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HCC with arterioportal Shunt|TACE |68|Male
HCC with arterioportal Shunt|TACE |68|Male
Hepatocellular Carcinoma|TACE, Thermoablation/Radiofrequency Ablation|Male
Hepatocellular Carcinoma|TACE, Thermoablation/Radiofrequency Ablation|Male
Hepatocellular Carcinoma | TACE, Thermoablation/Radiofrequency Ablation | Female
Hepatocellular Carcinoma | TACE, Thermoablation/Radiofrequency Ablation | Female
Hepatocellular Carcinoma (Multi-focal)|Thermoablation/Microwave Ablation|67|Male
Hepatocellular Carcinoma (Multi-focal)|Thermoablation/Microwave Ablation|67|Male
Hepatocellular Carcinoma, Colorectal Metastases | TACE, Thermoablation/Radiofrequency Ablation | 69 | Male
Hepatocellular Carcinoma, Colorectal Metastases | TACE, Thermoablation/Radiofrequency Ablation | 69 | Male
Hepatocellular Carcinoma|TACE (Segmental)|67|Male
Hepatocellular Carcinoma|TACE (Segmental)|67|Male
Hepatocellular Carcinoma|TACE (Conventional)|67|Female
Hepatocellular Carcinoma|TACE (Conventional)|67|Female
Hepatocellular Carcinoma, Arterial Injury|TACE (Conventional) (Repeat)|51|Male
Hepatocellular Carcinoma, Arterial Injury|TACE (Conventional) (Repeat)|51|Male
Hepatocellular Carcinoma, Post-embolization Syndrome (Post-TACE), Liver Infarction|TACE (DEB)|61|Female
Hepatocellular Carcinoma, Post-embolization Syndrome (Post-TACE), Liver Infarction|TACE (DEB)|61|Female
Hepatocellular Carcinoma (Multi-focal)|TACE|65|Male
Hepatocellular Carcinoma (Multi-focal)|TACE|65|Male
Hepatocellular Carcinoma|TACE|53|Male
Hepatocellular Carcinoma|TACE|53|Male
Metastatic Carcinoid (Parasitized Right Inferior Phrenic)|TACE|63|Female
Metastatic Carcinoid (Parasitized Right Inferior Phrenic)|TACE|63|Female
Metastatic Carcinoid (Parasitized Omental)|TACE|
Metastatic Carcinoid (Parasitized Omental)|TACE|
Hepatocellular Carcinoma (Solitary, Child B), HCV Cirrhosis|DEB TACE|65|Male
Hepatocellular Carcinoma (Solitary, Child B), HCV Cirrhosis|DEB TACE|65|Male
Recurrent Hepatocellular Carcinoma, Arterioportal Shunt|DEB TACE, Coil Embolization|65|Male
Recurrent Hepatocellular Carcinoma, Arterioportal Shunt|DEB TACE, Coil Embolization|65|Male

This is a good case of mine,

hes' a 68 year old male. He has alcohol cirrhosis and esophageal varices, he's not a prisoner. But he doesn't speak English, so just putting that out there. He's a child Pugh A5, he had a total bilirubin of 0.7 his AFP was 43

so not indicative, and his ECOG was 0-1 when he saw me for the first time in clinic and this is what his initial CT scan showed, to from my clinic, he had not been followed up appropriately and just came in with a belly ache and they noted this very large mast in his right hepatic lobe.

Further down you can see that the tumor extends more inferiority and you are getting a very avid enhancement of the portal vein and you can see there's some portal vein thrombosis in there. So the arrow is really pointing at what I was reading as an arterial portal shunt. So knowing that this is what you are going to face ahead of time

sort of can help you plan. So arterial portal shunting diagnosis can very often be made on multiphasic CT scans so you know I'm sure you all get those patients that come from an outside hospital with HCC diagnosis and they have one phase of imaging so it's really important to get that multi phase imaging

CT or MRI because you can make these diagnosis. So this group showed that about 15% of patients can be or actually have this and the diagnosis can be made on CT scan and then they just talked about where these arterial portal shunts are about half of them essential or 24 from a peripheral and then 22 of them are mix. So you can't really tell if they're central or peripheral on the CT

imaging. And then how severe are they, 35% are severe. Severe means that on that arterial phase imaging your portal vein is as bright as your aorta. And 41 or about moderate which is you know.

You can imagine what moderate is and then 24 are mild so you just saying it's within the peripheral areas. Interestingly about half of these patients that do have arterial portal shunting also have portal vein thrombus so even if you just have single phase image and you have portal vein thrombus you can sort of start thinking in your head that these patients may have an arterial portal shunt and they actually

went on to get hepatic and angiography, 22 of these patients went on to get hepatic and angiography and of those patients 86% had arterial portal shunting the author said that they probably all had it they just missed it on angiography. So what's the prevalence really there is not a lot of great data on there you see I went all the way back to 97 to see if I could

actually get a prevalence but overall arterial venous shunting. They said it was about 31%. If you had arterial portal shunting or arterial venous shunting of that, 31% of patients that HCC 92% had arterial portal shunting. So what's the treatment?

So as you can imagine we've all come up with creative things we've been at this meeting all week. And, you go into a room and you can imagine everyone's doing these different things. So, if you can find a single feeding vessel, a coil is a great choice

if you can find it. Glue, if you have a network of vessels and you don't think that glue is gonna get stuck proximally to prevent you from treating the tumor eventually. And particle embolization is a good option. You can use large particles if they don't cross over into the shunting

I had a patient that had a large, we'll get to them in a minute, but it was a very bad complication from outside the hospital. And the other thing is you can try lipidol based embolization and that's not well supported in literature but there are case reports talking about it.

So for my treatment planning, because he had portal vein thrombosis I decided that I was gonna go ahead and do a 190 based on the literature. And so, he showed up to the suites and we had planned for the shunt study. So the initial angiography you can see,

as soon as I'm seeing the arterial phase of imaging. And this is seconds after the injector goes. you can see filling that portal vein, the main portal vein.

And you can see, the filling defect within the main portal vein indicating that he had portal vein thrombus. So, this severe arterial portal shunting was noted. I couldn't find a single vessel, it's just this huge network of vessels that was supplying or communicating with

the portal vein I didn't think I could do glue because I was worried that the glue would embolize the proximal artery and I'll never be able to go back in treat it, and because the tumor was in the right hepatic lobe I just wanted to see is there, I have

had a pulmonary shunt as well as the ulterior portal shunt and so I went ahead and infused the MIA. The lung shunt fraction as is very typical was 20%. And so that brings us to hepatopulmonary shunting. How common is this?

Is it a prevalence of overall again arterial venous shunting is 31% and of those hepatopulmonary shunting is much less so it's 8% of those patients. And all patients with HCC they say the prevalence is about 2.4%. Again in my clinic it's probably much higher than that. So the typical shunting in HCC this is Ron Gaver's/g group who talked

about what's the prevalence based on lung shunt fractions they said about 56% of patients are gonna have no lung shunt fractions to less than 10%. 10 to 20% of lung shunt fraction you got 30% of patients with HCC and those higher lung shunt fractions are going to be 14% of your patients that you are treating.

So they also found that there is correlations how can you sort of predict this on imaging sometimes you can't see this hepatic pulmonary shunts on imaging so if you do have an infiltrate of tumor that was correlated with hepatic pulmonary shunting if you had greater than 50% hepatic tumor burden, if you had portal vein thrombosis or

portal vein compression so the tumor is actually pushing on the portal vein you are going to see a higher degree of hepatic pulmonary shunting. If you have arterial portal shunting that's interesting that also correlated with the hepatopulmonary shunting. And if your tumors are hypervascular,

all tumors are hypervascular so that's not gonna be very helpful again how do you treat this? So embolization again if you can see that single feeding vessel that's fantastic and you can do it again glue is possible particle and hepato-based embolization is also then reported. Systemic therapy with Sorafenib has some literature saying that

if you start patients on Sorafenib you can reduce the shunting, this is the case serious with couple of patients, that they showed that the mean shunt fraction in the patients was 26.5 prior to starting Sorafenib therapy, and post sorafenib therapy, went down

to 7.5. But again the time it takes to treat patients with Sorafenib to get those shunts to come down sometimes can be longer than the patient would survive otherwise. And what about if we do the Y90 what if we,

go ahead and do Y90 therapy is there real risk of radiation pneumonitis? So this is out rehabs group and he found that of his 403 patients now these are patients not only with a HCC but all comers 58 of those patients or 14% actually received greater than three gray accumulative lung dose and of those just so I wanted to highlight that HCC population

74% of those patients with those elevated or high lung shunt fractions were actually patients with HCC with sort of a similar to the data that I showed you earlier. And the mean shunt fraction in the HCC patients was 20% and the mean accumulative

of lung dose is 54 Gy to those patients and his report he had no cases of imaging or clinical real issue of pneumonitis. And so you can quote that to your patients that you know a very large series has shown that there's no risk of having any risk issues with the lungs other patients or other series have sort of talked about may be having radiation pneumonitis.

So really the things to consider when I was treating this patient are you have severe arterial portal shunting on the angiogram because we're seeing filling of that main portal vein and now he's also has a hepatic pulmonary shunt which is almost 20% and so do I go on to do Y90? With an arterial portal shunt you have to really think about where

the beads are gonna go so if they cross over into the main portal vein, where are they gonna lodge? So they are gonna lodge any where in the liver and we have started to do or what I've started to do is if you see these large arterial portal shunts you can do CT spect with your MAA and then you can see where the bead is gonna go because that really is a good indicator.

I had a patient a couple of weeks ago that we did that and it actually shunted to the contralateral lobe, so I felt why don't we just treat the whole liver except all of the beads would have got the contralateral lobe not the lobe where the tumor was. So I would have had an effective dose and I would have just cause atrophy of the wrong lobe of the liver.

So that sort of a trick you can think about. With hepatic pulmonary shunting you have to think about can I get a dose high enough to effectively treat the liver without having it just bypass around and go into lungs. And so if that's the case, do I have to worry about this cummulative/g

lung dose? Do I, do I not or can I do some sort of fancy technique in the end of my hepatic vein and do an occlusion during my Y90 administration to get those beads to lodge in, take out the balloon afterwards get an effective treatment.

And really, is it affectatious, do I go ahead and treat and is this gonna affect these patients, appropriately? So again, here's the image this huge tumor. Here's the shunt.

Here's my hepatopulmonary shunt. So, I'll bring my first team question up. [BLANK_AUDIO] So given the clinical and imaging characteristics below, how would you treat the tumor?

Anyone change the words from a monograph. So a, systemic chemotherapy, percutaneous ablation, c, full dose radioembolization d, conventional chemoembolization or e, reduced dose radioembolization.

[BLANK_AUDIO] Good answers. I love it. [LAUGH] I don't think there's a right answer. I chose the answer D,

conventional chemoembolization, and if we can go back to my slide. I said it was incorrect. You can do Sorafenib and I don't think that's the wrong answer it's just a matter of how long are you willing to wait and how often are you gonna re-image these patients to try to shut down their

shunts again. The studies showed that their follow up was up to 270 days, that's almost a year that the patients need to out to be able to get these shunts to shut down. You're never gonna ablate a tumor like this.

It's too big. C. I said is incorrect because the Y90 is gonna disperse throughout the entire liver unless of course you do that spect imaging and then you can sort of determine that it's really gonna go to where you want it to go. So I said I probably wouldn't just go ahead and treat the whole

liver if the patient's is cirrhotic. In the patient that has liver metastasis since they may be willing to or able to tolerate it just depending on how bad your patient's overall liver function is. I thought D was the correct choice,

patient is candidate for conventional chemoembolization. Cuz it really provides treatment while potentially reducing the shunts and allowing the future radioembolization. The other thing I like about lipidal based chemoembolization is you can see it.

So the shunts crosses over, you can see where it's going, so you know if it's going only to the left at the time we can see if it's going only to the right if you're not doing your pre Y90 ahead of time instead of beads where you sort of can't see where they're going and don't really have a good handle on it at the time.

And then C, they've talked about in a literature doing a load of stuff that guys at Stanford published trying to decrease your dosing when you do Y90 and they actually show that it had decreased efficacy of treatment. So that's probably not the best choice according to the literature that we have now.

So I went ahead and I proceeded with TACE I did the lipiodol based TACE. We don't have any support in Wisconsin I think that's probably universal in the United States these days. So I used Doxorubicin and mitomycin I mix my lipiodol thicker so it would get stuck into those blood

vessels so it would trap it so it wouldn't cross over into the portal veins so I did a two to one and sometimes I'll even do a three to one just to get that lipiodol thicken and sludging in instead of just crossing over into the portal vein,

and now embolized into the back end with 3 to 5 PVA. So this is what my angio looked like at the end. It was sort of shocking that we had shut down that shunt with the lipiodol based TACE. We always get CT scans the day following.

I would show you the picture but really, you can't appreciate where the lipiodol is because it's so defused throughout the entire liver, I thought this is never gonna work. I called the medical oncologist and I said can we start the Sorafenib?

And I told the patient and his family I didn't have very good hope that this was going to work but we were gonna try to take care of him. On follow up imaging about a month later, this is what it looked like so you can see that that huge mass is gone,

I thought I had the wrong patient. Study pulled up and then, did you scan the wrong patient? I looked at the other anatomical structures, those were his kidneys,

no, this is this guy. It really melted away that tumor. You can see some residual lipiodol there and he did have a residual viable tumor that you could see. His portal vein thrombus had melted away so that was no longer there and on the arterial phase imaging there was no longer any appreciable

or arterial coral shunting. So we decided why don't we go ahead and repeat the shunt study and see what's happened to the hepatopulmonary shunt and see if that was also effectively treated. This is the second study. I took these pictures and I told my fellow this was the most traumatic

case that I had ever seen in my life and everyone should go back and look at the pre-images because I've never seen this that you have zero arterial portal shunting after one session of TACE, is a very dramatic change in his imaging. I did a CT spin just to

see if I could figure out the distribution of was there anything going to that left hepatic lobe you can see this is residual viable tumor enhancing here and nothing is going to that left hepatic lobe again we did hepato pulmonary, a lung shunt fraction calculations and

it came down to 7.4%. We went on to do a Y90 radio embolization of the right hepatic artery and on seven month follow up the patient is disease free, he has no residual viable tumor he has no portal vein thrombus and he tells me that he prayed and I told him to tell me to whom he prayed

cuz I wanna give that to all of my other patients.

can see there, the day is June 2007 and the patient went and had the TACE.

You can see the nice blush there. And then we follow it with the ablation. So if you look at the path that we take, it's very long but I think it's the safest path to get to the back of the tumor. We're gonna be rebooting/g the diaphragm for sure we know that.

But you tell the patient I'm gonna try and get rid of all your tumor and also in a lesion like this you really don't want to go straight down to the tumor, and spill the tumor out you get the bleeding and then you have seeding and you're basically upstaging the patient. So take a long path is fine which we did and [BLANK_AUDIO]

So the patient became febrile a couple weeks later so, and then follow up imaging show an abscess in that area. So we already talked abscess formation and in my experience it takes a long long time to cure this abscess you put a drain in, you have to treat the patient with antibiotics and you tell the patient you might have this treatment for like one or two

months. Just to start it, it's unusual to get a resolution in a week or two. So this patient inevitably pulls catheter out so we did follow up imaging, looked at it, and still there so we put in a catheter and then the catheter was removed when they were decrease in output and the patient became sick again,

showed up and now had and intrapleural abscess. So how do we treat this? Again we just put him in a catheter and just have him wait it out. So by October 2009 follow up study everything is gone. The tumors are gone,

the abscess are no longer there, we have some scarring. Unfortunately 4.5 years later there's a recurrence in almost the same area a little bit lower down and then so we retreat the patient with combination therapy and at follow up the tumor was gone. So

the point about abcess is that you have to like really wait it

so here is a patient with a large left lobe HCC, underwent a re-section, she's like an old Japanese American woman, gives me a hug every time she sees me in clinic or she sees me in the hall, so she had re-section and then she had a recurrence in the right lobe

multiple areas and so we went ahead and did the TACE, conventional TACE, you can see a lot of [INAUDIBLE] here which is tumors and then we went ahead and did the ablation, requiring multiple times cuz the tumors were pretty big and as you can see across the flora here, the lung even, and this was done intentionally so that we can maximize

our burn area. So patient had pneumothorax, which we went ahead and treated with the pneumothorax kit and she did well, she did fine. So how many of you here actually go transpleural or transparenthimal/g to get into the tumor, okay. So it's a recent benefit ratio right and the Pleural reflection, if you go into early,

things are kind of squeeze together so there is more chance of you going through the lung and the pleura if you go in too early, this study show that about 45% of the patient actually get pneumothorax to intentionally go through the lung, but only 18% of them will require a chest tube. And that paper show cases where you should go through the lung if

you have no other alternative. And patients don't really do well with chest tube. And if you have a dome lesion you may want to spare the diaphragm if possible and this paper shows that you can manipulate a needle and patient's breathing in order to get the needle in between the diaphragm and the liver dome to inject saline or D5W to

protect the diaphragm. But in reality what I usually do, dome's technique, I would just burn the diaphragm and we do that routinely and we haven't had too many issues with it but I will show you a case when that becomes a problem.

Here is a lesion, very small, but patient also had other lesions as well above them not showing, so patient underwent combination therapy. The other two lesions above was fine, and then this small lesion

I figure it's easy. So I watch from outside and decide to leave the area, left the fellow alone and so the patient after the procedure can clean up persistent pain, and this is the final post procedure image. As you can see there is something going on here,

it's kind of a softish with density, right along the rib, so our postulation was that some kind of bleeding, and patient had persistent pain so we did a repeat MRI later on and it

shows the ablation tract actually extend to the substitute tissue. So you need to make sure that you measure out very in detail. The path of your needle and how deep it's gonna be and how long the burden is gonna be along the needle tract. Also if you're using two microwave ablation needles and the tips are too close together ,you're making it change the whole electro

dynamic of the burn and what happen is that the burn zone propagates back from the tip of the needles. So when you're using multi antenna, make sure the tip of the needle at least 1 to 1.5 cm apart. If they're too far apart you don't get the synergistic

effect, we have a nice brown burn they become [INAUDIBLE] but if you get that tip of the needles too close to each other the burn zone propagates back and then it's gonna end up in your wall or your skin. Any questions? Feel free to interject.

presented for liver directed therapy, patient has systemic chemotherapy as part of the treatment so this is what you see on imaging, we just took a static image but there's contrasting out there and

they're not going anywhere, so this will be a dissection. So same question, what would you do at this point? >> Just to take a step back. Was this manipulating a microcatheter or is this from a glide wire, or were you trying to get a four French catheter out into the hepatic artery,

what was the. >> This is just a microcatheter trying to get out distally and then so the fellow saw that this contrast stasis and then he just pulled everything out and he called me. >> So certainly this is the same person that Ryan had early today, cross trained in Chicago.

>> Yeah I think he's been making the rounds. >> This is not uncommon, you don't see this usually with HCC patients though in my case it was HCC, wasn't a dissection but you mentioned chemotherapy, what chemotherapy is in, and what was the time place here?

>> I don't remember but this patient had [UNKNOWN] and usually when the patient is on chemotherapy for us to do any kind of local treatment we'd like to take the patient off chemotherapy for at least two or four weeks or so. So this patient is fighting off whatever chemo he had for like about four weeks before we do this local regional arterial therapy.

>> What I'm driving at a little bit here is bevacizumab which maybe what these patients are on and sometimes four weeks and many times is not enough, many people advocate six weeks but I've seen even at six weeks there would have been very bad antegrate flow, cranky vessels you try to do anything, there is another one where

I may do an angiogram, now to do a good ciliac angiogram, I usually use reverse curve catheters, I try not to get them out there and if there is preferential flow to the spleen, the antegrade flow in the liver looks bad it doesn't stop me from doing my angiogram and we are probably doing different procedures here but in terms of mapping for radio embolization,

I don't even catheterize the left hepatic artery because I feel like I'm gonna get myself into trouble so I'm just mapping them, I'll just get to a right hepatic angiogram put the MA and give them a month or more off of chemotherapy or they can go back on a chemotherapy. Maintenance chemotherapy, without the bevacizumab and bringing them

back to treat, but I think the key here I think is really before trying to get too selective or even selective of left and right hepatic arteries is to really analyse your ciliac angiogram. Because these vessels can be very difficult to navigate and you end up with problems like this that are very difficult to deal with.

>> Yeah. So the question now is- >> I think there is a question from the group over here. >> Okay, right. >> [INAUDIBLE] >> That's a little bit rogue and a little bit outside

of almost any intervention oncology guideline or practice pattern. I think last year we had a workshop and we had created a workbook from it and almost everybody suggests around six weeks off, I don't always adhere to that. I will do angiograms, the patient's honor or not and I say that.

But again I have a lot of angiograms number one and number two. I do a ciliac angiogram, and if the flow does not look good, I hold it. Many times you can predict something like this. In the cases that I've seen we don't see all the other images but,

the hepatic arterial tree is very diminutive. The flow is preferential into the spleen. You do an angiogram one foot five in the counter hepatic artery it all reflects back to the spleen that's a problem. So in general most

advocate and you may find one or two people that don't, but most advocate holding the bevacizumab if you are going to do angiograms with people on bevacizumab you will see some problems and if you try to be, you are not even aggressive with your catheterizations, Dan Brown who's very highly regarded in my opinion and he's got a I would say a great case but it's a horrific case of something

like this, that went from a dissection to a pseudo aneurysm to include the whole nine yards and I think he's very experienced. So and [INAUDIBLE] I believe has a very similar case, Charlie nodding, I've seen case after case, meetings where this is the norm when people are on bevacizumab. So if people are saying that they got to be careful of the message that people leave in this meeting is that

yeah, don't worry about bevacizumab, I think that is the wrong message. So anyway you know we do quite a few [INAUDIBLE] with the patient beyond different agents before, and I will have to say our dissection rate is not as high as I would expect but

you run to a patient whose vessels look diminutive and kind of fragile, you just know you gonna be in trouble, so I think it's also a patient dependent as well. So in this case what we did was we went across and we put up a balloon lightly hopefully to get some flow and then we went ahead and did the chemoembolization. So at follow up,

this is the angiogram after the chemoembo and we did a follow up CT angiogram couple of weeks later just see where the things were going and this is [INAUDIBLE] at the area of dissection but that flow was to be established very well and you know for every case that looks like this, I can remember a case that the vessel is just thrombozed

completely. And then you get recarnalization via collaterals. >> Let me ask you why, I think there's evidence and you showed a lot of evidence for combination treatments in HCC but what about metastatic diseases.

I haven't seen a lot of evidence for that. >> You're right, you're absolutely right. As a matter of fact we do use 190 for [INAUDIBLE] most of the time. I don't remember why in this case we get the combination therapy but [INAUDIBLE] methods and a different beast and HCC for sure, all

the data that I've shown you pertains to HCC not in [INAUDIBLE] but I chose this case because of the dissection which you will see a lot in HCC. So here is a paper that many years ago our aligning issue with dissection in such patients who gotten chemotherapy.

So with that, we're gonna move to case one. This is a 67 year old man with cirrhosis. He has right hepatic lobe HCC.

He has other tumors as well. He had a previous TACE and he is a Child-Pugh A BCLC A guy. He has this 1.2 cm tumor in the right hepatic lobe. We pursued TACE. And this is our initial hologram. You can see the hypervascular tumor fed by right hepatic lobe branches.

We pursued a conventional Lipiodol TACE with doxorubicin and mitomycin. And we tried to perform it from a segmental approach. There you can see the hypervascular tumor. It's got some little vessels supplying the tumor itself nothing to select further from here and therapy was applied from this segmental location.

Patient did fine, he was discharged after overnight observation. However he returned to medical attention five days post-TACE. He complained of epigastric abdominal pain and anorexia since the procedure. This prompted a CT scan. This is a non-con CT obtained from the

ED. You can see there's tumor coverage with the chemotherapy mixture but Unfortunately there is also coverage of the pancreatic head with lipiodol chemotherapy mixture so this was a case of non-target embolization . This is something we commonly think about with radioembolization

but don't consider it as much with chemoembolization. So in terms of his course, he had some collaborative labs drawn, he had Amylase and Lipase elevation consistent with pancreatitis. And actually he just underwent symptomatic pain control.

Now going back with the retrospectoscope, if we look at the angiogram what we see is a non-target pancreatic arterial branch headed to the vicinity of the pancreatic head not noticed by the operator at the time of the procedure. Easily overlooked, but again highlights the need for careful angiographic review.

A search for vessels that seem to head outside of the confines of the normal liver as we do for radioembolization. I'm sorry. Yeah we have a question. >> [INAUDIBLE]

>> That's absolutely a great point. I think that's a very key avoidance technique or avoidance measure. And we don't routinely apply them across all TACEs that we do. But we do utilize them sometimes for pre-procedure planning. So in this case the patient had asymptomatic improvement over time. He came back in one month and actually the lipiodol had cleared

from the pancreatic head very nicely and actually he had a nice complete response.

this was actually a trainee case. This was a woman with a very small left hepatic lobe tumor, some

variant anatomy with a gastrohepatic trunk. You can see TACE was prescribed and you can see the gastric branches on the left hepatic trunk arteriogram. And actually this was late in the year, the trainee was by himself in the case and

he mistook the gastric fundal blush as tumor, didn't notice the left draining left gastric vein. Usually you would anticipate from liver to see hepatic venous drainage and began to get his catheter in a more selective position and give chemotherapy to the gastric fundus.

At that point I came by the room said, whoa! Let's stop, we re-positioned the catheter, stopped injecting the chemotherapy, advanced the catheter, saw the true enhancing tumor and applied treatment,

nice chemotherapy uptake. And in this case the patient actually did pretty nicely, no abdominal pain, nausea, vomiting, tolerated oral intake, after TACE without issue and she was discharged home. We added a PPI for her but she remained asymptomatic,

and a nice result at one month.>> So was whoa the only thing that you actually said when you- >> [LAUGH] I like to take it easy on these guys

yeah. >> [INAUDIBLE] >> Sometimes it's nice to know you can get away with I guess right? >> [INAUDIBLE] That was the procedure that had happened to the patient in the past for that patient. So that's a good point perhaps the patient had recruited

vessels from the hepatic circulation to supply that previously embolized location. So that's an astute observation there. >> Why are you treating those [INAUDIBLE] >> The question is why are we even treating those with TACE, can

you->> [INAUDIBLE] >> The hepatic tumor in case one? Either one of them, I guess that's an institutional and personal preference and there's a lot of options for us. At our institution we use all three forms of therapy but in these

particular cases. The operator had selected conventional TACE which I think is appropriate for parenchymal lesions like we saw in those two cases. Yeah question >> [INAUDIBLE] >> Well that-

>> [INAUDIBLE] >> We won't get too lost in the weeds on answering those types of questions but nonetheless, patient did pretty well. I wanna briefly overview non-target embolization, incidence is pretty low. It can span from anything from colocentesis,

pancreatitis, all sort of lesions, and the severity can be related to the embolic load size and collateral perfusion. We see high attenuation chemotherapy on CT, might not be able to see it on MR.

And we talked about some avoidance techniques, careful angiographic review, selective therapy, cone beam CT for real time therapeutic monitoring. You can embolize vessels or use cold packs to avoid non-target to superficial structures and consider vasodilation of treatment beds with things like

Nitroglycerine and then there's some specialty catheters obviously. For management I think subclinical cases can be observed. We use PPIs in our second case to help prevent EGI symptoms and symptomatic improvement to improve patient comfort and then escalation is needed.

This is a 51 year old man with HCV cirrhosis and a right hepatic lobe HCC which is recurrent after RFA 10 months prior. This is the arterial phase from his CT scan. You can see recurrent enhancing tumor around the ablation site, kinda nodular tumor on both lateral aspects of the abrasion site.

We've prescribed conventional TACE. We use triple therapeutic cocktail in this case and you can see the right hepatic angiogram showing multifocal disease, the patient underwent an uneventful therapy here. However given the multifocal disease he was brought back for multiple rounds of therapy. You can see this is a repeat TACE

five months later. Now we're starting to see some vessel abnormalities. Slight vessel attenuation in the right hepatic artery, again repeat TACE six months after that you can start to see multifocal vessel attenuation, vessel occlusion with an abrupt cutoff. And now one

month after that again lots of occlusions, lots of attenuation that completely obliterated right hepatic arterial system 13 months later. So this is a guy who has arterial injury or arterial occlusion related to TACE. This is not a complication per say but I think this is part of the natural history of multiple local-regional

therapies with embolic type treatments. The incidence spans anywhere from about 10 to 50%. You can get loss of vascular patency when TACE is performed to stasis or near stasis endpoint in a good percentage of cases. And I think most people take this to be related to caustic chemotherapy and embolics precipitating the hepatic injury. And obviously the

major consequence is loss of future access for local-regional therapy. It's been described for multiple chemotherapy drugs and embolic agents. And obviously what you're looking for here is attenuation, stenosis,

slow flow or occlusion in the vascular bed that you're treating. I don't think there's any real way to avoid this if you're gonna do multiple local-regional therapies, although you can consider embolizing to a substasis angiographic endpoint, use of temporary

embolic agents. And some practitioners will advocate bland particle embolization in this case, stating that there's a reduced rate of arterial occlusion, although I'm not necessarily certain that we know this for sure. From a management standpoint, I think this is a permanent event.

If one wants to pursue local-regional therapy you can consider looking for parasitized extra hepatic blood supply to HCC's in particular. However, I think at this point, systemic therapy is a pretty good option.

And this gentleman actually was prescribed sorafenib after his hepatic arterial loss. He underwent 7 total TACEs to both lobes and he expired more than 3 years after his first TACE, so he actually did pretty good for his tumor burden. Any questions or thoughts about this case?

>> [INAUDIBLE] >> We usually aim for complete tumor devascularization and maintenance of antegrade flow in the treated vascular bed. Given that he had so many TACEs I can't promise you that that was the case for every single procedure but that's our usual approach to these chemoembolizations. >> Has anybody got a question?

[INAUDIBLE] The question is, what's the threshold for switching modalities, if we start to see such changes after multiple TACEs. And the answer is it's probably operator preference again, I'll put that to the

to the group here. Would you guys switch modalities if you started to see arterial abnormalities in the treated vascular bed after some TACE procedures? >> I think some of it depends on your response. I'm not sure with this patient I wouldn't have gone right to Y90 you know multifocal

disease or bilobar disease or PVT is typically when I would go to a Y90 initially instead of TACE. If I could mention one thing about the temporary agent. In the past we used to use that in all patients, right, rather

than lipiodol, you kinda chase it with gel foam and I think, to be perfectly honest it didn't work. You see just as many cases like this with the temporary agent as you would. Because it's three weeks to three months generally in terms of

with gel foam particles when these things are gonna recanalize. So by then you're already persositizing it and frankly I just don't think work and it hurt very badly. >> Not to make this too complicated, we can all snicker but we started radioembolization obviously at North Western but for other reasons is because of this.

Some of these patients get many treatments over the course. You had seven TACE procedures here and we know in general with radioembolization, we can repeat the therapy. So we tend to do radial embolization if we decide that it's not working or there's early progression or we've reached radiation dose limits, then we do chemoembolization.

It's anecdotal that's the way we kinda run it now. In this particular patient you had seven time points. If you noticed that the vessels are starting to go away you know in the back of your mind that there may be a point that you're not gonna be able to do any more therapies. You could consider

going into something else such as radioembolization at that point but it's a little bit convoluted by the fact that there's evidence that doing repeated TACEs is better than doing TACE in one session and you wonder why did you do seven, is it not working. It didn't seem like you're doing

a lot of different segments, it was all re-occuring in the same spot so. >> I think it's a great point and I think it's one worth considering in a case like this. What I will say is we typically practice on demand therapy so this

gentleman actually having a response at each time point but then recurrence and repeat TACE. So I think to Bob's point, the therapy that we were applying was working although we were having kind of collateral damage

effects here. >> Who would have started with conventional TACE here? Who would have started with Y90? Who would have started with line/g embo/g? Cerefolin? Guess mostly Y90. You guys aren't answering much by the way.

>> All right I'm gonna move on to case three,

this is an elderly woman with cirrhosis in her left hepatic lobe HTC. She's had prior therapy. She's status post TACE times three to other tumors. This is a virgin tumor,

has never been treated and she is a BCLC B person.Since we're talking about TACE complications, we obviously prescribed TACE in this case. The practitioner did this case selected for, actually I think it was me,

doxorubicin loaded drug-eluting beads, and this is the patient's initial hepatic arteriogram. You can see that the ciliac anatomy is conventional. We micro catheterized the left hepatic artery and you can start to see the enhancing tumor supplied by the segment three branch to the left hepatic artery.

Got the microcatheter into a more selective location, you can see the segment three hypervascular tumor. And we performed segmental TACE using 100 to 300 micron drug-eluting beads loaded with doxorubicin. This was our angiographic endpoint. This is the post-embolization ateriogram, you can see the embolized left hepatic artery segment three branch.

Complete tumor devascularization. Not much much flow to segment three of the left hepatic lobe. Probably a slightly more aggressive end point that I might have desired however nonetheless this is our outcome. [BLANK_AUDIO] In terms of course this patient had what we thought was post-embolization post-procedure.

However it was poorly controlled with pain med medications, and upon lab check was found to have profound transaminitis AST and ALT measuring over 1000 on post TACE days two and three. And that prompted a CT scan and we came to find that the patient had a left hepatic lobe infarction.

So actually, I might pose the question to the group here. Was the angiographic endpoint aggressive in your mind? [BLANK_AUDIO] >> What do you guys think? Without looking at this picture. Well who would have used conventional TACE? DEB TACE? I would have too

RFA? It is funny isn't it if you're in one institution you default to one, if you're at another institution, you default to the other. And I think the reason for that is because, other than some compelling data now with combination therapy,

I don't know that we've really proven that one therapy is better than another depending on the size of the tumor. That's why we all do it differently. >> [INAUDIBLE] >> I can't hear you, I'm sorry.

>> Why wont you ablate it? Its such a [INAUDIBLE] small lesion. [INAUDIBLE] >> Yeah. >> It's a great point. I think you'd be 100% right if you decided to ablate this lesion.

I think it would be sonographically visible. It's within size for complete ablation. So I So I think that's a perfectly appropriate approach. >> You might not be presenting it here though- >> Absolutely complications

of transarterial chemoembolization, right. Yeah? >> [INAUDIBLE] >> That's a great point. We're gonna take a look a little bit further in a second. Yeah?

>> [INAUDIBLE] >> Absolutely a possible Possible approach here, yeah. I think that would be totally feasible and appropriate. >> [INAUDIBLE] >> I think in general in our practice,

once we apply a transarterial therapy I tend to stay with it. I tend to use ablation as a first line approach and then transarterial to clean up. So we typically don't do that but I think that'd be a reasonable approach for this particular tumor.

All right, I'm gonna move on. So we've established that this patient had left hepatic lobe infarction. It's an ischemic complication of TACE. Actually the incidence in the literature is higher than I thought but that's the 3 to 12% incidence kinda spans liver and biliary system.

And the main signs and symptoms are high transaminase levels and then symptoms of weakness, fatigue, confusion, if you have poor hepatic reserve and jaundice. Again we're looking for kinda geographic hypoattenuation, non-enhancement

of liver parenchyma in a vascular distribution. And there are some risk factors for this actually, non-selective catheter position, high embolic load or dose, small beads, lack of portal venous flow which was brought up and previous hepatic surgery maybe disrupting collateral arcades.

So actually in this case going back this patient had a congenital portosystemic shunt. So you can see on this sequential CT images that the left portal vein had a direct communication with the other middle hepatic vein or IVC. This was actually demonstrated angiographically on a study that

was performed several years prior for this person. Here's an SMA gram showing portal venous flow directly into the systemic circulation by the middle hepatic vein. So actually given that finding how does that change the panel's thought about the modality selection for therapy? >> I think you treat it like PVT for the most part cuz you have no portal flow to the left. So getting back to

his point about ablation, I think that's one more reason to consider ablation. [INAUDIBLE] >> Not necessarily, I gotta be honest I didn't see the original tumor, but it's a straightforward it was a portal vein out doing Y90 will be pretty straight forward. >> I'd probably go with ablation but that's just my preference and the other risk factor is you use a Surefire anti-reflux catheter. I've seen [INAUDIBLE] report of by using that you are putting so

much more agent that you can cause infarction like this. So that would be another risk factor. >> That's a good point there. It's not just the anti-reflux catheter the surefire now, there's also we're seeing some literature and companies producing these balloon occlusion TACE.

So microcatheters with a balloon that you blow it up and you can force a lot of things in it and yesterday in an embolization session [UNKNOWN] from Europe showed a nice case where he didn't see a falciform artery and he delivered regulating beads with one of these catheters. And the patient had significant cutaneous toxicity probably because he drove a lot of this in through that process

that it might not have been delivered had he not had the balloon up, so good point. >> Well confounding the decision making in this case was the fact that the patient had tolerated three previous TACEs well albeit conventional TACE and for me in retrospect I probably would have pursued a conventional TACE instead of a drug-eluting bead TACE

in this case. This is a direct portal systemic catheterization of the vessel, and I think the combination of portal venus diversion, small particles maybe an aggressive endpoint precipitated the infarction to avoid it maybe consider less symbolic therapy ablative therapy, a lot of things that were mentioned here.

And we just treated this patient supportively, normalization of enzymes over time and then Bob I'd like to point out the nice chemo lobectomy here. So this patient, good news tumor gone, bad news the left lobe is gone too actually.

But she made it to transplant as far as I remember and this was 30 months post TACE. So I think I've taken up about 20 minutes. I'm gonna let the next speaker Don go. >> Let me ask you a question going back to your first case Ron. >> Sure.

>> That was conventional TACE. The accessory left gastric artery what if you had done drug-eluting beads or Y90 you think you would have gotten away with it? >> I don't know the answer is I don't know I think it's hard to make these sort of judgments with single few case experience,

anecdotal experience I think it's anybody's guess. Sometimes I wonder how much subclinical non-target occurs that we just don't catch and whether we're just sort of underestimating the amount of non-target that we're getting and only a few patients are manifesting. But as that case shows,

we got away with it very fortunately. I don't want it to happen so we do our best to avoid it

So, lets just start with like a basic case such as this. This is a guy with multifocal hypervascular tumors which was diagnostic of hepatocellula carcinoma. You can see Bilovar disease and he's got kind of labs that many

of us see in the mid-range overall chop UA. And so we chose to do chemoembolization. And I'm gonna just go through the basics of how we do chemoembolization. So, this is our initial workup. They usually get evaluated in a multidisplinary liver tumor board or I'd say about 50% of the patients just get a direct referral to IR instead.

So we do an initial outpatient consultation, get cross sectional imaging, labs, tumor markers, stage them. This is an example. I just kind of did a screenshot of our pre-procedural order set.

It constitutes of IV fluids, some steroids and antibiotics. And obviously antibiotics are different depending on your institution and in terms of your existence flora. So if you are getting this started at your own practice it's important to talk to your pharmacists and talk to infectious disease to find out what antibiotics are most appropriate in our specific

setting. Okay, so this is my basic template of how I do a liver angiogram. And I used to do a lot of abdominally aortogram just kinda with a multi-side hole flash catheter. I've gone away from that just because our arterial phase CT, or MRs

I find reasonable enough to where I don't feel I need an abdominal aortogram. So if I have the baseline imaging which has a really bad arterial phase then I might still do an abdominal aortogram but otherwise I'll skip that. And so, I'll typically first go to the SMA,

and I'll talk a little bit about my catheter selection. I tend to do a slow, long run and that's to extend it out into the portal venous phase to look for portal vein thrombosis. Obviously we're also looking for variance such as replace right hepatic artery etc.

And then I put the notation as to what my flow rates are. So my SMA run is a 3 for 30. And I find that this gets good antegrade flow, with minimal amount of reflux into the aorta.

So this is my ciliac run. I typically do a 4 for 15, then again this is a patient with standard branching anatomy. So in terms of catheter selection, I typically get arterial access with a five French sheath. And I know there's a big push to do radial access. We haven't moved

over to radial access much. Have you guys done much move your practice over to radial? We haven't. Anybody in the audience primarily doing radial access. >> A loud No. [CROSSTALK]

>> As all of you know there's a lot of radial access talks here. So I'm not gonna belabor the point about femoral verse radial. But we are traditionalist. I think that the one thing in livers if you are gonna do a lot of CRM CT, if you're gonna do radial you have to figure out a good way to coordinate

that. So that's one challenge. My personal preference is to use a 5 French 65 cm Simmons-1. And this is how I learned in fellowship. But I find that compared to a SOS, the AP diameter on a Simmons-1 is much fatter so it sits on the the back of the aorta.

So the nose sits well in the mesenteric vessels. It doesn't bounce out when you do your angiogram. So there's almost no contrast that refluxes down into the aorta. The key thing is forming a Simmons. There's a Cope suture technique and you can just search this on YouTube if you haven't heard of it or look in a Coffin/g or Balgy's/g

textbook. And I typical just position this at the branch vessel origin instead of just driving it out into the common hepatic, right hepatic, left hepatic etc. In rare cases I will use a 4 French C 2. But my go-to is a Simmons 1 on almost every case, so I just basically

tell the techs open it on the the table as they are prepping. What do you guys typically use? >> Cobra for us. >> Cobra for you? Okay. I use Mickles. Mickles? So a 100 cm? So that means like a 110 cm microcatheter is probably too short.

>> Yeah we use high, about 130s. >> 130s? Okay >> I think, what I mean you trained with me. >> So you brain washed me. >> I like your approach to the case. But I think that many people probably here,

how many people are using SOS Omni for this? Raise your hand. Most people are using reverse curve catheter? Raise your hand. So most are using Cobra's catheter, is that correct then?

>> Don't you think we can discuss that from the CT? If you have a celiac access that goes down then you need a Simmons one which is very convenient. If it goes up or goes straight Cobra is really sufficient. >> I use Simmons for all of them. Despite that.

It sits pretty well. Everybody has their preference, I think that's interesting but I don't know if makes a big difference. I think what makes a big difference is when you have large hypervascular tumors. Maybe be it's people with a lot of ascites and you need better imaging.

Cause then you can get your Cobra catheter out into the hepatic atrial tree and get some more robust runs. I think when you have, in those situations microcatheters often aren't enough. But I think otherwise it's sort of a dealers choice.

>> Right. We use a common hepatic run and using a Cobra so we can get really good pictures of the hepatic arteries. >> So John when you are doing that though, let's you have a guy who's been on Avastin four weeks ago right? And then you shove a Cobra out there. Are you having any cases of a lot of spasm,

dissection anything like that? Because we have seen that and- >> Very rare. That doesn't happen too often with us and the other catheter that we like, actually I like a lot is the RH catheter or Rosch Hepatic. They use a lot of that in Asia.

>> Any other suggestions? Any one else have a better idea? No? Okay. >> But I think one the interesting things as you sort of alluded to it, when you use a shorter catheter, Cobras can be shorter. The Simmons

when you order a special Simmons at 65 you can use shorter micro catheters. Because I think there's an advantage from an imaging stand point, the shorter microcatheters. When you use a 100 cm catheter you use a bare catheter like SOS or Mickleson you have to use longer microcatheters to get out into the liver.

And that's similar with the radial access, you would have longer microcatheters. It is dependent on that. There are equations that govern that principle. But I have seen when go to longer microcatheters, I don't often times don't get as good as imaging which is important in some of

these air piece we do. So I'd like to you a shorter base catheter when possible. >> I think like if we've done comparisons within patients comparing like Prowler 110 verses a Prowler 150 and there is a, even though the PSI ratings are the same.

There's a remarkable difference in terms of the flow dynamics, in terms of the image quality of a 110 compared to 150. So that's become our preference, at least to use 65 cm which is nice and short and will fit with several inches outside

the sheath. In this case we did celiac. Let's see if this plays. Oh, it's playing up there. Okay. So if you recall we had bilobar tumors. And so this is a Progreat 2.8 French selective catherization of the left.

And you can see kind of infiltrative tumor on the left. And then we switched over to the right. So my initial plan was to treat the right side, and he has multifocal tumor on the right.

So in this case I elected to actually treat the left first just because he had infiltrative tumor. So I went back to the left and did a TACE there and then brought him back for a TACE on the right side. I won't discuss the details of how we do chemoembolization. There's

plenty of other workshops for that. But just real briefly in terms of this- >> Do you wanna talk a little bit about, you mentioned a microcatheter, one or two- >> Yeah >> You've mentioned a Prowler and-

>> And I'm gonna go over that. I'll bring that up, yeah. Okay, so this is our real brief screenshot about post-procedure order set. Again standard nursing stuff like vital signs post-op check etc diet.

And then again we have a standard antibiotics that we use in our hospital and then we kind of have this mishmash of different types of pain meds, steroids and antinausea stuff. So we just kind of have this blank very standardized order steps for basically every patient. Bob mentioned in terms of microcatheters selection. I think their

is a large debate about this. And this is what we stock. I look at it as three categories, like large small and super small. The large one's we use probably for 90% of our work, these are the 2.8 French distal outer diameters.

We mostly stop the Progreat mostly because we have good contracting on with Terumo. Again as disclosure I don't have any relationship with any of these companies. This are great for diagnostic angiograms and lobar treatments. I personally don't like them for really selective super selective

sub-segmental treatments. Any case with glue or onyx, I find that the dead space in a Renegade Hi-Flo or Progreat is really high. So putting onyx of NBCA through these catheters can be a little challenging. And then moving down to the small microcatheters, this is probably

our other 15% of cases, the 2.3 French distal outer diameter. My personal preference is the Prowler plus. These are great for coil embolization because your ID is around 0.021 so it fits an 018 coil really well. Great for sentimental infusions but the diagnostic angiograms are

obviously not as good because your PSI is limited. The super small once we use I would say rarely. This are for like ultra segmental sub-segmental infusions. So I'll use this in probably about maybe 2 or 3% of cases at most. They are great for really small vessels.

Any case with glue or onyx they work wonderfully. If you are gonna do particles, we use this, I use a curve tip Excelsior SL10 for our prostrate artery embolizations. And so if we inject 1 to 300 micron embosphers we just have to dilute it like crazy. And it will still go, you just have to have it diluted.

The diagnostic component of these catheters are terrible so your diagnostic angiography is almost, is borderline useless. So that's one thing to keep in mind. I just listed the more well-selling brands. There's obviously a ton of different manufacturers which you can see down at the exhibit booths. Any preferences for you guys?

>>We do. We have the same practice. We start with 2.8 and when needed we switch to angulated or smaller diameter if needed, for the right gastric for instance. >> John?

>>I'd start with a good 5 French runs and then once I need to get selective I use 2.3 French Prowler plus and a Fathom wire. And for me, in my hands, I can get into any artery with that combination. [CROSSTALK]. >>You kind of skip the Progreat/Renegade Hi-Flo and then

just go from base catheter- >> Go base to - >> Small. >> I skip the whole large microcatheters. >> Just to be a little bit of a devil's advocate. Again, I don't have a horse in the race here and there are a lot of microcatheters.

Probably people in the room are using microcatheters that aren't listed here. But the Prowler plus, again it goes back to we all have our own contracts but that's about twice as expensive as these other catheters listed. >>I only open one catheter instead of two.

>> I couldn't tell you the last time I opened two. But in the imaging it's not very good. You said okay diagnostic angiography. But I think that it's actually relatively poor diagnostic angiography with the Prowler plus. I get it, you're doing your big runs is with your different practice.

You're putting in your 4 or 5 French catheter out into the common or proper hepatic. But it's just something to take into consideration. It depends on how distal and selective you're going to be. But some of these other microcatheters will tract just as well as a Prowler.

>> Is it through your post-op procedure,orders, post-procedure orders, do you admit your patients anymore or do you admit some or none-? >> You mean for chemoembolization? >> Yeah. >> We admit probably 25% right now. Again it's a practice variation.

I think that all of that is probably local and depending on your patient population. Honestly I admit that the guys who want that free dinner, the crappy hospital food. So most of them we're doing as out patients.

Any other, I mean does anyone have any other thoughts on microcatheter selection, how they do it so that we can all benefit from that? Cause I think there's a lot of debate here and there's obviously no right answer. >> Does anyone use the nitinal hypotube high pressure microcatheters that you can put 1200 PSI through an 021?

>>So that's the direction [CROSSTALK]. >>Correct. >> Some people see it as a nice hybrid between the two, they can do better imaging and then if they have coil work to do, they can

engage their coils with less chance for buckling etc. And get into smaller vessels. Just something to consider. >> I think the bottom line is no matter what liver therapy you're doing or if you're trying to embolize something in the liver otherwise is to get good imaging.

And there different ways to do it. There's a trade off between being able to get good imaging, and it tracking in different things so there's a wide variety. One thing you didn't bring up is microwires

I don't know- [CROSSTALK] >> That's right. No, no I didn't bring that up but it's something we can talk about. But real quick are people doing routine coil embolization through the high-flow catheters, through 2.8 French? >> Yeah.

>> Yeah? Any issues are you guys getting? Because the ID is big right. So it's like an 027 so you have a lot of dead space. Any time I know I'm gonna coil a GDA I tend to go down, I down size. >> It depends which coil you use actually.

If you use Concerto for instance it will be trapped within the lumen. So it's not ideal for this kind of microcath, but if you go for the other companies, the Cook coils it works well, so no issues

with that. >> Well it depends if your putting a detachable coil versus a, and if you're going to push it in, if you're going to puff to get it in. >> And I guess that was more referring to let's say a pushable

fibered 018. Right, so where you're basically pushing it out with a 018 wire pusher. At least we've had issues with, you get that coil wire overlap,

so that's why we've routinely kind of gone to the 2.3 French if we're gonna do a lot of pushable coil work. So any other thoughts from anyone on how they do it? >> Okay, Bob you mentioned something about wires. You have a wire preference? >> Well, I typically, I'm really partial to the double angle Glide GT wire,

a Terumo wire. I like it. It's a short angle on it but it selects a lot of branches I don't use it if patient has been on chemotherapy and I'm worried about it will get stuck on one little branches, and you can cause some vasospasm etc.

If I need to shaper wire, currently I'm using the Fathom which is Bosche Scientific. It's usually my shapeable wire of choice. And again when I'm worried about vessels I'm worried about, it's something really straight, a falciform for instance, I wanna get there far out there. I'll use a Headliner 90 wire.

>> And were similar, we use I think Fathom for half the work and then we'll use an 014 Synchro for matching it up with the smaller microcatheters. Those are very shapeable. And very soft and atraumatic, so kind of a similar concept. John any,

>> I usually start with a Fathom and it's the opposite, I use the double angle GT once I've trouble selecting. >> Anything else? >> We use Progreat so there's a guide wire inside. So we solve most of the problems and when we have issues I use the same Terumo double angulation,

mainly for right gastric. Because it's really well angulated and you can't go backwards. >> Okay. >>If people are not familiar with these catheters, I think they

exhibit hall is open. A lot of these companies have all of these wires and these catheters. It be be good to just go through it and look at them. >> Anyone have suggestions on good wire-catheter combinations that we can all use?

>> What size Fathom do you use? Do you use the 016 or 014? >> Our preference is to use an 016 with the large microcatheters, I think there's a little better fit. The 014 with a 2.8 French has a bigger mismatch. So even when you're able to get out there there's sometimes a little

more hesitancy in pushing your microcatheter over it. Believe it or not the 016 is just a little smoother. I use a Fathom 016 and then if I'm gonna use the Prowler or an Excelsior we'll go with an 014 Syncro >> Another cheap wire I use is a Runthrough.

That's like $80. 014 wire, it's shapeable. >> Is it transcend? >> Yeah. >> Guide wire, very cheap as well. >> Still doesn't make up for

your Prowler plus but okay, >> To drive a Mercedes or an Audi. >> And I work at a state institution so I couldn't care less how much that cost, so we just run up the bill on everybody.

>> Yeah, exactly. So this is a case where you can see a small tumor near

the adrenal gland. This was intrahepatic. And this was a standard celiac anatomy. And hopefully this works. This was with a Prowler Plus and I could not get, I could get wired into this vessel, but could not get catheter in. It just would not

feed. And then I started getting little vasospasm as I kept on trying. So what one of the rare cases where I'll put in an Echelon 10 and we were able to get in. And the 1.7 French catheters can basically get into almost anything. The downside is that your diagnostic angiograms are almost

useless. That's one thing to keep in mind. And then we just did an LCB on that. >> Let me ask do you do a cone beam in that? >> Yes we did. >> Then what did you say? 1 to 300? How much did you get in?

>> That one, very little. Clearly less than a vial. Probaly less than 0.5 vials of the total amount. Because it was a small tumor, small vessel. All right why don't we switch over now. In the interest of time. Is that good?

>> Okay. Sounds good. [SOUND] >> [INAUDIBLE] >> Yeah absolutely. So a couple of things >> Repeat the question.

>> Yeah so in terms of doing C-arm CT, keep in mind the C-arm CT is variable depending on whatever hospital, whatever hospital whatever equipment you have. And even with the same equipment, for example we have Philips. The Philips setting in our rooms are different than the Philips

settings in a different hospital. So we just kind of had Philips the manufacture tweek it to us. I can get, for obvious reason you can get better C-arm CT images with bigger catheters. So we adjust it. Mostly we adjust the delay rate and we adjust the

PSI in our power injector to accommodate that. So there's a little bit of a learning curve in terms of the smaller microcatheters clearly get probably poor quality C-arm CTs compared to a larger microcatheter or the base catheter. >> Do you use full strength or half strength? >> So we use for C-arm CT or for?

>> For C-arm CT. >> So if we have a C-arm CT with a Progreat we use two thirds. >> Two thirds. >> Yeah. But keep in mind people in Washington work out so everyone's thin. So I did residency in Ohio where like two thirds are not gonna cut it.

People need like a lot more contrast. So again it has to do with your practice preference, and we have very odd power injectors which don't really do well with a 100% contrast. >> We're gonna talk more about cone beam CT a little later as well,

but we'll spend some time talking about it. So we'll have a chance to talk about it cause actually I don't know if I agree with the statements because if you give the right injection for the right volume and time it appropriately you're staining the tissue. I think you can get pretty good diagnostic imaging to at least know if you're perfusing the tumor or not. But we'll see what Bob says. He's gonna talk about that.

So here in your angiography, you're missing the top part of the tumor and along the diaphragm. So you're thinking right inferior phrenic,

in this case will embolize with 500 to 700 embosphere particles and then redistribute that back to the liver. So you see immediate consolidation back to the hepatic arteries as indicated by your cone beam CT, angiography, tech MAA and then

afterwards when you deliver the Y90, or the chemoembolization you will get treatment response in that area that matches the rest

perfusion and you think bottom of the liver

tip, that's omentum. So that comes off the GDA and you'll embolize that with 500 to 700 embospheres, and then you get reperfusion, redistribution back to the liver. So you can deliver Y90 because no one is gonna

deliver Y90 through your GDA omental, that's a little painful. So parasitized vessels, I think the most common and ones we think to about are for us, the right inferior phrenic, intercostals,

I think those are the ones that occur most frequently and just remember use particles. Plus or minus coils if you wanna use them. Also, pay attention to the variants, there's a great discussion about how blood supply can come up from the SMA,

can come up from the gastrics or the other locations. And if you missed these areas then, you're not treating all the tumors, you're not treating all the bad guys. Because the blood supply is coming from somewhere else other than

the liver. And in these cases you coil, don't use particles cuz you're just trying to block it off, so that it's recruiting back from the liver.

a day to day basis. So here's a nice, normal,

very typical example of a small HCC in the left hepatic lobe, and the first thing we all kind of encounter is what modality do we use. What is the most appropriate modality? How many RF users do we still have in here today?

So we've got a couple. What about microwave? More. What about cryo in the liver? I think saw a couple. Okay.

So, the answer, in my opinion, is number one, you should always use what you're most familiar with because your best results are gonna be with the equipment that you are comfortable with. That being said I really think that you ought to consider working towards identifying the best equipment and that's really a big

challenge. Because not only do we have numerous modalities any ethanol users by the way, any old school people? Every now and, yeah, so you have ethanol, so chemical ablation, you have heat and you have cold and amongst those, not only do you have the different modalities, the microwave, RF,

laser, etc. But you also have all the different companies and every company's system is a little bit different and you have to be very familiar with the system that you're gonna choose to use. And so I'm not gonna talk about any specific systems but I really encourage you when you do choose a system that you make sure that you

are comfortable with that system, and how it works and make sure you understand the physics behind how it works because that's very important. So I literally have two hour lectures based truly on what modalities to use.

There's not a straight forward answer. There is a paper we wrote in RadioGraphics, you can see there in October 2014 that goes over specifically all of the kind of underlying issues behind each modality, and where the advantages and disadvantages lie. And I encourage you to read that article or others if you have questions, but the bottom line is as Darren indicated

is that the microwave really is rapidly replacing RF and there's really good reasons for that microwave has a lot of advantages on the physics side compared to RF. There's a lot of limitations to what you can accomplish in RF primarily because most of the heating is conductive heating which is a very inefficient mechanism of heating,

and so that limits the damage that you can do. With the microwave systems in the current day you really can do anything you can do with RF, if you want to run them at temperatures and powers that give you RF-like results you can do that.

But you can do a lot more as well and that's the biggest advantage of microwave and usually here I show a picture of a Yugo and Ferrari, and RF is the Yugo and yeah, it will get you there, but you can do a lot more with the Ferrari.

Doctor Claus/g kind of went over cryo a little bit,, and I will kind of reiterate what he said, which is, you have to be really careful with cryo, especially in a sclerotic patient.

We've down over a thousand liver ablations in our practice, and we've had only one patient fatality that was procedure related. And that was a PE. But if you look at cryo series out in the literature, you'll actually

find some significant death rates, procedural death rates associated with cryo shock particularly in sclerotic patients. So if you're gonna do that, you have to be really careful about it and you have to really think twice.

Because the reality is that heat is definitively in my opinion and in the literature's opinion a safer option. So I don't see a good argument for using cryo. And then don't forget about ethanol, even though it's kind of fallen out of favor and it's not as sexy as the heat based ablation modalities.

It's certainly has times when it can be very useful. So, I think in that case, I would use microwave. You would probably use whatever you use, but I think microwave is pretty straight forward.

So let's talk about targeting and Dr. Klaus/g also kind of touched on this, which is how you target this. How many of you use CT as their primary targeting modality? How many use ultrasound?

That's very encouraging. Maybe I wouldn't have to argue as hard as I thought I might have to to convince you to use ultrasound. And the reason is right here. We all have kind of realized, at least in the liver non-contrast

CT is a very challenging modality to utilize for guidance. Sometimes almost impossible. You're essentially going off landmarks, you often don't have any real true indication of where that tumor is. So here we are in the non-contrast CT in the center pale, you could

hallucinate something, you could go based upon landmarks but you realistically can not see that tumor. So you either do something fancy like give a little contrast to give you an idea of where it is, and then do other things to try and make sure you're in the right

place. Create a bigger ablation zone than you have to in order to make sure that you cover it etc, etc. But the reality is these are almost always very visible on ultrasound.

So here's a nice example. This tumor is extremely exquisitely visible on ultrasound, very easy to identify and to target. So here we are during the ablation. So now we've got our ablation antenna place.

You can see we put in a single microwave antenna, 65 watts, 5 minutes, and here's the post ablation. So how well does that gas cloud correlate with the zone of ablation? That's a good question, right? And there is a fair amount of data on RF looking specifically

at that issue and it turned out okay but not great correlation. Turns out that the correlation with microwave is probably quite a bit better. We just finished a postery that's gonna get published pretty soon, that shows that your ablation zone is probably two or three millimeters larger than the gas cloud.

So you can safely assume that if your target is within the cloud of gas, that it's completely ablated. And then you kind of assess your margin based upon that. So, let's see moving on here. So here's our preempt post, and this is another thing I'll talk

a little bit about as we go through this, but we do an immediate post-ablation assessment while the patient's still on the cable. I know that there's some people that don't do that. How many people here do that? Either with ultrasound or with CT so it looks like about a third of you.

I really encourage you to consider that, you know some people will say well just bring him back but the reality is that's a whole another procedure, a whole another anesthesia whole other utilization of resources that probably wouldn't have been necessary if you had just accessed it at the moment and realize that you hadn't gotten a complete ablation. And so we do this and about 10% of the

time we go back and retreat mainly not because we didn't see residual tumor but we realize our margins are not quite where we want them to be. So you really should strongly consider that, I think it really helps. We actually studied guidance and we had twice the rate of

LTP when we use CT for guidance as compared to ultrasound. So once again ultrasound, if you are comfortable with it there's a great way to do it. So how big is the antenna? Does the ablation need to be in?

Dr. Klaus once again kinda touched on this briefly, but really this is getting at ablation zone margins, right? And margins are probably the best predictor of how well we're gonna

do. So you really need to think long and hard about your margins and how big they are, and the common teaching is half a centimeter for HCC and full centimeter for mets. So if I have a three centimeter tumor I really have to get, in the

case of [INAUDIBLE] a five centimeter ablation, that is a big ablation right? I mean that is really pretty significant and so if I kind of go through this, here is your adequate ablation zone of five centimeter with a nice big margin. Of course that way, it seems they are perfectly centered.

But the reality is that none of us are as perfect as we think we are. And we often a little off the center and then you end up even with a five centimeter ablation with a relatively narrow ablation margin. And the reality is we often get smaller ablations zones than we think we are going to as well.

And so add that in and then you get into the situation we actually have residual tumor. So you really have to be thoughtful in your planning about how you're gonna do these procedures, and how big your margins are gonna be and how big your ablations zone needs to be.

And then also remember that as Dr. Klaus/g mentioned as well, that your ablation zone is not spherical. It doesn't matter what system you use, there is no such thing as a spherical ablation zone no matter what some of the propaganda

out there says. So you really are actually having an oval [INAUDIBLE] ablation zone in some way shape or form. And remember that your adequate ablation margin is actually your shortest access dimension and so in order for this to adequate it has to be five centimeters in the short access dimension which means it's inevitably gonna

be larger in the long access division. And so once again this gives you wiggle room so that if you're not perfect, you can actually get it where often times we end up with situations like this. So realistically a lot of our LTPs actually result from poor planing where we just don't adequately plan for a large enough ablation zone.

So keep that in mind if you do this. I tell my residents and fellows all the time, one of the worst complications and in fact in [UNKNOWN] disease is pretty much guaranteed to be fatal is to leave tumor behind. This is, one chance at a cure a lot of times and if we don't get

an adequate ablation zone we take that away from them. So taking that into account, here we are a three centimeter tumor, how big of ablation zone do we need for an HTC ? We need a four centimeter minimum ablation zone. So then we have to think about how we're gonna do that, and how you're

gonna accomplish that depends upon the equipment that you use. I use the convenient system, well value lab convenient/g electronic system with RF for many years and a four centimeter ablation would be a challenge. You'd have to probably use three electrodes to get a short access dimension for a similar ablation and burn for at least 12 to 16

minutes. So that's a pretty big undertaking or if you just look at this you might think this would be easier I could do this with one or two electrodes, but the reality is this is really not true.

So in this case we need a four centimeter ablation so if we move through here we are. You can also see if there is complication of left hepatic vein is really close by. So Dr. Klaus also kind of briefly mentioned heat sinks and that's a

definition issue. You have to think about that particularly with RF but also with microwave and cryo. And take those into consideration. And so you are gonna put a little bit more power into this ablation than you might have otherwise.

So here we are, we decided to use two antennas, so we got one antenna along the medium margin, one antenna along the diateral margin/g. Here is our post ablation assessment monitoring with ultrasound. You can see that gas cloud is completely enveloped that tumor and so that looks like a good outcome.

Here is our immediate post ablation assessment and you can see that looks great. It looks like there's a nice ablation zone it's a little over 4 centimeters in both dimensions. One think I will mention, is with multi applicator microwave ablations, I have found that you can get

pretty close to spherical ablation actually although not perfectly spherical, but so nice result and adequate and we already talked about the immediate assessment. So here is just an example, I'm just gonna run this movie. And this shows you one reason that we think the multiple applicators are so helpful.

The reality is that when you use a single applicator there is two issues that happen. So number one, your heat tends to be kind of misplaced in a way. All this circles aren't in the right spot. But the heat tends to be misplaced in a way because it's really in the center of the tumor whereas the biologically active part of the

tumor tends to around the periphery. In the case of a double or multi-applicator ablation, you tend to distribute that heat more at the periphery of the tumor so not only do you get bigger margins which are also applying the heat, in the more biologically active portion of the tumor, both of which

are critical to excellent results and so that's one of the big advantages of having multiple applicators over a single applicator no matter how big the single applicator ablation may be. So here's another case, this is a 57 year old female metastatic breast cancer to the liver and bones, she already had multiple interventions

over the years, surgeries and etc. But now she had this rapidly growing tumor right next to the IVC here. So is this safe? How many of you guys would try to give this a try? A safe ablation not too many are too excited about it.

[LAUGH] What about the heat sink, of the IVC, is that a problem? Are you worried about injuring the IVC is another thing to ask yourself, right. so those are definitely considerations.

I will start with the IVC injury, you can place an ablation antenna directly on to the IVC and ablate to your heart's content and you will never thrombose the IVC, it's just not possible. We've tried it in animals and it just doesn't happen.

Don't worry about injuring the IVC from that standpoint, you certainly don't wanna puncture it but I wouldn't worry about thrombosing it. As for the heat sink considerations, that's significant and you

really have to make sure you have a modality that's gonna give you an adequate ablation, in this case I need over a 5cm ablation So five and a half centimeters or right up against the CIVC so there is defiantly a challenge. Here is the intra-operative images. By the way the patient was my mum's best friend so the pressure

was on. But so here is the intra operative images and you can see that I have one of these antennas directly on the IVC essentially in attempt to overcome that heat sink effect. And in addition, I have placed three of these antennas which is a lot of power.

In here you can see afterwards is a 5.6 by 4.8 cm ablation, it's big enough. I wish it had been a little bit bigger and I wish their wasn't this one little dog near here, but I felt like it was adequate. Here she is, she is now four years out and everything looks great so, fortunately it

went really really well. So that brings me to the heat sink. Microwave really does overcome heat sink. This is where the chip downed in with a per fuse liver model. And you can see on the right side of this table here, the top is

microwave. And you can see even within very high perfusion rates, there is really no change in the size of the ablation zone. Whereas with RF it drops off over a different perfusion rate and

that just because RF's conducted heating gets overwhelmed by the perfusion of the tissues. So Microwave can be very advantageous here. What about the risk of thrombosis? Well this is the state that we did in our lab where we looked specifically at can we thrombose vessels?

And this are the hepatic arteries. You can see the hepatic arteries essentially do not thrombose, no matter how hard you try. Bigger vessels did not thrombose no matter how hard we try. What you can see is actually the portal vein was the most vulnerable structure, and you do have to be a little bit careful with the portal

vein and worrying about thrombosis. In our experience we've had a couple of these that happened and fortunately they often respond to inter-coagulation, and open back up. But obviously whether that's sclerotic, it can be an issue.

So you gotta be a little bit ablating close to large central portal veins. Here is another one. This is an interesting case, they have a large hepatic hemangioma. It's progressed in size and it's giving him back pain.

A young man and he's kind of a little bit desperate at these point actually, so we were asked to take a look at him. So here is the tumor about 14 by 12 by 10 cm or so. We think this is a good case for ablation, how many would take this case on? Hands up , I see my colleague and maybe one or two others.

So the short answer is, I actually think that these kinda cases are probably the best cases we can have for ablation, benign tumors are an excellent target, both from the stent point,

it's an excellent option for the patient, and number two is an excellent growth opportunity for what we do. So, it is a completely untapped territory as far as I can tell. This is the procedure I did, I kinda split the tumor into two separate

portions, one is a superior margin and one is an inferior margin. And I took it and I did three burns in each location, placing the deep margin burns, pulled back burns, pull back burn and then pull them out.

In the end, let's see here, here's what it looked like, so you can tell by looking at it there's probably some enhancement around the periphery. So I probably didn't get a complete ablation, probably 90% of the

volume of the tumor, but that's more than adequate actually in this case. And the reason is this, if you look at this, this is a movie showing you tissue contraction especially with microwave,

tissue contraption is very dramatic, so if you watch this you can actually see the tissues getting pulled in, those green markers mark where those markers were at the start of the tumor during ablation, and you can see them getting sucked towards the center.

Almost all the contraction occurs in the short access which is one reason that our short access of ablation zone is shorter than the long access but, you can see, very significant tissue contraction. And the end result of that in this case, is you can see there is

my pre-ablation volume, and here is my post, and my arrow is not showing up. There it is, maybe. You can see,

so it's about half of the volume, immediately after the procedure and now I've had the patient gotten immediate pain relief, because he was getting pain from mass effect not from the tumor itself, other than the mass effect.

So this is a very important thing when it comes treating benign tumors. Remember, our goals of treatment are very different. We're trying to devascularize a tumor in the case of adenoma in particular, to decrease the risk of hemorrhage, we're trying to

decrease mass effect in this kind of malignant transformation risks associated with adenomas, but remember you don't have to get every single cell. So even if it's a big tumor like that it's not my goal to kill the entire tumor with a margin it's my goal to improve the patient's

symptoms, and quality of life. And they also seem to ablate easier than malignant tumors probably somewhat because the perfusion may be a little bit less. And so we can even target very large tumors. That's when the larger ones we've done, but we've done many tumors in similar size. So this really as a less invasive answer to a minor problem,

if you are a young person would you want a major liver surgery or would you want just a simple ablation? Hepatic adenomas are very easy to do too, here's a four and a half centimeter hepatic adenoma. You can see we kinda have nice ablation zoen.

These patients go back to work within days, versus the surgery where it tends to be long recovery. Here's kinda the cautionary tale. A young medical student, he wanted to be a surgeon and I think as

a result, he was kind of taking down the pathway of getting a hemihepatectomy. We wanted to do an embolization followed by ablation. And here is what happened to him. He actually needed a re-exploration for high grade bowel obstruction, and we all know that he's kind of headed fast in trouble to the

rest of his life probably related to adhesions and adhesive disease and bowel obstruction. So realistically, we could have done in a merry minimally invasive way and instead, he's got a major surgery. Works for hepatic cyst too. We place the antennas and we drain the cyst around the antennas

and then we do a relatively short burst of ablation, and we can get excellent result. Here is the cyst before and the cyst after. Six months later, you can see is about 10% of the volume of the cyst left.

The patient was completely asymptomatic. Here is another case. Seems relatively straight forward. A little over 2 centimeter ablation HCC and you can see the one thing that you might think about, here is the pancreas right behind it.

Here is the stomach right over here. So we thought, okay, we'll put our antennas in and we'll see what we see. So here's our placement of our antenna. You can see it's relatively essentially positioned and that HCC

everything looks good. Here's our CT scan after placement before ablation. There's a couple of issues to get here. One is even though we used ultrasound for guidance we definitely utilize CT for the big picture. Some of it's a resource allocation issue,

but we're able to utilize CT and ultrasound for our procedures and if you can do that, it's a very strong powerful combination. So in this case, this was good because we saw not only are we close to the pancreas we don't wanna burn that,

but we're also very close to the stomach and we definitely don't wanna burn that. So what do we do at this point, we've already got the antenna in place. What would you guys do?

Anybody? >> [INAUDIBLE] >> [INAUDIBLE] And if you're gonna do ablation in this day and age you really need to be comfortable with the theories and the performance fighter deception. It's critical. In this case I just put a spinal needle through the left lobe,

inject a bunch of fluid into the kind of retrohepatic space here between the pancreas and the stomach and the tumor. And it gave me great separation, allowed me to do the procedure. Here's the intra-procedural monitoring see some of the saline here

kind of the hydrated section fluid/g. And here's afterwards, and you can see if I would have done the ablation without the hydrated section it would have gone like this. And that would have definitely incorporated both the pancreas and the stomach.

So definitely you have to be able to do [UNKNOWN] and be comfortable with it's performance. I recommend doping your saline or if in the case of RF make sure you use D5 because that allows you to differentiate it from soft tissue. If you just inject saline,

you expect it to be low attenuation that you can differentiate it from the liver and adjacent structures, but for whatever reason it does not turn out that way. So Dr. Klaus also mentioned exophytic tumors. How many of you guys do exophytic tumors in your practice?

See only a couple of you. Yeah so I actually encourage you to take this on, they're actually not nearly as challenging as you may think they are and the reason is because there are techniques that you can utilize, where you don't

necessarily have to puncture directly into the tumor. Everybody is a little bit scared to puncture directly into the tumor for risk of bleeding and tumor seeding. So how do you approach this? Well actually we use the no touch or wedge technique fairly frequently

and what you do is you put your antenna as you have to have multi antenna system or multi applicator system to do this. But if you can put your antennas around the tumor like this without directly puncturing and here's the tumor, here's the antenna, here's the other antenna,

we haven't actually touched the tumor and so you have to, in that case you are being allowed that risk and yet you can get a good ablation. So here's a movie, a wedge ablation and what you'll see is the green is kind of complete ablation and even though we're not actually touching

the tumor in the center here. Let's say there's a tumor right here, you can see that the ablation zone's actually grow together in the center there because of the way that the synergy of the two antennas work. And so the way I do this is I do an ablation like this and then

I remove one of the antennas and replace it into the center of the tumor after it's already been devascularized and mostly killed and that works really, really well. There we are afterwards. Then here's this ablation and now I can see we're starting to

ablate deep into the tumor but over time it goes to grow up to incorporate the tumor. And here's the post-ablation assessment and it looks quite good. You're gonna get a little bit of a bigger ablation zone than you would normally, but it's usually adequate. So here's another tough one, right. So and Dr. Klaus

showed a case almost exactly like this. You can see this HCC just right on top of the hepatic duct here, so this is one of the, I think it was the right hepatic duct, and so what do you do in that case? How can you manage that? What would you guys do, anybody?

>> [INAUDIBLE] >> Okay, so you can do biliary perfusion, essentially some people do that. There's the LA group I know does that quite a bit. Any other ideas? [BLANK_AUDIO]

How many of you would do intra arterial therapies for this? Maybe. Yeah, so intra-arterial therapies are definitely a consideration, you might think about a TACE or something like that in this case though I actually think that this is one of the places where ethanol

plays a role. You really are probably gonna make the patient worse off if you ablate their duct than they were to start with. So you really wanna you really wanna avoid that in any way shape or form, and I don't

think with either cryo or microwave you can safely say you can ablate this completely without possibly doing damage to the duct, but with ethanol, actually you can get a very nice treatment and you can ablate this tumor with minimal risk of damage to the the adjacent duct, interestingly when you use ethanol,

I don't know if you haven't used it, it actually kinda looks like a heat based ablation and causes this gas cloud and you can follow that quite well in ultrasound. Often we should almost already expect a come back and have to do

a re-treatment or two with ethanol. You almost never get it all in the first go around for whatever reason, it's just the way ethanol works and if you look at the historical kind of literature you'll see that most of them, if you look at the treatments, most of them take two to three sessions and you

should expect that to be the case. They're are inferior to heat based ablation as far as overall outcomes but they're still quite good. You can have local tumor progression rates in the 20% range which is actually pretty, it's not too bad considering a lot of time you're trying to bridge these patients to transplant.

>> Can you do intra arterial therapy followed by ethanol [INAUDIBLE] >> Sure, you can. If you're gonna do intra arterial therapy my approach would probably be to do the intra arterial therapy follow the patient and if in fact it shows evidence of local tumor progression, which they often

do over time, then at that point I would go back with the ethanol. But there's nothing to stop you from combination treatment and that's actually what this case is about so good segway. So in this case we have a patient with two HCCs. Here's one. It's a little under four centimeters right next to the gall bladder.

The gall bladder's kinda out of plane here but it's right underneath this tumor. So that brings the question of is it safe to ablate next to the gall bladder? And here's the other one. This one's a little bit higher.

You can see it's relatively indistinct. I can see there's a tumor there but but you can see the margin are distinct. Those measure out 3.6 centimeter but we weren't really sure how big it is. And so that brings up this concept of combination therapy. And I think combination therapy is not gonna be critical to our

success in the kinda intermediate sized tumors. With our microwave program we've actually shown that we can get complete ablation and tumors up to four centimeters so we kinda broken that magical three centimeter barrier and taken it to four centimeter but still you're going to have tumors like this that are kinda border line indistinct and are over four centimeters or what

do you do with them? Well we do believe in combination therapy and we do this frequently. So here's a nice example, nice TACE, you can see good up take in both these tumors, everything looks pretty good. We came back three weeks later and microwave ablated the one in the more superior tumor there

and you can see what looks like a nice response with good coverage, everybody was pretty happy. We decided to leave the one next to the gall bladder alone because we were a little bit worried about proximity to one of the bile ducts and such, but here's what it looks like

that one that we did the combination therapy. Everything looks good, you can see the [UNKNOWN] in the tumor itself and then you can see the margin of the ablation around the edge. So you can actually see the result quite well and that did great.

Unfortunately as often it happens with TACE alone as you know, the other one progressed over time, so here's that cuff of enhancing growing soft tissue around the rim of [UNKNOWN] that happened over the course next here and actually on this one you can really see how close

it is to the gall bladder. And so we reconsidered what we thought about the combination therapy, we decided we better go ahead and ablate this, so we put two PRs in this, the gall bladder and common duct were quite close, here is our ablation and here is our results. So here

is our ablation zone. After the gas starts to resolve you can actually see it a little bit better sometimes, so there is the ablation zone touching the gall bladder, the gall bladder wall itself got a little thicken, this patient had

some mild abdominal pain, but they never had any adverse outcome. [UNKNOWN] is published on that, there's been some other publications. It's actually very, very safe to ablate next to the gall bladder. >> [INAUDIBLE]

>> That's a perfect question with no good answer. The short answer is you could actually make arguments in both directions that you should actually do the ablation first followed by the intra-arterial therapies and vice versa. So the argument for doing the ablation first followed by the intra-arterial therapy is that you get that hyperemic rim around the margin of an

ablation zone. Which actually might in theory make your TACE more effective, better uptake, etc. We've taken the opposite tact which is we know that TACE is often not a complete treatment whereas we feel like ablation can be a

curative therapy. So we do it the way we think it will make the ablation more effective. So if you devascularize a tumor with TACE before hand you make your ablation more effective and therefore more likely to get a complete treatment. We usually separate them by a week,

in this case there is some logistical reason that we couldn't do it for three weeks, but the reality is any time within a month is probably adequate. All right so here's the gall bladder wall once again thickened, we've

done lots of these procedures, and we've never had anybody who's had a serious complication related to gall bladder. And I have a colleague who calls it the cockroach of the abdomen and I think that's a pretty accurate assessment, it really is pretty

hard to just hurt the gall bladder. So here's before and here's after and now this patient is several years out, everything looks good, no evidence of disease, so a good outcome. So here's our approach to combo therapy and you have to kinda take whatever approach you feel most comfortable with,

but this is what we do and we've actually incorporated this, not into only in our practice, but into the practice of our institution. So when we talk about these patients at Liver Tumor Board this is the approach that we always take.

If you're less than 3 cms we feel very, very comfortable and we can always, or nearly always, we have about a 7% local tumor progression rate but those are usually easily retreated, treat these with ablation alone.

If they're between 3 to 4 centimeters and they have have some worry, some characteristic. Infiltrated margins, location, things that makes it more challenging to ablate, things like that,

then we will consider doing a combination therapy. Anything over 4 centimeters and less than seven will almost always get a combination therapy but over 7 centimeters ablation kind of falls off the map. That's been our approach and we've had very good results with this and so I can say you guys have to do what you're comfortable with

but definitely a consideration. So this case is used to illustrate some problem that we all have. So here's HCC in the right hepatic lobe. It's actually a cyst next to it which is a really good landmark. This is a 53 year old male and we got in and we do this ablation.

You can see we kinda undercut the tumor in this case. Rather than doing the wedge we actually kind of undercut it from one side but it works just as well, and here we are at the end of the ablation everything looks good. You'll see by the way that there's a very consistent theme in how I do my ablation, you'll see five minutes at 65 watts for almost every

patient. And there's a lot of reasons for that but probably the most important one is I'm kind of a simple guy and if I start messing around with a whole bunch of different settings and change in the way I do things then I find it difficult for me to predict what I'm gonna get. I just think the simple you keep it the more consistent you make

it the more likely you are to get consistent reproduce-able results. So we mess around a lot in the lab in the pigs, working on their livers and kidneys but when I'm working on a patient I wanna make sure I have a predictable consistent result that's gonna give them a great outcome. And so five minutes, 65 watts I use pretty routinely. The only alteration

I'll make to that, is number one, if I'm getting too big of an ablation I'm gonna injure something, I'll turn down the power or number two if I'm not quite covering as much as I want I'll continue the ablation for more time and that gives me a little bit larger ablation zone.

But once again it depends upon your equipment that you use. So here we are afterwards everything looks good on the ultrasound, and the question comes up do we have a complete ablation. I told you earlier that we should do immediate assessments and determine if we've got a complete ablation. So how do we know if we've got a complete ablation?

Well we usually do something like measure from a landmark and try to figure out if the tumor is centered there, things like that, how big our ablation zone is etc. This looks really good but are we sure that that's ablated and that's always a challenge for each and everyone of us as we go through these cases.

I wish it was simple and straightforward but it's often not. The good news is, is there's things coming to help and it's technology driven and every manufacturer pretty much has something like this in the works, this is one of the systems that I'm familiar with and as you can see what they allow you to do,

I don't know if you can tell, there's a little red circle in the center of that and that's the tumor pre-ablation and then the green is the overlaid ablation. And they do a registration technique to make sure that those line up and they make sure you've got a complete ablation.

So there's a lot of software coming down the pipe right now. Cryoablation has one that not only does this, but also shows you a planning before hand predictive of what they think the ablation zone would be. I haven't actually worked with it so I don't know how accurate it is but those kind of things are definitely gonna evolve and they are gonna make our jobs actually a lot easier to be honest with you.

So I have throw a cryo case in here just because we do do them every now and then so most of the time we are doing in kidneys these days and even then relatively rarely. But this is a patient who's had a left hepatectomy, too big tumor with lots of little daughters lesions. So you can kinda see these lesions are kinda scattered around it.

So we need a really big ablation here probably eight or nine centimeters and that's really challenging if not impossible to accomplish with current heat based modalities. But you can do it with cryo. And here's the cryoablation you can see this very large ablation zone that incorporates the entire tumor and a very large margin.

And so this is something that cryo is good at and there's a reason to use cryo in some cases. Unfortunately in this case there were other mets that developed down the line, this is a year later. You can see the ablation zone looks great but unfortunately they got another little tumor.

And that often happens in these patients obviously. So remember if you are going to use cryo there's no such thing as a single cryo probablation, it's just not effective. This is Peter Littrup's work when he looked at the thermal concentric, I'm blanking on the word but anyhow the temperature at different

levels out from the cryo probe based upon how many probes you have put in and you can see with a single probe you only have a very small zone of ablation around that probe. So a couple of things to remember, these are the two main rules people use, one cryoprobe per centimeter of tumor so if you have

a five centimeter tumor you need five cryoprobes, etc. And the two in one rule which essentially states that no more than two centimeters between the cryoprobes and no more than one centimeter from the edge of the tumor, and you'd figure the center of the tumor is gonna get incorporated because of the synergy of the ablation.

So if you do do cryo keep that in mind. So here's another case, it's a little bit more of an advanced case maybe but this is something that comes out fairly frequently for us. Which is through the tumor, this is the one with metastatic

breast cancer. And she has four metastasis and two and three are right underneath the heart. So we actually had this referred to us from a fairly well know institution that said this was not safe. How many of you guys would try doing something right next to the

heart like that? So not a lot of excitement for it. So not only did we do this case but it kinda sparked our curiosity and we decided to do a study to figure out if it really was safe. So here is the case, I did this case about probably four or five

years ago now, and you can see these two were kind of ablated in combination with each other. This one, you can see this cryoprobe, this antenna is almost right underneath the heart and this one fairly close as well. Here is the afterwards and you can see this ablation zones technically release, this one

will incorporate a portion of the heart into the oblation zone. So it really made us start thinking well is this really safe? Or am I being kinda cowboy to go ahead and do this. So we did both a animal study and a clinical study and what we found was actually this is very safe. And probably the main reason is,

is because the heart is not a stationary object. It is moving constantly as you do this and when we do this in open situations where we're looking at the heart, we're looking at the lung, we actually did a clinical animal study in the lungs so we can get even closer to the heart.

And what you find is that if you're more than three millimeters away from the heart, your probably not gonna do any damage to the heart. And it probably has to do with its perfusion and its motion. So it's really very safe and we showed in our clinical practice

as well that it doesn't cause cardiac events. So don't be too concerned, obviously you don't wanna hit the heart but as far as ablating next to it.

So The Patient. This is the case that I'm gonna present today and for the remainder of my presentations. It's a 65 year old male with HCV cirrhosis with a performance status of 1, a trialled's B8 mostly for his ascites, and low albumin. His Bili is a little bit elevated.

No encephalopathy. The gentleman has a 4cm HCC that's in the segment 5/6 and his goal is liver transplantation. So I just kinda bring this up and you've probably seen this talked a lot about as we're kinda shifting away in our clinical practice, away from the BCLC guidelines and moving it more towards a

Hong Kong staging. And one of the reasons why the BCLC doesn't fit is, this gentleman who's a performance status one, the guidelines here would recommend he gets Sorafenib. That clearly doesn't make any sense and I hope no one would practice

this way. You have to realize that when these guidelines were made, they were, you know, in the late 90s, early 2000s. They were mostly early stage ACC's treated by resection or liver

transplant or ethanol injection. They compared them to intermediate stages that were being untreated. And so really not reflective of our current practice or other ideologies as far as beyond HCV. And like I said, there's other issues too that it lumps all the extrahepatic disease with Local Portal Vein Thrombosis. And again it limits embolization

and RFA to just performance status 0 which is just unbelievable. And so this is more practical, the Hong Kong classification and I'll kind of whiz through it. But you can see this patient is gonna be classified in Hong Kong stage as an early tumor.

Its solitary, its less than five centimeters. Even though the ECOG 1/Child B are gonna be moving this person towards liver transplantation, and at most US centers that means that these are gonna receive some type of bridging therapy. And this is just to remind you that kind of these intermediate tumors and locally advanced tumors are kind of split up in the Hong Kong

classification unlike in the BCLC. And then you will see that you're gonna be treating these patients with transarterial therapies. I don't think there's time for that. But this is just to describe my practice right. So for locally advanced or any intermediate stage where it's palliative

by definition, pretty much they use Theraspheres or conventional TACE. It really depends on the extent of portal vein thrombus and their liver function. And to some degree, I do receive patients that come from outside of hepatology pretty frequently. And they've kinda been driven and told by their referring physicians

that they're gonna come see me for radioembolization. If I think that's reasonable, there's not really a compelling reason for me to rock that boat and try to convince them that, no, no, no, you don't want Theraspheres, we should really do conventional TACE.

And so I'm so I'm fine with it. And ultimately I'm in a teaching the institution, I need to expose my fellows to a wide variety of practice. So early stage, like I said before, is mostly bridging or downstaging for liver transplant and in here I use both DEB-TACE and conventional

TACE. And some of it is location dependent but I have to recognize that at some centers they're still gonna use Theraspheres and oblation and that will be totally appropriate. But again here, I work at two different centers,

one is a VA medical center, and the other is the university hospital. At the VA we're largely built around DEB-TACE and largely built around conventional TACE at our university institution. [BLANK_AUDIO] I highlighted it for some reason. So this gentleman right,

he actually turns out to be a veteran, so the plan I think totally appropriate is DEB-TACE. If I have to make an argument as to why to treat this gentleman with DEB-TACE, this specific patient, let's say if I had both as an option, and I want to make an argument why,

we could make the general arguments on why we use drug eluting beads, right? We maximize our drug delivery to the liver, and limit side effects, and get consistent reproducible drug delivery, unlike conventional TACE, which tends to be a little bit more user dependent. It does give you a more sustained slower release of the drug. And

that supposedly shouldn't lead to more lethality, because you have longer dwell time in higher delivery of the drug to the local environment. And in terms of toxicity, there's trials out there to show that it is less toxic and this the precision five, I'm sure everyone's familiar

with. You know at Penn we kind of often will, you know of prove this because we do a lot of chemoembolization. And I have to tell you that 25% of my patients do not lose their hair, or report losing their hair, so I find this to be a little weird.

But this is some rationale for the toxicity related to DEBs is less than conventional TACE. They didn't find any difference in the primary end point so you can still support using conventional Chemoembolization if you like. But they did show on their subgroup analysis and this fits very nicely with this patient, that DEBs suggests that there's a little bit

better response in the Child's Pugh and the performance status one patients, because they cannot handle the toxicity of conventional Chemoembolization. And so, I think there's some scientific rationale in this patient, why you could support using DEBS. This battle will just keep raging on. There's tons of meta analyses,

can't find any difference. Just seems that most of the transit favored drug eluting beads disappear when you start doing this meta analysis and compounding the randomized trials together. In terms of it just specifically as a bridging therapy, which is

the scenario we're using it for this patient, there are some studies that basically when you look at the patients who get a transplant, the survival is no different. And that probably makes sense everyone, and Y90

is also very similar. So when you're using a bridging therapy in my mind, it's because the tumor is limited, and their performance status tends to be pretty good that it probably doesn't matter what you do. What really matters is getting the patient to transplant. And some of this is gonna be driven by your local expertise, so if

you're very comfortable using one of these therapies over the other, and you get a reasonable result, and you don't have a large de-listing rate, you are probably doing

So again this is what we did, right? 150 to 300 micron with 75mg Dox. This patient who had the ring of enhancement around the tumor, around our post study. We would just book him for one month follow up.

You can see here on the arterial face, I'd only show the arterial face image here, but the tumor is basically dead he has a small amount of perihepatic fluid following that. This patient then, after we would've typically seen him at one month, we would go into a kind of cue three month

follow-up pattern. Kind of sticking with the requirements that they'll need for transplantation, and allow them to gain their exception points. This patient maintained a CR up to one year, although he's not transplanted yet. At that time, at the one year follow-up, there was a new hypervascular lesion in segment two.

I guess I should have thought about not showing this case given Ron's talk, but this patient, you can see it's very high in their liver. It restricts diffusion, it washes out, certainly an HCC.

We went out into the hepatic lobe into segment two. Much like we would have done before. We are very selective, we're just treating this single segment two vessel with our standard mixture, same drug that we'd done before. It takes in my mind even greater

patience to actually get all of that therapy into this small distribution, but it can be done. We just need lots of time in between injections, a very slow infusion.And we start the clock over again. This patient did have pretty

good coverage. Again, looked homogeneous to us in our cone beam CT, we start the clock over, follow up again a month later, unfortunately these are arterial on top,

venous on the bottom, from superior to inferior. You can see for this gentleman, the very superior most aspect of the tumor continues to enhance and wash out, while the more inferior portions of the tumor are completely necrotic.

So, this is the type of patient who we would typically bring back and go looking for extrahepatic supply to the tumor. I don't think retreating would be a wise idea here. Again, lobar DEB TACEs is not something we do.

I usually give a patient two chances at the same therapy before switching the therapy type. Obviously the location of this makes it kind of absurd to consider ablation. It's very close to the diaphragm, it's already been treated, it will probably

be very hard to localize and treat appropriately. So, not surprisingly we found this phrenic supply. You can see this blotch of contrast here. Maybe I showed a really bad image, but there is some supply to the diaphragm here off this phrenic. We thought we could either,

as Ron said, we could consider bland embolizing from here. We could consider cooling off this phrenic vessel and then deliver our DEB TACE from where we're located. We could bring the patient back and do something different.

But I think really, you're already there, these are your options, you've already paid for your DEB TACE, so we are basically gonna try to coil this off and deliver it from here. Insert a coil, cut of the blood supply. The vessel's still there,

we missed our DEB TACE. This is our post-embolization run. You can see, again, neurostasis, devascularization of the tumor. And we're refluxing all the way back. Unfortunately, this guy ended up having another recurrence more

recently, and we had to go re-treat it again. This kind of brings up Dr.Golzarian's point that we're going back and back to treat this guy, and not infrequently you don't have to bring patients back to retouch them up after DEB TACE. So this is again the previously treated lesion. I see an area of enhancement with washout again, the phrenic is still closed off,

I don't know, I accidentally got into the thing so we just shot it. That fistula that we had coiled off is closed. Unfortunately, in the process of coiling that off we also sacrificed that vessel that ran out to that portion of the liver. But we were able to get out into this area here to find our tumor. [BLANK_AUDIO]

I'm gonna skip some details but then ultimately we [INAUDIBLE] therapy and get again good tumor staining. We did this a couple of months ago so we don't have any follow up yet. But in general from my HCC follow-ups, kinda showing you it's kind of a typical pattern that we'll see. We're following these patients every month with MRIs and CTs,

we always get lab values, we always see them in a clinic with each set of imaging, kind of just of refresh the patient on where we're going, how we're doing, touch base with our colleagues in transplant, see how close we are to transplantation,

there's a lot of variables that can go into that. Some of our patients we have on a large living donor program at Penn, so some of our patients would be much closer that you would think otherwise. Typically the only thing that alters this kind of cue

three month follow-up when someone goes for a very extended CR, with no new tumors for two years, and I kinda start to space out a little bit longer. And I just wanna remind everyone, if you're in those scenarios where you're actually down staging patients who are outside of Milan. You know, kind of look at their response.

You need to make sure you're re-addressing the status of the multi-disciplinary tumor board, to verify whether or not they've been reconsidered for transplantation.

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