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250: ICC in Radiology and Nuclear Medicine

LEC 08: INTRODUCTION TO INTERVENTIONAL RADIOLOGY
Exam 01| Dr. Jason Catibog <3| September 01, 2013

OUTLINE
I. Interventional Radiology
E. Transarterial
Procedures
Chemoembolization
A. Vascular Procedures
(TACE)
B. Non-vascular Procedures
V. Non-vascular Procedures
II. Catheters and Guidewires
A. Biopsy
III. Seldinger Technique
B. Radiofrequency Ablation
IV. Vascular Procedures
C. Percutaneous Drainage
A. Angiography and DSA
D. Percutaneous
B. Embolization
Cholecystostomy
C. Angioplasty and Stenting
E. Percutaneous
D. Transjugular Intrasystemic
Transhepatic Biliary
Shunt (TIPS)
Drainage (PTBD)

I. INTERVENTIONAL RADIOLOGY PROCEDURES
Diagnostic or therapeutic
Vascular or non-vascular

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 useful in locating nodules by sampling venous
drainage and identifying the one with highest peak

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.
o Ex. Obstructive biliary ectasia stagnant bile prone to
developing infection sepsis septic shock death. For us
to avoid semicholangitis we put a tube to drain the biliary
tree
Endoscopic retrograde cholangiopancreatography done by GI
Sialography
Joint aspiration orhto or rheuma

II. CATHETERS AND GUIDEWIRES
Depending on the need
Some wires are coated with hydrophilic substance, so its literally
slippery when wet
Others are left bare
Most wires have curve at the end, if we twist one end the other
end will follow

Trick, C har, Cy ,Ton

Figure 1. Interventional Catheters
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 high-
flow 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

III. 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

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

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LEC 08: INTRODUCTION TO INTERVENTIONAL RADIOLOGY

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
Digital Subtraction Angiography (DSA)
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

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 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.
o It results to lesser blood loss during surgery and easier
identification of tumor parts due to surrounding edema.
Traumatic Hemorrhage in the Pelvis
o The damaged artery is identified and occluded to lessen the
hemorrhage.

Figure 3. Digital Subtraction Angiogram of the Cerebral vessels Left:
Actual angiogram, Right: Digitally subtracted image, Top: Arterial
phase, Bottom: Venous phase

B. Embolization
Aneurysm Coiling
Use of microcatheter <1mm
Pack aneurysm with coils (made of alloy/Platinum)
o Coils can have thrombogenic material like cotton, polyvinyl
alcohol, or even blood clots
Coils protect dome of aneurysm from rupturing

Figure 5. Embolization of Traumatic Pelvic Hemorrhage A. Avulsion

of the superior gluteal artery with extravasation (arrow). B.
Embolization of the superior gluteal was performed with coils
(arrow), and the hemorrhage was well controlled. (Images from
Brant and Helms, 2007)

C. Angioplasty and Stenting
Angioplasty- a process to widen a narrowed blood vessel
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)
Example : Patients may present with hypertension due to renal
artery stenosis

Figure 4. Embolization of an Aneurysm (Top left: endovascular coil,

Top right: process diagram of ambolization, Bottom: actual
angiogram during embolization)

Trick, C har, Cy ,Ton

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 Intrasystemic 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 toesophageal 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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LEC 08: INTRODUCTION TO INTERVENTIONAL RADIOLOGY

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

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

Figure 8. Guided Biopsies, CT-guided lung mass biopsy (L), UTZ-
guided breast mass biopsy (R)

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 9.
Radiofrequency
Ablation

Figure 7. TIPS Diagram (Top), actual angiogram (Bottom)

C. Percutaneous Drainage
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

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
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.

Trick, C har, Cy ,Ton

Figure 10. Percutaneous Liver Abscess drainage, CT Radiographs

(top), pigtail catheter (bottom L), drianage diagram (bottom R)

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LEC 08: INTRODUCTION TO INTERVENTIONAL RADIOLOGY

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.

Ray: Yey to transing from scratch! Okay lang, masaya naman ako
nung actual lecture. Teeeheee. <3

There are apparently a lot of memes on Radiology, some quite
fitting. Enjoy!

Figure 11. Percutaneous Cholcystostomy diagram (UL), radiograph
(UR), Sonogram guidance (bottom) showing a stent through the gall
bladder

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.

Figure 12. 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.

END

Trick, C har, Cy ,Ton

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