intervention radiology— an introduction dr. muhammad bin zulfiqar

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Interventional Radiology— An Introduction Dr. Muhammad Bin Zulfiqar PGR IV FCPS Services Institute of Medical Sciences / Hospital [email protected]

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Page 1: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Interventional Radiology— An Introduction

Dr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical Sciences / Hospital

[email protected]

Page 2: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Agenda Definition Coverage of field Seldinger technique Cannulas Guide wires Vascular sheaths Catheters Angioplasty Balloons Stents Biopsy Needles Embolization Techniques

Page 3: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

What is interventional radiology?

Interventional radiology is a subspecialty which provides minimally invasive diagnosis and /or treatment using imaging (ultrasound, CT, or fluoroscopy) to target the intervention and show the results of the intervention.

Page 4: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

INTERVENTIONAL RADIOLOGY

Interventional radiology also known as Image-Guided Surgery or Surgical Radiology, is a subspecialty of Radiology, in which minimally invasive procedures are performed using image guidance. Some of these procedures are done for purely diagnostic purposes (e.g., angiogram), while others are done for treatment purposes (e.g., angioplasty).

Page 5: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

What kind of things can be done?

Treatment of vascular problems angiogram; angioplasty +/- stenting Biopsies Drainage of fluid collections abscesses, kidneys or bile ducts/gallbladder Embolization (blockage) of arteries to stop bleeding or treat tumours, etc. Treatment of infertility Insertion of feeding tubes Treatment of liver tumours

Page 6: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

These procedures can replace certain surgeries

faster recuperation than with surgery usually no hospital admission required (done as an outpatient) local anaesthetic used instead of general anesthesia safe and effective

Page 7: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Seldinger Technique

Page 8: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Seldinger Technique

Method for catheterization of vesselsDeveloped 1950’s still popular todayPercutaneous (through the skin) technique for arterial and venous access 3 vessels considered:

Femoral –preferred site for arterial (size + accessibility)BrachialAxillary

Page 9: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

PrerequisiteSelection based on strong pulse / absence of diseaseSite cleaned, area draped, local given

Sven-Ivar Seldinger Swedish Radiologist—1921-1998

Page 10: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Seldinger Technique ( step-by-step)

Insertion of needle

Placement of needle in lumen

Insertion Guide wire- thru needle, advance 10 cm

Removal of Needle- guide wire in position

Threading of catheter to area of Interest- fluoro used

Removal of guide wire- catheter remains in place

Page 11: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

SELDINGER TECHNIQUE

1. Insertion of needle (with inner cannula)2. Placement of needle in lumen of vessel (inner cannula removed)3. Insertion of guide wire4. Removal of needle5. Threading of catheter to area of interest6. Removal of guide wire

Page 12: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Two less common methods used

Cut down- minor surgical procedure to expose vessel of interestTrans-lumbar- patient prone, long needle passed thru T12- L2 into aorta

Page 13: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Cannulas

Page 14: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Simple 18 guage angiographic puncture needle - one-piece open needle with a sharp beveled tip.Guidewire is introduced directly through the needle once the tip is fully within the bleeding vessel lumen. This style of needle can be used for both arterial and venous punctures.

Page 15: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Guidewire is introduced directly through the needle once the tip is fully within the bleeding vessel lumen.

Page 16: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Insertion of cannula and guidewire

Page 17: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Guide Wires

Page 18: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Common guide wiresLeft to right Straight 0.038-inch J-tipped 0.038-inch with

introducer device (arrow) to straighten guide wire during insertion into needle hub

Angled high-torque 0.035-inch Angled hydrophilic-coated

0.038-inch nitinol wire with pinvise(curved arrow) for fine control

0.018-inch platinum-tipped microwire.

Page 19: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Basic construction of common guide wires.

1 and 2, Curved and straight safety guide wires with outer coiled spring wrap, central stiffening mandril welded at back end only, and small safety wire (arrow) welded on inside at both ends.

3, Movable-core guide wire in which mandril can be slid back and forth and even removed completely to change wire stiffness, using handle incorporated into guide wire (arrow).

4, Mandril guide wire in which soft spring wrap is limited to one end of guide wire (arrow). Remainder of guide wire is a plain mandril. 5, Mandril guide wire coated with hydrophilic substance (arrow).

Page 20: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Guide wires

• Guide wires are available in a number of thicknesses, lengths, tip configurations, stiffness, and materials of construction.

• Guide wire - the same as or slightly smaller than the diameter of the lumen at the tip of the catheter or device that will slide over it.

Page 21: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Guide wires• Too big will jam, usually at the tip of the catheter.

• If a guide wire is much smaller than the end hole of the catheter or device, there will be a gap between the guide wire and catheter that can cause vessel injury or prevent smooth movement over the guidewire.

• Thickness measured in one hundrethds of an inch : 0.038 Inches,0.035 inches, 0.014 inches etc.

Page 22: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Vascular Sheaths

Page 23: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Vascular sheath : Placed over the wire, through the access site. open at one end and capped with a hemostatic valve at the other. Walls are non tapered – beveled to closely match the dilator size so as to give a smooth transition between sheath and dilator. Available in various lengths and diameters. Diameter of a sheath is measured in “French”. Sheath selection is based on intended purposeShort 4 / 5 Fr sheaths for diagnostic purposes. Long sheaths with larger diameters for interventions.

Page 24: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Balkin’s Cross over sheathPlaced on contralateral side after crossing over

the aortic bifurcation.Facilitates easy access and treatment to lesions in

the Iliac / SFA and high tibial arteries.

Page 25: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar
Page 26: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Catheters

Page 27: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Charles T. Dotter M.D. (1920-1985)

Interventional RadiologistPioneer in the Field of Minimally Invasive Procedures (Catheterization)Developed Continuous X-Ray Angio-CardiographyPerformed First Angioplasty (PTCA) Procedure in 1964.

Page 28: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Trademark of Dr. Dotter

“If a plumber can do it to pipes, we can do it to blood vessels.”

Charles T. Dotter M.D.

Page 29: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Common catheter shapes.

6. Rösch celiac7. Visceral (very similar to Simmons1) 8. Mickelson 9. Simmons 210. Pigtail11. Tennis racket.

1. Straight2. Davis (short angled tip)3. Multipurpose (“hockey-stick”) 4. Headhunter (H1)5. Cobra-2 (cobra-1 has tighter curve, cobra-3 has larger and longer curve);

Page 30: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Flush cathetersAllow high-flow injections into the aorta or inferior vena cava.Uniform dispersal (with minimal recoil) of contrast media via multiple side holes.The tip is usually designed to help center the shaft in the vessel and prevent engagement and injection into a branch vessel.

Selective cathetersHave rotational stiffness to seek a vessel orifice, but with enough flexibility to pass the catheter far into the vessel.Shaped in a particular way to seek intended vessel ostium.

Page 31: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Structure of Catheter Catheter outer size is described in French gauge (3F = 1 mm).Diameter of the end hole (and therefore the maximum size of the guide wire the catheter will accommodate) is described in hundredths of an inch.The length of the catheter is described in centimeters (usually between 65 and 100 cm).The shape of the tip is named for either something the catheter looks like (“pigtail,” “cobra,” “hockey stick”), the person who designed it (Simmons, Berenstein, Rösch), or the intended use (celiac, left gastric, “head-hunter”)

Page 32: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Complex CathetersComplex catheter shapes must be re-formed inside the body after insertion over a guid ewire.

Any catheter will resume its original shape, provided there is sufficient space within the vessel lumen and memory in the catheter material.

Some catheter shapes cannot re-form spontaneously in a blood vessel, particularly the larger recurved designs like the Simmons.

Page 33: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Aortic spin technique for re-forming a Simmons catheter (works best for Simmons 1). Catheter is simultaneously twisted and advanced in proximal descending thoracic aorta.

Page 34: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Selective catheterizationChoosing a selective catheter shape:

A. Angled catheter when angle of axis of branch vessel from aortic axis is low.B. Curved catheter (e.g., cobra-2, celiac) when angle of axis of branch vessel is between 60 and 120 degrees. C. Recurved catheter (e.g., SOS, Simmons) when angle of axis of branch vessel from aorta is great.

Page 35: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

How to use a cobra catheter:

1. Catheter advanced to position proximal to branch over guide wire, then pulled down(arrow).

2. Catheter tip engages orifice of branch. Gentle injection of contrast agent to confirmed location.

3. Soft-tipped selective guidewire has been advanced into branch.

4. Guidewire is held firmly, and catheter is advanced.

5. Catheter in selective position.

Page 36: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

How to use a Simmons catheter:1. Catheter is positioned above

branch vessel with at least 1 cm of floppy straight guide wire beyond catheter tip.

2. Catheter is gently pulled down (arrow)until guidewire and tip engage orifice of branch.

3. Continued gentle traction results in deeper placement of catheter tip.

4. To deselect branch, push catheter back into aorta (reverse steps 1-3).

Page 37: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Micro-catheters

Small catheters (3F or smaller outer diameter) that are specially designed to fit coaxially within the lumen of a standard angiographic catheter are termed micro-catheters.Typically 2F to 3F in diameter, with 0.010- to 0.027-inch inner lumens.Designed to reach far beyond standard catheters in small or tortuous vessels.Wide range of characteristics:

1. stiffness, 2. braiding, 3. flow rates, 4. hydrophilic coatings.

Page 38: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Progreat Micro-catheterThis is a commonly used micro-catheter in peripheral vasculature used to facilitate embolization of Bronchial arteries, GI bleeds, Uterine Fibroid embolization etc.This micro-catheter allows embolization with micro-particles as well as 0.018 coils.

Page 39: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Exelcior SL 10Echelon 90 *

These are microcatheters commonly used in embolization of intracranialAneurysms.

Page 40: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

How to use micro-cathetersWhen using a micro-catheter, a standard angiographic catheter that accepts a 0.038- or 0.035-inch guide wire is first placed securely in a proximal position in the blood vessel.The micro-catheter is then inserted through the outer catheter and advanced in conjunction with a specially designed 0.010- to 0.025-inch guide wire through the standard catheter lumen. Once a superselective position has been attained with the micro-catheter, a variety of procedures can be performed, including embolization, sampling, or low-volume angiography.

Page 41: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Guiding catheters• Designed to make selective

catheterization and interventions easier.

• These catheters can be used in some situations to help position and stabilize standard catheters.

• These catheters can be used in some situations to help position and stabilize standard catheters.

• They are used in circumstances in which standard catheters are difficult to position selectively.

Page 42: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Guiding Catheter

• These are large lumen catheters that are placed proximal to give stable position for placement of instruments like micro-catheters, coils, stents within target lesion.

Page 43: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Y Connector

• These are connected on the hub of guiding catheters for hemostasis and for placement of micro-catheters as well as allow a continuous infusion of heparinized saline from the side port.

Page 44: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Angioplasty Balloon

Shaft length , wire compatibilty, sheath compatibilityRadio opaque markersSizingMax atm pressure

Page 45: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Principle of Angioplasty :

Plaque Fracture

Intimal Tearing

Medial Stretching

Page 46: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Catheter Types and Applications(continued)

Therapeutic Catheters – PTCA (Percutaneous Trans luminal Angioplasty)– Distal Protection Devices– Dialysis– Drainage – Drug and Stent Delivery– RF Ablation

Page 47: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Stents

Page 48: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Self Expanding Stent

Have radial force that anchors stent to target vessel as it deploys.Can be made of Nitinol that has thermal memory, they reach full

expansion at normal body temperature. Nickel titanium alloy.

Page 49: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Balloon Mounted Stent

Mounted over a balloon, expansion of the balloon Causes deployment of this type of stent.Precise positioning is required and is more rigid.These are not placed over joints as can fracture.

Page 50: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Stent Grafts

Stent-grafts represent a combination of stent and surgical bypass conduit technology. Internal bypasses.

Page 51: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Embolic Protection Devices

Page 52: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Atherectomy Device

Page 53: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Biliary Internal – External DrainThis has proximal as well as distal drainage holes that allow drainage of bile proximal to lesion externally.If the drain is internalized, that is the lesion is crossed and distal end is placed in the duodenum then bile is drained via the proximal holes into the Duodenum via distal holes.

Chiba NeedleUsed to gain access to bilary ducts.This can be done under Fluoroscopic Or USG guidance.

Page 54: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Trapease Filter Greenfield filter

Endovascular Filters

• Used to prevent pulmonary embolism in patients with DVT in whom long term therapy is contraindicated. Commonly placed in infra-renal IVC after confirming negative jet of renal veins.

• Can be permanent or temporary. Temporary filters have to be removed within 6 weeks to prevent endothelization of the filter.

Page 55: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Biopsy Needles

Page 56: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Biopsy NeedlesA biopsy needle is the instrument used to obtain a tissue as specimen for microscopic examination to find out cases of malignancy in patients.

Typically, the instrument includes a thin, long probe, called a stylet, inside a close-fitting hollow needle, called a cannula. In using the biopsy needles, a firing device first projects the stylet into the tissue, and the cannula follows immediately.

The stylet comes with a notch into which the tissue will prolapse once the stylet makes its way into the tissue. When the cannula later slides over the stylet, it severs the prolapsed tissue in the surrounding mass and then captures the prolapsed tissue like a specimen in the notch.

To be able to enhance the precision of a biopsy sampling, it is necessary to have biopsy needle guidance systems to carry out a successful medical procedure.

Page 57: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Biopsy Needles

Coaxial Disposable Guide Disposable Biopsy Needles PAN Aspiration Needle Soft Touch Spring Loaded Biopsy Needles Westcott Biopsy Needles Disposable Automatic Core Biopsy Needles

Page 58: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

FNAC Needles

Traditional fine needle aspiration biopsy needles which harvest cells for cytological evaluation.

Page 59: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Semiautomatic Biopsy Needle

Page 60: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Biopsy Gun

Page 61: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Embolization Agents

Page 62: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Pathophysiology

Deliberate occlusion of a blood vessel to achieve a therapeutic result

Page 63: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Diverse Usage

Technique has evolved to include nearly every vascular territory and has been used in such diverse clinical applications as :

Treatment of tumors VaricositiesVascular malformationsAneurysms and pseudoaneurysmsFibroidsGastrointestinal bleeding

Page 64: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Device selection

vascular territory to be embolizedpermanence of occlusiondegree of occlusion—proximal or distal—desired

Page 65: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Permanent Large-Vessel Occlusions

CoilsBalloonsAmplatz Vascular PlugGuide wiresSilk suture materialPorcine submucosa

Page 66: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Permanent Small-Vessel Occlusions

ParticlesLiquid sclerosantsLiquid adhesiveEthiodolThrombinOnyx

Page 67: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Temporary Large-Vessel Occlusions

Gelfoam sponge

Autologous clot

Page 68: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Temporary Small-Vessel Occlusions

Gelfoam powder

Starch microspheres

Fibrillated collagen

Page 69: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

General Embolization Scheme and Clinical Indications

Vessels Permanent Temporary

Large vessel Coils (e.g., pulmonary AVM)

Gelfoam sponge (e.g., trauma)

Small vessel

Particles (e.g., UFE); no organ deathLiquid agents (e.g., renal ablation); organ death

Gelfoam particles, fibrillated collagen (e.g., chemoembolization)

Page 70: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

AUTOLOGUS CLOT

Advantagesimmediate availability, absence of cost, and lack of adverse

reaction. Methodaspirate roughly 20 mL of the patient's blood and allow it to clot,

then discard the supernatant and reintroduce the clot through the catheter. If desired, the clot can be opacified by adding sterile tantalum powder.

Drawback : Rapid lysis time, which can lead to recanalization within 6 to 12

hours. This problem can be partially overcome by modification of the autologous clot.

Page 71: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

If a very proximal occlusion is desired, Gelfoam "torpedoes" can be formed by compressing and rolling strips of Gelfoam, which are then loaded into the nozzle of a 1- or 3-mL syringe.

Gelfoam Pledgets Gelfoam Torpedo

Page 72: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

For more distal embolization, a slurry of Gelfoam can be created by macerating the pledgets with two syringes and a three-way stopcock: the more passes the Gelfoam makes through the stopcock, the more it is fragmented and the smaller the pieces become.

Page 73: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Gelfoam Embolization

Gelfoam embolization provides a temporary occlusion lasting approximately 3 to 6 weeks.

Used for embolization of pelvic trauma or postpartum hemorrhage, especially when there are multiple punctuate bleeding sites from various branches of the internal iliac artery. In such situations, embolization should be initiated with Gelfoam slurry to achieve a relatively distal level of occlusion and then followed by Gelfoam pledgets or torpedoes.

Page 74: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

PVA Particles

Used in bronchial artery embolization and Uterine fibroid embolization etc.

Page 75: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

PVA ParticlesPolyvinyl alcohol (PVA) is essentially a plastic sponge that is fragmented and then filtered to a certain size range.

PVA is available in sizes between 50 and 2000 µm, the typical size ranges used clinically are 300 to 500 µm or 500 to 700 µm.

Smaller particles have a significant risk of tissue infarction due to their distal level of occlusion. Larger particles may occlude the delivery catheter

Page 76: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Uses of PVAPredominantly for tumor embolization, either for preoperative devascularisation or as definitive treatment, such as in uterine fibroid embolization, JNA embolization.

PVA can be used when treating hemorrhage of a vascular bed with multiple small branches e.g. hemoptysis in patients with chronic inflammatory lung disease.

Prior to bronchial embolization, the presence of a spinal artery originating from the treated vessel should be excluded.

Page 77: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Other Particulate agents :Microspheres (Embosphere, BioSphere Medical, Rockland, MA).

Embospheres are precisely calibrated, spherical, hydrophilic, microporous beads made of an acrylic copolymer, which is then cross-linked with gelatin.

The hydrophilic surface prevents aggregation, allowing a more predictable, uniform vessel occlusion than PVA, as well as easier delivery through small catheters.

SIR Spheres : Ceramic microspheres have been embedded with the beta emitter Yttrium-90. Provide internal radiation of hepatic malignancies

Page 78: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Use of PVA Particles

Page 79: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Pre and Post Uterine Fibroid Embolization

Use of PVA Particles

Page 80: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Coils First embolic coils consisted of pieces of stainless steel guide wires onto which strands of wool had been woven to add a matrix for thrombus formation.Stainless-steel coils are best suited for high-flow applications due to their high radial force, which helps prevent dislodging. Platinum coils are highly visible under fluoroscopy and are much softer than stainless steel. This facilitates accommodation of the coil to the vessel.Appropriate sizing is important to ensure occlusion of the vessel at the intended location.Gugliemi detachable coil : Coil is welded to the pusher wire in the desired position, the wire is attached to a battery device that sends a current along the wire. The current melts the welded connection between the coil and the wire and detaches the coil without any force. GDCs are mainly used for treatment of intracranial aneurysms.

Page 81: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Detachable Coils

Used in Intracranial Aneurysm Coiling.

Page 82: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Pushable Coils

Used in Peripheral Embolization.

Page 83: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Uses Embolization with coils produces a focal occlusion, leaving the vessel distal to the coil patent, similar to surgical ligature. Therefore, coils are utilized in almost any application in which precise vessel occlusion--but not tissue ablation--is necessary.

Applications for coil embolization include treatment of hemorrhage, occlusion of arteriovenous fistulas, and preoperative or pre-stent graft vessel occlusion.

Page 84: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Coil embolization

27 yr old female patient with secondary PPHTaken up for Uterine Artery Embolization.Pre-Procedure Angiogram done

Page 85: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Coil embolization

Bilateral uterine arteries were embolised using pushable coils. There was no further bleeding.Patient was stable.

Page 86: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Endovascular Coiling of Intracranial Aneurysms

Page 87: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Liquid - PolymersOnyx : Liquid embolic agent, consisting of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx, Micro Therapeutics Inc., Irvine, CA).Onyx contains tantalum powder to render it radiopaque. After Onyx is injected into the target lesion, the dimethyl sulfoxide solvent rapidly diffuses away, causing precipitation of the polymer and formation of a spongy cast. The cast solidifies from the outside inj. Onyx allows a prolonged, controlled embolization because of its non-adhesive nature. Used mainly in Cerebral and Peripheral AVM embolization

Page 88: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Liquid - Polymers

Used for embolization of Cerebral AVMs,Peripheral AVMs.

Page 89: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Glue + lipidioln butyl cyanoacrylate.This agent is a permanent rapidly acting liquid, similar to glues sold under trade names such as "SuperGlue," that will polymerize immediately upon contact with ions. It also undergoes an exothermic reaction which destroys the vessel wall. Since the polymerization is so rapid, it requires a skilled surgeon. During the procedure, the surgeon must flush the catheter before and after injecting the NBCA, or the agent will polymerize within the catheter. The catheter must also be withdrawn quickly or it will stick to the vessel. Oil can be mixed with NBCA to slow the rate of polymerization.Ethiodol - Made from iodine and poppyseed oil, this is a highly viscous agent. It is usually used for chemoembolizations, especially for hepatomas, since these tumors absorb iodine. The half life is five days, so it only temporarily embolizes vessels.

Page 90: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar
Page 91: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Sclerosing Agents

Cause protein denaturation, leading to endothelial destruction and vascular occlusion. Occlusion by sclerosants is usually permanent.

Sodium tetradecyl sulphate (Setrol) and Polidocanol

Uses : ablation of tumors, solid organs, veins, or vascular malformations.

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Page 93: Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

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