“INTERVENTIONAL RADIOLOGY”

INSTITUTE OF PARAMEDICAL SCIENCES

KHYBER MEDICAL UNIVERSITY PESHAWAR

Prepared By: SHAIKH ATIF MEHMOOD

BS Medical Imaging Technology, MSc Ultrasound

Certificate in Health Profession Education (CHPE), Khyber Medical University Peshawar

Clinical Implementation of Ultrasound in Breast Imaging (CME Certificate)

Certificate in Radiation Terror (John Hopkins Bloomberg School of Public Health)

Certificate in Cone Beam CT better to guide Biopsies (University of Pennsylvania)

Certificate in Advanced Abdominal CT (Institute for Advanced Medical Education)

Certificate in 3D imaging Boosts Breast Cancer Detection (University of Pennsylvania)

Certificate in the Emerging Role of MRI in Prostate Imaging (Postgraduate Institute for Medicine Englewood)

Certificate in Cardiac CT best practices: Building and implementing injection Protocols (Institute for
Advanced Medical Education)

Certificate in Extracellular and Hepatobiliary MRI Contrast Agents in the Evaluation of Liver Diseases

(American Registry of Radiologic Technologist (ARRT)

LECTURER -COORDINATOR (RADIOLOGY) IPMS-KMU

 “Interventional Radiology”
 Interventional radiology (abbreviated IR or VIR for Vascular and
Interventional Radiology, also referred to as Surgical Radiology) is an
independent medical specialty, which was a sub-specialty of radiology.

 Until recently, that uses minimally invasive image-guided procedures to

diagnose and treat diseases in nearly every organ system.

The concept behind interventional radiology is to diagnose and treat patients using
the least invasive techniques currently available in order to minimize risk to the
patient and improve health outcomes

 As the inventors of angioplasty and the catheter-delivered stent, interventional

radiologists pioneered modern minimally invasive medicine.

 Using X-rays, CT, ultrasound, MRI, and other imaging modalities,

interventional radiologists obtain images which are then used to direct
interventional instruments throughout the body.

 These procedures are usually performed using needles and narrow tubes
called catheters, rather than by making large incisions into the body as in

traditional surgery. Many conditions that once required surgery can now be
treated non-surgically by interventional radiologists. By minimizing the
physical trauma to the patient, peripheral interventions can reduce infection
rates and recovery time, as well as shorten hospital stays.

 History:
 Interventional radiologists are minimally invasive specialists.

 The landscape of medicine is constantly changing, and for the past 30 years,
interventional radiologists have been responsible for much of the medical
innovation and development of the minimally invasive procedures that are
commonplace today.

 Interventional radiologists pioneered modern medicine with the invention of

angioplasty and the catheter-delivered stent, which were first used to treat
 peripheral arterial disease. By using a catheter to open the blocked artery,
the procedure allowed an 82-year-old woman, who refused amputation
surgery, to keep her gangrene-ravaged left foot.

 To her surgeon’s disbelief, her pain ceased, she started walking, and three
"irreversibly" gangrenous toes spontaneously sloughed. She left the hospital
on her feet—both of them.

 Interventional radiologist Charles Dotter, MD, known as the "Father of

Interventional Radiology" for pioneering this technique, was nominated for the
Nobel Prize in Physiology or Medicine in 1978.

 Alexander Margulis coined the term "interventional" for these new, minimally
invasive techniques.

 He emphasized that to continue to be on the forefront of innovation,

interventional radiologists must possess special training, technical skill,
clinical knowledge, ability to care for patients, and closely collaborate with
surgeons and internal medicine subspecialists.

 Development of stents began slowly.

 In 1969, Dotter conceived the idea of expandable stents with an intra-arterial

coil spring. The first stents developed by Dotter and Andrew Craig were made
of nitinol.

 Gianturco introduced his self-expandable Z stent.

 Hans Wallsten introduced a self-expandable mesh stent, Ernst Strecker a

knitted tantalum stent and Julio Palmaz his balloon expandable stent, which
was later perfected and introduced to clinical practice.

 Angioplasty and stenting revolutionized medicine and led the way for the
more widely known applications of coronary artery angioplasty and stenting
that revolutionized the practice of cardiology.

 Treatment of GI bleeding has a storied tradition. After introduction of selective

vasoconstrictive infusions by Baum, Josef Rösch introduced selective
arterial embolization for treatment of uncontrollable bleeding in the early 70s.

 Anders Lundequist treated variceal bleeding with the technique of

transhepatic variceal embolization in the mid 70s.
 Interventions in the biliary tract were developed by several pioneers.

 Interventional Radiologist Joachim Burrhenne invented and perfected the

technique of percutaneous removal of retained billiary stones.

 Plinio Rossi and Hall Coons enriched biliary interventions with their work
using biliary stents.

 The innovative interventionalists Kurt Amplatz, Willi Castaneda and Dave

Hunter pioneered percutaneous uroradiologic interventions.

 They popularized nephrostomy drainage, percutaneous stone extraction, and

ureteral stenting

 Milestones Pioneered by Interventional Radiologists:

 1964 Angioplasty

 1966 Embolization therapy to treat tumors and spinal cord vascular

malformations by blocking the blood flow

 1967 The Judkins technique of coronary angiography, the technique still

most widely used around the world today

 1967 Closure of the patent ductus arteriosis, a heart defect in newborns of a

vascular opening between the pulmonary artery and the aorta

 1967 Selective vasoconstriction infusions for hemorrhage, now commonly

used for bleeding ulcers, GI bleeding and arterial bleeding

 1969 The catheter-delivered stenting technique and prototype stent

 1960-74 Tools for interventions such as heparinized guidewires, contrast

injector, disposable catheter needles and see-through film changer

 1970s Percutaneous removal of common bile duct stones

 1970s Occlusive coils

 1972 Selective arterial embolization for GI bleeding, which was adapted to

treat massive bleeding in other arteries in the body and to block blood supply
to tumors

 1973 Embolization for pelvic trauma

 1974 Selective arterial thrombolysis for arterial occlusions, now used to treat
blood clots, stroke, DVT, etc

 1982 TIPS (transjugular intrahepatic portosystemic shunt) to improve blood

flow in damaged livers from conditions such as cirrhosis and hepatitis C

 1982 Dilators for interventional urology, percutaneous removal of kidney

stones

 1983 The balloon-expandable stent (peripheral) used today

 1985 Self-expanding stents

 1990 Percutaneous extraction of gallbladder stones

 1990 Radiofrequency ablation (RFA) technique for liver tumors

 1990s Treatment of bone and kidney tumors by embolization

 1990s RFA for soft tissue tumors, i.e., bone, breast, kidney, lung and liver
cancer

 1991 Abdominal aortic stent grafts

 1994 The balloon-expandable coronary stent used today

 1997 Intra-arterial delivery of tumor-killing viruses and gene therapy vectors

to the liver

 1999 Percutaneous delivery of pancreatic islet cells to the liver for

transplantation to treat diabetes

 1999 Developed the endovenous laser ablation procedure to treat varicose

veins and venous disease

 Imaging Modalities:
 Common interventional imaging modalities include fluoroscopy’ computed
tomography (CT), ultrasound (US), and magnetic resonance imaging(MRI) as
well as traditional (plain) radiography.

Fluoroscopy and computed tomography use ionizing radiation that may be

potentially harmful to the patient and the interventional radiologist.
 However, both methods have the advantages of being fast and geometrically
accurate.

 Ultrasound is frequently used to guide needles during vascular access and

drainage procedures. Ultrasound offers real-time feedback and is
inexpensive. Ultrasound suffers from limited penetration and difficulty
visualizing needles, catheters and guide wires.

 Magnetic resonance imaging(MRI) provides superior tissue contrast, at the

cost of being expensive and requiring specialized instruments that will not
interact with the magnetic fields present in the imaging volume

 Disorders
1. Vascular:

 Varicose veins Pooling of blood in the veins from weak valves resulting in
enlarged, swollen vessels causing pain and cosmetic complaints.

 Interventional endovenous laser treatment or sclerotherapy may be used to

heat the vein from the inside, sealing it closed. Other healthy veins carry
blood from the leg to reestablish normal flow.

 Peripheral artery disease (PAD) Most commonly a result of atherosclerosis,

occlusion of normal blood flow in the upper and lower extremities may result
in pain, skin ulcers, or gangrene.

 Stenting, angioplasty, and mechanical atherectomy are available

interventional treatments.

 Deep vein thrombosis (DVT) The formation of a thrombus, or blood clot, in

the deep leg veins which may lead to swelling, discoloration, and pain. DVTs
can result post-thrombotic syndrome and pulmonary embolism.

 Post-thrombotic syndrome is irreversible damage from a long standing DVT in

the affected leg veins and valves, leading to chronic pain, swelling, and
severe skin ulcers.

 Pulmonary embolism is a life-threatening condition which occurs when a deep

vein thrombus (DVT) breaks off and travels to the lungs, resulting in difficulty
breathing. Catheter-directed thrombolysis, balloon angioplasty,
or stenting may be performed in the affected vein to dissolve the clot and
restore normal blood flow.
 Pulmonary embolism A potentially life-threatening occlusion of the arteries
supplying the lungs with blood clots, manifesting in shortness of breath,
fatigue, palpitations, and fainting.

 Catheter-directed thrombolysis may be performed for this condition, where a

catheter is inserted into the leg, threaded up to the lung, and then used to
infuse "clot-busting" drugs into the occlusion.

 IVC filter placement Patients who have a history of, or are at risk
for, pulmonary embolism may receive temporary or permanent inferior vena
cava (IVC) filters to prevent the migration of blood clots to the lungs, and
consequently prevent recurrence of pulmonary embolism

 Abdominal aortic aneurysms (AAA) A weakening and dilatation of

the abdominal aorta wall that can result in abdominal or back pain, and
potentially life-threatening bleeding if it ruptures.

 Interventional treatment of this condition via non-surgical means

is endovascular aneurysm repair, using angiography and stenting to occlude
the AAA and prevent its continued growth.

 Thoracic aortic aneurysms (TAA) and Aortic dissection Anuerysms, or

dilatations, of the thoracic (chest cavity) aorta may be caused
by atherosclerosis, syphilis trauma, or multiple other conditions.

 Aortic dissections are tears in the thoracic aorta resulting from trauma or
weakening of the aortic vessel walls from conditions such
as hypertension, atherosclerosis, and congenital conditions such as Marfan
syndrome.

 Interventional treatments for TAAs and aortic dissections utilize stent grafts,
sometimes in combination with surgery, to prevent blood flow from enlarging
the diseased area or rupturing the aorta.

 Acute limb ischemia The sudden disruption of blood flow to an arm or a leg
due to arterial occlusion by a blood clot or other debris, potentially treated with
catheter-directed thrombolysis or mechanical thrombectomy.

 Acute mesenteric ischemia A medical emergency resulting from interruption

of the blood supply to the abdominal organs due to blockage of
the mesenteric arteries or veins by thrombus, embolus, or aortic dissection.
 Treatment varies by etiology of the ischemia, but may
include thrombolysis, stenting, or angioplasty.

 Aneurysms of visceral arteries Dilatation of visceral arteries supplying

organs such as the spleen, liver, or gastrointestinal tract can result in pain and
life-threatening bleeding.

 Stenting, embolization, liquid occlusion, and thrombin injection are the

available interventional therapies for these disorders

 Arteriovenous malformations (AVMs) Aberrations in normal vascular

anatomy treatable by embolization which may cause pain, bleeding, heart
problems, or cosmetic concerns.

2. Oncologic:

Various interventional therapies exist to treat cancers.

 Tumor type, size, extent of disease, operator experience, and involvement of
anatomical structures all factor into deciding which therapy is most
appropriate.

 Some therapies, such as transarterial chemoembolization, block the blood

supply to tumors.

 Other techniques--radiofrequency ablation (RFA),microwave

ablation, cryoablation, irreversible electroporation (IRE), and high-intensity
focused ultrasound (HIFU)—directly damage the cancerous tissue.

 All of these treatments are delivered locally, minimizing damage to nearby

tissue and avoiding the systemic side-effects of chemotherapy.

 Liver cancer For liver cancer, curative treatment is liver resection or liver
transplant; however, cryoablation, radiofrequency ablation, percutaneous
ethanol injection, chemoembolization, and radioembolization are options for
patients that are poor candidates for resection or transplantation.

 Lung cancer Surgery (lobectomy) remains the reference for treating early
stage lung cancer, however, most patients are not surgical candidates at the
time of diagnosis

 For these patients, minimally invasive treatment options, including high-

dose radiation therapies and percutaneous thermal ablation therapies such
 as radiofrequency ablation, microwave ablation, and cryoablation have
emerged as safe and effective treatment alternatives.

 Kidney Cancer

 Bone Cancer

 Breast Cancer

 Surgery remains the best curative option for patients with breast cancer.
However, for those patients who aren’t surgical candidate, minimally invasive
options such as those offered by interventional radiologists remain a viable
option.

 In particular, thermal ablation, including radiofrequency ablation

and cryoablation, and laser ablation therapies have been used to provide
targeted therapies for breast cancer.

 Prostate Cancer

3. Neurologic:
 Stroke

 A neurological condition occurring when the brain is starved of oxygen and

nutrients resulting from the blockage of blood vessels supplying it (ischemic
stroke) or from bleeding (hemorrhagic stroke).

 Symptoms include language, motor, sensory, and vision deficits.

 Interventional neuroradiologists play a critical role in determining the type of

stroke (ischemic or hemorrhagic) using non-contrast computed tomography
(CT) imaging or magnetic resonance imaging (MRI), and then treating the
stroke using minimally invasive treatment, if possible.

 Carotid artery stenosis A narrowing of the carotid artery supplying the brain
which can lead to stroke and disability.

 Carotid artery stenting (CAS) is an alternative to surgical carotid

endarterectomy (CEA) which may be performed in patients who have
symptomatic carotid atherosclerotic disease but who are poor candidates for
open surgery.

 Multiple Sclerosis Angioplasty of the cervical veins has been suggested as an

interventional treatment of chronic cerebrospinal venous insufficiency
 (CCSVI) that, hypothetically, contributes to the pathogenesis of multiple
sclerosis.

4. Spine:
 Spinal fractures

 Vertebroplasty and kyphoplasty, the percutaneous injection of biocompatible

cement into fractured vertebrae, are two available treatments for vertebral
fractures

5. Hepatobiliary:
 Portal hypertension

 A condition in which the normal flow of blood through the liver is slowed or
blocked by scarring (cirrhosis) or other damage (e.g. hepatitis).

 Patients with the condition are at risk of internal bleeding or other life-
threatening complications.

 Transjugular intrahepatic portosystemic shunt (TIPS) formation is a minimally

invasive treatment to alleviate this impaired blood flow.

 Bile Duct Obstruction

 Patients with liver cancer, bile duct cancer, cholecystitis, cholangitis, or

other hepatobiliary pathology may experience obstruction of bile ducts.

 Interventional radiologists commonly perform procedures such

as percutaneous transhepatic cholangiography (PTHC or PTC) to image
these obstructions, and may treat these conditions using percutaneous
transhepatic biliary drainage (PTBD),
 Where in catheters or stents are placed through the skin and into the bile
ducts to drain the bile for prolonged periods of time or until surgery.

6. Kidney:
 Renal artery stenosis

 A narrowing of the arterial supply of the kidneys which may result in high
blood pressure (hypertension) or renal insufficiency

 Diagnosis of these conditions is made by measuring the diameter of stenosis,

the blood pressure across the area of stenosis, renal vein renin sampling,
and captopril challenge testing.

 Stenosis may be treated by balloon angioplasty or stenting.

 Renal failure/Dialysis catheter placement Patients in renal failure may

require the placement of a hemodialysis catheter prior to initiating
hemodialysis for renal failure

 Dialysis fistula/Arterio-venous graft clot

 Dialysis fistulae and grafts may become occluded by blood clots, requiring an
interventional “declot” procedure in which mechanical or chemical
thrombolysis is performed to eliminate the clot.

 Nephrostomy tube placement

 In conditions where a blockage exists between the kidney and the urethra,
such as with kidney stones, a tube may be placed into the kidney under
imaging guidance to allow the drainage of urine and to prevent kidney
damage.

 Renal Sympathetic Denervation

 An ablation catheter can be used to denervate the renal arteries in resistant

hypertension, often reducing the blood pressure.

TYPES OF INTERVENTIONAL PROCEDURES:

 Interventional radiology procedures began in the 1930s with angiography;
needles and contrast media were used to enter and highlight an artery.
 In the early 1960s, Mason Jones pioneered transbrachial selective
coronary angiography—entering select coronary arteries through an artery
of the arm.

 Also during the 1960s, transfemoral angiography—entering an artery in the

thigh—of selective visceral, heart, and head arteries was developed.

 Melvin Judkins introduced coronary angiography, and Charles Dotter

introduced visceral angiography.

 Angiography refers to the opacification of vessels through injection of contrast

media.

 Angioplasty, thrombolysis, embolization, vascular stents, and biopsy are

interventional therapeutic procedures that are conducted in and through
vessels.

 Following is list of the types of imaging and interventional procedures that are
likely to be conducted in an IR suite.

Imaging Procedures Interventional Procedures

1. Angiography 1. Stent placement
2. Aortography 2. Embolization
3. Arteriography 3. Intravascular stent
4. Cardiac 4. Thrombolysis
catheterization 5. Balloon angioplasty
5. Myelography 6. Atherectomy
6. Venography 7. Electrophysiology

Vascular-Interventional Radiography Procedures

A. Neurological

1. Neurologic Angiography 2. Spinal arteriography

3. Embolization 4. Thrombolysis
5. Thrombectomy 6. Angioplasty
7. Stent placement 8. Vertebroplasty and/or
Kyphoplasty 9. Discography

B. Thoracic

1. Thoracic aortography 2. Pulmonary arteriography

3. Superior vena cava (central venography) 4. Embolization
 C. Abdominal

1. Abdominal aortography 2. Selective visceral angiography

3. Renal angiography 4. Adrenal angiography
5. Reproductive angiography 6. Inferior vena cava
7. Embolization 8. Angioplasty
9. Stent placement 10. Stent graft placement
11. Caval filter placement 12. Caval filter removal
13. Venous sampling 14. TIPS
15. Chemoembolization

D. Genitourinary and Gastrointestinal, non-vascular

1. Nephrostomy 2. Ureteral dilatation and/or stents

3. Percutaneous renal stone extraction 4. Biliary stone extraction
5. Percutaneous transhepatic cholangiogram (PTC)
6. Biliary drainage and/or stenting 7. Cholecystostomy
8. Gastrostomy or gastrojejunostomy

E. Peripheral

1. Upper extremity arteriography 2. Lower extremity arteriography

3. Extremity venography 4. Dialysis angiography
5. Embolization 6. Thrombolysis
7. Thrombectomy 8. Angioplasty
9. Stent placement 10. Atherectomy
11. Central venous access (non-tunneled/PICC line)
12. Central venous access (tunneled/port)

F. Miscellaneous

1. Biopsy 2. Percutaneous drainage

3. Removal of foreign body 4. Radiofrequency ablation

BASIC PRINCIPLES:
1. Arterial Access:
 In 1953, Sven Ivar Seldinger described a method of arterial access in which a
catheter was used.
 The Seldinger needle is an 18-gauge hollow needle with a stylet.

 After the Seldinger needle is inserted into the femoral artery and pulsating
arterial blood returns, the stylet is removed.

 A guidewire then is inserted through the needle into the arterial lumen.

 With the guidewire in the vessel, the Seldinger needle is removed, and a
catheter is threaded onto the guidewire.

 Under fluoroscopic view, the catheter then is advanced along the guidewire

 In angiography, the common femoral artery is most often used for arterial
access.

 The common femoral artery can be palpated by locating the pulse in the groin
below the inguinal ligament, which passes between the symphysis pubis and
the anterior superior iliac spine.

2. Guidewires:
 After the catheter is in place, the guidewire allows the cardiologist to position
the catheter within the vascular network.

 Guidewires are fabricated of stainless steel and

contain an inner core wire that is tapered at the end to a soft, flexible tip.

 This core wire prevents loss of sections of the wire if it breaks.

 The trailing end of the guidewire is stiff and allows the guidewire to be
pushed and twisted so the catheter can be positioned in the chosen vessel.

 Guidewires allow the safe introduction of the catheter into the vessel.

 Conventional guidewires are 145 cm long.

 Catheters overlaying the guidewire are usually 100 cm long or less.

They are coated with a hydrophilic material so the catheter slides over the wire
more easily.

 This coating makes guidewires more resistant to thrombus (blood clot) and
easier to irrigate while they are in the vascular system.
 The coatings on guidewires are materials that are designed to reduce friction;
they include Teflon, heparin coatings, and, more recently, hydrophilic
polymers.

3. Catheters
 Similar to guidewires, catheters are designed in many different shapes and
sizes.

 Usually, catheter diameter is categorized in French (Fr) sizes, with 3 Fr

equaling1 mm in diameter.

 The shaped tip of the catheter is required for selective catheterization of

openings into specific arteries.

 The H1 or headhunter tip designed by Vincent Hinck is used for the femoral
approach to the brachiocephalic vessels.

 The Simmons catheter is highly curved for approach to sharply angled

vessels and was also designed for cerebral angiography but was later
adopted for visceral angiography.

 The C2 or Cobra catheter has an angled tip joined to a gentle curve and is
used for introduction into celiac, renal, and mesenteric arteries.

 Pigtail catheters have side holes for ejecting contrast media into a compact
bolus

The jet effect is minimized with the curved pigtail, which prevents injury to the
vessel.

 After the catheter is introduced into the vessel, the guidewire is removed.
 The catheter then must be flushed immediately to prevent clotting of blood
within the catheter

 Heparinized saline generally is used to flush catheters.

 After catheter placement, a test injection is performed under fluoroscopy

before static imaging to check that the catheter tip is not wedged and that it is
in the correct vessel.

 Injection rates of the automatic power injector are gauged by the test flow
speed.

4. Contrast Media:
 Vessels under investigation in angiography are injected with radiopaque
contrast media.

 Initially, ionic iodine compounds were used for contrast injections; however,
nonionic contrast media have largely replaced ionic agents.

 Because of their low concentration of ions (low osmolality), physiologic

problems and adverse reactions are reduced for patients undergoing
angiographic injection with nonionic contrast media.

Patient Preparation and Monitoring:

 Before angiography is performed, the cardiologist visits the patient to
establish rapport and to explain the procedure and its risks.

 A history and physical examination are necessary to assess the patient for
allergies and other conditions so the cardiologist can conclude whether a
procedure is indicated and which route is optimal.

 Orders are written for intravenous hydration and a diet of clear liquids.

 The patient may be premedicated in the IR suite to reduce anxiety.

 During the procedure, monitoring by electrocardiography, automatic blood

pressure measurement, and pulse oximetry is mandatory.

Risks of Arteriography:
 The most common complication associated with catheter angiography is
continued bleeding at the puncture site.

 Of course, the risk of reaction to contrast media is present, and other risk
factors are related to kidney failure.

 Minimization of these risks requires a complete patient medical examination

and the taking of surgical and allergy histories before any angiographic
procedure can be done.

 Although uncommon, serious adverse reactions related to blood clot

formation or catheter or guidewire penetrating injury can occur.

INTERVENTIONAL RADIOLOGY SUITE:

 Different from radiography and fluoroscopy, IR requires a suite of rooms.

 The procedure room itself should not be less than 20 ft along any wall and not
less than 500 ft2. This size is necessary to accommodate the quantity of
equipment required and the large number of people involved in most
procedures.

 The procedure room usually has at least three means of access.

 Patient access should be available through a door wide enough to

accommodate a bed.

 Access to the procedure room from the control room with the operating
console does not usually require a door.

 An open passageway is adequate. Such doors interfere with movement of

personnel.

 The procedure room should be finished with consideration for maintaining a

clean and sterile environment.

 The floor, walls, and all counter cabinet surfaces must be smooth and easily
cleaned.

 The control room should be large, perhaps 100 ft2.

 Ideally, this room should communicate directly with the viewing areas.

 It also should have positive air pressure and filtered incoming air
 Personnel:

 A radiological Technologist can specialize in many different fields.

 A Technologist who specializes in IR requires additional skills.

 Two or three Technologists may be present in the IR suite, as well as the

interventional radiologist and a radiology nurse, who carefully monitors the
patient.

 During procedures that require the patient to be highly medicated, an

anesthesiologist also may be present.

Equipment

 The x-ray apparatus for an IR suite is generally more massive, flexible, and
expensive than that required for conventional radiographic and fluoroscopic
imaging.

 Advanced radiographic and fluoroscopic equipment is required.

 Generally, two ceiling track–mounted radiographic x-ray tubes are required

along with a digital fluoroscope mounted on a C- or an L-arm.

1. X-ray Tube.
 The x-ray tube used for IR procedures has a small target angle, a large-
diameter massive anode disc, and cathodes designed for magnification
and serial radiography.

 A small focal spot of not greater than 0.3 mm is necessary for the spatial
resolution requirements of small vessel magnification radiography.

 Neuroangiography can be performed in contrast-filled vessels as small as 1

mm with typical selection of geometric factors and careful patient positioning.

 A 0.5-mm vessel will be too blurred to be seen. Any vessel larger than 1.0
mm will be imaged.

 All other essential characteristics of an interventional x-ray tube are based on

required tube loading.

 The size and construction of the anode disc determine the anode heat
capacity, which in turn influences the power rating.

 An x-ray tube with a minimum 80 kW rating and 1 MHU heat capacity is

required.

2. High-Voltage Generator. High-frequency generators are increasingly

popular in all x-ray examinations, including IR procedures.

 However, some IR procedures require higher power than may be available

with high frequency generators.

 High-voltage generators with three-phase, 12-pulse power capable of at least

100 kW with low ripple are needed for such high power requirements.
 3. Patient Couch. Whereas most general fluoroscopy imaging systems have
a tilt table, IR imaging systems do not.

 General fluoroscopy often requires head-down and head-up tilting of the

patient for manipulation of contrast media.

 Imaging techniques such as myelography require a tilt couch; therefore, such

procedures are common in general fluoroscopy

 Other imaging and interventional procedures do not require a tilt couch, but a
stationary patient couch with a floating or movable tabletop is used instead.

 Controls for couch positioning are located on the side of the table and are
duplicated on a floor switch.

 The floor switch is necessary to accommodate patient positioning while a

sterile field is maintained.

 The patient couch may have computer-controlled stepping capability. This

feature is necessary to allow imaging from the abdomen to the feet after a
single injection of contrast medium.

 An additional requirement of this stepping feature is the ability to preselect the

time and position of the patient couch to coincide with the image receptor.

4. Image Receptor. Several different types of digital image receptors can be

used in IR procedures. The digital image receptor begins with a television
camera pickup tube or a charge-coupled device (CCD).

 Charge-coupled devices are photosensitive silicon chips that are rapidly

replacing the television camera tube in the fluoroscopic chain.

 CCDs resemble computer chips and can be used anywhere that light is to be
converted to a digital video image.

 Procedures:
 Common IR procedures are:

 Angiography:

 Imaging the blood vessels to look for abnormalities with the use of various
contrast media, including iodinated contrast, gadolinium based agents, and
CO2 gas.
 Balloon angioplasty/stent:

 Opening of narrow or blocked blood vessels using a balloon; may include

placement of metallic stents as well (both self-expanding and balloon
expandable).

 Cholecystostomy:

 Placement of a tube into the gallbladder to remove infected bile in patients

with cholecystitis, an inflammation of the gallbladder, who are too frail or too
sick to undergo surgery.

 Drain insertions:

 Placement of tubes into different parts of the body to drain fluids (e.g.,
abscess drains to remove pus, pleural drains).

 A common problem is that these tubes get clogged and have to be replaced
or removed before all the material is drained.

 Endovascular aneurysm repair

 Embolization:

 Blocking abnormal blood (artery) vessels (e.g., for the purpose of stopping
bleeding) or organs (to stop the extra function e.g. embolization of the spleen
for hypersplenism) including uterine artery embolization for percutaneous
treatment of uterine fibroids.

 Various embolic agents are used, including alcohol, glue, metallic coils, poly-
viny alcohol particles, Embospheres, encapsulated chemo-microsphere, and
gelfoam.

 [Link]:

 Delivering cancer treatment directly to a tumour through its blood supply,

then using clot-inducing substances to block the artery, ensuring that the
delivered chemotherapy is not "washed out" by continued blood flow.

 [Link]:

 Embolization of tumors with radioactive microspheres of glass or plastic, to kill

tumors while minimizing exposure to healthy cells.

 Thrombolysis:
 Treatment aimed at dissolving blood clots (e.g., pulmonary emboli, leg vein
thrombi, thrombosed hemodialysis accesses) with both pharmaceutical (TPA)
and mechanical means.

 Biopsy:

 Taking of a tissue sample from the area of interest for pathological

examination from a percutaneous or transjugular approach.

 Radiofrequency ablation (RF/RFA):

 Localized destruction of tissue (e.g., tumours) by heating.

 Cryoablation:

 Localized destruction of tissue by freezing.

 Central venous catheter placement:

 Vascular access and management of specialized kinds of intravenous devices

(IVs) (e.g. PIC lines, Hickman lines, subcutaneous ports including
translumbar and transhepatic venous lines).

 Inferior vena cava filter (IVC filters):

 Metallic filters placed in the inferior vena cavae to prevent propagation of

deep venous thrombus, both temporary and permanent

 Vertebroplasty:

 Percutaneous injection of biocompatible bone cement inside

fractured vertebrae.

 Nephrostomy placement:

 Placing a catheter directly into the kidney to drain urine in situations where
normal flow of urine is obstructed. NUS catheters are nephroureteral stents
which are placed through the ureter and into the bladder.

 Radiologically inserted gastrostomy or RIG:

 Placement of a feeding tube percutaneously into the stomach and/or jejunum.

 Dialysis access and related interventions:

 Placement of tunneled hemodialysis catheters, peritoneal dialysis catheters,
and revision/thrombolysis of poorly functioning surgically placed AV fistulas
and grafts.

 TIPS:

 Placement of a Transjugular Intrahepatic Porto-systemic Shunt (TIPS) for

management of select patients with critical end-stage liver disease and portal
hypertension.

 Biliary intervention:

 Placement of catheters in the biliary system to bypass biliary obstructions and

decompress the biliary system.

 Also placement of permanent indwelling biliary stents.

 Endovenous laser treatment of varicose veins:

 Placement of thin laser fiber in varicose veins for non-surgical treatment of

venous insufficiency

Tools:
 There are a number of catheters used in interventional radiology that can be
loosely divided into five types:

 Diagnostic angiographic catheters

 Micro catheters

 Drainage catheters

 Balloon catheters

 Central venous catheters

 Angiography:
 Angiography or arteriography is a medical imaging technique used to
visualize the inside, or lumen, of blood vessels and organs of the body, with
particular interest in the arteries, veins, and the heart chambers.

 This is traditionally done by injecting a radio-opaque contrast agent into the

blood vessel and imaging using X-ray based techniques such as fluoroscopy.
 The word itself comes from the Greek words angeion, "vessel", and graphein,
"to write" or "record".

 The film or image of the blood vessels is called an angiograph, or more

commonly, an angiogram.

 Though the word itself can describe both an arteriogram and a venogram, in
its everyday usage, the terms angiogram and arteriogram are often used
synonymously, whereas the term venogram is used more precisely

 The term angiography is strictly defined as based on projectional radiography;

however, the term has been applied to newer vascular imaging techniques
such as CT angiography and MR angiography.

 The term isotope angiography has also been used, although this more
correctly is referred to as isotope perfusion scanning.

History:
 The technique was first developed in 1927 by the Portuguese physician and
neurologist Egas Moniz at the University of Lisbon to provide contrasted x-
ray cerebral angiography in order to diagnose several kinds of nervous
diseases, such as tumors, artery disease and arteriovenous malformations

 He is usually recognized as one of the pioneers in this field.

 Moniz performed the first cerebral angiogram in Lisbon in 1927, and Reynaldo
Cid dos Santos performed the first aortogram in the same city in 1929.

 With the introduction of the Seldinger technique in 1953, the procedure

became markedly safer as no sharp introductory devices needed to remain
inside the vascular lumen.

Technique:
 Depending on the type of angiogram, access to the blood vessels is gained
most commonly through the femoral artery, to look at the left side of the heart
and at the arterial system; or the jugular or femoral vein, to look at the right
side of the heart and at the venous system.

 Using a system of guide wires and catheters, a type of contrast agent (which
shows up by absorbing the x-rays), is added to the blood to make it visible on
the x-ray images.
 The X-ray images taken may either be still images, displayed on an image
intensifier or film, or motion images.

 For all structures except the heart, the images are usually taken using a
technique called digital subtraction angiography or DSA.

 Images in this case are usually taken at 2 – 3 frames per second, which
allows the interventional radiologist to evaluate the flow of the blood through a
vessel or vessels.

 This technique "subtracts" the bones and other organs so only the vessels
filled with contrast agent can be seen.

 The heart images are taken at 15–30 frames per second, not using a
subtraction technique.

 Because DSA requires the patient to remain motionless, it cannot be used on

the heart.

 Both these techniques enable the interventional radiologist or cardiologist to

see stenosis (blockages or narrowings) inside the vessel which may be
inhibiting the flow of blood and causing pain.

Uses:
 Coronary angiography

 One of the most common angiograms performed is to visualize the blood in

the coronary arteries. A long, thin, flexible tube called a catheter is used to
administer the X-ray contrast agent at the desired area to be visualized. The
catheter is threaded into an artery in theforearm, and the tip is advanced
through the arterial system into the major coronary artery.

 X-ray images of the transient radio contrast distribution within the blood
flowing inside the coronary arteries allows visualization of the size of the
artery openings.

 Presence or absence of atherosclerosis or atheroma within the walls of

the arteries cannot be clearly determined.

 To detect coronary artery disease, Computed Tomography (CT) Scan is

better than Magnetic Resonance Imaging (MRI).
  CT (mainly multislice CT) is more accepted, more widely available, more
favored by patients, and more economic.

 Moreover, CT requires shorter breath-hold time than MRI.

Coronary angiography is a specialised X-ray test to find out detailed information

about your heart (coronary) arteries. It is mainly used if you have angina, to assess
the extent and severity of the angina. It involves a procedure called catheterisation.

What is coronary angiography?

Coronary angiography is a special X-ray of the heart (coronary) [Link]
arteries do not show up on a plain X-ray. With coronary angiography, dye is injected
down the coronary arteries. The arteries and their smaller branches then show up
clearly on an X-ray 'like a road map'. Dye is injected into the coronary arteries by
using a catheter. (A catheter is a thin, flexible, hollow tube.)

Therefore, coronary angiography can show the exact site and severity of any
narrowing of the coronary arteries. This helps the doctor to decide on what
treatment you may need. For example, if the narrowing is mild and does not need
surgery; or, if the narrowing is severe and you should have a coronary artery bypass
graft or coronary angioplasty.

Understanding the arteries of the heart:

The heart is mainly made of special muscle. This heart muscle pumps blood into
blood vessels (arteries) which take the blood to every part of the body.

Like any other muscle, the heart muscle needs a good blood supply. The heart
(coronary) arteries take blood to the heart muscle. The coronary arteries are the first
arteries to branch off the aorta(Ascending). The aorta is the large artery that takes
blood from the left ventricle of the heart to the body.

Right Coronary Artery Left Coronary Artery

RMA = right marginal CB = circumflex branch

PIA/PDA = posterior descending LAD/AIB = Left anterior
AB = atrial branches descending/Anterior interventricular
SANB = sinuatrial nodal LMA = left marginal(obtuse marginal)
RMA = right marginal(acute marginal) DB = Diagonal branch
AVN = atrioventricular nodal
What is angina and what causes it?
Angina is a pain that comes from the heart. The usual cause of angina is narrowing
of one or more of your heart (coronary) arteries. This reduces the blood supply to a
part or parts of your heart muscle. The blood supply may be enough when you are
resting. However, your heart muscle needs more blood and oxygen when it works
harder. For example, when you walk fast or climb stairs, your heart rate increases to
deliver the extra blood. If the extra blood that your heart needs during exertion
cannot get past the narrowed arteries, the heart 'complains' with pain.

The narrowing of the arteries is caused by atheroma. Atheroma is like fatty patches
or 'plaques' that develop within the inside lining of arteries. (This is similar to water
pipes that get 'furred up' with scale.) Plaques of atheroma may gradually form over a
number of years in one or more places in the coronary arteries. In time, these can
become bigger and cause enough narrowing of one or more of the arteries to cause
symptoms.

The diagram below shows three narrowed sections as an example. However,

atheroma can develop in any section of the coronary arteries.

How is coronary angiography done?

You lie on a couch in a catheterisation room. An X-ray machine is mounted above
the couch. A thin, flexible tube (a catheter) is inserted through a wide needle or
small cut in the skin into a blood vessel in the groin or arm. Local anaesthetic is
injected into the skin above the blood vessel. Therefore, it should not hurt when the
catheter is passed into the blood vessel.
The doctor gently pushes the catheter up the blood vessel towards the heart. Low-
dose X-rays are used to monitor the progress of the catheter tip which is gently
manipulated into the correct position. You may be able to see the progress of the
catheter on the X-ray monitor.

The tip of the catheter is pushed just inside a main coronary artery. Some dye is
then injected down the catheter into the artery. Several X-ray films are rapidly taken
as the dye is injected (the dye shows up clearly on X-ray films). The X-ray films are
recorded as a moving picture and this is called an angiogram. The angiogram shows
the vessels filling with blood and the sites of any narrowing can be seen.

The tip of the catheter is then put into the other main coronary artery and the test is
repeated. So, an angiogram picture is built up of each of the coronary arteries and
their branches.

You cannot feel the catheter inside the blood vessels. You may feel an occasional
'missed' or 'extra' heartbeat during the procedure. This is normal and of little
concern. During the procedure your heartbeat is monitored by electrodes placed on
your chest which provide a tracing on an electrocardiograph (ECG) machine.
Sometimes a sedative is given before the test if you are anxious.
When the test is over, the catheter is gently pulled out. If it was inserted through a
small cut in the skin in the arm then you will normally need a few stitches. If it was
inserted through a wide needle in your groin then a nurse will press over the site of
insertion for about 10 minutes to prevent any bleeding.

How do I prepare for a coronary angiography?

You should get instructions from your local hospital about what you need to do in the
days leading up to the test. The sort of instructions may include:

 Before the day of the test you may need a blood test and an ECG to make sure
you are OK to have the procedure.
 If you take a 'blood-thinning' drug (anticoagulant), such as warfarin, then you
are likely to need to stop this for 2-3 days before the test. (This prevents
excessive bleeding from the site of the small, flexible tube (catheter) insertion.)
 If you take insulin or medicines for diabetes, the timing of when to take these on
the day of the test may need to be clarified.
 If you may be pregnant, you need to tell the doctor who will do the test.
 You may be asked to stop eating and drinking for a few hours before the test.
 You may be asked to shave both groins before the test.
 You will have to sign a consent form at some point before the test to confirm
that you understand the procedure, understand the possible complications (see
below), and agree to the procedure being done.

How long does coronary angiography take?

It usually takes about 30 minutes. In most cases it is done as a day-case procedure.

After the test

 The doctor will discuss what he or she found during the test. A letter is also sent
to your GP giving details of the test results.
 You will need to rest for a few hours after the test. You should ask a friend or
relative to accompany you home. Most people are able to resume their normal
activities the next day.
  There may be some bruising at the site of the small, flexible tube (catheter)
insertion which may be a little sore when the anaesthetic wears off. Painkillers
such as paracetamol will help to ease this.
 You may need to have some stitches removed after about seven days if a small
cut was made to insert the catheter.

Are there any risks or side-effects?

Most of the side-effects are minor and may include:

 A bruise, which may form under the skin where the small, flexible tube
(catheter) was inserted (usually the groin). This is not serious, but it may be
sore for a few days.
 The small wound where the catheter is inserted sometimes becomes infected.
Tell your GP if the wound becomes red and tender. A short course of antibiotics
will usually deal with this if it occurs.
 Some people get a short angina-type pain during angiography. This soon goes.
 The dye may give you a hot, flushing feeling when it is injected. Many people
also describe a warm feeling in the groin when the dye is injected - as if they
have 'wet themselves'. These feelings last just a few seconds (and the operator
will tell you when they are about to inject the dye). Rarely, some people have an
allergic reaction to the dye.

Serious complications are rare, but do sometimes occur. For example, some people
have a stroke or a heart attack (myocardial infarction) during the procedure. Also,
rarely, the catheter may damage a heart (coronary) artery. The risk of serious
complications is small and is mainly in people who already have serious heart
disease. As a consequence of serious complications, some people have died during
this procedure. Your doctor will only recommend coronary angiography if they feel
the benefits outweigh the small risk.
 Microangiography:

 Microangiography is commonly used to visualize tiny blood vessels.

 Neuro-vascular angiography:

 Another increasingly common angiographic procedure is neuro-

vascular digital subtraction angiography in order to visualise the arterial and
venous supply to the brain.

 Intervention work such as coil-embolisation of aneurysms and AVM gluing

can also be performed.

 Peripheral angiography:
 Angiography is also commonly performed to identify vessel narrowing in
patients with leg claudication or cramps, caused by reduced blood flow down
the legs and to the feet; in patients with renal stenosis (which commonly
causes high blood pressure) and can be used in the head to find and repair
stroke

 These are all done routinely through the femoral artery, but can also be
performed through the brachial or axillary (arm) artery.

 Any stenoses found may be treated by the use of atherectomy.

Complications:

 cardiac arrhythmias

 kidney damage

 blood clots (which can cause heart attack or stroke)

 hypotension

 pericardial effusion

 bleeding or bruising at the site where the contrast is injected, blood vessel
damage on the route to the heart from the catheter (rare) and allergic
reaction to the contrast.
 Angioplasty:
 Angioplasty (or Balloon angioplasty) is an endovascular procedure to
widen narrowed or obstructed arteries or veins, typically to treat
arterial atherosclerosis.

 An empty, collapsed balloon, known as a balloon catheter, is passed over a

wire into the narrowed locations and then inflated to a fixed size.

 The balloon forces expansion of the stenosis (narrowing) within the vessel
and the surrounding muscular wall, opening up the blood vessel for improved
flow, and the balloon is then deflated and withdrawn.

 A stent may or may not be inserted at the time of ballooning to ensure the
vessel remains open.

 The word is composed of the combining forms of

the Greek words angīon ‘vessel’/‘cavity’ (of the human body) and
plasso ‘form’/‘mould’.

 Angioplasty has come to include all manner of vascular interventions that are
typically performed in a minimally invasive or percutaneous method.

Uses:
 Coronary angioplasty

 Peripheral angioplasty

 Carotid angioplasty

 Renal artery angioplasty

 Venous angioplasty

Contraindications:
 Angioplasty requires an access vessel, typically the femoral or radial
artery or femoral vein to permit access to the vascular system for the wires
and catheters used.

 If no access vessel of sufficient size and quality is available, angioplasty is

contraindicated. Small diameter, the presence of posterior calcification,
 occlusion, hematoma, or a bypass origin may all render a vessel inadequate
to serve as an access point to the vascular system

Technique:
 Access to the vascular system is typically gained percutaneously (through the
skin, without a large surgical incision).

 An introducer sheath is inserted into blood vessel via the Seldinger

technique.

 Fluoroscopic guidance and radiopaque contrast dye are used to guide angled
wires and catheters to the region of the body to be treated.

 To treat a narrowing in a blood vessel, a wire is passed through

the stenosis in the vessel and a balloon on a catheter is passed over the wire
and into the desired position.

 The positioning is verified by fluoroscopy and the balloon is inflated using

water mixed with contrast dye to 75 to 500 times normal blood pressure(6 to
20 atmospheres).

 A stent may or may not also be placed.

 At the conclusion of the procedure, the balloons, wires and catheters are
removed and the vessel puncture site is treated either with direct pressure or
a Vascular closure device.

Risks and Complications:

 Embolization, or the launching of debris into the bloodstream
 Arterial rupture from over-inflation of a balloon catheter or the use of an
inappropriately large or stiff balloon, or the presence of a calcified target
vessel.

 Hematoma or pseudo aneurysm formation at the access site

Recovery:
 After angioplasty, most of the patients are monitored overnight in the hospital
but if there are no complications, the next day, patients are sent home.

 The catheter site is checked for bleeding and swelling and the heart rate and
blood pressure is monitored.

 Usually, patients receive medication that will relax them to protect the arteries
against spasms.

 Patients are typically able to walk within two to six hours following the
procedure and return to their normal routine by the following week

 Angioplasty recovery consists of avoiding physical activity for several days

after the procedure. Patients are advised to avoid any type of lifting, or other
strenuous physical activity for a week.

 Patients will need to avoid physical stress or prolonged sport activities for a
maximum of two weeks after a delicate balloon angioplasty.

 Patients with stents are usually prescribed an antiplatelet, clopidogrel, which

is taken at the same time as acetylsalicylic acid (aspirin).

 These medicines are intended to prevent blood clots and they are usually
taken for at least the first months after the procedure is performed. In most
cases, patients are given these medicines for one year.

 Patients who experience swelling, bleeding or pain at the insertion site,

develop fever, feel faint or weak, notice a change in temperature or color in
the arm or leg that was used or have shortness of breath or chest pain should
immediately seek medical advice.
 DRAIN INSERTIONS:
 A surgical drain is a tube used to remove pus, blood or other fluids from
a wound.

 They are commonly placed by surgeons or interventional radiologists.

 Drains inserted after surgery do not result in faster wound healing or prevent
infection, but are sometimes necessary to drain body fluid which may
accumulate and in itself become a focus of infection or retained blood
complications

 Uses:
 The routine use of drains for surgical procedures is diminishing as better
radiological investigation and confidence in surgical technique have reduced
their necessity.

 It is felt now that drains may hinder recovery by acting as an 'anchor' limiting
mobility post surgery and the drain itself may allow infection into the wound. In
certain situations their use is unavoidable.

 Drains may be hooked to wall suction, a portable suction device, or they may
be left to drain naturally.

 Accurate recording of the volume of drainage as well as the contents is vital to

ensure proper healing and monitor for excessive bleeding.

 Depending on the amount of drainage, a patient may have the drain in place
one day to weeks.

 Drains will have protective dressings that will need to be changed daily/as
needed

Complications:
 Drains have a tendency to become occluded or clogged, resulting in retained
fluid that can contribute to infection or other complications.

 Thus efforts must be made to maintain and assess patency when they are in
use.

 Once a drain becomes clogged or occluded, it is usually removed, as it is no

longer providing any benefit.
 Types of drains:
 Surgical drains can be broadly classified into:

 Tube drains

 Corrugated drains

 Some types of surgical drains are:

 Jackson-Pratt drain - consists of a perforated round or flat tube connected to

a negative pressure collection device. The collection device is typically a bulb
with a drainage port which can be opened to remove fluid or air. After
compressing the blub to remove fluid or air, negative pressure is created as
the bulb returns to its normal shape.

 Blake drain - a round silicone tube with channels that carry fluid to a negative
pressure collection device. Drainage is thought to be achieved by capillary
action, allowing fluid to travel through the open grooves into a closed cross
section, which contains the fluid and allows it to be suctioned through the
tube.

 Penrose drain - a soft rubber tube

 Negative pressure wound therapy - Involves the use of enclosed foam and
a suction device attached; this is one of the newer types of wound
healing/drain devices which promotes faster tissue granulation, often used for
large surgical/trauma/non-healing wounds

 Redivac drain

 Pigtail drain - has an exterior screw to release the internal "pigtail" before it
can be removed

 Davol

 Chest tube - is a flexible plastic tube that is inserted through the chest wall
and into the pleural space or mediastinum

 Wound manager
 Embolization:
 Embolization refers to the passage of an embolus within the
bloodstream(An embolus plural emboli is any detached, traveling
intravascular mass (solid, liquid, or gaseous) carried by circulation, which is
capable of clogging arterial capillary beds create an arterial occlusion at a site
distant from its point of origin).

 It may be pathological, for example as a surgical complication, or therapeutic,

as a treatment for bleeding or some types of cancer by deliberately blocking
blood vessels

Uses:
 Therapeutic embolization is a nonsurgical, minimally invasive procedure
performed by interventional radiologists and interventional neuroradiologists.

 It involves the selective occlusion of blood vessels by purposely

introducing emboli, in other words deliberately blocking a blood vessel.

 Embolization is used to treat a wide variety of conditions affecting different

organs of the human body

 Hemorrhage

 Growths

 Malignant hypertension

 Other (Portal Vein)

Technique:
 A therapeutic embolization is a minimally invasive alternative to surgery. The
purpose is to prevent blood flow to an area of the body, which can effectively
shrink a tumor or block an aneurysm.

 The procedure is carried out as an endovascular procedure by a consultant

radiologist in an interventional suite. It is common for most patients to have
the treatment carried out with little or no sedation, although this depends
largely on the organ to be embolized.
 Patients who undergo cerebral embolization or portal vein embolization are
usually given a general anesthetic.

 Access to the organ in question is acquired by means of a guidewire and

catheter(s). Depending on the organ this can be very difficult and time
consuming.

 The position of the correct artery or vein supplying the pathology in question
is located by digital subtraction angiography (DSA). These images are then
used as a map for the radiologist to gain access to the correct vessel by
selecting an appropriate catheter and or wire, depending on the 'shape' of the
surrounding anatomy.

 Once in place, the treatment can begin. The artificial embolus used is usually
one of the following

 Coils: Guglielmi Detachable Coil or Hydrocoil

 Particles

 Foam

 Plug

 Microspheres or Beads

 Once the artificial emboli have been successfully introduced, another set of
DSA images are taken to confirm a successful deployment.

Agents:
1. Liquid embolic agents- Used for AVM, these agents can flow through
complex vascular structures so the surgeon does not need to target his
catheter to every single vessel.
 Onyx is an example for a liquid embolic agent.

 nbca - n-butyle-2-cyanoacrylate

 Ethiodol

2. Sclerosing agents - These will harden the endothelial lining of vessels.

They require more time to react than the liquid embolic agents. Therefore,
they cannot be used for large or high-flow vessels.
 Ethanol
 ethanolamine oleate

 Sotradecol

3. Particulate embolic agents- These are only used for precapillary

arterioles or small arteries. These are also very good for AVM deep within
the body.
 The disadvantage is that they are not easily targeted in the vessel. None of
these are radiopaque, so they are difficult to view with radiologic imaging
unless they are soaked in contrast prior to injection.

 Gelfoam hemostasis

 polyvinyl alcohol (PVA)

 acrylic gelatin microspheres

4. Mechanical occlusion devices - These fit in all vessels. They also have
the advantage of accuracy of location; they are deployed exactly where
the catheter ends.
 coils

 detachable balloon

Advantages:

 Minimally invasive

 No scarring

 Minimal risk of infection

 No or rare use of general anesthetic

 Faster recovery time

 High success rate compared to other procedures

 Preserves fertility and anatomical integrity

Disadvantages:

 User dependent success rate

 Risk of emboli reaching healthy tissue potentially causing gastric, stomach or
duodenal ulcers. There are methods, techniques and devices that decrease
the occurrence of this type of adverse side effect.

 Not suitable for everyone

 Recurrence more likely

 Transcatheter arterial chemoembolization:

 Transcatheter arterial chemoembolization (TACE) is a minimally invasive
procedure performed in interventional radiology to restrict a tumor's blood
supply.

 Small embolic particles coated with chemotherapeutic agents are injected

selectively into an artery directly supplying a tumor.

 Principles:
 TACE derives its beneficial effect by two primary mechanisms. Most tumors
within the liver are supplied by the proper hepatic artery, so arterial
embolization preferentially interrupts the tumor's blood supply and stalls
growth until neovascularization.

 Secondly, focused administration of chemotherapy allows for delivery of a

higher dose to the tissue while simultaneously reducing systemic exposure,
which is typically the dose limiting factor.

 This effect is potentiated by the fact that the chemotherapeutic drug is not
washed out from the tumor vascular bed by blood flow after embolization.
Effectively, this results in a higher concentration of drug to be in contact with
the tumor for a longer period of time.

Therapeutic applications:
 Transcatheter arterial chemoembolization has most widely been applied
to hepatocellular carcinoma(HCC) for patients who are not eligible for surgery.

 TACE may also be used to downstage HCC in patients who exceed the Milan
criteria for liver transplantation.
 Other treated malignancies include neuroendocrine tumors, ocular
melanoma, cholangiocarcinoma, and sarcoma.

 Transcatheter arterial chemoembolization plays a palliative role in patients

with metastatic colon carcinoma.

 There is a possible benefit for liver-dominant metastases from other primary

malignancies

Procedure:
 TACE is an interventional radiology procedure performed in the angiography
suite. The procedure involves gaining percutaneous transarterial access by
the Seldinger technique to the hepatic artery with an arterial sheath, usually
by puncturing the common femoral artery in the right groin and passing
a catheter guided by a wire through the abdominal aorta, through the celiac
trunk and common hepatic artery, and finally into the branch of the proper
hepatic artery supplying the tumor.

 The interventional radiologist then performs an selective angiogram of

the celiac trunk and possibly the superior mesenteric artery to identify the
branches of the hepatic artery supplying the tumor(s) and threads smaller,
more selective catheters into these branches.

 This is done to maximize the amount of the chemotherapeutic dose that is

directed to the tumor and minimize the amount of the chemotherapeutic agent
that could damage the normal liver tissue

 When a blood vessel supplying tumor has been selected, alternating aliquots
of the chemotherapy dose and of embolic particles, or particles containing the
chemotherapy agent, are injected through the catheter.

 The total chemotherapeutic dose may be given in one vessel's distribution, or

it may be divided among several vessels supplying the tumors.

 The physician removes the catheter and access sheath, applying pressure to
the entry site to prevent bleeding.

 The patient must lie stationary for several hours after the procedure to allow
the punctured artery to heal.

 The patient will often be kept overnight for observation and will likely be
discharged the following day. The procedure is normally followed up with
 a CT scan several weeks later to check the response of the tumor to the
procedure.

Agents:
 Lipiodol

 Drug eluting particles

 Polyvinyl alcohol microspheres

 - Superabsorbent polymer microspheres

 - Gelatin microspheres

Adverse effects:
 hemorrhage and/or damage to blood vessels.

 Pseudoaneurysm

 allergic reaction

 Symptomatic hypothyroidism

 Thrombolysis:
 Thrombolysis is the breakdown (lysis) of blood
clots by pharmacological means, and commonly called clot busting.

 It works by stimulating secondary fibrinolysis by plasmin through infusion of

analogs of tissue plasminogen activator (tPA), the protein that normally
activates plasmin.

 Agents:
 Thrombolysis mainly involves the use of thrombolytic drugs, which dissolve
blood clots.

 These drugs are either derived from Streptococcus species, or, more recently,
using recombinant biotechnology whereby tPA is manufactured by bacteria,
resulting in a recombinant tissue plasminogen activator or rtPA.

 Some commonly used thrombolytics are:

 streptokinase

 urokinase

 Recombinant tissue plasminogen activators

 alteplase (rtPA)

 reteplase

 Tenecteplase

 Principles:
 Formation of blood clots lies at the basis of a number of serious diseases.

 By breaking down the clot, the disease process can be arrested, or the
complications reduced. While other anticoagulants (such as heparin) prevent
the "growth" of a clot, thrombolytic agents actively reduce the size of the clot.

 Most thrombolytic agents work by activating the enzyme plasminogen, which

clears the cross-linked fibrin mesh (the backbone of a clot). This makes the
clot soluble and subject to further proteolysis by other enzymes, and restores
blood flow over occluded blood vessels

 Ultrasound-Accelerated Thrombolysis:
 A recent multicenter randomized trial (DUET) compared standard catheter-
directed thrombolysis (CDT) versus ultrasound-accelerated thrombolysis
(USAT, EKOS Corporation) for the treatment of acute peripheral arterial
thrombotic occlusions. Results showed that, on average, patients treated with
USAT were completed 12 hours sooner than those treated with standard CDT
with no increase in "serious adverse events.“
 Plans are underway to commence the DUET II study, which will be a non-
randomized trial using the EKOS system with an even lower hourly drug dose
with an expectation of further reducing bleeding complications.

 Uses:
 Diseases where thrombolysis is used:

 Myocardial infarction

 Stroke (ischemic stroke)

 Massive pulmonary embolism

 Acute limb ischemia

 Contraindications:
 Previous intracranial bleeding at any time, stroke in less than 6 months,

 closed head or facial trauma within 3 months,

 suspected aortic dissection,

 ischemic stroke within 3 months (except in ischemic stroke within 3 hours

time),

 active bleeding diathesis,

 uncontrolled high blood pressure(>180 systolic or >100 diastolic),

 known structural cerebral vascular lesion,

 arterio-venous malformations,

 thrombocytopenia,

 Biopsy:
 A biopsy is a medical test commonly performed by a surgeon, interventional
radiologist, or an interventional cardiologist involving
sampling of cells or tissues for examination.
 It is the medical removal of tissue from a living subject to determine the
presence or extent of a disease. The tissue is generally examined under
a microscope by a pathologist, and can also be analyzed chemically.

 When an entire lump or suspicious area is removed, the procedure is called

an excisional biopsy.

 When only a sample of tissue is removed with preservation of

the histological architecture of the tissue’s cells, the procedure is called
an incisional biopsy or core biopsy

 When a sample of tissue or fluid is removed with a needle in such a way that
cells are removed without preserving the histological architecture of the tissue
cells, the procedure is called a needle aspiration biopsy.

 Biopsies are most commonly performed for insight into possible cancerous
and inflammatory conditions.

 Conditions identified with biopsies:

 Cancer( fine needle aspiration biopsy)

 Cancer liquid biopsy

 Precancerous conditions

 Inflammatory conditions

 Biopsied sites:

 Bone marrow

 Gastrointestinal tract

 Lung

 Liver

 Prostate

 Nervous system

 Urogenital system(renal biopsy, endometrial biopsy)

 Other Other sites include breast biopsy, lymph node biopsy, muscle biopsy,
and skin biopsy
 Dialysis:
 Dialysis a process for removing waste and excess water from the blood, and
is used primarily as an artificial replacement for lost kidney function in people
with renal failure.

 Dialysis may be used for those with an acute disturbance in kidney function
(acute kidney injury, previously acute renal failure), or progressive but
chronically worsening kidney function—a state known as chronic kidney
disease stage 5 (previously chronic renal failure or end-stage renal disease).

 Principle:

 Dialysis works on the principles of the diffusion of solutes and ultrafiltration of

fluid across a semi-permeable membrane.

 Diffusion is a property of substances in water; substances in water tend to

move from an area of high concentration to an area of low concentration.

 Blood flows by one side of a semi-permeable membrane, and a dialysate, or

special dialysis fluid, flows by the opposite side.

 A semipermeable membrane is a thin layer of material that contains holes of

various sizes, or pores.

 Smaller solutes and fluid pass through the membrane, but the membrane
blocks the passage of larger substances (for example, red blood cells, large
proteins).

 This replicates the filtering process that takes place in the kidneys, when the
blood enters the kidneys and the larger substances are separated from the
smaller ones in the glomerulus.

 The two main types of dialysis, hemodialysis and peritoneal dialysis, remove
wastes and excess water from the blood in different ways.

 Hemodialysis removes wastes and water by circulating blood outside the

body through an external filter, called a dialyzer, that contains
asemipermeable membrane.
 The blood flows in one direction and the dialysate flows in the opposite.

 In peritoneal dialysis, wastes and water are removed from the blood inside
the body using the peritoneum as a natural semipermeable membrane.

 Wastes and excess water move from the blood, across the peritoneal
membrane, and into a special dialysis solution, called dialysate, in
the abdominal cavity.

 Dialyzable substances

 Characteristics

 Dialyzable substances have following properties:

 low molecular mass

 high water solubility

 low protein binding

 prolonged elimination (long half life)

 small volume of distribution

 Substances

 Ethylene glycol

 Procainamide

 Methanol

 Isopropyl alcohol

 Barbiturates

 Lithium

 Transjugular intrahepatic portosystemic

shunt (TIPS):
 Transjugular intrahepatic portosystemic shunt or transjugular
intrahepatic portosystemic stent shunting (commonly abbreviated
 as TIPS or TIPSS) is an artificial channel within the liver that establishes
communication between the inflow portal vein and the outflow hepatic vein.

 It is used to treat portal hypertension (which is often due to liver cirrhosis)

which frequently leads to intestinal bleeding, life-threatening esophageal

bleeding (esophageal varices) and the buildup of fluid within the abdomen
(ascites).

 An interventional radiologist creates the shunt using an image-

guided endovascular (via the blood vessels) approach, with the jugular
vein as the usual entry site.

 Implantation:

 Transjugular intrahepatic portosystemic shunts are typically placed by an

interventional radiologist under fluoroscopic guidance.

 Access to the liver is gained, as the name 'transjugular' suggests, via

the internal jugular vein in the neck.

 Once access to the jugular vein is confirmed, a guidewire and introducer

sheath are typically placed to facilitate the shunt's placement.

 This enables the interventional radiologist to gain access to the

patient's hepatic vein by traveling from the superior vena cava into the inferior
vena cava and finally the hepatic vein.

 Once the catheter is in the hepatic vein, a wedge pressure is obtained to

calculate the pressure gradient in the liver.

 Following this, carbon dioxide is injected to locate the portal vein. Then, a
special needle known as a Colapinto is advanced through the liver
parenchyma to connect the hepatic vein to the large portal vein, near the
center of the liver.

 The channel for the shunt is next created by inflating an angioplasty balloon
within the liver along the tract created by the needle. The shunt is completed
by placing a special mesh tube known as a stent or endograft to maintain the
tract between the higher-pressure portal vein and the lower-pressure hepatic
vein.

 After the procedure, fluoroscopic images are made to show placement.

Pressure in the portal vein and inferior vena cava are often measured
  Use in hepatorenal syndrome:

 TIPS has shown some promise for patients with hepatorenal syndrome.

 Complications:

 hepatic encephalopathy

 umbilical hernia

 bleeding and direct injury to the liver

References:
1. Society of Interventional Radiology -- Global Statement Defining Interventional
radiology. [Link]
2. [Link]
3. SIR - Fellow Residents and Students - APDIR
4. [Link]
5. The Society for Pediatric Radiology
6. Hickey R et al. Cancer concepts and principles: primer for the interventional oncologist-part II." J Vasc
Interv Radiol. 2013 Aug;24(8):1167-88. doi: 10.1016/[Link].2013.04.023. Epub 2013 Jun 28. PMID
23810312 PMC 3800031
7. "Radiofrequency Ablation as a Treatment Strategy for Liver Metastases from Breast Cancer." Semin
Intervent Radiol. Dec 2008; 25(4): 406–412.
8. "Imaging studies challenge Zamboni theory of MS". Canadian Medical Association. Retrieved 14
April 2011.
9. "FDA Safety Communication: Chronic Cerebrospinal Venous Insufficiency Treatment in Multiple
Sclerosis Patients". Food and Drug Administration. May 2012.
10. "Percutaneous venoplasty for chronic cerebrospinal venous insufficiency for multiple sclerosis".
National Institute for Health and Clinical Excellence. March 2012.
11. Nonsurgical Treatment for Spinal Fractures From Osteoporosis - SIR
12. Male Infertility and Varicocele Treatment - SIR
13. Image-Guided Needle Biopsy - SIR
14. Pediatric Interventional Radiology - SI
15. Central Lines, Ports and Feeding Tubes - SIR

Helpful Resources
 Historic Highlights of Interventional Radiology, by Josef Rösch of Dotter Interventional
Radiology.
 Abrams’ Angiography: Vascular and Interventional Radiology. Herbert L. Abrams (Editor),
Stanley Baum (Editor) and Michael J. Pentecost (Editor) Little Brown and Co., [Link]
0781740894
 Advanced Radiographic and Angiographic Procedures: With an Introduction to Specialized
Imaging. Patrick A. Apfel, Marianne Rita Tortorici. F A Davis Co., 2010. ISBN 0803612559
 Handbook of Interventional Radiologic Procedures Krishna Kandarpa (Editor) and John E.
Aruny (Editor). Lippincott Williams and Wilkins Publishers, 2010. ISBN 0781768160
 The Birth, Early Years, and Future of Interventional Radiology by Josef Rösch, Frederick S.
Keller, and John A. Kaufman. (2003) J. Vasc. Interv. Radiol.14: 841-853
 The Catheter Introducers by Leslie A. Geddes and LaNelle E. Geddes of Cook Group
Incorporated, Mobium Press, Chicago. 1993. ISBN 0916371131