Introduction To Interventional Radiology Introduction To Interventional Radiology

Examples: Liver Cancer, Blood Clots, and Infection Examples: Liver Cancer, Blood Clots, and Infection

Karun Sharma

Children’s National Health System, Washington DC

October, 23, 2013

What is Interventional Radiology?

– Image guided Therapy: Combines patient care with cutting-edge technology, tools and techniques.

– A subspecialty of radiology that uses imaging guidance (X-ray, Ultrasound, CT Scan and MRI) to perform minimally invasive procedures (less invasive than surgery) using needles and catheters rather than scalpels

– www.sirweb.org

Uses Anatomy and Imaging to Navigate Inside the Body

Tools of the Trade: Where we work

Tools of the Trade: What we use

3 Fr=1mm

IR Procedures

• Vascular – Open up narrowed arteries (angioplasty & stenting)– Close off bleeding arteries (embolization: coils and

particles)– Put chemotherapy directly into tumors using arteries

• Chemoembolization (Liver Cancer) – Remove blood clots in arteries and veins

• DVT Thrombolysis

• Non Vascular– Image guided Biopsy (Liver, Kidney, other organs)– Image guided Tumor Ablation– Image guided Abscess Drainage

• Treatment of life threatening Infection

IR Tools - Hands On Session

• Catheters

• Multipurpose Drains

• Infusion Catheter

• Embolic Agents (coils and particles)

• Trellis device

Patient with Liver Cancer: Treatment with Chemoembolization

Liver Cancer: Hepatocellular Carcinoma

• 530,000 new cases in the world

• Very hard to treat – The best chemotherapy prolongs life for only 3 months – Surgery or Liver Transplant are best “cure” BUT many

patients can’t have these: too sick for surgery or too many tumors or tumors are too big

• Interventional Radiology offers a minimally invasive treatments – Needle ablation: heat and kill the tumor– Chemoembolization: deliver chemotherapy to tumor– Radioembolization - deliver radiation to tumor

Chemoembolization: Rationale

• Discrepancy in blood supply to liver and tumor – Normal Liver (20% artery : 80% portal vein)– Liver Tumors (80% artery : 20% portal vein)

• Use catheter to deliver ((chemochemo)) therapeutic into artery feeding the tumor and block it off to reduce blood supply ((embolizationembolization))– First described in Japan in 1970’s – Increases local drug concentration and dwell timeIncreases local drug concentration and dwell time

Chemoembolization: As easy as 1,2,3

Catheter

TumorLiver

HepaticarteryPortal

vein

1) Gain access 2) Select tumor feeding artery 3) Administer drug & embolic

Objective: Deliver a high dose of chemotherapy to the tumor and shut off the blood supply

Chemoembolization

Get the catheter into tumor feeding artery

Delivery chemotherapy (Lipiodol or Beads)

Shut off blood supply

High chemotherapy concentration in the tumor with lower systemic exposure

Patient Example

• 62 year old man• Hepatitis C cirrhosis • New 5.6 X 4.5 cm liver tumor - tennis ball

Pre-procedural Imaging - MRI

Early Arterial Enhancement

Less enhancement in Later (Portal Vein) phase

Contrast wash out in later phase

Procedural Steps

1. Define anatomySuperior Mesenteric Artery Celiac ArteryPortal Vein

2. Isolate tumor supply

3. Position Catheter

4. Deliver chemotherapy and embolic material

5. Follow- up angiography to monitor progress

6. Remove catheter and Sheath

Fluoroscopic Findings After TACE

No Residual Blood Flow to the tumor following TACE

Lipiodol Deposited in the tumor following TACE

CT scan and MRI after treatment

Tumor Marker Decreased (AFP: 59012) Doing well 3 years after Liver Transplant

Patient with Deep Vein Thrombosis (DVT): Treatment with Thrombolysis

American Public Health Association. Presented at: Public Health Leadership Conference: February 26, 2003: Washington, DC.

Heit et al., on behalf of the VTE impact assessment group. Poster #68. Presented at: 47th Annual Meeting and Exposition, American Society of Hematology; December 10-13, 2005; Atlanta, Ga.

Blood Clots (VTE) Disease: A Public Health Crisis

• Up to 2 million Americans suffer from blood clots annually

• Approximately 600,000 experience blood clots in lungs (PE)

• Almost 300,000 die from PE (majority from DVT)

• Post-thrombotic syndrome (PTS) results in:• Chronic leg pain and swelling• Skin ulcers

DVT Treatment

• Treatment Options:

Blood Thinners - Heparin and Coumadin (STANDARD TREATMENT)

Clot Busters - TPA - approved for Heart Attack, Stroke and PE

• IR Option:Combine Pharmacomechanical Thrombolysis (Local Device + Drug)

Local Thrombolytic Delivery: Drug + Devices

DVT Case

• 47 year old woman with left leg pain and swelling from DVT

• Tried blood thinning for two weeks but pain and swelling got worse – couldn’t walk

During Treatment – 8 mg tPA

Patient with abdominal abscess: Treatment with percutaneous drain placement

What is an abscess?

• Infected fluid collection (pus) – Surrounding Wall – Antibiotics may not help– Seen with Ultrasound– Seen with CT

• Clinical Signs– Pain and Fever– High WBC count– Sepsis can lead to death

Why drain an abscess?

• Symptoms– Infection (sepsis)– Pain and Fever– Very sick and in the ICU

• Common Causes– Appendicitis– Surgery/Trauma– Pneumonia– Pancreatitis– Diverticulitis

Case: AR

• 11 yo girl with appendicitis • Had surgery but developed fever and pain

– CT: pelvic fluid collection – US shows pelvic collection – CT guided abscess drain placed and 400 mL of pus was

drained– 1000 mL drained over the next two days– Symptoms resolved – Drain removed

Post OP CT: 11.30.12

US 12.05.12

CT guided Abscess Drain: 12.06.12

Thank you

kvsharma@cnmc.org