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 p.e.andersen@rsyd.dk
Radiologiens historie Wilhelm Conrad Röntgen 1845 1923 X - rays 1895
Wilhelm Conrad Röntgen 28/12-1895: Über eine neue art von strahlen. Medizinischen Gesellschaft zu Würzburg
10 uger senere Januar 1896 post mortem angio af hånd (Haschek & Lindenthal, Wien) kridtemulsion, kalciumsulfat, vismut, barium, kviksølv 25 år senere angio levende personer
1923 - karundersøgelser på levende personer, Frankrig (Sicard & Forestier), Tyskland (Berberich & Hirsch), U.S.A. (Brooks), Portugal (Santos, Moniz (thorotrast)) 1932 - Sverige og Danmark (hjernekar) 1948 - Perifere kar (Århus og Odense)
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.
Svenskeren S-I Seldinger kateterisationsteknik (1953)
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.
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. 1959 - Hjertets kranspulsårer angiografi (via arm) 1967 via lysken
1964 - PTA åbning af forsnævret eller lukket karlumen i benene med sonde katetre (USA) 50 % succes 1973 - PTA ballonkateter (Andreas Grüntzig) 1977 - PTCA 1977 - Danmark PTA (Herlev) 1991 - Danmark stent (Bispebjerg, Skejby, RH, Odense)
Ballon
Stent
Stent
Stent
Antal KAG 1974-1992 Antal PTCA 1986-1992 900 800 700 600 500 400 300 200 100 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Odense
PTCA Norden 1990 1991 1992 1993 Sverige pr. mill. Indbyggere 134 211 311 363 Finland 134 182 226 Norge 176 285 379 461 Danmark 65 104 165 195
1984 1988: PTA 1 25/år 1979 1988: UE 40 60/år (translumbal) 1990: UE 206 PTA 72 1991: UE 321 PTA 129 1992: UE 373 PTA 146 renal 39 PTRA 10 1994: UE 412 PTA 151 PTRA 12
Odense UE angio 21/10-1948 Seldinger 1955 Perifer PTA 1984 PTCA 1986 Perifer stent 1991 Coronar stent 1992 Carotis stent 1993 PAVM 1996 UFE 1999
Interventionsradiologi Hvor er vi og hvor er vi på vej hen? Non-vaskulær Vaskulær arteriel Vaskulær - venøs
Specialeplan 2015-2017 Diagnostisk Radiologi Radiologi Definition af interventionsradiologi indskrevet Lille skridt for menneskeheden, et stort skridt for radiologien
Non-vaskulære interventioner Biopsier ultralydvejledt, (røntgengennemlysningsvejledt), CT-vejledt, MR-vejledt Drænager, pleura, ascites absces, galdeveje, nyrer Brænding, kogning, frysning af tumorer
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.
Vaskulære interventioner - Aorta arterielle Perifere arterier Aneurysmer Emboliseringer - blødninger (traumer, GI, rumperede aneurysmer), tumorer, prostata, AV-malformationer Trombolyser Fremmedlegemefangst
3 timer 50 min senere TEVAR 3 timer senere
Lidt om benene
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
Ballooning first or primary stenting with bare nitinol stent or drugeluting stent will be preferred by most IR
64-year old male, Ankle pressure 40 mm Hg. Golf problem. Primary GOBA, followed by stent 6/60 mm.
PTA/Nitinol stents with medicine added Cilostazol (Pletal), randomized multicenter study, Japan Inhibits platelet aggregation, vasodilatator Iida O et al. Circulation 2013;127:2307-2315
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
Viabahn 7 mm/10 cm Are the decisions in these cases based on empiricism, common sense, experience or evidence?
Prevalence of peripheral arterial disease (PAD) Increased in diabetes (relative risk increase for PAD > 4.0); 20 30 % 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 1988-1994 1999-2004 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
1.36 F
Take five????
Aneurysmer 64-year old Admitted with abdominal pain, low BP, high pulse CT performed
Splenic artery aneurysm Proximal and distal branches to the aneurysm
Distal and proximal embolization intended Impossible to cath. the outflow art. dist. to the aneurysm. So, now what doctor?
Small coils delivered into the sac were flow directed to the distal branch.
After distal embolization with 5 coils and coil-packing the proximal inflow branch
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%
Aneurysm flow Thrombus
Open stent ready in renal artery but not expanded and deployed Microcatheter in the sack
Detachable hydrocoils and standardcoils
3 months follow-up
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
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
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
Mikropartikler Distal flowdirigeret embolisering
Standard coils
0.018 inch 24-10-2018 67
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
Teknisk succes 85 90% Klinisk succes (hæmodynamisk stabilitet) 90% (97% ved re-intervention) Reblødning 6 8%
39-årig, MC
Traumeblødninger Jylland 50 Sjælland Fyn Total 45 49 40 35 31 25 22 27 0 2001 2002 2003 2004 2005 2006 2007
24-10-2018 82
UFE
UFE - Method 10/24/2018 86
UFE - Method 10/24/2018 87
24/10/2018 PEA 88
10/24/2018 89
10/24/2018 90
10/24/2018 91
Livmoder fibrom 100 75 81 86 91 2005 2006 2007 50 59 47 58 56 Odense 62 70 68 Skejby 18 11 22 Herlev 0 5 1 25 2001 2002 2003 2004 2005 2006 2007
Apropos - Prostataembolisering
TACE 69 year old male Neuroendocrine gastric carcinoma
trombolyse
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
Closure devices
Venøse interventioner Cava sup. syndrom Pelvic congestion Perm Katetre TIPS Filtre PAVM Trombolyser og centrale PTA
TIPS Transjugular intrahepatic portosystemic shunt
RIS/PACS Sectra RIS 2001 Sectra PACS 2004 2005 Taelkengældelse 2008 2009 (Der ER forskel på, om man har én eller ingen tumor!) GE RIS/PACS jan. 2011
og dosisbesparelse Før: CT thorax ~ 400 thoraxbilleder, nu 1-2
Kontraststoffer
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
Alternative imaging modalities. CO2 angiography Sonography Duplex sonography MR and MR angiography CT and CT angiography MR guided intervention
24-10-2018 123 pea
Neuro
PEG Myelografi Carotispunktur - Og andre mordforsøg
Odense 1978
Tak for i dag Spørgsmål?