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Imperfect dissection - L3 MySpine Low Profile guide and K-Wire placement
Imperfect dissection - L3 MySpine Low Profile guide and K-Wire placement
Status Of Transcatheter Tricuspid Valve Implantation: Initial Experience
Status Of Transcatheter Tricuspid Valve Implantation: Initial Experience
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So I sort of intentionally made this L3 an imperfect dissection. I left some of the soft tissue on there and so it's a little bouncy. It's not perfect yeah just to illustrate some things. Wire.

Careful. There's a whole bunch of things you can just fiddle around with and again there's there's no rules I'm just gonna not buy this to convince myself that maybe this isn't perfect. I don't wanna drive this K-wire. Chuck key. In some

random location if out of my own yeah laziness I didn't do it perfect. Wire. You can just sort of breach the cortex as you would with any kind of k-wire base-case see where you are and nothing preventing you from

putting in 8 wires taking some APs and see the pedicle on three sides. You haven't bought anything. So if you had the easy driver you wouldn't have the wires chucked up so long Let me see an AP.

These are radiolucent? The guides? Yeah. Pretty. Can we see an AP? I left those wires real long and they're steal not nitinol so I don't want to bend them too much it's just a cadaver but...

- I thank very much and thank many thanks for the invitation again. Tricuspid regurgitation is frequent in patients with left heart failure and other valve disease. It is an independent predictor of mortality. It has become more important since we can treat aortic and mitral valve disease by catheter techniques.

Transcatheter tricuspid repair techniques are difficult and the results are not sufficient yet. Therefore transcatheter tricuspid valve implantation may become an alternative. I will not talk about valve in surgical valve something we do since many years.

I will not talk about ectopic valve implantation like in the inferior and superior cavalve. I will focus on this five minute talk about tricuspid valve in native valve implantation. There are actually two systems which are currently tested, the NaviGate and the Trisol system.

The NaviGate Tricuspid Valve is made of a nitinol tapered stent, height is 21 mm. It has annular winglets and leaflet anchors. Comes in sizes between 36 and 52 mm. Requires a 35 French sheath with an OD of 42 French. It's a trans jugular or right atrial axis.

The delivery system has two degrees of tip motion and allows a very controlled valve release. This is one of our patients. The patient also had a mechanical valve in mitral position. RV angiogram shows a very severe tricuspid regurgitation. You can see right atrial access has been obtained

via lateral mini thoracotomy. Stiff wires in the right atrium, right ventricul, and pulmonary artery. Coronary wires in the right coronary artery for fluoro guidance and the navigate valve at this point is just prior to deployment.

This is during deployment. The ventricular tines are exposed and this is after deployment the release of this valve. You can see the ECHO the TE before severe TR and after are close to zero residual TR in this patient. Thirty four attempts in 32 patients in 13 centers

around the globe have been attempted. When you look at the baseline demographics there are many risk factors which basically I cannot go through details here but I just showing this to you to make it clear that this is a very sick patient population.

The acute results attempts are as I said 34 attempts in 32 patients. Successful implant could be achieved in 24 patients. Success implantation not successful in 5 mainly due to access problems. And 5 additional patients had to be converted to surgery.

When you look at the implanted valve size you see a trend toward bigger valves which also shows and indicates that we are missing larger valves which means many patients had to be excluded because the appropriate valve size was not relatable.

Tricuspid regurge obviously before the procedure severe to very severe and after valve implantation non trivial in almost 80% of these patients and you can see on the right side of this slide the improvement in heart failure class. This is a busy slide showing the outcome

of all individual patients. You just maybe, just focus on the mortality overall after 30 days was 12.5%. When you focus on only those patients who received the valve. In those patients the survival more than 30 days was 75%.

The other concept which is still in animal trials is the Trisol valve. It's a very unique valve design as you can see here on the left upper side of the side. It's a transjugular approach, 30 French delivery system. The valve anchors on the leaflets.

It can be repositioned and retrieved again. It's still in animal trials. So basically tricuspid valve implantation has taken off. Thank you very much for your attention.

And it's a big case where, or a big example where the technologist can add a lot of value and help out a lot. So just a case example that kind of ties together. This was a 53 year old male. He's doing pretty good, except he kinda had

some progressive right hip pain for a few months, but was still walking and able to kind of do most things. Was diagnosed with myeloma. And this was his CT scan, kind of a coronal projection. You can see this large lytic destructive lesion

over his right acetabulum. With extensive kind of bony dehiscence and thinning of the cortex throughout. And so this was the plan to stabilize this. And help his pain from kind of a combined augmented screw, cement and screw approach.

These were the needle paths, and the screw paths that we used on pre-procedural imaging. You can kind of see representations of these here. So again it gives you a good idea of where these screws are gonna go, and in the case of the bottom right image

through a narrow corridor, this really allows us to achieve that. Using this live kind of overlay needle guidance. Several of these screws were placed. Again, up on the I guess top left, you can see this narrow ramus corridor,

that this kind of allows us to find. So again, just kind of more examples of how this case progressed. Registration is a key part again. This was the segmentation that I showed you earlier. And then kind of used this in real time

as we filled this entire area with cement. Again, given the bony destruction, at least the kind of posterior aspect of it was extremely difficult to see. Just under fluoroscopy, and I think without this nice contouring of our target lesion,

in cases that we've had, you know, previously, we would have stopped a lot earlier, thinking that we'd filled it. Whereas here we have kind of that confidence that there's a little bit more to go, a little bit more to fill.

So you can kinda see it, as this goes on, we are able to fill most of the target volume. And this was kind of the completion, you can kinda see that these are screws, and then the cement area here, kind of reforming almost the acetabulum roof.

So he did well, so this was all done percutaneously. He basically had three Band-aids from his three different screw entry sites. And was weight bearing within two hours. Afterwards, he underwent radiation therapy. He was on systemic therapy.

He's starting a Zometa for his kind of overall bone health, and he really doesn't have any specific right hip pain. And the biggest thing for him was that he was able to kind of move on to his systemic therapy and radiation therapy almost immediately afterwards. So a really good outcome, and one that I think that

without a lot of these advanced imaging techniques, we either wouldn't have been able to accomplish or probably would not have been able to provide as much structural reinforcement as we were.

But I'm really gonna focus on percutaneous ablation because it's particularly well suited to this application, minimally invasive for these potentially frail and elderly patients,

as well as high kill rate with tumors of many different histologies. So when we're choosing, this is the technique, so how do we do it? If we were facing a metastasis in the scapula like this, we can treat it with heat,

radiofrequency, or microwave ablation, or we can treat it with cryoablation, extreme cold temperatures, extreme cold or extreme heat, they'll both kill the tumor. How do we decide? Well, if we compare cryoablation versus microwave ablation

or radiofrequency ablation, ease of use, the heat-based therapies are certainly easier to use. They're generally faster, so the procedure duration is quite a bit shorter, but the energy transmission into bone is better with cryoablation.

It'll go through the cortex, whereas heat is limited in that regard. The predictability of the ablation zone, the cryoablation. As you can see in that scapular picture, we can actually see the edge of the ablation with several different modalities, CTMR and ultrasound.

Our ability to monitor that ablation then and prevent it from escaping into adjacent collateral structures. And then the ablation zone size, we can usually treat a larger area with cryoablation, and patient tolerance, their pain scores are generally less

after a cryoablation than a heat-based therapy. So in general, most of us who are treating for local tumor control would use cryoablation. These factors are a little less true these days where there are newer bipolar radiofrequency devices that are designed specifically for bone

so have better ability to control tumors within these sites.

- I try to dissect this convoluted title into two questions, basically, when is endovascular treatment of post coarctation aneurysm best, and when is an open surgical intervention required. A couple of years back in time, we looked at predictors

of aneurysmal formation in patients after surgical correction of coarctation, and we found essentially two predictors, which is previous surgical patch repair, and the age at the surgical repair, as predictors for the evolution of

a post coarctation aneurysm. In other words, these two predictors could actually become important for the selection of patient for open surgery. I come to this in a moment.

A year later, we could publish the feasibility of percutaneous endovascular repair of those post coarctation aneurysm, post surgical aneurysm, easily by a customized

or off the shelf stent graft. So that is basically accepted in the community, and reflected in guidelines, that basically come to the conclusion to the question, when is endovascular treatment

of post coarctation aneurysm best. In the case of a risk-benefit ratio high for open surgery, which is in case it's a redo surgery, of course, in presence of extensive collaterals, with a significantly increased bleeding risk,

adult patients above the age of 13.5 years, according to the statistical analysis, and when end to end anastomosis is not feasible, and of course, patients need to be suitable for an endovascular approach.

Patient preference may play a role, most recently, and of course, is conclusion of endo first should be executed in dedicated centers that have options to treat the patient even openly.

The second part of my title, or the second question is basically to the preferred use of open stents or covered stents, and in order to show our recent analysis on this, I had the privilege to compare

a group of patients from my previous institution that used self-expanding open stents, and with my current position in another place, that uses CP stents, or covered balloon expandable stent grafts

in the setting of coarctation as the first and only option. So we have no data from two different hospitals that show similar patient sets, a total of 52 in each group, that do not show any demographic differences

over a time of 10 years, collected over 10 years. Clinical presentation of comorbidities are essentially the same, so we're dealing with a comparable set of patients

and two different concepts of treating primary coarctation. The post interventional vascular events are also similar, no significant differences between the two concepts from two different sites,

with a trend towards more re-stenosis in the setting of ballon expandable stents being used as the first approach, but not significantly more. Even in hospital complications, comparing these two groups of 52 patients,

age didn't show any significant difference, with a trend for longer hospitalization in patients treated with the CP stent or covered stent. Maybe this is only a coincidental finding and a more cultural event

rather than medically driven. If you look at the outcome curves between both groups, with no mortality in either group, there is a similar shape of the Kaplan-Meier curves

over up to 90 months, with an interesting difference in the first post interventional phase, with three asymptomatic localized dissection in the balloon expandable stent graph group, however, no significant difference over time.

This next slide summarizes the ballon expandable procedure with the CP stent. After obtaining lumen and connection between this ectatic aorta, it was possible to stent the segment

with a covered CP stent very nicely. You see the result on the lower right corner. The other concept is a bare self expanding Nitinol stent placed first after recanalization of the coarctation and then potential post ballooning

to obtain an appropriate dimension and the lumen. In summary, comparing those two approaches and answering the question, when is an open operation still required, I think it's fair to say that in adult coarctation,

and endo approach should be chosen first, and bare, self-expanding Nitinol are relatively safe as a concept, and durable solution, without the risk of side branch obstruction, whereas covered ballon expandable CP stents

are also safe, and offer a durable solution, but have to respect the LSA anatomy. An open surgery I think should be reserved for infants and children younger than 13.5 years, only in view of an end-to-end anastomosis.

Thank you very much.

So what are the focal therapies we could use?

Well surgery's been used for years, and there's certainly clinical evidence for this in a number of scenarios. Pts who have colorectal metastases to the liver. They undergo a partial liver resection and they live longer. They are long-term survivors from that.

Same thing with resection of lung metastases, even adrenal metastases. Radiation therapy is certainly used for this in certain areas, particularly of the spine. Embolization is certainly used as a local regional therapy

for metastatic disease, particularly into the liver, and currently it's being used in patients who have more than oligometastasis, several metastases. Focus ultrasound is being used, it's really in the experimental stage now for actually developing local control,

not just in the uterine fibroid here or benign tumor, but in bone metastases.

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

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

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

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

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

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

improve those symptoms.

So we've looked at our experience in treating musculoskeletal limited metastatic disease for complete remission, and we looked at 52 metastases in 40 patients. A quarter of them were renal cell in this case. Had about two years followup,

and 87% were able to achieve local tumor control. And these patients live a long time. The median survival of these patients was almost four years with two years survival of 84% with acceptable complication rate. We looked at specifically in renal cell carcinoma,

treating those in multiple different sites. And you know, most of these patients did have locations in bone and soft tissue. So if we used those data to say is there evidence to support this? Well, in these 82 tumors the recurrence

resurvival was very high in 94%, and the patient's overall survival 83% were still alive two years later. In our local tumor control about 88% with an acceptable complication rate. So it is possible to treat these patients

and continue to have them live a long time without systemic therapy. Others have certainly looked at this. This is a group in Detroit that's looked at the same thing, renal cell carcinoma metastasis ablation, and they found the same thing,

median survival over two years in this group. And they actually did a little bit of a cost analysis and said what's the estimated cost even if we have to ablate these people twice and their cost per life year gained was $26,000, which is very reasonable

and compares favorably to systemic therapy, these patients who are put on systemic therapy, the cost is 30 to 45,000 in their study. I've seen estimates over $60,000 for a year. So it's certainly reasonable to do that. This is a busy chart that just shows

that there's a lot of evidence for treating musculoskeletal tumors for local tumor control for a variety of histologies from lung cancer to renal cell cancer to a mixed populations, and breast cancer, whether it's in the spine or other areas in the bone,

a variety of ablation modalities, cryoablation versus heat and the local tumor control rates are reasonable, 70 to 98% depending on the patient population we're looking at. And these data have been compelling enough that the National Cancer Care Network's guidelines

had been revised for patients with stage four renal cell carcinoma. Now that if they are not surgical candidates, ablative techniques in these metastases should be considered.

When we're treating these tumors for local tumor control we're really aggressive in ablating them. So we have a rib metastasis here, and we won't just put one probe in it and call it a day. We have to make sure that we have adequate cold temperatures surrounding the entire tumor with margin

to make sure that we can provide a long-lasting effect for these patients, rather than this case in which patient has a spinal metastasis, we put one probe in part of it and leave a little corner of tumor

when our goal is local tumor control that's not really adequate. And local recurrence really matters so in this study this is one example study of a patient who had surgical replacement of renal cell carcinoma, bone metastases.

And in this study they show that threefold higher hazard ratio of death in patients who develop local tumor recurrence at the site of the resection. So if we can, extrapolating that surgical data to ablation we wanna make sure we get that local control.

Unfortunately as we treat aggressively we are more at risk for developing complications. In this large metastasis that's in the supra-acetabulum here we try to be very cautious that we don't actually have that ice ball encroach upon the femoral head,

as opposed to this equally large metastasis in the supra-acetabulum where we actually have the ice that if you extrapolate those into that femoral head and then several months later the patient develops femoral head collapse and fracture, and their pain recurs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So what about if patients have more than just one renal cell carcinoma metastasis? What if they have multiple. So in this study from my institution,

the urology team looked at patients who had all of their tumors resected as opposed to patients who had any of their tumors resected compared to those who had none of them resected. And there was a survival benefit for each of those patients. And these authors wrote a really nice statement

I like in this scenario. And they said limited data exists on the outcomes of these types of patients, and we believe this may result in an unnecessary therapeutic anilism, whereby patients who have multiple lesions

are excluded from an aggressive approach. They're just put onto systemic therapy or comfort care. And why is the literature limited in this case? It's due to the morbidity of surgical resection. So really ablation in these minimally invasive IR techniques provide an opportunity to help this patient population.

However, in 1995 Drs. Welchselbaum and Hellman

wrote an opinion paper called Oligometastases and then rewrote on this subject in 2011 about the concept of oligometastasis, and they really described this as a distinct state in which tumors have an intermediate metastatic potential. So these patients have a limited number

and site of metastases, and these are variably defined in the literature, but usually people will say up to five metastases. And in these patients it makes sense to do focal therapy rather than systemic therapy. These patients do not have all of the changes

that are required to have distant metastatic spread.

Questions? Again, that's Max, that little baby. That's the dose that's in the syringe that the pharmacy gives us. Nothing, only for GFR, but then I talked about the residual.

For most, that's 20, 10% up or down. Their body acts as, almost, kinda a little bit of shield. So if I'm giving 20, in six hours it will be 10. That's the half life. But it won't go anywhere else.

It stays in the system. And again, it does get eliminated through urine, but nothing that fast. Yeah, it's still the same dose. It's not going anywhere else. That's our policy and procedures.

Our doctors have made, I'm not sure if there's a specific reason for that, but that's how, that's what our policy is. As we are injecting, I'm keeping an eye on it. There's always that you don't, I'm not looking at someone else,

I'm looking at the vein as I'm injecting to keep on assessing it as I'm doing it. Also, that eight millicuries that's in there, I take it to the pharmacy because I don't know if it's eight. They calculate that and then our doctors decide

if they want something comparable, if they want eight, or if they wanna add a couple more to it, write a new order, and then whatever is the new order, I inject according to that. It's actually a very small volume.

For, I think, bone scan, we get fresh doses throughout the days, it could be up to one milliliters, maximum. It's very tiny amount. - [Audience] How would you even know if it's a tiny amount that you did infiltrate the line?

- Because you're paying attention, well again, I'm trying to pay attention to the site of injection. No. I personally have not injected a patient who was intubated. Like I said, if they can't follow the instructions,

it's kinda hard to do it. We, about three to four, and there are days we have done more. We also do them for pre-surgical reasons, so there's that. - [Audience] Not necessarily (mumbles). - No more questions?

Okay, thank you.

So now we move from a potential case like this

where the patient has a large renal mass and a metastasis into their left femur, and that patient underwent a surgical resection here, replacement of that, a big operation for a patient with metastatic disease, now we take a similar kind of patient

with a left renal cell carcinoma and has two metastases, one in a rib and a small one in the acetabular region. And they undergo the nephrectomy and then ablation of these two areas. That may be the new model.

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

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

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

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

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

and the patient gets relief of their pain.

So is there any cellular or biologic basis for this understanding? Well over the last couple of decades really, there's been a lot of scientific study into tumors on a genomic basis.

And we find that tumors really have a lot of heterogeneity. So this clump of cells that are multicolored here represent the tumor and really, we see that the metastases that develop from this to the brain, liver, and lungs, and spread from different parts of that tumor.

And each of these parts of the tumor may develop different mutations. And even the tumors that spread, like that green metastasis to the liver, then may develop further mutations that allow it to spread further.

And so if we find patients who have a limited amount of metastatic spread, potentially those patients have a single mutation as a more homogeneous tumor. In which case, we could potentially have a therapeutic window in which we can

prevent them from having spread elsewhere. So if we take this example, patient who has a colon cancer and the colon cancer had spread to the liver, those metastases then develop further mutations that spread to the lung and the bone and then the bone metastasis further spreads to the brain,

we could potentially, if we find a patient who only has a liver metastasis and a bone metastasis, if we actually treat those areas focally potentially we can limit their metastatic progression, improve survival.

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

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

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

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

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

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

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

that you can actually develop diarrhea.

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

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

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

pulsed RF ablation, and cryoablation.

So let's just talk briefly about the evidence and I'll use metastatic renal cell carcinoma as a model case. Different tumor histologies will have different evidence and different studies to support them. So in this case of a patient who has a right renal mass

and develop this renal metastasis and we ablate that with the ice ball you can see very well. So does this oligometastatic state even occur in renal cell carcinoma met, patients? Well, it does. Most patients actually present

with limited metastatic disease. More than half the patients, when they present with metastases, have just a single site of disease, and that proportion actually increases as patients age. So the patients who are the most elderly,

the most frail, the least suited to surgery, actually are the most likely to have a single site of disease to treat. Is there a survival benefit from surgery if we extrapolate those data? Well, if patients have a wide or radical surgical resection

as opposed to a marginal, they're just pinning that metastasis, those patients do better who have a wide radical surgery. And if patients at the end of their surgery actually are free of disease, they don't have other sites of metastasis,

if we can actually treat all of their disease, they live longer.

Leave that a bit for later. While we were doing all the work in interventional radiology

we were asked to train a private practice MRI team north of Boston because they further wanted to reduce their claustrophobia rate and that's how we got into this whole issue of using Comfort Talk in the MRI setting

and what we are finding out now more and more is that patients who are claustrophobic it's PTSD. So for the one's of you who are doing nursing and are called in there, that's what it is. The situation, in one way shape or the other reminds them of past trauma.

There is now a fair amount of trauma exposure therapy, particularly these veterans who are coming back from the various wars where they go to the psychologist's office and they are re-introduced to the setting and this is reframed and then the hope is that they walk out of the office and feel better.

That's hard to do. However, when the patient shows up at your doorstep and is completely freaked out, they are in the trauma, they're in it, and all you can do is actually make it better because it is the setting where they are the very most motivated to improve it

and this is also why it kind of works. We had done a recent trial at Boston Medical Center, Tufts and Ohio State where we basically just look at what happens if you train a team in just changing their vocabulary a little bit, sometimes they would read a script

but most often not, what is gonna happen to the outcomes? And we didn't even insist that people would use the techniques, we said okay you get the training, do with it what you want but it kind of changes after you see how things work

that you are gonna see your results and then adaption becomes more. So we saw the incomplete and no show rates going down and a significant improvement in patient satisfaction and there's nothing that improves your stress level

more than if a patient comes and says, hey thank you very much you really helped me through that. Or they really express their appreciation. And we then moved on and did a randomized trial and I think that gets a bit back to the original slides I did

in you are not alone in this. You are in this environment of commercial pressures of patients who come in who are not coming and then what is happening to your practice base. The fascinating thing about this, and that was in Columbus, Ohio, that the trial,

we trained three teams in Comfort Talk and three teams we didn't and that was in one healthcare system of MRI and what had happened at time zero is a fascinating event which I call the adverse effects

that philanthropy can have. For those of you who have come from the Columbus area there is so much money out there, there are more wealthy people probably than in New York that don't show it, but there is a lot of richness, so for somebody to give a hundred million

to build a new tower for the hospital is not a big deal. So they build a new tower but then the competitor in town obviously couldn't let this go by and they also got this beautiful nine story newer tower. Obviously all of them having MRI.

Same thing happening in Boston. I mean it's amazing how many millions, hundred millions in philanthropy for new stuff and everybody has a new MRI. So now suddenly, and it was at time zero you have more scanners in an area than you have

patients to go around. And what happens, what we found is, and that's the blue line, the people who were trained in Comfort Talk, were able to keep their volume and the others lost volume. So even in big urban areas word gets around

of like where do people go or we see impact on no shows. Most no show are people are frequent offenders but in any event we saw that. So now obviously if you are working in an area where you have fewer and fewer patients showing up

your equipment utilization is going down. And keep in mind that the current regulations are you are supposed to have your equipment running 90% of time, that's what payment is based on, that CMS payment is based on. So if you see this line going down

and you work in a place like that you can count on your five fingers that somebody's gonna get fired making things even worse because that's how administrators really high up solve that situation. And what we have seen is that, in other settings

where we had trained people whose patients are happy and actually send that in, that's actually a very good insurance against being, quotation mark downsized and this is what happened with patient satisfaction. So once you stress out the personnel,

patient satisfaction is gonna go downhill and we had done that and seen that in a prior study too where, in that very first place that had hired us it was a joint venture of two hospitals for an outpatient facility and at the moment the reimbursement changed

to have more reimbursement hospital wise. They told everybody they'll get fired or transfer. That obviously did make a dip down in the patient satisfactions but then they came up again and at least throughout stayed longer than before training. I thought I'm gonna just share this

because that got published last week and our first author, who's actually at UCLA in economics, already has given three press interviews. So you might be hearing about that in the weeks to come. We trained a team at Duke and we looked at,

where do people waste, where does extra time go, where does extra expensive time go? And the two columns on the left side are the hospital based facilities and the two right columns are the free standing facilities.

Pre is before training, post is after training. Now the interesting thing is that in the hospital based places the amount of general anesthesia and conscious sedation didn't change because there are fixed slots, and every month, interestingly enough,

it's exactly the same. But that comes from the fact that places that don't have anesthesia and don't have sedation send them there until the slots are filled. But you might notice that green bar, the oral sedation went down, and particularly

disruptive motion. So the whole idea that you put somebody under general anesthesia and their breathe to you on command is not necessarily going to happen. If you look particularly at the freestanding places you've got a pretty big decrease in all these issues

that cost you extra time and run into money. So if you look at all, I think a paper that came out at Emory, what they call unanticipated events, I mean I don't call it unanticipated if a patient moves around, that's kind of life,

but if you look at those we found a drastic reduction but then also found even if you use Medicare reimbursement data quite a lot of more money. If you do 25,000 patients a year, and you make 12,800 times 25,000

that's nearly 300,000 for that you can keep some extra staff without anything else happening, or at least you can keep your structure intact or invest in new equipment. I think, since now we are all kind of really quiet,

I wasn't sure whether I would be showing you another video but I think you really need it with another great trick which is, if you're doing something and there's a repeat thing gonna happen again, some stimulus that's unpleasant,

and this actually really happened, the one we're playing now. Let's say you have the patient and let's say they're heavy and you know they take a breath in and they're gonna hit the equipment, which is kind of a bit scary for the patient,

or let's say you do a biopsy and you use the gun and it's gonna shoot all the time. So you have repeating, or you do a laser, you have a repeating stimulus coming, you can actually interestingly enough use that stimulus to make what we call an anchor.

Remember when I did the little hypnosis script with you, where I asked you to think either of a color or a sound or of a movement to anchor that with something really pleasant, the same you can use a stimulus that happens to anchor the patient in either getting more relaxed

or use that as a sign to numb the area around even more. It sounds spooky but it works.

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

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

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

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

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

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

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

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

in some of these complex pain patients.

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

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

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

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

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

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

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

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

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

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

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

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

- I'm going to talk briefly about why a helical stent is better than a straight stent. Those are my disclosures. So building on the basic science that came out of Imperial College in London since the 1970s, Veryan designed the helical stent, that imparts that helical structure

to the superficial femoral artery. And the stent, like any nitinol stent, is very easy to place. There are two principal forms of advantage. First of all, biomechanically, the stent was subjected to compression.

We all know now the complex forces that happen in the superficial femoral artery. A straight stent will compress, on average, at about 5% compression. The helical stent remains fracture free until about 14%, which is well passed physiological levels.

Sorry, is it possible to go back one? Thanks. Veryan also did some cadaver work, and this is a representation of the cadaver work. If you place a straight stent in the superficial femoral artery proximal popliteal then,

sorry, can we go back one? Yeah can we go back a slide please? Can we get, let's see if we've got video working. If you place a straight stent then not only does the stent kink and fracture but the artery below will kink as well because it doesn't allow for the foreshortening as needed

when you bend your knee. If you place a helical stent then that shortening can happen, you don't get the fractures, and you don't get the kinking. And after 6,000 implants there have been no recorded cases of fracture with this stent.

The other advantage is generating swirling flow. Now swirling flow is actually natural flow. Most of us think about flow as being laminar, faster in the middle than the outside. But actually swirling flow is what happens naturally because of the compression of the left ventricle

and the nonplanar configuration of the aortic arch and the branch vessels. That swirling flow generates a higher velocity on the peripheries and that increases the wall shear stress. And that's important because wall shear stress has been shown to affect both

restenosis and atherosclerosis. So you can map where atherosclerosis happens in vessels according to the wall shear stress, similar with restenosis. So low wall shear stress, more atherosclerosis and restenosis.

If you increase that wall shear stress, less atherosclerosis and less restenosis. And that goes some way to explaining the high prevalence of atherosclerosis and restenosis in the superficial femoral artery when compared to the aorta and iliac arteries.

The stent has been implanted now, as I say, in 6,000 people. And these are some images taken from the original MIMIC study. This is on knee flexion. Our engineers will take a map of the stent. Using computational fluid dynamics,

they will map the stent, look at the flow inside, and they can measure the wall shear. And you can see with swirling flow there's high wall shear on the peripheries. And when you map that using CAD then that wall shear is above the pathological level,

so should, in principle, be reflected by less restenosis. Similarly using CFD and duplex data, you can look at the flow in the straight stent or the helical stent. And the straight stent, as you'd imagine, you have laminar flow, but in the helical stent

you have swirling flow with the high wall shear stress. That is all well and good but at some stage you need to test it out. The initial testing was done in porcine model. The straight stent was placed in one carotid artery and the same stent but with the helical configuration

was placed in the other carotid artery, and the 30 days was 45% less intimal hyperplasia with the helical stent. A randomized trial was performed. The patients were randomized two to one to the helical stent versus a straight stent.

At two years there was significantly better patency with the helical stent than the straight stent, and you'll notice that between 12 and 24 months there was no clinically-driven TLR in the helical stent whereas there was the expected ongoing attrition with the straight stent.

The company built up on that initial randomized trial. They developed the MIMICS-2 trial, which Tim Sullivan's about to tell you about, which led to approval in the US and Japan and there's now global registry called MIMICS-3D. So in summary, it's designed to have

both biomechanical advantage and to produce swirling flow, which optimizes the wall shear stress. In a randomized trial it has been demonstrated to improve clinical outcomes compared to a straight stent. Thank you very much.

So when we're doing this technique, what do we need before we get started? We need adequate preprocedural imaging. So if we're seeing this tumor that's in a bit of a scary location in the proximal femur,

sometimes if we treat that too aggressively that can fracture, but this looks like it's isolated into the medullary cavity. But these patients have multiple imaging modalities and these help. So if we have functional imaging, in this case a PET scan,

we can see it's actually a bilobe lesion that actually is a little bit higher than we might just suspect from the CT alone. And so when we're ablating we make sure to cover that entire territory when we're in this indication

of trying to locally control that disease. Likewise, if we have a patient like this who has sclerotic metastases, prostate or breast cancer, they've been treated. It's a little bit hard to know which of these are actually active disease.

Have they already been treated? Because they'll look like this for the rest of their life. And we do a PET scan and we actually see there's really only one tumor that has FDG uptake or choline uptake and is actually active disease, and so we actually target that tumor.

- [Moderator] It is my pleasure to introduce Doctor Lang today. Doctor Lang is a national and international expert and pioneer in the application of hypnosis. She is also the founder of Comfort Talk. She has held faculty positions in Stanford, Iowa and Harvard and she's been in practice

for over 30 years. She has abundant government research funding, she has over 150 publications and she has received the Ernest Hilgard Achievement Award for a lifetime of published experimental work. So please welcome Doctor Lang today.

(audience applauds) - [Elvira] Well thank you very much. I'm really delighted to be here and share with you some coping strategies. When we were originally thinking what should the title be, the original title

was about resilience and stress management in IR which is for patients and at the same time for staff because as you will see they are just very, very much interrelated. Now all this work started back when I was at Stanford and at the VA in Palo Alto

and there was a young Vietnam veteran who was very difficult to even get on the table and he needed a repeat change of his intestinal tube and it was this huge production with tons of drugs and it would really delay the whole day and that's where I saw the first time

how some imagery process or hypnosis process or whatever you wanna call it could make a difference. So I said hmm, very, very interesting but is this gonna work for other people and where is this all gonna lead to,

does it work also within a team without making extra issues of their own? So I set up a research program surrounding that which I then took to Iowa and also to the Beth Israel Deaconess in Boston which ultimately then led to me founding the company.

And after pretty much NIH and DOD spent about 5.2 million on all the clinical trials we did we can say yes it works and yes we can train teams in it, but then there comes the moment where you have to jump into the ice cold water and say, okay you're gonna leave this

high paying job at the Harvard teaching hospital as division chief and you set up your own company. So (laughs) that's my disclosure, and we now focus on training frontline medical staff and a lot of insight I'm gonna share with you here today comes from this activity.

I also do receive royalties on two books I've written.

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

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

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

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

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

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

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