Post-Test Questions

Article One (67–77)

1. Three months after percutaneous catheter nephrostomy insertion, which of the following is the most appropriate treatment for pericatheter leakage of urine?

   • Initiation of oral antibiotics

   • Angiography

   • Tractogram

   • Catheter exchange

2. Which of the following is the most common reason for catheter dysfunction occurring 6 months after central venous catheter insertion?

   • Catheter kinking

   • Fibrin sheath formation

   • Catheter obstruction with debris

   • Catheter tip malposition

3. After percutaneous gastrojejunostomy insertion, a patient experiences bloating and pericatheter leakage of tube feeds during infusions. What is the most likely etiology?

   • Retrograde migration of the jejunal port tip into the stomach

   • Gastroparesis

   • Tube obstruction with pills

   • Buried bumper syndrome

   Article Two (78–88)

4. All of the following are important risk factors for the development of an abscess following thermal ablation in the liver EXCEPT:

   • Biliary-enteric anastomosis

   • Endoscopic biliary drainage catheter

   • Prior liver transplant

   • Pneumobilia

5. The eff ectiveness of preprocedural prophylactic antibiotics is established by level 1 data for which of the following procedures in interventional radiology?

   • Thermal ablation of liver malignancy

   • Transarterial embolization of liver malignancy

   • Percutaneous nephrostomy

   • Placement of a central venous catheter

   • None of the above

6. All of the following are established means to decrease the rate of catheter-related blood stream infections EXCEPT:

   • Standard hand hygiene

   • Avoid femoral vein access for tunneled central venous lines

   • Use of >0.5% chlorhexidine skin cleansing agent

   • Maximum sterile barriers (i.e., cap, mask, sterile gown, sterile gloves, sterile body drape)

   Article Three (89–97)

7. Regarding hemorrhage following percutaneous biliary catheter placement, which of the following is INCORRECT?

   • CT scans may be helpful to determine the location and specific source of bleeding.

   • Patients may present with melena.

   • Bleeding may occur secondary to side holes malposition in the biliary tree.

   • Upsizing the catheter may be eff ective in treating the bleeding.

   • If initial angiography is negative, the catheter should be removed entirely and angiography repeated. If biliary access is still needed, a new puncture should be performed.

8. Regarding bleeding from percutaneous renal interventions, which of the following is CORRECT?

   • The rate of vascular injuries requiring arterial intervention or nephrectomy is 1–4%.

   • Embolization must be performed proximal and distal to the vessel injury to prevent backbleeding from collateral channels.

   • Bleeding may occur from nonrenal arteries, such as intercostal or renal capsular arteries.

   • Even in the setting of mildly symptomatic bleeding, angiography and embolization should be performed to prevent catastrophic bleeding.

   • All of the above are incorrect.

9. Regarding bleeding following percutaneous biopsy, which of the following is INCORRECT?

   • Significant bleeding is expected to occur in between 1 and 4% of biopsies, depending on the organ.

   • Biopsy by using a coaxial system is theoretically beneficial in that it allows embolization of the tract.

   • Contrast-enhanced CT may be helpful in the postbiopsy hemorrhagic patient, to determine the site of bleeding and the need for intervention.

   • Nontarget embolization during biopsy tract embolization has been demonstrated.

   • All of the above are correct.

   Article Four (98–107)

10. For diagnostic cerebral angiograms, quality improvement guidelines recommend that transient neurologic deficits should occur in no more than X% of patients, and permanent neurologic deficits should occur in no more than Y% of patients.

    • X = 0.06%, Y = 0.02%

    • X = 0.7%, Y = 0.5%

    • X = 2.5%, Y = 1%

    • X = 12%, Y = 7%

11. Aneurysm perforation with a microcatheter or coil during embolization requires prompt recognition and careful intervention. In addition to heparin reversal with protamine, the following should be performed:

    • Leave the microcatheter and guide catheter in place, perform an immediate CT scan, and aggressively treat hypertension to a systolic blood pressure goal <140 mm Hg.

    • Remove the microcatheter, perform an immediate guide catheter angiogram, and undertake endovascular occlusion of the parent artery.

    • Advance the guide catheter to occlude the perforation with a larger diameter device.

    • Leave the perforating microcatheter in place and deploy additional coils until the aneurysm is protected.

12. Following intra-arterial thrombectomy for internal carotid artery occlusion and acute ischemic stroke, a patient develops a moderate headache without a new neurologic deficit. A CT scan of the head reveals areas of contrast extravasation in the left basal ganglia without overt hemorrhage. Management of this condition should consist of:

    • Reversal of heparin with protamine, and reverse antiplatelet agents with platelet transfusion

    • Aggressive blood pressure control to a systolic blood pressure goal <140 mm Hg

    • Mannitol 1 g/kg IV, perform frequent neurological examinations, keep the patient in the NICU, and consider ventriculostomy or craniotomy for evacuation of clot

    • Analgesics for headache and blood pressure control

    Article Five (108–122)

13. What anatomic landmark is used to locate the ideal arteriotomy site for femoral arterial access?

    • Greater trochanter

    • Cranial margin of femoral head

    • Equator of femoral head

    • Caudal margin of femoral head

    • Equator of acetabulum

14. Which of the following is a common theme for the endovascular treatment of iatrogenic vascular injury during arterial or venous procedures?

    • Maintain wire access across the injury

    • Remove wire and catheters and hold manual pressure

    • Coil or Gelfoam is used to thrombose the injured vessel

    • Obtain a surgical consult

    • None of the above

15. When is revascularization indicated for patient with peripheral artery disease?

    • Limb threatening ischemia

    • Lifestyle limiting claudication

    • Mild neuropathy

    • Choices A and B

    • All of the above

16. In patients with retrievable IVC filters, what is an indication for filter removal?

    • Fractured filter with embolized strut

    • Large thrombus burden in filter despite medical anticoagulation

    • Filter penetration with postprandial abdominal pain

    • All the above

    • A and C only

17. Compared to surgical bypass grafting, femoropopliteal angioplasty's primary patency rate is:

    • Greater than that of surgical bypass

    • Less than that of surgical bypass

    • The same as surgical bypass

    • Unknown

    Article Six (123–132)

18. During TIPS insertion, multiple needle passes were performed. The patient has developed hemodynamic instability and increasing abdominal distention. Which of the following is NOT an appropriate action?

    • Perform urgent hepatic arteriography

    • Perform inferior venacavography

    • Perform portal venography if portal venous access has been obtained

    • Perform a cone-beam CT

19. Three days after TIPS insertion, a patient develops severe encephalopathy, a total serum bilirubin level of 9.8, and an INR of 4.9. That patient is likely suff ering from what complication as the underlying cause:

    • Acute arterial hemorrhage

    • Acute hepatic failure

    • Transgression of the liver capsule with puncture of the kidney

    • Radiation injury

20. In a patient who has developed severe encephalopathy after TIPS insertion, which of the following is an appropriate next action?

    • Hepatic arteriography

    • Administration of fresh frozen plasma

    • Insert a parallel TIPS

    • A TIPS narrowing procedure for flow reduction

    Article Seven (133–155)

21. Which of the following regarding transplant renal artery stenosis (TRAS) is INCORRECT?

    • It most commonly occurs at the anastomotic site.

    • Diagnostic findings on Doppler ultrasound include a peak systolic velocity (PSV) of >200 cm/s and a ratio of >2 in the PSVs of the stenotic to prestenotic segment.

    • Percutaneous transluminal angioplasty (PTA) and stenting play little role in management, as essentially all cases must be managed surgically.

    • Hemodynamically significant TRAS is defined as narrowing of the luminal diameter >50% or pressure gradient >10 mm Hg across the stenosis.

22. Regarding liver transplant complications, which of the following is CORRECT?

    • Retransplantation is always necessary in cases of early hepatic arterial thrombosis.

    • In cases of upper caval anastomotic stenosis, flow reversal in the hepatic veins and absence of phasicity in the hepatic venous Doppler waveform may be seen.

    • Portal venous complications are common.

    • Biliary leaks are rarely seen at the T-tube site.

23. Which of the following is INCORRECT in regard to lung transplant?

    • Posttransplant complications are relatively rare in comparison to the incidence of complications seen with other solid organ transplants.

    • Pulmonary artery anastomotic complications are more common than complications involving the pulmonary venous anastomosis.

    • Self-expanding uncovered metallic stents are currently favored by most interventional radiologists and pulmonologists.

    • MDCT may define the extent and degree of a vascular stenosis.

    Article Eight (156–162)

24. A radiation-induced tissue reaction is best predicted by which of the following measures of radiation dose?

    • Fluoroscopic beam-on time

    • Air kerma at the interventional reference plane (K_a,r)

    • Peak skin dose (D_{skin, max})

    • Eff ective dose (H_E)

25. What is a temporal separation between multiple high radiation FGIs that may significantly decrease the risk of a tissue reaction, if clinically feasible?

    • 24 hours

    • 14 days

    • 8 weeks

    • 3 months

26. According to the Joint Commission, a single field skin dose of more than ___ constitutes a sentinel event.

    • 3 Gy

    • 5 Gy

    • 10 Gy

    • 15 Gy

    Article Nine (163–173)

27. Which of the following patients has had a major complication as defined by the Society of Interventional Radiology (SIR) Classification System for Complications by Outcome?

    • A 65-year-old man with end-stage liver disease and refractory ascites who dies 6 months after placement of a tunneled peritoneal drain

    • A 26-year-old woman with cystic fibrosis who presents with a small groin hematoma 6 hours after femoral puncture for pulmonary angiography who is discharged the next day

    • A 75-year-old man who is taken to the operating room for repair of a dominant large caliber left vertebral artery following return of pulsatile blood flow during placement of a central venous catheter

    • A 68-year- old man with end-stage renal disease on hemodialysis who presents with a thrombosed upper arm arteriovenous loop graft 5 days after declot procedure that included angioplasty

28. Which of the following agents should be held prior to elective arthrography and steroid injection of the knee?

    • Clopidogrel

    • Aspirin

    • Warfarin in a patient with INR of 3.5

    • None of the above

29. According to the Joint Practice Guideline for Sterile Technique during Vascular and Interventional Radiology Procedures published by the SIR, the majority of musculoskeletal procedures would generally be classified as:

    • Clean

    • Clean-contaminated

    • Contaminated

    • Dirty

    Article Ten (174–181)

30. In the pathophysiology of iatrogenic systemic air embolism, what is the final common step in the introduction of air into the systemic vasculature?

    • Access to pulmonary vein lumen

    • Access to the right atrium

    • Access to the coronary circulation

    • The establishment of a bronchovenous fistula

31. Which of the following is a reported risk factor for pneumothorax following thoracic interventions?

    • Multiple pleural punctures

    • Deeper lesions

    • Traversal of fissures

    • All of the above

32. Which of the following is associated with higher incidence of hemorrhagic complications?

    • Biopsy of large lesions (>1.5 cm)

    • Use of coaxial technique

    • Use of multi-tined ablative electrodes

    • All of the above

    Article Eleven (182–194)

33. All of the following are true of hepatic arterial injury EXCEPT:

    • This injury may result in ischemic cholangiopathy.

    • Transection is best treated by surgical intervention.

    • This injury may result in biliary anastomosis failure.

    • This injury has decreased in prevalence since the advent of laparoscopic surgeries.

34. Which of the following statements regarding pseudoaneurysms is INCORRECT?

    • Pseudoaneurysms result in dilatation of the vessel from injury to one or more vascular wall layers.

    • Minimally invasive techniques such as arterial embolization or placement of a covered stent are the first line of treatment for a pseudoaneurysm.

    • Pseudoaneurysms can be complicated by rupture and hemorrhage.

    • Pseudoaneurysms can be monitored without treatment until the patient is symptomatic.

35. All of the following are indications for percutaneous transhepatic cholangiography/drainage except

    • Redirection of bile flow for healing of bilomas

    • Treatment of primary sclerosing cholangitis

    • Anastomotic dehiscence

    • Permanent treatment of common hepatic duct injury from cholecystectomy

    Article Twelve (195–208)

36. During percutaneous nephrostomy tube placement, interventional radiologists traditionally attempt to target a dorsolateral calyx because

    • As this most likely represents a relatively avascular watershed zone known as Brödel's line resulting in less likelihood of vascular injuries

    • Central access can result in injury to the major vascular structure

    • Central punctures may be associated with urinary leakage due to incomplete sealing of the catheter tract, as the renal pelvis may not be completely surrounded by renal parenchymal tissue

    • All of the above

37. Which of the following is true CORRECT regarding symptomatic iatrogenic renal vascular injuries

    • Symptomatic iatrogenic renal vascular injuries are typically managed by minimally invasive techniques such as coil embolization, stent graft placement and/or thrombin injection

    • Symptomatic iatrogenic renal vascular injuries typically require only conservative management

    • Traditional open surgery is the standard of care for iatrogenic renal vascular injuries

    • None of the above.

38. What is the most common cause of iatrogenic urinoma?

    • Renal injuries

    • Ureteric injuries

    • Bladder injuries

    • None of the above

    Article Thirteen (209–216)

39. What is the mainstay of therapy for adult patients with tumor lysis syndrome?

    • Aggressive hydration

    • Immediate correction of metabolic derangement

    • Treatment of renal failure

    • All of the above

40. When converting to a new opiate, what is the purpose of reducing the new drug dose by 25 to 50%?

    • Allows for better pain control

    • Accounts for incomplete cross-tolerance between opiates

    • Reduces tolerance to the old medication

    • Allows for rapid escalation of dose

41. What is the recommended use of echocardiogram in the diagnosis of pulmonary embolism?

    • Evaluating chronicity of pulmonary embolism

    • Diff erentiating between myocardial injury and pulmonary embolism

    • Evaluating for right volume overload while stratifying treatment options in high-risk patients

    • Confirmation of pulmonary embolism after positive D-dimer in low-risk patients