Dr. Gary Kramer
Chairman of Radiology at Memorial Medical Center
Head of Interventional Radiology
Q: What is Interventional Radiology?
A: Interventional radiology is a big word. It’s one of the things we use as image-guided surgeons, some people call us. Basically, we take very complex, usually previously done surgical procedures and do them minimally invasive with small catheters, small wires, tiny little holes in the skin wherever we might enter the body.
Interventional radiology is an exciting field. It is not new. It has been developing and evolving over the past 25 years as a system to perform procedures that were traditionally done surgically, even under anesthesia. Now, they’re performed through tiny little nicks in the skin in a minimally invasive way from doing catheterization where we stick a catheter up and inject contrast in the arteries. Most people are familiar with cardiac catheterization. We do the same thing in the kidney arteries for people that have narrowing of the kidney arteries where we can put a balloon in or a stent to open up that renal artery.
The same thing in the legs where patients have blockages in their legs. They can get a stent or a balloon to open up vessels there. Very similar, again, the way we do in the heart. We also perform multiple minimally invasive procedures when it comes to people --- patients that may be bleeding from a trauma or anything else. We take a catheter up. We go into that small vessel and we block that vessel and stop it from bleeding whereas in the past they would’ve had to go in and get a big surgery and go in and openly stop that bleeding.
We have the ability to treat patients who have bleeding in their uterus from fibroid tumors and that is done by, again, taking the same catheter and wire techniques going into the uterine arteries, the arteries that feed the uterus, and blocking up both sides of the uterine artery and what that does it enables us to --- enables the patient to not have to undergo hysterectomy and it’s effective in 90 to 95 percent of patients. That is a completely women driven procedure because of the ability to not miss work for six weeks and then also enable them to be successful.
We have --- we do a lot of varicose vein work where patients now can get a laser ablation of one of their veins in their leg, potentially have some veins removed, both for swelling of the legs, painful bulging varicose veins, burning varicose veins, real simple whereas in the old days you used to do what’s called a stripping, which is a much more involved procedure and much more downtime and a high recurrence rate.
Q: What is Artis Z – How does it work?
A: The machine, itself, some people call it an Angiographic Suite where we image all our images and basically what it does is it captures both x-ray images and also when we do our catheterizations where we stick a catheter in and we inject dye or we have imaging taking place, it’s able to visualize the insides of vessels and the insides of a patient as we’re moving our catheter or wires to guide us to where we’re going.
Traditionally, old Angiographic Suites did everything just two-dimensionally. So you looked at your image and you saw what looks like a flat piece of paper like you had a drawing on it. What the Artis zee does is it’s able to take the C-arm which swings around a patient, which is always traditionally what they did, but now it swings around quickly and the computer technology that’s in there is able to shift all the imaging to a workstation and within a minute take those images and reconstruct them. So put them in a new image frame and enable you to get a three-dimensional image.
So now you’re looking at now say a globe, any sphere like a ball but you’re now looking --- you’re able to look in every single projection. So what that does for us, for example, if we’re looking at images of the brain, we’re trying to find an aneurysm which is a bulging of the artery in the head, traditionally in the past we’d have to take an image, a two-dimensional image, okay, now we see the aneurysm but the surgeon wants to know exactly where that’s coming off of the vessel. So now we got to take another image in another plane. No. Don’t see it there. And we have to get another image and sometimes multiple times each time radiating the patient, each time injecting contrast in the patient, both of which have --- or negative effects toward the patient. Now, we can do one spin in about a 270 degree arch and take that reconstructed image and look at it in every plane. So we’ve now just reduced the contrast. We’ve now reduced the radiation dose to the patient and we’ve also now found almost what the surgeons like to call a surgical view. They can actually perceive the images exactly how they’re going to see them when they’re inside operating on a patient. So it brings tremendous value, not only to the surgeon but also it’s safer and better for the patient.
We can then apply that technology, not only for the brain but for the chest if we’re doing something in your chest, for the pelvis if we’re doing a uterine artery embolization on a female. That’s the one main advantage. Other advantages is it now also can provide a generic CAT scan like image, which has really revolutionized things in that before we used to be able to do an image and do a study in CAT scan and in a much more difficult way.
For example, if we had a patient who had an abscess, a large fluid collection in their belly that needed to be drained, in the past we used to go down to CAT scan. We’d take images of those patients. We’d then stick a needle into that patient sort of blindly because you can’t visualize the CAT scan while you’re doing it and then actually put a drainage catheter in, a small tube that then drains the abscess to the outside to avoid surgery. The problem is there are many points in that procedure where you’re not seeing where you’re going and what interventional radiologists like to do is look at images and do things real-time.
What this machine now can do is provide the best of both worlds. So it enables us to see, get a --- when it spins around the patient it reconstructs that data again into a CAT scan like image, not as good as a regular CAT scan but pretty good that we can see where we’re going, that can initially direct us. This will also have guidance technology, which tells us exactly where the needle needs to go. Once we’re in the abscess now we can see everything under fluoro again, that can guide our needle and our wire and now we can do it all in one place, one location, safely with 95 to 99 percent accuracy whereas with CAT scan before to do a procedure like that it wasn’t as successful.
So it provides, now, a new type of imaging within one machine that enables us to do multiple procedures much easier, again, for the patient.
Q: Describe the detail of what you are able to see with this technology.
A: It’s remarkable. You now --- as the rest of the world is going when you’re talking about audio/visual and TV, you know, we have now flat-panel detectors and the flat-panel increases the resolution three-fold so that we can now depict smaller vessels. We can depict in bigger patients that were tougher to see because you had to penetrate them with more radiation, better images which guides us better, makes it safer for the patient and at the same token, because we can see better, we don’t have to necessarily magnify as much and do other things, which would normally increase the radiation dose, again, in lieu of patient safety.
Now, we can --- because of the great imaging that we have we can minimize the radiation dose to the patient and still get the same effect on the patient. So it’s really revolutionized the imaging quality that was there before.
Q: How about looking at a brain aneurysm today versus say 30 years ago? How much more detail are you able to see and why is that better for a patient, the surgeon?
A: The resolution is going to enable you to pick up things that you may not have been able to pick up before in a much easier way. More importantly, because of the way this can reconstruct images in three dimensions, it enables the surgeon to manipulate that data that we get in one rotation to see every possible angle to approach this aneurysm and also see all the vessels that are near that aneurysm that can possibly get in the way when they’re going to do the surgery.
One of the biggest negative things that can happen when you’re trying to go in and actually clip an aneurysm is you catch real vessels that you don’t want to clip that’s applied in normal parts of the brain. This gives them so much detail that it makes the overall operative procedure that much safer.
Q. Do you think it’s going to change outcomes for people?
A: Ultimately, I think it’s going to make surgery easier and therefore relate to better outcomes. If a surgeon knows exactly where the neck of that aneurysm is before he starts and knows exactly where he’s going to have to place his clip and he can preplan prior to the procedure and know what he’s going to expect it makes life a lot easier. When you’re going in and it’s hit or miss and you’re not sure where things are it adds time to the procedure, anesthesia time to a procedure and may lead you to mistakes down the line. So our surgeons here have greatly appreciated --- they come down to the Suite. They play with the images themselves. They talk to us about what they want to see and it enables them to have a much easier vassal approach to doing the surgery itself.
Q. Why did you feel it was important to bring this technology to this region?
A: Well, you know, two things. Number one; we were due for a new Suite, a new room. This is the newest technology. It’s going to enable us to do certain things that we couldn’t do before in terms of resolution, rotational 3D reconstruction, CT scanning along with it, enable us to make us grow as an interventional practice and also do things better for the patients.
You know, we’re fortunate enough this is the only scanner of its type between the University of Pennsylvania and the Cleveland Clinic and it enables us to set ourselves aside from the regional counties as well and keep us at the forefront of interventional radiology.
Q. What is Uterine Fibroid Embolization?
A: Uterine fibroid embolization, some people call it uterine artery embolization, is a procedure that has been one of those that is completely women driven. It was started back early in the early 1990s. So it’s been around for about 15 years and now there’s thousands that are being done. What it is is patients have uterine fibroids, fibroid tumors of the uterus, very common. In the past, most commonly treated with either myomectomy where they do a small surgical procedure and take out the fibroid itself or more commonly actually, hysterectomy, where they remove the entire uterus. Okay.
Just last year there was over 600,000 hysterectomies performed, almost 200,000 just for fibroids alone. So this has been one of those procedures where women say wait a second, do I have an alternative to hysterectomy where I don’t have to miss work for six weeks, where I don’t lose my uterus and that’s almost as effective. Hysterectomy is definitive. You will not have any bleeding. You will not have any bulk-related symptoms like constipation or pressure to have to urinate or just feeling like you’re full; however, you have all the downsides to hysterectomy in terms of the lost time from work as well as the possible complications of hysterectomy.
Uterine artery embolization works in 90 to 95 percent of patients for bleeding complications and also for bulk-related symptoms. Patients typically miss maybe one week of work and they have very good lifestyle after that. They maintain their uterus. There are long-term sequela, very rarely infection and other things that potentially happen with any procedure; however, again, I reiterate, this is something that’s been so much driven by women because they get the chance to keep their uterus and it’s an excellent alternative.
Q: What are Vertebroplasty and Kyphoplasty?
A: Vertebroplasty and kyphoplasty are, are two procedures sometimes called percutaneous augmentation, you know, lifting the vertebral body or filling the vertebral body. It’s a procedure that we do for compression fractures, acute or subacute compression fractures of the spine. Patients traditionally had either undergone back bracing, which is just wearing a brace and narcotic medications for weeks to months at a time, or big open surgeries, which they really don’t do anymore. Now, with either one or possibly two needles under direct fluoroscopic guidance or x-ray guidance we can guide the needles into the vertebral body and deposit cement in the vertebral body.
People may ask sometimes what’s the difference between a vertebroplasty and kyphoplasty. The only difference is with kyphoplasty before you put the cement in you actually put a small balloon in, which helps to hopefully lift the vertebral body and create a cavity to put the cement into. The neat thing about this procedure is that it’s 98 percent effective, literally a very small few of patients who don’t get better from this and I’m convinced that those patients have something else going on, a small rib fracture, a dislocation, something else because we’ve done well over 500 patients and there’s a handful of patients that haven’t gotten better.
In my experience half of those patients are completely better. They never know anything happened, which is wonderful, truly the most gratifying thing that we do. The other half, now they take a little bit of Aspirin or Advil for a mild ache that they have left and now can get back and be independent and do the things that they wanted to do, especially in the aging population they want to continue to do the things that they used to do every day, gardening, work around the house and if it stops them, the sense of independence they gain by just getting some of their, their life back is really truly rewarding for us.
Q. What procedures do Interventional Radiologists use to treat varicose veins?
A. Over time, patients who have what’s called venous insufficiency, back pressure into their veins, can get a lot of problems. One simple one is the manifestation or showing of just bulging veins. You can deal with that unless they’re painful. They can be painful. They can burn but also what can then happen is the back pressure can cause problems with the lower extremity flow and the flow in the lower leg and you get back pressure and then pigmentation changes, potentially can hurt. Skin can break down. You can get ulceration from severe venous insufficiency.
So there are patients with chronic venous insufficiency or venous increased pressure I like to say where there’s --- they need treatment. Right now, in the old days --- I’m sorry. In the old days, they would preferentially do surgery called a stripping where they go in and they actually undermine the whole vein and they strip out and you have a scar from your hip down to your knee. It was painful and the problem is 20 to 40 percent recurrence rate in about three to four years. Now, there’s different ways to actually get rid of the main vein, which is the one that causes the back pressure because the valve gets incompetent, either with laser or with ---- called RF, which is basically heat that actually ultimately destroys that vein and stops the reflux down there.
Now, there are other small veins which can cause it and there’s smaller areas that you can burn or heat to help do that. It’s a simple procedure. It’s done as an outpatient. Patients come in, very light anesthesia, conscious sedation we call it, local anesthetic. Following that procedure, if their veins are still present we then can do a small surgical procedure called and ambulatory phlebectomy and that’s where, again, under conscious sedation as an outpatient, same day in and out, we go in and make tiny small stab incisions and remove the residual veins, the veins that are left.
After a couple of months patients are feeling better, no longer burning, no longer with the venous insufficiency and from a cosmetic standpoint are thrilled with the way their legs now look. Lastly, sclerotherapy is really more for just the spider veins and that’s for a select few patients, usually more on a cosmetic level is why you do that but only for patients that ultimately want to do that in the end to finish up something that cosmetically now looks wonderful where we perform that as well.
Q. What is chemoembolization?
A. One of the most exciting things now is the ability that we have in the treatment of cancer. There are multiple things that interventional radiologists now do to help these patients, which in actually in some cases we’re creating some cures, which in the past we never really used to say that as interventional radiologists. You used to do things that would prolong a patient’s life. There’s a lot to be said for that in terms of giving them quality of life for several months or several years after they were taking traditional treatments.
What I mean is one, one mechanism we have is treating multiple tumors in the liver mainly with what’s called chemoembolization. It’s a lot to say but if we break it down it’s really not that confusing. Chemo for chemotherapy and embolization just means blocking an artery or a vessel and the way we do that is we do a catheterization just as somebody would have when they’re getting their heart catheterized and we go into the liver and we take pictures with dye and under our x-ray machine we can see the exact anatomy of the liver vessels and we can usually see where the tumors are being supplied.
If we can’t see that we know from previous CAT scan or MRI imaging where the tumors are so we know where to put our catheter. At that point, we then infuse into the catheter a combination of chemotherapy and blocking agents and what I mean by blocking agents are agents that slow the blood supply down, the idea being that you now put chemotherapy directly where the tumor is so you get maximum chemotherapy to the, to the lesions. You then slow down the blood supply so now that the blood can’t rush out of there so the chemotherapy stays longer or dwells longer. So now you get more of a longer effect and because it goes through the liver and gets somewhat metabolized first you don’t get all the systemic effects of the chemotherapy and in certain tumors --- for example, primary liver tumors, they’re called --- it’s called hepatocellular carcinoma.
There’s been several studies that show clear benefit and survival of these patients. Now, typically with chemoembolization we don’t talk about cure because typically you’re not necessarily curing the patient. There are certain types of tumors that spread to the liver where you can almost cure them but it’s not something we tell patients. We explain to them and we’re very clear and we work hand in hand with the oncologist to, to explain to them what their life expectancy is. Now, as a sidearm of that we do something else called RF ablation where we do image-guided --- image-guidance, usually with CAT scan.
We take a needle and we go down and usually individual tumors. You can treat up to three tumors in the liver. That’s, that’s okay based on what most of the literature says but typically it’s for one lesion but this can be done in the liver, the kidney, the lung. It’s also being done in bone and what you do is you take a needle under CAT scan guidance and go right down on a lesion just like you would a biopsy. We normally do that all the time but instead of just taking a biopsy, which we can do at that time, we then put out these tines, which come out almost like a mushroom, upside-down mushroom, and they actually burn the lesion and this is where we’re talking about cure here because in certain patients, in a lot of patients, that local lesion doesn’t come back.
So --- and that’s in up to 80 to 90 percent in most studies. The problem is if you’re treating a lesion that has spread to wherever you are, say the lung or the liver, there’s --- it doesn’t stop disease elsewhere. So those patients, if they get recurrence, it’s usually somewhere else in the liver or the lung, which we then potentially can either treat with RF ablation focally again or possibly chemoembolization now that there’s multiple lesions. So it’s really exciting and again, this is all done hand in hand with the oncologist as we move forward in our fight against cancer.
* * *