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Vascular/Interventional Rotation

Expectations of Residents in the Vascular/Interventional

The rotations in vascular and interventional radiology provide direct, hands-on experience in virtually the entire spectrum of vascular and interventional radiology. Residents work alongside and learn from faculty members who have pioneered interventional techniques and continue to expand the dimensions of this exciting subspecialty with ongoing research.

Residents learn how to use the various radiologic modalities to define circulatory-system anatomy. They learn when radiologic interventions are effective and circumstances under which they should be avoided. They are introduced to various procedures such as balloon angioplasty, IVC filter placement, tumor embolization and percutaneous drainage of infected fluid collections. Resident rotations are both at Tisch Hospital and Bellevue. Bellevue's active emergency service provides the residents with opportunities to gain extensive experience in imaging traumatic injuries.

Faculty

Timothy Clark, M.D.

Section Chief, NYU Hospitals

Hearns Charles, M.D.

Richard Lefleur, M.D. 

Attending, Tisch Hospital

Attending and Head of VIR,
Bellevue Hospital

Hillel Bryk, M.D.

Attending, Bellevue Hospital

Theresa Aquino, M.D.

Attending, Tisch Hospital and Manhattan VA Medical Center

Resident Rotations

Each resident assigned to the VIR service should endeavor to identify 1-2 significant cases per day (eg arteriogram, drainage procedure, etc,) in which they will participate.  Whenever possible, the case(s) will be assigned to the resident the day before the procedure. This allows the resident to read about the anticipated procedure(s) before they scrub in. Case assignments are the responsibility of the fellow; any questions should be arbitrated by an attending physician. In order to provide the most comprehensive experience possible, this participation should include the initial workup and pre-procedure evaluation of the patient as well as discussion of potential benefits, risks, and alternatives with the patient prior to obtaining consent.  The resident will perform the procedure with attending supervision.  After the procedure is completed, the resident is expected to provide clinical follow up for the patient in cases where this is necessary, assist with post-procedure paperwork and orders, and perform dictation immediately after the procedure. In addition to these 1-2 cases, residents should make every effort to participate in other procedures when the work from their dedicated procedures is complete.

Often, a particular procedure will attract the interest of both residents and fellows.  Not surprisingly, this tends to happen with procedures that may be challenging or unusual, and those that require complex interventions.  The fact that a fellow is involved in the case should not deter residents from participating.  The attending physician will make every effort to involve the resident as much as possible.  A typical example would involve a visceral angiogram and embolization for gastrointestinal bleeding.  In such cases, the resident may be able to perform the arterial puncture (applying the “3 strikes rule”) and some of the diagnostic arteriography (ie, non-selective catheterization) necessary to make a diagnosis, and the fellow will perform the more difficult selective catheterization and embolization.  Remember, the intent of the resident VIR rotation is to acquire strong diagnostic skills and a basic set of technical skills.  The intent is not to learn to perform complex interventions, as this requires a comprehensive fellowship.

Residents are expected to participate in all aspects of the VIR service.  There is no “VIR-Lite” rotation.  As with most things, what you will get out of this experience depends in large part on what you put into it. You are expected to return promptly to the VIR section after noon Case Conference/Didactic Rounds.  Like fellows, you are expected to answer the telephone, consult with referring physicians, discuss procedures with patients, scrub into procedures, see patients on the floor, etc.  We realize that the VIR rotation is challenging, both intellectually as well as physically.  Please do not hesitate to ask questions and to ask for help when you need it.  The VIR staff members are dedicated to providing residents with a pleasant and stimulating, if rigorous, learning experience.

Training Objectives for NYU Radiology Residents

Rotation 1:

Vascular & Interventional Radiology

Core competency in vascular and interventional radiology during the first resident rotation consists of clinical objectives, technical skills and image interpretation. 

Clinical objectives:

  1. Participate in the day-to-day running of the vascular and interventional service, including inpatient rounds, evaluation of and consenting of patients for vascular and interventional radiology procedures, pre and post procedure orders using the hospital information system, telephone consultations with referring physicians and housestaff.
  2. Manage mild to moderate coagulopathy through the administration of fresh frozen plasma, platelets and vitamin K, where appropriate.
  3. Be familiar with indications for pre-procedural antibiotics.
  4. Be able to identify patients at high risk for contrast nephropathy, and order intravenous hydration and sodium bicarbonate for patients with azotemia.

Technical Skills:

  1. Develop a working knowledge of common needles, catheters and guide wires, and the characteristics of each device appropriate to specific clinical applications.
  2. Be able to perform jugular and femoral punctures using Seldinger technique with real-time ultrasound guidance.
  3. Be able to place peripherally inserted central catheters under supervision.
  4. Be able to perform diagnostic and therapeutic paracentesis and thoracentesis with supervision.
  5. Be able to perform ultrasound and CT guided drainage of infected intra-abdominal fluid collections.
  6. Be able to perform ultrasound guided liver biopsies.

Image Interpretation:

  1. Develop familiarity with renal and visceral arterial and venous anatomy.
  2. Identify arterial and venous structures in the lower extremities from angiographic images, with CTA and MRA correlation.
  3. Identify hepatic arterial, biliary, portal and hepatic venous anatomy.

Rotation 2:

Vascular & Interventional Radiology

Core competency in vascular and interventional radiology during the first resident rotation consists of clinical objectives, technical skills and image interpretation.

Clinical Objectives:

Be able to function as a vascular and interventional radiology consultant for the evaluation of patients for the following emergency procedures:

  1. arteriography and embolization for gastrointestinal bleeding
  2. urgent transjugular intrahepatic portosystemic shunts
  3. embolization of gynecologic and obstetrical hemorrhage
  4. embolization of pelvic fractures, hepatic and splenic lacerations following major trauma

Call Responsibilities

All residents on VIR are required to take call one weeknight during each week they are on the VIR rotation. Call provides a learning opportunity in consultative skills, the triage/workup of urgent or emergent patients, and to perform emergency interventional procedures with the attending physician on call. When residents are called in from home during the night for an interventional procedure, in compliance with New York State 405 Regulations the resident is free of clinical responsibility on the VIR rotation on the post-call day.

Vascular and Interventional Radiology Conferences

There are regular conferences available to the interested resident while on the vascular and interventional radiology rotation including

  1. Vascular conference (Tuesday morning 7. Skirball 3)
  2. GI tumor board (Every second Tuesday of the month, NYU Cancer Center, 9th Floor Conference Room, 4:30)

Vascular and Interventional Radiology Clinic

Although not a requirement of the rotation, the VIR Clinic is the “engine” of the clinical practice where new patients are seen in consultation and follow-up patients are seen following interventions. The VIR Clinic is each Tuesday afternoon at Tisch Hospital and every other Tuesday at the NYU Comprehensive Cancer Care Center. Residents interested in pursuing interventional radiology as a career are welcome to join the IR attendings and fellows in the VIR Clinic.

Suggested Reading List

  1. Valji, K. Vascular and Interventional Radiology. W. B Saunders, Philadelphia, 1999.
  2. Kaufman, J.A. and Lee, M.J. Vascular and Interventional Radiology: The Requisites. Mosby, 2004.
  3. Baum, S. and Pentecost, M.J. Abrams’ Angiography Interventional Radiology, 2nd Edition, Lippincott, Philadelphia, 2006.

Vascular and Interventional Radiology Articles since 2005

  1. Cohen DL, Townsend RR, Clark TWI.  Renal artery stenosis due to fibromuscular dysplasia in an 18-week pregnant female.  Obstetrics & Gynecology 2005; 105(5 Pt 2):1232-5.
  2. Greben CR, Naidich JB, Charles HW, Naidich JJ.  Deep Venous Thrombosis, Upper Extremity.  Emedicine. March 2005
  3. Beardsley SL, Shlansky-Goldberg RD, Patel A, Freiman DB, Soulen MC, Stavropoulos SW, Clark TWI. Predicting infected bile among patients undergoing percutaneous cholecystostomy.  Cardiovasc Intervent Radiol. 2005 May-Jun;28(3):319-25
  4. Itkin M, Won JH, Clark TWI.  Evaluation in an animal model of a microcatheter arterial port system for transarterial regional cancer therapy. J Vasc Interv Radiol 2005; 16: 275-279.
  5. Harp RJ, Stavropoulos SW, Wasserstein AG, Clark TWI. Pulmonary hypertension among end-stage renal failure patients following hemodialysis access thrombectomy.  CardioVasc Interven Radiol 2005; 28(1):17-22.
  6. Kothary N, Soulen MC, Clark TWI, Wein AJ, Shlansky-Goldberg RD, Crino PB, Stavropoulos SW. Renal angiomyolipoma: long-term results after arterial embolization. J Vasc Interv Radiol. 2005;16: 45-50.
  7. Lau CT, Scott M, Stavropoulos SW, Soulen MC, Solomon JA, Clark TWI. Dacron-covered stent-grafts in transjugular intrahepatic portosystemic shunts (TIPS).  Radiology. 2005 Aug;236(2):725-9.
  8. Stavropoulos SW, Kim H, Clark TWI, Fairman RM, Velazquez O, Carpenter JP. Embolization of Type 2 Endoleaks after EVAR using Cyanoacrylate With or Without Coils. J Vasc Interv Radiol. 2005 Jun;16(6):857-61
  9. Stavropoulos SW, Clark TWI, Carpenter JP, Fairman RM, Litt H, Velazquez O, Insko E, Farner M, Baum RA. Use of CT Angiography to Classify Endoleaks After Endovascular Repair of Abdominal Aortic Aneurysms. J Vasc Interv Radiol. 2005 May;16(5):663-7
  10. Stavropoulos SW, Marin H, Fairman RM, Carpenter JP, Litt HI, Itkin M, Clark TWI. Recurrent Endoleak Detection and Measurement of Aneurysm Size with CTA Following Coil Embolization of Endoleaks. J Vasc Interv Radiol. 2005, 16(10):1313-7.
  11. Grande WJ, Trerotola SO, Reilly PM, Clark TWI, Soulen MC, Patel AA, Shlansky-Goldberg RD, Tuite CM, Solomon JA, Mondschein JI, Fitzpatrick MK, Stavropoulos SW. Experience with the recovery filter as a retrievable inferior vena cava filter. J Vasc Interv Radiol. 2005 Sep;16(9):1189-93.
  12. Shatsky JB, Berns JS, Clark TWI, Kwak A, Tuite CM, Shlansky-Goldberg RD, Mondschein JI, Patel AA, Stavropoulos SW, Soulen MC, Solomon JA, Kobrin S, Chittams JL,Trerotola SO.Single-center Experience with the Arrow-Trerotola Percutaneous Thrombectomy Device in the Management of Thrombosed Native Dialysis Fistulas.  J Vasc Interv Radiol. 2005;16(12):1605-11.
  13. Trerotola SO, Kwak A, Clark TWI, Mondschein JI, Patel AA, Soulen MC, Stavropoulos SW, Shlansky-Goldberg RD, Solomon JA, Tuite CM, Chittams JL.  Prospective Study of Balloon Inflation Pressures and Other Technical Aspects of Hemodialysis Access Angioplasty. J Vasc Interv Radiol. 2005;16(12):1613-8.
  14. Levit RD, Cohen RM, Kwak A, Shlansky-Goldberg RD, Clark TWI, Patel AA, Stavropoulos SW, Mondschein JI, Solomon JA, Tuite CM, Soulen MC, Trerotola SO. Asymptomatic central venous stenosis in hemodialysis patients: first, do no harm. Radiology 2006, 238:1051-6
  15. Itkin M, Trerotola SO, Stavropoulos SW, Patel AA, Mondshein JI, Soulen MC, Tuite CM, Shlansky-Goldberg R, Faust TW, Reddy KR, Solomon JA, Clark TWI.  Portal flow and arterioportal shunting following transjugular intrahepatic portosystemic shunts.  J Vasc Interv Radiol. 2006;17(1):55-62
  16. Clark TWI, Malkowicz BS, Stavropoulos SW, Soulen MC, Sanchez R, MD Patel AA, Itkin I, Mondshein JI, Wein AJ. Radiofrequency ablation of renal cell carcinoma using multitined expandable electrodes. J Vasc Interv Radiol. 2006;17(3):513-9.
  17. Carr CE, Tuite CM, Soulen MC, Shlansky-Goldberg RD, Clark TW, Mondschein JI, Kwak A, Patel AA, Coleman BG, Trerotola SO. Role of ultrasound surveillance of transjugular intrahepatic portosystemic shunts in the covered stent era. J Vasc Interv Radiol. 2006;17(8):1297-305.
  18. Clark TWI, Gervais D, Goldberg SN, et al.  Reporting standards for percutaneous thermal ablation of renal cell carcinoma.  J Vasc Interv Radiol. 2006 (in press)
  19. Clark TWI, Cohen R, Kwak A, et al.  Salvage of nonmaturing native hemodialysis fistulae by angioplasty.  Radiology 2006 (in press).