Interventional

Radiology

Aaroh Parikh, MD
R5 Radiology Resident
•What is Interventional Radiology?

•History of IR

•Discussion of selected techniques

•Interesting cases
• A subspecialty of
Radiology
• We use imaging guidance to
perform a wide range of
minimally invasive
procedures.
• Vascular vs. non-vascular
• Diagnostic and
interventional.
• ACGME Accredited
Residency Program
Breadth of the field
• Diagnostic angiography
• Peripheral (PAD)
• Visceral (GI bleeds, mesenteric ischemia)
• Cerebral (Stroke, aneurysms, AVMs)
• Vascular intervention
• Angioplasty (Atherosclerosis, fibromuscular dysplasia)
• Stent placement (Stenoses, aneurysms)
• Embolization (Liver tumors, Uterine Fibroids, BPH)
• Non-vascular intervention
• Tumor ablation
• Biliary Intervention
• Biopsies
• GI, GU interventions
 1953 – Seldinger Technique

 1964 - Angioplasty
 - Charles Dotter
• Patient: 82 y/o F severe PAD,
refusing amputation.
• Undergoes first endovascular
treatment of PAD
• To surgeon’s disbelief
• pain ceased
• ambulation improved
• 3 "irreversibly" gangrenous toes
spontaneously sloughed and healed.
• She left the hospital on her feet—both
of them.
 1969 – Catheter-delivered stent

 1977-83 Bland- and chemo-

embolization for treatment of
hepatocellular cancer and liver
metastases

 1974 – Catheter directed

thrombolysis

 1980 – Cryoablation

 1982 – TIPS (transjugular

intrahepatic portosystemic shunt)

 1990 - Radiofrequency ablation

(RFA) technique for tumors

 1991 - Abdominal aortic stent

grafts
• Vascular
• Arterial
• Venous
• Oncology
• GI/GU
• Neuro
• Pediatric
• Reproductive
• Dynamic vascular imaging
with iodinated contrast

• DSA = Digital Subtraction

Angiography.

• Cerebral, visceral,
extremity
 Many advances in
cerebral
angiography/thrombect
omy
 tPa window : 4.5 hours
 Contraindications:
 Intracranial
hemorrhage on ct
 Recent Neurosurgery (3
mo)
 GI hemorrhage (3
weeks)
• Opens blood vessels or other
structure by controlled
inflation of balloon

• Variety of applications-
arterial, venous, biliary, GU
• Metallic scaffold to maintain patency of tubular structures
• Vascular, Biliary, GI applications
• A COVERED stent in a blood vessel to create a new vessel
wall
• such as to cover an aortic aneurysm
• Synthetic material – PTFE
• Coils
• Glue
• Foam Pledgets
• Beads
• Etc
 • Emergent- Postpartum hemorrhage
• Elective- Symptomatic uterine fibroids
• Menorrhagia
• Bulk symptoms (dull pelvic pain, dyspareunia, urinary
frequency, constipation)

http://www.google.com/imgres?imgurl=http://3.bp.blogspot.com/_gbV7B6quyNY/Sf8tofvAXcI/AAAAAAAAAwg/yFEGgNJt5pI/s400/Condoleezza.jpg&imgrefurl=http://commonsense-gater.blogspot.com/2009_05_01_archive.html&usg=__Lx_iNvdJvpte3mOJWMLt5ckK_48=&h=297&w=225&sz=18&hl=en&start=0&zoom=1&tbnid=FZl3qkm2yZbjEM:&tbnh=129&tbnw=127&ei=CeE-
TtjtGpTHsQLG9-g_&prev=/search%3Fq%3Dcondoleezza%2Brice%2Bufe%26um%3D1%26hl%3Den%26sa%3DN%26biw%3D1536%26bih%3D710%26tbm%3Disch&um=1&itbs=1&iact=rc&page=1&ndsp=29&ved=1t:429,r:3,s:0&tx=63&ty=99&biw=1536&bih=710
Normal
Early Late
• 67 y/o female with bleeding duodenal ulcer,
refractory to endoscopic treatment
• Prevention of pulmonary embolism
• Pts with venous thromboembolic disease and
contraindication to, complication of, or failure of
pharmacologic anticoagulation
• Prophylactic- trauma pts with high risk of DVT due to
immobilization and contraindication to pharmacologic
prophylaxis
• >90% of filters placed at BT are retrievable
• Once patient may be safely anticoagulated and is in
therapeutic range
• Once patient has returned to baseline risk for
venous thromboembolic disease
 Pain, infertility
 Valvular incompetence
• Peripheral venous outflow stenosis most common
• Balloon angioplasty is first line treatment
• Long term access
• Antibiotics,
Chemotherapy
• Hemodialysis
• Apheresis
• Endovascular (TACE, Y90 radioembolization)
• Ablative (radiofrequency, microwave, cryoablation)
• Palliative vs. curative vs. downstaging/bridging to
liver transplant
• Direct delivery of chemotherapy and embolic to
tumors
• HCC, hepatic metastases (CRC)
 Glass or resin microspheres
impregnated with Y90, Beta
emitter

 Intra-arterial delivery of
radioactive particles
 Maximum range in tissue ~1
cm

 Similar technique to
chemoembolization
 Pass electrical current in the
range of radiofrequency
waves between the needle
electrode and the grounding
pads placed on the patient's
skin.

Coagulative necrosis of tumor

cells

 Commonly for HCC, liver

metastases, RCC, osteoid
osteoma
1 month follow up MRI- no residual enhancing tumor
• Vertebral augmentation (kyphoplasty,
vertebroplasty)
• Biliary drainage
• GU interventions
• GI interventions
• Biopsy
• Percutaneous fluid drainage
• Treatment of painful compression fractures
• Reduction of portal-systemic venous pressure gradient
 Calculi, tumor, iatrogenic stricture
 Percutaneous nephrostomy/nephroureteral catheter

Percutaneous nephrostomy
• Feeding tube inserted through abdominal wall
 Tissue sampling for
diagnosis

 Ultrasound, CT,
fluoroscopic, MRI
guidance
• 44M with RLQ pain
• Need safe “window.”

• Positioning, patient
breathing very important.

• Successful CT-guided
percutaneous drain
placement.
There is no patient, no organ system, no disease, nor any
medical subspecialty which does not directly benefit from
expertly delivered clinically oriented image guided
intervention.
• Barry Stainken, Former SIR President
• Uterine artery embolization as a treatment option for uterine myomas. Obstet Gynecol Clin
North Am. 2006 Mar;33(1):125-44. Review.
• The management of uterine leiomyomas. J Obstet Gynaecol Can. 2003 May;25(5):396-418.
• Uterine fibroid embolization: nonsurgical treatment for symptomatic fibroids. J Am Coll Surg.
2001 Jan;192(1):95-105.
• Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization. (Pelage et
al.) Radiographics. 2005 Oct;25 Suppl 1:S99-118.
• Long-term follow up of uterine artery embolisation--an effective alternative in the treatment of
fibroids. BJOG. 2006 Apr;113(4):464-8.
• Imaging manifestations of complications associated with uterine artery embolization.
Radiographics. 2005 Oct;25 Suppl 1:S119-32.
• Uterine artery embolization of symptomatic uterine fibroida . Initial success and short-term
results. Acta Radiol. 2001 Mar;42(2):234-8.
• Risk of intrauterine infectious complications after uterine artery embolization.
J Vasc Interv Radiol. 2004 Dec;15(12):1415-21.
• Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment--a
prospective, randomized, and controlled clinical trial. Radiology. 2003 Feb; 226(2):425-31.
• Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current
status. Eur J Radiol. 2005 Apr;54(1):136-47.
• Embolization of uterine fibroids (Helmberger). Abdom Imag. 2004 Nov; 29:267-277.
• Comparability of perioprative morbidity between abdominal myomectomy and hysterectomy for
women with uterine leiomyomas. Am J Obstet Gyn. 183:1448-1455.