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.