new and emerging advanced vascular & interventional radiology procedures

Thrombolytic Therapy and IVC filter use in Massive and Submassive Pulmonary Embolism a review and update

New and Emerging Advanced Vascular & Interventional Radiology ProceduresBjorn Engstrom, M.D.Vascular & Interventional RadiologyConsulting Radiologists, LtdAbbott Northwestern Hospital2015 ANW Innovation SummitSeptember 26, 2015

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DisclosuresEMBA Medical: Received honorarium testing of their Hourglass Embolization deviceI have no conflicts of interest or relevant financial disclosures in making this presentationOff-label use: Theraspheres approved as a HUD for HCC but outside of that off-label including for radiation segmentectomyProstate artery embolization for BPHUse of occlusion balloons, lipiodol and sotradecol in BRTOWallstent endoprosthesis in iliac veinsAside from ultrasound-accelerated thrombolysis, any CDI in PE

I have one financial disclosure but none relevant to this presentationWhat I will present to you is largely widely accepted although as is the case in much of IR many devices are used off label2

ObjectivesTo introduce audience to 6 New and Emerging Advanced Vascular & Interventional Radiology Procedures: Radiation segmentectomy Radial Artery access for Visceral Interventions (RAVI)Prostate Artery EmbolizationAdvanced Tumor AblationBalloon-occluded Retrograde Transvenous Obliteration (BRTO) Thrombolysis in Venous Thromboembolic disease

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Radiation segmentectomyTransarterial chemoembolization (TACE): Level 1 evidence for mortality benefit in HCCTAE and DEB-TACE same results w/ less toxicityRadioembolization: Infusion of microparticles containing Y-90, emitting beta-radiationSuperior to TACE for down-stagingwhen PVT presentlonger TTPless toxicityLo et al.Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002 May;35(5):1164-71Llovet et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet. 2002 May 18;359(9319):1734-9

We will first explore a potentially curative therapy for HCC called radiation segmentectomy

The newest liver directed therapy is

infusion of microparticles containing Y-90, emitting beta-radiation, killing tumor with minimal effect on blood flowntially curative liver directed therapy, called radiation segmentectomy used in primary hepatic malignancies4

Radiation segmentectomyRadioembolization limited to 2 or fewer segments with higher, ablative doseSolitary HCC 5 cm in difficult locations (dome, central, peripancreatic etc) when ablation and resection are not options Complete path necrosis in > 50%Vouche M, Habib A, Ward TJ et al. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology. 2014 Jul;60(1):192-201

Radiation segmentectomy is a new variant of radioembolization where the dose is limited to5

Radiation segmentectomy63-year-old female with hepatitis C cirrhosis, and 2.9 cm LI-RADS 5 lesion in segment 3

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Radiation segmentectomy

6 months post-treatment: Complete responseInfusion of radioactive particles

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Radioembolization in different patient

Note catheter approach

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Radial Artery access for Visceral Intervention (RAVI) BenefitsSuperficial and easily compressible with lower bleeding ratesDual blood supply to handReduced mortality in STEMI patientsImmediate ambulationCost savingsObese patientsPatients with back problemsBertrand OF, Belisle P, Joyal D, et al. Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis. American Heart J. 2012;163:632-648. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012;60:2481-2489 Mehta SR, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll Cardiol. 2012;60:2490-2499Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J. 1999;138(3 Pt 1):7

Fischman, Patel. The time is now for transradial intervention. Endovascular Today. April 2013; pp 50-58

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RAVI in Uterine Fibroid Embolization

41-year-old obese female w/ symptomatic uterine fibroids (bleeding + bulk), factor V Leiden disease, recent hx PE, with worsening severe bleeding on anticoagulation severe anemia

Particularly useful in UFE patients where crampy abdominal pain and nausea may be an issue as with radial access the patient may now immediately flex at the hip and ambulate10

Radial Artery access for Visceral Intervention (RAVI)

Why is this all of a sudden such a hot topic?...Well, to a large degree this is related to innovations at the access site where tiny hydrophilic sheaths with 4 French outer diameter such as this one has a hollowed out inner portion that allows for a 5 French catheter, and for hemostasis multiple venodors have bands such as this one where a balloon holds pressure at the access site and over 60-90 minutes the air is deflated 11

Prostate Artery Embolization PAE is a safe procedure, with low morbidity for BPHOutpatient procedure, moderate sedation (vs 5 days with TURP, and 5-7 days for open prostatectomy) Complications not common, and usually minor (such as UTI, or hematoma)No bladder neck contractures (TURP: 5% , Open: 80%)No urethral strictures (TURP: 1-29%)(Improved sexual function in 36% likely 2/2 cessation/reduction of prostatic medications)

Pisco et al. Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediate-term results. Radiology. 2013 Feb;266(2):668-77. Epub 2012 Nov 30

The jump from uterine fibroid embolization in the female to prostate artery embolization in the male is actually not a large one as the artery embolized in each procedure is the corresponding one for each sex and both are used to treat benign tumors for symptomatic relief, but PAE is a much more recent development12

Prostate Artery Embolization Effective therapy with good short- and intermediate term (24 months) results:Clinical improvement (reduction in IPSS):PAE better than medical rxSimilar to minimally invasive surgeries (transurethral microwave and transurethral needle ablation) Slightly less than TURPDoes not preclude surgical therapies May make surgical treatment safer (ie. in large prostate may make patient eligible for TURP as opposed to open prostatectomy)As with UFE, PAE likely to become complementary to existing therapies

Pisco et al. Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediate-term results. Radiology. 2013 Feb;266(2):668-77. Epub 2012 Nov 30

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Prostate Artery Embolization 84-year-old male with Foley-catheter dependent BPH refractory to medical therapy, non-surgical candidate

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Prostate Artery Embolization

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Prostate Artery Embolization

2 weeks later passed voiding trial after removing Foley

PVR 7516

Advanced Tumor AblationThermal AblationRadiofrequency (RFA)Microwave (MWA)Cryoablation (Cryo)Non-thermal AblationIrreversible electroporation

Advanced tumor ablation is the final tumor related VIR procedure covered, a tool applicable in multiple different organ systems including liver, kidney and lung.

IRE: Uses high-voltage electrical current to induce pores in the lipid bilayer of cells, resulting in cell death17

73-year-old female w/ primary biliary cirrhosis and a new 2.3 cm LIRADS 5B lesion in segment 3

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Hydro dissection anterior and posterior liver margin

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18G trocar used during ablation to displace lesion away from gastric outlet and pancreas

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US imaging during MWA

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*Complete response w/o residual or recurrent disease @ 18 months*Other advanced techniques:Hydroinfusion, CO2 pneumoperitoneum*Similar techniques in kidney and lung with good outcomes

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Balloon-occluded Retrograde Transvenous Obliteration (BRTO)Primarily for bleeding isolated gastric varicesMay also be used in lieu of TIPS in gastroesophageal varices if:Poor hepatic reserve (MELD >18)Severe encephalopathy (as BRTO may improve both)Duodenal or parastomal bleedingVery low risk of re-bleed (3% at 3 years)Does not preclude TIPS

Saad WE, Darcy MD.Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices. Semin Intervent Radiol. 2011 Sep;28(3):339-49Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol. 2012 Jun;29(2):118-28Sabri et al. Balloon-occluded Retrograde Transvenous Obliteration of Gastric Varices. Endovascular Today April 2010

We will now switch gears a little bit to explore some advanced venous interventions. First up is balloon occluded transvenous obliteration (BRTO)24

Balloon-occluded Retrograde Transvenous Obliteration (BRTO)

Sabri et al. Balloon-occluded Retrograde Transvenous Obliteration of Gastric Varices. Endovascular Today April 2010

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To conclude we will explore some advanced venous interventions including balloon occluded transvenous obliteration (BRTO), and thrombolysis in venous thromboembolism. As part of the latter we will discuss efforts of a new multidisciplinary initiative at Abbott Northwestern Hospital in the management of pulmonary embolism. 29

Thrombolysis in Venous Thromboembolic disease Iliofemoral DVTLevel 1 evidence of reduced risk of Post-Thrombotic Syndrome (PTS) and recurrent DVTSociety of Vascular Surgery recommendations: First episode of acute iliofemoral DVTSymptoms

new and emerging advanced vascular & interventional radiology procedures

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