Introduction to Medical

Imaging

Royal College of Surgeons in Ireland

Learning objectives
To understand the essential principles of
image acquisition for common imaging
modalities
To appreciate the utility and common
indications for imaging with different
modalities
To have an appreciation of the risks and
hazards associated with
Ionizing radiation
Intravenous contrast media

What is Radiation ?

Radiation is defined as energy in

the form of waves or moving
subatomic particles, so called
electromagnetic waves
The electromagnetic spectrum
classifies the range of radiant
energies by their wavelength
Light photons and microwaves are
forms of non-ionizing radiation
X-rays are a form of ionizing
radiation
Ionizing radiation causes atoms or
molecules to gain an electrical
charge after they are contacted by
the radiant beam

What are X-Rays?

X-rays were discovered
accidentally by a German
scientist, Wilhelm Conrad
Roentgen in 1895
He temporarily referred to
this previously unknown
radiation as "X", although
the name stuck
He won the first Nobel
Prize in Physics for his
discovery
The hand of Mrs Wilhem Roentgen: the first
X-ray

Radiation Hazards

X-rays can produce harmful effects in tissues due to ionization,

which is most clearly evident in the effects of the Hiroshima bomb
or nuclear plant disasters such as Chernobyl
This occurs because ionization generates free radicals
Free radicals are highly reactive atoms with an unpaired electron
which readily react with other molecules to cause tissue and cell
damage
Free radicals can inhibit cell growth and can lead to cell death
This is the desired effect of radiotherapy
Similarly this is the mechanism by which cataracts can form if
the orbits are involved in numerous CT scans of the head
Free radicals can modify DNA
Genetic mutations may be oncogenic (cause cancer) or result
in fetal malformation

Radiation Hazards

Importantly
There is no absolute safe level of radiation
exposure
Radiation dose is cumulative with increasing risk
from increased exposure over time

Background Radiation
Natural background radiation is present in every
environment
This radiation is emitted from atmospheric
sources, dietary sources and the earth itself
Doses received in radiological investigations can
thus be expressed in term of background dose
A chest x ray gives an effective dose of 0.03 mSV
which is the equivalent of 3 days of background
radiation
A CT Abdomen however has a dose of 10.0 mSv,
4.5 years of background radiation
This gives an estimated to give an overall lifetime risk of
fatal cancer of 1 in 2000

Radiation Dosimetry
Diagnostic
procedure

Typical
effective
dose
(mSv)

Equivalent
number of
Chest
X Rays

Equivalent
period of
natural
background
radiation

Limb x-ray

< 0.01

< 0.5

< 1.5 days

Lumbar spine

1.3

65

7 months

Barium enema

350

3.2 years

CT Brain

2.3

115

1 year

CT Chest

400

3.6 years

Bone scan

200

1.8 years

Reference: EU referral guideline for imaging. Radiation protection 118. 2000

Radiation: Responsible referral

Radiologists and the referring clinician need

always to consider the potential dose to patients

It is a legal requirement and responsibility of the

referring clinician to ensure that:

The correct patient is referred to avoid

irradiating the wrong patient

The examination has not been previously

performed, to avoid duplication of radiation
dose

Radiation: Responsible referral

Every test that is ordered should be justified

-

This means the test should be considered useful and appropriate

This is best assessed by the following questions
- Has the test already been performed?
- Will the result of the test change patient management?
- Is it there another test without radiation that can answer the question ?
-

Ultrasound or MRI

- Is there another test with a reduced radiation dose that could be performed?

Every test that is ordered should have the potential radiation dose
minimized, that is conditions should be optimized. This includes
Careful calibration of machinery
Minimizing exposure to the beam
Using low dose techniques where possible

Any unjustified exposure is in fact illegal and can lead to

prosecution for assault

Radiation effects on tissues

Radiation effects are especially important to consider in the

paediatric population where any potential genetic defect has
more time to express itself
Certain tissues such as those with rapid cell division are
particularly susceptible to injury
This includes the thyroid, breast, lens of the eye and male and
female gonads. Good technique is important in radiation
protection
Orbits are avoided whilst performing a CT brain
Thyroid guards are an important part of lead protective equipment
for radiologists
Gonadal shields are used in pelvic and abdominal imaging where
possible, especially in paediatric patients. This is obviously easier
in males

Radiology departments are specially constructed with lead

shielding to avoid unnecessary exposure to staff, in the
radiology department and the hospital as a whole

Pregnancy

Irradiation of the foetus is avoided whenever possible, including in

situations when pregnancy is not suspected by the patient
The responsibility for identifying such patients lies in large part
with the referring clinician
All patients who are to have exposure to radiation are asked
about the possibility of pregnancy
The date of the last menstrual period is recorded and the patient
signs a form to document they are not pregnant and that they
have had a period in the last 28 days
Certain examinations, where to dose to uterus may be high are
only performed in the first 10 days of the menstrual cycle
Abdominal and pelvic CT
Barium enema

MRI is also not advised if possible in the first trimester but is

considered safe in the second and third trimester

How are X-rays generated?

X-rays are produced in a vacuum
A current is passed into to a cathode, which cascades
electrons to an anode
When this electron beam hits a target, x-ray photons are
generated. These are focused to a point of interest as they
leave "the tube
The part of the patient to be X-rayed is placed between the
X-ray source and the image receptor to produce what is a
shadow of all the internal structure of that
particular part of the body being X-rayed.
X-rays are somewhat blocked ("attenuated") by dense
tissues such as bone, and pass more easily through soft
tissues

How are X-rays generated?

A standard chest x-ray is obtained at a fixed distance between

the tube and the cassette, (180cm)
The patient faces the cassette, the x-ray beam passes through
in the posterior to anterior direction
This is the method of obtaining a PA Chest X-ray
Modern imaging uses a digital cassette rather than the
previous direct film system

Xray tube
Cassette

The Radiographic Image

Always bear in mind the attenuation of tissues

Attenuation refers to the degree to which x rays are
absorbed and thus the density that results on the image

Tissue absorption

Radiographic result

Least
Air / gas
Fat
Soft tissue
Bone/calcium

Black
Dark grey
Grey

Most

White

Thicker structures can absorb a higher

proportion of the X-ray beam
Thus a higher doses is needed to demonstrate
the lumbar spine vertebral bodies compared to
the hand to look at the carpal bones

Denser structures also absorb a higher

proportion of the X-ray beam.
For example bones absorb most of the beam
which means less x-rays strike the detector
resulting in a white image
Gas absorbs none of the beam, resulting in a

Fat:
Subcutaneous
tissues
Fat:

Gas: Sigmoid colon

Muscle:
Gluteal
musculature

Between muscle
planes

Bone:
Femur

Fluoroscopy

A fluoroscopic/screening machine. The x-rays are emitted beneath the table and
the screen can be moved above it to the area of interest. The table can be
positioned in a lying or standing position

Fluoroscopy
Fluoroscopy is used to obtain real-time images
using an X-ray source and an image intensifier.
Still images can also be obtained
This technique allows dynamic assessment, such
as visualisation of the oesophagus during
swallowing in a barium swallow
It also allows imaging to be taken in multiple
projections as the patient moves around on the xray table. During a barium enema the patients
movements allows different portions of the bowel
wall to be seen

Fluoroscopy: Applications

Gastrointestinal tract

Orthopaedic

Barium enema demonstrate

a constricting annular
carcinoma of the sigmoid
colon

Intraoperative use to assess

position of internal fixation
devices and to assess
alignment

Endoscopic retrograde
Cholangiopancreatography
(ERCP)
Common bile duct stone
demonstrated after injection of
contrast through the ampulla
Cholecystectomy clips (green
arrow) and the gastroscope
are demonstrated (blue arrow)

Digital Subtraction
Angiography
This is another form of fluoroscopy used in
vascular imaging.
Images are obtained dynamically after arterial
puncture is made, typically into the femoral
artery. Catheters are then placed into the artery
of interest and contrast is injected to demonstrate
vascular anatomy and pathology.
Images are also obtained before the injection
and the pre-contrast image is digitally subtracted
from the post-contrast image
This process removes bones and soft tissues
from the image, leaving only the relevant blood
vessels.

Digital Subtraction Angiography

Any vessel (artery or vein) can be imaged in this manner.
Arteries are injected in angiograms, veins in venograms.
Peripheral angiograms are commonly used to assess
atherosclerosis before surgery or endovascular stenting.
Cerebral angiograms are used to demonstrate aneurysms and
arteriovenous malformations in the brain.

Angiogram of the
bilateral legs. Long
occlusions
identified by yellow
arrows
Cerebral angiogram with injection of
the right internal carotid artery (red
arrow). Two aneurysms are seen of
the middle cerebral arteries bilaterally
(green arrows).
Janka, R. et al. Radiology 2005;235:319-326

Digital Subtraction Angiography

Image reference: Engelke, C. et al. Radiographics 2001;21:1239-1248

The process of subtraction means that the

bony and soft tissue detail is removed
from the image to highlight the contrast
filled vascuature

This is an example of an subtracted (left )

and unsubtracted (right) DSA image of the
foot. The vascular detail is much more
pronounced on the subtracted image

This venogram was used to plan which

vessel could be used for an arterial bypass
procedure

The unsubtracted image includes the foot

bones as well as the veins that are
opacififed during this venoogram

Non invasive angiography

Both CT and MR
techniques can be
used to produce
angiograms (CTA,
MRA)
Here there is no need
for direct arterial
puncture
Contrast is again
used to demonstrate
the anatomy

CTPA (CT pulmonary angiogram)

revealing a saddle-type pulmonary
arterial embolus spanning the
main pulmonary artery, extending
into right and left arterial branches

Non invasive angiography

Peripheral CT angiogram
Images have been manipulated with CT software with resultant MPR and MIP reconstructions,
3D, standard views and subtracted images. Different formats are utilized to display information
to best advantage

Interventional Radiology
This subspeciality refers to use of image guidance to
perform minimally invasive procedures
This uses whichever modality is most useful to see the
lesion/region of interest
Ultrasound
Fluoroscopy
CT

Interventions may be performed for diagnosis (such as

angiograms) or more commonly for therapeutic reasons
The radiographic images provide a roadmap for radiologists
to guide instruments within the body to the appropriate site
Long and complex procedures can involve extensive
radiation to the patient but the benefits of the procedure
generally outweigh the risks from radiation.

Interventional Radiology:
Vascular Intervention
Common vascular interventions include:
Angiograms imaging the arteries following direct injection
of contrast under fluoroscopy.

Angioplasty and Stenting areas of narrowing or occlusion

in a blood vessel may be opened up by passing a balloon
within the lumen of the vessel and dilating the balloon.
Sometimes a stent is also placed to keep the vessel open.

Thrombolysis A catheter can be placed at the site of

acute blood clot in a vessel and thrombolytic agents (eg,
TPA) injected directly.

There are 2 focal calcified plaques in the right common iliac

artery (red and yellow arrows), causing significant stenosis.
A balloon-mounted stent (blue arrow) was placed across
this regionto improve blood flow.

Interventional Radiology:
Vascular Intervention
Embolisation Involves blocking blood vessels either

to stop haemorrhage or the blood supply to particular

tissues (eg, fibroids, neoplasm). Chemoembolisation is
where chemotherapeutic agents are directly injected into
the blood vessel supplying the tumour.

Venous Access Lines these include insertions of

dialysis catheters, Hickman lines, PICC lines and
portacaths. AV fistula studies are also performed.

IVC filter insertion of a metallic device within the

inferior vena cava to prevent thrombus from lower limb

veins embolising into the pulmonary arteries.

Interventional Radiology:
Non Vascular Intervention
Drain insertions
Biopsy usually using ultrasound or CT

guidance to obtain tissue samples.

Nephrostomy placing a catheter directly into
the kidney to relieve obstruction. Sometimes a
stent is also placed into the ureter.
Biliary intervention placement of catheter
into the bile ducts to relieve biliary obstruction. A
stent may also be placed.

Radiologically Inserted Gastrostomy

(RIG) A feeding tube is placed
percutaneously into the stomach.

Nephrostomy

IVC filters (arrow) are used to prevent

passage of thrombus to the right heart and
lungs. They are required in cases of
contraindication to anticoagulation, failure of
anticoagulation or complication to
anticoagulation in patients who have venous
thromboembolic disease. They may also be in
prophylactic use for patients with a high risk of
pulmonary embolism.

A drainage catheter
is inserted into
the dilated renal
collecting system to
relieve renal tract
obstruction.

Computed Tomography

A typical CT machine. The table moves the patient through the gantry ( blue
arrow). An injector pump (green arrow) regulates the injection of contrast at a
steady rate

Computed Tomography: CT
A CT scan is comprised of a
large series of x-rays
X rays are taken around a single
axis of rotation
A motor turns the ring so that the
x-ray tube and detectors rotate
around the body
Each revolution scans a slice of
the patient
As the x-ray tube and detector
make this 360 degree rotation,
the detector takes numerous
snapshots (called profiles) of the
attenuated x-ray beam

Coronal reconstruction of an abdominal CT in a patient with gallstone ileus. Gallstone (red

arrow), dilated small bowel loops (green arrow), collapsed gall bladder (blue arrow) are shown

Computed Tomography

Principles of attenuation are the same as x-ray.

Each portion of tissue has an attenuation value measured
Attenuation values are known as Hounsefield units and
these are values determine the gray scale of the tissues on
the displayed image
It must always be remembered that ionizing x-ray radiation
is used, this must be utilized judiciously to avoid harmful
biologic effect
Further advances in technology has led to multislice CT,
which allows several slices to be taken during one rotation
This results in
Faster imaging times
Improved image quality as thinner slices can be obtained in
the same time period which results in sharper images

Intravenous contrast

Contrast is administered by injection typically into the vein for CT and IVP studies.
It is iodine based which is dense thus adds density (whiteness) to the images.
Imaging can be performed at different stages depending upon the structure of interest
(arteries, solid organs, ureters)
The image on the left is a non contrast CT
The image on the right is post IV contrast
There is enhancement of the kidneys (red arrow) which are also excreting the contrast
(green arrow). A renal cyst is present (purple arrow)

Computed Tomography: CT

Computed Tomography: CT
Slices are obtained in the axial plane
Reconstructions in other planes are then applied to
better demonstrate findings
Sagittal and coronal planes are most commonly used
Angled and oblique planes can be useful to display
curved structures

Axial

Coronal

Sagittal

Computed Tomography: CT
Axial CT:
Normal abdominal CT
Click on image to begin

Computed Tomography: CT
Coronal CT:
Normal abdominal CT
Click to begin

Computed Tomography: CT
Sagittal CT:
Normal abdominal CT
Click to begin

Intravenous contrast

As with other medications however there are side effects and

contraindications

Patients will commonly have a warm feeling during the injection and
occasionally an odd taste in the mouth.
Others will feel nauseaous or have vasovagal type symptoms. These are
all examples of non anaphylactoid reastions or nonidiosyncratic reactions

Anaphylactoid/Idiosyncratic reactions are much less common but are

potentially life threatening

Incidence of severe reactions is 0.04% and very severe reactions 0.04%.

Risk factors for this type of reaction are

Asthma: 5 times risk
Previous reactions: 4-6 times increased risk
Cardiovascular and renal disease

(Katayama et al.Radiology 1990;175:621-628)

Intravenous contrast
In the presence of renal impairment IV contrast
agents can be nephrotoxic depending upon

Extent of renal impairment

Dose contrast
State of hydration
Other medications and comorbidities

In the presence of renal impairment

Reconsider need for contrast
Optimise hydration
A medication (N acetyl cysteine) is used in some
centres as a renoprotective agent
At this stage there is no conclusive benefit

Ultrasound

Ultrasound

Ultrasonic imaging is similar to radar in that pulses of sonographic waves

are propagated through the body.

The emitted and reflected waves originate and are then received back to
the ultrasound transducer which is applied to the patients skin.

During an ultrasound, millions of pulses and echoes are sent and received
each second. The probe can be moved along the surface of the body and
angled to obtain various views.

At the doses used in clinical practice, there is no adverse effect on the

bodys cells

There is no ionising radiation in the use of ultrasound which makes it the

perfect modality to use for paediatric and obstetric imaging

Ultrasound

Ultrasound waves travels through the body and are

reflected at the interfaces of tissues
Soft tissue and air
Bone and soft tissue

Reflected waves are detected by the machine; using the

distance = speed / time formula
Time is detected
Speed is known (1,540m/s in soft tissue)
Therefore distance can be calculated

A two-dimensional image is generated by using the

distance to the tissue and the intensity of the echo
received

Ultrasound

Ultrasound - modes

B (brightness mode)
This generates the usual 2 D ultrasound image

M ( motion mode)
This can be used to assess rate, for example the foetal
heart

Doppler
This is a subtype of ultrasound that measures blood flow
velocity
Velocity of blood flow can give us useful information about
the presence of arterial stenosis

Ultrasound: Applications

Image reference: /www3.medical.philips.co

Obstetrics & Gynaecology

Foetal evaluation
Viability: first trimester
Ectopic pregnancy, miscarriage, detection twins

Morphology: second trimester

Maternal evaluation: to assess for abdominal pain in pregnancy without irradiation to foetus
Investigation of pelvic pain, menorrhagia, dysmenorrhea
Ultrasound of the uterus with IUCD (blue arrow) in position

Ultrasound: Applications

Image reference: www3.medical.philips.com

Abdominal imaging
Examining the morphology of the liver and intra-abdominal organs
Can make the distinction between cystic and solid lesions
Test of choice for gall bladder pathology (normal gallbladder and
gallstone indicated with red arrow above)
Useful in screening in abdominal pain if a biliary or renal pathology
cause is suspected

Ultrasound: Applications
Vascular imaging
Screening for AAA
Work up of carotid and
peripheral vascular disease,
initial investigation of choice
Examination for venous
disease: thromboembolic
disease and for incompetence
in venous stasis
Cardiology
to examine structure of valves
and detect wall motion
abnormalities

Image reference: ww3.medical.philips.com

The colour indicates the direction of

flow.
Doppler waveform seen below
indicates the speed of flow and
provides information about the
resistance of the vascular bed.

MRI
Magnetic resonance imaging

The Magnet
MRI is similar to CT in that slices of information
are acquired to generate 2D images in the plane
of choice
The difference is that there is no radiation utilised
The strength of the magnet in the MRI is rated in
Tesla, with most machines today using magnetic
fields between 0.5 and 3 Tesla.
1 Tesla = 10,000 Gauss (another measurement
of magnetic field)
The earths magnetic field is 0.5 gauss, which
gives a good idea of how strong these magnets
are!

The Atom
The human body is made up
of billions of atoms
Each atom contains a
nucleus, which spins slightly
off the vertical axis.
For simplicity, we will consider
hydrogen atoms, which have
one proton in the nucleus.

The Atom In MRI

In a normal situation, all of these
nuclei are spinning in random
directions.
When placed in the powerful
magnetic field of an MRI scanner,
these hydrogen protons will align
in one direction or another - most
will cancel each other out.
There will be a few protons whose
magnetic fields will not cancel out
these are the atoms of interest

The atom affected in MRI

The MRI machine applies an RF (radiofrequency pulse) to the

hydrogen atoms from a coil which moves around the patient. The
pulse forces the few unmatched protons to spin at a specific
frequency and direction (Resonance)

The frequency is known as the Larmour frequency

The Magnets within the machine are then turned on in a specific

manner. The RF pulse is turned off, the protons return to their
natural alignment within the magnetic field and release energy.

This energy is detected by the machine and

used to generate an Image

M -> R -> I

MRI: Applications

MRI is superior to CT for imaging soft tissues

Tendons
Ligaments
Spinal cord
Brain
It is frequently used in neurological and
musculoskeletal applications and also has an
important role in body imaging

MRI: Applications

Sagittal MRI cervical spine

Sagittal MR of a knee
Patella: red, Femur: yellow, Tibia: blue,
Anterior cruciate ligament: green

Epidural abscess: blue

Spinal Cord: orange
Brain: pink
Vertebral bodies: purple

MRI: Safety

Due to the strength of the magnet there are specific safety

issues that need to be recognised. There is extensive screening
that takes place before patients are brought into the scanner

Metal objects can become very dangerous projectiles if taken

into the scanning room IV poles, O2 tanks

People with pacemakers should not go near an MRI scanner, as

the magnet may cause the device to malfunction

Aneurysm clips and metal fragments in the eye (even if in the

distant past) are contra-indications to MRI scanning as they may
shift which will have serious consequences

Credit cards will be erased by most MRI systems

Nuclear Medicine

Nuclear Medicine:
Basic principles
Nuclear medicine imaging techniques combine the use
of computers, detectors, and radioactive substances
Nuclear medicine examinations include:

Bone scans
Positron emission tomography (PET)
Single photon emission computed tomography (SPECT)
Cardiovascular imaging

Nuclear medicine has a role in assessing function as well as

structure of organs and systems
Response of myocardium to stress/exercise revealing
areas of ischaemia
Differentiates function split between the left and right
kidney
Determines the glomerular filtration rate of each kidney
Determines if the gallbladder fills and empties normally

Nuclear Medicine:
Basic principles
Nuclear medicine uses compounds that have been
labelled with radionuclides: radiopharmaceuticals
The investigations reveal the physiology of the
tissue being examined, as opposed to the
anatomical structure
Images from nuclear medicine studies and other
purely anatomic investigations can be combined
(eg. PET-CT)

Nuclear Medicine:
The compounds

Medical isotopes are produced in nuclear reactors

These compounds have a short half-life and be excreted readily in

the bowel or urine to avoid toxicity to the patient

For example:
Technetium-99m: used in skeletal scintigraphy
metastable nuclear isomer
Emits gamma rays
Half life of 6 hours
Fluorine-18: used in PET scans
Used to produced FDG: flurodeoxyglucose

Nuclear Medicine: Diagnostic

Radionuclide tracers are injected into the body and bind with the relevant
organs before excretion
For example, technetium-99m can be attached to MDP (methylenediphosphonate), which is taken up by the osteoblastic cells which make new
bone
Areas of increased activity indicated osteoblastic activity are indicated on the
images which occur in bony metastases, fractures etc
Bone scan on the left
demonstrating osteoarthritis at
the knee, acromioclavicular and
1st metocarpalphalangeal joints
(green arrows)
Bone scan with multiple
metastases on the right (red
arrows)
The injection site is also
indicated in the cubital fossa
(purple circle)

Nuclear medicine:
Therapeutic

Some cells are sensitive to damage by ionizing radiation;

this feature can be utilised for treatment

Iodine-123 (half life 13 hours) may be used as a tracer for

the diagnosis of thyroid pathology
Increased activity is detected in the hyperthyroid patient with
Graves disease

Iodine-131 (half life 8 days) can be used in the treatment of

Graves disease and certain tumours of the thyroid gland

Thyroid tissue can be ablated without affecting other tissues

as the agent is taken up only by thyroid cells

Positron Emission
Tomography: PET scan

Produces images of the body

by detecting the radiation
emitted from radioactive
substances
Such substances are injected
intravenously and labelled
with short-lived isotopes such
as C-11, F-18 or O-15
This means radiation is
emitted long enough for the
test but not so long as to
cause adverse effect to the
patient

PET scan

The isotope from the injected radiotracer is taken up selectively preferentially by

metabolically active tissues, e.g. the brain, heart, actively replicating tissue such as
tumours which allows imaging of organs of interest
The patient moves through the ring which contains gamma ray detectors
Gamma rays are released during radioactive decay from the injected radiotracer
Gamma ray photons contact the detectors to generate an electrical signal which is
then processed to generate an image

Single photon emission

computed tomography: SPECT
In a PET scan, the gamma camera
provides a 2D image of a 3D structure
(the whole body for review of all the bones
in a bone scan)
With SPECT, multiple 2D images are
obtained from different angles, by rotating
the gamma camera.
These images are then processed by a
computer to produce three dimensional
information, similar to a CT scan

PET scan of the

brain demonstrating
a map of glucose
metabolism and thus
activity

SPECT applications

Combined PET/CT
demonstrating
multiple pulmonary
metastases

SPECT can be used where 3D images are desirable

Myocardial perfusion scanning
Functional brain imaging

By combining SPECT with traditional CT, one can obtain high quality anatomical and
physiological information

Medical Imaging

Modern radiology departments offer multimodality diagnostic

imaging as well as a wide variety of therapeutic and diagnostic
intervention

Discussion between referrers and radiologists enables the most

appropriate investigation is utilized for the best outcome in each
patient

The EU has published referral guidelines for clinicians to enable

best practice and this includes further information upon
radiological safety and the specific indications for referral for
various conditions: EU referral guideline for imaging.
Radiation protection 118 (2000)

This document is available on Beaumont Hospital intranet or can

be downloaded at:
http://ec.europa.eu/energy/nuclear/radioprotection/publication/doc/
118_update_en.pdf

References

RadioGraphics 2001;21:1239-1248.Distal Venous

Arterialization for Lower Limb Salvage: Angiographic
Appearances and Interventional ProceduresChristoph
Engelke, Robert A. Morgan, John W. Quarmby, Robert S.
Taylor, and Anna-Maria Be