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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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15
Where is the most
common location that
dialysis fistulas stenose/
occlude?
Peri-anastomotic venous outflow
What is the estimated
rate of IVC filter-
induced thrombus?
2–10%
What is the best CT
protocol to visualize
aortic intramural
hematoma?
Non-contrast CT images are ideal to
detect for high-density intramural
aortic collections. Useful CT protocols
in evaluation of aortic and arterial
pathology include non-contrast,
arterial phase, and delayed phase
images.
What are the
components of the
Child-Pugh score?
Bilirubin, albumin, total protein,
ascites, and hepatic encephalopathy
What is a SAAG
score and how do you
interpret it?
SAAG is the serum to ascites albumin
gradient. A value > 1.1g/dL indicates
hepatic causes of the ascites, such as
cirrhosis with portal hypertension and,
less commonly, CHF.A value < 1.1g/dL
indicates malignancy or infection.
2 Presenting aPatient
https://t.me/med1917
17© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_3
Morning rounds or morning report is typically comprised of
discussion of all scheduled patients, including treatment
plans, a review of call cases from the previous night or week-
end, and review of patients on the IR service and/or consult
service. During morning report, individuals often give a very
brief “one-liner” history and procedure to be performed and
discuss any pertinent lab/imaging concerns. For more compli-
cated cases, this brief discussion may also include planned
access or path, device discussions, collaboration with other
departments, and additional needs, such as anesthesia.
Chapter 3
Morning Rounds
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
18
What is the most
common risk in
patients with popliteal
aneurysms? What
additional findings may
be seen in patients with
popliteal aneurysm?
Patients with popliteal aneurysms have
a high risk of thromboembolism
50% of popliteal aneurysms are
bilateral
Approximately 25% of patients with
popliteal aneurysms also have an aortic
aneurysm (<10% of patients with aortic
aneurysms have popliteal aneurysms)
How often should
vitals, neurovascular
checks, and groin
check be performed
following mechanical
thrombectomy for
stroke?
Q 15min × 2, Q 30min × 6, Q hourly
× 16
What is the 90-day
stroke risk following
TIA?
Very broad range, 8–77%, with half
occurring within the first 7 days
50% of those who experience a TIA
will have a stroke within 1 year
15% of all strokes are heralded by a
TIA
During ultrasound
evaluation of a TIPS,
what are normal
expected flow
velocities?
TIPS stenosis is marked by globally
decreased velocity (< 40–60cm/s)
within the shunt and focally increased
velocity (> 200cm/s) at the point of
stenosis
What is Kasabach-
Merritt syndrome?
Kasabach-Merritt syndrome
(hemangioma thrombocytopenia
syndrome) is found in infants with
large, highly vascular hemangiomas and
is responsible for thrombocytopenia,
microangiopathic hemolytic anemia,
and consumptive coagulopathy
C. Molloy and J. Huang
https://t.me/med1917
19
What is May-Thurner
syndrome?
Classic May-Thurner syndrome is
compression of the left common iliac
vein (CIV) by the right common iliac
artery resulting in decreased CIV
vessel diameter by 50%. A physiologic
pre-stenotic to post-stenotic gradient
of 2–3mmHg gradient has also been
suggested but has not been validated.
Treatment includes clot lysis and
stenting
What are expected
angiographic findings
in median arcuate
ligament syndrome
(MALS)?
MALS is characterized by extrinsic
compression of the celiac artery by the
median arcuate ligament:
During inspiration, as the diaphragm
and abdominal contents move down,
compression on the superior aspect
of the celiac artery by the MAL.The
celiac artery will appear widely
patent on the lateral projection
During expiration, the diaphragm
and abdominal contents will move up
and worsen the effect compression
on the celiac artery by the MAL,
which will be evident by focal
narrowing on the lateral angiographic
projection
What are typical
physical exam findings
in popliteal artery
entrapment syndrome
(PAES)?
Diminished distal lower extremity
pulses with plantar or dorsiflexion
What is a normal
portal-systemic
gradient?
≤ 6mmHg. Symptomatic manifestations
of portal hypertension are usually not
encountered until > 10 mmHg.
At what portal-systemic
gradient do patients
usually experience
variceal bleeding?
≥ 12mmHg
(continued)
3 Morning Rounds
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20
What are the Milan
criteria?
Milan Criteria used in patients with
hepatocellular carcinoma to assess
suitability for liver transplantation:
A single tumor with diameter ≤5
cm, or up to 3 tumors (each tumor
diameter must be ≤3 cm)
No extrahepatic involvement
No portal vein extension
How many MELD
“exception points”
do hepatocellular
carcinoma (HCC)
patients receive (while
waiting for liver
transplant)?
After 6 months within Milan criteria,
HCC patients are given a minimum
of 28 MELD points (however these
“exception points” are subject to
change in future iterations of OPTN
transplant protocol)
What medications
may be administered
to reduce hepatic
encephalopathy in
patients with cirrhosis
and liver failure?
Lactulose (15–45ml every 8–12 h)
titrated to 3 soft bowel movements per
day
Rifaximin (550mg orally BID)
C. Molloy and J. Huang
https://t.me/med1917
21© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_4
In some facilities, afternoon rounds may be an opportunity
to discuss discharge planning or post-procedural
dispositions.
What does qSOFA score
evaluate and how do you
calculate it?
Quick sequential organ failure
assessment score (qSOFA) score
of 2 (or more) at the onset of
infection is associated with a
greater risk of death or prolonged
intensive care unit stay.
qSOFA score includes:
Altered mental status
Respiratory rate>22
Systolic BP ≤ 100
Chapter 4
Afternoon Rounds
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
(continued)
https://t.me/med1917
22
What is SIRS and what are
the components of SIRS
score?
Systemic inflammatory response
syndrome (SIRS) describes whole
body response to infectious or
noninfectious insult. Note that
the JAMA SOFA/qSOFA report
advocates replacing SIRS with
SOFA in specific situations:
Temperature<36°C or>38°C
Heart rate>90bpm
Tachypnea >20 respirations per
minute
WBC <4000 cells/mm
3
or>12,000 cells/mm
3
A patient that your team
treated for PAD now has
a rapid decline in platelets
from 200,000 to 75,000.
What is the most likely
diagnosis and how do you
proceed?
The diagnosis is probably heparin-
induced thrombocytopenia (HIT).
The treatment is to discontinue
heparin products. Maintain
anticoagulation with non-heparin
products, such as direct thrombin
inhibitors (IV argatroban or PO
dabigatran). Warfarin should not
be started until platelets recover to
≥150×10
9
/L.
Your team placed an
infusion catheter in order
to perform prolonged tPA
infusion to treat acute
pulmonary embolism. The
plan is to keep the catheter
in place for at least 12h.
What labs should you order
to follow this patient?
Hemoglobin, hematocrit, and
fibrinogen q6h. If the fibrinogen
level drops to <150 (or decreases
by 1/2), the tPA infusion may
be decreased by 1/2 dose. If the
fibrinogen level is <100 or the
patient has severe bleeding, the
infusion is discontinued
What recommendations
and medications should
be considered in PAD
patients?
Smoking cessation
Supervised exercise program
Aspirin or clopidogrel (Plavix)
Beta-blocker
ACE inhibitor
High-intensity statin
Cilostazol
C. Molloy and J. Huang
https://t.me/med1917
23
What are the goals of
medical therapy after
intervention for limb
ischemia?
To reduce cardiovascular morbidity
and mortality, as well as reduce
adverse limb outcomes
What are the main findings
and recommendations from
the CLEVER trial?
Supervised exercise and stent had
better 18-month outcomes than
optimal medical care. Intermittent
exercise and rest improves oxygen
extraction. Exercise also improves
endothelial function, blood
pressure, cholesterol, glycemic
control, and overall functional
capacity. Supervised exercise
involves 30–45 min sessions, 3 times
a week, for 12 weeks. Patients are
instructed to walk until there is
pain, persist as much as possible,
and then rest. Only walking
minutes are counted. Supervised
exercise therapy improves walking
time, functional status, and quality
of life. It also increases the size and
number of collaterals.
What was the conclusion
of the 2002 Antithrombotic
Trialists’ Collaboration
for high-risk patients for
occlusive vascular events
(acute MI or ischemic
stroke, unstable or stable
angina, previous MI, stroke
or cerebral ischemia, PAD,
or atrial fibrillation)?
287 studies involving 135,000
patients in comparison with
antiplatelet therapy vs. control and
77,000 patients in comparison with
different antiplatelet regimens.
Aspirin is protective in high-risk
patients and low dose (75–150mg
daily) is effective for long-term use,
but in an acute setting, an initial
loading dose of at least 150mg may
be required
(continued)
4 Afternoon Rounds
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24
What were the findings of
the “Clopidogrel versus
Aspirin in Patients at
Risk of Ischemic Events”
(CAPRIE) study?
This was a multicenter,
multinational, randomized, double-
blind, parallel group analysis of
19,185 patients with atherosclerotic
disease (recent ischemic stroke,
recent MI, or symptomatic PAD)
with primary combined endpoint
of ischemic stroke, MI, or vascular
death and 1.9-year mean follow-up:
Approximately 9% additional
relative risk reduction in
primary combined endpoint with
clopidogrel versus aspirin
Approximately 9% additional
relative risk reduction in
cumulative rehospitalization rate
for ischemia or bleeding with
clopidogrel versus aspirin
What were the findings
of the EUCLID study
(Ticagrelor versus
Clopidogrel in Symptomatic
in Peripheral Artery
Disease)?
Symptomatic PAD (and clinically
significant ABI or prior lower
extremity revascularization) was
randomized to ticagrelor 90mg
twice daily (n=6930) versus
clopidogrel 75mg daily (n=6955):
Ticagrelor was not superior to
clopidogrel in preventing major
adverse cardiac events
Acute limb ischemia and major
bleeding were similar between
treatment groups
C. Molloy and J. Huang
https://t.me/med1917
25
The purpose of the
COMPASS trial was to
evaluate whether treatment
with rivaroxaban and
aspirin or rivaroxaban
alone is better than aspirin
alone in prevention of
MI, ischemic stroke, or
cardiovascular death in
patients with coronary or
peripheral arterial disease.
What medical therapy
would you recommend for
a patient with history of
revascularization and low
bleeding risk?
Randomized, placebo-controlled
study of 27,400 patients with CAD,
carotid stenosis, and PAD with
primary endpoints of MI, ischemic
stroke, cardiovascular death, and
major bleeding:
In patients with atherosclerotic
cardiovascular disease,
rivaroxaban plus aspirin resulted
in lower rates of composite
cardiovascular endpoint events
but higher rates of major
bleeding than with aspirin alone
Major adverse limb events were
increased in those with history of
prior revascularization compared
to claudicants or asymptomatic
PAD
In subgroup analysis, those with
polyvascular disease benefit the
most
What were the findings
of Evaluating Adverse
Events in a Global
Smoking Cessation Study
(EAGLES)?
This was a randomized, double-
blind, triple dummy, placebo-
controlled, and active-controlled
trial (nicotine patch 21mg/day
with taper) of those receiving
varenicline 1mg PO BID or
bupropion 150mg PO BID:
The study did not show
a significant increase in
neuropsychiatric adverse events
attributable to varenicline or
bupropion relative to nicotine
patch or placebo
Varenicline was more effective
than placebo, nicotine patch, and
bupropion in helping smokers
achieve abstinence, whereas
bupropion and nicotine patch
were more effective than placebo
4 Afternoon Rounds
https://t.me/med1917
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