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  1. 1. 2007 ACR Diagnostic Radiology In-Training Exam Rationales Section I Interventional Radiology 1. You are shown an AP view from a percutaneous trans-hepatic cholangiogram of a jaundiced patient (Figure 1). What is the MOST LIKELY diagnosis? A. Pancreatic carcinoma B. Sclerosing cholangitis C. Cholangiocarcinoma D. Cholelithiasis Findings: The cholangiogram shows a right-sided biliary diversion catheter. The left central intra-hepatic bile duct is obstructed and isolated from the right hepatic duct at the point where they would be expected to join to form the common hepatic duct. RATIONALES: A. Incorrect. Pancreatic carcinoma typically obstructs the common bile duct distally. B. Incorrect. Sclerosing cholangitis typically causes diffuse, multifocal strictures often with a beaded appearance in the intra and extrahepatic ducts. C. Correct. Cholangiocarcinoma typically arises at the confluence of the right and left central hepatic ducts and the cancer typically obstructs and isolates the ducts as shown here. This is an example of Klatskin tumor. D. Incorrect. The contrast does not outline biliary stones References: 1. LaBerge JM. Case 15. In Biliary Interventions – SCVIR Syllabus. Society of Cardiovascular & Interventional Radiology 1995; 337-342. 2. Soulen MC. Tutorial 16. In Biliary Interventions – SCVIR Syllabus. Society of Cardiovascular & Interventional Radiology 1995; 221-231
  2. 2. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 2. You are shown an image from a celiac arteriogram (Figure 2). What abnormality is present? A. Median arcuate ligament syndrome B. Occlusion of the splenic artery C. Occlusion of the portal vein D. Gastric arteriovenous malformation Findings: There is no proximal opacification of the proximal splenic artery. In its place there are numerous enlarged, tortuous arterial branches in the fundus of the stomach representing well developed collateral blood supply from the left gastric and right gastroepiploic arteries shunting the occluded splenic artery and eventually reopacifying splenic artery branches at the hilum of the spleen. Rationales: A. Incorrect. Gastroduodenal artery collaterals will develop in median arcuate ligament syndrome. The direction of flow is from the superior mesenteric artery to the celiac along the course of the duodenal sweep to bypass the proximal stenosis of the celiac artery. B. Correct. The findings are those of a chronic occlusion of the splenic artery. C. Incorrect. The splenic vein may well be occluded in this patient, were the splenic artery occluded by pancreatic carcinoma, but the patency of the splenic or portal vein cannot be determined from this arterial image. D. Incorrect. The tangled collateral arteries in the fundus of the stomach should not be mistaken for an arteriovenous malformation because there is no early opacification of the draining veins. Citation: 1. Abrams HL. Splenic Arteriography. In Angiography. 2nd edition, 1971. Vol II: 1003-1027.
  3. 3. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 3. You are shown a CT image during the course of a lung biopsy and a second image at a different level obtained 5 minutes later (Figures 3A and 3B). The patient has become short of breath and is coughing. The oxygen saturation with a facemask is 97%. What is your next step? A. Place a needle in the suspicious nodule. B. Place a chest tube in the right hemithorax C. Stat page thoracic surgery D. Obtain a chest radiograph in one hour Findings: There is a pulmonary nodule in the right lung. There is a pneumothorax that is enlarging. RATIONALES: A. Incorrect. You have already caused a pneumothorax. It is getting bigger. The second image actually shows a tension pneumothorax. The patient is in some respiratory distress and will not be able to easily cooperate with the procedure and the nodule is moving away from you. B. Correct. There is a large pneumothorax and a symptomatic patient. This warrants a chest tube. C. Incorrect. The skill required to place a chest tube is less than that needed to stick a needle into a pulmonary nodule. No need to find a surgeon. Quicker and better place the tube yourself with the patient on the CT table. D. Incorrect. Respiratory distress and an enlarging pneumothorax, this requires therapy. The literature citations for this question are: 1. Kaufman JA, Lee MJ. Vascular and Interventional Radiology. The Requisites. Mosby. 2004. LaBerge JM. Interventional Radiology Essentials. Lippincott 2000.
  4. 4. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 4. Based on the single frontal and lateral abdominal aortogram images shown in Figures 4A and 4B, the patient most likely was referred for the evaluation of: A. Abdominal angina B. Malignant hypertension C. Gastrointestinal hemorrhage D. Prospective renal donor Findings: The lateral image shows an almost compete occlusion of the celiac artery at its origin with thrombus in the lumen just distal to the stenosis. There is a complete occlusion of the superior mesenteric artery. There is a relative stenosis at the ostium of an inferior mesenteric artery. The frontal image shows filling of the hepatic artery, but no filling of the splenic or left gastric arteries. There is no antegrade filling of the superior mesenteric artery. There is a hypertrophied inferior mesenteric artery with retrograde filling into the distribution of the superior mesenteric artery primarily via the arc of Riolan. There is filling of the main and an inferior accessory right renal artery. There is no filling of the left renal artery. RATIONALES: A. Correct. An occluded superior mesenteric artery, an almost occluded celiac artery and ostial stenosis of the remaining main collateral pathway is sufficient to produce chronic intestinal ischemia. B. Incorrect. There is an infracted left kidney but a large right kidney. The images do not suggest a diagnosis of malignant hypertension. C. Incorrect. Biplane aortography is not part of the usual evaluation for gastrointestinal hemorrhage. D. Incorrect. A patient with advanced atherosclerotic disease and one nonfunctioning kidney is not a likely candidate to be a kidney donor. References: 1. Kaufman JA, Lee MJ. Vascular and Interventional Radiology. The Requisites. Mosby. 2004
  5. 5. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 5. You are shown subtracted and non-subtracted images from an inferior vena cavagram obtained prior to placing a filter (Figures 5A and 5B). What does it show? A. Eustachian valve B. Budd Chiari syndrome C. Renal vein thrombosis D. Right iliac vein thrombosis Findings: There is a valve at the junction of the inferior vena cava and the right atrium. RATIONALES: A. Correct. This valve, a remnant of the embryonic right valve of the sinus venosus, is called a Eustachian valve (valvula venae cavae inferioris). B. Incorrect. Budd Chiari syndrome is not necessarily caused by hepatic vein thrombosis and can be caused by web like obstructions in the suprahepatic inferior vena cava. But what is shown here are vein cusps not impeding the flow of blood. Notice there is no reflux of contrast into tributary veins. C. And D. Incorrect. It is a mistake to misinterpret the inflow of nonopacified blood from the iliac or renal veins as thrombus. References: 2. Kaufman JA, Lee MJ. Vascular and Interventional Radiology. The Requisites. Mosby. 2004. Schuchlenz HW et al. Persisting Eustachian valve in adults: relation to patent foramen ovale and cerebrovascular events. J Am Soc Echocardiogr 2004; 17:231
  6. 6. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 6. You are shown two images from a catheter-based contrast study (Figures 6A and 6B). Why was this procedure performed? A. To evaluate chronic pelvic pain B. Prior to embolization to increase an abnormal sperm count C. For staging of a seminoma in a nondescended testis D. Prior to embolization of uterine leiomyomata Findings: A. Correct. Note that the catheter ascends to the right of the midline, indicating that it is within the vena cava rather than the aorta. The catheter then crosses the midline at approximately L1 (likely in the left renal vein), and then descends to the left of midline (in the expected location of the left gonadal vein). The examination is a gonadal venogram. A normal gonadal venogram would demonstrate antegrade flow of contrast (back along the catheter). But this study demonstrates reflux down the incompetent left gonadal vein into the pelvis in the region of the female reproductive organs with anastomoses to the retroperitoneal veins and drainage via the left internal iliac vein. Rationale A. Correct. Pelvic pain is the most common presenting complaint in women with ovarian vein reflux. B. Incorrect. The varicocele is not within the scrotum. C. Incorrect. Gonadal venograms are not commonly performed to evaluate seminomas. D. Incorrect. This is a venous not arterial catheterization. Reference(s): Kadir. Diagnostic Angiography, 1st edition, p.488. SCVIR Workshop Book, 2000, pp. 125-132
  7. 7. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 7. Concerning popliteal artery entrapment syndrome, which of the following is TRUE? A. Medial deviation of the popliteal artery is common B. The majority of patients are women C. The syndrome is an acute complication of trauma D. Patients usually become symptomatic in the later decades of life Rationales A. Correct. The commonest form of popliteal artery entrapment, about 50% of cases, results from the popliteal artery deviating medial to the normally attached medial head of the gastrocnemius muscle. B. Incorrect. 90% of cases have been reported in men. C. Incorrect. Except for a rare surgical misadventure, this is a congenital condition resulting from an anomalous relation of the popliteal artery to the insertion of the calf muscles behind the knee. D. Incorrect. Although not all entrapped popliteal arteries become symptomatic, more than half of the patients present prior to or during the third decade of life. References: 1. Abou-Zamzam AM et al. Nonatherosclerotic Vascular Disease. In: Vascular Surgery; A Comprehensive Review, Moore, ed. W.B. Saunders; 1998, 132-134. 2. Murray A et al. Popliteal Artery Entrapment. Br J Surg 1991; 78:1414- 1419. Gibson MH et al. Popliteal Entrapment Syndrome. Ann Surg 1977; 185:341-348
  8. 8. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 8. After endograft repair of an abdominal aortic aneurysm, a type II endoleak is characterized by: A. reversal of flow in the aortoiliac branch arteries. B. proximal or distal graft attachment failures. C. modular graft component separation. D. porosity of the graft material. Rationales: A. Correct. One example. The left colic artery, a branch of the inferior mesenteric artery, often communicates freely with the middle colic artery, a branch of the superior mesenteric artery. Following the placement of a stent graft, the blood pressure in the excluded aneurysmal sac will decrease. Under this circumstance the higher blood pressure in the middle colic artery may reverse the direction of flow through the left colic artery, backing blood up into the aneurysmal sac. However, the hemodynamics of these type II leaks are complex. At the same time that there may be reversal of flow through some lumbar branch arteries to fill the sac, blood flow through other branches may be in the normal direction exiting the sac. B. Incorrect. Type I endoleak involves the proximal or distal attachment sites of the endograft. C. Incorrect. An endoleak that occurs at the junction of modular endograft components is classified as a type III. Disruption of the fabric of the endograft or a hole related to a suture are also classified as a type III endoleak D. Incorrect. Type IV endoleak is due to the porosity of the fabric of the endograft wall, during less than the 30-day period following implantation. Usually seen immediately following endograft implantation, this was more commonly seen with the first or second generation endografts. References: 1. Veith FJ et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference. J Vasc Surg 2002; 35:1029-35 2. Choke E, Thompson M. Endoleak after endovascular aneurysm repair: current concepts. J Cardiovasc Surg 2004; 45:349-66 3. Stavropoulos et al. Use of CT Angiography to Classify Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms. J Vasc Interv Radiol 2005; 16:663-667 4. Kaufman et al. Endovascular Repair of Abdominal Aortic Aneurysms. AJR 2000; 175:289-302
  9. 9. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 9. Preliminary to percutaneous vertebroplasty for a painful osteoporotic fracture, it would be fair to tell a patient that there is an approximately 25% chance that: A. the procedure may not relieve the pain. B. a local neurological complication may develop. C. a new vertebral body fracture may develop. D. the procedure cannot be successfully completed. RATIONALES: C. Correct. The expected outcome is that the procedure can be accomplished with immediate pain relief for about 95% of patients. The risks of local neurological complications are about 5%. But it has been well documented that after treatment the risk of developing new vertebral fractures is approximately 25%. All patients should be counseled regarding this and the potential need for additional treatment prior to undergoing vertebroplasty. References: 1. Voormolen MH, Lohle PN, et al. The risk of new osteoporotic vertebral compression fractures in the year after percutaneous vertebroplasty. J Vasc Interven Radiol. 2006; 17:71-76. 2. Perez-Higueras A, Alvarez L, Rossi RE, et al. Percutaneous vertebroplasty: long-term clinical and radiological outcome. Neuroradiology 2002; 44: 950-954. 3. Lin EP, Ekholm S Hiwatashi A, et al. Vertebroplasty cement leakage into disc increases the risk of new fracture of adjacent vertebral body. AJNR 2004; 25: 175-180. 4. Barragán-Campos HM et al Percutaneous vertebroplasty for spinal metastases: complications. Radiology. 2006 Jan;238(1):354-62.
  10. 10. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 10. Concerning conscious sedation, which drug is most appropriate to treat an overdose of midazolam (Versed)? A. Flumazenil (Mazicon) B. Reversid (RetroverZe) C. Naloxone (Narcan) D. Fentanyl (Sublimaze) RATIONALES: A. Correct. Midazolam (Versed) is a benzodiazepine. Flumazenil is a benzodiazepine antagonist useful to reverse the effects of midazolam or diazepam. Naloxone is an opiate antagonist useful for overdoses of fentanyl or morphine, but will not reverse the action of flumazenil. Clearly it would be an error to give fentanyl, a powerful opiate, to reverse the effects of midazolam. Reversid (RetroverZe) doesn’t exist. The literature citations for this question are: 1. Kaufman JA, Lee MG. Vascular and Interventional Radiology. The Requisites. Mosby. 2004 LaBerge JM. Interventional Radiology Essentials. Lippincott Williams & Wilkins 2000
  11. 11. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 11. An interventional fluoroscopy procedure results in a patient skin entrance dose of 2 Gy. Which of the following radiation-induced skin injuries MOST LIKELY can occur? A. Necrosis B. Main erythema C. Dry desquamation D. Early transient erythema A. Incorrect. Necrosis of the skin has dose threshold of >16 Gy. B. Incorrect. The dose threshold for main erythema is 6 Gy C. Incorrect. Desquamation occurs above 14 Gy. D. Correct. This effect has a lower dose threshold of 2 Gy. It may begin within hours after irradiation and peak at about 24 hour References: Balter S. Interventional Fluoroscopy: Physics, Technology and Safety, p.167.
  12. 12. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 12. Regarding image intensifier design, which of the following results due to the combination of a curved input screen and flat output screen? A. Pincushion distortion B. Increased contrast ratio C. Reduced radiation dose D. Increased brightness gain A. Correct. Mapping of an image from a curved input screen to a flat output screen results in increased magnification at the image periphery as compared to the image center B. Incorrect. The shape of the input and output screens does not affect veiling glare C. Incorrect. The shape of the input and output screens does not affect radiation dose D. Incorrect. Brightness gain depends on electronic gain and minification gain References: Bushberg JT, Seibert JA, Leidholdt EM, Boone JM. The Essential Physics of Medical Imaging, 2nd Edition, p. 235
  13. 13. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 13. Concerning primary renal artery stenting, which of the following is considered a well-accepted indication? A. Unilateral, less than 50% renal artery stenosis discovered during a cardiac catheterization B. Unilateral, greater than 90% renal artery stenosis in an elderly chronic azotemic patient C. Bilateral, greater than 75% renal artery stenoses in an elderly patient with rapidly developing renal failure D. Bilateral medial fibromuscular dysplasia in a young, hypertensive woman RATIONALES: A. Incorrect. The indications for renal angioplasty are to treat renal vascular hypertension or azotemia. It is incorrect to perform a drive-by intervention of a hemodynamically insignificant renal artery stenosis incidental to the evaluation of the coronary arteries. B. Incorrect. Unilateral renal artery stenosis is unlikely to be the cause of renal failure when the opposite renal artery is normal. C. Correct. Revascularization of the kidneys may reverse or at least preserve renal function. D. Incorrect. Certainly this patient with renal vascular hypertension should be treated, but usually with a balloon rather than a stent. The literature citations for this question are: 1. Rundback JH, Rozenblit GN, Poplausky MR. SCVIR Syllabus: Peripheral Vascular Interventions Renal Artery Stenting. Society of Cardiovascular &Interventional Radiology 2001. Kaufman JA, Lee MG. Vascular and Interventional Radiology. The Requisites. Mosby. 2004
  14. 14. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 14. Following percutaneous cholecystostomy, the patient rapidly became afebrile and the white count reverted to normal. When may the drainage catheter be safely removed? A. When the patient is well enough to leave the ICU B. When the catheter drainage has decreased below 10 ml per day C. Not before two to six weeks, regardless of other factors D. Only at the time of surgery for removal of the chronically inflamed gall bladder RATIONALES: C. Correct. The cholecystostomy tube must remain in place until a mature tract develops, usually somewhere between 2 to 6 weeks. If the tube is removed too early bile may spill from the gall bladder into the peritoneal cavity causing bile peritonitis. References: Boland GW, Lee MJ, et al. Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients. AJR 163: 339-342, 1993. Kaufman JA, Lee MG. Vascular and Interventional Radiology, The Requisites. Mosby. 2004
  15. 15. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 15. A patient with diffuse pedal ischemia, a nonhealing ulcer and focal gangrene of the foot was found to have an elevated rather than decreased ankle brachial index. Which of the following is the MOST LIKELY explanation? A. Diabetes B. Atrial fibrillation C. Congestive heart failure D. Venous gangrene RATIONALES: A. Correct. Medial arterial calcification is commonly found in diabetics with peripheral arterial disease. These heavily calcified vessels are frequently not compressible. This may lead to falsely elevated ankle brachial index measurements. References: Janssen A. Pulsatility index is better than ankle-brachial Doppler index for non- invasive detection of critical limb ischaemia in diabetes. Vasa 2005; 34:235-41. Sacks D et al. Position statement on the use of the ankle-brachial index in the evaluation of patients with peripheral vascular disease. J Vasc Interv Radiol2002; 13:353.
  16. 16. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 16. Concerning dysfunctional dialysis access grafts, the underlying abnormality is MOST frequently found: A. at the arterial anastomosis B. mid graft C. at the venous anastomosis D. involving central veins RATIONALES: C. Correct. The patency of hemodialysis access grafts becomes compromised primarily by areas of intimal fibromuscular hyperplasia and perivenous fibrosis causing stenoses that develop in response to turbulence and shear stress. Most commonly these events obstruct the venous outflow, primarily at the graft-to-vein anastomosis. References: 1. Vogel PM, Parise C. Comparison of SMART Stent Placement for Arteriovenous Graft Salvage versus Successful Graft PTA. J Vasc Interv Radiol 2005; 16:1619-26. 17. Typically, the ovarian artery arises from the: A. aorta B. uterine artery C. posterior division of the internal iliac artery D. circumflex iliac artery RATIONALES: A. Correct. The ovarian arteries arise anteromedially from the abdominal aorta inferior to the renal arteries in 80%-90% of cases. Other origins, adrenal, renal, lumbar, iliac arteries are rare. In about 4% of cases the uterine arteries alone supply the ovaries. References: Pelage JP et al. Uterine fibroid vascularization and clinical relevance to uterine fibroid embolization. Radiographics 2005; 25:S99-S117
  17. 17. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 18. When percutaneous nephrostomies are performed, needle placement into posterior calyces is preferred to anterior calyces because: A. the colon is more likely to be anterior to the kidney. B. Broedel’s line extends through the posterior calyces. C. the guide wire will take a less angled path using the posterior calyces. D. stones are less likely to form in the posterior calyces. RATIONALES: A. Incorrect. The colon is usually anterior to the kidney, where hopefully it is out of the way of the needle. Regardless, its position is not a consideration when choosing between an anterior or posterior calyx. B. Incorrect. Broedel’s line, demarking an avascular plane, is halfway between the anterior and posterior calyces. C. Correct. Percutaneous nephrostomies are performed with the patient prone. When using a posterior approach, the arrangement of the calyceal anatomy makes it easier to advance a guidewire through a needle in a posterior calyx into the renal pelvis than from an anterior calyx. The angle the guidewire must make with the needle is much more acute when trying to thread the infundibulum from an anterior calyx. D. Incorrect. I am uncertain whether stones are more or less likely to form in the posterior calyces, but this is not why posterior calyces are preferred. References: Kaufman JA, Lee MJ. Vascular and Interventional Radiology. The Requisites. Mosby. 2004. Pollack HM. Clinical Urography. Saunders. 1990.
  18. 18. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 19. Concerning transhepatic arterial chemoembolization (TACE) of hepatocellular carcinoma, which one of the following is TRUE? A. TACE is the treatment option of choice for hepatocellular carcinoma. B. TACE will prolong survival compared to systemic infused chemotherapy. C. The effectiveness of TACE depends greatly on the choice of drugs used. D. Thrombosis of the portal vein will increase the effectiveness of TAC RATIONALES: A. Incorrect. Although 20% or fewer qualify, the only options for cure are resection or transplantation. B. Correct. TACE has been proved to prolong survival compared to systemic infused chemotherapy. It is a useful treatment for unnresectable hepatocellular carcinoma. C. Incorrect. Multiple different drug regimens exist and no consensus has been reached as to which is best. D. Incorrect. Portal vein thrombosis is sometimes considered a contraindication to TACE because of the danger of infarcting the liver. Regardless, patients with portal vein thrombosis have a worse prognosis than those without. References: Georgiades CS. Safety and efficacy of transarterial chemoembolization in patients with unresectable hepatocellular carcinoma and portal vein thrombosis. J Vasc Interv Radiol 2005; 16:1653-1659. Brown DB. Hepatic arterial chemoembolization for hepatocellular carcinoma: Comparison of survival rates with different embolic agents. J Vasc Interv Radiol 2005; 16:1661-1666
  19. 19. 2007 ACR Diagnostic Radiology In-Training Exam Rationales 20. Concerning uterine artery embolization (UAE), the EMMY Trial, a multicenter randomized comparison between UAE and hysterectomy for treatment of menorrhagia showed: A. a lower technical failure rate with UAE. B. a lower complication rate with UAE. C. a shorter hospital stay with UAE. D. fewer post procedure hospitalizations with UAE. RATIONALES: A. Incorrect. The technical failure rate was significantly higher with UAE. Bilateral UAE failed in 4.9% of patients and unilateral failure in 6.2% of patients. B. Incorrect. Although not statistically significant, major complications developed in 4.9% of the UAE group and 2.7% following hysterectomy. C. Correct. Hospital stay for UAE averaged 2.5 days versus 5.1 days after hysterectomy. D. Incorrect. Patients had an 11% chance of readmission following UAE versus zero after hysterectomy in this study. References: Spies JB. Commentary. The EMMY trial of uterine artery embolization for the treatment of symptomatic uterine fibroid tumors: randomized, yes, but a flawed trial nonetheless. J Vasc Interv Radiol 2006; 17:413-415 21. A hemodynamically stable patient with a large pulmonary embolus is BEST treated by: A. anticoagulation B. systemic thrombolysis C. catheter directed thrombolysis D. surgical thrombectomy RATIONALES: A. Correct. Anticoagulation prevents formation of additional thrombus. Most emboli will then undergo spontaneous thrombolysis and fragmentation, although complete resolution can take several months. Aggressive intervention should be reserved for severely distressed, hypotensive, hypoxic patients. References: Kadir, Diagnostic Angiography, Chapter 20. Danhert, Radiology Review Manual.
  20. 20. 2007 ACR Diagnostic Radiology In-Training Exam Rationales Kaufman JA, Lee MJ. Vascular and Interventional Radiology. The Requisites. Mosby. 2004. 22. What is the advantage of using the Gunther Tulip vena cava filter? A. It can be removed. B. It can be placed via a peripheral vein. C. It can accommodate an ectatic vena cava. D. It doesn’t preclude magnetic resonance imaging. RATIONALES: A. Correct. The Gunther Tulip Filter has a hook on its superior end for transjugular retrieval. B. Incorrect. The Simon-Nitinol Filter has a low profile (7 French) delivery system, allowing placement via small veins such as the basilic vein. C. Incorrect. The Bird’s Nest filter has two V-shaped struts connected by four stainless steel wires. It can be safely deployed in vena cavae measuring up to 38 cm, about 10 cm greater than for most other filters. D. Incorrect. All filters are compatible with a magnetic resonance scanner. References: SCVIR Syllabus Series: Venous Interventions. Tutorials 23 and 24. 23. A 39-year-old male cigarette smoker with a past history of thrombophlebitis presents with lower extremity rest pain. An arteriogram shows distal arterial occlusive disease with prominent “cork-screw” collateral vessels. What is the MOST LIKELY diagnosis? A. Buerger’s disease B. Diabetes C. Cholesterol emboli D. Bechcet’s disease RATIONALE A. Correct. Buerger’s disease should be suspected in any patient presenting with peripheral vascular disease before the age of 45. There is a strong association with cigarette smoking and male gender. Migratory thrombophlebitis is also a feature of the disease. References: 1. Kaufman JA, Lee MJ. Vascular and Interventional Radiology. The Requisites. Mosby. 2004.