Vascularmalformationsclerotherapy And/Orembolizationin IR

Vascular malformation sclerotherapy and/or embolization in IR Barbara Wilkey, MD Bob Ryu, MD

Purpose: The purposes of this document are 1) To provide education pertaining to the process of vascular malformation sclerotherapy and/or embolization in IR. 2) To provide peri-procedure management suggestions.

Content: This content is a combination of published literature and peer recommendation (Interventional Radiology and Anesthesiology).

The procedure Most common indications: treatment of symptomatic or enlarging vascular malformations of the face, chest, abdomen, pelvis or extremities

Length of procedure: 1-4 hours of IR MD time.

Antibiotic prophylaxis: ancef or clindamycin, although enteric coverage may be occasionally needed, depending on anatomic locations

Imaging: ultrasound, fluoroscopy

Contrast agents: intravenous/intra-arterial iodinated contrast.

Ancillary procedures: foley catheter for longer cases (3-4 hours), Swan-Ganz catheters for high embolic volume cases (rare)

Preprocedural testing: Routine laboratory tests including comprehensive blood chemistries (Cr, etc), hematology (plt >50K, nl WBC), coagulation parameters (INR<2).

Patient positioning: highly variable and entirely dependent upon location of the targeted lesion; the IR operator will position accordingly.

Procedural details: “Direct stick” treatment: percutaneous placement of needles into a visible lesion, followed by administration of contrast material. A sclerosant, such as sotradecol, bleomycin or ethanol, is delivered through the needle in small aliquots. Reassessment of the lesion is performed with fluoroscopy or ultrasound. This may be repeated several times into different parts of the lesion. “Transarterial” treatment: Access through an artery (usually common femoral), diagnostic arteriography of the targeted lesion, delivery of embolic material through the catheter. The catheter may be repositioned several times to treat different parts of the lesion. After the catheter is removed, hemostasis is achieved with aclosure device or manual compression. "Transvenous" treatment: Access through a vein associated with the lesion, diagnostic venography of the targeted lesion, delivery of embolic material through the catheter. The catheter may be repositioned several times to treat different parts of the lesion. After the catheter is removed, hemostasis is achieved with manual compression.

The Anesthetic

The pre-anesthesia assessment starts with a standard evaluation, with careful attention to the disease process requiring intervention.

Either general anesthesia or MAC is appropriate depending on location of vascular malformation and patient factors. IR and anesthesia attending should discuss and decide what is best for patient and procedural outcome.

Room Setup standard set up plus IV pumps for any necessary infusions.

Anesthesia induction: Induction agent of choice.

Maintenance of choice.

Emergence/extubation/disposition is at the discretion of the anesthesia team. Generally home after PACU stay.

Procedural Risks - Site infection - Bleeding - Access site hematoma - Soft tissue injury from sclerosant - Non-targeted embolization (local tissue injury, or distal vascular bed involvement; rarely, pulmonary artery hypertension) - Can have some pain post procedure