Bryan T. Fisher Sr., MD January 23, 2017

Chief of Vascular Surgery and Co-Director of Limb

Preservation, Centennial Medical Center

U/S Guided Interventions for Complex Lower Extremity

DiseaseA Vascular Surgeons Effort to Significantly Reduce Radiation

Exposure

Disclosures• Abbott Medical

• Faculty Speaker• Research Consultant

• Cardiovascular Systems Inc• Faculty Speaker• Education Consultant

• W. L. GORE• Registry Parcticipant• Faculty Speaker

• Cordis (Cardinal Health)• Educational Consultant• Faculty Speaker

Objectives• Understand the importance of radiation

exposure over the course of a successful career

• Illustrate the feasibility of performing complex tibial interventions with minimal contrast and radiation exposure with a two man team

• What we did at Centennial Medical Center

• Case Illustration

The Problem• In early 2000, an roughly 650,000percutaneous

transluminal coronary angioplasty (PTCA) procedures were performed on adults in the United States1

• Coronary artery stent insertion doubled from 157 to 318 per 100,000 adults, aged 45-64, from 1996 to 20001

The Risks• Increasing number of case reports of skin

changes • hands

• lens of the eye in operators and assistants

• Cancer• Uncommon

• Leukemia

• Breast Ca

The Jihad Effect• Story well known

• Visit to Leipzig, Germany

• The rest is history

The Rest Is History in the US

A Different Approach• Limited staffing

• Often issues with staff staying late• Priority given to other specialties

• Limited capital• Resources spread over multiple departments

• Limited Interest• Wouldn’t last long

• Unlimited radiation• Reached annual limit @ month 5!

This Got Their Attention

31.2

27.3

39.337.4

1412

3 0

4.5% 4.4%

0.8%

0.0% 0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

0

10

20

30

40

50

Q1 2013 Q2 2013 Q3 2013 Q4 2013

Arterial Wounds (x10)

# of Amputations

% of Amputations

Nu

mb

er

of

Am

pu

tatio

ns

Centennial Setup

“Body Flossing”

11

What Are We Doing?

12

Why Ultrasound?

Capable of So Much

Overview• Materials

• GE system Fixed Unit• GE U/S Station• Jake and me!• No crossing devices• No re-entry devices

• Methods• 10 consecutive cases series utilizing as much u/s as

possible to reduce radiation exposure• Complex cases only

• Multi-level (above and below knee)• More than 1 tibial• Pedal arch intervention

• U/S limited below the ankle

Results

Radiation Exposure (milligray)Case Length (min)

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Case

1Case

2Case

3Case

4Case

5Case

6Case

7Case

8Case

9Case

10

Radiation Exposure and Case Length

Radiation Exposure (milligray) Case Length (min)

Case• 64 year old diabetic with type II DM, hyperlipidemia and htn

presents with “neuropathy” of the foot and a small medial arch wound

• Multiple specialists• “small vessel disease”• ”nothing can be done”

• Exam• Palpable DP and PT

• Noninvasive studies• ABI normal• Great TBI .4

17

Treatment and Final Result

Post Procedure• Some tingling in toes, but greatly improved

• TBI .75

• Wound healed at 4 weeks

20

Conclusion• Radiation exposure is bad but necessary

• U/S guided interventions are feasible without many resources

• If you don’t have one, find your Jake!

21

Thank You• Partners

• Billy Kim

• Allen Lee

• Adam Richter

• Right Hand Man• Jacob Swenson• Best Radiology Tech in the Universe

• Jihad Mustapha MD/Christopher Lesar MD

22

Thank You(Cont)

23

Bibliography

References• Frenz MB, Mee AS. Diagnostic radiation exposure and cancer risk. Gut. 2005;54(6):889-890. doi:10.1136/gut.2005.066605.

• Centers for Disease Control/National Center for Health Statistics, Health Care in America: Trends in Utilization, U. S. Department of Health and Human Services, DHHS Pub No. 2004-1031, 2004.

• Shiralkar S, Rennie A, Snow M, et al. Doctors’ knowledge of radiation exposure: questionnaire study. BMJ 2003;327:371–2.

• Faulkner,K. and Vaño,E. Deterministic Effects in Interventional Radiology. Rad Prot Dosim 2001; 94:95-8. International Commission on Radiological Protection. Avoidance of radiation injuries from medical interventional procedures. ICRP Publication No. 85. Ann ICRP 2000;30:7-67.

• de Gonzalez A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004;363:345–51.

• Koenig TR, Wolff D, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures . Am J Roentgenol 2001; 177:3- 20.

• Mettler F, Koenig TR, Wagner LK, Kelsey CA. Radiation injuries after fluoroscopic procedures. Seminars Ultrasound, CT, MRI 2002; 23:428-42.

• Miller DL, Balter S, Noonan PT, Georgia JD. Minimizing radiation-induced skin injury in interventional radiology procedures. Radiology 2002; 225:329-36.

Bryan T. Fisher Sr., MD January 23, 2017

Chief of Vascular Surgery and Co-Director of Limb

Preservation, Centennial Medical Center

U/S Guided Interventions for Complex Lower Extremity

DiseaseA Vascular Surgeons Effort to Significantly Reduce Radiation

Exposure