U/S Guided Interventions for Complex Lower Extremity Disease€¦ · • Centers for Disease...
Transcript of U/S Guided Interventions for Complex Lower Extremity Disease€¦ · • Centers for Disease...
Bryan T. Fisher Sr., MD January 23, 2017
Chief of Vascular Surgery and Co-Director of Limb
Preservation, Centennial Medical Center
U/S Guided Interventions for Complex Lower Extremity
DiseaseA Vascular Surgeons Effort to Significantly Reduce Radiation
Exposure
Disclosures• Abbott Medical
• Faculty Speaker• Research Consultant
• Cardiovascular Systems Inc• Faculty Speaker• Education Consultant
• W. L. GORE• Registry Parcticipant• Faculty Speaker
• Cordis (Cardinal Health)• Educational Consultant• Faculty Speaker
Objectives• Understand the importance of radiation
exposure over the course of a successful career
• Illustrate the feasibility of performing complex tibial interventions with minimal contrast and radiation exposure with a two man team
• What we did at Centennial Medical Center
• Case Illustration
The Problem• In early 2000, an roughly 650,000percutaneous
transluminal coronary angioplasty (PTCA) procedures were performed on adults in the United States1
• Coronary artery stent insertion doubled from 157 to 318 per 100,000 adults, aged 45-64, from 1996 to 20001
The Risks• Increasing number of case reports of skin
changes • hands
• lens of the eye in operators and assistants
• Cancer• Uncommon
• Leukemia
• Breast Ca
The Jihad Effect• Story well known
• Visit to Leipzig, Germany
• The rest is history
The Rest Is History in the US
A Different Approach• Limited staffing
• Often issues with staff staying late• Priority given to other specialties
• Limited capital• Resources spread over multiple departments
• Limited Interest• Wouldn’t last long
• Unlimited radiation• Reached annual limit @ month 5!
This Got Their Attention
31.2
27.3
39.337.4
1412
3 0
4.5% 4.4%
0.8%
0.0% 0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
0
10
20
30
40
50
Q1 2013 Q2 2013 Q3 2013 Q4 2013
Arterial Wounds (x10)
# of Amputations
% of Amputations
Nu
mb
er
of
Am
pu
tatio
ns
Centennial Setup
“Body Flossing”
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What Are We Doing?
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Why Ultrasound?
Capable of So Much
Overview• Materials
• GE system Fixed Unit• GE U/S Station• Jake and me!• No crossing devices• No re-entry devices
• Methods• 10 consecutive cases series utilizing as much u/s as
possible to reduce radiation exposure• Complex cases only
• Multi-level (above and below knee)• More than 1 tibial• Pedal arch intervention
• U/S limited below the ankle
Results
Radiation Exposure (milligray)Case Length (min)
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
Case
1Case
2Case
3Case
4Case
5Case
6Case
7Case
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9Case
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Radiation Exposure and Case Length
Radiation Exposure (milligray) Case Length (min)
Case• 64 year old diabetic with type II DM, hyperlipidemia and htn
presents with “neuropathy” of the foot and a small medial arch wound
• Multiple specialists• “small vessel disease”• ”nothing can be done”
• Exam• Palpable DP and PT
• Noninvasive studies• ABI normal• Great TBI .4
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Treatment and Final Result
Post Procedure• Some tingling in toes, but greatly improved
• TBI .75
• Wound healed at 4 weeks
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Conclusion• Radiation exposure is bad but necessary
• U/S guided interventions are feasible without many resources
• If you don’t have one, find your Jake!
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Thank You• Partners
• Billy Kim
• Allen Lee
• Adam Richter
• Right Hand Man• Jacob Swenson• Best Radiology Tech in the Universe
• Jihad Mustapha MD/Christopher Lesar MD
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Thank You(Cont)
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Bibliography
References• Frenz MB, Mee AS. Diagnostic radiation exposure and cancer risk. Gut. 2005;54(6):889-890. doi:10.1136/gut.2005.066605.
• Centers for Disease Control/National Center for Health Statistics, Health Care in America: Trends in Utilization, U. S. Department of Health and Human Services, DHHS Pub No. 2004-1031, 2004.
• Shiralkar S, Rennie A, Snow M, et al. Doctors’ knowledge of radiation exposure: questionnaire study. BMJ 2003;327:371–2.
• Faulkner,K. and Vaño,E. Deterministic Effects in Interventional Radiology. Rad Prot Dosim 2001; 94:95-8. International Commission on Radiological Protection. Avoidance of radiation injuries from medical interventional procedures. ICRP Publication No. 85. Ann ICRP 2000;30:7-67.
• de Gonzalez A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004;363:345–51.
• Koenig TR, Wolff D, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures . Am J Roentgenol 2001; 177:3- 20.
• Mettler F, Koenig TR, Wagner LK, Kelsey CA. Radiation injuries after fluoroscopic procedures. Seminars Ultrasound, CT, MRI 2002; 23:428-42.
• Miller DL, Balter S, Noonan PT, Georgia JD. Minimizing radiation-induced skin injury in interventional radiology procedures. Radiology 2002; 225:329-36.
Bryan T. Fisher Sr., MD January 23, 2017
Chief of Vascular Surgery and Co-Director of Limb
Preservation, Centennial Medical Center
U/S Guided Interventions for Complex Lower Extremity
DiseaseA Vascular Surgeons Effort to Significantly Reduce Radiation
Exposure