0:01

So you're on your way to meet the patient.

0:03

So what should you consider pre-procedure?

0:06

You want to understand the patient's history, right?

0:08

You want to understand sort of a lay of the land so

0:10

that you can meet this patient where he or she is.

0:12

You're going to provide a focused

0:14

physical examination, okay?

0:16

Perhaps you're looking at the skin of this

0:18

patient, um, in a patient that has high blood

0:21

pressure and hyperlipidemia to see if there's

0:22

any evidence of sort of tough, rough skin in the

0:26

lower extremities, shiny skin, gnarled toenails.

0:30

Maybe the patient has other findings that

0:32

would sort of kind of clue you into other

0:34

things that are happening with them, okay?

0:36

Looking at their pulse examination as well

0:38

would be sort of an important thing as you

0:40

determine your access of where you're going to

0:42

identify your access point, right?

0:45

Common femoral artery sort of kind

0:46

of being the most common site here.

0:49

Imaging review, you want to make

0:50

sure that you don't miss anything.

0:51

You would look at all the sort of reference imaging,

0:54

the cross-sectional imaging that is going to give you

0:56

an important sort of understanding of your access,

0:59

as well as the targeted focus for your intervention.

1:04

Of course, labs are very important.

1:06

We talk about sort of coagulation parameters.

1:09

We're talking about creatinine.

1:10

If you're going to have contrast, maybe you want to

1:12

see if the creatinine is within the limits of normal.

1:15

Of course, there's the BUN that in a patient that

1:17

may have ESRD or sort of renal insufficiency,

1:21

the BUN may be elevated in that sort of setting.

1:23

Maybe there's uremic-related platelet

1:25

dysfunction that may actually raise the

1:28

bleeding risks associated with our procedure.

1:31

So, informed consent is something that

1:33

is often not talked about, but it's

1:35

something that's extremely important.

1:37

You know, what I often sort of get uncomfortable

1:39

about is when my trainees say, yeah, I'm

1:40

gonna get informed consent from the patient.

1:42

Well, I don't know if that's really what we're doing.

1:45

You know, informed consent is something

1:46

that is really a shared understanding.

1:48

It's a discussion to ensure that the patient

1:51

understands and relays their understanding to

1:55

you of what it relates to the perceived risk of

1:58

the procedure, the alternatives to the procedure,

2:01

and the anticipated clinical benefits.

2:05

So, whenever we're sort of doing something of any great

2:08

importance, the question is, do we have a checklist?

2:11

You jump on a flight, I would hope to

2:14

think that that pilot has a checklist.

2:17

Both pilots have a checklist as they proceed.

2:21

So too us, as clinicians, as interventionists, there

2:24

should be a very clear checklist that we're ensuring

2:27

that we key into as we prepare this patient.

2:32

So, to hit patient history.

2:34

So, the patient history is something that allows us

2:36

to understand the patient's presenting complaints,

2:38

the past medical history, the surgical history,

2:41

their allergies, their medications, all this little

2:43

sort of clinical milieu that then allows us to

2:46

understand the symptomatology, and the onset, the timing.

2:49

And of course, for us, has the patient

2:52

received an assessment previously?

2:54

And then the ultimate question here

2:55

is, is this procedure indicated?

2:57

So that's the question that needs to be answered

2:59

after we perform the clinical assessment.

3:02

Now, then we proceed to the physical examination.

3:05

So, you know, one of the most important

3:07

things is, you know, direct relative, is we're

3:11

trying to get access, we need a patent vessel.

3:13

How do we determine a patent vessel?

3:16

Well, one of the things is checking pulse examination.

3:19

Okay, checking pulse examination at

3:20

the site as well as distal to the site.

3:22

So, if we're getting common femoral artery access,

3:24

well, maybe you want to check also popliteal.

3:27

Maybe you also want to check the DP and the PT,

3:30

the posterior tibial artery and the dorsalis pedis artery.

3:32

Okay.

3:33

And then, you know, you may actually do a little

3:35

Doppler, you know, just to sort of make sure that,

3:37

you know, you, you know, you, maybe the fingers

3:39

are, are not feeling, uh, so sensitive today.

3:41

All right?

3:41

So you can mark those pulses now so that

3:43

the individual that comes after you

3:45

in prepping the patient is very clear and

3:48

doesn't have to sort of reproduce that work.

3:49

Or they can go straight to the access and they

3:51

can monitor that and corroborate that finding.

3:55

So again, here the question that needs to be

3:57

answered is, does the PE (physical exam)

3:59

is it contraindicate or confound the proposed intervention?

4:02

102 00:04:02,830 --> 00:04:04,120 Alright, so imaging review.

4:04

If you try to get access and you're like, "Oh,

4:06

Doc, I'm a left-handed interventionist,

4:08

and so I like to be on the patient's left side."

4:10

Then I would say, "Okay, well, did you look at this

4:12

image on your patient and see that this large,

4:15

bulky calcification was precluding your access,

4:18

whereas on the right side it's fairly open?

4:20

Maybe this is a good patient to go on the right

4:23

side if your routine access is on the left."

4:26

So you want to be looking for vascular anatomy.

4:29

You want to look at, sort of, modified anatomical

4:31

considerations like the one we just noted.

4:33

You want to look, sort of, at any variants

4:35

that may complicate or contradict the

4:38

procedure that you're about to perform.

4:40

Alright, so at the end of the day, reviewing

4:42

this prior imaging is particularly clutch.

4:45

You want to look at your MRI, your CT scan, your

4:48

ultrasound, any radionuclide scans that are going

4:50

to inform, support, or corroborate, or confound

4:56

your clinical assessment to the lab review.

5:01

So one of the things that I think is extremely

5:03

important is ensuring that you have the appropriate

5:06

pre-procedure labs that may impact your intervention.

5:10

And so, of course, we've touched on

5:11

creatinine as it relates to contrast.

5:13

We've touched on INR, and PTT, and platelet

5:16

counts as it relates to, sort of, bleeding risks.

5:18

There are other things, okay?

5:20

And these things, sort of, allow us to guide

5:22

decisions to use contrast and anesthesia choice

5:25

in the case of potassium, if potassium

5:26

is elevated. In many institutions,

5:28

that may preclude conscious sedation.

5:30

You may have to opt to perform a procedure that

5:33

is supported by local anesthesia, lidocaine only.

5:37

So at the end of the day,

5:37

screening labs are recommended.

5:40

And oftentimes in elderly patients or those

5:42

with predisposing risk factors, you know,

5:45

the main focus is on, sort of, renal function

5:48

and coagulation status if we had to focus in.

5:51

You know, there are Society of Interventional

5:53

Radiology guidelines, and you want

5:54

to be mindful of these guidelines.

5:56

And these guidelines allow you to see, "Okay, you

5:58

know what, I'm performing an arterial access.

6:00

Alright, so I want to make

6:01

sure that my INR is less than 1.5.

6:03

Okay, I'm performing an arterial access,

6:05

I want to make sure that my platelet count is

6:08

greater than 50,000 or greater than 75,000."

6:11

So you want to be very mindful of what you're

6:13

doing and what, sort of, the standards of

6:15

practice or the recommendations as it

6:18

relates to coagulopathy and other lab values.

6:21

So what I mentioned to you

6:22

before was that informed consent

6:24

is an outline in a language and manner that

6:27

the patient can understand of the proposed

6:30

procedure, the associated risks, the anticipated

6:34

benefits, the known alternatives, and any

6:38

particular uncertainties or possible adjunctive

6:41

therapies you may anticipate being performed.

6:45

There may, sort of, be an understanding

6:46

of any contingencies that if something would occur

6:49

during the procedure,

6:51

you would employ.

6:52

So, in the end of the day, you're not getting

6:55

informed consent, like you're getting a gift

6:56

for Christmas, and once you open it, it's yours.

6:59

It's the kind of thing that, if the patient

7:01

says they want to not perform this procedure,

7:03

and they're about to get on the table,

7:06

just because you're holding a consent doesn't

7:07

mean that that procedure is going to happen.

7:10

The patient is ultimately in control, and we need

7:13

to respect, and most importantly, honor that.

7:16

So, on to the pre-procedural checklist.

7:19

So, the Cardiovascular Society in Europe

7:23

has really sort of been particularly, sort of,

7:25

on point as it relates to these checklists.

7:28

And here's a beautiful checklist that was

7:29

developed by CIRSE and actually validated.

7:32

And one of the things that we want to, sort of,

7:34

really be mindful of is, of course, MPO status.

7:37

Check, did the patient eat right before the procedure?

7:40

Well, if this is a necessary procedure,

7:42

then maybe you want to move with lidocaine only.

7:45

Or maybe the patient didn't eat, but,

7:46

you know, maybe they had some nice whole milk,

7:48

196 00:07:49,095 --> 00:07:51,465 you know, two hours before, well, maybe the

7:51

procedure shouldn't be performed right now.

7:53

Okay?

7:53

Does the patient have IV access?

7:56

Were there anticoagulation, you know, was that held?

7:59

Does the patient actually have

8:00

sort of known bleeding risks?

8:02

Are there other considerations that we want

8:04

to sort of really be mindful of as you prepare

8:06

this patient for the intended vascular access?