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. • Dr. Jason Wong- MD, FRCPC- Department of Interventional Radiology, Calgary Hospital, Calgary, Alberta • 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: • • • • • • 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.
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