Working in a community practice setting often comes with unique challenges. But being part of an innovative specialty, IRs are well equipped to find creative, safe and effective solutions, according to community practice physicians.
In “Non-extreme IR: How to safely perform unconventional procedures in a community practice setting” on March 6, panelists discussed performing procedures with unexpected twists and turns, sharing their advice for various cases in a community practice setting.
Pseudoaneurysm cases
Labib F. Haddad, MD, member of the West County Radiological Group, began with an unconventional treatment for pseudoaneurysms: thrombin.
Pseudoaneurysms (PSAs), Dr. Haddad said, are “an abnormal dilation of an artery or a vein that occurs as a result of a break in the wall of the vessel.” Unlike true aneurysms, the vessel wall is not completely dilated.
The use of thrombin injections in the treatment of PSAs is off-label, but it’s been used to treat PSAs since the 1940s, Dr. Haddad said, as thrombin catalyzes the conversion of fibrinogen into fibrin. “For those of you who cook, it’s like a thickening agent.”
He went on to describe four different cases in which he successfully used thrombin injections to resolve pancreatic, prostate bed, inferior epigastric artery and hepatic PSAs.
Dr. Haddad recommended that two people conduct the procedure—one person who mixes and injects the thrombin and another who images the PSA via ultrasound. For this procedure, he said, it’s also important to use an echogenic needle that can be seen on ultrasound.
“Sometimes you forget you have a tool that you can use,” Dr. Haddad said, “and sometimes you have a tool but you don’t know how to use it, like those thrombin bottles.”
Venous cases
Gretchen M. Foltz, MD, FSIR, of Madison Radiologists, followed by discussing unconventional treatments for venous cases.
In one case, a 45-year-old male with a history of chronic kidney disease presented with acute onset severe pain in the left lower extremity setting. Ultrasound showed deep venous disease from the common femoral vein, but the patient only minimally improved after 12 hours of heparin. After intervention, there was still some clot remaining. The patient also needed iliocaval reconstruction, which would have required being flipped over to get bilateral femoral access.
To avoid a lot of patient manipulation during the procedure, Dr. Foltz decided to stage the second procedure and complete it at a later date.
“Staging the procedure often is not detrimental to the patient and can provide you with an opportunity to get buy-in from all of the referring physicians and make sure that based on this patient’s complete care history, not just his DVT history, this really is the best thing to do for the patient,” she said.
Throughout the cases she described, Dr. Foltz emphasized the importance of planning the access site ahead of the procedure.
“We are very used to doing standard access sites, but sometimes you have to think outside the box just a little bit,” she said. “Maybe you have a different access site that’s going to be better suited for what you are trying to accomplish.”
She also noted that planning for filter removal with the patient ahead of time can help ensure they return for the removal procedure. “You have a much higher chance of having patients come back for filter removal if you actually plan for them to come back for filter removal at the time the filter goes in,” she said.
Dr. Foltz ended with advice for a successful venous practice.
“Your two biggest factors are going to be your pre- and post-procedural work, so your non-procedural time,” she said. “Those things that go into working up a patient and following them afterwards are going to get you your biggest success.”
Urology cases
Christina G. Marks, MD, formerly of Northern Virginia Radiology Consultants in Arlington, Virginia, and currently at the University of Mississippi Medical Center, shared her unconventional “adventures in urology-land,” including a complicated metal stent removal and a ureteral stent placement via a patient’s urostomy.
One of Dr. Marks’s patients was a 64-year-old female with history of colorectal cancer and multiple abdominal surgeries in need of another abdominal surgery. Because the patient had undergone so many surgeries, she requested that Dr. Marks enter through her ostomy site. Having never done that before, Dr. Marks successfully completed the procedure, using double J stents and tying them together outside of the ostomy.
“It might not be the most routine method of accessing the collecting system, but it is more patient-friendly than the antegrade approach,” she said. The approach is useful for patients on blood thinners who are considered too high risk to hold for antegrade approach.
“Knowing possible complications before a procedure is always preferable than experiencing the complications after,” she said, closing her portion of the session.
Bone and soft tissue cases
Finally, Guillermo Gonzalez, MD, of the West County Radiological Group, discussed bone and soft tissue cases from abdominal masses to osteoid osteomas.
In one case, a 23-year-old female had calf pain so severe that she walked with a limp. After an MRI, they found a fibroadipose vascular anomaly (FAVA), a subtype of venous malformation, and performed cryoablation with nerve monitoring.
Ahead of the procedure, Dr. Gonzalez reviewed the nerve anatomy in the affected area and decided to employ MEP monitoring to ensure there was no nerve damage from the cryoablation.
“When the ice ball starts to damage the nerve, you get blunting of that MEP transmission, which clues you in to stop freezing, and you can see that the nerve generally recovers,” he said.
Dr. Gonzalez shared the importance of following up with patients post procedure.
“The follow-up is key,” he said. “Personally, if I don’t do the follow-up and hear that they got better, it’s not as satisfying. I’d encourage everyone to follow up with their patients and assess for improvement, as some of them are going to need repeat or additional interventions.”
One of Dr. Gonzalez’s patients was a 62-year-old female with a history of cancer presenting with a new abdominal mass. She mentioned her severe, persistent pain to her oncologist, but they had not offered any treatment options. Speaking with her allowed Dr. Gonzalez to build trust and create a treatment plan that worked best for her.
“Maybe the most important thing I did that day was speak with her,” he said. “It’s important to remember that there are patients surrounding the lesions that we’re going to go biopsy.”
If you missed this session, be sure to purchase SIR 2023 On-demand!
