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interventional

Post-Traumatic Vascular Injury

CXR Signs

  • wide mediastinum
  • filling in of AP window
  • depressed L mainstem
  • rightward displacement of trachea or NG tube
  • L apical cap
  • L effusion
  • L upper rib fxs

Most Common Locations for TAI

  • Aortic root
  • Isthmus
  • Aortic hiatus

Classification of Dissections

Percentage 60% 10-15% 25-30%
DeBakey I II III
Stanford A B
Proximal Distal

Aortic Aneurysms

  • CT signs of impending rupture
    • high attenuation crescent between intraluminal thrombus and the wall

Types of Endoleaks

  • Type 1 - bad seal @ prox/distal end
    • treatment is emergent
  • Type 2 - endoleak via IMA or lumbar collaterals
  • Type 3 - leak thru internal seal
  • Type 4 - porosity of graft
    • resolves spontaneously
  • Type 5 - endotension
    • sac not getting smaller, but no leak

Takayasu's

  • dilation or irregularity of the ascending aorta
  • narrowing of the descending artery
  • long stenoses or occlusions of arch vessels (especially the subclavian)
  • CT/MR show enhancement of the artery wall in the acute phase
  • angioplasty and stent should be delayed until the disease is inactive if possible
  • Type 1 → stenoses of aortic arch and branch vessels
  • Type 2 → descending thoracic and abdominal aorta + abdominal branches
  • Type 3 → aortic arch plus abdominal aorta
  • Type 4 → pulmonary artery and aorta

Giant Cell Artieritis

  • affects older women, and usually involves the temporal artery
  • involves the distal subclavian or axillary arteries, but not the brachiocephalic, common carotids or proximal subclavians
  • lesions are long and smooth

DDx Midaortic Stenosis

  • Midaortic stenosis
    • noninflammatory nonatheromatous vascular d/o
    • can cause renal artery stenosis
  • Takayasu's
  • Radiation induced
  • Neurofibromatosis

Aortic Occlusion

Collateral Pathways

Contraindications

  • recent surgery (intracranial, abdominal, or thoracic)
  • recent GI bleed
  • recent stroke or CNS neoplasm
  • recent major trauma
  • pregnancy
  • severe HTN
  • bleeding diathesis
  • infected thrombus

TIPS

Indications

  • variceal bleeding that cannot be treated medically (acute or chronic)
  • intractable ascites

Contraindications

Absolute

  • polycystic liver disease
  • severe R heart failure
  • severe hepatic failure

Relative

  • severe hepatic encephalopathy
  • hypervascular liver tumor
  • portal vein thrombosis
  • severe acute infection

Technique

  • Do u/s first to assess PV patency, flow direction, status of hepatic veins, degree of ascites, and eval for liver tumor
  • Check coags and correct w/ FFP
  • Broad spectrum antibiotics
  • 10Fr sheath RIJ and assess RA and IVC pressures
  • Measure wedged hepatic vein pressure which will equal PV pressure, subtract the IVC pressure to get gradient
  • Insert needle
  • Opacify the portal vein via a wedged contrast injection
  • Stick the needle anteromedially into the right portal vein
  • Needle is then withdrawn a bit until you get blood back
  • Inject contrast to check your position
  • Advance a guidewire into the PV and then to the splenic vein or SMV
  • Dilate the parenchymal track with a 10mm balloon
  • Place 10 or 12 mm Wallstent so that one end is within 3 cm of the portal bifurcation, and the other within 3cm of the IVC
  • Dilate tract with a 10mm balloon
  • If gradient remains (>12mm Hg), redilate w/ 12mm balloon
  • If gradient persists, can employ parallel stent or embolize varices

Paget-Schroetter Disease

  • Best seen w/ provocative maneuver such as hyperabduction

Causes

  • cervical rib
  • congenital fibromuscular bands
  • 1st rib anomalies
  • muscle hypertrophy
  • clavicle fxs

Management

  • If severe or pt has embolization, then correction of underlying abnormality is recommended

Colonic bleed

  • Causes of lower GI bleed:
    • diverticular dz
    • angiodysplasia (dilated submucosal veins and capillaries in the bowel wall)
    • post biopsy or polypectomy
    • tumors
    • polyps
    • IBD
    • ischemia
  • Patients with a positive Tc RBC or SC scan should undergo angio
  • Sensitivity:
    • angio - 0.5cc/min
    • Tc RBC - 0.1cc/min
  • Most likely vessel, based on nucs scan, should be injected 1st
  • Otherwise SMA then IMA, and if both negative, then celiac
  • In angidysplasia, a bleeding vessel is usually not seen
    • instead, you see early venous drainage from one portion of the bowel, or a tram track sign from simultaneous opacification of a feeding artery and draining vein
  • Treatment:
    • vasopressin - 0.2 units per minute
      • after 30 minutes a repeat angiogram is done, the infusion is continued at that rate with the pt in ICU
      • if persists, increase to 0.4u/min and repeat angio in 30 minutes
      • if still bleeding, need to pursue other methods
      • rebleeding is common
      • Contraindications: severe coronary artery dz, severe HTN, dysrhythmias, bleeding at sites with a dual blood supply, bleeding directly from a large artery (eg spl artery aneurysm) and after embolotherapy
      • Side effects: bowel ischemia, angina, arrythmia, HTN, bradycardia, and allergy
    • embo - performed with macrocoils or microcoils and gelfoam
      • embo usually does not work long term for angiodysplasia or AVM, these will require surgery
      • placed distally in the arcades proximal to the bleeding vasa recta to minimize intestinal ischemia
      • inject the proximal vessel to make sure there is no bleeding thru collaterals
      • complictions include bowel infarct <20%

Pulmonary Embolism

  • Primary finding - intraluminal filling defect at least partly surrounded by contrast
  • Secondary signs - vessel cutoff, regional hypoperfusion, pruning of vessels, slow flow, and filling of collaterals

Technique

  • check for LBBB & use pacer if present
  • also check u/s for groin clot
  • check PA pressures before injecting main PA; cut back on injection if pressures are elevated

Transhepatic Cholangiogram

Procedure

  • Start w/ antibiotics to include gram negative coverage - one hour prior to any biliary work
  • Right sided approach:
    • 22G Chiba needle is placed in the midaxiallry line below the 10th rib (to avoid the pleura)
    • fluoro is used to check the position of the pleura in full inspiration, so that it may be avoided
    • needle is passed over a rib, to avoid injury to the nerves and vessels which run on the undersurface
    • needle is directed toward a plane parallel to the table top aimed toward T11
    • remove the stylet and inject 0.1cc of 60% strength contrast while slowly retracting the needle
    • when contrast fills a tubular structure and stays there, you are likely in a bile duct, and you should remove 5-10 cc of bile and send for gram stain and culture
    • then inject an additional 5-10cc contrast to confirm and determine duct diameter and location relative to porta hepatis
  • Left sided access:
    • from a left subcostal approach in the epigastrium
    • US is used to access a bile duct while avoiding artery and portal vein
  • Treatment:
    • pass a 0.018 wire thru the chiba needle you used for the THC, then exchange for a .038 wire, and advance a catheter over that wire
    • a dominant proximal stricture can be angioplastied
    • stents can be used for malignancy b/c the pts life expectancy is short and the stent will likely last as long as the pt needs
    • for benign dz, stents should only be used for pts who are not operative candidates and who failed angioplasty
    • a wallstent is the stent of choice

IVC Filter

Contraindications

  • IVC thrombosed
  • pregnancy (clot may come from ovarian veins)
    • place suprarenal filter

Nephrostomy

Technique

  • check labs; stop anticoagulants
  • prophylactic antibiotics 1hr preprocedure (ancef 1g and gentamycin 80mg or specific to the organism)
  • place pt prone and select puncture site (4 fingers from midline, just below 11th rib)
  • start by puncturing collecting system with a 22G Chiba needle and opacifying collecting system
    • aspirate urine for culture and remove urine before injecting contrast to minimize sepsis risk
  • choose best entry site under fluoro:
    • for simple decomression, it is safest to puncture a lower pole calyx b/c that has the lowest risk for PTX
    • if ureteral stent placement is planned, then go for an interpolar calyx to get an easier angle to get the catheter down the ureter
    • puncture at least 12 cm lateral to midline in order to avoid going thru paraspinal muscles
  • puncture a posterior calyx (know posterior b/c seen en face in AP plane, or can inject air) with an 18G needle
    • posterolateral approach, with needle angled 40 degress from vertical is best (Brodel’s avascular line)
  • if infected, initially just decompress, do not manipulate more until infection is treated
  • place a stiff amplatz .035 down into ureter
  • the tract is dilated, and a 10 fr pigtail is placed over the .035 wire and locked into position by forming the pigtail
  • secure to skin with adhesive dressing or suture.

Signs of Leg Ischemia

  • hair loss
  • nail changes
  • purple toes
  • skin loss
  • ulcers

Sources of Hemoptysis

Bronchial Artery

  • Cystic Fibrosis
  • Infection
  • Bronchiectasis
  • Tumor

Technique

  • place the catheter deep into the abnormal bronchial artery
  • if you can not get deep with your initial catheter, place a coaxial microcath thru it to go out deeper
  • findings in pts with a bronchial artery bleed include eenlarged bronchial artery, hypervascularity, parenchymal stain, amd bronchial to pulmonary artery shunting
  • contrast extrav is not usually seen, and is not necessary for treating
  • look for the small branches to the anterior spinal artery which arise form the proximal portion of the vessel and take a hairpin turn going 1st superior and then inferior toward midline
  • if there is a spinal artery branch, some people wont embolize, but some will embo if they can get the catheter well beyond the branch
  • embo agent is PVA (medium sized particles) or gelfoam
  • if no bronchial or collateral bleeding source is found, then you have to inject the pulmonary arteries

Pulmonary Artery

  • Rasmussen Aneurysm
  • Pulmonary AVM
    • Unlike other AVM's, as there is no real nidus
    • Therefore, it is the only AVM where you embolize the feeding vessel
    • Use coils!
  • PA Pseudoaneurysm

TPA Thrombolysis

  • Dose = 0.5 mg/hr infusion
  • No bolus needed

Contraindications

  • Motor weakness in extremity
    • Do not want to perfuse dead tissue

Popliteal Artery Disease (ABCDE)

  • Atherosclerotic disease / Aneurysm
  • Buerger's disease
    • corkscrew vessels
  • Baker's cyst
  • Cystic adventitial disease
    • cysts in vessel wall on IVUS
  • Dissection
  • Entrapment
    • induced by plantarflexion or forced dorsiflexion of foot
    • caused by abnormal relationship with medial head of gastrocnemius

General Technique

Seldinger

  • 18G - .035 wire
  • 22G - .018 wire

Stenting

Good Locations for Covered Stents

  • SFA
  • TIPS
  • Lacerated vessel

Embolization

  • always use medium size particles
  • 500-700 microns

Vasopressin

  • Done from origin of vessel
  • Usually only if embo is not possible

TPA Infusion

  • place multisidehole catheter across occlusion
  • 2mg initial TPA bolus
  • then infuse 1mg/hour
  • f/u angiogram in 12hrs
    • treat residual stenosis w/ angioplasty
  • give heparin prior to thrombolysis
    • 5000U bolus then 1000U/hr infusion

Anatomy

Celiac

SMA

sma.jpg

Adrenal

Three blood supplies to the adrenal:
  * superior adrenal artery from the inferior phrenic artery
  * middle adrenal artery form the aorta above the renal artery
  * inferior adrenal artery from the proximal renal artery

Hover over image for info

Run-off

Anterior ViewPosterior View

interventional.txt · Last modified: 2017/07/07 18:30 (external edit)