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So hopefully everyone can hear us right now. I think that should be all right. Um So welcome everyone to the fifth session of the National Radiology teaching series that we're hosting. Um Today, I have the pleasure of welcoming Doctor Peter Douglas who is a consultant in interventional radiology um here in Glasgow at the Queen Elizabeth University Hospital. Um So today, uh Doctor Douglas will be taking you through some interesting interventional radiology cases. Um looking at some challenges um faced, faced by the interventional radiologist in practice and looking kind of at the innovative um um solutions that, that they go through as well. Um And there will be a bit of AQ and a after the talk. So if you have any questions, just pop this in the chat and we'll, we'll take a look at them uh after the talk. Um But without further ado, um please feel free to take it away, Doctor Douglas. Uh Hi, everyone. Um Please let me know if there's any issues or the slides aren't coming across, just stick a message in the chat and we will see what we can sort out. Um Welcome everyone to this. Um I've been a consultant for almost five years now. I trained in Glasgow. So, uh I went to medical school in Glasgow. So I'm very much a west of Scotland boy, despite having grown up in northern Ireland, but I've been here longer than I was. Uh, I was there. Um, but there is fantastic ir happening all across the country. Um, and I'm hopefully going to give you a little bit of a flavor of that today. Uh So what is it like being an interventional radiologist? So if any of you have had any exposure at all, it'll probably have been some slightly disparaging comments about other people in the hospital about us. And they probably have us labeled as a bunch of people sitting around in an office, uh sipping espresso and uh looking at computer screens and kind of uh laughing at everyone else in the hospital or how silly their requests are before we cancel them. And first of all, this is, this is wrong in a number of ways. Uh First of all, we don't have any windows. Um despite us being on the second floor, we, I don't see daylight uh most days of the year. Um But aside from that, we also the actual practical portion of the job is an awful lot like playing a computer game. Now, I don't mean to be disparaging or put anyone off or be disrespectful to the patients when I say that. But in terms of our hand eye coordination and uh how we achieve our outcomes. Uh A lot of the time we're not looking directly at the patient as we do it, we're looking at our um TV screen or monitor, which is displaying live ultrasound or fluoroscopic X ray images. And rather than using a joystick and some buttons to control things, we're using catheters and wires. Now, that doesn't mean we're not talking to the patient and we're not uh liaising with them to ask how they're doing and things. Um uh And having this kind of computer game type interaction is brilliant because it allows us to do um incredibly minimally invasive solutions to some pretty significant problems. Um because we don't actually have to open up the patient for direct visualization. Uh But it also has some limitations. Um So, for example, it's an inherently less controlled scenario. Uh If a surgeon causes a problem and causes some bleeding, they can just stick their finger on something and then put a stitch in it. Um We can't do that because it's often way far up inside the patient somewhere very remote from, from uh where we've uh entered the patient. So we minimally invasive but also in some ways minimally controlled. But we have ways around that we can deal with those things. So practically, what is it like? Well, first of all, it's really collaborative. Um this is a picture of a newly installed IR suite. This is not where I work. This is just a stock image off the internet, but the first thing you should note about, notice about this room is that it is absolutely enormous. There is a huge amount of space in there. Any of you who have been in an operating theater, uh should think this is at least two or three times of the size of your average operating theater. Uh And that's for a number of reasons. Um First of all, the x-ray generating equipment itself, the C arm takes up a certain amount of space and needs a certain amount of space to move. Um as do our uh monitors to the images to us, but also the control monitors to read images to the radiographer. Uh We need space for our sterile trolleys for our equipment and bear in mind that uh some of our devices that we're gonna put inside the patient can be a meter and a half or even a little bit longer than that, which means we need to have a wire inside the patient. That's that long. And we need to have enough wire space outside the patient to put the device on before it goes inside. So the longest piece of equipment that we use routinely is 5 m long. Yeah, so 500 centimeters, 5 m long. So you need a bit of space to use that. Um But also you'll notice in here that there is an anesthetic machine in the back. Uh There's a pendulum for them to have oxygen and nitrous oxide steril i and vacuum and all that stuff. Um This room will probably also it has some theater lights. So theater teams will be able to come in to do hybrid procedures, most commonly vascular surgeons, but also a lot of other specialties, we can do hyb hybrid procedures along with. So you can have an awful lot of people in this room, radiologists, they're nurses, they're radiographers, sometimes translators, sometimes there's a whole surgical team, they're theater nurses and then a full anesthetic team. So we do have cases where there can be 15 to 20 staff members in a room. So you need a little bit of space for everyone to work. And of course, if you're trying to perform an invasive procedure on this person, especially in an emergency setting or if you're doing anything very high risk in order to do your job properly, to get a good outcome, you need to be communicating with all of those people sometimes at the same time. So you have to be collaborative. Now, the slight disadvantage of collaboration is that sometimes other people steal are work. Now, there's plenty of work to go around. Um The last time I checked sickness in humanity was still a problem. So there is lots to do. Uh But there's an awful lot of procedures that were invented by radiologists that have been taken away. So, for example, percutaneous coronary intervention for heart attacks. Um in the west of Scotland, patients get uh blue lighted from A&E departments to the Golden Jubilee Hospital where there's a 24 hour cardiac center and patients get their PC. Well, that was invented by interventional radiologists, same with uh E RCP or endoscopic ultrasound. And if any of you have seen a chest drain or an acidic drain go in, it's almost certainly been inserted using the Seldinger procedure, which, which was a radiological uh technique to invent. So it's kind of spread out to, to find lots of different areas. It's also really broad. So I mentioned vascular surgeons earlier on. And because in my practice, they're the team in the Queen Elizabeth Hospital that we work most closely with. But we also get a huge numbers of referrals from urology, gastroenterology. We work with the pancreatic surgeons across the city. Uh We get lots of referrals from on oncology and many of my colleagues do large volumes of interventional oncology, treating renal and liver cancers. There's also lots of M SK oncology, treating some M SK tumors. Uh We get lots of referrals from Abs and Gin doing things like uterine fibroid embolizations. But we also work with uh our obstetric teams uh around uh either big postpartum hemorrhages or patients who have abnormal placentas who are at high risk of large volume bleeding. We do some work in pediatrics and we actually have one IR consultant in Glasgow who does 50% adult and 50% pediatric work. And she's working to expand the range of ir services that we can offer Children in the west of Scotland. We also of course work with emergency medicine, uh patients with uh emergency bleeding problems, primarily uh or blocked kidneys and other septic issues that come in through emergency department or through the intensive care unit. Uh We get referrals from general surgery for um, gallbladder problems, biliary issues, uh obstructed colons, meaning colonic stents and from our respiratory colleagues uh in the west of Scotland, there's quite a lot of patients with cystic fibrosis and the bronchiectasis from that uh can cause some large volume bleeding, large volume hemoptysis and we can embolize that to, to get some good control. So I in an average week, I will speak to members from all of these teams, either about procedures that have happened, procedures that they want an opinion on or procedures that we're planning to do in the near future. But we always come back to our diagnostic skills and to be a really good interventional radiologist, you need to have a really safe base in x-ray interpretation. Uh The the best IRS that I know are actually fantastic diagnostic radiologists. Um It helps you plan your procedures. Uh It helps you choose the correct procedures to do and most importantly, which ones not to do. Um And although uh this skill element is definitely exaggerated, you do have to have a little bit of passion for imaging in general. If you want to go on and be an interventional radiologist, you can't completely forget about looking at x rays and scans. It definitely forms the bedrock on the basis of our procedures. And if you're struggling during an IR procedure, usually the safest and most effective thing you can do is to pause de scrub, look at your imaging to work out where you are and what's happened that you weren't expecting and then rejoin it. Um And, and go back to achieve a good outcome and we do that not infrequently. And the more experience I get, the more I do that and it makes my procedures uh faster, safer and more robust for the patients. So anything bad about being an interventional radiologist, I would say probably the biggest downside is trying to work with people who don't understand what you do and why you do it. Although that is predominantly patients, most patients in the UK, if not the entire world have never heard of interventional radiology as a specialty. Um They don't know what we can do. And sometimes, especially in modern medicine, the problems that they have are found almost incidentally. Uh the more uh CT and Mr scans that we do to the population at large, uh the more small problems that we find some of these get referred to us to see if we can do anything about it. So some of these patients come and they have no symptoms and we have been asked to do something to prevent the problem from occurring, uh, or to get someone ready for, for a subsequent procedure that, that they, they thought they need to get someone ready for a bigger surgery. Um, and sometimes that can be difficult to explain to patients and their families. In addition to that, though, an equally large challenge can sometimes be explaining to other specialties in the hospital, what you can offer their patients. Uh or the flip side, uh once you have some degree of procedural success in a few patients, it can be difficult to explain to other teams in the hospital why this particular patient is not suitable to undergo uh the same interventional procedure as the last ones. Uh Now everyone's job is getting harder and harder and times go on, especially in this kind of post COVID. Um post austerity period, resources are extremely limited. Uh But I suppose the wide breadth of specialties that we work with um means that when the hospital is in general, quite busy that all of these individual specialties who are referring to us are all busy. So we become very busy and it feels like we're being pulled in lots of different directions. Uh And it can be a struggle to try and balance the priorities in very very different patient groups. So we're trying to priority, you know, uh uh a young child who needs a feeding tube reinserted as opposed to a very elderly patient who needs a revascular revascularisation procedure for the ischemic leg to try and prevent an amputation. So that's a wee bit of background, we're gonna discuss three cases today. Um Just to give you a little bit of a flavor of what I do and how I do it. And the first one is a case from my very first on call as a consultant. So almost five years ago now it was a 22 year old woman. She had a single stab wound to her right flank. She was brought in by ambulance to A&E she was in shock. She was quite agitated and difficult to assess because she was drunk as well as quite upset. Uh Therefore, they intubated her in A&E so that they could assess her safely. She was stabilized with fluid resuscitation and she was transferred to CT because when you find an external stab wound, you have no idea what that knife has done on the inside and you can have a tiny little neck and have all sorts of damage. Now, at the point where they lifted this patient from the trolley from resource onto the CT scanner, she promptly tries to die. She goes into absolute shock immediately on the CT table before she's gone through the scanner. And they have to do an awful lot of work uh stabilizing her again. So within about 10 or 15 minutes of getting more fluid into her et cetera as she starts to stabilize and they get some control and then she goes through the scanner and this is uh what's called a MPA maximum intensity projection taking through her upper abdomen. So her spine is in the middle, uh things are back to front. So the patient's left is on the right hand side of the screen. So this is her left kidney, this is her right kidney. And those of you who may have seen a, a little bit of imaging before may appreciate that this white thing coming up from the right kidney pointing up to the abdomen is a spurt of arterial blood spurting up about 10 centimeters inside the patient. And that all of this mid gray stuff through the right side of the abdomen, extending across the front, across the midline. This is all hematoma. So she has lost a huge amount of blood uh inside her retroperitoneum from her kidney. And this is the most dramatic arterial bleed on CT I've ever seen. She is absolutely hosing um for this to be extending, you know, 5, 10 centimeters out of the kidney is horrendous and no one can bleed like this for very long uh before they bleed to death. So when you see a really, really dramatic bleed like that, it's usually some intermittent bleeding and that fits exactly with uh the back story. So she right in A&E they stabilized her So this retroperitoneal hematoma would have tampon at it. You know, it would have gone under pressure and kind of self uh pressed on the bleeding point. So the bleeding stops. Then when they lifted up her up for transfer and dropped her on the CT table again, it shakes free a little bit of clot and the bleeding starts again and she just acutely drops her BP uh immediately. So she uh became a wee bit stable after this. And they called me saying there's an awful lot of bleeding. Can you do something to stop it? So, going through the scan, the entry point for the wound is here in the right flank, it then goes in the kind of postural lateral margin of the kidney. And then the knife has gone all the way through to come out to the Antero medial portion of the kidney. It's gone through the pancreatic head and out the other side and there's a hole in the anthem of the stomach just before the pylori. Um So she has really been shish keba all the way through and the track between those two spaces is about 20 centimeters long. Now, if you see all this hematoma on the right side of her abdomen, the knife she was stabbed with almost certainly wasn't 20 centimeters long. Uh It was probably about half that length. But as the patient has bled, the hematoma has pushed all these structures apart and created a big space. No, the major bleeding point is coming from the kidney. Uh So of course, that's a retroperitoneal structure as is the pancreatic head and parts of the duodenum there. So most of this blood is in the is in this retroperitoneal space. And that has a really tough membrane across the front which you should all know called Gattis fascia. Now, that is really tough and that's what allows it to create this tamponade. The problem with her is that she's got a hole in her pancreas and she's got a hole in her stomach. So the general surgeons know that they have to go in and open this retroperitoneum to do an operation. And I didn't know this until this case, but there's a really common question in the surgical exams. Uh If you want to, to do your fr uh Fr CS, uh you will probably be gas a question. Uh There is a large retroperitoneal hematoma. Uh should you go and operate? And the answer is absolutely not because to open these fascia in the retro name, the patient completely loses all their tampon at the, the the pressure drops and they just start bleeding again and the bleeding is often so brisk that the surgeons cannot, may not be able to find the bleeding point to actually stop it. And the patient can bleed to death in front of you. Your only option then is we need to kind of pack it and hope that the bleeding stops. So I had a consultant urologist and a consultant surgeon. Um kind of begging. Can you please please please do something to stop this bleeding? Because I have to do an operation and everything I've ever been taught tells me don't do this operation, but we have to. So I went through an embolization procedure. So this is a DSA digital subtraction angiogram. So the reason that everything is gray is because we've subtracted one picture um from all the rest. So that the only thing we can see is our x-ray dye that were injected. So I punctured the right femoral artery came up into the aorta, put this plastic tube into her right kidney and injected this contrast dye and took these pictures. So does anyone see any obvious bleeding point? Cause I don't? So just stop and go home. Let's go a little bit closer and see what we can find. So when we're working, um and we have our giant uh x-ray monitors, uh the screen is divided into different portions. So I may ask the radiographer, please give me a reference image across there and they'll choose a frame and they'll put it across to one side of the screen as a reference image. And then that can stay up as we go further in, we can magnify up, we can change this and I still have my reference image as a map for how things expected. So we went a little bit further in injected a bit more contrast, still can't see any bleeding. Now, I know that you need to get quite close to a bleeding point to be able to see it. We know that from experience, especially in this period where there's tampon out. Um unless you can generate enough pressure with your contrast injection to overcome the pressure of the tamponade, you won't actually see the bleeding. So we're gonna go further again. So we went into this branch. Now, at this point, I'm starting to see something that doesn't look quite right arteries, especially in organs like the kidney or any other deeply vascular organ branch, just like the branches of a tree. And of course, as those branches get further out from big trunks to little trunks, to small branches, to twigs, they get smaller as they go out. What they don't do is suddenly taper off an end. So if you see this right in the middle of the screen, there's a normal branching more at the top, normal branching one at the bottom. And in between, there's something that doesn't really branch, it just tapers down very abruptly and ends. And this is sometimes what we would call a secondary sign of bleeding. Uh So sometimes the arteries can go into spasm once they've been injured. Uh So that the bleeding actually stops. Uh But that's only a temporary thing at some point that spasm will um will relax again. The artery will go back to its normal size and the patient will start bleeding. So we took a little tiny catheter, a little micro catheter. We went through that vessel and injected contrast and lo and behold, here's this fountain of, of uh bleeding and contrast that we saw on our CT scan. So I was able to put one little coil into that branch, do a check angiogram, make sure there's no further bleeding. Yep, nothing going further at that branch that looked pretty good. Did another couple of check angiograms. And as I said before, I wanted to do this really safely. So I de scrubbed and went back and checked her CT to make sure that the pictures that I'd taken here matched what I thought was there on the CT scan. It all looked good so I can spoke to both the general surgeon and the urologist and we finished up and I took this tube out and she went on to have her laparotomy. They opened her retro name with her brown trousers on and she was fine. There was a lot of hematoma there which they evacuated, but there was no active bleeding. So she went from the most active bleed on CT I've ever seen to complete hemorrhagic control with one coil. And I think that is, this is where Ir uh can offer the most value. It's not that we're amazing and we can do things that no one else can do. But that when we work collaboratively with other specialties together, we can achieve things that individually, no one can really achieve. So our next case is a vascular case. So there is a 56 year old man who has had an aorto bifemoral graft for iliac occlusions. And we'll go into that in a wee second. Unfortunately, his aortobifemoral graft became infected. So it needed to be removed and it was reconstructed using deep vein of the thigh. So generally, uh an aorto bifemoral graft uh shaped like a pair of trousers. It's a plastic tube and they'll switch the waistband of the trousers onto the aorta and then they'll take um each trouser leg down into the external iliac or, or the common femoral and they'll stitch that on and that one plastic tube will split in two and deliver blood uh down each of the patient's legs. Now, this is what the uh original surgery looked like. So you can see this white pair of truss here that's been stitched onto the distal aorta a little bit below the kidneys. It splits in two and one, what's called limb of the graft goes down into either groin to then supply the blood to either leg. And this is what that looked like in Sagittal. So you can see the aorta at the back, there's still a little bit of blood flow still in the aorta. And then this is the uh aorta bifemoral graft or sometimes called ABG at the front here. Now, two weeks later, this reconstruction was falling apart. So this has turned into a false aneurysm. So, despite the surgeon's best efforts, there was some residual infection at the site of their operation and the uh vein graft that they use um has started to fall apart. You can see there's a lot of stranding and probably some hematoma surrounding all of this. So this is a mixture of maybe some infection. But also there's probably at least some element of bleeding, uh filling in the fat here in the retroperitoneum around the aorta and the surgery. So this patient is in real trouble. They've had a definitive operation. It hasn't worked, it's got infected, they've had a redo operation, it still hasn't worked. And now his aorta is falling apart. So the surgeons came to us and said, I don't think this guy is gonna survive another operation even if I was able to do something. So they say the only thing that they can do is to tie off his aorta, which is essentially a palliative procedure. Yeah. So an aortobifemoral graft in a diagram form looks a bit like this for patients who have occluded iliac arteries. And this is almost the exact pattern that this man had because he external iliacs were occluded, but he still had some flow down his distal aorta going into his common Ilex into his internal iliacs. Uh but the aorto bifemoral graft itself went from the infrarenal aorta, the graft itself splits and then the right limb stitched onto the right, common femoral and the left limb onto the left common femoral. And of course, this poor gentleman had an explosion or a big false aneurysm at this proximal anastomosis with the aorta. Now, you may have heard of aneurysms in the abdominal aorta before. Um and they usually look something a bit more like this. So most aneurysms of the abdominal aorta are of course primary aneurysms um of the aorta itself rather than post surgical. Um You sometimes called true aneurysms, but really, it's just an aneurysm and in either a postoperative setting uh or, or a trauma setting, then if it doesn't involve all three layers of the wall, then it's known as a false aneurysm. Now, we have lots of good treatment modalities for abdominal aortic aneurysms. The good old fashioned one is surgery, but there's an interventional radiology, one known as evar, which you may have heard of which is endovascular reconstruction of uh oh my God. I've forgotten what the acronym stands for. I just write evar, it's fine. Uh So endovascular reconstruction of the aortic aneurysm. And in order to achieve that, um our evar devices come as modular components. So because patients are all different sizes, width, shapes, et cetera, we choose from the shelf, these different components that we need to build up something to match the patient's anatomy. So uh above the aneurysm in what's called the neck or the normal bit of the aorta just below the renal arteries. We choose what's sometimes called the bifurcated graft or the main body, which again is a bit like a pair of trousers and we put that on the top and they come in different diameters and we choose one for the patient's aortic size. We'll then choose an iliac extension to go down one leg of this to plumb into the iliac. Uh Then we'll cannulate the gate, we'll fa little wire up the short stub leg and then we'll choose another iliac extension to go in there. And these iliac extensions can be straight, they can be tapered and get narrower as they go further down or they can be flared and open up wider. Um So we went on the shelf and we looked at this guy CT and we looked at the shape of his aneurysm right at the top here. Now, we want to go from the abdominal aorta into the first portion of this ABG, but we don't want to go any further down because if we do, we'll cut off the blood blood supply to one leg. Now, sometimes that's a good thing to do or rather it, at the very least it's the least bad thing to do. Uh And the patient could get what's called a femoral femoral cross over graft. So you basically make one big pipe going from the aorta all the way down to the patient's common femoral artery and then they get a plastic tube put in by the vascular surgeons from one common fe to the other. And the one big tube uh supplies both of the legs. But this patient's already had multiple surgeries and has infection. So the surgeons don't want to do any further operating at this previous operative site. They say the whole thing will get infected and fall apart. They certainly don't want to stitch in any new prosthetic material because prosthetic material is incredibly hard to clear the infection off. It's effectively impossible. So they want us to plumb in the aorta to stay inside the uh main component of the uh aorta bifemoral graft without compromising, flow down either of these limbs. Now, there is a device that does that it's called an A UI or um aortouniiliac component and it does what I said, it goes one big tube in the aorta tapers down to go just down one iliac. So we measured this guy. Right. Right. We need something that's about 23 at the top 16 at the bottom and we went and checked on the shelf and we didn't have anything. We do not have an A UI at least not in that size. So we looked at everything else we had on the shelf and everyone was really struggling. Right. We don't have any other stent grafts in these size diameters that we can use to exclude this aneurysm. And stop this guy from bleeding to death. So then I had a look and I thought, hm hm hm. And I grabbed a couple of boxes from the cupboard and ran along to find the vascular surgeon and said, can you cut down into subclavian artery? And we'll put this tube in upside down? And he said, yes, that's very cool. So that's what we did. He did a distal left subclavian cut down, which is not a fast operation to do the subclavian artery is funnily enough below a clavicle. Uh So it's not easy thing to get at. So it takes a little while to get in there and you don't get particularly medial because of the other structures that are there. But we did a cut down. We got wire access through, down the aorta um through the aneurysm. We inserted our absolutely enormous device in around his subclavian artery down through his entire thra aorta passed all of his uh sma and renal arteries and into the aneurysmal component. And we deployed it with careful angiograms uh to work on exactly where we needed to be and what we didn't want to cover because we don't want to cover his kidneys. Uh And we don't want to cover his bifemoral graft and this is a follow up CT. So you can see this tapered thing goes from just below his renal arteries uh all the way down tapers down and we've landed it just at the very distal portion of uh of the main component of his aortobifemoral graft just before it splits. And you can see the contrast here running down both legs. He was put on broad spectrum antibiotics and he remains on broad spectrum antibiotics to this day. This guy is still alive. That was five or so years ago. That's a real success. No, the last case we're gonna do is in some ways not an interventional radiology case and in some ways an absolutely typical interventional radiology case. So I got a referral regarding a 51 year old woman who was chronically confused. She'd been an inpatient for months and was currently under neurology. She wasn't really eating and drinking and she wasn't really safe to eat and drink. And the referral was for a gastrostomy tube. So a feeding tube rather than a nasogastric feeding tube that you may be all fairly familiar with that goes in the nose down the esophagus. Some of the tips in the stomach patients hate those and they can fall out and get misplaced. So they're not the easiest thing to nurse something someone with either. Um but a gastrostomy goes straight through the abdominal wall and into the stomach and provides a very robust long term feeding solution for the patient and their carers. Her swallow is variable and its safety uh she can be agitated, she's confused. She has pulled out ng tubes and I suspect that a gastrostomy tube would be the best option and are asking for our advice, further email chat asking about the diagnosis and why the patient is confused. She said still no firm diagnosis, but the consensus is that it's definitely going to be a long term issue. Uh And the advice from the parent consultant was to refer to radiology for a gastrostomy tube. So I messaged back having looked at this patient's imaging and one of the main reasons why we look at their imaging for a gastrostomy tube is to make sure that their stomach is in a position that uh we can safely puncture to put in the feeding tube. Some patients have really big hiatus, hernias or have their colon anterior to the stomach. And then we don't have a safe window to puncture through without going through the colon. So you don't look clever when you do that. So her past history includes an intracranial peanut, which is a complex tumor that I'm not even going to try and describe. So she had an intracranial tumor that was treated with surgery and radiotherapy in 1984. So a long, long time ago, she subsequently had a meningioma resected in 2014. And that's really common for patients who had uh cranial radiotherapy. A long time ago, the doses were probably higher and a little bit less targeted. And radiotherapy related meningiomas are very common in this patient group. Uh and they become a lot larger than standard meningioma and often need resection. So she's had at least two episodes of intracranial surgery as well as radiotherapy. So she already has some underlying brain injury from multiple surgeries. Last year. She had two episodes of seizure. Uh and we don't know why. Again, very common in patients who have had multiple brain surgeries and radiotherapy she presented in December. So this was about four months before with confusion falls, vomiting and a low G CS. She's been extensively investigated and I mean, really extensively investigated her immunology results alone took up two pages on the clinical portal. She has had every test under the sun trying to work out why this woman is confused and they still aren't really sure. So I emailed back. She is obviously a complicated lady and the doctors in the ward are better at calling me for a direct discussion. Things the refer should know are, could this be hep panic encephalopathy? Have they had some treatment for that? Have they had any treatment for Wernicke or any other reversible causes such as in the context of the seizures? Could this be a non convulsive status, epilepticus? It sounds a bit weird but it's more common than you would think amongst these chronically confused in patients. I forgot any good evidence that this is a dementia. Is she able to consent if she's not able to consent for this procedure? Does she have a power of attorney or a guardian? We were in Scotland? There is the adults with Incapacity Act that we would use this again, that should have consent from the power of attorney. What do the family think if there isn't a power of attorney, who's the nearest relative? Will she be compliant with the procedure? Most of our procedures are not done under a general anesthetic. We give conscious sedation and some patients with neurological conditions cannot have midazolam because it can cause respiratory depression. So it was worth clarifying. Is there any feeling that she could have any of those neurological or usually neuromuscular conditions which would prevent us from sedating the patient. Uh And again, especially if you're talking about sedated, confused patients. We have a rather narrow X ray table and if she tries to fight us, she can either injure herself on the table or injure staff members who are trying to keep her safe on the table to get this done. And I have to take this moment to say that we have a spectacular nursing and radiographer team here in Glasgow. I have seen them coax patients through all sorts of stuff. They are so good. Anyway, final thought from the of my email having just looked at her CT, she has good going cirrhosis of the liver with a large portosystemic shunt. So the equivalent of something like gastroesophageal varices, but in her case, it's going from her splenic vein to her renal vein. Um So the shunts vein shunts blood from the portal venous system into the systemic venous system. Has she been discussed with gastroenterology? Is her confusion or is her encephalopathy thought to be hepatic in origin? And if it is hepatic in origin, if it's uh refractory to standard treatment, then embolization of the shunt is one treatment option. And I've done that quite a few times for patients who have hepatic encephalopathy because of a big portosystemic shunt. If you give them maximum medical therapy and it still doesn't work or they're not tolerant of it. If you shut off the shunt, they often get better. So that was the end of my email. A lot of questions uh for, can they have a feeding tube, please? And for a while I didn't hear anything back. So I chased it up a week or two later. Now, this is a bit long. We go through all of that, but in short, she was seen by Gastro, she was started on some lactulose and I've seen this patient on and off for the past few months and today is the brightest I've ever seen her. She's engaging in conversation and she's even orientated in, please. Whether it's because of her lactose and RFA mixin, it is hard to say, but at least it has correlated. She's got better since we've started that. I've continued both medicines. In the meantime, her swallow was much more safe after these medicines, she was able to eat and drink and get in enough calories and hydration and she received no interventional radiology procedure at all. So, as I said, at the beginning of the talk, the best interventional radiologist is one that relies on the diagnostic imaging to choose the right procedure for the right patient at the right time. So, what's it like being an intervention of radiology? Well, in some ways, it's a bit like surgery but magical guys, thank you all very much for giving up some time. After what I'm sure has been a busy and tiring day to listen to me pratt along. Um Does anyone have any questions that that uh like to ask? That's probably a no, if anyone would like to ask you a question, um Feel free to put it in the group chat. Thank you so much for a brilliant talk, Doctor Douglas. Um Yeah. As, as doctor Douglas said, if you have any questions, please feel free to put this in the chart, I'll also link the feedback form. Um So you guys can fill it out and um let us know what you thought was. Um Good about this dog, any suggestions uh for future talks and we'll just pop in the chat, hopefully that will, that will show up. Um So we've got one question here for you. How much time do you spend doing procedures versus time reviewing images? Uh So that can vary uh both kind of day to day versus um individual radiologists. So, um there are almost as many kind of job plans and individual set ups uh in um the UK as there are radiology departments. So, uh I do a full range of vascular and nonvascular interventional radiology. Um in some ways that's a wee bit unusual in uh other parts of the country. Um IRS will either do only vascular intervention or only nonvascular intervention. So that's more of the model that they have actually in Edinburgh uh in other parts of the country again. So more common in the south of England, uh someone may be a hepatic radiologist and they'll do liver imaging, they'll do uh tastes, so they'll treat liver cancers and they might do tips procedures. Um and they, then they might do some biliary intervention as well. Um So sometimes it is kind of body system specific. So, uh I currently spend approximately about half of my time reviewing images and half of my time doing procedures. But a lot of the time I'm reviewing images, I'm doing my image review to either plan procedures or follow up procedures that I've done. Um and or select the appropriate patient for the correct procedure. Uh but it does vary week to week. And of course, there are these kind of exhausting but very rewarding weeks. Uh usually in the summer holidays when everyone's away and you end up doing four weeks of intervention. Um Certainly as an interventionalist, we very rarely end up doing uh kind of uh multiple days or multiple weeks of only diagnostic imaging. Um That's usually not the limiting factor in a hospital. Usually it's the uh the kind of hands on practical skill. So I've, I've almost never been uh had to give up my IR list to do some reporting. Uh But plenty of times I've had to give up my imaging lists to do some procedures. Oh, that's brilliant. Um I don't think we have any other questions. Um Just some really lovely comments, beautiful presentation, great talk. Thank you for the talk and one saying no questions but just wanted you to say you guys are really cool. So that's a lovely comment. Um But no other questions coming in so far. Um So, well, I'll tell you what, I'll give it. I'll make one last final comment and see if uh any other questions come in during this last one. Is it if anyone has any interest whatsoever in either radiology or intervention? And uh maybe aren't quite sure if it's for you, what I would say is spend a little bit of time exploring it because you can make a radiology job, look like almost anything you want to. You can hide away in a dark basement and just look at pictures and not speak to a patient or a clinician. Ever again, if that's what you want to do or you can have a radiology clinic on a Monday. Uh uh You can have a face telephone clinic on a Monday, a face to face clinic on a Tuesday, you can have a really reality ward round reviewing your POSTOP patients. Uh You can have dedicated specialist clinics where you're, you're just seeing back all your feeding tubes, you're just seeing back your oncology patients. Uh and, and your procedure will work on top of that. Um I see patients and their families quite a lot, a lot of my colleagues will see them even more than I do. So this can this job can be whatever you want it to be with whatever mixture of body systems, specialties, imaging versus procedures, whatever else that job exists out there somewhere. And if not, you can convince someone to make it for you. That's brilliant. Um I was wondering, oh, we have a question. Um Ignore me. Uh what are the newest developments in IR are there any new treatments um slash Aris in the pipeline? Yes, there are always uh some new developments in IR. The question is how much that will be uh taken on? And the big question is always what is the role going to be in the wider management of the patient? Because although we think we're great and we do all this really cool stuff. Of course, we only provide one little element of treatment and um between GPS and individual referring hospital specialties and then follow up with specialist doctors. There are a whole big other pathway. So some of the uh, newest things that we've started doing, uh, would include prostate artery embolization. Uh, so patients with benign prostatic hypertrophy, standard treatments are either medications which are only moderately effective, um, or surgery which is pretty effective, but actually has a very significant side effect profile with things like erectile dysfunction and urinary incontinence. Um So many patients, not all patients, but many patients with BPH, you can actually embolize the prosthetic arteries. Um And as the prostate becomes ischemic, it shrinks down. It no longer has that pressure effect on the bladder and the urethra and the patient's able to pee again and the side effects are usually really minor. So they don't get urinary incontinence and they, uh and they don't tend to get erectile dysfunction. Um So that's something that we've started doing in the past few years. Uh The there's always gonna be new methods of embolize things. So the one that's maybe coming up next is actually it's, it may be um uh geniculate artery embolization. So patients who have osteoarthritis of the knees, everyone thinks of osteoarthritis as wear and tear. But if you dig deeply into the uh pathogenesis of it and the pathology of it is that there is an inflammatory component. Um And the synovium of the joint becomes hypervascularized. Uh and that contributes to the pain, the more blood vessels, there are, the more white blood cells can get in there, the more inflammation there is and the more the patient experiences pain. So there are a number of trials out there where patients have had um some a mixture of targeted or nontargeted embolization of the geniculate arteries, supplying the thyme of the knee. Uh and it's had some pretty good results again, no one's really sure where that fits into the overall management of patients with um, knee osteoarthritis. When we have already a really good treatment in uh knee replacement, there are some concerns that uh rendering the knee relatively ischemic may cause problems with healing if the patients then go on to have an operation. Uh So this is not an established practice just yet. And uh it's still in the research phases. One thing that I'm trying to get established just now here in the Queen Elizabeth Hospital is mechanical aspiration for large volume pulmonary embolism. So patients who have great big P ES, um the treatment for 30 years has been given some blood thinners or if they're really, really sick and you think they're about to die, you give them some place some li and hopefully that breaks down the clot. But if that either doesn't work or you don't have time for that to work as the patient's too sick, we can now go in and physically suck out that clot. A really simple principle. But the actual tools to deliver it have only been in invented or, or manufactured in the past couple of years. So that's something I'm hoping to deliver as a as a long term service here in the Kiwi. Yeah, that's super fascinating. Um It will be really fascinating to see um what new developments pop up over the next few years within um interventional radiology as well. I think. Um So any more questions from, from the chat? Are we feeling, feeling all informed and excited about interventional radiology and can't wait to go home and read more about it. Well, I hope to see all of you on a special study module or an elective you in the Queen Elizabeth at some point in the near future. Well, I think, I think that's all for us then. And um I'd just like to take a moment to say thank you so much for everyone to everyone for joining um this session. This is our fifth session of the National Radiology Teaching Series. Um And we've got a few more sessions coming up as well uh all the way into June. So I hope you guys join, join this as well. Um But uh other than that, thank you so much, Doctor Douglas for joining us today. Uh Brilliant talk, everyone really enjoyed it. Um um I thought it was brilliant. I, I'm super interested in interventional radiology now. Um So I can't want you to get out there and, and practice and, and get some experience with that as well. Um So thank you again, everyone for joining and if you can fill out the feedback form. That'd be absolutely brilliant and yeah, I'll see you guys next time. Thanks for having me. Have a nice evening, everyone. Bye.