REVIEW URRENT C OPINION
Common procedures and strategies for anaesthesia in interventional radiology Mary Landrigan-Ossar
Purpose of review This review describes the range of cases now available in the interventional radiology suite and summarizes suggestions for their anaesthetic and perioperative management. Recent findings The type and complexity of interventional radiology cases being performed increases from year to year. Anaesthesiologists’ presence in interventional radiology is increasing in turn, due to increasingly ill patients and intricate procedures requiring more than local anaesthesia for well tolerated completion. The literature available describing this is largely written by radiologists, with little attention paid to anaesthetic considerations. Summary Cases in interventional radiology are complex in terms of the logistics of working in an unfamiliar area, frequency of patient comorbidity and unfamiliar procedures. Ensuring familiarity with the variety of interventional radiology procedures and their periprocedure requirements can increase anaesthesiologists’ comfort in interventional radiology. Keywords interventional radiology, minimally invasive, nonoperating anaesthesia
INTRODUCTION Interventional radiology represents a hinterland for many anaesthesiologists into which they do not care to venture. This prejudice must be overcome; advances in interventional radiology tools and techniques over the past 50 years have expanded the range of procedures [1 ,2,3], and anaesthesiologists find their services in greater demand for adults and children [1 ,2,3]. In an adult interventional radiology suite, anaesthesiologists are necessary primarily for complex cases or medically challenging patients. In the paediatric interventional radiology suite, an anaesthesiologist has a greater presence. Often the patient and/or procedure will require a younger patient being at minimum deeply sedated for well tolerated completion. Knowledge of the procedure to be performed, its length, likely complications and intraoperative and postprocedure requirements will influence anaesthetic choice [4 ]. Overall safety in the nonoperating room environment is treated elsewhere in this issue; radiation safety is of particular importance in interventional radiology for patient and practitioner. The sine qua non of well tolerated practice is open communication within an effective team [5]. This &
&
&
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chapter will describe some common interventional radiology procedures and suggestions for their safe anaesthetic management.
Biopsies and drain placements Aspiration of fluid collections, drain placements and biopsies are common in any interventional radiology suite [6–8]. These can often be accomplished with ultrasound guidance, although deeper targets or those near vital structures can require computed tomographic (CT) guidance and apnoea. The location of the target and the imaging mode to be used help determine the type of anaesthesia required, although the patient’s overall health is the final determinant. Preprocedure communication Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA Correspondence to Mary Landrigan-Ossar, MD, PhD, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel: +1 617 355 7737; e-mail: [email protected] Curr Opin Anesthesiol 2015, 28:458–463 DOI:10.1097/ACO.0000000000000208 Volume 28 Number 4 August 2015
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Common IR procedures and strategies for anaesthesia Landrigan-Ossar
KEY POINTS Interventional radiology procedures are continually expanding in range and complexity. Anaesthesiologists working in interventional radiology must be comfortable with providing well tolerated care to ill patients in a nonoperating environment; effective communication with a dedicated team is crucial. Anaesthetic management of patients in interventional radiology requires knowledge of the procedure to be performed, intraoperative requirements with regard to fluid management/apnoea/positioning and postoperative management of this unique patient population.
with the radiologist about positioning, need for apnoea and patient condition is essential. Ultrasound-guided procedures can be done with sedation and spontaneous ventilation even in young infants, as the radiologist continually visualizes the needle. CT-guided procedures require an immobile patient, as motion necessitates additional scanning and irradiation. Soft tissue biopsies are minimally painful postoperatively; bone biopsies or drainage catheter insertion produce more discomfort. Complications are rare. They include bleeding and puncture of nontarget structures [8]. Solid organ biopsies should have blood bank specimens sent; bleeding risk is low but can be impressive when it occurs [9,10]. Abscess drainage can result in transient sepsis-like haemodynamic changes [11], but frank sepsis is less likely. Postprocedure care involves mild pain control and assistance with immobility after an organ biopsy.
simply to lie still and may require only anxiolysis. Patients at the extremes of size/age or those with multiple prior lines may need longer procedures, making an laryngeal mask airway (LMA) or endotracheal tube desirable. Pain postprocedure is minimal. For patients for whom sedation/anaesthesia is very high risk, preprocedure communication with the radiologist and referring service is recommended to determine whether the procedure is essential and whether it will be possible on a ‘moving target’.
Sclerotherapy of vascular and lymphatic malformations Vascular malformations and lymphatic malformations are slow-flow congenital vascular lesions that can be treated by a variety of interventional radiology methods [15], most commonly chemical sclerotherapy. Patients may have isolated small lesions or syndromes with lesions encompassing much of the body (Fig. 1). As these lesions will grow and become more complex over time [16,17], it is increasingly common for treatment to start in childhood. Sclerosing agents are described in Table 1 [18–23]. Simple sclerotherapy can last under 1 h while complex can last 8–10 h. Depending on positioning and procedure length, these cases can be done with an endotracheal tube, LMA or sedation. Blood loss is not generally significant, but access for hydration is essential. Hydration is recommended to offset the osmotic diuretic effect of intravenous (i.v.) contrast [24]. Alcohol and sodium tetradecyl sulphate (STS) cause dose-dependent haemolysis/haemoglobinuria
Percutaneous lesion ablation Percutaneous ablation of bone or soft tissue lesions is increasing. Chemical ablation with acetic acid or ethanol, thermal ablation with radiofrequency ablation or cryoablation has been described to treat tumours in every body part [12,13]. Target location, imaging mode and need for apnoea will influence anaesthetic plan; procedures are painful and require at least moderate sedation and good postoperative pain control. Complications involve injury to surrounding tissue, particularly nerves.
Central venous access These procedures are often done on complex patients or those who have failed line placement elsewhere [14]. Everything else being equal, patients need
FIGURE 1. Two-year-old boy with blue rubber bleb nevus syndrome and a massive venous malformation of the upper leg/flank.
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Anesthesia outside the operating room Table 1. Common sclerotherapy agents Agent
Indications
Swelling
Pain
Complications
Sodium tetradecyl sulphate (STS)
LM, VM
Moderate
Moderate
Haemoglobinuria, skin blistering [18,19]
Ethanol
LM, VM
Marked
Marked
Nausea, haemoglobinuria, skin blistering, ethanol intoxication, nerve injury, cardiovascular collapse [20]
Doxycycline
LM
Marked
Marked
Minimal [21]
Bleomycin
LM, VM primarily cervicofacial
Moderate
Moderate
Transient fever Concern for pulmonary fibrosis, never described after sclerotherapy [22]
OK-432
LM
Marked
Marked
Not FDA approved for use in USA [23]
FDA, US Food and Drug Administration; LM, lymphatic malformations; VM, vascular malformations.
treated with hydration and urine alkalinization [18]. Contrast reactions are a constant threat; their management is similar to that for anaphylaxis [25]. Arterial lines are rarely necessary. Pain and swelling postprocedure are agent dependent and may be significant. Ectatic veins with slow flow are at a high risk of intralesional thrombosis, leading to thromboembolism and consumptive coagulopathy [26]. Treatment is anticoagulation; a haematologist familiar with this pathophysiology should manage periprocedure anticoagulation. Cervicofacial malformations are particularly challenging (Fig. 2). Intubation can be difficult and elective tracheostomy may be necessary. Preprocedure consultation with otorhinolaryngologists is recommended. It is crucial to recognize that all sclerosants cause swelling that will not peak until several hours after injection. Extubation should be carefully considered if a peri-airway lesion is treated; intubation may be necessary for several days.
Transjugular intrahepatic portosystemic shunt and related procedures Procedures to reduce portal hypertension and associated variceal bleeding and ascites are performed on patients critically ill with end-stage liver disease [27]. These include transjugular intrahepatic portosystemic shunt (TIPS) creation and balloon occluded retrograde transvenous obliteration (BRTO) of varices with sclerosant [28]. These procedures are often performed under general endotracheal anaesthesia; procedure length, comorbid conditions and significant ascites make sedation a less attractive option. Invasive monitoring may be necessary on the basis of patient condition. Coagulopathy is often marked and may require correction peri-procedure. Complications of TIPS include encephalopathy and shunt stenosis, as well as haemorrhage [27]. BRTO complications include most commonly transient haemoglobinuria, vessel thrombosis or reaction to sclerosant is rare. Recovery may require ICU depending on patient condition.
Embolization for haemorrhage
FIGURE 2. Twelve-year-old girl with cervicofacial lymphatic malformation necessitating tracheostomy placement in early infancy. 460
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Catheter-based interventions for life-threatening haemorrhage have a track record of effectiveness in adult and paediatric trauma [29,30]. Advantages include less insensible fluid loss, less risk of hypothermia and access to a bleeding site without a surgical incision’s potential to disrupt tamponade. Although case series demonstrate more than 85% successful control of haemorrhage, the main predictor of failure is the amount of blood transfusion necessary before reaching the interventional radiology suite. Anaesthetic and fluid management for these cases depends largely on the degree of trauma sustained: preparations for massive transfusion may be necessary for major trauma, while minor cases can be managed more conservatively. Patient condition will dictate the need for endotracheal intubation and the need for ICU monitoring. Volume 28 Number 4 August 2015
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Common IR procedures and strategies for anaesthesia Landrigan-Ossar
Bronchial artery embolization for haemoptysis control presents a unique anaesthetic challenge. Embolization is effective in gaining short-term control of haemoptysis, even massive haemoptysis, but does not affect overall disease course [31,32]. Massive haemoptysis often necessitates single-lung ventilation and transfusion, but a grey area exists for more stable patients. Some reports have suggested that positive pressure ventilation may itself be detrimental particularly in cystic fibrosis patients, and that sedation at most is preferable [33]. This must be weighed against a patient’s ability to lie flat while in a state of respiratory compromise for a potentially prolonged procedure. With any patient undergoing semi-elective bronchial embolization, clear communication with the patient and family about goals of care in the event of catastrophe is recommended.
Venous thrombolysis Interventional radiology procedures alone or in conjunction with surgery are increasingly used for the treatment of venous thrombosis of the deep venous system and of dialysis access [34,35]. Catheters are inserted for a combination of mechanical thrombolysis and for delivery of thrombolytic medications. Balloon venoplasty and stent insertion are also employed. Procedures can be performed under sedation or general anaesthesia; airway control when elevated potassium is threatened may be desirable, and deeper levels of sedation are usually necessary for venoplasty, which is painful [36]. Mechanical thrombolysis results in haemolysis and potentially dangerous increases in potassium levels, particularly in dialysis-dependent patients [37]. During a course of treatment often extending over several days, close coordination with haematologists for management of anticoagulation is essential to minimize bleeding complications.
Diagnostic cerebral angiography Diagnostic cerebral angiograms generally last less than 1 h. They are the gold standard for delineating vascular disease, such as arteriovenous malformations (AVMs) and vasculitis [38]. In adults, sedation is rarely required. As younger patients may not safely cooperate, these cases are often performed with endotracheal intubation. Arterial catheters are rarely necessary. Contrast loads can be significant, and generous hydration is recommended. The most common complication is bleeding at the femoral puncture site [39]. Deep extubation possibly supplemented by sedative agents should be considered, as patients need to lie flat for several hours
after arterial decannulation [40]. Pain is not usually significant after these procedures.
Embolization of cerebral or peripheral arteriovenous malformations Intracranial AVMs requiring treatment are uncommon but challenging in the very young. Infants with cerebral AVMs (usually vein of Galen malformation) can present with heart failure [41] that is associated with poor prognosis. Older children and adults with intracranial AVMs more commonly present with hydrocephalus, headache, seizure or intracranial haemorrhage, which can be devastating [42]. Peripheral AVMs progress over time if untreated and can result in destruction of local structures and highoutput cardiac failure [43]. Cardiology input to evaluate and optimize cardiac function is recommended. Cerebral embolization procedures may last more than 8 h. Although adult patients may tolerate awake procedures when neurologic assessment is necessary, most adults and children have endotracheal intubation and consistent muscle relaxation [44 ]. Blood loss is usually minimal, but access for hydration is necessary to offset the diuretic effect of contrast [24]. Heparinized 0.9% saline is slowly infused via the femoral catheter to prevent cerebral microemboli [45], and this can add significant volume over time. Close blood pressure control is generally required, necessitating an arterial catheter. Vasoactive medications may be necessary to keep blood pressure below a predetermined maximum, but are less often necessary in paediatric patients. Pain is not significant. As mentioned above, deep extubation should be considered, as patients need to remain flat postoperatively. Haemodynamic changes may occur during AVM embolization. In some patients with heart failure due to high cardiac output, treatment of the AVM can result in immediate improvement in the patient’s physical status [46]. Cerebral embolization with ethylene vinyl alcohol copolymer glue (Onyx, Covidien, Plymouth, Minnesota, USA) has been reported to induce bradycardia [47]. Alterations in flow dynamics in a treated cerebral AVM may result in a period of increased haemorrhage risk, particularly in incomplete embolizations [48]. The most common complication is bleeding at the femoral artery puncture site. With injection of embolic agents, there is the possibility of inadvertent closure of arteries supplying nearby normal brain tissue, either through glue migration or because the target vessel supplies normal and abnormal tissue. This latter risk is fortunately extremely low [46]. In adults, intraprocedure neuropsychological testing under moderate sedation is used to &
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Anesthesia outside the operating room
determine the safety of embolization near eloquent cortex [49], but few children have been treated in this manner due to concerns about cooperation [50]. Postembolization care emphasizes control of blood pressure to avoid sudden increases [51], although there are few descriptions of how to achieve this in paediatric patients [40]. Peripheral AVM embolization may also last more than 8 h. Access to the lesion may be percutaneous or transarterial [52], and various embolic agents may be employed [53]. Hydration is recommended as above, as is consideration for lying flat postprocedure. Bleeding and pain are not usually significant. Complications such as nontarget embolization are rare but potentially devastating.
Acute ischemic stroke management Therapy for acute ischemic stroke has benefitted from research over the past decades, culminating in consensus statements on treatment from several bodies [54,55 ,56]. Anaesthesiologists may find their services necessary for either diagnostic imaging sedation or for sedation/anaesthesia for endovascular thrombolysis. Catheter-based interventions are generally reserved for patients for whom tissue plasminogen activator (TPA) therapy is contraindicated, although evidence may be shifting in favour of endovascular treatment [57]. Speed is of the essence when treating patients with ischemic stroke, and the need for preoperative workup must be balanced against time. Anaesthetic management by sedation versus endotracheal intubation should be based on the individual patient’s situation, as no advantage to either can be found in the literature. Arterial monitoring catheters should only be placed when they can be placed quickly. Close control of haemodynamics and glucose are key; oxygen and carbon dioxide levels should be kept within normal limits, and euvolemia and euthermia are recommended. Postprocedure care should be in an ICU or ward unit experienced in caring for stroke patients. &&
Intra-arterial chemotherapy Injection of chemotherapeutic agents into a tumour’s feeding artery is a therapy described for several cancers [58] including retinoblastoma, and thus may be performed in quite young children [59]. Access is obtained via the femoral artery, and chemotherapeutic agents are injected specifically into the affected ophthalmic artery. Anaesthesiologists can assist by giving oxymetazoline nasal spray to the ipsilateral nostril just prior to chemotherapy injection to shrink the nasal branch of the ophthalmic artery and drive flow to the ophthalmic portion. 462
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Albuterol is given at the same time, as this protocol is associated with a significant incidence of bronchospasm. PONV prophylaxis should be given even in young patients.
CONCLUSION The interventional radiology suite can be a daunting assignment for the unprepared anaesthesiologist, with its distance from the support of the main operating rooms and a host of unfamiliar procedures. Fluency with the proposed procedures, proper equipment selection and setup, adequate preoperative workup of patients and an interventional radiology staff with the training and motivation to provide effective backup in an emergency are essential elements of safe practice in this area. It is important to recognize one aspect of our role in this setting is to act as the de facto gatekeeper and final safety stop for patients. It is incumbent on us to ensure that patients are being appropriately referred for our services and are as medically optimized as is possible under the clinical circumstances. Once this is ensured, the anaesthesiologist can focus on providing exceptional care to some of the most challenging patients in the hospital. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Baum RA, Baum S. Interventional radiology: a half century of innovation. & Radiology 2014; 273 (Suppl 2):S75–S91. An excellent retrospective study of the developments in techniques in interventional radiology over the past half century. 2. Burrill J, Heran MK. Nonvascular pediatric interventional radiology. Can Assoc Radiol J 2012; 63 (Suppl 3):S49–S58. 3. Heran MK, Burrill J. Vascular pediatric interventional radiology. Can Assoc Radiol J 2012; 63 (Suppl 3):S59–S73. 4. Rubin D. Anesthesia for ambulatory diagnostic and therapeutic radiology & procedures. Anesthesiol Clin 2014; 32:371–380. An overview of cases in diagnostic and interventional radiology with suggestions for their well tolerated anaesthetic management. 5. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 2009; 53:143–151. 6. Uller W, Wohlgemuth WA, Hammer S, et al. Percutaneous treatment of biliary complications in pediatric patients after liver transplantation. Rofo 2014; 186:1127–1133. 7. Naumann H, Pittaway A, Lynn AM, Vo NJ. CT-guided percutaneous lung biopsy under general anesthesia: a pediatric case series and literature review. Paediatr Anaesth 2012; 22:469–475.
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Common IR procedures and strategies for anaesthesia Landrigan-Ossar 8. Brown C, Kang L, Kim ST. Percutaneous drainage of abdominal and pelvic abscesses in children. Semin Intervent Radiol 2012; 29:286–294. 9. Kennedy SA, Milovanovic L, Midia M. Major bleeding after percutaneous image-guided biopsies: frequency, predictors, and periprocedural management. Semin Intervent Radiol 2015; 32:26–33. 10. Dohan A, Guerrache Y, Dautry R, et al. Major complications due to transjugular liver biopsy: incidence, management and outcome. Diagn Interv Imaging 2015. [Epub ahead of print] 11. Lorenz J, Thomas JL. Complications of percutaneous fluid drainage. Semin Intervent Radiol 2006; 23:194–204. 12. Flanagin BA, Lindskog DM. Intraoperative radiofrequency ablation for osteoid osteoma. Am J Orthop (Belle Mead NJ) 2015; 44:127–130. 13. Filippiadis DK, Tutton S, Mazioti A, Kelekis A. Percutaneous image-guided ablation of bone and soft tissue tumours: a review of available techniques and protective measures. Insights Imaging 2014; 5:339–346. 14. Duszak R Jr, Bilal N, Picus D, et al. Central venous access: evolving roles of radiology and other specialties nationally over two decades. J Am Coll Radiol 2013; 10:603–612. 15. Cahill AM, Nijs ELF. Pediatric vascular malformations: pathophysiology, diagnosis, and the role of interventional radiology. Cardiovasc Intervent Radiol 2011; 34:691–704. 16. Hassanein AH, Mulliken JB, Fishman SJ, et al. Venous malformation: risk of progression during childhood and adolescence. Ann Plast Surg 2012; 68:198–201. 17. Hassanein AH, Mulliken JB, Fishman SJ, et al. Lymphatic malformation: risk of progression during childhood and adolescence. J Craniofac Surg 2012; 23:149–152. 18. Barranco-Pons R, Burrows PE, Landrigan-Ossar M, et al. Gross hemoglobinuria and oliguria are common transient complications of sclerotherapy for venous malformations: review of 475 procedures. AJR Am J Roentgenol 2012; 199:691–694. 19. Odeyinde SO, Kangesu L, Badran M. Sclerotherapy for vascular malformations: complications and a review of techniques to avoid them. J Plast Reconstr Aesthet Surg 2013; 66:215–223. 20. Bisdorff A, Mazighi M, Saint-Maurice JP, et al. Ethanol threshold doses for systemic complications during sclerotherapy of superficial venous malformations: a retrospective study. Neuroradiology 2011; 53:891–894. 21. Shergill A, John P, Amaral JG. Doxycycline sclerotherapy in children with lymphatic malformations: outcomes, complications and clinical efficacy. Pediatr Radiol 2012; 42:1080–1088. 22. MacIntosh PW, Yoon MK, Fay A. Complications of intralesional bleomycin in the treatment of orbital lymphatic malformations. Semin Ophthalmol 2014; 29:450–455. 23. Motz KM, Nickley KB, Bedwell JR, et al. OK432 versus doxycycline for treatment of macrocystic lymphatic malformations. Ann Otol Rhinol Laryngol 2014; 123:81–88. 24. Lenhard DC, Pietsch H, Sieber MA, et al. The osmolality of nonionic, iodinated contrast agents as an important factor for renal safety. Invest Radiol 2012; 47:503–510. 25. Iyer RS, Schopp JG, Swanson JO, et al. Safety essentials: acute reactions to iodinated contrast media. Can Assoc Radiol J 2013; 64:193–199. 26. Adams DM. Special considerations in vascular anomalies: hematologic management. Clin Plast Surg 2011; 38:153–160. 27. DeGasperi A, Corti A, Corso R, et al. Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia. J Clin Monit Comput 2009; 23:341–346. 28. Saad WE. Endovascular management of gastric varices. Clin Liver Dis 2014; 18:829–851. 29. van der Wilden GM, Velmahos GC, Joseph DK, et al. Successful nonoperative management of the most severe blunt renal injuries: a multicenter study of the research consortium of New England Centers for Trauma. JAMA Surg 2013; 148:924–931. 30. Vo NJ, Althoen M, Hippe DS, et al. Pediatric abdominal and pelvic trauma: safety and efficacy of arterial embolization. J Vasc Interv Radiol 2014; 25:215–220. 31. Hurt K, Simmonds NJ. Cystic fibrosis: management of haemoptysis. Paediatr Respir Rev 2012; 13:200–205. 32. Chun JY, Morgan R, Belli AM. Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization. Cardiovasc Intervent Radiol 2010; 33:240–250. 33. McDougall RJ, Sherrington CA. Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis. Paediatr Anaesth 1999; 9:345–348. 34. Hongsakul K, Rookkapan S, Sungsiri J, et al. Pharmacomechanical thrombolysis versus surgical thrombectomy for the treatment of thrombosed haemodialysis grafts. Ann Acad Med Singapore 2015; 44:66–70.
35. Mehrzad H, Freedman J, Harvey JJ, Ganeshan A. The role of interventional radiology in the management of deep vein thrombosis. Postgrad Med J 2013; 89:157–164. 36. Kukreja K, Gruppo R, Chima R, et al. Developing a pediatric endovascular thrombolysis program: a single-center experience. Pediatr Radiol 2013; 43:1024–1029. 37. Carrera LA, Reddy R, Pamoukian VN, et al. Massive intravascular hemolysis with mechanical rheolytic thrombectomy of a hemodialysis arteriovenous fistula. Semin Dial 2013; 26:E5–E7. 38. Wolfe TJ, Hussain SI, Lynch JR, et al. Pediatric cerebral angiography: analysis of utilization and findings. Pediatr Neurol 2009; 40:98–101. 39. Hoffman CE, Santillan A, Rotman L, et al. Complications of cerebral angiography in children younger than 3 years of age. J Neurosurg Pediatr 2014; 13:414–419. 40. Landrigan-Ossar M, McClain CD. Anesthesia for interventional radiology. Paediatr Anaesth 2014; 24:698–702. 41. Li AH, Armstrong D, terBrugge KG. Endovascular treatment of vein of Galen aneurysmal malformation: management strategy and 21-year experience in Toronto. J Neurosurg Pediatr 2011; 7:3–10. 42. Abla AA, Nelson J, Kim H, et al. Silent arteriovenous malformation hemorrhage and the recognition of ‘unruptured’ arteriovenous malformation patients who benefit from surgical intervention. Neurosurgery 2015; 76:592–600. 43. Lee BB, Baumgartner I, Berlien HP, et al. Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management. Int Angiol 2013; 32:9–36. 44. Joung KW, Yang KH, Shin WJ, et al. Anesthetic consideration for neuroin& terventional procedures. Neurointervention 2014; 9:72–77. A comprehensive review of neurointerventional procedures and anaesthetic management of these cases in the adult patient. 45. Blanc R, Deschamps F, Orozco-Vasquez J, et al. A 6F guide sheath for endovascular treatment of intracranial aneurysms. Neuroradiology 2007; 49:563–566. 46. Theix R, Williams A, Smith E, et al. The use of onyx for embolization of central nervous system arteriovenous lesions in pediatric patients. Am J Neuroradiol 2010; 31:112–120. 47. Lv X, Li C, Jiang Z, Wu Z. The incidence of trigeminocardiac reflex in endovascular treatment of dural arteriovenous fistula with onyx. Interv Neuroradiol 2010; 16:59–63. 48. Lv X, Wu Z, Li Y, et al. Hemorrhage risk after partial endovascular NBCA and ONYX embolization for brain arteriovenous malformation. Neurol Res 2012; 34:552–556. 49. Tawk RG, Tummala RP, Memon MZ, et al. Utility of pharmacologic provocative neurological testing before embolization of occipital lobe arteriovenous malformations. World Neurosurg 2011; 76:276–281. 50. Toth G, White JA, Pride GL. Intra-aneurysmal superselective pharmacologic testing in a child. J Clin Neurosci 2014; 21:1251–1253. 51. Natarajan S, Ghodke B, Britz G, et al. Multimodality treatment of brain arteriovenous malformations with microsurgery after embolization with onyx: single-center experience and technical nuances. Neurosurgery 2008; 62:1213–1226. 52. Ou CH, Wong HF, Yang MS, et al. Percutaneous direct puncture embolization for superficial craniofacial arteriovenous malformation. Interv Neuroradiol 2008; 14 (Suppl 2):19–22. 53. Medsinge A, Zajko A, Orons P, et al. A case-based approach to common embolization agents used in vascular interventional radiology. AJR Am J Roentgenol 2014; 203:699–708. 54. Sacks D, Connors JJ 3rd, Black CM. Society of interventional radiology position statement on endovascular acute ischemic stroke interventions. J Vasc Interv Radiol 2013; 24:1263–1266. 55. Talke PO, Sharma D, Heyer EJ, et al. Society for Neuroscience in Anesthe&& siology and Critical Care Expert consensus statement: anesthetic management of endovascular treatment for acute ischemic stroke: endorsed by the Society of NeuroInterventional Surgery and the Neurocritical Care Society. J Neurosurg Anesthesiol 2014; 26:95–108. An excellent summation of the latest research on care of patients needing therapy for acute ischemic stroke. 56. Poisson SN, Schardt TQ, Dingman A, Bernard TJ. Etiology and treatment of arterial ischemic stroke in children and young adults. Curr Treat Options Neurol 2014; 16:315. 57. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372:11–20. 58. Chapiro J, Tacher V, Geschwind JF. Intraarterial therapies for primary liver cancer: state of the art. Expert Rev Anticancer Ther 2013; 13:1157– 1167. 59. Gobin YP, Dunkel IJ, Marr BP, et al. Intra-arterial chemotherapy for the management of retinoblastoma. Arch Opthalmol 2011; 129:732– 737.
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Common procedures and strategies for anaesthesia in interventional radiology Mary Landrigan-Ossar
Purpose of review This review describes the range of cases now available in the interventional radiology suite and summarizes suggestions for their anaesthetic and perioperative management. Recent findings The type and complexity of interventional radiology cases being performed increases from year to year. Anaesthesiologists’ presence in interventional radiology is increasing in turn, due to increasingly ill patients and intricate procedures requiring more than local anaesthesia for well tolerated completion. The literature available describing this is largely written by radiologists, with little attention paid to anaesthetic considerations. Summary Cases in interventional radiology are complex in terms of the logistics of working in an unfamiliar area, frequency of patient comorbidity and unfamiliar procedures. Ensuring familiarity with the variety of interventional radiology procedures and their periprocedure requirements can increase anaesthesiologists’ comfort in interventional radiology. Keywords interventional radiology, minimally invasive, nonoperating anaesthesia
INTRODUCTION Interventional radiology represents a hinterland for many anaesthesiologists into which they do not care to venture. This prejudice must be overcome; advances in interventional radiology tools and techniques over the past 50 years have expanded the range of procedures [1 ,2,3], and anaesthesiologists find their services in greater demand for adults and children [1 ,2,3]. In an adult interventional radiology suite, anaesthesiologists are necessary primarily for complex cases or medically challenging patients. In the paediatric interventional radiology suite, an anaesthesiologist has a greater presence. Often the patient and/or procedure will require a younger patient being at minimum deeply sedated for well tolerated completion. Knowledge of the procedure to be performed, its length, likely complications and intraoperative and postprocedure requirements will influence anaesthetic choice [4 ]. Overall safety in the nonoperating room environment is treated elsewhere in this issue; radiation safety is of particular importance in interventional radiology for patient and practitioner. The sine qua non of well tolerated practice is open communication within an effective team [5]. This &
&
&
www.co-anesthesiology.com
chapter will describe some common interventional radiology procedures and suggestions for their safe anaesthetic management.
Biopsies and drain placements Aspiration of fluid collections, drain placements and biopsies are common in any interventional radiology suite [6–8]. These can often be accomplished with ultrasound guidance, although deeper targets or those near vital structures can require computed tomographic (CT) guidance and apnoea. The location of the target and the imaging mode to be used help determine the type of anaesthesia required, although the patient’s overall health is the final determinant. Preprocedure communication Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA Correspondence to Mary Landrigan-Ossar, MD, PhD, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel: +1 617 355 7737; e-mail: [email protected] Curr Opin Anesthesiol 2015, 28:458–463 DOI:10.1097/ACO.0000000000000208 Volume 28 Number 4 August 2015
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Common IR procedures and strategies for anaesthesia Landrigan-Ossar
KEY POINTS Interventional radiology procedures are continually expanding in range and complexity. Anaesthesiologists working in interventional radiology must be comfortable with providing well tolerated care to ill patients in a nonoperating environment; effective communication with a dedicated team is crucial. Anaesthetic management of patients in interventional radiology requires knowledge of the procedure to be performed, intraoperative requirements with regard to fluid management/apnoea/positioning and postoperative management of this unique patient population.
with the radiologist about positioning, need for apnoea and patient condition is essential. Ultrasound-guided procedures can be done with sedation and spontaneous ventilation even in young infants, as the radiologist continually visualizes the needle. CT-guided procedures require an immobile patient, as motion necessitates additional scanning and irradiation. Soft tissue biopsies are minimally painful postoperatively; bone biopsies or drainage catheter insertion produce more discomfort. Complications are rare. They include bleeding and puncture of nontarget structures [8]. Solid organ biopsies should have blood bank specimens sent; bleeding risk is low but can be impressive when it occurs [9,10]. Abscess drainage can result in transient sepsis-like haemodynamic changes [11], but frank sepsis is less likely. Postprocedure care involves mild pain control and assistance with immobility after an organ biopsy.
simply to lie still and may require only anxiolysis. Patients at the extremes of size/age or those with multiple prior lines may need longer procedures, making an laryngeal mask airway (LMA) or endotracheal tube desirable. Pain postprocedure is minimal. For patients for whom sedation/anaesthesia is very high risk, preprocedure communication with the radiologist and referring service is recommended to determine whether the procedure is essential and whether it will be possible on a ‘moving target’.
Sclerotherapy of vascular and lymphatic malformations Vascular malformations and lymphatic malformations are slow-flow congenital vascular lesions that can be treated by a variety of interventional radiology methods [15], most commonly chemical sclerotherapy. Patients may have isolated small lesions or syndromes with lesions encompassing much of the body (Fig. 1). As these lesions will grow and become more complex over time [16,17], it is increasingly common for treatment to start in childhood. Sclerosing agents are described in Table 1 [18–23]. Simple sclerotherapy can last under 1 h while complex can last 8–10 h. Depending on positioning and procedure length, these cases can be done with an endotracheal tube, LMA or sedation. Blood loss is not generally significant, but access for hydration is essential. Hydration is recommended to offset the osmotic diuretic effect of intravenous (i.v.) contrast [24]. Alcohol and sodium tetradecyl sulphate (STS) cause dose-dependent haemolysis/haemoglobinuria
Percutaneous lesion ablation Percutaneous ablation of bone or soft tissue lesions is increasing. Chemical ablation with acetic acid or ethanol, thermal ablation with radiofrequency ablation or cryoablation has been described to treat tumours in every body part [12,13]. Target location, imaging mode and need for apnoea will influence anaesthetic plan; procedures are painful and require at least moderate sedation and good postoperative pain control. Complications involve injury to surrounding tissue, particularly nerves.
Central venous access These procedures are often done on complex patients or those who have failed line placement elsewhere [14]. Everything else being equal, patients need
FIGURE 1. Two-year-old boy with blue rubber bleb nevus syndrome and a massive venous malformation of the upper leg/flank.
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Anesthesia outside the operating room Table 1. Common sclerotherapy agents Agent
Indications
Swelling
Pain
Complications
Sodium tetradecyl sulphate (STS)
LM, VM
Moderate
Moderate
Haemoglobinuria, skin blistering [18,19]
Ethanol
LM, VM
Marked
Marked
Nausea, haemoglobinuria, skin blistering, ethanol intoxication, nerve injury, cardiovascular collapse [20]
Doxycycline
LM
Marked
Marked
Minimal [21]
Bleomycin
LM, VM primarily cervicofacial
Moderate
Moderate
Transient fever Concern for pulmonary fibrosis, never described after sclerotherapy [22]
OK-432
LM
Marked
Marked
Not FDA approved for use in USA [23]
FDA, US Food and Drug Administration; LM, lymphatic malformations; VM, vascular malformations.
treated with hydration and urine alkalinization [18]. Contrast reactions are a constant threat; their management is similar to that for anaphylaxis [25]. Arterial lines are rarely necessary. Pain and swelling postprocedure are agent dependent and may be significant. Ectatic veins with slow flow are at a high risk of intralesional thrombosis, leading to thromboembolism and consumptive coagulopathy [26]. Treatment is anticoagulation; a haematologist familiar with this pathophysiology should manage periprocedure anticoagulation. Cervicofacial malformations are particularly challenging (Fig. 2). Intubation can be difficult and elective tracheostomy may be necessary. Preprocedure consultation with otorhinolaryngologists is recommended. It is crucial to recognize that all sclerosants cause swelling that will not peak until several hours after injection. Extubation should be carefully considered if a peri-airway lesion is treated; intubation may be necessary for several days.
Transjugular intrahepatic portosystemic shunt and related procedures Procedures to reduce portal hypertension and associated variceal bleeding and ascites are performed on patients critically ill with end-stage liver disease [27]. These include transjugular intrahepatic portosystemic shunt (TIPS) creation and balloon occluded retrograde transvenous obliteration (BRTO) of varices with sclerosant [28]. These procedures are often performed under general endotracheal anaesthesia; procedure length, comorbid conditions and significant ascites make sedation a less attractive option. Invasive monitoring may be necessary on the basis of patient condition. Coagulopathy is often marked and may require correction peri-procedure. Complications of TIPS include encephalopathy and shunt stenosis, as well as haemorrhage [27]. BRTO complications include most commonly transient haemoglobinuria, vessel thrombosis or reaction to sclerosant is rare. Recovery may require ICU depending on patient condition.
Embolization for haemorrhage
FIGURE 2. Twelve-year-old girl with cervicofacial lymphatic malformation necessitating tracheostomy placement in early infancy. 460
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Catheter-based interventions for life-threatening haemorrhage have a track record of effectiveness in adult and paediatric trauma [29,30]. Advantages include less insensible fluid loss, less risk of hypothermia and access to a bleeding site without a surgical incision’s potential to disrupt tamponade. Although case series demonstrate more than 85% successful control of haemorrhage, the main predictor of failure is the amount of blood transfusion necessary before reaching the interventional radiology suite. Anaesthetic and fluid management for these cases depends largely on the degree of trauma sustained: preparations for massive transfusion may be necessary for major trauma, while minor cases can be managed more conservatively. Patient condition will dictate the need for endotracheal intubation and the need for ICU monitoring. Volume 28 Number 4 August 2015
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Common IR procedures and strategies for anaesthesia Landrigan-Ossar
Bronchial artery embolization for haemoptysis control presents a unique anaesthetic challenge. Embolization is effective in gaining short-term control of haemoptysis, even massive haemoptysis, but does not affect overall disease course [31,32]. Massive haemoptysis often necessitates single-lung ventilation and transfusion, but a grey area exists for more stable patients. Some reports have suggested that positive pressure ventilation may itself be detrimental particularly in cystic fibrosis patients, and that sedation at most is preferable [33]. This must be weighed against a patient’s ability to lie flat while in a state of respiratory compromise for a potentially prolonged procedure. With any patient undergoing semi-elective bronchial embolization, clear communication with the patient and family about goals of care in the event of catastrophe is recommended.
Venous thrombolysis Interventional radiology procedures alone or in conjunction with surgery are increasingly used for the treatment of venous thrombosis of the deep venous system and of dialysis access [34,35]. Catheters are inserted for a combination of mechanical thrombolysis and for delivery of thrombolytic medications. Balloon venoplasty and stent insertion are also employed. Procedures can be performed under sedation or general anaesthesia; airway control when elevated potassium is threatened may be desirable, and deeper levels of sedation are usually necessary for venoplasty, which is painful [36]. Mechanical thrombolysis results in haemolysis and potentially dangerous increases in potassium levels, particularly in dialysis-dependent patients [37]. During a course of treatment often extending over several days, close coordination with haematologists for management of anticoagulation is essential to minimize bleeding complications.
Diagnostic cerebral angiography Diagnostic cerebral angiograms generally last less than 1 h. They are the gold standard for delineating vascular disease, such as arteriovenous malformations (AVMs) and vasculitis [38]. In adults, sedation is rarely required. As younger patients may not safely cooperate, these cases are often performed with endotracheal intubation. Arterial catheters are rarely necessary. Contrast loads can be significant, and generous hydration is recommended. The most common complication is bleeding at the femoral puncture site [39]. Deep extubation possibly supplemented by sedative agents should be considered, as patients need to lie flat for several hours
after arterial decannulation [40]. Pain is not usually significant after these procedures.
Embolization of cerebral or peripheral arteriovenous malformations Intracranial AVMs requiring treatment are uncommon but challenging in the very young. Infants with cerebral AVMs (usually vein of Galen malformation) can present with heart failure [41] that is associated with poor prognosis. Older children and adults with intracranial AVMs more commonly present with hydrocephalus, headache, seizure or intracranial haemorrhage, which can be devastating [42]. Peripheral AVMs progress over time if untreated and can result in destruction of local structures and highoutput cardiac failure [43]. Cardiology input to evaluate and optimize cardiac function is recommended. Cerebral embolization procedures may last more than 8 h. Although adult patients may tolerate awake procedures when neurologic assessment is necessary, most adults and children have endotracheal intubation and consistent muscle relaxation [44 ]. Blood loss is usually minimal, but access for hydration is necessary to offset the diuretic effect of contrast [24]. Heparinized 0.9% saline is slowly infused via the femoral catheter to prevent cerebral microemboli [45], and this can add significant volume over time. Close blood pressure control is generally required, necessitating an arterial catheter. Vasoactive medications may be necessary to keep blood pressure below a predetermined maximum, but are less often necessary in paediatric patients. Pain is not significant. As mentioned above, deep extubation should be considered, as patients need to remain flat postoperatively. Haemodynamic changes may occur during AVM embolization. In some patients with heart failure due to high cardiac output, treatment of the AVM can result in immediate improvement in the patient’s physical status [46]. Cerebral embolization with ethylene vinyl alcohol copolymer glue (Onyx, Covidien, Plymouth, Minnesota, USA) has been reported to induce bradycardia [47]. Alterations in flow dynamics in a treated cerebral AVM may result in a period of increased haemorrhage risk, particularly in incomplete embolizations [48]. The most common complication is bleeding at the femoral artery puncture site. With injection of embolic agents, there is the possibility of inadvertent closure of arteries supplying nearby normal brain tissue, either through glue migration or because the target vessel supplies normal and abnormal tissue. This latter risk is fortunately extremely low [46]. In adults, intraprocedure neuropsychological testing under moderate sedation is used to &
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Anesthesia outside the operating room
determine the safety of embolization near eloquent cortex [49], but few children have been treated in this manner due to concerns about cooperation [50]. Postembolization care emphasizes control of blood pressure to avoid sudden increases [51], although there are few descriptions of how to achieve this in paediatric patients [40]. Peripheral AVM embolization may also last more than 8 h. Access to the lesion may be percutaneous or transarterial [52], and various embolic agents may be employed [53]. Hydration is recommended as above, as is consideration for lying flat postprocedure. Bleeding and pain are not usually significant. Complications such as nontarget embolization are rare but potentially devastating.
Acute ischemic stroke management Therapy for acute ischemic stroke has benefitted from research over the past decades, culminating in consensus statements on treatment from several bodies [54,55 ,56]. Anaesthesiologists may find their services necessary for either diagnostic imaging sedation or for sedation/anaesthesia for endovascular thrombolysis. Catheter-based interventions are generally reserved for patients for whom tissue plasminogen activator (TPA) therapy is contraindicated, although evidence may be shifting in favour of endovascular treatment [57]. Speed is of the essence when treating patients with ischemic stroke, and the need for preoperative workup must be balanced against time. Anaesthetic management by sedation versus endotracheal intubation should be based on the individual patient’s situation, as no advantage to either can be found in the literature. Arterial monitoring catheters should only be placed when they can be placed quickly. Close control of haemodynamics and glucose are key; oxygen and carbon dioxide levels should be kept within normal limits, and euvolemia and euthermia are recommended. Postprocedure care should be in an ICU or ward unit experienced in caring for stroke patients. &&
Intra-arterial chemotherapy Injection of chemotherapeutic agents into a tumour’s feeding artery is a therapy described for several cancers [58] including retinoblastoma, and thus may be performed in quite young children [59]. Access is obtained via the femoral artery, and chemotherapeutic agents are injected specifically into the affected ophthalmic artery. Anaesthesiologists can assist by giving oxymetazoline nasal spray to the ipsilateral nostril just prior to chemotherapy injection to shrink the nasal branch of the ophthalmic artery and drive flow to the ophthalmic portion. 462
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Albuterol is given at the same time, as this protocol is associated with a significant incidence of bronchospasm. PONV prophylaxis should be given even in young patients.
CONCLUSION The interventional radiology suite can be a daunting assignment for the unprepared anaesthesiologist, with its distance from the support of the main operating rooms and a host of unfamiliar procedures. Fluency with the proposed procedures, proper equipment selection and setup, adequate preoperative workup of patients and an interventional radiology staff with the training and motivation to provide effective backup in an emergency are essential elements of safe practice in this area. It is important to recognize one aspect of our role in this setting is to act as the de facto gatekeeper and final safety stop for patients. It is incumbent on us to ensure that patients are being appropriately referred for our services and are as medically optimized as is possible under the clinical circumstances. Once this is ensured, the anaesthesiologist can focus on providing exceptional care to some of the most challenging patients in the hospital. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Baum RA, Baum S. Interventional radiology: a half century of innovation. & Radiology 2014; 273 (Suppl 2):S75–S91. An excellent retrospective study of the developments in techniques in interventional radiology over the past half century. 2. Burrill J, Heran MK. Nonvascular pediatric interventional radiology. Can Assoc Radiol J 2012; 63 (Suppl 3):S49–S58. 3. Heran MK, Burrill J. Vascular pediatric interventional radiology. Can Assoc Radiol J 2012; 63 (Suppl 3):S59–S73. 4. Rubin D. Anesthesia for ambulatory diagnostic and therapeutic radiology & procedures. Anesthesiol Clin 2014; 32:371–380. An overview of cases in diagnostic and interventional radiology with suggestions for their well tolerated anaesthetic management. 5. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 2009; 53:143–151. 6. Uller W, Wohlgemuth WA, Hammer S, et al. Percutaneous treatment of biliary complications in pediatric patients after liver transplantation. Rofo 2014; 186:1127–1133. 7. Naumann H, Pittaway A, Lynn AM, Vo NJ. CT-guided percutaneous lung biopsy under general anesthesia: a pediatric case series and literature review. Paediatr Anaesth 2012; 22:469–475.
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Common IR procedures and strategies for anaesthesia Landrigan-Ossar 8. Brown C, Kang L, Kim ST. Percutaneous drainage of abdominal and pelvic abscesses in children. Semin Intervent Radiol 2012; 29:286–294. 9. Kennedy SA, Milovanovic L, Midia M. Major bleeding after percutaneous image-guided biopsies: frequency, predictors, and periprocedural management. Semin Intervent Radiol 2015; 32:26–33. 10. Dohan A, Guerrache Y, Dautry R, et al. Major complications due to transjugular liver biopsy: incidence, management and outcome. Diagn Interv Imaging 2015. [Epub ahead of print] 11. Lorenz J, Thomas JL. Complications of percutaneous fluid drainage. Semin Intervent Radiol 2006; 23:194–204. 12. Flanagin BA, Lindskog DM. Intraoperative radiofrequency ablation for osteoid osteoma. Am J Orthop (Belle Mead NJ) 2015; 44:127–130. 13. Filippiadis DK, Tutton S, Mazioti A, Kelekis A. Percutaneous image-guided ablation of bone and soft tissue tumours: a review of available techniques and protective measures. Insights Imaging 2014; 5:339–346. 14. Duszak R Jr, Bilal N, Picus D, et al. Central venous access: evolving roles of radiology and other specialties nationally over two decades. J Am Coll Radiol 2013; 10:603–612. 15. Cahill AM, Nijs ELF. Pediatric vascular malformations: pathophysiology, diagnosis, and the role of interventional radiology. Cardiovasc Intervent Radiol 2011; 34:691–704. 16. Hassanein AH, Mulliken JB, Fishman SJ, et al. Venous malformation: risk of progression during childhood and adolescence. Ann Plast Surg 2012; 68:198–201. 17. Hassanein AH, Mulliken JB, Fishman SJ, et al. Lymphatic malformation: risk of progression during childhood and adolescence. J Craniofac Surg 2012; 23:149–152. 18. Barranco-Pons R, Burrows PE, Landrigan-Ossar M, et al. Gross hemoglobinuria and oliguria are common transient complications of sclerotherapy for venous malformations: review of 475 procedures. AJR Am J Roentgenol 2012; 199:691–694. 19. Odeyinde SO, Kangesu L, Badran M. Sclerotherapy for vascular malformations: complications and a review of techniques to avoid them. J Plast Reconstr Aesthet Surg 2013; 66:215–223. 20. Bisdorff A, Mazighi M, Saint-Maurice JP, et al. Ethanol threshold doses for systemic complications during sclerotherapy of superficial venous malformations: a retrospective study. Neuroradiology 2011; 53:891–894. 21. Shergill A, John P, Amaral JG. Doxycycline sclerotherapy in children with lymphatic malformations: outcomes, complications and clinical efficacy. Pediatr Radiol 2012; 42:1080–1088. 22. MacIntosh PW, Yoon MK, Fay A. Complications of intralesional bleomycin in the treatment of orbital lymphatic malformations. Semin Ophthalmol 2014; 29:450–455. 23. Motz KM, Nickley KB, Bedwell JR, et al. OK432 versus doxycycline for treatment of macrocystic lymphatic malformations. Ann Otol Rhinol Laryngol 2014; 123:81–88. 24. Lenhard DC, Pietsch H, Sieber MA, et al. The osmolality of nonionic, iodinated contrast agents as an important factor for renal safety. Invest Radiol 2012; 47:503–510. 25. Iyer RS, Schopp JG, Swanson JO, et al. Safety essentials: acute reactions to iodinated contrast media. Can Assoc Radiol J 2013; 64:193–199. 26. Adams DM. Special considerations in vascular anomalies: hematologic management. Clin Plast Surg 2011; 38:153–160. 27. DeGasperi A, Corti A, Corso R, et al. Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia. J Clin Monit Comput 2009; 23:341–346. 28. Saad WE. Endovascular management of gastric varices. Clin Liver Dis 2014; 18:829–851. 29. van der Wilden GM, Velmahos GC, Joseph DK, et al. Successful nonoperative management of the most severe blunt renal injuries: a multicenter study of the research consortium of New England Centers for Trauma. JAMA Surg 2013; 148:924–931. 30. Vo NJ, Althoen M, Hippe DS, et al. Pediatric abdominal and pelvic trauma: safety and efficacy of arterial embolization. J Vasc Interv Radiol 2014; 25:215–220. 31. Hurt K, Simmonds NJ. Cystic fibrosis: management of haemoptysis. Paediatr Respir Rev 2012; 13:200–205. 32. Chun JY, Morgan R, Belli AM. Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization. Cardiovasc Intervent Radiol 2010; 33:240–250. 33. McDougall RJ, Sherrington CA. Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis. Paediatr Anaesth 1999; 9:345–348. 34. Hongsakul K, Rookkapan S, Sungsiri J, et al. Pharmacomechanical thrombolysis versus surgical thrombectomy for the treatment of thrombosed haemodialysis grafts. Ann Acad Med Singapore 2015; 44:66–70.
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