Radio 250 [8]: ICC in Radiology and Nuclear Medicine

Lec ##: Introduction to Interventional Radiology

October 20, 2014

Jason Catibog, MD, FPCR, FPCVIR, FCTMRISP

TOPIC OUTLINE
I.

Interventional Radiology Procedures

A.
B.

II.

Catheters and Guidewires

Seldinger Technique

A. CATHETERIS AND GUIDEWIRES

Vascular Procedures
A.
B.
C.
D.
E.
F.

IV.

II. CATHETERIZATION

Catheterization
A.
B.

III.

Vascular Procedures
Non-vascular Procedures

Angiography and DSA

Embolization
Angioplasty and Stenting
Transjugular Intrasystemic
Shunt (TIPS)
Transarterial Chemoembolization (TACE)

Non-vascular Procedures
A.
B.
C.
D.
E.

Biopsy
Radiofrequency Ablation
Percutaneous Drainage
Percutaneous Cholecystostomy
Percutaneous Transhepatic Biliary Drainage (PTBD)

Legend:
Discussed by sir, not in the powerpoint
From 2016
I. INTERVENTIONAL RADIOLOGY PROCEDURES
Diagnostic or therapeutic
Vascular or non-vascular
Advantages of Interventional Radiology over Surgery
o
Minimally-invasive; no incision, sirs widest incision is 5mm
o
Sometimes, general anesthesia is not needed just IV sedation or
local anesthesia
o
Most procedures are done inside the catheterization lab

A. VASCULAR PROCEDURES
1. Increase Blood Flow
Mechanical methods
o
Dilatation of stenotic artery
o
Recanalization of occluded artery
o
Removal of embolus
Pharmacologic
o
Increase vasodilators
2. Decrease Blood Flow
Mechanical methods
o
Embolization
o
Balloon techniques
o
Intravascular electrocoagulation
Pharmacologic
o
Increase vasoconstrictors
3. Miscellaneous
Infusion of chemotherapeutic agents
Radioembolization
Laser angioplasty
Vena cava filtering
Renin sampling not just renin
o
Active pancreatic nodule: must be located by the interventional
radiologist; samples of venous blood are collected from head, body
and tail of the pancreas stimulate pancreatic cells to secrete
insulin by injecting CaGLuc get samples again after 1 minutes
graph determine where insulin is highest
B. NON-VASCULAR PROCEDURES
Mostly basic procedures done by radiologists
Biopsies
Abscess drainage
Puncture and drainage of cysts
Cysts sclerosing by introducing sclerotic agents like tetracyclines,
ethanol.
Placement of stents bile duct, ureter, GI tract, colon
Percutaneous transhepatic biliary drainage drain the biliary system.
Endoscopic retrograde cholangiopancreatography done by GI
Sialography
Joint aspiration orhto or rheuma

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Figure 1. Interventional Catheters

From 2016: Top Left (L to R): Neff catheter and pigtail catheter. Both are
used for invasive diagnosis with injection of contrast agents through
large arteries, so they have a multiperforated distal tip to enable highflow injection (such as in an aortogram)
Top Right (L to R): distal tips of a conventional J-tipped guidewire and a
curvedtip hydrophilic guidewire
Bottom Left (L to R): vertebral catheter, cobra catheter, and type I
Simmons catheter (for visceral blood vessels). These catheters all have
a preformed distal tip for selective catheterization; the choice of which
one to use depends on the procedure
Bottom Right (T to B): introducer sheath, dilator, and guidewire
B. SELDINGER TECHNIQUE
Most procedure are done using this technique
By using this technique we can insert big catheter into small vessel
To avoid collapsing of vessel
Puncture by needle, insert wire to maintain axis,
With a series of wire and catheter exchange maneuver we can
access small vessels with big tubes having the least trauma
Gradually dilating
Ensures atraumatic placement of catheter.
Can also be done in non-vessel structures i.e. bile duct, abscesses,
and cysts

Figure 2. Seldinger Technique

IV. VASCULAR PROCEDURES

A. ANGIOGRAPHY OR ANGIOGRAM
X-ray exam of arteries and veins to diagnose blockages and other blood
vessel problems
Simplest procedure done for the vascular system
Purely diagnostic
Vessel opacified by contrast medium
Catheter introduced using Seldinger technique
Uses:
1. For blockage or narrowing in a blood vessel
2. Aneurysms an area of a blood vessel that bulges or balloons out
3. Cerebral vascular disease, such as stroke or bleeding in the brain
4. Blood vessel malformations, hypervascular tumors

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Introduction to Interventional Radiology

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Digital Subtraction Angiography (DSA)

o
Gold standard in diagnosing vascular lesions; can assess
location, configuration, and hemodynamics
o
X-ray is taken and used like a mask. The contrast is
injected and then an image is subsequently taken.
o
The resulting picture is subtracted by the mask and the
vessels will be shown

Figure 3. Digital Subtraction Angiogram of the Cerebral

vessels
Left: Actual angiogram, Right: Digitally subtracted image, Top:
Arterial phase, Bottom: Venous phase

Figure 4. A DSA of an stenosed MCA showing collateral

vessels to maintain perfusion
B. EMBOLIZATION
Aneurysm Coiling
From 2016:
o
Use of microcatheter <1mm
o
Pack aneurysm with coils (made of alloy/Platinum)
o
Coils can have thrombogenic material like
cotton, polyvinyl alcohol, glue, or even blood
clots
o
Coils protect dome of aneurysm from rupturing

Figure 5. Embolization of an Aneurysm (Top left:

endovascular coil, Top right: process diagram of ambolization,
Bottom: actual angiogram during embolization)
Examples of Using Embolization
Uterine AVM
o
Common History: A young primigravid female with
ahyaditiform mole. She underwent chemotheryapy and as
a complication, AVM developed.
o
The feeding arteries appeared hypertrophied due to
increase demand of the nidus
o
Process: The feeding artery to a lesion is identified by
angiography and subsequently occluded to shrink the
aneurysm by means of a catheter and embolizing material.
Preoperative Embolism
o
Before the tumor is resected, the blood vessels are
occluded. Once the blood vessel is occluded it creates
edema on the affected tissue. This somehow makes the
differentiation of normal tissue from edematous tumor
during resection.
o
It results to lesser blood loss during surgery and easier
identification of tumor parts due to surrounding edema.
C. ANGIOPLASTY AND STENTING
ANGIOPLASTY- a process to widen a narrowed blood vessel
In angioplasty, deliberate trauma is induced to the intima of the
vessel leading to healing with a systematic scar
Disadvantage of angioplasty is that stenosis may recur

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Introduction to Interventional Radiology

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STENTING- a balloon is inserted to a stubborn blood vessels

o
Can be introduced after angioplasty
o
Some stents slowly release thrombolytic agents (esp.
coronary angioplasty)
Among interventional radiologists and interventional
cardiologists, the area of specialty is delineated by the aortic
root.
Example : Patients may present with hypertension due to renal
artery stenosis

Figure 7. TIPS Diagram (L), actual angiogram (R)

Figure 6. Angioplasty and Stenting A. Aortogram in a patient

with hypertension shows pronounced R renal artery stenosis
(arrow). B. Following placement of a balloon-expandable stent
shows an excellent radiographic result. (Images from Brant and
Helms, 2007)
D. TRANSJUGULAR INTRAHEPATIC SHUNT (TIPS)
The catheter goes through the jugular and this creates a shunt
between the portal circulation and the systemic
circulation.
Clinical Application: Patient presents with massive
hematemesis due to esophageal varices from severe portal
hypertension. In this case, the pressure must be relieved in
the portal circulation.
Procedure: The catheter is passed through the internal jugular
vein to the SVC -RA- IVC- hepatic vein then we drill a hole
connecting the hepatic vein and the portal vein and secure
this communication using a stent.

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E. TRANSARTERIAL CHEMOEMBOLIZATION (TACE)

The vascular supply of the tumor is identified and isolated and
the chemotherapeutic agents are inserted directly into the
tumor.
This results to lesser side effects since the chemicals are
injected directly into the tumor and the systemic circulation is
bypassed.
The procedure is repeated until the tumor is reduced to a
manageable size and can be resected. Constant monitoring is
important.
Clinical Scenrio: Hepatocellular CA- The catheter passes
through the femoral artery-aorta-celiac artery- hepatic artery
(identify and isolate) then the hepatic artery is fed with
chemotherapeutic agents as microspheres
Liver has dual blood supply hepatic artery and portal vein. In
hepatocellular carcinoma, where the tumor environment has
decreased O2 tension secondary to continued tumor
metabolism. Hepatic artery is more reactive than portal vein
in increasing blood supply to the tumor.
Procedure:
o
Access aorta and then celiac trunk
o
Look for feeders at the branches of the hepatic artery
o
Deliberately push chemotherapeutic agents to feeder
o
Occlude the feeding artery tumor involutes (poison
[chemotherapeutic agent] and starving [occlusion])

Figure 8. TACE Diagram (Top), actual angiogram

(Bottom)
Advantages of the procedure:
o
Increase concentration of agent at tumors, lowers
systemic dose
o
Longer dwelling time of chemo agent at tumor
o
Lower probability of recurrence and metastatic
dissemination
o
Chemo agent can be emulsified with lipiodol to
minimize collateral damage (normal hepatocytes have
lipases that can digest lipiodol normal hepatocytes
spared from chemo)
Indications
o
Surgically-unresectable tumor
o
Tumor confined at liver

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Introduction to Interventional Radiology

o
Liver disease as dominant source of morbidity
o
Liver-only or liver-dominant metastasis
Contraindications
o
Portal vein thrombosis (because you occluded the
hepatic artery, hepatocytes now rely on portal vein for
blood supply)
o
Uncorrectable coagulopathy
o
Presence of hepatic encephalopathy
o
Tumor > 50% of liver
o
Biliary obstruction (increase pressure of sinusoids
increases portal pressure which decrease blood flow to
liver parenchyma)
o
Child Pugh C

Radio 250

If we see something and we have the proper needle to access

that theres no reason for us not to puncture, whether lung,
retroperitoneum, or liver.

Figure 10. Guided Biopsies, CT-guided lung mass biopsy (L),

UTZ-guided breast mass biopsy (R)

Figure 9. Child Pugh Classification. Class A TACE can be

performed; Class B TACE can be done but with precaution;
Class C TACE is contraindicated

Complications
o
Non-targeted embolization to other organs
o
Contrast-related complications
o
Hematoma
Post-embolic symptoms (usually less than 1 wk duration)
o
Fever
o
Pain
o
Nausea
o
Vomiting
o
Fatigue
Selective Internal Radiotherapy

In 20-25 grays, normal liver tissue dies; however,

need 80-100 to kill tumors. SIRT allows targeted
delivery of radiation while sparing normal hepatocytes

Uses yttrium 90 that emits B radiation; usually 2-3 mm

relatively safe for normal hepatocytes which are
radiosensitive
IV. NON-VASCULAR PROCEDURES

A. BIOPSY
Minimally invasive way to diagnose benign and malignant
diseases
Small diameter needles 22 gauge to 18 gauge
Aspiration needles versus cutting needles
Ultrasound, fluoroscopy, CT or MRI as guide

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B. RADIOFREQUENCY ABLATION
Instead of puncturing the mass with just a needle, uses an
electrode connected to a radiofrequency generator.
Produce heat like a microwave. Effectively cooking the tumor.
On the way out the RF generator is still active so the needle
track is ablated and so there is no issue of bleeding or
hemostasis. They are effectively cauterized.

Figure 10. Radiofrequency Ablation. Showing the RF ablation

probe and the grounding pads on each thigh
Criteria for RF Ablation
o
Liver-dominant disease
o
Focal rather than diffused infiltration
o
3-5 lesions, < 6cm each if the location is feasbile
C. PERCUTANEOUS DRAINAGE OF ABSCESS
For drainage of fluid collections, including nephrostomy,
abscess, biliary gallbladder, pleural fluid, ascites, and
lymphoceles
For Liver abscess. Treating it with antibiotics is not enough. We
need to remove the pus through sound guidance and a
catheter

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Introduction to Interventional Radiology

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Figure 11. Percutaneous Liver Abscess drainage, CT

Radiographs

D. PERCUTANEOUS CHOLECYSTOSTOMY
Drainage of the
biliary system
For
cholesystitis, when the patient is in sepsis and theres
coagulopathy the patient is surgically unstable and cant be
operated on they cant just take the gall bladder out.
Insert
a
catheter and drain the pus inside and when the patient is
stable, operate.

Figure 12. Percutaneous Cholcystostomy diagram (UL),

radiograph (UR), Sonogram guidance (bottom) showing a stent
through the gall bladder

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FROM 2016: E. PERCUTANEOUS TRANSHEPATIC BILIARY

DRAINAGE (PTBD)
When the patient has obstructive biliary pathologies and the bile
becomes stagnant, he becomes prone to developing
infection, which can lead to sepsis, then shock, or even death.
To avoid ascending cholangitis we can put a tube to drain the
biliary tree so the bile is free flowing and decreases the
chance of sepsis.
Needle is placed into liver and bile duct
Guide wire is inserted through the needle and down into the bile
duct
Needle is removed and the catheter is passed over the guide
wire and into the bile ducts.

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Introduction to Interventional Radiology

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TANGCO: RADIOLOGY! RAD-YOLO-GY! LIKE FORT LIU!

HAZZA!

TURALDE: THANK YOU ANDREW FOR THE 3-5 CM LESION

<6CM IF LOCATION IS FEASIBLE
Figure 13. Percutaneous transhepatic biliary drainage, TOP:
Needle placed into liver and bile duct (A), a guidewire is passed
through the needle and down into the bile ducts(B), the needle
will be removed from the bile ducts and liver through the guide
wire (C), the soft plastic biliary tube catheter will be passed over
the guidewire and into the bile ducts (D), BOTTOM (L to R): The
percutaneous catheter is pushed through the stenosed common
bile duct, so that bile is advanced inside the catheter towards
the bowel loops; Metallic Stent is placed into the common bile
duct, keeping the stenosed area patent. Now the percutaneous
catheter can be taken out.

TY: HEY BITCHES!! EXTRA HEY HEY HEYLALOO SA

STAREXXX!! AT SIYEMPRE HETO NANAMAN KAMI NI
HUBBY KO MEHUEHUEHUE PAKYU SA HATERZZZ

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