intro to ir umd talk
TRANSCRIPT
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Introduction To Interventional Radiology Introduction To Interventional Radiology
Examples: Liver Cancer, Blood Clots, and Infection Examples: Liver Cancer, Blood Clots, and Infection
Karun Sharma
Children’s National Health System, Washington DC
October, 23, 2013
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What is Interventional Radiology?
– Image guided Therapy: Combines patient care with cutting-edge technology, tools and techniques.
– A subspecialty of radiology that uses imaging guidance (X-ray, Ultrasound, CT Scan and MRI) to perform minimally invasive procedures (less invasive than surgery) using needles and catheters rather than scalpels
– www.sirweb.org
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Uses Anatomy and Imaging to Navigate Inside the Body
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Tools of the Trade: Where we work
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Tools of the Trade: What we use
3 Fr=1mm
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IR Procedures
• Vascular – Open up narrowed arteries (angioplasty & stenting)– Close off bleeding arteries (embolization: coils and
particles)– Put chemotherapy directly into tumors using arteries
• Chemoembolization (Liver Cancer) – Remove blood clots in arteries and veins
• DVT Thrombolysis
• Non Vascular– Image guided Biopsy (Liver, Kidney, other organs)– Image guided Tumor Ablation– Image guided Abscess Drainage
• Treatment of life threatening Infection
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IR Tools - Hands On Session
• Catheters
• Multipurpose Drains
• Infusion Catheter
• Embolic Agents (coils and particles)
• Trellis device
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Patient with Liver Cancer: Treatment with Chemoembolization
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Liver Cancer: Hepatocellular Carcinoma
• 530,000 new cases in the world
• Very hard to treat – The best chemotherapy prolongs life for only 3 months – Surgery or Liver Transplant are best “cure” BUT many
patients can’t have these: too sick for surgery or too many tumors or tumors are too big
• Interventional Radiology offers a minimally invasive treatments – Needle ablation: heat and kill the tumor– Chemoembolization: deliver chemotherapy to tumor– Radioembolization - deliver radiation to tumor
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Chemoembolization: Rationale
• Discrepancy in blood supply to liver and tumor – Normal Liver (20% artery : 80% portal vein)– Liver Tumors (80% artery : 20% portal vein)
• Use catheter to deliver ((chemochemo)) therapeutic into artery feeding the tumor and block it off to reduce blood supply ((embolizationembolization))– First described in Japan in 1970’s – Increases local drug concentration and dwell timeIncreases local drug concentration and dwell time
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Chemoembolization: As easy as 1,2,3
Catheter
TumorLiver
HepaticarteryPortal
vein
1) Gain access 2) Select tumor feeding artery 3) Administer drug & embolic
Objective: Deliver a high dose of chemotherapy to the tumor and shut off the blood supply
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Chemoembolization
Get the catheter into tumor feeding artery
Delivery chemotherapy (Lipiodol or Beads)
Shut off blood supply
High chemotherapy concentration in the tumor with lower systemic exposure
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Patient Example
• 62 year old man• Hepatitis C cirrhosis • New 5.6 X 4.5 cm liver tumor - tennis ball
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Pre-procedural Imaging - MRI
Early Arterial Enhancement
Less enhancement in Later (Portal Vein) phase
Contrast wash out in later phase
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Procedural Steps
1. Define anatomySuperior Mesenteric Artery Celiac ArteryPortal Vein
2. Isolate tumor supply
3. Position Catheter
4. Deliver chemotherapy and embolic material
5. Follow- up angiography to monitor progress
6. Remove catheter and Sheath
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Fluoroscopic Findings After TACE
No Residual Blood Flow to the tumor following TACE
Lipiodol Deposited in the tumor following TACE
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CT scan and MRI after treatment
Tumor Marker Decreased (AFP: 59012) Doing well 3 years after Liver Transplant
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Patient with Deep Vein Thrombosis (DVT): Treatment with Thrombolysis
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American Public Health Association. Presented at: Public Health Leadership Conference: February 26, 2003: Washington, DC.
Heit et al., on behalf of the VTE impact assessment group. Poster #68. Presented at: 47th Annual Meeting and Exposition, American Society of Hematology; December 10-13, 2005; Atlanta, Ga.
Blood Clots (VTE) Disease: A Public Health Crisis
• Up to 2 million Americans suffer from blood clots annually
• Approximately 600,000 experience blood clots in lungs (PE)
• Almost 300,000 die from PE (majority from DVT)
• Post-thrombotic syndrome (PTS) results in:• Chronic leg pain and swelling• Skin ulcers
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DVT Treatment
• Treatment Options:
Blood Thinners - Heparin and Coumadin (STANDARD TREATMENT)
Clot Busters - TPA - approved for Heart Attack, Stroke and PE
• IR Option:Combine Pharmacomechanical Thrombolysis (Local Device + Drug)
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Local Thrombolytic Delivery: Drug + Devices
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DVT Case
• 47 year old woman with left leg pain and swelling from DVT
• Tried blood thinning for two weeks but pain and swelling got worse – couldn’t walk
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During Treatment – 8 mg tPA
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Patient with abdominal abscess: Treatment with percutaneous drain placement
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What is an abscess?
• Infected fluid collection (pus) – Surrounding Wall – Antibiotics may not help– Seen with Ultrasound– Seen with CT
• Clinical Signs– Pain and Fever– High WBC count– Sepsis can lead to death
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Why drain an abscess?
• Symptoms– Infection (sepsis)– Pain and Fever– Very sick and in the ICU
• Common Causes– Appendicitis– Surgery/Trauma– Pneumonia– Pancreatitis– Diverticulitis
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Case: AR
• 11 yo girl with appendicitis • Had surgery but developed fever and pain
– CT: pelvic fluid collection – US shows pelvic collection – CT guided abscess drain placed and 400 mL of pus was
drained– 1000 mL drained over the next two days– Symptoms resolved – Drain removed
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Post OP CT: 11.30.12
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US 12.05.12
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CT guided Abscess Drain: 12.06.12