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Introduction

• Simon Jones, MSN,RN,CNS

• SDSU

• Interventional Radiology, UCSD Hillcrest

Interventional Radiology

Simon Jones, MSN, CNS

Nurse Educator, IR

s5jones@ucsd.edu

Outline

• Access/ Closure

• Common Cases

• Radiation safety

• Contrast Reaction

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Interventional Radiology

1964

• Invention of angioplasty

• Catheter delivered stent

• Charles Dotter, MD. Nominated for the Nobel Prize in medicine (1978)

• Early procedures: Crude wires/ catheters, film imaging, contrast- high osmolar/ionic leading to frequent reactions, often no nursing presence.

Vascular Access

Needles for vascular catheterization. The single-wall needle (left) has a sharp beveled edge. The Seldinger-type needle with stylet (right) can also be used for most arterial catheterization procedures.

Micropuncture access set with a 21-gauge needle, a 0.018-inch steerable guidewire, and a 4-French transitional dilator.

Common femoral artery puncture. The inguinal ligament is demarcated by the inferior epigastric artery (arrow). The ideal arterial entry site is indicated by the asterisk .

If the puncture is too high (into the external iliac artery above the inguinal ligament), the risk of retroperitoneal or intraperitoneal bleeding is increased

The Kill Shot

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Closure Devices- 3 main kinds

• Collagen material placed on the external

surface of the punctured artery (e.g., AngioSeal device)

• Suture-mediated closure systems (e.g., Perclose, Proglide and Starclose devices)

• External skin patches that accelerate coagulation (e.g., D-stat)

Illustration of footplate fixed to the inner wall of the artery, with collagen plug being deployed on the outer surface (green arrow). This mechanism is anchored to the skin with the white suture. (Images courtesy of St. Jude Medical.)

Complications of Femoral Artery Catheterization

Type Frequency (%)

• Minor bleeding or hematoma 6–10

• Major hemorrhage requiring therapy 1

• Pseudoaneurysm 1–6

• Arteriovenous fistula 0.01

• Occlusion (thrombosis or dissection) 1

• Perforation or extravasation 1

• Distal embolization 0.10

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Common Procedures

• Common Cases

• IVC filter placement

• Angiogram

• Vascular Access

• Biliary System

• Neuro Interventional

• GI intervention

• Urologic

• Interventional Oncology

Neuro Intervention

Embolic Stroke

Penumbra

Merci Retriever

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Other Neuro Cases

• DCA

• Carotid stenting

• Pre- op Tumor Embolization

• Epistaxis

• Aneurysm coiling

• Head/ Neck trauma (dissection)

Vascular Access • Devices

– Tunneled, cuffed (Dacron- incites a fibrotic reaction)

– Ports

– PICCS

• Usually inserted through the IJV. – L side preferred (long term function is better)

• Avoid Subclavian (stenosis, thrombosis is more likely)

• Catheter Tip Position – it is now standard of practice to position the catheter tip in

the upper to mid-right atrium with the patient supine. – At this location, the catheter end-holes will rarely become

obstructed by a fibrin sheath because the tip hangs freely in the right atrium rather than plastered against the caval wall

Schutz JC, Patel AA, Clark TW , et al . Relationship between chest port catheter tip position and port malfunction after interventional radiologic placement . J Vasc Interv Radiol 2004 ; 15 : 581 .

Vesely TM. Central venous catheter tip position: a continuing controversy J Vasc Interv Radiol 2003; 14 : 527.

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G- tubes

• In critically ill adults and children, feeding by enteral tube is preferred over parenteral nutrition when the gastrointestinal tract is functional. Enteral feeding also prevents atrophy of intestinal villi and prevents or minimizes translocation of bacteria from the gastrointestinal tract to the bloodstream

• Glucagon 1 mg - closes the Pylorus.

Other procedures

• Organ decompression

• Abscess drainage

• Vascular embolization

Procedures

Vascular Vascular Interventional Techniques

• Balloon Angioplasty

• Vascular Stents: uncovered and covered

ex., TIPS and DIPS,

AVG or AVF venous stenting

• Thrombolysis: enzymes, mechanical

• Retrieval of Foreign Bodies

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Procedures

Non- Vascular

• Percutaneous Nephrostomy Tubes

• Ureteral Stent Placement

• Gastrostomy/Jejunostomy Feeding tubes

• Biliary Cholangiogram/

Decompession, stenting, and drainage of biliary system

• Cholecystostomy

Procedures

Non- Vascular

• Radiofrequency Ablation (RFA) and Microwave Ablation (MWA) of lesions

• Discogram

• Kyphoplasty

• Nerve Root Injection

• Epidural Injection

Pre-Procedure

• History and Physical • Laboratory Review-CBC, Plts, Coagulation, Renal function • Medication Review: allergies, anticoagulants, insulin, analgesics • Contrast Allergy Treatment: steroids, benadryl • Informed Consent • NPO • IV Fluids • Renal Protection: Mucomyst, Hydration, Na Bicarbonate

• Antibiotics appropriate for patient’s micro profile • GIVE ANTIHYPERTENSIVES/CARDIAC MEDS • Void before leaving floor

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Pre-Procedure

In General……

• Stop aspirin and clopidogrel (Plavix®) for 5 days

• Stop coumadin for 3-5 days, and repeat INR

• Stop heparin infusion for 4 hours and repeat aPTT

• Stop metformin the day of and 2 days after;

repeat Cr in 48 hours

• Stop LMWH 24-48 hours before

• Give ½ dose of long-acting insulin day of procedure, check FS glucose

• Give ½ of oral diabetes meds the night before or morning of the procedure

Pre-Procedure

Blood Component Therapy

• General Target Values:

Hct >25%

Plts >50K

INR <1.5

Fibrinogen >100

• Coagulopathy Correction/Factor VIIa Protocol

Contrast Reaction Types

• Anaphylactiod

• Nonanaphylactoid

• Delayed

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Pre- Medication • MCP 319.2

• Alternate – Hydrocortisone 200 mg IV. 6, 2hrs prior – Diphenhydramine 50mg IV 1 hr prior

• Standard Pre-medication

– Prednisone 50mg p.o. 13, 7, 1hr prior – Diphenhydramine 50mg p.o. 1hr prior

Systematic Review, BMJ (1996) Physicians dealing with patients receiving contrast media should not rely on the efficacy of premedication; routine prophylaxis should be abandoned. doi:10.1136/bmj.38905.634132.AE (published 31 July 2006)

Anaphylactoid

• Urticaria

• Facial/laryngeal edema

• Bronchospasm

• Circulatory collapse

Contrast Reactions

• How does the patient look?

• • Can the patient speak? How does the patient’s voice sound?

• • How is the patient’s breathing?

• • What is the patient’s pulse strength and rate?

• • What is the patient’s blood pressure?

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Contrast Reactions

• Anaphylaxis – Allergen IGE complex

Combination causes release of histamine from Mast cells

– H1 sites • Endothelial & Smooth muscle

– H2 sites • Gut

Management of Contrast Reactions

• Mild. Consider Diphenhydramine

• Moderate. Diphenhydramine + Consider Epinephrine

• Severe. Epi + Diphenhydramine + Code Blue

• It has long been recognized that anxiety plays a role in evoking and potentiating contrast reactions. (anecdotal)

Delayed Reactions

• Fever, chills

• Rash, flushing, pruritis

• Arthralgias

• Nausea, vomiting

• Headache

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Nonanaphylactoid Reactions

• Nausea/vomiting

• Cardiac arrhythmia

• Pulmonary edema

• Seizure

• Renal failure

Contrast Induced Nephropathy (CIN)

• CIN (Syndrome) formation and concentration of toxins, inc. acidity in renal tubules\

• CIN a leading causes of hospital-acquired acute renal failure. It is associated with a significantly higher risk of in-hospital and 1-year mortality, even in patients who do not need dialysis

• Barrett BJ, Parfrey PS (2006). "Clinical practice. Preventing nephropathy induced by

contrast medium". N. Engl. J. Med. 354 (4): 379–86. doi:10.1056/NEJMcp050801

UC San Diego Health System Intravenous Contrast Media Guidelines – Adult

Approved by P&T Committee 10/17/2013, 6/18/2014

MCP 319.2, Contrast Media Use

• If serum Cr> 1.5mg/dL or GFR<50mL – notify MD

• If Cr >1.5 in the diabetic pt, (or>2non-diabetic), or GFR<30 – discuss with primary team

– Hydrate pt • Bicarb150 mEq in 1L D5W

• PO

• Mucomyst

• ESRD- Consult with pt’s nephrologist.

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Sedation

• Mild Sedation (Oral Ativan)

• Moderate Sedation (Versed/Fentanyl)

• Deep sedation/MAC (Propofol)

• General Anesthesia

Post-Angiogram

• Vital Signs/Site Exam/Pulses

-every 15 minutes X4, then 30 minutes X 4, then every 3-6 hours X4

• Femoral/Radial/Distal pulses

• Keep leg straight for 3-6 hours

• HOB can be elevated 20 degrees

• NO sandbags/bulky compression dressings

IF BLEEDING OCCURS…

• YOU NEED AT LEAST 2 PEOPLE

• Apply direct digital pressure, slightly above the puncture site

• CALL THE IR FELLOW OR ATTENDING

• Call the Primary Medicine team

• Rapid Response Team if unstable

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25 year old male, S/P MCA at high speed, with ICB, C4 fracture, pelvic and left femoral

fracture. Scheduled for OR for orthopedic stabilization of spine and pelvis.

Selected Case Studies

Indications for IVC filter • Contraindication to anticoagulation • Complication of anticoagulation (e.g., bleeding, heparin-induced thrombocytopenia) • Failure of anticoagulation (recurrent embolism or progression of DVT despite adequate treatment) • Chronic pulmonary thromboembolism

Gunther-Tulip IVC Filter Retrieval

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TIPS/DIPS

Mr. I.M. Sicky is a 44 year old male with h/o ESLD from HCV, and decompensated cirrhosis. GIB X2,

ascites, Hepatic encephalopathy Stage 1, Hepatorenal Syndrome type 2 with Cr 1.5

Request for TIPS for portal hypertesion, HRS

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Post-Procedure

• To IMU Telemetry or Direct Observation

• Hemorrhage-H/H as needed

• Hepatic encephalopathy-monitor for AMS, continue lactulose, rifaximin

• Infection-antibiotics for Gm negs

• CHF-monitor fluid status

• CIN/Acute Kidney Injury-Cr, fluid status, hold diuetics and beta blockers

• TIPS Patency-U/S abdomen

Ablation of Tumors

54 y.o male, s/p TACE for HCC one month ago. Scheduled for staged radiofequency ablation (RFA) of hepatic tumor.

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Therapy Types

SURGICAL RESECTION

FOCAL ABLATIVE THERAPIES

• Chemical Ablation (ethanol, acetic acid)

• Thermal ablation (radiofrequency,microwave, laser, cryoablation)

REGIONAL THERAPIES

• Transarterial Chemoembolization (TACE)

• Selective Internal Radiation Therapy (SIRT)

• Bland Embolization

SYSTEMIC THERAPY

Zone of Coagulative Necrosis Created by 4cm Umbrella Array

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RFA

• All patients are admitted for pain control, r/o pneumothorax, hydration

• Can be performed for lung lesions

-often with chest tube post-RFA

-pain, oxygenation are issues

• For deep hepatic tumors, induced pneumothorax during procedure to mobilize lung from area

-serial CXR, HCT

Complications

• Hepatic Abscess

-Non-intact Sphincter of Oddi

-Biliary Obstruction

• “Heat Sink” effect

• Burns

• Electric Shock

• Tumor Seeding (<1%)

• Fistulas

VIR Percutaneous Gastrostomy Tube (PGT)

• OPEN placement of tube

• Thin barium given the PM before the procedure

• NPO After midnight

• Admitted overnight, NPO until examined by VIR the next day.

• First feed is WATER

• NO CRUSHED OR UNDISSOLVED MEDS! NO PSYLLIUM! Pharmacy consult for meds

• T-Tack removal in 11-14 days

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PGT: Pigtail or balloon secures the tube

Case Study-Diverticular Abscess

Ms. Pus C. Galore is a 79 year old female who presents with fever, abominal pain, and leukocytosis in the ED. H/O colon resection for diverticular disease, CABG, and DM Type 2.

CT-Guided Placement of Diverticular Pelvic Abscess Drain

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THE FOUR QUESTIONS ABOUT DRAINS AND TUBES:

1. WHAT is it?

2. WHERE is it?

3. What is it SUPPOSED to do?

4. What am I supposed to do with it?

The Four Questions About Drains and Tubes

1. WHAT is it? Pelvic Abscess Drain 2. WHERE is it? In the pelvic abscess 3. What is it SUPPOSED to do? Drain the pus in

the abscess 4. What am I supposed to do with it? Keep it

safe and patent, monitor and record the drainage, re-open after tPa treatment,obtain cultures as needed, flush with NS, change the dressing, teach patient and family drain care.

Case Study-Post-Renal Tx.

Ms. B.C. is 3 days post renal transplant. He c/o severe RLQ pain, temp is 100.3, WBC is 11.5. Abd U/S shows a perinephric fluid collection in the transplanted kidney.

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Renal Transplant Collections

Remember “HULA”:

Hematoma

Urine

Lymphocele

Abcess

THE FOUR QUESTIONS ABOUT DRAINS AND TUBES:

1. WHAT is it? Perinephric drain

2. WHERE is it? In the fluid surrounding the transplanted kidney.

3. What is it SUPPOSED to do? Drain the fluid around the kidney

4. What am I supposed to do with it? Keep it safe and patent, monitor and record the drainage, obtain cultures as needed, flush with NS, change the dressing, teach patient and family drain care.

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PCN

The Four Questions: Percutaneous Nephrostomy Tube

1. WHAT is it? PCN 2. WHERE is it? In the pelvis of the kidney 3. What is it SUPPOSED to do? Drain urine

produced by the functioning kidney 4. What am I supposed to do with it? Keep it

safe and patent, monitor and record the drainage, CALL THE MD for low or no output,obtain cultures as needed, flush with NS, change the dressing, teach patient and family drain care.

Safety Equipment

-Flush GENTLY

-Position is EVERYTHING.

For loose sutures, page the

responsible medical team

-Do NOT secure drainage bag to

the bed or bedclothes-one roll,

and it’s out.

-Use Burn Net belts for securing

-DSD daily

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Pt. M.S. is 3 months out from her 2nd liver transplant.

She presents in the ER with AMS, nausea, vomiting,

and chills. Abdomen is slightly tender.

Lab results

Glu-240; Cr-2.0; K-4.8; Bic 18; Mg-1.2; Albumin-1.9; AST-100;

ALT-85

WBC-12.4K; Hct-24%;

Temp 100.5 BP-88/40

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IR Research Is Needed

Pre-emptive analgesia and improved intra-procedural agitation-sedation management in liver cancer

patients:

A quality audit with retrospective medical record review.

Michael J. Thompson, RN, MPA, CNOR

Clinical Nurse III

Rhonda K. Martin, RN, CNS, ACNP

Radiology Medical Group

Interventional Radiology

University of California, San Diego

Why Retrieve Filters?

• FDA recommendation

• SIR best practice

• Complications

– Migration

– Fracture

– Vessel Damage

– Increase risk of DVT

– Vena Cava syndrome

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Original process

Baseline • 8% retrieval rate • 92% un-retrieved/ lost

to follow-up

Dec 2013- 14 92%

Retreived

Not retreived

8%

Retreived

Not retreived

Died

LTFU

30%

Post (preliminary)

Pre

Retrieved/ DeclaredPermanent/ Ongoingfollow-up

LTFU

Lost to follow-up down to 4% from 92%

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Conclusion

• IVC retrieval rate up to 30% from 8%

• Lost to follow-up rate down to 3%

• Meticulous patient follow up

• Remember: If your patient had an IVC filter placed for prophylaxis and they are now on anticoagulation- they should get the filter out

• Ultimately: Could the process be automated?

UCSD IR Website • http://www.ucsdir.edu

Other IR Websites Society of Interventional Radiology

http://www.sirweb.org/

American Society of Radiologic Technologists

https://www.asrt.org/

Association for Radiologic and Imaging Nurses

(formerly American Radiological Nurses Association)

https://www.arinursing.org/