complicatons in intervention
TRANSCRIPT
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Complications in Radiology and
intervention Radiology
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Barium studies
Barium is an inert substance and is
incapable of triggering a reaction. salt is insoluble in waterso is not
absorbed through the intestinal mucosa.
This makes this salt nontoxic and safe forhuman use.
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Barium studies
Incidence of complication is 4.17%
Hypersentivity reaction
Impacton Perforation
Aspiration
Intestinal obstruction
Failure of ileostomy/colostomy closure
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Hypersensitivity reactions
Additives to provide properties of the
product.
Generally a well-kept secret
- carboxymethylcellulose
Aluminum hydroxide gel, simethiconePolyxethylene monooleate silica,
artificial sweeteners/flavors.
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Impaction
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Prevention of Barium Impaction
2 before - low-residue diet and fluids to ensure
adequate hydration. Day of the examination - patient should drink
plenty of clear fluids
Laxatives and Cleansing enemas.
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Prevention of Barium Impaction
75 percent barium - evacuated from the
rectum with the patient prone
Cannula is left in place for 10 minutes toallow further drainage of the barium.
Patient is encouraged to evacuate his or
her bowels into the toilet.
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Perforation
Colon or Rectum is a serious complication
of the barium enema examination,
occurring in 0.02% to 0.04% of patients.
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Perforation
Extraperitoneal perforation is usually less
catastrophic
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Perforation
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Perforation
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Perforation
Four mechanisms of injury
1) Trauma from the enema tip
2) Overinflation of the balloon3) Recent colonoscopic instrumentation
especially associated with biopsy
4) The presence of rectal mucosal diseasesuch as cancer, stricture, diverticulosis or
inflammatory bowel disease.
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Prevention
Safe tip-balloon design should be used.
Retention balloon should be inflated only
under fluoroscopic monitoring Barium studies should be avoided in
patients with active colitis.
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Prevention
In cases of deep biopsy or polypectomy,
the examination should be delayed by at
least six days.
Generation of pressure greater than that
created by a column of barium suspension
ofone metershould be avoided
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Management
Non-operative approach is safe in small
extra-peritoneal injuries.
Extensive, extraperitoneal extravasation, if
not immediately treated, may cause a peri-
rectal tissue infection and lead to fatal
septicaemic shock within a few hours or
days.
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Less extensive contamination may lead to
pelvic sclerosis with later development of
rectal and ureteric stenosis
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Free intraperitoneal rupture - Rise to a
hypotensive state which can prove fatal.
Adequate resuscitation and early resection or
primary repair and an aggressive effort to
evacuate as much barium as possible are
mandatory.
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Aspiration
Aspiration ofBarium Sulphate can lead to
fatal effect of aspiration pneumonia.
Happen old person and young children- with obstructive/ motility disorders
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Aspiration
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Aspiration Microscopically, most of the particles
accumulate in alveolar spaces and few in the
interstitium.
Inert character does not stimulate inflammatory
reaction unless-
- Acid aspiration
-Barium HD (250 % W/V)
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Aspiration
Hypersensitivity reactions caused by one of the many
additives to commercial
barium preparations can occur .
Barium particles are phagocytized by alveolar
macrophages.
If any fibrotic response occurs - barium sulfate
mixtures act as mechanically obstructive
material leading to emphysema only in rare cases.
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Aspiration- water soluble contrast
media
If a mediastinal fistula is expected Gastrografin
can be used instead of barium sulfate to avoid
mediastinitis.
Can induce pulmonary edema when introduced
directly into normal lungs
Not the material of choice when aspiration is
probable .
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Intravasation
- 0.0040.04% of procedures.
Barium may also intravasate into the venous drainage
of the large bowel and enters the circulation as abarium embolus.
36 cases of barium intravasation have been reported
in thelast 50 years
The British Journal of Radiology (2006)
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Causes
Thinning of the rectal wall with age andproximity of the haemorrhoidal venous plexus
may contribute to intravasation.
Colon affected by disease.
when intraluminal pressure overcomes theresistance of the colonic wall affected by
colitis, diverticulitis or intestinal obstruction.
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Mortality- 26 -60 % more in systemic than portal embolization.
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Prevention
Balloon inflation under fluroscopy
Height of barium column.
Insufflate little air or little barium in start ofprocedure.
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Barium in intestinal obstruction
BMFT is indicated in small bowel
obstruction as there is enough dilution of
barium in small bowel so does not lead to
intestinal obstruction
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Large bowel
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Oral Barium Suftate in Partial Large-Bowel Obstruction - Radiology
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Retained barium in appendix
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Contrast media
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Contrast media
MRIX-ray& CT Scan Ultrasound
Positive
Contrast media
Negative contrast Media
. Air ,Co2
Iodinated Barium
Water based
Oil based
High osmolar
Low osmolar
Gadolinium
compounds etc
Ionic monomer
Ionic dimer
Non ionic monomer
Non ionic dimer
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Basic chemical structure of Iodinated contrast media
Iodine containing benzene ring
Side chains in positions C1-C3-C5 areimportant for the physicochemicalproperties.
C3 determines changes in thesolubility
C5 influences the excretion
R1
R2R3
I
II
1
5
3
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The physicochemical properties of CM play akey role in determining their physiological and
untoward effects: Iodine concentration:
Ionic charge
Hydrophilic properties Viscosity
Osmolality
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Ratio Iodine atomsper molecule
Particles permolecule
Type
3:2 3 2
Ionic monomer
DiatriazoateIothalamate
MetrizoateOsmolality- 1400 2000 mosm/kg water
3:1 3 1 Non Ionic monomer
Iopamidol
Iohexol
Ioversol
Osmolality- 600-800 mosm/kg water
3:1 6 2Ionic Dimer
IoxaglateOsmolality- 600-650 mosm/kg water
6:1 6 1Non Ionic Dimer
IodixanolOsmolality- 320 mosm/kg water
Osmolality of plasma 280 290 mosm/Kg water
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1. Idiosyncratic/ Anaphylactoid Reactions
2. Non Idiosyncratic Reactions
3. Combined Reactions
Contrast Media Reactions
ACR Contrast Media Manual 1991
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1. Estimated that 8 million people receive RCM annually in U.S.
2. Overall frequency of adverse reactions is 5% to 8%
3. Life-threatening reactions occur less than 0.1% with older
(hyperosmolar) agents
4. Mortality estimated at 1 in every 75,000 patients
5. With advent of second generation agents (low-osmolar oriso-osmolar agents) incidence of adverse reactions 1/5 that
of first generation agents
*Neuget AI. Ghatak AT. Miller RL. Anaphylaxis in the United
States: An investigation into its epidemiology.
Archives of Internal Medicine. 161(1):15-21, 2001 Jan 8.
Incidence
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Definition of Terms
Anaphylactoid events vs. Anaphylaxis1. Anaphylaxis: An immediate systemic reaction causedby rapid, IgE-mediated immune release of potentmediators from tissue mast cells and peripheral bloodbasophils.
2. Anaphylactoid events: Immediate systemic reactionsthat mimic anaphylaxis but are not caused by IgE-mediated immune responses
Non Idiosyncratic reactions: Usually dose related
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Possible Mechanisms for Idiosyncratic
Anaphylactoid Reactions
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Minor
Intermediate
Severe
Contrast Reactions
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Contrast Induced Nephropathy
Definition:- Is a condition in which an impairment in
renal function (increase in serum creatinine by 25%
or 44 Qmol /litre) occurs within 3 days following the
intravascular administration of a contrast medium in
the absence of an alternative etiology.
BJR August 2003,513 - 518
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Epidemiology
The percentage of patients at risk 3.5 -15.5%
Depends on presence of a preexisting impaired renal function, diabetes
mellitus, congestive heart failure, and hypertension and on the volume
of contrast used.
Third most common cause of hospital acquired renal failure 10% of
cases
Incidence in general population 2%
Incidence among diabetics 9-40 % Incidence among diabetics with renal insufficiency 50-90%
Ital Heart J 2003; 4 (10): 668-676
AJR: 183, Dec 2004;1673-1689
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10 25 % incidence for a transient need for
dialysis
30 % of pts , renal function fails to touch the
base lineRCNA July 2002
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Renal Handling of Contrast Media
Elimination half life in normal individuals - 2 hrs
75% of administered dose excreted in - 4 hrs
98% of administered contrast excreted in - 24 hrs
Less than 1 % excreted through extra renal route innormal individuals
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Formulas for Dose Calculation
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Mechanism ofContrast InducedNephropathy
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Mechanism of Contrast Induced Nephropathy
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Features
1. Oliguric / Non oliguric renal failure.2. Rise in serum creatinine by 24 hrs and peaks
by 3-5 days .
3. Persistent nephrogram on Radiography or CTscan 24 hrs after procedure.
- immediate dense and persistent nephrogram
- increasingly dense nephrogram.
4. Electrolyte imbalances
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Risk Factors forContrast Induced Nephropathy
AJR: 183, Dec 2004;1673-1689
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Contrast Induced Nephropathy
Serum creatinine is insensitivemeasurement in patients with normalkidney functions.
More than 50% reduction in GFR may
occur without any increase in serumcreatinine
( BJR- 1998)
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Contrast Induced Nephropathy
Serum creatinine can be used as an
accurate test in patients with renal
impairment to access any further
deterioration.
Relationship in fall of GFR and rise in serum
creatinine is more helpful after 50% declinein GFR.
( Normal GFR= 125ml/sec)
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Contrast Induced Nephropathy
Creatinine clearance
-GF
- Tubular secretion
so in general underestimate reduction in
GFR.
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1. Gadolinium K-edge 50.2 Vs 33 Kev iodine ,allows
imaging with a higher Kvp (77- 96).
2. Recommended dose limit 0.3- 0.4 mmol/kgdose for adequate visualization.
3. Best used for selective angiography of small&medium vessels.
(Evaluation of A- V fistulas and veingrafts,aortography ,visceralangiography,genitourinary & biliary studies.
RCNA July 2002
Gadolinium
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Gadolinium
Adverse effects-
Most common side effects - nausea,
emesis & headache.
Incidence 0.4
mmol/kg
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Complications due to embolization
material
E b li ti
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Embolization
Therapeutic introduction of various substancesinto the circulation to occlude vessels, either to
arrest or prevent hemorrhaging, to devitalize a
structure, tumor, or organ
-by occluding its blood supply, or to reduce
blood flow to an arteriovenous malformation
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Embolization may have 3 therapeutic goals
(1) An adjunctive goal- preoperative, adjunct
to chemotherapy or radiation therapy
(2) A curative goal- aneurysms,
arteriovenous fistulae (AVFs), arteriovenous
malformation (AVMs), and traumatic bleeding
(3) a palliative goal- relieving symptoms, such
as of a large AVM
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Material
Coils
Detachable balloons
Small particulate material- polyvinyl alcohol
-gelatin sponge
Liquids- glue
- alcohol and other sclerosants
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Coils
can be grouped into
- Micro coils
-M
acro coils
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Coils
Macro coils - also called Gianturco coils
Advantage - precisely positioned under
fluoroscopic control
Occlusion coil induce thrombosis rather
than mechanical occlusion of the lumen.
Thrombogenic effect increased with
dacron wool tails.
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Coils
Local misplacement
Distal migration.
Collateralization is a potentialdisadvantage of coil embolization
Proximal occlusion occurs with coil
embolization
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Detachable balloons
Premature deflation
Accurate positioning may be difficult to
maintain because of balloon shape.
Principle disadvantage with balloons
multiple catheter exchanges.
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Polyvinyl alcohol
Obtained by the reticulation of PVA (Ivalon) with
formaldehyde.
Supplied in dried state and expands when
comes in contact with liquid.
Histologically - agent causes intraluminal
thrombosis associated with an inflammatory
reaction, with subsequent organization of the
thrombus
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Polyvinyl alcohol
Marketed in various sizes
Non reabsorbable permanent occlusive
agent
(though some recanalization do occur)
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Polyvinyl alcohol
Administered in a mixture of contrast medium
and isotonic sodium chloride solution under
fluoroscopic guidance.
Aggregation of PVA particles can be minimized
by using dilute contrast medium in a matched-
density suspension eg Omnipaque and sodiumchloride solution can be used in a ration of1:0.4
for contour particle suspension.
P l i l l h l
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Polyvinyl alcohol
Complications parallel degree of devascularization
achieved.
Complete infarction is possible using it
however infarction of nontarget tissue can also occur ifcheck angiogram are not performed.
Non radiopaque substances are mixed with contrast
media to see flow pattern.
G l ti (G lf )
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Gelatin sponge (Gelfoam)
water-insoluble, off-white, nonelastic, porous,and pliable material.
May be cut without fraying, and it can absorb
and hold many times its weight in blood.
Acts as a matrix on which thrombus begin to
form and propagate.
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Gelatin sponge
Vascular occlusion is expected to last for 3
weeks.
Partial recanalization followed by complete
recanalization occurs 30 to 35 days.
degree of devascularization achieved with
gelatin is less: so complications are also
less.
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GLUE
Cyanoacrylate- rapidly hardening liquidadhesive.
Substance hardens (polymerizes) immediately
on contact with blood or other ionic fluid.Polymerization results in an exothermic reaction
that destroys the vessel wall.
Foreign body inflammatory reaction is the
primary disadvantage
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Ethanol
Absolute alcohol is the most commonly usedliquid agent.
Has
-a direct toxic effect on the endothelium- causes spasm along length of vessel
Has a potential effect of causing reflux intonon target areas.
Ethanol can be damaging if it reaches the
capillary bed of any given tissue
a1
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Slide 73
a1 that activates the coagulation system and causes the microaggregation of red blood cellsabc, 2/15/2007
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Ethanol
Slow, careful injections by using balloon
occlusion arterial catheters for delivery
By applying manual compression on the
draining veins (or tourniquet control)
or balloon occlusion of the draining system
1 mg/kg is the maximum amount that can be
injected during a single session.
a2
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Slide 74
a2 may decrease alcohol washout from the lesion and reduce acute systemic toxicityabc, 2/15/2007
Complications because of embolization
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Complications because of embolization
Vessels requiring embolization can be broadly
grouped into
Neoplastic vessels.
Arteriovenous communication.
Disrupted vessels with acute hemorrhage.
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Neoplastic vessels
Mainly related to nature of embolic agent .
Proximal occlusion- unlikely to be of any
benefit because of opening up of
collaterals.
Organ failure.
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Arteriovenous communication
Passage of embolic agent through shunt.
-if is on systemic side- eg in post biopsy renal
AV fistula : unlikely to cause major
complication- If shunt is in pulmonary circulation- embolus
may pass into left heart, may lead to disaster.
Di t d l d t
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Disrupted vessel and acute
hemorrhage
Objective is to achieve homeostasis
Non selective embolization should be
avoided as far as possible to avoid
infarction of organs.
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Post embolization syndrome-
Septicemia
Abscess formation. Infarction of embolized organ.
Ulceration in bowel
DIC
a3
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Slide 79
a3 a sequaele of procedure, pain - which usually start during procedure, may last for few days. fever , vomitting are otr features.
paralytic ilabc, 2/16/2007
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Complications of diagnostic
angiography.
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Puncture site-
hematoma
occlusion
pseudoaneurysmAV fistula
contrast extravasation
Non puncture site-
distal emboli
dissection of selected vessel
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Hematoma
Faulty technique: eg puncture above or belowfemoral head in femoral
puncture
Inadequate compression: 20 minute or arterial
10 minutes for venous
Laceration due to large size of needle and
patient coagulation profile.
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Thrombosis
Usually due to catheter: size relative to lumen
type of catheter
length Exposed to blood
Other factors : extent of intimal damage, vascular
spasm, patient coagulation state
Pseudoaneurysm
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Pseudoaneurysm
Pseudoaneurysm is a pulsating Hematomathat results from disruption of a portion of the
arterial wall.
Clotting occurs in the peripheral limits of the
Hematoma, while the center remains fluid and
communicates with the arterial lumen causing a
pulsatile mass.
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Pseudoaneurysm
Right femoral arteriogramDemonstrating Pseudoaneurysm
of SFA
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conclusion
Awareness of complications of a
procedure is the first requirement to
reduce incidence of complications.
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