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RFA Probe types | Ablations: Cryo, Microwave, & RFA
RFA Probe types | Ablations: Cryo, Microwave, & RFA
chapterMedtronicOsteoCool RF Ablation System
Transcript

so that was cryoablation and then the final modality to talk about is

microwave ablation this one should be relatively quick because the idea is pretty simple right this probe is got this electromagnetic energy it's in between the 924 50 megahertz range and basically like RF it causes the water

molecules adjacent to oscillate right so excuse me as you can see it creates this zone or these this this area of electromagnetic activity and all of the water molecules in that area will be activated at once

unlike RF a right so when it's right next to the probe the water molecules oscillate and then the temperature propagates by and by conduction this will essentially create this zone and that

immediately we'll we'll activate those tissues so if you've done microwave ablation you know if you do an ablation of a hundred watts for two minutes you'll get a three centimeter burn it's literally instantaneous as you turn it

on you get this huge burn and then after that anywhere between two minutes and ten minutes you're really only getting about another centimeter of burn and the reason you're doing that is because that's the the passive conduction so it

is very rapid it doesn't have the heat sink issues that RFA does as I mentioned there's this radius of molecules that are activated around the probe the size that radius depends on the wave link and the probe properties there are no

impedance issues so unlike RF a where you want to heat slowly microwave is instantaneous and it just cooks the tissue around the the probe many of the antennas have internal saline perfusion and that's just really to generate

uniform heating and prevent the heat from propagating along the shaft because you obviously don't want it to propagate back towards the skin same ideas are FA right so you want to increase the temperature to greater than 50 degrees

Celsius for about four to six minutes you get coagulation necrosis and you need about a point five a five millimeter margin on that advantages a

here we have a MRI that shows a lesion in the left kidney sorry I don't have a

pointer here really but you can see the lesion in the medial part of the left kidney there couple probes are placed under CT guidance you can already see the beginning of the formation of an ice ball there this is the second probe you

can see the ice ball forming and there's a good example of the ice ball it's got good coverage of the the lesion as well as a good margin around that cryoablation tends to be less detrimental to the collecting system of

the kidney so some of the concerns when you do renal ablation is that you're gonna cause your read or strictures or urine leaks because you're burning the collecting system essentially with cryoablation you tend not to see that

you don't have to use something called pilar profusion is often right the idea with pilo profusion is you put a small catheter into the ureter and you infuse the kidney with cold saline so that the collecting system stays cold while you

while you burn the tumor well you don't often times have to do that with cryoablation so that's one benefit of it and then this is a one month later scan this is the normal appearance you can see the ablation zone that and the

resolution of the tumor will follow these up for a few years to make sure that all that tissue goes away and this

you can pretty much put plastic at the end of any word you want so if you read or plasti whatever but not ablation truthfully it doesn't sound right ablation oblast ISA so as was mentioned my talk today and beyond ablation I have just one disclosure but consultant for

btg ablation so I guess just a quick raise of hands how many people are due oblations where they work I would hope nearly everyone okay perfect so I'm trying to sort of direct us towards the the way the oblation med modalities work

rather than procedural but we'll show some case examples of of where we can use these the three dominant modalities as many of you know are gonna be the radiofrequency ablation which is the oldest most common one used previously

cryoablation and then microwave ablation I'm not going to talk so much about Ayari it's considered one of the ablation modalities but it's really not done as commonly with ir around the country so we'll start with

radiofrequency ablation I suspect that many of you who are newer to I or maybe haven't used much RFA and people who have been in IR for a long time have used it quite extensively what we know

to talk about cryoablation which is very commonly used in a number of organs it can essentially be used anywhere in my opinion with cryoablation as many of you know the different idea is that you have a probe and it creates this ice ball and

that's what's killing the tissues rather than heating the tissue when they first came out with cryoablation they had these really large probes and that really limited what we could do well with technology obviously those probe

size decreased and we were able to do better ablations and safer oblations in patients so it really took off at that point and the general goal once again is to decrease the temperature to about minus 20 degrees Celsius and in doing so

you kill the tissue and we'll talk about the mechanism of how that works the cold spreads Bible directly molecular transfer right so you're starting to cool around the probe and that will propagate to the surrounding tissue

unlike our FA or microwave as the ice ball grows it doesn't impede further ice ball growth right you can continue to build on that ice ball as you increase the amount of argon infused in the increase the number of probes so that's

beneficial and that you can get a massive ablation depending on how many probes you want to place well talk a little bit of how it works so it works by what's called the joule-thompson effect idea here is if any of you've

done cry before you know you have to drag those huge tanks into the room and it just runs through all gone like nothing so when we first started doing cryoablation you had to have an all gone tank and a helium tank they've gone away

with the helium and now you really just need the argon tank which is really nice and that you don't have to drag those tanks around and they're working on actually doing with nitrogen but that hasn't come to fruition yet so the idea

is that you take a high-pressure gas right so it's in the tank it's pressurized it gets run through the center of the probe and then as it comes out the tip will not out the tip of the probe and within

the tip of the probe it goes to low pressure and that change in pressure allows the temperature of the probe tip to cool right and so if you're using argon or oxygen or nitrogen that'll cool if you're using helium it'll actually

heat the tissues and so that's why we used to have argon and helium to be able to to freeze and then actively Thor so as I mentioned the argon comes from a pressurized tank you have this dual chamber probe that allows the gas to

expand and as it expanded pools heat from the surrounding tissues so as many

something some case examples of where I use cryoablation right so this is a

patient who has a nodule in the in the back of their lungs in the right lower lobe and basically I'll place two probes into that notch on either side of Brackett the lesion and then three months later fall up you can see a nice

resolution of that nodule so when it comes to lung a couple things I'll mention is if the nodule is greater than eight millimeters I'll immediately go to two probes I want to make sure that I cover the lesion whereas microwave it's

pretty rare depending on what device you're using for you to put more than one probe in so some people's concern with cryo in the lung is more probes means more risk of pneumothorax but you can also see surrounding and proximal to

where we did the place you can see the hemorrhage that you see so if those of you out there that are doing the lung ablations you probably have physicians that are using something called the triple freeze protocol right so the

double freeze protocol is the idea that you go ten minutes freeze five minutes 30 minutes freeze five minutes thought well what we saw was lung early on in the studies was a very large ablation a freeze to start with caused massive

hemorrhage patients were having very large amounts of hemorrhage so what we do now in lung is something called a triple freeze protocol we'll do a very short freeze about three minutes and that'll cause an ice ball to form and

then we'll thaw that in other three minutes three minutes of thawr and as soon as that starts to thaw we'll freeze it again and we've shown us a substantial decrease in the amount of hemorrhage so if you're doing long and

you and you you're told to do a double freeze protocol perhaps suggest the triple freeze is a better idea so that's three months later so another example

is example as I mentioned about doing very large ablation so this is a lady who hadn't malignant melanoma and she

had metastases to liver we basically placed six probes into this mass as you can see there on that CT the image on the right is the appearance of those six probes it's all excited about how many probes I placed in this patient

like it's a game and then I just watched an ablation talk with a guy put 16 in so that didn't really make me feel much better so so we have six probes here and you can see what we what you do when you have lesions that are in the soft

tissues and you're worried about freezing to the skin you can have injury to the skin right essentially frostburn and so frostbite sorry and so what you can do is you can take either a warm glove fill it up with saline and put it

with the fingers amongst the probes so it keeps the skin warm because you don't want to freeze the skin or what people are doing sometimes as well as they've just put some gauze around all the probes and they spray that goes with

warm saline I just take one of those leader bags of saline put it in the microwave for a couple minutes and then just fill fill the bowl up with it and just spray the gauze on that or you can do the glove technique the main idea

here once again is you don't want to get skin injury when you do these and as you can see a pretty sizable ablation around that entire tumor you can even see the lightening sign which is the low attenuation sort of lightening looking

structures within the ice ball which is cracking of the ice ball as you form but you will see what this is immediately after the procedure the patient will have a very hard ice ball under their chest and it takes about an hour

for that to melt so if you notice bleeding off towards or what is perceived as bleeding before you panic you should realize that that ice pole is going to melt and it's going to come out the holes seep out of the holes that you

created so oftentimes if it's sort of a blood tinge fluid that's really just the ice ball melting in the fluid coming out of the the sites that you've punctured

you know the most common procedures in China this is kind of interesting I was blown away by this when I did the research on this I knew when I would go

into the hospitals and I was all over for I've been to Beijing shanghai nanjing to even the smallest little place is up in northern china and the one thing that blew me away I'm looking at the board and I'm seeing neuro case

after neuro case after neuro case I'm like it got 10 Narrows and and a pic line I'm like it's an interesting interesting Dysport of cases and the reason being is in China they consider diagnostic neuro

so neuro angio to be the primary evaluating factor for any type of neurological issue so you're not getting a CT if you come in with a headache you think you're gonna go get that cat scan now it's generally what not what they do

so you're talking about a case and I'll give you the case matrix of the break-up it's just proportionately high for a neuro very well trained in neuro and most of the guys that are trying to neuro very similar to what dr. well Saad

said a lot of the guys in Africa are trained in France so other neuro interventions have trained in France or lipstick in China and have received European training on that so you know the level of what they're doing some of

the stroke interventions some of the ways they're going after these complex APM's they'll Rob well anything you'll see here in the US so it is quite interesting to see and the second

largest is taste hepatocellular carcinoma is on the rise it's the highest level in the world is found in China and Korea for that matter and there's many reasons why we can go into it some of it is genetic factors and a

lot of societal factors alcohol is a very liberally lie baited in China and there is problems with you know cirrhotic disease and other things that we know could be particular factors for HCC so always found that very

interesting like I said I would go into a hospital and I'll see a PICC line a hemodialysis catheter and then 20 tase's on the board in one day so it is quite interesting how they do it and then biliary intervention stents tips and

then lung ablation you know the highest rates of HCC biliary cancer and lung cancer found in China and once again when we talk about lung cancer what are those contributing factors you're talking about certainly a genetic

component but mostly it's lifestyle factors smoking is prevalent in the US and in you know in Europe and in some areas in Asia we've seen obviously a big reduction in smoking which is fantastic China not so much you don't see that

it's a societal thing for them and unfortunately that has led to the the largest rates of cancer in the world in lung cancer so lung ablation is a big procedure for them over there as well so procedure breakdown this is kind of some

of that breakdown I was telling you about that cerebral procedure is some of the most commonly performed and you're talking about at very large numbers they're doing neuro intervention because they do it for die

Gnostic purposes and I would that kind of blew me away when I found out they do have cast scanners and certainly for trauma and things like that they'll do it but the majority of the stuff if you come in you have headaches you might end

up in the neuro suite so it's quite interesting how they can do that tumor intervention very high like I said you have the highest rates of HCC in the world you're getting cases they do have y9t available and in fact China just

made their largest acquisition ever with the by what you guys know a company they bought surtex there's a Chinese company now it got bought by China now the interesting is they don't currently have a whole lot of

y9t over there but they just opened up some of their own generators so they can actually start producing the white room 90 and I think you'll see probably a increase in those numbers of y9t cases but to date the number one procedure for

them is taste and they do a lot of them you know like I said on average a community hospital setting you might find 15 or 20 cases a day with three interventionalists so compared to what you guys do there's probably not many

people here unless you're working at a major institution that there's nothing but cancer doing 20 cases a day and I promise you're probably not doing it with only two interventionalists so it's amazing how fast and effective they've

gotten at and below therapy and unfortunately it is necessary because of those elevated HCC levels and like I said when we look at some of these things it's I go over there and I'm looking at the board there are very few

cases for you know PICC lines very few the frosted grams very new bread-and-butter abscess training procedures like we do here in the US they are very it's the prevalence is very simple it's neuro it stays and it's

biopsy and those are some kind of the big three for intervention in China and there it's such a large volume you get to learn a lot when you're over there and CLI PA D even though it's more prevalent in China than it is here

because smoking lifestyle factors certainly westernization of the diet in China which occurred since the 1950s and 60s has led to a lot of McDonald's and and fast food and things that weren't currently available prior to 1950s you

see a lot of PA d but it is very undertreated and certainly talking to some of my colleagues like whom are oh you'll get to see a little bit later on with CLI fighters one of the things that's kind of frustrating for them is

that it is so undertreated it's very common to see amputations in China instead of actually doing pipe in percutaneous intervention they normally like to go too far and you see a lot of amputation certainly above

normal so that's something I think as an interventional initiative when we look at these things coming from a Western perspective it's definitely something we need to pursue a little more aggressively but there it's very little

oh well you're talking about two you know two to three percent you know maybe up to six percent or PID cases very very low levels so equipment in equipment in

of cryoablation it's gentler than both microwave and RF a you can use it in a lot of locations because of that you can visualize the ice ball with CT multiple probes means potentially huge ablation zones and I'll show you an example of

that it's not painful and for me I know that I don't know about everyone else in the room but our anesthesia assistance is is very spotty or sporadic so it's nice to do stuff with conscious sedation in which case cryoablation you can

absolutely do most places with conscious sedation it's not painful at all whereas if you've done microwave you know the moment you turn the probe on the patient wants to punch you so so it's not particularly painful you can do it with

sedation and it has this immuno genic response that we're starting to learn more about right so when you cook tissue your since you just cha reverie and you just cook all the proteins and all the membrane of the cell with cryoablation

you actually keep some of the proteins in tact so what happens is as the cell dies your immune response comes in and it recognizes those tumor antigens right those tumor proteins and there's been lots of reports of where you oblate for

instance a renal mass and the patient's lung nodules will regress because of that so that's a very nice feature of it is that's got this immuno genic response and I'll use that often times if I'm doing a lung ablation for instance and

there's other nodules you can see a regression of those nodules the disadvantage as well you need you know there's these repeated freezes right so you do these freeze thaw cycles you go ten fighting you know ten freeze five

for ten freeze five for that ends up being a pretty long freeze time right and even if you do the triple freeze protocol which I can talk a little bit in a bit here you can see it ends up adding up a lot of time so the time you

save on not putting the patient to sleep and getting general anesthesia actually lose on the backend when you're standing and staring at the probes freezing whereas my crew of ablation as me as you know 10 minutes and you're

done there is this idea of a cold sink so like RFA if you put the probe right up against the blood vessel it's unlikely that that ice bowl is going to propagate into that blood vessel and you can use

that to your advantage once again I'll show you an example of that but cold sink is technically also a disadvantage and one of the main things people worry about with cryoablation is the bleeding aspect right so unlike our fa or

microwave you're essentially cooking the tissue it's a Bovie right you're very unlikely to have bleeding whereas cryo you freeze the tissue and when you thought all those blood vessels are now very porous and they can bleed and so

one of the concerns with cryo is that you have bleeding and you you'll often see this especially in renal and long and then do some early studies where where physicians were doing large liver oblations and they were getting into

something called cryo shock which we'll talk about in a little bit that's probably overhyped from the earlier studies but for that reason many people do not use cryoablation in the liver they would prefer to use microwave

we're going probes I think many of you have used our FA there's all sorts of different probes right so the most common well one of the most common ones is a probe like a Levine probe and what it does essentially is it increases the

number of tines so you put the probe in and you deploy these tines and it increases your ablation size a lot of companies went towards just a single probe and they infuse saline through the probe which will then decrease the rate

at which the temperature increases so that you get a consistent slow increase in temperature to prevent impedance other probes will actually infuse saline into the tissues so that it propagates the ablation better and then finally

there's by polar probes where you put two probes in next to one another and the the ablation occurs just between the two probes and so that's a very controlled ablation that's the most commonly what you see when you do the

spine augmentation procedures with the osteo cool system or whatever system you're using that's the bipolar probe approach so as I mentioned the

terms of imaging my favorite aspect of cryoablation is the fact that you can see the ice ball very well on CT and most procedures are done with CT guidance right so as you can see this is

a renal ablation the probe has been placed you can see the ice bowl forming around the probe right so that's very predictable you can see exactly where it is the only problem with cryoablation is that that ice bowl is not

necessarily the lethal ice ball right so that maximal ice ball is really your zero Degree and in actual fact the lethal zone is about five millimeters in from that so anytime you do a cryoablation you want to weigh over

freeze essentially to get those margins that you want so that's one important thing to remember the ice ball is not the lethal it's really five millimeters short of that okay so a little more information by cryoablation you don't

have to spend too much time on this but the idea is that the more energy you put in the larger ice ball you can get and so essentially more probes you place can just supplement that energy to increase the size of the ice ball so advantages

of you have worked with cryoablation you know they have 12 different types of probes and each probe is a different Ice Bowl that they they mark it as all this

ice force probe creates a very oblong freeze and this ice rod will create a slightly different freezin you can use an ice pearl which is a more rounded freeze and that is that in order to get the length of the ice ball depends

really on the probe insulation so they've insulated the probe prior to even putting it into the packaging and in doing so you can predict the length of the ablation the diameter on the other hand depends on the rate of

transfer of energy right so if you're putting a lot of energy into that you can create a more rounded ice ball to a certain extent what I will point out in any ablation whether it's microwave or cryoablation propagation from the tip of

the needle from their tip of the antenna is what's most controlled right so if you don't want to damage something in general you want to point the needle directly at it it seems like it's counterintuitive but if for instance you

wanted to ablate near the aorta you want to point the needle right at the aorta because it doesn't come very far off the tip of the probe almost everything propagates backwards and to the side and you can't control that as much and so

kryos the same way that one's here so in

advantages of radiofrequency ablation or that there's the most research on this

right so if you look up ablation research there's a whole lot of data and research on this as it's been the longest studied so that's always beneficial when you're trying to convince people that they should get an

ablation it's cheap right although some of the problem with that is a lot of manufacturers aren't making some of the devices anymore so to get replacement probes and that sort thing is difficult but it is certainly much cheaper than

the other modalities its gentler than microwave right so it's a slower increase in temperature and you can control it the disadvantages as we mention right so the ablation zone this is probably the worst part about

radiofrequency ablation is that the ablation zone is unpredictable right now we're trying to go towards this idea where we can predict the exact size of the ablation and really with RFA it was more experience related right so if

someone I've been doing them for 20 they can have a good idea how it's gonna it's gonna blade but that ablation zone is very unpredictable it's very tissue dependent right so if you have cirrhosis and the liver is

really scarred down you're gonna get a different ablation as to someone who has a normal appearing liver you have the heatsink effect which as I mentioned can be used as an advantage but usually as a disadvantage and then large large burns

are difficult right so anything greater than 4 centimeters even that is difficult to achieve with RFA it is possible to get skin burns at the grounding pad so if you're gonna do RFA make sure that the patient doesn't have

a hip prosthesis for instance and make sure you know it sometimes patients get sweat underneath the the pads and that can increase skin burns and those pads so that's one of another downside of a radiofrequency ablation so we'll move on

ablation also has a little disadvantage than that I don't know if you folks have heard of heat sink but the idea is that

if you put the probe immediately adjacent to a blood vessel that blood vessel is gonna suck the temperature away and so that you cannot oblate around blood vessels particularly well because the blood flow rate since

you just washes it out it's called heat sink effect and this is essentially showing infrared image of of an ablation how if you put a vessel nearby it stops the ablation now that can actually be used as an advantage depending on where

you're doing an ablation but truthfully if you're doing it in the liver and you're next to the portal vein or something like that it becomes a bit of a problem and any blood vessel greater than three millimeters is our concern so

so does anyone have any questions

I have a question about the workup before one of our challenges that we are having in my facility the texts run the we call it run the board and send for the patients so they are doing kind of the workup to see if the patient's ready

an IV and all that stuff one of the issues worth having is with blood thinners we do the time out and we I made it I'm the charge nurse and I had the nurses call out blood thinners as part of the timeout well we're fine

didn't issues with the blood thinners come at the last minute we're about to start and then we find wait they had a blood thinner this morning kind of what you were dealing with so we test the board runner to start you know checking

on blood thinners well they were checking but they're not telling anybody so they're writing we have slips on the board and you know with each patient so they'll write aspirin you know three 18 or whatever so now we're kind of getting

them in the habit of letting the physicians know with your plan how did y'all handle blood thinners like how who was responsible for not only looking up the blood thinners but letting the physician know hey they had Pradaxa this

morning or whatever okay so we started doing our work up sheets the day before so especially for like the if we knew a patient was an inpatient or outpatient like the day before we knew we knew they were on blood thinners we also have a

nurse navigator so the nurse navigator was the one who was kind of giving the pre-op instructions and at that time she would in she'd like go over their medication review with them and say oh I see you're on ella quest or i see you're

on coumadin when was your last dose and then she would tell them and speak with the doctor and say stop taking it on this day so we kind of had that so once they came in to the pre-op area we kind of made note of that and that she would

make note of that in the chart so when they got to the pre-op area that the pre-op nurses were able to see that but they also once again said hey I your medications were reviewed by Erica on this day however has anything changed

in the last 24 hours and we were catching it then the charge nurse would also look up the labs especially like on the inpatients and see and we'd also look at the medication list and see if they're on any blood

thinners also the concentr the people who did the consents where the AP pees in a lot of times the fellows they would also check the chart and see if the patient was on blood thinners now with between the AP PS and the

charge nurses we would try to catch any of those because sometimes it's you know the patient may be on a heparin drip and they end up coming down and we didn't know but with the phone the pre phone call that's made by the charge nurse not

having to be doing doing cases at the time she can concentrate and the AP PS we were able to catch more of these blood thinner issues and notify the physician before we send for the patient thank you one other thing we added that

was helpful is we had a group text so every morning whoever was in charge would start a group text with the physicians that were there that day the fellows the a PPS and the charge nurse so that if there were issues that came

up like if there was an add-on and a patient was on a blood thinner sometimes the doctors don't care they'll say yeah I'm gonna do the case anyway but at least you could send in the group text like this patient took Eliquis at this

time and then they could say let's move forward or no we're gonna need to reschedule this job document in the chart how did you document that you notify the doctor if they were on a blood thinner is that just a note that

y'all do yeah yeah yeah we did we did we did free-standing notes in our documentation yes great job and unfortunately this issue is not isolated to your hospital I I have been traveling around I'm now

at the third hospital but what I have a question for you and some of it you just answered but what is the a PP rule in the in your department I'm sorry what is the advanced practice provider role where do they fit in okay so the a

PPS do a couple things are there any a PPS from Emory here Oh Tracy they do a couple things come on up they're part of our team the both of these both of these Tracy and Erin are two a PPS from Emory and they'll kind of give you the

description there you're part of the 44 I went to a lecture yesterday that told me there was quite a few good afternoon sorry that we came in late but I'm Erin O'Connell this is Tracy Powell we are two of the ATP's that work at Emory

healthcare with our fantastic nursing staff and we couldn't do what we do without them it's as they already mentioned the collaboration between what we know as nurses because we're nurses at heart and what they have been doing

in preparation for the procedure so our primary role is working outpatients is the procedure appropriate for the patient I'm speaking with attending physicians on what would be the plan and then ultimately going to the patient and

describing what was going to happen what are the risks that we've discussed getting the consent you know all that process of getting the consent and then reporting back off any concerns especially in relationship to moderate

sedation a si criteria to our team members who are going to be providing the sedation and many other much more than just sedation and reference to the care of the patient during the procedure so that's sort of kind of the gist of

our role working in collaboration with the physicians and the nursing staff I think if you don't utilize like MPs or pas in your practice I think we do a very good job of sort of bridging that gap

of communication between the procedural team the nurses I mean just to have everyone know what's going on with that patient because in our facility where sometimes the first patient that will lay eyes especially on an inpatient and

to be able to bring those concerns back you know to the team is very very important and we have found that actually going to each patient's room assessing those patients because you really don't know especially about NPO

status we've had so many instances of patients coming and being put on the table ready for a procedure consent hasn't been done they've eaten blood thinners as you just talked about is a big big deal so we sort of bridge that

communication gap by doing that pre procedural in evaluation I hope that was helpful I have a question I also have kind of instituted the workup sheets and getting the nurses involved and getting ahead of the schedule and looking at

who's coming in and add-ons did you guys have any trouble with so the lead tech and the nurse collaborating and I think it's hard sometimes because the techs are so used to looking up the patient's and it was kind of hard for them to give

up that control and I think it was scary for them as well and so I kinda have like this you know so they kind of feel I don't want them to feel like I'm taking things away but they sometimes do feel that way so so yes I had that

problem okay now Eddie didn't Eddie a actually the the tech supervisor because she was so used to running the ship she was so used to making all the decisions so now a nurse is coming in she felt that we were

kind of like taken away part of her job so basically what we did was she gate there was a lot of push there was a lot of pushback to me and a lot of nonverbals and passive-aggressive but we kind of like worked through it a little

bit but here Eddie up with this list and she wrote it out on a piece of paper like this is what the charge nurse is responsible for and this is what you're responsible for and when she was able to see it on paper the

different roles and how she had more time now to go do her inventory to do her billing and and a lot of the pressure was left lifted off of her she actually was okay but it took a little bit of a process but it was because

Eddie was the mediator thank you yes yeah that's a nursing high so my question is that did you only use the lean methodology and data collection and have you employed a three process wherein you don't just look for the

common causes and you ask the all these questions until you get to the bottom or the root cause of a problem okay I'm sorry I don't so the lean methodology would involve who can you speak up in them okay

the lean methodology involves the identification of the problem and then collecting all data you said that you use the lean method and did you have to go to a series of these questions for each program that you encounter and then

you go to the bottom of the the costs not just a common causal but instead you go you ask all the whys and then you go to the root cause of the problem or else you will just have to perpetrate and it's gonna happen and again and again

and again the problem so we went yeah so we went to so when we went to the lean like when you're talking about the fishbone diagram or the or the tie or the measuring because I'm use I'm familiar with the lean methodology

wherein you used you identify the problem with all the background and the data collection and then you look for the root causes right and you do the countermeasures on the right side and implementation and

that will correspond to your PDS a yeah so what we do it was a combination a little bit of everything like the lean thing if we wanted to make it more structured because it wasn't structured so we eliminated all these little extra

pieces that we didn't need as far as some of the causes we identified what the causes were and we thought of ways how can we correct the causes as far as the measurement goes that's where that was we just did some time

measurement it's not necessarily lean but it kind of like fell into that group because we weren't sure where to put it and it was a financial component where we did cut off 10 minutes of each case so it turned out to be like a hundred

and twenty minutes a day which if you took it and we did the math if we were saving like I think it was like four hundred and eighty thousand dollars a month and just in just in just a salaries for employees and and not

including supplies so but we didn't put that in this project we just wanted to just do the basics and when you do the countermeasures did you have to prioritize your problems or you do oh yeah we yeah we we we prioritize for

sure patient safety was first and that's where we have to address that's what we needed to charge nurse in there we needed someone to identify right away and then we figured if we if everybody knew everybody's rules and

responsibilities then even like when the text came by the the nurses responsible responsible for medication review so the text didn't have to worry about that anymore the nurses worried about that abnormal lab results that the nurses own

that the text didn't have to worry about that so once we identified the roles and responsibilities of each of each person on our team then we were able to like move forward okay you're welcome hi my name is Sharon from USC and I first

would like to applaud you for your 15-minute window that was a big endeavor and kudos thank you my question is that how did what mechanisms did you guys go about to alleviate the back of the barriers to your project not just

writing down a list of duties because we have those all the time texts i mean people tend to like cross or go past the limit did you have any real concrete measures that you use to remove the barriers for for your delays

so so as far as our when we removed the barriers that was basically like if if something didn't go as planned we just said okay let's just move forward what did we learn from it and then what like like I didn't want to have this sense of

fear like oh my god we got to get the patient in there where Millie's gonna write us up there was no we didn't do anything punitive it was all like okay we didn't get the patient here on time why well the patient had to go to the

bathroom okay great so now moving forward we start calling a are you saying make sure the patient goes to the bathroom before they come here so we kind of like just kind of Capri and steady reinforcement that the staff knew

they can come to me and they say oh I forgot to check this or oh I forgot to do that I'm like okay well next time try to remember so we had a real positive reinforcement and we celebrated short winds so as we were doing great what I'd

bring doughnuts in or I'd buy lunch or say hey you guys were really doing a great job here so we kind of like did a lot of lunches and like that kind of like rewards thank you is there a way to get a video of this presentation okay

thank you oh yeah there's there's a video and we can send you the PowerPoint if you would like it what can okay okay so when we benched marked we actually one of our physicians was from

University of Maryland so we asked him can you call up there and get their workup sheet well we had some information from Dartmouth what Dartmouth was doing which is a similar organization similar to ours so we find

out what Dartmouth was doing the University of South Carolina one of the nurses knew someone who worked there and she was able to get their work up sheet so we wanted to look at these different workup sheets to see what other places

are doing - cuz they had some good information and we kind of like just a combination of everybody that's when we were working on our workup so that's when we benchmarked people so and then what do you do for emergent cases like

to use tend to get ten or fifteen or twenty emerging cases in a day or you know does that change up your whole schedule you mean is if an emerging Kasich like something's coming it yeah that turns into triage so basically we

would have a huddle in the morning and a huddle at lunchtime or we kind of like regroup with what's going on and in the morning the doctor the doctor triage - he would say I want to do this case first its case second this case third

and he would put a number and then all day long we kept retreating our patients to see how we were going to do them right so then but what do you do if you have like a stroke coming in trauma coming into your other bay and then

they're asking for something else and does that in other words that disrupt your whole day if you get that a lot or just sometimes no well sometime it did but we had we used to run three rooms so we would have a room that we would try

to not keep open but we would do like little cases in them so if something came in we had this room ready to go and we always had a float nurse and the float nurse would be a nurse that would could go in there or a nurse but we did

this one up system as far as our staffing goes we didn't put a nurse we didn't assign a nurse to a room because if our nurse is coming out of a room we had another nurse waiting to go in with the room so we always did this one up so

he kept a day moving all day long yeah that's great like she said rehad Alandra triage with the physician and say look we were getting ready to send for this PICC line do you want us to bump and you want this emergency case on

the table now these are your labs did you see that they're on heparin and you still want to do it so we we immediately and with the AAP peas as well you know we're we're we have that group text going so we can triage those emergencies

and say who do you want to let's bump something so you can get your patient on the table and everybody else kind of has to do a little backlog but yes so so we just triage to with the physician and the a PPS right and it helps that we're

not a trauma center we don't do neural but and you see all the patients and patients that need to get worked up yes or the fellow we have fellows a PP can we hire all of you I just have wait and then do you do trade you have transport

how do you transport the patients because we run into 35 minute delays just in transport alone we we had our tech assistant his name was Rudy we had Rudy do our transporting and then the nurses after the case a lot of the

nurses would take the patients and with with the with the are two nurses would go over and transport the patient if they had to so we used to transport what back and you have a transporter in the department yeah yes but we do a lot of

our transports do the transporter leaves at like 4:30 we the staff end up having to do transports and then you start early last question sorry though you start early everybody do you stay late a lot we work till 8 o'clock Mean Time and

were there till 10 or 12 at night so what we did was we had a couple one nurse came in at 6:30 and she'd get to get today going and then two nurses came in at 7:00 those are our first three cases and then we would have more nurses

coming in at 7:30 and then one coming in at 8:00 the nurse who came in at 6:30 she went home at 5:00 and then the nurse who came in later she stayed later and the other thing that we did we have a call system so we had the nurse who was

on call and see to nurse so that the nurse who was on call was the last nurse to leave for the day but the see to nurse hung around to make sure she didn't need anything because if she did she was there to help

her okay thank you very much okay thank you hi I have a very simple question how many rooms do you have how many procedure rooms for and how many staff do you have and we have nine nine nurses

wow that's a lot so I have very similar challenge what do you do with anesthesia patients or anesthesia patients we cut the day before we let anesthesia no or that morning if we knew they were going to have anesthesia and then anesthesia

would go and see them with the APB's would usually be the ones that say I'm gonna call anesthesia and they kind of like took care of that work for us therefore that's why you have the 15-minute mean that's why you're lucky

thank you well thank you and then one last question I work also in st. Joseph's in orange but I feel like you have the same scenario but my question is who's your manager who's above the nurses with you guys in a radiology

department well at the time at the time I was at the time I was a unit director so I was in charge of all the nurses um we didn't really anyone above me was a specialty director who is over the cath lab okay because my our frustration is

where we're under attack that's that's very hard for us but I'm just lucky that you we have the same system so but we don't have you guys so I guess with this seminar I will implement that to my boss okay thank you thank you very much

[Applause]

basically and a lot of projects you'll see like pre and post but here we had a little bit a little bit of a mix of a

lot of different project pieces so we did lean methodology and that's where we had our data collection tool and Eddie's going to go over our sheet about how we measure time and then we wanted to measure the arrival time to the

procedural time that that's the part that we really focused on our focus groups so we had frequent staff meetings so every Wednesday every Wednesday of every month we had something going on so we would either

have a one-to-one like nurse to nurse or tech to nurse or tech to leader or we had the techs all meeting together on one Wednesday I know the nurse is all met on another Wednesday and then on a third Wednesday we everybody met and we

talked about our findings like what what we thought was going to work the the big thing that we accomplished in these staff meetings was roll clear if it we all knew who was responsible for what and then our implementation plan is

that's when we optimized our tracking board because the doctors were the ones that came forward and said hey I want the insertion site on the tracking board and the nurses said I want that I want the name up there so that they know

who's doing the case as far as the medications on the tracking board everybody wanted to know that so we got some input from everyone and allergies was huge - and then we started the charge nurse role where the nurses were

we I had a group of the nurses and said who wants to be a charge nurse because I knew they wanted they were on the clinical ladder and the way our clinical ladder works is that the nurses start at the clinical level then they could

become an advanced nurse clinician then they go to an instance north clinician - and then a nurse scholar and then a chart and then a shift nurse manager so if you're an advanced nurse clinician - or a scholar you can be a charge nurse

so I had quite a few of those so I said who wants to be a charge nurse because they had lots of experience five of them stepped up and said they wanted to be the charge nurse so because I wanted to be able to show the vision to the to the

to our staff we use Carter's change model and in Cotters change model we started to create a sense of urgency and the reason why we use and so I have the Carters on the it's on the it's on the left right-hand side and on the

left-hand side I have the framework so create a sense of urgency that's where we had the unstructured workflow roles and responsibilities confusion and patient safety concerns especially with when the patient would come down about

the Eliquis or did you eat but those are important things that we needed to know and that those are things that kind of like delayed the cases build a guiding coalition number two and that's where the interprofessional team members all

the doctors the APB's and the nurses were involved involved I was the executive sponsor for the project but we also had to address our other stakeholders which were the nurses in dialysis

and the nurses in the ARU because that's where our patients are coming from them and going back to them and some of the nurses on the floors we had to form a shared vision for change and that's where we we had our staff meetings we

have lots of handouts we had some posters if we had a new change model which you'll see what we did have one we posted it on the wall and in the bulletin boards so that the nurses knew this is what we were doing so it was a

constant reminder remove all communicate the vision so that's where we researched the literature and then we shared the findings and so when we were researching the literature we would sit down and we have access to the library at Emory and

we would find articles that would pertain to our project and we went to a ORN they we used a lot of their work because of the Ori and the Perry OP which really gave us a lot of clarification and some safety guidelines

that we liked then then I printed out the articles for the other nurses and they had part of their project was they had to take the article articles home and read them on their spare time and come back and share at the next staff

meeting what they learned and then we designed the role the charge nurse but here it was the nurses that once I was like super busy so I gave him these articles like I want you guys to look these up they looked and printed them

out they came back and said this is what we want our charge nurse to look like and we also improved our communication methods are tracking board our daily Huddle's and we had lots of pictorials to help and then this way our nurses

were completely engaged and so as a staff so when the staff engagement survey came out because we use like these words if you're a leader in the room we'd say you're so engaged and then when they get that questionnaire do you

feel engaged then they're gonna say yes so your staff engagement scores go up so it was kind of a win-win for everybody and then the remove barriers that's where you empower the staff so basically that's where I was this leader where the

staff would say this isn't working and even though like I kind of had an idea it was gonna work they needed to either find out or if they did something and it didn't work as planned I was never punitive I'm like okay so plan a

didn't work let's try Plan B and because I had that that mindset my staff really trusted me another piece that worked for us is that we we did the PDSA model and we would plan it study it do it and act on it and we kept doing that over and

over and over with a lot of the pieces that we changed in our project then we had the create short-term wins so we had a quality and bulletin board and every month on the quality on bulletin board we would have a data for the impatience

the outpatients and the and then total and we measures like how the patients were going on a like a Ana tracking I forgot what I called that anyways it's a it's a time measurement scale and then we had then we said the next one is

sustain never let up so that's where we always had the constant reminders we kind of had nurses starting to champion different roles we had nurses say to one another like hey you aren't doing it right like the and they were like they

respected each other you're like you okay right I'll go back and change it and they didn't like talk about each other or something didn't work right and then anchor the change is that's where we had our frequent staff meetings we

always did an evaluation houses working we kept our workup sheets in a drawer so we can go back and on it if we had to and then we and then everybody met their performance appraisal criteria and like I said earlier for nurses advanced on

the plan so this was one of the this is one of our biggest breakthroughs is when we changed our leadership model care delivery when I first started it was the doctor and the I our radiology tech makin all the decisions like the nurses

was completely out of it so after we did these different things the doctor was in charge of the clinical treatment so anything that had to do with the patient care he he decided what we're gonna do the are in charge she was in charge of

clinical decisions daily operations and throughput so she basically was the air traffic for IR and then the lead tech which was the IR supervisor previously we changed the role to called to lead tech and they

were responsible for the IR sweeps all the supplies inventory and the IR technologist she cheated their schedule and then we changed it to our interprofessional model so where everybody was important and equal and so

microwave as I mentioned the reason people are switching to microwave is

that it's a very predictable burn right a lot of the companies are coming out with software that will give you an exact definition of what the size of the ablation is going to be like and that's very reassuring for the physician if

they're gonna put the probe direct it at some sort of structure they don't want to injure having an exact prediction of what that's gonna look like is very very reassuring so that's why a lot of people are going towards microwave it's very

quick there's no grounding pad issue there's no charring there's no heat sink it's ten minutes essentially the disadvantages is it's a hammer right so when you put it in you

turn it on you're getting a powerful burn so if you if you've got it somewhere wrong like it's up against the diaphragm or something like that you are gonna burn that structure so you just have to be careful with that and once

again the main property there is if you point the probe towards the structure you don't want to damage whatever it is you're unlikely to damage that structure because it will not propagate beyond the

bit in comparison to the US or try to at

least if I get this thing to work there you go so you know and compared to the US China the population is 1.3 8 billion so you're talking about a population that's for apps four times the United

States you know we always think about things and we think about everything we do in Western medicine and you know the vastness of that country and the amount of patients that are there I mean really it's its own income comparable you know

us you have thirty three twenty three point 1 million much less people you're in a much less diseased State 31 000 hospitals in China compared to us we got 6 200 hospitals really that are doing any type of case in procedure loads and

you talk about the size of the hospitals now they have very small hospitals you talking about 50 bed 40 bit hospitals and the world's largest hospitals actually in China as well it's 8 000 beds and they're predicted by 2020 to be

up to 10 000 beds in the u.s. the largest Hospital based on beds and I'm not talking about like systems or ID and so based on beds is New York Presbyterian Cornell will in their 2000 36 so you can kind of see that disparity

right there and when we talk about the Chinese population unlike what we see in Europe right now in the US or receive reduction in cancer rates across the board for multiple reasons new medications new interventions China

cancers rising and it's the highest rates of lung liver gastrointestinal cancers in the world make keep rising it's amazing when you go over there and we'll talk about this a little bit you know I went over there as you know a

Western colleague training Western ideology and medicine and you think you didn't go there and you're gonna be able to share all these new techniques I mean interventional oncology it'll blow your mind the number of procedures

you'll go in there on the board and they'll be 25 cases in one day for one practitioner to do so it's kind of the the amount in volume you can really learn a lot we're going to talk about that a little bit more in depth as well

so you know interventional radiology in

about RF a is that it was the first

ablation that we came up with all those that used it was first used in 1981 and it was really for the first liver ablation that we did RFA if any of you know about a Bovie knife the idea is the same the modality works the same as a

Bovie knife and still the main modality used in many parts of the world in the United States a lot of people will use it in certain areas but it's it's being slowly replaced by microwave ablation with time so as I mentioned some areas

are still using a fair amount of RF aimost or not I can honestly say that I haven't used much RF a at all I was sort of born into the generation of cryo and microwave places where we do use it or very commonly our Nerada meas for pain

control as well as spine ablations if any of you do the osteo cool system with Medtronic will do kyphoplasty in conjunction with an ablation that would be RFA and then Bowden oblations in conjunction with cement organizations

elsewhere right so in the pelvis if there's metastatic disease to the pelvis and you're going to ablate the lesion and then to cement augmentation the I

tip and I'll show an example of that so

right so this is that same lady actually with the malignant melanoma she has a lesion in her liver it's sort of the circumscribed structure we're in right next to the gallbladder there so we placed the probe actually under

fluoroscopic guidance with combi Ct we have a catheter in the hepatic artery so we're gonna inject some contrast and see what the ablation zone looks like but as you can see with injection of contrast very well

delineated margins on that ablation so I could tell with a lot of reassurance like I said that that we're not burning anything that we're worried about I'd say here's an example we've burnt right up towards the gallbladder but didn't

injure the goal though so that's very very nice to know so that's the benefits of microwave ablation in essentially you can use microwave nearly anywhere people are using a lot in renal and and liver nowadays you can use it in lung although

some issues with microwave is it is painful so if you burn the chest wall with microwave you're gonna know about it afterwards whereas cryo you can do near nerves like in a costal nerves and you do just fine so just a quick summary

I think we've talked a lot about this all through the this conference and with

our SAR partners about the vulnerabilities into the procedure areas we have a heightened risk of adverse events in procedures that are happening in nan-oh our areas ironically you know again the patients are twos deemed too

sick to go to the OU are and they come down to a remote area an interventional radiology hence the need for standards and streamlining and communicate and collaboration again we have you know increased acuity of our patient

population again increased volume of low-risk procedures on high-risk patients remote settings within the hospital our interventional radiology suite was buried behind our radiology department behind Diagnostics it was you

know signage wasn't very good and you know it was behind two double doors that needed to have badge access so that was oftentimes you know something it's minor but it was major when there was an emergency there was a lack of

significant team-building training and I can talk we'll talk a little bit about what kind of things you can do in your organization's that are really low cost for team-building training and then the procedure lists we know that they're

experts in their procedures but they're not trained in crisis management so and they you know luckily I have a team and I had a team of physicians that were aware of that and so we worked on methods of changing that supporting them

and supporting our team so again safety

about with cryoablation if you put the probes in and you create an ice ball and then you try and pull those probes out you can cause something called organ fracture basically and

essentially the idea is that you've trying to pull an ice ball out of a kidney or the reason you can tear that organ and it can have some pretty substantial complications related to that so once I've placed probes and

started freezing I don't touch them again even if you don't like where they are you don't want to pull them and move them around addition to that at the end of the case I'm always in a rush to get the probes out and you do this act of

thought thing and it's two minutes can I pull the probe I can I pull the probes out in the Reptoids I calm down calm down the idea that if you pull those out too early you can fracture the organ and

then as I mentioned with liver oblation specifically cryo shock was a concern these large liver oblations could cause the patient to become hypotensive going to di C raspberry compromise it was a big deal in the early studies and so a

lot of people stop doing cryo for liver now you're seeing a little bit of a resurgence of that but most still will do microwave for liver ablations

so the idea with cryoablation as I mentioned you create ice crystals in this the tissues outside the cells and then the water rushes out of the cell the ice forms then within the cell and when you thaw the water rushes back in

and this is essentially this whole shift of fluid from one to the other it causes the cell to die but the cell doesn't die like it does with microwave it going to go something called apoptosis which essentially means the

cell decides it wants to die right so it dissolves all of its membranes and whatever else the proteins are then left available for your immune system to help clean things up and that's for the immuno genic response that we talked

about earlier other things you worry

okay okay I have this question which is from a friend of mine she said my organization recently moved away from Joint Commission and is now utilizing DNV DET norske veritas has anyone

experienced this credentialing group and what experiences have you had with them I have not really experienced this group and I'm not very knowledgeable about this so if anybody has information please come up to the the and I see you

nodding you were nodding so come up to the microphone because I'd love to hear more about it it's something new on the horizon it sounds like and it's very good to share this information well that's that's my question

and so we just went away from Joint Commission for two reasons one because they're punitive and number two they cost a lot of money so dnv is another credentialing organization that's recognized by CMS and they are more

proactive for setting you up for success as my understanding well they just came last week the day before I left to come here and my director wasn't around and I'm the only nurse in the department so I had the opportunity to take this

clinical person around she asked me very little of what I did even though that I created my own job she was more interested in knowing about the badges that we have and how we handle our radiation and what we're

doing in our art IR lab which is on vascular world opening at the cath lab in two months so she didn't have a whole lot she said she was impressed with what I did but she didn't ask you what I do so I was kind of looking for feedback

for anybody else has experienced this organization so I've worked in facilities that use both Joint Commission one facility I worked in and another facility that use DMV so I've seen them both they are very similar in

the ways that they go around and look at certain guidelines and structures I will say though that DMV is not as punitive they are much more hey this is what we expect how can we help you these are guidelines and they will work with you

and it's not as I don't want to say scary but I remember when I used to work in a facility with Joint Commission it was like terrifying when they came by what DMV it was not as bad they were much more friendly much more willing to

work with you so that was kind of more my experience with them they asked similar questions to Joint Commission as Joint Commission yet who do they look at the similar aspects do they look at outcomes data look at you know mistakes

current entities go around our interventional room and say oh you have to take these posters down because they're not laminated they have to be you know 18 inches yeah so they do a lot they do a lot of the same guidelines as

Joint Commission they just are more willing to work with you and if I'm understand this correctly if this also gets you FEMA your your your Medicaid and Medicare population reimbursement so so what's the limitation on this or this

this company versus Joint Commission because I in California I've never heard of it yeah I'm what state what state Arizona Arizona and what state okay so I'm not in management background so I don't know

aspect of it but from a staff nurse in a procedural nurse in the two areas I've worked in they were very similar in that aspect thank you thank you DMV was with honor health thank you from New York so this is our fifth year at

DMV so they're very into document control which I love because many times new you have nurses copying documents that are 10 years old and the standards has changed so that's what I love about them and they're also when they visit

they give you a list of the things that you need to improve and they come back the next year and they look at those and see what you have done and what results okay thank you so be on the lookout for D and V maybe you're

possibly replacing Joint Commission's okay so we have a one minute time line

interventional perspective I talk to some of my colleagues you look at this handsome devil right here you guys know

dr. Kumar fantastic guy from Rush University with dr. arseling back there you know Kumar when I asked his opinion he was over in Guangzhou with si our initiative as a visiting professor you know one of the things in his main

for us was that you know even though the government limit some of these things that they want for excess it was amazing to him what they do with what they have you talking about very skilled physicians that we're doing intervention

very complex cases with but out the tools they probably need to do them and certainly when we talked about PA D which is very under-diagnosed and undertreated they're given the tools and the abilities they definitely want to do

more PA d work they just don't have exposure to it and then I talked also to David Trost from Cornell who's also a good friend of mine in ecology that's been overseas and you know his perspective is that you know when you

talk to the Chinese physician the majority of them are very aware of the clinical research going on here in the u.s. they're very well plugged into international societies and know what's going on so when you talk about them

they will speak very eloquently on on the current trials and clinical you know things going on that's you know like I said it was very surprising to me you definitely are dealing with colleagues of equal or even more so international

knowledge than you would imagine so

of all that all the the probes and the modalities I'm sorry so RFA you can have multiple probes the cost is cheap it's quick but the ablation zone is small and you have this heat sink issue the procedural pain is moderate but the best

attribute is that it is cheap so if you don't have a lot of money for ablation RFA is the way to go cryo on the other hand you can put in multiple probes which means you can get just enormous burn

I'm sorry ablation sizes but the time is slow right so you're gonna stand there for a while while the ice forms and freezes and forms again you get a higher risk of bleeding there's a moderate issue of heat sink effect or it's really

cold sink if you will but the procedural pain as I mentioned is is low so you can do with conscious sedation and my biggest benefit of that I perceive with cryo is the ability to visualize that ice ball and then finally microwave

which is the new kid on the block will you can use single or multiple probes depending on the vendor it's it is expensive depending on the probes you use in the vendor that you use but it's very quick as I mentioned 10 minutes

usually you can get a pretty sizable ablation zone size some will advertise up to four and a half centimeters which is pretty good size you don't really want to be doing a whole lot of ablations in most organs if the lesions

more than four and half centimeters so that's very comforting to have that large ablation that's very predictable there's no issue with heat sink but the procedural pain is high so if you want to do microwave you're gonna more than

likely have to use general anesthesia or somehow find a way to mitigate that pain and that's all I have on ablation so there's any questions of entertain them

China first of all point out look how handsome that guy is right there right that's kind of that guy's a stud no a joke and it's me but anyway interventional radiology in China you

know largest procedural case volume which is quite interesting that 1.6 million procedures a year roughly do you guys have an idea of how many interventional procedures are done here in the u.s. that we consider peer

interventional a year none that's what I'm here for you if you knew that then I won't have to be up here right so anyway o Medicare Medicaid when we look at CMS

and kind of get a rough estimate and then extrapolate looking at that Blue Cross Blue Shield private payer so you're talking about well over twice the amount of cases done yearly in China compared to the u.s. an intervention it

definitely is the biggest future market for medical device innovation when you have that many procedures being performed on that many patients you're gonna need new products there's gonna be new ideas and new innovations

but there are some issues with that in China we'll talk about that that makes it a little bit complex for companies from the outside that have different products that they want to bring into China it can be quite a complex process

and I'll kind of explain that to you a little bit as well you know iris especially was introduced in the 1980s early 80s X News 1983 when it was brought into China and the gentleman who brought it into China actually trained

at the daughter so he back in 1968-69 met Charles daughter and they started having a pen pal relationship and he was brought over in 19 9 and kind of introduced irn to Chinese the grandfather of Chinese intervention

his name is dr. Peng so who's out of Shanghai he's passed away now but you know it's kind of interesting that little historical tie back to daughter you know and and roughly about 7 000 practitioners identified themselves in

China as I are now I will tell you that that could be probably speculative they could be doing if you're a biopsy guy and you're doing you know lung biopsies are you an interventional radiologist in China you are because their process a

little bit different in how they train and how they identify themselves and like I said the thing that's interesting in China they have a Chinese society of interventional radiology there's more members of that than there are but the

SI R so the and I can tell you when you go to their meetings they have a better turnout you know their turnouts about 6 000 members they kind of have to go they don't have much choice that kind of told you gonna go so it does help in

getting that that turnover but it's so you'd have a very large society and they're very well abreast of what's going on internationally and when we talk about intervention you know for many many years in the US intervention

was a subset tied to diagnostic radiology you would have your diagnostic guys you'd have an interventional group you may if you're lucky have one or two recovery beds that you can use down the same day surgery afterwards to send your

patients China has always been very progressive in how they set up their interventional procedural Suites roughly about 50 percent of all interventional radiology departments in China have their own dedicated recovery unit their

own dedicated recovery staff and 1/3 of those are actually their own department so when you go you're going to vir similar to what we have in some of our major large academic institutions where interventional radiology interventional

neuro is separate from the diagnostic radiology department so that's quite impressive like I said you go over to China and you're expecting you know maybe a little bit different things to be a little small or maybe a little

slower absolutely not and certainly from my experience that wasn't the case so

and then one more example just to sort of illustrate the idea of a heat sink or

a cold sink right so this patient has a mass in their left adrenal gland right next to the aorta it's just anterior to the kidneys so the problem here is if you put a microwave ablation probe right next to the aorta you're likely to burn

the aorta and if you want to point the microwave ablation probe directly at the aorta well there isn't really a good window for that right you would have to go through the kidney you'll go through bowel and on route to getting there so

really I elected to do cryoablation right so that's the mass that's the aorta so you're obviously worried about injuring any order you place two probes into the lesion they obviously are streaking us out right now but that's

the aorta right there so we are four millimeters away from the aorta with these two probes you would think you'd be concerned about damaging it but using that cold sink effect you can see how the ice boss actually carves around the

aorta so you can get a really nice ablation on to that structure with that Waring that you're damaging the aorta or any nearby big vascular structure now that doesn't happen with pancreas if you freeze into pancreas you're going to get

a pancreatitis and if you freeze into bowel your bowel is going to have a perforation so that really just is with blood vessels that you can do that

so I've been a nurse at UC Irvine in interventional radiology for 12 years I'm a part-time employee which has allowed me to pick up additional shifts doing other roles and one of those other roles is allowed me to go into the clinics as a nurse practitioner before

the position was filled with our doctors seeing the outpatients for procedures today I'll be discussing transforming from clinical IR to clinical trials with syrup as me known as tpz and I have nothing to disclose so this is just a

little bit more about me here's our most a family picture of our most recent trip in Arizona and Antelope Canyon and then Utah yeah this is my husband we've been together 30 years two kids 19 year old son and an 18 year old daughter so I've

included a picture here of our team yeah I've got dr. Nadine abhi today she's our principal investigator on the left upper hand corner technologist on and trained on the lower left-hand corner and then there's a group photo which includes our

four attendings dr. Nadine abhi today dr. Carrie Nelson dr. James cat services and dr. diantha Fernando our nurse practitioners in the center Paul he's in the audience we've got three nurse practitioners two fellows residents

approximately 15 nurses 8 technologists a scheduler nurse navigator RN supervisor and RN manager just to give you an idea of what our sizes we have shared staff from CT MRI and anesthesiology we have 5 procedure rooms

available for body cases and we have one neuro room which is shared by three of our neuro I our attendings UCI has the is a 450 bed capacity hospital and we are the only level one trauma center in Orange

County so in August 2015 dr. Nadine OB today began phase one interventional oncology trials and is currently now in Phase two

deal with radiofrequency ablation is that you have a probe which acts as the

calf the current you then have the pads which act as the anode and when you place the probe in turn it on essentially there's a very small cross-sectional area and there's high flux of energy so lots of

current and then it spreads out over the patient's body and it grounds itself to the grounding pad in so the way is since she works is you generate this very very large alternating current right so the water molecules want to stay in

conjunction with that that current their dipoles arrangement they have positive and minuses and so they're gonna flip around to stay in alignment with that current and that rapid oscillation of those water molecules causes the the

tissue to heat up the way a cinch it works is by coagulation necrosis what does that mean well it's basically cooking a steak it just dies and and that's your your your death related to coagulation necrosis so with our FA

what's important to know is that the molecules immediately next to the probe are what heat up and then everything from there on out heats sort of by passive conduction and I'll describe how microwave works and that's different to

that but the probe tip never gets hot but the molecules immediately adjacent to the probe get hot and and everything propagates from there on out why is that important well it's important because if you rapidly heat the tissue with RFA

you're gonna get charring but some of you might have experienced this when you do the cases the tissue basically gets charred then it increases the the impedance or the ability to conduct it in which case you you limit your ability

to create an ablation all right so charring is a problem and it increases your impedance which is essentially the resistance to making an ablation cavity and then that decreases the ablation size and so that's really

one of the main reasons why people started moving away from RFA is that you really need tissue that's going to conduct this electrical current well and it's difficult to predict what tissue that's gonna be and so the goal with RFA

as with any other thermal ablation is to get the tissue temperature to between 50 and 100 degrees Celsius and then slow temperature rises are best right so however you want to achieve that slow temperature rise you want to do it

slowly rather than a rapid increase which is the opposite really of microwave ablation radiofrequency

today's objectives I'll start with reviewing hepatocellular carcinoma HCC

and the current treatment options I'll share the protocol inclusion and exclusion criteria and I will discuss the research treatment protocol briefly and next transitioning to research the preparation taken in the department with

staff members for trial lastly I will talk about what's involved intraoperatively from a nursing standpoint so hepatocellular carcinoma HCC is the most common primary liver manely malignancy and is a leading cause

of cancer-related deaths worldwide cirrhosis is a condition in which there is scarring to the liver causing permanent damage chronic medical conditions such as diabetes mellitus and obesity lead to chronic liver disease

obesity is a risk factor to diabetes and diabetes directly affects the liver because of the essential role the liver plays in glucose metabolism both cirrhosis and chronic liver disease remain the most important risk factor

for the development of HCC a which viral hepatitis and excessive alcohol intake are the leading risk factors of cirrhosis non-alcoholic fatty liver disease and non-alcoholic steatohepatitis which is nash our

conditions in which fat builds up in your liver thus having inflammation and liver cell damage along with fat in your liver these are other risk factors for HCC the incidence of HCC will continue to escalate as hepatitis C and obesity

become more prevalent in the United States so unfortunately the diagnosis of HCC is too often made with advanced liver disease when patients have become symptomatic and have some degree of

liver impairment at this late stage there is virtually no effective treatment that would improve survival in addition the morbidity associated with therapies unacceptably high modalities available for HCC screening include both

radiographic tests and serological markers radiological tests commonly used for surveillance include ultra sonography multi-phase CT and MRI with contrast ultrasound has historically been utilized to identify intrahepatic

lesions since the early 1980s both the photograph above shows a cirrhotic liver versus a normal liver there are visible differences in the portal and hepatic veins between the cirrhotic liver when compared to the non cirrhotic liver so

AFP alpha-fetoprotein has been used as a serum marker for the detection of HCC an AFP level of less than 10 is normal for adults an extremely high level of AFP in your blood greater than 500 could be a sign of liver tumors liver function

tests or lfts look at the part of your liver that is not affected by cancer to see how well your liver is working the lfts will be considered for diagnosis and determining the stage of HCC the tests look for levels of certain

substance in your blood such as bilirubin albumin ALP ast alt and GGT despite advances in prevention techniques screening and new technologies in both diagnosis and treatment incidence and mortality

continue to rise so treatment options for HCC can be divided into three categories surgical options non-surgical options and systemic therapy patients are screened diagnosed and treated accordingly of

these three options interventional radiologists offer the non-surgical approach which include trans arterial embolisation percutaneous ethanol injection radiofrequency ablation and microwave ablation so I want to talk

about the child pu classification the child pious core consists of five clinical measures and is used to assess the prognosis of liver disease and cirrhosis including the required strength of treatment and necessity of

liver transplant the child piu score was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices today it continues to provide a forecast of the increased increasing severity of

your liver disease and you're expected survival rate the Chao few score is determined by scoring five clinical measures of liver disease the five clinical measures are total bilirubin serum albumin prothrombin time ascites

and hepatic encephalopathy once scores are available in each of the five clinical measures all scores are added and the result is a child piu score their interpretation of the clinical measure is as follows so Class A would

be five to six points lease liver disease with one to five year survival weight at 95 percent Class B seven to nine points moderately severe liver disease one to five year survival rate at seventy five percent and Class C ten

to fifteen points most severe liver disease one to five year survival rate at fifty percent so which child pew scores do I our patients fall into for a research with the CPC and the majority of the HCC child pew scores a and B

seven with the survival rate of one to five years for 95% the best outcomes are achieved when patients are carefully selected for each treatment option regardless of the treatment approach

patients with HCC require a multidisciplinary approach to care to ensure optimal outcomes what we refer to as tumor board tumor board are meetings where specialists from surgery medical oncology radiation oncology

interventional radiology and others collaboratively review a patient's condition and determine the best treatment plan through this multidisciplinary approach patients have access to a diverse team of experts

instead of relying on a single opinion each specialty will have unique contributions to ensure optimal long term outcomes for patients with HCC so there are various algorithms for HCC treatment I actually have one on top of

the other there just to show you that if you're interested in the process you can look it up it's there's a few out there all right so how are the patients selected for treatment like I said tumor board and moving on now to the surgical

options there are two surgical options liver resection and liver transplant surgical resection is currently considered to be the definitive treatment for HCC and the only one that offers the prospect of cure or at least

long-term survival however most patients have unresectable disease at presentation because of poor liver function the overall resect ability rate for HCC is only 10 to 25 percent and even among those who undergo surgical

resection with curative intent there is a recurrence rate of it to 80% at five years post resection survival rates are in the range of 80 to 92% at one year sixty-one to 86 three years and 41 to 74 at five years

the most common sight of post resection recurrence is a remaining liver for patients who are not surgically resectable liver transplant is the only other potentially curative option virtually all patients who are

considered for liver transplant are unresectable because of the degree of underlying liver dysfunction rather than tumor extent down staging using local regional therapies can also be used to increase eligibility for orthotopic

liver transplant while on the transplant list patients disease progress and meeting criteria gets complicated so patients on the transplant list are and do get some other therapies

which I will later discuss so we're surgical resection is not possible for poor liver function liver transplant is a treatment of choice prior to 2008 no systemic therapy was available that demonstrated an improvement in survival

with the publication of two randomized placebo-controlled phase 3 trials the oral multi targeted tyrosine kinase inhibitor sorafenib has become the new standard of treatment for advanced HCC with an increased median survival from

seven point nine months and the placebo group to ten point seven months in the treatment group systemic therapy can be difficult to tolerate because of the side effects dose reduction or treatment interruption is often needed

despite the side-effects treatment is recommended and to be continued into a progression of the tumor is demonstrated the majority of diagnosed patients with HCC present with advanced disease oral therapy has taken two pills twice daily

equaling 400 milligrams B ID so interventional radiology it's like surgery only magic so I I always think about this when patients come in and pre-op beam and they think they're having surgery you know it's well a lot

of benefits to ir what we're doing so interventional radiology is where the magic happens and non-surgical approach procedures are performed percutaneous local ablation include ethanol injection and radiofrequency ablation microwave

ablation is utilized both percutaneously and intraoperatively and lastly there is trans arterial embolisation which depending on the embolization agent can either be chemo bland or radioisotopes percutaneous ethanol injection known as

Pei has a long track record and is very effective in destroying HCC tumors that are less than or equal to 2 centimeters in diameter performed under percutaneous ultrasound guidance a needle is placed into the tumor and absolute alcohol is

injected over recent years radiofrequency ablation referred to as RFA has largely replaced Pei at most centres RFA's also performed percutaneously advancing a specially designed electrode into the tumor and

applying radiofrequency energy to generate a zone of thermal destruction that encompasses the tumor and a 1 centimeter margarine surrounding liver RFA is thus preferable to ethanol injection for patients with solitary

tumors 2 to 4 centimeters in size for tumors smaller than 4 centimeters RFA can achieve initial complete response rates of over 90% in microwave ablation MWA microwaves are created from the needle to create small

regionals regions of heat the heat destroy the liver cancer cells RFA and microwave are effective treatment options for patients who might have difficulty with surgery or those whose tumors are less than one and a half inch

in diameter the success rate for completely eliminating small liver tumors is greater than 85% so can I get a show of hands from the audience on who what facilities are doing chemo embolization everybody pretty much are

you guys doing them next to the gentleman yeah okay so this is gonna be a boring review here alright so trans arterial embolisation a minimally invasive procedure performed to restrict to tumors blood supply it is performed

by advancing and angiography catheter into the branches of the hepatic artery supplying the tumor and injecting an agent mixed with orally contrast followed by a cluding agent known as beads the beads which range from 100 to

300 micrometers in diameter are carried by the circulation into the terminal hepatic arterioles where they lodge and include the vessel resulting in the schema tumor necrosis the procedure is done using moderate sedation patients

are monitored for 23 hours or less for pain and post embolization syndrome trans arterial chemo embolization thus is where the chemo therapeutic agent mixed with beads is injected to the tumor

these particles both blocked the blood supply and induced cytotoxicity attacking the tumor in several ways taste is the treatment of choice when the tumor is greater than four centimeters or there are multiple

lesions within the liver taste takes advantage of the fact that while the liver is refused by both the portal vein and the hepatic artery HCC survives its blood supply almost entirely hepatic artery tastes has been shown to

prolong survival in patients with intermediate stage HCC and objective responses were observed in the majority of patients tear trans arterial radioembolisation is a form of catheter directed internal radiation that

delivers small microspheres with Radio isotopes directly into the tumor y9t microspheres are administered and a procedure similar to taste the procedure has been shown to be safe and effective in cirrhotic patients with HCC the side

effects are usually well title tolerated one major advantage of y9t over taste is that it is indicated in the case of portal vein neoplastic thrombosis while taste traditionally has been considered a contraindication all right so there's

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