Question 26

College Answer

Therapeutic or diagnostic

Therapeutic:

CT or US guided drainage of abscess or fluid collections

Coiling of aneurysm

Embolisation of bleeding vessel Regional thrombolysis or clot removal TIPS procedure

Angioplasty for vasospasm Coronary intervention 
IVC filter insertion

Angioseal of cannulated vessel eg inadvertent arterial insertion of vascath Vascular access eg Hickman

Insertion PEG, nasojejunal tubes

Diagnostic:

Angiography to diagnose vasculitis, cerebral thrombosis, region of haemorrhage (especially intestinal), brain death

Efficacy

May be as effective as surgery (good evidence in aneurysmal SAH) with lower morbidity and mortality

Offers treatment option for patients unsuitable for surgery due to age or co-morbidities Good option in critically ill where surgical risks high eg laparotomy to drain abscess Preferred strategy in management pelvic trauma 
May avoid hysterectomy in post-partum haemorrhage

Limitations

Specific expertise needed but increasingly widespread

Needs to be performed in radiology suite with the risks and difficulties of managing a critically ill patient in a ‘hostile’ environment

Surgical back-up needed if intervention fails Risk of contrast use (allergy, CIN) Complications specific for each procedure

Discussion

These "discuss the role" questions are difficult to answer in a systematic fashion. The college suggests we "explain the underlying key principles".

The provided answer divides the issue into therapeutic and diagnostic roles, and then discusses the limitations of interventional radiology as a whole. This sort of structure lends itself well to a tabulated format.

The Role of Interventional Radiology in Critical Care

Application	Role	Advantages and Limitations
Generally		Exposure to IV contrast Risks of vascular access Risks of transport ("hostile" environment of the interventional radiology suite) Demand for skilled operators
Diagnostic	Diagnosis of cerebral vasculitis	Not as good as MRI
	Localisation of intestinal haemorrhage	Opportinuty to embolise within the same procedure
	Gold standard for confirmation of brain death	Preferred strategy More invasive than Tc99 HMPAO
Therapeutic	Radiologically guided drainage	Less invasive than surgical approach
	Coiling of aneurysms	Equivalent to surgery in efficacy
	Vasospasm vasodilation	Preferred strategy
	TIPS procedures	Safer than surgical shunt
	Embolisation of bleeding vessels	Available when surgical control fails
	Coronary intervention	Preferred strategy
	IVC filter insertion	Preferred strategy
	Vascular access	Available when all other approaches fail

Harris, K. G., et al. "Diagnosing intracranial vasculitis: the roles of MR and angiography." American journal of neuroradiology 15.2 (1994): 317-330.

Hunnam, G. R., and C. D. R. Flower. "Radiologically-guided percutaneous catheter drainage of empyemas." Clinical radiology 39.2 (1988): 121-126.

Nicolaou, Savvas, et al. "Ultrasound-guided interventional radiology in critical care." Critical care medicine 35.5 (2007): S186-S197.