Vascular and Interventional Radiology

Requirement

Please email Dr. Michael Cline (micline@med.umich.edu) three days prior to the start of your rotation. On the first day of the rotation, following orientation, you must contact Dr. Cline via pager #19115.

Introduction

This elective is designed to introduce students to Vascular & Interventional Radiology (IR) in the Department of Radiology. Interventional Radiology uses minimally-invasive, image-guided techniques to diagnose and treat a variety of disorders. Because of the highly clinical and (minimally-) invasive nature of IR, the IR residents and fellows require special training and skills to take care of patients. While on rotation, students will learn the Seldinger technique (the fundamental skill for gaining access into the body for angiography or interventions, both within and outside the vascular system) in the Clinical Simulation Center, ultrasound-guided vascular access, various interventional radiologic techniques, as well as indications and contraindications for procedures, and clinical care of patients. You will have the opportunity to participate in various procedures performed by fellows, residents and faculty. You will also participate in the clinical management, including the pre-procedure evaluation, interpretation of preliminary diagnostic films, and consultation with referring physicians. You will have additional exposure to more complex diagnostic and therapeutic interventional procedures, and administration of short and long-term follow-up care.

Daily Clinical Activity

Daily clinical activity in Vascular & Interventional Radiology is carried out at the University Hospital Interventional Radiology (B1 level) and Cardiovascular Center (4th level). Your elective rotation will alternate between these two procedure areas, based on the cases scheduled. If there are a large number of students on the rotation, students may be assigned to Consults under the supervision of a resident or fellow, or to Mott Hospital IR suite (4th level). Daily activity begins promptly at 6:30 a.m. with case conferences (Monday, Tuesday, Wednesday) or didactics (Thursday, Friday). The end of the day can be somewhat unpredictable, but is often at approximately 6:00 p.m. There may be additional lectures throughout the week to which all students are invited.

All students are expected to participate in the evaluation and consultation of patients referred for interventional procedures. This includes initially obtaining an appropriate, focused history and physical, reviewing the consult with a staff member, consenting patients for procedures, and following patients after their procedures. Students are allowed to participate in all types of procedures during his or her elective rotation.

Vascular/Interventional Radiology at University Hospital (B1 level)

In this area, most interventional oncologic interventions, nonvascular interventional procedures, and central venous access procedures are performed in five IR rooms (equipped with modern DSA capabilities). Room 5 is also equipped with modern 64-slice CT capabilities, which is extremely useful in percutaneous interventions, complex endovascular procedures including vascular recanalization, hepatic oncologic interventions and endocrine venous sampling. Interventional oncology procedures performed include transarterial chemoembolization (TACE) and Y90 radioembolization for the treatment of hepatocellular carcinoma and some ablations including lung and bone tumors. Nonvascular interventional procedures include genitourinary interventions (percutaneous nephrostomy, percutaneous nephrolithotomy, percutaneous ureteral dilatation), biliary interventions (percutaneous transhepatic biliary drainage, percutaneous choledochoscopy, percutaneous biliary dilation and stent placement, and percutaneous stone extraction) and gastrointestinal interventions (gastrostomy, gastrojejunostomy, gastrointestinal dilatation and stenting, percutaneous jejunostomy, and cecostomy). Two or three physician assistants perform most central venous catheter placement procedures including PICCs, Hickman, Neostar, and arm and chest ports. Students will have the opportunity to participate in central venous access procedures as well.

Vascular/Interventional Radiology at CVC (4th level)

In this area, most vascular procedures are performed by residents, fellows and faculty. There are two procedure rooms (IR Rooms 7 and 9) equipped with the state-of-the-art angiography equipment – the Siemens AXIOM Artis system. Students should participate in the writing of post procedure notes on MiChart under the supervision of the residents, fellows or faculty. Student should attend the reviewing session of the images and procedures following completion of the operation with the resident/fellow and attending.

Diagnostic vascular procedures performed in this area include: thoracic and abdominal aortography, peripheral arteriography, selective visceral arteriography, selective renal arteriography, pulmonary angiography, venography, inferior and superior venacavography, CO2 angiography, transhepatic portography, panhepatic angiography, and dialysis fistulography, among others.

Therapeutic vascular procedures performed in this area include: thrombolytic therapy, transcatheter embolotherapy, mechanical thrombectomy, angioplasty, stenting, vena cava filter placement, foreign body retrieval, transjugular liver biopsy, transjugular intrahepatic portosystemic shunt (TIPS), endovascular stent grafting, and fenestration therapy for aortic dissections, among others.

OTHER EXPERIENCE:

Students will learn about the history of angiography, evolution of interventional radiology, x-ray generators, radiation safety, use of needles, catheters, guide wires, and a variety of devices, physiologic monitoring, conscious sedation, antibiotics, analgesic, narcotics, and other drugs used in IR.

After the conclusion of elective rotation, students will be able to demonstrate and perform the Seldinger technique, determine indications and contraindications of various IR procedures, and be able to identify vascular anatomy on angiography and non-vascular anatomy on cross-sectional imaging.

On-Call Requirement

There are no required call responsibilities on this rotation. However, for those students that are interested in participating in call to get first-hand experience of the overnight tasks and responsibilities of an on-call interventional radiologist, the student should discuss this with Dr. Cline at the beginning of the rotation. There are many opportunities to stay late without taking call, so do not feel obligated.

VIR Outpatient Clinic

The IR Service has a busy outpatient clinic schedule. In outpatient clinic, interventional radiologists see new patient consultations as well as follow-up appointments related to previous inpatient and outpatient encounters/procedures. In addition to the IR clinic, several faculty also participate in the multidisciplinary PAD and Venous Health Program clinics, depending on the day. Our team of nurse practitioners and fellows schedule patients for clinic visits and help the clinic run smoothly. Students are encouraged to participate in a clinic day while on the rotation, which can be scheduled at the start of the rotation.

VIR Conferences

Educational conferences begin promptly at 6:30 each day. On Monday, Tuesday and Wednesday, conferences will take place in UH B1 IR reading room, and will consist of 30 minutes of case conference followed by 30 minutes to “run the board” (i.e., go over the cases planned for the day). Thursdays and Fridays, the conferences are shifted to the CVC library, room 5367. On Thursday, the 6:30 conference is often a 30-minute presentation by an equipment vendor, followed by one hour of didactic instruction and 30 minutes to run the board. On Friday, an hour-long didactic is followed by running of the board.

There will be a monthly IR QA Conference (M & M) at which all complication cases from the preceding months are discussed. This usually takes place on a Thursday in Danto Auditorium on the 2nd floor of the CVC.

A ten minute clinical presentation is required at the end of the rotation on a topic of IR that interests you. By the end of the second week, you should discuss your planned topic with Dr. Cline (micline@med.umich.edu). He will be available to help you prepare the case presentation or find a faculty mentor. Presentations will be given in the last two or three days of the rotation.

Recommended Textbooks

  1. Handbook of Interventional Radiologic Procedures, John E. Aruny, Krishna Kandarpa, Lippincott Williams & Wilkins
  2. Abrams’ Angiography Interventional Radiology, Stanley Baum & Michael J. Pentecost, Lippincott Williams, Wilkins
  3. Vascular and Interventional Radiology: The Requisites, John Kaufman and Michael J. Lee, Mosby
  4. Teaching Atlas of Interventional Radiology: Diagnostic and Therapeutic Angiography, Saadoon Kadir, http://www.amazon.com/gp/reader/0865777772/ref=sib_dp_pt - reader-linkThieme
  5. Vascular and Interventional Radiology, Karim Valji, Saunders
  6. Atlas of Vascular Anatomy: An Angiographic Approach, Renan Uflacker, Lippincott Williams & Wilkins
  7. Carbon Dioxide Angiography: Principles, Techniques, and Practices, Kyung J. Cho and Irvin F. Hawkins, Informa healthcare
  8. Gastrointestinal Angiography, Reuter SR, Redman HC, Cho KJ, W.B.Saunders Company
  9. Interventional Radiology: A Survival Guide, David Kessel, Elsevier Science Health Science
  10. Interventional Radiology Essentials, LeBerge Jeanne, Lippincott Williams & Wilkins