Interventional Radiology for Medical

Students

Author: Dr Liam Ingram, SpR

 Overview  
• Interventional  Radiology  (IR)  is  the  fastest  growing  and  one  of  the  
most  exciting  specialties  in  Radiology.  

• It  has  just  recently  been  accredited  with  sub-­‐specialty  status.      

• Interventional  radiologists  are  trained  in  diagnostic  Radiology  (3yrs  

training)  and  then  specialise  in  Interventional  techniques  (3yrs).  

• This  workbook  will  start  with  an    introduction  to  IR,  followed  by  a  
series  of  questions  and  case  based  problems  for  you  to  answer.    
 What  is  it?  
•   image  guided  procedures.  
Interventional  Radiology  (IR)  involves  
It  is  the  ‘doing’  part  of  Radiology  

• These  procedures  are  generally  split  up  into  percutaneous  

procedures  i.e.  going  directly  through  the  skin  into  the  target  
organ  or  an  endovascular  i.e.  via  blood  vessels.    

• Minimally  invasive  image  guided  techniques  are  increasing  being  

used  where  surgery  was  previously  the  only  option.    

• Trauma  is  one  area  where  IR  has  become  very  useful  in  stabilising  
bleeding  patients.    
 Percutaneous  procedures    
• Several  different  imaging  modalities  are  utilised  depending  on  the  target  organ.    
• Ultrasound  is  excellent  for  superficial  or  solid  organ  procedures  for  example  
placing  drains  in  infected  gallbladders  (cholecystostomy),  kidneys  
(nephrostomy)  and  abscesses.    
• In  deeper  areas  of  the  abdomen  and  pelvis  where  bowel  gas  may  be  obscuring  
our  view,  CT  can  be  used  to  place  a  drain.    
• In  many  situations,  multi-­‐modality  approaches  are  used  e.g.  percutaneous  
trans-­‐hepatic  cholangiograms  (PTC).  This  technique  is  often  combines  
ultrasound  and  fluoroscopy  to  obtain  access  into  the  biliary  system  via  the  skin  
and  then  liver  directly.    
• New  techniques  in  this  area  include  the  ablation  therapies.  These  generally  
employ  CT  or  US  guidance  to  deliver  a  probe  to  a  tumour  and  use  thermal  or  
cryotherapy  to  cause  tumour  necrosis.    
 Endovascular  Procedures    
• Involves  gaining  access  to  the  arterial  or  venous  system,  usually  via  the  
femoral  or  jugular  vessels.    
• Using  a  combination  of  wires  and  steerable  catheters,  most  places  in  the  
body  can  be  reached  and  treated.    
• The  number  of  procedures  in  this  area  is  growing  rapidly.  
•  Combinations  of  balloons  can  be  used  for  angioplasty,  stents  can  be  
deployed  to  open  narrowed  or  bleeding  vessels,  different  embolic  agents  
can  be  used  to  block  vessels  and  various  treatments  can  be  delivered  
directly  to  the  target  area  included  high  dose  chemotherapy  or  
radiotherapy.    
• New  techniques  in  this  area  include  prostate  artery  embolisation  for  
benign  prostatic  hypertrophy  (BPH)  and  chemo-­‐saturation  liver  therapy.  
 What  the  Medical  Student  Needs  to  Know  
About  IR  
• For  finals  -­‐  not  much!      
• Only  that  IR  exists  and  to  have  some  idea  about  
the  different  areas  where  it  is  useful.    
• During  your  post-­‐graduate  training  it  will  
become  more  prevalent  in  clinical  practice  and  
some  early  awareness  will  undoubtedly  be  
useful.    
 IR  Worksheet  -­‐  1  
The  Interventional  Radiologist  needs  to  master  one  
technique  which  is  the  basis  for  almost  all  of  
procedures.  You  may  have  already  used  it/seen  it  on  
the  wards.  This  is  called  the  SELDINGER  technique.    
 
1.  Write  or  draw  a  brief  description  of  the  Seldinger  
technique    
 
 Question  2  

(i)  What  is  fluoroscopy?  

(ii)  Can  you  think  of  other  examples  of  when  it  is  
used  in  radiology?    

(iii)  What  allows  us  to  ‘see’  blood  vessels  and  

what  is  important  to  check  before  using  it?  
 3.  Embolisation    
A  whole  group  of  IR  procedures  involve  ‘embolisation’.    

 (i)  What  does  this  mean?  

 (ii)  Can  you  think  of  any  groups  of  embolic  

 materials?  

 (iii)  What  does  ‘non-­‐target’  embolisation  mean,  

 and  why  is  it  bad  news?  
 Case  1  
Boris  is  56,  a  lorry  driver  who  is  overweight  and  
spends  a  lot  of  time  sitting  for  long  journeys.    

One  day  he  notices  that  his  calf  becomes  

painful,  swollen,  and  a  little  red.  He  goes  to  his  
GP  who  sends  him  to  the  acute  medical  unit.    
 Case  1  

(i)  What  do  you  think  the  diagnosis  is?  

(ii)  What  is  the  best  radiological  examination  to  

confirm  your  suspicion?    
 Case  2  
At  this  stage  Boris  is  haemodynamically  stable  and  not  short  
of  breath.  He  is  started  on  anti-­‐coagulation  therapy  and  is  
discharged  home.    
A  few  weeks  later,  despite  his  INR  being  in  the  therapeutic  
range,  he  develops  sudden  onset  pleuritic  chest  pain,  
shortness  of  breath,  feels  generally  unwell  and  is  hypoxic.  He  
attends  the  Emergency  department  who  suspect  he  has  
suffered  a  pulmonary  embolus  (PE).    His  CXR  is  normal.  
 Case  2  Continued  
(iii)  What  imaging  options  are  available  for  
confirming  this  diagnosis?  
(iv)  If  a  patient  has  a  confirmed  PE  whilst  on  
treatment  dose  anti-­‐coagulation,  what  IR  option  is  
available  for  protecting  against  further  PEs?  
(v)  Where  would  you  use  your  Seldinger  technique  
to  obtain  vascular  access  and  implant  this  device?    
 
 Case 1: Image 1
A IVC

This is a pig tail catheter

Catheter contrast flush run of the IVC.

(vi) The level of a particular

pair of important vessels must
be located, one is labelled as
(A), what is it?

Lumbar spine
 Case 1: Image 2
Case  1,  Image  2  
Device An implantable device is in
situ with and without contrast.

These are usually temporary,

sometimes they are
permanent.

(vii) How can we remove it?

Can you seen anything on
the device which may
help?

(Hint – image three may help)

Case 1: Image 3

This shows a common

problem where the device
has been deployed and
has ‘tilted,’ making
removal difficult.

(viii) How it can be

straightened?

(ix) Can you think of any

other indications for this
device, other than
recurrent PE on anti-
coagulation?
 Case 1: Image 4

4 (a) Balloon inflated to 4 (b) Device now collapsed

straightened device ready for removal
 Case  2:  The  Green  Man  

George  is  an  89  year  man  who  has  60  pack  years  
smoking  history,  has  type  II  diabetes,  ischaemic  heart  
disease,  hypertension  and  is  blind  in  one  eye.  He  has  a  
long  history  of  infected  and  poorly  healing  ankle  ulcers  
on  his  right  leg.  
Question  (i)  Name  three  non-­‐invasive  imaging  methods  which  
could  be  used  to  interrogate  this  patient’s  lower  limb  arteries?  
 Case 2: Image 1 SFA
Common
femoral artery
(CFA)

Profunda

Superficial
femoral artery
(SFA)
Popliteal
 Popliteal
Case 2: Image 2
TP trunk

AT PT - posterior
tibial artery

TP - tibioperoneal
trunk
Peroneal
PT
AT - anterior
tibial artery
 Case  2,  Images  1  and  2  
•  Images  1  &  2  –  this  shows  a  normal  lower  limb  
angiogram  from  a  common  femoral  artery  (CFA)  access.  

• Questions:  

–  (ii)  Now  look  at  Image  3  of  George,  how  are  his  

vessels  different?    Can  you  name  the  vessels  A-­‐C?  

– (iii)  Can  you  see  a  major  abnormality  which  could  be  

treated  to  improve  flow  to  the  patient’s  ankle?  

– (iv)  How  could  you  improve  flow?    

Case 2: Image 3
B

Knee
C
joint
Popliteal
Case 2: Image 4

(v) What are the tibial vessels

like? (i.e. the patient’s run off
- there should be 3!)

Compare with the normal

angiogram (images 1 and 2).

Tibia
Case 2: Image 5
Shows the result of your procedure.

Before After
 Case  3:  The  Red  Patient  
Ralph  is  17  and  sees  his  GP  who  refers  him  to  a  
Urologist  because  he  has  felt  what  feels  like  ‘a  bag  of  
worms’  in  the  left  side  of  his  scrotum.  It  causes  him  
some  discomfort  and  he  would  like  it  treated.  

   
Question  (i)  Which  imaging  investigation  is  best  to  
assess  his  scrotum?  
 
Testicle
Case 3: Image 1

(ii) This is the result of your

investigation, what do you
think it shows?
?

With Doppler flow

 Case  3  -­‐  Questions  
(iii)  Why  does  it  usually  occur  on  the  left  side?  

(iv)  What  IR  treatment  option  is  available?  

(v)  Where  would  you  use  your  Seldinger  

technique  to  gain  access?  Which  vessel  is  A?  
Case 3: Image 2

Catheter in IVC
Case 3: Image 3
(v) Which vessel is B?

B
Case 3: Image 4 – coils have been inserted to occlude the vessel

Coils

Notice the lack of distal contrast past the coils

 Case  4:  The  Yellow  Patient  
Yasmin  is  35  and  has  many  years  of  alcohol  abuse.  She  
has  cirrhosis  of  her  liver  with  several  admissions  due  
variceal  bleeding  and  decompensated  liver  failure.  She  
has  regular  ascitic  drainages  to  relieve  tense  ascites.  
She  has  portal  hypertension  and  the  Hepatalogists  
have  tried  several  therapies  and  have  now  requested  
assistance  by  IR.  
 Case  4:  Questions  
(i)  The  liver  has  a  ‘dual’  blood  supply.  What  vessel  provides  2/3  of  
the  blood  supply  to  the  liver?  

(ii)  What  are  the  3  main  smaller  vessels  which  combine  to  form  
this  major  vessel?  

(iii)  When  pressure  in  the  portal  venous  system  increases,  porto-­‐
systemic  shunts  occur  causing  varices.  Can  you  think  of  any  sites  
of  variceal  formation  and  hence  bleeding?  Image  1:  shows  two  
slices  of  her  CT  scan  through  her  liver,  note  the  varices,  ascites  
and  shrunken  nodular  cirrhotic  liver.  
Case 4: Image 1
Cirrhotic liver
Ascites

Varices filled
with contrast Spleen
Two slices of her CT scan through her liver, note the varices, ascites and
shrunken, nodular, cirrhotic liver.
 Case  4:  Questions  

(iv)    To  reduce  portal  pressure,  IR  can  form  a  tract/shunt  

between  the  systemic  blood  system  and  the  portal  venous  
system  called  a  TIPSS,  what  does  this  acronym  mean?  

(v)  As  the  name  suggests,  the  right  internal  jugular  vein  is  
usually  used  to  gain  access  to  the  vena  cava  then  right  or  
middle  hepatic  veins  (see  image  2).  How  do  you  think  
access  to  the  portal  system  is  achieved  (see  image  3!)?      
Case 4: Image 2

Catheter in IVC
Middle hepatic vein

IVC
Case 4: Image 3 - a needle is passed through the catheter and
positioned ‘blindly’ into where the portal vein branch should lie!

Needle – hepatic
vein to portal vein

Portal vein
branches
 Case  4:  Questions  
(vi)  Now  that  you  have  accessed  the  portal  system,  
how  do  you  keep  it  open  (see  image  4)?  

(vii)  As  seen  on  the  CT,  once  the  portal  system  is  
accessed  large  varices  are  visualised  which  may  
become  a  source  of  bleeding  (haematemesis  in  this  
case).  How  can  we  fix  those  (see  image  5)?  
Case 4: Image 4

TIPS stent in situ

Case 4: Image 5

Coils
Varices

Note the lack of flow

following coil insertion
 Case  5:  The  White  Patient  
Wilfred  is  a  72  year  old  male  who  has  been  involved  in  a  road  
traffic  collision  at  70mph.  He  has  obtained  multiple  blunt  force  
injuries  and  is  transferred  to  the  Emergency  department.  He  
was  initially  unstable  but  after  resuscitation  he  stabilised  and  
the  Emergency  Department  performs  a  F.A.S.T  scan  in  resus.  
They  find  some  fluid  around  the  liver  and  proceed  by  requesting  
a  multi-­‐trauma  CT  scan.  

  Question (i) What is a F.A.S.T scan?

Case 5: Image 1
Stomach
Liver

B
A

Spleen
 Case  5:  Questions  
(ii)  What  important  two  findings  are  shown  in  this  CT  image  
(image  1)?    

(iii)  The  IR  Consultant  has  been  asked  to  provide  

emergency  treatment,  what  procedure  should  be  
performed?  

(iv)  You  have  gained  access  into  the  right  common  femoral  
artery  and  navigate  to  the  coeliac  axis.  What  three  vessels  
make  up  the  conventional  coeliac  axis?    
Case 5: Image 2

Stomach
Liver

Pancreas
(v) A contrast run was
performed. What is the large
arrow pointing at?
Catheter
 Case 5: Image 3

Coils

(vi) A super-selective micro catheter was passed

into the area of abnormality and coiled. Why can
you embolise parts of liver and it not be too
troublesome for the patient (think back to the
case of the yellow patient!)?
The  End