Zofran works great (4 mg q4 or 8 mg q8)
Can add dexamethasone in non-diabetics (12 mg on day of treatment)
Compazine or droperidol for breakthrough nausea
Antibiotics
Puncture site
Labs
TACE
Post-procedure management
Fluids/Diet
Activity
Pain control
Nausea control
Antibiotics
- Not routinely needed unless high risk for infection
Puncture site
Labs
TACE
Post-procedure management
Fluids/Diet
Activity
Pain control
Nausea control
Antibiotics
This document provides guidance on basic interventional radiology (IR) procedures including venous lines, feeding tubes, and biliary drainage. It describes different types of venous lines including PICCs, ports, and Hickman/Permacath lines. Details are given on indications, contraindications, pre-procedure care, technical steps, post-procedure care, and potential complications. Guidance is also provided on placing feeding tubes including gastrostomy and gastrojejunostomy tubes using push or pull techniques. Technical tips, outcomes, and controversies are discussed for each procedure type.
This document provides an overview and responsibilities for an interventional radiology (IR) rotation. It outlines procedures, consenting, follow up, documentation and log keeping. It also covers topics like blood thinners, antibiotics, anesthesia, tube care, pain management, contrast, risks, radiation safety, labs and phone numbers relevant to the rotation. Resident testimonials highlight the busy and hands-on nature of the rotation.
This document provides tips for pre- and post-procedural evaluation of patients undergoing interventional radiology procedures. It discusses:
1) Performing a focused history and physical exam tailored to the reason for referral;
2) Evaluating patients for sedation risk and ensuring safe sedation;
3) Providing immediate post-procedure assessment and coordinating inpatient follow-up;
4) Conducting regular outpatient follow-up until care is no longer needed.
Endoscopy plays a crucial role in managing upper gastrointestinal bleeding by allowing diagnosis, risk assessment, and delivery of therapy. Recent guidelines recommend early risk scoring using the Glasgow-Blatchford Score and endoscopy within 24 hours. New endoscopic therapies like Hemospray and over-the-scope clips show promise in achieving hemostasis, though more data is needed. Achieving hemostasis can be challenging, and failed endoscopic hemostasis requires intervention like radiology, surgery, or stents.
This document provides guidance on transurethral resection of the prostate (TURP) techniques. It outlines a triphasic procedure involving 1) cone excision, 2) excavation of the prostate capsule, and 3) resection of apical tissue. This approach allows for rapid initial tissue removal while minimizing risks of injury. It emphasizes achieving hemostasis between stages for good visualization. Different resection methods are described for removing lateral and median lobes, including segmental, tangential, Nesbit's, Barnes', and Alcock & Flocks techniques. Landmarks like the bladder neck and veromontanum help guide apical resection.
Laparoscopy can be used to both diagnose and treat abdominal trauma. It is most effective for hemodynamically stable patients with penetrating injuries or blunt trauma with unclear internal injuries. Key benefits are lower morbidity rates compared to open surgery and ability to identify injuries often missed on imaging like diaphragmatic tears or mesenteric lacerations. The procedure allows for therapeutic repair of injuries to organs like liver, stomach or bowel when laparoscopic expertise is available. Contraindications include hemodynamic instability, clear need for open surgery, or limited laparoscopic resources.
CSF Shunt Infection: Diagnosis and TreatmentLiew Boon Seng
Ventricular shunt infection is a common complication of CSF shunting with an incidence rate of 8.5-15%. Risk factors include young age, prior revisions, and prolonged surgery time. Early infections are usually caused by skin flora like Staphylococcus epidermidis. Diagnosis involves CSF analysis showing pleocytosis and low glucose, along with culture of infected hardware. Treatment consists of removing the infected shunt and replacing it with a new shunt after the CSF is sterile, while administering intravenous antibiotics for 10-14 days. Prognosis depends on the organism, underlying pathology, and adequacy of treatment to prevent complications like cerebritis, abscesses, or recurrent infections.
This document provides guidance on basic interventional radiology (IR) procedures including venous lines, feeding tubes, and biliary drainage. It describes different types of venous lines including PICCs, ports, and Hickman/Permacath lines. Details are given on indications, contraindications, pre-procedure care, technical steps, post-procedure care, and potential complications. Guidance is also provided on placing feeding tubes including gastrostomy and gastrojejunostomy tubes using push or pull techniques. Technical tips, outcomes, and controversies are discussed for each procedure type.
This document provides an overview and responsibilities for an interventional radiology (IR) rotation. It outlines procedures, consenting, follow up, documentation and log keeping. It also covers topics like blood thinners, antibiotics, anesthesia, tube care, pain management, contrast, risks, radiation safety, labs and phone numbers relevant to the rotation. Resident testimonials highlight the busy and hands-on nature of the rotation.
This document provides tips for pre- and post-procedural evaluation of patients undergoing interventional radiology procedures. It discusses:
1) Performing a focused history and physical exam tailored to the reason for referral;
2) Evaluating patients for sedation risk and ensuring safe sedation;
3) Providing immediate post-procedure assessment and coordinating inpatient follow-up;
4) Conducting regular outpatient follow-up until care is no longer needed.
Endoscopy plays a crucial role in managing upper gastrointestinal bleeding by allowing diagnosis, risk assessment, and delivery of therapy. Recent guidelines recommend early risk scoring using the Glasgow-Blatchford Score and endoscopy within 24 hours. New endoscopic therapies like Hemospray and over-the-scope clips show promise in achieving hemostasis, though more data is needed. Achieving hemostasis can be challenging, and failed endoscopic hemostasis requires intervention like radiology, surgery, or stents.
This document provides guidance on transurethral resection of the prostate (TURP) techniques. It outlines a triphasic procedure involving 1) cone excision, 2) excavation of the prostate capsule, and 3) resection of apical tissue. This approach allows for rapid initial tissue removal while minimizing risks of injury. It emphasizes achieving hemostasis between stages for good visualization. Different resection methods are described for removing lateral and median lobes, including segmental, tangential, Nesbit's, Barnes', and Alcock & Flocks techniques. Landmarks like the bladder neck and veromontanum help guide apical resection.
Laparoscopy can be used to both diagnose and treat abdominal trauma. It is most effective for hemodynamically stable patients with penetrating injuries or blunt trauma with unclear internal injuries. Key benefits are lower morbidity rates compared to open surgery and ability to identify injuries often missed on imaging like diaphragmatic tears or mesenteric lacerations. The procedure allows for therapeutic repair of injuries to organs like liver, stomach or bowel when laparoscopic expertise is available. Contraindications include hemodynamic instability, clear need for open surgery, or limited laparoscopic resources.
CSF Shunt Infection: Diagnosis and TreatmentLiew Boon Seng
Ventricular shunt infection is a common complication of CSF shunting with an incidence rate of 8.5-15%. Risk factors include young age, prior revisions, and prolonged surgery time. Early infections are usually caused by skin flora like Staphylococcus epidermidis. Diagnosis involves CSF analysis showing pleocytosis and low glucose, along with culture of infected hardware. Treatment consists of removing the infected shunt and replacing it with a new shunt after the CSF is sterile, while administering intravenous antibiotics for 10-14 days. Prognosis depends on the organism, underlying pathology, and adequacy of treatment to prevent complications like cerebritis, abscesses, or recurrent infections.
Percutaneous transhepatic cholangiography (PTC) is a radiographic technique used to visualize the biliary tree. It can be used diagnostically when other imaging methods like MRCP or ERCP have been unsuccessful. PTC involves inserting a needle into the liver under imaging guidance and injecting contrast dye to outline the biliary ducts. It is indicated when ERCP has failed or is not possible, to evaluate biliary obstructions or leaks, or as the first step in percutaneous biliary interventions like stent placement. Potential complications include bile leakage, peritonitis, bleeding, and cholangitis.
The document discusses the history and management of penetrating abdominal wounds. It notes that in the 19th century such wounds were managed non-operatively with high morbidity and mortality rates, but that experience from wars led to more aggressive operative management. In 1960, Shaftan developed a selective approach of conservatism for stab wounds. The document focuses on abdominal stab wound exploration as a technique for determining if laparotomy is needed in asymptomatic patients, noting its safety, speed and cost-effectiveness. It provides details on patient selection, contraindications, anesthesia, equipment, positioning and technique for abdominal stab wound exploration.
We review the most important articles above the differents Precut techiques: Fistulotomy, Papillotomy and Transpancreatic Sphincterotomy. The techique is safe and effective. And a brief comment about my experience in Fistulotomy, "No Post ERCP Pancreatitis because No touch the papilllary orifice"
This document discusses approaches to managing abdominal trauma in the emergency department. It begins by outlining learning objectives which include identifying abdominal trauma, learning assessment approaches, and trauma management. It then discusses the primary and secondary surveys as well as indications of shock. Specific injuries like solid organ injuries, hollow visceral injuries, retroperitoneal injuries, and diaphragmatic injuries are examined. Mechanisms of injury, physical exam findings, ultrasound, and management are also reviewed to provide emergency physicians with guidance on evaluating and treating abdominal trauma.
- Capnography measures carbon dioxide levels and can be used to monitor cardiac output during cardiac arrest. An end-tidal carbon dioxide level below 10mmHg after 20 minutes of CPR indicates low likelihood of return of spontaneous circulation.
- Apneic oxygenation utilizes continued oxygen absorption in the alveoli even without breathing to prolong oxygen saturation during difficult intubations. Nasal cannula delivers high oxygen concentrations.
- The CRASH-2 trial showed tranexamic acid reduced mortality in trauma patients when given within 8 hours of injury by stopping clot breakdown. It is a cheap and effective treatment.
This document discusses various minimally invasive and endoscopic procedures for treating benign prostatic hyperplasia (BPH), including bipolar transurethral resection of the prostate (B-TURP), transurethral vaporization of the prostate (TUVP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral incision of the prostate (TUIP), and various laser treatments such as photoselective vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP). Many of the procedures provide improvements in urinary symptoms comparable to traditional TURP but with benefits such as less
Dr. Pragnesh Shah is the chair of FOGSI's endoscopy committee and coordinates the west zone of IAGE. He runs an advanced endoscopy training center in Ahmedabad and is interested in establishing standards for endoscopy training and accreditation in India. Some key points he discusses are the importance of hysteroscopy, proper instrumentation, fluid management, monitoring protocols, and preventing complications to ensure safe hysteroscopic procedures.
1. The patient presented with an alleged stab injury to the chest and showed signs of hypotension not responding to fluids and a distended abdomen. CT scan showed hemopericardium and ascites.
2. At operation, a 2cm rent was found in the left dome of the diaphragm with 1L of hemoperitoneum and a 2cm laceration in the right lobe of the liver but no active bleeding.
3. Post-operatively, the patient had occasional RV collapse seen on echo but normal cardiac enzymes and was discharged on post-op day 6.
Urinary retention is the inability to fully empty the bladder. It can be acute or chronic. Common causes include benign prostatic hyperplasia (BPH), urethral strictures, neurological conditions, and certain medications. Evaluation involves history, physical exam, urinalysis, imaging tests like ultrasound and urodynamic studies. Treatment depends on the underlying cause but may include medications, procedures like cystoscopy or TURP, and sometimes surgery. Differential diagnosis considers defects along the urinary tract from the bladder to urethra and neurological pathways.
1. A 20-year-old male was stabbed in the abdomen with a 10 cm knife during a fight. He was hemodynamically stable on arrival to the emergency room.
2. The emergency physician attempted to examine the wound but could not determine if it penetrated the peritoneum due to its depth. A CT scan or FAST exam was recommended to check for internal bleeding before deciding on observation or surgery.
3. For hemodynamically stable patients with abdominal stab wounds, selective non-operative management is usually recommended initially. Further examination with CT scan is important to identify any internal bleeding before deciding on observation versus laparotomy.
1) Abdominal trauma is commonly encountered and can be life-threatening. Identification of serious intra-abdominal injuries can be challenging.
2) Motor vehicle accidents account for 60% of abdominal trauma, with blunt trauma more common than penetrating injuries.
3) Injuries to solid organs like the spleen, liver, and kidneys require careful assessment and may be graded based on severity. Conservative management is often attempted initially if the patient is stable.
4) Diagnostic tools like FAST ultrasound, CT scans, and laparoscopy can help identify injuries, but repeated examinations are often necessary. Management may involve surgery or conservative approaches depending on injury severity and patient stability.
Minimal access surgery (MAS) a new surgical and interventional approach, was called by different name and one of the popular is minimally invasive surgery. However,unique complications are associated.
Laparoscopy in gynaecology presented by drs igbodike emeka philip and dr rotimiigbodikeobgyn
This slide will be helpful if the presentation revolves around laparoscopy in gynaecological practice. Kindly like , clip and share the slide. it is free!
Laparoscopic Urologic surgery, is a part of the curriculum of Minimal Access Surgery, and requires lot of skills and patience. All new surgeons carrying out Basic Laparoscopic surgery should aim at also doing Lap. Urological surgeries, which has a steep learning curve, but with with excellent outcomes.
This document outlines the history, surgical anatomy, approaches, techniques, and complications of adrenal gland surgery. It discusses:
- The history of open adrenalectomy dating back to the late 1800s and early adoption of laparoscopic approaches in the 1990s.
- Surgical anatomy of the right and left adrenal veins which can vary and need to be carefully managed.
- Indications for adrenalectomy including functional tumors and malignancy risk based on size.
- Various surgical approaches including open, laparoscopic, robotic, and newer minimally invasive techniques.
- Important technical aspects like patient positioning, gaining access, and intraoperative maneuvers for each approach.
- Post-operative care including
This document provides guidelines for nursing management of patients with nephrostomy tubes. Nephrostomy tubes are inserted through the skin into the kidney to provide drainage for various conditions. Tube types include pigtail and wide bore catheters. Care involves irrigation, securing tubes, monitoring output, and educating patients prior to discharge. Nurses must follow sterile technique, check tubes regularly for patency and complications, and maintain fluid balances. Medical orders are required for irrigation and tube removal.
Using and Building Open Source in Google Corporate Engineering - Justin McWil...OSCON Byrum
This document discusses Google's use of open source software within its corporate engineering department. It notes that CorpEng develops many of the solutions it uses internally, including video conferencing, device management, calendars, and more. These solutions are often built on Google App Engine and some are open sourced. Reasons for open sourcing include sharing solutions, recruiting talent, and aligning with Google's culture of openness. The document provides examples of popular open source projects used at Google like Memcached, JodaTime, and testing frameworks. It highlights some of Google's own open source projects like Simian for Mac management and Cauliflower Vest for encrypted recovery keys.
This document summarizes minimally invasive treatments for hepatocellular carcinoma (HCC) such as percutaneous ablation techniques, transarterial chemoembolization (TACE), and yttrium-90 radioembolization. It reviews the evidence for different ablation modalities like radiofrequency ablation (RFA), microwave ablation, and ethanol injection. It discusses how TACE selectively delivers chemotherapy to tumor vasculature while sparing normal liver and the evidence from clinical trials showing TACE improves survival compared to supportive care alone. It also introduces drug-eluting beads TACE which may provide more effective chemotherapy delivery to the tumor.
Percutaneous transhepatic cholangiography (PTC) is a radiographic technique used to visualize the biliary tree. It can be used diagnostically when other imaging methods like MRCP or ERCP have been unsuccessful. PTC involves inserting a needle into the liver under imaging guidance and injecting contrast dye to outline the biliary ducts. It is indicated when ERCP has failed or is not possible, to evaluate biliary obstructions or leaks, or as the first step in percutaneous biliary interventions like stent placement. Potential complications include bile leakage, peritonitis, bleeding, and cholangitis.
The document discusses the history and management of penetrating abdominal wounds. It notes that in the 19th century such wounds were managed non-operatively with high morbidity and mortality rates, but that experience from wars led to more aggressive operative management. In 1960, Shaftan developed a selective approach of conservatism for stab wounds. The document focuses on abdominal stab wound exploration as a technique for determining if laparotomy is needed in asymptomatic patients, noting its safety, speed and cost-effectiveness. It provides details on patient selection, contraindications, anesthesia, equipment, positioning and technique for abdominal stab wound exploration.
We review the most important articles above the differents Precut techiques: Fistulotomy, Papillotomy and Transpancreatic Sphincterotomy. The techique is safe and effective. And a brief comment about my experience in Fistulotomy, "No Post ERCP Pancreatitis because No touch the papilllary orifice"
This document discusses approaches to managing abdominal trauma in the emergency department. It begins by outlining learning objectives which include identifying abdominal trauma, learning assessment approaches, and trauma management. It then discusses the primary and secondary surveys as well as indications of shock. Specific injuries like solid organ injuries, hollow visceral injuries, retroperitoneal injuries, and diaphragmatic injuries are examined. Mechanisms of injury, physical exam findings, ultrasound, and management are also reviewed to provide emergency physicians with guidance on evaluating and treating abdominal trauma.
- Capnography measures carbon dioxide levels and can be used to monitor cardiac output during cardiac arrest. An end-tidal carbon dioxide level below 10mmHg after 20 minutes of CPR indicates low likelihood of return of spontaneous circulation.
- Apneic oxygenation utilizes continued oxygen absorption in the alveoli even without breathing to prolong oxygen saturation during difficult intubations. Nasal cannula delivers high oxygen concentrations.
- The CRASH-2 trial showed tranexamic acid reduced mortality in trauma patients when given within 8 hours of injury by stopping clot breakdown. It is a cheap and effective treatment.
This document discusses various minimally invasive and endoscopic procedures for treating benign prostatic hyperplasia (BPH), including bipolar transurethral resection of the prostate (B-TURP), transurethral vaporization of the prostate (TUVP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral incision of the prostate (TUIP), and various laser treatments such as photoselective vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP). Many of the procedures provide improvements in urinary symptoms comparable to traditional TURP but with benefits such as less
Dr. Pragnesh Shah is the chair of FOGSI's endoscopy committee and coordinates the west zone of IAGE. He runs an advanced endoscopy training center in Ahmedabad and is interested in establishing standards for endoscopy training and accreditation in India. Some key points he discusses are the importance of hysteroscopy, proper instrumentation, fluid management, monitoring protocols, and preventing complications to ensure safe hysteroscopic procedures.
1. The patient presented with an alleged stab injury to the chest and showed signs of hypotension not responding to fluids and a distended abdomen. CT scan showed hemopericardium and ascites.
2. At operation, a 2cm rent was found in the left dome of the diaphragm with 1L of hemoperitoneum and a 2cm laceration in the right lobe of the liver but no active bleeding.
3. Post-operatively, the patient had occasional RV collapse seen on echo but normal cardiac enzymes and was discharged on post-op day 6.
Urinary retention is the inability to fully empty the bladder. It can be acute or chronic. Common causes include benign prostatic hyperplasia (BPH), urethral strictures, neurological conditions, and certain medications. Evaluation involves history, physical exam, urinalysis, imaging tests like ultrasound and urodynamic studies. Treatment depends on the underlying cause but may include medications, procedures like cystoscopy or TURP, and sometimes surgery. Differential diagnosis considers defects along the urinary tract from the bladder to urethra and neurological pathways.
1. A 20-year-old male was stabbed in the abdomen with a 10 cm knife during a fight. He was hemodynamically stable on arrival to the emergency room.
2. The emergency physician attempted to examine the wound but could not determine if it penetrated the peritoneum due to its depth. A CT scan or FAST exam was recommended to check for internal bleeding before deciding on observation or surgery.
3. For hemodynamically stable patients with abdominal stab wounds, selective non-operative management is usually recommended initially. Further examination with CT scan is important to identify any internal bleeding before deciding on observation versus laparotomy.
1) Abdominal trauma is commonly encountered and can be life-threatening. Identification of serious intra-abdominal injuries can be challenging.
2) Motor vehicle accidents account for 60% of abdominal trauma, with blunt trauma more common than penetrating injuries.
3) Injuries to solid organs like the spleen, liver, and kidneys require careful assessment and may be graded based on severity. Conservative management is often attempted initially if the patient is stable.
4) Diagnostic tools like FAST ultrasound, CT scans, and laparoscopy can help identify injuries, but repeated examinations are often necessary. Management may involve surgery or conservative approaches depending on injury severity and patient stability.
Minimal access surgery (MAS) a new surgical and interventional approach, was called by different name and one of the popular is minimally invasive surgery. However,unique complications are associated.
Laparoscopy in gynaecology presented by drs igbodike emeka philip and dr rotimiigbodikeobgyn
This slide will be helpful if the presentation revolves around laparoscopy in gynaecological practice. Kindly like , clip and share the slide. it is free!
Laparoscopic Urologic surgery, is a part of the curriculum of Minimal Access Surgery, and requires lot of skills and patience. All new surgeons carrying out Basic Laparoscopic surgery should aim at also doing Lap. Urological surgeries, which has a steep learning curve, but with with excellent outcomes.
This document outlines the history, surgical anatomy, approaches, techniques, and complications of adrenal gland surgery. It discusses:
- The history of open adrenalectomy dating back to the late 1800s and early adoption of laparoscopic approaches in the 1990s.
- Surgical anatomy of the right and left adrenal veins which can vary and need to be carefully managed.
- Indications for adrenalectomy including functional tumors and malignancy risk based on size.
- Various surgical approaches including open, laparoscopic, robotic, and newer minimally invasive techniques.
- Important technical aspects like patient positioning, gaining access, and intraoperative maneuvers for each approach.
- Post-operative care including
This document provides guidelines for nursing management of patients with nephrostomy tubes. Nephrostomy tubes are inserted through the skin into the kidney to provide drainage for various conditions. Tube types include pigtail and wide bore catheters. Care involves irrigation, securing tubes, monitoring output, and educating patients prior to discharge. Nurses must follow sterile technique, check tubes regularly for patency and complications, and maintain fluid balances. Medical orders are required for irrigation and tube removal.
Using and Building Open Source in Google Corporate Engineering - Justin McWil...OSCON Byrum
This document discusses Google's use of open source software within its corporate engineering department. It notes that CorpEng develops many of the solutions it uses internally, including video conferencing, device management, calendars, and more. These solutions are often built on Google App Engine and some are open sourced. Reasons for open sourcing include sharing solutions, recruiting talent, and aligning with Google's culture of openness. The document provides examples of popular open source projects used at Google like Memcached, JodaTime, and testing frameworks. It highlights some of Google's own open source projects like Simian for Mac management and Cauliflower Vest for encrypted recovery keys.
This document summarizes minimally invasive treatments for hepatocellular carcinoma (HCC) such as percutaneous ablation techniques, transarterial chemoembolization (TACE), and yttrium-90 radioembolization. It reviews the evidence for different ablation modalities like radiofrequency ablation (RFA), microwave ablation, and ethanol injection. It discusses how TACE selectively delivers chemotherapy to tumor vasculature while sparing normal liver and the evidence from clinical trials showing TACE improves survival compared to supportive care alone. It also introduces drug-eluting beads TACE which may provide more effective chemotherapy delivery to the tumor.
A 42-year-old female presented with chest pain, shortness of breath, and hypotension due to massive bilateral pulmonary emboli. Initial treatment with thrombolytic infusion and pigtail rotation catheter failed to improve her condition. Angiojet mechanical thrombectomy was then performed across the clots, which improved her hypotension and oxygenation. Catheter-directed thrombectomy is an alternative treatment to systemic thrombolysis for massive pulmonary embolism when thrombolysis is contraindicated or has failed. It allows for direct delivery of thrombolytics or mechanical disruption of clots and can rapidly improve hemodynamics. However, the optimal technique and regimen remains uncertain given limited data currently.
This document provides an overview of interventional radiology procedures, with a focus on radiofrequency ablation (RFA). It describes how RFA works to coagulate and destroy tumor tissue using an electric current. Images show RFA being used to treat cancers of the liver, lung, bone, and other areas. The advantages of RFA are discussed, including preserving organ function, being minimally invasive, having local effects, and being repeatable. The document also reviews other interventional oncology procedures like chemoembolization and the use of TheraSphere microspheres to treat hepatocellular carcinoma. Additionally, it covers embolization procedures and their applications as well as treatments for arterial diseases and chronic venous insuff
Interventional Radiology : Devices and Embolic Agents that a Resident NEEDS T...Saurabh Joshi
Interventional Radiology is full of various devices and materials. The general radiology resident needs to know these in order to impress the examiner. This file also contains information on various embolic agents.
1) Liver transplantation provides the best chance of cure for hepatocellular carcinoma (HCC) in cirrhotic livers, but is limited by organ availability. The Milan criteria, which select patients with very early HCC, have been expanded to include slightly larger tumors without reducing survival.
2) Patients with HCC can be prioritized for liver transplant by receiving exception MELD scores, but these are only granted if tumors can be downstaged within defined criteria through treatments like ablation. Successful downstaging selects less aggressive tumors and predicts good post-transplant survival.
3) While downstaging expands access to transplant for some patients with larger tumors, eligibility criteria remain unclear as very advanced disease carries a
Principles of angioplasty -Endovascular Management of Peripheral Vascular Dis...Saurabh Joshi
This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
The document discusses peripheral arterial disease and endovascular treatment options. It provides an overview of various devices for treating peripheral artery disease including nitinol stents, stent-grafts, atherectomy devices, specialized balloons, and crossing devices. It then reviews the evidence from studies on these different technologies and discusses considerations for which devices may be best suited for different types of lesions.
1. Angiography is performed by inserting a catheter into an artery or vein using the Seldinger technique, which involves inserting a needle and guidewire before threading the catheter.
2. The angiography team includes a radiologist, nurse, and technologists who prepare equipment like catheters, guidewires, and injectors to visualize blood vessels and perform interventional procedures.
3. Digital subtraction angiography uses computer algorithms to subtract bone structures from images, clearly showing blood vessel anatomy for diagnostic and therapeutic purposes like angioplasty.
Interventional radiology uses minimally invasive techniques guided by imaging to diagnose and treat medical conditions. Procedures use small incisions or catheters inserted through blood vessels to access internal organs. The Seldinger technique is commonly used, involving insertion of a guidewire and catheter through a needle into the femoral artery. A variety of catheters and guidewires are used depending on the target vessel. Angiography involves injecting contrast dye to visualize vessels. Interventional radiology suites contain specialized equipment like large X-ray tubes and digital image receptors to facilitate complex image-guided procedures.
This document provides tips for using a PowerPoint presentation on retroperitoneal tumors. It recommends:
1. Freely downloading, editing, and modifying the slides and adding your name.
2. Not worrying about the number of slides, as half are blank except for the title to facilitate active learning sessions.
3. Showing the blank slides first to ask students what they know, then showing the content slide. This repeat process reinforces learning.
4. The presentation can also be used for self-study by viewing blank slides first before reading the content slides.
PPT.pptxfhj iytd jhjkj hgf uykjjn khgyfu iuf tyyf uyu v ctrc67 v ciytr57ikishansuyal
This document discusses the management of small renal masses (SRMs). Key points include:
1. SRMs are detected more frequently due to increased use of imaging and are usually less than 4cm.
2. Goals for managing early stage renal cell carcinoma include cancer survival, preserving renal function, and avoiding treatment morbidity.
3. Treatment options for SRMs include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Partial nephrectomy is the gold standard.
4. Cryoablation and radiofrequency ablation are emerging minimally invasive techniques for treating SRMs but long term data on oncologic outcomes is still lacking.
Opportunities in interventional oncology by henry wangaKesho Conference
This document discusses opportunities in interventional oncology. It provides information on various interventional radiology procedures for cancer including angiography, biopsy, drainage, tumor ablation, brachytherapy delivery, embolotherapy, and local delivery of chemotherapy. Examples of treatments used in local hospitals are discussed such as TAE, TACE, and ethanol ablation for liver cancer. Ratings and comments are provided on treatment options for different cases of hepatocellular carcinoma and metastatic liver disease.
This document discusses ablation as a treatment for renal cell carcinoma (RCC). It provides details on:
- RCC incidence, classification, staging, prognosis, and importance of preserving renal function.
- Minimally invasive ablation techniques for RCC including radiofrequency ablation, cryoablation, and emerging methods like microwave thermotherapy and irreversible electroporation.
- Results from studies show ablation techniques have acceptable short and intermediate-term oncologic outcomes for early-stage RCC with a low risk of complications compared to surgery. Ablation allows for renal function preservation in patients who need it.
1. Nephroblastoma, also known as Wilms tumor, is the most common renal malignancy in children. It typically presents as an abdominal mass and can metastasize to lungs, liver, and bone.
2. Treatment involves nephrectomy followed by chemotherapy based on stage and histology. Radiation therapy may be given for local control in certain high risk cases.
3. With multimodal therapy, the cure rate for Wilms tumor is now over 90%. Ongoing surveillance is important due to risk of recurrence or secondary tumors.
This document discusses stereotactic body radiotherapy (SBRT) for early stage lung cancer patients who cannot undergo surgery. It describes how SBRT delivers a high radiation dose to the tumor in just 1-5 sessions. Studies show SBRT provides improved tumor control compared to conventional radiotherapy, with surprisingly low toxicity. Early investigations found 3-year tumor control rates of 60-80% with SBRT, similar to surgery. Larger prospective trials of SBRT for medically inoperable early stage lung cancer patients demonstrated 3-year local control of 90-98% and low risks of side effects. SBRT provides an effective non-invasive alternative to surgery for these high-risk patients.
Urinary bladder collects urine from the kidney which is then passed through the urethra. Cancer is abnormal growth of cells leading to tumour in urinary bladder. Bladder Cancer is diagnosed with cystoscopy and biopsy . Treatment of Bladder cancer is done as per stage. It includes Radical Cystectomy, Plevic Lymphadenectomy, Ileal conduit, Neobladder as surgical options.
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
This document discusses the management of penile carcinoma. Surgery is the mainstay of treatment and may involve circumcision, laser ablation, Mohs micrographic surgery, or penectomy depending on the location, size, and stage of the tumor. Radiotherapy options include brachytherapy and external beam radiation therapy. Chemotherapy has a limited role and is mainly used perioperatively for unresectable disease. Treatment aims to balance tumor control with organ preservation and minimizing psychosocial and sexual morbidity. Close multidisciplinary care and discussion of treatment expectations is important.
Transarterial chemoembolization (TACE) involves delivering chemotherapy drugs and embolic agents directly into liver cancers via catheters in the hepatic artery. TACE is generally used to treat hepatocellular carcinoma that cannot be surgically removed. During the procedure, a catheter is placed into the hepatic artery supplying the tumor and chemotherapy mixed with iodinated oil is injected, followed by embolization of the artery with gelatin sponges. TACE can reduce tumor size and symptoms but common side effects include abdominal pain and nausea. Response to treatment is evaluated after 3-4 weeks using imaging to assess the extent of tumor coverage by the oil and residual enhancement.
Rectal carcinoma is the third leading cause of cancer death in the US. Risk factors include family history, inflammatory bowel disease, diet high in red meat and fat, and smoking. Staging follows the AJCC TNM system. Diagnosis involves history, physical exam, endoscopy, imaging like CT, MRI, PET. Treatment depends on stage but commonly includes surgery like low anterior resection or abdomino-perineal resection, with or without neoadjuvant chemoradiation, to completely remove the tumor while preserving sphincter function if possible. Ongoing surveillance after treatment monitors for recurrence or new cancers.
Cryoablation is a treatment option for renal tumors that offers several benefits:
1) It is effective for treating renal tumors less than 5cm in size with published success rates of 95-98%.
2) Cryoablation results in very little blood loss, a short hospital stay, and minimal pain for patients.
3) It can be used to treat renal tumors regardless of their location in the kidney, including those in difficult to access areas like the mid-pole.
Soft tissue sarcomas are rare malignant tumors that can arise in any soft tissue of the body. They are characterized by their genetic alterations and histological grade. Diagnosis is made through biopsy and imaging is used to stage the tumor. Treatment typically involves complete surgical resection with negative margins, along with possible adjuvant radiation and chemotherapy depending on tumor grade and size. Prognosis depends on factors like tumor size, grade, depth, and completeness of resection. Recurrence rates remain high, especially for retroperitoneal and visceral soft tissue sarcomas.
Anselmo A. Cirrosi Epatica e Tumori del Fegato: dalla Resezione al Trapianto....Gianfranco Tammaro
The document discusses cirrhosis and liver tumors, from resection to transplantation. It covers:
- The epidemiology of liver cancer, including risk factors, global incidence, and age-specific incidence.
- The pathogenesis and risk factors involved in the development of hepatocellular carcinoma (HCC).
- The clinical features, diagnosis, and management of HCC according to guidelines from EASL and other sources.
- Treatment options for HCC including resection, transplantation, and prevention.
The document discusses prophylaxis for deep vein thrombosis (DVT). It defines DVT and describes its pathophysiology. Risk factors for DVT include surgery, immobilization, old age, cancer, and inherited or acquired thrombophilias. Without prophylaxis, DVT can occur in 40-60% of major orthopedic surgeries and lead to pulmonary embolism. Methods of prophylaxis include mechanical methods like mobilization and compression devices as well as pharmacological methods like low molecular weight heparin, factor Xa inhibitors, and vitamin K antagonists. Guidelines recommend different prophylaxis options based on surgery type and patient risk factors
This document discusses osteosarcoma, including its classification, clinical presentation, investigations, and treatment techniques. It notes that osteosarcoma is the most common primary bone cancer and often occurs in teenagers. The main investigations discussed are plain X-rays, MRI, CT scan, bone scan, and biopsy. Treatment involves preoperative chemotherapy, surgical resection with wide margins (either amputation or limb-sparing surgery), and postoperative chemotherapy. Limb-sparing techniques like rotationplasty are described. The role of chemotherapy in improving outcomes is also summarized.
Cholangiocarcinoma is a rare cancer that affects the bile ducts. It occurs most often in older adults and risk factors include primary sclerosing cholangitis and liver flukes. The cancer is classified based on location and can be intrahepatic, perihilar, or distal. Surgical resection is the main treatment if the cancer is resectable, while palliative options are used for unresectable cases to relieve symptoms of biliary obstruction. Prognosis is generally poor due to late diagnosis but resection provides the best chance for survival.
This document provides an overview of rectal carcinoma. It discusses the epidemiology, risk factors, clinical presentation, investigations, staging, and treatment options. Rectal carcinoma is the third most common cause of cancer deaths in the USA, with over 150,000 new cases diagnosed annually. Treatment may involve local excision, low anterior resection, abdominoperineal resection, or multivisceral resection depending on the stage, size, and location of the tumor. Total mesorectal excision and adjuvant chemoradiation are important to reduce local recurrence rates.
Surgical management of adrenal mets third partJJSancho
1) Surgical resection of adrenal metastases may be indicated for patients with controlled primary cancer and isolated adrenal metastases.
2) Studies have shown median survival times following adrenalectomy ranging from 13 to 40 months, with some patients surviving over 5 years.
3) Laparoscopic adrenalectomy has been shown to be a safe and effective approach for resection of adrenal metastases.
Similar to Clinical management of ir patients in gonda (20)
The document discusses less commonly recognized branches of the celiac axis that can supply liver tumors, including the right inferior phrenic artery, omental arteries, and extrahepatic branches of replaced or accessory hepatic arteries. It notes that 17% of liver tumors have extrahepatic blood supply, increasing with repeated embolization. Identifying these collateral vessels is important for effective embolization treatment of liver cancers.
This study evaluated the accuracy of transcranial Doppler (TCD) bubble study to screen for pulmonary arteriovenous malformations (pAVMs) in 47 patients with hereditary hemorrhagic telangiectasia (HHT). TCD detected pAVMs with 100% sensitivity both at rest and with the Valsalva maneuver, but specificity was higher at rest (67%) than with Valsalva (33%). Higher TCD grades correlated with larger pAVM size on CT. The Valsalva maneuver did not increase sensitivity and decreased specificity, so it is not useful for detecting pAVMs. TCD is an effective initial screening tool for pAVMs in HHT patients.
Hepatic arterial anatomy and vascular optimization finalpryce27
1. This document summarizes hepatic arterial anatomy and variants based on a review of over 600 angiograms.
2. It describes the typical hepatic arterial anatomy and variants including replaced or accessory left/right hepatic arteries. Accessory arteries usually supply a distinct territory.
3. Extrahepatic collateral arteries are discussed which can supply hepatocellular carcinoma, including the phrenic, omental, intercostal, and adrenal arteries. Recognition of these collateral arteries is important to avoid complications during embolization.
Applications of ir in obstetrics and gynecology2pryce27
Uterine artery embolization and interventional radiology techniques like pre-operative balloon occlusion of the aorta or internal iliac arteries can help manage invasive placenta and reduce obstetric hemorrhage. These minimally invasive IR procedures are alternatives or adjuncts to traditional cesarean hysterectomy for invasive placenta and can decrease blood loss, increase time for surgical control of bleeding, and allow for potential uterine-sparing treatments. Close collaboration between obstetrics and interventional radiology can help lower rates of hysterectomy and transfusion requirements for patients experiencing obstetric hemorrhage.
This document discusses the role of interventional radiology in treating trauma-related hemorrhage. It describes how angiography and embolization can be used to treat bleeding from the pelvis, liver, spleen, and kidneys, which are commonly injured organs. The document reviews the angiographic techniques and technical success rates for embolizing various arterial branches to control bleeding in these organs.
This study compared the traditional "blind" renal transplant biopsy technique to an ultrasound-guided coaxial technique. The study found that both techniques obtained adequate biopsy samples in over 98% of cases. The traditional technique was associated with a significantly higher rate of minor complications like hematomas compared to the coaxial technique, but there was no significant difference in major complication rates between the two methods. Overall, both techniques demonstrated a low risk of complications and were effective in obtaining diagnostic biopsy samples.
This document reviews percutaneous ablation techniques for hepatocellular carcinoma (HCC), a type of liver cancer. It discusses how radiofrequency (RF) ablation has become a popular minimally invasive treatment for unresectable HCC tumors less than 3cm in size. The document reviews survival rates and complication risks of various ablation methods, including RF ablation, microwave ablation, cryoablation, and ethanol ablation. It emphasizes the importance of treatment planning to accurately assess tumor size, location, and relationship to vital structures to ensure complete ablation can be safely achieved.
This study compared the efficacy of transcranial Doppler (TCD) bubble study to transthoracic echo (TTE) bubble study in screening for pulmonary arteriovenous malformations (AVMs) in 9 patients with hereditary hemorrhagic telangiectasia (HHT). Both studies were performed at rest and during a Valsalva maneuver. TCD grades increased in 3 patients with Valsalva. TCD detected shunting in 5 patients while TTE detected shunting in 4. The study concluded that TCD bubble study is a viable alternative to TTE for detecting right-to-left shunting from pulmonary AVMs in HHT patients.
Liver diseases symposium interventional techniques and downstaging of hcc f...pryce27
The document discusses downstaging hepatocellular carcinoma (HCC) to make more patients eligible for curative treatments like orthotopic liver transplantation (OLT). It describes using interventional techniques like transarterial chemoembolization and radioablation to shrink tumors below size thresholds for OLT. If tumors can be successfully downstaged and remain downstaged for 3-6 months, long-term survival after OLT exceeds 50%, comparable to patients within standard Milan criteria. Determining which patients are best candidates for downstaging attempts remains unclear.
The document discusses treatment options for a 63-year-old male patient with hepatocellular carcinoma. It describes the patient's medical history and imaging findings, which show two liver lesions - a 4.7 cm lesion in the right lobe and a 1.5 cm lesion in the left lobe. The document then discusses and compares various locoregional treatment options for the patient's condition, including orthotopic liver transplantation, downstaging followed by transplantation, surgical resection, portal vein embolization prior to resection, radiofrequency ablation, transarterial chemoembolization, yttrium-90 radioembolization, transarterial chemoembolization combined with sorafenib, sorafenib
This document discusses radiation exposure and safety during interventional radiology procedures. It covers topics such as how x-rays are produced, different metrics used to measure radiation dose, stochastic and deterministic radiation effects, and strategies to minimize radiation exposure to patients and operators. Key points include that fluoro time is a poor indicator of dose, 3 Grays can cause skin injury, DSA uses about 10x more radiation than fluoro per unit time, and a typical embolization exposes patients to around 1000 chest x-rays worth of radiation, increasing cancer risk by about 0.5% for a 30-year old patient.
This presentation discusses the liver manifestations of Hereditary Hemorrhagic Telangiectasia (HHT). HHT is characterized by mucocutaneous and visceral angiodysplasias ranging from telangiectasias to arteriovenous malformations. Liver involvement is common, with over 50% prevalence in some studies. Imaging plays an important role in identifying shunt patterns and complications. Multiphase CT and Doppler ultrasound can demonstrate arteriovenous and arterioportal shunting. Treatment is tailored to clinical symptoms, with medical management preferred over embolization due to risks of hepatic necrosis. Transplantation may be considered for intractable complications such as heart failure or biliary disease.
This document discusses the use of intra-procedural contrast-enhanced CT following percutaneous ablation of liver lesions. It is performed as the final step of each ablation procedure at the authors' institution to assess the adequacy of ablation, detect any previously unnoticed lesions that could be ablated, and identify any complications that may require further management. Examples are provided of how intra-procedural CT has directed further on-table ablation of additional lesions detected, identified inadequate ablation margins for further treatment, and helped recognize and treat complications like pneumothorax, non-target ablation, and pericardial effusion.
This document provides a case study and overview of prostate artery embolization (PAE) for treating benign prostatic hyperplasia (BPH). It describes a 62-year-old male patient with severe lower urinary tract symptoms whose 140cc prostate made him a non-surgical candidate for traditional procedures. The document outlines the author's training in urology residency, literature research on PAE, and discussions with other physicians. It then details the patient's PAE procedure, follow-up visits showing symptom and prostate size reduction, and lessons learned. Finally, it discusses an upcoming randomized controlled trial to obtain FDA approval for PAE as a treatment for BPH.
This study compared the effectiveness and safety of traditional "blind" renal allograft biopsies versus real-time ultrasound guided coaxial biopsies. A retrospective review of over 800 biopsies in over 600 patients found that while both techniques obtained a diagnostic sample in over 99% of cases, the traditional technique resulted in significantly more minor complications such as hematomas and arteriovenous fistulas. However, the rates of major complications requiring intervention were not significantly different between the two groups. In conclusion, real-time ultrasound guided coaxial biopsies may reduce the risk of minor complications without increasing the risk of major complications compared to traditional blind biopsies.
1. Clinical Management
IR patients in the GOU
Justin McWilliams, M.D.
Assistant Professor of Radiology
UCLA
2. Outline
Intro to IR
General principles
IR procedures relevant to GOU
Description of procedure
Post-procedure management
Complications
Case scenarios
9. Liver cancer treatments
OLT
Treatment of choice for HCC, especially in cirrhotics
Milan criteria: one lesion up to 5 cm, or up to 3 lesions, each up to 3 cm. No vascular invasion or mets
5-year survival ~70%
Resection
Treatment of choice for HCC in non-cirrhotics
Any size lesion if limited to one lobe, PV invasion OK
5-year survival ~50%
RFA
Treatment of choice in non-operative candidates with limited disease
Effective in lesions up to 3-5 cm, up to 3 or 4 lesions
5-year survival ~40%
TACE
Treatment of choice in non-operative candidates with intermediate stage HCC (large or numerous tumors)
Give chemotherapy-eluting particles directly into arteries feeding the tumor
5-year survival ~20%
Nexavar
Treatment of choice in advanced HCC (extrahepatic spread or vascular invasion)
Tyrosine kinase inhibitor with proven survival benefit in RCT
Median survival 10 months (vs 7 months with placebo)
10. Transarterial chemoembolization
Rationale
HCC takes its blood supply almost
exclusively from the hepatic artery
Surrounding normal liver has dual
blood supply (with portal vein)
Chemotherapy + embolic agent
administered into hepatic artery
should selectively kill tumor while
sparing normal liver
11. TACE
Technique
1. Conscious sedation
2. Common femoral artery access
3. Catheter to select hepatic artery
4. Microcatheter to superselect tumor-bearing artery
5. Embolize to near-stasis or stasis
• Conventional TACE: Chemotherapy (doxorubicin, cisplatin,
mitomycin C) with Lipiodol, followed by Gelfoam or
Embospheres
• DEB-TACE: Doxorubicin-eluting LC beads
• Chemo elutes more slowly than with Lipiodol
• Reduced liver toxicity
• Less side effects
6. Arterial closure
7. Overnight admission
12. TACE
Llovet and Lo, 2002
RCT of TACE vs. symptomatic treatment for unresectable HCC
Llovet: 112 patients
3-year survival:
29% with TACE
17% with supportive care
Lo: 80 patients
3-year survival:
26% with TACE
3% with supportive care
13. TACE
Consensus statement
“TACE is first-line non-curative therapy for non-
surgical patients with large or multifocal HCC
who do not have vascular invasion or
extrahepatic spread (level I evidence).”
American Association for Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL).
14. Radiofrequency ablation
Rationale
RF current induces thermal
coagulation necrosis around an
electrode
• Complete ablation rates >80% for small
to medium HCC
• Local recurrence uncommon (1-12%)
Disadvantages
• Relies on thermal conduction (limited
ablation size)
Best for tumors <3 cm
Increasing technical failure and local
recurrence for tumors >3 cm
• Heat sink effect
• Slow
McWilliams J, et al. Percutaneous ablation of hepatocellular carcinoma: current status. J Vasc Interv Radiol 2010;21:S204-S213.
Hinshaw J. The role of image-guided tumor ablation in the management of liver cancer. Cancer News review article.
15. RFA
Technique
1. General anesthesia (usually)
2. Ultrasound used to guide 1-3 needles into tumor
3. CT to confirm and/or adjust position
4. Ablation performed (3-5 cm burn possible)
5. Adjust needle position and repeat as necessary
6. Needle removal with tract cauterization
7. Contrast CT to confirm adequate treatment
8. MRI after anesthesia wears off
9. Discharge same day (ideally)
16. Percutaneous ablation
Consensus statement
“Local ablation is safe and effective therapy for patients
who cannot undergo resection, or as a bridge to
transplantation.”
American Association for Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL).
18. General Principles
Post-embolization syndrome (PES)
Occurs in 80-90% of patients who undergo embolization (TACE, UFE, etc)
Within 24 hours of embolization, tissue and cell death begins, and breakdown
products are released into the circulation
• Pain – At site of embolization, may be severe
• Nausea/vomiting – About 1/3 of patients
• Fever – 15-30% of patients, up to 104 degrees
• Leukocytosis – 15-30% of patients, can exceed WBC 20k
• Fatigue – Most patients, can last for weeks
Some or all of these symptoms may not manifest until after patient discharge
Post-ablation syndrome consists of the same symptoms, but is less frequent
(<1/3 of patients)
Most symptoms resolve by 72 hours (except fatigue, and sometimes pain)
19. General Principles
Pain
Can occur during the procedure, but often does not
occur until post-procedure
Referred visceral pain from the liver is often found in
the right shoulder
Opioid analgesia is treatment of choice for severe pain
• Dilaudid or morphine
• PCA is often best method of delivery
NSAIDs can be useful for minor pain, but generally
avoid in liver patients
Tylenol is OK but limit to 1.5 grams/day in liver patients
20. General Principles
Nausea
Often multifactorial
• PES
• Chemotherapy
• Opioid use
Zofran works great (4 mg q4 or 8 mg q8)
Can add dexamethasone in non-diabetics (12 mg on day of
treatment)
Compazine or droperidol for breakthrough nausea
21. General Principles
Fever
15-30% of patients develop fever after intervention
• Usually at 24-48 hours
• May be up to 104, but usually <102
Leukocytosis is normal
• Can exceed 20k
Low grade or moderate fever in first few days after
treatment should not warrant fever work-up
Differentiating infection vs. PES is difficult
• Gas in embolized area on CT is normal, not abscess
• Fevers beyond 48 hours may require work-up
• Abscess usually occurs at 2-4 weeks
22. General Principles
Fatigue
Extremely common after embolization, and to a lesser
extent, ablation
Peaks several days after treatment
Can last for days or weeks
Risk factors
• Baseline fatigue
• High dose of chemo used
25. TACE
Post-procedure management
Fluids/Diet
• IV hydration NS ~250 cc/hr x 5 hours
• Advance diet as tolerated (do not start with Salisbury steak)
Activity
Pain control
Nausea control
Antibiotics
Puncture site
Labs
26. TACE
Post-procedure management
Fluids/Diet
Activity
• Bed rest at least 2 hours (closure device)
• Bed rest at least 6 hours (manual compression)
• Bed rest overnight (higher risk patients)
Pain control
Nausea control
Antibiotics
Puncture site
Labs
33. TACE
Complications
Liver failure
• Risk factors: Child B/C, total bili >3.0, albumin <2.0, ECOG >2
• Mechanism: TACE-related injury to “normal” liver parenchyma (poor reserve in
cirrhotic livers)
• Incidence: 13% of TACE patients suffer some degree of liver failure.
• Diagnosis: Elevated bilirubin/INR, jaundice, itchiness, dark urine, light stool
• Avoidance strategy: Superselective embo
• Treatment: Supportive care
• Outcome: Most recover. 30-day TACE-related mortality from liver failure is 2%
34. TACE
Complications
Bleeding (puncture site)
• Risk factors: Low platelets, high INR, obesity, closure device failure, uncooperative patient
• Mechanism: Platelet plug does not form or dislodges
• Incidence: Minor groin hematoma <10%. Major intramuscular or retroperitoneal bleed is rare but
devastating.
• Diagnosis: Groin swelling/pain (not if retroperitoneal), tachycardia, hypotension, orthostasis, pallor,
dizziness, lightheadedness, weakness
• Avoidance strategy: Careful access and closure, bed rest with leg straight
• Treatment: Pressure. IVF. Stat type/cross and transfuse. Stat CT. Consider angio.
• Outcome: Depends on blood loss.
35. TACE
Complications
Bleeding (variceal)
• Risk factors: Presence of varices, previous variceal bleed, low platelets, high INR
• Mechanism: Increased portal HTN in setting of periprocedural liver insult (varices)
• Incidence: <1%, anecdotal
• Diagnosis: Hematemesis, shock
• Avoidance strategy: Pre-TACE banding? Superselective TACE
• Treatment: IVF. Type/cross and transfuse. Immediate endoscopy with banding. Consider
emergent TIPS if no other options.
• Outcome: High mortality rate.
36. TACE
Complications
Nontarget embolization
• Risk factors: Lobar (nonselective) treatment
• Mechanism: Embolic material passes into gallbladder, stomach or intestine
• Incidence: <<10%
• Diagnosis: Ulceration, perforation, pain, bleeding
• Avoidance strategy: Superselective embo
• Treatment: NPO. Hydration. PPI. Prolonged observation. Consider surgery if bowel necrosis.
• Outcome: Most recover with supportive care alone.
47. RFA/MWA
Complications
Hemorrhage
• Risk factors: Low platelets, high INR, multiple needle placements, ascites
• Mechanism: Arterial injury by needle, or persistent oozing from liver puncture
• Incidence: ~1% clinically significant hemorrhage rate
• Diagnosis: Hypotension, tachycardia, pallor, pain, dizziness, orthostasis
• Avoidance strategy: Tract cauterization, FFP/platelet support
• Treatment: IVF resuscitation. Transfuse. Stat CTA (look for active extravasation).
Hepatic angiography and embolization.
• Outcome: Depends on blood loss.
48. RFA/MWA
Complications
Liver failure
• Risk factors: Child B/C, total bili >3.0, albumin <2.0, ECOG >2, large ablation zone, multiple
ablations
• Mechanism: Ablation of “normal” liver parenchyma (poor reserve in cirrhotic livers)
• Incidence: 12% risk of death from liver failure in ablation of Child C patients; <1% risk for
Child A or B
• Diagnosis: Elevated bilirubin/INR, jaundice, itchiness, dark urine, light stool
• Avoidance strategy: Staged ablation
• Treatment: Supportive care
• Outcome: Recovery is less likely than in TACE as liver is permanently damaged with ablation
49. RFA/MWA
Complications
Nontarget ablation
• Risk factors: Target tumor near stomach, bowel, bile ducts, gallbladder
• Mechanism: Nontarget tissues lie within ablation zone
• Incidence: 2%
• Diagnosis: Bowel or gallbladder perforation, bile leak or obstruction
• Avoidance strategy: Hydrodissection, positioning
• Treatment: Surgery or supportive care
• Outcome: Mortality is high for bowel injury in this population
50. RFA/MWA
Complications
Infection/abscess
• Risk factors: Hepatojejunostomy, biliary drainage tube
• Mechanism: Colonized biliary system seeds the necrotic treated ablation zone
• Incidence: <5% with normal sphincter of Oddi; 30-80% if compromised
• Diagnosis: Pain, fever
• Avoidance strategy: Periprocedural antibiotics, bowel prep
• Treatment: Antibiotics and drainage
• Outcome: Most recover
51. RFA/MWA
Complications
Tumor seeding
• Risk factors: Multiple needle insertions, concomitant biopsy
• Mechanism: Tumor cells on needle seed tract as needle is removed
• Incidence: <1%
• Diagnosis: Imaging
• Avoidance strategy: Tract ablation/cauterization with needle removal
• Treatment: Ablation or surgery
• Outcome: Most are detected on follow up and treated
52. TG
39 y/o female
Fibrolamellar HCC diagnosed in 2001
Left lobe resection of 9 x 11 cm mass in 2001
Recurrence 2007 with partial right lobe
resection
CT 4/9/2010: At least
Presents with multifocal recurrence 2/2010 10 hypervascular liver
masses
Not a surgical or transplant candidate
Presented at tumor board and referred for
locoregional therapy
53. TACE 5/3/2010 100 mg doxorubicin on
LC beads
2 weeks later, returns
with fevers, RUQ pain
54. CT 5/19/2010: near- complete
tumor necrosis
Prolonged CT 8/6/2010: Biloma
Percutaneous biloma catheter resolved, but
drainage drainage intrahepatic recurrence
and new lung nodule.
To study drug
57. Fibrolamellar hepatocellular carcinoma
Status post left lobectomy and partial right lobectomy
No longer a surgical candidate
OLT?
RFA?
TACE?
Chemotherapy?
58. Liver cancer treatments
OLT
Treatment of choice for HCC, especially in cirrhotics
Milan criteria: one lesion up to 5 cm in size, or up to 3 lesions, each up to 3 cm in
size. No vascular invasion and no mets.
RFA
Place ablation needle into lesion (under CT/US guidance) and cook it
Effective in lesions up to 3 cm (sometimes larger), up to 3 or 4 lesions
Damage to adjacent bile ducts or bowel can be a concern
TACE
CFA access, catheterize hepatic artery and subselect tumor feeders
Give chemotherapy-eluting particles
Block blood flow
Release tumoricidal chemotherapy
Targeted chemotherapy
Nexavar (tyrosine kinase inhibitor) – extends survival in advanced HCC
Avastin (monoclonal VEGF inhibitor) – promising but unproven
59. Liver cancer treatments
OLT
Too many lesions to qualify (outside Milan criteria)
Can consider Milan exception if we can decrease her disease burden
RFA
Too many lesions to effectively treat, and marginal location increases risk for
bowel/stomach injury
TACE
Suitable
Targeted chemotherapy
Suitable, if TACE fails
60.
61.
62. Status post 100 mg doxorubicin on 100-300 and 300-500 micron LC beads
63. Discharged home the next day, doing well
2 weeks later, having persistent high fevers to 103 and night sweats