Interventional Radiology for n00bs
This document is a brief orientation to the USC IR rotation for Radiology Residents. The document contains an outline of the daily schedule; tips on how to protocol; notes on common procedures; templates for common documentation; and other miscellaneous notes.
“What’s the one thing you can always control?
The skin.”
I. Daily Schedule
7:00 AM a. Protocol overnight requests & consent patients.
b. Round on any tenuous patients from prior procedure / consult, as indicated
8:00 AM Daily IR Conference in Radiology Conference Room
~9:10–9:20AM First Cases of the day should be underway.
Mid-day Lunch Break: find a good time to grab a bite during room turnover as a team, or alternate breaks with your colleagues.
~4:00–5:00PM a. Routine cases should finish up by around 4:00–4:30PM.
b. Coordinate with the fellow to prioritize cases for the next day. It is highly recommended to consent 1–2 inpatients before going home so they can be queued up easily the following morning.
c. On-Call resident stays to finish any remaining / emergent cases.
“Treat the patient, not the images.”
II. Protocoling
At 7:00AM, prioritize consenting patients so that two will be on the table ready to go, simultaneously, by 9:00AM. Ideally, plan to start with one (relative more) complex procedure that the fellow will perform, and one (more routine) case for a resident to be primary operator. If the nurses are busy, it is okay to call down for patients directly— just inform whoever is running the front desk that you have done so, and note the time on the logsheet.
Also communicate with the nurses about our preferences for subsequent sequence of procedures, so they can call transport well in advance and keep the day’s schedule moving along.
Each patient needs an iMed Consent for the procedure and moderate sedation. If the patient cannot consent, use family. If family is unavailable, the team needs to document medical necessity in the chart, and you will document agreement with the primary team plan.
For all patients: place orders for IR Procedural Sedation and complete “Ad Hoc Pre-Sedation” documentation.
For outpatients: they will require additional orders: “Place in Observation” and “Peripheral IV Insertion”.
III. Common Procedures, Indications, Contraindications
A. Permcath (Tunneled hemodialysis catheter)
Indication: ESRD requiring long-term HD
Notes: See below for step-by-step guide and consult note template. After placement, must order “Central Line Clear for use.”
B. IVC Filter
Indications: New clot or clot progression on therapeutic anticoagulation; contraindications to anticoagulation.
Notes: Can be placed via transjugular or transfemoral approach. Ideal location is infra-renal. Make sure to check a CT beforehand for variant renal vein / IVC anatomy.
C. Transjugular Liver Biopsy (TJLB)
Indications: Evaluate for alcoholic hepatitis.
Notes: Aim for the right hepatic vein. The takeoff is very close to the diaphragm, often more superior than expected. Be very careful about sharps as the biopsy needle is very long and can be unwieldy.
D. Gastrostomy Tube (G-tube)
Indications: Cannot tolerate PO intake with long-term nutrition needs.
Contraindication: Gastric cancer
Notes: Two common tubes—WOG (Wills-Oglesby Gastrostomy) and MIC (balloon tipped); WOGs were no longer being stocked in our department as of Spring 2018. A “PEG” tube is placed by GI (PEG stands for percutaneous endoscopic gastrostomy).
Follow up: After G-tube placed, enter communication order for “NPO, place nasogastric tube to low intermittent suction, and do not use G-tube until cleared by IR”. G-tubes require two days of clinical follow-up by IR team.
Day 1: Please examine the patient for peritonitis, or other signs of infection (fever, elevated WBC). If no signs of peritonitis or infection, instruct the primary team: "Ok to start trial feeds. Clamp NGT."
Day 2: If patient remains asymptomatic: "Please continue gastrostomy tube feeds. Do not crush meds. Nasogastric tube no longer needed by Interventional Radiology. Interventional Radiology to sign off. Please re-consult as needed. "
See documentation section for notes templates.
If a G-tube is placed on Thursday or Friday, sign it out to the weekend call person(s).
E. Percutaneous Transhepatic Cholangiogram (PTC)
Indications: Evaluate biliary system in a patient with elevated bilirubin and known obstruction; postoperatively
Notes: Give Zosyn beforehand —patients easily get infections after biliary manipulations.
F. Biliary Catheter
Indications: Cholangitis; intractable pruritus; sepsis; prior to chemotherapy
Notes: Often follows a PTC and has similar risks. Erroneously referred to as a “PTC” itself.
G. Percutaneous Nephrostomy Tube (PCNT)
Indications: Collecting system obstruction (stone, mass); infection.
Notes: PCNTs should be routinely exchanged every 3 months, at most (earlier if needed). If not on antibiotics already, should order dose of Levaquin.
H. Intra-arterial chemotherapy
Indications: HCC
Note: Typically done as a scheduled admission; patients usually require IV pain control afterwards.
I. AV Fistula Thrombolysis (“Declot”)
Indication: Poorly functioning fistula lacking a palpable thrill
Notes: Always ask about a balloon’s nominal pressure and burst pressure beforehand
J. Angiogram with Possible Embolization
Indication: Trauma; GI Bleed
Notes: Know your anatomy, especially variants! For pelvic bleeds, always evaluate the common, external, and internal iliac arteries.
K. Angiogram with Possible Thrombolysis
Indication: Thrombosis
IV. Documentation
— Dictate any studies for which you were primary operator. —
A. Brief Procedure Note:
Documenting a brief procedure note in PowerChart is optional. You may choose (or be asked) to document a brief note under certain clinical circumstances, or if the schedule is too busy to allow for a full dictation prior to handling other clinical work.
“VIR Brief Procedure Note
Pre-procedure Dx:
Post-procedure Dx:
Procedure:
Interventionalist: (resident), (attending)
Anesthesia:
Medications:
Contrast:
Fluoro time:
Estimated Blood Loss:
Complications:
Findings:
Dispo:
Please see full dictation to follow.
X94100”
B. Permcath
Stu (a.k.a Dr. Schroff) put together the following consult note that we place in PowerChart, which also includes the common contraindications that apply to nearly all procedures.
“VIR Tunneled Hemodialysis Catheter Consult Note
Request for tunneled hemodialysis consult placement received. The following are necessary prior to approval of this request:
1. Nephrology consult documenting patient’s anticipated long-term hemodialysis.
2. Vascular surgery appointment for fistula evaluation/planning.
3. Patient education and understanding that a permcath is not a permanent access
point for dialysis and that a fistula will be required in the near future.
4. Patient education with patient understanding of HD vs PD and documentation of
patient decision to have HD (or physician documentation that patient is not a candidate
for PD).
Once permcath placement is approved, the following are required prior to placement:
1. INR < 1.5 and Platelets > 50,000
2. NPO for 8 hours
3. IV Heparin held 1 hour, Lovenox held for 12-14 hours, and Plavix held for 5 days prior to procedure.
4. The patient must be able to consent to the procedure (or have a legally designated medical decision maker available able to consent for the patient).
5. Afebrile and WBC and negative blood cultures within normal limits (no infection) with rare exception.
Once these are documented in the electronic medical record, the patient can be scheduled for
permcath placement. Please call ext. 94100 if you have any questions or need to speak
to an IR resident/fellow.
x94100”
C. Gastrostomy Tube
1. Consult Note
“VIR Gastrostomy Tube Consult Note
Request for G tube consult placement received. The following are necessary prior to
approval of this request:
1. INR < 1.5 and Platelets > 50,000
2. NPO for 8 hours
3. IV Heparin held 1 hour, Lovenox held for 12-14 hours, and Plavix held for 5 days prior to procedure.
4. The patient must be able to consent to the procedure (or have a legally designated medical decision maker available able to consent for the patient).
5. Afebrile and WBC and negative blood cultures within normal limits (no infection).
Once these are documented in the electronic medical record, the patient can be scheduled for
G tube placement. Please call ext 94100 if you have any questions or need to speak
to an IR resident/fellow.
x94100”
2. G-Tube Post-procedure Day 1
“VIR Progress Note
S: Patient was seen and examined this AM and appeared to be in NAD.
O:
Vitals: _______.
Physical Exam
Gen: NAD
CV: RRR
GI: G-tube in place, wound clean dry intact, tender to palpation over midline surgical closure wound, no rebound or guarding
Labs: _______.
A/P:
Now s/p G-tube placement by IR on ______.
Recommendations:
- Okay to start trickle feeds per nutrition recommendations.
- NG tube can be clamped, but do not remove at this point.
- No crushed medications via G-tube. Medications must be converted to liquid form.
- Please call 94100 or page the on-call resident if there are any questions.
- IR will continue to follow.”
3. G-tube Post-procedure Day 2
“VIR Progress Note
S: Patient seen and examined at bedside. NAD. Denies abdominal pain.
O:
Vitals: _______.
Physical exam:
No tenderness elicited on palpation of the abdomen. Abdomen is soft and not distended. No guarding. G-tube secured to mid abdomen; dressing C/D/I.
Labs:_______.
A/P:
Now s/p percutaneous gastrostomy tube placement on _______.
Recommendations:
- G-tube is cleared for use; okay to advance feeds per nutrition recommendations if appropriate.
- Pneumoperitoneum seen on KUB is normal post-procedure.
- Enteric tube no longer needed by IR; can discontinue if it is no longer needed by other services.
- No crushed medications via G-tube. All medications must be converted to liquid form.
- Flush G-tube after each use with saline or water or it will become clogged.
- IR to sign off. Please call 94100 or page the on-call resident if there are any questions.”
V. A Step-by-Step Guide to Permcath Placement
The steps for Permcath placement (many of which are duplicated in other procedures) are listed below. Note that particular faculty may modify certain steps based on personal preference or particular patients.
1. Check the patient's height. If between 5ft and 6ft, in general use a 23cm tip-to-cuff AngioDynamics tunneled HD catheter.
2. Under ultrasound, visualize the right internal jugular vein which should be compressible (unless thrombosed). The pulsatile carotid should medial/posterior.
3. Anesthetize the skin.
4. Advance the 21-G micropuncture needle (green hub) into the jugular vein.
a. If spontaneous venous return, advance 0.018 inch microwire into SVC-RA under fluoro
b. If no return but likely in vessel, attach connection tubing and aspirate.
c. If bright red / pulsatile return, withdraw needle and hold pressure for 2-5 minutes.
5. Once access is gained, make a skin incision along the needle and then blunt dissect using the curved Kelly.
6. Exchange the needle for the 5-Fr micropuncture sheath and hub it.
7. Remove the inner 3-Fr stylet and the micropuncture wire, holding your finger over the 5Fr
lumen.
8. Insert 0.035 in. J-wire and advance into the inferior vena cava. Take care not to irritate the atrium (will cause PVCs). If difficult, ask patient take deep breath and hold, then advance. Make sure the J is facing right/posterior (take-off of IVC from RA).
9. Once J wire in IVC, ask for catheter. Flush dilators, peel away sheath, and both hubs.
10. Lay catheter on patient to judge where to make tunnel. The tip should be near the SVC-RA
junction.
11. Mark the tunnel entry point on the patient's chest (rule of thumb: 2-3 fingertips below the
clavicle).
12. Anesthetize the entry point, make an incision, anesthetize the tunnel, then blunt dissect the tunnel.
13. Attach the tunneling device and tunnel to the venotomy site in the neck. Pull the catheter all the way through.
14. Dilate the tract (12Fr blue, then 14fr pink) under fluoro until the tip is at the level of the clavicle, then insert the peel away sheath and hub it.
15. Pull out the inner obturator and wire. The valve should maintain hemostasis.
16. Insert the catheter as far as possible through the peel away, then remove the valve and break the peel away sheath.
17. Peel the sheath away while applying pressure to the catheter to keep it subcutaneous.
18. Check positioning - if at SVC-RA junction, fix in place. If too distal, pull back slowly while
making sure the cuff stays within the tunnel.
19. Flush both ports, give heparin (volume to give on hubs), Dermabond venotomy site, place
biostatic pad on tunnel entry site, and then suture to skin with 2-0 silk/prolene.
20. Fold a 4x4 and Tegaderm the port to skin.
VI. Miscellaneous:
A. The Attending Faculty: Drs. Katz, Hanks, Marx, Harrell, Ter-Oganesyan, and Schroff
B. Reading: Most of the knowledge can be learned on the rotation. If you would like additional information about the procedures, Vascular and Interventional Radiology Requisites has good basic information and numerous images. Netter’s and Core Radiology are good for a quick review of vascular anatomy, especially common variant anatomy.
C. We are responsible for protocoling and reading out all extremity CTAs and MRAs. Read-outs tend to occur at the end of the day, but this is dependent on scheduling and attending availability.
D. Always know the case you are scrubbing into: know the relevant patient history, prior interventions, and indications for the current procedure.
E. Always review prior available imaging—this is free information and invaluable in predicting challenges and preventing complications.
F. Scrubs must be worn in the control room—no street clothes allowed. Additionally, a hat and mask must be worn in the control room during patient prep and during procedures.
G. Have fun!
The core information was compiled in 2012 by A. Vyas; file was updated and posted online in 2018 by t. iafe.