It’s 7:30 on Wednesday morning and the liver cancer / hepatocellular carcinoma (HCC) meeting is about to start. The room is filled with gastroenterologists, a liver surgeon, oncologists, diagnostic and interventional radiologists, nursing staff and keen radiographers. Meetings like these are becoming a familiar sight across the country thanks to the ever-increasing tide of chronic liver disease predisposing to HCC.
The first patient is a 65 year old female with early stage liver cirrhosis, and reasonable functional status. She’s been treated in the interventional radiology (IR) unit for several years with different treatments to multiple lesions including microwave ablation and chemo-embolisation. Her one month follow up CT unfortunately demonstrates possible recurrence, though the changes may also represent post-operative inflammation. The discussion naturally turns to her willingness for further interventional options as well as the possibility for chemotherapy. The decision is made for close imaging follow up. The meeting moves on to the next patient and so it goes for the 10 patients on the list, many of them with treatment histories stretching back years. We have come a long way from an average life expectancy of seven months.
By 8:30 it’s time to get going on the first case of the day. John is a 54 year old hypertensive vasculopath with calcified vessels and critical stenoses of his renal arteries. The nurses are a little anxious that John’s blood pressure is sitting above 200 systolic but after titrating it down with some IV hydralazine everyone is a little more settled and we can get going. The case starts with a cone beam CT on the table of the angiography unit. This is then fused to the CT angiogram to give an impressive 3D map of the aorta and visceral vessels allowing us to access the renal artery without a drop of contrast (that will keep the nephrologist happy!).
In the suite next door the IR fellow is scrubbing in for a percutaneous transhepatic cholangiogram, in which the biliary system is accessed via a needle directly through the skin and liver. The patient is a jaundiced 70 year old woman who’s been waiting several days for the procedure.
We’re not sure what’s causing her biliary obstruction but we suspect cholangiocarcinoma (cancer of the bile duct) as the most likely cause. The gastroenterologists had already tried to get at it endoscopically but the tricky anatomy resulting from previous stomach surgery made the procedure too difficult. Now it’s up to us to relieve the obstruction and get a sample for tissue diagnosis by going directly through the liver. The fellow has done this before so he’s left to himself to gain access first before we join him later.
Sometimes distractions are part of the job, so while all this is happening the vascular surgeons stick their heads in to discuss a couple of cases of patients with carotid artery stenosis who will require stenting (a joint procedure usually requiring both the IR and vascular surgery team together). We all huddle around the workstation as we measure the vessel size, length of the plaque and try to predict how the vessel will react to landing the stent along that curve of vessel. Satisfied the vessel won’t kink and that the embolic protection device is going to sit nicely through the procedure we lock in the cases for next week.
As this is going on, the pressure measurements across the renal artery stenoses are significant and the stents go in without a hitch. The post angiogram shows good renal perfusion and everyone is happy with a job well done. The patient will follow up with the nephrologist and we hope to see the blood pressure significantly lower than when John arrived this morning.
One of the IR registrars returns to the unit having finished the morning ward round with the resident; it always takes a couple of hours. Even though most of the patients are nursed in the IR ward next to surgical short stay there are always a few outliers and patients with drains can be all over the hospital. One of these patients, Rose, a 75-year-old whose small renal cell cancer we cryo-ablated yesterday, felt so well she didn’t believe we actually did anything! The registrar was hard pressed to convince her otherwise. I’m not surprised Rose is a bit confused by it all; cryotherapy is so well tolerated patients often wake up with no more than a mild ache in their back, if at all. Rose will head home with her daughter and we’ll see her in clinic in three months’ time with a CT. The urologist is happy for us to follow her up and grateful she has another option to offer her patients particularly for some of the older folk who won’t contemplate or can’t tolerate surgery. Thankfully, there were no other issues on the ward round.
Meanwhile, the PTC is dragging on, not because of access issues but rather the tight stenosis blocking the common bile duct. Some fancy wire-work by the director is all it takes and the catheter pops satisfyingly into the duodenum. The biliary forceps are advanced down the sheath and bite off several small pieces of tissue at the level of the occlusion. Usually deployed via an endoscope, they have found a home in the IR suite as a useful addition to our bag of tricks. There’s blood casting in the ducts on the cholangiogram meaning a stent placed today is at risk of becoming blocked. While the pathology will almost certainly return a malignant result the decision is made to let things settle down with a drain in place and bring the patient back in a few days’ time for a check cholangiogram and stenting.
It’s lunch time now and International Nurses Day. This of course means a departmental shut down and we take the opportunity to check out the new coffee shop recently opened in the hospital foyer. We run into the hospital General Manager and stop to chat. She’s appropriately proclaimed 2017 the year of IR and we are hoping this at least translates into a few more nurses and radiographers for the department.
Suddenly, lunch is interrupted by a call from the Emergency Department. They are helicoptering in a pedestrian vs car with almost certain pelvic fractures and a blood pressure through the floor. We advise to take them straight to IR where we’ll need to do an emergency angiogram and likely end up embolising any injured iliac arteries. Trauma cases are unusual at this time but everyone will be happy to do this kind of difficult case in the light of day. It will need to be done in the hybrid suite, which sits in IR directly next to the operating theatre in case the orthopaedic surgeons need to be involved at the same time.
Down the corridor we are prepping for the prostate artery embolisation case on the chatty 63-year-old gentleman with benign prostate hyperplasia. He’s flown over from New Zealand for the procedure which adds to the anxiety that most men in this situation feel anyway. We’re hoping he’s going to be as happy as the last patient who two weeks after the procedure proudly proclaimed he was peeing like a racehorse and had never felt better!
About this time, the neurointervention team are kicking off their list as well. There’s a cerebral aneurysm to coil and a few follow up angiograms. It already feels like a full day and it’s only 2pm!
Dr Pieter J KrielDecember 6, 2017 at 8:40 pm
Good article – glad to see Prostatic Arterial Embolisation is becoming more available – long overdue 🙂