Primer on Vascular & Interventional Radiology

Transcription

1 Primer on Vascular & Interventional Radiology Barbara Nickel Hamilton, MD Quantum Medical Radiology Group 7/13/2015

2 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

3 1964 Angioplasty Milestones Pioneered by Interventional Radiologists 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 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 Transhepatic embolization for variceal bleeding Embolization technique for pulmonary arteriovenous malformations and varicoceles 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

4 Specialties within the field of Vascular & 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 nontunneled lines SVC recanalization Port-a-cath placement Interventional radiology Neuro IR Neurointerventional radiology Acute vessel recanalization in stroke Aneurysm coiling AVM Diagnostic angiography Spinal augmentation Kyphoplasty/ vertebroplasty

5 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)

6 Minimally Invasive Toolbox

7 Venous access Dialysis catheter Fistula/ graft work Port placement and evaluation PICC placement

8 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+

9 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

10 Ultrasound and CT- guided procedures Paracentesis, thoracentesis Lymph node, Thyroid nodule biopsy Liver, Renal biopsy- usually ultrasound guided Adrenal, pancreas, bone, abdominal mass biopsyusually 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

11 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

12 Peristomal abscess

13 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

14 Arterial Lysis for a cold leg

15 Endoleak

16 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.

17 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

18 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.

19 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

20 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

21 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

22 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?!

23 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

24 Resources IR staff X5961 My IR office/spectra-link X5946 X-ray control room X5937 Lead technologist Vera Edwards, RT

25 Thank you Looking forward to working with you!