Lecture: 1
Title: Minimally invasive palliative procedures under imaging
guidance - a new importance in the age of physician-assisted
suicide?
Saturday, April 25th, 2015
Time: 08:00-08:30 (30 minutes)
Objectives:
1. Describe the principles underlying the use of minimally invasive palliative
procedures.
2. Review types of procedures that can be utilized.
3. Discuss the value of establishing programs in any department doing
interventional radiology.
Palliative medicine has come into the limelight recently with the recent court rulings in Canada
on physician-assisted suicide. The purpose of minimally invasive imaging-guided palliative
procedures is to alleviate pain and improve quality of life in patients who typically have incurable
disease. Management of pain becomes one of the most crucial aspects in improving quality of
life and often requires a multidisciplinary approach. Unfortunately in Canada, the use of
imaging-guided palliative procedures is unevenly distributed and even in major centres is not
readily available.
Minimally invasive procedures using imaging guidance can be performed in any radiology
department. These procedures range from extremely simple, straightforward procedures, such
as joint blocks, all the way up to invasive procedures requiring specialized equipment.
Indications for these procedures will be reviewed, particularly in the setting of a multidisciplinary
conference when available. Procedures that will be touched on include joint, tendon sheath and
bursa blocks, nerve blocks, and nerve ablation procedures, as well as thermal ablation
techniques (radiofrequency ablation, cryoablation) and cementation of destructive bone lesions
(vertebroplasty, acetabuloplasty).
A series of illustrative cases will be provided showing how imaging-guided procedures can often
dramatically improve quality of life, even in the setting where widespread, destructive disease is
present which may not be amenable to previous conventional techniques (i.e. chemotherapy,
radiation therapy, surgery, etc.).
Dr. Peter Munk, MD, FRCPC, FSIR- Department of Radiology, Professor & Head of
MSK radiology/ VGH/UBC Hospital
Lecture: 2
Title: MSK Biopsy & Joint injections- Why & How they are done
Saturday, April 25th, 2015Time:
Time: 08:30-09:00
Learning objections:
Attendees will take away the following information:
1. Review basic MSK anatomy when doing biopsies and Joint injections.
2. Understand the technique of obtaining biopsy samples.
3. Appreciate different technical approach needed and considerations associated
with pain management joint injections.
4. Learn about the risks/benefits/ contraindications associated with MSK biopsy and
joint injection procedures.
5. Review the ancillary equipment necessary to obtain MSK biopsies and Joint
Injection procedures.
6. Review the pharmacological medications required for joint injection procedures.
Abstract:
Musculoskeletal (MSK) Biopsy and MSK Pain Management Joint injection procedures are
commonplace in most medical imaging departments today. This lecture will review the medicaltechnical and imaging aspects of both MSK biopsy and pain relief joint injection procedures.
Safe technical approach and accurate imaging considerations to MSK biopsy will be reviewed.
There will be a discussion on the pain management solutions that MSK intervention offer
patients suffering from bone and joint related symptoms. Finally, an overview of
pharmacological medications needed to provide safe injections will be covered.
Dr. Paul Mallinson, MD, FRCPC- MSK division Radiologists, Vancouver General Hospital
Lecture: 3
Title: First North American Trial of Ozone and Investigation of the use
of Cone beam CT in an angio suite for treatment of Herniated Lumbar
Discs with Ozone
Saturday, April 25th, 2015
Time: 09:00-09:30 (30 minutes)
Objectives: 4. Describe the principles underlying the use of Ozone in the treatment of Herniated
Lumbar Discs.
5. Review the use of an angio suite and coned beam CT to assist in targeting
herniated discs.
6. Discuss the value treating patients with ozone therapy in an IR setting.
Dr. Kieran Murphy, MD., FRCPC, Head of Neuroradiology, Toronto
General Hospital
Kieran Murphy MD FRCPC
Peter Munk MD FRCPC
2
Gavin Elias BA1
1
Jim Steppan PhD
1
Chett Boxley PhD, MBA
4
Balagurunathan Kuberan PhD
4
Xylophone Victor PhD
1
Thomas Meaders BS
3
Mario Muto MD
1)
2)
3)
4)
5)
Medical Imaging, University of Toronto, Toronto, Ontario, Canada
UBC Vancouver General Hospital
®
ActiveO , Salt Lake City, Utah
A. Cardarelli Hospital, Naples, Italy
University of Utah, Salt Lake City, Utah
Corresponding author:
Kieran Murphy MB FRCPC FSIR Professor of Radiology, Toronto Western Hospital 3MC 424 Bathurst St., Toronto [email protected] Keywords: ozone, herniated lumbar disc, mechanism of action,
ABSTRACT
We report the first North American trial of Ozone in the treatment of contained lumbar
spine disk herniations. We evaluated the speed and accuracy of CT guidance (the
standard Europe approach) to conventional angio suite fluoro guidance with cone beam
CT confirmation of gas distribution.
Methods
Percutaneous image-guided intradiscal oxygen/ozone treatment was performed in 36
patients in 2 centers. The Active O AO 1000 hand held disposable device was used in
all cases. 24 were treated at Vancouver General Hospital (VGH) with CT guidance. 12
were treated at the Toronto Western Hospital (TWH) 2 initially under CT and then the
following 10 under fluoro guidance with Cone beam CT. Angio fluoro discogram type
technique is used for access. 22 g 15-20 cm long needles were used. 2-3 ccs of ozone
was injected in the disc and 6-7 ccs just lateral to the annulus. This was followed with
1cc of 0.5% Marcaine and 40mg of depomedrol. IRB and Health Canada approval was
obtained for this multicenter study.
Results
1 patients was treated under Fluor guidance at L3/4. 14 patients were treated at L4/5, 8
under CT Guidance, 6 under fluoro guidance. 21 patients were treated at L5 S1, 17
under CT guidance, 4 under Fluoro guidance. There were no failures to access L3/4 or
L4/5. Access at L5/S1 was difficult under CT guidance. In 16 cases a co axial curved
needle approach was needed (18 g needle with curved 22 g), in 1 case we failed to
access the disc. 4 patients were treated at L5S1 under fluoro with extreme cranio
caudad ipsi lateral oblique angulation without difficulty. 22 g 15-20 cm long needles
were used .The average time for CT guided studies was 36 minutes. The average time
for fluoro guidance was 24 minutes. Cone beam CT reconstructions confirmed gas
distribution better than conventional CT images as greater cranio caudad coverage was
obtained. There were no procedural or post procedural complication, or disc infections.
Conclusions
Oxygen/ozone therapy has been used in Europe to treat herniated discs for over a
decade, with approximately 30,000 patients treated safely within this timeframe. This
study reports the first North American experience with Ozone in ontaine d herniated
disc.
We saw faster procedural times and better disc access with Angio fluoro
guidance. Ozone gas distribution was accurately confirmed with Cone beam CT.
Ozone’s MOA in relieving low-back pain associated with a contained, herniated disc is
volume reduction by ozone oxidation of proteoglycans in the nucleus pulposus into CO2
and H20.
Lecture: 4
Title: Allergic reactions to contrast medias
Saturday, April 25th, 2015
Time: 09:30-10:00
Objectives:
1. Review current literature regarding adverse reactions to radiocontrast agents
2. Understand the difference between anaphylactoid ("anaphylaxis-like") or nonanaphylactoid types of reactions
3. Review predisposed risks factors associated with allergic reactions
4. Review the prophylaxis pre-treatments for high-risk patients
5. Understand the treatment protocols available to health care providers for treating
allergic reactions.
Abstract:
Imaging techniques frequently employ contrast agents to improve image resolution and
enhance pathology detection. These gadolinium and iodine based media, although generally
considered safe, are associated with a number of adverse effects ranging from mild to severe.
Reactions are classified as either anaphylactoid ("anaphylaxis-like") or non-anaphylactoid,
depending on a number of elements that will be reviewed. Herein, we have summarized
predisposing risk factors for adverse events resulting from the use of contrast, their associated
pathophysiological mechanisms as well as known prophylaxis for the pre-treatment of high-risk
patients. In the unlikely event that a serious adverse reaction does occur, we have provided a
comprehensive summary of treatment protocols. Our goal was to thoroughly evaluate the
current literature regarding adverse reactions to radiocontrast agents and provide an up to date
review for the health care provider.
Dr. Kieran Murphy, MD, FRCPC, Head of Neuroradiology, Toronto General
Hospital
Lecture: 5
Title: Treatment of symptomatic Tarvlov Cysts
Saturday, April 25th, 2015
Time: 10:30-11:00 (30 minutes)
Objectives:
1. Understand what Tarlov cysts are in the spine and how they can be successfully
treated percutaneously in an CT- IR setting
2. Appreciate the role of CT/IR in the treatment of Tarlov cysts.
For submission to American Journal of Neuroradiology as an Original Research manuscript Treatment of Symptomatic Tarlov Cysts by CT-guided Percutaneous
Injection of Fibrin Sealant
Dr. Kieran Murphy, MB FRCPC FSIR- Department of Neuroradiology- Toronto General
Hospital Conclusions:
Despite widespread belief to the contrary, it has been known for some 70 years that perineural
cysts are sometimes symptomatic. Indeed, associated symptoms and neurological signs may be
relieved by successful treatment of the troublesome cyst, The aspiration-injection technique
described herein constitutes a safe and efficacious treatment option – one that holds promise for
relieving cyst-related symptoms in many patients with very small risk.
Kieran Murphy MB FRCPC FSIR,a Anne Louise Oaklander MD, PhD,b,c Donlin M. Long MD PhDd a
Kieran Murphy MB FRCPC FSIR. Department of Radiology, University of Toronto, Toronto, Canada Anne Louise Oaklander MD, PhDa,b b
c
Department of Neurology, Massachusetts General Hospital, Harvard Medical School.
Boston, MA, USA
Departments of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA, USA d
Donlin M. Long, M.D., Ph.D. Distinguished Service Professor Emeritus of Neurosurgery Neuroscience Consults, LLC Joppa Green II 2328 W. Joppa Road Suite 103 Lutherville, MD. 21093 Corresponding Author: Kieran Murphy MB FRCPC FSIR. Professor of Radiology Room 3 mc 424 Toronto Western Hospital 399 Bathurst St. Toronto, ON CANADA M5T 2S8 Phone: 416-‐603 5988 x2393 [email protected] Perineurial Tarlov cysts are outpouchings in the membranes around dorsal nerve-‐roots. They are visualized on 1-‐2% of spinal imaging studies, predominantly sacrally where intrathecal pressure is greatest. Approximately 25% cause symptoms, usually radicular pain or neurological dysfunction. Efficacy of several interventional treatments is supported by small, inconclusive series. Percutaneous treatment with intercavitary injection of fibrin sealant was developed with the rationale that inducing fibrosis might reduce cyst-‐wall compliance, CSF ingress, and facilitate cyst involution. To test this hypothesis, we analysed efficacy and safety of this procedure in 213 consecutive patients with apparently symptomatic Tarlov cysts treated by CT-‐guided two-‐needle cyst aspiration and fibrin sealing. METHOD STUDY DESIGN: This study, initiated in 2003 after institutional approval, was designed to retrospectively assess outcomes in all 213 patients who underwent CT-‐controlled aspiration and injection of one or more sacral TC at Johns Hopkins Hospital between the years of 2003 and 2013and Assessments were repeated at three months post-‐procedure, one year post-‐procedure, and yearly thereafter. METHOD OF ASPIRATION-‐INJECTION The conducted procedures all followed the technique described by Murphy et al.Error! Bookmark not defined. using two needles for aspiration and injection of the cyst. All procedures were carried out with local anesthesia and intravenous analgesia and/or sedation. Aspiration was preceded by performance of diagnostic CT (Aquilion 16-‐section multidetector CT unit; Toshiba, Nasu, Japan) in order to select the level providing access to the cyst through the thinnest overlying bone. , Two 18-‐guage needles were advanced into the cyst with the aid of intraoperative image guidance provided by CT fluoroscopy.The tip of the first needle was typically placed deep in the cyst, while the second was placed more superficially, near the cyst apex. The stylets were removed from both needles and fluid was aspirated via the deeper positioned needle. A commercially available fibrin sealant composed of human/bovine fibrin, fibrinolysis inhibitor, thrombin, and calcium chloride was then injected into the cyst through the deep needle (Tisseel VH; Baxter Healthcare, Westlake Village, California). OUTCOME ASSESSMENTS Outcomes were evaluated in clinic or by telephone at 3, 6 and 12 weeks post-‐procedure by an experienced nurse practitioner or a neurosurgeon trained in clinical research. Sacral MRI was repeated at 12 weeks and one year post-‐procedure. Subsequent yearly MRIs were recommended but not required. The primary outcomes, pain and function, were assessed using the LSOQ. NPRS scale This validated study instrument permits quantitation of pain and neurological loss including bowel, bladder, or sexual dysfunction. RESULTS The 213 patients had overall 289 cysts that were treated. 144 patients had unilateral, congruent cysts and symptoms and 69 patients had bilateral cysts. Multiple cysts ranged from two to nine and the average was three for each patient in whom multiple cysts were treated bilaterally. Nine patients had S4 or S5 cysts, but none were symptomatic in isolation. The group of patients reported here had all been followed for at least six months by the time of submission, with 192 (90%) of these patients having been followed for one year and 177 (83%) of them having been followed for between three and six years. NEUROLOGICAL SYMPTOMS AND SIGNS Local pain (often aggravated by sitting down) in the region of the cyst was the most common complaint in our cohort, though S-‐1, S-‐2 sciatica and neuropathy was also prevalent. Common bladder complaints included incontinence, urinary frequency or urgency, and inability to fully empty the bladder, while bowel dysfunction tended to involve urgency or mild incontinence. ASPIRATION-‐INJECTION OUTCOME All patients reported on in this study were followed for at least six months. 90% were followed for one year and 83% have been followed for between three and six years. At one year post-‐procedure, excellent results had been obtained in 104 patients (48.8%) and good or satisfactory results had been obtained in 53 patients (24.8%). Thus, 157 patients (73.6%) in all were initially satisfied with the outcome of treatment. In seven patients, aspiration was not technically feasible; in a further 40 patients, this procedure resulted in immediate failure. Nine patients were lost to follow-‐up, meaning their one year follow-‐up information was not available. During the three to six-‐year follow-‐up, excellent results were obtained in 106 patients (49.7%). This represented an increase from the equivalent statistic at one year; all those patients who were classified as excellent results at one year maintained this status into the latter follow-‐up period, and an additional two patients – who had fallen in the good or satisfactory category at one year – now qualified as excellent results. By contrast, only 25 patients (11.7%) now rated their outcome as satisfactory, a marked decline from the number that did so at one year. Overall, then, 131 patients (61.4%) were satisfied with treatment at three to six years follow-‐up. Only two patients have reported recurrence of symptoms after more than six years. 23 patients (10.7% of the treated cohort) underwent re-‐aspiration within the first six months due to recurrent symptoms after immediate short-‐term relief. 13 patients (6.1% of the treated cohort) underwent re-‐aspiration after six months. There were no documented infections or nerve injuries in the treated cohort. One patient had an allergic reaction with systemic hives, which led to overnight hospitalization but resolved without incident. Three patients appeared to experienced elevated inflammation; all resolved without treatment. CONCLUSIONS Despite widespread belief to the contrary, it has been known for some 70 years that perineural cysts are sometimes symptomatic. Indeed, associated symptoms and neurological signs may be relieved by successful treatment of the troublesome cyst, a feat classically accomplished by way of surgical interventions such as cyst resection, drainage and shunting, or decompression. These invasive methods are demonstrably effective but are also associated with risks such as infection or damage to neural tissue; these make them an imperfect first option treatment and suggest the need for continued development of alternative therapies, such as those utilizing a percutaneous, image-‐guided approach. The aspiration-‐injection technique described herein constitutes a tentatively safe and efficacious treatment option in this vein – one that holds promise for relieving cyst-‐related symptoms in many patients with very small risk. The 213 patients had overall 289 cysts that were treated. 144 patients had unilateral, congruent cysts and symptoms and 69 patients had bilateral cysts. Multiple cysts ranged from two to nine and the average was three for each patient in whom multiple cysts were treated bilaterally. Nine patients had S4 or S5 cysts, but none were symptomatic in isolation. The patients have all been followed for at least six months with 192 (90%) of these patients having been followed for one year and 177 (83%) of them having been followed for between three and six years. Local pain ( aggravated by sitting down) in the region of the cyst was the most common problem though S-‐1, S-‐2 sciatica and neuropathy was also prevalent. Common bladder complaints included incontinence, urinary frequency or urgency, and inability to fully empty the bladder, and bowel dysfunction. All patients reported were followed for six months. 90% were followed for one year and 83% for three to six years. 1 year post-‐procedure, excellent results had been obtained in 104 patients (48.8%) and good or satisfactory results had been obtained in 53 patients (24.8%). Thus, 157 patients (73.6%) in all were initially satisfied with the outcome of treatment. Overall, 131 patients (61.4%) were satisfied with treatment at three to six years follow-‐up. There were no documented infections or nerve injuries in the treated cohort. Close
Treatment of Symptomatic Tarlov
Cysts by CT-guided Percutaneous
Injection of Fibrin Sealant in 213
patients
Abstract No:
519
Submission Number:
519
Authors:
k murphy1, G Elias2, s kathuria3, D Long4, a oaklander5
Institutions:
University of toronto, toronto, - Choose State/Province -, 2university of toronto, Toronto,
ontario, 3Johns Hopkins, baltimore, MD, 4johns hopkin, baltimore, MD, 5MGH, boston, MA
1
Purpose:
To test this hypothesis, we analysed efficacy and safety of intervention in 213 consecutive patients
with symptomatic Tarlov cysts treated by CT-guided two-needle cyst aspiration and fibrin sealing.
Materials and Methods:
STUDY DESIGN:
This study, initiated in 2003 after institutional approval, was designed to retrospectively assess
outcomes in all 213 patients who underwent CT-controlled aspiration and injection of one or more
sacral TC at Johns Hopkins Hospital between the years of 2003 and 2013and Assessments were
repeated at three months post-procedure, one year post-procedure, and yearly thereafter.
METHOD OF ASPIRATION-INJECTION
The conducted procedures all followed the technique described by Murphy et al.1 using two
needles for aspiration and injection of the cyst. All procedures were carried out with local
anesthesia and intravenous analgesia. Aspiration was preceded by performance of diagnostic CT
followed by ct fluoro guidance. Two 18-guage needles were advanced into the cyst with the aid of
intraoperative image guidance provided by CT fluoroscopy.The tip of the first needle was typically
placed deep in the cyst, while the second was placed more superficially. The stylets were removed
from both needles and was aspirated via the deeper positioned needle. A commercially available
fibrin sealant composed of human/bovine fibrin, fibrinolysis inhibitor, thrombin, and calcium
chloride was then injected into the cyst through the deep needle (Tisseel VH; Baxter Healthcare,
Westlake Village, California).
Results:
The 213 patients had 289 cysts treated. The patients have all been followed for at least six months
with 90% of them followed for1 year and 83% of them having been followed for 3 and 6 years.
Local pain in the region of the cyst was the most common problem though S-1, 2 sciatica and
neuropathy was also prevalent. Common complaints included incontinence, urinary frequency, and
inability to fully empty the bladder, and bowel dysfunction.
1 year post-procedure, excellent results had been obtained in 104 patients (48.8%) and good or
satisfactory results had been obtained in 53 patients (24.8%). Thus, 157 patients (73.6%) in all were
initially satisfied with the outcome of treatment. 61.4%were satisfied with treatment at three to six
years follow-up. There were nerve injuries significant complications
Conclusions:
Despite widespread belief to the contrary, it has been known for some 70 years that perineural
cysts are sometimes symptomatic. Indeed, associated symptoms and neurological signs may be
relieved by successful treatment of the troublesome cyst, The aspiration-injection technique
described herein constitutes a safe and efficacious treatment option – one that holds promise for
relieving cyst-related symptoms in many patients with very small risk.
Categories:
SPINE, New Techniques
Reference One:
Murphy K, Wyse G, Gailloud P, et al. Two-needle technique for the treatment of
symptomatic Tarlov cysts. Journal of Vascular and Interventional Radiology 2008;19:771-73
Lecture 6:
Title: Inventions & New Device Development
Saturday, April 25th, 2015
Time: 11:00-11:30 (30 minutes)
Objectives:
1. Review the 4 types of Innovations
2. Understand the growth of interventional radiology devices over the years
Dr. Kieran Murphy, MD., FRCPC, Head of Neuroradiology, Toronto
General Hospital
This week I sat with the president of a successful Global Bank, my CEO a gifted leader, the VP
Research two professors from the School of business and the Director of an innovations
foundation and we discussed for two hours why our 270M research budget resulted in an
annual licensing and royalty return of 2 M dollars. The challenge we all face is to accelerate
innovation translation and commercialization. The belief is that this is something that can be
educated, initiated programmatically or “turned on”; that these are nascent skills in everyone
and that all Universities are capable of being successful. This is fundamentally wrong.
Grantsmanship has nothing to do with invention. MBAs are not necessarily entrepreneurs and
very few entrepreneurs have MBA’s. Large institutions or corporations are rarely where major
innovations occur. It’s too formal; Look at the classic facts, HP began in a garage. Steve Jobs
got fired from Apple before he came back to save it. Bill Cook and Brian Bates made catheters
in their bathtub. Inventors are eccentrics even within their own field. Innovation is about specific
people, about individuality, indifference to orthodoxy and the ability to ignore critics. Innovators
in our community are often rebels with a cause, anarchic individuals driven to create new
solutions. (1,2,3,4)
Just 4% of our Society of Interventional Radiology have creates the tools and procedures the
rest of us use every day. My belief that inventors and procedural pioneers are a small subset of
all humans is supported by our data from a survey of the SIR membership. This data was
presented at SIR 2010 and was a key part of the Innovation theme of the meeting. 3 gifted
summer students have worked on this project over 3 summers. They helped me cross
referenced the 6000 members of the SIR with filings at the US patent and trade mark office
(USPTO) and the European patent office (the PCT). 449 members had 2490 patents. In
particular a small number had a large number of patents (20-60 patents).. In essence less than
4% of the society membership created what we do today. I wanted to find out the factors that
enabled these people to succeed, where they came from and what motivated them. During
2011 we surveyed the patent holders about their training and who advised or influenced them
and created social network maps from the responder’s information. Using these social network
maps we could see the movement of people over time, and the key hubs of innovation were at
Hopkins Penn and Texas. One thing was clear from this data. Native ingenuity matters but
mentorship is critical. We mapped the influence of key centers over time, and the movement of
those centers trainees. More important than the center however was the mentor. The profound
influence of the generation of initial SIR leaders like Stan Cope with his wires, Palmaz and his
stents, David Williams and his aortic stent grafts can be seen through their diaspora of fellows
and the schools they in turn started in their own right. This process is about specific people not
institutions. To quote J. Robert Oppenheimer in his 1953 Reith lecture (5) “We are nothing
without the work of others, our predecessors, others our teachers others our contemporaries.
Even when in the measure of our inadequacy and our fullness new insight and new order are
created we are still nothing without others. “
Critical to innovation too is the willingness to be bothered by what you do and question if its
right, the willingness to say “yes ill take on that difficult patient” , a culture of accepting
challenges, of being the hospital of last resort and finding those difficult solutions is at the heart
of integrative and assimilative innovation.
Personality and Innovation
We would all agree that there is a fundamental personality type difference between the
specialities in our field. Diagnostic Radiology has always been conservative. During a
leadership retreat at U of Toronto we discovered that this was quantifiable with a Myers Briggs
test. Interventional radiologist and interventional neuroradiologist are very similar in personality
type (the swash buckling buccaneer), Breast imagers and pediatric radiologists were similar
(Subaru driving tree huggers!), as were Nuc Med and MRI folks (shy introverted mild Aspergers
syndrome a key element in a successful academic). These personality types make us choose
our fields and then that field, and our colleagues, form us. But even within the interventional
field there are further subsets based on risk tolerance and natural innovative tendencies. It is
clear that being slightly hyperthymic with periods of depressive realism are key traits of
successful innovators (6).
Types of Innovation
I think there are 4 types of innovation
-Quantum innovation like the major breakthroughs in theoretical physics that occurred in the
early 1900’s in a group dominated by Pauli Bohr, Fermi, Heisenberg and Einstein. This type of
innovation is very rare and only occurs in the great minds of a Tesla or Gugliemei, a Palmaz or
a Marco Leonardi . These are the quark like insights that create an entire new therapy. These
are the Darwinian leaps in evolution that don’t occur by increments. These are the random acts
of brilliance that form a field through constructive anarchy and change.
-Experimental observational. This is innovation derived from deliberate focused effort to
understand a process. Physicists discover things by systematic atomic analysis over years with
intense investigation like the Hadron super collider. They spend billions validating a theoretical
physicist’s moment of insight.
Observational innovations where we see something and identify a variation that allows us d
something better. Observational physicists identify/find things and make assumptions. Roentgen
and the x-ray is an example (though Tesla got there before him). An example in our field would
be drug eluting stents coated with restenosis inhibiting drugs. These are important steps but
are iterative or assimilative, (they take a technology or thought from a neighbouring field and
apply it integrate it new.) The USPTO often sees this as cause for an obviousness objection in
the patent world it would be obvious to one skilled in the art to combine two ideas and make
the device identified in the patent. These are often ideas created by association that occur in
Isolation and on reflection, but also sometimes when under intense pressure out of desperation
during a procedure.
-Iterative innovation. This is where a existing device is modified and made better by adding a
bell or whistle.
The last two are the field of the Stanford biodesign process approach. This process streamlines
the idea, capturing and reduction it to practice as is shown by this paper. The Stanford
biodesign process is powerful and valuable but it will only ever result in devices with predicates
eligible for the FDA 510K pathway. Prudence will iterate out risk and exclude truly great
innovative breakthroughs during the deal filtering process. That being said the paper published
in this edition of JVIR is a great one as it clearly demonstrates how the process works with a
clarity that we rarely see.
If 510k is the pathway you pursue you will be by definition based on a predicate and be
iterative. Bold vision Is the kiss of death at the FDA. It is impossible to get to market and thus
impossible to fund in USA. Here is an example. I have worked with a great team based in Salt
Lake City for 7 years with my disposable hand held Ozone device to treat contained herniated
disks only to be stymied by hack FDA reviewers. This destroys innovation and has led to
creative companies moving to Asia and Europe. Do not let the FDA and CMS reimbursement
limit your imagination. That’s the worst thing to do, its where mediocrity lies.
Fields in medicine go through windows of innovation like periods of incandescence ( 8), and
those fields attract the best people at those times of exuberant development like IR and INR
went through in the 90`s and early 2000`s. Now we are legit, a mature field, on label for most
things, and our societies focus in reimbursement. It’s time to move on and find more difficult
terrain. Great ideas have more to do with the Tourettes like humour of Robin Williams then
working groups and value stream mapping in a lean sigma improvement process. To quote
John Stuart Mill in ``on liberty 1896 `` “The amount of eccentricity in society has generally been
proportional to the amount of genius mental vigour and moral courage which it contained. That
so few now dare to be eccentrics marks the chief danger of the time”.
I would like to thank Gavin Elias a wonderful young man who has just graduated from High
school and gone to Oxford to study experimental psychology. He worked on the social network
mapping and data accumulation (2) Hussain Jaffer a gifted med student at U of Toronto with a
Hopkins MPH (3) Rashesh Mandai who while a law student doing a summer internship did the
painful work of cross referencing the membership of the SIR with filing sat the USPTO and
PCT(4). I look forward to working with them for many years and know they will be incredibly
successful. By way of advice to them I quote James Watson’s guidance to young scientists
on how to be successful (9).
-Don’t take up golf as you will become a`` thank God its Friday scientist`` your week end
experiments cease
-Stay in close contact with your intellectual competitors
-Never be the brightest person in the room
-Choose an objective ahead of its time
And lastly a thought from Jack Kerouac in On the Road
``The only people for me are the mad ones the ones who are mad to live mad to talk the ones
who never yawn or never say commonplace things but burn.
References
1) Strange brains and genius written by Clifford Pickover Harper 1998 ISBN 0688168949
2) It looked good on pape,r bizarre inventions design disasters and engineering follies written by
Bill Fawcett Harper 2009 ISBN9780061358432
3) The drunkards walk how randomness rules our lives, written by Leonard Mlodinow Vintage
Books 2009 ISBN 9780307275172
4) Notes on a beer mat, Drinking and why it’s necessary, written by Nicholas Pashley Collins 2001
ISBN 9781554682560
5) The strangest man the hidden life of Paul Dirac mystic of the atom, written by Graham Farmelo
Basic books 2009 ISBN 9780465018277
6) A first rate madness, written by Nassir Ghaemi uncovering the link between leadership and
mental illness Penguin NY ISBN 9781594202957
7) In praise of idleness, written by Bertrand Russell Allen and unwin 1935. Isbn 0414325064
8) Truants the story of men who deserted medicine yet triumphed, written by Daniel Lord Moynihan
Cambridge university press 1936
9) Avoid boring people, lessons from a life in science, written by James D Watson 2007 Knopf
ISBN 9780375412844
Lecture: 7
Title: CVAC- Central Venous Access Catheters
Saturday, April 25th, 2015
Time: 11:30-12:00 (30 minutes)
Objectives:
1.
2.
3.
4.
Review the various indications for CVAC devices
Overview of anatomy for placement of CVAC devices
Understand the indications and complications of these devices
Troubleshooting CVAC devise
Abstract:
Central Venous Access Catheters are commonplace in most Medical Imaging departments
today. From simple Peripherally Inserted Central Catheters (PICC) lines to indwelling tunneled
Ports and Central Lines make up the variety of catheters placed in the IR suite. This lecture will
review the basic placement techniques, indications, contraindications and complications of
these devices.
Dr. Gerald Legiehn, MD, FRCPC- Department of Interventional Radiology, VGH/UBC
Hospital
Lecture: 8
Title: IR Crash Cart – The agony of defeat, the thrill of victory
Saturday, April 25th, 2015
Time: 1:00-2:00 (1 hour)
This is an interactive case based session looking at morbidity and mortality cases as well as
interesting cases with salvages.
Objectives:
1. To introduce the concept and importance of non-confrontational morbidity and
mortality case rounds in an IR practice.
2. To learn from M&M cases, how did one get into a (bad) situation and how to
avoid these mistakes.
3. To highlight some “outside the box” thinking with some interesting cases.
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Dr. Jason Wong- MD, FRCPC- Department of Interventional Radiology,
Calgary Hospital, Calgary, Alberta
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Dr. Will Siu- MD, FRCPC- Department & Head of Interventional Radiology,
Royal Columbian Hospital, New Westminster, BC
Lecture: 9
Title: New Developments in Interventional Treatment for Acute Stroke
Saturday, April 25th, 2015
Time: 2:00-2:30 ( 30 minutes)
Objectives
1) to provide a review of the clinical evidence for interventional treatments for acute
stroke;
2) to discuss the clinical indications and appropriate patient selection for
interventional treatment of acute stroke;
3) to present cases which illustrate the techniques and the tools used in acute
stroke endovascular therapy .
Abstract
This presentation will provide an update on the recently published evidence supporting the use
of interventional techniques in the treatment of acute stroke. This latest development will
significantly change the paradigm in acute stroke management.
Dr. Will Siu- MD, FRCPC- Department & Head of Interventional Radiology, Royal
Columbian Hospital, New Westminster, BC
Lecture: 10
Title: Medical and Radiologic Management of Acute Pulmonary Embolism:
Rationale and Integration Within a
Multi-Disciplinary Pulmonary Embolism Response Team (PERT)
Saturday, April, 25th, 2015
Time: 2:30-3:00 (30 minutes)
Objectives:
1. To review the natural history and risk stratification of pulmonary embolism
2. To historically evaluate the rationale for the use of systemic thrombolytics for pulmonary
embolism
3. To review the best practices of thrombolysis for pulmonary embolism based on risk
stratification
4. To review the techniques of catheter directed interventions (CDI) for pulmonary embolism
5. To evaluate the efficacy and role of CDI within the larger management scheme of pulmonary
embolus
6. To present the VGH CDI experience
7. Describe past and present initiatives in established a pulmonary embolism response team
(PERT)
Dr. Gerald Legiehn, MD, FRCPC- Department of Interventional Radiology, VGH/UBC
Hospital
Lecture: 11
Title: Ionizing radiation monitoring and patient follow-up for fluoroscopically
guided interventional procedures
Saturday, April 25th, 2015
Time: 3:15-3:45pm (30 minutes)
The following lecture will provide an overview of ionizing radiation, biological effects of
ionizing radiation, patient radiation dose monitoring, and guidance on patient follow-up
after high radiation-dose procedures. Topics to be covered include the following:
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A overview of the physics of ionizing radiation
A review of biological effects of ionizing radiation
Deterministic versus stochastic effects of ionizing radiation
Deterministic effects associated with fluoroscopically guided procedures and their
corresponding dose thresholds
Ionizing radiation dose indicators in fluoroscopically guided procedures
Managing patient radiation dose before, during, and after fluoroscopically guided
procedures
Complex interventional procedures in radiology and cardiology often involve high doses
of ionizing radiation to a patient’s skin.1 High doses of ionizing radiation to the skin are
associated with deterministic effects, or tissue reactions.2 While mild tissue reactions
are an acceptable side effect when the procedure improves the patient’s quality of life,
more severe tissue reactions are associated with complications that can greatly reduce
one’s quality of life. Severe tissue reactions most often occur after a prolonged lifesaving procedure. During these cases, it is important for the clinical team to efficiently
monitor the patient’s radiation dose in order to make informed decisions regarding
radiation management, which can minimize the likelihood of severe tissue reactions.3
Monitoring a patient’s radiation dose enables the clinical team to effectively anticipate
and manage unavoidable outcomes.
Petar Seslija, MESc, MCCPM – Vancouver Coastal Health Authority Medical
Physicist
References
1.
T.R. Koenig, D. Wolff, F.A. Mettler, L.K. Wagner. “Skin injuries from fluoroscopically guided procedures:
part 1, characteristics of radiation injury”. American Journal of Roentgenology, vol. 177, pp. 3-11, 2001.
2.
E.J. Hall, and A.J. Giaccia. “Radiobiology for the radiologist”. Philadelphia: Lippincott Williams & Wilkins,
2006.
3.
S. Balter, J.W. Hopewell, D.L. Miller, L.K. Wagner, M.J. Zelefsky. “Fluoroscopically guided interventional
procedures: a review of radiation effects on patients’ skin and hair”. Radiology, vol 254, pp. 326-341, 2010.