primer on interventional radiology procedures

Interventional Radiology

Aaron Shiloh MD FSIRSection Chief

Interventional Radiology

A Primer on Minimally Invasive

Image Guided Therapies

Overview• Paracentesis• Thoracentisis• PICC Line• Can this be biopsied?

Overview• Basics of liver directed

therapy• Embolization• PE lysis• Arterial disease and CVI

Liver Directed Therapy

Local

• RFA

• Microwave

• Cryoablation

Regional

• Chemoembolization

• Drug-Eluting Bead embolization

• Y90 (Glass and Resin) Beads

Interventional Oncology

Local Treatment Options Microwave Ablation

Microwave Ablation (MWA)

MWA – “the application of high frequency electric currents to heat and coagulate

target tissue”

MWA – A Variety of Applications

Liver Kidney Bone Lung

MWA Pathology

Hyperemic Rim

Coagulation zone(= MWA lesion)

MWA AblationNSC Lung Cancer

3 cm MWA 3 mo S/P MWA/XRT

18 mo S/P MWA/XRT

Post MWAPre MWA

MWA Images Pre & Post CT

65 year old male with recurrent liver mets from CRC

after multiple cycles of chemo

Colorectal Metastatic Disease

Two PET positive lesions

Immediate post microwave ablation

6 month follow-up

84 yo malewith

multipleMedical

problems And a

growing RCC

Summary of MWA Advantages

Preserves liver function in cirrhotic patients Minimally invasive

Local effect Potential for improved quality of life when

combined with radiotherapy and chemotherapy Repeatable for recurring disease

Interventional Oncology

Regional Therapeutic Options

Interventional Oncology

Chemoembolization&

Bland Embolization

Chemoembolization & Bland Embolization

HCC Metastases

Neuroendocrine Colorectal Breast Melanoma RCC

TheraSphere®

HCC one of most common forms of cancer worldwide (est. 1 million new cases annually) In US, NCI estimate 19,160 new cases and 16,780

deaths in 20071

Incidence increasing with rise in hepatitis C-induced cirrhosis

5-10% of HCC patients are resectable2 1 National Cancer Institute www.cancer.gov (accessed December 1, 2008)2 Llovet, JM. Current Treatment Options for Gastroenterology. 2004;7:431-441

HCC Epidemiology

HCC: Difficult to Treat, Few Effective Treatment Options

Tenuous liver functions (cirrhosis, hepatitis)

Spontaneous decompensation Resistant to standard chemotherapy and

low dose radiation Responsive to high dose radiation

TheraSphere®

HCC Epidemiology

Limited Treatment Options for HCC

Therapeutic Options: Resection or transplantation

Unresectable HCC treatment options: Radiofrequency ablation Transarterial chemoembolization (TACE or Drug

Eluting Beads) Transarterial TheraSphere, Y90 Glass Microspheres External Beam radiation Systemic therapy (ie. Sorafenib) No treatment

TheraSphere®

What is TheraSphere®

20-30 µm glass microspheres Y-90 is an integral constituent of the glass

matrix Innovative treatment to deliver powerful, targeted

radiation inside the liver

Y-90 glass microspheres comparison to human hairTheraSphere dose vial

Administered via hepatic artery catheter

Targeted internal radiation due to tumor hypervascularity

Microspheres are trapped in the tumor arterioles and are minimally-embolic (microembolization)

Pure beta-emitter Average beta emission energy is

0.9367 MeV Average penetration range in

tissue is 2.5 mm Physical half-life is 64.2 hours and

decays to stable zirconium-90

TheraSphere®

Mechanism of Action

• 52 year old male with alcoholic hepatitis with ascites and pleural effusions.

• Cirrhosis lead to CT and MRI

• PMH: Ascites, Pleural effusions, right nephrectomy

• ECOG 0, CP A

• 3 cm Tumor seen in right lobe, segment 7

• AFP not elevated

June 2010

July 2010

Mapping August 2010

Therasphere administration

Sept 2010 – One month post treatment

Jan 2014

2010-2014

Embolization Tools

• Coils• Gelfoam• Alcohol• Particles• Glue

• 42 y/o obese female with Right 3 cm AML treated 8 yrs prior with

embolization at another institution when the AML was alledgedly 7 cm

and spontaneously bled.

Bronchial Artery

The patient presented with hemoptysis and a known right

perihilar lung cancer. The patient had been previously brought to the

operating room where an endotracheal tube was placed as

well as a bronchial blocker

GDA• Duodenal ulcer oversewn 10 days prior• Repeat severe upper gi bleeding• At endoscopy found to have a large visible

vessel that was bleeding and three clips were placed.

Embolization

Uterine Fibroid Embolization

Procedure Small incision

in skin

Uterine Fibroid Embolization

– Catheter inserted into femoral artery

Femoral Artery

Procedure

Uterine Fibroid Embolization

– Dye is injected

– Blood no longer reaches fibroids

UterineArtery

– Catheter is steered to uterine artery

– Small inert particles “emboli” are injected– Branches of uterine

artery are blocked

– Fibroids shrink over time

Procedure

PE and DVT lysis

• Basics of PE and DVT lysis

Massive PE Submassive PE Minor/Nonmassive PEHigh risk Moderate/intermediate risk Low risk

•Sustained hypotension (systolic BP <90 mmHg for ≥15 min)

• Inotropic support•Pulseless•Persistent profound bradycardia (HR <40 bpm with signs or symptoms of shock)

•Systemically normotensive (systolic BP ≥90 mmHg)

•RV dysfunction•Myocardial necrosis

•Systemically normotensive (systolic BP ≥90 mmHg)

•No RV dysfunction•No myocardial necrosis

RV dysfunction• RV/LV ratio > 0.9 or RV systolic dysfunction on echo• RV/LV ratio > 0.9 on CT• Elevation of BNP (>90 pg/mL)• Elevation of NTpro-BNP (>500 pg/mL)• ECG changes: • new complete or incomplete RBBB• anteroseptal ST elevation or depression• anteroseptal T-wave inversion

Jaff et al. Circulation 2011;123(16):1788-1830.

LVRV

Jaff et al. Circulation 2011;123(16):1788-1830.

Background and Definitions

− Registry of 1,416 patients

− Mortality rate: 1.9% if RV/LV ratio < 0.96.6% if RV/LV ratio ≥ 0.9

Fremont et al. CHEST 2008;133:358-362

How to Determine Risk

Degree of PE Treatment* Bleeding Risk

Non-Massive Heparin (I) Less

Sub-Massive Lytics (IIb)

Massive Lytics (IIa) More

20% risk of major bleeding3% risk of intracranial hemorrhage

*ACC/AHA Guidelines 2011 Circulation 2006;113:577-82

Treatment of High Risk Patients

The ULTIMA Trial

A Prospective, Randomized, Controlled Study of Ultrasound Accelerated Thrombolysis for the Treatment of Acute Pulmonary Embolism

Annual Meeting of the American College of Cardiology, March 9, 2013

Treatment of High Risk Patients

Systemic Lytics v Heparin

EKOS v Heparin

Total Lytics Dose 100mg 20.7mg (12.2mg)

Mortality 5.9% -> 4.3% 1/29 -> 0/30

RV Size Improved Improved

RV Function Improved Improved

Major Bleeding 20% 0/30

ICH 3% 0/30

Arterial DiseaseOne patient, many techniques

Chronic Venous Insufficiency

Epidemiology: Prevalence

Of the over 30 million Americansaffected:• Only 1.9 million seek treatment

annually1,2

• While the vast majority remain undiagnosed and untreated

CVI Prevalence*,1,2

30,000,000+

Seek Treatment *2 1,900,000

Treated447,0002 (Table 30)

*Statistics based on individuals over the age of 40

More than 30 million Americans suffer from varicose veins or a more seriousform of venous disease called Chronic Venous Insufficiency (CVI).1

1. Gloviczki P, et al. The care of patients with varicose veins and associated chronic diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. JVS; May 2011.2. Lee, A. US markets for varicose vein treatment devices 2011. Millennium Research Group, Inc. (A Decision Resource, Inc. Company), www.mrg.net, May 2011.

Epidemiology: Risk FactorsMany factors contribute to the presence of venousdisease and CVI including1,2,3,4,5:

• Gender

• Age

• Family history

• Multiple pregnancy

• Standing occupation

• Obesity

• Prior injury or surgery

1. "Chronic Venous Insufficiency." Vascular Web. Society For Vascular Surgery, Jan. 2011. Web. 17 Aug. 2011. http://www.vascularweb.org/vascularhealth/Pages/chronic-venous-insufficiency.aspx. 2. Maurins U, Hoffmann BH, Lösch C, Jöckel KH, Rabe E, Pannier F. Distribution and prevalence of reflux in the superficial and deep venous system—results from the Bonn vein study, Germany. J Vasc Surg.2008;48:680-87.3. Criqui MH et al. Epidemiology of chronic peripheral venous disease; JJ Bergan Editor, The Vein Book, Elsevier Academic Press .(2007):30.4. Chiesa R, Marone EM, Limoni C, Volonte M, Schaefer E, Petrini O. Chronic venous insufficiency in Italy: the 24-cities cohort study. Eur J Vasc Endovasc Surg. 2005;30:422-429.5. Rabe E, Pannier F. Epidemiology of chronic venous disorders; P. Glovicki, Editor, Handbook of venous disorders (3rd edition), Hodder Arnold.(2009);109.

Anatomy: Venous System

• Venous blood flows from the capillaries to the heart

• Flow occurs against gravity– Muscular compression of the

veins – Negative intrathoracic pressure– Calf muscle pump

• Low flow, low pressure system

Etiology & Pathophysiology

Healthy veins, with competent vein valves, keep blood moving in one direction back to the heart

Diseased veins, with damaged vein valves, cause blood to move in both directions, elevating venous pressure

Single puncture percutaneous access under ultrasound guidance

Temperature controlled 85°C heating at or below deep fascia

Endovenous ablation specifically indicated to treat incompetent perforator veins

The Venefit™ Procedure with the ClosureRFS™Stylet

The Venefit™ Procedure with the ClosureRFS™Stylet

• Ultrasound exam to diagnose vein reflux

• Outpatient or hospital procedure

• Local or general anesthetic

• Quick return to normal activities – often within a few days1

Click graphic to play video

1. Roth S, Endovenous radiofrequency ablation of superficial and perforator veins, Surg Clin N Am 87:1267-1284(2007)

*Indications, contraindications, warnings, and instructions for use can be found in the product labeling supplied with each device.CAUTION: Federal (USA) restricts this device to sale by or on order of a physician.

So I was working on this grand rounds talk. I was reviewing old presentations and I came upon this case presentation from 2013.

Case Presentation• 84 year old female with chronic autoimmune

hepatitis

• LFTs elevation lead to CT

• PMH: Atrial Fibrillation, Hypertension, hypothyroidism

• ECOG 0, CP A

• T. Bili 0.8, cr 0.8, AFP 3320

2016

Thank you!