Ir -- Procedures

Front 1

How do you perform a TIPS?

Back 1

1. Catheter is placed in a hepatic vein (usually the right) via an internal jugular vein approach.
2. A directional needle is passed through the hepatic parenchyma into the portal venous system.
3. Portal venography and pressure measurements are made
4. Hepatic tract is angioplastied
5. Stent is placed bridging the hepatic tract from the portal vein to the hepatic vein.

Front 2

1. How do you do an angioplasty?
2. Are there any specific guidelines for distal arteries (e.g. in the leg or foot)?

Back 2

1. Intra-arterial heparin is mandatory (5000 units). Cross the stenosis with a wire and then do angioplasty. After the procedure, pts are maintained on an antiplatelet agent such as clopidogrel.
2. Distal lesions (e.g. in the leg) are approached using an antegrade ipsilateral approach (i.e. if the stenosis is in the right leg, then you puncture the right leg).

Front 3

How do you do an angioplasty?

Back 3

- A few days prior to angioplasty, the pt is started on plavix and aspirin.
- During the procedure, 5000 units of heparin is given intaarterially.
- Nitroglycerin (50-100 micrograms) is given to prevent vasospasm.
- Stenosis is crossed with a wire
- **Wire access is maintained throughout the procedure.
- Angioplasty balloon is chosen approximating the size of the vessel.
- Angioplasty of the vessel is performed 3 times.
- Repeat angiogram is performed to assess the adequacy of angioplasty. If there is residual stenosis >30% of the vessel diameter or 15mmHg of residual stenosis, or flow limiting dissection then you have to place a stent.
- Note: angioplasty creates a dissection as you are fracturing the intima. So a dissection is the expected result of an angioplasty. During angiogram, the false lumen will have mass effect upon the true lumen and will fill after the true lumen.

Front 4

What are the indications for an angioplasty?

Back 4

NOTE: angioplasty is only performed if patient is symptomatic.
1. Claudication
2. Resting pain
3. Non-healing ulcer
4. HTN/renal failure
5. Graft salvage

Front 5

How do you treat a postcatheterization femoral pseudoaneurysm?

Back 5

1. Ultrasound guided compression therapy
2. Direct percutaneous injection of thrombin into the sac.

Front 6

1. What are the different kinds of balloons?
2. How do you select an angioplasty balloon?
3. What are appropriate balloon sizes for renal, common iliac, external iliac, SFA, popliteal, and tibial arteries?

Back 6

1.
- Non-compliant: used for angioplasty. The balloon inflates to a preset diameter; additional pressure does not result in enlargement of the balloon.
- Compliant: used for occlusion and embolectomy.
2.
- Diameter: 10% larger than the normal unaffected vessel.
- Length: span the length of the lesion and should not extend more than 1 cm on either side.
3.
Renal = 6mm
Common Iliac = 10mm
External Iliac = 8mm
SFA = 6mm
Popliteal = 5mm
Tibial = 3mm

Front 7

Which types of lesions respond best/worst to angioplasty?

Back 7

BEST:
Short-segment circumferential stenosis.
WORST:
Long, diffuse calcified lesions do not respond well to angioplasty.

Front 8

What are the complications of angioplasty?

Back 8

1. Puncture site: hematoma, pseudoaneurysm.
2. PTA site: acute thrombosis, rupture
3. Distal complications: thromboembolism, cholesterol emboli

Front 9

1. How do you place a pull type gastrostomy tube?
2. What are the advantages of a pull type G-tube?

Back 9

1.
- Prophylactic antibiotics are given before the procedure.
- Intravenous glucagon (1 mg) to stop gastric peristalsis
- Stomach is insufflated via NG tube.
- Stomach punctured 2-3 cm below costal margin and T-fastener placed.
- Guidewire and sheath are advanced into the esophagus and mouth. The guidewire is attached to a snare device.
- Once out of the mouth, the snare device is connected to the G-tube and pulled into the stomach.
- Dilator portion of tube is cut and a rubber disk is affixed.
2.
- more durable
- more secure
- less prone to dislodgment
- less prone to peristomal leakage

Front 10

IVC filter placement

Back 10

- Gain access into the IJV
- Extend a wire and catheter into the IVC. Try to extend the catheter into the left common iliac vein to exclude caval anomalies.
- Do cavagram with full strength contrast 15-20cc/sec X 2-3 sec in an AP projection
- Note the diameter ot the IVC, evaluate the level of the lowest renal vein, and look for filling defects.

Front 11

Things to do before a procedure

Back 11

- Take an appropriate history and perform a physical examination.
- Review baseline labs: CBC, platelet count, WBC, coags, LFT's, BUN/Cr
- Review any appropriate imaging tests.
- Obtain consent
-

Front 12

How do you do a percutaneous transhepatic cholangiogram?

Back 12

1. Give prophylactic abx (Ceftriaxone 1g IV)
2. Pts get moderate sedation
3. The puncture site for a right sided approach is in the mid-axillary line below the level of the 10th rib making sure that you are below the costophrenic angle (to avoid going into the pleura) and above the colon. For a left sided approach, the puncture site is in the subxiphoid region.
4. Using ultrasound guidane, a skinny needle is directed into the liver. Contrast is injected as the needle is withdrawn until we opacify a bile duct.
5. A wire is inserted via the needle into the bile duct and negotiated past the stricture or into the duodenum via the CBD.
6. A drain is placed over the wire and connected to a bag.

Front 13

1. Indications for PTC
2. Contraindications for PTC
3. Complications of PTC

Back 13

1.
- Usually done in pts who have failed ERCP or cannot get an ERCP.
- Decompress an obstructed biliary system.
- Dilate a biiiary stricture
- Remove bile duct stones
2.
- Bleeding disorder
- Ascites
3. Sepsis, hemorrhage (hematemesis, bleeding from the tube, melena, intraperitoneal hemorrhage as you puncture the liver capsule), death (1-2%).

Front 14

Cholecystostomy tube

Back 14

- 2 approaches: Transhepatic or transperitoneal.
- The transhepatic approach allows for earlier removal of the catheter due to the shorter time to development of a mature tract.
- When considering removal of percutaneous cholecystostomy tube:
1. Pts sx have resolved.
2. Do cholangiogram to make sure that there is no obstruction to bile flow and there are no stones in the gallbladder.
3. Do a trackogram by removing the catheter from GB over a wire while injecting contrast. You can remove the catheter if a mature tract has formed and there is no leakage into peritoneum (usually takes about 3-4 weeks).

Front 15

What are the advantages and disadvantages of a right sided PTC?

Back 15

Advantages:
1. Draining a larger portion of an obstructed liver.
2. The physician can more easily avoid hand irradiation.
Disadvantages:
1. More painful and harder to manage for the pt.
2. Due to pain with inspiration, may lead to atelectasis/PNA
3. Increased risk of traversing the pleura

Front 16

What are the advantages and disadvantages of a left sided PTC?

Back 16

Advantages
1. Subxiphoid approach avoids the pleura
2. Less discomfort with respiration and easier for the pt to manage the catheter.
3. Often better for Klatskin tumors as it takes a more straighter course.

Disadvantages:
1. Š Less hepatic parenchyma is drained.
2. The stomach or transverse colon may reside within the proposed needle track. Use US.
3. Operator hand exposure is potentially increased.
4. Watch out for internal mammary vessels.

Front 17

Flow rates

Back 17

Aortic arch: 30mL for total of 60mL
Abdominal aorta and IVC cavagram: 20cc for 40cc.
SMA/Celiac: 6cc for 30cc
IMA: 3cc for 25cc.
Renal: 6cc for 12cc.

Front 18

Filming Sequences

Back 18

In general, you want to obtain an arterial phase, capillary phase, and venous phase.
- 3 for 3 then out: film 3 images for 3 seconds then one image per second until 20 images.