Interventional radiology has become an integral part of patient care services offered
at many secondary and tertiary care hospitals in India. In addition to the routine
elective consultation and procedural care for various vascular, nonvascular, and oncologic
conditions, the interventional radiology service is being increasingly involved in
the treatment of emergency conditions such as acute stroke or acute pulmonary embolism.
The emergency interventional radiology service is more challenging compared with the
elective service in several aspects, including, but not limited to, the need for quick
decision-making given the clinical status of the patient, availability of resources
for early intervention, and availability of alternative therapeutic options.
There are several factors that influence the outcome of emergency interventional treatment.
These can be categorized into three groups: patient, material, and man power. The patient factors include the clinical status, ability to obtain the history and
consent in a timely fashion, presence of a known diagnosis linked to the emergency
problem, and associated comorbid conditions. It is important to assess the hemodynamic
status of the patient and the pertinent laboratory parameters when an invasive procedure
is planned. One has to be ready to make a balanced decision based on the clinical
and imaging information already available versus obtaining more imaging tests to prevent
further delay in offering a life-saving interventional therapy. If the clinical status
allows, it may be prudent to obtain further information to aid the decision to perform
a procedure or help steer the procedure in a particular direction. For example, in
a stable patient with suspected acute gastrointestinal hemorrhage, it would be useful
to know the site of hemorrhage on endoscopy or contrast-enhanced computed tomography
prior to the patient being considered for embolization.
Material factors refer to the hardware for the procedure. The availability of appropriate
devices (embolic materials, stent grafts, wires, catheters, etc.) is paramount in
achieving an adequate therapeutic result. For example, a patient bleeding from a pseudoaneurysm
requires an appropriately sized stent graft to exclude the aneurysm from the parent
artery. Given the constrains of Indian hospitals to house multiple varieties of hardware
for interventional procedures, it would be prudent to form a work group (consisting
of hospital administrators, interventional radiologists, and industry representatives)
within a city to mobilize the required material at a short notice.
Availability of personnel (man power) to provide care during the emergency is important
and should be part of the hospital process improvement. The technologists, nurses,
interventional radiologists, and, if required, the anesthesia team should be able
to arrive at the hospital in an emergency within a relatively short time and short
notice. Again, in our Indian scenario, it is important to work as a team of interventional
radiologists at any given city to provide emergency coverage to multiple hospitals.
The American College of Radiology (ACR) has published practice parameters on clinical
practice of interventional radiology. This is a collaborative document with the Society
of Interventional Radiology (SIR), the Society of Neurointerventional Surgery (SNIS),
and the Society for Pediatric Radiology (SPR).[1] The document includes suggestions for the clinical team, patient services, equipment,
quality improvement, radiation safety, etc. It has been recommended that the interventional
radiologist be dedicated to the clinical management of patients in addition to performing
the interventional procedures. Hospital admitting privileges have been mentioned as
critical for a successful clinical interventional radiology practice. The Royal College
of Radiologists has published “Standards for providing a 24-Hour Interventional Radiology
Service.”[2] The document highlights the need for considering the safety of the patient first.
One needs to be clear regarding the type of care provided. It also suggests discussing
with strategic health care facilities and other hospitals to provide the service at
any time.[2]. The availability and nonavailability of the type of emergency radiology services
should be clearly mentioned, so that the patients are treated within the window period.
Emergency as emergency, elective as elective. This summarizes that while it is important to identify a case as an emergency; it
is equally important to identify what case is not when it is erroneously referred as an emergency. The latter would avoid misusing
the emergency service and potentially compromising the patient care by offering the
procedure suboptimally.
As interventional radiologists, we are committed to providing emergency interventional
services. It is important that we, as a society, work together with the hospitals
in laying guidelines for emergency interventional radiology service. This would not
only improve the patient care and visibility of interventional radiology as one of
the pillars of medicine but also enhance the appeal of interventional radiology as
a specialty for future medical graduates.
