SARELGAURMD
Interventional Radiologist
y 90 treatment:
Planning arteriography
good paper for information including flow rates etc
basic overview:
review prior CTA and MR abd
perform SMA and Celiac DSA
Exclude GDA and other extrahepatic gastric or enteric collateral circulation (see paper for full list)
Perform DSA of Main HA, R HA and LHA
Identify tumoral supply and/or tumoral blush
Infuse MAA particles into artery of intended y90 infusion
Send pt to Nucs Dept for SPECT imaging and review before day's end
Review prior imaging:
Multiphasic CT
MR Abd including multiphasic post contrast sequence
Tumors include: HCC>>CRC mets>>>>>cholangio among others...
Procedure steps:
obtain access RCFA using micropuncture
delinate inferior aspect of femoral head, R
access using ultrasound or landmarks
introduce microwire, switch for 4F transitional sheath
advance Bentson into abd aorta
change for 5F vascular sheath with sidearm
remove sheath dilator slowly, attach flush tubing (hand spike to RN, drip saline till no bubbles and then attach to side arm stopcock)
Place 0 silk stich to secure sidearm
goal is to get reverse curve cath (ie Simmons, Sos, or Contra) into celiac and SMA
VS prefer Simmons
Form simmons in the lower abd aorta using technique of crossing the iliac bifuracation with catheter with tight reverse curve
After have simmons in the abd aorta, try to engage SMA
test run on table using 10 cc syringe of contrast
Hook up for DSA of SMA, 4 cc x 16 cc contrast, ask pt to hold breath
Exclude any hepatic supply
Engage Celiac with simmons, 5f, and perform DSA 4x16
with Simmons in Celiac ostium, start with Progreat 130 microcath-microwire
Goal is to image GDA and perform angiography and then embolization
Use Progreat to engage distal aspect of GDA
Use 4-5 mm coils, VS prefer POD penumbra coils, or can use Ruby coils
To detach coil: coil comes as long wire and plastic type sheath. place sheath into hub of microcatheter. start sliding wire through sheath and into microcatheter, therefore advancing coil. once reach end of wire, start to image and see coil coming out of end of the cath. form coil as desired. Once comfortable with coil position, use device to lyse end of wire to deploy coil. Check with fluoro to confirm deployment of coil. Remove wire and advancing sheath. Toss both into trash.
Can perform repeat DSA of GDA to confirm exclusion, wait some time for thrombosis. Rate: 3 for 9, hand injection. Ask for medallion syringes
Continue to advance microcath-microwire into proper hepatic circulation and can repeat DSA to evaluate for tumoral supply if in question. 4 for 16 ok, usually perform hand injection at table
If see extrahepatic arterial feeders, can subselect and intervene on these.
If see tumoral supply and can cannulate appropriate artery (RHA or LHA) place infusion catheter here and perform DSA (2 for 10, 3 for 15, in this range)
Once are satisfied with position of microcatheter, ask for tech99m MAA to be sent up
Get syringe (remember the syringe is in lead shield and contaminated). Infuse through microcatheter and then inject contrast and then saline flush.
Remove all wires and catheters from groin and close with Mynx Ace closure.
Mynx Ace Closure:
ask for short amplatz and device
Can perform DSA of sheath to confirm access
Place amplatz into CFA, remove indewlling sheath, advance Mynx Ace Sheath
Prime baloon using dilute contrast
advance device into sheath and click.
Inflate baloon and check with fluoro
Move baloon back to arteriotomy
2- 2 minutes wait for plug to form
...more coming soon...
Y90 Planning Radial Access ZB Method
First scan L Radial Artery, note size and do barbeau test. Make note of barbeau classification. There is a good video on youtube
Prep and drape left radial artery
Access L radial using glidesheath slender (terumo) kit. It has a short micropuncture
Once have access, slide wire through
Sheath goes in right over the wire. The sheath is hydrophilic and no nick is needed
Give cocktail through sidearm. Hemodilute so the cocktail burns less
Once are ready to start, use cera- radial (sp?) catheter over bentson to start case
As per ZB, start with SMA and do long DSA run to vis portal vein for patency (5 for 20 or so is reasonable)
Can pop into celiac by pulling catheter back and puffing contrast
Once in celiac, do DSA and then start with microcath
Preference is the progreat 2.5F and fathom boston scientific microwire
Goals would be to embolize GDA, R gastric if seen, any diaphragmatic branches, any supraduodenal
Want to position microcath into position for infusion of spheres
Once have suitable position, infuse mAA spheres
Do same for R, L and middle if applicable
Pull all wires and caths
Pull sheath, use TR band for radial closure
Case end
-note to self, will update with addt’l details
how to use TR band to close L radial artery access:
take down drape
leave glidesheath slender in place
the band should have the inflation baloon towards pt head
the green dot should be placed at arteriotomy (not at exit site of sheath)
secure band at this site
inflate with 15 cc of air
remove sheath carefully, have sponge ready to keep area clean
hemostasis should be present
slowly, remove 1 cc ata time until see blood emanating from access site
then infuse 1 cc of air and hand syringe to RN with total air infused
how to do a y90 planning arteriography from L radial approach, tips and tricks
start with 5F Sarah radial 110 cm i beleive over 150 cm bentson
remember when radial approach that turning catheter is somewhat opposite of the femoral appraoch
initialy have to hook SMA and then celiac
if engage SMA, center over liver, consider magging up and hold run out to the PV phase to exclude PV thrombosis
when engage celiac, also run out 5 for 25 and consider magging up
if magged, then can reference DSA image as image overlay by pressing ref and then green button
How use microcath-microwire (ZB method)
typical setup is 2.8F Progreat over a 016 bos-sci Fathom wire
make sure to place shape on the microwire using shaping tool
make sure to flush tuohy-borsht and attach flowswitch
to engage vessels "spin-spin-spin"
spin microwire while advancing
use tuohy to tighten and save position
once have a decent position in the liver, can do a DSA run on the table
can also follow that with a dyna-CT run
how to do a Dyna CT run:
for siemans
make sure arm is out of armboard and tightly strapped to patient's body
click on the DSA settings, come down to 6sDCT
make sure II is fully elevated
first fluoro at in the AP and adjust so see the liver mostly centered without cutting too much off
to make siemans machine go "forward" motion is to grab joystick push button and then push stick forward
C arm should spin lateral, will stop if items in the way
adjust lateral position
keep going, C arm will spin other way
prior to doing run, have to do another AP fluoro image
usual settings are something like ? but make sure 8 second delay, why not sure currently
give pt instructions
if C arm hits something on the way, image may not be correctly obtained
make sure to review images on seperate workstation and mention in report
how to infuse MAA
work on the backtable
have a fresh blue towel avail for spillage
have technologist infuse MAA directly into your 20 or 10 cc syringe
have that attached to threeway stopcock with flush attached
when attached to micro to infuse, also use a fresh towel
infuse MAA and then chase with saline
how to remove radiation contaminated catheters:
pull micro into base cath
have sponges ready to sandwich catheter tip (sarah radial)
grab tip, place into blue towel with all other catheters
place entire formation directly "radioactive trash"
Y90 infusion treatment
With theraspheres aka glass spheres
Can always call reps for help during case- they want to be avail
Check priors for plan for treatment which may include embolization of shunts or additional flow diverting embolization treatments
Check priors for catheter positions
Check prior for lung shunts etc
cG method
access R CFA US
have on table bentson and glidewire, non stiff (regulah)
use C2-Cobra 5F to access celiac
basically advance bentson upt o t12
advance cath up to match
pull betnson out so cobra forms
figure out which way its facing,s hould be facing anterior
try to keep everything straight – cg
once see the super subtle subtle little fip of the cath into the vessel, that’s its
do a test puff
can do a run from there
if want, which I do, advance glide into vessel gently and then “tuck” cath deeper in
then do run, cg likes even numbers like 6 for 18 or something like that
from there can use reference to get out to where your trying to go
can use hi flo renegade and 016 fathom wire as go to start
form curve on wire, be very careful, easyt o screw that up as I know
different methods to engage vessels
some people spin it a ton and hope to go where they want, using the torque and going in and out I don’t love this
some people like to “surgically” place the device where you want, I like this
ultaimtely use both techinques to “get the job done”
one in where you want to be do test puff, set up for run
for runs:
take breath in, blow it out, hold your breath, once theyre holding hit the mask
To infuse therasphers:
very easy, just infuse the 20 cc flush and the beads will fly in, can ask rep for help, have to set up box a bit, person will read off instructions
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DEB TACE
DEB= drug eluting beads
usually means LC beads coated with doxorubicin
comes in vials of 25 mg
one vial is 25 mg of doxorubicin
the embolic particle size is usally 150-300, sometimes 75-150
prior imaging will likely show MR or CT with new recurrence in liver
goal is to send microcatheter to that place, do DSA or CBCT and infuse to stasis or near stasis
infuse with three way and 1 cc syringe
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saw new technique, SD
use of a 6F flexor sheath instead of 5F catheter in celiac
cannulate celiac with sos, advance glide, swtich for glidecath cobra, bury this in the RHA DEEP (get deep)
switch for amplatz, put wicked curve on the amplatz so it tracks
remove cath and ssheat, advance 6F sheath (put curve) into celiac, into proper hepatic just past GDA
apparently it helps
need to learn 3D CT with GE machines- can alays ask later its not rocket science, its IR
fuck this negative energy
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y90 infusion, sir spheres
just did a case pretty much solo
L RA access glidesheath slender ain't nothing
use J tip glide and jacky or sarah
get down desecending
if having trouble can switch for pigtail flush and exchange length amplatz
remember to be silky in the artery or youll cause spasm and wierdness
can alsways fix with nitro IA
to know front and back from the L rad
remember - TMPR- rotate catheter towrads me, wil rorate to patients right
if it doesn't go that way its back facing
once in celiac- can infuse and push foward get purchase
do run
per DK, can always do R AO 30' for better outlay
use ref to get micro in
usual choice is 2.8 or 2.4F progreat over transcend
if can't getinto the artery you want adjust the microwire curve
spin that sh**
once in artery, get set up to infuse radiation
get a good viewo fhte catheter magged and collimated
put table down so beads dont hav eto go uphill
t
to set up y90 sir sphere box
a,b,c,d i think
two needles
C and D
C goes in center
D goes peripheral
stopcock spins from flush to beads
hook up line to catheter
make sure catheter dont move can chcek con fluoro
basically pump up the beads and then switch over to flush and flush tem in
check for stasis which is unlikely but possible
back and forth beads and flush until its done
you can see the beads kinda diluting
can do airphase tho not always
run the beads in and thats the business
discard of stuff aprop
then get scanned
rarely a bead might fall where it sholdn't
thats the concern
TO form a tevdek suture for femoral intervetions, DK
insert the suture into the sim glidecath 1
FOR VISCERAL INTERVENTION: DK USES SIM1 GLIDECATH FOR CELIAC-MESENTERIC
SIM3 bigger than SIM2 bigger than SIM1
just about to the apex of the sim
then load the catheter and suture over the wire
it might be sticky
pull the wire back to the tip of the catheter
now pull the suture just till its form
then push out the wir
pt pull back the wire
then remove the suture
catheter formed
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re y90 Planning study
million ways to infuse y90 spheres
million different setups
per DK
often have variant anatomy
such as accessory RHA orig from SMA
and accessory LHA from LGA
LGA may have variant takeoff
goal is to consolidate so can infuse y90 from as few positions as possible
so can coil off vessels such as accessory RHA and LHA
but coils can be problematic, so can use microvascular plugs MVP, there are devices that fit thru microcath
"you are what you consistently do"
"the more you do, the more you see"
"no one said this shit would be easy"
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Renal Cryoablation using Galil System
did a case around 12/2017
things to think about
prone position
do lots of hydrodissection
just use saline
use a drainer catheter, long
infuse like 200 cc
for the ablation
advance the needle as close to your target as possible
of course decide 1 needle or 2
keep positioning and repo until you get it right
per BA, dont go thru tumor and then pull back
do breathing instructions with anesthesiologist
ideally, have hold expiration for all needle advancements and all images
may have to go back and forth a lot, can get tedious
once your in - stick the needle
then consider teh biopsy
make sure your ablation area is clear of bowel, etc
freeze 10 min, thaw 6, 10 freeze, then 3 thaw
then remove needles carefully
do a post CT renal protocol
hopefully you are done
consider severe bleeding
consider poss of bowel injury
consider nerve injury