Percutaneous placement of inferior vena cava (IVC) filters and treatment of superior vena cava obstruction (SVCO) ( Ch. 44 ) are the cornerstones of venous intervention. Venous angioplasty, stenting and thrombolysis are sometimes performed but remain controversial techniques, except in the management of haemodialysis access ( Ch. 50 ). The principles of negotiating and treating venous stenoses and occlusions are exactly the same as in the…

Referrals for management of vascular access problems are among the most common requests for vascular intervention in centres where haemodialysis is performed. Tip Embrace the dialysis patients; they will be one of the most important training grounds for vascular access, catheter and wire manipulation, angiography, angioplasty/stenting and thrombolysis! For patients on haemodialysis, their fistula, graft or dialysis catheter is a lifeline. Unfortunately, problems are common and…

If you practice vascular intervention you will find yourself called to stop haemorrhage. This is one of the most challenging and rewarding aspects of practice and frequently life-saving. There are three ways you can help: Inflow occlusion balloon: this is the ‘radiological tourniquet’ and is used to buy time in severe haemorrhage by controlling bleeding until definitive treatment is provided. Stent grafting: this is used to…

Aneurysms can affect vessels of any size. Clearly, not every aneurysm requires immediate treatment but, when indicated, successful endovascular management requires exclusion of the aneurysm from the circulation. The main options can broadly be thought of as: Embolization techniques which sacrifice the target vessels: This is only used when it is safe to occlude part of the circulation, i.e. there is a collateral pathway or the…

Acute limb ischaemia describes a sudden reduction in perfusion of <3 days' duration. The ischaemia is usually due to thrombosis in native arteries or bypass grafts secondary to an underlying stenotic lesion. The severity of ischaemia is categorized using the Rutherford classification ( Table 47.1 ). Patients with rest pain without neuromuscular complications (Rutherford grade IIa) are the optimal candidates for thrombolysis in terms of time…

Angioplasty and stenting are cornerstone techniques in interventional radiology and have widespread non-vascular and vascular applications. The key skills and equipment choices remain largely the same, regardless of the site. This chapter assumes that you have already mastered the theory and techniques for getting to and crossing the lesion. Basic principles Refer back to the sections on equipment and the basic principles for further guidance on…

Having a high-quality route map of the target vascular bed and, if necessary, the access to it are the keys to successful vascular intervention. They determine the choice of approach, the best equipment to use and the suitability for intervention. A preliminary diagnostic angiogram is seldom now required and non-invasive diagnostic imaging using ultrasound (US), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) is the…

Treating tumours Understanding ablative techniques The objectives of tumour ablation are to increase patient survival and sometimes to palliate local symptoms and painful tumours. There are several techniques which cause either tissue heating (radiofrequency [RF], microwave, laser, focused ultrasound) or freezing (cryotherapy). Advantages over surgical tumour resection are due to the minimally invasive nature of these therapies, which allows a wider spectrum of patients to be…

Biliary intervention mainly involves biliary drainage and stent insertion. Magnetic resonance cholangiopancreatography (MRCP) and Computed tomography (CT) are the primary tools to investigate stones or other bile duct abnormalities and will usually determine the site and nature of biliary obstruction. Review of CT and MR cholangiography can be invaluable in planning the procedure, particularly for biliary drainage in patients with hilar lesions. Percutaneous transhepatic cholangiography Percutaneous…

Gastrointestinal interventions fall into two main groups: establishing enteral access for feeding and stenting to treat obstruction secondary to malignancy. Nasogastric/nasojejunal tubes Most nasogastric tubes are placed on the ward and most nasojejunal tubes are placed by endoscopists. If a request migrates to interventional radiology for these procedures, it is usually because of problems navigating the nasopharynx. Occasionally, it is an issue with an oesophageal stricture…

Nephrostomy Percutaneous nephrostomy is one of the most frequently performed interventional procedures and is a technique in which every radiologist should feel completely confident. Urgent drainage is required in an infected obstructed system due to the resultant rapid renal loss and septicaemia. Fortunately, nephrostomy is usually an elective procedure, as ureteric obstruction leads to gradual progressive renal loss. Acute renal colic with obstruction and persistent pain…

There are several conditions which have been grouped together relating to the urogenital tract and which loosely impact on fertility. Uterine artery embolization Indications for treatment The vast majority of uterine artery embolization (UAE) is performed to manage symptomatic fibroid disease and to a much lesser extent, other uterine pathologies associated with menorrhagia. UAE is an alternative to surgery (hysterectomy or myomectomy) for patients in whom…

Treating fluid collections and abscesses is part of the bread and butter of interventional radiology. The minimally invasive nature of interventional radiology (IR) drainage makes it an obvious choice for many postoperative collections, particularly in the elderly and frail. Pre-procedure planning Taking a few minutes to plan the procedure is essential and might mean that you actually plan not to do it! Selecting collections to drain…

A combination of increased use of diagnostic imaging and advances in therapeutic interventions means that obtaining tissue to aid diagnosis and cellular typing is now more essential than ever. Most diagnostic and interventional radiologists require core skills in biopsy. The vast majority of lesions can be biopsied with minimal risk. Determining a safe access route and accurate targeting requires a clear understanding of the principles of…

Despite being a great opportunity to talk to your patients, obtaining haemostasis after a diagnostic or therapeutic angiogram is tedious. Hence, the art of staunching the flow is often neglected or delegated to the most junior member of staff in the vicinity. This approach risks haematoma or haemorrhage; make sure you give as much importance to haemostasis as you do to arterial access ( Fig. 37.1…

Foreign body retrieval is almost exclusively reserved for iatrogenic problems, most of which will have been of your own making! The techniques and equipment described can also be used for snaring guidewires for pull-through procedures or to reposition misplaced central lines. The majority of foreign body retrieval is within the vascular system, although occasionally these techniques are required in the biliary or urinary system. The toolkit…

Embolotherapy is the deliberate blockage of blood vessels; it is usually performed to stop haemorrhage and may be life-saving in gastrointestinal bleeding and trauma. Embolization is sometimes used as an adjunct to surgery and in the treatment of a variety of benign and malignant tumours. Many types of embolic agents are available to block vessels of different sizes, from arteries to capillaries. The choice of the…

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Expandable stents are used to manage luminal narrowing in many systems from the aorta to the trachea. As with angioplasty, there is a common skill-set required for deployment, regardless of location but the indications and outcomes are very different so try to avoid a ‘have stent, will travel’ mentality. There is a simple basic concept regarding intent, which transcends most applications. A procedure may be undertaken…

Angioplasty and stenting are cornerstone techniques in interventional radiology and have widespread non-vascular and vascular applications. The key skills and equipment choices remain largely the same, regardless of the site. The main indication for angioplasty is the treatment of atherosclerotic plaque. Concentric plaque splits during balloon angioplasty and the intima and media stretch and tear ( Fig. 32.1 ). When there is eccentric plaque, the tears…