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Abstract No. 373: A stranger in a strange land: Interventional radiology in Kandahar, Afghanistan
Poster Sessions 䡲 JVIR
S152
Learning Objectives: Animal models are useful for testing and development of devices and drugs, including efficacy, safety and creation of disease models. Our objective is to present the criteria for animal selection including the anatomic similarities to humans, vascular system size, coagulation parameters and reproduction of diseases and problems affecting humans. Background: Twenty-one animal studies were retrospectively reviewed looking into the type of study, type of animal used, utilization of temporary or permanent device, drug or cell therapy and simulation of human diseases. The animals used were swine, canine and rodents. Devices tested included stents in the peripheral circulation and carotids, covered stents in the peripheral circulation and abdominal and thoracic aortic aneurysm model, angioplasty balloons, thrombectomy devices, IVC filters, venous valves, embolic materials, including particles, spheres and several types of coils. Drugs for angiogenesis and coagulation were also tested. Liver and kidney ablation with a variety of devices were performed. Human disease simulation included creation of renal artery stenosis, IVC stenosis, ureteral and biliary duct stenosis. Clinical Findings/Procedure Details: Large animals such as swine were adequate for testing human size devices, such as stents, balloons, IVC filters, thrombectomy and venous valves, however, exuberant fibrin formation and intimal hyperplasia posed problems for permanent implants. Embolic materials can be tested in any size animal simulation of human diseases are best tested in larger animals. Drug therapy and angiogenesis can use medium size animals or large size animals. Simulation of AAA and pseudoaneurysms is better executed in medium to large size animals. The capacity of fibrin development and intrinsic fibrinolytic mechanisms are variable among animals used for research and the animal model needs to match the device to be tested. Several examples will be presented. Conclusion and/or Teaching Points: Animal models are useful for training and for the testing and development of interventional radiology devices and drugs. Selection of the animal size, coagulation profile of the animal and anatomy target of the device or drug study is important for the success of the experiment.
Educational Exhibit
Abstract No. 373
A stranger in a strange land: Interventional radiology in Kandahar, Afghanistan
Poster Sessions
J. York1, S. Ferrara2, R. Boucher2, M. Brodie3; 1 Radiology, Naval Medical Center Portsmouth, Portsmouth, VA; 2Radiology, Naval Medical Center San Diego, San Diego, CA; 3Radiology, Tripler Army Medical Center, Honolulu, HI Learning Objectives: Interventional radiology, a specialty that relies on high-end imaging equipment and tools, can readily adapt to the challenges of a combat hospital and provide first-world care in a third world environment. Background: In October 2009, an Interventional Radiologist was deployed to the NATO Role 3 Multinational Medical Unit in Kandahar, Afghanistan in support of Operation Enduring Freedom. In a tent and plywood hospital, using a regular operating room table and C-arm, a variety of interventional procedures could be performed. Procedures ranged from routine venous access, to lower extremity run-offs, to emergent pelvic arteriography and
embolization in the hemodynamically unstable polytrauma patient. The integration of the interventional radiologist as a member of the operative team, in conjunction with the trauma surgeon and orthopedic surgeon, enabled us to perform multiple potentially life- and limb-saving procedures on critically injured patients during a short period of time. Clinical Findings/Procedure Details: Pictorial representation of the hospital and cases to include vertebral artery embolization, suprascapular artery embolization, pelvic embolization, profunda femoris embolization, inferior vena cava filter placement, drainage catheter placement, and nephrostomy placement. Conclusion and/or Teaching Points: Interventional radiology, known and respected for unique solutions to difficult clinical problems, can and does survive and thrive in the forward-deployed combat environment. The integration of interventional radiology into the operative team eliminates the concerns and impediments to other treatments since interventions were often performed in conjunction with operative procedures.
Educational Exhibit
Abstract No. 374
Pharmocologic thrombolysis of peri-catheter deep vein thrombosis while maintaining venous access K. Amin, P. Dixit; Vascular and Interventional Radiology, William Beaumont Hospital, Royal Oak, MI Learning Objectives: 1) To identify the signs, symptoms, and etiology of peri-cather deep vein thrombosis, 2) to identify the angiographic appearance of peri-catheter thrombosis, 3) to examine the treatment options and outcomes via a retrospective analysis of multiple cases involving peri-cather thrombosis, 4) to elucidate the most effective treatment of peri-cather thrombosis while maintaining long-term venous access. Background: Peri-catheter DVT is diagnosed fairly often mainly due to an increased number of patients with chronic medical conditions requiring prolonged central venous access. Pericatheter thrombus can not only lead to catheter malfunction, but also to severe, acute symptoms such as upper extremity/facial swelling, post-phlebitic syndromes, and the potential for pulmonary embolism. Previous treatments tended to be conservative, mainly involving anti-coagulation and catheter removal. Catheterdirected thrombolysis without removal of the offending catheter is a slightly more invasive technique designed to administer thrombolytic agent directly into the clot using infusion catheters with multiple sideholes. This method allows preservation of long-term venous access catheters which is especially beneficial in those patients who have limited venous access. Studies have shown rates of near-complete thrombus clearance ranging from 72% to 88% depending on the chronicity of the thrombus. Clinical Findings/Procedure Details: By retrospectively reviewing 10 cases of peri-catheter DVT from the January 2006 to June 2010, we found all cases were treated by catheter directed thrombolytic infusion without removal of the offending catheter. In two cases, an Angiojet device was used for pharmaco-mechanical thrombolysis prior to thrombolytic infusion without significant improvement. On 24 and/or 48 hour follow-up, all had either complete or near complete resolution of thrombus while venous access was maintained. Conclusion and/or Teaching Points: Conclusions: Catheterdirected, thrombolytic infusion appears to be an efficacious treatment option in patients with peri-catheter DVT who need main-
S152
Learning Objectives: Animal models are useful for testing and development of devices and drugs, including efficacy, safety and creation of disease models. Our objective is to present the criteria for animal selection including the anatomic similarities to humans, vascular system size, coagulation parameters and reproduction of diseases and problems affecting humans. Background: Twenty-one animal studies were retrospectively reviewed looking into the type of study, type of animal used, utilization of temporary or permanent device, drug or cell therapy and simulation of human diseases. The animals used were swine, canine and rodents. Devices tested included stents in the peripheral circulation and carotids, covered stents in the peripheral circulation and abdominal and thoracic aortic aneurysm model, angioplasty balloons, thrombectomy devices, IVC filters, venous valves, embolic materials, including particles, spheres and several types of coils. Drugs for angiogenesis and coagulation were also tested. Liver and kidney ablation with a variety of devices were performed. Human disease simulation included creation of renal artery stenosis, IVC stenosis, ureteral and biliary duct stenosis. Clinical Findings/Procedure Details: Large animals such as swine were adequate for testing human size devices, such as stents, balloons, IVC filters, thrombectomy and venous valves, however, exuberant fibrin formation and intimal hyperplasia posed problems for permanent implants. Embolic materials can be tested in any size animal simulation of human diseases are best tested in larger animals. Drug therapy and angiogenesis can use medium size animals or large size animals. Simulation of AAA and pseudoaneurysms is better executed in medium to large size animals. The capacity of fibrin development and intrinsic fibrinolytic mechanisms are variable among animals used for research and the animal model needs to match the device to be tested. Several examples will be presented. Conclusion and/or Teaching Points: Animal models are useful for training and for the testing and development of interventional radiology devices and drugs. Selection of the animal size, coagulation profile of the animal and anatomy target of the device or drug study is important for the success of the experiment.
Educational Exhibit
Abstract No. 373
A stranger in a strange land: Interventional radiology in Kandahar, Afghanistan
Poster Sessions
J. York1, S. Ferrara2, R. Boucher2, M. Brodie3; 1 Radiology, Naval Medical Center Portsmouth, Portsmouth, VA; 2Radiology, Naval Medical Center San Diego, San Diego, CA; 3Radiology, Tripler Army Medical Center, Honolulu, HI Learning Objectives: Interventional radiology, a specialty that relies on high-end imaging equipment and tools, can readily adapt to the challenges of a combat hospital and provide first-world care in a third world environment. Background: In October 2009, an Interventional Radiologist was deployed to the NATO Role 3 Multinational Medical Unit in Kandahar, Afghanistan in support of Operation Enduring Freedom. In a tent and plywood hospital, using a regular operating room table and C-arm, a variety of interventional procedures could be performed. Procedures ranged from routine venous access, to lower extremity run-offs, to emergent pelvic arteriography and
embolization in the hemodynamically unstable polytrauma patient. The integration of the interventional radiologist as a member of the operative team, in conjunction with the trauma surgeon and orthopedic surgeon, enabled us to perform multiple potentially life- and limb-saving procedures on critically injured patients during a short period of time. Clinical Findings/Procedure Details: Pictorial representation of the hospital and cases to include vertebral artery embolization, suprascapular artery embolization, pelvic embolization, profunda femoris embolization, inferior vena cava filter placement, drainage catheter placement, and nephrostomy placement. Conclusion and/or Teaching Points: Interventional radiology, known and respected for unique solutions to difficult clinical problems, can and does survive and thrive in the forward-deployed combat environment. The integration of interventional radiology into the operative team eliminates the concerns and impediments to other treatments since interventions were often performed in conjunction with operative procedures.
Educational Exhibit
Abstract No. 374
Pharmocologic thrombolysis of peri-catheter deep vein thrombosis while maintaining venous access K. Amin, P. Dixit; Vascular and Interventional Radiology, William Beaumont Hospital, Royal Oak, MI Learning Objectives: 1) To identify the signs, symptoms, and etiology of peri-cather deep vein thrombosis, 2) to identify the angiographic appearance of peri-catheter thrombosis, 3) to examine the treatment options and outcomes via a retrospective analysis of multiple cases involving peri-cather thrombosis, 4) to elucidate the most effective treatment of peri-cather thrombosis while maintaining long-term venous access. Background: Peri-catheter DVT is diagnosed fairly often mainly due to an increased number of patients with chronic medical conditions requiring prolonged central venous access. Pericatheter thrombus can not only lead to catheter malfunction, but also to severe, acute symptoms such as upper extremity/facial swelling, post-phlebitic syndromes, and the potential for pulmonary embolism. Previous treatments tended to be conservative, mainly involving anti-coagulation and catheter removal. Catheterdirected thrombolysis without removal of the offending catheter is a slightly more invasive technique designed to administer thrombolytic agent directly into the clot using infusion catheters with multiple sideholes. This method allows preservation of long-term venous access catheters which is especially beneficial in those patients who have limited venous access. Studies have shown rates of near-complete thrombus clearance ranging from 72% to 88% depending on the chronicity of the thrombus. Clinical Findings/Procedure Details: By retrospectively reviewing 10 cases of peri-catheter DVT from the January 2006 to June 2010, we found all cases were treated by catheter directed thrombolytic infusion without removal of the offending catheter. In two cases, an Angiojet device was used for pharmaco-mechanical thrombolysis prior to thrombolytic infusion without significant improvement. On 24 and/or 48 hour follow-up, all had either complete or near complete resolution of thrombus while venous access was maintained. Conclusion and/or Teaching Points: Conclusions: Catheterdirected, thrombolytic infusion appears to be an efficacious treatment option in patients with peri-catheter DVT who need main-