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Interventional Radiology in Palliative Care

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Essentials of Palliative Care

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Abstract

Interventional radiological procedures have expanded greatly over the past decade. This chapter aims to explore the utilisation of this exciting subspecialty in relation to the care of the terminally ill or dying patient. Whilst this particular group of patients may not be fit for major surgery, the interventional radiologist may offer a shorter alternative, aiming to provide greater comfort to the patient. It is not the purpose of this chapter to train the reader in performing these complex and difficult procedures, but rather provide an overview of what may be available when caring for the patient with palliative needs.

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Author information

Authors and Affiliations

  1. Leeds and Bradford Radiology Training Scheme, Leeds General Infirmary, Leeds, UK

    Oliver Hulson M.B.Ch.B. (Hons.) & Neal Larkman M.B.B.S., M.P.H.

  2. Department of Anaesthetics, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Surrey, UK

    Sreekumar Kunnumpurath M.B.B.S., M.D., F.F.P.M.R.C.A., F.R.C.A., F.C.A.R.C.S.I.

Authors
  1. Oliver Hulson M.B.Ch.B. (Hons.)
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  2. Neal Larkman M.B.B.S., M.P.H.
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  3. Sreekumar Kunnumpurath M.B.B.S., M.D., F.F.P.M.R.C.A., F.R.C.A., F.C.A.R.C.S.I.
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Corresponding author

Correspondence to Oliver Hulson M.B.Ch.B. (Hons.) .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Yale University, New Haven, 06520, Connecticut, USA

    Nalini Vadivelu

  2. Citrus Road 278, River Ridge, 70123, Louisiana, USA

    Alan David Kaye

  3. Keck School of Medicine, Department of Anesthesiology, Pain Medic, of the University of Southern California, Los Angeles, 90035, California, USA

    Jack M. Berger

Appendices

Review Questions

  1. 1.

    Absolute contraindications to interventional procedures include:

    1. (a)

      Pregnancy

    2. (b)

      Renal impairment

    3. (c)

      Coagulopathy

    4. (d)

      Significant haemodynamic instability

  2. 2.

    Regarding percutaneous interventional procedures:

    1. (a)

      The Seldinger technique is rarely utilised

    2. (b)

      Complications include retroperitoneal haematoma, pseudoaneurysm formation and vessel thrombosis

    3. (c)

      Angioplasty is the process of inserting a stent into a vessel to maintain luminal diameter

    4. (d)

      The usual order to gain vascular access is vessel puncture, catheter insertion, guide wire insertion

  3. 3.

    Regarding specific interventional procedures:

    1. (a)

      Chemoembolisation and radioembolisation are new procedures that can only be utilised in the treatment of unresectable liver metastases

    2. (b)

      Cerebral angiography is a relatively risk-free procedure that is available in most district general hospitals

    3. (c)

      Computed tomography (CT) and magnetic resonance (MR) angiography are useful alternatives to conventional cerebral angiography

    4. (d)

      Triple-A therapy is often implemented in the management of patients who have suffered a subarachnoid haemorrhage (SAH)

  4. 4.

    Regarding specific procedures:

    1. (a)

      In ischaemic stroke, the benefits of tissue plasminogen activator (tPA) outweigh the risks for up to 4½  h following symptom onset

    2. (b)

      If ischaemic stroke is suspected out-of-hours, tPA should be commenced as soon as possible, and imaging undertaken the following working day

    3. (c)

      In stage III ischaemia, intra-arterial thrombolysis, amputation of the affected limb may be prevented if intra-arterial thrombolysis (IAT) is commenced promptly

    4. (d)

      It is desirable that peripherally inserted central catheters (PICC) lines are inserted on the ward by appropriately trained staff, to avoid any patient disruption

  5. 5.

    Regarding specific interventional procedures:

    1. (a)

      Potential complications in vertebroplasty and kyphoplasty include infection, neurological sequelae and worsening of pain and/or symptoms

    2. (b)

      Percutaneous cholecystostomy is indicated as the first-line treatment in the management of the empyema of the gallbladder

    3. (c)

      Radiological inserted gastrostomy is advantageous in comparison to surgical and endoscopic methods as a larger tube can be inserted

    4. (d)

      TIPS procedure in the treatment of portal hypertension involves diverting the portal venous blood to the adjacent hepatic artery

Answers

  1. 1.

    (d) is true. Whilst pregnancy, renal impairment and coagulopathy may all discourage the radiologist from undertaking the procedure, if it is felt that the potential benefits outweigh the risks, it may be undertaken. In reality, the only truly “absolute” contraindication is haemodynamic instability such that the procedure cannot be undertaken without further patient compromise. A full and frank discussion should take place between the clinical team, the consultant radiologist and the patient and his or her family.

  2. 2.

    (b) is true. The usual order of vascular access is vessel puncture, guide wire insertion, catheter insertion. Angioplasty is the process of “ballooning” a vessel lumen open, which may then proceed to stent insertion to maintain luminal diameter. The Seldinger technique is standard procedure.

  3. 3.

    (c) is true. Chemoembolisation and radioembolisation are a possible treatment option in the management of hepatocellular carcinoma (HCC). Cerebral angiography is a procedure with significant risk attached, including stroke and death, and is provided only in specialist centres. Triple-H therapy (hypervolaemia, hypertension, and haemodilution) is implemented in the management of patients with SAH.

  4. 4.

    (a) is true. Out-of-hours imaging is now available in the vast majority of hospitals, and if stroke is suspected, CT imaging should be organised as soon as possible. Stage III ischaemia, is by definition, irreversible, and amputation is inevitable. PICC lines or tunnelled central venous catheters (CVCs) can be inserted on the ward by trained staff, but insertion in a dedicated theatre or imaging suite is advantageous as sterility can be ensured, and image-guidance available.

  5. 5.

    (a) is true. Percutaneous cholecystostomy is indicated when antibiotic treatment has failed in the management of empyema of the gallbladder. Radiological inserted gastrostomy is advantageous as it may be done under light sedation, but the disadvantage is that a smaller tube is employed. Transjugular intrahepatic portosystemic shunt (TIPS) procedure involves diverting the portal venous blood to the adjacent hepatic venous system, to treat associated portal hypertension.

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Hulson, O., Larkman, N., Kunnumpurath, S. (2013). Interventional Radiology in Palliative Care. In: Vadivelu, N., Kaye, A., Berger, J. (eds) Essentials of Palliative Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5164-8_15

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  • DOI: https://doi.org/10.1007/978-1-4614-5164-8_15

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