This document provides an overview of interventional radiology procedures including examples of treating liver cancer, blood clots, and infections. It describes how interventional radiology uses imaging guidance like ultrasound, CT, and MRI to perform minimally invasive procedures using needles and catheters. Specific procedures discussed include angioplasty and stenting to open narrowed arteries, embolization to close bleeding arteries, chemoembolization to deliver chemotherapy directly to tumors via arteries, removing blood clots, biopsy of organs, tumor ablation, and draining abscesses. Case examples provided include using chemoembolization to treat a patient's liver cancer and thrombolysis to treat a patient's deep vein thrombosis.
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Intro to ir umd talk
1. Introduction To Interventional Radiology
Examples: Liver Cancer, Blood Clots, and Infection
October, 23, 2013
Karun Sharma
Children’s National Health System, Washington DC
2. 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
6. 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
7. IR Tools - Hands On Session
•
•
•
•
•
Catheters
Multipurpose Drains
Infusion Catheter
Embolic Agents (coils and particles)
Trellis device
9. 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
10. 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 (chemo) therapeutic into artery
feeding the tumor and block it off to reduce blood supply
(embolization)
– First described in Japan in 1970’s
– Increases local drug concentration and dwell time
11. Chemoembolization:
As easy as 1,2,3
1) Gain access
2) Select tumor feeding artery
Tumor
Catheter
Portal
vein
3) Administer drug & embolic
Liver
Hepatic
artery
Objective: Deliver a high dose of chemotherapy to the
tumor and shut off the blood supply
12. 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
13. Patient Example
• 62 year old man
• Hepatitis C cirrhosis
• New 5.6 X 4.5 cm liver tumor - tennis ball
14. Pre-procedural Imaging - MRI
Early Arterial
Enhancement
Less enhancement in
Later (Portal Vein) phase
Contrast wash out in
later phase
15. Procedural Steps
1. Define anatomy
Superior Mesenteric Artery
Celiac Artery
Portal 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
16. Fluoroscopic Findings After TACE
No Residual Blood Flow
to the tumor following TACE
Lipiodol Deposited
in the tumor following TACE
17. CT scan and MRI after treatment
Tumor Marker Decreased (AFP: 59012)
Doing well 3 years after Liver Transplant
18. Patient with Deep Vein Thrombosis
(DVT): Treatment with Thrombolysis
19. 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
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.
20. 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)
22. 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
28. 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
29. Why drain an abscess?
• Symptoms
– Infection (sepsis)
– Pain and Fever
– Very sick and in the ICU
• Common Causes
–
–
–
–
–
Appendicitis
Surgery/Trauma
Pneumonia
Pancreatitis
Diverticulitis
30. 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
DVT, along with pulmonary embolism (PE), is a major public health crisis (NQF, JCAHO, Surgeon Generals Office) have made it a priority
Take a look at the figures: up to 2 million Americans suffer from DVT each year and about 600,000 experience PE
Nearly 300,000 people die from PE annually, the majority of these cases resulting from DVT
Studies show that complications from DVT kill more Americans each year than AIDS and breast cancer combined
Initial venogram, Note the extensive filling defect and lack of collateral channels in the left femoral and common iliac veins.
The thrombus has been traversed. The proximal and distal balloons have been inflated and tPA has been administered. Now the device is activated for about 10 minutes. At the end, the thrombus fragments and lytic are aspirated and the device is removed.
Here is a follow up venogram. Notice that the filling defects are gone and there is good flow in the femoval and external iliac veins. Because of the underlying etiology (May Thurner), a stent was placed in the damaged segment of the common Iliac vein. This is not necessary in most patients.