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RadCases.thieme.com RadCases Interventional Radiology
■ Case 95
1. Pseudoaneurysms (PSAs) resulting from pancreatic
pseudocysts in stable patients are usually managed by
which of the following?
a) Serial cross-sectional imaging studies to verify
stability
b) Serial Doppler ultrasound studies to evaluate for
spontaneous thrombosis
c) Surgical resection
d) Endoscopic options
e) Radiologic options
The correct answer is (e). Visceral artery PSAs have a high
risk of rupture, particularly when associated with pancreatitis. Therapeutic intervention is required; percutaneous
thrombin injection and embolization are rst-line options.
Imaging surveillance is not an option in most cases because of the high risk of rupture. Endoscopic options for
PSA treatment have been described, but radiologic options
are well-established and preferred. Surgical resection is
usually reserved when radiologic management fails or is
not feasible.
2. After embolization of a PSA caused by pseudocyst,
which of the following is false?
a) Repeat embolization or thrombin injection is rare.
b) Continued surveillance by Doppler ultrasound is
recommended.
c) Continued surveillance by multiphase CT may be
necessary.
d) Endoscopic drainage of the pseudocyst can be
considered.
e) Back-door arterial supply may necessitate
percutaneous thrombin injection.
The correct answer is (a). Recurrence rates are up to 25%,
making repeat therapeutic measures common. Recurrence
is caused by continued erosion of arterial walls by adjacent
pancreatic uids and structures and by back-door arterial
supply left untreated during the embolization procedure.
Continued Doppler surveillance is commonly used for
screening, and suspicious or dicult cases may require
evaluation for contrast enhancement and growth using
multiphase CT. Endoscopic drainage can be considered
after transarterial embolization, often with the addition
of endoscopic ultrasound to evaluate for arterial ow prior
to intervention.
■ Case 96
1. A poor surgical candidate with severe abdominal
pain, thinned bowel wall with pneumatosis, severe
metabolic acidosis, and CT scan showing arterial
thromboembolism should be considered for which of
the following treatments?
a) Mesenteric artery thrombolysis
b) Mesenteric artery stent placement
c) Operative bowel resection and arterial bypass
d) Anticoagulation
e) Endovascular thrombectomy
The correct answer is (c). Revascularization of necrotic
bowel is contraindicated.
2. Thrombus within branches of the ileocolic artery most
likely results from which of the following?
a) Chronic atherosclerosis of the ostium of the
superior mesenteric artery
b) Infection
c) Neoplasm
d) Crohn’s disease
e) Cardiac disease
The correct answer is (e). Thrombus within distal branches
of the mesenteric arteries is most commonly caused by
thromboembolism, usually from a cardiac source. The
aected bowel is typically more focal and the symptoms
are typically less severe compared to proximal mesenteric
artery thrombosis.
■ Case 97
1. Inferior mesenteric artery occlusion results in direct
reconstitution of its branches by all of the following
except…
a) Arc of Buehler
b) Superior rectal artery
c) Marginal artery of Drummond
d) Arc of Riolan
e) Middle and inferior rectal arteries
The correct answer is (a). The arc of Buehler connects the
celiac artery to the superior mesenteric artery. The other
choices provide direct reconstitution of the arterial distribution of the inferior mesenteric artery.
RadCases.thieme.com RadCases Interventional Radiology
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233
2. In cases of celiac artery obstruction, reversal of ow is
commonly seen in which of the following?
a) Splenic artery
b) Right gastric artery
c) Proper hepatic artery
d) Superior mesenteric artery
e) Common hepatic artery
The correct answer is (e). Collateralization occurs by
reversal of ow in the gastroduodenal artery to supply
antegrade ow in the proper hepatic artery and retrograde
ow in the common hepatic artery.
■ Case 98
1. Which of the following is true regarding acute iliocaval
thrombosis?
a) The incidence of subsequent postthrombotic
syndrome (PTS) is low.
b) An inferior vena cava (IVC) lter rather than
anticoagulation is recommended for extensive
IVC thrombosis.
c) Surgical management is indicated for extensive
IVC thrombosis.
d) Mechanical thrombectomy is reserved for cases
that fail thrombolysis.
e) IVC lter placement may not be necessary during
thrombolysis.
The correct answer is (e). The incidence of pulmonary
artery thromboembolism during deep venous thrombosis
(DVT) thrombolysis is very low. The incidence of PTS
exceeds 50% after DVT in many studies. Extensive IVC
thrombosis can be managed by anticoagulation or throm-
bolysis. Mechanical thrombectomy is used as a rst-line
adjunctive tool to thrombolysis to shorten procedure times
and improve outcomes.
2. Which of the following is most accurate regarding the
management of iliocaval thrombosis?
a) For complete IVC thrombosis, endovascular
treatment options are reserved for failed surgical
thrombectomy.
b) An IVC lter can be removed if clot occupies 50% of
the lter volume.
c) PTS is uncommon after untreated acute DVT.
d) Thrombolysis intervals of 2 to 3 days are typically
required for treatment.
e) Therapeutic heparinization is recommended
during recombinant tissue plasminogen activator
(r-tPA) infusion.
The correct answer is (d). For complete IVC thrombosis,
surgical thrombectomy is rare, and when treatment is
desired, nearly all cases are managed using endovascular
options. An IVC lter can be removed safely using the
standard method if the interior clot occupies , 20% of
the lter volume. PTS occurs in . 50% of cases of lower
extremity DVT (. 80% in some studies). Therapeutic
heparinization is contraindicated during r-tPA thrombolysis because of a high risk of bleeding complications.
■ Case 99
1. Angiomyolipoma is commonly associated with what
condition?
a) von Hippel–Lindau disease
b) Tuberous sclerosis
c) Neurobromatosis
d) Klippel–Trénaunay syndrome
The correct answer is (b). Tuberous sclerosis is associated
with angiomyolipoma, and von Hippel–Lindau disease is
associated with renal cell carcinoma.
2. What CT feature is most important in making the
diagnosis of angiomyolipoma?
a) Arteriovenous shunting
b) Arterial aneurysms
c) Extravasation
d) Fat
e) Tumor size
The correct answer is (d). Gross fat deposits within a renal
tumor are most consistent with angiomyolipoma, although
arterial aneurysms and extravasation can occur with these
lesions. Shunting is uncommon with benign tumors of
the kidney.
3. What feature would prompt endovascular treatment?
a) Size . 2 cm
b) Infection
c) Hemorrhage
d) Enhancement
The correct answer is (c). Hemorrhage is an indication
for embolization. Most authors recommend a diameter
of 4 cm for prophylactic treatment. Infection should be
treated to resolution before endovascular treatment except
in cases of active hemorrhage.
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RadCases.thieme.com RadCases Interventional Radiology
■ Case 100
1. Which of the following is most accurate regarding
pulmonary sequestration?
a) Intralobar sequestrations are more commonly
symptomatic than are extralobar sequestrations.
b) Extralobar sequestrations usually present with
recurrent infections.
c) Intralobar sequestrations drain via the systemic
veins.
d) Extralobar sequestrations have a separate pleural
membrane.
e) Conservative management is usually sucient for
complicated sequestrations.
The correct answer is (d). Extralobar sequestrations have
a separate pleural membrane, most commonly drain via
the systemic veins, and are more commonly symptomatic
within the rst 6 months of life because of a host of associated multisystem congenital anomalies, not because
of infection. Intralobar sequestrations usually drain via
the pulmonary veins. Complicated sequestrations require
intervention.
2. Which of the following is false regarding pulmonary
sequestrations?
a) Arterial supply occurs via systemic arteries.
b) Extralobar sequestration can have pulmonary
venous drainage.
c) Intra- and extrapulmonary sequestrations are
usually left-sided.
d) Surgical excision is a rst-line option in good
candidates.
e) Vascular supply is similar to that of pulmonary
AVMs.
The correct answer is (e). Sequestrations are supplied by
systemic arteries, are usually left-sided, and are usually
surgically excised when complications occur. Extralobar
sequestrations most commonly drain via the systemic
veins but can have pulmonary venous drainage.
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