THE ROLE OF INTERVENTIONAL RADIOLOGY IN CHRONIC KIDNEY DISEASE

LINDA ANNE HUGHES, MD Medical Director

Unique Interventional Radiology Pompano July 2019

MULTIDISCIPLINARY APPROACH

SPECIALTY NEPHROLOGY

INTERNAL MEDICINE

ENDOCRINOLOGY

TRANSPLANT SURGERY

VASCULAR SURGERY

GENERAL SURGERY

DIAGNOSTIC RADIOLOGY

INTERVENTIONAL RADIOLOGY

PODIATRY

PSYCHIATRY

PATHOLOGY

REHABILIATION MEDICINE

STAFF PHYSICIAN

NURSE PRACTITIONER

PHYSICIAN ASSISTANT

NURSE

TECHNOLOGIST

THERAPIST

SOCIAL WORKER

PHARMACIST

ADMINSTRATOR

AIDE

FAMILY

DIAGNOSTIC/ INTERVENTIONAL

RADIOLOGY

ULTRASOUND (US)

COMPUTED TOMOGRAPHY (CT/CTA)

MAGNETIC RESONANCE (MRI/MRA)

NUCLEAR MEDICINE

FLUOROSCOPY

ANGIOGRAPHY (ARTERIAL AND VENOUS)

INTRAVASCULAR ULTRASOUND (IVUS)

INTERVENTIONAL RADIOLOGY (IR)

•  Medical specialty which provides minimally invasive image guided diagnosis and treatment of disease

•  Broad range of procedures, vascular and nonvascular

•  Unifying concept is the application of image guidance and minimally invasive techniques in order to minimize risk to the patient

IR AND CKD

•  DIAGNOSIS

•  COMPLICATION MANAGEMENT

•  HEMODIALYSIS

•  PERITONEAL DIALYSIS

•  RENAL TRANSPLANT

•  COMORBID DISEASE MANAGEMENT

RENAL BIOPSY

MEDICAL BIOPSY

DIAGNOSE

STAGE

REJECTION

RENAL MASS DIAGNOSE

TREATMENT

NEPHRON SPARING

TUMOR:

CRYO/RFA/MICROWAVE

CYST:

ASPIRATE

SCLEROTHERAPY

BIOPSY COMPLICATIONS

BLEEDING

AV FISTULA

PSEUDOANEURYSM

EMBOLIZE

HEMODIALYSIS

•  PREOP ROAPMAP/VEIN MAPPING

•  CATHETER MANAGEMENT

•  FISTULA/GRAFT MANAGEMENT

•  FISTULA CREATION

HEMODIALYSIS CATHETER MANAGEMENT

•  PLACEMENT

•  REMOVAL

•  EXCHANGE

•  ANGIOPLASTY

•  THROMBOLYSIS

•  CLOT

•  FIBRIN SHEATH

•  STENOSIS/OCCLUDED VEINS

•  KINKS

•  SUBOPTIMAL PLACEMENT

HEMODIALYSIS CATHETER MANAGEMENT

HEMODIALYSIS FISTULA/GRAFT MANAGEMENT

•  SURVEILLANCE

•  BALLOON ASSISTED MATURATION (BAM)

•  COIL EMBOLIZATION

•  ANGIOPLASTY

•  STENT PLACEMENT

•  THROMBECTOMY/DECLOT

•  PERCUTANEOUS CREATION AVF

HEMODIALYSIS AVF/GRAFT MANAGEMENT

BAM COIL EMBOLIZATION ANGIOPLASTY/STENT

PERCUTANEOUS CREATION OF AVF FOR HD

•  NEW FDA APPROVED PROCEDURES

•  everlinQ endoAVF SYSTEM

•  ELLIPSYS ACCESS SYSTEM

•  MAGNETIC CATHETERS AND RF ENERGY TO CREATE AVF WITHOUT OPEN SURGERY

•  97% PROCEDURAL SUCCESS

•  88% FISTULA MATURATION @ 3 mo

•  75% SUCCESSFUL CANNULATION @ 6 mo WITH MINIMAL RE-INTERVENTION

•  1966 FIRST SURGICAL AVF

ADVANTAGES OF PERITONEAL DIALYSIS

•  Improved survival during first three years

•  Preservation of residual renal function

•  Less dependence on underlying cardiac function

•  Better blood volume and blood pressure control

•  Lower prevalence of Hepatitis C

•  Greater patient autonomy and quality of life

•  Decreased cost

WHO PERFORMS PD CATHETER PLACEMENT IN THE UNITED STATES?

PERITONEAL DIALYSIS COMPLICATIONS

Short Term •  Bowel perforation <1% •  Bladder puncture <1% •  Exit site infection within two weeks

of insertion <5% •  Peritonitis <5% •  Peritoneal leak <5% •  Hemorrhage <1%

Long Term •  Superficial cuff extrusion •  Catheter migration •  Omental wrap •  Peritonitis •  Cellulitis •  Catheter fracture, internal vs

external •  Catheter blockage

IR MANIPULATION OF EXISTING CATHETERS

•  Initially, IR’s only role in PD catheters

•  Malfunctioning catheter sent to IR to evaluate

•  Inspect external portion of the catheter

•  Under Fluoroscopy, document intraperitoneal location  

•  Inject contrast to document function, clogged, adhesions, migration, fractures

•  Introduce a stiff hydrophilic wire under fluoroscopy and advance out the end hole in attempt to lyse adhesions, clear catheter and reposition tip

PD OMENTAL WRAP WITH DISPLACEMENT

PD CATHETER IMPLANTATION APPROACHES

•  Fluoroscopic Percutaneous Technique (13%)

•  Open Surgical Dissection (42%) •  Surgical Laparoscopy (45%)

•  NO difference in complication rates

•  NO difference in primary function

•  One and two year technical survival higher in percutaneous group                                                      (90% and 82% vs 73% and 60%)

PERCUTANEOUS NEEDLE-GUIDEWIRE TECHNIQUE 

 

•  Moderate sedation vs anesthesia

•  Sterile surgical prep

•  Prophylactic IV antibiotic

•  US to visualize the peritoneal space, inferior epigastric artery and introduce Needle

•  Contrast injected under fluoroscopy to confirm intraperitoneal location

PERCUTANEOUS NEEDLE-GUIDEWIRE TECHNIQUE 

•  Abdomen filled with 300-500ml

saline

•  Sequential dilatation prior to placing peel-away sheath which is advanced over guidewire

•  PD Catheter is inserted through sheath toward pelvis

FLUOROSCOPIC-DIRECTED NEEDLE GUIDEWIRE PLACEMENT 

•  Radiopaque catheter tubing stripe permits fluoroscopic imaging of final catheter configuration

•  External portion of the catheter tunneled subcutaneously

•  Can be advanced through skin without prior incision and provides for the smallest skin hole possible for passage of the catheter

INTERVENTIONAL PD CATHETER PLACEMENT

Advantages •  Often easier and faster to schedule •  Less invasive •  Less expensive •  Moderate Sedation vs General

Anesthesia •  Not every patient is an ideal candidate

for IR placement

Disadvantages •  Patients come in all shapes and sizes •  Morbid obesity •  Previous abdominal surgery; adhesions •  Intra-abdominal anatomical

considerations •  Patient still makes urine, bladder fills •  Bowel or bladder perforation •  Large fibroid uterus •  Polycystic kidneys

ADJUNCTIVE PROCEDURES TO SURGICAL IMPLANTATION

•  Prophylactic omentopexy (omental

tacking procedure)

•  Adhesiolysis to eliminate compartmentalization of peritoneal cavity.

•  Resection of redundant epiploic appendices, epiploectomy

•  Tacking up redundant colon, colopexy

•  Diagnosis and treatment of previously unsuspected hernias.

RENAL TRANSPLANT •  PERINEPHRIC FLUID COLLECTIONS ASPIRATION/DRAINAGE

•  ABNORMAL VASCULATURE RENAL ARTERY STENOSIS/PTA/STENT

•  COLLECTING SYSTEM STENOSIS PCN/PTA/URETERAL STENT

•  REJECTION BIOPSY

•  ABSCESS

•  SEROMA/LYPHOCOELE

•  HEMATOMA

DEEP VEIN THROMBOSIS (DVT)

•  ESRD PATIENTS HIGHER RISK

•  AGE GREATER THAN 50

•  DYSLIPIDEMIA INCREASED RISK

•  RISK FOR PULMONARY EMBOLISM

•  US or VENOGRAM FOR DIAGNOSIS

•  CATHETER DIRECTED EMBOLECTOMY

•  CATHETER DIRECTED THROMBOLYSIS

•  IVC FILTER PLACEMENT/RETRIEVAL

KYPHOPLASTY

•  CKD-MBD

•  RENAL PATIENTS HAVE COMPROMISED BONE STRENGTH

•  4-13X HIGHER RISK OF HIP FRACTURES

•  INCREASED PREVALENCE OF VERTEBRAL COMPRESSION FRACTURES (strong association with vascular calcifications)

FLUID OVERLOAD PLEURAL EFFUSIONS

THORACENTESIS

PLEURX CATHETER PLACEMENT

PLEURODESIS

ASCITES

PARACENTESIS

PLEURX CATHETER PLACEMENT

ARE WE STILL AWAKE?

PERIPHERAL ARTERY DISEASE (PAD)

•  > 2 MILLION WORLDWIDE

•  25% PAST DECADE

•  4.3% US POPULATION > AGE 40

•  24% WITH CKD STAGE 3 OR >

•  RISK WITH GFR

PERIPHERAL ARTERY DISEASE

•  CKD PATIENTS HIGHER RISK

•  RISK FACTORS COMMON IN CKD

•  AGE

•  TOBACCO ABUSE

•  DIABETES

•  HYPERTENSION

•  HYPERLIPIDEMIA

•  ADDITIONAL UNIQUE RISK FACTORS

•  UREMIA: CHRONIC INFLAMMATION

•  HYPOALBUMINEMIA

•  ENDOTHELIAL DYSFUNCTION

•  MEDIAL ARTERIAL CALCIFICATION (MAC)

•  LIMB AND MORTALITY OUTCOMES WORSE, ESP ON DIALYSIS

•  > 50% ON DIALYSIS DIE WITHIN 2 YRS OF AMPUTATION

PERIPHERAL ARTERY DISEASE

•  VULNERABLE POPULATION

•  IDENTIFY AND RESOLVE GAPS IN CURRENT CARE MODEL

•  IMPROVE CLINICAL OUTCOMES

•  EVIDENCE BASED PREVENTION

•  DETECT CLAUDICATION IN EARLIEST STAGES

•  PREVENT DEVELOPMENT OF CLI

•  COST EFFECTIVE

PAD CLINICAL GOALS

•  PROACTIVELY RECOGNIZE BURDEN OF PAD IN CKD AND BURDEN OF CKD IN PAD

•  FACILITATE APPROPRIATE USE OF PAD DIAGNOSTIC TESTING

•  SUSTAIN USE OF RISK REDUCTION INTERVENTIONS TO ACHIEVE PRESPECIFIED METRICS OF TARGET GOAL SUCCESS

PAD SCREENING/SURVEILLANCE

ABI

•  SIMPLE

•  INEXPENSIVE

•  RISK FREE

•  RESTING OR WITH EXERCISE

•  LIMITED SENSITIVITY with MAC

•  FALSE NORMAL

•  > 0.9 < 1.4

TBI

•  DIGITAL ARTERIES SPARED FROM MAC

•  > 0.7

•  LIMITED AVAILABILITY

PAD DIAGNOSIS ULTRASOUND SEGMENTAL LIMB PRESSURES

PULSED AND COLOR DOPPLER

COST EFFECTIVE

NONINVASIVE

NO RISK

CTA/MRA ABNORMAL DUPLEX AND SYMPTOMS

EXCELLENT DIAGNOSTIC UTILITY

CT; CONTRAST INDUCED NEPHROPATHY

MR: NEPHROGENIC SYSTEMIC FIBROSIS

ANGIOGRAPHY SEVERE CLAUDICATION

CHRONIC LIMB ISCHEMIA (CLI)

NOT RESPONSIVE TO NONINVASIVE THERAPY

CONTROL AMOUNT OF CONTRAST

DIAGNOSTIC AND THERAPEUTIC

PAD INTERVENTION

•  ANGIOPLASTY (PTA) •  DRUG COATED BALLOON PTA

(DCB) •  STENT PLACEMENT •  THROMBOLYSIS

•  ATHERECTOMY

PAD INTERVENTION

PAD INTERVENTION

CO2 ANGIOGRAPHY

•  CO2 COLORLESS ODORLESS GAS

•  SAFE AND USEFUL CONTRAST AGENT

•  FIRST USED IN 1920’s – retroperitoneum

•  1950’s IV delineate RA to detect pericardial effusion

•  UNDERUTILIZED

CO2 ANGIOGRAPHY

UNIQUE PHYSICAL PROPERTIES

•  HIGH SOLUBILITY (28x O2/54x N)

•  LOW VISCOSITY (400x < contrast)

•  DISPLACES BLOOD

•  GAS BUBBLES UNDILUTED

•  UNLIMITED VOLUMES

•  INEXPENSIVE c/w CONTRAST

CO2 ANGIOGRAPHY

INDICATIONS PERIPHERAL ANGIOGRAPHY

MESENTERIC ANGIOGRAPHY

NATIVE RENAL ANGIOGRAPHY

RENAL TRANSPLANT ANGIOGRAPHY

DETECTION OF BLEEDING

TUMOR AVF/AVM EMBOLIZATION

VENOGRAPHY

PORTAL VENOGRAPHY/TIPS

ARTERIAL/VENOUS INTERVENTION

EVAR

CONTRAINDICATIONS THORACIC AORTOGRAPHY - SEIZURE

CORONARY ANGIOGRAPHY-ARRHYTHMIA

CEREBRAL ANGIOGRAPHY-NEUROTOXICITY

PULMONARY HYPERTENSION- PAP

COPD

INTRAVASCULAR ULTRASOUND (IVUS)

•  MINIATURIZED US PROBE AT TIP OF CATHETER

•  ABILITY TO SEE BLOOD VESSELS FROM INSIDE

•  VISUALIZATION OF LUMEN AND ATHEROMA ”HIDDEN” IN THE WALL

•  FIRST ANIMAL TRIALS 1956

•  LATE 1980’S HUMAN TRIALS/APPLICATION

•  DIFFERENTIATE PLAQUE FROM CLOT

•  MORPHOLOGY OF PLAQUE; calcified, soft or fibrotic

•  ANEURYSM AND DISSECTION TX

•  MEASURE STENOSIS

•  CONFIRM BLOCKAGE

•  SIZING FOR TREATMENT

IVUS

•  EXCELLENT DEMONSTRATION OF ANATOMY

•  BEHAVIOR OF ATHEROSCLEROSIS PROCESS (CAD/PAD)

•  IMPACT ON DIFFERENT TREATMENT STRATEGIES

IR SERVICE LOCATIONS

HOSPITAL OUTPATIENT CENTER

CONCLUSION

•  MULTIDISCIPLINARY COLLABORATION

•  STRONG COMMUNICATION

•  SKILLED KNOWLEDGEABLE STAFF

•  CONTINUING RESEARCH AND EDUCATION FOR OPTIMIZING PATIENT CARE AND OUTCOMES

THANK YOU!

REFERENCES AVAILABLE UPON REQUEST