ACR Inservice Recall

1. Section I – Interventional Radiology
Figure 1
6. You are shown an arch aortogram (Figure 1) of a 33-year-old male. Which one of the following is the most
likely diagnosis?
A. Atherosclerotic aneurysm
B. Type B aortic dissection
C. Syphilitic aneurysm
D. Traumatic false aneurysm
E. Penetrating ulcer
Diagnostic In-Training Exam 2003 1

2. Section I – Interventional Radiology
Question #6
Findings: There is a focal dilatation of the proximal descending aorta, with linear defects projecting transversely across
the aorta at the proximal and distal aspects of the focal dilatation. An endotracheal tube, a left chest tube, and a
nasogastric tube are present.
Rationales:
A) Incorrect. The aorta and proximal great vessels appear normal with the exception of the findings described.
Atherosclerotic disease is usually extensive and affects multiple vessels. It also usually affects older individuals.
B) Incorrect. A Type aortic dissection involves the ascending aorta, which is normal in this case. Aortic dissection usually
develops after age 50, and is more common in males.
C) Incorrect. Syphilitic aneurysms more commonly affect the ascending aorta or arch. They are typically saccular in
appearance and are a late complication of syphilis, occurring 10 to 30 years after the primary infection.
D) Correct. The proximal descending aorta is the most common location of a traumatic false, or pseudoaneurysm, of the
aorta. The presence of a chest tube, an endotracheal tube, and a nasogastric tube support the diagnosis of a traumatic
injury. It most commonly occurs in young adults or adults, with a mean reported age of 35 in one large study.
E) Incorrect. A penetrating ulcer is usually an eccentric, focal outpouching of the aorta. It occurs in older age groups and
is associated with underlying atherosclerotic disease.
Citations:
Razzouk AJ, Gundry SR, Wang N, del Rio MJ, Varnell D, Bailey LL. Repair of traumatic aortic rupture: a 25-year
experience. Arch Surg. Aug 2000;135(8):913-918; discussion 919.
Kampmeier RH. The late manifestations of syphilis. Med Clin North Am 1964;48:667–697.
Pressler V, McNamara JJ. Thoracic aortic aneurysm: natural history and treatment. J Thorac Cardiovasc Surg
1980;79:489–498.
Tittle SL, Lynch RJ, Cole PE, et al. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta.
J Thoracic Cardiovascular Surgery. Jun 2002;123(6):1051-1059.
Hemley S, Kanick V, Kittredge R, Finby N. Dissecting aneurysms of the thoracic aorta: their angiographic
demonstration. AJR 1964;91:1263
2 American College of Radiology

3. Section I – Interventional Radiology
Figure 2
7. A 55-year-old female presents with recent onset of severe hypertension. You are shown an aortogram
(Figure 2). Which one of the following is the best management option?
A. Transcatheter thrombolysis
B. Percutaneous transluminal angioplasty
C. Primary arterial stenting
D. Surgical aortorenal vein bypass
E. Renal vein renin sampling
Diagnostic In-Training Exam 2003 3

4. Section I – Interventional Radiology
Question #7
Findings: There is irregularity of the left main renal artery, extending to the main bifurcation, with alternating areas of
aneurysm and narrowing. The aorta and other opacified visceral vessels appear normal.
Rationales:
A) Incorrect. While the vessel appears irregular, there is no filling defect to suggest acute thrombus. Therefore,
thrombolysis is not indicated.
B) Correct. The alternating aneurysms and narrowing is characteristic of the “sting of beads” appearance of
fibromuscular dysplasia (medial fibroplasia type). It usually affects the mid and distal segments of the main renal
arteries, and is usually bilateral. Stenoses due to fibromuscular dysplasia of the renal artery respond favorably to
percutaneous transluminal angioplasty (PTA), which is the treatment of choice.† Five-year patency rates are
approximately 90%.
C) Incorrect. While angioplasty with stent placement is typically necessary in patients with an atherosclerotic etiology of
renovascular hypertension, angioplasty alone is highly effective for the treatment of the medial fibroplasia type of
fibromuscular dysplasia. Stent placement following angioplasty in patients with fibromuscular dysplasia should be
reserved for use in treating a hemodynamically significant dissection as a complication of angioplasty.
D) Incorrect. Surgical aortorenal vein bypass is an effective treatment for severe, long segment stenoses of the main renal
artery causing renovascular hypertension. These stenoses usually result from atherosclerotic disease. Angioplasty with
stenting is less effective with long segment stenoses.
E) Incorrect. Renal vein renin sampling is performed to evaluate for a renovascular cause for hypertension. In
hypertensive patients with a documented unilateral etiology for the hypertension, as in the present patient, there is
no additional information gained by performing renal vein renin sampling. The hypertension is presumed to be
caused by the severe narrowing caused by the fibromuscular disease, and balloon angioplasty is indicated.
Citations:
Amsterdam EA, Couch NP, Christlieb AR. Renal vein renin activity in the prognosis of surgery for renovascular
hypertension. Am J Med 1969;47:860.
Itzchak Y, Katznelson D, Boichis H, Jonas A, et al. Angiographic features of arterial lesions in neurofibromatosis. AJR
1974;122:643.
Klinge J, Willem PT, Puijilaert CB, Geyskes GG, Becking WB, Feldberg MA. Percutaneous transluminal renal
angioplasty: initial and long-term results. Radiology 1989;171:501–506.
Sacks D, Rundback JH, Martin LG. Renal angioplasty/stent placement, and hypertension in the year 2000. J Vasc Interv
Radiol Sep 2000;11(8):949-953.
4 American College of Radiology

5. Section I – Interventional Radiology
Figure 3
8. You are shown a venacavagram (Figure 3) of a 58-year-old male performed prior to placement of an inferior
vena caval filter. Which one of the following is the most likely diagnosis?
A. Venacaval occlusion with azygous continuation
B. Extension of left renal vein tumor thrombus
C. Duplicated inferior vena cava
D. Hypovolemic shock
E. Venacaval occlusion with recanalization
Diagnostic In-Training Exam 2003 5

6. Section I – Interventional Radiology
Question #8
Findings: The inferior vena cava is patent. The infrarenal segment is narrowed for the entire length. There is an absence
of inflow artifact from the left iliac vein. There is a large inflow artifact from the left renal vein, and the inferior vena cava
becomes much larger in diameter cephalad to the renal vein level.
Rationales:
A) Incorrect. The vena cava appears patent and in the normal location. The azygous vein would be located more
medially. There would also likely be large collateral veins present.
B) Incorrect. Left renal vein tumor thrombus would be possible if the filling defect in the inferior vena cava cephalad to
the renal vein was an isolated finding. However given the other associated findings described above, this is less likely
Another cause of thrombus in the IVC would be extension from a lower extremity deep venous thrombosis.
However, filling defect would be evident extending cephalad from an iliac vein.
C) Correct. All of the described findings are seen with a duplication of the inferior vena cava, with insertion of the
duplication into the left renal vein. This explains the absence of inflow from the left iliac vein, and the larger than
normal inflow artifact from the left renal vein.
D) Incorrect. Hypovolemic shock can cause a diffuse decrease in the diameter of the inferior vena cava. However, the
vena cava cephalad to the renal vein level appears normal. Common etiologies of hypovolemic shock are trauma or
sepsis, and the patient has associated clinical findings of tachycardia and hypotension.
E) Incorrect. The inferior vena cava appears normal in contour, and without filling defects. A venacaval occlusion with
recanalization would result in an irregular vena caval contour, and chronic coaptations or filling defects. Collateral
veins would also likely be present.
Citations:
Hicks ME, Malden ES, Vesely TM, Picus D, Darcy MD. Prospective anatomic study of the inferior vena cava and renal
veins: comparison of selective renal venography with cavography and relevance in filter placement.
J Vasc Interv Radiol. Sep-Oct 1995;6(5):721-729.
Jeffrey RB Jr, Federle MP. The collapsed inferior vena cava: CT evaluation of hypovolemia. AJR 1988;150:431–432 3
Ney C. Thrombosis of inferior vena cava associated with malignant renal tumors. J Urol 1946;55:583–590.
6 American College of Radiology

7. Section I – Interventional Radiology
Figure 4A
Figure 4B
9. You are shown a celiac arteriogram (Figure 4A) and a superior mesenteric arteriogram (Figure 4B) of a
46-year-old male prior to hepatic chemoembolization. Which one of the following findings is present?
A. Arc of Buehler
B. Arc of Riolan
C. Pathway of Winslow
D. Anomalous right hepatic artery
E. Anomalous left hepatic artery
Diagnostic In-Training Exam 2003 7

8. Section I – Interventional Radiology
Question #9
Findings: Figure 4A is a selective superior mesenteric arteriogram. There is a large vessel arising from the proximal
portion of the superior mesenteric artery which course towards the right upper quadrant. The branching pattern of
this vessel is consistent with a hepatic artery. Figure 4 B is a selective celiac arteriogram. Left gastric, left hepatic,
gastroduodenal, and splenic arteries are identified.
Rationales:
A) Incorrect. An Arc of Buehler is a persistent embryologic ventral anastomosis between the celiac artery and the
superior mesenteric artery.
B) Incorrect. An arc of Riolan is an anastomotic artery between the left and middle colic arteries.
C) Incorrect. The Pathway of Winslow is a collateral pathway through the epigastric arteries to provide blood flow
to the lower extremities. In the presence of significant aortic stenosis or occlusion, blood can travel from the
internal mammary arteries through the superior epigastric arteries, then retrograde through the inferior
epigastric arteries and into the external iliac arteries.
D) Correct. The described findings are diagnostic of an anomalous origin of the right hepatic artery, which occurs
in approximately 10% of individuals. The anomalous vessel typically arises from the proximal portion of the
superior mesenteric artery.
E) Incorrect. As seen in Figure 4B, the left hepatic artery, and gastroduodenal artery, arise from the celiac artery.
Citations:
Kadir S. Atlas of Normal and Variant Angiographic Anatomy. W.B. Saunders. 1991
Lunderquist A. Arterial segmental supply of the liver: an angiographic study. Acta Radiol Suppl (Stockh)
1967;272:1.
8 American College of Radiology

9. Section I – Interventional Radiology
Figure 5
10. A 57-year-old female presents with acute left chest pain two weeks following a hemorrhagic stroke. She is
hemodynamically stable. You are shown a pulmonary angiogram (Figure 5). What should the next step in
this patient’s management should be?
A. Anticoagulation
B. Thrombolytic therapy
C. Percutaneous mechanical thrombectomy
D. Contrast enhanced CT Scan
E. Inferior vena cava filter placement
Diagnostic In-Training Exam 2003 9

10. Section I – Interventional Radiology
Question #10
Findings: Figure 5 is a selective left pulmonary angiogram. There are multiple filling defects in the left main
pulmonary artery, and in the lobar and segmental branches.
Rationales:
A) Incorrect. Recent major abdominal, thoracic, or neurological surgery is risk factors for hemorrhage with
anticoagulation therapy. Central nervous system events in the prior 6 months are also considered a
contraindication to anticoagulation. Other contraindications include recent or ongoing hematuria, or
gastrointestinal bleeding.
B) Incorrect. There is no proven benefit to thrombolytic therapy or to mechanical thrombectomy compared with
anticoagulation therapy in hemodynamically stable patients. However, in patients with hemodynamic
instability or patients with poor cardiopulmonary reserve, more aggressive therapy such as thrombolysis or
thrombectomy may be indicated.
C) Incorrect. As noted above, there is no proven benefit to percutaneous thrombectomy in hemodynamically
stable patients.
D) Incorrect. The pulmonary angiogram is the gold standard imaging modality for the diagnosis of pulmonary
embolism. A contrast enhanced CT scan would not add any additional useful information. At this point, a
therapeutic decision is required
E) Correct. The standard therapy for deep venous thrombosis and it major complication, pulmonary embolus,
is anticoagulation. Placement of an inferior vena caval filter is preferred if anticoagulation is contraindicated.
It protects the patient from further pulmonary emboli while the body autolyses the existing pulmonary
thrombi. Contraindications for anticoagulation are noted above in option A. The recent stroke in this patient
is a contraindication to anticoagulation and thus, the best alternative therapy is an inferior vena caval filter.
Citations:
Savin MA, Panicker HK, Sadiq S, Albeer YA, Olson RE. Placement of vena cava filters: factors affecting technical
success and immediate complications. AJR Am J Roentgenol. Sep 2002;179(3):597-602.
Riedel M. Acute pulmonary embolism 2: treatment. Heart. Mar 2001;85(3):351-360.
10 American College of Radiology