INTERVENTIONAL RADIOLOGY- ADVANCES INTERVENTIONAL RADIOLOGY. IR: HiTech in Medicine 10/2/2014
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1 INTERVENTIONAL RADIOLOGY- ADVANCES SANJIV PARIKH, M.D MedicaI Director, Interventional Radiology RADIA Seattle, WA INTERVENTIONAL RADIOLOGY Image guided surgery Fluroscopy, CT, Ultrasound, MRI A subspeciality with significant growth in the last two decades Microinvasive rather than minimally invasive IR: HiTech in Medicine Microinvasive image guided surgery Surgery of the 21 st century! Innovation-drug coated stents (rabamycin, paclitaxol) AAA stent grafts Targeted cancer therapy:monoclonal Abs, gene therapy 1
2 IR: Technology revolution EVOLUTION OF INTERVENTIONAL RADIOLGOY Charles Dotter-1964 successfully dilated femoropopliteal artery with catheters Seldinger technique- a revolution! Gruntzig-1979 first ballon angioplasty Palmaz-1987 stents 1997 stent grafts Dotter it! 2
3 GOOGLE IT! DOTTER S PROVERBIAL LIGHT, CREATIVITY AND COMPASSION CATHETER TRAVERSAL THROUGH AN ILIAC OCCLUSION! THIS WAS FOLLOWED BY MANY CASES WHERE HE USED A GUIDEWIRE AND TEFLON CATHETERS TO DILATE STENOSIS 3D MR ANGIOGRAPHY 3
4 Seldinger Technique Stenotic/Occlusive disease: Stents Stents have revolutionized treatment of occlusive disease Patency rates in primary branches of aorta: 70-80% 1yr;restenosis does occur IR: Inherent Advantages Minimal tissue disruption Usually under regional anesthesia Minimal blood loss Poor surgical risk pts-cad, COPD Decreased post procedural morbidity, decreased hospital LOS Significantly shortened recovery times 4
5 IR: Blood Conservation IR-minimal blood loss <10cc Jehovah s witness Natural alliance with advance bloodless programs (ABP) High risk patients, coagulopathy Acute Care: Role of Interventional Radiology MEDICAL EMERGENCIES Acute massive pulmonary embolism Acute stroke Acute significant bleeding: GI, trauma,post partum, hemoptysis, epistaxis Catheter based techniques in the right setting can save a life and/or prevent significant clinical sequalae 5
6 PORTAL HYPERTENSION: TIPS TIPS: POST F/U Role of IR in Emergency Medicine Management of Tension Pneumothorax Percutaneous management of acute renovascular ischemic disease, mesenteric vascular disease Thrombolytic therapy in acute limb ischemia 6
7 Transcatheter Embolization: Materials Autologous clot Gelfoam pledgets PVA Embospheres Glue Coils Onyx Post Surgical Bleeding:Embolization Acute Care: Role of Interventional Radiology MEDICAL URGENCIES IVC Filter placement in prevention of PE Treatment of Acute massive iliofemoral DVT Treatment of embolic/thrombotic peripheral vascular disease: cold foot, occluded graft Acute acalulous cholecystitis, malignant biliary obstruction Acute obstructive nephropathy Percutaneous management of intraabdominal, thoracic and other abscesses Loculated pleural effusions 7
8 Acute Care: Role of Interventional Radiology Provide Central Venous Access in ICU setting, telemetry-piccs, Triple lumens, Hohn, Monitoring caths ESRD : Temporary and tunelled hemodialysis catheters PUS-BUSTERS, CLOTBUSTERS! Sub-acute Care: Role of Interventional Radiology Central Venous Access-mid term, longterm lines: PORTs, Hickmans, Groshongs, Tunelled caths Percutaneous CT and Ultrasound guided biopsies Management of low back painpercutaneous vertebroplasty, nerve blocks, facet blocks, epidurals IR: HITECH DIAGNOSIS Noninvasive 8
9 IR: Emerging Role Gynecological therapies- Fibroids, pelvic congestion syndrome, fallopian tube recanalization AAA repair with stent grafts Spine- Vertebroplasty for acute compression fractures UAE: PRE/POST EMBO 9
10 UAE: CLINICAL RESULTS Menorrhagia: 92% Mass effect: 85% Dysmenorrhea: 88% Future pregnancy not an absolute contraindication Recurrence : <1% Infection: 1-2% Ovarian failure:1-4% DVT: cath directed lysis Temporary IVC filter Jugular or Femoral approach for placement FDA approved (permanent or up to two weeks for removal) Must be removed from jugular approach 10
11 Venous Hypertension Valves damaged Fibrointimal changes Varicosities, ulcers, hyperpigmentation, swelling, phlegmasia Ambulatory Venous Hypertension Osteoporotic Compression Fractures 11
12 Percutaneous Kyphoplasty Compression Fracture: Vertebroplasty Deformity alone leads to serious health consequences The highest standard of non-surgical management does not prevent deformity, leading to: Future fracture Impaired health Loss of physical function Loss of QOL Reginster Osteoporos Int
13 Biomechanics of the Spine Fusion Does Alter Load Transfer because the Least Stiff Component (the disc) has been stiffened VB VB PMMA FUSED Functional Spine Unit (FSU) Meanwhile, the Clinical Literature Reports that Deformity Correction is Important Deformity Debilitation Disability Depression Death PVD: TREATMENT 13
14 PVD: Lysis, PTA/Stents RENOVASCULAR HYPERTENSION Chronic Mesenteric Ischemia: Pre/Post 14
15 Restenosis- Interventionalist s nightmare Early occlusion: acute thrombosis 2-6 mth: neointimal hyperplasia 1-2 yr:progression of disease Assisted Patency: PTA, IVBrachytherapy, DRUG COATED STENTS! Case Study 19 yr old Male, 3 day old symptoms secondary to trauma one year prior. Clot: 10 cm in right subclavian vein Reteplase (rpa) u/hr for 4 hours, then 0.25 u/hr Complete resolution of clot confirmed by angiography at 23.5 hours. Critical stenosis resolved by cutting balloon and PTA Excellent result no residual clot and brisk venous flow Case Study Pre Lysis 15
16 Case Study - Post-Lysis / Final Complete Lysis: Valves and Vessel IR: EMERGING ROLE IN CANCER THERAPY Precision image guided targeted therapy- Angio, CT, US, CT, MRI guidance Placement of catheters for chemotherapy/longstanding IV support- Chestports, armports, Groshongs, Hickmans, PICCs, Plasmapheresis Liver-chemoembolization, RF ablation, acetic acid, alcohol therapy Relieving malignant obstructions-biliary, nephroureteral, tracheal, esophageal, colonic 16
17 Liver Metastases:RF ablation Liver Mets.: pre/post Chemoembolization ACUTE DVT: Failure of routine anticoagulation Clot dissolution only 14-20% with std heparin therapy Clot propagation not at all guaranteed PE 33-50% pts. Chronic sequalae of Venous hypertension : 25-70% 17
18 Ac DVT: Rationale for Lytic & Adjunct therapy Clot dissolution & preservation of valve function Decrease PE Decrease recurrence Prevent chronic venous hypertension ENDOVASCULAR STENT GRAFTS AAA- Aneurx (Medtronic AVE), Encure (Guidant),Excluder (Gore) Suprarenal/mid aorta- Talent Thoracic-Gore device, shelf design Thoraco-abdominal: experimental AAA: AneuRx Stent Graft 18
19 CONCLUSION : IR Rapid recovery period with minimal tissue disruption with faster healing Despite minimally invasive procedure clinical outcome comparable to open surgery Risks and complications are less compared to open procedures THANK YOU FOR YOU ATTENTION! 19
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