emergency ir-bengaluru-2016-dr shyamkumar n keshava

Emergency Interventional Radiology

Dr Shyamkumar N Keshava MBBS DMRD DNB FRCR FRANZCR

Professor and Head Department of Radiology

Christian Medical College, Vellore. India

Society for Emergency Radiology 2016. Bengaluru

Emergency IR: challenges

May be life saving!

Most of the indications include life threatening haemorrhages, sudden vascular occlusions, obstructed systems (biliary, urinary)

Definitive or “tide over”

• Confirm the emergency

• Identify the system / site of problem – clinical, scopies, imaging

• What is the preferred treatment?

Emergency IR: challenges

Risk versus benefit

Emergency IR: challenges

A 51 year old lady with carotid body tumor

243965C

19 05 2010

20 05 2010: 10.30am

•Surgical excision of carotid body tumor; internal carotid artery was temporarily clamped during the procedure

•Immediate post-operative period – no problems

20 05 2010: 5.30pm

•Dense left hemiparesis

20 05 2010: 5.49pm

20 05 2010: 6.15pm

A 51 F

Dense deficit

Window period ? 7hours

No haemorrhage

No established infarct

“Time is brain”

Penumbra – mechanical clot retriever

20 05 2010: 6.40pm

A young man, epistaxis 1 month following trauma

A 30 year lady with massive haemoptysis

Natural course of massive haemoptysis in bronchiectasis

“Massive haemoptysis most often is episodic in nature”

Spontaneous massive haemoptysis (due to rupture of a hypertrophied systemic artery)

Fall in BP, local haemostasis

Cessation of the bleeding

Aortogram

PVA particles 250-500 microns

Outcome N Success Failed BAE

Repeat BAE

Death Sucessful Repeat BAE

Cause of Death

Hemoptysis control rate

Lost to follow up

Immediate (< 2 weeks)

58 54 4 3 1 2 Hemoptysis 93.1% 9

30 days 48 42 6 1 0 1 - 85.7% 0

3 months 43 39 4 0 1 0 Invasive fungal sepsis

79.5% 1

6 months 37 31 6 1 0 1 - 63.2% 2

1 year 30 25 5 1 1 1 Haemoptysis 51% 3

2 years 23 19 4 0 1 0 Respiratory failure

38.7% 3

After 2 years

15 12 1 0 3 0 Hemoptysis -2MDRTB

infection and hemoptysis-1

24.5% 0

BAE for massive haemoptysis due to TB or post TB sequelae (58)

Anuradha Chandramohan et al, CMC

• A 45 M - melena, fall in Hb

• Haemodynamically unstable

• Normal upper and lower GI scopies

• “Emergency angiogram negative”

Splanchnic Artery Aneurysms

Shabana F. Pasha et al Mayo Clin Proc. 2007;82(4):472-479

Splanchnic arterial aneurysms Covered stent Sandwich technique

A 45 year man post-Whipple’s with massive GI haemorrhage

778486D

Covered stent: Atrium 5mm x 22mm

An 82 year gentleman with lower GI bleeding, collapsed

Bleeding ulcer in the ascending colon on scopy

Post liver biopsy

Patient on Aspirin and Clopidogrel, presented with cough and severe abdominal pain

Case Study: Rapidly Enlarging Rectus Sheath Hematomas: The Value of CT Angiography in the Identification of Active Bleeding Master Mobin, Shyamkumar Keshava, Vascular Disease Management 4( 5) 2007. 156 - 158

Pelvic bleed – Arterial? Venous?

A 40 year old driver, c/o a swelling in the right supraclavicular region, not able to move right upper limb

Polytrauma, extradural hematoma one month ago

Slipped in guide wire

A young lady with acute DVT – left lower limb

Left SFV

Pulmonary embolism

Post-thrombotic syndrome (leg pain, swelling, skin pigmentation and leg ulcers)

Deep vein thrombosis (DVT)

Reduction in the volume of thrombus reduces the dose of thrombolytic agent

Check venogram

May- Thurner syndrome

Intervention – Balloon angioplasty

27 Feb 2012

A 36 year, lady –

Diagnosed to be having Budd Chiari Syndrome, on oral anticoagulation and Propranalol 15 months

Variceal bleed in January 2012: EVL done and oral anticoagulation stopped

She was being evaluated for DIPS: Doppler abdomen done on 27/2/12

1 Mar 2012

Presented with acute pain abdomen

Next option?

A.Medical management

B.Endovascular

wikipedia

Transjugular Intrahepatic Porto-systemic Shunt (TIPS)

US

Fluoroscopy

Direct intrahepatic cavo-portal shunts in Budd-Chiari syndrome: Role of simultaneous fluoroscopy and trans-abdominal ultrasonography. Keshava Shyamkumar N, Kota Gopi Krishna, Mammen Thomas, Jeyamani R, Moses Vinu, Govil Shalini, Kurian George, Chandy George IJG 2006

10 mm X 4 cm balloon

Oblique view

Post Ant

Suction thrombectomy 6F guiding catheter local tPA 10mg over 1 hour

2 year 3 months later

TIPS – 1) improving both the background BCS &

2) acute portal vein thrombosis

A middle aged man, short h/o painless jaundice,

MRCP showed hilar occlusion

Percutaneous cholecystostomy

Patient

I R manpower“Environmental”

Outcome Factors

Emergency IR: challenges

•Confirm the emergency

•No delay in decision making - Benefit vs Risk

•Identify the system / site of problem - clinical, endoscopies, imaging (CTA)

•Adequate knowledge about the anatomy, adequate hardware

•Consent

Emergency interventional radiology

A picture drawn by Ms MC, who presented with massive GI bleed

Thank you for your attention

All you need to know about Vascular AnomaliesVascular Anomalieshttp://www.cmcwintersymposium.com