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Uterine Fibroid Embolisation

Oct 22 | 1:30 PM

Join us for another incredible turf expansion programme by IRIA Kerala, in which Dr. Shakthi Parvathy discusses Uterine Fibroid Embolisation (UFE), a well-established procedure for uterine fibroids, and its outcomes.

[Music] so to all the viewers this session is by irie kerala and it is part of the turf expansion program uh the speaker we have today with us is dr uh so sorry dr shakti fanati who is an interventional radiologist for medical trust hospital now i call dr to introduce her father thank you so warm welcome to ira kerala stuff expansion program today today as part of the turf expansion program i'm proud to introduce a distinguished speaker a human radiologist is real shakti of ira who has ventured into intervention radiology long back dr shakti parvati did her mbbs from td medical college ilp then did a dmrd from trichor medical college and then dnb and then did interventional radiology training from prestigious km institute and tata memorial hospital mumbai so that was the passion she had years back for interventional radiology and after that she came back here and started her interventional radiology opd and practice here at medical trust hospital coaching she has been doing excellent work in avery's field of interventional radiology she is the right speaker for the day for the turf expansion program and today she will be talking to us on uterine artery eutron fibroid embolisis an area that has to be explored further radiologists interventional radiologists has to directly reach out to the patients and can make a big difference significant difference especially in cases of multiple fibroids other in patients with infertility so i'm really happy to have shakti parvati here today to talk to us on uterine fibroid embolization iris women's wing is called as shakti and i'm proud that shakti parvati is representing shakti today kerala over to you thank you sir a good evening to all of you thank you dr rijo for the very kind words of introduction i talk today on uterine fibroid embolization uterine fibroid embolization has been around for a long long time almost 30 years yet very few people are aware of it and it is still not a mainstream line of treatment in india or in kerala so i'm truly grateful to iria kerala and netflix for giving me this opportunity to talk about uterine fibroid embolization and increase awareness about this um uterine fibroid embolization we all know what fibroids are they are a very common problem that many women face around 40 percent of women over 35 have fibroids fibroids oleomyomas are benign growths in the uterus which come from muscle and connective tissue this classification is also very familiar to all of us we classify fibroids based on the location intramural fibroids are fibroids which are in the wall of the uterus submucosal fibroids are fibroids which come protrude into the uterine cavity um subserious fibroids are fibroids which are subsea which protrude outwards from the wall of the uterine cavity and pedunculated fibroids are fibroids which have a stalk so you can have a pedunculated subserious fibroid or you can have a pedunculated submucous fibroid and cervical fibroids which are fibroids which are seen in the cervix now this classification is very very important when it comes to uterine fibroid embolization because it is very pertinent in taking a decision as to the management of the patient so the most common symptoms are excessive menstrual bleeding severe pelvic pain or heaviness many people have infertility either getting pregnant or even staying pregnant with higher incidences of abortion and there are compressive symptoms on the rectum and bladder with painful or difficult bowel movements or frequent micturition there are a wide variety of treatments available with hysterectomy and myomectomy surgical management which is a mainstay of treatment of fibroids with hysterectomy being the more common surgical treatment but in the later years in the recent years there has been a big interest in non-invasive methods of management which help to retain the uterus and one of these is uterine fibroid embolization so uterine fibroid embolization as i mentioned before has been around since 1995 dr ravina at all was a person who reported it first in the landsat initially it was done um to assist surgeons because they used to do the embolization to reduce blood loss during surgery but accidentally they discovered that the embolization procedure itself was very very beneficial and the fibroid shrunk even without the surgery and that was when interest in this method was generated and it has been developed and now it has become a mainstream line of management it is also classified as a first line of management which has to be offered to patients with fibroids so it is a fundamentally different procedure the advantages are it is minimally invasive there are no surgical incisions you can access the body through the femoral artery complication rates are very very low the post procedure recovery is very fast and it is as effective as surgical treatments like hysterectomy or myomectomy and it is a time tested method so when the patient comes to you we of course ah we have to go into detail into their symptoms we have to get a detailed menstrual history and also you ask if there are any pressure symptoms we have to find out whether the patient is pregnant or no and very important we have to also find out about their gynecological history whether they have completed their family or they are planning another child because you then all these factors will um influence the decision that you will take and also you can decide on whether the patient is an ideal candidate for the procedure or not so physical examination we have to rule out infection we have to rule out malignancy we definitely need a pap smear and a biopsy endometrial biopsy before we proceed because malignancy is an absolute contraindication at the same time we also have to rule out other coexisting conditions like adenomyosis endometriosis any agnex cell pathology which can influence the management and the outcome of the procedure and of course we have to also find out about diabetes hypertension other comorbidities history of drug allergies so that you can manage the patient holistically taking into account all these factors then we go the next step is always an investigation with ultrasound being the main line of investigation being cheap easily available and usually we get a very good idea by doing trans and trans abdominal and trans vaginal ultrasound we get a good idea about the location the extent the endometrial cavity and the ethnician pathology but nowadays the latest guidelines suggest that we have to do an mri because before we take up the patient for a procedure because mri is get gives much better soft tissue delineation you can locate the fibroids more accurately you can locate the accident and it really helps in decision making and also in a prognosis so the patient will get much more information so the patient can take an informed decision as to whether to go in for the procedure or not so i will take a little time on this slide because i wanted to dwell on each point separately size of course you get a much if big sizes um big size fibroids are not so well seen on ultrasound so mri will help there and usually what we find is that the bigger the fibroid the chance of the treatment is less successful then location when you come to location of course like i mentioned before if they are submucous fibroids then the chances of post procedure complications like bleeding are more because a fibroid can get expelled and uh if they are pedunculated fibroids then we have to see because they may recruit arteries from other vessels other than the uterine artery so again the procedure may not be as effective and the patient may benefit more from a surgical procedure so size and location and also the enhancement characteristics if the fibroid is already degenerated if there is if it is cystic if it is necrotic then the or if it is calcified the patient is not going to benefit much from the procedure if it is a well enhancing cellular fibroid those are the patients which will benefit the maximum so all these points like you see help us to decide whether the patient will benefit from the procedure or not and so we can give the patient the entire entire picture and of course most importantly we can rule out other things like adenomyosis endometriosis malignancy ethnic cell masses these things which we have not suspected and which will completely change our line of management and nowadays for mri we always do a contrast study with 3d imaging so you can also have an excellent delineation of uterine artery anatomy so with uterine artery anatomy so well delineated you can plan the procedure you can find out what are the difficulties that you're likely to face you can also see whether there is any supply from any other pelvic vessels is the over ovarian artery supplying the fibroids so you get a lot of additional information so your procedure can be planned meticulously and when you do the procedure you don't come up against unpleasant uh surprises and of course we can follow up in cases of recurrence of symptoms with again mri which is also a bit much width which gives you a much better idea about what has happened whether the fibroid is completely infected or not is there any other problem which is causing a symptom recurrence so we are all familiar with how the fibroids look and these are the main pointers that it is better to um these are the main points that we should see too and we should mention when we report uh fibroids um report mri for you prior to uterine fibroid embolization one is the size of the uterus the number of fibroids are not really if they are very small and multiple fibroids we don't have to really mention the exact number but an i am approximate amount number will do but we have to mention the size of the index or the important fibroids which are likely to be causing the symptoms and which have to be tackled during the procedure so for those fibroids we have to mention their exact location their exact size and the enhancement pattern and of course as everybody is familiar we can always pick out other pathology like adenomyosis endometriosis ethnic cell masses and we can get a detailed anatomy of the uterine artery neutron arteries on both sides these are the pointers that we look into and specifically mention prior to reporting a patient who has come for pre-procedure treatment planning so the ideal patient that we are going to take up is a pre-menopausal woman who has completed her family and they should not be should have ruled out infection malignancy or other gynecological problems which are likely to change the line of management and also we confirm with all our symptomatology examination and investigations that the present symptoms of the patient are due to the fibroid and preferably we prefer to take patients with fibroids which are less than 10 centimeter because the results are better so what are the contraindications very few the absolute contraindications are infection of course we can tackle the infection and then go in for the procedure pregnancy ongoing pregnancy is an absolute contraindication so are gynecological malignancies relative contraindications contrast energy can be managed with the change of contrast using on iso or smaller contrast and managing allergy with drugs bleeding disorders can also be controlled with blood products and vitamin k renal impairment of course we have to be very careful we have to consider the scenario and do the procedure only if it is absolutely imperative and the patient is not a kind candidate for a surgical procedure so in each situation we have to customize it to the patient and to the condition that the patient is taking the whole picture now submucous fibroids pedunculated subserious fibroids and large fibroids were important contraindications before and we used to always counsel patients to not take up uterine fibroid embolization if we found these fibroids on imaging but lately even these fibroids are being tackled with neutron fibroid embolization and we will talk about this in a little more detail in the coming slides so the technique so what do we do first we take a femoral puncture with a seldinger technique then we put in a sheath into the femoral artery and introduce a sheath through the sheath as you can see we have passed in a catheter and this catheter goes into the uterine artery so you can do it with a single puncture because you see that we are coming from the right and going into the left tube trine artery so you can similarly take a left puncture and go from the left into the right uterine artery or you can take a single puncture and negotiate the catheter into both uterine arteries that is personal preference now as you see the catheter has to be the uterine artery has a descending a transverse and an ascending segment which you can see in this slide so you try to ideally negotiate the catheter into the ascending segment so when you do that you are safe and you sure that your particles that you are injecting do not go into any other vessels and they go only into the fibroid so sometimes we may not uh sometimes we can get into the ascending segment with just the catheter if not we may have to take recourse to a micro catheter which is a much smaller catheter which we put through this catheter into the ascending segment so what we have to see that we go into the ascending segment so we avoid other branches and we can avoid non-target embolization then we use embolic agents called polyvinyl alcohol or embospheres which we inject into the blood vessels supplying the uterus here our aim is to go as distally as possible so you use smaller particles you use more dilute particles so that you don't clog the artery proximally if you clog the artery proximally you can get incomplete infection of the fibroid and it can recruit vessels from other places so your procedure will be unsuccessful so your aim is to go as distally as possible into the fibroid bed as much as possible and then you inject till you find some stasis still you find stasis so your aim is to inject and occlude the uh arterial on the bed supplying the fibroid but you should not occlude the uterine artery so you do this whole procedure injection under fluoro guidance and when you see that the arterial blush or the arterial supply is gone and the uterus uterine artery is maintained and stable you can stop your procedure at that point i'll just illustrate it in the next slide so you here you can see that a catheter and a micro catheter have been taken and you can see the blush caused by the fibroids so you inject and uh you inject till the blush disappears but you can still see the uterine artery the arrows showing the stumps of the utrin artery so here we have preserved the uterine artery but we've removed the blush from the fibroids and of course here you can see the mri follow-up showing that the fibroids will shrink another point that i want to mention is this fibroid has shrunk really dramatically but many fibroids do not shrink so much so even if you have done the procedure and the patient comes to you after a few months the fibroid may actually remain almost the same in size so usually there may be just a one centimeter diameter or two centimeter diameter reduction but actually that leads to a greater volume reduction and more importantly the fibroid does not grow so even if the fibroid has not really reduced in size you can reassure the patients who come because they get very good symptomatic relief and our aim is to see that this fibroid does not grow so that is something we may often see that the fibroids may not shrink so much and that is something that we have to counsel the patient or they will come back to you and say this procedure was done but the fibroid is still there so this is a point that we all have to remember so outcomes are excellent very comparable to the outcomes following myomectomy and hysterectomy and menorrhagia 90 to 92 percent so if you have done a uterine fibroid embolization in more than 90 percent of patients the next cycle that the lady has is usually normal sometimes it might take a month or two for the cycles to normalize in rare cases after the procedure if the women are perimenopausal they may even attain menopause so these are also the things that we have to bear in mind and counsel the patient and reassure them bulk symptoms are also ah show good response to uterine fibroids but they take a little more time for the effect to show usually menorrhagia responds much faster so these these outcomes are very good and very comparable to surgical treatment recovery is much faster compared to surgery and even though surgery has very little complications fibroid embolization has even fewer complications compared to surgery and quality of life when they compare in many many trials that they have done they were both comparable uh i mean the quality of life was comparable for uterine fibroid when compared to hysterectomy and biometer so we now come to the less than ideal scenarios which were more stronger relative contraindications earlier but now slowly eutron fibroid embolization is making inroads into these areas also and having an impact even in these areas so the advantage is that the patient has more options open suppose a patient wants to retain her uterus or suppose a patient is not a surgical candidate and she needs to treat her fibroids initially we used to be a little hesitant to take up these patients but now we can do it with little more confidence with little more confidence that we can benefit the patient so patients have recourse to treatment when other options are not available for them but cervical fibroids still are not a good option for uterine fibroid embolization unfortunately they do not respond well they usually the infection is incomplete and surgery surgery is still the preferred method of treatment for cervical fibroids and also another point is infertility now in some cases uterine fibroid embolization may be the only option for people ladies who want to conceive if they are not good candidates for myomectomy or if they are not good candidates for surgery or there are other issues which but through due to which they cannot undergo surgery but but those are rare scenarios so usually they say that uterine fibroid embolization is not generally advised as a first line management for people uh who wish to conceive again though there is a lot of data saying that even after uterine fibroid embolization ladies have conceived we don't have enough data to confidently reassure the patient that they have they can conceive in some scenarios taking into consideration everything we can treat ladies for infertility but usually we do not offer this as the first line management for people who do have not completed their family so coming to the relative contraindication size a lot of studies have been done which show that uterine fibroid embolization can be done in fibroids which are more than 10 centimeter they have found that the incidence of complications major and minor are not as bad as expected they are in fact comparable to treating uterine fibroids which are smaller in size and they are also as safe and as effective as treating smaller fibroids the incidence of re procedure or reintervention are not as high as it was initially thought so size is also a negotiable criteria for uterine fibroid embolization another ah situation is a pedunculated fibroid so initially everybody was afraid that if we treated a pedunculated fibroid it would detach and go into the pelvic cavity and cause severe pain and it may even need surgery but many studies have now shown that even pedunculated fibroids can be treated safely now when you say pedunculated you mean that the stock diameter is 50 narrower than the diameter of the fibroid usually for treating pedunculated fibroids we consider two centimeter of stock diameter as a cut off but studies have shown that even stock diameters less than two centimeters can be treated safely with you um by uterine fibroid embolization so even pedunculated subserious fibroids are no longer a contraindication for uterine fibroid embolization now coming to sub mucus fibroid which is the fibroid which causes the most symptoms after the surgery so you just usually happens because when the fibroid gets infected it is likely to get expelled via the endometrial cavity so when it gets expelled it can cause bleeding it can cause vaginal discharge it can cause severe pain and infection also so it's usually what happens is the fibroid just gets expelled as a whole and patients are not so symptomatic but in many cases the they will have all these symptoms and they may also end up in either a dnc or if they are very unlucky it may even end up in a hysterectomy so these are the fibroids which we have to be very careful about treating and we have to they are not a contraindication and can be done but we have to counsel the patient uh really well and really carefully and then they have to take a very informed decision as to whether they want it or not so the mri again helps here because mri you can assess the extent of the fibroids interface with the uterine cavity so you take the interface dimension ratio you measure the largest endometrial surface of the fibroid which is opposed to the which is in connection or income in contact with the endometrial cavity and then you take the largest dimension of the fibroid the ratio of these two gives the interface dimension ratio so if the interface dimension ratio is more than 0.5 or if the fibroid is more than 6 centimeters the chances of complications after procedure are higher and it is better to advise the patient to go in for another modality of treatment or if they choose to take this treatment they should be prepared for the complications and even for the possibility of hysterectomy so then you give them all the options and then they can take an informed decision so the interface dimension ratio again and that is again another place where mri is really helping you to assess the situation and give all the details to the patients so that they know what they are getting themselves in for submu so even but even submucosal fibroids 92 percent do not have major complications the fibroids are expelled without any problem or they just shrink in c2 but of course eight percent have significant post procedure symptoms which can be quite bad so the complications like we've said before are usually pain pain is a significant complication after the procedure so even before we start the procedure we put the patient on ketoluck injection and post procedure we can manage with opioids and ketolic injection sometimes you can even do a hypogastric nerve block so this hypogastric nerve block clearly helps to relieve pain after the first day of monitoring when the patient is discharged we manage pain with either opioids and also very strong non-steroidal anti-inflammatory drugs another very common complication is post embolization syndrome which is usually seen after any embolic procedure the patient will have fever they may have malaise they may have loss of appetite nausea this is usually self-limiting many of it much of the symptoms will go with just reassurance or it can be managed with drugs bleeding is always a dreaded complication of course and like i mentioned before bleeding is more likely to occur with some mucosal fibroids which are being expelled subserious or intramural fibroids usually do not cause bleeding infection also is much more common for submucosal fibroids and it is also a dreaded complication which can even end up in hysterectomy another complication that we that we see are that we see can be amenorrhea so what happens is sometimes even though we do a detailed study and assess the anatomy sometimes some there may be small connections and you between the uterine artery and the ovarian artery and when you embolize you can get ovarian failure and amenorrhoea and like i mentioned before some perimenopausal women after uterine fibroid embolization also go in for they get menopause so amenorrhea is also a factor but now with detailed study and mri and planning amenorrhea is not that common we can assess the anatomy and do the procedure accordingly fertility again they say that there are studies showing that uterine fibroid embolization after the procedure some patients are not able to conceive or sometimes they have a higher incidence of abortions or sometimes they are not able to carry their pregnancy to term but all these studies are very few and so we still do not have enough data regarding fertility and of course if you have bleeding severe bleeding or infection you may end up in a hysterectomy and also sometimes some fibroids do not respond well to your treatment and then you may have to go in for a repeat procedure you can repeat the procedure and they can go in for a reintervention or sometimes we may have to treat them with either hysterectomy or myomectomy and they may have to take recourse to a surgical procedure but what we have to keep in mind is that though there is this big list of complications the percentage of complications is very very less considering the vast number of people who have already undergone the symptoms so the complication rate is just four plus less than five percent so like i mentioned before it is a non-invasive procedure you're just making a nick into the fibroid femoral artery and nowadays we are doing it via the radial artery so that is the latest trend so we are trying to do all the procedures via the radial artery which makes the patient ambulant much faster it is almost like an ob procedure they can come in the morning get the procedure done and go back home the complication rates are much less like i mentioned before the procedure is extremely effective repeatable is necessary no need of any general anesthesia and the recovery time is faster even after procedure patients can go back to their normal activities in a much faster time than they can do after hysterectomy so to uterine fibroid embolization has come a long way since 1995 it is a first-line treatment for the management of fibroids the american college of gynecology has mentioned it as a first line treatment um and it is we are supposed to offer it all doctors are supposed to offer this modality of treatment to any patient who comes for treatment of fibroids so it has become it has established itself it has expanded the scope it has become much more widely applicable and it is treating pedunculated subserious submucous and large fibroids also so in conclusion neutron fibroid is safe effective and a time proven procedure for the treatment of fibroids which should be offered as an alternative to be to surgery and it can be considered as an alternative to surgery thank you so much thank you once again for your kind attention thanks once again to netflix and iria for this opportunity any questions i'll be glad to answer thank you dr shakti that was a wonderful presentation and then you opened up the new possibilities but this is still not very popular known not very much known to the general public yes yeah many people doesn't know there is an option called uh inter uterine artery and uterine fibroid embolization with interventional radiology and there are a lot of peop ladies who suffer who has got menorrhagia with intramural fibroids with significant endometrial pressure effects which are the ideal candidates i feel for this procedure and they will get a lot of relief from menopause and with by the shrinkage of the fibroid but in cases of myomectomy also i think there is a residual element of fibroid which is which is not people many many people think that after surgery or even it is called as post myomectomy the fibroid is the element of fibroid is totally gone it is not like that no am i right yes yes you're absolutely right that is why i said it is actually comparable the only definitive treatment for fibroid is hysterectomy that is the only definitive and it is the one which is resorted to the most um but um if you want to retain your uterus you are not so old and for those cases uterine fibroid embolization is very ideal and like you said you are very very right awareness about this procedure is abs almost zero it's almost nil people don't know about it and even doctors are not aware of it and they do not offer it as a form of treatment which i feel is actually very sad because many patients will benefit they may not be candidates for surgery so they are not aware that these options are actually available we are actually closing a door to a patient if he's if she's not a candidate for surgery if she wants to retain her uterus and she wants to get her condition treated we have excellent minimally invasive procedures available so like you say always say we need more and more talks and we need to improve awareness uh we have a lot of work actually ahead of us to improve awareness and make more people know about this procedure you've got an interventional radiology opd and medical tester yes sir we have so this is the first step and i'm very very grateful to all of you for giving me this chance yes we have an overview so this is this is actually a lot of numbers are there actually a lot of ladies who doesn't want to go for surgery or ideally not a candidate for surgery yes managing with medically with uh menorrhagia but still mentally is not under control yes and yeah there are lots and lots of ladies who can benefit out from this particular procedure so i think it is time radiologist one of the problems is that message also has to go in actually awareness is a major issue people are not aware so once the awareness comes because it is a very beneficial procedure it's very very beneficial patients recover so fast it is a it's all it's a wonder treatment so i'm really happy that i could get one this is the first step and i think we should have we should do more intensive uh talk so that we can spread more awareness about not only uterine fibroid about so many procedures that are there an intervention that people are not aware of right right true very true i i remember a case of a phenyl fracture treated by you yes yes yes arterial sinusitis yes yes a lot of possibilities are emerging with interventional radiology and especially a lot of lady radiologists the shakthi of ira are into the interventional radiology yes the next month and this year's international day of radiology is interventional radiology the radiology is in active patient care yes so that is the theme and i think dr shakti palvadi and dr jasim khoya two interventional radiologists from kerala are planning a program for ira care on november eighth international yes there is one this thing on response in adenomyosis by ufe so ah uf even adenomyosis um there are studies saying that you can treat adenomyosis also with ufv but not established we don't have enough data so we don't offer it as a first line management for adenomyosis but they are saying that adrenal meiosis also responds there are a lot of write-ups and articles saying that adenomyosis also responds but it is not established treatment like uterine fibroid embolization better to manage either surgically or medically no especially when there is a localized adenomyosis can can this be a benefit especially in patients with infertility being treated for infertility can rather than [Music] it's not as established as uterine fibroid embolization they are saying that all over the whole even if we tackle only the fibroids some the whole uterus as a whole has a reduction in the vascularity which itself may help to control the adenomyotic foresight but we have not we cannot confidently recommend to the patient like we can recommend you trying fibroid embolization so i think that the major category of people that whom uh who will be beneficial who will benefit out of this thing is menorrhagia yes so those are the who are not the ideal candidates who are not responsive to medicine they will all benefit from this and also preferably they should have completed their family perimenopause i i've seen cases where post myomectomy again fibroids grow and then and a lot of indications are there and now interventional radiology and dr shakti parvati is available here at medical trust if there are no more questions can i have a joint convener of a turf expansion program of ira kerala dr justin and me to give the vote of thanks thank you dr vaudeville secretary of uh years back when i joined as a trainee under the mentorship of dr joe matthew he always used to remind me never get stuck on basic imaging modalities radiology is an evolving subject with advancement of technologies unless we expand our stuff other specialties will encourage our field of science in today's talk on uterine fibroid embolization dr shakti parvati has enlightened us all with a interesting topic in a simple manner though we diagnose uterine fibroid in our daily practice as backstage performance possibility of treating fibroids by uterine artery butane fibroid embolization by radiologists will open a new horizon and dr parvati has seen us interesting many of the radiologists attended today's webinar thank you dr parvati for your wonderful presentation thank you thank you i thank all senior faculty coordinators and all fellow radiologists who are participating in this webinar and made this a wonderful session thank you thank you all thank you dr justin that was dr justin anthony the joint convener of the turf expansion program of indian radiological and imaging association kerala now i think it is time to wind up this session okay thank you so much man that was a very insightful session i'm sure people enjoyed it a lot and thank you all the viewers for joining in uh thank you to iria kerala

BEING ATTENDED BY

Dr. Sasikanth Reddy & 164 others

SPEAKERS

dr. Shakthi Parvathi

Dr. Shakthi Parvathi

Interventional Radiologist, Medical Trust Hospital

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. M.C.J. Prakash

Dr. M.C.J. Prakash

Consultant Radiologist | President - IRIA, Kerala

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dr. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapuram

+ Details
dr. Shakthi Parvathi

Dr. Shakthi Parvathi

Interventional Radiologist, Medical Trust Hos...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. M.C.J. Prakash

Dr. M.C.J. Prakash

Consultant Radiologist | President - IRIA, Ke...

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dr. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapur...

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