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interventional [2017/07/07 18:30] (current)
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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% ​ |  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 =====
 +{{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 (external edit)