After Imaging: Interventional Radiology in the ED
Joshua L. Weintraub, MD, and Thomas J. Ward, MD
Dr Weintraub is an interventional radiologist and executive vice chairman of the department of radiology
at New York Presbyterian/Columbia University Medical Center, New York. Dr Ward is a postgraduate fifth-year resident in interventional radiologist in the department of radiology at Mount Sinai Medical Center, New York, NY.
Interventional radiologists play an increasing role in treating patients in the ED setting. Simplistically, these roles are usually divided into one of three broad categories: to drain or aspirate infected fluid, to halt active bleeding, or to restore blood flow through an occluded vessel. While all of these procedures are critical, the newest advance in interventional radiology (IR) set to benefit the ED patient is not technical or procedural at all, but rather a philosophical one.
Fluid Aspiration and Drainage
In the ED, the need to drain or aspirate infected fluid is probably the most common indication for consult with an interventional radiologist. Perforated appendicitis or diverticulitis with an intra-abdominal abscess is generally managed with percutaneous drainage and antibiotics. If the clinical situation necessitates, and the location of the collection allows, this procedure may be performed at bedside with local anesthesia under ultrasound guidance. In the septic patient, the minimally invasive nature of this procedure confers significant benefits.
Nonoperative patients presenting with acute cholecystitis rapidly improve after the placement of a percutaneous cholecystostomy tube, and this procedure can be performed under ultrasound guidance. IR may also be indicated in cases of failed endoscopic retrograde cholangiopancreatography or cystoscopy in patients with cholangitis or urosepsis for benign or malignant obstruction. Percutaneous access is facilitated by a dilated system, and temporary decompression can be obtained until more definitive therapy is planned.
Active Bleeding
Active bleeding is another common presentation warranting an IR evaluation. Gastrointestinal, intracranial, posttraumatic, postsurgical, and postpartum bleeding, as well as massive hemoptysis, can all be managed endovascularly. Advances in microcatheter technology, covered vascular stents, and embolic agents have increased the efficacy of these interventions, and improved computed tomography angiography protocols facilitate accurate and timely diagnosis of active bleeding. With the availability of these techniques, waiting several hours for a tagged red blood cell nuclear scan is a thing of the past at many institutions. Embolization has become the mainstay of treating bleeding related to trauma in most major trauma centers.
Ischemia
An IR consult may be ordered for patients presenting with the sequelae of ischemia, which can range from a diabetic foot to an acute stroke. Percutaneous balloon angioplasty, endovascular stents, and catheter-directed thrombolysis were all monumental advances in the treatment of ischemia—conceptualized or introduced into clinical practice by interventional radiologists. This spirit of innovation continues. A variety of technical advances, atherectomy, and re-entry devices have been introduced to help recanalize chronically occluded vessels. New devices allow the interventional radiologist to quickly restore blood flow and function to patients suffering from cerebral embolus. There is increased interest in the use of catheter-assisted-embolectomy for submassive pulmonary embolism when intravenous fibrinolysis is unsuccessful or contraindicated.
Conclusion
The five decades of pioneering technical innovation highlighted in this article allow for minimally invasive treatment of the ED patient. The newest advance in IR is not technical, but rather philosophical, and a change in the role that the interventional radiologist plays. The American Board of Radiology has recently approved a new IR training pathway that more than doubles the amount of clinical training that graduating IR fellows now receive. This signals a renewed commitment to running a truly clinical service. Patients in the ED can be evaluated and treated by an interventional radiologist in the hospital and then discharged under the care of an interventional radiologist at an IR clinic. Several IR sections across the country currently practice in such a manner. Although this model is currently the exception and not the rule, the goal of the new training pathway hopes to change this, with increased advances and benefits to patients in the ED setting.
Suggested Reading
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