Chapter 1: Understanding Interventional Radiology

In simple terms, I want to share a medical narrative that captures the essence of my work as an Interventional Radiologist, which can be likened to a minimally invasive surgeon. Utilizing advanced technologies—such as wires, balloons, and tubes known as catheters and stents—I conduct procedures within patients' bodies, guided by medical imaging.

One common task for interventionalists like myself involves maintaining high-flow blood pathways in patients suffering from kidney failure who undergo hemodialysis—a treatment that acts as an artificial kidney to filter their blood. To facilitate this, surgeons often implant grafts, which are synthetic U-shaped tubes, beneath the skin of the forearm. These grafts connect the elbow artery to the elbow vein, allowing for rapid blood flow, which dialysis technicians can easily access using large needles. This setup enables the blood to be filtered and returned to the body promptly.

My role revolves around maintaining these grafts. I compare it to performing regular oil changes for a car, which typically occur every 3 months or 3,000 miles. Patients visit my operating room for graft maintenance every 3 to 6 months, where I employ balloon dilation or sometimes place stents to ensure everything operates smoothly, allowing them to attend dialysis sessions multiple times a week. If we fail to address any narrowing (or stenosis) with these interventions, the graft can become occluded, leading to more complex procedures that may not always succeed.

Early in my career, about a year out of training, a patient came in for his routine graft maintenance. As usual, I donned my lead apron and sterile gown. The patient was positioned on the movable table with his arm extended. After the standard sterile preparation and administering lidocaine anesthesia, I accessed the graft using a needle, followed by an injection catheter, to conduct a typical angiogram under live x-ray imaging. This imaging revealed a narrowing at the venous end of the graft, known as venous anastomosis, a common complication for such grafts over time.

I proceeded to dilate the narrowing with a balloon, but while the angiogram showed some improvement, it was clear that further intervention was needed. On this occasion, I decided to use a newly available covered stent to keep the graft open and reduce the risk of clotting over the next three months. With the assistance of a clinical sales representative, we selected a 5 mm diameter covered stent.

As luck would have it, we were both relatively inexperienced with this new stent. After preparing it for deployment, I successfully positioned it under live x-ray. Initially, everything appeared perfect; the angiogram indicated that the narrowing had resolved, and blood flow was excellent.

But then, as I bent the patient's elbow to check the stent's position, I realized it was missing!

The One That Almost Got Away - YouTube This gripping narrative showcases a close call in the operating room, highlighting the importance of precision in medical procedures.

As I quickly discovered, the graft was now carrying arterialized blood at high pressure, which had dislodged the stent and sent it floating into the bloodstream. Within moments, the nurse monitoring the patient shouted that he was experiencing dangerous heart rhythms, prompting a frantic call for the crash cart.

The situation escalated rapidly as the team prepared for potential chest compressions and defibrillation. The patient, feeling faint and in pain, became a ticking clock, and my heart raced with the weight of responsibility.

Suddenly, in a miraculous turn, the patient’s heart rhythm normalized, which gave us a momentary reprieve. But my concern shifted to the stent, which I could now see on the live x-ray, lodged above his heart in the left pulmonary artery—the main vessel supplying blood to his left lung.

Recognizing the urgency, I instructed my interventional x-ray technologist to prepare for a snare procedure. I utilized a retractable wire loop, akin to a cowboy's lasso, to retrieve the stent before it could cause further harm.

The One That ALMOST Got Away - YouTube An exploration of the critical moments in an interventional procedure that could have led to disaster.

With swift action, I accessed a vein in the groin, allowing me to maneuver the snare toward the stent. Thankfully, I was able to successfully capture it and bring it back through the pulmonary artery, heart, and down to the groin.

However, I soon realized that I had not made the initial incision large enough to extract the stent. In a moment of panic, I gripped my tools and pulled, which caused some discomfort to the patient but ultimately freed the stent without serious harm.

Tragedy averted! After applying the necessary dressings, I decided to let the patient go home, believing he had good odds of recovery. He returned three months later, and I successfully placed a correctly sized stent this time.

This incident has served as a lasting lesson throughout my career: always ensure proper sizing of medical devices, regardless of external advice. Since then, I have been fortunate to avoid similar close calls, for the sake of both my patients and myself.