I walked into angio five minutes before needing to be there,
dressed in “business casual” and ready for a quick morning. After meeting with
the area manager, she took me to change into scrubs. Not having been told to
dress for standing all day (although I had asked), I didn’t have on tennis
shoes. Oh, well. She introduced me to Dr. Cooney, and he briefly went over the
case he was about to work – a scheduled basilar stent placement and aneurysm
coiling. Don’t know what those are? That’s ok. I’m about to give you a brief
overview so you can understand what I experienced today. (And by brief I mean a
simplistic overview, even though this post appears forever long. Stick with it
if you’re curious, though. You won’t be disappointed. Plus, there are pictures
to keep your attention. J)
First, let me give you a snapshot of what interventional
radiology shadowing involved:
·
Types of procedures typically performed: stents,
vertebral biopsies, dialysis catheters, and more.
·
Had to don scrubs, hair net, mask, plastic
glasses, shoe covers, and lead apron while in the procedure room.
 |
| In the IR attire - scrubs, mask, hair net, glasses, lead apron and shoe covers. And scrub jacket because it was freezing. |
·
By the way, lead aprons weigh a ton; you need to
work out just to wear those things! The radiology student in the room advised
me I’d be sore tomorrow. I guess I’ll find out soon. However, the lead was so
heavy it helped with the next bullet point. Keep reading…
·
Freezing cold, nearly literally. Apparently, the
cold temperatures help with keeping germs at bay – think operating room cold.
Also, their equipment functions better at cooler temperatures.
·
Sterile field. The doc and his radiology
co-worker were suited up in sterile attire (gowns, gloves) working with a
sterile field. They even had the monitors covered with sterile plastic so they could
navigate the screens.
[Google
image showing IR room, sterile field, and monitors similar to the set-up I saw
today]1
·
Persons involved: there are usually 4-5 people
on the scene. The doc, the radiology technologist, the “hander” (who grabs any
equipment necessary so they don’t have to re-sterilize everything), anesthesia,
and the patient.
So, what did I see today? Well, I mentioned the whole stent
and coiling deal previously. First, let’s talk about aneurysms so you can
follow the procedures.
·
Definition: “An aneurysm is a
balloon-like bulge or weakening of an artery wall. As an aneurysm enlarges it becomes
thinner and weaker. It also puts pressure on surrounding structures, causing
headache or vision problems, and may eventually rupture. A ruptured aneurysm
releases blood into the spaces around the brain, called a subarachnoid
hemorrhage (SAH) – a life-threatening type of stroke."2
·
Causes: people can be born with them (congenital);
some are hereditary; development influenced and aggravated by methamphetamine and IV drug
usage and/or elevated blood pressure; some proponents suggest smoking contributes to
development as well (questionable).
·
If under 4 mm, physicians
typically do nothing unless aneurysm is ruptured. Aneurysms of these dimensions are considered small.
·
If over 10 mm (1cm), then aneurysm is considered
“giant” in radiology terminology and radiologist must take action - usually placing a stent, although there are other options.
[insert diagram for
visual learners like me]2
This figure illustrates several types of aneurysms:
 |
| Anatomy of an aneurysm (top). Different types of aneurysms (bottom). |
[back to text]
Now that you have an idea of what aneurysms are and what
they look like, let’s move on to the procedure Dr. Cooney performed today.
·
The patient was a 50-ish year old female. Time
of aneurysm onset was 1 year ago. Stent placed at that time. During a follow-up
appointment, aneurysm displayed significant growth, causing further bulging of
blood vessel.
·
Procedure objective: place 2nd stent
in left artery and add additional coils to ballooning original aneurysm. Part
one’s success was questionable. Part two was a guaranteed occurrence.
·
Patient was prepared: IV placed for anesthesia, groin shaved and scrubbed.
·
The catheter(s), guide wires(s), and stent first
entered the femoral artery in left groin, flowed through the left vertebral
artery, and then were guided (taking a backward loop approach) into the right
vertebral artery at the basilar junction.
[insert
helpful information here] 2
·
Blood
supply of the brain: Blood is carried to the brain by
two paired arteries, the internal carotid arteries and the vertebral arteries.
·
One of the guide wires had a radio opaque tip,
so it was more noticeable on the monitor. Contrast was also used periodically
to visualize blood flow through the arteries of the brain.
·
The technologist would occasionally take x-ray
shots of the contrast (fluoroscopy) images so that they could overlay that
screen shot over what was presently taking place (shown via regular x-ray
imaging).
·
It took over 2.5 hours to complete part one.
After trying multiple times to guide the wire where it needed to be, the doc
finally got it. He, himself, admitted it was a “miracle” exclaiming “Thank God”
when he finally succeeded. Just goes to show that success is not dependent on
skill alone but on God’s grace and intervention.
·
There were eight monitors stacked in sets of two
connected in a big rectangle to each other. It was moveable, and it was what
everyone relied on to view the images. Throughout this procedure, they only
used 4-6 of the 8 monitors at a time.
·
After stent placement, they performed a CT to make
sure there was no hemorrhaging caused by the guide wire poking around trying to
follow the flow in the vessels. On a CT involving a hemorrhage, the blood shows
up as white. There was no hemorrhage in this patient’s case.
·
With the brain hemorrhage free, the doc
proceeded with part two: filling the original aneurysm with more coil to
protect it from further ballooning.
·
This process involved threading catheter wires into
the aneurysm, gradually decreasing in diameter size. As the wires were
threaded, they coiled into themselves, filling the space from the top of the
aneurysm down toward the first stent.
[insert webpage
information and diagram for clarity] 2, 3
·
Endovascular
coiling: In contrast to surgery,
another form of treatment is endovascular coiling.In a coiling procedure, a
catheter is inserted into an artery in the groin and then passed through the
blood vessels to the aneurysm. The doctor guides the catheter through the
bloodstream while watching a fluoroscopy (a type of x-ray) monitor. Through the
catheter, the aneurysm is packed with material, either platinum coils or
balloons, that prevents blood flow into the aneurysm (Fig. 6).
 |
| The aneurysm is packed with platinum coils by way of a small catheter. The arrow indicates bloodflow through the artery, but not the aneurysm. |
 |
Aneurysm Coil Embolization
|
[back to procedure one]
·
Catheter tidbits:
o
Metal wires have “memory” and will retain shape:
circular, square, etc.
o
Begin with catheter size just smaller than the
size of the aneurysm. For example, if aneurysm is 10mm, then use a 9 mm
catheter to begin. Gradually decrease catheter size. Dr. Cooney compared the
process to the opposite of Russian stacking dolls, starting with largest to
smallest size.
·
In total, they used 14+ catheters to fill the aneurysm.
·
Patient was taken to PACU (recovery room part of
surgery) after procedure, and would then be transferred to a bed in the
hospital to be monitored.
Other Angio Tidbits
·
There are three layers of blood vessels: tunica intima
(inner), tunica media (middle), tunica adventitia (exterior).
·
Stents bend like bananas – possible to thread a
second stent through first to create a “y”-shaped double stent placement
formation. If stunts placed side by
side, stent placement called a double barrel formation.
The procedure was scheduled to begin at 8:00 A.M. We started
at 9:25 A.M. and ended around 1:30 P.M. After the first procedure, we took a
quick break and grabbed lunch. When we returned from the doctor’s lounge, the
second patient was being readied. He was an elderly male. His procedure: a
biopsy and cementing of fractures of the T11 vertebra (lower back). Fortunately,
in comparison to the first procedure, this one only lasted about 35 minutes.
·
The patient was placed stomach-down, sedated,
and anesthetized locally. Sterile technique was used in this procedure as well.
[insert
another Google image illustration]4
 |
| Patient positioning for vertebroplasty. Padding flattens the spinal curvature while maximizing patient comfort. |
[back to text]
·
I didn’t catch the terminology as well on this
procedure since it was so short. In addition, it was at the end of Dr. Cooney’s
work day and everyone was tired by this point.
·
The doc identified the vertebra of interest, hammered
a hollow metal tube into the body of the vertebra, and used a biopsy needle to
aspirate a sample, which was placed in a dry specimen cup.
[insert additional Google
image illustrations]4, 5
 |
| PMSB : Ostycut needle, penetration performed with surgical hammer |
 |
Disassembled components of a standard needle/trocar unit used in vertebroplasty. 14-gauge biopsy needle set
|
The x-rays of the procedure looked like this:
 |
| (B) Posteroanterior and (C) lateral fluoroscopic images during vertebroplasty. |
[back to procedure]
·
Then he repeated this procedure on the other
side of the vertebra body, so that in the end, there were two metal tubes symmetrically
sticking out of the man’s back. A 2nd sample was obtained and placed
in a fluid-filled specimen cup.
·
Cement was squeezed into the hollow tubes using
the aspiration needle and a syringe.
·
Then the tubes were removed and the procedure
was officially finished.
[another view thanks
to Google images]6
 |
| Puncture surgical hammer. |
 |
| Puncture. |
 |
| Vertebral body biopsy. |
This was my second shift shadowing in radiology. The first time was in musculoskeletal (MSK), and interventional radiology was different in many ways. For one, there was quite a bit of hands-on work as well as interaction with patients. In contrast to just looking at images and dictating findings, IR had a tactile component or placing or removing something in the body using radiology images to aid the procedure. I'm headed back to angiography tomorrow to view neuro radiology. But that's all for now...
1. http://www.bendbulletin.com/article/20110817/NEWS0107/108170408/
2. http://www.mayfieldclinic.com/PE-AneurUn.htm
3. https://neurosciences.beaumont.edu/aneurysm-coil-embolization
4. http://www.sciencedirect.com/science/article/pii/S0033838908000663
4. http://www.sciencedirect.com/science/article/pii/S0033838908000663
5. http://www.openradiology.org/zosirws/survey/biopsies/bonepen
6. http://www.openradiology.org/zosirws/survey/vertebroplasty/technique/puncture
