Interventional Radiology and the Critically Ill

Reviewed and revised 21 December 2015

OVERVIEW

Main goals of interventional radiology (IR) therapies:

• stop bleeding without the physiological stress of surgery (embolisation or balloon occlusion)
• relieve obstruction (e.g. stents, directed thrombolysis, balloon dilatation)
• drain collections
• insert therapeutic or prophylactic devices (e.g. pacemakers, IVC filters)

IR should be considered in critically ill patients when the risk of more invasive procedures is greater

INDICATIONS

Haemorrhage

• transcatheter arterial embolisation (e.g. hepatic, splenic, pelvic, GIH, pulmonary)
• preoperative placement of uterine artery balloons prior to Caesarean for placenta percreta (control of bleeding during Caesarean Hysterectomy)
• Angioseal of cannulated vessel e.g. inadvertent arterial insertion of vascath

Venous

• IVC filter in prevention of PE
• TIPS procedure in portal hypertension
• thrombolysis and thrombectomy e.g. ileofemoral DVT, thrombosed AV fistula
• Vascular access eg Hickman, PICC lines

Aneurysms

• coiling in berry aneurysms
• endovascular stent placement in AAA

Ischemia

• coronary interventions in AMI
• angioplasty or vasodilators in vasopasm
• carotid stenting
• intra-arterial thrombolysis or thrombectomy

Mass lesions and collections

• guided biopsy/drainage

Device insertion

• AICD or pacemaker/pacing wire insertion
• percutaneous valve replacement
• IVC filter insertion
• PEG insertion

Obstruction

• Colonic stenting
• nephrostomy insertion for obstructed kidney

Diagnostic

• Angiography to diagnose vasculitis, cerebral thrombosis, region of haemorrhage (especially intestinal), brain death

ADVANTAGES

•  anecdotal cases and case series suggest effectiveness
• avoids physiological stress, complications and recovery times of surgery and anaesthesia
  — e.g. elderly or multiple co-morbidities
  — e.g. critically ill where surgical risks high such as laparotomy to drain abscess
• preserves organs — e.g. avoid splenectomy, avoid hysterectomy in post-partum haemorrhage
• minimal cosmetic effects
• can be as effective as surgery with lower morbidity and mortality
  — Preferred strategy in management pelvic trauma
  — good evidence in aneurysmal SAH

LIMITATIONS

• absence of high quality evidence in most settings (especially long-term outcomes)
• remote location anaesthesia and difficult access to patient
• requires specialised IR staff and equipment, systems and protocols to be developed
• still need surgical back up if there is failure or if there is a complication
• risks of contrast (contrast induced nephrotoxicity and anaphylactoid reactions
• radiation exposure and long-term cancer risk
• complications specific for each interventional procedure
• time, cost and availability
• lack of 24 hour cover (<10% centers in the USA)

CONTROVERSIES

• increasing role in unstable patients
• evidence base
• pelvic hematoma management (embolisation to decrease arterial inflow in the absence of blush)