Radio 250 [8]: ICC in Radiology and Nuclear Medicine

Lec ##: Introduction to Interventional Radiology

#
October 20, 2014

Jason Catibog, MD, FPCR, FPCVIR, FCTMRISP

TOPIC OUTLINE
I.

A.
B.
II.

A. CATHETERIS AND GUIDEWIRES

Catheters and Guidewires

Seldinger Technique

Vascular Procedures
A.
B.
C.
D.
E.
F.

IV.

Vascular Procedures
Non-vascular Procedures

Catheterization
A.
B.

III.

II. CATHETERIZATION

Interventional Radiology Procedures

Angiography and DSA

Embolization
Angioplasty and Stenting
Transjugular Intrasystemic
Shunt (TIPS)
Transarterial Chemoembolization (TACE)

Non-vascular Procedures
A.
B.
C.
D.
E.

Biopsy
Radiofrequency Ablation
Percutaneous Drainage
Percutaneous Cholecystostomy
Percutaneous Transhepatic Biliary Drainage (PTBD)

Legend:
Discussed by sir, not in the powerpoint
From 2016
I. INTERVENTIONAL RADIOLOGY PROCEDURES
Diagnostic or therapeutic
Vascular or non-vascular
Advantages of Interventional Radiology over Surgery
o Minimally-invasive; no incision, sirs widest incision is 5mm
o Sometimes, general anesthesia is not needed just IV sedation or
local anesthesia
o Most procedures are done inside the catheterization lab
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 not just renin
o Active pancreatic nodule: must be located by the interventional
radiologist; samples of venous blood are collected from head, body
and tail of the pancreas stimulate pancreatic cells to secrete
insulin by injecting CaGLuc get samples again after 1 minutes
graph determine where insulin is highest

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.
Endoscopic retrograde cholangiopancreatography done by GI
Sialography
Joint aspiration orhto or rheuma

TANGCO & TURALDE

Figure 1. Interventional Catheters

From 2016: 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
B. 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
Ensures atraumatic placement of catheter.
Can also be done in non-vessel structures i.e. bile duct, abscesses,
and cysts

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
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 Gold standard in diagnosing vascular lesions; can assess location,
configuration, and hemodynamics
o X-ray is taken and used like a mask. The contrast is injected and
then an image is subsequently taken.

Page 1 / 4

Introduction to Interventional Radiology

o The resulting picture is subtracted by the mask and the vessels
will be shown

Figure 3. Digital Subtraction Angiogram of the Cerebral vessels

Left: Actual angiogram, Right: Digitally subtracted image, Top: Arterial
phase, Bottom: Venous phase

Radio 250

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 The feeding arteries appeared hypertrophied due to increase
demand of the nidus
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. Once
the blood vessel is occluded it creates edema on the affected
tissue. This somehow makes the differentiation of normal tissue
from edematous tumor during resection.
o It results to lesser blood loss during surgery and easier
identification of tumor parts due to surrounding edema.
C. ANGIOPLASTY AND STENTING
ANGIOPLASTY- a process to widen a narrowed blood vessel
In angioplasty, deliberate trauma is induced to the intima of the vessel
leading to healing with a systematic scar
Disadvantage of angioplasty is that stenosis may recur
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)
Among interventional radiologists and interventional cardiologists, the
area of specialty is delineated by the aortic root.
Example : Patients may present with hypertension due to renal artery
stenosis

Figure 4. A DSA of an stenosed MCA showing collateral vessels to

maintain perfusion
B. EMBOLIZATION
Aneurysm Coiling
From 2016:
o Use of microcatheter <1mm
o Pack aneurysm with coils (made of alloy/Platinum)
o
Coils can have thrombogenic material like cotton,
polyvinyl alcohol, glue, or even blood clots
o Coils protect dome of aneurysm from rupturing

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 INTRAHEPATIC 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
to esophageal 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.

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

Figure 5. Embolization of an Aneurysm (Top left: endovascular coil,

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

TANGCO & TURALDE

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.

Page 2 / 4

Introduction to Interventional Radiology

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
Liver has dual blood supply hepatic artery and portal vein. In
hepatocellular carcinoma, where the tumor environment has
decreased O2 tension secondary to continued tumor metabolism.
Hepatic artery is more reactive than portal vein in increasing blood
supply to the tumor.
Procedure:
o
Access aorta and then celiac trunk
o
Look for feeders at the branches of the hepatic artery
o
Deliberately push chemotherapeutic agents to feeder
o
Occlude the feeding artery tumor involutes (poison
[chemotherapeutic agent] and starving [occlusion])

Radio 250

Complications
o
Non-targeted embolization to other organs
o
Contrast-related complications
o
Hematoma
Post-embolic symptoms (usually less than 1 wk duration)
o
Fever
o
Pain
o
Nausea
o
Vomiting
o
Fatigue
Selective Internal Radiotherapy

In 20-25 grays, normal liver tissue dies; however, need 80-100

to kill tumors. SIRT allows targeted delivery of radiation while
sparing normal hepatocytes

Uses yttrium 90 that emits B radiation; usually 2-3 mm

relatively safe for normal hepatocytes which are radiosensitive
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.

Figure 8. TACE Diagram (Top), actual angiogram (Bottom)

Advantages of the procedure:
o
Increase concentration of agent at tumors, lowers systemic dose
o
Longer dwelling time of chemo agent at tumor
o
Lower probability of recurrence and metastatic dissemination
o
Chemo agent can be emulsified with lipiodol to minimize
collateral damage (normal hepatocytes have lipases that can
digest lipiodol normal hepatocytes spared from chemo)
Indications
o
Surgically-unresectable tumor
o
Tumor confined at liver
o
Liver disease as dominant source of morbidity
o
Liver-only or liver-dominant metastasis
Contraindications
o
Portal vein thrombosis (because you occluded the hepatic artery,
hepatocytes now rely on portal vein for blood supply)
o
Uncorrectable coagulopathy
o
Presence of hepatic encephalopathy
o
Tumor > 50% of liver
o
Biliary obstruction (increase pressure of sinusoids increases
portal pressure which decrease blood flow to liver parenchyma)
o
Child Pugh C

Figure 10. Guided Biopsies, CT-guided lung mass biopsy (L), UTZguided 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 10. Radiofrequency Ablation. Showing the RF ablation probe

and the grounding pads on each thigh
Criteria for RF Ablation
o
Liver-dominant disease
o
Focal rather than diffused infiltration
o
3-5 lesions, < 6cm each if the location is feasbile
C. PERCUTANEOUS DRAINAGE OF ABSCESS
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

Figure 9. Child Pugh Classification. Class A TACE can be

performed; Class B TACE can be done but with precaution; Class C
TACE is contraindicated

TANGCO & TURALDE

Page 3 / 4

Introduction to Interventional Radiology

Radio 250

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 OF TRANSCRIPTION
TANGCO: RADIOLOGY! RAD-YOLO-GY! LIKE FORT LIU! HAZZA!
Figure 11. Percutaneous Liver Abscess drainage, CT Radiographs
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.

TURALDE: THANK YOU ANDREW FOR THE 3-5 CM LESION <6CM

IF LOCATION IS FEASIBLE

TY: HEY BITCHES!! EXTRA HEY HEY HEYLALOO SA STAREXXX!!

AT SIYEMPRE HETO NANAMAN KAMI NI HUBBY KO
MEHUEHUEHUE PAKYU SA HATERZZZ

Figure 12. Percutaneous Cholcystostomy diagram (UL), radiograph

(UR), Sonogram guidance (bottom) showing a stent through the gall
bladder

FROM 2016: 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 13. 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

TANGCO & TURALDE

Page 4 / 4