5B.DIAGNOSTIC AND THERAPEUTIC NON VASCULAR INTERVENTIONAL STUDIES -by Ravindra Kumar.pptx

Intervention is the sub- specialty of radiology which deals with minimally invasive image guided procedures to diagnose & treat disease in nearly every organ of the body.
Done for catheterization or stenting of organ ductal system.
For biopsy or to drain fluids out of an organ.
Done for tumor ablations in many organs of the body.
Intervention is the sub- specialty of radiology which deals with minimally invasive image guided procedures to diagnose & treat disease in nearly every organ of the body.
Done for catheterization or stenting of organ ductal system.
For biopsy or to drain fluids out of an organ.
Done for tumor ablations in many organs of the body.
imaging with CT, MRI, USG, Fluoroscopy ,CT Fluoroscopy.
A biopsy is the removal of tissue from any part of the body to examine it for disease .
Often ,the tissue is removed by placing a needle through the skin to the area of abnormality.
As it is done directly through the skin ,it is called percutaneous biopsy.
Biopsy can be done in any part of the body -Liver biopsy
Renal biopsy
Chest biopsy/Lung biopsy
Adrenal biopsy
Pancreas biopsy
Spleen biopsy
Thyroid biopsy
Breast biopsy.
Ablation therapy is a minimally invasive procedure used to destroy abnormal tissue in radiologic guidance by:

Radiofrequency Ablation (RFA)
Irreversible Electroporation (IRE)
Micro Wave Ablation
Cryoablation.
Role of radiological technologist in interventional radiology has a great importance for better procedure outcomes with best image quality.

Patient management: to check patient requisition form, consent, to form a to-do list, arranging patients on the basis of their emergency status.
Patient Preparation: check patient previous history, reports, records, tools and medications required for the procedure etc. always have excess of tools so that everything is on hand during procedure & does not create a chaos.
Equipment preparation: equipment working conditions are good or not, primary QC tests before start (if necessary) should be performed, sterility of the eqpt is necessary.
Room preparation: must check availability of emergency drugs, antiseptic and sterilizing solutions, lead aprons, patient gowns and draw sheets.
Interventional Radiology procedures are minimally invasive, targeted treatments performed using image guidance like CT , fluoroscopy or ultrasound.
These procedures have less risk, less pain and less recovery time compared to open surgery.
Percutaneous image-guided aspiration and drainage has become the "first line" treatments for the management of pleural and mediastinal collections.
Many Advancements like various ablation therapies, CT & MR guided procedures occur in this field.

1. Diagnostic & Therapeutic Non Vascular Interventional Studies department of radio-diagnosis and imaging, pgimer, Chandigarh Ravindra kumar M.SC. Medical Technology (Radiodiagnosis and imaging) PGIMER Chandigarh, India PRESENTER RAVINDRA KUMAR TECHNOLOGIST

2. Contents Introduction Imaging modalities Radiological procedures for non-vascular intervention. Advancements in intervention radiology Role of radiologic technologist Conclusion.

3. Introduction Intervention is the sub- specialty of radiology which deals with minimally invasive image guided procedures to diagnose & treat disease in nearly every organ of the body. Done for catheterization or stenting of organ ductal system. For biopsy or to drain fluids out of an organ. Done for tumor ablations in many organs of the body.

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5. ABLATION THERAPY

6. Imaging Guidance Sonography Fluoroscopy CT Fluoroscopy MRI

7. Percutaneous Biopsy/ FNAC A biopsy is the removal of tissue from any part of the body to examine it for disease . Often ,the tissue is removed by placing a needle through the skin to the area of abnormality. As it is done directly through the skin ,it is called percutaneous biopsy . 11

8. Indications Diagnosis of any malignancy and neoplasm, metastatic disease Tumor staging Recurrent disease after treatment. Diagnosis of inflammatory or infectious processes, abnormal fluid collections Diffuse organ disease.

9. Contraindications Uncorrectable coagulation abnormalities. Lack of a safe percutaneous pathway to the lesion. An uncooperative patient in whom motion may increase the risk of bleeding. Biopsy usually is not indicated in a patient who will undergo surgery.

10. Tools Required Disposable plastic syringes Betadine Gloves Drapes and sheets Local anesthesia Speci-can Biopsy needles are required Higher the G number(20-25G) lesser be the lumen of the needle. Lesser G needles(14-19G) are used to get cytological as well as histological sample data where as larger G needles are used for fine needle aspiration. The risk of hemorrhage may increase as the needle size increases Chiba needle is used for fine needle aspiration.

11. NEEDLES 16

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13. Technique Several different techniques can be used to obtain a sample in a percutaneous biopsy. CORE BIOPSY : In a core biopsy, a large-bore needle is inserted and used to pull out a chunk of soft tissue or bone. FINE NEEDLE ASPIRATION : In fine needle aspiration biopsy, a smaller needle is inserted and a syringe is used to create a vacuum, sucking a sample up into the needle.

14. Procedure The patient can be in supine, prone or oblique position as required . The shortest path to the lesion is preferred. It is best to start with smaller needles. During needle advancement and biopsy, the patient should suspend respiration to minimize motion of the needle. The position of the needle tip can be observed continuously during biopsy so that different sectors of the lesion are sampled to increase the diagnostic yield. Before the needle is removed the suction is released to prevent the entire sample from being aspirated into the tubing or syringe.

15. Biopsy can be done in any part of the body Liver biopsy Renal biopsy Chest biopsy/Lung biopsy Adrenal biopsy Pancreas biopsy Spleen biopsy Thyroid biopsy Breast biopsy

16. COMPLICATIONS Bleeding Organ injury Tumor seeding AFTER CARE Blood counts should be checked 4 hours after the biopsy to exclude significant bleeding. If the patient and blood count are stable, no further evaluation other than follow-up with the biopsy results.

17. CT Guided Biopsy CT-guided biopsy  is a procedure by which the physician uses a very thin needle and a syringe to withdraw a tissue or fluid specimen from an organ or suspected tumour mass. The needle is guided while being viewed by the physician on a computed tomography ( CT ) scan.

18. CT-guided FNAC  of thoracic mass lesions is a safe, rapid, and reliable procedure with minimal complications. It provides very early diagnosis and exact sub classification of various lung tumours on the basis of Cytomorphology.

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20. MRI Guided Biopsy MR guided breast biopsy : Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous. An MRI-guided breast biopsy is most helpful when MRI imaging shows a breast abnormality such as: A suspicious mass not identified by other imaging techniques An area of distortion An area of abnormal tissue change.

21. Biliary System ANATOMY The biliary system consists of the organs and structures that secrete and transport bile, including the liver, gallbladder, and bile ducts. Liver secretes bile and Bile flows from liver through hepatic ducts into the gallbladder. Gall bladder stores and concentrates bile. Rt and Lt hepatic ducts unite to form common hepatic duct. Common hepatic and cystic duct from GB unite to form common bile duct . This runs from liver to the duodenum.

22. Percutaneous Trans-hepatic Cholangiography (PTC) Percutaneous trans-hepatic cholangiography (PTC) is a way of examining the bile duct system . This procedure is done under local anesthesia by a radiologist. During the exam , a thin needle is inserted through the skin (percutaneous) & through the liver (trans hepatic) into a bile duct . The contrast is injected & the bile duct system is outlined.

23. Indications To see the position of bile duct. Prior to biliary drainage procedures/stenting To define the level of obstruction in patients with obstructive biliopathy. To evaluate for presence of suspected choledocholithiasis. To determine the etiology of cholangitis. To evaluate suspected bile duct inflammatory disorders. To demonstrate site of bile duct leak. Undiagnosed jaundice Chronic pancreatitis

24. Contraindication Coagulopathy Low PL count Sensitivity to c/m Severe heart disease Severe jaundice Ascites Anemia Biliary tract sepsis

25. Pre procedure evaluation and preparation The initial workup of a patient includes - Clinical evaluation with history taking Physical examination Laboratory tests. Check clotting profile & platelet count. Fasting 4 hours prior to procedure. Antibiotics should be started prior to the procedure as bacteremia and sepsis can develop during the procedure. Venous access should be secured. Conscious sedation should be used for adequate pain control. Informed consent must be taken.

26. Technique of PTC Patient is lying down in supine position on the fluoroscopy table, upper abdomen is cleaned and draped. The skin puncture site is anesthetized with local anesthetic(2% lidocaine) up to the liver capsule. If peripheral biliary radicles are dilated they can be punctured under ultrasound guidance. If not dilated the procedure is performed under fluoroscopic guidance.

27. Conti. A fine (22G) Chiba needle is advanced into the liver aiming for the right lateral aspect of the 12th thoracic vertebral body . After the stylet is removed the needle is slowly withdrawn while injecting a small amount of contrast. When contrast is seen to opacify the biliary tree , needle withdrawn is stopped and cholangiography performed to delineate the biliary anatomy.

28. Conti. PRECAUTIONS: Ensure no air in the system No high injection flow rate Maintain sterility COMPLICATIONS: Sepsis Perforation of bile duct Intra abdominal bleeding

29. Percutaneous Fluid Drainage PFD uses imaging guidance to place a needle or catheter through the skin into the abscess to remove or drain the infected fluid. PFD provides definitive treatment of most sterile and infected collections in the chest, abdomen, pelvis, and musculoskeletal system. It has largely replaced surgical incision and drainage as first-line treatment for these conditions.

30. Indications CHEST: Pleural effusion Emphysema Pulmonary abscess ABDOMEN: Appendicitis Post-traumatic collection Pancreatic fluid collection Acalculous cholecystitis Abscess due to Crohn's disease SOFT TISSUE INFECTIONS: Joint effusion Cellulitis Osteomyelitis Neck abscesses

31. Patient Preparation Coagulopathies must be corrected before the procedure. Patients with suspected infected fluid collections usually are receiving antibiotics by the time drainage is requested. Otherwise, a broad-spectrum cephalosporin (e.g., 1 g of cefazolin IV) is given within 1 hour of the procedure . PFD is performed with intravenous conscious sedation and local anesthesia. Informed consent is must.

32. Technique Sonography and fluoroscopy is preferable because they allow real-time monitoring and less radiation to the patient than with CT . Small collections and those situated deep in the chest, abdomen, or pelvis are drained under CT guidance. The shortest distance between the skin and the collection without interposing vessels is chosen for needle entry and catheter insertion. The area is sterilized, and local anesthesia is applied to the skin and soft tissues where the needle and catheter will be inserted.

33. Procedure Puncture the site with 18G needle . Follow needle till its tip is well inside the fluid/abscess cavity Remove stylet of needle Aspirate 2 to 5 ml of fluid Store in sterile vial for microbiological analysis or completely aspirate all fluid as a single stage therapeutic procedure. A 0.035 inch guide wire is inserted through an 18G thin walled needle (e.g., Chiba) and coiled.

34. Conti. Remove the needle. Dilate tract to the size above catheter size. Place catheter in abscess cavity over a guide wire. Remove the guide wire. Connect catheter to negative suction collection system. Suture catheter & skin wound. Secure catheter to skin with adhesive tape Flush abscess cavity with antibiotics saline periodically. Remove the catheter when drainage stops completely.

35. Results And Complications The major complications of PFD are bleeding, bowel or bladder perforation , and sepsis . Hemorrhage is more likely to occur in a patient with an uncorrected coagulopathy or when a sub-optimal access route was used for catheter insertion.

36. Percutaneous Trans-hepatic Biliary Drainage (PTBD) PTBD is a therapeutic procedure that consists of sterile puncture of a peripheral biliary radicle under image guidance followed by placement of a catheter or stent for internal or external drainage of bile. In this technique a drainage catheter is introduced percutaneously through the liver into the CBD for drainage of bile. Procedure may be performed to improve jaundice or sepsis.

37. INDICATIONS Biliary stones Malignant Biliary stricture Malignancy Obstructive jaundice/Cholangitis Undiagnosed jaundice CONTRAINDICATIONS Sepsis Bleeding disorder Contrast hypersensitivity Pregnancy Ascites

38. Preparation CT/US/MRI prior to PTBD which provide useful information regarding the level of obstruction. Check clotting profile & platelet count Fasting 4 hours prior to procedure. Monitoring equipment will be attached to measure blood pressure , heart rate and oxygen saturation. Local anesthesia will be administrated into the skin. Venous access should be secured. Informed consent must be taken.

39. Procedure After anesthetizing the skin ,a 18G puncture needle is used to enter the selected biliary radicle. In a dilated system ,allow little amount of bile to drain after the puncture before injecting contrast to prevent over-distention of the biliary system which can result in bacteremia and sepsis. Little contrast is injected to opacify the biliary tree. A 0.035 inch hydrophilic guide wire is then passed through the needle and manipulated into the biliary tree. The needle is withdrawn and 4F or 5F sheath is introduced. The slippy guide wire can be exchanged for a stiffer (Teflon coated) guide wire over which the 8F drainage catheter is placed after dilatation of the tract with dilators. If the tip of catheter is in CBD , a catheter of the pigtail type is placed.

40. Conti.

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42. PTBD is performed in two stages: Stage 1: The ducts are approached through the Right lobe of liver & punctured using a 22G Chiba needle under US or fluoroscopic guidance . PTC is done by injecting c/m into the ducts first done to: Confirm the presence of obstruction To see the location & nature of obstructing lesion

43. Stage 2: Req:18G needle, sheath , dilators , multiple side hole drainage catheter with guide wire. If drainage is indicated , then an 18 G needle with stylet is introduced into the duct. GW is inserted ,needle removed , introduce sheath . Dilators are applied. A floppy guide wire is used to as it has good bending as well as torque capabilities. Catheter is advanced to the biliary tract , if lesion is there then catheter should be left in place in intrahepatic duct & external drainage should be done. After 48 hrs. of drainage , it is possible to advance the guide wire through the obstruction. Guide wire is then replaced by a multiple side hole catheter. Catheter is encroached to the skin with a suture & bile is drained for 24-48 hrs.

44. Aftercare Regular follow up to detect catheter migration or obstruction at early stage. Bile output ,color and body temperature should be recorded every day . Serum bilirubin and amylase levels should be checked. The normal daily output of bile is 400-800ml and is clear and yellow in color. Any decrease in output ,change in color or increased turbidity are signs of cholangitis. Catheter should be exchanged every 2-3 months to prevent blockage or breakage.

45. Complications Hemorrhage Shock due to injection of contrast medium or sudden biliary decompression. Sepsis and bile peritonitis due to slippage of catheter. Pancreatitis occur due to edema of the CBD. Pneumothorax or pleural effusion Cholangitis occur if there is blockage of the catheter or if some intrahepatic ducts remain undrained.

46. Biliary Stenting Biliary stenting is a procedure done under radiologic guidance to treat the benign biliary stricture . A biliary stent is a plastic or metal tube that is inserted into a bile duct to relieve narrowing of the duct (also called bile duct stricture). There are a number of conditions malignant or benign, that can cause strictures of the bile duct. Pancreatic cancer is the most common malignant cause, followed by cancers of the gallbladder, bile duct, liver, and large intestine.

47. Conti. Noncancerous causes of bile duct stricture include: Injury to the bile ducts during surgery for gallbladder removal Pancreatitis (inflammation of the pancreas) Primary sclerosing cholangitis (an inflammation of the bile ducts that may cause pain, jaundice, Itching, or other symptoms) Gallstones Radiation therapy Blunt trauma to the abdomen

48. ERCP Endoscopic retrograde cholangiopancreatography is a therapeutic approach and imaging technique. It is done to image CBD , pancreatic ductal system and gall bladder by a catheter and endoscopic guidance. ERCP is a gold standard for evaluation of pancreatic and bile duct. Useful to clear the complex ductal anatomy.

49. Indications Biliary obstruction-suspected or known Pancreatic obstruction Identification of malignant & benign tumor Persistent jaundice Evaluation & treatment of sphincter of oddi dysfunction Ca pancreas Recurrent pancreatitis Evaluation & treatment of biliary duct injuries Removal of stones or other biliary debris Stent placement Balloon dilation of ductal stricture

50. Contraindication Esophageal obstruction Gastric outlet obstruction Severe cardiac /respiratory disease Pancreatic pseudocyst Previous gastric surgery that prevents access to duodenum Recent attack of acute pancreatitis. Coagulopathy Hypersensitivity to contrast media Pregnancy

51. Patient Preparation Patient must be NPO midnight prior to exam. Review the history & images. Patient should be well hydrated, empty bladder before the exam. Patient must bring all the things required for the procedure. Use urobag for long procedures. If any intervention planned patient’s Hb , PTI & platelets are checked.

52. Technique ERCP is performed using a side viewing endoscope and requires both endoscopic & fluoroscopic skills for interpretation. Preliminary film of upper abdomen in prone & left anterior oblique position is taken to check for opaque gall stone & pancreatic calcification.

53. Conti. Endoscopic insertion: The pharynx is anesthetized with xylocaine spray. The patient then lies on the left lateral / prone position & endoscope is inserted through the mouth, down the oesophagus , into the stomach ,through the pylorus into the duodenum where the ampulla of Vater (the opening of common bile duct & pancreatic duct ) exists. Any residual secretions in stomach should be aspirated before entering stomach. Glucagon may be given to minimize peristalsis.

54. Conti. Catheter Insertion: Once papilla is visualized the endoscope is kept still. Then the GW is inserted from channels of the endoscope and catheter with angled tip is used over GW to cannulate the papilla cannulation & contrast is injected into the bile duct and/pancreatic duct . Cannulation of main pancreatic duct can be done once the catheter is in hepatopancreatic ampulla (ampulla of vater ) & catheterization of bile ducts can be done. If it is desired to opacify the biliary tree & pancreatic duct , the pancreatic duct should be cannulated first. When needed , the opening of ampulla can be enlarged (sphincterotomy) with an electrified wire ( sphincterotom ) & access into the bile duct is obtained so that gall stones may be removed or other therapy performed .

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56. Precautions The contrast media is injected into the ductal system at a slow pressure . c/m is inserted into ampulla , having ensured that all air bubbles are excluded. Pancreatic duct should be cannulated first to avoid any possible spillage. Injection is stopped when lateral branches of duct are seen when patient complains of pain. Avoid over filling of pancreatic duct.

57. Complications Increased post procedural vomiting & nausea due to use of glucagon. Post ERCP pancreatitis Post ERCP bacteremia or sepsis Duodenal perforation Bleeding due to endoscopic.

58. Benefits Of ERCP Diagnostic as well as therapeutic. Better resolution. Biopsies can be done. Limitations Of ERCP Expertise required. We can not see beyond stricture. Uncomfortable for patient. Chances of hemorrhage

59. After Care Stay in the Hospital under observation for 1-2Hrs after the procedure. Vitals signs should be frequently monitored. Appropriate analgesic should be given.

60. Renal Tract Studies Renal Biopsy Percutaneous Nephrostomy Percutaneous Nephrolithotomy Ureteric stenting

61. Renal Biopsy During a renal biopsy, a needle is used to remove a small sample of kidney tissue for laboratory testing. The biopsy needle is inserted through the skin and is often directed using the guidance of an imaging device, such as ultrasound.

62. INDICATION OF RENAL BIOPSY Diagnosis of any malignancy and neoplasm, metastatic disease Tumor staging Recurrent disease after treatment. Diagnosis of inflammatory or infectious processes, abnormal fluid collections Diffuse organ disease.

63. Percutaneous Nephrostomy(PCN) Percutaneous nephrostomy is an interventional procedure used mainly in the decompression of the renal collecting system . PCN is the insertion of a drainage catheter into renal collecting system percutaneously under radiological control. It has completely replaced surgical nephrostomy.

64. Indications Ureteric Obstruction: Calculus disease Pyelonephritis Ureteral Stricture Pelvic malignancy Nonfunctioning stent for pelvic malignancy Assessment of recoverable function in chronic obstruction Urinary Diversion : Intractable vesicle fistula Traumatic ureteral transection Access For Subsequent Interventional Procedure: Urethral stent placement Nephrolithotomy/Lithotripsy Stone dissolution Dilatation of ureteral stricture Ureteral occlusion for urinary fistula Biopsy of urothelial lesion Foreign body or fungal ball removal

65. Contraindication Uncontrolled bleeding i.e. coagulopathy H/o allergy to c/m Renal/cardiac failure Recent myocardial infarction Patient with sickle cell anemia and diabetes Pregnancy

66. Instruments 18G ,20 cm needle with stylet (Chiba needle ) 0.035 in or 0.038 in diameter,100 cm long j shaped guidewire. Drainage catheter 8-12 F , pigtail with multiple holes or Malecot catheter Graded Teflon dilator 8-12 F Urine collection bag Sterile surgical blade Xylocaine 2 % Contrast Connector Suture and needle for fixation of catheter Nephrostomy Tubes

67. Currently, most radiologist use 2 main types of nephrostomy tubes. Both of these types have an end that is secured in the renal pelvis by locking the distal portion of the tube . Pigtail catheter (locking-loop or Cope-loop): The locking loop of the catheter is formed within the renal pelvis by tugging gently on the internal suture and locking the catheter in place. Malecot catheter (tulip-shaped) : The catheter tip slightly retracts so that the tulip portion is larger than the tube diameter. These catheters are mainly used when the renal pelvis is small because of the patient's size or when a large staghorn calculus is present.

68. Patient Preparation Fasting for 6 hrs. Patient should come on trolley in hospital gown Patient should bring latest PTI report Patient should bring all previous investigations Patient should empty bladder just prior to the procedure. Informed consent must be taken.

69. Procedure The patient is commonly placed in a prone or prone-oblique position; the side to be punctured is elevated. The region should be evaluated with sonography, CT, or fluoroscopy, and the site should be marked. This region should then be prepared (e.g., cleansed with betadine solution) and draped. The patient is given a local anesthetic, usually 2% xylocaine to anesthetize the skin. A small incision is made to facilitate passage of the needle into the skin.

70. Conti. 18 G needle is angled toward calyx under ultrasound guidance. Once the needle is inserted into the calyx and into the collecting system, the stylet is removed, and urine is returned if an obstruction is present. Once access into the collecting system is obtained .A 0.035inch j-tip wire is placed into the renal pelvis. Then the tract should be dilated with Teflon dilators. The catheter should be advanced into the proximal renal parenchyma over a 0.035 inch guide wire. Remove guide wire . Connect catheter to urine bag. Suture the catheter and skin wound. Secure catheter to skin with adhesive tape.

71. Conti.

72. Complications Major complications with percutaneous nephrostomy tube placement include bleeding, sepsis, and injury to an adjacent organ. Massive hemorrhage requiring transfusion, surgery, or embolization Pneumothorax Microscopic hematuria (common) Pain (common) Urine extravasation Sepsis Catheter dislodgement during the first month

73. Aftercare Patient should be admitted for 24 hrs. after procedure and regular flushing of tube should be done every 4 hrs. Vitals signs should be frequently monitored to evaluate for the potential of ongoing blood loss or the development of septic complications. Appropriate analgesic should be given.

74. Percutaneous Nephrolithotomy Percutaneous nephrolithotomy, or PCNL, is a procedure for removing medium-sized or larger renal calculi (kidney stones) from the patient's urinary tract by means of a Nephroscope passed into the kidney through a track created in the patient's back. The purpose of PCNL is the removal of renal calculi in order to relieve pain, bleeding or obstruction of the urinary tract, and urinary tract infections resulting from blockage.

75. Technique After the patient has been anesthetized, the surgeon makes a small incision, about 0.5 inch (1.3 cm) in length in the patient's back on the side overlying the affected kidney. The surgeon then creates a track from the skin surface into the kidney and enlarges the track using a series of Teflon dilators. A sheath is passed over the last dilator to hold the track open. After the track has been enlarged, the surgeon inserts a Nephroscope.

76. Conti. With a fiber optic light source and two additional channels for viewing the inside of the kidney and irrigating (washing out) the area , The surgeon use a device with a basket on the end to grasp and remove smaller kidney stones directly. Larger stones are broken up with an ultrasonic or electro hydraulic probe, or a holmium laser lithotripter. The holmium laser has the advantage of being usable on all types of calculi. A catheter is placed to drain the urinary system through the bladder and a nephrostomy tube is placed in the incision in the back to carry fluid from the kidney into a drainage bag. The catheter is removed after 24 hours.

77. Conti.

78. Ureteric stenting An ureteral stent is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The stents are designed to stay in the urinary system by having both the ends coiled. The top end coils in the kidney and the lower end coils inside the bladder to prevent its displacement. The stents are flexible enough to withstand various body movements. The length of the stents used in adult patients varies between 24 to 30 cm.

79. Indications Bypass ureteral obstructions. Divert urinary stream to allow leaks to heal. Maintain ureteral caliber after interventions. Facilitate stone fragment passage during shock wave lithotripsy.

80. Contra-indications Bladder outlet obstruction Noncompliant bladder Bladder fistula Active hematuria Active infection

81. Ureteric Stenting Technique The two principal routes used for ureteric stent placement are 1. Antegrade (percutaneous) approach and 2. Retrograde (transurethral) approach.

82. Follow-up Stents should be regarded as urinary tract foreign bodies and hence all stents act as a nidus for calcium deposition and will in time obstruct.. Stent should be changed every 3 months. Stent exchange is best performed on an outpatient basis using a flexible cystoscope and C-arm fluoroscopy under light sedation and intravenous analgesia.

83. ABLATION THERAPY

84. Ablation Therapy Ablation therapy is a minimally invasive procedure used to destroy abnormal tissue in radiologic guidance by: Radiofrequency Ablation (RFA) Irreversible Electroporation (IRE) Micro Wave Ablation Cryoablation

85. Radiofrequency Ablation (RFA) Radiofrequency ablation (RFA) is a newly developed percutaneous image guided tumor ablation technique for small HCC as well as metastatic deposits. It induces necrosis of the tumor by deposition of thermal energy around the tip of the electrode inserted in the tumor.

86. Conti. Radiofrequency ablation is used to treat: Hepatocellular Carcinoma, which is a primary liver cancer (meaning it begins in the liver). Colon cancer that metastasizes or spreads from the colon to the liver. Renal cell carcinoma Radiofrequency ablation is most effective treating tumors that are less than 3 cm in diameter.

87. Conti. TUMOR SELECTION: Solitary lesions 3 cm or less Non small cell histology Not contiguous with major vessels or nerves No extension to hilum/mediastinum Safe & reasonable percutaneous route

88. Conti.. CONTRAINDICATIONS OF RFA: Uncontrolled coagulopathy Tumor adjacent to large vessels Poor performance status Inability to safely access the tumor Cardiac devices such as pacemaker

89. RFA Equipment RFA GENERATOR The radiofrequency generator produces alternating electrical currents in the range of radiofrequency waves. It is connected by insulated wires to the needle electrodes and to grounding pads that are placed on the patient's back or thigh. RFA PROBE Radiofrequency ablation needle device that contains multiple curved retractable electrodes . The electrodes are kept inside the needle until its tip is positioned within a tumor.

90. Procedure Patient is positioned on the examining table. Patient is connected to monitors that track heart rate, blood pressure and pulse during the procedure. The area where the electrodes are to be inserted is sterilized and covered with a surgical drape. Local anesthesia is given. A very small nick may be made in the skin to make it easier to pass the RFA electrode into liver. Using imaging-guidance, the needle electrode is insert through the skin and advance it to the site of the tumor.

91. Conti.

92. Conti. Once the needle electrode is in place, radiofrequency energy is applied. Alternating current is passed through the probe with energies 60 to 200 watts for a period of 6 to 12 minutes. Local temperature of more than 60 is maintained. At the end of the procedure, the needle electrode will be removed and pressure will be applied to stop any bleeding and the opening in the skin is covered with a dressing.

93. Follow Up Immediate observation Immediate CECT Follow up imaging-1, 3, 6, & after 1st yr.

94. Complications Related to image guided electrode placement: Bleeding Infection Pneumothorax Tumor seeding Related to thermal therapy: Non target thermal damage(GB/Biliary ducts) Grounding pads burns.

95. Benefits RFA is a relatively quick procedure and recovery is rapid Radiofrequency ablation is less expensive No surgical incision is needed. Treatment-related serious complications are infrequent and discomfort is minimal.

96. Irreversible Electroporation (IRE) IRE is a soft tissue ablation technique using ultra short but strong electrical fields to create permanent and hence lethal nanopores in the cell membrane, to disrupt the cellular homeostasis. The resulting cell death results from apoptosis instead of necrosis. Its main use is in tumor ablation in regions where precision and conservation of extracellular matrix, blood flow and nerves are of importance. IRE is used with NanoKnife system.

97. Conti. Nano knife may provide a minimally invasive option for patients with in-operable or difficult to reach tumors, including tumors located near critical structures & major blood vessels. Potential benefits of Nano Knife include: No open incisions Less damage to healthy tissue Minimal post operative pain Fewer side effects Short hospital stay

98. Working: Instead of using microwave energy , extreme heat & extreme cold , the Nano knife system uses electric currents to treat tumors . While the patient is under general anesthesia , the interventional radiologist carefully guides up to six thin needles (electrodes) into the patient’s body & strategically places them around the tumor. Then the Nano Knife sends electrical pulses or current between each set of needles to puncture permanent Nano pores into the tumor . This process called IRE causes the cancer cells to be unbalanced & triggers a cell “suicide “; thereby destroying the tumor.

99. Advantages Of IRE Its capability of preserving vital structures within the IRE-ablated zone . In all IRE ablated liver tissues , critical structures such as the hepatic arteries , hepatic veins , portal veins & intrahepatic bile ducts were all preserved. In IRE , no heat sink effect, which is the cause of many problems and decreases the predictability of the treatment field. It takes short time less than 5 minutes to place the electrode and start treating tumor cells. The treatment volume can be visualized , both during and after the treatment . Possible visualization methods are ultrasound & CT.

100. Disadvantages The strong electric fields created by IRE, due to direct stimulation of the neuromuscular junction, cause strong muscle contractions. The mechanism of cell death following IRE relies on cellular apoptosis, which results from the pore formation in the cellular membrane. Tumour cells, known to be resistant to apoptotic pathways, may require higher thresholds of energy to be adequately treated. The presence of metal, for example with biliary stents, can result in variances in energy deposition.

101. Micro Wave Ablation Microwave ablation is a form of thermal ablation used in interventional radiology to treat cancer. MWA uses electromagnetic waves in the microwave energy spectrum (300MHz- 300 GHz) to produce tissue heating effects . The oscillations of polar molecules produces frictional heating , ultimately generating tissue necrosis within solid tumors. It is generally used for the treatment and/ or palliation of solid tumors in patients who are non surgical candidates.

102. Technique With image guidance , the tumor is localized , and a thin (15 gauge) microwave antenna is placed directly into the tumor . A microwave generator emits an electromagnetic wave through the exposed , non insulated portion of the antenna. Electromagnetic microwaves agitate water molecules in the surrounding tissue, producing friction & heat , this inducing cellular death via coagulation necrosis .

103. Advantage The main advantage of microwave technology when compared with existing thermos ablative technologies include consistently higher intramural temperature, larger tumor ablation volumes , faster ablation times & improved convection profile. No heat sink effect of the blood flow. No grounding pads. Multiple antennas can be used simultaneously. Less painful.

104. Cryoablation Cryoablation is a treatment to kill cancer cells with extreme cold. During cryoablation , a thin , wand like needle ( cryoprobe ) is inserted through the skin & directly into the cancerous tumor. A gas is pumped into the cryoprobe in order to freeze the tissue. By using argon gas, cryo -probe tips can reach temperature of -187°C & then by rapidly exchanging helium into the probe , a thawing cycle is created where the tip is rapidly reheated to a temperature of 67°C.

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107. Conti..

108. Conti. INDICATIONS: Bone cancer Cervical cancer Eye cancer Kidney cancer Liver cancer Lung cancer Prostrate cancer CONTRAINDICATIONS: Active systemic infection In patients with one or more pulmonary vein stents

109. Complications High visibility of the ice ball on imaging Potentially severe systemic reactions ( cryoshock ) Relatively small ablations compared with more contemporary technologies Potentially greater risk for bleeding complications

110. Role Of Radiologic Technologist Role of radiological technologist in interventional radiology has a great importance for better procedure outcomes with best image quality. Patient management : to check patient requisition form, consent, to form a to-do list, arranging patients on the basis of their emergency status. Patient Preparation : check patient previous history, reports, records, tools and medications required for the procedure etc. always have excess of tools so that everything is on hand during procedure & does not create a chaos. Equipment preparation: equipment working conditions are good or not, primary QC tests before start (if necessary) should be performed, sterility of the eqpt is necessary. Room preparation: must check availability of emergency drugs, antiseptic and sterilizing solutions, lead aprons, patient gowns and draw sheets.

111. Conclusion Interventional Radiology procedures are minimally invasive, targeted treatments performed using image guidance like CT , fluoroscopy or ultrasound. These procedures have less risk, less pain and less recovery time compared to open surgery. Percutaneous image-guided aspiration and drainage has become the "first line" treatments for the management of pleural and mediastinal collections. Many advancements like various ablation therapies, CT & MR guided procedures occur in this field.

112. References www.google.com CT and MR guided interventions in Radiology, Mahnken,A.H,2009 AJR,2000,174: 1191-1199 Mechanisms of Cryoablation , 2013 Elsevier Irreversible Electroporation( NanoKnife ), Gastrointest Interv 2014 Radiofrequency ablation: technique and clinical applications, Diagn . Interv Radiol 2012 Cryoablation : mechanism of Action and Devices, J vasc Interv Radiol , 2010 Microwave Ablation: Principles and Applications, Radiographics 2005

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