text:
let me show you a case of massive PE
this launched our pert pert PE response team 30 year-old man transcranial resection of a pituitary tumor post-op seizures intracranial frontal lobe hemorrhage okay so after his brain surgery developed a frontal lobe
hemorrhage and of course few days after that developed hypotension and hypoxia and was found to have a PE and this is what the PE look like so I'll go back to this one that's clot in the IVC right there and
that's clot in the right main pulmonary artery on this side clot in the IVC clot in the right main pulmonary artery systolic blood pressure was around 90 millimeters of mercury for about an hour he was getting more altered tachycardic
he was in the 120s at this point we realized he was not going the right direction for some reason the surgeon didn't want to touch him still to this day not sure why but that was the case he was brought to the ir suite and I had
a great Mickey attending who came with him and decided to start him on pressors and basically treat him like an ICU patient while I was trying to get rid of his thrombus so it came from the neck because I was conscious of this clot in
the IVC and I didn't want to dislodge it as I took my catheters past it and you see the Selective pulmonary and on selective pulmonary angiogram here and there's some profusion to the left lung and basically none to the right lung
take a sheath out to the right side and do an injection that you see all this cast of thrombus you really see no pulmonary perfusion here you can understand why at this point this man is not doing well what I did at this point
was give a little bit of TPA took a pigtail started trying to spin it through aspirated a little bit wasn't getting anywhere he was actually getting worse I was starting to feel very very nervous I had remembered for my AV
fistula work that there was this thing called the cleaner I don't have any stake in the company but I said you know I don't have a lot to lose here and I thought maybe this would be better than me trying to spin a pigtail through
the clock so the important thing about the cleaners it does not go over a wire so you have to take the sheet out then take out the wire then put the cleaner through that sheath and withdraw the sheath
you can't bareback it especially in the pulmonary circulation the case reports are poking through the pulmonary artery and causing massive hemorrhage and the pulmonary artery does not have an adventitia which is the outer layer just
a little bit thinner than your average artery okay so activated it deployed it and you started to get better and this is what it looked like at the end now this bonus question does somebody see anything on this this picture here that
made me very happy on this side this picture here that made me feel like hey we're getting somewhere I'm sorry the aorta the aorta you start to see the aorta exactly and that that was something I was not seen before the
point being that even though this doesn't look that good in terms of your final image the fact that you see filling in the aorta and mine it might have been some of the stuff I had done earlier I can't I can't pinpoint which
of the interventions actually worked but that's what I'm looking for I'm looking for aortic blood flow because now I've got a hole in that in that clot that's getting blood flow to the left ventricle which starts to reverse that RV
dysfunction that we were concerned about make sure I'm okay with time so we'll
the traditional three pillars are
surgical medical and rad honk which actually was once part of radiology and separated just like interventional radiology has and where is the role for this last column so many patients are not medically operable so if you set the
gold standard you know that the cure for someone has a primary liver mass well about 20 percent of patients who present can undergo resection what you do for the remaining portion so Salvage is what we offer when someone has undergone
standard of care and it didn't work how do we hop back in and try to see how much these folks it's low-risk it's not very expensive at all as compared to things like surgery and the recovery is usually the same date so
this concept here of tests of time is kind of interesting a lot of times when we look at a tumor let's say it's 2 centimeters it's not really the size of the tumor but it's how nasty of a player it is and it's
difficult to find out sometimes so what we do is we'll treat it using an IR technique and watch the patient and if they do well then we can subject them then to the more aggressive therapy and it's more worthwhile because we've found
that that person is going to be someone who's likely going to benefit you can use this in conjunction with other treatments and repeat therapy is well tolerated and finally obviously palliation is very important as we try
to focus on folks quality of life and again this can be done in the outpatient setting so here's a busy slide but if you just look at all the non-surgical options that you have here for liver dominant primary metastatic liver
disease everything that's highlighted in blue is considered an interventional oncology technique this is these the main document that a lot of international centers use to allocate people to treatments when they have
primary liver cancer HCC and if you see if you see at the very bottom corner there in very early-stage HCC actually ablation is a first-line therapy and they made this switch in 2016 but it's the first time that an
intervention illogic therapy was actually recommended in lieu of something like surgery why because it's lesions are very small its tolerated very well and it's the exact same reason why your dermatologists can freeze a
lesion as opposed to having to cut everything off all the time at a certain point certain tumors respond well and it's worth the decrease in morbidity so
you know the most common procedures in China this is kind of interesting I was blown away by this when I did the research on this I knew when I would go
into the hospitals and I was all over for I've been to Beijing shanghai nanjing to even the smallest little place is up in northern china and the one thing that blew me away I'm looking at the board and I'm seeing neuro case
after neuro case after neuro case I'm like it got 10 Narrows and and a pic line I'm like it's an interesting interesting Dysport of cases and the reason being is in China they consider diagnostic neuro
so neuro angio to be the primary evaluating factor for any type of neurological issue so you're not getting a CT if you come in with a headache you think you're gonna go get that cat scan now it's generally what not what they do
so you're talking about a case and I'll give you the case matrix of the break-up it's just proportionately high for a neuro very well trained in neuro and most of the guys that are trying to neuro very similar to what dr. well Saad
said a lot of the guys in Africa are trained in France so other neuro interventions have trained in France or lipstick in China and have received European training on that so you know the level of what they're doing some of
the stroke interventions some of the ways they're going after these complex APM's they'll Rob well anything you'll see here in the US so it is quite interesting to see and the second
largest is taste hepatocellular carcinoma is on the rise it's the highest level in the world is found in China and Korea for that matter and there's many reasons why we can go into it some of it is genetic factors and a
lot of societal factors alcohol is a very liberally lie baited in China and there is problems with you know cirrhotic disease and other things that we know could be particular factors for HCC so always found that very
interesting like I said I would go into a hospital and I'll see a PICC line a hemodialysis catheter and then 20 tase's on the board in one day so it is quite interesting how they do it and then biliary intervention stents tips and
then lung ablation you know the highest rates of HCC biliary cancer and lung cancer found in China and once again when we talk about lung cancer what are those contributing factors you're talking about certainly a genetic
component but mostly it's lifestyle factors smoking is prevalent in the US and in you know in Europe and in some areas in Asia we've seen obviously a big reduction in smoking which is fantastic China not so much you don't see that
it's a societal thing for them and unfortunately that has led to the the largest rates of cancer in the world in lung cancer so lung ablation is a big procedure for them over there as well so procedure breakdown this is kind of some
of that breakdown I was telling you about that cerebral procedure is some of the most commonly performed and you're talking about at very large numbers they're doing neuro intervention because they do it for die
Gnostic purposes and I would that kind of blew me away when I found out they do have cast scanners and certainly for trauma and things like that they'll do it but the majority of the stuff if you come in you have headaches you might end
up in the neuro suite so it's quite interesting how they can do that tumor intervention very high like I said you have the highest rates of HCC in the world you're getting cases they do have y9t available and in fact China just
made their largest acquisition ever with the by what you guys know a company they bought surtex there's a Chinese company now it got bought by China now the interesting is they don't currently have a whole lot of
y9t over there but they just opened up some of their own generators so they can actually start producing the white room 90 and I think you'll see probably a increase in those numbers of y9t cases but to date the number one procedure for
them is taste and they do a lot of them you know like I said on average a community hospital setting you might find 15 or 20 cases a day with three interventionalists so compared to what you guys do there's probably not many
people here unless you're working at a major institution that there's nothing but cancer doing 20 cases a day and I promise you're probably not doing it with only two interventionalists so it's amazing how fast and effective they've
gotten at and below therapy and unfortunately it is necessary because of those elevated HCC levels and like I said when we look at some of these things it's I go over there and I'm looking at the board there are very few
cases for you know PICC lines very few the frosted grams very new bread-and-butter abscess training procedures like we do here in the US they are very it's the prevalence is very simple it's neuro it stays and it's
biopsy and those are some kind of the big three for intervention in China and there it's such a large volume you get to learn a lot when you're over there and CLI PA D even though it's more prevalent in China than it is here
because smoking lifestyle factors certainly westernization of the diet in China which occurred since the 1950s and 60s has led to a lot of McDonald's and and fast food and things that weren't currently available prior to 1950s you
see a lot of PA d but it is very undertreated and certainly talking to some of my colleagues like whom are oh you'll get to see a little bit later on with CLI fighters one of the things that's kind of frustrating for them is
that it is so undertreated it's very common to see amputations in China instead of actually doing pipe in percutaneous intervention they normally like to go too far and you see a lot of amputation certainly above
normal so that's something I think as an interventional initiative when we look at these things coming from a Western perspective it's definitely something we need to pursue a little more aggressively but there it's very little
oh well you're talking about two you know two to three percent you know maybe up to six percent or PID cases very very low levels so equipment in equipment in
and then one more example just to sort of illustrate the idea of a heat sink or
a cold sink right so this patient has a mass in their left adrenal gland right next to the aorta it's just anterior to the kidneys so the problem here is if you put a microwave ablation probe right next to the aorta you're likely to burn
the aorta and if you want to point the microwave ablation probe directly at the aorta well there isn't really a good window for that right you would have to go through the kidney you'll go through bowel and on route to getting there so
really I elected to do cryoablation right so that's the mass that's the aorta so you're obviously worried about injuring any order you place two probes into the lesion they obviously are streaking us out right now but that's
the aorta right there so we are four millimeters away from the aorta with these two probes you would think you'd be concerned about damaging it but using that cold sink effect you can see how the ice boss actually carves around the
aorta so you can get a really nice ablation on to that structure with that Waring that you're damaging the aorta or any nearby big vascular structure now that doesn't happen with pancreas if you freeze into pancreas you're going to get
a pancreatitis and if you freeze into bowel your bowel is going to have a perforation so that really just is with blood vessels that you can do that
you can pretty much put plastic at the end of any word you want so if you read or plasti whatever but not ablation truthfully it doesn't sound right ablation oblast ISA so as was mentioned my talk today and beyond ablation I have just one disclosure but consultant for
btg ablation so I guess just a quick raise of hands how many people are due oblations where they work I would hope nearly everyone okay perfect so I'm trying to sort of direct us towards the the way the oblation med modalities work
rather than procedural but we'll show some case examples of of where we can use these the three dominant modalities as many of you know are gonna be the radiofrequency ablation which is the oldest most common one used previously
cryoablation and then microwave ablation I'm not going to talk so much about Ayari it's considered one of the ablation modalities but it's really not done as commonly with ir around the country so we'll start with
radiofrequency ablation I suspect that many of you who are newer to I or maybe haven't used much RFA and people who have been in IR for a long time have used it quite extensively what we know
Sean I know you have not seen these slides at all you wanted I John can talk about this with his eyes closed so it's
not like there's anything but this is the data that was published from the Jade publishing jvi are from what Sean has written and it's just the current standards relating to what you should be expecting what we tell our patients that
they should expect for outcomes as it relates to uterine artery embolization again I'm not really here to try to point this I know you can google these you can get the information yourself but just to say that all of our procedures
have risk and we need to be clear with our patients about them now I believe that with all of these risks combined the benefits of doing uterine fibroid embolization for most patients is far greater than the risk and that's why I
really do have my practice so these are the benefits right shorter hospital stay and I would say more cost-effective and that is really debatable because gynecologists have become smarter and smarter now they're doing like same-day
hysterectomies if you have a vaginal hysterectomy then maybe a UFE is not as cost-effective because they don't have to do an MRI beforehand and they don't get an MRI afterwards and do all of that anyway and if you look at the long-term
cost of that then maybe having a hysterectomy in some patients could be that but we know for sure that patients are more satisfied when they get a embolization procedure than in my MEC to me not in the beginning run because the
procedure can be very painful that is not the procedure itself is painful but post embolization syndrome which could last anywhere from five to seven days can can be very painful again this is the comparative data that was published
by dr. Spees who is our gold medal winner this year understand a lot a lot of work in this space has allowed us to have this conversation with our gynecology partners but also with our patients as we talked about like when
can you return to work how long are you going to be all for you know am I going to need extra child care or whatever how long would I be in the hospital this information helps us to inform our patients about that then on average
you'll stay in the hospital around you know a day or so and most uterine artery embolization procedures are same-day procedures and interventional radiologists are doing these in freestanding centers as well as other
providers without any issues so we're almost down to the end we know that fibroid embolization is proven to be an effective and durable a procedure for controlling patient symptoms it's minimally invasive and it's outpatient
most patients can go back to some normal activity in one to two weeks it has a low complication rates and some patients mein neatest to surgery and should have surgery so in our practice we send around 1/3 of our patients or so to
surgery and the reason that that is that high is that patients are allowed to come and see myself or dr. de riz Nia from the street they do not have to be referred from their gynecologist and so they're just coming from the street then
you will be referring them to a gynecologist because of some of the things that may not make them a good candidate for embolization such as this
next is me talking about Egypt and Ethiopia and how I are how IRS practice in Egypt and Ethiopia and I think feather and Musti is gonna talk a little bit about Ethiopia as well he's got a
lot of experience about in about Ethiopia I chose these two countries to show you the kind of the the the the difference between different countries with within Africa Egypt is the 20th economy worldwide by GDP third largest
economy in Africa by some estimates the largest economy in Africa it's about a hundred million people about a little-little and about thirty percent of the population in the u.s. 15 florist's population worldwide and has
about a little over a hundred ir's right now 15 years ago they had less than ten IRS and fifteen years ago they had maybe two to three IRS at a hundred percent nowadays they're exceeding a hundred IRS so tremendous gross in the last 15 years
in the other hand Ethiopia is a very similar sized country but they only have three to five IRS that are not a hundred percent IRS and are still many of them are under training so there are major differences between countries within
within Africa countries that still need a lot of help and a lot of growth and countries that are like ten fifteen years ahead as far as as far as intervention ready intervention radiology
most of the practice in Ethiopia are basic biopsies drainages and vascular access but there is new workshops with with embolization as well as well as well as vascular access in Egypt the the ir practice is heavily into
interventional oncology and cancer that's the bulk that's the bulk of their of their practices you also get very strong neuro intervention radiology and that's mostly most of these are French trained and not
American trains so they're the neuro IRS in Egypt or heavily French and Belgian trains with with french-speaking influence but the bulk of the body iron that's not neuro is mostly cancer and it involves y9e tastes ablations high-end
ablations there's no cryoablation in Egypt there is high-end like like a nano knife reverse electric race electroporation in Egypt as well but there is no cryo you also get a specialty embolization such as fibroids
prostate and embroiders are big in Egypt they're growing very very rapidly especially prostates hemorrhoids and fibroids is an older one but it's still there's still a lot of growth for fibroid embolization zyou FES in Egypt
there's some portal portal intervention there's a lot of need for that but not a lot of IRS are actually doing portal intervention and then there's nonvascular such as billary gu there's also vascular access a lot of
the vascular access is actually done by nephrology and is not done by not not done by r is done by some high RS varicose veins done by vascular surgery and done by IRS as an outpatient there's a lot of visceral angiography as well
renal and transplants stuff so it's pretty high ends they do not do P ad very few IR s and maybe probably two IR s in the country that actually do P ad the the rest of the P ad is actually endovascular PA DS done by vascular
surgery a Horta is done all by vascular surgery and cardiothoracic surgery it's not done it's not done by IR IR s are asked just to help with embolization sometimes help with trying to get a catheter in a certain area but it's
really run by by vascular surgeons but but most more or less it's it's the whole gamut and I'm going to give you a little example of how things are different that when it comes to a Kannamma 'kz there's no dialysis work
they don't do Pfister grams they don't do D clots the reason for that is the vascular surgeons are actually very good at establishing fishless and they usually don't have a
lot of problems with it sometimes if the fistula is from Beau's door narrowed it's surgically revised they do a surgical thrombectomy because it's a lot cheaper it's a lot cheaper than balloons sheaths and and trying to and try a TPA
is very expensive it's a lot cheaper for a surgeon to just clean it out surgically and resuture it there's no there's no inventory there are no expensive consumables so we don't see dialysis as far as fistula or dialysis
conduits at all in Egypt and that's usually a trend in developed in developed countries next we'll talk
know we're running a bit short on time so I want to briefly just touch about
some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for
that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see
it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a
segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access
power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of
times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete
lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you
have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see
these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or
you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can
repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find
non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was
quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you
treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is
where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the
stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small
esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have
a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going
so why staging important well when you go to treat someone if I tell you I have a lollipop shaped tumor and you make a lollipop shape ablation zone over it you have to make sure that it's actually a lollipop shaped to begin with so here's
a patient I was asked to ablate at the bottom corner we had a CT scan that showed pretty nice to confined lesion looked a little regular so we got an MRI the MRI shows that white signal that's around there then hyperintensity that's
abnormal and so when we did an angiogram you can see that this is an infiltrate of hepatocellular carcinoma so had I done an ablation right over that center-of-mass consistent with what we saw on the CT it
wouldn't be an ablation failure the blasian was doing its job we just wouldn't have applied it to where the tumor actually was so let's talk about
terms of imaging my favorite aspect of cryoablation is the fact that you can see the ice ball very well on CT and most procedures are done with CT guidance right so as you can see this is
a renal ablation the probe has been placed you can see the ice bowl forming around the probe right so that's very predictable you can see exactly where it is the only problem with cryoablation is that that ice bowl is not
necessarily the lethal ice ball right so that maximal ice ball is really your zero Degree and in actual fact the lethal zone is about five millimeters in from that so anytime you do a cryoablation you want to weigh over
freeze essentially to get those margins that you want so that's one important thing to remember the ice ball is not the lethal it's really five millimeters short of that okay so a little more information by cryoablation you don't
have to spend too much time on this but the idea is that the more energy you put in the larger ice ball you can get and so essentially more probes you place can just supplement that energy to increase the size of the ice ball so advantages
here we have a MRI that shows a lesion in the left kidney sorry I don't have a
pointer here really but you can see the lesion in the medial part of the left kidney there couple probes are placed under CT guidance you can already see the beginning of the formation of an ice ball there this is the second probe you
can see the ice ball forming and there's a good example of the ice ball it's got good coverage of the the lesion as well as a good margin around that cryoablation tends to be less detrimental to the collecting system of
the kidney so some of the concerns when you do renal ablation is that you're gonna cause your read or strictures or urine leaks because you're burning the collecting system essentially with cryoablation you tend not to see that
you don't have to use something called pilar profusion is often right the idea with pilo profusion is you put a small catheter into the ureter and you infuse the kidney with cold saline so that the collecting system stays cold while you
while you burn the tumor well you don't often times have to do that with cryoablation so that's one benefit of it and then this is a one month later scan this is the normal appearance you can see the ablation zone that and the
resolution of the tumor will follow these up for a few years to make sure that all that tissue goes away and this
to talk about is indirect angiography this is kind of a neat trick to suggest to your intervention list as a problem solver we were asked to ablate this lesion and it looked kind of funny this patient had a resection for HCC they
thought this was a recurrence so we bring the comb beam CT and we do an angio and it doesn't enhance so this is an image here of indirect port ography so what you can do is an SMA run and see at which point along the
run do you pacify the portal vein and you just set up your cone beam CT for that time so you just repeat your injection and now your pacifying the entire portal vein even though you haven't selected it and what to show
well this was a portal aneurysm after resection with a little bit of clot in it the patient went on some aspirin and it resolved in three months so back to our first patient what do you do for someone who has HCC that's invading the
heart this patient underwent 2y 90s bland embolization microwave ablation chemotherapy and SBRT and he's an eight-year survivor so it's one of those things where certainly with the correct patient selection you can find the right
things to do for someone I think that usually our best results come from our interdisciplinary consensus in terms of trying to use the unique advantages that individual therapies have and IO is just one of those but this is an important
lesson to our whole group that you know a lot of times you get your best results when you use things like a team approach so in summary there are applications to IO prior to surgery to make people surgical candidates there are definitive
treatments ie your cancer will be treated definitively with curative intent a lot of times we can save when people have tried cure intent and weren't able to and obviously to palliate folks to try to buy them time
and quality of life thermal ablation is safe and effective for small lesions but it's limited by the adjacent anatomy y9t is not an ischemic therapy it's an ablative therapy you're putting small ablative radioactive particles within
the lesion and just using the blood supply as a conduit for your brachytherapy and you can use this as a new admin application to make people safer surgical candidates when you apply to the entire ride a panic globe
thanks everyone appreciate it [Applause] [Music]
so that was cryoablation and then the final modality to talk about is
microwave ablation this one should be relatively quick because the idea is pretty simple right this probe is got this electromagnetic energy it's in between the 924 50 megahertz range and basically like RF it causes the water
molecules adjacent to oscillate right so excuse me as you can see it creates this zone or these this this area of electromagnetic activity and all of the water molecules in that area will be activated at once
unlike RF a right so when it's right next to the probe the water molecules oscillate and then the temperature propagates by and by conduction this will essentially create this zone and that
immediately we'll we'll activate those tissues so if you've done microwave ablation you know if you do an ablation of a hundred watts for two minutes you'll get a three centimeter burn it's literally instantaneous as you turn it
on you get this huge burn and then after that anywhere between two minutes and ten minutes you're really only getting about another centimeter of burn and the reason you're doing that is because that's the the passive conduction so it
is very rapid it doesn't have the heat sink issues that RFA does as I mentioned there's this radius of molecules that are activated around the probe the size that radius depends on the wave link and the probe properties there are no
impedance issues so unlike RF a where you want to heat slowly microwave is instantaneous and it just cooks the tissue around the the probe many of the antennas have internal saline perfusion and that's just really to generate
uniform heating and prevent the heat from propagating along the shaft because you obviously don't want it to propagate back towards the skin same ideas are FA right so you want to increase the temperature to greater than 50 degrees
Celsius for about four to six minutes you get coagulation necrosis and you need about a point five a five millimeter margin on that advantages a
about RF a is that it was the first
ablation that we came up with all those that used it was first used in 1981 and it was really for the first liver ablation that we did RFA if any of you know about a Bovie knife the idea is the same the modality works the same as a
Bovie knife and still the main modality used in many parts of the world in the United States a lot of people will use it in certain areas but it's it's being slowly replaced by microwave ablation with time so as I mentioned some areas
are still using a fair amount of RF aimost or not I can honestly say that I haven't used much RF a at all I was sort of born into the generation of cryo and microwave places where we do use it or very commonly our Nerada meas for pain
control as well as spine ablations if any of you do the osteo cool system with Medtronic will do kyphoplasty in conjunction with an ablation that would be RFA and then Bowden oblations in conjunction with cement organizations
elsewhere right so in the pelvis if there's metastatic disease to the pelvis and you're going to ablate the lesion and then to cement augmentation the I
different applications renal ablation is very common when do we use it
high surgical risk patients primary metastatic lesions some folks are actually refused surgery nowadays and saying I'll have a one centimeter reno lesion actually want this in lieu of surgery people have
familial syndromes they're prone to getting a renal cancer again so we're trying to preserve renal tissue it is the most renal parenchymal sparing modality and obviously have a single kidney and a lot of these are found
incidentally when they're getting a CT scan for something else here's a very sizable one the patient that has a cardiomyopathy can see how big the heart is so it's you know seven centimeter lesion off of the left to superior pole
against the spleen this patient wouldn't have tolerated bleeding very much so we went ahead and embolized it beforehand using alcohol in the pide all in a coil and this is what it looks like when you have all those individual ice probes all
set up within the lesion and you can see the ice forming around I don't know how well it projects but in real time you can determine if you've developed your margin we do encompass little bit of spleen with that and you can see here
that you have a faint rim surrounding that lesion right next to the spleen and that's the necrotic fat that's how you know that you got it all and just this ablation alone caused a very reactive pleural
effusion that you can see up on the CT over there so imagine how this patient would have tolerated surgery pulmonary
no way around this I'm gonna read to you the inclusion criteria right off the protocol it's kind of long so confirmed diagnosis I wrote some single line there that can help you follow along confirm diagnosis of HCC number two patients
above age 23 patients with single or multiple nodules HCC who are unsuitable or unwilling for surgical resection or RFA the largest tumor nodule should be less than 10 centimeters in the large largest diameter total volume of tumor
cannot exceed 50% of the liver patients are candidates for trans arterial embolisation no tumor invasion to portal vein or thrombosis and main and first branch of the portal vein 5 patients have no lymph node involvement or
distant metastasis 6 ECoG score at 0 to 1 with no known cardiac pulmonary or renal dysfunction 7 child pew score group a and B 7 eight patient should have measurable disease by contrast MRI nine prior local
therapies such as surgical resection radiofrequency ablation and alcohol injection are allowed as long as tumor progresses from the prior treatment and the patients are still candidates for tae 10 patients have normal organ
function based on some labs eleven patients are able to understand and willing to sign the informed consent and twelve men and women of childbearing age need to commit to using two methods of contraception and the exclusion criteria
ablating things in the bones well musculoskeletal blasian we're fortunate within our practice that we have a doctor councilman Rochester who's
a probably one of the biggest world's experts on this and these are his cases that he shared but you can see when you have small little lesions and bones that are painful you can place probes in them and you freeze them the tumor dies and
musculoskeletal things remain intact what about when you have cases like this where there's a fracture going through the iliac bone on the left with an infiltrate of malignancy well you can cryo blade it and what's cool about is
you can using CT guidance do percutaneous cannulated pins and screws and a cement o plasti ver bladed cavity and when you're done the patient who initially couldn't walk now can and whose pain scale went down to one so I
think that's that's very important to realize the potential of image-guided medicine this is something that previously would have had to been done in the orthopedic lab so you know I think this is extending options where
otherwise it would have been difficult same thing applies to the spine you can ablate and fill them with cement so
we're going probes I think many of you have used our FA there's all sorts of different probes right so the most common well one of the most common ones is a probe like a Levine probe and what it does essentially is it increases the
number of tines so you put the probe in and you deploy these tines and it increases your ablation size a lot of companies went towards just a single probe and they infuse saline through the probe which will then decrease the rate
at which the temperature increases so that you get a consistent slow increase in temperature to prevent impedance other probes will actually infuse saline into the tissues so that it propagates the ablation better and then finally
there's by polar probes where you put two probes in next to one another and the the ablation occurs just between the two probes and so that's a very controlled ablation that's the most commonly what you see when you do the
spine augmentation procedures with the osteo cool system or whatever system you're using that's the bipolar probe approach so as I mentioned the
advantages of radiofrequency ablation or that there's the most research on this
right so if you look up ablation research there's a whole lot of data and research on this as it's been the longest studied so that's always beneficial when you're trying to convince people that they should get an
ablation it's cheap right although some of the problem with that is a lot of manufacturers aren't making some of the devices anymore so to get replacement probes and that sort thing is difficult but it is certainly much cheaper than
the other modalities its gentler than microwave right so it's a slower increase in temperature and you can control it the disadvantages as we mention right so the ablation zone this is probably the worst part about
radiofrequency ablation is that the ablation zone is unpredictable right now we're trying to go towards this idea where we can predict the exact size of the ablation and really with RFA it was more experience related right so if
someone I've been doing them for 20 they can have a good idea how it's gonna it's gonna blade but that ablation zone is very unpredictable it's very tissue dependent right so if you have cirrhosis and the liver is
really scarred down you're gonna get a different ablation as to someone who has a normal appearing liver you have the heatsink effect which as I mentioned can be used as an advantage but usually as a disadvantage and then large large burns
are difficult right so anything greater than 4 centimeters even that is difficult to achieve with RFA it is possible to get skin burns at the grounding pad so if you're gonna do RFA make sure that the patient doesn't have
a hip prosthesis for instance and make sure you know it sometimes patients get sweat underneath the the pads and that can increase skin burns and those pads so that's one of another downside of a radiofrequency ablation so we'll move on
microwave as I mentioned the reason people are switching to microwave is
that it's a very predictable burn right a lot of the companies are coming out with software that will give you an exact definition of what the size of the ablation is going to be like and that's very reassuring for the physician if
they're gonna put the probe direct it at some sort of structure they don't want to injure having an exact prediction of what that's gonna look like is very very reassuring so that's why a lot of people are going towards microwave it's very
quick there's no grounding pad issue there's no charring there's no heat sink it's ten minutes essentially the disadvantages is it's a hammer right so when you put it in you
turn it on you're getting a powerful burn so if you if you've got it somewhere wrong like it's up against the diaphragm or something like that you are gonna burn that structure so you just have to be careful with that and once
again the main property there is if you point the probe towards the structure you don't want to damage whatever it is you're unlikely to damage that structure because it will not propagate beyond the
about with cryoablation if you put the probes in and you create an ice ball and then you try and pull those probes out you can cause something called organ fracture basically and
essentially the idea is that you've trying to pull an ice ball out of a kidney or the reason you can tear that organ and it can have some pretty substantial complications related to that so once I've placed probes and
started freezing I don't touch them again even if you don't like where they are you don't want to pull them and move them around addition to that at the end of the case I'm always in a rush to get the probes out and you do this act of
thought thing and it's two minutes can I pull the probe I can I pull the probes out in the Reptoids I calm down calm down the idea that if you pull those out too early you can fracture the organ and
then as I mentioned with liver oblation specifically cryo shock was a concern these large liver oblations could cause the patient to become hypotensive going to di C raspberry compromise it was a big deal in the early studies and so a
lot of people stop doing cryo for liver now you're seeing a little bit of a resurgence of that but most still will do microwave for liver ablations
of you have worked with cryoablation you know they have 12 different types of probes and each probe is a different Ice Bowl that they they mark it as all this
ice force probe creates a very oblong freeze and this ice rod will create a slightly different freezin you can use an ice pearl which is a more rounded freeze and that is that in order to get the length of the ice ball depends
really on the probe insulation so they've insulated the probe prior to even putting it into the packaging and in doing so you can predict the length of the ablation the diameter on the other hand depends on the rate of
transfer of energy right so if you're putting a lot of energy into that you can create a more rounded ice ball to a certain extent what I will point out in any ablation whether it's microwave or cryoablation propagation from the tip of
the needle from their tip of the antenna is what's most controlled right so if you don't want to damage something in general you want to point the needle directly at it it seems like it's counterintuitive but if for instance you
wanted to ablate near the aorta you want to point the needle right at the aorta because it doesn't come very far off the tip of the probe almost everything propagates backwards and to the side and you can't control that as much and so
kryos the same way that one's here so in
of cryoablation it's gentler than both microwave and RF a you can use it in a lot of locations because of that you can visualize the ice ball with CT multiple probes means potentially huge ablation zones and I'll show you an example of
that it's not painful and for me I know that I don't know about everyone else in the room but our anesthesia assistance is is very spotty or sporadic so it's nice to do stuff with conscious sedation in which case cryoablation you can
absolutely do most places with conscious sedation it's not painful at all whereas if you've done microwave you know the moment you turn the probe on the patient wants to punch you so so it's not particularly painful you can do it with
sedation and it has this immuno genic response that we're starting to learn more about right so when you cook tissue your since you just cha reverie and you just cook all the proteins and all the membrane of the cell with cryoablation
you actually keep some of the proteins in tact so what happens is as the cell dies your immune response comes in and it recognizes those tumor antigens right those tumor proteins and there's been lots of reports of where you oblate for
instance a renal mass and the patient's lung nodules will regress because of that so that's a very nice feature of it is that's got this immuno genic response and I'll use that often times if I'm doing a lung ablation for instance and
there's other nodules you can see a regression of those nodules the disadvantage as well you need you know there's these repeated freezes right so you do these freeze thaw cycles you go ten fighting you know ten freeze five
for ten freeze five for that ends up being a pretty long freeze time right and even if you do the triple freeze protocol which I can talk a little bit in a bit here you can see it ends up adding up a lot of time so the time you
save on not putting the patient to sleep and getting general anesthesia actually lose on the backend when you're standing and staring at the probes freezing whereas my crew of ablation as me as you know 10 minutes and you're
done there is this idea of a cold sink so like RFA if you put the probe right up against the blood vessel it's unlikely that that ice bowl is going to propagate into that blood vessel and you can use
that to your advantage once again I'll show you an example of that but cold sink is technically also a disadvantage and one of the main things people worry about with cryoablation is the bleeding aspect right so unlike our fa or
microwave you're essentially cooking the tissue it's a Bovie right you're very unlikely to have bleeding whereas cryo you freeze the tissue and when you thought all those blood vessels are now very porous and they can bleed and so
one of the concerns with cryo is that you have bleeding and you you'll often see this especially in renal and long and then do some early studies where where physicians were doing large liver oblations and they were getting into
something called cryo shock which we'll talk about in a little bit that's probably overhyped from the earlier studies but for that reason many people do not use cryoablation in the liver they would prefer to use microwave
deal with radiofrequency ablation is that you have a probe which acts as the
calf the current you then have the pads which act as the anode and when you place the probe in turn it on essentially there's a very small cross-sectional area and there's high flux of energy so lots of
current and then it spreads out over the patient's body and it grounds itself to the grounding pad in so the way is since she works is you generate this very very large alternating current right so the water molecules want to stay in
conjunction with that that current their dipoles arrangement they have positive and minuses and so they're gonna flip around to stay in alignment with that current and that rapid oscillation of those water molecules causes the the
tissue to heat up the way a cinch it works is by coagulation necrosis what does that mean well it's basically cooking a steak it just dies and and that's your your your death related to coagulation necrosis so with our FA
what's important to know is that the molecules immediately next to the probe are what heat up and then everything from there on out heats sort of by passive conduction and I'll describe how microwave works and that's different to
that but the probe tip never gets hot but the molecules immediately adjacent to the probe get hot and and everything propagates from there on out why is that important well it's important because if you rapidly heat the tissue with RFA
you're gonna get charring but some of you might have experienced this when you do the cases the tissue basically gets charred then it increases the the impedance or the ability to conduct it in which case you you limit your ability
to create an ablation all right so charring is a problem and it increases your impedance which is essentially the resistance to making an ablation cavity and then that decreases the ablation size and so that's really
one of the main reasons why people started moving away from RFA is that you really need tissue that's going to conduct this electrical current well and it's difficult to predict what tissue that's gonna be and so the goal with RFA
as with any other thermal ablation is to get the tissue temperature to between 50 and 100 degrees Celsius and then slow temperature rises are best right so however you want to achieve that slow temperature rise you want to do it
slowly rather than a rapid increase which is the opposite really of microwave ablation radiofrequency
blasian it's well tolerated and folks with advanced pulmonary disease there's a prospective trial that showed that
there are pulmonary function does not really change after an ablation but the important part here is a lot of these folks who are not candidates for surgical resection have bad hearts a bad coronary disease and bad lungs to where
a lot of times that's actually their biggest risk not their small little lung cancer and you can see these two lines here the this is someone who dr. du Puy studied ablation and what happens if you recur and how your survival matches that
and turns out that if you recur and in if you don't actually a lot of times this file is very similar because these folks are such high risk for mortality outside or even their cancer so patient selection is really important for this
where do we use it primary metastatic lesions essentially once we feel that someone is not a good surgical candidate and they have maintained pulmonary function they have a reasonable chance for surviving a long
time we'll convert them to being an ablation candidate here's an example of a young woman who had a metastatic colorectal met that was treated with SPRT and it continued to grow and was avid so you can see the little nodule
and then the lower lobe and we paste the placement prone and we'd Vance a cryo plugs in this case of microwave probe into it and you turn off about three to five minutes and it's usually sufficient to burn it it cavitate s-- afterwards
which is expected but if you follow it over time the lesion looks like this and you say okay fine did it even work but if you do a PET scan you'll see that there's no actually activity in there and that's usually pretty definitive for
those small lesions like that about three centimeters is the most that will treat in a lot of the most attic patients but you can certainly go a little bit larger here's her follow-up actually two years
that had no recurrence so what do you do when you have something like this so this is encasing the entire left upper lobe this patient underwent radiation therapy had a low area of residual activity we followed it and it turns out
that ended up being positive on a biopsy for additional cancer so now we're playing cleanup which is that Salvage I mentioned earlier we actually fuse the PET scan with the on table procedural CT so we know which part of all that
consolidated lung to target we place our probes and this is what looks like afterwards it's a big hole this is what happens when you microwave a blade previously radiated tissue having said that this
was a young patient who had no other options and this is the only side of disease this is probably an okay complication for that patient to undergo so if you follow up with a PET scan three months later there's no residual
activity and that patient actually never recurred at that site so what about
to talk about cryoablation which is very commonly used in a number of organs it can essentially be used anywhere in my opinion with cryoablation as many of you know the different idea is that you have a probe and it creates this ice ball and
that's what's killing the tissues rather than heating the tissue when they first came out with cryoablation they had these really large probes and that really limited what we could do well with technology obviously those probe
size decreased and we were able to do better ablations and safer oblations in patients so it really took off at that point and the general goal once again is to decrease the temperature to about minus 20 degrees Celsius and in doing so
you kill the tissue and we'll talk about the mechanism of how that works the cold spreads Bible directly molecular transfer right so you're starting to cool around the probe and that will propagate to the surrounding tissue
unlike our FA or microwave as the ice ball grows it doesn't impede further ice ball growth right you can continue to build on that ice ball as you increase the amount of argon infused in the increase the number of probes so that's
beneficial and that you can get a massive ablation depending on how many probes you want to place well talk a little bit of how it works so it works by what's called the joule-thompson effect idea here is if any of you've
done cry before you know you have to drag those huge tanks into the room and it just runs through all gone like nothing so when we first started doing cryoablation you had to have an all gone tank and a helium tank they've gone away
with the helium and now you really just need the argon tank which is really nice and that you don't have to drag those tanks around and they're working on actually doing with nitrogen but that hasn't come to fruition yet so the idea
is that you take a high-pressure gas right so it's in the tank it's pressurized it gets run through the center of the probe and then as it comes out the tip will not out the tip of the probe and within
the tip of the probe it goes to low pressure and that change in pressure allows the temperature of the probe tip to cool right and so if you're using argon or oxygen or nitrogen that'll cool if you're using helium it'll actually
heat the tissues and so that's why we used to have argon and helium to be able to to freeze and then actively Thor so as I mentioned the argon comes from a pressurized tank you have this dual chamber probe that allows the gas to
expand and as it expanded pools heat from the surrounding tissues so as many
ablation also has a little disadvantage than that I don't know if you folks have heard of heat sink but the idea is that
if you put the probe immediately adjacent to a blood vessel that blood vessel is gonna suck the temperature away and so that you cannot oblate around blood vessels particularly well because the blood flow rate since
you just washes it out it's called heat sink effect and this is essentially showing infrared image of of an ablation how if you put a vessel nearby it stops the ablation now that can actually be used as an advantage depending on where
you're doing an ablation but truthfully if you're doing it in the liver and you're next to the portal vein or something like that it becomes a bit of a problem and any blood vessel greater than three millimeters is our concern so
so my name is Paul I'm one of the nurse practitioners from UCI Irvine healthcare and what am i one of our minerals in there is basically working on patients for consultations doing the patient rounds writing notes ordering labs etc we also have several clinics that we run
at UCI Medical Center involving patients needing consultations for Libra direct therapies ablations and so forth and one of the more recent clinic that we started running is basically treating patients with BPH and so what we would
know inspiration is basically treating and regarding their symptoms and the procedures pretty much called a prostate artery embolization so the main purpose of this patient excuse me the main purpose of this
topics is basically to provide the general information of what the procedures are about illustrating indications risk and to hopefully help our nursing staff to better take care of these patients sorry so first and
foremost I just wanted to thank my team UC Irvine for allowing me to take some time off of work and enjoying Austin and its many food and object and and allowing me to speak to you guys a little bit about prostate ammo on our
pitchers basically you can't I don't know laser printer but our physicians dr. Karen Nelson she's one of our chief of IR dr. Dan through Fernando dr. Nadine a bitch day and dr. James Castro thesis
he's got daughter Kat Reese is our main doctor that does most of our process embolization our excellent iron nursing team and of course my fellow nurse practitioners who is holding the fort back home Pamela and Takara and watch
and Lou sorry but so our objectives for discussions basically to illustrate the indications and benefits of prostate artery embolization we're going to go over the side effects and risk complications associated with this
procedure and also recognize the value of nursing care going starting from the workup leading to the proper process in trot process and post procedure care sort of a brief outline of what we're gonna be
talking about we're just gonna go over the basic fundamentals of BPH as well as the treatment for PAE and the second portion of this lecture is going over how we walk patients up in clinic what we tell patients and we're gonna go
through the proper care and drop care ask well ask the post-op care and we're going to go through a couple of cases in there it's just to describe to you guys how we care for these special population
is example as I mentioned about doing very large ablation so this is a lady who hadn't malignant melanoma and she
had metastases to liver we basically placed six probes into this mass as you can see there on that CT the image on the right is the appearance of those six probes it's all excited about how many probes I placed in this patient
like it's a game and then I just watched an ablation talk with a guy put 16 in so that didn't really make me feel much better so so we have six probes here and you can see what we what you do when you have lesions that are in the soft
tissues and you're worried about freezing to the skin you can have injury to the skin right essentially frostburn and so frostbite sorry and so what you can do is you can take either a warm glove fill it up with saline and put it
with the fingers amongst the probes so it keeps the skin warm because you don't want to freeze the skin or what people are doing sometimes as well as they've just put some gauze around all the probes and they spray that goes with
warm saline I just take one of those leader bags of saline put it in the microwave for a couple minutes and then just fill fill the bowl up with it and just spray the gauze on that or you can do the glove technique the main idea
here once again is you don't want to get skin injury when you do these and as you can see a pretty sizable ablation around that entire tumor you can even see the lightening sign which is the low attenuation sort of lightening looking
structures within the ice ball which is cracking of the ice ball as you form but you will see what this is immediately after the procedure the patient will have a very hard ice ball under their chest and it takes about an hour
for that to melt so if you notice bleeding off towards or what is perceived as bleeding before you panic you should realize that that ice pole is going to melt and it's going to come out the holes seep out of the holes that you
created so oftentimes if it's sort of a blood tinge fluid that's really just the ice ball melting in the fluid coming out of the the sites that you've punctured
something some case examples of where I use cryoablation right so this is a
patient who has a nodule in the in the back of their lungs in the right lower lobe and basically I'll place two probes into that notch on either side of Brackett the lesion and then three months later fall up you can see a nice
resolution of that nodule so when it comes to lung a couple things I'll mention is if the nodule is greater than eight millimeters I'll immediately go to two probes I want to make sure that I cover the lesion whereas microwave it's
pretty rare depending on what device you're using for you to put more than one probe in so some people's concern with cryo in the lung is more probes means more risk of pneumothorax but you can also see surrounding and proximal to
where we did the place you can see the hemorrhage that you see so if those of you out there that are doing the lung ablations you probably have physicians that are using something called the triple freeze protocol right so the
double freeze protocol is the idea that you go ten minutes freeze five minutes 30 minutes freeze five minutes thought well what we saw was lung early on in the studies was a very large ablation a freeze to start with caused massive
hemorrhage patients were having very large amounts of hemorrhage so what we do now in lung is something called a triple freeze protocol we'll do a very short freeze about three minutes and that'll cause an ice ball to form and
then we'll thaw that in other three minutes three minutes of thawr and as soon as that starts to thaw we'll freeze it again and we've shown us a substantial decrease in the amount of hemorrhage so if you're doing long and
you and you you're told to do a double freeze protocol perhaps suggest the triple freeze is a better idea so that's three months later so another example
Disclaimer: Content and materials on Medlantis are provided for educational purposes only, and are intended for use by medical professionals, not to be used self-diagnosis or self-treatment. It is not intended as, nor should it be, a substitute for independent professional medical care. Medical practitioners must make their own independent assessment before suggesting a diagnosis or recommending or instituting a course of treatment. The content and materials on Medlantis should not in any way be seen as a replacement for consultation with colleagues or other sources, or as a substitute for conventional training and study.


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January 10th at 8:28am
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CRA gives an expansive interpretation to the GST/HST definition of "debt security"
21 August 2019 - 12:34am
CRA gave the following rationale for an NSF cheque charge being for an exempt financial service:
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Auto Carry Can
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West Indies must rethink their tactical method and tempo their innings higher on the Cricket World Cup if they're to get the very best out of a facet filled with expertise, in response to cricketing nice Clive Lloyd.
West Indies are eighth within the standings after six matches having gained only one sport — a seven-wicket demolition of Pakistan of their opening match.
Jason Holder's facet, nonetheless, might have been in a a lot stronger place heading into their subsequent match towards India in Manchester on Friday had they not misplaced to front-runners New Zealand narrowly or let Australia off the hook.
"West Indies could be one of the best teams around — they have the talent," Lloyd stated in his column for the Worldwide Cricket Council.
"Ultimately, the difference has been that the West Indies just aren't settling in and making big scores (and) they're not putting the clinical finishing touches necessary to win games."
The Guyanese, who captained the West Indies to the primary two World Cup titles in 1975 and 1979, stated the five-run loss to New Zealand was the proper illustration of his argument.
The West Indies had a blistering begin, however suffered a top-order collapse and solely a rearguard maiden century from all-rounder Carlos Brathwaite meant they received near New Zealand's 291 for eight.
The method was criticized by quick bowling nice Michael Holding throughout his commentary of the New Zealand match, stating he felt the facet lacked the power to buckle down.
Holding stated that a few of the top-order batsmen appeared to have the mentality that in the event that they scored "80-odd" earlier than they received out that they had finished their job and it was then as much as the remainder of the facet to get the group residence.
Holding's fellow Jamaican Chris Gayle raced to 87 towards New Zealand however was dismissed within the 24th over to depart his facet at 152 for 5.
Lloyd added that if his former facet had a participant like New Zealand captain Kane Williamson, who scored 148 by accumulating runs and ready for the unhealthy ball he might put away, they might have gained extra video games in England.
"Had the West Indies batsmen turned some of those 50s, 60s and 70s, 80s into hundreds they would have been in a better position in the points standing," Lloyd stated, highlighting the truth that six West Indies gamers, moreover Brathwaite, had handed 50 throughout the event.
"In opposition to New Zealand, they have been properly conscious of the asking price; all they needed to do was knock it round. It wasn't about enjoying massive photographs.
"I simply hope that they've realized from their errors and that they'll rectify them as a result of they're gifted cricketers." (Reporting by Greg Stutchbury; Modifying by Sudipto Ganguly)
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Greg Stutchbury


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My keyless entry stopped working, how do I fix it?
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1 Answer
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Los Angeles issued the nation's first license for an "open-air" Marijuana restaurant this week; allowing diners to smoke cannabis while eating outdoors.
"The nation's first cannabis restaurant was approved by West Hollywood's Business License Commission in a landmark decision. Lowell Farms: A Cannabis Cafe will be an open-air restaurant at 1201 N. La Brea Avenue, and promises cannabis cuisine and a smoking area," reports the Los Angeles Patch.
"However, the cannabis cafe will sit across the street from a synagogue, which has an outdoor area used by the congregation. A rabbi at Tuesday's city meeting asked for the business license to be rejected, and left without a word when it was approved," adds the report.
Marijuana shops opened in West Hollywood back in 2018, but the approval of the open-air restaurant is a first nationwide.
Los Angeles is currently facing a new public health risk from a massive rat infestation largely ignored by local officials; raising serious concerns over 'medieval' illnesses re-emerging across the country's second largest city.
"An ever-growing number of rodents in California — particularly in Los Angeles — is being fueled by a spiking homeless population and restrictions on rodenticides that are risking a public health crisis, according to a study released Tuesday," reports Fox News.
"The report by political action committee Reform California cites recent rodent-related events over the past six months, including an employee at the Los Angeles Police Department contracting Typhus and a rat falling from the ceiling of a Buffalo Wild Wings onto the menu of a patron, as proof of an 'undeniable problem' in the Golden State," adds Fox.
"California is being overrun by rodents," said Carl DeMaio, chairman of Reform California. "Without immediate emergency action by state and local government, we face significant economic costs and risk a public health crisis."
Property owners and residents of shelters on skid row are going to court to block a contentious legal settlement that restricts Los Angeles' ability to clear homeless encampments that they say have brought rats and diseasehttps://t.co/UHJpCgzB1g
— KTLA (@KTLA) July 5, 2019
"Contrary to common belief, being bitten by a rodent is rare and is not the most common way diseases are spread. Nonetheless, reports of city workers being bitten by rodents is on the rise – with most recent cases being reported in Los Angeles," the report notes. "Two other vehicles of transmission are far more prevalent: fleas and urine droppings."
The report comes weeks after officials confirmed a massive infestation at Los Angeles City Hall.
Experts are now blaming the infestation on "homeless camps" circling the public property.
"When faced with complaints earlier this year from city workers about rats infesting L.A. City Hall, most city officials said little about whether the problem was connected to several homeless camps right outside," reports the Los Angeles Times.
"But a newly uncovered report from a pest control company hired by the city has raised fresh questions about whether officials wrongly downplayed that possibility during discussions at City Council meetings," adds the newspaper.
According to the pest control company hired to clear city hall, workers found "poor sanitary conditions" including human waste, food, and needles throughout the property.
"The homeless are using the grated areas above the pits as their bathroom and relieving themselves," wrote David Costa, building construction and maintenance superintendent. "This is also attracting the rats. Custodial will need to do some hazmat cleaning of the grates and the pits. There are even hypodermic needles being tossed in the pits along with human waste and other garbage."