Role of IR in treatment of Varicose veins and Bone lesions. Newer modality: HIFU Videos on Embolization techniques, role of IR in hepatobiliary system and in portal hypertension.

1. INTERVENTIONAL RADIOLOGY-II
 BY : DR. CHANDNI WADHWANI
Resident doctor
Department of Radiology
SSG Hospital Vadodara.
 References:
 RSNA
 Radiographics
 Grainger

2. Agenda
 Definition
 Role in treatment of Varicose veins
 Bone lesions
 Newer modality: HIFU
 Videos :Embolization
 hepatobiliary system
 Portal hypertension

3. INTERVENTIONAL RADIOLOGY
(Image-Guided Surgery/Surgical
Radiology)
 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. VARICOSE VEINS:
1. THERMALABLATION
2. SCLEROTHERAPY

5. ENDOVENOUS THERMAL
ABLATIONS
•Endovenous laser therapy (EVLT)
• Radiofrequency ablation (RFA).
The abnormal venous segment is treated by occluding
it through the delivery of heat
Percutaneously placed laser fiber in EVLT and a
radiofrequency catheter in RFA

6.  Local anesthesia
 Placement of a percutaneous catheter in
the affected vein
 Guided by ultrasonography.
 Endothelium destruction
 Fibrotic occlusion of the vein

7. Endovenous laser treatment
 Uses 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
 Optical fiber is slowly withdrawn.
 Dilute local anesthesia is injected around and
along the vein.

8. RFA(radio frequency ablation):
 Using a bipolar RFA probe
 Delivers radiofrequency energy(rf waves) to
vein walls.
 Rf energy creates conductive heating
 Contracts the vein wall
 Shortening and thickening of collagen fibrils
 Vein lumen diameter shrinkage and fibrotic
sealing of the vein.

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

12. 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

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

16. 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%).

17.  Serious complications
 Skin burns (0.5%),
 Deep venous thrombosis (0.4%),
 Pulmonary embolism (0.1%),
 And nerve injury (0.8%).

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

20. Closurefast catheter:
 Heats vein in 7 cm segments
 20 sec treatment cyscles
 Vein shrinkage and occlusion
 93% success rates at 3 yr post treatment.

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

24. Bone lesions:

25. RFA in osteoid osteoma

26. Vertebroplasty and
kyphoplasty:
 Image guided procedure which entails
perutaneous injection of surgical
polymethylmethacrylate/ cement into
diseased vertebra.
 Pain relief
 Strengthening of vertebra weakened by
disease

27. Indications:
 Fracture of vertebra
 Hemangioma
 Multiple myeloma
 Metastates in vertebra

28. Complications:
 Leakage of vertebroplasty:
• Compression of adjacent structures
• IVC(inferior vena cava) syndrome
 Cement extravasation:
• Cement pulmonary embolism
• Extravasation into paravertebral veins

30. ROLE OF INTERVENTIONAL
RADIOLOGY IN URINARY SYSTEM

31. PERCUTANEOUS NEPHROSTOMY
 It is a basic technique in interventional
uroradiology which provides a direct
access to urinary tract for diversion of
urine.

32. PCN

33. INDICATIONS
1. SUPRAVESICAL URINARYTRACT OBSTRUCTION
 Calculi
 Neoplasm
 Ureteral stricture
 Pyonephrosis
2. Urinary diversion in leak or fistula
3. Access for subsequent intervention
 Antegrade ureteral stenting
 Nephrolithotomy/nephrolithotripsy
 Stone dissolution
 Biopsy of urothelial lesion
 Foreign body removal

34. Contraindications:
 Relative:
coagulopathy
(should be corrected prior to procedure)
 Absolute :
Nil

36. Complications:
 Systemic:
• Sepsis(pyelovenous reflux)
 Local:
• Bleeding(transient hematuria is seen upto 24
hours)

37. Uterine artery embolisation:

38.  which uses focused sound energy to
heat tissue to destroy it
HIFU
( high intensity focussed
ultrasound)

39.  At the focal point of the transducer,
ultrasound energy is concentrated
 absorbed by the tissue
 generates temperatures that can exceed
80° C
 Results in coagulative necrosis and the
destruction of tissue.

40. HIFU Technology
 High-energy ultrasound waves to destroy tissue at focal
point of a transducer
 Without injuring the intervening tissue.
 Strong ultrasound waves in the inaudible sound range
 10,000 times stronger than diagnostic ultrasound are
generated
 This focal point is located 3 to 4 cm distant from the
transducer
 Its size and shape is dependent on the
 energy emitted by the transducer
 geometric configuration of the transducer
 characteristics of the tissue.

41. Technique:
 General or regional anaesthesia.
 A transducer probe placed in a balloon filled with liquid (cooled or
room temperature)
 Inserted into rectum (serves as an acoustical interface and to cool
the rectal wall)
 There are two transducers on these devices
 Low-energy transducers (3 to 4 mHz) for imaging
 High-energy transducers for treatment.
 The prostate is imaged (sagittal and coronal)
 Target treatment zone is outlined.
 There is a treatment cycle in which the treatment zone is heated and
then a cooling period during which the computer-controlled device
moves to the next treatment zone distant from the first.

42. HIFU in prostate lesions:

43. Indications:
Ideal indications for HIFU as primary therapy are:
 Older patients (≥70 years) with clinical stage T1-T2 N0 M0
prostate cancer
 Gleason score < 7
 PSA < 15 ng /ml
 Prostate vol < 40 ml
 Particularly if patient refuses/unsuitable for radical
therapy
 In this situation a lymph node evaluation is unnecessary
and best chance for local control of cancer seems to be
present.

44. HIFU IN PROSTATIC CANCER:

45. Advantages:
 Precision.
 Unique for localised prostate cancer
 Lack of adjacent tissue damage
 HIFU is a repeatable technology
 Prostate gland retains its general anatomic
configuration
 Shrinks to a small size (≈15 ml) over 3 to 6 months
post therapy.
 Post-hifu biopsies show fibrosis only.

46. GENERAL CLINICAL USE of HIFU
 Spleen, liver, kidney, breast, uterus, and bone
 most well studied in treatment of prostatic
conditions
 HIFU currently has FDA approval for the
treatment of uterine fibroids
 2 HIFU devices are available for the treatment
of prostate:- Ablatherm and Sonoblate -500

47. Limitation:
 HIFU has not been widely used for the
treatment of symptomatic BPH
 relatively invasive nature in comparison to
other thermal-based modalities such as
microwave and radiofrequency ablation.
 HIFU does not have USFDA approval.

48. Safety
 MC complications after primary therapy with HIFU are
 UTI
 SUI
 ED
 Rectal burn and rectourethral fistula/Retention
 Stenosis or strictures (Urethral/bladder neck)
 The use of TURP before HIFU also significantly decreases incidence
of SUI, UTI, stenosis / strictures and BOO requiringTURP.
 TURP is therefore indicated before HIFU. But this does not have any
affect on disease control

49. HIFU in Localized Prostate Cancer
 Madersbacher and colleagues (1995) were the first to examine the
feasibility of HIFU for treatment of localized prostate cancer.
 They demonstrated that HIFU resulted in a sharply demarcated
lesion
 with no treatment effects in areas immediately adjacent to the
treatment zone
 no heat damage was noted to rectum/neurovascular bundle
 even though HIFU was extended to prostatic capsule

50.  HIFU- as a body slimming
agent

52. HIFU IN SKIN LIFTING

54. Embolisation for cerebral aneurysm

55. TACE for hepatic tumors:

56. TIPSS for portal hypertension:

57. Biliary drainage:

58. THANK YOU
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