We spoke to Dr. Yilmaz to learn more about his presentation at CIRSE 2022.
Thyroid diseases have become one of the main areas of interest for interventional radiology in recent years. Benign thyroid nodules have been successfully treated by chemical ablation with ethanol, by thermal ablation with laser, radiofrequency or microwave [1,2]. In the literature, numerous studies have shown that percutaneous ablation (PA) produces marked shrinkage of the thyroid nodules with very few side effects [1-5]. At six months, a 50-80% volume reduction of the treated nodule is generally seen, and the results are durable over time [3,4]. Ideal patients for percutaneous ablation are those with a single or a few thyroid nodules of small to medium size. It is generally accepted that percutaneous ablation is less effective in nodules with a volume of >30 ml compared to smaller ones. If the nodules are numerous, very large or extend into the thoracic cavity, then the procedure will be more technically challenging, time consuming and probably less effective [4,5].
In such cases of nodules and in diffuse toxic goiter (Graves disease) where PA is not a good option, thyroid artery embolisation (TAE) may be a viable alternative [6,7]. In Graves disease, the first line of treatment is medical therapy, which successfully controls the disease in more than 70% of the cases . However, some patients do not respond or are not suitable for medical therapy. In these patients, radioactive iodine (RAI) treatment and surgery are generally recommended. However, RAI exposes the thyroid to a high dose of radiation and frequently results in permanent hypothyroidism. In the case of surgery, the patient loses the thyroid gland and is exposed to the risks of hypoparathyroidism and recurrent laryngeal nerve palsy [8,9]. The most important advantages of TAE over the conventional RAI and surgery are the absence of surgical complications, high dose radiation exposure and hypothyroidism [6,7,10].
TAE is performed via a common femoral artery approach under local anesthesia and conscious sedation. After the thyroid arteries are selectively catheterized, PVA particles or similar are injected via a coaxial microcatheter until stagnation is achieved. Depending on the underlying pathology and location of the lesions, 2,3 or 4 thyroid arteries can be embolised [6,10]. Because of the proximity of the thyroideal arteries to the carotid and vertebral arteries, TAE should be performed by interventional radiologists who have a certain level of experience in neurovascular procedures. Adequate anticoagulation and extreme caution against reflux of embolic particles are essential .
If appropriate measures are taken, the risks of TAE are few and generally mild. After the procedure, most patients experience mild to moderate neck pain that lasts for several days and temporary hyperthyroidism for several weeks. Although TSH drops and thyroid hormones become high, symptoms are not severe and patients typically become euthyroid in one to two months after the procedure [6,10].
In the past, TAE has been successfully used in the treatment of Graves disease at some centres in Asia and Europe [6,7,10]. Embolisation had a success rate of around 80%, and in all the embolised patients, there was also a marked volume reduction in the thyroid gland. Interestingly, this “secondary effect” did not receive enough attention and thyroid embolisation has not been used for this purpose, except for some case reports [12,13]. In 2021, our group published an article on TAE for nodular goiter . In this study, 56 patients with a giant solitary nodule or multiple thyroid nodules underwent TAE. At the six months follow up, there was a statistically significant reduction in the volumes of the nodules, thyroid gland and the degree of retrosternal goiter extention (p<0.001). The health-related quality of life (HRQoL) scores also significantly improved after TAE (p<0.001). In patients with hyperthyroidism, thyroid hormones returned to normal in 86% of the cases [10,11]. These results and the data in previously published articles suggest that TAE may be an attractive alternative to conventional surgery and RAI in the treatment of diffuse or nodular toxic or nontoxic goiters with Bethesda 2-3 fine needle biopsy results. These findings should be taken into consideration when offering the treatment options to patients with goiter.
Figure 1: A 48-year-old male with nocturnal dyspnea and snoring, preoperative photography shows a large cervical goiter (FIG 1A). On the preoperative sagittal reformatted CT image, the goiter is composed of several nodules that contain cystic areas (FIG 1B). The patient underwent TAE. On angiography, the nodules were fed by the left superior thyroideal artery (FIG 1C) and left inferior thyroideal artery (FIG 1D). These arteries were embolised with PVA particles. One year after the embolisation, a neck photography shows a remarkable size reduction of the goiter (FIG 1E). The patient is asymptomatic and very satisfied with the cosmetic improvement.
Varisson Radiology and IR Center, Istanbul/TR
Dr. Yilmaz is the founder and chief interventional radiologist of the Varisson Radiology and IR Center. He was educated at Istanbul University Medical School and became a radiology professor at Akdeniz University Medical School. For the last 30 years, he has worked as a dedicated interventional radiologist in many fields including peripheral arterial interventions, neurovascular interventions, varicose veins treatments, embolisations and oncologic interventions. He authored more than 80 scientific papers in peer-reviewed journals that received more than 700 citations and had seven scientific awards in interventional radiology. He pioneered several interventions in Turkey including subintimal angioplasty, endovenous laser ablation, uterine, varicocele and thyroid embolisations and percutaneous cryoablation. His main areas of interest are interventional oncology, thyroid interventions and embolotherapy.
- Guan SH, Wang H, Teng DK. Comparison of ultrasound-guided thermal ablation and conventional thyroidectomy for benign thyroid nodules: a systematic review and meta-analysis. Int J Hyperthermia 2020; 37:442-449.
- Hahn SY, Shin JH, Na DG et al; Korean Society of Radiology. Ethanol Ablation of the Thyroid Nodules: 2018 Consensus Statement by the Korean Society of Thyroid Radiology. Korean J Radiol 2019; 20:609-620.
- Trimboli P, Castellana M, Sconfienza LM et al. Efficacy of thermal ablation in benign non-functioning solid thyroid nodule: A systematic review and meta-analysis. Endocrine 2020; 67:35-43.
- Pacella CM, Mauri G, Achille G et al. Outcomes and Risk Factors for Complications ofLaser Ablation for Thyroid Nodules: A Multicenter Study on 1531 Patients. J Clin Endocrinol Metab 2015; 100:3903-3910.
- Lim HK, Lee JH, Ha EJ, Sung JY, Kim JK,Baek Radiofrequency ablation of benign non-functioning thyroid nodules: 4-year follow-up results for 111 patients. Eur Radiol 2013; 23:1044-1049.
- Xiao H, Zhuang W, Wang S et al. Arterialembolization: a novel approach to thyroid ablative therapy for Graves’ disease. J Clin Endocrinol Metab 2002; 87:3583-3589.
- Zhao, B.L. Gao, H.Y. Yang, et al. Thyroid artery embolization to treat Graves’ disease. Acta Radiol 2007; 48:186-192.
- Haugen BR, Alexander EK, Bible KC et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016; 26:1-133.
- Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev 2012; 33:920-980.
- Yilmaz S, Habibi HA, Yildiz A, Altunbas H. Thyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients. J Vasc Interv Radiol. 2021; 32:1449-1456.
- Yilmaz S. Safety of Thyroidal Artery Embolization. J Vasc Interv Radiol. 2022; 33:200-201.
- Ducloux R, Sapoval M, Russ G. Embolization of thyroid arteries in a patient with compressive intrathoracic goiter ineligible to surgery or radioiodine therapy. Ann Endocrinol (Paris) 2016; 77:670-674.
- Tartaglia, F.M. Salvatori, G. Russo et al. Selective embolization of thyroid arteries for preresection or palliative treatment of large cervicomediastinal goiters. Surg Innov 2011; 18:70-78.