The second part of our overview of interventional radiology with Dr. Bobby Chiong, board-certified interventional radiologist and chair of radiology at SBH Health System, with a focused look at some common IR procedures, namely abscess drainage and GI bleeding. Listen to part 1 here.
- Common goals would be INR <2.0, platelets >50k. If leaving an indwelling line or device, less may be okay, as it will tamponade the spot. Ignore the INR completely for purely cirrhotic patients. Although guidelines are fairly clear, many clinicians use their own rules.
- Fluid collections are abscesses if they have rim enhancement on contrast CT. Without contrast you’re left guessing. (No oral contrast please!)
- If necessary, most collections can be drained, somehow. Relevant considerations such as anatomy are subtle and often operator-dependent. Move the bladder out of the way by draining it, move bowel by hydrodissection, go in transvaginally or transrectally… options are numerous but not universal. Talk to your proceduralist.
- When hoping to find and embolize bleeding, you’re usually best to start with a CTA. You need two phases, so non-contrast and arterial, or arterial and delayed, or… whatever. (No oral contrast please!) But find the bleeding. CTA is more sensitive than catheter angiography, and gives a general idea as to the region of bleeding. Going straight to IR without the CTA and without even a general idea of the region means a looong process of searching by catheterizing numerous vessels. Skipping the CTA isn’t even necessarily contrast-sparing, as it may take several hundred cc’s of contrast just to find the source.
- With gastric bleeding, usually start with femoral artery access, access the celiac trunk, find the left gastric artery, then either just empirically start placing some gelfoam to reduce arterial pressure, or localize the specifically bleeding vessel if possible.