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M.U.S.T. pedicle screw placement
M.U.S.T. pedicle screw placement
2016chaptercortexMedactaNASSnoindexpediclescrewtechnique
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRchapterfull videointercostalpainpleuralsagittalskinthermalultrasound
Nerve Block Conclusions | Nerve Blocks, Neurolysis, and Rizotomies
Nerve Block Conclusions | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRchapterdocsfull videopain
Lumbar Sympathetic Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
Lumbar Sympathetic Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
2018anteriorarinarteritisAVIRblockchainchapterdefiniteextremityfull videoimprovelumbarpainpatientreflexstentsympatheticvasodilatationvertebral
Female | 55 | Pancreatic Ca | Celiac Plexus Neurolysis and Cryo | Nerve Blocks, Neurolysis, and Rizotomies
Female | 55 | Pancreatic Ca | Celiac Plexus Neurolysis and Cryo | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationanteriorarinAVIRceliacchaptercontrolcryocryoablationecogepigastricfull videogloveimprovementinvadinglivermetastasesmultipleneedlepainpancreaticpatientsalineultrasound
Anesthesiologists | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
Anesthesiologists | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
2018anesthesiaanesthesiologistanesthesiologistsanestheticarinAVIRbreathingchapterfull videonervepatientperioperativespecialty
Celiac Plexus Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
Celiac Plexus Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRbiliaryblockceliacchapterdiarrheadilatationepigastricfull videogastricimproveintractablenauseaparasympatheticplexus
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
2018anterioraortaarinAVIRceliacchapterconductioncurvedfull videogaugelidocaineneedlenerveplexusposterior
Indications And Advantages Of Antegrade In Situ Fenestration For F/EVAR: How To Do It
Indications And Advantages Of Antegrade In Situ Fenestration For F/EVAR: How To Do It
aneurysmantegradeaorticaxillarybailoutbrachialbridgingceliacCutting BalloonendoleakendovascularevarfenestratedfenestrationgraftischemiclaserLaser Atherectomy CatheterLaser ProbelfEVARmidtermprobeproximalrenalretrogradesitusteerablestentingsubclaviantechniquethoracicthoracoabdominalTurbo-Eliteunfitvisceral
Sympathetic NS | Nerve Blocks, Neurolysis, and Rizotomies
Sympathetic NS | Nerve Blocks, Neurolysis, and Rizotomies
2018arinautonomicAVIRchapterfull videosomaticurinary
Oligometastases Revisited | Bone Ablation for Local Tumor Control
Oligometastases Revisited | Bone Ablation for Local Tumor Control
2018arinAVIRchapterfull videometastaticpatientssystemictumors
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockbupivacainecervixchapterfull videolidocainemedialnervepatientperinealperineumposteriorpudendalrectalsciatic
Objectives | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
Objectives | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
2018anesthesiaanesthesiologistsarinAVIRchaptercrisisfull videopatientteam
Laser Guidance Imaging and CBCT  | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Laser Guidance Imaging and CBCT | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018advancedarinAVIRcenterchaptercrossfluorofluoroscopicfull videoimaginglasersneedleorthogonaloverlaysiemenstechniquestrocar
Goal of Neurolysis and Nerve Ablation | Nerve Blocks, Neurolysis, and Rizotomies
Goal of Neurolysis and Nerve Ablation | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationalcoholarinAVIRchaptercryoablationfull videoradiofrequency
Superior Hypogastric Block | Nerve Blocks, Neurolysis, and Rizotomies
Superior Hypogastric Block | Nerve Blocks, Neurolysis, and Rizotomies
2018aorticarinarteryAVIRbasicallybifurcationchaptercontractilefluoroscopicfull videohypogastricinnervateischemianeedlepelvicsplanchnicuterinevertebral
46 | Chronic L Shoulder/Arm Pain | Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
46 | Chronic L Shoulder/Arm Pain | Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockbupivacainecarotidchapteresophagusfull videojugularlidocaineneedlepatientvertebral
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbupivacainechapterfull videoinferiorlateralmedialsuperior
Male | 53 | Myeloma | Augmented/Semented Screw | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Male | 53 | Myeloma | Augmented/Semented Screw | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018arinAVIRbonycementchaptercoronalcortexdehiscencefull videoneedleposteriorradiationramusscrewsegmentationsystemictechnologisttherapy
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablationalignarinAVIRchapterfull videoguidancehydrodissectionnarrowneedleoverlayplacementstraight
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbasicallychapterconductioncryoablationdorsalfull videonervepulsedthermal
Block and Neurolysis of Ganglion of Impar | Nerve Blocks, Neurolysis, and Rizotomies
Block and Neurolysis of Ganglion of Impar | Nerve Blocks, Neurolysis, and Rizotomies
2018anteriorarinAVIRbupivacainechapterfull videogaugeinjectneedlesacrum
CPBN Meta Analysis | Nerve Blocks, Neurolysis, and Rizotomies
CPBN Meta Analysis | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRchaptereffectivefull videometapainpatients
Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockchapterembolicesophagusfull videopainpatientsrefractorysyndromesuppervasospasmvertebral
Transcript

Right about here I like to remind people definitely try it the way it's suggested. But

technique guides are made to be ignored so there's no rules here. You can help these to identify the pedicle ingress. Then run a drill and you know grab a gear shift or anywhere in between from perc to mini-open whatever suits your fancy.

So that's meant to basically be a start point to the first one. That's the idea. That's a cortex breach. The bi technique is I go right to screw next so there's no drilling no tapping. You know what I wouldn't mind doing is putting a tap down taking this wire out and just having a floating probe. As I said no rules.

Things are designed to help you. Want a poker? Any kind of clamp? I'm just going to take a probe...Yeah spot on. It's more me just wanting to check the system. As much as anything else. Once I trust the system more or i would probably... What was that screw length? 45. Is that a 5-0? what's the trick to getting your system off. Counterclockwise.

Let's go right to the screw on this one. Rachet? Yeah.

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

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

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

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

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

In conclusion, nerve blocks are important

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

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

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

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.

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.

And this is interesting that since 2000, this paper, there's came out is Anesthesia Practice and Clinical Trends in Interventional Radiology. Even in 2000 they were saying there's a rapid growth of IR.

And we kept on sayin' that, and sayin' that, and sayin' that, but it's finally here. You know the procedures are so complex. And me bein' down in IR, and I say down in IR because see, this is me talkin' about we're up in the clouds,

and IR for us in the basement. But it's not, it's really not. It's actually on the second floor. And we're on the forth, third floor. That's all the difference. But it seems like another different world.

But the things that we're able to do, that the radiologist's are able to do, the IR team's able to do with very sick patients is amazing. I mean you know, treating cancer percutaneously. You know, pain issues.

The services that are rendered are very, very impressive. I'm very amazed and I'm happy actually to be involved. So we can see the procedures are more complex, more time consuming. The patient populations keeps on getting sicker and sicker.

And from the previous presentations we've seen that a lot of the slides start with a patient, non surgical candidate. Patient non surgical candidate. So you know they're very sick. And then the next question is like,

okay so what kind of support do they get? Can they lay flat? How's their heart? Is it barely beating? you know, they have a tomato for a heart. Or not.

But these is a study of the amount of off site anesthesia cases that are bein' done. And you can see since 2010 to 2014 the trend is increasing. So now we're up to like 40%. And that's nationally.

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

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

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

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

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

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

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.

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.

- So, my topic today is: Antegrade In Situ Fenestration for Fenestrated EVAR: How To Do It. Here are my disclosures. So, Jean Panneton has shown already the validity of retrograde laser fenestration. That is a feasible technique,

an effective option for acute thoracic pathology, with an excellent midterm patency, which it is very easy to do retrograde laser fenestration compared to an anterograde technique. We have done a lot of bench tests to perform all like this (mumbles).

So, the in situ laser fenestration technique is an off-label procedure. It is a bailout solution, and dedicated to emergent cases, patient unfit to open repair, or unfit to CMD device.

And we use this technique for left subclavian arch, and the anterograde technique for visceral arteries, and in a few cases of TEVAR. This is a technique. I use a Heli-FX 16 French. And I use

a 0.9 laser probe. We don't need to use another laser probe for this technique to avoid any larger hole. This is the steps for the technique. I do a primary stenting of the arteries using your effusion.

And then I do the endovascular exclusion. I position the steerable sheath at the level of the targeted artery and then do laser fenestration. This is a pre-stenting. And then the graft deployment

at the level of the seating zone. This was a type 1A endoleak after EVAR. The next step is to do the laser fenestration. You can see the tip of the laser probe. (Mumbles)

You could see the tip of the laser probe coming in the lumen of the SMA. And, we'll then, after this laser fenestration, quite easy, we'll then do

an enlargement of the ULL, using first a small cutting balloon and then do a progressive dilation using a bigger balloon, four millimeter, and then a six millimeter balloon.

The next step is to do, like, what we do for fenestrated cases, we do the bridging covered stent. Yeah, at the level of the SMA, and then the flairing, to have a good sealer

of the proximal part of the bridging stent. After the SMA, we then do the renal fenestration. And we used to stop with the celiac trunk. Our main indications are juxta para renal aneurysm, or type 1A Endoleak when there is a straight aorta. And in a few cases, thoracoabdominal aortic aneurysms.

This is an example of a type 1A endoleak, as I have presented. This is our first trial with 16 patients, treated on between three years. And we have now 29 patients with laser fenestration EVAR,

66 fenestrations, 5% of aortic aneurysm treated in our center. The median ischemic time is 12 minutes for the SMA, one hour for the renal arteries, and around two hours for the celiac trunk. The fenestration success rate is 95%.

Here are the outcomes. There was no mortality, even for very old patients. 16% of transitory dialysis. No spinal cord ischemia, one case of pneumonia, and the short follow-up of 22 months with 24 re-operations

in seven patients. Here are my conclusion. The laser fenestration EVAR must not be used for elective cases. In our strategy, the best options for urgent thoracoabdominal is to use

an off-the-shelf graft, like the T-branch. If a custom-made device graft is not available, the laser fenestration will be our reference treatment, and you don't need any brachial or axillary approach for this technique. Thank you very much.

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.

- [Audience member] How about children?

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

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

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

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

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

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

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

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

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

in the pediatric population on a broad scale there.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

so our story starts out at MGH, the IR, you know in grade two, where we do it. We have six rooms where we do anesthesia. Every room is actually outfitted with anesthesia equipment. So room four's our CT. Room six we do our anesthesia cases.

Room two we do our complex cases, CERTs, pre CERTs. Room one, neuro IR. So it's typical IR program I think. But I think a lot of special things happen. And although it doesn't seem like that at some point. But I believe that we're at the leading edge

of the contemporary trend that's coming. So IR at MGH our case growth has increased by 20% over the past year. From 2016 to 2017 we went from 1200 cases to 1400 cases with, this is IR anesthesia only. We're growin' pretty rapidly.

It's 20% growth. And I believe that we're gonna grow more this year just because, I'm not sure what's goin' on, put the patients just keep on getting sicker and sicker. And our services keep on getting more and more wanted, I suppose.

The top three cases that we do are G-tubes, tunneled line catheters, our fistulagrams. Our CT microwaves as well. So those are the top three, top four cases that you can see where general anesthesia is utilized. We do about 50-50% of inpatients and outpatients.

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,

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.

So I'm from Massachusetts General Hospital.

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

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

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

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

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

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

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

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

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

in some of these complex pain patients.

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

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

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

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.

So needle guidance is one of the main tools that we use. This is basically a straight line overlay.

Distinct starting and ending points. We draw this again on cross sectional imaging. Automatically, you can align the C-arm to the, to kind of align with the path that you've drawn, in either a bullseye line of sight orientation, or also a kind of tangential view.

And really you can use this for anything that has straight line geometry. Bone trocars, cement cannulae, ablation probes, screws, temperature probes, hydrodissection needles, anything that more or less is straight line geometry. Just a couple examples of this.

On the right side you can see an example of bullseye needle guidance orientation, and then a more tangential view from the side of the same pathway, so that you can have real time kind of overlay guidance of needle placement as you rotate the II, with a detector,

back and forth real time. And one of the benefits of this is to be able to achieve placements within narrow corridors. Example on the left is placing a screw through a scapular body, which

you know, is pretty thin with a narrow corridor, but this really facilitates placement in this circumstance.

For us anesthesiologists the NORA challenges

are the ergonomics, or unfamiliarity with the landscape, limited help, we're consultants to consultants. And this is like, you know you read, you turn the book and you read, everything is the same story you know. And I find these excuses,

because I don't think we've, we hide under these challenges. And I think a lot of people refuse to accept that we're here, and we're here to stay. And you know, you're gonna love us. You're gonna love us, and we're gonna

love you no matter what, so these challenges are just the misconceptions I think. Traditional misconceptions that I hope that I can, for you, invite you, and tell you that, you know, these are just misconceptions.

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

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

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

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

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

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.

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

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

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

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

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

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

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

The 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.

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