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4
professional attitude and espouse team work at all times.
Included in the below chapters are a range of questions that
provide only a sample of the breadth of knowledge and curi-
osity that should be sparked within the IR rotation.
What imaging modalities
are used during
interventional radiology
procedures?
Ultrasound, fluoroscopy, CT, and/or MRI
How is fluoroscopy
different from general
radiography (X-ray)?
Fluoroscopy utilizes lower milliampere (mA)
voltage as compared to X-ray, as well as pulsed
radiation to compensate for the longer necessary
exposure time
What measures are
taken to minimize
radiation exposure
of interventional
radiologists?
Lead gowns, lead-lined eyeglasses, shields,
ALARA (as low as reasonably achievable), etc.
Radiation exposure is monitored monthly to
avoid excess of the recommended limit.
How many French (Fr)
are in 1mm?
3 Fr=1mm or 1 Fr=0.33mm. Sheath sizes are
defined by their inner diameter. Catheters and
wire sizes are defined by their outer diameter.
The size of an arteriotomy or venotomy created
by a sheath is approximately 1.5–2 Fr larger than
the labeled sheath size.
How are sheaths, wires,
and catheters described
in terms of size?
Sheaths are described in French sizes, indicative
of the inner diameter, and total length
Wires and catheters are described in French
sizes (catheters) and inches (wires), indicative of
outer diameter. The length of all of these devices
is described in centimeters
According to Poiseuille’s
law, what has greatest
impact of flow through
a tube?
According to the law, a change in radius
corresponds to a proportional change in flow by
a factor of the fourth power Flow is also directly
proportional to the change in pressure.
Smaller-bore catheters will require a greater
change in pressure to be able to maintain forward
flow of the contents
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What is the mechanism
of action and plasma
half-life of unfractionated
heparin?
Heparin binds to and activates the enzyme
antithrombin III, which then binds to and
inactivates thrombin and factor Xa. The half-life
is 60–90min. Approximately 1mg of protamine
sulfate will inactivate 100units of heparin.
What is the mechanism
of action and plasma
half-life of low molecular
weight heparin
(LMWH)?
LMWH also inactivates thrombin and factor
Xa. The half-life of protamine is 7min and,
therefore, LMWH lends itself to repeat dosing.
What pharmacological
agent can be used in
patients with heparin
allergy?
Direct thrombin inhibitors, such as bivalirudin,
argatroban and dabigatran. Bivalirudin requires
dose adjustment for renal impairment and is not
monitored with ACT. Argatroban and dabigatran
undergo hepatic clearance and can be monitored
with ACT. Bleeding complications for these agents
can be treated using recombinant factor VIIa.
What is the goal
for therapeutic
anticoagulation
during interventional
procedures?
A baseline “activated clotting time” (ACT)
should be established before relevant
procedures. Anticoagulation is considered
therapeutic when the ACT is 1.5–2 times above
the baseline
What medication may
improve coagulation
in patients with uremic
platelet dysfunction?
DDAVP (desmopressin)
What is used to reverse
the effects of midazolam
(benzodiazepine)?
Flumazenil
What is used to reverse
the effects of fentanyl
(opiate based narcotic)?
Naloxone
What doses of midazolam
and fentanyl are typically
given during moderate
sedation?
IV bolus doses of 25–100 mcg of fentanyl and
0.5–2mg midazolam, respectively, are given.
Chronic pain medication use may require higher
doses of fentanyl.
What is the relative
duration of effect of
fentanyl and midazolam?
Fentanyl and midazolam have a relatively
long duration of effect, 30–60 and 30–80min,
respectively. It is important to remember that
the level of sedation may deepen even after the
procedure.
(continued)
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What factors must always
be kept in mind for
patients receiving
sedation and analgesia?
Any major comorbidities
Any abnormalities of the airway (does the
patient have a known or suspected difficult
airway?)
Tolerance to pain medications
Obesity or history or obstructive sleep apnea
Will the case require prone positioning?
Does the patient have claustrophobia?
What is the antibiotic
coverage of vancomycin?
Gram positive, including MRSA
What is the antibiotic
coverage of piperacillin-
tazobactam (Zosyn)?
Gram positive, negative, anaerobe. Not MRSA
or fungus
What can be added to
penicillins, ampicillin
(IV), and amoxicillin
(PO) to create broad
coverage?
Beta-lactamase inhibitors; clavulanic acid
(Augmentin or amoxicillin- clavulanate) and
sulbactam (Unasyn or ampicillin-sulbactam)
What are the
third- generation
cephalosporins?
Ceftazidime and ceftriaxone are third-
generation cephalosporins with lower efficacy
against gram-positive organisms as compared to
first- and second-generation cephalosporins, but
with broad gram-negative coverage
Which cephalosporin will
treat Pseudomonas?
Cefepime is a fourth-generation cephalosporin
with gram- negative only coverage, including
Pseudomonas
Which antibiotics have
good anaerobe coverage?
Clindamycin provides good anaerobe coverage
for organism encountered on the skin, head,
and neck. Metronidazole provides good GI/GU
anaerobe coverage
What is a good antibiotic
choice to treat cellulitis?
Start with a first- or second- generation
cephalosporin
Consider options, such as vancomycin (MRSA),
clindamycin (MRSA and anaerobes), or TMP/
SMX if cephalosporins fail
What are the main types
of medical shock that
patients may encounter?
Septic, hypovolemic, cardiogenic, neurogenic,
and anaphylactic
C. Molloy and J. Huang
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What are the major signs
and symptoms of shock?
Type RR HR BP Skin TempUrine Other
Anaphylactic
Flushed,
swollen,
itchy
No
Change
No
Change
No
Change
Urticaria, pruritus,
bronchoconstriction
Cardiogenic
Pale, cool,
clammy
Pale, cool,
clammy
Pale, cool,
clammy
Chest discomfort, syncope, JVD,
pulmonary edema, orthopnea
Hypovolemic
Anxiety, thirst, syncope, weakness,
confusion, dizziness, weak pulse
Obstructive
Muffled heart sounds, JVD, decreased
LOC, signs of poor perfusion
Neurogenic
Warm,
flushed,
dry
No
bladder
control
Paralysis distal to injury site, priapism
Septic
(Distributive)
Flushed,
then pale
and cool
Bounding pulse, altered LOC
What clinical features
further define certain
forms of shock?
Type MAPCO DO2 CVPMPAPPCWPSVR
Cardiogenic
Hypovolemic
obstructive
Septic
(Distributive)
What conditions require
emergent IR
intervention?
Acute ischemia (limb, end- organ, pulmonary
embolus, etc.), hemorrhage (hemoptysis,
hematemesis, ruptured aneurysm, traumatic,
iatrogenic, etc.), closed- space infections
(pyonephrosis, cholangitis, abscess, etc.)
How do you know if a
patient can provide their
own consent?
The patient must be (1) alert; (2) oriented; (3)
be able to understand and ideally reiterate the
risks, benefits, and alternatives of procedure; and
(4) have legal capacity
What are the current
Anesthesia Society of
America (ASA)
guidelines for eating
and drinking prior to
procedures performed
with moderate sedation?
No solid foods 6h prior to procedure
No clear fluids for 2h prior to procedure
Where would you find
prophylactic antibiotic
recommendations for
planned procedures?
The 2019 Society of Interventional Radiology
(SIR) Antibiotic Prophylaxis Guidelines during
Procedures
Where would you find
recommendations
regarding holding
anticoagulation prior
to planned procedures?
The 2019 Society of Interventional Radiology
(SIR) Periprocedural Anticoagulation
Guidelines
(continued)
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What are the ASA
classifications?
Class I: Normal healthy patient
Class II: Mild systemic disease
Class III: Severe systemic disease
Class IV: Severe systemic disease which is a
constant threat to life
Class V: Moribund patient who is not expected
to survive without the procedure
Class VI: Declared brain-dead patient whose
organs are being removed for donor purposes
What is the modified
Mallampati score?
Class I: Soft palate, uvula, fauces, pillars visible
Class II: Soft palate, major part of uvula, fauces
visible
Class III: Soft palate, base of uvula visible
Class IV: Only hard palate visible
What are the differences
between nasal cannula,
venturi mask, non-
rebreather, and high-flow
nasal cannula (HFNC)?
Nasal cannula: Provides oxygen at a low flow
rate
Venturi: Controls/restricts the amount of
entrained air and therefore the FiO2
Non-rebreather: Delivers the highest FiO2 at
standard flow rates
HFNC: Provides warmed, humidified
supplemental oxygen at a rate of up to 60L/min
Remember that supplemental oxygen
will not treat hypercapnia due to alveolar
hypoventilation and may misleadingly raise
pulse oximetry readings
What scoring system
may be used to
stratify atherosclerotic
cardiovascular risk?
Atherosclerotic Cardiovascular Disease
(ASCVD) risk calculator from the AHA/ACC
What is the main clinical
patient assessment tool
used in the evaluation of
acute stroke?
The NIHSS score describes the physical
limitations caused by the acute stroke.
Neurologic impairment is classified based on its
severity and extent. The scale is between 0 and
42 with higher scores (≥21) indicating a severe
stroke
What is the classification
system for acute and
chronic limb ischemia?
Rutherford
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What is the Couinaud
system of liver
segmentation?
The liver is divided inferiorly and superiorly
by the portal vein. The right and left hepatic
lobes are divided by the falciform ligament,
which contains the obliterated umbilical vein
(ligamentum teres), the falciform artery, and the
paraumbilical veins. The hepatic vein borders
define the Couinaud segments: superiorly left-
to-right, 2, 4a, 8, and 7 and inferiorly left- to- right,
3, 4b, 5, and 6. The middle hepatic vein should
intersect the gallbladder fossa
Name the locations of the
various types of varices
that may be found related
to portal hypertension
Left gastric venous collaterals
Esophageal
Paraesophageal
Recanalized paraumbilical vein
Abdominal wall
Perisplenic
Retrogastric
Omental
Retroperitoneal-paravertebral
Mesenteric
Sites of previous surgery or inflammation
Patients with chronic
mesenteric vessel
occlusion may
demonstrate collateral
vascular pathways. What
are the common
mesenteric collateral
pathways?
Arc of Buhler: remnant artery that directly
connects the proximal celiac artery with the
proximal superior mesenteric artery (SMA)
Arc of Riolan (mesenteric meandering artery
[of Moskowitz] or central anastomotic
mesenteric artery): collateral path from the
middle colic branch of the SMA to the left colic
branch of the inferior mesenteric artery (IMA)
Marginal artery of Drummond: connects the
terminal branches of the SMA and IMA
Pancreatic cascade: connects superior
pancreaticoduodenal artery branches of the
gastroduodenal artery (GDA) to the inferior
pancreaticoduodenal branches of the SMA
Arc of Barkow (gastroepiploic cascade, arcus
epiploicus magnus): collateral path connecting
the right gastroepiploic (branch of the GDA)
to the left gastroepiploic (branch of the splenic
artery)
1 The Role ofaSubintern
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11© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_2
Different attending physicians will prefer different forms of
presentation. These variations are often based on the indi-
vidual attending preference, but variations in presentation
may also be commonly driven by the type of specialty or form
of disease. Since interventional radiology is a clinical and
procedural specialty, students and residents will likely be
expected to present relevant history with pertinent negative
findings, specific disease-related lab results, and key findings
from diagnostic imaging and prior interventions with close
attention to patient-specific anatomy and specifications of
the prior tools used in treatment.
Chapter 2
Presenting aPatient
ChrisMolloy andJunjianHuang
C. Molloy (*)
Department of Vascular and Interventional Radiology, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
J. Huang
Department of Vascular and Interventional Surgery, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
https://t.me/med1917
12
What key lab findings
are important for
chronic kidney disease
patients prior to image-
guided procedures?
PT/INR, platelets, GFR, and BUN
(uremic platelet dysfunction leads to
prolonged bleeding)
How can symptoms of
acute arterial ischemic
stroke be differentiated
from other causes
of ischemic cerebral
pathology?
Acute arterial ischemia disease
manifestation is related to the acute
drop in glucose and oxygen delivery,
with the extent of damage reliant upon
the degree of ischemia and ability to
recruit collateral vasculature
Central retinal artery occlusion
(CRAO) presents as painless
monocular vision loss with a cherry
red spot visible on fundoscopic
examination
Cerebral venous sinus thrombosis
(CVST) manifests as symptoms related
to impaired venous drainage, including
headache, blurred vision, painful loss
of vision, loss of bodily control, seizure,
and coma
What imaging finding
may indicate increased
bleeding risk during
percutaneous liver
biopsy?
The presence of ascites increases the
risk of intraperitoneal hemorrhage.
These patients should either receive
paracentesis prior to percutaneous
liver biopsy or be offered a
transjugular liver biopsy instead.
What medical therapy
should be considered
in large-volume
paracentesis (>5L
ascitic fluid removal)?
An albumin infusion of 6–8g/L of fluid
removal improves survival
What other disease
processes affect chronic
limb ischemia patients?
Myocardial infarction (25% in 5years),
stroke
C. Molloy and J. Huang
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13
What medications
should chronic limb
ischemia patients be on?
Aspirin, beta-blocker, high-intensity
statin, ACE inhibitor, +/– cilostazol
What are disadvantages
of duplex ultrasound to
CTA in pre-procedural
evaluation of limb
ischemia intervention?
Though less expensive, duplex
ultrasound has less spatial resolution
than CT and can be limited by
operator experience and body habitus.
Calcium can pose a problem for both
modalities. Typically, if a patient has
palpable and symmetric femoral
pulses, CTA can be avoided.
Will endograft stent
placement fix type 2
endoleaks?
No. Balloon remodeling and endograft
stent placement are treatment options
for type 1 endoleaks, which are caused
by inadequate seal at the proximal
or distal stent attachment sites.
Embolization is the first-line treatment
for type 2 endoleaks.
What scoring system
may be used to predict
pulmonary embolism
(PE) 30-day outcomes?
Simplified Pulmonary Embolism
Severity Index (PESI) score may be
used to determine and stratify severity
of PE:
Class I=score≤65 (1.1% 30-day
mortality)
Class II=score 66–85 (3.1%
30-day mortality)
Class III=score 86–105 (6.5%
30-day mortality)
Class IV=score 106–125 (10.4%
30-day mortality)
Class V=score>125 (24.5% 30-day
mortality)
(continued)
2
Presenting aPatient
https://t.me/med1917
14
The PESI score is
divided into which
demographic, comorbid
illness, and clinical
finding predictors?
Age (1pt./yr.)
Male (10 pts.)
Cancer (30 pts.)
Heart failure (20 pts.)
Chronic lung disease (20 pts.)
AMS (60 pts.)
SBP <100mmHg (30 pts.)
HR ≥110 (20 pts.)
RR ≥30 (20 pts.)
Temp <36 °C (20 pts.)
Arterial oxygen saturation <90%
(20 pts.)
What antibiotics should
patients be given prior
to cholangiogram?
Ceftriaxone or cefotetan (unless
the patient is allergic, in which case
another option, such as vancomycin or
clindamycin + an aminoglycoside may
be used)
What is the initial
medical management of
a chyle leak?
Chyle leaks may be post-traumatic
or iatrogenic in nature and should
be initially managed with low-fat
diet or TPN, octreotide infusion, and
percutaneous drainage
What are the
components of
MELD-Na score?
Creatinine, bilirubin, INR, and serum
sodium
What is APACHE II
used for and what do
the letters in APACHE
represent?
APACHE II helps to determine
severity of disease and mortality
prediction of ICU patients
The acronym APACHE is “Acute
Physiology and Chronic Health
Evaluation”
Where is the most
common location where
dialysis graft stenosis
occur?
At the graft-vein anastomosis
C. Molloy and J. Huang
https://t.me/med1917
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