Interventional Radiology

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

讲课内容 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

重 点 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

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

Radiology

Purpose of Radiology--diagnosis



X-ray



Computed tomography (CT)



Magnetic Resonance Imaging (MRI)



Ultrasound



Radioisotope (RI)



Angiography

Angiography - early “Interventional 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

 Insert a needle or catheter directly into a vessel  Inject some contrast media ( CM )  Take films/movie  Achieve diagnosis

DSA machine Digital subtruction angiography

Traditional angiography DSA

Diagnosis on angiography — stenosis of artery Dilate it!!!

Diagnosis Treatment

Radiologist intervened clinical issues from diagnosis alone to therapeutic activities.

Dr. Dotter

History of Interventional Radiology-1

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-2

1956: Oedman 等改进了导管头的弯度 1964 : Dotter 成功施行首例 PTA 1967 ： 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 PTA 20 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

3 milestones in history of IR

 1929

年

:

Forssman

将导管插入自己心脏

 1953

年

:

Seldinger

穿刺法

 1964

年

:

Dotter

血管成型术

Never forget Wilhelm Conrad Roentgen (1845-1923) 1895: X-ray

Never forget

Forssman 1929:cardioangiography

Never forget 1953 Sven Ivar Seldinger

:

Seldinger’s technique

Never forget

Charles Dotter (1920-1985) 1964:

PTA

by coaxial catheter

Never forget

Cesare Gianturco

Never forget

Andreas Gruentzig (1939-1985) 1974: Double-lumen balloon catheter 1977 ： First

PTCA

( P ercutaneous T ransluminal C oronary A ngioplasty)

Interventional Radiology ( IR ) 

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 Margulis : Interventional Diagnostic Radiology -a New Subspecialty (AJR)



1976 Wallace : Interventional Radiology (Cancer)

介入放射学技术

Techniques of IR

     通 堵 注 取

Recanalization, Opening Embolization, Occlusion Injection, Infusion Drainage, Sampling, Biopsy, Retrieval

其他

Filter

、

and ---

开通或再通技术— 通

Recanalization

       

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

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



T

hrombolytic agent



Chemotherapeutics



Sclerosing agent



hemostatics



antibiotics

引流/活检/血样/异物/取石— 取

Retrieval



Biliary draining

（

tumor/lithiasis)



Percutaneous removal of biliary calculi



Percutaneous nephrostomy



Draining of cyst/abscess



Sampling/biopsy



Retrieval of foreign body



Percutaneous lumbar discectomy

Content of IR

Vascular IR

 经动脉栓塞 : 出血 ,  动脉瘤 , 动静脉畸形 , 肿瘤等 经动脉药物注入 : 抗癌药 , 血管收缩 / 扩张剂 , 血栓溶解剂 等  血管成型术 : 气囊 , 旋切 , 激光 , 支架等  血管内异物取出  静脉溶 / 取栓术  静脉栓塞术 : 消化道静脉曲张 , 精索静脉曲张等  下腔静脉滤器放置术 

Nonvascular IR

 肝静脉 门静脉分流术 支架放置术

:

消化道

,

气道

,

胆道

,

尿道等  引流术

:

胆道

,

脓肿

,

囊肿等  造瘘术

:

胃

,

膀胱

,

肾等  取石术

:

胆道

,

胆囊

,

尿道等  药物注入法

:

囊肿硬化

,

骨硬化

/

成型

,

溶核等  旋切

/

抽吸术

:

椎间盘脱出

Access in vascular IR

Types of arterial approaches  Right femoral artery  Left femoral artery  Left axillary artery  Right axillary artery  Translumbar aorta  Brachial arteries  Antegrade femoral artery  Through a surgical graft Right femoral artery is the preferred route  Easily accessible for manipulations and hemostasis  Large-caliber vessel  Well-defined landmarks exist  Most angiographers are right-handed  Low complication rate compared to other approaches

Anatomy of femoral puncture site 2-4cm below the inguinal ligament

Seldinger’s Technique

guidewire needle Double wall puncture

Seldinger Technique con’t

sheath catheter

Traditional Seldinger’s technique

Modified Seldinger Technique Single (anterior) wall puncture

Modified Seldinger’s Technique

Complications of IR

There are 4 types of complications  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)

Puncture site complications  Minor hematoma, >5%  Major hematoma (require surgical therapy) <0.5%  Arteriovenous fistula (AVF),0.05%  Pseudoaneurysm, 0.01%  Vessel thrombosis,0.1%  Neuritis  Infection Contrast complications  Renal failure  Cardiac failure  Phlebitis (venography)  Anaphylactoid reactions (rare with arteriography) Catheter-related complications  Cholesterol emboli  Thromboembolism  Cerebrovascular accident  Arterial dissection

Instruments for IR 

Puncture needle



Sheath



Guidewire/microguidewire



Catheter/microcatheter



Balloon catheter



Stent



Stent-graft



Distal protection device



Coil



Filter



Snare

Catheter

 Thermoplastic materials (polyurethane and polyethylene) are very commonly used for catheter manufacturing  Nylon: combined with polyurethane to manufacture high-flow, small-French catheters  Teflon: very stiff, low-friction material  Braided catheters: internal wire mesh improves torquability

Guidewire

All nonspecialty guidewire have a similar construction:  Central stiff steel core with a distal taper  Wire coilspring wound around core  Thin filamentous safety wire holding the other 2 components together  Most wires are coated with Teflon to decrease friction

Sheath

 Short-cathter with valve at the end to avoid reflux  A patered dilator for smooth insertion through a wire

guidewire needle sheath dilator dilator sheath

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)

DPD FilterWire EX ™

Embolic Protection System

EV3 spider

DPD

stents

Stainless steel, Nitinol

Stent-graft

4 major contents of vascular IR



Embolization



Thrombolysis



Perctaneous transluminal angioplasty ( PTA )



Vascular stenting

Embolization

Indication:

 Hemorrhage --GI bleeding --Varices --Traumatic organ injury --Bronchial artery hemorrhage --Tumors --Postoperative bleeding  Vascular lesions --AVM or AVF --Aneurysm/Pseudoaneurysm  Preoperative devascularization --Renal cell carcinoma --AVM --Vascular bone metastases  Other --Hypersplenism --Gonadal varices --Hepatic chemoembolization

Embolic agents



Temporary

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

Permanent

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

Complications of embolization

 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.

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%  Indications --Arterial graft thrombosis --Native vessel acute thrombosis --Prior to percutaneous intervention --Hemodialysis AVF or graft --Venous thrombosis  Contraindications Absolute --Active bleeding --Intracranial lesion (stroke, tumor) --Pregnancy --Nonviable limb Relative --Bleeding diathesis --Cardiac thrombus --Malignant hypertension --Recent major surgery --Postpartum

PTA

( P ercutaneous T ransluminal A ngioplasty)  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)

Intravascular stents

Indications:  Long segment stenosis  Total occlusion  Unsuccessful PTA  Large post-PTA dissection flap  Recurrent stenosis  Ulcerated plaque  Renal ostial lesion  Venous obstruction, thrombosis  Transjugular intrahepatic portosystemic shunt ( TIPS )

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 IR

Transarterial embolization-

堵

Embolization of hemarrhage

Extravasation of CM

DSA

41M, traumatic liver rupture pseudoaneurysm

microcatheter Post-embolization

Extravasation of CM on enhanced-CT 73M,hematemesis; aortic graft 2 years ago

angiography

stenting

Postpartum massive bleeding

Embolization of tumor

CT DSA Primary hepatocellular carcinoma ( HCC )

Follow-up CT

43

43M, hepatitis B CT:HCC

99.8

CT

DSA

3-year later 4-year later

39F, hepatic hemangioma Enhanced-CT

microcatheter DSA Superselective embolization with lipiodol

3-m later 9-m later

71M,unoperable renal cell carcinoma ( RCC )

2001.12 2002.9

2002.12

2001.12 2002.9 2002.12

73F, RCC of congenital single kidney MRI CT

DSA, aortogram tumor DSA, right renal arteriogram catheter

Superselective embolization of the tumor

DSA

well deposition of drug

Follow-up CT

34F

Uterine myoma

MRI

Pre-embolization 3-m after

42F

Uterine cervical carcer: Pre-operative embolization Stage-down Shrinkage of tumor Decrease bleeding

DSA

Hypersplenism

DSA preembolization

PLT: pre 10000 post 80000 DSA postembolization

Stent-graft for aneurysm

Pseudoaneurysm of rt iliac artery Stent-graft deployment

Aortic stent-graft

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

81M, 2002.8, CT

2004.7, CT

2004.7, CT

2004.7, DSA

Pre-stenting post-stenting

Follow-up CT

Follow-up CT

Open operation

Minimally invasive: Small inguinal incision

43M, cough and hemoptysis

Plain CT Enhanced CT

Enhanced-CT

DSA Huge pseudoaneurysm of rt. Subclavian a.

50x12mm Wallgraft

，

24h after stenting

Pre Post 1m Post 5m Post 12m

Early

50x12mm Wallgraft

，

6m later Enhanced CT

Delay

CT

Reconstructed coronal images stent

Vascular IR

Transarterial infusion —

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 激活剂(t-PA) PAE (pulmonary arterial embolism)

54M, urinary bladder cancer Rt. Internal Iliac artery tumor DSA

Vascular IR

PTA and stenting —

通

Stenosis of transplanted renal artery. Balloon PTA

Atherosclerotic stenosis of rt. common iliac a.

Atherosclerotic stenosis

stenting

41M, claudication. stenting

Renal arterial stenosis stenting ( RAS )

RAS:

--Hypertension --Renal function impairment

Stenosis of subclavian a: stenting

Stenosis of carotid a:

--TIA --Minor stroke --Major stroke

ICA ECA CCA

Carotid arterial stenting ( CAS ) stenosis

DPD DPD stent Distal protection device ( DPD )

pre-stenting post-stenting

stenosis Stenting of intracranial arteries

Stenosis of vertebrobasilar a.

Stenosis of SVC (superior vena cava): stenting

HV Budd-Chiari syndrome: HV occlusion. Stenting

stent

Budd-Chiari syndrome: IVC occlusion. Stenting

Balloon dilatation (PTA)

stenting

stenosis HV Stenosis of transplanted HV.

PTA alone.

balloon

3-m later Immediately after PTA

stenosis stenting Stenosis of pulmonary a..

Invasive thymoma.

TIPS

TIPS: Decrease portal pressure --Portal HT --Ascites T ransjugular I ntrahepatic P ortosystemic S hunt ( TIPS )

Vascular IR

Retrieval of foreign body —

取

Chest X-ray

Vascular IR

Venous embolization

— 堵

varices

Sketch of percutaneous transhepatic occlusion of gastric varices

61M,hepatitis B & cirrhosis.

Gastric varices.

endoscopy

CT

varices

PV varices SV

Pre-CT Post-CT

Vascular IR

IVC filter —

其他

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

IVC filter

IVC filters with different design

Vascular malformation of surface- sclerosing

Nonvascular IR

Dilatation/recanalization

— 通

pre

post

Esophageal stenosis

：

Balloon dilatation

Infertility caused by occlusion of Fallopian tube occlusion Recanalization of rt.

Recanalization of lt.

draining catheter

External draining

Obstructive jaundice

Obstructive jaundice Internal draining

Nonvascular IR Stenting

— 通

stenting

Obstructive jaundice stent

Graft-stent

Esophageal cancer

fistula esophagus

Graft-stent

：

通

+

堵

Bronchtracheal Ca.

stenosis

stenting

stent

tumor stenting

Ca. of sigmoid colon.

ileus

Interventional Radiology in Medicine

Surgery IR Internal Medicine Radiology

Summary

-What is Interventional Radiology?

-What can IR do?

介入血管外科简介

 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）

Thanks