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2. Which of the following is most accurate regarding TOS?
a) Angioplasty should be attempted before surgery for
vascular compression resulting from TOS.
b) Imaging should be performed with the arm
internally rotated.
c) Doppler typically shows doubling of the peak
systolic velocity when the arm is placed in the
stressed position.
d) Surgery provides relief in the minority of cases.
e) Radiographs rarely identify an associated
abnormality
The correct answer is (c). Surgical decompression should
be performed before angioplasty; thrombolysis may be
helpful prior to surgery for thrombotic complications
of TOS. Imaging tests and physical exam should be performed with external rotation and hyperabduction of the
arm. Surgery is successful in 86% of cases, but preexisting
thrombotic complications portend a poor surgical result.
Bone abnormalities are commonly discovered radiographi-
cally in patients with TOS.
■ Case 68
1. Denitive treatment of a type B aortic dissection
complicated by acute limb ischemia may be possible
with all of the following except:
a) Antihypertensive and analgesic medication
b) Stents
c) Stent grafts
d) Angioplasty balloons
e) Surgical management
The correct answer is (a). Conservative medical management is common for type B dissections, but the complication of acute limb ischemia requires either endovascular
or surgical revascularization. Endovascular options include
restoring vessel patency by deploying stents/stent grafts or
fenestrating the intima with angioplasty balloons.
2. Unstable patients with tearing chest pain suspicious
for aortic dissection typically undergo:
a) CT/CT angiography
b) Conventional angiography
c) MR/MR angiography
d) Transesophageal echocardiogram (TEE)
The correct answer is (d). TEE can be performed rapidly at
the bedside in unstable patients, avoiding the delays and
risks associated with options a through c. TEE is sensitive
for the detection of coronary artery involvement and
involvement of the aortic root, which would indicate a
type A dissection that requires emergent surgery.
3. Which of the following is true regarding conventional
angiography to evaluate suspected aortic dissection?
a) Conventional angiography is a rst-line option for
evaluating stable patients.
b) Conventional angiography provides poor
delineation of branch vessel perfusion.
c) Conventional angiography is primarily used to
guide surgical and endovascular treatment.
d) Conventional angiography is associated with a high
rate of complications.
The correct answer is (c). Conventional angiography provides excellent delineation of entry and exit points as well
as branch vessel perfusion and is associated with a low
complication rate, but it is primarily used to guide therapy.
TEE and cross-sectional imaging are rst-line options.
■ Case 69
1. Which of the following is true regarding splenic artery
aneurysms (SAAs) and pseudoaneurysms?
a) Atherosclerosis is the most common cause.
b) Most are asymptomatic.
c) Most patients are young adults.
d) Rupture is typically not life threatening.
e) Aneurysms , 3 cm are typically followed with
CT surveillance.
The correct answer is (b). Most are discovered incidentally
on imaging studies. Pancreatitis is the most common
cause, the peak age is in the sixth decade of life, rupture is
associated with a mortality rate of 35 to 90%, and aneurysms , 2 cm are sometimes followed by CT surveillance.
2. Concerning treatment of SAAs, which is most accurate?
a) Hilar aneurysms usually require splenectomy.
b) Mycotic aneurysms cannot be embolized.
c) Embolization of the mid-portion of the splenic
artery typically results in splenic infarction.
d) Older patients with 2-cm aneurysms should
undergo immediate embolization because of an
increased risk of rupture.
e) Most intrasplenic aneurysms are treated with
splenectomy.
The correct answer is (a). Embolization at this location
risks splenic infarction and abscess. Mycotic aneurysms
can be embolized after treatment with antibiotics. Embolization of the mid-portion of the splenic artery is safe in
the majority of cases because of reconstitution of the distal
splenic artery. Older patients with 2-cm aneurysms are
often watched with serial CT scans because the lifetime
rupture rate is low. Intrasplenic aneurysms can be treated
with selective embolization of each of the arterial feeders.
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■ Case 70
1. Which of the following is the best option for a wideneck, saccular gastroepiploic artery aneurysm caused
by pancreatitis?
a) Embolizing the gastroepiploic artery with coils
using back door–front door (BD-FD) technique
b) Performing percutaneous thrombin injection
c) Embolizing the gastroepiploic artery with particles
d) Embolizing the gastroepiploic artery with Gelfoam
e) Placing a stent graft within the gastroepiploic artery
The correct answer is (a). BD-FD coil embolization is used
routinely for small to mid-sized visceral arteries. In this
case, sacrice of the gastroepiploic artery results in no
risk to tissue perfusion because of collateralization via the
splenic artery. Percutaneous thrombin is a poor choice
for wide-neck aneurysms, and particles and Gelfoam will
cause nontarget distal embolization. Stent grafts would be
dicult to place in the gastroepiploic artery because of the
rigidity of available delivery systems, and preservation of
ow in the gastroepiploic artery is unnecessary because of
adequate collateralization.
2. Which of the following is not a standard option for
treatment of visceral artery pseudoaneurysms?
a) Stent graft placement
b) Thrombin injection
c) BD-FD coil embolization
d) Coil packing
e) Sclerotherapy
The correct answer is (e). Pseudoaneurysm treatment
requires stent graft placement, coil embolization, or
thrombin injection.
■ Case 71
1. Which of the following is false regarding pelvic
congestion syndrome (PCS)?
a) Pain is sharp and increases with menstrual cycle.
b) PCS commonly occurs in the setting of polycystic
ovaries.
c) Ovarian vein diameter exceeds 4 mm by pelvic
ultrasound.
d) Ovarian vein diameter exceeds 6 mm by
conventional venography.
e) Medical management is an option prior to
endovascular or surgical intervention.
The correct answer is (a). Pain is actually dull, chronic,
and noncyclical. Option b is true, possibly related to the
common potential risk factor of estrogen stimulation.
Options c and d are true regarding ovarian vein diameter.
Medical management is an option with the goals of sup-
pressing ovarian function, reducing inammation, and
increasing venous contraction.
2. Which of the following is false regarding endovascular
venous obliteration to treat PCS?
a) Clinical success rates of venous obliteration and
hysterectomy are similar.
b) Common agents include coils, glue, and sclerosants.
c) Procedure-related premature menopause is
uncommon.
d) Embolization of the distal outow of the ovarian
vein is the primary goal.
e) Clinical success rates exceed 70%.
The correct answer is (d). For clinical success, sclerotherapy
and embolization of the pelvic collaterals and the entire
length of the ovarian vein are recommended. Clinical
success rates of venous obliteration and hysterectomy
for PCS are surprisingly similar and typically exceed 70%.
This result argues for the minimally invasive approach to
reduce complications. Common agents are coils and liquid
agents. No change in menstrual cycle or fertility is observed after venous obliteration.
■ Case 72
1. Which of the following is true regarding microwave
ablation (MA) and radiofrequency ablation (RFA)?
a) RFA causes thermocoagulation by frictional energy.
b) MA relies on ischemia and protein denaturation to
cause cell rupture.
c) MA is limited by the heat-sink eect.
d) MA is associated with a higher risk of skin burns.
e) MA results in higher temperatures and burn radius
than RFA.
The correct answer is (e). This may result in a future
advantage of MA for lung tumors, but data are still limited.
RFA causes thermocoagulation by electrical energy and MA
by kinetic energy (option b). RFA rather than MA is limited
by the heat-sink eect. RFA has a higher risk of skin burns
than MA because of the need for grounding pads.
2. Which of the following is most accurate regarding
thermal ablation of lung tumors?
a) Thermal ablation is palliative for patients with
primary lung cancer.
b) Surgical resection is reserved for recurrence after
thermal ablation.
c) Patients with coronary artery disease are poor
candidates.
d) Patients with severe interstitial lung disease are
considered poor candidates.
e) Patients with metastatic lesions are not candidates.
The correct answer is (d). Severe interstitial lung disease
can be exacerbated by thermal ablation. The goal of ablation of early lung cancer is cure. Surgical resection is still
considered rst line, but poor surgical candidacy caused
by comorbidities such as coronary artery disease makes
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thermal ablation a better option. Symptomatic palliation
of metastatic lung tumors is an indication for thermal
ablation.
■ Case 73
1. Venous malformations (VMs) are most closely
classied with what anomaly in the list below?
a) Peripheral arteriovenous malformations (AVMs)
b) Hemangiomas
c) Arteriovenous stulas
d) Lymphatic malformations
e) Hemangiopericytoma
The correct answer is (d). Both anomalies are considered
low-ow vascular malformations. Hemangiomas and
hemangiopericytomas are classied as vascular tumors.
AVMs and arteriovenous stulas are classied as high-ow
vascular malformations.
2. Regarding treatment of VMs, which of the following
is true?
a) Surgical management is more eective but more
invasive.
b) Coil embolization is the primary treatment
strategy.
c) Low-dose aspirin may reduce symptoms.
d) Ethanol is less eective than other sclerotherapy
agents.
e) Fluoroscopic imaging is usually unnecessary
during treatment.
The correct answer is (c). Aspirin reduces thrombotic
events that cause pain. Surgical management is not as effective as sclerotherapy for most vascular malformations
but may be required as an adjunctive or salvage strategy.
Sclerosis of VMs is the primary strategy, although coils may
be used to block venous outow to slow ow for treatment.
Ethanol is more eective but is associated with more major
complications. Fluoroscopic imaging is necessary to prevent
nontarget therapy and determine the extent and characteristics of the VM during therapy. Subtraction methods to
gauge treatment progress are advocated by most operators
(e.g., roadmap technology).
■ Case 74
The correct answer is (d). Systemic arterial thromboembolism is not a feature of KTWS. GI and GU bleeding may result from capillary malformations, heart failure may result
from arteriovenous malformations, and venous thrombosis
may result from varicose veins.
2. Which of the following is not a feature of Klippel–
Trénaunay syndrome (KTS)?
a) Hemangiomas
b) Varicose veins
c) Absence of the deep venous system of the leg
d) Venous malformations
e) Soft tissue hypertrophy
The correct answer is (a). KTS is associated with capillary
malformations, not hemangiomas. The remaining options
are known features of KTS.
■ Case 75
1. Which of the following is true regarding patients with
Raynaud’s disease?
a) Raynaud’s disease is often caused by environmental
exposures.
b) Denitive diagnosis of Raynaud’s phenomenon
requires imaging studies.
c) Treatment of Raynaud’s phenomenon may require
medical or surgical therapies.
d) Primary Raynaud’s often results in tissue loss.
The correct answer is (c). Pharmacologic options or surgical
sympathectomy may be required. Raynaud’s phenomenon
is often caused by environmental exposures. Imaging
studies may support the physical examination and history
in making the diagnosis, but no study is denitive. Primary
Raynaud’s is usually mild and self-limiting.
2. Regarding small vessel disease of the hand, which of
the following is true?
a) Buerger’s disease results in diuse non-opacication
of the digital arteries.
b) Diuse non-opacication of the digital arteries
usually results from thromboembolic disease.
c) Occupational and environmental exposure results in
hypothenar hammer and Raynaud’s phenomenon.
d) Scleroderma and rheumatoid arthritis result in
corkscrew collateral vessels.
1. Which of the following is not a feature of Klippel–
Trénaunay–Weber syndrome (KTWS)?
a) Gastrointestinal (GI) bleeding
b) Genitourinary (GU) bleeding
c) Heart failure
d) Systemic arterial thromboembolism
e) Venous thrombosis
The correct answer is (c). Hypothenar hammer results in
occlusion of the ulnar and hypothenar digital arteries because of repetitive occupational injury, and Raynaud’s phenomenon can result from exposure injury (cold, electrical,
polyvinyl chloride). Buerger’s disease, or thromboangiitis
obliterans, results in scattered, focal small vessel occlusions
and corkscrew collaterals in patients who smoke. Thromboembolic disease more commonly results in focal occlusions
unless associated with secondary Raynaud’s, as in this case.
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3. Ischemic symptoms associated with acute brachial
artery thromboembolic disease are usually treated by
which of the following?
a) Thrombectomy
b) Angioplasty
c) Stent placement
d) Surgical bypass
The correct answer is (a). Either surgical or endovascular
thrombectomy shortens the treatment time and limits the
risk of showering distal thromboemboli associated with
thrombolysis, angioplasty, and stent placement.
■ Case 76
1. The etiology of angiodysplasia is most likely which of
the following?
a) Acquired
b) Neoplastic
c) Iatrogenic
d) Infectious
e) Congenital
The correct answer is (a). Angiodysplasia is theorized to be
an acquired vascular malformation resulting from enlargement and shunting of submucosal vessels with repeated
mural stress.
2. In general, embolization for the treatment of
angiodysplasia:
a) Is the denitive therapy
b) Is associated with high recurrence rates
c) Is associated with high complication rates
d) Is not possible
e) Is contraindicated
The correct answer is (b). Endoscopic techniques tend to
be the rst-line treatment options because angiodysplasia
has a tendency to recur after embolization. Surgical
resection and transarterial embolization are second-line
options.
3. Regarding CT for the evaluation of lower gastrointestinal
hemorrhage, which of the following is true?
a) Can replace the tagged red blood cell (RBC) study
for detection of active extravasation
b) Requires careful timing of IV and oral contrast
administration
c) Is less sensitive than conventional angiography
d) Is used mainly for surgical planning
e) Is more sensitive than the tagged RBC study for
active extravasation
The correct answer is (a). Multiphase contrast-enhanced
CT without oral contrast is more sensitive than conventional angiography and approaches the sensitivity of the
tagged RBC study. Therefore, contrast-enhanced CT is
used as a rst-line screening tool for lower gastrointestinal
bleeding. Oral contrast is not administered to allow for
clear visualization of contrast extravasation.
■ Case 77
1. Prior to being scheduled for balloon-occluded
retrograde transvenous obliteration (BRTO), patients
should undergo all of the following except…
a) Contrast-enhanced cross-sectional imaging
b) Conventional venography
c) Doppler ultrasound
d) Upper gastrointestinal endoscopy
The correct answer is (b). Without catheter access to the
gastric veins, conventional venography is not possible.
Selective arteriography of the celiac artery with venousphase imaging provides excellent visualization of gastric
varices and drainage pathways, but it has largely been
replaced by coronal reformatted, contrast-enhanced crosssectional imaging for this purpose. Doppler ultrasound is
useful as a screening tool to determine the patency of the
portal vein (PV) and splenic vein. Endoscopic management
is the rst-line option for diagnosis and treatment of
isolated gastric varices (IGVs).
2. In the setting of IGVs and complete portal venous
occlusion, BRTO…
a) Is the best therapeutic option
b) Improves hepatic function and encephalopathy
c) Is a common alternative to transjugular
intrahepatic portosystemic shunt (TIPS)
d) May result in mesenteric ischemia
The correct answer is (d). Without a patent PV, mesenteric
venous drainage relies on physiologic portosystemic shunts.
Elimination of one or more of these shunts may cause
mesenteric venous ischemia. In the setting of a patent PV
and IGVs, poor liver function and encephalopathy may be
improved after BRTO by the resultant reduction of portosystemic shunting. TIPS with PV recanalization is actually
an alternative to BRTO in the setting of PV thrombosis.
3. Retrograde transvenous obliteration of IGVs may
involve the use of all of the following except…
a) Coils
b) Plugs
c) Alcohol
d) Gelfoam
e) Sotradecol
The correct answer is (c). The remainder of the options
may be used for BRTO, vascular plug-assisted retrograde
transvenous obliteration (PARTO), or coil-assisted retrograde transvenous obliteration (CARTO) procedures.
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■ Case 78
1. Which of the following is true regarding refractory
ascites (RA)?
a) Most patients with cirrhosis and RA undergo
liver transplantation, which is the gold-standard
treatment.
b) Repeated large-volume paracentesis (LVP) results in
longer transplant-free survival.
c) External drainage catheters are standard for the
management of RA caused by cirrhosis.
d) LVP reduces portal hypertension and associated
complications.
e) RA caused by cirrhosis is associated with a
50% survival rate at 1 year.
The correct answer is (e). Only 20% of patients with
cirrhosis who have RA undergo liver transplantation
because of limitations in graft availability and patient
candidacy. Transjugular intrahepatic portosystemic shunt
(TIPS) results in better transplant-free survival rates
than LVP and is the standard option for cirrhosis-related
RA. TIPS reduces portal hypertension and all associated
complications, which is a major advantage over LVP.
2. Which of the following is an advantage of
peritoneovenous shunts over permanent external
drainage for RA?
a) Lower infection risk
b) Lower catheter occlusion rate
c) Lower risk of adhesions/septations
d) Ease of catheter maintenance
e) Ease of use
The correct answer is (a). Peritoneovenous shunts are totally implanted, resulting in a lower infection risk, similar
occlusion rates, similar rates of adhesions/septations, more
dicult catheter maintenance (requiring an incision), and
more intense patient involvement compared with external
peritoneal drainage catheters.
■ Case 79
1. Which of the following is true regarding endovascular
interventions to treat iliac artery peripheral
atherosclerotic disease (PAD)?
a) Endovascular interventions result in higher 5-year
patency rates than surgical bypass.
b) Stent placement is recommended if the systolic
pressure gradient exceeds 10 mm Hg after
angioplasty.
c) Balloon-expandable stents are not recommended.
d) Complete occlusions usually respond to angioplasty.
e) Heparinization during stent placement is required
in all cases.
The correct answer is (b). Suboptimal angioplasty is
indicated by a systolic gradient that exceeds 10 mm Hg
and a residual stenosis that exceeds 30%; stent placement
is indicated. Surgical bypass results in 85% 5-year patency
compared with 65 to 77% 4-year patency after endovascular revascularization. Either balloon-expandable or selfexpanding stents can be used for aortoiliac PAD. Complete
occlusions are primarily stented. Many investigators feel
that heparinization is optional for aortoiliac PAD since ow
rates in this system are high.
2. Which is the most accurate statement regarding
aortoiliac PAD?
a) Diminished popliteal pulses are highly suggestive
of aortoiliac PAD.
b) Ankle-brachial index of 0.5 corresponds with a high
risk of rest pain.
c) Aortoiliac PAD occurs in younger patients than
femoropopliteal PAD on average.
d) Aortoiliac PAD is less commonly symptomatic than
femoropopliteal PAD.
e) Conventional angiography is usually recommended
after a positive screening Doppler ultrasound.
The correct answer is (c). Diminished femoral rather than
popliteal pulses are highly suggestive of aortoiliac PAD. An
ankle-brachial index of , 0.3 corresponds to a high risk of
rest pain and tissue loss. Aortoiliac PAD is more commonly
symptomatic than femoropopliteal PAD. A positive screening Doppler ultrasound should prompt CT or MR angiogra-
phy in most cases. Occasionally, conventional angiography
is performed for evaluation of the distal runo vessels
when cross-sectional imaging is inadequate. Conventional
angiography is usually performed to guide concurrent
endovascular treatment.
■ Case 80
1. Which of the following is not an indication for partial
splenic embolization (PSE)?
a) Portal hyperperfusion syndrome
b) Splenic laceration
c) Hypersplenism
d) Portal hypertension with encephalopathy
e) Superior mesenteric vein thrombosis
The correct answer is (e). Splenic vein thrombosis is
an indication for PSE when bleeding gastric varices are
refractory to medical management. The remainder of the
options are all possible indications for PSE.
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2. Which of the following is the best next step after failed
endoscopic management of bleeding gastric varices
related to chronic splenic vein thrombosis (SVT)?
a) Balloon-occluded retrograde transvenous
obliteration (BTRO)
b) Transjugular intrahepatic portosystemic shunt
(TIPS)
c) Percutaneous thrombolysis
d) Surgical portosystemic shunt
e) Surgical splenectomy
The correct answer is (e). Surgical splenectomy is commonly performed in this setting; PSE is an alternative,
particularly for poor surgical candidates. BRTO removes
the portosystemic shunt and, if incomplete, can exacerbate
variceal bleeding. TIPS does not address the cause of the
portal hypertension (SVT). Thrombolysis is typically not an
option for chronic SVT, and no surgical shunt options exist
in most cases.
■ Case 81
1. Which of the following is true regarding renal
arteriovenous shunts?
a) They are usually congenital.
b) They usually contain multiple vascular channels.
c) They are common within benign tumors of the
kidney.
d) They usually present with hypertension.
e) They complicate 15% of renal biopsies.
The correct answer is (e). Renal arteriovenous shunts are
usually acquired (iatrogenic or traumatic), involve communication between a single artery and vein (simple arte-
riovenous stula), are more common in malignant renal
tumors such as renal cell carcinoma, and usually present
with hematuria.
2. Which of the following is a common treatment strategy
for large renal arteriovenous shunts?
a) Gelfoam embolization
b) Particle embolization
c) Ethanol sclerotherapy
d) Medical therapy
e) Ultrasound-guided compression
The correct answer is (c). Permanent treatment is recommended via coil embolization or ethanol sclerotherapy.
Gelfoam embolization and particle embolization would
risk paradoxical embolization to the lung, and Gelfoam is
a temporary agent. Medical therapy and compression are
not valid options.
■ Case 82
1. Which of the following is not a typical feature of
“burned-out” Takayasu’s arteritis (TA)?
a) Arterial stenosis
b) Arterial aneurysm
c) Arterial wall enhancement
d) Pulmonary artery involvement
e) Normal erythrocyte sedimentation rate
The correct answer is (c). Arterial wall enhancement is a
sign of active-phase TA with inammation. The rest of the
options are all signs of burned-out TA.
2. Which of the following is true regarding angioplasty of
renal artery stenosis caused by TA?
a) Antihypertensive medication should be continued
for 24 hours after the procedure.
b) The need for reintervention is common.
c) Angioplasty should be performed in the early phase.
d) Residual stenosis of 50% indicates success.
e) Antiplatelet therapy is typically unnecessary after
the procedure.
The correct answer is (b). Cumulative 5-year patency
is 67% (the patency achieved with reinterventions).
Antihypertensive medication is discontinued after renal
artery angioplasty to measure the degree of resolution of
renovascular hypertension and to avoid severe hypotension. Angioplasty is performed only after resolution of the
active phase. One measure of angiographic success after
renal angioplasty is , 30% residual stenosis. Antiplatelet
therapy is indicated after renal angioplasty, particularly
when stents are required.
■ Case 83
1. Which of the following is true regarding hemangiomas?
a) Very small and very large hemangiomas have
similar patterns of contrast enhancement on crosssectional imaging.
b) Kasabach–Merritt syndrome (KMS) is a life-
threatening condition.
c) The majority of people have at least one hepatic
hemangioma.
d) Most focal liver lesions are hemangiomas.
e) Rapidly involuting congenital hemangioma (RICH)
lesions tend to persist.
The correct answer is (b). KMS is associated with a 10 to
15% mortality rate. Very small hemangiomas are dicult
to characterize based on contrast enhancement pattern.
Only 20% of people have hepatic hemangiomas. Most focal
liver lesions are cysts. RICH lesions rapidly involute, by
denition.
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2. Which of the following is true regarding the
management of hemangiomas?
a) Arterial embolization is the most common option
for minimally invasive management.
b) Surgical management is usually reserved as a
second-line option.
c) Large hepatic hemangiomas require surgical or
minimally invasive management.
d) Incidentally discovered hemangiomas should be
followed with serial imaging studies.
e) Leukocytosis and fever after embolization usually
indicate infection.
The correct answer is (a). Currently, embolization from the
arterial approach is most commonly described, although
some cases may benet from combined arterial and venous embolization. Thermal ablation has been described.
Surgical resection is a rst-line option, and embolization
is often performed to reduce blood loss prior to resection.
Large hemangiomas are usually incidentally discovered;
asymptomatic hemangiomas require no therapy. No further imaging is required for asymptomatic liver lesions
with pathognomonic ndings of hemangioma on imaging
studies. Leukocytosis, fever, elevated liver function tests,
nausea, pain, and hypertension result most commonly
from postembolization syndrome.
■ Case 84
1. Which of the following is true regarding the treatment
of malignant biliary obstruction?
a) Medical and surgical options should be considered
prior to stent placement.
b) Percutaneous biliary drainage (PTBD) is typically
the rst-line option to provide both diagnosis and
intervention.
c) PTBD is associated with a higher rate of major
complications than endoscopic biliary drainage
(EBD).
d) Patients with hilar cholangiocarcinoma are not
surgical candidates.
e) Pancreatitis associated with EBD is uncommon.
The correct answer is (a). If medical therapy may resolve
the obstruction, or if curative resection is possible, stent
placement may be unnecessary. PTBD is second-line to
EBD to avoid external catheters and their associated complications; however, PTBD and EBD have similar rates of
major complications. Hilar cholangiocarcinoma is managed
by partial hepatectomy and hilar node resection in many
cases. Pancreatitis occurs in 5 to 15% of ERCP cases.
2. Which of the following is false regarding stent
placement for malignant biliary obstruction?
a) Metal stents are more eective than plastic stents
in most cases.
b) Covered metal stents result in longer patency rates
compared to uncovered metal stents.
c) Plastic stents are used for temporary drainage.
d) Stent placement prior to surgical resection and
reconstruction may increase infection rates.
e) Mean patient survival rates tend to exceed mean
stent patency rates.
The correct answer is (e). The opposite is true, which
serves as the basis for metal stent placement in these
patients. The rest of the options are true.
■ Case 85
1. Which of the following is true regarding grade V liver
lacerations?
a) They require surgical management in most cases.
b) Transarterial embolization (TAE) is the rst-line
therapy in stable patients.
c) Medical management is the rst-line therapy in
stable patients.
d) Hepatic artery embolization results in hepatic
infarction in most cases.
The correct answer is (c). Medical management is the
rst-line consideration in stable patients. Clinical progression despite medical management may indicate the need
for TAE or, uncommonly, risky exploratory laparotomy.
Hepatic artery embolization rarely results in hepatic
infarction in otherwise healthy individuals with a patent
portal vein. Transient elevation of serum transaminase
levels is common after TAE.
2. In patients with hepatic laceration, intrahepatic
arterial pseudoaneurysm or arterioportal stula is best
treated by which of the following?
a) Medical management if stable
b) TAE
c) Exploratory laparotomy
d) Covered stent placement
The correct answer is (b). In such cases, TAE is a rst-line
option because spontaneous resolution of these abnormalities is uncommon and the risk of clinical sequelae is high.
Covered stent may be an option for injury or pseudoaneurysm involving larger vessels such as the main hepatic
artery.
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■ Case 86
1. Which of the following is most accurate regarding
nutcracker syndrome (NS)?
a) Both right and left renal veins (RVs) can be aected.
b) Isolated NS can be treated with angioplasty.
c) It is most common in overweight patients.
d) It is the most common cause of gross hematuria.
e) It shares its root cause with superior mesenteric
artery (SMA) syndrome.
The correct answer is (e). NS results from a narrow aorto-
mesenteric angle, as does SMA syndrome. It aects the left
RV, is treated with stent placement, and is more common
in thin patients. The most common symptom is gross
hematuria, but gross hematuria more commonly has other
etiologies.
2. Which of the following is true?
a) Supine positioning may lead to underdiagnosis of
pelvic congestion syndrome (PCS).
b) Ultrasound screens for other etiologies of RV
compression.
c) RV compression is suspected when the RV to caval
pressure gradient exceeds 10 mm Hg.
d) PCS can be treated with coil placement at the cranial
aspect of the gonadal vein to prevent caudal reux.
e) NS results from incompetent venous valves.
2. Which of the following is most accurate regarding
transjugular intrahepatic portosystemic shunt (TIPS) in
the setting of portal vein occlusion?
a) Traditional TIPS technique using only a transjugular
approach results in high success rates regardless of
portal vein patency.
b) TIPS improves portal vein patency after
thrombolysis of acute portal thrombosis in patients
with cirrhosis.
c) Transsplenic portal vein recanalization with TIPS
creation is usually unsuccessful.
d) Successful TIPS in the setting of cavernous
transformation usually fails to relieve symptoms of
portal hypertension.
e) Portal vein thrombosis is a contraindication for
TIPS creation.
The correct answer is (b). Traditional TIPS technique results
in 40 to 66% technical success in the setting of chronic portal
vein occlusion. The newer technique incorporating transsplenic recanalization of the portal vein results in success
rates similar to TIPS creation in the setting of a patent portal
vein. Successful TIPS usually relieves symptoms of portal hy-
pertension. Portal thrombosis makes TIPS more dicult, but
is not a contraindication. After portal thrombectomy, TIPS
is commonly performed in cirrhotic patients since sluggish
ow in the portal vein makes recurrence likely in this setting.
The correct answer is (a). Upright positioning increases
venous distention, and reverse Trendelenburg can help
make the diagnosis when performing ultrasound. Crosssectional imaging is required to rule out other causes of
RV compression. The renal–caval gradient can be as low as
2 mm Hg in NS. PCS requires more complete embolization/
sclerotherapy to avoid recurrence caused by extensive collateralization of the gonadal vein plexus. NS results from
RV compression by the aorta and SMA.
■ Case 87
1. Which of the following is most accurate regarding
cavernous transformation of the portal vein?
a) The portal vein is typically patent.
b) Flow within periportal collateral veins is hepatofugal.
c) Development of cavernous transformation relieves
portal hypertension in most cases.
d) After recanalization, the portal vein can be used for
liver transplantation.
e) A cavernoma is a benign neoplasm of the portal vein.
The correct answer is (d). Cavernous transformation usually occurs in the setting of chronic portal vein occlusion;
ow is hepatopetal into periportal, pericholecystic, and
intrahepatic collateral veins; portal hypertension remains
in up to 90% of cases; and the mass-like group of collateral
veins is often referred to as a cavernoma.
■ Case 88
1. Which of the following is an indication for
vertebroplasty?
a) Acute traumatic fracture
b) Severe vertebra plana (. 90%)
c) Fracture of the posterior cortex of the vertebral body
d) Asymptomatic compression fracture
e) Impending fracture caused by a hemangioma
The correct answer is (e). Options a through d are
contraindications.
2. Regarding outcomes of vertebroplasty and
kyphoplasty, which option is true?
a) Pain relief typically takes a few weeks.
b) Approximately 50% of patients report pain relief.
c) Pain recurs within a year in most patients.
d) Leakage of cement during injection is more
common with vertebroplasty.
e) Neurologic complications are common.
The correct answer is (d). Leakage of cement during vertebroplasty occurs in . 40% of cases, compared to 8 to 9% of
kyphoplasty. This is believed to be related to lower pressures required during cement injection after kyphoplasty
balloon ination. Pain relief often occurs the day of the
procedure, 90% report pain relief, and relief typically lasts
beyond a year. Neurologic complications can occur from
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leakage of cement into the epidural space or compression of
the spinal cord and neural foramina. The incidence is , 1%,
and symptoms range from radiculopathy to paralysis.
■ Case 89
1. Which of the following is true regarding endovascular
infrapopliteal interventions?
a) Long-term patency is the primary goal in most
cases.
b) Amputation is averted in . 75% of cases performed
for critical limb ischemia.
c) Atherectomy is not an option because of the small
caliber of infrapopliteal arteries.
d) Stents are not an option because of the small
caliber of infrapopliteal arteries.
e) Surgical revision is recommended for anastomotic
stenosis of distal bypass grafts.
The correct answer is (b). Limb salvage is achieved in 75 to
85% of cases presenting with critical limb ischemia. Limb
salvage is the primary goal of most infrapopliteal interventions, atherectomy and stent placement are commonly
used, and endovascular techniques are rst-line treatment
for distal anastomotic stenosis (high cumulative 3-year
patency rates).
2. The range of patency rates 3 years after endovascular
treatment of focal infrapopliteal occlusions is…
a) 10–30%
b) 30–50%
c) 50–70%
d) 70–90%
The correct answer is (b). Patency rates are low, but
healing rates of tissue breakdown related to critical limb
ischemia are high, making endovascular techniques an
excellent option for limb salvage.
■ Case 90
1. Which of the following is false regarding the prostate
arteries?
a) The most common source is the internal pudendal
artery.
b) The majority are fed by branches of the anterior
division of the internal iliac artery.
c) Predictable arterial anatomy facilitates prostate
artery embolization (PAE).
d) Common origins with other branches increase the
risk of nontarget embolization.
e) Corkscrew surface branches help identify prostatic
arteries.
The correct answer is (c). Prostatic artery anatomy is quite
variable. The rest of the options are all true.
2. Which of the following is true regarding prostate artery
embolization?
a) Postprocedure admission is unavoidable because
major complications are common.
b) Particles are most commonly used.
c) PAE is the rst-line therapy for lower urinary tract
symptoms (LUTS) associated with benign prostatic
hypertrophy (BPH).
d) Transurethral resection of the prostate (TURP) is more
eective than PAE for LUTS associated with BPH.
e) Prostatic hematuria usually requires PAE.
The correct answer is (b). Permanent particles are the
most common embolic agent for prostatic hematuria and
LUTS related to BPH. PAE is associated with a low rate of
major complications, and some operators perform PAE on
an outpatient basis. Medical therapy is the rst-line treatment for BPH. Current data show that TURP and PAE are
equally eective. Prostatic hematuria usually responds to
conservative management.
■ Case 91
1. First-line treatment of hepatic encephalopathy after
transjugular intrahepatic portosystemic shunt (TIPS)
placement involves:
a) Shunt reduction using covered stents
b) Coil embolization of varices
c) Coil embolization of the TIPS
d) Medical management
e) Liver transplantation
The correct answer is (d). Medical management to control
hyperammonemia is rst-line therapy and successful in 95%
of cases. Shunt reduction with covered stents, coil embolization, and ultimately, liver transplantation are options
in refractory cases. Coil embolization of varices is typically
used for refractory bleeding after TIPS, but may reduce
shunting, improve portal perfusion, and as a result, improve
hepatic encephalopathy.
2. The suspicion of hepatic encephalopathy after TIPS is
based most strongly on:
a) Imaging nding of a large physiologic portosystemic
shunt
b) Imaging nding of persistent, large
gastroesophageal varices
c) Ultrasound nding of a widely patent TIPS with
low resistive index
d) Clinical presentation
The correct answer is (d). Imaging ndings are typically
nonspecic, showing only a patent TIPS. Suspicion of hepatic
encephalopathy is based on clinical presentation of obtundation, disorientation, and confusion after TIPS. Choices a,
b, and c: These imaging ndings are not specic for hepatic
encephalopathy but may be present in this condition.
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3. All of the following may improve hepatic encephalopathy
except:
a) Embolization or sclerotherapy of gastroesophageal
varices using the TIPS pathway
b) Angioplasty of TIPS stenosis
c) Embolization or sclerotherapy of physiologic
portosystemic shunts
d) Non-absorbable antibiotics
e) High-ber diet
The correct answer is (b). Angioplasty of a TIPS stenosis
will likely worsen hepatic encephalopathy. All of the other
options may improve this condition.
■ Case 92
1. If left untreated, which of the following best describes
the natural history of most pulmonary arteriovenous
malformations (AVMs)?
a) Involution
b) Thrombosis
c) Stabilization
d) Progression
e) Hemorrhage
The correct answer is (d). Serial CT exams have demonstrated
gradual increase in size over time rather than involution or
stabilization. Therefore, many radiologists embolize all visible
pulmonary AVMs at the time of intervention rather than only
those with feeding arteries exceeding 3 mm. Thrombosis and
hemorrhage may occur but not commonly.
2. Paradoxical embolization caused by pulmonary AVMs
can result in all of the following except:
a) Stroke
b) Brain abscess
c) Myocardial infarction
d) Mesenteric infarction
e) Pulmonary thromboembolus
The correct answer is (e). Pulmonary thromboembolus can
occur from thromboembolus from the systemic venous circulation, or paradoxical thromboembolus from a systemic
arterial source through a peripheral AVM. The remainder
of the options may result from paradoxical embolization
from a pulmonary AVM.
■ Case 93
The correct answer is (b). AVMs are present but often not
apparent at birth and grow with the patient without involuting. Growth may be exacerbated by pregnancy, puberty,
or trauma and is continuously stimulated by the high-ow
state. Some may stabilize, but most continue to grow or
evolve new pathways. Involution is not seen with AVMs
but is seen with rapidly involuting congenital hemangiomas (RICH). Thrombosis and malignant degeneration are
not features of high-ow vascular malformations.
2. What is the best rst-line treatment strategy for most
high-ow AVMs?
a) Surgical resection
b) Coil embolization of arterial feeders
c) Obliteration of the nidus or venous outow
d) Surgical ligation
e) Thermal ablation
The correct answer is (c). Obliteration of the nidus and
venous drainage oers the best chance for persistent
reduction or cure. Surgical resection alone, surgical ligation, and coil embolization of arterial feeders often lead to
recurrence. Thermal ablation is not an option.
■ Case 94
1. Which of the following is true regarding Lemierre’s
syndrome (LS)?
a) LS most commonly occurs in older adults.
b) Thromboembolism is limited to the pulmonary
arteries.
c) Mortality rates are low with appropriate antibiotic
treatment.
d) LS is usually fatal if untreated.
e) LS is septic thrombophlebitis of the superior vena
cava.
The correct answer is (d). Mortality is 90% if untreated
and 6–15% with appropriate treatment. LS occurs most
commonly in adolescents and young adults, may cause
thromboembolism to the systemic arterial circulation, and
is septic thrombophlebitis of the internal jugular vein.
2. All of the following can result from LS except…
a) Renal abscess
b) Carotid artery thrombosis
c) Empyema
d) Pulmonary abscess
e) Sepsis
1. What is the typical natural course of arteriovenous
malformations (AVMs) without treatment?
a) Involution
b) Continued growth
c) Stabilization
d) Thrombosis
e) Malignant degeneration
The correct answer is (b). Septic thrombophlebitis describes venous rather than arterial thrombosis. The remaining options have been associated with cases of LS.
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