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Multiple Myeloma|Vertebral Augmentation (KIVA)|67|Male
Multiple Myeloma|Vertebral Augmentation (KIVA)|67|Male
2015Benvenue MedicalchemoelevateGRIBOImyeloma
New Developments in Vertebral Augmentation | The Cutting Edge of Vertebral Augmentation
New Developments in Vertebral Augmentation | The Cutting Edge of Vertebral Augmentation
adjacentballoonballoonsbindbonecementchaptercharacteristicscomparedcomparingdevicedirectlyexothermicfracturesfull videoGRIBOIimplantmechanicalmetastasesosteolyticpainperformancepressureprettyreductionstatisticallystudytermstrialversus
Backpain in Elderly Patients and Vertebral Compression Fractures | Dementia & Imaging “ Big data”, Spine Interventions in Aging Canadians- Keeping folks out of Nursing Homes
Backpain in Elderly Patients and Vertebral Compression Fractures | Dementia & Imaging “ Big data”, Spine Interventions in Aging Canadians- Keeping folks out of Nursing Homes
2017compressioncystsdenseembolizationendometriosisepiduralmrispainrisksacralsciatictarlovtreatingvertebralvertebroplastyWCICwomen
Tarlov Cyst Multiple Case Review | A Discussion of Tarlov Cyst Treatment with Long Term Follow Up
Tarlov Cyst Multiple Case Review | A Discussion of Tarlov Cyst Treatment with Long Term Follow Up
anterioraxialbladderbonybraincortexcystcystsdistensionduralerosionexpansionfenestratedforamenherniationhypotensionimageslaminalaparoscopicmeningealnerveoverlyingpatientpatientsposteriorradiculopathyretroperitonealsacralsacrumsagittalsciaticsignalsubarachnoidtarlovthoracicvalsalvavertebral
Immobility Fram VCFs Produces | The Cutting Edge of Vertebral Augmentation
Immobility Fram VCFs Produces | The Cutting Edge of Vertebral Augmentation
acuteaugmentationbonecaucasianchaptercompressiondensitydvtsembolismfracturefull videoGRIBOIlossmarrowmorbiditiesmuscleorthopedicorthostaticpatientspermanentphasepulmonarytibialvertebral
Risk Factors and Comorbidities for Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Risk Factors and Comorbidities for Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
administrationagentsaxillarycancerchapterchemocliniciancomorbiditiescontrastdiagnosticextravasationfactorsfull videoinjectioniodinatedmediamultiplepatientpatientspediatricradiologicrisksloanvascularveinsvolumes
Visceral and Peipheral Interventions | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
Visceral and Peipheral Interventions | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
ambulateambulationchapterchemodecreasingfull videoparticipatingpatientsradialrecoverysedatedsitevisceral
Results Conclusion & Q&A | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
Results Conclusion & Q&A | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
2016alterationsAngiodynamicsantennaantennasapproachbeneathcardiologistcardiovascularchaptercirrhosisdifferencedischargefrequencyfull videoheartinterferencemaximizemicrowaveno transcriptpacemakerpacemakersprobessbvSIRstudytumortumorsultrasoundventricleventricular
Physics of MRI 5: Relaxation and Image Contrast - Part 2b
Physics of MRI 5: Relaxation and Image Contrast - Part 2b
2012acquirecartilagecausedcentercontrastcorrespondsdefineddegreeechoessentiallyfastfastergenerategradientinitialintensitylobemagneticmetersmovesoccursparameterplaypulserelativerotatingsignalspacespintimetipsUHN
Objectives Methods Data Collection & Analysis  | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
Objectives Methods Data Collection & Analysis | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
2016anesthesiaAngiodynamicsantennasassessbiopsychaptercomplexitycomplicationsconsciousemphasisfull videomicrowavemitigationrenasbvscannerSIRtumor
Techniques with Procedure Examples | A Discussion of Tarlov Cyst Treatment with Long Term Follow Up
Techniques with Procedure Examples | A Discussion of Tarlov Cyst Treatment with Long Term Follow Up
aspirateaxialcystcystserosionfibrinfluidimagesinjectlaminaneedleneedlesposteriorsubarachnoidtarlovtechniquevertebroplasty
Background Purpose & Methods | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
Background Purpose & Methods | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
2016anesthesiaAngiodynamicsantennaantennasbeneathcardiovascularchaptercomplicationscontourdetermineenhancingfull videohearthyperimaginglivermeasuredmicrowaveno transcriptpatientsperipheralprocedurerhythmsbvSIRtumortumors
Introduction | Transarterial Chemoembolization
Introduction | Transarterial Chemoembolization
2018AVIRchapterfull videointerventionaloncology
Elderly Population Growth | The Cutting Edge of Vertebral Augmentation
Elderly Population Growth | The Cutting Edge of Vertebral Augmentation
augmentationbullchaptercommondiseasefracturesfull videoGRIBOIsilververtebral
Biomechanical Implications of Vertebral Compression Fractures and Vertebral Augmentation | The Cutting Edge of Vertebral Augmentation
Biomechanical Implications of Vertebral Compression Fractures and Vertebral Augmentation | The Cutting Edge of Vertebral Augmentation
adjacentaugmentationbiomechanicalbodychaptercortexdatadegreediscfracturefull videoGRIBOIplastypressurepressurizationreducereductionsegmentationstrainstressvertebral
Physics of MRI 5: Relaxation and Image Contrast - Part 2b
Physics of MRI 5: Relaxation and Image Contrast - Part 2b
2012acquirecartilagecausedcentercontrastcorrespondsdefineddegreeechoessentiallyfastfastergenerategradientinitialintensitylobemagneticmetersmovesoccursparameterplaypulserelativerotatingsignalspacespintimetipsUHN
Vertebral Compression Fractures and Vertebral Augmentation Mortality Data | The Cutting Edge of Vertebral Augmentation
Vertebral Compression Fractures and Vertebral Augmentation Mortality Data | The Cutting Edge of Vertebral Augmentation
adjustedaugmentationaveragecaucasianchapterdatademonstratedembolismexpectancyfull videoGRIBOIincreasedinpatientmeasuredmedicaremortalitypneumoniariskskilledstatisticallysurgicalsurvivaltibialulcersvertebral
Results Complications Urinomas & Follow-up | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
Results Complications Urinomas & Follow-up | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
2016Angiodynamicsbiopsychaptercomplicationscortexfollowupfull videoimagingmonthsneedlepatientpatientsprocedurerecurrencesbvSIRthirtytumortumors
Suggesting Change | Radiation Safety
Suggesting Change | Radiation Safety
antennascancerchapterpracticesradiationsafetytechnologist
Intro & Objectives | The Cutting Edge of Vertebral Augmentation
Intro & Objectives | The Cutting Edge of Vertebral Augmentation
augmentationchapterfull videoGRIBOItalkvertebral
Radiation Cataractogenesis - Increase Risk of L Sided Brain Tumors | Antioxidants Prevent DNA Damage from Radiation
Radiation Cataractogenesis - Increase Risk of L Sided Brain Tumors | Antioxidants Prevent DNA Damage from Radiation
braincardiologistschaptercorrelatesdoseembolizationfull videointerventionallensposteriorradiologistsreceivetumorsvertebroplasty
Current Treatment Options For Limb Threatening Hand Ischemia: How Good Are Their Results
Current Treatment Options For Limb Threatening Hand Ischemia: How Good Are Their Results
amputationarteriovenousarterycriticaldiseaseembolizedendoscopicFistulahandhemodialysisischemiaischemicmultiplemyelomaoccludedocclusionpalmarPathophysiologypatientpatientsprosthesesproximalradialradiocephalicshortestthoracictotallytransplantulnarvascular
Vertebral Augmentation Implant Based Surgical Techniques | The Cutting Edge of Vertebral Augmentation
Vertebral Augmentation Implant Based Surgical Techniques | The Cutting Edge of Vertebral Augmentation
anteriorballooncementchaptercomplicationsdeviceexpandedfull videoGRIBOIradiographicsecuredspinestentstentingtitaniumvertebralviscositywire
Meta-Analysis of Vertebral Augmentation vs Non-Surgical Management | The Cutting Edge of Vertebral Augmentation
Meta-Analysis of Vertebral Augmentation vs Non-Surgical Management | The Cutting Edge of Vertebral Augmentation
andersonangioplastyarticlesaugmentationbracingchaptercomparingdataevidencefracturefracturesfull videogoldGRIBOIlevelmetaorthopedicpainpelvicplastyreductionspinestatisticallystentstudiedstudiessupportivetrialsversusvertebral
Evolution of VCF Treatment | The Cutting Edge of Vertebral Augmentation
Evolution of VCF Treatment | The Cutting Edge of Vertebral Augmentation
augmentationbonecementchapterfull videoGRIBOIimplantintroductionkyphoplastyretrievalvertebral
Summary & Conclusion | The Cutting Edge of Vertebral Augmentation
The Future | The Cutting Edge of Vertebral Augmentation
The Future | The Cutting Edge of Vertebral Augmentation
bonechaptercombinationdevicefillingfull videofutureGRIBOIignoreinterventionalmaterialstera
Case: Cryoablation of Rib Metastasis | Interventional Pain Management
Case: Cryoablation of Rib Metastasis | Interventional Pain Management
2018ablateablatedablationablativeAVIRcancerchaptercryoablationdiagnosisembolizefull videomodalitiespainpatientradiofrequency
Transcript

with L1 with Kivaplast you see the Kivaplast down here. This implant, we have seen there also, right so this fracture was a bit older. So was not able to elevate the fracture,

but you see there is no leakage and I was able to elevate those fractures. And also I showed these at this German spine meeting, everybody was a big outcry, you have to correct the kyphotic angle. You have to cut and do a substraction/g you have to fuse the whole

patient, and then say come on this six to seven year old patient, might have been myeloma all over the bodies. And this is what we've given up with chemo and so on. You're not going to operate and the patient was pain free, and didn't die she went through the operation.

This is a slide from John Carlo/g [UNKNOWN] where he uses this implant

All right, let's look at some new things.

So I'm going to go through this pretty quickly, cement is one of the things I really like. There are cements that are new that have great components. This is a hydrodicy appetite cement And I compare this with the other new material that came out, it's called Cortas/g. Call Mike Glasren/g and try resident polmer and this is Cortas/g in the pain reduce as compared with this level on trial with vertebralplasty and cement . So

Cortas/g is relatively non exothermic and we could say it's non- exothermic so the pain reduction, we used to say caused by adverse effects, and the heat of the C-fiber and it sounded good and it got you to say C-fibers, it makes you seem smart but it doesn't really, this indicates the reduction in pain has to do specifically with the reduction in the mechanical instability. Cortas/g one of the things I liked about Cortas/g was the ability

to bind directly to bone and it does't form the fibrous reaction. The acrylic palmer/g that also would bind directly to bone and this comes primarily from dental research is hydroxyapetide/g impregnated bone cement and this is stuff It bonds directly to bone, I really like that.

There's other film materials, there's cement coming out that has the same biochemical properties as bone, there's cement coming out that has very high hydroxyapetide/g content, there's cement

coming out that has amino acids attached to it that are analogs to bone protein Provides it not only to be osteo-conductive but osteo-inductive. There's lots of new products coming up, most of which are not quite ready for prime time but to give you a snapshot of this cement, there it is.

Some of the high pressure balloons recent advancements in the last five years this is comparing expander one. That is a higher pressure balloon. Semitronic/g product versus Ivast by Striker and Abermax by Care Fusion in terms of mean inflation volume and mean inflation pressure and performance characteristics you will find us a higher volume.

A much higher pressure compared 762 PSIs compared with 450 with striker balloon that came in second place in this direc cadaver compassion study. What does that mean? How much pressure is it necessary to reduce strong ,sometimes sclerotic

and healed bone? Answer is about 450 and 550 PSI. Performance characteristics were pretty good and when you have low compliance balloons, they blow up to the typical shape, they burst very easily because they're not elastic, don't wanna group you then give you a lecture about elasticity of balloons.

But the performance characteristics will do pretty good because they are not elastic, they don't form a little balloon animals and they tend to not to herniate. They tend to abate against flat surfaces, they come in contact with. This is an example of the ivast balloons that herniated through an inplate.

Another topic is implants, so this is the first implant approved in the United States is called Kiva made by Benevenue. This is a peak implant poly three through key tone and is designed to be put in through pedical unilaternally. The cement is injected into the implant and directed centripetally, and this provides structural support, provides security with

cement. And the original study will support the investigational device exemption trial was supported by this data which was a 300 patients, 21 centre trial called the Cas/g trial. Primary end points, pain and function,

secondary end points, cement, amount extravation rate, per-tubual body structures and angulation. So this a direct comparison of balloon cadioplasty, I want you to look at these very closely. This is a 70 point Reduction and visual analogue skill pain and a 40% increase in wester/g disability function.

This is about as good as we give you a basis of comparison in all of medicine there's nothing I know that comes this close. This is as good as it gets. This is a shot over center field fence and it's out of the park rolls was into the parking lot. So this is pretty good in terms of a none theoretical/g study with

vertebral implants comparing the Kiva device. In terms of significance. Non fear for pain and function. The only significant difference was less cement extravation and less cement volume.

No difference in adjacent fractures and a better improvement in the kyphotic angle. I'm gonna go through a couple of quick articles about Kiva to give you an idea about the reproducibility of this. Core visas in level 1 trial 190 patients showed the same thing. Showed less cement volume less extravisation rate

was able to improve the segmental vertibral angle or the gardener angle better although the height reduction wasn't statistically significantly changed. But the pain function quality life measurements were all the same. A lot of food marker, this is interesting because this is a match

pair trial that compared balloon versus Kiva implant It's interesting in the fact that it showed statistically significant reduction in terms of Kiva pain response at six months and a significant reduction in adjacent level fractures. And this is the first trial that I'm aware of this showing a statistically significant reduction in adjacent level fractures with a mechanical

device versus balloons and this is kinda what we're after. This is nipping around the edges of this and it was better in terms of pain. Gian Carlo Anselmetti did this study in osteolytic metastases. Which is very difficult because osteolytic metastases hurt a lot,

you extrapolate a lot, so this is pretty good for osteolytic metastases. Best characteristic of this study relatively low gravitation rate 16.3% is remarkably low I think in terms of osteolytic metastases and you get a medium pain response that goes from ten to one.

Okay, let's talk about back pain in the elderly. Every Friday and Thursday, I treat two people and I see about five other patients.

And I love treating elderly people. I have sort of two parts of my practice in terms of spine intervention. One is women who can't sit. There's a whole population of women who can't sit. Women get back pain for different reasons than men,

and yet we read their MRIs just the same and it's wrong. Because women have all this stuff in their pelvis that can compress the sciatic nerves, and endometriosis can go anywhere, and implant and lumbar sacral nerves can cause pain. So I have all these women who come into my office

and they stand. And often they turn out to have Tarlov cysts in the sacrum. And I've treated about 213 of them, published a paper in AJR and that. Then there's the other population, the elderly patients. And these folks, they have backs like this.

And they've had multiple compression fractions treated by vertebroplasty. They have spinal stenosis. There's nothing wrong with their brains, and yet because they can't walk they wind up in a nursing home

because they can no longer live independently. So I'm fortunate to work in a Portuguese neighborhood. I see a ton of little old ladies right before Easter and right before Christmas, Little Nonas. And I sort of do little nerve blocks,

and then they go home for Easter and for Christmas, and they can bake and they're all happy. And they come back next year. It's great, it's lovely. And it's very low stress and it has a big impact on social networks.

And it's terrific. Now, the conventional surgical alternative of this will be this. So Peter and I and others have developed methods of treating compression fractures. And I had the pleasure working with Cook

for many, many, many years on this, and I've accomplishments I didn't disclose because all the Cook vertebroplasty stuff is mine. But you know, if you have one fracture the risk of another one goes way up. If you have two fractures, the risk increase 12 times.

If you three fractures, the risk goes up 75 times, which is pretty bad. The cement we inject, it comes from the per specs in the cockpit of this airplane, the Spitfire. It's polymethylmethacrylate.

And so you know, it's an embolization of a vertebral body under X-ray guidance. That's how I see it. Here you see the injection of cement. You see the little particles, the little fishies going in. And then we watch it carefully

to make sure you don't fill the epidural space or it goes to the lungs or anything like that. It's one of the simplest things I do, but it brings great pleasure because people get pain relief. It's a very simple reason that I like being a doctor. I'm not sure I can express it any more complex.

So there you go, anyway. So the cements, I worked very hard to make them dense enough. I now have four different cements. One is really dense for L45. One is really hot.

Oh, and you can navigate vertebral bodies by using curved needles and things.

so a couple a couple of ground rules first of all I'm a fish out of water I'm not your stereotypical position and I always say that uh that that's how I ended up in New Orleans because you can get lost in New Orleans if you're crazy and I said I didn't get I didn't go to

that course where they inserted this stick in your rectum in medical school so I am not politically correct okay and I don't know if any of you know the Jimmy Valvano story but um you know he got up there in front of everybody and

said I got a hundred and fifty holes in my bone so I want to see a little red light blinking what are you gonna do to me and well I'm similar to that if I'm not politically correct and you're offended I would please leave now

because there's nothing you can do to me because I'm on my way out anyway so it doesn't matter but and it's really funny that I just walked in when Vicki marks was talking and I think I'm a product of the early days of interventional because

we would do cases for eight hours and get eight hours of flora back to back it was that when we learned in tips when we were learning and after you read oral and we just take our badge and throw it and and I swear that that's the reason

why I ended up with myeloma anyway so some of this stuff I'm going to talk about I always like to insert humor so it does so it's not morbid and there are slides sometimes I'm you know being Italian I'm

kind of a wuss I cry at raindrops and and some sometimes I cannot get through the slide because it brings back kind of kind of crummy memories but anyway so I entitled this from the other side of the glass and I actually Photoshop that's me

looking at me getting treated in CT so I

This is an example of a patient which is a Tarlov cyst and you can see erosion of with this fluid-filled cyst. When you think about the pressure needed for a CSF space to erode a vertebral body

and the duration over that's quite remarkable. Here we see the axial and you can see that the anterior aspect of the cortex overlying So this patient actually could have pain

from sacral mechanical insufficiency. And on the T2 axials you see mass effect on the So not only can this patient have pain from the dural distension and but they can also have mass effect

upon adjacent nerve roots which could cause them to Many of these patients come to me and they're unable to sit. And one of the common presenting problems is a woman unable to sit.

I go out into the waiting room or even sometimes lying on the floor because of the discomfort of sitting. Now naturally when a male physician goes out to the waiting room and finds a patient with

it triggers all their alarm bells about this patient being a lunatic. And of course an aversion reaction occurs and you don't want to or be near them and get But this is a fixable problem.

In this patient we have a in a patient who has On the left side we see On the right side we see some and some contrast entering You see expansion of the adjacent bone

and you see a ball-valve at the point of entry of the Now this patient has clearly what I would call meningeal diverticulum at the S1/2/3/4 level with chronic expansion

and spinal canal in the sacrum. And this is more of a Clearly chronically These are very difficult people to treat and I don't have a good Most of the patients I see

that grow slowly over years at a millimeter or less per year. And here we see a small cyst at S2 and we can see it on the axial images and you can see the measurements there. And then when I followed

there had been a subtle increase in size of three or four with an increase in bony erosion and now resorbtion of the lamina overlying the posterior And that erosion of the lamina

is my point of access into the cyst. You can see too that the signal on the is higher than the signal And this tells me that and the fluid in that cyst

and therefore is saturated as it were. Its protons are saturated and therefore higher in signal on T2 than the subarachnoid space which is pulsating with systole diastole and brain movement.

Some of these patients in other areas. And this person has a at the thoracolumbar junction. So I look on the images in a patient with perineural

or Tarlov cysts in the sacrum and the words are interchangeable for perineural cysts on the sagittal T2 images. And the more that there are the more likely in my mind

that they have an underlying So here we see this in the thoracic spine and clearly this could cause an intercostal nerve radiculopathy by compression of the exiting nerve root

which runs along that rib. This patient has presacral meningoceles. In other words expansion in the presacral space from with bony erosion. This would fall into a category

These are very difficult to treat. You can go trans-sacral you can go through the sciatic It is hard to make these people better. Sometimes these patients... This patient's name is clearly

We have to edit this slide okay? Sometimes these patients because a perineural and there will be a CSF And you see we see descent of the brain down into the foramen magnum

tonsillar herniation loss and evidence of intercranial hypotension from a CSF leak from a tear in a dural cyst and loss of CSF. Here again we see effacement

of the quadrigeminal plate cistern of the perimesencephalic cistern with brain descent from CSF leak. And the cause in this patient were these thoracal lumbar which are treated by

Sometimes sacral can cause intercranial I've seen this a couple of where the valsalva of pregnancy results in a rupture of the cyst. Now when you look at this

design of cysts in the sacrum it looks kind of like a This is clearly a patient with a congenital cause and these are expansile which are a component

for this person to have And these can be symptomatic but they're just not possible and the surgical outcomes are not good. This poor young woman and she has a deficiency

We see the bladder compressed we see the Foley catheter in the bladder and we see this huge presacral meningocele with a very wide neck and unfortunately there In the past some folks have done

retroperitoneal laparoscopic and fenestrated the cysts. But what happens is the patient gets the worst and intercranial hypotension We need some kind of

where we can use some kind of

One of the things I find interesting about tibial augmentation is

that a lot of us just treat the fracture and don't worry about it. You know this bothers me, if my mother, who is a thin Caucasian female northern European descent, aged 74. If she fell down and broke her

hip and she had a T score of minus 3.5, 3.7 and one of our orthopedic colleagues slaps a screwing a gamma nail in her, just didn't worry about the T score of minus 3 point. I wouldn't be happy yet we do this everyday and I think this is inappropriate and I would encourage you

guys to modify the practice to be able to treat the complications of the disease process which is the fracture in addition to the underlying disease process which is the low bone marrow density osteoporosis. So if you have somebody who has a morbidity, we went through mortality

and I'm going to blaze through morbidity, but if you have somebody that falls down as a vertebral compression fracture and they have in the acute phase 1-2% bone marrow density loss per week in the acute phase before it settles down, it's permanent, it's a permanent loss and if you have game, the only two things that put bone marrow densityback on are high impact exercising.

Tera-peratide is called Pertaio/g trade named. And this is the only anabolic bone agent currently that we have. So you can permanently affect, increase or cause loss in somebody that has a vertebral compression fracture. So this is important.

Bone loss is generally a permanent thing. There's not too many patients that are in fact doing exercise. Some were worried about the morbidities here. The important ones, I've already mentioned to you the pulmonary problem and about a third of patients get PEs, DVTs rather.

And out of the patients that get DVTs between 2% and 12% get pulmonary embolism and between 0.5% and 10% of those the PEs are fail. Muscle strength loss four to five weeks after somebody has a vertebral compression fracture they're half as strong as they were before the fracture, and strength is

a primary determinant of stability and balance. So it's very important they get muscle contraction, you get a whole host of things we covered press rolls, there's cardiac performance, orthostatic hypertension GI urinary tract problems etc.

Now, let's go to the risk factors of contrast extravasation. I've grouped them into three. First are the patient factors. In patient factors we have age,

the elderly and pediatric patients, because of their small, fragile veins, and their reduced ability to report symptoms. Then we have patients with altered mental status, because of their inability to communicate effectively. And, another is a history of extravasation.

This information is usually volunteered by the patient themselves, and believe me, they know exactly when it happened, which institution it happened, and even if the nurse did everything right and it was not her fault,

she is going to be the person responsible for the extravasation. Therefore, as clinicians, we should make every effort to try other sites first before that site of previous extravasation. And under patient factors,

we have comorbidities that further increase their risk. And first we have patients with vascular diseases such as Raynaud's, patients with diabetes, because of poor vascular circulation, and third, is very relevant to our institution, is cancer.

Memorial Sloan Kettering Cancer Center is a tertiary care cancer center. And the patients who come to us for cancer treatment require hospitalization, and surgeries with or without axillary node dissections. They also have to through multiple laboratory tests,

which equals multiple venipunctures. Frequent diagnostic radiology, diagnostic imaging studies, for diagnosing the extent of disease, or to evaluate the effectiveness of treatment. And that also equals multiple venipunctures

plus the injection of a vesicant, which is the radiologic contrast medias. They also go for radiation therapy and chemotherapy. Chemotherapy involves the administration of vesicant, sclerosing, and irritating agents through the patient's veins.

All of these factors result to what our patients love to call their chemo veins. What are chemo veins? Chemo veins are veins that are hard, they are scarred, they are sclerosed, and they move. And in very extreme circumstances,

you've got that vein but there's no blood return, nothing. Now let's go to the next group of risk factors that I love to call the contrast media factors. First is the type of contrast. Almost all contrast media are categorized as vesicants, and that goes for both iodinated contrast media

and the gadolinium-based contrast agents for MRI. We have the methods of administration, which is automated power injection, which allows for large volumes of extravasated contrast media in a short period of time. As opposed to a hand injection or a straight injection,

where the clinician injecting has absolute control over the administration of contrast. Third, larger volumes to be infused, and faster injection rates. These all contribute to increased risk of contrast media extravasation.

Having said that, iodinated contrast agents have a far greater risk of extravasation than that of gadolinium-based contrast agents. In terms of their method of administration which is power injection, the volume, which are larger volumes to be infused,

and the faster injection rates required within the protocol. So all of these factors are all associated to increased instances of contrast media extravasation.

In summary producing is...relation of...a real soccer sonoma has promising

...outcomes but up to fifteen, fifteen months of clinical and forty six months of imaging follow-up the declined india far was minimum and the mobility related to the operation procedure itself ...low your numbers can be avoided by using a tangential approach and avoiding direct puncture of the collecting system and,...of...include that as a single center study using one ...system and we longer follow-up.

Thank you I can take any questions...may... Yes, one question I have some a little bit confused as to what the term complexity means and how you ...yes so they really don't know from a tree score it's a standardized standardize of what it takes ...consideration is the size of the tumor the end of it like...it component

...units to the collecting system and then if it how close to the middle of the kidney it is so each one is given a number and then for the six is considered low seventy nine is moderate in above that is highly complex? So, we're using any treasury rover cooling of the questions...from ...interfering tumors were not. One thing I was curious about...wouldn't matter whether it tumor was a great for y which

can contemplate something like that. And, it displaying ...better question for fred but what I understand is that to myself as more complex if you miss just a little bit of it it's more likely to recur versus we've seen that if you actually don't have a complete margin with less complex tumors for some reason those tumors don't recur even if you don't the entire thing?

So with our peripheral and visceral interventions, some of the benefits for radial access,

and this is one thing I have to emphasize to my physicians, because when they teach the course, they're very big on oh, the minute you're done with the procedure, they can get up and ambulate. They can get up and ambulate if they haven't been sedated and it's safe for them to get up and ambulate.

But there is an earlier ambulation time with radial. Greater patient satisfaction with recovery, as you all know, a lot of our patients are sick, they don't wanna lay on their back, rejecting chemo and radiation and things, we're killing things, they wanna roll over,

and vomiting and problems, so with radial access, they can immediately sit up, they can look at their own site and help recover themselves. It's a shorter length of stay, and we'll go into the time a little bit later. But after an hour of compression,

we start decreasing the compression band, after two hours, they can go back home. Where with non, with femoral sites, if we're not using a closure site, it's four hours recovery at least. Fewer access site complications.

The other thing that I just mentioned was that the families and the patients are very big on participating in their care, so they can look at their site when we start deflating it. If they do see any signs of anything, we can immediately notify the recovery nurse,

to say hey, let's medicate this. So they're participating in their care a lot more. And their ability to get up, use the bathroom, not having to be on a bedpan. (static drowns out dialogue) And a lot of our patients suffer from chronic back pain

so being able to throw it away is a huge satisfier. Decreasing the amount of medicines they need.

What we found is that there was no significant difference in the number of or in the tumor types between the two groups? The tumor size was also not significantly different. And, the distance from the heart was difference different just based on the study design itself with the mean tumor size of only one point three centimeters from the heart itself.

The way that these tumors were approached was no different between whether they were located beneath...versus within the periphery of deliver away from the heart. Of both...number of antennas was approximately two the ...our and duration was not significantly different and as a result the ...size was no different suggesting that there's a negligible effect from the credit

heat sync on the tumor...volume and there was no significant cardiac or other complication within the group of tumors treated beneath the heart. Cardio-vascular alterations was also no difference between the two groups and there was no ventricular arithmetic that developed between the two groups during the procedure. Afterwards before the patient is discharge there was no it difference in number

of cardiovascular or human dynamic alterations while the patient was on the floor. And, there was no evidence ...patient developed...after discharge within the study period. Median imaging follow-up with similar between the group two groups and there is a low local tumor regression rate which was not significantly different. To case examples to conclude a sixty one-year-old woman with pepsi cirrhosis had a three-point-four

centimeter...segment to the lever as you can see just beneath the right atrium this tumor was approach that ultrasound guidance as we're ninety percent of the cases in ...study you can see the proximity of the antenna next to the right ventricle on the interprocedure ultrasound images and how...of castle approach was needed two position the probes in this position immediately after the relation you can see how the operations on ...the tumor...seven months there's no evidence of local tumor

...on the post...actual tone and the subtraction image? Ok, and, to concludemicrowave the relations beneath the heart can be approach the same technique as those tumors remote from heart associate with a similar low risk of local to our progression ...low-risk cardiovascular complications I'd be happy to take any questions. Coming up to the microphone please thanks.

...closeness tangential to the heart on all the cases or where they? Typically what we found to maximize the geometry that from the appalachian ...actually best point directly at the heart at the base of the patrick ...that way because you only have about with the probes we most commonly used ...have about three millimeters of the microwave field extending beyond

the tip so if you if you point at right at the base the heart within the tumor you can maximize the emission point opposition within the tumor and have a very low risk for...much beyond that? Would you do what you do these cases in...with pacemakers? Good question and we looked at our data to see if any of our patients had a pacemaker that we...plated and just by chance they had it but it would not serve

as an exclusion criteria for these cases so I have a case that some of the people in this room may have seen that with radio frequency appalachian I have a movie and as I turn on the our you see the heart slow down ...about thirty five beats something like that ...called the cardiologist and he said that he can survive with thirty so I did the... And, there have been papers that if compared microwave radio frequency impatiens that I've had

pacemakers one by...pushy and what they found is that with three frequency you certainly have to have a cardiologist...cardio cardiologist technician two-d activated for the procedure that certainly that there's, there's interference and that's study how they found that there was no interference microwave and, it's just based on basically the mechanism of heating and how there's probably? No, interference with microwave on pacemaker function so I don't think in our practice

we would consider that an exclusion...patient. Okay, thank you very much appreciate.

So now we're going tomove on to discussing some of the contrast mechanisms underlying spin echo. So just a brief review of the spin echo pulse sequence, so again it's actually very similar to the gradient echo. So here we have our initial RF pulse, and our gradients to read out the data. So the only two differences are first of all, we almost always use a 90 degree pulse in spin echo scan. And the major adddition is we add this 180 degree refocusing pulse, which

as we saw in previous lectures, purposes to refocus the magnetization. So let's just show what's going on here. So initially we play out our 90 degree RF pulse that tips the magnetization down, and we know that begins the signal. Now, we then do our 180 that tips the magnetization around by 180 degrees, and then we do our turn on our gradients, and that reads out the case based data. So again

we put on a negative X gradient that means it's out to the left hand side of case base then we turn on a positive polarity gradient that allows us to sweep out a line of case base and acquire a line of case base data. So that's the basic mechanism underlying spin echo pulse sequence. So now we are going to show in the next couple of slides how we can generate contrast, what sorts of contrast we can generate

with this pulse sequence. So now let's examine what sort of contrast we can generate with the spin echo pulse sequence. So in this slide I'm going to consider the case again where we have three different water molecules which you see a slightly different magnetic field. So initially we play out RF pulse or initial 90 degree RF pulse that tips the magnetization down into the translation/g plane. So now let's

see what occurs a period of time after we've tipped our magnetization down. So we call again that each of the water molecule sees a slightly different magnetic field, because it sees a slightly different magnetic field we're going torotate at slightly different frequencies and therefore over time they are going to be begin to deface relative to each other. So for example let's say

the white one is going tobe rotating in the counter clockwise relative to the others. The orange one is going tobe stationary relative to the others and the black one is going tobe rotating in the clockwise direction relative to the others. Now we saw from earlier, from the T2* decay that when you have this dephasing that causes a signal loss. And this as I mentioned is the T2* decay because now

the magnetization adds up destructively because now they're incoherent relative to each other. So now the next thing we do, we play out our 180 degree RF pulse. So this seems like a relatively simple thing to do but as you see it has a profound effect so when we do a 180 pulse that rotates the magnetization around by 180 degrees. Now the key to note that occurs here is the white one that's still

rotating at the same speed. We've flipped it around but it's still rotating at the same speed relative to the others. So in particular it's still rotating in the counter clockwise direction, similarly the black one is also rotating at the same speed it's rotating in the clockwise direction. So after a period of time this individual the magnetizaion associated

with these individual water molecules will begin to re-phase relative to each other at this time point here. So the analogy that people often use to explain this concept is runners in a race. Let's say, runners at a race start off in a race, and after a 100 meters, the faster runners will be further ahead than the slower runners. If at a 100 meters they all turn around and run back

to the starting line, and by the time they get back to the starting line they'll all be again in phase with each other. Each other because the faster runners will still be running faster, the slow runners will still be running slower but the faster runners now have further to go. And this concept of turning around after 100 meters is exactly the same as the 180 degree pulse so it essentially

causes the magnetization to reverse what it had previously done. So because the magnetization is now back in phase signal will then re-grow, sort of re-grow and we'll get back the signal. And in fact this is called an echo or a spin echo because it is essentially an echo of the original signal we have, so we re-grow signal. Now one important feature to note about the way I

have drawn this is if you notice the echo is actually the lower intensity than the initial signal intensity. And the reason for that is because well we've been able to correct for the decay caused by inhomogeneities, we are not able to correct for the decay caused by T2 decay. So simultaneous with this, all this 180 degrees rephasing and dephasing that's occurring, we're getting an overall T2 decay

of the tissue. So, this signal is decaying away with T2. So, our echo is never quite the same intensity as our initial value. And, the echo time, the TE, controls when that rephasing occurs. So, the rephasing occurs exactly at the echo time TE. So that's the parameter that we're going to control in a spin echo sequences, the echo time. So, if you're called from, what I mentioned earlier

in my first talk, signal loss caused by inhomogeneities is often described as e^-t/T2*. And the overall signal loss is then going to be the sum of the T2 signal loss and the T2 prime signal loss. And that's reflected in a T2* value, e^-t/T2*. So, the

effect of spin echo, is essentially to remove this T2 prime component. So remove any decay caused by inhomogeneities so the spin echo produces a decay that's purely due to T2. So there's no T2* in this case it's equal to T2 cause there's no T2 prime component. So, here we have an example of a T2 weighted image produced by spin echo. So, these are two images of the knee acquired in an

echo time of 7 milliseconds and an echo time of 33 milliseconds. I'm going to highlight three different tissues here we have muscle with a T2 value of about 50 milliseconds, fluid with a T2 value of about a 1,000 milliseconds and cartilage with a T2 value somewhere between 30 and 70 milliseconds. So in our initial, here we have our initial

echo time of 7 milliseconds and if we compare that to an image a part of the later echo time 33 milliseconds, you can see that the cartilage and the muscle have decayed away substantially relative to the signal from the fluid. Because again the fluid has a much longer T2 value so its signal has not decayed away to a great extent in comparison with the cartilage and the muscle. So I want to make

a final comment on contrast we generate with fast spin echo imaging. Because as I have mentioned in previous lectures fast spin echo has virtually replaced spin echo in routine clinical MR scans. So, here we have the basic fast spin echo pulse sequence which we'll just briefly review here, so we start out with our initial

90 degree RF pulse followed by the 180 degree RF pulse which we now know the purpose is to revoke its magnetization. We then play out our initial Y gradient which again we are starting in the center of case space this moves us down to a particular line in case space and we then play out the negative lobe of our X gradient which moves us to the left hand

side of case space followed by the positive lobe of the X gradient which allows us to read out a line of case space. Now up to this point, this is the same as fast spin echo. So if this is spin echo we would stop here. But in the case of fast spin echo we then repeat that procedure, following another 180. So we play another 180 that again refocuses the magnetization and then we acquire

another line of case space. So we essentially play out another Y gradient that moves up, on the vertical direction, moves to another line of case space and we read out the second line in case space. We can repeat that procedure as many times as we want in some cases, you can do what is called a single shot fast spin echo imaging when you essentially acquire the full extentive case space following the initial 93 RF pulse. So one question that arises

here is what is the echo time in this case? Because in this case we're actually going through multiple lines of case space. It's not just one single line. Well the echo time in this case is defined as the time between the initial RF pulse and the time where we go through the very central portion of case space. So whichever line in here corresponds to when we go through the very central portion

of case space, that is defined as the echo time or the TE value of a fast spin echo pulse sequence. And let's just look what goes on with the signal in a fast spin echo pulse sequence. So here we have our initial spin echo pulse sequence, so again we have our decay and the refocusing so we have the echo here. If we add in another 180 then again we're going to refocus the magnetization a second time

following this 180. And again recall that during this period of time we have consistent T2 decay occurring. So the echo time TE again just corresponds to time at which we acquire the central line of case space and that T2 waiting will correspond to how much decay has occurred during that period time. So let's just summarize the concepts for contrast in spin echo or equivalently fast spin echo. So in this

case we just had really a single parameter that we can vary which is the echo time or the TE and again defined as a time between the RF pulse and a time when we acquire the center of case space, which in case the spin echo follows 180 degree pulse. Generally speaking the longer the TE the heavier the T2 weighting because this allows more time for T2 decay and therefore allows for more signal discrepancy

with tissues with different T2 values. So that's the end of the relaxation and contrast lecture thank you.

Ok, the next room,... be doctor ...rich. ...hurricanes microwave operation...one hundred...a real so carson always short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications thank you I'm ...capital medical student working with the relation team at the university of wisconsin. I have nothing to disclose my coffers may have a potential conflict of interest with related to new wave medical.

To start off...relation is eh he base their modality that kills tissues by heating it through a little temperature or...to radio frequency...heats temperatures faster. He says you faster into higher temperature. The objective of this study is to evaluate the early and...archaeological advocacy of microwave of relation for a hundred...proven to enable soccer sonoma with emphasis

...complexity and mitigation of complications. Our study is a single center retrospective studies done over for your time period ...patients had to any...online and all by fsix our biopsy proven meaning that if a biopsy was not done prior to the procedure or a patients by actually results are inconclusive they were excluded from the study. Of the operations are performed by radiologists with...nineteen years of experience.

For the procedure the patient...on a ct scanner a wide dorothy scanner under general anesthesia or deep conscious situation the seventeen engage gas called microwave probes were placed under ct and our and our alzheimer guidance the majority under ultrasound as the tumor size increased the amount the number of antennas we use increases while immediately post operation ...perform the ct a conscious enhance et to assess for to

suffer adequate margin as well as to assess for complications and all treatment intense ...curator of...done in a single session. Our data collection was fairly standard we also...the rena from adjacent score which assesses tumor complexity in our follow-up is listed as shown here.

Rarely are the cysts at S4 or S5. One patient had cysts involving L4 and L5.

The technique is simple. I use conscious sedation. An IV is placed 22-gauge IV. The patient gets IV fluids And they lie head-first on their tummy in the gantry of the CT scanner.

And I use strict sterile technique. I've developed a number of approaches. The single-needle technique. This can cause pain during the procedure. The double-needle technique where I put in two needles

I aspirate the fluid with the deep needle and air goes in through and the cyst decompresses easily that way. Sometimes if the lamina is very dense I will put a vertebroplasty and then an 18-gauge needle

and I get that two-needle Occasionally I've gone I prefer not to have to do that. This is an example of a classic two-needle Here we see an S2-level

with erosion of the lamina and this large cyst. So I put in two needles and you can pass them through the lamina just by twisting your fingertips and the needle descends

You can feel it give. One goes deep and one goes superficial. So you take the stylets out of both you aspirate the fluid and then air goes in through You develop an air-fluid level.

You aspirate some more fluid the air-fluid level gets bigger. And then you wait. You wait for four five minutes and see if there's refilling of the cyst. If there's a wide neck

you can't get an air-fluid level at all you're not going to inject fibrin because the fibrin will get in the subarachnoid space You would get a If you get an air-fluid level like this you wait four or five minutes. You see if it refills. If it doesn't refill and then you inject fibrin glue Baxter TISSEEL fibrin glue.

It's simple stuff to handle just make sure you and the mixing instructions before you try and use I inject about 80% of the I try not to fill the cyst

a lot of pain and inflammation afterwards. And really the objective of the fibrin is to block the ball valve to This person had a myelo CT. You can see on the myelogram non-filling of the Tarlov cyst.

On the CT you see there's some Here we see axial images and you can see down the right side there is laminar erosion with erosion of the posterior Here's an image from the CT fluoro

showing that thin lamina Here are images from the procedure where two needles have and you see the air-fluid

These are disclosures. So, per case microwave operation...a steps treatment option for both malignant and benign liver tumors as we know it's used as a bridge to liver transplant

this...population it's also affected for the treatment of I'll go magnetic disease deliver it's even been shown to be useful for symptomatic command geometry and... However, it's use beneath the heart in the liver dome has not been well-studied for instance is there a risk of cardiovascular complications related to appalachian in such close proximity to the heart and is the year

...risk of a decrease in ...own volume related to the extensive heat sync provided by the heart of this result in a higher risk of local to...progression? Therefore the purpose of this study was to evaluate the complications ...of pertaining simulation of these tumors located beneath the heart. To do this we did a retrospective analysis over

a five-year period and all peripheral microwave regulations so we defined a peripheral live regulation as one that result in ...extending to five millimeters or less from deliver capsule. From this population those ...which extended to five millimeters or less from the heart procedure imaging form the study group.

Whereas remainder formed a control group. There was no difference between the two groups in mean patient age or gender ratio or in the number of patients who had a pre-existing a rhythm our ...induction disorder such as a bundle branch block. What we did is we first noted histology of the tumor that was avoided? We measured the tumor size based on procedure imaging using recessed one-point-one criteria.

And, we also measured a...on size that followed each... Next we measured the outer contour of the enhancing tumor or in cases of hyper vascular tumor correct on that for instance the edge of the tumor itself from the enhancing mile carting them. We also review the procedure notes to determine how many antennas were used the our

and the duration that they were run and the distance between the heart and the antenna tip. These cases are performed with anesthesia who throughout the procedure monitors the patients cardiac rhythm and ...also obtain vital signs routinely we use these records to determine if an arithmetic...during the procedure and also the number of episodes of any sort of cardiovascular alteration whether it's a sinus

...pretty card hyper hypertension between the two groups and then after the procedure when they were admitted usually for an overnight ...before they were discharge we reviewed the nursing notes to determine the frequency ...cardio-vascular alterations between the two groups which are typically more but patients so cardio-vascular fluctuations aren't uncommon.

- From this next session, which, I just wanna take one second to thank BTG for their support, both for this and the CLI panel. We couldn't put on these great meetings if it wasn't for our vendor support. We're really excited because everybody knows the massive trend in growth in the interventional,

or IO, if you will, within I-rad, that we've been seeing over the last decade and I think we have some really amazing expert panelists. We're gonna go through this in a little different way than the panel. We're gonna do one after another.

We'll probably leave a couple of minutes for questions after each one of those. It's mostly just because we need to get through this and people have to run to different sessions, so it's not gonna be so much of a panel, same concept, though.

I have the pleasure of introducing Dr. White. She received her medical degree from the University of Medicine and Dentistry in New Jersey. She also completed her residency in radiology and surgery at the University of Pennsylvania. She also holds a master's degree

in clinical investigation from Northwestern. A prolific researcher in oncology and cancer, receiving numerous awards that's helped support her practice of interventional oncology. She's also spent some time with the NIH, the National Institute for Health Research,

and she's been widely awarded for this. It's a great pleasure to have such an accomplished person with us and a dear friend of the AVR and support of us, so with that, Dr. White. (applause) - I don't know who he was talking about,

but I'm not that nerdy person. I'm a really cool person that spends lots of time doing fun things.

So they says this is designed to show you how the big market is

so let me have a show of hand who does vertebral augmentation in the crowd? By show of hands. Good, so this is gonna be near and dear to your heart because this is a bull market right. Everybody looks like a genius in a bull market, this is the saying, this

is definitely a bull market. You go back 10 years before or 20 years osteopathic population is estimated by the number of patients over 65 years old doubles right. If you go back to 1960 forward to 2030 increase is 4.2 times. This is huge and obviously compared to disease state if you compare with things that are common stroke, heart attack and breast cancer is far more prevalent in terms

of the prevalence of the disease it's very common and it's actually because my kids need to eat, go to college and there's five fractures are more than twice as common as hip fractures that are more than occupied distal radial fractures and hip fractures combined, so vertebral

compression fracture represents a lion's share, and this is updated information, 700,000 spine fractures a year, and this new data from Necrosis Oestreoncrosis foundation compared to the old data which was 2005. A friend of mine, Porter Mc

Robert calls this condition known as the Silver Tsunami, right? So I love this little Silver Tsunami cartoon because this is really the onset of a new opportunity and new focus on this increasingly expanding group of over 65.

Talk briefly a little bit about biomechanical implications and this is really what gives rise to adjustable fractures. This isn't Pat Warden data. This is data I live because it really tells us why we see what we do after vertebral augmentation or without vertebral augmentation.

If you do a stress of strain gauge measurement on the adjacent cortex above and below where you get a fracture after the fracture has been treated with vertebral augmentation. You will find if you don't reduce that fracture you get a doubling of the stress on the adjacent cortex even after vertebral augmentation. If you have a fracture the disc doesn't pressurize provide the inter body

strut because the disc is attached by a pair of vertebral ligaments to the bone is fractured this doesn't pressurize one of the things that we like about the lack of this pressurization what you see in here are purple as compared to the normal disc it doubles the stress in the adjacent cortex one of the best things about this is this is pre-fracture state in the disc and the ability

to transmit pressure in the red. This represents the ability of the disc to not transmit pressure but if you reduce this with oestious augmentation or able to reduce in almost to normal functioning of the disc after a restoration of the integrity the underlying bone,

the sub condrion bone. This is Roman data and this is data that's a perfect augment no pan intended to Pat warden data because it says if you fracture, create fractures and if you were to restore the height, it reduces the pressure in the disc adjustical level of fracture far more

than just oestious segmentation of the vertebral body itself. So the weight shift and tear league provides a lot worse as to strain in the lack of reduction maintains that increased stress and strain far more than the reduction of the stress and strain by this augmentating vertebral body without providing reduction what does that mean? A reduction is incredibly important by Neur/g in 2013 published this

and this was published in spine. This is a subset of the free data this is the cadioplasty data comparing cadioplasty balloon plasty with non surgical management said that the greater the degree of reduction the greater the degree of improvement in this patient population the greater degree of improvement in terms of pain,

function, quality alive so is reduction important. This says it is and this is level one data, says the more that you reduce the better the patients do in terms of all the clinical indicators. All right, let's look at some new things.

So now we're going tomove on to discussing some of the contrast mechanisms underlying spin echo. So just a brief review of the spin echo pulse sequence, so again it's actually very similar to the gradient echo. So here we have our initial RF pulse, and our gradients to read out the data. So the only two differences are first of all, we almost always use a 90 degree pulse in spin echo scan. And the major adddition is we add this 180 degree refocusing pulse, which

as we saw in previous lectures, purposes to refocus the magnetization. So let's just show what's going on here. So initially we play out our 90 degree RF pulse that tips the magnetization down, and we know that begins the signal. Now, we then do our 180 that tips the magnetization around by 180 degrees, and then we do our turn on our gradients, and that reads out the case based data. So again

we put on a negative X gradient that means it's out to the left hand side of case base then we turn on a positive polarity gradient that allows us to sweep out a line of case base and acquire a line of case base data. So that's the basic mechanism underlying spin echo pulse sequence. So now we are going to show in the next couple of slides how we can generate contrast, what sorts of contrast we can generate

with this pulse sequence. So now let's examine what sort of contrast we can generate with the spin echo pulse sequence. So in this slide I'm going to consider the case again where we have three different water molecules which you see a slightly different magnetic field. So initially we play out RF pulse or initial 90 degree RF pulse that tips the magnetization down into the translation/g plane. So now let's

see what occurs a period of time after we've tipped our magnetization down. So we call again that each of the water molecule sees a slightly different magnetic field, because it sees a slightly different magnetic field we're going torotate at slightly different frequencies and therefore over time they are going to be begin to deface relative to each other. So for example let's say

the white one is going tobe rotating in the counter clockwise relative to the others. The orange one is going tobe stationary relative to the others and the black one is going tobe rotating in the clockwise direction relative to the others. Now we saw from earlier, from the T2* decay that when you have this dephasing that causes a signal loss. And this as I mentioned is the T2* decay because now

the magnetization adds up destructively because now they're incoherent relative to each other. So now the next thing we do, we play out our 180 degree RF pulse. So this seems like a relatively simple thing to do but as you see it has a profound effect so when we do a 180 pulse that rotates the magnetization around by 180 degrees. Now the key to note that occurs here is the white one that's still

rotating at the same speed. We've flipped it around but it's still rotating at the same speed relative to the others. So in particular it's still rotating in the counter clockwise direction, similarly the black one is also rotating at the same speed it's rotating in the clockwise direction. So after a period of time this individual the magnetizaion associated

with these individual water molecules will begin to re-phase relative to each other at this time point here. So the analogy that people often use to explain this concept is runners in a race. Let's say, runners at a race start off in a race, and after a 100 meters, the faster runners will be further ahead than the slower runners. If at a 100 meters they all turn around and run back

to the starting line, and by the time they get back to the starting line they'll all be again in phase with each other. Each other because the faster runners will still be running faster, the slow runners will still be running slower but the faster runners now have further to go. And this concept of turning around after 100 meters is exactly the same as the 180 degree pulse so it essentially

causes the magnetization to reverse what it had previously done. So because the magnetization is now back in phase signal will then re-grow, sort of re-grow and we'll get back the signal. And in fact this is called an echo or a spin echo because it is essentially an echo of the original signal we have, so we re-grow signal. Now one important feature to note about the way I

have drawn this is if you notice the echo is actually the lower intensity than the initial signal intensity. And the reason for that is because well we've been able to correct for the decay caused by inhomogeneities, we are not able to correct for the decay caused by T2 decay. So simultaneous with this, all this 180 degrees rephasing and dephasing that's occurring, we're getting an overall T2 decay

of the tissue. So, this signal is decaying away with T2. So, our echo is never quite the same intensity as our initial value. And, the echo time, the TE, controls when that rephasing occurs. So, the rephasing occurs exactly at the echo time TE. So that's the parameter that we're going to control in a spin echo sequences, the echo time. So, if you're called from, what I mentioned earlier

in my first talk, signal loss caused by inhomogeneities is often described as e^-t/T2*. And the overall signal loss is then going to be the sum of the T2 signal loss and the T2 prime signal loss. And that's reflected in a T2* value, e^-t/T2*. So, the

effect of spin echo, is essentially to remove this T2 prime component. So remove any decay caused by inhomogeneities so the spin echo produces a decay that's purely due to T2. So there's no T2* in this case it's equal to T2 cause there's no T2 prime component. So, here we have an example of a T2 weighted image produced by spin echo. So, these are two images of the knee acquired in an

echo time of 7 milliseconds and an echo time of 33 milliseconds. I'm going to highlight three different tissues here we have muscle with a T2 value of about 50 milliseconds, fluid with a T2 value of about a 1,000 milliseconds and cartilage with a T2 value somewhere between 30 and 70 milliseconds. So in our initial, here we have our initial

echo time of 7 milliseconds and if we compare that to an image a part of the later echo time 33 milliseconds, you can see that the cartilage and the muscle have decayed away substantially relative to the signal from the fluid. Because again the fluid has a much longer T2 value so its signal has not decayed away to a great extent in comparison with the cartilage and the muscle. So I want to make

a final comment on contrast we generate with fast spin echo imaging. Because as I have mentioned in previous lectures fast spin echo has virtually replaced spin echo in routine clinical MR scans. So, here we have the basic fast spin echo pulse sequence which we'll just briefly review here, so we start out with our initial

90 degree RF pulse followed by the 180 degree RF pulse which we now know the purpose is to revoke its magnetization. We then play out our initial Y gradient which again we are starting in the center of case space this moves us down to a particular line in case space and we then play out the negative lobe of our X gradient which moves us to the left hand

side of case space followed by the positive lobe of the X gradient which allows us to read out a line of case space. Now up to this point, this is the same as fast spin echo. So if this is spin echo we would stop here. But in the case of fast spin echo we then repeat that procedure, following another 180. So we play another 180 that again refocuses the magnetization and then we acquire

another line of case space. So we essentially play out another Y gradient that moves up, on the vertical direction, moves to another line of case space and we read out the second line in case space. We can repeat that procedure as many times as we want in some cases, you can do what is called a single shot fast spin echo imaging when you essentially acquire the full extentive case space following the initial 93 RF pulse. So one question that arises

here is what is the echo time in this case? Because in this case we're actually going through multiple lines of case space. It's not just one single line. Well the echo time in this case is defined as the time between the initial RF pulse and the time where we go through the very central portion of case space. So whichever line in here corresponds to when we go through the very central portion

of case space, that is defined as the echo time or the TE value of a fast spin echo pulse sequence. And let's just look what goes on with the signal in a fast spin echo pulse sequence. So here we have our initial spin echo pulse sequence, so again we have our decay and the refocusing so we have the echo here. If we add in another 180 then again we're going to refocus the magnetization a second time

following this 180. And again recall that during this period of time we have consistent T2 decay occurring. So the echo time TE again just corresponds to time at which we acquire the central line of case space and that T2 waiting will correspond to how much decay has occurred during that period time. So let's just summarize the concepts for contrast in spin echo or equivalently fast spin echo. So in this

case we just had really a single parameter that we can vary which is the echo time or the TE and again defined as a time between the RF pulse and a time when we acquire the center of case space, which in case the spin echo follows 180 degree pulse. Generally speaking the longer the TE the heavier the T2 weighting because this allows more time for T2 decay and therefore allows for more signal discrepancy

with tissues with different T2 values. So that's the end of the relaxation and contrast lecture thank you.

So let's segway on to mortality data and mortality data is important because I opened this up with one of the reasons why we do this is something we can positively reflect mortality data. So for the skeptics in the audience it's okay, it's okay to be skeptical, it's even healthy to be skeptical but I'll present some data to

you so if there's one mortality paper that you would know to be on this paper, 858,000 patients, this is a yeoman's job. It analyzed four years of medicare claims based analysis entire database for four years and this includes 119,000 cadioplasty and almost 64,000

of vertebralplasty patients, so what did he find? Well, he found that if you boil it down to, you get a better survival with vertebral augmentation cadioplasty in this point it's only balloons, it's not with any mechanical devices that existed back in 2005

to 2008. And it was Statistically significantly better than vertebralplasty on the average if you were to boil it down and say one thing about this, median life expectancy in the average patient. And what was the average patient in this population? 75 year old Caucasian female northern European descent between three

and five co-morbidities, you increase their life expectancy between 2.2 and 7.3 years. Pretty nice, especially given the average age of people that get osteoporotic/g vertebral compression fractures. All right, so one the progression analysis that was done here,

somewhat difficult to control for the non surgical management portion of it. If you take non surgical management and you control it in an inpatient basis, bracing, analgesics, bed rest and girdling/g did at over

13 years in this inpatient trial. And what do you find? You find that you get increased survival, as compared with those patients that were treated with non surgical management, increased survival

with osteososis/g augmentation and you get increase survival with osteososis augmentation regardless of age, gender, number of co-morbidities or number of fractures. Pretty impressive. This is an inpatient trial done over 13 years,

it's a United States trial. Chen/g published JBJS in 2013, just very recently. He looked at survivorship, he looked and he got basically a 40, 50, 60 in terms of three year survival rates for vertibalplasty, for cadioplasty

and for non-surgical management, non surgical management 40, vertibalplasty 50, roughly, as you can see the real numbers listed here, and cadioplasty 60, and had a 20% adjusted risk adjusted risk of death that was lower for cadioplasty than for the

ratibleplastic/g group, two other things he measured here were very interesting. He measured the kyphotic ulcers and he measured pneumonia, why is pneumonia important? Because we talk about risk of death, it's increased about 8.6 times

age math control in terms of mortality rate for this I'm referring to Coly, osterososis international 2000 and if you compare that and you compare what kills people, what vertebral fractures? Why do they die? Is it fadimobile/g and lungs, like a bad car accident with a femur fracture, no it's primary pulmonaries, they die from immobility. Pulmonary embolism and pneumonia, so pneumonia is important because it's a cause of death.

The decubitus/g is interesting that the decubitus/g also is important but they are quantifiable because you can remember 70 over 70. 70% of patients over 70 get the decubitus/g ulcers each one of which costs between $15 and 20 thousand dollars so that's why this is important. So increase

survival. Zampini, this is the paper I like, it demonstrated another survival benefit but in addition to that it demonstrated that the people that were inpatient were more likely to go home than to be discharged to a skilled nursing facility.

And people in skilled nursing facilities were more likely to go home than to bounce back to the hospital. So it demonstrated increased return to independent patient function and at lower mortality rate statistically significant in all points in time. One of the things I find interesting about tibial augmentation is

Here are patient characteristics now that we had a fairly morbid population as well as a high...the tumors are also fairly complex with fifty

...being moderate to highly complex and you can see here that the decline india far was insignificant. Technical success. Was a hundred-percent and cancer specific survival...also ...hundred-percent with no evidence of medicine attic recurrence...any of our patients today. We experienced eleven early complications according to the

craving general system which are within the first thirty days ...procedure three the three involved were directly related to the procedure majority of...the main the bad complications where due to patients core abilities, for example, this patient had a stroke seven days after the procedure but he had past history of stroke and number four shows my according on...twenty three days ...procedure in a patient with severe coronary artery disease.

We did have six-year ...that were detected incidentally I'm followup more than thirty days plus procedure three which were associated with critical atrophy. Here you can see that all technique that we use the probes... Too deep into the collecting system and actually penetrated into the...sinus. You can see here.

The...the ...extends from the real sinus through the cortex into the pairing of space and this allows for the...to leak through in accumulate. And, twenty four months follow-up imaging ...the situated sequence you can see the enormous running the kidney...in the ...the prince you can see this completely the vascular...tumor...the year...is surrounding it.

Here's another example with the probes pointed toward the...here...not penetrating the sinus. So, although we don't like to do this anymore this is nap associated with your ...additionally if you coming from a tangential approach in the brain extends into the collecting system this also was not associated with your enormous. However, to avoid that we now use... here we come from the side and since we implemented this

...twenty fourteen we have no...enormous today. So, showing that data when the...pointed...collecting system? And, physics humor's six of the patients...whereas when we use the tangential approach zero percent of the patience of our tournaments with the same tumor complexity. Here's our follow-up we have nineteen months nineteen months of clinical follow-up with sixteen months of imaging follow-up we had one local team

regression and this was in a patient ...a needle biopsy was permitted to he was ...follow-up and came back we sell local recurrence so he went ...radical...me an x plants histology was graded as affirming great for which is an aggressive tumor that we normally do not like to a plate so due to the needle biopsy sample we probably it probably was

a it was affirming great for to begin with and this is a two-minute initially went to a plated so that accounts for the local recurrence most likely. Primary patients pass away due to conditions not related to the relation itself, for example, one patient died of an mri another gi ...another of subsets. Giving us...cancer specifics, specifics survival of a hundred-percent.

You can see are certified patient follow-up we have thirty six patients with less than one year of ...follow-up...with thirty, thirty six month of imaging follow-up sorry excuse me thirty six patients with one or two years of imaging follow-up twenty with two to three and six patients with greater than three are continuing to follow up all these patients are...our follower term.

doctors have antennas and I think sometimes it's very difficult as a technologist to tell the doctor what to do so if I hear a you're seeing somebody

with bad habits that you think the radiation safety in the room could be improved and you find that person it's difficult to talk to or to suggest things do I have secret suggestion which is not during a case you know or maybe

the end of the day or sometimes be careful is the start a conversation about changing and Hannah with this phrase ready I am open to other thoughts because nobody can say no to that nobody can say nothing so we want to have a

conversation that may improve the radiation safety habits of practices in the room is in developing habits to optimize radiation safety I have sir one focus in mind which is that I want to have little

light and hand work practices and I'm working in a radiation environment where I will get to the end of my career and have no regrets about how I manage my work environment live without regrets and when I say that because a lot of us

in this room are going to get some kind of cancer and everybody knows the radiation cost me but everybody knows when he gives rain so my goal is to get to be in the rear and if I had a cancer to be confident that it was just

and unless it's quite always and it's like to present a head games with the left and I would suggest the best an easier way to frame developing the creation safety practices that seemed too afraid of it relying on your

memorization of physics things and they can stuff so that's my philosophy I know this assures everything have any questions yes

Okay. Welcome and it's good to have everybody here for the kickoff of GRIBOI 2015. We wanna talk to you a little bit today about some of the cutting edge of vertebral augmentation, here my disclosures. And I wanna to talk to you about a few things, so the disease process gives rise to the vertebral compression fractions needs to be emphasis more than it does.

I wanna talk to you a little bit about what we do in terms of vertebral platys all the way through to vertebral augmentation with implants. We need to know why we do what we do and are are gonna address a literature that really tells us why we need to do what we do and provides a good objectives support for that and solve the new techniques and the new developments.

papers has been on this topic of looking at our progression of understanding. And the dose that we are allowed now annually receive to our lens has been reduced seven-fold in the last two years. This is a cross section of a lens. We

see the normal structure the cornea etc. And the posterior aspect of that lens is where our radiation-induced cataracts occur in thirty-eight percent of us. One my colleagues Vitor Pereira put together a beautiful study in

Geneva were he and his colleagues wore DLDs all over their bodies during interventions. And what was striking here with the dose to the left side of the head is six times higher than the dose to the right side of the head. This

correlates well with a paper demonstrating increased risk of left-sided brain tumors in interventional radiologists interventional cardiologists. In this paper of 31 interventional cardiologists

with brain tumors eighty-five percent were left-sided. The dose we receive is higher with the longer procedures. Cerebral embolization vertebroplasty etc... longer procedures have more dose

- Good afternoon to everybody, this is my disclosure. Now our center we have some experience on critical hand ischemia in the last 20 years. We have published some papers, but despite the treatment of everyday, of food ischemia including hand ischemia is not so common. We had a maximum of 200 critical ischemic patients

the majority of them were patient with hemodialysis, then other patients with Buerger's, thoracic outlet syndrome, etcetera. And especially on hemodialysis patients, we concentrate on forearms because we have collected 132 critical ischemic hands.

And essentially, we can divide the pathophysiology of this ischemic. Three causes, first is that the big artery disease of the humeral and below the elbow arteries. The second cause is the small artery disease

of the hand and finger artery. And the third cause is the presence of an arterial fistula. But you can see, that in active ipsillateral arteriovenous fistula was present only 42% of these patients. And the vast majority of the patients

who had critical hand ischemia, there were more concomitant causes to obtain critical hand ischemia. What can we do in these types of patients? First, angioplasty. I want to present you this 50 years old male

with diabetes type 1 on hemodialysis, with previous history of two failed arteriovenous fistula for hemodialysis. The first one was in occluded proximal termino-lateral radiocephalic arteriovenous fistula. So, the radial artery is occluded.

The second one was in the distal latero-terminal arteriovenous fistula, still open but not functioning for hemodialysis. Then, we have a cause of critical hand ischemia, which is the occlusion of the ulnar artery. What to do in a patient like this?

First of all, we have treated this long occlusion of the ulnar artery with drug-coated ballooning. The second was treatment of this field, but still open arteriovenous fistula, embolized with coils. And this is the final result,

you can see how blood flow is going in this huge superficial palmar arch with complete resolution of the ischemia. And the patient obviously healed. The second thing we can do, but on very rarely is a bypass. So, this a patient with multiple gangrene amputations.

So, he came to our cath lab with an indication to the amputation of the hand. The radial artery is totally occluded, it's occluded here, the ulnar artery is totally occluded. I tried to open the radial artery, but I understood that in the past someone has done

a termino-terminal radio-cephalic arteriovenous fistula. So after cutting, the two ends of the radial artery was separated. So, we decided to do a bypass, I think that is one of the shortest bypass in the world. Generally, I'm not a vascular surgeon

but generally vascular surgeons fight for the longest bypass and not for the shortest one. I don't know if there is some race somewhere. The patient was obviously able to heal completely. Thoracic sympathectomy. I have not considered this option in the past,

but this was a patient that was very important for me. 47 years old female, multiple myeloma with amyloidosis. Everything was occluded, I was never able to see a vessel in the fingers. The first time I made this angioplasty,

I was very happy because the patient was happy, no more pain. We were able to amputate this finger. Everything was open after three months. But in the subsequent year, the situation was traumatic. Every four or five months,

every artery was totally occluded. So, I repeated a lot of angioplasty, lot of amputations. At the end it was impossible to continue. After four years, I decided to do something, or an amputation at the end. We tried to do endoscopic thoracic sympathectomy.

There is a very few number of this, or little to regard in this type of approach. But infected, no more pain, healing. And after six years, the patient is still completely asymptomatic. Unbelievable.

And finally, the renal transplant. 36 years old female, type one diabetes, hemodialysis. It was in 2009, I was absolutely embarrassed that I tried to do something in the limbs, inferior limbs in the hand.

Everything was calcified. At the end, we continued with fingers amputation, a Chopart amputation on one side and below the knee major amputation. Despite this dramatic clinical stage, she got a double kidney and pancreas transplant on 2010.

And then, she healed completely. Today she is 45 years old, this summer walking in the mountain. She sent to me a message, "the new leg prostheses are formidable". She's driving a car, totally independent,

active life, working. So, the transplant was able to stop this calcification, this small artery disease which was devastating. So, patients with critical high ischemia have different pathophysiology and different underlying diseases.

Don't give up and try to find for everyone the proper solution. Thank you very much for your attention.

So here's how the cubic device looks like, it's put over nickle titanium wire

and the peak implant goes in over the wire cement is injected by behind it and this is what it looks like and this is a very nice case result with the cleft. Another device, Spine Jack, this is not approved in the US at least being used a lot in Europe and if you were to look at this I can show this to my wife that doesn't know anything about

anything for anything that I do or spine it on what is thing you put on the table so what does this thing look like? Looks like a jack, I don't know she knows, has ever seen the one at the back of trunk of her car far less how to use it, but that's very recognizable thing and this thing is called the spine deck

it goes in as a cylinder. And this thing is expanded it's got three different sizes and this is put in through an eight gauge canular all the way up to a much larger devices. This minimum this can destruct 500 newtons so the maximum 1000. So we were talking about really the ability distract and here's

how it's put in needle, wire, drill, trial devise followed by Spine Jacket itself and secured by cement. So here is how it is. Bipedicular access established with a wire, you convert the wire

to the drill to the template the spine jacket devices are put in bilaterally, little righty tighty action, you're able to get these to jack up the vertebral body. Very impressive the amount of reduction on those anterior portions

of the skiis on the jack, does expands more than the posterior, and this is very characteristic. And this is secured in place by spine smith. This is after a little horse shoe pattern induction spine cement. The cement that they use is called cohesion. I like this stuff, this is about 400 pascal seconds so for those

of you who are interested in cement this is something that's very useful, you mix this up and it's relatively quick to dough. The viscosity is the most important, this is Lepels article I'm listing right here, viscosity is the single most important component for extravation and cement control.

And it's also zirconium based, we had several cases of barium induced Osteolysis. So this is rocuronium/g, is this any better? It's

already opaque, and it may be better, but it looks to be a pretty good cement combined with the new spine jack. This is from Noreaga/g. This is not even 40 Pesos per trial, but compared with balloons

we get great pain reduction, quality of life measurements. I'm not gonna show you the reduction, comparisons between the spine jack and balloon but suffice to say we can show that to you later if you wanna see this in terms of radiographic analysis it's

definitely better in terms of direct comparison with the balloon. I'm gonna give you one slide of a vertebral body stenting and this was really not an optimal trial. This is the stent that was made by Synthes. This is 100 patients. This is level one evidence ladies and gentlemen.

The problem is with that, we get a lot higher pressure with the stent to be able to expand the stent. The stent looks like this. This metallic stent is expanded by a balloon, and then cement is

introduced in the the problem is it's a lot more higher pressure than the balloon cadioplasty and they found device complications with no significant benefit over tube bub body stenting versus at the balloon plasty. So the conclusion was no significant benefits and more complications which is unfortunate but the way it goes.

Well, what I really like to do is focus on the why, why we do this, so if you were to name two things in medicine that we do that are demonstrably life saving to people what would they be? Would it be angioplasty to stent placement?

No. Cancer surgery? Nope. Hip fracture repair? Spine fracture repair, right? These are things that we

do that are demonstrably life-saving, and life-prolonging for people. So given that, knowing that we're doing it for For these reasons, it also behooves us to know a little bit about literature, the literature on that. So there's controversy back in 2009 in a couple of articles

were published in New England Journal, it said the vertebral plasty was better than non-surgical management, right? No, didn't say that at all, said vertebral plasty wasn't statistically better than sham or fake surgery treatment. So if you analyze all of them, this was done in 2012, this is a juggernaut of them all so if you're gonna know one article about vertebral augmentation, this is it,

pop the stash out and here it is, there's 1587 articles in English language, there's 27 level one, level two studies of that there's nine randomized control trials and this is the results of that. So if you ask a pain guide what is a good result out of the procedure

in terms of pain reduction in numeric rating score? The answer is four. Patients come back with four points reduction in pain that's a good response. They come back and say you know I feel better.

Thank you, thank you very much. So that's four is a shot over center field fence, 5, you get 4.55 with vertebroplasties you see here. 5.07 with kyphoplasty, what's a five?

What's a shot into the upper deck? And I'll show you some of the recent data with some of the implants, and some with the modified data with balloons we're getting seven points reduction depends on how high the pain level is going in. In addition to that, subsequent adjacent level fractures probably caused by spinal pelvic imbalance inprocrosis not

necessarily in the material put in the vertebral body, it's okay not to believe that, I'll show you evidence in the contrary which is really supported by if you compare by non surgical management versus pace got vertebral augmentation using the best evidence that we have, we cut the rate of medicinal or adjacent level fractures in half so they also said in the nice recommendations go a long with this, you'd be treated within the first seven weeks you get a better reduction in pain, you get a better result. So you also get a better result, and this is important, with vertebral augmentation

terms of quality of life you get a better result than you do with vertebroplasty. It's what the best studies will say. This is quick analysis. I'll go over this quickly is by Anderson Counsel et al with vertebroplasty, and wanna

kinda put this to rest they started it early being 12 weeks they've studied light meaning 6 to 12 months and they studied pain, function, quality of life and this is meta analysis including eight articles, two repeated twice including the Camas/g bug binder trials conclusion of Paula Anderson provided strong evidence in support of vertebralplasty for

vertebral compression fracture treatment. In addition they looked using a conquering risk biased tables, the levels of evidence for primary researchers is based by NAS and some of the other organizations we work with, and found that if

you use inclusion, exclusion criteria for both of Cama/g bug binder trials, and the crossover rate for the Cama/g trials don't supply for level one evidence. We downgraded this to a level two which is very important. So if you look at all the evidence. This is my third grade slide set.

Cause my son is in third grade, that green is good, green means go and we like to go. What does red mean? So red means stop, red's bad. And yellow he said going anyway but go faster, that's my boy, that's what I like.

This means green is supportive evidence for T-blog augmentation, the yellow is non statistically significant data that the Cama/g bug trials, no significant difference. There's no studies that said the T-blog augmentation is more supportive than non-surgical management, and one time when I gave a talk about bracing, you gotta love orthopedic spine colleagues, but they said,

the gold standard for treatment is bracing. Gold standard is bracing, it's interesting. If you really look at it, Fifer is the only

evidence and it is level on evidence, it is the only evidence comparing bracing versus oestroposis treatment with calcium vitamin D and a postphate not even a metabolic bone agent was used there. And there's no studies comparing bracing oddly enough with vertebral augmentation even though that view is gold standard.

So let's change the gears here and I'm gonna talk to you about what

we used to do as opposed to what we do currently. Vertebral augmentation started off in mid 80s and has gone from cement that we mix with high-tech instruments known as a bowl and a spoon to fully developed kits for Vertebroplasty. Then advance on to blue kyphoplasy to VVS right there, stands for retrieval

body stenting. I'll talk only briefly about that and then a whole bebi, a whole spew of spinal implants. So retrieval plastic for those of you who don't know which is probably nobody in this room. It's just injects of film material usually methy methacrylate into the

bone itself after introduction by needle. Balloon kyphoplasty involves an inflatable bone temp/g followed by removal of the temp/g, and introduction of cement usually after that. And then implants, and there's a bevy of these things,

a variety, but only one approved in the United States where I practice, and this a Kiva implant made by Ben Benue/g and you can see the Kiva impant here, this is the peak, the polyethre/g the kypho implant surrounded by cement

injected directly into the implant themselves.

So you will see options.

I didn't go over all the different implant options this morning. At least right now, these will provide greater reduction probability, probably better pain reduction, probably less adjacent level fractures, and this provides something that's gonna be good for the future. In terms of what we do and how we do it,

it's good to know the literature. This is a very controversial area primarily stimulated by two articles in a high profile journal, but if you and this is an occurrence that I consider very, very beneficial.

Because this caused us to pay attention to what we're doing. And if you look at the literature analysis, it's very compelling to support exactly what we're doing in terms of pain function, quality life and life mortality. So the whole focus will be to take care of patients that have fractures

knowing that they're fragile, knowing that they have an increased mobility and mortality, and pulling on all the stops to figure out exactly how to treat them because each thing should not be used for everybody.

You're gonna have a choice to how to treat these people, and what we're going to do in future is define based on the literature what treatment is right for what patient and to be able to pull out all the stops to make a difference in these patients' lives. Thank you very much.

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Okay so far? So lessons learned. This is a huge piece of what I think all of us as IR nurses need to think about. Millennials as our workforce in nursing.

It is the largest generational group in the United states as of 2015. And so it is defined as people born between 81 and 97. And the age of adults in 2018, is 21 to 37.

They have a lot of strengths. A lot of strengths. Tap into it. Don't walk away from it, you'll shoot yourself in the foot later. I found as a preceptor

it really buoyed me, you know. I was kinda getting the drags a little bit after doing this for so long, and then I found somebody who was like a sponge and it was like, whoa. This is different.

This feels different than a nurse who has some experience. This is somebody who you can shape into the nurse that you would like to have take care of you. You kind of have to think of it that way.

Expect feedback, 'cause they'll give it to you. You may not want it all, but they'll give it to you. They definitely want to be a part of the team. And they want to share responsibilities. And from day one they were asking us,

what else can I do? Well you know, we'll get to that. You have to kind of hold them back a little bit, because they are so enthusiastic. You'll want that, but you want to temperate a little bit

in the beginning especially. You want them to have opportunities where they can feel a part of the team and not a fringe dweller. Think yourself as you were a new IR nurse, you came in from whatever field maybe

you were doing before, you were an expert in your field and now you enter IR where you're a beginner again and you're like oh my God, I don't know anything. A new grad nurse is gonna feel that 10 times more because, they really don't know even the basics.

I myself can remember when I graduated from nursing school. I thought I had it down, I thought I was great, until that first day where I'm charge nurse and I'm like, oh my Gosh. I'm an idiot, I don't remember anything.

You know you're surprised at how little you know. So you have to kind of help them through that, 'cause they will go through that. And they will, they will talk to you about it. We have cohort classes

for nurse, new nurse graduate UVA. That is a year long responsibility. They are obligated to go to it once a month. And so they go once a month with all new graduate nurses throughout the hospital. So it's kind of a support system for them.

They are self sufficient. Orienting a millennial who's a novice learner can be particularly challenging though, I can speak from that for experience. Be very clear about expectations and guidelines. Don't leave anything to chance.

Be very clear. They are every tech dependent and they're used to getting info very quickly. Which I found personally wonderful because I am not tech savvy. So I would go to them and say,

okay, help me out with this. So that was kind of their way of helping me in feeling included. It kinda was a joke between us, but it helped. We loaded all the lectures that we gave them into a thumb drive,

so all of them have those loaded, they can go home and read them, they can pull up that information on the computer, during the case, in case they're doing something that they've never done before.

Like a chemo embolization of a liver. They can pull it all up there and they go, oh yeah, alright I remember that now. And they are social media machines.

So the future of all of this is probably a combination of things. Evolution is leading to device. And device probably, in terms of mechanical implanted intrabody device is probably the future of where we're headed. We need better filling materials.

We need better cement choice. We need filling materials that do things after we put them in. We need film materials that will integrate better the bone. We need a filling material we can put on a 15 year old if we had to, assuming they were gonna live until they were 105. Medications, I introduced to you the anabolic bone agents that we have.

Is tera peratide or Porteo. We also had tow new ones coming out, buzosymaromi/gs those are scrorastin/g inhibitors. Combination of those over the course of three years can increase bone marrow density 25%. What is that called? It's called a lifetime benefit.

So we can ignore that now, we're not gonna be able to ignore when we had the whole pan of things to play with. So medications combined with interventional procedures is probably the future of what we have to look forward to.

Same patient came back to clinic, no more cane, and this is true, I'm not making this story up. No more cane, says his back pain is gone,

but he forgot to tell me that he's got rib pain. Since we did such a great job on his back, is there anything we can do about that rib? So back to the same thing. We know he's got a diagnosis of cancer, so he's probably gonna fall in one of these boxes,

not that a patient with a diagnosis of cancer can't have osteoarthritis, but most likely the pain that they're presenting with is gonna be in one of these boxes. There were no more lesions in the spine, but PET, he certainly had this huge area

of abnormal radiopharmaceutical activity and he was pointing there saying, this hurts. So that makes it pretty easy, we'd drop him into this box, which is a cancer-related pain that's not in the spine. And so what options do we have in this box? These, ablative techniques, meaning cryoablation,

microwave ablation, radiofrequency ablation, nerve ablations, which are the same modalities but targeted at the nerves that are carrying the pain, I'll show you what I mean about that, and then catheter techniques. Sometimes if we have a huge vascular mass,

we can embolize the vessels and de-bulk the mass. So let me go back. So cancer pain, not in the spine, these are our options. For this particular patient... Skip that. For this particular patient, we chose to use cryoablation

at the epicenter of the mass. This is the mass eating away at the rib, eating away at the adjacent soft tissues. The mechanism of relief here is death of the cancer cells that are in contact with the soft tissue. So it's important that we...

If we just ablated here, and then attempt to de-bulk this, the patient wouldn't do well. But if we continue to ablate and let the ablation zone engulf the entire tumor, then the patient leaves the CT table feeling better than they did the day before.

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