Endovascular Interventions - Endovascular Therapy - Endovascular Angioplasty

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Interventional Radiology ….A Paradigm Shift DR. TEJAS P. DHARIA VASCULAR & INTERVENTIONAL RADIOLOGIST AROGYANIDHI, BSES, CRITICARE(W & E), HOLY FAMILY,HOLY SPIRIT, NANAVATI MAX Endovascular Interventions ……Recent Advances

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INTERVENTIONAL RADIOLOGY MEDICAL MANAGEMENT BEGINNING OF MINIMALLY INVASIVE PROCEDURE SURGICAL MANAGEMENT 1950 Subfield of Radiology. Diagnostic and Therapeutic treatment Day care Procedures Local Anaesthesia

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• Image Guided Interventions - USG/CT Guided FNAC/Biopsy/Pigtailed Catheter insertion - Radiofrequency Ablation • Revascularisation Interventions - Peripheral Angiography/Angioplasty - Thrombectomy/Thrombolysis • Venous Interventions - Varicose Veins Laser Ablation/Venaseal Injection - Deep Vein Thrombosis • Neuro-Interventions - Stroke - Intracranial Aneurysm Coiling - Venous Sinus Thrombosis - AVM Glue Embolisation V & IR Procedures

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DIABETIC PATIENTS • CALCIFICATION AND HARDENING OF ARTERIES • LONG SEGMENT OCCLUSION AND STENOSIS • HIGHER INCIDENCE OF SMALL DISTAL VESSEL DISEASE • BILATERAL DISEASE- MILD TO MODERATE INJURY COULD END UP WITH LIMB LOSS Peripheral Vascular Disease LEG ATTACK

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TREATMENT OPTIONS MEDICAL • ANTI PLATELETS • ANTI-DIABETICS • STATINS • PROMOTE COLLATERALS etc REVASCULARISATION IS THE KEY TO INCREASE THE FLOW • ANGIOPLASTY • STENTING • THROMBOLYSIS

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INCREASE BLOOD FLOW TO DOWNSTAGE THE DISEASE STAGE SYMPTOMS POST Rx I CLAUDICATION INC. WALKING DISTANCE II REST PAIN COMFORTABLE TO REST III NON HEALING ULCER ULCER TO HEAL (LIMB SALVAGE) IV GANGRENE LIMB AMPUTATION

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What’s New- CO2 ANGIOGRAPHY

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CO2 Angiography CARBON DIOXIDE (CO2) • Safe and useful alternative contrast agent • Only proven safe contrast agent in Renal Failure and Contrast allergy • is highly soluble & has low viscosity • displaces the blood and produces a NEGATIVE CONTRAST on DSA • should not be used in thoracic aorta, coronary artery and cerebral circulation- Neurotoxicity and Cardiac Arrhythmias • Eliminated by the lungs in a single pass

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CASE 58Yrs, Male Non HTN DM since 15 yrs ℅ Claudication…. Max Distance of 10mins On Doppler: severe atherosclerotic calcific changes in the Superficial fem On Investigations: CBC is normal but, S. Creat : 1.7. Referred for Angiography SOS Angioplasty.

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CO2 ANGIOGRAPHY

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WHY HAVE WE STARTED PERFORMING THESE PROCEDURES ► MARKED IMPROVEMENT IN STENT TECHNOLOGY Stent fractures are associated with restenosis and re-occlusions • DEVICES AVAILABLE FOR CROSSING DIFFICULT LESIONS • BETTER DRUGS

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NEWER OPTIONS ►DRUG ELUTING BALLOONS ►DRUG ELUTING STENTS ►PLAQUE EXCISION (ATHERECTOMY) ►BIODEGRADABLE STENTS

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76 yr old lady Non healing ulcer at the left ankle

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VENOUS INTERVENTIONS Peripheral Venous Access a) PICC(Peripherally Inserted Central Catheter) Line b) Hemodialysis(Temporary/Permanent) Catheter Revascularisation Venous Interventions a) A-V Fistulas in CKD patients b) Central Venous Stenosis Deep Vein Thrombosis Varicose Veins

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PICC(Peripherally Inserted Central Catheter) • Limited vascular access • Administration of highly osmotic or caustic fluids or medications

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• Used for intermediate to long term therapy • May be single or double lumen • Polyurethane/Silastic • Inserted percutaneously ➡ Basalic vein ➡ Cephalic vein • Threaded upto the superior vena cava PICC(Peripherally Inserted Central Catheter)

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• Sterile Dressing • Dressing acts as a bacterial shield and helps anchor cath • Measure and document external length of PICC with each dressing change • Unused ports must be flushed with Heparin solution and clamped PICC(Peripherally Inserted Central Catheter)

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DEEP VEIN THROMBOSIS Risk Factors • Illness or injury that causes prolonged immobility • Age > 40 • Pregnancy, birth control pills and hormone replacement therapy • Cancer and its treatment • Major surgery (ex: abdomen, pelvis, hip facture, knee fracture, hip or knee replacement) • Obesity • Previous DVT or PE

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Presentation 50-year old woman who presents with complains of pain in her left calf, which has been present for a week. Venous Doppler Study: an extensive occlusive acute clot in the common femoral, superficial femoral, popliteal and tibial veins vein. What Next CASE

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In the Past Start treatment with LMWH as soon as possible and continue it for at least 5 days and then switch over to oral anticoagulants Standard of Treatment In addition to the LMWH, you should now consider IVC Filter Placement & Catheter-directed thrombolytic therapy for her because she is otherwise well, has a normal life expectancy, has a low risk of bleeding and the DVT is of less than 14 days’ duration. so we plan for IVC Filter Placement Catheter Directed Thrombolysis(CDT)

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Temporary IVC Filter Placed to reduce the risk of Intraprocedure Pulmonary Embolism

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Pt turned prone and Left Popliteal Vein punctured under sono-guidance Multiple passes are made and the thrombus load aspirated

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Post Thrombo Aspiration • A bolus of r-TPA or Urokinase is given • An infusion of r-TPA is started at 1mg /hr from the popliteal sheath and of Heparin at 500 IU from the right femoral sheath. • Pt shifted to the ICU for 24hrs and Check Venogram after 24 hrs

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Contra-Indications for CDT • Active Internal Bleeding • Any major surgery within 3 months • Head trauma within 3 months • Any known Intracranial abnormality • What’s New-

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ANGIOJET CATHETER

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AngioJet ™ has 2 components ULTRA console Combined Pump Set and Catheter (integrated, sterile, and packaged as one) 2015 BOSTON SCIENTIFIC CORPORATION OR ITS AFFILIATES. ALL RIGHTS RESERVED; PI 330901 AA JULY 2015

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Saline jets travel backwards at approximately half the speed of sound to create a low pressure zone. AngioJet™ Catheter Mechanism of Action Jet tube shown inside AngioJet catheter tip

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Drug + Potentially Lower doses of lytic Devices to debulk the thrombus Pharmaco-mechanical Thrombectomy (PMT) PMT may be used to maximize and combine the advantages and minimize the risks and disadvantages of both Chemical Thrombolysis and Mechanical Thrombectomy1. AngioJet™ + Thrombolytics = PMT

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AngioJet ™ is isovolumetric, which means unchanging volumes. Thus, the volume of saline that is delivered equals the fluid volume that is removed from the patient Saline escapes from the outflow window of the catheter and acts to loosen thrombus and push it toward the inflow windows The thrombus is captured through the inflow windows, fragmented within the AngioJet ™ catheter and evacuated through the catheter.

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Sequential venograms performed following thrombectomy passes

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Advantages • Safe and effective treatment • Reduction of the need for concomitant CDT • No ICU care required • Reduction of thrombolytic agent dose and infusion time • Reduction of the bleeding risk associated with CDT. Pharmaco-mechanical Thrombectomy (PMT)

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HEPATOCELLULAR CARCINOMA- Transarterial Chemoembolisation

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NEWER PROCEDURES • Varicocele Embolisation • Uterine Fibroid Embolisation • Prostatic Artery Embolisation Interventional Radiology ….A Paradigm Shift

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VARICOCELE • Dilatation and tortuosity of the pampiniform plexus and also of the testicular vein. • Seen commonly in men aged 15-30yrs and rarely after 40 yrs. • Occurs in 15-20% of all the males and 40% of all infertile males. • Normal vessels of the plexus -0.5mm; --- More than 2mm-Varicocele

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VARICOCELE • Seen commonly on the Left side • Longer • Enters at rigt angle to the renal vein • Left Testicular artery arching over it • Compressed between the aorta and SMA. • A loaded Sigmoid colon.

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VARICOCELE- aetiology • Primary/Idiopathic: • due to Incompetent valves • 98% occur on the left side • Secondary: Pelvic or abdominal mass- RCC, RP Fibrosis/Adhesions Nutcracker’s Syndrome- SMA compressing the Left vein.

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VARICOCELE- Symptoms SYMPTOMS • Swelling • Dragging or aching pain in the groin • ‘Bag Of Worms’ feelings • Bow Sign- hold varicocele b/w thumb and fingers, pt is asked to bow- reduces in size • Cough Impulse present • Fertility problem

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VARICOCELE- Investigation Venous Doppler of the Scrotum and Groin - - -Standing/Valsalva Manouevre USG Abdomen- to look for any Kidney tumours Semen Analysis

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VARICOCELE- Indication for Surgery • Palpable Varicocele • Couple with documented Infertility • Female has normal fertility or potentially correctable infertility • Male Partner- one or more abnormal semen parameters or sperm function test • In Adolescents-

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VARICOCELE- Treatment • Varicocelectomy • Microdissection • Laproscopy • What’s New

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Endovascular Coil Embolisation Tiny metallic coils or other embolic agents introduced into the testicular vein under fluoroguidance(in Cathlab) • Minimally Invasive Procedure • No stitches needed • Patient can go in 6hrs. • Lower rates of complications

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Varicocele Embolisation

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Varicocele Embolisation

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UTERINE ARTERY EMBOLISATION

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UTERINE FIBROID • Most common tumour of the pelvis • Benign tumour of uterine smooth muscle • Fibroids are not considered to be precancerous • Fibroids are linked to oestrogen • > 50% women eventually develop fibroids • 10-30% are symptomatic

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UTERINE FIBROID -Symptoms • Heavy prolonged Menstrual Bleeding • Pain • Dyspareunia - painful intercourse • Infertility or Miscarriage • Pressure Symptoms - Frequent Urination or constipation - Constant urge to urinate

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UTERINE FIBROID -Diagnosis • Clinical Examination • USG Pelvis • MRI Pelvis

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UTERINE FIBROID -Treatment ►Medical - 1st Line of Rx • Gonadotrophin releasing Hormone(GnRH) analogue ►Surgical • Myomectomy • Hysterectomy ►Uterine Artery Embolisation(UAE)

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Uterine Artery Embolisation- Protocol ►Day care ►Minimal Invasive ►One hour procedure ►Local Anesthesia Femoral Artery access taken and a 5Fr catheter introduced Superselective cannulation of the Uterine Artery done Embolised with 300 micron PVA particles, causing ischemia & Shrinkage of the Fibroids

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Uterine Artery Embolisation- Results • 90% women require no further treatment • 50-70% decrease in fibroid volume • Effective for multiple fibroids • recurrence is very rare • does not affect fertility- Infact Improves it.

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IDEAL PATIENT FOR UAE • 30-45 yr old woman or younger. • Heavy menstrual bleeding, severe pelvic pain during menstrual cycle. • wants to avoid painful recovery from hysterectomy • poor surgical candidate

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PROSTATIC ARTERY EMBOLISATION It has been suggested that Prostatic Artery Embolisation- (PAE) for symptomatic Benign Prostatic Hyperplasia(BPH) may become a popular treatment like Uterine Artery Embolisation for Uterine Fibroids(Carnevale, GEST 2012)

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BENIGN PROSTATIC HYPERPLASIA-BPH • Most common urologic problem in male adults • Benign enlargement of the prostate gland • Gland enlarges, extending upwards into the bladder and obstructing the outflow of urine • 50% of all men in their lifetime develop BPH

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BPH- Clinical Manifestation • Hesitancy in starting urination • Increase frequency of urination • Nocturia • Urgency • Decrease in Volume and Force of urinary stream • Dribbling • Sensation of incomplete emptying of the bladder

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PAE- Protocol Inclusion Criteria • Patient who are non surgical candidates - prostate too big - underlying co-morbidities • Patient with severe LUTS due to BPH • Prostate size minimum 40mg • Patient who have failed medical management - Insufficient improvement with medical therapy - Intolerance to medical therapy Exclusion Criteria • Renal Failure • Uncorrectable coagulopathy • Disease of the Lower Urinary Tract - Prostate: Cancer, prostatitis - Bladder: Neurogenic dysfunction, cancer, calculi - Urethra: stricture, cancer

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PAE- Protocol Investigations - CBC, PT/INR, S. Creatinine, S. PSA. Diagnostic Tests - Non Invasive urine flow studies - USG KUB( Prostate Size, PVR) - TRUS Guided Prostate Biopsy - MRI

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PAE- Technique • Urinary Catheterisation • Right Femoral Artery access under LA • Cathetherisation of the Internal Iliac arteries • Identification of the Prostatic artery and embolisation with PVA particles(150-250 microns) using a microcatheter-wire combination. • Discharge after 24hrs. • Follow up after 1 month.

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PAE- images

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PAE- Results No major complication recorded Minor complications like Fungal cystitis- treated successful with anti-fungal drugs.

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PAE- Conclusion • PAE is a Breakthrough Interventional technique, suggested to be popular as UAE and may replace TURP. • PAE is a promising minimal invasive procedure for pts who prefer to avoid surgery. • PAE is feasible, safe, and highly effective technique ….. Nevertheless Challenging!!! • Increase the awareness - Physicians & Patients - Promotion through Media/Internet - Dedicated IR Clinic promotion

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Future of Interventional Radiology --- Emerging Techniques • Haemorrhoid Embolisation - embolising the Superior Rectal Artery • Bariatric Embolisation - embolising the Left Gastric Artery • Embolisation in Painful Musculoskeletal Disorders- Osteoarthritis/Frozen Shoulder/Tendinopathy