So let's just talk briefly about the evidence and I'll use metastatic renal cell carcinoma as a model case. Different tumor histologies will have different evidence and different studies to support them. So in this case of a patient who has a right renal mass
and develop this renal metastasis and we ablate that with the ice ball you can see very well. So does this oligometastatic state even occur in renal cell carcinoma met, patients? Well, it does. Most patients actually present
with limited metastatic disease. More than half the patients, when they present with metastases, have just a single site of disease, and that proportion actually increases as patients age. So the patients who are the most elderly,
the most frail, the least suited to surgery, actually are the most likely to have a single site of disease to treat. Is there a survival benefit from surgery if we extrapolate those data? Well, if patients have a wide or radical surgical resection
as opposed to a marginal, they're just pinning that metastasis, those patients do better who have a wide radical surgery. And if patients at the end of their surgery actually are free of disease, they don't have other sites of metastasis,
if we can actually treat all of their disease, they live longer.
This is another example. This is a complex aneurysm. This is an aneurysm that's actually involved the common trunk of the SMA and the splenic artery. So we can't embolize the splenic artery. That's not a good thing.
This shows you a lot of teaching points, a lot of technical teaching points about the management of these complex aneurysms. So this is a complicated... This is a complicated aneurysm. It involves the common trunk of the SMA and the celiac axis.
So the plan is, we need, going down low, is actually the SMA, so what we need to do is to embolize the splenic artery, proximal as possible, okay, to allow as much collateral as possible to go to the spleen. Do a stint graft from the aorta into the SMA to exclude the aneurysm and then thrombose it.
The embolizing material in this case, plugs, it could be coils as well, would do the same principle of preventing back bleeding into the aneurysm. So you're kinda seeing all these principles being put together in this complex procedure.
So the first thing, we went up to the splenic artery and we embolized it with plugs, okay and that's kind of embolized, and then we went into the SMA and put balloon expandable stints and excluded the aneurysm. Here you see the aneurysm with the eggshell calcification,
see this anatomy perfectly, almost on the dead lateral. We put the stint grafts. On our follow up CT, the aneurysm had shrunk partially thrombosed, but still there is still more flow in the aneurysm. So this most likely kind of like a type 1 endo leak
into the aneurysm. The patient was on Plavix and on Aspirin. So technically, what you can do is to put another stint proximally and close that kind of type 1 endo leak. What we chose to do is actually stop the Plavix and stop the Aspirin, just stop it,
'cause they're anticoagulants, stop it for a month and follow up CT. That helps actually thrombose it. Okay so instead of subjecting a patient to another procedure, you just stop the Aspirin and Plavix for a month. Maybe that's enough to help it thrombose.
Then resume the Aspirin and Plavix, and that's all we needed to do is just stop the Aspirin and Plavix. Kind of several technical and medical teaching points
This is the technique under CT guidance. This was an actual patient who had chronic pain in the left shoulder with arm pain. This diagnostic block is to determine whether there is a sympathetic component.
You bring your needle down, avoiding the carotid and sometimes you do have to pass through the jugular vein, but that's okay because you're using a small needle. And then as we're getting closer to the spine at the T1 level you also have to avoid the vertebral artery. So we bring the needle down and we basically dock the needle
just lateral to the esophagus at the junction between the rib head and the T1 vertebral body and that's exactly where the stellate ganglion lives. We inject a little contrast to make sure that we're not intervascular, and then the lidocaine and bupivacaine mixture.
Patients often get immediate relief on the table. This patient did well with this block. We've had several patients that have undergone this block for hot flashes and have had improvement in their symptoms. We've had some failures, but this is one that is not often offered and can really help
in some of these complex pain patients.