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Chemoembolization for Hepatocellular Carcinoma

Clinical Relevance Hepatocellular carcinoma (HCC) is the most common primary liver cancer, ranking fifth for men and seventh for women as a source of primary malignancy. Cirrhosis secondary to chronic infection with hepatitis B and/or hepatitis C is the main risk factor for developing HCC. Nonalcoholic fatty liver disease–related cirrhosis is a rising risk factor in developed countries. Increasing incidence rates of HCC, in conjunction with…

Transvenous Pressure Measurements and Liver Biopsy

Transvenous Pressure Measurements Clinical Relevance Chronic inflammation of the liver results in hepatic fibrosis and leads ultimately to cirrhosis. Portal hypertension is the hallmark of liver cirrhosis and is defined as a portal pressure gradient (pressure gradient between portal vein and inferior vena cava [IVC]) of greater than 5 mmHg. The portal pressure gradient is considered clinically significant when greater than 10 mmHg. Portal hypertension is…

Renal Artery Embolization

Clinical Relevance Embolotherapy of the renal arteries was introduced into the portfolio of the interventional radiologist many years ago. It was most popular in the 1980s and 1990s when preoperative embolization of kidneys containing a renal cell carcinoma (hypernephroma) was widely used as a routine procedure in the belief that preoperative embolization might avoid tumor seeding during surgery. Because no oncological benefit has since been proved…

Renal Ischemia

Acute renal ischemia occurs because of a transient sudden drop in the total or regional blood flow to the kidney. Acutely diminished renal perfusion results in acute kidney injury. Impaired blood flow to both kidneys or to a solitary functional kidney can occur due to generalized hypoperfusion in cases of hypovolemia or to decreased cardiac output in acute cardiac decompensation, leading to acute renal failure. Acute…

Renal Vasculature

Acknowledgments The authors wish to acknowledge the contributions of authors Morvarid Alaghmand, Ali Noor, Aaron Reposar, Rishabh Chaudhari, and Ramy Khalil, who contributed to this chapter in the second edition. Understanding the vascular anatomy of the kidneys, ureters, adrenals, and bladder is essential for performing image-guided therapy. For example, a patient with a traumatic fistula between the renal artery and vein may benefit from transcatheter embolotherapy.…

Chronic Mesenteric Ischemia

Although chronic mesenteric ischemia (CMI) is a relatively uncommon entity due to the robust mesenteric arterial collateral circulation, detection of intestinal angina and CMI is of critical importance. If the diagnosis is overlooked or missed, acute mesenteric ischemia can result. Once acute mesenteric ischemia develops, patient mortality rates become extremely high. In addition, an accurate diagnosis and pretreatment noninvasive evaluation will facilitate treatment planning and affect…

Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a life-threatening vascular emergency that requires early diagnosis and intervention to adequately restore mesenteric blood flow and prevent fatal bowel necrosis. Causes include arterial embolus, which occurs most frequently (40%–50%), arterial thrombosis (20%–30%), venous obstruction (5%–18%) and nonobstructive causes (20%–30%). Clinical signs vary considerably and are nonspecific. Patients present with severe abdominal pain that is initially out of proportion to any…

Management of Lower Gastrointestinal Hemorrhage

Clinical Relevance Lower gastrointestinal (GI) hemorrhage (LGIH) is much less common than upper GI tract hemorrhage. The incidence of LGIH is approximately 20.4 cases per 100,000 adults per year. However, it is associated with a 10% mortality rate, and although less common than upper GI bleeding, it more often demands the specialized skills of the interventional radiologist. These cases are frequently less amenable to endoscopic management,…

Management of Upper Gastrointestinal Hemorrhage

Clinical Relevance Upper gastrointestinal (UGI) hemorrhage (UGIH) is a common medical problem, with 50,000–70,000 hospital admissions per year in the United Kingdom (UK). It is the second most common medical reason for transfusion after hematological conditions, accounting for 14% of all blood transfusions. Mortality is between 5% and 14% in the UK and North America. Around 15% of UGI bleeds occur in patients who are already…

Anatomy of Alimentary Tract Vasculature

Clinical Relevance An understanding of the vascular anatomy of the alimentary tract allows a wide range of therapeutic options for patients who traditionally were treated by open surgery. In addition to the use of catheter-directed embolotherapy and pharmacologic vasoconstriction for gastrointestinal (GI) hemorrhage, a knowledge of variant anatomy may prevent complications such as non–target organ embolization. For example, recognition of variant anatomy during hepatic artery chemoembolization…

Endovascular Treatment of Dissection of the Aorta and Its Branches

Management of aortic dissection is complex and directed by multiple patient and disease-specific factors requiring a complication-specific approach. Appropriate aortic imaging is paramount for both diagnosis and treatment planning. Initial blood pressure, heart rate control, and monitoring in the intensive care unit setting are critical. Descending aortic dissections (Stanford type B, DeBakey III) complicated by rupture, rapid false lumen expansion, tissue malperfusion, or intractable pain or…

Endoleaks: Classification, Diagnosis, and Treatment

Clinical Relevance Endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) produces clinical results similar to those of open surgery after observation periods of 6 and 10 years, respectively, with EVAR having an advantage in postoperative mortality and morbidity. Unlike open repair where the branch vessels to the aneurysm are ligated, perigraft blood flow outside the endoprosthesis but inside the aneurysm sac may occur after…

The Management of Thoracoabdominal Aortic Aneurysms by Branched Endograft Technology

This chapter specifically describes the management of aortic aneurysms that involve both the thoracic and abdominal segments of the aorta and its associated visceral branches. The reader should note that extensive aortic pathologies commonly require solutions incorporating combinations of open surgery and fenestrated and branched endovascular solutions. Since the publication of the first edition of this book, the total endovascular repair of thoracoabdominal aortic aneurysms (TAAAs)…

Fenestrated Stent-Grafting of Juxtarenal Aortic Aneurysms

Continuous development in endovascular treatment of ab-dominal and thoracic aortic aneurysms, together with growing experience and encouraging results, have paved the way for a new generation of stent-grafts, to treat those previously unsuitable for conventional endovascular repair. One such advancement is the fenestrated graft, which allows extension of the proximal landing zone and preservation of the renal and visceral arteries. Since the first reported fenestrated endovascular…

Endovascular Aortic Repair

Clinical Relevance Abdominal aortic aneurysms (AAAs) occur in approximately 5% to 10% of the male population older than 65 years, and the incidence increases with advancing age. The risk of rupture is very low for aneurysms less than 5 cm in diameter, but increases substantially with aneurysms larger than 6 cm in diameter. Mortality rates for traditional open repair of AAAs vary widely, depending on the…

Vascular Anatomy of the Abdominal Aorta and the Inferior Vena Cava

Abdominal Aorta The abdominal aorta continues from the thoracic aorta as it passes posterior to the median arcuate ligament and between the crura of the diaphragm (aortic hiatus), in front of the body of the T12 vertebra and then descends slightly to the left of midline. Clinically, the abdominal aorta is often divided into suprarenal and infrarenal arterial segments. The rationale for this division is the…

Management of High-Flow Vascular Anomalies

Vascular anomalies are often poorly managed for a number of reasons: they are uncommon (other than the true infantile hemangioma), their mode of presentation is extremely variable, their classification has been very confusing and is still poorly understood by the majority of doctors, and their treatment is challenging. The interested interventional radiologist is in an ideal position to play a major, if not the lead, role…

Management of Low-Flow Vascular Malformations

The goal of sclerotherapy is to obliterate abnormal channels by damaging the endothelium, thereby resulting in subsequent inflammation and fibrosis. Venous malformations (VMs) are caused by abnormal development of the vein wall, with thinning and asymmetric disruption of the smooth muscle layer of the vein in association with endothelial cell abnormalities. This results in progressive, often asymmetric, dilation of the affected channels. Associated absence or insufficiency…

Congenital Vascular Anomalies: Classification and Terminology

Vascular anomalies are a complex group of developmental abnormalities due to inborn errors of vasculogenesis or angiogenesis that present significant challenges in diagnosis and management. Because of the rarity and diverse presentation of these anomalies, patients are often seen by multiple specialists before correct diagnosis can be reached and treatment instigated. Accurate and timely diagnosis is crucial, and a multidisciplinary team approach is essential for the…

Revascularization: Infrapopliteal

In most countries, critical limb ischemia (CLI) has an incidence estimated to be 50 to 100 per 100,000 every year. CLI has a high mortality and morbidity rate and consumes important health and social care resources. , Aging of the population, increasing incidence of diabetes and renal failure, and limitations in the ability to reduce tobacco consumption explain the high likelihood of increased incidence in the…