Starting with the Definition, Coverage of field, Seldinger technique, Instruments used in IR we move forward into the embolization Techniques and applications, IR procedures in hepatobiliary system, Portal hypertension, Varicose veins
and lastly RFA for bone tumors like ostoid osteoma
This presentation provides sufficient material for anyone who wants is interested in interventional radiology. Here we will discuss the available facilities, mechanisms and equipments.
In my opinion this presentation will prove a footstep in interventional radiology
This presentation provides sufficient material for anyone who wants is interested in interventional radiology. Here we will discuss the available facilities, mechanisms and equipments.
In my opinion this presentation will prove a footstep in interventional radiology
This presentation include biliary anatomy ,indication, contraindication post op care of percutaneus transhepatic biliary drainage with important technique. and advantage and disadvantage of different technique. This is important for radiologist, radiographers, intervention radiologist radiology resident. Thanks
Interventional radiology part 2 final-Dr Chandni WadhwaniChandni Wadhwani
Role of IR in treatment of Varicose veins and Bone lesions.
Newer modality: HIFU
Videos on Embolization techniques, role of IR in hepatobiliary system and in portal hypertension.
Basics of Interventional Radiology and Vascular Interventions RVRoshan Valentine
Brief overview of the general principles of interventional radiology, DSA, vascular interventions, catheters, guidewires, patient management, complications
VERY BASICS OF CONTRAST MEDIA IN RADIOLOGY.
CLASSIFICATION OF CONTRAST MEDIA.
APPLICATION OF CONTRAST MEDIA.
XRAY, CT, ULTRASOUND AND MRI CONTRAST AGENTS.
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
Neurointerventional Therapy for Brain Aneurysms and Acute Stroke Allina Health
By Yasha Kadkhodayan, MD. Overview of interventional neuroradiology approaches to brain aneurysm and stroke care, discussion of processes in place at Abbott Northwestern to enhance the delivery of stroke care.
This presentation include biliary anatomy ,indication, contraindication post op care of percutaneus transhepatic biliary drainage with important technique. and advantage and disadvantage of different technique. This is important for radiologist, radiographers, intervention radiologist radiology resident. Thanks
Interventional radiology part 2 final-Dr Chandni WadhwaniChandni Wadhwani
Role of IR in treatment of Varicose veins and Bone lesions.
Newer modality: HIFU
Videos on Embolization techniques, role of IR in hepatobiliary system and in portal hypertension.
Basics of Interventional Radiology and Vascular Interventions RVRoshan Valentine
Brief overview of the general principles of interventional radiology, DSA, vascular interventions, catheters, guidewires, patient management, complications
VERY BASICS OF CONTRAST MEDIA IN RADIOLOGY.
CLASSIFICATION OF CONTRAST MEDIA.
APPLICATION OF CONTRAST MEDIA.
XRAY, CT, ULTRASOUND AND MRI CONTRAST AGENTS.
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
Neurointerventional Therapy for Brain Aneurysms and Acute Stroke Allina Health
By Yasha Kadkhodayan, MD. Overview of interventional neuroradiology approaches to brain aneurysm and stroke care, discussion of processes in place at Abbott Northwestern to enhance the delivery of stroke care.
I am a Neurosurgeon with advanced training in Interventional vascular Neurosurgery(FINR) from Zurich, Switzerland, and FMINS-Fellowship in minimally invasive and Endoscopic Neurosurgery from Germany.
I am presently working in Columbia asia hospitals, Bangalore.
My areas of interest are Vascular Neurosurgery, Stroke specialist, interventional neuroradiology,
I am a Neurosurgeon with advanced training in Interventional vascular Neurosurgery(FINR) from Zurich, Switzerland, and FMINS-Fellowship in minimally invasive and Endoscopic Neurosurgery from Germany.
I am presently working in Columbia asia hospitals, Bangalore.
My areas of interest are Vascular Neurosurgery, Stroke specialist, interventional neuroradiology.
SELDINGER TECHNIQUE & INTERVENTIONAL RADIOLOGYRiyas M K
its a basic introduction about Seldinger technique and Intervetional radiology.In interventional radiology, procedures generally start with the Seldinger technique to access the vasculature, using a needle through which a guidewire is inserted, followed by navigation of catheters within the vessels.
APPROACH TO VASCULAR REPAIR, VASCULAR GRAFTS.pptxBipul Thakur
This presentation discusses briefly on Vascular Injuty, their tyoes, different types of Vascular repair, anastomosis and Various typea of Vascular frafts and their compostion, uses and the possible complicayiona of vascular injury including compartment syndrome, reperfusion injury and management including Fasciotomy.
Case of the week - superficial femoral artery pseudoaneurysmDr Abdalla M. Gamal
A presentation about an interesting case that came to the Radiology Department of Sebha Medical Center.
A 16 years old male, victim of stab wound in the lower part of the back of the right thigh, and was found to have a pseudoaneurysm in the superficial femoral artery when he was examined by ultasound one month after the injury.
The presentation contains 37 slides, and is divided into the following parts :
1 - The case
2 - Pseudoaneurysms
3 - Imaging of pseudoaneurysms
4 - Treatment of pseudoaneurysms
This presentation was prepared and presented by me in cooperation with D.Mabroka Ellafi in the tutorials of the Radiology Department of Sebha Medical Center.
Abstract
Carotid body tumors are rare, slow-growing, hypervascular neuroendocrine tumors. Although these tumors are benign neoplasm, they also have a tendency to malignant transformation. Complete surgical excision is the gold standard therapeutic modality for the treatment of carotid body tumors. Early surgical removal is recommended to prevent the development of larger and more advanced tumors, which are associated with higher morbidity and mortality. In this report, we presented three cases of carotid body tumor which were successfully treated with complete surgical excision, and reviewed the current literature. Furthermore, it was emphasized the necessity of early surgical management regardless of patient age and tumor size.
Ultrasound Physics Made easy - By Dr Chandni WadhwaniChandni Wadhwani
History of ultrasound, Principle of Ultrasound.
Ultrasound wave and its interactions
Ultrasound machine and its parts, Image display, Artifacts and their clinical importance
what is Doppler ultrasound, Elastography and Recent advances in field of ultrasound.
Safety issues in ultrasound.
Introduction to mammography and its equipment.
Different views on mammography & supplementary views.
Birads mammographic lexicon
Birads ultrasound lexicon
Imaging of suspicious mammary lymph nodes
Categories in BIRADS 2013.
Concise overview of all the information that a Medico must know for his knowledge as well as to appear for entrance exams as well as for physicians for their routine practice.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Interventional radiology part 1
1. INTERVENTIONAL RADIOLOGY- An
overview:PART 1
BY : DR. CHANDNI WADHWANI
Resident doctor
Department of Radiology
SSG HospitalVadodara.
References:
RSNA
Radiographics
Grainger
2. Agenda
Definition
Coverage of field
Seldinger technique
Instruments used in IR
EmbolizationTechniques and applications
IR procedures in hepatobiliary system
Portal hypertension
Varicose veins
RFA for bone tumors like ostoid osteoma
4. 8 out of 10 procedures use skin incisions smaller than
5 mm.
9 out of 10 procedures use only local anaesthetic,
sometimes with sedation.
Up to 8 out of 10 patients go home the same day
5. What kind of things can be done?
Treatment of vascular problems
angiogram; angioplasty +/- stenting
Embolization (blockage) of arteries
to stop bleeding or treat tumours, etc
Biopsies
Drainage of fluid collections
abscesses, kidneys or bile ducts/gallbladder
Insertion of feeding tubes
Treatment of liver tumors, bone tumors,varicose veins,
portal hypertension etc.
6. ANGIOGRAPHY
The radiologic examination of vessels after the
introduction of a contrast medium.
Post mortem injection of mercury salts in Jan,1896.
7. Seldinger Technique(1953)
Method for catheterization of vessels
(through the skin) technique for arterial and
venous access
3 vessels considered:
Femoral –preferred site for arterial (size +
accessibility)
Brachial
Axillary
8. Prerequisite
Selection based on
strong pulse / absence
of disease
Site cleaned, area
draped, local given
Sven-Ivar Seldinger Swedish Radiologist—
1921-1998
9. SELDINGER TECHNIQUE
Seldinger needle.
18gauge single use,sterile needle.
2 parts-- a solid inner needle(stylet) & an outer thin wall
needle for smooth passage.
a hub---good instrument balance
winged handle---good control.
10.
11.
12.
13. GUIDEWIRES
Guide the catheter.
Allow safe introduction of catheter into the vessel.
Made of stainless steel.
Usually about 145 cm long
An inner core wire that is tapered at the end to a soft
flexible tip.
14. Covered by a coating—teflon, heparin and recently
hydrophilic polymers(glide wires) are used.
Coating reduces friction, gives strength to GW.
Tips at the end of GW
Straight
J- tipped—prevents subintimal dissection of artery.
15.
16. CATHETERS
• Many shapes and sizes.
• diameter in French(Fr)—3Fr=1mm.
• Straight- end hole only—smaller vessels/minimal
contrast.
Pigtail- circular tip with multiple side holes —larger
vessels/ more contrast.
H1 or Head hunter tip– used for femoral approach to
brachiocephalic vessels.
Simmons catheter is highly curved --- for sharply angled
vessels--cerebral and visceral angiography.
C2 or Cobra catheter has angled tip joined to a gentle
curve—celiac, renal & mesenteric arteries
17. Common
catheter
shapes.
6. Rösch celiac
7.Visceral (very similar to
Simmons1)
8. Mickelson
9. Simmons 2
10. Pigtail
11.Tennis racket.
1. Straight
2. Davis (short angled tip)
3. Multipurpose (“hockey-stick”)
4. Headhunter (H1)
5. Cobra-2 (cobra-1 has tighter
curve, cobra-3 has larger and
longer curve);
18. Self Expanding Stent
Have radial force that anchors stent to target vessel as it
deploys.
Can be made of Nitinol that has thermal memory, they reach full
expansion at normal body temperature. Nickel titanium alloy.
19. Balloon Mounted Stent
Mounted over a balloon, expansion of the balloon
Causes deployment of this type of stent.
Precise positioning is required and is more rigid.
These are not placed over joints as can fracture.
20. Stent Grafts
Stent-grafts represent a combination of stent and
surgical bypass conduit technology. Internal
bypasses.
22. Trapease Filter Greenfield filter
Endovascular Filters
• Used to prevent pulmonary embolism in patients with DVT in
whom long term therapy is contraindicated. Commonly placed in
infra-renal IVC after confirming negative jet of renal veins.
• Can be permanent or temporary.Temporary filters have to be
removed within 6 weeks to prevent endothelization of the filter.
23. FNAC Needles
Traditional fine needle aspiration biopsy needles
which harvest cells for cytological evaluation.
26. Diverse Usage
Treatment of tumors
Varicosities
Vascular malformations
Aneurysms and pseudoaneurysms
Fibroids
Gastrointestinal bleeding
27. Device selection
vascular territory to be embolized
permanence of occlusion
degree of occlusion—proximal or distal
28. General Embolization Scheme and
Clinical Indications
Vessels Permanent
Temporary
Large vessel
Coils (e.g., pulmonary
AVM)
Gelfoam sponge (e.g.,
trauma)
Small vessel
Particles (e.g., UFE); no
organ death
Liquid agents (e.g.,
renal ablation); organ
death
Gelfoam particles,
fibrillated collagen
(e.g.,
chemoembolization)
29. AUTOLOGUS CLOT
Advantages
immediate availability
absence of cost
lack of adverse reaction.
Method
aspirate roughly 20 mL of the patient's blood
allow it to clot
discard the supernatant
reintroduce the clot through the catheter
If desired, the clot can be opacified by adding sterile tantalum
powder.
Drawback :
Rapid lysis time(recanalization within 6 to 12 hours
30. •proximal occlusion is desired
• Gelfoam "torpedoes" can be formed by compressing and
rolling strips of Gelfoam,
•loaded into the nozzle of a 1- or 3-mL syringe.
Gelfoam Pledgets GelfoamTorpedo
31. Gelfoam Embolization
temporary occlusion
lasting 3 to 6 weeks.
Uses:
embolization of pelvic trauma
postpartum hemorrhage, (multiple bleeding sites from various
branches of the internal iliac artery.)
embolization should be initiated with Gelfoam slurry to
achieve a relatively distal level of occlusion
followed by Gelfoam pledgets or torpedoes.
32. PVA Particles
Used in bronchial artery embolization and Uterine
fibroid embolization etc.
33. PVA Particles
plastic sponge fragmented and filtered to a certain
size range.
typical size ranges used clinically are 300 to 500 µm
Smaller particles -risk of tissue infarction due to their
distal level of occlusion.
Larger particles-occlude the delivery r
34. Other Particulate agents :
Microspheres
Embospheres are precisely calibrated, spherical, hydrophilic,
microporous beads made of an acrylic copolymer, which is
then cross-linked with gelatin.
The hydrophilic surface prevents aggregation, allowing a
more predictable, uniform vessel occlusion than PVA, as well
as easier delivery through small catheters.
SIR Spheres (selective internal radiation therapy): Ceramic
microspheres have been embedded with the beta emitter
Yttrium-90.
hepatic malignancies
43. Coils
stainless steel guide wires onto which strands of wool had
been woven to add a matrix for thrombus formation.
for high-flow applications due to their high radial force, which
helps prevent dislodging.
Platinum coils are highly visible under fluoroscopy
much softer than stainless steel
facilitates accommodation of the coil to the vessel.
Appropriate sizing is important to ensure occlusion of the
vessel at the intended location.
44. Detachable Coils
Used in Intracranial Aneurysm Coiling.
Gugliemi detachable coil : Coil is welded to the pusher wire in the desired position, the
wire is attached to a battery device that sends a current along the wire.The current
melts the welded connection between the coil and the wire and detaches the coil
without any force. GDCs are mainly used for treatment of intracranial aneurysms
48. Uses
coils produces a focal occlusion
leaving the vessel distal to the coil patent(surgical
ligature)
precise vessel occlusio-but not tissue ablation
Applications :
treatment of hemorrhage
occlusion of arteriovenous fistulas
preoperative or pre-stent graft vessel occlusion.
49. Liquid – Onyx
consisting of ethylene vinyl alcohol copolymer
dissolved in dimethyl sulfoxide
Onyx contains tantalum powder to render it
radiopaque.
After Onyx is injected into the target lesion, the
dimethyl sulfoxide solvent rapidly diffuses away,
causing precipitation of the polymer and formation
of a spongy cast.
The cast solidifies
Onyx allows a prolonged, controlled embolization
because of its non-adhesive nature.
Cerebral and Peripheral AVM embolization
51. Glue
n butyl cyanoacrylate.
permanent rapidly acting liquid
that will polymerize immediately upon contact with ions. It
also undergoes an exothermic reaction which destroys the
vessel wall.
polymerization is so rapid, it requires a skilled surgeon.
During the procedure, the surgeon must flush the catheter
before and after injecting the NBCA, or the agent will
polymerize within the catheter.
The catheter must also be withdrawn quickly or it will stick to
the vessel.
Oil can be mixed with NBCA to slow the rate of
polymerization.
52. INTERVENTION IN HEPATOBILIARY SYSTEM:
I. HEPATIC MALIGNANCIES
II. BILIARY OBSTRUCTION: Benign or
malignant
III. PERCUTANEOUS CHOLECYSTOSTOMY
IV. PERCUTANEOUS MANAGEMENT OF
BILIARY CALCULI
V. PERCUTANEOUS MANAGEMENT OF
PORTAL HYPERTENSION
53. Interventional treatments for
liver tumours:
1. Chemical ablation with ethanol or acetic
acid.
2. Transcatheter arterial
chemoembolisation(TACE)
3. Transcatheter arterial embolisation(TAE)
4. Transcatheter arterial radionuclide
therapy(TART)
5. Right portal vein embolisation
6. Hepatic vein stenting
54. TACE(Transcatheter Arterial
Chemo Embolisation):
A targeted therapy for HCC confined to liver.
Involves intra arterial delivery of high
concentration of chemotherapeutic agent
emulsified with lipiodol combined with a
embolic agent.
55.
56. Principle:
Based on the differential supply to liver and
tumour.
In non tumour liver, portal vein supplies 75 to
83% of blood, hepatic artery supplies only
20%
In HCC, hepatic artery supplies 90 to 100% of
blood.
57. Candidates:
Palliative treatment for unresectable HCC
Patients on transplant list
Prior to RFA
Residual tumours
Patients with metastaic neuroendocrine
tumours in liver
59. Relative CI:
Borderline liver function
total bilirubin>4mg/dL
Serum creatinine> 2mg/dL
Portal vein thrombosis
Uncorrectable coagulopathy
Poor general health
Significant AV shunting through tumour
Analpylactic reaction to contrast
60. CHEMOTHERAPAEUTIC AGENTS:
Mitomycin C,Doxorubicin, cisplatin,
adriamycin, epirubicin
Mixed with lipiodol to form an emulsion
LIPIODOL(iodine containing lipid 38%by
weight)
Drug targeting effect of lipiodol- increases
concentration.
Slow release of drug from emulsion- prolong
contact time of tumor cells to drug
61. LIPIODOL
Made from iodine and poppyseed oil
highly viscous agent
used for chemoembolizations, especially for
hepatomas, since these tumors absorb iodine.
The half life is five days,
temporarily embolizes vessels.
62. EMBOLISATION AGENT:
PVA particles or Gelfoam.
Synergistic effect of tumor necrosis due to
ischemia
Slow blood flow: increases contact time.
Ischemia induces transmembrane pump-
greater absorption of drug.
63. Follow up: CT or MRI
Reduction in size
Amount of necrosis
Lipiodol retention
65. RFA:
Percutaneous image guided technique which
induces tumor necrosis by deposition of
thermal energy around the tip of electrode
inserted in the tumor.
66. PRINCIPLE:
AC current is passed through probe with
energies ranging from 60 to 100W for a
period of 6-12 minutes.
Rapid change in polarity of current results in
fast oscillations of intracellular molecules,
which in turn causes friction and heat
generation.
Local temparature of >60 degrees is
maintained for more than 5 minutes.
67. Indications:
Small HCC(less than 5 cm)
Metastasis lesions (less than 5 in number)
Patients in whom surgery is contraindicated
To reduce size of tumor inTACE candidates
68. Contraindications:
Large lesions
Multiple metastatic lesions(>5)
Close to liver capsule or gall bladder(<1 cm),
increases chances of peritonitis and
cholecystitis
Tumors very close to main branches of portal
and hepatic vein
69.
70. COMPLICATIONS:
Severe pain
Hemorrhage
Peritonitis
Cholecystitis
Colitis
Vascular injury
Thrombosis
Tumour seedling (avoided by ablating the
tract)
71. Follow up:
To assess the degree of necrosis and
completeness of ablation.
Shows a hypodense non enhancing area,
corresponds to necrosis.
A thin peripheral hyperemic rim may be seen,
which represents inflammatory reaction to
thermal injury(dissappears within a month)
72. Results:
Response is inversely proportionate to the
size of tumour.
Less than 2 cm: 85% response
Tumour of 3 cm: 35% response rate
75. ERCP
The diagnostic procedure of choice for
abnormalities of the biliary and pancreatic
ducts offers options of intervention:
Stone extraction
Sphincterotomy
Placement of stents
76. A side viewing endoscope is advanced into
the descending duodenum the papilla of
Vater is identified and cannulated contrast is
injected to visualize the pancreatic duct and
biliary duct systems
77. Causes for ERCP failure include:
Upper GI stricture/stenosis
Complete ductal obstruction limiting
retrograde filling
Postsurgical biliary-enteric fistula
Technical failure
MRCP is an effective alternative when ERCP is
unsuccessful
78.
79. Percutaneous Transhepatic
Cholangiography
Old reliable
Accurate technique for defining the site of
obstruction
Provides option of tissue biopsy and/or
intervention with drain or stent
Has been largely replaced by non-invasive
techniques
80. Biliary Internal – External Drain
This has proximal as well as
distal drainage holes that allow
drainage of bile proximal to
lesion externally.
If the drain is internalized, that
is the lesion is crossed and
distal end is placed in the
duodenum then bile is drained via
the proximal holes into the
Duodenum via distal holes.
Chiba Needle
Used to gain access
to bilary ducts.
This can be done
under Fluoroscopic
Or USG guidance.
81. Indications
Failed ERCP / ERCP not feasible (e.g. patients
with gastrojejunostomy)
Biliary system delineation in presence of intra
and extrahepatic biliary calculi
To identify obstructive cause of jaundice; and
differentiate from medically treatable cause
Anatomic evaluation of complications of ERCP
Delineating bile leaks
83. Technique
Standard technique:Thin needle puncture in ninth
or tenth intercostal space
Contrast injected during slow withdrawal of the
needle under fluoroscopic guidance
When duct placement confirmed, additional
injection
Films taken in AP, right and left oblique
86. Three types of drains
1. External – does not cross obstruction, drains
percutaneously
2. Internal-external – bile in obstructed
segment enters through the side holes of
the catheter and emerges beyond the
obstruction; the external segment can be
capped
3. Internal – drains only into enteric system
87.
88. METALLIC STENTING(benign stricture)
INDICATIONS
ALL SURGICAL OPTIONS ARE EXHAUSTED AND DILATATION
HAVE FAILED
PROCEDURE
Gianturco stent no 8, 10, 12 mm
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
90. Percutaneous cholecystostomy
Image-guided placement of drainage
catheter into gallbladder lumen.This
minimally invasive procedure can aid
stabilization of a patient to enable a more
measured surgical approach with time for
therapeutic planning.
91. Indications
poor surgical candidate/high risk patients
with acute calculous or acalculous
cholecystitis.
unexplained sepsis in critically ill patients
(Diagnostic for cholecystitis as etiology of
sepsis if clinical improvement after
cholecystostomy).
access to or drainage of biliary tree following
failed ERCP and PTC.
92. Contraindications
Absolute contraindications
usually none
Relative contraindications
bleeding diathesis: all attempts should be
made to correct coagulopathy.
ascites
gallbladder tumor that might be seeded
gallbladder packed with calculi preventing
catheter insertion
96. TIPSS
is a percutaneously created connection within
the liver between the portal and systemic
circulations.
ATIPS is placed to reduce portal pressure in
patients with complications related to portal
hypertension.
98. OBJECTIVE
to divert portal blood flow into the hepatic vein,
so as to reduce the pressure gradient between
portal and systemic circulations.
Shunt patency is maintained by placing an
expandable metal stent across the intrahepatic
tract.(created under image guidance)
103. RELATIVE CONTRAINDICATIONS
Active intrahepatic or systemic infection
Severe hepatic encephalopathy (poorly
controlled with medical therapy)
Hypervascular hepatic tumors
PV thrombosis
104. Shunt surveillance
at regular 3 to 6month intervals
Assessment of:
MORPHOLOGY
Ascites
Portosystemic collaterals
Size of spleen
Diameter of stent (usually 8 to 10 mm)
Configuration of stent: areas of narrowing
Extension of stent into portal + hepatic veins
105.
106. Doppler Criteria for compromised TIPS function
1. Shunt velocity of <50 cm/sec
2. Increase or decrease in shunt velocity of
>50cm/sec compared with initial post-
procedure value
3. Hepatofugal flow in main portal vein
107. COMPLICATIONS
(A) Obstruction to flow
Shunt obstruction (38%)
Hepatic vein stenosis
(B)Trauma
(a)Vascular injury
Hepatic artery pseudoaneurysm
Arterioportal fistula
Intrahepatic/subcapsular hematoma
Hemoperitoneum (due to penetration of liver
capsule)
108. (b)Biliary injury
Transient bile duct dilatation (due to
hemobilia)
Bile collection
(C) Stent dislodgment with embolization to right
atrium, pulmonary artery, internal jugular vein .
112. local anesthesia
placement of a percutaneous catheter in the
affected vein while being guided by
ultrasonography.
The abnormal venous segment is treated by
occluding it through the delivery of heat with
a percutaneously placed laser fiber in EVLT
and a radiofrequency catheter in RFA,
resulting in endothelium destruction and
fibrotic occlusion of the vein in both.
113. Endovenous laser treatment
using an optical fiber that is inserted into the
vein to be treated
laser light, normally in the infrared portion of
the spectrum, shines into the interior of the
vein.
This causes the vein to contract, and the
optical fiber is slowly withdrawn.
Dilute local anesthesia is injected around and
along the vein.
114. MECHANISM of RFA:
Using a bipolar RFA probe
delivers radiofrequency energy(RF waves) to
vein walls.
RF energy creates conductive heating that
contracts the vein wall causes shortening and
thickening of collagen fibrils and vein lumen
diameter shrinkage and fibrotic sealing of the
vein.
115. RADIOFREQUENCY ABLATION DEVICE:
Bipolar RFA probe, both the electrodes are in the same probe with an insulator
between the electrodes.
Radiofrequency generator unit.
116.
117.
118. PURPOSE OF TUMESCENT
INFILTRATION:
Compresses vein around heating element.
Creates depth between skin surface and
anterior vein wall.
Produces heat sink to protect perivenous
tissue from thermal injury.
Serves as anaesthesia
122. Complications of RFA or EVLA
Minor complications
bruising (51%),
hematoma (2.3%),
temporary numbness (3.8%),
phlebitis (7.4%),
induration (46.7%),
sensation of tightness (24.8%).
serious complications
skin burns (0.5%),
deep venous thrombosis (0.4%),
pulmonary embolism (0.1%),
and nerve injury (0.8%).
123. ADVANTAGES:
Quicker procedure
Local anaesthetia
Cheaper
Obviates need for admission to hospital
Less morbidity
Faster return to normal activities.
Useful alternative to surgical procedures.
124. Sclerosing Agents
Cause protein denaturation, leading to
endothelial destruction and vascular occlusion.
Occlusion by sclerosants is usually permanent.
Sodium tetradecyl sulphate (Setrol) and
Polidocanol
Uses : ablation of tumors, solid organs, veins, or
vascular malformations.
Site cleaned, area draped, local anesthetic given.
The seldinger needle is introduced into the artery.
When pulsating blood returns, the stylet is removed.
A guide wire is inserted through the needle.
With guide wire in vessel, needle is removed.
Catheter is threaded onto the guide wire.
Under fluoro, the catheter is then advanced and the guide wire is removed.
PVA is suspended in contrast so you can see where it is going
Minimally invasive targeted therapy
Chemotherapeutic agent with an embolisation agent in form of tiny particles
Via femoral artery into aorta and thru celiac artery into common hepatic artery and into the feeding vessel of tumour via xray guidance
Adjacent normal tissues remain unaffected.
Follow up MRI scan after 4-6 weeks shows shrinkage of tumour.
Few sideeffects compared to regular chemotherapy systemic effects
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
As the very high blood flow in these vessels will cause dissipation of heat and cause cooling effect.
Rfa is a minimally invasive technique used for treating the liver tumors which are not the candidates for surgery.
Out of all pts with liver tumorsonly 15% are candidates for surgery, rest inoperable.
Here the tumoral tissue is burned out with the use of radiofrequency waves with an electrode which is guided via image guidance using USG, CT or MRI.
After the pre procedural workup, pt is made to lie down and grounding pads are applied, now with the help of digital imaging, CT in this case;
After insertion of needle electrode via image guidance, multiple tiny wires come out and tumor tissue gets heated up and fibrosed.
In same sitting multiple lesions can be treated.
Tumor tissue is replaced by scar tiisue
This technique is preferably done under general anesthesia
After puncture of the jugular vein (most often the right jugular vein) under sonographic guidance, a catheter is introduced into one hepatic vein and wedged in the liver parenchyma.
Gentle injection of dye allows the retrograde visualization of intrahepatic portal vein branches.
CO2 can be used in patients with renal function impairment to avoid dye nephrotoxicity. The intrahepatic portal vein then is entered with a modified Ross needle.
A guide wire is advanced into the main portal vein. The tract between the hepatic and the portal vein is dilated with an angioplasty balloon catheter (8–10 mm) followed by stent placement to maintain the communication between both vessels patent
PATIENT PREPARATION FOR TIPS PLACEMENT
prophylactic broad-spectrum antibiotics.
Appropriate resuscitation with fluid and blood products.
Portal vein (PV) patency should be confirmed prior to attempts at TIPS placement by Doppler sonography, arterial portography and MRI.
In Patients with cirrhosis severe coagulopathy should be addressed prior to procedure.