Interventional Radiology

Aaron Shiloh MD FSIRSection Chief

Interventional Radiology

A Primer on Minimally Invasive

Image Guided Therapies

Overview• Basics of liver directed

therapy• Embolization• Arterial disease and CVI

Liver Directed Therapy

Local

• RFA

• Microwave

• Cryoablation

Regional

• Chemoembolization

• Drug-Eluting Bead embolization

• Y90 (Glass and Resin) Beads

Interventional OncologyLocal Treatment Options

Radiofrequency Ablation

Radiofrequency Ablation (RFA)

RFA – “the application of high frequency electric currents to heat and coagulate

target tissue”

RFA – A Variety of Applications

Liver Kidney Bone Lung

How RF Ablation Works

RF Pathology

Hyperemic Rim

Coagulation zone(= RF lesion)

Colorectal metastases

RFA cluster electrode

MR scan 1 week post treatment

CT scan after 14 minute RFA

Radiographic Images, Pre, Intra & Post

Treatment

Post RFPre RF

RFA Images Pre & Post CT

Radiofrequency AblationNSC Lung Cancer

3 cm RFA 3 mo S/P RFA/XRT 18 mo S/P RFA/XRT

RFA for Bone Metastasis

Summary of RFA Advantages

Preserves liver function in cirrhotic patients Minimally invasive

Local effect Potential for improved quality of life when

combined with radiotherapy and chemotherapy Repeatable for recurring disease

Interventional Oncology

Regional Therapeutic Options

Interventional Oncology

Chemoembolization&

Bland Embolization

Chemoembolization & Bland Embolization

HCC Metastases

Neuroendocrine Colorectal Breast Melanoma RCC

TheraSphere®

HCC one of most common forms of cancer worldwide (est. 1 million new cases annually) In US, NCI estimate 19,160 new cases and 16,780

deaths in 20071

Incidence increasing with rise in hepatitis C-induced cirrhosis

5-10% of HCC patients are resectable2 1 National Cancer Institute www.cancer.gov (accessed December 1, 2008)2 Llovet, JM. Current Treatment Options for Gastroenterology. 2004;7:431-441

HCC Epidemiology

HCC: Difficult to Treat, Few Effective Treatment Options

Tenuous liver functions (cirrhosis, hepatitis)

Spontaneous decompensation Resistant to standard chemotherapy and

low dose radiation Responsive to high dose radiation

TheraSphere®

HCC Epidemiology

Limited Treatment Options for HCC

Therapeutic Options: Resection or transplantation

Unresectable HCC treatment options: Radiofrequency ablation Transarterial chemoembolization (TACE or Drug

Eluting Beads) Transarterial TheraSphere, Y90 Glass Microspheres External Beam radiation Systemic therapy (ie. Sorafenib) No treatment

TheraSphere®

What is TheraSphere®

20-30 µm glass microspheres Y-90 is an integral constituent of the glass

matrix Innovative treatment to deliver powerful, targeted

radiation inside the liver

Y-90 glass microspheres comparison to human hairTheraSphere dose vial

Administered via hepatic artery catheter

Targeted internal radiation due to tumor hypervascularity

Microspheres are trapped in the tumor arterioles and are minimally-embolic (microembolization)

Pure beta-emitter Average beta emission energy is

0.9367 MeV Average penetration range in

tissue is 2.5 mm Physical half-life is 64.2 hours and

decays to stable zirconium-90

Mechanism of Action

TheraSphere®

Embolization tools

• Coils• Gelfoam• Alcohol• Particles• Glue

It wouldn’t be an IR conference if I didn’t show a case that happened

yesterday…

• 42 y/o obese female with Right 3 cm AML treated 8 yrs prior with

embolization at another institution when the AML was alledgedly 7 cm

and spontaneously bled.

Bronchial Artery

The patient presented with hemoptysis and a known right

perihilar lung cancer. The patient had been previously brought to the

operating room where an endotracheal tube was placed as

well as a bronchial blocker

GDA• Duodenal ulcer oversewn 10 days prior• Repeat severe upper gi bleeding• At endoscopy found to have a large visible

vessel that was bleeding and three clips were placed.

Embolization

Uterine Fibroid Embolization

Procedure Small incision

in skin

– Catheter inserted into femoral artery

Femoral Artery

Uterine Fibroid Embolization

Procedure

– Dye is injected

– Blood no longer reaches fibroids

UterineArtery

– Catheter is steered to uterine artery

– Small inert particles “emboli” are injected– Branches of uterine

artery are blocked

– Fibroids shrink over time

Uterine Fibroid Embolization

Procedure

Arterial DiseaseOne patient, many techniques

Chronic Venous Insufficiency

Epidemiology: Prevalence

Of the over 30 million Americansaffected:• Only 1.9 million seek treatment

annually1,2

• While the vast majority remain undiagnosed and untreated

CVI Prevalence*,1,2

30,000,000+

Seek Treatment *2 1,900,000

Treated447,0002 (Table 30)

*Statistics based on individuals over the age of 40

More than 30 million Americans suffer from varicose veins or a more seriousform of venous disease called Chronic Venous Insufficiency (CVI).1

1. Gloviczki P, et al. The care of patients with varicose veins and associated chronic diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. JVS; May 2011.2. Lee, A. US markets for varicose vein treatment devices 2011. Millennium Research Group, Inc. (A Decision Resource, Inc. Company), www.mrg.net, May 2011.

Epidemiology: Risk Factors

Many factors contribute to the presence of venousdisease and CVI including1,2,3,4,5:

• Gender

• Age

• Family history

• Multiple pregnancy

• Standing occupation

• Obesity

• Prior injury or surgery

1. "Chronic Venous Insufficiency." Vascular Web. Society For Vascular Surgery, Jan. 2011. Web. 17 Aug. 2011. http://www.vascularweb.org/vascularhealth/Pages/chronic-venous-insufficiency.aspx. 2. Maurins U, Hoffmann BH, Lösch C, Jöckel KH, Rabe E, Pannier F. Distribution and prevalence of reflux in the superficial and deep venous system—results from the Bonn vein study, Germany. J Vasc Surg.2008;48:680-87.3. Criqui MH et al. Epidemiology of chronic peripheral venous disease; JJ Bergan Editor, The Vein Book, Elsevier Academic Press .(2007):30.4. Chiesa R, Marone EM, Limoni C, Volonte M, Schaefer E, Petrini O. Chronic venous insufficiency in Italy: the 24-cities cohort study. Eur J Vasc Endovasc Surg. 2005;30:422-429.5. Rabe E, Pannier F. Epidemiology of chronic venous disorders; P. Glovicki, Editor, Handbook of venous disorders (3rd edition), Hodder Arnold.(2009);109.

Anatomy: Venous System

• Venous blood flows from the capillaries to the heart

• Flow occurs against gravity– Muscular compression of the

veins – Negative intrathoracic pressure– Calf muscle pump

• Low flow, low pressure system

Etiology & Pathophysiology

Healthy veins, with competent vein valves, keep blood moving in one direction back to the heart

Diseased veins, with damaged vein valves, cause blood to move in both directions, elevating venous pressure

Single puncture percutaneous access under ultrasound guidance

Temperature controlled 85°C heating at or below deep fascia

Endovenous ablation specifically indicated to treat incompetent perforator veins

The Venefit™ Procedure with the ClosureRFS™Stylet

The Venefit™ Procedure with the ClosureRFS™Stylet

Click graphic to play video

• Ultrasound exam to diagnose vein reflux

• Outpatient or hospital procedure

• Local or general anesthetic

• Quick return to normal activities – often within a few days1

1. Roth S, Endovenous radiofrequency ablation of superficial and perforator veins, Surg Clin N Am 87:1267-1284(2007)

*Indications, contraindications, warnings, and instructions for use can be found in the product labeling supplied with each device.CAUTION: Federal (USA) restricts this device to sale by or on order of a physician.