Routine DSA use?

[Baron Samedi]

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Just curious what others' practices are. I don't perform CTFESI, which would be my primary use for it. Generally, for LTFESI I use live fluoro and for SGBs I use live fluoro and an epi wash for another vascular marker. This has left me questioning when else it would be appropriate? Celiac plexus blocks through big red, maybe? Certainly for any of the above if live fluoro gives a questionable pattern.

 

[callmeanesthesia]

Cervical TFESI only (and I try to avoid those). Lumbar I’m using dex so the increased radiation exposure to represents greater harm than the risk of an occasional failed injection. Stellate I do under fluoro and ultrasound, but I’d consider DSA.

 

[deleted993114]

Just curious what others' practices are. I don't perform CTFESI, which would be my primary use for it. Generally, for LTFESI I use live fluoro and for SGBs I use live fluoro and an epi wash for another vascular marker. This has left me questioning when else it would be appropriate? Celiac plexus blocks through big red, maybe? Certainly for any of the above if live fluoro gives a questionable pattern.

I had it on a c-arm at one office.

It gives you prettier pictures, if surgeons are asking for evidence of a selective block, particularly if you have a “swing and a miss” with initial contrast.

Otherwise, I don’t see the need for it. It’s one of those things that if available in the c-arm, great. If not- fine.

It’s kind of like rad techs for a c-arm. If they are there- great. If not- fine.

 

[DOctorJay]

https://www.painphysicianjournal.com/current/pdf?article=MTgwMQ==&journal=71

 

[soccrwz]

Tim Maus: isn't foolproof, not recommended for routine use<- at one of his lectures

 

[MD87]

I really don’t understand the value of routine DSA or even live fluoro for lumbar TFESI if using non-particulate steroid. DSA misses some vascular, and live misses even more vascular. If I inject a little contrast and take a picture and something looks off, then I will inject under live to get a better sense of things. I inject 10mg of dex, and that one study says 4mg+ is all the same as far as efficacy. If a still fluoro shot shows epidural flow, even if half of the medication ends up being vascular, I figure enough of it is going in the epidural space that it should help the patient. Who cares if some of it ends up venous or even arterial? All of the vascular coring and vasospasm stuff is theoretical (I think? Please tell me if I'm wrong), and I figure repositioning if you a tiny bit of vascular flow may end up causing more damage to the vessels in that area than just injecting and pulling the needle out and being done with it. I almost feel that if the fear of hitting an artery is SO great even if using dex, then we should just abandon TFESI all together and stick to ILESI.

I love SIS, but they have “Fact Finders” that say that you need to use DSA and/or Live for TFESI, and their explanation as to why really just doesn’t do it for me. If detection of vascular is so important, how can you be OK with using just live, when we know DSA is superior to it?

 

[epidural man]

Cervical TFESI only (and I try to avoid those). Lumbar I’m using dex so the increased radiation exposure to represents greater harm than the risk of an occasional failed injection. Stellate I do under fluoro and ultrasound, but I’d consider DSA.

This is a good point.

I use it for all TFESI's and for lumbar and thoracic plexus blocks - especially with ETOH/Phenol injections.

However, maybe routine use for TFESI causes more harm. I'll have to think about this.

I will say this - data would suggest that DSA increases sensitivity to finding intravascular injections. However, I have never picked up on a vascular placed injection on DSA that I didn't already see with just live fluoro.