interventional
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— | interventional [2017/07/07 18:30] (current) – created - external edit 127.0.0.1 | ||
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+ | ====== 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 ===== | ||
+ | | |{{db1.png}}|{{db2.png}}|{{db3.png}}| | ||
+ | | Percentage | 60% | 10-15% | ||
+ | | DeBakey | I | II | III | | ||
+ | | Stanford | A || B | | ||
+ | | | Proximal | ||
+ | ====== 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' | ||
+ | * 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, | ||
+ | * lesions are long and smooth | ||
+ | |||
+ | ====== DDx Midaortic Stenosis ====== | ||
+ | * Midaortic stenosis | ||
+ | * noninflammatory nonatheromatous vascular d/o | ||
+ | * can cause renal artery stenosis | ||
+ | * Takayasu' | ||
+ | * Radiation induced | ||
+ | * Neurofibromatosis | ||
+ | ====== Aortic Occlusion ====== | ||
+ | ===== Collateral Pathways ===== | ||
+ | |||
+ | |||
+ | ===== Contraindications ===== | ||
+ | * recent surgery (intracranial, | ||
+ | * 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, | ||
+ | * 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, | ||
+ | |||
+ | ====== 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, | ||
+ | * 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: | ||
+ | * Side effects: bowel ischemia, angina, arrythmia, HTN, bradycardia, | ||
+ | * 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, | ||
+ | |||
+ | ===== 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, | ||
+ | * 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, | ||
+ | * 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, | ||
+ | * 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' | ||
+ | * corkscrew vessels | ||
+ | * Baker' | ||
+ | * 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 ===== | ||
+ | {{celiac.gif}} | ||
+ | |||
+ | ===== SMA ===== | ||
+ | {{sma.jpg}} | ||
+ | |||
+ | ===== Adrenal ===== | ||
+ | {{adrenalbs.jpg|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 ===== | ||
+ | {{antro.gif|Anterior View}}{{postro.gif|Posterior View}} |
interventional.txt · Last modified: 2017/07/07 18:30 by 127.0.0.1