23204964

28th Annual

In-Training Examinationfor DiagnosticRadiology ResidentsRationalesSponsored by:Commission on EducationCommittee on Residency Training in Diagnostic Radiology

February 3, 2005

The American College of Radiology www.acr.org

American College of Radiology

Section IV – Interventional Radiology

95. You are shown a chest radiograph (Figure 1) obtained after the placement of a temporaryhemodialysis catheter. Where is the catheter located?

A. Superior intercostal vein

B. Descending aorta

C. Hemiazygous vein

D. Duplicated SVC

Figure 1

Diagnostic In-Training Exam 2005


Question #95

Findings:There are pacing electrodes entering the heart normally via a right-sided superior vena cava. On the left,taking a parallel course, is an Ash-type dialysis access catheter.

Rationales:

A. Incorrect.

B. Incorrect.

C. Incorrect.

D. Correct. In less than 1% of normal patients—patients without congenital heart disease—the leftbrachiocephalic vein does not cross the midline to join the right brachiocephalic vein, but rather drainsinto the coronary sinus as a second left-sided superior vena cava.

Citations:Kaufman JA, Lee MJ. Vascular and Interventional Radiology: The Requisites. St. Louis, Mo: Mosby; 2004.



Figure 2

96. A patient with a history of renal carcinoma presents with a painful pelvic mass six weeks following apercutaneous lymph node biopsy. What does the pelvic arteriogram (Figure 2) show?

A. Acquired arteriovenous fistula

B. Congenital arteriovenous malformation

C. Vascular metastasis

D. Hemodialysis access graft



Question #96

Findings:Just above the left hip joint there is a saccular dilation of the external iliac artery with communication to andearly opacification of the left iliac vein and vena cava.

Rationales:

A. Correct. Arteriovenous fistulas are point-to-point communications between an artery and a vein. Acquiredconditions, the most common etiology in a hospital setting, is iatrogenic.

B. Incorrect. Arteriovenous malformations are high-flow congenital lesions. The distinguishing feature fromacquired arteriovenous fistulas is the central tangle of communicating arterioles and venules termed “thenidus.”

C. Incorrect. Metastases from renal cell carcinoma can be very vascular with arteriovenous shunting, but thereis no vascular metastasis present here to be seen.

D. Incorrect. Grafts are placed usually below the hip joint and the synthetic material connecting the artery andvein is recognizable.




Figure 3

97. A 67-year-old man presents with acute onset of back pain. You are shown a thoracic aortogram(Figure 3). What is the MOST likely diagnosis?

A. Intraluminal thrombus

B. Traumatic laceration

C. Dissecting hematoma

D. Mycotic aneurysm



Question #97

Findings:Arising just distal to the left subclavian artery, there is a double-barrel descending thoracic aorta with densefilling of the compressed true lumen, a less densely opacified false lumen, and an intimal flap between.

Rationales:A. Incorrect.

B. Incorrect.

C. Correct. Aortic dissection is the separation of the intima from the adventia by blood within the mediallayer of the artery.

D. Incorrect.




Figure 4

98. A 52-year-old construction worker had bluish discoloration and numbness of the fifth finger of hisright hand. You are shown an arteriogram (Figure 4) of the right hand and wrist. The proximalarteries were intact. What is the MOST likely diagnosis?

A. Paget-Schroetter syndrome

B. Giant cell arteritis

C. Scleroderma

D. Hypothenar hammer syndrome



Question #98

Findings:There is disruption of the ulnar artery at the wrist.

Rationales:A. Incorrect. All 4 possible answers are associated with occlusions of upper extremity blood vessels. However,

Paget-Schroetter is a syndrome of venous occlusion at the thoracic outlet.

B. Incorrect. Giant cell arteritis is associated with long strictures of the subclavian and axillary arteries.

C. Incorrect. Scleroderma does cause small vessel occlusions of the arteries of the hand and wrist and should beseriously considered in the differential diagnosis, but the patient is a male construction worker, and it is theulnar artery that is occluded.

D. Correct. Finger ischemia resulting from repetitive trauma to the ulnar artery, often the result of occupationalexposure, is hypothenar hammer syndrome.

Citations:

Taylor LM. Hypothenar hammer syndrome. J Vasc Surg. 2003;37:697.

Valji K. Vascular and Interventional Radiology. Philadelphia, Pa: W.B. Saunders; 1999.

Vedantham S, Gould J. Case Review Vascular and Interventional Imaging. St. Louis, Mo: Mosby; 2004.



Figure 5

99. A 74-year-old man has had right-sided claudication for the past 4 weeks. You are shown anarteriogram (Figure 5) at the level of the patient’s knees. What is the MOST likely diagnosis?

A. Thrombosed popliteal artery aneurysm

B. Diabetic atherosclerotic occlusive disease

C. Popliteal artery entrapment

D. Adventitial cystic disease



Question #99

Findings:On the right side, the popliteal artery is obstructed. On the left side there is opacification of a long fusiformpopliteal artery aneurysm.

Rationales:

A. Correct. All 4 possible answers are associated with occlusions of the popliteal artery. Popliteal arteryaneurysms are bilateral in the majority of cases and much more frequent in men than woman. Arterialocclusive symptoms result either from thrombosis of the aneurysm, as in this case, or from distalembolization.

B. Incorrect. Diabetes is a common condition, certainly associated with arterial occlusive disease, but is notthe best choice in the face of the contralateral aneurysm.

C. Incorrect. Typically popliteal artery entrapment presents in young athletes with a pathognonomic findingof medial deviation of the popliteal artery. Although aneurysms may rarely develop, they would be anunusual complication of an unusual condition.

D. Incorrect. Adventitial cystic disease is a rare condition characterized by the extrinsic compression of thepopliteal artery by a mucinous filled cyst.


LaBerge JM. Interventional Radiology Essentials. Baltimore, Md: Lippincott, Williams & Wilkins; 2000.



100. Concerning acute gastrointestinal hemorrhage, which statement is TRUE?

A. Radionuclide scanning should not be performed.

B. Bright red blood per rectum excludes an upper gastrointestinal bleed.

C. The angiographic diagnosis is based upon the visualization of contrast extravasation into thebowel lumen.

D. Bleeding from Mallory-Weiss tears may be diagnosed upon injection of either the superior orinferior mesenteric arteries.

Question #100

Rationales:A. Incorrect. Radionuclide scanning is more sensitive than arteriography in detecting gastrointestinal

hemorrhage and can be helpful in localizing the bleed.

B. Incorrect. About 10% of patients with brisk upper gastrointestinal hemorrhage, bleeding proximal to theligament of Treitz, will have bright red blood per rectum.

C. Correct. The hallmark of gastrointestinal hemorrhage is extravasation of contrast material into the bowel.

D. Incorrect. Mallory-Weiss tears occur at the gastroesophageal junction, not in the distribution of either thesuperior or inferior mesenteric arteries.





101. Concerning inferior vena cava filters, which statement is TRUE?

A. Removable filters are not available.

B. The ideal location for filter placement is at the iliac vein confluence.

C. Current filters require surgical cut down for placement.

D. Current filters can be placed from femoral or jugular venous approach.

Question #101

Rationales:A. Incorrect. Removable filters are now commercially available.

B. Incorrect. The ideal location is just below the renal veins.

C. Incorrect. Most devices are placed percutaneously.

D. Correct. Current devices can be placed via a transfemoral or transjugular access.

Citations:Kinney TB. Update on inferior vena cava filters. J Vasc Interv Radiol. 2003;14:425-440.



102. Regarding standards of practice in uterine artery embolization for leiomyomata, which statement isFALSE?

A. A viable pregnancy is an absolute contraindication to uterine artery embolization.

B. Ultrasonography or magnetic resonance imaging should be performed prior to embolization.

C. Coil occlusion of the uterine artery is preferred.

D. Post procedure analgesia is necessary.

Question #102

Rationales:A. Incorrect. True. Res ipsa loquitur.

B. Incorrect. True. The purpose of the imaging is to confirm the diagnosis of leiomyomata, exclude other pelvicpathology and provide baseline measurements to assess the effects of treatment.

C. Correct. False. Successful treatment of uterine leiomyomata requires distal occlusion of all branches feedingthe uterine leiomyomata. Proximal occlusion of larger arteries with coils would not be expected to provideclinical success.

D. Incorrect. True. A pain management strategy is required for all patients.

Citations:Andrews RT, Spies JB, Sacks D, et al. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv

Radiol 2004;15:115-120.



103. Concerning indications for percutaneous nephrostomy, ALL of the following are true EXCEPT:

A. Urinary tract obstruction

B. Pyonephrosis

C. Life threatening hyperkalemia

D. Access for endoscopic urinary tract procedures

Question #103

Rationales:

A. Incorrect. Urinary tract obstruction is the most frequent indication for percutaneous nephrostomy.

B. Incorrect. These patients are at high risk for gram-negative sepsis. Emergency drainage is indicated.

C. Correct. Life threatening hyperkalemia is NOT an indication for nephrostomy. It is true that patientsin renal failure will elevate their potassium and that percutaneous nephrostomies will reverse renal failurewhen the cause is urinary tract obstruction. However, severe hyperkalemia is actually a contraindication topercutaneous nephrostomy because of the risk of cardiac arrest. The emergency treatment is hemodialysis.

D. Incorrect. Access for stone removal is one example of an indicated endoscopic procedure that requires apreliminary percutaneous nephrostomy.

Citations:

Ramchandani P, Cardella JF, Grassi CJ, et al. Quality improvement guidelines for percutaneous nephrostomy.J Vasc Interv Radiol. 2003;14:S277-S281.




104. What is the diameter of an 18 French catheter?

A. 3 mm

B. 6 mm

C. 12 mm

D. 18 mm

Question #104

Rationales:

A. Incorrect.

B. Correct. French is a scale used for denoting the size of catheters and other tubular instruments.

Each unit is roughly equivalent to .33 mm; 18 French indicates a diameter of 6 mm.

C. Incorrect.

D. Incorrect.

Citations:Dorland Newman WA. Dorland’s Illustrated Medical Dictionary. 27th ed. Philadelphia, Pa: W.B. Saunders;

1988.

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