Interventional Radiology

Staff Writer
Columbus CEO

Kate Hackett was 18 when she was diagnosed with a massive deep vein thrombosis and two pulmonary embolisms. Interventional radiology (IR) saved her life.

"After an ultrasound revealed that I had a blood clot blocking all circulation in my right leg, I was admitted into the hospital," Hackett says. "That night, I had a CT scan and was diagnosed with the two pulmonary embolisms."

Doctors from Riverside Radiology and Interventional Associates extracted the clot and placed a filter in the inferior vena cava to protect Hackett against further embolisms.

Hackett spent about a week in the hospital, and three of those days were spent in ICU. But recovery was rapid. Four weeks after her life-threatening illness, she competed for a spot on the Miami University rowing team and made it into the top boat. "I was extremely lucky to have IR as a resource during my illness," she says.

Successful outcomes like Hackett's help explain why interventional radiology has become a thriving subspecialty in modern American medicine. Radiologists used to be the docs who deciphered mysterious X-rays so that other doctors could design a treatment plan. X-rays still play a major role in medicine. But with so many new imaging modalities at their fingertips, radiologists have branched out and are treating patients from initial diagnosis to the final all-clear.

In many cases, doctors no longer need to cut into a patient to assess what may be going on inside. With the use of computer tomography, or CT, scans, magnetic resonance imaging and ultrasound, radiologists can identify problems without ever picking up a scalpel.

Central Ohio, a center for both scientific and medical research, is at the forefront of many IR technologies. Here's a look at some of the ways interventional radiology is making a difference.

Cardiovascular Health

The development of imaging technology and related tools has improved stroke treatment significantly. Doctors can locate a clot and, using a tiny corkscrew-like device, retrieve the clot before it causes permanent damage or death. The window for successful treatment has been expanded from three hours to eight. With thrombolysis, clot-busting drugs can be delivered directly to the site of a clot.

It's not just emergency situations that call for radiological procedures. Dr. Mark Dean of Riverside Radiology and Interventional Associates can map the circulatory system using angiography, and open up narrowed arteries using angioplasty. "We use X-ray guidance to show us where the arteries are open and where they are narrowed or closed," Dean says.

When a problem is detected, the doctor inserts a tiny balloon into the artery. The balloon is encased in a collapsed metal tube called a stent, which expands when the balloon is filled with fluid. Once the balloon is deflated, the stent remains in place, providing an open pathway for blood to flow.

Dean says the results of angioplasty are particularly remarkable in patients who have suffered from blocked arteries in the legs. "When you restore that blood supply, they want to get up and get moving," he says. "Even sitting becomes easier, because they no longer have to shake their legs to restore blood flow."

Varicose veins can also impede circulation. Instead of blockages, the blood vessels may have faulty valves that allow too much blood to remain in the legs. This can cause discomfort, fatigue, ulcerated skin and swelling.

Dr. Stephen Jung, an interventional radiologist with Radiology Inc., a practice affiliated with Mount Carmel Health System, says problems with varicose veins creep up slowly. "Most people who have venous disease don't experience excruciating pain all of a sudden," Jung says. "It's an insidious process."

It used to be that a surgeon had to strip out the vein that was suspected of causing the problem, but surgery was painful and often didn't solve the real problem. With the use of radiology, doctors can observe how blood is flowing in the veins.

At the Vein Center at Highfield, jointly operated by Radiology Inc. and Mount Carmel, "We go in with ultrasound, visualize what the problem is, and find out exactly what vein to treat," Jung says.

The doctor inserts a probe into the vein at the groin or behind the knee. It is maneuvered to the source of the problem, and using heat in the form of a laser or radio frequency ablation, the vein is sealed. The circulatory system adapts easily and the blood continues flowing through other veins. In the old days, vein stripping meant a day or two in the hospital, but now patients go home the same day and can be back at work the next day.

Cancer Treatment

Interventional radiology is rapidly becoming a fourth front in the war on cancer, alongside surgery, chemotherapy and radiation.

Dr. John Lippert, an interventional radiologist and oncologist with Riverside Radiology and Interventional Associates, frequently employs IR in treating liver cancer. Because the liver produces proteins that humans need to survive, it can't be removed, and it can't be irradiated beyond repair. The solution: Go into the liver and kill the tumors at their source.

"If I can see the mass, I can target it," Lippert says. "We treat the tumor but spare the surrounding tissues." When only one mass is present, Lippert uses ultrasound or a CT scan to locate the tumor, and a probe to deliver heat or cold so extreme that the tumor cannot survive it. Microwave ablation and radiowave ablation both deliver temperatures of up to 100 degrees Celcius--the boiling point of water.

Cryoablation blasts the tumor with temps dipping to -40 Celcius. Argon gas is used to freeze the tissue, and helium thaws it, all through a tube the size of an IV. No surgery is needed, because the body naturally breaks down the dead cancer cells. The procedure takes about an hour, and the patient heads home that day or the next.

When many small masses are present, Lippert employs chemoembolization. "Tumors tend to get most of their oxygen from the arteries, but the liver tends to get most of its oxygen from the vein," Lippert says. By putting chemotherapy drugs directly into the artery, doctors can attack the tumors and cut off their oxygen and nutrient supply, while not disrupting the flow to the rest of the liver. Chemoembolization patients generally stay in the hospital overnight and experience fatigue for a couple of weeks and some liver pain for about one week.

Another technique, called radioembolization, implants tiny radioactive beads directly into each tumor. Over the course of a few months, the tumor begins to scar and shrink. At about 25 microns in diameter, the beads are narrower than a human hair, but they pack a lot of power, often working when other treatments have ceased to be effective.

Patients go home the day of the procedure and may experience general fatigue, but Lippert says, in general, the procedure is very well tolerated.

Dr. Jonathon Lee, a nonvascular interventional radiologist with Riverside Radiology and Interventional Associates, uses radiofrequency ablation to treat kidney cancer without surgery.

A needle is inserted directly into the kidney. High temperatures are applied to the affected area, and while the tumor literally boils within the patient's body, the massive volume of body-temperature blood continually rushing through the organ keeps the rest of the kidney operating as normal. In about three minutes, the tumor has been killed, and the kidney has suffered little or no collateral damage.

"This leads to a cure with the same rates as surgery, and it has very little impact on the kidney itself," Lee says.

With surgery, a 20-year-old patient could expect four to six weeks of recovery time. With radiofrequency ablation, the patient will be home within hours, and back to work within two days. "Except for a Band-Aid on their back, they can't tell anything has been done," Lee says.

Radiology also makes many exploratory surgeries unnecessary. "It used to be that if you had a tumor in your liver, lung or anywhere, you had to cut it out to figure out what it was," Lee says. With today's minimally invasive biopsies guided by radiology, a needle is often all you need.

Managing Pain

Interventional radiologists can use intradiscal electrothermal therapy, or IDET, to treat chronic back pain caused by degeneration of vertebral discs. Thermal energy is applied to tissues that are causing the pain, and the carefully controlled heat kills selected nerve fibers and shrinks collagenous tissue.

Broken bones cause considerable pain. Some people grow more susceptible to fractures as they age and osteoporosis causes bones to become porous and weak. Dean says patients who experienced a major break used to lie in bed in a brace for six months, on heavy meds to manage the pain. "Sometimes, at the end of all that, we'd find out they were no better off," he says. "They hadn't healed because their bones were just too soft."

Today doctors are using radiology to assess bone structures, and a special cement to fill the porous bone and repair the fracture. In about 20 minutes, the cement hardens and the bone is strong again. The hips, wrists and spine are the most commonly cemented areas.

Doctors still brace patients and give them a chance to heal on their own. But some can't tolerate the pain meds, or the medication doesn't make the pain bearable, so they opt for the cementing procedure. "In about an hour, all their pain is gone," Dean says.

Pediatric Applications

Radiology is also being used to treat disorders commonly discovered in childhood.

Dr. William Shiels, chief of radiology at Nationwide Children's Hospital, is a leader in the treatment of lymphatic malformations. In addition to veins and arteries, the vascular system includes another set of vessels that carry plasma, the yellow component of blood. These lymphatic channels are part of a network that covers the entire body. But sometimes, in utero, the vessels form clusters instead of proper channels. The plasma can't return to the heart to keep circulating, and it collects and forms fluid-filled cysts.

"Instead of branching into tubes, it looks like a honeycomb," Shiels says. Three years ago, he pioneered a new, minimally invasive procedure to correct the problem permanently. Using ultrasound and a specially developed dye, Shiels aspirates the fluid in each cyst and fills the space with a drug that kills the lining. The dye allows the doctor to differentiate between fluid (black) and drug (white).

The needle is so small that the procedure leaves a scar no larger than a freckle, Shiels says. The procedure generally takes about an hour, and the drug injected into the cysts may cause some stinging for about two hours. Doctors from around the world have visited Columbus to learn the technique, and Shiels will present it at a European conference in May.

The same procedure and the same drug--doxycycline, which has been used to treat staph infections, acne and now lymphatic malformations--can also be used to treat debilitating bone conditions.

For example, an aneurysmal bone cyst eats away at a bone from the inside, causing it to balloon and become as thin as an eggshell. The traditional treatment involved scraping out the affected cells, applying a bone graft and hoping the disease didn't regenerate and destroy the bone graft. Surgery failed 71 percent of the time, Shiels says.

Now with ultrasound guidance, doctors can insert a needle into the bone and deliver a dose of doxycycline that's lethal to the cyst. What's more, Shiels says, the doxycycline somehow signals the body to spur bone growth. New bone becomes visible on X-rays within a few weeks, and bones start to return to their normal shape. After the first treatment, the patient's pain is gone, he says. Shiels says patients are advised to eat a high-calcium diet, "be careful and live a normal life."

Sometimes doxycycline seems nothing short of a miracle drug. Shiels recalls a 4-year-old boy who had been confined to a wheelchair. "He got his first treatment in October, and by Christmas Eve, he was out of the wheelchair," Shiels says.

Reproductive Health

Interventional radiologists perform procedures that treat infertility and other reproductive health issues in both men and women.

One IR technique is useful in treating enlargement of the prostate gland. "Almost all men, if they live long enough, will experience this," Riverside Radiology's Dean says. "The prostate grows larger and will interfere with urination."

Fortunately, treatment is simple. "We go in through the arteries, close off the primary artery to the gland, and the gland begins to shrink on its own," Dean says. Tiny beads, each the size of a grain of sand, are deposited. "That clogs up the arteries so normal nutrients can't get through," Dean says. The process allows the gland to shrink enough that urinary function is restored, but not so much that sexual function is affected.

A blockage of the fallopian tube is a common cause of infertility in women. Imaging technology is used to find the blockage and a catheter opens the pathway. In males, tangled blood vessels in the testicles can cause infertility. The troublesome blood vessel can be embolized, causing it to shrink, which often restores fertility.

In women, the same procedure can be used to eliminate the blood flow to uterine fibroid tumors, which can cause pain and heavy bleeding. A catheter is inserted into the artery feeding the tumor, and the artery is sealed. With the blood supply cut off, the tumor shrinks.

Perhaps in a few years, Kate Hackett, whose own life was saved by interventional radiology, will be using some of the same techniques--or new ones yet to be developed--to save other lives. Now 20, Hackett is a pre-med student at Miami University. Her dad is a physician and her mom is a nurse, so she's known since kindergarten that she wanted to go into medicine. Her recent life experience has altered that path slightly, though.

"Becoming an interventional radiologist is now my dream job," Hackett says. "I think that the work that they do is so rewarding and fascinating."

Kristin Campbell is a freelance writer.

Reprinted from the April 2011 issue of Columbus C.E.O. Copyright © Columbus C.E.O.