This presentation provides sufficient material for anyone who wants is interested in interventional radiology. Here we will discuss the available facilities, mechanisms and equipments. In my opinion this presentation will prove a footstep in interventional radiology

1. Interventional Radiology— An
Introduction
Dr. Muhammad Bin Zulfiqar
PGR IV FCPS Services Institute of Medical Sciences / Hospital
radiombz@gmail.com

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

3. 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.

4. 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).

5. 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

6. 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

8. Method for catheterization of vessels
Developed 1950’s still popular today
Percutaneous (through the skin) technique for
arterial and venous access
3 vessels considered:
Femoral –preferred site for arterial (size +
accessibility)
Brachial
Axillary

9. Selection based on
strong pulse / absence
of disease
Site cleaned, area
draped, local given
Sven-Ivar Seldinger Swedish Radiologist—
1921-1998

10. 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

11. 1. Insertion of needle (with inner cannula)
2. Placement of needle in lumen of vessel (inner cannula removed)
3. Insertion of guide wire
4. Removal of needle
5. Threading of catheter to area of interest
6. Removal of guide wire

12. Two less common methods used
Cut down- minor surgical procedure to expose
vessel of interest
Trans-lumbar- patient prone, long needle passed
thru T12- L2 into aorta

14. 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.

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

18. Left 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.

19. 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).

20. • 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.

21. • 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.

23. 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 purpose
Short 4 / 5 Fr sheaths for diagnostic purposes. Long sheaths with
larger diameters for interventions.

24. Balkin’s Cross over sheath
Placed on contralateral side after crossing over
the aortic bifurcation.
Facilitates easy access and treatment to lesions in
the Iliac / SFA and high tibial arteries.

27. Charles T. Dotter M.D. (1920-1985)
Interventional
Radiologist
Pioneer in the Field of
Minimally Invasive
Procedures
(Catheterization)
Developed Continuous
X-Ray Angio-
Cardiography
Performed First
Angioplasty (PTCA)
Procedure in 1964.

28. Trademark of Dr. Dotter
“If a plumber can do it to
pipes, we can do it to
blood vessels.”
Charles T. Dotter M.D.

29. 6. Rösch celiac
7. Visceral (very similar to
Simmons1)
8. Mickelson
9. Simmons 2
10. Pigtail
11. Tennis racket.
1. Straight
2. 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);

30. Flush catheters
Allow 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 catheters
Have 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.

31. 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”)

32. Complex 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.

33. 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.

34. Choosing 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.

35. 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.

36. 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).

37. 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.

38. Progreat Micro-catheter
This 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.

39. Exelcior SL 10Echelon 90 *
These are microcatheters commonly used in embolization of intracranial
Aneurysms.

40. When 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.

41. • 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.

42. • 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.

43. • 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.

44. Shaft length , wire compatibilty, sheath compatibility
Radio opaque markers
Sizing
Max atm pressure

45.  Plaque Fracture
 Intimal Tearing
 Medial Stretching

46. Catheter Types andApplications
(continued)
Therapeutic Catheters
– PTCA (Percutaneous Trans luminal Angioplasty)
– Distal Protection Devices
– Dialysis
– Drainage
– Drug and Stent Delivery
– RF Ablation

48. 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.

49. 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.

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

53. Biliary Internal – External Drain
This 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 Needle
Used to gain access to bilary ducts.
This can be done under Fluoroscopic
Or USG guidance.

54. Trapease Filter Greenfield filter
• 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.

56. A 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.

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

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

62. Deliberate occlusion of a blood vessel to
achieve a therapeutic result

63. Technique has evolved to include nearly every
vascular territory and has been used in such
diverse clinical applications as :
Treatment of tumors
Varicosities
Vascular malformations
Aneurysms and pseudoaneurysms
Fibroids
Gastrointestinal bleeding

64. vascular territory to be embolized
permanence of occlusion
degree of occlusion—proximal or distal—
desired

65. Coils
Balloons
Amplatz Vascular Plug
Guide wires
Silk suture material
Porcine submucosa

66. Particles
Liquid sclerosants
Liquid adhesive
Ethiodol
Thrombin
Onyx

67. Gelfoam sponge
Autologous clot

68. Gelfoam powder
Starch microspheres
Fibrillated collagen

69. Vessels Permanent Temporary
Large vessel
Coils (e.g., pulmonary
AVM)
Gelfoam sponge (e.g.,
trauma)
Small vessel
Particles (e.g., UFE); no
organ death
Liquid agents (e.g.,
renal ablation); organ
death
Gelfoam particles,
fibrillated collagen
(e.g.,
chemoembolization)

70. Advantages
immediate availability, absence of cost, and lack of adverse
reaction.
Method
aspirate 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.

71. 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

72. 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.

73. 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.

74. Used in bronchial artery embolization and Uterine fibroid
embolization etc.

75. Polyvinyl 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

76. Predominantly 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.

77. 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

79. Pre and Post Uterine Fibroid Embolization

80. 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.

81. Used in Intracranial Aneurysm Coiling.

82. Used in Peripheral Embolization.

83. 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.

84. 27 yr old female patient with secondary PPH
Taken up for Uterine Artery Embolization.
Pre-Procedure Angiogram done

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

87. Onyx : 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

88. Used for embolization of Cerebral AVMs,
Peripheral AVMs.

89. n 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.

91. 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.

93. THANK YOU