Interventional radiology
Division of Radiology focused on minimally invasive procedures guided by diagnostic imaging
- Covers all minimally invasive procedure that can be guided by diagnostic imaging
Angio Suite
- in CAT lab
- If you place imaging in normal OR you have then an hybrid OR
Modalities
Fluoroscope (most common)
- Nowadays fluorescent screens are no longer in use
- Replaced by digital detectors - continuous x-ray images stacked to resemble
real time x-ray movie
Digital subtraction angiography
- One flaw to fluoroscopy, we can see lateral projection of the skull (pre and
post contrast) the contrast agent is injected into the common carotid artery
and we can trace the course of the internal carotid but branches of the
external carotid are lost.
- Basic concept is to treat a picture of a fluoroscopy mask and is subtracted
from all consecutive pictures, so we get an image of only the contrast.
Rotation angiography
- During acquisition of images c arm is rotated around the patient, creating a set of images that can
be interpreted as 3D angiography
Ultrasound
- Easy and useful while gaining vessel access or while puncturing body
cavities like pleural cavity
- Enables drainage of fluid collections or receiving tissue samples while
biopsying organs
Computed tomography (CT)
- In interventional radiology we use CT for procedures where ultrasound
guidance is not sufficient (deep lying structures/ structures that need to
be visualized after contrast agent administration)
- Flaws, both patient and operator exposure to radiation also more
technical issue is that you can operate only in a single layer while in
fluoroscopy you can see all the operated area or in ultrasound you can
adjust the position of the porbe, in CT you only operate in the single plane.
Magnetic resonance imaging (MRI)
- Compared to CT, MRI has higher tissue resolution so you
can distinguish 2 types of tissue with higher accuracy.
- 2 main inconveniences: you need to operate in magnetic
field so your tools have to be adjusted and secondly you
need a special scanner that has open magnet (not a tube)
Range of procedures:
- Cardiac surgery
- Urology
- Neurosurgery
- Anesthesiology
- Gastroenterology
- General surgery
- Vascular surgery
- Cardiology
It is minimally invasive
Usually short procedures (1-2 hours)
Generally doesn’t require general anaesthesia (good for patients with other morbidities)
Results immediately
- No.1 advantage for him - dont have to limit yourself to one organ or system, during your career
you can subspecialize and widen spectrum
Not all patients are eligible
- Sometimes open surgery is better
Non-vascular
- Drainage
- Percutaneous biliary interventions
- Biopsy
- Ablation
- Direct drug injection
Vascular
- Angioplasty
- Embollisation
Seldinger technique (50’s)
Technique of easy and safe vessel (or other hollow structures) access using
catheters and guide wires.
- First just for contrast but realised later could be used for other tools
- 10 years later daughter invented angioplasty balloon
- His student invented the first stent
3 main steps
- Localising the vessel you want to get access to (palpation, ultrasound).
You need to puncture this vessel looking for pulsating outflow of
arterial blood.
- Then you introduce guide wire through the needle to the vessel and you pull out the needle
- On the guide wire you insert catheter (in endovascular procedure its called a sheath - has valve
which enables blood to flow out and enables you to introduce other tools without the need for
another puncture)
Interventional radiology tools
Catheters (diagnostic, guided, sheath)
- Catheters: 3F (french) = 1mm
- Also have microcatheters for small vessels
Guidewires
- Filaments made of plastic or metal
- Varies in sizes, widths, stiffness
- Help navigate catheters to the site
Balloons
- Eg. balloon angioplasty
- Navigate guidewire through stenosis, the you push the balloon through the
stenosis and pump it up to dilate vessels
Stents
- Two types: balloon (expandible), self expanding stent (as soon as
the stent is pushed out from the stealth, it takes its shape.
Stent Grafts
- Built like a stent but also covered by a kind of fabric which is non-
permeable to blood
- Mainly used for aortic aneurysms or disessections
Embolic materials (coils)
- Embolization - a procedure that can be performed both in routine
(aneurysms and tumors) and acute (ruptured aneurysms) situations.
- Coil = a filament made of platinum. To place a coil at the site of
embolism you need a catheter. The mechanisms behind coil
embolism is the action of laminar blood flow, if we disrupt this the
thrombi are trapped between the loops of the coil and the thrombi are
embolized.
Other embolic materials include:
- liquid embolic materials
- Gel foam: to stop bleeding, usually GI bleeding. Administered via catheter. Effective
temporarily.
- N-Butyl Cyanoacrylate
- ONYX
- Solid embolic materials:
- Polyvinyl alcohol: comes as a powder
- Embolic spheres: they are hollow inside so they can be loaded with
something (usually with chemotherapeutics - delivered to tumor directly
through arterial supply). Advantages: you give chemo directly to the tumor
of the affed organ, secondly that besides chemo, there is also an ischemic
effect.
Occulders
- Amplatzer: made of 2 disks and is used to close the
atrial septal defect
- Vascular plug: used to close the lumen of vessels
- Watchman: used to close the left atrial appendage in
patients with Afib
Loops, snares, forceps
- Loops and snares: Used to free something from the
blood vessel
- Forceps: usually to treat complications
Valves
- In the early 2000s transcatheter valves were available
- Main indication: aortic stenosis that cannot be treated with open
surgery.
- Looks similar to stent graft: composed of frame and inside is fabric
(porcine or bovine)
Filters
- Indication for vena cava filter = DVT that cannot be
treated with anticoagulants or anticoagulant treatment
was ineffective
- Filter is composed of mesh that captures thrombi from
blood current. Also has anchors that attach to the vena
cava walls. And finally a hook which enables withdrawal of the filter
- Usually implanted at the levels of the renal veins.
- Can be permanent or temporarily (most often temporary as if left in longer than 3 months it can
lead to inter-vena cava thrombosis)
Interventional radiology - complications
Local, on the access site (most common)
- Haematoma, pseudoaneurysm, dissection, infection
Local, on intervention site
- Dissection of parent vessel, AV fistula, stroke, accidental or non-target embolisation,
pneumothorax, haematoma, abscess, biloma, loose of equipment inside patients body, post
embolisation syndrome
Related to contrast agent, radiation or other measures
- Contrast induced nephropathy, stochastic radiation effects
Pseudoaneurysm
= a rupture in the vessel wall, when the blood is pouring out of the vessel into the soft tissues surrounding
the vessel.
Symptoms:
- Pain, bruising, swelling, bleeding (not that common), loud murmur on auscultation, yin-yang sign
in color doppler ultrasound
Management:
- Compression dressing for 24 hours
- Direct thrombin injection - if the neck of the
aneurysm is long (>1cm)
- Surgical management - if neck is short (<1cm)
Fluid collect drainage
79 yo female.
Presented with back pain, fever, does not respond to empirical therapy.
Cross sectional imaging findings are consistent with spondylodiscitis.
- 2 vertebrae are affected by inflammatory processes, between them
is a destroyed intervertebral disk. And a small fluid collection in the
left psoas muscle.
- They weren't able to drain fluid under ultrasound so moved to
hybrid OR where a CT was used to puncture the psoas muscle.
Hemorrhage
63 yo female
Presented with Anemia, Hematuria
History of urolithiasis (kidney stones) so had
nephrostomy (drainage installed in renal pelvis)
- She accidentally removed this drainage and
caused bleeding.
- Patient underwent CT - we can affected left kidney with
bleeding site inside, with a huge retroperitoneal
hematoma below the kidney
- Patient was transferred to the kidney cath lab to have
vessels embolized.
- Vessel was sealed with glue
Inferior vena cava syndrome
41 yo female
Colorectal cancer, liver metastasis, lower extremities oedmaciala
- In the CT we can see there is a huge mass occupying the whole liver
lobe
- Patient was referred to interventional radiology for vena cava
angioplasty
- A self-expanding stent was placed
Percutaneous biliary drainage
92 yo female
Pancreatic head adenocarcinoma, bilirubin 20mg/dl
- Open surgery not an option due to comorbidities
- Bypassed occlusion at the pancreatic head using guidewire, and
installed drainage into duodenum through the common bile duct so
bile is drained in 2 places: outside into a bag and
secondly into the duodenum.
Ruptured intracranial aneurysm
41 yo male
sudden , severe headache
- Non-contrast CT was performed, revealing blood in subarachnoid
space.
- CT angiography confirmed ruptured aneurysm and was referred to
interventional radiology for embolisation
- Aneurysm sac was embolized with 5 detachable coils
Aortic dissection
63 yo male
Sudden, severe chest pain, ECG and cardiac specific
troponins ruled out AMI
- CT angio confirmed aortic dissection (B-type)
- Referred to interventional radiology for
implantation of stent graft
- Catheter was delivered to ascending aorta
- Then a stiff guidewire was inserted to push the
stent into but make sure its not covering the
carotid artery.
Take home points
- Interventional Radiology is an interesting career path that gives you opportunity to operate at the
junction of various medical specialties. It does not limit You to a single organ or system.
- If You are not personally interested in IR just remember, that IR frequently offers solutions to
various clinical dilemmas. Just pick up the phone and call ;-)
- What is Seldinger technique?
- What are IR tools?
- What are most common IR complications, and how to deal with pseudoaneurysm?
