Application of Interventional

Radiology
Paul Byra, MIV
USC-SOM

Procedures Performed
Angioplasty w/ vascular
stenting
Angiography
Embolization
CTA
Cryotherapy
Endovenous ablation of
varicosities
MRA
MR guided biopsies
Radiofrequency ablations of
tumors

Thrombolysis
Transjugular Intrahepatic
Portosystemic Shunt (TIPS)
Ultrasound guided biopsies
Uterine fibroid embolization
Vascular access procedures
Vertebroplasty
Biliary drainage and stenting
Fallopian tube catherization
Gastrostomy tube insertion
Urinary tract obstruction

And many more

Case 1
60 y.o male w/ hx sig. for HTN, NIDDM,
and 80 pack year smoking hx who
presents with signs of claudication
Bilateral femoral, right popliteal, dorsalis
pedis, and posterior tibial pulses present
No palpable popliteal, dorsalis pedis,
posterior tibial pulses present on the left

Catheter Angiography
Image blood vessels for disease,
narrowing, occlusion, or aneurysms
Catheter is threaded through the vascular
system to area of interest
Contrast is injected and visualized
radiographically

Catheter Angiography
Left common
iliac stenosis
Not pictured
superficial femoral
and proximal
popliteal artery
occlusion

Catheter Angiography

Left iliac angioplasty and stent placement

Catheter Angiography

Post stent placement

Case 2
30 y/o female with 16
week sized uterus
Negative UPT
Ultrasound significant
for uterine fibroids
MRI of uterus
White arrows indicate
the fibroids

Uterine Fibroid Emoblization

Arteriogram is performed,
identifying fibroid vessels
Embolization is
performed on one side
until near stasis is
achieved, then the other
side is embolized
Normal myometrial
vessles are spared

Uterine Fibroid Emoblization

3 months S/P
embolization
Uterine volume
decreased by 66%

Case 3
50 y/o male with hx of Chronic Hepatitis
and portal hypertension causing severe
variceal bleeding
Patient is on beta-blocker and has failed
sclerotherapy

TIPS
A catheter is placed in the right
jugular vein
The catheter is threaded
through the superior and inferior
vena cava to the hepatic vein
Wall of the hepatic vein is
punctured and the needle is
directed across an approximate
2 inch gap to the portal vein.
Successful passage into the
portal vein is determined by the
pattern of dye injected through
the catheter

TIPS
A guide wire is
threaded through
the needle to
maintain the
passage between
the hepatic and
portal veins.

TIPS
A balloon may be
used across the
passage to widen
the holes in the
vessel walls and
the passage
through the liver
tissue

TIPS
Two stents are then
positioned along the
passage, overlapping in
the liver tissue and
extending into both veins.
The stents are opened to
their maximum width with
balloon dilation
Blood flow from the portal
vein across the stents to
the hepatic vein and on to
the vena cava is
confirmed with dye
injection.

Case 4
72 y.o female with history significant for HTN,
hyperlipidemia, and DM develops in the early afternoon
a sudden, severe headache that is followed by left sided
weakness of the arm and leg
Patient arrives to the ER 3 hours post-onset of
symptoms
CT indicates nonhemorrhagic stroke
Patients BP 150/90, plt count >100k, normal bld glc; w/o
history of intracranial hem., recent stroke or head
trauma, recent MI, anticoagulation therapy, major
surgery w/in past 14 days, or seizure during stroke
Basically no contraindications to tPA therapy butit has
been over 3 hourshmmm

Thrombolysis
When therapy cannot be initiated within three hours or
when treatment with tPA during the first three hours is
not sufficient to dissolve the blood clot, interventional
neuroradiologists can provide intra-arterial thrombolysis
treatment
Using x-ray guidance, an IR will insert a catheter through
the femoral artery to the artery where the clot is present
and will place the thrombolytic drug directly on the clot or
break up the clot mechanically
When given locally this way, the tPA can be
administered up to six hours after the onset of stroke
symptoms

Thrombolysis
CT perfusion images show decreased cerebral blood
volume and cerebral blood flow with mean transit time
representing ischemia.

CTA shows cutoff

of right middle
cerebral artery

Thrombolysis
Initial angiogram shows the
middle cerebral artery cutoff

Road map angiogram shows

the microcatheter crossing the
clot before administration of
tPA and microwire manipulation

Thrombolysis
At admission

Post thrombolysis
angiogram

References
Society of Interventional Radiology. SIRweb.org
Transjugular Intrahepatic Portosystemic Shunt. University of
Michigan Gastroenterology.
http://www.med.umich.edu/1libr/aha/umliver09.htm
Interventional Neuroradiology. Massachusetts General Hospital.
http://www.mgh-interventional-neurorad.org
Peripheral Vascular Disease. University of Toronto.
http://surgclerk.med.utoronto.ca/