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Presenter: Dr Anil Meetei
Moderator: Dr Th Chito
Asst prof, CTVS
Endovascular surgery
Endovascular surgery is a form of minimally invasive
surgery/procedures for imaging the circulation o...
Scope of endovascular therapy
 Baloon angioplasty
 Endovascular cryotherapy
 Stenting
 Angioscopy /intravascular ultra...
 Basic instruments
 Needles
 Guidewires
 Catheters
 Sheaths
Endovascular device sizing
 DEVICE MEASUREMENT UNIT
1. Entry needle outer diameter gauge
2. Guide wire outer diameter inc...
 Common interventions
 Balloons
 Stents
 Stent grafts
 Filters
 Thrombolytics
 Closure devices
 IVUS
 Contrast media
 Ionic
 Non ionic
Contrast agents
Iso osmolar-iodixanol, iotrolan(non ionic)
Low osmolar
Ionic dimer-meglumine ioxaglate
Non ionic monom...
 ACCESS
 Common femoral artery, popliteal, tibial, axillary,
brachial, radial, carotid, subclavian
 Bone/bony prominenc...
 Puncture site: common femoral artery on the medial
3rd of femoral head 1-2 cm below the inguinal ligament
 A puncture s...
 ACCESS
 1. Retrograde-relatively large diameter, ease of
compression, options for image guided puncture
 2. Antegrade-...
 ACCESS
 1. Single wall Puncture
 2. Double wall Puncture
Guidewires
 • Composite construction
 • Materials
 – Stainless Steel
 – Nitinol
 – Jacketed Composite
 Hydrophilic/h...
 • Core
 • Stainless Steel
– Used for support
– Stiffness varies based on taper / diameter of core
 • Nitinol
– Used fo...
Grind & tip performance
 • Stiff
 • Intermediate
 • Floppy
Sheaths
 Sheaths are hemostatic conduits inserted into the
vessel. They allow passage of guidewires, catheters and
interv...
Sheaths
 Peripheral and coronary sheaths have a universal color code
 Universal color coding
4 Fr = red
5 Fr = gray
6 Fr...
catheters
• Guide catheter
• Diagnostic catheter
• Non selective
• Selective
• Crossing
Endovascular surgery
 Typically performed under LA
 Less invasive
 Quicker return to function
 Durability compared to ...
Complications of endovascular
procedures
 Systemic, access site, or wire/catheter related complications
 Contrast induce...
Seldinger technique
 Sven Ivar Seldinger- Swedish radiologist (1953)
 The Seldinger technique is a medical procedure to ...
Balloon angioplasty
 Fogarthy (1963)- used endovascular catheter for extraction of arterial
emboli and thrombi
 Dotter a...
Technique
 Shortest distance from the access vessel to the target vessel
 Retrograde right common femoral artery access
...
 Iliac and femoro popliteal segments. Less successful
for below knee narrowing
 Coronary arteries
 Complications- failu...
Subintimal angioplasty
 Bolia et al (1989)-for chronic total occlusions
 Creating an intentional subintimal plane across...
 Types of balloon
 Complaint balloon
 Non complaint balloon
Complaint balloon
–expand in the direction of least resista...
 Cutting balloon angioplasty-
 Ballon loaded with metal atherotome or microsurgical blades
 Designed to create controll...
 Endovascular cryotherapy
 Balloon catheter inflated with nitrous oxide delivering cold
thermal energy(-10 C) to the art...
 Drug coated balloons(DCBs)
 Substantial amounts of antiproliferative agents were delivered
to the arterial wall during ...
Stenting
 Stent-comes from 19th century London dentist-
Charles Stent
 Charles Dotter (1983)-nitinol stents were first u...
Balloon expandable Self expandable
 High radial/longitudinal
force
 Precise placement
 Further expansion with larger
ba...
Angioscopy
 Used for visualizing the interior of blood vessels
 Arterial embolism, adjunctive procedure during
vascular ...
Intravascular ultrasound
 Uses miniature ultrasound probe attached to distal
end of an intravascular catheter(uses 20-40M...
Atherectomy
 Endovascular atherectomy allows the physical removal of
atherosclerotic plaque material from the blood vesse...
 Directional atherectomy
 Best suited for discrete calcified atherosclerotic lesions
of infrainguinal arteries. Not used...
 Rotational atherectomy utilizes a rotating burr or
blade to excise plaque, whose microparticles are either
aspirated or ...
 Laser atherectomy
 Utilized in CTOs, both de novo or in in stent thrombosis
 Cold tip laser that delivers burst of ult...
Thromboembolectomy
 Management of acute thrombotic or embolic arterial
occlusions
 Fogarty catheter
 Purely percutaneou...
 Simple aspiration either via a large sheath or guide
catheter work well in small vessels< 6mm
 Rheolytic devices utiliz...
Inferior vena cava filter
 Prevent life threatening pulmonary emboli
 Retrievable/ permanent
 Indications
 DVT/PE with...
Intraarterial thrombolysis
 In IA thrombolysis, the cervicocephalic arterial tree is
traversed with an endovascular micro...
 Myocardial infarction, ischaemic stroke, massive PE,
acute limb ischaemia
 Recanalization rates for IAT have been shown...
Contraindications to thrombolysis
 Intolerable ischaemia(for arterial thrombosis)
 Active bleeding(not including menses)...
Endovascular aneurysm
repair(EVAR)
 Indications-
 Symptomatic aneurysm of any size
 Aneurysm >5.5cm in size(5 cm in fem...
 EVAR-suitable in 50% of infrarenal aneurysms
 Reduced mortality and morbidity, shorter hospital stay
 Similar rates of...
 Complications
 Early-branch occlusion, distal embolization, graft
thrombosis and arterial injury
 Arterial dissection
...
Endovenous ablation of various
veins
 Endovenous laser ablation(EVLA)- 2001
 Radiofrequency ablation(RFA)
 Indicated in...
 Complications- pain. RFA>EVLA
 Skin burns
 DVT and pulmonary embolism(1%)
 Vein perforation and hematoma
 Paresthesi...
 Tumescent anaesthesia-dilute
lidocaine+adrenaline+bicarbonate
 Max dose (xylocaine+ adrenaline)in tumescent
anaesthesia...
Embolisation
 Therapeutic embolization is a nonsurgical, minimally invasive
procedure performed by interventional radiolo...
 Kidney lesions
 Liver lesions, typically hepatocellular carcinoma
(HCC). Treated either by particle infarction or
trans...
Embolic agents
 Liquid embolic agents
-used in AVMs. Flows through complex vascular
structures, so need not target each v...
 Particulate embolic agents
 Gelfoam
-temporary occludes vessels
-used for hemostasis
 Poly vinyl alcohol(PVA)-
-micros...
 Mechanical occlusive device
 Coils
-used for AVM, aneurysm and trauma
-good for fast flowing vessels- immediately clot ...
Advantages
 Minimally invasive
 No scarring
 Minimal risk of infection
 No or rare use of general anesthetic
 Faster ...
Disadvantages
 User dependent success rate
 Risk of emboli reaching healthy tissue potentially
causing gastric, stomach ...
Transcatheter arterial
chemoemolization
 Transcatheter arterial chemoembolization (also called
transarterial chemoemboliz...
 Embolization induces ischemic necrosis of tumor
causing a failure of the transmembrane pump,
resulting in a greater abso...
 Lipiodol- mixed with chemotherapeutic agents
 Drug eluting particles
-PVA microspheres-loaded with doxorubicin
COMPLICA...
Thank you
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
Endovascular surgery
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Endovascular surgery

  1. 1. Presenter: Dr Anil Meetei Moderator: Dr Th Chito Asst prof, CTVS
  2. 2. Endovascular surgery Endovascular surgery is a form of minimally invasive surgery/procedures for imaging the circulation or for treating vascular disorders from within the circulation, through catheters/miniature instruments inserted percutaneously into the blood vessels
  3. 3. Scope of endovascular therapy  Baloon angioplasty  Endovascular cryotherapy  Stenting  Angioscopy /intravascular ultrasound  Atherectomy  Thromb0embolectomy /intraarterial thrombolysis  Embolization  Endovascular aneurysm repair (EVAR)  Endovenous laser ablation (EVLA)  Endovascular RFA  Transcatheter aortic valve implantation (TAVI)  Percutaneous mitral valve repair
  4. 4.  Basic instruments  Needles  Guidewires  Catheters  Sheaths
  5. 5. Endovascular device sizing  DEVICE MEASUREMENT UNIT 1. Entry needle outer diameter gauge 2. Guide wire outer diameter inch 3. Sheath inner diameter french 4. Guiding outer diameter french catheter 5. diagnostic outer diameter french catheter
  6. 6.  Common interventions  Balloons  Stents  Stent grafts  Filters  Thrombolytics  Closure devices  IVUS
  7. 7.  Contrast media  Ionic  Non ionic
  8. 8. Contrast agents Iso osmolar-iodixanol, iotrolan(non ionic) Low osmolar Ionic dimer-meglumine ioxaglate Non ionic monomer- iopamidol, iohexol(omnipaque), ioversol, iopromide High osmolar Ionic monomer- meglumine diatrzoate(hypaque, gastrograffin, urograffin)
  9. 9.  ACCESS  Common femoral artery, popliteal, tibial, axillary, brachial, radial, carotid, subclavian  Bone/bony prominence beneath the artery  Avoid diseased areas  Away from side brances, bifurcations, or crossing veins  External skin markings, ultrasound guided, fluoroscopy
  10. 10.  Puncture site: common femoral artery on the medial 3rd of femoral head 1-2 cm below the inguinal ligament  A puncture site below the ligament cannot be compressed and could result in a large pelvic hemorrhage  Puncture of the SFA must be avoided to prevent pseudo-aneurysm and hematoma correlate to the inefficacy of the compression
  11. 11.  ACCESS  1. Retrograde-relatively large diameter, ease of compression, options for image guided puncture  2. Antegrade- commonly used for infrageniculate interventions, aortic bifurcations that are prohibitive to a contralateral retrograde CFA access and for chronic total occlusions  straight line approach- easy maneuvering
  12. 12.  ACCESS  1. Single wall Puncture  2. Double wall Puncture
  13. 13. Guidewires  • Composite construction  • Materials  – Stainless Steel  – Nitinol  – Jacketed Composite  Hydrophilic/hydrophobic
  14. 14.  • Core  • Stainless Steel – Used for support – Stiffness varies based on taper / diameter of core  • Nitinol – Used for it’s flexibility, memory and kink resistance  • Tip  • Platinum / Gold – Provides radiopacity – Atraumatic – Ribbon formed for shaping tip
  15. 15. Grind & tip performance  • Stiff  • Intermediate  • Floppy
  16. 16. Sheaths  Sheaths are hemostatic conduits inserted into the vessel. They allow passage of guidewires, catheters and interventional devices.  Hemostatic valve at the tip and a side port for aspiration/administration of drugs  Helps minimize local trauma to the vessel from repeated exchanges as well as decrease blood loss and hematoma formation
  17. 17. Sheaths  Peripheral and coronary sheaths have a universal color code  Universal color coding 4 Fr = red 5 Fr = gray 6 Fr = green 7 Fr = orange 8 Fr = blue 9 Fr = black 10 Fr = violet 11 Fr = yellow  Sheaths are measured inner diameter in french size (1fr = .33mm)
  18. 18. catheters • Guide catheter • Diagnostic catheter • Non selective • Selective • Crossing
  19. 19. Endovascular surgery  Typically performed under LA  Less invasive  Quicker return to function  Durability compared to open surgical options  Highly skilled operator  Endovascular suite with fluoroscopy  Costly
  20. 20. Complications of endovascular procedures  Systemic, access site, or wire/catheter related complications  Contrast induced nephropathy  Increase age(>75 yrs), CRF(creatinine>1.5mg/dl), heart failure, DM, preprocedural hypotension, anaemia , ionic contrast medium  Proper hydration, Minimum contrast dose  Access site-MC  Hematoma(3%), thrombosis(2%), bleeding, AVF, pseudoaneurysm  Hematoma-reversal of anticoagulation, vol resuscitation, hematoma evacuation  Catheter related-  dissection, distal embolization, perforation
  21. 21. Seldinger technique  Sven Ivar Seldinger- Swedish radiologist (1953)  The Seldinger technique is a medical procedure to obtain safe access to blood vessels  The desired vessel is punctured with a sharp hollow needle called a trocar, with ultrasound guidance .  Guidewire is then advanced through the lumen of the trocar, and the trocar is withdrawn. A "sheath" or blunt cannula is passed over the guidewire into the cavity or vessel. After passing a sheath or tube, the guidewire is withdrawn.  A sheath can be used to introduce catheters or other devices to perform endoluminal procedures.  Fluoroscopy is used to confirm the position of the catheter and to manoeuvre it to the desired location. Injection of radiocontrast may be used to visualize organs.  Upon completion of the desired procedure, the sheath is withdrawn. a sealing device may be used to close the hole made by the procedure.
  22. 22. Balloon angioplasty  Fogarthy (1963)- used endovascular catheter for extraction of arterial emboli and thrombi  Dotter and Judkins (1964)-transluminal treatment of arterial stenosis  Types  Percutaneous transluminal angioplasty (PTA)  Subintimal angioplasty  PTA with stenting
  23. 23. Technique  Shortest distance from the access vessel to the target vessel  Retrograde right common femoral artery access  Tibial occlusive disease-I/L anterior common femoral access  Heparinization-5000 IU as standard bolus dose after arterial access. 1000 IU/L heparinized saline for flushing  Arteriography to identify the lesion and severity  Lesion crossed and contrast injected  Balloon diameter and length carefully chosen  IVUS/CTA- for sizing the lesion  Balloon inflated for 1 min, withrawn after deflating  Contrast injection to assess the PTA result
  24. 24.  Iliac and femoro popliteal segments. Less successful for below knee narrowing  Coronary arteries  Complications- failure, hematoma formation, bleeding, thrombosis, distal embolisation
  25. 25. Subintimal angioplasty  Bolia et al (1989)-for chronic total occlusions  Creating an intentional subintimal plane across the occlusion with a guidewire and wire redirected back into the true lumen  Iliac and femoropopliteal occlusions- successful in highly calcified lesions, long occlusions(>15 cm)  Higher patency rates were observed in limbs treated for claudication than limbs treated for chronic total occlusions and criticallimb ischaemia  12 month patency <70%  Mean increase in ABI is 0.3  Technical failure rate ~26%- mostly due to inability to reenter the true lumen distal to the occlusion(70%)
  26. 26.  Types of balloon  Complaint balloon  Non complaint balloon Complaint balloon –expand in the direction of least resistance - more potential for arterial injury -potentially treat vessels of varying diameter Non complaint balloon -polyolefin copolymer/polyethylene/nylon reinforcement -provide higher uniform dilating force –highly calcific lesions
  27. 27.  Cutting balloon angioplasty-  Ballon loaded with metal atherotome or microsurgical blades  Designed to create controlled incisions into the thrombus and dilate the vessel with less force than conventional balloon angioplasty  CBA- reasonable option for infrainguinal vein graft stenosis -superior results to PTA -more chance of perforation
  28. 28.  Endovascular cryotherapy  Balloon catheter inflated with nitrous oxide delivering cold thermal energy(-10 C) to the arterial wall.  Alters healing response after angioplasty, principally inducing smooth muscle cell apoptosis rather than necrosis, thus reducing myointimal hyperplasia  CLIMB study -initial success rate 95% -stents required in 17% -primary patency at 12 months @56% and comparible with those achieved with conventional PTA -recommended for lesions >55mm
  29. 29.  Drug coated balloons(DCBs)  Substantial amounts of antiproliferative agents were delivered to the arterial wall during short periods of balloon inflation.  For prevention of re stenosis and myointimal hyperplasia  Paclitaxel coated balloons deliver drug during balloon inflation( superficial femoral artery)  Drug eluting stents (DES) -coronary circulation/infrainguinal arterial occlusive disease -Sirolimus/paclitaxel-inhibits smooth muscle cell proliferation
  30. 30. Stenting  Stent-comes from 19th century London dentist- Charles Stent  Charles Dotter (1983)-nitinol stents were first used  Palmaz et al (1985)-balloon expandable stent  Two types  Bare metal stent  Stent graft  Two types based on deployment method  Balloon expandable  Self expanding
  31. 31. Balloon expandable Self expandable  High radial/longitudinal force  Precise placement  Further expansion with larger balloons  Radiopaque  Short length  Prone to crushing  Flexibility  Long stent lengths  Continued radial force if oversized  Crush resistant  Ability to clamp the stent  Low radial force  Inaccurate/less precise placement  Limited radiopacity
  32. 32. Angioscopy  Used for visualizing the interior of blood vessels  Arterial embolism, adjunctive procedure during vascular bypass to visualize valves within venous conduit  Visualize stents in catheterization lab
  33. 33. Intravascular ultrasound  Uses miniature ultrasound probe attached to distal end of an intravascular catheter(uses 20-40MHz)  Useful with unreliable angiographic images-lumen of ostial lesions, or in regions with multiple overlapping arterial segments  Advantages over angiography-measures atheroma hidden within the vessel wall, identifies vulnerable plaque. Measures the effect of different treatment strategies for changing the evolution of the atherosclerosis disease process
  34. 34. Atherectomy  Endovascular atherectomy allows the physical removal of atherosclerotic plaque material from the blood vessel, with a theoretical benefit of removing the obstructing plaque rather than mere displacing it, as with angioplasty and stenting  Open atherectomy remains the gold standard. Endovascular atherectomy is useful in vessels with difficult access  Excisional atherectomy catheters remove and collect the atheroma, whereas ablative device fragment the atheroma into small particles  3 types of atherectomy devices  Directional  Rotational  Laser
  35. 35.  Directional atherectomy  Best suited for discrete calcified atherosclerotic lesions of infrainguinal arteries. Not used for chronic total occlusion  Silverhawk plaque excision system-the device is advanced under fluoroscopic guidance to the proximal portion of the target lesion, where a carbide cutter excise the atheroma and traps it within the nose come of the device; once filled with plaque the device is removed, the nose cone is emptied, and the device is reintroduced over a guidewire
  36. 36.  Rotational atherectomy utilizes a rotating burr or blade to excise plaque, whose microparticles are either aspirated or allowed to embolize distally  Jetstream – device success rate 99%.TLR -15% and 26% at 6 and 12 months respectively; restonosis 38% at 1yr  May cause vasospasm-calcium channel blockers/ nitroglycerine
  37. 37.  Laser atherectomy  Utilized in CTOs, both de novo or in in stent thrombosis  Cold tip laser that delivers burst of ultraviolet xenon energy in short pulse duration.  Key features is the ability to debulk tissue without damaging surrounding tissue, minimizing restenosis COMPLICATIONS -embolism 1.3%
  38. 38. Thromboembolectomy  Management of acute thrombotic or embolic arterial occlusions  Fogarty catheter  Purely percutaneous thrombolectomy  Aspiration  Rheolytic devices  Mechanical fragmentation with or without pharmacologic lysis
  39. 39.  Simple aspiration either via a large sheath or guide catheter work well in small vessels< 6mm  Rheolytic devices utilize jets of saline, directed from the tip of the catheter back toward its more proximal portion, to create a venturi effect, resulting in clot lysis and aspiration.  Arterial access is ideally made antegrade to the area of thrombotic occlusion. Lower extremity lesions are approached through contralateral femoral artery
  40. 40. Inferior vena cava filter  Prevent life threatening pulmonary emboli  Retrievable/ permanent  Indications  DVT/PE with contraindications to anticoagulation  Recurrent VTE despite adequate anticoagulation  Poor patient compliance(INR unstable), thrombolysis Complications-device migration, filter embolization, filter fracture, perforation of IVC, recurrent DVT, vena cava thrombosis
  41. 41. Intraarterial thrombolysis  In IA thrombolysis, the cervicocephalic arterial tree is traversed with an endovascular microcatheter delivery system, the catheter port is positioned immediately within and adjacent to the offending thrombus, and fibrinolytic agents are infused directly into the clot. This delivery technique permits high concentrations of lytic agent to be applied to the clot while minimizing systemic exposure.  In acute ischaemic stroke within 6 hours of symptom onset  It is usually infused over 1 to 2 hours while serial angiographic studies are obtained  reduced hemorrhagic complications (due to the use of lower doses of pharmacologic thrombolytics
  42. 42.  Myocardial infarction, ischaemic stroke, massive PE, acute limb ischaemia  Recanalization rates for IAT have been shown to be superior to those for IVT for major cerebrovascular occlusions, averaging 70% versus 34%  Agents used  Streptokinase  Urokinase  Recombinant tpa  Alteplase  Reteplase
  43. 43. Contraindications to thrombolysis  Intolerable ischaemia(for arterial thrombosis)  Active bleeding(not including menses)  Recent stroke or neurosurgical procedure < 2 months  Intracranial neoplasms  Recent major surgery(<2 weeks), major trauma,parturition, organ biopsy  Active peptic ulcer or recent GI bleed(<2 weeks)  Uncontrolled HTN  Bacterial endocarditis, left heart thrombus, hemorrhagic diabetic retinopathy  Coagulopathy or current use of warfarin  pregnancy
  44. 44. Endovascular aneurysm repair(EVAR)  Indications-  Symptomatic aneurysm of any size  Aneurysm >5.5cm in size(5 cm in females)  Increase in diameter > 0.5 cm/yr  Saccular aneurysms  Poorly controlled HTN(DBP>100mmHg)  Significant COPD(FEV1 <50% of predicted value)  Contraindications-recent MI, intractable CHF, unreconstructible CAD, life expectancy <2 yrs, incapacitating neurologic disease after a stroke
  45. 45.  EVAR-suitable in 50% of infrarenal aneurysms  Reduced mortality and morbidity, shorter hospital stay  Similar rates of survival to open surgery  Close follow up with CT necessary  Unsuitable- short, flared or angulated neck, presence of intraluminal thrombus and significant calcification, renal artery/large accessory renal artery arising from proximal neck, horseshoe kidney, iliac artery tortuosity, calcification and luminal narrowing
  46. 46.  Complications  Early-branch occlusion, distal embolization, graft thrombosis and arterial injury  Arterial dissection  Bowel ischaemia, renal dysfunction  Graft migration(1-6%)  Endoleak- is defined as failure to exclude the aneurysmal sac fully from arterial blood flow, potentially predisposing to rupture of the aneurysm sac
  47. 47. Endovenous ablation of various veins  Endovenous laser ablation(EVLA)- 2001  Radiofrequency ablation(RFA)  Indicated in primary and recurrent varicose veins(recurrent surgery-40% complication rate)  Procedure includes the insertion of a probe into the greater saphenous vein under usg guidance. Emits either laser or radiofrequency energy, which coagulates the vein walls, causing lumen obliteration.  RFA-85-120 celsius  Effectively treats junctional and truncal incompetence. Varicosities are better treated with concomitant phlebectomy
  48. 48.  Complications- pain. RFA>EVLA  Skin burns  DVT and pulmonary embolism(1%)  Vein perforation and hematoma  Paresthesia  phlebitis(<5%)  recurrence
  49. 49.  Tumescent anaesthesia-dilute lidocaine+adrenaline+bicarbonate  Max dose (xylocaine+ adrenaline)in tumescent anaesthesia-45-50mg/kg body weight  Provides analgesia, increasing contact with vein wall and laser/RF, protect adjacent structures- skin, nerves
  50. 50. Embolisation  Therapeutic embolization is a nonsurgical, minimally invasive procedure performed by interventional radiologists and interventional neuroradiologists . It involves the selective occlusion of blood vessels by purposely introducing emboli.  Recurrent hemoptysis  Arteriovenous malformations(AVMs)  Cerebral aneurysm  Gastrointestinal bleeding  Epistaxis  Varicocele  Primary post-partum hemorrhage  Surgical hemorrhage  Uterine fibroids
  51. 51.  Kidney lesions  Liver lesions, typically hepatocellular carcinoma (HCC). Treated either by particle infarction or transcatheter arterial chemoembolization (TACE).  Uterine fibroids  Access to the organ by guidewire and catheter  Location of the pathology by DSA
  52. 52. Embolic agents  Liquid embolic agents -used in AVMs. Flows through complex vascular structures, so need not target each vessel  N-butyl-2 cyanoacrylate  Ethiodole  onyx  Sclerosing agents -slow setting, cannot be used for large/high flow vessels  Ethanol  Ethanolamine oleate  sotradecol
  53. 53.  Particulate embolic agents  Gelfoam -temporary occludes vessels -used for hemostasis  Poly vinyl alcohol(PVA)- -microspheres of 50-1000 micron -cause inflammatory reaction causing vessel occlusion  Acrylic gelatin microspheres
  54. 54.  Mechanical occlusive device  Coils -used for AVM, aneurysm and trauma -good for fast flowing vessels- immediately clot the vessel. Platinum or steel -induce clot due to dacron wool tails around the wire  Detachable baloon - balloon implanted into a vessel, fill with saline
  55. 55. Advantages  Minimally invasive  No scarring  Minimal risk of infection  No or rare use of general anesthetic  Faster recovery time  High success rate compared to other procedures  Preserves fertility and anatomical integrity
  56. 56. Disadvantages  User dependent success rate  Risk of emboli reaching healthy tissue potentially causing gastric, stomach or duodenal ulcers. There are methods, techniques and devices that decrease the occurrence of this type of adverse side effect.  Not suitable for everyone  Recurrence more likely
  57. 57. Transcatheter arterial chemoemolization  Transcatheter arterial chemoembolization (also called transarterial chemoembolization or TACE) is a minimally invasive procedure performed in interventional radiology to restrict a tumor's blood supply. Small embolic particles coated with chemotherapeutic agents are injected selectively into an artery directly supplying a tumor.  two primary mechanisms. - arterial embolization preferentially interrupts the tumor's blood supply and stalls growth until neovascularization. - focused administration of chemotherapy allows for delivery of a higher dose to the tissue while simultaneously reducing systemic exposure, which is typically the dose limiting factor. Effectively, this results in a higher concentration of drug to be in contact with the tumor for a longer period of time.
  58. 58.  Embolization induces ischemic necrosis of tumor causing a failure of the transmembrane pump, resulting in a greater absorption of agents by the tumor cells. Tissue concentration of agents within the tumor is greater than 40 times that of the surrounding normal liver.  Clinical applications- hepatocellular carcinoma, neuroendocrine tumours, ocular melanoma, cholangiocarcinoma, sarcoma, metastatic colon cancer
  59. 59.  Lipiodol- mixed with chemotherapeutic agents  Drug eluting particles -PVA microspheres-loaded with doxorubicin COMPLICATIONS -necrosis of tumours release cytokines causing pain, fever and malaise -intrahepatic abscess, irreversible hepatic necrosis - Restrict TACE to single lobe or major branch of hepatic artery
  60. 60. Thank you
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postgraduate cirriculam

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