Recurrent Hepatocellular Carcinoma (Multifocal) | Radioembolization | 65 | Male
Recurrent Hepatocellular Carcinoma (Multifocal) | Radioembolization | 65 | Male
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So my case is kind of reiterate some of the same points. So the first case is a 65 old male, HCV cirrhosis, newly diagnosed HCC potential liver transplant candidate. It's not working? So a look at the liver status as well as

the performance status, get the lab, look at the CT, so he's beyond milan, there is 4.5 centimeter segment five LIRADS five lesion, and a 2.6 centimeter segment five lesion as well.

So then I see the patient in clinic and I have a discussion with them of kind of like what Mike was saying, of between what the options are and what the benefits and risks are of each one of them, and so there is no good randomized control trial comparing

these. So I go over some of the retrospective trials that are out there. So I talk to them how there's no difference in the survival. [BLANK_AUDIO] I talk about how there's no difference in the survival with the patients and then if there are a transplant candidate I talk about how a retrospective

study showed that the downstaging rate from t3 to t2, was better with Y90 that TACE. Time to response also shown to be better with Y90. Time to progression better with Y90. Looking at pathologic response and explants, two separate papers but at the same institution show that Y90 was a little better.

Toxicity profile also has shown again retrospectively Y90 a little bit better. >> Not really. >> So looking at TACE, I talked to them about why TACE and it's kinda of what Mike was saying that you can get them to treatment faster, potentially.

It depends where you are so at North Western we could, see them in clinic one week and the next week treat. Not only do the full study and treat them the same day. At Jefferson I can't do that. That was one of the biggest shocks when I first got there.

I have to wait about two weeks to get insurance approval then I have to do the full study. I'm not allowed to be the authorized user so I have to wait for Radhoc/g to figure out the dosing. It takes another two weeks to get the dose. So it takes a month till I can treat the patient versus TACE I can

do the next day. So I talk about that with my patients and TACE shorter time to evaluation results, so it's embolic and on imaging we look at enhancement. So TACE, one month out you can tell whether you need to go back in or not Y90. Sometimes you can tell,

and I'll show an example of that, but generally I usually get an imaging at one month and then another one in three to four months, and it's that second imaging that I go off of whether I needed the treatment more. And then I also talk about micro-embolic versus macro-embolic so it's all theoretical but I feel like if I do Y90 first I may still

preserve the vasculature to be able to do more TACE later. Do you guys have any comments on any of that? >> Well just that I mean the whole the idea of who goes first is, a little bit of a myth in that some people say why should you do Y90 first coz with chemoembolization shall

block the vessels. Well, if you do chemoembolization first the tumor grows, then there's obviously there's arteries to treat and the Y90 will get in there and we actually went and looked retrospectively the bunch of patients we treated with Y90 who either had or did not have prior chembolization. There is absolutely no difference in dose delivery

between the two groups and no difference in tumor response between the two groups. So you really can't go on either order, and you're not comprising anything. >> So I went with Y90 in the patient, after discussion agreed.

So just a little about how I do it. So I give some peri-procedure medications. Before treatment they're on protonix a week before and then four weeks after, and I send them home with zofran and oxycodone. So in terms of catheters that I use, I use different catheters

for planning versus treatment. For guiding catheters there is a lot of different things you can use, I generally use a Simmons one. For planning treatments, I want something short and higher flow so that I can get good contrast delivery and see things well,

so I tend to use the 110 2.8 F Progreat. When training I did the Renegrade Hi-Flow but if I wanna coil I don't wanna use the 2.8 F microcatheter so I use the 2.4 F catheter if I can predict that I'm gonna coil something. And then for treatment I want something that's longer with a smaller

diameter so that I don't just rush in Y90, it might just be theoretic but to decrease the risk of reflex I tend to use a 130 Maestro for that. Do you guys put things in that order or is that just my OCD? [LAUGH]

>> OCD >> OCD [LAUGH] It's also the North Western way. [LAUGH] So this is that treatment, you can see that the lesion, I didn't

see the smaller lesion, this is the planning arteriogram but the bigger lesion was treated, was supplied by both mainly the posterior branch but a little bit of the anterior branch. And I do a lot of cone beam CT,

I'm a cone beam CT junkie, I do it in my pre-planning and on my treatment days. So I got in and decided I need treat both, line spred function was 6.15. And so on the same day I treated both with two separate vials, and

I like to use extended shelf life in my mind it's still less embolic than SIR-Spheres but you get better coverage within the tumor especially if it's something that's very hypervascular. And so based on the volumes I did 18 Gigabecquerel vials, that's a relatively large amount of beads to segment six, seven and then a smaller one to the other

one, but that was based on volume, not based on how much the tumor is getting covered. >> So then one month out, no viability in the tumor and it's 4.1 centimeters.

So we started the transplant evaluation. And then nine moths out, they started, the tumor got smaller but then there started being some LIRADS three lesions. >> They developed the ascites. >> And they developed ascites, yes. Which you don't know whether it's the Y90 or whether it's the natural

progression of the cirrhosis, could be a combination. But unfortunately at 12 months, multifocal bilobar HCC and distant mets so, this kinda shows for down staging why some people think that there needs to be a waiting period. Because something that's bigger might be more aggressive but something that big is not necessarily more

aggressive so, if you can find those ones that aren't, then they can do well in transplant but those ones are aggressive then you've weeded them out, so that's how we do it so unless there is a question.

incredibly successful with it. But it was not a long-term solution so we would have patients that they would come back and they would have restenosis so we had treated them we had good technical

success but they were still experiencing some of the symptoms or the atherosclerosis would reform. And so through that again so one thing leads to another we started to say what if there was like a

balloon that we could leave behind in the artery and that began the development of stents. Stents are not perfect they're far from perfect but they are providing a little bit longer lasting well significantly longer

lasting results than PTA alone in some instances. So again very similar to what we saw on our balloon right here we see and I don't know if you can see from where you are but we have a stent that we've essentially placed in this artery to act

as a scaffolding to keep the artery open and keep the atherosclerosis at bay. So a lot of a lot of the early interventional procedures were done in the periphery they were done in the leg. But it wasn't very long before we were starting to see

their use in other areas of the body too like the mesenteric system and the kidneys. If you have decreased blood flow to your kidneys that can result in in hypertension you can have an elevated blood pressure. And so it wasn't

long before we saw a good application for utilizing balloons to treat things like this banding ou see in this renal artery dysplasia or in treating the origins of

kidneys to improve blood flow to them to help these patients who... "I'm going to see my PCP. I'm on 3...4 blood pressure medications nothing seeming to help". If we could put a balloon in here we can blow it up and we can improve the inflow to your kidney

and reduce your hypertension. What you're seeing over here is the application of a stent in a superior mesenteric artery so again we have patients when we think of peripheral vascular disease and blood clots a lot of times we think about

strokes we think about our heart we think about our legs we think about our hands and we don't always think about our mesentery but always think about the blood vessels that are feeding on our bowel but that is a very real problem for

a lot of people. Atherosclerosis is not selective and it will develop in the origins of the blood vessels that feed your bowel as well. So this is a stent that is allowing for adequate reperfusion in somebody's superior

mesenteric artery.

you're going to see obvious signs of external bleeding end-organ or extremity ischaemia a pulsatile hematoma or internal bleeding with shock...the hard signs Soft signs are diminished pulse location or proximity to an injury or an artery or

some degree of neurologic dysfunction that might potentially be due. These are kind of our clinical signs that we use in immediate examination of a patient. Venus injury generally low pressure dark blood external bleeding non

expanding hematomas and shock is rare and less associated with an arterial injury. But major venous injuries either pelvic or abdominal can present with the with some really profound symptoms. We look at blood

vessel areas partial lacerations transections contusions pseudoaneurysm or external compression. Usually those patients are the ones that have femur fractures or dislocated knees joints that can basically once

they're reduced or fixed these orthopedic injuries you'll get improvement in circulation almost rapidly. Asking should I take the patient to the operating room or do further investigations? Any patients with

the following signs should not wait. Any external bleeding obviously expanding hematoma with shock or limb ischaemia. Hospital-based iatrogenic trauma you see it with venous central venous access hematomas local or central guidewire

puncture of innominate vein SVC or right atrium. Arterioles obviously we do that all the time in the cath lab with our diagnostic and therapeutic angiograms with catheterization. You can get pseudo- aneurysm arterial dissection and

thrombosis distal embolization leading to basically limb ischaemia and of course AV fistula formation. Pseudoaneurysms - walled-off extra luminal circulation of the blood as a result of arterial wall destruction can occur also

due to shrapnel injuries in the battlefield but very commonly we all see these in the cath lab. Moving a little bit fast through this. We use conservative management for smaller sizes. Ultrasound-guided compression and

then of course duplex directed thrombin inejction and surgery. Want to show you an interesting case we have here as well. Pseudoaneurysm indications for surgical intervention ongoing bleeding limb ischaemia nerve compression anything to

need aggressive anitcoagulation or threatened skin viability and a pseudoaneurysm surrounded by large hematoma. Here's an example of a large pseudoaneurysm that's caused skin

compromise. Community-based trauma. Not dissimilar in certain sense. More knife penetrating and gunshot wound injuries and impaled objects blunt trauma or associated with a lot of orthopedic and neurologic injuries. You have an open

book pelvic fractures you have thoracic- aortic transections from MVAs from rollovers and they can be obviously more often multi-system. But once again we see this a lot in the battlefield as well particularly where it relates to soldiers driving

an uneven terrain the mountains of Afghanistan the deserts of Iraq. These vehicles are unstable with very heavy bases and a lot of these civilian type trauma vascular injuries and nonvascular injuries

we've seen in the battle is well. And that's why we've worked closely in concert with our civilian counterparts to improve these trauma outcomes. Extremity vascular injuries 10%

treat. They'll bring in you know pig feet. They'll bring in cow stuff. They'll bring in eyeballs you know and stuff that we can then use these devices on to embolize to coil to do all sorts of

procedures. And it allows us all to get to know the devices. As a nurse I really don't get to be involved at all in the procedure side because I'm doing moderate sedation. I would love to embolize the liver.

I would love to cryo a liver. This is so cool. I see it but I'm usually trying to sedate the patient to keep them from feeling pain. So I don't get to look up close and really ask a lot of questions.

This is the day that we get to do that. We have it for two hours in the morning. We started six were done by eight so that we can start to get the first ts on the table. But we all g residents love it are attending are the

intracerebral hemorrhage like the other types of stroke is a neurological

emergency. You're not going to find an underlying vascular abnormality and if you look for it. And if you do find it its...many of these are treatable like the aneurysm the AVM the fistula...these are treatable entities. And

where you find aneurysms even when they don't present the present with subarachnoid hemorrhage if they present in other ways clinically treating them can minimize or reverse the symptoms that they're having. So time of brain. And thank you for your attention.

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