Advanced Procedures

Endoscopic Ultrasound (EUS) a minimally invasive procedure that assess gastrointestinal and lung diseases.

A special endoscope uses high-frequency sound waves to produce detailed images of the lining and walls of the digestive tract and chest, nearby organs such as the pancreas and liver, and lymph nodes. When combined with a procedure called fine-needle aspiration, EUS allows the doctor to sample (biopsy) fluid and tissue from the abdomen or chest for analysis. EUS with fine-needle aspiration can be a minimally invasive alternative to exploratory surgery.

Why is it done?

EUS is used to find the cause of symptoms such as abdominal or chest pain, to determine the extent of diseases in the digestive tract and lungs, and to evaluate findings from imaging tests such as a CT scan or MRI.

EUS may help in the evaluation of:

• Cancer of the colon, esophagus, lung, pancreas or stomach, and ampullary and rectal cancers
• Lymphoma
• Barrett’s esophagus
• Neuroendocrine tumours
• Pancreatitis and pancreatic cysts
• Bile duct stones
• Sarcoidosis

EUS can help:

• Assess how deeply a tumour penetrates the abdominal wall in esophageal, gastric, rectal, pancreatic and lung cancers
• Determine the extent/stage of cancer, if present
• Determine if cancer has spread to the lymph nodes or other organs
• Provide precise information about non-small cell lung cancer cells, to guide treatment
• Evaluate abnormal findings from imaging tests, such as cysts of the pancreas
• Guide drainage of pseudocysts and other abnormal collections of fluid in the abdomen
• Permit precise targeting for delivering medication directly into the pancreas, liver and other organs

EUS is performed on an outpatient basis and is well-tolerated by most people.

What are the risks involved?

EUS is generally safe when performed at a centre with an experienced and expert health care team. The doctor discusses with the patient the risk of complications from EUS. These risks are most commonly associated with fine-needle aspiration.

Risks may include:

• Bleeding
• Infection
• Tearing of the intestinal wall or throat
• Pancreatitis, if fine-needle aspiration of the pancreas is done

These risks associated with Endoscopic ultrasound can be prevented by following the instructions of the doctor carefully during the preparation process of Endoscopic ultrasound.

There might be some signs and symptoms observed after the Endoscopic ultrasound scan, which are to be taken care of. However, consulting the doctor is always advisable:

• Difficulty in breathing
• Fever
• Pain in the chest
• Difficulty in swallowing
• Vomiting
• Dark or black coloured stool
• Persistent or severe pain in the abdomen

How to prepare for the procedure

The doctor will give specific instructions to prepare for the EUS. The patient may be asked to:

• Fast before EUS to make sure stomach is empty. Generally, fast for at least 6 hours before the test is needed.
• Prepare the rectum, if EUS is being done in the rectal area. Patient may be asked to take a laxative or have an enema and to follow a liquid diet before the procedure.
• Stop taking certain medications, such as blood thinners. Blood thinners may increase the risk of bleeding if fine-needle aspiration is performed during EUS. If one has chronic conditions, such as diabetes or high blood pressure, then the doctor would give specific instructions regarding medications.
• Plan ahead for your recovery, if the patient would be sedated before EUS. Most people who have EUS are given medication to relax them.

What are the expected results?

The gastroenterologist and pulmonologist are the ones who interpret the images of the scan carefully. If the scan is combined with the fine needle aspiration, then the lab report is sent by the pathologist and the doctor discusses the finding with the patient and plans for the treatment if any abnormality is detected.

Intravascular ultrasound (IVUS) – a combination of echocardiography and a procedure called cardiac catheterization. IVUS uses sound waves to produce an image of the coronary arteries and to see their condition. The sound waves travel through a tube called a catheter. The catheter is threaded through an artery and into the heart. This test lets doctors look inside your blood vessels.

IVUS is rarely done alone or as a strictly diagnostic procedure. It is usually done at the same time that a percutaneous coronary intervention, such as angioplasty, is being performed.

How does it work?

IVUS uses high-frequency sound waves (also called ultrasound) that can provide a moving picture of the heart. The pictures come from inside the heart rather than through the chest wall. The sound waves are sent with a device called a transducer. The transducer is attached to the end of a catheter, which is threaded through an artery and into the heart. The sound waves bounce off of the walls of the artery and return to the transducer as echoes. The echoes are converted into images on a television monitor to produce a picture of the coronary arteries and other vessels in the body.

Advantages of Intravascular Ultrasound

• IVUS enables a physician to get inside the artery with a camera-like device.
• IVUS can quantify the percentage of narrowing and give insight into the nature of the plaque.
• It also may reveal what in the past has been referred to as “re-stenosis” (a recurrence of the plaque build-up that may have previously been removed).
• There is evidence that this is not a re-stenosis but rather the IVUS’s ability to see build-up that may have been missed during an angiogram and angioplasty.

What to Expect During Intravascular Ultrasound?

IVUS is an invasive procedure and, as such, comes with the risks associated with any invasive procedure.

The entire procedure might take less than an hour or as long as several hours:

• An area around the groin will be shaved and cleaned in preparation for the insertion of a catheter (a thin tube)
• A mild sedative is administered to aid in relaxation
• A local anaesthetic is injected into the catheter site
• The imaging physician directs this catheter, painlessly, through arteries until it reaches the area to be studied
• A guide wire with an ultrasound probe on its tip is inserted into the catheter and guided to the furthest position to be imaged
• Sound waves are emitted from the probe. The probe also receives and returns the echo information, sending images to a computer
• The guide wire is held in place and the probe is slid backwards – usually under steady, smooth, motorized control – sending and receiving ultrasound images along the way.

Results of the Intravascular Ultrasound

The blood vessel wall inner lining, atheromatous disease within the wall, and connective tissues are echogenic (they return echoes making them visible on the monitor). Blood and healthy muscular tissue are echolucent (they return no images, just black spaces on the monitor).

Heavy calcium deposits are very echogenic, which means they reflect sound, and are distinguishable by shadowing. Heavy calcifications are reflected as bright images with shadowing behind it.

Patients need to meet with their physician to discuss their test results and any recommended treatment plans.

MICRA – World’s smallest pacemaker

Bradycardia is a condition where one’s heart rate is slower than normal (less than 60 times a minute). This can turn into a serious condition if it leads to the heart not pumping enough blood into the body. Dizziness, fatigue, shortness of breath, chest pain and confusion are common symptoms. Some patients also experience blackouts.

A Pacemaker is a device that is implanted inside the body to regularize the patient’s heartbeat. Over the years advancing medical technology has seen vast improvements in the device, making it longer lasting, reducing the complications and making it easier to monitor. Traditional pacemakers work by sending electrical impulses through wires, or leads, and come with a pulse generator (to create electric pulses) and electrodes (which sense the natural heartbeat and send the pulse when it becomes abnormal). These are placed outside the heart, either in the chest or abdomen.

Leadless pacemaker is a relatively new device that has no wires. It is a small and compact device with the pulse generator and electrodes inside it. It is placed inside a chamber of the heart through a small tube inserted in the vein.

Research and development work is on to make the device more user-friendly while increasing its performance and longevity. The latest innovation in this field, MICRA is the world’s smallest leadless pacemaker.

• It is as large as a vitamin capsule and 93% smaller than most conventional pacemakers.
• It is implanted via a vein in leg which makes the procedure less invasive.
• It has fewer medical complications and fewer post-implant activity restrictions.

Features of MICRA

• Allows safe magnetic resonance imaging (MRI)
• Adjusts heart rate automatically by sensing changes in the body as per your activity level
• Its battery lasts between 8 and 13 years

Some common queries you may have about the MICRA?

Will items containing magnet affect it?

Yes, it may. It is best to keep items containing magnets at least 6 inches away from the implanted pacemaker. This includes mobile phones, magnetic therapy products, stereo speakers, and handheld massagers. It is best not to put a mobile phone in your shirt pocket or use magnetic mattress pads and pillows.

Is it safe to exercise after the implant?

Yes, one can return to usual activities and exercise, as long you do not exceed your fitness level

What happens when the battery runs low?

When a new device is required, the Micra device may either be turned off or be removed from the body before the other device is implanted. The doctor will determine what is best for you.

What is the follow-up routine post implant?

Usually the first follow-up is after a month of the implant and at every 6-12 months gap after that, or as per your doctor’s advice.

Sustained low-efficiency dialysis or SLED is a renal replacement therapy for patients with end stage kidney disease in the intensive care unit. A hybrid therapy, it has features of both conventional intermittent haemodialysis (IHD) and continuous renal replacement therapy (CRRT). Because of certain inherent advantages, it plays an important role in critically ill patients.

Advantages of SLED

• The sessions are shorter, thus the patient’s exposure to anticoagulant is also less
• Efficient clearance of small solutes
• Good hemodynamic tolerability – much better than IHD
• Flexible treatment schedules – the short duration of the therapy leaves the patient free most of the day
• Easy to perform
• Anticoagulant may not be required as saline flushes are usually sufficient
• A lot cheaper than other therapies

A minimally invasive heart procedure, TAVR is performed to replace a narrowed aortic valve that fails to open properly. It can also sometimes be referred to as transcatheter aortic valve implantation (TAVI). It is a good option for people who are at high risk of complications of an open-heart surgery.

When is it required?

Thickening and calcification of the heart’s aortic valve can lead to stenosis, preventing the valve from functioning properly and opening fully, which limits blood flow from the heart to the rest of the body. Symptoms like chest pain, fatigue, swelling in the leg and shortness of breath, are common fallouts and may sometimes lead to heart failure or even sudden cardiac death. Post examination and diagnostic tests to understand the seriousness of the condition, your heart team (of cardiologists and cardiac surgeons) may recommend TAVR depending on your medical history and other complications.

TAVR is usually a recommended option if:

• You are showing signs and symptoms of stenosis
• You are at risk of complications from surgical aortic valve replacement or have a Kidney or lung disease that increases your risk of complications during surgical aortic valve replacement.
• You have a tissue valve but it is not working well

Is it risky?

No more than other interventional procedures. Risk of complications like bleeding, blood vessel complications, stroke and infections remain, they are, however, minimal and depend largely on the experience of the clinical team and the medical facility.

After the procedure

One may need to spend the night in the intensive care unit for monitoring after the procedure. However, some may need two to five days recovering in the hospital.

You doctor will prescribe certain medications, including blood thinners, post the procedure and shall recommend certain lifestyle changes that are essential for the continuing good health of your heart.