Many of you have probably read the WSJ article. If not, here's the link:
http://online.wsj.com/article/SB10001424052748704655004575114623837930294.html?mod=WSJASIA_hpp_MIDDLEThirdNews#articleTabs%3Darticle
As always there is more to the story than can be captured in an article. I thought I'd provide some of that background. I will try to explain things as much as possible in laymen's terms.
From a professional perspective it was a great day. There was a patient who had been shot in the legs and I came from one OR where I stopped some arterial bleeding in his leg to the other OR where the patient mentioned in the story was on the table. From a surgical perspective, operations in the junctional areas (e.g, the base of the neck, the groin) can be challenging because to operate on a blood vessel you need to gain proximal control of the vessel...which in the neck area can mean removing the clavicle and sometimes cracking the chest. So, if we were able to treat this via an endovascular approach (meaning through the blood vessel directly with catheters) then we could spare this patient a rather involved surgery in an area with an artery that we know is damaged, which increases the risk.
So, I insert a catheter into the right common femoral artery (right groin) and manipulate it up through the aorta into the right vertebral artery, at the base of his neck. I inject contrast (also called dye) which is visible on fluoroscopy - realtime xray. We then are able to see the arterial injury which is called a pseudoaneurysm, meaning injury to the arterial wall which is bulging outwards. Unfortunately what we also see is some blood clot in the artery past the pseudoaneurysm, meaning, closer to the brain. This, as you may imagine, is problematic because any manipulations we do, either surgical or endovascular, carry the risk of dislodging the clot and sending it to the brain.
At this point, we actually took a brief break for all parties involved (me, the general surgeon, and the trauma surgeon) to call a colleague. We all had our own professional opinion of how to handle the case, but I'll admit, based on the blood clot that we saw, we wanted to make sure we were doing the right thing. So, after phone consultation, we all came to the same decision that the best option was to place small metal coils in the artery to stop the flow in it. I considered placing a stent across the injured area, but in my mind that had a higher risk of dislodging the clot since I would have to get a larger sheath (tube) into his neck through which to deploy the stent.
I walked back into the OR, saying a brief prayer, something to the effect of "Oh, God, please help me not to kill this guy." So, I advance the wire through the catheter just a bit more so I can advance the catheter just a bit more into the damaged artery. I need to get the catheter just a bit more into the vertebral artery so I can safely deploy the coils. The goal of coil embolization is to stop the blood flow in the place you want to by safe and proper placement of the coils in the exact spot...meaning, you really don't want to have a coil accidentally end up in the wrong spot, thereby stopping blood flow in a different place, because you didn't have the catheter placed exactly in the right spot. That is considered bad form. When I did that, I just had the sense that the wire and catheter didn't move exactly where or how I thought they should. You have to remember, I'm looking at a 2-D image of a 3-D structure and a lot of what we do is mental extrapolation from the 2-D image to a 3-D image in our head as we try to move wires and catheters through arteries. So, I removed the wire and injected a little bit of contrast to opacify the artery, and sure enough, the pseudoaneurysm had burst. I will say that at this time several things happened in the OR: 1) Everyone's heart rate shot up!
2) The surgeons prepped for possible emergent surgery 3) The trauma surgeon uttered what is now a rather famous line at our hospital: "Coil the motherf@#k#r!!!!" 4) So, I did...in rather expeditious fashion. The bleeding stopped. The vessel thrombosed. The patient was medevac'd out the next day.
And now you know the rest of the story.
Good day.
As always there is more to the story than can be captured in an article. I thought I'd provide some of that background. I will try to explain things as much as possible in laymen's terms.
From a professional perspective it was a great day. There was a patient who had been shot in the legs and I came from one OR where I stopped some arterial bleeding in his leg to the other OR where the patient mentioned in the story was on the table. From a surgical perspective, operations in the junctional areas (e.g, the base of the neck, the groin) can be challenging because to operate on a blood vessel you need to gain proximal control of the vessel...which in the neck area can mean removing the clavicle and sometimes cracking the chest. So, if we were able to treat this via an endovascular approach (meaning through the blood vessel directly with catheters) then we could spare this patient a rather involved surgery in an area with an artery that we know is damaged, which increases the risk.
So, I insert a catheter into the right common femoral artery (right groin) and manipulate it up through the aorta into the right vertebral artery, at the base of his neck. I inject contrast (also called dye) which is visible on fluoroscopy - realtime xray. We then are able to see the arterial injury which is called a pseudoaneurysm, meaning injury to the arterial wall which is bulging outwards. Unfortunately what we also see is some blood clot in the artery past the pseudoaneurysm, meaning, closer to the brain. This, as you may imagine, is problematic because any manipulations we do, either surgical or endovascular, carry the risk of dislodging the clot and sending it to the brain.
At this point, we actually took a brief break for all parties involved (me, the general surgeon, and the trauma surgeon) to call a colleague. We all had our own professional opinion of how to handle the case, but I'll admit, based on the blood clot that we saw, we wanted to make sure we were doing the right thing. So, after phone consultation, we all came to the same decision that the best option was to place small metal coils in the artery to stop the flow in it. I considered placing a stent across the injured area, but in my mind that had a higher risk of dislodging the clot since I would have to get a larger sheath (tube) into his neck through which to deploy the stent.
I walked back into the OR, saying a brief prayer, something to the effect of "Oh, God, please help me not to kill this guy." So, I advance the wire through the catheter just a bit more so I can advance the catheter just a bit more into the damaged artery. I need to get the catheter just a bit more into the vertebral artery so I can safely deploy the coils. The goal of coil embolization is to stop the blood flow in the place you want to by safe and proper placement of the coils in the exact spot...meaning, you really don't want to have a coil accidentally end up in the wrong spot, thereby stopping blood flow in a different place, because you didn't have the catheter placed exactly in the right spot. That is considered bad form. When I did that, I just had the sense that the wire and catheter didn't move exactly where or how I thought they should. You have to remember, I'm looking at a 2-D image of a 3-D structure and a lot of what we do is mental extrapolation from the 2-D image to a 3-D image in our head as we try to move wires and catheters through arteries. So, I removed the wire and injected a little bit of contrast to opacify the artery, and sure enough, the pseudoaneurysm had burst. I will say that at this time several things happened in the OR: 1) Everyone's heart rate shot up!
2) The surgeons prepped for possible emergent surgery 3) The trauma surgeon uttered what is now a rather famous line at our hospital: "Coil the motherf@#k#r!!!!" 4) So, I did...in rather expeditious fashion. The bleeding stopped. The vessel thrombosed. The patient was medevac'd out the next day.
And now you know the rest of the story.
Good day.
I'm in awe.
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