94: Interventional radiology

Interventional radiology

Sidney Z. Brejt1 and Sergei A. Sobolevsky2

1 Columbia University Irving Medical Center, New York, NY, USA

2 Modern Vascular Hospital, Mesa, AZ, USA

Percutaneous tumor therapies

Vascular and interventional radiology utilize minimally invasive, image‐guided, targeted procedures to diagnose and treat diseases in nearly every organ system. In the past decade, advances in technology have combined with the skill set of interventional radiologists and resulted in significant changes in patient care. Interventional radiology procedures frequently offer less risk, less pain, and less recovery time compared to open surgery.

Treatment of primary and secondary liver cancer

Image‐guided therapies for primary and secondary liver cancer include intraarterial therapies and percutaneous ablative techniques. With respect to the former, local drug delivery is facilitated by lipiodol emulsions (conventional transarterial chemoembolization, cTACE) or drug‐eluting beads (DEB‐TACE). Alternatively, radioembolization affords deposition of radiation via β‐emitters following intraarterial local delivery, markedly reducing systemic radiation dose. In the context of the liver, ablative therapies utilize thermal heating (microwave or radiofrequency ablation) (Figures 94.194.7).

Vascular interventions

Vascular interventions of the gastrointestinal tract are directed at maintaining sufficient perfusion of the abdominal viscera, stopping bleeding, and equilibrating venous pressure. Angiography of the abdominal vasculature is employed both for diagnosis and treatment planning for stenotic vessels, aneurysm formation, and hemorrhagic source. Angiography is also used to treat bleeding in other body regions. In addition, venous interventions are performed to provide crucial dialysis access, restore blood flow past stenosis and tumors, and for venous access in difficult situations (Figures 94.894.14).

Transjugular intrahepatic portosystemic shunt and portal vein interventions

Portal hypertension is a common manifestation of chronic liver disease. In the appropriate patient populations, treatment of an increased portal pressure gradient can be achieved with placement of a transjugular intrahepatic portosystemic shunt (TIPS). For example, patients with Budd–Chiari syndrome can undergo TIPS placement or direct intrahepatic portocaval shunt (DIPS) in order to relieve liver congestion, thus obviating the immediate need for liver transplantation. Direct portal interventions can be performed either through a TIPS or transhepatically for treatment of mesenteric venous stenosis, thrombosis or hemorrhage (Figures 94.1494.16).

Biliary interventions in interventional radiology

There are innumerable strategies employed by interventionalists for the treatment and diagnosis of diseases affecting the biliary tract, including percutaneous transhepatic cholangiography, biliary drain placement, biliary stent placement, and cholecystostomy tube placement (Figures 94.1794.21).

Enteric and miscellaneous interventions

Abdominal interventions are readily used to achieve short‐ or long‐term enteric access for nutritional support or gastrointestinal decompression. Transjugular pressure measurement and biopsy aid in the diagnosis of liver disease with risk stratification. Percutaneous abdominal abscess drainage allows for minimally invasive treatment of infections that previously may have required surgery (Figures 94.2294.24).

Photo depicts radiofrequency ablation.

Figure 94.1 Radiofrequency ablation. A patient with a 2.5 cm hepatocellular carcinoma lesion in the left lobe of the liver. (a) Baseline magnetic resonance image (MRI) shows enhancement of the target lesion (arrowhead). (b) Radiofrequency ablation needle placed under computed tomography guidance (arrowhead). (c) Ablation zone in a follow‐up MRI 1 month after treatment (arrowhead).

Photo depicts drug-eluting beads transarterial chemoembolization (DEB-TACE) for bridge to resection.

Figure 94.2 Drug‐eluting beads transarterial chemoembolization (DEB‐TACE) for bridge to resection. A patient with a 7 cm hepatocellular carcinoma lesion in the right lobe of the liver. (a) Baseline MRI shows homogeneous enhancement of the target lesion (arrowhead). (b) Angiogram of the right hepatic artery shows a tumor blush (arrowhead). (c) Follow‐up MRI 1 month after treatment shows a largely necrotic lesion (arrowhead). (d) MRI after surgical resection of the right lobe.

Photo depicts conventional transarterial chemoembolization (cTACE).

Figure 94.3 Conventional transarterial chemoembolization (cTACE). A patient diagnosed with hepatocellular carcinoma presented with two new 3 cm lesions in the left lobe. (a) Baseline MRI shows two enhancing lesions (arrowhead indicates the target lesion for the initial cTACE). (b) Angiogram of the arteries supplying the target lesion (tumor blush, arrowhead). (c) Postprocedural computed tomography (CT) scan shows successful deposition of embolic material (arrowhead). (d) Follow‐up MRI shows necrotic target lesion (arrowhead) next to a viable nontarget lesion. (e) Second cTACE, angiogram of the viable lesion (tumor blush, arrowhead). (f) Intraprocedural cone‐beam CT showing fresh embolic material within the target lesion (large arrowhead) and remaining material within the previously treated lesion (small arrowhead).

Photo depicts drug-eluting beads and microparticles.

Figure 94.4 Drug‐eluting beads and microparticles. H & E‐stained slide of a hepatocellular carcinoma lesion, treated with cTACE and DEB‐TACE, shows both microparticles (darker blue) and drug‐eluting beads (damaged through cutting artefacts).

Photo depicts histopathology of a target lesion after DEB-TACE.

Figure 94.5 Histopathology of a target lesion after DEB‐TACE. H & E‐stained slide of a tumor after surgical resection in a patient with hepatocellular carcinoma shows complete necrosis of the lesion and accumulation of drug‐eluting beads within the tumor capsule.

Photo depicts shunt study and yttrium-90 radioembolization.

Figure 94.6

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Nov 27, 2022 | Posted by in GASTROENTEROLOGY | Comments Off on 94: Interventional radiology

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