Starting with the Definition, Coverage of field, Seldinger technique, Instruments used in IR we move forward into the embolization Techniques and applications, IR procedures in hepatobiliary system, Portal hypertension, Varicose veins and lastly RFA for bone tumors like ostoid osteoma

1. INTERVENTIONAL RADIOLOGY- An
overview:PART 1
 BY : DR. CHANDNI WADHWANI
Resident doctor
Department of Radiology
SSG HospitalVadodara.
 References:
 RSNA
 Radiographics
 Grainger

2. Agenda
 Definition
 Coverage of field
 Seldinger technique
 Instruments used in IR
 EmbolizationTechniques and applications
 IR procedures in hepatobiliary system
 Portal hypertension
 Varicose veins
 RFA for bone tumors like ostoid osteoma

3. INTERVENTIONAL RADIOLOGY
(Image-Guided Surgery/Surgical
Radiology)
 is a subspecialty of Radiology, in which
minimally invasive procedures are performed
using image guidance
 purely diagnostic purposes (e.g., angiography),
 treatment purposes (e.g., angioplasty).

4.  8 out of 10 procedures use skin incisions smaller than
5 mm.
 9 out of 10 procedures use only local anaesthetic,
sometimes with sedation.
 Up to 8 out of 10 patients go home the same day

5. What kind of things can be done?
 Treatment of vascular problems
 angiogram; angioplasty +/- stenting
 Embolization (blockage) of arteries
 to stop bleeding or treat tumours, etc
 Biopsies
 Drainage of fluid collections
 abscesses, kidneys or bile ducts/gallbladder
 Insertion of feeding tubes
 Treatment of liver tumors, bone tumors,varicose veins,
portal hypertension etc.

6. ANGIOGRAPHY
 The radiologic examination of vessels after the
introduction of a contrast medium.
Post mortem injection of mercury salts in Jan,1896.

7. Seldinger Technique(1953)
 Method for catheterization of vessels
 (through the skin) technique for arterial and
venous access
 3 vessels considered:
 Femoral –preferred site for arterial (size +
accessibility)
 Brachial
 Axillary

8. Prerequisite
 Selection based on
strong pulse / absence
of disease
 Site cleaned, area
draped, local given
Sven-Ivar Seldinger Swedish Radiologist—
1921-1998

9. SELDINGER TECHNIQUE
 Seldinger needle.
 18gauge single use,sterile needle.
 2 parts-- a solid inner needle(stylet) & an outer thin wall
needle for smooth passage.
 a hub---good instrument balance
 winged handle---good control.

13. GUIDEWIRES
 Guide the catheter.
 Allow safe introduction of catheter into the vessel.
 Made of stainless steel.
 Usually about 145 cm long
 An inner core wire that is tapered at the end to a soft
flexible tip.

14.  Covered by a coating—teflon, heparin and recently
hydrophilic polymers(glide wires) are used.
 Coating reduces friction, gives strength to GW.
 Tips at the end of GW
 Straight
 J- tipped—prevents subintimal dissection of artery.

16. CATHETERS
• Many shapes and sizes.
• diameter in French(Fr)—3Fr=1mm.
• Straight- end hole only—smaller vessels/minimal
contrast.
 Pigtail- circular tip with multiple side holes —larger
vessels/ more contrast.
 H1 or Head hunter tip– used for femoral approach to
brachiocephalic vessels.
 Simmons catheter is highly curved --- for sharply angled
vessels--cerebral and visceral angiography.
 C2 or Cobra catheter has angled tip joined to a gentle
curve—celiac, renal & mesenteric arteries

17. Common
catheter
shapes.
6. Rösch celiac
7.Visceral (very similar to
Simmons1)
8. Mickelson
9. Simmons 2
10. Pigtail
11.Tennis racket.
1. Straight
2. Davis (short angled tip)
3. Multipurpose (“hockey-stick”)
4. Headhunter (H1)
5. Cobra-2 (cobra-1 has tighter
curve, cobra-3 has larger and
longer curve);

18. Self Expanding Stent
Have radial force that anchors stent to target vessel as it
deploys.
Can be made of Nitinol that has thermal memory, they reach full
expansion at normal body temperature. Nickel titanium alloy.

19. Balloon Mounted Stent
Mounted over a balloon, expansion of the balloon
Causes deployment of this type of stent.
Precise positioning is required and is more rigid.
These are not placed over joints as can fracture.

20. Stent Grafts
 Stent-grafts represent a combination of stent and
surgical bypass conduit technology. Internal
bypasses.

21. Embolic Protection Devices

22. Trapease Filter Greenfield filter
Endovascular Filters
• Used to prevent pulmonary embolism in patients with DVT in
whom long term therapy is contraindicated. Commonly placed in
infra-renal IVC after confirming negative jet of renal veins.
• Can be permanent or temporary.Temporary filters have to be
removed within 6 weeks to prevent endothelization of the filter.

23. FNAC Needles
 Traditional fine needle aspiration biopsy needles
which harvest cells for cytological evaluation.

24. Biopsy Gun

25. EMBOLIZATION AGENTS:
Deliberate occlusion of a blood vessel
to achieve a therapeutic result.

26. Diverse Usage
 Treatment of tumors
 Varicosities
 Vascular malformations
 Aneurysms and pseudoaneurysms
 Fibroids
 Gastrointestinal bleeding

27. Device selection
 vascular territory to be embolized
 permanence of occlusion
 degree of occlusion—proximal or distal

28. General Embolization Scheme and
Clinical Indications
Vessels Permanent
Temporary
Large vessel
Coils (e.g., pulmonary
AVM)
Gelfoam sponge (e.g.,
trauma)
Small vessel
Particles (e.g., UFE); no
organ death
Liquid agents (e.g.,
renal ablation); organ
death
Gelfoam particles,
fibrillated collagen
(e.g.,
chemoembolization)

29. AUTOLOGUS CLOT
Advantages
 immediate availability
 absence of cost
 lack of adverse reaction.
Method
 aspirate roughly 20 mL of the patient's blood
 allow it to clot
 discard the supernatant
 reintroduce the clot through the catheter
 If desired, the clot can be opacified by adding sterile tantalum
powder.
Drawback :
 Rapid lysis time(recanalization within 6 to 12 hours

30. •proximal occlusion is desired
• Gelfoam "torpedoes" can be formed by compressing and
rolling strips of Gelfoam,
•loaded into the nozzle of a 1- or 3-mL syringe.
Gelfoam Pledgets GelfoamTorpedo

31. Gelfoam Embolization
 temporary occlusion
 lasting 3 to 6 weeks.
Uses:
 embolization of pelvic trauma
 postpartum hemorrhage, (multiple bleeding sites from various
branches of the internal iliac artery.)
 embolization should be initiated with Gelfoam slurry to
achieve a relatively distal level of occlusion
 followed by Gelfoam pledgets or torpedoes.

32. PVA Particles
Used in bronchial artery embolization and Uterine
fibroid embolization etc.

33. PVA Particles
 plastic sponge fragmented and filtered to a certain
size range.
 typical size ranges used clinically are 300 to 500 µm
 Smaller particles -risk of tissue infarction due to their
distal level of occlusion.
 Larger particles-occlude the delivery r

34. Other Particulate agents :
 Microspheres
 Embospheres are precisely calibrated, spherical, hydrophilic,
microporous beads made of an acrylic copolymer, which is
then cross-linked with gelatin.
 The hydrophilic surface prevents aggregation, allowing a
more predictable, uniform vessel occlusion than PVA, as well
as easier delivery through small catheters.
 SIR Spheres (selective internal radiation therapy): Ceramic
microspheres have been embedded with the beta emitter
Yttrium-90.
 hepatic malignancies

35. UTERINE ARTERY
EMBOLISATION(UAE)

36. INDICATIONS:
 FIBROIDS: menorrhagia, pelvic pain, pre op
measure for large fibroids
 Post partum hemorrhage
 DUB
 Adenomyosis
 Uterine artery pseudoaneurysm
 Uterine AVM

37. Uterine artery embolisation
 Day case
 Sedation – Diazepam (5mg/min IV infusion)
 Analgesia - Paracetamol (500mg IV)
 Local anaesthesia - Lidocaine
• Morphine (5mg IV)
• Metoclopramide (10mg IV)

39. Embolic agents:
 Fibroids
o PVA (300-500 microns)
o Embospheres
Post partum hemorhage
o Gelfoam particles
o Glue(n-butyl-
cyanoacrylate)

40. Pre and Post Uterine Fibroid Embolization
Use of PVA Particles

41. Bronchial artery embolisation
 Done for uncontrolled hemoptysis in:
1. Neoplasms
2. Bronchiectasis
3. Infections likeTB, necrotisng pneumonia,
aspergilloma, abscess.
4. Bronchial AVM
5. Vasculitis like wegener’s granulomatosis/ behcet’s
disease.

42. Use of PVA Particles

43. Coils
 stainless steel guide wires onto which strands of wool had
been woven to add a matrix for thrombus formation.
 for high-flow applications due to their high radial force, which
helps prevent dislodging.
 Platinum coils are highly visible under fluoroscopy
 much softer than stainless steel
 facilitates accommodation of the coil to the vessel.
 Appropriate sizing is important to ensure occlusion of the
vessel at the intended location.

44. Detachable Coils
Used in Intracranial Aneurysm Coiling.
Gugliemi detachable coil : Coil is welded to the pusher wire in the desired position, the
wire is attached to a battery device that sends a current along the wire.The current
melts the welded connection between the coil and the wire and detaches the coil
without any force. GDCs are mainly used for treatment of intracranial aneurysms

45. Endovascular Coiling of Intracranial
Aneurysms

47. Pushable Coils
Used in Peripheral Embolization.

48. Uses
 coils produces a focal occlusion
 leaving the vessel distal to the coil patent(surgical
ligature)
 precise vessel occlusio-but not tissue ablation
 Applications :
 treatment of hemorrhage
 occlusion of arteriovenous fistulas
 preoperative or pre-stent graft vessel occlusion.

49. Liquid – Onyx
 consisting of ethylene vinyl alcohol copolymer
dissolved in dimethyl sulfoxide
 Onyx contains tantalum powder to render it
radiopaque.
 After Onyx is injected into the target lesion, the
dimethyl sulfoxide solvent rapidly diffuses away,
causing precipitation of the polymer and formation
of a spongy cast.
 The cast solidifies
 Onyx allows a prolonged, controlled embolization
because of its non-adhesive nature.
 Cerebral and Peripheral AVM embolization

50. Liquid - Polymers
Used for embolization of Cerebral AVMs,
Peripheral AVMs.

51. Glue
 n butyl cyanoacrylate.
 permanent rapidly acting liquid
 that will polymerize immediately upon contact with ions. It
also undergoes an exothermic reaction which destroys the
vessel wall.
 polymerization is so rapid, it requires a skilled surgeon.
 During the procedure, the surgeon must flush the catheter
before and after injecting the NBCA, or the agent will
polymerize within the catheter.
 The catheter must also be withdrawn quickly or it will stick to
the vessel.
 Oil can be mixed with NBCA to slow the rate of
polymerization.

52. INTERVENTION IN HEPATOBILIARY SYSTEM:
I. HEPATIC MALIGNANCIES
II. BILIARY OBSTRUCTION: Benign or
malignant
III. PERCUTANEOUS CHOLECYSTOSTOMY
IV. PERCUTANEOUS MANAGEMENT OF
BILIARY CALCULI
V. PERCUTANEOUS MANAGEMENT OF
PORTAL HYPERTENSION

53. Interventional treatments for
liver tumours:
1. Chemical ablation with ethanol or acetic
acid.
2. Transcatheter arterial
chemoembolisation(TACE)
3. Transcatheter arterial embolisation(TAE)
4. Transcatheter arterial radionuclide
therapy(TART)
5. Right portal vein embolisation
6. Hepatic vein stenting

54. TACE(Transcatheter Arterial
Chemo Embolisation):
 A targeted therapy for HCC confined to liver.
 Involves intra arterial delivery of high
concentration of chemotherapeutic agent
emulsified with lipiodol combined with a
embolic agent.

56. Principle:
 Based on the differential supply to liver and
tumour.
 In non tumour liver, portal vein supplies 75 to
83% of blood, hepatic artery supplies only
20%
 In HCC, hepatic artery supplies 90 to 100% of
blood.

57. Candidates:
 Palliative treatment for unresectable HCC
 Patients on transplant list
 Prior to RFA
 Residual tumours
 Patients with metastaic neuroendocrine
tumours in liver

58. Contraindications:
 Absolute:
 Extensive liver disease
 Encephalopathy
 Large burden metastatic lesions outside liver

59. Relative CI:
 Borderline liver function
 total bilirubin>4mg/dL
 Serum creatinine> 2mg/dL
 Portal vein thrombosis
 Uncorrectable coagulopathy
 Poor general health
 Significant AV shunting through tumour
 Analpylactic reaction to contrast

60. CHEMOTHERAPAEUTIC AGENTS:
 Mitomycin C,Doxorubicin, cisplatin,
adriamycin, epirubicin
 Mixed with lipiodol to form an emulsion
 LIPIODOL(iodine containing lipid 38%by
weight)
 Drug targeting effect of lipiodol- increases
concentration.
 Slow release of drug from emulsion- prolong
contact time of tumor cells to drug

61. LIPIODOL
 Made from iodine and poppyseed oil
 highly viscous agent
 used for chemoembolizations, especially for
hepatomas, since these tumors absorb iodine.
 The half life is five days,
 temporarily embolizes vessels.

62. EMBOLISATION AGENT:
 PVA particles or Gelfoam.
 Synergistic effect of tumor necrosis due to
ischemia
 Slow blood flow: increases contact time.
 Ischemia induces transmembrane pump-
greater absorption of drug.

63. Follow up: CT or MRI
 Reduction in size
 Amount of necrosis
 Lipiodol retention

64. Post TACE CT Image:

65. RFA:
 Percutaneous image guided technique which
induces tumor necrosis by deposition of
thermal energy around the tip of electrode
inserted in the tumor.

66. PRINCIPLE:
 AC current is passed through probe with
energies ranging from 60 to 100W for a
period of 6-12 minutes.
 Rapid change in polarity of current results in
fast oscillations of intracellular molecules,
which in turn causes friction and heat
generation.
 Local temparature of >60 degrees is
maintained for more than 5 minutes.

67. Indications:
 Small HCC(less than 5 cm)
 Metastasis lesions (less than 5 in number)
 Patients in whom surgery is contraindicated
 To reduce size of tumor inTACE candidates

68. Contraindications:
 Large lesions
 Multiple metastatic lesions(>5)
 Close to liver capsule or gall bladder(<1 cm),
increases chances of peritonitis and
cholecystitis
 Tumors very close to main branches of portal
and hepatic vein

70. COMPLICATIONS:
 Severe pain
 Hemorrhage
 Peritonitis
 Cholecystitis
 Colitis
 Vascular injury
 Thrombosis
 Tumour seedling (avoided by ablating the
tract)

71. Follow up:
 To assess the degree of necrosis and
completeness of ablation.
 Shows a hypodense non enhancing area,
corresponds to necrosis.
 A thin peripheral hyperemic rim may be seen,
which represents inflammatory reaction to
thermal injury(dissappears within a month)

72. Results:
 Response is inversely proportionate to the
size of tumour.
 Less than 2 cm: 85% response
 Tumour of 3 cm: 35% response rate

73. Biliary interventions :
1. Percutaneous or endoscopic (ERCP)
2. Percutaneous transhepatic cholangiography
(PTC)
3. Percutaneous transhepatic biliary drainage
(PTBD)
4. Biliary stenting for benign stricture
5. Percutaneous cholecystostomy (PC)
6. Extraction of biliary calculi

74. ERCP

75. ERCP
The diagnostic procedure of choice for
abnormalities of the biliary and pancreatic
ducts offers options of intervention:
 Stone extraction
 Sphincterotomy
 Placement of stents

76.  A side viewing endoscope is advanced into
the descending duodenum the papilla of
Vater is identified and cannulated contrast is
injected to visualize the pancreatic duct and
biliary duct systems

77. Causes for ERCP failure include:
 Upper GI stricture/stenosis
 Complete ductal obstruction limiting
retrograde filling
 Postsurgical biliary-enteric fistula
 Technical failure
MRCP is an effective alternative when ERCP is
unsuccessful

79. Percutaneous Transhepatic
Cholangiography
 Old reliable
 Accurate technique for defining the site of
obstruction
 Provides option of tissue biopsy and/or
intervention with drain or stent
 Has been largely replaced by non-invasive
techniques

80. Biliary Internal – External Drain
This has proximal as well as
distal drainage holes that allow
drainage of bile proximal to
lesion externally.
If the drain is internalized, that
is the lesion is crossed and
distal end is placed in the
duodenum then bile is drained via
the proximal holes into the
Duodenum via distal holes.
Chiba Needle
Used to gain access
to bilary ducts.
This can be done
under Fluoroscopic
Or USG guidance.

81. Indications
 Failed ERCP / ERCP not feasible (e.g. patients
with gastrojejunostomy)
 Biliary system delineation in presence of intra
and extrahepatic biliary calculi
 To identify obstructive cause of jaundice; and
differentiate from medically treatable cause
 Anatomic evaluation of complications of ERCP
 Delineating bile leaks

82. Contraindications
 Bleeding diathesis
 Gross ascites

83. Technique
 Standard technique:Thin needle puncture in ninth
or tenth intercostal space
 Contrast injected during slow withdrawal of the
needle under fluoroscopic guidance
 When duct placement confirmed, additional
injection
 Films taken in AP, right and left oblique

85. PTBD(percutaneous
transhepatic biliary
drainage)
Surgical resection offers potential for cure but is rarely
possible
Palliation alternatives:
1. Surgical bypass
2. Percutaneous drainage
3. Endoscopic or percutaneous stent placement

86. Three types of drains
1. External – does not cross obstruction, drains
percutaneously
2. Internal-external – bile in obstructed
segment enters through the side holes of
the catheter and emerges beyond the
obstruction; the external segment can be
capped
3. Internal – drains only into enteric system

88.  METALLIC STENTING(benign stricture)
 INDICATIONS
 ALL SURGICAL OPTIONS ARE EXHAUSTED AND DILATATION
HAVE FAILED
 PROCEDURE
 Gianturco stent no 8, 10, 12 mm
 Via percutaneous transhepatic route via existing t- tube
 Catheter placed over wire and contrast injected via side
adapter
 Dilator passed along the stricture and followed by small peel
away introducer
 Introducer peeled away with the self retaining stent in place

89. Metallic stent placement in a
patient with benign stricture

90. Percutaneous cholecystostomy
 Image-guided placement of drainage
catheter into gallbladder lumen.This
minimally invasive procedure can aid
stabilization of a patient to enable a more
measured surgical approach with time for
therapeutic planning.

91. Indications
 poor surgical candidate/high risk patients
with acute calculous or acalculous
cholecystitis.
 unexplained sepsis in critically ill patients
(Diagnostic for cholecystitis as etiology of
sepsis if clinical improvement after
cholecystostomy).
 access to or drainage of biliary tree following
failed ERCP and PTC.

92. Contraindications
Absolute contraindications
 usually none
Relative contraindications
 bleeding diathesis: all attempts should be
made to correct coagulopathy.
 ascites
 gallbladder tumor that might be seeded
 gallbladder packed with calculi preventing
catheter insertion

94. PERCUTANEOUS CHOLECYSTOLITHOTOMY (PCCL)
Direct
percutaneous
extraction of
stone fragments
and removal of
stone after stone
fragmentation or
contact
dissolution

95.  TRANSJUGULAR
INTRAHEPATIC
PORTOSYSTEMIC
SHUNTS (TIPS)

96. TIPSS
 is a percutaneously created connection within
the liver between the portal and systemic
circulations.
 ATIPS is placed to reduce portal pressure in
patients with complications related to portal
hypertension.

97. DIAGRAMMATIC REPRESENTATION OF TIPS
PLACEMENT

98. OBJECTIVE
 to divert portal blood flow into the hepatic vein,
so as to reduce the pressure gradient between
portal and systemic circulations.
 Shunt patency is maintained by placing an
expandable metal stent across the intrahepatic
tract.(created under image guidance)

99. TIPSS

100. Steps in a TIPS procedure

102. ABSOLUTE CONTRAINDICATIONS
 Right-sided heart failure with increased central
venous pressure
 Polycystic liver disease
 Severe hepatic failure

103. RELATIVE CONTRAINDICATIONS
 Active intrahepatic or systemic infection
 Severe hepatic encephalopathy (poorly
controlled with medical therapy)
 Hypervascular hepatic tumors
 PV thrombosis

104. Shunt surveillance
 at regular 3 to 6month intervals
 Assessment of:
 MORPHOLOGY
 Ascites
 Portosystemic collaterals
 Size of spleen
 Diameter of stent (usually 8 to 10 mm)
 Configuration of stent: areas of narrowing
 Extension of stent into portal + hepatic veins

106. Doppler Criteria for compromised TIPS function
1. Shunt velocity of <50 cm/sec
2. Increase or decrease in shunt velocity of
>50cm/sec compared with initial post-
procedure value
3. Hepatofugal flow in main portal vein

107. COMPLICATIONS
(A) Obstruction to flow
Shunt obstruction (38%)
Hepatic vein stenosis
(B)Trauma
(a)Vascular injury
Hepatic artery pseudoaneurysm
Arterioportal fistula
Intrahepatic/subcapsular hematoma
Hemoperitoneum (due to penetration of liver
capsule)

108. (b)Biliary injury
Transient bile duct dilatation (due to
hemobilia)
Bile collection
(C) Stent dislodgment with embolization to right
atrium, pulmonary artery, internal jugular vein .

111. ENDOVENOUS THERMAL
ABLATIONS
•endovenous laser therapy (EVLT)
• radiofrequency ablation (RFA).

112.  local anesthesia
 placement of a percutaneous catheter in the
affected vein while being guided by
ultrasonography.
 The abnormal venous segment is treated by
occluding it through the delivery of heat with
a percutaneously placed laser fiber in EVLT
and a radiofrequency catheter in RFA,
resulting in endothelium destruction and
fibrotic occlusion of the vein in both.

113. Endovenous laser treatment
 using an optical fiber that is inserted into the
vein to be treated
 laser light, normally in the infrared portion of
the spectrum, shines into the interior of the
vein.
 This causes the vein to contract, and the
optical fiber is slowly withdrawn.
 Dilute local anesthesia is injected around and
along the vein.

114. MECHANISM of RFA:
 Using a bipolar RFA probe
 delivers radiofrequency energy(RF waves) to
vein walls.
 RF energy creates conductive heating that
contracts the vein wall causes shortening and
thickening of collagen fibrils and vein lumen
diameter shrinkage and fibrotic sealing of the
vein.

115. RADIOFREQUENCY ABLATION DEVICE:
Bipolar RFA probe, both the electrodes are in the same probe with an insulator
between the electrodes.
Radiofrequency generator unit.

118. PURPOSE OF TUMESCENT
INFILTRATION:
 Compresses vein around heating element.
 Creates depth between skin surface and
anterior vein wall.
 Produces heat sink to protect perivenous
tissue from thermal injury.
 Serves as anaesthesia

121. INDICATIONS:
Patients with superficial reflux disease.
CONTRAINDICATIONS:
Patients with thrombosis in the vein segment to
be treated.

122. Complications of RFA or EVLA
 Minor complications
 bruising (51%),
 hematoma (2.3%),
 temporary numbness (3.8%),
 phlebitis (7.4%),
 induration (46.7%),
 sensation of tightness (24.8%).
 serious complications
 skin burns (0.5%),
 deep venous thrombosis (0.4%),
 pulmonary embolism (0.1%),
 and nerve injury (0.8%).

123. ADVANTAGES:
 Quicker procedure
 Local anaesthetia
 Cheaper
 Obviates need for admission to hospital
 Less morbidity
 Faster return to normal activities.
 Useful alternative to surgical procedures.

124. Sclerosing Agents
 Cause protein denaturation, leading to
endothelial destruction and vascular occlusion.
Occlusion by sclerosants is usually permanent.
 Sodium tetradecyl sulphate (Setrol) and
Polidocanol
 Uses : ablation of tumors, solid organs, veins, or
vascular malformations.

127. RFA in osteoid osteoma