1 Interventional Radiology Role in Caring for Primary Sclerosing Cholangitis and CholangiocarcinomaDustin Thompson, MD Associate Staff  |  Interventional Radiology Associate Program Director | Interventional Radiology Fellowship Clinical Assistant Professor of Radiology  |  Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic  |  9500 Euclid Ave. L10  |  Cleveland, OH (216)

2 Goals Know what an Interventional Radiologist isKnow what bile ducts look like Know some of the interventional radiology procedures available

3 Biliary anatomy This image has been released as part of an open knowledge project by Cancer Research UK. If re-used, attribute to Cancer Research UK / Wikimedia Commons

4 CT of dilated bile ducts

5 Hilar mass on magnetic resonance cholangiopancreatography (MRCP)

6 When to get more invasiveImaging studies show an abnormality Elevated bilirubin levels Elevated liver enzymes Infection in the biliary system

7 Endoscopic retrograde cholangiopancreatography (ERCP) versus percutaneous transhepatic cholangiography (PTHC) When ERCP can't reach its goal Altered anatomy due to surgery Difficulty finding ampulla Mass or stricture too tight to pass with ERCP

8 Initial cholangiogram

9 Internal external biliary drain

10 Left sided biliary tube after right hepatectomy for cholangiocarcinoma

11 Multiple biliary drains required due to hilar mass

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13 Bridging to resection or transplantPortal vein embolization Intra-arterial treatments Bland embolization Transarterial Chemoembolization (TACE) Radioembolization 90Y Ablation

14 Portal vein embolizationDual blood supply to the liver Hepatic arteries supply bile ducts and are recruited by tumors Portal veins supply majority of blood flow to normal liver Portal vein embolization performed to induce growth of normal liver on the opposite side

15 Portal vein embolization

16 Intra-arterial treatmentsArterial embolization is performed to target tumors that have recruited blood supply and to preserve normal liver Bland embolization Transarterial Chemoembolization (TACE) Drug eluting beads (DEB-TACE) 90Y Radioembolization (SIR SPHERE, THERASPHERE)

17 Hepatic angiogram and chemo embolization or radioembolization

18 Ablation Radiofrequency Microwave

19 Conclusions Difficult to perform “gold standard” randomized controlled trials due to variability of patients, disease process, and multiple number of available treatments Optimal care depends on multiple consultants Important to have varied approaches to the disease that can be adapted to patient’s specific situation

20 Goals Know what an Interventional Radiologist isKnow what bile ducts look like Know some of the interventional radiology procedures available

21 To learn more Arellano R, Sahani D. Imaging of cholangiocarcinoma, Dig Dis Interv 2017; 01(01): https://www.thieme-connect.com/products/ejournals/html/ /s Ierardi, A.M., Angileri, S.A., Patella, F. et al. The Role of Interventional Radiology in the Treatment of Intrahepatic Cholangiocarcinoma. Med Oncol (2017) 34: 11 https://link.springer.com/article/ %2Fs Ray CE Jr, Edwards A, Smith MT, Leong S, Kondo K, Gipson M, et al. Metaanalysis of survival, complications, and imaging response following chemotherapy-based transarterial therapy in patients with unresectable intrahepatic cholangiocarcinoma. J Vasc Interv Radiol. 2013;24(8):1218–26

22 Thank you!