DR. AKSHAY GURSALE
(RESIDENT RADIOLOGY)
What is a
CATHETER ?
2
DEFINITION:
A catheter is a hollow flexible tube that can be inserted into a body
cavity, duct or vessel. Catheters thereb...
What is a Catheter made up of ?
Materials:
A range of polymers are used for the construction of
catheters, including silic...
PARTS OF A CATHETER
BODY

 HUB
 BODY
HUB

TIP

 TIP

5
MEASUREMENT:
FRENCH CATHETER SCALE:
The French catheter scale (most correctly abbreviated as Fr, but also often
abbreviate...
TYPES OF CATHETERS:
CLASSIFICATION :

Catheters can be classified depending on
 SIDE HOLES :

-: Single Hole

-:End Hole ...
TYPES OF CATHETERS
 SHAPES
 Straight Catheter

 Pigtailed Catheter
 Cobra Shaped Catheter

 Side Winder Catheters (Sh...
Some Other Types of Catheters:
 Hydrophilic Catheters :

Hydrophilic-coated catheters have a layer of polymer
coating tha...
Different Catheter Curves
For Different Purposes:
> Judkins Left (JL)
> Judkins Right ( JR)
> Judkins Left Short Tip
> Jud...
CATHETERS CAN BE BROADLY CLASSIFIED
UNDER THESE GROUPS:
 DIAGNOSTIC CATHETERS
Used for Angiographs .

 GUIDING CATHETERS...
PUNCTURE NEEDLES:
Used to cannulate or puncture the artery.

Usual Sizes include

18 ga, 19 ga , 20ga, 21 ga.

Seldinger N...
GUIDE WIRE:
Diagnostic guide wires are used to traverse vascular anatomy to aid in
placing catheters and other devices. Gu...
Shape of the Tip :
J Tip / Straight Tip

14
 In 1929 Werner

Forssmann
demonstrated that a simple
Rubber catheter could be passed to
the pulmonary artery through the...
In 1953 ,
Sven –Ivar Seldinger invented

The technique of gaining access
Percutaneusly into an artery
without An arterioto...
TECHNIQUE OF INSERTING A CATHETER
SELDINGER TECHNIQUE:
The technique of catheter insertion via
double-wall needle puncture...
18
COMPLETE APPARATUS:
> Needle
 Guide Wire
 Sheath
 Catheter

19
COMMON CORONARY CATHETERS
USED FOR ANGIOGRAPHY
1. HEAD HUNTER
2. JUDKINS LEFT CORONARY
3. JUKINS LEFT AND RIGHT
CORONARY C...
CATHETERS USED FOR
PERIPHERAL
ANGIOGRAPHY AND
NON VASCULAR
INTERVENTION
1. MICROCATHETER
2. PIGTAIL CATHETER
OTHER CATHETERS
GUIDEWIRES USED IN
ANGIOGRAPHY
1. TEREMO WIRE
2. TIGER CATHETER
MULTIPURPOSE FOR
BOTH LEFT AND
RIGHT CORON...









INTERVENTION THERAPIES FOR
HEPATIC MALIGNANCIES
BENIGN BILIARY OBSTRUCTION
MALIGNANT BILIARY OBSTRUCTION
PE...


Regional arterial infusion and

chemoembolisation is the most common
technique used in hepatic malignancies


Chemoemb...


The arterial supply of the liver is mapped out and portal vein
patency is established, catheterization of the hepatic a...
CELIAC ANGIOGRAPHY IN
CIRRHOSIS AND
HEPATOCELLULAR CA
HEPATOCELLULAR CARCINOMA
WITH PORTAL VIEN
THROMBOSIS
SIMMOND S
CATHETER
WAS USED

METASTATIC OCULAR MELANOMA WITH SELECTIVE CATHETERISATION AND
OCCLUSION OF COLLATERAL FROM SU...
SELECTIVE EMBOLISATION OF RIGHT GASTRIC
ARTERY
HYPERVASCULA
R LIVER TUMOUR
AND FISTULA
FROM LEFT
HEPATIC ARTERY
TO IVC
COIL BLOCKAGE
OF FISTULA
BEFORE
CHEMOEMBOLIS
ATION...
HEPATIC METASTASIS FROM COLORECTAL CA
RT LOBE OF LIVER WITH HYPEREMIC BORDER


RADIOFREQUENCY ABLATION




underlying principle is the local creation of heat, via a percutaneously or
surgically pl...




Complete and accurate demonstration of the bile duct
obstruction and of the bile ducts above and below the lesion is...


Dilatation


percutaneous biliary dilatation using balloon dilation catheters include
those of Burhenne (1975) via a T...
POSITION OF PATIENT FOR PTBD AND THE OPACIFICATION
OF BILIARY RADICLE AS SHOWN IN THE SECOND IMAGE
WITH DILATION OF CBD
PATIENT WITH OPEN CHOLECYSTECTOMY AND DAMAGE TO
RIGHT HEPATIC DUCT WHICH WAS REPAIRED BY ROUX EN Y
FUTHER SUFFERED CHOLANG...


METALLIC STENTING


INDICATIONS
 ALL SURGICAL OPTIONS ARE EXHAUSTED AND

DILATATION HAVE FAILED
 Gianturco stent app...
METALLIC STENT
PLACEMENT IN A
PATIENT WITH BEIGN
STRICTURE


ROLE OF RADIOLOGIST
PERFORM CECT OR MRCP TO PROPERLY DELINEATE
THE LIVER AND BILIARY TRACT ANATOMY
 FUTHER DEFINE THE ...
the general location of the puncture site within the
biliary tree (i.e., peripherally or centrally); (2) the
angle formed ...


PERCUTANEOUS MANAGEMENT OF BILE DUCT
STONES


STONE EXTRACTION THROUGH T -TUBE TRACT
TRANSHEPATIC CHOLEDOCHOLITHOTOMY
1. a 21- or 22-gauge needle is used to access the duct of interest. A 0.018-inch guide
wi...


TRANS JEJUNAL CHOLEDOCHOLITHOTOMY









PERCUTANEOUS CHOLANGIOSCOPY






IN DISEASES ASSOCIATED WITH REC...
PERCUTANEOUS CHOLECYSTOLITHOTOMY (PCCL)
DIRECT PERCUTANEOUS
EXTRACTION OF STONE
FRAGMENTS AND
REMOVAL OF STONE
AFTER STONE...


IT INCLUDES THE FOLLOWING PROCEDURES
1.

TRANSHEPATIC VARICEAL EMBOLIZATION

2.

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMI...
1. TRANS
HEPATIC
PORTOGRAM
HEPATOFUGAL
FILLING
1. CORONARY
VEIN
VENOGRAM
2. VENOUS
OCCLUSION
BY CONTRAST
3. SPLENIC
PORTOG...
PERCUTANEOUS
TREATMENT OF PORTAL
HYPERTENSION
1. TRANS HEPATIC
PORTOGRAM
OCCLUSION OF
PORTAL VIEN
2. SPLENIC PORTOGRAM
SHO...
TIPS PLACEMENT IN DISTAL PORTAL VEIN AND SPLENIC VEIN THROMBOSIS
Intervention radiology hepatobiliary system
Intervention radiology hepatobiliary system
Intervention radiology hepatobiliary system
Intervention radiology hepatobiliary system
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Intervention radiology hepatobiliary system

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Intervention radiology hepatobiliary system

  1. 1. DR. AKSHAY GURSALE (RESIDENT RADIOLOGY)
  2. 2. What is a CATHETER ? 2
  3. 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. 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. 5. PARTS OF A CATHETER BODY  HUB  BODY HUB TIP  TIP 5
  6. 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. 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. 8. TYPES OF CATHETERS  SHAPES  Straight Catheter  Pigtailed Catheter  Cobra Shaped Catheter  Side Winder Catheters (Shepherd) 8
  9. 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. 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. 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. 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. 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. 14. Shape of the Tip : J Tip / Straight Tip 14
  15. 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. 16. In 1953 , Sven –Ivar Seldinger invented The technique of gaining access Percutaneusly into an artery without An arteriotomy. Sven- Ivar Seldinger 16
  17. 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. 18
  19. 19. COMPLETE APPARATUS: > Needle  Guide Wire  Sheath  Catheter 19
  20. 20. COMMON CORONARY CATHETERS USED FOR ANGIOGRAPHY 1. HEAD HUNTER 2. JUDKINS LEFT CORONARY 3. JUKINS LEFT AND RIGHT CORONARY CATHETERS IN COMBINATION
  21. 21. CATHETERS USED FOR PERIPHERAL ANGIOGRAPHY AND NON VASCULAR INTERVENTION 1. MICROCATHETER 2. PIGTAIL CATHETER
  22. 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. 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. 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. 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. 26. CELIAC ANGIOGRAPHY IN CIRRHOSIS AND HEPATOCELLULAR CA
  27. 27. HEPATOCELLULAR CARCINOMA WITH PORTAL VIEN THROMBOSIS
  28. 28. SIMMOND S CATHETER WAS USED METASTATIC OCULAR MELANOMA WITH SELECTIVE CATHETERISATION AND OCCLUSION OF COLLATERAL FROM SUPERIOR MESENTERIC ARTERY
  29. 29. SELECTIVE EMBOLISATION OF RIGHT GASTRIC ARTERY
  30. 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. 31. HEPATIC METASTASIS FROM COLORECTAL CA RT LOBE OF LIVER WITH HYPEREMIC BORDER
  32. 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. 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. 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. 35. POSITION OF PATIENT FOR PTBD AND THE OPACIFICATION OF BILIARY RADICLE AS SHOWN IN THE SECOND IMAGE WITH DILATION OF CBD
  36. 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. 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. 38. METALLIC STENT PLACEMENT IN A PATIENT WITH BEIGN STRICTURE
  39. 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. 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. 41.  PERCUTANEOUS MANAGEMENT OF BILE DUCT STONES  STONE EXTRACTION THROUGH T -TUBE TRACT
  42. 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. 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. 44. PERCUTANEOUS CHOLECYSTOLITHOTOMY (PCCL) DIRECT PERCUTANEOUS EXTRACTION OF STONE FRAGMENTS AND REMOVAL OF STONE AFTER STONE FRAGMENTATION OR CONTACT DISSOLUTION
  45. 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. 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. 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. 48. TIPS PLACEMENT IN DISTAL PORTAL VEIN AND SPLENIC VEIN THROMBOSIS
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