INTERVENTIONAL RADIOLOGY

DR. M. A. BARADIA

Supervisors: Dr. Wanga, Dr. Sitati

IR/Surgical radiology Sub-speciality of radiology Minimally invasive Image guided procedures

Body plumbing Charles Dotter MD – Father of IR, Nobel

1978 82 yr old gangrenous left foot – Jan

1964 Angioplasty 1964 Embolization for pelvic trauma 1973 Arterial thrombolysis 1974 Embolization/RFA of Bone tumors 1990

Imaging modalities Fluoroscopy Computed tomography Ultrasound Magnetic resonance imaging

Orthopedic IR Spine Vascular Oncology Trauma Infection

Spine Vertebroplasty Kyphoplasty

VCF

To do or not to do? 2 placebo controlled, double blinded trials

found no benefit Adverse effects BUT…

Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis.Staples MP, Kallmes DF, Comstock BA, Jarvik JG, Osborne RH, Heagerty PJ, Buchbinder R. - BMJ. 2011 Jul 12;343:d3952. doi: 10.1136/bmj.d3952.Vertebroplasty and kyphoplasty--a systematic review of cement augmentation techniques for osteoporotic vertebral compression fractures compared to standard medical therapy. - Maturitas. 2012 May;72(1):42-9. doi: 10.1016/j.maturitas.2012.02.010. Epub 2012 Mar 16.

Vascular Limb revascularisation Peripheral artery disease DVT/Pulmonary embolism

Limb revascularisation Percutaneous transluminal angioplasty (PTA) Cryoplasty Cutting and scoring balloons Nitinol stents – nickel and titanium

superelasticity & thermal shape memory

Nitinol stent grafts/covered stents Drug eluting stents

Limb revascularisation Debulking devices – excimer laser and

excisional atherectomy – thermal damage – photochemical rather than thermal

Rotational atherectomy

Limb Revascularisation Percutaneous thrombectomy

Rheolytic thrombectomy Aspiration thrombectomy

Factors leading to poor results*

length of the diseased segmentthe presence of total occlusion – 20 – 40%diabetes mellituspoor distal runoffcritical limb ischemia as the clinical presentation

* Overview of New Technologies for Lower Extremity RevascularizationJason H. Rogers, MD; John R. Laird, MD: Circulation.2007; 116: 2072-2085

Oncology Biopsy – guided biopsies Embolization

Vascular embolization Chemo-embolization Radio-embolization

Radiofrequency ablation cryoablation

Vascular Embolization indications*

definitive treatment of benign lesions reducing the risk of bleeding prior to biopsy or surgery palliation of pain, bleeding, fever, and hypercalcemia-

like symptoms in inoperable tumors preventing further dissemination of a tumor increasing the response to chemotherapy and

radiotherapy, retention of selectively delivered anti-mitotic agents or

monoclonal antibodies deep into the tumor substance*Embolization of bone tumors Andreas F. Mavrogenis, MD; giuseppe rossi, MD; Orthopedics April 2011 - Volume 34 · Issue 4: 303-310

Figures 2A-2B: AP radiograph of the left elbow of a 70-year-old man with a metastatic renal cell carcinoma of the olecranon (A). Pre-

embolization angiography showed 3

feeding vessels originating from the

median (1) brachial, (2) and ulnar (3) artery (B).

Embolic agents Nontoxic Sterile Radiopaque easy to prepare

or to obtain

gelatin sponge polyvinyl alcohol

(PVA) particles liquid (absolute

alcohol), Coils tissue adhesives Ethanol microfibrillar

collagen autologous blood

clot.

Pelvic Trauma Embolization of bleeding arterial vessels

– Transcatheter Embolization (TCE) Bleeding from

Presacral venous plexus Fractured cancellous bone vessels

*Transcatheter Embolization in Pelvic Trauma Scott R. Broadwell, M.D.1 and Charles E. Ray, Jr., M.D: Semin Intervent Radiol. 2004 March; 21(1): 23–35

Pelvic Trauma* Digital subtraction angiography Vessels affected

superior gluteal internal pudendal Obturator lateral sacral arteries

Embolization techniques Selective embolotherapy Shot gun embolotherapy

Embolic agents Size of the vessel Permanence Familiarity to the

IR

Autologous clot Gelfoam pledgets or slurry Coils if coag system working Particles/silk suture material

Pelvic trauma – Cx & Limitations nontarget

embolization of lower extremity vessels

Rhabdomyolysis that may be worsened by ischemia,

acute renal failure colonic and ureteric

infarctions perineal wound

sepsis

sacral nerve injury sexual dysfunction

(impotence) rectal dysfunction

(difficulty defecating)

avascular necrosis of the femoral head

death.

Infection Percutaneous drainage of abscesses and

fluid collection

Advantages Minimal incisions/scarring Shorter hospital stay/outpatient Reduced recovery time Anesthetic Lower risk of complications Treatment option in poor/risk prone

patients

Disadvantages Technical expertise – demanding Equipment Cost Adverse effects unique to each

procedure

The future

IR

surgeon

gynae cardio oncologist

Fractures are safe… for now!

THANK YOU