Endovascular Interventions - Endovascular Therapy - Endovascular Angioplasty

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Endovascular Interventions
Recent Advances
Interventional Radiology .A Paradigm Shift
DR. TEJAS P. DHARIA VASCULAR INTERVENTIONAL
RADIOLOGIST AROGYANIDHI, BSES, CRITICARE(W E),
HOLY FAMILY,HOLY SPIRIT, NANAVATI MAX
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INTERVENTIONAL RADIOLOGY
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
1950 BEGINNING OF MINIMALLY INVASIVE
PROCEDURE Subfield of Radiology. Diagnostic and
Therapeutic treatment Day care Procedures Local
Anaesthesia
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V IR Procedures

• 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

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Peripheral Vascular Disease

• 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

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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Whats 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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58Yrs, Male
Non HTN
CASE
DM since 15 yrs o 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)
• BIODE GRADABLE 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
• PICC(Peripherally Inserted Central Catheter) Line
• Hemodialysis(Temporary/Permanent) Catheter
• Revascularisation Venous Interventions
• A-V Fistulas in CKD patients
• 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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PICC(Peripherally Inserted Central Catheter)

• 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

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PICC(Peripherally Inserted Central Catheter)

• 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

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DEEP VEIN THROMBOSIS

• Risk Factors
• Illness or injury that causes prolonged
  immobility
• Age gt 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.
CASE
Venous Doppler Study an extensive occlusive
acute clot in the common femoral, superficial
femoral, popliteal and tibial veins vein.
What Next
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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

• Whats 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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AngioJet Catheter Mechanism of Action
Jet tube shown inside AngioJet catheter
tip Saline jets travel backwards at
approximately half the speed of sound to create a
low pressure zone.
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AngioJet Thrombolytics PMT
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.
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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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Pharmaco-mechanical Thrombectomy (PMT)

• 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.

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HEPATOCELLULAR CARCINOMA-
Transarterial Chemoembolisation
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.A Paradigm Shift
Interventional Radiology

• NEWER PROCEDURES
• Varicocele Embolisation

• Uterine Fibroid Embolisation

• Prostatic Artery Embolisation

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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
• Nutcrackers 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

• Whats 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
• gt 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
Femoral Artery access taken and a 5Fr catheter
introduced
Superselective cannulation of the Uterine Artery
done

• Day care
• Minimal Invasive
• One hour procedure
• Local Anesthesia

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
• Uncorrec table 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

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THANK YOU
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