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