INTERVENTIONAL RADIOLOGY IN HEPATOBILIARY SYSTEM

DR. AKSHAY GURSALE(RESIDENT RADIOLOGY)

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What is a CATHETER ?

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DEFINITION:

A catheter is a hollow flexible tube that can be inserted into a body cavity, duct or vessel. Catheters thereby allow drainage or injection of fluids , distend a passageway or provide access by surgical instruments.The process of inserting a catheter is catheterization.In most uses a catheter is a thin, flexible tube: a "soft" catheter; in some uses, it is a larger, solid tube: a "hard" catheter.

The first curve is called primary curve for Engagement.The second curve is called secondary curve to give support to that Catheter against theVessel wall.

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What is a Catheter made up of ?Materials:

A range of polymers are used for the construction of catheters, including silicone rubber latex and thermoplastic elastomers. Silicone is one of the most common choices because it is inert and unreactive to body fluids and a range of medical fluids with which it might come into contact.Materials:CATHETER:Polyvinylchloride (PVC)Polyethylene (PE)Fluoropolomers (PTFE) (TEFLON)Polyurethane (PUR)Silicone (SI)

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PARTS OF A CATHETER

HUB

BODY

TIPHUB

BODY

TIP

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FRENCH CATHETER SCALE:

The French catheter scale (most correctly abbreviated as Fr, but

also often abbreviated as FR or F) is commonly used to measure the outer diameter of cylindrical medical instruments including catheters ,needles etc.

In the French Gauge system as it is also known, the diameter in millimeters of the catheter can be determined by dividing the French size by 3, thus an increasing French size corresponds with a larger diameter catheter. The following equations summarize the relationships:

D(mm) = Fr/3 or Fr = D(mm)*3

MEASUREMENT:

Most commonly in adult Diagnostic Catheters of 5 – 7 Fr is used.

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TYPES OF CATHETERS:CLASSIFICATION :Catheters can be classified depending on SIDE HOLES : -: Single Hole -:End Hole with side holes. -:Blocked end with side holes only. SIZES :Abdominal – 6-80 cm Thoracic or Carotid Arteries – 100-120 cm NOTE: Size depends on : > age of the patient > selective or super selective study > size of the vessels.NOTE: Ideal practice is to use the smallest diameter catheter feasible for any particular study to minimize the risk of arterial damage by the procedure.

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TYPES OF CATHETERS

SHAPES Straight Catheter

Pigtailed Catheter

Cobra Shaped Catheter

Side Winder Catheters (Shepherd)

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Some Other Types of Catheters:

Hydrophilic Catheters : Hydrophilic-coated catheters have a layer of polymer coating that is bound to the catheter surface. The polymer absorbs and binds water to the catheter, resulting in a thick, smooth and slippery surface.

Intermittent Catheters: Intermittent catheters are hollow tubes used to drain urine from the bladder.

Pediatric Catheters: Usually its around 80cm.

Different Catheter Curves For Different Purposes:

> Judkins Left (JL)

> Judkins Right ( JR)

> Judkins Left Short Tip

> Judkins Right Short Tip

> Amplatz Left ( AL)

> Amplatz Right ( AR)

> Left Coronary Bypass

> Right Coronary Bypass

> Cardiac Pigtail

> Multipurpose

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CATHETERS CAN BE BROADLY CLASSIFIED UNDER THESE GROUPS:

DIAGNOSTIC CATHETERS Used for Angiographs .

GUIDING CATHETERSUsed for Angioplasty.

• Guiding catheters are like angiography catheters only difference is that guiding catheters are more stiffer & firm as it carries Balloon catheters, PTCA wires and stent delivery system.

• Mild stiffness comes due to the wire braided design.

• Good Push ability .

• Good Tractability.

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PUNCTURE NEEDLES:Used to cannulate or puncture the artery.

Usual Sizes include

18 ga, 19 ga , 20ga, 21 ga.

The selection of the Size depends on the guide wire going to be inserted through that needle port.

Seldinger Needle

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GUIDE WIRE:Diagnostic guide wires are used to traverse vascular anatomy to aid in placing catheters and other devices. Guide wires are used for both Cardiology and Radiology angiographic procedures.

• Guide wires are relatively simple spring type wires that

provides necessary firmness and the control to the site where

Angiogram will be taken.

• A the name suggests it ‘ Guides’ the catheter.

• PTFE coated Soft tip for the smoothness during the insertion

• Less trauma to the intimal wall of the artery

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Shape of the Tip : J Tip / Straight Tip

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In 1929 Werner Forssmann demonstrated that a simple Rubber catheter could be passed to the pulmonary artery through the Anti- Cubital Vein and An angiographic film could be obtained using radiographic contrast.

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Sven- Ivar Seldinger

In 1953 , Sven –Ivar Seldinger inventedThe technique of gaining access Percutaneusly into an artery without An arteriotomy.

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TECHNIQUE OF INSERTING A CATHETER

SELDINGER TECHNIQUE:

The technique of catheter insertion via double-wall needle puncture and guide-wire is known asThe SELDINGER TECHNIQUE.

Double Wall Puncture:Mostly done. Compression to prevent Hematoma of the other wall. Rotatory movement to get the needle into the lumen.

Single Wall Puncture:Usually done for patients co-agulation time is less.

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COMPLETE APPARATUS:

> Needle

Guide Wire

Sheath

Catheter

COMMON CORONARY CATHETERS USED FOR ANGIOGRAPHY1. HEAD HUNTER2. JUDKINS LEFT CORONARY3. JUKINS LEFT AND RIGHT

CORONARY CATHETERS IN COMBINATION

CATHETERS USED FOR PERIPHERAL ANGIOGRAPHY AND NON VASCULAR INTERVENTION1. MICROCATHETER2. PIGTAIL CATHETER

OTHER CATHETERS GUIDEWIRES USED IN ANGIOGRAPHY1. TEREMO WIRE2. TIGER CATHETER

MULTIPURPOSE FOR BOTH LEFT AND RIGHT CORONARY

3. CATHETER FOR ANOMALOUS ORIGIN OF RT CORONARY AND IN PDA

INTERVENTION IN HEPATOBILIARY SYSTEM CAN BE DIVIDED CAN BE

DIVIDED INTO FOLLOWING HEADINGS

INTERVENTION THERAPIES FOR HEPATIC MALIGNANCIES

BENIGN BILIARY OBSTRUCTION MALIGNANT BILIARY OBSTRUCTION PERCUTANEOUS MANAGEMENT OF

PORTAL HYPERTENSION PERCUTANEOUS CHOLECYSTOSTOMY PERCUTANEOUS MANAGEMENT OF

BILIARY CALCULI

Regional arterial infusion and chemoembolisation is

the most common technique used in hepatic

malignancies

Chemoembolisation agents should have characters

of rapid first pass clearence, steep dose response

curve

Temporary agents commonly used are gelfoam

cause recanalisation in 4-6 weeks

Permanent are polyvinyl alcohol cause

angiogenesis

Lipiodol is agent used for diagnostic imaging in

liver

Procedure technique The arterial supply of the liver is mapped out and portal vein patency

is established, catheterization of the hepatic arteries is undertaken.

With the new lubricious coatings, this usually can be accomplished

with 5.0-5.5 French catheters

cirrhosis and hepatocellular carcinoma coexist frequently in patients

with chronic hepatitis, the portal circulation should also be assessed

for hepatofugal flow.

Because the hepatic artery is to be embolized intentionally,

confirmation of portal vein patency is essential. This can be

accomplished with superior mesenteric or splenic artery angiography

to rule out thrombosis

repeated chemoembolizations, the blood supply of the liver must be

reassessed continuously because different flow patterns will emerge

over time this is mainly due to collateral formation from the “culprit

vessels” from peripheral arteries

CELIAC ANGIOGRAPHY IN CIRRHOSIS AND HEPATOCELLULAR CA

HEPATOCELLULAR CARCINOMA WITH PORTAL VIEN THROMBOSIS

METASTATIC OCULAR MELANOMA WITH SELECTIVE CATHETERISATION AND OCCLUSION OF COLLATERAL FROM SUPERIOR MESENTERIC ARTERY

SIMMOND S CATHETER WAS USED

SELECTIVE EMBOLISATION OF RIGHT GASTRIC ARTERY

HYPERVASCULAR LIVER TUMOUR AND FISTULA FROM LEFT HEPATIC ARTERY TO IVC COIL BLOCKAGE OF FISTULA BEFORE CHEMOEMBOLISATION TO PREVENT LEFT TO RIGHT SHUNT

HEPATIC METASTASIS FROM COLORECTAL CART LOBE OF LIVER WITH HYPEREMIC BORDER

RADIOFREQUENCY ABLATION underlying principle is the local creation of heat, via a percutaneously or

surgically placed probe, that destroys tumor tissue while insulating and sparing adjacent normal liver.

using probes as small as 15-gauge to 17-gauge needles, alternating current causes tissue coagulation by frictional heating. Tumor tissue is ablated as temperatures reach 50-100°C, and yet, noncancerous tissue as close as 0.5 cm away is spared

Benign biliary obstruction Complete and accurate demonstration of the bile duct

obstruction and of the bile ducts above and below the lesion is a key element in the management of bile duct stenoses and obstructions. This will usually require opacification of the bile ducts by percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), or injection of contrast through any indwelling catheters such as T tubes.

Procedures performed are:- Dilatation Endoprosthesis Metallic stenting

Dilatation percutaneous biliary dilatation using balloon dilation catheters include

those of Burhenne (1975) via a T-tube tract and of Molnar and Stockum (1978) via the transhepatic route.

The balloon size should match the estimated caliber of the duct on either side of the stricture and is usually in the 4- to 8-mm range. Duct rupture is most unusual with correctly sized balloons even though high pressures (up to 16 atm) are not infrequently needed to dilate the stricture. Progress in balloon manufacture now provides balloons that can be used at up to 20 atmospheres in pressure. Stricture dilatation can be very painful, and adequate sedation and pain control are important.

A drainage catheter, of 10-12 French and occasionally 14 French, is left across the stricture for 6 weeks and then exchanged for a new self-retaining catheter positioned in the biliary tree above the stricture.

POSITION OF PATIENT FOR PTBD AND THE OPACIFICATION OF BILIARY RADICLE AS SHOWN IN THE SECOND IMAGE WITH DILATION OF CBD

PATIENT WITH OPEN CHOLECYSTECTOMY AND DAMAGE TO RIGHT HEPATIC DUCT WHICH WAS REPAIRED BY ROUX EN Y FUTHER SUFFERED CHOLANGITIS DUE TO STRICTURE TREATED BY BALLON DILATATION

METALLIC STENTING INDICATIONS

ALL SURGICAL OPTIONS ARE EXHAUSTED AND DILATATION HAVE FAILED

Gianturco stent appears to provide reasonable palliation PROCEDURE

GIANTURCO STENT NO 8, 10, 12 MM IS USED VIA PERCUTANEOUS TRANSHEPATIC ROUTE VIA

EXISTING T- TUBE CATHETER PLACED OVER WIRE AND CONTRAST

INJECTED VIA SIDE ADAPTER DILATOR PASSED ALONG THE STRICTURE AND

FOLLOWED BY SMALL PEEL AWAY INTRODUCER INTRODUCER PEELED AWAY WITH THE SELF RETAINING

STENT IN PLACE

METALLIC STENT PLACEMENT IN A PATIENT WITH BEIGN STRICTURE

MALIGNANT BILIARY OBSTRUCTION

ROLE OF RADIOLOGIST PERFORM CECT OR MRCP TO PROPERLY DELINEATE

THE LIVER AND BILIARY TRACT ANATOMY FUTHER DEFINE THE ANATOMY USING PTC AND

PERFORM A PTBD IMPROVE METABOLIC STATUS OF THE PATIENT PERFORM A HEPATIC ARTERIOGRAPHY TO RULE OUT

AND TUMOUR OR MASS ENCASING THE LIVER AND FOR MARKING THE LIVER ANATOMY

the general location of the puncture site within the biliary tree (i.e., peripherally or centrally); (2) the angle formed by the junction of the needle and the specific duct entered; and (3) the therapeutic objectives of future biliary interventions. After the diagnostic PTC is performed using a 21- to 23-gauge “skinny needle” (Chiba needle or trocar needle), a percutaneous biliary drainage (PBD) is performed

Eventual placement of an 8-10F multi-side-hole locking pigtail catheter across the obstruction

PERCUTANEOUS MANAGEMENT OF BILIARY CALCULI

PERCUTANEOUS MANAGEMENT OF BILE DUCT STONES STONE EXTRACTION THROUGH T -TUBE TRACT

TRANSHEPATIC CHOLEDOCHOLITHOTOMY

1. a 21- or 22-gauge needle is used to access the duct of interest. A 0.018-inch guide wire is advanced through the needle, maneuvered into the common bile duct, and exchanged for a standard 0.035-inch guide wire over an intermediary exchange dilator

2. an appropriate catheter and guide wire may be manipulated through the distal duct and bowel. It would be traumatic to extract large calculi through the transhepatic tract.

3. Therefore, a technique that will allow expulsion of stones or stone fragments through the duct into the duodenum must be used.

TRANS JEJUNAL CHOLEDOCHOLITHOTOMY IN DISEASES ASSOCIATED WITH RECURRENT CALCULI AND BILE

DUCT STRICTURES FREE ASSESMENT OF HEPATIC DUCT AND FOR LONG TERM LINE

PLACEMENT TO ENSURE COLON IS NOT PUNCTURED IT IS PRE OPACIFIED BY

BARIUM ONE DAY PRIOR HEPATIC FLEXURE METALLIC ANCHOR DEVICE IS PLACED IN SMALL BOWEL FOR

JEJUNOPEXY DRAIN CAN BE EASILY REINSERTED IF IT FALLS OFF EASY RECATHETERISATION

PERCUTANEOUS CHOLANGIOSCOPY A 3-5 MM ENDOSCOPE CAN BE PASSED THROUGH THE T TUBE

TRACT FOR ASSESSMENT AND REMOVAL OF THE STONES ESWL ANGIOPLASTY BALLON CATHETERS FOGARTHY CATHETERS

PERCUTANEOUS CHOLECYSTOLITHOTOMY (PCCL)

DIRECT PERCUTANEOUS EXTRACTION OF STONE FRAGMENTS AND REMOVAL OF STONE AFTER STONE FRAGMENTATION OR CONTACT DISSOLUTION

PERCUTANEOUS MANAGEMENT OF PORTAL HYPERTENSION

IT INCLUDES THE FOLLOWING PROCEDURES

1. TRANSHEPATIC VARICEAL EMBOLIZATION

2. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC

SHUNTS (TIPS)

3. PERCUTANEOUS REVISION OF SURGICAL

PORTOSYSTEMIC SHUNTS

4. CHECK SHUNT PATENCY

TRANS HEPATIC VARICEAL EMBOLISATION IN A PATIENT WITH UNCONTROLLED BLEEDING VARIECES

1. TRANS HEPATIC PORTOGRAM

HEPATOFUGAL FILLING

2. CORONARY VEIN VENOGRAM

3. VENOUS OCCLUSION BY CONTRAST

4. SPLENIC PORTOGRAM SHOWS NO VARIECES

DIAGRAMMATIC REPRESENTATION OF TIPS PLACEMENT

PERCUTANEOUS TREATMENT OF PORTAL HYPERTENSION1. TRANS HEPATIC

PORTOGRAM OCCLUSION OF PORTAL VIEN

2. SPLENIC PORTOGRAM SHOWS LEFT GASTRIC COLLATERALS

3. WALLENT,S STENT DEPLOYED AFTER OCCLUSION

4. SPLENIC PORTOGRAM SHOWS NORMAL FLOW WITH NO COLLATERALS

TIPS PLACEMENT IN DISTAL PORTAL VEIN AND SPLENIC VEIN THROMBOSIS

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