BackTable / VI / Podcast / Transcript #322

Podcast Transcript: Renal Trauma Embolization

with Dr. Nima Kokabi

In this episode, host Dr. Chris Beck interviews Dr. Nima Kokabi about renal trauma embolizations, including imaging workup, embolization technique, and a warning on renal biopsies. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Renal Trauma & Kidney Biopsies

(2) Renal Trauma Presentation & Management

(3) Renal Embolization Procedure: Radial or Femoral Access

(4) Renal Trauma Embolization: Coils and Microcatheters

(5) Technical Considerations After Renal Trauma Embolization

(6) Renal Trauma Embolization Post-Procedural Care

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[Chris Beck MD]
Today we're going to be talking about embolizations. We'd already covered splenic embolization in a couple other podcasts. Today we're going to be covering kidney if we have time, liver, but probably just kidney. To help us with this topic today, we have Dr. Nima Kokabi from the University of North Carolina UNC, who is here to help us today. Nima, glad to have you on the show, man.

[Nima Kokabi MD]
Thank you, Chris. Thanks for having me. I am a big fan of BackTable, but I never met you guys in person, so thank you for having me on.

[Chris Beck MD]
It's like longtime listener, first-time caller?

[Nima Kokabi MD]
Yes. Funnily enough, actually, I saw Aaron on a flight back from SIR, he was on his way to Paris. I had no idea he lives in Paris. What a life he is leading?

[Chris Beck MD]
We just have a jet setter, CEO, part-time hire, living in Paris. He's the envy of many.

[Nima Kokabi MD]
Yes.

[Chris Beck MD]
All right, tell us about your practice, your background. Actually, to start out, just give us a quick background like training, where you came up from, and how you found yourself at, Chapel Hill.

[Nima Kokabi MD]
Sure. I did my undergrad. I was born in Iran, grew up in Iran until the age of 15, and then we moved to Canada at the time. I finished high school in Canada, did undergrad in electrical engineering in Canada, did some biomedical engineering projects in the process. I became interested in image processing and radiology from that avenue. Then I applied for medical school.

I actually ended up going to Sydney, Australia for my medical school because I don't know if you're aware or not, there are only eight English-speaking medical schools in Canada, so they're extremely difficult to get into and very competitive.

[Chris Beck MD]
Hold on. The other ones are French-speaking?

[Nima Kokabi MD]
All French-speaking, yes.

[Chris Beck MD]
Wow.

[Nima Kokabi MD]
They're actually more French-speaking than English-speaking, even though the French population is smaller, significantly smaller than the English-speaking ones.

[Chris Beck MD]
Quite a Canadian nuance.

[Nima Kokabi MD]
I ended up going to Sydney, Australia. One good thing with studying in Australia or any of the Commonwealth countries is that coming back to Canada would be much easier, that was the idea behind it.

[Chris Beck MD]
Awesome.

[Nima Kokabi MD]
Once I was near finishing the medical school, I knew I wanted to do radiology, but I became more interested in interventional radiology. Because of that, I decided to do my postgraduate training in the US because there were more opportunities. That's how I ended up at Emory for my residency. I did my fellowship at Yale and I came back to Emory as an attending, and I just left Emory and joined University of North Carolina.

[Chris Beck MD]
All right, and quite the route. At Yale, a lot of trauma at Yale?

[Nima Kokabi MD]
Fairly, quite a bit of trauma, not as busy as Emory,

[Chris Beck MD]
Well, I can imagine.

[Nima Kokabi MD]
There were not as many trauma centers that we had around Yale as we have in Atlanta. Emory is in charge of Grady, which is one of the busiest trauma centers in the country, and because of that and the nature of the much larger city than New Haven, we saw a lot more trauma at Emory compared to Yale for sure, but we had a fair share of trauma.

[Chris Beck MD]
Sure. I have a partner that did fellowship at Emory, and he always described Emory IR as a fellow as full contact sport.

[Nima Kokabi MD]
It is. Who was that?

[Chris Beck MD]
His name's John Iser. Good guy.

[Nima Kokabi MD]
Oh yes.

[Chris Beck MD]
Good, good guy.

[Nima Kokabi MD]
I actually saw John at SIR again. This SIR, I met a lot of people. I was a second-year resident, I think when John was doing his fellowship at Emory. He had a lot of funny stories to tell me about his time.

[Chris Beck MD]
No doubt about that, he is full of them. All right. Let's get into just talking about - we can borrow from your experience either at Emory or at UNC or both - but just talk about IR's relationship with trauma, and how you guys fill into the trauma team.

[Nima Kokabi MD]
At Emory, we have a very close relationship with trauma surgeons. I feel that more and more they rely on us for even things that you and I probably learned in medical school, or even during radiology residency, as being surgical cases, including penetrating trauma. Nowadays, I don't know what your experience is, Chris, but nowadays, more and more we get phone calls to even deal with penetrating trauma. We had a fair share of that in Atlanta with percutaneous management as opposed to surgical management.

In my anecdotal experience, there is a lot more reliance on interventional radiology for trauma, both penetrating and blunt. Another thing that we had to go through at Emory was that over the past two years or so, the Grady Healthcare System was going through re-certification for their Level 1 trauma center. One thing that became significantly more apparent and there was significantly more emphasis on was the availability of IR, and documentation of availability of IR in a Level 1 trauma center within 30 minutes of the phone call that was being made. It became even more of a significant reliance, but also from the aspect of documentation and availability, sometimes challenging because Grady was not the only hospital that we are covering. We had other hospitals that we were covering at the same time, but for the most part, for acute trauma, we were there within 30 minutes.

[Chris Beck MD]
Wow. Sometimes, I can just like see logistically that could be sometimes pretty difficult in Atlanta. I don't know what time people stay in house or how close you have to live, but Atlanta's big city, and there's a lot of traffic.

[Nima Kokabi MD]
A lot of times the unfortunate truth was that as physicians, we would get in, but the nurses, the technologies wouldn't be there by the 30 minutes. A couple of times we ended up starting the cases without the IR nurse and we had the nurse from trauma team and ICU helping us. As you know, Atlanta's a big city. This is becoming more and more, I guess significant emphasis on availability within 30 minutes to a point that, at least when I was at Emory, the thought was that we may need to eventually turn the Grady call into an in-house call to meet that 30-minute standard or expectation rather.

(1) Renal Trauma & Kidney Biopsies

[Chris Beck MD]
Wow. All right. Moving out of logistics, let's dig in a little bit into kidney injury specifically. We were joking offline, like a lot of alley-oops from people who do kidney biopsies. You were joking about interventional nephrology. Let's talk about just kidney injury in general. In your practice, what was the most common setting for IR consults for kidney injury?

[Nima Kokabi MD]
I was half joking, you know that behind every joke there is a pinch or lies of truth. To be honest with you the majority of the traumas that would require intervention, at least in my experience at Emory, and I've heard from other colleagues of mine around the country that the majority of kidney traumas that require intervention by IR or are iatrogenic from non-targeted renal biopsies are done in the office setting, a lot of times without appropriate imaging. Nowadays, more and more nephrologists have access to ultrasound at least doing these renal biopsies, but even in those cases, I feel that the mantra that we follow for biopsies in terms of being in the lower pole, trying to avoid the areas of high vascularity in the kidneys, those are generally not followed unfortunately by a nephrologist. That is why a lot of these biopsies are, at least anecdotally, the number of traumatic iatrogenic cases that we get from nephrology biopsies are higher than our own.

That is not to say, we don't actually cause renal bleeds, meaning IR doesn't cause renal bleeds, suppose biopsies, of course. In my opinion, it's actually one of the more scary biopsies to do, particularly in the setting of renal failure, which is the majority of these cases, particularly, at least in my experience in the setting of lupus. Those patients in my experience have bled the most at least.

It is a very humbling procedure to do. People think it's an easy procedure, that it's a cheap shot, but I've seen people die from it, to be honest with you.

[Chris Beck MD]
I totally agree with you on that, in that when I think about solid organ biopsies, like outside of the spleen Give me a liver or lung any day, but starting a kidney sometimes after two or three o'clock, especially on in-house patients, I'm always like, "Oh, where are they coming from? What's their status? What's their blood pressure?" I think there's a lot that goes into it.

(2) Renal Trauma Presentation & Management

[Chris Beck MD]
Not to dwell too much on solid kidney biopsies, but outside of just kidney biopsies, did you guys treat a fair amount for partial nephrectomies, or just either penetrating, or blunt trauma?

[Nima Kokabi MD]
Partial nephrectomy for sure, as well as more blunt trauma than penetrating. I feel that when it's involving the kidney, again, I don't have the data to back it up, but I feel that if there is a penetrating trauma involving the kidney, probably the threshold is much lower to go to the operating room.

[Chris Beck MD]
As far as diagnosis goes, you suspect a renal bleed. Did all of those patients move on to cross-sectional imaging in some way, or CTA is absolutely necessary, or with a high enough pretest probability, would you take some patients to the angio straightaway?

[Nima Kokabi MD]
Generally, for renal, we get a CT beforehand. In the past three years, we actually migrated from having a single-phase, PAN scan of the chest, abdomen, and pelvis in mostly the venous phase to actually having a two-phase arterial and venous phase, which actually increases the pretest probability of a renal bleed significantly. Again, not backed up by data, but at least anecdotally.

Generally, for those patients, we do a CT beforehand. The ones that we generally go to embolization without a CT are the pelvic traumas. If they're in shock, a lot of times there's just no time to chat in much words, so we go straight to angio. They know basically based on an x-ray that there is an open book pelvic fracture, and then there's no other, at least visual trauma to the abdomen, so they usually ask us to do those without doing the CT scan.

[Chris Beck MD]
Sure. Are those guys using the AAST Renal Injury Scale? Is that something that was very much built into the algorithm?

[Nima Kokabi MD]
Recently, in the past two to three years, we had an emergency radiology department at Emory that was working very closely with the trauma surgeons. Because of that, they actually made sure that on all reports for solid organ injuries, there is a grading scale that is reported.

[Chris Beck MD]
If any times like if active extravasation or pseudoaneurysm was identified, was that almost an automatic call to IR?

[Nima Kokabi MD]
Yes, it was.

[Chris Beck MD]
Were there any situations where the kidney injuries, where it just looks like an unexploded kidney, were those patients move on to nephrectomy, or?

[Nima Kokabi MD]
Yes, particularly if you do a two-phase and you don't see any enhancement. If it is a completely evolved kidney, you don't see any enhancement of the parenchymal more delayed phase, I think those are very good scenarios that you should not intervene on because there's basically nothing. Either the artery is completely transected, or maybe the artery and vein are both transected, so in the interest of not wasting time, those patients should go to the operating room directly.

[Chris Beck MD]
Was the urology service at Emory, I guess it would be urology that would take those patients there who are not trauma?

[Nima Kokabi MD]
Interestingly, it's trauma that takes care of those patients, at least at Grady.

[Chris Beck MD]
The trauma team and trauma surgeons werepretty aggressive, very reasonable, and willing to helping people out?

[Nima Kokabi MD]
They're in a good relationship with IR. Rarely did we had disagreement in terms of how to manage a patient.

[Chris Beck MD]
Can you paint any scenarios, especially for younger IR docs. I think it's sometimes easy to know when to take a patient to angio and it's easy to know when, "Hey, this is not an IR issue, it's more a surgical issue." Are there any patients that fall into like, "I think this would be more reasonable to watch and wait it out, rather than to intervene at all"?

[Nima Kokabi MD]
When there are small pseudoaneurysms, yes, a lot of times actually. I remember reading a paper, I don't know the exact number, but post renal biopsy, if you actually do a high-quality CTA or angiogram, a very large proportion of those patients have a pseudoaneurysm. We don't obviously biopsy all these patients there. We know that a lot of patients have a small perinephric hematoma that stops, and we just move on, and they don't require any further intervention.

Just seeing a tiny pseudoaneurysm that there's no significant hematoma around it, the patient is rock solid stable with the vital signs, that doesn't require an intervention right away. What you need to do at that point is to follow up with those patients very closely. Maybe do another CTA in 48 hours and if it's stable, do another CTA in two weeks. There's no real set protocol on how closely you need to monitor those patients, but the bottom line is, you need to monitor those patients, those who require further imaging. Which is still much less morbid than subjecting them to angiography. Especially, for those tiny pseudoaneurysms, a lot of times you cannot get into the sack, you may need to actually sacrifice quite a bit of kidney to embolize that pseudoaneurysm. Sometimes less is more, for sure.

[Chris Beck MD]
Especially like you said, you paint a scenario where you have a rock solid patient. It’s been my experience, especially with post-biopsy patients, that even when I go to see them in the post-procedural area, it's almost like you just know they have something going on. They're writhing in pain, the blood pressure is lower than what they were baseline and they just have a certain look of uncomfortableness to them. That's just unrelenting and not relieving your standard post-pain medications.

[Nima Kokabi MD]
That is part of the art of IR, as opposed to the science. A lot of that is really not easy to teach. It's an experience you gain through the years, and all of us have been subjected to those patients. I think the more you do, the more you realize those nuances.

(3) Renal Embolization Procedure: Radial or Femoral Access

[Chris Beck MD]
Totally agree. All right, say we have a patient either in BC with blunt trauma or iatrogenic - could be post partial nephrectomy. Now you have a patient that you do want to take to angio, can you talk about your procedure prep, access, what you do to get that patient ready to just have an angio and prep for a potential embo?

[Nima Kokabi MD]
Sure. I'm a big fan of radial access.

[Chris Beck MD]
All right, radial access man.

[Nima Kokabi MD]
I was actually not trained, apart from a couple of attendees that I had at Yale, almost everybody else was a groin access or femoral, as you want to call them. I didn't have much of a radial experience, again, apart from maybe 10 or 15 cases I did with a couple of surgeon attendings. By the time I got to Emory, Zach Bercu, who was one my partners at Emory, he trained at Sinai. Being trained at Sinai, obviously, you become a radiologist whether you like it or not. He basically really taught me different techniques for radial, and I can tell you, I used that.

There is a bit of a learning curve initially, especially when you are all used to standing on the right side of the patient, and I'm right-handed as well. It is not the easiest learning curve, but once you learn it and you're comfortable with it, I think the quality of the images from radial access because of the extra side hole that most of the radial catheters have for both liver, I do all my IO cases radial, if possible.

[Chris Beck MD]
Sure.

[Nima Kokabi MD]
For trauma as well, particularly for pelvic trauma, which we're not talking about today, but because they usually have binders, it’s much easier to go from the radial, in my opinion. That was another change that we made in the past two or three years at Grady to make sure that people are comfortable taking care of these patients afterwards.

Anyways, long roundabout answer to your question, but if I can, I do radial access for these patients. My go-to catheter for accessing the renal artery, the base catheter is Sarah or Jacky. They're actually really easy to use to select the renal artery and then you can get good angiography. Generally, you need at least two projections for the kidney to figure out what artery is bleeding and whether you have to go to the upper pole, middle pole or the lower pole of the kidney.

Once I have that information - and those angiographies are done with the base catheter, which is a 5 French catheter in the case of Sarah and Jackie, then I use a microcatheter to select the renal artery if there is a artery to be targeted for embolization. Generally, if you have significant bleeding you will get a pseudoaneurysm or you get an active extravasation.

[Chris Beck MD]
Hold on. Before you get into the microcatheter, one thing that I wanted to ask you is like going back to the radial access, radial versus femoral, but it seems like you feel pretty good moving between both worlds, right?

[Nima Kokabi MD]
Yes, for sure. Actually that's one of my concerns about some of our fellows at Emory because a lot of us we do radial. Luckily we had a good group of people from all over the country, so the newer attendings were actually femoral access people, so our fellows would learn both. The bottom line is you need to be comfortable with both, for sure.

[Chris Beck MD]
I totally agree. Going back to doing radial access in the setting of trauma, which we're not a trauma center at the place that I work, but we do see fair amount of iatrogenic injuries. I've stayed away from radial access and trauma, but it's not because I'm not comfortable with it, but I always thought like, "Oh, the vessels are going to be clamped down or I'm going to have a lot of trouble getting into the radial." Is that not the case whenever you have someone?

[Nima Kokabi MD]
Not unless they're in significant shock and even if they're in significant shock, a lot of times you can get it. People that have concerns about that. I always tell them if an anesthesiologist can do an art-line on a patient with shock, you are definitely more equipped than them to do it, so you can actually access the radial.

[Chris Beck MD]
Well said. You were starting out, and I also wanted to ask you a little bit about your angiography technique for the renals. All hand-injections with these?

[Nima Kokabi MD]
Yes. All hand-injection. Some people are concerned about atherosclerotic plaques, so they do no-touch technique, which I don't do, and I'm not very good at it. Luckily, I've had no issues with just selecting the artery and parking my base catheter in the proximal aspect of the renal.

[Chris Beck MD]
That was the other thing I was going to ask you, if you just fully engage. Then once you do engage, you take an AP and then with your other oblique, is it just based on which side of the kidney it's just in oblique?

[Nima Kokabi MD]
Usually, you do contralateral oblique to open up the kidney.

[Chris Beck MD]
It also takes it off the spine?

[Nima Kokabi MD]
Yes.

(4) Renal Trauma Embolization: Coils and Microcatheters

[Chris Beck MD]
After you've done your runs through your base catheter, and you've identified either pseudoaneurysm, active extrav, sometimes you see like an AV fistula, next step is micro and what do you like for micro?

[Nima Kokabi MD]
Next step is micro.

[Chris Beck MD]
Then also like, are you picking your micro, do you have an idea of what you want to embolize with?

[Nima Kokabi MD]
Depending on the CT, generally you have a fair idea of what you want to embolize with. In the kidneys, I would say majority of the time, at least for me, it's coils. I generally do coils. If I'm treating AML, I do alcohol and lipiodol. Sometimes for larger Renal Cell Carcinomas that I'm planning to do an ablation, I do a pre-ablation embolization to get better margins and reduce bleeding. My go-to ablation is cryoablation. For larger tumors, there could be a risk of bleeding, but if I'm doing that, I use particles. For trauma purposes, generally I use coils. I have partners that use glue as well, but I feel more comfortable with coils.

[Chris Beck MD]
As far as coils, glue, Gelfoam, have some of the Gelfoam on the table?

[Nima Kokabi MD]
Gelform, rarely in the kidney, a lot in the liver. That's my go-to in the liver, unless I see blood pouring out of the liver, I feel comfortable gel-forming the whole liver, if I have to, but also pelvic trauma, for sure, that's my go-to. For spleen and kidney, rarely. Rarely.

[Chris Beck MD]
All right. Coils are the workhorse.

[Nima Kokabi MD]
Yes.

[Chris Beck MD]
You've got the base catheter done, you have an idea what you're going to embolize with. What do you like for micro and how do you get distal?

[Nima Kokabi MD]
Generally for kidney, the vessels are generally smaller than the liver or spleen, so you want a smaller microcatheter. Anything from 2.0 to 2.4 is what you should aim for because you have to think about, depending on the type of coil you use, you're going to be using smaller coils in general. I would say in the past three years or so, when the TruSelect microcatheter came out by Boston Scientific, that has become my go-to microcatheter for all my IO cases, as well as my embolizations. I love it. Generally, kidneys are not super tortuous, like the liver, especially the IO cases that have been treated in the past, they become very tortuous, especially if they're on chemotherapy.

Even in kidney, I like the TruSelect a lot and you get good images, even if you're doing a selective angiography, because although the tip of the microcatheter is a 2.0 French, the distal aspect of it is a 2.8 French. It gives you that extra volume for your contrast injection.

[Chris Beck MD]
All right. Still getting pretty good pictures. Having the smaller microcatheter, does it limit you on which coils you like, or you're fan of detachable versus pushable?

[Nima Kokabi MD]
I'm a big detachable person.

[Chris Beck MD]
I’m quite detachable coils also.

[Nima Kokabi MD]
Yes, and I feel most of the younger IRs are detachable users, and most of the older IRs are pushable. They probably called us a bunch of wusses, who are using all these detachable coils, but I feel comfortable. Especially in smaller areas, I'd like to have that control, that if I don't like the place then I can retrieve it. I use detachable almost all the time.

[Chris Beck MD]
Okay.

[Nima Kokabi MD]
With some of the newer coils that are on the market, that whole issue of knowing what size coil you need to use to match that with a certain microcatheter has been resolved, particularly the coil that I like. That's another issue that we've dealt with in the past with many of the coils that if you're going for smaller coils, for example, you cannot use a 2.7 or a 2.8 French microcatheter because the coil actually forms in the microcatheter itself. The Embold Coil by Boston Scientific, that came out about a year and a half ago or a year ago now, actually is compatible for every microcatheter with an inner diameter from 2.1, I believe to 2.7. Even though the 2.0 French microcatheter, the TruSelect that I use, the inner diameter is 2.1, it's been okay. I've used anything from a 2 millimeter coil with a TruSelect all the way to the 32 millimeter coil.

[Chris Beck MD]
Really?

[Nima Kokabi MD]
Yes.

[Chris Beck MD]
What were you doing with those 32 millimeter?

[Nima Kokabi MD]
32 was a pseudoaneurysm that was coming in a patient with FMD that was coming off the pancreaticoduodenal arcade.

[Chris Beck MD]
Wow, okay. All right, going back though to a renal case, you like the TruSelect microcatheter, very nice, very slick, then Embolds are your coil of choice, detachable coils. If you see pseudoaneurysm versus extrav, how you approach those? Is it really any different, or you just group all those into vascular injury, treat it all the same, where you're just doing a vessel takedown?

[Nima Kokabi MD]
I generally do that. Sometimes I maybe do a touch of Gelfoam before I do the coil, but generally in the kidney, coil is enough because you don't have to worry about collateral vessels. In the GDA area, if I'm using coil, which is again my go-to, you do the back door, I sometimes do some Gelfoam in the middle and then do the front door, but generally, in the kidney, coil has been good enough for me.

[Chris Beck MD]
I like it. How subselective do you get? I know it sounds basic, but for the younger audience, do you get as absolute distal as possible? You try and leave as much kidney on the table?

[Nima Kokabi MD]
Exactly. You want to keep as much of the kidney, but again, you have to have the context of the clinical picture of the patient in mind as well. I had an attending at Yale who would tell us, life over kidneys anytime. They asked us, "Oh, but the patient has renal failure, can we give contrast, blah, blah, blah?" You have to put that in context, that if the patient is crashing on the table, you may not be able to be as selective as possible, but obviously, try to save as much of the kidney as you can.

(5) Technical Considerations After Renal Trauma Embolization

[Chris Beck MD]
Sure, absolutely. After you do your coils, you get your coils deployed, post-injection, do you do one through the microcatheter in the base catheter?

[Nima Kokabi MD]
Yes, I do both. I do one through the microcatheter because the idea with that is that if there's anything left to be done, you can continue with the coiling, and if everything is good, I'm also a big fan of doing another injection through the base catheter because sometimes you may be fooled with the microcatheter that yes, the flow through the vessel that you're embolizing has stopped, but then you do your injection through the base catheter and actually, it has not.

[Chris Beck MD]
Let me ask you this. How long do you wait from embolization to your post runs?

[Nima Kokabi MD]
It is a quick takedown. That's another thing I like about Embold because it is a fibered coil.

[Chris Beck MD]
Oh, they're fiber?

[Nima Kokabi MD]
Yes, they are. It's similar to the interlock, but I never liked using interlock because to me, it wasn't a really truly detachable coil. Once you had pushed it out of the microcatheter, you could never retrieve it, but people that use it, it's very popular, particularly among the vascular surgeons, the interlocks because A, it comes in a O35 platform as well, but the more important thing is the fact that it has fibers and a lot of times they use it for pre-EVAR. You end up using less coils. You don't have to get a perfect feeling of the vessel or the pseudoaneurysm that you get to get a cessation of flow.

Generally, the embolization is quicker, in terms of when you use any coil that has fibers on it, which both interlock and the Embold coil, which I use now for most of my embolization, actually has that. Particularly, that's important in the setting of a patient who has hemodynamic instability and hemorrhagic shock. You want to be as quick as possible. That's one of the advantages of it.

Then the other thing that I like about it is the fact that it actually is the only coil that I know of on the market that actually the pusher is nitinol. I'm very impatient. I don't know about you, Chris, when I'm pushing these coils in, I want to go as fast as possible. A lot of times I end up bending coils that are actually on a non-nitinol base. For the first time, there is a coil that I can push as fast as I can, and I can totally bend it even 180 degree and it doesn't actually kink. That's another advantage of the Embold coil that I like.

[Chris Beck MD]
How long do you wait after you embolize, it's almost immediate?

[Nima Kokabi MD]
With the fiber coils, I give it about a minute to two. With the purely metal coils, you need to probably do more coils because you want to get complete feeling, because you're solely relying on the metal to stop the blood flow. Generally with the metal, I would say about four to five minutes before I make a decision if I need another coil, whereas with the fibers, about two minutes.

[Chris Beck MD]
Sometimes that two minutes and that five minutes - that can be a long time.

[Nima Kokabi MD]
I know. Again, I'm not waiting between every coil, two or five minutes. When I feel visually that it is good enough for that vessel, then that's the time I would wait.

[Chris Beck MD]
Special considerations, is there any conversation around, or do you have any clinical scenarios where you have patients with nephrostomy tubes, and they're having hematuria, but you can't find the bleed with the drain in? It's similar to when you have it with same thing with biliary drains. Do you do anything different where you have them prone, and then you take out the drain, do an angio?

[Nima Kokabi MD]
That's actually another good thing for people that are radial fast.

[Chris Beck MD]
Exactly what I was thinking.

[Nima Kokabi MD]
That's another good application for doing an angiography through a radial access because unlike the liver, which is much easier, if you have a biliary drain and they have hemobilia to do an angiography with the patients supine, you can remove the catheter or wire, and then do another angiography. With kidneys, it becomes very difficult to do that. If you put them in a prone position, you can easily actually access the radial artery with the arm of the patient on their side, and then go into the kidney, do an angiogram with the nephrostomy tube in place, and then if you don't see anything removed in a nephrostomy tube over the wire, then repeat that angiogram. I think for people that are not a believer in radial access, that's another good application for it.

[Chris Beck MD]
I think that's actually super elegant solution. I've never had to do it, but I feel pretty comfortable with radial and I've always known that that's in my back pocket. I kind of feel similar to you, Nima, about radial access, that it's not appropriate for every case, but it's a good fit for some patients. If you're comfortable in both worlds, I think there's going to be a lot of clinical scenarios that you're going to be glad you have it in your back pocket.

[Nima Kokabi MD]
I think as a trainee particularly, and I know you have a lot of trainee fans who listen to you guys religiously, I think you should make every effort to become proficient at both techniques because a lot of times in very difficult situations, one may be a better option than the other. You would like to have both proficiencies in your back pocket, for sure.

[Chris Beck MD]
All right. Anything that I didn't cover in terms of embolization or technique because I was going to move on to post-care? Anything I missed that you were thinking, Nima?

[Nima Kokabi MD]
No, I think that was very comprehensive. Thank you.

(6) Renal Trauma Embolization Post-Procedural Care

[Chris Beck MD]
All right. Post-care. Standard angio precautions, clearly. I would like to know, how long do you stay on board for trauma injuries? How long do you continue to follow patients, and when do you sign off the service? Because these trauma patients can hang around for a pretty long time, they have a long road ahead of them. I was just curious like how long they set on service.

[Nima Kokabi MD]
Admittedly a lot of IRs, including myself and my group, a lot of times we don't do a very good job of following these patients for at least extended period of time. We are busy, we get all these other consults that we have to do, and these are patients, as you said, that stay sometimes in the hospitals for months because of all the other distracting injuries that they have.

Generally, we do one to two days of follow-up, and then if they're stable from the standpoint of the area that we've worked on, we sign off on them. A lot of times, I learn from my cases when I go back and look at them for presentation purposes, that actually, oh, a lot of things have happened that I wish I knew if I was following the patients.

My advice is the longer you can follow the patients, the better. We all have to be realistic, in terms of the world we live in. A lot of times we don't have those options.

[Chris Beck MD]
Bare minimum, you guys at least stay on, one or two days to check access sites, and make sure patients are clinically stable?

[Nima Kokabi MD]
Yes, for sure.

[Chris Beck MD]
I guess in the trauma setting, almost all of them end up either on a trauma floor or in high-acuity floor, right?

[Nima Kokabi MD]
That's correct.

[Chris Beck MD]
Anything else that I didn't mention in terms of like, I sometimes think kidney injuries, any reason to track GFR? Are there any labs that you look at after, but really when you're thinking trauma, I feel like over you, choose life over kidney and that you want to preserve as much kidney's function, you want to reduce your contrast load, but in the end, you really have to stop a bleed from a patient who's acutely ill?

[Nima Kokabi MD]
No. just I would again go back to biopsy. I know this wasn't biopsy talk, but be very vigilant with biopsies. For the trainees in the audience, watch those patients very carefully. A lot of times, if I'm worried about a bleed, I would keep the patient for another five minutes on the table, post-biopsy and repeat it. If the bleeding hasn't increased in size, then I would let them go to the post-procedure area. Be very scared of renal biopsies is what I'm going to say, because they can cause a lot of trouble for the patients if they bleed.

[Chris Beck MD]
I think that's very telling, especially for the younger audience, like the trainees, I'll drill down on it like Nima did. We're talking about embolizations for trauma and kidney, but really how we started and ended our talk was about just be careful with kidney biopsies.

[Nima Kokabi MD]
Yes.

[Chris Beck MD]
Well, Nima, thank you so much for coming on the show. Any final thoughts or anything I didn't mention that you wanted to bring up?

[Nima Kokabi MD]
No. Thanks, Chris, for having me. This is great. I've personally learned a lot from your BackTable podcast. Keep up the good work is all I'm going to say.

[Chris Beck MD]
Well, as long as we have good IRs like you who are willing to come along and donate some of your time with us, we're going to keep putting it out there. We really appreciate it.

[Nima Kokabi MD]
Oh, you can count on me.

[Chris Beck MD]
All right. Thank you, Nima.

[Nima Kokabi MD]
Any time, yes.

[Chris Beck MD]
That goes to all of our hosts out there who are listening, we really appreciate you guys. To our audience, also, thank you for listening. If you enjoyed the show, but want more, check out the show notes of this episode we're going to put some up. We have a lot of people that work very hard on those. You can find those at https://www.backtable.com/ . Remember, the show notes are where you can also find a link to get some free CME.

For others interested in supporting the show, like, subscribe, or share this podcast on social media, or just go old school, tell a colleague about it. Word of mouth goes a long way to help us continue to build this community.

That wraps things up. We'll see you next time on the BackTable podcast. Nima, thanks for coming on the show, dude.

[Nima Kokabi MD]
Thank you.

Podcast Contributors

Dr. Nima Kokabi

Dr. Nima Kokabi is an interventional radiologist at Alberta Health in Calgary, Canada.

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Cite This Podcast

BackTable, LLC (Producer). (2023, May 15). Ep. 322 – Renal Trauma Embolization [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.