23205048

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. 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. 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. 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:
Requisites. Mosby. 2004

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:
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. 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. 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. 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. 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. 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.
1. Kaufman JA, Lee MG. Vascular and Interventional Radiology. The
Requisites. Mosby. 2004
LaBerge JM. Interventional Radiology Essentials. Lippincott Williams & Wilkins
2000

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. 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. 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.
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. 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. 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. 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

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.

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

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.

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:

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