Introduction to Introduction to Interventional RadiologyInterventional Radiology

Thea Moran, MDThea Moran, MDAsst Professor Asst Professor

LSU Health Sciences CenterLSU Health Sciences CenterNew OrleansNew Orleans

What is interventional What is interventional radiology?radiology?

Interventional radiology is a Interventional radiology is a subspecialty which provides subspecialty which provides minimally invasive diagnosis and/or minimally invasive diagnosis and/or treatment using imaging (ultrasound, treatment using imaging (ultrasound, CT, or fluoroscopy) to target the CT, or fluoroscopy) to target the intervention and show the results of intervention and show the results of the intervention.the intervention.

1. Percutaneous biopsy1. Percutaneous biopsy

US, CT or fluoroscopyUS, CT or fluoroscopy Random sampling or Random sampling or

sampling of a masssampling of a mass Lung, mediastinum, Lung, mediastinum,

pleura, chest wall, pleura, chest wall, nodesnodes

Liver, adrenal gland, Liver, adrenal gland, pancreas kidneys, pancreas kidneys, lymph nodeslymph nodes

Liver biopsyLiver biopsy

Lung biopsyLung biopsy

2. Percutaneous abscess 2. Percutaneous abscess drainagedrainage

US, CT or fluoroscopyUS, CT or fluoroscopy Aspiration or drainage Aspiration or drainage

tube placementtube placement Usually for infectionUsually for infection Pleura, lungPleura, lung Hepatic (intra/sub), Hepatic (intra/sub),

pericolic gutters, pericolic gutters, perisplenic, perisplenic, peri/intrapancreatic, peri/intrapancreatic, pouch of Douglas, pouch of Douglas, psoas, abdominal wallpsoas, abdominal wall

3. Arteriography3. Arteriography

Injection of contrast Injection of contrast media directly into media directly into arteries and vis via arteries and vis via fluoroscopyfluoroscopy

Usually immediately Usually immediately precedes and precedes and intervention is intervention is angioplasty, stenting, angioplasty, stenting, embolization, embolization, thrombolysisthrombolysis

Aorta, pelvis, lower Aorta, pelvis, lower and upper extremities, and upper extremities, kidneys, gut, lungskidneys, gut, lungs

Aortic angiographyAortic angiography

Lower extremity Lower extremity angiographyangiography

Upper extremity Upper extremity angiographyangiography

Mesenteric angiographyMesenteric angiography

Pulmonary and bronchial Pulmonary and bronchial angiographyangiography

4. Angioplasty4. Angioplasty

FluoroFluoro Done to relieve narrowing Done to relieve narrowing

in a vessel (most in a vessel (most frequently) or other tubular frequently) or other tubular anatomic structureanatomic structure

Balloon measurements in Balloon measurements in length and width, burst length and width, burst and nominal pressureand nominal pressure

Cutting, cryoplasty, low Cutting, cryoplasty, low profile, high pressureprofile, high pressure

Sometimes need Sometimes need buttressing with a stentbuttressing with a stent

Renal angioplastyRenal angioplasty

Lower extremity arterial Lower extremity arterial angioplastyangioplasty

Stenosis at cephalic/axillary vein Stenosis at cephalic/axillary vein confluence pre and postangioplasty in confluence pre and postangioplasty in

patient with dialysis graftpatient with dialysis graft

5. Stenting5. Stenting

FluoroFluoro Plastic or metal tube Plastic or metal tube

used to buttress a used to buttress a tubular vascular tubular vascular structure prone to structure prone to narrowing and narrowing and occlusionocclusion

Arterial, venous, Arterial, venous, biliary, or urinarybiliary, or urinary

Need monitoring after Need monitoring after placementplacement

Iliac artery stentingIliac artery stenting

Celiac and SMA stentsCeliac and SMA stents

Renal artery stentingRenal artery stenting

6. Embolization6. Embolization

Usually fluoro guidanceUsually fluoro guidance Purpose is to “plug” a Purpose is to “plug” a

vessel that may be vessel that may be bleeding or bleeding or hypertrophied and hypertrophied and supplying a supplying a hypervascular structurehypervascular structure

Permanent or Permanent or temporary agentstemporary agents

Need to spare as much Need to spare as much normal parenchyma as normal parenchyma as possiblepossible

Bronchial embolizationBronchial embolization

Renal embolizationRenal embolization

Uterine artery embolizationUterine artery embolization

Varicocele embolizationVaricocele embolization

Pelvic embolization post Pelvic embolization post traumatrauma

LGI bleed embolized with LGI bleed embolized with coilscoils

Splenic embolizationSplenic embolization

7. Vasopressin infusion7. Vasopressin infusion

FluoroFluoro Alternative to embolization Alternative to embolization

for bleeding in the GI tractfor bleeding in the GI tract Acts by constricting the Acts by constricting the

vessels giving the bleeding vessels giving the bleeding vessel time to healvessel time to heal

Selective infused through Selective infused through catheter in affected vessel catheter in affected vessel

Not if CADNot if CAD Starting max dose of 0.4 Starting max dose of 0.4

U/min U/min Infusion never stopped Infusion never stopped

abruptly; always taperedabruptly; always tapered

Before and after vasopressin Before and after vasopressin infusioninfusion

8. Thrombolysis8. Thrombolysis

FluoroFluoro TPA or UK used to break TPA or UK used to break

up a clot in arteries or up a clot in arteries or veinsveins

Clots often occur if Clots often occur if underlying coagulopathy, underlying coagulopathy, defect in the vesseldefect in the vessel

Emboli located often at Emboli located often at bifurcationsbifurcations

Infuse through infusion Infuse through infusion catheter in affected vessel catheter in affected vessel for several hours with f/u for several hours with f/u angio until resolved or angio until resolved or result is staticresult is static

Embolus treated with TPA for Embolus treated with TPA for 12 hrs12 hrs

9. Venography9. Venography

FluoroFluoro Contrast injected Contrast injected

directly into vein to r/o directly into vein to r/o reflux, occlusionsreflux, occlusions

Ascending venography Ascending venography in upper extremityin upper extremity

Descending and Descending and ascending venography ascending venography in lower extremityin lower extremity

Usually precursor to Usually precursor to interventionsinterventions

Lower extremity venogramLower extremity venogram

10. Central venous 10. Central venous catheterscatheters

Fluoro, USFluoro, US Tunneled and Tunneled and

nontunneled nontunneled catheters as well as catheters as well as ports can be placedports can be placed

IJV and CFV are most IJV and CFV are most frequent sites but frequent sites but can also place in can also place in SCV, HV, collaterals, SCV, HV, collaterals, IVCIVC

Hickman (L), tunneled dialysis Hickman (L), tunneled dialysis catheter (R)catheter (R)

Portacath in SCV (L) and HV Portacath in SCV (L) and HV (R)(R)

11. Dialysis accesses11. Dialysis accesses

Fistulae or graftsFistulae or grafts Most often in the arms, Most often in the arms,

sometimes legssometimes legs Intended to last yearsIntended to last years Need frequent Need frequent

surveillance at dialysis; surveillance at dialysis; if abnormal, inject if abnormal, inject under fluorounder fluoro

Better to intervene ie Better to intervene ie PTA before access clotsPTA before access clots

Dialysis grafts – upper Dialysis grafts – upper extremity (L), lower extremity extremity (L), lower extremity

® ®

12. IVC filter12. IVC filter

Prevents clots in the Prevents clots in the lower extremity veins lower extremity veins from developing into a from developing into a pulmonary embolismpulmonary embolism

Infrarenal IVCInfrarenal IVC CFV vs IJV accessCFV vs IJV access Fluoroscopic and Fluoroscopic and

sonographic guidancesonographic guidance Retrievable and Retrievable and

permanent varietiespermanent varieties

Bird’s nest filter (L), Trapease Bird’s nest filter (L), Trapease (R)(R)

Simon Nitinol filter (L), Vena Simon Nitinol filter (L), Vena Tech (R) Tech (R)

Tulip (L), Recovery (R)Tulip (L), Recovery (R)

13. Foreign body retrieval13. Foreign body retrieval

Most frequently Most frequently guidewires or guidewires or catheterscatheters

Usually in the right Usually in the right heart or pulmonary heart or pulmonary arteryartery

Retrieval under Retrieval under fluoroscopic guidance fluoroscopic guidance using snares needed using snares needed given infection, given infection, arrhythmia riskarrhythmia risk

Wire looped around tricuspid valve Wire looped around tricuspid valve needing open heart surgery for needing open heart surgery for

retrievalretrieval

14. TIPS14. TIPS

Fluoro, USFluoro, US Transjugular (IJV) Transjugular (IJV)

intrahepatic intrahepatic portosystemic shunt portosystemic shunt connecting the RHV to connecting the RHV to the RPV via Wallstents the RPV via Wallstents most often to relieve most often to relieve portal HTN and its portal HTN and its sequelae ie intractable sequelae ie intractable variceal bleeding, variceal bleeding, ascitesascites

Gradient 3-12Gradient 3-12 F/u surveillance with F/u surveillance with

USUS

TIPS US (L) TIPS US (L)

TIPS with varices and clot at PV TIPS with varices and clot at PV end of stent end of stent

15. Cholangiography and 15. Cholangiography and biliary drainagebiliary drainage

Fluoro, USFluoro, US Cholangiogram – inject Cholangiogram – inject

transhepatically into biliary transhepatically into biliary tree and intervene with tree and intervene with plastic or metal stents, stone plastic or metal stents, stone removal, plasty, etc.removal, plasty, etc.

Drains/stents can be internal, Drains/stents can be internal, internal-external or externalinternal-external or external

Interventions tend to be Interventions tend to be painful so need good painful so need good anesthesiaanesthesia

Often useful when GI cannot Often useful when GI cannot delineate lesion retrogradedelineate lesion retrograde

Internal and external biliary Internal and external biliary stents (L), T tube stents (L), T tube

cholangiogram (R)cholangiogram (R)

Cholangiogram (L), internal Cholangiogram (L), internal external drainage from the L external drainage from the L

(R)(R)

Angioplasty of biliary stricture Angioplasty of biliary stricture (L), kissing biliary stents ®(L), kissing biliary stents ®

16. Nephrostogram and nephrostomy 16. Nephrostogram and nephrostomy tube and ureteral stent placementtube and ureteral stent placement

US and fluoro US and fluoro guidanceguidance

Used to check patency Used to check patency of collecting system of collecting system and relieve and relieve obstructions putting obstructions putting the patient at risk for the patient at risk for kidney failure, sepsiskidney failure, sepsis

Tubes need constant Tubes need constant monitoring after monitoring after placement placement

PCNL (L), PCNL x 2 (R)PCNL (L), PCNL x 2 (R)

Nephroureteral stent (L), Nephroureteral stent (L), double J stent (R) double J stent (R)

17. Gastrostomy tubes17. Gastrostomy tubes

Fluoro guidance facilitating Fluoro guidance facilitating direct percutaneous direct percutaneous placement of G tube into placement of G tube into the stomachthe stomach

Indicated for pts with Indicated for pts with difficulty swallowing often difficulty swallowing often due to neurological or ENT due to neurological or ENT causescauses

G tubes can also be placed G tubes can also be placed by surgery but IR is less by surgery but IR is less invasiveinvasive

GI can also place G tubes GI can also place G tubes except when the esophagus except when the esophagus is blocked by a massis blocked by a mass

Gastrojejunostomy tubeGastrojejunostomy tube

18. Chemoembolization18. Chemoembolization

Fluoro guidanceFluoro guidance Agents injected Agents injected

selectively into the selectively into the hepatic artery for hepatic artery for palliative tx of carcinoid palliative tx of carcinoid mets, hepatoma (most mets, hepatoma (most frequently)frequently)

Patent portal vein, Patent portal vein, selective injection past selective injection past gastric artery, cystic gastric artery, cystic artery, GDA imptartery, GDA impt

19. Radiofrequency ablation 19. Radiofrequency ablation

CT, USCT, US Thermal ablation using Thermal ablation using

electrodes advanced into electrodes advanced into lesionlesion

Most used in the liver; has Most used in the liver; has been used in lung, kidney, been used in lung, kidney, bonebone

Probe heats the tissue via Probe heats the tissue via rapid alternating current for rapid alternating current for a set amount of time as per a set amount of time as per tissuetissue

Needs imaging f/u to check Needs imaging f/u to check tumor responsetumor response

Image from website Image from website http://sdihms.com/images/sdi-ablation-img3.jpg

20. Vertebroplasty20. Vertebroplasty

Fluoro guidanceFluoro guidance PMMA injected into PMMA injected into

vertebral body vertebral body affected by affected by osteopenia, osteopenia, metastases most metastases most frequently for pain frequently for pain reliefrelief

Usually done in the Usually done in the lumbar spine through lumbar spine through the pediclesthe pedicles