Interactive Transcript
0:02
Hello and welcome to Case Crunch Rapid case
0:04
review for the core exam hosted by Medality.
0:08
In this rapid-fire format, faculty will
0:10
show key images along with a multiple-choice
0:12
question, and you'll respond with your
0:14
best answer via the live polling feature.
0:17
After a quick answer explanation,
0:19
it's on to the next case.
0:22
You'll be able to access the recording of today's case
0:24
review and previous case reviews by creating a free
0:27
account using the link provided in the chat. Today,
0:31
we are honored to welcome Dr. Dan Patel for a vascular
0:34
and interventional radiology board prep case review.
0:37
Dr. Patel completed his radiology residency at
0:40
Case Western Reserve University Hospitals and
0:43
subspecialty training in vascular and interventional
0:46
radiology at Massachusetts General Hospital.
0:50
He's currently the division chair for
0:51
Vascular and Interventional Radiology
0:53
at Mayo Clinic in Phoenix, Arizona.
0:56
Questions will be covered at the end if
0:58
time allows, so please remember to use the
1:00
Q&A feature to submit your questions.
1:03
With that, we are ready to begin today's board review.
1:05
Dr. Patel, please take it from here.
1:09
Hi all.
1:09
Uh, thanks and welcome.
1:12
Um, I'll be sharing my screen here in just a minute.
1:15
Um, and, uh, it'll be rapid-fire.
1:20
Hopefully, you can see the screen, and we'll get started.
1:23
Um, warm-up. Uh, we'll initially just be me
1:27
disclosing no disclosures and, uh, a quick
1:31
little, um, poll here for you guys to answer.
1:45
All right, so it looks like, um, most of
1:48
you are residents studying for the core,
1:51
um, and about two attending physicians
1:55
and a couple here just for the, uh, cases.
1:59
Welcome, and, um, we'll proceed.
2:02
Case one.
2:03
A patient receives four milligrams of IV
2:06
midazolam and 50 micrograms of IV fentanyl.
2:10
Uh, they start to become a little bit
2:11
hypoxic, bradycardic, and they're not really
2:15
responding well to verbal or painful stimuli.
2:19
They're really not arousable.
2:21
Um, in this case, in this scenario, what would the
2:24
reversal agent of choice be for, uh, a benzodiazepine?
2:36
And it sounds like flu-, um, is the top choice.
2:41
Uh, 14.
2:42
Uh, out of the 16, I think you guys
2:44
can all see the responses as well.
2:47
Um, so.
2:50
Flumazenil, as you should know, or, or hopefully
2:53
by the end of this, is a selective competitive
2:55
antagonist of the GABA receptor, and it's the
2:58
only available specific antidote for benzodiazepines.
3:01
So, midazolam is a benzodiazepine.
3:04
Naloxone is for opioids.
3:07
So fentanyl is the opioid, um, and acts
3:10
as an agonist, essentially reversing
3:12
and blocking, um, other opioids as well.
3:14
Heroin, morphine, oxy.
3:16
Um, diphenhydramine is the H1
3:18
receptor, uh, inverse agonist.
3:21
And it reverses the effects of
3:23
histamine, um, reducing allergic reactions.
3:26
Um, typically, we use that for contrast reaction.
3:28
Same with epinephrine.
3:29
It works on the alpha-1 receptors, increasing
3:33
vascular smooth muscle contraction,
3:35
and a bunch of other, um, activities.
3:39
Case two: Uh, what does this arrow point to?
3:44
Um, what are some reasons that this could
3:47
happen? And then, uh, is this acute or chronic?
3:51
So, as you take a case, you should kind of look at
3:53
what the image is showing, what it's identifying,
3:58
what are some reasons this could be happening?
4:01
And then lastly, uh, by the
4:02
imaging, is this acute or chronic?
4:05
So, in this case, what's the most common
4:07
risk factor for portal vein thrombosis?
4:18
And again, it looks like a good majority.
4:20
Um, liver cirrhosis is the correct answer.
4:24
Um, I could have made it a little
4:25
bit harder by not saying portal vein
4:27
thrombosis and asking you to identify it again.
4:29
Cirrhosis is the most common
4:31
cause of portal vein thrombosis.
4:33
It can occur in up to 20% of patients
4:36
waiting for liver transplantation.
4:38
Even though you think of cirrhosis and high
4:40
INR and low platelets, actually, a
4:44
majority of them are in a procoagulant state
4:46
and will develop, uh, portal vein thrombosis.
4:49
Other risk factors include abdominal
4:50
trauma, whether iatrogenic or not.
4:53
Um, hypercoagulable states—um, cirrhosis
4:55
is and can be a hypercoagulable state.
4:57
And then malignancy, particularly hepatocellular
5:00
carcinoma, where you can get tumor thrombus, which
5:02
will be enhancing, um, as opposed to bland thrombus.
5:07
Case three.
5:07
Um.
5:09
What is the artery catheterized here?
5:11
Uh, whenever you get a case, you should try to, um,
5:13
answer that if you have an angiogram, and then, you know,
5:17
try to identify the vessels, um, that it opacifies.
5:20
And then what area, um, is the blood supply
5:24
going to? Um, so in this case, what arrow is
5:28
this particular artery on the angiogram pointing to?
5:38
And again, the options: splenic, left gastric,
5:42
gastroduodenal, right hepatic, and left hepatic.
5:52
Okay.
5:53
So, um, left hepatic. Uh, again, the majority
5:56
got it, but, uh, a little bit scattered.
5:58
So it's good to recognize, um, the anatomy,
6:01
know that you're in the celiac artery, and
6:03
then kind of know the branches of the celiac.
6:08
Um.
6:09
So again, here's the celiac trunk.
6:11
Um, you have the splenic artery, the left gastric
6:14
artery, the common hepatic artery, um, the GDA,
6:20
the right gastric, and then the left and right hepatic.
6:22
Hopefully, you guys can see my arrows.
6:24
If not, I think I can, um, do a laser.
6:31
Let's see.
6:32
Laser pointer.
6:33
Here we go.
6:34
Yeah, there we go.
6:35
Okay.
6:35
Hopefully, you can see my laser pointer now.
6:38
Um, so it's important to identify the, um,
6:41
normal anatomy and the vascular structures there.
6:44
Here's a companion case.
6:45
Um, 61-year-old.
6:47
Man is in the endoscopy suite.
6:49
He has uncontrolled, um, bleeding from an
6:52
ulcer in the first portion of the duodenum.
6:54
The endoscopist calls IR for
6:56
assistance and possible embolization.
6:58
Patient is hypertensive, tachycardic, has a
7:01
need for three units of packed RBCs within the
7:03
past four hours, so he is actively bleeding.
7:06
Um, what arteries should you perform an angiogram on?
7:13
Again, if you kind of know your
7:14
anatomy, um, you can kind of answer this
7:17
question, uh, without really any imaging.
7:20
Splenic, left gastric, gastroduodenal, or right hepatic?
7:24
Right hepatic.
7:29
Great.
7:30
Good job, everybody.
7:31
Gastroduodenal artery.
7:33
Um.
8:35
Again, uh, the GDA supplies the pylori of the stomach,
8:40
the proximal, you know, first to second portion of
8:42
the duodenum, as well as the head of the pancreas.
8:45
It's the most common reason for an upper GI bleed.
8:49
Um, and again, usually due to
8:52
peptic ulcer disease.
8:55
Um, here's just one such companion imaging.
8:58
Um, here's a 59-year-old female.
8:00
She has NASH cirrhosis.
8:02
Um, she's undergoing a segmental Y-90 transarterial
8:07
radioembolization for a 4.1-centimeter
8:10
HCC. Um, what type of particle is
8:15
Y-90, and what is the half-life of Y-90?
8:19
Again, is it an alpha emitter with a 26-hour
8:22
half-life, an alpha emitter with a 64-hour half-life,
8:26
an alpha emitter with an 85-hour half-life, a beta emitter
8:29
with a 26-hour, beta emitter with a 64-hour, or an 85-hour?
8:41
Okay.
8:42
Um, again, the majority got it, but, uh, 50%,
8:45
um, all over the place, but I'm correct.
8:49
Uh, beta emitter, 64 hours. Again, um,
8:54
yttrium-90, it's a pure beta emitter, has a
8:56
half-life of about 2.6 days or 64 hours.
9:00
It decays from strontium to
9:01
yttrium to then stable zirconium.
9:04
It can travel up to a depth maximum of 1.1 centimeters,
9:08
but on average, it's about two to three millimeters.
9:11
Um, it's stopped
9:12
by plastic.
9:13
Um, alpha emitters, uh, on the opposite spectrum,
9:17
are very, very strong, and they're harmful.
9:19
If internalized, they can be
9:20
stopped by a sheet of paper.
9:22
So again, alpha emitters are stopped by a sheet
9:24
of paper, beta emitters are stopped by plastic,
9:28
and then gamma, uh, requires something thicker.
9:32
K-six.
9:33
Um, look at the imaging here.
9:40
And again, what is the anomaly pictured?
9:44
Is it a right-sided aortic arch?
9:46
Is it a duplicated aortic arch, an aberrant
9:49
right subclavian artery, a bovine
9:52
aortic arch, or coarctation of the aortic arch?
10:04
Good.
10:05
Um, aberrant right subclavian. Uh, majority.
10:08
Uh.
10:12
And again, um, you kind of see that here. Uh, the
10:15
first artery coming off the aortic arch is the right.
10:18
Um, here's a companion for it.
10:20
Um, what is this clinical presentation?
10:23
Um, I don't have a question or a poll.
10:27
I. Um, you can see how, uh, it makes this vascular ring.
10:30
Vascular rings are important.
10:32
Um, there are many different types.
10:33
Aberrant, right?
10:34
Subclavian, uh, is the most common of them.
10:37
It's when the, um, right subclavian artery,
10:41
uh, basically courses behind the esophagus.
10:44
Right here.
10:45
And that can cause dysphagia.
10:47
Uh, RIO, that's the name.
10:49
10% of adults can have it.
10:51
It's, uh, pretty, um, low prevalence, but of the
10:55
vascular rings, this is the most common type.
11:00
Um, vascular rings are important,
11:02
should definitely know them.
11:03
But that is, uh, again, I'm trying to ask you the most
11:05
common of them and hopefully try to jog some memory.
11:10
Uh, this angiogram here.
11:14
Um, what is it, uh, pointing to
11:17
and what is the significance of it?
11:23
Again, hopefully with the first couple
11:25
questions that kind of showed you, you know,
11:27
where you catheterized, what are the
11:30
arteries that you're kind of looking at?
11:33
What does it supply? From there, hopefully,
11:36
you should be able to, um, kind of
11:38
narrow down some of your answer choices.
11:45
Um, again, a little bit scattered, but
11:47
uh, it looks like the majority got it.
11:49
Um, so Corona Mortis variant, um, and it's
11:52
a potential source of bleeding, um, and
11:55
trauma, um, that you need to be, uh, aware of.
11:58
Uh, again, it's a variant.
11:59
It's called the Crown of Death.
12:01
Corona Mortis.
12:02
It's an anastomosis between
12:04
the external iliac artery here.
12:06
Or sometimes it comes off of the,
12:09
um, inferior epigastric artery.
12:11
Uh, and, and kind of goes into
12:14
this, the obturator foramen.
12:15
It's a very high risk for hemorrhage, especially
12:17
in pelvic trauma, or it can be iatrogenic as well.
12:20
Um, other important collateral pathways: the
12:23
iliolumbar artery, um, inferior epigastric
12:27
artery is this anatomic landmark, which kind of—
12:29
delineates the external iliac to the, uh, femoral,
12:33
uh, and then the medial circumflex arteries just
12:35
to supply to the femoral, um, head and neck.
12:39
Um, so what artery, again, is being injected,
12:43
and what arteries are being supplied here?
12:45
Right.
12:46
Um, anytime you get a question, you
12:48
kinda have to look at that and kind of—
12:51
what, uh, parenchyma are you staining?
12:53
So, based off of that, hopefully you
12:55
can tell what artery is occluded here.
12:59
So it's just inferring some things.
13:01
Is it the superior mesenteric artery?
13:03
Is it the celiac artery?
13:05
Is it the gastroduodenal artery
13:07
or the right hepatic artery?
13:18
Okay, so a little bit challenging.
13:21
This one, I guess, um, majority
13:23
did not get it, but it's okay.
13:25
Um, so we're injecting the superior
13:27
mesenteric artery here, right?
13:29
So the superior mesenteric artery.
13:31
Um, you can see, um, is, is, is
13:34
what's actually being injected.
13:36
You have the branches that kind of go to the, um,
13:39
small bowel, colon, and then you have the gastroduodenal
13:43
artery here, pancreaticoduodenal
13:45
arcade into the gastroduodenal artery, which then—
13:49
supplies the liver here, right?
13:52
The right hepatic artery.
13:54
So this is a collateral pathway, and the reason this
13:56
is formed is because the celiac artery up here is,
14:00
um, not, um, being, um, you know, uh, uh, opacified.
14:07
So there's a collateral pathway here.
14:09
So the green are the important collateral pathways.
14:11
Again, the pancreaticoduodenal
14:14
gastroduodenal arcade here.
14:15
Going to the liver, the arc of Bühler, you can
14:18
sometimes also see, so off the SMA directly into the
14:21
celiac trunk, um, the arc of Riolan is more medial.
14:26
The marginal artery of Drummond is more lateral.
14:29
And that's the collateral pathway between SMA and IMA.
14:32
If there's an occlusion, um, iliolumbar
14:34
here, I've kind of talked about before,
14:37
um, as well as the porta of Winslow.
14:40
Which is an inferior mesenteric, um,
14:43
collateral pathway to the internal, um, iliac.
14:48
So case number nine, a
14:50
42-year-old, uh, male with trauma.
14:53
Um, you see some corresponding images.
14:58
Um.
14:59
Hopefully, you can see some of the abnormalities here.
15:04
Um, place in descending order the frequency
15:07
of solid visceral organ involvement.
15:19
So is liver most common?
15:21
Is spleen most common?
15:23
Is kidney most common?
15:25
Um, and then what's the next most common?
15:27
And then the—
15:38
Good.
15:40
Um, so spleen, and then liver,
15:43
and then kidney, and then other.
15:45
Um, so the spleen is the most commonly injured,
15:49
um, again, men more than women in trauma.
15:52
Um, you should kind of know the AAST classification,
15:56
and you should kind of know when to do conservative
15:58
management—typically grade one and two.
16:02
And then when IR is a little bit
16:03
more involved—grade three or four.
16:05
And then when do you do OR?
16:12
Not only for splenic, but that's probably the most
16:14
commonly asked. Um, hepatic injury, same thing.
16:18
They'll, um, show you potentially, you know,
16:20
more than 50% subcapsular bleed or a
16:24
three-centimeter parenchymal depth bleed.
16:27
And, you know, you'll kind of have
16:28
to know that it's a grade three.
16:32
Same with renal, but renal is not as commonly
16:34
asked because it's not, um, as commonly seen.
16:38
Um, what type of endoleak is this?
16:42
So again, as I present the cases, they get just
16:45
minimally more tough in the sense that I'm not gonna
16:47
show you arrows, but again, you'll kind of have to see
16:52
the abnormality, see what type it is, see where it's
16:56
located, uh, identify if there is or isn't an endoleak.
17:00
I guess I could have made it minimally harder.
17:09
So good.
17:10
Um.
17:12
Type II endoleak again.
17:14
Type II.
17:15
Um, it's right there.
17:16
You can kind of see this, uh, a little.
17:19
Um.
17:20
Uh, artery, um, that's retrograde filling into the sac.
17:24
Um, again, Type I is if you have a graft leak,
17:28
either proximally or distally into the aneurysm sac.
17:33
Um, Type II is if you have a lumbar, um, artery
17:38
or an inferior mesenteric artery, or in the
17:42
above case, it was actually a thoracic endoleak.
17:45
Um.
17:46
Uh, Type III, uh, junctional separation.
17:50
So the graft themselves either
17:52
fracture or break, or you have a tear.
17:55
Um, Type IV is graft
17:57
porosity, uh, meaning it's leaking
17:59
from the actual graft itself.
18:01
And then Type V, you know,
18:03
quote-unquote "endotension."
18:05
It's just expansion without real evidence for a leak.
18:08
Um, case 11, here's a 29-year-old
18:12
male with left arm pain.
18:15
Um, I apologize.
18:17
It should be right arm pain.
18:20
Um, which of the following interventions
18:23
should not be performed for this patient?
18:28
So, again, right arm pain.
18:30
Anticoagulation should not be performed.
18:33
Catheter-directed thrombolysis should not be performed.
18:35
Catheter-directed thrombectomy, angioplasty,
18:38
and stenting, or surgical decompression.
18:50
Uh, good.
18:51
So, it sounds like the majority—um, angioplasty
18:55
and stenting. Uh, here's their abnormality here.
18:57
You can kind of see a filling
18:59
defect thrombus within the, um, right
19:04
subclavian vein here.
19:06
Um.
19:07
So, why should we not perform
19:10
angioplasty and stenting in this case?
19:14
Uh, again, this patient has Paget-
19:16
Schroetter, or effort thrombosis.
19:18
Typically, it's seen in younger,
19:20
healthier patients with repetitive motion.
19:23
Uh, a male-to-female predominance.
19:25
Thrombolysis or thrombectomy can
19:28
be performed less invasively.
19:31
Um, you can do angioplasty alone
19:33
for the underlying stenosis.
19:34
But, um, don't necessarily leave a stent behind.
19:38
If you do leave a stent behind, um, in that
19:41
area without surgical decompression,
19:44
uh, you can fracture the stent.
19:46
Um, you can read thrombosis in the area.
19:49
Essentially, you wanna maintain patients on
19:51
anticoagulation and/or antiplatelet therapy,
19:54
um, with surgical decompression of the subclavian vein.
19:58
Um.
19:59
An important anatomical landmark is that it
20:01
crosses through the costoclavicular space.
20:04
That's a commonly asked question, as
20:06
well as, um, the subclavian vein passes
20:08
anterior to the anterior scalene muscle.
20:12
Um, and commonly because of that repetitive
20:14
motion and otherwise younger, healthier, fit
20:17
individuals, um, you can get, um, you know, repeat
20:21
compression of that area.
20:24
Um, the subclavian artery passes
20:27
posterior to the anterior scalene muscle.
20:31
Um, and again, it's in this costoclavicular space,
20:35
and typically, it's because of compression of the, uh,
20:38
clavicle and the first rib in the anterior scalene muscle.
20:44
Next case, Case 12.
20:46
Um, 38-year-old female with postprandial abdominal pain.
20:52
Um, again, age of patient, um,
20:55
sex of patient, uh, symptoms.
20:58
Um, these all matter, um, as well as what
21:02
you're catheterizing and what you are imaging.
21:06
Um, so this entity, is it worse with blank?
21:12
And is it likely secondary to blank?
21:17
So is this worse with inspiration
21:19
and secondary to Nutcracker syndrome?
21:22
Worse with expiration and secondary to SMA stenosis?
21:28
Um, worse with expiration and due
21:32
to median arcuate ligament syndrome.
21:35
Worse with inspiration and median arcuate ligament syndrome.
21:39
Expiration Nutcracker, or inspiration Athero.
21:48
Um, this one's always tricky, and this one is
21:51
commonly asked before because of that reason.
21:53
Um, so it sounds like everybody
21:54
understood that it was because of MALS.
21:57
Um, again, the age, the sex, and the
22:00
clinical presentation of the patient, um,
22:03
led you to MALS—the correct, um, entity.
22:07
Um, but expiration is what makes it worse.
22:12
So again, the median arcuate ligament
22:14
is, uh, from the diaphragm.
22:17
It causes extrinsic compression of the celiac artery.
22:21
And that's kind of why you
22:22
have this, um, narrowing here.
22:25
Um, and it's worse on expiration.
22:28
I. Um, it's younger patients, it's thinner patients.
22:33
It's a female-to-male predominance,
22:35
and again, it's worse with expiration.
22:38
With that said, sometimes, um, you know, in your
22:40
review boards or studies, um, you hear inspiration.
22:44
And what it is, is, um, ideally, you, um, image in
22:49
inspiration so that we don't get a false positive.
22:54
Hopefully, that makes sense.
22:56
Um, again, it, uh...
22:58
Is common with postprandial nausea, vomiting,
23:03
and weight loss, and it's non-atherosclerotic.
23:05
Atherosclerotic, um, disease is right
23:08
at the ostium, and it's not necessarily
23:10
affected by inspiration or expiration, whereas...
23:14
Non-atherosclerotic chronic diseases.
23:16
And again, it's best to image during inspiration because,
23:20
um, you have less chance for a false positive, so
23:23
you can truly see the, um, underlying disease.
23:28
Um, due to MALS, if it's present.
23:31
Again, it's worse with expiration,
23:34
but best to image during inspiration.
23:36
And I think that's the, um, key distinction
23:39
and I think the confusion that most
23:41
trainees kind of have with that question.
23:44
And that's why it's commonly asked in sort of that term.
23:49
Case 13.
23:50
Um, here's a 23-year-old female
23:53
with left thigh swelling.
23:55
Um, hopefully, you know where we're injecting
23:58
and hopefully, you can see the findings.
24:01
Um, so what structure is causing compression
24:06
of, um, this arrow here, this black arrow?
24:10
And, um, what is this syndrome's name?
24:15
So again, you saw the.
24:18
Finding, and this is the, um, compression here.
24:25
And so what structure is causing that compression?
24:29
And, um, what is the syndrome's name?
24:36
So good majority.
24:38
Um, so it's the, uh.
24:44
Right common iliac artery and,
24:47
um, it is May-Thurner syndrome.
24:51
Um, so again, the right common iliac artery mayner
24:55
syndrome, it's typically the left iliac vein.
24:59
Um, it's posterior and it's being compressed
25:02
anteriorly by the, um, right common iliac artery.
25:06
Here you can see that, uh, posteriorly, you'll
25:09
have the spine, and so that compression,
25:12
um, causes, uh, narrowing, scarring.
25:17
Stricture and can sometimes lead to DVT.
25:20
Mayer neuroanatomy is just that anatomy.
25:23
Having the iliac artery compressing anteriorly,
25:27
uh, syndrome is when you actually have,
25:29
um, compression leading to DVT in symptoms.
25:33
Again, there's a female to male predominance,
25:35
three to one, typically younger patients.
25:38
Nutcracker syndrome, uh, I think
25:40
a few of you guys answered that.
25:41
Uh, it's left renal vein.
25:44
Being compressed, um, between the SMA and the, um,
25:50
aorta, and it typically causes, uh, left flank pain,
25:54
you'll have some dilation of the left renal vein.
25:57
Because of that, it typically has hematuria.
26:00
It shouldn't be confused with SMA syndrome.
26:02
SMA syndrome is, um, an acute angulation.
26:06
I don't think I have a picture of that, but SMA
26:07
syndrome is basically an acute angulation of the.
26:12
Superior mesenteric artery as it
26:14
comes off of the abdominal aorta.
26:16
And that acute angulation causes compression of
26:19
the third portion of the duodenum, and that can
26:22
lead to nausea, vomiting, and weight loss.
26:26
Um, Loin syndrome.
26:28
This is an image finding of Loin syndrome
26:30
and it's basically, um, ATO occlusive
26:33
disease, um, below the renal arteries.
26:37
And, um, due to that you can have diminished,
26:40
uh, femoral pulses, claudication, uh,
26:44
buttock issues, and, um, impotence.
26:47
And again, usually elderly male,
26:49
um, kind of have this, uh, syndrome.
26:53
Case 14.
26:54
Um, here's a patient 52-year-old male,
26:58
uh, with TIA transient ischemic attack.
27:03
Um.
27:06
What is the disease entity?
27:10
Polyarteritis nodosa.
27:12
Fibromuscular dysplasia.
27:16
SSU Arteritis, standing waves,
27:19
subclavian steal, or Athero disease.
27:31
Good.
27:32
Um, FMD, um, sounds like majority understood and got it.
27:37
Um, that was an atypical location,
27:39
um, for a common appearance of FMD.
27:43
Um, so things like that will be commonly asked in
27:46
the sense that, um, it, you know, it's a little bit.
27:49
Easy to, to give, uh, a renal artery with an appearance.
27:53
Um, and or give you, you know, questions
27:55
related to that you'll kind of already know.
27:57
FMD is, again, the most common appearance, the medial.
28:01
Does give a beaded appearance.
28:03
There are, you know, four or five different types,
28:05
but you won't necessarily be asked that in the boards.
28:07
It's, it's a little bit, um,
28:09
you know, uh, uh, more in depth.
28:11
Um, it's a female to male predominance.
28:14
Again, renal arteries are most common and it's a mid.
28:17
A distal, um, sort of distribution
28:20
versus atherosclerotic disease.
28:22
I.S.T.E. and proximal, uh, cardio-polyarteritis
28:26
Noosa, um, tends to have, uh, medium-sized
28:29
arteries as well as little, uh, small
28:32
intrarenal, um, aneurysms, um, throughout.
28:36
And then Tatsu is generally younger.
28:38
Um, kids, um, children, uh, giant cell arteritis
28:43
is also known as, as well as pulseless disease.
28:46
And again, it's usually secondary to
28:48
thickening, uh, vasculitis of the aortic
28:51
wall, uh, typical upper extremity arches
28:54
and, and the large vessel subclavian steal.
28:58
Um, again, subclavian steal is
29:00
typically, uh, again, here's a thoracic,
29:03
um,
29:04
arch aorta.
29:06
Uh, typically you have three, um, arteries coming off.
29:09
Uh, you'll have the, um, right, uh,
29:13
brachiocephalic and, and then the, um, left,
29:16
uh, carotid and then the left subclavian here.
29:19
You don't see the left subclavian artery
29:22
at all until the delayed imaging here.
29:26
Um, so because of that, um, you kind of
29:28
know that there is retrograde filling
29:32
of the, um, you know, uh, uh, vertebral
29:38
artery around the circle of Willis.
29:39
And then down, um, the, uh, ipsilateral side
29:44
to then continue on, uh, the subclavian artery.
29:48
Um, again, that's because there's,
29:50
um, proximal ostial narrowing here.
29:55
Uh, case 15, uh, 15-year-old
29:58
female with cystic fibrosis.
30:00
She presents with hemoptysis.
30:05
So what is this an angiogram of?
30:07
And, um, what do you block this bleeding with?
30:15
This, an intercostal artery with beads,
30:18
intercostal artery and coils, pulmonary artery and
30:21
beads, pulmonary artery and coils, bronchial
30:24
artery and beads, or bronchial artery and coil.
30:44
Um, again, the bronchial artery
30:46
anatomy is very variable.
30:47
It's most common.
30:49
Um, two on the left side and one on the right.
30:51
Um, sort of a common trunk, uh,
30:54
and by most common, um, 28 to 40%.
30:56
So as you can see, it's pretty highly variable.
31:00
Um, you do wanna avoid coils in this region.
31:03
You pretty much just wanna use, um.
31:06
Uh, particles, beads, uh, potentially even glue.
31:09
Um, and, and, and the reason for that is because
31:12
you want to block the distal flow, but you want
31:16
to keep the main channel open, um, in case there
31:19
is recanalization or in case there is bleeding.
31:23
Uh.
31:23
Um, you need to, want to go back.
31:25
You really wanna avoid, cause in this case,
31:27
it's a common cause for massive hemoptysis.
31:30
Uh, most common, again, the age and the sex.
31:32
Um, along with the history of cystic fibrosis,
31:36
um, TB, uh, can also sometimes be seen, uh.
31:39
TB, typically you'll get, uh, more so pulmonary
31:42
artery, um, aneurysms or pseudoaneurysms.
31:45
Uh, rasmus, um, aspergilloma or mycetoma can
31:49
also form cavitary, um, lesions that can lead
31:53
to, um, uh, hemoptysis and bronchiectasis.
31:58
Bronchiectasis in general.
31:59
Um, like with, uh, LAM and um, cystic fibrosis.
32:04
Um, as well as others can also cause, um, hemoptysis.
32:08
Um, this artery here is the artery of Kovi.
32:12
And, um, that artery you want to avoid if you see
32:16
it, um, in, uh, a P in a broncho artery angiogram.
32:21
Um, you should not, um, embolize.
32:24
Um, and again, it has this characteristic sort of
32:28
hairpin turn and, um, it can cause, you know, paralysis.
32:34
Um, X case case 16.
32:36
So how do you convert, um, French
32:39
size to diameter and millimeters?
32:44
So does one French equal 0.18 millimeters?
32:47
Does one French equal 0.33 millimeters,
32:51
does one French equal 0.35 millimeters,
32:54
or one French equal 0.67 millimeters?
33:04
Good.
33:05
Um, again, a good majority, uh, a little bit
33:08
scattered, but, um, again, this is very commonly asked.
33:11
Um, it is one French equals 0.3
33:15
millimeters, three three millimeters.
33:18
Um, sort of a companion case.
33:20
And then I'll go over sort of the explanation
33:21
and kind of what, um, the reason for this is.
33:24
So the companion case here.
33:26
Um, Guidewire thickness is measured in French
33:34
hundredth of an inch, millimeter, or centimeter.
33:50
Okay.
33:51
A little bit challenging and, and I get it.
33:53
Um, so measured.
33:58
And I know that seems, you know, strange and odd.
34:01
Why are you measuring things in French and
34:03
then millimeters and then hundredths of an inch.
34:07
Um, so just to try to, uh, you know, hopefully
34:11
clarify this for you guys, um, a little bit more.
34:14
Uh, and again, this is very
34:16
commonly asked, so you do kind need
34:20
one French is.
34:23
So a catheter refers to the French size
34:27
of the outer diameter, so six French.
34:30
Um, if you multiply that by 0.3, three,
34:32
three, it'll be pretty much two millimeters.
34:35
You know, 1.8 8 8 8 9, 9 9, something like that.
34:38
1.999. Um, so it's two millimeters and
34:41
that's the outer diameter of a six catheter.
34:43
A sheath refers to the inner diameter.
34:47
Um, so when we say a six French sheath,
34:50
what we mean is that the six French catheter
34:53
can fit inside the six French sheath.
34:57
Makes sense.
34:58
When we talk about, um, you may or may not be
35:01
asked this, but when you talk about the sheath.
35:03
Size overall, we're saying what
35:07
is the outer diameter of a sheath?
35:11
And so it's technically an eight French.
35:13
It's pretty much six French plus two
35:15
more French, so eight French outer.
35:18
And then how do you calculate that?
35:20
Again, you just measure eight.
35:21
Uh, you just calculate, um, eight times.
35:26
And that's kind of how you get the inner diameter, um,
35:30
is sized in hundredths of an inch, and that's how you
35:34
know, um, what the maximal guide wire thickness will be.
35:41
So the G wire thickness is always measured in
35:43
hundredths of an inch, and that's why when you,
35:46
uh, if you remember during higher rotations.
35:48
You hear the terms, you know, 0 1 8 or 0 3 5 or 0 3 8.
35:53
That's the thickness of the guidewire
35:55
that'll fit inside the inside of a catheter.
36:01
Hopefully that makes sense, again, is commonly asked.
36:05
Um, case 18.
36:07
Um, so, uh, here's imaging findings.
36:11
Um, you kind of see a CT.
36:14
As well as an angiogram.
36:15
Uh, hopefully you know what organ
36:17
this is and what we're looking at.
36:19
Um, so which of the following is true in this case?
36:25
The entity is malignant.
36:28
The majority are seen with a
36:33
syndrome.
36:34
The entity typically contains, uh, calcium.
36:39
It typically is treated one
36:41
greater than two centimeters.
36:44
Or, um, the patient may have
36:46
multiple cysts in their lung.
36:56
Okay.
36:58
Um, sounds like the majority got it, but a little
37:00
bit, um, still varied, you know, only about 60%.
37:04
Got it.
37:05
Um.
37:06
So patients have multiple cysts in their lungs.
37:10
Um, so first you have to identify
37:11
what the, um, imaging finding is.
37:13
It's a fatty lesion, um, in the kidney.
37:17
Um, that's, you know, vascular.
37:20
Um, so, uh, what is it?
37:21
It's a renal angiomyolipoma.
37:24
Um, it's a benign entity.
37:26
Uh, it's composed of fats.
37:28
Uh, vessels and PNMA, um, most are sporadic.
37:33
Um, so it, they most are not
37:36
associated with the syndrome.
37:37
Um, the remaining 20% are associated with the syndrome.
37:40
Tuberous sclerosis.
37:42
Uh, usually, and again, 80%, up to 80%
37:46
of patients with tuberous sclerosis will
37:48
have, um, a renal angiomyolipoma.
37:51
The ones that are sporadic are typically single.
37:54
The ones that are associated with, uh, FMO ptosis, um,
37:58
tuberous sclerosis tend to be bilateral and multiple.
38:01
It can also sometimes be associated with VHL.
38:05
Um, typically, um, they're small, but sometimes they
38:09
can get very, very large and they can be pretty,
38:11
you know, um, mostly fatty like this one, um, India
38:15
ink artifact, um, on, in and out phase of imaging.
38:19
This is what it looks like.
38:20
Um, so again, I'm just trying to show you a variable
38:23
number of presentations or things that they can
38:25
show you, um, to try to basically ask you the same
38:29
question or similar, you know, thoughts of question.
38:31
Typically, um, when it's greater than four
38:34
centimeters is when you'll intervene because that's
38:36
when they're vascular, that's when they can bleed.
38:39
Um, again, they present with Bleed Flank, andria.
38:44
Tuberous sclerosis.
38:45
Um, other characteristics, um, symptoms.
38:47
You can have seizures, intellectual disabilities,
38:49
developmental delay, and behavioral problems.
38:52
You can have benign tumor growth of the central
38:54
nervous system as well as malignant, um, tumor
38:57
growth of the skin, the lungs, the heart, the.
39:00
Uh, skin, uh, most commonly, um, affected.
39:04
And you kind of have these sort
39:06
of, um, uh, manifestations.
39:09
Um, you know, you can have adenoma, sation,
39:12
you can have, um, facial angiofibromas.
39:15
That's what this is.
39:15
You can have ash leaf spots here.
39:18
You can have, um, hypomaculars, and then
39:21
you can have shag patches, which is this.
39:24
And then lastly, you can have periungal, um,
39:27
fibromas, um, also known as koenen tumors.
39:30
In the central nervous system,
39:31
you can have cortical tubers.
39:33
Um, like here, um, you can have subependymal
39:38
nodules like here within the ventricles, or
39:41
you can have a giant cell astrocytoma like
39:44
here, which can, um, grow and block the, uh,
39:48
CSF flow and lead to hydrocephalus the lungs.
39:52
Um, again, with Tuberous Sclerosis, you
39:54
can have, uh, multiple cysts bilaterally.
39:58
Um, it's, you know, pretty much
40:01
similar to lymphangioleiomyomatosis.
40:03
And, um, again, one of these common associations,
40:06
uh, renal angiomyolipomas, um, are seen
40:10
in 88% of patients up to 80-90% of patients.
40:14
Um, with TSC as well as, uh, lymph
40:16
angioleiomyomatosis, um, usually predates the
40:20
onset of the pulmonary disease, though.
40:23
So again, you kind of have to scan this.
40:25
Um, and then TSC-related land may occur, obviously
40:28
still following lung transplantation, just
40:31
like cystic fibrosis still can in the heart.
40:34
Um, cardiac, um, abdomyoma, again, a um,
40:39
sort of a benign type of, uh, um, uh, a tumor.
40:43
But, um, typically, uh, seen in, um.
40:49
Fetuses as well as infants.
40:50
And, um, it can cause obstruction and cause
40:53
sort of like a, a ball valve type phenomenon.
40:56
And, um, pretty much exclusively during pregnancy
40:59
or within, um, pretty much the first year of life.
41:03
Uh, and then lastly in the eyes, you can
41:05
kind of have this, um, FMitotic here
41:08
and that's what they mean, um, by osis.
41:11
Uh, or you can have, uh, like a
41:13
here, which is basically this.
41:16
Cat's eye looking like edema.
41:20
791 00:41:21,755 --> 00:41:21,975 Um.
41:23
Can I please explain more in detail why we avoid coils?
41:26
Yes.
41:27
Um, so, uh, coils, um, we avoid in the
41:31
bronchial artery typically, um, because you
41:35
want to maintain, um, access to the bronchial
41:39
arteries for embolization, for future bleeds.
41:43
Um, patients that have cystic fibrosis, um.
41:47
Cytomas and other, they sometimes can
41:50
have repeat, um, episodes of bleeding.
41:53
Uh, so you, you can stop it.
41:56
And then maybe two years later, four years later,
41:58
other, um, arteries get recruited and, uh, they
42:02
dilate if you, um, block, um, it, uh, with um.
42:09
Coils, you can have distal flow beyond, um, that
42:14
coil pack, and then sometimes it can become,
42:16
you know, almost impossible or challenging
42:18
to block the recruited, um, arteries, um, uh,
42:23
that sort of get recruited in those patients.
42:26
So it typically just, um, you know,
42:29
particles, beads, or glue, um, to maintain
42:32
the parent vessel bronchial artery.
42:35
Hopefully that makes sense.
42:37
Um, that is all I have.
42:40
Um, if any other questions, I'm happy to answer.
42:45
Um, I think, um, it looks like one other person
42:49
had a question about the inspiration, um, an
42:54
expiration for median arcuate ligament syndrome.
42:57
Um, hopefully, um, that was before my, um, explanation.
43:02
Um.
43:03
And, and you understand that with, um,
43:07
expiration, um, you can have more compression
43:12
of the artery and then with inspiration, um,
43:16
you have less of a, uh, a false positive, uh.
43:24
That is it.
43:25
Thank you, guys.
43:26
Thank you, Dr. Patel, for that case review.
43:27
Really appreciate it.
43:29
And if anyone has any other questions, please
43:31
go ahead and put those into the Q and A
43:32
box, and we will try to get to all of them.
43:39
Uh, sure.
43:40
Hold on.
43:41
Uh, case two and three.
43:43
Sure.
43:44
Um, so I think it was this one maybe.
43:48
Uh.
43:49
It is.
43:50
And two.
43:51
Yeah.
43:51
Perfect.
43:52
Yeah.
43:52
Sorry.
43:53
Um, so.
43:54
Two was just, uh, what's the most common
43:56
risk factor for portal vein thrombosis?
43:58
Um, it's liver cirrhosis.
44:01
Uh, and this is just a, um, uh, a filling
44:04
defect seen in the left, uh, portal vein.
44:08
Um, you know, you kind of have
43:10
to be able to identify it.
44:11
And then what are some common risk
44:12
factors and is it acute or chronic?
44:15
Again, cirrhosis is the most common.
44:17
Um, cause for portal vein thrombosis, these are other
44:21
causes for portal vein thrombosis, but it's not the
44:23
most common: pancreatitis, um, gastric bypass, trauma.
44:28
Um, other hypercoagulable states.
44:30
Um, other causes like malignancy are also common.
44:33
Again, with malignancy though, you'll see, um.
44:38
Hypervascular, um, tumor thrombus.
44:42
Um, and so it won't be bland thrombus.
44:45
And again, the most common cause
44:46
for thrombus is, um, cirrhosis.
44:49
And then for case three, this is, um, anatomy and
44:53
again of the vascular territory and anatomy, the most
44:57
commonly asked one is going to be the celiac artery,
45:01
um, from the body, um, angio-interventional perspective.
45:05
And the reason.
45:06
For that is, um, because, um, it is the most
45:13
commonly, um, asked one, it, it's, it's fairly
45:17
straightforward anatomy and, and less variable,
45:20
you know, with the splenic, the, uh, right gastric,
45:23
the left gastric, the gastroduodenal, um, branches.
45:27
Um, and, and this is the most sort of.
45:31
Common, uh, typical presentation.
45:35
Um, so it looks like Mortiz.
45:40
And then I'll explain the, um,
45:43
inspiration expiration one more time.
45:47
Um, Corona Mortis is this one.
45:50
Um, so, uh, this is injection of
45:54
the external, um, iliac artery.
45:57
Um, but right before it becomes a
45:58
common iliac, uh, common femoral artery.
46:01
Um, and so if you see here, this is the
46:05
inferior epigastric artery, and this
46:07
artery here is going down into the, um.
46:12
You know, obturator foramen.
46:14
Uh, when you see this variant here,
46:16
it's called the crown of death.
46:19
And the reason is because, um, you.
46:22
Commonly have, uh, bleeding here into the pelvis.
46:25
And, um, you may not recognize it because typically,
46:30
uh, when you have pelvic trauma, uh, you're typically
46:35
worried or concerned about the internal iliac artery,
46:38
the Corona Mortis, uh, because it's the obturator.
46:41
Uh, um.
46:42
Typically, it supplies the acetabular rim, in this
46:45
case, instead of coming off the internal iliac artery
46:47
to the obturator artery, it's the, um, external iliac
46:51
artery that sort of gives rise to this and then mals.
46:55
One more time.
46:58
Um, I think it was,
47:06
sorry, this one.
47:08
Um.
47:09
So this is, um, inspiration and this is expiration.
47:14
You can see on expiration.
47:17
Um, you do have, um, uh, the most
47:21
significant, um, compression there.
47:24
Um, it is worse with expiration.
47:27
Um, and, and again, it's, it's
47:29
one of those things that, um.
47:32
Is commonly confused and commonly, um, sort of asked.
47:37
Um, and then it's best to sort of image
47:39
during inspiration because you do have
47:43
the less chance of false positives.
47:46
Um, I, I hear what you're saying where when you inspire,
47:50
the diaphragm moves down, but it's kind of flattened.
47:53
Um, and so you don't have, um, that,
47:56
um, sort of, uh, same, um, effect.
48:05
You do risk some false negatives.
48:07
I think that was your second part of your question.
48:09
I think it says there, um, with inspiration.
48:12
Um, but typically, um, this is done with inspiration.
48:16
So you can kind of see, um, how you can
48:19
still have that mediastinal ligament there.
48:21
Expiration makes it more pronounced.
48:24
And during expiration you should
48:26
see more, um, you know, sort of, um.
48:31
Uh, significant, um, uh, occlusion
48:35
or stenosis, like in this case.
48:39
Awesome, Dr. Patel, I think you got 'em all.
48:41
Awesome.
48:42
Thank you all.
48:43
Next time I have more cases.
48:46
Well, thank you so much for this case review.
48:48
It was very helpful for everyone online
48:51
and for everyone else for participating.
48:53
Thank you so much.
48:54
Be sure to join us Monday, May 6th with Dr.
48:57
Claire Meyer.
48:58
She's going to lead us in a rapid review of GI
49:01
imaging cases and you can register for that at
49:03
the link provided in the chat and follow us on
49:06
social media for updates on future case reviews.
49:09
Thanks again for learning with
49:10
us and we will see you soon.
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