Volume 13 No 3 / Jun 2017 Quarterly publication of The Royal Australian and New Zealand College of Radiologists THE FUTURE OF INTERVENTIONAL RADIOLOGY Introduction A Day in the Life of a Modern Interventional Radiology 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 angioplasty and and HCC nursing staff and keen first case of the day. He is a 54-year- in the years that followed, he and radiographers. 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 medicine with that was at risk of stretching to several of his renal arteries. He was seen in the development of catheter directed hours by the prospect of an ever- the interventional clinic several weeks therapies and other minimally invasive increasing tide of chronic liver disease 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 microwave 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 aorta and visceral vessels Internationally, the transformation which it operates is enabling renal artery 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 clinics, 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 hospital 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 surgery and radiation oncology, which and they only start after they’ve finished persistent disease versus post treatment we must learn. the electroconvulsive therapy list in inflammation. 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 interventional oncology; 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 cholangiocarcinoma 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 ultrasound 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 carotid artery stenosis, 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 stent 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 stents 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 biopsies 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 aneurysm to coil and a few follow up CBD.