Page 1 of 91
ABIM INTERVENTIONAL CARDIOLOGY
CERTIFICATION EXAMINATION PRACTICE***
QUESTIONS AND VERIFIED ANSWERS |
2026/2027 UPDATE | + RATIONALES
Section 1: Questions 1–50
1. A 68-year-old man with a history of hypertension,
hyperlipidemia, and stage III chronic kidney disease presents
to the emergency department with chest pain while raking
leaves. His ECG reveals ST-segment elevations in leads V1-V4.
He is given 324 mg of aspirin. The interventional team elects
to take him emergently to the catheterization laboratory. The
nurse asks which access sites should be prepped. Which of the
following is the most appropriate response?
A. Right radial artery only
B. Radial artery and bilateral femoral arteries
C. Bilateral femoral arteries only
D. Left radial artery only
❖ Rationale: Radial artery access is the preferred vascular
access site for coronary angiography and PCI in patients
with ACS (Class I, LOE A) due to reduced mortality,
bleeding, and vascular complications. However, prepping
,Page 2 of 91
bilateral groins in addition to the radial artery provides a
backup strategy for urgent mechanical circulatory support
placement or transition to femoral access should radial
access fail. In institutions where the radial artery is
routinely used for surgical grafting, this potential future
use should be considered when selecting vascular access .
2. A 55-year-old woman with a history of diabetes and
hypertension undergoes elective PCI of a mid-LAD lesion.
During the procedure, she develops chest pain, hypotension,
and ST-segment elevation. Angiography reveals a large spiral
dissection extending from the mid-LAD to the distal vessel.
What is the most appropriate immediate management?
A. Administer intravenous heparin and observe for 30 minutes
B. Place a covered stent to seal the dissection
C. Implant drug-eluting stents to cover the entire dissected
segment
D. Terminate the procedure and administer fibrinolytic therapy
❖ Rationale: Large spiral dissections with flow compromise
require immediate bailout stenting to restore flow and
prevent vessel closure. Drug-eluting stents are preferred
over covered stents for coronary dissections, as covered
stents have higher rates of thrombosis and restenosis.
Observation may be appropriate for Type A dissections, but
,Page 3 of 91
this is a large flow-limiting dissection requiring
intervention .
3. A 72-year-old man with severe aortic stenosis (valve area
0.6 cm², mean gradient 55 mmHg) and a Society of Thoracic
Surgeons (STS) score of 12% is referred for transcatheter aortic
valve replacement (TAVR). He has severe peripheral arterial
disease with bilateral femoral arteries measuring 4.5 mm in
diameter with severe calcification. What is the most
appropriate access approach?
A. Transfemoral access using a 14 Fr sheath
B. Transapical access
C. Transcarotid access
D. Transaortic access
❖ Rationale: Transcarotid access is increasingly used for TAVR
when femoral access is not feasible due to small vessel
caliber (<5.5 mm) or severe calcification. It provides a more
direct route than transapical or transaortic approaches and
has been associated with lower morbidity. Transfemoral
access would be contraindicated given the severe
calcification and small vessel size. Transapical and
transaortic approaches are associated with higher
morbidity and mortality .
4. A 62-year-old man with non-ST-elevation myocardial
infarction (NSTEMI) undergoes coronary angiography showing
, Page 4 of 91
a 90% stenosis of the proximal RCA. During PCI, the operator
attempts to advance a guidewire but cannot cross the lesion
despite multiple attempts with different wires. What is the
most appropriate next step?
A. Terminate the procedure and schedule for CABG
B. Attempt to cross the lesion with a tapered, high-torque wire
C. Administer intracoronary nitroglycerin and adenosine
D. Perform rotational atherectomy to facilitate wire passage
❖ Rationale: When a standard guidewire fails to cross a
lesion, a tapered, high-torque wire (e.g., Confianza, Miracle
Bros) should be attempted. These wires provide better
penetration and support. Intracoronary nitroglycerin may
help if vasospasm is suspected but is unlikely to help a
fibrous/calcific lesion. Rotational atherectomy requires
wire crossing first. Premature termination and CABG
referral would be premature .
5. A 58-year-old woman with a history of hypertension and
hyperlipidemia presents with dyspnea on exertion and chest
tightness. Her echocardiogram shows a left ventricular
ejection fraction of 35%. Coronary angiography reveals a 70%
stenosis of the left main coronary artery and three-vessel
disease. Which of the following factors would most favor
CABG over PCI in this patient?
ABIM INTERVENTIONAL CARDIOLOGY
CERTIFICATION EXAMINATION PRACTICE***
QUESTIONS AND VERIFIED ANSWERS |
2026/2027 UPDATE | + RATIONALES
Section 1: Questions 1–50
1. A 68-year-old man with a history of hypertension,
hyperlipidemia, and stage III chronic kidney disease presents
to the emergency department with chest pain while raking
leaves. His ECG reveals ST-segment elevations in leads V1-V4.
He is given 324 mg of aspirin. The interventional team elects
to take him emergently to the catheterization laboratory. The
nurse asks which access sites should be prepped. Which of the
following is the most appropriate response?
A. Right radial artery only
B. Radial artery and bilateral femoral arteries
C. Bilateral femoral arteries only
D. Left radial artery only
❖ Rationale: Radial artery access is the preferred vascular
access site for coronary angiography and PCI in patients
with ACS (Class I, LOE A) due to reduced mortality,
bleeding, and vascular complications. However, prepping
,Page 2 of 91
bilateral groins in addition to the radial artery provides a
backup strategy for urgent mechanical circulatory support
placement or transition to femoral access should radial
access fail. In institutions where the radial artery is
routinely used for surgical grafting, this potential future
use should be considered when selecting vascular access .
2. A 55-year-old woman with a history of diabetes and
hypertension undergoes elective PCI of a mid-LAD lesion.
During the procedure, she develops chest pain, hypotension,
and ST-segment elevation. Angiography reveals a large spiral
dissection extending from the mid-LAD to the distal vessel.
What is the most appropriate immediate management?
A. Administer intravenous heparin and observe for 30 minutes
B. Place a covered stent to seal the dissection
C. Implant drug-eluting stents to cover the entire dissected
segment
D. Terminate the procedure and administer fibrinolytic therapy
❖ Rationale: Large spiral dissections with flow compromise
require immediate bailout stenting to restore flow and
prevent vessel closure. Drug-eluting stents are preferred
over covered stents for coronary dissections, as covered
stents have higher rates of thrombosis and restenosis.
Observation may be appropriate for Type A dissections, but
,Page 3 of 91
this is a large flow-limiting dissection requiring
intervention .
3. A 72-year-old man with severe aortic stenosis (valve area
0.6 cm², mean gradient 55 mmHg) and a Society of Thoracic
Surgeons (STS) score of 12% is referred for transcatheter aortic
valve replacement (TAVR). He has severe peripheral arterial
disease with bilateral femoral arteries measuring 4.5 mm in
diameter with severe calcification. What is the most
appropriate access approach?
A. Transfemoral access using a 14 Fr sheath
B. Transapical access
C. Transcarotid access
D. Transaortic access
❖ Rationale: Transcarotid access is increasingly used for TAVR
when femoral access is not feasible due to small vessel
caliber (<5.5 mm) or severe calcification. It provides a more
direct route than transapical or transaortic approaches and
has been associated with lower morbidity. Transfemoral
access would be contraindicated given the severe
calcification and small vessel size. Transapical and
transaortic approaches are associated with higher
morbidity and mortality .
4. A 62-year-old man with non-ST-elevation myocardial
infarction (NSTEMI) undergoes coronary angiography showing
, Page 4 of 91
a 90% stenosis of the proximal RCA. During PCI, the operator
attempts to advance a guidewire but cannot cross the lesion
despite multiple attempts with different wires. What is the
most appropriate next step?
A. Terminate the procedure and schedule for CABG
B. Attempt to cross the lesion with a tapered, high-torque wire
C. Administer intracoronary nitroglycerin and adenosine
D. Perform rotational atherectomy to facilitate wire passage
❖ Rationale: When a standard guidewire fails to cross a
lesion, a tapered, high-torque wire (e.g., Confianza, Miracle
Bros) should be attempted. These wires provide better
penetration and support. Intracoronary nitroglycerin may
help if vasospasm is suspected but is unlikely to help a
fibrous/calcific lesion. Rotational atherectomy requires
wire crossing first. Premature termination and CABG
referral would be premature .
5. A 58-year-old woman with a history of hypertension and
hyperlipidemia presents with dyspnea on exertion and chest
tightness. Her echocardiogram shows a left ventricular
ejection fraction of 35%. Coronary angiography reveals a 70%
stenosis of the left main coronary artery and three-vessel
disease. Which of the following factors would most favor
CABG over PCI in this patient?
