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)

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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