0:00

So look at the background as it relates

0:03

to track embolization, which is a key protective

0:06

concept that we'd like to unpack.

0:09

So let's get embolization at a glance. So what

0:12

exactly is an embolization, of course, we've heard

0:15

of an embolization and what it is is reduction of blood

0:18

flow or obstruction of blood flow and

0:21

usually it's by injecting some sort of including agent.

0:24

Of course, we have heard about embolizations in

0:28

the vascular setting. What about the non-vascular setting?

0:31

The vascular setting is where there's high

0:34

volume Arturo or even low volume venous

0:37

bleeds their settings where there's tumor

0:40

blood supply that we may aim to block off

0:43

as well. But in the non-vascular setting which

0:46

is really the focus of our talk today. The goal

0:49

is to prevent bleeding from biopsy tracks.

0:53

Every successful biopsy that we perform technically

0:56

the question is is there a risk

0:59

for bleeding that we could have prevented in the

1:02

setting of complications that do and can result.

1:06

A preemptive mitigating technique is often

1:09

very much warranted and that is tracked

1:12

embolization, which we will impact.

1:15

So what are some substances that are used in iron embolizations?

1:19

broad Strokes

1:21

They're highly varied in terms of the different materials. We can

1:24

have liquid embolics. We can

1:27

particle we can have coils.

1:30

But the indications for what we use very depending on

1:33

where they're we're in the blood vessel in the vascular setting or

1:36

in the non-vascular setting again, which is

1:39

the focus of what we're discussing today. It could

1:42

be related to the specific condition that we're treating or if

1:45

we want to achieve a temporary occlusion or

1:48

a permanent occlusion.

1:51

So in nonvascular biopsies the most common embolics

1:54

include mechanical coils.

1:56

Either little platinum or stainless steel

1:59

coils that are deployed through non detachable

2:02

mechanisms, which is typically how

2:05

they're pushed directly into the site through and

2:08

introducer of some sort. And these coils are

2:11

used to damage the vessel intima

2:14

and cause and promote platelet activation oftentimes

2:17

in the case of non-vascular biopsies.

2:20

These coils are placed into the track, of

2:23

course and wherever there is a tract of

2:26

damage vessels and capillaries and tissues where

2:29

there's oozing these coils provide a

2:32

scaffold in order for platelets to aggregate

2:35

in similar fashion gel form particulates gel

2:38

foam is an agent that is

2:41

on the temporary side as it relates

2:44

to involics. It's typically absorbed and

2:47

begins being absorbed within minutes, but it creates

2:50

a micro environment really to promote and support from

2:53

this formation and it's something that we're going to talk about.

2:56

in a bit

2:57

One of the things we want to know is when do we perform embolization

3:00

for biopsies interventionalists diagnostic Radiologists

3:03

when they are performing embolization of

3:06

a biopsy track, it's important that this particular

3:09

setting that in any sort of situation where

3:12

there's concern for bleeding after

3:15

the fact that this is

3:18

a technique that's employed.

3:20

Intra procedurally. So what we want to think is

3:23

stitch in time saves nine. So if there's any chance that

3:26

bleeding could be exacerbated in

3:30

this particular setting or pronounced or

3:33

something that's high risk in this setting we

3:36

want to ensure that we perform in embolization of our

3:39

tract and what are some reasons for this performing a

3:42

biopsy of the tract. They can be broken down into lesional

3:45

factors procedural factors or patient factors.

3:49

So let's discuss some lesional factors. These would

3:52

be characteristics specific to the

3:55

lesion in question.

3:56

Perhaps we're in an environment where there is

3:59

particularly high density of

4:02

vasculature. The spleen would be an example of this or the

4:05

kidney where there are quite a number of vessels Regional

4:08

to.

4:10

The site of biopsy if this is

4:13

the case if the mass is located proximal to a

4:16

major blood vessel, for example, if the site is

4:19

in a highly vascular or organ again, like the spleen or

4:22

the kidney then we want to be thinking

4:25

that yes. This is a setting when we

4:28

may want to consider attract embolization.

4:30

And then their procedural factors where the aspects

4:33

of the biopsy itself May predispose the patient to post procedural

4:36

bleeding. These would be settings. We're using a large engage needle

4:39

a 16 versus an 18 gauge or 20 gauge.

4:42

For example, instead of taking three passes with an

4:45

18 gauge. We've taken eight passes and these multiple

4:48

passes which the more times we pass our

4:51

needle to damage the tissues the higher the risk of

4:54

bleeding perhaps we're actually instead of taking and introducer within

4:57

Striking Distance of the lesion in question. We are

5:00

opting to use

5:01

Just the biopsy needle again through the skin through the

5:04

soft tissues into the lesion of Interest taking our sample

5:07

back out of the patient.

5:09

Harvesting the sample back in the patient so that non-cog

5:12

sale technique would actually provoke a

5:15

high risk of bleeding.

5:16

In the case of a cutting needle much better for

5:19

the solid lesions, but can

5:22

be particularly higher risk given

5:25

how aggressive they are to the

5:28

tissues in question.

5:30

So what about patient factors?

5:32

These would be characteristics that predispose the patient to

5:35

bleeding in the setting of percutaneous biopsy. What would

5:38

be the elephant in the room? That would be coagulopathy. What would

5:41

be those things that would make a patient more prone to

5:44

bleeding? Well if you guessed if a

5:47

patient's on antiplatelets

5:50

Perhaps yes, they may be an aspirin a baby

5:53

aspirin for example would be something that yes, even

5:56

in the baby aspirin's form that can promote high

5:59

risk for bleeding perhaps the patient is

6:02

on anti-coagulation low molecular weight

6:05

Heparin or perhaps they're on Direct anticoagulants

6:08

in those particular setting

6:11

those direct oral anticoagulants that would

6:14

increase the risk for bleeding in the setting of a biopsy

6:17

in the case of patients that have thermocytopenia low

6:20

platelets less than 75 or 50,000 that

6:23

could also increase the risk for bleeding. There

6:26

are patients who have conditions such as

6:29

end stage renal disease where there's high blood

6:32

urea nitrogen levels that result in platelet dysfunction

6:35

individuals that are hypothermic cold

6:38

also results function or

6:41

individuals that have liver disease in case

6:44

of liver disease low from religion levels

6:47

would be great markers less than 150.

6:50

Than 100 vibration markers of coagulopathy in

6:54

the setting of a patient with liver disease hematologic malignancies

6:57

patients with pansytopenia. For example,

7:00

thrombocytopenin would be one of those characteristics in

7:03

this patients parent cytopenia, which of

7:06

course by Nature what increased the risk for bleeding and

7:09

then there's uncontrolled hypertension, whereby if

7:12

there's high pressure in the

7:15

blood. Of course, if we were to damage those vessels, they would

7:18

be harder to achieve hemostasis in