• What is "Interventional Radiology"
• Indications, contra-indications and complications of commonly encountered procedures
• Percutaneous biopsy
• Percutaneous drainages
• Transcatheter treatment

• Non-surgical intervention to provide diagnosis and treatment
• Image-guided
• Risks attached - "intervention"
• Contraindications - related to the risks of bleeding (deranged clotting profile), infection (eg. Skin you want to biopsy through), trauma to other organs
• Post-procedure care - input from clinicians
• Requires proactive consent from either patients or their carers

ALWAYS check Pt's blood profile + obtain Pt's consent

Diagnosis (biopsy)

• To obtain tissue samples from masses or fluid collections for microbiology, histology and cytology
• These tissues or fluid are obtained by percutaneous puncture with a needle of the mass or collection
• This is performed using imaging to guide the needle (needle can be very fine - 22 gauge)

Treatment

Image guided

• Lung
• Liver
• Kidney
• Thyroid
• Soft tissue masses
• Others - lymph node, pancreas, adrenal gland, breast

• X-rays with fluoroscopic image obtained 2 planes (AP and lateral) to localise position of lesion
• Traditional method
• Superseded by US and CT guided
• Real time
• Used more 20-30y ago

 Ultrasound

• Abdomen - liver, kidney
• Neck - thyroid
• Breast
• Extremities

These are structures where the organs can easily be visualised using US with no overlying structures such as bone, bowel or lung

• CT uses x-rays and the x-ray tube goes around the patient in 350°
• CT presents data in true cross section
• No trouble with overlying structures such as bones, bowel or lung

Thorax

• Abdomen: pancreas, adrenal gland, bowel, retroperitoneal masses
• Neck masses not seen on US
• Visualise the adrenal and pancreas clearly
• Not so easy with US due to overlying bowel and fat
• Select a section where the target lesion is found
• Place a grid on the section
• Helps localise the lesion via markers on the skin
• Aids determination of needle entry point

• Needle is inserted through the skin into the lesion

• Positive tissue: 80% - 95%
• Complication rate (overall SAFE!)
• Overall < 2%
• Mortality rate : 0.006% - 0.031%

• Vascular damage - bleed, arterio- venous fistulas, pseudoaneurysm
• Infection
• Organ injury (pancreatitis 2-3% if normal pancreas punctured)
• Needle tract tumour seeding (rare, 0.003-0.009%)

• Arteriovenous fistula, which is a communication between the arterial (white arrow) and venous system (red arrow) secondary to biopsy

• Pneumothorax - up to 57%. Chest drain required in 3-20%
• Haemoptysis: 2-12%, usually mild
• Air in pleural space outside the lung

• Uncorrected bleeding diathesis
• Platelets less than 50,000/mm3
• INR > 1.5
• Inaccessible lesion e.g. surrounded by bone or vessels without safe path
• Uncooperative, confused or unwilling patient

Principles

• Uses image guidance as biopsies
• Fluoroscopy, US and CT
• Similar precautions and contraindications as biopsies
• Similar risks with additional ones relating to organ to be drained

Common ones

• PTBD - percutaneous transhepatic biliary drainage
• Percutaneous nephrostomy
• Percutaneous abscess drainage

• It involves identifying dilated bile ducts usually by US
• Puncturing the duct through the skin and liver
• Injecting contrast material to opacify the ducts using fluoroscopy

When do we do PTBD?

• To treat obstructive jaundice (benign or malignant)
• To treat biliary sepsis (cholangitis)
• Before surgery to decompress the biliary system

Acute complications

• Bleeding into biliary system most common
• Infection - Septic shock
• Pancreatitis - rare
• Puncture of other organs - lung, kidney
• Overall 5-10% PTBDs

Delayed complications

• Biliary sepsis (cholangitis)
• Catheter migration
• Bile leak
• Metastatic seeding
• Skin infection
• 45-50% of all PTBDs

• It involves identifying dilated pelvicalyceal system with US
• Puncturing the calyx through the skin
• Injecting contrast material to opacify the collecting system using fluoroscopy

Indications

• When a kidney is obstructed (hydronephrosis)
• When there is urine leakage secondary to trauma, infection or neoplasm
• Prior to instrumentation such as stone extraction, stricture dilatation and ureteral stenting

Stone extraction

• PCN is also performed to create a tract to allow stone extraction during lithotripsy

Complications

1. Minor complications (10%)

• Haemorrhage, pain, catheter malfunction

1. Serious Complications (4-5%)

• Haemorrhage or sepsis
• Pneumothorax, peritonitis, urinoma (rare)
• Death : 0.2%

• The systematic withdrawal of fluids and discharges from a wound, sore and cavity
• Usually ultrasound or CT guided
• Same risks and contraindication applies generally
• Safest route - avoid overlying blood vessels, viscera, pleura
• Hydatid cyst cannot be drained - anaphylactic shock
• Contrast CT shows gas containing complex cystic mass in the pelvis
• Posterior approach chosen - easiest route
• Prone position
• Needle inserted through the gluteal muscle
• Still in prone position
• Catheter inserted over guidewire and placed into abscess cavity
• PA film shows position of catheter in the pelvis
• Ultrasound guided
• Catheter in liver abscess

• Sepsis
• Haemorrhage
• Death (2^o to sepsis or haemorrhage)

• Transcatheter treatment of cancers
• TOCE
• Regional chemotherapy
• Transcatheter embolisation of bleeding sites
• Lacerated vessels
• Bleeding viscera

Transcatheter oily chemoembolisation (TOCE)

Treatment of inoperable hepatocellular cell carcinoma

• Femoral artery punctured and a catheter placed into the coeliac artery
• Injection of mixture of iodised oil (lipiodol ultrafluid) and cytotoxic agent (Cisplatin) into hepatic artery, followed by injection of Gelfoam particles

Principle

• HCC is a vascular tumour supplied almost solely by the hepatic artery
• Iodised oil is selectively taken up by HCC cells
• Cytotoxic mixed into an emulsion with lipiodol will thus be carried to the tumour cells in high concentration to be released slowly
• Gelfoam particles block the washout by the arterial flow and "locks" in the cytotoxic within the tumour cells

Complications

• Post-embolisation syndrome (common)
• Nausea, vomiting, abdominal pain, loss of appetite, fever
• Others (Uncommon) - Cholecystitis, upper GI bleeding, gastric/duodenal necrosis, acute pancreatitis, hepatic abscess, rupture

Contraindications

• Main portal vein tumour thrombosis: embolisation of hepatic artery may cause complete occlusion and total ischaemia to the liver
• Extrahepatic metastases
• Poor liver function: procedure induces ischaemia & liver damage

Regional chemotherapy

• Catheter placed in the artery supplying the tumour to optimise drug delivery
• Reduces systemic circulation of the cytotoxic
• Smaller doses used
• Stomach cancer at QMH

Embolisation of lacerated arteries or bleeding viscera

• Selective catheterisation of artery that is lacerated or bleeding
• Particulate matter is injected - gelfoam, coils
• Trauma, gastrointestinal bleeding

• Non-surgical management of patient to provide diagnosis and treatment
• Involves procedures that are associated with risk factors
• Weigh need versus risk
• Consent from patients or carers
• Requires inpatient aftercare and therefore clinician input
• Know your patients - to avoid preventable complications such as haemorrhage (bleeding diasthesis)