8 th Interventional Radiology Conference May 1 st, 2010 H.R. Macmillan Space Centre and Vancouver Museum

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1 8 th Interventional Radiology Conference May 1 st, 2010 H.R. Macmillan Space Centre and Vancouver Museum Sharon Armes, RN, CINA Clinical Education Coordinator for Bard Canada Central Venous Catheter Tip positions Central Venous Access (CVAC) access devices and placement has been common to the IR suite for several years now. This lecture will review specifically the appropriate placement techniques with an emphasis on the ideal line placement location within the interventional patient. Objectives: Educate and review of current published literature of accepted catheter tip location within central veins. Dr. John Aldrich Interventional Radiology and Patient Dose In general there are two types of radiation damage deterministic effects (eg erythema) where a decrease in the number of cells affects the performance of the organ, and stochastic effects like cancer. Interventional radiology is one of the few areas of diagnostic imaging where both effects may occur. This talk will review typical interventional doses, ways in which these may be monitored and optimized in our clinics. Dr. John Aldrich Digital Radiography and Patient Dose Since 2001 most major hospitals have moved from screen-film to digital systems such as computed radiography and direct digital detectors. Film-screen systems operated in a narrow dose range and over-exposure was evident to the operator. However, all digital systems have a very wide dose response and it is easy to use a higher dose than necessary. Based on experience in VCHA, where patient doses have been tracked for eight years, the talk will explore dose indicators, Reference Doses and ways in which you can limit the dose to your patients. Dr. David Liu Radioembolization Yttrium 90 interventions on liver cancer (Yittrium for Dummies) Radio embolization is a procedure in which the hepatic artery is angiographically selected, and subsequent injection of radioactive materials [for the treatment of both primary and secondary liver tumors] is used. Yttrium-90 microspheres [both ceramic and resin], the most commonly used embolic material, are approximately 30 to 60 µm in size, and emit high energy beta particles. Via intra-arterial injection, the particles impregnate into the hypervascular portions of a tumor, exposing the tumor to high doses of radiation,

2 with relative low radiation exposure to the surrounding normal liver. The purpose of this lecture is to review basic principles of radio embolization, and highlight clinical scenarios in which this procedure may be applicable, and prove to be of benefit. Dr. Peter L. Munk IR Management of Musculoskeletal Metastases Metastatic disease to soft tissue and bone is an unfortunately common occurrence particularly late in the evolution of cancer. These can often be remarkably symptomatic and treatment with conventional therapies such surgery, radiotherapy and chemotherapy are often inadequate. Interventional radiologic procedures such as embolization, radio frequency and cryoablation and cementoplasty offer important and useful therapeutic alternatives. This talk will review the clinical setting in which this problem arises, outline the different alternatives under advantages and disadvantages and illustrate the application of these techniques with clinical examples. Dr. Ferco Berger Pelvic & hip polytrauma: how to save lives In this presentation the anatomy of the bony pelvis and acetabulum and standard conventional radiography imaging techniques will be briefly discussed. A simple classification of sacral and acetabular fractures based on mechanism will be discussed. Polytrauma cases will be used as guide to further elude: value of additional views (obturator and inlet/outlet views), significance of trauma mechanism to injury pattern, signs to trigger MDCT imaging, potential associated abdominal trauma and need for A&P MDCT, risks associated with bladder rupture and use of cystograms (XR or CT?) to diagnose the different types and significance of proper technique. Interaction with the audience will be encouraged with a small quiz. Dr. Brad Halkier Radio Frequency Ablation of the Lung Increasingly radio frequency ablation is being used in the treatment of both primary and metastatic lung tumours. This technique is often helpful in patients who are not surgical candidates for resection of tumours due to underlying lung disease or other problems, but still may still potentially benefit from removal of the tumour. Likewise, some patients where the principal tumour manifestation is that of metastatic disease to the lung can theoretically have improved survivorship if tumours are treated. The technique of radio frequency ablation in the lung will be reviewed, potential complications and how they may be best avoided are discussed and selective illustrative cases will be provided.

3 Dr. John Mayo Lung cancer imaging and interventions Lung cancer is now the most common cause of cancer death in both men and women. Because early lung cancer leads to minimal or non-specific symptoms, the majority of patients present with advanced disease. Although surgical, chemo- and radiotherapy techniques have progressed in the last 20 years, these advanced lesions remain resistant to therapy and overall five-year survival is unchanged at 15%. Multiple studies have shown that the best lung cancer survival occurs in the minority of patients who present with small, early stage lesions that are completely surgically excised. Therefore, there is a great interest in developing screening tests that detect lung cancers as early as possible. The most promising current technique to detect early lung cancer in the lung parenchyma is non contrast enhanced computed tomography (CT) imaging. Early lung cancer detection using CT is based on finding non-calcified nodules (NCN) in the lung parenchyma that are thought to be the precursor of advanced lung cancers. Depending on the section thickness and nodule size criterion, non-randomized lung cancer screening trials in high risk current and former heavy smokers have reported varying prevalence of NCN ranging from as low as 5.1% to as high as 51.4%. In these studies, the rate of surgically proven lung cancer has been shown to vary from 0.3 to 2.7%. Therefore, even in the subjects with the highest risk factors for lung cancer, most NCN are benign. CT detection of growing small lung nodules raises the possibility of early lung cancer causing anxiety in patients and referring clinicians. Unfortunately, confident separation of benign from malignant small lung nodules cannot be reliably achieved using CT criteria, and pathologic diagnosis using needle or excision biopsy is usually required. Excision biopsy removes the entire nodule at one setting and eliminates the sampling error associated with needle biopsy, making it appealing to physicians and patients. To reduce post operative morbidity, costs and volume of lung removed, excision biopsy is often performed using video assisted thoracoscopic surgery (VATS) techniques. It is noted that there is particular difficulty in surgically locating semi-solid or ground glass nodules since they are difficult to palpate, even at thoracotomy. These non solid nodules, especially the semi solid variety, are noted to have a higher probability of malignancy than solid nodules and are more commonly negative at PET scanning. A number of small nodule localization techniques have been developed in an attempt to guide VATS resection, but none have been widely adopted. The safety and efficacy of a new localizing technique that uses CT guidance to place commercially available fibre coated microcoils with one end adjacent to the suspicious nodule and the other end in the pleural space has been recently demonstrated in a human feasibility trial. In this talk we will discuss the relative utility of the three commonly used sampling techniques for growing lung nodules in patients at risk of lung cancer; fine needle aspiration biopsy, core needle biopsy and fuzzy wire localization to direct VATS excision biopsy.

4 Dr. Michael Martin Advances in minimally invasive techniques for SFA revascularization The superficial femoral artery (SFA) is particularly susceptible to atheroocclusive disease, and flow limitation through this structure is frequently responsible for development of lower extremity ischemia. Open surgical reconstruction of the SFA territory has been performed for many years but is associated with a very high rate of surgical morbidity and mortality, and early treatment failure. The first use of transluminal angioplasty in humans was in the SFA territory. In the interests of reducing treatment morbidity and mortality there has been an understandable interest in refining minimally invasive methods of revascularizing patients with lower extremity ischemia. While traditional percutaneous techniques such as balloon angioplasty and uncovered stents remain the mainstay of treatment for the majority of revascularization procedures, more novel techniques including brachytherapy, cryotherapy, drug elution, covered stents, subintimal recanalization, laser atherectomy, and mechanical atherectomy are being tested in an attempt to improve initial clinical results and to improve the longevity of the revasacularization. The purpose of this presentation is to discuss some of the newer revascularization techniques being developed in the treatment of peripheral extremity ischemia, to review the potential advantages of these techniques relative to more established methods, and to discuss what (if any) evidence exists to support the use of these techniques. At the completion of this presentation attendees will: Be more familiar with newer techniques of percutaneous lower extremity revascularization. Be aware of the limitations and potential advantages of these techniques.

5 Gerald M Legiehn, MD, FRCPC Clinical Assistant Professor Division of Interventional Radiology Vancouver General Hospital University of British Columbia Current Concepts and Controversies in Percutaneous Dialysis Access Management In 1997, the National Kidney Foundation created the Kidney Disease Outcomes Quality Initiative (NKF-KDOQI TM ) for the purposes of providing evidence-based clinical practice guidelines for all stages of chronic kidney disease (CKD) and related complications. In addition to providing medical guidelines relating to indications for dialysis, type of dialysis access, and monitoring of dialysis adequacy, these guidelines have become particularly important to the interventional radiologist and interdisciplinary team. Whether it be temporary/catheter access or permanent arteriovenous fistula (AVF) or arteriovenous graft (AVG), indications for clinical monitoring and diagnostic imaging are recommended within the KDOQI TM guideline framework. Based on these clinical and imaging parameters, optimal percutaneous (or surgical) management can be instituted based on the best available medical evidence. Frequent NKF-KDOQI TM updates have and will allow the guidelines to incorporate the latest novel therapies and technologies including balloon assisted maturation of AVFs (BAM procedure), percutaneous thrombectomy, alternative access, cutting balloons, stents, or stent grafts. The goals of this lecture are to provide the attendee with: 1. A working knowledge of the structure of the NKF-KDOQI TM framework as it pertains to the medical dialysis access monitoring and indications for diagnostic radiologic investigations. 2. An understanding of current indications, techniques, and expectations of outcomes for percutaneous interventions for dialysis access according to the most recent 2006 NKF-KDOQI M Updates Clinical Practice Guidelines and Recommendations. 3. Exposure and incorporation of the latest percutaneous vascular access interventional technologies, techniques, and controversies into existing practice and the most recent NKF-KDOQI TM guidelines.

6 Dr. Chris Morris Clinical Professor Angio/Intervention of GI Bleeding Problem Solving Any number of difficult situations or problems can arise when performing angio/intervention in a patient with gastrointestinal hemorrhage. For simplicity three broad areas will be covered: 1. When is it appropriate to perform angiography? In other words, what are the best clinical indicators and the role of nuclear medicine and CT angiography based on recent literature. 2. Problems arising when performing the procedure: To minimize these, a clear understanding of vascular anatomy, especially arcades and the potential for continued bleeding if all flow to the bleeding site isn t controlled. 3. Problems with embolization. By the end of the session, attendees should be familiar with: a) The most appropriate clinical indications for doing angiography and the role of CT angiography in providing anatomic detail and targeting for embolization. b) Appreciate the variant anatomy and rich collateral network of the GI tract and means to catheterize difficult vessels, especially the inferior pancreaticoduodenal artery. Most efficient ways to embolize a bleeder including the concept of prophylactic embolization.

7 Title of Presentation: TEN THINGS THAT I WISH PEOPLE TOLD ME Presenter: Manraj Kanwal Singh Heran, MD, FRCPC Clinical Associate Professor Diagnostic & Therapeutic Neuroradiology (VGH) Pediatric & Interventional Radiology (BCCH, VGH) manraj.heran@vch.ca Objectives: 1. Discuss problems in interventional radiology requiring innovative solutions 2. Review technical issues regarding catheters, embolics, and inflation pressures 3. Illustrate, through case examples, common myths and challenges in IR Overview: Interventional radiology is a diverse field which is constantly presenting new opportunities and challenges. However, as we proceed forward, situations arise which test our basic knowledge and understanding of simple concepts, or equipment compatibilities. Urban legends and common misconceptions in IR abound, and can create unique problems if not addressed through educating the IR team. This presentation will look at 10 different issues which, through a better understanding, have relevance in neuro- and non-neuro intervention, both in the adult and pediatric settings. Common myths, challenges, and dilemmas will be presented, with clinical pearls offered, meant to enhance the overall understanding of what we use, why we use it, and why it s done.

8 Non-Vascular Renal Intervention Charles Zwirewich, MD FRCPC Clinical Professor, UBC Division of Abdominal Imaging, VGH A spectrum of renal interventional procedures is available to diagnose and treat a variety of renal disorders. These range from straightforward image guided renal biopsy and percutaneous nephrostomy to advanced procedures to treat urinary tract calculi and malignancy. An emphasis will be placed on the practical application of these procedures in everyday practice. A close working relationship between the radiologist and Nephrology/Urology is essential to optimize patient care and reduce complications. Objectives: 1. To understand the spectrum of non-vascular renal interventions in modern interventional practice. 2. To be aware of specific renal disorders which are ideally suited to imaging guided interventional therapy.