m

 


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p Describe common interventional Radiology procedures and

describe some of the technologies that are involved
à



 

p Margeted treatments with image guidance

p Less pain, less risk, faster recoveries than open surgery

p Interventional Radiologists are certified physicians

à



 

p Interventional Radiology (IR) Ȃ a medical

subspecialty that utilizes imaging to perform minimally
invasive procedures in treatment of disease
p Young Specialty

p Unrecognized specialty

p One of technologically most advanced specialties

p Charles Dotter, MD - the Dzfather of interventional radiologydz was

nominated for the Nobel Prize in medicine in 1978
à

 







p Most procedures can be performed on an outpatient basis or require only a
short hospital stay

p General anesthesia usually is not required

p Risk, pain and recovery time are often significantly reduced

p Mhe procedures are usually less expensive than surgery or other alternatives
à
  
 

0ascular interventions

Non-vascular interventions
à
  
 
0ascular interventions
p mngiography
p Balloon mngioplasty
p Blood vessel Stenting
p Catheter delivered chemotherapy for cancer
p Endovascular embolization
p Endovascular recanalization and thrombolysis
p MIPS
p Long term venous access for dialysis and drug administration
p Mransjugular liver biopsies.
p Intravascular retrieval of devices.
p I0C filter placement.
à
  
 
Non-vascular interventions

p mbscess drainage
p Diagnostic and therapeutic pleural and ascitic aspiration.
p U/S guided FNm thyroid
p U/S guided liver biopsy
p Bile drainage for obstructed liver bile ducts
p Percutaneous nephrostomies and stenting
p Radiofrequency ablation (RFm) of tumors
p Gastrostomy for feeding
p CM guided needle biopsy
p PMC and percutaneous transhepatic drainage
p Percutaneous Nephrostomy and mntegrade DJ stenting
p U/S guided cholecystostomy
p MRUS prostatic biopsies
à

 

 


 



p Our image guidance is only as good as
the imaging equipment

p Our limitations are largely due to our

inability to see or precisely localize the
focus of disease we want to treat
Multidetector
Fluoro - CM
mdvantages

p Combines the advantages of

Fluoroscopy with CM cross
sectional imaging
Computed Momography
p Good contrast

p Conventional CM is not real time

p (Fluoro-CM is real time, but limited availability)

p High radiation dose to the operator

Ultrasound
p Real time
p Excellent for soft tissue
interventions
p Limited by poor
penetration of bone and
air filled structures
p Hard to see your
instruments
Fluoroscopy
p Real time

p Overwhelming use and long

clinical experience

p Limited contrast and poor

organ/structure definition
Fluoroscopy
m


p Radiological examination of the arteries and veins to diagnose blockages and
other blood vessel problems
p Uses a catheter to access the blood vessel and a contrast agent to make
the artery or vein visible
m


p Enabling Mechnology:
p Digital Subtraction mngiography (DSm)
p Subtracts the bones and soft tissues out to only display blood vessels once
radiographic contrast is injected
m


p Intervention based on
knowledge of anatomy and
memory of what was just
seen.
CT

 
p CMm uses X-rays to visualize arterial and venous vessels
throughout the body.
p CM combines use of x-rays with computerised analyzis
of the image.
p CMm is much less invasive and more patient friendly
than catheter angiography.
C
p Mo examine pulmonary arteries to rule out pulmonary
embolism.
p 0isualize blood flow in the renal arteries in patients with
high blood pressure and those suspected of having kidney
disorders. mlso done in kidney donors.
p Identify aneurysms in the aorta or in other major blood
vessels.
p Detect atherosclerosis disease that has narrowed the
arteries to the legs.
p Detect thrombosis (clots) in veins, for example large veins
in the pelvis and legs.
6  
p Before the actual exam a contrast agent is injected into a
vein.
p During the examination, the rotating device spins around
the patient, creating a fan-shaped beam of x-rays, and the
detector takes snapshots of the beam after it passes
through the patient.
p ms many as one thousand of these pictures may be
recorded in one turn of the detector.
p Mhen reconstruction techniques are used to view images as
desired.
G
 
p CMm can be used to examine blood vessels in most
parts of the body.
p More precise than MR mngiography and Ultrasound
p Useful way of screening arterial blood vessels because
it is safer and less time consuming than Catheter
mngiography.
 
p Risk of allergic reactions because of contrast agents
like iodine.
p Dangerous for patients with kidney disorders and
diabetes.
p Skin damage may occur because of excess contrast
agent.
 

 
p MRI produces images of the body without the use
of X-rays.
p Mhe electromagnetic energy that is released when
exposing a patient to radiofrequency waves in a
strong magnetic field is measured and analyzed by
a computer
p MRm is MRI study of the blood vessels.
p Provides detailed images of the images without
using contrast agents.
C
p Used in checking patients for diseased intracranial (in
the head) arteries.
p Used to detect disease in the aorta and in blood vessels
supplying the kidneys, lungs and legs.
p Used for confirmation of carotid artery stenosis.
6  
p Mraditional MRI units are used.
p Patient is placed in the MRI unit.
p Exposing the patient to radio waves in a strong
magnetic field generates data that are used by a
computer to create images of tissue slices that may
be viewed in any plane or from any direction.
p Contrast material used is Gadolinium. It is given
by I0 injection during one of the imaging
sequences.
G 
p G 

D Procedure time and time to recover is relatively small.
D Cost-effective procedure.
D No exposure to x-rays.
D 0ery useful for patients having allergic reactions to contrast
material.
D Possible to defer surgery.
G 
p

D In case of implants being present, it is difficult to get a
good quality image.
D Pregnant women cannot be allowed for this procedure.
 m

 

p Used to unblock narrowed arteries in the legs, kidneys, liver or elsewhere in the
body

p Opens blocked or narrowed blood vessels by inserting a small balloon into the
vessel and inflating it

p Balloons delivered over thin catheters to function at the location of disease

without having to surgically Dzopendz the patient
p Minimally invasive procedure to improve blood flow in
arteries.
p Surgeon threads a balloon tipped catheter to the site.
p Mhe balloon is inflated in order to open the artery Ȃ
deflated and then removed.
p 0ascular stenting also may be done at the same time.
p Stent is a permanent device left in the artery
p mssists the healing of the artery in the open position after
angioplasty.
C
p Peripheral 0ascular Disease.

p Renal 0ascular Hypertension.

p Haemodialysis access maintenance.

p Carotid mrtery Disease.

p Coronary mrtery Disease.

6  
p Balloon inserted Ȃ inflated Ȃ deflated Ȃ removed.
p Stents placed over the catheter- scaffolding for the artery
walls.
p Drug-coated stents Ȃ used in case of coronary arteries (FDm
approval).
p Stents coated with medication Ȃ to prevent 
 .
p Sometimes stent is not necessary.
G 
p G 

D Compared to bypass Ȃ much less invasive, low cost and low
risk.

D No general anesthetic required.

D No surgical cuts or incisions needed.

D Patient can return to normal activities after the procedure.

G 
p

D Catheter insertion can lead to injury of the artery.
Balloon can also cause blood clots or rupture the artery.

D Blockages can recur.

D Heavy bleeding requires special medication or even
blood transfusion.
D Risk of stroke when performed on g
 
 .
D mbrupt vessel closure Ȃ emergency bypass also may be
done.
(Back)
G

m


G

m


complications

p Plaque embolization

p Blood vessel dissection

p Disease recurrence

p 0essel rupture
x 



p Insertion of a tube into the kidney
p Used in patients whose kidney or ureters are obstructed from kidney stones or
cancer
G  
  

    
 G
p Insertion of a tube into
the hepatobiliary system
obstructed from stones
or cancer.
 

 

 
p Surgical removal of liver tumors offers the best chance for a cure

p Surgical removal is not possible for more than 75% with primary and
90% with secondary (metastases) liver cancer
 

 

 
Delivers a high dose of cancer-killing drugs directly to
the tumor while depriving the tumor of its blood
supply by blocking (embolizing) the arteries feeding
the tumor
 

 

 

p Delivery of cancer-fighting
agents directly to the site
of a liver tumor
p Currently being used
mostly to treat cancers of
the liver and endocrine
tumor metastases to the
liver
 

 

 

Using imaging, a catheter is

fed through the femoral artery
to the blood vessels feeding
the tumor
 

 


 

Small embolic particles are

injected to block the blood vessel
 

 


 

Mhe drugs and lack of blood

supply cause the tumor to shrink

 

 

 
 

 

 

 
!
m
 "m


p Using radiofrequency (RF) energy to cook and kill
cancerous tissue
p mlternative to surgical resection
p Only option in most patients with metastasis from colon cancer to liver
C




  

 

 

p Non surgical, localized treatment that kills the targeted tissue with heat,
while sparing the healthy tissue
p Usually few side effects

 

 

p Non surgical, localized treatment that kills the targeted tissue with heat,
while sparing the healthy tissue
p Usually few side effects

 

 


p Nonsurgical, localized
treatment that kills the
targeted tissue with heat,
while sparing the
healthy tissue
p Usually few side effects

 

 

PRE POSM

 

 

#  

m

  


 
" 
p Dissolves blood clots by injecting clot dissolving drugs at the
site of the clot (Urokinase, mlteplase)
p Reopens blood flow without surgery
 


 
" 
p Dissolves blood clots by injecting clot dissolving drugs at the
site of the clot (Urokinase, mlteplase, Menectaplase)
p Reopens blood flow without surgery
 


  
" 
Mechanical filter prevents clots from flowing to the lung
(pulmonary embolism)
$   


  
p m procedure to prevent fatal hemorrhage in patients with liver disease
p Usually awaiting transplant
 %
 

p DzEmbolizationdz Ȃ way of occluding blood vessels which are
doing more harm than good.
p Material is passed through the catheter with its tip lying in
or near the blood vessel to be closed.
p 0ery useful to control excessive bleeding or cut off blood
supply to a tumor.
p Mherapeutic Embolization serves to eliminate m0M.
p Embolus Ȃ medication or synthetic material to occlude the
blood vessel.
C
p Controlling bleeding from injury, tumor or stomach ulcer.
p Mo cut off blood supply to a tumor. Can be used in
conjunction with chemotherapy.
p Mo treat benign fibroid tumors of the uterus Ȃ an
alternative to hysterectomy. Multiple fibroid tumors can be
treated at one time.
p Excellent for treatment of m0M (abnormal connection of
the artery and the vein like a Dzshort circuitdz).
p For plugging of an aneurysm in the brain.
p Mreatment of hemangiomas.
6  
p Mhe equipment used is same as in Catheter angiography.
p Mhe first step is angiography (injection of x-ray dye into an artery or
vein) to locate the exact site of bleeding or abnormality
p m catheter is introduced and contrast material is injected (normally
through femoral artery).
p mn appropriate embolic material then is chosen and injected through
the catheter to lodge at the treatment site
p Repeat angiograms are done until bleeding is controlled or there is
enough embolic material in a tumor or vascular malformation
9  
 

p Gelfoam - used to control bleeding until the causeȄsuch as a bone
fracture can be identified and fixed, or until it has time to heal on its
own.
p Permanent particulate agents - Mhese agents are used to occlude small
blood vessels permanently. Mhey are used to stop bleeding or block
arteries to a tumor when the underlying lesion is not likely to heal.
Mhey are the materials used most often to embolize uterine fibroid
tumors. Eg : Polyvinyl alcohol (P0m).
9  
 

p 
 g made of stainless steel or platinum may be used to occlude
large arteries. Mhey come in a range of sizes.
p „ g  
 such as alcohols are used to purposely
destroy tissue. Mhis might be desired to treat a large malformation of
veins by filling it with the liquid to induce clotting and damage the
inner lining of the veins
G
 
p 0ery effective way of controlling bleeding especially in emergency.
p Used to treat tumors and vascular malformations.
p It is much less invasive than conventional open surgery.
p When embolization is used to treat an intracranial arteriovenous
malformation (m0M), injection of a small amount of material
minimizes the risk of serious brain dysfunction.
G
 
p Embolus can lodge in the wrong place and deprive normal tissue of its
oxygen supply.
p Risk of infection after embolization, even if an antibiotic has been
given.
p Because angiography is part of the procedure, there is a risk of an
allergic reaction to contrast material and also there is a risk of kidney
damage in patients with diabetes or other pre-existing kidney disease.
m 
 


  
p Embolization procedure of uterine arteries to stop life-threatening post delivery
bleeding
p Usually preventing hysterectomy
p Preserves fertility
î m
%
 

" 


p mn embolization procedure of uterine arteries to shrink painful, benign
tumors in the uterus.

p mlternative to surgical hysterectomy or myomectomy

î m
%
 

" 


p m e lizati r ce re f teri e arteries t s ri
ai f l, e i t rs i
t e ter s.

p mlter ative t s r ical ysterect y r y ect y


&

p Carotid artery narrowing is a common cause of stroke

p Mhe vessel can close and brain is deprived of blood = stroke

p Small plaque can break from the arterial wall and embolize to the brain
= stroke

&
p Preventing Stroke
p Mreating Dzhardening of the arteriesdz in the carotid
artery in the neck with stenting

&
C  

p Cryotherapy, also called cryosurgery, cryoablation or
targeted cryoablation therapy, refers to the application
of extreme cold to destroy diseased tissue, including
cancer cells.
C!
p Used to destroy skin tumors, pre-cancerous skin moles, nodules, skin
tags or unsightly freckles.
p Used to destroy Retinoblastomas.
p Physicians have begun to perform cryotherapy for prostate, liver and
cervical cancer, especially if surgery is not possible.
p Current research on cryotherapy for tumors of the bone, brain, kidney,
lung and spine.
6  
p Carried out using cryoprobe (attached via tubing to a source of N or
mr).
p For external masses, liquid N is applied directly with a cotton swab or
spray device.
p For internal tumors, liquid N or mr gas is circulated through the
cryoprobe, which comes into contact with the diseased tissue.
6  "
p More advanced forms of cryotherapy, such as for treatment of liver
cancer, involve the insertion of the probe through an incision or
threaded through the skin. Mhen using imaging device the physician
targets and freezes the tumors.
p Likewise, for prostate cancer, six to eight needle probes can be inserted
through the perineum (the tissue between the rectum and the
scrotum/penis) and ultrasonically guided to freeze the cancer.
G
 
p For intraoperative cryotherapy recovery time is much less than for
major surgical removal of the tumor.
p Percutaneous cryotherapy has great potential to evolve into an
outpatient procedure.
p Less traumatic than open surgery since only a small incision is needed.
p It causes minimal scar tissue and apparently no calcifications.
G
 "
p Mreatment of the liver can damage bile ducts or cause heavy bleeding
p Mreatment of the kidney can damage the urine-collecting systems or
cause heavy bleeding.
p Mreatment of lung tumors can cause the lung to collapse and fluid to
accumulate around the lung.
p Care must be taken anywhere nerves are near the tumor. Completely
frozen nerves can cause motor weakness or numbness in the area
supplied by the nerves.