CHAPTER 30

### KEY POINTS

• Interventional radiology (IR) provides a gamut of minimally invasive therapies well suited for the critical care patient population.

• The dictum of “smaller, faster, safer, better” is the ideal of minimally invasive image-guided therapy. In the appropriate patient, this type of therapy is invariably better tolerated than more invasive techniques.

• Three primary image modalities are used to guide IR procedures: fluoroscopy, computed tomography (CT), and ultrasound (US). Increasingly, hybrid suites are equipped with all three modalities

• Appropriate ICU-monitoring devices and support personnel must be available in the IR suite to best serve the critical care population.

Interventional radiology (IR) is a field of medicine devoted to using image-guided minimally invasive techniques to improve patient care. Rather than being unified by an organ system or disease, interventional radiologists are guided by the dictum of “smaller, faster, safer, better” therapy. As such, the interventional radiologist treats patients of all demographics. Commonly, IR procedures are performed instead of traditional open surgical procedures because minimally invasive procedures are often better tolerated with less morbidity and lower mortality. This is particularly important in critical care patients who often have significant comorbidities. The overwhelming majority of procedures offered in the IR suite are performed using conscious sedation, which also tends to limit risks associated with these therapies. As such, it is critical that patients be able to minimally cooperate with interventional radiologists. If patients are combative or unable to lie still, anesthesiologists may be required to assist.

### WHERE SHOULD THERAPY BE PERFORMED?

Provided appropriate personnel and monitoring devices are available, as a general rule, the safest and best place to perform an IR procedure is unquestionably in the IR suite. Some very straightforward procedures such as drainage of a large, superficial abscess can be done at bedside but there are significant disadvantages to initiating IR therapy in the ICU. First, the safety and effectiveness of nearly all IR procedures are predicated on high-quality imaging. In many procedures, more than one imaging modality is used in an IR suite to provide the largest margin of safety. For example, when cholecystostomy is performed in the IR suite, the gallbladder is punctured using ultrasound (US) guidance and the remainder of the procedure is completed using fluoroscopic guidance. While it is possible to perform the procedure using only US guidance at bedside, sonographic visualization of needles, wires, dilators, and tubes may be limited, particularly in large patients. Portable fluoroscopy units are typically inadequate because they are awkward, have a small field of view, and provide no meaningful radiation shielding. Second, and more importantly, an interventional radiologist has a limited ability to recognize and treat any complication that occurs during a bedside procedure. Complications that may prove lethal at bedside may be easily handled in an IR suite given the superior imaging and immediate access to specialized catheters and other equipment. One common dilemma involves the patient who needs an IR therapy but ...

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