5.DIAGNOSTIC AND THERAPEUTIC VASCULAR INTERVENTIONAL STUDIES.pptx By Ravindra Kumar.pptx

Interventional radiology is a medical sub-specialty of radiology utilizing minimally-invasive image-guided procedures to diagnose and treat diseases in nearly every organ system.
The concept behind interventional radiology is to diagnose and treat patients using the least invasive techniques currently available in order to minimize risk to the patient and improve health outcomes.
These procedures have less risk, less pain and less recovery time in comparison to open surgery.
A cerebral angiogram is a neurological test which evaluates the blood vessels that supply the brain.

Using the Seldinger technique , Picard catheter is advanced in the arch of aorta from where selective catheterization of internal carotid artery of both the sides as well as vertebral arteries of both sides is performed.
The Common femoral artery (CFA) is the simplest and safest arterial access route because:
Large
Superficial
Usually disease free
Can be compressed easily against the head of femur to close the puncture.The CFV usually lies 0.5 to 1.5 cm medial to the CFA.
The skin entry is made just medial to the arterial pulse and just below the bottom of femoral head.
A single wall needle is preferred to avoid unknowingly passing through the artery before entering the vein. Otherwise an arteriovenous fistula could result.
The Seldinger technique is used for percutaneous arterial catheterization. It involves the use of a
Needle
Vascular sheath set,
Guidewire,
Catheter.
The first agent used for Embolotherapy was autologous blood clot. This was easily and quickly obtained and was inherently biocompatible.
Silk threads were also historically used as embolic agents, notably for intracranial vascular malformations.
Today, these old agents are replaced with the advent of modern liquid and particulates.
Trans jugular Liver Biopsy (TJLB)
Trans arterial chemoembolization (TACE)
Trans arterial Radioembolization (TARE)
Trans jugular Intrahepatic Portosystemic Shunt (TIPS)
Sclerotherapy.
Interventional Radiology procedures are minimally invasive, targeted treatments performed using imaging for guidance.
These procedures have less risk, less pain and less recovery time compared to open surgery.
The risk is involved with radiation so appropriate radiation protection should be taken.

1. Diagnostic & Therapeutic Vascular Interventional Studies Department Of radiodiagnosis and imaging, pgimer, Chandigarh 1 Ravindra kumar M.SC. Medical Technology (Radiodiagnosis and imaging) PGIMER Chandigarh, India PRESENTER RAVINDRA KUMAR TECHNOLOGIST

2. Contents Introduction Imaging Modalities Material Required Cerebral angiography Cerebral angioplasty Embolization Occlusive Agents Trans jugular Liver Biopsy ( TJLB) Trans arterial chemoembolization (TACE) Trans arterial Radioembolization (TARE) Trans jugular Intrahepatic Portosystemic Shunt (TIPS) Sclerotherapy Conclusion References 2

3. Introduction Interventional radiology is a medical sub-specialty of radiology utilizing minimally-invasive image-guided procedures to diagnose and treat diseases in nearly every organ system. The concept behind interventional radiology is to diagnose and treat patients using the least invasive techniques currently available in order to minimize risk to the patient and improve health outcomes. These procedures have less risk, less pain and less recovery time in comparison to open surgery. 3

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6. Imaging Modalities 6

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11. Puncture Needle (18G) Vascular sheath Guide wire Catheter Surgical Blade Contrast media Material Required 11

12. Local Anesthesia Anticoagulant (Heparin) Disposable / Luer lock syringes Cannula (16G T0 24G) Saline Gloves 12

13. Sterile Trolley Setup Access needle. Vascular sheath set Luer lock syringe Kidney tray x 2 Guide wire 0.017” and 0.035 inch Catheter 5-7F STENT AND COIL Gauze piece 13

14. Non Sterile Trolley Setup Betadine (Skin Cleanser) Contrast Media (LOCM – Non Ionic) Local Anesthesia Normal Saline Anti – Coagulant (heparin) Anti – Spasmodic (Priscol) Elastoplast 14

15. Vascular Sheaths Sheaths are placed when lengthy vascular interventions and multiple catheter/guidewire exchanges are anticipated. They provide a safe passage of guidewires and catheters into the artery . Sheaths can also be placed to control persistent oozing or hematoma at the arterial access site. Sheaths are composed of an inner stiffener and outer thin wall. The inner stiffener is present to prevent buckling during insertion and is removed once access has been established. 15

16. They also have a valve at the proximal end to prevent free backflow. A side arm is available for injection of contrast. Vascular access catheter consisting of sheath with a side arm and inner dilator. 16

17. Guidewires Guidewires, as the name implies, are used primarily to direct catheters into specific locations within a blood vessel, cavity, or organ. Guidewires mainly differ in length, diameter, stiffness, tip characteristics, and pliability. The exterior may be hydrophobic or hydrophilic . Standard guide wires come in 0.035 or 0.038-inch diameters. Micro guidewires are available for micro catheters or small gauge needles. Choice of guidewire is based on the preference of the Radiologist and procedure being performed. 17

18. 18

19. Catheters An angiography or diagnostic catheter is intended for use in angiographic procedures. It delivers radiopaque media and therapeutic agents to selected site in the vascular system. It is also used to lead a guidewire or a micro catheter to the target site. HH COBRA COBRA RUC SIM2 SIM1 SIM3 19

20. PIGTAIL PICARD COBRA HEAD HUNTER SIMMONS CATHETER BALLOON CATHETER 20

21. NAME OF CATHETERS CHARACTERISTICS USES PIGTAIL ( 3F – 8F ) Multiple side holes Flush angiogram PICARD ( 5F ) End holes - Tip is angled at 100 forward facing the bronchial arch Cerebral angiography COBRA ( 3F – 7F ) It has angled tip jointed to a gentle curve Celiac , renal ,mesenteric vessels RENAL DOUBLE WIRE 2 curves Renal vessels HEAD HUNTER ( 3F – 7F ) 3 curves Femoral arch to brachiocephalic vessels SIMMONS CATHETER ( 4F – 6F ) Highly curved and Sharply angled vessels Cerebral and visceral angiography SLIP CATHETER( 4F – 6F ) Special hydrophilic coating Coronary angiography BALLOON CATHETER ( 7F – 9F ) Balloon mounted close to distal end Balloon angioplasty 21

22. Balloons Inflatable balloons are used to open stenosis within vessels, or other parts of the body. Using an inflation device, the balloon can be inflated or deflated to a measurable pressure using air, saline, or contrast. It causes a controlled stretch injury to the lumen, which then scars into place. Balloons differ by diameter, length, shape, burst pressure, surface, and pliability. Balloons are also used to expand stents placed within vessels and channels. They are inflated within the stent to achieve the desired lumen diameter and force the stent to oppose the wall of the vessel or channel. 22

23. Stents Stents are used to maintain luminal patency within arteries and artificially created channels. Stents are tubular metallic cages that differ by length, longitudinal flexibility, elasticity or plasticity, radial force, composition, radiopacity, and compatibility with magnetic resonance imaging (MRI). There are self-expanding, balloon-expandable, drug-eluting, and covered stents. Choice of stent varies by procedure and comfort level of the Radiologist. 23

24. Balloon-expandable stent placement to treat renal artery stenosis . 24

25. FLOW DIVERTOR 25

26. CLOSER DEVICE 26

27. ENDOVASCULAR SNARE 27

28. Cerebral angiography A cerebral angiogram is a neurological test which evaluates the blood vessels that supply the brain. Using the Seldinger technique , Picard catheter is advanced in the arch of aorta from where selective catheterization of internal carotid artery of both the sides as well as vertebral arteries of both sides is performed. 28

29. Indications Aneurysm Arterial occlusion Thrombosis Pseudo aneurysm Non traumatic Hemorrhage Arterial dissection or laceration Arterio-venous malformation (AVM) Atherosclerosis Arterio-venous fistula (AVF) Foreign body Anomalies stenosis Organ or Tumor vascularity Prior to Therapeutic Angiography 29

30. Contraindications Bleeding tendencies or anticoagulant therapy. Pulse not palpable at vascular access site. Thrombogenic tendency. Skin infections or swelling at the site of artery puncture. Abnormal renal function. Hepatic failure. Cardio vascular disease History of allergy, skin rashes or asthma. If patient history for any contrast reaction Pregnancy. 30

31. Preparation For The Procedure Patient should be admitted one day prior to the procedure. Patient should be well hydrated. The patient must wear a hospital gown. Groin region must be shaved properly. Peripheral pulses should be marked. Intravenous line must be in place. All previous record must be taken and examined. PTI must be taken and should not be less than 70%. 31

32. Preparation For The Procedure Prior to any procedure, an informed consent must be obtained. To provide this, the patient must understand the procedure planned, reasons for undergoing the procedure, risks and benefits, and alternative therapies including consequences of refusing the procedure. The consent also includes the risk of CIN and allergic reaction to contrast agents. Sedation and anesthesia are also addressed as part of the consent. If sedation or anesthesia is planned, the patient is to be NPO (nothing by mouth) for 4-6 hours prior to the procedure. Medications such as antihypertensive and insulin should not be discontinued prior to the procedure. Antibiotics should be given within 2 hours of procedures. 32

33. Intra procedural Care During the procedure, some important steps should be taken to reduce radiation exposure to the patients and staff by using techniques such as: Collimation Reduced fluoroscopy time Pulsed fluoroscopy Reduced patient to image intensifier distance Increased distance from the radiation source Use of lead shields Wearing protective aprons 33

34. Steps should be taken to prevent blood-borne pathogen (hepatitis B or C, HIV) exposure. The patient's vital signs should be monitored. Room should be ready to manage/treat intra procedural events such as hypotension, respiratory depression with hypoxia, vasovagal reactions, hypertension, hemorrhage, and contrast reactions. 34

35. Procedure Gaining Arterial Access Selective Arterial Catheterization. Image Acquisition Closure Of Arterial Access 35

36. 36

37. Retrograde Femoral Artery Catheterization The Common femoral artery (CFA) is the simplest and safest arterial access route because: Large Superficial Usually disease free Can be compressed easily against the head of femur to close the puncture. 37

38. High Brachial artery Catheterization Indications Absent femoral pulses Recanalization of steeply down going mesenteric or renal artery Treatment of obstructions in upper extremity arteries. History of prior retrograde aortic catheterization The high brachial is preferred over the axillary or mid brachial because complications are less frequent. 38

39. Antegrade femoral artery Catheterization Antegrade (downhill) femoral artery Catheterization is occasionally required for infra- inguinal procedures. The skin puncture is made over the top of the femoral head to enter the middle of the CFA below the inguinal ligament. 39

40. Femoral vein catheterization The CFV usually lies 0.5 to 1.5 cm medial to the CFA . The skin entry is made just medial to the arterial pulse and just below the bottom of femoral head. A single wall needle is preferred to avoid unknowingly passing through the artery before entering the vein. Otherwise an arteriovenous fistula could result. 40

41. Internal Jugular vein catheterization The jugular vein begins in the neck at the level of angle of jaw . IJ vein is accessed for certain procedures like Trans Jugular Intra Hepatic Porto systemic shunt (TIPS) creation , IVC filter insertion. The vein is entered above the clavicle using direct sonography guidance in transverse plane to avoid arterial puncture or pneumothorax. 41

42. Seldinger Technique The Seldinger technique is used for percutaneous arterial catheterization. It involves the use of a Needle Vascular sheath set Guidewire Catheter 42

43. Conti.. Vascular access is most commonly attained via the common femoral artery. Using the femoral head and inguinal ligament as a landmark under fluoroscopy, an appropriate skin entry site in chosen. Local anesthetic is given using 1% or 2% lidocaine at the beginning of the procedure in an intradermal and subcutaneous fashion. 43

44. A small incision is given by inserting Medicut Needle into the artery. While palpating the femoral artery pulse, an 18 gauge needle is advanced in a controlled fashion at a 45 degree angle toward the femoral head. Brisk pulsatile bright red blood is encountered upon a successful arterial puncture. 44

45. A 0.035-inch Bentson wire is advanced through the needle into the common femoral artery and abdominal aorta under fluoroscopic guidance. While holding pressure at the puncture site, the needle is slowly removed and a sheath is then advanced over the guidewire into the common femoral artery in a smooth fashion. The guidewire and sheath inner stiffener is removed and the sheath is flushed with normal saline. The sheath can then be used to exchange for different types, sizes, and length of catheters. Catheters are always advanced over a guidewire to prevent arterial injury. 45

46. A single-wall needle with a sharp beveled edge for vascular catheterization. 21 gauge needle is preferred and thinner 0.018-inch guidewire to access the common femoral artery. This can then be upsized to a 0.035-inch Bentson wire using a 5 French (Fr) sheath (1 Fr = 1/3 mm). Complications of this procedure include: Retroperitoneal hemorrhage if the arterial access is too high. Low arterial access into the superficial or deep femoral artery increasing the chance of arterial thrombosis, pseudoaneurysm, or arteriovenous fistula formation Arterial injury, dissection, or occlusion. 46

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48. Closure Of Arterial Access 48

49. Balloon Angioplasty Balloon Angioplasty remains the first line minimally invasive technique for treatment of stenosis. The balloon catheter is designed for Atherosclerotic obstructed vessels. 49

50. Indications: Dilation of localized vascular stenosis Recanalization of occluded segments of vessels in selected cases. 50

51. Contra Indication: It is essential that the balloon be safely positioned with the selected guide wire therefore if the guide wire cannot pass the obstruction, the intervention should be discontinued 51

52. Mechanism of action Inflation of angioplasty balloon in the stenotic artery causes de-squamation of endothelial cells, splitting or dissection of atherosclerotic plague and adjacent intima, and stretching of media and adventitia. This controlled stretching increases the cross section area of the vascular lumen. With the angiographic catheter or balloon catheter itself near the stenosis , the lesion is crossed with a guide wire. With the balloon centered over the obstruction, it is inflated with a dilute contrast material. 52

53. Conti.. The catheter is a double lumen shaft, onto the distal tip of which a balloon is welded. The double lumen shaft is branched at the proximal end so that one lumen forms the entrance to the guide wire while the other tube is used to inflate and deflate the dilated balloon. 53

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55. Complications Thrombosis Vessel rupture Distal embolization Pseudo aneurysm Guide wire perforation 55

56. Precautions To minimize the balloon rupture, the recommended dilation pressure of the balloon must never be exceeded. The nominal diameter of balloon must be selected so that it is the same or smaller than the diameter of the vessel to the obstruction. Only a mixture of saline and contrast media is used to fill the balloon. 56

57. Stent Placement Stents maintain the luminal patency by providing a rigid scaffold that compresses Atherosclerotic disease , or dissection flaps. Indications: Primary treatment of coronary ,iliac and renal artery obstructions Immediate or long term failure of balloon angioplasty 57

58. Procedure Many angioplasty procedures also include the placement of a stent, which support the damaged artery walls. Stents can be self-expandable (opens up itself upon deployment) or balloon expandable (balloon needed to open the stent). Balloon expandable stents are typically placed over a balloon-tipped catheter so that when the balloon is expanded, it pushes the stent in place against the artery wall. When the balloon is deflated and removed, the stent remains permanently in place. 58

59. 59

60. Renal artery stenosis Renal artery stenosis (RAS) refers to a narrowing of a renal artery. 60

61. Catheter Embolization Control or prevent abnormal bleeding Occlude or close off the vessels Eliminate an arteriovenous malformation (AVM) or arteriovenous fistula (AVF) (abnormal connection or connections between arteries and veins). Treat aneurysms (a bulge or sac formed in a weak artery wall) 61

62. Intracranial Aneurysms An aneurism is local weakness of the wall of the artery may be due to aging, disease. It is any out pouching on the vessel wall and can be: Saccular Fusiform Dissecting 62

63. Four vessel angiogram should be done. 3D reconstruction is useful to assess the aneurysm dome, neck, parent vessel and adjacent vessel. 63

64. 64

65. Arteriovenous Malformation Development of communication system between arterioles and venules occur through capillary network. Direct communication between arteries and veins without the capillary network is called arteriovenous malformation 65

66. Internal /External cerebral circulation, vertebra- basilar system angiogram and selective micro catheterization to identify the feeding arteries and draining veins. High speed runs of 4-6 fps are taken to clarify anatomy of AVMs . 66

67. Occlusive/Embolic Agents The first agent used for Embolotherapy was autologous blood clot. This was easily and quickly obtained and was inherently biocompatible. Silk threads were also historically used as embolic agents, notably for intracranial vascular malformations. Today, these old agents are replaced with the advent of modern liquid and particulates. 67

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70. Gel-foam Gelatin foam has been used as an intravascular embolization agent for more than 30 years. Gelatin foam is a biologic substance made from purified skin gelatin. It is available in sterile sheets and as a powder comprised of 40 to 60 µ m particles. Sheets can be cut into small 1 to 2mm pieces can be mixed with dilute contrast and injected as pledgets , or be prepared as slurry. Another standard use of gelatin foam is to form a small torpedo that can be injected into the target vessel for a more proximal occlusion. 70

71. Gelatin foam particles can aggregate or swell on hydration into larger particles. Gelatin foam causes mechanical obstruction, slowing blood flow and hastening thrombus formation. In addition, it provides a scaffold for clot formation. Gelfoam embolization provides temporary vessel occlusion, allowing recanalization in a few weeks. Advantages: Low cost Versatility of use Extensive clinical experience. 71

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73. Polyvinyl Alcohol Particles The particles are made from a PVA foam sheet that is vacuum dried and rasped into particles and are biocompatible. The particles are filtered with sieves and are available in sizes ranging from 100 µ m to 2000 µ m. Because of the method of preparation, PVA particles are slightly irregular in size which promotes aggregation. They can be oblong, oval, irregular, sharp, and angulated with small fragments after suspension. 73

74. Polyvinyle alcohol particles provide permanent occlusion by adherence to the vessel wall, causing stagnation of flow, in addition to lodging in the smallest vessel into which they will fit. 74

75. Tris acryl Gelatin Microspheres Embospheres are available in six size ranges: 40 to 120 µ m, 100 to 300 µ m, 300 to 500 µ m, 500 to 700 µ m, 700 to 900 µ m, and 900 to 1200 µ m. Embospheres are packaged in 20-mL prefilled syringes containing 2 mL of spheres in saline. 75

76. Conti. Tris -acryl gelatin microspheres are made from an acrylic polymer matrix impregnated and embedded with porcine gelatin. They are non resorbable hydrophilic particles that are precisely calibrated by size. Unlike PVA particles, TAGM are smooth and spherical in shape and fragmentation is not observed 76

77. N-butyl Cyanoacrylate (Glue) N-butyl cyanoacrylate is supplied as a free monomer , which is clear and free-flowing. When exposed to an anionic environment such as blood or water, polymerization occurs . Polymerization rate can be altered by varying the NBCA concentration with Ethiodol (LIPIODOL) or glacial acetic acid. NBCA is that it works instantly, completely occludes vessels, and is permanent. 77

78. Ethylene Vinyl Alcohol Copolymer(Onyx) Ethylene vinyl alcohol copolymer is an embolic agent for cerebral AVM. It is a copolymer of ethylene vinyl alcohol prepared with dimethyl sulfoxide (DMSO) as solvent. Tantalum powder is added for opacity. On contact with blood, the DMSO diffuses away allowing polymerization of the EVOH, which forms a cast of blood vessels. EVOH is available under the trade name Onyx , and comes prepared as Onyx 18 and Onyx 34, which differ in viscosity. Lower concentration of Onyx results in a lower viscosity solution that can be injected into smaller vessels. 78

79. Coils Coils are permanent embolic agents that come in a variety of shapes and sizes. In general, they are easy to see, control, and deploy. They are typically used for occlusion of larger vessels and cause complete occlusion equivalent to surgical ligation. Coils cause vessel occlusion by inducing thrombosis. Deployment of a coil acts by physically slowing or stopping blood flow, providing a thrombogenic surface for clot formation, and causing vessel wall damage that results in release of thrombogenic factors. Typically, thrombosis occurs within less than 5 minutes after deployment. 79

80. Conti. Coils are generally made of steel or platinum. Although more expensive, platinum coils are more malleable and radiopaque and are easier to see under fluoroscopy compared with similarly sized and shaped steel coils. Coils range in size from 0.008 to 0.052 inches and from 1 to 300 mm. Available coil shapes include: J- or C-shaped Helical Conical Tornado Straight complex three dimensional (3D) 80

81. Conti. Coils may be bare or fibered with material such as Dacron, nylon fibers, polyester, wool, silk, or PVA embedded within them to increase thrombogenicity . The methods of coil delivery are numerous and include: Simple pushing Injecting Commercial detachment systems 81

82. Detachable Balloon The detachable balloon is not currently FDA approved for use in the United States. Its advantages are the ability to occlude large vessels and the possibility of being repositioned. Disadvantages are Rupture risk, Deflation, Migration Premature detachment. The balloon is made of latex or silicon available in 6 to 14 mm and 4 to 10 mm respectively. They would be ideal in cavernous carotid fistulas, pulmonary AVMs, and large-vessel occlusion. 82

83. Amplatzer Vascular Plugs Amplatzer Vascular Plug are relatively new and include a family of expandable nitinol mesh vascular occlusion devices that are derived from septal occluders commonly used in cardiology. The Amplatzer does not cause instantaneous thrombosis, and in high-flow situations may take several minutes . 83

84. It ranges in size from 3 to 22 cm in diameter and 6 to 18 cm in length. These devices have a stainless steel screw attachment to a delivery wire and radio-opaque marker bands at both ends. The delivery wire allows for precise placement, and the deformability of the plug allows it to be recaptured by advancing the delivery catheter over the plug. 84

85. Conti. They are prepackaged with a loader and attached to a delivery wire. The loader is inserted into the delivery catheter, which should be less than 100 cm in length. The Amplatzer is pushed through the catheter with the deliver wire to the level of desired occlusion. The catheter is then withdrawn to unsheathe the device and allow it to expand. If the device is satisfactorily in position, the plug is released by rotating the delivery wire counterclockwise. 85

86. Sodium Tetradecyl Sulfate (STS) Sodium Tetradecyl Sulfate is an ionic detergent that is used in the treatment of pelvic congestion syndrome,varicocele and venous malformations as a sclerosant . 86

87. Abdominal Angiography An abdominal angiogram is an angiogram of the blood vessels of the abdomen. An abdominal angiogram may be used to assess the blood flow to organs of the abdomen, such as the liver and spleen. It may also be used to deliver medication into structures of the abdomen to treat cancer. 87

88. Trans-Jugular Liver Biopsy ( TJLB) Is an alternative to a percutaneous liver biopsy . In Trans-Jugular Liver Biopsy a small sample of liver tissue is taken and send to the lab to evaluate the characteristics of the tissue. INDICATION :- Chronic liver disease. Transplant patient. Patient with clotting disorder. Patient with large amount of fluid in abdomen. 88

89. Procedure Catheter is inserted into the internal jugular vein under the US guidance and the catheter is passed into the RHV and finally in to the liver . A small needle is inserted into the liver through the sheath and small piece of liver tissue is obtained and collected into the biopsy specican . 89

90. 90

91. Trans-Arterial Chemoembolization (TACE) Trans-Arterial Chemoembolization(TACE) is a specific type of chemoembolization that blocks the hepatic artery to treat liver cancer. Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. 91

92. Conti. This type of tumor grows a large number of blood vessels. These blood vessels get most of their blood supply from the hepatic artery , while the rest of the liver tissue gets blood from the portal vein. Because of this, the hepatic artery can be blocked to cut off the blood supply to the tumor without affecting the rest of the liver. Agents Used: PVA particles with doxorubicin. Gelatin microspheres loaded with cisplatin. 92

93. 93

94. CONTI. DEB-TACE is a new way of delivering chemotherapy during TACE. It uses special beads that already have the chemotherapy drug in them (called drug-eluting beads, or DEBs). After these beads are injected into the arteries in the liver, they slowly release the drug to treat the tumor. These drug-eluting beads are as effective as using the sponge or injecting chemotherapy drugs in the arteries. 94

95. Use of Drug-Eluting Microspheres Drug-eluting microspheres are made of polyvinyl alcohol hydrogel . They are biocompatible, hydrophilic, and non resorbable. They isolate doxorubicin hydrochloride from solution by ion exchange mechanism and release it in tissues again by similar mechanisms. This allows for a sustained release of chemotherapeutics agent over a long period of time as compared with more rapid release of agents from lipiodol solution in conventional TACE therapy . This increases the contact time of drugs with tumor and lower systemic concentration of the drugs leading to improved objective tumor response as well as decreased systemic side effects and decreased rates of liver failure . 95

96. Side Effects Of TACE TACE for liver cancer may cause post-embolization syndrome, which is a group of symptoms that includes: Fever Pain  in the upper-right abdomen, under the ribs Nausea and vomiting Fatigue 96

97. TACE can also cause: Bruising or bleeding at the catheter site Hair loss Lowered ability to fight off infections Abnormal liver function Pneumonia Pleural effusion Pulmonary embolism Inflammation of the gallbladder Ascites Abscess at the site of tumor destroyed. 97

98. Transarterial Radioembolization (TARE) Transarterial Radioembolization (TARE) uses beta-emitting radioactive elements Yttrium-90, Rhenium, or Iodine-131 . The preferential deposition of microspheres within the tumor allows selective irradiation of the target tumor rather than the normal hepatic parenchyma, thereby reducing the risk of radiation-induced liver disease. An intratumoral radiation dose of 100–150  Gy is achieved, which is highly effective for tumor destruction. 98

99. Conti. Y-90 bearing microspheres are commercially available in two formulations: Glass microsphere (Thera-Sphere) Resin microsphere (SIR-Spheres) Beta-emitting radioisotopes have a very small range of penetration (1–2 mm), and thus act as a point source of radiation. Radioembolization combines the minimal embolic effect on tumor vascularity and cytotoxicity of radiation, thus acting as brachytherapy. 99

100. 100

101. Planning Angiogram A detailed angiogram is performed to map arterial supply to the tumor . All collaterals to gastrointestinal tract are embolized to prevent intractable radiation ulcer of the stomach and the small bowel. The vascular supply to the tumor is thus skeletonized. A 5-mCi dose of 99mTc MAA (macro aggregated albumin) is injected into the hepatic artery and a planar scintigraphy is done to calculate the lung shunt fraction. The lungs may tolerate an unintended radiation dose of 30 Gy during a single treatment and a cumulative maximum dose of 50 Gy ; higher dose incurs a risk of radiation pneumonitis. 101

102. Dose Calculation After calculating volume of the disease with CT volumetry and lung shunt fraction, dose is calculated using specialized software. The desired vial of Y-90 spheres is then ordered and delivered within a week’s time. This vial is calibrated taking into account the exponential decay of Y-90. 102

103. Delivery Delivery of microspheres requires performance of a second angiogram. The Y-90 vial is loaded into a specialized delivery kit by nuclear medicine physician and delivered intra-arterially without any radiation exposure to the operator . Response Evaluation Cross-sectional imaging (CCT/MR) is repeated at 6 weeks to evaluate response. The combination of necrosis and change in tumor size is the accurate method to evaluate response. Necrosis is defined as a lack of enhancement (a change in attenuation by less than 10 HU) after the administration of contrast material at CT. A transient thin rim of enhancement represents granulation tissue, whereas a growing enhancing nodule represents treatment failure. 103

104. Trans-jugular Intrahepatic Portosystemic Shunt (TIPS) Trans-jugular intrahepatic Portosystemic shunt (TIPS) is a procedure that may be used to reduce  portal hypertension  and its complications, especially variceal bleeding . INDICATION: Uncontrolled esophageal or gastric variceal hemorrhage Hepatic hydrothorax Severe portal hypertension Gastropathy 104

105. CONTRAINDICATION: Uncontrolled systemic infection or sepsis. Severe pulmonary hypertension. Severe coagulopathy Thrombocytopenia Portal vein thrombosis Obstruction of all hepatic vein 105

106. 106

107. Procedure Under fluoroscopic guidance access to the liver is gained via internal jugular vein in neck . Then a guide wire and catheter is introduced to facilitate shunt placement by travelling through SVC into IVC and finally the hepatic vein and after that portal vein is located. Then a special needle (cola pinto) is introduced through the liver parenchyma to connect the hepatic vein to large portal vein. The channel for the shunt is created by inflating an angioplasty balloon within the liver along the tract created by needle. Then the shunt is completed by stent mesh. 107

108. Conti.. 108

109. IVC Filter Insertion Patients who have a history of, or are at risk for, pulmonary embolism may receive temporary or permanent inferior vena cava (IVC) filters to prevent the migration of blood clots to the lungs, and consequently prevent recurrence of pulmonary embolism. 109

110. Indications IVC filters is recommended for those with contraindications to anticoagulation who either have acute PE or acute proximal (above the knee) DVT (Deep vein thrombosis). CONTRAINDICATIONS: Those receiving therapeutic anticoagulants. Those with thrombus between the venous access site and expected deployment site. Patients expected to undergo MRI after filter placement. 110

111. Placement IVC filters are placed endovascular . Historically ,IVC filters were placed surgically ,but with modern filters they can be compressed into much thinner catheters. Access to the venous system can be obtained via the femoral vein and the internal jugular vein . Choice of route depends mainly on number and location of blood clot within the venous system. To place the filter , a catheter is guided into the IVC using fluoroscopic guidance, then the filter is pushed through the catheter and deployed into the desired location . 111

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113. Sclerotherapy Sclerotherapy is a medical procedure whereby a chemical, the sclerosant, is injected into a vein to entirely obliterate it. The sclerosant damages the innermost lining of the vessel, resulting in a clot that blocks the blood circulation in the vein beyond. Veins carry unoxygenated blood from the peripheral tissues back to the heart. Since the blood pressure in the veins is low, the blood is pumped forward by contractions of the heart. To prevent back-flow, most veins have valves that only allow blood to flow in the direction of the heart. 113

114. When these valves become incompetent, veins become enlarged and bulging (varicose). Smaller veins that feed these varicose veins can also become enlarged and appear as red or blue spider veins in the skin. Varicose veins can lead to a chronic swelling condition of the leg called venous insufficiency. The destruction of these types of veins can be desirable both medically and cosmetically. 114

115. INDICATIONS:- Telangiectasias (spider veins) Venulectasias Reticular veins ABSOLUTE CONTRAINDICATIONS: Previous anaphylaxis to proposed sclerosants Acute DVT (Deep vein thrombosis) Relative contraindications: Deep venous obstruction Peripheral vascular disease Acute SVT ( Paroxysmal Supraventricular Tachycardia ) Pregnancy 115

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117. Procedure In sclerotherapy, the salt solution i.e. sodium tetradecyl sulfate(STS) or polidocanol is injected within a blood vessel using a pair of syringes-one with a sclerosant in it and other with usually air,thereby mixing it to create foam.This is aslo called foam sclerotherapy. The procedure is performed under ultrasound guidance to treat varicose veins and spider veins. The procedure lasts for 15-20 minutes. Compression stockings: Class I (20-30 mm Hg) for spider and reticular veins. Class II (30-40 mm Hg) for varicose veins. 117

118. Post Procedural Follow-up Post procedural care is dictated by the type of procedure performed. Arterial punctures with placement of sheaths require application of digital pressure above, at, and below the puncture site for at least 15 minutes post sheath removal. The site needs to be carefully monitored for enlarging hematoma. The patient should be on bed rest with the ipsilateral extremity immobile for 6 hours. Use of arterial closure devices has the advantage of hemostasis almost immediately following deployment and much shorter bed rest time. 118

119. Conti. Solid organ biopsies (liver, spleen, and kidney) have a higher chance of bleeding and the patient is monitored for 3 to 4 hours post procedure for signs of bleeding. Lung biopsies are followed by immediate and 3-hour chest x-rays to monitor for a pneumothorax, which may need to be evacuated by chest tube placement in symptomatic patients. Specific orders regarding activity, diet, pain control, hydration, and monitoring vital signs are also written. Discharge or transfer criteria include tolerance of oral intake, adequate pain control, appropriate mentation, and stable vital signs. 119

120. Conclusion Interventional Radiology procedures are minimally invasive, targeted treatments performed using imaging for guidance. These procedures have less risk, less pain and less recovery time compared to open surgery. The risk is involved with radiation so appropriate radiation protection should be taken. 120

121. References AIIMS-MAMC-PGI’s Comprehensive textbook of diagnostic radiology, vol.1section-2 Grainger & Allisons Diagnostic Radiology, 6th Ed. Radiological Procedure (Dr. Bhushan N Lakhar ) A Guide to Radiological Procedures (Stephen Chapman ) Wikipedia.com Google.com 121

122. THANK YOU 122