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Introduction to interventional radiology feb 2013


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Introduction to interventional radiology feb 2013

  1. 1. Interventional Radiology Dhruv Patel
  2. 2. Objectives • What is it? • Who’s bright idea was this? • What can IR do for your patient?
  3. 3. What is it? • Interventional Radiology is the use of imaging to do procedures, like: – Angiograms – Central Line placement – Biliary stenting – Tumor therapy • Almost all current catheter based and [non-laparoscopic] minimally invasive procedures have their origin in IR
  4. 4. History • Pioneered by Dr. Dotter from Oregon • Originally all radiologists would perform angiograms (but only diagnostic) • One of his patients had severe PAD and gangrenous toes, but was refusing amputation • He decided to use a dilator to open up the blood vessel and thus angioplasty was born
  5. 5. History • Most IR procedures would be impossible without this man: Dr. Sven Ivar Seldinger
  6. 6. What can IR do for you…I mean your patient? • If you can think of a problem, an Interventional Radiologist can come up with the solution • We invented ways to: – Open blockages – Biopsy masses – Treat tumors – Drain abscesses • All without needing to do surgery
  7. 7. What IR Invented • 1964 Angioplasty • 1966 Embolization therapy to treat tumors and spinal cord vascular malformations by blocking the blood flow • 1967 The Judkins technique of coronary angiography, the technique still most widely used around the world today • 1967 Closure of the patent ductus arteriosis, a heart defect in newborns of a vascular opening between the pulmonary artery and the aorta • 1967 Selective vasoconstriction infusions for hemorrhage, now commonly used for bleeding ulcers, GI bleeding and arterial bleeding • 1969 The catheter-delivered stenting technique and prototype stent • 1960-74 Tools for interventions such as heparinized guidewires, contrast injector, disposable catheter needles and see-through film changer • 1970’s Percutaneous removal of common bile duct stones • 1970’s Occlusive coils • 1972 Selective arterial embolization for GI bleeding, which was adapted to treat massive bleeding in other arteries in the body and to block blood supply to tumors • 1973 Embolization for pelvic trauma • 1974 Selective arterial thrombolysis for arterial occlusions, now used to treat blood clots, stroke, DVT, etc. • 1974 Transhepatic embolization for variceal bleeding • 1977-78 Embolization technique for pulmonary arteriovenous malformations and varicoceles • 1977-83 Bland- and chemo-embolization for treatment of hepatocellular cancer and disseminated liver metastases • 1980 Cryoablation to freeze liver tumors • 1980 Development of special tools and devices for biliary manipulation • 1980’s Biliary stents to allow bile to flow from the liver saving patients from biliary bypass surgery • 1981 Embolization technique for spleen trauma • 1982 TIPS (transjugular intrahepatic portosystemic shunt) to improve blood flow in damaged livers from conditions such as cirrhosis and hepatitis C • 1982 Dilators for interventional urology, percutaneous removal of kidney stones • 1983 The balloon-expandable stent (peripheral) used today • 1985 Self-expanding stents • 1990 Percutaneous extraction of gallbladder stones • 1990 Radiofrequency ablation (RFA) technique for liver tumors • 1990’s Treatment of bone and kidney tumors by embolization • 1990’s RFA for soft tissue tumors, i.e., bone, breast, kidney, lung and liver cancer • 1991 Abdominal aortic stent grafts • 1994 The balloon-expandable coronary stent used today • 1997 Intra-arterial delivery of tumor-killing viruses and gene therapy vectors to the liver • 1999 Percutaneous delivery of pancreatic islet cells to the liver for transplantation to treat diabetes • 1999 Developed the endovenous laser ablation procedure to treat varicose veins and venous disease
  8. 8. Common Procedures • Vascular: – Central Lines – Angioplasty – Aortic Endografts – TIPS • Biliary and Urologic: – Cholecystostomy – Biliary drainage – Nephrostomy • Cancer – Biopsies – Tumor Ablation
  9. 9. Central Lines • Placed using a combination of ultrasound and fluoroscopy • Proven reduced complication rate than non-imaged guided placement of central lines • Majority are semi-permanent lines, such as: – PICC Lines – Ports – Tunneled central venous catheter
  10. 10. Angioplasty • Predominantly performed by Cardiologists and Vascular Surgeons • Most common arterial based intervention is left-sided cardiac catheterization • Less frequently, lower extremity or renal angiograms, as well as aortograms, are performed • If a stenosis is considered significant, usually greater than 70%, we can balloon dilate and place a stent
  11. 11. Angioplasty
  12. 12. Angioplasty
  13. 13. Angioplasty
  14. 14. Aortic Endografts • Pinnacle of intra-arterial intervention • Complex procedure, often involving multiple access points • Requires precise planning with high-resolution CT imaging to characterize aorta • Saves a great deal of morbidity in comparison to open procedure
  15. 15. Open Abdominal Aorta Repair
  16. 16. Aortic Endograft Placement
  17. 17. TIPS • Another high profile procedure • Wha does it stand fo? – Transjugular Intrahepatic Portosystemic Shunt • We: – Place a huge needle in the right IJ that goes through the heart – Punctures a portal vein – Pass a wire and balloon through this needle – Form a tract, then dilate and stent it
  18. 18. TIPS
  19. 19. TIPS
  20. 20. TIPS
  21. 21. TIPS
  22. 22. Biliary • Cholecystostomy is performed as a bridge to cholecystectomy – Usually if the patient is too sick to have surgery • Biliary drainage is performed in those that have ductal obstruction not amenable to ERCP, usually from cancer
  23. 23. Cholecystostomy
  24. 24. Biliary Drainage
  25. 25. Biliary Drainage
  26. 26. Biliary Drainage
  27. 27. Nephrostomy • Very similar to biliary drainage procedures • Usually always used in a circumstance where access from below is impractical or impossible – Cancer – Large stones • Also used as a guide for percutaneous stone access for Urology
  28. 28. Nephrostomy
  29. 29. Nephrostomy
  30. 30. Nephrostomy
  31. 31. Biopsies • Now performed by “body” radiologists at most academic institutions • Often biopsy of very small masses is difficult and requires skill with fine needle manipulation • Most commonly is used for: – Lung nodules – Random liver – Soft tissue masses – Random kidney
  32. 32. Biopsy
  33. 33. Tumor Ablation • We can do this in two ways: – Percutaneous – Intra-arterial • With percutaneous therapy we use: – Cryo – Microwave – Radiofrequency • Most common intra-arterial therapy is Liver Chemoembolization
  34. 34. Percutaneous Tumor Ablation
  35. 35. Percutaneous Tumor Ablation
  36. 36. Percutaneous Tumor Ablation
  37. 37. Newer Procedures • Uterine Artery Embolization • Pancreatic Islet Cell Transplantation • Dural Venous Sinus Angioplasty