THE ROLE OF INTERVENTIONAL RADIOLOGY IN CHRONIC KIDNEY DISEASE
LINDA ANNE HUGHES, MD Medical Director
Unique Interventional Radiology Pompano July 2019
MULTIDISCIPLINARY APPROACH
SPECIALTY NEPHROLOGY
INTERNAL MEDICINE
ENDOCRINOLOGY
TRANSPLANT SURGERY
VASCULAR SURGERY
GENERAL SURGERY
DIAGNOSTIC RADIOLOGY
INTERVENTIONAL RADIOLOGY
PODIATRY
PSYCHIATRY
PATHOLOGY
REHABILIATION MEDICINE
STAFF PHYSICIAN
NURSE PRACTITIONER
PHYSICIAN ASSISTANT
NURSE
TECHNOLOGIST
THERAPIST
SOCIAL WORKER
PHARMACIST
ADMINSTRATOR
AIDE
FAMILY
DIAGNOSTIC/ INTERVENTIONAL
RADIOLOGY
ULTRASOUND (US)
COMPUTED TOMOGRAPHY (CT/CTA)
MAGNETIC RESONANCE (MRI/MRA)
NUCLEAR MEDICINE
FLUOROSCOPY
ANGIOGRAPHY (ARTERIAL AND VENOUS)
INTRAVASCULAR ULTRASOUND (IVUS)
INTERVENTIONAL RADIOLOGY (IR)
• Medical specialty which provides minimally invasive image guided diagnosis and treatment of disease
• Broad range of procedures, vascular and nonvascular
• Unifying concept is the application of image guidance and minimally invasive techniques in order to minimize risk to the patient
IR AND CKD
• DIAGNOSIS
• COMPLICATION MANAGEMENT
• HEMODIALYSIS
• PERITONEAL DIALYSIS
• RENAL TRANSPLANT
• COMORBID DISEASE MANAGEMENT
RENAL BIOPSY
MEDICAL BIOPSY
DIAGNOSE
STAGE
REJECTION
RENAL MASS DIAGNOSE
TREATMENT
NEPHRON SPARING
TUMOR:
CRYO/RFA/MICROWAVE
CYST:
ASPIRATE
SCLEROTHERAPY
BIOPSY COMPLICATIONS
BLEEDING
AV FISTULA
PSEUDOANEURYSM
EMBOLIZE
HEMODIALYSIS
• PREOP ROAPMAP/VEIN MAPPING
• CATHETER MANAGEMENT
• FISTULA/GRAFT MANAGEMENT
• FISTULA CREATION
HEMODIALYSIS CATHETER MANAGEMENT
• PLACEMENT
• REMOVAL
• EXCHANGE
• ANGIOPLASTY
• THROMBOLYSIS
• CLOT
• FIBRIN SHEATH
• STENOSIS/OCCLUDED VEINS
• KINKS
• SUBOPTIMAL PLACEMENT
HEMODIALYSIS FISTULA/GRAFT MANAGEMENT
• SURVEILLANCE
• BALLOON ASSISTED MATURATION (BAM)
• COIL EMBOLIZATION
• ANGIOPLASTY
• STENT PLACEMENT
• THROMBECTOMY/DECLOT
• PERCUTANEOUS CREATION AVF
PERCUTANEOUS CREATION OF AVF FOR HD
• NEW FDA APPROVED PROCEDURES
• everlinQ endoAVF SYSTEM
• ELLIPSYS ACCESS SYSTEM
• MAGNETIC CATHETERS AND RF ENERGY TO CREATE AVF WITHOUT OPEN SURGERY
• 97% PROCEDURAL SUCCESS
• 88% FISTULA MATURATION @ 3 mo
• 75% SUCCESSFUL CANNULATION @ 6 mo WITH MINIMAL RE-INTERVENTION
• 1966 FIRST SURGICAL AVF
ADVANTAGES OF PERITONEAL DIALYSIS
• Improved survival during first three years
• Preservation of residual renal function
• Less dependence on underlying cardiac function
• Better blood volume and blood pressure control
• Lower prevalence of Hepatitis C
• Greater patient autonomy and quality of life
• Decreased cost
PERITONEAL DIALYSIS COMPLICATIONS
Short Term • Bowel perforation <1% • Bladder puncture <1% • Exit site infection within two weeks
of insertion <5% • Peritonitis <5% • Peritoneal leak <5% • Hemorrhage <1%
Long Term • Superficial cuff extrusion • Catheter migration • Omental wrap • Peritonitis • Cellulitis • Catheter fracture, internal vs
external • Catheter blockage
IR MANIPULATION OF EXISTING CATHETERS
• Initially, IR’s only role in PD catheters
• Malfunctioning catheter sent to IR to evaluate
• Inspect external portion of the catheter
• Under Fluoroscopy, document intraperitoneal location
• Inject contrast to document function, clogged, adhesions, migration, fractures
• Introduce a stiff hydrophilic wire under fluoroscopy and advance out the end hole in attempt to lyse adhesions, clear catheter and reposition tip
PD CATHETER IMPLANTATION APPROACHES
• Fluoroscopic Percutaneous Technique (13%)
• Open Surgical Dissection (42%) • Surgical Laparoscopy (45%)
• NO difference in complication rates
• NO difference in primary function
• One and two year technical survival higher in percutaneous group (90% and 82% vs 73% and 60%)
PERCUTANEOUS NEEDLE-GUIDEWIRE TECHNIQUE
• Moderate sedation vs anesthesia
• Sterile surgical prep
• Prophylactic IV antibiotic
• US to visualize the peritoneal space, inferior epigastric artery and introduce Needle
• Contrast injected under fluoroscopy to confirm intraperitoneal location
PERCUTANEOUS NEEDLE-GUIDEWIRE TECHNIQUE
• Abdomen filled with 300-500ml
saline
• Sequential dilatation prior to placing peel-away sheath which is advanced over guidewire
• PD Catheter is inserted through sheath toward pelvis
FLUOROSCOPIC-DIRECTED NEEDLE GUIDEWIRE PLACEMENT
• Radiopaque catheter tubing stripe permits fluoroscopic imaging of final catheter configuration
• External portion of the catheter tunneled subcutaneously
• Can be advanced through skin without prior incision and provides for the smallest skin hole possible for passage of the catheter
INTERVENTIONAL PD CATHETER PLACEMENT
Advantages • Often easier and faster to schedule • Less invasive • Less expensive • Moderate Sedation vs General
Anesthesia • Not every patient is an ideal candidate
for IR placement
Disadvantages • Patients come in all shapes and sizes • Morbid obesity • Previous abdominal surgery; adhesions • Intra-abdominal anatomical
considerations • Patient still makes urine, bladder fills • Bowel or bladder perforation • Large fibroid uterus • Polycystic kidneys
ADJUNCTIVE PROCEDURES TO SURGICAL IMPLANTATION
• Prophylactic omentopexy (omental
tacking procedure)
• Adhesiolysis to eliminate compartmentalization of peritoneal cavity.
• Resection of redundant epiploic appendices, epiploectomy
• Tacking up redundant colon, colopexy
• Diagnosis and treatment of previously unsuspected hernias.
RENAL TRANSPLANT • PERINEPHRIC FLUID COLLECTIONS ASPIRATION/DRAINAGE
• ABNORMAL VASCULATURE RENAL ARTERY STENOSIS/PTA/STENT
• COLLECTING SYSTEM STENOSIS PCN/PTA/URETERAL STENT
• REJECTION BIOPSY
• ABSCESS
• SEROMA/LYPHOCOELE
• HEMATOMA
DEEP VEIN THROMBOSIS (DVT)
• ESRD PATIENTS HIGHER RISK
• AGE GREATER THAN 50
• DYSLIPIDEMIA INCREASED RISK
• RISK FOR PULMONARY EMBOLISM
• US or VENOGRAM FOR DIAGNOSIS
• CATHETER DIRECTED EMBOLECTOMY
• CATHETER DIRECTED THROMBOLYSIS
• IVC FILTER PLACEMENT/RETRIEVAL
KYPHOPLASTY
• CKD-MBD
• RENAL PATIENTS HAVE COMPROMISED BONE STRENGTH
• 4-13X HIGHER RISK OF HIP FRACTURES
• INCREASED PREVALENCE OF VERTEBRAL COMPRESSION FRACTURES (strong association with vascular calcifications)
FLUID OVERLOAD PLEURAL EFFUSIONS
THORACENTESIS
PLEURX CATHETER PLACEMENT
PLEURODESIS
ASCITES
PARACENTESIS
PLEURX CATHETER PLACEMENT
PERIPHERAL ARTERY DISEASE (PAD)
• > 2 MILLION WORLDWIDE
• 25% PAST DECADE
• 4.3% US POPULATION > AGE 40
• 24% WITH CKD STAGE 3 OR >
• RISK WITH GFR
PERIPHERAL ARTERY DISEASE
• CKD PATIENTS HIGHER RISK
• RISK FACTORS COMMON IN CKD
• AGE
• TOBACCO ABUSE
• DIABETES
• HYPERTENSION
• HYPERLIPIDEMIA
• ADDITIONAL UNIQUE RISK FACTORS
• UREMIA: CHRONIC INFLAMMATION
• HYPOALBUMINEMIA
• ENDOTHELIAL DYSFUNCTION
• MEDIAL ARTERIAL CALCIFICATION (MAC)
• LIMB AND MORTALITY OUTCOMES WORSE, ESP ON DIALYSIS
• > 50% ON DIALYSIS DIE WITHIN 2 YRS OF AMPUTATION
PERIPHERAL ARTERY DISEASE
• VULNERABLE POPULATION
• IDENTIFY AND RESOLVE GAPS IN CURRENT CARE MODEL
• IMPROVE CLINICAL OUTCOMES
• EVIDENCE BASED PREVENTION
• DETECT CLAUDICATION IN EARLIEST STAGES
• PREVENT DEVELOPMENT OF CLI
• COST EFFECTIVE
PAD CLINICAL GOALS
• PROACTIVELY RECOGNIZE BURDEN OF PAD IN CKD AND BURDEN OF CKD IN PAD
• FACILITATE APPROPRIATE USE OF PAD DIAGNOSTIC TESTING
• SUSTAIN USE OF RISK REDUCTION INTERVENTIONS TO ACHIEVE PRESPECIFIED METRICS OF TARGET GOAL SUCCESS
PAD SCREENING/SURVEILLANCE
ABI
• SIMPLE
• INEXPENSIVE
• RISK FREE
• RESTING OR WITH EXERCISE
• LIMITED SENSITIVITY with MAC
• FALSE NORMAL
• > 0.9 < 1.4
TBI
• DIGITAL ARTERIES SPARED FROM MAC
• > 0.7
• LIMITED AVAILABILITY
PAD DIAGNOSIS ULTRASOUND SEGMENTAL LIMB PRESSURES
PULSED AND COLOR DOPPLER
COST EFFECTIVE
NONINVASIVE
NO RISK
CTA/MRA ABNORMAL DUPLEX AND SYMPTOMS
EXCELLENT DIAGNOSTIC UTILITY
CT; CONTRAST INDUCED NEPHROPATHY
MR: NEPHROGENIC SYSTEMIC FIBROSIS
ANGIOGRAPHY SEVERE CLAUDICATION
CHRONIC LIMB ISCHEMIA (CLI)
NOT RESPONSIVE TO NONINVASIVE THERAPY
CONTROL AMOUNT OF CONTRAST
DIAGNOSTIC AND THERAPEUTIC
PAD INTERVENTION
• ANGIOPLASTY (PTA) • DRUG COATED BALLOON PTA
(DCB) • STENT PLACEMENT • THROMBOLYSIS
• ATHERECTOMY
CO2 ANGIOGRAPHY
• CO2 COLORLESS ODORLESS GAS
• SAFE AND USEFUL CONTRAST AGENT
• FIRST USED IN 1920’s – retroperitoneum
• 1950’s IV delineate RA to detect pericardial effusion
• UNDERUTILIZED
CO2 ANGIOGRAPHY
UNIQUE PHYSICAL PROPERTIES
• HIGH SOLUBILITY (28x O2/54x N)
• LOW VISCOSITY (400x < contrast)
• DISPLACES BLOOD
• GAS BUBBLES UNDILUTED
• UNLIMITED VOLUMES
• INEXPENSIVE c/w CONTRAST
CO2 ANGIOGRAPHY
INDICATIONS PERIPHERAL ANGIOGRAPHY
MESENTERIC ANGIOGRAPHY
NATIVE RENAL ANGIOGRAPHY
RENAL TRANSPLANT ANGIOGRAPHY
DETECTION OF BLEEDING
TUMOR AVF/AVM EMBOLIZATION
VENOGRAPHY
PORTAL VENOGRAPHY/TIPS
ARTERIAL/VENOUS INTERVENTION
EVAR
CONTRAINDICATIONS THORACIC AORTOGRAPHY - SEIZURE
CORONARY ANGIOGRAPHY-ARRHYTHMIA
CEREBRAL ANGIOGRAPHY-NEUROTOXICITY
PULMONARY HYPERTENSION- PAP
COPD
INTRAVASCULAR ULTRASOUND (IVUS)
• MINIATURIZED US PROBE AT TIP OF CATHETER
• ABILITY TO SEE BLOOD VESSELS FROM INSIDE
• VISUALIZATION OF LUMEN AND ATHEROMA ”HIDDEN” IN THE WALL
• FIRST ANIMAL TRIALS 1956
• LATE 1980’S HUMAN TRIALS/APPLICATION
• DIFFERENTIATE PLAQUE FROM CLOT
• MORPHOLOGY OF PLAQUE; calcified, soft or fibrotic
• ANEURYSM AND DISSECTION TX
• MEASURE STENOSIS
• CONFIRM BLOCKAGE
• SIZING FOR TREATMENT
IVUS
• EXCELLENT DEMONSTRATION OF ANATOMY
• BEHAVIOR OF ATHEROSCLEROSIS PROCESS (CAD/PAD)
• IMPACT ON DIFFERENT TREATMENT STRATEGIES
CONCLUSION
• MULTIDISCIPLINARY COLLABORATION
• STRONG COMMUNICATION
• SKILLED KNOWLEDGEABLE STAFF
• CONTINUING RESEARCH AND EDUCATION FOR OPTIMIZING PATIENT CARE AND OUTCOMES