Where Are We Today - Conclusion and Questions | Prostatic Artery Embolization
Where Are We Today - Conclusion and Questions | Prostatic Artery Embolization
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alright so where are we today with tae Seok eh it's performed all around the

country papers have come out of eight different countries at this point so it's all over the world rather in the u.s. tae is not FDA approved if you're treating lower urinary tract symptoms okay hopefully a couple in bollocks will

soon get indications for for bph were hoping on that it however if the if you're bleeding if the prostate is bleeding that is approved that's an indication you can treat or if there's a hyper vascular cancer which we're not

really doing that often but that's something that you can treat as well with FDA approval so just to conclude so pae at this point is shown to be effective in reducing the prostate improving urinary symptoms and the best

thing about PA is is very safe alright so we had one major complication out of 600 cases it's just a really safe procedure hopefully it stays that way there won't be you know more major complications coming out but that's

really the selling point of it right now and the other thing is that for men who have particularly large prostates which is considered probably 80 grams and above Terp is not the ideal procedure at that point they usually have to go on to

something else like an actual open prostatectomy or a laparoscopic prostatectomy or home IAM laser which is another option but that's where pae really can can fill a void or be a better option on the bigger prostates

alright thank you [Applause] ya know is bilateral each time yeah the pictures i show you are single but we aim for bilateral each time and we do that in about greater than ninety-five

percent of our case yeah yeah that's a really good question we're trying to figure that out right now I think there is but we need to we need to study and figure out what it is exactly so potentially so you know some patients

who go on to have brachytherapy there's a size limit for brachytherapy so it's I think it's about 60 or so so some patients have their prospects are too big so we can potentially reduce the size of their prostate and then they can

have brachytherapy which would be good another thing that's potentially out there is that post radiation a lot of patients get bad urinary symptoms so maybe we can do something with that if we do at post radiation but the problem

with that is you can have radiation arteritis like the arteries can get all ragged and then the thing they published at a miami just on treating a materia in prostate cancer [Applause]


asymptomatic now bilateral CAS and you're going to say well he's 73 so he's

not high risk by age alone but what's a high-risk criteria and so bilateral lesions will qualify you as high-risk. Both sides are greater than seventy percent. And again CTA done with calcium in the arch. Calcium here

which looks not very favorable. Here's the right-sided lesion which actually was not as bad as the left side occlusion. So again done with the TCAR in the OR. And there's the final

all our cases with TCAR I'm going to show you the last case here which is a 75 year old who had a previous left carotid endarterectomy for an asymptomatic stenosis with a patch. He had a laryngeal nerve palsy which is one of the things

that clearly stent buys you advantage with with no laryngeal palsies. And 18 months later came back with a high-grade asymptomatic recurrence that you see here. But a nice looking flat type 1 arch which was then done in the GORE scaffold

trial. And I just show you this because remember i told you this is a membrane covered stent and people were worried about preserving flow to the external. But it really actually looks very nice when it's done. So here's my answer.

clot can go distally which is not which is not ideal anywhere but it's especially not ideal in your brain. And so we have these micro catheters we have

these tiny coils we can go in and we can embolize other things in the body. What's to stop us from going in and filling up these aneurysms in the brain with coils as well. And so what was used to be an incredibly invasive procedure is now

being treated with again that femoral access by Dr. Seldinger and we're going up and we're coiling these aneurysms in the brain. Another pathology that our tools of the trade allow us to treat is our arteriovenous malformations. So you have your

normal blood flow you have an artery you have an arterial you have a capillary bed of venule and a vein which turning that some patients unfortunately have a mess in the middle of their capillary exchange - it's called a nidus -

they don't have a healthy communication between their arteries and veins. It's just shunting in between both of them. And so these need to be shut down. They're often very painful for the patients and they also create and they create a

variety of symptoms including poor perfusion because the blood vessels that are supposed to be perfusing that area instead of perfusing them adequately they're shunting over to the vein. And so what you're seeing right

here is this is an injection of a pulmonary artery you see the pulmonary artery going down and you see immediate venous return happening. So when you see an artery and vein and the same picture it's usually not a good thing.

And so there's some exceptions to that but in this situation it's not a good thing. And so what we can do as opposed to a pulmonologist having to cut down on this patients lung and remove the nidus of

the arteriovenous malformation just like we do with all other situations requiring embolisation we can go in we can embolize the parent artery and prevent the patient from having to undergo a pretty impressive and

massive surgery. And so coils aren't the only embolic agents that we utilize we also utilize a lot of beads a lot of embospheres. And so embospheres embozene microspheres and multiple other injectable agents. And so

what these injectable agents allow us to do is they allow us to get even further. Ok so there's some pathologies there's some situations where we want to embolize more than just the tiny arterial filling with the area of interest. We want to go

deeper and we want to embolize at the capillary level. And so one of those one of those situations in which we like to do that is we like to in patients that have uterine fibroids. So women that develop these fibroids in their uterus

once upon a time the treatment used to be a hysterectomy. And so now what were able to do is so this is a angiogram of a pelvis so we have the common iliac here we have the internal iliacs and we have the uterine arteries coming here

and you're starting to see them perfuse a fibroid. And so you have your fibroid here and if we put a coil right here our tiny little embolic agent what would happen is that fibroid would basically just revascularization would reperfuse

and so what we have to do is we have to go in and we have to shut it down at the capillary level. And so by injecting those tiny little microspheres that allows us to do that. Those microspheres and those injectable

embolic agents also come in very handy.

up with. So this is a 75 year old man with sudden vision loss in his left eye. The usual risk factors. Had a have a PVL and outside institution which was deemed normal. And then there was a CTA done to look at the culprit lesion.

And I'm going to show you just some still pictures because I want you to look at a couple of things. So calcium in the arch. Again 75 year old man remember. Bovine arch. So all of a sudden now we got two complicating factors and a

calcified lesions here symptomatic. And here's what it looks like. Obviously we did this with TCAR so there's a little carotid cut down here. You can see our retractor in place. And a very tight lesion which doesn't look perfect but

a little different to the cardiologist who say...yeah it's a little bit hazy here and it's not perfect...we would accept that. Because if you remember if you go from a 90% lesion to a 30-percent lesion in the carotid you never

treat a primary 30-percent carotid lesion. And again the proof is in the pudding. So the hemodynamics the next day by duplex... this is an internal crowded waveform in the stent and they're normal. So leave that alone.

Don't get crazy about trying to make it look perfect.

work if you can see this is an mr image with contrast and we're looking at the

prostate i do have a laser on here don't he ok so right here is the prostates right here right and and what you're seeing are the darker parts this is post contrast imaging so the darker parts are areas that are infarcted and that's what

we're trying to do is we're trying to create infarcts within the prostate and those infarctions result in the prostate shrinking down we also think that there might be an effect on the alpha adrenergic nerves which caused a

contract contraction of the smooth muscle in the prostate and so that may result in relaxation of the prostate and softening of the prostate this is a slide demonstrating post embolization demonstrating an arterial here with

anabolic particle and we have a bunch of confluent fibrosis and then these are all this is glandular tissue so this is what the prostate looks like after it's been in boys all right can you start that video for me so this is how we do

pae we start with a really good CTA so we this is going to demonstrate where the prosthetic arteries are rising from and once we have that we can use it to measure prostate volume so we use a tear recon and use a segmentation technique

to measure the volume of the prostate we can also take that same data set and 3d render it and create a 3d model to kind of figure out what are the best angles that we should use them are actually in the case what obliquity should we put

the AI to so that we can get into the prostate prosthetic artery the best and on this particular image you can see you can see the arrows right here are pointing to the obturator artery and then this arrow right here this is the

prostatic artery right here and so you create that image ahead of time and you figure out how you basically plan your case okay and so this is the coral at the DSA correlate here and you can see that we've put the eye is the same

obliquity that we planned and we get a similar image so here's the obturator artery again and here's the prostatic artery coming off and that makes it quite easy to get to where you want to go because you've already planned it

ahead of time I start the video so once we have that data set we can also we have a seaman system and we can overlay it over our live floral and use it as a roadmap and so that's what this is demonstrating it just showed how we used

it to get our five french catheter into the internal iliac artery so I'm gonna

this is what I call the battle of the portuguese-speaking IRS so there's these

two guys the guy on the left there is dr. carnevale from Brazil and the guy on the right is dr. T scale from Portugal and they both started publishing about 2010 and that's what started the human data for pae and so the first paper came

out from Brazil and it was a two patients and you know what basically what it showed was that this procedure could be technically successful and it could decrease the size of the prostate doctor pisco then came out with 15

patients and what he showed was that these 15 patients 11 out of 14 work done success were clinically successful meaning that they improved urinary symptoms and that there was one major complication in this but and so one out

of 15 what it's not a great but it proved later on to be not as frequent as that and this was these were the images from the bat paper and they showed on MRI that the prostate before was larger and then it was smaller after

embolization so what was the complication the major complication in that study was bladder ischaemia that required surgical resection and as we'll see as we kind of go through the data this one major complication is really

one of the only major complications that's ever really been reported with proximal ization so it kind of happened in the very early experience and then is still the major complication that we talked about this is probably the best

study that's ever been done on prostate immobilization and was done in China and what they did was they randomized 57 patients or 114 patients total 57 into into two arms one arm of cross minimization and one arm of terp so

turpitude anima feel familiar with dirt but it's transurethral resection of the prostate use a scope to go through the penis to the urethra and you scrape out the prostate that way and that's the gold

standard for surgical therapy for bph at this point and so what they found these are some great graphs that they put together but if you look at the top to you see ipss and quality of life shows those two questionnaires I was showing

you before and you can see that initially turp is more effective in reducing symptoms so from at the one month three-month and six-month mark it was more effective and then at about six months to 12 months the pae and turf

started kind of equalizing and that's they followed ever went out to about 24 months and at that point the data was pretty similar and so basically if you had to summarize this you would say turf is more effective in reducing urinary

symptoms in the short term but over the long term they appear to be equivalent now again the question is about safety so the advantage of pae is supposed to be that it's safer and so if we look here we can see that at the bottom and

they reported for tae eight major complications but they included technical failure and clinical failure as major complications and we wouldn't consider those complications in our studies so there really weren't any real

major complications for the pae group whereas there were a couple major complications for the turf group so this was a paper that I worked on we tried to compile compile the data that was available we took seven different papers

and took all the patient data that they had for that and we kind of came up with what we called pool weighted means and so if you look you can see that the there are five hundred and thirty-two patients that were analyzed the initial

baseline ipss is very high 24 such severe urinary symptoms and then at six months the ipss had come down to ten in the 423 patients so it's about a 14 point drop in the ipss which is good and then at 12 months there are a few less

patients at 3 45 and the ipss was 10 and so what this demonstrated is when you take everybody study seven different studies and you put them all together you still have this very good effect of prostate analyzation as far as

complications go this is the SI our grading scale and the major complications are great seeing above and you can see there's one major complication amongst all those patients and that was that non-target

embolization to the bra bladder that we required surgery so pretty safe right 500 some patients one major complications not bad so how does PA you

tumors okay you have to make tumors when

you're doing science and we just x plant deliver you just make a teeny tiny incision UX plant deliver you inject those cells we talked about before you let them grow for a couple of days you monitor by MRI this is just showing that

the tumor is growing and then you can see it going from white to dark sunaina particles are getting there this is just the fancy stuff we talked about before where you have the color map showing a different way to show it goes from light

to dark and then there is a change in the color this is all this map is showing you that this is a change of the color from white to dark these are again we explanted delivers exploit to the tumors you can see this deposition that

blue stuff this deposition of the iron around the tumor which is what we want to see and then we look where did that where did the nanoparticles goat in this case we used ivy we didn't do site selective this is a small animal model

it's hard to get it exactly where he wants we tried a divey to see if it would work it actually did deposit in the tumor but look where it went mostly at re s right they went to the spleen exactly where we thought it was going to

go so we did have some effects from that so then we did photothermal blasian after we infused the nanoparticles we waited and then we put the laser on the tumor and we said okay let's heat it up and let's see if this works and what we

found as you can see the nanoparticle and the monoclonal antibody nanoparticle got the same amount of heat which doesn't really make sense right because I just showed you those images where the cells take up those those nanoparticles

and the other so the nanoparticles that weren't tagged weren't taken up by the cell so why is the temperature the same you'd think it would heat up more if the cells heads gold within them well this camera that

we take pictures with to determine temperature is superficial so it's not going to show you what's happening deep down into the tissue and here is images from our histology and you can see the dotted line shows you just what kind of

burn we get so if we just have a nano particles that don't have the monoclonal antibodies on them so they don't home they just go because of the EPR effect you can see it's just a very superficial burn but if you look at the monoclonal

antibody with tags nanoparticles you get the huge donut ablation it's deep within the tissue so this in fact if we would use this in humans would allow us to get a much deeper penetration without the risk of damaging those surrounding

structures and this just shows you the percent necrosis when we use those different nanoparticles so when I

weekend so I'm going to and jet pretty soon after this talk but I will spend a little bit i'm in the lobby if you have any questions are interested in getting involved in this procedure please and

don't hesitate to come and talk to me. I would love to point you in that direction because I'm like I said with Dr. Seldinger her when he started developing his techniques he was a student and there's been countless other

students throughout the years that have developed things that have played big big future is it's limitless. The more we understand our anatomy the more we understand our

pathology the more research we do the smaller the stuff gets the more that we're going to be able to do. And I'm very much looking forward to the next 10 years of IR and I hope that some of you are going to be there on that journey

with us. So have a great rest of your weekend and thank you very much for your time and attention.

right so one more case when we look at it at 57 year old male 10-year history

of issues treated with two medications IPSS really bad at 28 quality of life I've and then his prostate is large not as large as the other guys but in the 50s so one thing that we worked on trying to develop at UNC is how to do

this okay how to do this procedure from the radial artery as you probably know radial artery is becoming very popular in interventional radiology and we wanted to see if it was reasonable to do

a procedure down deep in the pelvis from the radial artery so what why would you want to do it from radio in general radial access provides a kind of a better recovery it's easier on the patient than want the lie flat right

additional advantages for paer that sometimes PA can be really long case if it's a hard case it could be a three-hour case if a patient has lower back pain you can put a bump under their legs right and kind of help them with

their back pain we can't really do that when we're doing some real axis the other thing that's important is that a lot of times we don't we don't like to place foley catheters for this because if you ask a lot of a lot of men who've

gone through this they'll say that placing of folios was the worst part of it so far worse than the actual embolisation so we try to avoid it as much as possible the problem is is that afterwards when they're lying flat for

two hours we've just given them all this contrast and their bladder is really full and they say they have to urinate but because of their obstruction a lot of times they can't urinate lying down so being able to get up and ambulate

right away facilitates their urination and so that's another perk to radial for for radial access so this is just how we set it up and now there's two different ways of yes they do it at Miami a bunch too and they set it out with the arm out

to the side at 90 degrees I like to work like I'm working in the groin because it's what we're used to so I believe we put the arm down by the side now that can present an issue right if you're doing cone beam CT it can be a little

bit so a lot of times sorry I'll be step away from the microphone second a lot of times what we'll do is we'll put the arm kind of folder with the with the elbow event will prep the arm over the belly a little bit so you can take the armboard

out and that facilitates to your cone beam CT okay you know the other thing you can do is go arm up at to your home beam CT but if you have a catheter sticking out of it that's not making a little nervous so it depends it depends

how skinny the person is if they're skinny you can get away with an arm board but if they're a bigger person so that potentially could be an issue but we've tend to work around it and I think it

also depends on which you know what type of floor unit you have okay start the video please so this is just another video of a prompt analyzation done from the radial artery and so we've gotten access into the radial artery we're

running a catheter up have a glide wire so it can get stuck in some side branches so we keep stranding it out we run it up to the chest we go down the descending thoracic aorta we get down into the abdomen keep the glide wire in

the aorta and now we get to where we have the 3d overlay again you remember the trim dealer case the wire keeps wanting to go in the external so we change it around and get into the internal drop down now I'm trying to get

into the obturator which is this down to this branch here and so this is a little aggressive getting my five French into that but I you know I think it turned out okay so there's our DSA run we put our microcatheter in micro wire advance

into the prostatic artery there's our run demonstrate rosetta call ready with another branch that's also supplying the prosthetic and that's our post embolization demonstrating spaces so that's how easy it is you can do it in

15 seconds prostate embolization from the radial artery the great part about radial access as you guys know if you do this is the top of TR band or whatever compress with van der using on afterwards and no one's holding pressure

no one's worried about placing a closure device or anything so it's really nice alright so follow up for this patient so we saw him three to four weeks post pae at six weeks his symptoms worsened and he went into acute urinary retention so

that's the problem he couldn't couldn't urinate at all he was catheterized and they thought he had some prostatitis so he was treated for that the catheter was removed a week later and he was able to urinate at three months he had another

issue but then he passed debris from his penis and his urinary symptoms were instantly better so this was probably hanging out there six months after pae his IPSS was eight and the quality of him too so he's doing well and I think I

have a picture so that's you know little graphic picture for you so that's and he sent it to me in a little baggie he tried to preserve it by wetting a paper towel and putting it in a paper towel on the baggie and I

actually submitted it to our laboratory to see if they could tell me what it was but it was they couldn't they said it was necrotic debris thank you for that

Here's a 63 year-old who presented with bilateral amaurosis fugax. She's morbidly obese. Here's your BMI and the usual risk factors. And her duplex showed

that her right carotid was occluded and the left side had a real lesion. She again had CTA for anatomy and again we've got calcified arch. Here's the origin of the left carotid which here looks bovine...it's really not...but clearly

there's a little speck of calcium there as well. Here's the right side that's occluded and here's your left side that actually has a very tight lesion at its origin. And another picture there so here's the lesion intraoperatively. Again

here's our retractor down here. So she was done with a transcarotid revascularization as well and here's that picture there. This again

started this talk I said that nanoparticles are all around us and we see them every day and we don't even

know about them I was going to give a talk about nanoparticles over in Europe and I was in the O'Hare and on the wall they had all these images of nanoparticles as art so not only are we using them in science and and everyday

use they're also art and I think I'll stop there happy to take questions and of course these are all my collaborators and everybody that helps do the work at Fontaine dr. Emerich satisfied [Applause]

are there any questions for dr. white were any of the other presenting I'll tell you dr. over just asked me was that me parachuting no that's not how it broke my foot so that's a picture of a patient and I always put that at the end

of all of my talk so I should have explained that so I had a patient that came in to me and he was given a terminal diagnosis I said you have a to see and you three months to live and you're going to die because he had

metastatic disease on presentation and I saw him because they had put a chest port in and know they were doing a lung biopsy to see if it was a met and while they did we're doing a lung biopsy they they caught in pneumothorax so they

called me and I said can you come run and put a chest tube in and I said sure and then i said what is the biopsy for and they said oh we think it's metastatic HTC i said well what do you mean he has a terminal diagnosis we can

treat this and so we treated him we treated him with seven conventional T mobilizations and he actually lived for three years and his goal was that he wanted to go parachuting with his son when it's done turned 30 and that was

him parachuting with the Sun we turn 30 and so going from a terminal diagnosis of you have three months left to live or not 23 years later parachuting was a son that's why i always put this at the end of talks because i always want to

remember remind myself why we do this not just the fancy technology but it's the save patients life or to let them live longer [Applause] the reference so there there are

actually trials in humans and we've we've phase 1 phase 2 trials there's a lot of stuff being done by the ablation ests because they think that this nanotechnology can increase ablative capability so there's doxorubicin that

has sort of been utilized what's that now that's it yeah so that we have these these nano particle like doxorubicin structures that they've been using to see if they can increase ablative technologies there's a lot of stuff in

the breast that they're using nanotech nanoparticles for so it is in human trials that that slide I gave you with all that that list those are all human trials clinical trials going on at Santo technology so it's out there it's being

used a lot of the gold stuff that I talked about is actually not you know FDA approved for certain uses and can be used for ablation

you know let's say they have one isolated metastasis in the liver and this is what i'm showing you example is we can do an ablation an ablation really only works if you're about 4 centimeters ok if it's bigger if

it's on the order of you know five centimeters we're getting bigger we're not going to get a complete ablation and so the other issue is that there's really a risk of damage to the adjacent structures if i turn my power up I can

get a bigger ablation zone but in this picture you can see I'm adjacent to the coal and I'm adjacent to the gallbladder and so I could kill the tumor but now I've got a perfect colon and the patient you know is in the ICU and has to be to

collect me so the purpose of the studies that i'm going to present to you is that we've basically developed a new ablation therapy that would enhance the ablation zone to treat colorectal liver metastases we were going to use the

inherent capacity of gold so that that ability to heat up to increase our

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