Interventional radiology

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one by: Bassam Flayh Hasan Barcelona Gr. / Arabic board
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 What is the interventional
?radiology

Interventional radiology (IR) is an

expanding subspeciality of radiology
that uses imaging guidance and
minimally invasive techniques to
.diagnose and treat a patient

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1/3 The
?scope
The scope of the speciality is too broad to be effectively covered in this
show, but the procedures used include the following:

Angiography: A vein or artery can be punctured with ultrasound guidance, and

contrast is injected mapping the vessel anatomy under fluoroscopy. Stenoses and
occlusions can be characterized and an expandable balloon is used to improve
.’blood flow. This is termed ‘angioplasty
Biopsy: Ultrasound (superficial lesions) and CT (complicated or deep lesions) can
help to guide a needle accurately to a lesion of interest for core biopsy and
.histological characterization
Drainage: Inserting a drain can offer a conduit for decompression of infected
collections or uncomfortable ascites. Optimal and accurate placement is obtained
.by imaging guidance

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2/3 The
?scope

Stenting: Expandable stents can be inserted into a vessel or duct to act as

‘scaffolding’ and can exert radial force to maintain patency in atherosclerosis or
.tumour stenosis

Line insertion: Patients on long-term therapy (e.g. dialysis, antibiotics,

chemotherapy)
require definitive vascular access (e.g. Hickman line, portacath) to avoid the
.discomfort of recurrent peripheral cannulation and thrombophlebitis
Embolization: Instilling an embolic agent (coils, particles or glue) into a selectively
cannulated vessel can control active haemorrhage, prevent aneurismal rupture or
infarct a tumour (e.g. uterine fibroid). An adjunct to this is chemoembolization,
where a chemotherapy agent is instilled directly to a tumour and then the blood
.vessel is embolized to cause tumour infarction

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3/3 The
?scope

Radiofrequency ablation: Small malignant lesions can be cauterized via a specialized

.electrical probe that is inserted under image guidance for accurate placement

Vertebroplasty: Guiding the infusion of inert cement into a collapsed spinal vertebra
can provide stability in cases of osteoporotic or metastatic collapse

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Femoral access
and
complications

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Femoral access
and
complications
Hematoma

Pseudoaneury
sm
Arteriovenous fistula (AVF)

Air embolism

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Hematoma
.• A hematoma may be superficial or retroperitoneal
A superficial subcutaneous hematoma  generally benign clinical course
.A retroperitoneal hematoma  risk of fatal hemorrhage

There is increased risk of retroperitoneal hematoma with a high (more cranial) arterial puncture •
.above the pelvic brim

Pseudoaneurysm
• Pseudoaneurysm formation occurs in approximately 1% of arterial punctures. On color
Doppler, a pseudoaneurysm appears as a swirling yin-yang with high-velocity flow at
the site of communication with the femoral artery.
.• Watchful waiting  a small pseudoaneurysm <1 cm in size
.Ultrasound-guided thrombin injection  pseudoaneurysm >1 cm
Less commonly, ultrasound-guided compression of the neck of the pseudoaneurysm can be
.performed to thrombose the pseudoaneurysm

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Arteriovenous fistula (AVF)
• An arteriovenous fistula (AVF) is an anomalous connection between an artery and
a vein. AVFs are usually asymptomatic but may enlarge and ultimately cause high output cardiac failure.
• On Doppler ultrasound, an AVF demonstrates arterial flow within a vein and there is loss of the normal
triphasic waveform in the artery. Increased diastolic flow is often seen in the artery proximal to the
.fistula

Air embolism
.• Air embolism is a rare but potentially life-threatening
The most dangerous portion of a venous access procedure is the insertion of the catheter into the •
peel-away sheath.
-:• If air embolism is suspected
the patient should be immediately placed in the left lateral decubitus (left side down) position so the
.air bubble remains anti dependent in the right heart
oxygen should be administered. If practical, fluoroscopy can be used to identify the air bubble. 100%
.Catheter aspiration can be considered if the air bubble is large

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Injection rates

”.The terminology for injection rates for angiographic runs is “cc/sec for total cc •
.For instance, “25 for 50” means an injection rate of 25 cc/sec for a total of 50 cc

Aortogram (aortic arch): 20 for 30.

Abdominal aorta: 20 for 20.
pulmonary artery 20 for 40
Inferior vena cavogram: 20 for 30.
Mesenteric artery: 5 for 25.
Renal artery: 5 for 15.
.Distal artery: 3 for 12

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Percutaneous
1/2 transluminal angioplasty (PTA)
fist-line technique for treatment of a stenosis, where a balloon is inflated across the stenosis to create a •
.controlled stretch injury and increase the luminal cross-sectional area

When treating a stenosis caused by atherosclerotic plaque, angioplasty widens the luminal diameter due •
.to disruption of the intima and extension of the plaque into the media

Most balloons are non-compliant. That is, they have a fixed diameter that does not expand no matter •
the air pressure. If a non-compliant balloon is inflated above its rated maximum pressure, the balloon will
.burst

.In general, a balloon should be selected that is 10–20% larger than the vessel diameter •

Balloons are sized by diameter in millimeters and length in centimeters. For instance, •
. a 10 × 6 balloon is 10 mm in diameter and 6 cm in length

:Risks of angioplasty include •

.distal emboli, vessel rupture, and dissection

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Percutaneous
2/2 transluminal angioplasty (PTA)

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 Stents
covered
balloon-expandable and self-expandable stents. •
 balloon-expandable stents have a higher radial force upon deployment but will not rebound if crushed. Thus,
balloon-expandable stents are suboptimal for sites prone to external compression, such as around joints or the
adductor canal in the leg.
 Self-expandable stents are more flexible and trackable through vessels than balloon expandable stents. Their
.use is favored when the route to the lesion is tortuous or when the anatomy is prone to external compression

.In general, 1–2 cm longer than the stenosis, 1–2 mm wider than the unstenosed vessel lumen •
.A rule of thumb is 10% oversizing of an arterial stent and 20% oversizing of a venous stent

Most stents are fenestrated and provide only a scaffolding-like support; however, covered stents are •
employed for treatment of pseudoaneurysm, dissection, and TIPS

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 Principles of
embolization
Embolic permanent (coils, particles, glue and sclerosing agent)
materials
temporary (absorbable gelatin sponge and autologous clot)

Coils - Create thrombosis by inducing vascular stasis.

- Advantage: the ability for precise and quick placement, without distal embolization.-
- Disadvantage: is sacrifice of distal access: Once a vessel is coiled, it cannot be re accessed for
retreatment.
When using coils for embolization of a specific lesion, the general technique is to fist coil distal to
the lesion, then proximal to it. This prevents recurrent bleeding from retrograde collaterals.

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 Principles of
embolization
- flow distally to occlude the small capillaries.
Particles - Two types of particles are trisacyl gelatin microspheres (Embospheres,
BioSphere Medical) and polyvinyl alcohol.

Sodium tetradecyl sulfate is a sclerosing agent used for vascular malformations and varices.
Sclerosing agent

Glue Cyanoacrylate is a special glue that rapidly hardens when it comes in contract with blood

absorbable gelatin - (Gelfoam, Pfizer) is the most commonly used temporary embolic agent,
- lasting 2–6 weeks.
- Of important note, because Gelfoam is dissolved foam, post-procedural CT imaging can show
numerous gas locules in the embolized organ. This appearance can mimic abscess and careful
clinical observation is necessary to prevent unnecessary interventions.
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 Principles of
embolization
Complications of
embolization

Post-embolization syndrome- occurs within the fist day after embolization

- clinically presents with pain, cramping, fever, and nausea/vomiting,
thought to be due to release of endovascular inflammatory modulators
by infarcted tissue.
- Treatment is NSAIDS, opioids when appropriate, and IV fluids.

Non-target embolization - unintentional embolization of structures other than the target.

- For instance, during uterine fibroid embolization there is a risk of non-
target embolization of the ovaries. During bronchial artery embolization,
there is a risk of non-target embolization to the brain causing stroke and
to the spinal arteries causing paralysis.

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Cathete
rs

Catheter sizing - Catheters are sized in French (Fr)

- where 1 Fr = 0.33 mm.
- The luminal diameter will be slightly smaller.

• Sheath versus catheter: A sheath has a defied luminal diameter;

however, the overall
diameter of the catheter will be slightly larger. For instance, a 6 Fr sheath can by
definition a 6 Fr catheter inside, but will be 7 or 8 Fr in external diameter

Catheters types  High-flow catheters

 Selective and superselective catheters

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Cathete
rs

High-flow
catheters

- Also known as flush catheters

- Have multiple side-holies.
- May be coiled.
- Most commonly known as a pigtail / omniflush
catheter.
- Curved or straight. pigtail
- are used for large vessel angiography, such as the
aorta and vena cava

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Cathete
rs SOS

Selective and
superselective
catheters

- have a single hole at the end of the catheter.

- There are numerous shapes of the distal portion,
Berenstein
each tailored towards a specific situation or general
purpose use.
- C2 and SOS are reverse curved-tip catheters; and
Berenstein is an angled-tip catheter

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Wire
s

Wire sizing - are sized in inches

- with a standard wire measuring 0.035” in diameter and
a microwire measuring 0.018” in diameter.

Types Standard floppy tip

wires
Hydrophilic wires

Stiff wires

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Wire
s
Standard floppy tip
wires

- have a floppy tip or J-tip, which allows the wire to be safely inserted
blindly (although once in the vessel the course should be followed on fluoroscopy).
- A Bentson wire is a typical floppy tip wire; Rosen is a J-tip wire.

Bentson Rosen

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Wire
s
Hydrophilic wires

- are used to cross a stenosis or for initial cannulating of an indwelling device, as would
be performed for a routine check and change.
- Roadrunner (Cook) and Glidewire (Terumo) wires are hydrophilic.

Roadrunner

Glidewire
Glidewire

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Wire
s
Stiff wires

- are used when structural rigidity is required. For instance, a devices that dilates the
subcutaneous tissues (such as a sheath, biliary drain, nephrostomy tube, etc.) needs to be
inserted over a stiff wire.
- An Amplatz (Boston Scientific) wire is a commonly used superstiff wire

Amplatz

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 Angiography

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 ……Example of cases

Thoracic angiography

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Giant cell arteritis
(GCA)

medium and large-vessel vasculitis

GCA > 50 Y
Takayasu < 50 Y

The medium-sized upper extremity

arteries are most commonly
affected

The aorta is rarely involved, unlike Selective angiogram of the axillary artery (catheter is not visible)
in Takayasu arteritis

Definitive diagnosis is with

temporal artery biopsy

.Treatment is steroids

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Left superior vena cava
(SVC)
persistence of the embryological left anterior cardinal vein
and regression of the right anterior cardinal vein

The left SVC usually drains directly into the coronary sinus 
right atrium

Rarely, the left SVC drains directly into the left atrium
causing a right to left shunt

Left-sided SVC is weakly associated with congenital heart

disease (CHD)

Left SVC is an incidental finding in 0.5% of the population

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Duplicated superior vena cava
(SVC)
persistence of both the right and left anterior cardinal
.veins

carries an association with congenital heart disease

Coronal CT shows right and

left SVCs. The left SVC (arrow)
is more opacified with
contrast because of the left-
.sided contrast injection

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superior vena cava (SVC)
obstruction

Acute obstruction of the SVC causes SVC syndrome A classic cross-sectional abdominal imaging finding in SVC
obstruction is increased enhancement of hepatic segment IVa
clinically presents as facial and upper extremity due to collateral opacification of the vein of Sappey
edema and cyanosis
Combined internal jugular and femoral approaches may be
.is a vascular emergency necessary for treatment of SVC occlusion. Stenting is often
necessary
chronic occlusion or stenosis of the SVC may be
asymptomatic. If symptoms are present, facial
edema that improves with standing is
.characteristic

causes are compression by thoracic malignancy,

catheter-associated thrombosis, and mediastinal
.fibrosis after histoplasmosis exposure

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with internal mammary vein

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Pulmonary artery angiography
technique

1st  do an ECG
. check if there is a LBBB
Because pulmonary artery catheter may cause temporary
RBBB, if so  may cause complete heart block & death

2nd  if there is LBB

. do temporary pacer prior to arteriography

Normal right-sided pressures:

Right atrium: 0–8 mm Hg.
Right ventricle: 0–8 mm Hg diastolic; 15–30 mm Hg systolic.
Pulmonary artery: 3–12 mm Hg diastolic; 15–30 mm Hg systolic

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Pulmonary arteriovenous malformation
(AVM)
right to left shunt

multiple pulmonary AVMs in Osler– Weber–

Rendu syndrome

Clinically present with brain abscess, stroke, or artery

recurrent epistaxis (due to nasal mucosa
.telangiectasia)

Coils must be used to embolize a pulmonary

AVM. Particles are contraindicated as the vein
right to left shunt would cause brain emboli
.and infarction
Nonselective DSA early arterial
Most pulmonary AVMs have a single feeding phase angiography of the left
artery and coiling of this inflow artery (via a pulmonary artery in LAO
pulmonary arterial approach) is usually orientation with a pigtail catheter in
.sufficient treatment the left PA shows a faint contrast
blush representing the AVM nidus
(arrow). Venous drainage is not yet
visible. This was treated with coils
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Note that the treatment of peripheral (e.g., in a limb) AVM
generally requires elimination of the entire nidus, which is
.often fed from multiple arterial branches

indication for treatment:-

-An asymptomatic lesion with a feeding artery size >3 mm
-or a symptomatic lesion (i.e., prior infarct or brain abscess)

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Bronchial artery embolization for
hemoptysis
Massive hemoptysis (hemoptysis of >300 mL/24 h)

The vast majority (90%) of cases of hemoptysis

involve the bronchial arteries

In the USA, cystic fibrosis and thoracic malignancy are the most common causes of hemoptysis. Worldwide, tuberculosis
and fungal infection are more common

The bronchial arteries arise from the thoracic aorta at T5–T6, although the arterial anatomy is quite variable. There are
.usually one or two bronchial arteries on each side

Embolization is performed with a distal embolic agent, most commonly particles. Initial angiography should carefully
evaluate for the rare presence of a left to right shunt prior to particle embolization to prevent inadvertent cerebral
embolization.
Because rebleeding after treatment is common, coils are rarely used to treat hemoptysis. Because coils prevent repeat
access, the use of coils would preclude retreatment.

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A potentially devastating complication is nontarget embolization of the spinal cord via
the anterior spinal artery or smaller tributaries arising from bronchial and intercostal
arteries. A complete neurological exam should be documented prior to the procedure.

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Abdominal & pelvic angiography

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Polyarteritis nodosa
(PAN)
systemic necrotizing vasculitis of small and medium-sized
arteries that causes multiple small visceral aneurysms

.P-ANCA is usually elevated

typically affects renal, hepatic, and mesenteric end-

.arterioles

PAN is associated with several medical conditions

remembered with the mnemonic CLASH
(cryoglobulinemia, leukemia, rheumatoid arthritis,
Sjögren syndrome, and hepatitis B)

.Treatment of PAN is with steroids, not procedures

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Splenic artery
aneurysm
Splenic artery aneurysm is the most common visceral aneurysm

Multiparous females and patients with portal hypertension are

at increased risk of developing splenic artery aneurysms

have an increased risk of rupture during pregnancy

A splenic artery pseudoaneurysm may be the result of trauma

or pancreatitis

Indications for treatment of a splenic artery aneurysm include

presence of symptoms (such as left upper quadrant pain),
aneurysm size >2.5 cm, and prior to expected pregnancy

Endovascular coil embolization is the preferred approach. Coils

are fist placed distal to the aneurysm neck (to exclude
retrograde collateral flow), then placed proximally
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Angiodysplasia
cause of chronic intermittent lower GI
bleeding, most typically located in the right
colon or cecum

identified in up to 15% of patients

incidentally

the presence of angiodysplasia in a

bleeding patient should not stop the hunt
for other possible sources

angiodysplasia is a tangle of vessels with

early filing of an antimesenteric draining
vein
Angiodysplasia of the right
The typical tram-track appearance is colon: Superselective
caused by simultaneous opacification of angiography (right image)
.the parallel artery and vein demonstrates prominent
capillary blush and early
Treatment is endoscopy with
filling veins (black arrows)
electrocoagulation, laser therapy, or other
(images courtesy of The
.techniques
.Alfred Hospital)
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Diverticular
bleed
Diverticulosis is the most common cause
.of lower GI bleeding in older adults

Most patients respond to conservative

management, but angiography can be
used for stable or unstable patients who
fail medical management

If active extravasation is seen, potential

therapies include superselective
embolization (most commonly with coils)
.or vasopressin infusion

Initial selective DSA Superselective DSA angiogram After placement of

angiogram of the SMA of the middle colic artery several coils in the
middle colic
branches
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Renal angiography

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Atherosclerotic renal artery
stenosis
most common cause of renal artery stenosis in older adults

tends to affect the ostia (origin) of the renal arteries

Angioplasty and stenting have greater long-term patency

compared to angioplasty alone + medical treatment

Delayed nephrogram

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Fibromuscular dysplasia
(FMD)
an idiopathic vascular disease affecting primarily the renal and
carotid arteries

.Bilateral two thirds of the tie

predominantly seen in young or middle-aged women

affect the mid or distal third of the renal arteries

The most common form of FMD is the medial fibroplasia subtype (80%),
which features the classic string of pearls or string of beads
appearance on angiography

A less common form is intimal fibroplasia, which is more common in

children and appears as a smooth stenosis, not the string of
pearls typical of medial fibroplasia
MIP image from an MR-angiogram

Perimedial and adventitial fibroplasia are less common variants

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FMD clinically responds well to angioplasty alone

Restenosis following angioplasty occurs relatively frequently, in

10–15% of patients

Stenting of FMD is not recommended, as stenting can

complicate retreatment with angioplasty and lead to in-stent
stenosis due to initial hyperplasia

Neurofibromatosis may cause renal artery stenosis in children

DDx for intimal fibroplasia

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Renal cell carcinoma
(RCC)
Most renal cell carcinomas (RCC) are hypervascular

Feature arteriovenous shunting and venous lakes,

with a classic angiographic appearance of bizarre
.neovascularity

AVM with characteristic

early draining vein

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Oncocytoma

benign renal mass that cannot be reliably distinguished from

.renal cell carcinoma on imaging

Angiography classically shows a spoke wheel appearance

with a peritumoral halo

In contrast to RCC, bizarre neoplastic vessels are absent

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Angiomyolipomas
(AML) FATSAT
hypervascular hamartoma
containing blood vessels(angio),
smooth muscle (myo), and fat
(lipoma)

diagnosed on cross-sectional
imaging as a renal mass containing
macroscopic fat

Angiography shows tortuous

feeding arteries, which have a
sunburst appearance No AVM

Occasionally, small aneurysms are

visible, which predispose to risk of
hemorrhage, especially if the AML
is >4 cm in diameter
shows intense tumor
not always possible to differentiate an AML After super-selective embolization with particles,
blush in the lower pole (red
from RCC on angiography there is markedly reduced flow. Tortuous feeding
arrow). There is no AV
54 arteries are still present peripherally
.shunting
Renal trauma

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 Arterial, venous, and visceral
abdomino-pelvic compression
syndromes

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Median arcuate ligament syndrome
(MALS)
celiac artery compression by the median arcuate ligament, a
part of the diaphragmatic crura. Arterial compression
worsens with expiration

.asymptomatic, or present with crampy abdominal pain

Definitive treatment is surgical release of the median

arcuate ligament to enlarge the diaphragmatic hiatus

Angioplasty is not effective

Nonselective lateral DSA aortagram

with the pigtail catheter

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Superior mesenteric artery (SMA) syndrome

compression of the duodenum between the aorta and the

.SMA, and is also known as Wilkie syndrome

occurs in thin children, burn victims, and patients who have lost
.weight

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 Nutcracker syndrome in
Nutcracker syndrome a 26-year old woman.
Catheterization of the
left renal vein. Contrast
venography by injection
compression of the left renal vein between the aorta and the through the introducer
SMA. This is similar to SMA syndrome, but the renal vein is located in the renal vein.
.compressed instead of the duodenum The end of the guide is
located in the gonadal
A posterior variant, called posterior nutcracker, is the vein Direct left renal
compression of a retroaortic (or circumaortic) renal vein venogram shows a
between the aorta and the vertebral body hemodynamically
significant pressure
including pain, hematuria, orthostatic proteinuria, pelvic gradient of 5 mmHg
across the LRV (9 mmHg
congestion, and varicocele (in a male)
in the LRV and 4 mmHg
in the IVC)
The majority of cases of hematuria resolve within two years
.of observation

If treatment is desired, angioplasty and stenting of the renal

.vein can be performed

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 May–
Thürner
Venous thrombosis of the left common iliac vein caused by
compression from the crossing right common iliac artery

Chronic compression leads to a fibrous adhesion in the vein,

predisposing to thrombosis

.Treatment is endovascular thrombolysis followed by stenting

impression of the right common iliac

artery crossing the left common iliac
vein (a subtraction image), discrete
venous dilation and pelvic collateral
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circulation
 Inferior vena cava (IVC) and pelvic venous
disease
Others ‘within
’abdomen
Inferior vena cava (IVC) filter
placement
The purpose of an IVC filter is to reduce the risk of pulmonary embolism (PE)
originating from a lower extremity DVT

Indications
DVT and contraindication to anticoagulation-
recurrent PE while anticoagulated-
high risk of developing DVT/PE in a patient with contraindication-
.to anticoagulation, such as a multitrauma patient

Complication of IVC filter placement

access site thrombosis,-
-followed by IVC thrombosis
IVC perforation occurs not uncommonly, but is almost always-
inconsequential
.Filter fracture or embolization is rare-
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The fist step of the procedure is an inferior vena cavogram, performed with a
high-flow (pigtail) catheter

If a duplicated IVC is present, in order to prevent a clot from circumnavigating

the filter, either a single filter is placed above the IVC confluence or a filter is
placed in each duplicated IVC. If pre-procedural imaging is not available, a clue
to the presence of a duplicated IVC on initial cavography is the absence of iliac
vein influx contralateral to the side injected

An IVC diameter >28 mm generally requires a special bird’s nest filter,

which can be placed in IVCs ranging from 28–40 mm

If the IVC is >40 mm in diameter, separate IVC filters can be inserted in each
common iliac vein

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The preferred location of the IVC filter is immediately inferior to the lowest
renal vein, including any variant renal veins (circumaortic or retroaortic)

The presence of preexisting IVC thrombus may interfere with the positioning
.of IVC filter, requiring higher than normal placement

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Varicoce
le
dilation of the pampiniform venous plexus

Primary varicocele (most common) is due to absent or

incompetent valves in the proximal gonadal vein causing
venous reflux

Secondary varicocele is due to a mass obstructing venous return

The vast majority of varicoceles are left sided as the left gonadal
vein drains into the left renal vein, while the right gonadal vein
drains directly into the IVC. A solitary right varicocele should
prompt the workup for an obstructing retroperitoneal mass

Diagnosis by scrotal ultrasound shows a dilated (>2 mm) venous

plexus with a bag of worms appearance, which worsens on
.Valsalva maneuver

Treatment is coil embolization or surgical ligation of the gonadal

vein; these have been shown to be equivalent in outcome

Not done, unless endovascular intervention is

intended due to risk of radiation
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Transjugular intrahepatic portosystemic
shunt (TIPS)
lowers elevated portal pressures by the creating of a direct connection between the portal vein and the hepatic vein

The most common indication for TIPS is treatment of variceal hemorrhage that cannot be controlled endoscopically.
.Other indications for TIPS include refractory ascites and Budd–Chiari (hepatic vein thrombosis)

.Portal vein patency should be established pre-procedure with cross-sectional or US imaging

Absolute contraindications to TIPS include:

-Right-sided heart failure, which will be worsened by TIPS, as right sided venous return increases.
-Severe active hepatic failure, as the post-TIPS shunting of blood beyond the hepatic sinusoids can cause liver function
to worsen further.
-Severe hepatic encephalopathy, which TIPS can worsen

CO2 is the preferred contrast agent as it is 400 ties less viscous than iodinated contrast and is therefore easily able
.to pass through the hepatic sinusoids

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TIPS
:
Step
by
step

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 Percutaneous transhepatic cholangiography
(PTC)

is the injection of contrast into the biliary tree through a percutaneous approach, traversing the hepatic parenchyma

The two most common indications for PTC are relief of biliary obstruction and to provide biliary diversion in the case of
ductal injury, which may be post traumatic or post surgical

Pre-procedure prophylactic antibiotic are administered, typically with levofloxacin

The right biliary tree is accessed via a right midaxillary line two-puncture approach. The needle should be inserted
.directly over the ribs, as the neurovascular bundle runs underneath each rib
A 22 gauge needle is inserted, parallel to the table and to the inferior border of the liver
Contrast is injected as the needle is withdrawn in an attempt to opacify the biliary tree
Once a bile duct is opacified, the needle is temporarily left in place and a second puncture is made
.with a 21 gauge needle as low as possible to access the duct
Once the second needle has accessed a duct, a 0.018” wire is advanced, exchanged for a 5 or 6 Fr
sheath, and subsequently a hydrophilic wire (such as a Roadrunner or Glidewire) is guided into the
.small bowel
The hydrophilic wire is exchanged for a stiff wire (e.g., Amplatz) and the biliary drain is placed
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The left biliary tree is accessed by a left subxiphoid approach The left side is
accessed in a similar manner to the right; however, ultrasound can often visualize dilated
.ducts, obviating the need for two punctures

If stent placement is required to treat a stricture, a metallic stent is usually only placed
in patients with a life expectancy of less than 6 months. Most metallic stents cannot be
removed and have a median patency of 6–8 months, although newer covered metal
.stents can be removed

Plastic stents, which are placed endoscopically, do allow regular exchange

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:Most contraindications to PTC are relative
intrahepatic tumor (primary or metastasis)  can be traversed-
ascites  can be therapeutic-
Platelets less than 100 × 109 L–1  can give FFP-
-Prothrombin time prolonged >2 s more than control  can give vit. K

:Complications of percutaneous biliary drainage include

sepsis-
hemorrhage-
bile leak-
hemobilia (due to arterial–biliary fistula)-
.abscess-

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 Bile duct
injury

The most common cause of bile duct injury is

iatrogenic from a laparoscopic cholecystectomy. A less
common cause of bile duct injury is from orthotropic
liver transplant.

• Treatment is to provide biliary diversion to a

drainage bag to allow the leak to heal (4w)

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 Sclerosing
cholangitis
chronic inflammatory and Fibrosing process

multifocal strictures of the intra- and extrahepatic biliary tree

obstructive jaundice, malaise, and abdominal pain

More commonly in men

.associated with inflammatory bowel disease (ulcerative colitis)

leads to biliary cirrhosis and increases the risk of developing

.cholangiocarcinoma
 Sclerosing cholangitis.
Treatment of sclerosing cholangitis is liver transplant, although  Primary biliary cirrhosis
 Multifocal cholangiocarcinoma
DDX
percutaneous biliary drainage can provide palliative relief for
the symptoms of obstructive jaundice  Chronic bacterial cholangitis
 AIDS cholangitis (usually associated with papillary
stenosis)

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Malignant biliary obstruction

Pre-procedure MRCP may be helpful to delineate biliary

anatomy

which most often requires two biliary drains, ,)Klatskin tumor(

one each in the right and left ducts. Occasionally an anatomic
anomaly, such as anomalous drainage of the right duct directly
into the left duct, may allow complete drainage of a hilar
obstruction with a single biliary drain

72
 Cholecystostomy

indicated for the treatment of acute calculous or acalculous

cholecystitis in patients who are not surgical candidates
is a temporizing measure
prophylactic antibiotic are given
approaches: transperitoneal, transhepatic 2
The drainage tube must remain in place until :
The gallbladder is punctured with an 18 or 19 gauge needle - clinically improved. There is a risk of sepsis if the
under ultrasound guidance. Bile can then be aspirated for tube is removed prematurely.
microbiological studies. A 0.035 guidewire is used to exchange - Cystic duct and common bile duct are demonstrated
the needle for a dilator and an 8 French or larger pigtail drain is to be patent on repeat cholangiogram.
placed within the gallbladder. The drain can often be visualized - At least six weeks have passed since placement to
under ultrasound. Aspiration of bile/pus from the drain allow a fibrous tract to develop extending from the
.confirms satisfactory position gallbladder to the skin puncture.
If the tube is removed prematurely there is a risk of
A trial of clamping the catheter for 24 hours is .bile peritonitis
.usually done prior to removing the catheter
73
 Percutaneous nephrostomy

The most common indication :

- Obstruction
- pyonephritis

Technique:
- Direct visualization of the collecting system
- The patient is positioned prone
- 22 gauge needle is used for direct posterior access (zone of
Brödel)

74
.. Examples in

Distal aorta, iliac,

pelvic, and leg
arteries

75
Atherosclerotic distal aortic occlusive disease (Leriche
syndrome)
chronic occlusive atherosclerotic disease of the distal
abdominal aorta

producing the classical quartet of impotence, buttock

claudication, absent femoral pulses, and cold lower extremities

:collaterals develop

76
Persistent sciatic artery

persistent sciatic artery is a very rare vascular anomaly where

the fetal sciatic artery persists to supply the majority of blood
supply to the leg

arises from the internal iliac artery (usually from the

inferior gluteal artery) and continues distally to the popliteal
.artery. A rudimentary femoral artery may be present

77
Pelvic vascular
trauma
Pelvic trauma can lead to catastrophic
hemorrhage from arterial injury. It is
possible to exsanguinate completely
within the pelvis: A 3 cm diastasis of
the symphysis pubis doubles the
potential intra-pelvic volume to
.approximately 8 liters
angiography is usually performed
prior to orthopedic surgery
The fist step in treating a pelvic arterial injury is to
perform a nonselective pelvic arteriogram, followed
by selective bilateral internal iliac arteriograms of the
.anterior and posterior divisions

Because of the rich collateral supply in the pelvis, rapid

nonselective gelfoam embolization of either the entire
anterior or posterior division of the internal iliac artery is often
acceptable. A potentially tie-consuming superselective
embolization should be avoided in the setting of life-
.threatening
78 hemorrhage
 Uterine artery embolization (UAE)

The two primary indications for uterine artery embolization

(UAE) are symptomatic treatment of fibroids and postpartum
hemorrhage

The goal of fibroid treatment is to produce hemorrhagic

infarction of the hypervascular fibroids while still maintaining
adequate perfusion to the endometrium and myometrium,
thus preserving future fertility

.Polyvinyl chloride particles are used

There is approximately a 1.25% serious complication rate for

UAE, which is especially important to consider as many of these
patients are otherwise healthy reproductieage women. Serious
:complications include
abscess, endometritis, and ovarian necrosis
due to non-target embolization, leading to subsequent
.premature menopause

79
Popliteal aneurysm

defied as a popliteal artery measuring 8 mm or more

almost always due to atherosclerosis

Approximately 20% of patients with a popliteal aneurysm also
have an aortic aneurysm, and up to half have bilateral popliteal
.aneurysms

Treatment is recommended for all symptomatic popliteal artery

.aneurysms and asymptomatic aneurysms >2 cm in diameter

80
 Burger disease

medium and small vessel occlusive vasculitis

affects the lower extremities > hands

seen in adult male smokers

On angiography, there are segmental stenoses

of the medium and small arteries in the leg,
with typical corkscrew collaterals in the vasa
.vasorum

he larger arteries, including the common

femoral artery, superficial femoral artery, and
.popliteal artery, are typically spared
Post Rx
Primary treatment is smoking cessation

81
Popliteal entrapment syndrome

compression of the popliteal artery by a calf muscle

or fibrous band, most commonly an aberrant medial
head of the gastrocnemius

.Bilateral involvement is common

Treatment is surgical release of the offending muscle

Angiography is only used for diagnosis, not therapy

82
Cystic adventitial
disease
rare cause of distal claudication where one or more mucoid
cysts in the adventitia surrounding the popliteal artery leads to
.luminal compression

middle-aged men presenting with claudication

MRI is the best diagnostic tool, as the cystic component can be

.readily identified with typical T2 hyperintensity

Treatment is surgical resection of the cyst or surgical bypass

83
.. Examples in

Upper limb vascular lesions

84
Thoracic outlet syndromes
(TOS)

Overview of thoracic outlet syndromes

Thoracic outlet syndromes are a controversial

spectrum of disorders caused by compression of
:either
the brachial plexus
subclavian artery
subclavian vein

The brachial plexus and subclavian artery pass through the interscalene triangle. In contrast, the subclavian vein does
not pass through the interscalene triangle

Neurogenic thoracic outlet

syndrome
Subclavian artery
compression
Paget-Schroetter syndrome (subclavian vein compression)
85
Paget-Schroetter syndrome (subclavian vein
compression)

compression and thrombosis of the subclavian vein as

it enters the thorax and is usually seen in muscular young
men

During diagnostic venography, it is necessary to evaluate the

arm both in neutral position and abducted. Both sides should
.be evaluated

Treatment is thrombolysis, then subsequently surgical

.thoracic outlet decompression

if pre-procedure imaging demonstrated no mechanical cause,

then angioplasty can be performed

Stents should generally not be used, especially if there is a

.mechanical obstruction, due to high risk of device failure

86
 Subclavian steal syndrome

proximal stenosis or occlusion of the subclavian artery, which

leads to retrograde flow from the vertebral artery into the
subclavian artery distal to the flow-limiting lesion

clinically presents with vertebrobasilar insufficiency or

syncope exacerbated by arm exercise

Subclavian steal is best diagnosed with angiography. The early

arterial phase shows the proximal subclavian flow-limiting
lesion and the later arterial phase shows retrograde flow from
.the vertebral artery into the subclavian

Treatment options include surgical bypass or angioplasty of the

.flow-limiting lesion

87
Hypothenar
hammer
Hypothenar hammer syndrome
represents injury to the ulnar artery
as it crosses the hamate bone.
Chronic repetitive trauma causes the
ulnar artery to be chronically
traumatized at the hamate, leading to
intimal injury, thrombus, aneurysm,
or pseudoaneurysm

The classic clinical history of hypothenar hammer

syndrome is a jackhammer operator with ischemia of
the fourth and fit digits

Treatment is surgical
Hypothenar hammer: Digital subtraction angiogram of the hand shows
an approximately 2–3 cm occlusion of the ulnar artery (between the
blue arrowheads), and multifocal occlusions of the proper palmar digital
.arteries in the 2nd through 4th digits (red arrowheads)

88
Buerger disease of the hand

89
Raynaud disease

small arterial vasospasm triggered by cold temperature

On imaging, there is decreased perfusion of the distal digital arteries, with improvement upon warming or
vasodilator administration

.Reynaud disease is associated with scleroderma and other connective tissue disorders

90
91
 liver
Fine needle aspiration
(FNA)
Core biopsy needle

Coaxial needle

92
 lung

19G guiding coaxial needle positioned within

the lateral portion of an RUL lesion to avoid the
medially placed vessels. The 20G cutting
needle was then placed via this guiding needle
into the lesion to obtain the tissue cores

93
 Trephine needle (Laredo type)

bone Ostycut Bone biopsy needle

(8G)
For lesions with mild
condensation, primary
(14G) bone tumors, and
For lesions with mild lymphoma
Temno coaxial biopsy needle (14– ossification, surrounded by
18G) minimal cortex, and spinal
For soft tissue and biopsies, Surgical hammer
lytic lesions without used for penetration of cortex
ossification

94
 kidney

Fine-needle aspiration (FNA): 20–25G needles

Core biopsy: 15–18G core biopsy needles, placed via a introducer

system

95
 Lymph nodes
Beveled/angled aspiration needles – generally 20–23G, thin walled with •
beveled tip

– Specimens suitable for cytologic examination

– Examples include Chiba, Turner, and Franseen (Cook Medical, Bloomington,

IN)

• Cutting/core needles – generally 18–20G

– Two main types – side and end cutting

Chiba

96
 thyroid

Fine-needle aspiration: 25 gauge 5 cm long •

needles

• Core biopsy: 20 gauge 6 cm long core biopsy

needle

97
Transrectal ultrasound transducer with needle •
guide

• 18 gauge cutting needle biopsy gun

98
The following is a quiz in interventional radiology instruments, from
.…RadioGyan

Answers in the end of slide show

99
Spotters
Source: RadioGyan

35 Collected by BFH