Interventional Radiology Techniques Research Articles

Interventional Radiology Treatments to Address Chronic Pelvic Pain in Females.

Chronic pelvic pain (CPP) affects about one in four women globally and has a variety of etiologies, including gynecologic causes. Interventional radiology (IR) offers minimally invasive treatment options for several of these etiologies. This review provides an overview of IR interventions for treating gynecologic causes of CPP, including fibroids, adenomyosis, pelvic venous disease (PeVD), endometriosis, and peritoneal inclusion cysts (PICs). A narrative review was conducted on IR techniques for managing gynecologic causes of CPP, with emphasis on procedural applications, clinical presentation, and diagnostic approaches. Uterine artery embolization (UAE) has shown effectiveness in treating fibroids and is increasingly applied for adenomyosis, while gonadal vein embolization is effective for managing PeVD. Emerging IR techniques show promise for treating endometriosis and PICs. This review discusses patient presentation, diagnostic evaluation, and procedural details unique to each condition. As IR options for CPP expand, a comprehensive understanding of the clinical and procedural nuances can broaden the scope of effective treatment options.

Management of portal vein thrombosis in liver transplant candidates.

Portal vein thrombosis (PVT) is a frequent event among patients with advanced liver disease, with a prevalence reaching up to 26% in those awaiting liver transplantation (LT). Extensive thrombosis affecting the mesenteric vein confluence correlates with increased morbidity and mortality post-LT, particularly when it impedes physiological anastomosis or contraindicates the LT. Current guidelines advocate for routine PVT screening in all potential liver transplant candidates and prompt treatment upon detection. The main objective in LT candidates is to facilitate physiological portal-to-portal anastomosis. Anticoagulation serves as the first-line therapy, achieving recanalization rates between 33 and 75%. Discontinuation of anticoagulation significantly heightens the risk of rethrombosis in a substantial proportion of patients and therefore, it is recommended to continue anticoagulation until LT for those awaiting LT or potential LT candidates. Nevertheless, 30-60% of patients fail to respond to anticoagulation, with PVT progression occurring in up to 14% despite anticoagulation. In such cases, TIPS placement emerges as a viable alternative to maintain portal vein patency. While the feasibility of TIPS placement diminished with the presence of portal cavernoma or chronic portal vein thrombosis, the introduction of novel interventional radiological techniques to recanalize the portal venous axis through transplenic, transmesenteric and/or transhepatic routes is revolutionizing this landscape. These advancements achieve TIPS placement and recanalization in 90-100% of patients, warranting consideration in cirrhotic patients with chronic PVT for whom LT would otherwise be contraindicated or when physiological anastomosis is not feasible.

Enteric Tube Placement and Management: Tips for Interventional Radiologists

AbstractThere is a significant risk of malnutrition and aspiration among hospitalized patients, particularly the elderly, patients with head and neck malignancy, and those with a chronic debilitating disease. Enteral feeding is preferred over parenteral feeding for patients with functional gastrointestinal tracts but who have impaired swallowing due to its cost-effectiveness, lesser complications, and theoretical benefits such as preserving mucosal architecture and gut-associated lymphoid tissue. While nasogastric and nasojejunal tubes address short-term feeding needs, long-term enteral feeding tubes are crucial for patients requiring nutritional support beyond 4 weeks. Enteric tube placement can be performed surgically, endoscopically, or radiologically, with radiologically inserted gastrostomy emerging as a safe and effective method. This review article discusses various interventional radiological techniques for enteral feeding, including percutaneous gastrostomy, gastrojejunostomy, jejunostomy tube placement, and gastrointestinal tract decompression procedures like cecostomy. It covers procedural considerations, patient selection criteria, technical aspects, and outcomes, drawing on current evidence and clinical experience. The review also addresses emerging trends, advancements, and future directions in interventional radiology for enteral feeding and gastrointestinal tract decompression, aiming to contribute to the ongoing evolution of clinical practice and patient care. Key recommendations from international guidelines are summarized, emphasizing individualized risk assessment for optimal enteral feeding strategies.

Clinical management of active bleeding: what the emergency radiologist needs to know.

Active bleeding is a clinical emergency that often requires swift action driven by efficient communication. Extravasation of intravenous (IV) contrast on computed tomography (CT) is a hallmark of active hemorrhage. This can be seen on exams performed for a variety of indications and can occur anywhere in the body. As both traumatic and non-traumatic etiologies of significant blood loss are clinical emergencies, exams demonstrating active bleeding are often performed in emergency departments and read by emergency radiologists. Prompt communication of these findings to the appropriate emergency medicine and surgical providers is crucial. Although many types of active hemorrhage can be managed by interventional radiology techniques, endoscopic and surgical management or clinical observation may be appropriate in certain cases. To facilitate optimal care, it is important for emergency radiologists to understand the scope of indications for embolization of bleeding by interventional radiologists (IR) and when an IR consultation is warranted. Similarly, timely comprehensive diagnostic radiology reporting including pertinent positive and negative findings tailored for IR colleagues can expedite the appropriate intervention.

Advancements in hydrogel-based embolic agents: Categorized by therapeutic mechanisms.

Transcatheter arterial embolization (TAE) is a crucial technique in interventional radiology. Hydrogel-based embolic agents show promise due to their phase transition and drug-loading capabilities. However, existing categorizations of these agents are confusing. This review tackles the challenge of categorizing hydrogel-based embolic agents based on their therapeutic mechanisms, including transportation, accumulation, interaction, and elimination. It also addresses current challenges and controversies in the field while highlighting future directions for hydrogel-based embolicagents. We conducted a systematic review of papers published in PUBMED from 2004 to 2024, focusing primarily on preclinical trials. Various kinds of hydrogel embolic agents were introduced according to their therapeutic mechanisms. Most hydrogel embolic agents were specifically designed for effective accumulation and interaction. Recent advancement highlight the potential of multifunctional hydrogel embolic agents. This new categorizations provided valuable insights into hydrogel embolic agents, potentially guiding material scientists and interventional radiologists in the development of novel hydrogel embolic agents in transarterial embolization.

Renal embolization for trauma: a narrative review.

Renal injuries commonly occur in association with blunt trauma, especially in the setting of motor vehicle accidents. Contrast-enhanced computed tomography is considered the gold-standard imaging modality to assess patients for renal injuries in the setting of blunt and penetrating trauma, and to help classify injuries based on the American Association for the Surgery of Trauma injury scoring scale. The management of renal trauma has evolved in the past several decades, with a notable shift towards a more conservative, nonoperative approach. Advancements in imaging and interventional radiological techniques have enabled diagnostic angiography with angiographic catheter-directed embolization to become a viable option, making it possible to avoid surgical interventions that pose an increased risk of nephrectomy. This review describes the current management of renal trauma, with an emphasis on renal artery embolization techniques.

Exploring the Efficacy of Combining Radiofrequency Thermal Ablation or Microwave Ablation with Vertebroplasty for Pain Control and Disease Management in Metastatic Bone Disease-A Systematic Review.

Interventional radiology techniques have become pivotal in recent years in managing metastatic bone disease, which frequently results in skeletal complications such as fractures and severe pain. Thermoablative methods like radiofrequency ablation (RFA) and microwave ablation (MWA), when combined with vertebroplasty (VP), are proving increasingly beneficial for these patients. The search was independently conducted by two radiologists on MEDLINE databases, using specified strings up to April 2024. Methodological quality was assessed using PRISMA guidelines. Studies meeting inclusion criteria investigated thermoablation techniques (RFA and/or MWA) combined with VP, focusing on pain management and disease control outcomes in adults. Among 147 results, 42 articles met the criteria, with varied prospective and retrospective designs and sample sizes averaging 49 patients, predominantly involving RFA (30 studies), MWA (11 studies), and one comparative study. Our review highlights significant pain reduction, effective local tumor control, and favorable safety of combined RFA or MWA with VP, supporting its potential in managing vertebral pathologies and warranting further clinical integration. The combined treatment of RFA/MWA with VP demonstrates significant pain reduction and local tumor control, with a rapid onset of analgesic effect. These findings support its crucial role in clinical practice for managing vertebral metastases.

Interventional Radiology for Bleeding Ectopic Varices: Individualized Approach Based on Vascular Anatomy.

Ectopic varices are rare but potentially life-threatening conditions usually resulting from a combination of global portal hypertension and local occlusive components. As imaging, innovative devices, and interventional radiologic techniques evolve and are more widely adopted, interventional radiology is becoming essential in the management of ectopic varices. The interventional radiologist starts by diagnosing the underlying causes of portal hypertension and evaluating the afferent and efferent veins of ectopic varices with CT. If decompensated portal hypertension is causing ectopic varices, placement of a transjugular intrahepatic portosystemic shunt is considered the first-line treatment, although this treatment alone may not be effective in managing ectopic variceal bleeding because it may not sufficiently resolve focal mesenteric venous obstruction causing ectopic varices. Therefore, additional variceal embolization should be considered after placement of a transjugular intrahepatic portosystemic shunt. Retrograde transvenous obliteration can serve as a definitive treatment when the efferent vein connected to the systemic vein is accessible. Antegrade transvenous obliteration is a vital component of interventional radiologic management of ectopic varices because ectopic varices often exhibit complex anatomy and commonly lack catheterizable portosystemic shunts. Superficial veins of the portal venous system such as recanalized umbilical veins may provide safe access for antegrade transvenous obliteration. Given the absence of consensus and guidelines, a multidisciplinary team approach is essential for the individualized management of ectopic varices. Interventional radiologists must be knowledgeable about the anatomy and hemodynamic characteristics of ectopic varices based on CT images and be prepared to consider appropriate options for each specific situation. ©RSNA, 2024 Supplemental material is available for this article.

Lymphatic Malformations: Review of Diagnosis and Management for the Interventional Radiologist.

Lymphatic malformations (LMs) arise from errors in lymphatic vascular development during embryogenesis and encompass an array of conditions that span from common cystic LMs to complex lymphatic anomalies (CLAs). Manifestations of LMs are wide-ranging, from clinically inconsequential to life-threatening. Proper diagnosis and management can be challenging and often benefit from an experienced multidisciplinary team. Cystic LMs are localized entities for which percutaneous sclerotherapy is the mainstay treatment. CLAs, on the other hand, are more diffuse in involvement and typically require multimodal therapy. With advances in the genetic understanding of LMs, targeted systemic therapies have been increasingly utilized with promising results. Thoracic duct interventions, both surgical and percutaneous, have a limited role in CLAs and should be approached cautiously to avoid significant complications. In this review, we discuss the genetic basis, imaging findings, and management options for LMs, with a particular focus on relevant interventional radiology techniques.

Comprehensive Review of Surgical and Radiological Management of Hemorrhagic Pancreatitis: Current Strategies and Outcomes.

Hemorrhagic pancreatitis, a severe complication of acute and chronic pancreatitis, involves bleeding due to vascular disruptions. This condition presents significant clinical challenges and is associated with high morbidity and mortality. The bleeding can result from arterial or venous complications, often exacerbated by inflammatory and enzymatic damage to blood vessels within the pancreas. Patients with hemorrhagic pancreatitis may experience symptoms such as abdominal pain, nausea, vomiting, and gastrointestinal bleeding. Diagnostic imaging, including CT and MRI, is crucial in identifying the source of bleeding and guiding treatment decisions. Management strategies have evolved over the past two decades, shifting from purely surgical approaches to including interventional radiology techniques. Surgical intervention is often reserved for hemodynamically unstable patients or those with large pseudoaneurysms, offering definitive treatment but carrying higher risks of complications. Endovascular techniques, such as transcatheter embolization, provide a less invasive alternative with high success rates and shorter recovery times, though rebleeding may occur. Treatment choice depends on various factors, including the patient's stability, the size and location of the bleeding, and the availability of specialized expertise. Overall, the management of hemorrhagic pancreatitis requires a multidisciplinary approach, combining surgical and radiological techniques to optimize patient outcomes and reduce the risk of mortality. Long-term follow-up is essential to monitor for recurrent disease and manage the metabolic consequences of pancreatic insufficiency.

Endovascular embolization of a biliary–digestive loop bleeding

Delayed massive hemorrhage after biliary surgery is a severe complication and carries a high mortality rate. Upper gastrointestinal (GI) tract bleeding is usually managed endoscopically. However, the presence of altered anatomy following hepato-biliary surgery does preclude endoscopic exploration of the anastomoted loop. In our case of hemorrhage from biliodigestive anastomosis, CT angiography provides accurate information about the presence of active bleeding and its source. We present a case of bleeding from a biliary–digestive loop. The patient exhibited several bleeding risk factors, notably cirrhosis and dual antiplatelet therapy. Furthermore, the site of bleeding, the biliarydigestive loop, had experienced a fistula with a hepatic abscess 2 years earlier, following percutaneous thermoablation. Endovascular embolization with microparticles 300–500 µm and one microcoil 2mx4cm proved to be a safe and effective treatment in this high-risk patient with persistent bleeding. Developments in interventional radiology equipment and techniques, such as low-profile catheter systems and advanced embolic agents, validate embolization as a suitable therapeutic option.

The Management of Esophageal Perforation: A Systematic Review.

Esophageal perforation, a rare and serious condition, has seen a reduction in mortality from 30% to 15% over the last three decades due to advancements such as gastrointestinal stents, minimally invasive surgeries, and improved interventional radiology techniques. This review analyzes management strategies for esophageal perforation based on 14 English-language articles published from 2009 to 2024, primarily utilizing surveys and national database analyses. The management of esophageal perforation is complex, with challenges in diagnosis and treatment strategy. Despite surgery being the traditional treatment, the role of less invasive methods is growing. Effective management of esophageal perforation involves advanced imaging for diagnosis, hemodynamic stabilization, and a multidisciplinary approach to treatment, including surgical and non-surgical interventions. The evidence for different treatment outcomes remains limited, highlighting the need for comprehensive care involving thoracic surgery, interventional radiology, gastroenterology, and critical care in an intensive care unit setting.

Methods of interventional radiology in the diagnosis and treatment of liver tumor

Over the past two decades, interventional radiology techniques have become an integral part of the treatment of primary and metastatic liver tumors. Today, interventional radiology has at its disposal a wide range of diagnostic and therapeutic minimally invasive technologies that are used as stand-alone treatment options or in combination with other therapies for cancer patients. The development and increasing adoption of interventional radiology in clinical practice makes it possible to achieve treatment results comparable to classical surgery. The aim of the present work is to provide an overview of the possibilities of interventional radiology methods in the treatment of primary and metastatic liver tumors. The description of techniques, brief historical reviews, classifications and indications for their performance are given.

Clinical Implications and Management of Spontaneous Portosystemic Shunts in Liver Cirrhosis.

Portal hypertension from chronic liver disease leads to the formation of collateral blood vessels called spontaneous portosystemic shunts (SPSS). These shunts may form from existing vessels or through neo-angiogenesis. Their location affects clinical outcomes due to varying risks and complications. This review summarizes current knowledge on SPSS, covering their clinical impact and management strategies. Recent data suggest that SPSS increases the risk of variceal bleeding, regardless of shunt size. The size of the shunt is crucial in the rising incidence of hepatic encephalopathy (HE) linked to SPSS. It also increases the risk of portopulmonary hypertension and portal vein thrombosis. Detecting and assessing SPSS rely on computed tomography (CT) and magnetic resonance imaging. CT enables precise measurements and the prediction of cirrhosis progression. Management focuses on liver disease progression and SPSS-related complications, like HE, variceal bleeding, and portopulmonary hypertension. Interventional radiology techniques such as balloon-occluded, plug-assisted, and coil-assisted retrograde transvenous obliteration play a pivotal role. Surgical options are rare but are considered when other methods fail. Liver transplantation (LT) often resolves SPSS. Intraoperative SPSS ligation is still recommended in patients at high risk for developing HE or graft hypoperfusion.

Advancements in Interventional Radiology for Managing Hepatic Encephalopathy: A Comprehensive Review.

Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome resulting from liver dysfunction, leading to cognitive, behavioral, and motor impairments. The management of HE has traditionally relied on pharmacological treatments, dietary modifications, and liver transplantation. However, recent advancements in interventional radiology (IR) have introduced minimally invasive procedures that offer promising alternatives. This comprehensive review explores the latest IR techniques, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), portal vein embolization (PVE), and Yttrium-90 (Y90) radioembolization. The efficacy, clinical outcomes, and potential complications of these techniques are examined through an analysis of current studies and trials. The review highlights the benefits of IR in reducing portal hypertension and improving hepatic blood flow, ultimately alleviating HE symptoms. Additionally, it underscores the importance of multidisciplinary collaboration, ongoing research, and the development of clear patient selection criteria to optimize the use of IR in HE management. By integrating these advancements into clinical practice, healthcare providers can enhance the quality of care and improve outcomes for patients with HE.

Role of Interventional Radiology in the Management of Liver Transplant Complications in Children

AbstractLiver transplantation (LT) is a common solid organ transplant in the pediatric population. The common indications for LT, as well as its complications, differ between adults and children. This difference necessitates unique pediatric interventional radiology (IR) interventions. This article focuses on unique vascular complications occurring post-pediatric LT and highlights the importance of IR in their management. It explores IR's involvement in the workup of patients' pre-LT and management of complications following portosystemic shunts. We discuss advantages and disadvantages of different access routes as well as the prevalence, clinical picture, diagnosis, and management of complications after pediatric LT. These complications encompass portal vein stenosis, portal vein thrombosis, hepatic artery stenosis, hepatic artery thrombosis, hepatic artery pseudoaneurysm, arterioportal fistula, hepatic vein stenosis, and inferior vena cava stenosis. The choice of endovascular technique for a clinical indication depends on vascular anatomy, time since LT, and patient-specific factors. Transsplenic access is a useful alternative to transhepatic or transjugular access. The decision to place a stent in a child is influenced by the expected growth of the child and risk of focal narrowing at stent edge (because of recipient growth). Technical challenges in pediatric patient management, including uncooperative patients and sedation issues, must be considered. Pediatric LT complications can present with significant challenges in the posttransplant care of recipients and may lead to serious morbidity and graft failure if not managed effectively. IR techniques like balloon angioplasty, stent placement, thrombolysis, and embolization have demonstrated success in treating these complications, improving patient outcomes, and reducing long-term morbidity and mortality. By enhancing the understanding of medical practitioners and interventional radiologists about complex vascular complications, this article aims to contribute to better posttransplant care and improved outcomes for LT in pediatric populations. Continued collaboration between specialties and research will advance the field of pediatric LT and IR, to create even more effective treatment strategies.

Local Treatment of Desmoid Tumors: An Update.

Desmoid tumors (DTs) are rare fibroblastic proliferations, characterized by infiltrative growth and a propensity for local recurrence. Traditional strategies such as surgery, radiotherapy, and chemotherapy are the mainstays of treatment, each with its limitations and associated risks. The trend in DT management leans toward a "wait-and-see" strategy, emphasizing active surveillance supported by continuous MRI monitoring. This approach acknowledges the unpredictable nature of the disease, and a multidisciplinary management of DT requires a nuanced approach, integrating traditional therapies with emerging interventional techniques. This review highlights the emerging role of minimally invasive interventional radiological technologies and discusses interventional radiology techniques, including chemical, radiofrequency, microwave, cryoablation, and high-intensity focused ultrasound ablations as well as transarterial embolization.

The stuck haemodialysis catheter—a case report of a rare but dreaded complication following kidney transplantation

BackgroundTunnelled cuffed haemodialysis catheters are at increased risk of incarceration or becoming ‘stuck’ via fibrotic adhesion to the central veins when left in situ for prolonged periods of time. Stuck catheters cannot be removed using standard techniques such as bedside dissection of the cuff. Whilst there are several strategies published for the removal of these incarcerated lines, there is no consensus on the best approach. Here we present a challenging case of a stuck haemodialysis catheter in the acute post transplantation period.Case PresentationA 66-year-old female on haemodialysis presented for kidney transplantation with a tunnelled-cuffed haemodialysis catheter in situ for five years. Following transplantation, removal of the line was unsuccessful despite dissection of the cuff, with traction causing a choking sensation with tracheal movement. Eventually, the line was removed without complications utilising sequential balloon dilatation by interventional radiology and the patient was discharged without complications.ConclusionsThis case serves as a timely reminder of the risks of long-term tunnelled haemodialysis catheters and as a caution towards proceeding with kidney transplantation in those with long-term haemodialysis catheters in situ. Greater nephrologist awareness of interventional radiology techniques for this challenging situation will help to avoid more invasive strategies. The risks of a stuck catheter should be included in the discussions about the optimal vascular access and transplantation suitability for a given patient.

Pathophysiology, Diagnosis, and Management of Portal Hypertension in the Pediatric Population

AbstractPortal hypertension is caused by resistance to the portal blood flow, which most commonly occurs in the setting of cirrhosis. Complications of portal hypertension can cause significant morbidity and mortality in the pediatric population. Portal hypertension is diagnosed when the hepatic venous pressure gradient (HVPG) is more than 5 mm Hg, and potential bleeding complications from esophageal and gastric varices are more likely when the HVPG is more than 10 mm Hg. Diagnosis can be made clinically; however, liver biopsy with measurement of the HVPG is ultimately required. The management of portal hypertension in pediatric patients is typically aimed at treatment of the complications. Despite the multiple pharmacologic, endoscopic, surgical, and interventional radiologic management techniques that are available, some pediatric patients will ultimately require liver transplant. Prompt referral is needed in such cases.

Evaluation of Radiation Exposure and Influential Factors in Cone-Beam Computed Tomography (CBCT) of the Head and Abdomen during Interventional Procedures.

Cone-beam computed tomography (CBCT) is a widely used imaging technique in interventional radiology. Although CBCT offers great advantages in terms of improving comprehension of complex angioarchitectures and guiding therapeutic decisions, its additional degree of radiation exposure has also aroused considerable concern. In this study, we aimed to assess radiation exposure and its influential factors in patients undergoing CBCT scans of the head and abdomen during interventional procedures. A total of 752 patients were included in this retrospective study. Dose area product (DAP) and reference air kerma (RAK) were used as measures of patient dose. The results showed that the median values of DAP were 53.8 (50.5-64.4) Gy⋅cm2 for head CBCT and 47.4 (39.6-54.3) Gy⋅cm2 for that of the abdomen. Male gender and body mass index (BMI) were characterized by increased DAP and RAK values in both head and abdominal CBCT scans. Larger FOV size was associated with a higher DAP but a lower RAK value, especially in head CBCT scans. Exposure parameters under automatic exposure control (AEC) also varied according to patient BMI and gender. In conclusion, the patients received slightly higher radiation doses from head CBCT scans than from those applied to the abdomen. BMI, gender, and FOV size were the key factors that influenced the radiation dose administered to the patients during CBCT scans. Our results may help to define and minimize patients' exposure to radiation.