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]

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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

come a long way since the early days.

Essentially what would happen is we would put some sort of catheter in the lower leg and we would drip a lytic through it and that was that. Now we have ways to both more efficiently deliver the lytic but then

also to actually vacuum the clot out or macerate the clot inside the body. Ok so if someone develops an acute blood clot we have ways of treating that very very quickly and safely. And again these

are other ways that you see...we see a long strand of thrombus here and then we also see some thrombus here. And so fortunately before interventional radiology this would require a surgical cut down. Again if you developed a

clot they would cut down on your artery or your vein they would introduce a balloon into your artery or vein and they would pull the clot out. Today we have the opportunity to utilize the Seldinger technique and introduce the catheter and

just dissolve the lytic over time.

periphery or in the mesenteric. And so we have these tiny little coils that we're able to introduce into the body to stop bleeding. And these little fibers are there

intentionally they help to promote the embolic process and these are we have these we can introduce these through our traditional 5 Fr catheters but more often than not we're utilizing them with a microcatheter

system. And so again this is a patient who came in just a couple weeks ago and was the middle of the night they were in a car accident they experience the splenic laceration. And so this is your splenic artery

these are branches of your splenic artery and then this right here is obviously active extravasation where the patient was bleeding. And so through the utilization of a microcatheter were allowed to get out and were allowed to

be super selective and embolize just the segment of the spleen that is bleeding. Ok so it's helped to take our procedures to the next level. Prior to this procedure being

offered by interventional radiology the treatment for any sort of spleen trauma was just to take your spleen out so they would just do a splenectomy. So we applaud ourselves that we're not having spleens taken out anymore but taking it

one step further so aneurysms involving the brain and so one who developed any so traditional means of treating that was to clip the aneurysm and so essentially

what that would have all involved is brain surgery. So they would have to obviously do a craniectomy and they would have to go and they would have to locate the aneurysm and they would have to apply a clip to it to prevent the

aneurysm from perfusing any more. The two risks associated with aneurysm is obviously that they rupture but also aneurysms have a tendency to form clot. So once the blood enters into your aneurysm

it starts to swirl around and become

complex than adult stroke symptomatology is more varied our curiosities are really important cause pediatric stroke as our other causes cardio ambala

dissection venous thrombosis metabolic we didnt talk about but it definitely involved theres a new classification system and nomenclature for pediatric stroke meth called cascade and pediatric stroke centers are stream of the first

of all were forming pediat primary pediatric stroke centers and because we're doing that we're streamlining and making treatment of pediatric patients more rapid and we need a higher index of suspicion we need more rapid stroke

imaging we need a faster activation of the pediatric stroke service just like we did in adults and if we do all of that our neurological outcomes in our little people with their strokes is going to be improved and they'll benefit

for the whole rest of their hopefully long lives and thank you very much [Applause] how many pediatric stroke centers are there throughout the United States at the end of the trial in 20 I don't know

what is today but the end of the trial in 2013 there were now 17 certified pediatric Primary Stroke Center and I think a lot of us are building stroke teams the amount of regulation is breathtaking if you've ever put together

an adult system you know it takes several years and they're reams and reams of paper will have to go through i'm trying to convince our group right now that we must get a nurse coordinator if we really want to go to the next

level right now i mean our biggest job is launching and most of the most places like us you have to have a full team that has ed Rapid Response pick you we have I mean it's like there's like 15 people to get notified every time a

child as a stroke as opposed to like five people every time an adult gives a stroke so a lot of places like us are aiming towards becoming primary pediatric stroke centers of our goals we status 2018 if you can probably be 20 19

but there are some truly up and running pediatric services near the questions of that precede you I think thank you i'm curious some with the UM what is your H frame for the when you talk about pediatric stroke up to adolescent 15 16

and and the different entities that you mentioned are some more common in let's say the teen age and the preteen area of the you know age and the other question is mo Roderick Strong how that's more common i suppose and children then we

think in adults like twenty percent of all strokes what is what is your experience with that i didn't talk about humoristic if i only had an hour like a two hours they could have been covered all hemorrhagic hit our

institution in most places p.s because anything under the age of 18 so 18 is the cutoff and once you're 18 and older than they are considered results and they're treated on the adult side so we recall that the big house they go to a

big house when they're 18 above they say the Children's Hospital when they're below 18 I think most Pediatrics ischaemic stroke is underdiagnosed and so I don't really know that your incidents clearly if you believe you

shows up on a scan and you see it big and dramatic the things that happen to children fewer aneurysms and children although can't have them like be true aneurysms even book a child five years of age the youngest i've ever treated as

a brain aneurysm they have a fistula they have a BM they don't tend to bleed as much as adults to bleeding julia starts often at the age of you know in the 30s you have native galen malformations could mildura lady fistula

and the vein of galen most of those children don't forget when the hemorrhage although they can neural and choroidal there's a lot of other than two entities that we're not going to talk about today because it's just lack

of time I just wanted to focus on a scenic cause of stroke in terms of what is the most common I think if yo pathak is probably the most common still we still don't know i think infectious etiologies under recognizes

under-diagnosed so you were to look at everything i would say probably the perfect storm is like the child I had in the hospital right now her grandfather has a coagulopathy he's been on khuvon in for Pease and DDT's of pts and she

was 20 she gets six of the cold comes in correctly every vein her head fly off so she has underlying coagulopathy and she just hydrated and we have the perfect storm question yeah first I want to thank you you know the passion you give

with your presentation you know it's really enjoyable and kind of palpable but I also want to ask you know in regards to nationally our people really kind of on board with the same type of protocols you presented or is it you

know you know your uniform to where we are lagging way behind the adult side but there is a true passion out there to develop pediatric stroke services and I reach when I was developing hours along with

my colleague we I reached out to Bob some children's I big sales to Seattle I reached out to Cleveland and they were so generous I mean people share the order sets they shared their protocol I'm happy to share with anybody that

wants the data that we have I can give you a list of all the people that you need and so this is kind of a grassroots effort it reminds me of 20 years ago with adults I think we have work of dedicated people that treat Chuck

pediatrics we have in the neuron adapter world we have we're developing just a pediatric subsection 2 sniffs and to all these other things and Darren Orbach in Boston Children's and I were talking and there's a whole people around the world

we're getting just the peach people I do adults too i mean i do everything from burst ninety-year-old but but you know not everybody wants to pee and so we're trying to just join you have a little log in truth now so that we can ask each

other questions show each other cases so I think this is really guilty and I think every children's hospital she you know Big Shoulders hospital needs an organized team like this and the smaller hospitals around us need to recognize

that this could be a stroke and get these kids to us as fast as possible yes sir I think I think the passion is real as the few and it's the fourth line and one last question on average monthly how many Pete's droves to you treat yeah if

you're talking about just arterial that go to the angio suite we probably get we probably take about one every three months to the enviously you're just looking at arterial if you're looking at venous occlusion we probably take maybe

two kids a year that's because we're really aggressive on the medical side I'm aunt actually living in that child rooms is wednesday you know i am there i am there I on the phone i'm checking i'm getting up in the middle of the night

second second second laughs because it is absolutely essential that you keep that child hydrated keep that heparin high and you have to no one else is going to drive it like you're going to drive it so you know thank you again hey

um in the same vein of the increased passion for theater stroke how do you increase the the heightened awareness in ed even if I mean how do you balance that with you know judicious use of imaging it's clearly not practical to

send every kid even for a 10 minute stroke MRI yeah there are places I went to two years ago to a stroke meeting and one of the guys they had an mr in there ed never Nikki room in any k to Compton it has the first time see you go

straight to the skin and they do a VW is a bed now that's the perfect world we don't live in the perfect world so if your kid comes in to have a seizure and has some transient neurological deficits and then completely normalizes that's

the kids it probably is a lower risk for stroke whereas if that kid comes in with a seizure for example and has persisted many characters that has a stroke until proven otherwise do you guys do a little bit of clinical you know work on that

and then what other illnesses that the child have is that or do they have a history of a mimic or something like this but I think we have to have a bunch of false negative we have to be aggressive that means you have to put

some resources into it that's not just for mr and see imaging that can see the angio sleep we are possible to invest in more technologists we need are technologists not to be working around the clock all

the time they need to be hostile acts is recognized that we're asking people to do this we need more of them and they have to be supported facing for our nurses this is truly a team effort not one person can do all of this in a

vacuum the other answer your question is education we are we are planning on our small strokes group which which has ed representation 50 representation pharmacy records representation we're going to go give grant around all of the

people that we think are gonna see these children and try against you know educate the residents to know our trainees as well as all the nurses and other staff what to look for but the first thing is just be suspicious and I

would much rather have you know five or six negative scans and miss that one child 10 negative scan then miss miss miss net1 childís you'll all have that window of opportunity to close this and then you've got nothing you can do yeah

thank you [Applause] [Applause]

nodularity and it's best seen because of these linear echogenic

bands, which are bands of fibrosis. In this patient, the surface nodularity is not very apparent, using a curvilinear probe, but then we look at the same patient with a linear probe, we can start to appreciate the smooth angulations on the anterior surface of the liver that is definitive for cirrhosis, as a direct sign.

[BLANK_AUDIO] In this patient, we can see that the ascending branch of the left portal vein and the horizontal portion of the left portal vein have enlarged because of the portal hypertension. The medial segment of the left lobe, that lies to the right of the ascending branch of the left portal vein, has decreased in size, and this leads

to widening of the falciform ligament, and also the change in the axes of the ascending branch, which starts turning towards the right. [BLANK_AUDIO] In this patient we can also see that there is widening of the fossa for the ligamentum venosum because of some atrophy of the left

lateral lobe and the caudate lobe as well.

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

is really important and this is where it's helpful when you know whoever your internal medicine folks are on your team getting their sense of who's the people

to talk to in our case the ed and jen men have been our biggest customers probably like 5050 but definitely tons of cases from neurosurgery from going on from ortho all over the hospital given talks

everyone hospital in neighboring hospitals i would say don't forget the physician extenders the residents rotate out every year to the PSN piece tend to stay so you'll save yourself work if you really focus your energy on those folks

and I a friend whose idea this was but don't forget about your chest CT readers your institution because those folks are definitely on your side they're definitely want to help you out you give them a sense of what you're doing what

you're building and give a bunch of free pens and then they started calling us directly there was one time where i showed the patient's bed before the team even knew there was a PE which is pretty cool and then now sometimes radiology

will actually write in the report that they should consider calling the PE team next is you know as part of getting the word out so you know signage people love hospital people hospital of protocols hang up posters we made cards made the

Pens protocols you can hand out freebies are always nice people of free official residence of freebies and then you can reach out to you know these days and the stage most people's hospitals are our sort of conglomerating two chains and

you can reach out to the smaller hospitals your system for transfers we definitely done a lot of those and then hospital newsletters can be very helpful so this thing apparently and even know it existed i just found out about it and

hospital and then this part goes like 10000 people all over the Northeast gotta consult based on this from Connecticut two states away a few months after it came out so that can be helpful to get the word out getting started and

then i would i would really focus on you know prioritizing quality from day one so you should definitely think about having a month or monthly lecture series there's new stuff happening NP every week and and you could have a

set of electricity different people come to speak you can bring Grand Rounds speakers yourself can be a ground speaker institutions and we've instituted a monthly kind of tumor board for clots where we discuss more

difficult cases and sort of QA cases when there have been issues and then on that note also you probably should ahead of time reach out to your hospital QA committee or your quality officer ahead of time to kind of let them know what

you're doing and and then it's go time so i would say choose your first cases wisely really focus on that multidisciplinary decision making because it is everyone's you know it's on everyone's shoulders which is nice

keep your core faculty from each specialty involved in the first few cases for the first few months and know ahead of time that it will probably happen on a weekend and probably a holiday weekend and this is my VTE

prevention program chasing the twins around the house all day long this joke is stolen from our next speaker thank you

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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.

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.

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