Nanomedicine | Applications of Nanotechnology in Interventional Oncology
Nanomedicine | Applications of Nanotechnology in Interventional Oncology
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the particular usage of nanotech

nanoparticles in medicine and the reason that we think it fantasia's is it's really the size of of things in nature and things in medicine so you can see red blood cells are in the order of nanometers and antibodies

these are all sort of in that same size range there's nano nano particles come in different flavors to liposomes if you think of a cell it has a by lipid layer membrane layer and that's just what a lysosome is and we can create these in

the lab we can create dendrimers it's basically like roots of a tree where we can grow them out to be different sizes that gold nanoshells is just a particle of gold and the reason we like gold is that you can heat it up in it it makes

things hot and then there's some other types of nanoparticles so it's not just one thing it's just a bunch of different structures that we can develop that are

who has a Fem-AT bypass and he had multiple occlusions. He had a history of Afib, he was also Lupus anticoagulant, had a CHADS2 score of three so had to be anticoagulated with chronic vitamin

K coumadin or something along those lines, hypertensive, hyperlipidemic, had laryngeal cancer and had a tracheostomy and long standing history of PADs, had a stent put in, then he left our institution and went somewhere else and had a bypass done and came back. And so when he presented he had,

these are the velocity measurements that were there and you can see that he's occluded his bypass. Again here's what the ulcer looks like. This is what the ulcer looks like after you have it debrided. So in our wound care clinic,

which is right next to where we examine patients, the wound care is done by vascular medicine or internal medicine people. You can get an idea of will this wound heal? How much blood is down there? If you scrape the wound and it doesn't bleed,

that's a bad sign. Implying that some kind of intervention needs to be done. And so over time this is what his intervention looked like. This is the bypass that's occluded. We were lacing this bypass and and after two days of lysis, this

patient was handed off to me and said can you follow up the lytic case. So this is two days of lysis. That's the hood of the graft, this is the proximal anastomosis. This where the anastomosis.

It's a Fem-AT bypass, and I decide at this time, I thought there was very nice competitive flow through the SFA, and I thought his chances of revascularization in my hands were probably better if I were to revascularize the native SFA and the posterior tibial

artery. And so following the [UNKNOWN] concept that we talked about, I went for a PT, posterior tibial artery recanalization, and this is what he looked like. We touched up the SFA, put in some stents, and then recanalized

the PT all the way down to his foot which backfilled the AT. And that's what it looked like in all the pictures. He went on over a period of time to heal this. This was a very long process for him. It took him several months but he did heal and he's currently healed.

does the nanoparticle nanoparticles are

just a description of a very small entity so so just to put it in perspective imagine me holding a marble and it's a marble to the size of the earth that's how small it is when we think about things one nanometer is a

billionth of a mirror that doesn't mean anything to me that's why i used the marble in that analogy but two nanometers would be the diameter of a DNA helix a very very tiny size that we're talking about so what's the

history of nanoparticles Richard Feynman wrote a book called there's plenty of room at the bottom in 1959 and he sort of imagined a world where we could sort of take atoms and manipulate them and create new things the term

nanotechnology was coined by nereo taniguchi in 1974 and then Eric Drexler wrote this engines of creation book where he where he imagined a world where we could have the entire library of congress on something the size of the

sugar cube and we're there right we have these teeny tiny little microchips in your computer that can have tons of information so we spend about ten

tumor so there's something called a lecture of nano therapy which is essentially using electroporation so if you've ever heard of this you know there's a bunch of people that do electroporation essentially what it is

is your electrocuting the tissue you have to have two probes in and there's a signal that goes from one probe to the other and at electrocute thing if you've ever seen us in real life it's very eye-opening it's shocking because you're

justyou're electrocuting a person so the whole little patient will go like this so they have to give you paralytic so you don't do that in animals we don't give them paralytics and it's very shocking the first time you do it

because the whole animal chicking around on the table and kind of freaks me out but any event what happens is the cells instead of if you do reversible electroporation what will happen is the cells instead of being the membranes

instead of being tight they'll loosen up and they'll actually they'll actually be pores within the membrane if you do it irreversibly the pores open and what happens is the things around it will go in and the cells can explode or those

shrivel up if things go move out of the cell so the cytoplasm depending on which direction and you ph and all these other factors they can either explode the cells will explode of the shrivel up when they'll die and so

that's if we couple that with nano nano technology it actually works and we can get more penetration of drug and nanoparticles into the tumors and this is just an example where we did electroporation followed by a

nanoparticle injection and you can see that it turns from light to dark as we want to see and the tumors okay this is just a color map a different way of looking at the white to dark the other thing we can do is photo thermal

ablation I talk to you about gold nanoparticles so we can essentially inject nano particles that have gold in them as soon as gold sees light we have lasers that we can use you put a laser and it hits the gold and the gold makes

it hot you can increase your ablative

billion dollars annually on nanotechnology and research if you can

imagine that so nanotechnology is not just in the lab it's everywhere I was giving a lecture and they I was at I should say that I was at a national meeting and they're talking about biomimicry and actually the stuff they

spray on your windshield to make the water beat up that's nano technology so it's a part of your everyday life you just don't know it but that's that

so how do we get its site selectively there well we can just do enter to Merle

injections if we can just inject directly into the tumor we an interventional radiology or leaders and how to you know get something through a needle somewhere and they showed in this study that if you do inject it directly

into the tumor it gets there first of all and second of all it's high concentrations it stays there and sort of all it decreases the growth of the tumor so that's really amazing these images are from actually dr. omaree's

lab and thanks to them for giving me these images but this is essentially nano embolisation where we're doing just what I talked about on that conventional chemo Malaysian slide where we're injecting nanoparticles directly into

the tumor and this is a rabbit liver it allows us to get high concentrations it circumvents that sequestration so they're not going to be sucked out by the spleen or the lymphatics and you can actually see where they're going you can

visualize where they're going the other fancy thing we can do is we can put some iron in it and when we image iron on MRI it changes what color it looks like so tumors look like they're bright so they're sort of whitish that's what's

outlined on by the red and the after picture you can see it turns dark so that's what iron does then we say oh we actually nailed the tumor because the tumor went from white to dark if you have non-target or two or nanoparticles

to go to the liver you'll see the liver double turn Burke as well and so some of the things that happen in humans after we do chemo Malaysian is that angiogenic factors get turned on now this is in human safety test date they drew the

blood and these are angiogenic factors so those are the factors that to tumor says I need more blood supply I need more blood supply and we tested that in humans and it turns out that those angiogenic factors get elevated so is

there a way that we can with nanotechnology get these levels decrease because we don't want those signals turned on we want the cells to be dead we won't don't want them to be saying I need more blood supply how can I get it

in cancer research well you can use them

in a bunch of different ways you can use them in drug screening you can use them to deliver genes i have an example in my lab we're working with an ophthalmologist who is trying to figure out how to treat diabetic retinopathy

and so he's developed a gene vector and if he gives it through through the IV it never makes it to the eye because it gets sequestered out by all the other cells and so what we do is we go up into the artery that supplies the eye and we

deliver this gene locally and it actually helps prevent diabetic retinopathy and so that's just a way of using nanotechnology particles are very tiny we can use it for diagnosis so if if these nanoparticles will hone to

tumor cells we can say yep that's a tumor that's not a tumor we can deliver drugs there an we're going to talk a lot about that because that's what we do particularly in my lab again detection where are these things we can track them

we can say how much drug was delivered and then diagnosis and monitoring so patients coming for follow-up do they have two more don't they have ten where we can use it that way so how does cancer work since I am a cancer doctor

there's a bunch of different things that cells have to be able to do to be cancerous they have to evade apoptosis so those signals that the cells are telling them I you have to die you have to diet has to say I don't care I'm not

going to die you can tell me that but I'm not going to they have to be self-sufficient so they don't have to rely on their surroundings to survive because they have to move they have to go from their site of origin and

metastasize elsewhere they also have to be insensitive to those anti growth signals so when the body says you know it's not time for me to replicate they have to say you know what I don't care i'm going to replicate

they have to be able to invade and metastasize so that's sort of what I voted to earlier and they have to be able to continue to reproduce over and over and over again because what good would a cancer cell be if it couldn't

reproduce itself and then they have to be able to sustain angiogenesis or what that means is that they have to be able to get nutrient and how do they get nutrient they send out signals that say I need blood you need to develop blood

blood vessels so I can continue to grow so this is sort of a six hallmark of what cells have to do to be able to do

was in our lab and she developed the Saracen and microspheres so why is that you know why is that important what does that mean why can't you just give her the drug patients the drug well it turns

out that this drug is very poorly tolerated patients get sloughing of their skin on their hands in their feet so they can't walk but maybe they get the benefit of the drug the other difficulty with this drug is why can't

you just infuse it like we do for key memorization what's lipophilic so it's that right so if you infuse fat it's just going to come out it's not going to go it needs to be so she dances she developed these

very fancy nanoparticles that would go into the bloodstream they wouldn't precipitate out they wouldn't be fat globules and we could inject them into tumors and what we found is you know she put iron on them so that we could see

and this is just images from the MRI showing you that as we go up in concentration the images go from white to black that means we can see them and we know that as the concentration goes up it gets darker and darker and so does

it work so we tested it in vitro so that's just in a petri dish we put it in with a petri dish and does it kill cell so it actually does kill cells which is good what we want and then we delivered it into the into the liver this is just

a tumor before we embolize this is after you see pruning of the vessels and on an MRI you can see again it goes from white the dark now it's not completely dark you're getting that speckled appearance but that means that those nanoparticles

are actually getting to the tumor we do histology so we take it out iron iron turns blue on particularly Prussian blue staining so we know that the iron actually got to the tumor but it didn't look like if you look at that last slide

it didn't look like it penetrated the tumor so that big clump in the center that's the actual tumor but it sort of looks like it went around the tumor so how can we get it into the tumor how can we get it to penetrate more into the

88-year old male, non-healing ulcers,

and most of our treatment indications are patients with critical limb ischemia for non-healing wounds, some rest pain. We rarely ever treat claudication. They're either gangrene, or ulcers, or pre-amputation, planned amputation,

to make sure that the amputation heals. This patient initially got the angiogram, planned the treatment, but had a CVA. Discharged, came back awhile later. According to the son, the wound was getting

worse, and then decided to bring his father to the hospital for the wounds. And then he's feeling better in general, but the wound, foot pain is getting worse, etc., he's not doing well in that regard. He's about to lose his leg.

So these are some history, I'm gonna skip these. We'll go to the case. This is his left lower extremity that we treated. I'm not gonna go into that one.

He has complete occlusion of the SFA, and we did our access on the flouro to make sure we don't go through this stent graft here. We always check with our accesses, you don't wanna get a high access. I just saw a complication from a high access

earlier today that turned into a big mess, and eventually the patient died. It's simple as this, you should always check. Our practice is we put our micropuncture and put our wire in. Always get a fluoro image,

making sure that we're in the mid cam of it, it takes just a few seconds. If you're too high, too low it may become issue. >> You use ultrasound much for access? >> No, we use flouro. We use ultrasound sometimes on difficult

patients. We use flouro, but we check with fluoro before we proceed with the sheath. So if this access was too high, what I usually do is I just leave the wire in there as a target.

In this patient, you have the calcification still, and just use the micropuncture needle to stick exactly where I need to be. So after getting access, this is our angiogram. [BLANK_AUDIO] So it's heavily calcified, deep femoral disease, SFA is occlusive,

multiple calcifications. Going further down, not much flow or collaterals. [BLANK_AUDIO] This is just PlayView, and in addition to everything else patient does have a popliteal aneurysm which is thrombosed,

that becomes important. Has anyone done a chronic occlusion treatment through a popliteal artery aneurysm? Okay, so I thought this was interesting. So sometimes you think something is interesting, and ten people

have done it already. So this is below the knee area. We do have, [UNKNOWN] Going well for him. They're not the most healthiest, but he has an AT, peroneal and a PT.

They are kind of diseased, especially AT is severely diseased, but it goes all the way down to the foot. So we do assessment of the whole leg from aorta to the foot, before we start because all those things that you're gonna do, things may go wrong, etc. You wanna know

where your starting point was, and then to make sure you made things worse or better. So this is at the level of the foot. Kind of decent actually, better than most of our patients at this level. So we went ahead and got a magnified image to see where we're going,

so going to the SFA. Our usual technique is use a glidewire and a Berenstein catheter. Angiographic Berenstein catheter, we just try to go through. If it doesn't work then you try to use more advanced tools, or

dedicated tools like a Quick-Cross or a Zig Zag, some sort of Crossing catheter. Sometimes 014 or 018 wires, either V-18, V-14 or PT Graphix, otherwise there's a lot of them out there. All companies provide these to you, so whatever you like should work.

>> Gonna stop you for a second there. What do you guys normally for your fem-pop disease occlusions, let's say? What is your first go-to wire? Do you start O35, or do you?

>> O35, the LLT. >> Same, same. Yeah. >> I like to use the 014. I guess I'm the anomaly. >> Okay.

So just further down, as you get in there, you can see how irregular it is. There are areas of very high grade stenosis, maybe occlusions, etc., but it looks patent at least upto a level, and then you have the total occlusion with the collaterals around it that's

typical. And this is just kind of a video showing how you may get stuck at one level with the wire, just a glidewire actually. It's usually kind of my go-to wire in these scenarios. So sometimes just the wire angle doesn't work, so you have to get the

catheter in there. I use this a lot, both catheter with the wire. The combination gives you a little additional kind of ability to do stuff, and by approaching the catheter over there, you pass one of them. And this was just one of the probably ten we did until we reached

from the femoral to the popliteal, it took about an hour to get to that level. Just to demonstrate the things that you may come across. And eventually we went subintimal,

sometimes it's gonna go subintimal. There is no reason to fight it, you just have to go where it goes because the lumen may not be just crossable. So we fell into this popliteal artery aneurysm, so it's really

not gonna go anywhere from here. We ballooned everything to create a track because it's hard to push from the subintima without dilating the areas. I always balloon it with two or three balloons. So if you're gonna get another device down the road, you don't have pushability problems.

And after doing this, we were kind of floating in there, it's not going anywhere, and we ballooned it a little larger just to create a channel. And there was no way we were gonna be able to go distally from the upper and lower approach. So we got access from the lower extremity,

this is the AT after the pedal access. You can see that it's actually, this is diseased quite a bit. It doesn't look it. if you don't look at a magnified view, sometimes you don't recognize these subtle lesions.

I'd recommend everyone to get magnified images of tibial arteries. You may recanalize the whole tibial artery if you just do a completely de-mag image look at it. It's flowing fine, but there may be a few stenosis in there, tiny little ones, 90% etc. For wound healing, it's gonna become an issue.

You wanna leave no significant stenosis, and getting nice big images will allow you to assess that better. And so we went from below, again same thing. This is a hydro or a selective guidewire. You can see, this

is an issue you're gonna come across. This is I think a PT Graphix wire. So it's like a stenosis in a relatively larger lumen area. The wire doesn't follow, it gets ballooned up. It's not happening.

I changed my wire. I'm very liberal, and I don't think you should persist on something that doesn't work. I've worked with a lot of people, everyone has different approach.

I've seen somebody for example, they would try it with the same wire for about an hour until they give up. If something is not working, just move on. There's a lot of things out there. Don't waste stuff obviously,

you need to be cost-effective. But another added fluoro over here without reaching anywhere is a bigger waste than using another wire. I'm actually sorry, I think wanted to show that, how the other wire worked. So this is the heavy-tipped wire, it just went through with no problem. So on the straight areas,

I use heavy-tipped wires, there's a lot of them out there. But if you're gonna take a turn, this wire will not take a turn. What I do is I come to that angle of the anterior tibial and follow with my Crossing catheter. At that point I go back to GlideTech wire

because this wire is just gonna try to go straight. It's too heavy to reach it. And this is our angiogram at that level, showing the trifurcation kind of diseased, but patent in that area and so we tried to come from below, it's in a different plane.

You can't see how the wires opened it up, so we're subintimal. And we attempted a lot to get connected with the origin of the kind of, I don't know if you can appreciate it, but calcification is here. This is where it's connected, this area with the oblique field. Definite oblique band we had.

It just was coming out, it wasn't going in the right direction. So, attempted a little bit more. We spent quite a bit here with different wires, different catheters. It's just not reaching to the higher level, and you can push as aggressively as you want.

You're in an occlusive space, you're not gonna do harm. Sometimes it will just pop, and I will go through, it's gonna give in. Sometimes it won't happen, but the worst thing is it's not going to happen. So trying different wires, and pushing as much as you can is not

a big deal. So as you can see this is very odd, from the area. So we were set from the AT access, we're just subintimal, and at this point I think we're even outside the artery potentially. Because

subintimal, you're almost adjacent outside, but adjacent to the calcification. In this one, we were way out of the calcification. So what do you do? We have one access, we came back. I'm not gonna kind of go into those parts.

I tried to re-enter that popliteal artery with different, very different catheters, it just goes through the same track. It's just - >> Going sideways or from both sides? >> Well, but we're not able to reach the aneurysm, that's the problem. Our wire is from the AT access that I had, it's just coming out of the

vessel, and we tried different wires. I ballooned that track to create a little different path for myself. I sometimes inflate the balloon, use a rigid wire to push into a

different plane, if your current plane is not working. So that will allow you to maybe find a better path for yourself. Whatever view that it didn't happen from the AT because from the beginning of the distal end of the popliteal artery, we were always coming into the subintimal tract. And again, ballooned those areas, etc., It

didn't work, it didn't work. Then we decided to get an access from the PT. This is our PT access. This is very calcified, so you use fluoro. Most of the time we use ultrasound, but I quite often I also use flouro for this, and you can see that your wire is going through

no problem, and this is further up. So from the posterior tibial access, the reason that I did that is I thought the popliteal artery was more in line with the posterior tibial artery origin, and we were right. You can actually see, now it's actually

in the lumen of the artery over here. [BLANK_AUDIO] And this is our angiogram right there. You can see that the posterior tibial artery is as far as in the lumen of the popliteal, and the other wire is

in this plane, and so that allowed us actually to move a little bit more forward. At this point actually I left, I had to do a radiangle/g next door. Another colleague of mine came in, and he kind of progressed a little bit further. Turba came in and he got into that area. He actually advanced the wire further near the aneurysm by

pushing, pushing. Now we're in the right place, we're following the aneurysm. It's still a problem that with the three dimensionals, those wires could be like way away from each other, but we did oblique fields from the kind of fluoro. At this

location, they were within a centimeter of each other. It opened up a little bit, but it didn't open up enough that it was too far away. [BLANK_AUDIO] So, the next step is, let's move on.

So the next step is to get, sorry. So this is what we have from above injection, and the wire is over there, and what do you do at this stage? Any suggestions?

>> To snare. You snare it. >> Snare from where? >> From top. Get the snare down into the aneurysm, and get the wire from below and just snare it. >> But this is not in the aneurysm.

This is in the subintimal space of the popliteal aneurysm. >> But you can use a different tube, and one different from above and one different from below. >>Mm-mh. >> Make the two balloons one - >> Create a space in between in that area? >> Create the balloons, [INAUDIBLE] >> I don't know if everyone can hear that.

Sorry, it's really loud. That's actually a very good technique that he just mentioned, we use that. It's basically a kissing balloon. If you take two balloons that are in different planes, and usually you just need to overlap a very small part, but that will create a rent in the intimal and allow the wires to communicate.

In my experience, it works about 70 to 80% of the time. It's definitely worth trying cause it's easy. >> Yeah, exactly. Put one balloon here and the other balloon here, try to kind of match those. It may or may not happen. In my experience, I would say 50/50.

And since it's not working all the time, we actually stopped doing that any more. What we do is we just kind of put a snare in there, but how are you gonna get the other wire into the snare? That's the problem. Snare is the easy answer,

you have to snare it otherwise this is not gonna work. But you have to connect the wires, and you have to be able to capture it. >> So you can get an Outback? >> Exactly.

So that's what we do. So we bring an Outback from above, and then we bring the snare from below. Position that over there, and this is our micro snare. Since you're coming from below, you cannot use 75, 1 cm snares,

we have 4mm and 2mm micro snares. Those are the ones that we generally use for this, and open up the snare. And then once you puncture with the Outback, you just gently, kind of gently pull it down to see if you're actually over the needle.

If you're over the needle, then you push the wire out and then take the needle, retract the needle back and capture the wire and move forward. This was kind of testing. You normally want a lot more wire here, longer distance. Because pushing and pulling through Outback, which is a long metal

cannula tracted catheter, is not easy, there is a lot of friction. There's many cases that I lost access, not be able to pull-push at the same time. So you want to make sure that while you're pulling it, it's not pulling, it's actually pushing action. The snare is just gently bringing down

in a kind of coordinated fashion. Okay, we're almost there. Okay, and then this is just the snare going all the way down. Once we got it kind of through and through, we just stented the whole thing with wire band in this case.

Obviously nothing else probably would have worked. Balloons. This is our angiogram, and this is pre and post. In this area, it didn't look great. Time is up, so I'm gonna go really fast.

And this is like, we came from above in this area to treat that. This is subintimal of our initial, so we took that one out. We were actually able to get back into the AT from above, from the true lumen.

We snared that one to make sure we're in the right lumen, and we pulled that out, and what we did is this area was a problem. So we brought a coronary stent here while protecting the tibial peroneal trunk with a balloon from below, and placed the coronary stent and

got this result in the end. Any questions? >> Yeah. >> Go ahead. >> I'm sorry to disagree, whilst it's a fantastic technical result. >> Mm-hm, >> You started off with a very, very heavy calcification and you started out with large popliteal aneurysm. You've been at it for three hours, for four hours, with two access into micro vessels. >> Correct. >> Has he been clinically tested for these devices? >> He was evaluated for a bypass.

If you read the initial story, he's 88. He had a stroke, he was discharged, he received TPA, he doesn't have a vein. I think if you did a prosthetic bypass on this patient, the chances are he would have died. If he made it, yeah.

get them there in sort of a creative way you know we're interventional

radiologists and we like to you know pave the way you saw dr. Walton he paves away so this group looked at nanoparticles and they put a magnetic component in it and then they put a magnet over the side of the tumor and

look at that the nanoparticles will actually go to where the tumor is it's fascinating right all you have to do is put a magnet on your belly and now all of a sudden I'm getting treated for cancer and I'm decreasing the amount of

systemic drug that's floating around my body so that's sort of a creative way this is just again nano therapeutics and I are image-guided delivery is how we think we can do it better than just putting a magnet on your belly okay we

don't have to do that we can actually get into those arteries and deliver it locally so you all are very you know adept at conventional team mobilization this is just an image of an HTC and it's the tumor is on a stock and you can

imagine if i have a nanoparticle i could inject it directly into that tumor and have a good effect the other types of things that we do and I are you guys know this thermal ablation this is an image of an ultrasound probe going into

a liver and the image on the screen right is image from my lab this is when we did cryoablation of a tumor and a rat and the reason I show you this is that it when we all do cryoablation we never see it right we just suit sort of this

defect on CT you never could see the ice ball so when I did this for the first time I thought this is the coolest thing at everything's been like oh my god have to see what the ice boat looks like turns out that before I got this I froze

the whole mouth because you have to use mouse settings or not human settings but nonetheless here is a nice bowl after much after much going back and forth

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.

The other thing to do is in this deep pelvis,

other ways to get around bony structures is to take a transgluteal approach. The mantra for transgluteal approach in my mind is to hug the sacrum and stay below the piriformis as much as you can, in which this case demonstrates.

In order to minimize the risk of vascular injury to gluteal vessels, as well as entry into the cyatic nerves so hug the sacrum, and stay below the piriformis not quite below the piriformis here, but based on the anatomy this is where we had to go, and this allowed us to get to the small collection in the deep pelvis again, we're anteriorly, and posteriole/g [INAUDIBLE] Would

have been blocked by bone, and a variant to this technique, or an extension of this technique if you will. Is to utilize the power of the angled gantry. And as radiologists we always tend to think in 90 degrees. AP or lateral, frontal or lateral, but

we don't have to think. This gets us a little bit closer to ultrasound real time imaging we have a wide variety of angles to which you can approach lesions. With most CT scanners you can get about a 20 to 25 degree angulation. And sometimes anything within that range is enough to create a window

that avoids ball, avoids vessel, avoids bone. And so in this example that we utilize that angle again, the technique to find a window that gives us what we though was the most optimal approach to these deep pelvic lesions.

So just a series of cases really to think a little bit outside the box, how to dissection, moving things away, creating different angles and different approaches to get out some deep pelvic lesions. And thank you for your attention. I'm happy if

to take questions. Okay [BLANK_AUDIO] One last section which is the other way to get access to these deep pelvic lesions are transrectal or transvaginal approaches. Demonstrating sort of a technique that we use, an ultrasound probe cover over a transvaginal or prostate ultrasound

probe. This is the sheath of a pillow. The sheath that we affix using some elastic rubber bands. And use it in the transrectal or transvaginal approach. We gain access to give us very close proximity to deep pelvic lesions, and here's a case here demonstrating a collection behind the uterus

and to the rectum. And by ultrasound imaging you can see a needle coming in and there's our catheter finally in place, running into that colder sack behind the uterus and enter into the rectum. And the thing to keep in mind

this technique is often utilized at least the transrectal approach in pediatric patients. For the transvarginal approach, one thing to keep in mind is that the vaginal cuff is very, very, thick very muscular and certainly require some force to get through that.

Discussing this case with Dr. Agostino a few days ago he emphasized the point of minimizing the use of a speculum if you can. Because the speculum often times displaces and pushes your target further away just adding another element of challenge. So hydrodissection angled entry transvaginal transgluteal approaches.

Things to keep in mind, when you are approaching [UNKNOWN] Often times it migrate down into the pelvis. Can we have our IT, are they available? Looks like we've lost our signal here. Let me see.

[BLANK_AUDIO] Sorry about that we'll find somebody here in a moment. [SOUND] Any questions or clarifications or disagreements? >> How many of you do transvaginal and rectal drainages? [SOUND]

Do you use speculum or you do it without speculum? Who does it with speculum? >> [INAUDIBLE] >> It cannot clean and you can clean the vagina, well, you're gonna clean this rectum.

>> [INAUDIBLE] [BLANK_AUDIO] >> They're trying to find somebody [INAUDIBLE] >> Okay. Any questions regarding any of the previous discussions?

>> [INAUDIBLE] So we suture all our tubes into the skin, and one of the advantages of having a big tube, and it's a little bit of a selfish reason, but sometimes they do fall out and they fall out we're usually

on call on a Saturday night and we happen to be in the ER and when you have a tract that has been occupied by 24 French tube for several weeks, that is unblood type tract. And so I've gone down to ER, taken the tube, it's usually straight shot into the cavity,

advanced the tube without a wire without anything straight into the tract. And then the pus starts coming, coming right out. But to answer the main question I do suture directly to the skin. We've evolved a little bit,

we do [INAUDIBLE] And switch it to the disk, butterfly, start lock devices and that sort of thing for all sorts of drain/g. Nothing is as reliable as a [INAUDIBLE] Although that's as you know not 100% reliable as well. >> [INAUDIBLE]

>> No, no. We just create a mesentery, just one strike through the skin, create a little mesentery and just wrap around. >> Question?

>> [INAUDIBLE] At the time [INAUDIBLE] >> Yeah our usual protocol at the time of drainage is to evacuate everything that we can and then flush with three or four [UNKNOWN] Of normal saline just to clean things up. And then for the period of time the catheter remains,

we'll flush at least twice a day about 10 CCs. Of that 10 CCs about 5 go into keeping the catheter clear and the

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