Brian Holben R.T.(R)(VI)(ARRT)avir.org/pdf/panel.pdfBrian Holben R.T.(R)(VI)(ARRT) What is a...
Transcript of Brian Holben R.T.(R)(VI)(ARRT)avir.org/pdf/panel.pdfBrian Holben R.T.(R)(VI)(ARRT) What is a...
Brian Holben R.T.(R)(VI)(ARRT)
What is a percutaneous nephrostomy Anatomy Indications Contraindications Pre-procedure evaluation Patient preparation Procedure Techniques w/ case studies
It is an interventional procedure in which access through the skin via a needle is obtained into the renal pelvis of the kidney.
Can be referred to as a PCN or PercNeph
Renal Calyx
Case courtesy of Dr Omar Bashir, Radiopaedia.org
Brodel’s Bloodless Line• Posterior portion of
Kidney• Relatively Avascular• Main artery divides into
anterior and posterior branches
Drainage of obstructed renal collecting system◦ Most common
Percutaneous access for urologic interventions◦ Percutaneous nephrolithotripsy◦ Antegrade ureteral stenting◦ Stricture balloon dilation◦ Tumor biopsy/ ablation
Urine diversion◦ Urine leak/ fistula◦ Hemorrhagic cystitis◦ Decompress urinoma
Uncorrectable coagulopathy
Prior Imaging◦ Cross-sectional Kidney Orientation Stones Duplicate collecting system
Relevant Labs◦ INR 0.9-1.2◦ Platelets 150-450◦ PTT 32-45sec◦ Serum Creatinine 0.5-1.2
Informed consent
◦ 59-year-old male◦ History of metastatic renal cell carcinoma◦ Per prior CT Peroneal Lymphadenopathy Left ureteral Obstruction Evidence of Hydronephrosis
Abdominal Bladder
- Renal Cortex- Renal Calyx
-18G Hawkins Needle- Needle Guide
- Contrast was injected to confirm needle location.
.035 180cm Amplatz wire-Key image
After NT is placed contrast was injected to confirm placement into the renal pelvis.
68-year-old female History of Transitional cell carcinoma of the
bladder Right ureteral CIS Left tube for BCG therapy
Abdominal Bladder
Non-dilated Calyces not easily
visualized.
“Down the barrel”
Inject contrast to highlight system Inject air to highlight posterior calyx
2nd 22-gauge Chiba needle accessKey Image
Confirm placement of Nephtube into the renal pelvis
Abdomen Bladder
Covey, Anne M, John E Aruny and Krishna Kandarpa. "Percutaneous Nephrostomy and Antegrade Ureteral Stenting." Kandarpa, Krishna and Lindsay Machan. Handbook of Interventional Radiologic Procedures. Philadelphia: Lippincott Williams & Wilkins a Wolters Kluwer business, 2011. 590-610.
Dogra, Vikram s and Wael e Saad. Ultrasound-Guided Procedures. New York: ThiemeMedical Publishers, Inc., 2010.
Kogut, Matthew, Todd L Kooy and Steven B Oglevie. "Urologic and Genital Systems." Valiji, MD, Karim. The Practice of Interventional Radiology. Philadelphia: ElsevierSaunders, 2012. 684-695.
Endovascular Abdominal Aortic Aneurysm Repair
David B. Nicholson RT(R)(CV)Clinical Coordinator
Charles J. Tegtmeyer School of Interventional Radiology and Special Procedures
AVIR- Vice President
Objectives
• Proper patient selection– Pre-imaging– Anatomical
Considerations• Properly sizing an
endograft– Measurements– Device selection
• Procedure– Inventory– Procedural Steps– Intra-procedural
imaging– Follow-up Imaging
Endovascular AAA Repair
Indications
High-risk/Low-
risk surgical candidates
Staging procedures
Minimally Invasive
Anatomical Considerations
Angulation/ TortuosityCalcification/ Thrombus
Diameter
Prox Aorta
Iliacs
Distal Aorta
Femorals
Ideal Morphology
• Adequate iliac/femoral access compatible with the required introduction systems.
• Iliac artery distal fixation site that has:– length >10 mm
(preferably > 20 mm)– diameter 7.5 to 20 mm
• Non-aneurysmalinfrarenal neck that has:– length >15 mm– diameter 18 to 28 mm
(outer wall to outer wall)
– angle <60º relative to long axis of aneurysm
– angle <45º relative to axis of suprarenal aorta
Pre-Imaging
Measurements
Procedure- Inventory
• Access sets depending on approach• Wires, both general for access and gate selection and
stiff wires for device delivery• Catheters- diagnostic, flush, and calibrated• Balloons- aortic balloon, angioplasty balloons• Sheaths- Depending on devices and vessel integrity
Bilateral Access• Primary- Main body of device• Secondary- Imaging and delivery of contralateral limb
Femoral Access
Positioning the Endograft
Cannulating the Gate
Confirmation of Cannulation
• Ipsi limb injection• Rotating of catheter in neck
Sizing Contralateral Limb
Key areas to visualize• Flow Divider• Bottom of gate• Internal iliac artery
Molding Endograft
Key areas to dilate• Proximal neck• Gate overlap• Both Iliac distal limbsPrecautions• Be aware of flow divider • Be conservative with non grafted vessel
Preferred Order of Dilitation• Proximal neck (from contra side)• Overlap (from contra side)• Distal iliac on contra side• Proximal neck (from primary side)• Distal iliac on ipsi side
Molding the Endograft
Molding the Endograft
Post Angiogram
Areas to identify• Renal arteries• Internal iliacs• External iliacs• Graft patency• Endoleaks
Post Angiogram
Case Discussion
Case 1
20yo F with lower abdominal, pelvic pain that is worse on the left than the right. Pain is worse after standing, but
is relieved if she lies down
Diagnosis
• Enter your diagnosis here_____________________________________________________________________
__________________________________
Answer- Case 1
• Nutcracker Syndrome (Phenomenon) also known as “left renal vein entrapment”
• Clinical Presentation:– The most common clinical manifestation of the nutcracker syndrome is intermittent macroscopic hematuria.– Pelvic pain with relief upon lying down and elevation of the legs
• Treatment options: – left renal vein transposition – superior mesenteric artery transposition – nephrectomy – endovascular stent placement
Dan Bernard BS.R.T.(R)(VI)
Transjugular Intrahepatic Portosystemic Shunt
◦OR……
Totally Intterupted Plans◦ On
Saturday
A Non-Anatomic pathway created to allow blood to bypass the diseased liver.
The pathway(Shunt) is created through the liver Parenchyma connecting the Portal Vein directly to the Hepatic Vein.
Portal Hypertension, Primarily caused by liver Disease.◦ Bleeding Varices◦ Refractory Ascites
Tips is considered if PT does not Respond to initial Medical Therapies.
Bleeding Varices◦ Primarily Esophageal
Refractory Ascites
Bud-Chiari Syndrome-Hepatic Venous outflow obstruction
Hepatic Hydrothorax Hepatorenal Syndrome Hepatopulmonary Syndrome Ectopic Varices
Absolute◦ Right sided heart failure with increased central
venous pressure.◦ Polycystic Liver disease◦ Severe hepatic Failure
Relative◦ Active intrahepatic systemic infection◦ Severe hepatic Encephalopathy◦ Portal Vein Thrombosis
Ultrasound◦ Access and the identification of Refractory Ascites.
Flouroscopy
Needle for jugular access Tips needle Wires◦ .018 if using micro puncture.◦ .035 Bentson or floppy tip wire.◦ .035 Glide Wire◦ .035 Amplatz or stiff wire
Sheath◦ 10 fr 40-45cm with a radiopaque distal tip
Catheters◦ 5 fr. MPA or angled for access in Hepatic Vein◦ 5 fr. Sizing Pig Tail for Stent
Balloons◦ Occlusion balloon for wedge pressure.◦ Angioplasty balloon for Tract Dilation.
Stent◦ Grafted Viattor
Jugular access. .035 wire into IVC. 10 fr Sheath placed first for support. Hepatic Vein accessed with MPA Catheter Wedge pressures performed and and Co2 inj
for portal venous phase. Amplatz wire placed into hepatic Vein.
Tips needle is inserted and plunged into the liver parechyma toward the portal vein.
Once portal Vein is accessed a stif wire is advanced into the Duodenum.
The sizing catheter is then placed for venogram to determine the correct length for stent.
The Stent is then placed and the shunt is created.
Post dilation may need to be perfomeddepending on secondary Pressure measurments.
Goal is 8-12 gradient
Encephalopathy-◦ Can be improved by partialy occluding shunt
Tips worsens hepatic functions so hepatic failure is a possability.
Good Luck!
Percutaneous Transhepatic Cholangiography ALISHA HAWRYLACK RT(R)(VI)
Right Hepatic
Left Hepatic
Common Hepatic
Common Bile
Cystic
Percutaneous Transhepatic Biliary Drainage
Why?Why?
Compression or obstruction impedes the normal flow of bile from the liver to the intestinal tract.
Percutaneous Transhepatic Biliary Drainage
Obstruction
Malignant Obstruction
Stone
Anastomotic stricture
Leak
Surgical
Percutaneous Transhepatic Biliary Drainage
Biochemical derangements Jaundice
Cholangitis Pruritis
Risks
Percutaneous Transhepatic Biliary Drainage
Contraindications
Coagulopathy
Ascites
Contrast allergy
Diffuse hepatobiliary disease
Percutaneous Transhepatic Biliary Drainage
Review imaging Predict cholangiogram
Plan appropriate
access
Percutaneous Transhepatic Biliary Drainage
Right Sided Biliary Drainage• Low intercostal approach near the
midaxillary line• At or below the superior margin of the 11th
ribLeft Sided Biliary Drainage • Visualized utilizing US• Needle is advanced into the liver and
angled approximately 30-45 degrees posteriorly and superiorly
Percutaneous Transhepatic Biliary Drainage
Percutaneous Transhepatic Biliary Drainage
Percutaneous Transhepatic Biliary Drainage
Percutaneous Transhepatic Biliary Drainage
Percutaneous Transhepatic Biliary Drainage
Percutaneous Transhepatic Biliary Drainage
Complications
Sepsis
Hemorrhage
Pleural transgression
Death
Percutaneous Transhepatic Biliary Drainage
Post Procedure Care and Follow Up• Monitor patient
• Infection • Bleeding
• Resume pre-procedure diet• Continue antibiotics• Educate patient regarding dressing changes and follow
up procedures