Radiology Notes

My notes during radiology residency, fellowship, and beyond…

Archive for the ‘interventional’ Category

May-Thurner syndrome

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  • DVT of left ileofemoral vein by compression of left common iliac vein from overlapping right common iliac artery
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Written by lmwong

February 6, 2010 at 1:36 pm

Elbow MRI Dictation

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Clinical statement: [x]

Technique: [x]

Comparison: [x]

Findings: The extensor tendons and lateral collateral ligaments, including the ulnar band of the lateral collateral ligament, are maintained. The medial collateral ligament and flexor pronator origin are unremarkable.

As visualized in extension, the ulnar nerve is localized in the ulnar sulcus and the posterior interosseous nerve at the level of the supinator has preserved fat planes. The biceps, triceps, and brachialis insertions are normal. Articular cartilage is maintained.

Impression: [x]

Written by lmwong

April 7, 2008 at 9:26 pm

TIPS procedure Dictation

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Clinical history: [x]
Technique: Informed consent was obtained. The patient was identified and placed in the supine position. General anesthesia was administered by anesthesiology staff who remained in attendance. The right side of the neck was prepped and draped in the usual sterile fashion. Under ultrasound guidance, the right internal jugular vein was accessed using a 21 gauge micropuncture needle and an 0.018 inch guidewire was passed. The needle was exchanged for a 4.5 French vascular introducer. The 0.018 inch guidewire was removed and replaced with an 0.035 inch Bentson guidewire . The vascular introducer was exchanged for a 5 French specialty catheter (from a transjugular intrahepatic access set) which was used to cannulate the hepatic vein. CO2 portogram was performed to define the portal system. The right hepatic vein was selected and after several attempts, the right portal vein was successfully accessed using a transjugular needle and a guidewire was passed. The tract between the right hepatic vein and the right portal vein was dilated with a balloon catheter and a repeat venogram was obtained. The TIPS coduit was stented with two 10mm X 68mm Wallstents . The measured pre-Tips pressure gradient was 16 mm Hg and the corresponding post-TIPS value was 6 mmHg. An excellent immediate post-TIPS result was documented. The vascular introducer was removed and hemostasis was obtained at the puncture site by direct compression. The patient tolerated the procedure well, was hemodynamically stable throughout the entire procedure and was successfully extubated .
Dr. [x], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.
Impression:
1. Small liver with hepatopetal flow.
2. Minimal varices .
3. Successful creation of TIPS shunt between the right hepatic vein and the right portal vein. Pre-TIPS and post-TIPS pressure gradients were 16 mm Hg and 6 mm Hg, respectivel

Written by lmwong

April 7, 2008 at 9:23 pm

Right lower extremity angiogram and thrombolysis Dictation

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Clinical History: [x]
Technique: [x]
After obtaining informed consent, the patient was placed supine on the angiography table. The left groin was prepped and draped in a sterile fashion. Following the administration of lidocaine , the left common femoral artery was accessed using a 19 gauge needle. A Bentson wire was threaded into the abdominal aorta. The needle was removed and a 4 French omni flush catheter was threaded over the wire into the lower abdominal aorta. A pelvic aortogram was performed.
Utilizing road-mapping technique, the catheter was then advanced over a wire into the right common femoral artery. An angiogram and runoff were performed. A guidewire was advanced into the right superficial femoral artery followed by the catheter. A Rosen wire was then utilized to cross the area of stenosis and occlusion. The omni flush catheter was removed and a 5.5 French long Balkan sheath was placed over the bifurcation in the proximal right superficial femoral artery. Through the sheath and over a wire, a pulse spray catheter was placed within the occluded segment and within the occluded graft. A repeat angiogram through the catheter was performed to confirm position. Through the catheter, 5 mg of TPA were pulse-sprayed into the occluded segment.
The sheath and catheter were taped to the patinent’s leg and infusion of TPA through the catheter was started at 0.5 mg/hour. An infusion of heparin at 300 units/hour was also started through the sheath and the patient was transferred to the surgical ICU for monitoring overnight.
Findings:
There is complete thrombosis of the right fem-pop endovascular graft. There is reconstitution of the popliteal artery distal to the graft with stenosis in the popliteal artery below the knee. There is a single vessel runoff via the right anterior tibial artery. Thrombolysis of the graft was initiated as described above.
Dr. [x], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.
Medications: Fentanyl [x] ug IV, Versed [x] mg IV, [x] mg TPA IA , Heparin [x] U IV.
Contrast : [x] cc of 50 % Omni.
Impression:
1. Thrombosed right fem-pop graft.
2. Reconstitution of the popliteal artery distal to the graft with stenosis below the knee.
3. Single-vessel runoff via AT.
4. Thrombolysis as described above.

Written by lmwong

April 7, 2008 at 9:22 pm

Renal angiogram and embolization Dictation

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Radiologists: [x]
Clinical History: [x]
Technique and findings:
After obtaining informed consent, the patient was placed supine on the angiography table. The right groin was prepped and draped in a sterile fashion. Following the administration of lidocaine , the right common femoral artery was accessed using a 19 gauge needle. A Bentson wire was threaded into the abdominal aorta. The needle was removed and a 5 French sheath was placed into the right common femoral artery.
Through the sheath, a 4 French omni flush catheter was threaded over the wire into the upper abdominal aorta. An aortogram was performed.
The catheter was removed and a Cobra catheter was then used to cannulate the left renal artery and an angiogram was obtained.
A Renegade high flow catheter was then advanced into multiple branches of the left kidney, where 4 cc’s of Embospheres 700-900 micron and 2 vials of Contour 700-900 micron to complete stasis. Three 8 mm coils were then placed in the mid left renal artery. Post embolization angiogram demonstrates no flow to the left kidney.
The splenic artery was then selectively catheterized and an angiogram demonstrates the splenic artery to be displaced superiorly, with no branches feeding the left upper pole mass.
A flush catheter was then re-advanced into the upper abdominal aorta and repeat aortogram was performed.
The catheter and sheath were removed and pressure was applied to the right groin until hemostasis was achieved. A sterile dressing was applied.
Dr. [x], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.
Medications: Fentanyl [x] ug IV, Versed [x] mg IV, Ancef [x] g IV
Contrast: [x] cc of Omni 300.
Impression:
Large mass in the left kidney, successfully embolized as described above. No flow is seen towards the left kidney on repeat angiogram.

Written by lmwong

April 7, 2008 at 9:21 pm

Retrograde exchange of ureteral stent Dictation

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History: [x]
Procedure: Retrograde exhange of [right] ureteral stent
Technique: Informed consent was obtained. The patient was identified and placed in the supine position. A Foley catheter was inserted into the bladder. The perineum was prepped and draped in the usual sterile fashion. 2 % lidocaine was used for local anesthesia.
The bladder was distended with fluid and contrast. The Foley catheter was cut and a J-wire was advanced into the bladder. The Foley was exchanged over the wire for a 14 French vascular sheath. A snare was introduced through the sheath and the lower loop of the ureteral stent was snared and pulled back into the vascular sheath. A Bentson wire was threaded through the stent into the upper collecting system. The stent was exchanged for a Bernstein catheter, through which contrast was injected. A 10 French 20 cm long custom made ureteral stent was then advanced, with the upper loop forming in the upper collecting system in the lower loop forming in the bladder.
Findings:
Markedly dilated [right] upper collecting system.
Dr. [x], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.
Medications: Fentanyl [x] mcg IV, versed [x] mg IV
Impression:
Retrograde exchange of a 10 French 20 cm custom made [right] ureteral stent .

Written by lmwong

April 7, 2008 at 9:21 pm

Abdominal aortogram , bilateral selective renal artery angiograms and bilateral renal artery stenting Dictation

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Procedure: [x]
1. Abdominal aortogram .
2. Fluoroscopically guided bilateral selective renal artery angiogram.
3. Bilateral renal artery stenting .
Radiologist: [x]
History: [x]
Technique:
After obtaining informed consent, the patient was placed supine on the angiography table. The right groin was prepped and draped in a sterile fashion. Following the administration of lidocaine , the right common femoral artery was accessed using a 19 gauge needle. A Bentson wire was threaded into the abdominal aorta. The needle was removed and a 4 French omni flush catheter was threaded over the wire into the upper abdominal aorta. An aortogram was performed.
The flush catheter was removed a 5 French sheath was placed into the right common femoral artery. Through the sheath and over the wire a Sos Omni 2 selective catheter was then used to cannulate the right renal artery. Nitroglycerin was injected through the catheter and pressure measurements were acquired. Heparin was administered. A wire was threaded through the omni catheter into a more distal right renal artery. The omni catheter and sheath were removed and a long, 6 French Balkan sheath was then threaded over the wire into the mid-abdominal aorta. A 6 mm x 15 mm stent was then threaded over the wire into the proximal right renal artery and deployed. An additional angiogram and pressure measurements were acquired.
The catheter was then withdrawn from the right renal artery and, after some difficulty, the left renal artery was cannulated . Nitroglycerin was injected through the catheter and pressure measurements were acquired. Heparin was administered. A wire was threaded through the omni catheter into a more distal left renal artery. A 6 mm x 15 mm stent was then threaded over the wire into the proximal left renal artery and deployed. An additional angiogram was performed.
The catheter and wire were withdrawn and the sheath was retracted into the right external iliac artery. The sheath was taped to the patient’s skin and the patient was transferred to the recovery room.
While in the recovery room the sheath was removed and pressure was applied to the right groin until hemostasis was achieved.
Findings:
The initial aortogram demonstrates a mild-to-moderately calcified and irregular aorta.
There is a 15 mm long moderate to severely stenotic segment in the proximal right renal artery which yielded a 40 mm pressure gradient initially. Following angioplasty with the 6 mm x 20 mm balloon there is a residual 50% stenosis with a significant pressure gradient. Following placement of a 6 mm x 15 mm omni flex stent there is no pressure gradient and excellent angiographic results.
Angiogram and measurements in the left renal artery demonstrates a 15 mm long moderate stenosis with a 5-10 mm pressure gradient.
Dr. [x], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.
Medications: Fentanyl [x] ug IV, Versed [x] mg IV, heparin [x] units IV, nitroglycerin [x] ug intra-arterial.
Contrast: [x] cc of 60% ionic contrast.
Impression:
1. Moderate to severely stenotic right proximal renal artery which was successfully stented with no residual pressure gradient.
2. Moderate left proximal renal artery stenosis with no clinically significant pressure gradient.
3. Mildly calcified and irregular abdominal aorta.

Written by lmwong

April 7, 2008 at 9:13 pm