Intervention radiology hepatobiliary system
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Intervention radiology hepatobiliary system

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Intervention radiology hepatobiliary system Presentation Transcript

  • 1. DR. AKSHAY GURSALE (RESIDENT RADIOLOGY)
  • 2. What is a CATHETER ? 2
  • 3. DEFINITION: A catheter is a hollow flexible tube that can be inserted into a body cavity, duct or vessel. Catheters thereby allow drainage or injection of fluids , distend a passageway or provide access by surgical instruments. The process of inserting a catheter is catheterization. In most uses a catheter is a thin, flexible tube: a "soft" catheter; in some uses, it is a larger, solid tube: a "hard" catheter. The first curve is called primary curve for Engagement. The second curve is called secondary curve to give support to that Catheter against the Vessel wall. 3
  • 4. What is a Catheter made up of ? Materials: A range of polymers are used for the construction of catheters, including silicone rubber latex and thermoplastic elastomers. Silicone is one of the most common choices because it is inert and unreactive to body fluids and a range of medical fluids with which it might come into contact. Materials: CATHETER: Polyvinylchloride (PVC) Polyethylene (PE) Fluoropolomers (PTFE) (TEFLON) Polyurethane (PUR) Silicone (SI) 4
  • 5. PARTS OF A CATHETER BODY  HUB  BODY HUB TIP  TIP 5
  • 6. MEASUREMENT: FRENCH CATHETER SCALE: The French catheter scale (most correctly abbreviated as Fr, but also often abbreviated as FR or F) is commonly used to measure the outer diameter of cylindrical medical instruments including catheters ,needles etc. In the French Gauge system as it is also known, the diameter in millimeters of the catheter can be determined by dividing the French size by 3, thus an increasing French size corresponds with a larger diameter catheter. The following equations summarize the relationships: D(mm) = Fr/3 or Fr = D(mm)*3  Most commonly in adult Diagnostic Catheters of 5 – 7 Fr is used. 6
  • 7. TYPES OF CATHETERS: CLASSIFICATION : Catheters can be classified depending on  SIDE HOLES : -: Single Hole -:End Hole with side holes. -:Blocked end with side holes only.  SIZES : Abdominal – 6-80 cm  Thoracic or Carotid Arteries – 100-120 cm  NOTE: Size depends on : > age of the patient > selective or super selective study > size of the vessels. NOTE: Ideal practice is to use the smallest diameter catheter feasible for any particular study to minimize the risk of arterial damage by the procedure. 7
  • 8. TYPES OF CATHETERS  SHAPES  Straight Catheter  Pigtailed Catheter  Cobra Shaped Catheter  Side Winder Catheters (Shepherd) 8
  • 9. Some Other Types of Catheters:  Hydrophilic Catheters : Hydrophilic-coated catheters have a layer of polymer coating that is bound to the catheter surface. The polymer absorbs and binds water to the catheter, resulting in a thick, smooth and slippery surface.  Intermittent Catheters: Intermittent catheters are hollow tubes used to drain urine from the bladder.  Pediatric Catheters: Usually its around 80cm. 9
  • 10. Different Catheter Curves For Different Purposes: > Judkins Left (JL) > Judkins Right ( JR) > Judkins Left Short Tip > Judkins Right Short Tip > Amplatz Left ( AL) > Amplatz Right ( AR) > Left Coronary Bypass > Right Coronary Bypass > Cardiac Pigtail > Multipurpose
  • 11. CATHETERS CAN BE BROADLY CLASSIFIED UNDER THESE GROUPS:  DIAGNOSTIC CATHETERS Used for Angiographs .  GUIDING CATHETERS Used for Angioplasty. • Guiding catheters are like angiography catheters only difference is that guiding catheters are more stiffer & firm as it carries Balloon catheters, PTCA wires and stent delivery system. • Mild stiffness comes due to the wire braided design. • Good Push ability . • Good Tractability. 11
  • 12. PUNCTURE NEEDLES: Used to cannulate or puncture the artery. Usual Sizes include 18 ga, 19 ga , 20ga, 21 ga. Seldinger Needle The selection of the Size depends on the guide wire going to be inserted through that needle port. 12
  • 13. GUIDE WIRE: Diagnostic guide wires are used to traverse vascular anatomy to aid in placing catheters and other devices. Guide wires are used for both Cardiology and Radiology angiographic procedures. • Guide wires are relatively simple spring type wires that provides necessary firmness and the control to the site where Angiogram will be taken. • A the name suggests it ‘ Guides’ the catheter. • PTFE coated Soft tip for the smoothness during the insertion • Less trauma to the intimal wall of the artery 13
  • 14. Shape of the Tip : J Tip / Straight Tip 14
  • 15.  In 1929 Werner Forssmann demonstrated that a simple Rubber catheter could be passed to the pulmonary artery through the Anti- Cubital Vein and An angiographic film could be obtained using radiographic contrast. 15
  • 16. In 1953 , Sven –Ivar Seldinger invented The technique of gaining access Percutaneusly into an artery without An arteriotomy. Sven- Ivar Seldinger 16
  • 17. TECHNIQUE OF INSERTING A CATHETER SELDINGER TECHNIQUE: The technique of catheter insertion via double-wall needle puncture and guide-wire is known as The SELDINGER TECHNIQUE. Double Wall Puncture: Mostly done.  Compression to prevent Hematoma of the other wall.  Rotatory movement to get the needle into the lumen. Single Wall Puncture: Usually done for patients co-agulation time is less. 17
  • 18. 18
  • 19. COMPLETE APPARATUS: > Needle  Guide Wire  Sheath  Catheter 19
  • 20. COMMON CORONARY CATHETERS USED FOR ANGIOGRAPHY 1. HEAD HUNTER 2. JUDKINS LEFT CORONARY 3. JUKINS LEFT AND RIGHT CORONARY CATHETERS IN COMBINATION
  • 21. CATHETERS USED FOR PERIPHERAL ANGIOGRAPHY AND NON VASCULAR INTERVENTION 1. MICROCATHETER 2. PIGTAIL CATHETER
  • 22. OTHER CATHETERS GUIDEWIRES USED IN ANGIOGRAPHY 1. TEREMO WIRE 2. TIGER CATHETER MULTIPURPOSE FOR BOTH LEFT AND RIGHT CORONARY 3. CATHETER FOR ANOMALOUS ORIGIN OF RT CORONARY AND IN PDA
  • 23.       INTERVENTION THERAPIES FOR HEPATIC MALIGNANCIES BENIGN BILIARY OBSTRUCTION MALIGNANT BILIARY OBSTRUCTION PERCUTANEOUS MANAGEMENT OF PORTAL HYPERTENSION PERCUTANEOUS CHOLECYSTOSTOMY PERCUTANEOUS MANAGEMENT OF BILIARY CALCULI
  • 24.  Regional arterial infusion and chemoembolisation is the most common technique used in hepatic malignancies  Chemoembolisation agents should have characters of rapid first pass clearence, steep dose response curve  Temporary agents commonly used are gelfoam cause recanalisation in 4-6 weeks  Permanent are polyvinyl alcohol cause angiogenesis  Lipiodol is agent used for diagnostic imaging in liver
  • 25.  The arterial supply of the liver is mapped out and portal vein patency is established, catheterization of the hepatic arteries is undertaken. With the new lubricious coatings, this usually can be accomplished with 5.0-5.5 French catheters  cirrhosis and hepatocellular carcinoma coexist frequently in patients with chronic hepatitis, the portal circulation should also be assessed for hepatofugal flow.  Because the hepatic artery is to be embolized intentionally, confirmation of portal vein patency is essential. This can be accomplished with superior mesenteric or splenic artery angiography to rule out thrombosis  repeated chemoembolizations, the blood supply of the liver must be reassessed continuously because different flow patterns will emerge over time this is mainly due to collateral formation from the “culprit vessels” from peripheral arteries
  • 26. CELIAC ANGIOGRAPHY IN CIRRHOSIS AND HEPATOCELLULAR CA
  • 27. HEPATOCELLULAR CARCINOMA WITH PORTAL VIEN THROMBOSIS
  • 28. SIMMOND S CATHETER WAS USED METASTATIC OCULAR MELANOMA WITH SELECTIVE CATHETERISATION AND OCCLUSION OF COLLATERAL FROM SUPERIOR MESENTERIC ARTERY
  • 29. SELECTIVE EMBOLISATION OF RIGHT GASTRIC ARTERY
  • 30. HYPERVASCULA R LIVER TUMOUR AND FISTULA FROM LEFT HEPATIC ARTERY TO IVC COIL BLOCKAGE OF FISTULA BEFORE CHEMOEMBOLIS ATION TO PREVENT LEFT TO RIGHT SHUNT
  • 31. HEPATIC METASTASIS FROM COLORECTAL CA RT LOBE OF LIVER WITH HYPEREMIC BORDER
  • 32.  RADIOFREQUENCY ABLATION   underlying principle is the local creation of heat, via a percutaneously or surgically placed probe, that destroys tumor tissue while insulating and sparing adjacent normal liver. using probes as small as 15-gauge to 17-gauge needles, alternating current causes tissue coagulation by frictional heating. Tumor tissue is ablated as temperatures reach 50-100 C, and yet, noncancerous tissue as close as 0.5 cm away is spared
  • 33.   Complete and accurate demonstration of the bile duct obstruction and of the bile ducts above and below the lesion is a key element in the management of bile duct stenoses and obstructions. This will usually require opacification of the bile ducts by percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), or injection of contrast through any indwelling catheters such as T tubes. Procedures performed are:   Dilatation Endoprosthesis Metallic stenting
  • 34.  Dilatation  percutaneous biliary dilatation using balloon dilation catheters include those of Burhenne (1975) via a T-tube tract and of Molnar and Stockum (1978) via the transhepatic route.  The balloon size should match the estimated caliber of the duct on either side of the stricture and is usually in the 4- to 8-mm range. Duct rupture is most unusual with correctly sized balloons even though high pressures (up to 16 atm) are not infrequently needed to dilate the stricture. Progress in balloon manufacture now provides balloons that can be used at up to 20 atmospheres in pressure. Stricture dilatation can be very painful, and adequate sedation and pain control are important.  A drainage catheter, of 10-12 French and occasionally 14 French, is left across the stricture for 6 weeks and then exchanged for a new selfretaining catheter positioned in the biliary tree above the stricture.
  • 35. POSITION OF PATIENT FOR PTBD AND THE OPACIFICATION OF BILIARY RADICLE AS SHOWN IN THE SECOND IMAGE WITH DILATION OF CBD
  • 36. PATIENT WITH OPEN CHOLECYSTECTOMY AND DAMAGE TO RIGHT HEPATIC DUCT WHICH WAS REPAIRED BY ROUX EN Y FUTHER SUFFERED CHOLANGITIS DUE TO STRICTURE TREATED BY BALLON DILATATION
  • 37.  METALLIC STENTING  INDICATIONS  ALL SURGICAL OPTIONS ARE EXHAUSTED AND DILATATION HAVE FAILED  Gianturco stent appears to provide reasonable palliation  PROCEDURE  GIANTURCO STENT NO 8, 10, 12 MM IS USED  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
  • 38. METALLIC STENT PLACEMENT IN A PATIENT WITH BEIGN STRICTURE
  • 39.  ROLE OF RADIOLOGIST PERFORM CECT OR MRCP TO PROPERLY DELINEATE THE LIVER AND BILIARY TRACT ANATOMY  FUTHER DEFINE THE ANATOMY USING PTC AND PERFORM A PTBD  IMPROVE METABOLIC STATUS OF THE PATIENT  PERFORM A HEPATIC ARTERIOGRAPHY TO RULE OUT AND TUMOUR OR MASS ENCASING THE LIVER AND FOR MARKING THE LIVER ANATOMY 
  • 40. the general location of the puncture site within the biliary tree (i.e., peripherally or centrally); (2) the angle formed by the junction of the needle and the specific duct entered; and (3) the therapeutic objectives of future biliary interventions. After the diagnostic PTC is performed using a 21- to 23gauge “skinny needle” (Chiba needle or trocar needle), a percutaneous biliary drainage (PBD) is performed Eventual placement of an 8-10F multi-side-hole locking pigtail catheter across the obstruction
  • 41.  PERCUTANEOUS MANAGEMENT OF BILE DUCT STONES  STONE EXTRACTION THROUGH T -TUBE TRACT
  • 42. TRANSHEPATIC CHOLEDOCHOLITHOTOMY 1. a 21- or 22-gauge needle is used to access the duct of interest. A 0.018-inch guide wire is advanced through the needle, maneuvered into the common bile duct, and exchanged for a standard 0.035-inch guide wire over an intermediary exchange dilator 2. an appropriate catheter and guide wire may be manipulated through the distal duct and bowel. It would be traumatic to extract large calculi through the transhepatic tract. 3. Therefore, a technique that will allow expulsion of stones or stone fragments through the duct into the duodenum must be used.
  • 43.  TRANS JEJUNAL CHOLEDOCHOLITHOTOMY        PERCUTANEOUS CHOLANGIOSCOPY     IN DISEASES ASSOCIATED WITH RECURRENT CALCULI AND BILE DUCT STRICTURES FREE ASSESMENT OF HEPATIC DUCT AND FOR LONG TERM LINE PLACEMENT TO ENSURE COLON IS NOT PUNCTURED IT IS PRE OPACIFIED BY BARIUM ONE DAY PRIOR HEPATIC FLEXURE METALLIC ANCHOR DEVICE IS PLACED IN SMALL BOWEL FOR JEJUNOPEXY DRAIN CAN BE EASILY REINSERTED IF IT FALLS OFF EASY RECATHETERISATION A 3-5 MM ENDOSCOPE CAN BE PASSED THROUGH THE T TUBE TRACT FOR ASSESSMENT AND REMOVAL OF THE STONES ESWL ANGIOPLASTY BALLON CATHETERS FOGARTHY CATHETERS
  • 44. PERCUTANEOUS CHOLECYSTOLITHOTOMY (PCCL) DIRECT PERCUTANEOUS EXTRACTION OF STONE FRAGMENTS AND REMOVAL OF STONE AFTER STONE FRAGMENTATION OR CONTACT DISSOLUTION
  • 45.  IT INCLUDES THE FOLLOWING PROCEDURES 1. TRANSHEPATIC VARICEAL EMBOLIZATION 2. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTS (TIPS) 3. PERCUTANEOUS REVISION OF SURGICAL PORTOSYSTEMIC SHUNTS 4. CHECK SHUNT PATENCY
  • 46. 1. TRANS HEPATIC PORTOGRAM HEPATOFUGAL FILLING 1. CORONARY VEIN VENOGRAM 2. VENOUS OCCLUSION BY CONTRAST 3. SPLENIC PORTOGRAM SHOWS NO VARIECES TRANS HEPATIC VARICEAL EMBOLISATION IN A PATIENT WITH UNCONTROLLED BLEEDING VARIECES
  • 47. PERCUTANEOUS TREATMENT OF PORTAL HYPERTENSION 1. TRANS HEPATIC PORTOGRAM OCCLUSION OF PORTAL VIEN 2. SPLENIC PORTOGRAM SHOWS LEFT GASTRIC COLLATERALS 3. WALLENT,S STENT DEPLOYED AFTER OCCLUSION 4. SPLENIC PORTOGRAM SHOWS NORMAL FLOW WITH NO COLLATERALS
  • 48. TIPS PLACEMENT IN DISTAL PORTAL VEIN AND SPLENIC VEIN THROMBOSIS