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Introduction to Interventional Radiology Dr Tejas Kotwal FY2 Doctor Barts Health NHS Trust October 24th 18:30 @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS BRITISH INDIAN MEDICAL @BIMA ASSOCIATION BIMA Radiology Crash Course The British Indian Medical Association (BIMA) - The British Indian Medical Association (BIMA) is a national non-profit organisation founded on developing a supportive network amongst students and doctors across the UK - Provides tutorial series, conference events, networking, careers talks, socials and more! - For more information follow us on social media and stay up to date with latest academic events by joining our mailing lists: BIMA Clinical and OSCE series: https://forms.gle/CidGvWAc9YY9WSSs8 BIMA Fundamentals of Medicine & Pathology series: https://forms.gle/KfAgeoX55GPAWqee8 BIMA Radiology Crash Course SPEAKER BIOGRAPHY Dr Tejas Kotwal MBBS, BSc (Hons) Tejas is a current SFP F2 doctor at the Royal London Hospital and graduated from Kings College London in 2022. He has been a part of both BIMA and BISA previously, as Welfare Officer and Networking and Specialties Lead. He has a keen interest in Radiology, in particular the use of interventional techniques and the application of AI within the specialty. Outside of medicine he is a keen hockey player, having played for GKT throughout university. BIMA Radiology Crash CourseBIMA Radiology Crash Course Radiology for Finals/FY1s- National Radiology Teaching series run by Foundation level Doctors as part of BIMA National Curriculum 3 October – Chest X-Ray interpretation 10 October- Abdominal X-Ray interpretation th 17 October- Limb X-Ray interpretation 24 October- Interventional Radiology 31 October- CT Scanning BIMA Radiology Crash CourseMedAll You can answer questions and contribute by using the MedAll chat function. Also able to ask questions using this! BIMA Radiology Crash CourseContents/Objectives 1. What is IR 2. Pathway to becoming specialised in IR 3. Common Applications of IR (overview) 4. Detailed look into the most common procedures BIMA Radiology Crash Course What is Interventional Radiology • IR is a minimally invasive alternative to open surgery that uses radiological image guidance (X-rays, ultrasound, CT and MRI) to aid treatment. • IR developed in diagnostic angiography in the 1960s • The term ‘interventional radiology’, however, was not conceived until March 1967 when an American radiologist, Alexander Margulis, described it in an edition of the American Journal of Roentgenology. BIMA Radiology Crash Course What is Interventional Radiology • IRs have expertise in guiding small needles, catheters and other medical equipment into the body through tiny (5–10 mm) incisions in the skin to treat disease. • When combined with imaging allows clinicians to target specific organs and body systems • IR can also be used as an adjuvant to surgery and combined procedures with surgeons can optimise patient care. • Both elective and emergency procedures can be tackled BIMA Radiology Crash Course Advantages of Interventional Radiology • Targeted Treatment • Reduced risks compared to surgical options • Suitable for a wide range of patients • Faster recovery • Better cosmetic results BIMA Radiology Crash Course Challenges facing Interventional Radiology • Turf wars • Lack of patient awareness of the specialty • Lack of availability across the UK BIMA Radiology Crash CourseSo you want to become an Interventional Radiologist? BIMA Radiology Crash Course Pathway to becoming specialised in IR • The basic skills of an IR are still image interpretation and, therefore, core diagnostic radiology is at the heart of interventional radiology training • To become an interventional radiologist, you should apply for ST1 clinical radiology training • Both interventional and non-interventional radiologists undertake the same initial training. • Opportunity to now select IR-themed programmes BIMA Radiology Crash Course Common Applications of IR Vascular Vascular Non-Vascular Interventional Intervention Intervention Intervention Oncology (Arterial) (Venous) BIMA Radiology Crash CourseCommon Applications of IR Vascular Intervention Vascular Intervention Non-Vascular Intervention Interventional Oncology (Arterial) (Venous) Angioplasty/Stenting Acute Arterial Catheter Directed Thrombolysis Uterine Uterine Fibroidsion - for Prostate Artery Embolisation - For Benign Prostatic Hypertrophy (BPH) Embolisation for Post-Partum Bleeding Embolisation for Gastrointestinal Bleeding Embolisation for Trauma Endovascular Aneurysm Repair (EVAR) BIMA Radiology Crash CourseCommon Applications of IR Vascular Intervention Vascular Intervention Non-Vascular Intervention Interventional Oncology (Arterial) (Venous) Angioplasty/Stenting Varicocoele Embolisation Acute Arterial Catheter Directed Long Term Venous Access Thrombolysis Arterio-Venous Fistuloplasty Uterine Artery Embolisation - for Uterine Fibroids Thrombolysis Prostate Artery Embolisation - Thrombectomy For Benign Prostatic Hypertrophy (BPH) Transjugular Intrahepatic Embolisation for Post-Partum Portosystemic Shunt (TIPS) Bleeding Inferior Vena Cava (IVC) Filters Embolisation for Gastrointestinal Bleeding Embolisation for Trauma Endovascular Aneurysm Repair (EVAR) BIMA Radiology Crash CourseCommon Applications of IR Vascular Intervention Vascular Intervention Non-Vascular Intervention Interventional Oncology (Arterial) (Venous) Angioplasty/Stenting Varicocoele Embolisation Nephrostomy & Ureteric Stent Acute Arterial Catheter Directed Long Term Venous Access Percutaneous Transhepatic Thrombolysis Cholangiogram (PTC) Arterio-Venous Fistuloplasty Uterine Artery Embolisation - for Radiologically Inserted Uterine Fibroids Thrombolysis Gastrostomy (RIG) Prostate Artery Embolisation - Thrombectomy Vertebroplasty For Benign Prostatic Hypertrophy (BPH) Transjugular Intrahepatic Image Guided Biopsies Embolisation for Post-Partum Portosystemic Shunt (TIPS) Image Guided Drains Bleeding Inferior Vena Cava (IVC) Filters Cholecystostomy Embolisation for Gastrointestinal Bleeding Cholecysto-duodenal Stenting (a.k.a GUPTAS procedure) Embolisation for Trauma Endovascular Aneurysm Repair (EVAR) BIMA Radiology Crash CourseCommon Applications of IR Vascular Intervention Vascular Intervention Non-Vascular Intervention Interventional Oncology (Arterial) (Venous) Angioplasty/Stenting Varicocoele Embolisation Nephrostomy & Ureteric Stent Percutaneous Tumour Ablation Acute Arterial Catheter Directed Long Term Venous Access Percutaneous Transhepatic Portal Vein Embolisation (PVE) Thrombolysis Cholangiogram (PTC) Arterio-Venous Fistuloplasty Pre-Operative Tumour Uterine Artery Embolisation - for Radiologically Inserted Embolisation Uterine Fibroids Thrombolysis Gastrostomy (RIG) Trans-Arterial Chemo- Prostate Artery Embolisation - Thrombectomy Vertebroplasty Embolisation (TACE) For Benign Prostatic Hypertrophy (BPH) Transjugular Intrahepatic Image Guided Biopsies Embolisation for Post-Partum Portosystemic Shunt (TIPS) Image Guided Drains Bleeding Inferior Vena Cava (IVC) Filters Cholecystostomy Embolisation for Gastrointestinal Bleeding Cholecysto-duodenal Stenting (a.k.a GUPTAS procedure) Embolisation for Trauma Endovascular Aneurysm Repair (EVAR) BIMA Radiology Crash CourseBIMA Radiology Crash Course Seldinger Technique • The Seldinger technique is the mainstay of vascular and other luminal access in interventional radiology • An over-wire technique of catheter insertion to obtain safe percutaneous access to vessels and hollow organs • The desired vessel or cavity is punctured with a sharp hollow needle, with ultrasound guidance if necessary. A round-tipped guidewire is then advanced through the lumen of the needle, and the needle is withdrawn. A sheath or blunt cannula can now be passed over the guidewire into the cavity or vessel. BIMA Radiology Crash CourseMost Common IR Procedures Case 1 • A 50 year old male presented to the emergency department with sudden chest pain that started 2 hours ago • Background of diabetes and dyslipidaemia • Observations: • HR 72 • BP 100/60 • O2 Sats 92% • Investigations: • Hb 110 • Urea 11 • Troponin 129 • ECG: ST-segment elevation in lead II, III, aVF with reciprocal changes in aVL BIMA Radiology Crash Course Angioplasty and Stenting • Angioplasty is a minimally invasive procedure used to treat an artery which has become blocked or narrowed. • For angioplasty, a long, thin tube (catheter) is put into a blood vessel and guided to the blocked coronary artery. The catheter has a tiny balloon at its tip. Once the catheter is in place, the balloon is inflated at the narrowed area of the heart artery. This presses the plaque or blood clot against the sides of the artery, making more room for blood flow. • Stents are small, strong expandable tubes made of metal mesh which when placed in the blood vessel support its walls from the inside. • Stents are frequently used in conjunction with balloon angioplasty. If the narrowing cannot be extended sufficiently by means of a balloon dilatation, a stent can be placed into the vessel, to hold the artery open • Fluorscopy is a special type of x-ray that is used during the procedure • It creates an ‘x-ray movie’ with multiple consecutive images that help the doctor find the blockages in the heart arteries as a contrast dye moves through the arteries. BIMA Radiology Crash CourseAngioplasty and Stenting BIMA Radiology Crash CourseAngioplasty and Stenting BIMA Radiology Crash Course Case 2 • An 86-year-old male patient was admitted to the hospital due to progressive dysuria with gross hematuria for three years. • No back pain, fever, nausea or vomiting • Investigations: • Urine: 1+ Nitrites, 3+ Blood • Hb 89 • Prostate-Specific Antigen: 4.5 • DRE Abnormal • 50ml of residual bladder volume after urination • After admission, the patient underwent placement of an indwelling three-way urinary catheter to facilitate continuous bladder irrigation BIMA Radiology Crash Course Prostate Artery Embolization • Prostatic artery embolization (PAE) is a minimally invasive treatment that helps improve lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH). • It can help with the following symptoms which are interfering with the patients quality of life: • Urinary incontinence, which can range from some leaking to complete loss of bladder control • Irritative voiding symptoms • Increased urinary frequency, urgency and pain upon urination • PAE is performed through a small catheter inserted by your interventional radiologist into the artery in your wrist or groin. • A Foley catheter (a thin, hollow tube held in place with a balloon at the end) may be inserted into your urethra and positioned in your bladder to provide a reference point for the surrounding anatomy. • Tiny round microspheres (particles) are injected through the catheter and into the blood vessels that feed your prostate to reduce its blood supply. • Following this procedure, the prostate will begin to shrink, relieving and improving symptoms, usually within days of the procedure. BIMA Radiology Crash CourseProstate Artery Embolization BIMA Radiology Crash Course Case 3 • A 40 year old female has presented due to an aching pain, throbbing and itching in her legs • She is also bothered by the appearance of her legs, which she describes as ‘unsightly’ • On examination you find the following: • Dilated veins measuring >3mm • Varicose Eczema • Lipodermatoscleoris (hard, tight skin) • Hyperpigmentation • Investigations: • Venous duplex ultrasound demonstrates retrograde venous flow BIMA Radiology Crash Course Endovenous Laser Therapy • Traditionally, varicose veins have been managed using surgical techniques, most commonly tying and stripping • However it is expensive, time consuming, uncomfortable at best and usually requires a general anaesthetic • Endovenous Laser Therapy is a new IR technique that uses heat from a laser to shrink and close the varicose veins, sealing off the vein and forcing blood to flow through other nearby veins instead • Doppler ultrasound will be used to check the location and characteristics of the veins before the procedure • The procedure is performed through a tiny cut at the knee level, usually only 1-2mm long, under local anaesthetic • The catheter with a laser fibre inside it is guided into the varicose vein • As the doctor slowly pulls out the catheter, the laser will heat up the length of the vein. The vein will close up and should eventually shrink. • This process is repeated multiple times depending on the number of varicose veins BIMA Radiology Crash CourseEndovenous Laser Therapy BIMA Radiology Crash Course Case 4 • A 65-year-old Caucasian man with known benign prostatic hypertrophy presented underwent a renal ultrasound examination for ongoing lower urinary- tract symptoms. • PMH: obesity, uncontrolled hypertension, diabetes, asthma, and liver disease • He was found to have a peripherally situated tumor on his left kidney which was 21 mm in size which was confirmed by CT • After discussion at the MDT, it was concluded that due to his co-morbidities he would not be a candidate for a total/partial nephrectomy to remove the tumour BIMA Radiology Crash Course Kidney Tumour Ablation • Traditionally, cancer has been treated by a combination of surgery, radiotherapy and chemotherapy. Radiofrequency ablation (RFA) involves the use of heat to cause destruction of cancer cells. Small needles are used and inserted into the tumour. The needles are heated and cause thermal damage and eventual destruction of the cancer cells. • Cryoablation (also known more simply as “cryo”) involves the use of ice to freeze tumours. The ice used is at a temperature of less than -100 ° C and provides a very efficient means of destroying tumour cells • Much like RFA, cryoablation involves inserting small needles into the tumour under imaging guidance. • Generally, these types of treatment are used for small renal tumours, usually less than 3 to 5cm in diameter. • Several other factors will be considered when deciding upon whether or not RFA/cryotherapy is the best treatment option for your tumour. Such factors include the location of the tumour, the surrounding structures close to the tumour, your overall health and age, how well your kidneys are functioning, local expertise and obviously, patient preference. BIMA Radiology Crash CourseKidney Tumour Ablation BIMA Radiology Crash Course Case 5 • A 26-year-old male presented to the emergency department with colicky right lumbar pain radiating to the groin • Also complained that the last time he passed urine he saw blood • Has taken lots of pain relief and nothing is helping • No significant past medical history • Physical examination and observations were normal • Investigations: • Blood tests showed a raised creatinine and reduced eGFR • Non-contrast CT performed BIMA Radiology Crash Course Percutaneous Nephrolithotomy • Removal of kidney stones using keyhole surgery • A fine bore tube is passed from below using an endoscope into the kidney through your bladder. • Using x-ray/ultrasound guidance, a wire is passed to where the stone is located • A 1cm cut is made into the back of the kidney and a temporary rigid tube is placed from the skin onto the kidney • A camera is used to visualize the stone which is extracted after it has been fragmented • The process can be repeated multiple times based on the stone burden • There are a number of different methods that can be used to manage kidney stones (observation, open surgery, external shock-wave treatment), and percutaneous nephrolithotomy is usually performed due to the following indications: • Stones larger than 1.5cm in the kidneys or the ureter. • Stones larger than 1cm in the lower pole of the kidney. • Staghorn shaped stones. • Patient choice BIMA Radiology Crash CourseReferences https://www.uhcw.nhs.uk/interventional-radiology/what-is-interventional-radiology-ir/ https://www.bsir.org/patients/what-is-interventional-radiology/ https://www.uhcw.nhs.uk/interventional-radiology/common-ir-procedures-explained/ https://blog.nbir.com.au/benefits-of-interventional-radiology-patient-outcomes https://radiopaedia.org/articles/seldinger-technique?lang=gb https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-020-01612-z https://litfl.com/seldinger-technique/#:~:text=Description,cannulation%20method%20for%20performing%20arteriography. https://www.bsir.org/patients/angioplasty-and-stenting/#what-is-angioplasty https://drraghu.com/services/cath-lab-procedures/coronary-angioplasty-stents/ https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/angioplasty-and-stent-placement-for-the-heart https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.038518 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9985851/ https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/prostatic-artery-embolization https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/endovenous-laser-varicose-vein-surgery https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.medicalnewstoday.com%2Farticles%2F240129&psig=AOvVaw1PamlazZ_WOvvTIKR7cS3E&ust=1697539733190000& source=images&cd=vfe&opi=89978449&ved=0CBIQjhxqFwoTCIDTqriy-oEDFQAAAAAdAAAAABAE https://www.sth.nhs.uk/clientfiles/File/pd4480_EndovenousLaserTherapy.pdf https://www.v-zo.ch/en/therapies/ https://www.bsir.org/patients/kidney-tumour-ablation/#col_right https://www.researchgate.net/figure/Radiofrequency-ablation-RFA-of-a-renal-cell-carcinoma-of-the-right-kidney-A_fig2_330564918 https://www.bsir.org/patients/percutaneous-nephrolithotomy/#col_right BIMA Radiology Crash Course THANK YOU FOR LISTENING Please do complete the Feedback form in order to obtain your certificate! 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