2. TECHNIQUE
Diagnostic Angiography-
The Common Femoral Artery is the commonly
used entry site for percutaneous approach because
of
Its accessibility,
The ease of compression against the femoral
head for hemostasis,
The low rate of complications when punctured.
Contralateral femoral artery is used.
5. The catheter is placed selectively in the major
vessel supplying the tumor and angiographic
runs are taken with contrast medium injection.
Various selective injections are taken depending
upon the tumor supply.
The amount of contrast injection depends on
the size and location of the lesion.
6. Angioembolization-
Refers to the introduction of an embolic
agent into a vessel through a selectively
placed catheter to achieve therapeutic
vascular occlusion.
The embolization is usually performed using
the access used for diagnostic angiography.
After the initial diagnostic angiography the
angiographic catheter is advanced into the
artery supplying the tumor before
introduction of embolic material.
7. The embolization should preferably be
performed in angiography suite equipped
with C-arm mounted image intensifier with
digital subtraction angiography of high
quality resolution.
8. Angiography In Bone
Tumors
The role of angiography in bone tumors is limited
because of the following reasons:
If the definitive angiographic features of
malignancy are present, it can be assumed that
the lesion is malignant, but normal arteriogram
does not entirely rule out a malignancy.
It is often not possible to distinguish between
various types of bone tumors from the
angiographic features alone.
9. The angiographic features of
malignancy include
Neovascularity,
Pooling or laking of contrast material,
Tumor stain or blush,
Encasement and occlusion of vessels,
Extension of the tumor vascularity
outside bone,
Displacement of vessels,
Arteriovenous shunts,
Abnormal draining veins,
Tumor invasion of veins.
10. Neovascularity and pooling of contrast are
important features of malignancy.
Ewing’s tumor
(A) Lytic lesion with periosteal reaction and soft tissue mass of
ulna,
11. The presence of a Tumor Blush does not indicate
malignancy but may suggest the size and extent of the
tumor.
12. Osteochondroma
These bone tumors because of their size and
location may cause vascular complications in the
form of thrombosis and pseudoaneurysms as well
as displacement of vessels.
Angiography can show all these complications
13. Osteoid
Osteoma
The angiographic feature is dense,
circumscribed blush in the early arterial phase
which persists in late venous phase.
This feature differentiates it from osteomyelitis,
Brodie’s abscess and stress fractures that do not
have the feature of dense vascular blush
14. Osteosarcoma
Angiography can demonstrate that the tumor is
malignant.
Accurately define the degree of soft tissue
extension.
15. Giant Cell
Tumor
Angiography can
accurately define the
intra as well as
extraosseous extent of
the tumor because the
tumors are usually
hypervascular and
show neovascularity,
intense blush and
early venous filling.
16. Aneurysmal Bone
Cyst
Angiography can differentiate Aneurysmal Bone
Cyst from Giant Cell Tumor.
On angiography, it is poorly vascularized tumor,
devoid of arteriovenous fistulae and soft tissue
invasion.
17. Angiography In Bone And Soft Tissue Lesions Of
Vascular Origin
Hemangioma-
Hemangiomas can be grouped into four
categories:
Capillary,
Cavernous,
Venous hemangiomas
Arteriovenous malformations.
18. Arteriography can define the extent, degree of
vascularity, source of vascular supply, local
recurrence in follow-up case and differentiate from
arteriovenous malformations.
Angiography may show mild to marked vascularity
with coarse, irregular, enlarged arteries and pooling
of contrast material.
19. Soft tissue hemangioma leg.
Digital subtraction angiography shows fine vessels
with some pooling of contrast (arrow). This painful
lesion was successfully treated by percutaneous
injection of sclerosing agent.
20. Arteriovenous Malformations
(AVMs)
The angiographic findings include enlarged, tortuous feeding
arteries, a dense nidus of malformations and early
opacification of draining veins.
Transcatheter embolization close to nidus of the lesion has
now attained a primary role in the management of AVMs.
Arteriovenous
malformations of cheek.
(A) CT shows soft tissue
vascular mass overlying
maxilla, mandible, inferior
orbital margin,
(B) On DSA, the mass is
supplied by branches of
left external carotid artery
with early venous filling
21. Angiography In Metastatic Tumors In Bone And
Soft Tissues
Most metastatic lesions have the same vascular
characteristics that are exhibited by their primary
tumors.
Angiography In Peripheral Trauma-
Important role in the management of patients with
suspected vascular injury both for diagnosis and
treatment.
Angiography is both sensitive and specific for
the diagnosis of vascular injury (active bleeding,
pseudoaneurysms and arteriovenous fistula)
22. The DSA in different patients of trauma: (A and B) Fracture femur and fibula with
patent arteries, (C) Fracture femur with thrombosed superficial femoral artery
(arrow) with collaterals, (D) Soft tissue injury left shoulder with thrombosed axillary
artery-brachial artery is filling from collaterals, (E) Large pseudoaneurysm from
axillary artery, (F) Large pseudoaneurysm from right superficial femoral artery, (G)
Arteriovenous fistula between popliteal artery and vein.
23.
24.
25. Image Guided Interventions In Bone And Soft
Tissue Lesions
The commonly used image guided interventions
are
Fine needle aspiration cytology and trucut
biopsies,
Embolizations,
Intra-arterial chemotherapies,
Vertebroplasties,
Radiofrequency, Laser ablation of benign
bone lesions.
26. 1. Aspiration Cytology and
Biopsy
The role of aspiration cytology is limited since most
lesions require biopsy.
Percutaneous biopsy is less invasive, requires
smaller dose of anesthetics and analgesics,
causes minimal bleeding and biopsy tract
contamination, and is a cost effective method.
27.
28. For bone biopsy thick needles
(11G) with diamond tip is
preferred.
29. 2. Embolization
Preprocedural Preparations-
The patient must be informed about the
procedure, benefits, alternative procedures and
potential complications.
The patient should be well hydrated and standby
general anesthesia may be needed for
uncooperative patients and children.
Severe coagulopathy should be corrected and
sometimes antibiotics are also given.
The sedation is given during the procedure
depending upon the type and duration of the
30. The indications of embolization in bone and soft tissue
tumors are-
To control hemorrhage
To reduce operative bleeding
As palliative treatment
To relieve from chronic pain due to tumors
As a part of treatment
Contraindications-
Hemorrhagic diathesis
Puncture site infection.
31. Embolizing Materials-
The materials can be categorized as short,
intermediate and long acting or as particulate or
liquid agents depending upon the physical properties.
32. Preoperative embolization of a very large hemangioma
around knee for reconstructive surgery.
(A) Preembolization,
(B) Post-embolization angiograms
33. Painful metastatic deposit in the spine treated by
therapeutic arterial occlusion.
(A) Pre-embolization,
(B) Post-embolization angiograms
34. (A) Hemangioma submandibular region,
(B) Supplied by right facial and lingual arteries,
(C) The common origin of which embolized by steel
coils (arrow)
35. Complications-
The common complications are
postembolization syndrome in the form of
nausea, vomiting, fever and pain due to tissue
ischemia.
The uncommon complications reported are
inadvertent embolization, misplaced or migrated
steel coils, abscess formation, spinal cord injury,
aneurysm formation or vessel rupture.
36. 3. Intra-arterial
Chemotherapy
Patients with sarcomas not
amenable to cure by
surgical resection alone
can benefit from
preoperative intra-arterial
chemotherapy.
In this chemotherapeutic
drug is injected in tumor
bed with the help of
angiographic catheter
placed in the artery
supplying the tumor.Soft tissue sarcoma thigh. Postoperative angiogram was done to look for residual
mass and intra-arterial chemotherapy.
37. 4. Percutaneous Vertebroplasty-
Percutaneous vertebroplasty is a well-accepted
interventional procedure for the treatment of
painful vertebral lesions.
The technique first introduced in 1984 for a
vertebral hemangioma, has been subsequently
used for the treatment of numerous lesions
causing back pain associated with vertebral
involvement like osteoporotic vertebral collapse,
metastatic disease, multiple myeloma and
symptomatic vertebral hemangiomas.
38. In a vertebral hemangioma, the fine trabeculae are
replaced by venous channels, which predispose the patient
to painful microfractures.
39. Technique
Instilling acrylic bone cement into the affected
vertebra through a bone biopsy needle by a
percutaneous approach.
The cement consists of polymethyl-
methacrylate.
The cement is injected into the lesion after needle
placement, under fluoroscopic control.
The cement polymerizes and subsequently sets,
affording support to the vertebra.
Approximately 6 ml of PMMA cement is injected.
Patient is placed in supine position for three hours
after the procedure and is discharged after 6
hours.
40. (A) A 30-year-old female with symptomatic D12 vertebra
hemangioma, successfully treated with percutaneous
vertebroplasty using polymethyl methacrylate bone
cement.
T2W pretreatment MR shows D12 vertebral body
hemangioma, (B) The vertebroplasty needle is seen in
41. Complications
Cement leaks outside the vertebra are mostly
inconsequential, but can cause local or radicular pain,
neurological damage and pulmonary embolism.
Inaccurate needle placement can injure nerve root or
spinal cord.
Pain exacerbation may occur due to substantial
cement leaks.
Rarely puncture site infection and bleeding may
occur.
42. Although vertebroplasty can give considerable
pain relief, it is not very useful in vertebral body
height restoration.
A new technique called Kyphoplasty involves
the inflation of a bone tamp within the vertebral
body to restore the height of the vertebra, and
subsequently placing bone cement for
augmentation of strength.
Esthetic improvement, improved posture and a
reduced risk of fracture of the adjacent vertebra
43.
44.
45.
46. 5. Percutaneous Treatment of Disk Herniation-
Low backache is one of the major cause of chronic
pain and morbidity.
These include Percutaneous laser disk
decompression (PLDD), percutaneous ozone
therapy and percutaneous/endoscopic nucleotomy
PLDD- In PLDD, laser energy is delivered into
nucleus pulposus by laser fiber, through a needle.
The aim of PLDD is to vaporize a small portion of the
nucleus pulposus. The ablation of this small volume
results in reduction of intradiskal pressure, thus
reducing the disk herniation.
47.
48. Percutaneous Ozone Treatment-
Mixture of ozone-oxygen gas is administered into
nucleus pulposus through the needle.
This mixture has a direct effect on the
proteoglycans of the nucleus pulposus, resulting in
release of water molecules and subsequent
degeneration of matrix and reduction of volume.
Approximated 4 ml ozone-oxygen mixture is
injected.
49. 6. Percutaneous Ablation of Bone Tumors-
Percutaneous image guided tumor ablation with
thermal energy source such as radiofrequency, laser or
microwave energy is used in the treatment of both
benign (osteoid osteoma, osteoblastoma,
enchondroma, etc.) and malignant (metastatic) lesions.
The procedure is performed with CT guidance either
under general anesthesia or conscious sedation.
A proper bone biopsy needle is placed into the lesion
with the help of a hammer or a drill.
Radiofrequency probe or laser fiber is introduced
through the cannula and proper energy is delivered for
ablation.
50. Percutaneous RF ablation of osteoid osteoma. Radiograph of left hip AP view (A),
unenhanced axial (B) and coronal (C) CT images showing a small calcified nidus
(small arrow) with surrounding sclerosis (long arrow). After placement of bone
biopsy needle (small arrow) into the lesion under CT guidance the stylet was
withdrawn and the RF probe (long arrow) was introduced (D). Axial CT image at
the time of procedure (E) showing tip of the biopsy needle in the lesion. Post-
treatment (one week) AP radiograph (F) does not show nidus and patient is
51. Conclusion
If the Angiointervention procedures are used
properly in conjunction with other diagnostic
studies like CT & MRI, it can play a valuable role in
the diagnosis and treatment of bone and soft
tissue lesions.
