interventional radiology 介入放射学介入放射学 tong xiao-qiang 佟小强 dept. of...

Interventional Radiology

介入放射学介入放射学

TONG Xiao-qiang

佟小强

Dept. of Interventional Radiology & Vascular Surgery

The First Hospital of Peking University

介入血管外科 , 北京大学第一医院

第一部分：介入放射学总论-- 什么是介入放射学-- 介入放射学历史-- 介入放射学所需器械-- 介入放射学适应证

第二部分：介入放射学各论-- 介入放射学在血管系统的应用通，堵，注，取-- 介入放射学在非血管系统的应用通，堵，注，取

讲课内容

1. 了解介入放射学的概念2. 了解介入放射学的适应证3. 掌握介入放射学的技术内容：通，堵，注，取4. 掌握常用专业英文词汇

重点

第一部分介入放射学总论

什么是介入放射学介入放射学历史介入放射学所需器械介入放射学适应证

X-rayComputed tomography (CT)Magnetic Resonance Imaging (MRI)UltrasoundRadioisotope (RI)Angiography

Radiology

Purpose of Radiology--diagnosis

Vascular disease --Occlusion --Stenosis --Aneurysm --Arterio-venous malformation --Arteriovenous fistula --Hemorrhage

Hypervascular tumor --Hepatocellular carcinoma --Renal cell carcinoma

Relationship between vessel and tumor

Angiography--early “Interventional Radiology” --diagnosis

Insert a needle or catheter directly

into a vessel

Inject some contrast media (CM)

Take films/movie

Achieve diagnosis

Angiography

DSA machineDigital subtruction angiography

Traditional angiography DSA Traditional angiography DSA

Diagnosis on angiography —stenosis of artery

Dilate it!!!

Diagnosis Treatment

Dr. Dotter

Radiologist intervened clinical issues from diagnosis alone to therapeutic activities.

1895 ： Roentgen 发现 X 射线（诺贝尔奖）1895 ： Hascnek 首次在截肢术上作动脉造影尝试1896 ： Morton 开始做尸体动脉造影研究1904 ： Dawbam 开始肿瘤手术术前栓塞（颈外动脉）1910 ： Franck 等成功将造影剂注射到活体动物动脉内1923 ： Verberich 将造影剂注入到人体血管内造影1924 ： Brooks 成功进行第一例股动脉造影1927 ： Maniz 成功施行颈动脉直接穿刺造影1929 ： Dos Santos 成功施行经皮腹主动脉穿刺造影1929 ： Forssman 从上臂静脉将导尿管插入自己的右心房首创心导管造影术（诺贝尔奖）1941 ： Farmas 采用股动脉切开法施行主动脉造影1953 ： Seldinger 首创经皮股动脉穿刺法 : 简便易行（诺贝尔奖）

History of Interventional Radiology-1

History of Interventional Radiology-2

1956: Oedman 等改进了导管头的弯度1964 : Dotter 成功施行首例 PTA1967 ： Judkins 行冠状动脉造影1967: Richarson 首先使用 Fogarty 球囊导管行颈动脉拉栓术1968 ： Newtont 成功施行脊髓血管畸形动脉栓塞1968 ： Nusbaum 等首先报道经动脉导管灌注血管加压素及栓塞剂治疗出血1969 ： Kauae 首先报道经皮肝穿胆道引流术1972: Rosch 等首先介绍对肝肾等肿瘤进行栓塞1974: Gruentzig 发明双腔球囊导管1977: Gruentzig 成功施行冠状动脉 PTA20 世纪 80 年代： DSA 技术1983 ： Dotter 等报道用镍钛合金支架的实验成果1985 ： Wright 和 Palmaz 分别报道金属自扩式 Z 型支架和球囊扩张式支架1988 ： Richter 等成功实施 TIPS 治疗严重门静脉高压1991 ： Parodi 首次用直型内支架行腔内隔绝术治疗腹主动脉瘤

19291929 年年 : : ForssmanForssman 将导管插入自己心将导管插入自己心脏脏

19531953 年年 : : SeldingerSeldinger 穿刺法穿刺法

19641964 年年 : : DotterDotter 血管成型术血管成型术

3 milestones in history of IR3 milestones in history of IR

Wilhelm Conrad Roentgen (1845-1923)1895: X-ray

Never forget

ForssmanForssman1929:cardioangiography1929:cardioangiography

Never forget

Sven Ivar Seldinger1953 :Seldinger’s technique

Never forget

Charles Dotter (1920-1985)1964: PTA by coaxial catheter

Never forget

Never forget

Cesare Gianturco

Andreas Gruentzig (1939-1985)1974: Double-lumen balloon catheter1977 ： First PTCA (Percutaneous Transluminal Coronary Angioplasty)

Never forget

Guided by imaging facility: X-ray, CT, US, MRI

Utilizing instruments as guidewire, catheter, et al

Minimally invasive: usually puncture

Not only diagnosis but therapeutic efficacy

1967 1967 Margulis Margulis :: Interventional Diagnostic RadiologyInterventional Diagnostic Radiology

-a New Subspecialty (AJR)

1976 Wallace : Interventional Radiology (Cancer)

Interventional Radiology (IR)

通 Recanalization, Opening

堵 Embolization, Occlusion 注 Injection, Infusion

取 Drainage, Sampling, Biopsy, Retrieval 其他 Filter 、 and ---

介入放射学技术 Techniques of IR

Vessel— PTA,stenting,thrombolysis

Airway— stenting

Gastrointestine — dilatation,stenting

Biliary duct — drainage,dilatation,stenting

Urinary tract — dilatation,stenting

Tubal obstruction — recanalization

Lacrimal duct obstruction — recanalization

Establish channel— TIPS,drainage

开通或再通技术— 通 Recanalization

栓塞技术— 堵 Embolization

tumor: malignancy, benign

AVM, AVF, aneurysm

bleeding

hypersplenism

others ： varices, fistula, priapism

动脉局部药物灌注— 注 Infusion

Thrombolytic agent Chemotherapeutics Sclerosing agent hemostatics antibiotics

引流 / 活检 / 血样 / 异物 / 取石— 取 Retrieval

Biliary drainingBiliary draining （（ tumor/lithiasis)tumor/lithiasis)

Percutaneous removal of biliary calculiPercutaneous removal of biliary calculi

Percutaneous nephrostomyPercutaneous nephrostomy

Draining of cyst/abscessDraining of cyst/abscess

Sampling/biopsySampling/biopsy

Retrieval of foreign bodyRetrieval of foreign body

Percutaneous lumbar discectomyPercutaneous lumbar discectomy

Vascular IRVascular IR经动脉栓塞经动脉栓塞 : : 出血出血 ,, 动脉瘤动脉瘤 ,, 动静脉畸形动静脉畸形 , , 肿瘤等肿瘤等经动脉药物注入经动脉药物注入 : : 抗癌药抗癌药 , , 血管收缩血管收缩 // 扩张剂扩张剂 , , 血栓溶解剂等血栓溶解剂等血管成型术血管成型术 : : 气囊气囊 , , 旋切旋切 , , 激光激光 , , 支架等支架等血管内异物取出血管内异物取出静脉溶静脉溶 // 取栓术取栓术静脉栓塞术静脉栓塞术 : : 消化道静脉曲张消化道静脉曲张 , , 精索静脉曲张等精索静脉曲张等下腔静脉滤器放置术下腔静脉滤器放置术肝静脉肝静脉 -- 门静脉分流术门静脉分流术Nonvascular IRNonvascular IR支架放置术支架放置术 : : 消化道消化道 , , 气道气道 , , 胆道胆道 , , 尿道等尿道等引流术引流术 : : 胆道胆道 , , 脓肿脓肿 , , 囊肿等囊肿等造瘘术造瘘术 : : 胃胃 , , 膀胱膀胱 , , 肾等肾等取石术取石术 : : 胆道胆道 , , 胆囊胆囊 , , 尿道等尿道等药物注入法药物注入法 : : 囊肿硬化囊肿硬化 , , 骨硬化骨硬化 // 成型成型 , , 溶核等溶核等旋切旋切 // 抽吸术抽吸术 : : 椎间盘脱出椎间盘脱出

Content of IRContent of IR

Types of arterial approachesRight femoral arteryLeft femoral arteryLeft axillary arteryRight axillary arteryTranslumbar aortaBrachial arteriesAntegrade femoral arteryThrough a surgical graft

Right femoral artery is the preferred routeEasily accessible for manipulations and hemostasisLarge-caliber vesselWell-defined landmarks existMost angiographers are right-handedLow complication rate compared to other approaches

Access in vascular IR

Anatomy of femoral puncture site

2-4cm below the inguinal ligament

Seldinger’s Technique

needleguidewire

Double wall puncture

Seldinger Technique-con’t

sheath

catheter

Traditional Seldinger’s technique

Modified Seldinger Technique

Single (anterior) wall puncture

Modified Seldinger’s Technique

Puncture site complications

(e.g., groin hematoma)Contrast agent complications

(e.g., anaphylactoid reaction)Catheter-related complications

(e.g., vessel dissection)Therapy-related complications

(e.g., CNS hemmorhage during UK administration)

Complications of IR

There are 4 types of complications

Cholesterol emboliThromboembolismCerebrovascular accidentArterial dissection

Minor hematoma, >5%Major hematoma (require surgical therapy) <0.5%Arteriovenous fistula (AVF),0.05%Pseudoaneurysm, 0.01%Vessel thrombosis,0.1%NeuritisInfection

Puncture site complications

Contrast complicationsRenal failureCardiac failurePhlebitis (venography)Anaphylactoid reactions (rare with arteriography)

Catheter-related complications

Puncture needleSheathGuidewire/microguidewireCatheter/microcatheterBalloon catheterStentStent-graftDistal protection deviceCoilFilterSnare

Instruments for IR

CatheterThermoplastic materials (polyurethane and polyethylene) are very commonly used for catheter manufacturingNylon: combined with polyurethane to manufacture high-flow, small-French cathetersTeflon: very stiff, low-friction materialBraided catheters: internal wire mesh improves torquability

All nonspecialty guidewire have a similar construction:Central stiff steel core with a distal taperWire coilspring wound around coreThin filamentous safety wire holding the other 2 components togetherMost wires are coated with Teflon to decrease friction

Guidewire

SheathShort-cathter with valve at the end to avoid refluxA patered dilator for smooth insertion through a wire

sheath

dilator

needle

guidewire

sheath

dilator

Double-lumen PTA balloon catheter

自膨式支架self-expanding stent

球囊扩张式支架balloon-expanding stent

远端滤伞保护装置 Distal Protection Device （ DPD)

FilterWire EX™

Embolic Protection System

DPD

EV3spider

DPD

stents

Stainless steel, Nitinol

Stent-graft

Embolization

Thrombolysis

Perctaneous transluminal angioplasty (PTA)

Vascular stenting

4 major contents of vascular IR

Hemorrhage --GI bleeding --Varices --Traumatic organ injury --Bronchial artery hemorrhage --Tumors --Postoperative bleedingVascular lesions --AVM or AVF --Aneurysm/PseudoaneurysmPreoperative devascularization --Renal cell carcinoma --AVM --Vascular bone metastasesOther --Hypersplenism --Gonadal varices --Hepatic chemoembolization

Embolization

Indication:

Permanent --Steel coil --Microcoil --Detachable balloon --Polyvinyl alcohol (Ivalon) --Absolute ethanol --Plastic polymers: glue, tissue adhesive

Embolic agents

Temporary --Surgical gelatin (Gelfoam) --Pledgets are cut to size to occlude large vessels; Gelfoam powder occludes distal vessels and causes infarction

Postembolization syndrome (fever, elevated WBC)Infection of the embolized area (administer

prophylactic antibiotics)Reflux of embolic material (nontarget embolization)Alcohol causes skin, nerve, and muscle infarction if

used in the periphery; its use should be restricted to

solid parenchymal organs.

Complications of embolization

Indications --Arterial graft thrombosis --Native vessel acute thrombosis --Prior to percutaneous intervention --Hemodialysis AVF or graft --Venous thrombosis

ContraindicationsAbsolute --Active bleeding --Intracranial lesion (stroke, tumor) --Pregnancy --Nonviable limbRelative --Bleeding diathesis --Cardiac thrombus --Malignant hypertension --Recent major surgery --Postpartum

Thrombolysis

Complication--Major hemorrhage requiring termination of UK, surgery or transfusion (e.g., intracranial bleeding)--Minor hemorrhage--Distal embolization--Pericatheter thrombosis--Overall, termination of therapy is required in 10%

Indication --Claudication or rest pain --Tissue loss --Nonhealing wound --Establish inflow for a distal bypass graft --Hemodialysis AVF or graft

Complications --Groin complications (same as diagnostic angiography) --Distal embolism --Dissection --Arterial rupture (rare) --Renal infarction or failure (with renal PTA)

PTA (Percutaneous Transluminal Angioplasty)

Long segment stenosisTotal occlusionUnsuccessful PTALarge post-PTA dissection flapRecurrent stenosisUlcerated plaqueRenal ostial lesionVenous obstruction, thrombosisTransjugular intrahepatic portosystemic shunt (TIPS)

Intravascular stents

Indications:

Time to take a break

第二部分介入放射学各论

-- 介入放射学在血管系统的应用通，堵，注，取-- 介入放射学在非血管系统的应用通，堵，注，取

Vascular IRVascular IR

Transarterial embolization-Transarterial embolization- 堵堵

Embolization of hemarrhageEmbolization of hemarrhage

41M, traumatic liver rupture

DSA

pseudoaneurysm

Extravasation of CM

microcatheter

Post-embolization

73M,hematemesis;aortic graft 2 years ago

Extravasation of CMon enhanced-CT

angiography

stenting

Postpartum massive bleeding

Embolization of tumorEmbolization of tumor

Primary hepatocellular carcinoma (Primary hepatocellular carcinoma (HCCHCC))

CT

DSA

Follow-up CTFollow-up CT

43

43M, hepatitis BCT:HCC

99.8

DSA

CT

3-year later

4-year later

39F, hepatic hemangiomaEnhanced-CT

DSASuperselective embolizationwith lipiodol

microcatheter

3-m later

9-m later

原发性肝癌原发性肝癌

71M,unoperable renal cell carcinoma (71M,unoperable renal cell carcinoma (RCCRCC))

2001.12 2001.12

2002.92002.9

2002.122002.12

2001.12 2002.9 2002.122001.12 2002.9 2002.12

MRI

CT

73F, RCC of congenital single kidney

DSA, aortogram

DSA, right renal arteriogram

tumor

catheter

DSA

Superselective embolization of the tumor

Follow-up CT

well deposition of drug

Uterine myomaUterine myoma 34F

Pre-embolization 3-m after

MRI

Uterine cervical carcer:Uterine cervical carcer:Pre-operative embolizationPre-operative embolization

42F

DSA

Stage-downShrinkage of tumorDecrease bleeding

PLTPLT: pre 10000: pre 10000 post 80000post 80000

HypersplenismHypersplenism

DSA DSA postembolizationpostembolization

DSA preembolization

Stent-graft for aneurysm

Pseudoaneurysm Pseudoaneurysm of rt iliac artery of rt iliac artery

Stent-graftStent-graftdeploymentdeployment

Aortic stent-graft

Abdominal aortic aneurysm (AAA)Abdominal aortic aneurysm (AAA) 81M, 2002.8, CT

81M, 2002.8, CT

2004.7, CT

2004.7, DSA

Pre-stenting post-stenting

Follow-up CT

Open operation

Minimally invasive:Small inguinal incision

43M, cough and hemoptysis

Enhanced CT

Plain CT

Enhanced-CT

DSAHuge pseudoaneurysm of rt. Subclavian a.

50x12mm Wallgraft ，24h after stenting

Pre-

Post 5m

Post 1m

Post 12m

50x12mm Wallgraft ，6m later

Early

Delay

Enhanced CT

CTReconstructed coronal images

stent


Transarterial infusion—Transarterial infusion— 注注

Regional chemotherapy: feasible to most of the malignant tumors (liver tumor Including HCC and metstases, urinary bladder cancer, uterine cancer, breast cancer,lung cancer, malignant tumor of head and neck Selective thrombolysis --Arterial graft thrombosis --Native vessel acute thrombosis --Prior to percutaneous intervention --Hemodialysis AVF or graft --Venous thrombosis

组织纤溶酶原组织纤溶酶原激活剂激活剂 (t-PA)(t-PA)

PAE (pulmonary arterial embolism)

54M, urinary bladder cancer54M, urinary bladder cancer

DSA

Rt. InternalIliac artery

tumor


PTA and stenting—PTA and stenting— 通通

Stenosis of transplanted renal artery. Stenosis of transplanted renal artery. Balloon PTABalloon PTA

Atherosclerotic Atherosclerotic stenosis of rt. stenosis of rt. common iliac a.common iliac a.

Atherosclerotic stenosisAtherosclerotic stenosis stentingstenting

41M, claudication. stenting

Renal arterial stenosisRenal arterial stenosisstenting stenting ((RASRAS))

RAS:--Hypertension --Renal function impairment

Stenosis of subclavian a: Stenosis of subclavian a: stentingstenting

Stenosis of carotid a:--TIA--Minor stroke--Major stroke

CCA

ICA

ECA stenosis

Carotid arterial stenting (CAS)

Distal protection device (DPD)

DPD

stent

DPD

pre-stenting post-stenting

Stenosis of vertebrobasilar a.

Stenting of intracranial arteries

stenosis

Stenosis of Stenosis of SVCSVC (superior vena cava): stenting (superior vena cava): stenting

Budd-Chiari syndrome: Budd-Chiari syndrome:

HVHV occlusion. Stenting occlusion. Stenting

HV

stent

Budd-Chiari syndrome: Budd-Chiari syndrome: IVCIVC occlusion. Stenting occlusion. Stenting

Balloon dilatation (PTA)

stenting

Stenosis of transplanted HV.PTA alone.

balloon

stenosis

HV

Immediately after PTA

3-m later

Stenosis ofStenosis of pulmonary a..pulmonary a..Invasive Invasive thymoma.thymoma.

stentingstenting

stenosis

TTransjugular ransjugular IIntrahepatic ntrahepatic PPortosystemic ortosystemic SShunt hunt ((TIPSTIPS))

TIPS:

Decrease portal pressure

--Portal HT

--Ascites

Retrieval of foreign bodyRetrieval of foreign body—— 取取


Chest X-ray

Venous embolizationVenous embolization—— 堵堵


Sketch of percutaneous transhepatic occlusion of gastric varices

varices

61M,hepatitis B & cirrhosis.Gastric varices.

endoscopy

CT

varices

PV

varices

SV

Pre-CT

Post-CT

IVC filter—IVC filter— 其他其他


IVC Filter:Prevention of pulmonary arterial embolism (PAE) from deep venous thrombus (DVT)

IVC

filter

IVC filters with different design

Vascular malformation Vascular malformation of surface--of surface--sclerosingsclerosing

Nonvascular IRNonvascular IR

Dilatation/recanalizationDilatation/recanalization—— 通通

Esophageal stenosis ： Balloon dilatation

pre

post

Infertility caused by occlusion of Fallopian tube

occlusion

Recanalization of rt.

Recanalization of lt.

Obstructive jaundiceObstructive jaundice

External drainingExternal draining

draining catheter

Internal drainingInternal draining


StentingStenting—— 通通

Nonvascular IRNonvascular IR

stentingstenting


stent

Esophageal Esophageal cancercancer

Graft-stentGraft-stent

esophagus

fistula

Graft-stentGraft-stent ：：通通 ++ 堵堵

Bronchtracheal Ca.Bronchtracheal Ca.

stentingstenting

stenosis

stent

stenting

Ca. of sigmoid colon.ileus

tumor

Interventional Radiology in MedicineInterventional Radiology in Medicine

SurgerySurgery InternalInternalMedicineMedicine

RadiologyRadiology

IRIR

-What is Interventional

Radiology?

-What can IR do?

Summary

原为医学影像科（放射科）的介入组2003 年底“独立”，成立介入血管外科现有医生 8 名，护士 15 名，技术员 2 名，病床数 25 张工作内容： 1. 肿瘤的介入治疗 2. 血管病的介入治疗 3. 血管病的外科手术治疗门诊时间：周一—五下午联系我们：二部导管室 66551122 Ext 2622/2633 三部病房 64003976 ， 64004280 ( 注：在不久的将来，介入病房将从第三住院部迁至第二住院部）

介入血管外科简介

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interventional radiology 介入放射学介入放射学 tong xiao-qiang 佟小强 dept. of...