emergency ir-bengaluru-2016-dr shyamkumar n keshava
TRANSCRIPT
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