Primer on Vascular &

Interventional Radiology

Barbara Nickel Hamilton, MD Quantum Medical Radiology Group

7/13/2015

Structure

■ Introduction to my field & a bit of history

■ IR team

■ IR tools

■ Major categories of IR procedures

■ How to order exams & procedures

■ Patient consent and preparation

■ Follow-up

■ Resources

Milestones Pioneered by Interventional Radiologists

■ 1964 Angioplasty ■ 1966 Embolization therapy to treat tumors and spinal cord vascular malformations ■ 1967 The Judkins technique of coronary angiography ■ 1967 Closure of the patent ductus arteriosis ■ 1967 Selective vasoconstriction infusions for hemorrhage ■ 1969 The catheter-delivered stenting technique and prototype stent ■ 1960-74 Tools for interventions such as heparinized guidewires, contrast injector, disposable catheter needles ■ 1970’s Percutaneous removal of common bile duct stones ■ 1970’s Occlusive coils ■ 1972 Selective arterial embolization for GI bleeding, which was adapted to treat massive bleeding in other arteries in the body and to

block blood supply to tumors ■ 1973 Embolization for pelvic trauma ■ 1974 Selective arterial thrombolysis for arterial occlusions, now used to treat blood clots, stroke, DVT, etc. ■ 1974 Transhepatic embolization for variceal bleeding ■ 1977-78 Embolization technique for pulmonary arteriovenous malformations and varicoceles ■ 1977-83 Bland- and chemo-embolization for treatment of hepatocellular cancer and disseminated liver metastases ■ 1980 Cryoablation to freeze liver tumors ■ 1980 Development of special tools and devices for biliary manipulation ■ 1980’s Biliary stents to allow bile to flow from the liver saving patients from biliary bypass surgery ■ 1981 Embolization technique for spleen trauma ■ 1982 TIPS (transjugular intrahepatic portosystemic shunt) ■ 1982 Dilators for interventional urology, percutaneous removal of kidney stones ■ 1983 The balloon-expandable stent (peripheral) used today ■ 1985 Self-expandable stents ■ 1990 Percutaneous extraction of gallbladder stones ■ 1990 Radiofrequency ablation (RFA) technique for liver tumors ■ 1990’s Treatment of bone and kidney tumors by embolization ■ 1990’s RFA for soft tissue tumors, i.e., bone, breast, kidney, lung and liver cancer ■ 1991 Abdominal aortic stent grafts ■ 1994 The balloon-expandable coronary stent used today ■ 1997 Intra-arterial delivery of tumor-killing viruses and gene therapy vectors to the liver ■ 1999 Percutaneous delivery of pancreatic islet cells to the liver for transplantation to treat diabetes ■ 1999 Developed the endovenous laser ablation procedure to treat varicose veins and venous disease

Specialties within the field of Vascular &

Interventional radiology Body IR ■ “Below the neck” ■ Plumbing: arteries & veins

❑ DVT, PE ❑ PVD

■ Trauma ❑ Active bleeding ❑ Pelvic crush inj ❑ Splenic embo

■ Liver intervention ❑ HCC ❑ Biliary obstruction

■ Urinary obstruction ■ Heme/onc

❑ Biopsy ❑ Locoregional tx

■ Men’s health ❑ Varicocele embo

■ Womens health ❑ UAE

■ Venous access ❑ Graftograms, fistula

declot procedures ❑ tunneled and non-

tunneled lines ❑ SVC recanalization ❑ Port-a-cath placement

Neuro IR

Neurointerventional radiology

Acute vessel recanalization in stroke

Aneurysm coiling

AVM

Diagnostic angiography

Spinal augmentation

Kyphoplasty/ vertebroplasty

Who makes up your IR team?

■ Consists of a group of radiologists, specialized IR technologists, and IR nurses

■ There is one IR at DRMC per week

■ One technologist, first assist

■ 1-2 RNs depending on stability of patient, i.e. in the case of an unstable stroke or pelvic trauma patient

Shawn, Vera, Rocky, Janet, Sheri, Lita (&

Barbara, not pictured)

Minimally Invasive Toolbox

Venous access

■ Dialysis catheter

■ Fistula/ graft work

■ Port placement and evaluation

■ PICC placement

Venous access guidelines

■ Generally not urgent

■ No such thing as a “stat” PICC line

■ Central lines may be placed on floor

■ We place non tunneled access for emergent HD

❑ Coagulopathic pts, elevated K+

Venous thromboembolic disease

■ Majority of patients treated medically

■ Intravascular therapy may be indicated: ❑ IVC filtration

❑ PE with hemodynamic instability, right heart failure

❑ Acute and Chronic DVT

■ With associated limb ischemia (PCD)

■ Life limiting, i.e. Pagett Schroeder

■ Iliofemoral DVT, +/- May Thurner

Ultrasound and CT- guided

procedures ■ Paracentesis, thoracentesis

■ Lymph node, Thyroid nodule biopsy

■ Liver, Renal biopsy- usually ultrasound guided

■ Adrenal, pancreas, bone, abdominal mass biopsy- usually CT ❑ Depends on location, sonographic window, depth, organ ❑ E.g. lung biopsy generally requires CT guidance as air

results in acoustic shadowing. Therefore you will not be able to see a lung mass sonographically unless it is a large pleural based mass

❑ CT allows for rapid chest tube placement for pneumothorax

Gastrostomy placement & evaluation

■ G- and GJ tubes

❑ Indication ■ Feeding; venting; i.e. Dysphagia in setting of head and

neck ca

■ Reflux &/ Aspiration-> GJ

❑ Contraindications ■ Coagulopathy

■ Anatomy

❑ Intrathoracic stomach

❑ Colonic interposition

Peristomal abscess

Arteriography & embolization

■ Ischemia

■ Hemorrhage

■ Tumor

■ AVM

■ Gastrointestinal bleeding ❑ Most lower GIB ceases on its own

❑ Has Gastroenterology seen the patient?

❑ Has the bleeding been localized?

■ CTA abdomen/ pelvis preferred

❑ Multiphase study without and with contrast (arterial, venous,

delayed phases) which can show active extravasation as well as

potential cause (i.e. diverticulosis, mass, AVM, esophageal or

gastric varices

Arterial Lysis for a “cold leg”

Endoleak

GIB

■ Localization saves time in the angiographic suite, likewise

reducing patient morbidity and radiation exposure.

■ Patient should be stable enough to tolerate angiography

■ Important information for Interventionalist:

❑ stability of the patient, how many units of blood products they

have received, h/o and location of prior bleeds, and any

comorbidities they have.

TIPS Transjugular intrahepatic portosystemic shunt

■ Emergent, urgent, or elective

■ Indications

❑ Cirrhosis complicated by

■ Acute or repeated UGIB

■ Ascites

■ Hepatic hydrothorax

❑ Contraindications

■ Encephalopathy

■ Right heart compromise/ CHF

■ MELD score >20

Be prepared to provide information when

consulting your IR ■ Patient name, age, and location

■ Requesting physician and their contact information (including attending name)

■ Can the patient give their own consent? If not, who will give consent and how are they to be contacted?

■ Speaks English? If not, what language do they speak?

■ Anticoagulants. When was their last dose?

❑ Lovenox, NSAIDS 24hr

❑ ASA 36 hr

❑ Plavix 5 days

❑ Coumadin- check INR

❑ Heparin gtt- short half life-continue or D/C on call to procedure

❑ SubQ unfractionated heparin 8 hr

■ What are the patient’s platelet count and INR?

❑ For most procedures, platelets >60. For thora, para, INR <=2

❑ For solid organ biopsies, INR <=1.4

■ Contrast allergy?

❑ What was the reaction?

❑ Anaphylaxis is an absolute contraindication to repeat use of iodinated contrast

❑ For mild to moderate reactions, premedicate with 32 mg methylprednisolone 24 and 2 hr prior to the procedure.

Moderate Sedation

■ Most IR procedures done with moderate sedation

■ Fentanyl is a short acting, potent opioid for pain relief.

■ Versed for anxiolysis, sedation, and variable, transient amnestic effects

■ Patient maintains their own respiration and is monitored by dedicated RN at all times, under supervision of IR MD

■ Patient must be NPO for a minimum of 6 hours

Requesting exams and procedures

■ Orders are billing based ■ Try typing IR to start ■ When in doubt call and ask

■ When ordering a dialysis line or removal please give details ❑ Permcath removal for bacteremia/

sepsis; line holiday ❑ permcath removal; functioning RUE

fistula ❑ permcath removal; ARF resolved

Priority

■ Nephrostomy ❑ If there are signs of an infected, obstructed system

❑ Signs of sepsis

■ Abscess drainage ❑ If pt hemodynamically unstable, marked discomfort

❑ For these cases the patient must have IV abx on

board, as needle access-> transient bacteremia

Consent process

■ Written, informed consent from patient or legal representative

■ Obtained for the procedure itself and for moderate sedation (separate consent)

■ For general anesthesia cases (TIPS), anesthesia performs consent for their piece

■ Emergency two physician consent

■ Explain the need for the procedure prior to sending patient to IR. This is good for patient care, and prevents refusal when a new face offers to stick a giant needle where?!

Informed Consent Process: Discuss Risks

■ Bleeding, infection, pain

❑ Access site hematoma

■ Exposure to radiation

■ Exposure to sedation Rx

■ Procedure failure

■ Need for additional

procedure(s)

■ Lung bx: pneumothorax,

hemoptysis, dreaded air

embolism

■ Angio: vessel damage incl.

perforation, dissection,

occlusion

Resources

http://www.sirweb.org/medical-professionals/

IR staff X5961

My IR office/spectra-link X5946

X-ray control room X5937

Lead technologist Vera Edwards, RT

Thank you

■ Looking forward to working with you!