Interventional Radiology — MCQs

Interventional Radiology Indian Medical PG Practice Questions and MCQs

Question 11: All of the following modalities can be used for in situ ablation of liver secondaries, except?

A. Ultrasonic waves (Correct Answer)
B. Alcohol
C. Radiofrequency ablation
D. Cryotherapy

Explanation: **Explanation:** The goal of in situ ablation is to destroy tumor tissue (liver secondaries) directly within the organ using thermal, chemical, or electrical energy. **Why Ultrasonic Waves is the Correct Answer:** Diagnostic **ultrasonic waves** (Ultrasound) are used for **imaging and guidance** during ablation procedures, but they do not possess the energy density required to destroy tissue in situ. While a specific technology called HIFU (High-Intensity Focused Ultrasound) exists, standard ultrasonic waves are non-invasive imaging tools, not an ablative modality themselves. Therefore, it is the "except" in this list. **Analysis of Other Options:** * **Alcohol (Chemical Ablation):** Percutaneous Ethanol Injection (PEI) involves injecting absolute alcohol into the lesion, causing immediate protein denaturation and cellular dehydration, leading to coagulative necrosis. It is highly effective for small hepatocellular carcinomas and some secondaries. * **Radiofrequency Ablation (RFA):** This is the most common thermal ablation technique. It uses high-frequency alternating current to generate frictional heat (60°C–100°C), causing thermal coagulation and tissue death. * **Cryotherapy (Cryoablation):** This involves the use of a cryoprobe (using liquid nitrogen or argon gas) to freeze the tumor tissue to temperatures as low as -40°C. The formation of intracellular ice crystals leads to cell membrane disruption and vascular stasis. **Clinical Pearls for NEET-PG:** * **Gold Standard for Small HCC:** RFA is generally preferred over PEI for lesions >2 cm due to better local control. * **Microwave Ablation (MWA):** A newer thermal modality that is faster than RFA and less affected by the "heat-sink effect" (cooling by adjacent large blood vessels). * **Indication:** Ablation is typically indicated for patients with limited liver secondaries (usually <3-5 lesions, <3 cm each) who are not candidates for surgical resection.

Question 12: What is the most common complication following TIPS procedure?

A. Encephalopathy (Correct Answer)
B. Hepatic ischemia
C. Infection
D. Life-threatening hemorrhage

Explanation: **Explanation:** The **Transjugular Intrahepatic Portosystemic Shunt (TIPS)** is a procedure used to manage complications of portal hypertension (e.g., refractory ascites, variceal bleeding) by creating a low-resistance channel between the portal vein and the hepatic vein. **Why Encephalopathy is the correct answer:** Hepatic Encephalopathy (HE) is the most frequent complication, occurring in **25–45%** of patients. By creating a shunt, blood bypasses the liver’s detoxification process. Neurotoxic substances (primarily ammonia) enter the systemic circulation directly, leading to cognitive impairment and altered consciousness. Risk factors include older age, pre-existing HE, and a high MELD score. **Analysis of Incorrect Options:** * **Hepatic Ischemia:** While the liver loses some portal venous inflow after TIPS, the increased compensatory flow from the hepatic artery usually prevents significant ischemia. It is a rare complication. * **Infection:** "Sepsis" or "Endoleaks" (infection of the stent) can occur but are uncommon due to sterile techniques and prophylactic antibiotics. * **Life-threatening hemorrhage:** While intraperitoneal hemorrhage is a feared acute complication (due to accidental puncture of the liver capsule), it occurs in less than 1–2% of cases, making it far less common than encephalopathy. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** Secondary prophylaxis of variceal bleeding and refractory ascites. * **Absolute Contraindications:** Severe congestive heart failure (due to sudden increase in venous return), polycystic liver disease, and severe uncontrolled systemic infection. * **Monitoring:** Doppler Ultrasound is the first-line investigation to check for shunt patency or stenosis. * **Management of HE post-TIPS:** Usually managed medically (Lactulose/Rifaximin); if refractory, the shunt diameter may need to be reduced.

Question 13: All of the following are indications for TIPS except?

A. Prevention of acute variceal bleed.
B. Hepatorenal syndrome.
C. Refractory ascites.
D. Hepatopulmonary syndrome. (Correct Answer)

Explanation: **Explanation:** **Transjugular Intrahepatic Portosystemic Shunt (TIPS)** is a procedure used to reduce portal hypertension by creating a low-resistance channel between the portal vein and the hepatic vein. **Why Hepatopulmonary Syndrome (HPS) is the correct answer:** Hepatopulmonary syndrome is characterized by a triad of liver disease, increased alveolar-arterial oxygen gradient, and **intrapulmonary vascular dilatations**. Performing a TIPS can actually **worsen** HPS because the shunt allows more blood to bypass the liver, potentially increasing the delivery of vasodilators to the pulmonary circulation, thereby exacerbating the ventilation-perfusion mismatch and hypoxemia. Therefore, HPS is generally considered a relative contraindication rather than an indication. **Why the other options are incorrect:** * **Prevention of acute variceal bleed:** TIPS is indicated for secondary prophylaxis of variceal bleeding when endoscopic or pharmacological treatments fail (Refractory bleeding). * **Hepatorenal syndrome (HRS):** TIPS can improve renal perfusion and function in patients with Type 1 and Type 2 HRS by reducing the portal pressure that triggers systemic vasodilation. * **Refractory ascites:** This is a classic indication. By reducing portal pressure, TIPS decreases the formation of ascitic fluid and improves the response to diuretics. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications for TIPS:** Congestive heart failure (due to sudden increase in venous return), severe pulmonary hypertension, and polycystic liver disease. * **Most common complication:** Hepatic encephalopathy (due to bypass of nitrogenous toxins). * **Preferred Stent:** PTFE-covered stents (Gore-Tex) are preferred over bare metal stents as they have higher patency rates. * **Goal of TIPS:** To reduce the Portosystemic Pressure Gradient (PPG) to **<12 mmHg**.

Question 14: What is true about TIPS?

A. It is a type of portacaval shunt.
B. It is an intrahepatic shunt. (Correct Answer)
C. It is performed by passing endoscopes.
D. It is most suitable for patients undergoing liver transplantation.

Explanation: **Explanation:** **TIPS (Transjugular Intrahepatic Portosystemic Shunt)** is a high-yield interventional radiology procedure used primarily to manage complications of portal hypertension, such as refractory ascites and variceal bleeding. **Why Option B is Correct:** TIPS involves creating an artificial channel within the liver parenchyma to connect the **portal vein** (high pressure) to the **hepatic vein** (low pressure). Because this tract is created entirely within the liver tissue using a metallic stent, it is classified as an **intrahepatic shunt**. **Analysis of Incorrect Options:** * **Option A:** TIPS is a **Portosystemic** shunt, specifically a side-to-side **Porto-Hepatic** shunt. A "Portacaval" shunt specifically refers to a connection between the portal vein and the Inferior Vena Cava (IVC), which is typically a surgical procedure. * **Option C:** It is a **radiological procedure**, not endoscopic. It is performed under fluoroscopic guidance by an Interventional Radiologist, usually via the **Right Internal Jugular Vein**. * **Option D:** While TIPS can be used as a "bridge" to transplantation, it is **not** the "most suitable" for these patients compared to other options, as the stent can technically complicate the subsequent transplant surgery. Furthermore, it is contraindicated in patients with severe heart failure or polycystic liver disease. **High-Yield Clinical Pearls for NEET-PG:** * **Access Route:** Right Internal Jugular Vein → SVC → IVC → Right Hepatic Vein → Liver Parenchyma → Portal Vein. * **Indications:** Refractory ascites (most common), recurrent variceal bleed, Budd-Chiari syndrome. * **Absolute Contraindications:** Severe Right-sided Heart Failure (due to sudden increase in venous return), Polycystic Liver Disease, and Severe Hepatic Encephalopathy. * **Major Complication:** New-onset or worsening **Hepatic Encephalopathy** (due to bypass of detoxification).

Question 15: What is the minimum amount of gastrointestinal bleed that can be detected by angiography?

A. 0.5 ml/min (Correct Answer)
B. 0.1 ml/min
C. 5 ml/min
D. 2 ml/min

Explanation: **Explanation:** The detection of gastrointestinal (GI) bleeding depends significantly on the sensitivity of the diagnostic modality used. **Conventional Angiography** (Catheter Angiography) requires an active bleeding rate of at least **0.5 ml/min** to visualize the extravasation of contrast into the bowel lumen. This is considered the "gold standard" for localization when therapeutic intervention (like embolization) is planned, but it requires the patient to be bleeding actively during the procedure. **Analysis of Options:** * **0.5 ml/min (Correct):** This is the established threshold for conventional angiography. It is less sensitive than nuclear medicine but more specific for anatomical localization. * **0.1 ml/min (Incorrect):** This is the sensitivity threshold for **Technetium-99m (Tc-99m) tagged RBC scintigraphy**. Nuclear scans are the most sensitive non-invasive tests for GI bleeds, capable of detecting rates as low as 0.1–0.4 ml/min. * **0.3 - 0.5 ml/min (Context):** **Multidetector CT Angiography (MDCTA)** typically detects bleeding at rates of 0.3–0.5 ml/min, making it slightly more sensitive than conventional angiography in some clinical settings. * **2 ml/min and 5 ml/min (Incorrect):** These rates are well above the detection limits of modern imaging and would represent brisk, massive hemorrhages easily seen on any vascular study. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Sensitivity:** Tagged RBC Scan (0.1 ml/min) > CTA (0.3-0.5 ml/min) > Conventional Angiography (0.5 ml/min). * **Advantage of Angiography:** It allows for immediate therapeutic intervention (e.g., coiling or Gelfoam embolization). * **Prerequisite:** For a positive angiogram, the bleed must be **active** at the time of contrast injection. * **First-line for unstable patients:** CTA is often the initial investigation of choice due to speed and high sensitivity.

Question 16: In cerebral angiography, through which artery is the dye typically injected?

A. Femoral artery (Correct Answer)
B. Brachial artery
C. Axillary artery
D. Radial artery

Explanation: **Explanation:** In cerebral angiography, the **Femoral artery** (specifically the common femoral artery) is the most common site for percutaneous arterial access. This approach is known as the **Seldinger technique**. **Why Femoral Artery is the Correct Choice:** The femoral artery is the preferred route because it is a large-caliber, superficial vessel that is easily compressible against the femoral head to achieve hemostasis. Its relatively straight course through the aorta provides a direct and stable pathway for navigating catheters into the carotid and vertebral arteries. This allows for the use of larger catheters and complex interventional devices if needed. **Analysis of Incorrect Options:** * **Brachial and Axillary Arteries:** These were used more frequently in the past. However, they are associated with a higher risk of neurovascular complications (e.g., brachial plexus injury) and are more difficult to compress, leading to a higher risk of hematoma. * **Radial Artery:** While the transradial approach is gaining popularity (especially in cardiology and increasingly in neuro-interventions) due to lower site-related bleeding risks and earlier patient mobilization, the **femoral artery remains the traditional "gold standard" and the most common answer expected in standard examinations.** **High-Yield Clinical Pearls for NEET-PG:** * **Seldinger Technique:** The universal method for vascular access (Needle → Guide wire → Dilator/Sheath → Catheter). * **Access Site:** The puncture is made below the inguinal ligament to avoid retroperitoneal hemorrhage. * **Gold Standard:** Digital Subtraction Angiography (DSA) via the femoral route remains the gold standard for diagnosing cerebral aneurysms and Arteriovenous Malformations (AVMs).

Question 17: What is an early complication of the TIPS procedure?

A. Shunt stenosis
B. Capsular hemorrhage
C. Encephalopathy (Correct Answer)
D. Recurrent variceal bleed

Explanation: **Explanation:** **TIPS (Transjugular Intrahepatic Portosystemic Shunt)** is a procedure used to manage complications of portal hypertension (e.g., refractory ascites, variceal bleeding) by creating a low-resistance channel between the portal vein and the hepatic vein. **Why Encephalopathy is the correct answer:** Hepatic Encephalopathy (HE) is the most common **early** complication, occurring in approximately 25–40% of patients. By creating a shunt, blood bypasses the liver's detoxification process, allowing nitrogenous wastes (like ammonia) to enter the systemic circulation directly. This typically manifests within the first few weeks post-procedure. **Analysis of Incorrect Options:** * **A. Shunt Stenosis:** This is a **late** complication (months to years later), usually caused by pseudointimal hyperplasia within the stent. * **B. Capsular Hemorrhage:** This is an **immediate/procedural** complication caused by accidental puncture of the liver capsule during the needle pass from the hepatic vein to the portal vein. While it occurs early, it is less frequent than encephalopathy in the post-procedural period. * **C. Recurrent Variceal Bleed:** This is generally a sign of **shunt failure or occlusion** (a late complication) rather than an expected early side effect of a functioning shunt. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Secondary prophylaxis for variceal bleed, refractory ascites, and Budd-Chiari syndrome. * **Contraindications:** Absolute contraindications include severe congestive heart failure (due to sudden increase in venous return), polycystic liver disease, and severe active systemic infection. * **Monitoring:** Doppler Ultrasound is the primary modality used to monitor shunt patency. * **MELD Score:** A high MELD score (>18) is a predictor of poor prognosis post-TIPS.

Question 18: Aerial embolization is indicated in all of the following conditions EXCEPT?

A. Uterine arteriovenous malformation
B. Postpartum hemorrhage
C. Bleeding fibroid
D. Prevention of bleeding in endometriosis (Correct Answer)

Explanation: **Explanation:** **Uterine Artery Embolization (UAE)** is a minimally invasive interventional radiology procedure used to occlude the blood supply to the uterus or specific lesions within it. **Why Option D is Correct:** **Endometriosis** is characterized by the presence of endometrial-like tissue outside the uterus (e.g., ovaries, peritoneum). Since these ectopic implants are scattered and derive blood supply from various systemic and pelvic vessels, localized uterine artery embolization is **not an indicated or effective treatment** for preventing bleeding in endometriosis. Medical management (hormonal therapy) or surgical excision remains the standard of care. **Why Incorrect Options are Wrong:** * **A. Uterine Arteriovenous Malformation (AVM):** UAE is the treatment of choice for symptomatic AVMs to prevent life-threatening hemorrhage while preserving fertility. * **B. Postpartum Hemorrhage (PPH):** UAE is a critical emergency intervention for refractory PPH (especially after failed medical management or uterine atony) in hemodynamically stable patients. * **C. Bleeding Fibroid:** Uterine Fibroid Embolization (UFE) is a well-established indication to reduce the size of the fibroid and control menorrhagia. **High-Yield Clinical Pearls for NEET-PG:** * **Access:** Usually performed via the **Common Femoral Artery** (CFA) or Radial Artery. * **Embolic Agents:** Most commonly used are **Polyvinyl Alcohol (PVA) particles** or Tris-acryl gelatin microspheres. * **Contraindications:** Pregnancy, active pelvic infection, and suspected uterine malignancy. * **Post-Procedure:** "Post-embolization syndrome" (pain, low-grade fever, nausea) is the most common complication.

Question 19: What is an early complication of TIPS procedures?

A. Hepatic encephalopathy
B. Capsule rupture and bleeding (Correct Answer)
C. Stenosis of the shunt
D. Thrombosis of the shunt

Explanation: **Explanation:** **Transjugular Intrahepatic Portosystemic Shunt (TIPS)** is a procedure used to manage complications of portal hypertension by creating a low-resistance channel between the portal vein and the hepatic vein. **Why Option B is Correct:** **Capsule rupture and intraperitoneal hemorrhage** is a dreaded **early/acute complication** that occurs during the procedure. It happens if the needle used to puncture the portal vein from the hepatic vein passes through the liver parenchyma and inadvertently pierces the liver capsule (Glisson’s capsule). This leads to immediate hemoperitoneum and can be life-threatening. **Analysis of Incorrect Options:** * **A. Hepatic Encephalopathy:** While a common complication (occurring in ~25-30% of patients), it is typically considered a **subacute to chronic** complication. It occurs because the shunt allows unfiltered nitrogenous waste (like ammonia) to bypass the liver and enter the systemic circulation. * **C. Stenosis of the Shunt:** This is a **late complication**, usually occurring months after the procedure due to pseudointimal hyperplasia within the stent. * **D. Thrombosis of the Shunt:** This can occur early or late, but it is less common than bleeding complications during the initial periprocedural period. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Refractory ascites and variceal bleeding unresponsive to endoscopic therapy. * **Absolute Contraindications:** Severe congestive heart failure (due to sudden increase in venous return), polycystic liver disease, and severe uncontrolled systemic infection. * **Monitoring:** Doppler Ultrasound is the primary modality used to monitor shunt patency. * **Goal:** To reduce the Portosystemic Pressure Gradient (PPG) to **<12 mmHg**.

Question 20: A Seldinger needle is used for what procedure?

A. Liver biopsy
B. Suturing skin
C. Arteriography (Correct Answer)
D. Lymphography

Explanation: **Explanation:** The **Seldinger technique**, named after Swedish radiologist Sven-Ivar Seldinger, is the gold standard method for obtaining safe percutaneous access to hollow organs or blood vessels. **Why Arteriography is correct:** Arteriography (and most endovascular procedures) requires the insertion of a catheter into a blood vessel. The Seldinger needle is the initial tool used to puncture the vessel. Once blood flashback is observed, a **guidewire** is passed through the needle, the needle is withdrawn, and a **sheath or catheter** is then advanced over the wire. This "over-the-wire" method minimizes trauma to the vessel wall and prevents bleeding, making it the foundation of interventional radiology. **Why other options are incorrect:** * **Liver Biopsy:** Typically performed using specialized biopsy needles like the **Tru-Cut** or **Menghini** needle, which are designed to capture a core of tissue rather than provide a channel for a wire. * **Suturing Skin:** This requires surgical needles (curved or straight) attached to suture material, not a hollow-bore Seldinger needle. * **Lymphography:** This historical procedure involves the direct cannulation of a lymphatic vessel (usually on the foot) using a very fine, small-gauge needle or cannula after injecting blue dye to visualize the lymphatics. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Seldinger Technique:** Used for venous access (e.g., Central Lines, PICC lines). * **Components of a Seldinger Kit:** Hollow needle, guidewire (often J-tipped), dilator, and catheter/sheath. * **Complications:** The most common complication of the Seldinger technique is **hematoma** at the puncture site. * **Key Step:** Always remember to "never advance the wire against resistance" to avoid vessel dissection or perforation.

Practice by Chapter

Vascular Access Techniques

Practice Questions

Angiography and Angioplasty

Practice Questions

Embolization Procedures

Practice Questions

Thrombolysis and Thrombectomy

Practice Questions

Transjugular Intrahepatic Portosystemic Shunt

Practice Questions

Biliary Interventions

Practice Questions

Genitourinary Interventions

Practice Questions

Gastrointestinal Interventions

Practice Questions

Percutaneous Biopsy Techniques

Practice Questions

Drainage Procedures

Practice Questions

Tumor Ablation Techniques

Practice Questions

Venous Interventions

Practice Questions

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