Whoever Does Image-Guided Palliative Care Needs to Be Properly Trained to Do So.

Vascular and interventional radiologists (VIRs) often offer image-guided palliative care procedures, despite having little training in clinical medicine, let alone in palliative medicine. Informed consent tends to be inadequate, as does postprocedure patient care. This article proposes that VIRs who perform image-guided palliative procedures be sufficiently trained in palliative care or that surgeons or internists subspecialized in palliative care be sufficiently trained to provide image-guided techniques.

All the World Is a Nail: Why Are Surgeons Resistant to Learn How to Place Cholecystostomy Drains in Seriously Ill Patients With Acute Acalculous Cholecystitis?

Surgeons routinely provide palliative care, but often the technical procedure needed for the palliative intervention is beyond our training and comfort zone. This case is an example of surgical palliative care that utilizes image-guided techniques to provide optimal care. A frail elderly patient with multiple comorbidities who had been hospitalized for other diseases was diagnosed with acute acalculous cholecystitis. General surgery and gastroenterology were initially consulted, and the patient was referred to interventional radiology for a percutaneous cholecystostomy. The procedure was technically successful, and the patient's clinical status improved. A few days later, a follow-up cholecystogram showed a decompressed gallbladder, patent cystic duct, a common bile duct free of stones, and dilute contrast in the duodenum. After 2 weeks, the fistula tract was interrogated and found to be intact. The cholecystostomy tube was removed without incident. This case is presented as a call to action for surgeons to learn the skills required to place percutaneous cholecystostomies themselves and to add it to their surgical armamentarium.

Image-Guided Palliative Interventions.

This article reviews a few surgical palliative care procedures that can be performed by surgeons and interventional radiologists using image-guided techniques. Treatment of recurrent pleural effusions, gastrostomy feeding tube maintenance, percutaneous cholecystostomy, and transjugular intrahepatic portosystemic shunts (TIPS) with embolotherapy of bleeding stomal varices is discussed.

Subcapsular hematoma in blunt splenic injury: A significant predictor of failure of nonoperative management.

BACKGROUND: In patients with blunt splenic injury (BSI), patient selection, angiography, and embolization have contributed to low nonoperative management (NOM) failure rates. Despite these advances, some patients will fail NOM. We noted that a significant proportion of NOM failures had subcapsular hematomas (SCHs) identified on imaging. We sought to determine if there is a correlation between SCH and higher risk of NOM failure after BSI. METHODS: Our institutional trauma registry was queried for all patients with BSI during a 2-year period. Charts were reviewed to determine grade, presence of SCH, and outcome of NOM. Under current institutional protocol, all stable patients with BSI Grades III to V and those with contrast blush on computed tomography are referred for angiography and embolization. Failure of NOM was declared if splenectomy was required for bleeding after an initial plan of nonoperation. RESULTS: From May 2012 to May 2014, 312 patients with BSI were identified. A total of 253 patients (81%) underwent NOM. Overall, 15 (5.9%) failed NOM. Of those undergoing NOM, 34 had SCH and 12 failed (35.3% vs. 1.5% without SCH, p = 0.0001). Failure rates in Grades 1 to 4 were 2.3%, 3.8%, 8.8%, and 19.2%, respectively. NOM failure rates in the subset with SCH for Grades I to IV were 20%, 25%, 30.8%, and 80%, respectively. These are significantly higher than patients without SCH in Grades II to IV (0%, p = 0.003; 2.3%, p = 0.008; and 4.8%, p = 0.016) and approach significance in Grade I (1.2%, p = 0.11). There were no SCHs and no failures of NOM in Grade V injuries. CONCLUSION: The NOM failure rate of BSI patients with SCH is significantly higher than those without SCH. Patients with BSI Grades I to III slated for NOM must be observed as the failure rate approaches 30%. Splenectomy should be considered in patients with Grade IV BSI with SCH, as NOM failure rate is 80%. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Informed Consent Challenges in Frail, Delirious, Demented, and Do-Not-Resuscitate Adult Patients.

Without informed consent, any invasive procedure becomes an assault. The prevailing legal and ethical standard is that the physician has a fiduciary duty to give enough information to the patient so that a reasonable person can make an informed decision to accept or refuse the proposed treatment. The patient's frailty, delirium and/or dementia, and end-of-life concerns and expectations can make informed consent a difficult task. This review examines informed consent requirements for adults and provides communication tools to enable shared decision making while engendering patient-physician trust.

Role of allograft nephrectomy following kidney graft failure: preliminary experience with pre-operative angiographic kidney embolization.

INTRODUCTION: Allograft nephrectomy (AN) is not without morbidity following graft failure (GF) in kidney transplantation (KT). METHODS: Single center retrospective review of all adult patients undergoing AN following KT, including a subset of patients who underwent pre-operative angiographic kidney embolization (PAKE). RESULTS: Over a 104 month period, 853 adult patients underwent deceased donor KT. With a median follow-up of 3.5 years, 174 patients (20.4%) developed GF and 38/174 (21.8%) underwent AN. The rate of AN was higher in patients with delayed graft function [DGF, Odds Ratio (OR) 2.15, p = 0.023] and early GF (OR 1.7, p = 0.064). For patients undergoing PAKE (n = 13, mean timing of AN 27.5 months post-KT), the estimated intra-operative blood loss was reduced from a mean of 375 ± 530 to 100 ± 162 ml (p < 0.10), mean peri-operative transfusion requirements were reduced from 3.36 ± 4.8 to 0.23 ± 0.44 units (p < 0.05), and total mean operating time was reduced from 192 ± 114 to 141 ± 38 min (p = NS) compared to 13 control patients undergoing AN in the absence of vascular thrombosis or PAKE. Mean length of hospital stay was decreased from 8.5 ± 9 to 5.5 ± 3 days (p = NS) in patients with PAKE. Surgical complication and infection rates and hospital charges were comparable. CONCLUSIONS: Delayed graft function and early GF are associated with a higher rate of AN. PAKE may result in less blood loss, fewer transfusions, reduced operating time, and shorter length of stay, which may translate into reductions in morbidity.

Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved.

BACKGROUND: Nonoperative management (NOM) of blunt splenic injury is well accepted. Substantial failure rates in higher injury grades remain common, with one large study reporting rates of 19.6%, 33.3%, and 75% for grades III, IV, and V, respectively. Retrospective data show angiography and embolization can increase salvage rates in these severe injuries. We developed a protocol requiring referral of all blunt splenic injuries, grades III to V, without indication for immediate operation for angiography and embolization. We hypothesized that angiography and embolization of high-grade blunt splenic injury would reduce NOM failure rates in this population. STUDY DESIGN: This was a prospective study at our Level I trauma center as part of a performance-improvement project. Demographics, injury characteristics, and outcomes were compared with historic controls. The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization. In historic controls, referral was based on surgeon preference. RESULTS: From January 1, 2010 to December 31, 2012, there were 168 patients with grades III to V spleen injuries admitted; NOM was undertaken in 113 (67%) patients. The protocol was followed in 97 patients, with a failure rate of 5%. Failure rate in the 16 protocol deviations was 25% (p = 0.02). Historic controls from January 1, 2007 to December 31, 2009 were compared with the protocol group. One hundred and fifty-three patients with grade III to V injuries were admitted during this period, 80 (52%) patients underwent attempted NOM. Failure rate was significantly higher than for the protocol group (15%, p = 0.04). CONCLUSIONS: Use of a protocol requiring angiography and embolization for all high-grade spleen injuries slated for NOM leads to a significantly decreased failure rate. We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries.

The splenic artery stump pressure is affected by arterial anatomy after proximal embolotherapy in blunt splenic injury.

BACKGROUND: Proximal splenic artery embolotherapy can be used as an adjunct to nonoperative management of blunt splenic injury (BSI); however, the hemodynamic changes in the distal splenic artery after proximal splenic artery occlusion are unknown. METHODS: A retrospective review of 48 patients who underwent transient occlusion of the proximal splenic artery with distal splenic artery pressure measurements was performed. Patients were grouped into those with celiac artery stenosis and those with normal celiac anatomy as determined by contrast-enhanced computed tomography. RESULTS: Celiac stenosis was identified in 12 (25.0%) of the 48 patients. The celiac stenosis and normal anatomy groups were not statistically different in their systolic pressure, diastolic pressure, mean arterial pressure, age, sex, and splenic injury grade. Transient occlusion of the proximal splenic artery resulted in a decreased distal splenic artery systolic pressure, diastolic pressure, and mean arterial pressure and a decreased systolic and mean perfusion gradient in all patients (42.6 ± 20.8 mm Hg, 39.7 ± 17.8 mm Hg, 40.9 ± 18.9 mm Hg, 67.4 ± 14.5%, and 55.4 ± 17.9%, respectively). The distal splenic artery stump pressure values in the celiac stenosis and normal anatomy patients differed significantly (72.7 ± 32.0 mm Hg vs. 36.7 ± 11.2 mm Hg, 66.6 ± 26.5 mm Hg vs. 34.4 ± 9.3 mm Hg, 69.0 ± 27.9 mm Hg vs. 35.5 ± 10.2 mm Hg, 46.1 ± 19.7% vs. 71.6 ± 8.9%, 28.8 ± 21.6% vs. 60.6 ± 11.7%, for systolic pressure, diastolic pressure, mean arterial pressure, systolic gradient, and mean gradient in celiac stenosis and normal anatomy BSI patients, respectively; all values of p < 0.0001). CONCLUSION: In hemodynamically stable BSI patients, the systolic pressure in the distal splenic artery is decreased by an average of 67% after proximal splenic artery embolotherapy; however, the pressure reduction in those patients with celiac stenosis is significantly less. This finding may explain some postembolotherapy delayed splenic hemorrhage events. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis.

BACKGROUND: Observation and splenic artery embolotherapy (SAE) are nonoperative management (NOM) modalities for adult blunt splenic injury; however, they are quite different, inconsistently applied, and controversial. This meta-analysis compares the known outcomes data for observational management versus SAE by splenic injury grade cohort. METHODS: Thirty-three blunt splenic injury outcomes articles, published between 1994 and 2009, comprising 24 unique data sets are identified. Of these, nine gave outcomes data by splenic injury grade for observational management and SAE separately. Failure rates were collected and analyzed using random effects estimates. RESULTS: Overall, 68.4% of the 10,157 patients were managed nonoperatively. The overall failure rate estimate of NOM is 8.3% with a 95% confidence interval (CI) of 6.7% to 10.2%. The observational management failure rate estimate without SAE increases from 4.7% to 83.1% in splenic injury grade 1 to 5 patients. The overall failure rate estimate of SAE is 15.7% (95% CI, 10.4-23.2) and did not vary significantly from splenic injury grades 1 to 5 (p=0.413). The failure rate of observational management without SAE is statistically higher than the failure rare estimate of SAE in splenic injury grade 4 and 5 injuries: 43.7% (95% CI, 25.5-63.8) versus 17.3% (95% CI, 7.8-34.1), p=0.035 and 83.1% (95% CI, 45.2-96.7) versus 25.0% (95% CI, 8.7-53.8), p=0.016, respectively. CONCLUSIONS: This meta-analysis synthesizes NOM outcomes data by modality and splenic injury grade. The failure rate of observational management increases with splenic injury grade, whereas the failure rate of SAE does not change significantly. SAE is associated with significantly higher splenic salvage rates in splenic injury grade 4 and 5 injuries.

Image-guided palliative care procedures.

The image-guided procedures discussed in this article are used to alleviate pain and suffering of patients with malignancies and/or multiple comorbidities. It is not possible to discuss the entire breadth of image-guided palliative procedures; only a few commonly requested procedures are reviewed: cholecystostomy, biliary decompression, enteral feeding and decompression tubes, chemical neurolysis (for pain control), cementoplasty, tunneled drainage catheters, transjugular intrahepatic portasystemic shunt pleurodesis, tube thoracostomy, thermal and chemical tumor ablation, transcatheter arterial chemoembolization, and selective internal radiation therapy. A decision tree is given with each procedure/disease. This review provides referring surgeons a framework for end-of-life treatment and palliation discussions.

Aberrant obturator artery is a common arterial variant that may be a source of unidentified hemorrhage in pelvic fracture patients.

BACKGROUND: Similar to all pelvic arteries, the aberrant obturator artery (AOA) and its branches are at risk for injury when the pelvic ring is fractured; however, because of its unique origin, bleeding from this artery may be unrecognized and, thus, treatment ineffective. The purpose of this study was to describe the incidence of the AOA using angiography and determine the sensitivity of 64-slice computed tomography angiography (CTA) at identifying the AOA. METHODS: Imaging from patients undergoing pelvic angiography, for any reason, during 2009 was retrospectively reviewed to determine the incidence of the AOA. The angiographically determined arterial anatomy was the compared with CTA findings. RESULTS: Pelvic angiography, performed in 174 patients, identified the AOA in 60.0% of males, 52.3% of females, 55.1% of all patients, and 38.4% of hemipelvises. The sensitivity/specificity of CTA at identifying the AOA is 90.0%/100% and 63.6%/92.3% in nonpelvic fracture and pelvic fracture patients, respectively; the sensitivity difference being significant (p=0.0351). Three of the 13 (23.1%) AOA identified in pelvic fracture patients demonstrated extravasation when the inferior epigastric artery was cannulated; however, flush angiography failed to demonstrate the extravasation. CONCLUSIONS: The AOA is a common arterial variant occurring in more than half of the population and, if present in pelvic fracture patients, commonly injured. Although CTA is effective at identifying the AOA in nonpelvic trauma patients, it is not as effective in pelvic fracture patients. Failure to consider this arterial variant may result in untreated arterial bleeding with the attendant consequences.

The radiologist as a palliative care subspecialist: providing symptom relief when cure is not possible.

OBJECTIVE: The purpose of this study was to determine the percentage of patients referred to an interventional radiology (IR) practice who need palliative care and to examine the training required for a diplomate of the American Board of Radiology (ABR) to qualify for the hospice and palliative medicine certifying examination. MATERIALS AND METHODS: This retrospective study reviewed all patient referrals to an academic vascular and IR practice during the month of August 2009. The demographics, underlying diagnosis, and the type of procedures performed were ascertained from the electronic medical record. The requirements for a diplomate of the ABR to obtain certification as a hospice and palliative medicine subspecialist were evaluated and summarized. RESULTS: Two-hundred eighty-two patients were referred to the IR service and underwent a total of 332 interventional procedures. Most of the patients (229 [81.2%]) had underlying diagnoses that would warrant consultation with a hospice and palliative medicine subspecialist; these patients were significantly older (58.5 vs 44.7 years; p < 0.01) and underwent more procedures (1.21 vs 1.02; p < 0.01). To obtain a subspecialty certification in hospice and palliative medicine, a radiologist needs certification by the ABR, an unrestricted medical license, 2 years of subspecialty training in hospice and palliative medicine, 100 hours of interdisciplinary hospice and palliative medicine team participation, active care of 50 terminally ill adult patients, and successful performance on the certification examination. CONCLUSION: Procedures related to palliative care currently compose the majority of our IR cases. Certification in hospice and palliative medicine can be achieved with a modest investment of time and clinical training.

Real-time ultrasound-aided central vein cannulation failure rate: establishing a benchmark.

BACKGROUND: The use of real-time two-dimensional B-mode ultrasound (RTUS)-aided central venous access device (CVAD) insertion has been recommended by health-care agencies, but a realistic failure rate for bedside attempts is unknown. METHODS: The failure rate of RTUS-aided CVAD insertion is estimated using data from adult inpatients and outpatients referred to a tertiary referral radiology department for a new CVAD insertion during the 2.5-year period ending February 29, 2008. Cannulation failure, complications, and additional fluoroscopic interventions per central vein cannulation attempt and per patient encounter were retrospectively collected and evaluated. RESULTS: Of the 2456 consecutive patient encounters, the index central vein cannulation failure rate using only RTUS and fluoroscopy was 4.8%; ultimate failure rate was 0.3%. The procedural mortality rate was 0.04%. If the index upper-body central vein cannulation failed, an ipsilateral upper-body attempt through a different central vein failed in 63.6%, whereas a contralateral upper-body attempt failed in 26.7% (p = 0.11) and a common femoral vein attempt failed in 11.5% (p = 0.0039). CONCLUSIONS: The minimum bedside failure rate of RTUS-aided CVAD insertion is 4.8% for the index central vein cannulated. The ultimate failure rate of 0.3% and the mortality rate of 0.04% are due to RTUS, fluoroscopy, and the additional equipment available in an IR suite. If the upper-body index central vein cannulation fails, cannulation of the common femoral vein is more likely to succeed than additional attempts in other ipsilateral upper-body central veins.

Distal splenic artery hemodynamic changes during transient proximal splenic artery occlusion in blunt splenic injury patients: a mechanism of delayed splenic hemorrhage.

BACKGROUND: Delayed splenic hemorrhage after proximal splenic artery embolotherapy (SAE) in patients with blunt splenic injury is a well-known outcome. The hemorrhage is thought to be due to rupture of a splenic parenchymal pseudoaneurysm. This study attempts to explain at least part of the mechanism involved in the delayed hemorrhage event. METHODS: Hemodynamically stable patients with blunt splenic injury, without active extravasation, who underwent splenic artery angiography, also had the distal splenic artery pressure determined with transient balloon occlusion of the proximal splenic artery. RESULTS: Seven patients were referred for splenic artery angiography. The average mean aortic pressure was found to be 89.0 ± 21.9 mm Hg. The average mean distal splenic arterial pressure with temporary proximal occlusion was 47.1 ± 25.8 mm Hg (range = 25-98 mm Hg). The average mean pressure drop was 41.9 ± 19.0 mm Hg or 48.0 ± 19.3%. The average systolic pressure drop was 75.4 ± 24.0 mm Hg (range = 40-113 mm Hg). However, one of our seven patients only had a 14.8% mean arterial pressure drop and maintained a 102 mm Hg systolic pressure in the distal splenic artery. CONCLUSIONS: The arterial pressure in the distal splenic artery after SAE is highly variable and may depend on the robustness of pre-SAE collaterals.