Moderne radiologi specielt interventionsradiologi

Transkript

1 Moderne radiologi specielt interventionsradiologi Et historisk tilbageblik, overblik og state-of-the-art Poul Erik Andersen Specialeansvarlig overlæge, Professor Radiologisk afdeling Odense Universitetshospital, Syddansk Universitet

2 Radiologiens historie Wilhelm Conrad Röntgen X - rays 1895

3 Wilhelm Conrad Röntgen 28/ : Über eine neue art von strahlen. Medizinischen Gesellschaft zu Würzburg

4 10 uger senere Januar 1896 post mortem angio af hånd (Haschek & Lindenthal, Wien) kridtemulsion, kalciumsulfat, vismut, barium, kviksølv 25 år senere angio levende personer

5 karundersøgelser på levende personer, Frankrig (Sicard & Forestier), Tyskland (Berberich & Hirsch), U.S.A. (Brooks), Portugal (Santos, Moniz (thorotrast)) Sverige og Danmark (hjernekar) Perifere kar (Århus og Odense)

6 Cardiac catheterization was first performed when Werner Forssmann (D), in 1929, created an incision in one of his left antecubital veins and inserted a (urinary) catheter into his venous system. He then guided the catheter into his right atrium.

7 Svenskeren S-I Seldinger kateterisationsteknik (1953)

8 In 1958, Interventional Radiologist Charles Dotter began working on methods to visualize the coronary anatomy via sequential radiographic films. He invented a method known as occlusive aortography in an animal model. Occlusive aortography involved the transient occlusion of the aorta and subsequent injection of a small amount of radiographic contrast agent into the aortic root and subsequent serial x-rays to visualize the coronary arteries.

9 Later in 1958, while performing an aortic root aortography, Mason Sones at the Cleveland Clinic, noted that the catheter had accidentally entered the patient's right coronary artery. Before the catheter could be removed, 30cc of contrast agent had been injected. While the patient went into ventricular fibrillation, the dangerous arrhythmia was terminated by Dr. Sones promptly performing a precordial thump which restored sinus rhythm. This became the world's first selective coronary arteriogram Hjertets kranspulsårer angiografi (via arm) 1967 via lysken

10 PTA åbning af forsnævret eller lukket karlumen i benene med sonde katetre (USA) 50 % succes PTA ballonkateter (Andreas Grüntzig) PTCA Danmark PTA (Herlev) Danmark stent (Bispebjerg, Skejby, RH, Odense)

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12 Ballon

13 Stent

14 Stent

15 Stent

16 Antal KAG Antal PTCA Odense

17 PTCA Norden Sverige pr. mill. Indbyggere Finland Norge Danmark

18 : PTA 1 25/år : UE 40 60/år (translumbal) 1990: UE 206 PTA : UE 321 PTA : UE 373 PTA 146 renal 39 PTRA : UE 412 PTA 151 PTRA 12

19 Odense UE angio 21/ Seldinger 1955 Perifer PTA 1984 PTCA 1986 Perifer stent 1991 Coronar stent 1992 Carotis stent 1993 PAVM 1996 UFE 1999

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21 Interventionsradiologi Hvor er vi og hvor er vi på vej hen? Non-vaskulær Vaskulær arteriel Vaskulær - venøs

22 Specialeplan Diagnostisk Radiologi Radiologi Definition af interventionsradiologi indskrevet Lille skridt for menneskeheden, et stort skridt for radiologien

23 Non-vaskulære interventioner Biopsier ultralydvejledt, (røntgengennemlysningsvejledt), CT-vejledt, MR-vejledt Drænager, pleura, ascites absces, galdeveje, nyrer Brænding, kogning, frysning af tumorer

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26 Existing hybrid imaging modalities comprise: PET/CT PET/MR ultrasound and MR ultrasound and CT MR and CT The general benefits of hybrid imaging include increased diagnostic accuracy a further step towards individualized medicine precise monitoring of interventional procedures reduced radiation exposure, e.g. dynamic US after obtaining CT map.

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28 Vaskulære interventioner - Aorta arterielle Perifere arterier Aneurysmer Emboliseringer - blødninger (traumer, GI, rumperede aneurysmer), tumorer, prostata, AV-malformationer Trombolyser Fremmedlegemefangst

29 3 timer 50 min senere TEVAR 3 timer senere

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33 Lidt om benene

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36 77-year old male Hemodialysis for many years Amputation right lower leg in 2010 Currently CLI left lower leg with foot damage in an early stage

37 Ballooning first or primary stenting with bare nitinol stent or drugeluting stent will be preferred by most IR

38 64-year old male, Ankle pressure 40 mm Hg. Golf problem. Primary GOBA, followed by stent 6/60 mm.

39 PTA/Nitinol stents with medicine added Cilostazol (Pletal), randomized multicenter study, Japan Inhibits platelet aggregation, vasodilatator Iida O et al. Circulation 2013;127:

40 78-year old No history of claudication Fell 3 4 steps from ladder Immediately no severe symptoms and continued cutting hedge One week after the traume increasing pain and swelling of the right thigh, low Hb Haematoma measuring 10 x 15 cm on right medial thigh and tenderness

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42 Viabahn 7 mm/10 cm Are the decisions in these cases based on empiricism, common sense, experience or evidence?

43 Prevalence of peripheral arterial disease (PAD) Increased in diabetes (relative risk increase for PAD > 4.0); % have PAD Increases steeply with age (40 49 years 1% > 80 years 22% ~ doubled each decade) Increases in CKD Increases in smoking (2.5), hypertension (1.5), dyslipidemia (1.1), high body mass index, black race Prevalence of Chronic Kidney Disease (CKD) in USA In U.S. population > 40 years 4.5% (~ 12 mil.) have PAD (AB index < 0.9) (NHANES), > 60 years over 10 % Stage 1 (persistent albuminuria + normal GFR) 1.7% 1.8% Stage 2 (persistent albuminuria + GFR 60 89) 2.7% 3.2% Stage 3 (GFR 30 59) 5.4% 7.7% Stage 4 (GFR 15 29) 0.2% 0.4% Stage 5 (kidney failure) 0.2% Total 10.0% 13.1% The National Kidney Foundation, USA 2003 The National Health and Nutrition Examination Surveys (NHANES) The National Center of Health Statistics (NCHS) Coresh J et al., JAMA, 2007, vol. 298 The prevalence of diabetes is rising at an alarming speed, and the number of patients will (pandemicly) double by 2030 Development of new dedicated materials for BTK technical evolution To take home: Therefore, the BTK business increases enormously and will

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49 1.36 F

50 Take five????

51 Aneurysmer 64-year old Admitted with abdominal pain, low BP, high pulse CT performed

52 Splenic artery aneurysm Proximal and distal branches to the aneurysm

53 Distal and proximal embolization intended Impossible to cath. the outflow art. dist. to the aneurysm. So, now what doctor?

54 Small coils delivered into the sac were flow directed to the distal branch.

55 After distal embolization with 5 coils and coil-packing the proximal inflow branch

56 52-year old Presently hematuria, indicating CT. Accidentally discovered 2.7 cm aneurysm in segmental artery. No other symptoms Normal kidney function with functional distribution left/right kidney 57/43%

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58 Aneurysm flow Thrombus

59 Open stent ready in renal artery but not expanded and deployed Microcatheter in the sack

60 Detachable hydrocoils and standardcoils

61 3 months follow-up

62 Embolisering Definition Minimalt invasiv, non-operativ metode til behandling af bl.a. blødninger ved selektiv aflukning af de blødende arteriegrene med materialer, der indføres gennem et kateter under røntgengennemlysning. Intern karlukning. Temporær eller permanent

63 Emboliseringsmaterialer Temporære Gelfoam - gelatin sponge - spongostan Absorberer mange gange dets vægt Billigt Lille vævsreaktion Varighed 5 6 uger EmboCept (Degradable starch microspheres) halveringstid 35 min

64 Emboliseringsmaterialer Permanente Mikropartikler Flydende materialer Coils Vascular plugs Balloner Flydende emboliseringsmaterialer, e.g. Ethylene vinyl alcohol copolymer (Onyx), N-Butyl-2- CyanoAcrylate (Glue - Histoacryl), Sodium tetradecyl mixed contrast

65 Mikropartikler Distal flowdirigeret embolisering

66 Standard coils

67 0.018 inch

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70 Bækken traume blødning Aorta ballonokklusion en mulighed Mortaliteten nedsat fra omkring 50 % til < 20 % efter indførelsen af pelvis embolisering i behandlingsprotokollerne (organlæsioner, MOF) Manglende kontrast extravasation på CT har 99,6% neg. prædiktiv værdi for yderligere angiografi

71 Teknisk succes 85 90% Klinisk succes (hæmodynamisk stabilitet) 90% (97% ved re-intervention) Reblødning 6 8%

72 39-årig, MC

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81 Traumeblødninger Jylland 50 Sjælland Fyn Total

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84 UFE

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86 UFE - Method 10/24/

87 UFE - Method 10/24/

88 24/10/2018 PEA 88

89 10/24/

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92 Livmoder fibrom Odense Skejby Herlev

93 Apropos - Prostataembolisering

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95 TACE 69 year old male Neuroendocrine gastric carcinoma

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99 trombolyse

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101 Fremmedlegemefangst Lokalanalgesi med snare Metode Seldingers punkturteknik Sædvanligvis a. eller v. femoralis (Biplan) røntgengennemlysning Fremmedlegemet fanges i snaren Fremmedlegemet fikseres til kateteret og ekstraheres evt. sammen med sheath en

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106 Closure devices

107 Venøse interventioner Cava sup. syndrom Pelvic congestion Perm Katetre TIPS Filtre PAVM Trombolyser og centrale PTA

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115 TIPS Transjugular intrahepatic portosystemic shunt

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118 RIS/PACS Sectra RIS 2001 Sectra PACS Taelkengældelse (Der ER forskel på, om man har én eller ingen tumor!) GE RIS/PACS jan. 2011

119 og dosisbesparelse Før: CT thorax ~ 400 thoraxbilleder, nu 1-2

120 Kontraststoffer

121 Before any examination with contrast media Identify high risk patients (se-creatinine/egfr) If in high risk Reconsider indication Consider alternative exam. methods Always restrict amount of contrast Patients well hydrated

122 Alternative imaging modalities. CO2 angiography Sonography Duplex sonography MR and MR angiography CT and CT angiography MR guided intervention

123 pea

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125 Neuro

126 PEG Myelografi Carotispunktur - Og andre mordforsøg

127 Odense 1978

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134 Tak for i dag Spørgsmål?

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