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Creating 3D guides
2016chapterimagingindividualMedactaNASSnoindexvertebra
New ESVS Guidelines For Treatment Of Occlusive Disease Of The Celiac Trunk And SMA: What Do They Tell Us About The Best Current Treatment
New ESVS Guidelines For Treatment Of Occlusive Disease Of The Celiac Trunk And SMA: What Do They Tell Us About The Best Current Treatment
acuteaneurysmangiographyarteriarterialbowelclinicianembolicembolusendovascularESVSguidelinesimagingischaemialactatemesentericrecommendationrepairrevascularisationthrombotic
Celiac Plexus Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
Celiac Plexus Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRbiliaryblockceliacchapterdiarrheadilatationepigastricfull videogastricimproveintractablenauseaparasympatheticplexus
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbasicallychapterconductioncryoablationdorsalfull videonervepulsedthermal
Conclusion | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Conclusion | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018arinAVIRchapterfluoroscopicfull videotechnologistverification
IR Treatment Topics | Nerve Blocks, Neurolysis, and Rizotomies
IR Treatment Topics | Nerve Blocks, Neurolysis, and Rizotomies
2018arinautonomicAVIRblockschapterfull videonarcoticnerveneuropainpulsedtalk
Lumbar Sympathetic Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
Lumbar Sympathetic Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
2018anteriorarinarteritisAVIRblockchainchapterdefiniteextremityfull videoimprovelumbarpainpatientreflexstentsympatheticvasodilatationvertebral
Nerve Block Conclusions | Nerve Blocks, Neurolysis, and Rizotomies
Nerve Block Conclusions | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRchapterdocsfull videopain
Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockchapterembolicesophagusfull videopainpatientsrefractorysyndromesuppervasospasmvertebral
Nerve Blocks and Sympathetic Blocks | Nerve Blocks, Neurolysis, and Rizotomies
Nerve Blocks and Sympathetic Blocks | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbupivacainechapterfull videolidocaine
Anesthesiologists | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
Anesthesiologists | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
2018anesthesiaanesthesiologistanesthesiologistsanestheticarinAVIRbreathingchapterfull videonervepatientperioperativespecialty
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRchapterfull videointercostalpainpleuralsagittalskinthermalultrasound
CPBN Meta Analysis | Nerve Blocks, Neurolysis, and Rizotomies
CPBN Meta Analysis | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRchaptereffectivefull videometapainpatients
Intervertebral Disc Herniation - Percutaneous Infiltrations | Disc Intervention
Intervertebral Disc Herniation - Percutaneous Infiltrations | Disc Intervention
airanestheticanticoagulantattemptblindchapterclinicalcombinecomplicationcontraindicationscontrastcorticosteroidcorticosteroidsdecompressiondiathesisendoscopicepiduralfacetfull videohemorrhagicherniationimaginginfiltrationinjectioninjectionsintervertebralneedlenerveorthopedicozoneparticulatepatientpercutaneousperformedproperretroperitonealsteroidsystemictherapyventricularverify
Laser Guidance Imaging and CBCT  | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Laser Guidance Imaging and CBCT | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018advancedarinAVIRcenterchaptercrossfluorofluoroscopicfull videoimaginglasersneedleorthogonaloverlaysiemenstechniquestrocar
Objectives | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
Objectives | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
2018anesthesiaanesthesiologistsarinAVIRchaptercrisisfull videopatientteam
Goal of Neurolysis and Nerve Ablation | Nerve Blocks, Neurolysis, and Rizotomies
Goal of Neurolysis and Nerve Ablation | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationalcoholarinAVIRchaptercryoablationfull videoradiofrequency
Female | 55 | Pancreatic Ca | Celiac Plexus Neurolysis and Cryo | Nerve Blocks, Neurolysis, and Rizotomies
Female | 55 | Pancreatic Ca | Celiac Plexus Neurolysis and Cryo | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationanteriorarinAVIRceliacchaptercontrolcryocryoablationecogepigastricfull videogloveimprovementinvadinglivermetastasesmultipleneedlepainpancreaticpatientsalineultrasound
Q&A: Balancing Managing Preoperative Anxiety Against Informed Consent | Rapid Resilience for Staff and Patients in IR
Q&A: Balancing Managing Preoperative Anxiety Against Informed Consent | Rapid Resilience for Staff and Patients in IR
2018arinAVIRchapterembolizationexperiencefull videoinformedlymphpainfulpromise
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockbupivacainecervixchapterfull videolidocainemedialnervepatientperinealperineumposteriorpudendalrectalsciatic
Block and Neurolysis of Ganglion of Impar | Nerve Blocks, Neurolysis, and Rizotomies
Block and Neurolysis of Ganglion of Impar | Nerve Blocks, Neurolysis, and Rizotomies
2018anteriorarinAVIRbupivacainechapterfull videogaugeinjectneedlesacrum
Superior Hypogastric Block | Nerve Blocks, Neurolysis, and Rizotomies
Superior Hypogastric Block | Nerve Blocks, Neurolysis, and Rizotomies
2018aorticarinarteryAVIRbasicallybifurcationchaptercontractilefluoroscopicfull videohypogastricinnervateischemianeedlepelvicsplanchnicuterinevertebral
46 | Chronic L Shoulder/Arm Pain | Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
46 | Chronic L Shoulder/Arm Pain | Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockbupivacainecarotidchapteresophagusfull videojugularlidocaineneedlepatientvertebral
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbupivacainechapterfull videoinferiorlateralmedialsuperior
Sympathetic NS | Nerve Blocks, Neurolysis, and Rizotomies
Sympathetic NS | Nerve Blocks, Neurolysis, and Rizotomies
2018arinautonomicAVIRchapterfull videosomaticurinary
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
2018anterioraortaarinAVIRceliacchapterconductioncurvedfull videogaugelidocaineneedlenerveplexusposterior
Transcript

that's done that information goes back

to Switzerland and then for each individual vertebra that you're planning to instrument a model vertebra is made by 3D imaging as well as an individual guide. This is a a picture of our back

- Thank you so much. I have no disclosures. These guidelines were published a year ago and they are open access. You can download the PDF and you can also download the app and the app was launched two months ago

and four of the ESVS guidelines are in that app. As you see, we had three American co-authors of this document, so we have very high expertise that we managed to gather.

Now the ESVS Mesenteric Guidelines have all conditions in one document because it's not always obvious if it's acute, chronic, acute-on-chron if it's arteri

if there's an underlying aneurysm or a dissection. And we thought it a benefit for the clinician to have all in one single document. It's 51 pages, 64 recommendations, more than 300 references and we use the

ESC grading system. As you will understand, it's impossible to describe this document in four minutes but I will give you some highlights regarding one of the chapters, the Acute arterial mesenteric ischaemia chapter.

We have four recommendations on how to diagnose this condition. We found that D-dimer is highly sensitive so that a normal D-dimer value excludes the condition but it's also unfortunately unspecific. There's a common misconception that lactate is

useful in this situation. Lactate becomes elevated very late when the patient is dying. It's not a good test for diagnosing acute mesenteric ischaemia earlier. And this is a strong recommendation against that.

We also ask everyone uses the CTA angiography these days and that is of course the mainstay of diagnoses as you can see on this image. Regarding treatment, we found that in patients with acute mesenteric arterial ischaemia open or endovascular revascularisation

should preferably be done before bowel surgery. This is of course an important strategic recommendation when we work together with general surgeons. We also concluded that completion imaging is important. And this is maybe one of the reasons why endovascular repair tends to do better than

open repair in these patients. There was no other better way of judging the bowel viability than clinical judgment a no-brainer is that these patients need antibiotics and it's also a strong recommendation to do second look laparotomoy.

We found that endovascular treatment is first therapy if you suspect thrombotic occlusion. They had better survival than the open repair, where as in the embolic situation, we found no difference in outcome.

So you can do both open or endo for embolus, like in this 85 year old man from Uppsala where we did a thrombus, or the embolus aspiration. Regarding follow up, we found that it was beneficial to do imaging follow-up after stenting, and also secondary prevention is important.

So in conclusion, ladies and gentlemen, the ESVS Guidelines can be downloaded freely. There are lots of recommendations regarding diagnosis, treatment, and follow-up. And they are most useful when the diagnosis is difficult and when indication for treatment is less obvious.

Please read the other chapters, too and please come to Hamburg next year for the ESVS meeting. Thank You

The celiac plexus block is one that is much better known and I think you probably have all experienced this in your practices, but the celiac plexus block and neurolysis is for the treatment of intractable epigastric pain, most often in pancreatic cancer,

but it can also be in patients who have liver masses or have biliary dilatation and have biliary tubes placed and are having pain related to their biliary tree. But it's also used for intractable nausea and vomiting. If you have somebody who has profound nausea and vomiting and is not responding to normal medications,

a celiac plexus block and neurolysis can improve that. The permanent block blocks the sympathetics and allows the parasympathetic system to start working unopposed, so it actually can improve gastric emptying, which is why we think it improves the nausea and vomiting.

It can improve GI motility, so it can actually improve patients' appetite. The only sort of danger to this block and neurolysis is that it can cause diarrhea by having that parasympathetic system working in overdrive without the sympathetics to balance,

that you can actually develop diarrhea.

as well as the chemical. In thermal RFA, the target is to get the nerve to 70 to 90 degrees, which basically then disrupts the axonal continuity.

You get this Wallerian degeneration of the nerve because you disrupt the myelin, and the axon, and the endoneurium. Basically you're doing what the surgeon does by basically stopping that conduction of the nerve. Pulsed RFA is a newer way of addressing this

and this is not entirely well understood. Basically you're doing a non-lethal ablation affecting what's called modulations. You're modulating the nerve by passing an electric current across the nerve. And what that's supposed to do is reset the nerve.

There's actually genetic changes that occur in the dorsal root ganglion based on doing this modulation. I will tell you that if I ask my colleagues on this esteemed panel, how does pulsed RFA work, they would all give me kind of funny looks, I suspect. Because it really isn't totally understood right now.

Cryoablation is similar to thermal RFA where you basically are damaging the nerve

So in conclusion, recent fluoroscopic software advances enable these various forms of,

ends up kind of being augmented fluoroscopy. The points, lines, volumes, really you can apply these in a lot of different creative ways. Dataset registration, verification is critical. Advanced imaging ends up being trusting the computer. And so a knowledgeable technologist is really invaluable

in terms of making sure that things are done correctly from the workstation standpoint and the registration as a case kind of goes along. So, thanks for your attention.

We're gonna talk about image guided blocks for pain syndromes. The goals of these blocks are often to reduce narcotic requirements, manage acute pain crises, and what we've learned is that the autonomic nervous system contributes significantly to many pain syndromes.

We'll talk about some neuro blocks, neurolysis, and nerve ablations. When we talk about neurolysis and nerve ablations, what we're trying to do rather than a block which is just a temporary fix and control of pain, we now wanna try to make it at least semi-permanent

to give that patient some time to allow them to ramp down their narcotics, maybe have an improved quality of life. The agents that we use for neurolysis are alcohol and phenol, but more recently, we're starting to use both thermal ablation,

pulsed RF ablation, and cryoablation.

Lumbar sympathetic block and neurolysis is another block that's not often used and actually can solve a lot of difficult problems.

In the lower extremities, if you have non-reconstructible vascular disease, patient can't have a bypass or a stent. If you have vasospasm, again if you have frostbite, if you have some of these more rare entities like Buerger's disease or these arteritis syndromes,

you can use this block to improve pain control. Phantom limb pain if you've had an amputation, peripheral neuropathies. But also this can be good for patients that have pain related to their kidneys, ureters, or genitalia. If you have somebody who has a terrible kidney stone

and they're not being controlled well with their narcotics, you can actually do this block and temporarily improve their pain. The lumbar sympathetic chain is just there, lateral and anterior to the vertebral body, just behind the aorta and the IBC.

It runs on both sides of the vertebral body all the way down into the pelvis. A block at three levels followed by injection of alcohol effects this neurolysis. We basically disrupt the sympathetic chain and you get reflex vasodilatation

in the lower extremity that you've treated. In this particular patient who has rest pain and can't have a bypass, we do this block and lo and behold, you get this reflex vasodilatation. It's a little bit subtle based on my poor photography, but there was definite hyperemia,

definite improved blood flow. This has been shown to reduce the incidence of amputations. It gets people out of rest pain and can be a nice bridge if you're waiting for your stent or other procedure. Just a nice simple way to help a patient and improve their quality of life and pain control.

That's basically what I just said, so let's skip that slide.

In conclusion, nerve blocks are important

because you can diagnose and sort of hone in on where is the pain coming, so it has a diagnostic role. You can get people out of an acute pain crisis so you can present a huge value to your patients. This has become a big part of our practice. The palliative care docs love us

because we're very responsive as a practice and we can get these people out of pain. Once you've diagnosed that and proven that the block works, you can then do a more permanent ablation or neurolysis as we've demonstrated. I would say that these are easy, low risk procedures

that again, I would take this back to your practice and bug your IRs and say, "How come we're not doing these?" if you guys aren't doing these because patients love this stuff. They really appreciate these very simple procedures. Thank you for your attention.

The stellate ganglion is one of the higher blocks and it's actually probably one of the more difficult blocks. Many of the pain specialists will do these blind which I think is kind of amazing,

considering you have the vertebral artery, you have the carotid artery, you have the esophagus in the vicinity, and so this is a block that I think should definitely be done under image guidance. There have been papers showing that when done under CT guidance, that there's a much greater accuracy

and success with this block. The stellate ganglion block is used to treat complex regional pain syndromes in the upper extremities, like reflex sympathetic dystrophy, hyperhidrosis. So if you have patients who have heavy sweating in the hands, you can use this block to address that.

It's also been used for refractory angina, which I thought was interesting. Phantom limb pain in patients that have had amputations of their upper extremity. Herpes zoster, as well as pain in the head and neck. This block also is used in Raynaud's syndrome

in a scleroderma, it's used in vasospasm syndromes, in patients that are post traumatic or have experienced frost bite, or have embolic syndromes in the upper extremity. And again, intractable angina is one that I actually learned when I was reading about this talk.

One of the indications that is not well known is the use of the stellate ganglion block for hot flashes in the setting of breast cancer. Many of these patients are on tamoxifen and other types of agents that can cause intense hot flashes and a stellate ganglion block can actually

improve those symptoms.

We've talked a little bit or touched on some of the traditional blocks, Demetrius has kind of run through some of those, so I won't be covering those. But the concept is that basically you put your needle

in the space, you inject a little contrast to make sure you're in a safe position and then you give a combination of lidocaine and a longer acting agent like bupivacaine with a steroid and then that's the block. Once you've done that and diagnosed that that's actually

addressed the problem and is addressing the pain, you can then move on to the neurolysis and ablation where you're sort of more permanently blocking that. We started incorporating some of the more complex sympathetic blocks into our practice which really, many of the pain specialists out there

shy away from because they're much more heavily reliant on imaging and that's where we shine, and that's where you all come in to help us to use the guidance techniques that William talked about to sort of get us to some of these more difficult places to reach.

And in terms of talking about understanding our culture, our knowledge,

I just wanna give you a reminder of what anesthesiologists actually do. And give you a brief description. An anesthesiologist is a perioperative acute care physician. We evaluate patients. Give recommendations on how to optimize them.

We provide advanced life support during procedures. We formulate perioperative anesthetic plans of care. So we administer general anesthesia, you know when a patient has a breathing device, a breathing tube, they don't have any recollection, they're still.

We can also do a neuraxial anesthesia for a laboring patient where we do a spinal, epidural, and we get rid of the pain, and you know we have a safe delivery. We also can do peripheral nerve blocks. We've kinda heard about nerve blocks,

'cause that's one of our specially for shoulder surgeries. You know we do general anesthesia, and we combine these sometimes. We also offer various levels of sedation. Anywheres from really deep sedation to conscious sedation.

And you know, people who practice here and give sedation, they know that there's different levels and that's where our specialty is. In addition we also manage post surgical pain. And also complications, and support the patient.

and stopping conduction. Just to finish up, a couple of nice cases. This one that we did recently, a guy had pleural plaques and had significant neuropathic lancinating pain

in his rib cage and you can see on the right hand side, we've brought the needle down underneath the ribs, so this is sort of a sagittal view on ultrasound of the rib. You go and target underneath the rib where the intercostal nerve runs. You do your diagnostic block.

We did that and the patient had significant improvement in pain, and then we come in behind that and do thermal ablation, so we're taking the RF probes and we're placing them in multiple intercostal nerves around where the patient's pain is

and you can see that we've marked on his skin the exact areas where he has profound pain. You can't even touch his skin without him having severe pain. And after we finished the thermal ablation, he still had pain, but he could rub his skin,

he could wear a shirt, he could do more things. That was definitely successful.

These have been looked at and there's meta analysis of over a thousand patients that shows that this is a highly effective way to control pain if offered early. The later you offer this, these blocks,

the less effective they are. But 70 to 90% of patients experienced either partial or complete pain relief at some time prior to their death.

The third (mumbles) for intervertebral disc herniation includes four steps. We can start with conservative therapy course of four to six weeks. We can move on to percutaneous infiltrations

then to percutaneous decompression techniques and finally to endoscopic or surgical techniques. Obviously we can combine infiltrations with conservative therapy or with percutaneous decompression techniques. Starting with injections in the spine, do we actually need the imaging guidance?

According to the literature, imagine guidance increases the technical and clinical efficacy and decreases potential complication rate. It has been written that blind interlaminar epidural infiltrations are inaccurate in more than one third of the cases.

And if we go to clinical cases, these are two examples of injections which were performed blindly. On the upper row you can see it was an attempt for an ozone injection of the facet joint by an orthopedic surgeon. It was a blind attempt and you can see that the oxygen,

ozone transforms to oxygen after three minutes, is everywhere in the retroperitoneal space, but it's not in the facet joint. And the lower row you can see a blind attempt of epidural infiltration by anesthesiologist. The patient after the injection was reporting

severe headache, that is the center scan and you can see air inside the ventricular system of the brain. Percutaneous infiltrations can be performed through a trans-foraminal access to an interlaminar paramedial access through the sacro-coccigial hiatus and in all cases, you can use contrast or air control

before your steroid injection. These injections they go way back to 1950s and in 1970s you have the first trans-foraminal nerve root blocks. What we're actually injecting is long-acting corticosteroid and we do need the imaging for particulate ones because they can cause some complications

as we will see later. We do tend to combine corticosteroids with local anesthetic and we need contrast medium to verify the proper position of the needle. In all cases, when you are using contrast medium, you should be using agents approved for myelography.

Corticosteroids actually provide an anti-inflammatory effect, a direct neural membrane stabilization effect and they do modulate peripheral nociceptor input. On the other hand, local anesthetic interrupts the pain-spasm cycle, interrupts the transmission of the noxious stimuli and resets the nerve itself.

Contraindications include the patient who is unwilling to consent to the procedure, local or systemic infection, hemorrhagic diathesis or anticoagulant therapy and an allergy to any component mixture. As far as I'm concerned, I do prefer to apply three to four sessions of steroid injections

within 12-months period with a maximum of two infiltrations per session. And in all cases, we are using imaging guidance. We can use fluoroscopy, we can use CT or even MRI guidance and here we are using air or contrast medium to verify proper needle position.

And proper needle position does not mean only in the right spot, but you should have the needle outside a vessel. You will cause complication and problems to the patient if you perform intervascular injection of particulate corticosteroids.

- [Instructor] Thank you for the invitation. It's great to be here, lots of energy in the room. I'm gonna talk briefly on some advanced imaging guidance that we've used in some MSK applications in the angiosuite. So really I think of this as augmented reality in the IR suite.

(laughing) Next, next says no disclosures here. Yeah, we're just gonna go over some advanced fluoroscopic overlay techniques really. Touch on needle guidance, some polyline point overlay,

volumetric segmentations, some registration. And then tie it together with a case example, just so that you guys have some exposure to this, and understand what we're doing with some of these advanced imaging techniques. So kind of the basic, one of the basic techniques

is laser guidance, that is available in our system, which is, most of these images are gonna be Siemens systems, but I know that there are other applications and other vendors and such. Really, this is orthogonal lasers that are attached to the imaging detector.

And the cross point is really in the center of the field of view. These two orthogonal lasers will cross at a point that's directly in the center of the field of view. Again, and you can line up a needle or any kind of bone trocar of sorts,

just using the lasers. So actually reduces the need for fluoroscopy. You can do a lot of needle placement, really without having fluoro on. Really the mainstay of a lot of these overlay techniques is having good cross sectional imaging.

The easiest way to do this is with cone-beam CT, at the beginning of a procedure. Automatically registers to the patient location in space, at the time of the procedure. Again this is non-contrast imaging with limited resolution.

But then on this 3D dataset, more stack of CT images, is you can then draw annotations, different objects that you can then project live on fluoroscopy.

- [Dr. Vazquez] Honor to be here. And Stephanie, thanks for inviting me. I think I'm one of the few anesthesiologists that are, have been given the chance, opportunity to talk here but I think this is just a sign of the trend that's gonna happen here.

I think we're gonna see more and more anesthesia involvement in these national talks because it's gonna be, it's a very exciting time to be in. We're gonna see more of us. The title of my topic today is IR Anesthesiology, Nursing, and Technologists: Three Teams with One Goal.

You guys can probably guess what that one goal is. And I have no financial disclosures. And the objectives for today are three fold. Gain insight about the future of Non-OR Anesthesia in the IR suite. Learn how the anesthesia team works with the IR team

to enhance patient care and experience. And learn how closer team collaboration enhances patient safety during crisis situations. And you know, we just heard, you know, the previous talk about a crisis that happened and I can only imagine all the commotion

that was going on with the patient that was exsanguinating and all the key team players that were there, you know, weren't highlighted, but kind of like the unsung heroes. But I wanna talk about that.

That we can actually, we're gonna get more of that. And that's where we should get better and focus our attention. And everyone of you is important and vital for patient safety.

So I'm from Massachusetts General Hospital.

That's where I practice. Here is the, you can see the, let me see this, we have a highlighter? We don't but that's the old hospital right there. We're famous for the Ether Dome which you can see pictured in the bottom left.

And it's important, or it's importance of that is that was the first public demonstration of anesthesia, of Ether, by H.E. Moore. And you can see in the bottom left the picture right there, of the excision of a mass on this patient.

That changed the entire world of surgery. So it was novel. You know I've been workin' in IR full time for the past two years. And one thing that stands out is this lie, the cultural differences.

You now you have the same hand gesture but it means different things in different cultures. And it's kind of like the same for anesthesia in IR. When I first got there it seemed like we were different cultures. We were always in different silos.

You know and you never, and I think we have to make more of, and we've made more of an effort of knowing the local culture and knowledge. And we've actually have done something very special.

Just finishing up, neurolysis and nerve ablation. We talked a little bit about this, but the goal is to permanently disrupt the axons and the myelin sheath. You can do it chemically with alcohol or phenol. But more and more people now are offering

radiofrequency ablation or cryoablation as a more precise way of performing these ablations. Radiofrequency ablation probably has the most data after alcohol and phenol. It's inexpensive and it has a long track record. Cryoablation is now being reported in the literature.

It's easy to see on CT as my colleagues have demonstrated. It's good in soft tissue tumors, but we still have very early data. Some people are actually looking at MR-guided focus ultrasound, very sexy, very expensive technology, very niche.

I don't really see that becoming a major player. I think it's really gonna be RFA and cryoablation,

IR in the modern era. It's busy. You know, this media you can see all the innovations, all difference of specialties. It's a very complex operation that's underestimated. And I think it's underestimated by the surgical people.

Because everybody's world revolves around their own world. So our world for anesthesiologists is the operating room. Anything off site of that is foreign. It's almost, you know we're almost dismissive of that. But vice versa, you know for the radiologist,

or you know, corresponding clinicians, their world revolves around their specialty. So IR, you know everything revolves around them and they don't really know much about us. And that is just cultural differences that I think we're gonna see less and less.

This particular patient had significant improvement, did have some diarrhea, but demonstrated significant improvement after that block. This is an actual patient that we treated several years ago. 55 year old woman, she was very cathectic. She was in the end stages of her life

and she had pancreatic cancer. She had an abdominal wall met that was actually invading into her liver and she had severe epigastric pain and constipation. Her ECOG status was poor and she was on a lot of narcotic medications.

She had one of these metastases resected and her pain had come back immediately. You can see just anterior to the liver, there's this soft tissue mass that's invading into the liver. She has multiple liver metastases and her pancreatic cancer

is invading into her celiac plexus. So using a combination of what Nick has talked about and these nerve blocks, as an interventionalist, we can offer multiple things to these patients to improve their outcomes. I'm a huge fan of ultrasound, so I use ultrasound

to guide my needles as often as possible. I'm using a glove because I'm gonna end up doing cryoablation in the near field of that metastasis that I showed you. On the image on the right hand side, you can see the cryoprobe going down

into the shadowing cryoablation defect. It's treating that lesion, but just above that, you can see a horizontal white line, which is actually a needle that I'm injecting saline to keep the skin safe as we're doing the cryoablation. By using the glove with the saline in it,

I can actually use that as a standoff pad to sort of see that skin and make sure that the cryo energy and that ablation zone is not coming up into the skin. Just a nice technique with ultrasound, very simple. And then, at the same time, while I'm doing the cryoablation just lateral to that,

I'm taking an ultrasound guided approach and dropping a needle down in front of the aorta and doing that celiac plexus block and neurolysis at the same time. So the patient gets the ablation for pain control and they get the neurolysis for pain control

and had significant improvement in their pain. You can see there the cryo defect. We delivered the alcohol to perform the neurolysis and the patient had significant improvement for a while. Ultimately, her pain recurred, but she then ended up going to hospice and passing.

We definitely offered her improved pain control and quality of life for at least a short period.

Yes. - [Audience member] So we do lymph nodes integrity

inductions in the breast. They're extremely painful and patients come not prepared for a discussion about what's gonna happen to them. How would you give informed consent to let them know what's gonna happen

without giving them negative stimulus? - [Elvira] Well typically in those settings when you do your informed consent, whether it's something painful or where you potentially might kill somebody you still obviously have to describe what might happen

but what you're gonna do about it. Say, okay you know, and you explain what's happening, so say we'll be numbing up the skin and then we'll be injecting the material and you might feel that. Some people experience it as warm, some as hot,

some as a sense of tingling yeah, but the key thing is we want you to be comfortable and it's very, very important that you always tell me what is happening. If something, let's say your risk of killing somebody during your procedure, you say, and I've done

a fair amount of high risk cases. If, for example, while we're going through your heart and do that your heart stops we are going to resuscitate you and while we can never guarantee any outcomes I can promise you we will be doing everything known to mankind

to make this go well. I mean that is all I can promise so one can go somewhere deeper into that but I am open and some people in embolization say well, is it gonna hurt? I say well you know, different patients

experience it very different. The key thing is you are gonna let me know anytime how you feel like. I do not want you to be a hero, even if you say I do not want you to be a hero, still the hero is still in there,

I really want you to work with me and I'm gonna do whatever I can to make this a good experience for you. Which is, I mean it's honest, it's what you really want.

And for us, for anesthesiologists when we practice outside of anesthesia we call that non-OR anesthesia. It's NORA for short. And for us that's the final frontier. So you know I'm a big Trekkie,

and I always picture myself, you know, like being in the you know, Enterprise. And I'm havin' my little journal, Star Date 2019, 2018, you know, I'm goin' down to IR world, and we're gonna see the different life forms.

And they have really advanced techniques. We're not really familiar, but we're gonna you know, get ourselves, or equipment and see what's goin' on. These people can be hostile. (laughter) We're not sure.

You know, so you can see that. And that's what I felt like. That's why I put this in. So that's our final frontier for us. Again non-OR anesthesia is anesthesia that's practiced outside of the operating room,

our comfort walls. So NORA sites for us is IR, EP, endoscopy, cath lab.

The pudendal nerve block is also sort of a deeper block that can help in perineal pain. It's the block that's used actually by the obstetricians in child delivery if you're not having an epidural. They do an internal block through the cervix and vagina

and basically block the pudendal nerve there just medial to the acetabulum and the ischium. We can do this block under CT guidance and you can see I've done the block here on the right hand image from a posterior approach, avoiding the sciatic nerve, obviously,

and injecting a little bit of contrast and then the bupivacaine and the lidocaine and you can get a nice deep block. This is an actual case of a patient who had profound rectal cancer invading the perineum and actually passing through the skin, unfortunately.

The patient was in extreme pain, couldn't get out of bed, just absolutely miserable. And by doing the block and then neurolysis where we actually inject alcohol, you can actually improve this patient's pain syndrome and that in fact is what happened.

Some other less often understood or offered blocks are the ganglion of impar block

which is just anterior to the sacrum, kind of at the junction of the sacrum and coccyx. The ganglion of impar, again, sympathetic chain innervates the rectum, the perineum, and is very useful in patients who have coccydynia, patients that have a coccyx fracture

or have coccydynia, which is actually much more common than you might expect, than you might think. Very simple to do, you can either do it under fluoroscopy laterally, but I think that with our imaging capabilities, we can do this in a very elegant manner,

so you can go just across the sacrum or through the sacro-coccygeal ligament. You can see that I've brought an 18 gauge needle down through the bone and through that needle, I pass a 22 gauge needle. Obviously you have to watch out

for the important structures anterior, so I had to come right up to the rectum, but I couldn't pass the needle through the rectum, that would be a bad day. I inject a little bit of contrast, inject some bupivacaine and lidocaine,

and the patient gets relief of their pain.

The superior hypograstric block is becoming kind of more commonly seen. In those practices that are doing it, a lot of uterine artery embolization, this is a really nice way to improve patients'

crampy abdominal pain or crampy pelvic pain that's related to uterine ischemia after uterine artery embolization. There have been authors that have proposed that to do UAE as an outpatient procedure, that we should couple the UAE procedure with this block.

It's good for pelvic pain, both uterine contractile pain, but also for cervical, vaginal pain, rectal, as well as bladder related pain. For those cancer patients, this is also a good block to consider. These are all palliative interventions

that are very simple to perform and can really improve patients' quality of life. Again, getting back to this really busy slide, if you target this lower hypogastric region, you're basically picking up the splanchnic nerves that innervate the large intestine,

the small intestine, the ovaries, the scrotum, the urinary bladder, and the perineum. On the right hand side, you can see the fluoroscopic guided way to do this, which is basically just to target the disc space between L5 and S1.

The other way that people do it is that during their uterine artery embolization, they'll take a catheter and put it up and over the bifurcation so that you basically then outline where the bifurcation is and then you just stick your needle right there in the V of your aortic bifurcation.

You take the needle just underneath the aortic bifurcation and dock it up against the vertebral body, pull your needle back, do your block, and you have a significant improvement in the patient's pain.

Alright, so you know in conclusion,

if you have a happy patient you're going to have a happy staff and the key ingredient really is this rapid rapport piece, to reframe the experience, avoid these negative suggestions and you can use a bit of this hypnotic language and it doesn't need to take extra time.

Thank you. (audience applauds)

This is the technique under CT guidance. This was an actual patient who had chronic pain in the left shoulder with arm pain. This diagnostic block is to determine whether there is a sympathetic component.

You bring your needle down, avoiding the carotid and sometimes you do have to pass through the jugular vein, but that's okay because you're using a small needle. And then as we're getting closer to the spine at the T1 level you also have to avoid the vertebral artery. So we bring the needle down and we basically dock the needle

just lateral to the esophagus at the junction between the rib head and the T1 vertebral body and that's exactly where the stellate ganglion lives. We inject a little contrast to make sure that we're not intervascular, and then the lidocaine and bupivacaine mixture.

Patients often get immediate relief on the table. This patient did well with this block. We've had several patients that have undergone this block for hot flashes and have had improvement in their symptoms. We've had some failures, but this is one that is not often offered and can really help

in some of these complex pain patients.

We're doing this in the knee where we do the geniculate nerves. We target the medial and lateral superior geniculate nerves, as well as the inferior medial geniculate nerve.

This is the approach, you can see the probe placed right where the geniculate nerve lives in the lateral position. This is what it looks like when we're placing the probes. We place these sheath needles. We inject some bupivacaine and lidocaine,

and then we form the RFA. This is another patient where we performed the medial and lateral superior geniculate and then the inferior medial geniculate ablation with significant relief of this patient's pain.

- [Audience member] How about children?

- [Elvira] Children, the beauty with children is that they have a very great imagination. I mean they are Batman, they are whatever they want to be and you can get them very quickly into their state. So for a kid, all you may need to do is,

oh what do you like to do? And then when they tell you what they like to do we use a little, how shall we say, ego strengthening piece in it. So for example, we do work a lot with Toronto Hospital for SickKids

and obviously what kids love there to do is play hockey, and so they go and play hockey and all the sounds there is your fans cheering you on and then they're gonna hit a goal and that kind of makes them really proud. What I may also add to that,

I've been thinking about this earlier to include in that is landscape in medicine is really, really shifting and what is happening that nursing and technologists, frontline staff are gonna be determining what is happening with patients.

We see this more and more, I mean doctors don't have really that much to say anymore and at Toronto Hospital for SickKids the nurse is running an absolutely landmark study. She's 11 patients away from 170 and this is gonna be the very first trial

that shows can you actually, if you decrease pre-operative anxiety, and that's kids who have cardiac ablations under general anesthesia, can the pre-intubation anxiety reduction, is that gonna result in better post operative behavior? Because there's a lot of research that you basically

create PTSD in these kids who come, they're in this environment the next time it's gonna be worse and worse. So she follows them up. But the other thing too is there always has been some thought about how much do patients

actually hear? When they are under, so with those kids we're actually also looking at not only a script at the onset but right before extubation. How is that gonna affect how they recover in recovery? What's it gonna do afterwards, what's it gonna do

for the whole safety? So I think particularly in kids, anesthesia is a problem because brain development can be affected depending on the age so we are very much into, hopefully soon, knowing exactly what is happening

in the pediatric population on a broad scale there.

This is a super busy diagram, but basically this looks at both the somatic nerves and the autonomic system. I don't think we have a laser, unfortunately. Basically the autonomic system innervates the liver, the gallbladder, the stomach, and the upper epigastrium,

but also innervates the large and small intestine. And then as we move down from top to bottom into the lower sympathetic chain, there's innervation of the kidneys, of the uterus, ovaries, scrotum, the urinary bladder, and the perineum. So, in thinking about it that way,

we then can understand where we're gonna target our blocks based on where the pain syndrome is.

This is where the celiac plexus lives, so it's around the celiac artery, usually just slightly above, but is actually a mantle of nerve tissue that is from the celiac down to the SMA. You can see on the image on the right,

we've approached from the posterior paraspinous approach and we're using a curved needle where we basically dock the base needle which is a 22 gauge needle adjacent to the aorta and then we take a 25 gauge needle that's curved and bring it anterior to the aorta and that's where we can eject the contrast.

You can see the contrast now layering just anterior to the aorta, hopefully not in the aorta. But the beauty is, you're using a 25 gauge needle, so you really can't do much harm. Once you've injected the contrast, the lidocaine and bupivacaine, you can then either move directly

to giving the neurolytic which is absolute alcohol, usually about 15 to 20 CCs, or you can use phenol, which is more commonly used in Europe. This basically denatures the myelin, destroys the myelin sheath, and stops the conduction of those nerve fibers.

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