Trends in embolisation

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Two of the three directors and organisers of GEST USA, Jafar Golzarian, USA, and Marc Sapoval, France, told Interventional News about some of the key trends that they saw emerging from the meeting in San Francisco, USA.

“Embolisation is a critical part of an interventionalist’s armamentarium. It is absolutely essential. It has come of age practically in a wide variety of indications, for example, gastrointestinal haemorrhage. It is also clearly of value in its incarnation as chemoembolisation and radioembolisation in the treatment of liver tumours.The main thing we have to do is to demonstrate its value in prospective randomised, controlled trials. We have to demonstrate it clearly to the people who pay the insurance companies and the Government, not just to the people who might refer to us, because if you perform a procedure that does not get reimbursed, then it will no longer be performed. So yes, it has come of age in practical terms, but we have to demonstrate its value in real evidence-based terms for some procedures so that people outside of interventional radiology recognise this,” said Matthew S Johnson, USA.

Expanding role of imaging for embolisation

 

GEST USA 2010 saw that imaging was becoming a key part of all aspects of embolisation. Sapoval said, “The expanding role of non-invasive imaging in embolisation in general, covers both the pre-intervention work-up (especially in acute patients, including trauma, upper or lower gastrointestinal bleed, and haemoptysis) and the role of per intervention image guidance, including cone beam CT and fusion imaging. Imaging also plays an essential role in better understanding the outcome of treatment after embolisation, especially in cancer patients.

“We have been hearing about this for many years, but you do get the feeling from the research and presentations here that there is a global trend, even if you do not have very precise figures that there is an overall consciousness about imaging techniques,” he said.

 

“I think the cost of imaging is not really known. When we are talking about pre-imaging in acute bleeding patients, the costs are very difficult to consider because patients are dying and a large number of health resources are needed in a short period of time.”

 

“It is different when you talk about cone beam CT, as this has to be considered, when you buy an angio facility and you need to have additional software, and a flat panel detector, so the system costs more. Up to now, there is no evidence that the additional cost for hospitals or healthcare systems is justified. I believe that it is, at least in some cases, because it is known that in a patient with hepatocellular carcinoma, when you do transarterial chemoembolisation, you can find new lesions with this type of imaging and this alters the way you work, so it is highly likely that it is related to the survival of the patient,” he said.

Combining materials is on the rise

 

From GEST USA 2010, it has also become clear that the age of puritanism when it comes to the choice of embolic agents is rapidly collapsing. Today’s interventional radiologist has to master the characteristics of a wide variety of materials and also learn to use them in combination with one another to obtain the optimum results. “In our training and daily work, we are now becoming increasingly convinced that there is a place for combining materials. By knowing more about the specifics of each material we can take the combination to a better level. In embolisation for abdominal wall bleeds, trauma or gastrointestinal bleeding, sometimes the lesions should be treated with a combination of coils, gelfoam, or particles. Dr (Robert) White, Dr (Lindsay) Machan and Dr Hunter, in different talks and case presentations, have shown their results of using a combination of coil and sclerotherapic agent to treat varicocoeles. Previously, most IRs used to treat varicocoeles with coils. With more understanding of the vascular system, and rising cost-awareness, we see that leaders in the field are using a combination of materials by placing one or two coils distally in the spermatic vein to prevent the sclerotherapic agent from affecting the testes. They then use sotradecol to embolise all the collaterals and then finish, perhaps, with another coil.

In this way, you use fewer coils, so it is less expensive and still shows a great result,” said Golzarian.

GEST USA has international faculty

 

Both Golzarian and Sapoval emphasise that GEST USA is one of the only meetings to have over 20 faculty members from Japan and other countries in the Far East. This adds value due to the exchange of experience, they say.One important observation that Golzarian and Sapoval share is that the international aspect of GEST‰ÛöUSA 2010 translates to a huge educational value. “The different types of disease and methods employed to treat them in the East and West are complementary. For instance the hepatocellular carcinoma that the Japanese patients get is mostly due to hepatitis whereas a similar disease in Europe would be mostly cirrhotic, and so it is interesting to confront the differences in approach the treatment of the lesions,” said Golzarian.


Added Sapoval: “What is interesting, more generally, is that we can share the experience of people who have perhaps 10 times the number of patients that we regularly have. This is very striking for some attendees. In the Western world, an interventionist may consider himself an expert if he does 50 cases a year, but some of our fellow interventionists in the East perform something like 500 cases a year. You can really learn a lot from someone like this, if he understands his experience well, and communicates it well. There is definitely complementary input. There are also interesting differences in the manipulation and preparation of certain embolic materials, particularly gelfoam. We see that there are several different approaches and experiences which are specific to different countries, and this is new for other delegates and becomes an important teaching point,” he said.