Interventional radiology lecture 2013

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  • Tunneled catheters and totally implanted VADs are associated with a lower rate of infection since they are specifically protected from extraluminal contamination. On the other hand, tunneling and SC implantation require a minor surgical procedure, which is contraindicated in patients with low platelet counts or coagulation abnormalities.; . Bishop L, Dougherty L, Bodenham A, et al. Guidelines on the insertion and management of central venous access devices in adults. Int J Lab Hematol 2007;29:261–278.
  • Fayman, Louie
  • Interventional radiology lecture 2013

    1. 1. Interventional Radiology for the InternistAnne M Covey MD, FSIRAssociate Professor of RadiologyInterventional Radiology ServiceMemorial Sloan-Kettering Cancer CenterThe following material is intended for MSKCC internal medicine housestaff teaching purposesonly. The slides are courtesy of Dr. Anne Covey and were updated for the LibGuide in 2012-2013.
    2. 2. Interventional Oncology Tool Bag Venous access Biopsy Palliative procedures– Pleur-x, Tenckhoff, Nephrostomy, Biliary– Venous and arterial revascularization– IVC filter– Abscess drain Tumor Ablation/Embolization
    3. 3. Venous access
    4. 4. Commonly Used Devices Non-tunneled central catheters– Midline/PICC– Triple lumen– Hohn Tunneled Catheters– Groshong/Hickman/Broviac– Dialysis/Pheresis Implantable ports
    5. 5.  Short term– IV (3-5 days)– Triple lumen catheters (weeks) Intermediate term– Midline/PICC (1-3+ months)– Hohn (1-3 months) Long term– Tunneled catheters• Groshong, Hickman, Broviac (months – years)• Port (months – years)Commonly Used Devices
    6. 6. Catheter options Type of catheter Catheter material Access site: chest vs. arm Subclavian vs. IJ venipuncture Single vs. Double vs. Triple lumen Groshong vs. Open-ended catheter Catheter coating Power injectable
    7. 7. Maintenance Each time port is accessed site must be sterilizedwith Betadine or chlorhexadine Huber needle (non-coring) required for access Each time port is de-accessed catheter must beflushed with heparin Port must be flushed every 4-6 weeks
    8. 8. Complications Pneumothorax Air embolism Catheter migration Port malposition (“flipped port”) Fibrin sheath Catheter occlusion Infection Venous thrombosis Diaphragm failure
    9. 9. Palliative procedures
    10. 10. Pleurx Pleural Effusion DrainOne-Way Valve& CapDacron CuffMultiplefenestrations15.5 Fr.
    11. 11. Ascites Management:Tenckhoff or Denver ShuntTenckhoff CatheterDenver Shunt
    12. 12. Nephrostomy Nephroureterostomy Retrograde Ureteral stentnephrostomy
    13. 13. Biliary drainage cathetersExternal biliary drain Internal-external biliary drain Biliary wallstent
    14. 14. Tumor Embolization
    15. 15. Embolic agents• Coils, plugs• Particles– Spherical vs non spherical– Temporary vs permanent• Liquids– ETOH, glue• Detachable balloons
    16. 16. Why do we do embolization?Indications Tumor– Primary treatment, survival extension– Palliation– Adjunctive treatment Vascular– Iatrogenic injury– Hepatic artery pump related– Tumor related
    17. 17. Tumor embolization Palliation• Hormonal• Bulk• Bleeding– HCC most common Adjunctive– Preop• RCC mets (bone)– With ablation
    18. 18. Liver Blood Supply Portal vein– About 70-75% of blood flow Hepatic artery– About 25-30% of blood flow– Predominant supply to tumors
    19. 19. Tumor Embolization Bland Embolization Chemoembolization Drug-Eluting Beads Radioembolization
    20. 20. ChemoEthiodolChemoEmulsionTACEGoal• Devitalize tumor viachemotherapeuticeffect
    21. 21. Goal• Devitalize tumor viachemotherapeuticeffectTACE
    22. 22. TAEGoal• Devitalize tumor viaischemic damage
    23. 23. TAEGoal• Devitalize tumor viaischemic damage
    24. 24. TAEGoal• Devitalize tumor viaischemic damage
    25. 25. TAEGoal• Devitalize tumor viaischemic damage
    26. 26. TAEGoal• Devitalize tumor viaischemic damage
    27. 27. Neuroendocrine Bland EmbolizationPre embo Embo 1 month postembo
    28. 28. HCC Bland EmbolizationPre embo 1 month post embo
    29. 29. Pre procedure Good imaging– Tumor #, size, extent, location– Portal vein status– Arterial anatomy, tumor supply Clinic– Routine labs including liver chemistries Plan
    30. 30. Day of the procedure Clears / NPO Zofran Antibiotics– Ancef if no allergy– Cefotetan for patients with colonized bile
    31. 31. Skin issuesPhrenic treated for HCC
    32. 32. Skin issuesPhrenic treated for HCChead ↑
    33. 33. Results of recentchemoembolization studiesLlovett et al, Lancet 2002 Randomized between bland embolization, chemoembolization &supportive care 112 patients randomized and treated between 1996 – 2000, groupscontained 37, 40 & 35 patients Embolization with gelatin sponge fragments, chemoembolizationwith doxorubicin, lipiodol and gelfoam Survival benefit demonstrated for chemoembolization oversupportive treatment Study terminated before any conclusion could be reachedregarding effect of bland embolization
    34. 34. Results of recentchemoembolization studiesLlovett et al, Lancet 20021, 2, and 3 year survivals– Supportive care 63%, 27%, and 17%– Gelfoam embolization 75%, 50%, 29%– Chemoembolization 82%, 63%, 29%
    35. 35. Results of recent chemoembolizationstudiesLo et al, Hepatology 2002 Randomized trial of TACE vs supportive care 80 patients randomized between 1996-1997 Chemoembolization performed with cisplatin,lipiodol, and gelatin sponge 1mm pellets Survival benefit demonstrated in TACE group
    36. 36. Results of recentchemoembolization studiesLo et al, Hepatology 20021, 2, and 3 year survival– Supportive care 32%, 11%, and 3%– Chemoembolization 57%, 31%, 26%
    37. 37. Results at MSKCC of ParticleEmbolization for HCCMaluccio, 2006 322 patients treated between 1997-2004 Median follow-up 20 months Median survival 21 months 1, 2, and 3 year survival 70%, 46%, 32% Excluding patients with portal vein tumor orextrahepatic disease 1, 2, & 3 year survival is 85%,68% and 42%
    38. 38. Comparison of survival at 1, 2, and 3 years intreated groups Llovett (doxorubicin)– 82%, 63%, 29% Lo (cisplatin)– 57%, 31%, 26% MSKCC (spherical embolics)– 70%, 46%, 32% (extrahepatic or p.v. involvement)– 85%, 68% and 42%
    39. 39. Complications• Pain• Hypertension• Nausea/vomiting• Vessel injury• Contrast reaction• Non-target embolization– Flow related– Shunting– Hepatic vein– Portal vein
    40. 40. When embolization complete Catheter / sheath removed from femoral artery– Closure device• Star Close• Mynx– Old fashioned compression• No sandbags Bedrest 1-4 hours
    41. 41. How about after the embo?• Post Embolization Syndrome– Pain– Fever– Nausea– Elevated WBC count– Self limited
    42. 42. Embolization + ablation HCC 3 or fewer 5 cm or smaller Thermal or chemical
    43. 43. EtoH cirrhosis with biopsy proven HCC insegment III, and hemangioma in segment IV
    44. 44. Post-embolization arteriogram, left hepatic artery,segment III branch
    45. 45. PEIT following embolization
    46. 46. Triple phase CT scan 6 months after treatment
    47. 47. Patient with HCV & HCC
    48. 48. Pre-Embolization arteriogram
    49. 49. Post-embolization angiogram
    50. 50. RF Ablation the dayfollowing embolization
    51. 51. Pre-treatment and post-treatment CT scans:
    52. 52. Summary Image-guided therapies have an importantrole at all stages in the care of the oncologypatient*Diagnosis*Treatment*Palliation
    53. 53. How IR works at MSKCC Available 24/7 2.5 angio, 1 CT, 1 CT-angio Routine cases 8 am – 6 pm Out-patients schedule in am In-patients generally in pm TRIAGE
    54. 54. How you can help us Patient preparation Communicating with IR
    55. 55. Patient preparation Does the patient know about the procedure? Are the labs acceptable? Diet? Contrast allergy? Able to consent? Are antibiotics necessary? Special considerations: position,anesthesia?
    56. 56. Patient preparation WBC/ANC Platelets >50,000 PT/INR <2.0 (except RFA, biliary: <1.5) PTT Creatinine Bilirubin Potassium 3.2-5.6 for central venousaccess
    57. 57. Patient preparation Diet appropriate for procedure?– PICC/hickman removals: regular diet– Most cases NPO * 6 hours Contrast allergy or renal failure?– CVC, abscess drain, ablation DO NOT requirecontrast– Angiogram, biliary, nephrostomy, IVCF requirecontrast
    58. 58. Communicating with IR: language– External: obligate external drainage• Nephrostomy, external biliary, abscess– Internal-external• Nephroureterostomy, int-ext biliary drains– May be capped in some cases– Stents• Internal drainage without exteriorized device***if in doubt, check the most recent IR report inPACS***
    59. 59. Communicating with IR How to order a procedure/consultation– PLACE A REFERRAL IN CIS!!
    60. 60. Communicating with IR When to call IR NP (Beep 2772, 2775, 5032,5810)– Catheter issues (in and out patient)– Post procedure patient care issues When to call IR MD (ext 7514)– Complicated cases/procedures
    61. 61. Communicating with IR When not to call– To get your case done earlier– “Heads up”
    62. 62. IR Clinic Every day at mainhospital Consultations Pre-procedure Care Post-procedure Care

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