The team began searching for a solution. “The cases were incredibly complex, and the technical approaches required a lot of thought,” says Dr. Rilling. “We bounced things off one another constantly. But it was a new challenge, and an exciting opportunity.”
The baby was in distress, and there wasn’t much time to work through the options. With a maximum timeframe of a couple of days, Drs. Tutton and Rilling bounced ideas off of one another constantly. “We asked ourselves, What can we grab off the shelf and adapt?” Rilling says. The stability of the device was their greatest concern—a big unknown made especially difficult with a moving baby. They decided on a Seldinger- based technique, in which a skinny needle (18 gauge) was used to guide a wire with a smaller catheter threaded over the wire. “It was tried and true, widely used in many systems,” Dr. Tutton says. “We adapted the concept to these fetal interventions, believing that the smaller needle would require less force, therefore being less invasive and less risky.”
The basic technique remained the same, but the team made refinements in the size of the shunt to optimize positioning and used a peel-away sheath for deployment. They adapted a catheter that had been used in babies with blocked ureters, a 4.5 French double J pigtail catheter. They modified the catheter, trimming it down, and cut off the back end so it would culminate in a pigtail loop. After the catheter was guided into the baby’s chest cavity, the trailing end hung out of the chest so that the fluid would drain out of the lung into the amniotic sac.
Other crucial considerations included ensuring that the baby was facing the right way, toward the “placement window” deemed optimal for the catheter insertion, and that he would not move or turn away. “We needed to provide anesthesia for the fetus,” says Dr. Tutton. “That’s not something we usually think about.” The team delivered a mild paralytic and a pain medication into the baby’s thigh, striving to minimize distress and discomfort.
The procedure took 20–40 minutes. There was lots of built-up pressure in the chest cavity due to the fluid. The tube was a check valve, and the team was able to see the chest expand and return to equilibrium through the use of sophisticated color Doppler US.
That first patient is now five years old. Last year, he and the entire medical team were honored at a Milwaukee Brewers game. In all, the team performed the procedure five times; they were unsuccessful in one case and had to place a second catheter.
The technical challenges were not the only ones posed in these cases; there were ethical considerations as well. “The babies were 100 percent viable, but the condition was 100 percent fatal; it was a high-stakes situation. There was a clear consensus among the members of the team that we should move forward with the procedure,” says Dr. Tutton, who notes that their plan was reviewed not only by the department chairs but an objective second group of doctors was well. The procedure was performed usually at 23 to 28 weeks gestation, which delayed the birth long enough for the babies’ lungs to mature.
“Technology used in other organ systems was reinvented to create a procedure that was safer for mom and baby,” says Sarah B. White, MD, MS, who collaborated with Drs. Tutton and Rilling to publish the series of five cases in the Journal of Interventional Radiology.
The nature of the profession enables and nurtures innovation, Dr. Tutton says. “The way I look at it, the surgical world is maximally invasive. We are all about administering our skill set and expertise to reduce invasiveness, which reduces pain, suffering and risk. Anytime we are in a difficult situation, we have our eyes open to the steps involved and look for things in our own world that are similar, better, and think, How can I adapt that? IR is a good substrate for thinking outside the box.”
Dr. Tutton applies his design thinking to many aspects of his practice—an intentional approach to innovation. “I ask myself, What things in our daily workflow irritate me? I try to reexamine
Read more cases like this in JVIR “Extreme IR” articles
If you’d like to read about other IRs responding to clinical situations prompted by extreme necessity, watch for the Extreme IR series in the Journal of Vascular and Interventional Radiology (JVIR). This series highlights innovative solutions to unusual, unanticipated interventional radiologic and endovascular procedural dilemmas that require extraordinary measures. Past topics have included (among others):
• Retrograde renal ablation via the renal vein as a new treatment option for renovascular hypertension
• Handling double-barrel stent-graft catastrophe
• Spinal cord radiofrequency destruction
the tools and procedures from a different perspective.”
Perhaps enthusiasm and intellectual curiosity also enable innovation. Drs. Tutton and Rilling approach their practice from a like-minded perception of themselves as problem solvers. Despite their experience and successes, they are anything but jaded.
“After 19 years, I find the work so intellectually stimulating. It gets me up in the morning,” says Dr. Tutton.
“When you’re coming upon a unique problem with cooperation, communication and varying perspectives, it’s amazing what can be accomplished. That’s innovation,” says Dr. Rilling.
Jennifer J. Salopek is a freelance writer based in McLean, Virginia. She can be reached at
jjsalopek@cox.net.
WINTER 2016 | IR QUARTERLY 17
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