Специальность рентгенохирургия.

[Abugov]

Ань! По-моему, там есть выход из кардиологов. Посмотрите внимательнее.

[Aminazinka]

Пардон муа, но по-моему, выхода из кардиологов там нет никуда, как и раньше.

[Proxor]

Принятие этого приказа на мой взгляд, определенный шаг вперед, но
пародокс в том, что все мы читаем, принимаем во внимание гайдланы и опираемся на многоцентровые исследования сделанные в Европе и Штатах, на наших столах лежат многочисленные авторитетные техтбуки и мануалы. А почему нельзя использовать многолетний и успешный опыт подготовки и обучения специалистов по интервенционной кардиологии и радиологии например в США? У меня базовая специальность кардиология, учитывая необычные условия нашей действительности пришлось проходить первичку по рентгенологии и ccх, включая получение сертификатов, сейчас через 10 лет полсе аспирантуры, думаю пройти на всякий случай интернатуру по хирургии, благо есть связи и возможность, невозможно предугадать, что придумают наши маститые рентгеноэндоваскулярные диагности и лечебники в будующем!!!

[cerebellum]

Сообщение от FRSM

"....обучение интервентов происходит изначально на тренажерах? И, если да, это компьютерные симуляторы или настоящая cath lab с манекеном?"


Почти настоящая cath lab с манекеном.

Так и знал! Спасибо!

Сообщение от Abugov

Катетеризационная лаборатория с манекеном, также не вызвала бурю восторга. От реальности отличается значительно. При этом не моделируется клиническая ситуация.
Моим ребятам больше всего понравились просто прозрачные трубки, имитирующие коронарные артерии. Было очень интересно посмотреть, как различные виды бифуркационного стентирования выглядят снаружи.

Уважаемый Сергей Александрович, а много ли было среди "Ваших ребят" таких, чей опыт самостоятельных пластик первым оператором стремился к нулю?
Маститые специалисты поразительно единодушны в прохладных оценках
И все же, попробуйте встать на место начинающего рентгенохирурга, для которого даже последовательность действий не вполне очевидна.
Неужели бесполезно не в условиях боевых действий, а в спокойной обстановке смоделировать кончик проводника, почувствовать его в руках, смело покрутить цангой под контролем просвечивания (без страха угробить девайс за 400$ неловким движением); покрутить гайд, почувствовать что такое рельса, заинтубировав на проводнике "коронар" сантиметров на 8 (исключительно для ощущений), почувствовать как легко носитель клинится, и где баланс решительности и нежности, когда им надо отходить, понять что такое дополнительная поддержка баллоном при дистальной работе, научиться следить за катетером во время позиционирования etc... Особенно когда в пультовой сидит опытный наставник, комментирует действия и ошибки, когда отдельный этап манипуляции можно повторить еще раз, и еще раз, и еще раз, - пока не станет очевидно. ИМХО, это эффективнее, чем перехватывать на живом пациенте, когда неопытный врач начинает притормаживать
Мне кажется, мануальные навыки быстрее скорректируются, когда практическая теория вопроса станет вполне очевидна.

Прозрачные трубки для бифуркационной пластики очень наглядны и убедительны; правда для сопоставления ангиографической и реальной картины есть и другой фантом - аутопсия
А вот если бы манекен был доступен в России, и его можно было бы спокойно поубивать дней 5, а не 2-3 часа, когда в спину начинает дышать следующая группа курсантов - это было бы благо.

Когда я только начинал, взял домой пару юзаных катетеров, наделал дырок коробке из-под сока, и часами тренировал селективную катетеризацию, в т.ч. на скорость. Тот еще тренажер по мануальным навыкам Но определенную пользу, мне кажется, и это имело.

P.S.: по сабжу - также оскорблен приказом в лучших чувствах, т.к. исходно терапевт... (

[Abugov]

Большинство из "моих ребят" не имело опыта интервенций. Манекен очень красив, но далёк от реалий. Не могу сказать, что тренажёры бесполезны, но ожидания от их пользы несколько завышены (ИМХО). Главное, с моей точки зрения, они тренируют способность быстрой выработки правильного тактического решения.

[Pankov]

Сообщение от cerebellum

...почувствовать как легко носитель клинится, и где баланс решительности и нежности, когда им надо отходить, понять что такое дополнительная поддержка баллоном при дистальной работе...

как красиво и эротично...в меморис!

[Maltsev]

Сообщение от Pankov

как красиво и эротично...в меморис!

Да, Бунин с "Темными Аллеями" отдыхает .

--
С Уважением,
Мальцев А.А.

[Gilarov]

Сообщение от Aminazinka

Пардон муа, но по-моему, выхода из кардиологов там нет никуда, как и раньше.

А я-то, вдохновленный Сергеем Александровичем, размечтался... Приказ на официальном уровне зафиксировал тот факт, что у всех терапоидов руки растут из... скажем так, перевернутого сердца.

[cerebellum]

Коллеги, будет вам издеваться =) Да, наболело вот.. что ж с того


Михаил Юрьевич, зато мы можем стать водолазами... С руками не свезло, зато жабры всем на зависть!

[FRSM]

Сейчас начали пробовать:

Simulation of Medical Procedures using Virtual Environments

Training in Interventional Radiology and Surgery has traditionally followed the apprentice method which is both time comsuming and may result in discomfort and some risk to patients. Virtual Environments have the potential to provide a learning environment away from the operating table where trainees and experienced clincians may reheasrse procedures safety.

A number of projects are currently being undertaken in the School of Computing between the Vision and Visualization and Virtual Reality research groups, to develop Virtual Environemnts for clinical training. The School is also a member of CRAIVE which is a UK multi disciplinary group interested in the development of Virtual Environments for procedures in Interventional Radiology.

Simulation of Ultrasound Guided Needle Insertion Procedures
Derek Magee, Yanong Zhu, David Kessel and Rish Ratnalingam


Physics-based virtual environment for training in vascular interventional radiological procedures
Yi Song, Ken Brodlie, Andy Bulpitt and David Kessel

The aim of this project is to develop and validate a computer generated virtual environment (VE) with variable virtual anatomy, in which the appearance, 'feel' and human factors of invasive radiological procedures (interventional radiology, IR) in patients can be reproduced and assessed. The final product will encompass needle puncture as well as guidewire and catheter insertion and manipulation, and will be based on a task analysis of interventional procedures. We are developing methods of semi-automatically processing medical imaging data to create a variable range of 3D geometry of anatomy.
For ultimate fidelity, we will determine and localise the forces experienced by an operator during IR procedures in patients using miniature sensors, enabling the 'feel' of a real procedure to be accurately reproduced. This will allow us to simulate needle puncture, and introduction of a guidewire and catheter into a blood vessel, with realistic behaviour of tissue and vessels. At the same time we will reproduce the feel of a pulse to guide instrumentation of an artery using a novel device which mimics a patient's physiological pulse. Simulated ultrasound will also guide needle puncture of an artery, and fluoroscopy will be simulated for guidance of the guidewire and catheter as they are manipulated within an artery. Finally, we will validate the VE and assess its potential for training and certification. We will also make suggestions for inclusion in curricula and criteria for certification. The VE developed in this project will be generic, capable of incorporation into an existing system, or of forming the basis of a new generation of systems applicable to training.

This project started in November 2006 and is being funded by the EPSRC.

Collaborators: University of Liverpool, University of Hull, University of Wales Bangor, University of Leeds, Imperial College London, Manchester Business School.
Development and Validation of a Virtual Reality Simulator for Training in Interventional Radiological Visceral Needle Puncture Procedures
Richard Holbrey, Ken Brodlie, Andy Bulpitt and David Kessel

This proposal¿s aim is to develop and validate a virtual reality (VR) simulator for training visceral interventional radiology (IR) needle puncture procedures which use medical imaging and touch to guide needles. The skills required are currently learnt in an apprenticeship in patients: this is time consuming and inevitably associated with discomfort and occasionally, complications. We are using a computer to generate variable virtual environments (VE) from imaging data, with stereo, 3D visual presentation and devices conveying touch sensation (haptics) to realistically mimic procedures on patients. This VR training model will be based on a Task Analysis of procedures and will simulate accurately the forces encountered during IR procedures. It will be validated to confirm suitability for training and certification within existing curricula, and the Royal College of Radiologists¿ (RCR) Integrated Training Initiative. The project end point of a pre-market, validated, authentic simulation of IR needle access procedures will remove this area of basic skills training from patients, improve safety and efficiency in the NHS and reduce the time to attain and maintain higher levels of competence.

This project started in November 2006 and is being funded by the Department of Health under the Health Technology Devices (HTD) Programme.

Collaborators: Medic Vision, University of Liverpool, University of Hull, University of Wales Bangor, University of Leeds, Imperial College London, Manchester Business School.

[FRSM]

К вопросу об одном из узких направлений инвазивной радиологии, ИМХО, интересная статья:

[Ссылки доступны только зарегистрированным пользователям ]

[cerebellum]

Уважаемый FRSM, не могли бы Вы скинуть статью куда-нибудь на нейтральную территорию? Ссылка ведет в "RSM Members only area", а membership очень даже платный, и никакой информационной халявы для стран третьего мира Королевским Обществом не предусмотрено

[FRSM]

Сорри, не учёл. Попиратствую:

Review

The expanding role of interventional radiology in head and neck surgery
Stephen Broomfield1 Iain Bruce1 Andrew Birzgalis1 Amit Herwadkar2
1 Department of Otolaryngology, Head and Neck Surgery, University Hospital of South Manchester NHS Foundation Trust Manchester, UK
2 Department of Neuroradiology, Salford Royal NHS Foundation Trust Manchester, UK

Correspondence to: Stephen Broomfield [Ссылки доступны только зарегистрированным пользователям ]

Introduction

Interventional radiology is defined by the Society of Interventional Radiology as ‘the delivery of minimally invasive, targeted treatments, performed using imaging for guidance’. Although the principles of angiography for diagnosis have existed since the 1920s, and today remain a well-established modality for the diagnosis of many common conditions, it was not until the 1960s that the American Charles Dotter, and other pioneers, extended these techniques from diagnosis to treatment.1 Their foresight, together with ever-increasing technological capability, allowed the use of transluminal angioplasty for the treatment of peripheral vascular disease and led Dotter to say, in 1964, that ‘it should be evident that the vascular catheter can be more than a tool for passive means for diagnostic observations: used with imagination it can become an important surgical instrument’.2,3 Thus, interventional radiology as a specialty was born. Work on the cerebral vasculature began in the 1970s, largely for neurosurgical conditions. It is perhaps not surprising that the initial, and still best known, uses of interventional radiology were for the highly accessible vascular system, and for the type of non-vascular conditions that offered poor surgical access, such as in neurosurgery. More recently, interventional radiology techniques have been applied to head and neck cancer patients, initially with the use of detachable balloon occlusion in patients with laryngeal cancer and impending carotid artery rupture. From this, the range of applications of interventional radiology in the extra-cranial head and neck has continued to evolve and expand. These applications include line placement, foreign body removal, placement of feeding tubes (primary gastrostomy, gastrojejunostomy or jejunostomy tubes), and oesophageal or bronchial dilatation and stenting. The main focus of this review is on the vascular applications of interventional radiology in the head and neck, which can be divided into three main categories: management of acute haemorrhage (e.g. epistaxis, carotid blowout); management of vascular lesions (e.g. tumours, arterio-venous malformations); and venous sampling.

Management of acute haemorrhage

Epistaxis
Epistaxis is one of the most common complaints presenting to the otolaryngologist, the majority being from an anterior nasal vessel, and dealt with using simple techniques such as cautery and nasal packing. There is, however, significant controversy about the best management for intractable posterior epistaxis when posterior nasal packing has failed. Traditional open surgical treatment includes ligation of the anterior ethmoidal artery via a Lynch-Howarth (peri-orbital) incision, or neck exploration with ligation of the external carotid artery or internal maxillary artery. The widespread use of endoscopes has meant that such open techniques are now reserved for the most refractory of cases, with most surgeons advocating endoscopic trans-nasal or trans-antral sphenopalatine artery ligation or endoscopic anterior ethmoidal artery ligation as a first line approach.4–6 Selective embolization of bleeding vessels with particles or coils is an increasingly used treatment for such cases of refractory epistaxis, and has been shown by many to be safe and effective.7–12 Figure 1 shows how bleeding was managed using embolization in a patient with intractable epistaxis who was not considered fit for general anaesthesia.






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Figure 1. (a) Digital subtraction angiogram showing nasal vasculature with bleeding point (black arrow) and catheter (white arrow); (b) after selective embolization there is no blood flow to the bleeding point (black arrow). Blood flow to the anterior part of the nose has been preserved (white arrow)




At present, there is little consensus as to which treatment modality is preferable or most cost effective, as both surgery and embolization carry similarly acceptable complication rates. Each patient is therefore managed on an individual basis, taking into account the experience of the surgeon, the fitness of the patient for general anaesthesia and the availability of interventional radiology services.

[FRSM]

Management of vascular lesions
Tumour embolization
Embolization has been used in the treatment of a wide variety of head and neck vascular tumours, including congenital haemangiomas. The aim in most cases is to devascularize the tumour prior to surgical excision, although in patients unfit for anaesthetic, embolization may be used as a palliative measure. The commonest use of embolization is in the management of juvenile nasal angiofibroma (JNA), a rare, highly vascular benign tumour found in adolescent males. This lesion commonly originates in the pterygo-palatine fossa, and then expands aggressively through the sphenopalatine foramen into the nasopharynx and nasal cavities followed by the sinuses and orbit, finally extending intracranially. Traditional surgical treatment has comprised an open approach using lateral rhinotomy or mid-facial degloving techniques. More recently, an endoscopic transnasal approach has been successfully described as safe and effective for all but the largest tumours.23 Embolization devascularizes the tumour, minimizing blood loss during surgery and making an endoscopic approach more feasible, and for these reasons is now a well accepted part of the treatment of JNA.24 Figure 3 shows how effective embolization can be in devascularizing JNA. For larger tumours, particularly those showing deep invasion of the sphenoid, there is evidence that a more radical surgical approach is preferable. In these cases, preoperative embolization may make complete tumour excision more difficult, and is not recommended.25 Preoperative imaging with CT and MRI is therefore essential in planning the treatment for each case of JNA.






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Figure 3. (a) DSA of juvenile nasal angiofibroma (JNA) showing microcatheter (black arrow) and tumour blush (white arrow); (b) after embolization there is minimal vascularity of the JNA




Embolization is also used in the treatment of paragangliomas, which are tumours arising from paraganglionic chemoreceptor cells. The commonest examples are glomus tympanicum, glomus jugulare and carotid body tumours. These tumours, which take their blood supply from the ascending pharyngeal artery, may be multicentric, and their ability to spread locally and small malignant potential are well described. Aggressive treatment is therefore recommended, and although surgery remains the mainstay of treatment, preoperative embolization has led to improved resectability and reduced morbidity ( Figure 4).26,27




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Figure 4. (a) Tumour blush of a large glomus tumour before embolization; (b) after embolization of the ascending pharyngeal artery with coils and particles the vascularity is reduced




Arterio-venous fistulas
These abnormal vascular connections can be congenital, spontaneous or traumatic. Treatment of congenital lesions is a challenge, as these have multiple, diffuse anastamoses with the surrounding vasculature.28 Traumatic lesions can also be difficult to treat, in part due to the urgency of treatment required in order to prevent life-threatening haemorrhage, neurological deficit or visual complications. These lesions, such as the carotid to cavernous sinus fistula occurring after head injury, are also often inaccessible surgically. The principle of treatment of arterio-venous fistulas is preservation of the normal vasculature where possible, while ensuring that both the distal and proximal vessels of the fistula are occluded. Various treatment modalities have been described, including embolization with detachable balloons, particles or sclerosants, using both arterial and venous approaches, as well as placement of endovascular stents.28–30 Proper planning of treatment is the key to success, and again requires close cooperation between the interventional radiologist and the head and neck surgeon.
Venous sampling
In recent years, a minimal access approach to parathyroidectomy for the treatment of primary hyperparathyroidism has evolved, making preoperative localization of the abnormal parathyroid gland increasingly important. The usual techniques employed for this include combinations of sestamibi, ultrasound, computerized tomography (CT) and magnetic resonance (MR) scans. When necessary, usually if the above techniques have not convincingly localized the affected gland, or in re-operative cases, a further technique available is that of intra-operative selective venous sampling. In this technique, the veins draining the parathyroid glands can be catheterized and blood sampled for parathyroid hormone. Elevated levels identify the abnormal gland and can be seen to return to normal after surgery. This technique, though invasive, has a high sensitivity and accurately predicts patients who have been successfully cured.31

[FRSM]

Carotid blowout
Carotid blowout can be defined as ‘bleeding from the carotid artery or its branches’. The modern definition of carotid blowout describes a distinct syndrome that includes threatened (where there is radiological or clinical evidence to suspect future haemorrhage, such as an exposed carotid artery) and imminent (where there has been minor bleeding that has settled or been controlled) bleeding as well as acute carotid haemorrhage.13 Carotid blowout is a well-known and much feared complication of advanced head and neck malignancy, whether treated surgically or with radiotherapy, and occurs in up to 3–4% of patients following neck dissection.14 Surgical intervention for such patients, who often pose a high anaesthetic risk due to significant co-morbidity, is technically difficult, and it is often impossible to identify the exact source of bleeding due to tumour bulk, ongoing infection or soft tissue fibrosis following prior surgery or radiotherapy; surgery for carotid blowout is known to carry up to 40% overall mortality, with a 60% incidence of neurological complications.13–15 For this reason, patients experiencing acute carotid blowout have traditionally been managed with end-of-life comfort measures.

Endovascular treatment is now considered by some to be the gold standard for this group of patients. There are three main options available to the interventional radiologist. The first is permanent balloon occlusion (PBO), in which a detachable balloon is placed in the common carotid artery, preventing blood flow into the bleeding vessel.13 In order to predict which patients are at risk from cerebral ischaemia, most advocates of this technique perform a temporary balloon occlusion test prior to PBO ( Figure 2), although there is a recognized incidence of delayed cerebral ischaemia of up to 20%.16 The second interventional technique available is selective embolization, using a variety of materials to occlude bleeding vessels, leaving the main carotid trunks intact.17 The third option is placement of an endovascular stent, which also allows continued cerebral blood flow, and may be used alone or in combination with embolization.16,18–20 Successful treatment of patients with carotid blowout has led to the emergence of a new group of patients who present with recurrent haemorrhage or with delayed complications of endovascular stents.21,22 Whether a new presentation or a recurrence, it remains important for the head and neck surgeon to work closely with the interventional radiologist, as a part of the multidisciplinary team, and where possible with the patient, in order to decide when such treatment is appropriate and will lead to a continued quality of life for the patient.





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Figure 2. (a) Temporary balloon occlusion test. The inflated balloon is seen in the left common carotid artery of a patient with uncontrolled haemorrhage secondary to malignant erosion of the carotid artery; (b) lateral view of the same patient after coil embolization; (c) this patient required permanent balloon occlusion to fully control the haemorrhage