Primer on interventional radiology
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Grand rounds lecture from 1/2017 on the amazing minimally invasive procedures offered in IR including microwave ablation of tumors, y90 radioembolization, UFE, arterial disease, and CVI.
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Primer on interventional radiology
- 1. Interventional Radiology Aaron Shiloh MD FSIR Section Chief Interventional Radiology A Primer on Minimally Invasive Image Guided Therapies
- 2. Overview • Paracentesis • Thoracentisis • PICC Line • Can this be biopsied?
- 3. Overview • Basics of liver directed therapy • Embolization • PE lysis • Arterial disease and CVI
- 4. Liver Directed Therapy Local • RFA • Microwave • Cryoablation Regional • Chemoembolization • Drug-Eluting Bead embolization • Y90 (Glass and Resin) Beads
- 5. Interventional Oncology Local Treatment Options Microwave Ablation
- 6. Microwave Ablation (MWA) MWA – “the application of high frequency electric currents to heat and coagulate target tissue”
- 7. MWA – A Variety of Applications Liver Kidney Bone Lung
- 8. MWA Pathology Hyperemic Rim Coagulation zone (= MWA lesion)
- 9. MWA Ablation NSC Lung Cancer 3 cm MWA 3 mo S/P MWA/XRT 18 mo S/P MWA/XRT
- 10. Post MWA Pre MWA MWA Images Pre & Post CT
- 11. 65 year old male with recurrent liver mets from CRC after multiple cycles of chemo
- 12. Colorectal Metastatic Disease Two PET positive lesions Immediate post microwave ablation 6 month follow-up
- 13. 84 yo male with multiple Medical problems And a growing RCC
- 14. Summary of MWA Advantages Preserves liver function in cirrhotic patients Minimally invasive Local effect Potential for improved quality of life when combined with radiotherapy and chemotherapy Repeatable for recurring disease
- 15. Interventional Oncology Regional Therapeutic Options
- 17. Chemoembolization & Bland Embolization HCC Metastases Neuroendocrine Colorectal Breast Melanoma RCC
- 18. TheraSphere® HCC one of most common forms of cancer worldwide (est. 1 million new cases annually) In US, NCI estimate 19,160 new cases and 16,780 deaths in 20071 Incidence increasing with rise in hepatitis C-induced cirrhosis 5-10% of HCC patients are resectable2 1 National Cancer Institute www.cancer.gov (accessed December 1, 2008) 2 Llovet, JM. Current Treatment Options for Gastroenterology. 2004;7:431-441 HCC Epidemiology
- 19. HCC: Difficult to Treat, Few Effective Treatment Options Tenuous liver functions (cirrhosis, hepatitis) Spontaneous decompensation Resistant to standard chemotherapy and low dose radiation Responsive to high dose radiation TheraSphere® HCC Epidemiology
- 20. Limited Treatment Options for HCC Therapeutic Options: Resection or transplantation Unresectable HCC treatment options: Radiofrequency ablation Transarterial chemoembolization (TACE or Drug Eluting Beads) Transarterial TheraSphere, Y90 Glass Microspheres External Beam radiation Systemic therapy (ie. Sorafenib) No treatment TheraSphere®
- 21. What is TheraSphere® 20-30 µm glass microspheres Y-90 is an integral constituent of the glass matrix Innovative treatment to deliver powerful, targeted radiation inside the liver Y-90 glass microspheres comparison to human hair TheraSphere dose vial
- 22. Administered via hepatic artery catheter Targeted internal radiation due to tumor hypervascularity Microspheres are trapped in the tumor arterioles and are minimally-embolic (microembolization) Pure beta-emitter Average beta emission energy is 0.9367 MeV Average penetration range in tissue is 2.5 mm Physical half-life is 64.2 hours and decays to stable zirconium-90 TheraSphere® Mechanism of Action
- 24. • 52 year old male with alcoholic hepatitis with ascites and pleural effusions. • Cirrhosis lead to CT and MRI • PMH: Ascites, Pleural effusions, right nephrectomy • ECOG 0, CP A • 3 cm Tumor seen in right lobe, segment 7 • AFP not elevated
- 25. June 2010
- 26. July 2010
- 29. Sept 2010 – One month post treatment
- 30. Jan 2014
- 31. 2010-2014
- 32. Embolization Tools • Coils • Gelfoam • Alcohol • Particles • Glue
- 33. • 42 y/o obese female with Right 3 cm AML treated 8 yrs prior with embolization at another institution when the AML was alledgedly 7 cm and spontaneously bled.
- 39. Bronchial Artery The patient presented with hemoptysis and a known right perihilar lung cancer. The patient had been previously brought to the operating room where an endotracheal tube was placed as well as a bronchial blocker
- 44. GDA • Duodenal ulcer oversewn 10 days prior • Repeat severe upper gi bleeding • At endoscopy found to have a large visible vessel that was bleeding and three clips were placed.
- 48. Procedure Small incision in skin Uterine Fibroid Embolization – Catheter inserted into femoral artery Femoral Artery
- 49. Procedure Uterine Fibroid Embolization – Dye is injected – Blood no longer reaches fibroids Uterine Artery – Catheter is steered to uterine artery – Small inert particles “emboli” are injected – Branches of uterine artery are blocked – Fibroids shrink over time
- 50. Procedure
- 58. PE and DVT lysis • Basics of PE and DVT lysis
- 59. Massive PE Submassive PE Minor/Nonmassive PE High risk Moderate/intermediate risk Low risk •Sustained hypotension (systolic BP <90 mmHg for 15 min) •Inotropic support •Pulseless •Persistent profound bradycardia (HR <40 bpm with signs or symptoms of shock) •Systemically normotensive (systolic BP 90 mmHg) •RV dysfunction •Myocardial necrosis •Systemically normotensive (systolic BP 90 mmHg) •No RV dysfunction •No myocardial necrosis RV dysfunction • RV/LV ratio > 0.9 or RV systolic dysfunction on echo • RV/LV ratio > 0.9 on CT • Elevation of BNP (>90 pg/mL) • Elevation of NTpro-BNP (>500 pg/mL) • ECG changes: • new complete or incomplete RBBB • anteroseptal ST elevation or depression • anteroseptal T-wave inversion Jaff et al. Circulation 2011;123(16):1788-1830. Jaff et al. Circulation 2011;123(16):1788-1830. Background and Definitions
- 60. 60 − Registry of 1,416 patients − Mortality rate: 1.9% if RV/LV ratio < 0.9 6.6% if RV/LV ratio ≥ 0.9 Fremont et al. CHEST 2008;133:358-362 How to Determine Risk
- 61. Degree of PE Treatment* Bleeding Risk Non-Massive Heparin (I) Less Sub-Massive Lytics (IIb) Massive Lytics (IIa) More 20% risk of major bleeding 3% risk of intracranial hemorrhage *ACC/AHA Guidelines 2011 Circulation 2006;113:577-82 Treatment of High Risk Patients
- 64. The ULTIMA Trial A Prospective, Randomized, Controlled Study of Ultrasound Accelerated Thrombolysis for the Treatment of Acute Pulmonary Embolism Annual Meeting of the American College of Cardiology, March 9, 2013 Treatment of High Risk Patients
- 65. Systemic Lytics v Heparin EKOS v Heparin Total Lytics Dose 100mg 20.7mg (12.2mg) Mortality 5.9% -> 4.3% 1/29 -> 0/30 RV Size Improved Improved RV Function Improved Improved Major Bleeding 20% 0/30 ICH 3% 0/30
- 67. Arterial Disease One patient, many techniques
- 82. Epidemiology: Prevalence Of the over 30 million Americans affected: • Only 1.9 million seek treatment annually1,2 • While the vast majority remain undiagnosed and untreated CVI Prevalence*,1,2 30,000,000+ Seek Treatment *2 1,900,000 Treated 447,0002 (Table 30) *Statistics based on individuals over the age of 40 More than 30 million Americans suffer from varicose veins or a more serious form of venous disease called Chronic Venous Insufficiency (CVI).1 1. Gloviczki P, et al. The care of patients with varicose veins and associated chronic diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. JVS; May 2011. 2. Lee, A. US markets for varicose vein treatment devices 2011. Millennium Research Group, Inc. (A Decision Resource, Inc. Company), www.mrg.net, May 2011.
- 83. Epidemiology: Risk Factors Many factors contribute to the presence of venous disease and CVI including1,2,3,4,5: • Gender • Age • Family history • Multiple pregnancy • Standing occupation • Obesity • Prior injury or surgery 1. "Chronic Venous Insufficiency." Vascular Web. Society For Vascular Surgery, Jan. 2011. Web. 17 Aug. 2011. http://www.vascularweb.org/vascularhealth/Pages/chronic-venous- insufficiency.aspx. 2. Maurins U, Hoffmann BH, Lösch C, Jöckel KH, Rabe E, Pannier F. Distribution and prevalence of reflux in the superficial and deep venous system—results from the Bonn vein study, Germany. J Vasc Surg.2008;48:680-87. 3. Criqui MH et al. Epidemiology of chronic peripheral venous disease; JJ Bergan Editor, The Vein Book, Elsevier Academic Press .(2007):30. 4. Chiesa R, Marone EM, Limoni C, Volonte M, Schaefer E, Petrini O. Chronic venous insufficiency in Italy: the 24-cities cohort study. Eur J Vasc Endovasc Surg. 2005;30:422-429. 5. Rabe E, Pannier F. Epidemiology of chronic venous disorders; P. Glovicki, Editor, Handbook of venous disorders (3rd edition), Hodder Arnold.(2009);109.
- 84. Anatomy: Venous System • Venous blood flows from the capillaries to the heart • Flow occurs against gravity – Muscular compression of the veins – Negative intrathoracic pressure – Calf muscle pump • Low flow, low pressure system
- 85. Etiology & Pathophysiology Healthy veins, with competent vein valves, keep blood moving in one direction back to the heart Diseased veins, with damaged vein valves, cause blood to move in both directions, elevating venous pressure
- 86. Single puncture percutaneous access under ultrasound guidance Temperature controlled 85°C heating at or below deep fascia Endovenous ablation specifically indicated to treat incompetent perforator veins The Venefit™ Procedure with the ClosureRFS™Stylet
- 87. The Venefit™ Procedure with the ClosureRFS™Stylet • Ultrasound exam to diagnose vein reflux • Outpatient or hospital procedure • Local or general anesthetic • Quick return to normal activities – often within a few days1 Click graphic to play video 1. Roth S, Endovenous radiofrequency ablation of superficial and perforator veins, Surg Clin N Am 87:1267-1284(2007) *Indications, contraindications, warnings, and instructions for use can be found in the product labeling supplied with each device. CAUTION: Federal (USA) restricts this device to sale by or on order of a physician.
- 91. So I was working on this grand rounds talk. I was reviewing old presentations and I came upon this case presentation from 2013.
- 92. Case Presentation • 84 year old female with chronic autoimmune hepatitis • LFTs elevation lead to CT • PMH: Atrial Fibrillation, Hypertension, hypothyroidism • ECOG 0, CP A • T. Bili 0.8, cr 0.8, AFP 3320
- 96. 2016
- 98. Thank you!
Editor's Notes
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- Transplantation rates are low (similar to resection rates) due to advanced stage of cancer at diagnosis
- Historical perspective: With advent of sorafenib, seeing some response to standard chemotherapy but tox profile may make this undesirable for many patients high dose radiation has been used for several decades and the tumors have responded to this therapy Causes some collateral damage due to lack of specificity of radiation beam
- resection or transplantation represent the potential for cure only a small proportion of patients are eligible for such treatments majority present with multi-focal diffusely distributed disease, which eliminates the possibility of curative treatment options. of the options available for unresectable disease, each has its shortcomings. historical systemic chemotherapy (ie. doxorubicin) has showed minimal tumor response with attendant toxicities and morbidity, rendering this approach not ideal. Recent approval of sorafenib is addressed on a later slide. RFA may be used in cases of smaller tumors (3-5 cm); however, this therapy is limited for larger tumors or multi-focal presentations due to inadequate probe coverage (positive margins) or technically difficult procedures. RFA is also operator dependent, and relies on the experience and expertise of the user. Moreover RFA is not optimal for edge positioned tumors or tumors proximal to major hepatic vessels (e.g. the portal vein). External beam radiation has been associated with an increased risk of RILD due to the low tolerance of normal liver tissue to irradiation, as well as the increased exposure of bystander organs to an unfocused beam. Conformal radiation has permitted more focal radiation to be delivered to the tumor; however, some irradiation to normal liver parenchyma is likely. This procedure is also complex and is not practiced at many institutions. TACE is associated with potentially significant toxicities (nausea, vomiting, fever, abdominal pain) resulting in a hospital stay of at least 2-3 days. TheraSphere, with its low toxicity profile, is an outpatient procedure that permits the patient to be treated and discharged within 4-6 hours the same day. However, it is a permanently implanted radioactive device and some patients/physicians may have issues with this
- incorporation of 90Y into the glass matrix of the microspheres results in a stable compound with no risk of leaching or de-labeling of the isotope Will always have a consistent, standardized and reproducible delivery of Yttrium-90.
- As tumors grow, blood flow parasitized from hepatic artery (estimated 80% tumor blood volume comes from hepatic artery) microspheres preferentially delivered to tumor area microspheres are trapped in the microvasculature Assumes the vessels are smaller than 20µm maximum penetration range is approximately 1 cm (width of smallest finger) after 7 half-lives, the majority of the radiation has dissipated
- Based on a target volume of 717 gms the patient was prescribed a 18.5 GBQ custom dose on to be delivered on tuesday of week 2 at 10 am to allow for better distribution of the particles given the large size of the tumors. Therasphere was administered under an IRB HDE protocol.
- A tiny incision is made in your skin…8 above where a blood vessel – the femoral artery – is found. The small, flexible catheter is then inserted through that incision and into the femoral artery.
- Your fibroids receive blood from your uterine arteries – blood vessels that branch from your femoral arteries on both sides of your uterus. The physician will first steer the catheter up to the uterine artery on the far side of your uterus. X-rays will be taken as the catheter is advanced to make sure that it is placed correctly. 8 Once the catheter is in place, the physician injects a special dye to examine the fibroids. 8 Then, small particles called PVA are injected through the catheter. 8 These particles – or “emboli” – flow into the branches of your uterine artery, blocking the vessel and…8 preventing blood from reaching the fibroids. 8 Deprived of oxygen and nutrients, your fibroids will shrink, relieving your symptoms. The catheter is then positioned in the uterine artery on the near side of the uterus and the procedure is repeated, ensuring that there is complete blockage of the blood flow. After the procedure is complete, a small dressing is placed over the skin incision in your groin.
- Notes: When left untreated, venous reflux can lead to significant clinical issues, like pain, swelling, varicose veins, skin changes, and ulcers Gloviczki, P., MD., Comerota, A., MD., Dalsing, M., MD., Eklof, B., MD., Gillespie, D., MD., Gloviczki, M., MD.,… Wakefield, T., MD. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May; 53(5 Suppl): 2S-48S Lee, A. US markets for varicose vein treatment devices 2011. Millennium Research Group, Inc. (A Decision Resource, Inc. Company), www.mrg.net, May 2011.
- Notes: Gender: There is a significantly higher prevalence in women1,2 Age: older age is a risk factor in both men and women1,3 Heredity: family history of venous disease is a risk factor1,3 Pregnancy: studies have shown an increase in venous reflux symptoms among women who have had one or more pregnancies1,4 Standing occupation: causes a great amount of pressure to develop in the leg veins and is a strong risk factor for venous disease1,3 Obesity: in both men and women, there is a strong correlation between BMI and increased risk for chronic venous insufficiency1,5 Prior trauma or surgery: lower limb trauma has been found to be a risk factor for chronic venous insufficiency3
- This diagram shows the interrelation between superficial and deep venous systems and the perforators that connect the two systems Deep venous system Superficial venous system Saphenous veins Lateral venous complex Perforating veins
- Notes: Consider showing the healthy and damaged vein valve animation Healthy leg veins contain valves that open and close to assist the return of blood back to the heart Venous reflux develops when the valves that keep blood flowing out of the legs and back to the heart become damaged or diseased Venous reflux is the result of over-dilation of the venous vessels in the legs. This dilation eventually prevents the valve cusps from closing properly, resulting in reflux. The pooling of blood results in ineffective flow back to the heart. In some cases the reflux is caused not only by the over-dilation of the vessel wall, but also by damaged or absent valves. In this case, the valves have been so badly damaged, or degenerated, that they are almost nonexistent and no longer function To assess if reflux is present, a duplex ultrasound scan is performed
- Minimally invasive outpatient procedure which can be performed under local anesthesia in the physician's office To play the video, click on the graphic. Video file RFS Animation needs to be in the same folder as the PowerPoint presentation for this video to play
- Arterial phase imaging clearly demonstrated three encapsulated hypervascular masses in the setting of cirrhosis consistent with multifocal hepatocellular carcinoma. The largest mass (blue arrow) measured 7.1 cm in segment 8. Immediately adjacent was a 5.6 cm mass (red arrow) in segments 5/6. The third mass measured 2 cm (yellow arrow) and was in segment 7.
- Arteriography demonstrated classic hepatic arterial anatomy. The largest two tumors are clearly seen (blue arrows) in the early arterial imaging. There was no overt venous shunting identified. The gastroduodenal artery (yellow arrow) and right gastric artery (red arrow) were not embolized since the microcatheter could be placed in the distal right hepatic artery for a planned lobar injection and there was no risk of reflux using Therasphere. Following the injection of 99Tc-MAA into the right hepatic artery at the completion of the procedure, a radionuclide scan demonstrated a 2% Lung Shunt Fraction. Based on a target volume of 717 cc the patient was prescribed a 18.5 GBQ custom dose to deliver 120Gy to the tumors on tuesday of week 2 at 10 am. A lobar infusion of Therasphere was administered from the distal right hepatic artery. Therasphere was administered under an IRB HDE protocol.
- Followup CT 6 months later shows complete necrosis of the largest mass with involution of the smaller adjacent mass and complete disappearance of the third small mass. The AFP has dropped from 3320 to 2.
- In summary, a single lobar treatment with Therasphere of multifocal hepatocellular carcinoma in the right lobe resulted in an excellent response at 6 month followup in an elderly female with multiple comorbidities.