablation zone should include a 2-cm margin
surrounding the tumor.
The correct answer is (a). Cryotherapy is preferred by
many operators for the resultant well-circumscribed
margins that help rule out residual tumor. Enhancement
surrounding the ablation zone may be benign peri-ablational enhancement. Imaging surveillance is performed
more frequently, typically at 1, 3, 6, and 12 months; then
every 6 months for 1 year; and every 12 months thereafter,
although protocols vary. Exophytic tumors have a low rate
of residual tumor following ablation compared to other
locations. The ablation zone should be 5 to 10 mm.
■ Case 60
1. Which of the following is true regarding lower
gastrointestinal (GI) bleeding?
a) Endoscopy is usually reserved if endovascular
treatment fails or is infeasible.
b) Lower GI bleeding most commonly responds to
conservative medical management.
c) Embolization of left colonic and rectal bleeding
results in a higher recurrence rate than
embolization of right colonic bleeding.
d) Endovascular sclerotherapy is rst-line treatment
for arterial bleeding.
The correct answer is (b). Most cases of lower GI bleeding resolve with conservative management and observation, although protracted cases may trigger interventional
therapies. Diagnostic studies are still indicated to de-
termine the cause. Endoscopy is rst-line treatment for
lower GI bleeding. Right rather than left colonic bleeding is
associated with a higher recurrence rate after embolization
because of the higher incidence of angiodysplasia at this
location. Embolization rather than sclerotherapy is used
for arterial GI bleeding to avoid bowel necrosis.
2. Which of the following is false regarding Dieulafoy
lesions?
a) They occur twice as often in men compared to
women.
b) They result in repeated episodes of GI bleeding.
c) They are often associated with other comorbidities.
d) They are usually associated with local
inammatory disease.
e) They are most likely developmental in origin.
The correct answer is (d). Dieulafoy lesions are more
commonly associated with systemic comorbidities rather
than local inammatory or neoplastic disease, making
them more likely to be developmental in origin. They are
associated with recurrent GI bleeding.
■ Case 61
1. Which of the following is true regarding treatment of
symptomatic uterine broids?
a) Medical therapy is a rst-line option in most cases.
b) Myomectomy has a lower recurrence rate than
uterine artery embolization (UAE).
c) Hysterectomy has a lower rate of major
complications than UAE.
d) Gelfoam embolization is an option for relief of bulk
symptoms.
e) Particle embolization provides clinical success in
almost all cases.
The correct answer is (e). Particle embolization is perma-
nent, treats the entire broid burden, and results in an
85 to 96% clinical success rate. Myomectomy treats only
select broids and has a high recurrence rate. Hysterectomy has a higher rate of major complications. Gelfoam
embolization is reserved for temporary indications,
typically postpartum hemorrhage.
2. Which of the following is true regarding treatment of
uterine bleeding?
a) Treatment with trisacryl gel particles is the usual
rst-line option for postpartum hemorrhage.
b) Treatment with Gelfoam is the usual rst-line
option for hypermenorrhagia.
c) UAE for bulk symptoms results in similar clinical
success rates as UAE for uterine bleeding.
d) Hysterectomy is the rst choice for postpartum
hemorrhage.
e) Pedunculated broids are more likely to cause
uterine bleeding.
The correct answer is (c). Clinical success is high for both
bulk symptoms and uterine bleeding. Trisacryl particles
are permanent agents and, therefore, are used for treat-
ment of uterine broids. Gelfoam is a temporary agent that
recanalizes in weeks and is more suitable for postpartum
hemorrhage. Hysterectomy is usually a backup treatment
to UAE for severe, unrelenting postpartum hemorrhage.
Submucosal broids cause bleeding most commonly.
Pedunculated, subserosal broids typically result in bulk
symptoms.
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■ Case 62
1. Which of the following is true regarding bronchial
artery aneurysms?
a) They can be followed to stable size by serial
imaging studies.
b) They are most commonly idiopathic.
c) They are most commonly multiple.
d) They are most commonly mycotic.
e) They require embolization.
The correct answer is (e). They are believed to have a high
risk of life-threatening rupture and require treatment.
They usually occur in the setting of advanced, chronic
lung disease, are most commonly singular, and are rarely
mycotic.
2. Which of the following is true regarding bronchial
artery embolization (BAE)?
a) BAE is mainly performed after failed surgical
treatment for most indications.
b) Particle embolization is used for most cases of BAE.
c) Tissue necrosis is a common complication.
d) Spinal artery originating from an
intercostobronchial trunk is a rare nding.
e) Neurologic complications are common.
The correct answer is (b). BAE is usually performed for
chronic, benign lung diseases such as cystic brosis,
bronchiectasis, and granulomatous diseases. Surgery is
performed after failed or infeasible BAE for most cases of
benign lung disease. Tissue necrosis is rare, spinal arteries
originate from an intercostobronchial trunk in approximately 10% of cases, although they are not always visualized angiographically, and neurologic complications occur
in 0.6% of BAEs.
■ Case 63
1. If variant venous anatomy is suspected by inferior vena
cava (IVC) venography before lter placement, which
of the following is the best next step?
a) Repeat IVC venography at a higher rate of contrast
injection.
b) Order a cross-sectional imaging study.
c) Order a Doppler ultrasound study.
d) Perform selective venography.
e) Place a suprarenal lter.
2. In patients with duplicated IVC requiring lter
placement for bilateral femoral deep venous
thrombosis, which of the following is a common
choice?
a) Placement of a single lter in the infrarenal IVC
b) Placement of bilateral common iliac vein lters
c) Placement of a bird’s nest lter
d) Placement of a single lter in the suprarenal IVC
The correct answer is (d). Suprarenal placement aords
protection from pulmonary emboli from both legs. A single
lter in the infrarenal IVC does not protect the patient
from embolism from the contralateral side. Bird’s nest
lters and bilateral common iliac vein lters are placed in
patients with congenital megacava.
■ Case 64
1. Which of the following conditions excludes a patient
with resectable right lobe cholangiocarcinoma from
portal vein embolization (PVE)?
a) Hepatic steatosis
b) Child–Pugh class A cirrhosis
c) Portal hypertension
d) Previous exposure to hepatotoxic chemotherapy
e) Bland thrombus in the ipsilateral portal veins
The correct answer is (c). Portal hypertension is a contraindication to hepatic resection, and therefore, PVE is
unnecessary. Options a, b, and c determine the targeted
standardized future liver remnant (sFLR) after successful
PVE. Ipsilateral tumor thrombus is a contraindication.
2. Which of the following is false regarding PVE?
a) Enlargement of the FLR takes 2 to 4 weeks in
otherwise normal livers.
b) Extended right hepatectomy typically leaves an
sFLR of , 20% without PVE.
c) Nontarget PVE of the contralateral portal veins
typically excludes patients from attempts at
curative resection.
d) Associated morbidity and mortality range from
10 to 20%.
e) The indocyanine green test estimates hepatic
reserve to screen patients for PVE.
The correct answer is (d). Signicant morbidity occurs in
, 3%. The rest of the statements are true.
The correct answer is (d). Although cross-sectional
imaging provides an accurate assessment of the IVC and
associated branches, selective venography is similarly
sensitive, detecting variant anatomy in 20 to 37% of cases.
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■ Case 65
1. Which of the following is true regarding median
arcuate ligament syndrome (MALS)?
a) Imaging during inhalation is critical for diagnosis.
b) Celiac stenosis on ultrasound and cross-sectional
imaging that varies with respiration indicate MALS.
c) MALS may be congenital or acquired.
d) MALS is more common in elderly patients.
The correct answer is (c). MALS is postulated to be congenital in most cases but has been observed after trauma,
abdominal surgery, and pancreatitis. The stressed state
is during exhalation, when the median arcuate ligament
descends on the celiac artery. MALS is a clinical diagnosis.
Celiac stenosis that varies with respiration is seen in up to
20% of asymptomatic people. Median age is 35 years.
2. Which of the following is the most accurate statement
regarding treatment of MALS?
a) Pancreaticoduodenal artery aneurysms require coil
embolization.
b) Median arcuate ligament release is the only
surgical option.
c) Approximately 40% of patients describe symptom
relief after surgery.
d) Surgical options are reserved for patients failing
endovascular revascularization.
The correct answer is (a). Collateral artery aneurysms have
a high risk of rupture. Ligament release is performed with
celiac ganglion neurolysis. Clinical success rates after surgical treatment range between 65 and 75%. Surgical options
should obviate the need for or precede endovascular
revascularization.
2. For patients with head and neck cancer, which of the
following is true?
a) They are not candidates for percutaneous
gastrostomy placement.
b) Endoscopic placement is the best option to protect
the airway.
c) Push-type (transabdominal rather than transoral)
placement is the best option.
d) Infection of the stomal tract is the primary concern
during gastrostomy placement.
The correct answer is (c). Push-type gastrostomy avoids
the inadvertent seeding of the stomal site with tumor cells
that has been described with pull-type placement. For this
reason, pull-type gastrostomy using either endoscopic or
imaging guidance is typically avoided. Regarding option a,
for head and neck cancer, gastrostomy placement improves
survival and quality of life and is commonly prescribed.
For option d, metastatic seeding to the abdominal wall is
the primary concern in these patients.
3. The most common arterial injury during percutaneous
gastrostomy placement involves which of the
following?
a) Superior epigastric artery
b) Gastroduodenal artery
c) Left gastric artery
d) Inferior epigastric artery
e) Gastroepiploic artery
The correct answer is (e). This vessel courses along the
entire greater curvature and is injured in cases involving
anomalous gastric positioning, inadequate gastric insuation, or low gastric puncture. Options a through d are less
commonly injured.
■ Case 66
1. Prior to uoroscopic percutaneous gastrostomy
placement, which of the following should be
performed?
a) CT scan with contrast
b) Abdominal ultrasound
c) Abdominal radiography
d) Barium swallow study
e) History and physical examination
The correct answer is (e). History and physical examination is essential to rule out factors that may change or
contraindicate the procedure. Existing imaging studies are
key components of the patient’s history; additional studies
prior to routine gastrostomy placement are unnecessary
unless indicated by ndings in the history and physical
examination.
■ Case 67
1. Which of the following is most accurate regarding
thoracic outlet syndrome (TOS)?
a) Most cases present with neurologic symptoms.
b) Most cases present with pallor and cyanosis.
c) Most cases present with swelling.
d) Most cases present with thrombosis.
e) Most cases result from compression by the
sternocleidomastoid muscle.
The correct answer is (a). Up to 95% of cases involve compression of the nerves of the brachial plexus, resulting in
numbness and weakness. Arterial and venous compression
is less common, as are thrombotic complications. Most
commonly, compression results from the scalene muscles
(anterior and middle).
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