Interventional Radiology

“Interventional Radiology” (IR) refers to a range of techniques which rely on the use radiological image guidance (X-ray fluoroscopy, ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) to precisely target therapy. As many IR procedures start with passing a needle through the skin to the target it is sometimes called pinhole surgery! Interventional radiology is a medical specialty that has been called “The Surgery of the 21st Century.”

Interventional radiologists are doctors who are trained in radiology and interventional therapy. The essential skills of an interventional radiologist are in diagnostic image interpretation and the manipulation of needles and the use of fine catheter tubes and wires to navigate around the body under imaging control. Remarkably, most incisions are no larger than the lead tip of a pencil!

There is hardly any area of hospital medicine where IR has not had some impact on patient management. The range of conditions which can be treated by IR is enormous and continually expanding.

Well recognised advantages of these minimally invasive techniques include reduced risks, shorter hospital stays, lower costs, greater comfort, smooth convalescence and quicker return to work. The effectiveness of treatment is often being better than with traditional treatments

DIAGNOSTIC INTERVENTIONS

• Biopsy: Taking a tissue sample from the area of interest for pathological examination from a percutaneous approach guided by Ultrasound or CT.
• Transjugular liver biopsy (TJLB) in patients with coagulopathy and ascites.

GI BLEED

• Embolization: Endovascular delivery of an embolic substance (coils, stent-graft, gel-foam, polyvinyl alcohol) to stop bleeding related to pancreatitis, trauma, postoperative bleeds, small and large bowel bleeds.

MESENTERIC ISCHEMIA

• Acute mesenteric ischemia: Thrombolysis by infusion catheter at the site of an occlusion.
• Chronic mesenteric ischemia: Trans-arterial angioplasty and stenting of the occluded artery.

PORTAL HYPERTENSION (IN COLLABORATION WITH HEPATOLOGY)

• HVPG: is a clinical measurement of the pressure gradient between the WHVP and the free hepatic venous pressures, and thus act as a diagnostic index to plan suitable therapy for the patient.
• TIPS: Creation of an artificial shunt between the intrahepatic portal vein and preferably right hepatic vein with subsequent placement of PTFE covered stent graft for select patients with refractory variceal bleed and refractory ascites in critical end-stage liver disease and portal hypertension.
• BRTO / BATO: a minimally invasive technique that is used to treat gastric variceal bleeding. The procedure involves selectively blocking the dilated varices, reducing the risk of rupture. BRTO is also used for management of recurrent hepatic encephalopathy

BUDD-CHIARI SYNDROME (BCS)

• Sometimes the liver is affected because the outflow of blood from the liver is blocked. When this happens patients can develop bleeding and ascites. These complications can be managed by IR
• IVC / Hepatic venoplasty and stenting: Opening of narrow or blocked blood vessels using a balloon, with or without placement of metallic stents to aid in keeping the vessel patent and manage complications of portal hypertension
• DIPS: Placement of a Direct Intrahepatic Porto-systemic Shunt (DIPS) between the intrahepatic IVC and intrahepatic portal vein.

HEPATOCELLULAR CARCINOMA AND COLORECTAL HEPATIC METASTASES

• Radiofrequency ablation (RFA):. It is an Interventional radiology technique of applying heat to tumours as a means of killing cancer cells is been in clinical use for a couple of years. However, this type of treatment, called tumour ablation, is a relatively new technique which uses a special needle to kill cancer cells by using heat generated by medium frequency alternating currents. These are used to treat liver cancers, and thus getting the results at par with surgery.
• Microwave ablation (MWA): it is a local treatment which uses a special needle to destroy tissue by using heat generated by microwaves
• Percutaneous Ethanol Injection.
• Trans-arterial Chemoembolization (TACE): It is a direct injection of the chemotherapeutic agent into the arterial blood supply of a tumour, along with lipiodol, drug eluting beads or spheres with an intent of both local administration of chemotherapy and decreasing tumour arterial supply.
• Radioembolization (TARE): it is a combined injection of radioactive and embolic agents into the arterial blood supply of a tumour, with the goal of both local administration of radiotherapy and also decreasing tumour arterial supply in patients with HCC and portal vein thrombosis

OBSTRUCTIVE JAUNDICE

• Placement of drainage catheters in the biliary system to bypass biliary obstructions and decompress the biliary system.
• Management of Hepato-jejunostomy strictures by sequential dilatation, balloon sweeping for calculi removal.
• Reconstruction of Biliary tree in malignant biliary obstruction by placement of permanent indwelling biliary stents (Self Expanding Metallic Stents).
• Endobiliary RFA for malignant biliary obstruction and stent blockage by killing cancer cells maintain stent patency for longer periods and also improve quality of life.
• Management of post-operative Bile duct injury by catheter drainage and stenting
• Percutaneous Cholecystostomy (PCC): Placement of a tube into the gallbladder to remove infected bile in patients with cholecystitis, who are too frail or too sick to undergo surgery.

FLUID COLLECTION

• Placement of tubes to drain pathologic fluid collections (e.g., liver abscess, ascites, pleural effusion).
• Management of pancreatic necrotic collections( in collaboration with medical Gastroenterology): This may be achieved by percutaneous, trans-gastric, trans-hepatic or trans-splenic approach
  • Placement of catheters to drain fluid collections
  • Percutaneous pancreatic necrosectomy – to remove necrotic debris
  • Internalization of trans-gastric drainage catheters
• Percutaneous aspiration injection and re-aspiration (PAIR): in the management of hepatic hydatid cyst.

VARICOSE VEINS

• Endovenous laser treatment of varicose veins: Placement of thin laser fibre in varicose veins for non-surgical treatment of venous insufficiency.
• Dilated veins in the pelvis or scrotum (Varicocele). These can be treated by blocking the vein by sclerosants and embolisation techniques.

POST-LIVER TRANSPLANT COMPLICATIONS

• Trans-arterial management of pseudoaneurysms and bleed by stent-graft and embolizations
• Trans-arterial management of vascular anastomotic strictures by angioplasty and stenting
• Management of biliary anastomotic strictures and bile leaks
• Percutaneous catheter drainage of post-operative collections.