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Yeah, so today said, so this session is going to be on interventional radiology. Again, it's another installment in our final Z series. My name is nish, head of education and one of the co founders are squeezy, um So in terms of interventional radiology, um as I said before, please fill out the pre session form, but in terms of interventional radiology, what it generally is referring to is it's a it's a specialty in itself okay. A lot of people think think of radiology. In general is that you just interpret images, but in recent years, intervention radiology has become its own thing okay. It's all about the use of medical imaging okay, so using images you know two x rays, ultrasound, fluoroscopy, mri, using those things that using that skill of interpreting images, but using it, not just for not for diagnostic purposes, but to actually treat patient's so it's an intervention okay and there's many different types of interventional radiology procedures, but the idea is it's about minimally invasive procedures okay, so there, it's all, it's all about being an alternative to these surgical procedures, which are much more invasive, much higher, have a much higher risk of causing harm to patient's and so by doing these interventional minimally invasive procedures, uh The idea is that hopefully is it has better patient outcomes, shorter stays in hospital, and it's generally uh safer option for, for treatment of patient's so intervention, radiology, or i. R. S, intervention radiologist, they perform procedures that are highly technical okay. Um You know the idea of accessing just through a small blood vessel and perform procedures is a very technical, they're very technical technical procedures and you're using it, you're not doing it in surgery, where you can just do it visually using your own vision. You need to be able to you're doing it by looking at scans okay. You you have to be able to interpret different imaging like philosophy, x rays, and what and do the procedures at the same time because it's a very technical and skilled specialty, um and there's many different equipment involved okay, we'll talk about some of the key stuff throughout the session, uh but commonly used interventional radiology equipment include guidewires, catheters, sheets, angioplasty balloons, and stents okay. We'll talk about some of these different things and uh there's gonna be loads of images and just wanna credit Sissy, which is the sort of European Board for intervention radiology for letting us use images from their website, so we're gonna start off with just some basic principles about interventional radiology okay. This session is going to be filled with loads of single best answer questions relevant to undergraduate um studies, okay. We're going to be covering common conditions, which will be treated, which we're not just treated by interventional radiology, okay just common conditions and talk about the general management of them, but we also incorporate how the interventional aspects comes into it okay, and so once we enter in conditions, it should become more clear, but I want you guys to just tell me what is this image the series of images representing here what's what are these series of images. If you go from a to e, what is this procedure called. If anyone knows him to chat, let me know what what do you guys does anyone know. This is the absolute bread and butter of interventional radiology. If you, if you guys take away one thing from this session, you guys should be very familiar with what this technique is and what it involves very good well, then this is the cell danger technique okay. This is the this is the absolute bread and butter of interventional radiology okay This is the technique of gaining access to blood vessels to do procedures okay. If the the gold started method of gaining vascular access, So in terms of actual procedure, going from a to e. Okay, so a, so, this is how we're gaining access to a blood vessel okay, Similar to if you guys have done uh intravenous cannulation. Um You guys might be generally familiar with the process, but sell dangers is a much more detailed and special specialized way of gaining vascular vascular access, so initially you're gaining access to the artery, okay puncture it, look for the flashback. Then you're gonna insert a leader over over over where you've punctured the artery, uh so we withdraw the needle and then insert your catheter okay, So the idea of procedures is you want to get the catheter into because the catheter is the thing you're going to be feeding into the arteries and what you're going to be doing the main interventional procedures. With once you've let let the catheter in uh then you can remove the leader and that's your Seldinger technique okay, so it's essentially puncturing the artery, use a leader and guidewires to allow entry of a catheter into the blood vessel okay, but remember this is. This is the Seldinger technique. If you ever start doing these procedures, you need to become very confident in this technique okay. This applies to loads of procedures okay from chest trains, angiography, pEG tube's pacemaker insertion, i. C. D, in insertion okay loads of different techniques you need to be able to do the self injure technique to effectively get effectively gain access to perform the procedure, so let's do let's go into our first single best answer question and um see what you guys think, so. We're gonna start off by covering some vascular stuff, which is a major aspect of the job of intervention, radiologist and then we'll start moving toward some other common conditions. Uh A little depo, give you guys about 45 seconds for each question okay. I'll call it there. Most of you've had to go cool, so um most of you gone for answer option B and that is the correct answer, so um let's go through this okay, so we're going to start off by talking going through peripheral arterial disease um So this is a patient who has a history of critical limb ischemia okay one of the subtypes, one of the uh stages of critical of peripheral artery disease. You know you start with progressive arterial narrowing. You can start getting symptoms of peripheral artery disease. You know mild narrowing You're getting intermittent claudication type pain, but with the significant narrowing, you start getting the symptoms of critical limbersky mia, So this patient's had a seven month history of critical limbersky, me symptoms the first time management which will cover is to do supervised exercise therapy. Okay This is part of that conservative steps of managing peripheral arterial disease. Okay conservative steps include stopping smoking, exercise. Okay, supervised exercise therapy is the absolute gold standard for initial steps for managing peripheral arterial disease. Okay, typically around 30 to 45 minutes per week, 33 times per week. You here around two hours per week of supervised exercise therapy, where patient's should uh keep walk walker as far as they can until they get the maximum amount of claudication pain and then take take some rest okay. That's the sort of gold standards. Exercise therapy minimum of 12 weeks should be trial before you can say it hasn't improved okay, so I've told you that they've done this supervised exercise therapy. There's been no improvement in his symptoms. A ct angiogram has been done okay, so ct angiogram is the gold standard for visualizing arterial disease in the, in the legs okay. If they have, unless they have you know chronic kidney disease and you can't give contrast, then you can do an mri mri angiogram okay but generally most patients will be a ct angiogram to check for narrowing in blood vessels and I told you that there is a single site of narrowing on the femoral artery, just distal to the femoral canal and distal pulses are palpated, So the question is asking what is the most appropriate management, so in terms of management options, um we've got option a nafta dial free trial oxalate, which is a type of medical therapy um It's a type of essentially peripheral visa dilator okay. It's not at this stage because patient has been hasn't responded to conservative measures, we need to consider more definitive steps okay, actually consider revascularization therapies, so in terms of revascularization therapies, we can either go for this interventional procedure, okay called percutaneous transluminal angioplasty or you can do surgery okay, surgical bypass okay. These are the two types of revascularization therapy, so percutaneous transluminal angioplasty is the correct, is the more appropriate option compared to surgical bypass. Can anyone tell me why why why is why do you go for an angioplasty rather than surgery in this patient, why is that a more appropriate management option. Anyone based on what I've said, yeah so angioplasty is more appropriate here because I've told you that there's only a single site of narrowing on the femoral artery. Ok, so the way angioplasty works is you're gonna feed a catheter and that's gonna essentially open up a balloon, which will open up the narrowing and keep hold the blood vessel open and patent, so it's more appropriate here, it's the more appropriate option here because this a pulses are palpated, so there's adequate blood flow through the narrowing, and there's only a single site of narrowing okay, so it can be easily access and you, and it's only limited to one single blood vessel, so that's why angioplasty is more appropriate than surgical bypass um above the amputation, so this patient hasn't got signs of gangrene or sepsis, so there's no indication to amputate here. Have you got this question, though it's again a peripheral arterial disease question um load up the pool again, so again another question I ask asking about the management of career for arterial disease, sorry, while you're well, you're doing the question that's just a pre session survey for the new people who have uh come in, we're just trying to see if um interventional radiology is something worth continuing in our series um and uh whether it's been implemented well in med school curriculum as well, so if you could please do help us fill in the precession survey. Oh I'll end it down okay, so yeah most of you got the correct answer again, so um cancer here was the surgical bypass, so let's go through it again okay, so again we've got a patient who has symptoms of peripheral arterial disease, okay. Claudications symptoms for the past four months. Um In terms of examination findings, there's necrosis on the distal 3rd and 4th toes um so okay, so a scheme scheme Ick symptoms distantly. There's I've told you some of the findings from the ct angiogram, which again remembers the gold standard for visualizing arterial disease and the legs, so there's a patent normal left femoral artery, but the significant occlusion of the left popliteal artery and segmental stenosis of the left tibial arteries okay. So um there's a occlusion of the popliteal and tibial arteries and the fibula artery, but distantly there's still blood flow okay, so the distal anterior tibial artery is still patent and then multiple collaterals. So in terms of choosing management here, this is different to the first one, okay, so the first one there was the narrowing was limited to a single artery okay and so that would be easily access and be amenable to angioplasty, but here you can't do angioplasty necessarily okay because there's more extensive disease okay. There's occlusion in three different arteries okay pop, popliteal, tibia, and fibula artery, so you can't just put a stent in one artery, and that's not going to just improve the symptoms okay, So this is why surgical bypass is a more appropriate option because you can essentially bypass all these occlusions by inserting a graft okay, so because I've told you that this li, there's still blood flow and there's multiple collaterals, you can insert a surgical graft that bypasses the seclusion and restores blood flow distally okay. So that's why the correct answer here is surgical bypasses, femoral bypass surgery can be done uh for revascularization because this is. I've told you that there's multi focal stenosis okay um that's why some more appropriate option. Smoking cessation should be advised in all patient's okay, but I haven't told you that's not the most at this stage, you need to do revascularization therapy, amputation. Again, uh if they don't, if there's signs of gangrene and sepsis okay, that's when you start consider amputation and exercise therapy, so this patient has uh two is too symptomatic for to, to just rely on exercise therapy at this stage because that's why the correct answer here is surgical bypass so quick, quick anatomy quiz here okay, So this is a ct angiogram of the leg okay. This is what an interventional radiologist would look at before he decides uh before they decide how to treat it okay, so to be good intervention, radiology you need to know your anatomy really well, so I've got this image of ct angiogram of blood vessels in the leg and all you guys to try and have a go at labeling these blood vessels and see how much how well do you guys know your anatomy uh does anyone know which blood vessel a is pointing towards just list them in the chart. You can private message me your answers as well. If you don't, if you don't want to put it in the main chart, anyone have any ideas or option is which blood vessel option is okay. We got one answer uh yeah, so it's uh so you've got to be specific, not just tibial artery, it's the anti right anterior tibial artery uh I'll just go, I'll just go through the rest of them just just for the sake of time, So this is the right anterior tibial artery. It's a branch of the popliteal artery um then see what is the, is another branch of popliteal artery before it splits into the tibial and peroni arteries. We've got this big trunk here, tibia, peroneal trunk, and so this one here the letter D is the posterior tibial artery, and letter E is the peroneal artery, okay, also known as the fibula artery and so that's just a quick and not to be quiz, just quickly talk about the management principles, which we've already discussed in good detail okay. So in terms of management of peripheral artery disease. Generally, you want to think about it in terms of conservative, medical, surgical, and the interventional aspects okay. So in terms of conservative steps, smoking cessation super super important okay smoking is a huge respective for peripheral arterial disease. Structure excise therapy gold standard initial step okay first try supervised exercise therapy and modified diet as well in terms of medical therapies, which can optimize um peripheral arterial disease control, so anti platelet therapy, clopidogrel typically, statins okay so atorvastatin, statin is given to all patient's, uh managing BP, managing any diabetes and after, and this peripheral vasodilator, this can be considered and patience as well and then you have to decide between revascularization therapies okay so either surgical therapies or bypass procedures or interventional procedures okay, so they put continuous transluminal angioplasty with or without a stent, so this is what a this is what intervention, radiologist would do okay, so this is where they would get involved for management of peripheral arterial disease, so uh typically considered in patient's who have single short segment disease or if they have disease affecting the, the photo iliac area okay um so what they'll do is, they'll feed a catheter into the blood vessel affected um So this is a blood vessel affected by um atherosclerosis okay, it's a atheroma plaque um They'll insert the cap to expand the balloon and that's going to help revascularize that section of stenosis. Okay, cool, let's keep going on, so we're going to go into another condition now cool. I will end the poll there and yeah well done guys, so this is really important um scenario In terms of if you guys are ever work in the emergency department and how you should um investigate patient's who present with the symptoms so uh most of you went for a and that is the correct answer okay, so let's go through this. You know tell me what it was the diagnosis here. Yeah good subarachnoid hemorrhage, but if you want to be really specific, okay, you should say classify if this is a traumatic subarachnoid hemorrhage or a aneurysmal subarachnoid hemorrhage, okay, so there's no history of trauma here okay, so the most, it's most likely we're thinking this is a aneurysmal subarachnoid hemorrhage okay, so hemorrhage caused by rupture of an annual of a cerebral aneurysm, So why is this a subarachnoid hemorrhage, so this is a pretty pretty box standard history of subarachnoid hemorrhage okay. Most of you guys should be familiar with these symptoms, so acute onset, severe worst headache of someone's life okay, thunderclap headache classically description, and there's uh features of meninges um okay, so photophobia um vomited three times as well, okay. Very important if someone is vomiting uh with acute headache. History okay be very concerned about someone having a subarachnoid hemorrhage and there's no history of migraines as well okay, so you don't need, so you need to think this is a secondary cause of a headache okay, not a primary headache like migraines or cluster headaches, so it's a pretty clear box standard subarachnoid hemorrhage history, so questions asking what is the most appropriate initial test okay, so uh you guys absolute crucially should know anyone who's presenting with suspected intracranial bleed okay whatever type of intracranial bleed. The first line investigation you should do is a plain ct head okay, noncontrast ct head anyone tell me why, do we need why, do why do we need to make sure it's non contrast what's the problem with using contrast. If they like for the first scan. If they present acutely why do we why is it better to avoid using contrast, yeah because you want to see blood okay. So, if you the idea is, if they present acutely okay, I do if they present within six hours of a suburb. Econet enbridge a noncontrast ct head will most of the time show up show the blood okay, remember blood on a ct is bright okay, it's hyperdense uh If they present within six hours, okay ct head has over 96% sensitivity and over 99% specificity for being able to detect blood okay, so plain ct head is that initial test you should do If they're not able to, if you don't see anything on the ct head okay, then that's when you start thinking about other things okay, so what if you if you don't see anything on a ct head, but you're still worried about them having a subarachnoid hemorrhage. What do you need to do do you do do you just discharge the patient. If you if the ct head is negative what do you do yeah lumbar puncture good, okay, so if so the noncontrast ct head is negative, but there's still clinical suspicion of a subarachnoid hemorrhage, then you should consider doing a lumbar puncture. Remember you should wait um 12 hours, six hours before you do a lumbar puncture and the reason is because you know you need to sorry it's 12 hours before you do a lumbar puncture, so the reason is you need to allow the blood allows certain physiological processes to take place before you can see things on the lumber puncture, okay things like xanthochromia okay, billy ruben in the blood okay, so breakdown products of the red blood cells, you might see the increased red blood cells and on the lumber puncture increase opening pressure okay, so that's why, so that if the ct head is negative, wait, wait and then you can do the lumbar puncture and that will be they will confirm the diagnosis if they really had a subarachnoid bleed. Other options, so ct angiogram and ds, a, so these are done after you've confirmed the diagnosis okay, So once you've confirmed the subarachnoid hemorrhage on a ct head or a lumber puncture, then you can do these things okay. Ct angiogram is where you are looking at uh arterial blood flow okay and you can accurately determine if there's blood if there's blood leaking from a, from an aneurysm okay. It's the gold standard for actually characterizing where blood, where, if there's an aneurysm and where it is an accurate characterize, uh which space blood is leaking into okay because you can actually see the flow of blood through arteries. Digital subtraction angiogram is the procedure done by interventional radiologists okay. So this is where you are inserting a catheter okay, typically through the femoral artery into the cerebral blood vessels and that's why you're doing procedures okay and we'll talk about procedures in a bit but correct answer Here is a so in terms of digital subtraction energy and this is what an interventional radiologist would look at okay, so the media capita into the cerebral arteries with contrast and then under fluoroscopic guidance, this is what the image will look like okay, So this is, these are all the sort of uh cerebral blood vessels um This is the major blood vessel, maybe blood vessel going into the brain okay into internal carotid artery um and so you're you're looking at all the blood vessels and looking to see if there's any sort of filling defects or blood leaking from any part of the blood vessels okay. It's a very uh technically challenging procedure okay to accurately interpret uh the angiogram and see which blood vessels are leaking, but this is what it will look like okay and this this is not just a diagnostic procedure okay. Once you see if there's any aneurysms uh, then you can also treat that okay and the treatment which is done by interventional radiologist is known as coiling, uh So we'll talk about, let's talk about treatment of subarachnoid hemorrhage, okay. Uh In terms of general things to be thinking about initially some medical treatment options would include observing them okay, monitoring their g. C. S, giving a pain relief, antiemetics, monitoring their fluid balance correctly, and electrolytes, particularly sodium um calcium channel blockers, so nimodipine is given as a you know infusion um is people incorrectly say it's done to reduce vasospasm okay. It's not the technical reason why, but it is given been shown to improve outcomes and patient's with subarachnoid hemorrhage and the ct head is done to the ct angiogram is done to uh accurately see which vessels being affected, surgical options, um So if someone's develop complications from subarachnoid hemorrhage okay, so if they've developed a complication known as hydrocephalus, where the actual ventricles become really enlarged okay, uh blood blood or cerebrospinal fluid that's accumulated significantly and cause the hydro, catalysts okay and it's affecting causing raised intracranial pressure causing um symptoms, then you need to you can do inserted drain okay so you can insert a x o ventricular drain or you might insert a lumber drain to treat hydrocephalus. Uh micro surgical clipping okay, so this is a procedure which is done by the interventional radiologist okay, so, during the actual digital subtraction angiogram where they're feeding the catheter okay. If they actually if they see an aneurysm, then they can treat that aneurysm by using a coil okay so so sorry by uh using a coil okay, sorry, but uh this is uh clipping is referring to the surgical procedure okay, so clipping is different to coiling okay clipping is a surgical procedure where they do a craniotomy okay, so open the open inside of the skull and surgically clip it okay, but the interventional procedure I was referring to is coiling, so during digital subtraction angiogram, If they see an aneurysm, they can put platinum coils, which will basically fill the aneurysm and induce a thrombosis okay, of cause, a clot, which will help block, stop blood accumulating okay, so if I just draw a quick, if I just do a quick diagram to show you guys, so if this is an aneurism aneurism here um so basically intervention, radiologist would feed a calf it okay, so this is a typical appearance for very aneurysm in the circle of willis and they can feed coils in this area and that will induce a plot to try and stop blood going that way okay. I'll make sure blood is just staying in moving this way and avoid expansion of that aneurysm and reduce the risk of that aneurysm rupturing okay. Um So that's the basic idea of platinum coils by interventional radiologist uh oh Someone's asked these techniques are not used to treat already ruptured aneurisms, so if they're they're ruptured uh then you're not gonna um coil it okay is um so if it's already ruptured, you can't you can't toilet okay, then uh you that's straight for surgery okay. If it's already ruptured is see if you can clip it cool, uh so we just briefly covered subarachnoid hemorrhage okay. The sort of management aspects of it have a go at this question, another vascular presentation uh The the answers here are a bit longer, but it's mainly to just to try and explain some of the key principles to think about management here. So make sure to read each of the answer options and try and think about which one sounds the most correct uh Someone asked can you do coiling for traumatic subarachnoid hemorrhage now. If it's if it's a traumatic subarachnoid hemorrhage, interventional neuroradiologist aren't going to be interested. Ok you can't really um uh coil do coiling for um traumatic subarachnoid hemorrhage. This is specifically for um aneurysmal um bleeds okay, okay, so correct up, so a lot of you have uh had to go uh yeah let's end the pool there. So interestingly most of you have gone for a uh but the correct answer option is actually e, okay, so this is a question. This uh important question just to drill some important learning points with regards to management of uh abdominal aortic aneurysms okay, so let's go through it. So this is a patient who presented for his um his annual screening for triple A okay so uh any old men over the age of 65 should be having surveillance for uh has offered surveillance for um uh abdominal aortic aneurysms okay. We'll go. We'll go through the sort of screening program for triple a's, but his aneurysm size has been found to be 5.8 centimeters okay. Now importantly, if you guys know your guidelines okay, any aneurysm over the size of uh 5.5 centimeters, they should be referred to vascular surgery within two weeks, okay for consideration of um of definitive of surgical treatment, okay or surgical or interventional treatment, so this patient needs to needs treatment for his abdominal aortic aneurysm and we've got a bunch of different answer options, describing some points regarding his treatment, so if you go through each one okay, so in terms of management of triple A's okay definitive management, there's two general options okay either it's the interventional option, which is eva, okay, so endovascular uh aortic repair, or it's open repair okay, so it's a surgical procedure to try and repair the um aneurysm, so we go through each one okay so answer option, A long term mortality is significant, low, and even compared to open repair, okay. This hasn't been definitively proven as true okay. The short term, short term mortality rates has has been shown to be a bit lower in EVA compared to open repair, but long term the actual outcomes had this hasn't been shown to be a significant difference in the uh mentality rates okay. It's just a short term there's better um it's less invasive, shorter hospital stays, and that's been shown to have better outcomes in the short term um. Option B graft is less likely to be secure following EVA compared to open repair, so not true okay, so an open repaired, there's a higher risk of the graft feeling and leading to complications like migration of the graft or fistula formation optional, See, so POSTOP complications is higher and EVA compared to open repair uh not too as well um It's less for EVA compared to open ripper, okay. Remember interventional procedures are generally because they're less invasive, there's less anesthetic risk, that's you know, there's no risk as much risk of damaging other blood vessels, so the post operative complications isn't going to be as higher in the interventional procedures. Okay option D very long segment triple A is an absolute country indication to open repair, but not to IVA okay, not true okay. It's um contraindications to IVA okay because you can't access the um the aneurysm. If it's really it's a huge aneurysm okay option is the correct one okay, so according to nice guidelines, um open repair, so the option of surgical procedure is the preferred method of treating ruptured aneurisms in women okay, so an old woman and men over the age of 70 if they have a ruptured abdominal aortic aneurysm, okay, so the actual aneurysm has ruptured and it's bleeding the preferred method of treating that is to do the interventional procedure okay so and the vascular aortic repair and, and all other patient, so in men under the age of 70 then you would go for the surgical option. So let's talk about abdominal aortic aneurysms okay. So in terms of the national screening for triple a's, uh this is the sort of guidelines, we have okay, so less than three centimeters is normal, uh between 3 to 4.4 that's considered a small aneurysm and patient should be um should have a repeat ultrasound after a year to monitor progression less than 5.4, but more than 4.5. They should have an earlier ultrasound at three months and like the patient we just saw in the single best answer question if it's over 5.5 centimeters that is considered a big aneurysm and they should be referred for surgery for vascular surgery within two weeks okay. It's just the management of triple a's okay, so we need we think about management and two whether it's a rupture triple a or if it's um ruptured, okay so rupture triple a. So if the actual aneurysm is ruptured and bleeding that's an emergency okay, so uh abdominal aortic aneurysm can kill patient's very quickly okay, so rupture triple A is a massive uh emergency okay. You take you're gonna be extremely worried about them and seek surgical opinion very, very quickly okay and we talked about the options okay, so in terms of urgent repair for ruptured aneurisms, the interventional options, so even is the preferred option in all women and men over the age of 70 and all other patient's open repair is the preferred option in unwrap third aneurysms okay, so the, if it's not actively bleeding currently, so you know if they come from surveillance and uh it's a sort of elective procedure um and then uh there's different considerations, If they're symptomatic with it okay, then you do the repair urgently, If it's not then you can do as an elective procedure okay, so if they, if it's a symptomatic but over 5.5 centimeters, so we talked about the the guidelines okay, that's an elective procedure, asymptomatic, but over four centimeters, but it's grown quickly okay, so it's grown more than one centimeter in a year. Again you have to treat that okay as an elective procedure, but again key thing if they're symptomatic, that's uh that's an indication for an urgent repair okay. So, if they have having back pain with it, any other symptoms associated with it okay, That's an indication for an urgent repair. In terms of how in the method, according to nice guidelines, uh the general method is to do open repair for elective procedures, but if they're not suitable for the surgical option, uh then you can do interventional radiology okay, so it's quite complex the decision between who gets open surgery and who gets interventional radiology okay, but generally, if they, if they have significant co morbidities, they're not suitable surgery, there a big anesthetic risk, there's co, co, pathology in the abdomen okay um then you would consider doing eva, okay as a safer, safer alternative to surgery. So in terms of the actual procedure, this is what the interventional procedure looks like okay, so essentially they'll access the arteries through the common femoral, the common through femoral access, and insert a graft that extends across the aneurysm above and below and extends into the iliac vessels as well okay. Pick next question okay, let's call it that it's the interesting choices there, but we'll go through it, so we got a split between A and B, but correct answer here is actually option E, okay, percutaneous nephrostomy, so this is an important important some important learning points here okay in terms of approaching obstruct urinary tract obstruction um So let's go through this okay, so even though this is an interventional radiology teaching session, okay don't just assume the answer is relating to intervention procedures like percutaneous nephrolithotomy um let's go through it, So this is a patient presenting with a history of renal stones uh presenting with severe loin, two groin pain, okay classic for renal colicky type pain. Uh Noncontrast ct k. U. B. Has been done okay, so noncontrast ct kb is the gold standard investigation for confirming renal or ureteric stones. Okay remember it's non contrast because contract. If you give contrast, the contrast can might have a similar density to uh stones and that might um obscure, obscure, obscure, obscure the image, or make it hard to actually discern where the stones are uh so generally that's where you go for the non contrast, especially for stones that will light up significantly on a c. C. T. K. B. Um and I've told you that there's a calculus six millimeter calculus at the left pelvi ureteric junction okay. Um If you guys remember your anatomy, hopefully, you guys might remember where the common sites of narrowing are in the Euro to okay, so the pelvi ureteric junction is one of the common, is one of the three common is one of the three narrowing points in the Euro to okay, so one of the narrowings is the pelvi ureteric junction. The second narrowing is where the iliac vessels cross over the ureter okay. That's the second point of narrowing where patient's commonly develop stones okay where stones can get obstructed, and the third one is where the urine to joins into the bladder okay, so the your auto vesicular junction is what they call that okay, so the pelvis your attack junction is a common site for patient's develop urinary tract obstruction from stones, so I've told you what her observations are here are as well okay, so she's saturating okay 97% of room air. Her BP is is fine, ok, 95 or 70. She's not currently hypertensive, but she has a fever and she's tachycardia okay. So key thing in this history, we've got a patient who has a known history of a stone, recurrent stones, has a large calculus in the, in her cavuto, rick junction, and she is coming out as a fever and she is tacky codec, okay, so in this patient, you definitely we worried if she's um septic, okay, so key learning point, anyone who is septic, acutely septic from a renal stone or any urinary tract obstruction, then you need to do a nephrostomy procedure okay. You need to take them to theater, refer them speak urgently to seek urgent surgical opinion and because they will be needed to be taken to theater and a decompression procedure will need to be done okay, so the nephrostomy tube will need to be inserted, so before you can actually do anything to treat the stone like a nephrolithotomy procedure or lithotripsy procedure. You need to do an f. Rostami procedure where you essentially create uh you know access the kidneys from through the skin, okay, through the percutaneous route to try and decompress that area okay, try and divert the urine away from the obstruction um to um uh would you to try to try and resolve the sepsis, okay because if they're becoming septic, it means that obstruction is leading to potential um infection or leading to a systemic inflammatory response okay. So that's why the correct answer here is nephrostomy okay because you need to resolve and decompress the, the urine above the obstruction before you consider uh interventions to get rid of the stone okay. Hopefully, that makes sense, um so let's talk about management of stones okay, so renal stones and ureteric stones, so I've got here the sort of nice guidelines for management of stones okay. It's it's quite complicated. I wouldn't necessarily say you need to remember this in detail, but try and remember the prince's general principles for if they're small stones or large stones and what you do okay so generally, for small stones okay less than five millimeters. If they, if it's in the euro to or in the kidneys, you can watch, watch and wait ok, so manage them expectantly okay. If the stones are less than five millimeters, then and most patient's they should pass spontaneously within you know 30 days okay so for small stones, especially if they're located distally in the ureter uh, then most of them should be able to pass spontaneously, the stones that are slightly bigger, okay so 5 to 10 millimeters um Then you can initially offer medical expulsion therapy especially if they're in the euro to okay, so things like alpha blockers like tamsulosin can be used for your ureteric stones. Um If not, then you can do a procedure called extracorporeal shockwave lithotripsy okay, so e. S. W. L, so, this essentially where you're firing shockwaves to try and break up the stone um. So for smaller stones, this is a this is an appropriate option for bigger stones okay so for over 10 millimeters if they're in the ureters, then you can do your ureteroscope, ureteroscopy okay so feeding a sort of small camera and catheter through the ureter and try and fragment the stone to break it up okay, but for even for bigger stones okay. If they're in the kidneys, uh, then the definitive procedure is to do a percutaneous nephrolithotomy okay, but again key learning point okay. If you don't want to remember all this, ok, remember the key thing to remember as a junior doctor from in terms of safety for patient's if they've developed complications from the stones okay, so if they have uncontrolled symptoms or they develop complications like your oh sepsis, like our patient was developing in our in our SBA, or if they've developed an acute kidney injury okay, so if they've developed a post renal acute kidney injury, um Those are all indications to do a percutaneous nephrostomy procedure okay, so you can see here, they've inserted access the kidneys through the skin, uh connected a inserted a catheter through the skin and connected it to a catheter bag to try and drain the urine away from the obstruction okay um so that that that's critical for patient's who are who have developed any complications. Cool Question six have ago, this we have we only have nine questions today okay, so not too too much too many more questions to go okay. I'll call it that very interesting again okay let's call it there okay, so most of you have gone for be in this in this question, but the correct answer afternoon is actually see um so let's go through it okay. It's uh it's some again important learning points there, but um probably some something you probably haven't been talked too much about so let's go through, so we have a patient who has recently had surgery for a interest for intracranial hemorrhage okay, so this patient has had a subdural hematoma okay and has had a craniotomy procedure to try and relieve the pressure from the hematoma. And four days after the surgery, the patient has developed essentially symptoms of a deep vein thrombosis, okay DVT in his right leg, so uh there's a lot of things pointing towards the DVT here okay, so there's a severe pain and swelling of the right leg, it's swollen, warm erythematosus uh Dorsey flexion is causing pain okay. It is a classic hoffman's sign. Um It's just a classic sign of uh deep vein thrombosis okay, and I've I've, I've told you. At the end that the patient has been confirmed to have a right sided deep vein thrombosis on an ultrasound, so questions asking is how how do you manage this patient okay. This patient has developed a deep vein thrombosis okay, what do you do so let's go through it okay, so why, so what's the problem with giving anti coagulation to this patient why can't we give why is anti coagulation um contra indicated here can everyone trying to tell me why recent surgery okay, but not not if you not just recent surgery okay. This is a patient who's very recently just had a subdural bleed okay. This patient has an acutely had an inter cranial bleed okay. There's probably probably it might potentially still be bleeding okay. They've only just had they've only had a craniotomy procedure to just relieve the pressure okay, so if you give anti coagulation to this patient's that could potentially kill them because they're just they might just bleed even further and you you could potentially kill the patient okay so that's why the options here isn't to give anti coagulation immediately um the, into, the other things so thrown back to me iliac artery stenting okay. It's not indicated currently to treat the DVT okay iliac artery stenting is that's not for DVTS okay as for peripheral arterial disease, so inferior vena cava filter is the most appropriate treatment option here okay, so what is the vena cava filter okay. We'll talk about ever. Essentially it's a device that will be inserted into the vena cava to try and prevent any thrombus migrating and causing a pulmonary embolism okay, so it's essentially a device used in patient's who have absolute contraindications to anti coagulation okay such as in this patient, so if you can't give any type of anti coagulation to them, but you need you need to do you need to do something to stop them from developing complications from the DVT uh like upon re embolism or um you know just embolism of that thrombus uh then you can insert a inferior vena cava filter. Okay. Again, if there's a contract Tronto, indications to anti coagulation or thrombolysis or thrombectomy procedures okay. This is when you would consider it okay, so it's a very it's not not going to be something that's done often okay. It's a very specific patient who has recently had a uh interesting intercranial hemorrhage and is then developed a DVT okay, so it's a very specific type of patient who would be considered for a iVc filter, but that that's why this is the most appropriate option here uh Some of us what our unfractionated heparin and low molecular weight heparin you spot so that these would in a standard uh in a patient who is uh who is not recently postop from a intracerebral hemorrhage okay. Most appropriate treatment for DVTS is uh to use Dulcolax okay, so direct acting all anticoagulants uh like um apixaban or anything like that ok, that's the current options. Um If they have. If they have current kidney disease like in this patient, then you can go for a low molecular heparin, uh but the key thing in this, this patient was the contraindications for anti coagulation okay cool. Uh Someone asked why is the answer option, not surgical from back to me okay, so throw it back to me, so come back to me would be done uh for if they develop complications on the DVT okay. Um It's not I've haven't told you if they've developed like an infection or um I've forgotten the name name of it. But if you get a dangerous complication of a DVT, then you might consider doing a thrown back to me okay. There's there's no indication that this is a complicated deep vein thrombosis, thrombosis, and that's why that's the correct option, not not the correct option, So in terms of investigations for DVT okay, this is this kind of stuff you, guys, should should know for your exams okay um So similar to pommery embolisms, we can do a scoring system for DVTS called the wealth score okay, but it's a specific to level DVT well score. If the score is more than or equal to to, uh then patient's then it's and that means that a DVT is likely, so they should have an ultrasound within four hours, okay. Um If it's less than one or equal to one ok, then initially you can do a d dimer blood test in the emergency department. Ideally, you should do that within four hours and if that's positive, then you can do the, then you should do the ultrasound quickly. Um If you can't do the ultra, do the d dimer blood tests acutely, then um you can offer interim anti coagulation okay before you can get the d dimer blood test, but this is the main, the main sort of steps you want to do if the leg vein ultrasound is negative, you can do the d dimer blood test to confirm if it's positive and uh you've diagnosed the DVT, then you'd start treatment with anti coagulation. If it's appropriate if the d dimer is positive, but leg vein ultrasounds negative, then you should just stop the anti coagulation. Patient is on and repeat the ultrasound a week later. Okay Sassy General general sort of investigation approach to DVT, so let's quickly talk about DVT ivc filters, so we said it's used in patients with DVT who are at a high risk of developing complications like a like a pulmonary embolism okay and specifically is used in patients who have contraindications to anti coagulation and thrombolysis okay such as in our patient, so examples would include someone who is actively bleeding okay, so if they have a subdural hematoma like in our patient and had recent major surgery or recent intercranial hemorrhage. These would be specific contraindications to giving anti coagulation or thrombolysis okay. Um In terms of the actual device, so it's a filter that's inserted just below the renal veins okay. Very very important to deploy them just below the renal veins. Because if you, if you put the device above or at the level of the renal veins, you could potentially block blood leaving the renal veins okay, you can cause an outflow obstruction, uh which could potentially lead to an acute um thrombosis in the renal veins and lead to renal renal infection. Okay so very very important in terms of the procedure to actually make sure the filter is below the level of the renal veins and the filter also has perks to stop it from moving up and potentially causing embolize ing itself and causing symptoms cool. We have a couple of questions again moving on to another another condition. It's a bit of a whistle stop tour of interventional radiology. Trying to just go through some uh couple of different sets of conditions where uh intervention would be considered cool, Let's go through it okay Most of you picked interruption be and that is the correct answer, so well done guys, so this is when we were going to some hepatology, um so intervention radiologist can insert a device known as a trans juggler intra pathic portosystemic shunt or a tips device. Um So uh we've talked we talked about this. I talked about this in a lot more detailed in my hepatology for final session, which is currently available on youtube and on medal. So, I recommend if you guys want to learn a lot go into a lot more detail and learn about uh liver cirrhosis and uh tips devices in good detail. Go check out that lecture if you want to understand the full indications of pathophysiology of cirrhosis and things, uh but in this session uh In this question, we're just going to go through some of the key principles of tips okay, so tips is inserted in patient's uh. The most classic indication is someone who has uh end stage cirrhosis okay. Um Specifically the strongest indication is if they've developed a complication of cirrhosis called viruses okay so because of the liver cirrhosis, uh they've developed back pressure, which is leading to um increased pressure in the veins sort of the portal system supplying um which are going to deliver that's causing back pressure and leading leading to enlargement of veins such as the esophageal veins draining the esophagus and upper aspects of the stomach, so patient's going to cirrhosis can develop dangerous complications including variceal bleeding, okay so variceal hemorrhage, um so typically we'll go through management variceal hemorrhage, but someone who has recurrent variceal hemorrhage okay. That's the strongest indication for tips device because the tips can be a definitive option for treating recurrent virus is because you're definitively treating that portal hypertension, so resolving any sort of back pressure that's being built up because of the cirrhosis or the, or the uh the, what the pathologist leading to the fibrosis like in the alcoholic liver disease in this patient. In terms of the other options, so variceal hemorrhage is the strongest option. Hepatic encephalopathy is the most wrong option okay, so hepatic encephalopathy, specifically a contra indication to tips procedure okay, so hepatic encephalopathy is where patient's have developed essentially a confused state okay because of liver failure, they're not draining they're not processing important waste products like ammonia okay. They're not clearing ammonia from the blood properly and that ammonia and other toxic metabolites is causing patient's to become confused and leading to symptoms like um asterixis um reduced ccS okay. If you instead of tips, tips in these patient's that could be potentially even more problematic because, if you instead of tips, you're you're not, you're bypassing the liver essentially okay, so that would be problematic and careful opathy, hepatorenal syndrome is it's not the treatment for repatha, renal syndrome is to just is to transplant okay. If someone has developed such end stage liver disease where they've developed renal failure with it okay. They are the only chance they have is to do a transplant liver transplant uh had to sell a carcinoma on its own. There's no indication to do a tips okay um to treat cancer. There's different options including surgical resection, chemotherapy, and radiotherapy options okay, but tips wouldn't be indicated for cancer on its own and hydrothorax is where patient's develop plural effusions because of the liver, liver failure okay, so you're not going to insert a tips device to treat a pleural effusion. Okay. You're going to insert a chest train to treat a plural fusion, okay, so that's why correct answer option here is recurrent variceal hemorrhage okay, so this is slide uh taken from my hepatology for final session okay. I recommend just watching that that lecture on youtube and or on medal to see um understand the management of variceal hemorrhage. Okay. I'm not going to go through this. Again again key thing is if someone has developed variceal hemorrhage that is refractory to all of these other options like band ligation or medical treatments like trauma, injections uh then that would be an indication to insert a tips device okay, so if someone who has refractory or recurrent variceal hemorrhage that's when you insert a tips device, and this is what a tips device looks like okay. Essentially, you're you're inserting a shunt that bypasses the liver okay, that bypasses that portal hypertension, to inserting a shunt from the hepatic vein to the portal venous system okay so that by creating that shunt, you're bypassing all that fibrosis in the liver and resolving that pressure that's being built up in the portal venous system. Cool um have a good this question okay, let's send it there cool, so we got a bit of a split between A and d okay, yeah just perfect split between a and E, so let's go through this, so correct answer option is actually e, so proximal middle cerebral artery uh This question is not, is not as complicated as you, guys, think it is okay, so this patient is developed symptoms of a stroke okay as there's dense, unilateral weakness, okay, right sided weakness, uh unilateral hemiparesis, right sided visual field field defect okay, anonymous hemianopia with a speech impairment okay, so there's aphasia as well, and so this patient has presented with an acute stroke um and is being considered for definitive treatment option okay, So they've uh we'll talk about management okay, but they presented within this timeline considered amenable for mechanical thrombectomy, so in terms of thrombectomy, thrombectomy is a procedure done by interventional neuroradiologist, where they'll insert a catheter and try and mechanically retrieve the plot, okay, retrieve the thrombus, and that would be considered a potentially definitive treatment option for someone's um stroke okay. So in terms of questions, questions asking a thrombus if a thrombus was located in any of these arteries, which of these arteries would be most likely to be beneficial from a thrombectomy procedure, and the most correct answer option here is a proximal m. C. A. Occlusion okay, so patient's who have proximal emcee, a inclusions those are the ones that has the best outcomes from thrombectomy okay and if you think about it, it makes sense ok. If it's proximal, it's easily accessed and the they're more likely to be amenable to a thrombectomy procedure, okay. If it's distals, it's harder for the catheter to go through and reach the, the location um So that's why correct answer option here is proximal middle cerebral artery thrombosis, so ischemic stroke okay. This is a quick overview slide of how of the uk, or nice guidelines um approach to managing ischemic stroke okay, so it's all about the, it can be very confusing ok thinking about the timelines and things, but the key thing is if they present within 4.5 hours, okay off symptoms okay, not of when they present to the hospital okay well when they present, it's the timeline of when the symptoms started. If they present within 4.5 hours uh then you can give thrombolysis okay, so you give a tissue plasminogen activator and give that start okay as a t. P. A. Start and consider thrown back to me okay. We'll consider we'll talk about when you do thrown back to me an ischemic stroke. If you give thrombolysis, then after 24 hours you need to do a ct head and also give aspirin 300 mg okay, you need to do a do a repeat ct head after thrombolysis uh to make sure you haven't um uh you haven't caused a bleed okay by giving thrombolysis okay, that's one of the major risks you need to think about with thrombolysis is inadvertently causing someone to hemorrhage instead, so you do a ct head to rule out a hemorrhagic transformation. If they present after 4.5 hours, then you they're not going to be suitable for thrombolysis, okay. You can't give thrombolysis after this period, you can consider if they're suitable for thrombectomy okay well, which we'll talk about, but you should give aspirin 300 mg immediately if they presented after 4.5 hours, so the question of when you do thrown back to me can be very complicated okay. Um You should it's you according to nice guidelines, you should use a scoring system known as the ranking scale and the n. I. H. S s. Score to really determine if they're going to be suitable for thrown back to me procedures okay you can have a look on md cult to see which what the actual criteria for these schooling systems are. But if they have a modified ranking scale of less than three, and then I head chester score of over five, then that suggests that they're gonna be they're gonna benefit from a throwback team procedure, so in terms of when you do it okay If they present less than six hours after symptoms onset and a ct head uh or mri, has confirmed occlusion of the proximal anterior circulation okay, so approximal anterior middle cerebral arteries, then you should do a throat back to your procedure okay, so again less than six hours and confirmed occlusion of the proximal anterior circulation should do it, you should do a thrombectomy okay and that that would be combined with thrombolysis because they presented. If they presented within 4.5 hours, if they present between six and 24 hours, okay, and you've confirmed approximate anterior circulation occlusion and there's potential to salvage brain tissue okay. So this is essentially, if they, if you do a specific uh ct angiogram and you see that there's uh if a radiologist determines based on certain criteria like uh which is a bit complex to go into, but if a radiologist determines that there's potential to salvage brain tissue uh, then you can also do a throwback team procedure okay. Key thing is thrombectomy can only be done less than 24 hours off symptom symptom onset okay. If they, if they present after 24 hours, you can't do thrown back to me, um but yeah those are the sort of timelines to be thinking about okay for posterior circulation occlusions. If they present within 24 hours and this confirmed occlusion, then you can consider it as well okay, but yeah those are the sort of timelines to be thinking about with a ski mix stroke management cool have ago this one we have uh three more three more questions uh There's two questions for this one and then um just covering some gynie presentations, and then we have one more question um covering um central venous access okay, let's call it that. Uh This is again a bit a bit more of an anatomy type question, which again, if you're gonna be, if you guys ever going to be interventional radiologist, you guys should be very confident in your anatomy uh So let's go through this, so we got a bit of a split between C and D uh uh correct answer, afternoon is actually see uh so internal iliac arteries okay, So this is this is a question talking about basically postpartum hemorrhage okay, so um bit of obstetrics topic, so this patient who has had a prolonged labor has developed as developed hemorrhage after labor okay, so postpartum hemorrhage, severe vaginal bleeding, boggy uterus okay, So this is suggesting a lack of tone and the uterus, which is leading to a postpartum hemorrhage. We'll talk about well. I've got an overview slide covering management of postpartum hemorrhage but initial steps for management of p. P. H. S. To do a uterine massage especially if there's if it's due to lack of tone in the uterus and give uterotonic medications like oxytocin to try and stimulate contractions, uh So these are general sort of initial medical steps to take for a postpartum hemorrhage. If patient's are refractory to these initial treatment steps, then you to then you can consider more invasive steps like surgery and interventional radiology, so embolization basically means you're trying you occlude a blood vessel okay, so inserting materials that will block a blood vessel, so if any blood vessel is bleeding, then you can do an embolization procedure to try and block it off okay, so questions asking which for, uh so the question's asking which of the following arteries is likely to be access to controller bleeding and preserving fertility. So for postpartum hemorrhage the artery you need to access to do the embolization is the uterine artery okay, so it's a uterine artery embolization procedure which needs to be done and the artery would that will need to be accessed is the internal iliac arteries okay, so the so the uterine arteries are branches of the internal iliac arteries and so those are the ones that would need to be accessed okay. Internal pudendal arteries, so those are arteries that supply the external genitalia okay, So they're not the ones that that will be accessed for uh embolization procedures, necessarily ovarian arteries. Um They're not the ones that they they don't branch into uterine arteries, but ovarian arteries do are the ones that provide the collateral blood flow okay. So a lot of a lot of people get confused why you can include the uterine arteries and still maintain you try and function. The reason why you can block off the uterine arteries and the uterus is still able to maintain its function. Is because the ovarian arteries are able to to supply a collateral blood flow okay, so that's why internal I like artery is the correct option. Again, another, another question okay is that of interest if you didn't want to preserve fertility, which artery would you embolize, so it's the uterine arteries if, for postpartum hemorrhage, it's the uterine arteries which, which get embolized okay because they're they're the ones, which will, which are directly supplying the uterus and uh and the spiral arteries from the uterine artery is the one that's um bleeding out okay, so it's not necessarily about which arteries to choose it's the uterine arteries which you need to access for treatment of the postpartum hemorrhage and in terms of fertility, so we'll talk about it a bit, but the fertility. The evidence for maintaining fertility with our uterine artery embolization isn't that well defined, uh but yeah we'll talk about that briefly uh for we launched the pool well, let's under that okay, so most of you pick see a couple of um for d as well, uh so the correct answer is actually C. Okay. So this is a question talking about again patient bleeding okay, but this is an obstetric presentation. This is more of a gynie presentation okay. So this is a patient who is presented with menorrhagia okay and, and the public, and we ultrasound has confirmed that this is menorrhagia due to fibroids okay, so leo myomas if you want to pick the technical term okay, so his patient has developed bleeding um development of radio from her fibroids. In terms of what we've already done, so she's had transit stomach acid and she has been trying she wants to conceive okay Very very important in, in any menorrhagia, history okay always uh when considering treatment from menor, asia, always clarify if patient is planning on conceiving okay, think about the age of the patient and think about whether she's trying to conceive okay. Very important when thinking about what the ideal treatment option for patient's will be. Uh pregnancy test is negative, okay, so we ruled out pregnancy as a cause okay, so we know that it's not going to be due to you know ectopic pregnancy or miscarriage or anything like that and so the ultrasound has confirmed a submucosal fibroid that distorts the uterine cavity okay, so there's uh answer options. Myomectomy is the most appropriate option. Okay Myomectomy is the gold standard treatment for sub mucosal fibroids, especially and woman who uh want to conceive okay. Myomectomy is considered one of the uterine preserving operations okay um So that's why that's the correct option okay. The main thing is because she wants to conceive, and because it's a submucosal fibroid myomectomy is going to be the most uh appropriate surgical option, okay, just the other one, so 11 or just point our us so i us might might maybe an appropriate option for is an, is an effective option for treating menorrhagia, okay, but this one this woman wants to conceive and you shouldn't insert an eye us in someone who has a really big fibroid, which is distorting the uterine cavity okay, so it can be dangerous to insert a. I us in these patient's hysterectomy is obviously not going to be appropriate, okay, so hysterectomy is considered the last line option, especially this woman who wants to conceive. Um It's not going to be the most appropriate option here. Endometrial ablation is not going to be the most appropriate option. I guess well okay because she wants to conceive, is not considered a you train preserving operation, and in terms of the interventional procedure okay, so uterine artery embolization is the interventional procedure which can be considered, but the key thing is that the evidence for it being able to preserve fertility isn't that well defined compared to myomectomies okay, so it's only considered in someone who has symptomatic fibroids who don't desire who do not desire fertility, but they want to maintain, they don't want to have a hysterectomy okay, so they want to still have maintained their uterus. Um that's when they would be considered for uterine artery embolization okay. So again, if they there's no desire for fertility, but they don't want to have a hysterectomy. That's when you would consider you try an artery embolization cool, so we cover some of the guinea presentations here okay. So this is slide covering the general management of postpartum hemorrhage. Okay, so I've included this pneumonic to try and go through the sort of logical order of how you manage patient's with postpartum hemorrhage. Um uh This is we covered this in our obstetric station in a lot more detail okay, but if you guys like pneumonic, so I've included this pneumonic for your own learning, uh so you can have a read in your own time. The key things is is that an acute resuscitation, you try and massage giving oxytocin and prostate landings and if they're not responding to any of those measures than considering surgical surgical interventions like balloon tamponade, um compression compression teachers, ligating arteries through pelvic d, vascular ization, or if they're suitable for a uterine artery embolization okay. As a last line, you can do a hysterectomy if they're not responding to any of the surgical interventions in terms of fibroids management, so we talked about it okay. So if the asymptomatic, you don't treat fibroids okay. Very important uh medical options include Nsaid like method, emmick acid, uh antifibrinolysin fiber analytics like transit, stomach acid, and c. O. C. P. And uh us can be used in patient's as well surgical options, so might we talked about myomectomies, hysterectomies, ablation therapies okay. Myomectomy is the gold standard uterine preserving operation, especially for sub mucosal fibroids and interventional, so uterine artery embolization. Uh We talked about it. It's used in women who want to preserve the uterus, uh but they don't deserve they don't desire fertility necessarily okay fertility rates after you tried uh embolization, it hasn't been uh that well defined okay, so that's when you try an artery embolization is used okay. This is the last question okay we're nearly there now, so have it go uh Some of us how do contraceptives help with fibroids, what's the mechanism. Uh It's interesting so uh general home hormonal, so, fibroids. In general, they are very hormonal in nature, okay as in uh they grow in response to you know things like excess estrogen and things like that um so by giving, by altering with the hormonal system, okay uh If you give you can use things like g n r h analogs, which have been shown to help shrink five fibroids, okay, so it's it's obviously it's because of affecting the reproductive hormones Um that's what that's why contraceptives are useful in treating fibroids okay. So five the fibroids are very responsive to the changes in reproductive hormones. Okay, Let's end up there, I'm not sure if I did I not relaunch the pole, yeah, I'll just let you guys answer again quickly yes, the last question okay, let's end it there uh yeah most of your rights uh so uh this correct answer option here is to do a chest x ray, so this is a patient who has had a central line inserted basically okay, so this is a patient who has had progressive uh cough, shortness of breath, fever, and charles for the past seven days, is distress, flushed, and diaphoretic crackles and bronchial breath sounds I heard over the right post to your lung base. We've started. I've told you that we've started the sepsis six protocol okay. We haven't been able to insert a a cannula okay. We haven't been able to get intravenous access, so we can assume that patient has been referred to intensive care for insertion of a central line okay, so a large herbal central venous catheter is inserted to the internal jugular vein, so the question is asking what is the absolute most appropriate next step to do after you've inserted a central line okay. So once you the key thing is once you as, as soon as you've inserted a central line okay whether it's been a it's a juggler line or a sub subclavian um catheter, okay. You need to do a chest x ray immediately after okay because you need to make sure you rule out important complications okay, particularly pneumothorax, hemothorax, okay complications from inserting a central venous catheter. Um That's the most important important step okay. Other things like uh intravenous adrenaline not necessarily indicated okay. It's more important to do a chest actually okay because it's simple, cheap and you can rule out the major complications from central line insertion okay. Ct thorax would take too long to do again, You don't necessarily need to do it. You don't need such a invasive definitive investigation to rule it out uh similar to bronchoscopy and echocardiogram. Um A simple chest x ray is all you need to do after you've inserted a central line, so just quickly talk about central lines okay, So the most common thing one you'll see in intensive care. These tunnels lines okay so to gain central venous access. They can insert a catheter that uh either through the internal jugular vein or the subclavian vein that will be passed down towards the right atrium okay um and then they can basically they can tunnel the catheter below the skin here and the idea is by tunneling under the skin that helps with stability, okay by tunneling under the skin and also reduces the risk of infection as well, ok, so that's what a procedure is okay, that's what the procedure procedure of a tunneled central venous catheter is or a tunnel central line. So common indications is when you need to gain uh invasive access for things okay, so if you need to give someone loads of fluids okay, if they're severely hypokalemic, or you know that you're going to need to give iV medications over a long period of time like chemotherapy agents. If they don't have uh iv access like an outpatient, or if you need to give irritants like if you need to give uh nutrition like a total parental nutrition, you can do that by a central venous line as well, or if you need to, if you need to monitor someone hemodynamically okay. If you need to take regular blood samples from them, uh you can do it very easily from a central venous catheter okay and another one which you might guys see is a thing called implantable venous access port okay, so similar thing where you're trying to gain central venous access, okay, but by using this kind of access ports okay, so essentially they just bury the port underneath the skin, um it's a bit more cosmetically appealing, okay. They don't have to have this big scar of where they tunnel the captive below the skin and also they it's a bit more portable okay. They can shower shower with these, and it's a bit more convenient for their general activities of daily living as well, okay, but the thing you'll see most often in hospital are the tunneled central venous catheters okay and that was that was just a sneak peek whistlestop tour of some of the interventional radiology procedures. This is this is a list of all of the other types of procedures which interventional radiologists can do okay. So there's a whole lot lot of different types of interventional procedures okay as I recommend just if you guys are interested, just have a read of what some of these different procedures and hopefully you guys found it found it useful to get some insight into interventional radiology, but yeah thank you guys for coming today. I hope you Guys enjoyed it was a different type of session okay, not necessarily something that gets taught too often in medical school level. I really appreciate you guys can fill out the feedback form, which has been sent okay, and there's a post session survey with that as well. And yeah Thank you guys for tuning in and I hope you guys enjoyed. If you guys have any other questions, do, let me know, remember, we're starting our Rosky series soon as well uh First week of march, we've already got some of the events out on facebook, so please make sure to put to click interested to click going on the facebook events to make sure you're notified and yeah it's a very exciting views, it's in, we're probably in collaboration with geeky medics for the series as well. Um It's gonna we're really gonna I think for the quality of our teaching is going to be super high for that for that series, so yeah make sure you guys tune in for our first session on the cardiology station, um which will hopefully be a really good start to our series seventh of march, I think yeah um did you manage to answer the question they're different the difference between a percutaneous, naturally thought to me and nephrostomy oh uh yeah good question, um so I didn't so the key thing to realize that nephrostomy is not a treatment for the stone. Ok nephrostomy is purely a procedure to divert urine away from an obstruction okay and nephrostomy is where you basic insert a catheter through the skin and try and drain some of the urine out to prevent to try and relieve relieve the obstruction. Okay, nephro lif, lif oh uh nephrolithotomy. Is where you're actually trying to break up the stone okay, so you're inserting a catheter through the skin to actually try and break up the stone okay, so it's an actual treatment for the, for the urinary tract obstruction. Okay, remember if they, if they anyone develops complications from the urinary tract obstruction. The first step is to do a nephrostomy, and you can also insert a stent with that as well to try and drain during the urine away around. You want to stop recording.