Updated: Mar 10, 2019
Our interventional radiologist guests cover what tools you need to get started with pressure directed therapy in Y90 radioembolization; as well as different clinical scenarios to consider when preparing for your next hepatocellular carcinoma procedure.
The BackTable Brief
Having performed over 200 pressure directed procedures in hepatocellular carcinoma, Dr. Nutting uses Surefire’s guide catheter and proprietary microcatheters when working with the Surefire Infusion System.
The Surefire microcatheters come in multiple sizes and lengths depending on sub-segmental, segmental, or lobar treatment locations. The 025M delivery system works in small (2-4 mm) vessels for selective treatments, and the 025L system is appropriate for larger (4-6 mm) vessels in lobar treatment. The microcatheter usable lengths range up to 150 cm to support a trans-radial approach.
A pressure directed device can help increase control of the delivery agent, reduce chance of reflux, and drive embolic therapy deeper into the tumor.
Learn more about when to use pressure directed therapy in our last article.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Guide catheters and microcatheters that complement the Surefire Infusion System
“I've only used the Surefire catheter a handful of times, and a couple of those times were in training. What do you think of the actual usage of the catheter? So what I mean is, typically if we talk about tools for a second, since it is a tool ... we go in with a Five French Tig through the groin, or if I'm doing a treatment I go in radial, and I use some other catheter, a SOS, or if I'm going radial, I use a Sarah, and then I'll go microcatheter through that.
How do you find the actual tools themselves? Because I know that I asked some folks, and sometimes people complain that the catheter is big, or it's stiff, or it doesn't track, and also complain that you have to use the microcatheter that's supplied by surefire. I'm just curious to know what your experience is.”
“...So I've performed probably a couple hundred procedures with the Surefire devices and different iterations. I think with the precision microcatheter, if I know that I'm going in to do a pressure-directed therapy with radioembolization or drug-eluting beads, then I would use their proprietary guide catheter from the beginning. It's Five French, it'll fit through a Five French sheath, but it's got the larger ID.”
“What's the shape of it?”
“I tend to use a Sim 1.”
“Oh, so they have a whole array of proprietary microcatheters, got it. Okay.”
“Yes. So they have a C2, a SOS-like, and a Sim 1, and I tend to do most of my liver-directed therapy with a Simmons 1 shape reverse-curve catheter. And I think with the latest generation, the 021 precision catheters, it is very trackable over a wire, and it doesn't change my workflow if I know I'm gonna be using that from the beginning; then I'll use their guide catheter. There is a two to four millimeter device deployment, so it does work in small vessels, and I've been able to use that segmentally, sub-segmentally, and lobar.”
“Okay. And I guess my other question - because this is something that I started to think about over the course of the last week as we prepared for this discussion - you know, you have to purchase the guide catheter separately, is that right? They don't come packaged with microcatheters?”
“I believe that's true.”
“Okay, so for anyone that wants to try to use this, certainly, I'm sure the Surefire reps will let you know, but just keep in mind that you're gonna wanna have both the guide catheter and the microcatheter available to you.”
Sizing your Surefire catheter deployment for unique HCC clinical scenarios
“...what do you find, if you're parked in a lobar distribution, let's just say in the main right proximal to the take-off of the cystic? Do you find that the catheter is still occlusive enough, so to speak, to change perfusion? Particularly in a guy - let's just make it easier - a guy who's got a hypertrophied hepatic artery because he's got portal vein thrombosis, and you wanna do a lobar right, with a pretty large diameter, in the right hepatic artery.”
“Knowing that from the beginning - probably from doing a mapping/study/CAT scan - I would choose the larger device; they are diameter-dependent devices with smaller and larger, and then there's actually a larger second-generation device that you can use in the right hepatic artery. But I would say, sizing, we've been able to treat some of the larger vessels with the four to six millimeter device.”
“And then, obviously, the smaller ones with the smaller device. I just would say that I haven't had a vessel that was too large to be able to use the device if it was appropriately sized.”
“Yeah, that's kinda my question, you know, sometimes - and I think that could be another area where this might be beneficial, because I've certainly been in a case where the guy's got a larger diameter vessel, and you've really got no control. I use a tuohy Cantata a lot of times, but you've got no control over where that tip is gonna be located within the vessel. And so if you believe in differences in laminar flow through one of these hypertrophied vessel, you've got even less control over whether or not it's gonna go to the tumor. So I think that's actually probably another exciting area where this could be applied.”
Dr. Charles Nutting is a practicing interventional radiologist with RIA Endovascular in Denver, Colorado.
Dr. Nainesh Parikh is a practicing interventional radiologist with Moffitt Cancer Center in Tampa, Florida.
Cite this podcast:
BackTable, LLC (Producer). (2017, November 5). Ep 16 – Pressure-Directed Therapy in Y90 [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.
The podcast referenced in this article was sponsored by Surefire Medical.