Thread by @keithppereira

Today's 8 am #UFE begging to leave hospital at 10.30 am....we found a middle ground 11 am

The secret 🤫: #RadialFirst and #SHNB

#Tweetorial on technique and troubleshooting....

🧵1/

Relevant anatomy:
Sup hypogastric nerve plexus- sympathetic nerve plexus anterior to L5 body
Aortic bifurcation-L4
Venous confluence- L5, L5-S1 disc (*overlies the plexus 😱)

2/

Although arterial opacification can be avoided with an angiogram, venous opacification is sometimes inadvertent and maybe seen in nearly 1 in 5 cases.

We still go ahead with #SHNB:
➡️ Adjust needle position
➡️ Multiple aspirations
➡️ Test dose

3/

Technique:
1️⃣ Prep belly before Radial access
2️⃣ Aortogram after embo
3️⃣ Flat panel CC view for AP view of L5
4️⃣ 21 G 20 cm Chiba
5️⃣ Target AP, confirm 'on bone' ( lower L5)
6️⃣ Inject contrast
7️⃣ Lateral view and contrast

4/

8️⃣ Test dose 0.5% Ropivacine ( less motor issues, less AE)
🔟 Inject about 15-20 cc in 3 cc aliquots

During injection:
✴ on bone, off bone, aspirate no🩸, inject 💉

5/

Troubleshooting:

Large body habitus and uteri:
Difficult to direct ⏩ 20 G needle, sometimes 18 G 20 needle

👀 Watch for Local Anesthetic Systemic Toxicity (LAST): rare but serious complication

6/

SHNB is a useful tool in the Interventional armamentarium to
make UFE a better experience for patients with fibroids, allowing for better pain control and facilitating SAME DAY DISCHARGE. Lets strive to achieve the best for our patients.

Link @cvirendo:
cvirendovasc.springeropen.com/articles/10.11…