FINALS 1
- Percutaneous coronary intervention -
CARDIAC INTERVENTIONS
Interventional Cardiology
- Primarily focuses on hemodynamics -
To relief abnormalities of the heart -
Specialty for diagnostic and
assessment or treatment of heart
abnormalities accomplished with
angiographic catheterization
techniques
- Relatively safe
IR: diagnostic study to determine the nature
of the anatomy and pathology in conjunction
with w/ IR procedures to prevent
non-surgical treatment.
Main goal:
- prevent or minimize complications of
surgery
- For pt not candidate for such surgery
Thoracic aorta
- Cardiac angiography first - map -
Use transfemoral approach
- Use arterial sheath catheter
- Guiding sheath placed in orifice/
opening of the intended coronary
artery
- gw thru guide sheath
- Angioplasty catheter placed across
stenotic area
*Methods vary depending on the type of
catheter used stent placed to avoid
restenosis.
PERCUTANEOUS CORONARY
INTERVENTION:
Coronary artery disease - result of buildup
of plaque in the vessels supplying the heart
muscle with blood - stenosis/narrowing of
the lumen
- Coronary bypass surgery - invasive
non invasive, recent
PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY (PTA)
- techniques that enlarge the lumen of
the stenosed vessel
- Balloon angioplasty, angioplasty w/
stent placement(effective to avoid
stenosis), and transluminal
atherectomy
- All three is similar but different
mechanism
Mechanism:
- Balloon inflated number of times -
Lasts for severals seconds to minutes,
result to compress the plaque against
the lumen of vessel restoring blood flow
- Expansion of the balloon has effect of
stretching and weakening of the
vessel wall, in w/c sometimes result
to aneurysm and diameter shrinks
causing restenosis - RECOIL
- Elasticity may be lost
- Reduced by balloon stent system -
Provides additional support to arterial
wall - SCAFFOLDING - remains the
patency of the vessel - Balloon stent
applied REMAINS!
Restenosis - is possible with either system
Stent - added advantage support for vessels
Drug Eluting Stent System
- Newer
- Promise in reducing incidents of
restenosis
Transluminal Atherectomy
- Atherectomy - debulking/ debulk -
Advantage of simple transluminal
angioplasty of accomplishing the
physical removal of plaque from the
 artery
- Decrease possibility of rapid restenosis
Atherectomy - used if the vessel lumen is
larger and if the stenosis is continued to the
level orifice/opening.
Drawback:
- much more larger, requires larger
sheath
But not a method of choice, rarely applied
today in recanalization
- Increase potential for secure
complications.
USED IF:
- Vessel lumen is larger
- Stenosis confirmed in orifice
PERCUTANEOUS BALLOON
VALVULOPLASTY (PBV)
- Similar to PTA, only difference is
angioplasty is used to repair stenotic
vessel
- PBV is used to repair heart valve and
poorly functioning due to stenosis
and scarring - causes heart attacks
- When valve is compromised, heart
works harder to push the block
through the stenosed vessel, this is
also build up of pressure in
pulmonary circulation due to back up
of blood w/c can lead to DYSPNEA -
stenosed vessel
- As scarring progresses, it fuses the
leaflets, they touch
- Leaflets - causes it to open completely
restricting blood flow
*closed - healthy
*incomplete closure - ds
- The point at which leaflets of valves
fused is referred to as
COMMISSURE, and repair of
procedure of valve is called
COMMISSUROTOMY.
- The process causes breaking of the
band holding the leaflets and allows
it to operate in much improve
fashion.
REPAIR METHOD:
- Surgical separation of the leaflets of
the valve via open heart surgery or
valve replacement (used mechanical
or animal valve usually pig valve)
- In most cases PBV will eliminate the
necessity for surgical interventions
Valvuloplasty - commonly employed when
there is stenosis in the mitral valve - Also
used to relieve tricuspid valve stenosis, anti
valve stenosis and pulmonary stenosis, as
well as some congenital valvular disease.
Self- expansion technique - used to repair
the valve.
SPECIFIC VALVE VIA VALVULOPLASTY
1. PERCUTANEOUS BALLOON MITRAL
VALVULOPLASTY
(PBMV)
process:
- a mitral valve must be
accessed from an antegrade
position via transfemoral
approach or through septum
- separates the chamber.
- Catheter is inserted either
upper or lower ex. Commonly
from femoral vein
- Once inserted in the right
atrium, catheter is passed
through intra-arterial opening
of transseptal approach is
used, pierce it through the
septum using brockenbrough
needle, then dilator sheath is
applied through the mitral
valve.
R&L atrioventricular valve - pababa na
valves
Pulmonary & aortic semilunar - palabas
Measurement of cardiac output are made
using a thermodilution or once the catheter
is in the right atrium, then the specialized
design INOUE BALLOON CATHETER is
made of polyvinyl chloride with balloon at
its distal end, balloon has a latex band
around the center to restrict the inflation of
the center of the balloon, when it is fully
inflated, it will resemble an hourglass shape.
Once the opening in the left atrium has been
accomplished and dilated, the deflated
inoue balloon is placed in the atrial chamber.
PBMV
A. Catheter is placed on the mitral valve
B. Front half of the catheter on distal end
of the catheter is inflated and floated
across the mitral valve
C. Catheter is retracted to place distal
portion against mitral valve
D. Inflated portion of the balloon
separates the commissures
E. Additional inflation of balloon enlarges
the mitral valve opening
F. Balloon is almost fully inflated.
2. PERCUTANEOUS BALLOON AORTIC
VALVULOPLASTY (PBAV)
- Same as PBMV
- Catheter is placed via retrograde from
the peripheral artery
- M.c route - femoral artery
- In cases of several peripheral vascular
diseases, brachial route can be
used, in upper ex. Approach (small
diameter catheter)
- Balloon is passed through aorta,
across aortic valve
- Dilation process is accomplished using RF- combination of electric and magnetic
several sizes of catheter. Is energy, occurs naturally and visible light
succession
- Gradually increasing the size of the
procedure
Objective:
- Reduce the pressure gradient between
left ventricle and aorta below
30mmHg, pressure corresponding as
diameter increases
3. PULMONARY VALVULOPLASTY
(pulmonary semilunar valve)
- Be used to relieve pulmonary stenosis
- Does not differ from previous
procedures
Route: FEMORAL VEIN
- Pass across pulmonary valve and
expanded to reduce stenosis
Catheter Ablation - accomplished using RF
waves
Ablation - general term referring to the
process of destroying and removing tissues -
A technique used in various parts of the
body to necrose and remove tumor tissues
- Can also be used to set straight the
rhythm of the heart
- Used in bone metastases
Cardiac electrophysiology - done for the
heart rhythm to be okay again
Arrhythmias - disruption of normal rhythm of
the heart
- Causes atrial fibrillation, atrial flutters
and various tachyarrhythmias
Transcatheter Ablation - was originally
accomplished using direct current. However,
RF waves in the range of 1,200 kHz are
now being used.
radiowaves and microwaves.
RF Generator - electromagnetic energy
used in catheter ablation is produced by
RFG
- Energy is directed to a specific focal
points by the means of specialized
catheter electrodes that are used
ELECTRICAL SYSTEM THAT MAINTAINS
CARDIAC RHYTHM
Sinoatrial Node - begins
- Called as cardiac pacemaker
- One that sets the phase, the rhythm of
the heart
- Located at the right atrium close to the
osteum of the heart
- Acts produces steady rhythm of the
heart muscle to contract
approximately 7-80x per minute
goes into the AVN
Atrioventricular Node
- After reaching the AVN bundle, when it
separates it reaches the BUNDLE
OF HIS,
- Once BOH enters the ventricular
septum, the impulse travels down to
the VS as it passes and divides into
the PURJINKE FIBERS
- Goes to the cardiac muscles and
stimulates the ventricular muscles to
contract
FINALS 2:
Nonvascular Interventional Radiography
Gastrointestinal system - a hollow tube
that begins in the mouth and ends in the
rectum and it has its accessory organs
• accessory organs - are used to serve as
an aid in processing of the food or material
that has gone through or gastrointestinal • by the liver and then the bile that is
system
functions:
- to process food and fluids that are
taken by our mouth
- functions to process food and fluid
taken by our mouth
salivary glands - which are used to add
fluid and enzymes to the materials that are
being breakdown by our mouth to aid in the
breakdown of carbohydrates
- the liver utilizes amino acids that are
produced by the gastrointestinal
tract to produce new proteins you
know this is the process of breaking
down and producing new proteins by
the use of amino acids right make
bond,
• that bile is stored in the gallbladder which
is used among the pancreatic and intestinal
secretions to digest fats and carbohydrates
nutrients, electrolytes and water produced
by this process are absorbed into the
bloodstream by the small intestine and large
intestine ,there different disorders that can
affect our GI system and some cases,
therapies are used as
interventions • drug therapy
• diet alteration
• stress reduction
have been proven successful few of them
like eating disorders can be but it’s also
mental health cause it mentally ill, eating
disorders maybe you have ulcer, however
many pathologic conditions have And using
interventional techniques By doctors
How is Bile produced?
produced along with the pancreatic juice the
intestinal secretions are used to digest or
help in digesting materials but
• bile is stored in the gallbladder
• if the patient eats Fatty food this Bile is
ejected affect from the gallbladder because
it is stimulated to release it to aid in the
digestion of These food
• the liver Gallbladder and pancreas has
intimate connection with the duodenum
• provide and aid in the digestive process
• LIVER is one of the heaviest organ in the
body
• one of its function is to normal normalize
the concentration of blood glucose, patients
that are diabetic usually have problems with
the liver and their kidneys also
• necessary for the liver to Do a
carbohydrate metabolism
• It also plays an important role in the part of
synthesizing facts and are stored in the
adipose tissue
Primary function of the liver is to produce
bile
• ex: the bile for goes down to the left and
right hepatic duct
• They fuse to form the common hepatic
duct
• The the cystic duct and the common trace it, this is specified in CT and MRI
hepatic duct joins together along with The
pancreatic duct it is called the common bile Kidneys, ureters, bladder
duct
• the common bile duct empties in the
duodenum.
the cycle on how bile is produced stored
and is released so although the liver
appears to be a single large structure,
according to Claude,
- A French surgeon Claude - described that
the liver has its segments in which…..
- Describe 8 areas of the liver with 2 lobes
- function of the bile of the show in cases of
blockage or obstruction of the bile of the
ducts by accumulation in the liver causing
the Bile salts and pigments to enter the
bloodstream
- increased number of Bile in the blood Is an
increase of bilirubin in the blood symptoms
like that is caused by other pathologic
factors like hepatitis, liver cirrhosis, trauma
biliary surgery , biliary cancer because of
the accumulation increase of number
Bilirubin in the blood
Segments and lobes of the liver
• the right lobe
- 4S 4B 85 76,
• Left lobe
- we have segments 2 and segments3 - 1 on
the posterior part The caudate lobe
- Appreciated if you scan on the left lobe
And position of probe in ultrasound is
Longitudinal
Example:
- there is a hyper echoic Solid mass in the
right lobe in the segment Lateral Superior
segment of the left lobe(segment two) so
the left lobe align segment so the doctor will
• this is the urinary an integral part of the
excretory mechanism
• Also help regulate blood pressure • For
hypertensive patients RENIN The kidneys
into the renal veins to regulate blood
pressure fluid balance
• are important in the stimulation of red
blood cell Production in the bone marrow
• another hormone aldosterone which
regulates Sodium and potassium levels in
the blood
• This substance is important to regulate
sodium and potassium levels • RENIN also
maintains electrolyte Balance in the body,
• This mineral maintains cardiac function
and muscle contraction and brain activity
usually Determine in the laboratory and they
can indicate several pathologic conditions
Naturally occurring narrows in
three places,
• The first one is the junction between the
ureter and the renal pelvis
• the second narrowing is level of the
common iliac artery sa baba na banda
• the junction between the bladder and the
ureter
Different length of urethra Of two sexes
is actually different for the male and female
Male: 20 cecentimeter, 8 inches long
Female: 4 centimeter 1 1/2 inch long
They have two valves, the internal and
external uretheral sphincter which control
the release of the urine. Can also be
psychological but most of the time it is
pathological.
Percutaneous fine needle aspiration
Needle biopsy
- eliminate surgically opening their Patients For tissue examination of the mass if fluid
- purpose: there’s a needle for type like thyroid, percutaneous fine needle
percutaneously through the skin so they aspiration, ultrasound guided
don’t need to open the patient
- Interventional procedure Less
complicated, less invasive
- diagnostic Processing the many areas of
the body including the thyroid intracranial
and intraorbital structures, spinal cord,
abdomen, lungs, Accessory regions,
Genitourinary, Lymphatic and biliary
systems, Soft tissues and bones
- the mass or whatever they have seen is
accessible and can be reached by the If not
another intervention is performed
Two basic method of biopsy:
● large Gauge core-type needle method
● Percutaneous fine needle aspiration
large gauge core type needle method
Solid masses
● it has a larger gauge than fine
aspiration needle because it's pierce
through the mass to get samples of
the mass Into the laboratory for a
cycle psychological process to know
what this mass is so for example
usually pag sa breasts center we
use this large gauge to get biopsy of
breast massess
● core gun with click To close and cut
through a little piece
● Histologic analysis or study of the
are then required by this technique
specimens for large gauge core
type needle analysis,
 sampling there are difference between this
● Psychological analysis that fine two
needle aspiration Method so if
FNAB Ultrasonography - is performed either by
static or dynamic scanning when we say
Prevention of procedure for lesser static- 2D images only, like fluoroscopy live
complications complications that can result scanning
from these Are varying -to locate needle puncture route should
always have the shortest distance
-depending upon the type of procedure possible
-location of the mass lesion
-and possible needle sites -and the scan continues by manipulating the
transducer to see the chosen puncture path,
To successfully localize lesions, support for
you to find out where this lesions are -if puncture path is seen, skin surface is
specifically found you need to use guidance marked by the doctor
doctors cannot go on blindly
-the patient is prepped
this is actually Minimally invasive procedure
we do needle biopsy can Pierce through because of course you’re still piercing your
different organs which can cause patients but with sterile area and physician
introduces local anesthetic
• pneumothorax - if you puncture the lungs
• peritonitis - puncture to the peritoneum The scan is repeated in which the purchase
• also cause hemorrhage and can be and doctor then shoot get specimen if
deadly aspiration scanning
• sepsis so there's actually localize this • volumized by the doctor So after scanning
lesions through the procedure must be after determining which parts
guided, this guidance is accomplished with li
one of these modalities are usually used • doctor will aspirate and then if she reached
alone or in combination to provide maximum the volume that has been calculated
diagnostic information
• ask for another usd scan and then upon
Modalities the choice of method scanning That
depends on the
• decisions preference • the cystic mass is already deflated •
• equipment availability and •
hospital protocols doctor can remove the needle
• most requires Under USD or CT guided
biopsy needles precisely. CT- when ultrasound is contraindicated CT
can be used for the localization and needle
this techniques pinpoint the lesion’s guidance for the lesion puncture
location and allow we have accuracy in

- usually saw lungs, liver, deep
structures since ultrasound again
can’t penetrate that deep , doctors
first do planning
- The most accessible side with the
shortest distance
- to where can be avoid most of the
vessels and organs,
- they calculate distance and length of
their needle to Pass from the skin to
the mass and the length of the
needle
- Through spiral or helical CT, with rapid
image reconstruction
- Then the pathway is marked on the
skin if they choose site during
preliminary CT scan,
- pt is prepped for sterilizing and draping
the skin.
- Local anesthetic applied
- needle is inserted along with the
pathway that is desired,
- after placing the needle, require
another scan to determine whether if Ex. Kidney, prone- retrospect part of the
the needle is accurately inserted body
through the lesion, it should pierce
the lesion,
- shoot needle and scan again, confirm,
remove needle, submit to the lab.
Percutaneous needle puncture techniques
for the diagnosis of cystic masses and the
percutaneous drainage of the fluid
accumulation
Those have been proven safe with relatively
low complication rates to the first one we
have is the percutaneous puncture
Example: Renal Mass, cystic mass,
- After mass is identified or localized,
after if it’s determined by several
methods of diagnosis, usd,
nephrotomography arteriography
and needle puncture
- if then determined if solid or cysts
percutaneous needle puncture can
be now then used to provide
samples psychologic or histologic
analysis of the mass.
Procedure for percutaneous puncture such
as the kidney is relatively simple method
and does not require sophisticated
equipments for the successful lesion
puncture, USD is used easier to manipulate
mass in different angles angle for needle,
fluoro, syringes, anesthesia, lidocaine
needles different sizes of needles, puncture
needles and anesthetic
Actual puncture set varies with the anatomic
area of interest
- percutaneous puncture procedures are
usually in considered as minor or
operative procedure and should be
done under aseptic conditions
- if renal is puncture, pt in prone position
for preparation in puncture, lesion is
localized (USD OR FLUORO) if usd
 use the needle follows the path the cyst.
presented by the transducer and - Cyst deflates.
then shorter actual procedure time - If cyst in the kidney is found,
- doctors don’t do anything with small
- if fluoro, continuous shoot while needle cysts.
is inserted. Stop, mark, shoot! - Interventional procedures of cyst are
excessive radiation exposure performed if the cyst is big and
disrupts the function of the urinary
Fluoro: system, to prevent it from bursting.
- lesion is a localized mark
- then needle insertion is then tracked by Percutaneous drainage
the fluoroscopy, - drains commonly Abscess The
- puncture needle and insert segment drainage of fluid collections like
where anesthesia is placed. abscesses in the urinary system
- Needle is advanced slowly with biliary system and the abdominal
fluoroscopic monitoring of the cavity can be done through
needle's progress continuous catheter drainage
- successfully puncturing it, methods
- confirmed by aspiration of cystic fluid. - also enables physicians to dilate
- Once removed, this substance is sent stenosis channels, occluded areas
to the lab for psychological analysis, of leakage, close or fistulas infuse
- a followup examination is performed to substances to dissolve or remove
pt, with a contrast agent for the calculi and performed biopsy
internal examination of the the obvious advantage of this technique: - it
pathology. requires fewer surgical procedures
that must be performed on the patient
Complications: - pt don’t have to be opened up for such
- there are complications for the procedures, reduce complication
percutaneous procedure but it does rate.
not include a great risk to the
patient although 3 phases to a successful percutaneous
most common complication: puncture:
- hemorrhage and 1. to access the fluid collection
- extravasation of contrast agent 2. to ask an aspirational of fluid confirm
through the cyst. position
3. placement of drainage catheter
Tip of the needle usually has an artifact,
it is also important that during this
Example: percutaneous access precise guidance is
- the insertion of contrast material used and that the entry point in fluid
through the kidney to determine accumulation is avoidance of puncturing the
saan ang cyst. needle to the bowel that can cause
hemorrhage, sepsis, extravasation,
- Needle is inserted for the aspiration of

definition also be accomplished through
cannulation of the sinus tract associated
with the abscess
What are the most common
percutaneous method:
- percutaneous drainage of Abscess
usually hepatic Abscess
- Abdominal paracentesis the drainage
all of normal accumulation in the
peritoneal cavity
Two most common use procedure for
drainage catheter placement
● two trocar cannula and
● the modified seldinger technique
The first grouping technique that we will
encounter aside from the percutaneous
drainage and puncture methods we have
this percutaneous nephrostomy - is a
procedure for the external drainage of the
urinary system through the percutaneous
catheter nephrostomy (PCN)
-Pt have patho in urinary that does not able
them to urinate normally
-Provides temporary drainage of the
obstructed urinary system,
-also primarily used to relieve the
obstruction resulting from a urinary calculus. that has been aspirated to avoid the
-PCN relies on the placement of the system if obstruction exist, in simpler
character within the renal pelvis through a
percutaneous insertion technique
Trocar cannula methods- Popular use
during PCN because this allows them by
their system to introduce a larger diameter
to be passed through the kidney
How is Percutaneous Nephrostomy
done?
- PCN patients are mildly sedated and
well hydrated before the beginning of
the procedure.
- prepped and draped in a prone
position.
- Localize kidney using IV of the kidney
or through the catheters
- Prepare rotations,
- prepare to shoot contrast media dali
lang mawala, be careful with the
central ray
- Local anesthetic is administered, -
kidney punctured with 22 gauge spinal
needle it enters the collecting systems of
the kidneys,
- attach flexible connector tube- first fluid
to release is taken to the lab,
- then connected to the catheter for
external drainage,
- antegrade pyelogram is obtained - So
after like antegrade pyelogram which
means doctors views the kidneys, shoot
again, this will determine if pt needs to
undergo percutaneous nephrostomy
tube insertion.
- Doctor will leave this, since pt can’t
urinate
So it is important to instill an amount of
contrast media equal to the amount of urine
possibility of trauma to the urinary
words yung inaspirate mo na urine, all of
that is equal to the volume of contrast media
that we will be inserting To avoid trauma in
the urinary system if may obstruction of
nephrolithiasis maybe sa proximal or distal
ureter, to avoid trauma. done trocar, flexible and drain

- Pt can feel the urge to urinate This is the percutaneous puncture through
an operator shot through modified seldinger
Radiography during this phase is directed method this one is the technique of trocar
by the radiologist performing the procedure PCN, trocar and antegrade needle
and if antegrade pyelogram is indicated for
the necessity of PCN the physician chooses PROCEDURE:
a catheter size usually highest catheter size 1. to place the patient in the prone
used in PCN are oblique position with affected side
- 8french or 12 french catheter, either elevated 45 degrees
soft or stiff 2. once this is done, prepare the site for
- When mass, it is done by IRT, if in puncture the next one is applying
deeper parts it is referred to local anesthesia to the area
urologists. 3. Make a small nick in the skin for the
- Radiologists because they cannot do point of entry
that unless they open their patients 4. Once done, 22 gauge needle is
but interventional radiologist can advanced to the chosen calyx
perform it can do techniques on how 5. Once collecting system is entered,
to take a specimen of this mass remove stylet, adjust needle
without opening your patience but 6. Ensure urine can be aspirated
usually during this percutaneous 7. Sent to the laboratory
nephrostomy tube insertion or PCN, 8. Guidewire introduced to the catheter
nangangailangan sila ng guidance 9. Small nick be dilated/ widen by dilator
from the radiologist sheath
10. Accept dye, nephrostomy catheter
Example: 11. Introduce trocar to facilitate the
- PCN, if tube insertion, USD is used. - passage of catheter in the urinary
They use their own machine in the OR, system
call the radiologist, when it's time to 12. Once done, trocar can be removed
insert their catheters. 13. 2 ways to lock the catheter within
- RT, assists radiologist, uro asks for the kidneys:
advice antegrade pyelogram is used
to determine if there is a need for pigtail catheter or locking loop or cope
PCN loop catheter- This system forms a loop that
- to identify the renal calyx that will be locks the kidney after placement
used to implant the catheter
- the choice of calyx will be determined Malecot catheter also locks in place by
by the pathology present - And the making the distal end larger than the
procedure is now done insertion path; this is accomplished by
retracting the catheter tip, and can be used
schematic of anatomy for continuous when the renal pelvis is small or when there
puncture so this is percutaneous puncture is is a large calculus present. Distal end is
shaped somewhat like a tulip factions, catheter dislodgement,
catheter obstruction and
14. after the category is anchored, this will hemorrhage
be anchored externally by the use of ..
devices or attaching it to the pt skin, 1. First figure, it is a mechanism for
sometimes it is wrapped diverting the urine in case of Nick in
the ureter you’re using a balloon
external drainage can be continued until the catheter and an external drainage
compression is achieved indwelling catheter
occasionally the catheter must be Ex. Leak of urine
changed in result of obstruction that can
be cleared can also be used to dislodge, 2. this the mechanism for progressive
This is accomplished by the returning the dilation of stenosed through the
distal portion to its original size shape or by using graduated catheters so mean
removing it into the system it'll what if there is a restenosis of the
ureters, guidewire inserted, catheter,
Is the technique for trocar PCN, a catheter to dilate stenosed ureters,
schematic relation within defined puncture dilations in 2 week interval, change
needle and the trocar cannula and unit catheter every 2 weeks.
PROCEDURE: 3. This is the mechanism to dilate
- Method of catheter insertion is that stenosed ureter using a balloon
trocar cannula method unit is catheter, inflate
inserted somewhat laterally from the
22 gauge fine needle 4. the mechanism for stent placement
- this is accomplished by making a small through the trocar cannula unit open
nick in the skin usually 2 obstructed or leaky ureter
centimeters deep with a scalpel so
once that is done that trocar cannula example:
is inserted under fluoroscopic there is an obstructed or stenosis ureter
guidance ultrasound guidance and because there is a permanent obstruction
such for example may cancer bladder cancer,
- And it is monitored until kidney is prostate cancer, cervix cancer, uterus
punctured when the trocar is remove cancer or temporary obstruction like may
appropriate categories now inserted operation doon, they insert stent for this
to the kidney and ureters
- then cannula is removed then the
catheter now is secured in place or Percutaneous Calculi removal
the skin - from the word itself that means they
remove all of stones
Complications: - Kidney stones- nephrolithiasis - Reason
- The complication rate of PCN is again removal: salty foods drinking too much
relatively low because possible
complications may include like Percutaneous Calculi removal
- Renal calculi can be removed ducts. This procedure is actually performed
percutaneously, with the procedure four to six weeks after surgeries to allow
described, once the trocar cannula is biliary T tube traction. After procedure of
positioned, cholecystectomy- removal of gallbladder.
- You can place steerable catheter system in
which you can insert stone basket – like a T tube- placed in the biliary tree
foreign body retrieval device but it is used to Before the procedure, physicians give
remove stones from the system medication to relieve anxiety such as
- Stone baskets can be introduced into the diazepam- pampacalm, and antibiotic- to
kidney and has many variations - Ultimate reduce possibility of infection, in 4-6weeks
choice remains to the radiologist, urologist pt is still healing.
or physician
- The catheter with the stone basket is All the equipment necessary for the
inserted through the cannula and positioned operative biliary calculi removal, the
closely to the calculus for example this one equipments necessary is minimal
after the stone basket is opened, positioned Steerable catheter system
and maneuvered to engage the calculus 1. Stone baskets to remove stone 2.
- the basket is then retracted until it contacts Curved distal tip catheter 3. Guide
with the catheter tip which has effect of wire
closing the basket over the calculus - once 4. Fogarty Balloon catheter- to remove
retracts, it passes through the catheter, foreign bodies
which now closes and stones are removed 5. Syringe- for cm
- both the catheter and the stone basket are
then removed together through the cannula Inserted percutaneously,
so
- when all the Calculi are removed, a Procedure: PBCR
nephrostomy catheter is placed into the 1. Begins with t-tube cholangiogram – to
kidney and secured place determine location and number of calculi
- catheter again, to observe pt for several that remains, as well as to provide to
days removal of the stones - and then necessary contrast for the procedure
follow-up radiograph should be taken with - after procedure of gallbladder
the use of contrast medium to determine the cholecystectomy, they place t-tube to assist
patent see of the urinary tract and the in the drainage of bile,
presence or absence of the calculi - T-tube cholangiogram can be done in
- usually USD, x-ray, OPD to examine patency of biliary
- also remove calculi in biliary tree system if they can actually remove the gb, -
done in OR
FINALS 3: - done by General surgeons - be
Postoperative biliary calculi removal attentive
stones might come from nagcalcify na - T-tube cholangiogram, t-tube attached
calcium salts sa gallbladder. If lalabas sa directly to the syringe, cm is inserted, rt will
gallbladder can be dislodge can cause rotate, if cm is finished (naubos), surgeon
obstruction in the flow of bile in the biliary will signal to shoot.
- Either fluoro, c-arm *gallbladder stones can be released
together with feces
2. Guidewire can be inserted,
Complications:
A. T-tube cholangiogram - risks associated with post operative biliary
B. Guidewire inserted to the tube, reaching calculi removal are actually minimal, most
the stone problems occur because of improper
C. Tube is removed, a steerable catheter is catheter advancement that results in
inserted hemorrhage, periductal leaks, duct
D. Gw is left in the biliary tract at the lower perforations and pancreatitis.
end of the duct, positioned close to the - Depends on the physician, on how he/she
calculus to be removed manipulates the catheter, usually
E. Gw removed, stone basket inserted and complications arise from that
advanced to the tip of catheter, near the Non operative percutaneous biliary
calculus calculi removal
F. Several positioning methods is done, to - Gallbladder is still intact
snare the calculus in the stone basket - this method of percutaneous biliary calculi
(rotate, pull and push) removal was developed as a modification
G. Steerable catheter, stone basket are for percutaneous transhepatic
removed extracting the calculus, cholangiography
- with the use of interventional radiography,
If multiple calculi are encountered, aintroduce catheter in the biliary tree
steerable catheter must be reinserted and
manipulated to remove subsequent stones. Risks:
possibility of peritonitis as result of the
Multiple gw can be inserted into the biliary puncture (inflammation of peritoneum), -
tract, into the t-tube to create reinsertions that’s why physicians require antibiotic
treatment for at least 1 day before the
Occasionally, if maliit ang stones and is procedure and 2-3 days after the puncture
placed in the lower ducts, they can be to eliminate such risks
maneuvered to the duodenum - Another means of reducing incidents of
peritonitis is by the use of a catheter
Ducts has close relationship with the sheathed needle.
duodenum, the first part of the small
intestine- where bile is nilalabas to help in PROCEDURE: NOPBCR
digestion of fats Non operative percutaneous biliary
calculi removal
Ex. Balloon is inflated, balloon can be- after patient is prepared,
inserted to push stones towards duodenum,
and goes with the feces A. biliary tract must be opacified, by the use
*di pwede isabay ug kuha tanan, because of fine needle transhepatic
biliary ducts can be damaged, causing cholangiography technique (nagtutusok
complications directly to the transhepatic system, then
introduce cm to do FNTCT to visualize
biliary system) The basic procedure for percutaneous
transhepatic biliary drainage (PTCD)
B. this procedure involves percutaneous allows other interventional procedures to be
puncture of the lining with the use of small performed in the biliary tract.
gauge needle - In PTCD, another interventional procedure
- After the puncture of the lining has been in the biliary tract can be done, more
confirmed, contrast media is injected to efficient
provide necessary contrast visualization of
the biliary tree. PROCEDURE: PTCD
- Percutaneous biliary catheterization can A. Obstructed biliary tract
be done using the opacified biliary tract and B. Catheter sheathed needle is inserted C.
fine needle system as reference point. Needle is removed , gw inserted through the
sheath then to the duodenum
C. Catheter sheathed needle is guided by D. Sheath is removed, dilation catheter is
fluoroscopy, as it enters the biliary tract, inserted all throughout until the duodenum
needle is then removed E. Dilation cath, is replaced by drainage
- Syringe is then attached to the catheter catheter with a curved tip, to assist in the
sheath, for injecting small amount of cm to drainage
confirm if successful ang intubation
Different interventional procedures that
D. Catheter is positioned close to the hilum can be done in PTCD
of the lining, and the bile is drained
*Removal of biliary calculi is done several 1. Fine-needle transhepatic
days after the initial intubation to provide cholangiography
adequate drainage of bile for patient As cm is introduced to the biliary tract,
stabilization biliary tree is visualized
*stenosis in biliary tract, tube is placed to
assist in bile drainage in the duodenum 2. Percutaneous transhepatic biopsy,
naay bioptome claws in the catheter to get
E. after a few days, removal is done, as samples of a possible mass in the biliary
determined, biliary calculi is removed, And tree
the original placed catheter is exchanged for
a non tapered variety and two guide wires 3. Percutaneous transhepatic stone
are inserted into the biliary tree. reconstruction, claws to remove stones 4.
Percutaneous transhepatic
F. catheter is removed and a steerable choledocoplasty, chole- gb, doco- ducts,
catheter and catheter stone basket system plasty- surgical repair,,, usually w/leaks, the
is introduced to the biliary tree removal of gb is through the flap/ residual
*kaya dalawa because ang isa serves as skin is tinatapak sa duct w/o even opening
drainage cath, and other is used to the pt,
introduce the stone basket
5. Percutaneous transhepatic stent
insertion, stent insertions are important for
stenotic biliary ducts, stent is inserted to
provide scaffolding para hindi magcollapse,
making the flow of bile to the duodenum is
smooth, seen in USD, doctors
ginapadetermine ang patency of stents
placed
Complications: Percutaneous transhepatic
biliary calculi removal
- Similar to postoperative biliary calculi
removal
- Added risks: infections by the insertion and more punctures is needed
removal of needles, gw and catheters
- Most problems treated by antibiotic
therapy and no long term effects
Endoscopic Retrograde
Cholangiopancreatography (ERCP) -
A very common procedure now, replaces
surgeries of the biliary tract - ERCP become
a commonly practiced procedure for biliary
pathologic diagnosis, biliary intervention for
stone removal, and biliary drainage
- although the removal of biliary calculi is
the primary complication of ERCP,
Tip of endoscope has camera
insert endoscope- mouth, esophagus,
stomach then to the duodenum
As it reaches the duodenum, the sphincter
of oddi- the joining of pancreatic and
common bile duct, empties in the duodenum
Catheterization of the duodenum is through
the tip of the endoscope, catheter inserts to
the sphincter of oddi to the biliary tree. No
- The catheterization procedure helps
diagnose and treat various pathologic
conditions in the gallbladder, liver and
pancreas
- Once diagnosis is made, treatment is
given
1. Explain to the patient the procedure,
consent form is negotiated
- Sedation is applied IV midazolam and
meperidine
- Sedative orally then sedation thru IV -
Prone position

Indications include; 2.Endoscope passed to the mouth,

number of diff biliary and pancreatic disease esophagus, stomach then Into the
processes such as cholangitis, obstructive duodenum using the endoscope opening
jaundice, acute biliary pancreatitis and the bile duct and pancreas is located with
evaluation of pancreatic trauma and the use of this catheter,
suspected pancreatic cancers
*In most cases, ERCP replaces 3. A catheter is passed into the duct and
percutaneous biliary drainage and and perc. contrast media is administered to determine
Transhepatic cholangiography as diagnostic the nature and pathologic process.
and interventional tool
*very versatile and helpful to doctors - into the biliary tree, inflated balloon is seen

PROCEDURE: ERCP 4. the procedure is followed by they can

Involves passing endoscope from the mouth spot films by the fluoroscopy and record
to the duodenum images, essential to visualize the biliary tree
to see obstructions
 Medication reaction; allergic reactions to
- RT should provide image of biliary tree - cm, decreased cardiac and respiratory
ERCP long time, make u dizzy due to function with the use of sedatives
radiation exposure - Pt often feel minor complications –
nausea, vomiting and sore throat
5.After biliary tree is seen, balloon catheter - If the physician chooses to perform an
is then Then inserted to the sphincter as a interventional procedure on possible
seal and if blockage is noted, treatment can complication standing create increase like
be administered such as stents, drainage for example perforation of duodenum,
tubes bacteremia, hemorrhage or infection can
Doctors can also perform endoscopic be cholangitis or pancreatitis while the
retrograde sphincterotomy – tip of complication rates for this procedure ranges
endoscope has mechanism to pierce 5-10% , operator dependent, skills of
through with the use of heat to dilate, some physician in manipulating equipments
patients has obstruction in the sphincter, - Surgical interventions is performed if
heat or laser is used to cut through, It complicated na ang pt
makes a cut into the papilla to enlarge the
opening of the papilla Extracorporeal Shock wave lithotripsy
- Allows for the placement of various (ESWL)
instrument to remove blockage - Is a non invasive method that is used
- Basket catheter can be used to remove therapeutically for both urolithiasis and
stones and fragmentize stones making it polylithiasis, ESWL has been applied to
smaller- Mechanical lithotripsy fragmentation of uroliths since 1980
- to fragmentized um kidney stones, ureteral
Mechanical lithotripsy- utilizes a stones since 1980
specialized catheter basket after lithotripsy - it has become the method Of choice or of
to capture the stones and retract it against a treatment of most upper tract urinary stones
metal sheet but almost easier matanggal sa kidneys
- Pag Retract and remove pwede igawas sa - recently, modification is used the technique
duodenum has been investigated in the treatment of
- If the treatment is successful then the patients with biliary calculi it has also shown
endoscope and other instruments are to be cytotoxic to certain tumors
removed and the patient is monitored after
that of course sedated patient is monitored PROCEDURE: ESWL
and placed into the PACU observed for - So ESWL is based on the use of
signs of apnea, diaphoresis, cardiac lithotripter, with the use high energy
changes, respiratory complications, shockwaves through fragmentized the
laryngospasms, and hypotension stones without actually causing significant
- and once the patient is stable the damage to the normal surrounding
intravenous line can be removed and the structures This one the focus shock waves
patient can be discharged are directed to the kidney stones
- It can be generated electromagnetic,
Complications: ERCP mechanical, or piezoelectric techniques
- 3 AREAS:
the smaller fragments resulting from the
procedure TIPS PRIMARY INDICATION:
can be dissolved 3 ways - PORTAL HYPERTENSION - Increase
pressure in portal system, where all veins
- either orally by drugs (pwede maihi ng seen in the lower part w/c empties in the
pt), portal vein
-can pass through the organ - Can also occur due to liver problems
physiologically or (cirrhotic, lodge materials causing
-can be removed mechanically obstruction)
- Development of this stents are used to
Specialized equipment is necessary for thesuccessfully treat portal hypertension and
performance of this procedure likegastrointestinal bleeding with a means of
lithotripter, equipment is manufactured by percutaneous interventional procedure that
several companies and different modificationprovides a connection between the portal
had been done to such machines and hepatic venous system
- Portal and hepatic vein meet to empty in
Transjugular Intrahepatic Portosystemic the inferior vena cava
Shunting (TIPS) - Although these mechanical/metallic shunts
- 2 Interventional procedures that doesn’t fit has provided patency, stenosis of the shunt
to vascular and non vascular procedure: is still possible so, they put drug eluting
stents because they give long term patency
TIPS and Vena Cava Filter placement for portosystemic shunts – they use stents
w/ drug eluting mechanism
Other interventional procedures actually are
two this one like I said interventional INDICATIONS: TIPS
radiology kasi is an expanding Minimally - Budd-chiari syndrome- thrombus lodge in
invasive therapeutic technique procedures the hepatic or portal system that can cause
are being pioneered because of this obstruction w/c can lead to pressure w/in the
innovations and then vascular liver and causes liver cell damage then
catheterization and endoscope techniques causes portal hypertension
or just few of this modifications in - The procedure is actually contraindicated
interventional procedures some does not fit in cases of severe liver failure, biliary
the categories obstruction, polycystic liver disease,
systemic infections and heart diseases.
TIPS
- Portal hypertension has traditionally been PROCEDURE: TIPS
treated to invasive surgery by placing stents Uses specific routes
in the biliary system to decompress the *jugular, transhepatic, transfemoral,
pressure in the portal system this results inexternal jugular or vena cava access
this approach not encouraging because of
the stenosis of vessels so the development right jugular vein is actually a gigamit as
of stent is used to stabilize vessels by usual approach, pero if compromised, left
providing long term patency, stentJV can be used.
placement to relieve portal hypotension
 pressures are taken, ideally portosystemic
PROCEDURE : TIPS gradient should be reduced by </= 12mmhg.
-Transjugular approach- 9-10 french tip This is critical since this determines the
sheet is used Inserted to the vessel and success of the TIPS procedure, especially to
advanced to the right atrium, those cases with esophageal variceal
-At this point, many potential arrhythmias bleeding, due to hypertension
can happen, pt should be monitored -Once the procedure has been completed
carefully the catheters and guidewires found now be
removed
-After reaching the right atrium, then, curved
tip catheter is used to select the rightA. internal jugular veins in the right side
hepatic vein at this time venography can begoing to the right atrium then to the right
performed to confirm the patency of thehepatic vein,
portal vein (pagpierce sa right hepatic vein,
cm is inserted, venography) B. Once the pressure measurements are
taken a pathway is created from deliver
-Needle is then paneled through the hepatic parenchyma from the hepatic vein into the
parenchyma to the underside of the liver portal vein
and through the chosen portal vein.
C. A metallic stent is then placed in the
-As portal vein is identified, they can go pathway and secured and the stent is
through the back side of the liver to pierce expanded until pressures are less than or
thru the specific/ chosen portal vein equal to 12 mmHG and the pressure in the
catheter is then removed leaving this shunt
-Guidewire is then passed from the hepaticthere
vein to the Liver parenchyma into the portal
vein and into the splenic and superior COMPLICATTION: TIPS
mesenteric vein, portal and hepatic vein Most Common- restenosis or occlusion of
pressure is then measured to providethe shunt & hepatic encephalopathy - Pt
portosystemic gradient should have ultrasound 24hours before the
procedure to ensure success of this
-After that, 8-10mm in diameter of procedure to establish a baseline
angioplasty balloon is advanced through the measurement for routine follow up
liver parenchyma to span the connection, monitorings
that’s why its called shunt because it creates
connection b/n hepatic and portal vein to Vena Caval Filter Placement
alleviate pressure, stents of grafts are used - The primary purpose of insertion of filter in
to line the parenchymal tract this stents the vena cava is to produced or prevent the
should extend from the both the hepatic and possibility of pulmonary embolus, these
portal veins. other devices simply used to as a filter to
trap an embolus before it reaches the
-After placing the stent or shunt, Betweenpulmonary circulation
these two, repeat hepatic end portal vein- It will not prevent the formation of emboli
and nor it will eliminate the presence of this
emboli or blood clots it’s just used as a filter also indicate that in cases of massive
and any of the emboli that are trapped or pulmonary embolus which requires surgical
designed these device to permanently be interventions, pts w/ dvt are candidate at
placed in the vena cava however a number risk for vcf
of them are actually
removable but the current ones several contraindications primarily related to
types of vena cava filters are available A. patency and access things
Green field filter - Sagittal view B. Green if the vena cava is totally thrombosed of
field filter- Bird’s eye view C. Bird’s nest course filter is then improperly placed,
filter – impractical
D. Bird’s nest filter –
E. LGM vena tech filter Although the inability to gain access to the
F. LGM vena tech filter vena cava would prevent the procedure
G. Simon Nitinol Filter from being done the percutaneous method
H. Simon Nitinol Filter of vessel access is used to introduce the
vena cava filter into the vena cava and
This filters are they have different materials depending upon the type of filter used and
and sizes and whether they’re permanent or pt anatomy variety of routes can be used
removable for example
- the birds nest filter is made up of the primary access route for this procedure
stainless steel, 12 french size placed is via the femoral or the internal jugular
permanently vein other routes includes can also be
- the Greenfield are made of stainless steel translumbar characterization can be
and comes in the sizes of 15 and 28 percutaneous puncture of the subclavian
French sizes they are permanently placed vein or through the veins of the upper
in the body extremity the filter is usually placed in the
- Nitinol and comes in the size of 9 French inferior vena cava
this is actually also placed permanently
but although in cases that of upper
INDICATIONS: VCF extremity vein thrombosis, VCF should be
- DVT- deep vein thrombosis - placed in the superior vena cava, orientation
Pulmonary embolus of this filter should be with the flow, apex of
the filter should placed towards the heart
CONTRA:
- Anticoagulant therapeutic agents Indicated IVC- should be inferior to the renal veins,
if DVT is presented incases w/c Suprarenal placement of filter is used if pt
anticoagulant medication can be has history of renal vein thrombosis, but
discontinued, they can no longer medically ideally, it should be below the renal veins
performed their purpose or their effectivity,
antithrombotic agent medicine used is not Transfemoral approach is actually also
effective anymore favored for this one and once the catheter is
placed in the femoral vein an injection of
contrast media should be made to
determine the status of the inferior vena
cava
PROCEDURE: VCF
1. Once determined the placement of
IVC filter, tip can be advanced to a
position that will place the filter
inferior to the renal vein
Each of the types of filter has its own
method of introduction and discharge
or the upper extremity veins if
superior vena cava and the apex of
the filter should always be Towards
the heart.
4. However, the apex should not be
placed within the right atrium of
course Once in place within the right
atrium, not as common as IVC
Indicated of pulmonary embolus is in upper

You have to read the box of these materials ex.

because our manufacturers are actually the
ones who put the instructions on how the
introduction in discharge of this filters use
their the ones who better mean that it’s very
important to read first the filter kit and should
be familiarize with the deployment
2. Once the filter is in place, another
injection of contrast agent is given to
document the placement of the filter
to confirm its placement the
placement of a filter if naa sa SVC,
3. Generally uses the jugular approach
the filter is removable it can be removed and
another one can be re insert done here in
the case of permanent filters another filter
can be placed above it if permanently
mounting elevation here above the
The general complications of this procedure
are usually associated with the
percutaneous introduction of the filtered
delivery system so this can be extended
expected in large delivery systems if large
delivery systems are going to get more
complications
If smaller delivery systems not mind
complications are now produced other
complications than a includes a procedure
not all can be building or malposition of the
filter making it ineffective in this case is if

Migration of the filter can also occur, one of

the complication of the filter consequences
of this complication or generally not major
significance in each other near the
establishment of baseline Venn diagram is
demonstrated that demonstrating the filter is
important for follow up in case so baseline
vena grandma in Angola or follow up in such
cases