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MectaLIF overview
MectaLIF overview
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Program Implementation | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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PET/MRI Case Study #2 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
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Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
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products I personally have used all three of these with the exception of the anterolateral plate which is I think a European product but it's become one of my favorite Medacta implants. Here is a case

that is a one level 5-1 and I wanted to point out to you that this particular product was the plain vanilla PEEK spacer and I'm going to contrast that with the Ti PEEK spacer which we'll see in just a couple of slides of course

there's a offering of TLIF TPLIF and PLIF options and then also an anterior cervical system. I wanted to also

individually into each one of these trials but I want to just point out to you how busy the last 5 years have been because it has really caused a

resurgence in our interest in both treating PE better and what the gaps are in our knowledge so I will point out in 2014 this was an inflection point for 10 years we didn't have a major trial actually more like 12 or 15 years we

hadn't had a major trial in in PE and pytho was a 1000 patient study that informed us about how systemic thrombolytics interact with sub massive P and I'll go through the data that same year

catheterized thrombolysis is everybody familiar with catheter at the thrombolysis for submasters before Pease that's totally off the grid okay good well this was the first time we had a randomized trial for catheter directly

thrombolysis with some with some massive PE only problem was it was 59 patients in Europe so and that's all we have as far as randomized trials for CDT this is my soapbox issue I'm sorry if you've heard me say this but that's that's my

big goal is to try to change that 2015 had some follow-on CDT trials 2017 this is when we started thinking about the long term effects of PE on patients both of these studies started to examine the issue where a year after the PE patients

are not normal if you did a for example this elope long term study almost 50% of patients had an abnormal cardio pulmonary function test one year later 2018 we started to experiment with the dosage that we're

administering during CDT that's the optimized trial and we saw the first trial completed for a mechanical device called the NRA flow trailer which I'll show you later in the talk as well so that was an exciting inflection point as

well the extract PE trial which uses the indigo cat 8 device to aspirate thrombus in pulmonary embolism we just completed enrollment this year the future is hopefully bright for generating more data the PERT consortium registry is up

and running and is hopefully going to help us aggregate data and make better decisions and then you have a couple more devices coming in and I'll tell you our efforts to try to really improve the knowledge base on what CDT for sub

massive P that's the P track trial that's the last bullet point there okay

so are you ready here's the final project product tada that's what our d-h radiology nursing dashboard looks like today so as Tommy mentioned the goal of

our dashboard is to help the frontline objectively understand their performance and be proactive about making decisions to help their run day their day run smoothly all of these metrics on the dashboard work together to achieve those

goals so for example at the top right here the procedural workup pending and calls pending help to see the volume of pending workup and phone calls that need to be completed over the next few days another exam

well here on the bottom left the nursing case volume that's another it helps us to sort of see the different levels of nursing resources needed by hours of the day the dashboard is not just for nurse managers and for supervisors but for the

frontline users as well we had to teach your nurses how to use this information in real time what we have learned that by using actual data to drive decision-making nurses are able to deliver patient care more consistently

and in compliance with standard practice they are also able to manage variation and optimize utilization of resources the dashboard proves to be an easy tool to apply and capture meaningful metrics around the radiology nursing workflow

this is the framework we use to educate the frontline nurses on the real-time application of the dashboards we broke it down into four simple steps look so looking at the data interpret and gain insight 3 apply and maybe take action

and for what are the results and how are we assessing those results the next few slides will look at some specific components of the indicators on the dashboard and demonstrate how we use this model look interpret apply and

assess to increase the utilization of the frontline staff in their everyday work this is one of the dashboard components that you saw on the dashboard called buffer time the buffer time is the amount of time left till the patient

scheduled appointment time so for example the patient's appointment time is at 12:00 you can see the check-in time generally what we have found that it takes about 60 minutes from the time the patient checks in to get them into

the procedural room so based on that we have the appointment time at 12 12 o'clock the patient checked in at 10 11 and we have a buffer time you have 21 more minutes to go until there a scheduled appointment

time so let's use the look interpret apply and assess model to help better understand how this dish board indicator works so look as you can see we have multiple patients that have checked in interpret we have three patients

highlighted in red that indicates their past their appointment time and then we have four patients in green indicating time left till scheduled appointment time so what action can we take on this well first I'd look at the red patients

since they're late and I would determine next steps there's an ir case in room two that's nine minutes late and then we have an MRI our nurse that is also nine minutes late and it looks like we have a CT case that has nineteen minutes late

oftentimes I know this just because it's our area but if I was to look at this in our nurses too we would confirm that the CT three case really needed a nurse and generally we don't do procedures in our CT room three as far as the green

patients are concerned we would look at the we'd look at both these two twenty one minute buffer times and say and confirm that the pre-work is on track that we're ready to go and we're going to be able to get those patients in as

far as these two patients you can see they checked in way early then there's 60-minute time and at this point I wouldn't do anything else for that and then as far as assessing generally that's done sort of like later in the

day to discuss in the huddle future actions that needed to be taken maybe to prevent this okay let's try another component of it of our dashboard this here is our procedural patient workup turnaround time so here the first box is

the time in which it takes the RN to do her workup so that might be checking the patient in verifying labs vital signs placing an IV etc and then this middle box is the total workup time which includes the fizz

since time as well so a si and Malley mallampati assessment consent that kind of thing and then the third box is the total time the patient was in the pre room so let's apply our model again so as we can look the RN pre workup is

taking 22 minutes on average the pre procedural workup time total is taking 39 and the total patient time 65 so what can we gather from that as I mentioned earlier we give about us it's about 50 minutes generally when we've done a lot

of audits but we give a 60 minute window so that's why we asked our patients to come in 60 minutes before their before their actual scheduled appointment time so what can we interpret from this so as I'm looking the RN process time is

within 30 minutes so we're good there the total workup time was is in within the 50 minute expectation and we still have our 10 minute buffer remember however the total time in pre exceeds the 60 minute expectation so what action

might we take as a frontline either charge nurse or the any of the nurses say what should we do next so here what I might do is talk to the charge tech who sort of does all the orchestrating of the rooms and say so what's the

possible bottleneck because we've got our patients ready to go within 39 minutes to gain on time start but however it looks like we're stuck I will tell you that there is some of those variations like we had a stroke come in

or a trauma that actually bumps cases we get that piece but why are the rooms running what can we do can we maybe make a person that was scheduled going to room to go into our overflow room in five if say a power authorities like are

less acuity room so those are type of things that we can talk about in real time to get patients moving and so we don't continue to have late start delay so we'll move on to the next one

pressure of 60 over 40 minimally responsive I'll give you that

there are probably two right answers if you were going to figure to go by the book on this this PE qualifies as a good I agree with a now what about e somebody pointed this out the other day and I was like oh yeah it's a reasonable point

exactly it has to be greater than 15 minutes so theoretically e is correct as well but that's not what I meant when I put question together all these pitfalls okay

multiple choice question number two seventy year old woman blood pressure of 128 over eighty heart rate of 115 RV strain on echo elevated troponin what type of PE is this I hear a lot of C's that's correct

so let's go through this so yes this person has RV strain on both echo and an elevated troponin so meets that criterion but how do we know the especi is or the passier the especi is positive here the heart rate exactly so the heart

rate on that scale had to be greater than 110 it's 115 so positive especi RV strain and echo elevated troponin high risk intermediate PE 24 year old woman blood pressure of 150 over 80 heart rate of 95 no RV strain large central embolus

what type of PE is this sorry can someone be a little louder dee dee is correct so just the the the thing I was trying to trip you up on is the large central embolus at this point we still do not use where the embolus is as

a criterion for stratification okay now I will say that large central embolus tends to correlate with our V strain so you will see a lot more patients with central embolus have our V dysfunction at the same time and so they'll often

meet the criteria for the sub massive are massive but if you have just a totally normal right ventricle no elevation and the in their troponin and their BNP that is still technically a low risk PE and we'll see this sometimes

to our case study the first case study is the normal whole body pet MRI the the

image song to your left it's a regular pet MRI the one on the right as you could see it's a big difference there is very vivid image and you could pinpoint the organs they are not to me of the patient this is normal

scan there is normal uptake on the brain the ureters the bladder the kidneys those are normal there's no abnormal uptake or there's no hypermetabolic uptake noted the next case study is a 59

program is the stuff requirements and

stuff education all personnel who works in this department the radiology department have to complete successfully the web-based training for level 1 and level 2 safety MRI training including the housekeeping

and also the hospital staff that comes to the department have to fill up a screening form after doing so you'll be given a sticker placed in the back of your ID and it's good for a year and that serves as your pass coming to MRI

so you don't need to fill it up every time you come in and the initial radiation safety training is given by our safety radiation safety officer in the start all it's on higher and also the best training for RT Sundarbans

course training to nuclear med and the pet department it is important if you work in the radial pharmaceutical area that you know the basic concept of spill management the acronym cares I would like to acknowledge that this acronym is

done or formulated by our nurse leader le carré leer C stands for contains pill and opened the checklist the checklist should be available or posted to all areas where major pharmaceutical agents are administered a s alert the

technologist and supervisor they're very knowledgeable in taking care of the spills our is to restrict the area don't let anyone come in and step onto his areas of spill remove the patient if possible he is to educate the patient

you have to reassure the patient there is no health hazard or nuclear hazard to them yes is to sanitize sanitize the area of spill and record in the medical record is very important but what to do when this bill occurs in the zone for of

the MRI we were prior to going that I would like to show you the how our Rachel active spill checklist looks like this is formulated by Pierre Robson it would take you I would give you guidelines on how to do step by steps in

case of nuclear spill and what to do for spills that occur in MRI so on for first cover the area with absorbable material remove patient from stone for prior to proceeding to the decontamination process contact

radiology leadership they're the one to direct surface contamination within zone four and remember the Geiger counters are MRI unsafe so how we check the Geiger counts you have to use an absorbable material you keep wiping and

then bring it out and measure the Geiger level until you keep doing that until it gets cleared also remember that the MRI magnet is always on so have someone is done guard outside the door so anyone that would need to go inside the room

would have to be scanned again and screen this is our ms KCC clinical

I want this to be as instructive as possible I do have some multiple-choice questions that are peppered in there and hopefully you guys feel comfortable enough to shout out answers I really don't care if you get it right or wrong so but if I teach it right I hope it's

clear what the answers are okay so and and I know the title test says that I'm going to be talking about parts frankly I think there's a lot more to talk about about PE other than parts and I'm not going to be emphasizing that

but if there's time to ask questions or I'm happy to speak about that as well because I think the disease and the treatments are really the crux of PE at this point okay so I start with something called the landscape where are

we with pulmonary embolism well you know I don't know how many of you have seen PE in the IR suite or have dealt with these patients or even have friends or family that have had a PE but I don't think anybody who's interacted with this

disease would argue with the fact that PE is a big deal why do I say that statistically speaking well there are 900 000 VTE events per year that's DVT or PE that's a lot it's almost a million now the number of deaths from PE every

years quoted to be as high as 300 000 but is around 60 150 is what we think so quite a few this affects everybody you know you might have heard of Serena Williams getting a PE Chris Bosh and Serena Williams I think had a massive PE

which I'll tell you the definition of that later but it's a it's it's something that can affect a young person and kill that young person so that's what makes it a little bit tougher than some of the other diseases it's the

third most common cause of cardiovascular death stroke mi then PE ten percent are fatal within the first hour so a lot of these patients you're not even gonna see and when you do see them you've got a big task ahead of you

because they're you're trying to rescue them from death that's basically the same statistic now if you were to take every patient who comes into the hospital and you put an echocardiogram on them and you looked at the right

ventricle their right ventricle would show some evidence of dysfunction and so that's an interesting statistic because right ventricular dysfunction is you'll see on a subsequent slide is actually a pretty big deal and is actually at the

crux the pathophysiology of PE now if you were to do a VQ scan around six months after people got a PE you would find that 1/3 of those patients actually have residual thrombus so we think that you

know PE is a acute disease but what we're finding is that it's actually a cute disease that can become chronic and a lot of people and we're actually revealing unveiling the fact that maybe a year or two years after their PE these

patients aren't doing as well as we thought so that this is a burden it's a chronic it's a chronic disease that causes a burden on their lives so this is the disease and and you know as an IR you look at this and you say well that's

pretty exciting looks like we can intervene on something meaningfully but there are some caveats we should remember first most patients have low risk PE s I'll define that in a little bit but these patients don't need an

intervention they just need anticoagulation to the best of our knowledge that says all this this group needs sub massive PE I'll spend quite a bit of time on and it's a very controversial topic and there's a

lot of different attitudes between interventionalists and non interventionists about sub massive PE when you get a massive PE patient this is the patient that's crashing and burning most of them should receive

systemic thrombolysis which is an IV in the arm and a drug through their vein it's the fastest thing you can do and it doesn't involve corralling an IR suite the team for the IR suite or a surgical team and as I just said there's a wide

range of attitudes regarding treatment aggressiveness so I'm not going to go

okay pathophysiology right ventricular the right ventricle is everything when it comes to the pathophysiology of this disease I'm gonna lead you through this because I think it's interesting and important I'm gonna go to this side this

time be fair to both sides of the room so when you have a PE that increases your pulmonary vascular resistance normally the pulmonary vasculature is a very low resistance circuit but when you start putting clots in it it's restive

Gong its its resistance goes up it's kind of analogous to the left an electrical circuit what does that do to the right ventricle well it increases the after load on that right ventricle so what that does is it causes the right

ventricle to blow up like a balloon now by Laplace's law if you take a balloon and you blow it up the intramural pressure is higher in the balloon so if you can imagine that thin walled balloon if you took the pressure at each point

inside of the balloon because it still got a finite thickness the pressure is higher than if it's decompressed now the problem with that is that how does the right ventricle get blood it gets blood from the coronary arteries but if the

pressure inside the ventricle is higher than the pressure differential is less and what what what is Flo rely upon it relies upon a difference in pressure from point A to point B so if that starts to equalize your blood flow to

the right ventricle decreases okay that's why the right ventricle gets ischemic now when the right ventricle becomes ischemic it can't squeeze as hard so it gets hypokinetic when it dilates it also does

not seem to squeeze out as well because the muscle fibers aren't overlapping as well okay so both of those things lead to both so that the right ventricle is now not squeezing is hard and it's not getting blood forward to the left

ventricle so that results in LV preload reduction though LV is not seeing as much blood on top of that when the right ventricle dilates it starts impinging on the left ventricle so now the left ventricular cavity is smaller and it can

accept less blood your output is only as good as your input okay so that's where you start developing systemic hypotension because your left ventricle can't pump out as much blood what happens when your left ventricle can't

pump out as much blood you don't get as much blood into your coronary arteries you don't get as much blood into your coronary arteries you're not getting as much blood into your right ventricle this is the vicious cycle that leads to

right ventricular failure and the progressive death that you see with massive PE now if you were to draw a line like that everything above the line is sub massive PE everything below the line is massive PE okay this is a big

experiment I did we were trying to create sub massive PE we created a massive PE this used to be mostly the L the left-sided chambers and all of a sudden became the right-sided chambers to me this drove home how much the right

side can blow out and dilate that's the only point of this picture I hope I didn't cross you out okay so let's talk

that's background let's talk about what I mean when I say massive sub massive low risk high risk intermediate risk low risk all these definitions they're

actually pretty precise and so I think we need to be on the same page for that so when you see this what do you call it saddle saddle is a reasonable one large because there's I'm not sure automatically did that but would you

call it a massive PE how many would say yes this should be called a massive PE okay how many no okay it's not a big deal I'm not remembering faces but this is not necessarily a massive P I'd be surprised

if it wasn't but it's not necessarily because I haven't given you a key piece of information the hemodynamics massive PE is all about hypotension so what does that mean so this is from the American Heart Association in 2011 a massive PE

is an acute PE with sustained hypotension meaning a systolic blood pressure of less than 90 millimeters of mercury for greater than 15 minutes or requiring inotropic support okay so doesn't matter where the clot is

doesn't matter how much clot there is if you're hypotensive for greater than 15 minutes then you fit in the massive category okay sub massive PE okay you have a normal blood pressure but your right ventricle is dysfunctional so

either by echo CT biomarkers such as BNP or troponin your EKG shows right heart strain basically your right ventricle shows some measure of duress but it has not totally decompensated to the point you're starting to get hypotensive and

I'll give you a pathophysiologic explanation in a couple slides low risk basically means that you have no hypotension no RV dysfunction no myocardial necrosis so you have clot in your pulmonary arteries absolutely but

your right ventricle is acting normal and you have no issues with hypotension that's 60% of pease that present to the hospital fortunately sub massive about 25% and massive five to ten percent okay why do we care about this categorization

is there any functionality this yes massive PE carries about a 25 to 65 percent mortality so it's a coin flip whether these patients are gonna live or die that's how severe this disease is sub massive PE you know these are the

patients that are compensated from a blood pressure standpoint but have RV dysfunction these patients have a three percent mortality or so in the most recent randomized now back in the late 90s and early 2000s

the mortality seemed to be higher on the order of 10% but I think we're settling around a 2 to 4 percent mortality for this group now these patients do have a higher rate of clinical deterioration than the low-risk group meaning they can

progress from the sub massive category to the massive category that's that 5% number there so this this group is a little bit that's why I said in yellow and the top group is in red low-risk patients anticoagulate them they'll be

fine so that was the eh-eh-eh in 2011 well the Europeans have to had to have their own version in 2014 and they said you guys you Americans are not doing this quite right so that's where they I'm sorry I can't put two pointers at

the same time that would be pretty cool but I'll start on this side if I can everybody over there see that all right so this intermediate group here is the same as the sub massive category I'm gonna walk you through this just because

it's you know we're more and more going towards the European Society guidelines so they break down this sub massive category into intermediate high and intermediate low and the reason they did that is they're saying that not all sub

massive pease are the same and that's probably true there's some some sub massives that are really not looking good and going towards massive and sub some some sub masters that are just rock solid stable and beside a little bit of

RV dysfunction they're probably gonna do just fine and just you know go towards the low-risk with a little bit of anticoagulation so what how do they break this down well both of them have this positive especi or pecci I'll show

you on the next slide what that is basically it's a pulmonary embolism severity index okay so you have to have that being abnormal or positive for you to fit in the intermediate category but then this is where it differentiates so

if you have an imaging test such as a CT or an echocardiogram and you have your laboratory biomarkers such as a troponin or BMP being elevated or abnormal then you fit into this intermediate high-risk category but if you have only one of

them or neither of them being positive in the intermediate low-risk category so what's the big deal why does that matter well but we don't really know frankly but what the European guidelines recommend

is if you're in this intermediate high category you should be watched because you have a risk of clinical deterioration and if you're going towards that they say consider reperfusion reperfusion could be

anything it could be systemic thrombolytics it could be catheter directed lytx or it could it could be surgery that's that's the way they put it if you're in the intermediate low-risk category you can be discharged

pretty early this is that pesi score and you can see why they tried to simplify it the s pesky because you have all of these factors and they're all assigned these points the more points you have the worse you are but let's focus on the

simplified pesky scale if you have a score of one or more of these then you're considered to have a 10% mortality in the next 30 days so that's these are what they thought were the highest impact issues in a patient

presenting with PE it doesn't tell you that just because you have a positive s peso you should intervene it just says that this is what may happen with these circumstance and we'll go through the first set just for a second here so age

greater than 80 years that's a that's an issue if you have cancer if you have heart failure or pulmonary disease a heart rate greater than 110 the systolic blood pressure less than 100 or an arterial oxygen saturation off of nasal

canula or supplemental oxygen less than 90% you get a point okay all right are we ready for the first question 65 year old man blood

turned the mic to my FA which she will be speaking about program implementation staff education requirements clinical work form and review some case studies

Thank You rose and good afternoon ladies and gentlemen I'm Rafael Donna I'm one of the regular genders at Memorial sloan-kettering I'd like to thank you now because I don't know later I might pass out because just a nervousness if

that possible let me know later okay I would like to acknowledge Pyrrha she's trying to leave now she's have to go back to New York thank you for helping us to make this presentation possible and Renee

he's here he's our clinical radiology director he's very supportive of us and thank you too Larisa Sanchez our nurse leader and Erika leer and are in for making this giving us opportunity to present before

I go into my part of the presentation let's say let's do a PET scan into to our MRI team you see the white floating areas over there let's pretend us the normal uptake from pet SDG but if we do pet MRI look what happens yay you see

their smiles it's very very vivid colors our team is very diverse you could see from all we come from all over different parts of the world they are awesome they help us give us this very good images that we're going to present today

the MS Casey pet MRI program planning and implementation took over a year the department have to hire dual modality artis who specifically trained for pet and MRI the cross training of our ends because we all MRI nurses we have to

cause cross train to nuclear medicine and pet department the construction of the radio pharmacy in the MRI suite and the development of the pet amar protocols in collaboration with the bio engineers physicists the radiology

leadership the attending radiologist the radiology leadership our ends and the artis also the compliance with the State Department of Health regulation guidelines very important part of this

these are our prospective CDT trials it's a lot to go through them so I'm not going to suffice it to say that the only one of these that is randomized is the

one in the top left the ultimate trial with 59 patients the rest of these are single set are single arm studies the optimized trial was randomized but the key arm it did not have was a control arm so all it did was vary the amount of

drug but there was no control arm to tell us how are people doing if they just get heparin well and I'll show you one result from these trials that is the most important result and that is up from the ultimate trial at 24 hours CDT

catheter to thrombolysis reduces the RV to lv ratio to a greater extent than heparin alone what does that mean so you saw all those pictures with the big dilated right ventricles our surrogate measure for right ventricular

dysfunction is the ratio of the diameter the inner diameter of the right ventricle to the left ventricle what we found in this study was that that ratio got reduced to a greater extent at 24 hours in the CDT arm compared to heparin

alone that means that CDT seems to reduce our V dysfunction faster than heparin now importantly 30 days later the echos looked identical so really it's a question of time which is not surprising what we've noticed in

our practice is that patients feel better faster okay I'm gonna go through the rest of this because I'm out of time but I want to give you a little bit of a sense of where we're going because there's bleeding associated with CDT and

maybe I'll show you this that in the Seattle to trial there was an 11% major bleeding rate now this was a pretty conservative definition but there were some serious bleeds and there were no intracranial

hemorrhages in this study but we have realized that CDT is not risk-free it's not like we've all of a sudden gained all of the advantages of systemic thrombolytics and none of the disadvantages now the rate of

intracranial hemorrhage seems to be about tenfold less but it does happen about 0.2 to 0.4% of the time the rate of major bleeding seems to be about 5% which is about half the rate of major bleeding that we see with system or

thrombosis so bleeding is still there it just doesn't seem to be as frequent so that's where some of these other devices are coming in then our a float Reaver the the the extra penumbra indigo cat 8 device and so the the float Reaver is

has actually gone through the full trial and the results are about to be published what is this thing well it's this pretty big hose which is about 20 French and it goes through the right heart and goes up there and it takes

this clot and literally aspirates it out and these are some of the things that will come out and that's sort of your post picture right there the data showed something similar to what we saw with the catheter directed thrombolysis

trials they had looked at 106 patients are vlv ratio was reduced again there's no comparator arm here so this is just the device on its own with a 3.8 percent adverse event rate and so now we're talking about mechanical devices that

don't use a clot-busting medication therefore you're gonna you can expect less bleeding but you're trading some of that off for a mechanical device that can cause injury to either myocardial structures or to the pulmonary artery so

that's something we have to be highly cognizant of as they're introduced into the market this is the penumbra cat 8 this is from Jim Benenati publication basically showing a couple things that's the separator that is the actual

catheter and that's the sheath back there so you've got poor profusion because of a clot in the inter lobar pulmonary artery and then at the end of it you have better perfusion for lung down there so we actually just completed

enrollment into the extract PE trial 120 sub massive PE patients the same efficacy endpoint you have to remember that has been established by the FDA as a way to get approval this is not the final

study nor should it be the final study when we evaluate these devices so to summarize sub massive PE what does the data not tell us CDT probably reduces the RV to LV ratio at 24 hours that is the main outcome that I want you

guys to remember from the ultimate trial it's associated you didn't see this data so don't worry about that we do see major bleeding and sometimes rarely but sometimes we see intracranial bleeding with CDT as well so what we're missing

from catheter directed thrombosis for sub massive PE is what are the clinical outcomes the RV to LV ratio is a surrogate outcome what about death what about clinical deterioration what about recurrent hospitalization what

about recurrent VTE how are people doing in the long term are they walking as well as they were before we don't know any of this none of the data right so far can tell us any of this information so where do we go from here for sub

year old patient diagnosed with

glioblastoma lesion is located on the left frontal lobe this is done after radiation and surgery the image to your left is just a regular MRI with contrast gadolinium is the one used this time we always be the drum in the context of

choice is gadolinium in our institution you could notice the big size of the glioblastoma lesion onto the left frontal lobe of the patient as indicated in the round ring patient went for treat radiation and surgery look at the two

images to your right the one in the middle is done Pet MRI without the contrast take a note on the area where the lesion was before there is normal uptake but you don't notice any abnormal uptake and on to your right is post

treatment MRI is that those two are done the same day and with gadolinium the deletion the area where the the ring it is enhanced by the contrast but look at it there is no hypermetabolic uptake that means that the lesion is not viable

so the malignancy is not viable this time this scan is done to evaluate the effectiveness of the treatment it's a good sign before I go to the third case

female recently diagnosed with cervical cancer this is the baseline imaging the

one on the left is pet the one on to your right is pet MRI which one you think the doctor likes better so there is a cervical lesion you could see the abnormal uptick or hypermetabolic uptake in the cervical area that's what we call

hot spots but we do a closer look because the pet MRI this time is used or done for planning for surgery or treatment look at the actual pet MRI you could see the hypermetabolic uptake in the cervical area the normal bladder

and normal uterus those are normal updates under your right you could see the uterus full the full outline of the uterus and exactly where the cervical lesion is located and the bright one at

the bottom is the normal blood er this scan is done to help the doctors plan for the surgery and to check if there is metastasis at this time there's none and the path MRI is choice of modality of choice for this reason because MRI is

the only modality that could do all the planes and it does very good in differentiation of tissues this is the end of our presentation and if you have any questions feel free to do so I did not pass out thank you

[Applause] [Music] [Applause]

about massive PE so let's remember this slide 25 to 65 percent mortality what do we do with this what's our goal what's

our role as interventionalists here well we need to rescue these patients from death you know this it's a coin flip that they're going to die we need to really that there's only one job we have is to save this person's life get them

out of that vicious cycle get more blood into the left ventricle and get their systemic blood pressure up what are our tools systemic thrombolysis at the top catherine directed therapy at the right and surgical level that what

unblocked me at the left as I said before the easiest thing to do is put an IV in and give systemic thrombolysis but what's interesting is it's very much underused so this is a study from Paul Stein he looked at the National

inpatient sample database and he found that patients that got thrombolytic therapy with hypotension and this is all based on icd-10 coding actually had a better outcome than those who didn't we have several other studies that support

this but you look at this and it seems like our use of thrombolytics and massive PE is going down and I think into the for whatever reason that that the specter of bleeding is really on people's minds and and for and we're not

using systemic thrombolysis as often as we should that being said there are cases in which thrombolytics are contraindicated or in which they fail and that opens the door for these other therapies surgical unblocked demand

catheter active therapy surgical unblocked mean really does have a role here I'm not going to speak about it because I'm an interventionist but we can't forget that so catheter directed therapy all sorts

of potential options you got the angio vac device over here you've got the penumbra cat 8 device here you've got an infusion catheter both here and here you've got the cleaner device I haven't pictured the inari float

Reaver which is a great new device that's entered the market as well my message to you is that you can throw the kitchen sink at these patients whatever it takes to open up a channel and get blood to the left ventricle you can do

now that being said there is the angio jet which has a blackbox warning in the pulmonary artery I will never use it because I'm not used to using it but you talk to Alan Matsumoto Zieve Haskell these guys have a lot of experience with

the androgen and PE they know how to use it but I would say though they're the only two people that I know that should use that device because it is associated with increased death within the setting of PE we don't really know you know with

great precision why that happens but theoretically what that causes is a release of adenosine can cause bradycardia bradycardia and massive p/e they just don't mix well so

as Chris described to you we really walked this journey around bridging the data gap from our front lines all the way to our senior leaders and we thought

this was very important because we didn't think we could drive a sustainable organization if everyone was not on the same page or even in the same book so we had to start helping the staff understand the story behind the

numbers and help them understand that every number actually has a story and is connected to their work it's not just random numbers these are things that also define patient care and can help us improve the way that we take care of our

patients and so the scorecards were really key in creating that alignment across the organization because as you can see on this chart here the senior leaders the radiology mid-level leaders and the

frontline staff all review the scorecards so AB monthly staff meetings the radio radiology leaders review the scorecards with the frontline staff and then we have our radiology director and our clinical chair review the scorecards

with the institutional senior leaders as well so all across the organization everyone had the same understanding around performance and if there was a strategy strategic vision that our senior leaders had they could easily see

how we could accomplish that based on the numbers that we had on our scorecard and then when it came to the dashboards these were as Chris mentioned more real-time frontline tools that were applied by our staff and but the metrics

on the dashboards were also included on the scorecards as well so when we designed the dashboard we pulled some metrics from the scorecards and thought about which which of these metrics would be more relevant in real time for our

frontline staff and so that way we restraints where we were continuing to build that competency for our frontline staff to help them to understand how to use data to drive decision-making in real-time and finally when it came to

the strategic plan we still have our senior leaders design strategic plans but our radiology leaders were able to move that strategic plan through our strategy to deployment program to define more specific strategies for radiology

and then roll that down to our frontline staff through their one on one performance management goals so this really helped us to start to create the same level of expectation across the organization as Chris mentioned we might

have senior leaders say well we have our strategic vision of increasing or falling by 10 percent over the next year and for our frontline staff that might be difficult because if they to them their work might be chaotic and they

think they cannot possibly do any more volume but when we presented the scorecard for example on s Chris showed in I arm at a 65 percent utilization everyone could see that if our benchmark was 80 to 85 percent we still had more

capacity in our rooms to be able to service more patients and on the same scorecard we could see our on-time start rate which was actually kind of low around 50% and so that helped us engage in conversation

with our frontline staff to help them understand that our issue was not necessarily a capacity issue we had the capacity to increase volume but the way that we were managing our workflow as you can see from an on-time start was

not great and so this helped them to start to identify projects that they could lead to help to manage their workflow better and with the dashboards they could actually see real-time improvement or real-time changes as they

made decisions around their workflows so again our goal to this journey or our journey to this one box was around bridging the data gap and to really create a sustainable organization where each frontline staff was empowered to

solve problems and have the data that they needed to do that objectively so now Jeanne will go over the current state of our nurses as we embark on that next steps of up - specific dashboards for them thanks to me

quo in 2009 looked at the data for this and basically unfortunately we do not have high with so strong level 1 data to tell us how to treat this disease but

this showed that we had an 86 and a half percent success rate at treating massive PE if that's the case this should be the first-line treatment from a soapie problems you look at the data and 500 of the patients actually came from

retrospective case series which really does not capture the full gamut of massive PE you're only going to report the cases that you're successful with that's just something we do so we there's a lot there's a lot more cases

that are excluded from this that we don't know what happened to them either with or without so where are we with the data for ass massive p/e we have these techniques from a catheter standpoint it can be

used if systemic lytx are contraindicated we don't know which one of these devices works the best we definitely don't know we probably won't know that on a comparative basis because massive P happens relatively rarely

whether it should be used in combination with other therapies and which patients should get this therapy and we should get surgery and we should get lytic sore which should get some combination and so where do we go from here for massive PE

I won't belabor this point but I think what we need is a is a massive PE prospective registry and hopefully something like the perk insertion will help us gather all the data from all the Centers it's just that you know we're

probably gonna see five to ten ten to fifteen massive pease per year per institution that's just not enough information to rapidly get up to speed with what's working so if Li if we can get all our resources together put it in

one place then we can develop algorithms around how to better treat massive PE but there's a lot of promise out there I'll give you that okay sub massive PE

let me show you a case of massive PE

this launched our pert pert PE response team 30 year-old man transcranial resection of a pituitary tumor post-op seizures intracranial frontal lobe hemorrhage okay so after his brain surgery developed a frontal lobe

hemorrhage and of course few days after that developed hypotension and hypoxia and was found to have a PE and this is what the PE look like so I'll go back to this one that's clot in the IVC right there and

that's clot in the right main pulmonary artery on this side clot in the IVC clot in the right main pulmonary artery systolic blood pressure was around 90 millimeters of mercury for about an hour he was getting more altered tachycardic

he was in the 120s at this point we realized he was not going the right direction for some reason the surgeon didn't want to touch him still to this day not sure why but that was the case he was brought to the ir suite and I had

a great Mickey attending who came with him and decided to start him on pressors and basically treat him like an ICU patient while I was trying to get rid of his thrombus so it came from the neck because I was conscious of this clot in

the IVC and I didn't want to dislodge it as I took my catheters past it and you see the Selective pulmonary and on selective pulmonary angiogram here and there's some profusion to the left lung and basically none to the right lung

take a sheath out to the right side and do an injection that you see all this cast of thrombus you really see no pulmonary perfusion here you can understand why at this point this man is not doing well what I did at this point

was give a little bit of TPA took a pigtail started trying to spin it through aspirated a little bit wasn't getting anywhere he was actually getting worse I was starting to feel very very nervous I had remembered for my AV

fistula work that there was this thing called the cleaner I don't have any stake in the company but I said you know I don't have a lot to lose here and I thought maybe this would be better than me trying to spin a pigtail through

the clock so the important thing about the cleaners it does not go over a wire so you have to take the sheet out then take out the wire then put the cleaner through that sheath and withdraw the sheath

you can't bareback it especially in the pulmonary circulation the case reports are poking through the pulmonary artery and causing massive hemorrhage and the pulmonary artery does not have an adventitia which is the outer layer just

a little bit thinner than your average artery okay so activated it deployed it and you started to get better and this is what it looked like at the end now this bonus question does somebody see anything on this this picture here that

made me very happy on this side this picture here that made me feel like hey we're getting somewhere I'm sorry the aorta the aorta you start to see the aorta exactly and that that was something I was not seen before the

point being that even though this doesn't look that good in terms of your final image the fact that you see filling in the aorta and mine it might have been some of the stuff I had done earlier I can't I can't pinpoint which

of the interventions actually worked but that's what I'm looking for I'm looking for aortic blood flow because now I've got a hole in that in that clot that's getting blood flow to the left ventricle which starts to reverse that RV

dysfunction that we were concerned about make sure I'm okay with time so we'll

projects that I care about I've become very involved in the treatment of back pain in women women get back pain for

different reasons than men twenty percent of the time the cause of the back pain is not in the vertebral column of the neural foramina or the disc it's in the paravertebral soft tissues or the soft tissues anterior to the sacrum in

the pelvis so every tuesday i see five to seven women who've been told they're crazy by orthopedic or neurosurgeons because they have sciatica but their MRI is normal because they looked there and they don't look over there

so I just published a paper on gender bias and female back pain and it's taken me 12 years of work this began as you guys remember me doing tarlof cysts and then it's expanded into other causes of sciatica like endometriosis cyclicals

sciatica in women from endometriosis on their lumbosacral plexus now most people have never even heard of that but it's a real thing so and this in the BMJ when you publish there has to be a patient impact statement so the patient in the

case report wrote this wonderful letter so this is a series of six papers that has taken me ten years to write so when you have these ongoing projects it gets you up in the morning it keeps you engaged and so um I've worked very hard

on this area of tart of cysts and it'll take about ten or fifteen years to change medical practice because it takes about that long for physicians to change what they do I'll skip through this but this is how you treated you put in two

needles into the cyst you aspirate fluid from one air goes in the other then you inject fibrin glue and it works about 72 percent of the time it's really easy

we know try to make this painless but I think it's kind of interesting

so metabolism is just talking about converting a medication into a less or more active form and that gets converted into what we call metabolites within metabolism you have your cytochrome p450 system which is responsible for

metabolism of a lot of the drugs that we give and essentially that's just a family of enzymes that are responsible for metabolism properties are going of the drug are going to influence the duration of action and the half-life of

your medication so for instance of a pee if a drug is highly protein bound what it does when you administer it is it binds to the protein molecules and slowly dissociates so you have a longer duration of action

because when it's bound to the protein it's in active half-life again any properties that increase the duration of action are going to be something we want to pay attention to and how is the drug excreted you can have excretion through

the bile feces renal system a big thing I think for us and IR is drugs that are really excreted benzodiazepines are the mainstay in providing the sedative component a procedural sedation it's going to enhance the inhibitory effect

of the gaba neurotransmitter in the central nervous system why do we care about that does anyone know have something to do with our reversal so our gaba neurotransmitter is responsible for inhibiting the activity

in the brain so if we didn't have a gaba neurotransmitter we would have seizures all day patients who have seizure history of seizure disorder are sometimes on benzodiazepine therapy at home if you sedate them and they require

reversal and you give them flemeth know you can potentially precipitate a seizure so it's just something you want to keep in the back of your mind it doesn't mean you're not going to reverse them you just want to be prepared to

handle a seizure if that occurs versed is our number one drug that we use onset of action and peak effect or seen in 3 to 5 minutes the antagonist as I mentioned is flumazenil and the half-life is three

hours typically in our department we give one milligram depending on the patient's physical condition and what they require and how anxious they are we may give 0.5 or up to two in one dose now you're gonna see and an Aaron says

this to in their procedural sedation guideline that you shouldn't exceed five milligrams I don't complete and that means overall in one case I don't completely agree with that I'll explain more why later but I think patients are

really complex and there can be a lot of drug interactions that are occurring that may cause them to require more sedation than a typical patient so it's not so cut and dry you could look at five milligrams and go that's kind of

more than the norm and maybe I need to look at is the sedation not working but you may have a patient that could take 10 11 12 milligrams of versed and be

study I would like to share to you in personal note that my training school

books and experiences never prepared me for all the different types of cancer I have seen while working at Memorial sloan-kettering I have come to realize that cancer does not discriminate it doesn't matter how old you are

socioeconomic status gender race color of your skin and geographical location and religious beliefs and taking care of the young pediatric patients makes me the saddest if cancer hits you it hits you

the youngest patient that ever took care of is two months old infant diagnosed with glioblastoma I remember that day clearly because I booboo the whole day based on this here comes the third case study this is a four year old child

diagnosed with hepatoblastoma a pet MRI with anesthesia is done the image to your left is pet and on the right is pet MRI you see the difference in the images this scan is done for the doctor to evaluate the extent of the disease you

could see there is a hypermetabolic uptake in the liver and in the pelvic area the color red on top of the head the patient that's normal that's a normal uptake there is no increase in the uptake so this considered normal

we're gonna do our closer look and I would like to show you the difference between the PET CT and the pet MRI the image on the middle is the PET CT done on March you could see how where are the areas that are you could see all the

increased uptake on the areas like the chest the neck thoracic region and the abdominal region the the bright area there at the bottom Dustin or my bladder up take look at the image on to your right that's a close-up loop of the

sagittal PET CT done on same month you could see clear I could see where the location of the abnormal act uptake are circled by the the white circle there is abnormal uptake in the spine and in the chest and

of course where the hepato blastoma is located but looking to your left that's the bet MRI you see how the image is so clear and defined you could now count from the you could count where the exact location is it's on T 11 and is in the

vertebra and there's evidence of the actual cord compression with all you know all you know is a neuro emergency this is a four year old child and the other abnormal app takes you could see also so this child don't only have

hepatoblastoma but also have OSHA's metastases so the scan is done to evaluate the extent of the cancer the last cases study is the 41 year old

so what is it like to be a nurse in radiology all four of these boxes represent the essential part of radiology nursing workload and staffing speaks to how our rit nurses cover all seven modalities in radiology in a

variety of functions these functions include but are not limited to sedation IV therapy triage recovery education and emotional support for our patients regarding staffing this requires deploying nurses in multiple locations

at one time to ensure that the patients are receiving the best care at the right time for us the challenge was how do we adequately deploy the staff to multiple areas while being efficient fiscally responsible but continue to provide

compassionate care the next box epic which is our electronic medical record centers around orders and documentation as Cris mentioned earlier in 2015 we went live with radiant and epic plugin specific

for radiology workflow the radiant functionality was exam specific and less patient flow specific this presented a problem for nurses who cover patients and all modalities and had more documentation requirements than the

technologist did and the last box engagement as we know is so important our nurses felt like they were getting pulled in multiple directions and often time misunderstood by the other modalities and radiology that really are

just focused on their modality and it risks nursing job satisfaction and increased our burnout rate right so as Jeannie described to you that was the current state that our nurses we're facing and as we designed or created the

dashboards we had to understand how we could create meaningful metrics for the nurses to address all these different issues that they were facing our nurses and dartmouth-hitchcock radiology did not just cover interventional radiology

so they were covering MRI CT fluoro so they were all over at the department and it was really hard to capture all of that work and really help them understand how to align their staffing to cover all these multiple modalities

and that also made it difficult for engagement sometimes as they interacted with different staff across the department so we have to consider all of this on top of the complexity with documentation in our EMR system we had

to combine all of these factors as we designed the dashboard so fortunately for us we did not follow Dilbert's boss's philosophy we had much more intent international intent as we design our dashboards so when it came to build

in the radiology nurse dashboard if we could sort of break down the steps we took we would go over these three categories the first category is identifying what measures were relevant for the nurses given the current

situation that they were facing the second category was where that information lived and how we could pull this in to the dashboards meaningfully and the last is how that data needs to be

displayed on the dashboard so going to our first category here which is what measures are relevant we have two main goals the first goal was to select measures that could help our nurses monitor their performance in real-time

so again this was part of our journey around competency building and sustainability across the department and we knew that for our frontline staff including our nurses they were not used to looking at data especially data in

real-time to make decisions and a lot of their description about their day was very variable and really driven by perception of what they were feeling at any given moment so our objective or our goal around monitoring real time for

performance was to create an objective understanding across the board around how the day went so if someone said that they were really busy what did that actually mean so trying to make sure everyone speak in the same language

using data and objectively understanding their performance the second goal around our measures was to help the nurses be more proactive around decision making so as a part of this journey we wanted our frontline

staff to be better problem solvers and be empowered to make decisions around their workflow and so we wanted the measures to be relevant around helping them make more proactive decisions to be more efficient around their daily work

to the left here as an example of some of the metrics that we selected Gina will go into more details around to the dashboard but that's just a real quick snap short of some of the metrics that we selected and a lot of those metrics

are showing pending work for our nurses and a lot of what that does for them is decide how they can align their staffing on a daily basis to accomplish a lot of the pending work that they have so that's just an example of some of the

measures that we selected to accomplish those goals so moving on to the second category here which is where the information lives as Chris and Jeannie both mentioned and I'll mention it again because it was a real pain when we went

live with radiance in 2015 it wasn't great for nursing it didn't capture a lot of the nursing work accurately and because our nurses covered so many different modalities it was difficult for them to see all of their work in one

place in a way that made sense so part of our journey or one of the biggest things as we built the dashboard was to create nurse resources within radiance that helped us accurately capture all of the nursing work and described it in a

way that was easy for them to understand and differentiate between the different kinds of work that they did in radiology and then we am partnered with epic to participate in a cojito project cojito is a branch of epic which builds

dashboards almond does analytic reporting so this was a paid engagement where we told them what we wanted and they had their analytic team built and designed the dashboards within the epic system the engagement took about 12

weeks to complete and that was not just for the nursing dashboard we had about 17 different dashboards that we were building across radiology and so all that entire engagement took about 12 weeks to complete and so that was how we

partnered or that was where we partnered with the epic cojito team to actually build those dashboards within the EMR system and then finally in our process of building the radiology nursing dashboard we had to figure out how the

data needs to be displayed so again we were dealing with frontline nurses who are not used to looking at data and at first we're really opposed to looking at it because they didn't really understand what it meant to them and so we had to

make sure that the data was simple and easy for them to to understand especially in real time for the dashboards it has to be something that they would look at it would be visually appealing and they could really get

enough context in real time to make a decision around their workflow so we had to juggle all of these different pieces as we built and design our radiology nurse dashboard and in a minute you will go over what that actually looked like

when we're done but before that I wanted to show you a prototype of what we started with as we embarked on the cojito project so this is just a PowerPoint template or design that we shared with the Epico hero

team when we started this was our way of sharing or showing our vision of what we wanted on the dashboard we knew that there were a team of analytic people who didn't necessarily understand our operations of workflow so we wanted to

make it easy for them to understand what we needed and we also had to do some shadowing and training in real time with the analytics team as they embarked on this project to build our dashboard but of course when we presented this to them

we knew that our actual product would would the result of the final product would be constrained by what they had in the system so for example they did not have as many callers in their color palette to create a dashboard and so as

Jeanne goes over our final product you might not see as many beautiful colors in there that was their upgrading to more colors and that was great but we knew that as we move forward we would have to be restricted by what they

actually had in the system for a final product or outlook but I just wanted to share this just to give you if you're thinking of embarking on their journey to build dashboards you can start simple just create a wait just have a way to

share your vision with the with whoever the Analects analytics team is that is built in the dashboard you don't have to know what it would look like exactly on the system itself so now Jeanne is gonna walk you through

our actual dashboards and how we apply them in real time thanks to me

so where we are now these are my concluding slides massive PE is lethal systemic lysis should be used surgery should be discussed immediately in the ECMO which I didn't really get a chance

to talk about it's probably a game-changer because it's almost like a temporizing measure for any of these therapies patient comes in you immediately put them on cardiopulmonary bypass support and then you can decide

what to do should this patient get an embolectomy should this patient get a free directive therapy should we just wait and let the patient write it out and that is a right answer actually just keep them an anticoagulation so this

will be a game-changer for massive PE sub massive PE is dangerous to some of the patients risk benefit of systemic thrombosis is not favorable for most but for some it might be and CDT appears to be promising but we have a lot of work

to do so where we need to go from here is that I think for mass pe we need a prospective registry and we really need a randomized control trial for CDT for sub massive PE thank you very much guys thanks for your attention

so why staging important well when you go to treat someone if I tell you I have a lollipop shaped tumor and you make a lollipop shape ablation zone over it you have to make sure that it's actually a lollipop shaped to begin with so here's

a patient I was asked to ablate at the bottom corner we had a CT scan that showed pretty nice to confined lesion looked a little regular so we got an MRI the MRI shows that white signal that's around there then hyperintensity that's

abnormal and so when we did an angiogram you can see that this is an infiltrate of hepatocellular carcinoma so had I done an ablation right over that center-of-mass consistent with what we saw on the CT it

wouldn't be an ablation failure the blasian was doing its job we just wouldn't have applied it to where the tumor actually was so let's talk about

sub massive PE is an unknown entity so we still have these patients coming to us how do I approach it today

well those patients that are high-risk sub massive so high risk intermediate just like that ESC slide who look like they're about to Crump or look bad like they have an elevated lactate even if they don't meet the criteria for

hypotension those are patients that I'll almost always try to repr fuse and and that can be reproducing with any technique it could be surgical unbel ectomy it could be systemic thrombosis it could be Katherine directed therapy

but that's where the PERT concept where you bring together multiply multiple disciplines in a relatively short time and and make a consensus life decision that is thought to be the added value of the pert these other ones are getting

less and less common in terms of intervention so I used to intervene on a lot of these patients but as the data has come out and I've noticed that with the tincture of time 24 hours of heparin actually gets these people out of the

danger zone I've actually made my practice a little more conservative than it used to be and low risk sub massive Pease should pretty if if you're frequently doing this it's probably a time to re-examine your practice because

it may not be based on evidence or truth

who came in with just over she had a four month with delayed heal wound she finally presented at us after the wound

healed because she had rest pain that wasn't recognized they thought the pain was due to the the wound the wound healed and they realized oh she still has pain well that's because she has crippled limb ischemia and so she was

she was brought in for that just you know she has bilateral disease I'm just gonna concentrate on talking about the right leg for for today's discussion but she does have inflow disease in these types of patients I do get

cross-sectional imaging so I can determine just how extensive the iliac diseases or if it involves the aorta to then determine what it what to make sort of jumping into it so the right leg again she has about a 10-7

occlusion of the bright SFA this occlusion here's the femur for reference the knee is actually down way down here so this is actually just above the a doctor again tried to use in this case I did do wire work I got past a good

portion of it here's my wire right here and here's the O pacified lumen so what you can see is the wires actually adjacent to the lumen so at this point I'm re said suspecting that I'm sub intimal I confirm that by removing the

wire do little puff there's blushing that blush is up intimal so I know I'm sub intimal so at this point what were the things you can do obviously the first things you do try to pull that back try to find a different space a

different location to wreak analyze when that's not successful then you start thinking about southern super recanalization multiple devices for that there's the outback device which is a little hook that you can try to spear

yourself into the main lumen and pass a wire there's also device from Medtronic about the anterior device what this is it's a balloon that you inflate to sort of stick yourself into that wall it has two ports that are on the side one

points one direction one points the other direction it allows you to find that open lumen and we use a re-entry angled wire to get back in so in this case just as a cartoon here's the the anterior device place downward this is

would be the balloon inflated you would basically jab into the port into the into the main lumen so that's sort of basically what I did here again here's the agile device each of the ports you can see as a little divot once you put

it sideways you can determine which we are going to stick there's my wire right into the lumen and there it is down further into the rest of the the vessel subsequent to that pre-dive it with a three and then overlapping

since were used finally here is her post i did treat both legs but you can see just the dramatic difference going from the monophasic waveforms to tri-phasic waveforms restoration table api's for her I couldn't help but throw this in

the ablation concept in general is to provide an environment that is

completely hostile to tumor minus 40 degrees Celsius 150 degrees Celsius 500 gray which is a radiation dose we say it's very hard for it's about anything to survive but so why is it that it doesn't always work well that's a

function of all those parameters that you see there we got to make sure we pick the right patients we got to make sure that we treat tumor where we think it is and avoid trading things that don't need treatment avoid causing

damage to collateral structures and getting a reasonable margin where we actually get some of the tumor that's microscopic there are a lot of ablation modalities radiofrequency alternates electrical current very rapidly so that

generates friction within the lesion and causes heat it looks like this a lot of times you see these little times that stick out so that you can increase the size of your blasian zone and here's a one of those deployed in a patient who

had a colorectal Curren after hepatectomy cryoablation freezes things and it pushes a gas that once it goes through a pin hole tends to expand and cause rapid freezing he can also push another gas right through it and cause

rapid heating but this is just bringing tumors to that minus 20 degree minus 40 degree threshold the nice part about cryoablation is that you can visualize your ablation zone so we're right up against the bile duct here and it tends

to be a little more respectful of tissues so that's why cryoablation is chosen every once in a while we're do frequency ablation is an excellent tool we have lots of data for it but likes it sometimes it's difficult determine where

the ablation zone is interprocedural e microwave ablation there was just a randomized study that came out that compared microwave ablation to radiofrequency ablation and the results are very similar

it was a very very experienced institution doing it but the whole point here is that a lot of these tools work pretty well there's no clear superiority on them but one thing that microwave offers it's very fast so generates

temperatures to boiling within the tumor in about five minutes and so it's certainly very fast as compared to radiofrequency and you can see boiling happening within this tumor that's been accessed eventually there that gas is

actually literally fluid that is boiling away from the tumor couple of cool ones this one's reversal expiration what we do here is we place probes throughout the lesion and we pulse it to confuse the membrane on the cell to think that

it's a it has holes in it that it cannot close and so what is happening is the contents inside the cell leave and that's pretty much consistent with not being able to survive the nice part is we can accomplish all that without

thermal ablation what do we mean that we don't go over about 40 degrees Celsius so if something is involving a bile duct or involving a critical structure like the ureter it's not actually going to damage it it just basically tells all

the the cells within there to stop stop undergoing the cellular mechanisms responsible for life it's a little more finicky to place you have to place these little parallel probes here's one we did that was directly write on the

bifurcation of the main bile ducts and you can see here afterwards is an immediate post contrast scan how that whole area is ablative it does not take up contrast and this patient never developed biliary strictures that side

massive PE well let's remember this at this point including all the trials that preceded the pytho trial almost 1 700 patients have been randomized into systemic lytic trials for some massive p yep all we have on the CDT side is the

ultimate trial of 59 patients non-us single was a single trial that's where this initiative is coming from to improve the data this trial called P track and I have preliminary information that we just made our first breakthrough

in fronting from the NIH so very excited that we have a planning grant to potentially get this thing moving so P tract is basically designed to be a randomized control trial of catheter directed therapy versus no catheter

directed therapy for sub massive PE to really try to answer this question just like the pytho trial tried to do for systemic thrombolysis in the setting of catheter Ida thrombolysis and this time we're not just using surrogate endpoints

we're not you the rvw ratio is probably not even gonna be calculated but what we want to know are these are patients doing better in one arm or the other and we're going to use outcomes that are important to both patients and providers

400 to 500 patients most likely looking at sites all across the so but we are still in this time when

I'm the FDG is have a radio pharmacy located on the second floor no New York State does allow nuclear medicine

technologist and nurses to inject the con the FDG isotope I know in other states one in particular is is New Jersey the the nurses are not allowed to inject isotope and the technologist has to do it also in addition certain

isotopes and certain scans the ducts have to inject the contrast like the the cervical Lin scintigraphy and some so my question has to do with discharge instructions so just like you give them that little card that they keep with

them so they trigger some radiation alarm and a bridge or on a highway do you give them discharge instructions about if there's small children at home that they're not sitting in their lap for extended period what kind of

instructions do you give on discharge after these patients so we when they come in coupled with the screening forms that they fill out we have some instructions attached to it and does that does have

the discharge instructions but we reiterate to them you know if they have small children or babies and pregnant women and just try to keep their distance for the next 12 to 24 hours just to until the really activity has

wear off so the FDG is like two hours almost for the half life FDA FDA has 60 minutes 116 minutes half life and usually by 12 hour by the 12 hour period they're mostly background radiation okay thank you

we had they have a written instruction like it's like a packet that we give into the market that we do to the patient and the patient have accessed to the web portal that they have and they can be the instructions from there

this is correct so betta bar is still investigational for the most part the only way you can build for it is two different scans you build for a pet and you build for our mr so you've got to get approval for both what you are not

going to get reimbursed for is the registration and that's where it gets a little bit challenging because then you need a radiologist who is both certified uncredentialed to read a pet and an mr so right now most institution bill it as

two different procedures so that's why you that's how we get the approvals just a little information on the side I went back to this case study because I forgot to tell you that in order for the PET CT to have as clear image as the pet MRI

the pet portion I mean the city portion and the pet city would have to be done diagnostically and that this would expose the patient to radiation three times that's why they prefer the pet MRI because yeah the reason why we do it if

we do it mostly for for for pediatrics and it's it and it's because of radiation because you know like our my team is saying you you are going to have this patient have constant follow-up so if you can reduce the amount of

radiation they have from a younger age as we all know it work in radiology DNA injuries occur when you're younger then more is more severe than than later our MRI the pet MRI injection they're all lined with lead and our MRI the pet

MRI room is actually lined with lead so we don't really have Needham let aprons we don't know we don't have wear aprons they are allowed to go to other appointments after they are pet MRI usually with the FDG most of the

radiation after the Tessa's finish is gone they're not more than what not more than radioactive than background radiation so they are are safe to be around people yes that's more for precautionary

measures yes no they go straight to the PACU so we our MRI table is detachable we have an area for where we keep our inpatient bay area we have a structured ready for them to go into right after the test and the

anesthesiologist and if they are Pediatrics the pediatric nurse is with them and they go straight to pack you do like probably like probably less than ten a week right now some weeks we are busy we do for how we do that much some

it varies like we'll do three or four but we are trying because the reimbursement that's one of the big issue our institution is actually eaten eating the cost for some of these to provide a patient with less radiation

especially or pediatric population we have one pet MRI machine for the whole institution three at the main campus we have two we have multiple and other regional sites so the yes

no less than 15 GFR except for the EU vist less than 30 then we notified the radiologists eeeh this is harder to so you this is the it's a linear contrast as opposed to the Catalan bettervest which is

macrocyclic so it's easier for the body to get rid of well there yes well they're only they're already getting dialysis so it's really not much of a harm yes we do patients on dialysis but we make sure the dialysis is done within

24 hours after receiving the contrast yes um sometimes you know you just have it to have it we don't require it for all the tests if you have it we have it we check if it's already in the chart we

acknowledge it you know we don't require for outpatient we don't require but in patients we do all right anything okay so Bernie pet/ct the scanning time for pet/ct is about 30 minutes to 45 minutes Patsy pet/ct is about 30 to 45 minutes

with the pet MRI sometimes they they order dedicated pet MRIs so that is a little longer you have to take note that we do a whole body scan whole body scans for even just for a regular MRI is at least an hour so we try to eliminate

just you know having them have to have to or point to different appointments and just one waiting room one waiting time so that cuts down the response for the patient themselves yes we do for adults it's 12 for the

whole body and then for the pet brain it's about 10 if I'm not mistaken and then plus or minus 10% and then the pediatric doses are cultured calculated base of their height and their weight and there are all protocol by a

radiologist because we have a lot of whole-body protocols we have the bone survey actually that's about 30 or 40 minutes and yes that's an hour and then we have longer whole body protocols diseases

specific and sometimes they try to depends on what the patient's diagnosis is we have whole body scans where they have to check the bone marrow and that needs to be from tips of the toes and tips of the fingers and that can be a

challenge especially if the patient is tall because that has to be in sequest sequestered and sequential patient and positioning is also a challenge alright thank you so much thank you thank you so much


no thanks to the avir we really wouldn't be able to do anything that we can without y'all so I take great great pride in sharing things from our perspective said you folks can start contributing your own thoughts your own opinions and your own vision during

these cases I think it's certainly something that I've appreciated since the first day of doing invention where do you all do so having said that we're just a smidge in the behind side so we'll try to focus today is mainly a

survey to stimulate everyone in terms of what's actually happening on the other end of the catheter with respect to the patient why are we doing these things where's our role and I think that's gonna add hopefully some value the next

time you folks step in on one of these cases alright so as you know dr. daughter first was able to visualize the inside of a blood vessel and find a stenosis and a lady who had limb ischemia and then was able to use a

dilator to fix that so obviously that gave birth to interventional radiology so we started taking pictures of tumors just to diagnose tumors back in the day before we had actual imaging and what we found

was well if tumors have a high demand for blood just like anything else what happens if we take away that blood and this is a 1975 image of renal cell carcinoma is to call them hyper and if Roma's back then but basically the

concept of interventional ecology was born the moment you could do something to make the environment for the tumor less hospitable and to try to palliate patients if they weren't subject to the the gold treatment standards like

resection in this case so fast forward to 2016 there was a huge study was International where they looked at over 3 000 patients who have primary liver cancer or her pata cellular carcinoma and what they found was that regardless

of where but if you sum all the treatment decisions that are related to those patients about 70% will see treatment by an interventional radiologist as you know that was a astounding amount

so si are listened to a lot of these types of messages even outside of obviously oncology basically we realize that there's a tremendous responsibility and the best thing to do is to dedicate ourselves fully to that and that's why I

think with IR now is a separate medical specialty we're going to start seeing more of the clinical involvement of this and certainly think the caseloads going to go up so why interventional oncology

much more controversial so you it was pretty clear that we have to rescue

massive PD patients from death but with these statistics what are we supposed to do with sub massive PE well are we supposed to prevent mortality it's gonna be hard to do if the mortality is only 2 to 3% because you're trying to really

improvements of a very low statistic are you trying to reduce the rate of hemodynamic deterioration that's a possibility what about long-term disability if you remove clot upfront

will these patients do better six months one year or two years down the road frankly we don't know the answer to any of this and the reason is that the pytho trial made things quite difficult for us to interpret the pytho trial was the

trial that was going to answer all uncertainty this was a trial where it took some massive PD patients in that high-risk intermediate category and randomized them to receive a bolus of tenecteplase which is similar to TPA but

is not the same versus anticoagulation alone what did it show well it showed there was no difference in death between tenecteplase and placebo so they actually gave a placebo drug so that no it was a double blinded

study now if you look at the next line though a lot more patients decompensated if they receive the placebo than that's not to place this is not a bad thing you know it's not it's not great when you have to intubate somebody or initiate

pressors so if you can avoid that outcome that's it that's a pretty good thing so maybe it is the right thing to give systemic thrombolysis in the setting of sub massive PE problem was this the bleeding you look down here

there was an eleven percent rate of major bleeding in the tenecteplase arm there was a two percent rate of intracranial hemorrhage so now we've got this therapeutic window that's hard to interpret so we seem to be improving

outcomes from an efficacy standpoint but then we're also increasing the rate of bleeding so basically what we've sort of coalesced around is that systemic thrombolysis has a questionable risk benefit profile because the rate of

bleeding and the rate of really serious bleeding is makes us nervous so is that an opportunity for catheter director thrombolysis and I'll call this the poster child for Catherine throwing license if this is how it worked every

time we might have a homerun so this is gentleman looked terrible well still in the sub massive category but breathing at 35 times a minute hypoxic had his main PA systolic pressure of 60

millimeters of mercury you look over here and there's this large clot in the right upper lobe go to the left side and then there's all this clot in the left lower lobe as well so what do we do we put in bilateral infusion catheters this

can be an E Coast catheter it can be a standard catheter these areyou nafeez catheters have side holes starting from here and ending it's hard to see but there's another radiopaque marker somewhere down there on this side there

and somewhere over there and between those markers you have multiple side holes and those are put up inside the clot so you're dripping TPA at a rate of about 0.5 to 1 milligram per hour and you're getting it directly into the

clock that's the theory and so after 20 to 24 hours of that you know you're given 20 to 24 milligram of TPA that's compared to 50 or a hundred that you get was sitting with systemic thrombolysis you get something

that looks like this where the pulmonary arteries look pristine the PA still the systolic pressures come down the patient feels great now the skeptic would look at this and say well if you just tried some heparin and you just infuse saline

would you have the same result and frankly if you were to conduct the experiment you might find something interesting or not interesting but we never have conducted that experiment but you know I'll tell you a little bit

about the ultimate trial if I have time I don't want to go to overtime though

the traditional three pillars are

surgical medical and rad honk which actually was once part of radiology and separated just like interventional radiology has and where is the role for this last column so many patients are not medically operable so if you set the

gold standard you know that the cure for someone has a primary liver mass well about 20 percent of patients who present can undergo resection what you do for the remaining portion so Salvage is what we offer when someone has undergone

standard of care and it didn't work how do we hop back in and try to see how much these folks it's low-risk it's not very expensive at all as compared to things like surgery and the recovery is usually the same date so

this concept here of tests of time is kind of interesting a lot of times when we look at a tumor let's say it's 2 centimeters it's not really the size of the tumor but it's how nasty of a player it is and it's

difficult to find out sometimes so what we do is we'll treat it using an IR technique and watch the patient and if they do well then we can subject them then to the more aggressive therapy and it's more worthwhile because we've found

that that person is going to be someone who's likely going to benefit you can use this in conjunction with other treatments and repeat therapy is well tolerated and finally obviously palliation is very important as we try

to focus on folks quality of life and again this can be done in the outpatient setting so here's a busy slide but if you just look at all the non-surgical options that you have here for liver dominant primary metastatic liver

disease everything that's highlighted in blue is considered an interventional oncology technique this is these the main document that a lot of international centers use to allocate people to treatments when they have

primary liver cancer HCC and if you see if you see at the very bottom corner there in very early-stage HCC actually ablation is a first-line therapy and they made this switch in 2016 but it's the first time that an

intervention illogic therapy was actually recommended in lieu of something like surgery why because it's lesions are very small its tolerated very well and it's the exact same reason why your dermatologists can freeze a

lesion as opposed to having to cut everything off all the time at a certain point certain tumors respond well and it's worth the decrease in morbidity so

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