U/S Guided Interventions for Complex Lower Extremity Disease
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1 U/S Guided Interventions for Complex Lower Extremity Disease A Vascular Surgeons Effort to Significantly Reduce Radiation Exposure Bryan T. Fisher Sr., MD January 23, 2017 Chief of Vascular Surgery and Co-Director of Limb Preservation, Centennial Medical Center
2 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 Disclosures
3 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
4 The Problem In early 2000, an roughly 650,000percutaneous transluminal coronary angioplasty (PTCA) procedures were performed on adults in the United States 1 Coronary artery stent insertion doubled from 157 to 318 per 100,000 adults, aged 45-64, from 1996 to
5 The Risks Increasing number of case reports of skin changes hands lens of the eye in operators and assistants Cancer Uncommon Leukemia Breast Ca
6 Story well known The Jihad Effect Visit to Leipzig, Germany The rest is history
7 The Rest Is History in the US
8 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 month 5!
9 Number of Amputations This Got Their Attention % % 4.4% % % Arterial Wounds (x10) % # of Amputations % of Amputations % 1.0% % 0.0% Q Q Q Q4 2013
10 Centennial Setup
11 Body Flossing 11
12 What Are We Doing? 12
13 Why Ultrasound?
14 Capable of So Much
15 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
16 Results Radiation Exposure and Case Length 1,800 1,600 1,400 1,200 1, Case 1 Case Case Case 2 Case 3 Case Case 7 Case 8 Case 9 Case 10 Case Length (min) Radiation Exposure (milligray) Radiation Exposure (milligray) Case Length (min)
17 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 17
18
19 Treatment and Final Result
20 Post Procedure Some tingling in toes, but greatly improved TBI.75 Wound healed at 4 weeks 20
21 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! 21
22 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 22
23 Thank You(Cont) 23
24 Bibliography
25 References Frenz MB, Mee AS. Diagnostic radiation exposure and cancer risk. Gut. 2005;54(6): doi: /gut 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 , Shiralkar S, Rennie A, Snow M, et al. Doctors knowledge of radiation exposure: questionnaire study. BMJ 2003;327: 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: 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: Miller DL, Balter S, Noonan PT, Georgia JD. Minimizing radiation-induced skin injury in interventional radiology procedures. Radiology 2002; 225:
26 U/S Guided Interventions for Complex Lower Extremity Disease A Vascular Surgeons Effort to Significantly Reduce Radiation Exposure Bryan T. Fisher Sr., MD January 23, 2017 Chief of Vascular Surgery and Co-Director of Limb Preservation, Centennial Medical Center
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