Applied Interventional Radiology

12/11/2021

A day in the life of this

24/01/2020

29 yo female presents to ER with anemia, profound hypotension and vaginal bleeding. She is s/p cesarean section one month ago which complicated by two episodes of heavy post-partum bleeding that led to treatment one week ago with a D & C (dilation and curettage). Hg at presentation is 6.3. CT in the arterial phase (image 1) shows subtle abnormality on the left in the lower uterine segment. This persists on the venous phase (image 2). Angiogram was performed and demonstrates extravasation from a right uterine artery pseudoaneurysm (image 3 and 4). 6cc of Gelfoam slurry embolization of the uterine artery appeared to achieve stasis (image 5), but a five minute delayed internal iliac angiogram surprised me by revealing persistent hemorrhage (image 6). The microcatheter was advanced to the pseudoaneurysm but could not be advanced beyond it (image 7). Coil embolization was performed and follow up internal iliac angiogram showed cessation of bleeing and thrombosis of the uterine artery (image 8). A contralateral internal iliac artery angiogram was performed to interrogate for cross pelvic collateral flow which is absent (image 9).

Have any of you been surprised by the failure of a gelfoam slurry to achieve embolization of pelvic arteries?

Peace.

23/01/2020

76 yo male with sepsis and right renal stones on CT (image 1). Patient underwent a percutaneous nephrostomy placement. Usually, for patients with renal stones, I obtain access via direct puncture under fluoroscopy. However in this case I was surprised to see that the stones which were so apparent on CT were radiolucent at fluoroscopy (image 2). US showed the echogenic shadowing calculi nicely (image 3), and was used for uncomplicated access to the inferior pole. Contrast nephrostogram (image 4) shows large filling defects at the ureteropelvic junction and within the calyx representing the large stones.

In IR it always pays to expect the unexpected.

Peace.

,

29/11/2019

Trainees in Interventional Radiology -

Always ask yourself the following four questions:

1. Does the potential benefit to the patient from the procedure outweigh the risk?
2. Is there a lower risk alternative which can achieve the same benefit?
3. What could go wrong?
4. How will I manage any complication?

Remember, nothing is ever routine.

13/10/2019

Interventional Radiology Tutorial: Gelfoam Pledgets for Hemostasis after Solid Organ Biopsy

How to use Gelfoam Pledgets to achieve hemostasis after a percutaneous biopsy of the liver or kidney

11/10/2019

Image 1 is from a routine CT guided random biopsy of the liver for abnormal liver function tests in a middle aged woman who did well and was discharged pain free after three hours of observation. Patient then returned to the ER approximately 12 hours later tachycardiac, hypotensive and obtunded. CT with contrast was obtained (image 2) showing extensive parenchymal and subcapsular hemorrhage grossly disproportionate to the routine biopsy. Angiogram (not shown) revealed at least three small left hepatic artery pseudoaneurysms which were embolized and the patient recovered. Take home point - there are no “routine” biopsies.

11/10/2019

"Until those laws, regulations, quality metrics and criteria are revisited, we will have to live with a heart-breaking conflict between what well-intentioned experts think is good practice and what our health system and laws incentivize,"

This quote nicely describes the nature of the moral injury which has become an inevitability in the practice of medicine and explains the high burn out rates and emotional divestiture of physicians today. Although this comes from an article on opioid withdrawal, virtually all medical decision making is filtered through a densely tangled mesh made of laws, regulatory controls, research restrictions, payer policies which are essentially implements of financial extortion, unproven quality metrics, and fears of litigation (or in extreme cases like the opioid epidemic even fears of incarceration). The only outcome can be actual injury to a physician’s practice or moral injury to a physician’s psyche.


Quote Credit - https://www.npr.org/sections/health-shots/2019/10/10/768914092/dont-force-patients-off-opioids-abruptly-new-guidelines-say-warning-of-severe-ri

13/04/2019

This is a 28 yo patient from Muhimbili National Hospital in Tanzania who needed a biopsy. Tanzania has begun an ambitious project to bring IR to their country by collaborating with Yale University and other prestigious academic centers to bring volunteer physicians, nurses and technologists to train their gifted and compassionate radiology residents in the art and science of this essential field of medicine. The project is on Instagram at . Give them a follow and watch the amazing transformation of Tanzania’s healthcare as it happens over the next few years. My time will be up soon, but the residents and staff radiologists, nurses and techs have impressed me immensely and are poised to truly save and improve innumerable lives. It’s great stuff.

10/04/2019

I have the pleasure and privilege of serving the great people of Tanzania for two weeks at Muhimbili National Hospital helping the talented physicians build the first Interventional Radiology program in this country of 46 million people. There is a tremendous need for these services and the potential among these gifted and compassion healthcare workers is abundant. To learn more about this project organized by Yale University, or to simply follow along, check out on Instagram or facebook. It’s good stuff.
@ Dar es Salaam, Tanzania