RCIS exam questions with worked answers: 24 cases, every step shown

How RCIS items are written

CCI's Registered Cardiovascular Invasive Specialist exam has 170 questions: 150 scored questions plus 20 unscored pretest questions, unmarked and mixed in at random. The format is mostly single-best-answer items with four options, plus multiple-response, hot-spot and drag-and-place items. Because a pretest item looks exactly like a scored one, every item deserves the same care.

Under the item type, the stems fall into seven recurring styles. The table maps each style to the questions on this page that show it, so you can drill a style as well as a topic.

Hot-spot and drag-and-place items are answered on an image rather than from a list of options. In text practice, this page included, a pressure trace is described in words: when the peak arrives, how the wave changes on pullback, what a damped line looks like. None of the 24 below is a waveform item; the trace cases sit in the diagnostic procedures guide.

How to read a worked solution

1. Answer from the stem first

   Read the stem and name your answer before you look at the four choices. A well-built item can be answered that way, and doing it keeps a plausible distractor from steering you.

2. Commit to a letter, then open the working

   Each question has a Show the answer and the working toggle. Open it only after you have chosen. On Q01 to Q03 the working is split into one line per step, so you can find the exact line where your number went wrong.

3. Read all four option notes

   Every wrong option stands for a specific slip: the diastolic pressure used where the peak belongs, the right drug one cycle too early, a device built for a different problem. The note names that slip in a sentence.

4. Log the slip, not just the topic

   Keep three columns: question number, domain letter, slip type (formula, sequence, device, threshold). After 24 items, the longest column tells you what to study next week.

Work these untimed. The exam gives you 2 hours 50 minutes of question time for 170 items, close to one minute a case, and that speed is easier to build on the timed practice test once the reasoning holds.

Diagnostic calculations: Q01 to Q04

Diagnostic procedures carry 40% of the scored exam, about 60 of the 150 items, and hemodynamic math lives inside this domain. The four items cover an aortic valve area by the Hakki shortcut, systemic resistance with the Wood-unit conversion, a regurgitant fraction from ventriculogram volumes, and the error hidden in an assumed-VO₂ Fick output.

1. Q01B3Diagnostic

   Question 1: Diagnostic (B3) Calc

   Data: LV 200/15 mmHg, aorta 130/80 mmHg, CO 5.0 L/min, HR 75 bpm, BSA 2.0 m². Using the Hakki formula with the peak-to-peak gradient, what is the approximate aortic valve area?

   1. A0.30 cm²
   2. B0.60 cm²
   3. C0.46 cm²
   4. D0.07 cm²

   Show the answer and the working

   Answer B 0.60 cm²

   Step by stepCalc

   1. Peak-to-peak gradient
   2. =200 − 130
   3. =70 mmHg
   4. AVA
   5. =CO ÷ √70
   6. =5.0 ÷ 8.37
   7. ≈0.60 cm²

   The peak-to-peak gradient is 200 − 130 = 70 mmHg, so AVA = CO ÷ √70 = 5.0 ÷ 8.37 ≈ 0.60 cm², which is severe AS. 0.46 subtracts the aortic diastolic pressure (a gradient of 120 mmHg), and 0.30 divides the cardiac index (2.5) instead of CO. 0.07 forgets the square root.

   • ANot this0.30 divides the cardiac index (2.5) instead of the cardiac output.
   • BCorrectPeak-to-peak gradient 200 − 130 = 70 mmHg, so AVA ≈ 5.0 ÷ √70 = 5.0 ÷ 8.37 ≈ 0.60 cm².
   • CNot this0.46 uses LV systolic minus aortic diastolic (120 mmHg), which is not the peak-to-peak gradient.
   • DNot this0.07 forgets the square root of the gradient.
2. Q02B3Diagnostic

   Question 2: Diagnostic (B3) Calc

   Data: AO 130/70 (90) mmHg, RA mean 5 mmHg, CO 4.2 L/min. What is the systemic vascular resistance in dyn·s·cm⁻⁵?

   1. AAbout 1240
   2. BAbout 1710
   3. CAbout 1620
   4. DAbout 20

   Show the answer and the working

   Answer C About 1620

   Step by stepCalc

   1. SVR
   2. =(MAP − RA) ÷ CO × 80
   3. =(90 − 5) ÷ 4.2 × 80
   4. ≈20.2 WU × 80
   5. ≈1620 dyn·s·cm⁻⁵

   SVR = (MAP − RA) ÷ CO × 80 = (90 − 5) ÷ 4.2 × 80 ≈ 20.2 WU × 80 ≈ 1620 dyn·s·cm⁻⁵, which is elevated. 1710 omits the RA pressure, and 1240 uses the aortic diastolic pressure (70 mmHg) instead of the mean. 20 is the Wood-unit value without the ×80 conversion.

   • ANot this1240 uses the aortic diastolic (70) instead of the mean pressure.
   • BNot this1710 leaves out the RA pressure.
   • CCorrect(90 − 5) ÷ 4.2 = 20.2 WU, and × 80 ≈ 1620 dyn·s·cm⁻⁵.
   • DNot this20 is the Wood-unit value without the × 80 conversion.
3. Q03B2Diagnostic

   Question 3: Diagnostic (B2) Calc

   In a patient with MR, the ventriculogram gives EDV 240 mL and ESV 120 mL. Fick CO is 5.04 L/min at a heart rate of 70 bpm. What is the regurgitant fraction?

   1. A40%
   2. B60%
   3. C67%
   4. D50%

   Show the answer and the working

   Answer A 40%

   Step by stepCalc

   1. Total (angiographic) SV
   2. =240 − 120
   3. =120 mL
   4. Forward SV
   5. =5040 ÷ 70
   6. =72 mL
   7. Regurgitant volume
   8. =48 mL
   9. RF
   10. =48 ÷ 120
   11. =40%

   Total (angiographic) SV = 240 − 120 = 120 mL, and forward SV = 5040 ÷ 70 = 72 mL. The regurgitant volume is 48 mL, so RF = 48 ÷ 120 = 40%. 60% is the forward SV divided by the total SV, 50% is the ejection fraction (120 ÷ 240), and 67% divides the regurgitant volume by the forward SV instead of the total.

   • ACorrectTotal SV 120 mL, forward SV 5040 ÷ 70 = 72 mL, so RF = 48 ÷ 120 = 40%.
   • BNot this60% is forward SV divided by total SV, the share that goes forward.
   • CNot this67% divides the regurgitant volume by the forward SV instead of the total SV.
   • DNot this50% is the ejection fraction (120 ÷ 240), not the regurgitant fraction.
4. Q04B3Diagnostic

   Question 4: Diagnostic (B3) Calc

   Fick CO is calculated using the assumed VO₂ of 125 mL/min/m² in a febrile, septic patient with a high metabolic rate. How is the calculated CO affected?

   1. AIt is overestimated
   2. BIt is unaffected, because only SvO₂ matters
   3. CIt is unaffected, because VO₂ is indexed to BSA
   4. DIt is underestimated

   Show the answer and the working

   Answer D It is underestimated

   CO = VO₂ ÷ AV O₂ difference. Fever and sepsis raise true oxygen consumption, so using the lower assumed value puts too small a number in the numerator and underestimates CO. Indexing to BSA does not correct for metabolic rate, which is why the assumed VO₂ is the largest source of error in the Fick method. Both VO₂ and the saturations determine the result.

   • ANot thisOverestimation would need an assumed VO2 higher than the true value, the reverse of this patient.
   • BNot thisCO depends on VO2 as well as the saturations, so a wrong VO2 changes the result.
   • CNot thisIndexing to BSA scales for body size, not for metabolic rate.
   • DCorrectFever raises true VO2, so the lower assumed value in the numerator makes the calculated CO too low.

Two more formulas to work on paper

Q04 asks only which way the Fick output moves. Here is the full calculation behind it, followed by the shunt ratio, which uses the same saturations in a different arrangement.

Twelve more diagnostic cases, seven of them calculations, run on the diagnostic procedures guide.

Emergency procedures: Q05 to Q16

Emergency procedures and protocols are 13% of the scored exam, about 20 items. This page carries 12 of them, since the domain has no guide of its own yet. They sort into five problems:

• Arrest and rhythm drugs: Q06 (end-tidal CO₂ during CPR), Q08 (the drug after the second shock), Q11 (polymorphic VT with a long QT).
• A new neurological change mid-case: Q05 (during TAVR), Q07 (no flow behind a carotid filter).
• Retrieval and bailout devices: Q09 (an embolized wire tip), Q12 (a flow-limiting dissection), Q15 (a loose septal occluder).
• Support and oxygenation: Q10 (pads before draping), Q13 (an Impella suction alarm), Q14 (pulmonary edema on a nonrebreather).
• Reperfusion timing: Q16 (STEMI at a hospital without PCI).

1. Q05D3Emergency

   Question 5: Emergency (D3)

   During transfemoral TAVR under conscious sedation, the patient suddenly cannot move the right arm and has slurred speech. BP is 142/80 mmHg. What is the most appropriate initial action?

   1. AFinish the valve first, then assess
   2. BGive IV alteplase at once
   3. CNote time; activate stroke team
   4. DGive an extra heparin bolus

   Show the answer and the working

   Answer C Note time; activate stroke team

   A new focal deficit during TAVR is usually embolic (debris from the calcified valve or arch); the time of onset is recorded, the operator is told and the stroke team is activated for imaging and possible thrombectomy. Alteplase is not given without imaging and is often unsuitable after large-bore arterial access and heparin. Extra heparin before imaging may worsen a hemorrhage, and delaying assessment loses treatment time.

   • ANot thisFinishing the valve first loses treatment time for the stroke.
   • BNot thisAlteplase is never given before imaging and is often unsuitable after large-bore access and heparin.
   • CCorrectA new focal deficit during TAVR is likely embolic; record the time and activate the stroke team for imaging.
   • DNot thisExtra heparin before imaging could worsen a hemorrhagic stroke.
2. Q06D4Emergency

   Question 6: Emergency (D4)

   During CPR on an intubated patient, the waveform capnogram shows a consistent ETCO2 of 7 mmHg. What should the team do?

   1. ANothing; 7 mmHg shows adequate CPR is being done
   2. BImprove compression depth/rate; swap compressor
   3. CStop CPR, since ETCO2 below 10 means ROSC occurred
   4. DIncrease ventilations to 30 breaths per minute now

   Show the answer and the working

   Answer B Improve compression depth/rate; swap compressor

   During CPR, ETCO2 reflects blood flow generated by compressions. A value below 10 mmHg suggests inadequate compressions, so the team should check depth (at least 5 cm), rate (100–120/min), full recoil and minimal pauses, and switch compressors to avoid fatigue. Reversible causes such as tamponade or massive PE should also be considered. Ventilation should stay at about 10 breaths/min with an advanced airway, because hyperventilation raises intrathoracic pressure and lowers venous return. ROSC produces a sudden rise in ETCO2, not a low value.

   • ANot this7 mmHg means poor blood flow, not adequate CPR.
   • BCorrectETCO2 below 10 mmHg during CPR means poor compressions, so improve depth and rate and swap the compressor.
   • CNot thisROSC causes a sudden rise in ETCO2, not a persistently low value.
   • DNot thisHyperventilation raises intrathoracic pressure and lowers venous return; keep about 10 breaths/min.
3. Q07D3Emergency

   Question 7: Emergency (D3)

   During carotid stenting with a distal filter, flow in the internal carotid artery slows to a standstill after post-dilation. The patient is neurologically intact. What is the correct next step?

   1. AInject IC nitroglycerin and continue as planned
   2. BGive IV alteplase before the filter is removed
   3. CRetrieve the filter at once without aspirating
   4. DAspirate the ICA column, then retrieve filter

   Show the answer and the working

   Answer D Aspirate the ICA column, then retrieve filter

   Slow or no flow during carotid stenting with a filter usually means the basket is full of debris. Retrieving it immediately can release that debris, or the stagnant column, into the brain. The column above the filter is first aspirated with a catheter until the debris is cleared, and only then is the filter recaptured. Nitroglycerin treats spasm but not a full filter. Systemic lysis adds bleeding risk and does not treat the debris the filter has trapped.

   • ANot thisNitroglycerin treats spasm, not a filter packed with debris.
   • BNot thisSystemic lysis adds bleeding risk and does not remove the trapped debris.
   • CNot thisPulling the filter at once can spill its debris into the brain.
   • DCorrectA full filter is cleared by aspirating the stagnant column first, and only then is the filter recaptured.
4. Q08D4Emergency

   Question 8: Emergency (D4)

   A patient in VF in the cath lab has received two biphasic shocks and 2 minutes of CPR, and IV access is working. VF persists and CPR is resumed after the second shock. Which drug is given now?

   1. AAmiodarone 300 mg IV
   2. BAdenosine 6 mg IV push
   3. CAtropine 1 mg IV push
   4. DEpinephrine 1 mg IV

   Show the answer and the working

   Answer D Epinephrine 1 mg IV

   In the AHA VF/pulseless VT algorithm, the first shock is followed by 2 minutes of CPR with IV/IO access. After the second shock, epinephrine 1 mg is given and repeated every 3–5 minutes. After the third shock, amiodarone 300 mg (then 150 mg) or lidocaine is given for shock-refractory VF. Amiodarone therefore comes one cycle later. Atropine has no role in VF. Adenosine is for stable, regular narrow-complex tachycardia. High-quality CPR with minimal pauses continues throughout.

   • ANot thisAmiodarone comes one cycle later, after the third shock.
   • BNot thisAdenosine is for stable, regular narrow-complex tachycardia.
   • CNot thisAtropine has no role in VF.
   • DCorrectIn the AHA VF algorithm, epinephrine 1 mg is given after the second shock and repeated every 3–5 minutes.
5. Q09D2Emergency

   Question 9: Emergency (D2)

   During PCI, a fractured guidewire tip embolizes into a proximal coronary segment. Which device is most commonly used to retrieve an embolized wire fragment or unexpanded stent?

   1. ACutting balloon catheter
   2. BLoop (gooseneck) snare
   3. CRotational atherectomy burr
   4. DDistal embolic filter

   Show the answer and the working

   Answer B Loop (gooseneck) snare

   A loop snare, for example a gooseneck or multi-loop snare, is advanced through the guide. The loop is closed around the free end of an embolized wire or stent, which is then withdrawn into the guide. It is the standard retrieval device. A cutting balloon has blades that modify plaque and cannot grasp a fragment. A distal embolic filter captures debris during SVG or carotid work but is not designed to retrieve hardware. A rotational burr ablates calcium and could fragment or trap the wire further.

   • ANot thisA cutting balloon modifies plaque and cannot grasp hardware.
   • BCorrectA loop (gooseneck) snare is closed around the free end of the fragment and pulled back into the guide.
   • CNot thisA rotational burr could fragment or trap the wire even further.
   • DNot thisA distal filter catches debris during SVG or carotid work but is not built to retrieve a wire.
6. Q10D4Emergency

   Question 10: Emergency (D4)

   Before a high-risk PCI, radiolucent defibrillator pads are applied to the patient before draping. What is the main reason?

   1. AThey deliver more energy than paddles
   2. BThey are needed only for pacing
   3. CThey shield the skin from X-ray burns
   4. DShocks without breaking sterility

   Show the answer and the working

   Answer D Shocks without breaking sterility

   Pads placed before draping let the team defibrillate or pace within seconds without contaminating the field, and radiolucent pads do not hide the heart on fluoroscopy. They do not deliver more energy than paddles; the energy is set on the device. They are used for both defibrillation and pacing, and they give no protection from radiation skin injury.

   • ANot thisEnergy is set on the defibrillator; pads do not deliver more than paddles.
   • BNot thisPads are used for both defibrillation and pacing, not only pacing.
   • CNot thisPads give no protection from radiation skin injury.
   • DCorrectPads placed before draping let the team shock or pace in seconds without contaminating the sterile field.
7. Q11DEmergency

   Question 11: Emergency (D)

   A patient with a QTc of 560 ms develops polymorphic VT with twisting QRS axis that self-terminates and recurs; a pulse is present. Which drug is most appropriate first?

   1. ASotalol 100 mg IV
   2. BMagnesium sulfate 2 g IV
   3. CProcainamide 20 mg/min IV
   4. DAmiodarone 150 mg IV

   Show the answer and the working

   Answer B Magnesium sulfate 2 g IV

   Polymorphic VT with a long QT is torsades de pointes; magnesium sulfate 1–2 g IV suppresses the triggering afterdepolarizations even when the serum magnesium is normal, and correcting potassium and stopping QT-prolonging drugs follows. Amiodarone, procainamide and sotalol all prolong the QT interval and can worsen torsades. Sustained or pulseless torsades is defibrillated.

   • ANot thisSotalol is a QT-prolonging drug and can provoke torsades.
   • BCorrectPolymorphic VT with a long QT is torsades, and IV magnesium suppresses the triggers even with normal serum levels.
   • CNot thisProcainamide also prolongs the QT and can make torsades worse.
   • DNot thisAmiodarone prolongs the QT and can worsen torsades.
8. Q12D3Emergency

   Question 12: Emergency (D3)

   After SFA balloon angioplasty, a flow-limiting spiral dissection remains despite prolonged low-pressure balloon inflation. There is no contrast extravasation. Which device should be prepared for bailout?

   1. ASelf-expanding bare nitinol stent
   2. BCovered stent graft for the SFA
   3. CCatheter-directed alteplase infusion
   4. DDistal embolic protection filter

   Show the answer and the working

   Answer A Self-expanding bare nitinol stent

   A persistent, flow-limiting dissection after angioplasty is tacked down with a stent. In the femoropopliteal segment this is usually a self-expanding nitinol stent, which tolerates flexion and compression. There is no perforation, so a covered stent graft is not needed. Covered stents are for rupture or extravasation and can cover collaterals. Thrombolysis does not repair an intimal flap and adds bleeding risk. An embolic filter prevents debris showers but does nothing to seal a dissection.

   • ACorrectA flow-limiting dissection in the femoropopliteal segment is tacked down with a flexible self-expanding nitinol stent.
   • BNot thisA covered stent graft is for rupture or extravasation, and none is present.
   • CNot thisThrombolysis does not repair an intimal flap and adds bleeding risk.
   • DNot thisAn embolic filter catches debris but does nothing to seal a dissection.
9. Q13D1Emergency

   Question 13: Emergency (D1)

   An Impella CP running at P-8 for cardiogenic shock alarms repeatedly for suction and its flow falls. RA pressure is 3 mmHg and echo shows a small, underfilled LV. What is the most appropriate response?

   1. AGive volume and reduce the P-level
   2. BRaise to P-9 to overcome the suction
   3. CPush the device 2 cm deeper into LV
   4. DGive IV furosemide to lower preload

   Show the answer and the working

   Answer A Give volume and reduce the P-level

   Suction alarms mean the inlet is pulling against too little blood or against the LV wall. The common causes are hypovolemia, RV failure or poor positioning. With a low RA pressure and a small LV cavity, the patient is underfilled, so volume is given and the P-level temporarily reduced until flow stabilizes. Position is then rechecked on echo (inlet about 3.5 cm below the aortic annulus). Increasing speed worsens suction and hemolysis. Diuresis empties the LV further. Pushing the device deeper puts the inlet against the apex or mitral apparatus.

   • ACorrectA low RA pressure and a small LV mean the pump is underfilled, so give volume and lower the P-level.
   • BNot thisA higher speed pulls harder on an empty ventricle and worsens suction and hemolysis.
   • CNot thisPushing the pump deeper puts the inlet against the apex or mitral apparatus.
   • DNot thisDiuresis empties the LV further and makes suction worse.
10. Q14D1Emergency

    Question 14: Emergency (D1)

    A patient in acute pulmonary edema is sitting upright on a nonrebreather mask at 15 L/min with SpO2 86%, BP 170/100 mmHg, and is alert and cooperative. IV nitroglycerin has started. What is the best next step to improve oxygenation?

    1. ALay the patient flat for the next cine run first
    2. BIV bolus of 1 liter of normal saline right away
    3. CNoninvasive positive pressure (CPAP or BiPAP)
    4. DOral beta-blocker to slow the heart rate now

    Show the answer and the working

    Answer C Noninvasive positive pressure (CPAP or BiPAP)

    In cardiogenic pulmonary edema with persistent hypoxemia, noninvasive positive-pressure ventilation (CPAP or BiPAP) recruits flooded alveoli, lowers work of breathing and reduces preload and LV afterload. It often avoids intubation in an alert, cooperative patient who can protect the airway. Intubation is needed if the patient tires, becomes obtunded or does not improve. A saline bolus worsens congestion. An acute beta-blocker can precipitate cardiogenic shock. Lying flat increases venous return and dyspnea.

    • ANot thisLying flat increases venous return and worsens dyspnea.
    • BNot thisA saline bolus adds volume to a congested patient.
    • CCorrectCPAP or BiPAP recruits flooded alveoli and reduces preload and afterload in an alert, cooperative patient.
    • DNot thisAn acute beta-blocker can push a decompensated patient into cardiogenic shock.
11. Q15D3Emergency

    Question 15: Emergency (D3)

    Immediately after release of an ASD occluder, TEE shows the device free in the left atrium, no longer attached to the septum; BP and rhythm are stable. What is the most appropriate next step?

    1. ARetrieve it with a snare
    2. BEmergency surgery right away
    3. CDeploy a second occluder
    4. DAnticoagulate and observe

    Show the answer and the working

    Answer A Retrieve it with a snare

    An embolized septal occluder must be removed before it passes through the mitral valve into the LV or aorta; a stable patient is managed by percutaneous snare retrieval through a large sheath, with surgery if that fails. Going straight to surgery is unnecessary in a stable patient. Observation risks valve entrapment or embolization, and a second occluder does not address the loose device.

    • ACorrectA stable patient with an embolized occluder has it retrieved percutaneously with a snare, with surgery as backup.
    • BNot thisSurgery is the backup if snaring fails, not the first step in a stable patient.
    • CNot thisA second occluder does nothing about the loose device already in the LA.
    • DNot thisObservation risks the device crossing the mitral valve or embolizing further.
12. Q16D1Emergency

    Question 16: Emergency (D1)

    A patient presents to a hospital without PCI capability 2 hours after STEMI onset. The expected first-medical-contact-to-device time after transfer is 150 minutes. What is the recommended strategy?

    1. ATransfer for primary PCI anyway
    2. BObserve and repeat the ECG in 1 hour
    3. CFibrinolysis, then transfer
    4. DMedical therapy only, no reperfusion

    Show the answer and the working

    Answer C Fibrinolysis, then transfer

    Primary PCI is preferred when first medical contact to device can be achieved within 90 minutes at a PCI center or within 120 minutes when transfer is needed. When the expected delay exceeds 120 minutes and symptoms began less than 12 hours ago, fibrinolytic therapy should be given (ideally within 30 minutes of arrival), followed by transfer. Waiting or withholding reperfusion loses myocardium.

    • ANot this150 minutes exceeds the 120-minute transfer limit, so waiting for PCI loses myocardium.
    • BNot thisObservation withholds reperfusion from an evolving STEMI.
    • CCorrectWhen transfer would push first contact to device beyond 120 minutes, fibrinolysis is given early and the patient transferred.
    • DNot thisA STEMI 2 hours from onset needs reperfusion, not medical therapy alone.

Pre-procedural activities: Q17 to Q20

Pre-procedural activities are 8% of the scored exam, about 12 items, and they are some of the cheapest points available: skin prep, imaging review before a structural case, sedation risk and baseline labs. Q20 is a lab definition presented as arithmetic, and its working applies both parts of the definition to the same creatinine.

1. Q17A2Pre-procedural

   Question 17: Pre-procedural (A2)

   Both groins are being prepped for a planned femoral approach. Which practice best reduces the risk of an access-site infection?

   1. AShave the groin with a razor the evening before
   2. BClip hair; let chlorhexidine–alcohol dry
   3. CApply povidone-iodine and drape while it is still wet
   4. DClean the site with 70% isopropyl alcohol alone

   Show the answer and the working

   Answer B Clip hair; let chlorhexidine–alcohol dry

   Clipping avoids the micro-abrasions a razor leaves, and chlorhexidine–alcohol is the preferred antiseptic; it must dry fully to work and to avoid pooling under the drape. Shaving the night before lets bacteria colonize the nicks, which raises infection rates. Draping over a wet prep cuts contact time, and alcohol alone has no persistent antimicrobial effect.

   • ANot thisRazor shaving leaves micro-abrasions that bacteria colonize overnight, which raises infection rates.
   • BCorrectClipping avoids razor nicks, and chlorhexidine–alcohol only works fully once it has dried.
   • CNot thisDraping over a wet prep shortens antiseptic contact time and lets solution pool under the drape.
   • DNot thisAlcohol alone kills on contact but leaves no persistent antimicrobial effect.
2. Q18A3Pre-procedural

   Question 18: Pre-procedural (A3)

   Before transfemoral TAVR, which pre-procedure imaging is reviewed to confirm that the iliofemoral arteries can accept the delivery sheath?

   1. AA resting ankle–brachial index of both legs
   2. BA duplex ultrasound of both carotid arteries
   3. CA standard PA and lateral chest radiograph
   4. DCT angiography, aorta to femoral arteries

   Show the answer and the working

   Answer D CT angiography, aorta to femoral arteries

   Transfemoral TAVR uses large-bore sheaths (about 14–18 French), so the minimum iliofemoral lumen diameter, calcification and tortuosity are measured on a contrast-enhanced CT angiogram from the aorta to the femoral arteries. The same CT is used to size the annulus and judge coronary height. A chest X-ray does not show vessel diameters. Carotid duplex looks at the carotid arteries, not the access route. An ABI screens for PAD but cannot measure vessel size or show calcium distribution.

   • ANot thisAn ABI screens for PAD but gives no vessel diameters or calcium distribution.
   • BNot thisCarotid duplex looks at the neck vessels, not the access route for the sheath.
   • CNot thisA chest X-ray cannot measure iliofemoral vessel diameters.
   • DCorrectCT angiography from the aorta to the femorals measures the minimum lumen diameter, calcium and tortuosity of the access route.
3. Q19A3Pre-procedural

   Question 19: Pre-procedural (A3)

   Before moderate sedation, which finding in the pre-procedure assessment most increases the risk of airway obstruction?

   1. AWell-controlled essential hypertension
   2. BA documented allergy to penicillin
   3. CA prior uneventful sedation for colonoscopy
   4. DObstructive sleep apnea with a thick neck

   Show the answer and the working

   Answer D Obstructive sleep apnea with a thick neck

   Obstructive sleep apnea, obesity with a short, thick neck, and a high Mallampati class predict upper-airway obstruction and hypoventilation under benzodiazepines and opioids. These patients need careful titration of sedation, capnography, airway adjuncts ready and sometimes anesthesia support. Well-controlled hypertension does not affect the airway. A previous uneventful sedation is reassuring. A penicillin allergy has no bearing on airway risk or on the sedation drugs used in the lab.

   • ANot thisControlled hypertension does not affect the airway.
   • BNot thisA penicillin allergy has no bearing on airway risk or on the sedatives used.
   • CNot thisA previous uneventful sedation is reassuring rather than a risk factor.
   • DCorrectSleep apnea and a short, thick neck predict upper-airway obstruction once sedatives take effect.
4. Q20A3Pre-procedural

   Question 20: Pre-procedural (A3) Calc

   A patient's serum creatinine was 1.1 mg/dL on the morning of cardiac catheterization. Which follow-up result meets the KDIGO definition of contrast-associated acute kidney injury?

   1. A1.3 mg/dL, measured 24 hours after contrast
   2. B1.5 mg/dL, measured 48 hours after contrast
   3. C1.2 mg/dL, measured 72 hours after contrast
   4. D1.4 mg/dL, measured 10 days after the contrast

   Show the answer and the working

   Answer B 1.5 mg/dL, measured 48 hours after contrast

   KDIGO defines AKI as a creatinine rise of at least 0.3 mg/dL within 48 hours, or a rise to at least 1.5 times baseline within 7 days. A value of 1.5 mg/dL at 48 hours is a rise of 0.4 mg/dL inside the 48-hour window, so it qualifies. A rise to 1.3 mg/dL is only 0.2 mg/dL. A rise to 1.2 mg/dL is only 0.1 mg/dL. A value of 1.4 mg/dL at 10 days is outside both time windows and is less than 1.5 times baseline (1.65 mg/dL). Creatinine usually peaks 2 to 5 days after contrast, which is why follow-up labs are drawn in that window.

   • ANot thisA 0.2 mg/dL rise is below the 0.3 mg/dL threshold.
   • BCorrectA 0.4 mg/dL rise within 48 hours meets the KDIGO threshold of 0.3 mg/dL in 48 hours.
   • CNot thisA 0.1 mg/dL rise is far too small, and 72 hours is outside the 48-hour window.
   • DNot thisDay 10 is outside both windows, and 1.4 is less than 1.5 times the baseline (1.65 mg/dL).

Post-procedural activities: Q21 to Q24

Post-procedural activities are the smallest domain at 5%, about 8 items. They test what you watch for after the sheath is out: a held drug, a dose report that needs follow-up, and two complications that surface days later rather than on the table.

1. Q21E3Post-procedural

   Question 21: Post-procedural (E3)

   After a diagnostic cath, a patient with type 2 diabetes on metformin has an eGFR of 24 mL/min/1.73 m². According to ACR guidance, what should the discharge instructions say about metformin?

   1. AStop metformin permanently after any contrast
   2. BHold it 48 h, restart with no creatinine check
   3. CContinue it as usual; no hold is needed
   4. DHold for 48 h; restart after a kidney recheck

   Show the answer and the working

   Answer D Hold for 48 h; restart after a kidney recheck

   Current ACR guidance limits metformin holding to patients with eGFR below 30 or acute kidney injury. In them, metformin is withheld at the time of contrast and for 48 hours afterward, and restarted only after renal function has been rechecked and found stable. This small risk of lactic acidosis is what the rule guards against. With eGFR 24, this patient needs the hold and the recheck. Patients with eGFR 30 or higher and no AKI can continue metformin without interruption. The old 'hold for everyone' rule is outdated, and permanent discontinuation is not indicated.

   • ANot thisPermanent discontinuation is not indicated.
   • BNot thisAt eGFR below 30 the kidney recheck before restarting is the whole point of the rule.
   • CNot thisContinuing without change is for eGFR 30 or higher with no AKI, not 24.
   • DCorrectWith eGFR below 30, metformin is held for 48 hours and restarted only after renal function is rechecked.
2. Q22E4Post-procedural

   Question 22: Post-procedural (E4)

   Which post-procedure dose report from a long CTO case requires patient notification and a skin follow-up check (NCRP Report 168)?

   1. AFluoroscopy time of 38 minutes
   2. BKerma-area product of 180 Gy·cm²
   3. CReference air kerma (Ka,r) of 6.1 Gy
   4. DReference air kerma (Ka,r) of 1.8 Gy

   Show the answer and the working

   Answer C Reference air kerma (Ka,r) of 6.1 Gy

   NCRP 168 sets substantial radiation dose levels (SRDLs) that trigger documentation, patient notification and skin follow-up at 2–4 weeks. The SRDLs are Ka,r 5 Gy, peak skin dose 3 Gy, kerma-area product 500 Gy·cm² and fluoroscopy time 60 minutes. A Ka,r of 6.1 Gy exceeds the SRDL, and Ka,r is the metric that best predicts deterministic skin injury. A fluoroscopy time of 38 minutes, a Ka,r of 1.8 Gy and a kerma-area product of 180 Gy·cm² are all below their SRDLs. Fluoroscopy time is also the weakest predictor of skin dose.

   • ANot this38 minutes is below the 60-minute SRDL, and fluoroscopy time is the weakest skin-dose predictor.
   • BNot this180 Gy·cm² is below the 500 Gy·cm² kerma-area product SRDL.
   • CCorrectKa,r above the 5 Gy NCRP 168 SRDL triggers notification and a skin check at 2–4 weeks.
   • DNot this1.8 Gy is well below the 5 Gy Ka,r SRDL.
3. Q23EPost-procedural

   Question 23: Post-procedural (E)

   Two days after carotid stenting of a critical stenosis, a patient develops a severe ipsilateral headache and a focal seizure. BP is 196/104 mmHg. What is the most likely diagnosis?

   1. AContrast-induced renal injury
   2. BCarotid sinus baroreflex response
   3. CCerebral hyperperfusion syndrome
   4. DVasovagal reaction to the stent

   Show the answer and the working

   Answer C Cerebral hyperperfusion syndrome

   After a tight carotid stenosis is opened, cerebral autoregulation downstream may be impaired. Restored flow under high BP can cause hyperperfusion syndrome: ipsilateral headache, seizures, confusion and even intracerebral hemorrhage, typically hours to days later. Strict BP control is the key treatment. The carotid sinus baroreflex response causes bradycardia and HYPOtension, usually right after stent expansion. Contrast-induced kidney injury does not cause seizures. A vasovagal reaction lowers BP rather than raising it.

   • ANot thisContrast kidney injury does not cause headache or seizures.
   • BNot thisThe baroreflex response causes bradycardia and hypotension, usually right after stent expansion.
   • CCorrectHeadache, seizure and high BP days after opening a critical stenosis are cerebral hyperperfusion syndrome.
   • DNot thisA vasovagal reaction lowers BP rather than raising it.
4. Q24E2Post-procedural

   Question 24: Post-procedural (E2)

   Five days after femoral cath closed with a collagen-based closure device, a patient has fever, groin redness, warmth and purulent drainage. What is the most likely diagnosis?

   1. AFemoral arteriovenous fistula
   2. BInfected closure device site
   3. CExpected collagen reabsorption
   4. DDelayed contrast skin reaction

   Show the answer and the working

   Answer B Infected closure device site

   Closure devices leave foreign material (collagen, anchor, suture or sealant) at the arteriotomy. Infection is uncommon but more likely than after manual compression. It presents days to weeks later with fever, erythema, warmth and purulent drainage, and it can progress to an infected pseudoaneurysm. Cultures, IV antibiotics and often surgical debridement are needed. Normal reabsorption is silent. Delayed contrast reactions are itchy rashes without pus or fever. An AV fistula gives a continuous bruit, not purulence.

   • ANot thisAn AV fistula gives a continuous bruit, not purulent drainage.
   • BCorrectFever, redness, warmth and pus days after a collagen closure device indicate infection of the device site.
   • CNot thisNormal reabsorption of collagen is silent.
   • DNot thisDelayed contrast reactions are itchy rashes without fever or pus.

Traps that cheap RCIS question sets still carry

Free question sets and shared dumps often keep answer keys that were correct years ago, or never were. Eight of them are below, each with the stale key and the answer that current guidelines and the standard cath lab texts support.

Review material printed before mid-2024 may also carry an older domain split; the study guide shows how to check.

Where the rest of the question bank is

Interventional procedures (34% of the exam) have no items on this page by design: they run as cases on the interventional guide. No question on the site appears on two pages, so after these 24 every set below is new to you.

If you keep one habit from this page, make it this: write the formula down before you touch the numbers.

Questions people ask