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.
But it's really key to pay attention during
you know, your procedure. Patient movement during the procedure leads to misregistration of the overlay objects. And inaccurate needle placement. And so you really have to kind of periodically verify this registration and alignment.
This an example just from a case where you can see that the overlay is off from the actual fluoroscopic image. Which means that all of the objects that are tied to that overlay are also gonna be off.
And so while the needle guidance and the advanced imaging can be helpful, you do have to kind of pay attention as a proceduralist to what you're doing, and whether it makes sense fluoroscopically. So you can see here that this
bullseye orientation needle guidance placement is really not exactly where it needs to be. It really should be shifted over a little bit more, into this AP corridor. So registration becomes kind of a iterative process during cases.
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.
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.
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.
- [Nick] Good morning everyone. My name's Nick Kurup, I'm from Mayo Clinic. And I'd just like to thank Kristin and the leadership for inviting me to speak. I'm gonna be talking about bone ablation for local tumor control, and these are my disclosures, research stuff,
and writing about this subject. So I'm mostly gonna focus on the why. Why do we do bone ablation for local tumor control and I'll talk about a rationale for focal therapy in these patients, a little bit about technique,
and then some evidence supporting ablation for these patients. So there's been an evolution in our understanding of patients with metastatic disease. Starting in the late 1800s with Dr Halsted, he described the orderly and contiguous understanding
of metastatic spread in the case of breast cancer. So the primary tumor moving through the lymphatics to the lymph nodes before spreading systemically. And he used this as justification for patients undergoing mastectomy or radiation therapy to the breast.
Another understanding of metastatic disease is that it's always widely disseminated. So if we have a patient like this that has a melanoma metastasis to the liver, if we only had more sensitive imaging techniques could really see what's going on,
we would see that there's not only the single metastasis, but really a host of other metastases, and these patients all have micrometastasis, cats out of the bag, there's nothing to do focally for these patients.
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.
So in conclusion, recent fluoroscopic software advances enable these various forms of,
ends up kind of being augmented fluoroscopy. The points, lines, volumes, really you can apply these in a lot of different creative ways. Dataset registration, verification is critical. Advanced imaging ends up being trusting the computer. And so a knowledgeable technologist is really invaluable
in terms of making sure that things are done correctly from the workstation standpoint and the registration as a case kind of goes along. So, thanks for your attention.
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.
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.
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.
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.
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 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.
Moving on to percutaneous decompression techniques for the discs, we can have decompression and we can have regeneration techniques for the discs. Specifically for the decompression techniques we can have thermal techniques using laser, continuous or pulsed radiofrequency and plasma energy ablation.
We can have mechanical decompression using a wide variety of devices and we can have chemical decompression by means of Discogel or ozone intradiscal injections. All these techniques, what they are actually based on is that fact that a intervertebral disc is a closed hydro-ablic space and when you are removing a small
part from the nucleus, you are actually causing a significant decrease in the intradiscal disc and this disc pressure actually is what makes the herniation move inwards. And we have these techniques from back in the 1940s. The indications for these kind of treatments
in the intervertebral discs include patients who are capable of providing consent with a symptomatic small to medium-sized herniation and when we are speaking about the size of the herniation, if you have a theoretical line between the facet joints, all herniations which do not cross this line,
they can be percutaneously treated. And when we are speaking about symptomatic cases, symptoms should be consistent with the segmental level where the herniation is located on the MR imaging. For example, if you have a left L4-L5 foraminal herniation, you are expecting the patient
to report a left L4 root neuralgia. Absolute contraindications include sphincter dysfunction, extreme sciatica and progressive neurologic deficit. And actually all these are indications for surgery. Additional absolute contraindications include sequestration or the presence
of asymptomatic herniation, local or systemic infection, spondylosthesis and stenosis of the vertebral canal, anticoagulants, coagulation disorders and the patient refusing to provide informed consent. Most of these techniques are performed under fluoroscopy so we (mumbles) projection with 45-degrees angulation
of the fluoroscopy beam and as far as the lumbar spine is concerned, we perform a direct posterior lateral (mumbles) in the disc. In the final position, we need to have the needle in the anterior third of the disc in the lateral projection towards the midline in the AP projection and you can see
how important the technologist is because we need to have good visualization of what we are doing. Once you are there, you have access to the disc and you can insert any kind of product that you are familiar with, starting from thermal, going to mechanical or chemical decompression.
The magic number for all these techniques concerning success rate is around 80%. The complication rate is very low, between 0.5%. What we do know so far from the literature is that there are no studies of evidence of superiority of one technique over the other.
As we've already said, complications are really rare. Spondylodiscitis is the most fearsome one with a percentage of 0.24% per patient.
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.
And you kinda see in, in real time, in fluoro, this is at the same point and time, but from different projections
that these different contours actually project differently based on how the detector is rotated, so that you can kind of have, in a real time feedback as to where the edges of your intended ablation or cement fill are.
And sometimes again, and this can be very hard to tell, using just fluoroscopy in a pelvis or a bone that's had extensive destruction. Where you don't have good cortico kind of markers under fluoroscopy. Registration is really a key to all this,
and a big part of where the technologist come into play. This is really the process of aligning one data set with another. There's different ways you can do this. Two dimensional, three dimensional,
or three dimensional, three dimensional registration. What this allows you to do is potentially draw those objects of overlays on a separate 3D data set, so maybe a pre-procedural imaging study that has contrast, where you can actually see your targets a little bit clearer.
And then be able to fuse or register this with you know, real time, time of procedure, cone-beam CT. So that you can kind of then stack and fuse those objects that you've drawn on a more detailed study before.
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.
Moving on to breast lymphoscintigraphy or breast mapping.
We use sulfur colloid for this. Indications for it is the patient's probably getting the surgery, either the day of or the day after and the doctors need to know which sentinel node biopsy do they need to do. It shows the first draining lymph node.
We do two kind of mapping. One is the same day surgery mapping and the second it's a day before as it says, same day is for the patients who are having surgery today and day before is the patients who are having surgery the day, the next day.
Doses, same day surgery at 0.1 millicuries, and day before is 0.5, it's tiny. Yes, we do use that little syringe. For procedure, you confirm the patient, you confirm the order, and the breast laterality, not just with the patient but also their chart.
Because how many times has it happened, the patient is like, "But I'm getting surgery "on both breasts." The order is for right because there is a reason. They're only doing breast biopsy on the right. Also, it can eliminate them of the wrong orders
that might happen in the system. You wanna confirm. We have a tendency at MSK to look at the consents, the mammograms, the CIS order and so this pathology reports just to make sure everything is in order. I like to educate my patients beforehand.
A lot of patients come in, oh it's a test, it's a nuclear medicine test, they have no clue. I like to just go over it. Any patient that come in after I confirm everything with them, I'd tell them, "So today we are doing "breast mapping, I will be injecting
"a little bit of radioactive isotope "right underneath the skin so it's intradermal, "it goes at the six o'clock perioral, sorry, "peri-areolar area." You can show it on yourself and most patients know what six o'clock is, they're adults.
When I inject, there will be a little pinch and a burning stinging sensation. If the patient has had a recent biopsy or a recent radioactive seed placement, they are more sensitive than others, so at that point, if I know they have had it,
or they say, "Oh yeah, I have had this today," we tell them, "Yes you might be more sensitive to it "than a regular patient. "But just be patient, it will pass. "It is not that long." You inject the isotope, it's like I said,
it's intradermal, so even though that's a PPD test, it kinda looks like that. You do see a little bubble as you inject. After the injection, I'd cover it with gauze, put some paper tape on it, because I really don't want anything else, and I use a couple fingers,
put it at the point and start a pointed massage. It doesn't matter which way you move, just as well you keep it moving, so that it facilitates the isotope to go towards the first draining left node. It disperses the isotope.
I show the patient as I'm doing it, this is how you're doing it, and then I wait there for about 30 seconds to a minute to make sure they're doing it. Some patients, as soon as they start doing it, they go like this, they're caressing,
they're not actually moving it. Some people are being really vigilant and they are like just kinda digging it and you don't want them to get tired before the 10 minutes are up. I just make sure they're doing it right,
tell them, if this hand tires, you can use your second hand and then leave the room. We have, thankfully, we have volunteers whom I can say, "Hey, in 10 minutes, "at exactly this time, can you let the patient know "to get dressed and wait in the waiting area
"until one of our technologist bring them back in "for a 10 to 15 minutes scan." If I do not have the volunteers, I have used a timer, because God knows we have all forgotten whether the patient was in there for more than 10 minutes massaging their breast.
Happens, unfortunately it happens. Someone calls you for something else, and you get busy in that. This is the view, and this is actually, I especially chose this one because you can actually see almost three lymph nodes.
The first, the lower part is the point of injection, and there are a couple up there, that's the anterior and the lateral view. The next day, when the patient goes into the OR, their doctors just have to use their wand to see where the radioactive isotope is.
This picture is actually for us to make sure that it has drained into the lymph nodes.
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.
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.
Alright so now if there's still a bit of disbelief in, oh let's just look a bit how it can normally look,
and how you might be able to change it, there we go.
V/Q scan. We use MAA for IV and I did not add D.T.P.A in the aerosol form. Indication. Pulmonary embolism for pre-surgical testing or the patient is unable to have a CAT scan
with contrast because either they're allergic to the iodinated contrast or they have a decreased eGFR. V/Q scan has two components, the ventilation, which has aerosol dose of 40 millicuries and then a perfusion dose IV of five millicuries. Sorry, going back, actually those are the containers
that we use to carry those doses. Ventilation, patient either gets an oral, disposable oral mouthpiece or often disposable mask on their face and it can, the radioactive isotope can be infused with either air or oxygen depending on patient's need.
Patient is told to take nice, deep breath through their mouth, not through their nose. We want them to take deep breaths through their mouth for about two to three minutes until the isotope is all gone, and this part is done all by technologist and then they scan them for about 20 minutes.
Those are ventilation pictures. Where the isotope is, you can see all the darkness, because if there's a PE, it won't travel further. It wouldn't travel because there is a clot. The isotope cannot infuse. Perfusion, that's where the nurse comes in.
You confirm the patient, you confirm the allergies, and you inject. Now MAA is always only injected in peripheral IV, central line, because MAA is very concentrated, so if we inject in central line, including PIC lines or Medi-Ports, it can cause a PE.
We don't really want to do that to the patient. Patient is instructed to take deep, even breaths, so when I come in as I'm putting in an IV or assessing their IV if they have one, I usually talk to them about that time period, and I talk, give them the education
that I will be injecting the radioactive isotope, I will be flushing it with two to three normal saline depending on what kind of IV excess it is and varieties and if it has an extension or not. And I want you to do yoga breathing for me. 'Cause I've had patient who have literally
hyperventilated on me, thinking that they're helping me. Yoga breathing is my term, I really love it. Nice, deep, even breaths and it also helps with the stress. Once you're done, just remember to tell them to breath normally, not, don't tell them stop breathing. Done that, didn't go very well.
- [Audience] Don't tell them to hold their breath. - Yeah, so just breath normally. This is the perfusion picture. As per a doctor's, I'm gonna step up here, it didn't prefuse, stop right up here, so they actually found that PE there
because the isotope did not travel to the full lungs. There was a little PE, so it didn't actually trans. - [Audience] Seeing the black in this case is a good thing? - Yes. - [Audience] 'Cause that means it perfuses correctly. - This is another picture.
It's a perfusion. The darkened areas are where it's not going through the isotope. Yeah. Okay so this is another case where the CT was normal, the doctors were still not sure,
they sent it to us, the ventilation scan went great, the pictures looked great. Then, perfusion scan, you can see the little, a big area, that's darkened, the isotope did not go. Right, the colors are amazing. Contraindication.
Patients who are unable to follow instructions, that could be because of altered mental status or sedation. Patients who are in too much pain because they will not hold still for the scan. And pulmonary hypertension. A regular MAA is 0.5 million particles.
It consists of 0.5 million particles. For pulmonary hypertension, we can only inject up to 100, 250,000 particles. If you use 0.5 million particle, a regular MAA dose, you can cause capillary blockage causing a cardiac arrest right there on the scanner.
Not something we do need. We have had patients who are elderly. We do not know their history or they are unsure, so it's always great to have a doctor in the room while you are injecting, just to be on the safe side and we have had that, especially later in the evening,
when we don't have as much help. V/Q scan, this was one where we weren't sure. Actually the lower pictures are of a patient who was in a lot of pain. Upper pictures are normal. As you can see, you don't know if you're seeing
an angel or vulture. Depends on the patient, right? Or the person who's looking at it. Patient kept moving, instead of breathing in through the mouth, they gasped, and they, the radioactive isotope
went into their stomach and we could see esophagus and the stomach and it was just not a happy scan. It's always great to make sure your patient is comfortable before you start doing all of these procedures with them.
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.
- Thank you, I'd like to start by thanking Dr. Veith, not only for the privilege of the podium, but for many years ago teaching me how to do these exposures. If you've missed some of the pictures, many of these were published by Enrico, Dr. Veith, and myself not too long ago in JVS.
So vascular exposure through scarred or infected wounds, as we know, leads to increased OR time, increased risk of blood loss, infection, and damage to vessels and nerves. This afternoon I'm going to show you how to avoid going back into those scarred groins.
On the scarred groin which is seen in the left lower-hand corner, a good inflow vessel is the external iliac artery. It's very easily dissected out in thin patients through a very small incision, about two breaths above the inguinal ligament.
Once you go through the internal and external oblique, you can gently pull up the retroperitoneum, and they're easily exposed. Sometimes even more difficult than the exposure is tunneling through the scarred tissue. You want to tunnel deep to the inguinal ligament
and anterolateral to the artery, usually involving a counterincision to avoid injury to the venous branches. If it's for infection and you're tunneling through the obturator canal, please remember to tunnel inferomedial
to avoid the neurovascular bundle that is superiolateral. The profunda femoris in its mid and distal portions can be a good inflow or outflow vessel. As you see on the left, it lives right underneath the sartorius muscle. The picture on the right shows incision to expose it,
either medial or lateral to the sartorius muscle. Lateral is usually for more distal. The picture on the left shows the course of the dissection once you get deep to the superficial femoral vessels. There is a fibrous band between the adductor longus and vastus medialis,
and once you get through that tissue plane, the profunda vessels are right there. Here you can see the sartorius muscle and superficial femoral artery pulled laterally. When there's scarring medially, you need to get to the popliteal artery.
The above-knee popliteal artery is easily exposed through an incision between the iliotibial tract and the biceps femoris tendon. Once you get through this tissue plane, you can bluntly get into the popliteal fossa and dissect out the above-knee popliteal artery.
The below-knee popliteal artery is a little more difficult. You have to worry about the peroneal artery, I'm sorry, the peroneal nerve that is there, as long as the fibula. You have to dissect off the common peroneal nerve, detach the biceps femoris tendon,
divide the rest of the ligamentous attachments. But once you get out that fibula which causes almost no disability, the below-knee popliteal artery is right there. When tunneling to these, we usually tunnel in a subcutaneous fashion
across the thigh and laterally. If you have lateral infection or scarring and you need to get to the very origin of the anterior tibial artery, you can get there medially. You would dissect the below-knee popliteal artery as usual,
as well as the tibia peroneal trunk. You can almost always see the anterior tibial artery poking through the interosseous membrane. You can put a right-angle clamp in there and very carefully divide that interosseous membrane and expose about the first five centimeters
of the anterior tibial artery. This was used, as you can see here, in a medial vein bypass to the origin of the anterior tibial artery. Lastly I'm going to show you a lateral approach to all three tibial arteries.
It does require a fibulectomy. I have only actually done two out of the three. An incision is made over the fibula in the lower leg. One you get through the fascia, I usually take the Bovie cautery right down onto the fibula. A combination of Bovie cautery and periosteal elevator
will clear all the tissues off of the fibula for at least about eight to 10 centimeters. You have to be very careful posteriorly because the peroneal vessels sit right there. When you divide the fibula as seen in the lower right-hand corner,
you have to protect the peroneal vessels. I usually put an Army-Navy in there, and you can divide it any number of ways. But once you divide the fibula, the peroneal vessels are immediately behind it. That's a very easy exposure.
If you pull down the posterior tibialis muscle, you can very easily get to the anterior tibial artery, and posterior and deep to the peroneal vessels you can get to the posterior tibial artery. Here is just a scheme showing the peroneal artery, anterior tibial artery,
and posterior tibial artery with the fibula resected. And one last picture is a peroneal bypass, you can see the absence of the fibula here. And I thank you for your time.
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.
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 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.
- Like to thank Dr. Veith and the committee for asking me to speak. I have no conflicts related to this presentation. Labial and vulvar varicosities occur in up to 10% of pregnant women, with the worst symptoms being manifested in the second half of the pregnancy.
Symptoms include genital pressure and fullness, pruritus, and a sensation of prolapse. These generally worsen with standing. Management is usually conservative. Between compression hose, cooling packs, and exercise, most women can make it through to the end of the pregnancy.
When should we do more than just reassure these women? An ultrasound should be performed when there's an early presentation, meaning in the first trimester, as this can be an unmasking of a venous malformation. If there are unilateral varicosities,
an ultrasound should be performed to make sure that these aren't due to iliac vein thrombosis. If there's superficial thrombosis or phlebitis, you may need to rule out deep venous extension with an ultrasound. When should we intervene?
You may need to intervene to release trapped blood in phlebitis, or to give low molecular weight heparin for comfort. When should a local phlebectomy or sclerotherapy be performed? Should sclerotherapy be performed during pregnancy?
We know very little. Occasionally, this is performed in a patient who is unknowingly pregnant, and there have been no clear complications from this in the literature. The effectiveness of sclero may also
be diminished in pregnancy, due to hormones and increased venous volume. Both polidocanol and sodium tetradecyl sulfate say that there is no support for use during pregnancies, and they advise against it. So what should you do?
This following case is a 24 year old G2P1, who was referred to me at 24 weeks for disabling vaginal and pelvic discomfort. She couldn't go to work, she couldn't take care of her toddler, she had some left leg complaints, but it was mostly genital discomfort and fullness,
and her OB said that he was going to do a pre-term C-section because he was worried about the risk of hemorrhage with the delivery. So this is her laying supine pre-op, and this is her left leg with varicosities visible in the anterior and posterior aspects.
Her ultrasound showed open iliac veins and large refluxing varicosities in the left vulvar area. She had no venous malformation or clot, and she had reflux in the saphenofemoral junction and down the GSV. I performed a phlebectomy on her,
and started with an ultrasound mapping of her superficial veins and perforators in the labial region. I made small incision with dissection and tie ligation of all the varicosities and perforators, and this was done under local anesthesia
with minimal sedation in the operating room. This resulted in vastly improved comfort, and her anxiety, and her OB's anxiety were both decreased, and she went on to a successful delivery. So this diagram shows the usual location of the labial perforators.
Here she is pre-op, and then here she is a week post-op. Well, what about postpartum varicosities? These can be associated with pelvic congestion, and the complaints can often be split into local, meaning surface complaints, versus pelvic complaints.
And this leads into a debate between a top down treatment approach, where you go in and do a venogram and internal coiling, versus a bottom up approach, where you start with local therapy, such as phlebectomy or sclero.
Pelvic symptoms include aching and pressure in the pelvis. These are usually worse with menstruation, and dyspareunia is most pronounced after intercourse, approximately an hour to several hours later. Surface complaints include vulvar itching, tenderness, recurrent thrombophlebitis, or bleeding.
Dyspareunia is present during or at initiation of sexual intercourse. I refer to this as the Gibson Algorithm, as Kathy Gibson and I have talked about this problem a lot, and this is how we both feel that these problems should be addressed.
If you have an asymptomatic or minimally symptomatic patient who's referred for varicosities that are seen incidentally, such as during a laparoscopy, those I don't treat. If you have a symptomatic patient who has pelvic symptoms, then these people get a venogram with coils and sclerotherapy as appropriate.
If they are not pregnant, and have no pelvic symptoms, these patients get sclero. If they are pregnant, and have no pelvic symptoms, they get a phlebectomy. In conclusion, vulvar varicosities are a common problem, and usually conservative management is adequate.
With extreme symptoms, phlebectomy has been successful. Pregnancy-related varicosities typically resolve post-delivery, and these can then be treated with local sclerotherapy if they persist. Central imaging and treatment is successful for primarily pelvic complaints or persistent symptoms.
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