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Interventional Radiology Done By: Faten Zaidan Zahra AlHaj Issa Areej Hussain Content: • • • • • • • Brief History Definition and Advantage Types Indications Contraindications Patients’ Preparation Side Effects and Complications Since when it started? Charles Dotter, 1960’s "Father of Interventional Radiology" Definition The use of radiology, image guidance, to perform minimally invasive procedures for diagnostics and treatments. Advantage Offer patients the least invasive option first, Types Heart and Vascular care 1) Coronary Angiography 2) Abscess Angiography 3) Angioplasty and Vascular Stenting 4) Cerebral Angiography 5) Deep Venous Thrombosis 6) Stent Graft Repair of Aneurysms 7) Stent for Stenosis/Obstruction 8) Thrombolysis 9) Central Venous Access 10)Embolization 11)Varicose Vein Treatment: VNUS and EVLT Phlebectomy and Sclerotherapy, Laser Vein Ablation 12) Vena Cava Filter: Placement and Removal Gastointestinal care 1) Biliary Drainage and Stentin 2) TIPS – Transjugular Intrahepatic Portosystemic Shunt 3) Gastrostomy/Jejunostomy tube Genitourinary care 1) 2) 3) 4) 5) 6) Nephrostomy Varicocele Embolization Ureteral Stent or Embolization Fallopian Tube Recanalization Suprapubic Cystostomy Uterine Fibroid Embolization (UFE) Pain Management Care 1) 2) 3) 4) Epidural Steroid Injections Nerve Blocks Facet Blocks SI Joint Injections Breast Care 1) 2) 3) 4) Needle Biopsy Pre-op Needle Localization Stereotactic Core Biopsy Ultrasound Guided Core Biopsy & Fine Needle Aspiration Biopsy Cancer Care Chemoembolization & Radiofrequency Ablation We will focus on the following types: -Angiography of Coronary Arteries. -Angioplasty of Coronary Arteries. -Varicose Veins Endovenous Laser Treatment. -Chemoembolization of Hepatocellular Carcinoma (HCC). Indications & Contraindications Angiography of Coronary Arteries Indications: •Detection of CAD in sussceptable patients. •Preoperative coronary assessment prior to noncoronary cardiac surgery •Evaluation of new or worsening symptoms of CAD •Risk assessment post-revascularization •Evaluation of cardiac structure and function Angiography of Coronary Arteries Contraindications: •Pregnancy is considered an absolute contraindication. •Since an iodine-containing contrast agent is used, contrast agent allergy, hyperthyroidism or renal function impairment are relative contraindications. Angioplasty of Coronary Arteries Indications •Acute ST-elevation MI (STEMI) •Non–ST-elevation acute coronary syndrome (NSTE-ACS) •Asymptomatic or mildly symptomatic patient with objective evidence of a moderate-sized to large area of viable myocardium or moderate to severe ischemia on noninvasive testing •Angiographic indications include hemodynamically significant lesions in vessels serving viable myocardium (vessel diameter >1.5 mm). Angioplasty of Coronary Arteries Contraindications • Intolerance of chronic antiplatelet therapy • The presence of any significant comorbid conditions that severely limit patient lifespan (this is a relative contraindication). • Relative angiographic contraindications include the following: • Arteries < 1.5 mm in diameter • Diffusely diseased saphenous vein grafts • Other coronary anatomy not amenable to PCI Varicose Veins Endovenous Laser Treatment Indications • Symptoms affecting quality of life like: Aching, Throbbing, Heaviness, Fatigue, Restlessness, Night cramps, Pruritus and Spontaneous hemorrhage • Skin changes associated with chronic venous hypertension like: eczema, Healed or active ulceration and pigmentation. • Cosmetic (restorative) concerns. • Anatomical indications are as follows: Significant reflux documented on DUS examination (reflux >0.5 seconds) Straight vein segment Varicose Veins Endovenous Laser Treatment Contraindications • Patients who are pregnant or breastfeeding (concerns related to anesthetic use and heated blood effluent that may pass through the placenta to the fetus) • Obstructed deep venous system inadequate to support venous return after ELA • Liver dysfunction or allergy making it impossible to use a local anesthetic. • Severe uncorrectable coagulopathy • Severe hypercoagulability syndromes • Thrombus or synechiae in the vein or tortuous vein making passage of an endovenous device impossible Chemoembolization of HCC Indications • • • • • Palliative treatment for unresectable HCC Patients on transplant list Prior to Radio frequency ablation Residual tumors Patients with metastatic neuroendocrine tumors in liver Chemoembolization of HCC Contraindications ABSOLUTE ◉Extensive liver disease ◉Encephalopathy ◉Large burden metastatic disease outside the liver RELATIVE ◉Borderline Liver function ◉Portal vein thrombosis ◉Uncorrectable coagulopathy ◉Poor general health ◉Significant AV shunting through tumor ◉Anaphylactic reaction to chemotherapeutic drugs or contrast Patient Preparation The following is a list of important information all patients must know prior to having any procedure with Interventional Radiology: • Most patients must have a ride home. • All patients having angiograms need someone to stay with them overnight. • Most procedures require no food or drinks after midnight except for sips of water to take with medication. • All blood pressure medications need to be taken the morning of the procedure. • If patient is on insulin, the patient should only take half of their morning dosage. • If there are any questions about medications, patients should bring their meds with them, or a complete list of the medication which include the dosage. • All blood thinners and aspirin need to be held 5 days prior to the procedure. Ibuprofen is 24hours. Angiography • The contrast medium that is used usually produces a sensation of warmth lasting only a few seconds, but may be felt in a greater degree in the area of injection. • If the patient is allergic to the contrast medium, much more serious side effects are inevitable; however, with new contrast agents the risk of a severe reaction are less than one in 80,000 examinations. • Additionally, damage to blood vessels can occur at the site of puncture/injection, and anywhere along the vessel during passage of the catheter. • If digital subtraction angiography is used instead, the risks are considerably reduced because the catheter does not need to be passed as far into the blood vessels; thus lessening the chances of damage or blockage Balloon angioplasty • Embolization, or the launching of debris into the bloodstream • Arterial rupture from over-inflation of a balloon catheter or the use of an inappropriately large or stiff balloon, or the presence of a calcified target vessel. • Hematoma or pseudoaneurysm formation at the access site • Angioplasty may also provide a less durable treatment for athrosclerosis, and be more prone to re-stenosis, relative to vascular bypass or coronary artery bypass grafting Vericose veins Endovenous laser treatment Side effects can be categorized as minor, or serious. • Minor complications include: Bruising Hematoma Temporary numbness Phlebitis Induration Sensation of tightness • More serious complications include: Skin burns Deep venous thrombosis Pulmonary embolism Nerve injury Retinal damage is a serious but very rare complication (<1%) that can occur during the use of lasers. Chemoembolization • As with any interventional procedure, there is a small risk of hemorrhage and/or damage to blood vessels. • Pseudoaneurysm can develop at the site of puncture in the femoral artery. • During this procedure contrast media is utilized, to which patients may develop an allergic reaction. • Symptomatic hypothyroidism may result from the high retained iodine load of the contrast. Specialized techniques and devices may decrease the risk. • The resulting necrosis releases cytokines and other inflammatory mediators into the bloodstream. A self-limiting postembolization syndrome of pain, fever, and malaise may occur due to hepatocyte and tumor necrosis.