Up close
No longer just behind the scenes, radiologists now offer innovative therapies
by Kathleen Phalen Tomaselli
Not long ago, open surgery was the only treatment option for many patients suffering serious illness. But today, with the help of doctors known as interventional radiologists and neurointerventional radiologists (who specialize in head, neck and spine conditions), a growing number of less-invasive procedures can successfully treat even complicated conditions. Unlike most radiologists who interpret images behind the scenes, these uniquely trained doctors get up close with patients. Interventional radiologists can insert chemotherapy directly into a patient's tumor, dislodge a stroke-causing blood clot, and even repair a damaged artery.
"We are now becoming an integral part of the medical and surgical management of many patients who have vascular disease, cancer, stroke and many other conditions," says Michael Dake, M.D., chair of UVA's Department of Radiology, which has two divisions and several radiologists devoted to interventional procedures. "It may seem like there has been some sort of burst on the scene. But it's been a slow evolution of less invasive, more convenient procedures," he adds.
Here are some of the conditions now treated by interventional radiologists with less-invasive techniques:
liver tumors
Chemotherapy is a critical treatment for cancer, but traditionally has involved dosing the entire body with powerful chemicals intended for the tumor. But interventional radiology is changing that. "We can inject chemotherapy directly into the arteries that supply tumor(s) in the liver. This ability to be very selective injecting the chemotherapy allows us to get very high concentrations of drug into the cancer, without having high doses circulating to other parts of the body," says J. Fritz Angle, M.D., director of interventional radiology at UVA. "This therapy has been around for many years, but recent advances in the drugs we have available to inject, and the accuracy we have in placing the drug, have further improved our results and minimize complications."
For even more precise results, UVA doctors were among the first in the nation to employ the Artis Zeego® system-an imaging system that can create high quality 3-D images during a procedure. "Zeego gives new insight into where to inject the chemotherapy," Angle says. "We can also inject radioactive particles into the artery supplying the tumors in the liver. This ability to be precise allows us to put very high radiation doses into the liver tumors without irradiating any of the surrounding structures."
uterine fibroids
While not an option for all women with uterine fibroids-noncancerous tumors that grow within the wall of the uterus-a procedure called embolization can be an alternative to hysterectomy. "Although hysterectomy is a tried-and-true cure for fibroids-and is the best approach for some women-it does have its drawbacks," says Alan Matsumoto, M.D., a UVA interventional radiologist. "Uterine fibroid embolization (UFE) is a less-invasive, low-risk alternative that spares the uterus while offering very good results."
During the procedure, plastic particles-the size of sand grains-are injected through a hollow tube to block blood flow to the fibroids. Without blood supply, the fibroids begin to die. "Although we have been doing this procedure for 11 years, UFE is now fairly common worldwide," Matsumoto says. "One advantage: women are back to work in one to two weeks versus six."
deep vein thrombosis
Every year, millions of Americans are affected by deep vein thrombosis (DVT)-a blood clot forming in one of the major deep veins of the lower legs. This clot can block blood flow, causing pain, swelling, loss of limbs and even death if the clot breaks loose and travels to the lung.
"Exercise and weight loss is the best prevention," says Ulku Turba, M.D., a UVA interventional radiologist. "Once DVT or pulmonary embolism (a sudden blockage in a lung artery) develops, blood thinning agents are used for approximately three to six months," Turba says. "But if the clot is large, the problem recurs, or the patient can't take blood thinners, the interventional radiologist steps in." These doctors can insert small metal filters into the vein to prevent the clot from moving from the legs to the lungs. These filters are inserted through a small hole-about the size of a pencil point-in the groin or neck vein; the procedure takes about 15-30 minutes and the patient can go home in two to four hours. In addition, with the use of a small plastic tube placed by an interventional radiologist directly into the blood clot, a blood clot-dissolving drug can be delivered directly to the clot and melt the clot away to allow the return of normal blood flow more rapidly.
aortic dissection
This is a condition in which there is bleeding into and along the wall of the aorta (the major artery from the heart). This most often occurs because of a tear or damage to the inner wall of the artery. Although aortic dissection can affect anybody, it is most often seen in men 40 to 70 years old. In the most severe cases, vital organs are starved of blood. The dissection is abrupt and severe. The pain-in the chest, the middle of the back or down the spine-is searing. Previously, surgical intervention for complicated dissections was the only option. But now, interventional radiologists and surgeons work together to insert a stent (a tiny, plastic cloth-covered expandable coil) to get the aorta to come back together. "This requires a team approach," says Dake. "These patients are complicated and intervention requires a lot of experience. Some centers may not have the experience to handle this; but we have a team here at UVA with broad experience."
blocked leg arteries
The main treatment for patients with long occlusions-blockages-in leg arteries has been open surgical bypass and this is still the best option in certain situations. However, for patients who are not good surgical candidates, endovascular techniques may offer another option. During an endovascular procedure, an interventional radiologist inserts a catheter (small hollow tube) containing medications or miniature devices into a blood vessel.
Endovascular interventions are becoming quite common for these occlusions and have a high success rate-over 95 percent. "In our interventional radiology division, an unsuccessful procedure to open an occlusion, regardless of the length, is extremely rare," says Bulent Arslan, M.D., a UVA interventional radiologist. "Since we are a referral center, many of our patients have the most severe degree of occlusions and associated problems. Many are considered untreatable in other places and given the option of amputation only."
The procedure is usually performed by passing a wire through the blocked segment of the artery, and then opening the artery using one of several devices. "There are several new devices, including stents and lasers that are covered and may help to prevent the blockage from coming back," Arslan says. "There have been significant improvements in the size of these devices as well. Smaller devices now make percutaneous (through-the-skin) use easier and make for a faster recovery for the patient."
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This article appeared in the Fall 2008 issue of Vim & Vigor, a family health magazine sponsored by UVA Health System. If you don't already receive it at home, sign up today. It's free.