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