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Nonthermal Ablation of Liver Lesions

Liver lesions have a wide spectrum of presentation, from an incidentally discovered and asymptomatic simple liver cyst to multifocal primary or metastatic liver tumors. The interventions used to treat this wide range of lesions are equally as varied, and percutaneous chemical ablation has a continually evolving role. Chemical Ablation of Benign Liver Lesions Simple Liver Cysts Simple liver cysts are estimated to be present in approximately…

Cryoablation of Liver Tumors

Indications Cryoablation can be used to treat primary malignant liver lesions such as hepatocellular carcinoma (HCC), as well as benign lesions such as symptomatic hemangiomas and liver adenomas. Nonetheless, the most common use of cryoablation in the liver in the United States is for metastatic disease typically from colon, breast, and neuroendocrine primaries ( Fig. 98.1 ). Because only 10%–25% of patients with metastatic liver tumors…

Thermal Ablation of Liver Lesions

Thermal ablation includes several different energy-based therapeutic modalities, all united in exposing tumoral lesions to cytotoxic temperatures, with consequent induction of cell death while preserving normal liver parenchyma. These features have promoted their widespread use in the management of liver malignancies, especially in patients with unresectable tumors or who are deemed to be poor candidates for surgery. According to the temperatures reached, energy-based ablative treatments are…

Management of Biliary Calculi

Acknowledgments The authors wish to acknowledge authors Daniel B. Brown and Daniel D. Picus for their contribution to this chapter in the second edition of this textbook. Clinical Relevance Gallstones affect more than 10% to 15% of the US population. Approximately 250,000 people have symptomatic gallstones that require specialized intervention every year. Gallstones are the most common cause of acute cholecystitis. Surgical interventions for symptomatic gallstones…

Percutaneous Cholecystostomy

Clinical Relevance Acute cholecystitis (AC) is a prevalent condition that carries significant risks of morbidity and mortality. AC may present with a spectrum of disease stages ranging from a mild self-limited illness to a fulminant potentially life-threatening illness. The 2018 Tokyo guidelines for the management of AC stratifies each presentation as mild (Grade I), moderate (Grade II), or severe (Grade III) based on clinical and biochemical…

Management of Biliary Leaks

Biliary leakage is defined as diversion of bile via a defect in the ductal wall leading to the formation of bilomas, fistulas, or free spillage into the peritoneal cavity. It is a common complication after liver and biliary surgery. With emerging laparoscopic techniques and transplantation, the rate of bile leakage is reported to range from 0.8% to 12%. Massive hepatic trauma with subsequent biliary leakage has…

Management of Benign Biliary Strictures

Management of benign biliary strictures, whether surgical, percutaneous-transhepatic, or by endoscopic means, is difficult. These lesions are formed of cicatricial fibrosis and are recalcitrant to many minimally invasive techniques. They can be a contributing factor to recurrent cholangitis, hepatic segmental atrophy, hepatic graft dysfunction (in cases of transplanted livers), and, in the long-run, obstructive biliary cirrhosis. Benign biliary strictures are a heterogenous group of lesions that…

Management of Malignant Biliary Tract Obstruction

Malignant bile duct obstruction (MBDO) occurs when tumor within or adjacent to bile ducts impedes the normal passage of bile from the liver to the intestinal tract. Tumors of pancreobiliary origin, such as cholangiocarcinoma and gallbladder and pancreas cancer, are the most common causes of MBDO. Other etiologies include lymphoma and metastases from any primary neoplasm. Many benign conditions may also cause biliary obstruction. Differentiation of…

Gastrostomy and Jejunostomy

The interventional radiologist can play a central role in the provision of enteral nutrition through the placement of gastrostomy and jejunostomy tubes. Traditionally, enteral feeding tubes have been placed by surgical or endoscopic techniques. The first successful placement of a percutaneous endoscopic gastrostomy (PEG) was described in 1979 by Gauderer and Ponsky. This was followed 2 years later by the first percutaneous radiologic gastrostomy (PRG), performed…

Preoperative and Palliative Colonic Stenting

Colorectal cancer is the fourth leading cause of cancer death in the United States after lung cancer and carcinoma of the breast and prostate. Close to a million new cases of colorectal cancer are detected each year worldwide, and almost 500,000 deaths are attributed to malignant tumors of the colon and rectum. Up to 40% of these patients experience acute partial or complete obstruction, with up…

Intervention for Gastric Outlet and Duodenal Obstruction

Gastric outlet obstruction is a preterminal complication of advanced malignancies of the pancreas, stomach, and duodenum. Patients with gastric outlet obstruction experience intractable nausea, vomiting, and anorexia, which may in turn cause electrolyte imbalance, dehydration, and malnutrition. Furthermore, these patients are at constant risk for aspiration and pneumonia. The primary goal of treatment is palliation of obstructive symptoms, thereby improving quality of life. Although surgical gastrojejunostomy…

Esophageal Intervention in Malignant and Benign Esophageal Disease

With the development and improvement of different technologies and devices, treatment for many diseases of the esophagus is now within the scope of minimally invasive interventional radiology-guided procedures. In this chapter, we describe the methods of image-guided intervention of benign and malignant conditions of the esophagus. Although endoscopy is helpful in confirming the diagnosis, it is not necessary for the treatment of esophageal strictures under imaging…

Percutaneous Biopsy and Abscess Drainage in the Abdomen and Pelvis

Background The expansion in the use of image-guided percutaneous biopsy and abdominopelvic abscess drainage reflects the ability of these procedures to offer safe minimally invasive techniques with superior outcomes compared with previously utilized operative approaches. Advances in technique, instruments, and imaging modalities have made these procedures among the most commonly performed in both the inpatient and outpatient setting. Increasing demands from patients, referring physicians, and hospitals…

Thoracic Duct Embolization for Postoperative Chylothorax

The thoracic duct, a primary central common drainage pathway for the lymphatic system of the trunk and lower extremities, is anatomically close to the esophagus. Roughly 0.5% to 2.0% of patients undergoing thoracic surgery, especially esophagectomy, will suffer iatrogenic thoracic duct disruption, an injury that can result in intractable high-volume chylous pleural effusions. The thoracic duct carries 2 to 4 liters of lymph daily, the major…

Subcutaneous Ports

Clinical Relevance After the introduction of tunneled silicone central venous catheters (CVCs) in the 1970s by Broviac and Hickman, the next decade brought the development of subcutaneous ports, which are also referred to as totally implantable venous access devices. Although originally developed in the surgical arena, subcutaneous port insertion under image guidance soon evolved and improved the safety profile of the procedure by essentially eliminating the…

Tunneled Central Venous Catheters

Tunneled central venous catheters (CVCs) fill a vital role in patient treatment, especially with new cancer-fighting regimens. The catheters are durable and fit nicely into interventionalists’ armamentarium alongside peripherally inserted central catheter (PICC) lines and chest or arm ports. There are many sizes, lengths, and technologic advancements that allow safe, long-term venous access. These catheters enable the physician to safely administer caustic medications centrally, draw blood…

Peripherally Inserted Central Catheters and Nontunneled Central Venous Catheters

Peripherally inserted central catheters (PICCs) and nontunneled central venous catheters (CVCs) are indispensable in current medical practice, with both serving central venous access needs. They are used for infusion therapy, exchange therapy, and hemodynamic monitoring. The central venous system includes the pulmonary arteries, right side of the heart, superior vena cava (SVC), inferior vena cava (IVC), brachiocephalic veins, subclavian veins, and iliac veins. It should be…

Percutaneous Arterial Venous Fistula Creation

Hemodialysis is a tremendous socioeconomic burden within industrialized countries, with costs exceeding 1.5 billion dollars in Europe and within 2.9 billion dollars in annual costs in the United States. A large and essential component for delivery of dialysis is a stable and usable hemodialysis access. There are primarily three kinds of access: the catheter, a dialysis graft, and a dialysis fistula. The latter, a direct surgical…

Management of Clotted Hemodialysis Access Grafts

Thirty million people in the United States have chronic kidney disease and millions more are at increased risk. In 2015 in the United States alone, 468,000 patients required dialysis (peritoneal dialysis or hemodialysis) for end-stage renal disease. Because many of these patients require hemodialysis, a reliable long-term dialysis access is their lifeline. Although an increase in fistulas is the goal of the National Kidney Foundation Kidney…

Surveillance and Management of Failing Hemodialysis Access

Large numbers of patients depend on hemodialysis for their survival. Worldwide the number of patients receiving renal replacement therapy is expected to rise from 2.6 million to 5.5 million by 2030, with most of the growth expected to occur in Asia. In the United States, approximately 475,000 individuals were receiving hemodialysis for end-stage renal disease (ESRD) through 2016. The increased incidence of diabetes in the US…