Interventional Radiology: what we do. October 17, 2015
Interventional Radiology: what we do. David M. Tabriz, MD
University of Florida College of Medicine Department of Interventional Radiology
What is an Interventional Radiologist?
Newest recognized medical specialty Separate from diagnostic radiology
6 years of post-graduate medical training: Clinical internship (1 year) Diagnostic and Interventional radiology residency (4 years) Interventional radiology fellowship (1 years)
What is Interventional Radiology? Diagnostic Radiology trained (head to toe) - Image interpretation (including prior studies) - Image consultation and protocolling - Disease process management - Recommended follow up (imaging, physician, etc.)
Interventional Radiology additional training (head to toe) - Pre-operative consultation - Image interpretation (including prior studies) - Procedure - Diagnostic (minority) & therapeutic procedures - Post-procedure care Benefits: Decreased cost & post-procedural care Decreased morbidity & mortality Faster recovery Only Option
Coding Fiesta 2015 David M. Tabriz, MD 1 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
IR: tools of the trade.
Needles
Guidewires
Catheters
Contrast Agents
Drainage catheters/tubes
Stents
Angioplasty Balloon
Many, many more
Tools: Access Needles
IR: tools of the trade – Seldinger technique
Coding Fiesta 2015 David M. Tabriz, MD 2 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Tools: Guidewires
Material
Thickness
Stiffness
Length
Tools: Catheters
Material
Thickness
Stiffness
Length
Flow rate
Tools: Contrast Agents
Iodinated Contrast
MRI (Gadolinium) Contrast
Carbon Dioxide (Gas)
Coding Fiesta 2015 David M. Tabriz, MD 3 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Tools: Drainages catheters/tubes Type
Material
Length/Diameter
Tools: Stents
Type
Material
Covered
Length/Diameter
Confusing…
Coding Fiesta 2015 David M. Tabriz, MD 4 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Tools: Angioplasty Balloon
Type
Pressure
Length/Diameter
Quick history.
1927 – First angiogram (Egas Moniz) 1964 – First angioplasty (Charles Dotter) “Father of interventional radiology” 1966 – Embolization of tumors 1967 – Coronary angiography (Melvin Judkins) 1969 – First stent deployed 1980 – Biliary interventions 1982 – Interventional Urology 1991 – Abdominal aortic stent grafts
“Operating room” Angio suite IR suite
Coding Fiesta 2015 David M. Tabriz, MD 5 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
What is an Interventional Radiologist? Like a surgeon taking consultations.
Diagnostic radiology interpretations guide procedure (head to toe).
Pre-, intra-, and post-procedure care.
Wide variety of practices.
E.g. Ultrasound guided abscess drainage. Fluoroscopic guided arteriogram and embolization.
IR CONTINUUM Image Access Diagnose/Treat Manage
IR CONSULT?
Coding Fiesta 2015 David M. Tabriz, MD 6 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Common IR Practice
Access and Diagnose/Treat (head to toe): Vascular, GI, Urologic, Gynecologic, and Hepatobiliary Trauma Liver Disease Pain management Oncology Cosmetic*
Interventional Procedures for Diagnosis
Biopsy and Drainage
Sentinel IR procedures that started it all. Usually performed by the Body Imaging Service.
Coding Fiesta 2015 David M. Tabriz, MD 7 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Sclerotherapy
Central Venous Access
Common Procedure
Dialysis and Central lines
Tunneled and Non-tunneled
Chronic Catheterization Damage
Coding Fiesta 2015 David M. Tabriz, MD 8 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
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Coding Fiesta 2015 David M. Tabriz, MD 9 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Coding Fiesta 2015 David M. Tabriz, MD 10 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
IVC filters and Pulmonary Embolism Thrombolysis Inferior vena cava filter barrier that allows blood flow through the IVC, but does not allow large clots
Break up large volume clots in symptomatic and unstable patients
Coding Fiesta 2015 David M. Tabriz, MD 11 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Coding Fiesta 2015 David M. Tabriz, MD 12 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Nephroureteral Obstruction
Relieve mechanical obstruction Ureteral stricture dilation Urinary diversion Stone removal
Coding Fiesta 2015 David M. Tabriz, MD 13 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Percutaneous Biliary Intervention
Cholangitis Bile duct strictures Pancreaticobiliary malignancy Repair of surgical injury Biliary stones
Coding Fiesta 2015 David M. Tabriz, MD 14 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Arterial Injury and Flow Limitation
Trauma Post Operative GI bleeding Atherosclerotic disease Vascular compression Anticoagulation related
Coding Fiesta 2015 David M. Tabriz, MD 15 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Coding Fiesta 2015 David M. Tabriz, MD 16 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Coding Fiesta 2015 David M. Tabriz, MD 17 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
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http://www.fda.gov/ucm/groups/fdagov- public/documents/image/ucm372843.jpg
Coding Fiesta 2015 David M. Tabriz, MD 18 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Vascular Malformations
Coding Fiesta 2015 David M. Tabriz, MD 19 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Example Case: Vascular Malformation
Vascular Malformations
Portal Hypertension: Ascites and Variceal Hemorrhage
Coding Fiesta 2015 David M. Tabriz, MD 20 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Musculoskeletal and Pain Interventions
Coding Fiesta 2015 David M. Tabriz, MD 21 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Why Interventional Oncology?
Many patients are medically inoperable
Surgical, regional, and systemic salvage
Low risk, less expensive, and quick recovery
Test of time for potentially under staged patients
Synergistic (not an either/or situation)
Repeat therapy is well tolerated
Palliation
EVIDENCE IS GROWING
Percutaneous Ablation
Radiofrequency Cryoablation Microwave Irreversible Electroporation
Coding Fiesta 2015 David M. Tabriz, MD 22 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
StarBurst® Talon
Images courtesy of Dr. Matt Callstrom, MD, PhD
Coding Fiesta 2015 David M. Tabriz, MD 23 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Coding Fiesta 2015 David M. Tabriz, MD 24 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Endovascular Oncology
Transarterial Chemoembolization Drug Eluting Bead Chemoembolization Radioembolization Bland Embolization/Intravascular ethanol Percutaneous Hepatic Perfusion Portal Vein Embolization
Bland Embolization
Removal of tumor blood supply alone, typically with bland particles
Embolization of benign disease for bulk reduction and symptom control (ex. uterine leiomyomata)
UFE
Coding Fiesta 2015 David M. Tabriz, MD 25 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Drug Eluting Bead Chemoembolization (DEBTACE) Chemotherapeutic agent is adsorbed to flexible particles that impregnate tumor vascular supply
Several studies have indicated an overall survival benefit for unresectable HCC as well as reduced liver toxicity and drug related adverse events
More permanent and aggressive embolic agent which may make up for less total chemotherapeutic dose
Extended antibiotic prophylaxis for incompetent biliary system or severe liver diesease
Radioembolization
External beam radiation therapy is challenged by the sensitivity of normal liver radiation
Hepatic treatmnent dose estimated from 50-70 Gy while the liver tolerance dose is 35 Gy
Selective intra-arterial yttrium-90 beta emission enables doses over 120 Gy without liver toxicity
Well tolerated, single session, outpatient treatment
Coding Fiesta 2015 David M. Tabriz, MD 26 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Multifocal Liver Involvement
Radioembolization
POINT SOURCE BRACHYTHERAPY WITHIN TARGET ORGAN: EFFECTIVE (3-12 mm margin)
Coding Fiesta 2015 David M. Tabriz, MD 27 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Coding Fiesta 2015 David M. Tabriz, MD 28 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
Pre Y-90 (Tc-99m Post Y-90 (Bremsstrahlung) MAA)
Cosmetic IR
Varicose vein ablations Laser liposuction
Coding Fiesta 2015 David M. Tabriz, MD 29 University of Florida College of Medicine Interventional Radiology: what we do. October 17, 2015
What is an Interventional Radiologist? Recap.
Like a surgeon taking consultations.
Diagnostic radiology interpretations guide procedure (head to toe).
Pre-, intra-, and post-procedure care.
Wide variety of practices.
Questions?
THANK YOU
Coding Fiesta 2015 David M. Tabriz, MD 30 University of Florida College of Medicine