Primer on Vascular & Interventional Radiologyucrhealth.weebly.com/uploads/4/7/6/9/47693407/07... ·...
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Primer on Vascular &
Interventional Radiology
Barbara Nickel Hamilton, MD Quantum Medical Radiology Group
7/13/2015
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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
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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
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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
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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)
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Minimally Invasive Toolbox
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Venous access
■ Dialysis catheter
■ Fistula/ graft work
■ Port placement and evaluation
■ PICC placement
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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+
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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
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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
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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
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Peristomal abscess
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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
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Arterial Lysis for a “cold leg”
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Endoleak
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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.
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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
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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.
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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
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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
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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
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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?!
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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
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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
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Thank you
■ Looking forward to working with you!