23205004

Section XI – Interventional

Figure 1
265. You are shown a chest film of a patient referred for your evaluation from an oncology office
because of the inability to aspirate blood from the implanted port (Figure 1).
What action do you take?

A. Reassure the oncologists that they may infuse even if they cannot aspirate
B. Instill 40 mg TPA to lyse the thrombus within the catheter
C. Use a snare to dislodge the fibrin sheath encasing the catheter
D. Use a snare to remove the intravascular catheter

1
Diagnostic In-Training Exam 2006

Question #265
Rationales:
A. Reassure the oncologists that they may infuse even if they cannot aspirate
B. Instill 40 mg TPA to lyse the thrombus within the catheter
C. Use a snare to dislodge the fibrin sheath encasing the catheter
D. Use a snare to remove the intravascular catheter

2 American College of Radiology


Figure 2
266. You are shown a single image from a percutaneous transhepatic cholangiogram of a jaundiced
patient (Figure 2). What is the MOST LIKELY diagnosis?

A. Gallbladder carcinoma
B Sclerosing cholangitis
C. Pancreatic carcinoma
D. Choledochocele


Question #266
Findings: There is a tapering almost to the point of complete obstruction of the strictured distal com-
mon bile duct. There is marked dilatation of the intra and extra hepatic ducts proximal to the stricture.
There is partial filling of a markedly distended gall bladder.
Rationales:
A. Incorrect. Gallbladder carcinoma causes obstruction at the level of the proximal common hepatic
duct or higher. Because gallbladder carcinoma usually arises in the setting of chronic cholecystitis
you will not expect to see a distended gallbladder.
B. Incorrect. Sclerosing cholangitis typically causes diffuse, multifocal strictures often with a beaded
appearance in the intra and extrahepatic ducts.
C. Correct. The “rat tailed” appearance of the extrinsic obstruction and the location of the stricture at
the level of the head of the pancreas make this diagnosis the favorite. The “Courvoisier’s gallblad-
der” is also typical.
D. Incorrect. A choledochocele appears as a focal cystic collection of contrast at the level of the
ampulla.

4


Figure 3
267. You are shown a single image from a non-contrast-enhanced CT scan of the chest (Figure 3).
Which of the following statements is true?

A. An excisional biopsy should be the next diagnostic step.
B. A percutaneous needle biopsy should be the next diagnostic step.
C. Radiofrequency ablation is the standard therapy for this disorder.
D. Coil embolization is a standard therapy for this disorder.


Question #267
Findings: A single cross sectional image in this case shows a nodule associated with two dilated tortu-
ous pulmonary vessels.
Rationales:
The findings are diagnostic for a pulmonary arteriovenous malformation. The nodule is the saccular
communication between the feeding pulmonary artery and the draining pulmonary vein. It is incorrect
to think this is a solid tumor, perhaps a small lung cancer. The diagnosis could be confirmed with a CT
angiogram, but certainly it would be incorrect to perform a needle biopsy of a vascular lesion. Standard
therapy is coil embolization. It would be too invasive to excise this lesion, particularly as they are so
often multiple. Radiofrequency ablation at this point is an experimental technique for malignant lung
lesions not amenable to surgery. Not recommended here.

6


Figure 4A

Figure 4B
268. The patient presented with sudden onset of facial and upper extremity swelling. You are shown
biplanar angiographic images (Figures 4A and 4B). What action should be taken?

A. Emergency surgery
B. Catheter directed thrombolysis
C. Systemic chemotherapy
D. Angioplasty and stent placement


Question #268
Findings: There is extrinsic narrowing of the superior vena cava with some filling of collateral veins.
Rationales:
The clinical history confirmed by the angiogram is diagnostic of superior vena cava syndrome. Acute
superior vena cava syndrome is considered a medical emergency. The treatment options for superior
vena cava syndrome are endovascular therapy and external beam irradiation. The response to angioplas-
ty and stent placement is more rapid than to radiotherapy. In this case there is no clot to lyse.

8


Figure 5
269. You are shown duplex Doppler ultrasound images of the right greater saphenous vein during a
Valsalva maneuver (Figure 5). What is the MOST LIKELY diagnosis?

A. Superficial thrombophlebitis
B. Venous insufficiency
C. Arteriovenous fistula
D. Phlegmasia cerulea dolens


Question #269
Findings: Spectral analysis shows reversal of flow in the greater saphenous vein during a Valsalva
maneuver.
Rationales:
Superficial thrombophlebitis and phlegmasia can be easily eliminated as correct answers because there
is flow through a patent vein and no clot is demonstrated. An arteriovenous fistula will show a pulsatile
arterial wave form. The retrograde flow through the greater saphenous vein on Valsalva demonstrates
incompetence of the venous valves. Venous insufficiency is the correct answer.

10


Figure 6
You are shown an image from an abdominal aortogram (Figure 6). Which one of the following
270.
BEST describes the patient?

A. 25-year-old woman with recently discovered hypertension
B. 45-year-old man with acute renal failure
C. 70-year-old man with poorly controlled hypertension
D. 80-year-old woman being evaluated for an aortic stent graft


Question #270
Findings: There is a severely atherosclerotic, but not ectatic abdominal aorta with atheromatous
plaques and ulcers including an atheromatous plaque causing osteal stenosis of the right renal artery.
Rationales:
A. Incorrect. This is an elderly patient with atheromatous disease. In a young woman, a more common
cause for renal vascular hypertension would be fibromuscular dysplasia, the most characteristic
appearance of which is a string-of-bead appearance along the course of the renal artery.
B. Incorrect. Even for a 45 year-old, this is advanced atherosclerotic disease and renal failure is unusu-
al with unilateral renal artery stenosis. Not the best choice.
C. Correct. The age is right for the amount of disease in the aorta. The renal artery stenosis could easi-
ly explain the difficult to control hypertension.
D. Incorrect. Aortic stent grafts are typically used as an alternative to surgery for abdominal aortic
aneurysms.

12

271. Drug-eluting stents have been used in the treatment of coronary artery disease. What is the pur-
pose of the drugs?

A. To retard post-procedure elastic recoil
B. To retard post-procedure platelet aggregation
C. To retard the development neointimal hyperplasia
D. To retard the progression of atherosclerotic occlusive disease

Question #271
Rationales:
The advantage of a stent over angioplasty alone is it prevents elastic recoil. The purpose of the eluted
drugs is to retard neointimal hyperplasia as a cause for in-stent stenosis. These are not antiplatelet med-
ications or drugs to inhibit progressive atherosclerosis. Although drug eluting stents have revolutionized
the treatment of coronary artery disease, it has been difficult to show that they are an improvement over
bare stents for the treatment of superficial femoral artery disease.


272. For patients requiring permanent hemodialysis, what is the advantage of a native
arteriovenous fistula?

A. Most durable
B. Most easily declotted
C. Most easily accessed
D. Most rapidly available for use after placement

Question #272
Rationales:
Fistulas have superior longevity in comparison to bridge grafts. But they take several weeks for the
access to mature, for the egress veins to enlarge sufficiently to provide adequate blood flow and become
large enough to accept large bore needles. They may never mature. Synthetic grafts are ready for use in
two weeks. Tunneled catheters are available for use immediately following placement. Further, tunneled
catheters are the most easily accessed. The patient doesn’t have to be struck. But tunneled catheters are
not recommended for long-term hemodialysis because of the risk of infection and early failure rate.
Bridge grafts are easier to declot than native fistulas because the clot is usually confined to the synthetic
graft, the grafts are superficial and the anatomy straightforward.

14

273. Concerning fluoroscopy, which of the following techniques will MOST LIKELY increase patient
radiation dose rate?

A. Heavy x-ray beam filtration
B. Increased patient-to-image-receptor distance
C. Increased focal-spot -to-patient distance
D. Low-frame-rate pulsed fluoroscopy

Question #273
Rationales:
A. Incorrect. Heavy beam filtration, such as 0.1-0.9 mm copper, reduces lower energy x-rays that are
absorbed in patient tissue contributing to patient dose
B. Correct. The dose rate to the image receptor is maintained at a constant level so increasing the dis-
tance between the patient and the image receptor increases the fluoroscopic dose rate
C. Incorrect. Dose is inversely proportional to the square of the distance from the focal spot, so
increasing the distance results in a lower fluoroscopic dose rate
D. Incorrect. Pulsed fluoroscopy operating at low frames results reduces the fluoroscopic dose rate


Concerning conscious sedation, which one of the following drugs may be used by an
274.
interventional radiologist to achieve the desired effect?

A. Lidocaine
B. Fentanyl
C. Flumazenil
D. Propofol

Question #274
Findings: Conscious sedation may be defined as a drug induced depression of consciousness during
which patients respond purposefully to verbal commands, either alone or accompanied by light tactile
stimulation
Rationales:
A. Incorrect. Lidocaine is the most widely used local anesthetic. It should be used liberally to diminish
the amount of conscious sedation necessary to maintain the patient’s comfort, but is not itself an
agent for conscious sedation.
B. Correct. Fentanyl is a potent synthetic opioid often used for conscious sedation.
C. Incorrect. Flumazenil is a benzodiazepine antagonist used to counteract an overdose of midazolam,
for example.
D. Incorrect. Propofol is commonly used by anesthesiologists to induce and or maintain a level of
anesthesia where loss of protective reflexes is anticipated. It is not suitable for use by a radiologist
for conscious sedation.

16

275. Concerning vena cava filter placement, what is the BEST indication for a bird’s nest filter?

A. A left-sided vena cava
B. A duplicated vena cava
C. An ectatic vena cava
D. A retroaortic renal vein

Question #275
Rationales:
The advantage of a bird’s nest filter is that it can be safely placed in a vena cava with a diameter as
large as 40 mm. The maximum cava diameter for most other filters is 28 or 30 mm.


Which one of the following conditions primarily involves the veins of the lower extremity?
276.

A. Kasabach-Merritt syndrome
B. Kawasaki disease
C. Klatskin’s tumor
D. Klippel-Trenaunay syndrome

Question #276
Rationales:
A. Incorrect. Kasabach-Merrit syndrome is a consumption coagulopathy associated with large heman-
giomas.
B. Incorrect. Kawasaki disease, mucocutaneous lymph node syndrome is a childhood necrotizing vas-
culitis affecting small and medium sized arteries. Coronary artery aneurysms are the most striking
cardiovascular manifestation.
C. Incorrect. Klatskin’s tumor is a cholangiocarcinoma.
D. Correct. Klippel-Trenaunay syndrome is a congenital disorder that features markedly abnormal
lower extremity veins.

18

277. Child-Pugh, Apache II and MELD are all scoring systems that may be used for assessing the
severity of disease affecting which organ?

A. Liver
B. Kidney
C. Lung
D. Brain

Question #277
Rationales:
MELD stands for Model End Stage Liver Disease. All three scoring systems have been used to predict
the outcome of patients undergoing TIPS procedures.


278. Concerning the natural history of atherosclerotic peripheral arterial disease, which is
MOST LIKELY?

A. Intermittent claudication will progress to gangrene
B. Mortality will be from coronary artery or cerebrovascular disease
C. If the patient is initially asymptomatic, angioplasty or by-pass surgery will improve prognosis
D. If initially asymptomatic, the patient will enjoy an unaltered life

Question #278
Rationales:
Peripheral arterial disease (PAD) is an important manifestation of generalized atherosclerosis and is
defined as obstructive arterial disease that reduces blood flow to the lower extremities. The symptoms
of PAD progress rather slowly. After 5 to 10 years more than 70% of patients report no change or
improvement in their symptoms. But patients with PAD have a threefold increase in cardiovascular
mortality. Patients with asymptomatic PAD appear to have the same increased risk of cardiovascular
events and death as those with intermittent claudication. The indications for lower extremity by-pass
surgery or angioplasty are limb-threatening ischemia or incapacitating claudication.

20

Concerning ultrasonography of the superficial femoral artery, which one is TRUE?
279.

A. There is reversal of the direction of flow in early diastole in a normal artery at rest.
B. There is reversal of the direction of flow in late diastole in a normal artery after exercise.
C. There is accelerated velocity of flow through a short segment occlusion with exercise.
D. Peak systolic velocity is increased though the superficial femoral artery in the presence of a
stenotic iliac artery.

Question #279
Rationales:
A brief reversal of flow direction is normal in the superficial femoral artery during early diastole at rest.
With exercise the flow changes from high to low resistance with increased antegrade flow throughout
diastole. Regardless, with or without exercise antegrade flow is normal in late diastole. An iliac artery
stenosis dampens flow down stream and there is no flow through an obstruction.


280. Concerning transjugular liver biopsy, for which situation would this procedure be MOST
indicated?

A. A patient with obstructive jaundice
B. A patient with an elevated INR
C. A patient with a suspicious nodule near a hepatic vein
D. A patient with a suspicious nodule near the liver capsule

Question #280
Rationales:
The advantage of the transjugular approach is a diminished risk of bleeding because hopefully bleeding
will follow the needle tract into the hepatic vein and be harmless. But with this technique you cannot
reliably direct the needle into a discrete lesion whether near or remote from the hepatic vein.
Transjugular biopsy is indicated for patients with diffuse parenchymal disease who are at increased risk
for bleeding.

22

281. Concerning the mechanism of radiofrequency tumor ablation, which is the MOST important
parameter governing tissue destruction?

A. Radiofrequency
B. Tissue vascularity
C. Tissue temperature
D. Number of probes

Question #281
Rationales:
Radiofrequency along with microwave, laser and high-intensity focused sonography are all thermal
ablation techniques used to destroy the tumor. The mechanism of ablation, of cellular death, is coagula-
tion necrosis, achieved by raising the temperature in the treated tissue to between 50 and 100 degrees of
Celsius. Thus the most important parameter governing tissue destruction is temperature. The number of
probes, the tissue vascularity, even perhaps the radiofrequency (more so for microwave ablation) cer-
tainly do have bearing, but only to the extent they contribute to the distribution of heat throughout the
lesion.


282. The digital radiography system that employs direct conversion of x-rays into a signal (electrons)
is best represented by which one of the following?

A. Photostimulable storage phosphor imaging system (computed radiography)
B. Optically coupled charge-coupled device (CCD) camera
C. CsI – TFT flat panel array
D. Amorphous selenium – TFT flat panel array

Question #282
Rationales:
A. Incorrect. X-rays are converted to latent image electrons in the BaFBr storage phosphor, then
“processed” by a scanning laser beam which then produces light photons that are reconverted to
electrons by a photomultiplier tube, and then digitized.
B. Incorrect. X-rays are converted to light photons in an x-ray scintillator, which are subsequently
focused onto a small CCD camera photosensitive layer, where the light photons are converted to
electrons, amplified, and then digitized.
C. Incorrect. X-rays are converted to light photons in the cesium-iodide scintillator, and channeled to
photodiodes attached to each detector element in the thin-film-transistor array. Electrons are pro-
duced, captured by storage capacitors at each element, and then actively read by the electronic
switching of the transistors. Although the flat panel array directly reads out the signal, the x-rays go
through a conversion to light photons before the final signals are captured.
D. Correct. Amorphous selenium is a semi-conductor material that directly produces electron-hole
pairs in proportion to the number of x-ray photons incident on the detector. A high-voltage bias
placed across the semiconductor actively collects the electrons and holes, thereby producing the sig-
nal that is amplified and digitized, without any secondary signal conversion.

24

283. The left colic artery is typically a branch of what larger artery?

A. Celiac artery
B. Superior mesenteric artery
C. Inferior mesenteric artery
D. Left internal iliac artery

Question #283
Rationales:
The left colic artery is a branch of the inferior mesenteric artery.


Concerning varicoceles, which one is TRUE?
284.

A. They may impair spermatogenesis.
B. They may obstruct the seminiferous tubules.
C. Most are diagnosed by ultrasound.
D. They are more common on the right than on the left.

Question #284
Rationales:
A varicocele is a dilatation of the pampiniform plexus. Most occur on the left side, likely the result of
reflux through incompetent left testicular veins. They are a cause of male infertility because of impaired
spermatogenesis with reduced sperm count and motility. They do not obstruct the seminiferous tubules.
Ultrasound can surely confirm the diagnosis and detect small varicoceles in males with infertility, but
most varicoceles are diagnosed on physical examination by palpation of a worm like tangle of veins.

26

285. You are asked to perform a pulmonary angiogram to confirm the presence of small peripheral
pulmonary emboli. Which one is TRUE?

A. The procedure is contraindicated in the presence of a right bundle-branch block.
B. Pulmonary artery pressures should be measured before injecting contrast.
C. Contrast may be injected through a catheter positioned in the right atrium.
D. Contrast may be injected through a Swan-Ganz catheter in the pulmonary artery.

Question #285
Rationales:
A. Incorrect. The danger is a preexisting left, not right bundle branch block, because while passing the
catheter through the right ventricle the procedure it can cause a right bundle branch block. This may
then result in complete heart block. Even in these patients the procedure may safely proceed if a
temporary pacing wire is placed first.
B. Correct. Severe pulmonary hypertension is dangerous. The pulmonary vascular bed may be largely
obliterated. In such cases the amount of contrast that can be safely injected, if any, is markedly
reduced.
C. Incorrect. There is too much dilution of the contrast by non opacified blood to obtain high quality
images with the catheter in the right atrium. The catheter tip should be positioned selectively in
each the right and left pulmonary arteries.
D. Incorrect. Don’t try it. The catheter will blow apart at the hub.


286. A young healthy patient presents with acute right subclavian vein thrombosis following vigorous
exercise. What is the MOST likely diagnosis?

A. May-Thurner syndrome
B. Budd-Chiari syndrome
C. Paget-Schroetter syndrome
D. Parkes-Weber syndrome

Question #286
Rationales:
A. Incorrect. May-Thurner syndrome involves the left iliac vein
B. Incorrect. Budd-Chiari is a syndrome of hepatic venous drainage
C. Correct. Paget Schoetter is an upper extremity effort thrombosis syndrome.
D. Incorrect. Parkes-Weber syndrome is characterized by hypoplasia or absence of the deep veins of
the legs, limb hypertrophy, atypical varicosities, port-wine stains and high-flow arteriovenous mal-
formations.

28

A patient with symptomatic fibroids is considering uterine artery embolization. Which one is
287.
CORRECT advice?

A. There is an 80% to 90% chance of the procedure producing menopause.
B. There is an 80% to 90% chance of the procedure producing relief of symptoms.
C. The fibroids will shrink by 80% to 90%, but may not go away completely.
D. There is an 80% to 90% chance of being released from the hospital in 3-5 days.

Question #287
Rationales:
A. Incorrect. The incidence of premature menopause following the procedure is approximately 2-5%.
B. Correct. This is why the treatment is effective.
C. Incorrect. Following treatment, fibroids on average will reduce in volume only by 40-60%.
D. Incorrect. If not done as an out-patient, most patients go home the next day.


A patient presents with venous insufficiency and varicose veins. Which one of the following is a
288.
CONTRAINDICATION for catheter-based vein ablation?

A. Venous stasis ulcer
B. Lymphedema
C. Deep venous thrombosis
D. Pelvic congestion syndrome

Question #288
Rationales:
With deep venous thrombosis, the deep veins may be obstructed. It would be a mistake in these patients
to obliterate the superficial veins because they are needed as an important source of collateral circula-
tion to permit egress of blood from the lower extremities.

30

289. Concerning the selection of a balloon diameter for angioplasty of an iliac artery stenosis, what
size should the balloon be?

A. Approximately 10% larger than the normal diameter of the artery
B. Approximately 10% smaller than the normal diameter of the artery
C. Approximately 10% larger than the diameter of the stenosis being treated
D. Size doesn’t matter so long as after inflation the balloon waist is obliterated.

Question #289
Rationales:
Size does matter. Acute elastic recoil is a potential cause of treatment failure, as is a residual stenosis.
Thus the balloon should be large enough to both obliterate the stenosis and stretch the artery slightly
beyond the vessel’s elastic limit. Over dilation by 10-15% usually is considered to be optimal.
Haphazard choice of balloon size can lead to anything from early failure secondary to elastic recoil or
residual stenosis if the balloon is sized too small; to arterial rupture were the balloon size too large.


Which one of the following embolic agents should be selected for temporary occlusion of
290.
an artery?

A. Gelfoam pledgets
B. Absolute alcohol
C. Polyvinyl alcohol
D. N-Butyl cyanoacrylate

Question #290
Rationales:
A. Correct. Gelfoam pledgets are absorbed by the body over 4-6 weeks and are very useful when tem-
porary occlusion is desired. Gelfoam powder is of course also absorbed by the body, but because the
powder particles are so small they often infarct tissue which is of course permanent.
B. Incorrect. Absolute alcohol is a powerful sclerosant, destroying any tissue it comes in contact with.
On or off target it does permanent damage.
C. Incorrect. Polyvinyl alcohol, despite the name is solid particulate matter. It is considered a perma-
nent agent, but occluded arteries sometimes do recanalize, perhaps because of the tendency of the
material to clump.
D. Incorrect. N-Butyl cyanoacrylate, a glue, polymerizes into a permanent contour-filling solid upon
contact with blood.

32

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