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Home , Interventional radiology

Volume 13 No 3 / Jun 2017

Quarterly publication of The Royal Australian and New Zealand College of Radiologists

THE FUTURE OF INTERVENTIONAL Introduction

A Day in the Life of a Modern Unit

Interventional radiology (IR) has been It’s 7:30am on Wednesday morning and many of them with treatment histories a dynamic field since its inception the HCC meeting is about to start. The stretching back years. We have come over 50 years ago through the work room is filled with gastroenterologists, a a long way from an average life of early pioneers in the field. In hepatic surgeon, oncologists, diagnostic expectancy of seven months. 1964, Charles Dotter described and and interventional radiologists, IR By 8:30am, it’s time to get going on the performed the first and and HCC staff and keen first case of the day. He is a 54-year- in the years that followed, he and . It’s a relatively new old hypertensive vasculopath with other innovators brought about a meeting borne out of the UGI meeting calcified vessels and critical stenoses revolution in procedural with that was at risk of stretching to several of his renal . He was seen in the development of directed hours by the prospect of an ever- the interventional several weeks and other minimally invasive increasing tide of chronic before for a pre-procedural assessment image guided techniques. (viral and NASH) predisposing to HCC. where he was fully worked up and Today, modern IR and the healthcare The first patient is a 65-year-old female paperwork completed so there are no system in which it operates is with cirrhosis, Child-Pugh A and ECOG hold ups getting him on the table. The dramatically different to that of years 1. She’s been treated in the IR unit nurses are a little anxious that his blood past. While technical prowess has for several years initially having had a pressure is sitting above 200 systolic often been the foremost attribute of ablation of a small lesion in but after titrating it down with some an interventional radiologist, more her right lobe followed by a DEB-TACE IV hydralazine everyone is a little more recently there has been a growing settled and we can get going. The awareness that procedural ability case starts with a cone beam CT on the is only a component of the skill “Modern IR and the table of the single plane, floor-mounted set required by IRs to thrive in the departmental workhorse. This is then modern healthcare environment. healthcare system in fused to the CT angiogram to give a 3D map of the and visceral vessels Internationally, the transformation which it operates is enabling renal access without of interventional radiology into a drop of contrast. Have to keep the an integrated clinical specialty is dramatically different nephrologist happy. well underway. Whether through outpatient , dedicated wards to that of years past.” In the biplane suite next door, the IR or primary patient responsibility, fellow is scrubbing for a PTC on a yellow IRs are increasingly becoming and 70-year-old woman who’s been waiting embolisation to a subsequent lesion in importantly seeing themselves as for several days for the procedure. The segment 4a. Her one month follow up first and foremost clinicians. We have hold-up has been anaesthetics, not that CT demonstrates a rim of enhancement come full circle and are being given it’s their fault. The only funds at the site of recent embolisation lessons by our colleagues in medicine, two general anaesthetic lists per week and we discuss the possibilities of and radiation , which and they only start after they’ve finished persistent disease versus post treatment we must learn. the electroconvulsive list in . The discussion turns to theatre. Who would have thought there From angioplasty and stenting her willingness for further interventional is that much ECT going on? So we have to coiling and clot retrieval, options as well as the possibility for had to fight for this add on list and there embolisation, ablation and the broad sorafenib chemotherapy. Additional will need to be a bus crash for us to let suite of ; loco-regional therapy with a repeat the anaesthetists escape back to their the ways in which IRs can treat our embolisation could be warranted but emergency theatre lists. patients has expanded dramatically the alpha fetoprotein has dropped to and consistently and almost every almost nothing and we are just not We’re not sure what’s causing her biliary branch of medicine has benefited. sure if that smooth rim of enhancement obstruction but is With so many new and compelling is definitely a tumour. The decision is the most likely cause. She failed ERCP developments and a shifting self- made for close imaging follow up and due to a previous Billroth II, it’s unclear perception within the profession, subsequent discussion. The meeting why they attempted at all, so the only it is an exciting time to be an moves on to the next patient and so other option for decompression and interventional radiologist! it goes for the ten patients on the list, a tissue diagnosis is percutaneously

6 Inside News Introduction

through the liver. The �ellow has done this be�ore so he’s le�t to himsel� to gain access to the biliary tree with guidance and fuoro i� that �ails. Meanwhile the vascular team stick their heads in; they want to discuss a couple o� cases. There are patients with , both outpatients, who will require stenting. These are generally done as combined cases with vascular and IR and the results over the last �ew years have been solid. We all huddle around the Terarecon workstation as we measure the vessel size, length o� the plaque and try to predict how the vessel will react to landing the along that curve o� vessel. Satis�ed the vessel won’t kink and that the embolic protection device is going to sit nicely through the procedure, we lock the cases in �or next week.

As this is going on, the pressure the IR ward next to surgical short stay patients o�ten wake up with no more measurements across the renal artery there are always a �ew outliers and than a mild ache in their back, i� at all. stenoses are signi�cant at >25mm Hg patients with drains can be all over the She’ll head home with her daughter and and the go in without issue. The hospital. The 75-year-old whose small we’ll see her in clinic in three months post angiogram doesn’t show any renal RCC we cryo-ablated yesterday is so time with a CT. The urologist is happy per�usion de�ects so everyone is happy asymptomatic she doesn’t believe we �or us to �ollow her up and grate�ul she with a job well done. Access was with a actually did anything and the reg was has another option to o��er her patients 7F sheath via the right common iliac and hard pressed to convince her otherwise. particularly �or stroppy older �olk who given that we started him on clopidogrel She was admitted under the IR service won’t contemplate surgery. in clinic, it isn’t going to be �un pressing on the groin �or the next hal� an hour... There are no other issues on the round. especially as the �ellow is busy next The uterine �broid embolisation patient door. We decide on a closure device “Some �ancy wirework has her PCA down and is going home. which deploys well under ultrasound She was re�erred by an out o� area guidance. The patient will �ollow up with by the director is all it O&G and was also admitted under IR the nephrologist and we hope to see the without a problem except �or the middle blood pressure signi�cantly lower than takes and the catheter o� the night phone call to the on call when he arrived this morning. In the pops satis�yingly into IR, like clockwork at 2:00am, in regard meantime, we try to get him out o� the to the patient’s cramps. All the drains hospital and away �rom a blood pressure the duodenum.” placed over the past �ew days are either cu�� be�ore the hydralazine wears o��. draining well or out, and at 10:30am the resident has ward chores to do and The IR registrar, rotating �rom the reg is sent to consent the patients overnight only because she lives in diagnostics �or three months, is back waiting in trolley bay and get stuck into a small town several hours away and in the unit having �nished the morning some and a �ew more drains. ward round with the resident; it always couldn’t get home late in the a�ternoon. takes a couple o� hours. Even though We’re not surprised she’s a bit con�used most o� the patients are nursed in by it all; cryotherapy is so well tolerated continued over...

Volume 13 No 3 I June 2017 7 Introduction

Back in biplane the PTC is dragging day. It will need to be done in the hybrid The neuro IR’s are kicking off their on, not because of access issues but suite, which sits in IR directly next to list in biplane now as well. There’s an rather the tight stenosis blocking the theatre in case orthopedics need to get to coil and a few follow up CBD. The fellow is suggesting a sharp involved at the same time. cerebral DSAs. It already feels like a full recanalisation option, which is perhaps day and it’s only 2:00pm... Down the corridor, we are prepping for a little premature even two hours in. the artery embolisation case on Some fancy wirework by the director the chatty 63-year-old gentleman with is all it takes and the catheter pops Dr Jules Catt BPH. He’s a little anxious; he flew over satisfyingly into the duodenum. The Consultant Interventional Radiologist from New Zealand for the procedure biliary forceps are advanced down the Liverpool and Prince of Wales , and anyway most men are about this sheath and bite off several small pieces Sydney kind of thing. We’re hoping he’s going of tissue at the level of the occlusion. to be as happy as the last guy, who two Dr Glen Schlaphoff Usually deployed via an endoscope, weeks later proudly proclaimed he was Director of Interventional Radiology they have found a home in our IR suite peeing like a racehorse and had never Liverpool Hospital, Sydney as a useful addition to the bag of tricks. felt better. It’s a PIRADS 2 and the MR There’s blood casting in the ducts on the shows the prostate pressing up into the cholangiogram and while the bladder with a particularly large central will almost certainly return a malignant zone. It’ll be radial artery access so when result, the decision is made to let things Would you like to contribute it’s all done he’ll be up and walking settle down and bring the patient to the feature articles of Inside about within the hour – they are always back in a few days’ time for a check News? Contact Sarah Hall pretty keen to get to the bathroom. cholangiogram followed most likely by on [email protected] We’ll follow up by phone. biliary stenting. or +61 2 9268 9752. It’s lunch time now and International Nurses Day. This of course means a departmental shut down and we take the opportunity to check out the new coffee shop recently opened in the hospital foyer. We run into the hospital General Manager and stop to chat. She’s appropriately proclaimed 2017 as the year of interventional radiology and we are hoping this translates into a few more nurses and radiographers, even if not the combined angio/CT suite and interventional MRI we are all barracking for. Lunch is interrupted by a call from the ED staff. They are helicoptering in a pedestrian vs car with almost certain pelvic fractures and a blood pressure through the floor. We advise to take them straight to IR where we’ll need to do an emergent angiogram and likely embolisation of the iliac arteries. It’s a little uncommon to get trauma cases at this time and despite how it throws out the list, everyone will be happy to do this kind of difficult case in the light of

8 Inside News