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I. Mhm. And person ask for injection because it, I see. I don't you one. Mhm. Yeah. Ok. Yeah. Uh Hello Rayvon. Thank you for joining us today evening. Uh for our first installment in our new series, an introduction uh to in uh to our new series Essentials of Clinical Radiology. And uh we are set to begin the series with an introduction to intervention Radiology by uh Jade who is an Ir registrar uh working in Eden Brooks. Uh she's doing her ST four there. She is also the founder of WP MN and Cofounder of Rare and also the vice chair of uh British Society of Intervention Radiology Training Committee. So uh without further ado I'd uh pass on the stage to Jade. Thank you, man. So hopefully you can, everyone can hear me and see the slides. So I've been asked to do a talk on the introduction to interventional radiology and the target audience was sort of foundation doctors. But I've got a little bit more for anyone who's a medical student or, and some more as well if you're a registrar. So hopefully you'll be able to get something from it today. But as I said, I'm ST four and currently at Adam Brooks, where I've done all of my radiology training before I was in London for in Hillingdon and Chelsea Westminster for my F one and F two. And then I trained up in Manchester. So been up and down a little bit as well. So I thought we would cover four key areas which I thought would be, I would have liked to know as a foundation doctor, what I would have thought would be useful to know. So some of it's about requesting the correct ct for specific areas in vascular radiology which overlaps significantly with ir even though Ir sometimes split into vascular and nonvascular. So we look at acute aortic syndrome, look at traumatic aortic injury and then a little bit on gi bleeding as well. We focus on lower gi bleeding in this case that I've got. And then second aim is to just be aware of the range of procedures that Ir offers and it will be different within each trust in each hospital, but just to sort of sit back and just look at the breadth, then we'll move over to some of the key information when you're requesting procedures, what you need to know and what's really useful to have on hand. And then we'll just end with a couple of complications postoperatively to think about whether that's you may be seeing a patient in A&E or you might be seeing them on the wards. Ok. So we'll start with the first one and we're gonna just sort of sit back and think about acute aortic syndrome. So, in the chat box, if you're able, I'm just gonna open the chat box here as well. So I have it, would you be able to sort of note down what you think encompasses acute aortic syndrome? And if you don't know that's ok, but I'll give you about 10 seconds or so just to pop anything in the chat that you think of when you hear acute aortic syndrome. So we'll go through four key areas. There are some more that's also talked about in the literature and lots of other sort of acronyms as well. But I'll focus on the key for when we do imaging for acute aortic syndrome. So the CT is the main modality of imaging. There's a few things that we want specifically from that CT. So we'd want a arterial face CT, which I've put in the middle here, that's going to help us see clearly the aorta and also the great vessels and lots of the visceral arteries as well. But we also want a non contrast CT and we'll show you why in one of the cases later from Raia. Lastly, I've also put down that we'd like a gated study. So this is in time with the heartbeat in diastole. So we could get rid of lots of the artifacts that you get from motion artifact from the heart. This enables us to see the aortic root better but also the coronary arteries. So, aortic acute aortic syndrome encompasses aortic dissection. So for some of you, this might be a bit of a revision. But aortic dissection, there is a class, a couple of classifications in um structures now. So there's three different ones. There's the, there's Stanford and there's also the 10 classification criteria. But in essence, aortic dissection, you have an entry tear in the intima, you have blood which is flowing within a false lumen. And this is what's depicted here on this image from raped. So when you've got blood flowing in the false lumen, and you've also got blood flowing in the true lumen, often what happens is the false lumen is actually bigger and that sort of compresses and puts pressure effect onto the true lumen. And if you look at the CT scan that we have adjacent in the axial slice, we've got the ascending aorta that we can see anteriorly posteriorly next to the vertebra on the left, you can see the descending thoracic aorta. And then we can also see in between the two, the main pulmonary artery and also the right pulmonary artery. When looking at the ascending and the descending aorta, we can see that sort of wiggly wavy line through the ascending and sort of that curvy line through the descending, which is the interna, which is sort of broken off and come to the middle. And then we've got the bright contrast, which is in the true lumen. And then we've got reduced attenuation, which is in the false lumen. And that one's a bit more gray blood is flowing at a different pace and there's less pacification of that blood as well. So we've got the entry tear in this case, which we can't see the specific entry tear, but we can tell that it's within the ascending aorta might be evolving the aortic root. We can't see the coronaries clearly on here, but it could be involving the coronaries. We don't know. But that's something we worry about when it's involving the aortic root. And then we've also got lots of haziness around the aorta anteriorly and posteriorly and even some behind the pulmonary artery. And that's all blood within the mediastinum. So that's a rupture. So we're going to go over a few different classifications of aortic dissection, blood flow within the false lumen. So you just mentioned rupture. So, rupture of the aorta can also happen though, you can have thoracic rupture, we can also have rupture of the abdominal aorta. It's good to think of these things in the continuum. As we saw with the previous case aortic dissection. You can also have a rupture associated with it. This one is just a aneurysm that's ruptured without the dissection component. On the left, we just got the blue arrow pointing to the normal aorta and on the in the middle image, we've got the blue arrow now pointing to aneurysmal well, thoracic descending abdominal aorta. And you can see that there's discontinuation the calcification around the edge of this. So the calcification is the white around the edge of the aorta. You've also got some unusual patterns of gray, different attenuation of the blood and that's for the abnormal flow within this large aneurysmal sac and then around it, you've got the yellow arrow. So you've got axial image in the middle, that sort of slices through the patient. And then we've got Coronal on the side and you can see all of the sorry sagittal and you can see all of the blood there that's in the yellow arrow is pointing to inferiorly and that's all within the abdomen. It's all retroperitoneal. And you can see that the left kidney is sort of being pushed forward by all of this blood that's within the abdomen. So it's a very quick overview. So we've looked at dissection rupture and this is the reason why for this condition, intraneural hematoma, which is why we like to have the non contrast CT as well. So going back to dissection, we had blood flowing within the false lumen and we also had blood flow within the true lumen. If we're looking at the image on the right now, we can see within the ascending aorta that we still have blood flowing here. And we can see that contrast is within the ascending aorta, then you've got this on the right image, some hypo pod, so darker dark gray crescent. And if you look really carefully, it can be quite tricky to see on the non contrast image on the left, there's this hyper, slightly brighter crescent. So it looks like a moon shape and that is clotted blood within the technically the false lumen. So it's people describe it as blood break like breaking of blood vessels in the face of a zum. So within the wall of the aorta specifics of how it got there, it's quite difficult to explain because it can also you can also have a aortic dissection. If the blood then clots within the false lumen, it then looks like an intraneural hematoma. So it really does depend on when we're actually doing the CT scan of the patient. What we're describing is based on what we see at that point in time, but it can be a bit of a continuum. So intramural hematoma can present clinically very similar to all of the other that we've mentioned acute aortic syndromes. But it's just one that we pick up on imaging, but it's just important to put here because this is why we have a non contrast CT. And then the last one that I'm going to discuss in that comes his acute aortic syndrome is the penetrating atherosclerotic ulcer. I think I've only seen one of these so far in the 3.5 years I've been doing radiology and lots of my consultants that I've spoken to. It's the one that they see the least in this condition. The patient must have sort of the atherosclerotic plaque and then you get an ulcer through the wall of the artery. So this is the P AU. So, moving on now from acute aortic syndrome, which we were just looking at to traumatic aortic injury. Again, it has its own different classifications and we're just gonna have a look at a couple of entities which this encompasses. I've put two different types of CT protocol on here. So we have a Bastian and then we have a standard. The standard is quite variable depending on which trust you go to. We do arterial phase imaging and portal phase imaging. Unless we were specifically concerned there was a penetrating abdominal injury or penetrating thoracic injury and we wanted to do a non contrast as well. But our standard for trauma tends to be portal and will have the arterial. And for those who are not within radiology yet or not sure how the images are acquired, we would image and do a full CT scan and standard after between 30 to 40 seconds for the arterial. So we're getting the best contrast medium within the arteries and then we'll do one around 70 seconds where you get to see the enhancement of the, of the solid organs a lot better like the spleen, which you don't see very well on arterial phase. And that's done at a time when the contrast is time to be best within the portal venous system. Whereas bastion is a what we do for some traumas if we're not expecting any aortic injury or any bleeding. But we want to have a great look at all of the solid organs and see any major abnormalities. And we would do one ct scan that we inject contrast medium at two different times. So we have a good opacification of the arterial vessels. And then we also have a good opacification of the venous vessels and the solid organs as well. So it encompasses both of those because we've given two different timing of contrast, but then we do one scan. So we get all of that for less radiation dose. So it varies with traumatic aortic injury, which might just be an intimal injury. You might have a little intimal tear. And here what we've got is a pseudoaneurysm. So there are certain points where the aorta is fixed, which are most likely to get injury, especially if it's sort of like an RTC. And you've got that deceleration and that'll be at the root at the isthmus and at the diaphragm. So here what we can see is a bulge on the first image which is the sagittal image just distal to the origin of the left fla artery. And this is a common location for aortic injury. When we look at the middle image, we've now got the patient that's under like path treatment pathways been decided and they've had an angiogram. So the images acquired here most likely. So two punctures in the groin, the common femoral arteries then able to get access. We've got this little in the ascending aorta, you can see a little loop and that's attached to the catheter. So that's the pigtail catheter where we can inject contrast and get good opacification of the rest of the aorta. And with the blue arrow, we can see that pseudoaneurysm is still present. Pseudoaneurysm different from a true aneurysm. True aneurysms involve all of the vessel walls. Whereas here we've got a defect in the one at least one layer of the artery wall. So in the third image, we can see actually that that large aneurysm that we could see on both the CT and the angiogram has is no longer present. And that's because the stent graft has now opened and that's allowed blood to flow normally down the aorta and not into this out pouching. So that's an example of a traumatic aortic injury most likely from blunt trauma. But you can also get pseudos from other trauma as well and also in lots of different organs. The next entity is aortic transection. Again, you've got three images. The first image with the labels is not one from the same patient, but the other two images are. So I'll just give you just a moment to have a look at numbers 1 to 7, just to see if you can figure out what they're labeling. So I'll just give you about 30 seconds. Yeah. So number one on here is pointing to the superior vena cava, whereas three is pointing to the inferior vena cava. But you might have also said the cardiophrenic angle two, we're having a look at the right atrium and then if we go up to number four on the top, on the left there, we've got the aortic knuckle and five, we've got the pulmonary artery and you have to have that little ap window that we have a look at in between six, you've got the left atrial appendage and then we've got seven as the left ventricle. So now if we use some of that anatomy to have a look at the middle image, you can see that there's widening of the mediastinum, especially the superior mediastinum there, we can see that it's quite hazy, quite fuzzy and you can't really depict all of those structures that we described. And then if you sort of, it's quite small. But if you look really closely at the last image, you're able to see what operations that they've had in the interim. So this was an aortic transection which of the next stage up from a pseudoaneurysm in traumatic aortic injury and what you have is disruption of the vessel wall. And I think most of these patients don't actually make it to the hospital. So we often don't see imaging for as many patients that actually have this and what you can see that's been inserted in the meantime is a stent graft. And this is similar to the case we looked at before. When you had exclusion of that pseudoaneurysm, you're giving structure that aorta with that stent graft, which is coming over the arch of the aorta there and then into the descending thoracic aorta. Some of these surgeries may be done depending on what centers you're at. And the condition that the patient comes in by ir otherwise, some patients will need open surgery. And it depends again if there's involvement of how much of the aorta the arch and if it goes across to the aortic root, the main thing to think about when requesting a CT scan for gi bleeding is triple phase. So if you're concerned that the patient is bleeding right now, and we at a certain rate, we'll be able to pick that up on CT, then a triple phase is what we need to be requesting. When having a look at the triple phase, you need non-contrast arterial and portal phase imaging. So we have this case from raped and I've put arrows on it, but we just have a look in order. So non contrast just having a look at the sigmoid colon which is arrowed in blue and yellow on the subsequent CT S the middle one is arterial phase and the third one is a portal phase. So on the first ct, we can see that bit sigmoid colon that kind of comes across from the center and to the left. And you can see there's some out pouching, that's the diverticulosis throughout the sigmoid colon. But on the arterial phase, the middle one where we can see that blue arrow, it's pointing to some high density within the sigmoid colon, which we do not see on the non contrast image. So we do not see that on the first image. If we just had this alone, it might be quite difficult to say exactly what this is. It you in the clinical situation where someone has said they're concerned for bleeding. And if we only had that arterial phase, we could say this is concerning but other things show up as high density on CT as well. So it's hard to be very specific when we only have that. So then if we look across to the third image, this is the portal venous phase. So this is the one that's acquire about 35 seconds or so later than the arterial phase. And what we can see is that density that really high density the white on there has actually increased in size. And that shows us the dynamic process, the patient is bleeding. And over that time, there's an increased pooling of contrast medium within the lumen of that bowel. So this is someone which is bleeding. And then potentially some of these patients are the ones that would then be discussed with ir to see if they're suitable or if it was necessary to do something. At that point in time, we can't always tell the specific artery. But sometimes you can figure that out from the anatomy where that part of not, there's not always bowel that we're looking at, but and there's not always lower gi bleeding, but which artery is going to that area, especially with lots of the liver lacerations that we have. So that was thinking more about the CT and requesting and the protocol on why we look at certain images, why we need non contrast. Now, we're just moving on to look at the range of procedures offered by IR which again, like I said, it's very, very variable and trust and it's really important depending on where you are to know sort of what the IRS can do. So break it up into vascular, looking at arterial and then we'll have a look at some venous and then we'll have a look at some nonvascular as well. So here what we've got on this abdominal X ray is a procedure known as ev or endovascular aortic repair depending on how fit the patient is and also comorbidities that would often depend on if the patient will have an open repair or if they would have a endovascular repair. Some hospitals, some of the vascular surgeons will be doing some of the endovascular repair. Sometimes it will be working together with the IRS and some hospitals. It's only the IRS. So it's very variable depending on where you work here. It could be also done in an elective case where you've had time to have a look at the specifics, which will decide if an endovascular repair will be possible. For example, how long the neck is before you get to that aneurysm. If it's infrarenal, if it's juxtarenal, if you need to do more of a complex aortic repair, and you have to have fenestrations of the stent graft as well. So there's lots to think about when planning these, if elected in the emergency situation, it can be quite different. But you can also have the, the thoracic or tars these in the thoracic aorta embolization is a big part of ir again, it can be for the arterial side as well. It can be either elective or it can be emergencies. Emergencies might come through by like penetrating abdominal injuries and they might be using coils, they might be using glue. There's so many different types of things we can use or it might be elective, such as if someone has a mass on their kidney like a al angio my lipoma, then you might be wanting to coil that to reduce the blood supply there to then hopefully that A L would not rupture in the future. So if it gets over four centimeters. There is a concern that it might sort of rupture and that can bleed, the patient can bleed significantly from that. Yeah, the last one I've put on the arterial, even though it's not the, this is not the only three things that encompasses within the ir arterial work is angioplasties. So here we're looking at often lower limbs of patients with tissue loss, which might be ulcers, for example, gangrenous toes or foot and also patients with rest pain and angioplasty is the ballooning of the arteries. So, increase the blood supply and hopefully prevent or delay amputation for patients. There's lots of work with which patients are eligible for angioplasties or actually is that if they've got lots of calcification within their vessels in the lower limbs, perhaps another procedure is better, but there's lots of different endovascular options and recanalization of different vessels as well. So there's lots of significant work that can be done in the area. But like I said, this is not the only arterial work. This is a few of the key areas within the arterial work. Venous is another large area within interventional radiology. And some centers will offer some of these, some of them might offer all of them. There's also fistuloplasty and lots of other work, but we've got tips here. So, transjugular. So that's where we get the access through the jugular vein intrahepatic where we're traveling with our catheter and wire portosystemic shunt and that's in patients which might have bleeding varices, for example, to divert some of the blood flow into the systemic circulation from the portal venous system to reduce the portovenous pressure. There's also thrombectomy and lysis, which is done in many centers and then embolization as we discussed for arterial can also be done for venous. And that may be a we I've seen recently ovarian vein embolization and there's also you, you'll see lots of other different types of embolization in the venous system other than that too. So that's another interesting area, similar sort of mechanism, how you do it with coils but different types of coils that are used in different catheters for preference of different consultants. There's also transjugular liver biopsies which is quite similar to the tips, which we mentioned first. So, transjugular is the access to the neck and then taking a biopsy of the liver. Often this is done if a patient needs wedge pressures. So trying to make the portal venous pressure or it might be done if the patient has ascites but needs the liver biopsy or if their coagulation is really, really off, then this is often the safer route. So those are the three main indications for a trans dot liver biopsy rather than doing a percutaneous phenogram are common as well. So this might be in patients with known like long term, they might have pheno occlusive disease dvts that they've had previously. And for planning surgical planning or ir planning for stents, there's also adrenal vein sampling, looking at hormone levels. There's so many different types of venous work that's done. And initially, I think when I started interventional radiology, I was just thinking about all the arterial work and then we move over to the non vascular. So depending on where you are, the cholecystotomy might be done by the gi radiologist and, or it might be done by IR or a mixture of both. There's also gastrostomy insertions which again, gastro might do some pegs. Otherwise, some patients might have radiologically inserted gastrostomies. And for this procedure, the stomach has expanded with air, patients often have act previously just to see if there's bowel overly in the stomach. So what you sort of do is pin the stomach to the anterior abdominal wall before you put the gastrostomy in situ and percutaneous transhepatic cholangiogram. So that's going through skin into the liver, into the bile duct. And other, other than just imaging that with contrast is maybe see whether the tumor is causing a blockage often at the hilum, but it could be lower. You might be then planning to put an external drain in to reduce the jaundice and the symptoms that the patient is having or you might be putting a stent across the lesion as well. So there's lots of options there for PTC S and that's usually paired with other procedures. Urology is another large part of IR work and this is just a couple of procedures. Nephrostomy is very, very common procedure within ir whether that's to secondary to hydronephrosis, needing to drain that kidney or an infected obstructed system, needing to drain that kidney or perhaps the patient is postoperative and they've had um genic injury to the ureter. So actually, it's not that they've got hydronephrosis, but you need to divert that urine for a specific amount of time. So there's different indications for nephrostom. Most common though it's an obstructed system. And then you also have ureteric stents, which might be er again for many reasons. Lots of the stent changes that I do have patients that have had an ileal conduit formation and then we're doing retrograde ureteric stent insertions. And this image is just of two nephrostomy. Bilateral nephrostomy oncology is a huge area, very exciting area to see. And there's an annual meeting that if you're interested in this area with BSI R but trans arterial embolization and then we've got chemo embolization. And then we've got c with the radiotherapy that we do alongside with our nuclear medicine colleagues that come in and then there's ablations as well. So there's a whole variety and certain criteria for when we do. So. For example, for the t the trans arterial embolization, specific tumors, specific sizes, specific criterias to have a look at. But these access is quite similar, which you tend to do through the groin coming up with a catheter shaping it in the aorta coming back down to the celiac trunk. It's important if you've got previous ct to know the anatomy because there's lots of variant anatomy with the hepatic arteries as well. But oncology is a very, very interesting area and it's forever expanding and I think probably expand great to a greater extent, impedes ir as well. So that was just a whistle stop tour of a range of procedures. We couldn't go into much depth just because of the time that we have. But just moving on now for a quick slide on, just looking at the key information I'm requesting in our procedure. So I think just give you about 30 seconds again. Just have a think of what you think is the important things to mention to the IR radiologist if you're giving them a call and you would like a certain procedure. So I put some of the, what I think is the key ones on here and all of these someone's missed out at some point in time when they've called, but starting from the introduction. So, so important, whoever you're calling in a hospital setting, whichever clinical team you're referring to that introduction is very, very key patient details, checking that they're actually ok to talk about this patient at that point in time, making sure you have the M RN number on hand and the patient's hospital number just dis discussing the procedure you'd like, but also the clinical indication often on the form, it's not very put in very clearly, but make sure you put it on, on the form clearly. When you're discussing it, you're very clear about why this is needed. And the time scale of when you would like this to be done by the main bloods are important, generally, is hemoglobin, platelets and prothrombin time. However, depending on what procedure you do, for example, bilirubin might be really important. So there's other key bloods, but I'll just put the overall ones that we'd like to know. And then medication is the patient on any anticoagulation. If they are, when do they have their last dose, any allergies is really important and also bleeding history, which often is forgotten as part of the clinical history taking. And there's just a couple of complications that I would like to touch on one of them is what I guess what we often do punctures of the groin. In vascular radiology, you might be doing punches at another place as well. We do some of the brachial and we do some radial and also we haven't covered nearer ir either. But if I just go on to the next slide, we're just thinking about the puncture. So if the puncture, if we imagine like this is a ultrasound image of the groin, the lower circle is the artery, whereas the upper circle is a pseudoaneurysm. So you've got that Ying Yang appearance of the blood flowing, then that pseudoaneurysm. And if a puncture is too high. So we do ultrasound when we're doing a puncture to aim for the, not everyone uses ultrasound guidance, but most people use ultrasound guidance to aim for the common femoral artery. And if you're going to, and that's when we press at the end, even though we might use closure devices and then do some manual compression. But when we compress at the end, we want to prevent these sort of complications happening. And if that puncture is too low, then we're concerned about pseudoaneurysms like this one. And we discussed pseudoaneurysms earlier and also arteriovenous fistula. So if you're making that channel genic from the artery to the vein, so you can see both the artery and the vein when you're doing the ultrasound. So it's something to be aware of if you're too low. And the reason that we know we're at good space with the common femoral artery, there's not any anatomical variation is that we're seeing the femoral head quite nicely and that's what we're going to compress onto with the groin punctures. The problem if you're too high, so you might be in the external iliac artery is actually retroperitoneal bleeding and you can lose quite a lot of blood quite quickly into that space. So that's also the concern and that assessment of that patient would be a standard a assessment if the patient's back on the ward and it's something to think about early post. Well, quite recent post on I procedure where they've done a puncture. Another, this is a complication. I didn't really know about until I did I have a post embolization syndrome. So patients that have had embolization, whether that's liver for a large tumor or it might be a fibroid embolization. Some of the fibroids that are very, very large. And when you do embolization of these within sort of usually 24 to 48 hours, some patients will experience symptoms which are like infections. So fever, some abdominal pain, feeling really tired, nauseous and it can be quite difficult to differentiate from infection. But that's something where you'd often clinically get a senior involved because these patients will be of the patients that have been discharged, you can be discharged the same day from fibro embolization and some of the liver tumor embolizations. But the patients coming back through A&E people that have had recent procedures, think of post embolization syndrome, but also think of sepsis as well cause infection would be a complication as well of the procedure. So it's good to have both in mind. Whereas post embolization syndrome, no specific treatment is needed. You would need to think of infection, but it's just being aware that post embolization syndrome does exist. So today, we've covered quite a few key points which I sort of wish I knew as a foundation doctor and hopefully it's been able to help you depend if you're at different stages to that. As Well, so we've gone through the importance of a CT and requesting the right CT for the whole host of acute aortic syndromes. We looked at traumatic aortic injury with pseudoaneurysms and transection and we had an example of lower gi bleeding with sigmoid within the sigmoid colon. We then looked at the range of procedures offered by IR ranging from non vascular with HPV and GI and urology. And then we looked at vascular arterial and broke it down to venous as well. We looked at the key information in the request to specifically the bloods with knowing the recent hemoglobin, having prothrombin time platelet count and also having knowledge of the recent medication, especially anticoagulation, the most recent dose. And then we just looked at a couple of complications related to the puncture, but also post embolization syndrome. So that's everything from me. These images that I've used were cases from radio pia and I also used one from Cersei as well and happy to take any questions. Uh Thank you, Jade. It was a very nice presentation and was very insightful. Um The floor is now open for questions. If uh you have any questions, you could either post it in the messages here or you could send it as a query to us and we could forward it to Jay as well. So uh we posted a feedback link for uh the teaching. So if um you could fill out the feedback forms uh and uh it would be really helpful for us to improve our sessions as well. Thank you. So I can't see any questions in the chart. So I think uh we could essentially conclude uh the meeting and then uh if you had any other questions, you could email us. Thanks, dude. Thank you for the session. No problem. Thanks for attending.