Essential

Interventional
Radiology
Review
A Question and Answer Guide
Rajat Chand · Adam E. M. Eltorai ·
Terrance Healey ·
Sun Ahn Editors

123
Essential Interventional Radiology
Review
Rajat Chand • Adam E. M. Eltorai
Terrance Healey • Sun Ahn
Editors

Essential
Interventional
Radiology Review
A Question and Answer Guide
Editors
Rajat Chand Adam E. M. Eltorai
The Hospital for Sick Children Radiology
Toronto, Ontario Brigham and Women’s Hospital,
Ontario, Canada Harvard Medical School
Boston, MA, USA
Terrance Healey
Brown University Sun Ahn
East Providence, RI, USA Brown University
Providence, RI, USA

ISBN 978-3-030-84171-3    ISBN 978-3-030-84172-0 (eBook)

https://doi.org/10.1007/978-3-030-84172-0

© Springer Nature Switzerland AG 2022

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Preface

What Is Interventional Radiology?

One of the newest primary medical specialties, as recognized
by the American Board of Medical Specialties, interventional
radiology (IR) is a field within radiology that offers mini-
mally invasive diagnostic and treatment strategies for a broad
range of illness. IR is proven to provide effective treatment
options, generally associated with lower surgical risk, compli-
cations, and overall morbidity. Often considered to intersect
clinical care, minimally invasive procedures, and radiologic
diagnosis and guidance, IR practitioners have the unique
opportunity to partake in the care of many different disease
processes, as well as partake in cutting-edge and ground-
breaking research. Since the field’s inception, when the radi-
ologists Seldinger and Dotter laid the path for minimally
invasive procedures, IR has today become a primary specialty
of medicine that provides any IR practitioner the opportunity
for a career filled with rich patient interaction experienced
through longitudinal clinical care. The core principles of this
field and its society are to: expand access to the high-quality
care IRs can provide, continuously translate innovation into
better patient outcomes, provide comprehensive and lifelong
education to practitioners at all levels, and always work
alongside other medical specialties to thrive for the best pos-
sible outcomes for patients.
vi Preface

Using this Book

This review-style book is written in a question-and-answer
format for medical students and residents to utilize during
their interventional radiology rotation. It is designed to be a
quick reference, as well as a tool for independent study, and
covers many general and subspecialty topics in interventional
radiology. As it would be impossible to provide the complete
breadth of education for all disease processes interventional
radiologists treat in this single text, our goal is rather to pro-
vide a resource to help accurately answer many on-the-spot
questions, which are commonly encountered during proce-
dures and clinical management.
Essential Interventional Radiology Review is organized to
first offer some basic knowledge to help acquaint the reader
with important clinical and technical considerations of the IR
workspace, and then focuses on system-based review. The
span of content covers most of the commonly encountered
pathologies in IR, as well as some emerging techniques. We
hope this book serves as a convenient resource and aids in
contributing pearls to all of the rich, educational discussions
taking place in IR training programs across the world.

Toronto, ON, Canada Rajat Chand

Boston, MA, USA Adam E. M. Eltorai
East Providence, RI, USA Terrance Healey
Providence, RI, USA Sun Ahn
Contents

Part I Daily Workflow

1 The Role of a Subintern�������������������������������������������������   3
Chris Molloy and Junjian Huang

2 Presenting a Patient������������������������������������������������������� 11
Chris Molloy and Junjian Huang

3 Morning Rounds������������������������������������������������������������� 17
Chris Molloy and Junjian Huang

4 Afternoon Rounds��������������������������������������������������������� 21
Chris Molloy and Junjian Huang

5 Taking Call ��������������������������������������������������������������������� 27

Chris Molloy and Junjian Huang

6 Pre-procedure����������������������������������������������������������������� 31
Chris Molloy and Junjian Huang

Part II Vascular Site

7 Patient Preparation ������������������������������������������������������� 37
Matthew Czar Taon

8 Running the Table ��������������������������������������������������������� 41

Matthew Czar Taon

9 Choice of Access������������������������������������������������������������� 43
Matthew Czar Taon
viii Contents

10 Seldinger Technique������������������������������������������������������� 47
Matthew Czar Taon

11 Guidewires����������������������������������������������������������������������� 49
Matthew Czar ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­Taon

12 Catheters������������������������������������������������������������������������� 55
Matthew Czar Taon

13 Connectors ��������������������������������������������������������������������� 59
Matthew Czar Taon

14 Balloons��������������������������������������������������������������������������� 63
Matthew Czar Taon

15 Stents������������������������������������������������������������������������������� 67
Matthew Czar Taon

16 Embolization������������������������������������������������������������������� 71
Matthew Czar Taon

Part III Vascular Disease

17 Abdominal Aortic Aneurysms ������������������������������������� 81
Dania Daye

18 Thoracic Aortic Aneurysm Chapter����������������������������� 93

Peyton Cramer and Lourdes Alanis

19 Angiography������������������������������������������������������������������� 111
Mertalaine Mulatre

20 Peripheral Arterial Disease������������������������������������������� 127

Omowunmi Ajibola and Abeer Mousa

21 Acute Venous Thromboembolic Disease��������������������� 151

Sabeeha Chowdhury and Peyton Cramer
 Contents ix

22 Mesenteric Ischemia������������������������������������������������������� 177

Akhil Khetarpal

23 Arteriovenous Malformation (AVM) ������������������������� 193

Charles Hua

24 Central Venous Access��������������������������������������������������� 215

Gaurav Gadodia

25 Carotid Artery Stenosis������������������������������������������������� 245

Gaurav Gadodia

26 Renovascular Hypertension ����������������������������������������� 277

Gaurav Gadodia

27 Varicose Vein������������������������������������������������������������������� 303

Anushi Patel

28 Varicocele Embolization����������������������������������������������� 333

Avinash Pillutla

29 Vena Cava Filter������������������������������������������������������������� 349

David Maldow

30 Peripheral and Visceral Artery Aneurysm ����������������� 361

Jesse Chen and Amit Ramjit

31 Hemodialysis Access Interventions ����������������������������� 379

Rana Rabei

32 Hybrid and Complex Aortic Aneurysm

Endovascular Repair ����������������������������������������������������� 389
Omosalewa Adenikinju, Sofia C. D. Vianna, and
Brandon P. Olivieri
x Contents

Part IV Oncology
33 Hepatic Interventional Oncology��������������������������������� 415
Seth I. Stein

34 Pulmonary Oncology����������������������������������������������������� 443

John Smirniotopoulos and Maria Mitry

35 Renal Oncology ������������������������������������������������������������� 465

Shaji Khan and Monica J. Uceda

36 Breast Oncology������������������������������������������������������������� 479

Monica J. Uceda and Shaji Khan

Part V Hepatobiliary
37 Percutaneous Biliary Interventions����������������������������� 497
Jacob J. Bundy, Jeffrey Forris Beecham Chick, and
Ravi N. Srinivasa

38 Transjugular Intrahepatic Portosystemic

Shunt (TIPS)������������������������������������������������������������������� 513
Andrew Moore

39 Balloon-Occluded Retrograde Transvenous

Obliteration (BRTO)����������������������������������������������������� 529
Rupal Parikh

Part VI Genitourinary
40 Percutaneous Nephrostomy ����������������������������������������� 551
Marco Ertreo and Ifechi Momah

41 Uterine Artery Embolization��������������������������������������� 567

Ifechi Momah-Ukeh and Marco Ertreo

42 Prostate Artery Embolization��������������������������������������� 579

Marco Ertreo, Rakesh Ahuja, and Keith Pereira
 Contents xi

Part VII Neuro
43 Stroke������������������������������������������������������������������������������� 597
Sarah E. Pepley and Agnieszka Solberg

44 Percutaneous Vertebral Augmentation����������������������� 627

Ryan Bitar, Barrett O’Donnell, and Charles Hyman

45 Management of Benign and Malignant

Back Pain by Interventional Radiology����������������������� 645
Lynsey Maciolek and Steven Yevich

Part VIII Vascular Emergencies

46 Trauma Embolization ��������������������������������������������������� 673
Justin J. Guan

47 Spleen������������������������������������������������������������������������������� 697
Justin J. Guan

48 Pelvis ������������������������������������������������������������������������������� 713

Justin J. Guan

49 Bronchial Artery Embolization ����������������������������������� 733

Justin J. Guan

50 Upper Gastrointestinal Bleeding��������������������������������� 747

Kartik Kansagra, Harout Dermendjian, and
Cuong H. Lam

51 Lower Gastrointestinal Bleeding��������������������������������� 763

Christopher Barnett

52 Uterine Artery Embolization – Vascular

Emergency����������������������������������������������������������������������� 777
Kartik Kansagra and Cuong H. Lam

53 Contrast Reactions��������������������������������������������������������� 785

Matthew Czar Taon
xii Contents

Part IX Lymphatic
54 Thoracic Duct Embolization����������������������������������������� 793
Kyle A. Wilson and Bill S. Majdalany

Part X Pediatrics
55 Pediatrics – Central Venous Access����������������������������� 813
Maegan Kellie Garcia Lazaga and Harris Chengazi

56 Pediatrics – Enteral Access������������������������������������������� 831

Harris Chengazi and Maegan Kellie Garcia Lazaga

57 Vascular Anomalies������������������������������������������������������� 847

Madeline Leo

58 Pediatric Genitourinary Interventions������������������������� 861

Ethan J. Speir, C. Matthew Hawkins, and Anne Gill

Part XI Other and New Procedures

59 Tubes and Biopsies��������������������������������������������������������� 873
Oleksandra Kutsenko and Mohammed Jawed

60 Bariatric Embolization��������������������������������������������������� 893

Clifford R. Weiss and Godwin Abiola

61 Interventional Radiology-Operated Endoscopy ������� 905

Jacob J. Bundy, Jeffrey Forris Beecham Chick, and
Ravi N. Srinivasa

62 Sphenopalatine Ganglion Nerve Block����������������������� 915

Parth Shah and Avinash Pillutla

Index����������������������������������������������������������������������������������������� 929
Contributors

Godwin Abiola Beth Israel Deaconess Medical Center,

Boston, MA, USA
Omosalewa Adenikinju Department of Vascular and
Interventional Radiology, Mount Sinai Medical Center,
Miami Beach, FL, USA
Rakesh Ahuja Vascular & Interventional Radiology, Einstein
Medical Center, Philadelphia, PA, USA
Omowunmi Ajibola University of Utah, Salt Lake City, UT,
USA
Lourdes Alanis Interventional Radiology, Radiology
Associates of San Luis Obispo, San Luis Obispo, CA, USA
Christopher Barnett Department of Radiology, New York
Presbyterian-Weill Cornell Medical Center, New York, NY,
USA
Ryan Bitar Long School of Medicine 2021, University of
Texas Health Science Center at San Antonio, San Antonio,
TX, USA
Jacob J. Bundy Department of Radiology, Wake Forest
Health, Winston Salem, NC, USA
Jesse Chen Department of Radiology, Staten Island
University Hospital, Staten Island, NY, USA
Harris Chengazi Department of Imaging Sciences, University
of Rochester, Rochester, NY, USA
xiv Contributors

Jeffrey Forris Beecham Chick Department of Interventional

Radiology, University of Washington, Seattle, WA, USA
Sabeeha Chowdhury Department of Interventional
Radiology, Medstar Georgetown University Hospital,
Washington, DC, USA
Peyton Cramer Department of Radiology, New York
Presbyterian Hospital Weill Cornell Medicine, New York,
NY, USA
McGovern Medical School, UT Health Science Center at
Houston, Houston, TX, USA
Dania Daye, MD, PhD Department of Radiology,
Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA
Harout Dermendjian Kaiser Permanente Los Angeles
Medical Center, Vascular and Interventional Radiology, Los
Angeles, CA, USA
Marco Ertreo Department of Radiology and Interventional
Radiology, Medstar Georgetown University Hospital,
Washington, DC, USA
Gaurav Gadodia Department of Radiology, Imaging
Institute, Cleveland Clinic, Cleveland, OH, USA
Anne Gill Department of Radiology and Imaging Sciences,
Division of Interventional Radiology and Image Guided
Medicine, Emory University School of Medicine, Atlanta,
GA, USA
Department of Radiology and Imaging Sciences, Division of
Pediatric Radiology, Children’s Healthcare of Atlanta,
Atlanta, GA, USA
Justin J. Guan Division of Interventional Radiology,
Department of Diagnostic Radiology, Cleveland Clinic,
Cleveland, OH, USA
C. Matthew Hawkins Department of Radiology and Imaging
Sciences, Division of Interventional Radiology and Image
 Contributors xv

Guided Medicine, Emory University School of Medicine,

Atlanta, GA, USA
Department of Radiology and Imaging Sciences, Division of
Pediatric Radiology, Children’s Healthcare of Atlanta,
Atlanta, GA, USA
Charles Hua Mount Sinai Interventional Radiology, Icahn
School of Medicine at Mount Sinai, New York, NY, USA
Junjian Huang Department of Vascular and Interventional
Surgery, Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA
Charles Hyman Brown Medical School 2018, University of
Texas Health Science Center at San Antonio Radiology
PGY-2, San Antonio, TX, USA
Mohammed Jawed Radiology Department, SUNY Upstate
University Hospital, Syracuse, NY, USA
Kartik Kansagra Kaiser Permanente Los Angeles Medical
Center, Vascular and Interventional Radiology, Los Angeles,
CA, USA
Shaji Khan Department of Radiology, Presence Health
St. Francis Hospital, Evanston, IL, USA
Akhil Khetarpal Department of Vascular and Interventional
Radiology, Virginia Interventional and Vascular Associates
(VIVA), Fredericksburg, VA, USA
Oleksandra Kutsenko Radiology Department, SUNY
Upstate University Hospital, Syracuse, NY, USA
Cuong H. Lam Kaiser Permanente Los Angeles Medical
Center, Vascular and Interventional Radiology, Los Angeles,
CA, USA
Maegan Kellie Garcia Lazaga Department of Imaging and
Radiology, Augusta University/Medical College of Georgia,
Augusta, GA, USA
xvi Contributors

Madeline Leo Department of Radiology, UPMC Medical

Education, Pittsburgh, PA, USA
Lynsey Maciolek The University of Texas MD Anderson
Cancer Center, Houston, TX, USA
Bill S. Majdalany Michigan Medicine, University of Michigan,
Department of Radiology, Ann Arbor, MI, USA
David Maldow University of Rochester Medical Center,
Rochester, NY, USA
Maria Mitry Department of Radiology, New York
Presbyterian Hospital/Weill Cornell Medicine, New York,
NY, USA
Chris Molloy Department of Vascular and Interventional
Radiology, Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA
Ifechi Momah Department of Radiology and Interventional
Radiology, Medstar Georgetown University Hospital,
Washington, DC, USA
Ifechi Momah-Ukeh Department of Radiology and
Interventional Radiology, Medstar Georgetown University
Hospital, Washington, DC, USA
Andrew Moore Department of Radiology, Integris Baptist
Medical Center, Oklahoma City, OK, USA
Abeer Mousa University of Arizona College of Medicine-
Phoenix, Phoenix, AZ, USA
Mertalaine Mulatre ESIR/Diagnostic Radiology Residency
Program, INTEGRIS Baptist Medical Center, Oklahoma
City, OK, USA
Barrett O’Donnell McGovern Medical School 2018,
University of Texas Health Science Center at San Antonio
Radiology PGY-2, San Antonio, TX, USA
 Contributors xvii

Brandon P. Olivieri Department of Vascular and

Interventional Radiology, Mount Sinai Medical Center,
Miami Beach, FL, USA
Rupal Parikh Division of the Interventional Radiology,
Hospital of the University of Pennsylvania, Philadelphia, PA,
USA
Anushi Patel Department of Radiology, University of
Florida College of Medicine – Jacksonville, Jacksonville, FL,
USA
Sarah E. Pepley University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
Keith Pereira Division of Vascular Interventional Radiology,
Saint Louis University Hospital, St. Louis, MO, USA
Avinash Pillutla Department of Radiology, Virginia
Commonwealth University Health System, Richmond, VA,
USA
Rana Rabei UCSF Interventional Radiology, San Francisco,
CA, USA
Amit Ramjit Department of Radiology, Staten Island
University Hospital, Staten Island, NY, USA
Parth Shah Department of Radiology, Virginia
Commonwealth University Health System, Richmond, VA,
USA
John Smirniotopoulos Interventional Radiology, MedStar
Georgetown University Hospital/MedStar Washington
Hospital Center, Washington, NY, USA
Agnieszka Solberg University of North Dakota, Grand
Forks, ND, USA
Ethan J. Speir Department of Radiology and Imaging
Sciences, Division of Interventional Radiology and Image
Guided Medicine, Emory University School of Medicine,
Atlanta, GA, USA
xviii Contributors

Ravi N. Srinivasa Department of Radiology, Division of

Interventional Radiology, University of California- Los
Angeles, Los Angeles, CA, USA
Seth I. Stein Department of Radiology, NewYork-
Presbyterian Hospital, Weill Cornell Medical Center, New
York, NY, USA
Matthew Czar Taon Kaiser Permanente Los Angeles Medical
Center, Los Angeles, CA, USA
Monica J. Uceda Department of Radiology, Presence Health
St. Francis Hospital, Evanston, IL, USA
Sofia C. D. Vianna Department of Vascular and
Interventional Radiology, Mount Sinai Medical Center,
Miami Beach, FL, USA
Clifford R. Weiss Department of Radiology, Division of
Vascular and Interventional Radiology, The Johns Hopkins
School of Medicine, Baltimore, MD, USA
Kyle A. Wilson Michigan Medicine, University of Michigan,
Department of Radiology, Ann Arbor, MI, USA
Steven Yevich The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
 Part I
Daily Workflow
Chapter 1
The Role of a Subintern
Chris Molloy and Junjian Huang

The purpose of the subinternship (some institutions may

refer to this as Sub-I, acting intern, or AI) is to allow fourth
year medical students to assume a greater role in the direct
care of patients in IR. Taking on increased responsibility
empowers medical students to more actively engage in the
care of their patients, as well as to demonstrate their decision-­
making and patient management skills to the medical team.
A subintern’s responsibility includes performing consulta-
tion, rounding on IR patients, pre-procedural workup and
evaluation, understanding of relevant pathophysiology, assist-
ing in procedures, and post-procedural and longitudinal care.
The subinternship is an opportunity to spend time reading
about and becoming familiar with expert-level anatomy, the
various pathologies encountered and indications for inter-
vention, as well as the vast array of tools that will be encoun-
tered on the back table. A subintern should maintain a

C. Molloy (*)
Department of Vascular and Interventional Radiology, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
J. Huang
Department of Vascular and Interventional Surgery, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 3

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_1
4 C. Molloy and J. Huang

professional attitude and espouse team work at all times.

Included in the below chapters are a range of questions that
provide only a sample of the breadth of knowledge and curi-
osity that should be sparked within the IR rotation.

What imaging modalities Ultrasound, fluoroscopy, CT, and/or MRI

are used during
interventional radiology
procedures?

How is fluoroscopy Fluoroscopy utilizes lower milliampere (mA)

different from general voltage as compared to X-ray, as well as pulsed
radiography (X-ray)? radiation to compensate for the longer necessary
exposure time

What measures are Lead gowns, lead-lined eyeglasses, shields,

taken to minimize ALARA (as low as reasonably achievable), etc.
radiation exposure Radiation exposure is monitored monthly to
of interventional avoid excess of the recommended limit.
radiologists?

How many French (Fr) 3 Fr = 1 mm or 1 Fr = 0.33 mm. Sheath sizes are

are in 1 mm? defined by their inner diameter. Catheters and
wire sizes are defined by their outer diameter.
The size of an arteriotomy or venotomy created
by a sheath is approximately 1.5–2 Fr larger than
the labeled sheath size.

How are sheaths, wires, Sheaths are described in French sizes, indicative
and catheters described of the inner diameter, and total length
in terms of size? Wires and catheters are described in French
sizes (catheters) and inches (wires), indicative of
outer diameter. The length of all of these devices
is described in centimeters

According to Poiseuille’s According to the law, a change in radius

law, what has greatest corresponds to a proportional change in flow by
impact of flow through a factor of the fourth power Flow is also directly
a tube? proportional to the change in pressure.
Smaller-bore catheters will require a greater
change in pressure to be able to maintain forward
flow of the contents
 1 The Role of a Subintern 5

What is the mechanism Heparin binds to and activates the enzyme

of action and plasma antithrombin III, which then binds to and
half-life of unfractionated inactivates thrombin and factor Xa. The half-life
heparin? is 60–90 min. Approximately 1 mg of protamine
sulfate will inactivate 100 units of heparin.

What is the mechanism LMWH also inactivates thrombin and factor

of action and plasma Xa. The half-life of protamine is 7 min and,
half-life of low molecular therefore, LMWH lends itself to repeat dosing.
weight heparin
(LMWH)?

What pharmacological Direct thrombin inhibitors, such as bivalirudin,

agent can be used in argatroban and dabigatran. Bivalirudin requires
patients with heparin dose adjustment for renal impairment and is not
allergy? monitored with ACT. Argatroban and dabigatran
undergo hepatic clearance and can be monitored
with ACT. Bleeding complications for these agents
can be treated using recombinant factor VIIa.

What is the goal A baseline “activated clotting time” (ACT)

for therapeutic should be established before relevant
anticoagulation procedures. Anticoagulation is considered
during interventional therapeutic when the ACT is 1.5–2 times above
procedures? the baseline

What medication may DDAVP (desmopressin)

improve coagulation
in patients with uremic
platelet dysfunction?

What is used to reverse Flumazenil

the effects of midazolam
(benzodiazepine)?

What is used to reverse Naloxone

the effects of fentanyl
(opiate based narcotic)?

What doses of midazolam IV bolus doses of 25–100 mcg of fentanyl and

and fentanyl are typically 0.5–2 mg midazolam, respectively, are given.
given during moderate Chronic pain medication use may require higher
sedation? doses of fentanyl.

What is the relative Fentanyl and midazolam have a relatively

duration of effect of long duration of effect, 30–60 and 30–80 min,
fentanyl and midazolam? respectively. It is important to remember that
the level of sedation may deepen even after the
procedure.

(continued)
6 C. Molloy and J. Huang

What factors must always Any major comorbidities

be kept in mind for Any abnormalities of the airway (does the
patients receiving patient have a known or suspected difficult
sedation and analgesia? airway?)
Tolerance to pain medications
Obesity or history or obstructive sleep apnea
Will the case require prone positioning?
Does the patient have claustrophobia?

What is the antibiotic Gram positive, including MRSA

coverage of vancomycin?

What is the antibiotic Gram positive, negative, anaerobe. Not MRSA

coverage of piperacillin-­ or fungus
tazobactam (Zosyn)?

What can be added to Beta-lactamase inhibitors; clavulanic acid

penicillins, ampicillin (Augmentin or amoxicillin-­clavulanate) and
(IV), and amoxicillin sulbactam (Unasyn or ampicillin-sulbactam)
(PO) to create broad
coverage?

What are the Ceftazidime and ceftriaxone are third-

third-­generation generation cephalosporins with lower efficacy
cephalosporins? against gram-positive organisms as compared to
first- and second-generation cephalosporins, but
with broad gram-negative coverage

Which cephalosporin will Cefepime is a fourth-generation cephalosporin

treat Pseudomonas? with gram-­negative only coverage, including
Pseudomonas

Which antibiotics have Clindamycin provides good anaerobe coverage

good anaerobe coverage? for organism encountered on the skin, head,
and neck. Metronidazole provides good GI/GU
anaerobe coverage

What is a good antibiotic Start with a first- or second-­generation

choice to treat cellulitis? cephalosporin
Consider options, such as vancomycin (MRSA),
clindamycin (MRSA and anaerobes), or TMP/
SMX if cephalosporins fail

What are the main types Septic, hypovolemic, cardiogenic, neurogenic,

of medical shock that and anaphylactic
patients may encounter?
 1 The Role of a Subintern 7

What are the major signs Type

Anaphylactic
RR HR BP Skin
Flushed,
Temp
No
Urine Other
Urticaria, pruritus,

and symptoms of shock? swollen,

itchy
Change bronchoconstriction

Cardiogenic Pale, cool, No Chest discomfort, syncope, JVD,

clammy Change pulmonary edema, orthopnea
Hypovolemic Pale, cool, No Anxiety, thirst, syncope, weakness,
clammy Change confusion, dizziness, weak pulse
Obstructive Pale, cool, Muffled heart sounds, JVD, decreased
clammy LOC, signs of poor perfusion
Neurogenic Warm, No Paralysis distal to injury site, priapism
flushed, bladder
dry control
Septic Flushed, Bounding pulse, altered LOC
(Distributive) then pale
and cool

What clinical features Type

Cardiogenic
MAP CO DO2 CVP MPAP PCWP SVR

further define certain

Hypovolemic
forms of shock?
obstructive

Septic
(Distributive)

What conditions require Acute ischemia (limb, end-­organ, pulmonary

emergent IR embolus, etc.), hemorrhage (hemoptysis,
intervention? hematemesis, ruptured aneurysm, traumatic,
iatrogenic, etc.), closed-­space infections
(pyonephrosis, cholangitis, abscess, etc.)

How do you know if a The patient must be (1) alert; (2) oriented; (3)
patient can provide their be able to understand and ideally reiterate the
own consent? risks, benefits, and alternatives of procedure; and
(4) have legal capacity

What are the current No solid foods 6 h prior to procedure

Anesthesia Society of No clear fluids for 2 h prior to procedure
America (ASA)
guidelines for eating
and drinking prior to
procedures performed
with moderate sedation?

Where would you find The 2019 Society of Interventional Radiology

prophylactic antibiotic (SIR) Antibiotic Prophylaxis Guidelines during
recommendations for Procedures
planned procedures?

Where would you find The 2019 Society of Interventional Radiology

recommendations (SIR) Periprocedural Anticoagulation
regarding holding Guidelines
anticoagulation prior
to planned procedures?

(continued)
8 C. Molloy and J. Huang

What are the ASA Class I: Normal healthy patient

classifications? Class II: Mild systemic disease
Class III: Severe systemic disease
Class IV: Severe systemic disease which is a
constant threat to life
Class V: Moribund patient who is not expected
to survive without the procedure
Class VI: Declared brain-dead patient whose
organs are being removed for donor purposes

What is the modified Class I: Soft palate, uvula, fauces, pillars visible
Mallampati score? Class II: Soft palate, major part of uvula, fauces
visible
Class III: Soft palate, base of uvula visible
Class IV: Only hard palate visible

What are the differences Nasal cannula: Provides oxygen at a low flow
between nasal cannula, rate
venturi mask, non-­ Venturi: Controls/restricts the amount of
rebreather, and high-flow entrained air and therefore the FiO2
nasal cannula (HFNC)? Non-rebreather: Delivers the highest FiO2 at
standard flow rates
HFNC: Provides warmed, humidified
supplemental oxygen at a rate of up to 60 L/min
Remember that supplemental oxygen
will not treat hypercapnia due to alveolar
hypoventilation and may misleadingly raise
pulse oximetry readings

What scoring system Atherosclerotic Cardiovascular Disease

may be used to (ASCVD) risk calculator from the AHA/ACC
stratify atherosclerotic
cardiovascular risk?

What is the main clinical The NIHSS score describes the physical
patient assessment tool limitations caused by the acute stroke.
used in the evaluation of Neurologic impairment is classified based on its
acute stroke? severity and extent. The scale is between 0 and
42 with higher scores (≥21) indicating a severe
stroke

What is the classification Rutherford

system for acute and
chronic limb ischemia?
 1 The Role of a Subintern 9

What is the Couinaud The liver is divided inferiorly and superiorly

system of liver by the portal vein. The right and left hepatic
segmentation? lobes are divided by the falciform ligament,
which contains the obliterated umbilical vein
(ligamentum teres), the falciform artery, and the
paraumbilical veins. The hepatic vein borders
define the Couinaud segments: superiorly left-
to-right, 2, 4a, 8, and 7 and inferiorly left-­to-­right,
3, 4b, 5, and 6. The middle hepatic vein should
intersect the gallbladder fossa

Name the locations of the Left gastric venous collaterals

various types of varices Esophageal
that may be found related Paraesophageal
to portal hypertension Recanalized paraumbilical vein
Abdominal wall
Perisplenic
Retrogastric
Omental
Retroperitoneal-paravertebral
Mesenteric
Sites of previous surgery or inflammation
Patients with chronic Arc of Buhler: remnant artery that directly
mesenteric vessel connects the proximal celiac artery with the
occlusion may proximal superior mesenteric artery (SMA)
demonstrate collateral Arc of Riolan (mesenteric meandering artery
vascular pathways. What [of Moskowitz] or central anastomotic
are the common mesenteric artery): collateral path from the
mesenteric collateral middle colic branch of the SMA to the left colic
pathways? branch of the inferior mesenteric artery (IMA)
Marginal artery of Drummond: connects the
terminal branches of the SMA and IMA
Pancreatic cascade: connects superior
pancreaticoduodenal artery branches of the
gastroduodenal artery (GDA) to the inferior
pancreaticoduodenal branches of the SMA
Arc of Barkow (gastroepiploic cascade, arcus
epiploicus magnus): collateral path connecting
the right gastroepiploic (branch of the GDA)
to the left gastroepiploic (branch of the splenic
artery)
Chapter 2
Presenting a Patient
Chris Molloy and Junjian Huang

Different attending physicians will prefer different forms of

presentation. These variations are often based on the indi-
vidual attending preference, but variations in presentation
may also be commonly driven by the type of specialty or form
of disease. Since interventional radiology is a clinical and
procedural specialty, students and residents will likely be
expected to present relevant history with pertinent negative
findings, specific disease-related lab results, and key findings
from diagnostic imaging and prior interventions with close
attention to patient-specific anatomy and specifications of
the prior tools used in treatment.

C. Molloy (*)
Department of Vascular and Interventional Radiology, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
J. Huang
Department of Vascular and Interventional Surgery, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 11

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_2
12 C. Molloy and J. Huang

What key lab findings PT/INR, platelets, GFR, and BUN

are important for (uremic platelet dysfunction leads to
chronic kidney disease prolonged bleeding)
patients prior to image-­
guided procedures?
How can symptoms of Acute arterial ischemia disease
acute arterial ischemic manifestation is related to the acute
stroke be differentiated drop in glucose and oxygen delivery,
from other causes with the extent of damage reliant upon
of ischemic cerebral the degree of ischemia and ability to
pathology? recruit collateral vasculature
Central retinal artery occlusion
(CRAO) presents as painless
monocular vision loss with a cherry
red spot visible on fundoscopic
examination
Cerebral venous sinus thrombosis
(CVST) manifests as symptoms related
to impaired venous drainage, including
headache, blurred vision, painful loss
of vision, loss of bodily control, seizure,
and coma
What imaging finding The presence of ascites increases the
may indicate increased risk of intraperitoneal hemorrhage.
bleeding risk during These patients should either receive
percutaneous liver paracentesis prior to percutaneous
biopsy? liver biopsy or be offered a
transjugular liver biopsy instead.
What medical therapy An albumin infusion of 6–8 g/L of fluid
should be considered removal improves survival
in large-volume
paracentesis (>5 L
ascitic fluid removal)?
What other disease Myocardial infarction (25% in 5 years),
processes affect chronic stroke
limb ischemia patients?
 2 Presenting a Patient 13

What medications Aspirin, beta-blocker, high-intensity

should chronic limb statin, ACE inhibitor, +/– cilostazol
ischemia patients be on?
What are disadvantages Though less expensive, duplex
of duplex ultrasound to ultrasound has less spatial resolution
CTA in pre-procedural than CT and can be limited by
evaluation of limb operator experience and body habitus.
ischemia intervention? Calcium can pose a problem for both
modalities. Typically, if a patient has
palpable and symmetric femoral
pulses, CTA can be avoided.
Will endograft stent No. Balloon remodeling and endograft
placement fix type 2 stent placement are treatment options
endoleaks? for type 1 endoleaks, which are caused
by inadequate seal at the proximal
or distal stent attachment sites.
Embolization is the first-line treatment
for type 2 endoleaks.
What scoring system Simplified Pulmonary Embolism
may be used to predict Severity Index (PESI) score may be
pulmonary embolism used to determine and stratify severity
(PE) 30-day outcomes? of PE:
 Class I = score ≤ 65 (1.1% 30-day
mortality)
 Class II = score 66 – 85 (3.1%
30-day mortality)
 Class III = score 86 – 105 (6.5%
30-day mortality)
 Class IV = score 106 – 125 (10.4%
30-day mortality)
 Class V = score > 125 (24.5% 30-day
mortality)
(continued)
14 C. Molloy and J. Huang

The PESI score is Age (1 pt./yr.)

divided into which Male (10 pts.)
demographic, comorbid Cancer (30 pts.)
illness, and clinical Heart failure (20 pts.)
finding predictors? Chronic lung disease (20 pts.)
AMS (60 pts.)
SBP < 100 mmHg (30 pts.)
HR ≥ 110 (20 pts.)
RR ≥ 30 (20 pts.)
Temp < 36 °C (20 pts.)
Arterial oxygen saturation <90%
(20 pts.)
What antibiotics should Ceftriaxone or cefotetan (unless
patients be given prior the patient is allergic, in which case
to cholangiogram? another option, such as vancomycin or
clindamycin + an aminoglycoside may
be used)
What is the initial Chyle leaks may be post-traumatic
medical management of or iatrogenic in nature and should
a chyle leak? be initially managed with low-fat
diet or TPN, octreotide infusion, and
percutaneous drainage
What are the Creatinine, bilirubin, INR, and serum
components of sodium
MELD-Na score?
What is APACHE II APACHE II helps to determine
used for and what do severity of disease and mortality
the letters in APACHE prediction of ICU patients
represent? The acronym APACHE is “Acute
Physiology and Chronic Health
Evaluation”
Where is the most At the graft-vein anastomosis
common location where
dialysis graft stenosis
occur?
 2 Presenting a Patient 15

Where is the most Peri-anastomotic venous outflow

common location that
dialysis fistulas stenose/
occlude?
What is the estimated 2–10%
rate of IVC filter-­
induced thrombus?
What is the best CT Non-contrast CT images are ideal to
protocol to visualize detect for high-density intramural
aortic intramural aortic collections. Useful CT protocols
hematoma? in evaluation of aortic and arterial
pathology include non-contrast,
arterial phase, and delayed phase
images.
What are the Bilirubin, albumin, total protein,
components of the ascites, and hepatic encephalopathy
Child-Pugh score?
What is a SAAG SAAG is the serum to ascites albumin
score and how do you gradient. A value > 1.1 g/dL indicates
interpret it? hepatic causes of the ascites, such as
cirrhosis with portal hypertension and,
less commonly, CHF. A value < 1.1 g/dL
indicates malignancy or infection.
Chapter 3
Morning Rounds
Chris Molloy and Junjian Huang

Morning rounds or morning report is typically comprised of

discussion of all scheduled patients, including treatment
plans, a review of call cases from the previous night or week-
end, and review of patients on the IR service and/or consult
service. During morning report, individuals often give a very
brief “one-liner” history and procedure to be performed and
discuss any pertinent lab/imaging concerns. For more compli-
cated cases, this brief discussion may also include planned
access or path, device discussions, collaboration with other
departments, and additional needs, such as anesthesia.

C. Molloy (*)
Department of Vascular and Interventional Radiology, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
J. Huang
Department of Vascular and Interventional Surgery, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 17

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_3
18 C. Molloy and J. Huang

What is the most Patients with popliteal aneurysms have

common risk in a high risk of thromboembolism
patients with popliteal 50% of popliteal aneurysms are
aneurysms? What bilateral
additional findings may Approximately 25% of patients with
be seen in patients with popliteal aneurysms also have an aortic
popliteal aneurysm? aneurysm (<10% of patients with aortic
aneurysms have popliteal aneurysms)
How often should Q 15 min × 2, Q 30 min × 6, Q hourly
vitals, neurovascular × 16
checks, and groin
check be performed
following mechanical
thrombectomy for
stroke?
What is the 90-day Very broad range, 8–77%, with half
stroke risk following occurring within the first 7 days
TIA? 50% of those who experience a TIA
will have a stroke within 1 year
15% of all strokes are heralded by a
TIA
During ultrasound TIPS stenosis is marked by globally
evaluation of a TIPS, decreased velocity (< 40–60 cm/s)
what are normal within the shunt and focally increased
expected flow velocity (> 200 cm/s) at the point of
velocities? stenosis
What is Kasabach-­ Kasabach-Merritt syndrome
Merritt syndrome? (hemangioma thrombocytopenia
syndrome) is found in infants with
large, highly vascular hemangiomas and
is responsible for thrombocytopenia,
microangiopathic hemolytic anemia,
and consumptive coagulopathy
 3 Morning Rounds 19

What is May-Thurner Classic May-Thurner syndrome is

syndrome? compression of the left common iliac
vein (CIV) by the right common iliac
artery resulting in decreased CIV
vessel diameter by 50%. A physiologic
pre-stenotic to post-stenotic gradient
of 2–3 mmHg gradient has also been
suggested but has not been validated.
Treatment includes clot lysis and
stenting
What are expected MALS is characterized by extrinsic
angiographic findings compression of the celiac artery by the
in median arcuate median arcuate ligament:
ligament syndrome  During inspiration, as the diaphragm
(MALS)? and abdominal contents move down,
compression on the superior aspect
of the celiac artery by the MAL. The
celiac artery will appear widely
patent on the lateral projection
 During expiration, the diaphragm
and abdominal contents will move up
and worsen the effect compression
on the celiac artery by the MAL,
which will be evident by focal
narrowing on the lateral angiographic
projection
What are typical Diminished distal lower extremity
physical exam findings pulses with plantar or dorsiflexion
in popliteal artery
entrapment syndrome
(PAES)?
What is a normal ≤ 6 mmHg. Symptomatic manifestations
portal-systemic of portal hypertension are usually not
gradient? encountered until > 10 mmHg.
At what portal-systemic ≥ 12 mmHg
gradient do patients
usually experience
variceal bleeding?
(continued)
20 C. Molloy and J. Huang

What are the Milan Milan Criteria used in patients with

criteria? hepatocellular carcinoma to assess
suitability for liver transplantation:
 A single tumor with diameter ≤5
cm, or up to 3 tumors (each tumor
diameter must be ≤3 cm)
 No extrahepatic involvement
 No portal vein extension
How many MELD After 6 months within Milan criteria,
“exception points” HCC patients are given a minimum
do hepatocellular of 28 MELD points (however these
carcinoma (HCC) “exception points” are subject to
patients receive (while change in future iterations of OPTN
waiting for liver transplant protocol)
transplant)?
What medications Lactulose (15–45 ml every 8–12 h)
may be administered titrated to 3 soft bowel movements per
to reduce hepatic day
encephalopathy in Rifaximin (550 mg orally BID)
patients with cirrhosis
and liver failure?
Chapter 4
Afternoon Rounds
Chris Molloy and Junjian Huang

In some facilities, afternoon rounds may be an opportunity

to discuss discharge planning or post-procedural
dispositions.

What does qSOFA score Quick sequential organ failure

evaluate and how do you assessment score (qSOFA) score
calculate it? of 2 (or more) at the onset of
infection is associated with a
greater risk of death or prolonged
intensive care unit stay.
qSOFA score includes:
 Altered mental status
 Respiratory rate > 22
 Systolic BP ≤ 100
(continued)

C. Molloy (*)
Department of Vascular and Interventional Radiology, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
J. Huang
Department of Vascular and Interventional Surgery, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 21

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_4
22 C. Molloy and J. Huang

What is SIRS and what are Systemic inflammatory response

the components of SIRS syndrome (SIRS) describes whole
score? body response to infectious or
noninfectious insult. Note that
the JAMA SOFA/qSOFA report
advocates replacing SIRS with
SOFA in specific situations:
 Temperature < 36 °C or > 38 °C
 Heart rate > 90 bpm
 Tachypnea > 20 respirations per
minute
 WBC < 4000 cells/mm3
or > 12,000 cells/mm3
A patient that your team The diagnosis is probably heparin-­
treated for PAD now has induced thrombocytopenia (HIT).
a rapid decline in platelets The treatment is to discontinue
from 200,000 to 75,000. heparin products. Maintain
What is the most likely anticoagulation with non-heparin
diagnosis and how do you products, such as direct thrombin
proceed? inhibitors (IV argatroban or PO
dabigatran). Warfarin should not
be started until platelets recover to
≥ 150 × 109/L.
Your team placed an Hemoglobin, hematocrit, and
infusion catheter in order fibrinogen q6h. If the fibrinogen
to perform prolonged tPA level drops to < 150 (or decreases
infusion to treat acute by 1/2), the tPA infusion may
pulmonary embolism. The be decreased by 1/2 dose. If the
plan is to keep the catheter fibrinogen level is < 100 or the
in place for at least 12 h. patient has severe bleeding, the
What labs should you order infusion is discontinued
to follow this patient?
What recommendations Smoking cessation
and medications should Supervised exercise program
be considered in PAD Aspirin or clopidogrel (Plavix)
patients? Beta-blocker
ACE inhibitor
High-intensity statin
Cilostazol
 4 Afternoon Rounds 23

What are the goals of To reduce cardiovascular morbidity

medical therapy after and mortality, as well as reduce
intervention for limb adverse limb outcomes
ischemia?
What are the main findings Supervised exercise and stent had
and recommendations from better 18-month outcomes than
the CLEVER trial? optimal medical care. Intermittent
exercise and rest improves oxygen
extraction. Exercise also improves
endothelial function, blood
pressure, cholesterol, glycemic
control, and overall functional
capacity. Supervised exercise
involves 30–45 min sessions, 3 times
a week, for 12 weeks. Patients are
instructed to walk until there is
pain, persist as much as possible,
and then rest. Only walking
minutes are counted. Supervised
exercise therapy improves walking
time, functional status, and quality
of life. It also increases the size and
number of collaterals.
What was the conclusion 287 studies involving 135,000
of the 2002 Antithrombotic patients in comparison with
Trialists’ Collaboration antiplatelet therapy vs. control and
for high-risk patients for 77,000 patients in comparison with
occlusive vascular events different antiplatelet regimens.
(acute MI or ischemic Aspirin is protective in high-risk
stroke, unstable or stable patients and low dose (75–150 mg
angina, previous MI, stroke daily) is effective for long-term use,
or cerebral ischemia, PAD, but in an acute setting, an initial
or atrial fibrillation)? loading dose of at least 150 mg may
be required
(continued)
24 C. Molloy and J. Huang

What were the findings of This was a multicenter,

the “Clopidogrel versus multinational, randomized, double-­
Aspirin in Patients at blind, parallel group analysis of
Risk of Ischemic Events” 19,185 patients with atherosclerotic
(CAPRIE) study? disease (recent ischemic stroke,
recent MI, or symptomatic PAD)
with primary combined endpoint
of ischemic stroke, MI, or vascular
death and 1.9-year mean follow-up:
 Approximately 9% additional
relative risk reduction in
primary combined endpoint with
clopidogrel versus aspirin
 Approximately 9% additional
relative risk reduction in
cumulative rehospitalization rate
for ischemia or bleeding with
clopidogrel versus aspirin
What were the findings Symptomatic PAD (and clinically
of the EUCLID study significant ABI or prior lower
(Ticagrelor versus extremity revascularization) was
Clopidogrel in Symptomatic randomized to ticagrelor 90 mg
in Peripheral Artery twice daily (n = 6930) versus
Disease)? clopidogrel 75 mg daily (n = 6955):
 Ticagrelor was not superior to
clopidogrel in preventing major
adverse cardiac events
 Acute limb ischemia and major
bleeding were similar between
treatment groups
 4 Afternoon Rounds 25

The purpose of the Randomized, placebo-controlled

COMPASS trial was to study of 27,400 patients with CAD,
evaluate whether treatment carotid stenosis, and PAD with
with rivaroxaban and primary endpoints of MI, ischemic
aspirin or rivaroxaban stroke, cardiovascular death, and
alone is better than aspirin major bleeding:
alone in prevention of  In patients with atherosclerotic
MI, ischemic stroke, or cardiovascular disease,
cardiovascular death in rivaroxaban plus aspirin resulted
patients with coronary or in lower rates of composite
peripheral arterial disease. cardiovascular endpoint events
What medical therapy but higher rates of major
would you recommend for bleeding than with aspirin alone
a patient with history of  Major adverse limb events were
revascularization and low increased in those with history of
bleeding risk? prior revascularization compared
to claudicants or asymptomatic
PAD
 In subgroup analysis, those with
polyvascular disease benefit the
most
What were the findings This was a randomized, double-­
of Evaluating Adverse blind, triple dummy, placebo-­
Events in a Global controlled, and active-controlled
Smoking Cessation Study trial (nicotine patch 21 mg/day
(EAGLES)? with taper) of those receiving
varenicline 1 mg PO BID or
bupropion 150 mg PO BID:
 The study did not show
a significant increase in
neuropsychiatric adverse events
attributable to varenicline or
bupropion relative to nicotine
patch or placebo
 Varenicline was more effective
than placebo, nicotine patch, and
bupropion in helping smokers
achieve abstinence, whereas
bupropion and nicotine patch
were more effective than placebo
26 C. Molloy and J. Huang

What were the findings 9541 patients at least 55 years old

of the “Heart Outcomes with history of vascular disease
Prevention Evaluation” or diabetes and at least one other
(HOPE) trial? risk factor randomized in a double-­
blind manner to ACE inhibitor
(ramipril) or placebo for 4–6 years
with primary outcome of combined
rate of cardiovascular death, MI, or
ischemic stroke:
 At the end of 4 years, primary
endpoint was 22% lower in
ramipril group than placebo
group
Chapter 5
Taking Call
Chris Molloy and Junjian Huang

The “call” experience will vary and is based on the institution

and the attending physician. In most institutions, “call” means
covering the service after-hours and on weekends. The subin-
tern may hold the call pager and answer any immediate ques-
tions or see consults. It helps to understand what is a
medically emergent case, because in many institutions the
rest of the call team (nurse, scrub tech, etc.) will not be acti-
vated and the procedure will not be performed unless the
case is a medical emergency. The individual taking call should
be comfortable with routine postoperative care, management
of pain and complications, as well as handling emergent con-
sults in the fields of trauma, emergent ischemia and hemor-
rhage, thromboembolic disease, as well as infection.

C. Molloy (*)
Department of Vascular and Interventional Radiology, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
J. Huang
Department of Vascular and Interventional Surgery, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 27

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_5
28 C. Molloy and J. Huang

Describe how Position the patient in the supine position.

to obtain and Measure the bilateral brachial blood
calculate ankle-­ pressures and measure the bilateral ankle
brachial index blood pressures. Calculate the highest
(ABI)? brachial pressure divided by the ankle blood
pressure to determine the ABI
How is the ABI ABI range
interpreted and 0.9 – 1.2: Normal range
what ranges are 0.8 – < 0.9: Mild arterial disease
abnormal? 0.5 – < 0.8: Moderate arterial disease
< 0.5: Severe arterial disease
How do you In diabetics, the ABI may be spuriously
explain normal or elevated due to medial calcific sclerosis
elevated ABIs in (Mönckeberg sclerosis). In this scenario, toe-­
a diabetic patient brachial index (TBI) and toe pressures are
with vascular more reliable measures of arterial perfusion.
claudication?
What is the
National Institutes
of Health Stroke
Scale (NIHSS)?
 5 Taking Call 29

What diagnosis Acute aortic dissection

should be
considered if you
see the “floating
viscera sign”?
What are the acute 1. Acute aortic dissection
aortic syndromes? 2. Intramural hematoma
3. Penetrating atherosclerotic ulcer
What are the Ascending aorta diameter > 5 cm
predictors of Hematoma diameter > 2 cm
mortality in Pericardial effusion
patients with
aortic intramural
hematoma?
What types of Acute hemorrhage (often visceral bleed
trauma cases may or pelvic trauma). Bilateral selective
be IR-related arteriograms in the internal iliac arteries
emergencies? with multiple obliquities are necessary to
clear the pelvis.
What kidney cases Pyonephrosis, acute urinary obstruction,
are considered Page kidney
IR emergencies
requiring urgent
intervention?
What are the To relieve obstruction, create urinary
indications for diversion, pyonephrosis, to establish access
percutaneous for other genitourinary procedures
nephrostomy?
What lung/ Massive or submassive PE, massive
pulmonary cases hemoptysis
are considered
IR emergencies
requiring urgent
intervention?
(continued)
30 C. Molloy and J. Huang

What Rutherford Class IIb requires immediate intervention

classifications for limb salvage. Classes I and IIa are
of acute limb salvageable with urgent intervention.
require immediate
intervention?
What are the “Yin-yang” sign on color Doppler
sonographic To-and-fro flow within the pseudoaneurysm
findings of arterial neck on Doppler waveform
pseudoaneurysm?
What are the Non-compressible veins
sonographic Echogenic thrombus visualized within the
findings of deep vein lumen
acute deep vein Absence of color flow within the vein lumen
thrombosis? Absence of respiratory phasicity suggests
a more central venous obstruction, and
further evaluation with CT venogram or MR
venogram is warranted
What IR Bronchial artery embolization
procedure is
usually performed
for massive
hemoptysis?
Where do the The left bronchial arteries (typically
bronchial arteries two) usually originate directly from the
usually originate descending aorta. The right bronchial artery
from? Where can (typically one) arises from a right posterior
the bronchial intercostal or left bronchial artery. They can
artery originate also originate from internal mammary and
from in normal subclavian arteries.
anatomic variants?
What is the corona Named the “crown of death,” an anatomic
mortis? variant artery, which connects the obturator
artery via the external iliac artery. It may be
injured during pelvic trauma and surgery or
may cause type 2 endoleak.
Chapter 6
Pre-procedure
Chris Molloy and Junjian Huang

According to SIR The below 2019 updates to periprocedural

guidelines, how bleeding risk and recommendations should be
is procedural reviewed prior to the IR rotation:
bleeding risk  Society of Interventional Radiology
stratified? Consensus Guidelines for the Periprocedural
Management of Thrombotic and Bleeding
Risk in Patients Undergoing Percutaneous
Image-­Guided Interventions—Part I: Review
of Anticoagulation Agents and Clinical
Considerations
 Society of Interventional Radiology
Consensus Guidelines for the Periprocedural
Management of Thrombotic and Bleeding
Risk in Patients Undergoing Percutaneous
Image-Guided Interventions—Part II:
Recommendations

(continued)

C. Molloy (*)
Department of Vascular and Interventional Radiology, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA
J. Huang
Department of Vascular and Interventional Surgery, Kaiser
Permanente Los Angeles Medical Center, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 31

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_6
32 C. Molloy and J. Huang

What value INR ≤1.5 prior to a high-risk procedure

should a patient’s
INR be prior to a
high bleeding risk
procedure?
What value should Platelets ≥50,000/μL: if platelets ≤50,000/μL,
the patient’s transfuse prior to a high-risk procedure
platelets be prior
to a high bleeding
risk procedure?
Some patients Erythropoietin and desmopressin
refuse transfusion
of blood products
due to religious
preferences.
What adjunctive
medications may
be considered
to improve
hemoglobin levels
and decrease
bleeding in
patients who
refuse blood
transfusions?
What agent can Desmopressin. Dose 0.3 μg/kg is given
be administered intravenously
to improve
platelet function
in patients with
uremic platelet
dysfunction? At
what dose?
What lab is used Anti-factor Xa activity
to monitor low
molecular weight
heparin therapy?
 6 Pre-procedure 33

How long Hold LMWH for 24 h or usually 2 doses prior

should LMWH to high-­risk procedures
be held prior
to a procedure
considered high
bleeding risk?
What is the Though variable between institutions, generally
minimum number two unique identifiers should be used during
of unique patient the pre-­procedural timeout, for example, the
identifiers that MRN and date of birth
should be used
during the pre-­
procedural
timeout?
 Part II
Vascular Site
Chapter 7
Patient Preparation
Matthew Czar Taon

In patients undergoing According to the 2019 Society of

procedures with a Interventional Radiology Consensus
high risk of bleeding, Guidelines for the Periprocedural
how long should Management of Thrombotic and
clopidogrel and Bleeding Risk in Patients Undergoing
aspirin be withheld Percutaneous Image-Guided
prior to procedure? Interventions, in procedures associated
with a low risk of bleeding, clopidogrel
does not need to be withheld. In
procedures associated with a high risk of
bleeding, clopidogrel should be withheld
for 5 days.
In procedures associated with a low risk
of bleeding, aspirin does not need to be
withheld. In procedures associated with
a high risk of bleeding, aspirin should be
withheld for 3–5 days.
(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 37

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_7
38 M. C. Taon

The off-label use Desmopressin (DDAVP) 0.3 mg/kg. It

of what medication reaches maximal effect 30–60 min after
has been shown to administration.
reduce bleeding time
and complications in
uremic patients?
When administering Activated clotting time (ACT) with a
periprocedural point-of-care device.
prophylactic The activated clotting time (ACT) is
antithrombotics for an assessment of overall coagulation
peripheral arterial and represents the time it takes the
interventions, what whole blood to clot in the presence of
is the recommended an activator. For many interventional
method of procedures, the patient should be
anticoagulation heparinized to maintain an ACT range of
measurement? approximately 250–300 s.
An initiating dose of full-dose
unfractionated heparin for therapeutic
purposes during interventions can be
either empiric or weight based. An
empiric dose is a 5000-unit IV bolus
followed by a continuous infusion
of 1000 units/hour IV. A weight-­
based dosing regimen with a bolus
of 70–100 units/kg, followed by a
continuous 18-unit/kg/hour infusion,
was found to be more effective in
preventing recurrent thromboembolism
when compared with non-weight-based
regimens.
For heparin reversal at the end of the
procedure, 1 mg of protamine will
neutralize approximately 100 units of
heparin.
 7 Patient Preparation 39

In a “dirty” procedure Prophylactic antibiotics should be

that involves entering administered 1 h prior to procedure
an infected purulent and continued for at least 48 h post-­
site, a clinically procedure.
infected biliary or
genitourinary site, or a
perforated viscus, how
long should antibiotics
be administered?

Consent
The ALARA (as low as Minimizing time, maximizing
reasonably achievable) distance, and using shielding.
principle focuses on which
three basic radiation protective
measures?
What is the maximum effective Maximum effective dose for
radiation dose for exposed an exposed radiation worker
radiation workers in a 1-year in any single year is 50 mSv.
and consecutive 5-year period? Maximum effective dose for
an exposed radiation worker in
a consecutive 5-year period is
100 mSv.
What is the principle of using CO2 gas displaces the blood
carbon dioxide (CO2) as a and produces a negative
contrast agent for angiography? contrast for digital subtraction
imaging.
What medication can be used Flumazenil with an initial dose
to reverse the sedation effects of 0.2 mg IV administered over
of benzodiazepines? 15 s to 1 min. Repeat dosing
may be necessary since the half-­
life of flumazenil is shorter than
that of most benzodiazepines.
(continued)
40 M. C. Taon

30-day, 3-month, and 6-month Patients with MELD > 18 have a

mortality after transjugular significant increase in mortality
intrahepatic portosystemic when compared to patients with
shunt (TIPS) is significantly MELD less than or equal to 17.
increased after what Model The MELD score was initially
for End-Stage Liver Disease developed to predict short-term
(MELD) score? survival after TIPS and was
subsequently found to be useful
for triaging patients for liver
transplantation. Scores ≥ 18 have
been found to be associated with
1-month and 3-month mortality
of 18% and 35%, respectively.
What are the Anesthesia Though variable depending on
Society of America (ASA) institution, 6 h fasting for solids
requirements for fasting prior and 2 h fasting for liquids.
to moderate sedation?

Contrast Allergy Prophylaxis

What does the A combination of 12–13 h of steroids

American College of and antihistamine administration.
Radiology recommend A common regimen includes 50-mg
for contrast allergy prednisone 13, 7, and 1 h before contrast
prophylaxis? administration and 50-mg Benadryl 1 h
prior to contrast administration.
Chapter 8
Running the Table
Matthew Czar Taon

The number of viable The number of persons present in the

airborne bacteria in a operating room. This underscores the
surgical suite is directly importance of limiting traffic flow
proportional to what through the angiography suite only to
aspect of the operating necessary tasks.
room?
According to The recommended time frame is less
consensus, what is than 1 h, preferably immediately
the recommended before the procedure.
time frame between
preparation of the sterile
instrument back table
and the use of the back
table?
What is considered the Hand hygiene
most important step in
reducing the spread of
infection?
(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 41

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_8
42 M. C. Taon

When performing a The Centers for Disease Control and

procedure that involves Prevention (CDC) recommends that
catheter insertion, how a sterile drape should be large enough
long should a sterile to cover the entire patient and any
drape be? hardware attached to the operating
table.
Regarding pre-­ 70% alcohol
procedural skin
preparation, if a
patient is sensitive
to chlorhexidine and
povidone-iodine
solution, what solution
can be used to cleanse
the skin?
When injecting contents Every syringe on the table should be
from a syringe into a labeled and, when injecting, should
catheter, how should the be held upright to ensure that any air
syringe be prepared and will travel toward the syringe plunger,
what position should the away from the catheter.
syringe be held?
When preparing contrast Diluting contrast into a 1:1 contrast to
syringes for a procedure, saline ratio. In extremities, a 1:3–1:5
what is an effective contrast to saline dilution ratio can be
method for reducing enough to provide diagnostic images.
iodinated contrast dose? In the abdomen, a 1:2 contrast to
saline dilution ratio can be enough
to provide diagnostic images if the
patient is able to hold respiration
adequately and if they are of the
correct body habitus.
Chapter 9
Choice of Access
Matthew Czar Taon

How does real-time Real-time ultrasound-guided

ultrasound-guided vascular vascular access provides active
access compare to the use visualization of the target, access
of anatomic landmarks or vessel, as well as visualization and
vessel palpation in terms of avoidance of surrounding, vital
success rate, time to access, structures.
and complication rates?
What Barbeau test Type D Barbeau waveform. This
waveform is considered a waveform appears as a flat line
contraindication to radial on the pulse oximeter and persists
artery access? beyond 2 min, indicating no
collateral supply from the ulnar
artery to the radial side of the
hand.

(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 43

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_9
44 M. C. Taon

Prior to transradial artery Nitroglycerin 200 mcg, verapamil

interventions, a combination 2.5 mg, and heparin 2500 units
of what medications can
be mixed and prepared
to be infused through the
access sheath in an attempt
to prevent radial artery
occlusion and spasm?
Where is the optimal access The common femoral artery should
of the common femoral be accessed at the level of the
artery (CFA)? femoral head. Access above the
femoral head risks retroperitoneal
hemorrhage, and access below
the femoral head risks thigh
hematoma/pseudoaneurysm.
What are methods to Arteries demonstrate pulsatility.
differentiate a vein versus Veins demonstrate compressibility.
artery on ultrasound? Veins have valves. The common
carotid artery is located medial
to the internal jugular vein. The
common femoral artery is located
lateral to the common femoral vein.
Assess the direction of Doppler
flow.
What is a proposed benefit Ipsilateral, antegrade access
to ipsilateral, antegrade provides a short working length,
access of the common which can improve steerability and
femoral artery (CFA) to pushability of wires and catheters.
treat infrainguinal arterial Also, this technique avoids
disease? aortoiliac crossover, which can be
challenging if there is a steep iliac
bifurcation, tortuous or stenotic
iliac arteries, or presence of an
aortoiliac endoprosthesis.
 9 Choice of Access 45

When accessing a Thrombus within the segment of

thrombosed hemodialysis overlapping sheath tips would
fistula or graft, why is it be inaccessible to catheter
important to ensure that the thrombectomy.
antegrade and retrograde
sheaths face each other but
do not overlap?
In patients with underlying Central venous catheterization
left bundle branch may result in transient right bundle
block, central venous branch block. In a patient with pre-­
catheterization may result existing left bundle branch block,
in what lethal dysrhythmia? this may result in life-threatening
complete heart block. Techniques
to mitigate risks include using a
guidewire marked at every 10 cm,
to facilitate more careful guidewire
manipulation and preparing
a noninvasive transcutaneous
pacemaker at bedside for patients
with known left bundle branch
block. If transcutaneous pacing
is not successful, a transvenous
pacemaker may be necessary. If
the iatrogenic injury leads to a
persistent third-degree AV block,
permanent pacemaker placement
should be considered.
What are the three Transarterial embolization of
endovascular methods to the inflow and outflow arteries
access and treat type II supplying and draining the
endoleaks? endoleak, translumbar direct
percutaneous puncture of the
aneurysm sac with embolization,
and transcaval puncture of the
aneurysm sac with embolization

(continued)
46 M. C. Taon

Pedal access should be Claudicants with single vessel

avoided in which type of runoff, since pedal access can
patients? compromise the only remaining
arterial supply to the foot
What are the relative Vascular access above the inguinal
contraindications to using ligament, small (<5 mm) vessel
vascular access closure size, large arteriotomy size unless a
devices? pre-close technique is performed,
severe atherosclerosis, need for
repeat arterial access, and allergy to
a device component
Chapter 10
Seldinger Technique
Matthew Czar Taon

Describe the Obtain vascular access with a trocar needle,

Seldinger insert soft curved tip guidewire, secure
technique. guidewire and remove trocar needle,
exchange a sheath/cannula/catheter over
the guidewire into the lumen or cavity, and
withdraw guidewire. Seldinger described
this technique as “needle in, wire in, needle
off, catheter on wire, catheter in, catheter
advance, wire off.”
What are potential Failed access, hemorrhage, infection, air
complications embolus, guidewire embolus, injury to
associated with adjacent tissue, and pseudoaneurysm
the Seldinger formation
technique?
What units are Gauge; increasing gauge numbers denote
percutaneous decreasing wire diameters. In general, an
needle diameters 18-gauge needle accepts a 0.035–0.038-inch
measured in? guidewire, and a 21-gauge needle accepts a
0.018–0.021-inch guidewire.

(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 47

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_10
48 M. C. Taon

What units Inches. This correlates with the units of wire

are catheter diameters.
inner diameters
measured in?
What units are Inches
wire diameters
measured in?
What are the units Centimeters
of catheter length?
Sheath French Inner diameter. Select sheath size based
sizes refer to what on the goal of the procedure and what
measurement? interventional device (balloon or stent) will
be used.
The outer diameter Sheath outer diameter, and therefore size
of a sheath is how of arteriotomy or venotomy is 1.5–2-French
much bigger than sizes bigger than that of its inner diameter.
its inner diameter?
Chapter 11
Guidewires
Matthew Czar ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­Taon

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 49

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_11
 50
What are the Core, tip, body, and coating. Guidewires can be made of various materials including stainless steel,
four major nitinol, platinum, or other alloy metals. The core of a guidewire, referred to as a mandrel, is composed
components of a stiff, inner, central wire upon which subsequent layers are wound. The shaft of wires can have
of a different degrees of stiffness and facilitates structural integrity during wire use. The stiffness of the
guidewire? shaft is primarily attributed to the metal type and thickness of the core.
The distal end of the guidewire is referred to as the tip. If the core extends up to the tip of the wire, it
M. C. Taon

is referred to as a “core-to-tip” design, which provides good tactile feedback, tip control, tip load, and
torqueability. If the core does not reach the distal tip of the wire, a small, flat metal ribbon provides
the continuity to the distal most tip, and is referred to as a “shaping ribbon” design. This design
provides good wire shape retention, softness, and flexibility of the tip, but with decreased tip torque
control. Historically, guidewire designs incorporated a fine “safety wire” along the full length of the
wire to prevent the outer wire coil from uncoiling and breaking off. This precursor to the safety ribbon
design allowed the wire to be shaped but resulted in added tip stiffness. Some wire tips lack a shaping
ribbon altogether resulting in greater wire flexibility and safety but with decreased directional control.
The body of a guidewire includes coils, covers, and sleeves. The body of the guidewire, surrounding the
core, is typically made of coils or polymer (plastic) covering. If a guidewire consists of a polymer cover
along the body but leaves the distal free coils along the tip uncovered, this is referred to as a sleeve.
The spring coil design contributes to a wire’s shapeability, shape retention, and tactile feedback. A
polymer cover design can improve guidewire deliverability but may decrease tactile feedback.
The body of the wire, whether it be a spring coil or polymer cover design, can have an additional
coating. This additional coating can reduce surface friction, improve tactile feedback, and improve
guidewire tracking. Hydrophilic coating attracts water to create a slippery “gel-like” surface for
improved trackability. Alternatively, hydrophobic coating repels water to create a “waxlike” surface
which enhances tactile feedback but decreases slipperiness and trackability.
What is the Both the stiffness and torsional strength of a guidewire are directly proportional to the fourth power
relationship of the core diameter.
between
columnar
strength
(stiffness)
of a wire,
torsional
strength, and
radius of the
wire?
What are the Guidewire stiffness and the coefficient of friction
two factors
of guidewires
that
determine
frictional
resistance?

(continued)
11 Guidewires
51
 52

What is the Inverse relationship. As lubricity increases, tactile feedback decreases.

relationship
between
lubricity of
a guidewire
and tactile
M. C. Taon

feedback?
What is tip Tip load is the measure of how many grams of force (gram-force) are required to buckle a wire tip
load? when forced against a standard surface.
What is Penetration power is calculated as wire tip load divided by wire tip area. Tapered tip wires have
penetration higher penetration power as compared to non-tapered wires, even if tip load is equivalent, given the
power? decreased wire tip area. Also, penetration power can be increased for any wire if there is an over-the-
wire device in place, such as a microcatheter, with minimal wire protrusion.
How does Wires with a long core-to-tip taper provide improved vessel tracking but less support. Wires with a
a long core- short core-to-tip taper provide more support but greater tendency to prolapse.
to-tip taper
compare to
a short core-
to-tip taper
in terms of
support and
trackability?
What is the Hydrophilic coatings attract water to create a “gel-like,” lubricious wire surface. Given the ease
difference of advancement, these carry a risk of dissection or perforation. Hydrophobic coatings repel water
between to create a “waxlike” wire surface with improved tactile feedback but decreased lubricity and
hydrophilic trackability.
and
hydrophobic
wire
coatings?
How long Ideally, an exchange wire should be two times the length of the catheter to maintain wire positioning
should an during catheter exchange.
exchange
wire be in
relation to
the length of
the catheter
being
utilized?
What is the SAFARI refers to subintimal arterial flossing with antegrade-retrograde intervention. It involves
SAFARI obtaining through-and-through wire access in the subintimal space to cross a chronic total lower
technique? extremity arterial occlusion.
11 Guidewires
53
Chapter 12
Catheters
Matthew Czar Taon

What is the Nonselective flush catheters are designed

difference between a to withstand high injection pressures
nonselective (flush) and provide high-flow rate contrast
catheter and a injections with uniform contrast dispersal
selective catheter? and minimal recoil. Selective catheters
are designed to provide improved
torqueability, facilitate cannulation of a
vessel orifice, and obtain distal access.
A guiding catheter is a type of selective
catheter and is constructed to have a larger
inner diameter to assist in delivering and
stabilizing interventional devices.
Generally, what are An outer layer composed of polyurethane
the three layers of a or polyethylene to provide stiffness, a
guiding catheter? middle layer composed of a wire matrix for
torque generation, and a lubricious inner
coating made of polytetrafluoroethylene
(PTFE) to allow for smooth passage of
balloon catheters and stents.
(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 55

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_12
56 M. C. Taon

What are the three A hub for connection; a shaft with varying
basic components of diameter, length, and stiffness; and a soft
a guiding catheter? tip
What is one method The catheter tip is facing the anterior
to determine if position if it turns right with clockwise
a catheter tip is rotation and left with counterclockwise
facing anterior or rotation. The catheter is facing the
posterior? posterior position if it turns left with
clockwise rotation and right with
counterclockwise rotation.
What is the Passive support is dependent on the
difference between inherent physical characteristics of the
passive and active guide catheter wall and the preformed
support methods shape of the catheter. Minimal
to keep a guiding manipulation of the catheter is required.
catheter in position Active support requires operator-­
and to provide a dependent catheter manipulation to seat a
stable platform? catheter beyond the ostium of a vessel or
mold the catheter within the endovascular
space to obtain stable position.
What is the double For catheters at or above the thoracic
flush technique? aorta, a double flush technique is used
to prevent migration of blood clots into
the cerebral circulation. This technique
requires two syringes: one is utilized to
aspirate the catheter with subsequent
disposal of the contents, while the other
syringe is utilized to flush the catheter.
What are the Braided catheters have increased axial
characteristics of a rigidity, have improved stability, are less
braided catheter? vulnerable to kinking or rupture, but have
less ability to be steam shaped.
In general, why To prevent the catheter tip from scraping
must a catheter be the vessel wall and causing dissection or
advanced over a emboli
wire?
 12 Catheters 57

What is a method to Remove the guidewire slowly and drip/

prevent inadvertent inject heparinized saline into the catheter
air embolus from hub during wire withdrawal.
occurring during
guidewire removal
from a catheter?
What is the With a rapid exchange (monorail) system,
difference between the guidewire exits the catheter relatively
a rapid exchange close to the tip of the catheter, allowing
(monorail) system the use of shorter wire lengths and smaller
compared to an wire, catheter, and interventional device
over-the-wire diameters. With an over-the-wire (OTW)
system? system, the guidewire passes through the
entire length of the catheter lumen in a
coaxial fashion.
Chapter 13
Connectors
Matthew Czar Taon

What are examples of Flow switches, metal or plastic

flow-control devices? stopcocks, K-switch valves used
for CO2 angiography, and rotating
hemostatic valves
What is the difference A Luer-lock tip has a collar with an
between a Luer-lock and internal thread and requires twisting
a Luer-slip connection? and locking of the connection tip.
It is used for injections requiring a
secure connection. A Luer-slip tip is
composed of a smooth spigot without
a collar. It requires a friction-fit
connection utilizing push-and-twist
technique. Luer-slip tips are used for
rapid refilling or for tasks involving
multiple adapters.
(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 59

R. Chand et al. (eds.), Essential Interventional Radiology
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60 M. C. Taon

What are the parts of A rotating Luer-lock male connector

a Tuohy-Borst rotating tip, an angled female Luer-lock
hemostatic valve? connection for continuous flush, and
a valve which allows placement of
additional catheters or wires while
preventing backflow of saline flush or
blood
If an air embolus Stop the flush immediately to prevent
is suspected in a additional forward flow of fluid and air
patient with a rotating emboli. Open the rotating hemostatic
hemostatic valve and valve and allow backflow of the blood
saline flush, what can be and air embolus. Immediately place
done to prevent further the patient left side down or head
embolization? down. Air emboli will float to the least
dependent position. The Trendelenburg
position keeps a left-ventricular air
embolus away from the coronary
artery ostia to prevent the occlusion
of coronary arteries. Left lateral
decubitus positioning helps to trap air
emboli in the nondependent segment
of the right ventricle to prevent
flowing into the pulmonary arteries.
The left lateral decubitus position may
also prevent air emboli from passing
through a patent foramen ovale
into the left ventricle where it could
embolize to distal arteries, including
intracranial arteries.
When utilizing a coaxial Avoid thrombus from forming between
catheter combination the outer catheter and inner catheter
with an outer guiding
catheter and smaller
inner catheter/
microcatheter, why
is it recommended to
connect an extra flush
system to the outer
guiding catheter?
 13 Connectors 61

When deploying a To prevent the coil from deploying

detachable coil, why within the hub of the catheter
is it important to
advance the long plastic
introducer completely
into the catheter hub
before advancing the
coil?
What is a problem Oil-based contrast agents such as
that oil-based contrast Ethiodol (Lipiodol) can dissolve or
agents such as Ethiodol crack certain types of plastics and
(Lipiodol) can cause rubber stoppers. Materials made of
when using connectors, polycarbonate are more susceptible
catheter hubs, syringes, to damage by Ethiodol. Metal, glass,
or three-way stopcocks polypropylene, polyamide, and
made of soft plastics? polysulfone materials provide more
durable connections when using oil-­
based contrast agents.
When preparing a Clear air from the bag and tubing prior
heparinized saline to procedure to prevent air embolus.
flush bag and tubing,
what is one of the most
important steps?
What kind of tubing Noncompliant pressure tubing. These
should be used with are designed for high pressures
power injection pumps? and high flow rates. Low-pressure
connection tubing is more compliant
and may burst if used with a power
injector.
Chapter 14
Balloons
Matthew Czar Taon

How is an Method 1: Attach a 50-mL syringe filled with

angioplasty one-half (or one-third dilute contrast to the
balloon angioplasty balloon hub). Aspirate the syringe
prepped? to create a vacuum. Upon release of the syringe
plunger, contrast will replace the air within the
balloon lumen. Repeat several times to maximize
air reduction. Lastly, replace the syringe with an
inflation device containing the same contrast
dilution, via a wet-to-wet connection.
Method 2: A balloon can also be prepped using
a three-way stopcock. Attach an inflation device
containing dilute contrast to a three-way stopcock,
and open the stopcock to aspirate the balloon
lumen. The resulting vacuum draws contrast
from the inflation device into the balloon lumen,
replacing the air within the balloon lumen. Rotate
the stopcock to the open port and expel excess
air from the inflation device. Repeat this process
several times to maximize air reduction. Air within
the balloon lumen must be completely replaced
with contrast to ensure that the entire balloon
lumen can be visualized. Air bubbles can obscure
the image and hide a stenosis.
(continued)
M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 63

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_14
64 M. C. Taon

What is the Nominal pressure is the amount of pressure,

nominal in atmospheres (atms), required to inflate the
pressure? balloon to its labeled diameter.
What is the The pressure level, in atmospheres (atms), a
rated burst balloon can expand to without rupture. The rated
pressure? burst pressure is based in vitro testing. Generally,
at least 99.9% of the balloons (with 95%
confidence) will not burst at or below their rated
burst pressure.
What is the Working range is the inflation range between
working range nominal and rated burst pressure.
of a balloon
catheter?
What is the The surface of the balloon that contacts the vessel
working length wall when inflated
of a balloon
catheter?
What is the Plaque fracture, vessel stretching, and lumen
mechanism expansion. Essentially, plain balloon angioplasty
of plain creates controlled vessel wall ripping of the intima
old balloon and some of media.
angioplasty
(POBA) to
treat an arterial
atherosclerotic
stenosis?
What are the Torsional stress, radial stress, and longitudinal
types of wall stress. Torsional stress is imparted on the vessel
stresses wall through a twisting motion when a balloon
involved unfolds during inflation. Radial stress is imparted
with balloon outwardly on the vessel wall as a balloon unfolds.
angioplasty? Longitudinal stress elongates the vessel wall
during balloon inflation.
 14 Balloons 65

What is the There is a direct relationship between vessel injury

relationship and the rate at which the vessel wall is stretched.
between vessel Slow, low-­pressure inflations tend to minimize
injury and the trauma.
rate of vessel
wall stretching?
What are the Antiproliferative drug and drug-­transferring
two excipient. Antiproliferative drugs include
components paclitaxel and sirolimus which reduce in-stent
of a drug-­ restenosis. Excipients, such as urea and shellac,
coated are polymers that create a matrix which functions
balloon to both retain the drug on the balloon surface
matrix and transfer it to the vascular endothelium. The
coating? molecular characteristics of the excipient influence
the adhesion and diffusion of drugs into the
vascular endothelium.
What are the Flow-limiting dissection, vessel rupture, elastic
complications recoil, and restenosis
associated
with balloon
angioplasty?
Chapter 15
Stents
Matthew Czar Taon

What Balloon-expandable stents demonstrate

characteristics increased radial strength and more
differentiate a predictable placement but are generally
balloon-expandable less flexible compared to self-expanding
stent from a self-­ stents. Balloon-expandable stents are not
expanding stent? recommended at flexion points due to risk
of stent collapse. Self-expanding stents are
highly flexible, can be placed at flexion
points due to their ability to re-expand,
but have a less predictable deployment
compared to balloon-expandable stents.
Additional balloon angioplasty may be
performed after a self-expandable stent
is deployed to obtain better vessel wall
apposition.
(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 67

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_15
68 M. C. Taon

What A covered stent (stent graft) is a metal stent

characteristics lined with polytetrafluoroethylene (PTFE)
differentiate a or Dacron. They can be available in self-­
covered stent from expanding or balloon-expandable platforms.
a non-covered Generally, covered stents require a larger
stent? sheath size compared to non-covered stents.
Covered stents can completely exclude
plaque and thrombus.
How does IVUS is superior to angiography for sizing
intravascular vessel diameters since it provides a two-­
ultrasound dimensional axial view of the vessel lumen
(IVUS) compare and vessel wall. In addition to sizing, IVUS
to contrast can offer much valuable information,
angiography in including plaque characterization, whether
terms of sizing or not atherectomy should be performed
vessel diameters? prior to balloon angioplasty or stent
placement, and after stent deployment to
assess for appropriate wall apposition and
plaque coverage.
In failing dialysis-­ Use of a stent graft is associated with
access grafts, how longer patency and freedom from repeat
does the use of interventions compared to standard balloon
covered stent grafts angioplasty.
compare to balloon
angioplasty in
terms of patency?
What is the Drug-eluting stents work mechanically
mechanism of to treat elastic recoil and dissection and
action of drug-­ molecularly via the antiproliferative drug,
eluting stents to paclitaxel, to mitigate peripheral arterial
treat peripheral disease progression, injury response, foreign
arterial disease? body reaction, and in-stent restenosis.
 15 Stents 69

What are the Venous vessel walls are very thin.

factors that can Veins are inherently compressible.
make venous Venous flow is much slower than arterial
stenting more flow.
challenging? Veins contain valves.
No accurate noninvasive or invasive test
is available to evaluate the hemodynamic
significance of venous outflow obstruction.
The degree of venous stenosis that is
hemodynamically critical is unknown.
Chapter 16
Embolization
Matthew Czar Taon

What are the two general Temporary agents which include

classifications of embolic autologous blood clot and
agents? Gelfoam. Permanent agents
which include coils and vascular
plugs, particulates, and liquid
(alcohol, sodium tetradecyl sulfate
(Sotradecol), cyanoacrylate, and
ethylene vinyl alcohol (Onyx)).
What are the three important Assess the size of the vessel/
aspects to evaluate when vascular bed to be embolized.
choosing an appropriate Determine whether the goal
embolic agent? is temporary or permanent
occlusion. Determine whether the
embolized tissue should remain
viable after embolization.
(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 71

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_16
72 M. C. Taon

Prior to administering NBCA 5% dextrose solution. This

(n-butyl-2-cyanoacrylate) nonionic solution is used instead
glue for embolization, what of an ionic saline flush to prevent
solution should be flushed polymerization of the NBCA
through the microcatheter mixture on contact with residual
to prevent the glue from blood or saline in the catheter
prematurely solidifying tip. Furthermore, injecting
upon contact with an ionic dextrose creates a local nonionic
solution? environment at the catheter tip
which enables more distal NBCA
progression.
Prior to administering Dimethyl sulfoxide (DMSO).
ethylene vinyl alcohol Onyx is an ethylene vinyl alcohol
(Onyx) for embolization, copolymer dissolved in the
what solvent should be organic solvent dimethyl sulfoxide
flushed through the catheter (DMSO) opacified with tantalum
to prevent precipitation powder. Once it comes into
within the lumen of the contact with an ionic solution,
microcatheter? such as blood, the DMSO
dissipates and the Onyx solidifies
into a spongy, cohesive embolic
material.
Prior to preparing a catheter The microcatheter must be
with DMSO, what aspect DMSO compatible. DMSO
of the catheter should be can break down many plastic
verified? materials.
What is the relationship In general, the smaller the embolic
between embolic agent size agent, the greater the likelihood
and likelihood of organ of organ ischemia. Smaller
ischemia? embolic agents are able to flow
more distally into arterioles and
capillary beds, thereby increasing
risk of necrosis. The larger the
particle size, the less likely the risk
of ischemia given the presence of
collateral arterial flow.
 16 Embolization 73

What is nontarget Migration of the embolic device

embolization? or material from the intended
target artery into an undesired
artery due to reflux or unintended
catheter movement.
When performing bronchial Any arterial supply to the spinal
artery embolization, what cord, specifically the anterior
are the critical vessels to be spinal artery, since nontarget
aware of? embolization of the anterior spinal
artery can cause paraplegia.
What are the most important Target vessel diameter
properties of embolization Configuration (tertiary
coils? configuration, loop diameter, and
length)
Stiffness
Volume (packing density)
Define coil packing density. Packing density is defined as the
number of coils multiplied by
coil volume divided by aneurysm
volume. High packing density
and low residual aneurysm
volume decrease the likelihood of
aneurysm recanalization.

Further Reading
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Boyce JM, Pittet D. Guideline for hand hygiene in health-care set-
tings: recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HICPAC/SHEA/APIC/
IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol.
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Brunicardi F. Schwartz’s principles of surgery. 9th ed. McGraw Hill;

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Chan D, Downing D, Keough CE, et al. Joint practice guide-
line for sterile technique during vascular and interventional
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Interventional Radiological Society of Europe and the Canadian
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Doby T. A tribute to Sven-Ivar Seldinger. AJR Am J Roentgenol.
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tribution with changing coil stiffness and length in intracranial
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Ginsburg M, Lorenz JM, Zivin SP, Zangan S, Martinez D. A practical
review of the use of stents for the maintenance of hemodialysis
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Goldfarb S, Mccullough PA, Mcdermott J, Gay SB. Contrast-­induced
acute kidney injury: specialty-specific protocols for interven-
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tional radiology, diagnostic computed tomography radiology,

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Hankey GJ. How I interpreted the randomised trials of carotid
angioplasty/stenting versus endarterectomy. Eur J Vasc Endovasc
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tional procedures. Semin Intervent Radiol. 2010;27(4):368–73.
Kandarpa K, Machan L. Handbook of interventional radiologic
procedures. Lippincott Williams & Wilkins; 2011.
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niques: snorkels, chimneys, periscopes, fenestrations, and branched
endografts. Cardiovasc Diagn Ther. 2018;8(Suppl 1):S175–83.
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 Part III
Vascular Disease
Chapter 17
Abdominal Aortic
Aneurysms
Dania Daye

Evaluating Patient

What are the Midline palpable pulsatile abdominal mass

findings of AAA
on physical exam?
What is the > 3 cm or 1.5x the normal diameter
diameter that is
used to define an
AAA?
Who should be The USPSTF recommends onetime
screened for ultrasound screening of men between the
AAA? ages of 65 and 75 with a smoking history.
The USPSTF also recommends selective
onetime ultrasound screening of men aged
65–75 based on patient’s medical history,
family history, and risk factors.
The USPSTF states that data is insufficient
to recommend AAA screening for women
with and without smoking history.
(continued)

D. Daye (*)
Department of Radiology, Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 81

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_17
82 D. Daye

What study is Ultrasound

used to screen a
patient for AAA
and follow the
aneurysm size over
time?
What study should CT with contrast in usually recommended.
be ordered if an However, a non-contrast CT can be
AAA leak or sufficient if there is concern for contrast-
impending rupture induced nephropathy.
is suspected? Abdominal CT allows differentiating
ruptured from non-ruptured aneurysms,
allows the identification of the extent of the
aneurysms, and provides important anatomic
information to determine suitability for
endovascular repair.
What are the signs Retroperitoneal hematoma or stranding.
of abdominal Indistinct aortic wall or loss of fat plane
aortic rupture on between aortic wall and surrounding tissues.
CT? The “draped aorta” sign is an inseparable
tissue plane between a concave posterior
aorta and the adjacent lumbar vertebral
body. It is associated with impending
or contained rupture. Retroperitoneal
fibrosis may also cause loss of tissue
plane distinction but often pulls in the
ureters medially (aneurysm will push
them out) and contributes to upstream
hydroureteronephrosis, as well as often
narrows the aorta and IVC.
Contrast extravasation.
What is the Abdominal pain, hypotension, and pulsatile
presentation triad abdominal mass
of a patient with a
leaking AAA?
 17 Abdominal Aortic Aneurysms 83

What medical Statins: Decrease C-reactive protein (CRP)

therapy may a and matrix metalloproteinase-A (MMP-A)
patient with AAA Tetracyclines: Inhibit MMP-9
be on?  Aneurysms demonstrate decreased growth
rates at 6 and 12 months.
ACE-I: Decrease risk of rupture
ARB: Decrease rate of formation and
expansion

High Yield History

What factors are Smoking, increasing age, coronary artery

associated with disease, high cholesterol, hypertension,
AAA? peripheral vascular disease, and family history
What are Rupture and distal embolization
the major
complications of
AAA?
What are the risk Large diameter (> 5 cm), recent rapid
factors that are expansion, poorly controlled hypertension,
associated with and COPD
AAA rupture?
What is the most Atherosclerosis. AAA is the result of a
common etiology combination of inflammation, smooth muscle
of AAA? cell apoptosis, and extracellular matrix
protein degeneration. This ultimately results
in subintimal fibrosis and decreased delivery
of oxygen and nutrients to the aortic wall.
Combined with shear stress of hypertension
on the vessel wall and within the adventitial
vasa vasorum, gradual wall degeneration and
expansion occur.
84 D. Daye

Indications/Contraindications

When is an Diameter > 5.5 cm (male) or > 5.0 (female),

aneurysm recent rapid aneurysm expansion (> 5 mm in
repair 6 months or 10 mm per year), patient symptoms,
indicated? and AAA leak or rupture
Earlier repair may be indicated in the presence
of the following:
 Inheritable condition; intervene at diameter
> 5.0 cm (male) or > 4.5 (female).
 Saccular aneurysm.
 Presence of penetrating atherosclerotic ulcer.
 Presence of pseudoaneurysm.
 Presence of thrombotic or embolic
complications.
 Signs or symptoms of infection or
inflammation.
 Presence of coexisting iliac disease.
What are Open surgical repair (mortality as high as
the available 7% and morbidity as high as 50% with open
treatment elective repair)
options for Patients with cardiac, pulmonary, or renal
AAA? dysfunction can pose high operative and/or
anesthesia risk.
EVAR
Who are ideal Those with infrarenal aneurysms. Juxta-­
candidates for renal aneurysm risk graft occlusion of the
EVAR? renal arteries. Juxta-renal AAA is defined
as involving the infrarenal abdominal aorta
adjacent to or within 1 cm of the lower margin
of the renal artery origins. Accessory renal
arteries should be identified as coverage may
lead to infarction of part of the kidney, and/or
lead to a path for future endoleak.
Access vessel large enough to accommodate
stent graft delivery system (6–8 mm).
Non-tortuous vessels.
Patients in whom the IMA is not the
predominant blood supply to the colon (as may
be seen in the setting of significant narrowing of
the SMA).
 17 Abdominal Aortic Aneurysms 85

Relevant Anatomy

What is a unique The number of collagen layers in the

change of the aortic media decreases. The size and number of
wall as it descends adventitial vasa vasorum also decrease.
from the thorax to
the abdomen?
What is the Aneurysm expansion is proportional
pathophysiology to the degree of wall stress and
of aneurysm inversely proportional to wall thickness.
formation? Degenerative thinning of the media is
seen. Aneurysmal walls demonstrate
decreased number and degraded
organization of concentric smooth muscle
cells and elastic lamina. Fragmented
collagen is also seen.
Where are most 95% of AAA are located below the renal
AAAs located? arteries (infrarenal). Up to 40% of AAAs
are associated with iliac artery aneurysms,
which may require the placement of a
bifurcated aortic endograft.
What is the Localized dilation of all three layers of a
definition of a true vessel
aneurysm?
What is the most Fusiform
common shape of
an atherosclerotic
aneurysm?
What is the most Mycotic aneurysms are most often
common shape of a pseudoaneurysms and saccular in structure.
mycotic aneurysm? Blood culture is positive 50% of the time
(approximately 50% S. aureus, frequently
salmonella).
Can the size of an No. Large aneurysms often have a mural
aortic aneurysm be thrombus. With only the lumen opacified,
reliably evaluated by the outer size of the aneurysm cannot be
angiography? appropriately evaluated.
86 D. Daye

Relevant Materials

What are the types Straight

of stent graft that Tapered
are available? Bifurcated
Fenestrated
Branched
What are the A delivery system for graft introduction and
general three deployment
components of an A high radial force, self-expanding metallic
endoprosthesis stent framework
device?  Supports and allows for vascular
attachment
Graft fabric that excludes the aneurysm and
serves as a new conduit for blood flow
What is the most Bifurcated stent graft
commonly used
device to repair an
AAA?
Which features of At least 15 mm in length
the aneurysm neck Non-aneurysmal (18–32 mm in diameter
are suitable for with parallel walls)
EVAR? Angled less than 45°
Relatively free of major calcification or
thrombus
What is the 10–20% greater than the diameter of the
recommended implantation site
diameter of a stent
graft?
What is an The common femoral artery, external iliac
important artery, and common iliac artery diameters
anatomic should all be measured from inner wall
consideration to inner wall on axial CT and should be
for access compatible with accommodating 16–22
when planning Fr introducer sheaths for delivery of
endovascular AAA endografts.
repair?
 17 Abdominal Aortic Aneurysms 87

General Step by Step

What are the general, Imaging and planning

overall steps involved Graft and patient selection
with any AAA patient The EVAR procedure
scheduled to undergo Post-procedure surveillance
EVAR? Management of EVAR-related
complications
What is the usual access Bilateral common femoral arteries
used in EVAR?
What type of catheter Calibrated/marker pigtail or straight
is typically first flush catheter
introduced?
Where should the first Lowest renal artery origin
marker on the catheter
be positioned for length
measurements?
Once the stent graft At the level of the lowest renal artery
device is introduced over
a superstiff wire, where
is the superior end of the
endograft positioned?
When placing a Preserve hypogastric artery flow.
bifurcated stent graft, Limbs should terminate within 1 cm of
what is the purpose of the hypogastric artery.
performing a retrograde If a suitable distal landing zone is not
angiogram at the bottom present in the common iliac artery,
of the graft limbs? limbs may need to be extended into
the external iliac artery, which may
require embolization of one or both
hypogastric arteries.
What should you Aneurysm exclusion without presence
look for on the final endoleaks. Normal perfusion of
angiogram? kidneys and lower extremities.
(continued)
88 D. Daye

What is the Admit overnight: Analgesia, IV

postoperative fluids, diet, monitor access, CPR
management following status, ambulation ability, and overall
EVAR? postoperative state.
Medical management should be in line
with management of coronary artery
disease.

Complications

What is an Residual blood flow in the aneurysm sac

endoleak?
How do you assess CTA, MRA, or US. Contrast-enhanced
for endoleaks? ultrasound is an emerging, cost-effective
modality, which may be used to assess for
endoleak.
What are the Type I: leak at endograft ends due to an
five types of inadequate seal
endoleaks? Type II: aneurysm sac filling via a branch
vessel
Type III: leak through a defect in the graft
fabric or junctional separation of modular
components
Type IV: porous graft
Type V: endotension (the continued expansion
of the aneurysm sac without radiographic
evidence of a leak site)
What is the most Type II: collateral vessels leading to residual
common type of flow into aneurysm sac.
endoleak? Treatment is considered somewhat
controversial, though some accepted
indications for treatment include growth of
the aneurysm sac by 5 mm or other features
that indicate persistent pressurization of the
native sac, such as persistent endoleak on
follow-up, large feeding or draining artery, and
presence of high flow within the aneurysm sac.
The most commonly involved feeding arteries
are the IMA and lumbar arteries.
 17 Abdominal Aortic Aneurysms 89

In what case can Occlusion of the IMA by the endograft in a

colonic ischemia patient who does not have well-developed
take place collaterals
following EVAR?
What is anterior Paraplegia, loss of pain/temperature sensation,
spinal syndrome? and loss of bladder/bowel control
If a patient The artery of Adamkiewicz
presents with
anterior spinal
syndrome after
EVAR, which
vessel did the
endograft occlude?
If a patient Erectile dysfunction
has undergone Buttock claudication
bilateral Spinal cord, bladder, and colon ischemia
hypogastric artery This procedure may be staged prior to EVAR
embolization to in an effort to promote collateral circulation
prevent type 2 formation and avoid ischemic complications
endoleak, which prior to exclusion.
symptoms may
be expected on
follow-up?
What are Aortoenteric fistula
other possible Aortovenous fistula
complications of Erectile dysfunction
EVAR? Graft infection
What are some More common in the open surgical
clinical features population (0.6–2.0% annual incidence)
of aortoenteric Abdominal pain and sepsis
fistula? Classically a “herald,” self-limited bleed
followed by catastrophic bleeding
Nearly always involves the duodenum
On cross-sectional imaging, expected peri-­
graft edema, fluid, and ectopic gas can persist
up to 3–4 weeks. Persistence beyond this
period of time should raise suspicion for
infection. Look for loss of fat planes between
graft and bowel.
90 D. Daye

Landmark Research

According to recent Lower blood loss

studies, what are the Fewer days in hospital post-procedure
main advantages of Lower complication rates
EVAR compared to Decreased in-hospital and 30-day
open repair? mortality
How does the long-­ Lower mortality at 4 years with EVAR
terms mortality differ (4%) compared to open repair (7%),
between EVAR and though longer-term mortality rates
open surgical repair? demonstrate similarity
What is the utilization EVAR has been progressively replacing
trend of EVAR that has open surgical repair for infrarenal AAA
been recently reported repair.
in the literature?

Common Questions

How does endovascular EVAR demonstrates lower rates

abdominal aortic of morbidity and mortality when
aneurysm repair compared with open surgical repair in
(EVAR) compare to the early perioperative period (within
open surgical repair in 30 days post-procedure), equivalent
the early perioperative outcomes after 2 years, but higher
period? After 2 years? total mortality and aneurysm-related
After 8 years? mortality after 8 years.
What is Laplace’s law The law states that tension (T) equals
and how does it relate pressure (P) multiplied by the diameter
to aneurysms? (D). It states that the larger the radius
of the sphere, the greater the wall
stress. As the aneurysm enlarges, the
greater the stress on the aortic wall
increases the risk of rupture.
How long is endograft Indefinitely
imaging surveillance
recommended after
EVAR?
 17 Abdominal Aortic Aneurysms 91

At what time intervals Follow-up may be obtained at 1 month

is imaging surveillance and 12 months. A 6-month follow-up
performed after EVAR? may be obtained if there is presence
of an endoleak, and then yearly. Key
features to be able to identify are
any evidence for graft thrombosis,
migration, or fracture.

Further Reading
Beebe HG, et al. Screening and perioperative imaging of candidates
for conventional repair of abdominal aortic aneurysms. Semin
Vasc Surg. 1999;12:300–5.
Diwan, et al. Incidence of femoral and popliteal artery aneurysms
in patients with abdominal aortic aneurysms. J Vasc Surg.
2000;31(5):863.
EVAR trial participants. Endovascular aneurysm repair vs. open
repair in patients with abdominal aortic aneurysm (EVAR trial 1):
randomized control trial. Lancet. 2005;365:2179–86.
Giles KA, et al. Decrease in total aneurysm-related deaths in the era
of endovascular aneurysm repair. J Vasc Surg. 2009;49:543–50.
Guirguis-Blake JM, et al. Ultrasonography screening for abdom-
inal aortic aneurysms: a systematic evidence review for
the U.S. Preventive Services Task Force. Ann Intern Med.
2014;160(5):321.
Hiramoto JS, et al. Long-term outcomes and reintervention after
endovascular abdominal aortic aneurysm repair using the Zenith
stent graft. J Vasc Surg. 2007;45:461–6.
Lawrence PF, et al. The epidemiology of surgically repaired aneu-
rysms in the United States. J Vasc Surg. 1999;30(4):632.
Parodi JC, et al. Transfemoral intraluminal graft implantation for
abdominal aortic aneurysms. Ann Vasc Surg. 1991;5:491–9.
Prinssen M, et al. A randomized trial comparing conventional and
endovascular repair of abdominal aortic aneurysms. N Engl J
Med. 2004;351:1607–18.
Veith FJ, et al. Nature and significance of endoleaks and endoexten-
sion: summary of opinions expressed at international conference.
J Vasc Surg. 2002;35:1029–35.
Chapter 18
Thoracic Aortic
Aneurysm Chapter
Peyton Cramer and Lourdes Alanis

Evaluating Patient
What is a thoracic Localized dilatation of the thoracic aorta
aortic aneurysm greater than 50% of normal. The upper
(TAA)? limit of normal caliber for the descending
thoracic aorta is 3–3.5 cm.
What are the two 80% are fusiform (uniform and
major types of circumferential) and 20% are saccular
aneurysms? (localized outpouching).
What chest X-ray Widening of the mediastinal silhouette,
findings that should raise enlargement of the aortic knob, and
suspicion for a thoracic tracheal or esophageal deviation
aortic aneurysm?
(continued)

P. Cramer (*)
Department of Radiology, New York Presbyterian Hospital Weill
Cornell Medicine, New York, NY, USA
McGovern Medical School, UT Health Science Center at Houston,
Houston, TX, USA
e-mail: [email protected]
L. Alanis
Interventional Radiology, Radiology Associates of San Luis
Obispo, San Luis Obispo, CA, USA

© Springer Nature Switzerland AG 2022 93

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_18
94 P. Cramer and L. Alanis

Which imaging Computed tomography angiography

modality is most (CTA) from the thoracic inlet to the
critical for evaluating femoral artery bifurcations. Non-contrast
thoracic aortic images help visualize calcifications and
aneurysms? intramural hematomas, while arterial-
phase angiography provides accurate
aneurysm measurements.
What are additional Magnetic resonance angiography
imaging modalities (MRA), transesophageal echo (TEE),
that can be used and intravascular ultrasound (IVUS)
to further evaluate
thoracic aortic
aneurysms?
Why is it important Significant tortuosity, thrombus,
to thoroughly assess or calcification might preclude an
the femoral and iliac endovascular approach. Adequate vessel
vasculature? caliber is essential for accommodating
the endograft delivery system.

High Yield History

What is the prevalence of 6–10 per 100,000
thoracic aortic aneurysms?
What is the average age of 65 years old, with women
diagnosis? presenting approximately
10 years later than men
Is there a gender Slightly, with a male-to-female
predominance? ratio of 1.5:1–1:1
What are the risk factors? Atherosclerosis, aortic
dissection, connective tissue
disorders, family history, trauma,
infection, and vasculitis
 18 Thoracic Aortic Aneurysm Chapter 95

Which connective tissue Marfan syndrome, Ehlers-

disorders are associated with Danlos syndrome, Loeys-Dietz
TAAs? syndrome, and Turner syndrome
What are the symptoms of Chest discomfort and
thoracic aortic aneurysms? surrounding organ compression
(new onset hoarseness,
dysphagia, dyspnea, hemoptysis)
What are the risk factors for Size > 6 cm, increasing age, and
aneurysm rupture? tobacco use
What is the most common Acute onset of back and/or
complaint associated with chest pain
rupture or impending rupture?

Indications/Contraindications
What are the methods Aneurysms of the ascending
available for thoracic aorta generally require surgical
aortic aneurysm repair? reconstruction, while aneurysms of
the descending aorta are addressed
with either surgical or endovascular
techniques.
What does TEVAR Thoracic endovascular aortic repair
stand for?
TEVAR is approved Aortic aneurysmal disease, type B aortic
to treat which medical dissection, traumatic aortic transection,
conditions? and penetrating atherosclerotic ulcer
What are the 1. Size (greater than 5.5 cm)
indications for thoracic 2. Rapid expansion (greater than 5 mm
aortic aneurysm repair? within 6 months)
3. Symptoms

(continued)
96 P. Cramer and L. Alanis

What are the Avoidance of thoracotomy or

advantages of TEVAR sternotomy, decreased blood loss,
over open surgical reduced spinal cord ischemia, and
repair? shorter hospitalizations
What is an endograft The landing zones are the sites proximal
“landing zones”? and distal to the aneurysm where
the endograft will “land” during the
endovascular repair. In order to ensure
stable fixation and adequate seal, there
must be 2 cm of healthy, parallel aortic
wall both proximal and distal to the
aneurysm.
How is the landing From inner wall to inner wall, excluding
zone diameter calcifications but including intraluminal
measured? thrombi and plaque
Is unfavorable No, various techniques have been
anatomy an absolute developed to overcome these barriers,
contraindication to such as additional cuffs or fenestrated
TEVAR? grafts.
Is TEVAR No, because the fragile tissue is not
recommended suitable for long-term endograft seal.
in patients with
underlying connective
tissue disorders or
Takayasu?

Relevant Anatomy

What are the three 1. Ascending aorta

components of the 2. Aortic arch
thoracic aorta? 3. Descending aorta
 18 Thoracic Aortic Aneurysm Chapter 97

Where is the most The aortic isthmus is the most common

common site of thoracic site of origin of aortic dissection. The
aortic injury when isthmus is a constriction of the aortic
the body undergoes arch just distal to the origin of the left
significant deceleration? subclavian artery at the site of the
ductus arteriosus.
Which vessels supply the The vertebral arteries
anterior spinal cord?
Which vessels supply the The posterior inferior cerebellar arteries
posterior spinal cord?
What is the great The principal vessel that feeds the lower
radicular artery of thoracic, lumbar, and sacral portions
Adamkiewicz? of the spinal cord. The vessel most
commonly arises between T9 and T12
from a single intercostal artery as the
anterior radiculomedullary artery that
continues as a hairpin loop, forming the
characteristic appearance of the artery
of Adamkiewicz. Specifically, the artery
arises on the left from the radicular
anterior artery of the spinal branch of the
posterior intercostal artery. The origin of
the artery can occur as high as T6.
Which vessel(s) gives The subclavian arteries provide the
rise to the intercostal first two intercostal arteries and the
arteries? descending thoracic aorta provides the
remaining nine intercostal arteries.
(continued)
98 P. Cramer and L. Alanis

Relevant Materials

What are the recommended Proximal and distal neck

aortic measurements for diameter of less than 42 mm is
stent-graft placement in a recommended to prevent stent
descending TAA? migration.
Aneurysm length and total
treatment length measurements
ensure adequate stent coverage of
the aneurysm.
Radius of curvature of greater
than 35 mm or aortic angulation
of less than 60° is recommend to
achieve adequate circumferential
seal and prevent endoleaks.
For descending TAAs, 10–20% to select the most correct
the stent-graft diameter is diameter of the endoprosthesis
generally oversized by how and to ensure a tight
much relative to luminal circumferential seal and secure
diameter of the landing anchoring to prevent migration
zones?
An access vessel of what size A vessel of at least 8 mm in
is necessary for a standard 24 diameter given 1 Fr is equal to
Fr delivery device? 0.33 mm diameter, and therefore,
24 Fr is equal to 8 mm diameter.
In calcified vessels, open surgical
cutdown is preferred.

General Step by Step

Why should In addition to continuous monitoring of

arterial pressure vital signs, arterial pressure should be
be continuously closely monitored to avoid hypotension
monitored during and decrease the risk of spinal cord
the thoracic stent-­ ischemia.
graft placement?
 18 Thoracic Aortic Aneurysm Chapter 99

What can be used Intraoperative somatosensory-evoked

to detect neurologic potentials (SSEP) and motor-evoked
complications? potentials (MEP) help monitor spinal cord
function to prevent injury and allow for
early treatment if detected. Intervention
includes draining CSF if CSF pressure
becomes elevated and ensuring adequate
spinal cord blood flow by maintaining
a minimum distal arterial pressure of
60 mmHg.
What should the Patients should be anticoagulated
achieved activated throughout the procedure to achieve an
clotting time be activated clotting time of 250–300 s to
in heparinized reduce thromboembolic complications.
patients? However, increased activated clotting
times > 300 s may increase bleeding
complications. Protamine is given for
reversal of heparin anticoagulation.
Most serious reaction to protamine is
anaphylaxis, characterized by circulatory
shock, severe bronchospasm, and
occasionally cardiac arrest.
What is the Common femoral artery (external iliac
preferred arterial or common iliac arteries may also be
access for thoracic accessed)
stent-graft
placement?
After gaining Place a vascular sheath and advance
arterial access in marker pigtail catheter to the proximal
the contralateral aortic arch.
common femoral
artery for the initial
aortogram, what
should be done
next?
(continued)
100 P. Cramer and L. Alanis

What injection rate Injection rate of 15 cc/second for a total of

and size marker 30 cc and 5- to 7-Fr pigtail catheter should
pigtail catheter be used.
should be used for
injection in the
ascending aorta?
The thoracic stent-­ Super stiff 0.035″ guidewire
graft delivery system
should be advanced
over what type of
wire?
For the initial Left anterior oblique (LAO) to visualize
aortogram, the arch and accurately profile the great
how should the vessels
fluoroscope be
positioned?
For the thoracic Perpendicular to the proximal landing
stent-graft zone
deployment,
how should the
fluoroscope be
positioned?
After advancing the Locate the radiopaque markers and
endograft delivery expose the first two springs. Ensure the
system to the target proximal and distal springs are at adequate
site, how do you landing zones of at least 20 mm.
confirm positioning?
How should the Under continuous fluoroscopic
thoracic stent-graft visualization to confirm positioning
be deployed?
What can be done Maintain low mean arterial pressure
to prevent migration (MAP) (60–70 mmHg) with the use of
of the thoracic sodium nitroprusside.
stent-graft during
deployment?
 18 Thoracic Aortic Aneurysm Chapter 101

After deployment of A completion angiogram to confirm stent-­

the stent graft and graft placement and absence of endoleak
careful withdrawal of
the delivery catheter,
what should be done
next?
What is the role of It helps model the stent graft to the vessel
compliant balloon wall to ensure wall apposition and seal
angioplasty?
What if additional Ensure an overlap of a minimum of 30 mm
devices are needed of the stent-graft material. In areas of
for adequate angulation or curvature, an additional
coverage of the overlap of 50 mm is required with a
TAA? minimum of 45 mm.

Complications

TAA can cause Rupture, distal embolization, compression

what types of of adjacent structures (trachea, esophagus,
complications? pulmonary vein or artery, superior vena
cava), stretching of the recurrent laryngeal
nerve, fistula (trachea or bronchus,
superior vena cava, esophagus), or
infection
What are some Aortic perforation, endoleaks, stent
early and late fracture, and device malposition,
complications of the migration, or collapse
thoracic stent-graft
placement?
(continued)
102 P. Cramer and L. Alanis

What is an An endoleak is the persistent perfusion of

endoleak? the aneurysm sac outside of the stent graft.
Endoleak complications may occur up to
25% of the time.
What are Spinal cord ischemia (0.8–3%) resulting in
the dreaded paraparesis or paraplegia, anterior spinal
complications after syndrome, and cerebrovascular stroke
treatment of a TAA? (2.1–3.6%)
How can you Prophylactic CSF drainage should
prevent and reverse be considered in patients with prior
spinal cord ischemia? history of abdominal aortic aneurysm
repair, hypotension (mean arterial
pressure < 70 mmHg), stent-graft
coverage between T8 and L2, and
treatment length >20 cm. If detected
early, it may be reversed with prompt
CSF drainage and maintaining a
mean blood pressure between 80 and
90 mmHg.
What are the types Thrombosis, dissection, rupture, and
of complications avulsion
that can occur at the
vascular access site?
What is It is a self-limited early complication
postimplantation of stent-graft placement, which usually
syndrome? resolves within a week. Patients may
present with low-grade fever, elevated
C-reactive protein, mild leukocytosis, and
possible reactive pleural effusion. The
symptoms usually resolve within 1 week
and are managed with analgesics and anti-­
inflammatory agents.
 18 Thoracic Aortic Aneurysm Chapter 103

Landmark Research

In the VALOR Trial, what TEVAR using the Talent Thoracic

was the bottom line of the Stent Graft System demonstrated
5-year follow-up with the sustained protection from thoracic
Talent Thoracic Stent Graft? aortic aneurysm-related mortality,
aneurysm rupture, conversion to
surgery, and durable stent-graft
performance.
What are the results of the Kaplan-Meier estimates for
VALOR Trial through the freedom from all-cause mortality
5-year follow-up? at 1 year and 5 years were 83.9%
(standard error [SE] 2.6%) and
58.5% (SE 3.7%), respectively.
Estimated freedom from
aneurysm-related mortality
(ARM) at 1 year and 5 years was
96.9% (SE 1.3%) and 96.1% (SE
1.4%), respectively.
Freedom from secondary
endovascular procedures was
81.5% (SE 3.3%).
5-year estimate of survival free
from aneurysm rupture was 97.1%
(SE 1.5%).
5-year estimate of conversion-free
survival was 97.1% (SE 1.4%).
5-year estimate of freedom from
stroke was 88.2% (SE 6.0%), and
spinal cord ischemia (SCI) was
92.3% (SE 4.8%).
(continued)
104 P. Cramer and L. Alanis

What are the main lessons At 5 years, no ruptures, one

from the 5-year follow-up migration, no collapse, and 20
for treatment of thoracic instances of fracture in 19 patients
aneurysms with TEVAR were noted in the TAG group
using the Gore TAG with authors claiming occurred
compared with open surgery? prior to the Gore TAG revision.
Treatment of thoracic aneurysms
is superior to surgical repair at
5 years:
Aneurysm-related mortality
was lower for TAG 2.8%
compared with open repair 11.7%
(P = 0.008).
No differences in all-cause
mortality between TAG 68% and
67% of open repair (P = 0.43).
Major adverse events were
significantly reduced in the TAG
group 57.9% vs open repair 78.7%
(P = 0.001).
Endoleaks in the TAG group
decreased from 8.1% at 1 month
to 4.3% at 5 years.
 18 Thoracic Aortic Aneurysm Chapter 105

What are the 5-year results Similar survival estimates from

between open surgical repair all-cause mortality for TEVAR
and thoracic endovascular were 62.9% and 62.8% for open
aortic repair with Zenith repair and aneurysm-related
TX2 in the treatment of mortality with TEVAR 94.1%
degenerative aneurysms and compared with open repair 88.3%.
ulcers of the descending Kaplan-Meier estimates of
thoracic aorta? freedom from severe morbid
events (paraplegia, return to
operating room for bleeding, and
permanent dialysis) for TEVAR
and open repair were 87.3% vs
64.3% at 1 year and 79.1% vs
61.2% at 5 years.
Kaplan-Meier estimates of
freedom from secondary
intervention were 91.5% for
TEVAR and 88.4% for the open
repair at 5 years.
TEVAR with the TX2 is a
safe and effective alternative
to open surgical repair for the
treatment of anatomically suitable
descending thoracic aortic
aneurysms and ulcers.
(continued)
106 P. Cramer and L. Alanis

At the 2-year follow-up, It showed the safety and

what did the RELAY effectiveness of RELAY and
Endovascular Registry RELAY NBS stent grafts for
for Thoracic Disease II elective endovascular thoracic
(RESTORE II) study aortic repair, as well as their lower
demonstrate? rate of perioperative complication
compared with the RELAY first-­
generation device.
Rate of all-cause 30-day
mortality was 4.2% vs the
RESTORE registry 7.2%.
Perioperative neurologic
complications were lower in
RESTORE II vs RESTORE
study paraplegia/paraparesis
(2.9% vs 2.0%) and stroke (0.6%
vs 1.6%), respectively.
Device-associated
complications were detected
in 4.6% of the patients in
RESTORE II vs 5.3% in
RESTORE study.
Endoleak rate was 6.4% (type I
5.8% and type II 1.7%).

Common Questions

What are the types of Type 1: Inadequate seal of proximal/distal

endoleaks? attachment site
Type 2: Retrograde perfusion of the
aneurysm via branch vessels
Type 3: Inadequate seal between
endograft components
Type 4: Endograft porosity (rare)
Type 5: Endotension (aneurysm sac
expansion without an identifiable
endoleak on angiography or CTA)
 18 Thoracic Aortic Aneurysm Chapter 107

What is the most Type 2

common type of
endoleak?
Which type(s) of Type 1 and type 3 because of the
endoleak should be increased risk of aneurysm rupture
treated immediately? secondary to the direct communication
with high-pressure arterial blood. Type 1
endoleaks may be corrected by securing
the attachment sites with balloon
angioplasty to produce an adequate seal
between the stent and vessel wall. If the
vessel leak persists, then balloon-mounted
bare metal stents or stent-graft extensions
can be used to secure the attachment
sites. Type 3 endoleaks may be corrected
by covering the inadequate seal between
endograft components with a stent-graft
extension. If type 1 and type 3 endoleaks
continue following an endovascular
approach, then conversion to open repair
should be considered.
What is the type of CTA may be performed at 1–3, 6, and
imaging surveillance 12 months. The CTA should include an
recommended for unenhanced, enhanced arterial phase,
clinical follow-up? and a delayed series to evaluate for
endoleak, graft migration, or aneurysm
sac enlargement. MRA can be used as an
alternative to CTA in patients with renal
disease (compatibility of stent graft must
be verified prior to imaging the patient).
Unenhanced images help visualize
calcifications, which may be confused
for an active arterial bleed or intramural
hematomas, which are hyperdense on non-­
contrast studies and may be less obvious
after contrast administration.
(continued)
108 P. Cramer and L. Alanis

What is the technical 98–99.5%

success rate for
thoracic stent-graft
placement?
At 1 year, what is 91–92.9%
the percentage of
descending TAAs
that remain stable or
decrease (>5 mm) in
size?
At 5 years, what is 2.8–5.9% with TEVAR compared with
the aneurysm-related 11.7–12% for open surgery
mortality of TAAs
with TEVAR versus
open surgery?

Further Reading
Bonci G, Steigner ML, Hanley M, Braun AR, Desjardins B,
Gaba RC, et al. ACR appropriateness criteria((R)) thoracic
aorta interventional planning and follow-up. J Am Coll Radiol.
2017;14(11s):S570–s83.
Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA,
Mansour MA, et al. The Society for Vascular Surgery practice
guidelines on the care of patients with an abdominal aortic aneu-
rysm. J Vasc Surg. 2018;67(1):2–77.e2.
Dash D. Thoracic endovascular aortic repair. In: New approaches
to aortic diseases from valve to abdominal bifurcation. Academic
Press; 2018. p. 445–54.
Dorman BH, Elliott BM, Spinale FG, Bailey MK, Walton JS,
Robison JG, Brothers TE, Cook MH. Protamine use during
peripheral vascular surgery: a prospective randomized trial. J
Vasc Surg. 1995;22(3):248–55.
Fanelli F, Dake MD. Standard of practice for the endovascular
treatment of thoracic aortic aneurysms and type B dissections.
Cardiovasc Intervent Radiol. 2009;32(5):849–60.
Fairman RM, Criado F, Farber M, Kwolek C, Mehta M, White R, et al.
Pivotal results of the medtronic vascular talent thoracic stent
graft system: the VALOR trial. J Vasc Surg. 2008;48(3):546–54.
 18 Thoracic Aortic Aneurysm Chapter 109

Fairman RM, Tuchek JM, Lee WA, Kasirajan K, White R, Mehta

M, et al. Pivotal results for the Medtronic Valiant Thoracic Stent
Graft System in the VALOR II trial. J Vasc Surg. 2012;56(5):1222–
31.e1.
Foley PJ, Criado FJ, Farber MA, Kwolek CJ, Mehta M, White RA,
et al. Results with the Talent thoracic stent graft in the VALOR
trial. J Vasc Surg. 2012;56(5):1214–21.e1.
Grabenwoger M, Alfonso F, Bachet J, Bonser R, Czerny M,
Eggebrecht H, et al. Thoracic Endovascular Aortic Repair
(TEVAR) for the treatment of aortic diseases: a position
statement from the European Association for Cardio-Thoracic
Surgery (EACTS) and the European Society of Cardiology
(ESC), in collaboration with the European Association of
Percutaneous Cardiovascular Interventions (EAPCI). Eur J
Cardiothoracic Surg. 2012;42(1):17–24.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey
DE Jr, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/
SIR/STS/SVM Guidelines for the diagnosis and management of
patients with thoracic aortic disease. A Report of the American
College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines, American Association for
Thoracic Surgery, American College of Radiology, American
Stroke Association, Society of Cardiovascular Anesthesiologists,
Society for Cardiovascular Angiography and Interventions,
Society of Interventional Radiology, Society of Thoracic
Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol.
2010;55(14):e27–e129.
Hoel AW. Aneurysmal disease: thoracic aorta. Surg Clin North Am.
2013;93:893–910. ix
Kaufman J. Chapter 9: Thoracic aorta. In: Kaufman JLM, editor.
The requisites: vascular and interventional radiology. 2nd ed.
Philadelphia: Elsevier; 2014. p. 177–98.
Makaroun MS, Dillavou ED, Kee ST, Sicard G, Chaikof E, Bavaria
J, et al. Endovascular treatment of thoracic aortic aneurysms:
results of the phase II multicenter trial of the GORE TAG tho-
racic endoprosthesis. J Vasc Surg. 2005;41(1):1–9.
Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP. Five-­year
results of endovascular treatment with the Gore TAG device
compared with open repair of thoracic aortic aneurysms. J Vasc
Surg. 2008;47(5):912–8.
Matsumura JS, Cambria RP, Dake MD, Moore RD, Svensson LG,
Snyder S. International controlled clinical trial of thoracic endo-
110 P. Cramer and L. Alanis

vascular aneurysm repair with the Zenith TX2 endovascular

graft: 1-year results. J Vasc Surg. 2008;47(2):247–57; discussion
57.
Matsumura JS, Melissano G, Cambria RP, Dake MD, Mehta S,
Svensson LG, et al. Five-year results of thoracic endovascular
aortic repair with the Zenith TX2. J Vasc Surg. 2014;60(1):1–10.
Moreno-Cabral CE, Miller DC, Mitchell RS, et al. Degenerative and
atherosclerotic aneurysms of the thoracic aorta. Determinants
of early and late surgical outcome. J Thorac Cardiovasc Surg.
1984;88:1020–32.
Nation DA, Wang GJ. TEVAR: endovascular repair of the thoracic
aorta. Semin Interv Radiol. 2015;32(3):265–71.
Stavropoulos SW, Carpenter JP. Postoperative imaging surveillance
and endoleak management after endovascular repair of thoracic
aortic aneurysms. J Vasc Surg. 2006;43(Suppl A):89A–93A.
Therasse E, Soulez G, Giroux MF, Perreault P, Bouchard L, Blair JF,
et al. Stent-graft placement for the treatment of thoracic aortic
diseases. Radiographics. 2005;25(1):157–73.
Wang D SaD, Thoracic aortic aneurysms and dissections. In:
Kandarpa K Machan L, and Durham JD, editor. Handbook
of interventional radiologic procedures. 5th ed. Philadelphia:
Wolters Kluwer; 2016. p. 204–215.
Zipfel B, Zaefferer P, Riambau V, Szeberin Z, Weigang E, Menendez
M, et al. Worldwide results from the RESTORE II on elective
endografting of thoracic aneurysms and dissections. J Vasc Surg.
2016;63(6):1466–75.
Chapter 19
Angiography
Mertalaine Mulatre

Evaluating Patient
What must the If available, the evaluation of prior imaging
IR physician and reports (noninvasive vascular studies,
review prior prior angiograms, and correlative imaging)
to embarking is essential prior to the commencement of a
on an invasive procedure. Evaluation of the imaging helps
procedure? the interventionalist identify the pathology
to treat, determine a path for treatment when
necessary, evaluate patency of vessels, and
identify any anatomic variants.
After assessing When accessing the puncture site,
the puncture site, documentation of any fresh surgical incision,
what else must the presence of an abdominal pannus, or
be evaluated? cellulitis should be included. The strength
of the pulses should then be recorded using
a consistent system. If distal pulses are not
palpable, Doppler may be utilized to assess
pulses.
(continued)

M. Mulatre (*)
ESIR/Diagnostic Radiology Residency Program, INTEGRIS
Baptist Medical Center, Oklahoma City, OK, USA

© Springer Nature Switzerland AG 2022 111

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_19
112 M. Mulatre

What labs can Lab tests such as international normalized

be considered to ratio [INR], prothrombin time (PT), activated
obtain prior to a partial thromboplastin time (aPTT), platelet
procedure? count, and serum creatinine (Cr) may be
considered to help identify patients at
increased risk of bleeding or with underlying
renal dysfunction.
What are Typically, approximately 6 hours after an
the general arterial puncture and 4 hours after a venous
guidelines for puncture.
bedrest after a
procedure?
When Although criteria for discharge can vary
discharging based on the procedure performed, in general
a patient, prior to discharge, the patient should be able
what must be to tolerate a diet, have pain controlled with
considered and oral medications, have puncture site without
evaluated? complications, and have a family member or
responsible adult available for transport to the
patient’s home.
What are the Duplex sonography, ankle-brachial index
initial steps (ABI), and pulse volume recordings are often
for evaluating used in conjunction to help ascertain the
a patient for segment of arterial disease and its physiologic
peripheral complications. The ABI is performed by
arterial disease using a blood pressure cuff or ultrasound to
(PAD)? evaluate the pressure in the brachial artery
in both arms and the anterior and posterior
tibial arteries in both legs. The higher of the
two brachial artery pressures and the higher
of the anterior or posterior tibial artery
pressures are used for the index. An ABI of
1.0–1.3 is normal, 0.4–0.9 indicates mild to
moderate PAD, and 0.4 or lower indicates
severe PAD.
 19 Angiography 113

High Yield History

What are the essential The essential elements of a pre-­
elements of a pre-­ procedure note include:
procedure note?  Current history and physical
 Assessment of prior sedation and
outcomes
 Assessment of the airway, heart, and
lungs
 Procedural plan, including side or site
of delineation of indicated
 Plan for sedation, including drugs to
be used
 Level of sedation intended for the
procedure
What are the For moderate sedation and general
Anesthesia Society anesthesia, the ASA requirements for
of America (ASA) fasting are 6 hours for solids and 2 hours
requirements for for clear liquids in adults. Clear liquid
fasting prior to a examples include water, fruit juices
procedure? without pulp, carbonated beverages,
clear tea, and black coffee.
What is the ASA
physical status
classification system?

ASA I A normal healthy patient

ASA A patient with mild systemic disease
II
ASA A patient with severe systemic disease
III
ASA A patient with severe systemic disease that is a constant
IV threat to life
ASA A moribund patient who is not expected to survive
V without the operation
ASA A declared brain-dead patient whose organs are being
VI removed for donor purposes
(continued)
114 M. Mulatre

What are the When obtaining consent, the

considerations for interventionalist must describe the
obtaining consent? procedure in plain English to the
patient. If the patient does not speak
English, a medical translation service
must be used. Whether speaking
in English or using a translator,
appropriate descriptions and
associations should be made within the
patient’s field of understanding. The
IR doctor must know and describe the
risks, benefits, and alternatives of the
procedure. They must also allow time
for the patient to ask questions. Lastly,
the patient should be able to describe
the procedure in their own words.
What is the minimum The minimum required elements to
information that must include in a procedure note include:
be in an immediate  Postoperative diagnosis
postprocedure note?  Procedure(s) performed with brief
description of each procedure
 Findings
 Primary surgeon and assistants
 Estimated blood loss
 Specimens removed
 19 Angiography 115

Relevant Anatomy
Where does The common femoral artery (CFA) begins
the common inferior to the inguinal ligament. It is
femoral artery important to avoid accessing the CFA above
begin? What and below the inguinal ligament to decrease
is the ideal the risk of retroperitoneal hemorrhage and
position to thigh hematoma, respectively. The ideal
access the location to access the femoral artery is the
femoral artery? inferomedial margin of the femoral head. This
allows for utilization of the femoral head to
aid with manual compression of the vessel
above the arteriotomy site to achieve arterial
hemostasis following sheath removal.
When does As the superficial femoral artery (SFA)
the superficial courses through the adductor hiatus, it
femoral artery becomes the popliteal artery. The branches
become the of the popliteal artery are the geniculate and
popliteal artery? sural arteries, which supplies some of the
What are the structures in the knee and calf. The popliteal
branches of the artery also gives rise to the anterior tibial
popliteal artery? artery and the tibioperoneal trunk.
When accessing The left upper extremity should be used
the upper because this allows the catheter to only cross
extremity for one cerebral artery, the left vertebral artery.
an abdominal
aorta or lower
extremity
procedure,
which arm
should be used?
Why?
Where does the The brachial artery divides near the
brachial artery antecubital fossa. It divides into the radial and
divide? What ulnar arteries, which course distally to form the
arteries does it deep and superficial palmar arches.
divide into?
(continued)
116 M. Mulatre

What tests are The modified Allen test and Barbeau test are
used to ensure used to ensure preservation of flow to the
adequate hand.
perfusion
to the hand
before radial or
brachial access?
What are Commonly encountered variants are replaced
common or accessory left hepatic artery originating
variations of the from the SMA, replaced or accessory left
hepatic arterial hepatic artery originating from the left gastric
supply? artery, and replaced common hepatic artery
originating from the SMA.
What upper The basilic and cephalic veins are a part of the
extremity veins superficial venous system. The veins connect
are considered in the antecubital fossa via the median cubital
a part of the vein.
superficial
venous system?
What lower Anterior tibial, posterior tibial, peroneal,
extremity veins popliteal, and deep femoral and common
are considered a femoral veins are considered a part of the deep
part of the deep venous system of the lower extremity.
venous system?

Relevant Materials
What types Needles provide a central channel for
of needles introduction of a guidewire. Double wall
are used needles consist of a metal cannula, stylet, and
for vascular hub. The double wall needles are typically 18G
access? or 19G. Single wall needles consist of beveled
cannula and hub. They are typically 18G or 21G.
 19 Angiography 117

What are A guidewire consists of three parts: coil spring,

the inner mandrel, and wire guide. The outer portion
workings of a of the guidewire is the coil spring. It is tightly
guidewire? coiled wire made of stainless steel. The mandrel,
core of the guidewire, gives the guidewire
its characteristics. The wire guide runs the
length of the coil spring and prevents it from
unraveling. Stainless steel wires are more prone
to kinking, and nitinol wires are more flexible
with less support, though wires can be made
with combined materials. Larger core wires
provide more support and torque, and can also
aid in straightening of your equipment and the
vessel. Smaller core diameter wires provide more
flexibility and trackability, though are better
suited for more tortuous vessels.
What is the The “grind” is the constant diameter of the wire.
difference Wires taper a certain distance from the constant
between the diameter, which can either be broad (improved
core and the wire tracking) or short (greater tendency to
taper? prolapse, less atraumatic). From taper to grind
(core-to-tip), there is a change in stiffness, which
contributes to differences in steerability and
tactile feedback.
What is the Penetration power is the tip stiffness divided
penetration over the area of the wire tip. Core-to-tip design
power of a incorporating high tip load with a reduced
wire? tip diameter generates higher tip pressure for
any tip stiffness. Steerability refers to stiffness
in the rotational axis and competes with
softness (flexibility in bending/low tip loading).
Corrugated core-to-tip designs contribute to
rotational axis rigidity, which translates tactile
feedback to the operator.
Guidewires The commonly used wire sizes are 0.038, 0.035,
are accepted 0.018, and 0.014 cm. A 21-G needle accepts
through what 0.018–0.021-cm wires. An 18G needle accepts
needle gauge 0.035–0.038-cm wires.
sizes?
(continued)
118 M. Mulatre

What are A catheter’s outer diameter is measured in

catheters sized French (Fr). One Fr equals 0.33 mm or 3 Fr
as? equals 1 mm.
What are flush They are nonselective catheters used to
catheters and deliver large boluses of contrast to the large
what are their vessels of the body. They can have different tip
uses? configurations (pigtail, omni, and straight) to
allow the interventionalist more control and
options in directing flow of the contrast.
What is Microcatheters are 1.5–3-Fr catheters. They are
the size of used in super selective interventions.
microcatheters
and what
are their
purposes?
What are the Acceptable contrast agents should be relatively
characteristics inert and soluble in blood and provide adequate
of contrast opacification.
agents? Iodinated agents may be ionic or nonionic:
 Ionic agents are high-osmolar and less viscous/
more reactive.
 Nonionic agents are more inert and more
viscous/less reactive:
   Visipaque is based on the nonionic dimer,
iodixanol, and is isoosmotic to blood plasma.
   Omnipaque is based on the nonionic
monomer, iohexol, and has an osmolality
about twice that of plasma.

General Step by Step

What are some In selecting an arterial access, one should
general guidelines ensure a patent artery, a superficial location
for selecting an over the bone, healthy overlying skin, and
arterial access? communication with the artery of interest.
 19 Angiography 119

What is the In a short-axis view, the image plane is

short-axis view perpendicular to the course of the vessel and
(longitudinal to the needle (needle is “out of plane”). The
approach) and vessel should appear as an anechoic circle
the long-axis on the screen with the needle visualized as a
view (transverse hyperechoic point in cross section. In a long-­
approach) during axis view, the image plane is parallel to the
an ultrasound-­ course of the vessel (needle is “in plane”).
guided vascular The image should show the course of the
access? vessel across the screen and the shaft and
point of the needle as it is advanced.
Describe the The Seldinger technique consists of
Seldinger percutaneous puncture of a blood vessel
technique. with a hollow needle at a 45° angle. Once
blood return is visualized, an atraumatic
guidewire is introduced through the needle.
The needle is then removed while the
guidewire remains in place. An angiographic
catheter is advanced into the vessel over the
guidewire. Once the catheter is in the vessel,
the guidewire is gently pulled out.
What is the “a for b” where “a” is rate of injection in
terminology for mL/s and “b” is volume of injection
injection rates?
What are the
typical injection
rates?

Thoracic aorta 20 mL/s

Abdominal aorta 15 mL/s
Abdominal aortic bifurcation/iliac 5–10 mL/s
arteries
Femoropopliteal arteries 4–6 mL/s
Celiac/SMA 4–6 mL/s
Main pulmonary artery 20 mL/s
(continued)
120 M. Mulatre

Selective right or left pulmonary 10 mL/s

artery
IVC 10–20 mL/s

When would a longer Longer injections are ideal when

injection time be ideal? studying a larger vascular bed, detecting
a small or peripheral bleed, and
studying the venous outflow of an
organ.
What are the key steps Before embarking on a pulmonary
for pulmonary artery artery angiogram, a baseline EKG
angiography? should be performed to assess for heart
block. Insertion of a catheter or sheath
can introduce a right bundle branch
block. Patients with a left bundle branch
block should have immediate access to
pacing. Imaging during the angiography
should be performed on full inspiration.
An angled pigtail catheter or flow-
directed balloon catheter should be
used to quickly negotiate the right
ventricle outflow tract and minimize
contact and irritation with the right
atrium and ventricle. Once in the main
pulmonary artery, the intravascular
pressure is measured. Normal pressure
is roughly 25/10.
What is DSA? Digital subtraction angiography refers
to a process in which the radiologist
attempts to acquire maximal diagnostic
opacification of vessels, using the least
amount of injected contrast material
as possible. DSA removes, from the
projection, non-opacified structures
that are present on the pre- and post-­
contrast images (stationary anatomy).
Body and organ movement results in
misregistration artifact and incomplete
subtraction of tissues.
 19 Angiography 121

Why do individuals Air kerma used in digital subtraction

leave the angiosuite angiography is higher than air kerma
during a “run?” used in conventional digital fluoroscopy
to reduce quantum mottle. This is
because images to be subtracted
must be imaged (in order to identify
stationary anatomy), as well as the
structures opacified by the contrast. The
subtracted image has approximate 40%
more noise than the non-subtracted
image and therefore requires a
considerable increase in dose.
What is a roadmap? A roadmap utilizes a single DSA
reference image as a fluoroscopic
“mask,” which the fluoroscopy unit
stores digitally. Live fluoroscopy images
are then subtracted from projected
mask, which allows the radiologist to
detect the location of live catheters and
wires with respect to the previously
visualized opacified vessels (seen in the
mask).
What is a fluoroscopic A roadmap utilizes a single DSA
fade? reference image from a prior
angiographic “run” to serve as a mask
for live fluoroscopy images. Therefore, it
avoids repeat double exposure required
for repeat DSA, as well as the need to
administer additional contrast material.
What is the best DSA The abdominal aorta is best seen via an
projection for imaging AP projection. The internal iliac artery
certain vessels? division is best seen via contralateral
oblique projection. The internal iliac
artery anterior division is best seen via
the ipsilateral oblique projection. The
femoral and popliteal/tibioperoneal
bifurcations are best viewed via the
ipsilateral oblique projection. The pedal
vessels are best viewed in the lateral or
contralateral oblique projection.
(continued)
122 M. Mulatre

What are some ways Limiting use of magnification and DSA

dose can be reduced Increasing the source-to-image distance
during angiography? Utilizing pulsed fluoroscopy or
decreased frame rates
Decreasing FOV and use of collimation
and filters

Complications
What are the Hematoma, pseudoaneurysm, thrombosis,
complications of arterial dissection, retroperitoneal hemorrhage,
vascular access? and arteriovenous fistula are complications of
arterial vascular punctures.
What is the If a hematoma develops, it is outlined with a
management for marking pen and inspected at regular intervals
the above-stated to ensure no expansion. If the hematoma is
complications? massive and expanding, surgical evacuation
may be required.
If an arterial dissection is not flow-limiting,
it is managed with imaging surveillance. If it
is flow-­limiting, it is managed with balloon
inflation across the dissection to reattach the
dissected intima with the vessel media.
Nonocclusive thrombosis is managed with
antiplatelet therapy. Occlusive thrombus is
typically treated with surgical thrombectomy.
Retroperitoneal hemorrhage occurs when the
CFA is accessed above the inguinal ligament or
when primary hemostasis is not achieved with
an appropriately placed puncture. Standard of
therapy is surgical repair. If the patient is not
a surgical candidate, a covered stent can be
placed across the vascular injury.
 19 Angiography 123

What is the The options for management of a

management of a pseudoaneurysm include observation,
pseudoaneurysm? ultrasound-guided compression, ultrasound-­
guided thrombin injection, and surgery. Small
pseudoaneurysms that are less than 2 cm can
be observed with weekly duplex ultrasound
until thrombosis occurs. They can also be
managed with ultrasound-guided compression
or ultrasound-guided thrombin injection. If a
pseudoaneurysm is >2 cm, has a short (<4 mm)
neck width, is enlarging, or is associated
with significant pain, surgical repair may be
necessary.
What are the Venous complications include perforation of
complications of vein, thrombosis of puncture site, hematoma,
venous punctures? and inadvertent arterial injury. In the jugular
and thoracic veins, complications include
pneumothorax, hemothorax, and air embolism.
What is the Control source, turn patient to left decubitus
management of position, administer oxygen, and aspirate air
central venous air from the heart with catheter.
embolism?
How is wire- or Nitroglycerin can be directly injected. It is
catheter-­induced typically provided as a bolus between 50 and
vasospasm 300 mcg and has a nearly immediate onset.
managed? Nitroglycerin must be used with caution in
patients taking PDE5 inhibitors. Intra-arterial
verapamil can also be used. It is typically given
as a 2.5–5-mg bolus. Its onset of action is within
a few minutes and lasts 20 minutes.

Landmark Research
1. Irani F, Kumar S, Colyer WR Jr. Common femoral artery
access techniques: a review. J Cardiovasc Med (Hagerstown).
2009;10(7):517–22.
124 M. Mulatre

2. Kalish J, Eslami M, Gillespie D, Schermerhorn M, Rybin D,

Doros G, et al. Routine use of ultrasound guidance in fem-
oral arterial access for peripheral vascular intervention
decreases groin hematoma rates. J Vasc Surg.
2015;61(5):1231–8.
3. Campeau L. Percutaneous radial artery approach for coro-
nary angiography. Catheter Cardiovasc Diagn.
1989;16(1):3–7.
4. Fischman AM, Swinburne NC, Patel RSA. Technical guide
describing the use of Transradial access technique for
endovascular interventions. Tech Vasc Interv Radiol.
2015;18(2):58–65.

Further Reading
Abouleish AE, Leib ML, Cohen NH. ASA provides examples to
each ASA physical status class. ASA Monit. 2015;79:38–9. http://
monitor.pubs.asahq.org/article.aspx?articleid=2434536
Baum S. Abram’s angiography. 4th ed. Boston: Little Brown; 1997.
Bishay VL, Ingber RB, O’Connor PJ, Fischman AM. Vascular access
techniques and closure devices. In: Keefe N, Haskal Z, Park A,
Angle J, editors. IR playbook. Cham: Springer; 2018.
Campeau L. Percutaneous radial artery approach for coronary angi-
ography. Catheter Cardiovasc Diagn. 1989;16(1):3–7.
Dubel G, Murphy T. Stents. In: Mauro M, Murphy K, Thompson K,
et al., editors. Image-guided interventions, vol. 1. Philadelphia:
Saunders Elsevier; 2008. p. 85–105.
Fischman AM, Swinburne NC, Patel RSA. Technical guide describ-
ing the use of Transradial access technique for endovascular
interventions. Tech Vasc Interv Radiol. 2015;18(2):58–65.
Irani F, Kumar S, Colyer WR Jr. Common femoral artery access
techniques: a review. J Cardiovasc Med (Hagerstown).
2009;10(7):517–22.
Kandarpa K, Arum JE. Handbook of interventional radiologic pro-
cedures. 3rd ed. Boston: Little Brown; 2001.
Kalish J, Eslami M, Gillespie D, Schermerhorn M, Rybin D, Doros
G, et al. Routine use of ultrasound guidance in femoral arte-
rial access for peripheral vascular intervention decreases groin
hematoma rates. J Vasc Surg. 2015;61(5):1231–8.
 19 Angiography 125

Kaufman J, Lee M. Vascular and interventional radiology: the requi-

sites. 1st ed. Philadelphia: Elsevier; 2004.
Madia C. Management trends for postcatheterization femoral artery
pseudoaneurysms. J Am Acad Physician Assist. 2019;32(6):15–8.
Northcutt BG, Shah AA, Sheu YR, Carmi L. Wires, catheters, and
more: a primer for residents and fellows entering interventional
radiology: resident and fellow education feature. Radiographics.
2015;35(5):1621–2. https://doi.org/10.1148/rg.2015130155.
Practice guidelines for preoperative fasting and the use of phar-
macologic agents to reduce the risk of pulmonary aspiration:
application to healthy patients undergoing elective procedures:
an updated report by the American Society of Anesthesiologists
Task Force on preoperative fasting and the use of pharma-
cologic agents to reduce the risk of pulmonary aspiration.
Anesthesiology. 2017;126(3):376–93.
Sarin S, Turba U, Angle F, et al. Balloon catheters. In: Mauro M,
Murphy K, Thomson K, Venbrux A, Zollikofer C, editors. Image-­
guided interventions. 1st ed. Philadelphia: Saunders Elsevier;
2008. p. 75–84.
Taslakian B, Ingber R, Aaltonen E, Horn J, Hickey R. Interventional
radiology suite: a primer for trainees. J Clin Med. 2019;8(9):1347.
Published 2019 Aug 30. https://doi.org/10.3390/jcm8091347.
Chapter 20
Peripheral Arterial
Disease
Omowunmi Ajibola and Abeer Mousa

Evaluating Patient
What is the According to a 2010 estimate, there are
prevalence of about 200 million people worldwide living
peripheral artery with PAD. In the United States, PAD affects
disease (PAD)? about 8–12 million people, with many cases
remaining undiagnosed. As of 2015 in
the United States, an estimated 5,04,000
individuals (of a total estimated population
of 295.5 million) were living with a major
amputation due to PAD; this is a number that
is projected to more than double by 2050.
(continued)

O. Ajibola (*)
University of Utah, Salt Lake City, UT, USA
e-mail: [email protected]
A. Mousa
University of Arizona College of Medicine-Phoenix,
Phoenix, AZ, USA

© Springer Nature Switzerland AG 2022 127

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_20
128 O. Ajibola and A. Mousa

What exam Physical exam consists of evaluating the limb

techniques are at risk for skin color changes, swelling and
used to evaluate erythema, ulcers, wounds, and so on. It also
patients for consists of a head-to-toe evaluation of the
PAD? patient looking for carotid bruit, irregular
heartbeat or heart rhythm, and abdominal
bruit. An ankle-brachial index (ABI) is
usually the first noninvasive test used to
assess PAD. It is 95% sensitive and 100%
specific. It is important to remember that
heavily calcified arteries have diminished
compressibility, often seen in diabetics and
those with end-stage renal disease, which can
falsely elevate the results of the test.
How is an ABI The ABI test is a noninvasive exam which is
performed and used to evaluate for PAD. A cuff is placed
what is the around the limb – usually the upper arm
interpretation of and ankle – and is inflated to a pressure just
the values? above the systolic blood pressure. Then, an
ultrasound Doppler probe is used to locate
the brachial artery in the arm and dorsalis
pedis or posterior tibial artery at the level
of the ankle. The cuff is then slowly deflated
and the pressure when return of signals is
audible is recorded. This is done on each
side. The higher of the posterior tibial artery
or dorsalis pedis pressures is divided by the
highest brachial artery pressure to calculate
the ABI. The values are as follows:
 0.9 – < 1.3: Normal
 < 0.9 – .7: Mild PAD
 < 0.7 – .4: Moderate PAD
 < 0.4: Severe PAD
What is the This is a way of classifying the symptoms of
Rutherford chronic limb ischemia to help determine the
classification course of action in regard to interventions
for chronic limb and treatment.
ischemia?
 20 Peripheral Arterial Disease 129

Category Clinical description Objective criteria

0 Asymptomatic – No Normal treadmill or
hemodynamically reactive hyperemia test
significant occlusive disease
1 Mild claudication Completes treadmill
exercise; AP after
exercise > 50 mmHg
but at least 20 mmHg
lower than resting value
2 Moderate claudication Between 1 and 3
3 Severe claudication Cannot complete
standard treadmill
exercise, and AP after
exercise < 50 mmHg
4 Ischemic rest pain Resting AP < 40 mmHg;
flat or barely pulsatile
ankle or metatarsal
PVR; TP < 30 mmHg
5 Minor tissue loss Resting AP < 60 mmHg,
nonhealing ulcer, focal ankle or metatarsal
gangrene with diffuse pedal PVR flat or barely
ischemia pulsatile; TP < 40 mmHg
6 Major tissue loss extending Same as 5
above the tarsometatarsal
level, functional foot no
longer salvageable
AP ankle pressure, PVR pulse volume recording, TM tarsometatar-
sal, TP toe pressure

What is “chronic According to the 2019 Global Vascular

limb-threatening Guidelines, CLTI is a clinical syndrome
ischemia” (CLTI defined as PAD in combination with rest
versus “critical pain, gangrene, or a lower limb ulceration
limb ischemia” greater than 2 weeks of duration. As
(CLI)? opposed to CLI, which relies on a threshold
ABI value for diagnosis, CLTI represents
more of a continuum of disease.

(continued)
130 O. Ajibola and A. Mousa

Which PAD In patients with known PAD, the risk for

patients are at development of CLTI appears to be greater
greatest risk for in men, in patients who have had a stroke or
development of are in heart failure, and in patients with DM
CLTI? (strongest association). Patients who present
de novo with CLTI (no prior diagnosis of
PAD) seem more likely to be older and
male and to have pre-existing cardiovascular
disease (including hypertension, myocardial
infarction, heart failure, or stroke), as well as
renal failure.
Typically, at Below an ABI of 0.3 – 0.4. Below this level
what ABI value is associated with high amputation rate
in chronic limb (30%) and mortality (25%).
ischemia are
findings of CLTI
(tissue compromise
and pain at rest)
present?
When are toe TBIs are used when tibial vessels are
pressures or toe-­ heavily calcified, thus providing inadequate
brachial index compressibility to be analyzed by the
(TBI) utilized? ABI. A normal TBI is > 0.75. When
suspecting CLTI, toe pressures and TBI are
the preferred measures.
In addition to Additional noninvasive measurements,
ankle and toe such as pulse volume recording (PVR),
pressures, indices, transcutaneous oximetry, or skin perfusion
and waveforms, pressure, are used. PVR detects changes in
what else should volume of blood flow. This is measured at
be assessed? multiple levels along the extremity, and the
magnitude and contour of PVR readings
between segments is compared.
 20 Peripheral Arterial Disease 131

What labs should There are many risk factors for vascular
be ordered during disease that can be evaluated with lab tests,
patient evaluation? including a lipid panel and fasting blood
glucose. Routine blood tests such CBC,
BMP/CMP, aPTT, and PT/INR may be
obtained prior to angiography. Evaluating
for hereditary and acquired risk factors for
hypercoagulable disease can be important
in certain patients to identify whether there
are other reasons for vascular insufficiency.
What medical Venous claudication related to DVT
conditions may and venous insufficiency, neurogenic
mimic arterial claudication, musculoskeletal pain, vascular
claudication and malformations, pelvic congestion, and
what must be tumors or masses all may mimic arterial
excluded before claudication. Specific inquiries about the
diagnosing PAD? pain should explore duration, location,
progression, reproducibility with exercise,
and amount of rest time necessary for
symptoms to resolve. Venous, traumatic,
embolic, and nonatherosclerotic etiologies
should be excluded before making a
diagnosis of CLTI.
132 O. Ajibola and A. Mousa

High Yield History

What is angioplasty Angioplasty is a minimally invasive
and what are procedure where a pressure-inflated
the common balloon is used to open a narrowed or
conditions treated occluded blood vessel by breaking apart
by angioplasty/ any plaque in the vessel wall and stretching
stenting? the vessel wall. There are many indications
for stenting, and the exact reasons why the
stent was placed (including progression
or improvement in disease), the type of
stent, location, and evident complications
or in-stent stenosis as well as all interval
studies and total indwell time should be
documented. Stents can be uncovered,
covered, self-expanding, or balloon-­
expandable. The type of stent placed
depends on underlying anatomy and the
specific indication.
What are the risk The most common risk factor is
factors associated atherosclerosis. Other risk factors are
with PAD? chronic kidney disease or CKD, diabetes
mellitus, tobacco use, diet, obesity, high
blood pressure, and high cholesterol.
What are the Patients usually present with pain in the
characteristic affected limb with exercise or walking
clinical symptoms and relief of symptoms at rest. Other
in patients with characteristic symptoms include numbness
PAD? and/or paresthesia, cramping, skin ulcers or
gangrene, hair loss in the affected area, and
weakness of the affected limb. In patients
with severe disease, there is no symptom
relief at rest, also known as rest pain. Rest
pain is typically located in the mid or
forefoot and can be present at all times
throughout the day, and even awaken the
patient from sleep.
 20 Peripheral Arterial Disease 133

What is the This is pain of the affected limb at rest and

characteristic it represents progression of ischemia. It is
description of made worse with elevation and is better
ischemic rest pain? with the limb in a dependent position. The
pain is usually worse with cold exposure and
better with heat exposure. It is associated
with one or more of the following abnormal
hemodynamic parameters:
 ABI < 0.4Ankle pressure < 50 mmHg
 Toe pressure < 30 mmHg
 Transcutaneous partial pressure of oxygen
(TcPO2) < 30 mmHg
 Flat or minimally pulsatile pulse volume
recording waveforms
What is Leriche’s This is the triad of buttock and thigh
syndrome? claudication, diminished femoral pulses,
and impotence, which indicates aortoiliac
occlusive disease.
Based on the If confined to the calf, it is likely the
described location superficial femoral or popliteal artery
of claudication by disease, though more proximal disease
the patient, how cannot be excluded.
may the physician If it involves the thigh and calf, it is likely
localize the likely due to common femoral or external iliac
level of disease? artery disease.
What should you Hyperhomocysteinemia. Homocysteine
suspect in a young levels are higher in several case-control
patient with PAD PAD cohort studies, although the benefits
and no other risk of folate supplementation appear to be
factors? negligible. The disease is characterized
by toxicity to endothelial cells and the
reduced ability to generate and release
nitric oxide, arterial wall inflammation, and
smooth muscle cell proliferation, as well as
increased levels of plasminogen activator
inhibitor.
(continued)
134 O. Ajibola and A. Mousa

What is the Acute limb ischemia is a new and sudden

difference between onset of limb pain with changes in
acute and chronic neurological function of the said limb,
limb ischemia? in a patient who was previously not
symptomatic. Acute limb ischemic changes
may be superimposed on a patient with
underlying chronic limb ischemia, as well.
What The percentage of arterial stenosis and the
characteristics length of the occlusion.
of the occlusion
are important for
understanding
the outcomes of
angioplasty?
Describe patency Primary patency: Time from original
of stents. intervention to a second intervention, such
as angioplasty, atherectomy, or thrombolysis,
in which patency is restored. In other words,
it is how long patency is maintained without
any repeat intervention.
Primary-assisted patency: Primary patency
time period plus time gained from a second
intervention that was required to maintain
patency. This defines the durability of an
intervention that failed (but not to the
level of thrombosis) and required a second
intervention to maintain patency.
Secondary patency: Time from initial
intervention to a second intervention,
such as catheter-directed thrombolysis
or thrombectomy, which is required to
treat specifically thrombosis or occlusion.
Secondary patency refers to the durability
of the second intervention in this respect.
What is critical Critical stenosis refers to critical narrowing
stenosis? of a vessel which results in significant
reduction in maximum blood flow to a
distal area. This is the area that is usually
targeted during the process of angioplasty
and stenting.
 20 Peripheral Arterial Disease 135

Indications/Contraindications
In the field of Peripheral artery disease (PAD). Other
interventional indications include renal artery stenosis,
radiology, what is central venous occlusion, and stenoses
the most common of dialysis AV fistulas or grafts.
indication for
angioplasty and
stenting?
What are the Patients with critical limb ischemia or
indications for those who have moderate or severe
intervention in patients claudication and do not respond to
with PAD? maximal medical therapy
Lesions with what Short segment stenosis or occlusions
characteristics Concentric, noncalcified stenosis
are better treated Distal runoff to vessels downstream
percutaneously?
What are some There are no absolute contraindications
contraindications for angioplasty and stenting. A relative
to angioplasty and contraindication includes patients with
stenting? chronic kidney disease.
What are the TASC The TASC II or TransAtlantic
guidelines? Inter-Society Consensus for the
Management of Peripheral Arterial
Disease are guidelines made to provide
recommendations in the evaluation,
diagnosis, and treatment of patients
with PAD. The most utilized parts of
these guidelines are the anatomical
classification of the pattern of disease
and guidance of revascularization
strategy (open vs. endovascular) based
on anatomical location and complexity
of disease. The revised TASC II
guidelines resulted in reclassification
of more complex anatomies into
less severe categories and therefore
amenable to endovascular management.
The classifications of lesions are as
below.
(continued)
136 O. Ajibola and A. Mousa

TASC Endovascular method with excellent results and should

A be the treatment of choice
TASC Endovascular method with good results and should be
B the preferred treatment unless an open revascularization
is required for another associated lesion in the same
anatomic area
TASC Open revascularization produces superior results
C compared to endovascular means, and endovascular
treatment should be reserved for patients at high risk for
open repair
TASC Endovascular methods do not yield good enough results
D to justify as the primary treatment. Open repair is
preferred

What is the TASC II

classification of aortoiliac
disease?

TASC Uni-/bilateral common iliac artery stenosis

A Uni-/bilateral < 3 cm external iliac artery stenosis
TASC < 3 cm stenosis of infrarenal aorta
B Unilateral common iliac artery occlusion
Unilateral stenosis > 3 cm or occlusion of the external
iliac artery not involving internal iliac or common
femoral arteries
TASC Bilateral common iliac artery occlusion
C Heavily calcified external iliac artery occlusion
Bilateral external iliac artery stenosis or unilateral
external iliac artery occlusion extending into the
common femoral or internal iliac arteries
TASC Infrarenal aortic occlusion
D Unilateral common and external iliac artery occlusion
Bilateral external iliac artery occlusion
Iliac stenosis in patients needing open AAA repair
Diffuse aortoiliac artery occlusive disease
 20 Peripheral Arterial Disease 137

Trials evaluating surgical vs. endovascular treatment of

lesions, especially of TASC C and D lesions, are difficult to
perform and are uncommon. Current data shows that endo-
vascular procedures are associated with lower complication
rates, shorter length of stay, and lower hospital costs than
surgical management. Recent meta-analyses have demon-
strated good primary and secondary patency rates of TASC
C-D lesions treated endovascularly.

What is the TASC II classification of femoral-popliteal

disease?

TASC Single stenosis < 5 cm

A
TASC Multiple < 5 cm stenosis/occlusion
B Single < 15 cm stenosis/occlusion not involving the
infrageniculate popliteal artery
Heavily calcified < 5 cm occlusion
Single popliteal stenosis
TASC Multiple stenosis/occlusion > 15 cm
C Recurrent stenosis/occlusion after two endovascular
interventions
TASC Chronic total occlusion of common femoral or
D superficial femoral artery > 20 cm involving the popliteal
artery
Chronic total occlusion of popliteal artery and proximal
trifurcation

As with aortoiliac disease, enrollment in trials comparing

surgical to endovascular management of femoropopliteal
disease is difficult. Comparing the results of these treatments
is also difficult as patients referred to endovascular therapy
often have intermittent claudication, whereas those referred
to surgery often have CLTI, which is associated with increased
periprocedural morbidity and mortality.
138 O. Ajibola and A. Mousa

Why has endovascular Due to many factors such as

therapy become the improvement in vascular testing
primary strategy and imaging, improvement of the
for the treatment of technology used in endovascular
symptomatic PAD? treatment, and decreased length of
time in the hospital and with recovery

Relevant Anatomy
What are the Aortoiliac (buttock and thigh claudication),
different levels of femoropopliteal (calf claudication), and
disease in PAD? infrapopliteal (plantar claudication). Below-­
knee arteries typically become increasingly
involved as the overall severity of disease
worsens.
What layers of There arterial wall is made of three parts.
the arterial wall From outside in they are the adventitia,
are affected by the media, and the intima. Angioplasty is
angioplasty? considered controlled vessel wall injury.
The intraluminal plaque can compress and
fracture, the intima can separate, and the
media can stretch. Over time, this leads to
a reparative response by the vessel termed
“neointimal hyperplasia,” a major contributor
to in-stent restenosis.
 20 Peripheral Arterial Disease 139

What are the They are as follows:

major collateral  Pathway of Winslow: Subclavian artery
pathways for → internal thoracic artery → superior
lower extremity epigastric artery → inferior epigastric
blood supply artery → external iliac artery.
in aortoiliac  SMA → IMA → superior rectal artery
occlusive disease? → middle and inferior rectal arteries →
internal iliac artery → external iliac artery.
 Lumbar, intercostal, subcostal arteries →
deep circumflex iliac artery → external
iliac.
 Lumbar, intercostal, subcostal arteries →
iliolumbar and lateral sacral arteries →
internal iliac → external iliac artery.
 Uncommon pathway can develop between
the gonadal artery and the inferior
epigastric artery with flow back into the
common femoral artery and subsequently
down the leg.
Which outflow Superficial femoral artery
artery is most
commonly
associated with
intermittent
claudication?
Which artery Popliteal and tibial arteries are more
tends to be commonly associated with CLTI due to the
most diseased lack of collateral vascular pathways by these
in patients lesions. Posterior tibial artery is most often
with CLTI and diseased with relative sparing of the peroneal
infrapopliteal artery. In patients with DM, there may also
disease? be sparing of the DP artery.
(continued)
140 O. Ajibola and A. Mousa

What is a During normal embryological development,

persistent sciatic the axial artery regresses to the inferior
artery? gluteal artery, and the superficial femoral
artery becomes the dominant artery to the
leg. In 0.5% of individuals, this regression
does not occur, and the axial limb artery
persists as a continuation of the internal
iliac artery along the posterior buttocks
through the greater sciatic foramen below the
piriformis muscle, into the thigh alongside the
sciatic nerve eventually anastomosing with
the popliteal artery. Posterior positioning
makes the artery susceptible to repetitive
injury and aneurysm formation, and patients
may present with a painful posterior
mass or distal extremity ischemia from
thromboembolic disease.
What is a Also known as peroneal magnus, this is when
dominant the peroneal artery is the sole main artery
peroneal artery? that continues below the knee, branching
at the ankle to supply the dorsalis pedis
and posterior tibial arteries. There are
different forms of this anatomy with variable
hypoplasia or aplasia of the anterior and
posterior tibial arteries.

Relevant Materials
What is the According to the law of Laplace, tension
difference between (hoop stress) within a balloon is equivalent
compliant and to the pressure × diameter. Compliant
noncompliant balloons may dilate in certain areas beyond
balloons? their stated diameter and can be used
to mold a stent graft, for example, in the
aorta. Noncompliant balloons will not
dilate beyond their stated diameter, even at
pressures much higher than nominal.
 20 Peripheral Arterial Disease 141

What is the Nominal pressure is the insufflation

difference between pressure required for the balloon to reach
nominal and burst its stated diameter. Burst pressure is the
pressure? pressure at which 99.9% of balloons will
not rupture with 95% confidence.
What is the In an over-the-wire system, the guidewire
difference between enters the balloon catheter and remains
“over-the-wire” and in the catheter along the entire length of
monorail balloon the balloon, exiting at the distal catheter
delivery systems? opening. This system has good pushability,
though is prone to loss of wire positioning
during balloon removal. In the monorail
system, the guidewire enters the balloon
catheter but exits the catheter through
a side port of the balloon catheter. This
system is less pushable, though allows for
more rapid wire exchange.
What two types of Balloon-expandable and self-expandable
stent configurations stents. Either stent can have open (flexible)
are available? or closed (less flexible, less risk of plaque
protrusion) cell design, and either stent can
be covered or uncovered.
Where are they Balloon-expandable stents are stiff with
commonly used? high radial strength to avoid vessel recoil,
which make for good use in a vessel with a
calcified ostial lesion. These stents are sized
1:1 to the vessel and need a balloon to be
properly deployed. Self-expandable stents
have high elasticity and shape memory with
low radial force, meaning they are more
flexible and are usually placed in tortuous
vessels or those which may experience
movement such as the iliac and femoral
arteries. Self-expandable stents should
be slightly oversized by approximately
10–15%. Balloon-expandable stents are not
suited for anatomical areas of flexion as
this can lead to permanent crushing of the
stent.
(continued)
142 O. Ajibola and A. Mousa

What is a drug-­ Drug-eluting stents may contain polymer

eluting stent? (Eluvia; Boston Scientific) or polymer-­
free (Zilver PTX; Cook Medical) coating
containing a chemotherapy drug, paclitaxel,
which is an antimitotic agent. The rationale
for drug coating is to help prevent the
process of neointimal hyperplasia and
in-stent restenosis and improve patency
of stents. It is important to remember
that neointimal hyperplasia is reparative
response of the artery to angioplasty, and
while it contributes to in-stent restenosis,
it is actually protective against platelet
aggregation. Therefore, dual antiplatelet
therapy following these procedures is very
important.

General Step by Step

What is the The choice of access is variable and dependent
preferred access on disease location and extent, coexisting iliac
site for PAD and femoral disease, and plaque morphology.
treatment? Depending on the planned treatment, access
can be unilateral or bilateral, ipsilateral or
contralateral, or even be approached from
the upper extremity (axillary, brachial, radial).
Traditionally, retrograde femoral artery access
is most common and is most safely performed
under ultrasound and fluoroscopic guidance
over the level of the femoral head.
 20 Peripheral Arterial Disease 143

What is the This is to connect the sheath to a continuous

next step drip of heparinized saline and use a wire to
after gaining gain access to the true lumen of the vessel
arterial access across the lesion to be treated. Occlusions may
and placing a require hydrophilic wires and angled braided
sheath? catheters for directional change. Heparinized
saline is given to prevent clot formation which
can break up and flow downstream causing
new, distal vessel occlusion.
What is vessel Operators may choose to “prep” the vessel
preparation? with atherectomy to decrease the amount of
disease in the vessel prior to angioplasty and
stent placement, which can help in enhancing
the effects of angioplasty, reducing the chances
for dissection, and improve luminal gain and
drug delivery from stents. There are many
atherectomy devices available, as well as
protective devices for distal embolization,
which can be used concurrently to trap any
dislodged clots.
What if I Sometimes, plaque morphology favors
can’t cross an approach from the opposite direction, so
occlusion or retrograde access beyond the lesion may
my wire enters be considered. If planning stent placement,
the subintimal reentry devices are available to bypass the
space? lesion in the extra-intimal space and then
reenter the true lumen beyond the level of
disease.
What do I do Balloon angioplasty can be performed after
after I deploy a deploying self-expanding stents to promote
stent? good wall adherence. Postprocedural
angiography should be performed at the level
of the disease to ensure good inline flow, as
well as in the distal extremity to document any
improved flow or distal capillary blush.
(continued)
144 O. Ajibola and A. Mousa

What is a Manual pressure above the arteriotomy

closure device? site can be utilized to achieve hemostasis,
typically for 10–15 minutes or even longer in
an anticoagulated patient. Closure devices are
tools that can deposit thrombogenic material
on top of the arteriotomy site or introduce a
suture to close the arteriotomy, which helps
in achieving hemostasis. These tools should
be supplanted by manual pressure and close
observation for possible incorrect deployment
or device failure.

Complications
Aside from Remember that angioplasty is controlled
access vessel injury and there is always a risk of
complications, vessel wall rupture and/or dissection, which
what may be visualized as a dissection plane or
complications extraluminal contrast extravasation. Procedural
can occur pearls are to never lose wire access across a
during an lesion and always have a balloon and covered
endovascular stent available to tamponade bleeding. The
procedure? most common complication is distal occlusion
secondary to emboli from an atherosclerotic
plaque. Other complications are distal
occlusion secondary to emboli from an
atherosclerotic plaque or new clot, which can
form during the procedure if heparinized saline
fails to run through the vascular sheath.
What are some Stent fracture, stent migration, and stent
more late-term collapse.
complications?
How do you Evaluation of the puncture site, femoral, and
monitor distal pulses should be checked routinely
for acute during the immediate post-op period and
complications? daily until the patient is discharged from the
hospital.
 20 Peripheral Arterial Disease 145

What are the Dissection, thrombosis, pseudoaneurysm, and

complications fistula.
that can occur
at the puncture
site?

Landmark Research
What was the The PARC study was designed to address the
goal of the lack of standardized definitions in the field
PARC study? of lower extremity peripheral artery disease
research. The Peripheral Academic Research
Consortium (PARC), the US FDA, and the
Japanese Pharmaceuticals and Medical Devices
Agency joined forces to develop a set of
definitions for clinical characterization and
treatment options to be used by clinicians,
researchers, and medical device developers.
What are The study helped define patient symptoms
some things according to already existing classification
that were systems – the Fontaine and Rutherford systems.
defined by the Other definitions were established in the
PARC study? following categories:
 Anatomy, including characteristics of lesions
and vessels
 Acute procedural outcomes
 Clinical outcomes
 Imaging and physiologic surrogate endpoints
Why were They are important because it helps classify
these patients into groups that be easily followed in
definitions research when evaluating new therapies as well
important? as continued improvement of existing treatment
options. It allows for all parties involved in
the diagnosis and treatment of PAD to have a
common language, allowing research in this field
to grow.
(continued)
146 O. Ajibola and A. Mousa

What is the The IN.PACT SFA trial was a prospective

INPACT trial? multicenter randomized controlled trial that
involved 331 patients to compare drug-coated
balloon (DCB) angioplasty with traditional
percutaneous transluminal angioplasty (PTA) in
the treatment of superficial femoral artery (SFA)
and proximal popliteal artery disease. There were
many other clinical trials that addressed similar
goals, including the LEVANT and the RAPID
trials; however, the INPACT trial was the largest
prospective, multicenter, randomized trial.
What are the The IN.PACT SFA trial showed that DCB was
results of the superior to PTA in improvement of patient
INPACT trial? outcomes for peripheral arterial disease and that
they had a favorable safety profile when treating
femoropopliteal arterial disease.
How were Functional outcomes for both investigational
the results and control groups were unchanged from
demonstrated baseline in terms of quality of life. Both groups
in functional also demonstrated improvement from baseline
outcomes? in terms of walking impairment in a period of
12 months; there was no statistical difference in
both groups.
So then, how Three- and five-year data shows patients
are DCBs that underwent DCB had better primary
more effective vessel patency and a marked reduction for
than PTAs? revascularization and retreatment of the target
lesion. This means that DCBs were able to keep
areas of critical stenosis open longer and reduced
the need for retreatment of the area down the
road. Although functional outcomes were similar
across both groups, DCB proved to be safer and
with less complications.
 20 Peripheral Arterial Disease 147

Common Questions
What is Patients should not eat or drink anything at least
the pre-­ 4–6 hours before their procedure. Patients who
procedure take medications should discuss with their doctor
status for a which medication can and cannot be taken the
patient? day of the procedure and, also importantly, when
certain medications can be stopped and resumed
after the procedure.
Why is It is important to monitor results of the
patient intervention performed and to prevent further
follow-up disease progression.
important?
Is there a There has not been much vigorous research
standardized and trials in regard to the timeline for patient
imaging follow-up and what imaging study should be used
technique to evaluate the patient. There is an agreement that
or protocol the same imaging modality should be used when
when it following patients to have stable comparisons.
comes to
patient
follow-up?
What is the The modality of choice for follow-up is
modality ultrasound. There are many advantages to this
of choice modality such as being noninvasive, low cost,
for imaging wide availability, and lack of radiation. The
follow-up? major disadvantages are its operator dependent
and artifacts on imaging which can happen with
calcifications and stents.
(continued)
148 O. Ajibola and A. Mousa

What other Other imaging modalities include computer

modalities tomography angiography or CTA and magnetic
are used for resonance angiography or MRA. CTA is a
follow-up? noninvasive imaging modality that is widely
available, is not significantly operator dependent,
can be rapidly performed, and can accurately
evaluate the complications of PAD intervention.
Disadvantages of CTA are ionizing radiation
and the risk of contrast-induced contrast injury.
MRA is another noninvasive imaging modality
that can be used to evaluate PAD interventions.
Limitations include artifacts such as susceptibility
and flow-related.
What Patients are usually advised and encouraged
are some to stop smoking. Patients are also started on
important antiplatelet therapy; most patients are started on
actions after aspirin and Plavix. Patients are also encouraged
a procedure to exercise and eat healthy food. These are just as
is done? important as the procedure in ensuring long-term
success.
When should Patients are usually seen in clinic for the first time
a person 1 month after their intervention. Imaging should
be seen have been done before the visit. A good history
for clinical and physical should be performed including
follow-up? examination of the affected extremity.

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versus uncoated balloon angioplasty. JACC: Cardiovasc Interv.
2014;7(1):10–9. ISSN 1936-8798. https://doi.org/10.1016/j.
jcin.2013.05.022.
Schillinger M, Minar E. Percutaneous treatment of peripheral artery
disease: novel techniques. Circulation. 2012;126(20):2433–40.
https://doi.org/10.1161/CIRCULATIONAHA.111.036574.
Sos T. Brachial and axillary arterial access. Endovasc Today.
2010;5:55–8.
Tepe G, Laird J, Schneider P, et al. Drug-coated balloon versus
standard percutaneous transluminal angioplasty for the treat-
ment of superficial femoral and popliteal peripheral artery
disease: 12-month results from the IN.PACT SFA randomized
trial. Circulation. 2015;131(5):495–502. https://doi.org/10.1161/
CIRCULATIONAHA.114.011004.
Valji K. The practice of interventional radiology. 2nd ed. Philadelphia:
Saunders; 2012.
Chapter 21
Acute Venous
Thromboembolic Disease
Sabeeha Chowdhury and Peyton Cramer

Evaluating Patient
Acute venous Deep vein thrombosis (DVT) and
thromboembolic pulmonary embolism (PE)
(VTE) disease includes
which two entities?
What is a deep vein Deep vein thrombosis refers to the
thrombosis (DVT)? presence of thrombus, or blood clot,
within veins of deep compartments of the
body, most commonly within the lower
extremities. Thrombi within superficial
veins are not DVT but are a part of a
separate more benign entity known as
superficial thrombophlebitis.
(continued)
S. Chowdhury (*)
Department of Interventional Radiology, Medstar Georgetown
University Hospital, Washington, DC, USA
P. Cramer
Department of Radiology, New York Presbyterian Hospital Weill
Cornell Medicine, New York, NY, USA
McGovern Medical School, UT Health Science Center at Houston,
Houston, TX, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 151

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_21
152 S. Chowdhury and P. Cramer

How does an acute Most will have symptoms at the site of

DVT present? thrombus such as swelling, warmth, pain,
tenderness, or skin redness.
How are DVTs By the duration of symptoms:
classified?  Acute: 0–14 days
 Subacute: 15–28 days
 Chronic: Greater than 28 days
What is a A pulmonary embolism refers to the
pulmonary intravascular migration of a venous
embolism (PE)? thrombus to a pulmonary artery through
the process of clot fragmentation and
embolization.
What is the A low-risk PE is defined by the absence
difference between of right heart strain (as indicated on
a low-risk, imaging as a RV:LV < 0.9), a PESI score
intermediate-risk, less than 1, or a patient lacking significant
and high-risk PE? clinical symptoms. An intermediate-risk
PE is defined by right heart dysfunction
(RV:LV ≥ 0.9) or PESI score ≥ 1 in the
setting of normal systemic blood pressure.
Intermediate-risk PE is further divided into
intermediate low risk and intermediate
high risk based on the absence or presence,
respectively, of elevated cardiac biomarkers.
A high-risk PE indicates that there is
severe right heart dysfunction resulting
in sustained hypotension (systolic blood
pressure < 90 mmHg for at least 15 minutes
or requiring inotropic support).
 21 Acute Venous Thromboembolic Disease 153

What͐ is the The PESI score is a risk stratification

Pulmonary tool that can be used to determine risk
Embolism Severity of mortality and long-term morbidity in
Index (PESI) and patients with newly diagnosed PE. This
how is it used in PE score takes into account 11 clinical criteria
management? including age, gender, history of malignancy,
history of heart failure, history of chronic
lung disease, heart rate ≥ 110, systolic
blood pressure < 90, respiratory rate ≥ 30,
temperature < 36°C, altered mental status
(AMS), and oxygen saturation (SpO2)
< 90. Various points are given for each
clinical feature (with the heaviest weight
placed on AMS, history of malignancy, and
hypotension) to place patients into risk
categories. These categories are associated
with the following 30-day mortality rates:
 Very low risk: 0–1.6%
 Low risk: 1.7–3.5%
 Intermediate risk: 3.2–7.1%
 High risk: 4.0–11.4%
 Very high risk: 10.0–24.5%
This tool can also aid in distinguishing
which patients can be treated as an
outpatient and which require higher level
of care. Very low- and low-risk patients are
often considered for outpatient treatment
of PE (anticoagulation and follow-up care
in the PE/DVT clinic, with a primary care
physician, and hematology); however, the
decision ultimately takes into account the
entire clinical scenario.
What is the utility Echocardiogram provides very useful data
of echocardiogram in the evaluation of right heart strain and
in evaluation cardiac physiology, including potential
of pulmonary identification of a PFO.
embolism patients?
(continued)
154 S. Chowdhury and P. Cramer

What symptoms Rapid onset dyspnea, pleuritic chest pain,

should raise the hypoxia, tachycardia, and an increased
suspicion for alveolar-arterial oxygen gradient without
a pulmonary another obvious explanation
embolism?
What is May-­ May-Thurner syndrome is an anatomic
Thurner syndrome? variant in which the left common iliac
vein is compressed by the right common
iliac artery against the lumbar spine.
This compression may result in left lower
extremity thrombus formation related to
the altered flow mechanics in this disease
state.
What is a A venous thromboembolism that traverses
paradoxical through an intracardiac or pulmonary
embolism? (right-to-left) shunt and embolizes into the
systemic circulation. Depending on the site
of embolization, this can lead to stroke,
myocardial infarction, gastrointestinal
ischemia, renal infarction, or ischemic
extremities.
What is post-­ PTS is a chronic condition related to
thrombotic venous outflow obstruction, inflammation
syndrome (PTS)? and valve destruction, and negative
remodeling of the veins. It is characterized
by high venous pressures and can present
clinically as varicose veins, venous stasis
dermatitis, venous stasis ulcers, and venous
claudication. Venous hypertension and
inflammation can lead to increased vessel
permeability and lymphedema.
 21 Acute Venous Thromboembolic Disease 155

High Yield History

What is Virchow’s Three factors that predispose to
triad? thrombus formation: slow blood flow,
hypercoagulability, and endothelial
damage.
What are some Factor V Leiden (most common),
genetic causes of antithrombin III deficiency, protein
hypercoagulable states? C deficiency, protein S deficiency,
hyperhomocysteinemia, and
prothrombin G20210A mutation
What are some Surgery, trauma, malignancy,
acquired causes of immobilization, smoking, obesity,
hypercoagulable states? nephrotic syndrome, and oral
contraception pills
What is a Wells score? The Wells score is a noninvasive
scoring system to determine the pretest
probability of having an acute PE. A
score of four or less makes a PE
“unlikely,” whereas a score of greater
than four points makes a PE “likely.”
What factors are Clinical signs and symptoms of
incorporated into the DVT, heart rate >100 bpm, previous
Wells score? immobilization or surgery, previous
PE or DVT, hemoptysis, or recent
malignancy
What is the best test D-dimer is often used because of its
for a patient with low high sensitivity. A negative test can
probability of having rule out acute thrombus; however, a
VTE? positive test is inconclusive because it is
nonspecific.
What is the best test Ultrasound with Doppler. The four
for a patient with a signs seen on ultrasound include non-­
high probability of compressibility of the vein, intraluminal
having a DVT? echogenicity, loss of flow, and loss
of augmentation response. The most
specific sign is non-compressibility of
the vein.
(continued)
156 S. Chowdhury and P. Cramer

What are the important Sinus tachycardia is the most common

electrocardiographic finding. The S1Q3TE pattern is the
considerations for “classic” finding; however, it is rarely
pulmonary embolism? present. Another important finding to
be aware of is left bundle branch block
(LBBB), in which there is widening
of the QRS interval and patients
are susceptible to complete heart
block during pulmonary angiogram
or intervention (risk of RBBB and
therefore complete heart block).
These patients should be checked
for a permanent pacemaker, should
have minimal manipulation of the
RV septum during intervention, and
should be considered for backup
temporary pacing or electrophysiology
consultation.
What findings on Wedge-shaped peripheral airspace
plain film suggest a disease (Hampton hump), focal
pulmonary embolism? oligemia (Westermark sign), prominent
central pulmonary artery (knuckle sign),
or prominent right main pulmonary
artery (Fleischner sign)
What is the best test Computed tomography pulmonary
for a patient at high angiography (CT-PA) because the fast
risk for PE? data acquisition, thin slices, and rapid
bolus of IV contrast injection produce
maximal opacification of the pulmonary
arteries with little or no motion artifact.
CT-PA has a sensitivity in excess of 90%
for identifying partial or complete filling
defects within the pulmonary arteries.
 21 Acute Venous Thromboembolic Disease 157

What is the significance An increased RV to LV ratio is one of

of the RV to LV ratio? the criteria used to risk stratify patients
between low and intermediate risks.
An important concept to understand
here is RV/LV interdependence. As the
RV pressure increases from pulmonary
hypertension, the interventricular
septum is pushed into the LV cavity,
which impairs diastolic filling and
reduces cardiac output and blood
pressure. An increased RV to LV ratio
indicates a larger than normal RV and
a smaller than normal LV. The RV is
perfused during systole and diastole
and is very sensitive to systemic
hypotension, and ischemia plays a major
role in onset of cardiogenic shock.

Indications/Contraindications
What is the standard Oral anticoagulation for 3–6 months
treatment for acute
DVT?
What is catheter-­ Percutaneous introduction of a catheter
directed thrombolysis into the venous system to infuse a
(CDT)? pharmacologic thrombolytic agent
directly into the thrombus. CDT is
more efficacious for acute (fibrin-rich)
vs. chronic (collagen-rich) clot. Its use
requires inpatient admission and close
monitoring in the ICU for any possible
signs of bleeding or hemodynamic
instability while receiving thrombolytic
infusions.
(continued)
158 S. Chowdhury and P. Cramer

Are percutaneous No, they are recommended as adjuncts

thrombectomy and to systemic anticoagulation.
CDT stand-alone
therapies in the setting
of acute DVT?
What are the 1. Acute iliofemoral DVT in ambulatory
indications for patients with low bleeding risk and long
CDT according life expectancy
to the Society of 2. Highly symptomatic subacute and
Interventional chronic iliofemoral DVT
Radiology (2014) 3. Acute or subacute IVC thrombosis
recommendations? 4. Limb-threatening conditions
Why is aggressive These patients tend to be highly
therapy recommended symptomatic and are at high risk
for iliofemoral for recurrent DVT, post-thrombotic
thrombus? syndrome, and late disability when
treated with anticoagulation alone.
What are the absolute 1. Active internal bleeding or DIC
contraindications to 2. Recent cerebrovascular event,
CDT? neurosurgery, or intracranial tumor (<3
mo)
3. Absolute contraindication to
anticoagulation
4. Intracranial trauma within the last
3 months
What is the standard Oral anticoagulation for 3–6 months
treatment for low-risk (provoked) or life (unprovoked), similar
PE? to acute DVT
 21 Acute Venous Thromboembolic Disease 159

What is the standard Systemic thrombolysis, thrombectomy,

treatment for and CDT are all acceptable options
intermediate- or high-­ for massive PE treatment. The Society
risk (traditionally of Interventional Radiology (2018)
“submassive” and recommendations state that data are
“massive”) PE? insufficient to support the routine use
of CDT for patients with submassive
PE. Mechanical thrombectomy is an
emerging strategy used to treat massive
and submassive PE with promising
results, though early data is limited.
Mechanical thrombectomy has been
considered the primary alternative to
surgical embolectomy in patients with
submassive to massive PE in whom
there is an absolute contraindication for
or failure of systemic thrombolysis. In
patients with submassive PE, catheter-­
directed therapy has been shown
to decrease the need for treatment
escalation and decreases time for
clinical improvement but does not
increase overall survival.
When should a When a patient has evidence of PE or
therapeutic inferior DVT (IVC, iliac, or femoropopliteal)
vena cava filter be plus one or more of the following:
placed?  Absolute or relative contraindication
to anticoagulation
 Complication of anticoagulation
 Failure to reach therapeutic levels of
anticoagulation
 Propagation/progression or
recurrence of DVT or PE while on
therapeutic anticoagulation
 Massive PE with residual DVT in a
patient at risk for further PE
 Free-floating iliofemoral or IVC
thrombus
 Severe cardiopulmonary disease and
DVT
(continued)
160 S. Chowdhury and P. Cramer

Relevant Anatomy
What are the Popliteal, femoral, deep femoral, common
proximal deep femoral, iliac, and IVC. When referring to
veins of the lower iliocaval intervention, inflow veins are the
extremity? femoral, deep femoral, common femoral,
and iliac veins. Normalized inflow and
outflow are the goal to restore patency,
including in cases of PTA or stent.
What are the deep Anterior tibial, posterior tibial, peroneal,
veins of the calf? and/or deep muscular veins
What are the deep Radial, ulnar, brachial, axillary, and
veins of the upper subclavian veins
extremities?
Where is the IVC The IVC forms at the confluence of the
located? right and left common iliac veins (L5),
travels along the right aspect of the
vertebral column, and passes through the
central tendon of the diaphragm (T8) to
empty into the right atrium.
At which Main pulmonary, truncus anterior,
pulmonary interlobar, and basal trunk arteries
arterial levels are
interventions most
efficacious?
 21 Acute Venous Thromboembolic Disease 161

Relevant Materials
What type of catheter For pharmacologic CDT, a catheter
should be used during with multiple side holes, known as
pharmacomechanical an infusion catheter, such as Cragg-­
CDT? McNamara, can be placed across
the entire length of the thrombus to
allow for infusion of a thrombolytic
agent directly within the clot. For
mechanical thrombectomy, there are
numerous devices available that allow
for maceration and/or aspiration
of thrombus. Pharmacomechanical
therapies involve a combination of
both of these methods.
What is a common type A coaxial system with a 5- or 6-Fr
of infusion system used sheath at the access site and a 5-Fr
during pharmacologic infusion catheter of appropriate length
CDT? to reach the site of thrombus is a
common system used.
Which thrombolytic Alteplase (tPA) or reteplase (rPA).
agents are commonly Relatively low doses of thrombolytic
used during CDT? agents are required during CDT in
comparison with systemic therapy
since the clot is directly bathed in
thrombolytics. A commonly used
dose of tPA is about 0.01 mg/kg/h or
0.5–1.0 mg/hr in CDT, as opposed to
the 0.9 mg/kg/h required in systemic
delivery tPA.
What is the appropriate Patients should be anticoagulated
activated clotting time throughout the procedure to achieve
for CDT or mechanical an activated clotting time (ACT) of
thrombectomy? 250–300 seconds or at least 1.5–2 times
a baseline ACT. When a baseline ACT
is unavailable, it can be assumed to be
less than 150 seconds.
(continued)
162 S. Chowdhury and P. Cramer

What is a benefit Mechanical thrombectomy avoids the

of mechanical use of a lytic agent and the associated
thrombectomy complications. It also obviates the need
compared to CDT or for ICU stay.
pharmacomechanical
thrombectomy?
What types of stents are Venous stents have high radial force
used in the iliac veins? and are resistant to compression.
Wallstents (Boston Scientific; Boston,
MA) were traditionally used off-label,
but newer, high radial force stents are
available, which are FDA approved for
iliac vein stenting.

General Step by Step

What are the The posterior tibial or popliteal veins
preferred access on the affected side are preferred sites
sites during lower to gain access. However, access can be
extremity VTE obtained from any deep venous system
intervention? lower extremity vein or the internal
jugular vein.
What is the preferred Generally, the right femoral vein at the
access site for PE groin is the preferred access site in the
intervention? absence of iliofemoral thrombosis. Some
operators prefer internal jugular vein
access.
 21 Acute Venous Thromboembolic Disease 163

What cardiac 1. Obtain an EKG and echocardiogram.

precautions should 2. Continuous cardiac monitoring is
be taken prior required in all patients and in select cases;
to performing consult with anesthesia consultation
pulmonary artery may be helpful (need for intubation
catheterization? and general anesthesia in borderline
stable patients). Intubation and general
anesthesia worsen right ventricular strain
and should only be used when absolutely
needed (unstable patients and those with
progressive respiratory distress).
3. After obtaining venous access, right heart
and pulmonary arterial pressure should be
obtained. Right ventricular end-­diastolic
pressure should be ≤ 20 mmHg, and
pulmonary artery systolic pressure should
be ≤ 70 mmHg. Higher pressures have
been associated with underlying pulmonary
hypertension and increased mortality. In
cases of pulmonary hypertension pressure,
use of nonionic contrast media and
modification of the injection technique,
such as performance of subselective
injection, can be employed as safety
measures.
How is the patient If accessing from the posterior tibial or
positioned on the popliteal veins, the patient must be prone
table in order to gain on the table.
posterior access?
(continued)
164 S. Chowdhury and P. Cramer

After gaining access Venography is performed using a

into the deep venous diagnostic catheter to visualize the clot
system, how is the burden under fluoroscopy. Intravascular
anatomic extent of ultrasound (IVUS) is an adjunctive tool to
thrombus defined? aid in mechanical thrombectomy and iliac
stenting. It is very useful to characterize
clot, as well as size and place stents (and
ensuring appropriate stent apposition to
the wall post-deployment). It can also
help ensure clot removal (extent of clot
often not fully visualized on venography)
as residual clot burden plays a role in
reduced inflow and stent patency, as well
as persistence and possible worsening of
post-thrombotic syndrome.
How long are For DVT, CDT is typically performed
thrombolytic infusion for 24–48 hours. For PE, it is typically
catheters generally performed for 12 hours or less. Certain
kept in place? devices may be placed for dwell for a
30-minute time period, which can be
followed by maceration and/or active
aspiration of thrombus.
If initial infusion-­ Balloon maceration, catheter aspiration,
first CDT does not thrombectomy device systems, and/or
achieve an open vein additional thrombolytics can be used to
or prevent immediate remove residual thrombus.
re-thrombosis, what
adjunctive therapies
can be applied?
What is the endpoint The endpoint is variable upon the clinical
of therapy? circumstances. General guidelines used to
define completion of procedure in various
studies include observation of near-­
complete (> 90%) clot burden reduction
on venogram, signs of clinical bleeding,
or visible reduction in clot burden on two
consecutive venograms with restoration
of flow.
 21 Acute Venous Thromboembolic Disease 165

In what settings Stenting would be reasonable to treat

would stenting be obstructive or stenotic lesions in the
appropriate for DVT affected vein with ≥ 50% diameter
management? narrowing or the formation of robust
collateral veins, seen as numerous
capillary-like vessels that form in response
to prolonged obstruction as a bypass.
Obstructive lesions in the distal femoral
or popliteal veins are often treated
with percutaneous transluminal balloon
angioplasty without stent placement as
stents have a higher likelihood of failure
near mobile joints. However, treatment
varies greatly between cases.
Is CDT commonly Although there are no dual-armed
used to treat randomized control trials to compare
pulmonary embolus the effectiveness of CDT over systemic
(PE)? anticoagulation for PE treatment,
numerous endovascular techniques and
devices have been used off-label to treat
PE. Small reviews have found faster
resolution of the thrombus when treating
with CDT than with heparin alone and
significant reduction of pulmonary
hypertension within 2 hours of treatment.
CDT may reduce mortality in PE patients
who are hemodynamically unstable but
has not been seen to decrease mortality or
recurrent PE in stable patients.
When should the Although this is typically up to physician
sheath be removed discretion, sheaths should not be removed
from the access sites? any less than 1 hour after the final dose
of thrombolytics or unfractionated
heparin bolus is given. If using manual
compression to achieve hemostasis,
consider doubling the compression time.
For larger mechanical thrombectomy
systems and venotomies, figure-of-eight
stitch and vascular closure devices can be
used.
(continued)
166 S. Chowdhury and P. Cramer

How long should The patient should remain at bedrest with

the patient’s treated the accessed limb immobile for 4–6 hours,
extremity remain after which the patient may ambulate as
immobile post-­ tolerated. Early ambulation is desirable to
procedure? encourage optimal flow dynamics within
the vasculature.
When should Therapeutic anticoagulation should be
therapeutic resumed within 2 hours after sheath
anticoagulation removal and access site hemostasis.
be restarted post-­ Unfractionated heparin and low
procedure? molecular weight heparin are often
used to bridge patients to an oral
anticoagulation agent until therapeutic
levels are reached. The oral anticoagulant
is started the same day as sheath removal.
For DVT cases, oral anticoagulant should
be continued for 3 months to 6 months,
depending on presence or absence of
PTS. If stents are placed, antiplatelet
therapy should be added.
What is the Follow-up after treatment of lower
follow-up regimen extremity DVT consists of imaging
after treating lower surveillance often with venous duplex
extremity DVT? ultrasound and monitoring for clinical
signs and symptoms of recurrent DVT or
development of PTS. The time frame for
follow-up is extremely variable depending
upon severity of initial disease and
institutional practice often ranging from a
few weeks to months post-procedure. For
any patient who develops acute symptoms
of DVT recurrence, a CT venogram may
be considered.
 21 Acute Venous Thromboembolic Disease 167

Complications
What is the Bleeding is the most common complication
most common of CDT. Large volume hemorrhage is
complication of rare, which is generally considered to be
CDT? that which requires transfusion (about
3–5%) and causes intracranial bleeding or
bleeding that leads to fatality.
What measures Upsizing the sheath and/or compression
can be taken in the can be used to control percutaneous
event of bleeding at bleeding at the access site. If this
the venous access is unsuccessful, the thrombolytic
site? administration is generally discontinued.
What are the most Intracranial bleeding has been found to be
lethal complications associated with the highest mortality rate
associated with in this procedure.
CDT?
What is the risk of The absolute risk of intracranial
intracranial bleeding bleeding following CDT is unclear, but
with CDT? generally has been found to be rare in
the literature. A pooled analysis of 19
studies discussed in the 2014 quality
improvement guidelines for the treatment
of lower extremity DVT in JVIR found
reported rates to be between 0 and 1%
for intracranial bleeding following CDT,
in comparison with 3–6% with systemic
tPA, and about 0.25–1.5% with standard
oral anticoagulation. This data justifies
the contraindication for IV tPA use in the
treatment of most DVTs.
(continued)
168 S. Chowdhury and P. Cramer

What is the RIETE It is a score to predict the risk for major

score? bleeding within 3 months of anticoagulant
therapy in patients with acute deep vein
thrombosis. On multivariate analysis, age
> 75 years, recent bleeding, cancer,
creatinine levels > 1.2 mg/dl, anemia, and
pulmonary embolism at baseline were
independently associated with an increased
risk for major bleeding. The score is
composed of assigning 2 points to recent
bleeding, 1.5 to abnormal creatinine levels
or anemia, and 1 point to the remaining
variables.
 0 – low risk
 1–4 – intermediate risk
 > 4 high risk
What are common Hemoglobin < 9 mg/dl, INR > 1.6 before
laboratory starting warfarin therapy, or platelets
guidelines that < 100,000/mL. It should be noted that
suggest a poor these laboratory values are loosely defined
candidate for CDT? and differ based on individual clinical
scenarios.

Landmark Research
Attract trial
Vedantham S, Goldhaber SZ, Julian JA, et al.
Pharmacomechanical catheter-directed thrombolysis for
deep-vein thrombosis. N. Engl. J. Med. 377, 2240–2252 (2017).
• Multicenter analysis with 692 patients comparing rates of
post-thrombotic syndrome in patients with acute proximal
DVT receiving anticoagulation therapy alone versus anti-
coagulation plus pharmacomechanical thrombolysis
• Between 6 and 24 months of follow-up, there was no sig-
nificant difference in the percentage of patients who devel-
oped post-thrombotic syndrome (PTS) between the
 21 Acute Venous Thromboembolic Disease 169

anticoagulation alone and anticoagulation plus pharma-

comechanical thrombolysis groups
• The severity scores of PTS were significantly lower in the
pharmacomechanical thrombolysis group
• Pharmacomechanical thrombolysis also reduces early
deep vein thrombosis symptoms such as leg pain and calf
circumference
• Pharmacomechanical thrombolysis led to less major bleed-
ing (fatal or intracranial hemorrhage) than found in past
studies

CaVenT study
Enden T, Haig Y, Klow NE, et al. Long term outcome after
additional catheter-directed thrombolysis versus standard
treatment for acute iliofemoral deep vein thrombosis (the
CaVenT study): a randomised controlled trial. Lancet
2012;379:31–8.
Haig Y, Enden T, Grøtta O, et al. Post-thrombotic syn-
drome after catheter-directed thrombolysis for deep vein
thrombosis (CaVenT): 5-year follow-up results of an open-­
label, randomised controlled trial. Lancet Haematol
2016;3:e64-e71.
• Multicenter analysis with 209 patients comparing long
term outcome in patients with acute DVT
• This study found a decreased risk of PTS over periods 2
and 5 years in patients receiving catheter-directed throm-
bolysis as opposed to anticoagulation alone
• The difference in the CaVenT results and Attract trial have
been thought to be due to the difference in sample size,
geographic and demographic scope of the patients assessed
in each study, and the greater use of mechanical therapies
in the Attract trial as opposed to longer thrombolytic infu-
sions used in the CaVenT.
170 S. Chowdhury and P. Cramer

ULTIMA RCT
Kucher N, Boekstegers P, Müller OJ, et al. Randomized, con-
trolled trial of ultrasound-assisted catheter-directed throm-
bolysis for acute intermediate-risk pulmonary embolism.
Circulation. 2014 Jan 28;129(4):479-86. doi: https://doi.
org/10.1161/CIRCULATIONAHA.113.005544. Epub 2013
Nov 13.
• 59 patients with acute main or lower lobe pulmonary
embolism and echocardiographic right ventricular to left
ventricular dimension (RV/LV) ratio ≥1.0 were random-
ized to receive unfractionated heparin and ultrasound-­
assisted catheter directed thrombolysis (CDT) or
unfractionated heparin alone
• This study found significant reversal of right ventricular
dilatation at 24 hours in the CDT group, whereas no
improvement in right ventricular enlargement was found
in the heparin alone group.
• No major bleeding was found in either group

Society of Interventional Radiology Position Statement on

Catheter-Directed Therapy for Acute Pulmonary Embolism
Kuo, William T. et al. Society of Interventional Radiology
Position Statement on Catheter-Directed Therapy for Acute
Pulmonary Embolism. Journal of Vascular and Interventional
Radiology, Volume 29, Issue 3, 293–297.
• “The Society of Interventional Radiology (SIR) considers
the use of catheter directed therapy (CDT) or thromboly-
sis to be an acceptable treatment option for carefully
selected patients with massive (ie, high-risk) pulmonary
embolism (PE) involving the proximal pulmonary arterial
vasculature, in accordance with multidisciplinary guide-
lines. SIR defines acute proximal PE as new main or lobar
emboli identified on radiographic imaging within 14 days
of PE symptoms.”
 21 Acute Venous Thromboembolic Disease 171

SEATTLE II
Piazza G, Hohlfelder B, Jaff MR, et al. A Prospective, Single-­
Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-­
Directed, Low-Dose Fibrinolysis for Acute Massive and
Submassive Pulmonary Embolism: The SEATTLE II Study.
JACC Cardiovasc Interv. 2015 Aug 24;8(10):1382–92. doi:
https://doi.org/10.1016/j.jcin.2015.04.020.
• 150 patients with acute massive (n = 31) or submassive
(n = 119) PE and right ventricular to left ventricular diam-
eter (RV/LV) ratio ≥0.9 on chest computed tomography
received catheter directed thrombolytics to assess safety
and efficacy of CDT in treating PE in a single arm, pro-
spective, multi-center trial
• The study found that catheter-directed, low-dose fibrinoly-
sis reduced RV dilation, decreased pulmonary hyperten-
sion, decreased anatomic thrombus burden, and yielded a
lower rate of intracranial hemorrhage in patients with
acute massive and submassive PE.

PERFECT
Kuo WT, Banerjee A, Kim PS, et al. Pulmonary Embolism
Response to Fragmentation, Embolectomy, and Catheter
Thrombolysis (PERFECT): Initial Results From a Prospective
Multicenter Registry. Chest. 2015 Sep;148(3):667–673. doi:
https://doi.org/10.1378/chest.15-­0 119.
• Prospective multicenter study of 101 patients treated with
CDT for acute PE to evaluate for safety and efficacy of
CDT.
• Clinical efficacy was defined as achieving stabilization of
hemodynamics, improvement in pulmonary hypertension,
or improved right-sided heart strain.
• Efficacy was achieved in 24 of 28 patients with massive PE
(85.7%; 95% CI, 67.3%–96.0%) and 71 of 73 patients with
submassive PE (97.3%; 95% CI, 90.5%–99.7%)
• CDT improves clinical outcomes in patients with acute PE
while minimizing the risk of major bleeding
172 S. Chowdhury and P. Cramer

FLARE study
Tu T, Toma C, Tapson VF, Adams C, et al. A Prospective,
Single-Arm, Multicenter Trial of Catheter-Directed
Mechanical Thrombectomy for Intermediate-Risk Acute
Pulmonary Embolism. JACC Cardiovasc Interv. Volume 12,
Issue 9, May 2019. doi: https://doi.org/10.1016/j.
jcin.2018.12.022.
• Prospective multicenter study of 106 patients treated with
percutaneous mechanical thrombectomy (FlowTriever
System) for treatment of acute intermediate-risk PE to
evaluate safety and effectiveness
• Primary effectiveness endpoint was defined as reduction
in RV/LV ratio. Primary safety endpoint included any
major bleeding or device related complication within
48 hours of treatment.
• There was an average 25% reduction in RV/LV ratio with
minimal major bleeding or device-related complications (4
patients, 3.8%).
• Mechanical thrombectomy is safe and effective in treat-
ment of PE, as previously found in prior studies.

Common Questions
How long is Oral anticoagulation is recommended
anticoagulation for a minimum of 3 months after initial
therapy VTE. Optimal duration of anticoagulation
recommended after past 3 months remains unknown and
initial VTE? depends on the underlying cause of VTE, if
identifiable.
 21 Acute Venous Thromboembolic Disease 173

What is the best It is important to maintain adequate

way to prevent anticoagulation before, during, and after
symptomatic any endovascular DVT treatment. It is
PE after DVT also important to avoid the use of only
treatment? mechanical thrombolysis in patients who
are eligible to receive pharmacologic
thrombolysis as well. Routine
placement of IVC filters before or after
pharmacomechanical therapy procedures is
not recommended.
What is the utility To monitor for recurrent DVT, valvular
of ultrasound insufficiency, or other venous damage
surveillance during
clinical follow-up?
When should IVC Patient has no indication for permanent
filter removal be filter.
considered? Risk of PE is acceptably low (achievement
of sustained appropriate primary treatment
or change in clinical status).
Patient is not anticipated to return to a
high-risk hypercoagulable state for PE.
Life expectancy is greater than 6 months.
Filter can be safely retrieved.
Patient agrees to removal.
What resources Patients may be offered the option to
can be offered wear graduated compression stockings
to patients post-­ (20–30 mmHg or 30–40 mmHg) daily.
procedurally to Although stockings are generally effective
reduce lower at decreasing lower extremity swelling, they
extremity swelling? have not been shown to prevent PTS.
When should a The patient should be evaluated in clinic
patient follow within 1 month of procedure. Proper
up in clinic post-­ maintenance of oral anticoagulation is
procedure? essential to avoid re-thrombosis.
174 S. Chowdhury and P. Cramer

Further Reading
Albers GW, Bates VE, Clark WM, Bell R, Verro P, Hamilton
SA. Intravenous tissue-type plasminogen activator for treat-
ment of acute stroke: the Standard Treatment with Alteplase to
Reverse Stroke (STARS) study. JAMA. 2000;283(9):1145–50.
Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz
J, Roy PM, Fine MJ. Derivation and validation of a prognostic
model for pulmonary embolism. Am J Respir Crit Care Med.
2005;172(8):1041–6. Epub 2005 Jul 14
Baldwin Z, et al. Catheter-directed thrombolysis for deep venous
thrombosis. Vasc Endovasc Surg. 2004;28(1):1–9.
Caplin DM, Nikolic B, Kalva SP, Ganguli S, Saad WE, Zuckerman
DA, et al. Quality improvement guidelines for the performance
of inferior vena cava filter placement for the prevention of pul-
monary embolism. J Vasc Interv Radiol. 2011;22(11):1499–506.
Fleck D, Albadawi H, Shamoun F, Knuttinen G, Naidu S, Oklu
R. Catheter-directed thrombolysis of deep vein thrombosis:
literature review and practice considerations. Cardiovasc Diagn
Ther. 2017;7(Suppl 3):S228–37.
Kaufman JA, Kinney TB, Streiff MB, Sing RF, Proctor MC, Becker
D, et al. Guidelines for the use of retrievable and convertible
vena cava filters: report from the society of interventional
radiology multidisciplinary consensus conference. J Vasc Interv
Radiol. 2006;17(3):449–59.
Kuo WT, Sista AK, Faintuch S, Dariushnia SR, Baerlocher MO,
Lookstein RA, et al. Society of interventional radiology position
statement on catheter-directed therapy for acute pulmonary
embolism. J Vasc Interv Radiol. 2018;29(3):293–7.
Miller DJ, Simpson JR, Silver B. Safety of thrombolysis in acute isch-
emic stroke: a review of complications, risk factors, and newer
technologies. Neurohospitalist. 2011l;1(3):138–47.
Oklu R, Wicky S. Catheter-directed thrombolysis of deep venous
thrombosis. Semin Thromb Hemost. 2013;39(4):446–51.
O’sullivan GJ, Semba CP, Bittner CA, Kee ST, Razavi MK, Sze DY,
et al. Endovascular management of iliac vein compression (may-­
thurner) syndrome. J Vasc Interv Radiol. 2000;11(7):823–36.
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A
novel user-friendly score (HAS-BLED) to assess 1-year risk of
major bleeding in patients with atrial fibrillation: the Euro Heart
Survey. Chest. 2010;138(5):1093–100.
 21 Acute Venous Thromboembolic Disease 175

Protack C, Bakken A, Patel N, Saad W, Waldman D, Davies

M. Long-term outcomes of catheter directed thrombolysis for
lower extremity deep venous thrombosis without prophylactic
inferior vena cava filter placement. J Vasc Surg. 2007;45:992–7.
Ruíz-Giménez N, Suárez C, González R, Nieto JA, Todolí JA,
Samperiz AL, Monreal M. RIETE Investigators. Predictive
variables for major bleeding events in patients presenting with
documented acute venous thromboembolism. Findings from the
RIETE Registry. Thromb Haemost. 2008;100(1):26–31.
Thompson AE. Deep vein thrombosis. JAMA. 2015;313(20):2090.
Tu T, Toma C, Tapson VF, Adams C, et al. A prospective, single-
arm, multicenter trial of catheter-directed mechanical throm-
bectomy for intermediate-risk acute pulmonary embolism.
JACC Cardiovasc Interv. 2019;12(9) https://doi.org/10.1016/j.
jcin.2018.12.022.
Vedantham S, Millward SF, Cardella JF, Hofmann LV, Razavi MK,
Grassi CJ, et al. Society of interventional radiology position
statement: treatment of acute iliofemoral deep vein thrombosis
with use of adjunctive catheter-directed intrathrombus throm-
bolysis. J Vasc Interv Radiol. 2009;20(7 Suppl):S332–5.
Vedantham S, Sista AK, Klein SJ, Nayak L, Razavi MK, Kalva
SP, et al. Quality improvement guidelines for the treatment of
lower-extremity deep vein thrombosis with use of endovascular
thrombus removal. J Vasc Interv Radiol. 2014;25(9):1317–25.
Watson L, Broderick C, Armon MP. Thrombolysis for acute deep
vein thrombosis. Cochrane Database Syst Rev. 2014:CD002783.
Windecker S, Stortecky S, Meier B. Paradoxical embolism. J Am Coll
Cardiol. 2014;64(4):403–15.
Chapter 22
Mesenteric Ischemia
Akhil Khetarpal

Evaluating Patient
What are the two Acute mesenteric ischemia and chronic
main categories mesenteric ischemia.
of mesenteric
ischemia?
What is the main Delay in diagnosis is the main cause of the
reason for high high morbidity and mortality in patients
morbidity/mortality with acute mesenteric ischemia. The
in patients with symptoms can often be nonspecific and
acute mesenteric similar to other causes of abdominal pain,
ischemia? which can lead to misdiagnosis.
What are the Chronic mesenteric ischemia is associated
most common with chronic, intermittent postprandial
symptoms of pain and involuntary weight loss. These
chronic mesenteric symptoms should especially heighten your
ischemia? concern for diagnosis of this disease in the
elderly or in patients with cardiovascular
disease.
(continued)
A. Khetarpal (*)
Department of Vascular and Interventional Radiology, Virginia
Interventional and Vascular Associates (VIVA),
Fredericksburg, VA, USA

© Springer Nature Switzerland AG 2022 177

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_22
178 A. Khetarpal

What are the most Acute mesenteric ischemia is associated

common symptoms with severe abdominal pain, typically
of acute mesenteric epigastric pain, out of proportion to
ischemia? physical exam findings. Unfortunately,
these symptoms are nonspecific and may
be associated with many other common
causes of abdominal pain such as bowel
obstruction or infection. Acute mesenteric
ischemia should always be considered in
the differential for patients who present
with abdominal pain and also have risk
factors for acute mesenteric ischemia.
What laboratory A basic laboratory workup including a
tests should be CBC, BMP, and coagulation profile should
obtained? be obtained when evaluating patients with
mesenteric ischemia. In the case of acute
mesenteric ischemia, lactic acid should also
be monitored to help determine if there is
evidence for bowel ischemia and infarction.
What imaging tests A CTA of the abdomen and pelvis
should be obtained? should be obtained to evaluate the
mesenteric vessels for evidence of
thrombosis, embolism, or spasm. The
benefit of CTA is that it also allows you to
evaluate for evidence of bowel ischemia
(bowel distension, mucosal edema,
hyperenhancement, pneumatosis, free
air), as well as plan your intervention. In
patients with poor renal function or severe
iodinated contrast reactions, additional
imaging considerations include MRA and
Duplex US.
 22 Mesenteric Ischemia 179

How may arterial Underlying atherosclerotic disease may

intestinal ischemia be a clue toward arterial source of disease.
be differentiated Filling defects should be investigated in
from venous the arteries and veins, which may suggest
intestinal ischemia thrombus and embolus as etiologies. Lack
on CT? of mucosal enhancement is more common
with arterial ischemia, while “misty”
stranding of infiltrated mesenteric fat is
seen more with venous ischemia. Increased
attenuation of the bowel wall related to
submucosal hemorrhage or hyperemia and
pneumatosis intestinalis are also features
of venous ischemia.

High Yield History

What are the Chronic mesenteric ischemia is a slowly
important progressing etiology for abdominal pain.
elements of the Important questions to ask when performing a
patient history history in these patients are to determine the
in chronic chronicity of pain, any associated weight loss,
mesenteric if the pain is specifically postprandial, and if
ischemia? the patient has any history of cardiovascular
disease.
What are the Acute mesenteric ischemia has a rapid onset
important of symptoms. Important questions to ask when
elements of the performing a history in these patients are to
patient history in determine the acuity of pain, the quality of
acute mesenteric the pain (traditional description is pain out
ischemia? of proportion to exam findings), location of
pain, and any high-risk predisposing factors
for embolic events (e.g., atrial fibrillation) or
hypercoagulable state (e.g., factor V Leiden,
malignancy, protein C and S deficiency, etc.).
(continued)
180 A. Khetarpal

What is NOMI? NOMI stands for “nonocclusive mesenteric

ischemia.” This is a form of acute mesenteric
ischemia associated with low cardiac
output/hypovolemic states. There is no
focal obstructive lesion causing decreased
mesenteric blood flow but rather an overall
diminished volume of the mesenteric vessels.
What are the In cases of suspected NOMI, the history
important should aim at determining potential causes
elements of the of low cardiac output states. These include a
patient history history of heart failure, myocardial infarction,
in instances of recent hypovolemic state, renal failure, and
NOMI? liver failure.
What is an Mesenteric venous thrombosis resulting in
additional non-­ bowel ischemia is another form of acute
arterial cause mesenteric ischemia to know. Bowel ischemia
of mesenteric in this case is caused by venous outflow
ischemia to be obstruction due to venous thrombosis instead
aware of? of an arterial etiology.
What are the In cases of suspected mesenteric venous
important thrombosis, the history should aim
elements of the at determining potential causes of a
patient history hypercoagulable state. These causes can
in mesenteric include genetic predisposition, medication-­
venous induced hypercoagulability, liver failure, and
thrombosis? low cardiac output states resulting in venous
stasis.
 22 Mesenteric Ischemia 181

Indications/Contraindications
What is the most The presence of necrotic bowel
important factor that contraindicates an endovascular-­
would necessitate an only approach to treatment of acute
additional surgical mesenteric ischemia. In these cases, the
approach to treatment nonviable portion of the bowel needs
of a patient with acute to be resected. In these cases, open
mesenteric ischemia? surgical treatment of the affected vessel
can be performed, or a hybrid open and
endovascular approach to treatment can
be used.
What are the surgical The surgical options for treatment
options for treatment of acute mesenteric ischemia include
of acute mesenteric exploratory laparotomy/laparoscopy to
ischemia? evaluate for bowel ischemia followed by
mesenteric bypass, endarterectomy, or
embolectomy.
What are the The endovascular options for treatment
endovascular options of acute mesenteric ischemia include
for treatment of acute aspiration embolectomy, angioplasty,
mesenteric ischemia? stenting, and catheter-directed lysis.
The choice of treatment is dependent
on the underlying etiology behind
the development of acute mesenteric
ischemia.
What are treatment The treatment of NOMI is aimed at
options for NOMI? improving the generalized diminished
blood flow to the mesenteric vessels.
The treatment should employ a strategy
of general improvement in volume
status and treating the underlying cause
of the low cardiac output/hypovolemic
state. Catheter-directed vasodilator
injection into the mesenteric vascular
bed (papaverine) is a described
treatment strategy for NOMI.
(continued)
182 A. Khetarpal

What are treatment Treatment strategies in cases of

options for mesenteric mesenteric venous thrombosis are
venous thrombosis? aimed at both removing the clot burden
in the mesenteric venous system and
preventing the propagation of further
clot. Treatment options include systemic
anticoagulation, catheter-directed lysis,
and catheter-directed thrombectomy.
As in other cases of acute mesenteric
ischemia, nonviable bowel should be
surgically resected.
What is a It is important to know the
contraindication to contraindications to thrombolytic
use of thrombolytic therapy as they are applicable to many
therapy? disease processes treated in IR. The
major contraindications include patients
with high risk of bleeding, recent
trauma, recent large surgery, recent
gastrointestinal bleed, recent stroke, and
history of malignancy with associated
risk of bleeding from a large malignant
mass.
What are the surgical The open surgical options for treatment
options for treatment of chronic mesenteric ischemia include
of chronic mesenteric mesenteric bypass and mesenteric
ischemia? vessel endarterectomy.
What are the The endovascular treatment options
endovascular options for treatment of chronic mesenteric
for treatment of ischemia include mesenteric angioplasty
chronic mesenteric and stenting.
ischemia?
 22 Mesenteric Ischemia 183

Relevant Anatomy
What general bowel The celiac axis mainly supplies the
territory does the stomach and small bowel including the
celiac axis supply? duodenum and jejunum (more proximal
portions).
What general bowel The SMA mainly supplies the jejunum
territory does the (more mid and distal portions), ileum,
superior mesenteric right colon, and transverse colon.
artery (SMA) supply?
What general bowel The IMA mainly supplies the left colon,
territory does the sigmoid colon, and superior portion of
inferior mesenteric the rectum.
artery (IMA) supply?
What is the source The gastroduodenal artery provides the
of major collateral major collateral pathways between the
pathways between the celiac axis and SMA.
celiac axis and SMA?
What is the name of The marginal artery of Drummond which
the major arterial is found along the mesenteric border
collateral pathway of the colon and is formed by terminal
between the SMA branches of the middle colic artery (from
and IMA? What is the SMA) and terminal branches of the
the name of a direct left colic artery (from the IMA). The
arterial connection arc of Riolan is a branch that provides
between the SMA a more direct connection between SMA
and IMA? and IMA, usually connecting a more
proximal middle colic branch to a more
proximal left colic branch.
What is the most SMA
common artery
involved in cases of
acute mesenteric
ischemia?
(continued)
184 A. Khetarpal

What is the most SMV

common vein
involved in cases of
mesenteric venous
thrombosis?
In cases of mesenteric When vessel stenosis/thrombosis is
ischemia caused the underlying etiology for mesenteric
by vessel stenosis/ ischemia, the process typically occurs
thrombosis, what near the origin/proximal portion of the
portion of the vessel vessel.
is most commonly
involved?
In cases of mesenteric In embolic etiologies for mesenteric
ischemia caused by ischemia, the SMA is most commonly
embolic event, what involved, and the embolus typically
portion of the vessel lodges distal to the origin, beyond the
is most commonly first branch points.
involved?

Relevant Materials
What size base catheter A 4 or 5 French curved or reverse
is generally suitable for curved base catheter is generally used
selecting the mesenteric to select the mesenteric vessels. In
vessels? patients with a very downward-sloping
SMA origin, upper extremity access
may facilitate selecting the vessel.
What are the general The general categories of devices
categories of devices used in treating chronic mesenteric
that may be used in the ischemia are angioplasty balloons and
treatment of chronic endovascular stents.
mesenteric stenosis/
thrombosis?
 22 Mesenteric Ischemia 185

What are the general Devices used in treating acute

categories of devices mesenteric ischemia are angioplasty
that may be used in balloons, endovascular stents, lysis
the treatment of acute catheters, and suction/aspiration
mesenteric embolism/ embolectomy devices.
thrombosis?

General Step by Step

What is the most Femoral artery access is the most
common access commonly used access for mesenteric
site for mesenteric interventions.
interventions?
What are the Brachial artery or radial artery access is
situations in which typically used in cases of severely diseased
upper extremity iliofemoral vessels or in cases where the
access is beneficial origin of the SMA is difficult to cannulate
in performing from the femoral approach, such as in cases
mesenteric of a very downward-sloping SMA origin.
interventions? Left, as opposed to right, brachial or radial
artery access allows the operator to cross
over less of the head and neck vasculature
along the aortic arch.
When is a situation In certain cases, direct puncture into the
where direct access SMA may be performed, for example, in a
into the SMA is case where the patient’s abdomen is being
obtained? surgically explored to resect necrotic bowel
and endovascular revascularization is being
planned at the same time.
What additional If an intervention is planned, such as stent
support should deployment, a long sheath can be used to
be placed if add additional support to the catheter/
endovascular wire system to stabilize the system prior to
intervention is intervention, for example, a 6 or 7 French
planned on the curved sheath.
mesenteric vessels?
(continued)
186 A. Khetarpal

What are access The most commonly involved vessel in

options in cases of cases of mesenteric venous thrombosis is
mesenteric venous the SMV. The SMV drains into the portal
thrombosis? venous system which affects the type of
available access options. Percutaneous
transhepatic, percutaneous transplenic, or
TIPS access into the portal vein and SMV
can be obtained.

Complications
What type of Patients with acute mesenteric ischemia
monitoring do patients should be monitored in the ICU setting
with acute mesenteric if they are undergoing lytic therapy.
ischemia need after
intervention with
thrombolysis?
Why are patients The decreased blood supply to the
with acute mesenteric bowel results in degradation of the
ischemia at higher intestinal mucosa resulting in easier
risk of bacterial translocation of gastrointestinal flora
translocation and/or into the bloodstream, thus making close
sepsis? monitoring for signs and symptoms of
sepsis critical.
What is the Bleeding events are the major
major associated associated complication with the use
complication with the of thrombolysis. Patients should be
use of thrombolysis? monitored closely in the ICU setting for
signs of intracranial and intra-abdominal
bleeding. Additional signs of concerning
bleeding are access site hematoma, large
volume of bleeding at the access site,
and drop in hemoglobin. Monitoring
of fibrinogen levels is also performed
at some centers. If patients are also
receiving systemic heparin, PTT values
should be checked as well as platelet
values to evaluate for heparin-induced
thrombocytopenia.
 22 Mesenteric Ischemia 187

What contrast-related In patients with diminished renal

complications should function, there should be monitoring for
the interventionalist acute kidney injury. The benefits versus
be aware of during the risks of performing an endovascular
endovascular intervention should be weighed in
treatment of patients with diminished renal function.
mesenteric ischemia? As with all interventions requiring
iodinated contrast, any contrast allergy
and the severity of the allergy should be
clearly understood with premedication
administered as clinically warranted.
What are rare Complications associated with
complications endovascular treatment of the
associated with mesenteric vessels to be aware of include
angioplasty and/ vessel perforation, dissection, and stent
or stenting of the malposition/migration.
mesenteric vessels that
the operator should be
conscious of?
What is reperfusion Reperfusion injury is a paradoxical
injury? increase in tissue damage caused by
oxidative stress from rapid return of
blood supply to tissues after flow is
restored in an occluded mesenteric
vessel. The mechanism of this injury is
multifactorial; however, some proposed
causes include tissue damage resulting
from oxygen free radicals and cytokine
release.

Landmark Research
Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC,
Pomposelli FB. Mesenteric revascularization: management
and outcomes in the United States, 1988–2006. J Vasc Surg.
2009 Aug;50(2):341–348.
188 A. Khetarpal

• Retrospective review of nationwide database looking at

patients who underwent open surgical (16,071 patients) or
endovascular treatment (6342 patients) treatment of acute
and chronic mesenteric ischemia from 1988 to 2006.
• Lower mortality rate for endovascular treatment of acute
and chronic mesenteric ischemia when compared to open
surgical treatment.
• Showed that endovascular treatments were appropriate as
first-line therapy for appropriately selected patients.
• Inherent selection bias in this retrospective study since
patients who necessitated open surgical treatment often
were sicker already with more severe states of disease (i.e.,
needing bowel resection).
Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC,
Chung TK, Cambria RP. Surgical revascularization versus
endovascular therapy for chronic mesenteric ischemia: a
comparative experience. J Vasc Surg. 2007
Jun;45(6):1162–71.
• Retrospective analysis of open surgical treatment (49
patients) versus endovascular treatment (31 patients) for
chronic mesenteric ischemia at a single center
(Massachusetts General Hospital) from 1991 to 2005
• Similar incidence of symptomatic recurrence requiring
reintervention in surgical and endovascular groups with a
decreased rate of primary patency and primary assisted
patency seen in the endovascular group
• Similar incidence of inhospital morbidity and mortality in
both groups
• Showed that open surgical and endovascular treatment
options should be selectively applied in cases of chronic
mesenteric ischemia based on individual patient anatomy
and comorbidities
Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ,
Burger CD. Acute mesenteric ischemia: a clinical review. Arch
Intern Med. 2004 May 24;164(10):1054–62. Review.
 22 Mesenteric Ischemia 189

• In-depth review of the evaluation and treatment of acute

mesenteric ischemia including discussion on the diagnostic
and treatment challenges involved with this disease
process
• Outlines the pathophysiology and common causes of acute
mesenteric ischemia

Common Questions
What is the mortality The mortality of acute mesenteric
associated with acute ischemia is high and shown to range from
mesenteric ischemia? 40 to 90%.
What vessel is most The SMA is most commonly involved due
commonly involved to its oblique angle of takeoff from the
in cases of acute abdominal aorta.
mesenteric ischemia
from embolic sources
and why?
What are common Common risk factors for embolic
risk factors for etiologies of acute mesenteric ischemia
embolism leading include cardiac arrhythmias (e.g., atrial
to acute mesenteric fibrillation), cardiac valve disease,
ischemia? history of myocardial infarction, and
an aneurysmal disease of the thoracic/
abdominal aorta with intraluminal
thrombus.
What is the common In cases of acute mesenteric ischemia due
mechanism of to thrombotic etiologies, there is usually
thrombotic etiologies superimposed acute thrombosis of a
for acute mesenteric chronically stenosed origin of the SMA
ischemia? and/or celiac axis.
What is the Cardiovascular disease risk factors such
common mechanism as hypertension, hyperlipidemia, and
of thrombotic diabetes.
etiologies for chronic
mesenteric ischemia?
(continued)
190 A. Khetarpal

What treatment Treatment of underlying cardiovascular

should be instituted risk factors should be initiated
after interventions including management of hypertension,
for mesenteric hyperlipidemia, and diabetes and smoking
ischemia? cessation. In cases of acute mesenteric
ischemia, therapeutic anticoagulation
and broad-spectrum antibiotic coverage
should also be administered.
If the patient has a If an arterial stent is used for the
stent placed, what treatment of mesenteric ischemia,
other medications antiplatelet medications including aspirin
should be and/or Plavix should be considered based
considered? on patient risk factors.
What kind of Patients should undergo routine clinical
surveillance should follow-up to evaluate for recurrence of
be performed symptoms as well as compliance with
on patients who prescribed medications and lifestyle
have undergone modifications (e.g., smoking cessation).
endovascular If patients have undergone endovascular
interventions for stent placement, it is reasonable to
mesenteric ischemia? perform routine imaging surveillance
with duplex ultrasound and/or CTA to
evaluate for stent patency and stenosis.

Further Reading
Arthurs ZM, Titus J, Bannazadeh M, et al. A comparison of endovas-
cular revascularization with traditional therapy for the treatment
of acute mesenteric ischemia. J Vasc Surg. 2011;53:698.
Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC, Chung TK,
Cambria RP. Surgical revascularization versus endovascular
therapy for chronic mesenteric ischemia: a comparative experi-
ence. J Vasc Surg. 2007;45(6):1162–71.
Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Long-term
results after surgery for acute mesenteric ischemia. Surgery.
1997;121:239.
 22 Mesenteric Ischemia 191

Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger

CD. Acute mesenteric ischemia: a clinical review. Arch Intern
Med. 2004;164(10):1054–62. Review
Plumereau F, Mucci S, Le Naoures P, et al. Acute mesenteric isch-
emia of arterial origin: importance of early revascularization. J
Visc Surg. 2015;152:17.
Rasmussen T, Darrin Clouse W, Tonnessen B. Handbook of patient
care in vascular diseases. 5th ed. Philadelphia: Lippincott
Williams & Wilkins; 2008.
Ryer EJ, Kalra M, Oderich GS, et al. Revascularization for acute
mesenteric ischemia. J Vasc Surg. 2012;55:1682.
Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC, Pomposelli
FB. Mesenteric revascularization: management and outcomes in
the United States, 1988-2006. J Vasc Surg. 2009;50(2):341–8.
Sidawy A, Perler B. Rutherford’s vascular surgery and endovascular
therapy. 9th ed. Elsevier; 2018.
Silen W, Cope Z. Cope's early diagnosis of the acute abdomen. 22nd
ed. Oxford: Oxford University Press; 2010.
van Petersen AS, Kolkman JJ, Meerwaldt R, et al. Mesenteric ste-
nosis, collaterals, and compensatory blood flow. J Vasc Surg.
2014;60:111.
Chapter 23
Arteriovenous
Malformation (AVM)
Charles Hua

Evaluating Patient
According to the Capillary malformation, arteriovenous
ISSVA, what are malformation, arteriovenous fistula, venous
the five major malformation, and lymphatic malformation.
simple vascular Mixed variants also exist, and combined
malformations? vascular malformations are defined as two
or more vascular malformations found
within the same lesion.
What do Arteriovenous malformation and
arteriovenous arteriovenous fistula are classified as high-­
malformations and flow lesions.
arteriovenous fistula
have in common?
How do soft tissue The mass may be felt with a palpable
AVMs present on thrill. The skin may be red and warm
physical exam? to touch. There may be a bruit on
auscultation.
(continued)

C. Hua (*)
Mount Sinai Interventional Radiology, Icahn School of Medicine at
Mount Sinai, New York, NY, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 193

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_23
194 C. Hua

How do you Low-flow venous malformations do

differentiate not have a palpable thrill. Simple low-­
AVMs from flow malformations include venous
low-flow venous malformation, capillary malformation, and
malformations on lymphatic malformation. These low-flow
physical exam? lesions may empty on compression and
collapse if raised above the level of the
heart.
True or false? Brain False. Approximately 0.2% of patients
AVMs are a frequent with headache and normal neurological
cause of headaches. exam were found to have an AVM.
Name two types The two types of benign vascular tumors
of benign vascular are infantile hemangiomas, also known as
tumors as classified hemangiomas of infancy, and congenital
by ISSVA and their hemangiomas. Infantile hemangiomas
associated properties. appear after birth, usually within the
first 2 months of life, and the majority
require no specific treatment as they
spontaneously involute over a period
of years. Propranolol may be used for
large hemangiomas that may cause
disfigurement and growth disturbance,
intrude upon the eye or impact the lips,
and prevent attachment during feeding.
Congenital hemangiomas are typically
fully formed at birth and may rapidly
involute (rapidly involuting congenital
hemangioma) or not involute (non-­
involuting congenital hemangioma).
Embolization of large hemangiomas
may be performed prior to planned
surgical resection to minimize the risk of
intraoperative bleeding.
Where are AVMs Liver (41–85%), pulmonary (23–61%),
typically found? and central nervous system (10%)
 23 Arteriovenous Malformation (AVM) 195

What are common Flow voids are demonstrated on both

findings of AVM T1 and T2 sequences. There may be
on MRI T1 and T2 associated muscle atrophy with a lack
sequences? of mass effect. Of note, phleboliths and
calcifications seen in slow-flow venous
malformations may also show signal
voids, which is demonstrated on all pulse
sequences. Draining veins in AVMs
may show early enhancement on MR
angiography due to shunting.

High Yield History

What are Hemorrhage, pain, ulceration, high-output
the common cardiac failure, pulsatile mass, ischemia, and
symptoms cosmetic deformation
associated with
arteriovenous
malformation?
What syndrome Osler-Weber-Rendu syndrome, also known
predisposes as hereditary hemorrhagic telangiectasia
patients to (HHT)
pulmonary AVMs
(PAVMs)?
What additional Hemoptysis, headaches, paradoxical
clinical embolization, and pulmonary hypertension
manifestations can
be seen in patients
with PAVM?
What percentage HHT is an autosomal dominant disorder
of patients with found in 95% of patients with PAVM.
PAVM have
HHT?
What is the The estimated occurrence of HHT
prevalence of is 1 in 10,000. However, this is likely
HHT? underestimated because many cases are
asymptomatic.
(continued)
196 C. Hua

List two Pregnancy may lead to PAVM growth from

populations that the effects of estrogen and progesterone,
are at greater which increase venous distensibility, resulting
risk of PAVM in increased vascular volume and cardiac
complications. output.
The second population at risk of PAVM
complications are patients with severe
pulmonary hypertension. The elevated
vascular resistance can result in increased
blood flow through the PAVM. Embolization
of the PAVM in patients with severe
pulmonary hypertension may alter the
hemodynamics (increased preload)
and worsen the underlying pulmonary
hypertension.
What are the A consensus of the clinical diagnostic
clinical diagnostic criterion for HHT, known as the Curaçao
criteria for HHT? criteria, is based upon the four findings
outlined in Table 23.1. The diagnosis of HHT
is “definite” if three criteria are present;
“possible or suspected” if two criteria
are present; and “unlikely” if fewer than
two criteria are present. HHT can also be
diagnosed using genetic testing.

Table 23.1 Curaçao diagnostic criteria for hereditary hemorrhagic

telangiectasia
Criteria Description
Epistaxis Spontaneous and recurrent
Telangiectasia Multiple, at characteristic sites, including the lips,
mouth, fingers, and nose
Visceral Gastrointestinal telangiectasia; arteriovenous
lesions malformations in the lung, liver, and central
nervous system
Family history A first-degree relative with HHT
 23 Arteriovenous Malformation (AVM) 197

Why do patients Arterial steal phenomenon occurs when a

develop distal high volume of blood is shunted through the
ischemia in AVM and away from the distal extremity. The
extremity peripheral limb beyond the AVM can present
AVMs? with pain, appear pale, or even ulcerate.
What type of Low-flow venous malformation
vascular anomaly
are phleboliths
associated with?
What is Klippel-­ A congenital, but not heritable, venous
Trenaunay syndrome defined as having at least two of the
syndrome following: cutaneous capillary malformation,
(KTS)? atypical varicose veins, venous malformations,
and unilateral limb hypertrophy.
What is a patent Also known as the Klippel-Trenaunay vein
vena marginalis or the lateral marginal vein of Servelle, it is a
lateralis? persistent embryonic vein ascending along the
lateral leg, which lacks normal venous valves
and is associated with limb length discrepancy,
deep venous system hypoplasia of the affected
extremity, chronic venous insufficiency, and
venous thromboembolic disease. It is commonly
associated with KTS and its presence should
warrant further investigation. Most practitioners
recommend surgical excision. The persistent
sciatic vein is another persistent embryonic
remnant associated with KTS and courses along
the midline of the posterior thigh.
How does PWS is more rare as compared to KTS
Parkes-Weber and involves high-flow arteriovenous
syndrome (PWS) malformations. KTS is associated with low-­
compare to flow malformations. Both syndromes manifest
KTS? as unilateral soft tissue and bone hypertrophy.
What type Venous malformation
of vascular
malformation
is Maffucci
syndrome
associated with?
198 C. Hua

Indications/Contraindications
What are indications Cosmetic disfiguration, large mass, severe
to treating AVMs? pain, recurrent bleeding, ischemia, growth
disturbance, and high-output cardiac state
Why do clinicians Treating AVMs may not be necessary for
choose “watchful asymptomatic patients since treatment
waiting” rather than represents a long-term commitment to the
treating extremity patient and family. Early therapy should
AVMs early in their only be considered if there is evidence of
discovery? worsening symptoms, such as shunting,
and the patient is willing to undergo the
potential for multiple staged sessions.
What are the Surgical resection oftentimes yields
advantages of poor results because AVMs are often
endovascular extensive, crossing normal tissue planes.
therapy over Endovascular embolization allows super-­
surgical repair? selective catheterization of the feeding
vessel; however, cure is not always
achievable, and treatment may require
multiple procedures.
Why is it important PAVM embolization in someone with
to evaluate for severe pulmonary hypertension may
severe pulmonary further worsen their pulmonary artery
hypertension when pressure, leading to cor pulmonale—right-­
embolizing PAVM? sided heart failure secondary to increased
pulmonary vascular resistance.
Why might certain Vascular malformations are responsive
treated vascular to stimuli, such as injury or incomplete
malformations treatment of the nidus. This may be seen in
worsen (i.e., certain patients who present with a rapid
enlarge)? growth of their previously unperceived
AVM over a relatively short time period
following localized trauma. Therefore,
obliterating the nidus should be the
therapeutic goal, as incomplete destruction
will stimulate vascular growth and possible
enlargement of the AVM.
 23 Arteriovenous Malformation (AVM) 199

How is worsening Although initially asymptomatic,

right-to-left worsening shunting will develop as arterial
shunting in PAVM hypoxemia, manifested as dyspnea, fatigue,
manifested? cyanosis, clubbing, and polycythemia.

Relevant Anatomy
Why might one MRI is the mainstay of AVM imaging,
consider MRI especially if there are additional findings
as an imaging that will affect treatment decision. There is
modality for no ionizing radiation in MRI, and the high
pre-procedural contrast resolution of MRI is used to classify
workup? the vascular anomaly and assess the extent
of the lesion from the involved anatomy. The
three-dimensional dynamic MR angiography
sequences provide important information
about the abnormal flow hemodynamics.
What are the The nidus is the central tangle of
components of an communicating arterioles and venules with
AVM? one or more feeding arteries, and one or
more draining veins.
What is the The PAVM nidus may be a single aneurysmal
“nidus” in PAVM? sac or a plexiform septated connection. They
may be acquired or congenital.
How do the origin The pulmonary arteries receive blood from
of the pulmonary the right ventricle. The bronchial arteries
arteries and receive blood from the thoracic aorta.
bronchial arteries PAVMs are abnormally dilated vessels that
differ? provide direct communication between a
pulmonary artery and pulmonary vein.
What is the Simple PAVMs have one feeding artery,
difference while complex PAVMs have multiple feeding
between simple arteries.
PAVMs and
complex PAVMs?
(continued)
200 C. Hua

In a patient with This patient most likely has a liver AVM. The
known HHT, clinical presentations of liver AVMs
what is the most include high-output cardiac failure, portal
likely etiology hypertension, biliary necrosis, portosystemic
of a variceal encephalopathy, and intestinal ischemia/steal
hemorrhage? syndrome.
Why is it important Treatment of mesenteric AVMs can result in
to treat high- severe portal hypertension as more blood is
flow mesenteric now being drained through the portal system.
AVMs in a staged
fashion?
What is the Anterior branches of the internal iliac artery,
most common inferior mesenteric artery, and median sacral
multivessel supply artery
for pelvic AVMs?
What is the target Elimination of the nidus while preserving
of embolization in flow to normal vessels. Incomplete
AVMs? eradication of the nidus may stimulate
growth of the AVM. Treating too proximal
may block access to the nidus for future
interventions.
What is the most It is almost always preceded by an obstetric
common factor event (postpartum, postabortion, or dilation
that predisposes and curettage).
women to uterine
AVM?

Relevant Materials
Compare the efficacy Ethanol is more effective in
and toxicity of absolute obliterating vascular lumens, but
ethanol versus other more toxic, as well. STS is a sclerosing
embolic agents (n-butyl-­ agent that is less toxic but less
2-cyanoacrylate (NBCA) effective compared to ethanol. STS
glue and sodium is a sclerosing agent that has gained
tetradecyl sulfate (STS)). popularity in recent years. NBCA glue
has no sclerosant effect but is very
useful for vessel occlusion and can
significantly slow down the flow.
 23 Arteriovenous Malformation (AVM) 201

What is the mechanism Absolute ethanol causes direct tissue

of action of absolute toxicity, causing endothelial damage
ethanol? and rapid thrombosis resulting in
permanent occlusion. It has a poor
safety profile due to its direct intrinsic
toxicity and higher likelihood of skin
necrosis and neuropathy.
What is the purpose of NBCA is an adhesive that rapidly
mixing ethiodized oil polymerizes upon contact with any
(Ethiodol) with NBCA ionic solution. Ethiodol is an oil used
glue? to provide radiopacity to the glue,
as well as slow the polymerization
time. Higher ethiodol to NBCA
ratio leads to longer polymerization
time. Therefore, different ratios of
Ethiodol to glue will result in different
viscosities and polymerization times,
necessitating user experience and
careful manipulation of technique
depending on the mixture.
What is typically used to Nonionic, 5% dextrose in water is
flush the catheter when used to flush the catheter prior to
using NBCA? administering NBCA to completely
remove ionic substances and allow
distribution of the NBCA glue. NBCA
polymerizes after coming into contact
with ionic substances.
How does occluding Dominant venous outflow occlusion
the dominant venous will slow the flow through the
outflow facilitate NBCA lesion and allow the NBCA glue to
embolization? concentrate at the nidus.
202 C. Hua

General Step by Step

What are the AVMs may be accessed via transvenous,
available access direct puncture, or transarterial routes.
routes to treat Transarterial access to embolize the nidus
AVMs? has been conventionally preferred. If there
is no reasonable transarterial access, such
as multiple arterioles shunting into a single
venous component, or if the remaining
feeding arterioles are too small or tortuous
to catheterize, then direct puncture of the
nidus may allow for effective embolization.
In addition to requiring a safe access window
for percutaneous direct puncture, there
are inherent risks, such as air embolization
introduced by the access needle and
pneumothorax as a result of transthoracic
access.
Why should Embolization of the proximal portion of the
embolization feeding artery without obliterating the nidus
of the proximal will prevent future access to the viable nidus
portion of the and will promote collateral resupply over
feeding artery be time.
avoided?
Is there an ideal No. There is no ideal embolic agent that
embolic agent for encompasses both safety and efficacy.
all AVMs? There are a wide range of agents available,
including absolute ethanol, liquid-casting
agents (NBCA glue), sclerosant (STS),
embolization coils, vascular plugs, and
ethylene vinyl alcohol copolymers (Onyx).
Onyx has weak sclerosant properties and acts
through polymerization. Occluding devices
(coils, vascular plugs, or microvascular
plugs) will benefit fistula-like connections.
It is better to embolize the nidus for
complex malformations by taking advantage
of the blood flow mechanics and using
flow dependent embolic agents, such as
microspheres, NBCA glue, Onyx, or absolute
ethanol.
 23 Arteriovenous Malformation (AVM) 203

Why may The passage of embolic materials into the

embolization of draining outflow vein can cause nontarget
the vein in AVMs embolization. A situation in which
not be preferred? embolization of the draining vein is preferred
is when there are multiple inflow arterioles
draining into an aneurysmal venous sac. The
mechanical occlusion of the venous drainage
can then be combined with retrograde
injection of the nidus with a liquid embolic
or sclerosant.
Why do some Absolute ethanol is toxic, and escape of the
operators use agent into the central circulation has been
Swan-Ganz associated with cardiac arrhythmias, acute
monitoring when pulmonary vasoconstriction, and pulmonary
using absolute embolization. Due to these risks, some
ethanol? operators prefer careful monitoring using a
Swan-Ganz. Additionally, nerve monitoring
may be beneficial if the treatment area is
within close proximity of a major nerve.
Why should Embolizing multiple feeding arteries may
treatment be lead to peripheral ischemia. Therefore, in
limited to only a addition to eradicating the nidus of the AVM,
few vessels when limited treatment of a few involved vessels
treating AVMs in will decrease the occurrence of ischemic
the extremity? complications. This may require multiple
sessions to accomplish.
Where is the ideal The goal is to occlude all the feeding
site of occlusion arteries, as distal as possible and beyond any
for PAVMs? significant supply to normal lung.
What is an ideal Mechanical agents, such as coils, are typically
embolic agent for recommended.
PAVMs?
204 C. Hua

Complications
What is an initial Topical antiseptic cream, such as 1%
treatment consideration silver sulfadiazine (Silvadene) and
for skin ulcers that non-steroidal anti-inflammatory drugs.
develop following
treatment?
What should one Embolization of the embolic agent or
consider if a patient iatrogenic introduction of air into the
develops shortness of pulmonary circulation
breath and chest pain
following embolization
of high-flow
malformations?
What is a differential Pleurisy is the most common side
consideration in effect after PAVM embolization, which
someone with chest may develop in 3%–16% of patients
pain and fever following several days after the procedure. In
PAVM embolization? patients with delayed pleurisy, a chest
radiograph will show infiltrates, which
are usually self-limiting.
Describe the Spetzler-­ The Spetzler-Martin grading scale
Martin grading scale for estimates the risk of surgery on the
intracranial AVMs. basis of size, neurological eloquence
of adjacent brain, and pattern of
venous drainage. The grade is based
on the total score, with higher grades
correlating with increased surgical
morbidity and mortality
(See Table 23.2).

Table 23.2 Spetzler-Martin grading scale for intracranial AVMs

Score
Size
< 3 cm 1
3–6 cm 2
> 6 cm 3
(continued)
 23 Arteriovenous Malformation (AVM) 205

Table 23.2 (continued)

Score
Location
Non-eloquent brain area (anterior frontal or temporal 0
lobes, or cerebellar cortex)
Eloquent brain area (sensorimotor, language, visual 1
cortex, hypothalamus, thalamus, internal capsule, brain
stem, cerebellar peduncles, and deep cerebellar nuclei)
Deep venous drainage
Absent 0
Present 1

What is An air embolism passing into a PAVM is a

a serious serious risk because it can pass directly into the
complication left-sided circulation and into the brain.
when treating
PAVMs?
What is a The garlic-like smell that follows Onyx
common administration is due to DMSO, and it usually
side effect dissipates within 2 days. DMSO is slowly injected
following the inside the microcatheter to fill its dead space
use of Onyx? and prevent direct contact with the bloodstream,
thereby preventing its solidification prematurely.

Landmark Research
Pollak JS, White RI Jr. Distal cross-sectional occlusion is the
“key” to treating pulmonary arteriovenous malformations. J
Vasc Interv Radiol. 2012;23(12):1578–1580.
206 C. Hua

What are the four ways Recanalization of the vessel

persistence or reperfusion Growth of a missed or previously
of an apparently successfully small accessory artery
embolized PAVM may Bronchial artery or other systemic
occur? artery collateral flow into the
pulmonary artery beyond the level
of the embolization
Pulmonary artery-to-pulmonary
artery collateral flow about the
occlusion
Ratnani R, Sutphin PD, Koshti V, Park H, Chamarthy M,
Battaile J, Kalva SP. Retrospective Comparison of Pulmonary
Arteriovenous Malformation Embolization with the
Polytetrafluoroethylene-Covered Nitinol Microvascular Plug,
AMPLATZER Plug, and Coils in Patients with Hereditary
Hemorrhagic Telangiectasia. J Vasc Interv Radiol. 2019
Jul;30(7):1089–1097.

What are the persistence The persistence rates for PAVM

rates associated with the with coil embolization are
coils, AMPLATZER vascular 47%, compared with 15% for
plugs, and microvascular AMPLATZER vascular plug, and
plugs when treating PAVM? 2% with the microvascular plug.

Faughnan ME, Palda VA, Garcia-Tsao G, Geisthoff UW,

McDonald J, Proctor DD, Spears J, Brown DH, Buscarini E,
Chesnutt MS, Cottin V, Ganguly A, Gossage JR, Guttmacher
AE, Hyland RH, Kennedy SJ, Korzenik J, Mager JJ, Ozanne
AP, Piccirillo JF, Picus D, Plauchu H, Porteous ME, Pyeritz
RE, Ross DA, Sabba C, Swanson K, Terry P, Wallace MC,
Westermann CJ, White RI, Young LH, Zarrabeitia R; HHT
Foundation International - Guidelines Working Group.
International guidelines for the diagnosis and management
of hereditary haemorrhagic telangiectasia. J Med Genet. 2011
Feb;48(2):73–87.
 23 Arteriovenous Malformation (AVM) 207

At what PAVMs with feeding artery diameter

diameter feeding of 3 mm or greater should generally be
artery should treated. Targeting sub-3 mm feeding arteries
embolization may also be appropriate, if technically
of PAVM be feasible. It has been shown that paradoxical
considered? embolization is independent of feeding
artery diameter.

Cho SK, Do YS, Shin SW, Kim D, Kim YW, Park KB, Kim
EJ, Ahn HJ, Choo SW, Choo IW. Arteriovenous malforma-
tions of the body and extremities: analysis of therapeutic
outcomes and approaches according to a modified angio-
graphic classification. J Endovasc Ther. 2006
Aug;13(4):527–38.

Name the four main types of AVMs based on nidus

angiographic morphology.

Type of Nidus morphologic Angiographic

AVM structure Description appearance
I Arteriovenous fistula Three or less Clear
arteries shunt communication
into a single of the feeding
vein arteries and
draining vein
II Arteriolovenous/ Four or more Plexiform
plexiform fistula arterioles
shunt to a
single vein
IIIa Arteriolovenulous Multiple Blush or fine
fistula without arterioles striation
dilation communicating
with multiple
venules
208 C. Hua

Type of Nidus morphologic Angiographic

AVM structure Description appearance
IIIb Arteriolovenulous Multiple Complex
fistula with dilation shunts between vascular
arterioles and network
venules

Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS,

Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL,
Houdart E, Cordonnier C, Stefani MA, Hartmann A, von
Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K,
Libman R, Barreau X, Moskowitz AJ; international ARUBA
investigators. Medical management with or without interven-
tional therapy for unruptured brain arteriovenous malforma-
tions (ARUBA): a multicentre, non-blinded, randomised
trial. Lancet. 2014 Feb 15;383(9917):614–21.
What was Medical management alone is superior to
the main medical management with interventional
conclusion therapy (i.e., neurosurgery, embolization, or
of the “A stereotactical radiotherapy) for the prevention
Randomized of death or stroke in patients with unruptured
trial of brain AVMs. There were a higher number of
Unruptured strokes and neurological deficits in patients
Brain in the interventional therapy group. The trial
Arteriovenous was criticized because only 13% of screened
Malformations” patients were randomized in the trial. Majority
(ARUBA) of the patients that were excluded had
trial? What potentially more aggressive AVMs that are
were the main more representative of brain AVMs in the
controversies of community. The mean follow-up of 33 months
this trial? was too short for a disease with a long natural
history, favoring the medical management
group. Lastly, the small number of patients who
underwent microsurgical resection, the gold
standard in the interventional arm, biased the
trial in favor of medical management.

Cartin-Ceba R, Swanson KL, Krowka MJ. Pulmonary arte-

riovenous malformations. Chest. 2013 Sep;144(3):1033–1044.
 23 Arteriovenous Malformation (AVM) 209

Why is it There is a high incidence of morbidity

recommended (e.g., paradoxical embolism, hemothorax,
that pregnant hemoptysis) and mortality in pregnant patients
patients with with PAVM. Embolotherapy in maternal
significant PAVM regardless of feeding vessel size is
PAVMs undergo recommended. Embolotherapy has been shown
embolotherapy? to be safe and effective after 16 weeks of
gestation, and the estimated radiation exposure
to the fetus is minimal when performed by an
experienced interventional radiologist.

Common Questions
What are the Feeding artery(ies), a nidus, and draining
components of an vein(s)
AVM?
What is the most Epistaxis
common presenting
symptom in patients
with HHT?
Where is the most Most PAVMs are seen in the lower lobes.
common location
for PAVM?
What does ISSVA The International Society for the Study of
stand for and who Vascular Anomalies (ISSVA) is the main
are they? organization responsible in classifying all
vascular lesions.
List the spectrum Skin and mucous membranes, liver,
of organs involved gastrointestinal tract, pulmonary, and
with HHT. central nervous system
210 C. Hua

What is the most Stroke, brain abscess, or massive

common cause of hemoptysis and spontaneous hemothorax
death in patients
with HHT?

Further Reading
Al-Shahi R, Warlow C. A systematic review of the frequency and
prognosis of arteriovenous malformations of the brain in adults.
Brain. 2001;124(Pt 10):1900–26.
Arnold R, Chaudry G. Diagnostic imaging of vascular anomalies.
Clin Plast Surg. 2011;38(1):21–9.
Bertino F, Braithwaite KA, Hawkins CM, Gill AE, Briones
MA, Swerdlin R, Milla SS. Congenital limb overgrowth syn-
dromes associated with vascular anomalies. Radiographics.
2019;39(2):491–515.
Blatt J, McLean TW, Castellino SM, Burkhart CN. A review of con-
temporary options for medical management of hemangiomas,
other vascular tumors, and vascular malformations. Pharmacol
Ther. 2013;139(3):327–33.
Burrows PE. Vascular malformations involving the female pelvis.
Semin Interv Radiol. 2008;25(4):347–60.
Cartin-Ceba R, Swanson KL, Krowka MJ. Pulmonary arteriovenous
malformations. Chest. 2013;144(3):1033–44.
Cho SK, Do YS, Kim DI, Kim YW, Shin SW, Park KB, Ko JS, Lee
AR, Choo SW, Choo IW. Peripheral arteriovenous malforma-
tions with a dominant outflow vein: results of ethanol emboliza-
tion. Korean J Radiol. 2008;9(3):258–67.
Cho SK, Do YS, Shin SW, Kim D, Kim YW, Park KB, Kim EJ, Ahn
HJ, Choo SW, Choo IW. Arteriovenous malformations of the
body and extremities: analysis of therapeutic outcomes and
approaches according to a modified angiographic classification.
J Endovasc Ther. 2006;13(4):527–38.
Contegiacomo A, Del Ciello A, Rella R, Attempati N, Coppolino D,
Larici AR, Di Stasi C, Marano G, Manfredi R. Pulmonary arte-
riovenous malformations: what the interventional radiologist
needs to know. Radiol Med. 2019;124(10):973–88.
Do YS, Yakes WF, Shin SW, Lee BB, Kim DI, Liu WC, Shin BS, Kim
DK, Choo SW, Choo IW. Ethanol embolization of arteriovenous
malformations: interim results. Radiology. 2005;235(2):674–82.
 23 Arteriovenous Malformation (AVM) 211

Dunham GM, Ingraham CR, Maki JH, Vaidya SS. Finding the nidus:
detection and workup of non-central nervous system arteriove-
nous malformations. Radiographics. 2016;36(3):891–903.
Edmondson AC, Kalish JM. Overgrowth syndromes. J Pediatr
Genet. 2015;4(3):136–43.
Evans RW. Diagnostic testing for the evaluation of headaches.
Neurol Clin. 1996;14(1):1–26.
Faughnan ME, Palda VA, Garcia-Tsao G, Geisthoff UW, McDonald
J, Proctor DD, Spears J, Brown DH, Buscarini E, Chesnutt MS,
Cottin V, Ganguly A, Gossage JR, Guttmacher AE, Hyland RH,
Kennedy SJ, Korzenik J, Mager JJ, Ozanne AP, Piccirillo JF,
Picus D, Plauchu H, Porteous ME, Pyeritz RE, Ross DA, Sabba
C, Swanson K, Terry P, Wallace MC, Westermann CJ, White RI,
Young LH, Zarrabeitia R. HHT Foundation International -
Guidelines Working Group. International guidelines for the
diagnosis and management of hereditary haemorrhagic telangi-
ectasia. J Med Genet. 2011;48(2):73–87.
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Chapter 24
Central Venous Access
Gaurav Gadodia

Evaluating Patient
What are important Indication for use
questions in determining Frequency of use (continuous or
access type? intermittent)
Patient status/length of use (inpatient
or outpatient)
Patient on or at risk for needing
hemodialysis (HD) (i.e., those with
chronic kidney disease (CKD) or
diabetes)
Patient bacteremic or septicemic
What primarily Length of therapy
determines if a non-­
tunneled or tunneled line
is needed?
(continued)

G. Gadodia (*)
Department of Radiology, Imaging Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 215

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_24
216 G. Gadodia

Why is it important to Dialysis or potential dialysis patients

know if the patient has a should:
history of chronic kidney  Not have peripherally inserted
disease (CKD) or diabetes catheters (PICCs or midlines)
mellitus (DM)? placed so as to preserve
upper extremity veins for
future arteriovenous grafts or
arteriovenous fistulae (AVGs or
AVFs)
 Have dialysis access separate from
other needs of central venous
access
 Have as small as bore catheters
placed as able (lower risk for SVC
occlusion)
What are the INR
recommended lab values  < 2 for non-tunneled lines and
to assess for coagulation PICCs
status pre-procedurally?  < 1.5 for tunneled lines and port
catheters
Platelets
 Institution dependent, often the
goal is > 25–30k.
 50k is ideal per SIR.
 If lower, it is recommended to
have a unit of platelets infusing
during the procedure.
aPTT: No consensus
recommendation
What electrolyte level is Potassium, as it should be corrected
important to measure, and prior to procedure if elevated
why? as there is an increased risk of
arrhythmia with hyperkalemia
What devices should a Pacemakers, defibrillator/AICDs, and
patient be evaluated for, other catheters, as they may decrease
and why? the flow or lumen size of the SVC,
predisposing to complications
 24 Central Venous Access 217

What are important Prior central venous access

questions to ask the procedures and complications
patient while obtaining Drug allergies
history?  Especially to anesthetic, sedation,
or contrast (if needed)
Active medications, especially blood
thinners

High Yield History

What general types of Peripherally inserted central catheters
central venous catheters (PICCs)
exist? Centrally inserted central venous
catheters
 Non-tunneled
 Tunneled
 Subcutaneous port
In the appropriate setting, PICCs can be removed in an office or
why might a PICC be nursing home, while tunneled central
preferred over a tunneled venous catheters are removed in a
central venous catheter? procedural setting.
In the appropriate setting, Tunneling lowers the risk of infection,
why might a tunneled along with being more comfortable
catheter be preferred over for patients and less likely to be
non-tunneled access? dislodged, making this type of access
more durable and allowing for use in
the outpatient setting.
In the appropriate Easier to hide/better cosmetic
setting, why might a appearance and ability to swim or
subcutaneous port bathe
catheter be preferred
over a tunneled central
venous catheter?
What is a distinguishing High flow rates (dialysis, 400–
feature of catheters used 600 mL/min, at least > 300 mL/min;
for pheresis/dialysis pheresis, 150–250 mL/min)
catheters?
218 G. Gadodia

Indications/Contraindications
What are general Therapeutic
indications for central  IV fluids/hydration (may be emergent
venous access? in settings of resuscitation)
 Blood products
 Pressors
 Plasmapheresis
 Hemodialysis
 Antibiotics
 Ionotropic medications
 Chemotherapy
 TPN
 Other IV medications
Diagnostic
 Central venous pressure monitoring
 Repeated blood sampling, especially
in patients with poor peripheral
venous access
 24 Central Venous Access 219

What are general PICCs:

indications for the  Short-term, inpatient or outpatient
different categories access
of central venous  Medications, commonly outpatient
catheters? antibiotics
Centrally inserted central venous
catheters
 Non-tunneled:
   Inpatient only
   Short-term, temporary access,
including for ICU care, or need for
dialysis expected to resolve
   Unstable patients who cannot
travel or receive sedation
   Patients requiring a tunneled
catheter but currently with
contraindications
 Tunneled
   Longer-term access (weeks to
months, possibly years) in inpatient
and/or outpatient settings
    Small bore (usually < 7 Fr):
general durable central venous access,
fluids, most medications including
pressors and shorter-term antibiotics
    Large bore (7 Fr or >): higher
viscosity or vesicant fluids like TPN
and ionotropic medications, better for
blood products, sometimes used for
longer-term medications including
antibiotics
 Subcutaneous port
   Longer-term access (months to
years), mostly in outpatient settings,
chemotherapy being the most
common indication
What indications Number of lumens needed
distinguish types of Need for performance of HD
non-tunneled central
venous catheters?
(continued)
220 G. Gadodia

What are Absolute:

contraindications to  Cellulitis at insertion site
non-tunneled central    Choose another site.
venous catheters?  Allergy to catheter material
   Rare, find a catheter with another
material.
Relative:
 Central venous thrombosis/occlusion
 Uncorrectable coagulopathy
What are Absolute:
contraindications for  Sepsis or bacteremia
placement of tunneled  Cellulitis at insertion site
central venous    May choose another site, or place
catheters? temporary line at another site until
treated and resolves
 Allergy to catheter material
Relative:
 Venous stenosis
 Central venous thrombosis/occlusion
 Uncorrectable coagulopathy
 Hyperkalemia
Is there any indication No, a temporary non-tunneled catheter
for an emergent can be placed for emergent indications.
tunneled line?
What are indications Completion of therapy
for removal of a central Malfunction (can try to treat issue or
venous catheter*? exchange, discussed below)
Catheter access or exit site infection
(can exchange or re-site, discussed
below)
Bacteremia (can exchange, discussed
below)
Sepsis
 Possible emergent indication for
removal
*Note: A temporary non-tunneled
line or PICC can be placed at the
time of removal if needed for clinical
management (e.g., for pressors, etc.)
 24 Central Venous Access 221

Relevant Anatomy
What vein is preferred for Internal jugular (IJ) due to lower risk
central venous access and of complications (both immediate
why? and delayed)
Which side of internal Right is preferred over left, as it
jugular vein (IJV) is offers a more direct route to the right
preferred for central atrium and does not need to cross the
venous access and why? left brachiocephalic vein
 Lowers risk of complications (no
kink, less risk of fracture)
Where does the common Medial
carotid artery normally
run in relation to the
IJV?
Where should the IJV 1–5 cm above the clavicle, ideally at
be punctured for central the apex of the triangle formed by
venous access? the sternal and clavicular heads of the
sternocleidomastoid muscle, and the
clavicle
Why is lower venous Less chance of kinking or occlusion
access preferred in
tunneled lines placed in
the IJV?
What are options if the Recanalization of the occluded
jugular vein is occluded? jugular veins, access via nearby
collateral veins including the (often
enlarged) external jugular vein, or
choosing another site for access
(continued)
222 G. Gadodia

What vein is often Subclavian vein, less preferred than

preferred if the jugular jugulars because:
veins are contraindicated?  Higher risk of immediate
Why is it less preferred complication, especially
than the jugulars? pneumothorax
 Higher risk of delayed
complication, especially subclavian
stenosis causing arm swelling/pain
and possible loss of ability to place
future AV grafts of fistulae in that
arm
Where is the subclavian Anterior and inferior to the artery at
vein in relation to the the level of the first rib
subclavian artery?
How should the Over the anterior aspect of the first
subclavian vein be rib, lateral to the clavicle.
accessed? The underlying bone protects against
pneumothorax.
Infraclavicular approach accesses the
vein at the junction of the medial and
middle thirds of the clavicle.
If a patient has an upper On the side contralateral to the AVG/
extremity AVG or AVF, AVF
which side should jugular
and subclavian central
venous catheters be
placed?
Where are PICCs placed? In the upper arm, usually in the
brachial, basilic, or cephalic vein
What is the ideal final High-flow (dialysis/pheresis)
location for the tip of a catheters:
central venous catheter,  Proximal right atrium
and why? Low-flow catheters (all others,
including PICCs):
 Cavoatrial junction
The goal is to place the tips at the
locations with the highest flow rates
and largest lumen, making clot and
occlusion less likely.
 24 Central Venous Access 223

What is the approximate Two vertebral body units below the

location of the cavoatrial carina
junction on AP
radiographs?
In general, how can veins Veins are compressible, while arteries
reliably be distinguished retain their rounded shape.
from nearby arteries?
What other veins outside Femoral
the chest can be used for  Higher rate of infection and
central venous access, and occlusion than chest, meaning more
what are risks associated frequent interventions for catheter
with each? maintenance
 May result in IVC occlusion
Direct IVC (translumbar)
 Malfunction more than chest
catheters
   But similar infection rates
 IVC occlusion also a possibility
Transhepatic IVC or hepatic venous
catheters
 High malfunction rate due to
respiratory motion causing liver
and thus catheter movement
Transrenal
Direct right atrial (surgically placed)
 Does not allow for over the wire
catheter exchange
Many of these alternate routes also
pose increased risk of injury to major
surrounding structures due to difficult
and deep placement.
What structures form the Deep femoral and superficial femoral
common femoral vein? vein
Where should the Proximal to the saphenofemoral
common femoral vein be junction, over the femoral head
accessed?
(continued)
224 G. Gadodia

Where is the common Lateral and superficial

femoral artery in relation
to the CFV?
How is the IVC accessed Posterior approach in a prone patient,
via a translumbar to the right of the spine (same side as
approach? the IVC/away from the aorta) with a
low entry (often through the inferior
endplate of L3; A balloon or wire
may be inserted into the IVC as a
target.)
What anatomic obstacles Presence of an abdominal aortic
and issues may be present aneurysm
with translumbar IVC Anomalous left IVC
access? Right renal artery, which often is
posterior to the IVC at the level of
L2

Relevant Materials
In general, what is the The smallest bore (lowest risk of
ideal catheter to use? venous stenosis), least lumen (lower
risk of occlusion as lumens often
get smaller in diameter as more are
added), and most temporary device
possible for the needed indication is
the best
What materials come in a 21-gauge micropuncture needle
standard micropuncture 0.018-in. guidewire
kit used to initiate Micro-introducer dilator
most venous access
procedures?
What type of catheter Open tip (end hole)
tips exist? Groshong tip (side hole)
Staggered tip
 24 Central Venous Access 225

What are examples of Small bore:

common tunneled central  Hohn
venous catheters?  Broviac (mostly used for pediatric
patients)
Large bore:
 Hickman:
   Single lumen: TPN, ionotropic
medications, blood products and
draws
   Triple lumen/Trifusion: Stem cell
transplant
 Leonard
What are examples of Quinton: Two lumens with staggered
common temporary tips
non-tunneled dialysis Trialysis: Three lumens (two for HD,
catheters? one power injectable lumen) with
staggered tips
What types of tunneled Shape:
dialysis catheters exist?  Pre-curved
 Straight
Side hole design:
 Staggered tips are more common:
   Help to avoid recirculation, but
may be prothrombotic
Multiple brands
At least two lumens
Large outer diameter: up to 15.5–16
Fr
Length measured “tip-to-cuff”: 15, 17,
19, 23, or 28 cm
Flow rate > 400 mL/min
Coating:
 Antibiotic-impregnated catheters
(minocycline, rifampin)
   Significantly reduced infection
 Chlorohexidine and silver
impregnated
   Slight reduction in infection
Which patients may ICU patients
antibiotic-impregnated
catheters indicated for?
(continued)
226 G. Gadodia

What are the Usually single lumen, can be double

specifications of most lumen
port catheters? Open or Groshong tip
6.6–9 Fr
What does it mean for Allows for flow of 5 cc/s (pressures up
a catheter to be “power to 600 psi)
injectable” and why is  Can be used for contrast injection
this important? for imaging studies
What kinds of catheters Tunneled central venous catheters,
have Dacron retention including for dialysis
cuffs?  Not non-tunneled catheters or ports
What are the advantages Lower incidences of infection
of valved PICCs and
ports?
What valve placement Proximal
(proximal or distal)
is associated with the
lowest incidence of
infection and occlusive
complications?

General Step by Step

Are pre-procedural No
prophylactic antibiotics
generally recommended for
placement of tunneled or
temporary lines?
When are pre-procedural Line exchanges, especially if done
antibiotics indicated? for bacteremia
Port placements
What kind of anesthesia Local anesthesia only:
or sedation is generally  PICCs and midlines
recommended for each  Non-tunneled CVCs
type of procedure? Moderate sedation and local
anesthetic:
 Tunneled CVCs
 Port catheters
 24 Central Venous Access 227

How long should Clopidogrel (Plavix): 5 days

common anticoagulation Aspirin 81 mg: No need to hold
medications be held Heparin drip (gtt): 2 hours
prior to CVC placement, Lovenox:
especially for tunneled  Prophylactic (daily): 12 hours
catheters or ports?  Therapeutic (BID): 24 hours
Apixaban (Eliquis): 48 hours
Rivaroxaban (Xarelto): 24 hours
What should be done prior Physical exam of the site for
to patient positioning to cellulitis, other devices, or other
confirm site selection? issues
Ultrasound the site to ensure vessel
patency and favorable anatomy
What is ideal patient Supine and slightly Trendelenburg
positioning for attempted (head down) or legs up
IJ and subclavian access?  Helps increase central venous
pressure, distending veins
and lowering risk of some
complications
Head turned to contralateral side.
Use of a roll or pillow under the
ipsilateral shoulder can help expose
the area.
How can venous access be Fluoroscopically: The wire should
confirmed? pass below the diaphragm.
 Ideal, most reliable method
Ultrasound: Longitudinal views
to ensure placement within the
compressible venous system
 May be inaccurate in patients
with aberrant anatomy
Pressure manometry
 May be inaccurate in certain
patient positions or in a patient
with low pressures (such as in
shock)
What can make venotomy Small dermotomy
dilation easier?
(continued)
228 G. Gadodia

For tunneled lines and Approximately 2–3 fingerbreadths

ports, what is the ideal site (3–6 cm) inferolateral to the clavicle
for the catheter to exit/port
pocket?
What is the “over-the-­ Place initial guidewire tip in the
wire” method to measure desired location via fluoroscopy.
appropriate catheter Clip the wire at the level where it
length? emerges from the sheath.
Remove the initial wire with clip
in place, ensuring no air embolus
can enter the sheath (using a cap or
syringe, thumb, or the new wire).
Measure from the clip to the end of
the removed guidewire, taking into
account the amount that was within
the sheath outside of the vein,
and distance to tunnel exit site as
appropriate.
Select the catheter of the closest
length or trim the catheter to this
length, as appropriate.
For tunneled catheters, At least 1 cm
how far into the tunnel
should the cuff be placed?
After tunneling the Use of a peel-away sheath catheter
catheter, what are methods with a valve.
to prevent significant If there is no valve:
bleeding or air emboli  Keep finger on the top of the
while inserting it into the remaining peel-away sheath while
venotomy sheath? quickly removing the inner dilator
and guidewire.
 Pinch the sheath while inserting
the catheter, and have the patient
hum to avoid deep inspiration.
 24 Central Venous Access 229

After confirming Venotomy site:

tip placement with  Manual compression until
fluoroscopy, what are hemostasis is achieved.
possible methods to close  For tunneled lines and ports,
the venotomy site and close with preferred method, for
secure the catheter? example, absorbable suture, Steri-­
Strip, or skin glue
Catheter securement:
 PICC:
   StatLock dressing
 Tunneled or non-tunneled central
venous catheter:
   Nonabsorbable suture (e.g., 2-0
Prolene)
   Figure-of-eight, U-stitch, etc.
(per preference)
 Port:
   Secure port in pocket (optional
step) with absorbable or
nonabsorbable suture
   Deeper (dermal) closure:
    Two to three deep
interrupted sutures with braided
absorbable suture material (e.g.,
3-0 Vicryl)
   Skin closure:
   Running subcuticular suture
with monofilament absorbable
suture (e.g., 4-0 Monocryl, Quill)
   +/− Skin glue and/or
Steri-Strips (with or without
subcuticular suture, per
preference)
Dressing on catheter (including
biopatch, etc.)
What are recommended Normal saline for large-/small-bore
methods to lock the CVCs, PICCs, Groshong-tip ports
catheter to prevent Heparin for all other ports
future complication (air Citrate for dialysis catheters
embolism, clot formation)
before use (may be
institutional dependent)?
(continued)
230 G. Gadodia

What are unique features Positioning: usually nondominant

of PICC placement arm if able, abducted, and externally
(as compared to CVC rotated (can ask patient to put the
placement)? hand behind the head)
Use of tourniquet on upper arm
How are central venous Inject local anesthetic along the
catheters removed? tract.
 PICCs and non-tunneled
catheters:
   Cut sutures securing catheter
in place.
 Tunneled catheters:
   Cut sutures (at the skin, and
any deep sutures).
   Dissect (bluntly, with sharp
dissection as needed) around the
cuff.
 Port:
   Cut the skin over previous port
pocket incision, as able.
   Dissect out port, with care
taken to avoid cutting the
catheter.
   Cut sutures securing port into
pocket, as needed.
Pull the catheter out while patient
exhales, with simultaneous manual
pressure at the venotomy site.
Continue holding pressure over
venotomy site and along the tract
until hemostasis is achieved.
Ensure the entire catheter is
removed and intact.
Close/dress skin wound with
preferred method:
 For ports: suture pocket closed,
usually using the same method as
pocket was initially closed during
placement
 24 Central Venous Access 231

What should be done if the Removal, if able without further

cuff of a tunneled catheter dissection
stays in the skin? Otherwise, can usually be left
behind, with notification of patient
and primary providers
 Only must come out in the setting
of:
   Cosmetic concerns
   Failure of tract closure
   Infection
How can the subclavian Puncture a distal vein in the
vein be accessed using ipsilateral arm/hand.
fluoroscopy? Inject contrast under fluoroscopy to
confirm position of subclavian vein.
Use fluoroscopy for puncture (can
use roadmap function if available).
Advance the needle until blood
return, or tip contacts the first rib.
How can the subclavian Place the patient in Trendelenburg.
vein be accessed without Use a roll or pillow to elevate the
fluoroscopy? patient’s thoracic spine, and lower
the ipsilateral shoulder.
Turn the patient’s head away.
Puncture the skin 1 cm caudal to the
junction of the medial and middle
clavicle using palpation.
Advance the needle along toward
the sternal notch.
(continued)
232 G. Gadodia

How can the common Place the patient supine with hip in
femoral vein be accessed, neutral position.
without sonography? Palpate the CFA below the inguinal
ligament.
Start 1 cm below the inguinal
ligament, and 0.5–1 cm medial to
the CFA.
Palpate or locate the lower third of
the femoral head using fluoroscopy.
Direct the needle cephalad at a
45-degree angle.
Aspirate for return while keeping
the CFA localized and going medial
to this.
What is unique post-­ Bed rest with leg immobile for
procedural care after 3–4 hours
common femoral venous
access?
How can the IVC be Place the patient prone or in a left
accessed via a translumbar lateral decubitus position.
approach? Palpate the right iliac crest and the
spinous process superior to it.
Insert a long puncture needle about
10 cm to the right of the spinous
process.
Under fluoroscopy, advance the
needle at a 45-degree angle toward
the top of the L3 vertebral body,
but anterior to this, until blood is
aspirated.
What is unique post-­ Bed rest for 4–6 hours
procedural care after
translumbar IVC access?
 24 Central Venous Access 233

Complications
What are the overall and major Overall: ~7%
complication rates in image-­ Major: ~3%
guided central venous access?
What are possible complications Immediate, or procedure-­
in CVC placement? related:
 Bleeding
 Pneumothorax
 Hemothorax
 Access site hematoma
 Vein injury or perforation
 Air embolism
 Inadvertent arterial injury
 Procedure-induced sepsis
Delayed:
 Venous thrombosis
 Phlebitis (especially in
PICCs)
 Venous stenosis
 Occlusion/fibrin sheath
 Wound dehiscence
 Tunnel infection/sepsis
 Catheter malfunction (can be
immediate)
What catheter tip positions may Deep (i.e., distal right atrium)
cause complications? placement can cause ectopy
and arrhythmia.
Shallow (i.e., proximal/mid
SVC) placement can increase
chance of venous stenosis and
catheter malfunction or poor
flow due to vessel collapse.
(continued)
234 G. Gadodia

What are some possible site-­ IJ

specific complications?  Carotid artery trauma
 Pneumothorax (less likely
than subclavian access)
Subclavian
 Pneumothorax
 Hemothorax
 Chylothorax (especially in
left-sided access)
 Puncture of subclavian artery
Femoral
 Femoral nerve or artery
trauma (with higher risk
of hematoma and/or
pseudoaneurysm than at the
neck)
 Thrombosis of femoral or
iliac veins
Translumbar IVC
 Psoas or other
retroperitoneal hematoma
 Puncture of visceral artery or
organ, including the aorta
Other than Patients on TPN
immunocompromised patients,
which patient group has
the highest risk of catheter-­
associated infection?
How can an air embolism be Place the patient in left lateral
managed immediately? decubitus position.
 Keeps the air bubble trapped
against the nondependent
aspect of the right ventricle
and away from the right
ventricular outflow tract.
Use a catheter to access the
bubble under fluoroscopy and
suction out.
 24 Central Venous Access 235

How can suspected catheter-­ Non-tunneled CVC:

associated infections be  Exchange catheter (over
managed? wire, or with new access site)
Tunneled CVC:
 Remove and place
temporary access (non-­
tunneled) as needed.
Dialysis catheter:
 Bacteremic or infected
tunnel: exchange catheter
over wire +/− new tunnel.
 If symptoms persist over
36 hours, remove tunneled
catheter; place non-tunneled
dialysis catheter if needed.
   48-hour line holiday before
replacing
Septic patient with any type of
catheter: remove emergently;
place temporary access as
needed.
What are possible causes of Poor positioning (too
catheter malfunction (i.e., not superficial, causing vessel
flush and/or aspirate)? collapse, or too deep)
Tip against vessel wall
Catheter kink/fracture
Catheter thrombosis
Fibrin sheath
What is the first step Obtain chest X-ray to evaluate
in troubleshooting a if kinked, fractured, or poorly
malfunctioning line? positioned.
What can be done if a line Attempt manual reduction;
is kinked in superficial soft otherwise dermotomy and
tissues? open reduction if the kinking
is superficial versus catheter
exchange over wire if it is
deeper.
(continued)
236 G. Gadodia

What can be done in a Attempt declotting agents:

malfunctioning catheter that is  tPA (alteplase) 2 mg in each
not kinked/fractured and is in port for 30–120 min
proper position?    Repeat x 1 if flow does not
improve.
What is the next step if Injection study
declotting agents fail?  Evidence of fibrin sheath:
   Strip sheath with a snare*
   Exchange over wire if this
fails
 No fibrin sheath:
   Exchange over wire
   If TDC, a different brand
or make of catheter can be
attempted
*Note: Snares are generally
more expensive than catheters,
so exchanging may be cheaper.
What can be done in the event Resite the catheter, with or
of CVC occlusion if both without venography if central
thrombolysis and exchange fail? venous stenosis or occlusion
is suspected as the underlying
cause.

Landmark Research
Sasadeusz KJ, Trerotola SO, Shah H, Namyslowski J, Johnson
MS, Moresco KP, Patel NH (1999) Tunneled Jugular Small-­
Bore Central Catheters as an Alternative to Peripherally
Inserted Central Catheters for Intermediate-term Venous
Access in Patients with Hemodialysis and Chronic Renal
Insufficiency. Radiology 213:303–306.
 24 Central Venous Access 237

What did Sasadeusz et al. find Tunneled catheters are a

regarding the placement of viable alternative to peripheral
tunneled small-bore central catheters in patients with renal
venous catheters as compared issues, and preserve future
to PICCs in patients on HD or upper extremity HD access.
CKD?

Lund GB, Trerotola SO, Scheel PF, Savader SJ, Mitchell

SE, Venbrux AC, Osterman FA (1996) Outcome of tunneled
hemodialysis catheters placed by radiologists. Radiology
198:467–472.

What are important findings by Tunneled dialysis catheters

Lund et al. and Trerotola et al. placed by interventional
with regard to the placement of radiologists, especially in
tunneled hemodialysis catheters by the right internal jugular
interventional radiologists? vein, had equal or better
complication and success
rates as those placed by
surgeons.
Routine use of a single
dose of prophylactic
antibiotics was found to be
unnecessary:
 Use of antibiotic
prophylaxis by Lund et al.
was associated with a
higher infection rate than
the study by Trerotola
et al. not using antibiotics,
0.08/100 vs. 0.14/100
catheter days, respectively.

Ramos ER, Reitzel R, Jiang Y, et al. (2011) Clinical effec-

tiveness and risk of emerging resistance associated with pro-
longed use of antibiotic-impregnated catheters: More than
0.5 million catheter days and 7 years of clinical experience*.
Critical Care Medicine 39:245–251.
238 G. Gadodia

What did Significant decrease in central line-associated

Ramos bloodstream infections in the medical ICU
et al. find in (from 8.3/1000 to 1.2/1000, p < 0.001) in
regard to the patients with catheters coated with minocycline
prolonged use and rifampin, without increased bacterial
of antibiotic-­ resistance
impregnated
catheters?

Haas B, Chittams JL, Trerotola SO (2010) Large-bore

Tunneled Central Venous Catheter Insertion in Patients with
Coagulopathy. Journal of Vascular and Interventional
Radiology 21:212–217.

What did Haas et al. Placement of such catheters is safe

find in regard to even in patients with INR between 1.5
placing large-bore and 2.0, and/or platelet counts between
tunneled central 25,000/dL and 50,000/dL, without need
venous catheters for transfusion of coagulopathic blood
in coagulopathic products (no bleeding complications
patients? found in coagulopathic group of 626
patients).

Ponec D, Irwin D, Haire WD, Hill PA, Li X, Mccluskey ER

(2001) Recombinant Tissue Plasminogen Activator
(Alteplase) for Restoration of Flow in Occluded Central
Venous Access Devices: A Double-Blind Placebo-Controlled
Trial—The Cardiovascular Thrombolytic to Open Occluded
Lines (COOL) Efficacy Trial. Journal of Vascular and
Interventional Radiology 12:951–955.
Blaney M, Shen V, Kerner JA, Jacobs BR, Gray S, Armfield
J, et al. Alteplase for the Treatment of Central Venous
Catheter Occlusion in Children: Results of a Prospective,
Open-label, Single-arm Study (The Cathflo Activase Pediatric
Study). Journal of Vascular and Interventional Radiology.
2006;17:1745–51.
 24 Central Venous Access 239

What were the salient COOL-1 and COOL-2:

results of the COOL-1,  Adult patients
COOL-2, and CAPS  74–75% efficacy of one dose of
trials regarding the alteplase with an indwelling time of
use of alteplase for 120 min. (versus 17% after placebo),
treating occluded 88% efficacy of two doses, in catheters
catheters? occluded up to 14 days (72% in
occlusions greater than 14 days)
 74% cumulative patency at 30 days
 52% and 84% patency in one and two
doses with 30 min. indwelling times,
respectively
CAPS:
 Pediatric patients
 75% patency after one dose of
alteplase, and 83% patency after two
doses, with indwelling time of 120 min.
(53% and 80% with 30-min. dwell
times)
All demonstrated overall safety of using
alteplase for occluded catheters, without
increased risk of bleeding or intracranial
hemorrhages.

Common Questions

What is the preferred Right internal jugular vein

location for central
venous access?
What should be avoided PICC and midline placement
in patients with CKD Placement of catheter on the same side
and DM, and/or those as a maturing AVG or AVF
on HD?
(continued)
240 G. Gadodia

What is the main factor Length of access

in deciding between  Non-tunneled: Days to 1–2 weeks
placing a tunneled and  Tunneled: Weeks or longer
non-tunneled catheter?
In general, what is the The smallest bore (lowest risk of
ideal catheter to use? venous stenosis), least lumen (lower
risk of occlusion as lumens often
get smaller in diameter as more are
added), and most temporary device
possible for the needed indication is
the best.
Is there an emergent No, a non-tunneled central venous
indication for tunneled catheter can be placed for emergent
central venous access? indications.
During placement, Guidewire should pass below the
what is the best way diaphragm.
to confirm access into
the venous system
fluoroscopically?
How can an air Place the patient in left lateral
embolism be managed decubitus position.
immediately?  Keeps the air bubble trapped against
the nondependent aspect of the right
ventricle and away from the right
ventricular outflow tract
Use a catheter to access the bubble
under fluoroscopy and suction it out.
 24 Central Venous Access 241

How can suspected Non-tunneled CVC:

catheter-associated  Exchange catheter (over wire, or
infections be managed? with new access site)
Tunneled CVC:
 Remove and place temporary access
(non-tunneled) as needed.
Dialysis catheter:
 Bacteremic or infected tunnel:
exchange catheter over wire +/−
new tunnel.
 If symptoms persist over 36 hours,
remove tunneled catheter; place
non-tunneled dialysis catheter if
needed:
   48-hour line holiday before
replacing
Septic patient with any type of
catheter: remove emergently; place
temporary access as needed.
What can be done in a Attempt declotting agents:
malfunctioning catheter  tPA (alteplase) 2 mg in each port for
that is not kinked/ 30–120 min
fractured and is in    Repeat x 1 if flow does not
proper position? improve.

Further Reading
Baskin KM, Jimenez RM, Cahill AM, Jawad AF, Towbin
RB. Cavoatrial junction and central venous anatomy: implica-
tions for central venous access tip position. J Vasc Interv Radiol.
2008;19:359–65.
Beathard GA. Management of bacteremia associated with tunneled-
cuffed hemodialysis catheters. J Am Soc Nephrol. 1999;10:1045–9.
Blaney M, Shen V, Kerner JA, Jacobs BR, Gray S, Armfield J, et al.
Alteplase for the treatment of central venous catheter occlusion
in children: results of a prospective, open-label, single-­arm study
(the Cathflo Activase pediatric study). J Vasc Interv Radiol.
2006;17:1745–51.
242 G. Gadodia

Dariushnia SR, Wallace MJ, Siddiqi NH, Towbin RB, Wojak JC,
Kundu S, Cardella JF. Quality improvement guidelines for cen-
tral venous access. J Vasc Interv Radiol. 2010;21:976–81.
Deitcher SR. Safety and efficacy of Alteplase for restoring func-
tion in occluded central venous catheters: results of the
­cardiovascular thrombolytic to open occluded lines trial. J Clin
Oncol. 2002;20:317–24.
Ferral H, Lorenz J. Radcases interventional radiology. New York:
Thieme; 2018.
Funaki B. Central venous access: a primer for the diagnostic radiolo-
gist. Am J Roentgenol. 2002;179:309–18.
Gilbert RE, Harden M. Effectiveness of impregnated central venous
catheters for catheter related blood stream infection: a system-
atic review. Curr Opin Infect Dis. 2008;21:235–45.
Haas B, Chittams JL, Trerotola SO. Large-bore tunneled central
venous catheter insertion in patients with coagulopathy. J Vasc
Interv Radiol. 2010;21:212–7.
Hua C, Dreifuss R. Dialysis catheter access RFS Pre IR rotation mod-
ule. In: Common IR procedures. http://rfs.sirweb.org/medical-­
student-­section/introduction-­to-­ir/common-­ir-­procedures/. Oct
2018.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. Philadelphia: Lippincott Williams &
Wilkins; 2016.
Kaufman JA, Lee MJ. Vascular and interventional radiology: the
requisites. Philadelphia: Elsevier/Saunders; 2014.
Kohli MD, Trerotola SO, Namyslowski J, Stecker MS, Mclennan
G, Patel NH, Johnson MS, Shah H, Seshadri R. Outcome of
Polyester Cuff retention following traction removal of tunneled
central venous catheters. Radiology. 2001;219:651–4.
Lund GB, Trerotola SO, Scheel PF, Savader SJ, Mitchell SE, Venbrux
AC, Osterman FA. Outcome of tunneled hemodialysis catheters
placed by radiologists. Radiology. 1996;198:467–72.
Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS,
Walker TG, Saad WA. Consensus guidelines for periprocedural
management of coagulation status and hemostasis risk in per-
cutaneous image-guided interventions. J Vasc Interv Radiol.
2012;23:727–36.
Ponec D, Irwin D, Haire WD, Hill PA, Li X, Mccluskey
ER. Recombinant tissue plasminogen activator (Alteplase) for
restoration of flow in occluded central venous access devices:
a double-blind placebo-controlled trial—the Cardiovascular
 24 Central Venous Access 243

Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J

Vasc Interv Radiol. 2001;12:951–5.
Ramos ER, Reitzel R, Jiang Y, et al. Clinical effectiveness and risk of
emerging resistance associated with prolonged use of antibiotic-
impregnated catheters: more than 0.5 million c­ atheter days and
7 years of clinical experience*. Crit Care Med. 2011;39:245–51.
Sasadeusz KJ, Trerotola SO, Shah H, Namyslowski J, Johnson MS,
Moresco KP, Patel NH. Tunneled jugular small-bore central cath-
eters as an alternative to peripherally inserted central catheters
for intermediate-term venous access in patients with hemodi-
alysis and chronic renal insufficiency. Radiology. 1999;213:303–6.
Shaffer D. Catheter-related sepsis complicating long-term, tunnelled
central venous dialysis catheters: management by guidewire
exchange. Am J Kidney Dis. 1995;25:593–6.
Trerotola SO, Johnson MS, Harris VJ, Shah H, Ambrosius WT,
Mckusky MA, Kraus MA. Outcome of tunneled hemodialysis
catheters placed via the right internal jugular vein by interven-
tional radiologists. Radiology. 1997;203:489–95.
Trerotola SO, Stavropoulos SW, Mondschein JI, Patel AA, Fishman
N, Fuchs B, Kolansky DM, Kasner S, Pryor J, Chittams J. Triple-
lumen peripherally inserted central catheter in patients in
the critical care unit: prospective evaluation. Radiology.
2010;256:312–20.
Tritle B, McLennan G. Central venous access. Cleveland Clinic radi-
ology resident morning conference, 2018.
Venkatesan AM, Kundu S, Sacks D, et al. Practice guideline for adult
antibiotic prophylaxis during vascular and interventional radiol-
ogy procedures. J Vasc Interv Radiol. 2010;21:1611–30.
Weijmer MC, Vervloet MG, Wee PMT. Prospective follow-up of a
novel design haemodialysis catheter; lower infection rates and
improved survival. Nephrol Dial Transpl. 2007;23:977–83.
Chapter 25
Carotid Artery Stenosis
Gaurav Gadodia

Evaluating Patient
How do patients with Asymptomatic, with incidentally
internal carotid artery detected stenosis (majority)
(ICA) stenosis usually
present?
When present, what Non-disabling or transient ischemic
are symptoms that may attack (TIA) or transient retinal
indicate ICA stenosis? (amaurosis fugax) symptoms within
6 months
What physical exam Carotid bruit
finding might be present
in a patient with carotid
stenosis?
What is the imaging Carotid duplex ultrasound
modality of choice for
screening for carotid
stenosis in patients with
symptoms?
(continued)

G. Gadodia (*)
Department of Radiology, Imaging Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: [email protected]
© Springer Nature Switzerland AG 2022 245
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_25
246 G. Gadodia

What are possible Asymptomatic patients with known

indications for evaluating or suspected carotid stenosis (class I,
asymptomatic patients level of evidence: C)
with carotid duplex Asymptomatic patients with carotid
ultrasonography bruit (IIa, C)
(along with ASA/ACC Annual assessment of progression or
recommendation classes regression of disease and response to
and level of evidence)? therapeutic intervention in patients
with atherosclerosis and stenosis of
>50% (IIa, C)
Asymptomatic patients with
symptomatic PAD, CAD, and AAA
(IIb, C)
Asymptomatic patients with two or
more risk factors, including HTN,
hyperlipidemia, tobacco smoking,
family history of first-degree relative
with atherosclerotic issues manifested
before 60 years, or family history of
ischemic stroke (IIb, C)
When does evaluation Routine screening of asymptomatic
of ASYMPTOMATIC patients who have no clinical
patients with carotid manifestations of or risk factors for
duplex ultrasonography atherosclerosis
confer no benefit (class Routine screening of asymptomatic
III recommendation to patients with neurological or
screen)? psychiatric disorders unrelated
to ischemia (i.e., brain tumors,
degenerative diseases, infectious or
inflammatory conditions, psychiatric
disorders, or epilepsy)
Routine serial imaging in patients
without risk factors
Has screening No
asymptomatic patients
with ultrasound been
shown to reduce the risk
of stroke?
 25 Carotid Artery Stenosis 247

Is screening of No
asymptomatic patients
for carotid stenosis
recommended per the
US Preventive Services
Task Force?
What are the indications Initial evaluation in patients with
for evaluating transient retinal or hemispheric
SYMPTOMATIC neurological symptoms (I, C)
patients with carotid Evaluation of patients with focal
duplex ultrasonography? neurological symptoms corresponding
to the territory supplied by the left or
right carotid artery (I, C)
Can be considered when nonspecific
neurological symptoms may be caused
by ischemia (IIb, C)
What are other Cervical bruit in an asymptomatic
indications for evaluation patient
using carotid duplex Follow-up of known stenosis (>20%)
ultrasonography? in asymptomatic individuals
Vascular assessment in a patient
with multiple risk factors for
atherosclerosis
Stroke risk assessment in a patient
with CAD or PAD
Stroke in a candidate for carotid
revascularization
Follow-up after a carotid
revascularization procedure
Intraoperative assessment during
CEA or CAS
(continued)
248 G. Gadodia

What are parameters Primary parameters:

to evaluate on Peak systolic velocity (PSV) of
ultrasonography? blood flow in the carotid artery
Direct estimation of plaque
thickness
Secondary parameters:
End-diastolic velocity (EDV)
Ratio of ICA to common carotid
artery (CCA) PSV
What are pros and Pros
cons of duplex No ionizing radiation
ultrasonography? No contrast needed
Often cheaper and more readily
available
   Better for screening/initial
evaluation as per above indications
Cons
Operator variability
Uses velocity to estimate degree
of stenosis as opposed to direct
visualization of stenotic diameter:
   Degree of stenosis may be over-
or underestimated.
   May overestimate severity
of stenosis contralateral to ICA
occlusion (increased contralateral
velocity may mimic stenosis on
sonography).
   Cannot assess intrathoracic or
intracranial lesions
   May not be able to differentiate
between subtotal and complete
arterial occlusion
   Poor evaluation of heavily
calcified lesions due to acoustic
shadowing
 25 Carotid Artery Stenosis 249

When is CTA/MRA When ultrasonography cannot

indicated for the be obtained or yields equivocal/
evaluation of carotid nondiagnostic results in patients with
artery stenosis? acute, focal neurologic symptoms
corresponding to territory supplied
by the left or right ICA (I, C) or in
candidates for revascularization (IIa, C)
For confirmatory and planning
imaging in patients who are
candidates for revascularization to
evaluate severity of stenosis and
identify intrathoracic or intracranial
vascular lesions (IIa, C):
In practice, MRA is often the test
of choice to confirm US findings and
further evaluate intrathoracic and
intracranial anatomy.
What techniques can be Time of flight (no contrast)
used for carotid stenosis Phase-contrast MRA
evaluation via MRA? Contrast-enhanced
(continued)
250 G. Gadodia

What are some pros and Pros

cons of using MRA for  Anatomic imaging of the aortic arch
evaluation of carotid and major branch vessels
artery stenosis?    Allows for evaluation of both
intrathoracic and intracranial
vasculatures, unlike US
   No ionizing radiation
   Best noninvasive method for
evaluating heavily calcified lesions
   Overall best for assessing plaque
morphology including ulceration
and risk of thromboembolic event
   Lower risk of adverse
events (including allergy and
nephrotoxicity) from gadolinium-­
based contrast agents used in MRA
than from iodinated contrast agents
used in CTA
Cons
 Can overestimate stenosis
 Cannot reliably discriminate
subtotal vs complete occlusion
 Use limited in patients with:
   Claustrophobia
   Extreme obesity
   Certain incompatible implanted
devices
   Depending on type and amount
of gadolinium agent used and
possible risk of nephrogenic
systemic fibrosis (NSF) in some
patients with renal dysfunction:
   Alternatively, time-of-flight MRA
technique may be used to evaluate
the vessels without the use of
contrast.
What is a limitation of Accurate quantification of the degree
MRA in the evaluation of endoluminal stenosis due to motion
of carotid stenosis? artifact and flow voids
 25 Carotid Artery Stenosis 251

What are some pros and Pros

cons of using CTA for  Anatomic imaging of the aortic arch
evaluation of carotid and major branch vessels:
artery stenosis?    Allows for evaluation of both
intrathoracic and intracranial
vasculatures, unlike US
   Best noninvasive evaluation of
the arterial lumen and degree of
stenosis
   No limitations based on
implanted devices
   Often used in cases with
equivocal findings on US and
MRA, or with issues excluding
MRA evaluation
Cons
 Ionizing radiation
 Use of iodinated contrast:
   Higher risk of adverse event
including allergy and nephrotoxicity
than Gd-based agents used in
MRA:
    Limits use to patients without
renal dysfunction
   Poor evaluation of heavily
calcified lesions due to artifact
   Cannot reliably discriminate
subtotal vs complete occlusion
   Overlying metal including
implanted devices and surgical clips
may obscure evaluation due to
artifact.
(continued)
252 G. Gadodia

What is the gold standard Digital subtraction angiography

for evaluation of (DSA) of aortic arch, bilateral
carotid and intracranial carotids, and bilateral vertebral
atherosclerosis, and why? arteries including distal to the stenosis
Can assess for:
 Degree of stenosis:
   Most sensitive method, including
in evaluating possibly complete
occlusion
   Intrathoracic and intracerebral
disease
   Aberrant anatomy
When is DSA indicated When noninvasive testing is
over noninvasive imaging inconclusive or not feasible because of
(US, CTA, or MRA)? technical issues or contraindications
in patients with transient retinal/
hemispheric neurological symptoms of
suspected ischemic origin (IIa, C)
For evaluation of the possibility of
revascularization when noninvasive
testing suggests complete carotid
occlusion (IIb, C)
Of note: While it is the gold standard
for diagnosis, DSA is generally only
done during planned endovascular
therapeutic intervention.
What past medical History of radiation to the neck
history is especially History of coronary artery disease
important to know pre-­ (e.g., angina, stents, MIs, CABG)
procedurally?
 25 Carotid Artery Stenosis 253

High Yield History

What are potential Atherosclerotic plaque (most
underlying causes of carotid common)
stenosis? Aneurysm
Arteritis
Carotid dissection
Mass/neoplasm (both benign such
as glomus tumor and malignant
soft tissue tumors)
Radiation necrosis/intimal
hyperplasia
Vasospasm
Cystic medial necrosis
Fibromuscular dysplasia (FMD)
What are risk factors for Genetic (family history)
carotid stenosis? Hypertension (HTN)
Diabetes mellitus (DM)
Smoking
Hypercholesterolemia
What percentage of ischemic 20–30%
strokes are caused by
extracranial ICA disease?
What is the mechanism of Embolization of atherosclerotic
ischemic stroke from ICA debris or thrombotic material
disease? from plaque into more distal
cerebral vessels
How is carotid stenosis Moderate: 50–69%
graded (according to 2011 Severe: 70–99%
ASA/ACC guidelines)?
(continued)
254 G. Gadodia

What velocities on ultrasound Moderate stenosis (50–69%):

correspond to what level of  PSV of 125–230 cm/s
stenosis?  Ratio of ICA to CCA PSV of
2–4
 End-diastolic velocity (EDV) of
40–100 cm/s
Severe stenosis (>70%):
 PSV > 230 cm/s
 Ratio of ICA to CCA PSV of
>4
 EDV > 100 cm/s
What is the gold-standard Antiplatelet therapy with aspirin,
treatment for patients 75–325 mg daily (I, A):
with asymptomatic carotid If patient has HTN: add
stenosis from atherosclerosis? antihypertensives to maintain BP
below 140/90 (I, A).
What is the gold-standard Aspirin 75–325 mg daily alone
treatment for patients with Clopidogrel 75 mg daily alone
symptomatic carotid stenosis Aspirin plus extended-release
from atherosclerosis (overall dipyridamole (25 and 200 mg
class I, LOE B)? BID, respectively):
Better than aspirin and
clopidogrel together, which shows
no benefit within 3 months of
symptoms
Is there a role for Anticoagulation with
anticoagulation in the setting unfractionated or LMW
of carotid artery stenosis? heparin is not recommended in
symptomatic patients with carotid
stenosis (III, B):
Antiplatelet agents are
recommended over oral
anticoagulants in patients with
stenosis with (I, B) or without (I,
C) ischemic symptoms.
 25 Carotid Artery Stenosis 255

How should patients with an Using P2Y12 inhibitors on their

allergy to aspirin be treated own, including:
(IIa, C)?  Clopidogrel
 Prasugrel
 Ticagrelor
 Cangrelor
What are the major Surgical carotid endarterectomy
methods of carotid artery (CEA)
revascularization? Endovascular carotid artery
stenting (CAS)

Indications/Contraindications
What are the Symptomatic patients at low or average
indications for risk of procedural complication (<6%
revascularization in risk of major complication or mortality)
symptomatic carotid should undergo CEA or CAS for
artery stenosis? revascularization if the lumen of the
ipsilateral carotid artery is reduced by
>70% by noninvasive imaging or >50%
by angiography (class: I).
When should In cases where revascularization is
intervention be indicated in symptomatic patients
undertaken in relation without contraindications, reasonable to
to symptoms? do so within 2 weeks of symptom onset
(IIa, B)
(continued)
256 G. Gadodia

What are the Asymptomatic patients should

indications for undergo revascularization based on
revascularization in an assessment of comorbidities, life
asymptomatic carotid expectancy, and other individual factors
artery stenosis? (I, C):
Reasonable to do CEA in
asymptomatic patients with >70%
stenosis of the ICA and with low risk of
perioperative stroke, MI, or death (IIa,
A).
CAS may be considered in highly
selected patients with asymptomatic
carotid stenosis (minimum 60% by
angiography, 70% by validated Doppler
ultrasound) (IIb, B).
Of note: There is no data to prove
that this is really better than medical
therapy alone.
Overall, what If there are no contraindications, CEA
is the current is generally recommended over CAS:
recommendations Symptomatic patients
regarding treatment  50–69% stenosis:
choice in carotid    CEA (I, B)
revascularization?    CAS (I, B)
 70–99% stenosis:
   CEA (I, A)
   CAS (I, B)
Asymptomatic patients
 70–99% stenosis:
   CEA (IIa, A)
   CAS (IIb, B)
 25 Carotid Artery Stenosis 257

When should CAS be When neck or lesion anatomy is

chosen over CEA for unfavorable for arterial surgery (IIa, B),
revascularization? including:
 History of prior neck surgery or
radiation therapy to the neck
 Carotid dissection
 Tandem stenosis (carotid and
ipsilateral intracranial stenosis)
 Surgically inaccessible lesion
(intrathoracic or intracranial)
 Tumor encasing the carotid artery
 Existing tracheostomy
 Limitation in cross flow circulation:
   Contralateral carotid occlusion
or other disease requiring
revascularization
Stenosis after completed or
attempted CEA within past 31 days
In patients with significant cardiac
history and risk of periprocedural
cardiac event (controversial), including:
 Congestive heart failure
 LVEF < 30%
 Recent MI
 Significant coronary artery disease
 Unstable angina
 Uncontrolled diabetes
 Recent heart surgery (<6 weeks)
In what situations is <50% atherosclerotic luminal
revascularization not narrowing (III, A)
recommended? Chronic total occlusion of the target
artery (III, C)
In patients with severe disability caused
by cerebral infarction that precludes
preservation of useful function (III, C)
(continued)
258 G. Gadodia

What are absolute Chronic carotid artery occlusion

contraindications to Allergy to antiplatelet medications
CAS? Allergy to metals in stent
Uncorrectable coagulopathy
Incompatible anatomy
What are relative Acute clot within stenosis
contraindications to History of stroke within 6 weeks or
CAS? prior disabling stroke (modified Rankin
scale >3)
Recent intracranial hemorrhage
Bacteremia/sepsis
Immunocompromised state
Circumferential or near circumferential
calcified lesion
What are the Reasonable to repeat CEA or perform
indications for CAS in patients with symptomatic
re-intervening in cerebral ischemia (symptomatic
patients with restenosis patients) and recurrent carotid
after revascularization? stenosis due to intimal hyperplasia
or atherosclerosis, using the same
criteria as recommended for initial
revascularization (IIa, C).
Reasonable when duplex ultrasound
AND another confirmatory imaging
method identify rapidly progressive
restenosis that indicates a threat of
complete occlusion (IIa, C).
In asymptomatic patients with recurrent
stenosis, re-operative CEA or CAS
may be considered using the same
criteria as recommended for initial
revascularization (IIb, C),
What is a Asymptomatic patients with <70%
contraindication to stenosis (class III)
reoperation?
 25 Carotid Artery Stenosis 259

Relevant Anatomy
What three major branches Brachiocephalic trunk (innominate
commonly arise from the artery), left common carotid artery,
aortic arch? and left subclavian artery
What is the most common Common origin of the
aortic arch anatomic brachiocephalic and left common
variant? carotid arteries (often colloquially
called a “bovine arch,” which is a
misnomer, as it does not normally
occur in bovines)
Where do atherosclerotic At the external/internal carotid
lesions usually occur in the bifurcation
carotid?
Where do the external and At the level of the thyroid cartilage
internal carotid arteries
usually bifurcate?
What is the carotid bulb? Dilated portion at the origin of the
ICA extending for about 2 cm
What arteries provide Ipsilateral external carotid artery
collateral circulation to Ipsilateral vertebral artery,
territories possibly affected contralateral ECA, and vertebral
by a stenotic ICA? artery (via the circle of Willis)
What arteries should be Bilateral common carotids and
evaluated angiographically branches (external and internal
prior to endovascular carotids)
revascularization? Bilateral vertebral arteries

Relevant Materials

What kinds of catheter 4 or 5 Fr diagnostic catheter

can be used for carotid (e.g., Bernstein II, Sidewinder II,
angiography? Multipurpose, Vertebral, Headhunter)
(continued)
260 G. Gadodia

What type of catheter 6 Fr (sometimes 7 Fr) guide

is used for treatment catheter (e.g., Envoy by Codman
(balloon, stenting)? Neurovascular or Shuttle by Cook)
What types of devices Collapsible filters mounted on
are used for cerebral 0.014 in. guidewires and deployed past
protection (embolic the stenosis:
protection devices, or For example, Accunet, Emboshield
EPDs)? BareWire, FilterWire EX, Angioguard
RX, and Spider FX
Temporary balloon occlusion devices
to occlude the common and external
carotid to prevent antegrade or
retrograde flow into the ICA:
For example, Mo.MA Ultra Device
(Medtronic)
What can be used if the Predilation with a small
lesion is too small to (3–4 mm × 20 mm or smaller)
cross for a stent device? noncompliant PTA balloon or a low-­
profile cerebral angioplasty balloon
like Gateway (Stryker Neurovascular)
or Maverick (Boston Scientific Corp.)
What type of balloon 4.0–7.0 mm × 20 mm noncompliant
can be used to dilate the PTA balloon (diameter matching
stent? that of the normal artery distal to the
target lesion)
What types of stents are Self-expandable stents, due to superior
generally used for CAS crush resistance/ability to regain shape
of the ICA and why? when deformed:
 Important due to mobility of the
neck
Where should balloon-­ Common carotid artery ostial lesions:
expandable stents be  Mobility is limited by thoracic cage
used and why? (no crushing).
 It allows for more precise
placement.
How should stents be Oversized by 1–2 mm above diameter
sized? of vessel in the landing zones
 25 Carotid Artery Stenosis 261

What kind of stents Tapered stents

should be used if there
is a large discrepancy
between the proximal
and distal landing zone
diameters?

General Step by Step

What components of a NIHSS, modified Rankin scale,
neurological exam should be and Barthel index of ADLs
completed on the patient pre-­
procedurally?
What can help reduce the risk Use of EPD (IIa, C) when the
of stroke intraprocedurally in risk of vascular injury from such
CAS? a device is low
What medications should be Beta-blockers – already
held pre-procedurally, and potential for bradycardia during
why? manipulation near the carotid
bulb
Metformin (for 24 prior and
48 hours after) (due to contrast
use)
What medications should Dual-antiplatelet therapy:
be started prior to the  Clopidogrel (Plavix) 75 mg
procedure? daily
 Aspirin (ASA) 81–325 mg daily
How long pre-procedurally Elective cases: 5 days prior
should these medicines be Emergent cases (within 72 hours
started? of stroke):
 Loading dose of Plavix 300 mg
PO 3–4 hours prior
 Loading dose of ASA 650 mg
PO or PR 3–4 hours
(continued)
262 G. Gadodia

In addition to standard Arterial line, for more sensitive

hemodynamic monitoring, continuous blood pressure
what type of monitoring is monitoring
recommended during CAS,
especially with lesions near
the bifurcation?
How should Option 1: Unfractionated
anticoagulation be managed heparin with target ACT of 250–
intraprocedurally? 300 seconds
 50–70 IU/kg loading dose IV,
then titrate
Option 2: Direct thrombin
inhibitors (especially in patients
with HIT)
 Argatroban:
   15–30 ug/kg/min infusion
with 350 ug/kg bolus followed
by 25ug/kg/min infusion
 Bivalirudin:
   0.75 mg/kg bolus followed
by infusion at 1.75 mg/kg/h for
4 hours, all IV.
   ACT should be checked
5 min after bolus (give
additional 0.3 mg/kg bolus if
needed at this time).
What medication class can Glycoprotein IIb/IIIa inhibitors
be used if in-stent clot forms (e.g., eptifibatide (Integrilin) and
during the procedure, and abciximab (ReoPro)).
how are they used? Ensure baseline ACT
<200 seconds prior to
administration to reduce risk of
intracranial hemorrhage.
What medicine can be given Protamine
to reverse effects of heparin
activity?
 25 Carotid Artery Stenosis 263

How can intraprocedural Glycopyrrolate (0.2–0.4 mg IV):

bradycardia be managed? Can also be given
prophylactically in lesions near
the bulb to prevent bradycardia
Atropine (0.6–1.0 mg)
Dopamine (rarely used)
What medications can help Nicardipine, intra-arterial (IA)
manage intraprocedural Verapamil IA
vasospasm?
What IV fluid is best to Albumin helps improve cerebral
manage intraoperative microcirculation independent of
hypotension and why? BP.
Where is access usually Common femoral artery
obtained in cases of CAS? (preferred). Radial, brachial,
axillary, or direct carotid
punctures are also used, less
often.
What is the first step after Diagnostic angiography (four
obtaining access? vessels)
What are key points to assess Collateral blood supply via
during angiography? external carotids, posterior
circulation
Potentially dangerous
anastomoses to the ICA from the
external/vertebrobasilar system
Circle of Willis and intracranial
collaterals
Lesion length, degree of stenosis,
and regional anatomy (landing
zone, relation to bulb, tortuosity,
ulceration, thrombus, amount of
calcifications)
What should be attached to Pressurized bag of heparinized
the guide catheter after four-­ saline (1 drop/second continuous)
vessel angiography and prior
to attempts at crossing an
ICA lesion?
(continued)
264 G. Gadodia

What should be done after Cross the lesion using a 0.014 in.
accessing the carotid artery wire, and deploy a cerebral
with the guide catheter? protection device, followed by
angiography of the CCA.
What if the lesion is too small Predilate with PTA balloon or
to cross for a stent device? low-profile cerebral angioplasty
balloon.
What are ideal landing zone 5–10 mm on either side of plaque
dimensions for the stent?
What should be assessed after Angiography to evaluate for
stent placement? residual stenosis, significant if
over 10–15%
What should be done if there Balloon dilation
is significant residual stenosis
after stent placement?
What should be assessed on Vasospasm
final angiogram after stent Dissection
placement and removal of Distal emboli
EPD?
When is it most crucial to Anytime there is balloon dilation
monitor the patient for or other manipulation about the
bradycardia? carotid bulb
How should tortuous carotid Use two shorter, overlapping
arteries with stenosis be stents to avoid straightening
approached? the artery with a longer stent
and creating pseudo-occlusion/
kinking
For how long after the Dual-antiplatelet therapy with
procedure should antiplatelet aspirin (81–325 mg qd) and
therapy be continued? clopidogrel (75 mg qd) should
be continued for a minimum of
30 days after procedure (I, C).
Aspirin is usually continued
indefinitely.
 25 Carotid Artery Stenosis 265

How should patients be Overnight observation

managed post-procedurally? Vitals and neuro exam hourly
Bed rest until morning
General post-procedural
considerations:
 Hydration.
 Restart diet.
 Remove Foley catheter, if
placed.
 DVT prophylaxis.
How should the patient be Clinical neurological examination
clinically examined after for 24 hours after CAS (I, C)
CAS?
How should the patient be Noninvasive imaging of the
followed post-procedurally? extracranial arteries is reasonable
at 1 month, 6 months, and
annually after revascularization
to assess patency and exclude
development of new or
contralateral lesions (IIa, C):
 Usually with Doppler, but can
use CTA/MRA if anatomic
location is too superior for
Doppler
Can extend surveillance time
period once stable over an
extended period.
Can terminate surveillance if
patient no longer a candidate for
re-intervention.
266 G. Gadodia

Complications
What are possible acute General arteriographic procedure
and intraprocedural complications:
complications in CAS? Allergic reaction to contrast
Puncture site trauma/injury
including hematoma and
pseudoaneurysm
Retroperitoneal hematoma (in
cases of femoral access)
Arterial rupture
Arterial dissection
Stroke from distal embolization
Vagal symptoms including
bradycardia and hypotension
How can arterial Hydration, with pressor support as
hypotension be managed? needed
How can hemodynamically Immediate stenting, or stop the
significant arterial procedure and manage medically:
dissection be managed? Heparin bridge to Coumadin,
Coumadin for 6 months
How can acute Intra-arterial abciximab or
thromboembolism be eptifibatide or tPA
managed? Thrombectomy with stent retriever
Aspiration thrombectomy
Ancillary treatments like colloid
infusion/induction of arterial
hypertension
How can neck hematoma If minor, reverse heparinization
due to venous or arterial with protamine, usually self-­
rupture be managed? containing.
If major:
 Occlude vessel with balloon
catheter.
 Reconstructive methods like
emergent covered stent.
 Permanent endovascular
occlusion of the entire carotid
with coils should be considered.
 Consider emergency surgery.
 25 Carotid Artery Stenosis 267

What patients are at Patients with history of prior

highest risk for venous/ CEA, patients with previous neck
arterial rupture? irradiation and stricture, and
steroid-dependent patients
How can reperfusion brain Mannitol and corticosteroids
edema be managed?
How can intracerebral Consult neurosurgery
hemorrhage be managed?
Why does intracerebral Reperfusion-related, or delayed
hemorrhage occur? transformation of a small ischemic
insult

Landmark Research

What did the NASCET (North Significant benefit for CEA

American Symptomatic Carotid with medical therapy over
Endarterectomy Trial-1991) and medical management alone
ECST (European Carotid Surgery for symptomatic patients
Trial-2003) trials find regarding with 70–99% stenosis:
CEA versus medical management NASCET also found
alone for symptomatic patients? a benefit for CEA in the
moderate stenosis group
(50–69%), while ECST did
not.
What did the ACAS Significant benefit for CEA
(Asymptomatic Carotid with medical therapy in
Atherosclerosis Study-­1995) asymptomatic patients:
and ACST (Asymptomatic ACAS: with >60%
Carotid Surgery Trial-2010) stenosis versus medical
trials find regarding CEA versus therapy alone
medical management alone for ACST: with
asymptomatic patients? hemodynamically
significant stenosis versus
deferring CEA
268 G. Gadodia

CAS Versus CEA

What did the Findings:
CAVATAS Similar short- and long-term stroke
(Carotid and and mortality rates between CEA and
Vertebral Artery endovascular therapy
Transluminal Less other complications in the endovascular
Angioplasty arm
Study-1999) study Similar 30-day and 3-year effectiveness rates
find regarding Higher restenosis rate in the endovascular
CEA versus arm especially longer term
endovascular Limitations:
therapy in No use of cerebral protection devices, as this
symptomatic was prior to their invention
patients with Low stenting rate in endovascular arm,
low to moderate mostly just angioplasties
surgical risk, and
what was a major
limitation in the
endovascular arm?
What was a Unique feature:
unique feature of Only RCT comparing outcomes in high
the SAPPHIRE surgical risk patients (both symptomatic and
(Stenting and asymptomatic) undergoing CEA vs CAS with
Angioplasty with an EPD
Protection in Findings:
Patients at High Favorable results for CAS over CEA at
Risk for Endarter- 30 days and 1 year but mostly did not reach
ectomy-2004) trial, significance as study was stopped early for low
and what were its enrollment.
major findings and Equally effective at 3-year follow-up in
limitations? terms of stoke prevention.
Carotid artery stenting is non-inferior to
CEA in 30-day risk of stroke, death, and MI.
There was a statistically significant lower
rate of MI in the CAS population at 30 days.
Limitations:
Controversial as lab findings of cardiac
biomarkers were used to diagnose MI, not
necessarily EKG findings or symptoms.
The study stopped early for low enrollment,
so many endpoints did not reach significance.
 25 Carotid Artery Stenosis 269

What were the Findings:

major findings and Overall: no significant difference in long-term
limitations of the outcomes between CEA and CAS
EVA-3S EVA-3S:
(Endarterectomy Terminated early after much higher negative
Versus Angioplasty outcome rate in the CAS arm at 30 days
in Patients with However beyond 30 days no difference in
Symptomatic adverse outcomes
 SPACE:
Severe Carotid
Terminated early due to low enrollment
Stenosis-2006),
No significant difference in outcomes (stoke,
SPACE (Stent-
death) between CAS and CEA at 30 days or
Supported
2 years
Percutaneous CAS better for patients <70 years old, and
Angioplasty of the CEA better for patients >70 years old
Carotid Artery  ICSS:
Versus CEA was superior to CAS in terms of major
Endarterectomy- negative outcomes (stroke, death, MI) at
2006), and ICSS 120 days follow-up:
(International But at 5 years = no significant difference in
Carotid Stenting major outcome including mortality or disabling
Study-2010) trials stroke
comparing CAS Non-disabling stroke was higher in stenting
and CEA in group, but no difference in quality of life or
symptomatic disability.
patients with Limitations:
standard surgical  Both EVA-3S and SPACE required very
risk? minimal operator experience in the CAS arms.
EVA-3S:
5 prior CAS procedures if unsupervised, 0 if
supervised:
Trainees with little stenting experience could
perform CAS if proctored by qualified operators.
SPACE:
Operators needed to have a minimum number
of successful CEAs.
Also needed a minimum number of
endovascular angioplasty or stenting procedures
in the past, but did not have to be CAS.
EVA-3S also used single-antiplatelet medical
therapy after stenting, as compared to gold-
standard dual-antiplatelet therapy.
The use of EPDs was limited, not mandatory,
and nonuniform in all three trials.
(continued)
270 G. Gadodia

What was Design:

unique about  RCT comparing outcomes of CAS with EPD
the design of the to CEA in both symptomatic patients with
CREST (Carotid >50% stenosis and asymptomatic patients
Revascularization with >60% stenosis at standard surgical risk
Endarterectomy Findings:
Versus Stenting  CEA arm: significantly higher risk of
Trial-2010) trial, periprocedural MI
and what were its  CAS arm: significantly higher risk of
findings? periprocedural minor/non-disabling stroke
Of note, as study continued rates of
periprocedural events in CAS arm declined
significantly, suggesting a learning curve (no
similar change in CEA).
 At 4 years there was no significant difference
in mortality or overall stroke rate:
Higher rate of stroke in asymptomatic
patients at 4 years in CAS group
   No difference in stroke rate at 4 years in
symptomatic patients
 Like SPACE, CAS better for patients
<70 years old, and CEA better for patients
>70 years old
What are the At 30 days (peri-procedurally):
overall current  CAS associated with a significantly elevated
findings of pooled risk of stroke and death
research (per a  CEA associated with a significantly elevated
meta-analysis) risk of MI and cranial nerve injuries
comparing CEA Beyond 30 days (long-term), comparable
and CAS? findings
 25 Carotid Artery Stenosis 271

What trials are SPACE-2: Two parallel arms of asymptomatic

ongoing? patients with severe stenosis
 CEA and medical therapy vs medical
therapy alone.
 CAS and medical therapy vs medical
therapy alone.
 Trial currently stopped due to slow
recruitment, but data on previously recruited
patients (n = 513) continuing to be collected.
ACST-2: RCT of asymptomatic patients with
severe stenosis comparing CEA vs CAS
CREST-2: Two parallel arms of asymptomatic
patients with severe stenosis
 CEA and medical therapy vs medical
therapy alone
 CAS and medical therapy vs medical
therapy
What are the Both CAS and CEA can be done with low risk
overall findings by experienced operators.
from research Long-term outcomes might be the same.
at this point, CAS better for those with cardiac issues peri-
informing procedurally.
the above While risk of MI is higher in CEA than in
recommendations CAS, the higher stroke rate in CAS seems to
and guidelines? be more detrimental to overall health.
CEA favored for more elderly patients.
More research needs to be done with uniform
use of EPDs, with best medical therapy, and
in symptomatic patients with experience CAS
and CEA operators.

Common Questions
Overall, when is carotid Symptomatic patients with >70%
revascularization stenosis
(by CEA or CAS) Patients with <6% risk of
indicated? perioperative stroke or mortality
(continued)
272 G. Gadodia

When does a patient History of non-disabling stroke, TIA,

qualify as “symptomatic” or amaurosis fugax within the past
from carotid artery 6 months with ipsilateral carotid artery
stenosis? stenosis
Generally, when is CAS In patients with:
indicated over CEA?  Significant cardiac history
 Anatomic contraindications to
surgery, such as prior neck surgery
or radiation
What are the major Puncture site trauma
complications of CAS? Overall higher risk of periprocedural
stroke than CEA
What is the best Carotid duplex ultrasonography
screening and follow-up *Classification of recommendations
test? and level of evidence guide:
Class I: Benefit >> risk. Procedure
should be performed.
Class IIa: Benefit > risk. It is
reasonable to perform procedure.
Class IIb: Benefit >= risk. Procedure
may be considered.
Class III: No benefit, or there is harm.
Procedure is not helpful or may be
harmful.
Level A: Data from multiple RCTs or
meta-analyses.
Level B: Data from one RCT or from
non-randomized studies.
Level C: Limited data, only case
studies or expert opinion.

Further Reading
Bonati LH, Dobson J, Featherstone RL, et al. Long-term outcomes
after stenting versus endarterectomy for treatment of symptom-
atic carotid stenosis: the International Carotid Stenting Study
(ICSS) randomised trial. Lancet. 2015;385:529–38.
 25 Carotid Artery Stenosis 273

Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/

AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/
SVS guideline on the Management of Patients with Extracranial
Carotid and Vertebral Artery Disease: executive summary: a
report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines,
and the American Stroke Association, American Association
of Neuroscience Nurses, American Association of Neurological
Surgeons, American College of Radiology, American Society
of Neuroradiology, Congress of Neurological Surgeons,
Society of Atherosclerosis Imaging and Prevention, Society
for Cardiovascular Angiography and Interventions, Society
of Interventional Radiology, Society of NeuroInterventional
Surgery, Society for Vascular Medicine, and Society for Vascular
Surgery. Developed in collaboration with the American
Academy of Neurology and Society of Cardiovascular Computed
Tomography. J Am Coll Cardiol. 2011;57:1002–44.
Bulbulia R, Halliday A. The Asymptomatic Carotid Surgery Trial-2
(ACST-2): an ongoing randomised controlled trial comparing
carotid endarterectomy with carotid artery stenting to prevent
stroke. Health Technol Assess. 2017;21:1–40.
Cline J, Hong MJ. Carotid artery stenosis & management RFS
pre IR rotation module. In: Common IR procedures. http://rfs.
sirweb.org/medical-­student-­section/introduction-­to-­ir/common-­
ir-­procedures/. Oct 2018.
CREST-2: Medical study to prevent stroke caused by plaque buildup
in carotid arteries. In: CREST-2: Medical study to prevent stroke
caused by plaque buildup in carotid arteries. http://www.crest-
2trial.org/. Accessed Oct 2018.
Eckstein H-H, Reiff T, Ringleb P, et al. SPACE-2: a missed oppor-
tunity to compare carotid endarterectomy, carotid stenting, and
best medical treatment in patients with asymptomatic carotid
Stenoses. Eur J Vasc Endovasc Surg. 2016;51:761–5.
Eckstein H-H, Ringleb P, Allenberg J-R, et al. Results of the Stent-
Protected Angioplasty versus Carotid Endarterectomy (SPACE)
study to treat symptomatic stenoses at 2 years: a multinational,
prospective, randomised trial. Lancet Neurol. 2008;7:893–902.
Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD,
Stefanadis C. Carotid artery stenting versus carotid endarter-
ectomy: a comprehensive meta-analysis of short-term and long-
term outcomes. Stroke. 2011;42:687–92.
274 G. Gadodia

Ederle J, Bonati LH, Dobson J, et al. Endovascular treatment with

angioplasty or stenting versus endarterectomy in patients with
carotid artery stenosis in the Carotid And Vertebral Artery
Transluminal Angioplasty Study (CAVATAS): long-term follow-
up of a randomised trial. Lancet Neurol. 2009;8:898–907.
Ederle J, Dobson J, Featherstone RL, et al. Carotid artery stent-
ing compared with endarterectomy in patients with symptom-
atic carotid stenosis (International Carotid Stenting Study):
an interim analysis of a randomised controlled trial. Lancet.
2010;375:985–97.
European Carotid Surgery Trialists' Collaborative Group.
Randomised trial of endarterectomy for recently symptomatic
carotid stenosis: final results of the MRC European Carotid
Surgery Trial (ECST). Lancet. 1998;351:1379–87.
Ferral H, Lorenz J. Radcases interventional radiology. New York:
Thieme; 2018.
Halliday A, Harrison M, Hayter E, et al. 10-year stroke preven-
tion after successful carotid endarterectomy for asymptomatic
stenosis (ACST-1): a multicentre randomised trial. Lancet.
2010;376:1074–84.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. Philadelphia: Lippincott Williams &
Wilkins; 2016.
Lefevre ML. Screening for asymptomatic carotid artery stenosis:
U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med. 2014;161:356.
Long A, Lepoutre A. Corbillon, Branchereau A. Critical review
of non- or minimally invasive methods (Duplex ultrasonogra-
phy, MR- and CT-angiography) for evaluating stenosis of the
proximal internal carotid artery. Eur J Vasc Endovasc Surg.
2002;24:43–52.
Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG. The Carotid
Revascularization Endarterectomy Versus Stenting Trial
(CREST): stenting versus carotid endarterectomy for carotid dis-
ease. Stroke. 2010; https://doi.org/10.1161/strokeaha.110.595330.
Mas J-L, Trinquart L, Leys D, et al. Endarterectomy versus angio-
plasty in patients with symptomatic severe carotid stenosis
(EVA-3S) trial: results up to 4 years from a randomised, multi-
centre trial. Lancet Neurol. 2008;7:885–92.
Massop D, Dave R, Metzger C, Bachinsky W, Solis M, Shah R,
Schultz G, Schreiber T, Ashchi M, Hibbard R. Stenting and
angioplasty with protection in patients at high-risk for endar-
 25 Carotid Artery Stenosis 275

terectomy: SAPPHIRE worldwide registry first 2,001 patients.

Catheter Cardiovasc Interv. 2009;73:129–36.
North American Symptomatic Carotid Endarterectomy Trial
(NASCET) Collaborators. Beneficial effect of carotid endarter-
ectomy in symptomatic patients with high-grade carotid stenosis.
N Engl J Med. 1991;325:445–53.
Walker MD, Marler JR, Goldstein M, et al. Endarterectomy for
asymptomatic carotid artery stenosis. Executive Committee
for the Asymptomatic Carotid Atherosclerosis Study. JAMA.
1995;273:1421–8.
Chapter 26
Renovascular Hypertension
Gaurav Gadodia

Evaluating Patient
When should renovascular In patients with:
hypertension (RVH) be Refractory hypertension under
suspected? age 30
New onset of severe/refractory
hypertension after age 50
Abrupt worsening of controlled
hypertension
Hypertension with progressive
renal failure
Creatinine (Cr) rise over 20%
with ACE inhibitors (AKI when
put on ACE-I)
Secondary hyperaldosteronism
and resulting hypokalemia
Flash pulmonary edema in
patients with preserved LVEF
Unilateral small kidney with
difference >1.5 cm
(continued)

G. Gadodia (*)
Department of Radiology, Imaging Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 277

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_26
278 G. Gadodia

What is the definition of Poorly controlled hypertension

refractory hypertension? even on optimal medical
management with three
antihypertensive medications
What is the main underlying Renal artery stenosis (RAS)
cause of RVH? due to atherosclerosis (90%) or
fibromuscular dysplasia (FMD)
(10%)
How do patients with RAS Asymptomatic, with RAS
usually present? incidentally detected during
unrelated angiographic imaging
What physical exam finding Flank or abdominal bruit
may be found in RAS?
What is a possible severe Flash pulmonary edema
acute presentation of RAS?
What is the best initial/ Doppler ultrasonography (AHA/
screening imaging study for ACC class I, LOE: B)
evaluation of RAS?
What are direct signs of RAS Peak systolic velocity (PSV)
on Doppler? > 180 cm/s
Post-stenotic turbulence/bruit
Renal artery PSV to aortic
velocity ratio > 3.5
What are indirect signs of Tardus et parvus waveform distal
RAS on Doppler? to the stenotic lesion
Prolonged acceleration time
(> 0.07 seconds)
Loss of early systolic peak distal
to the lesion
Discrepancy in resistive index
(RI) before/after the lesion > 0.05
What is another noninvasive Computed tomographic
imaging modality that can angiography (CTA) (I, B)
help evaluate RVH when US
findings are equivocal?
 26 Renovascular Hypertension 279

What is a disadvantage Disadvantage: Contrast-induced

of CTA (especially in this nephropathy in patient population
population), and what is an with a high prevalence of ischemic
alternative test? nephropathy from stenosis
Alternative: Magnetic resonance
angiography (MRA) (I, B)
What is the gold-standard Digital subtraction angiography
test for diagnosing RVH? (DSA) (I, B)
What are other described Captopril renal scintigraphy (III,
diagnostic methods, and their C)
AHA/ACC recommendation Selective renal vein renin
class/level of evidence? sampling (III, B)
Plasma renin activity (III, B)
Captopril stimulation test (III, B)

High Yield History

About what percentage 5% (0.5–10%)
of patients with HTN
have underlying RAS?
What is the underlying Decreased renal perfusion ➔ renin
pathophysiology of release by juxtaglomerular cells ➔
RAS causing RVH? activates angiotensin II, causing:
 Efferent arteriole constriction to
increase renal perfusion
 Systemic hypertension
Aldosterone elevation leading to
sodium/water retention and diastolic
dysfunction
What is the definition 10% or greater mean translesional
of hemodynamically pressure gradient (and/or SBP gradient
significant RAS (ACC/ > 20 mmHg or > 10 mmHg mean
AHA and ACR/SIR)? gradient difference)
(continued)
280 G. Gadodia

What lab abnormality Creatinine > 3.0

is associated with a
worse prognosis in
RVH?
What are the Older men
demographics of
RAS caused by
atherosclerosis?
What are the Women aged 30–50 years old
demographics of
FMD?
What subtype of FMD Medial subtype, with intimal and
is associated with adventitial subtypes being much less
HTN? likely to cause HTN (< 15% combined)
What is the “Beading” of the artery due to
characteristic alternating stenoses and aneurysms
appearance of FMD?
What findings are True and dissecting aneurysms
associated with FMD? Arteriovenous fistulas
What is another Noninflammatory vasculitis
differential for RAS?
What is the Medial fibroplasia
most common
noninflammatory
vasculitis subtype?
How is this treated? Balloon angioplasty. Only pursue
stenting if angioplasty fails or there are
complications.
What are uncommon Renal artery aneurysm, Takayasu
etiologies for RVH? arteritis, neurofibromatosis, Iatrogenic
or traumatic injury causing dissection,
vessel injury damaging the intima
causing thrombosis, retroperitoneal
tumor encasement/compression,
Williams syndrome, segmental arterial
mediolysis, and midaortic syndrome
 26 Renovascular Hypertension 281

Indications/Contraindications
What is the gold- Medical management including (class
standard initial I, A):
treatment for RVH?  ACE inhibitors
 Angiotensin receptor blockers
 Beta-blockers
 Calcium channel blockers
When medical Surgical or endovascular
management fails, what revascularization
are invasive treatment
options?
What arteries are used Splenic artery for the left kidney and
for bypass in surgical hepatic and gastroduodenal artery
revascularization? (GDA) for the right
When is surgery FMD with segmental artery
indicated over involvement or with macroaneurysms
endovascular (I, B)
treatment? Atherosclerotic RAS with multiple
small renal arteries or early primary
branching of the main renal artery (I, B)
Atherosclerotic RAS with pararenal
aortic reconstructions (e.g., after prior
AAA treatment)
Refractory/recurrent RVH after
previous endovascular treatment
How is RVH treated Atherosclerotic RAS:
endovascularly?  Angioplasty and stenting
   May be treated with angioplasty
only if non-ostial location
FMD: Angioplasty only
(continued)
282 G. Gadodia

What are the Onset of HTN before age of 30,

indications for renal especially without family history (I, B)
vascular imaging or Recent onset of significant HTN after
angiography (RAS the age of 55 (I, B)
screening) based on Accelerated, resistant, or malignant
patient presentation HTN (I, C)
(per the SIR, with Sudden (flash) or recurrent pulmonary
ACA/AHA classes and edema, especially with azotemia (I, B)
levels of evidence)? Renal failure of uncertain cause,
especially with a normal urinary
sediment and less than 1 gram of
protein per daily urinary output
Coexisting, diffuse atherosclerotic
vascular disease, especially in heavy
smokers
Acute renal failure precipitated by
antihypertensive therapy, particularly
angiotensin-converting enzyme (ACE)
inhibitors or angiotensin II receptor
blockers (I, B)
Idiopathic unilateral atrophic kidney
(size difference >1.5 cm) (I, B)
Unexplained renal failure (IIa, B)
 26 Renovascular Hypertension 283

What are potential Asymptomatic patient with

indications for hemodynamically significant RAS (IIb,
revascularization C)
in RVH caused by Hemodynamically significant RAS with
RAS (ACC/AHA (IIa, B):
classes and levels of Accelerated HTN: sudden worsening
evidence)? of previously controlled HTN
Resistant HTN: HTN that cannot be
controlled (< 140/90, or SBP < 160 in
patients over 60) on a maximally dosed
triple-drug regimen including a diuretic
Malignant HTN: HTN with end-
organ damage including left ventricular
hypertrophy, congestive heart failure,
visual or neurologic disturbance, or
advanced retinopathy
HTN with an unexplained unilateral
small kidney
HTN with intolerance to anti-­HTN
medications
Progressive CKD with (IIa, B):
 Bilateral RAS
RAS to a solitary functioning kidney
Chronic renal insufficiency with
unilateral RAS (IIb, C)
Hemodynamically significant RAS with
cardiac destabilization syndrome (I, B),
including:
Recurrent, unexplained congestive
heart failure
Sudden, unexplained pulmonary
edema
Hemodynamically significant RAS and
unstable angina (IIa, B)
Acute, symptomatic, idiopathic renal
artery dissection with new flank pain,
hematuria, or accelerated HTN without
underlying connective tissue disorder
or other pathology (per ACR/SIR. No
AHA/ACC recommendation)
(continued)
284 G. Gadodia

What are absolute Hemodynamically nonsignificant

contraindications to stenosis
renal revascularization?
What are relative Long-segment total occlusion
contraindications to Severely diseased aorta, as there is
renal revascularization? increased risk of embolization of the
atheroma
When is stent Stenotic ostial atherosclerosis (within
placement indicated 1 cm of aortic lumen)
over balloon Restenosis after prior treatment
angioplasty? Postoperative (renal bypass,
transplanted renal arteries) stenosis
Highly eccentric renal artery stenosis
Acute failure or complication of PTA
including:
Vessel recoil with possible collapse
Complex dissections not responding
to prolonged reinflation
esidual stenosis > 30% or residual
pressure gradient > 10% MAP
Rupture or perforation (use covered
stent)
How can you treat Options include PTA and re-stent.
in-stent restenosis?
When is stent Branch vessel disease
placement relatively Stent placement that would traverse
contraindicated? renal artery branches
Lesion length > 2 cm
Renal artery diameter < 4 mm (can use
coronary-sized stent)
Unfavorable renal anatomy, without
enough vessel length distal to proposed
stenting to allow for future surgical
bypass if needed
Diffuse intrarenal vascular disease
Noncompliant lesion
Kidney size < 7 cm
 26 Renovascular Hypertension 285

What are indications To determine which patients may

for renal vein renin benefit from revascularization
sampling? To determine the physiologic
significance of RAS
What are Patients who are not candidates for
contraindications revascularization
to renal vein renin Patients with occlusions of the renal
sampling? vein/ICV or IVC filters
What can hinder Patients on chronic ACE inhibitors or
accurate interpretation beta-blockers not able to be safely taken
of renal vein renin off medication
sampling results?

Relevant Anatomy
How many renal One per side
arteries do patients
commonly have?
What are important Accessory renal artery arising from the
variations to normal aorta (can be unilateral or bilateral)
renal artery anatomy? Early branching of the renal artery,
within 1 cm of the aorta
What lesion location Ostial location (proximal third)
lends more to
atherosclerosis over
FMD?
Which underlying Atherosclerosis
cause is more likely
in bilateral RAS,
atherosclerosis or
FMD?
(continued)
286 G. Gadodia

What is the Usually involving the mid to distal

characteristic location portion (the proximal artery may be
of FMD? involved, but rarely in isolation). This is
often unilateral, with a preponderance
for the right side over the left.

Relevant Materials
What kind of sheaths Longer arterial sheaths (20–30 cm) are
should be used best as they help decrease the potential
for renal arterial for plaque disruption during exchanges
interventions, and manipulations. A 40 cm Flexor Ansel
especially in cases of Sheath (Cook Medical) is often used
atherosclerotic RAS? during intervention.
What kind of wire Soft atraumatic wire (e.g., Bentson)
and catheter can and recurved catheter (e.g., Sos Omni
be used to cross an Selective (AngioDynamics) or Simmons)
atherosclerotic RAS
lesion?
What balloon Approximately 1% larger than estimated
diameter should you normal vessel diameter (not size of post-
use for renal arterial stenotic dilation)
angioplasty?
What kind of stent Balloon-expandable metallic stents, due to
is best for RAS, precision of placement
especially for ostial
lesions, and why?
How do you choose Adequately covers the lesion in length
stent size? and with diameter matching normal (pre-
and post-stenotic) vessel diameter (usually
1–2 cm length, 4–8 mm diameter)
What type of Hydrophilic wires may cause perforation
guidewires should be or dissection and may not provide enough
avoided and why? support for stenting, though can be used
to atraumatically cross lesions and then
exchange for a working wire.
 26 Renovascular Hypertension 287

What do you use to Lowest profile pressure wire (such as

measure a pressure 0.014 in.)
gradient?
What kind of 5 Fr. Cobra 2 catheter with a side hole
catheter is ideal made at the distal tip 2–3 mm from end
for renal vein renin hole
sampling?
What catheters can Sidewinder or other recurve catheters
help access the renal
vein in difficult
sampling cases?

 eneral Step by Step (DSA and Endovascular

G
Revascularization)

Per the SIR, what are ideal INR < 1.5

coagulation parameters pre- Platelets: Transfusion if below
endovascular intervention? 50,000/L
Are prophylactic pre- No
procedural antibiotics
recommended
for endovascular
revascularization?
How should you manage Hydrate overnight with 0.45%
patients with chronic kidney saline with sodium bicarbonate
disease (CKD) or risk at a rate of 100–150 cc per
factors for AKI or CKD 4–12 hours.
(e.g., DM, MM, dehydration) At least 1 hour of hydration.
periprocedurally? Use 30–50% diluted iodinated
contrast or non-iodinated contrast
such as carbon dioxide.
How should you manage a Discontinue long-acting
patient’s hypertension prior antihypertensives and
to a renal revascularization manage with short-acting
procedure? antihypertensives instead, as able.
(continued)
288 G. Gadodia

Where should vascular access Femoral, preferably on the right

ideally be obtained?
Where should you obtain Left brachial access, or radial
access if the patient has access
distal aortic occlusion or
unfavorable renal artery
angle?
What is the next step after Diagnostic angiography starting
obtaining access? with a flush aortogram and then
selective renal angiogram
What is the best projection/ LAO, about 20° for the right renal
view angle for aortic disease arter
and ostia? LAO, about 5–10° for the left
artery
If disease is bilateral, on Start with the larger kidney, as
which kidney should you disease is usually less severe and
start intervening? if cannot successfully treat that
one, likely will not be able to treat
either (this can also allow for a
two-stage therapy, and at least
help the patient in the interim).
What are techniques “No touch” technique:
to decrease risk of 0.035 j wire placed alongside the
embolization especially from guidewire inside guide catheter
atherosclerotic aorta? that is in the suprarenal aorta
to lift the catheter tip off of the
aortic wall
“Sos flick” technique:
Soft atraumatic guidewire 1–2 mm
out of a SOS Omni Selective
catheter, advance up the aorta
with wire sticking out toward the
direction of renal artery want, will
“flick” in.
How do you prevent spasm Intra-arterial (IA) nitroglycerin
of the renal artery prior to (100–200 micrograms)
guidewire insertion?
 26 Renovascular Hypertension 289

How can you provoke 50 ug/kg dopamine IA (this has

a pressure gradient the best evidence)
to assess for need for 100–200 ug nitroglycerin IA
revascularization? 30–40 mg papaverine IA
1 mg isosorbide dinitrate IA
What do you do in the event Place a covered or uncovered
of occlusive dissection or stent.
perforation?
How do you prevent Heparin IV: administer a 5000
thrombosis once you have unit bolus, followed by infusion of
crossed the stenosis? 750–1000 U per hour.
What is the target activated 2.5× baseline (~ 300+ seconds)
clotting time (ACT) for
stenting/intervention?
What is the target ACT when < 180 seconds
removing the femoral sheath
at the end of the procedure?
How do you position the Place stent to extend 1–2 mm into
stent if the lesion is ostial? the aortic lumen.
How much stent overlap 2 mm
should there be if you are
stenting in series (multiple
stents)?
How long do you keep For 1 minute (or until/if patient
the balloon inflated for has severe pain)
angioplasty?
What do you do after Angiogram, avoiding recrossing
completing angioplasty/ the stenosis
stenting?
What do you do if the Upsize balloon to 1 mm larger
angiographic result is not than previous; repeat until good
good or a significant pressure result.
gradient still exists?
(continued)
290 G. Gadodia

What must you Angiography of possible donor

do if endovascular vessels, most importantly the
revascularization has celiac access
failed, and/or patient is
planned to undergo surgical
revascularization?
What is the imaging modality Renal Doppler ultrasound
of choice for follow-up after
stent placement?
What is the definition < 30% residual stenosis and a
of technically successful pressure gradient less than the
endovascular renal selected threshold for intervention
revascularization (ACR/ (< 10% and/or mean SBP gradient
SIR)? < 20 mmHg or 10 mmHg mean
gradient difference)
What is the overall technical 95% or greater
success rate of endovascular
revascularization with stent
placement in atherosclerotic
RAS?
What labs should you Serum creatinine and BUN
monitor for 24 hours after
the procedure?
How long should you At least 24 and up to 48 hours
monitor BP for?
What should you do if BP Infusion of normal saline IV
drops below normal levels?
What should you do if BP Administer an ACE inhibitor such
increases during or after the as captopril.
procedure? Use other short-acting medicines
if severely elevated.
Do any medications need If a drug-eluting stent was used,
to be continued post- then aspirin 81 mg or another
procedurally? antiplatelet medicine must be
used for 6 months.
 26 Renovascular Hypertension 291

When do most recurrences Within the first 8 months

happen?
What is the failure rate of ~11%
primary stent placement
requiring re-intervention?
What is the failure rate ~20%
of repeat intervention on
in-stent stenosis?
What are the risk factors for Stents dilated to less than 6 mm
restenosis after stenting? Female sex
Age greater than 65 years
Smoking
What is the technical success 95% or greater
rate of angioplasty in FMD?
What is the primary patency 69% at 4 years
of angioplasty-treated FMD?
What is the clinical response 22–39% cured and 31–59%
to angioplasty in patients improved/partial response
with hypertension due to
renal artery FMD?
What are the definitions Cured: BP< or = 140/90 without
of clinical evaluation after meds
revascularization? Improved/partial response:
diastolic BP decreased by
10–15 mmHg or greater on the
same or less meds, OR decreased
in diastolic BP by 10–15 mmHg
without medications (normal with
meds)
Stable: diastolic BP within
15 mmHg on the same or less
meds
Failed: diastolic BP unchanged on
the same or less meds
(continued)
292 G. Gadodia

What are the definitions of Improved: decreased serum

evaluating renal dysfunction creatinine by 20% or more over
after revascularization? baseline
Stable: creatinine within 20% of
baseline
Failure: elevation of creatinine of
20% or more over baseline

Step by Step (Renal Vein Renin Sampling)

How should you manage Off all antihypertensives for

patient’s hypertension prior 2 weeks prior; most importantly,
to renal vein renin sampling? off beta-blockers and ACE
inhibitors.
How can you increase the Captopril 60–90 minutes before
accuracy of renal vein renin procedure (increases renin
sampling? secretion on affected side)
Sodium depletion
What is a primary Venous puncture as opposed to
difference between renal arterial puncture
vein renin sampling
and renal endovascular
revascularization,
procedurally?
Where does left renal vein Beyond the orifice of the left
renin sampling occur? gonadal vein
Where does right renal vein Close to the IVC, no gonadal vein
renin sampling occur? drainage to worry about
Where do you obtain control The infrarenal IVC
samples from?
Can you use contrast in renal No, contrast affects the
vein renin sampling? Why/ production of renin, potentially
why not? altering the results.
What is the protocol for Obtain as closely together as
obtaining samples? possible (within 20 minutes), and
transport to lab on ice.
 26 Renovascular Hypertension 293

Complications

What is the overall mean ~14%

complication rate of
endovascular intervention?
What is the most common Groin hematoma and puncture
type of complication? site trauma including hemorrhage,
rupture, inadvertent venous
puncture, and arteriovenous
fistula (3–5%)
What are some possible Local thrombus
complications at the Nonocclusive dissection (caused
angioplasty site? by guidewire or angioplasty)
Arterial rupture
What is a risk of having Thrombus formation and possible
balloon up too long or vessel occlusion
taking too long to deflate the
balloon?
How do you manage Trial of local intra-arterial
local thrombus without thrombolysis: 5 mg t-PA over
significant dissection or vessel 30 minutes, followed by 0.5 mg
perforation? per hour for up to 24 hours
How do you manage arterial Gently inflate balloon across the
rupture? tear to tamponade.
Deploy covered stent, as needed.
How do you manage non- No management needed,
flow-limiting dissections? common occurrence
How do you manage flow- Prolonged reinflation of a
limiting dissections? 1 mm undersized balloon or
deployment of a covered stent
Which patients are at higher Those on chronic steroid therapy
risk of vessel rupture in renal
angioplasty?
What are other risk factors Current smokers
for general complications and Untreated hyperlipidemia
recurrence?
(continued)
294 G. Gadodia

What are some possible extra Emboli to extremities

renal complications? Puncture site complications
Myocardial infarction
What is the rate of major 3–11% (vs. 20% for surgery)
complication (requiring
surgery or prolonged
hospitalization)?
What are major Worsening of renal function
complications, and their due to contrast and/or multiple
incidence? small infarctions by microemboli
(3–5%)
Occlusion of renal artery (2–3%)
Segmental infarction and
perinephric hematoma (1–2%)
Need for surgical intervention
such as nephrectomy and salvage
(2%)
Death (1%)
What is the 30-day mortality, < 1%. Caused by renal artery
and what are the causes? perforation, cholesterol
embolization, ARF, and arterial
access above the inguinal
ligament with subsequent bleed
What is the 30-day surgical Up to 5%
mortality?
Which patients have a higher Atherosclerosis
rate of complication with
revascularization: those with
FMD or atherosclerotic
stenosis?
What has been found to be Operator experience
the most significant factor
in determining risk of
complication?
 26 Renovascular Hypertension 295

Landmark Research

What have studies One RCT showed no difference

evaluating surgical in outcomes including blood
versus endovascular pressure, patency, and complications,
revascularization for RAS but demonstrated a longer
found? hospitalization postsurgical repair.
A large meta-analysis showed better
long-term patency and decreased
blood pressure from surgical repair,
but demonstrated higher surgical
mortality, especially in poor surgical
candidates.
What about comparing One small RCT, plus one meta-
stenting versus angioplasty analysis, demonstrated that stenting
alone (in atherosclerotic had a significantly lower risk of
patients)? restenosis, with no difference in
blood pressure or renal outcomes,
making stenting more favored
when considering endovascular
intervention in these patients.
What were the findings of Multicenter randomized controlled
the STAR, ASTRAL, and trials which found no significant
CORAL trials comparing difference in progression or renal
medical therapy alone disease (STAR and ASTRAL) or
versus medical therapy cardiovascular events, blood pressure
plus endovascular changes, and all-cause mortality
revascularization? (CORAL), between medical therapy
alone and medal therapy with
endovascular revascularization
(continued)
296 G. Gadodia

What are some significant Poor selection criteria

limitations of these  STAR:
(STAR, ASTRAL, and Patients were selected by
CORAL) studies? inaccurate, non-angiographic
imaging.
No pressure gradient
measured (no measurement of
hemodynamically significance of
RAS).
Used 50% stenosis as threshold,
not 70% as is more standard.
 ASTRAL:
Patients were excluded based on
subjective opinion of their physician.
40% of patients had < 70%
stenosis (likely not hemodynamically
significant).
No pressure gradients measured.
Intervened on patients with
contraindications.
 CORAL:
Patients without HTN enrolled
(RAS may not have been clinically
significant).
Average % stenosis in treated
group was < 70%.
In most cases, these studies did
not include high-risk patients
(pulmonary edema, etc.).
Poor technical outcomes in some,
including higher complication rates
and lower technical success rates
than reported elsewhere, possibly
due to inexperience of operators.
What is an argument in Selection criteria and decisions to
favor of the findings of the intervene or not reflected current
CORAL trial, as opposed practice patterns at the time
to the others?
 26 Renovascular Hypertension 297

What is an Patient who underwent endovascular

important finding revascularization had a decrease in
possibly supporting the number of antihypertensives
revascularization in all needed to control their blood
of the above, and other pressure, and the procedure is usually
similar, studies? associated with a low complication
rate in the hands of experienced
operators.
What were the findings Endovascular revascularization
of studies that have was associated with reduced risk
included high-risk of death/survival advantage over
patients (including flash medical therapy alone. However,
or recurrent pulmonary these studies have mostly been
edema, multiple high- small, non-randomized, single-center
risk comorbidities, and studies.
progressive renal failure),
and what are their
limitations?
What is the current No strong evidence for endovascular
state of endovascular revascularization over medical
revascularization in therapy alone in the majority of
cases of renovascular cases of renovascular hypertension.
hypertension from In a minority of severe cases of
atherosclerotic RAS RVH, most notably in patients with
based on these studies, as flash or recurrent pulmonary edema,
summarized in multiple endovascular revascularization may
meta-analyses, review be indicated.
articles, and ACR-SIR Operator experience level seems
practice parameter? to be an important predictor of
outcomes.
More rigorous studies are needed,
especially in high-risk patients.
298 G. Gadodia

Common Questions
What is the clinical hallmark of Poorly controlled HTN on
renovascular hypertension or optimal medical therapy
HTN caused by RAS? with three different classes
of drugs
What are the main causes of Atherosclerosis
RAS? FMD
What subtype of FMD is most Medial
associated with RVH?
What is the best screening and Renal duplex ultrasound
follow-up imaging modality for
RAS?
What is the gold standard for DSA, ability to measure
diagnosis, and why? translesional gradients
What is hemodynamically > 10% or 10 mmHg mean
significant RAS? pressure gradient and
> 20 mmHg systolic pressure
gradient
What is the optimal treatment for Medical therapy including an
RVH due to RAS? ACE and/or an ARB
If intervening, what is the Atherosclerosis: Stenting
major difference in treating (usually with balloon
atherosclerotic versus FMD angioplasty or balloon-
lesions? mounted stents)
FMD: Balloon angioplasty
only
 26 Renovascular Hypertension 299

What presentation of RVH due RVH causing cardiac

to atherosclerotic RAS is the destabilization, including
only indication with a class I flash and/or recurrent
recommendation for endovascular pulmonary edema
revascularization? Key: Classification of
recommendations and level
of evidence
Class I: Benefit ≫ risk.
Procedure should be
performed.
Class IIa: Benefit > risk. It
is reasonable to perform the
procedure.
Class IIb: Benefit ≥
risk. Procedure may be
considered.
Class III: No benefit, or
there is harm. Procedure
is not helpful or may be
harmful.
Level A: Data from multiple
RCTs or meta-analyses.
Level B: Data from one RCT
or from non-randomized
studies.
Level C: Limited data,
only case studies or expert
opinion.

Further Reading
Abela R, Ivanova S, Lidder S, Morris R, Hamilton G. An analysis
comparing open surgical and endovascular treatment of ath-
erosclerotic renal artery stenosis. Eur J Vasc Endovasc Surg.
2009;38:666–75.
Ahmad N, Schiffman MH, Sos TA. Renal artery stenosis. In:
Interventional urology. Cham: Springer; 2016. p. 305–23.
American College of Radiology. ACR-SIR practice parameter for
the performance of angiography, angioplasty, and stenting for
the diagnosis and treatment of renal artery stenosis in adults.
300 G. Gadodia

2015. Available at: https://www.acr.org/-­/media/ACR/Files/

Practice-­Parameters/RenalArteryStenosis.pdf?la=en. Accessed
9 Dec 2014.
Balzer KM, Pfeiffer T, Rossbach S, Voiculescu A, Mödder U,
Godehardt E, et al. Prospective randomized trial of operative vs
interventional treatment for renal artery ostial occlusive disease
(RAOOD). J Vasc Surg. 2009;49:667–75.
Bavry AA, Kapadia SR, Bhatt DL, Kumbhani DJ. Renal artery
revascularization. JAMA Intern Med. 2014;174:1849.
Bax L, Mali WP, Buskens E, Koomans HA, Beutler JJ, Braam B,
et al. The benefit of STent placement and blood pressure and
lipid-lowering for the prevention of progression of renal dys-
function caused by atherosclerotic ostial stenosis of the renal
artery. The STAR-study: rationale and study design. J Nephrol.
2003;16(6):807–12.
Bax L, Woittiez AJ, Kouwenberg HJ, Mali WP, Buskens E, Beek
FJ, et al. Stent placement in patients with atherosclerotic renal
artery stenosis and impaired renal function: a randomized trial.
Ann Intern Med. 2009;150(12):840–8, W150–841.
Brussel PMV, Hoef TPVD, Winter RJD, Vogt L, Born
B-JVD. Hemodynamic measurements for the selection of
patients with renal artery stenosis. J Am Coll Cardiol Intv.
2017;10:973–85.
Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W,
Reid DM et al. CORAL Investigators Stenting and medical
therapy for atherosclerotic renal-artery stenosis. N Engl J Med.
2014;370:13–22.
Cooper CJ, Murphy TP, Matsumoto A, Steffes M, Cohen DJ, Jaff M,
et al. Stent revascularization for prevention of cardiovascular
and renal events among patients with renal artery stenosis and
systolic hypertension: rationale and design of the CORAL trial.
Am Heart J. 2006;152(1):59–66.
Ferral H, Lorenz J. Radcases interventional radiology. New York:
Thieme; 2018.
Henry M, Henry I. Renal angioplasty and stenting: are they still
indicated after ASTRAL, STAR and CORAL studies? J Indian
Coll Cardiol. 2016;6:15–20.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice
guidelines for the management of patients with peripheral arte-
rial disease (lower extremity, renal, mesenteric, and abdominal
aortic): a collaborative report from the American Association
for Vascular Surgery/Society for Vascular Surgery, Society
 26 Renovascular Hypertension 301

for Cardiovascular Angiography and Interventions, Society

for Vascular Medicine and Biology, Society of Interventional
Radiology, and the ACC/AHA Task Force on Practice
Guidelines (Writing Committee to Develop Guidelines for the
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Chapter 27
Varicose Vein
Anushi Patel

Evaluating Patient
What should be Physical exam should include inspection
evaluated on and palpation of both legs for asymmetry,
physical exam? edema, varicose veins, pigment changes, or
ulcerations. These features help classify the
severity of venous insufficiency.
What should be Pedal pulses should be evaluated to
ruled out on physical exclude peripheral arterial disease as
exam? the etiology of the patient’s clinical
presentation and symptoms. Any signs
of cellulitis or other infection are
contraindications to treatment.
(continued)

A. Patel (*)
Department of Radiology, University of Florida College of
Medicine – Jacksonville, Jacksonville, FL, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 303

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_27
304 A. Patel

What are different Physical exam maneuvers to evaluate for

physical exam tests venous reflux include the tap test, Perthes
that can be done to test, cough test, and Trendelenburg test.
evaluate for venous However, the use of duplex ultrasound
reflux? has largely replaced the need of these
maneuvers, which are now rarely
performed.
How is venous reflux Evaluation for venous insufficiency is
measured? often performed either with the patient
standing and supporting their weight with
the contralateral leg or lying in reverse
Trendelenburg. These maneuvers distend
the veins and allow for measurement of
reflux, usually with duplex ultrasound. The
most routinely evaluated areas for reflux
are the great saphenous vein (GSV), small
saphenous vein (SSV), intersaphenous
vein (ISV), any major tributary veins,
popliteal fossa, saphenofemoral junction
(SFJ), and any areas of symptoms.
What is the most Duplex ultrasonography is most frequently
frequently used used, which combines B-mode grayscale
imaging modality? images, color Doppler images, and
Doppler spectral waveform analysis.
Air plethysmography is another commonly
used modality that measures changes
in limb venous volume with different
maneuvers. This gives information
about reflux, calf muscle pump function,
ambulatory calf venous pressure, and
venous obstruction.
 27 Varicose Vein 305

What findings A linear ultrasound probe is most

indicate reflux commonly used for evaluation of
on ultrasound vascular structures. A normal venous
examination? waveform should be relatively uniform,
unidirectional, and nonpulsatile with
phasicity (variation in flow related to
respiration). Provocative maneuvers
are used during the exam, such as distal
venous compression with release (usually
performed with an inflatable cuff) or
Valsalva maneuver. If reflux (reversal
of blood flow) is present during these
maneuvers, there will be a transient
inversion of the waveform on the velocity
scale, indicating blood flow in the opposite
direction. The duration of reflux is
recorded. Incompetent perforating veins
can have bidirectional flow.
What is the The definition varies in the literature.
definition of venous When referring to superficial veins, the
reflux? most commonly accepted definition for
delayed flow is flow reversal lasting at least
0.5 seconds. Greater than 1 second of reflux
is abnormal. Perforating veins are considered
abnormal if the diameter is over 4 mm or if
normal in diameter with evidence for reflux
lasting at least 0.35–0.5 seconds.
What additional 1. Deep vein thrombosis (DVT) must
details should be excluded, as the superficial venous
be evaluated system likely provides an important
during ultrasound alternate drainage pathway (see below)
examination? 2. Variant superficial venous anatomy (see
below) including the level of the SFJ
3. Superficial thrombosis
4. Diameter of GSV, SSV, or other target
vein, including ≤2 cm from the deep
vein junctions (femoral or popliteal)
5. Localization of incompetent perforating
veins
(continued)
306 A. Patel

What is the utility CT and MRV are rarely needed for the
of computed evaluation of superficial venous disease
tomography (CT) as duplex ultrasonography is an adequate
and magnetic diagnostic modality. These modalities
resonance are more appropriate for patients with
venography (MRV) venous disease from suspected underlying
in the evaluation of proximal (iliofemoral) obstruction or
venous disease? iliac vein compression (May-Thurner
syndrome). MRV is helpful for evaluation
of vascular malformations from congenital
venous disease.
What are Infection, alterations in skin pigmentation,
complications of eczema, superficial thrombophlebitis,
superficial venous venous ulcers, loss of subcutaneous tissue,
insufficiency? changes in lower leg circumference,
lipodermatosclerosis, external perforation
causing bleeding, edema, and atrophie
blanche
How can chronic The CEAP (Clinical objective signs,
venous insufficiency Etiology of insufficiency, Anatomical
be categorized? distribution, Pathophysiology)
classification aids in categorizing disease
(Table 27.1). The Venous Clinical Severity
Score is an additional scale more geared
toward classifying the severity of disease
(Table 27.2). These tools can be used
during the initial and follow-up patient
evaluations.
 27 Varicose Vein 307

Table 27.1 CEAP classification of chronic venous disease

Classification Symptom
Clinical
C0 No visible or palpable signs of venous disease
C1 Telangiectases or reticular veins
C2 Varicose veins
C3 Edema
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer
S Symptomatic, including ache, pain, tightness,
skin irritation, heaviness, and muscle cramps,
and other complaints attributable to venous
dysfunction
A Asymptomatic
Etiologic
Ec Congenital
Ep Primary
Es Secondary (postthrombotic)
En No venous cause identified
Anatomic
As Superficial veins
Ap Perforator veins
Ad Deep veins
An No venous location identified
Pathophysiologic
Pr Reflux
(continued)
308 A. Patel

Table 27.1 (continued)

Classification Symptom
Po Obstruction
Pr,o Reflux and obstruction
Pn No venous pathophysiology identifiable
Level of
investigation
Level I Office visit, with history and clinical
examination, which may include the use of a
handheld Doppler scanner
Level II Noninvasive vascular laboratory testing, which
now routinely includes duplex color scanning,
with some plethysmographic method added as
desired
Level III Invasive investigations or more complex
imaging studies, including ascending and
descending venography, venous pressure
measurements, computed tomography, or
magnetic resonance
Example A patient has painful swelling of the leg, and
varicose veins, lipodermatosclerosis, and active
ulceration. Duplex scanning shows axial reflux
of the great saphenous vein above and below
the knee, incompetent calf perforator veins,
and axial reflux in the femoral and popliteal
veins. There are no signs of postthrombotic
obstruction. Classification according to
basic CEAP: C6,S, Ep,As,p,d, Pr. Classification
according to advanced CEAP: C2,3,4b,6,S, Ep,As,p,d,
Pr2,3,18,13,14 (2004-05-17, L II)
 27 Varicose Vein 309

Table 27.2 Venous Clinical Severity Score

Attribute Absent = 0 Mild = 1 Moderate = 2 Severe = 3
Pain None Occasional, Daily, Daily, severe
not moderate limiting
restricting activity activities or
activity or limitation, requiring
requiring occasional regular use of
analgesics analgesics analgesics
Varicose None Few, Multiple: GSV Extensive:
veins scattered varicose veins thigh and
branch confined to calf or GSV
varicose the calf or and SSV
veins thigh distribution
Venous None Evening Afternoon Morning
edema ankle only edema, above edema above
the ankle the ankle
and requiring
activity
change,
elevation
Skin None or Diffuse, but Diffuse over Wider
pigmentation focal, low limited in most of gaiter distribution
intensity area and distribution (above lower
(tan) old (brown) (lower 1/3) 1/3), recent
or recent pigmentation
pigmentation
(purple)
Inflammation None Mild Moderate Severe
cellulitis, cellulitis, cellulitis
limited to involves most (lower 1/3
marginal of the gaiter and above)
area around area (lower or significant
ulcer 2/3) venous
eczema
(continued)
310 A. Patel

Table 27.2 (continued)

Attribute Absent = 0 Mild = 1 Moderate = 2 Severe = 3
Induration None Focal, Medial or Entire lower
circum-­ lateral, less 1/3 of the leg
malleolar than lower 1/3 or more
(<5 cm) of the leg
Active ulcers, 0 1 2 >2
n
Active ulcer, None <3 months >3 months but Not healed
duration <1 year >1 year
Active ulcer, None <2 cm 2–6 cm >6 cm
size diameter diameter diameter
Compressive Not used Intermittent Wears elastic Full
therapy or not use of stockings compliance:
compliant stockings most days stockings +
elevation

High Yield History

What are symptoms Symptoms include pain, burning, itching,
of lower extremity aching, fatigue, swelling, restless legs,
superficial venous cramps, and heaviness. Symptoms are often
insufficiency? worse at the end of the day, especially
after periods of prolonged standing.
Lower extremity elevation can alleviate
symptoms.
What pertinent Pertinent history to collect includes
history should be pregnancy status, family history, allergies,
collected? prior or current DVT or pulmonary
embolism, recent diagnosis of malignancy,
prior treatments for venous disease,
and presence of known right-to-left
heart shunt such as a patent foramen
ovale (PFO), which increases the risk of
complications.
 27 Varicose Vein 311

What are risk factors Family history of venous disease (genetic

for developing lower predisposition), female sex, obesity, older
extremity varicose age, pregnancy, prolonged standing,
veins? occupations associated with orthostasis,
high estrogen levels, presence of an
arteriovenous shunt, lower extremity
trauma, ligamentous laxity (e.g., flatfeet),
and smoking
What are Exercise, leg elevation, weight loss, and
some lifestyle avoidance of prolonged standing
modifications
that can improve
the symptoms of
superficial venous
insufficiency?
What are rare Klippel-Trenaunay syndrome is
congenital characterized by deep vein hypoplasia
syndromes that with aberrant venous pathways such as
involve venous sciatic veins or persistent embryonic veins.
insufficiency? Parkes-Weber syndrome is characterized
by extensive lower extremity varices
and arteriovenous malformations. These
patients should be evaluated with both
duplex ultrasound and MRV.

Indications/Contraindications
What are the Any symptoms or complications
indications for attributed to superficial venous
nonconservative insufficiency refractory to conservative
treatment? measures. Treatment can also be offered
for asymptomatic cosmetic concerns.
(continued)
312 A. Patel

What are absolute DVT, pregnancy, lactation, immobility,

or relative uncorrectable coagulopathy, arterial
contraindications insufficiency, infection, May-Thurner
for treatment of syndrome, arteriovenous fistula,
superficial venous congenital venous malformation,
insufficiency? superficial thrombosis, presence
of implanted pacemaker or nerve
stimulator (only applies to first-­
generation radiofrequency ablation
devices due to potential for signal
interference), extreme tortuosity of
the target vein for catheter-based
ablation, severe edema for phlebectomy,
inability to comply with post-procedural
instructions, and allergy to local
anesthetic or sclerosing agent
Why is it Varicosities in the setting of deep venous
contraindicated system obstruction are hemodynamically
to intervene on useful collaterals for venous return.
superficial venous When they are treated or removed,
insufficiency when the patient can experience significant
there is an obstruction pain and swelling of the extremity,
of the deep venous recurrence of superficial varicose veins,
system? and increased risk of soft tissue changes
such as ulcers.
 27 Varicose Vein 313

What should be Evaluation for coexisting arterial

considered prior to insufficiency should be performed
the use of compression including lower extremity pulse exam
therapy? and ankle-brachial index (ABI),
as needed. In patients with arterial
insufficiency, compression therapy can
worsen their symptoms/disease by
limiting blood inflow. Therefore, it is
contraindicated in patients with severe
arterial insufficiency. Modified low-­
compression or nonelastic compression
therapy (e.g., Unna boot) can be
considered in patients with moderate
arterial insufficiency, if tolerable and
closely monitored for developing signs
of limb ischemia. Compression therapy
must also be used with caution in
patients with peripheral neuropathy
(contraindicated if severe), as they are
prone to iatrogenic compression wounds
or worsening pain, and in patients with
heart failure, since therapy can increase
cardiac preload.
What are the This minimally invasive procedure
indications for is often performed as an adjunctive
ambulatory therapy on varicosities that are palpable
phlebectomy? and closer to the skin surface, after
the GSV or other main feeding vein
is treated with endovenous therapy. It
can also be used as isolated therapy
for local disease. It can be performed
on many different types of veins
ranging from truncal veins (other
than GSV/SSV) to reticular veins
and perforators. Depending on user
preference, phlebectomy can be used
as an alternative to sclerotherapy. A
potential complication of sclerotherapy
is hemosiderin skin staining when used
on varicosities closer to the skin.
(continued)
314 A. Patel

What is the overall Practice varies but conservative

treatment approach? measures are commonly prescribed
for at least 3 months. This is often
required by many insurance payors
before nonconservative therapies are
approved. In some patients, if compliant,
compressive therapy is sufficient and
can be continued long term. However,
if there are persistent complications or
unsatisfactory relief of symptoms on
follow-up evaluation(s), nonconservative
interventions can be pursued with
typically one leg treated at a time.
Clinical practice guidelines are available
from various sources such as the Society
of Interventional Radiology (SIR) and
Society for Vascular Surgery (SVS) that
can help direct treatment planning.
When should Depending on operator preference,
adjunctive therapy be adjunctive phlebectomy or sclerotherapy
performed? can be performed during the same
procedural visit as truncal ablation
which can potentially decrease the
overall number of visits, provide faster
relief of symptoms, and decrease risk
of superficial phlebitis. Alternatively,
adjunctive therapy can be performed
a few weeks or months after truncal
ablation. This allows assessment for
interval improvement and avoids a
potentially unneeded procedure, since,
in many cases, truncal ablation may be
sufficient alone. This also allows the
remaining varicosities to shrink in size
which makes later adjunctive procedures
easier and more effective to perform, if
needed.
 27 Varicose Vein 315

Relevant Anatomy
What are the The venous system of the lower extremities
superficial veins is divided into the superficial and deep
of the lower venous compartments. Superficial veins
extremities? of the lower extremities are those located
between the deep fascia (which covers
the muscles) and the skin. The two main
superficial veins are the GSV and SSV. The
SSV is also referred to as the lesser
saphenous vein (LSV).
What is the This is an important anatomical landmark
saphenofemoral which denotes the junction between the
junction (SFJ)? great saphenous vein (superficial system)
and the common femoral vein (deep venous
system). Within this region, there is also a
confluence of multiple superficial inguinal
and thigh veins including the external
pudendal, inferior epigastric, and external
circumflex iliac veins, among others.
What are varicose Varicose vein (also known as a varicosity)
veins? is a general term referring to a permanently
dilated and tortuous subcutaneous vein
≥3 mm in diameter in the upright position.
What are truncal, Truncal veins are the major superficial veins
tributary, and such as the GSV, SSV, and large primary
perforating veins? tributary veins. Tributary veins are branches
of the major superficial veins. Perforating
veins connect the superficial and deep
venous systems and pass through the deep
fascia that separates the superficial and deep
compartments.
What are Telangiectasias (also known as spider veins)
telangiectasias and and reticular veins are dilated intradermal
reticular veins? and subdermal veins, respectively.
Telangiectasias are less than 1 mm in size.
Reticular veins are 1–3 mm in size.
(continued)
316 A. Patel

What are some Anatomical variations to consider include

important tortuosity of the target vein, atresia,
anatomical accessory veins, variable course and
variations? termination of the SSV, duplications, and
changes related to prior interventions (e.g.,
neovascularization or recanalization). For
example, 1% of the population is estimated
to have a duplicated GSV. Variations in
the tributary veins of the GSV are also
important. For example, many patients
have an accessory anterior saphenous vein,
which may also demonstrate reflux and need
treatment. These different types of variations
should be considered in preprocedural
planning and may change approach to
treatment.

Relevant Materials
What are the Conservative (compression therapy and
overall treatment lifestyle modifications), external laser,
options for endovenous (thermal and nonthermal)
superficial venous including catheter-based techniques and
disease? sclerotherapy, and open/surgical including
phlebectomy
How does Although there are many types of
compression compression therapies, stockings are the
therapy work? most routinely used. They exert the greatest
compression distally at the ankle with the
degree of compression gradually decreasing
up the garment as the limb circumference
increases. This graduated compression helps
blood to move up toward the heart and
decreases pooling. Throughout the treated
lower extremity, compression reduces
venous hypertension, by augmenting the
calf muscle pump, and decreases the vein
diameter, which increases blood flow
velocity. Overall, there is improved venous
return and lymphatic drainage.
 27 Varicose Vein 317

What is the Practice varies but frequently used is

recommended 15–20 mmHg for mild varicosities and
degree of pressure symptoms, 20–30 mmHg for moderate-­
for compression to-­severe varicosities and symptoms,
stockings? and 30–40 mmHg and above for severe
varicosities with chronic complications of
long-standing venous insufficiency. Degree
of compression can also be increased if
there is lack of clinical improvement.
Why is Compression therapy decreases recovery
compression time and post-procedural bruising/
therapy used hematoma formation, swelling, and pain.
following This also ensures collapse/occlusion of the
superficial venous treated vein to prevent recanalization after
interventions? endovenous therapy. There are variations
in clinical practice and in data regarding
the appropriate length of time or type
(e.g., waist high or above the knee) of
compressive therapy that should be used.
Treatment varies depending on operator
preference, but one common practice is for
patients to have compression 24/7 for at
least 1 week. Patients are also encouraged
to ambulate after the procedure to prevent
deep venous thrombosis, which is why
immobility is a relative contraindication.
(continued)
318 A. Patel

What are the Therapy includes thermal endovenous

different types ablation, most commonly for large tributary
of endovascular and truncal veins, and sclerotherapy, often
therapies? a subsequent adjunctive treatment for
the remaining small- to medium-sized
veins. Endovenous therapy can also be
classified into thermal techniques and
nonthermal techniques. Thermal ablation
includes endovenous laser therapy (EVLT),
radiofrequency ablation (RFA), and
steam vein sclerosis. Nonthermal ablation
includes chemical sclerotherapy, combined
mechanochemical ablation (MOCA), and
injection of cyanoacrylate glue. EVLT and
RFA are catheter-based ablation techniques
which have largely replaced traditional
surgical ligation and stripping.
What are the open/ Traditional surgical ligation/stripping
surgical treatment (includes the Linton procedure),
options? cryostripping, ambulatory phlebectomy,
powered phlebectomy, CHIVA technique,
ASVAL technique, and subfascial
endoscopic perforator surgery (SEPS)
What is tumescent A liquid local tumescent anesthetic (often
anesthesia? comprised of 0.1% lidocaine after dilution
with saline) is administered around the
target vein during thermal ablation or
phlebectomy. This protects the perivenous
tissue from the heat created during thermal
ablation, partially compresses the vein to
reduce the distance thermal energy must
travel to the endothelium, dissects the vein
free from surrounding tissues, and reduces
pain during the procedure. The solution is
usually buffered with sodium bicarbonate to
reduce discomfort during initial injections
of the anesthetic.
 27 Varicose Vein 319

General Step by Step

What is external This refers to non-endovascular laser therapy
laser therapy? used externally along the skin surface. This
therapy is usually used on telangiectasias and
smaller reticular veins for cosmetic purposes.
Different types of laser machines are available,
which deliver different wavelengths of light
that penetrate through the skin and into
the blood vessels where it is absorbed by
hemoglobin leading to thermocoagulation.
What is This is also referred to as chemical
sclerotherapy? endovenous ablation. This is performed
either with ultrasound guidance or direct
visualization if injecting smaller veins
along the skin. The lumen of the target
vein is injected with a sclerosing substance.
The sclerosing substance displaces blood
and reacts with the endothelium which
collapses and scars the vein. Different types
of sclerosing agents are available such as
hyperosmotic solutions (e.g., hypertonic
saline), detergents (e.g., sodium tetradecyl
sulfate), and corrosive/alcohol solutions (e.g.,
glycerin). Only a few detergents are approved
by the Food and Drug Administration (FDA).
Although it can be used to treat larger truncal
veins, sclerotherapy is most routinely used on
small- to medium-sized veins such as tributary
veins, smaller truncal veins, accessory veins,
perforators, reticular veins, and telangiectasias.
The concentration and volume of agent used
should correlate with the size of the targeted
vein.
(continued)
320 A. Patel

What is foam This refers to a method in which the sclerosing

sclerotherapy? agent is combined with air to form a foam
consistency. This is usually performed with
the Tessari method via a three-way stop cock
with about a 4:1 air to sclerosant agent ratio.
Compared to simple liquid sclerotherapy,
this causes an expansile effect with increased
displacement of blood and contact with the
endothelium for a suggested greater sclerosing
effectiveness. Foam sclerotherapy is usually
performed under ultrasound guidance.
How is the The patient is placed supine or oblique on a
patient table with external rotation of the extremity
positioned during at the hip and slight flexion at the knee. When
GSV ablation? access is obtained, the patient is placed in the
reverse Trendelenburg position to distend the
veins. When ablation is performed, the patient
is placed in the Trendelenburg position to
decrease intravascular volume and facilitate
contact of the catheter tip with the vein wall
for optimal ablation results.
What is the Most commonly, the target zone extends from
target zone about 2 cm distal to the SFJ (or just distal to
for thermal the origin of the superficial epigastric vein)
endovenous to around the level of the knee. If needed,
ablation of the an extended treatment of the below-knee
GSV? segment of the GSV can also be performed
(although less frequently performed due to
risk of damage to the adjacent saphenous
nerve) with a target zone extending down
to the inferior most point of reflux that is
accessible by the catheter length.
 27 Varicose Vein 321

How is thermal Using ultrasound guidance, antegrade access

endovenous is obtained at the distal aspect of the targeted
ablation of the vein with a micropuncture set which is
saphenous vein exchanged for a vascular sheath. The ablation
performed? catheter is threaded distal to proximal along
the target zone. This is because it is easier to
pass a catheter in the same direction of valve
opening. Tumescent anesthesia is administered
with ultrasound guidance. The catheter tip
emits energy (radiofrequency waves or laser),
and the catheter is continuously withdrawn
at a rate dependent on the targeted segment
of vein and the device and settings used (e.g.,
2 mm per second, with most targeting an
energy density of 80–100 J). As the catheter
is withdrawn endothelial damage and
thrombosis of the vein occurs.
How does the In RFA, the electrode directly contacts the
mechanism of vein endothelium releasing radiofrequency
action differ energy and causing resistive heat-­
between EVLT induced venous spasm, thrombosis, and
and RFA? denaturation of the wall collagen network
leading to fibrosis. Laser (EVLT) induces
a photothermolytic process which releases
thermal energy both to the blood, causing
blood to coagulate and form steam bubbles,
and to the venous wall, causing transmural
vein wall damage including microperforations.
This inflammatory process causes thrombosis
and fibrosis of the vein.
(continued)
322 A. Patel

How is Ambulatory phlebectomy, also known as stab

ambulatory phlebectomy, involves removal/avulsion of
phlebectomy varicose veins. With the patient standing, the
performed? target vein(s) is(are) mapped and marked
on the skin using visual skin changes or
ultrasonography. With the patient supine,
tumescent anesthesia is administered. With a
small blade, a series of 1–2 mm stab incisions
are made several centimeters apart in the
soft tissues overlying the targeted vein.
Avulsion of the vein is performed with hooks
or forceps that pull the vein to the surface
at each incision site. This releases the vein
from the surrounding tissues and severs
any connections. The targeted vein is then
removed. Since the incisions are small, they
are closed with Steri-Strips and dressings.

Complications
What are complications Most complications overlap among
of external laser therapy, the different therapies and include
sclerotherapy, endovenous skin pigmentation changes such as
ablation, and/or bruising or hemosiderin staining
ambulatory phlebectomy? (usually temporary), temporary or
permanent nerve injury/paresthesia
(most commonly affecting the
saphenous, sural, common peroneal,
and cutaneous nerves), superficial
thrombophlebitis, burns, deep venous
thrombosis, pulmonary embolism,
telangiectatic matting, hematoma/
bleeding, pain, allergic reaction to
the sclerosing agent or anesthetic,
recanalization/recurrence of veins,
infection, and tightness along the
course of the treated vein.
 27 Varicose Vein 323

What are additional Complications include pulmonary

rare complications of embolism, headache, visual
sclerotherapy? changes, transient ischemic attack
or stroke, heart attack, loss of limb
(arterial stick), and death. These
can be attributed to unintended
embolization of the sclerosing agent.
There is a greater chance of some of
these complications if the patient has
a PFO.
What are complications Skin changes at the incision sites
more specific to (blisters, keloid formation, dimpling,
ambulatory phlebectomy? induration), hematoma, seroma,
lymphocele, thrombophlebitis of
the remaining vein if incompletely
removed, telangiectatic matting, and
nerve damage
What are complications of Complications include limb ischemia,
compression therapy? contact dermatitis/allergic reaction,
pain, and skin necrosis/wound. These
complications can be prevented
or treated with local wound care,
adjustments in wrapping technique,
reduction in compression strength, or
termination of therapy.

Landmark Research
Brittenden J, Cotton SC, Elders A, Ramsay CR, Norrie J, Burr
J, et al. A randomized trial comparing treatments for varicose
veins. N Engl J Med. 2014;371(13):1218–27.
• Comparison of Laser, Surgery, and Foam Sclerotherapy
(CLASS) trial
• 798 participants with varicose veins were randomized to
foam sclerotherapy, endovenous laser ablation, or surgery.
• The primary outcomes included disease-specific quality of
life measures and generic quality of life measures at
324 A. Patel

6 months. Secondary outcomes included complications

and measures of clinical success.
• Quality of life measures were similar among the three
study groups except for a slightly worse disease-specific
quality of life measure in the foam treatment group but
similar outcomes in the laser and surgery groups.
• The frequency of complete successful ablation of the great
saphenous vein was similar in the surgery (84.4%) and
laser treatment (83.0%) groups but lower in the foam
treatment group (54.6%).
• The frequency of procedural complications was similar in
the foam (6%) and surgery groups (7%) but lower in the
laser group (1%).
Nesbitt C, Bedenis R, Bhattacharya V, Stansby
G. Endovenous ablation (radiofrequency and laser) and foam
sclerotherapy versus open surgery for great saphenous vein
varices. Cochrane Database Syst Rev. 2014;(7):CD005624.
• 13 randomized controlled trials of 3081 patients were
included to determine the efficacy of endovenous ablation
(radiofrequency and laser) and ultrasound-guided foam
sclerotherapy compared to open surgical saphenofemoral
ligation and stripping of GSV varices.
• Primary outcomes included recurrent varicosities, recana-
lization, neovascularization, technical procedure failure,
patient quality of life scores, and complications.
• Ultrasound-guided foam sclerotherapy and endovenous
ablation (radiofrequency and laser) are at least as effective
as surgery in the treatment of great saphenous varicose
veins.
van der Velden SK, Biemans AA, De Maeseneer MG,
Kockaert MA, Cuypers PW, Hollestein LM, et al. Five-year
results of a randomized clinical trial of conventional surgery,
endovenous laser ablation and ultrasound-guided foam
sclerotherapy in patients with great saphenous varicose veins.
Br J Surg. 2015;102(10):1184–94.
 27 Varicose Vein 325

• 224 legs were randomized to conventional surgery (69),

EVLT (78), and ultrasound-guided foam sclerotherapy
(UGFS) (77).
• The rates of great saphenous vein obliteration/absence
were 85%, 77%, and 23% in the conventional surgery,
EVLT, and UGFS groups, respectively, at 5 years.
• EVLT and conventional surgery were more effective than
UGFS in obliterating the great saphenous vein 5 years
after intervention.

Common Questions
What is the Incompetent valves allow blood to flow in
pathophysiology the opposite direction (reflux). This leads to
of venous pooling of blood, weakened vein walls (in
insufficiency? part due to changes in wall collagen/elastin
composition), failure of the calf muscle pump,
and dilated superficial veins due to high
pressure in a normally low-pressure system
(venous hypertension). Along with subsequent
leakage of fluid into surrounding soft tissues,
this overall process gives rise to the physical
manifestations of venous insufficiency (see
above). Etiology is either primary or may be
secondary to an occlusion in the deep venous
system with subsequent reflux via the deep-­
to-­superficial venous junctions or perforating
veins. The secondary etiology causes the
superficial venous network to function as a
collateral flow system.
What are some Reduced number and size of incisions,
benefits of performed outpatient with no need for
endovascular hospital stay, quicker recovery and return to
treatment over work, less post-procedural pain, and decreased
surgery? procedural time
(continued)
326 A. Patel

As a part of Revised Venous Clinical Severity Score

post-procedural Disease-specific quality of life (QOL)
clinical follow-up, questionnaire
what specific Duplex ultrasound (see below)
tools can be
used to assess
outcomes after
therapy other
than history and
physical exam?
What should you Short-term ultrasound evaluation should
see on follow-up demonstrate an occluded vein (absent flow),
ultrasound thickened venous wall, and decreased vessel
evaluation diameter. Long-term ultrasound evaluation
after successful may show absence of the treated vein or a
endovenous small residual scarred down cord. Practice
therapy? varies, but ultrasound follow-up is commonly
performed at 3 days, between 1 and 6 months,
and 1 year after the procedure.
Why are If laser therapy is used, state laws and
specific safety regulatory agencies often require specific
precautions safety measures. These include the use of
taken during appropriate eye protection and postage
EVLT? of warning signs at entry ways during the
procedure, among several other precautions.
The wavelength of light emitted from the laser
can otherwise damage the eyes and vision,
especially the retina.
 27 Varicose Vein 327

How are Treatment of the underlying refluxing veins

complications with the methods described above should
of venous be performed for more definitive results.
insufficiency However, there are many complications of
treated? venous insufficiency (see above) that require
separate management other than compression
therapy:
 Acute bleeding from vein perforation will
require leg elevation, a pressure hold to
achieve hemostasis, and a hemostatic suture,
if needed.
 Superficial thrombophlebitis is most
frequently treated with supportive care,
such as warm compress application, oral
NSAIDs, and topical therapies. If affecting a
longer segment of the vein (at least 5 cm) or
if located less than 3 cm from the SFJ, short-­
term anticoagulation can be considered.
 Soft tissue infections, such as cellulitis,
require antibiotic therapy.
 Patients with venous ulcers or other chronic
soft tissue changes related to venous
insufficiency will need regular wound care
follow-up for advanced wound dressings and
compression therapy with specialized wraps/
bandages such as an Unna boot. Venous
ulcers are most frequently located along
the medial malleolus. Oral medications
(e.g., phlebotonics or pentoxifylline) can
be considered. Ulcers may need surgical
debridement or skin grafting. Ulcers are
prone to superimposed infections which can
even lead to osteomyelitis of the underlying
bone, requiring long-term antibiotic therapy.
328 A. Patel

Further Reading
Almeida J, Boatright C. Candidacy for endovenous ablation.
Endovasc Today. 2012:27–30.
Andriessen A, Apelqvist J, Mosti G, Partsch H, Gonska C, Abel
M. Compression therapy for venous leg ulcers: risk factors
for adverse events and complications, contraindications – a
review of present guidelines. J Eur Acad Dermatol Venereol.
2017;31:1562–8.
Baliyan V, Tajmir S, Hedgire SS, Ganguli S, Prabhakar AM. Lower
extremity venous reflux. Cardiovasc Diagn Ther. 2016;6(6):533–43.
Biswas S, Clark A, Shields DA. Randomised clinical trial of the
duration of compression therapy after varicose vein surgery. Eur
J Vasc Endovasc Surg. 2007;33(5):631–7.
Brittenden J, Cotton SC, Elders A, Ramsay CR, Norrie J, Burr J,
et al. A randomized trial comparing treatments for varicose
veins. N Engl J Med. 2014;371(13):1218–27.
Cronenwett JL, Johnston KW. Rutherford’s vascular surgery. 8th ed.
Philadelphia: Elsevier; 2014.
Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P,
Kistner RL, et al, for the American Venous Forum International
Ad Hoc Committee for Revision of the CEAP Classification.
Revision of the CEAP classification for chronic venous disor-
ders: consensus statement. J Vasc Surg. 2004;40:1248–52.
Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose
veins and chronic venous insufficiency in men and women in
the general population: Edinburgh Vein Study. J Epidemiol
Community Health. 1999;53(3):149–53.
Fan CM, Rox-Anderson R. Endovenous laser ablation: mechanism
of action. Phlebology. 2008;23(5):206–13.
Fletcher J, Moffatt C, Partsch H, Vowden K, Vowden P. Principles
of compression in venous disease: a practitioner’s guide to treat-
ment and prevention of venous leg ulcers. Wounds International;
2013.
Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL,
Gloviczki ML, et al. The care of patients with varicose veins and
associated chronic venous diseases: clinical practice guidelines
of the Society for Vascular Surgery and the American Venous
Forum. J Vasc Surg. 2011;53(5 Suppl):2S–48S.
 27 Varicose Vein 329

Guo B, Tjosvold L. Endovenous thermal ablation interventions for

symptomatic varicose veins of the legs – an update. Institute of
Health Economics: Edmonton; 2016.
Hamdan A. Management of varicose veins and venous insufficiency.
JAMA. 2012;308(24):2612–21.
Hardman RL, Rochon PJ. Role of interventional radiologists in the
management of lower extremity venous insufficiency. Semin
Interv Radiol. 2013;30(4):388–93.
Hettrick H. The science of compression therapy for chronic
venous insufficiency edema. J Am Col Certif Wound Spec.
2009;1(1):20–4.
Jones RH, Carek PJ. Management of varicose veins. Am Fam
Physician. 2008;78(11):1289–94.
Kabnick LS, Ombrellino M. Ambulatory phlebectomy. Semin Interv
Radiol. 2005;22(3):218–24.
Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy
for VTE disease: antithrombotic therapy and prevention of
thrombosis, 9th ed: American College of Chest Physicians
evidence-based clinical practice guidelines. Chest. 2012;141(2
Suppl):e419S–94S.
Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous
reflux in lower-extremity veins. J Vasc Surg. 2003;38(4):793–8.
Lim CS, Davies AH. Graduated compression stockings. CMAJ.
2014;186(10):E391–8.
Malskat WS, Poluektova AA, van der Geld CW, Neumann HA,
Weiss RA, Bruijninckx CM, et al. Endovenous laser ablation
(EVLA): a review of mechanisms, modeling outcomes, and
issues for debate. Lasers Med Sci. 2014;29(2):393–403.
Mauro MA, Murphy K, Thomson KR, Venbrux AC, Morgan RA.
Image-guided interventions. 2nd ed. Philadelphia: Saunders
Elsevier; 2013.
Medical Advisory Secretariat. Endovascular radiofrequency abla-
tion for varicose veins: an evidence-based analysis. Ont Health
Technol Assess Ser. 2011;11(1):1–93.
Meissner MH, Moneta G, Burnand K, Gloviczki P, Lohr JM, Lurie F,
et al. The hemodynamics and diagnosis of venous disease. J Vasc
Surg. 2007;46(6):S4–S24.
Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of
saphenous vein reflux: long-term results. J Vasc Interv Radiol.
2003;14(8):991–6.
330 A. Patel

Nesbitt C, Bedenis R, Bhattacharya V, Stansby G. Endovenous

ablation (radiofrequency and laser) and foam sclerotherapy
versus open surgery for great saphenous vein varices. Cochrane
Database Syst Rev. 2014;(7):CD005624.
Nijsten T, van den Bos RR, Goldman MP, Kockaert MA, Proebstle
TM, Rabe E, et al. Minimally invasive techniques in the treat-
ment of saphenous varicose veins. J Am Acad Dermatol.
2009;60(1):110–9.
Piazza G. Varicose veins. Circulation. 2014;130:582–7.
Proebstle, TM, et al. Treatment of the incompetent great saphenous
vein by endovenous radiofrequency powered segmental thermal
ablation: first clinical experience. J Vasc Surg. 2008;47(1):151–6.
e1.
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous
laser therapy and radiofrequency ablation of the great saphe-
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CR, et al. Risks and contraindications of medical compression
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Sadovsky R. Managing lower extremity venous ulcers. Am Fam
Physician. 2003;68(4):755.
Terrie Y. Recognizing and treating venous stasis ulcers. US Pharm.
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Theivacumar N, Dellagrammaticas D, Mavor A, Gough
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van der Velden SK, Biemans AA, De Maeseneer MG, Kockaert MA,
Cuypers PW, Hollestein LM, et al. Five-year results of a random-
ized clinical trial of conventional surgery, endovenous laser abla-
tion and ultrasound-guided foam sclerotherapy in patients with
great saphenous varicose veins. Br J Surg. 2015;102(10):1184–94.
 27 Varicose Vein 331

Waybill PN, Brown DB. Patient care in vascular and interventional

radiology. 3rd ed. Fairfax: Society of Interventional Radiology;
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the lower extremities. Korean J Intern Med. 2019;34(2):269–83.
Chapter 28
Varicocele Embolization
Avinash Pillutla

Evaluating Patient
What are the common Varicoceles may be asymptomatic, but
physical exam findings commonly present with dull, aching,
in varicoceles? usually left-sided scrotal pain. Pain is
typically worsened with standing and
relieved by laying supine. Testicular
atrophy may be present, believed to be
from loss of germ cell mass by increased
scrotal temperature.
What is the differential Common causes of scrotal swelling
diagnosis in scrotal include inguinal hernia, hydrocele,
swelling? hematocele, and pyocele. Other
considerations include heart failure,
idiopathic lymphedema, liver failure,
and lymphatic or venous obstruction.
Epidermoid cysts of the scrotal wall
have also been described. Neoplastic
causes must be excluded.
(continued)

A. Pillutla (*)
Department of Radiology, Virginia Commonwealth University
Health System, Richmond, VA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 333

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_28
334 A. Pillutla

How are varicoceles The sensitivity and specificity of

diagnosed with the aid varicocele detection is close to 100%
of sonography? with color Doppler ultrasound (US). US
should be performed with the patient in
both a supine and a standing position.
The general appearance of a varicocele
consists of multiple, hypoechoic,
serpiginous, tubular structures of varying
sizes larger than 2 mm in diameter. Large
varicoceles can extend inferiorly to the
testis. Color flow and duplex Doppler
US demonstrates a venous flow pattern
of phasic variation and retrograde filling
during Valsalva maneuvering.
What are the grading Grade 1 denotes small-sized varicoceles
criteria for varicoceles? that are palpable only with Valsalva
maneuver.
Grade 2 denotes moderate-sized
varicoceles that are nonvisible on
inspection but palpable upon standing.
Grade 3 denotes large-sized varicoceles
that are visible on gross inspection.
Why are the findings Unilateral right varicoceles are rare and
of non-compressibility should therefore may represent more
and right-sided ominous pathologies that may cause
presentation generally inferior vena cava (IVC) obstruction since
more concerning the right internal spermatic vein (ISV)
features of varicoceles? directly drains into the IVC. Examples
include renal cell carcinoma with IVC
thrombus or right renal vein thrombosis
with extension to the IVC. All unilateral
right-sided varicoceles should be further
investigated with a computed tomography
(CT) of the abdomen and pelvis with
contrast. Varicoceles on either side that do
not decompress in the recumbent position
(non-­diminishing) also raise concern for
obstruction such as thrombus or extrinsic
masses and should be further evaluated
by CT.
 28 Varicocele Embolization 335

High Yield History

How common Varicoceles are a common finding and
are varicoceles in present in approximately 15–20% of
the postpubertal postpubertal males. In addition, up to 40%
population? of varicoceles are associated with male
infertility.
What is the most Idiopathic varicoceles most commonly
common age present between the ages of 15 and 25.
of presentation
for idiopathic
varicoceles?
Is there an While genetic mechanisms predisposing
inheritance factor in to varicocele formation have not yet
the development of been discovered, there may be a genetic
varicoceles? basis for valvular dysfunction leading to
varicocele development as suggested by
epidemiological studies.
How are varicoceles It is well established that varicoceles are
implicated in the strongly associated with male infertility.
development of Up to 40% of males presenting varicoceles
infertility? may suffer from infertility. Varicoceles can
result in disordered spermatogenesis, germ
cell sloughing within the seminiferous
tubules, testicular atrophy, and decreased
testosterone secretion.
Why is routine Varicoceles are present in 35–40% of
scrotal ultrasound infertile men and represent a highly
important in treatable form of male infertility.
evaluating men with Additionally, there is an association
infertility? between testicular malignancies and male
infertility; thus, scrotal ultrasound provides
valuable information in the diagnostic
evaluation of infertile men. Compared to
clinical palpation, US evaluation provides
added diagnostic information.
(continued)
336 A. Pillutla

What are the While symptomatic varicoceles warrant

treatment options treatment by themselves, there is evidence
for varicoceles? Is supporting improvement in male infertility
there a benefit in rates following varicocele treatment.
treating varicoceles Options include surgical varicocelectomy,
associated with which can be performed via open,
infertility? laparoscopic, and robotic approaches.
Newer microsurgical techniques also have
been described. Percutaneous varicocele
embolization has also emerged as a viable,
minimally invasive option with comparable
efficacy; however, no direct comparison
between surgical and radiological
approaches has been performed.

Indications/Contraindications

What are the Indications for endovascular treatment

indications for of varicoceles include chronic pain,
percutaneous infertility, recurrent varicocele after
endovascular treatment surgical repair, and testicular atrophy
of varicoceles? with or without evidence of worsening
semen parameters.
What are the For varicocele embolization, no
contraindications absolute contraindications exist
for percutaneous outside of contrast allergy and severe
endovascular treatment coagulopathy.
of varicoceles?
What are the Symptomatic varicoceles, hypogonadism,
indications for and infertility are all indications for
surgical treatment of surgical intervention. Criteria for
varicoceles? varicocele-associated infertility include
palpable varicocele with no evidence
of female infertility or abnormal semen
analysis.
 28 Varicocele Embolization 337

What are the Relative contraindications for surgical

contraindications for varicocelectomy for infertility include
surgical treatment of severe oligozoospermia or azoospermia,
varicoceles? high serum FSH concentrations,
and small testes. Varicoceles that
are clinically less severe than grade
1 can also be considered relative
contraindications.
How do surgical and Standard laparoscopic and robotic
endovascular treatment surgical approaches have shown a
of varicoceles compare considerable recurrence rate due to
in efficacy? venous collaterals bypassing the inguinal
portion of the spermatic cord, scrotal
collaterals, and dilated cremasteric
veins. Newer microsurgical techniques
perform better in ligating collateral flow
and have demonstrated low recurrence
rates. Varicocele embolization allows for
effective targeting of collateral flow of
the ISV in addition to treating the ISV
prior to branching within the inguinal
canal.

Relevant Anatomy

What is the definition A varicocele is defined as the

of a varicocele? dilatation or tortuosity of the veins
of the pampiniform plexus, which is a
collection of collaterals and tributaries
joining spermatic vein branches within
the scrotum.
What are the anatomic The left ISV drains perpendicularly into
differences between the left renal vein, whereas the right
the left and right ISV vein drains obliquely into the vena
internal spermatic cava. The course of the left ISV is also
veins? approximately 8–10 cm longer than the
right.
(continued)
338 A. Pillutla

On what side do Varicoceles are more common on the

varicoceles generally left side (85%) due to (a) longer course
occur? Why? of the left ISV; (b) perpendicular angle
of insertion of the left ISV into the left
renal vein; (c) occasional arching of the
left testicular artery over the left renal
vein causing external compression and
left ISV reflux; and (d) compression of
the left ISV by a distended descending
left colon.
What are all of the The following structures are located in
structures within the the spermatic cord: the testicular artery,
spermatic cord? the artery to the ductus deferens, the
cremasteric artery, the cremasteric nerve,
the testicular nerves, the vas deferens
(ductus deferens), the pampiniform
plexus, the tunica vaginalis, and
lymphatic vessels.
What is the anatomic The ISV begins to branch extensively at
level at which the the level of the inguinal canal.
internal spermatic vein
begins to demonstrate
extensive branching?
What are the possible Commonly developed collateral
collateral pathways to pathways to the ISV include parallel,
the internal spermatic colic, hilar, and capsular collaterals.
vein when treating
varicoceles?
What are the various There are multiple approaches to
surgical approaches to varicocelectomy: retroperitoneal ISV
varicocelectomy? ligation, laparoscopic ISV ligation,
and inguinal or subinguinal approach
varicocelectomies with or without
microsurgery.
 28 Varicocele Embolization 339

Relevant Materials

What are the The most common agents are metallic

most common coils and liquid sclerosants, such as sodium
embolic agents tetradecyl sulfate (STS) and glue. These
used in varicocele agents can be used independently or in
embolization? combination. Glue embolization requires
considerable operator experience. Sodium
tetradecyl sulfate (STS) is a common
liquid sclerosant. Metallic coils typically
are 0.035–0.038 inches in diameter and can
be delivered in the ISV with care not to
encroach into the renal vein.
What agents can Typically, a course of nonsteroidal anti-­
be used for post-­ inflammatory drugs (NSAIDs) with or
procedure pain without additional nonnarcotic analgesics
control? can be used. Narcotics are usually not used
or necessary.
What standard Use of the last image hold as opposed
features of to spot film acquisition and avoidance of
fluoroscopic formal DSA “runs.”
equipment can be
used to minimize
testicular radiation
exposure?

General Step by Step

What is the relevant Pre-procedural laboratory workup is

laboratory workup not routinely performed in otherwise
prior to varicocele healthy, young males.
embolization?
(continued)
340 A. Pillutla

What is the Successful advancement can be

technique for facilitated by coaxial insertion of a 4–5
successful retrograde Fr angled catheter with gentle injection
advancement of a of contrast to opacify the ISV in a
selective catheter in retrograde fashion through incompetent
the ISV? valves. Valsalva maneuvering will aid in
opacification of the ISV by increasing
abdominal pressure. Tilting the table
in a reverse-Trendelenburg position
may be of benefit if Valsalva cannot be
adequately performed.
What is a common Coil embolization of the entire ISV
technique of with or without liquid sclerosant for the
embolization? pampiniform
After embolization of Venography performed with Valsalva
the ISV and collateral maneuvering demonstrates no reflux of
flow, what findings on flow down the gonadal vein.
venography signify
procedural success?
After varicocele Repeat venography must be
embolization and stasis performed to identify and embolize
of flow in the gonadal any new significant collateral
vein and pampiniform pathways developing because of flow
plexus, what additional redistribution from embolization.
step is required to
prevent procedure
failure?
 28 Varicocele Embolization 341

Complications

What are the potential Surgical complications include testicular

complications of arterial injury, postoperative hydrocele,
surgical techniques testicular atrophy, infection, and
in treatment of recurrence of varicoceles. A newer
varicoceles? surgical technique called microsurgical
varicocelectomy has a higher success
rate and lower complication rates when
compared with older laparoscopic and
robotic techniques. The risk of general
anesthesia for surgical approaches should
also be considered.
What are the potential Varicocele embolization can result in coil
complications misplacement or migration, venospasm
of endovascular or venous perforation, phlebitis, and
techniques in testicular radiation exposure.
treatment of
varicoceles?
What steps can be Though rare with modern coils,
taken to minimize inappropriately sized metallic coils
the risk of metallic can become dislodged and migrate
coil migration centrally to the pulmonary circuit. Care
after varicocele must be taken to appropriately size
embolization? coils (approximately 120% of the ISV
diameter), and to avoid protrusion of
the cephalad-most coil into the left renal
vein.
What procedure-­ Commonly, patients may experience
related symptoms temporary back pain, mild scrotal
can be expected and swelling, and scrotal discomfort. These
are not necessarily symptoms are generally self-limited, but
considered can be treated with NSAIDs, heating pad,
complications? How and rest for 2–3 days.
can they be managed?
342 A. Pillutla

Landmark Research
Nork JJ, Berger JH, Crain DS, Christman MS. Youth varico-
cele and varicocele treatment: a meta-analysis of semen out-
comes. Fertil Steril. 2014;102(2):381–387.e6. https://doi.
org/10.1016/j.fertnstert.2014.04.049
• Meta-analysis of changes in semen as measured by semen
analysis (SA) in youth with varicocele or undergoing vari-
cocele treatment.
• Measured the effect of varicocele on semen and the effect
of varicocele treatment on semen as measured by SA.
• Sperm density, motility, and morphology were significantly
decreased when associated with a varicocele, and sperm
density and motility were significantly improved following
treatment of varicocele.
Kroese ACJ, de Lange NM, Collins J, Evers JLH. Surgery
or embolization for varicoceles in subfertile men. Cochrane
Database Syst Rev. 2012;10:CD000479. https://doi.
org/10.1002/14651858.CD000479.pub5
• Meta-analysis to evaluate the effect of varicocele treat-
ment on live birth and pregnancy rate in subfertile couples
with known male varicocele.
• Ten randomized controlled trials included which reported
pregnancy rates or live birth rates, and data in treated (sur-
gical ligation or radiological embolization of the ISV)
versus untreated or placebo groups.
• 894 men included from all studies. Study suggests low-­
quality evidence favoring benefit of varicocele treatment
over expectant management for pregnancy rate in subfer-
tile couples in whom varicocele was the only abnormal
finding.
Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing
the value of varicocelectomy as a treatment for male subfer-
tility with a new meta-analysis. Fertil Steril. 2007;88(3):639–
648. https://doi.org/10.1016/j.fertnstert.2006.12.008
 28 Varicocele Embolization 343

• Meta-analysis of two randomized controlled trials and

three observational studies to assess the efficacy of varico-
celectomy in treating male infertility by improving the
chance of spontaneous pregnancy.
• Included infertile men with abnormal semen analysis and
palpable varicocele who underwent surgical varicocelec-
tomy; measured endpoint was spontaneous pregnancy.
• Odds of spontaneous pregnancy after surgical varicocelec-
tomy were 2.87 (95% confidence interval [CI], 1.33–6.20),
and the number needed to treat was 5.7 (95% CI, 4.4–9.5).

Common Questions
What is the technical There is a 93–100% technical success
success rate of varicocele rate of varicocele embolization for
embolization? untreated and recurrent varicoceles.
What is the potential Too proximal of an embolization can
result of too proximal of lead to recurrence due to collateral
an embolization? pathways that can refill the varicocele
through an inferior segment of the
gonadal vein.
Does varicocele Varicocele embolization can be
embolization require performed in the outpatient setting,
inpatient hospitalization? requiring 2-hour monitoring prior
What is the expected to discharge. Typically, patients can
time to recovery? return to work by the next day.
What is the clinical Patients undergo a 3-month scrotal
follow-up of patients ultrasound to evaluate for adequate
after undergoing treatment response.
varicocele embolization?
Which embolic agents Glue and sclerosant embolics,
are most associated with especially if delivered below the
phlebitis? What is the level of the inguinal ligament, can be
treatment? associated with phlebitis. While self-­
limited, NSAIDs and reduced physical
activity can be recommended for
symptom management.
344 A. Pillutla

Further Reading
Agarwal A, Deepinder F, Cocuzza M, Agarwal R, Short RA,
Sabanegh E, et al. Efficacy of varicocelectomy in improving
semen parameters: new meta-analytical approach. Urology.
2007;70(3):532–8.
Al-Ali BM, Marszalek M, Shamloul R, Pummer K, Trummer
H. Clinical parameters and semen analysis in 716 Austrian
patients with varicocele. Urology. 2010;75(5):1069–73.
Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, et al.
Varicocele and male factor infertility treatment: a new meta-
analysis and review of the role of varicocele repair. Eur Urol.
2011;60(4):796–808.
Bilreiro C, Donato P, Costa JF, Agostinho A, Carvalheiro V, Caseiro-
Alves F. Varicocele embolization with glue and coils: a single
center experience. Diagn Interv Imaging. 2017;98(7–8):529–34.
Cantoro U, Polito M, Muzzonigro G. Reassessing the role of sub-
clinical varicocele in infertile men with impaired semen quality:
a prospective study. Urology. 2015;85(4):826–30.
Chehval MJ, Purcell MH. Deterioration of semen parameters over
time in men with untreated varicocele: evidence of progressive
testicular damage. Fertil Steril. 1992;57(1):174–7.
Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam
Physician. 2014;89(9):723–7.
Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the
scrotum. Radiology. 2003;227(1):18–36.
Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve-­year
study. Urology. 1977;10(5):446–9.
Dubin L, Amelar RD. Varicocele. Urol Clin North Am.
1978;5(3):563–72.
Eisenberg ML, Lipshultz LI. Re: does varicocele repair improve
male infertility? An evidence-based perspective from a random-
ized, controlled trial. Eur Urol. 2011;60(2):395.
Feneley MR, Pal MK, Nockler IB, Hendry WF. Retrograde emboli-
zation and causes of failure in the primary treatment of varico-
cele. Br J Urol. 1997;80(4):642–6.
Gandini R, Konda D, Reale CA, Pampana E, Maresca L, Spinelli
A, et al. Male varicocele: transcatheter foam sclerotherapy with
sodium tetradecyl sulfate--outcome in 244 patients. Radiology.
2008;246(2):612–8.
 28 Varicocele Embolization 345

Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco

C. Microsurgical inguinal varicocelectomy with delivery of
the testis: an artery and lymphatic sparing technique. J Urol.
1992;148(6):1808–11.
Gorelick JI, Goldstein M. Loss of fertility in men with varicocele
**Presented in part at the 45th Annual Meeting of the American
Fertility Society, San Francisco, California, November 13 to 16,
1989. Fertil Steril. 1993;59(3):613–6.
Grober ED, O’brien J, Jarvi KA, Zini A. Preservation of testicular
arteries during subinguinal microsurgical varicocelectomy: clini-
cal considerations. J Androl. 2004;25(5):740–3.
Iaccarino V, Venetucci P. Interventional radiology of male varicocele:
current status. Cardiovasc Intervent Radiol. 2012;35(6):1263–80.
Kadyrov ZA, Teodorovich OV, Zokirov OO, Ishonakov KS,
Muminov NO. Bilateral varicocele: epidemiology, clinical pre-
sentation and diagnosis. Urologiia. 2007;(3):64–8.
Kim HH, Goldstein M. Adult varicocele. Curr Opin Urol.
2008;18(6):608–12.
Kroese ACJ, de Lange NM, Collins J, Evers JLH. Surgery or emboli-
zation for varicoceles in subfertile men. Cochrane Database Syst
Rev. 2012;10:CD000479.
Lipshultz LI, Corriere JN. Progressive testicular atrophy in the vari-
cocele patient. J Urol. 1977;117(2):175–6.
Makris GC, Efthymiou E, Little M, Boardman P, Anthony S, Uberoi
R, et al. Safety and effectiveness of the different types of embolic
materials for the treatment of testicular varicoceles: a systematic
review. BJR. 2018;91(1088):20170445.
Marmar JL, Agarwal A, Prabakaran S, Agarwal R, Short RA, Benoff
S, et al. Reassessing the value of varicocelectomy as a treatment
for male subfertility with a new meta-analysis. Fertil Steril.
2007;88(3):639–48.
Masson P, Brannigan RE. The varicocele. Urol Clin North Am.
2014;41(1):129–44.
Mehta AL, Dogra VS. Intratesticular varicocele. J Clin Ultrasound.
1998;26(1):49–51.
Nork JJ, Berger JH, Crain DS, Christman MS. Youth varicocele and
varicocele treatment: a meta-analysis of semen outcomes. Fertil
Steril. 2014;102(2):381–7.e6.
Pajovic B, Radojevic N, Dimitrovski A, Radovic M, Rolovic R,
Vukovic M. Advantages of microsurgical varicocelectomy
346 A. Pillutla

over conventional techniques. Eur Rev Med Pharmacol Sci.

2015;19(4):532–8.
Pierik FH, Dohle GR, van Muiswinkel JM, Vreeburg JT, Weber
RF. Is routine scrotal ultrasound advantageous in infertile men?
J Urol. 1999;162(5):1618–20.
Reiner E, Machan L, Pollak J. Varicocele embolization. In:
Handbook of interventional radiologic procedures. 5th ed.
Philadelphia: LWW; 2016. p. 413–20.
Reiner E, Pollak JS, Henderson KJ, Weiss RM, White RI. Initial
experience with 3% sodium tetradecyl sulfate foam and fibered
coils for management of adolescent varicocele. J Vasc Interv
Radiol. 2008;19(2 Pt 1):207–10.
Rifkin MD, Kurtz AB, Pasto ME, Goldberg BB. Diagnostic capa-
bilities of high-resolution scrotal ultrasonography: prospective
evaluation. J Ultrasound Med. 1985;4(1):13–9.
Sayfan J, Soffer Y, Orda R. Varicocele treatment: prospective ran-
domized trial of 3 methods. J Urol. 1992;148(5):1447–9.
Schlegel PN, Goldstein M. Alternate indications for varicocele repair:
non-obstructive azoospermia, pain, androgen deficiency and pro-
gressive testicular dysfunction. Fertil Steril. 2011;96(6):1288–93.
Schlesinger MH, Wilets IF, Nagler HM. Treatment outcome after
varicocelectomy. A critical analysis. Urol Clin North Am.
1994;21(3):517–29.
Sze DY, Kao JS, Frisoli JK, McCallum SW, Kennedy WA, Razavi
MK. Persistent and recurrent postsurgical varicoceles: veno-
graphic anatomy and treatment with N-butyl cyanoacrylate
embolization. J Vasc Interv Radiol. 2008;19(4):539–45.
Tulloch WS. Varicocele in subfertility. Br Med J. 1955;2(4935):356–8.
Vanlangenhove P, Everaert K, Van Maele G, Defreyne L. Tolerance
of glue embolization under local anesthesia in varicoceles: a
comparative study of two different cyanoacrylates. Eur J Radiol.
2014;83(3):559–63.
Wang Y-J, Zhang R-Q, Lin Y-J, Zhang R-G, Zhang W-L. Relationship
between varicocele and sperm DNA damage and the effect
of varicocele repair: a meta-analysis. Reprod Biomed Online.
2012;25(3):307–14.
Wan X, Wang H, Ji Z. Microsurgical varicocelectomy for clinical
varicocele: a review for potential new indications. Andrologia.
2017;49(10):e12827.
 28 Varicocele Embolization 347

World Health Organization. The influence of varicocele on param-

eters of fertility in a large group of men presenting to infertility
clinics **Supported by the Special Programme of Research,
Development, and Research Training in Human Reproduction,
World Health Organization, Geneva, Switzerland. Fertil Steril.
1992;57(6):1289–93.
Chapter 29
Vena Cava Filter
David Maldow

Evaluating the Patient

What are the physical signs Leg pain, pitting edema, rubor,
and symptoms of lower and warmth
extremity DVT?
What is the initial imaging Duplex venous ultrasound
study of choice for evaluation
of extremity DVT?
What are the key findings Absent compressibility.
suggestive of venous
thrombus on duplex
ultrasound?
Loss of phasicity with Valsalva.
Absent color flow (if occlusive).
Lack of augmentation response.
Change in venous diameter
(generally increased if acute and
decreased if chronic).
(continued)

D. Maldow (*)
University of Rochester Medical Center, Rochester, NY, USA

© Springer Nature Switzerland AG 2022 349

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_29
350 D. Maldow

Proximal (iliofemoral) DVT –

consider CT/MR venography as
ultrasound exam is limited.
In pregnant patients, To reduce radiation exposure
why should one consider to the fetus and to prevent
suprarenal location for IVC complications between the fetus
filter placement? and filter
What is the optimal contrast Approximately 90-second delay
bolus timing for visualization
of the entire IVC on CT?

High Yield History

What is Virchow’s triad as it Stasis, endothelial injury, and
relates to the development of hypercoagulability
DVT?
Name two transient risk Surgery and severe trauma
factors for VTE. (multiple long bone/pelvic
fractures, spinal cord injury, and
closed head injury)
Name two long-standing risk Malignancy and inherited
factors for VTE. coagulopathy (e.g., factor V
Leiden deficiency)
Which allergy should be Iodinated contrast (patient may
included in the history when require premedication regimen
evaluating a patient for vena prior to procedure)
cava filter placement?
In the setting of iodinated CO2 and gadolinium chelates
contrast allergy, name two
alternative contrast agents
that may be used.
 29 Vena Cava Filter 351

Indications/Contraindications
What are the prophylactic and therapeutic indications for IVC
filter placement?

Therapeutic indications Prophylactic indications

DVT/PE with High-risk patient undergoing surgical
contraindication to procedure
anticoagulation
Recurrent DVT/PE Severe trauma (multiple long bone/
despite anticoagulation pelvic fractures, spinal cord injury, or
closed head injury)
DVT/PE with High-risk patient secondary to
hemorrhage-related underlying medical condition
complications (prolonged immobilization)
Inability to maintain
therapeutic
anticoagulation

What is the first-line Systemic anticoagulation (AC)

management of venous
thromboembolism (VTE)?
What is the dosing of Unfractionated heparin: 80 units
anticoagulation regimens? per kg IV bolus, followed by
maintenance infusion 18 units per kg
per hour titrated to a goal aPTT of
60–80 seconds or with Xa assay
Enoxaparin (Lovenox, low
molecular weight heparin): 1 mg per
kg subcutaneously every 12 hours or
1.5 mg per kg subcutaneously every
24 hours
Warfarin (Coumadin, vitamin K
antagonist): 5–10 mg PO once daily
titrated to INR 2 or greater

(continued)
352 D. Maldow

Apixaban (Eliquis, direct factor Xa

inhibitor): 10 mg PO twice daily for
7 days and then 5 mg twice daily
Rivaroxaban (Xarelto, direct factor
Xa inhibitor): 15 mg PO twice daily
for 21 days and then 20 mg once
daily
Dabigatran (Pradaxa, direct
thrombin inhibitor): 150 mg PO
twice daily
Note: minimum 3-month therapy
duration recommended
What type of filter is Cook Bird’s Nest: non-retrievable,
compatible for patients can be used with vena cava diameter
with megacava (caval up to 40 mm
diameter >28 mm)?
Name three absolute Active bleeding, acute stroke within
contraindications to the past 24 hours, uncontrolled
systemic anticoagulation. systolic hypertension (> or equal to
230/120 mmHg)
Recent surgery or epidural
intervention (e.g., lumbar puncture
or epidural anesthesia) within prior
4 hours or expected within the next
12 hours
Name five relative Acquired bleeding disorder (e.g.,
contraindications to inherited coagulopathy, liver failure)
systemic anticoagulation.
Stroke within the last 24 hours
Uncontrolled hypertension
(e.g., systolic > 230 mm Hg, diastolic
> 120 mm Hg)
Prior bleeding complication with
systemic AC
Sepsis
 29 Vena Cava Filter 353

Name three indications 1. Renal vein or gonadal vein

for suprarenal IVC filter thrombosis
placement.
2. IVC duplication
3. Low insertion of renal veins
Name four indications for Low risk of clinically significant PE
IVC filter removal. due to primary treatment.
Patient will not return to high risk
for PE status from interruption of
primary treatment.
Life expectancy of patient long
enough to realize benefit from filter
removal (at least 6 months).
Filter can safely be retrieved with
adequate venous access.
Name two 1. Significant thrombus within the
contraindications to vena filter
cava filter removal.
2. Patient unable to achieve
adequate anticoagulation or
prophylaxis

Relevant Anatomy
What defines a Venous thrombus involving the popliteal
proximal lower vein, femoral vein, iliac veins or IVC
extremity DVT?
What defines a distal Venous thrombus confined to the
lower extremity infrapopliteal veins
DVT?
What is the most Infrarenal
common location for
IVC filter placement?

(continued)
354 D. Maldow

What is the upper 28 mm (excluding Bird’s Nest filter)

limit of caval
diameter for filter
placement?
Name four things IVC duplication anomalies. In this case, a
to evaluate for on filter should be placed in both IVCs or in
prefilter placement the bilateral iliac veins.
cavogram.
Interrupted or absent IVC.
Presence or absence of IVC thrombus.
Determination of IVC diameter.
Location of renal vein inflow. In the
event of circumaortic left renal vein, the
IVC filter should be placed below the
level of the lowest renal vein or two can
be placed in the bilateral common iliac
veins.
What is the most Left renal vein
common route of
venous drainage in a
duplicated IVC?
Which gonadal vein Right
drains into the IVC?
How many left renal Two. The filter should be placed below
veins are seen with the level of the lowest renal vein.
the circumaortic left
renal vein variant?

Relevant Materials
What are the different types of historically available IVC
filters?
 29 Vena Cava Filter 355

Types of IVC Filters

a b c

d e f

g h

A Simon Nitinol
B Recovery/G2
C Günther-Tulip
D Greenfield Ti
i j k E Greenfield SS OTW
F Celect
G Vena Tech LP
H Vena Tech LGM
I TrapEase
J OptEase
K Bird’s Nest
L Option

What are the names of two types of Cook Celect;

retrievable filters and what is their conichrome
composition?
Cordis OptEase;
nitinol
What are the names of two non-retrievable Braun VenaTech LP
filter types and their composition? or LGM; Phynox
(continued)
356 D. Maldow

Cook Bird’s Nest;

stainless steel
Name a contrast agent that can be used in a CO2
patient with renal insufficiency or iodinated
contrast allergy.
Name a common device used for vena cava Snare
filter retrieval.

General Step by Step

What are the two usual Internal jugular vein and femoral
routes of peripheral venous vein
access for IVC filter
placement?
What is the usual contrast 15–20 cc/sec for 2 seconds
injection rate for a
cavogram?
How can you identify the Inflow of non-opacified blood or
contralateral iliac and renal reflux of contrast into the veins
veins on a cavogram?
For the purpose of prefilter At the confluence of the iliac
cavogram, where should the veins
tip of the pigtail catheter be
placed?
At what level should the tip Generally, the tip is placed at the
of the IVC filter be after confluence of the renal veins as to
deployment? allow renal inflow to help prevent
thrombus formation.

Complications
Name three procedural 1. Incomplete filter deployment
complications of IVC filter
placement.
 29 Vena Cava Filter 357

2. Filter malpositioning
3. Filter tilting
Name three late complications 1. Filter migration
of IVC filter placement.
2. Fractured filter limb
3. IVC thrombosis
What is a feared complication Recurrent pulmonary embolism.
of infrarenal IVC filter Filters should be placed in both
placement in the setting of a IVCs or in the bilateral iliac
duplicated IVC? veins.

Landmark Research
Haut et al. The effectiveness of prophylactic inferior vena
cava filters in trauma patients: a systematic review and
meta-analysis
• Weak association between IVC filter placement and
decreased incidence of nonfatal and fatal PE in trauma
patients. Benefits must be weighed against the inherent
risks of IVC filter placement. Targeted use of IVC filters
may be beneficial for those who are severely injured or
unable to tolerate anticoagulation, particularly in the set-
ting of retrievable filters.
Mismetti et al. Effect of a Retrievable Inferior Vena Cava
Filter Plus Anticoagulation vs Anticoagulation Alone on
Risk of Recurrent Pulmonary Embolism: A Randomized
Clinical Trial.
• In patients with PE at high risk for recurrence, routine
placement of a retrievable IVC filter does not reduce the
risk of recurrent PE when compared to anticoagulation
alone.
358 D. Maldow

Decousus et al. A Clinical Trial of Vena Caval Filters in the

Prevention of Pulmonary Embolism in Patients with Proximal
Deep-Vein Thrombosis.
• No difference in 2-year mortality for DVT patients ran-
domized to anticoagulation vs. filter.
• Although IVC filters reduced the risk of PE, they were
associated with more recurrent DVT.

Common Questions
True or false: vena cava filters False
help prevent formation of new
thrombus.
What imaging study should be Doppler venous ultrasound of
performed prior to removal both lower extremities may be
of a prophylactic vena cava obtained as clinically indicated
filter? to document absence of DVT.
Should anticoagulation be No
held temporarily for vena cava
filter removal?

Further Reading
Binkert C. Caval filtration. In: Mauro M, Murphy K, et al., editors.
Image-guided interventions. 2nd ed. Philadelphia, PA: Elsevier
Saunders; 2014.
Bjarnason H, Young P, McEachen J. Acute lower extremity deep
vein thrombosis: classification, imaging evaluation, indications
for intervention. In: Geschwind J-F, Dake M, editors. Abrams
angiography. 3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2014.
Dobromirski M, Cohen A. How I manage venous thromboembolism
risk in hospitalized medical patients. Blood. 2015;120:1562–9.
Haut ER, Garcia LJ, Shihab HM, et al. The effectiveness of prophy-
lactic inferior vena cava filters in trauma patients: a systematic
review and meta-analysis. JAMA Surg. 2013;149:194–202.
 29 Vena Cava Filter 359

Johnson M, Marshalleck F, Johnson C. Pulmonary embolism- IVC

filters: indications and technical considerations. In: Abrams'
angiography: interventional radiology. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014. p. 990–7.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. 5th ed. Philadelphia: Wolters Kluwer;
2016.
Kaufman JA. Guidelines for the use of retrievable vena cava filters.
Endovasc Today. 2006:42–7.
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for
VTE disease: CHEST guideline and expert panel report. Chest
J. 2016;149:315–52.
Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable infe-
rior vena cava filter plus anticoagulation vs anticoagulation
alone on risk of recurrent pulmonary embolism: a randomized
clinical trial. JAMA. 2015;313:1627–35.
Mokry T, Bellemann N, Sommer C, et al. Retrospective study in 23
patients of the self-expanding sinus-XL stent for treatment of
malignant superior vena cava obstruction caused by non-small
cell lung cancer. JVIR. 2015;26:357–65.
Molvar C. Inferior vena cava filtration in the management of venous
thromboembolism: filtering the data. Semin Interv Radiol.
2012;29:204–17.
Rao B, Duran C, Steigner ML, Rybicki FJ. Inferior vena cava filter–
associated abnormalities: MDCT findings. Am J Roentgenol.
2012;198:605–10.
Smillie RP, Shetty M. Imaging evaluation of the inferior vena cava.
Radiographics. 2015;35:578–92.
Weinberg I. Appropriate use of inferior vena cava filters. ACC
Expert Analysis; 2016. http://www.acc.org/latest-­in-­cardiology.
Wilbur J, Shian B. Deep venous thrombosis and pulmonary embo-
lism: current therapy. Am Fam Physician. 2017;95:296–302.
Chapter 30
Peripheral and Visceral
Artery Aneurysm
Jesse Chen and Amit Ramjit

Evaluating Patient
What and where are Although aortic aneurysms are more
PAAs? common, PAA is an enlargement in an
artery other than the aorta, the aorto-­
iliacs, the cerebral circulation, the visceral
circulation, or the coronary vessels. They
occur most commonly in the popliteal
arteries (nearly 70% of all PAAs),
followed by the iliofemoral arteries. Upper
extremity PAAs are relatively uncommon.
An aneurysm is a dilation of an artery
>50% of its native diameter, and it involves
all three layers of the arterial wall.
(continued)

J. Chen (*) · A. Ramjit

Department of Radiology, Staten Island University Hospital,
Staten Island, NY, USA

© Springer Nature Switzerland AG 2022 361

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_30
362 J. Chen and A. Ramjit

How do PAAs PAAs are usually asymptomatic and

present? identified incidentally during workup
for other reasons. Nonetheless, the most
common acute presentation includes
peripheral thrombosis with acute limb
ischemia (pain, numbness, loss of pulses,
etc.), representing roughly 50% of
symptomatic PAAs. If there is insufficient
flow past a thrombosed aneurysm, ensuing
chronic limb ischemia can mimic occlusive
atherosclerotic disease. Symptomatic
aneurysms may also present secondary
to compression of local structures (e.g.,
nerves, veins). PAAs are much less likely
to rupture than aortic aneurysms, with an
incidence of 2–4%.
What symptoms The most common presenting symptoms
are typical of upper result from subclavian artery aneurysms,
extremity PAAs? including a pulsatile neck mass, upper
extremity neuralgia, Horner syndrome, or
stridor from tracheal or recurrent laryngeal
nerve compression.
Are PAAs usually No. identification of a single PAA
isolated findings? warrants a thorough search for additional
aneurysms. Roughly 83% of patients
who have at least one PAA identified
will be found to have multiple, including
an increased risk for abdominal aortic
aneurysm (AAA). For example, isolated
popliteal artery aneurysms are very
uncommon, found in only 0.1–3% of
the population. Popliteal aneurysms are
bilateral in 50–70% of cases, and up to
70% of patients with a popliteal aneurysm
will have an AAA.
 30 Peripheral and Visceral Artery Aneurysm 363

How are PAAs Because many aneurysms are

evaluated and asymptomatic for a prolonged period,
followed? the true incidence of PAAs is unclear.
Ultrasonography has improved detection
of peripheral aneurysms above physical
exam, but computed tomography
angiography (CTA) and magnetic
resonance angiography (MRA) have
since surpassed duplex ultrasound.
Cross-sectional imaging provides better
anatomical detail, allows definition of both
inflow and outflow vessel diameter, and
assesses for the presence of aneurysmal
thrombus, all of which are important for
intervention.
What will be found PAAs are usually diagnosed incidentally by
on physical exam of imaging performed for other reasons. Due
a PAA? to differences in body habitus, physical
exam generally has low sensitivity for
PAA. Popliteal artery aneurysms, however,
are classic for presenting with a pulsatile
mass, found in 60% of patients. If a PAA is
thrombosed, the only finding on physical
exam to suggest its presence may be a
pulsatile mass on the contralateral side.
What is the most Subclavian artery aneurysm comprises
common upper 88% of upper extremity arterial aneurysms.
extremity PAA?
Where is the most Visceral artery aneurysms (VAAs) are
common visceral rare (estimated prevalence of 0.01–0.2%).
artery aneurysm? Although about 1/5 present as clinical
emergencies, an increasing number of
incidental VAAs are diagnosed due to the
increasing prevalence of cross-sectional
imaging. The splenic artery is the most
common site, then hepatic artery, celiac
artery, and SMA.
(continued)
364 J. Chen and A. Ramjit

What is the most The common femoral artery is the most

common site of common site of PSA, largely secondary
pseudoaneurysm to iatrogenic puncture for arterial
(PSA) formation? catheterization. Femoral PSA occurs in
0.6–6% of femoral interventions. The wide
prevalence of coronary interventions in
the United States accounts for a significant
portion of these PSAs, usually from a
“low puncture” where the artery is not
supported by surrounding structures
(e.g., femoral head) to aid in hemostasis.
Degenerative PSA formation over time
is also common in arteriovenous fistulas
created for hemodialysis.
How do Patients will present with symptoms of
pseudoaneurysms mass effect, bleeding, a palpable mass, or
present? the sensation of pain or a femoral bruit.
The expanding PSA may compress the
adjacent nerve or vein, resulting in distal
extremity numbness or edema, respectively.
The overlying skin may develop ischemia,
also from underlying compression.
How are Duplex ultrasonography has a sensitivity
pseudoaneurysms and specificity of 94% and 97%,
evaluated and respectively, for femoral PSA. Color
followed? Doppler will demonstrate a swirling
pattern of flow, often referred to as the
classic “yin-yang sign.” to-and-fro flow
signal in the PSA sac indicates a patent
and non-thrombosed pseudoaneurysm with
inflow and outflow.
 30 Peripheral and Visceral Artery Aneurysm 365

High Yield History

What are the Male gender (M:F ratio >20:1), hypertension,
risk factors family history of aneurysm, connective tissue
for PAA? disorder, smoking history, or prior aneurysm. In
contrast, certain visceral artery aneurysms (e.g.,
splenic artery, renal artery) are more common in
women.
What is The most common complication of popliteal
the natural artery aneurysms (the most common PAA) is
history of a acute ischemia, either from thrombosis or distal
PAA? embolization. Intermittent claudication, pain, and
venous compression resulting in DVT are also
potential complications. Femoral artery aneurysms
(FAAs), the second most common PAA, do
not have a well-defined natural history. Perhaps
due to the relatively low incidence and often
asymptomatic nature of FAA, multiple small case
series demonstrate wide variability in the rate of
complication. In general, PAA growth and the
potential for rupture are difficult to predict. Some
PAAs do not expand over time.
Upper extremity PAAs, however, more frequently
become symptomatic than lower extremity PAAs,
with thromboembolic complications being most
common. Rupture is less likely the more distal the
aneurysm in the upper extremity.
What is The natural history of VAAs is unknown. Most
the natural symptomatic patients present following rupture
history of with significant associated morbidity; however, no
visceral definite risk factors predisposing VAA to rupture
artery have been identified. Because even small VAAs
aneurysms can rupture, no size criteria for repair are defined.
(VAAs)? Although splenic artery aneurysms are least likely
to rupture, there is increased risk for rupture
during pregnancy. Hepatic artery aneurysms have a
relatively high risk of rupture.
(continued)
366 J. Chen and A. Ramjit

What is the Calcification has been traditionally thought

association to represent aneurysmal stability; however,
of splenic calcification is seen in 90% of ruptured splenic
artery aneurysms, and thus the presence of calcifications
aneurysms should not be used in risk assessment.
and arterial
calcification?
What are the Poor puncture technique (as above), inadequate
risk factors postprocedural puncture site compression,
for PSA periprocedural anticoagulation, large-bore sheath
formation? placement (≥7 Fr), hypertension, coagulopathy,
hemodialysis, and female gender

Indications/Contraindications
What is the All symptomatic PAAs should be repaired.
indication for Additionally, a PAA should be repaired when
PAA repair? it is twice the size of the native vessel or
when increasing in size. As a rule of thumb,
most aneurysms ≥2 cm require treatment.
Unfortunately, aneurysm diameter does
not predict risk of rupture as compared to
abdominal aortic aneurysm.
What patient Patients who often maintain >90° flexion
factors preclude of the knees (e.g., gardeners, carpenters)
endovascular have higher risk of stent kinking/occlusion.
repair of popliteal Additionally, stenting should not be
artery aneurysm? performed in patients with contraindication
to antiplatelet drugs.
In what clinical In cases of aneurysm rupture and
scenario is hemodynamic instability, or where the
open surgical patient’s anatomy is unsuitable for
intervention endovascular repair. There is currently no
recommended good data on endovascular management in
over endovascular the emergent setting.
repair for PAA?
 30 Peripheral and Visceral Artery Aneurysm 367

What is the Traditionally, intervention has been

indication for recommended for aneurysms ≥2 cm,
visceral artery aneurysms with rapid growth, or any
aneurysm (VAA) symptomatic aneurysm. With increasing use
repair? of endovascular repair, and with poor data on
size criteria as an indication for intervention,
earlier and more aggressive intervention is
replacing serial surveillance. Intervention
should be offered to pregnant women with
splenic artery aneurysm due to the increased
risk of rupture.
What is the The main consideration for treatment
indication for is whether the PSA will spontaneously
PSA treatment? thrombose, with likelihood generally tied to
the size of the PSA. Limited studies have
been inconsistent although, in general, a PSA
<2 cm can be safely observed, a PSA ≥3 cm
should be treated, and those measuring
2–3 cm should be more closely monitored
or treated. Otherwise, all symptomatic
PSAs should be treated. This would include
PSAs with associated soft tissue necrosis,
distal neuralgia or ischemia, pain, or rapid
expansion, regardless of size.
What are the A short, wide PSA neck is a contraindication
contraindications to thrombin injection for risk of thrombin
to ultrasound-­ distal embolization leading to thrombosis.
guided thrombin Additional contraindications include
injection of PSA? overlying tissue necrosis, presence of AV
fistula, and the presence of limb ischemia.
368 J. Chen and A. Ramjit

Relevant Anatomy
What are The external iliac artery turns into the common
the proximal femoral artery at the inguinal ligament. The
arteries of common femoral artery terminates after giving
the lower rise to the profunda femoris, then becoming
extremity? the superficial femoral artery. The superficial
femoral artery turns into the popliteal artery at
the adductor canal.
What are the The popliteal artery terminates as the anterior
distal arteries tibial artery and the tibioperoneal trunk. The
of the lower tibioperoneal trunk then divides into the
extremity? posterior tibial and peroneal arteries.
What are The subclavian artery terminates at the first
the arteries rib, then becoming the axillary artery. The
of the upper axillary artery terminates after giving rise to the
extremity? circumflex humeral arteries, then becoming the
brachial artery. The brachial artery bifurcates just
distal to the humeral trochlea giving rise to the
radial and ulnar arteries.
What part of Middle third. The proximal third is the second
the popliteal most affected, and aneurysm of the distal third
artery is most is the least common. Aneurysms of the distal
commonly third of the popliteal artery often extend into the
affected? tibioperoneal trunk and are much more prone
to thrombosis and subsequent embolization.
The popliteal artery may be of increased
susceptibility to aneurysm formation due to
a complex embryology, associated with three
original segments as described above.
What are the Cutler and Darling in 1973 originally classified
two types FAAs according to their relation to the femoral
of common artery bifurcation. Type 1 FAAs are limited to
femoral artery the common femoral artery, and type 2 FAAs
aneurysms extend into the bifurcation, involving the origin
(FAAs)? of the profunda or the superficial femoral artery.
 30 Peripheral and Visceral Artery Aneurysm 369

What portion Distal third, followed by middle third

of the splenic
artery is most
commonly
affected by
VAA?

Relevant Materials
What size sheath Depending on the intended stent-graft
is used during size, a 6- or 7-F sheath is usually used.
endovascular repair
of PAA?
How are stent-grafts Stents are advanced over a 0.018″ or
advanced into the 0.035″ guidewire which has been passed
PAA? beyond the aneurysm.
What is a commonly The Viabahn Endoprosthesis (Gore,
used stent-graft? Flagstaff, Arizona) is a commonly used
self-expanding, covered stent-graft. It has
improved flexibility compared to older
generation devices.
Are multilayered No. Multilayered stents have been
stents useful in PAA associated with increased risk of stent
repair? thrombosis, both in PAA and AAA repair.
What medications Heparin is often administered, with
are given during and antiplatelet therapy started post-repair.
after stent placement Antiplatelet (clopidogrel, aspirin) therapy
in PAA repair? has been shown to be a predictor of
endovascular repair success.
What size needle is A 22-gauge needle is usually sufficient;
typically used for however, a 21-gauge needle may be
ultrasound-guided necessary for deeper lesions.
thrombin injection of
a PSA?
370 J. Chen and A. Ramjit

General Step by Step

What is the Open repair including aneurysm resection and
gold standard placement of an interposition or bypass graft,
of treatment usually with a great saphenous vein graft. Repair
for PAA with a prosthetic (Dacron or PTFE) graft is
management? also possible. While aneurysm excision without
vascular reconstruction is possible, many of
these patients will subsequently have arterial
insufficiency symptoms.
What are the Endovascular techniques are increasingly
advantages of popular, particularly for patients with multiple
endovascular comorbidities who might not tolerate anesthesia
management and surgery. Open surgical repair can be
techniques associated with significant morbidity from major
for PAA? surgical dissection. Endovascular techniques often
afford decreased blood loss, shorter procedure
time, and decreased length of stay compared
to open procedures. Nonetheless, cost savings
afforded by endovascular management (e.g.,
decreased operative time and length of stay) may
be offset by the increased cost of devices needed
for endovascular repair.
Why are The close proximity to the inguinal ligament
femoral results in focal compression/bending, increasing
artery the risk of focal neointimal hyperplasia and
aneurysms possible stent fracture. Additionally, the proximity
less to the femoral bifurcation/profunda makes the
favorable for possibility of fracture particularly dangerous.
endovascular
repair?
 30 Peripheral and Visceral Artery Aneurysm 371

In a patient In general, any abdominal aortic aneurysm is

with multiple treated first, except in the case of acute limb
aneurysms, ischemia. Concomitant ipsilateral PAAs in tandem
which are can usually be repaired in the same operative
treated first? setting (e.g., femoral and popliteal aneurysm).
In contrast, a staged management algorithm is
usually used for contralateral PAAs.
What is the Many of the anatomical considerations of
endovascular endovascular therapy are similar to the treatment
treatment of of abdominal aortic aneurysm. Stent placement
PAA? requires a 1.5–2.0-cm proximal and distal landing
zone, according to manufacturer specification,
to minimize stent migration and endoleak.
Given that the distal vessel is often of smaller
diameter than the proximal aspect, multiple
devices of unequal diameters are often necessary.
The distal/smaller stent is placed first, and the
larger stents are placed inside the prior, building
proximally. Stent-graft size is often chosen with a
small amount (1 mm) of oversizing. Completion
angiography, often with a crossed joint in flexion,
is necessary to confirm aneurysm occlusion and to
ensure stent flexibility.
(continued)
372 J. Chen and A. Ramjit

How are The mainstays of treatment include ultrasound-­

PSAs guided direct compression of the PSA, ultrasound-­
treated? guided thrombin injection, and open surgical
repair. Less common endovascular approaches
include utilization of coils, glue, and occlusive
stents:
Ultrasound-guided compression: Pressure is
usually held for up to two cycles of 10–20 minutes,
assessing for persistent flow within the PSA after
each cycle. The patient should then keep the
affected leg flat for 6 hours, and the PSA should
be reassessed for flow 24–48 hours later. Success
rates of 66–86% are reported, depending on PSA
size, anticoagulation status, and body habitus.
Ultrasound-guided thrombin injection: The PSA
is punctured under direct visualization with US
guidance. 0.1–0.2-mL aliquots of 1000 U/mL of
thrombin are injected until flow in the PSA stops.
The patient should be placed on bed rest for
1 hour with neurovascular checks performed, and
the PSA should be reassessed for flow in 24 hours.
Success rates of 93–100% are reported.
Surgical repair: In general, surgical treatment
is indicated when (1) urgent control of the
PSA is needed (e.g., rupture, rapid expansion,
compressive neuropathy, or limb ischemia), (2)
if a soft tissue defect is present (e.g., suture line
dehiscence, wound infection, soft tissue ischemia),
or (3) if a secondary pathology requires surgical
intervention (e.g., presence of arteriovenous
fistula or if the patient is undergoing anesthesia
for separate procedure). To repair the PSA, a
direct cut down is made to achieve proximal
and distal control of the arterial lesion. The PSA
is then opened and the arteriotomy is directly
repaired with sutures, or, if there is significant
injury to the artery, a saphenous vein graft
may be used for an interposition graft or patch
angioplasty.
 30 Peripheral and Visceral Artery Aneurysm 373

Complications
Why is upper PAA in the upper extremity should be
extremity PAA repaired, even when asymptomatic, as
more dangerous there is a greater risk of thromboembolism.
than lower extremity
PAA?
What is the 42–75% of asymptomatic patients with
complication rate PAA that are treated conservatively will
of PAAs treated develop complications in 5 years, with
conservatively? risks varying based on aneurysm location.
14% of popliteal artery aneurysms become
symptomatic per year.
What complications Puncture site hematoma, stent occlusion,
arise from stent migration or fracture, and endoleak
endovascular repair
of PAA?
What is the Distal embolization is reported in
most common up to 2% of patients. In the event of
complication of embolization (either in the femoral artery
ultrasound-guided or distally), the patient should be placed on
thrombin injection therapeutic heparin, with a low threshold
of PSA? for catheter-directed thrombolysis with
tissue plasminogen activator (tPA).
How are infected Conservative treatments (discussed
PSAs treated? above) are not appropriate for infected
PSAs. Appropriate antibiotic therapy,
debridement of infected tissue, and arterial
repair (often with interposition graft) are
critical.

Landmark Research
Lovegrove RE, Javid M, Magee TR, et al. Endovascular and
open approaches to non-thrombosed popliteal aneurysm
repair: a meta-analysis. Eur J Vasc Endovasc Surg.
2008;36:96–100.
374 J. Chen and A. Ramjit

• Meta-analysis comparing open and endovascular repair of

popliteal artery aneurysm demonstrating no difference in
long-term patency. Endovascular repair was associated
with decreased operative time and length of stay, however,
with increased risk of thrombosis/reintervention at 30 days.
Open Versus Endovascular Repair of Popliteal Artery
Aneurysm Trial. Available from: https://clinicaltrials.gov/ct2/
show/NCT01817660. NLM identifier: NCT01817660.
• The Open Versus Endovascular Repair of Popliteal Artery
Aneurysm (OVERPAR) trial was a highly anticipated,
prospective, multicenter, randomized clinical trial which
began in 2013 and was expected to be the largest study to
date to guide treatment in patients with popliteal artery
aneurysm. The study was unfortunately terminated in 2017
due to difficulty in recruiting patients.
• Nevertheless, since the beginning of this trial, multiple
studies have compared the outcomes of open versus endo-
vascular repair of popliteal artery aneurysm.
Endovascular versus open repair of asymptomatic popli-
teal artery aneurysm. Cochrane Rev. 2014.
• At the time of publication, only one randomized con-
trolled trial compared endovascular stent-grafting with
conventional open surgery for unilateral or bilateral repair
of asymptomatic popliteal artery aneurysm (n = 15 in each
group). Given no clear difference in patency rates after 1
and 4 years between the two groups, it was concluded that
endovascular repair of popliteal artery aneurysm should
be a viable alternative to open repair on a case-by-case
basis.
Eslami MH, Rybin D, Doros G, Farber A. Open repair of
asymptomatic popliteal artery aneurysm is associated with
better outcomes than endovascular repair. J Vasc Surg.
2015;61(3):663–9.
• At the time of publication, this was the largest retrospec-
tive comparative analysis demonstrating increased
 30 Peripheral and Visceral Artery Aneurysm 375

f­requency of major adverse limb events at 1 year with

endovascular repair compared to open repair.
Shahin Y, Barakat H, Shrivastava V. Endovascular versus
open repair of asymptomatic popliteal artery aneurysms: a
systematic review and meta-analysis. J Vasc Interv Radiol.
2016; 27:715–722.
• The authors concluded that although endovascular repair
is associated with shorter length of hospital stay, the rate of
12-month primary patency was better with open repair.
Additionally, there are superior perioperative outcomes
(graft occlusion and reintervention rate) with open repair.
Leake AE, Segal MA, Chaer RA, et al. Meta-analysis of
open and endovascular repair of popliteal artery aneurysms.
J Vasc Surg. 2017; 65(1): 246–56.
• At the time of publication, this study represented the larg-
est published analysis of popliteal artery aneurysms, dem-
onstrating that endovascular repair afforded fewer wound
complications and shorter length of stay, however, with the
cost of an inferior primary patency at 3 years.

Common Questions
What is the An average of 300 u (0.3 ml) of thrombin
average dose of will result in stasis within a PSA.
thrombin needed in
ultrasound-guided
thrombin injection
of PSA?
What is the There is currently no specified duration
appropriate of antiplatelet therapy. Various studies
duration of have described postoperative antiplatelet
antiplatelet therapy? therapy ranging from 3 weeks to lifelong
treatment.
(continued)
376 J. Chen and A. Ramjit

What is the The initial sudden onset abdominal or

“double rupture” chest pain associated with aneurysm
phenomenon rupture stabilizes secondary to temporary/
regarding visceral local tamponade. 6–96 hours later, sudden
arterial aneurysm onset cardiovascular collapse results due to
(VAA)? internal hemorrhage.
What is the Hypertension
most common
presentation
of renal artery
aneurysm?
Type II endoleak Geniculate artery
after popliteal
artery aneurysm
repair is secondary
to backflow from
what vessel?
What is Aneurysmal origin of an aberrant left
Kommerell’s subclavian artery in the setting of a right-­
diverticulum? sided aortic arch
Which type of False aneurysms, without all three layers of
aneurysm is more arterial wall, are more likely to rupture.
likely to rupture:
True or false
aneurysm (PSA)?

Further Reading
Alemany J, Görtz H, Schaarschmidt K. Peripheral arterial aneu-
rysms. In: Chang JB, editor. Textbook of angiology. New York:
Springer; 2000.
Bajzer CT. Arterial supply to the upper extremities. In: Bhatt DL,
editor. Guide to peripheral and cerebrovascular intervention.
London: Remedica; 2004.
Dawson J, Fitridge R. Update on aneurysm disease: current insights
and controversies: peripheral aneurysms: when to intervene – is
rupture really a danger? Prog Cardiovasc Dis. 2013;56(1):26–35.
 30 Peripheral and Visceral Artery Aneurysm 377

Eslami MH, Rybin D, Doros G, et al. Open repair of asymptomatic

popliteal artery aneurysm is associated with better outcomes
than endovascular repair. J Vasc Surg. 2015;61(3):663–9.
Gupta PN, Basheer AS, Sukumaran GG, et al. Femoral artery pseu-
doaneurysm as a complication of angioplasty. How can it be
prevented? Heart Asia. 2013:144–7.
Hall HA, Minc S, Babrowski T. Peripheral artery aneurysm. Surg
Clin N Am. 2013;93:911–23.
Joshi D, James RL, Jones L. Endovascular versus open repair of
asymptomatic popliteal artery aneurysm. Cochrane Database
Syst Rev. 2014;(8):CD010149.
Leake AE, Segal MA, Chaer RA, et al. Meta-analysis of open and
endovascular repair of popliteal artery aneurysms. J Vasc Surg.
2017;65(1):246–56.
Lovegrove RE, Javid M, Magee TR, et al. Endovascular and open
approaches to non-thrombosed popliteal aneurysm repair: a
meta-analysis. Eur J Vasc Endovasc Surg. 2008;36:96–100.
Mohan IV, Stephen MS. Peripheral arterial aneurysms: open or
endovascular surgery? Prog Cardiovasc Dis. 2013;56(1):36–56.
Neglén P, Tackett TP Jr, Raju S. Venous stenting across the inguinal
ligament. J Vasc Surg. 2008;48(5):1255–61.
Open versus endovascular repair of popliteal artery aneurysm trial.
Available from: https://clinicaltrials.gov/ct2/show/NCT01817660.
NLM identifier: NCT01817660. Accessed 31 Aug 2018.
Patel SR, Hughes CO, Jones KG, et al. A systematic review
and meta-analysis of endovascular popliteal aneurysm repair
using the Hemobahn/Viabahn stent-graft. J Endovasc Ther.
2015;22(3):330–7.
Ronchey S, Pecoraro F, Alberti V. Popliteal artery aneurysm repair in
the endovascular era. Medicine (Baltimore). 2015;94(30):e1130.
Shahin Y, Barakat H, Shrivastava V. Endovascular versus open
repair of asymptomatic popliteal artery aneurysms: a systematic
review and meta-analysis. J Vasc Interv Radiol. 2016;27:715–22.
Uflacker R. Atlas of vascular anatomy, an angiographic approach.
Philadelphia: Lippincott Williams & Wilkins; 2007.
Wissgott C, Lüdtke CW, Vieweg H, et al. Endovascular treatment of
aneurysms of the popliteal artery by a covered endoprosthesis.
Clin Med Insights Cardiol. 2014;8(Suppl 2):15–21.
Chapter 31
Hemodialysis Access
Interventions
Rana Rabei

Evaluating Patient
What are the important Life goals and life expectancy,
factors to consider in timing and length of HD therapy,
vascular access selection? comorbidities, and risk of access-­
related complications
What is the appropriate Duplex ultrasound
imaging modality for
vascular access patency
surveillance?
What are the clinical Pulsatile flow, absent or weak thrill,
findings suggestive of low flows during dialysis, prolonged
vascular access failure? bleeding after needle removal, and
increased venous pressures
What clinical finding Ipsilateral arm, chest wall, or facial
suggests central venous edema
stenosis?

R. Rabei (*)
UCSF Interventional Radiology, San Francisco, CA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 379

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_31
380 R. Rabei

High Yield History

What is the Over 650,000 annually in the United States
prevalence of
ESRD?
What are the two Central venous catheters, referred to as
major categories “temporary” access, and arteriovenous
of HD vascular access, referred to as “permanent” access
access?
What is the Autologous AVF due to better patency rates
preferred mode of and lower rates of infection, associated with
access for HD? lowest mortality rates and lowest rates of
re-intervention compared to AVG and CVC
What is the A collaborative quality improvement
significance of initiative between with the Centers for
Fistula First Medicare and Medicaid Services (CMS)
Initiative? and the ESRD Network that began in 2003
to increase AVF use among hemodialysis
patients

Indications/Contraindications
When is placement of non-­ Temporary dialysis access for acute
tunneled catheters for HD HD needs, not recommended for
indicated? use longer than 1 week
What are indications for Clinical signs of graft dysfunction,
fistulogram? decreased intra-access blood
flow during hemodialysis, and
evaluation of non-maturing fistulas
When is angioplasty of A stenosis causing greater than
dialysis graft or fistula 50% reduction in luminal diameter
indicated? and clinical indicator of graft
failure
What are the procedures Surgical thrombectomy and
available to salvage a endovascular catheter-directed or
thrombosed fistula? mechanical thrombectomy
 31 Hemodialysis Access Interventions 381

Why is stent use limited in Relative high complication rates

treatment of AVF or AVG including stent migration, fracture,
stenosis? and infection
What are the relative Severe contrast allergy and
contraindications for coagulopathy
endovascular access site
interventions?
What is an absolute Active infection
contraindication for venous
access intervention?

Relevant Anatomy
What are the common sites Wrist/forearm, radiocephalic;
of AVF formation? upper arm, brachiocephalic or
brachiobasilic
What are the common sites Forearm, brachiocephalic (looped);
for AVG formation? upper arm, brachiobasilic or
brachioaxillary
What is the first choice for Radiocephalic, due to relative
AVF access? lower rates of steal syndrome and
preservation of future opportunities
for more proximal fistulas
What is the most Juxta-anastomotic segment
common site of stenosis
in a radiocephalic dialysis
fistula?
What is the most common Cephalic arch stenosis
site of stenosis in a
brachiocephalic dialysis
fistula?
What is the most common Proximal swing segment
site of stenosis in a
brachiobasilic dialysis
fistula?
(continued)
382 R. Rabei

What is the most common Venous anastomotic stenosis

site of stenosis in a dialysis
graft?

Relevant Materials
What is the Percutaneous transluminal angioplasty
preferred method (PTA)
of intervention for
graft stenosis?
What are the High-pressure noncompliant balloons.
preferred types of Less commonly cutting balloons and drug-­
balloons for PTA of coated balloons (DCBs). High-pressure
stenotic lesions? PTA and cutting balloons are popular in
in-stent restenosis. Recent data supports
use of DCBs in recurrent (< 90 days)
stenoses or stenoses involving the swing
segment or cephalic arch.
What is the Self-expanding covered stents
recommended stent
type in salvage AV
access procedures?
What are the two Ellipsys and WavelinQ EndoAVF which
FDA-approved use thermal energy to fuse arterial and
endovascular AVF venous walls and create a percutaneous
devices on the anastomosis
market?

General Step by Step

What imaging Ultrasound
modality is useful
to determine
optimal access site
for fistulogram?
 31 Hemodialysis Access Interventions 383

What is the Anterograde puncture toward the venous

most common outflow, just beyond the arterial anastomosis
access point for
fistulogram?
What areas should Entire access including arterial anastomosis,
be evaluated fistula or graft, outflow veins including vena
by diagnostic cava, and right atrium
fistulogram?
What angiography Presence of significant venous collaterals
finding is
suggestive
of significant
upstream
obstruction?
What is the utility Treatment of arterial or venous spasms
of nitroglycerin in
fistulography?
What is the basic Angioplasty catheter is inserted over
technique of guidewire and positioned across the lesion.
PTA for stenotic Balloon is then inflated until a waist is
lesions? visualized and eliminated. The balloon size
is chosen based on visual estimation of the
diameter of the vessel.
What is a Increased luminal diameter, visualization
successful and elimination of waist angiographically,
angioplasty improved physical exam, and resolution of
procedure? clinical symptoms
What factors The diameter, length and location of lesion,
should be and availability of surgical options
considered in
stenting stenotic
lesions that fail
PTA?
What medication 5000 U of heparin and/or tissue plasminogen
is typically given activator (tPA)
during declot
procedure?
(continued)
384 R. Rabei

What are Balloon maceration of clot, infusion of

examples of declot access with thrombolytic agents, catheter-­
techniques? directed thrombectomy and thrombolysis
using devices such as Arrow-Trerotola
percutaneous thrombolytic device (PTD)
(Arrow International, a division of Teleflex,
Durham, NC), AngioJet Peripheral
Thrombectomy System (Boston Scientific,
Natick, MA), and Trellis-8 peripheral
infusion system (Covidien, Mansfield, MA)
What is a common Advancing a Fogarty balloon (Edwards
technique for Lifesciences; Irvine, California) through
addressing arterial the retrograde sheath across the arterial
anastomotic anastomosis. Inflating the balloon and
stenosis/plug? pulling back across the arterial anastomosis
into the access

Complications
What is the most common Infection
complication of CVC?
What is the management Obtain cultures, perform appropriate
for CVC infection? antibiotic therapy, and catheters
should be removed and replaced at a
different site.
What are possible Angioplasty-induced rupture (2–3%),
complications of PTA bleeding from access site, persistent
treatment of failing stenosis, and embolism
fistula?
What is steal syndrome? Low blood flow or ischemia to the
extremity occurring due to flow into
the fistula
 31 Hemodialysis Access Interventions 385

Landmark Research
Young, et al. The Dialysis Outcomes and Practice Patterns
Study (DOPPS): An international hemodialysis study. Kidney
International. 2000; 57(74):S-74–S-81.
• DOPPS is an international prospective observational
study of hemodialysis patients which began in 7 countries
including the United States and has since expanded to 12
countries. This study aims to identify practice patterns
associated with the best outcomes over time.
• DOPPS demonstrated that dialysis patients have a higher
mortality in the United States compared to Japan and
Europe which has been attributed to differences in prac-
tice patterns, particularly the type of vascular access at
initiation of dialysis and length of dialysis sessions.
Astor B C, Eustace J A, Powe N R, Klag M J, Fink N E,
Coresh J, CHOICE Study Type of vascular access and sur-
vival among incident hemodialysis patients: the Choices for
Healthy Outcomes in Caring for ESRD (CHOICE) Study. J
Am Soc Nephrol. 2005;16 (5):1449–1455.
• CHOICE is a longitudinal observational cohort study of
1041 incident dialysis patients funded by AHRQ to mea-
sure several aspects of patients’ experiences and outcomes
related to modality of renal replacement therapy.
• Survival rates stratified by the type of access in use dem-
onstrated annual mortality rates of 11.7% for AVF, 14.2%
for AVG, and 16.1% for CVC. Adjusted relative hazards
(RH) of death compared with AVF were 1.5 for CVC and
1.2 for AVG. These results strongly support existing clinical
practice guidelines that the use of venous catheters should
be minimized to reduce the complications and to improve
patient survival.
Lok CE, Huber TS, Lee T, et al.; KDOQI Vascular Access
Guideline Work Group. KDOQI clinical practice guideline
for vascular access: 2019 update. Am J Kidney Dis. 2020;75
(4)(suppl 2):S1–S164.
386 R. Rabei

• The latest evidence-based hemodialysis vascular access

guidelines provided by the multidisciplinary workgroup of
the National Kidney Foundation’s Kidney Disease
Outcomes Quality Initiative (KDOQI).
• The 2019 update introduces the concept of ESRD Life-­
Plan, recommending a comprehensive evaluation of
patient’s needs and preferences and developing a contin-
gency plan on how to deal with vascular access complica-
tions during the initial planning of the first access. The
benefits of this patient-centered approach are preserving
vessels for future AV access, avoiding unnecessary proce-
dures, and limiting complications
Rajan DK, Ebner A, Desai SB, Rios JM, Cohn
WE. Percutaneous creation of an arteriovenous fistula for
hemodialysis access. J Vasc Interv Radiol. 2015;26
(4):484–490.
• Nonrandomized prospective study to evaluate safety and
efficacy of percutaneous system for creating AVF in dialy-
sis patients. The primary endpoints were successful cre-
ation of patent AVF, maturation over time, and adverse
events.
• 32 of 33 patients had successful AVF creation, cumulative
patency at 6 months was 96%, mean time to maturation
was 58 days, and there was one series procedure-related
adverse event.
Lok CE, Rajan DK, Clement J, et al.; NEAT Investigators.
Endovascular proximal forearm arteriovenous fistula for
hemodialysis access: results of the prospective, multicenter
Novel Endovascular Access Trial (NEAT). Am J Kidney Dis.
2017; 70 (4): 486–497.
• Prospective, single-arm, multicenter study to evaluate
safety, efficacy, patency, and adverse effects of endovascu-
lar AVF creation.
• 80 patients enrolled, 98% with successful AVF creation,
8% had a serious procedure-related adverse event, func-
tional usability was 64% in participants who received
 31 Hemodialysis Access Interventions 387

dialysis, 12-month primary patency was 69%, and cumula-

tive patency was 84%.
Haskal ZJ, Trerotola S, Dolmatch B, Schuman E, Altman S,
Mietling S, Berman S, McLennan G, Trimmer C, Ross J,
Vesely T. Stent graft versus balloon angioplasty for failing
dialysis-access grafts. N Engl J Med. 2010 Feb 11;362
(6):494–503.
• Prospective, single-arm, multicenter trial to evaluate safety
and 6-month arteriovenous graft patency in patients with
venous anastomotic stenosis following balloon angioplasty
or stenting.
• Patients who underwent stenting had significantly greater
rates of patency at the site of the anastomotic stenosis and
overall patency of the access circuit at 6 months with
equivalent rates of adverse events.

Common Questions
What is a mature Fistula that can be repetitively
fistula? cannulated and provide adequate blood
flow for dialysis
How long does it 4–6 weeks
take for a fistula to
mature?
What does primary Duration of access patency from the
patency refer to? date of vascular access creation/insertion
to thrombosis or any intervention to
facilitate, maintain, or re-establish
patency
What is the primary Stenosis with subsequent thrombosis
complication that
leads to graft failure?
(continued)
388 R. Rabei

What is the Intimal hyperplasia as a result of injury

underlying cause of of the endothelium by surgical or
access stenosis? hemodynamic stress leading to reduction
of lumen size
What is the fistula AVFs typically mature by 6 weeks post
rule of 6 s? creation, should have a diameter of
6 mm, be less than 6 mm below the skin
surface, and have a flow rate greater than
600 ml/min.
What is the life 3–7 years compared to 1–2 years
expectancy of
autologous fistula
compared to graft?

Further Reading
ACR-SIR practice parameters for endovascular management of
thrombosis or dysfunctional dialysis access. 2017. Available from:
https://www.acr.org/-­/ media/ACR/Files/Practice-­Parameters/
Dysfunc-­DialysisMgmt.pdf?la=en.
Daugirdas JT, et al. K1DOQI clinical practice guideline for hemodi-
alysis adequacy: 2015 update. AJKD. 2015;66(5):884–930.
El Kassem M, et al. The role of endovascular stents in dialysis access
maintenance. Adv Chronic Kidney Dis. 2015;22(6):453–8.
Lee T. Fistula first initiative: historical impact on vascular access
practice patterns and influence on future vascular access care.
Cardiovasc Eng Technol. 2017;8(3):244–54.
Quencer KB, Arici M. Arteriovenous fistulas and their characteristic
sites of stenosis. AJR Am J Roentgenol. 2015;205(4):726–34.
Sidawy AN, et al. The Society for Vascular Surgery: clinical practice
guidelines for the surgical placement and maintenance of arterio-
venous hemodialysis access. JVS. 2008;48(5 Suppl):2S–25S.
Chapter 32
Hybrid and Complex
Aortic Aneurysm
Endovascular Repair
Omosalewa Adenikinju, Sofia C. D. Vianna,
and Brandon P. Olivieri

Patient Evaluation
What preoperative CT angiogram (CTA) of the chest and/
imaging should be or abdomen and pelvis for chest and
obtained for planning? abdominal aortic pathology.
CTA of the head and neck for aortic
arch pathology. This aids in evaluating
the integrity of the circle of Willis,
observing vertebral dominance, as well
as identifying anatomic variants, which
dictate treatment approach.
What are the indications Dissection, acute aortic injury
for complex aortic involving the arch (i.e., rupture), or
repair? symptomatic or rapid growth of the
aneurysm, extending to involve branch
vessels or the proximal seal zone.
(continued)

O. Adenikinju (*) · S. C. D. Vianna · B. P. Olivieri

Department of Vascular and Interventional Radiology, Mount Sinai
Medical Center, Miami Beach, FL, USA

© Springer Nature Switzerland AG 2022 389

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_32
390 O. Adenikinju et al.

What factors are Patient factors: age > 65, renal failure,
important in stratifying CHF, and COPD
patients to undergo Surgical factors: unfavorable anatomy
hybrid thoracic aortic for open repair and unable to tolerate
aneurysm repair over circulatory arrest
open repair?
How is a complex hybrid Staging is appropriate when thoracic
aortic repair staged? and visceral or iliac artery treatments
are both needed or when a bypass
needs to be performed to maintain
branch vessel perfusion (carotid-­
subclavian or external-internal artery
bypass).
What are the advantages 1. Eliminate or decrease time
of thoracic aortic hybrid on extracorporeal membrane
procedures? oxygenation (ECMO) and
circulatory arrest
2. Decreased neurological
complications
3. Possibility of avoiding sternotomy
What are the 1. Risk of bypass thrombosis
disadvantages of 2. Technically challenging overall,
thoracic hybrid especially in patients with
procedures? unfavorable anatomy, such as steep
angulation which makes graft
deployment difficult
3. Risk of interval aneurysmal
rupture between staged operative
interventions
What postoperative Blood pressure management:
factor makes staged  First stage (open repair): low
hybrid TEVAR ideal MAPs preferred postoperatively
over single-session in patients who have undergone
therapy? open repair with cardiopulmonary
bypass +/− hypothermia to prevent
postoperative bleeding
 Second stage (endovascular): high
MAPs preferred to prevent cord
ischemia
 32 Hybrid and Complex Aortic Aneurysm… 391

Relevant Anatomy

Complex Thoracic Aortic Aneurysm

Aortic Arch Variants

Arch type Branches (proximal to distal)

Normal arch 1. Brachiocephalic trunk
2. Left common carotid artery
3. Left subclavian
Bovine arch (10–20%) 1. Brachiocephalic trunk with left
common carotid artery
2. Left subclavian artery
Isolated vertebral 1. Brachiocephalic trunk
(2.5–6%) 2. Left common carotid artery
3. Left vertebral artery
4. Left subclavian artery
Aberrant right 1. Right common carotid artery
subclavian (0.6%) 2. Left common carotid artery
3. Left subclavian artery
4. Right subclavian artery

< 2 cm
> 2 cm

Type I Type II Type III

Types of Aortic Arch

• Type I: If the origins of all the great vessels arise within the
arc segment of the aortic arch subtended by the first paral-
lel reference line
• Type II: If the origins of all the great vessels are included
in the arc segment of the aortic arch subtended by the
second index line
• Type III: If the origins of all of the great vessels are
included in the arc segment of the aortic arch subtended
by the third index line
392 O. Adenikinju et al.

LCCA LSA

BCA Zone 2
Zone 1

Zone 3

Zone 0

Zone 4

What are the landing zones for Zone 0: Proximal to the right
thoracic aortic interventions brachiocephalic artery
(Preventza, Xydas)? Zone 1: Between the right
brachiocephalic and left
common carotid arteries
Zone 2: Between the left
common carotid and left
subclavian arteries
Zone 3: Proximal descending
aorta, distal to the LSA
Zone 4: Mid-descending aorta
Where is the aneurysm or Transverse arch and/or proximal
pathology located in a zone 0 thoracic aorta
repair?
Where is the aneurysm or Mid to distal arch +/− into the
pathology located in a zone 1 descending thoracic aorta
repair?
 32 Hybrid and Complex Aortic Aneurysm… 393

Complex Abdominal Aortic Aneurysm

What Neck length of < 15 mm, an aortic neck diameter of

defines a > 25 mm, and aortic neck angulation of ≥ 45° and
complex < 10 mm of infrarenal aorta free of aneurysm
AAA? Involvement of at least one of its visceral branches such
as renal, superior mesenteric, or celiac vessels
Crawford-type IV thoracoabdominal aortic aneurysm
(TAAA) aneurysm that extends from the 12th intercostal
space to the iliac bifurcation involving the visceral aortic
segment and the origins of the renal, superior mesenteric,
and celiac arteries (EVT type IV, etc.)

Crawford classification (TAAA 1986)

Type I Below the left subclavian artery to above renal arteries
Type II Below the left subclavian artery to aortic bifurcation
Type III 6th intercostal space to aortic bifurcation
Type IV 12th intercostal space to aortic bifurcation
Type V 6th intercostal space to above renal arteries

High Yield
What is the basic Creating a way to maintain perfusion
principle of complex of the great vessels after ligation/
thoracic hybrid repair? embolization of their origin at the
arch, followed by aortic stent graft
delivery to treat underlying pathology
Most purely endovascular Zone 4 (mid-descending aorta).
thoracic aortic repairs are Current investigations are underway
performed for pathology examining technical success and
most commonly in which safety of treating arch aneurysms
zone? and acute aortic injuries, including
dissections in zones 0–2.
What are the types The exclusively endovascular
of EVAR options for repairs are divided into parallel
complex aortic repair? and nonparallel grafts, based on the
orientation of the branched stents in
comparison with the main aortic grafts.
394 O. Adenikinju et al.

Endovascular Hybrid
Debranching
Parallel Nonparallel EVAR
chEVAR (chimney Fenestrated
aka snorkel)
Periscope or Branched
reverse chimney
Sandwicha EVAS (endovascular
aneurysm sealing)a
Reference: Hybrid Repair of Suprarenal Abdominal Aortic
Aneurysm: Antegrade Debranching with Endovascular Aneurysm
Repair
a
Denotes only in complex AAA repair

chEVAR

L renal artery

R renal artery Main aortic graft

Gutter
Ch Ch

Aorta

What is a Chimney or snorkeling is also known as chEVAR

chEVAR? and involves the placement of single or multiple
stents in parallel to the main aortic graft. In order
to maintain perfusion to the visceral vessels, these
stents begin in the parent vessel adjacent to the
edge or sealing zone of the main aortic graft and
extend into branch vessels, which would normally
be excluded by the main aortic graft.
 32 Hybrid and Complex Aortic Aneurysm… 395

What is a A “periscope” or “reverse chimney” technique

periscope describes the placement of the covered stent
graft? below the distal edge of the main aortic stent
graft. This facilitates the extension of the distal
seal zone in thoracoabdominal or abdominal
aneurysms.
When used in TEVAR, it is used to preserve the
LSA (Hakim).
What are the The “sandwich” technique involves the placement
characteristics of a covered stent positioned between two
of a sandwich aortic main body components in order to
EVAR? maintain side branch perfusion in mid-graft
position. Novel approaches have been described
utilizing a combination of chimney grafts and
periscopes with and without sandwiching the
grafts with a bridging graft in the treatment of
thoracoabdominal aneurysms (TAAA).
Which are the The parallel techniques are performed using a
advantages of variety of endografts and covered or uncovered
using parallel stents that are readily available “off-the-shelf”
endografts? and employed on urgent cases. When compared
to fenestrated and branched grafts (fEVAR)
techniques, parallel techniques are usually
cheaper and can be less time-consuming.
Additionally, these techniques can be used as a
“bail out” procedure in the setting of accidental
over stenting of visceral aortic branches during
conventional EVAR.
Which are the The major disadvantage of EVAR via parallel
disadvantages techniques (chEVAR) is the development of
of the parallel gutter leaks, a form of type I endoleak caused by
endografts? blood flow into the potential space between the
aortic wall and the multiple stent grafts. Gutter
leaks can also result in kinking, compression,
and eventual occlusion of one or multiple graft
components. Hakim et al. report resolution
of most type 1a endoleaks after TEVAR on
follow-up scans.
(continued)
396 O. Adenikinju et al.

How can Techniques that improve graft-aortic wall

risk of gutter apposition decrease the rate of gutter formation.
formation be These include the use of more conformable aortic
decreased? stent grafts, oversizing of the main aortic stent
graft, and avoiding multiple chimney grafts.
What Positioning the snorkeled or chimney grafts
increases the obliquely rather than parallel to the main aortic
risk of gutter endograft decreases aortic wall apposition at the
formation? seal zone, resulting in increased chance for gutter
formation.
What are Fenestrated grafts are composed of a main aortic
fenestrated endograft body that extends its proximal sealing
endografts? zone above the infrarenal segment. These grafts
have fenestrations or scallops corresponding to
excluded visceral vessels in order to maintain the
visceral perfusion.
Fenestrated endovascular aortic repair (fEVAR)
maximizes the interaction between the aortic
endograft and the aortic wall while maintaining
visceral perfusion.
Planned overlap between aortic endograft and
branch stents reduces the risk of component
separation, type III endoleaks, and protrusion of
branch stents into the main stent graft.
They are currently designed specifically for
each patient using CT data, requiring time for
construction. However, off-the-shelf varieties,
which contain fenestrations and scallops to treat
the majority of patient anatomies, are currently in
development.
Fenestrated endografts can also potentially be
created by the physician on the “back table” in a
customized manner.
What are the Fenestrated endografts have lower risk of
advantages of proximal endoleaks in juxtarenal aortic
fEVAR? aneurysms since they are free of gutters creating
better sealing. They present better results in
short- and long-term data when compared to
chEVARs. The specific radiopaque markers offer
guidance for optimal positioning.
 32 Hybrid and Complex Aortic Aneurysm… 397

What are the Most limitations are associated with the length
disadvantages of time needed to manufacture the customized
of fEVAR? fenestrated devices and higher cost. They are
not available “off-the-shelf” thus they are not
available in urgent settings.
What is a Branched endografts are composed of a main
branched body device with renal and visceral branches
endograft? that extend to maintain flow. Manufacturers
offer different devices with a wide variety of
attachments for the branch components. The
branched EVARs are currently Investigational
Device Exemption (IDE) in the United States,
though most of them are already approved in
Canada and Europe.
What are the Branched devices also known as directional
advantages branched devices are used mainly for treatment
of branched of TAAAs. They present as an “off-­the-­shelf”
EVAR? option to long-segment TAAAs (Crawford IV),
and are suitable for emergent or urgent cases.
Which are the The coverage of long-segment TAAAs with
disadvantages endografts is associated with higher rates of
of the spinal ischemia and its complications.
branched
EVARs?
What is an The endovascular aneurysm sealing system
EVAS? (Nellix EVAS; Endologix, Irvine, CA, USA)
consists of two balloon-expandable stents which
support the aorta flow channel which expands
from the non-aneurysmal aorta proximally to the
iliac arteries distally. Surrounding the endografts,
nonporous PTFE-­based endobags are filled using
biocompatible polyethylene glycol polymer,
adjusting the endobag to fit the aneurysm sac
lumen. This allows sealing of the aneurysm and
resists displacement. At the time of authorship,
the Nellix System is an investigational device as
part of the EVAS2 study, in the United States.
(continued)
398 O. Adenikinju et al.

How much Thoracic endograft stent is oversized 0–20%

do the stent based on the pathology (i.e., aneurysm, dissection,
grafts need to trauma)
be oversized? Chimney stent graft sizing is based on the type of
graft:
 Self-expanding stent graft: oversized 0–20%
relative to the diameter of the branch vessel
(e.g., Gore Viabahn (W.L. Gore & Associates,
Flagstaff, AZ))
 Balloon-expandable stent graft: oversized
0–5% (e.g., Atrium iCast)
Which type Balloon-expandable stent grafts have higher
of chimney radial force when compared to self-expanding
stent grafts is stents, and thus have lower rates of reported
preferred? occlusion. However, it must be kept in mind
that the type of stent used is highly operator
dependent, in the context of chEVAR, since it is
considered an off-label procedure.
What is Ascending aortic hemiarch graft with proximal
a Dacron branch trifurcation anastomosis to the great
elephant vessels (simulating takeoff from a conventional
trunk graft three-vessel arch)
(ETG)? Frozen elephant trunk procedure is a surgical
option, which allows single-stage repair by
placing antegrade endovascular ETG in the
descending aorta under direct visualization
during hypothermia (Preventza, 2013).
What is the Serves as anchor for adjunct stent graft and
advantage prevents proximal endoleak
of using an
ETG?
How is 1. Four radiopaque clips at distal periphery of the
the ETG graft
identified 2. Pacing wires hang from the distal aspect of the
during the graft
second stage
endovascular
repair?
 32 Hybrid and Complex Aortic Aneurysm… 399

Indications/Contraindications
If proximal landing Zone 0 hybrid repair with Dacron
zone is <2 cm with the graft placement for landing zone
ascending aorta, what
approach is indicated?
What is the indication Unable to rebuild proximal landing
for elephant trunk zone in an aneurysmal ascending
technique? (zone 0) and descending aorta
pathology
What is the difference Pathology affecting zone 0 likely
in treatment strategy requires a sternotomy with
between pathology debranching as it must be repaired
affecting aortic zone with either open aortic arch
0 and aortic zones 1 replacement or a hybrid procedure
through 3? (i.e., elephant trunk followed by
TEVAR). Pathology affecting zones
1 through 3 frequently can be treated
without a sternotomy or debranching
with extra-anatomic bypasses to the
cerebral vessels with subsequent
TEVAR (Xydas et al.).
During zone 2 repair, Dominant left vertebral artery or
the left subclavian artery absent right VA
is not always preserved. Patent left LIMA-LAD bypass
What are the absolute Left AVF/AVG for hemodialysis
indications for LSA
revascularization?
What are the relative Prior LUE ischemia
indications for LSA Risk of spinal cord ischemia due to
revascularization? large stent graft (thyrocervical trunk
feeds anterior spinal artery)
400 O. Adenikinju et al.

General Step by Step

What are the Open: Vascular cutdown to the upper extremity or
various arterial femoral arteries or retroperitoneal aortic exposure
access options Minimally invasive:
that can be  Femoral: US-guided standard Seldinger
performed for technique followed by percutaneous
intervention? arteriotomy closure device (i.e., ProGlide
Abbott Vascular, Redwood City, CA)
 US-guided standard Seldinger technique for
brachial access
If a patient has When the device requires 24–26F access sheaths
small-­caliber
external iliac
arteries, when
should a
retroperitoneal
exposure be
considered?
What are The minimal vessel diameter must accommodate
the access on one side a conventional femoral approach
requirements 16–22F (for the main aortic device).
to perform The contralateral femoral access minimal sheath
a parallel size is highly variable by manufacturer and
grafting endograft type.
technique? For the visceral vessel to be stented, an additional
access for a 6–8 Fr sheath is typically required,
targeted at the vessel of interest.
What steps Determining if the access arteries will
must be accommodate large sheaths.
considered Prospective planning is needed to determine if
when planning exclusive percutaneous approach will be possible
complex aortic (availability of 2 femoral arteries +1 or 2 upper
repair? extremity) or surgical conduit needed.
Use of simulators or 3D printed models is growing
in order to attempt to decrease procedural time
and complications.
Meticulous analysis of measurements and
aneurysm characteristics: proximal neck length,
diameter, mural calcification, presence of
thrombus, and angulation.
 32 Hybrid and Complex Aortic Aneurysm… 401

Complex Abdominal Aortic Aneurysm (AAA)

What additional step Plan cannulation of the contralateral
must be accounted for gate.
during preoperative
AAA repair planning
after the main body is
deployed?
How are the abdominal The deployment of the main body and
aortic endografts iliac branched endografts is specific to
deployed? each manufacturer. However, once the
snorkeled/chimney stents are in place in
the visceral vessels, balloons are inflated
at the same time in a kissing balloon
fashion to form the final configuration.
What are the steps 1. Main aortic fenestrated graft (with
of a generic fEVAR visceral branch pre-cannulation or
procedure? nota)
2. Visceral branch covered stent
deployment
3. Distal bifurcated stent graft device
delivery
4. Iliac extension placement if needed
a
The aortic branch vessels can be pre-cannulated for alignment or
after the fenestrated device is placed for delivering the covered
stents

Complex TEVAR
Where is the 2 cm beyond the thoracic endograft in the
optimal position of ascending aorta and at least 2 cm within the
the chimney graft target vessel
in a TEVAR?
Where is the Beyond 2 cm of the endograft to decrease
optimal position of the chance of an endoleak
the periscope graft
in a TEVAR?
(continued)
402 O. Adenikinju et al.

What artery Left subclavian artery (LSA). If the landing

is targeted for zone is in zone 0 or 1, extra-anatomical
the side branch bypass is needed to revascularize the left
component common carotid artery (LCCA) and/or LSA.
of a branched
endograft with a
proximal landing
in zone 2?
What is the The GORE TAG Thoracic Branch
advantage of Endoprosthesis (TBE) can be deployed
having multiple via common femoral access only. However,
sites of access Hakim et al. advocate “through-and-­
when deploying a through” access where an exchange wire is
branched device? placed in the brachial artery (for zone 0 or
2 repair) or LCCA (in zone 1 repair) and
snared through the CFA to help deploy the
side branch, especially when the target vessel
is angulated or tortuous.

Hybrid: Open ± TEVAR

What are the steps of a zone 1 1. Carotid-carotid bypass
hybrid repair? anastomosis to mid left
subclavian artery:
 Alternative: Left carotid-­
subclavian bypass and then
snorkel LCCA as the stent
excludes the vessel
2. Occlude the left common
carotid artery and proximal
LSA.
3. Retrograde deployment of
endograft.
Why are the LSA and LCCA To prevent type 2 and type 1
ligated (or coiled) during zone 1 endoleaks, respectively
repair?
 32 Hybrid and Complex Aortic Aneurysm… 403

What are the steps of a zone 0 1. Left subclavian-carotid

hybrid repair? bypass
2. Debranching of LCCA and
assess for cerebral ischemia
via EEG with clamp test
3. Innominate artery
debranching
4. Retrograde or antegrade
deployment of endograft
How long is a typical clamp test 3 min
performed during a zone 1 hybrid
repair?
When a patient with an ascending Aortic wrapping with Dacron
aortic aneurysm cannot undergo graft (Preventza, 2013)
cardiopulmonary bypass,
what technique is utilized for
treatment?
What are the steps of a total 1. Modified Mt. Sinai
thoracic aortic aneurysm repair? technique: total arch
replacement + Dacron
elephant trunk
2. Snare pacing wires to
prevent intussusception
of endograft during
retrograde deployment of
endograft

Relevant Materials
What intraoperative Cardiopulmonary bypass
support/monitoring Spinal cord motor and sensory
can be used in complex neurophysiologic monitoring
aortic hybrid repairs? Transesophageal echocardiography
Electroencephalography (EEG) to
monitor for signs of ischemic infarction
during arch debranching (Zone 0
repair)
(continued)
404 O. Adenikinju et al.

During hemiarch Deep hypothermic circulatory arrest

replacement, what may with either selective antegrade cerebral
be used to maintain perfusion (SCAP) or retrograde
cerebral perfusion? cerebral perfusion (Preventza, 2013)
How is perfusion An arterial cannula allows bypass flow
maintained with thru an 8 or 10 mm Dacron graft that is
SCAP? anastomosed to the right axillary artery
allowing antegrade cerebral flow.
How is perfusion Retrograde flow via bypass cannula
maintained in RCP? in the SVC with goal central venous
pressure of less than 20 mmHg.
What periprocedural ECMO. During in situ fenestration
support is needed if (ISF) via laser or ablation techniques,
multiple fenestrations ECMO can be avoided if single-vessel
are planned during ISF is performed promptly by an
TEVAR? experienced operator.
When is preoperative Ideally, a preoperative lumbar drain is
lumbar drain placement placed in every TEVAR case, especially
indicated (Chisea)? in the setting of:
 1. Planned coverage of parent
intercostal artery giving rise to the
Adamkiewicz artery
 2. Long-segment endograft spanning
the native aortaa
 3. Early postoperative spinal cord
ischemia symptomatology
 4. Previous or concomitant repair of
infrarenal aorta
 5. Occlusion the internal iliac arteries
(reduced collaterals)
 6. When the segment treated includes
the thoracic aortic
 7. Coverage of the left subclavian
artery origin without
revascularization
 8. Renal failure
a
The length of the aortic segment treated is the most significant risk
factor for the occurrence of spinal ischemia (The longer the seg-
ment, the higher the risk)
 32 Hybrid and Complex Aortic Aneurysm… 405

Devices

Branch
Thoracoabdominal Abdominal Both stents
GORE TAG, Zenith GORE Atrium
C-TAG Fenestrated EXCLUDER iCast
(W.L. Gore and [ZFEN] (Cook Thora­ (Atrium
Assoc., Flagstaff, Medical, coabdominal Medical,
AZ) Bloomington, Branch Hudson,
IN) Endoprosthesis NH, USA)
(TAMBE)
(W.L. Gore and
Assoc., Flagstaff,
AZ)
Medtronic Talent Nellix EVAS Cook Zenith Gore VBX
(Medtronic, Santa (Endologix, t-Branch (W.L. Gore,
Rosa, CA) Irvine, CA, (Cook Medical, Flagstaff,
USA) Bloomington, AZ, USA)
IN)
Arch Branch GORE Cook Zenith
(IDE) (Cook EXCLUDER p-Branch
Medical, Iliac Branch (Cook Medical,
Bloomington, IN, Endoprosthesis Bloomington,
USA) (IDE) IN)
(W.L. Gore
and Assoc.,
Flagstaff, AZ)
Zenith Alpha
(Cook Medical,
Bloomington, IN,
USA)
Zenith TX2
(Cook Medical,
Bloomington IN)
Relay stent-graft
(Terumo Aortic,
Sunrise, Fla)
406 O. Adenikinju et al.

What imaging is performed for CTA: 1, 6, 12 months, and yearly

postoperative surveillance? US Doppler of fenestrated
target visceral arteries 1, 6, and
12 months
What medications are Plavix for 3 months and aspirin
prescribed status post complex for lifetime
aortic repair?
What should the clinical exam Neurological: paresthesias,
focus on after complex aortic paralysis, and stroke
repair? Cardiac: risk of perioperative
myocardial infarction (< 30 days
post-op)
Renal: function

Complications
What complications Paraplegia (Brat, 2018) and myocardial
are seen with complex infarction
hybrid thoracic aortic
repairs?
What are the mortality Up to 30% (Brat, 2018)
rates associated with Although, Zhao et al. and Kawaharada
complex hybrid thoracic report rates as low as 4–6% after
aortic repairs? stented elephant trunk graft (ETG)
What are the most Stroke and retrograde type A dissection
common post-op
complications after zone
0 hybrid repair?
What is the most Retrograde type A dissection (RTAD)
common cause of death
after zone 0 hybrid
thoracic aortic repairs?
 32 Hybrid and Complex Aortic Aneurysm… 407

What are the risk factors Native: Aneurysmal ascending aorta

of RTAD? and existing dissection.
Iatrogenic: clamp injury during
debranching and device injury.
Environmental change: alternate
anatomy leads to hemodynamic change
of blood flow and tissue mismatch
between graft and native aorta.
What eliminates the risk Use of Dacron ascending aortic
of retrograde type A graft. Stent-assisted coil placement
dissections? (SACP) decreases the risk of RTADs
and neurological complications after
complex thoracic aortic repairs (Xydas,
2015).
Which complex thoracic Zone 0; 1-year survival is similar for all
repair is associated with types of repair however at ~25%.
highest mortality at
30 days?
What is the most Type 2 (Brat, 2018)
common type of
endoleak after ETG
complex thoracic repair?
What is the most Hakim et al. report type 1c, which they
common type of treat with coil embolization. However,
endoleak with fEVAR? according to the Zenith trial, which
examined only ZFEN stent grafts, no
endoleaks were reported in that study.

Landmark Research
Andersen ND, Williams JB, Hanna JM, Shah AA, McCann
RL, Hughes GC. Results with an algorithmic approach to
hybrid repair of the aortic arch. Journal of Vascular Surgery.
2013;57(3):655–667. https://doi.org/10.1016/j.jvs.2012.09.039
• This study demonstrated ascending aorta zone 0 endograft
placement to be a univariate predictor of 30-day in-­
408 O. Adenikinju et al.

hospital mortality after complex hybrid thoracic aortic

repairs.
• Developed an algorithm for stratifying complex thoracic
aortic repair. The study examined 87 patients who under-
went zone 1 endograft coverage with extra-anatomic left
carotid revascularization (n = 19), zone 0 endograft cover-
age with aortic arch debranching (n = 48), or total arch
replacement with staged stented elephant trunk ­completion
(n = 20). Their data demonstrated high rates of retrograde
type A dissections leading to higher 30-day periprocedural
mortality in patients who had grafts placed in zone 0.
• Currently, there is no FDA-approved thoracic endograft
for labeled use in zone 0. Current investigations are under-
way examining the effectiveness and safety of novel tho-
racic endografts in zones 0–2.

Which chEVAR registry The Pericles Registry (898 chimney

observed the most grafts) observed intraoperative type Ia
common endoleak type endoleak in 41 patients (7.9%), which
in the intraprocedural only remained present in 2 patients
setting, as well as the on follow-up imaging. Intraoperative
factors associated with type Ia endoleak can be minimized
it? with landing zone >20 mm, prolonged
kissing balloon inflation, or additional
cuff placement.
Which publication Yu Lie et al. – Systematic review and
contains the most pooled data analysis of FEVAR vs.
extensive data analysis chEVAR compared outcomes for
comparing outcomes of juxtarenal aortic aneurysms (JAA)
FEVAR vs. chEVAR? for endoleak type I (3.7–7.6%), 30-day
mortality (1.1% vs. 3.8%), and all-­
cause mortality (6.46% vs. 13.3%).
 32 Hybrid and Complex Aortic Aneurysm… 409

Further Reading
AbuRahma AF, Campbell J, Stone PA, et al. The correlation of
aortic neck length to early and late outcomes in endovascular
aneurysm repair patients. J Vasc Surg. 2009;50(4):738–48. https://
doi.org/10.1016/j.jvs.2009.04.061.
Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL,
Hughes GC. Results with an algorithmic approach to hybrid
repair of the aortic arch. J Vasc Surg. 2013;57(3):655–67. https://
doi.org/10.1016/j.jvs.2012.09.039.
Al-Hakim R, Schenning R. Advanced techniques in thoracic
endovascular aortic repair: chimneys/periscopes, fenestrated
endografts, and branched devices. Tech Vasc Interv Radiol.
2018;21(3):146–55. https://doi.org/10.1053/j.tvir.2018.06.004.
Bajzer CT. Thoracic aorta and the great vessels. In: Bhatt DL,
editor. Guide to peripheral and cerebrovascular intervention.
London: Remedica; 2004. https://www.ncbi.nlm.nih.gov/books/
NBK27419/. Accessed August 22, 2019.
Brat R. Chapter 32 – Hybrid techniques for complex aortic surgery.
In: Ţintoiu IC, Ursulescu A, Elefteriades JA, Underwood MJ,
Droc I, editors. New approaches to aortic diseases from valve to
abdominal bifurcation. Academic Press; 2018. p. 373–82. https://
doi.org/10.1016/B978-­0-­12-­809979-­7.00032-­8.
Chiesa R, Tshomba Y, Melissano G, Logaldo D. Is hybrid procedure
the best treatment option for thoraco-abdominal aortic aneu-
rysm? Eur J Vasc Endovasc Surg. 2009;38(1):26–34. https://doi.
org/10.1016/j.ejvs.2009.03.018.
Choo XY, Hajibandeh S, Hajibandeh S, Antoniou GA. The Nellix
endovascular aneurysm sealing system: current perspectives.
Med Devices (Auckl). 2019;12:65–79. https://doi.org/10.2147/
MDER.S155300.
Endovascular Today. Global experience with the Zenith p-branch
device. Endovascular Today. https://evtoday.com/2015/11/sup-
plement/global-­experience-­with-­the-­zenith-­p-­branch-­device/.
Accessed July 21, 2019.
Endovascular Today. True long-term results: what have we learned?
Endovascular Today. https://evtoday.com/2017/03/true-­long-­
term-­results-­what-­have-­we-­learned/. Accessed July 21, 2019.
Endovascular Today. Two-year data from EVAS FORWARD
IDE trial presented for Endologix’s Nellix EVAS system.
Endovascular Today. https://evtoday.com/2017/05/two-­year-­data-­
410 O. Adenikinju et al.

from-­evas-­forward-­ide-­trial-­p resented-­for-­e ndologixs-­nellix-­

evas-­system/. Accessed July 21, 2019.
Endovascular Today. Type IV thoracoabdominal aneurysms: what’s
next? Endovascular Today. https://evtoday.com/2012/03/type-­iv-­
thoracoabdominal-­aneurysms-­whats-­next/. Accessed August 19,
2019.
Ganzel BL, Edmonds HL, Pank JR, Goldsmith LJ. Neurophysiologic
monitoring to assure delivery of retrograde cerebral perfu-
sion. J Thorac Cardiovasc Surg. 1997;113(4):748–57. https://doi.
org/10.1016/S0022-­5223(97)70234-­4.
Itagaki MW. Using 3D printed models for planning and guid-
ance during endovascular intervention: a technical advance.
Diagn Interv Radiol. 2015;21(4):338–41. https://doi.org/10.5152/
dir.2015.14469.
Kansagra K, Kang J, Taon M-C, et al. Advanced endografting
techniques: snorkels, chimneys, periscopes, fenestrations, and
branched endografts. Cardiovasc Diagn Ther. 2018;8(Suppl
1):S175–83. https://doi.org/10.21037/cdt.2017.08.17.
Kasipandian V, Pichel AC. Complex endovascular aortic aneurysm
repair. Contin Educ Anaesth Crit Care Pain. 2012;12(6):312–6.
https://doi.org/10.1093/bjaceaccp/mks035.
Kim MH, Shin HK, Park JY, Lee T. Hybrid repair of suprarenal
abdominal aortic aneurysm: antegrade debranching with endo-
vascular aneurysm repair. Vasc Specialist Int. 2014;30(4):151–4.
https://doi.org/10.5758/vsi.2014.30.4.151.
Kourliouros A, Vecht JA, Kakouros N, et al. Frozen elephant
trunk as an effective alternative to open and hybrid two-stage
procedures for complex aortic disease. Hellenic J Cardiol.
2011;52(4):337–44.
Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS. Bovine aortic
arch variant in humans: clarification of a common misnomer. Am
J Neuroradiol. 2006;27(7):1541–2.
Li Y, Hu Z, Bai C, et al. Fenestrated and chimney technique for
juxtarenal aortic aneurysm: a systematic review and pooled data
analysis. Sci Rep. 2016;6:20497. https://doi.org/10.1038/srep20497.
Oderich GS, Farber MA, Silveira PG, et al. Technical aspects and
30-day outcomes of the prospective early feasibility study
of the GORE EXCLUDER Thoracoabdominal Branched
Endoprosthesis (TAMBE) to treat pararenal and extent IV tho-
racoabdominal aortic aneurysms. J Vasc Surg. 2019;70(2):358–
368.e6. https://doi.org/10.1016/j.jvs.2018.10.103.
 32 Hybrid and Complex Aortic Aneurysm… 411

Patel RP, Katsargyris A, Verhoeven ELG, Adam DJ, Hardman

JA. Endovascular aortic aneurysm repair with chimney and
snorkel grafts: indications, techniques and results. Cardiovasc
Intervent Radiol. 2013;36(6):1443–51. https://doi.org/10.1007/
s00270-­0 13-­0648-­5.
Preventza O, Aftab M, Coselli JS. Hybrid techniques for complex
aortic arch surgery. Tex Heart Inst J. 2013;40(5):568–71.
Quatromoni JG, Orlova K, Foley PJ. Advanced endovascular
approaches in the management of challenging proximal aortic
neck anatomy: traditional endografts and the snorkel tech-
nique. Semin Intervent Radiol. 2015;32(3):289–303. https://doi.
org/10.1055/s-­0 035-­1558825.
Schanzer A, Simons JP, Flahive J, et al. Outcomes of fenestrated and
branched endovascular repair of complex abdominal and thora-
coabdominal aortic aneurysms. J Vasc Surg. 2017;66(3):687–94.
https://doi.org/10.1016/j.jvs.2016.12.111.
Tadros R, Safir SR, Faries PL, et al. Hybrid repair techniques for
complex aneurysms and dissections involving the aortic arch and
thoracic aorta. Surg Technol Int. 2017;30:243–7.
Xu J, Zhou Y, Guo J, et al. Mid- and long-term effects of endovas-
cular surgery and hybrid procedures for complex aortic diseases.
Biomed Res Int. 2019;2019(18):1–5. https://www.hindawi.com/
journals/bmri/2019/3247615/. Accessed July 21, 2019.
Xydas S, Mihos CG, Williams RF, et al. Hybrid repair of aortic arch
aneurysms: a comprehensive review. J Thorac Dis. 2017;9(Suppl
7):S629–34. https://doi.org/10.21037/jtd.2017.06.47.
 Part IV
Oncology
Chapter 33
Hepatic Interventional
Oncology
Seth I. Stein

Evaluating Patient
What are the most Depending on the primary indication
essential labs required to and procedure, common labs include
workup for possible liver-­ albumin, bilirubin, platelet count,
directed therapy? INR, alpha-fetoprotein (AFP),
carcinoembryonic antigen (CEA), and
eGFR.
What is the serum Bilirubin >3 mg/dL (if segmental
bilirubin level at which treatment can be performed, a higher
arterial embolotherapy bilirubin level may be acceptable)
is generally
contraindicated?
Why are hepatic Ischemic insult of the procedure can
embolotherapies worsen liver function.
avoided in patients with
diminished functional
liver reserve and liver
failure?
(continued)

S. I. Stein (*)
Department of Radiology, NewYork-Presbyterian Hospital, Weill
Cornell Medical Center, New York, NY, USA

© Springer Nature Switzerland AG 2022 415

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_33
416 S. I. Stein

How is lung shunt LSF is calculated by delivering

fraction (LSF) calculated Tc99m-MAA to the intended
and why is it relevant for treatment vessel during the mapping
TARE? angiographic procedure and
subsequently performing planar
nuclear scintigraphy and/or SPECT/
CT. Borderline (i.e., 10–20% LSF)
or elevated LSF may necessitate
dose reduction or preclude TARE
altogether. Absolute dose to the lung
>30 Gy per treatment or >50 Gy over
time is considered more relevant
to avoiding the risk of radiation
pneumonitis.
How is liver reserve/ The Child-Pugh scoring system
cirrhosis mortality utilizes clinical factors and laboratory
determined? values to estimate cirrhosis mortality:
 Useful for selecting the appropriate
liver-directed therapy.
 Factors include INR,
encephalopathy, bilirubin, albumin,
and ascites, which combine
to classify patients into three
categories:
   Class A = Score 5–6
   Class B = Score 7–9
   Class C = Score 10–15
 33 Hepatic Interventional Oncology 417

How is performance The ECOG (Eastern Cooperative

status classified? Oncology Group) performance status
is utilized to further classify patients
into the appropriate treatment option
based on the following scale (ECOG
0–2 is required for most interventional
treatments):
 ECOG 0 → Fully active
 ECOG 1 → Restricted in physically
strenuous activity. Able to do light
house or office work
 ECOG 2 → Self-care okay. No
work. Up/about >50% of waking
hours
 ECOG 3 → Limited self-care,
confined to bed or chair >50% of
waking hours
 ECOG 4 → Completely disabled.
No self-care. Confined to bed or
chair
 ECOG 5 → Dead
What is the BCLC The Barcelona Clinic Liver Cancer
staging system? (BCLC) staging system is a guideline
created for the staging of HCC,
considering the ECOG performance
status (PS), Child-Pugh (CP) staging,
and radiologic extent of disease.
What is the standard Three- or four-phase liver CT or
preprocedural imaging MRI to assess anatomy, extrahepatic
that should be performed tumoral supply, and presence of
before liver-directed ascites. Additional imaging may be
therapy? performed to exclude extrahepatic
disease.
418 S. I. Stein

High Yield History

What are the major Hepatitis B, hepatitis C, alcohol use,
risk factors for the NASH, hereditary liver diseases (e.g.,
development of HCC? hemochromatosis), and primary biliary
cirrhosis
What is the latency 1–3 decades
period of HCC?
What is the 3-year 28%
survival of HCC if
untreated?
After imaging A multidisciplinary team or tumor
evaluation is performed board consisting of hepatobiliary
confirming HCC or surgery, interventional radiology,
hepatic metastases, diagnostic radiology, radiation
which parties determine oncology, hepatology, medical
the appropriate oncology, and other specialties may be
treatment? involved in such cases.

Indications/Contraindications
What are the Milan 1 tumor ≤ 5 cm, or up to 3 tumors ≤ 3 cm
criteria for liver No vascular invasion
transplantation? No extrahepatic extension
What are the UCSF Higher threshold for transplantation
criteria? than Milan criteria
1 tumor ≤ 6.5 cm or 2 lesions ≤ 4.5 cm
with a total tumor diameter ≤ 8 cm
What are the main Favored for small isolated HCC (BCLC
indications for 0 and BCLC A disease).
percutaneous ablation? Data shows equivalent survival for
thermal ablation and surgical resection
in this group.
Resection is often preferred if tumor
is in a location difficult to get good
ablative margins (e.g., hepatic dome).
 33 Hepatic Interventional Oncology 419

What are the common Thermal and/or radiative ablation

reasons to perform is often utilized if mass is deemed
ablation over hepatic unresectable and there are poor liver
resection? function, multifocal disease/metastases,
or comorbidities negating surgical
treatment.
Ablation is less invasive, causes less
pain, and results in less complications, as
well as a shorter hospital stay.
Ablation can be performed as a bridge
to transplantation.
What areas are < 1 cm to a central bile duct, hepatic
generally avoided in dome or anterior exophytic lesions,
percutaneous ablation? adjacent to large high flow blood
vessels, near gastric and bowel tissue, or
near the gallbladder fossa
When is TACE utilized Treatment of unresectable disease,
in the treatment of including large tumors and multinodular
HCC? disease without evidence of vascular
invasion or extrahepatic spread
What are the common Advanced unresectable HCC with life
indications for TARE? expectancy > 3 months.
HCC with portal vein thrombosis.
Downstaging patients to resectable
disease (similar to TACE), particularly
in bilobar or multinodular disease
(> 5 tumors).
Increase functional liver reserve with
the goal of contralateral hypertrophy
prior to resection.
Radiation segmentectomy in early stage
disease.
Increasing use outside of HCC for
hepatic metastatic disease.
What are the Child-Pugh C disease with marginal
contraindications of hepatic reserve (serum bilirubin greater
TARE? than 3 mg/dL (except for segmental
injection)) and ECOG > 2
(continued)
420 S. I. Stein

When is TACE TARE not universally available in the

preferred over TARE? USA or worldwide
Patients susceptible to
radioembolization-induced liver disease
(REILD) or with hyperbilirubinemia
Tumor staining for thermal ablation
What is the benefit Added TACE to ablation in lesions
of adding TACE to larger than 3 cm, satellite tumors,
ablation? those in precarious location, poorly
encapsulated, or not well visualized on
US or CT can improve outcomes.
Tumor staining with Ethiodol improves
targeting for ablation.
Pre-ablation TACE increases ablation
zones by diminishing heat sink effect.
Results in overall improved survival in
tumors >5 cm.
Can targeted TARE is considered the best initial
therapies be used for intra-arterial locoregional therapy in
colorectal cancer liver treating CRC metastases. Drug-eluting
metastases? beads loaded with irinotecan (DEBIRI)
have also demonstrated improved
overall survival.
What is radiation Selective transcatheter delivery of Y-90
segmentectomy? is delivered to two segments or less,
with ablative intent

Relevant Anatomy
Why can arterial This is due to differences in the blood
embolization procedures supply to normal liver versus tumors.
be performed largely 80% of tumors are supplied by the
without causing liver hepatic artery. 70–75% of normal
necrosis and liver failure? liver parenchyma is supplied by the
portal vein.
 33 Hepatic Interventional Oncology 421

How is nontarget Patient positioning, general

anatomy protected during anesthesia with a paralytic to
percutaneous ablation? control breathing, chilled fluids
through biliary system, intentional
pneumothorax, intraperitoneal gas,
fluid, or balloons
Describe the normal The celiac trunk normally trifurcates
hepatic arterial branch into splenic, left gastric, and common
pattern from celiac trunk. hepatic arteries. The common hepatic
Approximately what artery then bifurcates into the
percentage of people have gastroduodenal artery and proper
this anatomy? hepatic artery. The proper hepatic
artery then gives rise to the left and
right hepatic arteries. The middle
hepatic artery, which supplies the
caudate lobe, most commonly arises
from either the left or right hepatic
artery, although in 10% of cases may
originate directly from the proper
hepatic artery.
(continued)
422 S. I. Stein

What are the most “Replaced” means the hepatic artery

frequently observed in its entirely arises from the variant
hepatic artery variants? origin, whereas “accessory” means
the hepatic artery is duplicated in
that there is a branch arising from the
normal origin, as well as an accessory
branch that arises from the aberrant
origin.
Common hepatic artery off aorta
or SMA, or trifurcation into right
hepatic, left hepatic, and GDA
Replaced left hepatic artery from left
gastric artery
Accessory left hepatic artery from
left gastric artery
Replaced right hepatic artery from
the SMA, celiac trunk, or aorta
Accessory right hepatic artery from
the SMA
A replaced or accessory right hepatic
artery typically originates from the
superior mesenteric artery, whereas
a replaced or accessory left hepatic
artery typically originates from the
left gastric artery.
Combinations of these variants occur,
for instance a patient may have
both replaced left and right hepatic
arteries, or may have a replaced
artery on one side and an accessory
artery on the other, although these
cases are exceedingly rare (<5%).
After multiple TACE Development of extrahepatic
procedures, what collateral vessels (i.e., right and
anatomical considerations left internal mammary, right and
are important to left inferior phrenic, right and left
consider? gastric arteries) is common (~25% of
TACE).
 33 Hepatic Interventional Oncology 423

How is cone-beam CT Accurate anatomic localization of

(CBCT) utilized during tumor-feeding arteries, following
hepatic arterial oncologic delivery of chemoembolic agent to
interventions? ensure adequate territorial coverage,
and to calculate of liver treatment
volumes for TARE
Why is mapping The mapping procedure is performed
procedure required to delineate tumoral blood supply.
prior to Y-90 Both celiac and SMA arteriograms
radioembolization? are performed, as well as selective
injections with or without the use of
cone-beam CT. Once the treatment
territory is confirmed, Tc99-MAA
is delivered via the microcatheter.
After the procedure, planar nuclear
imaging is performed to calculate
lung shunt fraction. SPECT/CT is
sometimes performed, and can be
used to assess for nontarget delivery
in the abdomen/pelvis.
What are the essential Cystic artery, right gastric
vessels to identify during artery, gastroduodenal artery,
the mapping procedure? pancreaticoduodenal arcade,
falciform artery, and any additional
feeders to hepatic tumors (i.e.,
inferior phrenic artery)

Relevant Materials
When is percutaneous This historical agent is an inexpensive
ethanol ablation option utilized for smaller tumors near
employed? heat-sensitive organs.
(continued)
424 S. I. Stein

How does RFA is a widely utilized method of

radiofrequency thermal ablation that induces coagulative
ablation (RFA) treat necrosis. Its survival benefit versus
tumors and what are ethanol ablation is most pronounced
its limitations? in tumors larger than 2 cm, and can be
used for tumors up to 3 cm. It has fallen
out of favor in some institutions due
to limitations of heat sink effect from
nearby vessels and the availability of
microwave ablation.
What is microwave Microwave ablation produces oscillation
ablation and what are of water molecules, friction, and thus
its benefits? very high temperatures, resulting in
coagulative necrosis in tumoral tissue. It
has replaced RFA in many institutions
because it can heat tissue faster, multiple
probes can be utilized simultaneously to
achieve larger ablation zones, and it is
less susceptible to heat sink effect.
How does Cycles of freezing and thawing disrupt
cryoablation work cell membranes of tumor cells (lysis)
and what are its inducing cell death. It is less painful
advantages? for patients than microwave ablation,
though it is less commonly utilized for
liver-directed therapy. The ablation zone
(ice ball) can be actively visualized on
intraprocedural imaging, helping to
confirm adequate coverage of the desired
treatment target.
What is a dreaded Cryoshock is an extremely rare
complication of complication of cryoablation caused
cryoablation? by cytokine release, which can lead to
disseminated intravascular coagulation
(DIC) and multi-organ failure.
 33 Hepatic Interventional Oncology 425

What is irreversible This is a nonthermal technique utilizing

electroporation high-energy electrical pulses to disrupt
(IRE) and when is it cell membranes and cause cell death.
utilized? IRE must be performed under anesthesia
with a neuromuscular blocking agent
and cardiac monitor to avoid muscle
contractions and arrhythmias. The benefit
is the ability to safely be utilized for
small tumors near blood vessels and bile
ducts due to its nonthermal mechanism
and lack of heat sink effect.
What is “bland Mechanical obstruction using
embolization”? embolic agent without the use of a
chemotherapeutic agent
What is ethiodized Embolic agent also utilized as a carrier
oil and why is it of chemotherapeutics
effective? Contains iodine, easily identified on
imaging
Attaches to the cancer cell membrane
of liver tumors and travels via the
peribiliary capillary plexus to the portal
branches, thereby depleting nutrient
supply to potential nonimaged satellite
lesions.
What is the typical Variable; single or multiple drug
chemotherapeutic regimens may be used. A common
dosing for regimen includes 50–100 mg cisplatin,
conventional TACE? 50–75 mg doxorubicin, and 10 mg
mitomycin C. The drugs are mixed with
contrast to improve visualization on
imaging and to stabilize the drug/oil
emulsion.
How much ethiodized The ratio of volume of drug to oil should
oil should be be 1:2.
administered in Ethiodized oil volume is tumor
TACE? dependent, typically less than 15 mL per
session.
(continued)
426 S. I. Stein

What should be Embolic material such as particles or gel

administered intra-­ foam prevents washout of ethiodized oil
arterially after from the treated zone.
chemotherapeutic/
ethiodized oil
emulsion?
What is DEB-TACE Drug-eluting beads lodge in small
and what are its tumoral arterioles, delivering a sustained
purported benefits release of chemotherapy.
over conventional Reduced liver toxicity and potential
TACE? systemic uptake.
Consistency and reproducibility of
treatment.

General Step by Step

What preprocedural CT or MRI within 2 weeks for colorectal
imaging should cancer metastases and 2–4 months for
ideally be performed HCC
prior to ablation
procedures?
What intraprocedural CT and ultrasound are most frequently
imaging is performed utilized for both probe/applicator
for ablation? placement and monitoring the ablation
zone. MRI can also be utilized if available
and probes are compatible. Ultrasound
and CT can be utilized to monitor ice ball
formation during cryoablation. After the
procedure, contrast-enhanced CT, MRI,
or ultrasound is performed to confirm
adequate ablation zone.
What are acceptable Circumferential ablation zone of 0.5 cm
ablative margins for for HCC and 1.0 cm for metastases
HCC and for liver
metastases?
 33 Hepatic Interventional Oncology 427

What microwave Synchronous ablation utilizing multiple

ablation technique overlapping probes
is utilized for larger
tumors or those with
insufficient margins?
How are ablation Monitored for pain and discharged with
patients typically pain medications.
monitored post-­ If necessary, the patient may be admitted
procedurally? overnight for pain control.
What medications Variable. Some use a combination of
may be given prior to antiemetics, steroids, diphenhydramine,
TACE? and/or antibiotics.
When are Controversial. Some prescribe antibiotics
preprocedural both 2–3 days before and for 2–3 weeks
prophylactic following the procedure in patients
antibiotics indicated with increased risk of developing a liver
for TACE? abscess (prior biliary interventions).
What vessel should SMA
be interrogated
after aortography to
assess for accessory
or replaced hepatic
arteries?
What vessels Aorta: 15–20 mL/s for 30–40 mL
are commonly SMA: 3–5 mL/s for 12–30 mL
interrogated, and Celiac: 3–4 mL/s for 12–15 mL
what are their Common hepatic artery (CHA): 3 mL/s
common injection for 12 mL
rates for hepatic Gastroduodenal artery (GDA): 2 mL/s
arterial interventions? for 8 mL
Proper hepatic: 3 mL/s for 12 mL
Left hepatic: 2 mL/s for 8 mL
Right hepatic: 2 mL/s for 10–12 mL
Phrenics: 1–2 mL/s for 4–6 mL
(continued)
428 S. I. Stein

Once the hepatic A microcatheter (2–2.8 Fr) should

tumoral supply is be used to obtain selective access for
identified, what segmental/subsegmental treatment.
maneuver is necessary
prior to delivery
of chemoembolic
emulsion?
How should the Aggressive IV hydration, pain control,
patient be managed such as with patient-controlled analgesia
immediately following (PCA), and antiemetics
TACE?
How is imaging Contrast-enhanced CT or MRI ~ 4 weeks
response to TACE after the procedure.
monitored? If there is no residual viable disease,
follow-up imaging should be performed
every 2–3 months.
Which medications PPI or H2 blocker 1 week prior and for
should be 4 weeks following procedure
administered for Nausea medication such as ondansetron
TARE? day of procedure
+/− steroids for postembolization
syndrome
+/− empirical antibiotics for biliary tract
infection
+/− oral analgesics
What is the dose Approximately 4–5 mCi
of 99mTc-MAA
delivered during the
mapping study?
Why is it essential to 30 Gy delivered per session or 50 Gy
calculate “lung shunt cumulatively to the lungs has been shown
fraction?” to induce radiation pneumonitis.
 33 Hepatic Interventional Oncology 429

What are the dose < 10% → no dose reduction.

reduction parameters 10–15% → 20% dose reduction.
for patients with 15–20% → 40% dose reduction.
lung shunting > 20% → radioembolization is
demonstrated on contraindicated (with the caveat that it
mapping study? may be performed in rare cases that total
absolute dose to the lung is less than
30 Gy in a single session or 50 Gy over
multiple sessions).
What imaging can Bremsstrahlung SPECT scan within 24 h
be performed to of TARE
document Y-90 Newer modality time-of flight PET-CT
deposition in tumoral
tissue?

Complications
How are patients protected Hydrodissection with 5% dextrose
from ablation of sensitive or sterile water can create a plane
nontarget tissue? between the ablation zone and
nontarget tissue.
What is the risk of tumor 0.2–2.8% with risk factors including
seeding from RFA? high AFP, undifferentiated HCC,
subcapsular lesions, and multiple
needle insertions
Which patients are most Prior biliary intervention
at risk for liver abscess
following liver-directed
therapy?
What is postembolization Fever, abdominal pain, nausea, and
syndrome? vomiting following an embolization
procedure
What is a commonly Administer intra-arterial
utilized intraprocedural lidocaine prior to delivery of
practice to control pain the chemoembolic emulsion and
from visceral embolization? between aliquots.
(continued)
430 S. I. Stein

What potential life-­ Pulmonary embolism from

threating complications hepatovenous shunting to the lungs
exist from administering and liver failure
too much ethiodized oil in
TACE?
How does the side effect TARE patients also may develop
profile of TARE compare constitutional symptoms including
to TACE? fatigue, abdominal pain, and nausea.
However, symptoms are usually not
as severe or immediate but can be
prolonged.
What are the complications Radiation pneumonitis,
of TARE? radioembolization-induced liver
disease (REILD), liver toxicity, GI
ulceration, gastritis, skin irritation,
and cholecystitis
Where should TARE be Distal to the cystic artery
performed relative to the
cystic artery?
How does REILD present Can present up to several months
and how is it managed? following TARE
Laboratory: elevated bilirubin and
decreased albumin
Clinical: ascites
Imaging: hepatic perfusion
abnormalities (veno-occlusive
disease)
Treatment: depends on severity,
may include diuretics, high-dose
steroids, sustained low-dose
heparin, ursodeoxycholic acid, and
pentoxifylline
What measures are taken Dose reduction strategies or
to avoid REILD when sequential sessions/fractionation
performing bilobar whole to each lobe separated by 1-month
liver TARE or when dosing to single lobe
prescribed activity is high?
 33 Hepatic Interventional Oncology 431

How are patients Prophylactic coiling or gel foam

protected from “nontarget embolization of potential nontarget
embolization” in TARE? arterial branches

Landmark Research

Ablation

Chen M-S, Li J-Q, Zheng Y, et al. A prospective randomized

trial comparing percutaneous local ablative therapy and par-
tial hepatectomy for small hepatocellular carcinoma. Ann
Surg. 2006;243(3):321–8.
• RCT comparing percutaneous RFA with partial hepatec-
tomy for early solitary HCC ≤ 5 cm.
• Ablation and resection for early HCC had similar 1-, 2-, 3-,
and 4-year survival rates.
• Resection had statistically significant increase in complica-
tions related to surgery, longer hospital stay, and increased
postoperative stay.
Loriaud A, Denys A, Seror O, et al. Hepatocellular carci-
noma abutting large vessels: comparison of four percutane-
ous ablation systems. Int J Hyperthermia. 2018;34(8):1171–8.
• RCT in patients with BCLC stage 0 and A with perivascu-
lar HCC comparing monopolar RFA, cluster RFA, multi-­
bipolar RFA, and microwave ablation.
• Primary endpoint: overall long-term progression.
• Multi-bipolar RFA and cluster RFA provided better local
tumor control than microwave ablation or monopolar
RFA.

Conventional TACE

Lo C-M, Ngan H, Tso W-K, Liu C-L, Lam C-M, Poon RT-P,
et al. Randomized controlled trial of transarterial lipiodol
432 S. I. Stein

chemoembolization for unresectable hepatocellular carci-

noma. Hepatology. 2002;35(5):1164–71.
• TACE vs. symptomatic treatment for unresectable HCC in
Asian patients
• TACE with improved overall survival at 1, 2, and 3 years
Llovet JM, Real MI, Montaña X, et al. Arterial embolisa-
tion or chemoembolisation versus symptomatic treatment in
patients with unresectable hepatocellular carcinoma: a ran-
domised controlled trial. Lancet. 2002;359(9319):1734–9.
• TACE vs. bland embolization vs. symptomatic treatment
for unresectable intermediate stage HCC in Caucasian
patients.
• The study was stopped due to consistent results showing
improved 1-, 2-, and 3-year survival of chemoembolization
patients.
• TACE group showed lower rates of vascular invasion and
lowest rate of death due to tumor progression, but the
study stopped prior to establishing improved effectiveness
compared to bland embolization.

DEB-TACE

Lammer J, Malagari K, Vogl T, et al. Prospective randomized

study of doxorubicin-eluting-bead embolization in the treat-
ment of hepatocellular carcinoma: results of the PRECISION
V study. Cardiovasc Intervent Radiol. 2010;33(1):41–52.
• Multicenter RCT with 1200 patients randomized to con-
ventional TACE vs. drug-eluting bead treatment of HCC,
with primary outcome of tumor response at 6 months.
• Demonstrated safety of DEB-TACE, unable to demon-
strate superiority of DEB-TACE to conventional TACE.
• Subgroup analysis showed DEB-TACE with improved
response in more advanced disease (CP B, ECOG 1) com-
pared to conventional TACE.
 33 Hepatic Interventional Oncology 433

• DEB-TACE with improved tolerability and decreased

serious liver toxicity overall.
Lencioni R, Llovet JM, Han G, Tak WY, Yang J, Guglielmi
A, et al. Sorafenib or placebo plus TACE with doxorubicin-­
eluting beads for intermediate stage HCC: the SPACE trial. J
Hepatol. 2016;64(5):1090–8.
• RCT comparing DEB-TACE alone vs. DEB-TACE +
sorafenib for intermediate stage HCC.
• Did not establish significant improvements in clinical out-
comes for combination group as opposed to DEB-TACE
alone.

Bland Embolization

Brown KT, Do RK, Gonen M, et al. Randomized trial of

hepatic artery embolization for hepatocellular carcinoma
using doxorubicin-eluting microspheres compared with
embolization with microspheres alone. J Clin Oncol.
2016;34(17):2046–53.
• Single-center RCT comparing bland embolization to
DEB-TACE for the treatment of HCC.
• Included BCLC A, B, and C patients in both groups
• No difference in imaging response, progression-free sur-
vival, or overall survival between the two groups

Transarterial Radioembolization

Salem R, Gordon AC, Mouli S, et al. Y90 radioembolization

significantly prolongs time to progression compared with
chemoembolization in patients with hepatocellular carci-
noma. Gastroenterology. 2016;151(6):1155–63.
• RCT conventional TACE vs. TARE for BCLC A and B
patients.
• Primary outcome: time to progression.
434 S. I. Stein

• TARE had a significantly longer time to progression

(>26 months) than conventional TACE (6.8 months).
Longer time to progression did not translate to increased
overall survival.
Lewandowski RJ, Gabr A, Abouchaleh N, et al. Radiation
segmentectomy: potential curative therapy for early hepato-
cellular carcinoma. Radiology. 2018;287(3):1050–8.
• Retrospective cohort study of BCLC stage 0 and A
patients at single center with solitary HCC ≤ 5 cm treated
with radiation segmentectomy (>190 Gy ablative dose).
• Median overall survival, 6.7 years; time to progression,
2.4 years.
• Response rates, tumor control, and survival comparable to
other “curative” therapies such as thermal ablation, partial
hepatectomy, and transplantation in early stage HCC.
Wasan HS, Gibbs P, Sharma NK, et al. First-line selective
internal radiotherapy plus chemotherapy versus chemother-
apy alone in patients with liver metastases from colorectal
cancer (FOXFIRE, SIRFLOX, and FOXFIRE-Global): a
combined analysis of three multicentre, randomised, phase 3
trials. Lancet Oncol. 2017;18(9):1159–71.
• Analyzed data from three trials to assess chemotherapy
alone vs. chemotherapy + TARE with resin microspheres
as first-line therapy for patients with liver-only colorectal
cancer metastases
• Found that adding TARE improved liver-specific progres-
sion and radiological response, but did not improve overall
or progression-free survival
Vilgrain V, Pereira H, Assenat E, et al. Efficacy and safety
of selective internal radiotherapy with yttrium-90 resin
microspheres compared with sorafenib in locally advanced
and inoperable hepatocellular carcinoma (SARAH): an
open-label randomised controlled phase 3 trial. Lancet
Oncol. 2017;18(12):1624–36.
• Multicenter RCT in France comparing the use of sorafenib
vs. TARE for patients with locally advanced stage (BCLC
 33 Hepatic Interventional Oncology 435

stage C) or intermediate stage (BCLC stage B failing

TACE) HCC.
• Primary endpoint: overall survival, which did not differ
between the two groups.
• TARE patients had improved QOL, improved tumor
response, and decreased adverse events (sorafenib can
have many toxic side effects).
Chow PKH, Gandhi M, Tan S-B, et al. SIRveNIB: selective
internal radiation therapy versus sorafenib in Asia-Pacific
patients with hepatocellular carcinoma. J Clin Oncol.
2018;36(19):1913–21.
• Multicenter RCT in comparing the use of sorafenib vs.
TARE for patients with locally advanced (BCLC stage B
or C) HCC.
• Primary endpoint: overall survival, which did not differ
between groups.
• TARE patients had fewer grade ≥ 3 adverse events than
sorafenib; TARE patients had better tumor response rate.
• Key differences from SARAH trial (above): Single TARE
(vs. SARAH with repeat TARE allowed), lower bilirubin
level threshold (32 mmol/L vs. <=50 SARAH), lower
proportion of BCLC C disease, and better survival in
­
patients with BCLC C disease treated with TARE in
SIRveNIB vs. SARAH.

Common Questions

What is the goal temperature of 60–100 °C (above 100 °C

RFA? is less effective due to
charring).
What is the primary model utilized Body surface area (BSA)
to calculate activity for delivery of model
Y-90 resin microspheres?
(continued)
436 S. I. Stein

What is the primary model utilized Medical internal radiation

to calculate activity for delivery of dose (MIRD)
Y-90 glass microspheres?
How long is the patient “radioactive” Y-90 has a 64-h half-life.
after TARE and what measures Patients should avoid close
should be taken? contact with pregnant
women and children for
3 days.
What is the typical surface radiation < 1 mrem/h.
dose from the patient after TARE?
What is the goal future liver remnant ≥ 40% of the preoperative
(FLR) before surgical resection in liver volume
patients with cirrhosis or chronic
hepatitis?
What is portal vein embolization Technique utilized to cause
(PVE)? compensatory hypertrophy
in the FLR.
PVE may increase FLR
by 30%.
Takes 3–4 weeks to induce
hypertrophy.
What is radiation lobectomy? Delivery of Y-90 in a lobar
fashion
Similar to PVE, causes
compensatory hypertrophy
to the contralateral lobe
prior to resection
Can take longer than PVE
to induce hypertrophy,
but has the advantage of
controlling the tumor(s)
What liver-directed therapies can be Depending on liver
used to target early HCC? transplantation candidacy
and location, thermal
ablation and radiation
segmentectomy can be
considered.
 33 Hepatic Interventional Oncology 437

What interventions are typically TACE +/− thermal

performed for asymptomatic large ablation and TARE
or multifocal HCC without evidence
of vascular invasion or extrahepatic
metastasis (intermediate stage HCC)
(assuming good performance status
and CP score)?
What treatment options are Sorafenib and TARE
available for symptomatic HCC with
vascular invasion or extrahepatic
spread (advanced stage HCC)?

Acknowledgments I would like to thank Dr. Anuj Malhotra for reviewing

and providing meaningful feedback to early versions of this chapter.

Further Reading
Ahmed M, Goldberg SN. Principles of radiofrequency ablation. In:
Mueller PR, Adam A, editors. Interventional oncology: a practi-
cal guide for the interventional radiologist. New York: Springer;
2012. p. 23–38.
Brace CL. Radiofrequency and microwave ablation of the liver,
lung, kidney, and bone: what are the differences? Curr Probl
Diagn Radiol. 2009;38(3):135–43.
Chen M-S, Li J-Q, Zheng Y, Guo R-P, Liang H-H, Zhang Y-Q, et al.
A prospective randomized trial comparing percutaneous local
ablative therapy and partial hepatectomy for small hepatocel-
lular carcinoma. Ann Surg. 2006;243(3):321–8.
Covey AM, Brody LA, Maluccio MA, Getrajdman GI, Brown
KT. Variant hepatic arterial anatomy revisited: digital sub-
traction angiography performed in 600 patients. Radiology.
2002;224(2):542–7.
De Baere T, Arai Y, Lencioni R, Geschwind J-F, Rilling W, Salem R,
et al. Treatment of liver tumors with Lipiodol TACE: technical
recommendations from experts opinion. Cardiovasc Intervent
Radiol. 2016;39(3):334–43.
Devulapalli KK, Fidelman N, Soulen MC, Miller M, Johnson MS,
Addo E, et al. 90Y radioembolization for hepatic malignancy in
438 S. I. Stein

patients with previous biliary intervention: multicenter analysis

of hepatobiliary infections. Radiology. 2018;288(3):170962.
Fairchild AH, White SB. Decision making in interventional oncology:
intra-arterial therapies for metastatic colorectal cancer-Y90 and
chemoembolization. Semin Intervent Radiol. 2017;34(2):87–91.
Fidelman N, Kerlan RK. Transarterial chemoembolization and (90)
Y radioembolization for hepatocellular carcinoma: review of
current applications beyond intermediate-stage disease. AJR
Am J Roentgenol. 2015;205(4):742–52.
Fiorentini G, Aliberti C, Tilli M, Mulazzani L, Graziano F, Giordani
P, et al. Intra-arterial infusion of irinotecan-loaded drug-eluting
beads (DEBIRI) versus intravenous therapy (FOLFIRI) for
hepatic metastases from colorectal cancer: final results of a
phase III study. Anticancer Res. 2012;32(4):1387–95.
Geschwind JFH, Salem R, Carr BI, Soulen MC, Thurston KG, Goin
KA, et al. Yttrium-90 microspheres for the treatment of hepa-
tocellular carcinoma. Gastroenterology. 2004;127(5):S194–205.
Han K, Kim JH. Transarterial chemoembolization in hepatocellular
carcinoma treatment: Barcelona clinic liver cancer staging sys-
tem. World J Gastroenterol. 2015;21(36):10327–35.
Huang Y-Z, Zhou S-C, Zhou H, Tong M. Radiofrequency abla-
tion versus cryosurgery ablation for hepatocellular carcinoma:
a meta-analysis. Hepatogastroenterology. 2013;60(125):1131–5.
Kallini JR, Gabr A, Salem R, Lewandowski RJ. Transarterial radio-
embolization with yttrium-90 for the treatment of hepatocellular
carcinoma. Adv Ther. 2016;33(5):699–714.
Kan Z, Madoff DC. Liver anatomy: microcirculation of the liver.
Semin Intervent Radiol. 2008;25(2):77–85.
Kulik LM, Carr BI, Mulcahy MF, Lewandowski RJ, Atassi B, Ryu
RK, et al. Safety and efficacy of 90Y radiotherapy for hepa-
tocellular carcinoma with and without portal vein thrombosis.
Hepatology. 2008;47(1):71–81.
Kumar N, Gaba RC, Knuttinen MG, Omene BO, Martinez BK,
Owens CA, et al. Tract seeding following radiofrequency abla-
tion for hepatocellular carcinoma: prevention, detection, and
management. Semin Intervent Radiol. 2011;28(2):187–92.
Lammer J, Malagari K, Vogl T, Pilleul F, Denys A, Watkinson A,
et al. Prospective randomized study of doxorubicin-eluting-­bead
embolization in the treatment of hepatocellular carcinoma:
results of the PRECISION V study. Cardiovasc Intervent
Radiol. 2010;33(1):41–52.
 33 Hepatic Interventional Oncology 439

Lee K-H, Sung K-B, Lee D-Y, Park S, Kim W, Yu J-S. Transcatheter
arterial chemoembolization for hepatocellular carcinoma: ana-
tomic and hemodynamic considerations in the hepatic artery
and portal vein. Radiographics. 2002;22(5):1077–91.
Lencioni R. Chapter 4: Hepatocellular carcinoma: ablation. In:
Gandhi RT, Ganguli S, editors. Interventional oncology (practi-
cal guides in interventional radiology). New York: Thieme; 2016.
p. 60–70.
Lencioni R, Llovet JM, Han G, Tak WY, Yang J, Guglielmi A, et al.
Sorafenib or placebo plus TACE with doxorubicin-eluting
beads for intermediate stage HCC: the SPACE trial. J Hepatol.
2016;64(5):1090–8.
Lencioni R, Petruzzi P, Crocetti L. Chemoembolization of hepato-
cellular carcinoma. Semin Intervent Radiol. 2013;30(1):3–11.
Lewandowski RJ, Gabr A, Abouchaleh N, Ali R, Al Asadi A,
Mora RA, et al. Radiation segmentectomy: potential cura-
tive therapy for early hepatocellular carcinoma. Radiology.
2018;287(3):1050–8.
Llovet JM, Bruix J. Systematic review of randomized trials for
unresectable hepatocellular carcinoma: chemoembolization
improves survival. Hepatology. 2003;37(2):429–42.
Llovet JM, Real MI, Montaña X, Planas R, Coll S, Aponte J, et al.
Arterial embolisation or chemoembolisation versus symptomatic
treatment in patients with unresectable h
­ epatocellular carcinoma:
a randomised controlled trial. Lancet. 2002;359(9319):1734–9.
Llovet JM, Ricci S, Mazzaferro V, Hilgard P, Gane E, Blanc J-F, et al.
Sorafenib in advanced hepatocellular carcinoma. N Engl J Med.
2008;359(4):378–90.
Lo C-M, Ngan H, Tso W-K, Liu C-L, Lam C-M, Poon RT-P,
et al. Randomized controlled trial of transarterial lipiodol
chemoembolization for unresectable hepatocellular carcinoma.
Hepatology. 2002;35(5):1164–71.
Meiers C, Taylor A, Geller B, Toskich B. Safety and initial efficacy
of radiation segmentectomy for the treatment of hepatic metas-
tases. J Gastrointest Oncol. 2018;9(2):311–5.
Padia SA, Johnson GE, Horton KJ, Ingraham CR, Kogut MJ,
Kwan S, et al. Segmental yttrium-90 radioembolization ver-
sus segmental chemoembolization for localized hepatocellular
carcinoma: results of a single-center, retrospective, propensity
score-­matched study. J Vasc Interv Radiol. 2017;28(6):777–785.
e1.
440 S. I. Stein

Padia SA, Kogut MJ. Chapter 5: Hepatocellular carcinoma: chemo-

embolization. In: Gandhi RT, Ganguli S, editors. Interventional
oncology (practical guides in interventional radiology).
New York: Thieme; 2016. p. 72–81.
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in hepatocellular carcinoma. Liver. 1990;10(2):72–8.
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et al. Radioembolization results in longer time-to-­progression
and reduced toxicity compared with chemoembolization in
patients with hepatocellular carcinoma. Gastroenterology.
2011;140(2):497–507.e2.
Salem R, Lewandowski RJ, Sato KT, Atassi B, Ryu RK, Ibrahim S,
et al. Technical aspects of radioembolization with 90Y micro-
spheres. Tech Vasc Interv Radiol. 2007;10(1):12–29.
Thakor AS, Eftekhari A, Lee EW, Klass D, Liu D. Chapter 6:
Hepatocellular carcinoma: radioembolization. In: Gandhi RT,
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interventional radiology). New York: Thieme; 2016. p. 84–107.
Valji K. Chapter 24: Interventional oncology. In: Valji K, editor. The
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Van Hazel GA, Heinemann V, Sharma NK, Findlay MPN, Ricke
J, Peeters M, et al. SIRFLOX: randomized phase III trial com-
paring first-line mFOLFOX6 (plus or minus bevacizumab)
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internal radiation therapy in patients with metastatic colorectal
cancer. J Clin Oncol. 2016;34(15):1723–31.
Vilgrain V, Pereira H, Assenat E, Guiu B, Ilonca AD, Pageaux G-P,
et al. Efficacy and safety of selective internal radiotherapy
with yttrium-90 resin microspheres compared with sorafenib
in locally advanced and inoperable hepatocellular carcinoma
(SARAH): an open-label randomised controlled phase 3 trial.
Lancet Oncol. 2017;18(12):1624–36.
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Mueller PR, Adam A, editors. Interventional oncology: a practi-
cal guide for the interventional radiologist. New York: Springer;
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 33 Hepatic Interventional Oncology 441

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Chapter 34
Pulmonary Oncology
John Smirniotopoulos and Maria Mitry

Evaluating the Patient

Do I need to Every lung biopsy patient should have a
evaluate the formal evaluation by an interventional
patient for a lung radiologist, and close inspection of cross-­
biopsy? sectional imaging, as these patients have a
risk of developing pneumothorax.
Are there The most common complication of a lung
particular biopsy or ablation is a pneumothorax.
considerations Therefore, it is good practice to not only
when consenting a explain that pneumothoraces are seen in up
patient for a lung to 20% of these procedures but also consent
procedure? the patient for a possible chest tube while
consenting them for the main procedure. This
will avoid any delay in placing such a tube
should the patient require one urgently.
(continued)

J. Smirniotopoulos (*)
Interventional Radiology, MedStar Georgetown University
Hospital/MedStar Washington Hospital Center,
Washington, NY, USA
M. Mitry
Department of Radiology, New York Presbyterian Hospital/Weill
Cornell Medicine, New York, NY, USA

© Springer Nature Switzerland AG 2022 443

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_34
444 J. Smirniotopoulos and M. Mitry

What is clinically Medical and surgical history with a focus on

relevant? cardiopulmonary status, bleeding risk, and
medications
Are there any Prior to lung biopsy and ablation,
adjustments to anticoagulation should be discontinued.
medications? Inpatients currently taking warfarin can
be transitioned to heparin infusion, which
should be stopped 2 hours prior to the
procedure for biopsy and 24 hours prior to
ablation.
How recent should Cross-sectional imaging of the chest (formal
a chest CT be for a CT or PET/CT) should be obtained within
procedure? 4 weeks of a procedure.

High Yield
What is the Lung cancer is the most common malignancy
prevalence of in the United States and worldwide, with 2.1
lung cancer? million new cases and 1.8 million related deaths
in 2018.
What is the The majority of patients diagnosed with lung
average age of cancer are older than 65, with an average age of
diagnosis? diagnosis of 70.
What is The age-adjusted death rate for lung cancer
the gender is higher for men (46.7 per 100,000) than for
difference? women (31.9 per 100,000).
What are the Smoking is the main attributable risk to small-­
risk factors? cell and non-small-cell lung cancers.
How much does Nonsmokers have a 20–30% greater chance of
secondhand developing lung cancer if they are exposed to
smoke affect secondhand smoke at home or work.
the risk of
developing lung
cancer?
 34 Pulmonary Oncology 445

Does screening Early detection, by low-dose CT screening,

work? can decrease lung cancer mortality by 14–20%
among high-risk populations.
What are the Solid: homogenous, soft-tissue attenuation
three types of nodules
lung nodules? Ground glass: hazy, nonuniform increased
attenuation, does not obscure underlying
vascular or bronchial structures
Part solid: both solid and ground glass
components
What are the Nodule size: >6–8 mm.
features of Nodule growth rate: assessed by volume
malignant doubling time (VDT). Malignant nodules can
nodules on have VDT from 20 to 400 days, with VDT
imaging ? <100 days associated with the highest risk of
malignancy.
Location: majority of malignancy is in the upper
lobes.
Other features: spiculated margins, pleural
indentation, vascular convergence, and/or air
bronchograms.
What are the Perifissural nodules are solid, smooth, and small
features of (<10 mm) and are in contact with the pleural
benign nodules surface or fissure. Perifissural nodules often
on imaging? represent benign intrapulmonary lymph nodes.
Calcified nodules are often benign, although the
pattern of calcification should be considered.
Diffuse, central, lamellated, and popcorn
calcifications are generally considered benign,
whereas punctate, eccentric, and amorphous
calcifications are indeterminate.
Intralesional fat suggests pulmonary hamartoma
rather than malignancy.
(continued)
446 J. Smirniotopoulos and M. Mitry

What are the Squamous cell carcinoma: typically centrally

most common located, cavitary lesions, and most commonly
types of lung associated with humoral hypercalcemia of
cancer? What malignancy (HHM)
are some Small-cell carcinoma: typically centrally
distinguishing located, poorer prognosis, and most commonly
features of each associated with hyponatremia from syndrome
type? of inappropriate antidiuretic hormone secretion
(SIADH), hypercortisolism from ectopic
Cushing’s syndrome (ECS), and proximal
muscle weakness from Lambert-Eaton
myasthenic syndrome
Adenocarcinoma: typically peripherally located,
often ground glass, or part solid lesion
 34 Pulmonary Oncology 447

How is non- TNM (tumor, nodes, metastasis) staging:

small-cell  T:
lung cancer T1: less than 3 cm
(NSCLC) T2: 3–5 cm, involvement of the main bronchus
staged? ≥2 cm distal to the carina, invasion of visceral
pleura, atelectasis, or obstructive pneumonitis
extending to the hilum
T3: 5–7 cm and/or invades the chest wall
(includes superior sulcus tumors), mediastinal
pleura, or parietal pericardium, involves the
main bronchus less than 2 cm distal to the
carina, atelectasis or obstructive pneumonitis
involving the whole lung, separate tumor nodule
in the same lobe
T4: greater than 7 cm and/or invades the
diaphragm, mediastinum, heart, great vessels,
trachea, carina, recurrent laryngeal nerve,
vertebral body, separate tumor nodule in a
different ipsilateral lobe
 N:
N0: No nodal metastases
N1: ipsilateral peribronchial and/or
hilar nodes, direct extension to ipsilateral
intrapulmonary nodes
N2: ipsilateral mediastinal and/or subcarinal
nodes
N3: contralateral mediastinal or hilar nodes
and/or ipsilateral or contralateral scalene or
supraclavicular nodes
 M:
M0: No distant metastases
M1: Distant metastases
 Staging:
Stage I (A and B): Disease only in the lung,
no nodal or distant metastases (T1 (A) or T2
(B), N0, M0)
Stage II (A and B): T1 N1 M0 (A) or T2 N0
M0, T3 N0 M0 (B)
Stage III (A and B):
A: T3 N1 M0, T1 N2 M0, T2 N2 M0, and T3
N2 M0
B: T4 N0 M0, T4 N1 M0, T4 T2 M0, T1 N3 M0,
T2 N3 M0, T3 N3 M0, and T4 N3 M0
Stage IV: any T or N with M1
(continued)
448 J. Smirniotopoulos and M. Mitry

How is NSCLC Stage I: Surgery

treated? Stage II: Surgery and adjuvant chemotherapy
Stage III: Surgery and adjuvant chemotherapy
+/− radiation
Stage IV: Chemotherapy +/− radiation
What are the Standard treatment: lobectomy with mediastinal
types of surgical nodal sampling.
treatments for Segmentectomy and wedge resection:
NSCLC?  Appropriate in patients with a nodule
≤2 cm and purely adenocarcinoma in situ on
histology, ≥50% ground glass appearance, or
long doubling time (>400 days)
 Poor pulmonary reserve or major comorbidity
that contraindicates lobectomy
 Must be able to achieve surgical margins
greater than or equal to 2 cm or the size of
the nodule
Pneumonectomy: when lobectomy is insufficient
for tumor removal (i.e., tumor crosses the
fissure, involves hilar structures, such as
pulmonary arteries/veins or mainstem bronchi).
T3 or T4 tumors require en bloc resection of the
involved structure with negative margins.
What makes A tumor is inoperable if appropriate surgical
lung cancer resection (lobectomy, segmentectomy/wedge
“inoperable”? resection, or pneumonectomy) cannot be
What are the performed due to a patient’s poor functional
treatment status or medical comorbidities, such as poor
options for pulmonary reserve and cardiac disease. In
these patients? these patients, definitive radiation therapy
(stereotactic ablative radiotherapy, SABR)
or image-guided thermal ablation may be
appropriate definitive treatment methods.
Further, in patients with invasive disease, if
en bloc resection of involved structures with
appropriate margins cannot be achieved, surgical
management is not indicated.
 34 Pulmonary Oncology 449

What are the Superior sulcus tumors are located in the apex
challenges of the lung and involve the apical chest wall
in treating and/or thoracic inlet structures. They are most
superior sulcus commonly adenocarcinomas. By definition,
(Pancoast) all superior sulcus tumors are at least T3 and
tumors? invade the chest wall and/or sympathetic chain.
If there is no nodal involvement (T3 N0),
superior sulcus tumors can be treated with
chemoradiation followed by surgical resection.
However, if there is invasion of vertebral bodies,
brachial plexus, or vascular structures, the tumor
is classified as T4. Because en bloc resection of
invaded structures (i.e., vertebral bodies and/
or subclavian vessels) is required, T4 superior
sulcus tumors may be rendered inoperable even
without nodal disease (stage IIIB).
What is the Limited stage: disease is confined to ipsilateral
staging of hemithorax, including regional lymph nodes,
small-cell lung which can fit into a radiotherapy plan.
(SCLC) cancer? Extensive stage: all other disease exceeding
above boundaries, including contralateral
disease involvement and distant metastases.
How is SCLC Chemoradiation therapy (not surgery)
treated?
What is the Development of lung cancers has been shown
role of targeted to be related to several genetic mutations,
therapy? including those involving the VEGF, EGFR,
ALK, ROS1, BRAF, RET, MET, and NTRK
genes. Drugs that target cells with these types of
mutations have been shown to be efficacious in
the treatment of metastatic lung cancer, in some
instances even improving overall survival when
compared to traditional chemotherapy regimens.
Immunohistochemical analysis of lung tumors
can thereby elucidate additional therapies for
patients.
450 J. Smirniotopoulos and M. Mitry

Indications/Contraindications
When to biopsy? Lung nodules > 8 mm, not amenable to
endobronchial approach. Please note that
this is highly variable from institution to
institution.
What is the To determine whether a pulmonary lesion is
purpose of a lung benign or malignant (i.e., new or enlarging
biopsy? mass)
Is there any A biopsy may be beneficial in determining
benefit to biopsy infectious or inflammatory etiology of a lung
of a nodule if it’s nodule, as this will direct patient care and
not cancer? therapies, such as steroids for noninfectious or
cryptogenic organizing pneumonia.
When to ablate Early (stage I/II) primary non-small-cell lung
primary lung cancer without lymph node involvement in
cancer? nonsurgical candidates
When to ablate For palliation in nonsurgical candidates
a metastatic lung
nodule?
What are Pulmonary AVM or venous aneurysm/
the absolute abnormality, as these increase the risk of
contraindications bleeding.
to lung biopsy? Inaccessible and/or a safer alternative is
preferred.
Lung biopsy should not be considered in
patients within 6 weeks of a myocardial
infarction.
What are Fibrotic and emphysematous lung disease
the relative with multiple blebs and bullae
contraindications History of pneumonectomy of the non-
to lung biopsy? affected lung
Uncorrected coagulopathy, unstable
cardiopulmonary status, and pregnancy
 34 Pulmonary Oncology 451

What are the Proximity to the hilum, large blood vessels,

contraindications and bronchi
for ablation? Bleeding diathesis, most relevant for
cryoablation
Prior pneumonectomy
Unilateral functioning lung
Life expectancy of < 12 months
Acute pneumonia
Severe pulmonary arterial hypertension
(> 40 mmHg)
Poor lung function (FEV1 < 1.0 L)

Relevant Anatomy
What are Parietal pleura: outer pleural layer, lines the inner
the relevant chest wall.
pleural layers Visceral pleura: inner pleural layer, lines the
in the lungs? surface of the lungs. Decreasing the number of
passes through the pleura during lung biopsy
or ablation decreases the risk of periprocedural
complications such as pneumothorax.
(continued)
452 J. Smirniotopoulos and M. Mitry

What are the Superior mediastinum:

borders of  Superior border, thoracic outlet; inferior
the superior/ border, sternal angle; lateral borders, medial
anterior/ pleural sacs; anterior border, dorsal surface
middle/ of manubrium; and posterior border, ventral
posterior surface of T1–T4 vertebral bodies
mediastinum,  Contains: thymus, trachea, aortic arch,
and what do brachiocephalic trunk, left common carotid and
they contain? brachiocephalic arteries, SVC, brachiocephalic
veins, arch of the azygous vein, thoracic duct,
left and right vagus and phrenic nerves, and
recurrent laryngeal nerve
Anterior mediastinum:
 Superior border, sternal angle; inferior border,
diaphragm; lateral borders, medial reflections
of the pleural sacs; anterior border, sternum;
and posterior border, pericardium
 Contains: thymus, internal thoracic arteries and
veins, and parasternal lymph nodes
 Anterior junction line: below the level of the
carina
Middle mediastinum:
 Superior border: sternal angle; inferior border:
diaphragm; lateral borders: medial reflections
of the pleural sacs; anterior and posterior
borders: pericardium
 Contains: heart, ascending aorta and great
vessels, SVC/IVC, pulmonary trunk, trachea
and main bronchi, phrenic nerve, vagus nerve,
and sympathetic nerves
Posterior mediastinum:
 Superior border, sternal angle; inferior border,
diaphragm; lateral borders, pleural reflections;
anterior border, pericardium; and posterior
border, T5–T12 vertebral bodies
 Contains: esophagus, descending thoracic aorta,
azygous and hemiazygos veins, thoracic duct,
vagus nerve, splanchnic nerve, and sympathetic
nerves
 Posterior junction line: above the level of the
aortic arch
 34 Pulmonary Oncology 453

Where do Intercostal veins, arteries, and nerves run along

the primary the inferior margin of the ribs, with the nerves
and accessory coursing most inferiorly. Therefore, percutaneous
neurovascular approach should be along the superior margin of
bundles lie? the inferior rib in the region of interest.
How does
this affect
percutaneous
approach?
What are Chest wall vasculature, such as the internal
the pertinent mammary and intercostal vessels and the
vascular subclavian and intrapulmonary vessels
structures
to pay close
attention to?
What is the Right: the right main bronchus branches in the
branching mediastinum; the right upper lobe bronchus
pattern of is behind and below the right pulmonary
the right and artery (eparterial – arises above where the
left mainstem right pulmonary artery crosses the right main
bronchi? bronchus).
Left: the left main bronchus courses below the
left pulmonary artery before branching into the
left upper lobe bronchus (hyparterial – arises
below where the left PA crosses the left main
bronchus).
How can At the hilum, the superior pulmonary veins
pulmonary are anterior and inferior to the pulmonary
arteries and arteries. In the lungs, the pulmonary veins course
veins be through the intersegmental septa (not adjacent
distinguished? to bronchi), whereas the segmental pulmonary
arteries course adjacent to the corresponding
bronchi.
(continued)
454 J. Smirniotopoulos and M. Mitry

What are The thoracic duct is located in the posterior

the major mediastinum and provides lymphatic drainage
intrathoracic from the abdomen, bilateral lower extremities,
lymphatic left hemithorax, left upper extremity, and
structures and left face/neck. Can be idiopathic, malignant,
their location? or traumatic (damaged during intrathoracic
surgery), and can result in chyle leaks, including
chylothorax. May be managed with nonfat diet,
surgery, or thoracic duct embolization.
What is the Azygos vein: originates at the junction of the
anatomy of right ascending lumbar and subcostal veins,
the azygos/ enters the chest at the aortic hiatus, courses
hemiazygos through the posterior mediastinum, and empties
system? anteriorly into the SVC at the level of T5–T6
(anterior to right main bronchus)
Hemiazygos vein: originates at the junction of the
left ascending lumbar and subcostal veins, enters
the chest at the aortic hiatus, and crosses midline
to join the azygos vein at the level of T8–T9,
posterior to the aorta
What would PLSVC: most commonly drains into the coronary
a persistent sinus (associated with unroofed coronary sinus),
left-sided usually not seen on chest X-ray unless catheter
SVC (PLSVC) is present, may see widened shadow of the aorta,
and total “half-moon” opacity from left of aortic arch to
anomalous middle of left clavicle. Often it co-occurs with a
pulmonary right SVC. It is associated with other anomalies
venous return such as anomalous pulmonary veins, coarctation
(TAPVR) of the aorta, tetralogy of Fallot, transposition of
look like? the great vessels, and dextroversion.
How are they TAPVR: all pulmonary veins drain directly to
differentiated/ the right atrium. “Snowman sign” on chest X-ray
what are they reflects dilated vertical vein on the left with a
associated dilated right atrium. It is associated with other
with? cardiac anomalies and heterotaxy.
 34 Pulmonary Oncology 455

What Hilar overlay: if hilar opacity obscures hilar

are some structures, abnormality is within the hilum. If
important hilar structures are visible, abnormality is either
radiographic anterior or posterior to the hilum.
signs for Cervicothoracic sign: distinguish if a mediastinal
masses? mass is anterior (ill-defined superior border, in
contact with soft tissue of the neck at or below
the clavicle) or posterior (well-defined superior
border since the posterior lung extends above
the clavicle). The upper border of an anterior
mediastinal mass cannot extend above the level
of the clavicles.
Incomplete border: distinguish if mass is
pleural/extrapleural versus intrapulmonary.
Intrapulmonary masses are surrounded by the
lung, so complete borders can be visualized,
whereas extrapulmonary mass borders are not
well delineated where they extend to the pleura/
chest wall.

Relevant Materials
What do I need for a A coaxial system is often used, even for
lung biopsy? fine needle aspiration (FNA). Typically,
a 17 or 19 gauge coaxial needle is
appropriate with biopsy needle
included in the kit, and 20–22 gauge
hollow needles with 10 cc syringes for
aspiration.
What are the types of 1. Microwave ablation
ablation modalities? 2. Radiofrequency ablation (RFA)
3. Cryoablation
Is one ablative tool If the nodule is < 3 cm, differing
superior over another? modalities are equally efficacious
(RFA = microwave = cryo).
If the nodule is > 3 cm, then microwave
> cryo > RFA.
(continued)
456 J. Smirniotopoulos and M. Mitry

Does location play If the nodule is within 1.5 cm of the

a role in the type of pleura, all modalities are equally
ablation probe? efficacious.
What may contribute to Heat sinks such as bronchi and adjacent
suboptimal ablation? vasculature
If there is concern Similar to nodules > 3 cm, if there is
for a heat sink, is concern for heat sink, microwave > cryo
one ablation probe > RFA.
superior?
The patient has a For pacemakers and other implantable
pacemaker/ICD/ cardiac devices, cryo > microwave >
LVAD. Does that RFA
matter?

General Step by Step

Lung biopsy 1. Position the patient, preferably prone
for a posterior approach. Lateral decubitus
positioning (biopsy side down) may help
prevent pneumothorax.
2. Apply guiding template or laser grid (if
possible); use CT to mark the point of entry.
3. Sterilize and anesthetize site, including
parietal pleura.
4. Use CT guidance to advance and confirm
position of coaxial/core biopsy needle.
5. Obtain FNA/core biopsy samples.
6. If there is concern for a pneumothorax,
administer 1–3 cc of patient blood for blood
patch, or other device such as BioSentry,
through the outer coaxial needle.
7. Remove the coaxial needle.
8. CT of the entire chest to rule out
pneumothorax.
 34 Pulmonary Oncology 457

Lung ablation: 1. Position the patient, preferably prone for a

posterior approach.
2. Securely apply grounding pads to the
opposite chest wall if RFA.
3. Apply guiding template or laser grid (if
possible); use CT to mark the point of entry.
4. Sterilize and anesthetize site, including
parietal pleura
5. Use CT to advance applicator(s).
6. Confirm position of applicator(s).
7. Apply energy to achieve tumor necrosis with
a 1 cm margin of normal lung parenchyma.
8. Remove applicator(s).
9. CT of the entire chest to rule out
pneumothorax and estimate area of ablation.
Sometimes Occasionally, due to complexity of a nodule
the pleura is location, inability to position the patient
transversed appropriately, or a combination of the two,
twice through a fissure must be crossed for a biopsy to be
a longer performed successfully. Therefore, the pleura
trajectory. Why? of more than one lobe is crossed, leading to a
technical passage of four layers of pleura.
Do I need One or two chest radiographs should be
additional obtained post-procedure depending on your
post-procedure institution.
imaging? Typically, a chest radiograph is obtained
immediately after the procedure and then
2 hours following the procedure.
The patient is If there is increasing pain or shortness of
having increased breath, repeat a chest radiograph to assess for
shortness of pneumothorax.
breath post-
biopsy. What do
I do?
(continued)
458 J. Smirniotopoulos and M. Mitry

The patient is 1. Monitor vitals, increase supplemental

complaining oxygenation, and draw labs for potential blood
of worsening loss (Hb, Hct).
chest pain post- 2. Oral analgesics for moderate pain (most
biopsy: situations).
3. PCA pumps or oral narcotics if severe/
increasing pain.
4. NSAIDs for 3–5 days following discharge
to limit pleural inflammation, thereby limiting
pain and risk of pleural effusion.

Complications
What can go Complications in lung ablation include
wrong? post-ablation syndrome, mild pyrexia,
pneumothorax, hemorrhage, hemoptysis,
bronchopleural fistulas, ARDS, and damage
to the surrounding skin (cellulitis) or abscess
formation.
What if the Look at incision sites to ensure absence
patient has pain of bleeding, or cellulitis (erythema (red),
at the puncture hyperemia (warm to touch), purulence, dolor
site? (pain), and tumor (swelling)):
 If there is no evidence of cellulitis – treat
with analgesics.
 If there is concern for cellulitis – consider
adding antibiotics (cefazolin).
(continued)
 34 Pulmonary Oncology 459

What do I need This may occur in up to 25% of patients,

to know about though not all pneumothoraces are treated
pneumothoraces the same way.
and lung biopsies/ If the pneumothorax is small, repeat a chest
ablations? X-ray to ensure stability. If the patient is
asymptomatic, they can likely be discharged
without additional intervention.
4–12% of pneumothoraces will require a
chest tube, which also includes Heimlich valve
chest tubes (patients can be discharged home
with this type of tube).
20% of pneumothoraces after ablation
resolve following evacuation of air with a
small needle or catheter.
What is the Pleural effusion after ablation may
risk of pleural occur in 6–19% of patients. Most resolve
effusion? spontaneously and rarely require
thoracentesis or chest tube.
What is the risk Hemoptysis may occur in up to 15% of
of hemoptysis? patients, though it is often self-limited and
does not require admission to the hospital.
What factors Incidence is correlated with biopsy or
influence severe ablation in close proximity to the hilum.
pulmonary
hemorrhage or
hemothorax?
What should I do Obtain a stat CTA and prepare for
if there is concern endovascular or surgical intervention.
for severe
hemorrhage?
What is post- Flu-like symptoms that develop within the
ablation first 24–48 hours of the procedure. Explain
syndrome (within to the patient that they may experience
24–48 hours)? fever, malaise, chills, myalgia, and nausea.
Productive cough with rust-colored sputum
may also occur.
(continued)
460 J. Smirniotopoulos and M. Mitry

Does post- This is typically self-limited, and may last up

ablation to 7–14 days.
syndrome require
treatment?
Are there other Infection, bronchopleural fistula, tumor
less common seeding, and air embolism
complications to
be aware of?

Landmark Research
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cations, techniques and controversies. Semin Intervent Radiol.,
U.S. National Library of Medicine. 2012;29(4):319–24. www.
ncbi.nlm.nih.gov/pubmed/?term=24293806%5Bpmid%5D.
Winokur RS, et al. Percutaneous lung biopsy: technique,
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U.S. National Library of Medicine. 2013;30(2):121–7.
Ahmed M, Brace CL, Lee FT Jr, Goldberg SN. Principles
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Dupuy DE. Microwave ablation compared with radiofre-
quency ablation in lung tissue—is microwave not just for
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Brace CL. Radiofrequency and microwave ablation of the
liver, lung, kidney, and bone: what are the differences? Curr
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Hinshaw JL, Lee FT Jr, Laeseke PF, Sampson LA, Brace
C. Temperature isotherms during pulmonary cryoablation
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 34 Pulmonary Oncology 461

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Z. Thoracic masses treated with percutaneous cryotherapy:
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Common Questions
What follow-up do Non-contrast/contrast chest CT at
post-lung ablation 1 month
patients require? Chest CT at 4 months
FDG-PET/CT at 6 and 12 months
Followed by PET/CT or contrast CT at
6-month intervals

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462 J. Smirniotopoulos and M. Mitry

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Hinshaw JL, Lee FT Jr, Laeseke PF, Sampson LA, Brace

C. Temperature isotherms during pulmonary cryoablation and
their correlation with the zone of ablation. J Vasc Interv Radiol.
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Hollings N, Shaw P. Diagnostic imaging of lung cancer. Eur Respir
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464 J. Smirniotopoulos and M. Mitry

National Comprehensive Cancer Network. NCCN Guidelines

Version 1.2021. Small cell lung cancer. Available at: www.nccn.
org. Accessed 11 Aug 2020.
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https://doi.org/10.2214/AJR.07.7081.
Piciucchi S, Barone D, Sanna S, et al. The azygos vein pathway: an
overview from anatomical variations to pathological changes.
Insights Imaging. 2014;5(5):619–28. https://doi.org/10.1007/
s13244-­0 14-­0351-­3.
Smirniotopoulos J, et al. Interventional oncology: keeping out
of trouble in ablation techniques. Tech Vasc Interv Radiol.
2018;21(4):223–7.
Stoddard N, Lowery D. Anatomy, thorax, mediastinum. StatPearls
Publishing; 2019.
Tyrak KW, Holda J, Holda MK, Koziej M, Piatek K, Klimek-
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Martínez M. Learning from the pulmonary veins. Radiographics.
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World Health Organization. Cancer fact sheet, 2018.
Chapter 35
Renal Oncology
Shaji Khan and Monica J. Uceda

Evaluating Patient
What are the most RCC, lymphoma, urothelial cell carcinoma,
common types of and metastasis. Of these, RCC is the most
renal malignancies? common.
Why has the Detection rates of RCCs have increased
incidence of RCC with increasing use of radiologic imaging,
increased over the as well as prevalence of smoking and
past decade? obesity.
What are some Symptoms of RCC are nonspecific and may
symptoms of RCC? include abdominal or flank pain, anemia,
fever, hematuria, a palpable lump, and
weight loss.
(continued)

S. Khan (*) · M. J. Uceda

Department of Radiology, Presence Health St. Francis Hospital,
Evanston, IL, USA
e-mail: [email protected];
[email protected]

© Springer Nature Switzerland AG 2022 465

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_35
466 S. Khan and M. J. Uceda

What is the A renal mass should be suspicious for

differential malignancy until proven otherwise.
diagnosis for an Differential diagnoses include
RCC on imaging? angiomyolipoma (AML) or oncocytoma,
renal abscess, hematoma, lymphoma,
metastasis, and a complex cyst.
What are some Clear cell (most common, 70%), papillary
subtypes of RCC? (10–15%), chromophobe (< 5%), and
medullary (rare)
What are imaging Clear cell: High T2 with microscopic
features of the fat (loses signal on out of phase);
different RCC heterogenous and avidly enhancing
subtypes?
Papillary: Low T2 and may contain
hemosiderin (loses signal on in-phase);
slow homogenous enhancement
(hypovascular)
Chromophobe: Typically low T2, commonly
with calcifications; intermediate vascularity;
may have stellate scar/spoke-wheel
enhancement similar to oncocytoma

High Yield History

What is the average Typical age at diagnosis of RCC is between
age of diagnosis of 50 and 70 years old.
RCC?
Does RCC Yes, males are more commonly affected at a
have a gender ratio of approximately 2:1.
predilection?
What are the risk Smoking, obesity, dialysis, and
factors for RCC? cyclophosphamide use. Sickle cell disease
or sickle cell trait is specifically a risk factor
for medullary type RCC.
 35 Renal Oncology 467

Is RCC associated von Hippel-Lindau (VHL)

with any
syndromes?
 Autosomal dominant; VHL gene on
chromosome 3
 Clear cell RCC, often multiple
Tuberous sclerosis
 Sporadic more often than inherited (AD);
TSC1 gene on chromosome 9 or TSC2 on
chromosome 16
 Multiple angiomyolipomas (rarely clear
cell RCC)
Hereditary papillary renal cell cancer
syndrome
 Autosomal dominant; c-MET gene on
chromosome 7
 Multiple papillary RCCs
Sickle cell trait
 Renal medullary RCC with very poor
prognosis
What is the 5-year In the absence of metastasis, the 5-year
survival of RCC? survival is 65–90%. With metastasis,
however, the 5-year survival is considerably
lower.

Indications/Contraindications
What are some treatment Thermal ablation techniques and
options interventional renal artery embolization with a wide
radiology can offer variety of embolic agents
for treatment of renal
malignancies?
(continued)
468 S. Khan and M. J. Uceda

What are some Radical nephrectomy and nephron-­

alternative invasive sparing surgery (NSS) either open or
treatment options for laparoscopic. These options are more
renal malignancies? ideal for larger, more centrally located
RCCs. NSS is preferred over radical
nephrectomy for localized RCC.
Is there a size threshold Yes, renal tumors <4 cm in size
for renal tumor thermal typically respond better to thermal
ablation? ablation. In fact, best results have
been reported for tumors <3 cm in
size and exophytic in location.
What are some Poor surgical candidates, advanced
indications for tumor age, solitary kidney, familial
ablation treatment of syndromes, and multiple comorbid
renal malignancies? conditions
What are the absolute Uncorrectable coagulopathy with
contraindications to INR >1.5 and platelets <50,000 per
thermal ablation? microliter
What are some relative Anteromedially/centrally located
contraindications for tumors with no safe route, hip
tumor ablation? prosthesis, and pacemaker/
defibrillator. Large tumor size and
inability to separate tumor from
nearby vital structures, such as the
bowel or ureter, should also be
considered.
When can renal Prior to nephrectomy, for palliation,
artery embolization in preparation for ablation, and for
be considered for the treatment of AMLs (>4 cm).
treatment? Indications for palliation in the setting
of advanced stage RCC include
hematuria, flank pain, and control of
paraneoplastic syndromes.
What are some Although there is no absolute
contraindications to renal contraindication, relative
artery embolization? contraindications include contrast
allergy, renal insufficiency, pregnancy,
infection, and solitary kidney.
 35 Renal Oncology 469

Relevant Anatomy
What is the basic The kidney has an outer cortex and inner
renal anatomy? medulla. The renal hilum located medially
is where the renal vessels, nerves, and
ureter pass. The kidneys, renal vessels,
proximal collecting systems, adrenal
glands, and some fat are located within the
perirenal space (a retroperitoneal space),
which is bound by perirenal fascia. The
two other retroperitoneal spaces are the
anterior and posterior pararenal spaces.
What are some Vascular pedicle and any neighboring
anatomic structures bowel and ureter. Also, it is best to avoid
to keep in mind traversing through the lung pleura, as this
when performing an can lead to a pneumothorax.
ablation?
What are common Variants include accessory renal arteries
anatomic variants and early division of the renal arteries.
that may be Being aware of these will help ensure as
encountered complete as possible of an embolization
during renal artery and procedure success.
embolization?
Are there any Hydrodissection is useful to separate
other special the structures when there is not enough
considerations margin in between the ureter/bowel and
and/or techniques the tumor.
one can use when
performing tumor
ablation for RCC?
As mentioned above, pre-ablation
embolization may reduce the risk of
hemorrhage and has the benefit of less
heat sink.
What else can be A retrograde ureteral stent can be
done to protect placed with infusion of fluid through the
the ureter during collecting system.
thermal ablation?
470 S. Khan and M. J. Uceda

Relevant Materials
What are the Radiofrequency ablation (RFA), microwave,
different kinds laser, and cryoablation. A newer procedure
of ablation called irreversible electroporation (IRE) uses
techniques electric currents to increase permeability of
currently the cell membranes. This disrupts cellular
available? hemostasis and induces cell death via
apoptosis or other internally induced necrotic
pathways.
What different Both linear and multi-tined or umbrella-­
arrays are shaped array devices may be used depending
available on the shape and size of the tumor. Straight/
for thermal linear electrodes may require multiple
ablation? insertions.
What are Coils, gelfoam, polyvinyl alcohol (PVA), and
some common Embospheres. Chemoembolization with drug-­
embolization eluting embolic (DEE) agent saturated with
materials that doxorubicin has also been shown to help in
are used? palliation of RCC. There may also be potential
for use of radioembolization with Yttrium-90
(Y-90) resin microspheres.
How does RFA Briefly, the RF electrode itself is not the
work? source of heat. Rather, the RF electrode
generates an alternating electromagnetic field
which agitates local molecules, resulting in
the production of heat. The high temperatures
results in coagulative necrosis of adjacent
tissue.
How does MWA uses an oscillating microwave
microwave electromagnetic field to increase kinetic
ablation (MWA) energy and produce heat. MWA produces heat
differ from faster, has a more predictable ablation zone,
RFA? and is not as affected by heat sink.
 35 Renal Oncology 471

How does When compressed gas, typically argon, is

cryoablation forced through the narrow opening of a
work? cryoprobe, the rapid expansion of the gas
results in a decrease in the temperature of
the gas (Joule-Thomson effect). Cryoablation
results in cell death by direct (cold-induced
cellular injury) and indirect (changes to the
cellular microenvironment and impairment of
tissue viability) effects.

General Step by Step

What is the ideal Prone in most cases and supine if the
patient positioning target is a transplanted kidney. Consider
for ablation? angling of the gantry in the prone position
to aid in determining ideal needle
trajectory. Oblique supine positioning
can be used for laterally located lesions
and also to displace the bowel medially.
Ipsilateral decubitus positioning is
useful for lower pole masses and aids in
displacing the lung, as well as reducing
target (ipsilateral) kidney motility.
What are some pre-­ Consultation including history, pre-­
procedure steps that procedure imaging, possible pre-­
should be taken? procedure biopsy, overnight fast, and
prophylactic antibiotics. A biopsy can also
be performed at the same time as the
ablation if necessary.
How is After achieving local anesthesia, a small
hydrodissection needle can be introduced between the
performed? tumor and adjacent vital structure.
Following this, saline can be injected and
infused continuously during the procedure
to help separate the tumor from the
adjacent vital structure.
(continued)
472 S. Khan and M. J. Uceda

How is A retrogradely placed ureteral stent is

pyeloperfusion connected to a bag of a slow drip infusion
performed? of 1–2 drops/second.
What is the ablation After advancing the ablation probe
technique utilized into the mass under imaging guidance,
for cryoablation? cryoablation can be performed with
freeze-thaw cycles, such as a 10-minute
freeze cycle followed by an 8-minute
thaw cycle, followed by an additional
freeze cycle. Temperatures < −40 °C are
necessary to ensure tumoral cell death.
What is the ablation After advancing the ablation probe into
technique for RFA the mass under imaging guidance, the mass
and MWA? is ablated for approximately 10 minutes
for RFA and a few minutes for MWA.
Why is it also This limits the possibility of a calyceal-­
important to ablate cutaneous fistula and tumor seeding.
the entry tract during Ablation should be stopped within 1 cm
tumor ablation? of the skin surface to prevent skin burns.
Tract ablation is performed with heat-­
based ablation.
What must be done Post-ablation multiphase CT scan must be
following ablation? performed to demonstrate lack of vascular
or collecting system injury.
How can the renal After acquiring arterial access, 5-Fr
artery be selected selective catheters, such as a Sos, Cobra,
for renal artery or Simmons catheters, can be used to
embolization? gain access into the renal artery. For
small tumors, selective catheterization
with microcatheters can also be achieved.
Accurate selection reduces the chance of
nontarget embolization and minimizes
non-tumoral nephron death.
What embolic The choice of embolic material depends
material should be on the operator’s experience and
used for renal artery preference. Post-embolization angiography
embolization? must be performed to demonstrate degree
of desired vessel occlusion.
 35 Renal Oncology 473

Complications
What are some Nephrectomy can increase the risk of
side effects chronic kidney disease, particularly if the
of radical patient is already diabetic. It also has a
nephrectomy? longer recovery period and is associated
with increased morbidity and mortality
compared to the other less invasive
techniques. Complications include infection,
bleeding, and even death.
What are some Hemorrhage, infection, ureteric stricture,
potential adverse bowel injury, nerve injury, adrenal crisis
effects of tumor (consider premedication with alpha-
ablation? and beta-blockers for a week), and
pneumothorax
What are potential Post-embolization syndrome consisting of
adverse effects fatigue, pain, fever, nausea, and vomiting.
of renal artery Other less likely complications include
embolization? infection and nontarget embolization.
What are the Decreased perioperative bleeding, creation
benefits of of a tissue plane which can ease in dissection
performing of the kidney, and reduction in tumor
renal artery bulk and possibly reduction in vascular
embolization prior thrombosis
to nephrectomy?
What can be done PES can be controlled symptomatically with
to minimize the pre- and post-medication, which includes
effects of post-­ steroids, pain control, antiemetics, and
embolization hydration.
syndrome (PES)
after renal artery
embolization?
(continued)
474 S. Khan and M. J. Uceda

If embolization was performed for

nephrectomy planning, performing the
nephrectomy within 48 hours of the renal
artery embolization can reduce the effects of
post-embolization syndrome. If nephrectomy
is performed >72 hours post-embolization,
the surgery can potentially become
technically difficult related to collateral
vessel formation.

Landmark Research
Clark W, Aslan P, Patel M, Vass J, Cade D, de Silva S, et al. The
RESIRT study: feasibility and dosimetry considerations of
selective internal radiation therapy (SIRT) using yttrium-90
(Y-90) resin microspheres in patients with primary renal cell
carcinoma (RCC). J Vasc Interv Radiol. 2017;28(2 Suppl):S164.
• SIRT with Y-90 microspheres was technically feasible in
patients with RCC. Tumors should be treated to imminent
stasis.
Hui GC, Tuncali K, Tatli S, Morrison PR, Silverman
SG. Comparison of percutaneous and surgical approaches to
renal tumor ablation: metaanalysis of effectiveness and com-
plication rates. J Vasc Interv Radiol 2008; 19:1311–1320.
• A percutaneous approach was found to be safer and just as
effective in treating RCC compared to an open or laparo-
scopic, although multiple treatments may be needed.
Jasinski M, Siekiera J, Chlosta P, et al. Radiofrequency
ablation of small renal masses as an alternative to nephron-­
sparing surgery: preliminary results. Videosurgery Miniinv.
2011;6:242–5.
• RFA can be safely used in treating T1a tumors as an alter-
native to partial nephrectomy. Careful follow-up is needed
to look for tumor recurrence.
 35 Renal Oncology 475

Karalli A, Ghaffarpour R, Axelsson R, Lundell L, Bozoki

B, Brismar T, et al. Transarterial chemoembolization of renal
cell carcinoma: a prospective controlled trial. J Vasc Interv
Radiol. 2017;28(12):1664–72.
• Drug-eluting embolization (DEE) is a safe way to treat
localized RCC and has a superior cytoreductive effect
compared to transarterial embolization (TAE).
Kunkle DA, Uzzo RG. Cryoablation or radiofrequency
ablation of the small renal mass: a meta-analysis. Cancer
2008;113: 2671–1280.
• Data suggested that cryoablation may require fewer re-­
treatments with improved local control and decreased risk
of metastatic progression compared to RFA.
Wagstaff P, Ingels A, Zondervan P, et al. Thermal ablation
in renal cell carcinoma management: a comprehensive review.
Curr Opin Urol. 2014;24:474–82.
• Thermal ablation is a safe way to treat small renal masses;
however, there is a small risk of residual disease.
Yin X, Cui L, Li F, et al. Radiofrequency ablation versus
partial nephrectomy in treating small renal tumors: a system-
atic review and meta-analysis. Medicine (Baltimore)
2015;94:e2255.
• RFA has a similar oncologic benefit compared to partial
nephrectomy with similar complications rates in treatment
of small renal tumors. There is a lower decline in eGFR
and a shorter length of stay (LOS) with RFA.
Zielinski H, Szmigielski S, Petrovich Z. Comparison of
preoperative embolization followed by radical nephrectomy
with radical nephrectomy alone for renal cell carcinoma. Am
J Clin Oncol. 2000;23(1):6–12.
• Preoperative renal artery embolization (PRAE) is a safe
technique in management of large and advanced
RCC. There was decreased median blood loss in the
PRAE group compared to the no-PRAE group (250 mL
versus 400 mL).
476 S. Khan and M. J. Uceda

Common Questions
What is the heat Perfusion-mediated cooling by adjacent vessels
sink effect? which limit the size of the ablation zone. This
is more of a technical challenge in RFA when
compared to microwave ablation. The heat sink
effect does not exist in IRE technique.
What is the A follow-up CT/MR with contrast can be
typical follow-up performed in 1–3 months post-ablation and
after ablation? then annually. There may be some post-­
procedural enhancement related to hyperemia;
however, an increase in the degree of
enhancement as well as any asymmetric and/or
nodular enhancement involving the margins of
the ablation zone on subsequent scans would
be suspicious for tumor recurrence/progression.
What is the ideal A 0.5–1-cm margin is ideal. If the margin
ablation margin? between the ablation zone and a vital
neighboring structure is <1 cm, hydrodissection
or pneumodissection can be used.
How does The 5-year recurrence-free survival rate of
tumor ablation partial nephrectomy has been reported to be
compare to the greater than 97% and that of thermal ablation
gold standard of to range from 87% to 97%.
radical or partial
nephrectomy?
How does Early 6-month cost comparisons show thermal
the cost of ablation to be cheaper than nephrectomy. As
thermal ablation outcomes become comparable with time, cost
compare to comparison may begin to play a larger factor in
nephrectomy? decision-making.
How do Results comparing cryoablation and RFA or
cryoablation and MWA do not vary greatly, and larger studies
RFA or MWA and trials are necessary to detect differences
compare in between the two. Therefore, the choice
performance? between them depends mostly on operator
experience and preference. There is a higher
bleeding risk with cryoablation compared to
RFA (4.8% versus 1.2%).
 35 Renal Oncology 477

Further Reading
Atwell TD, Carter RE, Schmit GD, et al. Complications following
573 percutaneous renal radiofrequency and cryoablation proce-
dures. J Vasc Interv Radiol. 2012;23(1):48–54.
Castle SM, Gorbatiy V, Avallone MA, et al. Cost comparison of
nephron-sparing treatments for cT1a renal masses. Urol Oncol.
2013;31:1327–32.
Clark W, Aslan P, Patel M, Vass J, Cade D, de Silva S, et al. The
RESIRT study: feasibility and dosimetry considerations of selec-
tive internal radiation therapy (SIRT) using yttrium-90 (Y-90)
resin microspheres in patients with primary renal cell carcinoma
(RCC). J Vasc Interv Radiol. 2017;28(2 Suppl):S164.
El Dib R, Touma NJ, Kapoor A. Cryoablation vs radiofrequency
ablation for the treatment of renal cell carcinoma: a meta-­
analysis of case series studies. BJU Int. 2012;110:510–6.
Georgiades CS, Rodriguez R. Renal tumor ablation. Tech Vasc
Interv Radiol. 2013;16:230–8.
Gervais DA. Cryoablation versus radiofrequency ablation for
renal tumor ablation: time to reassess? J Vasc Interv Radiol.
2013;24(8):1135–8.
Ginat DT, Saad WE, Turba UC. Transcatheter renal artery embo-
lization: clinical applications and techniques. Tech Vasc Interv
Radiol. 2009;12(4):224–39.
Hui GC, Tuncali K, Tatli S, Morrison PR, Silverman SG. Comparison
of percutaneous and surgical approaches to renal tumor abla-
tion: metaanalysis of effectiveness and complication rates. J Vasc
Interv Radiol. 2008;19:1311–20.
Jasinski M, Siekiera J, Chlosta P, et al. Radiofrequency ablation of
small renal masses as an alternative to nephron-sparing surgery:
preliminary results. Videosurg Miniinv. 2011;6:242–5.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. 5th ed. Philadelphia, PA: Lippincott
Williams and Wilkins; 2011. p. 283–9.
Karalli A, Ghaffarpour R, Axelsson R, Lundell L, Bozoki B,
Brismar T, et al. Transarterial chemoembolization of renal cell
carcinoma: a prospective controlled trial. J Vasc Interv Radiol.
2017;28(12):1664–72.
Knavel EM, Brace CL. Tumor ablation: common modalities and
general practices. Tech Vasc Interv Radiol. 2013;16(4):192–200.
478 S. Khan and M. J. Uceda

Kunkle DA, Uzzo RG. Cryoablation or radiofrequency ablation of

the small renal mass: a meta-analysis. Cancer. 2008;113:2671–1280.
Li D, Pua BB, Madoff DC. Role of embolization in the treatment of
renal masses. Semin Interv Radiol. 2014;31(1):70–81.
Pan XW, Cui XM, Huang H, et al. Radiofrequency ablation versus
partial nephrectomy for treatment of renal masses: a systematic
review and meta-analysis. Kaohsiung J Med Sci. 2015;31:649–58.
Sauk S, Zuckerman DA. Renal artery embolization. Semin Interv
Radiol. 2011;28(4):396–406.
Wagstaff P, Ingels A, Zondervan P, et al. Thermal ablation in renal
cell carcinoma management: a comprehensive review. Curr Opin
Urol. 2014;24:474–82.
Wah TM, Irving HC, Gregory W, Cartledge J, Joyce AD, Selby
PJ. Radiofrequency ablation (RFA) of renal cell carcinoma
(RCC): experience in 200 tumours. BJU Int. 2014;113(3):416–28.
Yin X, Cui L, Li F, et al. Radiofrequency ablation versus partial
nephrectomy in treating small renal tumors: a systematic review
and meta-analysis. Medicine (Baltimore). 2015;94:e2255.
Zielinski H, Szmigielski S, Petrovich Z. Comparison of preopera-
tive embolization followed by radical nephrectomy with radical
nephrectomy alone for renal cell carcinoma. Am J Clin Oncol.
2000;23(1):6–12.
Chapter 36
Breast Oncology
Monica J. Uceda and Shaji Khan

Evaluating Patients
What are the Recommendations differ between the
recommendations for United States Preventive Services Task
breast cancer screening Force (USPSTF) and the American
in women? Cancer Society (ACS);
USPSTF
 Age 40–49: Decision to screen should
be an individual one (Grade C).
 Age 50–74: Screen every 2 years
(Grade B).
 Age ≥75: No recommendation
(insufficient evidence).
(continued)

M. J. Uceda (*) · S. Khan

Department of Radiology, Presence Health St. Francis Hospital,
Evanston, IL, USA
e-mail: [email protected]; shaji.khan@
presencehealth.org

© Springer Nature Switzerland AG 2022 479

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_36
480 M. J. Uceda and S. Khan

ACS
 Women 40–44 can begin annual
screening mammography.
 Women 45–54 should undergo annual
screening mammography.
 Women ≥55 can transition to every-­
other-­year screening OR continue
annual screening mammography.
 Women should continue screening
mammography as long as their overall
health is good and they have a life
expectancy of 10 years or longer.
 Women at any age should not rely on
breast examination for breast cancer
screening.
What are the Irregular mass with obscured, indistinct
most suspicious or spiculated margins, pleomorphic
mammographic or fine linear branching calcifications,
findings? developing asymmetry, architectural
distortion, skin thickening, nipple
retraction and lymphadenopathy.
What are the most Round lesion, non-parallel and/
suspicious sonographic or irregular margins (angular),
findings? posterior shadowing, hypoechoic, not
circumscribed, internal vascularity and
lymphadenopathy.
What benign lesion can A scar can appear non-circumscribed
appear suspicious on and demonstrate posterior acoustic
ultrasound? shadowing, as well as spiculated
margins.
What is the work-up of Diagnostic mammogram and breast
a palpable mass? ultrasound.
What are ultrasound Parallel, oval, hypoechoic lesion with
features of circumscribed margins and no posterior
fibroadenoma? features.
 36 Breast Oncology 481

BIRADS-3; 6-month follow-up is

necessary to show stability.
Reasons to biopsy:
 Interval growth
 Patient anxiety
 High likelihood of losing the patient
during follow-up
What is the value of Screening for high-risk patients and
breast MRI? evaluating cancer extension.
What is a “second Targeted ultrasound of a corresponding
look” ultrasound? area of abnormal enhancement on MRI.
What additional Breast-specific gamma imaging (BSGI)
imaging modalities and positron emission mammography
can be used for further (PEM).
evaluation?

High Yield History

What is the 126.5 per 100,000 women and 1.1 per 100,000.
incidence of It is the most common cancer in women
breast cancer independent of race or ethnicity.
in the United
States?
What is the 20.3 per 100,000 women and 0.3 per 100,000
mortality of men. The mortality rate has recently decreased
breast cancer by 39% due to improved treatment and early
in the United detection.
States?
What is the 62 years old, with most cancer deaths in
average age at women ≥50.
diagnosis?
(continued)
482 M. J. Uceda and S. Khan

What are the Older age, personal history, family history,

risk factors? BRCA1/BRCA2 genes, radiation to chest
<30 years old, white race, obesity, nulliparous,
early menarche, late menopause, hormone
replacement therapy, smoking and dense
breasts.
What are Palpable mass, lymphadenopathy, skin
symptoms of thickening and nipple retraction. In the case
breast cancer? of inflammatory breast cancer: peau d’orange,
redness and swelling.

Indications/Contraindications
What are the methods Stereotactic interventions, US-guided
available for image-­ interventions, MR-guided breast
guided breast biopsies? biopsy, and the new vacuum-assisted
nuclear medicine breast biopsy
techniques.
What are common Bleeding disorders, uncooperative
contraindications for patient, morbid obesity.
the image-guided breast
biopsy?
What are the indications Newly diagnosed suspicious
for the stereotactic microcalcifications seen on
biopsy? mammography or digital
tomosynthesis classified as BI-RADS
4 or 5
Suspicious lesions seen best
in mammogram or without an
ultrasound correlate
What are the indications Any lesion definitely identified as
for the US-guided breast suspicious by ultrasound.
biopsy?
What are the advantages Real-time visualization, shorter
of the US-guided breast procedural time, patient’s comfort,
biopsy? and no radiation.
 36 Breast Oncology 483

What are the indications Suspicious lesions only visualized with

for the MR-guided breast MRI.
biopsy?
What are the techniques Radiofrequency ablation (RFA) and
available for breast cryoablation.
cancer ablation?
Which lesions could Breast cancer single lesions ≤1.5 cm
be best treated with and histologically different from
ablation? invasive lobular carcinomas.

Relevant Anatomy
What are the three zones of
the breast in mammography?

Boundaries Content
Premammary Skin to anterior Subcutaneous fat, blood
zone mammary fascia vessels, ligaments of
Cooper. May contain
ectopic ducts and TDLU
Mammary zone Anterior to Majority of ducts/TDLU,
posterior stromal fat, and stromal
mammary connective tissue
fascias
Retromammary Posterior Fat and posterior
zone mammary fascia suspensory ligaments
to chest wall

What are the layers Skin, subcutaneous tissue, glandular

identified in breast tissue, pectoralis major, and chest
ultrasound? wall.
484 M. J. Uceda and S. Khan

Relevant Materials
What is the set-up for Dedicated table or digital
stereotactic breast biopsy? mammography unit attachment and
a special chair for positioning.
What size biopsy needles 11-, 9-, 8-, or 7-gauge.
are utilized?
What are the benefits of Actively drawing tissue into the
vacuum-assisted devices? biopsy chamber allows for larger and
multiple tissue samples, and increases
diagnostic accuracy.
How do you select the Fine needle aspiration (FNA) for
appropriate device/ cystic or mixed lesions and core
technique for US-guided needle biopsies (CNB) for solid
breast biopsies? lesions.
What are the advantages Advantages: low cost and likelihood
or disadvantages of FNA? of hematoma.
Disadvantages: operator-dependent
and inability to differentiate between
DCIS and IDC.
What device options exist Automated spring-loaded or
for CNB? vacuum-assisted devices.
What are the advantages Advantages: higher likelihood of
or disadvantages of CNB? negative margins during surgery and
ability to perform oncologic markers
with the sample.
Disadvantages: higher cost and
need for multiple re-insertions with
automated devices.
When is a vacuum-assisted Suspicion of intraductal papillomas.
device preferred for CNB?
What are the available Grid system and pillar-and-post
MRI-guided biopsy system.
platforms?
 36 Breast Oncology 485

How is the needle placed Orthogonally to the compression

in a grid system? plate.
How is the needle placed Accommodates needle angulation up
in a pillar-and-post to 30 degrees.
system?
What are the components Needle guide, coaxial introducer
of the introducer set in the sheath, sharp nonferrous inner stylet,
MRI-guided biopsy? and plastic localizing obturator.
What is the mechanism of High-frequency alternating currents
action of RFA? cause thermal coagulation and
protein denaturation of tissues.
What is the advantage Minimally invasive procedures and
of ablation compared to improved cosmesis.
surgery?
What is the mechanism of Nitrogen or argon gas causes a local
the action of cryoablation? freezing reaction (“ice ball”) which
induces direct cell injury and death
via vasoconstriction.
What are the advantages Can be performed under mild
of cryoablation? sedation and local anesthesia.

General Step by Step

How is the patient Prone with the breast positioned
positioned for a dependently through an aperture in the
stereotactic breast table.
biopsy?
What types of +15 and − 15 degree images.
images are taken
before stereotactic
procedures?
What is the best 1. Select the projection in which the lesion
approach during is best visualized.
a stereotactic
procedure?
(continued)
486 M. J. Uceda and S. Khan

2. After initial imaging, the computer

generates x, y, and z coordinates.
3. Place the lesion in the center of the
biopsy chamber of the probe.
What if the lesion is Advance the probe to a position where the
too superficial? entire biopsy chamber is just beyond the
skin.
What if the lesion is Reposition the patient.
too deep?
Why is it important To confirm the lesion has been biopsied
to obtain a and identify the biopsy clip.
post-procedure
mammogram?
What size needle is 22- to 25-gauge needles.
used for FNA?
What is the best Several passes through different areas of
approach for FNA? the lesion.
What size needle is 12- to 14-gauge.
used for CNB?
What is the best 1. Advance device 1–3 cm proximal to the
approach for CNB? edge of the lesion.
2. Fire into the lesion.
3. Turn the needle and remove.
4. 3–5 passes are needed with automated
spring-loaded devices.
5. Place a biopsy clip.
What is the best 1. Place the patient prone in an MRI
approach to perform biopsy coil.
an MRI-guided
breast biopsy?
2. Scout images and contrast
administration.
 36 Breast Oncology 487

3. The computer generates x, y, and z

coordinates.
4. Coaxial sheath is inserted through the
stylet.
5. Stylet is removed and obturator is
placed.
6. Remove obturator and VAB is advanced
to obtain samples.
7. Place titanium clip.
What is the use of Document adequate clip placement,
a post-biopsy scan identify lesion removal, or decrease in size.
in the MRI-guided
breast biopsy?
If the lesion is not Decrease breast compression, second dose
identified in MRI, of contrast, short-term interval follow-up
what are the next MRI.
steps?
How is RFA Probes are placed under US guidance and
performed? ablation is performed under real-time
sonographic visualization. The procedure is
complete when the desired temperature is
obtained.
How is cryoablation Cryoprobes are placed under US guidance
performed? and ablation is performed under real-time
sonographic visualization. The “ice ball”
allows for homogenous tissue destruction.
Helium or passive thawing can be applied
after the freezing portion of the procedure.
What is the most Creating an “ice ball” larger than the
important step on tumor in order to ensure negative margins.
cryoablation?
488 M. J. Uceda and S. Khan

Complications
What are the most common Bleeding, and less
complications of image-guided frequently infection and
breast biopsies? persistent pain.
How can we avoid a pneumothorax Placement of the needle
during the US-guided breast parallel to the chest wall.
biopsy?
What are the complications of Skin burns and mass
breast cancer ablation? formation at the probe site.

Landmark Research
Tomkovich KR. Interventional radiology in the diagnosis and
treatment of diseases of the breast: a historical review and
future perspective based on currently available techniques.
American Journal of Radiology, 2014;203:725-733. https://doi.
org/10.2214/AJR.14.12994
Kreb DL, Looij BG, Ernst MF, et al. Ultrasound-guided
radiofrequency ablation of early breast cancer in a resection
specimen: lessons for further research. Breast 2013;22:543-7.
https://doi.org/10.1016/j.breast.2012.11.004
Nguyen T, Hattery E, Khatri VP. Radiofrequency ablation
and breast cancer: a review. Gland Surgery 2014;3(2):128-135.
https://doi.org/10.3978/j.issn.2227-­684X.2014.03.05
Garcia-Tejedor A, Guma A, Soler T, et al. Radiofrequency
ablation followed by surgical excision versus lumpectomy for
early stage breast cancer: a randomized phase II clinical trial.
Radiology 2018;00(0):1-7. https://doi.org/10.1148/
radiol.2018180235
Toshikazu I, Shoji O, Shinji N, et al. Radiofrequency abla-
tion of breast cancer: a retrospective study. Clinical Breast
Cancer 2017;18(4):e495-500. https://doi.org/10.1016/j.
clbc.2017.09.007
 36 Breast Oncology 489

Sabel MS, Kaufman CS, Whitworth P, et al. Cryoablation of

early-stage breast cancer: work-in-progress report of a multi-­
institutional trial. Ann Surg Oncol 2004; 11:542–549. https://
doi.org/10.1245/ASO.2004.08.003
Manenti G, Scarano AL, Pistolese CA, et al. Subclinical
breast cancer: minimally invasive approaches. Our experience
with percutaneous radiofrequency ablation vs. cryotherapy.
Breast Care (Basel) 2013; 8: 356–360. https://doi.
org/10.1159/000355707
Simmons RM, Ballmar KV, Cox C, et al. A phase II trial
exploring the success of cryoablation therapy in the treat-
ment of invasive breast carcinoma: results from ACOSOG
(Alliance) Z1072. Ann Surg Oncol 2016 Aug;23(8):2438-45.
https://doi.org/10.1245/s10434-­0 16-­5275-­3

Common Questions
What is the BI-RADS classification?
BI-RADS Annual mammogram
1 Normal
BI-RADS Benign Annual mammogram
2
BI-RADS Probably benign Short-term 6 months’
3 follow-up
BI-RADS Suspicious Tissue sampling
4
BI-RADS Highly suspicious Tissue sampling
5
BI-RADS Known biopsy-proven Treat accordingly
6 malignancy
How can we identify the location of breast lesions in
mammography?
490 M. J. Uceda and S. Khan

MLO CC

Superior Lateral

Medial
Inferior

Who is a high-risk BRCA positive (including untested

patient? first-degree relatives), history of chest
radiation, risk model ≥ 20%.
What are the Mammography (preferably
screening Tomosynthesis) and MRI.
recommendations for
high-risk patients?
What is the best time 7–14 days.
of the menstrual cycle
to perform a breast
MRI?
What is a “pancake Breast that compresses < 2 cm. This is a
breast”? specific contraindication for stereotactic
biopsy.
What is the best MRI breast with contrast.
method for follow-up
after breast cancer
ablation?
What devices are Covidien Cool Tip, Integra Elektrotom
available for RFA in HiTT, Boston Scientific LeVeen, and
the breast? Angiodynamics Starburst.
 36 Breast Oncology 491

What is the relevant In 2013, Kreb et al. analyzed the results

data supporting the of cryoablation in 20 lesions ≤ 1.5 cm.
use of RFA in early-­ Complete cell death of the target was
stage breast cancer? reported in 85% of lesions. In 2017, a
retrospective study in Japan evaluated
386 patients and obtained ipsilateral
breast tumor recurrence free (IBTR)
rates of 97%, 94%, and 87% for
tumors ≤ 1 cm, 1.1–2.0 cm and > 2 cm,
respectively.
How does RFA A very recent prospective randomized
compare to clinical trial with 40 subjects
lumpectomy in early-­ demonstrated RFA is effective for
stage breast cancer? local tumor control and that tumor-free
margins were obtained more often with
RFA than with lumpectomy.
How many freeze/ Two freeze/thaw cycles are recommended
thaw cycles are for complete treatment.
recommended
when performing
cryoablation?
What devices Sanarus Visca-2 system and Ice-Cure
are available for Medical IceSense-3 system.
cryoablation in the
breast?
What is the relevant A phase II clinical trial in 2017 evaluated
data supporting the 86 patients and 87 stage I breast cancer
use of cryoablation lesions. When multifocal disease outside
in early-stage breast of the targeted cryoablation zone was
cancer? not defined as an ablation failure, 92%
of the treated cancers had a successful
cryoablation. Littrup et al. analyzed 22
lesions in 11 patients and there were no
local recurrences in 18 months follow-up
after cryoablation.
(continued)
492 M. J. Uceda and S. Khan

How does A multicenter non-randomized clinical

cryoablation compare trial is being conducted to evaluate the
to lumpectomy in potential use of cryoablation instead of
early-stage breast resection in small breast tumors (FROST
cancer? trial). The accrual goal is 220 patients and
the lesions included are ≤1.5 cm without
nodal extension. The primary endpoint is
complete tumor ablation and secondary
endpoints include IBTR rate, breast
cosmesis, and adverse events.

Further Reading
Brant W, Helms C, Vinson E. Fundamentals of diagnostic radiology.
4th ed. Lippincott Williams & Wilkins; 2007. p. 536–67.
D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR
BI-RADS® atlas, breast imaging reporting and data system,
American College of Radiology. Reston, VA; 2013.
Garcia-Tejedor A, Guma A, Soler T, et al. Radiofrequency ablation
followed by surgical excision versus lumpectomy for early stage
breast cancer: a randomized phase II clinical trial. Radiology.
2018;00(0):1–7. https://doi.org/10.1148/radiol.2018180235.
Klein J, Brant W, Helms C, Vinson E. Fundamentals of diagnostic
radiology. 4th ed. Lippincott Williams & Wilkins; 2009.
Kreb DL, Looij BG, Ernst MF, et al. Ultrasound-guided radiofre-
quency ablation of early breast cancer in a resection specimen:
lessons for further research. Breast. 2013;22:543–7. https://doi.
org/10.1016/j.breast.2012.11.004.
Lanza E, Palussiere J, Buy X, et al. Percutaneous image-guided
cryoablation of breast cancer: a systematic review. J Vasc Interv
Radiol. 2015;26:1652–7. https://doi.org/10.1016/j.jvir.2015.07.020.
Mainiero MB, Moy L, Baron P, et al. ACR appropriateness criteria
breast cancer screening. J Am Col Radiol. 2017;14(11):s383–90.
https://doi.org/10.1016/j.jacr.2017.08.044.
Manenti G, Scarano AL, Pistolese CA, et al. Subclinical breast
cancer: minimally invasive approaches. Our experience with per-
cutaneous radiofrequency ablation vs. cryotherapy. Breast Care
(Basel). 2013;8:356–60. https://doi.org/10.1159/000355707.
Mauro M, Murphy K, Thomson K, Venbrux A, Morgan R. Image-­
guided interventions. 2nd ed. Elsevier; 2014. p. 1152–60.
 36 Breast Oncology 493

Nguyen T, Hattery E, Khatri VP. Radiofrequency ablation and

breast cancer: a review. Gland Surg. 2014;3(2):128–35. https://doi.
org/10.3978/j.issn.2227-­684X.2014.03.05.
Noone AM, Howlader N, Krapcho M, et al. (editors). SEER
Fast Stats, 1975–2015. Age-adjusted SEER incidence and mor-
tality rates, 2010–2015. National Cancer Institute. Bethesda,
MD. Accessed on April 19, 2018. https://seer.cancer.gov/fast-
stats/, 2018.
Sabel MS, Kaufman CS, Whitworth P, et al. Cryoablation of
early-stage breast cancer: work-in-progress report of a multi-­
institutional trial. Ann Surg Oncol. 2004;11:542–9. https://doi.
org/10.1245/ASO.2004.08.003.
Simmons RM, Ballmar KV, Cox C, et al. A phase II trial exploring
the success of cryoablation therapy in the treatment of invasive
breast carcinoma: results from ACOSOG (Alliance) Z1072.
Ann Surg Oncol. 2016;23(8):2438–45. https://doi.org/10.1245/
s10434-­0 16-­5275-­3.
Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society
guidelines for breast cancer screening: update 2003. Ca Cancer J
Clin. 2003;53:141–69.
Tomkovich KR. Interventional radiology in the diagnosis and treat-
ment of diseases of the breast: a historical review and future per-
spective based on currently available techniques. Am J Radiol.
2014;203:725–33. https://doi.org/10.2214/AJR.14.12994.
Toshikazu I, Shoji O, Shinji N, et al. Radiofrequency ablation
of breast cancer: a retrospective study. Clin Breast Cancer.
2017;18(4):e495–500. https://doi.org/10.1016/j.clbc.2017.09.007.
 Part V
Hepatobiliary
Chapter 37
Percutaneous Biliary
Interventions
Jacob J. Bundy, Jeffrey Forris Beecham Chick,
and Ravi N. Srinivasa

Evaluating the Patient

What are the common Percutaneous transhepatic
biliary interventions which cholangiography (PTC) and biliary
interventional radiology drainage (PTBD), percutaneous
may offer patients? biliary stent placement, and
percutaneous cholecystostomy
(PC).
(continued)

J. J. Bundy (*)
Department of Radiology, Wake Forest Health,
Winston Salem, NC, USA
e-mail: [email protected]
J. F. B. Chick
Department of Interventional Radiology, University of Washington,
Seattle, WA, USA
R. N. Srinivasa
Department of Radiology, Division of Interventional Radiology,
University of California- Los Angeles, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 497

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_37
498 J. J. Bundy et al.

What are the common The flow of bile may be

causes of benign biliary disrupted by either benign or
obstruction? malignant causes. Benign biliary
obstructions are commonly
caused by migrated cholelithiasis
(gallstones) into the common bile
duct (choledocholithiasis), benign
stricture formation following
invasive procedures, and strictures
related to chronic inflammation
secondary to chronic pancreatitis
or primary sclerosing cholangitis.
What are the common Malignant biliary obstructions
causes of malignant biliary are commonly caused by
obstruction? pancreatic adenocarcinoma,
cholangiocarcinoma, lymphoma,
and metastases from another
primary neoplasm.
What are the physical Jaundice, bilirubinuria (darkening
signs and symptoms of the urine), acholic stool, pruritus,
associated with biliary tree anorexia, nausea, and fatigue.
obstruction?
What are the laboratory The typical cholestatic pattern
studies which are indicative observed during a biliary
of a biliary obstruction? obstruction include elevation in
the serum bilirubin (conjugated
hyperbilirubinemia), elevation of
the serum alkaline phosphatase
out of proportion to the serum
aminotransferases, and elevated
gamma-glutamyl transpeptidase.
 37 Percutaneous Biliary Interventions 499

What imaging studies are Transabdominal ultrasonography

useful in the evaluation (US) is a common imaging
of suspected biliary modality used in the early
obstruction? evaluation; however,
overlying bowel gas may
limit extrahepatic bile duct
evaluation. Magnetic resonance
cholangiopancreatography
(MRCP) and computed
tomographic cholangiography offer
cross-sectional anatomic models to
evaluate the level of obstruction.
What is the role of ERCP is the preferred method
endoscopic retrograde of biliary intervention as it
cholangiopancreatography allows for simultaneous diagnosis
(ERCP) in the evaluation of and treatment of biliary
biliary obstruction? obstructions. Altered anatomy
(Roux-en-Y gastric bypass and
hepaticojejunostomy) and high
bile tree obstructions (obstructions
proximal to or involving the
confluence of the left and right
hepatic ducts), however, are
generally more amenable to
percutaneous interventions.

High Yield History

What is Charcot’s Charcot’s triad refers to the three
triad? Reynold’s classical features associated with
pentad? cholangitis; right upper quadrant pain,
fever, and jaundice. Reynold’s pentad
adds mental status changes and sepsis
or hypotension to the clinical findings
suggestive of cholangitis.
(continued)
500 J. J. Bundy et al.

What is the Bismuth-­ It is a classification system used in

Corlette classification? patients with hilar cholangiocarcinoma
to describe the anatomic location of high
bile ducts obstructions.
What surgical Laparoscopic cholecystectomy.
procedure is most
commonly associated
with biliary leaks?
When seen on imaging, Parenchymal atrophy is caused by
what is the significance chronic biliary or portal venous
of atrophy of affected obstruction. Drainage of these segments
liver segments? is less likely to provide a benefit to
recovered liver function.
What are the A dilated CBD > 6 mm is the generally
findings suggestive of accepted cutoff used to classify the duct
choledocholithiasis on as dilated.
transabdominal US?
The CBD diameter, however, increases
with age, so older adults may have a duct
> 6 mm in the absence of disease.
Other signs of hepatobiliary stone
disease include gallbladder wall
thickening, cholelithiasis, and
pneumobilia.
What is Mirizzi It is defined as the obstruction of the
syndrome and how common hepatic duct secondary to
does it present? extrinsic compression from a stone
located within the cystic duct or
Hartmann’s pouch of the gallbladder. It
also presents with jaundice, fever, and
right upper quadrant pain; however,
particular attention must be directed
toward the detection of potential
cholecystobiliary fistulas.
 37 Percutaneous Biliary Interventions 501

Indications/Contraindications
What are PTC and PTC is a minimally invasive diagnostic
PTBD? procedure that involves the placement
of a small-gauge needle into peripheral
biliary tract under image guidance,
followed by the injection of contrast
to delineate biliary anatomy and
detect biliary obstructions. Following
cholangiography, a tube or stent may be
placed for external or internal drainage
(PTBD).
What is PC? Cholecystostomy is a therapeutic
procedure that involves the image-­
guided placement of a tube for external
drainage of gallbladder contents.
What are the PTC: Define the level of obstruction
indications for in patients with dilated bile ducts,
percutaneous biliary evaluate for bile duct stones, determine
interventions according the etiology of cholangitis, evaluate and
to the Society of determine the site of bile duct leak, and
Interventional determine the etiology of transplanted
Radiology (2010) hepatic graft dysfunction.
guidelines?
PTBD: Provide biliary drainage,
decompress obstructed biliary tree,
divert bile and place stents in bile
duct defects, provide portal of access
to dilate biliary strictures, remove bile
duct stones, stent malignant lesions,
brachytherapy, endoluminal tissue
sample, and foreign body retrieval.
PC: Gallbladder access, management
of cholecystitis, portal for removal of
stones, biliary tract access, decompress
obstructed biliary tract, divert bile from
bile duct defect, and provide portal of
access for the therapeutic processes
listed under PTBD.
(continued)
502 J. J. Bundy et al.

What are the The primary absolute contraindication

contraindications to to these interventions is uncorrectable
percutaneous biliary coagulopathy. The Society of
interventions? Interventional Radiology generally
recommends correcting the INR
to ≤ 1.5 and transfusing platelets
to a level of ≥ 50,000/μL. Relative
contraindications include attempting
access into non-dilated ductal system or
a non-distended gallbladder, allergy to
iodinated contrast agents, and ascites.
When should the Stent placement should not be
placement of internal performed when there is infected bile
biliary stents be or active hemobilia.
avoided?

Relevant Anatomy
What is the route of The confluence of the right and left
biliary drainage? hepatic ducts (the primary biliary
confluence) forms the common
hepatic duct. The common hepatic
duct joins the cystic duct to form
the common bile duct. The common
bile duct joins the pancreatic duct
close to the ampulla of Vater, which
drains into the descending part of the
duodenum.
According to the The left lobe is composed of by
Couinaud classification segment 1 (caudate lobe), segment 2
of liver segments, which (superior and posterior), segment 3
segments compose the (anterior and inferior), and segment 4.
left hepatic lobe? Right The right hepatic lobe is divided into
hepatic lobe? the anterior (segments 5 and 8) and
posterior (segments 6 and 7) sectors
by the right hepatic vein.
 37 Percutaneous Biliary Interventions 503

What is the ideal location Third-order or higher bile ducts

for initial biliary tree are preferable for initial catheter
catheter cannulation? placement so as to avoid injury to
larger central vascular structures and
to ensure adequate working room
proximal to the site of duct injury or
occlusion.
Where are the ducts of The ducts of Luschka (subvesicular
Luschka located and ducts) are small, accessory biliary
what is their importance? ducts 1–2 mm in diameter that
originate in the right hepatic lobe and
course along the center or periphery
of the gallbladder fossa. Following
the cystic duct, the ducts of Luschka
are the most common cause of post-­
cholecystectomy bile leaks.
Where does Within the extrahepatic bile
cholangiocarcinoma most ducts. When the tumor involves
commonly develop? the hepatic bifurcation (hilar
cholangiocarcinoma), it is called a
Klatskin tumor.
What are the Type I: Tumors below the confluence
classifications of of the left and right hepatic ducts.
obstructions used in
Bismuth-Corlette system?
Type II: Tumors reach the confluence,
but do not involve the right and left
hepatic ducts.
Type III: Tumors occluding the
common hepatic ducts and either the
right (IIIa) or left (IIIb) hepatic duct.
Type IV: Tumors that are metacentric
or involve the confluence and both
the right and left hepatic duct.
504 J. J. Bundy et al.

Relevant Materials
Is antibiotic prophylaxis Antibiotic prophylaxis is recommended;
recommended however, no consensus has been
by the Society of reached on the first-line agent.
Interventional Common antibiotics choices include:
Radiology (2010) prior ceftriaxone, ampicillin/sulbactam,
to biliary interventions? cefotetan plus mezlocillin, and
vancomycin or clindamycin plus
aminoglycoside if penicillin-allergic.
What is an internal-­ It is a drainage catheter with a locking
external biliary drain? loop located in the duodenum and
multiple side holes. This form of drain
allows for either external drainage to
a bag or the exteriorized portion of
the catheter may be capped to force
internal drainage of bile.
When would an This form of drain may be placed
external biliary drain be when the biliary obstruction cannot be
placed? crossed or in septic patients in whom
minimal manipulation is desired.
When would stents be Biliary stents are generally placed for
placed within the biliary malignant biliary obstruction when
system? duct patency may be compromised for
a prolonged period. Once stent patency
is confirmed, drains may be removed
leaving the patient without external
devices and improved quality of life.

General Step by Step

What is the A low intercostal approach near the
common anatomic mid-axillary line is preferred to avoid
landmark to select transgression of the lung pleura. Generally,
for right-sided if the needle enters at or below the
biliary drainage? superior margin of the 11th rib, this
complication may be avoided.
 37 Percutaneous Biliary Interventions 505

What is the Sub-xiphoid US-guided puncture using a

common approach 21-gauge needle or fluoroscopic-guidance
for access of the left with the needle directed toward the
biliary system? liver and 30–45 degrees posteriorly and
superiorly.
What signs indicate As the needle is slowly withdrawn, contrast
the puncture of the is injected into the liver parenchyma. When
biliary system? contrast is injected into the hepatic arteries,
a pulsatile flow directed toward the liver
periphery is observed. Hepatic veins and
the portal venous system are non-pulsatile
with flow into right-angled tributaries. Bile
ducts are recognized by slow flow directed
centrally.
After gaining access A 0.018-inch guidewire is inserted into the
into the biliary needle within the biliary system and then a
system, how is coaxial transition set is advanced over the
the biliary system guidewire. This will consist of a 5- or 6-F
decompressed? sheath, which will allow bile to flow out of
the sheath sidearm. This bile may then be
sent for culture.
How are drainage Once obstructions have been crossed
catheters placed using a 0.035-inch straight, floppy tip wire
within the biliary and the wire has been passed into the
system? duodenum, the original wire is exchanged
for a 0.035-inch exchange guidewire. Over
this wire, the tract may be sequentially
dilated to allow placement of an 8- to 12-F
drainage catheter.
How are ductal High-pressure balloons, which are
strictures dilated? oversized by approximately 20% of the
estimated duct diameter, are used to dilate
ductal strictures.
(continued)
506 J. J. Bundy et al.

What are the Under US guidance, the gallbladder is

general steps accessed with a needle and placement
involved with PC? within the gallbladder is confirmed with
fluoroscopic contrast-injection. A guidewire
is then advanced through the needle and
coiled within the gallbladder. Following the
dilation of the tract, an 8-to-10-F locking
pigtail catheter is then advanced and
formed within the gallbladder to allow for
decompression.

Complications
What are the most Sepsis, bile leak, hemorrhage, and
common complications pneumothorax occur at a rate of 2%
following PTC? overall.
What is the most Sepsis generally results from over-­
common cause of sepsis injection of contrast into infected biliary
during PTC? ducts.
What are the most Major complications following
common complications PTBD occur in 8% of cases with
following PTBD? sepsis and hemorrhage as the leading
complications. Other complications
include abscess formation, pleural
transgression, colonic perforation, bile
leak, and death.
What is the leading Injury to the hepatic artery by a needle
cause of major or catheter may lead to extravasation
hemorrhage following or pseudoaneurysm formation.
biliary interventions Bleeding which does not subside within
and how is it managed? 24–48 hours generally requires an
arteriogram followed by intervention
with embolics.
What complications are Bile leak with associated peritonitis,
associated with PC? bleeding, sepsis, and catheter
dislodgement are documented to occur
in 5% of cases.
 37 Percutaneous Biliary Interventions 507

What is the ideal tract Tract placement through the liver and
placement for PC to bare area has been suggested as a more
avoid dislodgement? stable tract that minimizes the impact of
respiratory movement.

Landmark Research
Hepatic arterial injuries after percutaneous biliary interven-
tions in the era of laparoscopic surgery and liver transplanta-
tion: experience with 930 patients.
Fidelman N, Bloom AI, Kerlan RK, LaBerge JM, Wilson
MW, Ring EJ, et al. Hepatic Arterial Injuries after
Percutaneous Biliary Interventions in the Era of Laparoscopic
Surgery and Liver Transplantation: Experience with 930
Patients. Radiology. 2008 Jun 1;247(3):880–6.
• Retrospective review of 930 patients undergoing percuta-
neous biliary interventions to assess for factors associated
with arterial injuries.
• The overall rate of arterial injury in the study population
was 2.2% with no significant difference in the rate of arte-
rial injury among patients with malignant biliary obstruc-
tion, those with a history of bile duct injury, and those with
complications of liver transplantation.
• A 3.7-fold higher rate of AI was observed after PTBD than
after PTC.
Society of Interventional Radiology Quality Improvement
Guidelines for Percutaneous Transhepatic Cholangiography,
Biliary Drainage, and Percutaneous Cholecystostomy
Saad WEA, Wallace MJ, Wojak JC, Kundu S, Cardella
JF. Quality Improvement Guidelines for Percutaneous
Transhepatic Cholangiography, Biliary Drainage, and
Percutaneous Cholecystostomy. Journal of Vascular and
Interventional Radiology. 2010 Jun 1;21(6):789–95.
• Outlines the definitions, indications, and complications for
three commonly performed biliary interventions
508 J. J. Bundy et al.

• Provides procedure-related complication thresholds which

should require a review to be performed to determine
causes and to implement changes if the rates exceed the
thresholds
Comparison of percutaneous transhepatic biliary drainage
and endoscopic biliary drainage in the management of malig-
nant biliary tract obstruction: a meta-analysis.
Zhao X, Dong J, Jiang K, Huang X, Zhang W. Comparison
of percutaneous transhepatic biliary drainage and endoscopic
biliary drainage in the management of malignant biliary tract
obstruction: a meta-analysis. Dig Endosc. 2015
Jan;27(1):137–45.
• Meta-analysis of eight trials including 692 patients the with
management of malignant biliary tract obstruction.
• This study revealed no significant difference in therapeutic
success between PTBD and endoscopic biliary drainage.
• After excluding two studies that appeared to be outliers,
PTBD exhibited a better therapeutic success rate and a
lower incidence of cholangitis than endoscopic biliary
drainage.
Comparing percutaneous primary and secondary biliary
stenting for malignant biliary obstruction: A retrospective
clinical analysis.
Chatzis N, Pfiffner R, Glenck M, Stolzmann P, Pfammatter
T, Sharma P. Comparing percutaneous primary and second-
ary biliary stenting for malignant biliary obstruction: A retro-
spective clinical analysis. Indian J Radiol Imaging.
2013;23(1):38–45.
• Retrospective review of 62 patients undergoing percutane-
ous biliary stenting for obstructive jaundice.
• Secondary biliary stenting (staged procedure) patients had
a higher rate of complications in general as well as a higher
rate of severe complications than patients who underwent
primary biliary stenting.
• By virtue of requiring shorter hospital stays, primary stent-
ing is likely to be more cost-effective.
 37 Percutaneous Biliary Interventions 509

Percutaneous cholecystostomy: long-term outcomes in 324

patients.
Bundy J, Srinivasa RN, Gemmete JJ, Shields JJ, Chick
JFB. Percutaneous Cholecystostomy: Long-Term Outcomes
in 324 Patients. Cardiovasc Intervent Radiol. 2018
Jun;41(6):928–34.
• Retrospective review of 324 patients undergoing cholecys-
tostomy tube placement.
• Technical success rate of tube placement was 100% with
no major complications.
• Mean cholecystostomy tube indwelling time was 89 days;
however, there are a small proportion of patients (4%)
that are continually undergoing cholecystostomy tube
changes with no future plans for definitive treatment.

Common Questions
What is the ideal location Catheters should be positioned
of the drainage catheters to allow the sideholes to be both
to allow for appropriate proximal and distal to the leak or
decompression of the obstruction.
biliary system?
How often should biliary Drains draining bloody bile should
drains be flushed? be flushed with 5–10 mL of normal
saline every 6 to 8 hours. Once
normal appearing bile is draining,
flushing can be performed once
daily.
How long does it take for a Tracts must mature for
tract to mature? approximately 3 weeks before the
catheter may be removed; however,
it may take up to 6 weeks if a trans-­
peritoneal approach was used.
(continued)
510 J. J. Bundy et al.

How often should patients If long-term drainage is required,

under catheter exchanges? catheter exchanges should occur
every 1–3 months, at which time
tube cholangiograms should be
performed to confirm proper
placement.

Further Reading
Cozzi G, Severini A, Civelli E, et al. Percutaneous transhepatic
biliary drainage in the management of postsurgical biliary leaks
in patients with nondilated intrahepatic bile ducts. Cardiovasc
Intervent Radiol. 2006;29:380.
Ginat D, Saad WE, Davies MG, et al. Incidence of cholangitis and
sepsis associated with percutaneous transhepatic biliary drain
cholangiography and exchange: a comparison between liver
transplant and native liver patients. AJR Am J Roentgenol.
2011;196:W73.
Joseph T, Unver K, Hwang GL, et al. Percutaneous cholecystostomy
for acute cholecystitis: ten-year experience. J Vasc Interv Radiol.
2012;23:83.
Kandarpa K, Machan L, Durham JD. Handbook of interventional
radiologic procedures. 5th ed; 2015.
Kühn JP, Busemann A, Lerch MM, et al. Percutaneous biliary drain-
age in patients with nondilated intrahepatic bile ducts compared
with patients with dilated intrahepatic bile ducts. AJR Am J
Roentgenol. 2010;195:851.
Mauro, Matthew A, Kieran PJ, Murphy, Kenneth R, Thomson,
Anthony C, Venbrux, Robert A, Morgan. Image-guided inter-
ventions. 2014.
Morse BC, Smith JB, Lawdahl RB, Roettger RH. Management of
acute cholecystitis in critically ill patients: contemporary role
for cholecystostomy and subsequent cholecystectomy. Am Surg.
2010;76:708.
Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS,
Walker TG, et al. Addendum of newer anticoagulants to the SIR
consensus guideline. J Vasc Interv Radiol. 2013;24(5):641–5.
Patel N, Chick JFB, Gemmete JJ, Castle JC, Dasika N, Saad WE,
et al. Interventional radiology-operated cholecystoscopy for the
management of symptomatic cholelithiasis: approach, technical
 37 Percutaneous Biliary Interventions 511

success, safety, and clinical outcomes. AJR Am J Roentgenol.

2018;210(5):1164–71.
Srinivasa RN, Patel N, Hage AN, Chick JFB. Interventional radiol-
ogy-operated cholecystoscopy and cholecystolithotripsy: a guide
for interventionalists. J Vasc Interv Radiol. 2018;29(4):585.
Teplick SK, Flick P, Brandon JC. Transhepatic cholangiography in
patients with suspected biliary disease and nondilated intrahe-
patic bile ducts. Gastrointest Radiol. 1991;16:193.
Venkatesan AM, Kundu S, Sacks D, Wallace MJ, Wojak JC, Rose SC,
et al. Practice guidelines for adult antibiotic prophylaxis dur-
ing vascular and interventional radiology procedures. Written
by the Standards of Practice Committee for the Society of
Interventional Radiology and Endorsed by the Cardiovascular
Interventional Radiological Society of Europe and Canadian
Interventional Radiology Association. J Vasc Interv Radiol.
2010;21(11):1611–30.
Chapter 38
Transjugular Intrahepatic
Portosystemic Shunt (TIPS)
Andrew Moore

Evaluating the Patient

Which details of a It is important to evaluate the patient’s
cirrhotic patient’s overall functional status, baseline liver
history would be function, any baseline encephalopathy, the
most pertinent prior presence of a liver tumor, and any prior
to the procedure? treatments to the liver.
Why is it important TIPS can be performed under both
to evaluate the moderate sedation and general anesthesia.
patient’s mental Indications for general anesthesia may
status on physical include patients with severe hepatic
exam? encephalopathy, who are unable to follow
commands, as well as a critically ill patient
in the setting of intractable bleeding.
(continued)

A. Moore (*)
Department of Radiology, Integris Baptist Medical Center,
Oklahoma City, OK, USA

© Springer Nature Switzerland AG 2022 513

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_38
514 A. Moore

What physical exam The presence or absence of ascites. It

abdominal finding is common to perform a large-volume
may potentially paracentesis prior to the procedure for
interfere with the tense ascites. Additional pertinent physical
TIPS procedure? exam findings include evaluation of mental
status (as described above), presence of
asterixis, signs of right heart failure, and
stigmata of portal hypertension such as
caput medusa.
What are the CBC, PT, INR, serum albumin, total
necessary laboratory bilirubin, and serum creatinine.
values to obtain pre-­
procedurally?
In the elective Platelets > 50,000/cm3 and INR < 1.8.
setting, what are Coagulopathies should be corrected prior
acceptable platelet/ to proceeding, if possible.
INR values?
Why is it important Antibiotic prophylaxis should be
to clarify possible administered immediately prior to starting
antibiotic allergies the procedure per Society of Interventional
for the TIPS Radiology guidelines to prevent against
procedure? “endotipsitis” originating from possible
pathogens in the skin, biliary, and enteric
flora. Skin coverage is usually provided
by cefazolin while biliary and enteric
flora require much wider coverage.
Possible medication allergies would
guide an appropriate choice; for example,
vancomycin or clindamycin in those with
cephalosporin allergy. In addition, allergies
to contrast and lidocaine should be
clarified.
Which risks should The patient should be aware that there
be discussed with is a 1% procedure-related mortality.
and detailed for Additionally, there is inherent risk of
the patient during developing new or exacerbating pre-­
informed consent? existing hepatic encephalopathy.
38 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 515

What history is Any recurrent ascites in a patient with

pertinent for the a prior TIPS should be evaluated for
evaluation of a malfunction. Non-invasive evaluation of a
patient with a prior TIPS is performed utilizing color Doppler
TIPS placement? ultrasound to evaluate for signs of stenosis
Important or complete occlusion. Signs of possible
ultrasound findings? stenosis include a velocity of > 190 cm/sec
at a stenotic segment and/or a velocity of
< 90 cm/sec in non-stenotic segments of
the stent. Phasic waveforms are expected
within the TIPS stent.

High Yield History

What are the most Pre-sinusoidal: Portal vein thrombosis
common causes of pre-­ and extrinsic compression of the portal
sinusoidal, sinusoidal, vein
and post-sinusoidal
portal hypertension?
Sinusoidal: Cirrhosis
Post-sinusoidal: Budd-Chiari syndrome,
hepatic veno-occlusive disease and right
heart failure
For a cirrhotic patient Upper endoscopy should be the first-
with acute upper line diagnostic exam to confirm the
GI bleeding, what source of variceal bleeding and to
confirmatory exam document variceal location. Additionally,
should be performed endoscopy serves as the first-line
prior to considering treatment for patients who present with
TIPS? acute upper GI hemorrhage.
Which pre-procedural Preoperative CT or MRI of the liver
imaging procedures can can be helpful for assessing patency and
be helpful for operative position of the portal veins, presence of
planning? ascites, presence and location of varices
and spontaneous portosystemic shunts,
size of the liver, and signs of right heart
failure. Additionally, Doppler ultrasound
can confirm patency of the portal system.
(continued)
516 A. Moore

What information Prior episodes of variceal bleeding, as

specifically regarding well as whether or not endoscopic or
variceal bleeding is medical therapy has been attempted to
important to obtain control variceal hemorrhage.
from the patient’s
history?
Why is it important to If the patient’s post-procedure
establish and document encephalopathy is significantly
the patient’s baseline worsened from baseline, a TIPS
hepatic encephalopathy modification may be required.
pre-procedurally?
What is the importance MELD (calculation below) can be a
of the Model for End-­ predictor of patient mortality following
Stage Liver Disease a TIPS procedure. Additionally, it is
(MELD) score in the important to establish pre-procedurally
setting of possible TIPS whether or not the patient is a viable
placement? transplant candidate. The most recent
version of the MELD score corrects
for serum sodium level and scores ≥18
have demonstrated 18% and 35% 1- and
3-month mortality, respectively.
MELD = 9.6 log e (creatinine mg/dL)
+ 3.8 × log e (bilirubin mg/dL)
+ 11.2 × log e (INR) + 6.4
What is the most Decreased urine output in the setting of
pertinent patient known liver failure would be suspicious
history when for hepatorenal syndrome, especially
evaluating for in the setting of an acutely increased
hepatorenal syndrome serum creatinine level. A complex
(HRS)? phenomenon, HRS is thought to be
related to decreased renal blood flow
associated with changes of cirrhosis.
38 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 517

Indications/Contraindications
What are the Variceal hemorrhage not controlled by
principle indications endoscopy/medical therapy, refractory
for the TIPS ascites, refractory hepatic hydrothorax,
procedure? and Budd-Chiari syndrome.
Is hepatorenal Emerging indications for TIPS include:
syndrome an hepatorenal syndrome, portal hypertensive
indication for TIPS? gastropathy, TIPS for first-time variceal
hemorrhage, and early TIPS for ascites
What are the Severe hepatic failure, sepsis, severe
5 absolute heart failure, pulmonary hypertension or
contraindications to isolated gastric varices with splenic vein
TIPS? occlusion. Isolated gastric varices in the
presence of splenic vein occlusion is a sign
of sinistral (left-sided) hypertension, which
has different treatment options.
What are Severe hepatic encephalopathy, platelet
some relative count less than 50,000, INR >1.8, biliary
contraindications to dilatation, and portal vein cavernous
TIPS? transformation.

Relevant Anatomy
The TIPS procedure Hepatic vein to portal vein.
connects which vessels
within the liver?
Specifically, which is the Right hepatic vein (RHV) into right
most common vascular portal vein (RPV), which is typically
connection to make for a easiest technically and safest due
TIPS? to its spatial relationship with other
critical vascular structures.
What is the anatomic RHV is posterior and superior to the
relationship between the RPV.
RHV and RPV?
(continued)
518 A. Moore

What is the anatomic The MHV can lie anterior to the

relationship between the RPV, necessitating punctures to be
RPV and middle hepatic angled posteriorly.
vein (MHV)?
What risk is associated Hepatic capsular perforation.
with anterior puncture
from the middle hepatic
vein (MHV)?
What is the best Lateral projection can be easier than
projection for the AP projection to differentiate
distinguishing the RHV between the RHV and MHV.
from the MHV?
What two methods Wedged hepatic venography or
are available for intravascular ultrasound.
intraprocedural
visualization of the portal
veins?
Which contrast agents Conventional contrast or CO2.
are useful for portal vein
visualization?

Relevant Materials
What does a standard Multiple companies produce TIPS
TIPS set include? kits, including the Ring, Rosch-
Uchida and Colapinto sets. Although
kits slightly vary in contents, the
standard set includes:
 40 cm 10 Fr sheath with end
marker
 51 cm curved guide catheter with
metal stiffener
 60 cm long sheathed needle
38 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 519

Which guidewires are 3 mm J wire, regular and stiff curved

most commonly utilized hydrophilic wires, and regular and
and should be available? short-tip Amplatz wires.
What sizes of angioplasty 5–12 mm diameter by 4–8 cm in
balloons should you have length balloon catheters.
available during a TIPS?
What are the most 8, 10, and 12 mm. The most
common stent/stent graft commonly deployed size is 10 mm
diameter sizes used for in diameter with controlled-­
TIPS procedures? expansion technology, allowing
initial deployment to post-dilate
typically to 8 mm, with the possibility
of future dilatation to 10 mm if
clinically necessary.
What equipment is Vascular pressure transducer to
necessary for pressure measure the portosystemic pressure
measurements during the gradient. To obtain this gradient,
procedure? pressures are obtained in the right
atrium and in the accessed portal
vein.
What is the most GORE VIATORR TIPS
commonly used stent-graft Endoprosthesis.
for TIPS procedures?
Most modern TIPS stents The uncovered portion of the stent
are partially covered and should sit in the portal side of the
partially uncovered. What tract. A radiopaque band on the
is the most appropriate stent-graft should indicate the
orientation for the bare transition point between covered and
portion of the stent? uncovered stent.

General Step by Step

Where is the most Right internal jugular vein via
common site of initial ultrasound-guidance.
access?
(continued)
520 A. Moore

Which vessel is Hepatic vein, usually the right.

initially catheterized
in the liver?
What is the sequence Wedged hepatic venogram (with contrast
of steps that precede a or CO2), then puncture from hepatic vein
portal venogram? to intrahepatic portal vein, followed by a
portal venogram.
What is the purpose To assess the patency of the main portal
of the portal vein & major feeding vessels (splenic
venogram? vein and superior mesenteric vein), and
the presence or absence of varices.
After confirming Mean pressure gradient between the
the patency of the portal vein and right atrium.
portal vein, a pressure
gradient is then
measured between
which two structures
prior to advancing
with the TIPS
procedure?
Which step may need Dilation of the intrahepatic parenchymal
to be performed prior tract, typically with a 3–4 cm length
to deployment of the balloon.
stent graft?
What are the target If the indication is for variceal bleeding,
gradient goals for the target is < 12 mmHg. If the indication
variceal bleeding and is for refractory ascites, an approximately
refractory ascites? 50% reduction from the initial gradient
measurement may correspond well with
TIPS efficacy. However, some operators
use < 12 mmHg as a target goal for
refractory ascites as well. Depending
on these measurements, further shunt
dilation can be performed to achieve
target goals.
38 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 521

What additional step Embolization of varices.

should be considered
in patients whose
indication for TIPS is
variceal bleeding?
What is the final run Completion portal venogram
you should document demonstrating shunt patency.
for the procedure?

Complications
What is the There is a 1% peri-procedural mortality
peri-procedural risk for the TIPS procedure.
mortality risk for the
procedure?
What are some major Cardiac decompensation, acceleration of
acute postprocedural liver failure, intraperitoneal bleeding, and
complications hepatic encephalopathy.
following a TIPS
procedure?
Which patients are Patients with baseline poor hepatic
most at risk for synthetic function. Encephalopathy is
encephalopathy related to increased CNS exposure to
following the ammonia following TIPS.
procedure?
What are the Hepatic capsular perforation or extra-­
major causes of hepatic portal puncture.
post-procedural
intraperitoneal
bleeding?
(continued)
522 A. Moore

What is the MELD 0–12 is low risk, MELD 13–17

relationship between is some risk, MELD 18–25 is high risk,
TIPS complications MELD > 25 indicates TIPS to be used for
and the patient’s compassionate care only.
MELD (Model for
End-Stage Liver
Disease) score?
What is the most Graft stenosis.
common cause of
long-term TIPS
failure?
Which are expected Expected blood flow through a TIPS stent
ultrasound features of is toward the heart. Normal hepatopedal
TIPS evaluation? flow through the right and left portal
veins may change to hepatofugal
(retrograde) due to new, preferential flow
through the low-resistance shunt. US
findings – hepatopedal flow – portal vein
to hepatic vein, velocities between 80 and
180 cm/sec.
Which portion of the Hepatic vein side (cephalic) > mid-graft
graft is most likely to stenosis > portal vein side (caudal). Signs
develop stenosis? of cephalic stenosis are decreased main
portal vein and midshunt velocities,
especially if they are progressively
decreasing on the follow-up exam.
Velocity at the stenotic segment will
be increased (often >200 cm/s) and
demonstrate aliasing. It is important
to note that the length of the stenotic
segment between the hepatic vein and
IVC is variable.
What are signs of Acute variceal hemorrhage and
TIPS shunt severe reaccumulating ascites.
stenosis or occlusion?
38 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 523

Landmark Research
Colapinto, Rf, et al. “Formation of Intrahepatic Portosystemic
Shunts Using a Balloon Dilatation Catheter: Preliminary
Clinical Experience.” American Journal of Roentgenology,
vol. 140, no. 4, 1983, pp. 709–714., doi:https://doi.org/10.2214/
ajr.140.4.709.
• This research in the early 1980s demonstrated the use of
balloon dilation to improve effectiveness and patency of a
portosystemic shunt created in the liver.
García-Pagán, Juan Carlos, et al. “Early Use of TIPS in
Patients with Cirrhosis and Variceal Bleeding.” New England
Journal of Medicine, vol. 362, no. 25, 2010, pp. 2370–2379.
• Treatment of recurrent or refractory variceal bleeding in
patients with advanced liver disease can still have a poor
prognosis following a rescue TIPS procedure. This study
demonstrates potential benefit of having a lower threshold
for earlier TIPS placement in these patients in order to
achieve better long-term outcomes.
Laberge, J M, et al. “Creation of Transjugular Intrahepatic
Portosystemic Shunts with the Wallstent Endoprosthesis:
Results in 100 Patients.” Radiology, vol. 187, no. 2, 1 May 1993,
pp. 413–420.
• One of the first large group (100 patient) studies in the
early 1990s establishing the effectiveness of TIPS as a “reli-
able means of lowering portal pressure and controlling
variceal bleeding.”
Ochs, Andreas, et al. “The Transjugular Intrahepatic
Portosystemic Stent–Shunt Procedure for Refractory Ascites.”
New England Journal of Medicine, vol. 332, no. 23, 4 May
1995, pp. 1192–1197.
• Prospective study clearly demonstrating effectiveness of
TIPS to treat refractory ascites.
524 A. Moore

Palmaz, Jc, et al. “Expandable Intrahepatic Portacaval

Shunt Stents: Early Experience in the Dog.” American
Journal of Roentgenology, vol. 145, no. 4, 1985, pp. 821–825.
• Early work in dogs in the mid-80s demonstrating the use
of expandable stents within a portosystemic tract in liver
parenchyma, which helped lay groundwork for more long-­
term tract patency when implemented in human subjects.
Perarnau, Jean Marc, et al. “Covered vs. Uncovered Stents
for Transjugular Intrahepatic Portosystemic Shunt: A
Randomized Controlled Trial.” Journal of Hepatology, vol. 60,
no. 5, 2014, pp. 962–968.
• Large, multicenter, randomized controlled trial comparing
the effectiveness and patency of covered versus bare stents
for TIPS creation. Findings showed a 39% reduction in
stent dysfunction when using covered stents instead of
bare stents.
Richter, Goetz M., et al. “Transjugular Intrahepatic
Portacaval Stent Shunt: Preliminary Clinical Results.”
Radiology, vol. 174, no. 3, 1990, pp. 1027–1030.
• Early results from using balloon-expandable stents for
TIPS in human patients, described as a “promising alterna-
tive to current therapy in high-risk patients with esopha-
geal bleeding.”
Rossle, Martin, et al. “The Transjugular Intrahepatic
Portosystemic Stent-Shunt Procedure for Variceal Bleeding.”
New England Journal of Medicine, vol. 330, no. 3, 1994,
pp. 165–171.
• Large-volume (n = 100) study demonstrating the effective-
ness of TIPS for variceal bleeding in the setting of portal
hypertension secondary to hepatic failure.
Rösch, J., et al. “Transjugular Intrahepatic Portacaval
Shunt an Experimental Work.” The American Journal of
Surgery, vol. 121, no. 5, 1971, pp. 588–592.
38 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 525

• Initial description of the intentional percutaneous creation

of an intrahepatic shunt between the systemic and portal
circulation as an alternative to surgically created shunts for
portal hypertension.
Sanyal, Arun J., et al. “Transjugular Intrahepatic
Portosystemic Shunts Compared with Endoscopic
Sclerotherapy for the Prevention of Recurrent Variceal
Hemorrhage.” Annals of Internal Medicine, vol. 126, no. 11, 1
June 1997, pp. 849–857.
• Randomized, controlled trial comparing the effectiveness
of TIPS versus endoscopic sclerotherapy to prevent recur-
rent variceal bleeding. Study demonstrates equivalency
over the long-term, with possible survival benefit with
sclerotherapy.

Common Questions
What is the target 8–12 mmHg.
portosystemic gradient
post-TIPS?
What is the 1-year 50%.
primary patency rate for
bare-metal TIPS stents?
What is the preferred Interval follow-up Duplex ultrasound
modality for post-­ to confirm patency. Baseline evaluation
procedure TIPS should be obtained at 1 week for
surveillance/evaluation? Wallstents and 1 month for covered
stents. Follow-up ultrasound exams
should then be obtained at 3 months
after baseline and then every 6 months
thereafter.
What is a normal TIPS 90–190 cm per second.
velocity range?
(continued)
526 A. Moore

If there is concern for Venography.

stent malfunction, what
is the next best step for
diagnostic evaluation?
What is the most Balloon angioplasty and/or re-stenting.
common treatment for a
thrombosed stent?
What treatment options Reduction of the TIPS shunt can be
are available for a accomplished using a parallel stent
patient experiencing technique in which covered and
severe hepatic uncovered stents are placed in the
encephalopathy existing stent. After the dilation of the
following a TIPS covered stent, the uncovered stent can
procedure? then be dilated to a desired diameter,
which also narrows the diameter of the
adjacent covered stent.

Further Reading
Colapinto RF, et al. Formation of intrahepatic portosystemic shunts
using a balloon dilatation catheter: preliminary clinical experi-
ence. Am J Roentgenol. 1983;140(4):709–14.
García-Pagán JC, et al. Early use of TIPS in patients with cirrhosis
and variceal bleeding. New Engl J Med. 2010;362(25):2370–9.
Kaufman JA, Lee MJ. Vascular and interventional radiology.
Elsevier/Saunders; 2014.
Kessel D, Robertson I. Interventional radiology: a survival guide.
Elsevier; 2017.
Laberge JM, et al. Creation of transjugular intrahepatic portosys-
temic shunts with the wallstent endoprosthesis: results in 100
patients. Radiology. 1993;187(2):413–20.
Ochs A, et al. The transjugular intrahepatic portosystemic stent–
shunt procedure for refractory ascites. New Engl J Med.
1995;332(23):1192–7.
Palmaz JC, et al. Expandable intrahepatic portacaval shunt stents:
early experience in the dog. Am J Roentgenol. 1985;145(4):821–5.
38 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 527

Perarnau JM, et al. Covered vs. uncovered stents for transjugular

intrahepatic portosystemic shunt: a randomized controlled trial.
J Hepatol. 2014;60(5):962–8.
Richter GM, et al. Transjugular intrahepatic portacaval stent shunt:
preliminary clinical results. Radiology. 1990;174(3):1027–30.
Rossle M, et al. The transjugular intrahepatic portosystemic
stent-shunt procedure for variceal bleeding. N Engl J Med.
1994;330(3):165–71.
Rösch J, et al. Transjugular intrahepatic portacaval shunt an experi-
mental work. Am J Surg. 1971;121(5):588–92.
Rösch J, et al. The birth, early years, and future of interventional
radiology. J Vasc Interv Radiol. 2003;14(7):841–53.
Saad WEA, et al. Vascular and interventional imaging. Elsevier;
2016.
Sanyal AJ, et al. Transjugular intrahepatic portosystemic shunts
compared with endoscopic sclerotherapy for the prevention of
recurrent variceal hemorrhage. Annals of Internal Medicine.
1997;126(11):849–57.
Chapter 39
Balloon-Occluded
Retrograde Transvenous
Obliteration (BRTO)
Rupal Parikh

Evaluating the Patient

What is BRTO? Balloon-occluded retrograde transvenous
obliteration is an endovascular technique
used to treat gastric varices, particularly
when endoscopy fails or in patients with
contraindications to a transjugular intrahepatic
portosystemic shunt (TIPS) procedure.
BRTO dates back to 1984 when it was called
“transrenal-vein reflux ethanol sclerosis” and
was subsequently refined in Japan.
What are BRTO is used as a therapeutic adjunct or
the common alternative to TIPS in patients with isolated
indications for gastric varices and in patients with a de novo
BRTO? portosystemic shunt complicated by hepatic
encephalopathy. Thus, BRTO is performed in
patients with encephalopathy post-TIPS but
can also be performed in patients with isolated
gastric varices, such as in patients with splenic
vein thrombosis.
(continued)

R. Parikh (*)
Division of the Interventional Radiology, Hospital of the University
of Pennsylvania, Philadelphia, PA, USA

© Springer Nature Switzerland AG 2022 529

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_39
530 R. Parikh

What Approximately 30% of patients with cirrhosis

percentage develop variceal bleeding and of those,
of patients approximately 10–20% are gastric variceal
with cirrhosis bleeding.
develop variceal
bleeding?
What are the BRTO is less invasive than a TIPS procedure
advantages of and can be utilized in patients with hepatic
BRTO over encephalopathy and diminished hepatic
TIPS? reserve, suggesting a liver protective role. TIPS
is less efficacious in treating gastric varices as
compared with esophageal varices.
What causes Portal hypertension and portal vein thrombosis
gastric varices? secondary to cirrhosis result in back pressure
from hepatofugal flow, creating shunts, such as
gastrorenal and gastrocaval shunts, which feed
gastric varices.
Which gastric Hematemesis is one of the signs of actively
varices are bleeding gastric varices. Hemodynamically
prone to unstable patients must be clinically stabilized
rupture? with intravenous fluid and blood transfusion
while preventing volume overload or
exacerbating portal hypertension. Varices
at high risk for rupture are those that are
large, rapidly growing, and with red spots on
endoscopy.
What imaging Endoscopy with or without endoscopic
studies are ultrasound (EUS) is the initial diagnostic and
useful in the therapeutic step in the evaluation of gastric
evaluation varices. In addition, triple-phase computed
of suspected tomography (CT) or enhanced magnetic
gastric varices? resonance angiography/venography (MRA/
MRV) without enteric contrast can be used to
delineate the anatomy of the gastric varices.
How is a patient Endoscopic variceal banding should precede
with esophageal BRTO as BRTO can exacerbate esophageal
varices and high varices.
flow gastric
varices treated?
 39 Balloon-Occluded Retrograde Transvenous… 531

High Yield History

What is the most Esophageal followed by gastric
common cause of upper varices are the most common cause
gastrointestinal bleeding of upper gastrointestinal bleeding
in patients with portal in patients with a history of portal
hypertension? hypertension.
What is the Child-Pugh The Child-Pugh score is based on
score? the presence of ascites, presence
of hepatic encephalopathy, total
bilirubin, albumin, and prothrombin
time/INR to determine the severity of
liver dysfunction.

Factor 1 point 2 points 3 points

Ascites None Mild Moderate/
Severe
Hepatic None Grade 1 Grade 3 or 4
encephalopathy or 2
Total bilirubin (mg/ <2 2–3 >3
mL)
Albumin (mg/mL) > 3.5 2.8–3.5 < 2.8
PT (s) [or INR] < 4 [< 4–6 [1.71– > 6 [> 2.30]
1.7] 2.30]
Severity of cirrhosis
Child-Pugh A 5–6 points
Child-Pugh B 7–9 points
Child-Pugh C 10–15 points
(continued)
532 R. Parikh

What is the model The MELD score is a calculation based

for end-stage liver on total bilirubin, creatinine, and INR to
disease (MELD) determine the severity of liver dysfunction
score? and determine ranking for liver
transplantation. Serum sodium was later
added to the calculation, which is referred
to as the MELD-Na score.
What veins form the The splenic vein, superior mesenteric
portal vein? vein, and the right and left gastric veins
come together to form the portal vein.
Infrequently, the inferior mesenteric vein
also drains into the portal vein. The left
renal vein drains directly into the inferior
vena cava and provides an alternative
route of drainage in patients with portal
hypertension who have developed
gastrorenal shunts.
What is a TIPS is an endovascular treatment to
transjugular decompress the portal venous system by
intrahepatic placing a stent between the portal and
portosystemic shunt hepatic veins in patients with refractory
(TIPS)? ascites or variceal bleeding.
How are gastric Gastric varices secondary to splenic vein
varices from splenic thrombosis tend to involve multiple short
vein thrombosis gastric veins along the greater curvature
different from those of the stomach whereas those secondary
secondary to portal to portal hypertension are more likely to
hypertension? involve gastrorenal or gastrocaval shunts
in the fundus.
What are the most The most common causes of splenic
common causes vein thrombosis include pancreatitis,
of splenic vein local malignancy, and splenectomy.
thrombosis? Treatment options for gastric varices
secondary to splenic vein thrombosis
include splenectomy and splenic artery
embolization.
 39 Balloon-Occluded Retrograde Transvenous… 533

Indications/Contraindications
When would BRTO BRTO is used as an adjunct/alternative
be indicated? to TIPS in patients with gastric
varices and in patients with a de novo
portosystemic shunt complicated by
hepatic encephalopathy. Large fundic
or cardiac gastric varices with high flow
may be treated with BRTO as opposed
to endoscopic treatment due to the
increased risk of systemic delivery of
sclerosant with endoscopic management.
How does the In portal vein thrombosis, gastrorenal
presence of portal and gastrocaval shunts are the pathways
vein thrombosis affect by which venous return from the splenic
the management of and mesenteric vasculature occurs. By
gastric varices? embolizing these shunts, the mechanism
by which the splenic and mesenteric
systems drain would be eliminated.
This can lead to mesenteric venous
hypertension, mesenteric ischemia, and
mesenteric thrombosis, particularly
in the absence of other collateral
vessel formation (i.e., cavernous
transformation).
How does the BRTO will increase hepatopetal flow
presence of a and thus flow through the portal vein
diminutive/narrow would be increased and potentially
portal vein affect the overwhelmed.
management of gastric
varices?
What effect does BRTO can exacerbate abdominal ascites
BRTO have on pre-­ in patients with decompensated liver
existing abdominal failure. Thus, a risk-benefit discussion
ascites? should be had regarding the possibility of
future TIPS placement.
(continued)
534 R. Parikh

What are additional Additional contraindications include

contraindications for severe coagulopathy, portal vein
BRTO? thrombosis, and uncontrolled esophageal
variceal bleeding.
What is the most Hepatic reserve followed by
important determinant hepatocellular carcinoma (HCC)
in survival post-­ is the most important factor in
BRTO? determining survival after BRTO. Some
consider HCC greater than 5 cm a
contraindication to BRTO.

Relevant Anatomy
How is a gastrorenal Using either transjugular or transfemoral
shunt accessed? approach, the left renal vein is catheterized
to access the gastrorenal shunt.
What are other Alternative approaches to accessing a
non-conventional gastric-variceal system include transcaval,
methods of accessing trans-phrenic, trans-pericardiac, trans-
a gastric-variceal ieocolic, trans-TIPS, trans-gonadal, trans-­
system? azygous, and trans-renal capsular vein.
What are the The left gastric vein, posterior gastric
common inflow vein, and short gastric veins are the most
vessels? common afferent veins.
What are the most Gastrorenal and gastrocaval varices
common types of are the most common types of shunts.
shunts/varices? Gastrorenal shunts provide venous
outflow in 90% of cases.
 39 Balloon-Occluded Retrograde Transvenous… 535

How are One commonly used method to classify

gastroesphageal gastric varices is Sarin’s classification, an
varices anatomically endoscopic-based approach. Varices are
classified? classified into gastroesophageal (GOV)
and isolated gastric (IGV) varices.
Gastroesophageal varices are divided into
varices present along the lesser (GOV1;
70% of GV) versus greater curvatures
(GOV2; 20% of GV). Both GOV1 and
GOV2 arise from the left gastric vein and
drain to the IVC via the subdiaphragmatic
left vein. Isolated gastric varices are
divided into varices along the fundus
(IGV1; 7% of GV) and along the body
or antrum (IGV2; 2% of GV). IGVs arise
from short gastric veins or the posterior
gastric vein and may drain into the IVC
via the left subdiaphragmatic vein or
left renal vein via a gastrorenal shunt.
GOV2 and IGV1 are fundic varices.
GOV1 account for 20% of gastric variceal
bleeding, whereas fundic varices (30% of
GV) account for 70% of gastric variceal
bleeding.
What afferent Inferior phrenic veins.
veins are in close
proximity to GOV1/2
and IGV1 varices
and should be
embolized prior to
GV sclerosis?
(continued)
536 R. Parikh

What are the Venous drainage patterns are categorized

different types of as type A through D. Type A has a single
venous drainage draining vein, such as a gastrorenal shunt
patterns of a varix? and less commonly a gastrocaval shunt.
This is the simplest type of shunt. Type B
has a single shunt with multiple draining
veins that lead to the IVC/right atrium.
Type C has a gastrocaval and gastrorenal
shunt. Type D, which is not amenable to
BRTO, has multiple draining veins without
a shunt.
What are the There are B1 and B2 varices, in which
different types of the collateral draining veins are small to
Type B varices? medium in size and/or numerous. Type B3
varices have larger collateral veins, which
can be selected and embolized with coils
prior to variceal obliteration.
What are the There are C1 and C2 varices. C1 varices
different types of have a small shunt size. C2 varices have a
Type C varices? large shunt size.
What are the Draining veins include pericardiophrenic,
different draining ascending lumbar, intercostal,
veins? perivertebral, and least commonly, the
azygous vein.
What are the Varices can also be classified based on
different venous venous inflow patterns, types 1–3. In
inflow patterns? type 1 varices, there is a single afferent
gastric vein (i.e., the left or posterior
gastric vein). In type 2 varices, there are
multiple afferent gastric veins (i.e., left and
posterior gastric veins). In type 3 varices,
an afferent vein(s) drains into the shunt
without contributing to the gastric varix.
 39 Balloon-Occluded Retrograde Transvenous… 537

Relevant Materials

What is the An occlusion balloon aids in diagnostic

purpose of using evaluation of the gastric-variceal system/
an occlusion complex by occluding the gastrorenal/
balloon? gastrocaval shunt. An occlusion balloon also
aids in the therapeutic sclerosis of the varix
by minimizing reflux of sclerosant into the
systemic or portal systems.
What materials The original sclerosant utilized was
are commonly ethanolamine oleate iopamidol (EOI), which
used as is a hemolytic agent. Sodium tetradecyl
sclerosant? sulfate (STS) and polidocanol are also
sclerosants with 3% STS being the most
frequently utilized sclerosant in the United
States. Foam versions of these sclerosants
have better variceal wall contact and require
potentially less dose of sclerosant.
How do foam Foam sclerosants displace blood volume,
sclerosants form rise anti-gravitationally into the varix, and
better variceal also have a greater surface area for variceal
wall contact? wall contact. Expansion of the sclerosant
with Tessari methods (mixture of air with
sclerosant) allows for greater treatment with
less dose. Foam sclerosants are also used to
treat lower extremity varicose veins.
What are the STS is mixed with room air as well as lipiodol
foam sclerosants for visualization in a ratio of 2 mL of STS,
mixed with? 1 mL of lipiodol, and 3 mL air. A foam
version of EOI consists of 10 mL of 10%
ethanolamine oleate mixed with 10 mL of
iodinated contrast, 20 mL of air, and 2 mL
3% foam polidocanol.
(continued)
538 R. Parikh

How is selective A microcatheter can be advanced through

embolization the occlusion balloon and positioned near
performed? the afferent vein to facilitate the reflux of the
sclerosant, limiting the amount of sclerosant
needed and reducing the risk of balloon
rupture by spatially separating the balloon
from the sclerosant.
How is the Intermittent fluoroscopy is used to monitor
embolization the delivery and stagnation of sclerosant
monitored? within the varix. In anatomically challenging
cases, cone-beam CT may also be used.
What are newer Modified techniques include vascular plug-­
modifications to assisted retrograde transvenous obliteration
the classic BRTO (PARTO), coil-assisted retrograde
technique? transvenous obliteration (CARTO), and
balloon-occluded antegrade transvenous
obliteration (BATO).
What follow-up CT venography, MRV, or EUS can be used
imaging is for follow-up imaging to assess for variceal
performed? obliteration. Follow-up with endoscopy
is also performed, particularly in cases of
exacerbated esophageal varices.
What Antibiotics prophylaxis is determined
preprocedural based on local resistance patterns; however,
antibiotics are intravenous ceftriaxone 1 gram per day for no
administered? more than 7 days is currently recommended.
Fluoroquinolones have also been used for
gastrointestinal coverage.

General Step by Step

What is the Although right internal jugular approach can be
most common used, right femoral venous approach is the most
access approach common. Patient anatomy must be taken into
for BRTO? account when determining which approach is
more favorable.
 39 Balloon-Occluded Retrograde Transvenous… 539

How is the size The diameter of the occlusion balloon is based

of the occlusion on the size of the communicating gastrorenal
balloon shunt at the intended site of balloon occlusion,
selected? typically 6–20 mm. This is measured by
assessing the diameter of the base of the shunt
where it joins the left renal vein. Additional
areas of narrowing within the shunt are also
assessed for optimal balloon placement.
Occlusion balloon placement is dependent on
diameter and stability.
How are C1 C1 varices are catheterized through a
varices treated gastrorenal shunt and are coil embolized
differently from followed by delivery of sclerosant into the
C2 varices? shunt/varix. C2 varices are treated by inflating
one occlusion balloon in the gastrorenal shunt
and another in the gastrocaval shunt, which can
be positioned via an internal jugular approach.
Sclerosant is then administered to the shunt/
varix.
How are type 1 Type 1 varices are treated by administering
varices treated? sclerosant into the varix with eventual
stagnation due to back pressure from the portal
circulation. It is critical to control manual
pressure of injection as to not exceed the back
pressure from the portal system.
What is In type 2 varices, the two afferent vessels may
important to have differential pressures that lead to the
keep in mind reflux of sclerosant into the lower pressure
when treating system at the point of stagnation within the
type 2 varices? varix. However, because of the reflux out
of the higher pressure system, the higher
pressure afferent vein remains patent and will
persistently feed a portion of the varix, resulting
in only partial obliteration. This requires a
second BRTO.
(continued)
540 R. Parikh

How are Type 3 Type 3 varices are treated by advancing

varices treated? a microcatheter into the gastric varix and
administering sclerosant in a way that prevents
reflux into the afferent vein. If this is not
feasible, the afferent vein should be embolized
either percutaneously or via transjugular
approach prior to embolizing the varix.
What are the Utilizing standard angiographic technique,
general steps the right internal jugular or right femoral vein
involved with is accessed percutaneously. The gastrorenal
BRTO? shunt is then accessed by catheterizing the left
renal vein using a diagnostic catheter (e.g.,
Cobra catheter) placed in the inferior vena
cava or distal renal vein via a 6–12 Fr access
sheath. A 0.035 wire is advanced into the
shunt followed by exchange of the diagnostic
catheter for an occlusion balloon ranging from
8.5 to 32 mm (e.g., Python). The occlusion
balloon is positioned at a narrowing within
the shunt and inflated. A retrograde venogram
with or without Cone-Beam CT is performed
to determine the anatomy of the varix. The
microcatheter is then advanced through the
balloon catheter as proximally as possible and
the sclerosant mixture is then delivered to the
shunt/varix under fluoroscopic guidance.

What is the Technical success is considered when there is

endpoint of embolization of the varix with minimal filling of
BRTO? the afferent vein (i.e., posterior gastric vein) or
portal vasculature. Post-procedure cone-beam
CT can be utilized to ensure sclerosis.
How long is Occlusion balloon inflation times vary from 1 to
the occlusion 24 hours and are released under fluoroscopy.
balloon kept
inflated?
 39 Balloon-Occluded Retrograde Transvenous… 541

What are the Partial splenic vein embolization can be

steps to manage attempted to decrease the size of the shunt 2
a shunt that weeks prior to BRTO.
is too large
to occlude
with a balloon
catheter?
How are Collateral veins can shunt blood flow away
leaking from the varix, limiting the technical success
collateral veins of embolization. These can be occluded with
treated? coils or Gelfoam if necessary. When there
are different pressure gradients of multiple
afferent veins, repeat BRTO may be necessary
to address excessive reflux of the sclerosant
into the lower pressure pathway and residual
patency of the high pressure pathways.

Complications
What are the BRTO patients are medically complex
most common and require a multi-disciplinary approach.
complications Many reported complications, such as fever,
following BRTO? hemoglobinurua, chest pain, epigastric pain,
and back pain are self-limited or require
supportive care. Excessive reflux of the
sclerosant into the portal system may lead
to thrombosis-related complications. Ascites
and esophageal varices may be exacerbated.
(continued)
542 R. Parikh

What prophylaxis EOI, which is not FDA approved in the

is utilized for United States, can induce hemolysis. For
sclerosant-induced these patients, 4000U of haptoglobin is
hemolysis? administered intraprocedurally to bind
free hemoglobin released by EOI-induced
hemolysis. This minimizes renal tubular
disturbances and risk of acute renal failure.
The foam version of EOI can minimize
the dose delivered and thus minimize the
risks of BRTO. Additionally, EOI can also
be delivered in aliquots in multiple BRTO
sessions to decrease the risk of hemolysis-­
related renal failure.
What additional EOI can lead to cardiogenic shock,
adverse outcomes pulmonary edema, and disseminated
are associated intravascular coagulation. The total volume
with EOI of EOI should be limited to 40 mL per
administration? procedure.
What additional Balloon rupture, possibly due to direct
adverse outcomes contact with the sclerosant, during or after
are associated with embolization can result in pulmonary
BRTO? embolism, systemic delivery of sclerosant,
and increased mortality. BRTO can also
result in increased portal hypertension
leading to exacerbation of esophageal
varices and ascites as well as fulminate
hepatic failure.
What additional Air embolism to the pulmonary circulation
complication or to the systemic circulation via a patent
can arise from foramen ovale can result from the use of
the use of foam foam sclerosants.
sclerosants?
 39 Balloon-Occluded Retrograde Transvenous… 543

What are the long-­ Long-term complications include potential

term complications development of portal hypertensive
of BRTO? gastropathy with the formation of and
bleeding from esophageal/duodenal varices,
worsening of liver function in patients with
poor hepatic reserve and development
of ascites or hydrothorax, spontaneous
bacterial peritonitis, and portal/renal vein
thrombosis.
What factors Type I: inability to access the gastrorenal
contribute to shunt due to tortuosity or absence of shunt;
technical failure? extravasation of sclerosant
Type II: large shunt size leading to
inadequate occlusion of the gastrorenal
shunt
Type III (most common): extensively leaking
collateral veins that cannot be selectively
catheterized
Type IV: balloon rupture

Landmark Research
Prevalence, classification, and natural history of gastric vari-
ces: a long-term follow-up study in 568 portal hypertension
patients
Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana
UK. Prevalence, classification and natural history of gastric
varices: a long-term follow-up study in 568 portal hyperten-
sion patients. Hepatology. 1992;16 (6):1343–1349.
• Prospective review of 568 patients with gastric varices sec-
ondary to portal hypertension
• Gastric varices seen in 20% of patients at presentation and
9% of patients after treatment of esophageal varices
• Gastric varices less likely to bleed but more likely to bleed
significantly and have a higher mortality when compared
to esophageal varices
544 R. Parikh

• Classification of gastric varices by Sarin’s classification

system as detailed above
Long-term results of balloon-occluded retrograde transve-
nous obliteration for the treatment of gastric varices and
hepatic encephalopathy
Fukuda T, Hirota S, Sugimura K. Long-term results of
balloon-occluded retrograde transvenous obliteration for the
treatment of gastric varices and hepatic encephalopathy. J
Vasc Interv Radiol. 2001;12 (3):327–336.
• Restrospective review of 43 patients status post BRTO
• Gastric varices disappeared or significantly decreased in
size with the resolution of hepatic encephalopathy in 11/11
patients post BRTO
• Improvement in Child-Pugh score in 11% of patients on
follow-up at 1 year with relapse-free survival at 3 years of
87.4%
• Exacerbation of esophageal varices in 8 patients
• Most significant prognostic factor: Child-Pugh score
Balloon-occluded retrograde transvenous obliteration ver-
sus transjugular intrahepatic portosystemic shunt for the
treatment of gastric varices due to portal hypertension: A
meta-analysis
Wang Y.B., Zhang J.Y., Gong J.P., Zhang F., Zhao
Y. Balloon-occluded retrograde transvenous obliteration ver-
sus transjugular intrahepatic portosystemic shunt for treat-
ment of gastric varices due to portal hypertension: a
meta-analysis. J Gastroenterol Hepatol. 2016;31:727–733.
• Meta-analysis of 5 randomized control trials and cohort
studies comparing TIPS with BRTO for treatment of gas-
tric varices
• No statistically significant difference in technical success
rate, hemostasis rate, and incidence of procedure-related
complication
• Lower incidence of re-bleeding and post-operative
encephalopathy in BRTO
 39 Balloon-Occluded Retrograde Transvenous… 545

Balloon-occluded retrograde transvenous obliteration

(BRTO) for the treatment of gastric varices: review and
meta-analysis
Park J.K., Saab S., Kee S.T., Busuttil R.W., Kim H.J.,
Durazo F. Balloon-occluded retrograde transvenous oblitera-
tion (BRTO) for treatment of gastric varices: review and
meta-analysis. Dig Dis Sci. 2015;60:1543–1553.
• Meta-analysis of 24 studies with a total of 1016 patients
with acute bleeding or at-risk gastric varices treated with
BRTO
• Technical success rate of 96.4% with clinical success rate
(absence of recurrence/rebleeding or variceal obliteration)
of 97.3%
• Major complication rate of 2.6% with esophageal variceal
recurrence rate of 33.3%
Treatment of patients with gastric variceal hemorrhage:
endoscopic N-butyl-2-cyanoacrylate injection versus balloon-­
occluded retrograde transvenous obliteration
Hong C.H., Kim H.J., Park J.H., Park D.I., Cho Y.K., Sohn
C.I. Treatment of patients with gastric variceal hemorrhage:
endoscopic N-butyl-2-cyanoacrylate injection versus balloon-­
occluded retrograde transvenous obliteration. J Gastroenterol
Hepatol. 2009;24:372–378.
• Retrospective review of 14 patients treated with endo-
scopic sclerosant injection and 13 patients treated with
BRTO
• Higher risk of rebleeding after endoscopic sclerosant
therapy compared to BRTO (71.4% versus 15.4%) with no
rebleeding in 6/6 patients treated with rescue BRTO
546 R. Parikh

Common Questions
What is BRTO? Balloon-occluded retrograde transvenous
obliteration is an endovascular technique
used to treat gastric varices, particularly
when endoscopy fails or in patients
with contraindications to a transjugular
intrahepatic portosystemic shunt (TIPS)
procedure.
Who is considered the Many consider Kanagawa as the
inventor BRTO? inventor of BRTO, though the first
published attempt at balloon-occluded
sclerotherapy of the gastrorenal shunt for
the management of gastric varices was
authored by Olson et al. in 1984.
What must the IR Overly aggressive fluid resuscitation
physician be sensitive can exacerbate portal hypertension.
to regarding patient Therefore, lower than normal systemic
stabilization prior to blood pressures (and associated lower
BRTO? targets in goal hematocrit and platelet
count) are tolerated.
Which vessels serve as Gastrorenal shunts
the primary outflow
for the splenic and
mesenteric veins
in the presence of
main portal vein
thrombosis?
What caution must be A diminutive portal vein may be
taken in the presence overwhelmed by the BRTO procedure.
of a very diminutive This can lead to flow stagnation and
portal vein? portal vein thrombosis.
What essential Shunt anatomy and sizes, areas of
knowledge is needed narrowing, and available balloon-
prior to a BRTO occlusion catheter inventory
procedure?
 39 Balloon-Occluded Retrograde Transvenous… 547

What are benefits to The goal of balloon occlusion

using cone beam CT venography is to opacify the entire
during the BRTO gastric-variceal system, including all
procedure? afferent veins, as well as efferent veins
that decompress the system. Cone beam
CT can be used to better visualize this
anatomy and can be particularly helpful
for novice operators.
What is the endpoint Technical success is considered when
of BRTO? there is embolization of the varix with
minimal filling of the afferent vein or
portal vasculature.

Further Reading
Al-Osaimi AM, Caldwell SH. Medical and endoscopic management
of gastric varices. Semin Intervent Radiol. 2011;28(3):273–82.
Basseri S, Lightfoot CB. Balloon-occluded retrograde transvenous
obliteration for treatment of bleeding gastric varices: case report
and review of literature. Radiol Case Rep. 2016;11(4):365–9.
Published 2016 Oct 21. https://doi.org/10.1016/j.radcr.2016.09.009.
Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-­
occluded retrograde transvenous obliteration for the treatment
of gastric varices and hepatic encephalopathy. J Vasc Interv
Radiol. 2001;12(3):327–36.
Hong CH, Kim HJ, Park JH, Park DI, Cho YK, Sohn CI. Treatment
of patients with gastric variceal hemorrhage: endoscopic
N-butyl-2-cyanoacrylate injection versus balloon-­occluded ret-
rograde transvenous obliteration. J Gastroenterol Hepatol.
2009;24:372–8.
Kim DJ, Darcy MD, Mani NB, et al. Modified balloon-occluded
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 Part VI
Genitourinary
Chapter 40
Percutaneous
Nephrostomy
Marco Ertreo and Ifechi Momah

Evaluating the Patient

What patient position must Percutaneous nephrostomy

be maintained during a catheter placement is performed
percutaneous nephrostomy with the patient in the prone or
procedure? prone-oblique position.
Why is it important to Urinary obstruction with
evaluate for signs of infection? superimposed infection requires
emergent decompression.
How do you diagnose Flank pain, fever, leukocytosis,
pyonephrosis? and collecting system dilatation
on imaging.
Should pertinent imaging Yes, to confirm the diagnosis and
be available and why? What determine optimal approach to
valuable information can be the renal collecting system. The
obtained from cross sectional level of obstruction and potential
imaging? cause may also be deduced.
What laboratory studies CBC, BMP, urinary analysis, and
should be available? coagulatory profile.
(continued)
M. Ertreo (*) · I. Momah
Department of Radiology and Interventional Radiology, Medstar
Georgetown University Hospital, Washington, DC, USA

© Springer Nature Switzerland AG 2022 551

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_40
552 M. Ertreo and I. Momah

What category of bleeding Category 3: Significant bleeding

risk do SIR Standards of risk, difficult to control or detect.
Practice Committee assign
to percutaneous renal
interventions?
Is coagulopathy an absolute or Relative.
relative contraindication?
What INR is recommended Below 1.5–1.8.
prior to starting the
procedure?
What platelet count is Above 50,000/mm3.
recommended prior to starting
the procedure?

High Yield History

Is chronic Not unless there are signs of urosepsis.
unilateral
obstruction due
to malignancy
an indication
for emergent
percutaneous
nephrostomy?
What are risk Diabetes, immunosuppression, urinary tract
factors for obstruction, or anatomical predisposition
pyonephrosis? (horseshoe or pelvic kidney, duplicated
collecting system),
What should be Anesthesiology consultation.
considered if the
patient is ASA 3,
has difficulty with
prone positioning,
or experiences
respiratory
compromise while
prone?
 40 Percutaneous Nephrostomy 553

What kidney Both kidneys may be considered for

should undergo nephrostomy placement, depending on how
nephrostomy if long they have been obstructed and how
there is bilateral much estimated functioning parenchyma
obstruction? remains.
How can the With a renal scintigraphy or “renal scan,”
function of performed in the nuclear medicine
each kidney be department. This is performed following the
assessed? intravenous injection of radiopharmaceuticals
or tracers that allow the evaluation of
different aspects of renal function, such as
renal blood flow, glomerular filtration rate,
effective renal plasma flow, renal tubular flow,
and excretory function. The most commonly
used radiopharmaceutical is Tc-99 m-MAG3
(technetium 99 mercaptoacetyltriglycine)
and it allows evaluation of blood flow,
renal function, and excretion; Tc-99 m
DTPA (diethylenetriamine penta-acetic
acid) is used for GFR calculation, and
Tc-99 m-DMSA (dimercaptosuccinic acid)
is typically used to assess for scarring and
renal viability. When assessing for renal
function, a normally functioning kidney will
demonstrate, in order, normal perfusion,
good cortical uptake, corticomedullary
transit, and clearance without pooling in
the collecting system. A poorly functioning
kidney can have decreased cortical uptake or
corticomedullary transit and even decreased
blood flow in more advanced cases. In cases
of obstructive hydronephrosis, urine will
pool within the collecting system and ureter.
Renal scintigraphy also allows the calculation
of the percentage of renal clearance that
is performed by each kidney, which should
be split almost evenly in a healthy patient.
This functional information can aid the IR
in determining which kidney should undergo
nephrostomy placement.
554 M. Ertreo and I. Momah

Indications/Contraindications

What are the Percutaneous nephrostomy allows

indications for access to the renal collecting system,
percutaneous typically to relieve urinary obstruction
nephrostomy? in the emergent/urgent setting in a
septic patient, although it can also be
used for: gaining access to the collecting
system in order to perform other
percutaneous interventions (such as
antegrade ureteroplasty of a stricture,
ureteral stenting, ureteral occlusion,
lithotripsy) or to divert urinary flow (in
the setting of a urinoma, urinary leak or
fistula).
What does long-­ Loss of nephrons, atrophy, and eventual
standing collecting loss of renal function.
system dilatation
(hydronephrosis)
cause?
What are the main Ureteric stones, urinary malignancies
causes of ureteral (ureter, prostate, bladder), invasion by
obstruction? adjacent neoplasms, metastatic implants,
post-surgical and post-radiation
strictures, and retroperitoneal fibrosis.
When should As soon as possible after the diagnosis
the procedure be of obstruction.
performed?
When is emergent When there are signs of sepsis,
decompression indicating pyonephrosis.
indicated?
What are Uncorrectable coagulopathy and
contraindications to the patients unable to cooperate with the
procedure? procedure (inability to lay prone or
severe respiratory distress). Contrast
allergy is a relative contraindication.
 40 Percutaneous Nephrostomy 555

Relevant Anatomy

In what space The kidneys are retroperitoneal structures,

are the kidneys contained within the perirenal space. The
located? perirenal space is bounded by the renal
fascia, which is divided into the anterior
perirrenal fascia or Gerota’s fascia and
posterior perirenal fascia or Zuckerkandl’s
fascia. Anterior to the perirenal space is the
anterior pararenal space. This space crosses
the midline and contains the duodenum,
pancreas, and the retroperitoneal portions
of the ascending and descending colon. The
posterior pararenal space is located posterior
to the perirenal space and contains only
vessels, lymphatics and fat.
To what level 11th–12th rib.
does the posterior
pleura typically
extend?
Why is this It is important because the pleura could be
important and potentially punctured during nephrostomy
what potential access, increasing the risk of pneumothorax.
complication Traversing the 11th intercostal space
can develop with or above it carries a higher risk of
upper pole access? pneumothorax. If upper pole access and/or
puncture through the 11th intercostal space
is needed, pre-procedural cross-sectional
imaging should be obtained.
What structure The colon. Care should be taken to evaluate
can be located for colonic positioning before proceeding
posterior to the with nephrostomy placement.
kidney?
In what order are From anterior to posterior: renal vein, artery,
the renal artery, and pelvis.
vein, and pelvis
situated at the
hilum?
(continued)
556 M. Ertreo and I. Momah

How does the Anterior and posterior divisions.

renal artery
branch at the
hilum?
How many Anterior division: 3–4; posterior division: 1.
segmental
branches does
each division
have?
What is the Posterior calyx.
safest target for
percutaneous
nephrostomy
placement?
Can only posterior No, any calyx can be accessed. For example,
calyces be if the intent of obtaining access into the
accessed? collecting system is to treat nephrolithiasis,
then the calyx chosen should allow proper
access to the stone to be treated (mid
or upper pole for ureteral stone, which
facilitates system navigation into the ureter).
What is Brodel’s Brodel’s line is a relatively avascular plane
line and why is it in the posterolateral kidney, between the
important? distal anterior and posterior segmental
branches of the renal artery; hence there is
lower bleeding risk when crossing it with a
needle when compared to other regions of
the kidney. It is typically 30–45 degrees with
respect to the table with the patient in the
prone position.
Why should direct Because there is greater risk of causing
renal pelvis access hemorrhage and urinoma.
be avoided?
 40 Percutaneous Nephrostomy 557

Relevant Materials

What is a An external, self-retaining drainage catheter,

percutaneous which contains a distal Cope loop or tulip tip
nephrostomy with locking mechanism that is positioned
catheter? in the posterolateral renal collecting system
through the patient’s flank.
What size 8–12 French
nephrostomy
catheter is
typically used
in patients with
clear urine?
What size 10–12 French
nephrostomy
catheter should
be used in
patients with
purulent urine?
What size needle 21–22 gauge
is used for initial
access into the
calyx?
What initial 0.018″ guidewire
guidewire size is
used?
What is typically A single-stick upsizing introducer system,
used to access such as Neff Set by Cook (Blooington, IN) or
the calyx once Accustick by Boston Scientific (Natick, MA).
the 0.018″ Introducer systems are used in non-vascular
guidewire is procedures for over-the-wire placement, which
placed? then allow the introduction of an 0.035–0.038″
guidewire for greater support. The system is
a coaxial 4-Fr and 6-Fr dilator sheath with a
stiffening and locking inner cannula.
558 M. Ertreo and I. Momah

General Step by Step

Should antibiotics Yes, except for routine catheter exchange

be administered in low-risk patients. Although there is no
prior to the consensus regarding the first-choice antibiotic,
procedure? suggested regimens include a single dose of
1–2 gm IV of ceftriaxone. Clindamycin and an
aminoglycoside or vancomycin may be used
in penicillin allergic patients.
What imaging Ultrasound and/or fluoroscopy. Typically,
technique is most initial access into the kidney is performed
commonly used under sonographic guidance utilizing a
for nephrostomy curvilinear probe, which have a wide field
placement? of view and utilize lower frequencies,
allowing for visualization of deeper tissues.
Once access is confirmed, the procedure is
completed under fluoroscopic guidance.
How should Prone or prone-oblique with the side to be
the patient be accessed elevated, preferably to 45 degrees.
positioned?
Where is the Ipsilateral posterior axillary line, 2–3 cm
ideal skin entry below the 12th rib in order to avoid pleura.
site?
What is the best Approximately 30–45 degrees with respect to
angle for needle the table surface (along Brodel’s line).
entry?
Besides with The needle tip will move synchronously with
imaging, how the patient’s respirations.
can the operator
confirm the
needle has
entered the renal
parenchyma?
 40 Percutaneous Nephrostomy 559

How do you Once the needle is in place, urine will flow

confirm access out of the needle once the inner stylet is
into the collecting removed. The operator can also inject a
system? minimal amount of contrast (1–3 ml) to
opacify the collecting system, confirming
placement. Only a small amount of contrast
should be injected to avoid overdistention
of the collecting system, which can cause
bacterial translocation into the bloodstream
and bacteremia.
Once the needle No, because you risk decompressing the
is in the collecting pelvis, which limits your visualization of the
system, do you collecting system and threatens loss of access.
aspirate all the
urine?
What do you The 0.018″ wire.
introduce through
the needle
after it is in the
appropriate
position?
What is 0.018″ The single stick introducer set (Neff or
wire exchanged Accustick) and 0.038″ guidewire.
for?
Sequential One French larger than the final catheter size.
dilatation of the
tract should be
performed up to
what size?
Why is contrast To confirm correct catheter positioning
injected at
the end of the
procedure?
560 M. Ertreo and I. Momah

Complications

What is the Septic shock. Reported incidence rates

most common range between 1% and 10% of cases, with
complication lower incidence in the non-emergent setting
following the (1–4%) and higher incidence in patients
placement of with pyonephrosis (7–9%). Of note, patients
percutaneous might already be septic at the beginning of
nephrostomy? the procedure when performed emergently.
Septic shock can develop following the
procedure or while the patient is on the
procedural table.
How are sepsis Sepsis is defined as life-threating organ
and septic shock dysfunction caused by a dysregulated
defined? response of the host to infection. Septic
shock is a subset of sepsis where circulatory,
cellular, and metabolic abnormalities are
associated with a greater risk of mortality
than sepsis alone.
What can be used Bedside assessment of a patient with
to quickly assess suspected infection can be performed with
if a patent with the quickSOFA (qSOFA) score. The qSOFA
sepsis is likely score is a simplified version of the SOFA
to have a worse (Sequential Organ Failure Assessment) score,
outcome? which can be used to determine the degree
of organ dysfunction and mortality risk in
ICU patients with suspected infection. The
qSOFA score assigns a point to any Glasgow
Come Score <15, respiratory rate above 22,
and a systolic blood pressure <100 mmHg. A
score of 2 or above is considered positive and
suggests a higher risk of worse outcome.
 40 Percutaneous Nephrostomy 561

How should Initial management should focus on

suspected sepsis stabilizing the patient, focusing on securing
be initially the patient’s airway if compromised,
managed? stabilizing breathing through oxygen
supplementation and maintaining tissue
perfusion/circulation through aggressive
administration of intravenous fluids. Within
the first hour, blood samples for baseline
complete blood counts with differential,
complete metabolic panel with lactate level,
coagulation studies, and blood cultures
should be obtained. The serum lactate level
aids in determining the degree of sepsis (in
combination with clinical and laboratory
findings) and allows following the patient’s
response on subsequent draws. Within this
time frame, intravenous empiric antibiotic
treatment should also be administered.
What are potential Hemorrhage, perforation of colon, spleen,
complications with and liver.
anterior access?
Risk for which Pneumothorax. While small pneumothoraces
complication is might not be clinically evident and go
increased with unnoticed, larger pneumothoraces can cause
upper pole access? shortness of breath, labored breathing, the
use of accessory muscles during respiration,
decreased saturation, and even hemodynamic
compromise such as hypotension and
tachycardia if a tension pneumothorax has
developed. If a pneumothorax is suspected,
the patient should be stabilized, and imaging
should be obtained to confirm the diagnosis.
Either a chest radiograph or sonography
can be used (under ultrasound, the lung and
pleural interfaces slide on each other, while
with a pneumothorax the sliding is absent).
(continued)
562 M. Ertreo and I. Momah

Is hematuria Mild hematuria can occur following the

common after the procedure and it gradually clears within a
procedure? few days. If the bleeding does not resolve or
clear as expected, this may be due to venous
oozing, often from the drain being partially
retracted into the parenchymal tract. This
can be addressed by either repositioning the
drainage catheter further into the collecting
system under fluoroscopic guidance,
temporarily placing a balloon, or upsizing
the drain to tamponade any small oozing
vessels. Any time a drain is repositioned
or exchanged, this should be done over
an 0.035″ guidewire in order to provide
adequate support and access
How does major Major bleeding requiring transfusion is
bleeding present rare (1–4% of cases) and presents as heavy
and how can it be arterial bleeding into the collecting bag with
treated? tachycardia and decreasing hemoglobin
and hematocrit levels. The most common
causes include injury to branches of the renal
artery, creation of an arteriovenous fistula or
pseudoaneurysm formation during catheter
placement. While conservative management
can be attempted, treatment of these
complications will typically require renal
angiogram and embolization with either coils,
gelfoam or a combination. Reported rates
of vascular injuries requiring endovascular
treatment or even nephrectomy range
between 0.1% and 1% of cases.
What exam should CT angiogram of the abdomen, typically
be ordered to triple phase (unenhanced, arterial, and
diagnose active venous phases). This will allow for the
hemorrhage and evaluation of active bleeding and the
potential causes? culprit. If there is suspicion for a urine
leak, additional delayed imaging can
also be obtained to evaluate for contrast
extravasation from the collecting system
during the excretory phase of renal clearance.
 40 Percutaneous Nephrostomy 563

What other Sonography can be used to visualize renal

kinds of imaging artery pseudoaneurysms, which presents as
technique can be a hypoechoic focal dilatation of the renal
used to diagnose a artery with characteristic internal swirling
pseudoaneurysm pattern seen on color Doppler imaging,
and what are the known as yin-yang sign. The swirling
expected findings? represents bidirectional flow within the
aneurysmal sac.

Common Questions

What is Urinary tract obstruction and accumulation of

pyonephrosis? pus in the collecting system.
What is the Escherichia Coli.
most common
bacteria
isolated with
pyonephrosis?
What is used A single stick upsizing introducer system
to upsize after (Accustick or Neff sets).
initial access?
How often Every 6–8 weeks, unless it becomes dislodged or
should a drain other complications arise sooner.
be routinely
exchanged?
What is a Drainage bag. When connected only to a
PCN usually drainage bag, this is termed “external drainage.”
connected to? If the patient also has a nephroureteral stent,
this is termed “internal-external drainage.” If the
patient only has a nephroureteral stent, this is
termed “internal drainage.”
564 M. Ertreo and I. Momah

Landmark Research
Dyer RB, Regan JD, Kavanagh P V., Khatod EG, Chen MY,
Zagoria RJ. Percutaneous nephrostomy with extensions of
the technique: Step by step 1. Radiographics 2002
• Access via percutaneous nephrostomy not only allows
drainage of an obstructed collecting system but also allows
interventionalists and urologists to perform multiple pro-
cedures (i.e., lithotripsy, stone removal, stent placement,
tumor fulguration) in a minimally invasive fashion.
• Minor complications not requiring additional care can be
seen in up to 25% of patients, while major complications
are seen in 1–3% of patients.
Pieper CC, Meyer C, Hauser S, Wilhelm KE, Schild
HH. Transrenal ureteral occlusion using the amplatzer vascu-
lar plug II: A new interventional treatment option for lower
urinary tract fistulas. Cardiovasc Intervent Radiol. 2014
• Treatment of ureteral fistulas due to pelvic malignancy are
difficult to treat surgically.
• Transrenal ureteral occlusion performed via percutaneous
nephrostomy can be performed with different materials
including coils, tissue adhesives, balloons and others,
although can require additional interventions due to dislo-
cation or recanalization. Utilization of Amplatzer vascular
plugs with or without coils is equally efficacious and less
prone to dislocation.

Further Reading
Chehab MA, Thakor AS, Tulin-Silver S, Connolly BL, Cahill AM,
Ward TJ, et al. Adult and pediatric antibiotic prophylaxis during
vascular and IR procedures: a Society of Interventional Radiology
Practice Parameter Update Endorsed by the Cardiovascular and
Interventional Radiological Society of Europe and the Canadian
Association for. J Vasc Interv Radiol. 2018.
 40 Percutaneous Nephrostomy 565

Dyer RB, Regan JD, Kavanagh PV, Khatod EG, Chen MY, Zagoria
RJ. Percutaneous nephrostomy with extensions of the technique:
step by step 1. Radiographics. 2002.
Li AC, Regalado SP. Emergent percutaneous nephrostomy for
the diagnosis and management of pyonephrosis. Semin Interv
Radiol. 2012.
Mettler F, Guiberteau M. Essentials of nuclear medicine imaging;
2012.
Millward SF. Percutaneous nephrostomy: a practical approach. J
Vasc Interv Radiol. 2000.
Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008.
Pabon-Ramos WM, Dariushnia SR, Walker TG, Janne D’Othée B,
Ganguli S, Midia M, et al. Quality improvement guidelines for
percutaneous nephrostomy. J Vasc Interv Radiol. 2016.
Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS,
Walker TG, et al. Consensus guidelines for periprocedural man-
agement of coagulation status and hemostasis risk in percutane-
ous image-guided interventions. J Vasc Interv Radiol. 2012.
Pieper CC, Meyer C, Hauser S, Wilhelm KE, Schild HH. Transrenal
ureteral occlusion using the amplatzer vascular plug II: a new
interventional treatment option for lower urinary tract fistulas.
Cardiovasc Intervent Radiol. 2014.
Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer
R, et al. Surviving sepsis campaign: international guidelines for
management of sepsis and septic shock: 2016. Intensive Care
Med; 2017.
Singer M, Deutschman CS, Seymour C, Shankar-Hari M, Annane
D, Bauer M, et al. The third international consensus definitions
for sepsis and septic shock (sepsis-3). JAMA - J Am Med Assoc.
2016.
Saad NEA, Saad WEA, Davies MG, Waldman DL, Fultz PJ, Rubens
DJ. Pseudoaneurysms and the role of minimally invasive tech-
niques in their management. In: Radiographics; 2005.
Yoder IC, Lindfors KK, Pfister RC. Diagnosis and treatment of pyo-
nephrosis. Radiol Clin North Am. 1984.
Chapter 41
Uterine Artery
Embolization
Ifechi Momah-Ukeh and Marco Ertreo

Evaluating the Patient

Collaboration Gynecology. A multidisciplinary team
with which approach is more likely to provide the
specialty should patient with a thorough work-up and
be considered treatment plan.
when evaluating a
patient for UAE?
What are Heavy menstrual bleeding, pelvic pressure,
symptoms pelvic pain, back pain, urinary urgency,
associated with urinary frequency, incontinence, and
fibroids? dyspareunia.
(continued)

I. Momah-Ukeh (*) · M. Ertreo

Department of Radiology and Interventional Radiology, Medstar
Georgetown University Hospital, Washington, DC, USA

© Springer Nature Switzerland AG 2022 567

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_41
568 I. Momah-Ukeh and M. Ertreo

What is the MRI; studies have shown MRI to be

preferred imaging superior to ultrasound in accurately
modality to assess detecting fibroids, evaluating fibroid
the patient for location, and demonstrating abnormal
fibroids? enhancement. MRI has better interobserver
reproducibility when compared to other
modalities. Contrast-enhanced MRI has the
advantage of producing an MRA that may
be helpful in planning for UFE. Procedural
success is unlikely if there is little or no
enhancement of the fibroids.
Why is abnormal Pelvic malignancy can mimic fibroid disease
MRI enhancement and imaging differentiation between fibroids
worrisome? and leiomyosarcoma can be challenging
due to their overlapping features. Abnormal
enhancement, hemorrhage, and myxoid
degeneration on an MRI can sometimes
suggest an invasive/malignant component
within a uterine mass.
What symptoms Patients with weight loss, fatigue, other
should cause systemic symptoms, or rapid growth of
you to consider a single fibroid should be treated with
a uterine hysterectomy due to concern for uterine
malignancy? malignancy.
Additionally, all patients over 40 years old
with abnormal bleeding should undergo
pap smear and endometrial evaluation (e.g.,
biopsy, hysteroscopy, dilation, and curettage)
as part of the routine, pre-UFE workup
for because endometrial carcinoma can
coexist with fibroid disease and be a cause of
menorrhagia.
 41 Uterine Artery Embolization 569

Describe the post-­ Follow-up typically consists of an IR

UFE follow-up? clinic visit and MRI; however, timing and
specifics are institution dependent. Quality-­
of-­life data suggest that most patients are
symptomatically improved at 3 months
post-UFE and this interval for follow-up
can be utilized. Normal gynecologic well-­
woman care with a gynecologist should be
continued.

High Yield History

What clinical tests/ (a) Laboratory data (e.g., PT/INR,

procedure results should creatinine, hemoglobin/hematocrit,
be reviewed when seeing platelets)
a patient in consultation
for fibroid embolization?
(b) Pelvic examination
(c) Results of pap smear within 1 year
(d) Endometrial biopsy if treating
menorrhagia, especially if older than
40 years old
(e) Pelvic imaging
What other gynecologic Endometriosis and adenomyosis.
disorders overlap with Adenomyosis is well-identified on
uterine fibroids? T2 imaging and requires patient
counseling on the decreased
likelihood of treatment success.
What should patients be There is a 2–3% chance of early
counseled on if desiring menopause. Although UFE is likely
future fertility? to preserve the uterus, for women
who desire future childbearing, the
long-term effects on the menstrual
cycle and capacity for reproduction
are unknown.
570 I. Momah-Ukeh and M. Ertreo

Indications/Contraindications

What is the most common Symptomatic fibroids.

indication for UAE?
What are other indications for (a) Adenomyosis
UAE?
(b) Prepartum/preoperative
interventions
(c) Postpartum hemorrhage
(d) Inoperable gynecologic
tumors
(e) Uterine vascular
malformations
What are contraindications for (a) Leiomyosarcoma or
UAE? suspected gynecologic
malignancy
(b) Current gynecologic
infection
(c) Active pregnancy
What is the primary symptom Menorrhagia.
causing women to seek treatment
for fibroids?
What are the contraindications There are no
of UAE for patients with life-­ contraindications.
threatening hemorrhage?

Relevant Anatomy

What division of the Anterior division.

internal iliac (hypogastric)
artery does the uterine
artery arise from?
 41 Uterine Artery Embolization 571

What branch does the There is a wide variability in the

uterine artery directly arise origin of the uterine artery. Most
from? commonly, the uterine artery is
the first or second branch from the
anterior division of the internal
iliac artery.
What are the relevant From proximal to distal, the
segments of the uterine uterine artery can be divided
artery? into descending, transverse, and
ascending segments.
What small branches Cervical-vaginal branches.
originate from the mid
to distal uterine artery,
typically from the
transverse segment of the
uterine artery?
What is the common Hypertrophied tortuous corkscrew
radiographic appearance of configuration coursing medially in
uterine arteries? the pelvis.
What is a common Ovarian arteries, which arise from
collateral blood supply to the abdominal aorta inferior to the
fibroids? renal arteries and superior to the
inferior mesenteric artery (between
L2 and L3).
What is the classification of Submucosal: protrude into the
fibroids by location? endometrial cavity
Intramural: within the myometrium
Subserosal: protrude out of the
serosal surface, covered by parietal
peritoneum
Pedunculated: attached to the
uterus by a stalk
Cervical: located in the uterine
cervix
572 I. Momah-Ukeh and M. Ertreo

Relevant Materials

What embolic material is Particles such as trisacryl gelatin

most commonly used for microspheres (Embosphere®) or
fibroids? polyvinyl alcohol particles (PVA).
What embolic material Gelfoam slurry or pledgets
is most commonly used
for uterine/vaginal
hemorrhage?
Coils
n-Butyl-2-cyanoacrylate (NBCA;glue)
What size catheters are 4 or 5-Fr catheters or larger lumen
typically used to select microcatheters.
the uterine artery?
Why do some A microcatheter occupies a smaller
interventionalists prefer percentage of the cross-sectional area
microcatheters over 4- or of the uterine artery and is softer with
5-Fr catheters? a more flexible tip, which may reduce
the likelihood of catheter-induced
spasm.

General Step by Step

What access sites Unilateral common femoral artery
are commonly
used?
Bilateral common femoral arteries
Unilateral radial artery
Why are pelvic To map the uterine arteries.
angiograms
performed?
 41 Uterine Artery Embolization 573

What is the most Ipsilateral anterior oblique.

helpful view to
identify the uterine
artery?
Where should Transverse portion of the uterine artery, and
the catheter tip distal to cervico-vaginal branches to prevent
be positioned for non-target embolization.
treatment?
What is the goal of Slow flow or near stasis in the uterine artery.
treatment? The goal is not to cause complete stasis or
occlude the entire artery.
Which uterine Bilateral uterine arteries are embolized in
arteries are order to achieve ischemia and infarction of
treated? uterine fibroids. Unilateral uterine artery
treatment is likely to result in clinical failure
because the blood supply to the uterus has a
variety of collateral pathways.
When should Disproportionately small uterine arteries
aortography
for ovarian
arterial supply be
performed?
Spasm of the uterine artery, requiring
different approach
Non-perfused tissue on uterine angiography
Repeat embolization procedures
What are expected T1 signal intensity should increase relative
MRI findings to the myometrium due to increased
post fibroid methemoglobin from coagulative necrosis.
embolization? There should be no internal enhancement.
There should also be decreased size and
T2 signal intensity. With the onset of
liquefaction, T2 signal intensity will increase.
574 I. Momah-Ukeh and M. Ertreo

Complications

What are some methods of Pretreatment with nonsteroidal

reducing post-UAE pain? anti-inflammatory medications
several days before
Intra-procedural superior
hypogastric nerve block
Intraarterial lidocaine or Toradol
injection
Post-procedure anti-­
inflammatory medications and
analgesics like a PCA pump
What should be considered in Pedunculated fibroid detaching
a post-UAE patient presenting from the uterus and falling into
with inflammatory peritonitis? the pelvis
Uterine infection/perforation/
abscess formation
What should be considered in Fibroid passage through the
a post-UAE patient presenting cervical os.
with persistent vaginal
discharge, tissue passage, and/
or menstrual cramping?
Which type of fibroid is most Pedunculated large submucosal
at risk for fibroid passage? fibroid. Most will pass
uneventfully, though there is
risk of cervical obstruction and
infection, potentially requiring
surgery.
How is fibroid passage Observation +/− antibiotics
managed?
Dilation and curettage
Hysteroscopic resection
Manual extraction
Hysterectomy
 41 Uterine Artery Embolization 575

Which subtype of fibroid Pedunculated subserosal fibroid,

has the potential risk of especially with stalk diameter
detachment from the uterus <2 cm.
following infarction?
What is post-embolization Clinical symptoms including low
syndrome? grade fever, nausea, malaise, and
loss of appetite.
What is the treatment for Supportive management
post-embolization syndrome? including pain management and
fluids.
What are the 2 most common Permanent amenorrhea; 1–5% of
complications of UFE? women go into early menopause,
which is more common in
women older than 45 years old
Prolonged vaginal discharge
What is the effect of UAE on Studies have not been clear as to
fertility? the risk of infertility after UFE,
though; many patients have gone
on to have normal pregnancies.

Landmark Research
Moss, JG et al. Uterine-artery embolization versus surgery
for symptomatic uterine fibroids. NEJM. 2007; 356:360–370.
• Randomized, multi-center study that compared the effi-
cacy and safety of UAE to standard surgical methods for
treatment of symptomatic fibroids.
• UFE is less painful at 24 hours with shorter hospital stays
and quicker return to work.
• No difference in quality of life scores at 12 months.
• No difference in adverse events.
• UFE more likely to need re-intervention.
Hehenkamp, W et al. Uterine Artery Embolization vs
Hysterectomy in the Treatment of Symptomatic Uterine
Fibroids (EMMY Trial): Peri- and Postprocedural Results
576 I. Momah-Ukeh and M. Ertreo

From a Randomized Controlled Trial. American Journal of

Obstetrics and Gynecology. 2005 Nov;193(5):1618–29.
• Randomized controlled trial to evaluate the safety or
UAE compared to hysterectomy.
• UAE is similar to hysterectomy with a lower major com-
plication rate and with a reduced length of hospital stay.
• Higher readmission rates after UAE.
Goodwin SC, Spies JB, Worthington-Kirsch R, Peterson E,
Pron G, Li S, Myers ER. Fibroid Registry for Outcomes Data
(FIBROID) Registry Steering Committee and Core Site
Investigators. Obstetrics and Gynecology. 2008
Jan;111(1):22–33.
• To assess long-term clinical outcomes of UAE across a
wide variety of factors including long-term symptom con-
trol, patient satisfaction, rates of recurrence and need for
re-intervention
• UAE results in a durable improvement in quality of life.

Common Questions

What is the natural history Involution following menopause.

of fibroids?
When should Rapid fibroid enlargement and/or
leiomyosarcoma abnormal enhancement.
be considered in
postmenopausal women?
What are other treatment Medical therapy
options for fibroids and
adenomyosis that should be
discussed with the patient?
Conservative surgery
Hysterectomy
High Intensity Focused Ultrasound
 41 Uterine Artery Embolization 577

How does treating from the Fibroids have a more robust

uterine artery cause fibroid vascular supply compared to
infarction without infracting normal myometrial tissue and this
the normal uterus? allows normal myometrial tissue
to remain viable and not become
infarcted.
Chapter 42
Prostate Artery
Embolization
Marco Ertreo, Rakesh Ahuja, and Keith Pereira

Evaluating the Patient

What are the Though a predominance of voiding
symptoms of BPH symptoms are reported, both storage and
(benign prostate voiding symptoms are experienced and
hypertrophy)? include increased frequency of urination,
nocturia, urgency, hesitancy, and weak
urine stream (known as LUTS, “lower
urinary tract symptoms”)
What are storage and Storage: urgency, frequency, nocturia,
voiding symptoms? incontinence, bladder sensation
Voiding: slow stream, intermittent stream,
hesitancy, strain, dribble, dysuria
(continued)

M. Ertreo (*)
Department of Radiology and Interventional Radiology, Medstar
Georgetown University Hospital, Washington, DC, USA
R. Ahuja
Vascular & Interventional Radiology, Einstein Medical Center,
Philadelphia, PA, USA
K. Pereira
Division of Vascular Interventional Radiology, Saint Louis
University Hospital, St. Louis, MO, USA

© Springer Nature Switzerland AG 2022 579

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_42
580 M. Ertreo et al.

How can BPH OAB typically presents as urgency with or

be differentiated without urgency and incontinence.
clinically from
overactive bladder
(OAB)?
Storage symptoms predominate as
compared to BPH, in which voiding
symptoms predominate.
OAB: involuntary detrusor contraction
during filling allows for detection during
cystourethrogram.
What specialty does Urology.
the interventional
radiologist closely
work with for
management of these
patients?
How are LUTS Using the American Urological
quantified? Association urinary symptom score or
the International Prostate Symptom
Score (IPSS). Both utilize the same scale
and questions, but the IPSS includes an
additional question on disease specific
quality of life. The scores assign a
severity score of 0–5 in the categories
of incomplete emptying, frequency,
intermittency, urgency, weak stream,
straining and nocturia. It is an eight-­
question (seven questions on symptoms
and one question on quality of life) used
to screen for, rapidly diagnose, track the
symptoms of, and suggest management
of the symptoms of BPH. The total score
ranges from mild (0–7) to severe (20–35).
IPSS questionnaire
In the past month Not at all Less than 1 in Less than half About half the More than half Almost
5 times the time time the time always
Incomplete 0 1 2 3 4 5
emptying (how
often have you had
the sensation of
not emptying your
42

bladder?)
Frequency (how 0 1 2 3 4 5
often do you have
to urinate less than
every 2 hours?)
Intermittency (how 0 1 2 3 4 5
often have you
found you stopped
and started again
several times when
you urinated?)
Prostate Artery Embolization

(continued)
581
 582

Urgency (how often 0 1 2 3 4 5

have you found it
difficult to postpone
urination?)
Weak stream (how 0 1 2 3 4 5
often have you had
a weak urinary
M. Ertreo et al.

stream?)
Straining (how 0 1 2 3 4 5
often have you had
to strain to start
urination?)
Nocturia (how None 1 time 2 times 3 times 4 times 5 times
many times did you
0 1 2 3 4 5
typically get up at
night to urinate?)
Quality of life: how would you feel about living for the rest of your life with your urinary condition?
Delighted Pleased Mostly Mixed Mostly Unhappy Terrible
satisfied feelings dissatisfied
0 1 2 3 4 5 6
 42 Prostate Artery Embolization 583

How is BPH Digital rectal exam and correlation with

diagnosed? symptoms.
What laboratory PSA, coagulation profile, urinary analysis.
results should be
obtained?
What other Quality of life (QoL) scale, International
clinical metrics Index of Erectile Function (IIEF).
should be
considered
during patient
evaluation?
When should The American Urological Association
urodynamic recommends performing urodynamic studies
studies be in men with LUTS when invasive, potentially
performed? morbid or irreversible treatments are
considered.
What Measures of uroflowmetry include urinary
information peak flow rate (Qmax), average flow rate,
can be obtained voided volume, flow time, time to maximum
from urodynamic flow, and postvoid residual (PVR). A healthy
studies? adult male has a Qmax of approximately
25 mL/s. This decreases in patients with BPH
and is typically found to be below 12–15 mL/s.
Patients with BPH also have an elevated PVR
above 200 mL.
What imaging Prostate MRI and Pelvic CTA or MRA.
should be
available?

High Yield History

What other Neuropathic bladder (such as neurogenic
conditions can bladder disorder, multiple sclerosis and
simulate BPH-­ Parkinson’s disease), outflow obstruction
related LUTS? (bladder and prostate cancer), diuresis (due
to congestive heart failure), prostatitis.
(continued)
584 M. Ertreo et al.

Can medications Yes, particularly antidepressants, diuretics,

contribute to bronchodilators, and antihistamines. When
worsening LUTS? evaluating a patient, you should first consider
changing the medications which may be
causing LUTS before planning additional
therapies.
Is PAE indicated No, though early research is occurring for this
in patients with indication.
prostate cancer?

Indications/Contraindications

What is the Treatment of lifestyle limiting LUTS

current main symptoms. According to most recent
indication for guidelines, PAE should be contemplated only
prostate artery for highly symptomatic patients with BPH
embolization who are not responsive to medical treatment
(PAE)? and are unsuitable for surgery or refuse
surgery.
What are Severe prostatic hemorrhage secondary to
secondary prostate cancer, biopsy, or BPH. Embolization
indications for for prostatic hemorrhage was the original
PAE? primary indication for PAE.
How does PAE Embolization of arteries supplying the
work? prostate causes prostatic infarction and
reduction of gland size.
Who should IPSS > 18, moderate-to-severe LUTS for at
undergo PAE? least 6 months refractory to medical therapy,
prostate volume > 30 cm3.
What are Prostate volume < 30cm3, malignancy, active
contraindications? UTI, tortuosity and/or atherosclerosis of iliac
prostatic arteries, coagulopathy, neurologic
conditions affecting bladder tone, bladder
diverticula, or calculi. PAE efficacy has not
been demonstrated in other causes of LUTS,
such as prostate cancer, prostatitis, or urethral
strictures.
 42 Prostate Artery Embolization 585

Relevant Anatomy

What is benign Proliferation of smooth muscle and

prostatic epithelial cells in the transitional zone of the
hyperplasia prostate, which surrounds the urethra.
(BPH)?
How many lobes Anterior, median, lateral (left and right),
does the prostate and posterior lobes.
have?
What is the An enlarged median lobe can grow into the
importance of the bladder causing intravesical protrusion and
median lobe? bladder outlet obstruction. Patients with
LUTS caused by median lobe hypertrophy
have been shown to be less responsive to
medical therapies and more difficult to treat
with interventions.
How many zones Three; central, transitional, and peripheral.
is the prostate
divided in?
What zone is Transitional zone, because it surrounds the
usually responsible urethra.
for BPH and why?
In which zone does Peripheral zone; 70–80% of cancers arise in
cancer usually this zone.
arise?
What vessel Prostatic artery (PA), which has two
supplies the main branches: the anterolateral branch,
prostate? which supplies the central gland, and the
posterolateral branch, which supplies the
peripheral gland and capsule. The branches
may arise together from a common trunk
or separately. For successful PAE, both
branches must be embolized given the
significant anastomoses between the two
branches.
(continued)
586 M. Ertreo et al.

Where does the PA The PA typically arises from the inferior

arise from? vesical artery (IVA), a branch of the
anterior division of the ipsilateral internal
iliac artery (IIA). The internal iliac artery
is the main artery that supplies pelvic
structures and there is high variability in
regards to PA origin.
What are the 5 Type 1 – The IVA arises from the anterior
most common division of the IIA in a common trunk with
anatomical variants the superior vesical artery.
of PA origin?
Type 2 – The IVA arises separately and
inferiorly from the superior vesical artery.
Type 3 – The IVA arises from the obturator
artery.
Type 4 – The IVA arises from the internal
pudendal artery.
Type 5 – All other less common origins.
Type 1 and 4 are most common variants.
What acronym PROVISO, which stands for internal
can be used to Pudendal, middle Rectal, Obturator, Vesical
remember the Inferior and Superior in caudo-cranial
branches of the direction; the last O stands for Oblique,
anterior division as in ipsilateral oblique view, which is the
of the internal iliac projection in which the mnemonic is to be
artery? used.
 42 Prostate Artery Embolization 587

Relevant Materials
What particles Trisacryl gelatin microspheres (Embosphere®)
are used for or polyvinyl alcohol particles (PVA), size
embolization? ranging between 100 and 500 μm. Dimension
of the particles used during PAE vary in the
published experience from 50 to 300 to 500 μm.
Many studies have been performed and have
suggested that larger particles tend to perform
slightly better, but studies are heterogeneous,
and there is still not enough data to conclude
standard particle size.
What do Nontarget embolization.
smaller particles
increase risk of?
What kind Microcatheter.
of catheter is
used?

General Step by Step

Are preprocedural Operator dependent. Often, a quinolone
antibiotics (levofloxacin 750 mg twice daily) is
administered? administered for 2 days prior to the
procedure and for 7–10 days following it.
What other Pre-procedural medication regimens may
pre-procedure vary, though including oral diclofenac
medications should be 100 mg/d and famotidine 20 mg twice
administered? daily for 2 days before the procedure and
the morning of the procedure.
(continued)
588 M. Ertreo et al.

Why do many IRs This is helpful as an anatomical

place a bladder landmark (delineates prostate location,
catheter (iodinated internal iliac artery branches, and other
contrast medium structures).
(20–30%) and saline
solution in the
balloon) during the
procedure?
What kind of access Femoral, usually unilateral (right).
is used? Alternatively, radial access can be used
(usually left).
Are the prostatic Yes. Bilateral PAE is generally
arteries on each side accepted as the best choice in terms of
embolized? clinical results compared to unilateral
embolization, due to the deep
connections that exist between the PAs.
Bilateral PAE is feasible from a single-­
sided approach, due to intraprostatic
anastomoses and the possibility to cross
from one side to the other one. This
technique may be considered in patients
with an occluded internal iliac artery on
one side.
Where is the catheter Anterior division of the internal iliac
initially placed after artery.
access?
What are the best Anterior oblique (25°–55°, usually 35°)
projections to and caudal-cranial (10°–20°, usually 10°)
identify the prostatic projections.
artery anatomy after
appropriate catheter
placement?
 42 Prostate Artery Embolization 589

What technique Nitroglycerine or isosorbide mononitrate

can facilitate is a vasodilator used to prevent
microcatheter vasospasm and to increase artery size
navigation? to facilitate microcatheter navigation
and distal positioning. When the
microcatheter is advanced beyond the
collateral branches, the embolization can
start.
What is cone beam CBCTis an imaging technique that
CT (CBCT) and why utilizes the flat panel imaging detectors
would it be useful of the C-arm in the angiographic suite to
during PAE? obtain volumetric data and, ultimately,
deliver cross-sectional images similar
to those acquired with a traditional
CT. Images are acquired following
contrast injection with the catheter
tip in the target vessel. CBCT delivers
better soft tissue contrast and three-­
dimensional information compared
to digital subtraction angiography,
helping delineate vascular territories
and confidently identify the prostatic
arteries, decreasing the risk of non-target
embolization.
When is the injection At “near stasis” or complete stasis
of embolic material in the prostatic arteries. When
stopped? reaching stasis, some operators opt to
advanace the microcatheter into the
prostatic parenchymal branches for an
intraprostatic embolization.

Complications
What is post-­ Clinical symptoms including low-grade
embolization fever, nausea, malaise, and loss of appetite
syndrome? caused by an inflammatory response
(cytokine release).

(continued)
590 M. Ertreo et al.

What is the Supportive; pain management and fluids.

management of
post-embolization
syndrome?
What are some of PAE complications can be divided into
the most common minor and major. Minor: temporary urinary
complications after frequency, hematospermia, urinary tract
PAE? infections and balanitis, hematuria, dysuria,
rectal bleeding, acute urinary retention,
and inguinal hematoma. Major: Bbladder
ischemia (reported).
What is the Anti-inflammatory medications, pain
treatment? management.
What are potential Bladder, rectum, and seminal vesicles.
sites of non-target
embolization?
What is a Bladder wall necrosis.
severe but rare
complication?

Landmark Research
Pisco JM, Bilhim T, Pinheiro LC, et al. Medium- and Long-­
Term Outcome of Prostate Artery Embolization for Patients
with Benign Prostatic Hyperplasia: Results in 630 Patients. J
Vasc Interv Radiol. 2016
• Most clinical failures occurred within 12 months from the
procedure and most of these were within the first month.
• Clinical success, in terms of improvement of IPSS, quality
of life questionnaire (QOL), and no need for medical
therapy following PAE, was seen in 81.9% and 76.3% of
patients at medium (1–3 years) and long term (>3 years)
follow-up, respectively.
 42 Prostate Artery Embolization 591

• Overall, morbidity was low and patients did not experi-

ence sexual dysfunction or urinary incontinence.
Russo GI, Kurbatov D, Sansalone S, Lepetukhin A, Dubsky
S, Sitkin I, Salamone C, Fiorino L, Rozhivanov R, Cimino S,
Morgia G. Prostatic arterial embolization vs open prostatec-
tomy: a 1-year matched-pair analysis of functional outcomes
and morbidities. Urology 2015
• PAE patients had a higher risk of persistent symptoms and
lower peak flow at 1 year compared to open
prostatectomy.
• PAE patients experienced significantly lower complication
rates.
Gao Y, Huang Y, Zhang R, Yang Y, Zhang Q, Hou M, et al.
Benign Prostatic Hyperplasia: Prostatic Arterial Embolization
versus Transurethral Resection of the Prostate—A
Prospective, Randomized, and Controlled Clinical Trial.
Radiology 2014
• PAE is technically more challenging to perform compared
to TURP: the success rates for PAE and TURP were
94.7% and 100%, respectively.
• Fewer PAE patients were admitted to the hospital follow-
ing the procedure compared to TURP (48.1% versus
100%) and the average hospital stay was shorter following
PAE (2.9+/−1.6 days versus 4.8+/−1.8 days).
• Symptomatic relief from PAE occurs less rapidly com-
pared to TURP, but at 24 months improvement is similar
to patients that underwent TURP.
• The PAE group showed more adverse events and compli-
cations, although technical and clinical failures were con-
sidered adverse events in this study.
592 M. Ertreo et al.

Common Questions
What is the current Medical treatment, for patients with
first line of treatment mild to moderate LUTS, with α-blockers
for LUTS? (such as tamsulosin or doxazosine) and
5α-reductase inhibitors (finasteride or
dutasteride).
What is current gold Transurethral resection of the prostate
standard treatment (TURP).
for moderate-to-­
severe LUTS from
BPH?
Who is a candidate Patients with medication refractory LUTS
for TURP? and mild-to-moderate-sized prostate.
What is the current Open, laparoscopic, or robotic-assisted
surgical option for prostatectomy.
patients with large
prostates?
What are potential Electrolyte imbalance (due to saline
complications with infusion, also known as TURP syndrome),
TURP? acute urinary retention, urinary tract
infection, urethral stricture, retrograde
ejaculation, erectile dysfunction, urinary
incontinence, and, less common, bleeding
requiring transfusion.

Further Reading
AUA urodynamics guidelines. https://www.auanet.org/guidelines/
urodynamics-guideline.
Bagla S, Rholl KS, Sterling KM, et al. Utility of cone-beam CT imag-
ing in prostatic artery embolization. J Vasc Interv Radiol. 2013;
Bilhim T, Tinto HR, Fernandes L, Martins Pisco J. Radiological
anatomy of prostatic arteries. Tech Vasc Interv Radiol. 2012;
Carnevale FC, Antunes AA. Prostatic artery embolization for
enlarged prostates due to benign prostatic hyperplasia. How i do
it. Cardiovasc Intervent Radiol. 2013;
 42 Prostate Artery Embolization 593

Carnevale FC, Soares GR, de Assis AM, Moreira AM, Harward SH,
Cerri GG. Anatomical variants in prostate artery embolization:
a pictorial essay. Cardiovasc Intervent Radiol. 2017;
de Assis AM, Moreira AM, de Paula Rodrigues VC, et al. Pelvic
arterial anatomy relevant to prostatic artery embolisation and
proposal for angiographic classification. Cardiovasc Intervent
Radiol. 2015;
Gao YA, Huang Y, Zhang R, et al. Benign prostatic hyperplasia:
prostatic arterial embolization versus transurethral resection of
the prostate-a prospective, randomized, and controlled clinical
trial. Radiology. 2014;
Maron SZ, Sher A, Kim J, Lookstein RA, Rastinehad AR, Fischman
A. Effect of median lobe enlargement on early prostatic artery
embolization outcomes. J Vasc Interv Radiol. 2020;
Mirakhur A, McWilliams JP. Prostate artery embolization for
benign prostatic hyperplasia: current status. Can Assoc Radiol J.
2017;68(1):84–9.
Pereira JA, Bilhim T, Duarte M, Rio Tinto H, Fernandes L, Martins
Pisco J. Patient selection and counseling before prostatic arterial
embolization. Tech Vasc Interv Radiol. 2012;
Petrillo M, Pesapane F, Fumarola EM, et al. State of the art of
prostatic arterial embolization for benign prostatic hyperplasia.
Gland Surg. 2018;
Pisco JM, Bilhim T, Pinheiro LC, et al. Medium- and long-term out-
come of prostate artery embolization for patients with benign
prostatic hyperplasia: results in 630 patients. J Vasc Interv
Radiol. 2016;
Russo GI, Kurbatov D, Sansalone S, et al. Prostatic arterial emboli-
zation vs open prostatectomy: a 1-year matched-pair analysis of
functional outcomes and morbidities. Urology. 2015;
Wuerstle MC, Van Den Eeden SK, Poon KT, et al. Contribution of
common medications to lower urinary tract symptoms in men.
Arch Intern Med. 2011;
Young S, Golzarian J. Prostate embolization: patient selection, clini-
cal management and results. CVIR Endovasc. 2019;
Part VII
Neuro
Chapter 43
Stroke
Sarah E. Pepley and Agnieszka Solberg

Evaluating Patient
How does a Since 2009, the definitions of stroke and
transient ischemic TIA are no longer based on the duration
attack (TIA) differ of symptoms but on imaging findings. The
from a stroke? definition of stroke is “an infarction of
central nervous system (CNS) tissue.” A
TIA is a “transient episode of neurological
dysfunction caused by focal brain, spinal
cord, or retinal ischemia without infarction.”
Name the main The main classifications are ischemic stroke
classifications of and hemorrhagic stroke. Ischemic strokes
stroke and their are more common with an incidence of
relative incidence. 87%; hemorrhagic stroke incidence is 13%.
Hemorrhagic stroke can be divided into
intracerebral hemorrhage (ICH ~ 10%) and
subarachnoid hemorrhage (ICH ~ 3%).
What are ischemic stroke subtypes and their relative
incidence?

S. E. Pepley (*)
University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
A. Solberg
University of North Dakota,
Grand Forks, ND, USA

© Springer Nature Switzerland AG 2022 597

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_43
598 S. E. Pepley and A. Solberg

Cardioembolic 27%
Large artery atherosclerosis 13%
Small vessel disease 23%
Other known causes 22%
Unknown causes 35%
Describe the Embolic strokes occur when pieces of
pathophysiology of an plaque, thrombus, fat, or other materials
ischemic stroke. travel to become lodged in brain CNS
vasculature, decreasing blood supply
distal to the site of occlusion. Atrial
fibrillation, endocarditis, and long bone
fractures are risk factors for embolic
strokes.
Large vessel disease, particularly
carotid artery atherosclerosis, can also
lead to cerebral hypoperfusion or an
embolic ischemic stroke. Plaque rupture
may also occur, resulting in watershed
infarcts when collateral circulation via
the Circle of Willis (COW) is unable
to compensate (often seen in variant
incomplete Circle of Willis). Watershed
zones in the brain are site of collateral
circulation and may be susceptible to
embolic disease; cortical watersheds
occur between the MCA and ACA
(anterior), as well as the MCA and
PCA (posterior).
Small vessel disease of the smaller
penetrating arteries may cause ischemic
strokes, often due to thickening of the
arterial media or parent artery intimal
plaques at the origin of penetrating
artery.
 43 Stroke 599

What is the main The main assessment is the NIHSS

clinical patient Score – National Institute of Health
assessment tool used in Stroke Severity Score.
the evaluation of acute
stroke?
The NIHSS score describes the physical
limitations caused by the acute stroke.
Neurologic impairment is classified
based on its severity and extent. The
scale is between 0 and 42 with higher
scores (≥21) indicating a severe stroke.
What is the best CT of head without IV contrast is
primary imaging study the best primary imaging study. CT is
to order for suspected widely available and can quickly rule
stroke with onset of out intracerebral hemorrhage and
fewer than 6 hours? stroke mimics (neoplasm, arteriovenous
malformation, etc.).
According to the AHA/ASA guidelines,
door-to-imaging time should be within
25 minutes, while door-to-interpretation
time should be within 45 minutes.
What imaging study CTA of the head and neck.
should you order if
there is suspicion for
large vessel occlusion
(LVO)?
What additional CT perfusion or MR perfusion. A sign
imaging studies are of subacute to chronic occlusion is
ordered if the stroke increased collateral circulation in the
onset is between 6 and infarcted territory.
24 hours?
What non-imaging tests Glucose – because hypoglycemia and
should be ordered if hyperglycemia can mimic a stroke.
suspecting stroke and
why?
(continued)
600 S. E. Pepley and A. Solberg

Coagulation parameters (platelets,

PT/INR, aPTT) to assess coagulation
and screen for contraindications to
thrombolytics.
CBC and electrolytes/BUN/Cr may also
be checked – however if CTA needs to
be performed for an acute stroke with
suspicion for large vessel occlusion
(LVO), creatinine is not a prerequisite
in patients without the history of renal
impairment if it will delay therapy.
Troponin – baseline.
ECG – baseline.
With the exception of blood glucose
and INR ≥2, none of these tests should
delay the initiation of IV alteplase
(tPA).

High Yield History

What is the difference Non-modifiable
between modifiable
and non-modifiable
risk factors for
ischemic stroke?
 Family history
 Race
 Genetics
 Age/gender
 Previous history of stroke or TIA
Modifiable
 Hypertension
 43 Stroke 601

 Coronary artery disease

 Carotid artery disease
 A-fib or atrial flutter
 Diabetes mellitus
 Obesity
What are typical Typically, there is sudden onset of
symptoms of acute weakness, speech or visual disturbance,
ischemic stroke? confusion, headache, or sensation of
dizziness or imbalance.
Left hemispheric stroke:
 Left gaze preference
 Right visual field defect
 Right hemiparesis
 Right sensory loss
Right hemispheric stroke:
 Right gaze preference
 Left visual field defect
 Left hemiparesis
 Left sensory loss and inattention
Cerebellar stroke:
 Truncal/gait ataxia
 Limb ataxia
 Neck stiffness
Brainstem (posterior circulation) stroke:
 Nausea and vomiting
 Diplopia, deconjugate gaze, gaze palsy
 Dysarthria, dysphagia
 Vertigo, tinnitus
(continued)
602 S. E. Pepley and A. Solberg

 Hemiplegia, quadriplegia
 Hemiparesis
 Decreased level of consciousness
 Hiccups and abnormal respirations
Hemorrhagic
 Focal neurological deficits
corresponding to affected region
 Nausea and vomiting
 Headache
 Neck pain
 Light intolerance
 Decreased level of consciousness
What are risk factors Intracranial hemorrhage:
for intracranial
hemorrhage vs
subarachnoid
hemorrhage?
 Hypertension
 Alcohol
 Diabetes mellitus
 High cholesterol
 Tobacco
 Diet
 Inactivity
 Obesity
 Substance abuse
 Caffeine
Subarachnoid hemorrhage:
 Hypertension
 43 Stroke 603

 Tobacco
 Alcohol
 Substance abuse
 Family history
 Age >40
 Female gender
 Arteriovenous malformation
 Polycystic kidney disease, connective
tissue disorder, and neurofibromatosis
What is the modified The modified Rankin scale is a scale from
Rankin scale? 0 to 6 to assess degree to which stroke
has impacted a patient’s overall function
and independence performing activities
of daily living. The modified Rankin scale
is often used as an outcome measure in
clinical trials.
0 No symptoms
1 No disability despite symptoms
2 Slight disability; needs only minimum assistance to care for
personal affairs
3 Moderate disability; walks unassisted
4 Moderately severe disability; requires help walking
5 Severe disability; bedridden
6 Death
What are common Cortical-subcortical hypoattenuation in
neuroimaging a vascular territory estimates the area
findings on of the infarct but has low sensitivity
noncontrast in first 24 hours. Signs include: subtle
head CT in acute hypoattenuation, loss of gray/white matter
ischemic stroke? differentiation in basal ganglia, cortical
sulcal effacement, insular ribbon loss,
and hyperattenuation of a large vessel
(hyperdense MCA sign or dot sign).
(continued)
604 S. E. Pepley and A. Solberg

What is the The Alberta Stroke Program Early CT

ASPECTS score? Score standardizes the reporting of early
ischemic signs with superb interobserver
reliability. A normal CT scan receives 10
points. An ASPECTS score of ≤7 points
highly correlates with negative functional
outcome.

How are acute ischemic strokes classified by time?

Early hyperacute [oxyhemoglobin] 0–6 hours old (T1: isointense;
T2: bright)
Late hyperacute (or acute) 6–24 hours old (T1:
[deoxyhemoglobin] isointense; T2: dark)
Acute (or early subacute) 24 hours to 7 days old (T1:
[methemoglobin] bright; T2: dark)
Subacute (or late subacute) 1–3 weeks old (T1: bright;
[methemoglobin] T2: bright)
Chronic [hemosiderin] > 3 weeks old (T1: dark; T2:
dark)
What is the Penumbra is “at risk” tissue surrounding
penumbra in a central core of irreversible damage. This
neuroimaging? peripheral region of stunned tissue receives
blood supply via a collateral arterial network
from uninjured tissue and/or leptomeninges.
These areas are most likely to benefit from
reperfusion. Perfusion imaging identifies
penumbra as increased mean transit time
(MTT) with decreased cerebral blood flow
(CBF) and normal or mildly increased
cerebral blood volume (CBV). The mild
increase in CBV occurs secondary to
autoregulation. The infarct core demonstrates
a markedly decreased CBF and CBV. The
penumbra can be estimated by CBF-CBV and
is typically found to be 11–20 mL/100 mg/
min (normal >50 mL/100 mg/min). Software
is available to automatically quantitate
penumbra and infarct core size to aid the
interventionalist in clinical decision making.
 43 Stroke 605

Does every No, this is not the case. Patients with

stroke patient decreased consciousness or bulbar dysfunction
require resulting in airway compromise should
intubation or receive airway and ventilatory support.
supplemental Supplemental oxygen is recommended if
oxygen? required to maintain oxygen saturation >94%.
Hyperbaric oxygen is not recommended with
the exception of a cerebral air embolism.

Indications/Contraindications
What is the time 3 hours
window for IV
alteplase infusion in
stroke?
4.5 hours for a more selective group of
acute stroke patients (based on ECASS
III exclusion criteria)
How is t-PA prepared The dose of t-PA is 0.9 mg/kg (max dose
and administered? 90 mg) infused over 60 minutes.
 10% of this dose is administered as a
bolus that is infused over 1 minute.
The dose requires reconstitution and
comes as a bolus in a syringe.
A 30-minute post t-PA NIHSS should be
obtained.
The patient should be maintained NPO
until a speech and language evaluation
has been performed.
Avoid dextrose IV fluids (mitigates lactic
acidosis risk).
Head CT should be obtained 24 hours
after administration.
(continued)
606 S. E. Pepley and A. Solberg

What are the only Glucose and non-contrast head CT.

tests absolutely
required prior
to alteplase
administration?
It is not necessary to obtain PT, INR,
aPTT, or platelets if there is no suspicion
of underlying coagulopathy.
Non-contrast CT of the head should be
obtained within 20 minutes of patient
arrival.
What are absolute Wake-up stroke or time of symptom onset
contraindications to >4.5 hours
IV alteplase?
Acute intracranial hemorrhage on non-­
contrast CT
Ischemic stroke or severe head trauma
within 3 months
Intracranial/spinal surgery within
3 months
History of intracranial hemorrhage
Current structural GI malignancy or
recent GI bleed within 21 days of stroke
Coagulopathy – platelets < 100,000/mm3,
INR > 1.7, aPTT > 40s, PT > 15 s
Treatment dose of low-molecular-weight-­
heparin in past 24 hours; contraindication
does NOT apply to prophylactic doses
Treatment with direct thrombin inhibitors
or direct factor Xa inhibitors – unless
coagulation studies are normal and it has
been > 48 hours since last dose in the
setting of normal renal function
 43 Stroke 607

Glycoprotein IIb/IIIa receptor

inhibitors – cannot be administered
concurrently
Infective endocarditis
Aortic arch dissection
Intra-axial intracranial neoplasm
What are the ≥ 18 years old
indications for
mechanical
thrombectomy <
6 hours of symptom
onset?
Minimal prestroke disability (mRS 0–1)
Occlusion of ICA or proximal MCA (M1)
NIHSS score ≥ 6
Reassuring noncontrast head CT
(ASPECTS score ≥ 6)
Can be treated within 6 hours of last
known normal
It is also reasonable to treat M2 and M3
MCA segments, ACA, vertebral artery,
basilar artery, and the posterior cerebral
artery. It is reasonable to consider
candidates with higher mRS scores, and
lower ASPECTS and NIHSS scores;
however, these are IIb recommendations.
What are the The patient should present with an LVO
indications for in the anterior circulation. In addition, the
mechanical patient needs to meet additional DAWN
thrombectomy or DEFUSE 3 eligibility criteria.
6–16 hours after
symptom onset?
608 S. E. Pepley and A. Solberg

DAWN trial DEFUSE 3 trial

NIHSS score ≥ 10 ≥6
LVO location ICA, M1 ICA, M1
Thrombectomy 6–24 hours 6–16 hours
time window
Core infarct Group A Group B Group C CTP/MRP
size Age ≥ 80 Age < 80 Age < 80 core < 70 mL
core NIHSS NIHSS Penumbra/core
< 21 mL ≥ 10 core ≥ 20 core ≥ 1.8 mL
< 31 mL < 51 mL
What are the indications The patient should present with an
for mechanical LVO in the anterior circulation. In
thrombectomy addition, the patient needs to meet
16–24 hours after additional DAWN eligibility criteria.
symptom onset?
Is there a maximum age No, there is no maximum age limit.
limit for mechanical Mortality benefit has been shown in
thrombectomy? patients > 80 years old who undergo
thrombectomy, which is an age group
in which mechanical thrombectomy
has traditionally been controversial.
The patient selection criteria for
mechanical thrombectomy, however,
do change based on the patient’s age
if the patient presents 6–24 hours
since last known well or with wake-up
stroke.
What are absolute Absolute contraindications include
contraindications evidence of hemorrhagic conversion,
for mechanical midline shift, or expected “futility” of
thrombectomy? treatment (core infarct > 70 mL on
DWI, < 20% penumbra on perfusion
study, or ASPECTS score < 6 on
noncontrast CT).
 43 Stroke 609

True/false: If there This is false. Patients eligible for

is suspicion for large intravenous alteplase should receive
vessel occlusion and a the treatment even if endovascular
patient is a candidate procedures are being considered. IV
for mechanical alteplase should not delayed. Patients
thrombectomy, he/she who receive IV alteplase are still
should not be considered eligible for endovascular treatments.
for IV alteplase.
True/false: A patient This is false. If a patient who received
received IV alteplase IV alteplase is being considered for
and is being considered mechanical thrombectomy, observation
for mechanical to assess for clinical response should
thrombectomy. Is not be performed. The patient should
it reasonable to be rushed to the interventional suite.
observe the patient
for clinical response
prior to mechanical
thrombectomy?
What are typical Primary intraarterial thrombolysis
indications for the
administration of
intraarterial t-PA?
 Severe disabling neurological deficit
  Contraindication to IV
thrombolysis (e.g., recent surgery),
3–6 hours from symptoms onset
  Dense artery sign on the CT head
scan
Rescue thrombolysis
 Severe disabling neurological deficit
  No improvement with IV
thrombolysis
  No recanalization or early
reocclusion after IV thrombolysis
(continued)
610 S. E. Pepley and A. Solberg

Brainstem stroke
 Treatment can be delivered within
12 hours of symptom onset
 Occlusion of basilar artery
documented on 4-vessel
angiography
 Eligible even if consciousness
impaired or patient ventilated

Relevant Anatomy
What is the Common femoral artery, although radial
preferred artery, brachial artery, or infrequently carotid
access site for artery access may be used.
mechanical
thrombectomy in
ischemic stroke?
Why is the shape The shape and tortuosity of the aortic arch
of the aortic arch may affect the arterial access for the patient
important? (groin vs. other) and selection of the catheter.
The elongation of the arch occurs with
increasing age and makes selective
catheterization more difficult. Arch types
are determined by comparing the distance
(D) between the brachiocephalic origin to
the most cephalad margin of the arch and
the diameter of the brachiocephalic trunk or
left common carotid artery. Type 3 arches are
steepest and most difficult to navigate:
 1 = D < 1 reference vessel diameter
 2 = D is between1 and 2 reference vessel
diameters
 3 = D > 2 vessel diameters
 43 Stroke 611

What major Anterior circulation: anterior communicating

blood vessels arteries, anterior cerebral arteries, internal
compose the carotid arteries (middle cerebral arteries are
Circle of Willis? not considered part of the Circle of Willis)
Which compose
the anterior
versus posterior
circulation?
 Posterior circulation: posterior
communicating arteries, posterior cerebral
arteries
Describe the Aortic arch --> innominate artery
pathway of blood (right side only) --> R and L subclavian
flow from the arteries --> R and L vertebral arteries -->
aortic arch to basilar artery --> bifurcation to form R and L
the posterior posterior cerebral arteries.
circulation.

Relevant Materials
What is the typical Intra-arterial (IA) alteplase total doses
dose of intraarterial range from 10 to 20 mg.
alteplase?
What types of Clot retrievers (Catch device, MERCI
devices are available retriever, Phenox clot retriever),
for mechanical aspiration devices (Penumbra ACE
thrombectomy in and Medtronic Riptide), and stent
stroke? retriever devices (Medtronic Solitaire,
Stryker Trevo, Penumbra 3D, Cerenovus
EmboTrap II).
What is the Solumbra The Solumbra technique is the use of
technique? a stent retriever with an adjacent large
bore aspiration catheter to minimize
the chance of fragmentation and distal
embolization.
(continued)
612 S. E. Pepley and A. Solberg

What is the ADAPT ADAPT stands for A Direct Aspiration

technique? first Pass Technique. It utilizes aspiration
as the first approach to revascularize the
occluded vessel. If aspiration fails, then
an aspiration catheter is used with a stent
retriever to obtain revascularization.
What factors must Size and shape of aneurysm, relationship
be considered of aneurysm to cranial nerves, neck-to-­
when preparing for dome ratio of aneurysm, perforating
endovascular coil branches arising from aneurysm.
treatment (ECT) of
aneurysms?

General Step by Step

True/false: Always True, in order to rule out active bleeding/
obtain imaging of hemorrhage.
the brain before
initiating therapy
for acute ischemic
stroke.
What catheters Catheters include the Headhunter,
are typically used Sidewinder, Simmons, Newton, Osborn,
to select aortic Bentson, or Mani catheters, as they allow the
branches? operator to maneuver the sharp turns of the
arch vessels. Other useful catheters include
the Berenstein and vertebral catheter. The
choice of catheter depends on the operator
and arch shape/tortuosity.
Describe an Sheath – often an 8 French short (11 cm)
example of a sheath will be used.
typical set-up for a
stroke intervention
via groin access
(ADAPT
technique).
 43 Stroke 613

 Neurosheath – Neuron Max 088 (6F) is

usually navigated into the petrous ICA for
proximal support.
 Largest caliber aspiration catheter that
the vessel can accommodate is selected
(Commonly ACE 068 or JET 7) and
advanced with the aid of a microcatheter
(3Max) and microwire (Fathom). The tri-­
axial system allows for navigation past
the carotid siphon tortuosity, especially
the ophthalmic bend. The ACE must be
advanced to the thrombus.
 Once the system is advanced to the
thrombus, the microcatheter and
microwire are removed.
 Aspiration is begun via the ACE or JET
catheter.
 When the aspiration catheter is being
removed, aspiration is applied to the
sideport of the Neuron Max to prevent
dislodging of the thrombus.
 Some operators use a catheter with a
balloon to occlude forward flow in the
ICA during the thrombectomy.
What are the steps Similar to ADAPT - 8F sheath, NeuronMax,
of stent retrieval ACE 68.
mechanical
thrombectomy
after the clotted
vessel is identified
and selected?
Velocity microcatheter is usually used with
the microwire (Transcend). The wire and
microcatheter must be navigated past the
thrombus.
(continued)
614 S. E. Pepley and A. Solberg

Wire is removed and stent retriever is

advanced through the microcatheter.
Microcatheter is pulled back to deploy the
stent retriever.
Depending on type of stent retriever, it is
either pulled back into the microcatheter or
resheathed.
What are some Unable to navigate ACE60/68 past
reasons to switch ophthalmic artery – common reasons
from ADAPT include:
to Solumbra
technique?
 Proximal vascular tortuosity
 Large aneurysm proximal to site of
occlusion
 Tall patient
Aspiration does not work. Different centers
will try a different number of ADAPT
passes to achieve recanalization. Some may
try ADAPT up to 4 or 5 times, and some try
only one time before switching to Solumbra.
The goal is to re-perfuse to TICI 2b/3 as
quickly as possible.
What is the 5 minutes.
minimum time
required to allow
the clot to lyse
after administering
thrombolytic
agents?
What is the ideal Blood pressure ≤180/105 mm Hg during and
blood pressure to after the procedure.
maintain a stroke
patient before
reperfusion?
 43 Stroke 615

What is the This is a consensus scale (0–3), which

modified measures successful reperfusion following
thrombolysis in treatment. Scores of 2b and 3 are considered
cerebral infarction successful reperfusion.
score? (mTICI)?
 0: No reperfusion
 1: Flow beyond occlusion, no distal branch
reperfusion
 2a: Reperfusion of < 50% downstream
target arterial territory
 2b: Reperfusion of > 50% (< 100%)
downstream target arterial territory
 3: Complete reperfusion of the
downstream target arterial territory,
including distal branches with slow flow
Given a difference in outcomes between
2b and 3, a score of 2c has been recently
proposed to identify a subgroup of patients
with better outcomes than 2b group. 2c
represents near complete perfusion except
for a small number of distal cortical emboli.

Complications
What are the Intracerebral hemorrhage (~6%), puncture
most common site complications (5%; for example, groin
complications hematoma), and distal embolization of a
following new territory (4%).
mechanical
thrombectomy?
How is symptomatic Stop alteplase infusion.
intracerebral
hemorrhage
managed if resulting
after alteplase
administration?
(continued)
616 S. E. Pepley and A. Solberg

Laboratory evaluation – CBC, PT (INR),

aPTT, fibrinogen, type and cross-match
(these may not have been done prior
to alteplase administration if there
is no history of thrombocytopenia or
anticoagulation).
Emergent noncontrast head CT.
Cryoprecipitate 10 U. Additional doses for
fibrinogen <200 mg/dL.
Tranexamic acid or ε-aminocaproic acid IV
until bleeding is controlled.
Hematology and neurosurgery consultation.
Employ supportive therapy, including
airway and blood pressure management,
airway management. Steps to decrease
intracranial pressure (ICP) should be taken,
such as mannitol infusion or craniotomy.
Keep in mind temperature and glucose
control.
What is a feared Orolingual Angioedema.
complication
of alteplase
administration,
and what is the
treatment?
To treat:
 Maintain airway
 Stop alteplase and avoid ACEIs
 Administer IV methylprednisolone,
diphenhydramine, and ranitidine/
famotidine
 If there is no improvement,
administer epinephrine (0.1%) 0.3 mL
subcutaneously or 0.5 mL by nebulizer
 43 Stroke 617

 Sometimes Icatibant (selective

bradykinin B2 receptor antagonist) can
be used
 Supportive care
What are examples Arterial perforation, arterial dissection, and
of device-related vasospasm may occur. Arterial perforation
complications? is considered one of the most dangerous
of these complications due to the high
flow nature of the arterial system. If this
occurs, glue, coil, or stent grafts may be
used to repair the artery. Embolic ischemic
stroke in another vascular territory is also a
possibility.
When is peak Cerebral vasospasm following SAH
time for cerebral traditionally occurs between days 5 and
vasospasm 15, with the peak time of occurrence
following at 7–8 days. The FDA has approved
subarachnoid Nimodipine for use in treating vasospasm,
hemorrhage and data has illustrated this drug’s ability to
(SAH), and what decrease secondary ischemia.
is the standard
for prevention of
complication?
Why is Patients who suffer a large ischemic stroke
decompressive affecting >50% of MCA territory are
craniotomy useful at risk for severe cerebral edema. This
in some stroke cerebral edema can result in extremely high
patients? ICP and lead to eventual herniation with
resulting brain death; Thus, removing part
of the skull allows for brain swelling and
accompanying expansion.

Landmark Research
What has been shown by the DAWN and DIFFUSE trials?
• Changed stroke guidelines; Patients now eligible for
thrombectomy up to 24 hours after last known well
618 S. E. Pepley and A. Solberg

• Captured patients presenting in the 6–24 hours after last

known well window
• 35% increase in number of patients achieving functional
independence (mRS 0–2)
Why did the IMS III, SYNTHESIS, and MR RESCUE tri-
als not demonstrate a benefit in endovascular treatment over
alteplase?
• Primary interventions are outdated technology: IMS III
and MR RESCUE – MERCI device; SYNTHESIS – IA-­
tPA and fragmentation; these techniques are no longer
used.
• Most patients did not have LVO in IMS III and
SYNTHESIS.
–– IMS III 33% with LVO.
–– SYNTHESIS 34% with LVO.
• Successful recanalization rates were extremely low.
Although IMS III, SYNTHESIS, and MR RESCUE trials
did not demonstrate a benefit for endovascular treatment
over IV alteplase, what important information did we gain
from these trials?
• There is essentially no difference in post-treatment risk
profile (intracerebral hemorrhage and death) compared to
IV alteplase.
What was the first trial which demonstrated a benefit with
endovascular treatment vs. IV alteplase? What was different
about this trial compared to its predecessors?
• The first was the MR CLEAN trial, which required confir-
mation of a large vessel occlusion by CTA. Also, specific
measures were taken to minimize selection bias – 100% of
stroke centers in the Netherlands participated in the trial.
Which four additional RCTs demonstrated evidence for
endovascular intervention after MR CLEAN?
• ESCAPE
• EXTEND-IA
 43 Stroke 619

• SWIFT PRIME
• REVASCAT
TICI 2b/3 mRS 0–2 at
rate 90 days Death rate
ESCAPE 72% 53% vs. 29% 10% vs. 19%
EXTEND-IA 86% 71% vs. 40% 9% vs. 20%
SWIFT PRIME 88% 60% vs. 36% 9% vs. 12%
REVASCAT 66% 44% vs. 28% 18% vs. 16%

What are the main lessons from MR CLEAN, ESCAPE,

EXTEND-IA, SWIFT PRIME, and REVASCAT trials?
• Endovascular treatment has been shown to improve clini-
cal outcomes over IV alteplase alone in patients with acute
stroke secondary to a proximal large vessel occlusion.
• Endovascular thrombectomy is the only treatment option
for patients with LVO and a contraindication to alteplase.
• Careful patient selection and prompt recanalization maxi-
mize the likelihood of good patient outcome.
What are the results of the ASTER trial?
• ASTER trial compared ADAPT technique (3 passes then
adjunctive therapy) vs. stent retriever with balloon guide
catheter.
• No significant differences in characteristics except time
from clot contact to TICI 2b/3 was 13 minutes for ADAPT
vs. 22 minutes for stent retriever (p = 0.03).
• No difference between primary endpoint – mTICI 2b/3
post treatment.
• Trial confirms that ADAPT is safe and effective frontline
approach for mechanical thrombectomy.
What is the COMPASS trial?
• It is the US version of ASTER → stent retriever vs.
ADAPT. Direct aspiration was not inferior to stent
retriever in a randomized controlled trial of first-line treat-
ment in large vessel occlusion, in which functional inde-
pendence was the primary outcome.
620 S. E. Pepley and A. Solberg

Common Questions
How often should Every 15 minutes for the first hour, then
a patient receive every 1 hour for the next 24 hours.
neurological
checks in the ICU
post mechanical
thrombectomy?
What kind of follow-up Noncontrast CT to monitor for
imaging should these hemorrhagic transformation.
patients receive?
What level should If no IV alteplase: < 220/110 mmHg.
blood pressure be
maintained if the
patient has received IV
alteplase? What level
should be maintained
if the patient has not
received IV alteplase?
If already given IV alteplase:
< 180/105 mmHg.
In what circumstances Atrial fibrillation, hypercoagulable
should a patient disorders, mechanical prosthetic heart
receive long-term valves, and acute myocardial infarction.
anticoagulation after
ischemic stroke?
What is the “double-­ This refers to using one syringe to
flush technique” and aspirate the catheter and remove any air
why is it useful? bubbles present in the line. This syringe
is discarded and a second syringe
devoid of air bubbles is then used to
push forward flow. In this technique,
interventional radiologists can be sure
to avoid sending air bubbles into arterial
circulation and causing further embolic
ischemic damage to the brain.
 43 Stroke 621

List the three most Most common sites include: anterior

common sites of communicating artery (35%), internal
intracranial berry carotid artery including branches (30%),
(saccular) aneurysms. and middle cerebral artery (22%).
Note that 85% of saccular intracerebral
aneurysms occur at the Circle of Willis.
Vasospasm occurs in Confusion, restlessness, decreased sleep,
the 3–12 day window aphasia, hemiparesis
following SAH and
can be diagnosed with
transcranial Doppler.
What are its typical
signs and symptoms?

Further Reading
Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon
DL, et al. Classification of subtype of acute ischemic stroke.
Definitions for use in a multicenter clinical trial. TOAST. Trial of
ORG 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41.
Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-­
Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with
selection by perfusion imaging. N Engl J Med. 2018;378(8):708–18.
Allen LM, Hasso AN, Handwerker J, Farid H. Sequence-specific
MR imaging findings that are useful in dating ischemic stroke.
Radiographics. 2012;32(5):1285–97.
American College of Radiology. ACR Appropriateness Criteria®:
New focal neurologic defect, fixed or worsening. Less than 6
hours. Suspected stroke. Available at: https://acsearch.acr.org/
docs/69478/Narrative/. Accessed 30 Oct 2018
Balami JS, White PM, McMeekin PJ, Ford GA, Buchan
AM. Complications of endovascular treatment for acute
ischemic stroke: prevention and management. Int J Stroke.
2018;13(4):348–61.
Banks JL, Marotta CA. Outcomes validity and reliability of the
modified Rankin scale: implications for stroke clinical trials: a
literature review and synthesis. Stroke. 2007;38(3):1091–6. Epub
2007 Feb 1
622 S. E. Pepley and A. Solberg

Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reli-
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Chapter 44
Percutaneous Vertebral
Augmentation
Ryan Bitar, Barrett O’Donnell, and Charles Hyman

Evaluating Patient
Describe the Approximately 1.5 million cases of
prevalence VCF occur annually in the general US
of vertebral population. VCF most commonly occurs
compression in the elderly population (40% prevalence
fracture in the by age 80), particularly women; 25% of all
United States. postmenopausal women in the United States
will experience a VCF in their lifetime.
(continued)

R. Bitar (*)
Long School of Medicine 2021, University of Texas Health Science
Center at San Antonio, San Antonio, TX, USA
e-mail: [email protected]
B. O’Donnell
McGovern Medical School 2018, University of Texas Health
Science Center at San Antonio Radiology PGY-2,
San Antonio, TX, USA
e-mail: [email protected]
C. Hyman
Brown Medical School 2018, University of Texas Health Science
Center at San Antonio Radiology PGY-2, San Antonio, TX, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 627

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_44
628 R. Bitar et al.

What are the Osteoporosis is by far the most common

most common etiology for VCF; however, other significant
risk factors causes include trauma, infection, and
for vertebral neoplasm. Osteoporosis is most commonly
compression seen in post-menopausal women due to
fracture (VCF)? hormonal changes leading to decreased bone
mineral density and bone fragility prone to
fracture.
Most common While many fractures may develop
presentation of insidiously and may be detected incidentally
VCF? in asymptomatic patients with risk factors,
symptomatic patients may present with
sudden-onset severe focal back pain that may
radiate anteriorly and may be confused with
cardiac or pulmonary disease. The pain is
usually exacerbated by standing, sitting up, or
ambulating and improved by lying down. The
patient may demonstrate kyphosis, midline
spinal tenderness, and impaired respiratory
function.
Where do most While compression fractures may occur
VCF occur? anywhere from the occiput to the sacrum,
they most commonly occur at the
lumbodorsal junction. Most usually, T8-T12,
L1, and L4.
How is the Physical exam should include neurological
evaluation assessment to rule out nerve/spinal
and diagnosis compression. Initial diagnostic imaging
of vertebral should include plain radiograph, with
compression the classic finding of an anterior wedge
fracture fracture. Criteria for VF includes a decrease
conducted? in vertebral body height by 15–20% from
baseline height.
 44 Percutaneous Vertebral Augmentation 629

What additional While initial imaging should always consist

imaging workup of plain radiograph of the spine and is often
is useful when the only imaging necessary for a majority
planning vertebral of compression fractures. If necessary, CT
augmentation demonstrates improved anatomy for the
therapy? assessment of loss of height and spinal canal
compromise. MRI will provide the best
information regarding the fracture age, as
it may show bony edema for acute fracture.
Additionally, MRI short TI inversion recovery
(STIR) sequence may be useful for surgical
evaluation of fracture stability. A post-
contrast MRI study will detect a pathologic
fracture secondary to oncologic process.

High Yield History

What is the pathophysiology VCF occurs when the weight of the
behind the occurrence of upper body exceeds the capacity
a vertebral compression of a vertebral body to support
fracture? that weight, usually precipitated
in the event of trauma. Conditions
such as osteoporosis which lower
the bone mineral density thus
lower the severity of the trauma
necessary for fracture such as
tripping, lifting a heavy object, or
even sneezing. A healthy spine
may still be at risk for VCF in the
setting of severe trauma such as a
motor vehicle collision or hard fall.
What would serve as the Prior to the implementation of
surgical alternative prior PVA, the surgical rectification of
to the use of percutaneous compression fractures involved
vertebral augmentation decompression and fusion of the
for the treatment of vertebrae. This method would
compression fractures? often fail in the elderly usually
due to underlying osteopenia or
osteoporosis.
(continued)
630 R. Bitar et al.

How may one detect VCF in A proper evaluation of the

a cancer patient with back patient is crucial to assess the
pain? attributability of the back pain to
tumor burden. Focal pain should
be present at the lesion site, should
worsen with weightbearing, and
be relieved with the recumbent
position. Pain should lack
neurological symptoms and
typically be severe enough to affect
daily activity beyond the scope of
medical management.

Indications/Contraindications
What are common According to the Society of
indications for Interventional Radiology, common
percutaneous indications include: osteoporotic
vertebroplasty? vertebral compression fracture older
than 2 weeks and refractory to medical
therapy, painful vertebra with extensive
osteolysis, or invasion secondary to
malignant tumor.
What are indications The extrapedicular (posterolateral)
for an extrapedicular approach may be selected when the
approach versus patient presents with factors that make
the preferred the transpedicular approach difficult
transpedicular such as having a small pedicle, pedicular
approach? lysis, or pedicle screws.
What are the The absolute contraindications include
contraindications to hemorrhagic diathesis, asymptomatic
PVA? fracture, cement allergy, and infection.
Lesions with epidural extension are
relatively contraindicated for treatment
with vertebroplasty or kyphoplasty, as
they carry a higher risk of posterior
cement extravasation.
 44 Percutaneous Vertebral Augmentation 631

Relevant Anatomy
Describe The human spine consists of 24 vertebrae (7
the general cervical, 12 thoracic, 5 lumbar) along with the
components sacrum and the coccyx. There is a normal lordosis
of the spine. to the cervical and lumbar regions and a mild
kyphosis to the thoracic and sacral regions. The
vertebral arteries run through the transverse
foramina of the cervical spine. Thoracic vertebrae
have a rib attached to each lateral side. The sacrum
consists of 5 fused segments and the coccyx consists
of 4 segments with a variable fusion pattern.
Describe Each vertebra is separated via intervening discs.
the general Each vertebra consists of a body anterior to the
structure of a spinal canal, a pedicle which attached the body to
vertebra. the transverse process on each lateral side of the
spinal canal, and 2 lamina which connects each
transverse process to the posterior spinous process.
Describe the Distinguishing features of the lumbar vertebrae
anatomy of include larger vertebral body, a shorter and thicker
the lumbar as spinous process which projects more perpendicular
compared to from the body. Facets have a curved articular
the thoracic surface. The thoracic spine vertebrae are most
vertebrae. distinguished by the presence of costal facets.
Their spinous processes angulate downward.
The thoracic vertebrae have smaller pedicles
and are more prone to severe kyphotic fractures
than lumbar vertebrae, presenting a challenge to
execute the transpedicular approach.
Describe The intervertebral discs consist of three
the anatomy components: a thick outer ring of fibrous cartilage
of the (the annulus fibrosis), the gelatinous core (the
intervertebral nucleus pulposus), and the vertebral endplates,
discs. which contact the vertebrae. They are avascular
and receive their nutrients via diffusion.
(continued)
632 R. Bitar et al.

Describe the The vertebral bodies, epidural space, and nerve

blood flow of roots are supplied directly from arterial branches
the vertebral which leave the aorta. In regard to the spinal
bodies and cord, anterior segmental medullary vessels from
spinal cord. the aorta supply the anterior spinal artery, which
perfuses the anterior 2/3 of the spinal cord. Two
posterolateral spinal arteries supply the posterior
third of the spinal cord.
What Particularly in the case of thoracic spine, the
anatomical posterolateral approach introduces the concern of
structures injuring the pleura and lungs through the needle
may be at risk track, potentially introducing a risk of hemothorax.
in the case of In the case of the lumbar spine, there lies a risk
posterolateral in psoas hematoma or even retroperitoneal organ
approach? injury.

Relevant Materials
What are the Typically, the procedure occurs in a fluoroscopy
basic tools suite with conscious sedation. Multiple views
used for this are utilized to ensure precise anatomical
procedure? location. Local anesthetic with 1% lidocaine
is usually [employed]. Beveled, 11 or 13 G
styleted bone needles are used for penetrating
the target site at the anterior third of the
vertebral body. A small mallet is used to push
the needle forward into position. In the case
of kyphoplasty, a hand drill and balloon with
an inflation device are employed. Various
compounds are available for augmentation,
including poly (methyl methacrylate) (PMMA)-
based acrylic cements and biodegradable
calcium phosphate cement (CPC).
 44 Percutaneous Vertebral Augmentation 633

How does In addition to having sustainable mechanical

vertebral strength, vertebral augmentation cement
augmentation should be adequately viscous for injection,
cement differ have an appropriate setting time, and provide
from cement adequate contrast during fluoroscopic imaging.
used in other
surgical
procedures, such
as arthroplasty?
Is general Not routinely. Conscious sedation and local
anesthesia anesthetic may be suitable options for this
necessary for intervention. A combination of midazolam
this procedure? and fentanyl are suitable options for
intraprocedural pain and anxiety management.

General Step by Step

What preprocedural The patient should be NPO after midnight
steps should be for a morning procedure or at least 6 hours
taken? prior to an afternoon procedure. Small sips
of water and medication are acceptable.
Anticoagulation should be discontinued
prior to the procedure. Relevant
laboratory studies include complete blood
count and coagulation studies.
Why is the Most frequently, the transpedicular route
transpedicular is preferred; this approach lessens the risk
approach of injury to the pleura or lung, which are
preferred over complications potentially attributable to
the posterolateral the posterolateral approach. It is critical
approach, and why to avoid the medial aspect of the pedicle
must the medial as to avoid intrathecal transgression,
aspect of the pedicle which may damage intrathecal contents or
be avoided? allow for extravasation of cement into the
intrathecal space.
(continued)
634 R. Bitar et al.

What is the The patient usually resides in the prone

preferred positioning position. The initial incision is made is
of the patient and made ~1–1.5 cm lateral to the pedicle
location of initial lateral margin.
incision of the
trocar needle for
the transpedicular
approach?
Describe the Most commonly, the pedicle of interest
technique for is localized and an ipsilateral oblique
trocar needle projection is utilized to look down the
positioning prior to “barrel” of the pedicle. The needle, pedicle,
advancement via and targeted position in the anterior one-­
the transpedicular third of the vertebral body are lined up
approach. like a “bulls-eye.”
What are some Cement should be injected slowly and
guidelines regarding under lateral fluoroscopic view. It is
the injection of important to take care not to overfill
cement into the in order to reduce the risk of cement
vertebral body? extravasation. Though operator dependent,
injection should be halted once cement
distribution begins to reach the posterior
third of the vertebra body.
Describe the Patients should be subjected to 2 hours of
post-operative bed rest post-operatively. The patient may
management for the walk once their symptoms are tolerable
patient. and may be discharged the same day of the
procedure.

Complications
Most feared Extravasation of cement is considered a
complications of minor complication of vertebroplasty, though
PVA? it can be more serious when approaching
the posterior one-third as their is potential
to damage the spinal cord or even exiting
nerve roots. Venous intravasation into the
vertebral venous plexus of veins may lead to
pulmonary embolism.
 44 Percutaneous Vertebral Augmentation 635

What are the Vertebroplasty appears to demonstrate an

other general overall complication rate of about 1–10%.
complications Most complications include infection,
of percutaneous pain exacerbation, bleeding, a transient
vertebroplasty? radiculopathy, and fracture.
What risk factors One meta-analysis suggested that
increase the risk of intravertebral cleft, cortical disruption, low
cement leakage? cement viscosity, and high volume of injected
cement may be high risk factors for cement
leakage post-vertebroplasty.
A patient develops Uncommonly, cement may leak adjacent to
isolated radicular a nerve root, which may produce radicular
pattern pain. What pain. Analgesics combined with local
is the next step in steroids or anesthetics may provide adequate
management? management of this pain, so long as there
is no associated focal neurological deficit
associated with the pain.
If a patient The patient should undergo immediate
develops a focal neurosurgical consult, as it is likely a
neurological significant cement leak has occurred. A CT
deficit post-­ scan would highly be beneficial in order to
operatively, how assess the size and location of the suspected
should this patient cement leak.
be managed?
What are overall Substantial cement leaks may be avoided
techniques to with the use of high-resolution fluoroscopy,
limit the risk of and while not necessary, biplane fluoroscopy
substantial cement greatly facilitates the visualization of
leaks? cement formation during the procedure.
Patients with additional factors that limit
good visualization, such as obesity or
severe osteoporosis, may benefit from
the use of combined fluoroscopy and CT
imaging. Good cement opacification is
crucial for early recognition of a leak, which
requires the inclusion of barium sulfate
as an opacification agent in the cement
preparation.
(continued)
636 R. Bitar et al.

Landmark Research
Van Meirhaeghe J, Bastian L, Boonen S, et al. A randomized
trial of balloon kyphoplasty and nonsurgical management for
treating acute vertebral compression fractures: vertebral
body kyphosis correction and surgical parameters. Spine
(Phila Pa 1976). 2013;38(12):971–983. ­ doi:https://doi.
org/10.1097/BRS.0b013e31828e8e22
• The FREE trial was a randomized clinical trial comparing
nonsurgical management vs balloon kyphoplasty for the
treatment of acute vertebral compression fractures.
• The study concluded that over the course of two years,
pain, function, kyphotic angulation, and overall quality of
life were improved in comparison to nonsurgical
management.
Klazen CA, Verhaar HJ, Lampmann LE, et al. VERTOS II:
percutaneous vertebroplasty versus conservative therapy in
patients with painful osteoporotic vertebral compression
fractures; rationale, objectives and design of a multicenter
randomized controlled trial. Trials. 2007;8:33. Published 2007
Oct 31. doi:https://doi.org/10.1186/1745-­6215-­8-­33
• VERTOS II study, open-label RCT comparing vertebro-
plasty and conservative therapy, concludes that the tech-
nique is effective and safe, with immediate pain relief
sustained for at least one year greater than achieved by
conservative management. No difference in adjacent VCF.
Clark W, Bird P, Gonski P, et al. Safety and efficacy of ver-
tebroplasty for acute painful osteoporotic fractures
(VAPOUR): a multicentre, randomised, double-blind,
placebo-­controlled trial [published correction appears in
Lancet. 2017 Feb 11;389(10069):602]. Lancet.
2016;388(10052):1408–1416. doi:https://doi.org/10.1016/
S0140-­6736(16)31341-­1.
Buchpinder, et al. A Randomized Trial of Vertebroplasty
for Painful Osteoporotic Vertebral Fractures. New England
 44 Percutaneous Vertebral Augmentation 637

Journal of Medicine. 2009 August; 361: 557–568. DOI: https://

doi.org/10.1056/NEJMoa0900429
• Data regarding percutaneous vertebroplasty versus sham
procedure.
• It is unclear in literature which is superior. A 2009 NEJM
randomized clinical trial for vertebroplasty for osteopo-
rotic VCF showed no difference between vertebroplasty
and sham procedure.
• VAPOUR trial was more selective in patient recruiting,
better designed and masked trial demonstrating a benefit
from percutaneous vertebral augmentation.
Wang B, Zhao CP, Song LX, Zhu L. Balloon kyphoplasty
versus percutaneous vertebroplasty for osteoporotic verte-
bral compression fracture: a meta-analysis and systematic
review. J Orthop Surg Res. 2018;13(1):264. Published 2018
Oct 22. doi:https://doi.org/10.1186/s13018-­0 18-­0952-­5
• A meta-analysis performed by Wang et al. in 2018 demon-
strated no significant difference in clinical outcomes and
yield equally effective treatment modalities in the setting
of osteoporotic vertebral compression fracture, even
though kyphoplasty demonstrates the advantage of
decreasing the kyphotic wedge angle, thus increasing the
vertebral body height.

Common Questions
How rapid PVA treatment in the case of osteoporotic
is symptom vertebral fractures is associated with
improval immediate and significant long-term
following improvement in back pain, as well as quality
percutaneous of life due to improved functionality.
vertebral
augmentation?
(continued)
638 R. Bitar et al.

What are the The first percutaneous vertebroplasty

origins of the first was performed in 1984 by two French
vertebroplasty interventional neuroradiologists (Gakibert
performed? and Deramond) where they injected PMMA
into the C2 vertebra to treat a painful
vertebral hemangioma; the patient’s pain was
alleviated. Later, PMMA was employed to
treat osteoporotic vertebral fractures.
What is the In kyphoplasty, a balloon is used to create a
main difference cavity in the fractured vertebra, providing a
of kyphoplasty low-pressure lumen for the filling of cement,
as compared to thereby lowering the injection pressure and
vertebroplasty? lowering the risk of cement leakage.
What are some First-line medical therapy for vertebral
medical therapies compression fracture usually consists of
for VCF? conservative pain management. Most
commonly, NSAIDs are the first analgesic
of choice given their safety and low cost;
opioids for long-term pain control remains
largely controversial. Patients with underlying
osteoporosis and nontraumatic compression
fracture should receive bone-supporting
medication such as bisphosphonates, hormone
replacement therapy, and supplemental
vitamin D and calcium. Orthotic bracing and
physical therapy provide added benefit for
fracture recovery, as well. Unfortunately, none
of these added therapies can restore the loss
of height or reduce kyphotic deformity.
What are the both vertebroplasty and kyphoplasty are
main two types performed under fluoroscopic guidance.
of percutaneous Vertebroplasty involves the percutaneous
vertebral injection of bone cement into cancellous bone
augmentation of a vertebral body in order to alleviate pain
(PVA) and how and counter bone height loss. Kyphoplasty
do they differ? includes the inflation of a balloon to generate
a cavity for the cement to be injected.
 44 Percutaneous Vertebral Augmentation 639

How is bone Once a patient has received an initial

mineral density diagnosis of compression fracture, bone
assessed and density should be assessed using a DEXA
what is the scan. A DEXA scan will provide a T score
distinction which directly compares the bone mineral
between density of the patient to the mean bone
osteoporosis and mineral density of the young adult population.
osteopenia? A T score between −2.5 and −1.0 defines
osteopenia. A T score < −2.5 provides a
diagnosis of osteoporosis.
How long before Full recovery (or significant improvement)
a VCF is healed can be expected six to twelve weeks once
and how can the fracture has healed. Activities such as
patients decrease well-balanced diet, regular exercise, smoking
the risk of future cessation, and osteoporosis medication can
VCF? prove helpful in the prevention of future
fractures.
Could a Early in the development in the procedure,
unilateral percutaneous vertebral augmentation was
percutaneous bilateral; however, a unilateral approach
vertebral is becoming adopted. While a unilateral
augmentation approach would reduce surgical time and
prove to be as reduce overall complication rate, concerns still
efficacious as linger in regard to the efficacy of a unilateral
the traditional approach; however, studies demonstrate
bilateral that there is no difference in clinical or
approach? radiological outcomes between unilateral or
bilateral approaches.

Further Reading
Alexandru D, So W. Evaluation and management of vertebral
compression fractures. Perm J. 2012;16(4):46–51. https://doi.
org/10.7812/tpp/12-­037.
Blake GM, Fogelman I. The role of DXA bone density scans in
the diagnosis and treatment of osteoporosis. Postgrad Med J.
2007;83(982):509–17. https://doi.org/10.1136/pgmj.2007.057505.
640 R. Bitar et al.

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Chapter 45
Management of Benign
and Malignant Back Pain
by Interventional
Radiology
Lynsey Maciolek and Steven Yevich

L. Maciolek (*) · S. Yevich

The University of Texas MD Anderson Cancer Center,
Houston, TX, USA

© Springer Nature Switzerland AG 2022 645

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_45
646 L. Maciolek and S. Yevich

Evaluating the Patient

What are the key 1. How does the patient characterize the
medical questions pain?
to address  Location, duration, severity, exacerbating
in a patient and relieving factors, prior radiation,
presenting with associated neurological deficits (weakness,
musculoskeletal numbness, paresthesia, bladder and bowel
pain? deficits), and effect on activities of daily
living.
2. Can the described pain be correlated to an
abnormality on recent imaging? What is the
origin of that imaging abnormality?
 Trauma, degenerative disease (disc,
cartilaginous, osseous), infection, or tumor.
3. Does a biopsy need to be performed
to provide a definitive diagnosis before
treatment?
4. What noninvasive treatment can the patient
undergo to alleviate this pain?
 Oral pain regimen such as nonsteroidal
anti-inflammatory drugs (NSAIDs),
acetaminophen, opioids, and herbal/
traditional medication
 Non-oral pain treatments such as topical
creams and patches (lidocaine patches),
thermal therapy (ice or heat packs), and
transcutaneous electrical nerve stimulation
(TENS)
5. Have there been prior non-medicinal
treatments for this pain?
 Physical therapy, steroid injections,
locoregional ablation or radiation therapy,
and surgery.
6. What was the response to these treatments,
or why were these not pursued?
 45 Management of Benign and Malignant Back Pain… 647

In patients who Atypical symptoms for degenerative disease

present with include fever, chills, night sweats, fatigue,
pain presumed decreased appetite, unintentional weight loss,
to be from nonmechanical resting pain, nocturnal pain.
degenerative Cancer risk factors include age >50 years,
disc or osseous frequent tobacco or alcohol use, and personal
disease, what or family history of malignancy.
factors may Infection risk factors include
indicate a immunosuppression (HIV, prolonged
cancerous corticosteroid use, recent chemotherapy,
or infectious bone marrow transplant), intravenous drug
etiology that use, recent or current bacterial infection
will require (especially skin or urinary tract infection),
further work-up failure of response to initial treatment/
with additional therapy.
imaging and/or
biopsy?
What are Trauma
common reasons Osteoporosis
for a vertebral Tumor
compression Infection
fracture?
What is the Conservative (rest and bracing)
treatment for a Vertebral augmentation, which includes the
vertebral body treatment options of vertebroplasty and
compression kyphoplasty (Fig. 45.1)
fracture?
What is the Vertebroplasty is the stabilization of a
difference vertebral compression fracture deformity
between with the percutaneous injection of a bone
vertebroplasty filler, commonly polymethyl methacrylate
and kyphoplasty? (PMMA) or a calcium phosphate compound.
These bone fillers, colloquially known as bone
cement, harden to provide resistance to axial
compression forces, thus stabilizing the bone.
Kyphoplasty is similar in concept to
vertebroplasty but undertakes an additional
step to restore the vertebral body height
before the injection of the bone filler.
(continued)
648 L. Maciolek and S. Yevich

What are Facet hypertrophy, which can cause

common arthritic pain and also cause irritation and
degenerative inflammation of the adjacent median branch
etiologies for nerve
spine pain? Discogenic pain
 Lateral or para-medial disc protrusion into
the spinal canal, causing foraminal nerve
root impingement
 Central disc bulge into the spinal canal,
causing spinal canal stenosis or nerve root
compression
Sacroiliac degenerative changes leading to
joint inflammation
What is a Epidural steroid injection.
common
minimally
invasive
method to treat
discogenic pain?
What clinical Chronic low back stiffness with unilateral
features suggest low back pain that is most pronounced in the
degenerative morning and improves as the day progresses.
low back pain In addition, there is typically absence of
originates from a radiculopathy, pain aggravation by rotation/
facet joint? lateral bending/hyperextension, and pain
relief by flexion.
What are Median nerve branch block
percutaneous Median nerve branch ablation (rhizotomy)
treatment options Facet joint steroid injection
for facet joint
arthropathy?
 45 Management of Benign and Malignant Back Pain… 649

What is the best Pain palliation with steroid injection directly

objective method into the sacroiliac (SI) joint.
to determine
whether
degenerative
low back pain
originates in the
sacroiliac joint?
What more Sacroiliac joint fusion with implant.
invasive
percutaneous
treatment may
be pursued if
a patient with
sacroiliac joint
disease does not
have prolonged
relief with SI
joint steroid
injection?
What are Cementoplasty is the application of
percutaneous IR vertebral augmentation techniques outside
treatment options of the vertebral body. When applied to the
to palliate a sacrum, cementoplasty can be referred to as
sacral fracture? sacroplasty. The sacrum is accessed with bone
needles, and a bone cement is injected to
stabilize the fracture and reinforce the bone.
Percutaneous screw fixation, also known as
fixation by internally cemented screw (FICS).
This technique applies advanced imaging to
place a cannulated screw across the fracture
before filling in the fracture with PMMA
(Figs. 45.2, 45.3).
What are common Epidural steroid injcetion
minimally invasive Sacro-iliac joint steroid injection
image-guided Spinal nerve root block
procedures Facet steroid injection
to ameliorate Rhizotomy of the median branch nerves
neuropathic (Fig. 45.4).
pain?
650 L. Maciolek and S. Yevich

What are Epidural steroid injcetion

common Sacro-iliac joint steroid injection
minimally Spinal nerve root block
invasive Facet steroid injection
image-guided Rhizotomy of the median branch nerves
procedures (Figs. 45.2, 45.3, and 45.4).
to ameliorate
neuropathic
pain?

High Yield History

What are two Visual analog scale: A patient self-reported
scales commonly 10-point scale, with 0 on the left (no pain)
used to assess and 10 on the right (extreme pain) as anchor
musculoskeletal points. To perform the visual analog scale
back and pelvic appropriately, the patient should select the
pain? number based upon the face associated with
that number. In common practice, the visual
component might not be involved. Patients
can be asked for maximum, minimum, and
average pain levels in different activities
(resting, sitting, standing, and walking). This
scale is commonly used to assist in oral pain
medical distribution.
Oswestry Disability Index: In-depth patient
self-reported questionnaire designed to
characterize back pain based upon functional
impact, including pain intensity, personal
hygiene, activity, and impact on social
functions. Each section is scored on a 6-point
scale (0–5), with a higher score indicating
a higher level of disability. The numeric
summation of all 10 sections is calculated as
[(total scored)/(total possible score) × 100]
and can be used to trend response to
treatments over time.
(continued)
 45 Management of Benign and Malignant Back Pain… 651

a b

c d

Figure 45.1 Kyphoplasty of a painful L4 vertebral compression

fracture deformity using a bipedicular needle placement (a), balloon
inflation (b), and PMMA injection under fluoroscopy ((c) sagittal
view, (d) AP view)

a b

c d e

Figure 45.2 Insufficiency fracture of the right sacral ala causing

significant weight-bearing pain ((a) bone scan with increased activ-
ity in the right sacrum, arrow, (b) MRI with contrast with increased
intensity, arrow). Intra-procedural CT axial images during cemento-
plasty, with needle placement in a posterior short-axis approach (c),
followed by PMMA injection (d), and final procedure image with
needle removed (e)
652 L. Maciolek and S. Yevich

a b

c d

Figure 45.3 Painful, non-healing left sacral fracture from radiation-­

induced osteoporosis as a complication of colon cancer treatment
((a) MRI axial post-contrast with left sacral hyperintensity, (b)
oblique axial CT image with cortical disruption, arrow), treated with
fixation by internally cemented screw ((c) CT procedural oblique
coronal image demonstrated cannulated screw advanced over a
Kirschner wire, (d) CT procedural oblique coronal image after
PMMA injection around the screw)
 45 Management of Benign and Malignant Back Pain… 653

a b c

d e f g

Figure 45.4 Epidural steroid injection ((a) anterior-posterior pro-

jection, (b) sagittal projection with arrow identifying contrast layer-
ing in the epidural space). Right sacro-iliac joint steroid injection
((c), arrow). Spinal nerve root block at the left L4 neuroforamen
under CT guidance (d). Steroid injection into the right L4/5 facet
((e), obliqued anterior-posterior view). Rhizotomy for the right
L2-L4 median branch nerves ((f) anterior-posterior projection, (g)
obliqued projection)
654 L. Maciolek and S. Yevich

Indications/Contraindications
What are the two broad Diagnostic intervention to confirm
indications for epidural the source of back pain
steroid injections (ESI)? Therapeutic intervention to provide
temporary pain relief in the setting
of radiculopathy in patients with
discogenic or other spinal canal
pathology, unspecified nerve pain,
and recurrent radiculopathy post-­
laminectomy
What are the two broad Diagnostic intervention to confirm
indications for selective the source of back pain
nerve root blocks (SNRB)? Therapeutic intervention to provide
temporary pain relief in the setting
of radiculopathy in patients with
disc herniations and recurrent
radiculopathy post-discectomy
What are the Absolute:
contraindications to steroid  Coagulopathy
injections?  Active infection
 Pregnancy
 Maximum recommended
corticosteroid dose reached
Relative:
 Allergy to anesthetic or
corticosteroid
What are the limitations Anatomic variability.
for radiofrequency
ablation (rhizotomy) in the
treatment of median branch
nerve inflammation caused
by facet hypertrophy?
 45 Management of Benign and Malignant Back Pain… 655

What are the indications for Mechanical, weight-bearing pain in

vertebral augmentation? the spine that affects daily quality
of life and has not improved with
conservative measures
Imaging that confirms a vertebral
body compression fracture that
correlates with the location of the
mechanical pain
What are absolute and Absolute:
relative contraindications  Unstable vertebral column
for vertebral augmentation? fractures better treated with
surgical fixation
 Active infection
 Coagulopathy
Relative:
 Fracture protrusion into the
spinal canal
 Tumor erosion through the
posterior wall of the vertebral
body that increases risk for bone
filler injection to enter the spinal
canal
 Vertebral planum that precludes
bone filler injection

Relevant Anatomy
Review the below
depiction of important
spinal anatomy to refer
to throughout this
chapter (Figs. 45.5 and
45.6).
In the approach to The margins include the pedicle
spinal nerve root superiorly, the lateral border of the
injection for the L1-L4 vertebral body laterally and the outer
levels, what location margin of the spinal nerve medially.
has been termed the Needle tip placement into this location
fluoroscopic “safe minimizes the risk of damage to the
triangle” for needle nerve root as it exits the neuroforamen
passage? (Fig. 45.7).
656 L. Maciolek and S. Yevich

ESI MBB Facet

NRB
Dura

Median
branch nerve

Dorsal
nerve root

Dorsal ramus

Ventral ramus

Lumbar artery

Figure 45.5 Spinal anatomy detailed above, with the following

abbreviations detailed below. Dura dura mater, ESI epidural steroid
injection, MBB medial branch block, Facet facet joint, NRB nerve
root block

a b c

Figure 45.6 (a) central vertebral disc herniation, which is a posterior-­

facing bulge with the potential to interfere with the spinal cord. (b)
paramedial vertebral disc herniation, also known as posterolateral
herniated disc, which results from a disc bulge off-center (left or
right) and asymmetric into the lateral recess on the side of the spinal
cord. (c) extreme lateral vertebral disc herniation, which is a disc
bulge outside of the spinal canal causing nerve root compression at
the level above the prolapsed disc
 45 Management of Benign and Malignant Back Pain… 657

Intervertebral disc

Dorsal root
ganglion

Safe triangle

Nerve root

Pedicle

Figure 45.7 The safe triangle (green triangle) is the best approach
when administering a spinal nerve root injection at L1-L4 levels and
includes the following margins: the pedicle as the superior border,
the lateral edge of the vertebral body as the lateral border, and the
outer margin of the spinal nerve as the medial diagonal border
658 L. Maciolek and S. Yevich

Relevant Materials
What is typically Diagnostic injection: 1–2 mL of 2%
used for spinal lidocaine or 0.25%–0.5% bupivacaine
nerve root blocks Therapeutic injection: 1–2 mL of 2%
and epidural spinal lidocaine or 0.25%–0.5% bupivacaine +
injections? 1 mL of corticosteroid
Example of a common steroid solution:
40 mg triamcinolone and 2 mL 0.5%
bupivacaine (total volume of 3 mL)
Injection volume of anesthetic and/or
corticosteroid typically should not exceed
3 mL
What is typically Diagnostic injection: 0.5–1.5 mL of 2%
used for facet lidocaine or 0.5% bupivacaine
injections? Therapeutic injection: 0.5–1.5 mL of 2%
lidocaine or 0.5% bupivacaine + 0.5–1 mL
of corticosteroid
Injection volume of anesthetic and/or
corticosteroid should typically not exceed
2 mL
When and why Particle-free steroid, such as
might particle-free dexamethasone, may be more appealing
steroid be used for a to inject at the neuroforamen to minimize
steroid injection? the risk of embolization of a radicular
arterial branch that may contribute to
the anterior spinal artery. If a particulate
steroid is injected into a branch of the
anterior spinal artery, this may result in
spinal cord injury and paralysis. Particle-­
free steroids are also recommended for
cervical (neck) epidural injections given
the smaller epidural space at this level.
 45 Management of Benign and Malignant Back Pain… 659

What are the Polymethyl methacrylate (PMMA) is

common types of a nonresorbable bone filler with high
bone fillers that can compression resistance.
be percutaneously Calcium phosphate cements, derived from
injected for vertebral hydroxyapatite, are resorbable bone filler
body compression alternatives that are not as hard as PMMA
fractures and sacral and have less compression resistance. This
fractures? may be more appropriate for osteoporotic
fractures to minimize the risk of secondary
fractures of adjacent vertebral body levels.

General Step by Step

What are common Conservative measures: Physical therapy,
treatment options structured exercise programs, spinal
for lumbar manipulation, traction (manual or
radiculopathy? mechanical)
Pharmacologic interventions: NSAIDS,
tumor necrosis factor alpha inhibitors,
glucocorticoids, 5-hydroxytryptamine
receptor inhibitors, gabapentin, agmatine
sulfate, amitriptyline
Image-guided needle-directed therapy:
spinal nerve root block and epidural steroid
injection
Surgery: anterior lumbar/extreme lateral/
transforaminal lumbar/posterior lumbar
interbody fusion, lumbar laminectomy,
lumbar microdiscectomy, laminotomy,
lumbar spinal fusion, cage implantation,
pedicle screw, deformity correction
During SNRB, Radicular pain elicited by the needle tip.
what two factors Contrast injection opacifies the
will jointly confirm neuroforamina.
appropriate needle
tip position before
injection?
(continued)
660 L. Maciolek and S. Yevich

During ESI, Entrance into the epidural space will be

what confirms accompanied by a sudden loss of resistance
appropriate needle to pressure applied through a saline or air-­
tip position within filled syringe connected to the needle hub.
the epidural space?
What are the (2) Intra-articular injection: The source of facet
types of facet pain may be directly related to arthritic
procedures? inflammation within the joint. An intra-­
articular injection of anesthetic and/or
corticosteroid into the joint space can
relieve this primary pain source.
 (a) Diagnostic: Injection of local
anesthetic agent directly into the facet
joint can identify if pain is localized to
the joint itself.
 (b) Therapeutic: Injection of both local
anesthetic for short-term pain relief and
corticosteroid for more prolonged pain
relief.
Medial branch nerve block (MBB): The
medial branch nerve provides sensory
innervation to the facet joint. An MBB
inhibits the transmission of pain signals
from facet joints and relieves indirect nerve
inflammation caused by mechanical friction
of the hypertrophied facet joint with the
median branch nerve.
 (a) Diagnostic: Injection of local
anesthetic agent adjacent into the soft
tissue immediately lateral to the facet can
identify if pain is caused by either the
facet or a local irritation of the associated
median branch nerve.
 (b) Therapeutic: Injection of both local
anesthetic for short-term pain relief and
corticosteroid for more prolonged pain
relief.
 45 Management of Benign and Malignant Back Pain… 661

What methods Pressure resistance during needle

confirm needle advancement decreases with entry into the
placement within joint.
the facet during Patients typical describe decreased
facet injection? procedural pain stimulus upon needle entry
into the joint.
Contrast injection through the needle will
layer within the facet joint.

Complications
What are possible Abnormalities in blood glucose levels,
side effects from particularly in diabetic patients
steroid injections? Sleeplessness/insomnia
Mood disturbances
Transient immunocompromised state with
or without abnormal white blood cell count
What are possible Infection
complications for Bleeding
spine injections? Spinal fluid leakage causing decreased
intracranial pressures and/or spinal fluid
hydrocele
List some specific Nerve root blocks: needle trauma resulting
complications for in continued or worsened radicular pain,
spinal nerve root weakness/paresthesia, and rarely vascular
blocks and epidural occlusion/thrombosis that can cause spinal
spinal injections? cord infarction if the radiculomedullary
artery is injected with steroid containing
particles
Epidural spinal injections: needle trauma
causing dural puncture, epidural hematoma,
and spinal fluid leak that may result in
headaches or spinal fluid hydrocele that
might require surgery or blood patch
(continued)
662 L. Maciolek and S. Yevich

What are possible Damage to surrounding structures (muscle,

complications nerve, bone)
of palliative Hemorrhage
radiofrequency Infection
ablation Skin burn
(rhizotomy)
treatments?
What are possible Cement leakage that compresses a spinal
complications cord or nerve root
of vertebral Cement leakage into the periosteal venous
augmentation or plexus with cement embolus to the lungs
sacroplasty?27
What are possible Bleeding due to damage of a gluteal or
complications of internal iliac branch artery
percutaneous sacral Infection
fixation or fusion? Nerve damage due to procedural trauma
(screw misplacement or cement leakage)
 45 Management of Benign and Malignant Back Pain… 663

Landmark Research
What are Kallmes DF, Comstock BA, Heagerty PJ,
landmark et al. A randomized trial of vertebroplasty
research trials in for osteoporotic spinal fractures. [published
support of and correction appears in N Engl J Med.
against vertebral 2012 Mar 8;366(10):970]. N Engl J Med.
augmentation? 2009;361(6):569–579. doi:https://doi.
Please see the org/10.1056/NEJMoa0900563.
dedicated chapter VERTOS IV Trial: Firanescu CE, de Vries J,
on vertebral Lodder P, et al. Vertebroplasty versus sham
augmentation procedure for painful acute osteoporotic
for additional vertebral compression fractures (VERTOS
references. IV): randomised sham controlled clinical
trial [published correction appears in BMJ.
2018 Jul 4;362:k2937. Smeet AJ [corrected to
Smeets AJ]]. BMJ. 2018;361:k1551. Published
2018 May 9. doi:https://doi.org/10.1136/bmj.
k1551
VAPOUR Trial: Clark W, Bird P, Gonski P,
et al. Safety and efficacy of vertebroplasty
for acute painful osteoporotic fractures
(VAPOUR): a multicenter, randomized,
double-blind, placebo-controlled trial. The
Lancet. 2016; 388(10052):1408-1416.
EVOLVE Trial: Beall DP, Chambers MR,
Thomas S, et al. Prospective and Multicenter
Evaluation of Outcomes for Quality of Life
and Activities of Daily Living for Balloon
Kyphoplasty in the Treatment of Vertebral
Compression Fractures: The EVOLVE Trial.
Neurosurgery. 2019;84(1):169–178. doi:https://
doi.org/10.1093/neuros/nyy017
(continued)
664 L. Maciolek and S. Yevich

What were the Selective nerve root injections as a diagnostic

key findings test to identify the source of pain and
by Sasso et al. predicting surgical outcomes had a positive
regarding the predictive value of 91.2% and a negative
application of predictive value of 40.0%.
selective nerve Although the surgical decision to treat is
root blocks as heavily guided by local MRI abnormalities,
a pre-operative the negative predictive value of selective
intervention nerve root injections was significantly better
to confirm than MRI findings (z = 2.46, P = 0.01) to
pain source identify the source of pain.
and decrease Of the 91 patients in this study, seven patients
reoperation had an initial negative selective nerve root
rates for surgical injection, followed by a positive selective
decompression? nerve root injection at an adjacent level.
All seven of these patients went on to have
positive surgical outcomes.
Manchikanti Both groups showed an overall significant
et al. published improvement in numeric pain score and
a randomized, Oswestry Disability Index over the two-year
double-blind, study period.
active-control Despite the lack of a significant difference
trial on the between the groups, there was a general
effectiveness superior pain relief at 6 months in the steroid
of lumbar group, and similarly improved functional
interlaminar status at both 6 and 12 months.
epidural The steroid group only had one treatment
injections in failure, compared to ten in the local
disc herniation anesthetic group, suggesting that the inclusion
comparing of steroid may increase rates of treatment
treatments with success.
and without
steroids. Did
this study show
any superiority
in the group
that obtained
anesthetic +
steroid vs. those
who solely
received local
anesthetic?
 45 Management of Benign and Malignant Back Pain… 665

In their Radiofrequency ablation

application for Cryoablation
pain palliation of
bone metastases,
what (2) ablation
modalities are the
most commonly
used with robust
literature to
support their
use? 1
In regard to The freeze-passive thaw-freeze cycle was as
treatment of follows: 10 minutes - 8 minutes - 10 minutes,
metastatic bone respectively. Iceball coverage was monitored
tumors with via CT imaging every 2–5 minutes to
cryoablation set monitor coverage of the tumor and prevent
by Callstrom et al. ice extension over critical structures to be
in 2013, what was avoided.
the freeze-thaw Cryoablation therapies improved the pain
cycle used and level of 49% of patients by a 2-point mean
what were the reduction in worst pain within one week of
outcomes? treatment. 75% of patients reported 90%
or higher pain relief at some point in the
follow-up period. Throughout the follow-up
period of 24 weeks, only 14% of patients
reported a pain level equal to or greater than
their pain before the treatment.
Although it did not reach statistical
significance, the use of opioid analgesics
decreased by 83% among patients who
reported use prior to the procedure.
(continued)
666 L. Maciolek and S. Yevich

In the study Ablation was performed at a current of

Dupuy et al. 1100–2000 mA for a maximum of 4 minutes
in 2010, what to ensure the intratumoral temperature
was the general exceeded 60 degrees Celsius. If the
treatment intratumoral temperature was below 60
protocol for degrees Celsius in this process, another
radiofrequency 4-minutes treatment is performed at that
ablation of bone position.
metastases and Radiofrequency ablation had a statistically
what were the significant improvement in pain relief, patient
overall results? mood, pain intensity, and pain severity at one
and three months.

Common Questions
What should patients Steroid pain relief will take several
expect in the normal post-­ days to take effect. Therefore, a
procedure course after patient should expect return of
the therapeutic injection symptoms once local anesthetic wears
of anesthetic and steroid off in 6–24 hours until the steroids
for epidural and spine take their effect.
nerve blocks? Response is highly variable. The
mean duration of therapeutic spine
injections is 3–6 months. The mean
duration of therapeutic sacroiliac
joint injections is approximately
10 months.
What is the role of Ablation of vertebral metastasis
ablation for malignant provides pain palliation due to
vertebral body denervation of the periosteal nerves
compression fractures? and also aids in locoregional tumor
control to decrease the progression of
disease.

Acknowledgments The authors would like to acknowledge the contributions

of the Diagnostic Imaging media resource at the University of Texas, MD
Anderson Cancer Center. Specifically, we wish to thank Kelly Kage, MFA,
CMI, for her assistance with the medical illustrations in this chapter.
 45 Management of Benign and Malignant Back Pain… 667

Further Reading
Callstrom MR, Dupuy DE, Solomon SB, et al. Percutaneous image-
guided cryoablation of painful metastases involving bone: multi-
center trial. Cancer. 2013;119(5):1033–41.
Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of
lumbar zygapophysial (facet) joint pain. Anesthesiology.
2007;106(3):591–614.
Cross WW, Delbridge A, Hales D, Fielding LC. Minimally invasive
sacroiliac joint fusion: 2-year radiographic and clinical outcomes
with a principles-based SIJ fusion system. Open Orthop J.
2018;12:7–16.
Destouet JM, Gilula LA, Murphy WA, Monsees B. Lumbar facet
joint injection: indication, technique, clinical correlation, and
preliminary results. Radiology. 1982;145(2):321–5.
Deschamps F, Yevich S, Gravel G, et al. Percutaneous fixation
by internal cemented screw for the treatment of unstable
osseous disease in cancer patients. Semin Intervent Radiol.
2018;35(4):238–47.
Dupuy DE, Liu D, Hartfeil D, et al. Percutaneous radiofre-
quency ablation of painful osseous metastases: a multicenter
American College of Radiology Imaging Network trial. Cancer.
2010;116(4):989–97.
Fairbank JC, Pynsent PB. The Oswestry disability index. Spine
(Phila Pa 1976). 2000;25(22):2940–52. discussion 2952
Filippiadis DK, Kelekis A. A review of percutaneous techniques for
low back pain and neuralgia: current trends in epidural infiltra-
tions, intervertebral disk and facet joint therapies. Br J Radiol.
2016;89(1057):20150357.
Filippiadis DK, Yevich S, Deschamps F, Jennings JW, Tutton S,
Kelekis A. The role of ablation in cancer pain relief. Curr Oncol
Rep. 2019;21(12):105.
Gibbs WN, Doshi A. Sacral fractures and sacroplasty. Neuroimaging
Clin N Am. 2019;29(4):515–27.
Hao DJ, Duan K, Liu TJ, Liu JJ, Wang WT. Development and clinical
application of grading and classification criteria of lumbar disc
herniation. Medicine (Baltimore). 2017;96(47):e8676.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. 5th ed. Philadelphia: Wolters Kluwer;
2016.
668 L. Maciolek and S. Yevich

Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical

guideline for the diagnosis and treatment of lumbar disc hernia-
tion with radiculopathy. Spine J. 2014;14(1):180–91.
Ku KL, Wu YS, Wang CY, et al. Incorporation of surface-­modified
hydroxyapatite into poly(methyl methacrylate) to improve
biological activity and bone ingrowth. R Soc Open Sci.
2019;6(5):182060.
Lee DG,Ahn SH, Cho YW, Do KH, Kwak SG, Chang MC. Comparison
of intra-articular thoracic facet joint steroid injection and tho-
racic medial branch block for the management of thoracic facet
joint pain. Spine (Phila Pa 1976). 2018;43(2):76–80.
Lennard TA. Pain procedures in clinical practice. 3rd ed.
Philadelphia: Elsevier/Saunders; 2011.
Lotz JC, Haughton V, Boden SD, et al. New treatments and imag-
ing strategies in degenerative disease of the intervertebral disks.
Radiology. 2012;264(1):6–19.
Manchikanti L, Singh V, Cash KA, Pampati V, Falco FJ. A random-
ized, double-blind, active-control trial of the effectiveness of
lumbar interlaminar epidural injections in disc herniation. Pain
Physician. 2014;17(1):E61–74.
Mears SC, Edwards PK. Bone and joint infections in older adults.
Clin Geriatr Med. 2016;32(3):555–70.
Palmer WE. Spinal injections for pain management. Radiology.
2016;281(3):669–88.
Rasor J, Harris G. Opioid use for moderate to severe pain. J Am
Osteopath Assoc. 2005;105(6 Suppl 3):S2–7.
Roux C, Tselikas L, Yevich S, et al. Fluoroscopy and cone-beam
CT-guided fixation by internal cemented screw for pathologic
pelvic fractures. Radiology. 2019;290(2):418–25.
Roy C, Chatterjee N, Patro SN, Chakraborty A, Vijay Kumar
GR, Sengupta R. The efficacy of transforaminal epidural ste-
roid injections in lumbosacral radiculopathy. Neurol India.
2011;59(5):685–9.
Sasso RC, Macadaeg K, Nordmann D, Smith M. Selective nerve root
injections can predict surgical outcome for lumbar and cervical
radiculopathy: comparison to magnetic resonance imaging. J
Spinal Disord Tech. 2005;18(6):471–8.
van Loon AJ, Tijhuis M, Surtees PG, Ormel J. Lifestyle risk factors
for cancer: the relationship with psychosocial work environment.
Int J Epidemiol. 2000;29(5):785–92.
 45 Management of Benign and Malignant Back Pain… 669

Yevich S, Tselikas L, Gravel G, de Baère T, Deschamps

F. Percutaneous cement injection for the palliative treatment of
osseous metastases: a technical review. Semin Intervent Radiol.
2018;35(4):268–80.
Yevich S, Tselikas L, Kelekis A, Filippiadis D, de Baere T, Deschamps
F. Percutaneous management of metastatic osseous disease. Chin
Clin Oncol. 2019;8(6):62.
 Part VIII
Vascular Emergencies
Chapter 46
Trauma Embolization
Justin J. Guan

Evaluating Patient
In the setting of First evaluate and stabilize the patient’s
trauma, what should ABCs: airway, breathing, and circulation.
always be evaluated A comprehensive physical examination,
and stabilized before followed by directed imaging, will
undertaking further then dictate further treatment and
management? management.
(continued)

J. J. Guan (*)
Division of Interventional Radiology, Department of Diagnostic
Radiology, Cleveland Clinic, Cleveland, OH, USA

© Springer Nature Switzerland AG 2022 673

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_46
674 J. J. Guan

What imaging FAST (Focused Assessment with

evaluation is Sonography for Trauma) Exam. This
used to screen for exam is safe and noninvasive, can
intra-abdominal be performed at the bedside and
hemorrhage? incorporated into the primary and
secondary trauma survey, can be
repeated serially, and can avoid the need
CT scan and diagnostic peritoneal lavage
due to high specificity for the detection
of free fluid. The areas examined are:
 Right upper quadrant (Morrison’s
pouch).
 Left upper quadrant (left perisplenic
space).
 Pelvis axial and transverse views
(pouch of Douglas).
 Subxiphoid heart view (pericardial
space).
 Additional views obtained in
the E-FAST exam include right
anterior longitudinal chest view,
left anterior longitudinal chest view,
and longitudinal view of the IVC
(significant, >50% collapse of the IVC
in response to respiratory variation is
a sign of hemodynamic instability).
Which imaging Contrast-enhanced CT. Multiphase CTA
modality is most is most ideal to localize bleeding and to
critical in evaluating demonstrate active extravasation, as well
for active internal as differentiate arterial extravasation
hemorrhage? from pseudoaneurysm.
 46 Trauma Embolization 675

In the setting of Hemodynamic stability. Patients with

organ injury with intra-abdominal trauma who are
active hemorrhage, hemodynamically unstable should
what determines proceed to surgery, whereas patients who
whether a patient are stable can undergo angiography and
will undergo surgical embolization.
or nonoperative
(endovascular
or conservative)
management?
In the setting of pelvic Patients with suspected ongoing arterial
or extremity trauma, bleeding who are hemodynamically
when is angiography unstable and do not respond to
and embolization fluid resuscitation are indicated for
indicated? pelvic/extremity arteriography and
embolization. Unlike in intra-abdominal
bleeds where hemodynamic instability
generally necessitates surgery, the
anatomic complexities of the pelvis and
extremities increase the difficulty of
achieving hemostasis through surgery.

High Yield History

What are vital Mechanism of injury (blunt or
components of a penetrating, type of weapon or missile),
patient’s history in the location of injury, environmental factors,
setting of trauma? and time of occurrence
Presenting Glasgow Coma Score (GCS)
Knowledge of all imaging findings and
resuscitation efforts including amount
of fluids, pressors, and transfusions
administered
(continued)
676 J. J. Guan

What are vital Document any deformities, swelling,

components of hematomas and evaluate for any change
physical exam in the over time.
setting of trauma? Detailed neurologic exam.
Cardiovascular exam, including pulse
and BP.
List the “hard signs” Hard signs of arterial injury include:
of arterial injury in visible external arterial hemorrhage,
extremity trauma. rapidly expanding or pulsatile
What management hematoma, palpable thrill or audible
approach do these bruit, or obvious arterial occlusion on
signs generally exam such as findings of pulselessness,
portend? pallor, paresthesia, pain, paralysis, or
pokilothermia, especially after the
reduction of dislocation or realignment
of fracture. These findings generally
require immediate surgical management.
List the “soft signs” Soft signs of arterial injury include:
of arterial injury in history of arterial bleeding at scene of
extremity trauma. injury, proximity of major artery(ies)
What management to penetrating or blunt trauma,
approach do these diminished unilateral distal pulse, small
signs generally or nonpulsatile hematoma, neurologic
portend? deficit, ankle-brachial index <0.9,
or abnormal waveform on Doppler
ultrasound. In the presence of these
findings, one may consider following
with arteriogram or serial examinations.
In the setting of Distal pulses, ankle-brachial index
extremity trauma, what (ABI), wrist-brachial index (WBI).
are some objective
measurements that can
be used to evaluate for
adequate perfusion to
the distal extremities?
 46 Trauma Embolization 677

What are the general Predictive factors for the failure of

risk factors for non-operative management include
embolization failure? high severity of injury and underlying,
pre-existing disease, or the injury of the
organ in question.
What is the Gelfoam is broken down by the body
recanalization time of and thus recanalizes in 4–6 weeks,
Gelfoam, and why is making it a temporary embolic agent.
this knowledge useful? Temporary agents provide short-term
occlusion of vessels that will likely heal
once hemostasis is achieved, for instance
in cases of emergent GI bleeds, splenic
bleeds, or uterine bleeds. Gelfoam can
also be used as an adjunct to permanent
embolic agents to help achieve
thrombosis. A downside of temporary
agents is that if the material breaks
down before the vessel(s) can heal,
the patient may rebleed. An advantage
of temporary agents like Gelfoam is
that once the agent recanalizes, access
through the embolized vessel(s) may
still be possible, whereas after using
permanent agents like coils, future access
will not be possible.
678 J. J. Guan

Indications/Contraindications
When is angiography Angiography with embolization
and embolization is generally indicated in cases of
indicated in the setting organ injuries where patients are
of trauma? hemodynamically stable but shows
evidence of significant continued
bleeding, such as dropping hemoglobin,
continued need for fluid resuscitation
and blood transfusions, or CT evidence
of contrast extravasation. In cases of
suspected pelvic or extremity arterial
bleeds, embolization is indicated for
patients who are hemodynamically
unstable or require continued fluid
resuscitation.
What are the Active hemorrhage is demonstrated
key CT imaging on CT by extravasation of contrast,
features of active which appears as a linear, flame-shaped,
hemorrhage? How or irregularly shaped hyperdensity
does this differ from a that follows the density of contrast-­
pseudoaneurysm? enhanced arteries. The extravasation
will typically have irregular borders.
In cases of arterial bleeding, the
extravasation will be seen on arterial
phase and will quickly decrease in
density on delayed phases. If present, a
surrounding hematoma will also be seen
to enlarge on delayed phase imaging. In
comparison, a pseudoaneurysm typically
appears as a sharply defined, round or
oval area of hyperdensity that follows
the density of contrast-enhanced arteries
on arterial phase. It may also quickly
decrease in density on delayed phase
imaging; however, it will not be seen
blending into an enlarging hematoma.
 46 Trauma Embolization 679

Discuss in which Temporary: For short-term occlusion

circumstances of vessel in cases where the vessel is
temporary vs. expected to heal after damage, when a
permanent embolic permanent treatment method is planned
agents are indicated. at a later time (such as for cases of
temporary occlusion of bleeding splenic
arteries before open splenectomy), or
when need for repeat access to the site
of interest in foreseen future.
Permanent: When long-term occlusion
of vessel is preferred, such as in
case of pseudoaneurysm or AVM,
or when organ in question has rich
collateral supply more distally so that
recanalization for salvage of organ from
ischemia is not required, such as in GI
bleeds.
Discuss in which In general, proximal embolization
circumstances is performed to relieve the arterial
proximal vs. distal pressure head such as in blunt trauma
vessel embolization is to spleen or in times of severe
indicated. hemodynamic emergency when time is
critical. If an arterial injury is identified,
it is ideal to embolize proximal and
distal to the site of injury to avoid back
filling. Distal embolization only may be
performed when injury is supplied by a
single end-vessel, or when multiple end-­
vessel territories are affected and the
risk of ischemia is outweighed by control
of bleeding.
What are general Contraindications are generally relative
contraindications to and include hemodynamic instability,
arterial embolization pre-existing organ disease or injury,
for traumatic organ multisystem trauma, and associated
injuries? diaphragmatic or hollow viscous injury.
680 J. J. Guan

Relevant Anatomy
What is the dual The portal vein supplies approximately
blood supply to 75% of the liver’s blood supply, whereas the
the liver and what hepatic artery supplies approximately 25%.
proportion of liver
blood supply do
they each provide?
What are the Splenic artery, left gastric artery, and
classic branches of common hepatic artery.
the celiac trunk?
What are Gastroduodenal Artery – Branch of the
the common common hepatic artery, anastomoses
collaterals with the inferior pancreaticoduodenal
between the celiac artery via the anterior and posterior
trunk and superior pancreaticoduodenal arcades
mesenteric artery? Dorsal Pancreatic Artery – Branch of splenic
artery, anastomoses with the anterior and
posterior pancreaticoduodenal arcades
Arc of Buhler – Branch of the celiac trunk,
anastomoses with the superior mesenteric
artery
Arc of Barkow – Connects the left and right
gastroepiploic arteries
What are Arc of Riolan – Continuous arterial arcade
the common formed by connections between the proximal
collaterals branches of the SMA and the proximal
between the SMA branches of the IMA. Compared to the
and IMA? Marginal Artery of Drummond, the Arc of
Riolan runs more proximal to the mesenteric
root.
Marginal Artery of Drummond –
Continuous arterial arcade formed by
connections between the distal branches
of the SMA and the distal branches of the
IMA. Compared to the Arc of Riolan, the
Marginal Artery of Drummond runs more
distal to the mesenteric root, along the inner
border of the colon.
 46 Trauma Embolization 681

Relevant Materials
What is the difference Temporary embolic agents are broken
between temporary down by the body over a period of
and permanent embolic time and thus provide short-term
agents? Name two of occlusion of vessels, whereas permanent
each. embolic agents are not broken down,
thus preventing recanalization of
the occluded vessels. Examples of
temporary agents include Gelfoam
(perhaps most common), autologous
blood clot, and thrombin, while
permanent agents include coils, plugs,
and glues/polymers/polyvinyl alcohol.
Give examples of 1. Occlusion: Coils, plugs, particles,
techniques/tools gelfoam
that reduce vascular 2. Vasoconstriction: Vasopressin,
bleeding through (1) epinephrine
intraluminal occlusion, 3. Sclerosis: Ethanol, sodium tetradecyl
(2) vasoconstriction, sulfate, n-butyl cyanoacrylate
(3) vessel sclerosis/ 4. Vessel patching/covering: Vascular
scarring, (4) patching stent, stent-graft
or covering of holes
within the vessel wall.
How are embolization Coil wire diameter, coil wire length, and
coils labeled? Why is overall diameter taken up by coil when
this important? reformed.
 The diameter of the coil wire must
not be too small when compared to
inner diameter of delivery catheter to
prevent premature coil forming within
the catheter and causing jams.
 Reformed coil diameter must be
chosen carefully, as coils that are too
small may embolize distally past the
target region. Coils that are too big
may not form in place and lead to
insufficient vessel occlusion, or may
get displaced proximally and preclude
further access to the target artery.

(continued)
682 J. J. Guan

Define a “Gelfoam Occlusive embolization technique using

Sandwich.” Gelfoam and another occlusive tool
such as coils to cause permanent vessel
occlusion. After the initial placement
of coils, Gelfoam is injected to lodge
within the coils. Additional coils are
then again placed to cause complete,
permanent vascular occlusion.
Explain the indication, Vasopressin was often used in cases of
contraindication, and bleeding to temporarily decrease the
dosage for intraluminal blood pressure or volume of bleed but
administration when the preservation of flow is needed
of vasopressin in to prevent tissue ischemia or infarction.
gastrointestinal Such use of vasopressin is indicated
bleeding. in cases of gastrointestinal bleeding.
Since vasopressin causes systemic
vasoconstriction, it is contraindicated in
patients with coronary artery disease.
Initial administration dose is 0.2 U/min,
with a maximum dose of 0.4 U/min.

General Step by Step

What is the most Common femoral artery access is the most
common approach common approach due to its technical ease,
for vascular typically leading to faster time to access.
access in cases Access from the side opposite to the injury
of embolization or suspected site of bleeding is typically
for trauma or GI preferred. In certain cases where anatomic
bleeding? constraints limit access from the common
femoral artery, for instance in cases of pelvic
injuries requiring pelvic binders or arterial
branch characteristics that necessitates
special approach angles, radial artery access
may be used instead.
 46 Trauma Embolization 683

How do reverse-­ Reverse-curve catheters such as the Sos,

curve selective Simmons, and Michelson catheters contain
catheters differ a primary curve distally that selects the
from other branch artery, while a secondary curve
selective catheters? more proximally helps to stabilize the
What are the catheter within the aorta. While the general
benefits to the advantage of reverse-curve catheters is that
reverse curve? they help select more stenotic branches by
applying extra down-force as the catheter
is pulled down, these catheters are also
preferred in selecting branches that make
more acute angles from the aorta, such as
the SMA and IMA. Non-reverse curve
catheters like the Cobra make one primary
curve and can be used to select branches
that make less acute angles, such as the
celiac and renal branches.
What category of Coaxial microcatheter.
catheters is then
used to select
smaller organ
arterial branches?
(continued)
684 J. J. Guan

Discuss the pros Distal vessel occlusion is often desired when

and cons of there is a focal injury supplied by a single
proximal vessel end-vessel. Distal occlusion can be achieved
embolization more easily with liquid embolic agents such
vs distal vessel as glue. Distal embolization has higher risk
embolization. of tissue infarction due to lack of collateral
vasculature.
In comparison, the occlusion of a proximal
vessel is generally desired when a single
vessel supplies a target area with multiple
smaller injured branches that could not
be easily accessed. In the case of the
spleen, where a rich collateral supply is
present along the splenic artery, proximal
embolization is often preferred when
simply reducing the arterial inflow pressure
is enough to allow the spleen to achieve
hemostasis on its own, as the collateral
supply can prevent splenic infarction. The
drawback to proximal embolization is loss
of distal access, such that if significant
bleeding persists, unless the area can be
reached via a collateral pathway, further
embolization will not be possible.
In certain cases of significant splenic
bleeding, both distal and proximal splenic
artery embolization may be employed,
stabilizing focal areas of more significant
bleeding via distal embolization, followed
by proximal embolization to allow for
hemostasis of the less significant remaining
bleeds while preventing complete splenic
infarction.
Define treatment Need for operative management after
failure. How long attempting non-operative management.
should patients Patients are monitored for at least 1–3 days
be monitored as to rule out persistent or recurrent bleeding
inpatients after or for any complications.
non-operative
management of
organ injury?
 46 Trauma Embolization 685

Complications
Name some general Pseudoaneurysm at arterial puncture
complications that can site, hematoma, dissection, thrombosis,
happen after arterial organ infarction, infection with abscess
embolization. formation, nontarget embolization,
post-embolization syndrome.
Describe Post-­ Pain, fever, and/or nausea that develop
Embolization Syndrome. within 2-3 days after embolization
procedure due to target organ necrosis.
What is the treatment Treatment for post-embolization
and prognosis for post-­ syndrome is supportive and usually
embolization syndrome? include analgesics like acetaminophen
or ibuprofen for pain and/or fever, oral
anti-emetics such as ondansetron for
nausea, and IV fluids for hydration as
needed. The process is self-limited and
will typically start to improve within
72 hours.
What are some specific Complications include nontarget
complications after embolization to gallbladder, hepatic
the embolization necrosis, infection with abscess
of liver laceration? formation, bile leak or biloma
What are risk factors formation, and post-embolization
for developing these syndrome. Risk factors for developing
complications? these include high-grade liver
injury and/or increased transfusion
requirements.
What are some specific Important sequalae to be aware
clinical sequalae, which of include nontarget embolization,
may be experienced decreased renal function, infection
after embolization of with abscess formation, and post-­
kidney laceration? embolization syndrome.
686 J. J. Guan

Landmark Research
Padia SA et al. Society of Interventional Radiology Position
Statement on Endovascular Intervention for Trauma. JVIR.
2020; 31(3): 363–369.
• Most of the data in trauma management is weak level of
evidence. More emphasis is placed on assessing the
strength of evidence by balancing benefits and risks.
Strong recommendation – benefits of an intervention out-
weigh the risks. Weak recommendation – benefits and risks
closely balanced.
• Catheterization in the traumatic setting can be much more
difficult because the vasculature may be constricted as a
result of significant blood loss or surrounding hematoma.
–– Operators should have significant experience with
small vessel embolization, particularly in the elective
setting.
–– Operative experience, experience with nonvascular
intervention, or experience with large vessel interven-
tion (aortic repair) is inadequate to perform small ves-
sel catheterization and embolization in the setting of
trauma, specifically liver, kidney, or pelvis.
–– Similarly, endovascular repair of the aorta should be
done by an operator who has significant experience
with endovascular aortic reconstruction in the elective
setting.
• Currently no consensus whether to proceed directly to
angiography in the pelvic trauma patient in hemodynami-
cally stable condition with active contrast agent extravasa-
tion on CT.
–– Recommendation: Embolization for pelvic trauma
should be first-line therapy and the standard of care
over surgery (level of evidence, D; strength of recom-
mendation, strong).
• There has been a paradigm shift in liver trauma, with non-
operative management becoming the treatment of choice
 46 Trauma Embolization 687

in a majority of patients with blunt hepatic injury who are

in hemodynamically stable condition. This has resulted in
decreased abdominal infections, decreased transfusions,
and decreased lengths of hospital stay.
–– Recommendation: Nonoperative management should
be the treatment of choice in patients with blunt hepatic
injury who are in hemodynamically stable condition,
with embolization to be considered in cases of ongoing
bleeding, identification of an arterial source of bleeding
on imaging, or suspicion of a persistent source of arte-
rial bleeding despite operative intervention.
• Splenic embolization has shown high rates of success in
preventing splenectomy; however, this may result from
selection bias because low-grade injuries were included in
some early reported series.
–– Recommendation: Splenic artery embolization should
be considered for patients in hemodynamically stable
condition with grade IV/V blunt splenic trauma (level
of evidence, D; strength of recommendation:
moderate).
–– Recommendation: Embolization should be considered
in patients in hemodynamically stable condition with
any grade injury who have imaging or clinical evidence
of ongoing splenic hemorrhage (level of evidence, D;
strength of recommendation, strong).
DuBose JJ, Savage SA, Fabian TC, et al. The American
Association for the Surgery of Trauma PROspective
Observational Vascular Injury Treatment (PROOVIT) regis-
try: multicenter data on modern vascular injury diagnosis,
management, and outcomes. J Trauma Acute Care Surg. 2015;
78(2)215–222.
• First longitudinal multicenter registry designed to evaluate
the management and long-term outcomes of modern vas-
cular injury.
• Endovascular management of vascular injuries have
increased almost 30-fold in frequency from the early 1990s
688 J. J. Guan

to the early 2000s, from 0.3% to 9.0%, respectively; This

increase was most noteworthy and dramatic among blunt
injuries and specifically those to the internal iliac artery
(8.0% to 40.3%), thoracic aorta (0.5% to 21.9%), and com-
mon/external iliac arteries (0.4% to 20.4%).
• According to the PROOVIT Registry:
–– In thoracic aortic trauma, the most common initial man-
agement method was non-operative (63.8%), followed
by endovascular repair (41%), then open surgery
(5.1%).
–– In abdominal trauma, including injuries to the abdomi-
nal aorta, celiac artery, common hepatic artery, and
superior mesenteric artery, the most common initial
management method was non-operative (50–75%), fol-
lowed by endovascular repair (25–50%), then open
surgery (0%).
–– In renal arterial injuries, most common initial manage-
ment method was open surgery (44.4%), followed by
non-operative (22.2%%), then endovascular repair
(11.1%).
–– In pelvic trauma (common, external, or internal iliac
arteries), most common initial management method
was non-operative (50%), followed by endovascular
repair and open surgery (both ~30% each).
–– In lower extremity trauma (femoral, popliteal, tibial,
peroneal arteries), the most common initial manage-
ment method was more or less tied between open sur-
gery (14.3–61.1%) and non-operative (36.1–85.7%),
followed by endovascular repair (0–3.5%).
–– In upper extremity trauma (axillary through radial/
ulnar arteries), most common initial management
method was open surgery (37.5–73.8%), followed by
non-operative management (23.8–50%), then endovas-
cular repair (0–12.5%).
Miller P, Chang M, Hoth J, et al. Prospective trial of angi-
ography and embolization for all grade III to V blunt splenic
 46 Trauma Embolization 689

injuries: nonoperative management success rate is signifi-

cantly improved. J Am Coll Surg. 2014; 218(4)644–648.
• The use of angiography and embolization improves the
success rate of non-operative management for all-grade
(I-V) splenic injury.
• The use of angiography and embolization, regardless of
active extravasation on pre-procedural CT, improves suc-
cess rate of non-operative management for high-grade
(III-VI) splenic injury, (5% failure rate vs 31% failure rate
when angiography and embolization was not routinely
performed, p = 0.02).
Velmahos GC, Toutouzas KG, et al. A prospective study on
the safety and efficacy of angiography embolization for pelvic
and visceral injuries. J Trauma Acute Care Surg. 2002;
53(2)303–308.
• In patients with traumatic injuries to the pelvis and perito-
neum, angiographic embolization is successful in control-
ling hemorrhage in 93% of patients who have
angiographically proven bleeding. Embolization success is
95% if both patients with angiographically proven ­bleeding
and patients with only indirect signs of vascular injury or
hemodynamic instability are considered. Repeat emboliza-
tion was successful in controlling bleeding in 75% of
patients who failed initial embolization, raising the overall
embolization success to 98%.
• A significant complication rate of angiographic emboliza-
tion is 6%, with mechanisms comprised of organ necrosis
around the site of injury (3%), splenic artery injury (1%),
femoral artery occlusion at access site (1%), and AKI
(1%). A minor complication of access site hematoma
occurred in 3% of patients.
• Independent predictive factors for the presence of extrav-
asation on angiography include age >55 years, the absence
of long-bone fracture, and emergent angiography;
Probability is 95% when all three factors are present and
18% when all three are absent.
690 J. J. Guan

Common Questions
What are the top 1. Spleen
5 most commonly 2. Liver
injured abdominal 3. Kidneys
organs in trauma 4. Small bowel/mesentery
(in order of 5. Bladder
frequency)?
Describe the Grade I
AAST Liver Injury  Hematoma: Subcapsular, <10% surface
Grading Scale and area
summarize the Laceration: Capsular tear, <1 cm
properties of each parenchymal depth
grade. Grade II
 Hematoma: Subcapsular, 10–50% surface
area; intraparenchymal, <10 cm diameter
 Laceration: Capsular tear 1–3 cm
parenchymal depth, <10 cm length
Grade III
 Hematoma: Subcapsular, >50%
surface area of ruptured subcapsular
or parenchymal hematoma;
intraparenchymal, >10 cm or expanding
 Laceration: Capsular tear >3 cm
parenchymal depth
Grade IV
 Laceration: Parenchymal disruption
involving 25–75% hepatic lobe or involves
segments 1–3
Grade V
 Laceration: Parenchymal disruption
involving >75% of hepatic lobe or
involves > segments 3 (within one lobe)
 Vascular: Juxtahepatic venous injuries
(retrohepatic vena cava / central major
hepatic veins)
Grade VI
 Vascular: Hepatic avulsion
 46 Trauma Embolization 691

Describe the Grade I

AAST Kidney  Contusion: Microscopic or gross
Injury Grading hematuria, urologic studies normal
Scale and  Hematoma: Subcapsular, nonexpanding
summarize the without parenchymal laceration
properties of each Grade II
grade.  Hematoma: Nonexpanding perirenal
hematoma confirmed to renal
retroperitoneum
 Laceration: <1.0 cm parenchymal depth of
renal cortex without urinary extravasation
Grade III
 Laceration: >1.0 cm parenchymal depth
of renal cortex without collecting system
rupture or urinary extravasation
Grade IV
 Laceration: Parenchymal laceration
extending through renal cortex, medulla,
and collecting system
 Vascular: Main renal artery or vein injury
with contained hemorrhage
Grade V
 Laceration: Completely shattered kidney
 Vascular: Avulsion of renal hilum that
devascularizes the kidney
In which cases Although antibiotic prophylaxis is not
should antibiotic necessary in most cases of vascular
prophylaxis be embolization, cases in which antibiotics
considered? should be considered include patients who
What are possible are neutropenic or are asplenic. Coverage
choices? should include skin flora, with options
including cefazolin, clindamycin, and
vancomycin.
692 J. J. Guan

Further Reading
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David Richardson J, Franklin GA, Lukan JK, Carrillo EH, Spain
DA, Miller FB, et al. Evolution in the management of hepatic
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Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G,
et al. Improved success in nonoperative management of blunt
splenic injuries: embolization of splenic artery pseudoaneurysms.
J Trauma. 1998;44(6):1008–13. discussion 13-5
DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb
JB, et al. The American Association for the Surgery of Trauma
PROspective Observational Vascular Injury Treatment
(PROOVIT) registry: multicenter data on modern vascular
injury diagnosis, management, and outcomes. J Trauma Acute
Care Surg. 2015;78(2):215–22. discussion 22-3
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MC. Complications arising from splenic artery embolization: a
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Feliciano DV. Management of peripheral vascular trauma. ACS
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Chapter 47
Spleen
Justin J. Guan

Evaluating the Patient

What are the primary clinical Splenic hemorrhage, which,
manifestations of splenic depending on severity, may lead
injury? to tachycardia and hypotension.
Splenic infarction secondary to
hemorrhage may manifest as pain.
What is the ideal imaging CT with IV contrast (CT
exam used to evaluate for angiography).
splenic injury in the setting
of trauma (given the FAST
exam was already performed
as indicated by primary/
secondary survey)?
(continued)

J. J. Guan (*)
Division of Interventional Radiology, Department of Diagnostic
Radiology, Cleveland Clinic, Cleveland, OH, USA

© Springer Nature Switzerland AG 2022 697

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_47
698 J. J. Guan

Describe the AAST Spleen The AAST splenic injury grading

Injury Grading Scale. What scale is a CT-based splenic injury
are the main purposes of the scale developed to categorize
grading scale? splenic injury after trauma and
help guide management. Higher-­
grade injuries (AAST grade III
and higher) more often require
surgical intervention, whereas
lower-grade injuries are typically
managed non-operatively.
However, such image-based
grading systems have been found
to be poor predictors of patient
outcome and eventual success of
non-operative management.

AAST Splenic Injury Scale

Grade I
• Hematoma: Subcapsular, 10% surface area
• Laceration: Capsular tear, 1 cm parenchymal depth
Grade II
• Hematoma: Subcapsular, 10% to 50% surface area; intra-
parenchymal, 5 cm in diameter
• Laceration: Capsular tear, 1 to 3 cm parenchymal depth
that does not involve a trabecular vessel
Grade III
• Hematoma: Subcapsular, 50% surface area or expanding;
ruptured subcapsular or parenchymal hematoma; intrapa-
renchymal hematoma 5 cm or expanding
• Laceration: 3 cm parenchymal depth or involving trabecu-
lar vessels
Grade IV
• Any injury in the presence of a splenic vascular injury or
active bleeding confined within splenic capsule
 47 Spleen 699

• Parenchymal laceration involving segmental or hilar ves-

sels producing >25% devascularization
Grade V
• Any injury in the presence of splenic vascular injury with
active bleeding extending beyond the spleen into the
peritoneum

How was the American To reflect data demonstrating that

Association for the vascular injuries reduce the success
Surgery of Trauma rate of nonoperative management.
(AAST) organ system Identification of pseudoaneurysms
grading to define the and active extravasation are now
severity of splenic injury important parts of determining the
revised in 2018? injury grade, with the 2018 update
classifying these as grade IV or V.
What is the current success The success rate of nonsurgical
rate of non-operative therapy varies between 80 and
management after splenic 90%, thus identifying cases that
injuries? Why is splenic require surgical or angiographic
preservation preferred? interventions is critical. Splenic
preservation after trauma serves
as the aim of treatment given
important immunological functions
of the spleen.
What imaging Higher volume of hemoperitoneum
characteristic(s) may and presence of active and/or
predict the failure of contained vascular injuries, such as
nonsurgical management? contrast blush, pseudoaneurysms,
and arteriovenous fistulae) are risk
factors for failure of nonoperative
management.
(continued)
700 J. J. Guan

Describe the Western Step 1:

Trauma Association  The patient undergoes CTA.
Algorithm for the Step 2:
management of splenic  If splenic injury is diagnosed
injury patients who are with blush or pseudoaneurysm,
hemodynamically stable. perform endovascular
embolization and admit to ICU.
 If splenic injury is diagnosed
however without blush or
pseudoaneurysm, determine
injury grade: Grade I/II – Admit
to step-down unit for observation.
Grade III-V – Admit to ICU
for observation and medical
management.
Step 3:
 If the patient develops
hemodynamic instability or
peritonitis, perform laparotomy.
 If the patient remains
hemodynamically stable but
Hgb drops by >/= 4, perform
laparotomy or embolization.

High Yield History

What is the most commonly injured organ Spleen.
in the setting of trauma?
What is the most common cause of Overlooked splenic
preventable death in trauma patients? injury.
What proportion of patients have delayed Approximately
splenic rupture requiring intervention after one-third of
initially presenting with low-grade (grades I patients.
and II) splenic injury?
 47 Spleen 701

Indications/Contraindications
What has been the Laparotomy with splenectomy or
conventional treatment of splenorrhaphy (surgical removal of
choice for severe (Grade splenic pseudoaneurysm).
III-V) splenic injury?
What are the current All patients who are
indications for hemodynamically unstable undergo
operative versus non-­ laparotomy with splenectomy or
operative management splenorrhaphy.
(including splenic artery Non-operative management is
embolization) for splenic indicated for patients who are
injuries? hemodynamically stable. In this
group, splenic artery embolization
is performed when the patient
is found to have ongoing splenic
bleeding and the spleen is still
viable.
Moreover, splenic tissue
preservation is desirable in children,
in whom the spleen still performs
important immunologic functions.
What are the Absolute contraindication:
contraindications hemodynamic instability. Splenic
for splenic artery artery embolization in patients who
embolization? establish transient hemodynamic
stability after resuscitation can
lead to favorable prognosis if
embolization is performed early.
Relative contraindications: pre-­
existing splenic disease, multisystem
trauma, associated diaphragmatic
rupture, or bowel injury.
(continued)
702 J. J. Guan

Discuss the indications Selective, more distal splenic artery

for selective, distal splenic embolization is performed to stop
artery embolization focal areas of splenic hemorrhage.
versus main splenic artery Such approach preserves a larger
embolization. amount of splenic tissue but is
theoretically more likely to cause
focal splenic infarction.
Main splenic artery embolization
reduces splenic hemorrhage but
reducing the total amount of blood
flowing into the spleen. Complete
splenic infarction does not occur
due to the spleen’s collateral blood
supply.
Must patients receive Splenic tissue is usually preserved
Pneumococcus, H. after splenic artery embolization.
influenzae, or N. With the currently available
meningitidis vaccination evidence for residual splenic
after splenic artery function after proximal and distal
embolization? splenic embolization, routine
vaccination is not indicated.

Relevant Anatomy
What major aortic branch Celiac Trunk.
vessel does the splenic
artery arise from?
List the major branches Dorsal pancreatic artery, posterior
of the splenic artery. gastric artery, greater pancreatic
artery, left gastroepiploic artery, and
short gastric branches and unnamed
branches to the pancreatic tail.
What major branch has Posterior gastric artery (arises from
variable origin from the splenic artery <50% of time).
splenic artery?
 47 Spleen 703

Why is the splenic tissue The spleen has rich collateral supplies
typically not lost even from the splenic artery branches,
after proximal splenic including the short gastric, left
artery embolization? gastroepiploic branches, and smaller
unnamed branches.
What are some possible Accessory spleen or splenules,
anatomic variations of splenosis, polysplenia, wandering
the spleen? spleen, and asplenia.

Relevant Materials
What materials Coils or plugs.
are typically used
for proximal main
splenic artery
embolization?
What materials Coils, Gelfoam, glue or other liquid
are typically used embolics, and microparticles.
for selective distal
splenic artery
embolization?
Is antibiotic Routine antibiotics covering skin flora
prophylaxis should be administered during splenic
indicated for artery embolization, especially if more
splenic artery than 70% of the spleen is to be embolized.
embolization? Although no consensus is established for
What are possible 1st-line agent, some recommended regimens
regimens? include IV gentamicin 10 mg/kg/day, IV
cefoxitin 100 mg/kg/day, or IV amoxicillin-­
clavulanate 3 g/day, with the first dose
starting 2 hours before procedure and
continuing for 5 days post-procedure.
What are the Either IV conscious sedation or general
sedation options anesthesia depending on the availability
for splenic artery of anesthesia resources and the patient’s
embolization? clinical status.
(continued)
704 J. J. Guan

Is routine follow-up Follow-up CT imaging after discharge is not

CT imaging routinely recommended.
recommended after
discharge?

General Step by Step

Describe the different SAE can be performed via (1)
possible approaches for proximal occlusion between
splenic artery embolization the dorsal pancreatic artery
and their respective risks and and terminal splenic artery
benefits. branches, (2) distal occlusion
at the involved segmental
splenic arterial branch, or (3) a
combination of both.
Proximal SAE reduces bleeding
by decreasing splenic arterial
pressure but prevents splenic
infarction by allowing for
reconstitution of the distal
splenic artery branches via
collaterals. This approach is
used in cases of splenic injury
where no focal splenic branch
vessel injury can be identified on
angiography.
Distal SAE can be performed
when injury involves one or a
limited number of focal splenic
branch vessel territories and
allows for targeted vascular
occlusion. Since this approach
tends to exclude collateral
supplies, there is a higher risk of
splenic infarction.
How long are patients Patients are monitored as
monitored after embolization? inpatients for at least 1–3 days.
 47 Spleen 705

What may reduce morbidity Routine follow-up CT imaging

and mortality associated with 48 hours after nonoperative
delayed splenic rupture after management.
non-operative management of
splenic injuries?
What are the Return to normal daily activities
recommendations for return 2–3 months after management,
to normal daily activities and may be longer in higher grade
return to sports? injuries
Return to sports after 3 months
No clear consensus on when
to return to contact sports in
patients with high-grade splenic
injury

Complications
List the possible Splenic infarction leading to infection/
complications abscess, nontarget embolization of
after splenic artery pancreas causing infarction, access-site
embolization. pseudoaneurysm, arterial dissection,
hematoma, thrombosis, and post-­
embolization syndrome.
What are Localized or generalized pain, fever,
the clinical nausea/vomiting, and leukocytosis that
manifestations of develop within 3 days after embolization
post-embolization procedure
syndrome?
What is the Treatment is supportive; process is self-­
treatment and limited.
prognosis for
post-embolization
syndrome?
What are some Elevation of left hemidiaphragm, left lower
manifestations of lobe atelectasis, and left pleural effusion
splenic rupture?
(continued)
706 J. J. Guan

When does delayed 4–8 days after nonoperative management.

splenic rupture
typically occur?

Landmark Research
Miller P, Chang M, Hoth J, et al. Prospective trial of angiogra-
phy and embolization for all grade III to V blunt splenic
injuries: nonoperative management success rate is signifi-
cantly improved. J Am Coll Surg. 2014; 218(4)644–648.
• The use of angiography and embolization improves the
success rate of non-operative management for all-grade
(I-V) splenic injury.
• The use of angiography and embolization, regardless of
active extravasation on pre-procedural CT, improve suc-
cess rate of non-operative management for high-grade
(III-VI) splenic injury, (5% failure rate vs 31% failure rate
when angiography and embolization was not routinely
performed, p = 0.02).
Sabe AA, Claridge JA, Rosenburg DI, Lie K, Malangoni
MA. The effects of splenic artery embolization on nonopera-
tive management of blunt splenic injury: a 16-year experi-
ence. J Trauma. 2009; 67:565–572.
• Initial non-operative management for blunt splenic injury
has significantly increased compared to initial operative
management over the last two decades with relatively
stable severity of splenic injury.
• The use of splenic artery embolization and success of non-­
operative management for blunt splenic injury has signifi-
cantly increased over the last two decades.
• The use of splenic artery embolization improves the suc-
cess of non-operative management and leads to reduced
mortality, increased overall splenic salvage and shorter
hospital stays, although incorporation of a defined criteria
for initial splenic arterial embolization (including the pres-
 47 Spleen 707

ence of extravasation or pseudoaneurysm on CT, grade 3

injuries with large hemoperitoneum, or grade 4 injuries in
the setting of hemodynamic stability) did not improve
these outcomes compared to discretionary use of splenic
artery embolization based on clinical and CT findings.
Wahl WL, Ahrns KS, Chen S, Hemmila MR, Rowe SA,
Arbabi S. Blunt splenic injury: Operation versus angiographic
embolization. Surgery. 2004; 136:891–9.
• Higher injury severity score, lower systolic blood pressure
before intervention, lower ABG pH, GCS < 9, and
increased units of PRBC infused before intervention were
associated with increased mortality, regardless of surgical
or embolization intervention.
• Higher ISS, lower pre-treatment SBP, higher number of
pre-treatment transfusions of PRBCs, and lower ABG pH
were best predictors for the need of operative
intervention.
• Surgical intervention was associated with higher rates of
intra-abdominal complications, such as development of
intra-abdominal abscess, peritoneal fluid requiring aspira-
tion or drainage, pancreatic leaks, abdominal compartment
syndrome, wound dehiscence, and small bowel obstruc-
tion, as well as an increased number of subsequent imaging
studies to evaluate for intra-abdominal complications.
• After adjusting for GCS, ISS, a number of pretreatment
transfusions, spleen AIS, and age, there was no different in
overall treatment costs between patients who underwent
surgical or embolization intervention.

Common Questions
Why are patients in The need to rapidly control bleeding,
unstable condition which may not be from major arterial
managed operatively? sources.
(continued)
708 J. J. Guan

What is the overall Up to 90%. There appears to be no

success rate of splenic significant difference in treatment
artery embolization in failure regardless of proximal or distal
preventing splenectomy splenic artery embolization.
for high-grade splenic
injuries?
What is the most Infection by encapsulated organisms –
important long-term S. pneumo, H. flu, N. meningitidis.
complication after
splenectomy?
What is usually done Vaccination against encapsulated
to prevent infection by organisms.
encapsulated organisms
after splenectomy?
Is infection by Infection by encapsulated organisms
encapsulated organisms is not a typical risk after splenic
a risk after splenic artery embolization as splenic tissue
artery embolization? Is is usually preserved. Therefore,
vaccination against these vaccination against encapsulated
organisms required? organisms is generally not required.

Further Reading
Beuran M, Gheju I, Venter MD, et al. Non-operative management of
splenic trauma. J Med Life. 2012;5(1):47.58.
Cales RH, Trunkey DD. Preventable trauma deaths. A review of
trauma care systems development. JAMA. 1985;254(8):1059–63.
Chehab MA, Thakore AS, Tulin-Silver S, et al. Adult and pediatric
antibiotic prophylaxis during vascular and IR procedures: a Sociey
of Interventional Radiology practice parameter update endorsed
by the Cardiovascular and Interventional Radiological Society
of Europe and the Canadian Association for Interventional
Radiology. J Vasc Interv Radiol. 2018;29:1483–501.
Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G,
et al. Improved success in nonoperative management of blunt
splenic injuries: embolization of splenic artery pseudoaneurysms.
J Trauma. 1998;44(6):1008–13. discussion 13-5
 47 Spleen 709

DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb

JB, et al. The American Association for the Surgery of Trauma
PROspective Observational Vascular Injury Treatment
(PROOVIT) registry: multicenter data on modern vascular
injury diagnosis, management, and outcomes. J Trauma Acute
Care Surg. 2015;78(2):215–22. discussion 22-3
Ekeh AP, Khalaf S, Ilyas S, Kauffman S, Walusimbi M, McCarthy
MC. Complications arising from splenic artery embolization: a
review of an 11-year experience. Am J Surg. 2013;205(3):250–4.
discussion 4
Frandon J, Rodiere M, Arvieux C, Michoud M, Vendrell A, Broux C,
et al. Blunt splenic injury: outcomes of proximal versus distal and
combined splenic artery embolization. Diagn Interv Imaging.
2014;95(9):825–31.
Frandon J, Rodiere M, Arvieux C, Vendrell A, Boussat B, Sengel C,
et al. Blunt splenic injury: are early adverse events related to
trauma, nonoperative management, or surgery? Diagn Interv
Radiol (Ankara, Turkey). 2015;21(4):327–33.
Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative
management of blunt splenic injury: a 5-year experience. J
Trauma. 2005;58(3):492–8.
Hagiwara A, Fukushima H, Murata A, et al. Blunt splenic injury:
usefulness of transcatheter arterial embolization in patients
with a transient response to fluid resuscitation. Radiology.
2005;235(1):57–64.
Ierardi AM, Duka E, Lucchina N, Floridi C, De Martino A, Donat
D, et al. The role of interventional radiology in abdominopelvic
trauma. Br J Radiol. 2016;89(1061):20150866.
Kaufman JA. Fundamentals of angiography. In: Kaufman JA, Lee
MJ, editors. The requisites: vascular and interventional radiology.
2nd ed. Philadelphia: Saunders Elsevier; 2014. p. 25–55.
Kaufman JA. Vascular interventions. In: Kaufman JA, Lee MJ, edi-
tors. The requisites: vascular and interventional radiology. 2nd
ed. Philadelphia: Saunders Elsevier; 2014. p. 68–98.
Kaufman JA. Vascular pathology. In: Kaufman JA, Lee MJ, editors.
The requisites: vascular and interventional radiology. 2nd ed.
Philadelphia: Saunders Elsevier; 2014. p. 1–24.
Kaufman JA. Visceral Arteries. In: Kaufman JA, Lee MJ, editors.
The requisites: vascular and interventional radiology. 2nd ed.
Philadelphia: Saunders Elsevier; 2014. p. 229–64.
Keramidas DC, Kelekis D, Dolatzas T, Aivazoglou T, Voyatzis
N. The collateral arterial network of the spleen following liga-
710 J. J. Guan

tion of the splenic artery in traumatic rupture of the spleen;

an arteriographic study. Zeitschrift fur Kinderchirurgie : organ
der Deutschen, der Schweizerischen und der Osterreichischen
Gesellschaft fur Kinderchirurgie = Surgery in infancy and child-
hood. 1984;39(1):50–1.
McIntyre LK, Schiff M, Jurkovich GJ. Failure of nonoperative man-
agement of splenic injuries: causes and consequences. Arch Surg
(Chicago, Ill : 1960). 2005;140(6):563–8. discussion 8-9
Miller PR, Chang MC, Hoth JJ, Mowery NT, Hildreth AN, Martin
RS, et al. Prospective trial of angiography and embolization for
all grade III to V blunt splenic injuries: nonoperative manage-
ment success rate is significantly improved. J Am Coll Surg.
2014;218(4):644–8.
Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner
BD, Champion HR, et al. Organ injury scaling: spleen, liver, and
kidney. J Trauma. 1989;29(12):1664–6.
Nelson KJ, Mitchell D. Visceral and solid organ trauma. In: Keefe
NA, Haskal ZJ, Park AW, Angle JF, editors. IR Playbook. 1st ed.
New York: Springer; 2018. p. 357–69.
Olthof DC, van der Vlies CH, Goslings JC. Evidence-based manage-
ment and controversies in blunt splenic trauma. Curr Trauma
Rep. 2017;3(1):32–7.
Olthof DC, van der Vlies CH, Joosse P, van Delden OM, Jurkovich
GJ, Goslings JC. Consensus strategies for the nonoperative man-
agement of patients with blunt splenic injury: a Delphi study. J
Trauma Acute Care Surg. 2013;74(6):1567–74.
Padia SA, et al. Society of Interventional Radiology Position
Statement on endovascular intervention for trauma. JVIR.
2020;31(3):363–9.
Richard HM. Pelvic and extremity trauma. In: Keefe NA, Haskal
ZJ, Park AW, Angle JF, editors. IR Playbook. 1st ed. New York:
Springer; 2018. p. 371–7.
Sabe AA, Claridge JA, Rosenburg DI, Lie K, Malangoni MA. The
effects of splenic artery embolization on nonoperative manage-
ment of blunt splenic injury: a 16-year experience. J Trauma.
2009;67:565–72.
Schnuriger B, Inaba K, Konstantinidis A, Lustenberger T, Chan
LS, Demetriades D. Outcomes of proximal versus distal splenic
artery embolization after trauma: a systematic review and meta-­
analysis. J Trauma. 2011;70(1):252–60.
 47 Spleen 711

Schroeppel TJ, Croce MA. Diagnosis and management of

blunt abdominal solid organ injury. Curr Opin Crit Care.
2007;13(4):399–404.
Soto JA, Anderson SW. Multidetector CT of blunt abdominal
trauma. Radiology. 2012;265(3):678–93.
Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, et al.
American Association for the surgery of trauma organ injury
scale I: spleen, liver, and kidney, validation based on the National
Trauma Data Bank. J Am Coll Surg. 2008;207(5):646–55.
Varga I, Babala J, Kachlik D. Anatomic variations of the spleen:
current state of terminology, classification, and embryological
background. Surg Radiol Anat. 2018;40(1):21–9.
Venkatesan AM, Kundu S, Sacks D, Wallace MJ, Wojak JC, Rose SC,
et al. Practice guidelines for adult antibiotic prophylaxis dur-
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by the Standards of Practice Committee for the Society of
Interventional Radiology and Endorsed by the Cardiovascular
Interventional Radiological Society of Europe and Canadian
Interventional Radiology Association [corrected]. J Vasc Interv
Radiol. 2010;21(11):1611–30; quiz 31.
Wahl WL, Ahrns KS, Chen S, Hemmila MR, Rowe SA, Arbabi
S. Blunt splenic injury: operation versus angiographic emboliza-
tion. Surgery. 2004;136(4):891–9.
Chapter 48
Pelvis
Justin J. Guan

Evaluating Patient
What should initial Before arriving at the hospital, initial
evaluation and management of extremity trauma should
management of pelvic focus on control of bleeding and pelvic
trauma focus on? fixation/splinting of obvious fractures.
Upon presentation to the hospital,
management should focus on the
evaluation and stabilization of the
ABCs (airway, breathing, circulation)
and resuscitation efforts as necessary,
including fluids/transfusions and
pressors.
Comprehensive physical examination
and focused imaging evaluations guide
further management.
(continued)

J. J. Guan (*)
Division of Interventional Radiology, Department of Diagnostic
Radiology, Cleveland Clinic, Cleveland, OH, USA

© Springer Nature Switzerland AG 2022 713

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_48
714 J. J. Guan

What are key parts History – focus on mechanism of injury,

of the history and timing, and GCS
physical exam? Physical exam – should include
evaluation for hematomas and areas
of active bleeding, detailed neurologic
examination, and assessment of distal
pulses
What are some signs Hard signs – expanding pulsatile
of vascular injury on hematoma, bruit/thrill over wound,
physical exam? absent distal pulses, distal ischemic
changes (six Ps: pain, pallor,
pulselessness, poikilothermia,
paresthesia, paralysis)
Soft signs – nonexpanding hematoma,
peripheral neural deficits, history of
severe bleeding at the time of injury,
unexplained hypotension, significant
bony injury including significant fracture
displacement, and penetrating wound(s)
What imaging exam CT pelvis with IV contrast – can help
can be used to identify the location of active bleed
help localize active (contrast extravasation), as well as
bleeding while evaluate for hematomas, fractures, and
evaluating for other other injuries to the bowel and bladder
internal injuries before in order to guide selective angiography
angiography? CT angiogram of extremities – can better
characterize fracture and neurovascular
involvement to the pelvis and extremities
What additional FAST (focused abdominal sonography
imaging exams can for trauma) exam and plain films.
help identify internal
injuries?
What constitutes a Finding free fluid within any of the
positive finding on evaluated spaces raises concern for
FAST exam? What hemorrhage.
does this signify?
 48 Pelvis 715

Which patients with Stable patients with clinically significant

identified pelvic active arterial extravasation identified
ring injuries should on CT abdomen/pelvis. Currently, no
be considered for consensus based on the presence of
angiography? active arterial extravasation alone.
Angiography findings can be negative
despite contrast agent extravasation on
CT, and, on the contrary, angiography
findings can be positive when CT
has demonstrated no contrast agent
extravasation.
Unstable patients with negative FAST
and diagnostic peritoneal lavage (DPL),
no other sources of bleeding identified
and any of the following:
 Hypotensive (systolic BP < 90 mmHg,
>1 event)
 Persistent tachycardia (HR > 100
beats/min)
 BP maintained only with continuous
blood transfusion
 Significant drop in Hct/Hgb (> 6% Hct,
>2 Hgb)
What are the Iliopectineal line makes up the border
iliopectineal and of the iliopubic eminence, or the inner
ilioischial lines? What border of the pelvic brim on an AP
do disruptions of these pelvis radiograph. This line should be
lines signify? continuous, and any discontinuity raises
concern for an anterior column fracture
of the pelvis.
The ilioischial line is the projection
created by the quadrilateral plate of the
acetabulum on AP pelvis radiograph,
lying just lateral to the iliopectineal
line. This line should be continuous, and
any discontinuity raises concern for a
posterior column fracture of the pelvis.
(continued)
716 J. J. Guan

What makes older Patients older than 60 years have arterial

patients more prone calcifications that hinder effective
to significant arterial vasoconstriction in the setting of vascular
bleeding in the setting injury and thus are more prone to active
of pelvic fracture? bleeding.
How does this affect
imaging evaluation in
these patients?

High Yield History

What are the four Lateral compression, anterior-posterior
categories/mechanisms compression, vertical shear, and
of pelvic fractures? combined.
Give examples of the Lateral compression – typically car
different pelvic fracture accidents where patients are T-boned
mechanisms. Anteroposterior compression (open-­
book fractures) – front-end car
collisions or other high-force impact
Vertical shear – typically after falls
from height
 48 Pelvis 717

How do fracture The superior gluteal and internal

patterns predict vascular pudendal arteries are the most
injury? commonly injured arteries in pelvic
fractures, while the deep circumflex
iliac and inferior epigastric arteries are
more rarely injured.
Published fracture patterns that tend
to predict a high likelihood for arterial
injury are vertical shear-type fracture
pattern, combined mechanisms, and
high-grade anterior/posterior and
lateral compression fractures.
Common associations:
 Anterosuperior compression –
associated with injuries of superior
gluteal and internal pudendal
arteries
 Lateral compression – anterior
division internal iliac artery injury
 Pubic rami and open-book
fractures – injuries of internal or
external pudendal arteries
 Acetabular fracture – superior
gluteal arteries
Approximately what 65% of pelvic fractures are from
percentage of pelvic lateral compression, while 35%
fractures are from lateral are from non-lateral compression
compression versus mechanisms.
other mechanism(s)?
(continued)
718 J. J. Guan

How can bleeding from Pelvic fixation devices can stabilize

most pelvic fractures 99% of cases from lateral compression
be initially stabilized? pelvic injuries and up to 80% of
What percentage of pelvic injuries from non-lateral
bleed cases from pelvic compression mechanisms. 18–22% of
injuries can be stabilized cases from anteroposterior, vertical
in this manner? shear, and combined force injuries
lead to unstable injuries with bleeding
unresponsive to pelvic fixation.
What are the categories Posterior column, anterior column, or
of acetabular fractures? transverse.

Indications/Contraindications
What findings on Hemodynamic instability despite
clinical evaluation resuscitation, hemodynamically unstable
dictates immediate patient with imaging findings indicating
surgical exploration intraperitoneal hemorrhage, and hard
and repair? signs of vascular injury.
What are the surgical Primary surgical repair (suturing of
treatment options of laceration, end-to-end anastomosis of
vessel injury? transection)
Small vein patch over laceration
Synthetic or reverse venous graft to
repair damaged vessels or reapproximate
retracted vessels
Ligation or shunting with delayed
definitive repair after stabilization of
patient
 48 Pelvis 719

When is pelvic Patients who remain hemodynamically

arteriography unstable or have transfusion requirement
and embolization of more than 4–6 units of PRBCs
indicated? in 24 hrs, after pelvic fixation, with
injuries isolated to the pelvis or pelvic
retroperitoneum (intraabdominal injuries
are ruled out or repaired via laparotomy)
should undergo emergent pelvic
angiography and embolization.
Hemodynamically unstable patients
with pelvic arterial bleeding suspected
following exploratory laparotomy for
abdominal injuries.
Patients who are hemodynamically
stable with soft signs of vascular injury
or extravasation documented on CT
exam can proceed directly to pelvic
angiography.
Should pelvic No, retroperitoneal bleeds should not be
retroperitoneal repaired surgically as surgical repair of
bleeds found on the retroperitoneum is technically difficult
imaging or during and opening the retroperitoneum releases
laparotomy be the tamponade of the hematoma.
repaired surgically?
What is the success Pelvic angiography and embolization have
rate of angiography 85–97% success rate in controlling pelvic
and embolization in bleeding; 5–23% of patients may require
controlling pelvic and repeat angiography.
extremity bleeding? Extremity angiography and embolization
have 84–97% success rate in controlling
extremity bleeding.
720 J. J. Guan

Relevant Anatomy
Name the typical branches of Iliolumbar artery
the posterior division of left Lateral sacral artery
internal iliac (hypogastric) Superior gluteal artery
artery. Which is typically the The superior gluteal artery is
largest branch? typically the largest branch.
Name the typical branches of Vesicle artery (superior and
the anterior division of left inferior branches)
internal iliac (hypogastric) Obturator artery
artery. How do the branches Middle rectal artery
differ between males and Internal pudendal artery
females? Inferior gluteal artery
Uterine artery (females)
Prostatic artery (males)
Females have the uterine artery
(which branches into the uterine
and vaginal arteries). Branches
of the vaginal arteries may
also originate from the inferior
vesicle artery.
Males have the prostatic artery,
which can arise as a separate
branch from the anterior
division of the internal iliac
artery, as a branch from the
obturator, superior vesicle, or
inferior gluteal arteries, or from
the internal pudendal artery.
In males, the internal pudendal
artery branches into the perineal
artery (which supplies the
scrotum) and a common penile
artery, which branches into the
dorsal and deep penile branches.
 48 Pelvis 721

Which arterial branch often Median sacral artery, often

arises from the posterior anastomoses with the iliolumbar
wall of the abdominal aorta and rectal arteries.
just proximal to the aortic
bifurcation before coursing
inferiorly down the midline to
supply the sacrum and coccyx?
Which arteries does it usually
anastomose with?
What arteries can often form Ovarian, vaginal, vesicle, and
collateral supply to the uterus unnamed branches from the
apart from the uterine artery? broad ligament.
What arteries form collateral Uterine arteries.
supply to the ovary apart from
the ovarian artery?
What are some common Midline bleeding can be
collateral arterial pathways supplied by either/both internal
within the pelvis? iliac arteries; lateral pelvic
bleeds can be supplied by the
lumbar, iliac circumflex, deep
femoral, as well as internal iliac
branches.

Relevant Materials
What is the diagnostic CT with contrast (CT angiogram).
modality of choice in
evaluating bleeding
patients prior to
angiography?
What methods of Treatment can be performed using
vascular occlusion temporary agents, such as Gelfoam, or
can be employed to permanent agents, such as coils and/or
treat identified areas particulate embolics.
of arterial injury on
angiogram?
(continued)
722 J. J. Guan

What are the A diffuse agent such as Gelfoam

indications of using may be desired in cases of multiple
each method? scattered foci of extravasation, whereas
micro-coils may be used for fistulas or
pseudoaneurysms.
What are the dangers Nontarget embolization or distal
of using a diffuse embolization causing extremity ischemia
agent such as Gelfoam is more likely with materials that are
or particles to treat smaller and more uniform in size, such
vascular injuries? as Gelfoam slurry or particle embolics.
Thus, these materials are used less often
for extremity embolization.
What size catheters 4-Fr or 5-Fr catheters
are usually used for
pelvic angiography
studies?

General Step by Step

What are the options for Femoral artery is usually accessed,
arterial access in pelvic and bilateral access may be required
angiography? if multiple areas of pelvic bleeding
or multiple collateral feeding arteries
to the area of bleeding is suspected.
Radial access may also be used
depending on the case.
Where should the Within the abdominal aorta, 2–3 cm
angiogram catheter proximal to the aortic bifurcation.
be placed for initial
angiography run?
What is the typical range 6–8 cc/sec for 3 seconds.
of contrast injection rate
for pelvic angiography?
 48 Pelvis 723

What should always be Completion pelvic angiogram. This

done after the occlusion of ideally includes a pelvic angiogram
vascular injury to rule out in the frontal projection, followed by
continued bleeding from selective left and right internal iliac
collateral blood supply? angiograms, often with oblique views
to help “open up” the branches of
the internal iliac artery.
How can adequate Serial evaluation of extremity pulses
extremity perfusion should be performed.
be evaluated after
angiography and
embolization?

Complications
What is the key Reflux of embolic material or antegrade
complication flow into a clinically relevant branch vessel
associated contributes to nontarget embolization, which is
with pelvic associated with ischemic complications.
embolization?
What are Though the occlusion of the superficial femoral
the locations artery or popliteal artery can cause ischemia,
where emboli such cases are rare. Occlusions at branch
may lodge and vessels or small, distal branches are usually
cause extremity clinically silent.
ischemia?
Describe An increase in muscle compartment pressure
compartment after revascularization, occurring as a result of
syndrome. edema and reperfusion injury after ischemic
insult to the extremity, which may lead to
vascular compression and tissue necrosis.
(continued)
724 J. J. Guan

How is Compartment syndrome is most often

compartment diagnosed clinically based on the classic “P”s:
syndrome PAIN out of proportion to clinical examination
diagnosed? or injury, usually with passive stretching
How can it be or at rest, PARESTHESIA progressing to
prevented? hypoesthesia and anesthesia, PARALYSIS,
often a late findings due to prolonged nerve
compression or irreversible muscle damage,
PULSELESSNESS, also a late finding, and
PALLOR, secondary to compromised arterial
inflow. The affected extremity will often appear
swollen and feel firm. Definitive diagnosis
is made based on compartment pressure
monitoring showing elevated pressures.
Because compartment syndrome occurs
secondary to rise in compartment pressure,
such as from tissue swelling, bleeding, or
reperfusion injury following prolonged
ischemia, prevention of compartment
syndrome in the setting of trauma requires
high clinical suspicion, and close serial
examinations to catch impending cases before
they develop. If compartment syndrome is
likely to develop, prophylactic fasciotomy can
be performed to relieve compartment pressure.
How is Surgical fasciotomy; as detailed above, close
compartment examination for compartment syndrome
syndrome should be performed after revascularization
managed? procedures.
Define “Corona Corona mortis is a variant arterial branch that
Mortis.” Why is connects the obturator artery to the inferior
this important? epigastric artery, often running along the
posterior aspect of the superior pubic ramus.
This vessel can be the source of bleeding if
lacerated from a pelvic ring fracture and thus
should always be investigated during pelvic
trauma involving the superior pubic ramus.
 48 Pelvis 725

Landmark Research
Coccolini F, Stahel PF, Montori G, et al. Pelvic trauma: WSES
classification and guidelines. World J Emerg Surg. 2017; 12:5.
• Patients with pelvic fracture-related hemodynamic insta-
bility should always be considered for pre-peritoneal pel-
vic packing, especially in hospitals with no angiography
service; direct preperitoneal packing is an effective surgi-
cal measure of early hemorrhage control in hypotensive
patients with bleeding pelvic ring disruptions.
• CT-scan demonstrating arterial contrast extravasation in
the pelvic and the presence of pelvic hematoma are the
most important signs predictive of need for
angioembolization.
• Elderly patients with pelvic fractures should be considered
for pelvic angiography/angioembolization regardless of
hemodynamic status.
Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern
Association for the Surgery of Trauma practice management
guidelines for hemorrhage in pelvic fracture – update and
systematic review. J Trauma. 2011;71(6):1850–1868.
• The use of the pelvic orthotic device, such as a pelvic fix-
ator device, reduces fracture displacement and pelvic vol-
ume after pelvic fractures; however, it does not seem to
limit blood loss in patients with pelvic hemorrhage.
• Patients with pelvic fractures and signs of ongoing pelvic
bleeding such as hemodynamic instability after nonpelvic
sources of blood loss have been ruled out or, with arterial
extravasation on CT despite hemodynamic status, should
be considered for pelvic angiography and embolization.
• Although FAST has adequate specificity in patients with
unstable vital signs and pelvic fracture to recommend lapa-
rotomy to control hemorrhage, it is not sensitive enough to
exclude intraperitoneal bleeding in presence of pelvic
fracture.
726 J. J. Guan

• In the hemodynamically stable patient with a pelvic frac-

ture, CT abdomen/pelvis with IV contrast is recommended
to evaluate for intra-abdominal bleeding, regardless of
FAST results.
Ben-Menachem Y, Coldwell DM, Young JW, et al.
Hemorrhage associated with pelvic fractures: causes, diagno-
sis, and emergent management. AJR Am J Roentgenol.
1991;157(5).
• The high mortality rate in patients with pelvic fractures is
related directly and primarily to hemorrhage; some victims
die because of intractable shock and coagulopathy, while
others succumb to complications of hemorrhage, such as
infected hematomas or renal/multiorgan failure.
• Arterial injuries are most prevalent in patients in whom
the bony elements are fractured and ligamentous elements
are torn: anteroposterior compression types II and III,
lateral compression type III, vertical shear, and combined
mechanical injuries; The most frequently injured arteries
are the superior gluteal and internal pudendal arteries,
associated with AP compression fractures.
• If a patient is hemodynamically unstable, an immediate
arteriogram and embolization is of great benefit; even in
cases in which an operation is necessary, the angiographer
can accomplish almost instant hemodynamic stability by
occluding the lower abdominal aorta with a balloon.

Common Questions
Which is more common in Although less common, arterial
pelvic trauma, arterial or injury is more frequently associated
venous injury? with hemodynamic instability than
venous injury. Arterial source of
hemorrhage in pelvic injury is
identified in more than 70% of
patients with no response to fluid
resuscitation or transfusion.
 48 Pelvis 727

What is the likelihood of High with sensitivity ranging from

angiographically identifying 80% to 90% and specificity ranging
active arterial hemorrhage from 85% to 98%.
in a patient demonstrating
active contrast agent
extravasation on contrast
enhanced CT?
What are reported rates 0%–23%. In these patients,
of repeat angiography in findings at angiography frequently
patients with suspected demonstrate a new site of
ongoing or recurrent hemorrhage that was not treated
bleeding? or visualized on the initial study.
The following findings are highly
predictive of recurrent arterial
hemorrhage:
 Hypotension
 Disruption of the pubic
symphysis
 Transfusion requirement of
>2 U/h of packed red blood cells
 More than 2 arterial injuries
visualized on the initial pelvic
angiogram
How can resolution of Serial hemoglobin/hematocrit
bleeding be confirmed (H/H); If H/H continues to
clinically after the downtrend, repeat angiogram and
angiographic treatment embolization may be indicated.
of pelvic or extremity
bleeding?
What arterial branches The deep circumflex iliac artery
from the external iliac arising laterally and the inferior
artery mark the transition epigastric artery arising medially.
from external iliac artery to
common femoral artery?
(continued)
728 J. J. Guan

At which spinal vertebral L4-5.

level does the abdominal
aorta bifurcate into the
left and right common iliac
arteries?
Approximately what Pelvic ring only: about 60%
percentages of pelvic Acetabular involvement only: about
fractures are isolated to 30%
the pelvic ring, isolated to Pelvic ring and acetabular
the acetabulum, or involve involvement: about 10%
both?
What imaging Contrast extravasation,
manifestations on pelvic pseudoaneurysm, and large
angiogram suggest vascular arteriovenous fistula.
injury?

Further Reading
Abrassart S, Stern R, Peter R. Unstable pelvic ring injury with
hemodynamic instability: what seems the best procedure choice
and sequence in the initial management? Orthop Traumatol
Surg Res. 2013;99(2):175–82.
Alton TB, Gee AO. Classifications in brief: young and burgess
classification of pelvic ring injuries. Clin Orthop Relat Res.
2014;472(8):2338–42.
Ayella RJ, DuPriest RW Jr, Khaneja SC, Maekawa K, Soderstrom
CA, Rodriguez A, et al. Transcatheter embolization of autolo-
gous clot in the management of bleeding associated with frac-
tures of the pelvis. Surg Gynecol Obstet. 1978;147(6):849–52.
Ben-Menachem Y, Coldwell DM, Young JW, Burgess
AR. Hemorrhage associated with pelvic fractures: causes, diag-
nosis, and emergent management. AJR Am J Roentgenol.
1991;157(5):1005–14.
Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F,
et al. Pelvic trauma: WSES classification and guidelines. World J
Emerg Surg. 2017;12:5.
Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR,
Como J, et al. Eastern Association for the Surgery of trauma prac-
 48 Pelvis 729

tice management guidelines for hemorrhage in pelvic fracture-

-update and systematic review. J Trauma. 2011;71(6):1850–68.
Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ,
et al. Evaluation and management of penetrating lower extrem-
ity arterial trauma: an Eastern Association for the Surgery of
trauma practice management guideline. J Trauma Acute Care
Surg. 2012;73(5 Suppl 4):S315–20.
Halawi MJ. Pelvic ring injuries: emergency assessment and manage-
ment. J Clin Orthop Trauma. 2015;6(4):252–8.
Halawi MJ. Pelvic ring injuries: surgical management and long-­term
outcomes. J Clin Orthop Trauma. 2016;7(1):1–6.
Hussami M, Grabherr S, Meuli RA, Schmidt S. Severe pelvic injury:
vascular lesions detected by ante- and post-mortem contrast
medium-enhanced CT and associations with pelvic fractures. Int
J Legal Med. 2017;131(3):731–8.
Ierardi AM, Duka E, Lucchina N, Floridi C, De Martino A, Donat
D, et al. The role of interventional radiology in abdominopelvic
trauma. Br J Radiol. 2016;89(1061):20150866.
Juern JS, Milia D, Codner P, Beckman M, Somberg L, Webb T, et al.
Clinical significance of computed tomography contrast extrava-
sation in blunt trauma patients with a pelvic fracture. J Trauma
Acute Care Surg. 2017;82(1):138–40.
Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards
PJ, Giannoudis PV. Angiographic embolisation of pelvic ring
injuries. Treatment algorithm and review of the literature. Int
Orthop. 2011;35(9):1381–90.
Kaufman JA. Abdominal aorta and pelvic arteries. In: Kaufman JA,
Lee MJ, editors. The requisites: vascular and interventional radi-
ology. 2nd ed. Philadelphia: Saunders Elsevier; 2014. p. 199–228.
Kaufman JA. Fundamentals of angiography. In: Kaufman JA, Lee
MJ, editors. The requisites: vascular and interventional radiology.
2nd ed. Philadelphia: Saunders Elsevier; 2014. p. 25–55.
Kaufman JA. Vascular interventions. In: Kaufman JA, Lee MJ, edi-
tors. The requisites: vascular and interventional radiology. 2nd
ed. Philadelphia: Saunders Elsevier; 2014. p. 68–98.
Kaufman JA. Vascular pathology. In: Kaufman JA, Lee MJ, editors.
The requisites: vascular and interventional radiology. 2nd ed.
Philadelphia: Saunders Elsevier; 2014. p. 1–24.
Kerr WS Jr, Margolies MN, Ring EJ, Waltman AC, Baum
SN. Arteriography in pelvic fractures with massive hemorrhage.
J Urol. 1973;109(3):479–82.
730 J. J. Guan

Kim PH, Leopold SS. In brief: Gustilo-Anderson classification. [cor-

rected]. Clin Orthop Relat Res. 2012;470(11):3270–4.
Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D. Angiographic
embolization for pelvic fractures in older patients. Arch Surg
(Chicago, Ill : 1960). 2004;139(7):728–32. discussion 32-3
Margolies MN, Ring EJ, Waltman AC, Kerr WS Jr, Baum
S. Arteriography in the management of hemorrhage from pelvic
fractures. N Engl J Med. 1972;287(7):317–21.
Marzi I, Lustenberger T. Management of Bleeding Pelvic Fractures.
Scandinavian J Surg. 2014;103(2):104–11.
Matalon TS, Athanasoulis CA, Margolies MN, Waltman AC,
Novelline RA, Greenfield AJ, et al. Hemorrhage with pelvic
fractures: efficacy of transcatheter embolization. AJR Am J
Roentgenol. 1979;133(5):859–64.
Nelson KJ, Mitchell D. Visceral and solid organ trauma. In: Keefe
NA, Haskal ZJ, Park AW, Angle JF, editors. In: IR playbook. 1st
ed. New York: Springer; 2018. p. 357–69.
Padia SA, et al. Society of Interventional Radiology Position
Statement on endovascular intervention for trauma. JVIR.
2020;31(3):363–9.
Richard HM. Pelvic and extremity trauma. In: Keefe NA, Haskal
ZJ, Park AW, Angle JF, editors. IR Playbook. 1st ed. New York:
Springer; 2018. p. 371–7.
Ring EJ, Athanasoulis C, Waltman AC, Margolies MN, Baum
S. Arteriographic management of hemorrhage following pelvic
fracture. Radiology. 1973;109(1):65–70.
Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris
PD, et al. Indications for use of thoracic, abdominal, pelvic, and
vascular damage control interventions in trauma patients: a con-
tent analysis and expert appropriateness rating study. J Trauma
Acute Care Surg. 2015;79(4):568–79.
Scemama U, Dabadie A, Varoquaux A, Soussan J, Gaudon C, Louis
G, et al. Pelvic trauma and vascular emergencies. Diagn Interv
Imaging. 2015;96(7-8):717–29.
Shi J, Gomes A, Lee E, Kee S, Moriarty J, Cryer H, et al. Complications
after transcatheter arterial embolization for pelvic trauma: rela-
tionship to level and laterality of embolization. Eur J Orthop
Surg Traumatol orthopedie traumatologie. 2016;26(8):877–83.
Taylor RM, Sullivan MP, Mehta S. Acute compartment syndrome:
obtaining diagnosis, providing treatment, and minimizing medi-
colegal risk. Curr Rev Musculoskelet Med. 2012;5(3):206–13.
 48 Pelvis 731

Venkatesan AM, Kundu S, Sacks D, Wallace MJ, Wojak JC, Rose SC,
et al. Practice guidelines for adult antibiotic prophylaxis dur-
ing vascular and interventional radiology procedures. Written
by the Standards of Practice Committee for the Society of
Interventional Radiology and Endorsed by the Cardiovascular
Interventional Radiological Society of Europe and Canadian
Interventional Radiology Association [corrected]. J Vasc Interv
Radiol. 2010;21(11):1611–30; quiz 31.
Walker ML. The damage control laparotomy. J Natl Med Assoc.
1995;87(2):119–22.
Wong JJ, Roberts AC. Embolization and pelvic trauma. In: Golzarian
J, Sun S, Sharafuddin MJ, editors. Vascular embolotherapy: a
comprehensive approach. New York: Springer; 2006. p. 59–68.
Chapter 49
Bronchial Artery
Embolization
Justin J. Guan

Evaluating the Patient

What are important aspects Frequency and severity of
of the clinical history hemoptysis, any evidence of airway
during patient evaluation? compromise, and information or
history that may help determine the
underlying etiology.
What are important Evaluate for signs of respiratory
components of the physical distress (tachypnea, tachycardia,
exam during patient auscultation of lungs for wheezing
evaluation? or decreased breath sounds) and
hemodynamic instability (pulse,
BP).
What are important Hemoglobin/hematocrit to evaluate
laboratory values to for degree of anemia
consider during patient WBC and cultures to evaluate for
evaluation? infection
Coagulation profile and renal
function before arteriogram and
embolization
(continued)

J. J. Guan (*)
Division of Interventional Radiology, Department of Diagnostic
Radiology, Cleveland Clinic, Cleveland, OH, USA

© Springer Nature Switzerland AG 2022 733

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_49
734 J. J. Guan

What is the best CT angiography – Can identify

noninvasive imaging the etiology of hemoptysis and
modality for the evaluation demonstrate bronchial artery
of massive hemoptysis? anatomy, assisting in pre-procedural
planning.
Can CTA usually confirm CTA does not usually locate the
the site of bleeding and exact site of bleeding, but it can
evaluate for laterality lateralize the site of bleeding when
of involvement? Which the source is unilateral.
invasive diagnostic studies Fiber-optic bronchoscopy – Can
can help evaluate for help confirm bronchial etiology
bleeding site and also be for hemoptysis and identify the
therapeutic? laterality of involvement in up to
95% of cases. It can also treat the
source of hemoptysis in some cases.
Arteriography and embolization –
Both diagnostic and therapeutic;
first-line therapy for most cases
of massive hemoptysis; also
indicated when bronchoscopy
cannot adequately control ongoing
bleeding.
What is the typical One or more enlarged,
appearance of abnormal hypertrophied, and tortuous
bronchial arteries that may vessel extending along the
suggest sites of bleeding? tracheobronchial tree into
an extensive area of patchy
hypervascularity; AV shunting or
pseudoaneurysms may also be seen.
Active contrast extravasation is not
commonly seen.

High Yield History

Define massive Hemoptysis > 250 ml in volume within
hemoptysis. 24 hours.
 49 Bronchial Artery Embolization 735

Define a major Three or more days of hemoptysis in

hemorrhagic a week, with each day totaling greater
hemoptysis event. than or equal to 100 ml in volume.
What are the potential Hypovolemia and asphyxiation; this
clinical results of can lead to a mortality of 50–85% with
continuing hemorrhage conservative management.
into the airways?
What is the mortality
rate with conservative
management?
What are common Infections (Tb, Aspergillosis, chronic
etiologies for massive bacterial pneumonia)
hemoptysis? Chronic lung diseases (CF, sarcoidosis,
COPD, interstitial pneumonias)
Malignancy
Trauma
Massive hemoptysis Systemic arteries that supply the
is most commonly bronchial tree – bronchial arteries,
associated with the although pulmonary arterial system can
abnormality of which cause massive hemoptysis, this is rare.
circulation of the
lungs (bronchial or
pulmonary)?
What characteristic Occlusion of targeted bronchial arteries
of the bronchial causes little or no ischemia of the
airway system bronchial airways while having a high
makes bronchial success rate of stopping hemoptysis.
artery embolization This is because up to 95% of massive
an effective and hemoptysis cases originate from
safe intervention the bronchial artery system, yet the
for controlling bronchial system supplies less than 1%
hemoptysis? of blood flow to the lungs. More than
99% of the blood flow to the lungs is
supplied by the pulmonary system.
736 J. J. Guan

Indications/Contraindications
What is the gold Bronchial arteriogram with
standard or first-line embolization is now considered the
therapy for massive gold standard treatment for massive
hemoptysis? hemoptysis, as most massive hemoptysis
cases originate from the bronchial
arterial system. However, most patients
will have first undergone bronchoscopy
given its benefits of obtaining an
airway for oxygenation and its ability
to both localize and treat the source of
bleeding.
What are Non-bronchial artery source for
contraindications bleeding, i.e., pulmonary artery
to bronchial artery Contrast allergy
embolization? Inability to perform general
endotracheal anesthesia (GETA)
Is shunting between the Shunting may be seen during
bronchial arteries and angiography and is not an absolute
the pulmonary veins contraindication, though it may require
or arteries an absolute adjustment of technique.
contraindication to
embolization?

Relevant Anatomy
The bronchial T3-T8 levels, with most arising from T5-T6
arteries most levels. The left bronchial arteries (typically
commonly two) most commonly arise from the descending
arise from thoracic aorta.
which levels
of the thoracic
aorta?
What The trachea and major bronchial airways,
structures do esophagus, vagus nerve, visceral pleura,
the bronchial mediastinal lymph nodes, vasa vasorum of
arteries thoracic aorta, and pulmonary arteries
supply?
 49 Bronchial Artery Embolization 737

Define Orthotopic describes normal origins of the

orthotopic bronchial arteries from the descending thoracic
vs ectopic aorta, while ectopic describes variant origins of
origins of the bronchial arteries. In at least 20% of patients,
the bronchial at least one of the bronchial arteries can arise
arteries. What from the subclavian artery, internal mammary
are possible artery, thyrocervical trunk, superior intercostals,
ectopic sites? pericardiophrenic and inferior phrenic arteries,
abdominal aorta, or coronary arteries.
Which In the setting of prior embolization or chronic
collateral lung disease, parasitizing vessels may originate
arteries may from the intercostal, inferior phrenic, internal
hypertrophy thoracic arteries, or the costocervical and
and parasitize thyrocervical trunks.
sites of
bronchial
arterial
bleeding?
Describe Type I – Most common (40% of pts), single
the Caldwell right intercostcobronchial trunk and two left
variations of bronchial arteries with separate origins
the bronchial Type II – 20%, single right intercostcobronchial
artery trunk and only one left bronchial artery
branching Type III – 20%, right intercostcobronchial trunk
pattern. with additional right bronchial artery having
separate origin, and two left bronchial arteries
Type IV – 10%, right intercostcobronchial trunk
with additional right bronchial artery having
separate origin, and one left bronchial artery
Can the Yes, the right intercostobronchial trunk (which
bronchial gives rise to right-sided bronchial artery
arteries supply branches) can give rise to an anterior medullary
an anterior artery that supplies the spinal cord through an
spinal artery? anterior spinal artery. The anterior medullary
Why is this branch characteristically forms a hairpin turn
important? on angiogram. It is important to identify any
spinal artery supply from the bronchial arteries
to prevent inadvertent nontarget embolization
of the anterior spinal artery, which can lead to
paraplegia.
738 J. J. Guan

Relevant Materials
What is the key Airway patency is vital; in some cases, a
prerequisite for unilateral selective main stem bronchial
determining the use intubation may be required.
of general anesthesia
versus conscious
sedation when
performing bronchial
artery embolization?
Describe how an The endobronchial blocker is a device
endobronchial that can be inserted coaxially down the
blocker can be used tracheal tube after tracheal intubation
to achieve selective and into either the left or right mainstem
unilateral bronchial bronchus. The balloon attached to the
intubation. blocker is then insufflated, effectively
blocking that bronchus and achieving
unilateral intubation of the contralateral
side.
What sized catheters Selective catheterization of abnormal
are used to selectively vessels is performed with 4-Fr or 5-Fr
catheterize bronchial catheters. Superselective catheterization
arteries? can be performed using 3-Fr or smaller
microcatheters to select smaller, more
distal, or tortuous bronchial arteries.
 49 Bronchial Artery Embolization 739

Discuss the embolic Polyvinyl alcohol (PVA) particles

agent(s) typically and solid (tris-acryl gelatin, TAGM)
used for bronchial microspheres are the most commonly
artery embolization. used agents; coils provide more proximal
occlusion compared to PVA or liquid
embolizing agents and are thus used
in cases of aneurysm/pseudoaneurysm,
arteriovenous malformations, or to
occlude non-bronchial collateral vessels.
Although liquid embolic agents such as
n-Butyl-2-cyanoacrylate (NBCA) were
less preferred in the past due to fear of
distal embolization causing pulmonary
ischemia/infarction, more recent studies
have shown similar safety and efficacy
of using such liquid agents compared to
PVA particles. NBCA have also been
shown to achieve better hemoptysis
control rates and higher long-term
hemoptysis-free survival rates when
compared to PVA in patients with
bronchiectasis.
When using particles Gelfoam is not desirable as it can lead
to perform bronchial to early recanalization and rebleeding.
artery embolization, PVA particles and microspheres smaller
what embolic and than 300 um should be avoided, as these
which particle sizes particles can pass through broncho-­
should be avoided pulmonary anastomoses which have a
and why? mean diameter of 325 um, thus increasing
the risk for pulmonary ischemia or
infarct. If smaller embolic sizes are
used, embolization should be performed
super-selectively using 3 Fr or smaller
microcatheters.
740 J. J. Guan

General Step by Step

What are the options Femoral artery access is the preferred
for arterial access route for bronchial artery embolization
in bronchial artery due to better angulation. In cases
angiography and with more complex anatomy that
embolization? preclude femoral access, such as
tortuosity of aorta, radial access, and
even transaxillary routes have been
reported.
What is the typical Hypertrophied and tortuous. Dense
angiographic networks of neovascularity and
appearance of bronchial hypervascularity are often seen.
arteries contributing to
hemoptysis?
What should always be After embolization, performing a post-­
done after the occlusion procedural aortic angiogram is vital to
of vascular injury to rule ensure adequate arterial occlusion and
out continued bleeding to evaluate for any collateral branches
from collateral blood not previously visible that require
supply? embolization.
How can one evaluate Clinical cessation of bloody sputum
for successful bronchial expectoration.
artery embolization?
What is the reported 2–27%.
short-term recurrence
rate of hemoptysis
at one-month post
embolization?
What is the reported 10–52%.
long-term recurrence
rate of hemoptysis
at 46-month post
embolization?
 49 Bronchial Artery Embolization 741

Should embolization Yes. Active bleeding on angiography is

be performed in the often not seen.
setting of massive
hemoptysis and
absence of angiographic
visualization of
bleeding?

Complications
What are the Though not considered complications,
common causes incomplete embolization of the target
of recurrent vessel, failure to find and embolize all
hemoptysis after affected bronchial vessels, failure to find
bronchial artery and embolize collateral vessels from outside
embolization? of the bronchial system, collateralization
after embolization, and recanalization
of the embolized bronchial artery are all
possible causes of continued or re-bleeding
after the procedure.
What are the Transient chest pain and/or dysphagia from
most common the occlusion of intercostal or esophageal
side effects of arterial branches supplied by the bronchial
bronchial artery arteries.
embolization?
How are these side These symptoms are usually self-limited
effects managed? and can be treated with analgesics.
What is the most Anterior spinal cord syndrome from spinal
feared complication cord ischemia.
of bronchial artery
embolization?
What is the About 1%.
reported incidence
of spinal cord
ischemia?
742 J. J. Guan

Landmark Research
Tom LM, Palevsky HI, Holsclaw DS, Trerotola SO, Dagli M,
Mondschein JI, et al. Recurrent Bleeding, Survival, and
Longitudinal Pulmonary Function following Bronchial
Artery Embolization for Hemoptysis in a U.S. Adult
Population. Journal of vascular and interventional radiology:
JVIR. 2015;26(12):1806-13.e1.
• Technical success rate of bronchial artery embolization for
hemoptysis is 90%; technical failures included no bron-
chial or extrabronchial collateral vessel causing hemopty-
sis identified (3%), unsuccessful catheterization due to
vessel tortuosity, vasospasm, or dissection (5%), and case
termination due to major complication (2%).
• Of the technically successful cases, clinical success rates at
24 hrs and 30 days were 82% and 68%, respectively; 15%
of patients required two embolization procedures while
9% required three or more embolizations; recurrent bleed-
ing and mortality were increased in patients with
sarcoidosis.
• 51% of embolization cases were preceded by bronchos-
copy, of which 86% localized the bleeding.

Common Questions
What should be the Place the patient in dependent
initial management in positioning of the bleeding lung.
a patient with massive
hemoptysis?
Is massive hemoptysis Bronchial arteries.
more commonly
associated with
abnormalities of the
bronchial arteries or
pulmonary arteries?
 49 Bronchial Artery Embolization 743

What is a Rasmussen’s Rasmussen’s aneurysm is a post-­

Aneurysm? Why is it inflammatory aneurysm or
important with respect pseudoaneurysm that arise from a
to hemoptysis? pulmonary artery branch adjacent
to or within a tuberculous cavity.
Massive hemoptysis from rupture of
a Rasmussen’s aneurysm is a rare but
potentially fatal complication of cavitary
tuberculosis.
What does the Artery The artery arises from the anterior
of Adamkiewicz arise radicular branch of the spinal branch
from? What is the most of the posterior intercostal artery. The
common level for the artery most commonly level originates
Artery of Adamkiewicz on the left, at the T8-L1 levels, though
to arise from? has been reported to arise from either
side from the T3-L4 levels.

Further Reading
Bruzzi JF, Remy-Jardin M, Delhaye D, Teisseire A, Khalil C, Remy
J. Multi-detector row CT of hemoptysis. Radiographics: a review
publication of the Radiological Society of North America, Inc.
2006;26(1):3–22.
Bussieres JS. Iatrogenic pulmonary artery rupture. Curr Opin
Anaesthesiol. 2007;20(1):48–52.
Chung MJ, Lee JH, Lee KS, Yoon YC, Kwon OJ, Kim TS. Bronchial
and nonbronchial systemic arteries in patients with hemopty-
sis: depiction on MDCT angiography. AJR Am J Roentgenol.
2006;186(3):649–55.
Daliri A, Probst NH, Jobst B, Lepper PM, Kickuth R, Szucs-­Farkas
Z, et al. Bronchial artery embolization in patients with hemop-
tysis including follow-up. Acta Radiologica (Stockholm, Sweden:
1987). 2011;52(2):143–7.
Do KH, Goo JM, Im JG, Kim KW, Chung JW, Park JH. Systemic
arterial supply to the lungs in adults: spiral CT findings.
Radiographics: a review publication of the Radiological Society
of North America, Inc. 2001;21(2):387–402.
744 J. J. Guan

Furuse M, Saito K, Kunieda E, Aihara T, Touei H, Ohara T, et al.

Bronchial arteries: CT demonstration with arteriographic cor-
relation. Radiology. 1987;162(2):393–8.
Ittrich H, Klose H, Adam G. Radiologic management of haemopty-
sis: diagnostic and interventional bronchial arterial embolisation.
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der Nuklearmedizin. 2015;187(4):248–59.
Kalva SP. Bronchial artery embolization. Tech Vasc Interv Radiol.
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tors. The requisites: vascular and interventional radiology. 2nd
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Nguyen ET, Silva CI, Seely JM, Chong S, Lee KS, Muller
NL. Pulmonary artery aneurysms and pseudoaneurysms in
adults: findings at CT and radiography. AJR Am J Roentgenol.
2007;188(2):W126–34.
Pandu A, Bhalla AS, Goyal A. Bronchial artery emboliza-
tion in hemoptysis: a systemic review. Diagn Interv Radiol.
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Pelage JP, El Hajjam M, Lagrange C, Chinet T, Vieillard-Baron A,
Chagnon S, et al. Pulmonary artery interventions: an overview.
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Sopko DR, Smith TP. Bronchial artery embolization for hemoptysis.
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trol hemoptysis: a review. Cardiovasc Intervent Radiol.
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nal pulmonary function following bronchial artery embolization
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2015;26(12):1806–13.e1.
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New York: Springer; 2018. p. 239–46.
Van Den Berg JC. Bronchial artery embolization. In: Golzarian J,
Sun S, Sharafuddin MJ, editors. Vascular embolotherapy: a com-
prehensive approach. New York: Springer; 2006. p. 263–77.
Wholey MH, Chamorro HA, Rao G, Ford WB, Miller WH. Bronchial
artery embolization for massive hemoptysis. JAMA.
1976;236(22):2501–4.
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nonbronchial systemic artery embolization for life-threatening
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2002;22(6):1395–409.
Yoon YC, Lee KS, Jeong YJ, Shin SW, Chung MJ, Kwon
OJ. Hemoptysis: bronchial and nonbronchial systemic arteries at
16-detector row CT. Radiology. 2005;234(1):292–8.
Zhao T, Wang S, Zheng L, Jia Z, Yang Y, Wang W, et al. The value of
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Vasc Interv Radiol. 2017;28(4):533–41.e1.
Chapter 50
Upper Gastrointestinal
Bleeding
Kartik Kansagra, Harout Dermendjian, and Cuong H. Lam

Evaluating the Patient

What are signs and Hematemesis (bright blood or coffee-­
symptoms of upper ground appearing), melena (tarry black
GI bleeding? stools), and hematochezia when brisk
upper GI hemorrhage (5–10% of UGIB
presents with hematochezia, 11% of
hematochezia is due to an UGIB).
What are key Sometimes, the first sign is tachycardia
components to when the patient is normotensive. This
keep in mind when may be a sign of impending instability.
evaluating patients Additional vitals to check in a more
with hemodynamic stable patient include orthostatics.
instability, regardless Orthostatic hypotension is diagnosed with
of etiology? there is a fall in systolic blood pressure
by at least 20 mmHg or diastolic blood
pressure by at least 10 mmHg.
(continued)

K. Kansagra (*) · H. Dermendjian · C. H. Lam

Kaiser Permanente Los Angeles Medical Center, Vascular and
Interventional Radiology, Los Angeles, CA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 747

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_50
748 K. Kansagra et al.

What are key labs CBC, chemistry panel, Creatinine, lactate,

to order to aid in type and screen, PT, PTT, INR.
the workup and Look for elevated INR in a patient not
management? on anticoagulation to suggest underlying
liver disease.
Use chemistry panel to evaluate BUN
to suggest possible underlying uremia
preventing adequate platelet function.
However, BUN may also be elevated
secondary to the hemorrhage.
What is the medical Establish 2 large bore IVs (at least 18
management when gauge).
evaluating a patient Decide if the patient is stable or unstable.
with an upper GI If hemodynamically unstable, begin IV
bleed? fluids.
Type and cross the patient, but if
necessary, order O negative blood. When
blood products are available, initiate
massive transfusion protocol per the
results of the PROPPR trial.
If there is massive hemorrhage from
esophageal varices, an esophageal balloon
may be necessary.
Begin proton pump inhibitor therapy (IV
drip or BID push).
If there is concern for a variceal
bleed, start octreotide and antibiotics
(ceftriaxone 1 g IV).
 50 Upper Gastrointestinal Bleeding 749

What are transfusion Transfuse to keep Hgb > 7 g/dL, which

thresholds to use? was demonstrated to reduce mortality
in patients with acute UGIB compared
to a more liberal threshold of >10 g/dL
(Transfusion Strategies for Acute Upper
Gastrointestinal Bleeding).
For patients with CAD and hemodynamic
instability, transfuse to keep Hgb > 8–9 g/
dL or higher.
Transfuse to keep platelets >50,000 per
uL or with signs of bleeding.
Transfuse to keep INR < 1.5 (consider
Kcentra for rapid reversal in patients at
concern for volume intolerance, i.e., heart
failure).
At times for unstable patients or acute
large volume of hemorrhage, transfusion
may be required even with Hgb level at
8 or 9.
What imaging The initial step is upper endoscopy
modalities can be performed by gastroenterology.
considered as part of Rarely, a tagged RBC scan can be
the evaluation? performed to help differentiate gastric vs.
duodenal bleeding if the upper endoscopy
was inconclusive.
Occasionally, a CT angiogram (CTA) may
be performed for diagnosis, but more so
to help elucidate the arterial, systemic
venous, and portal venous anatomy.
What are scoring The Rockall – vomplete versus pre-­
systems utilized to endoscopy score (first 3 categories only)
risk stratify patients
with GI Bleeds?

Age < 60 years 0

60–79 years +1
> 80 years +2
Shock No shock 0
Tachycardia only +1
Hypotension +2
(continued)
750 K. Kansagra et al.

Comorbidities No major 0
Any except renal failure, liver +2
failure, and/or metastatic
malignancy
Renal failure, liver failure, and/ +3
or metastatic malignancy
Diagnosis Mallory-Weiss tear 0
No lesion identified 0
Other diagnosis +1
Upper GI malignancy +2
Major stigmata of None or dark spot only 0
recent hemorrhage Blood in upper GI tract +2
Adherent clot +2
Visible or spurting vessel +2

Glasgow Blatchford scoring system:

• Stratifies patients for inpatient versus outpatient
management
• Takes into account Hgb, BUN, hemodynamics, symptoms,
as well as cardiac and hepatic history
What is the first-line Endoscopy. It allows for diagnosis
treatment for upper GI and management for many of the
bleeding? etiologies of upper GI bleeding.
If GI bleeding is not Non variceal – endovascular
controlled with endoscopy, arterial embolization.
what IR procedures exist for Esophageal variceal hemorrhage –
further management? transjugular intrahepatic
portosystemic shunt (TIPS)
Gastric variceal hemorrhage –
balloon/coil/plug-occluded/
assisted retrograde transvenous
obliteration (BRTO/CARTO/
PARTO).
 Keep in mind that BRTO/
CARTO/PARTO may lead to
esophageal varices or worsen
ones that are already present.
 50 Upper Gastrointestinal Bleeding 751

High Yield History

What are the Gastric and duodenal ulcers, gastritis,
causes of upper GI esophagitis, esophageal or gastric varices,
bleeding? angiodysplasia, Mallory-Weiss syndrome,
mass/malignancy, Dieulafoy’s lesion,
aortoenteric fistula (consider in a patient
with prior endovascular aortic aneurysm
repair), and medication related.
How may the past Does the patient have history of liver
medical history of a disease?
patient help guide the  If so, do they have a prior upper
etiology of the bleed? endoscopy demonstrating esophageal
varices? This is key as the initial
management of a variceal bleed is
different than non-variceal.
History of alcoholism?
 This may suggest variceal hemorrhage,
gastritis, or Mallory-Weiss.
History of chronic NSAID use or known
H. pylori infection?
 Gastric or duodenal ulcer.
History of aortic stenosis?
 Angiodysplasia.
History of AAA or prior EVAR?
 Aortoenteric fistula.
History of pancreatitis?
 Splenic vein thrombosis with associated
varices.
Why is it important History of coronary artery disease will
to determine the help guide transfusion management. Also,
patient’s underlying severe CAD or ischemic cardiomyopathy
cardiopulmonary patients may be less tolerant of acute
health status? hemoglobin drop. Low EF patients
require careful volume resuscitation. If
an intervention or procedure is planned,
understanding the overall health is key to
help reduce periprocedural complications.
(continued)
752 K. Kansagra et al.

What neurological A history of encephalopathy or active

symptoms or key encephalopathy is important to recognize
history findings in patients with variceal bleeding as a
should be identified? potential treatment (TIPS) may worsen
the disease process.

Indications/Contraindications
What are the indications for Failed endoscopic management
endovascular treatment of Contraindications to endoscopy
upper GI bleeding? secondary to medical or
anatomic reasons
What are absolute Severe or rapidly progressive
contraindications to TIPS? liver failure
History of severe
encephalopathy
Heart failure, especially right-­
sided heart failure
Pulmonary Hypertension
Classicaly what MELD score MELD > 25.
is considered high risk for
perioperative mortality for
TIPS?
At what MELD score is the MELD > 17.
3-month survival rate lower
after elective TIPS creation?
What are relative contradictions Large esophageal varices and
to BRTO/CARTO/PARTO? decompensated cirrhosis with
poorly controlled ascites.
 50 Upper Gastrointestinal Bleeding 753

Relevant Anatomy
What anatomic Ligament of Treitz.
landmark separates
upper from lower
gastrointestinal
bleeding?
What artery would you The celiac artery should be
target first? interrogated first in an attempt to
evaluate the gastroduodenal artery.
Additional arteries to consider are
the gastric arteries and the SMA to
evaluate for collateral flow to sites of
bleeding in the GDA distribution.
What are angiographic Contrast extravasation and contrast
findings for upper GI pooling on venous phase.
bleeding?
What can be given to IV Glucagon.
help limit bowel motion
(misregistration) artifact
for angiograms?

Relevant Materials
What type of embolic Polyvinyl alcohol particles (PVA),
agents should be readily coils, Onyx, gelfoam, vascular plugs,
available? and n-Butyl-2-cyanoacrylate (NBCA;
glue).
For TIPS, what additional Access to transabdominal or different
equipment may be types of intravascular ultrasound may
helpful? aid in direct visualization of the TIPS
needle and help reduce the number
of needle passes.
(continued)
754 K. Kansagra et al.

For BRTO/CARTO/ A long sheath may be helpful to

PARTO what equipment maintain access within the shunt.
may be helpful? Also, a variety of microcatheter
systems may help to navigate the
tortuosity often encountered within
the varices.
What is the unique It has “controlled expansion”
feature of the technology, meaning it is usually
Gore Viatorr TIPS first dilated to 8 mm, though it can
Endoprosthesis? be ballooned to a larger diameter in
subsequent procedures if clinically
required based on continued
symptoms following the initial TIPS.
What are some of the STS, Polidocanol, n-Butyl-2-­
various sclerosant cyanoacrylate (NBCA), and ethanol.
agents available when
performing a retrograde
transvenous obliteration?

General Step by Step

What are the Arterial embolization: Femoral, brachial,
access options and radial.
for the various TIPS: Right internal jugular vein is
interventions? preferred. May need femoral vein access
if using simultaneous intravascular US for
guidance.
BRTO: Femoral vein or right internal
jugular veins. If a TIPS is present, consider
antegrade approach and use a transjugular
approach. Also, possible transhepatic or
trans-splenic access may be considered if
there are anatomic limitations to the more
conventional approaches.
 50 Upper Gastrointestinal Bleeding 755

Once you have Using preferred catheter and

access, what are microcatheter perform multiple digital
the steps for subtraction angiograms to identify the
embolization? correct area of bleeding. Once confirmed,
perform embolization to stasis. Perform
a post embolization angiogram. As
mentioned, consider an SMA angiogram
to look for collateral flow to the site of
extravasation.
If utilizing coils for Ideally, subselective branch embolization
embolization of the should be performed, though in cases
GDA, what is the where the GDA is to be sacrificed,
general technique for proximal and distal control of the vessel
where to place the should be obtained to prevent retrograde
coils and why? bleeding.
How is a TIPS shunt Once systemic venous access is obtained,
placed? pressures are measured and the pre-TIPS
portosystemic gradient is calculated.
Using a 10-Fr sheath and a curved MPA
catheter, the hepatic vein (usually right
hepatic) is selected. The catheter is
exchanged for the TIPS needle and used
to access the portal vein.
Then, through access is obtained with an
0.035″ wire and a 5F sheath is advanced
into the portal vein, preferably one with
side holes and radiopaque markers to help
determine the length of the stent. The
liver parenchymal tract is then pre-dilated
for passage of the stent. The access sheath
is then advanced into the portal vein and
the stent is advanced into position. The
sheath is drawn back and the stent is
deployed. A final portogram is performed
to confirm appropriate positioning. Post-­
TIPS portosystemic gradient is again
calculated.
(continued)
756 K. Kansagra et al.

How is a BRTO/ Access is obtained usually via a femoral

CARTO/PARTO approach. Then, using various wires,
performed? support catheters, and sheaths, the goal
is to obtain access into the splenorenal
shunt. If performing a BRTO, a balloon
occlusion catheter is used to occlude
the shunt and retrograde venogram is
performed. Once the varices have been
mapped, any preferred sclerosant agent
is used. Usually, a point of completion is
just prior to overspill of sclerosant into
the portal venous system. When doing
a CARTO or PARTO, the prolonged
balloon occlusion is substituted for coils
and plugs, respectively.

Complications
Why is ischemia less There is a rich network of collaterals
common in upper feeding the stomach and duodenum. If
GI embolization? the patient has had prior embolization of
surgery, the risk for ischemia is higher.
What are Worsening ascites and esophageal varices.
potential sequela
of retrograde
transvenous
obliteration?
What are common Non-target embolization, which may
complications result in bowel infarction, as well as
of embolization access site complications (hematoma and
therapy? pseudoaneurysm).
What are potential Hepatic encephalopathy, intra-abdominal
complications of bleeding, CHF, and acute liver failure/
TIPS? decompensation.
 50 Upper Gastrointestinal Bleeding 757

How do you Patients can be started on lactulose 30 g,

treat post-TIPS three times a day and titrated to 3 loose
encephalopathy? bowel movements a day. Also, consider
an induction dose of up to 120 g a day.
Additionally, patients can be placed on
Rifaxamin 550 mg, 2 times a day. If medical
therapy is not enough, the TIPS diameter
can be reduced and, if required, the TIPS
can be occluded.

Landmark Research
García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt
B, Luca A, et al. Early Use of TIPS in Patients with Cirrhosis
and Variceal Bleeding for the Early TIPS (Transjugular
Intrahepatic Portosystemic Shunt) Cooperative Study Group.
N Engl J Med [Internet]. 2010;362(10):2370–9.
The target population of the Early TIPS Cooperative
Study included 63 patients with cirrhosis and acute variceal
bleeding who had been treated with vasoactive drugs plus
endoscopic therapy randomized to PTFE covered stent
within 72 hours after randomization or continuation of
vasoactive-­drug therapy.
• Patients with acute variceal bleeding and high risk for
treatment failure, early use of TIPS was associated with
significant reduction in treatment failure and mortality.
• Rebleeding or failure to control bleeding occurred in 14
out of 31 patients randomized to drugs and endoscopic
band ligation and in 1 out of 32 patients randomized to
TIPS.
Jairath V, et al. Restrictive Versus Liberal Blood Transfusion
for Acute Upper Gastrointestinal Bleeding (TRIGGER): A
Pragmatic, Open-Label, Cluster Randomised Feasibility Trial.
Lancet. 2015. 386(9989):137–44.
• Multicenter clustered RCT randomized patients to a
restrictive (Hgb < 8 g/dL) or liberal (Hgb <10 g/dL)
758 K. Kansagra et al.

t­ ransfusion policy. 936 patients – 403 to restrictive and 533

to a liberal policy
• Non-significant reduction in RBC transfusion in the
restrictive policy
• No significant difference in clinical outcomes
Villanueva C et al. Transfusion strategies for acute upper
gastrointestinal bleeding. The New England Journal of
Medicine. 2013. 368(1):11–21.
• Probability of survival at 6 weeks was higher in the restric-
tive strategy group (transfusion for Hgb <7 g/dL) (95% vs
91%).
• Further bleeding occurred in 10% of restrictive strategy
patients compared with 16% of patients in the liberal-­
strategy group.
• Survival was significantly higher in patients with cirrhosis
and Child-Pugh class A or B.

Common Questions
What are the causes of Gastric and duodenal ulcers,
upper GI bleeding? gastritis, esophagitis, esophageal
or gastric varices, angiodysplasia,
Mallory-Weiss syndrome, mass/
malignancy, Dieulafoy’s lesion,
aortoenteric fistula, and medication
related.
What are factors predictive Patients presenting with shock, large
of endoscopic failure? ulcer and located along posterior
duodenum, and Hgb < 10.
What is commonly used to MELD. It is made up of Cr, total
risk stratify perioperative bilirubin, and INR. MELD-Na score
risk in patients undergoing corrects for serum sodium.
TIPS and what are its
components?
 50 Upper Gastrointestinal Bleeding 759

What is the mechanism Lactulose is metabolized by

of action of lactulose colonic bacteria to create an
in treating hepatic acidic environment and reduce the
encephalopathy? breakdown of nitrogen-containing
products to ammonia and other
cerebral toxins.
What is the anatomic Ligament of Treitz.
landmark that separates
upper from lower GI
bleeding?

Further Reading
Copelan A, Kapoor B, Sands M. Transjugular intrahepatic portosys-
temic shunt: indications, contraindications, and patient work-­up.
Semin Intervent Radiol. 2014;31(3):235–42.
Elsayed IAS, Battu PK, Irving S. Management of acute upper GI
bleeding. BJA Educ [Internet]. 2017;17(4):117–23. Available from:
http://linkinghub.elsevier.com/retrieve/pii/S2058534917300550
García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B,
Luca A, et al. Early use of TIPS in patients with cirrhosis and
variceal bleeding for the early TIPS (Transjugular Intrahepatic
Portosystemic Shunt) Cooperative Study Group. N Engl J Med
[Internet]. 2010;362(10):2370–9. Available from: http://www.ncbi.
nlm.nih.gov/pubmed/20573925
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski
JM, et al. Transfusion of plasma, platelets, and red blood
cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with
severe trauma: the PROPPR randomized clinical trial. JAMA.
2015;313(5):471–82.
Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi
KV, Decker GA, et al. The role of endoscopy in the manage-
ment of variceal hemorrhage. Gastrointest Endosc [Internet].
2014;80(2):221–7. Available from: http://linkinghub.elsevier.com/
retrieve/pii/S0016510713021391
Jafar W, Jafar AJN, Sharma A. Upper gastrointestinal haemorrhage:
an update. Frontline Gastroenterol [Internet]. 2016;7(1):32–40.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/28839832
760 K. Kansagra et al.

Jairath V, Kahan BC, Gray A, Doré CJ, Mora A, James MW, et al.
Restrictive versus liberal blood transfusion for acute upper gas-
trointestinal bleeding (TRIGGER): a pragmatic, open-label, clus-
ter randomised feasibility trial. Lancet. 2015;386(9989):137–44.
Jensen DM, Machicado GA. Diagnosis and treatment of severe
hematochezia. The role of urgent colonoscopy after purge.
Gastroenterology. 1988;95(6):1569.
Keefe N, Haskal Z, Park AW, et al. IR Playbook. Cham: Springer
International Publishing AG; 2018.
Laine L, Jensen DM. Management of patients with ulcer bleeding.
Am J Gastroenterol [Internet]. 2012;107(3):345–60. Available
from: https://doi.org/10.1038/ajg.2011.480
Navuluri R, Patel J, Kang L. Role of interventional radiology in the
emergent management of acute upper gastrointestinal bleeding.
Semin Intervent Radiol [Internet]. 2012;29(3):169–77. Available
from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid
=4000612&tool=pmcentrez&rendertype=abstract
Nelms DW, Pelaez CA. The acute upper gastrointestinal bleed. Surg
Clin North Am [Internet]. 2018;98(5):1047–57. Available from:.
https://doi.org/10.1016/j.suc.2018.05.004.
Park JK, Saab S, Kee ST, Busuttil RW, Kim HJ, Durazo F, et al.
Balloon-occluded retrograde Transvenous Obliteration (BRTO)
for treatment of gastric varices: review and meta-analysis. Dig
Dis Sci [Internet]. 2015;60(6):1543–53. Available from: https://
doi.org/10.1007/s10620-­0 14-­3485-­8
Ramaswamy RS. Role of interventional radiology in the man-
agement of acute gastrointestinal bleeding. World J Radiol
[Internet]. 2014;6(4):82. Available from: http://www.wjgnet.
com/1949-­8470/full/v6/i4/82.htm
Saad W. Balloon-occluded retrograde transvenous oblitera-
tion of gastric varices: concept, basic techniques, and out-
comes. Semin Intervent Radiol [Internet]. 2012;29(2):118–28.
Available from: http://www.thieme-­c onnect.de/DOI/
DOI?10.1055/s-­0 032-­1312573
Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Chang M,
Lai M. A quality improvement initiative reduces 30-day rate
of readmission for patients with cirrhosis. Clin Gastroenterol
Hepatol [Internet]. 2016;14(5):753–9. Available from: https://doi.
org/10.1016/j.cgh.2015.08.041
 50 Upper Gastrointestinal Bleeding 761

Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-­Gea

V, Aracil C, et al. Transfusion strategies for acute upper gastro-
intestinal bleeding. N Engl J Med [Internet]. 2013;368(1):11–
21. Available from: http://www.nejm.org/doi/10.1056/
NEJMoa1211801
Villanueva C, et al. Transfusion strategies for acute upper gastroin-
testinal bleeding. N Engl J Med. 2013;368(1):11–21.
Chapter 51
Lower Gastrointestinal
Bleeding
Christopher Barnett

Evaluating the Patient

Describe the Worsening hypovolemia correlates with
relationship of worsened hemodynamic instability,
bleeding severity with manifesting in degrees of tachycardia,
hemodynamic stability. hypotension, and altered mental status,
in addition to other signs of shock such
as dyspnea and decreased urine output.
Describe some Obtain vital signs, establish large-­
important initial bore IV access for resuscitation
management with crystalloid and blood products
considerations for a as necessary, provide supplemental
patient presenting with oxygen, and correct any underlying
hematochezia. coagulopathy, if possible.
What basic labs should Complete blood count, complete
be assessed? metabolic panel, coagulation studies,
type and screen or cross-match.
(continued)

C. Barnett (*)
Department of Radiology, New York Presbyterian-Weill Cornell
Medical Center, New York, NY, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 763

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_51
764 C. Barnett

When evaluating An upper GI bleed, which if brisk,

for possible LGIB, may cause hematochezia. An upper GI
what other source of bleed may be excluded with nasogastric
bleeding should also be lavage or upper endoscopy as clinically
considered? indicated.
What are the primary Computed tomography angiography
imaging modalities for (CTA), nuclear red blood cell (RBC)
diagnosing LGIB? scintigraphy, and direct catheter
angiography.
What are the minimum RBC scintigraphy: > 0.1 mL/min
flow rates required CTA: > 0.35 mL/min
to detect bleeding by Catheter angiography: > 0.5 mL/min
these different imaging
modalities?
Compare CTA and Generally, CTA should be obtained
RBC scintigraphy for first, as it is faster, more accurately
the diagnosis of LGIB. localizes bleeding, and may identify
underlying pathology contributing to
bleeding. Bleeding visualized on CTA
is also more likely to correlate with a
positive arteriogram. RBC scintigraphy
is more sensitive but offers less precise
bleed localization and may be less
readily available. RBC scintigraphy may
be helpful following a negative CTA in
the setting of intermittent bleeding, as
it involves continuous imaging over a
1–2 hour duration.
RBC Scintigraphy Technetium-99m.
utilizes what
radiotracer?
What phases are Non-contrast, late arterial, and delayed
typically included in a venous phases.
CTA for diagnosis of
GI bleeding?
 51 Lower Gastrointestinal Bleeding 765

High Yield History

Patients with acute Hematochezia; however bleeding from
LGIB typically the right-sided colon or small bowel may
present with what present as melena.
main symptom?
What is the most Diverticular disease (~30%).
common cause of
lower GI bleeding in
adults?
What are some Angiodysplasia, inflammatory bowel
additional common disease, ischemia, neoplasm, infectious
causes? colitis, rectal ulcer, radiation colitis/
proctitis, hemorrhoids, and post-­
polypectomy bleeding.

Indications/Contraindications
What has traditionally Often colonoscopy, which may
been the first-line potentially localize the source
intervention for of bleeding and has potential to
hemodynamically sample specimens, as well as provide
stable patients with therapeutic management.
lower GI bleeding?
In what scenarios might Colonoscopy is limited in emergent
colonoscopy be limited settings in which patients often
or not an ideal first-line cannot tolerate nor wait for bowel
intervention? preparation, and in whom significant
active hemorrhage may obscure direct
visualization of a bleeding source.
Additionally, endoscopy provides a
limited assessment of small bowel.
Thus, CTA is increasingly becoming a
first-line evaluation for LGIB in some
centers.
(continued)
766 C. Barnett

What are the Bleeding refractory to medical or

indications for catheter endoscopic treatment, non-diagnostic
angiography? endoscopy, or patients too unstable
for endoscopy. Given the potential
limitations of endoscopic intervention,
some institutions prefer angiographic
embolization as the primary therapy for
LGIB.
What are Generally, contraindications to
contraindications to angiography are relative and relate
catheter angiography to potential harms of contrast
and/or embolization for administration (e.g., severe allergic
LGIB? reaction or renal disease), or
uncorrectable coagulopathy, in
which case the risks and benefits of
intervention must be considered.
Potential contraindications to
embolization itself include inability
to identify bleeding or to super-­select
the bleeding artery, concurrent bowel
ischemia, or surgically altered vascular
anatomy, which may increase the
resulting ischemia and lead to unwanted
infarction.
Describe scenarios For example, if bleeding is not focal
in which surgery such as in the setting of inflammatory
may be preferable to bowel disease, then it may not be
embolization. amenable to target embolization.
Additionally, if the source of bleeding
were to itself ultimately require
resection, such as a bowel malignancy,
then it may be reasonable to manage
directly with surgery.
 51 Lower Gastrointestinal Bleeding 767

Relevant Anatomy
How is lower Gastrointestinal bleeding originating distal
gastrointestinal to the ligament of Treitz.
bleeding
(LGIB) defined
anatomically?
The arteries The superior mesenteric artery (SMA).
supplying the ileum
and jejunum branch
from what major
artery?
Name the main The ileocolic, right colic, and middle colic
arterial branches arteries.
from the SMA
suppling the colon.
Name the major Left colic artery, sigmoid arteries, and
branches of the superior rectal artery.
inferior mesenteric
artery (IMA).
From where does The internal iliac artery anterior division,
the middle rectal It anastomoses with distal superior rectal
artery branch? branches of the inferior mesenteric artery.
The inferior rectal The internal pudendal artery, a branch of
artery branches the internal iliac artery anterior division.
from what artery?
Discuss the The gastrointestinal tract’s rich collateral
significance of blood supply allows for super-selective
collateral circulation embolization to achieve hemostasis without
in management of completely de-vascularizing the involved
LGIB. bowel, thereby mitigating the risk of bowel
infarction. Thus, it is important to recognize
that bowel that is surgically altered or has
undergone radiation therapy may have
diminished collateralization and be more
prone to infarction.
(continued)
768 C. Barnett

What anastomoses The arc of Riolan and marginal artery of

provide the major Drummond.
collateral circulation
between the SMA
and IMA?

General Step by Step

What is the typical Transfemoral
catheter angiography
access for LGIB?
What sheath size is 5-French (Fr) sheath to allow for visceral
generally necessary? vessel catheterization, with coaxial
microcatheter advancement for super-­
selection of the bleeding vessel.
Which vessels should Vessels may be selected in the order of
be interrogated, and suspected bleeding source. For instance,
in what order? if small bowel or right-sided colonic
bleeding is suspected then the SMA may
be interrogated first, whereas if bleeding
is suspected from the descending colon,
then the IMA may be selected first. Of
note, as procedural contrast fills the
bladder, the IMA circulation may be
gradually obscured.
Which medication Glucagon (1 mg Intravenously).
can be given to
reduce bowel motion
(misregistration)
artifact during
catheter angiography?
 51 Lower Gastrointestinal Bleeding 769

Discuss complications/ Side effects are typically mild, most

contraindication frequently including nausea/vomiting
to glucagon Glucagon administration should
administration. be avoided in patients with known
hypersensitivity, pheochromocytoma,
insulinoma, or glucagonoma.
In the event of Provocative angiography, in which
negative angiography vasodilators, anticoagulants, or
due to intermittent thrombolytics are injected to induce
bleeding, what is bleeding after an initially negative
sometimes performed mesenteric angiogram.
to facilitate the  A technique described by Kim et al. is
localization of to initially administer an intraarterial
hemorrhage? vasodilator and heparin within an
artery of suspicion and subsequently
repeat angiography, which if negative
is followed by immediate infusion of
tissue plasminogen activator (tPA)
in incremental doses with repeat
angiography performed until a source
if bleeding is identified, or until a
maximum dose of tPA has been given
based on operator discretion and
patient characteristics.
Once bleeding is Many options are available, including
identified, what agents endovascular coils, microparticles, such
are available for as gelatin sponge and polyvinyl alcohol
treatment? (PVA), and liquid embolics, such as
n-Butyl-2-cyanoacrylate (NBCA) glue.
(continued)
770 C. Barnett

Discuss some major Choice of embolic agent is primarily

considerations in based on operator preference.
selecting an embolic Endovascular coils are commonly
agent. used, with the advantage of being
deployed precisely and with relative
preservation of the distal vasculature. The
main limitations of coils are that they
permanently occlude the targeted vessel
and they rely on a patient’s intrinsic
ability to form a thrombus at the site of
coil placement.
Glue (n-Butyl-2-cyanoacrylate; NBCA)
and creation of a glue cast may be
desirable and effective in the settings of
coagulopathy but requires a high level
of operator familiarity and has increased
potential for non-target embolization,
as well as ability to polymerize within
the catheter and at the catheter tip,
which may adhere to the vessel wall and
impede removal of the catheter.
Compared to coils, particulate and liquid
embolics have potential to occlude
distal vasculature at the arteriole level,
which may carry a higher risk of bowel
infarction.
At what arterial Embolization should be performed as
level should target distal to the site of bleeding as possible
embolization be within the marginal arteries or vasa
performed? recta. An animal study demonstrated
that ischemic bowel injury risk can
be reduced by limiting the number of
embolized vasa recta to three.
Following Angiography to confirm cessation of
embolization, what bleeding. If additional bleeding from
additional steps collateral a vessel is visualized, then the
should be performed? collateral vessel should be embolized, if
possible.
 51 Lower Gastrointestinal Bleeding 771

What should be Serial examination of puncture site and

included in the peripheral pulses, monitoring of vital
post-procedural signs, urine output, hemoglobin and
assessment? hematocrit, transfusion requirement,
and renal function. Additional signs of
ongoing bleeding should be assessed for,
such as hematochezia or melena.

Complications
What is the rate of significant Approximately 5%.
ischemia following the embolization
for LGIB?
What is the estimated post-­ 22–56%.
embolization re-bleeding rate?
In the event of re-bleeding, what Endoscopy, repeat
interventions should be considered? angiography, or surgery.

Landmark Research
“Arteriography for Lower Gastrointestinal Hemorrhage:
Role of Preceding Abdominal Computed Tomographic
Angiogram in Diagnosis and Localization.”
Jacovides CL, Nadolski G, Allen SR, Martin ND, Holena
DN, Reilly PM, et al. Arteriography for Lower Gastrointestinal
Hemorrhage: Role of Preceding Abdominal Computed
Tomographic Angiogram in Diagnosis and Localization.
JAMA Surg. 2015 Jul;150(7):650–6.
• Prospective study to help guide the use of diagnostic imag-
ing prior to catheter angiography in the setting of acute
LGIB.
• Compared to RBC scintigraphy, CTA resulted in better
localization of bleeding and corresponded to a greater
number of positive catheter angiography evaluations.
772 C. Barnett

“Superselective Arterial Embolization for the Treatment

of Lower Gastrointestinal Hemorrhage”
Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW,
Kastan D. Superselective arterial embolization for the treat-
ment of lower gastrointestinal hemorrhage. J Vasc Interv
Radiol. 2001 Dec;12(12):1399–405.
• Retrospective review over a 12-year period to determine
the safety and efficacy of transcatheter embolization for
LGIB.
• Concluded that embolotherapy was not only successful at
controlling LGIB, but did not result in significant bowel
ischemia or infarction on follow-up patient evaluations.
“Provocative Mesenteric Angiography for Lower
Gastrointestinal Hemorrhage: Results from a Single-­
institution Study”
Kim CY, Suhocki PV, Miller MJ, Khan M, Janus G, Smith
TP. Provocative mesenteric angiography for lower gastroin-
testinal hemorrhage: results from a single-institution study. J
Vasc Interv Radiol. 2010 Apr;21(4):477–83.
• Retrospective study demonstrating that in patients with
recurrent occult lower GI bleeds, provocative mesenteric
angiography with injection of a vasodilator and tissue plas-
minogen activator resulted in successful identification and
treatment of the bleed in one third of patients.
• No bleeding complications related to administration of
thrombolytic therapy were identified.

Common Questions
What is the incidence of LGIB? 20–27 cases per 100,000
persons.
Lower GI bleeds make up what Approximately 20–24%.
percentage of overall GI bleeds?
In what percentage of LGIB will 80–85%.
bleeding stop spontaneously?
 51 Lower Gastrointestinal Bleeding 773

What is the first clinical sign of mild-­ Resting tachycardia.

moderate hypovolemia in a stable
patient?
Approximately what percentage 15–30%.
of blood loss begins to result in
decreased systolic blood pressure?
Which types of lesions have a Angiodysplasias
particularly increased risk of and arteriovenous
bleeding recurrence following malformations (AVM).
embolization?

Further Reading
Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan
D. Superselective arterial embolization for the treatment
of lower gastrointestinal hemorrhage. J Vasc Interv Radiol.
2001;12(12):1399–405.
Cherian MP, Mehta P, Kalyanpur TM, Hedgire SS, Narsinghpura
KS. Arterial interventions in gastrointestinal bleeding. Semin
Intervent Radiol. 2009;26(3):184–96.
Darcy M. GI Bleeding. In: Keefe NA, Haskal ZJ, Park AW, Angle
JF, editors. IR playbook: a comprehensive introduction to inter-
ventional radiology. Cham: Springer International Publishing;
2018. p. 305–12.
DiGregorio AM, Alvey H. Gastrointestinal bleeding. In: StatPearls
[Internet]. Treasure Island: StatPearls Publishing; 2020.
Funaki B. On-call treatment of acute gastrointestinal hemorrhage.
Semin Intervent Radiol. 2006;23(3):215–22.
Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD,
et al. Superselective microcoil embolization of colonic hemor-
rhage. AJR Am J Roentgenol. 2001;177(4):829–36.
Gaieski D, Mikkelsen M. Definition, classification, etiology, and
pathophysiology of shock in adults. In: UpToDate, Parsons PE
(Ed), Finlay G (DepEd), UpToDate, Waltham, MA.
Ghassemi KA, Jensen DM. Lower GI bleeding: epidemiology and
management. Curr Gastroenterol Rep. 2013;15(7):333.
774 C. Barnett

Gunjan D, Sharma V, Rana SS, Bhasin DK. Small bowel bleed-

ing: a comprehensive review. Gastroenterol Rep (Oxf).
2014;2(4):262–75.
Hooper N, Armstrong TJ. Hemorrhagic shock. In: StatPearls
[Internet]. StatPearls Publishing; 2019.
Hur S, Jae HJ, Lee M, Kim H-C, Chung JW. Safety and efficacy of
transcatheter arterial embolization for lower gastrointestinal
bleeding: a single-center experience with 112 patients. J Vasc
Interv Radiol. 2014;25(1):10–9.
Ierardi AM, Urbano J, De Marchi G, Micieli C, Duka E, Iacobellis F,
et al. New advances in lower gastrointestinal bleeding manage-
ment with embolotherapy. Br J Radiol. 2016;89(1061):20150934.
Jacovides CL, Nadolski G, Allen SR, Martin ND, Holena DN, Reilly
PM, et al. Arteriography for lower gastrointestinal hemorrhage:
role of preceding abdominal computed tomographic angiogram
in diagnosis and localization. JAMA Surg. 2015;150(7):650–6.
Kim CY, Suhocki PV, Miller MJ, Khan M, Janus G, Smith
TP. Provocative mesenteric angiography for lower gastrointes-
tinal hemorrhage: results from a single-institution study. J Vasc
Interv Radiol. 2010;21(4):477–83.
Oppenheimer J, Ray CE, Kondo KL. Miscellaneous pharmaceuti-
cal agents in interventional radiology. Semin Intervent Radiol.
2010;27(4):422–30.
Peck DJ, McLoughlin RF, Hughson MN, Rankin RN. Percutaneous
embolotherapy of lower gastrointestinal hemorrhage. J Vasc
Interv Radiol. 1998;9(5):747–51.
Pham T, Tran BA, Ooi K, Mykytowycz M, McLaughlin S, Croxford
M, et al. Super-selective mesenteric embolization provides
effective control of lower GI bleeding. Radiol Res Pract.
2017;2017:1074804.
Qayed E, Dagar G, Nanchal RS. Lower gastrointestinal hemorrhage.
Crit Care Clin. 2016;32(2):241–54.
Ramaswamy RS, Choi HW, Mouser HC, Narsinh KH, McCammack
KC, Treesit T, et al. Role of interventional radiology in the
management of acute gastrointestinal bleeding. World J Radiol.
2014;6(4):82–92.
Ray DM, Srinivasan I, Tang S-J, Vilmann AS, Vilmann P, McCowan
TC, et al. Complementary roles of interventional radiology and
therapeutic endoscopy in gastroenterology. World J Radiol.
2017;9(3):97–111.
 51 Lower Gastrointestinal Bleeding 775

Speir EJ, Ermentrout RM, Martin JG. Management of Acute

Lower Gastrointestinal Bleeding. Tech Vasc Interv Radiol.
2017;20(4):258–62.
Strate L. Approach to acute lower gastrointestinal bleeding in
adults. In: UpToDate, Saltzman JR (Ed), Shilpa G (DepEd),
UpToDate, Waltham, MA.
Tan K-K, Strong DH, Shore T, Ahmad MR, Waugh R, Young
CJ. The safety and efficacy of mesenteric embolization in the
management of acute lower gastrointestinal hemorrhage. Ann
Coloproctol. 2013;29(5):205.
Walker TG, Salazar GM, Waltman AC. Angiographic evaluation
and management of acute gastrointestinal hemorrhage. World J
Gastroenterol. 2012;18(11):1191–201.
Walker TG. Mesenteric vasculature and collateral pathways. Semin
Intervent Radiol. 2009;26(3):167–74.
Zahid A, Young CJ. Making decisions using radiology in lower GI
hemorrhage. Int J Surg. 2016;31:100–3.
Chapter 52
Uterine Artery
Embolization – Vascular
Emergency
Kartik Kansagra and Cuong H. Lam

Evaluating the Patient

What is the Assess for hemodynamic stability using
first step when vital signs. Look for low blood pressure with
evaluating the tachycardia, orthostatic hypotension
patient?
What are key labs Chemistry panel, CBC, Cr, lactate, type and
to order to aid in screen, PT, PTT, INR.
the work up and
management?
What is the Establish 2 large bore IVs and begin IV
transfusion fluids
approach to Once available initiate mass transfusion
consider when protocol per the results of the PROPPR trial
patient is
unstable?
(continued)

K. Kansagra (*) · C. H. Lam

Kaiser Permanente Los Angeles Medical Center, Vascular and
Interventional Radiology, Los Angeles, CA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 777

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_52
778 K. Kansagra and C. H. Lam

In the setting Pelvic banding or wrapping should be

of trauma what initiated immediately
else should be
considered?
What are Tranfuse to keep Hgb > 7 g/dL. For patients
transfusion with CAD and hemodynamic instability
thresholds to use? transfuse to keep Hgb > 8–9 g/dL
Transfuse to keep platelets > 50000 per uL
or with signs of bleeding
Tranfuse to keep INR < 1.5
At times for unstable patients or acute large
volume of hemorrhage transfusion may be
required even with hgb level at 8 or 9
What imaging CT Angiogram may show extravasation but
modalities can be also will help elucidate the arterial anatomy.
considered as part May also aid with diagnosing the etiology
of the evaluation?
What Primary: blood loss > 500 cc within 24 hours
differentiates of delivery
primary from Secondary: Excessive vaginal bleeding
secondary PPH? occurring from within 24 hours and lasting
up to 6 weeks after delivery
What are Uterotonics (oxytocin), manual massage,
emergent or prostaglandins, coagulopathy correction,
medical options balloon tamponade of uterus, surgical
to consider when exploration/repair, compression sutures
treating significant
postpartum
bleeding?
 52 Uterine Artery Embolization – Vascular Emergency 779

At what Emergent UAE

timepoints may Bilateral hypogastric artery balloon
endovascular placement for insufflation during delivery or
therapies be surgery
utilized? UAE prior to surgery
UAE after delivery and prior to medical
management or surgery (uterine-­preserving
cesarean)
 As opposed to extirpative surgical
management (cesarean hysterectomy;
complicated by possible catastrophic
bleeding), conservative c-section with
the placenta left in-situ allows for the
possibility of placental involution and
medical management with methotrexate,
though is prone to complications of sepsis
and delayed hemorrhage
What are the Emergent hysterectomy, uterine artery
surgical options? ligation

High Yield History

What are causes of Postpartum hemorrhage, tumor-related
significant uterine bleeding, abnormal placentation,
bleeding? ectopic pregnancy related hemorrhage,
massive abnormal uterine bleeding
related to fibroids, malformation
(acquired or congenital), and trauma
What is considered Bleeding that is > 500 cc in vaginal
significant postpartum delivery and > 1000 cc in cesarean
hemorrhage? delivery
What is the leading cause Trauma. The major risk factor for poor
of death in patients outcomes are related to hemorrhagic
younger than 44? shock
What proportion MAP is a life-threatening condition
of patients with with a maternal mortality rate near 7%.
MAP require blood 90%. 40% require more than 10 units
transfusion?
780 K. Kansagra and C. H. Lam

Indications/Contraindications
What are indications Preoperative prior to delivery in the
for emergent uterine setting of abnormal placentation
artery embolization? Trauma with persistent or recurrent
hemodynamic shock, ongoing
hemorrhage, CT evidence of contrast
extravasation, large or expanding
retroperitoneal hematoma identified on
laparotomy, penetrating trauma
Bleeding from any of the above-­
mentioned etiologies that is clinically
significant
What are Absolute: In the setting of trauma
contraindications to hemoperitoneum requires surgical
the procedure? exploration
Relative: Pregnancy

Relevant Anatomy
Where does the uterine It is a branch off the anterior division
artery traditionally of the internal iliac artery
originate?
What anatomic arterial Uterine-ovarian anastomoses. These
variants must you be are even more clinically relevant when
cognizant of? utilizing permanent embolic agents

Relevant Materials
What type of embolic Polyvinyl alcohol particles (PVA),
agents should be embolic microspheres, coils, Onyx,
readily available? gelfoam, vascular plugs, N-butyl
2-cyanoacrylate glue
 52 Uterine Artery Embolization – Vascular Emergency 781

What size particles are 300–500 um or 500–700 um diameter

often used for uterine particles. Smaller particles have the
artery embolization? advantage of more distal occlusion thus
reducing the chance of collateral flow

General Step by Step

What access options The traditional access site was the femoral
are available? artery; however, with newer tools radial is
a reasonable alternative. Also available is
brachial access
What are the First a pelvic angiogram is usually
general steps for performed with a flush catheter to identify
emergent uterine the origin of the uterine artery. Then
artery embolization? a 4 or 5 French catheter is guided into
the internal iliac artery. A microcatheter
system is advanced coaxially through the 4
or 5 French catheter to perform selective
angiography of the uterine artery. The
entire vaginal canal should be visualized
and any intrauterine balloons should
be deflated during angiography. The
microcatheter is then utilized to administer
the embolic agent of choice
What is the It helps to identify any collateral feeders
purpose of the from the ovarian and inferior epigastric
post- embolization arteries
aortogram?
What is the Persistent column of contrast beyond 5
angiographic heart beats
endpoint of
treatment?
782 K. Kansagra and C. H. Lam

Complications
What are common Pain, non-target embolization resulting
complications in possible buttock ischemia, small bowel
of embolization necrosis, ovarian infarction, vaginal or
therapy? cervical necrosis, or bladder necrosis,
access site complications (hematoma and
pseudoaneurysm), vaginal discharge (ensure
not purulent)
What is post- Expected post-procedure syndrome
embolization manifesting with abdominal pain, fever,
syndrome? nausea, leukocytosis, and vomiting
Are there Case series have reported temporary
any possible neuropathy of the sciatic nerve, perineal
neurological paralysis, and lower limb numbness and
complications? paresthesias. However, the most common
long-term neurologic complication is mild
buttock numbness

Landmark Research
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE,
Podbielski JM, et al. Transfusion of plasma, platelets, and red
blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients
with severe trauma: The PROPPR randomized clinical trial.
JAMA - J Am Med Assoc. 2015;313(5):471–82.
• 680 patients with severe trauma injury receiving massive
transfusion randomized to a 1:1:1 ratio of
plasma:platelets:RBC to a 1:1:2 ratio.
• There was no difference in mortality at 24 hours or 30 days
between a 1:1:1 and 1:1:2 protocol.
• 1:1:1 group had greater proportion of hemostasis and
lower mortality due to exsanguination at 24 hours.
Sentilhes L, et al. Predictors of Failed Pelvic Arterial
Embolization for Severe Postpartum Hemorrhage. Obstetrics
and Gynecology. 2009; 113: 992–999.
 52 Uterine Artery Embolization – Vascular Emergency 783

• 100 patients over 13 years.

• Clinical success in 89% of patients.
• Patients who failed embolization had a higher rate of esti-
mated blood loss and higher transfusion requirements,
which may indicate delay in seeking endovascular
options for management.
Doumouchtsis, S, et al. Menstrual and Fertility Outcomes
Following the Surgical Management of Postpartum
Haemorrhage: A Systematic Review. British Journal of
Oncology. 2014; 121: 382–388.
• 28 studies included.
• Approximately 92% of patients resumed menstruation.
• 75% of patients achieved conception following
embolization.
• Number and quality of available evidence is of concern.
Lee, et al. Outcomes of Balloon Occlusion in the University
of California Morbidly Adherent Placenta Registry. American
Journal of Obstetrics and Gynecology MFM. 2020 Feb; 2(1):
1–10.
• 5 centers, 171 patients.
• Aortic and iliac artery balloon occlusion are associated
with decreased EBL, transfusions, ICU admissions, and
adverse events compared to internal iliac artery ligation or
no adjunctive interventions.
Wang, et al. Uterine Artery Embolization following
Cesarian Delivery but prior to Hysterectomy in the
Management of Patients with Invasive Placenta. JVIR. 2019;
30: 687–691
• UAE following cesarian delivery but before hysterectomy
in patients with placenta increta appears to be safe and
effective in decreasing EBL, transfusion requirements, and
length of ICU stay compared with cesarean-hysterectomy
alone.
784 K. Kansagra and C. H. Lam

Common Questions
What are causes of Postpartum hemorrhage, tumor related
significant uterine bleeding, abnormal placentation, ectopic
bleeding? pregnancy related hemorrhage, massive
abnormal uterine bleeding related to
fibroids, and trauma
Why is the incidence Increasing performance of uterine
of MAP increasing? instrumentation
What branch of The anterior division
Internal iliac does the
uterine traditionally
come off of?
What is the It is a temporary embolic agent
benefit of gel foam
embolization?

Further Reading
Browne RFJ, McCann J, Johnston C, Molloy M, O’Connor H,
McEniff N. Emergency selective arterial embolization for con-
trol of life-threatening hemorrhage from uterine fibroids. Am J
Roentgenol. 2004;183(4):1025–8.
Gonsalves M, Belli A. The role of interventional radiology in obstet-
ric hemorrhage. Cardiovasc Intervent Radiol. 2010;33(5):887–95.
Kandarpa K, Machan L. Handbook of interventional radiologic pro-
cedures. 4th ed; 2015.
Kim T-H, Lee H-H, Kim J-M, Ryu A-L, Chung S-H, Seok LW. Uterine
artery embolization for primary postpartum hemorrhage. Iran J
Reprod Med [Internet]. 2013;11(6):511–8.
Obata S, Kasai M, Kasai J, Seki K, Sekikawa Z, Torimoto I, et al.
Emergent uterine arterial embolization using n-butyl cyanoacry-
late in postpartum hemorrhage with disseminated intravascular
coagulation. Biomed Res Int. 2017;2017(Table 1).
Razavi M, Wolanske KA, Hwang GL, Sze DY, Kee ST, Dake
MD. Angiographic classification of ovarian artery-to-uterine
artery anastomoses: initial observations in uterine fibroid emboli-
zation. Radiology. 2002;224(3):707–12.
Chapter 53
Contrast Reactions
Matthew Czar Taon

Describe the The prednisone-based regimen

prednisone-based and involves administering 50 mg
methylprednisolone-­ prednisone by mouth at 13 hours,
based oral premedication 7 hours, and 1 hour before contrast
regimens for allergic medium administration, plus 50 mg
and allergic-like contrast diphenhydramine intravenously,
reactions intramuscularly, or by mouth
1 hour before contrast medium
administration.
The methylprednisolone-based
regimen involves administering
32 mg methylprednisolone by
mouth 12 hours and 2 hours before
contrast medium administration
with an option to include 50 mg
diphenhydramine.
(continued)

M. C. Taon (*)
Kaiser Permanente Los Angeles Medical Center,
Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 785

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_53
786 M. C. Taon

What are the Acute adverse events can be

classifications of acute categorized into allergic-like or
adverse events related to physiologic adverse events. They
contrast administration? can be further organized by severity
into mild, moderate, or severe
events. Distinguishing allergic-like
reactions from physiologic reactions
is important because allergic-­
like reactions may require future
premedication with steroids whereas
physiologic reactions do not require
premedication.
In what situations A patient who can take nothing by
should accelerated mouth (NPO). An outpatient with
intravenous contrast-­ a prior allergic-like or unknown
allergy premedication be reaction to the same class of contrast
considered? medium who has not received
premedication and whose exam
or procedure cannot be easily
rescheduled.
An emergency department patient or
inpatient with a prior allergic-like or
unknown reaction to the same class
of contrast medium in whom the use
of 12- or 13-hour premedication will
adversely delay care.
What clinical signs or Progressive swelling or pain, altered
symptoms associated tissue perfusion, decreased capillary
with severe contrast refill at any time after contrast
extravasation warrant a extravasation, development of focal
surgical consultation? paresthesia, change in sensation in
the affected limb, worsening passive
or active range of motion, or skin
ulceration or blistering.
 53 Contrast Reactions 787

Which patients are at Patients undergoing dialysis and

highest risk of developing those with stage 4 (glomerular
nephrogenic systemic filtration rate, 30–40 mL/min per
fibrosis? 1.73 m2) or stage 5 (glomerular
filtration rate < 30 mL/min per
1.73 m2) chronic kidney disease.
If a post-contrast patient Administer the following:
develops hives or  Oxygen at a rate of 6–10 L/min via
diffuse erythema with face mask
associated hypotension or  0.9% Normal saline (NS) wide
respiratory distress, what open
steps must be taken?  Epinephrine 0.3 cc of 1:1000 IM
(or autoinjector) or Epinephrine
1 cc of 1:10,000 IV with slow flush
or IV fluids
Elevate the legs > 60° and
considering calling 911 or CODE
BLUE based on severity.
If a post-contrast patient Preserve IV access, monitor vitals
develops hypotension q 15 m, and elevate the legs > 60
with tachycardia degrees. Administer the following:
(anaphylactoid reaction),  Oxygen 6–10 L/min via face mask
what steps must be  0.9% NS wide open
taken?  Epinephrine 0.3 cc of 1:1000 IM
(or autoinjector) or Epinephrine
1 cc of 1:10,000 IV with slow flush
or IV fluids
Considering calling 911 or CODE
BLUE based on severity.
What are the hallmarks of Hypotension with bradycardia (heart
a vasovagal reaction? rate < 60).
(continued)
788 M. C. Taon

If a post-contrast Preserve IV access and monitor vitals.

patient develops Administer the following:
expiratory wheezing and  Oxygen 6–10 L/min via face mask.
hypoxia, suggestive of  Beta-2 agonist inhaler (Albuterol
bronchospasm, what steps 90 mcg/puff) 2 puffs; repeat x 3.
must be taken?  If not responding or severe, then
use Epinephrine 0.3 cc of 1:1000
IM (or autoinjector) OR Epi 1 cc
of 1:10,000 IV with slow flush or
IV fluids 5.
Consider calling 911 or CODE
BLUE based on severity.
If a post-contrast patient Preserve IV access and monitor
develops stridor or vitals. Administer oxygen 6–10 L/
hypoxia, suggestive of min via face mask and Epinephrine
laryngeal edema, what 0.3 mL of 1:1000 IM (or autoinjector)
steps must be taken? or Epinephrine 1 mL of 1:10,000
IV with slow flush or IV fluids.
Considering calling 911 or CODE
BLUE based on severity.

Further Reading
Abu-Alfa AK. Nephrogenic systemic fibrosis and gadolinium-­based
contrast agents. AdvChronicKidney Dis. 2011;18(3):188–98.
ACR Manual on Contrast Media, Version 10.3 2018. ACR Committee
on Drugs and Contrast Media. American College of Radiology.
ISBN: 978–1–55903-012-0.
Beckett KR, Moriarity AK, Langer JM. Safe use of contrast
media: what the radiologist needs to know. Radiographics.
2015;35(6):1738–50.
Cohan RH, Leder RA, Bolick D, et al. Extravascular extravasation
of radiographic contrast media. Effects of c­ onventional and low-
osmolar agents in the rat thigh. Investig Radiol. 1990;25(5):504–10.
Greenberger PA, Patterson R. The prevention of immediate gen-
eralized reactions to radiocontrast media in high-risk patients. J
Allergy Clin Immunol. 1991;87(4):867–72.
Lasser EC, Berry CC, Mishkin MM, Williamson B, Zheutlin
N, Silverman JM. Pretreatment with corticosteroids to pre-
 53 Contrast Reactions 789

vent adverse reactions to nonionic contrast media. AJR Am J

Roentgenol. 1994;162(3):523–6.
Memolo M, Dyer R, Zagoria RJ. Extravasation injury with nonionic
contrast material. AJR Am J Roentgenol. 1993;160(1):203–4.
Peak AS, Sheller A. Risk factors for developing gadolinium-­
induced nephrogenic systemic fibrosis. Ann Pharmacother.
2007;41(9):1481–5.
 Part IX
Lymphatic
Chapter 54
Thoracic Duct
Embolization
Kyle A. Wilson and Bill S. Majdalany

Evaluating the Patient

What objective Fluid triglycerides should be > 110 mg/dL
criteria are used and the cholesterol should be less than the
to diagnose a true serum cholesterol.
chylous effusion? The specific gravity of the fluid should be
> 1.012.
Effusion should contain chylomicrons.
Cell differential is often > 70%
lymphocytes.
Patients on a low-fat diet or total
parenteral nutrition (TPN) may not meet
these criteria, but may still have a chylous
effusion
What labs should Fluid analysis of the effusion to confirm
be obtained prior to the diagnosis of chylothorax, coagulation
TDE? profile (PT/INR and PTT), complete
blood count
(continued)

K. A. Wilson (*) · B. S. Majdalany

Michigan Medicine, University of Michigan, Department of
Radiology, Ann Arbor, MI, USA

© Springer Nature Switzerland AG 2022 793

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_54
794 K. A. Wilson and B. S. Majdalany

What are the most Most commonly, pleural effusions present

common patient with dyspnea, chest pain, fever, and fatigue
symptoms and are all common symptoms. Frequently,
presentations of unilateral or bilateral chest tubes will be in
a chylous pleural place post-operatively.
effusion?
What imaging should A chest X-ray can screen for pleural
be reviewed prior to effusions and exclude alternative causes of
TDE or TDD? dyspnea.
Reviewing cross-sectional abdominal
imaging is helpful to exclude anatomic
abnormalities (abdominal aortic aneurysm
(AAA), horseshoe kidney, etc.) and plan a
safe access.
Lymphangiography is usually adequate to
diagnose traumatic chylous effusions.
In the setting of non-traumatic chylous
effusion, magnetic resonance (MR)
lymphangiography may be helpful
to detect masses, collaterals, leaks, or
retrograde lymphatic flow prior to the
procedure.
What position does The patient will be supine. It is helpful
the patient need to to assess the patient’s pulmonary reserve
maintain? in the supine position. If dorsal pedal
lymphangiography will be performed, their
feet should hang off the end of the table at
the ankles for greater patient comfort.
 54 Thoracic Duct Embolization 795

High Yield History

Define a Traumatic chylous effusions are attributable
traumatic chylous to recent trauma, often as a complication of
effusion, and cardiothoracic or neck surgeries.
give examples Examples include esophagectomy,
of traumatic thyroidectomy, and pulmonary resections.
etiologies. TDE and TDD have higher clinical success
rates for traumatic compared to non-­
traumatic chylous effusions.
Define a non-­ Non-traumatic chylous effusions are not
traumatic chylous associated with recent trauma, surgery, or
effusion, and instrumentation.
give examples of They may be caused by malignancy (e.g.,
non-traumatic lymphoma, mesothelioma, lung cancer,
etiologies. and multiple myeloma), lymphatic
vessel disease (e.g., Gorham disease,
lymphangiomyomatosis, Kaposiform
lymphangiomatosis) congenital disorders,
systemic diseases (e.g., SLE, Behçet disease),
infection (e.g., TB), disorders of lymphatic
conduction (e.g., heart failure or liver
cirrhosis), and idiopathic disease.
Lymph leaks can result from vessel
malformation or masses.
TDE and TDD have lower clinical success
rates in this patient population when
compared to patients with traumatic chylous
effusions.
What Patients can be placed on a medium-chain
conservative fatty acid diet or made nil per os and placed
therapies can be on TPN.
used to manage Octreotide may also be administered.
chylous effusion? If conservative therapy is successful (reported
rates vary from 16–80%), the effusion should
resolve in two to three weeks.
(continued)
796 K. A. Wilson and B. S. Majdalany

What surgical Thoracic duct ligation and pleurodesis are

therapies can be performed to treat chylous effusion.
used to manage a When performed as an open surgery, this
chylous effusion? procedure has a 2.1% mortality rate and a
38.8% morbidity rate.
Serial thoracentesis or placement of a drain
can palliate chylothorax.
What are the Major loss of chyle can result in weakness,
complications of dehydration, nutritional deficits and
chylous effusion? metabolic disturbances, cachexia, edema,
immunosuppression and hemodynamic
distress as the result of hypoproteinemia,
hyponatremia, and lymphopenia.
Mortality may be as high as 50%.

Indications/Contraindications
What threshold of Typically, daily chylous output
daily chyle output is < 500 mL/day can be managed
typically required before conservatively, and so procedural
procedural interventions interventions are considered once the
are considered? daily output is > 500 mL/day.
If the output does not decrease with
conservative measures or persists
for greater than two weeks, more
aggressive therapy may be warranted.
What are the absolute Uncontrollable coagulopathy and
contraindications to AAA or any other pathology that
TDE/TDD? would preclude percutaneous
abdominal access are the only
absolute contraindications to
percutaneous, transabdominal TDE/
TDD.
Note that, in patients with AAA, the
thoracic duct may be accessed and
embolized in a retrograde fashion via
the subclavian vein.
 54 Thoracic Duct Embolization 797

What are the relative Allergy to any of the necessary

contraindications to materials is a contraindication to the
TDE? procedure.
Right-to left cardiac shunts and
severe pulmonary disease, especially
pulmonary hypertension, can increase
the likelihood that pulmonary artery
embolization will be symptomatic.
A history of thoracic radiation can
increase the possibility left-to-right
shunt and cerebral embolization.
What are the relative Although cases of accidental aortic
contraindications to puncture have been reported without
TDD? significant harm to the patient, TDD
has historically not been attempted on
ducts that are too near the aorta due
to the risk of repeated aortic puncture
and maceration.
TDD should only be attempted when
a clear target is visualized. Therefore,
poorly opacified ducts are a relative
contraindication to the procedure.

Relevant Anatomy
What are the three The lymphatic system can be divided into
distinct divisions the soft tissue or peripheral lymphatics,
of the lymphatic the intestinal lymphatics, and the liver
system and which lymphatics. The intestinal and liver
produce the lymphatics produce approximately 80% of
majority of the the lymph. The intestinal system absorbs
lymph in the human dietary fats and the liver system transports
body? hepatic-derived proteins to systemic
circulation.
(continued)
798 K. A. Wilson and B. S. Majdalany

What is the function The lymphatic system collects excess

of the lymphatic interstitial protein and fluid and returns
system? it to the venous system. It is necessary to
preserve tissue oncotic and hydrostatic
pressure and fluid homeostasis.
Describe the The lymphatic primordia originate as small
embryonic sacs from the veins of the jugular-axillary
development of the region, retroperitoneum, mediastinum, and
lymphatic system. pelvis. The sacs ultimately fuse, and their
venous connections are obliterated, except
at the junctions of the internal jugular and
subclavian veins.
What is chyle? Chyle is an odorless, alkaline, sterile, milky
appearing fluid produced primarily by
the intestines. It contains proteins, lipids,
electrolytes, and lymphocytes.
Describe the The cisterna chyli is a polymorphous sac,
position of the 2–16 mm in diameter, that arises from the
cisterna chyli. left lumbar, intestinal, and occasionally
right lumbar lymphatic trunks.
It is usually found at L1-L2, between the
aorta and the IVC.
All three divisions of the lymphatic system
ultimately converge on the cisterna chyli.
Describe the The thoracic duct is a 2–6 mm wide
position of the structure that arises from the cisterna
thoracic duct. chyli below the diaphragm and extends
as long as 45 cm in a cephalad direction
before emptying into the junction of
the left internal jugular and subclavian
veins. It courses from retroperitoneum to
mediastinum through the aortic hiatus, and
lies between the aorta and azygous vein. It
usually crosses from the right of midline to
the left at T5.
The thoracic duct is known to have
multiple, parallel channels in 40–60% of
cases.
 54 Thoracic Duct Embolization 799

What is the flow The thoracic duct carries 1.5–4 L of fluid

rate of the thoracic per day.
duct? It drains the left hemithorax, left arm, left
half of the head, and everything below the
diaphragm – comprising approximately
80% and 90% of the lymph from the body.
Which regions are The right lymphatic duct drains the right
drained by the right hemithorax, right arm, and right half of the
lymphatic duct? head.
It drains into the junction of the right
internal jugular and subclavian veins.
Describe the The inguinal lymph nodes lie inferior to
position of the the inguinal ligament, and are divided into
inguinal lymph superficial and deep nodes by the fascia
nodes. lata and cribiform fascia.
The superficial nodes lie within a triangle
created by the inguinal ligament, sartorius,
and adductor longus and drain to the deep
inguinal nodes through the saphenous
hiatus and the cribiform fascia.
The deep inguinal nodes lie medial to the
femoral vein.

Relevant Materials
What lymphatic indicator Methylene blue or 1% isosulfan
dyes are used to opacify pedal blue may be injected in the web
lymphatic vessels during pedal spaces of the toes.
lymphangiography?
(continued)
800 K. A. Wilson and B. S. Majdalany

What type of contrast medium Nonionic, oil-based contrast

should be used to opacify the medium should be used
lymphatic vasculature during to opacify the lymphatic
lymphangiography? vasculature as water-soluble
contrast medium will leak out of
the ducts.
Currently, the only commercially
available contrast medium for
this purpose is Lipiodol.
What needle is used for A flexible 21–22 gauge needle
percutaneous abdominal access (Chiba) with inner stylet, usually
of the cysterna chylii? 15–20 cm long
What wire is used to access A stiff, 0.018 inch microwire (e.g.
the thoracic duct or large V-18, Transcend, etc.)
retroperitoneal lymphatic
trunks?
What catheter is initially used A range of 1.9–3.0 Fr
to access and embolize the microcatheters may be used.
thoracic duct?
What materials may be used to Microcoils and n-Butyl-2-­
embolize the thoracic duct? cyanoacrylate (NBCA) glue are
most commonly used.
Coils are typically used alone or
as a matrix upon which the glue
polymerizes.

General Step by Step

What antibiotic Gram positive coverage (e.g., cefazolin
prophylaxis is or clindamycin) prior to dorsal pedal
necessary prior to the lymphangiography as prophylaxis
procedure? against skin flora
Gram negative coverage (e.g.,
levofloxacin or second- or third-­
generation cephalosporins) prior to
abdominal puncture as prophylaxis
against gastrointestinal flora
 54 Thoracic Duct Embolization 801

What scout images Because early opacification of small

are necessary prior to lymphatic channels can be subtle, scout
lymphangiography? images of the chest and abdomen,
including obliques, should be obtained
prior to lymphangiography.
Describe dorsal pedal Dorsal pedal lymphangiography is
lymphangiography. performed by injecting a suitable dye
(see above) and cutting down on the
lymphatic vessels of the foot. Once
skeletonized, they are cannulated with a
30-gauge needle.
Lipiodol is infused at a rate of 5–8 mL/
hr up to 15 mL, followed by up to
20 mL of normal saline to facilitate the
opacification of the cisterna chylii and
thoracic duct.
Upon the completion of the procedure,
the wound should be closed with
vertical mattress sutures to reduce
tension on the incision.
Massaging the medial leg and thigh
can help propel the contrast cephalad
and reduce the overall time of the
procedure.
If unilateral dorsal pedal
lymphangiography is performed, the
right side is preferred as it is more likely
to opacify retroperitoneal ducts that
are a safe distance from the aorta for
percutaneous access.
(continued)
802 K. A. Wilson and B. S. Majdalany

Describe transnodal Transnodal (a.k.a. intranodal)

lymphangiography. lymphangiography is performed by
using real-time ultrasound guidance
and a 22–30 gauge needle to puncture
the inguinal lymph nodes at a shallow
angle, which reduces the likelihood of
needle dislodgement. The needle tip
is optimally located at the junction of
the cortex and the medulla to prevent
contrast extravasation or injection of
the vein.
3–12 mL of iodinated contrast oil is
then hand-injected at a rate of 0.1–
0.2 mL/min.
As with dorsal pedal lymphangiography,
saline can follow the Lipiodol to help
advance the contrast column into the
retroperitoneum. This is now the more
commonly performed technique.
What is the maximum Keeping the dose to a maximum of
recommended dose of 20 mL in adults reduces the likelihood
Lipiodol during a single of pulmonary artery embolization.
procedure? Why?
How is the progress The progress of lymphangiography
of lymphangiography should be monitored by serial,
tracked? overlapping images to ensure that the
entire lymphatic system is imaged.
Images should be obtained at
5–10 minute intervals in the leg
and thigh (when dorsal pedal
lymphangiography is used), 5 minute
intervals in the pelvis, and 3–5 minute
intervals in the abdomen.
What is the location Transabdominal access of the cisterna
of the percutaneous chyli or thoracic duct is achieved right
transabdominal of midline, 5–10 cm below the xiphoid
puncture site? and cephalad to the transverse colon.
The duct is accessed against the anterior
vertebral body.
 54 Thoracic Duct Embolization 803

Where else can the When no suitable abdominal targets

thoracic duct be can be identified, the thoracic duct may
accessed? be accessed in a retrograde fashion by
direct puncture of a cervical portion
of the duct, or through a transvenous
approach at the left jugulo-subclavian
venous angle.
How is the thoracic Digital subtraction lymphangiography is
duct imaged after performed by hand injection of <10 mL
catheterization? of a non-ionic iodinated contrast
centered on the upper abdomen and
chest to show the entire length of the
thoracic duct.
Describe the process of After successful needle puncture and
TDE. wire access into the thoracic duct, the
needle is exchanged for a microcatheter
above the level of the leak (when
possible) and multiple coils are
deployed across the leak. Thereafter, the
embolization can be augmented with a
liquid embolic agent, most commonly
glue.
What is TDD? Thoracic duct disruption is a misnomer,
as the process is typically performed on
small retroperitoneal lymphatic ducts
and their associated collaterals.
It is the process of probing, twisting,
and twiddling a needle to macerate
the retroperitoneal lymphatic vessels,
producing an inflammatory reaction and
a small hematoma.
This ultimately slows lymphatic
flow through the duct. Thoracic duct
disruption should be used if the
lymphatic ducts cannot be successfully
cannulated and embolized.
(continued)
804 K. A. Wilson and B. S. Majdalany

How should patients Initially, it is easiest to follow the output

be followed after the of chyle from a drain, if present.
procedure? Once the drain has been removed,
serial chest radiographs will reveal the
re-accumulation of chylothorax, if any.

Complications
What minor complications While some authors have
have been reported reported no minor complications
because of attempted in their patient cohort, others
lymphangiography and have reported asymptomatic
thoracic duct embolization? glue embolization of the
pulmonary artery, asymptomatic
glue embolization of the
portal vein, leg edema, pedal
suture dehiscence and wound
infection (where dorsal pedal
lymphangiography was used),
bile leakage and perihepatic
hematoma (where transhepatic
access of the cisterna chyli is
employed), shearing of guidewire
with retained fragments in the
retroperitoneum, hematoma at
the percutaneous access site,
periaortic hematoma, and chronic
diarrhea.
The acute complication rate
is 2–6%, while the long-term
complication rate is as high as
14%.
Needle puncture of interposed
viscera and the aorta have both
been described, but often do
not lead to clinically significant
complications.
 54 Thoracic Duct Embolization 805

What major complications While some authors have

have been reported reported no major complications
because of attempted in their patient cohort, others
lymphangiography and have reported symptomatic
thoracic duct embolization? glue embolization to the
pulmonary artery, pedal wound
infection (where dorsal pedal
lymphangiography is performed),
venous thromboembolism,
cerebral embolization, and death.

Landmark Research
Itkin M, Nadolski GJ. Modern techniques of lymphangiogra-
phy and interventions: current status and future develop-
ment. Cardiovasc Intervent Radiol. 2018; 41:366-76. doi:
https://doi.org/10.1007/s00270-­0 17-­1863-­2.
• Dynamic, contrast-enhanced MR lymphangiography
(DCMRL) is the process of using transnodal lymphangi-
ography to deliver gadolinium-based contrast into the
central lymphatics prior to MR imaging.
• Ongoing research suggests that TD access and drainage
may be useful to induce cellular immunodeficiency to treat
organ rejection or autoimmune disease, to harvest lym-
phocytes for autologous transplant, as an acute therapy to
remove excess fluid in the setting of heart failure or
hepatic cirrhosis, and to reduce the delivery of toxic meta-
bolic products from the intestine to the lungs to avoid
“gut-lung syndrome.”

Common Questions
What is the incidence The incidence of chylothorax is
of chylothorax? estimated at 1/6000 hospital admissions,
and is reported as high as 11.8% post-­
esophagectomy.
(continued)
806 K. A. Wilson and B. S. Majdalany

What size must a Most ducts > 2 mm in diameter can be

lymphatic duct be to successfully catheterized.
warrant attempted
catheterization?
Why is transnodal Transnodal lymphangiography is less
lymphangiography technically demanding, does not require
superseding a specific needle or injector, carries
dorsal pedal a lower risk of needle dislodgment,
lymphangiography requires neither a skin incision nor
as the preferred sutures, and reduces the volume of
technique? contrast and length of the procedure
since the leg lymphatics are excluded.
What are the four The four lymphangiographic
lymphangiographic presentations of non-traumatic chylous
presentations of non-­ effusion are (1) normal thoracic duct,
traumatic chylous (2) occlusion of the thoracic duct,
effusion, and how do (3) failure to opacify the thoracic
their clinical success duct, and (4) extravasation of chyle.
rates with TDE differ? The clinical success rates of thoracic
duct embolization given these
lymphangiographic presentations are
16%, 75%, 16%, and 50%, respectively.
How long does the With normal anatomy and an
procedure, from experienced operator, thoracic duct
lymphangiography embolization can take about two
to successful thoracic hours. The procedure is often longer,
duct embolization, necessitating careful attention to patient
usually take? positioning and comfort at the outset.
Consider placing a wedge beneath the
patient’s back or head for comfort.
What evidence The ability to catheterize the thoracic
suggests that the duct or retroperitoneal lymphatic ducts
procedure has or will is correlated with a higher cure rate.
succeed? A reduction in chylous output to 45%
of daily pre-procedural volume 24 hours
after the procedure has also been
correlated with clinical success.
 54 Thoracic Duct Embolization 807

What is the clinical Clinical success rates of 37–71% have

success rate of been reported for lymphangiography
lymphangiography alone in the setting of traumatic chylous
alone for chylous effusions with a daily output no greater
effusion? than 500 mL/day and no identifiable
leak on fluoroscopy.
The median time to resolution is
approximately 14 days.
What is the clinical When used for traumatic chylous
success rate of effusion, the clinical success rate of
lymphangiography lymphangiography and thoracic duct
and TDE for chylous embolization has been reported between
effusion? 72% and 91%.
The median time to resolution is
approximately 3 days.
What is the clinical The clinical success rate of transnodal
success rate for lymphangiography and TDD is not
lymphangiography and as high as that of TDE, and has been
TDD for chylothorax? reported in the range of 13–74%.
The median time to resolution is
approximately 7 days.
What are the benefits TDE or TDD can be performed under
of TDE or TDD for local anesthesia and conscious sedation,
chylous effusion? avoiding the risks of general anesthesia.
Thoracic duct opacification can help
identify anomalous lymphatic vessels
that may also contribute to an effusion.
All of the contributing vessels can then
be embolized directly.
The morbidity and mortality of
percutaneous techniques is generally less
than that of surgical intervention and
therefore can be performed immediately
upon the identification of a chylous
effusion, without waiting to see if the
effusion will resolve with conservative
management.
(continued)
808 K. A. Wilson and B. S. Majdalany

When TDE has been TDE fails when there is inadequate

reported to fail, why filling of the lumen of the duct with
does it fail? embolic agents. Embolization should
be performed to stasis to minimize
this possibility. Large body habitus
and operator inexperience can also
contribute to an unsuccessful procedure,
as they reduce the likelihood that the
lymphatic ducts can be successfully
catheterized.
Does chyle clot, like Chyle can clot as well as blood, but does
blood? so more slowly. Like blood, chyle is also
subject to coagulopathy when deficient
in its coagulation proteins.
How does TDE differ The procedure time is often less, as the
in pediatric patients? volume of contrast necessary for an
adequate lymphangiogram is less (0.5–
10 mL) and the transit of contrast into
the retroperitoneal lymphatics is faster.
Shorter needles and microcatheters may
also be necessary for embolization, given
the smaller AP diameter of a child.

Further Reading
Cope C, Kaiser LR. Management of unremitting chylothorax
by percutaneous embolization and blockage of retroperito-
neal lymphatic vessels in 42 patients. J Vasc Interv Radiol.
2002;13:1139–48.
Hsu MC, Itkin M. Lymphatic anatomy. Tech Vasc Interv Radiol.
2016;19:247–54. https://doi.org/10.1053/j.tvir.2016.10.003.
Itkin M, Kucharczuk JC, Kwak A, Trerotola SO, Kaiser
LR. Nonoperative thoracic duct embolization for traumatic tho-
racic duct leak: experience in 109 patients. J Thorac Cardiovasc
Surg. 2010;139:584–9. https://doi.org/10.1016/j.jtcvs.2009.11.025.
Itkin M, Nadolski GJ. Modern techniques of lymphangiogra-
phy and interventions: current status and future develop-
ment. Cardiovasc Intervent Radiol. 2018;41:366–76. https://doi.
org/10.1007/s00270-­0 17-­1863-­2.
 54 Thoracic Duct Embolization 809

Majdalany BS, Murrey DA Jr, Kapoor BS, Cain TR, Ganguli S, Kent
MS, et al. ACR appropriateness criteria chylothorax treatment
planning. J Am Coll Radiol. 2017;14(Suppl 5):S118–26. https://
doi.org/10.1016/j.jacr.2017.02.025.
Majdalany BS, Saad WA, Chick JFB, Khaja MS, Cooper KJ, Srinivasa
RN. Pediatric lymphangiography, thoracic duct embolization
and thoracic duct disruption: a single-institution experience in
11 children with chylothorax. Pediatr Radiol. 2018;48:235–40.
https://doi.org/10.1007/s00247-­0 17-­3988-­5.
Nadolski G, Itkin M. Thoracic duct embolization for nontraumatic
chylous effusion. Chest. 2013;143:158–63. https://doi.org/10.1378/
chest.12-­0526.
Nadolski G. Nontraumatic chylothorax: diagnostic algorithm and
treatment options. Tech Vasc Interv Radiol. 2016;19:286–90.
https://doi.org/10.1053/j.tvir.2016.10.008.
Pamarthi V, Stecker MS, Schenker MP, Baum RA, Killoran TP,
Han AS, et al. Thoracic duct embolization and disruption for
treatment of chylous effusions: experience with 105 patients. J
Vasc Interv Radiol. 2014;25:1398–404. https://doi.org/10.1016/j.
jvir.2014.03.027.
Stecker MS, Fan CM. Lymphangiography for thoracic duct inter-
ventions. Tech Vasc Interv Radiol. 2016;19:277–85. https://doi.
org/10.1053/j.tvir.2016.10.010.
Yannes M, Shin D, McCluskey K, Varma R, Santos E. Comparative
analysis of intranodal lymphangiography with percutaneous inter-
vention for postsurgical chylous effusions. J Vasc Interv Radiol.
2017;28:704–11. https://doi.org/10.1016/j.jvir.2016.12.1209.
 Part X
Pediatrics
Chapter 55
Pediatrics – Central
Venous Access
Maegan Kellie Garcia Lazaga and Harris Chengazi

Evaluating the Patient

When are laboratory tests Laboratory tests are required if a
required prior to central patient has a bleeding diathesis or
venous access? uncorrectable coagulopathy.
How long should patients
be kept nothing by mouth
(NPO) prior to sedation?

Solids and nonclear Clear

fluidsa fluids
Children <6 months old 4–6 hours 2 hours
Children 6–36 months 6 hours 2–4 hours
old
Children >26 months old 6–8 hours 2–4 hours
a
includes milk, formula, and breast milk

M. K. G. Lazaga (*)
Department of Imaging and Radiology, Augusta University/
Medical College of Georgia, Augusta, GA, USA
e-mail: [email protected]
H. Chengazi
Department of Imaging Sciences, University of Rochester,
Rochester, NY, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 813

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_55
814 M. K. G. Lazaga and H. Chengazi

What are the The goals for both sedation and anesthesia
goals of sedation are anxiety relief, pain control, minimizing
and anesthesia? psychological trauma, and maximizing
Which patients potential for amnesia and control of
are candidates for excessive movement. During procedures,
general anesthesia? patients should remain relatively motionless
for the safest possible outcome. This
outcome can be achieved with various levels
of sedation, as well as general anesthesia,
depending on the length of procedure,
degree of motion control, and ability of the
child to remain still with minimal sedative.
Patients may specifically require general
anesthesia with endotracheal intubation due
to the need for intermittent breath holds
during the procedure or when there is risk
for vasospasm and controlled hypercarbia
can help promote vasodilation, such as in
cerebral angiography and embolization.
When would you Femoral access would be first choice in
use femoral access neonates without umbilical venous access,
as primary access? congenital heart disease, emergent access,
SVC venous thrombosis, prior surgical
intervention, and overlying burns/infection.
Why is venous Venous access is not performed in
access not the antecubital fossa secondary to the
performed at the superficial nature of the access location and
antecubital fossa? final location of the catheter at the elbow
joint. This position of the catheter increases
the risk of phlebitis and mechanical injury
to the catheter, which predisposes to
catheter fracture and dysfunction.
What clinical Renal disease, given that the possibility of
history would future renal transplant precludes placement
preclude the of a femoral catheter (prevention of
placement of a iliac vein injury or thrombosis for future
femoral central transplant renal vein anastomosis).
venous catheter?
 55 Pediatrics – Central Venous Access 815

Where is the The preferred location of the catheter tip

preferred location for these approaches is the entrance to the
of the tip of a right atrium (cavoatrial junction).
catheter placed
from an upper
extremity vein in
both subclavian
and internal jugular
approach?
How do you The catheter tip is located at the cavoatrial
determine if the junction on a posterior-anterior view of the
catheter tip is chest when it is approximately two vertebral
at the cavoatrial bodies below the level of the carina.
junction using
fluoroscopy?
Where is the The preferred location of the catheter tip
preferred location for this approach is within the infrarenal
of the tip of a IVC or between the diaphragm and the
catheter placed inferior third of the right atrium, below the
from a common seventh thoracic interface.
femoral approach?
Why is catheter tip Appropriate catheter tip position makes the
position important catheter less prone to malposition related to
in central venous respiratory motion and patient positioning.
access? Appropriate catheter tip position also
helps prevent catheter occlusion against the
lateral walls of the vessel, endothelial injury,
and perforation of the vessel wall by the
catheter.

High Yield History

Name some common conditions Cystic fibrosis, malignancy
which may require long-term requiring chemotherapy, renal
central venous access. disease, short gut syndrome,
hemophilia, and sickle cell
disease.
(continued)
816 M. K. G. Lazaga and H. Chengazi

For each type of central

venous access (tunneled and
non-tunneled central venous
catheters, venous ports, PICCs)
what length of time of infusion
is usually required?

Non-tunneled central venous access < 7 days

Peripherally inserted central venous 2 weeks to > 3 months
catheter (PICC)
Tunneled central venous catheter 2 weeks to > 3 months
Venous port Intermittent use for
> 3 months

What are common findings Acute thrombus (< 14 days) – low

on ultrasound denoting echogenicity, distended vein, and
acute, subacute, and chronic loss of compressibility
thrombus within a vein? Subacute thrombus (2 weeks to
6 months) – increased/variable
echogenicity, reduction in vein
caliber, restoration of luminal flow
and thrombus adherence to wall,
and development of collaterals
Chronic (> 6 months) – wall
thickening, echogenic intraluminal
post-thrombotic scarring, valve
abnormalities with or without
reflux, and development of
collaterals
In a patient with a history of The types of imaging studies
multiple prior central venous which can be helpful for planning
catheters, the preferred central venous access in those with
pathways for access may complex access histories includes
not be available for use due ultrasound, magnetic resonance
to thrombosis, fibrosis, or angiography, CT, or diagnostic
venospasm and collateral fluoroscopic venogram.
pathways may need to be
used. What imaging studies
may be helpful for planning
future sites of central venous
access if needed?
 55 Pediatrics – Central Venous Access 817

What are some alternative Transbrachiocephalic access,

access sites for central transhepatic access, and
venous access when the translumbar access.
central venous pathways are
occluded?

Indications/Contraindications
What are common indications for
the various types of central venous
access (tunneled and non-tunneled
central venous catheters, venous
ports, PICCs)?
Non-tunneled central venous access Urgent/emergent vascular
access
Fluid/electrolyte
resuscitation
Antibiotic therapy
Hemodialysis/apheresis
Peripherally inserted central Antibiotic therapy
venous catheter (PICC) Hyperalimentation
Long-term fluid/electrolyte
therapy
Venous blood draws
Tunneled central venous catheter Chemotherapy
Hyperalimentation
Antibiotics
Chelation therapy
Long-term fluid and
electrolyte therapy
Hemodialysis/apheresis
Venous port Chemotherapy
Hyperalimentation
Long-term fluid and
electrolyte therapy
818 M. K. G. Lazaga and H. Chengazi

What is the purpose The Dacron cuff promotes tissue ingrowth

of the “cuff” in a onto the catheter, securing the catheter in
tunneled central the tunnel.
venous catheter?
Why would a PICCs do not have a cuff and are
patient need a susceptible to accidental dislodgement or
tunneled, cuffed malposition by the patient or caregiver
central venous during dressing changes. Tunneling a central
catheter instead of venous catheter also provides a barrier to
a PICC? infection.
What is a relative There are few contraindications to central
contraindication venous access. Uncorrectable coagulopathy
for central venous is a relative contraindication and the
access? procedure is still often attempted as these
patients often are seriously ill and require
central venous access for treatment. Platelet
or fresh frozen plasma administration can
be utilized as necessary at the time of the
procedure.
If a patient has In general, tunneled central venous access
symptomatic should be delayed until the patient has
bacteremia or received antibiotic therapy and there have
sepsis, should a been 48 hours of no growth on blood
tunneled central cultures. If emergent or urgent central
venous line be venous access is desired, a temporary, non-­
placed? tunneled central venous catheter can be
placed.
 55 Pediatrics – Central Venous Access 819

Relevant Anatomy
Which vein should The subclavian vein should be avoided
you avoid using for central venous access. The subclavian
for central venous vein is the final common pathway from
access? the ipsilateral extremity to the heart.
Additionally, accessing the subclavian
vein is associated with the highest risk of
complications, including arterial puncture,
thrombosis, pinch-off syndrome, and
pneumothorax.
Which vein is the The preferred access for upper extremity
preferred access for PICCs is the basilic or brachial veins as
an upper extremity they are the largest and most accessible
PICC? veins with the straightest course.
In young children, The smaller caliber of the terminal
the terminal arch segment of the cephalic vein forms
of the cephalic vein a terminal “C” or “Z” shape, making
is 1–2 French sizes navigation from the cephalic vein into
smaller than the the subclavian vein challenging. This
proximal cephalic “infantile” configuration can require more
vein. Why is this advanced techniques to navigate, including
important in the fluoroscopic road mapping, directional
placement of upper catheters, and angled or glide wires.
extremity PICCs?
What embryological The absorption of the right horn of the
process forms the sinus venosus and the remnant of the
cavoatrial junction? septum secundum forms the cavoatrial
junction.
If the left anterior If the left anterior cardinal vein does
cardinal vein does not obliterate during development, a
not obliterate during persistent left-sided SVC can result.
development, what is Catheterization of this vein will appear
the resulting variant to course parallel to the spine along the
anatomy? left mediastinal border into the heart. This
look can be mistaken for arterial course
and it is important to keep persistent left-
sided SVC in the differential.
(continued)
820 M. K. G. Lazaga and H. Chengazi

Where does a 80–90% of persistent left-sided SVC drain

persistent left-sided into the right atrium via the coronary
SVC commonly sinus. 10–20% of persistent left-sided SVC
drain into? drain into the left atrium.

Relevant Materials
What size wire is able 0.014 inch.
to pass through a
24-gauge needle?
What is the difference Tapered catheters have ends which
between a tapered taper to the size of the guidewire at
and a non-­tapered their insertion and do not require a
catheter? peel-away sheath. Non-tapered catheters
have a higher friction coefficient and
usually require a peel-away sheath for
insertion. Non-tapered catheters are
also sometimes harder to insert over a
guidewire than tapered catheters.
What determines the The catheter with the fewest lumens
number of lumens that and smallest internal diameter that will
should be selected? satisfy the clinical need is used. This is
because the greater number of lumens
decreases the cross-sectional area of the
catheter and decreases flow within that
lumen. This makes blood return more
difficult in smaller catheters, increasing
the potential for catheter dysfunction.
In general, what In general, for children weighing less
French sized catheter than 10 kg, a catheter size of 3-Fr or
is used for children less is utilized. There are multiple sizes
less than 10 kg? of catheters ranging from 1.1 to 2.6-Fr
which can be utilized. Choice in catheter
size should be based on infant weight
and clinical condition. For very small
infants, specialized techniques for access
of vessels may need to be used such
as a double wall puncture followed by
retraction.
 55 Pediatrics – Central Venous Access 821

In general, what 4-Fr.

French sized catheter
is used for children
greater than 10 kg?
In general, how many The fewest number of lumens with
lumens and what smallest internal diameter satisfying the
diameter should be clinical need should be chosen.
picked?
In general, dialysis or 7-Fr to 14-Fr.
apheresis catheters are
what size?
In patients not EMLA cream (topically applied
receiving sedation anesthesia).
or anesthesia, what
medication aside from
injectable lidocaine
can be used for pain
relief?
What is the general 5 mL/kg.
limit for contrast
administration in
pediatric patients in
mL/kg?
What type of Linear high-frequency transducer with a
ultrasound probe small footprint.
should be used?

General Step by Step

Why would an operator This position fills the jugular vein
place a patient in more prominently, allowing the vein
10–15 degrees of to be punctured with less risk to the
Trendelenburg prior surrounding structures, and decreases
to placing an internal the risk of air embolus.
jugular vein approach
central venous
catheter?
(continued)
822 M. K. G. Lazaga and H. Chengazi

What should a catheter Removed catheters should be

be inspected for inspected for defects in the catheter
following removal? and appropriate length to evaluate
for fracture and distal embolization. If
infection is suspected, some institutions
submit the removed catheter tip for
laboratory evaluation with stain and
culture.
What most commonly Vessel trauma with a wire.
causes vasospasm when
inserting a PICC?
What are some options Some techniques to treat venospasm
to treat venospasm include reducing the size of the
that will not allow catheter by one French size, waiting
a catheter to pass for the venospasm to resolve, infusing
forward in the vessel? a small amount of sterile saline to
allow passage of the catheter, or
administering pharmacologic agents
such as nitroglycerine, papaverine,
priscoline, or calcium channel blockers.
Why is a port A port reservoir is filled with
“heparinized” or heparinized saline at the time of
“packed with heparin” placement and after any time it is
and what is the accessed to prevent thrombus and
concentration of the occlusion. The concentration of heparin
heparin solution in U/ solution utilized is 100 U/mL
mL?
What maneuvers can Flush technique – A 3–5 mL syringe
be performed if the filled with sterile saline is used to
catheter is coiled within forcefully inject the catheter to push the
the proximal venous catheter into the appropriate position.
system before removal
and replacement?
How can you position Elevate the head of the bed 15–45
the patient to minimize degrees, reverse Trendelenburg or
post-procedural sitting position.
bleeding?
 55 Pediatrics – Central Venous Access 823

Complications
What is the Warm compress and time, NSAIDs if needed.
treatment for
phlebitis?
What constitutes Occlusion with inability to flush or loss of
catheter blood return and pain during flushes or
dysfunction? administration of fluids and medications.
What is the Ball-valve mechanism at the tip due to
problem if the wedging of the catheter tip against the wall,
catheter flushes tip thrombus, or fibrin sheath formation.
but is unable to
return blood?
What is a fibrin A fibrin sheath is a matrix of cells and debris
sheath and how that forms around catheters propagating
do you fix it? from the vein entry site towards the tip of
the catheter. Generally, this is managed with
catheter removal or exchange with or without
balloon maceration of the fibrin sheath or
installing a small dose of fibrinolytic agent
into the catheter. Stripping of the fibrin sheath
from a separate access may be successful,
though it is usually reserved for patients who
fail other methods of management.
If catheter If fracture is suspected, diagnostic venogram
fracture is through the indwelling catheter should be
suspected, what performed to evaluate for extravasation along
should be done? the catheter course, obvious fracture, and
embolization of fractured catheter fragments.
If fracture is detected, the catheter should be
carefully removed under fluoroscopy. If there
is an embolized catheter fragment, this can be
removed under fluoroscopic guidance with a
snare.
What is the A trial of thrombolytic therapy can be
treatment for tip used (tissue plasminogen activator (tPA),
thrombus? alteplase).
(continued)
824 M. K. G. Lazaga and H. Chengazi

What is the dose The initial dose of tPA is 0.5 mg left in the
of tPA utilized catheter for 30 minutes to 4 hours. After the
to treat tip initial dwell time, the catheter is aspirated
thrombus? to evaluate for reestablishment of blood
flow. This can be repeated for a second
dose of 1 mg and for a third dose of 2 mg.
Alternatively, a small dose of tPA such as
2–5 mg in 50–100 cc of saline can be infused
over 30 minutes (doses and time vary).
What is pinch off Narrowing/compression of the catheter as
syndrome? it courses between the clavicle and first rib.
This complication is seen with subclavian
vein approach central venous access and may
lead to mechanical malfunction and possible
fragmentation and distal embolization of the
line.
If you hear a This sound is heard when an air embolism
large sucking has occurred. The patient should be turned to
sound while lay on their left side in left lateral decubitus
placing a central position. This positioning traps the air within
venous catheter, the anti-dependent right atrium.
what should
you instruct
the patient to
do? What has
happened?
What organisms Coagulase positive and negative staphylococci.
are most likely
the cause of
catheter related
infection?
 55 Pediatrics – Central Venous Access 825

What should The course of action with an infected central

be done for an venous catheter depends on the type of
infected central catheter placed. Most catheter-related
venous line? infections can be treated with antibiotics
without removal of the catheter. Catheters
infected with pseudomonas and fungal
infections often require catheter removal.
Tunneled catheters that are infected with
the infection of the subcutaneous tunnel
most likely need to be removed. If there is
septicemia or septic thrombophlebitis, the line
needs to be removed.

Landmark Research
Cathflo Activase Pediatric Study Blaney M, Shen V, Kerner
JA, Jacobs BR, Gray S, Armfield J, Semba CP, CAPS
Investigators. Alteplase for the treatment of central venous
catheter occlusion in children: results of a prospective, open-
label, single-arm study (The Cathflo Activase Pediatric Study).
Journal of Vascular and Interventional Radiology. 2006 Nov
1;17(11):1745–51.

• 310 patient multicenter prospective, single-arm study

evaluating the use of alteplase in pediatric patients for the
treatment of central venous catheter and port occlusion.
• With a maximum of two instillations of alteplase for a
maximum dwell time of 120 minutes, the cumulative rate
function restoration was 82.9% with similar rates of func-
tion restoration among all types of catheters studied.
• The primary outcome was the rate of intracranial hemor-
rhage secondary to alteplase administration (0). Secondary
outcome was targeted serious events (major hemorrhage,
thrombosis, embolic event, sepsis, catheter-­related compli-
cation). Three cases of sepsis, 4 catheter-­related complica-
tions (rupture) for a total of 7 serious events occurred in 8
patients (2.6% incidence).
826 M. K. G. Lazaga and H. Chengazi

Common Questions
If the central drainage Hemiazygos and azygous veins.
pathways are occluded,
by what collateral
pathway does drainage
normally occur?
About how long does it 10–14 days.
take for significant tissue
ingrowth to occur around
the cuff in a tunneled
catheter?
What is the preferred Anterolateral chest wall.
exit site for a tunneled
catheter?
What is an important Injury to the breast bud which
consideration for the can result in abnormal breast
exit site and tunnel for a development.
tunneled catheter or port
placement location in
young females?
What is the name of the The needle used to access a port is a
needle used to access a “non-coring” hollow needle with a
port? beveled tip called a Huber needle. A
non-coring needle is used in order to
prolong the life of a port’s silicone
septum thereby prolonging the life of
the port reservoir.
Why might a port be Ports can be placed in the extremities
placed in the upper arm, in older children who do not want a
forearm, or leg? scar or bump on their chest. Other
sites of port placement that have been
described include the upper arm,
forearm, or upper leg.
Why would you avoid Higher likelihood of infection from
femoral access in the diaper and restriction of patient
neonates and infants? movement.
 55 Pediatrics – Central Venous Access 827

What is Paget– Effort thrombosis of the axillary

Schroetter’s disease? and/or subclavian vein, the venous
equivalent of thoracic outlet syndrome

Further Reading
Acord M, Cahill AM, Krishnamurthy G, Vatsky S, Keller M,
Srinivasan A. Venous ports in infants. J Vasc Interv Radiol.
2018;29(4):492–6.
American College of Radiology, & Society of Interventional
Radiology. ACR-SIR practice guideline for sedation/analgesia.
Reston (VA): American College of Radiology; 2010.
Arlachov Y, Ganatra RH. Sedation/anaesthesia in paediatric radiol-
ogy. Br J Radiol. 2012;85(1019):e1018–31.
Barnacle A, Arthurs OJ, Roebuck D, Hiorns MP. Malfunctioning
central venous catheters in children: a diagnostic approach.
Pediatr Radiol. 2008;38(4):363–78.
Baskin KM, Hunnicutt C, Beck ME, Cohen ED, Crowley JJ, Fitz
CR. Long-term central venous access in pediatric patients at
high risk: conventional versus antibiotic–impregnated catheters.
J Vasc Interv Radiol. 2014;25(3):411–8.
Blaney M, Shen V, Kerner JA, Jacobs BR, Gray S, Armfield J, et al.
Alteplase for the treatment of central venous catheter occlusion
in children: results of a prospective, open-label, single-­arm study
(The Cathflo Activase Pediatric Study). J Vasc Interv Radiol.
2006;17(11):1745–51.
Chait PG, Temple M, Connolly B, John P, Restrepo R, Amaral
JG. Pediatric interventional venous access. Tech Vasc Interv
Radiol. 2002;5(2):95–102.
Chau A, Hernandez JA, Pimpalwar S, Ashton D, Kukreja
K. Equivalent success and complication rates of tunneled com-
mon femoral venous catheter placed in the interventional suite
vs. at patient bedside. Pediatr Radiol. 2018;48(6):889–94.
Chow LM, Friedman JN, MacArthur C, Restrepo R, Temple M,
Chait PG, Connolly B. Peripherally inserted central catheter
(PICC) fracture and embolozation in the pediatric population. J
Pediatr. 2003;142(2):141–4.
Dasgupta N, Patel MN, Racadio JM, Johnson ND, Lungren
MP. Comparison of complications between pediatric peripher-
828 M. K. G. Lazaga and H. Chengazi

ally inserted central catheter placement techniques. Pediatr

Radiol. 2016;46(10):1439–43.
Donaldson JS. Pediatric vascular access. Pediatr Radiol.
2006;36(5):386–97.
Fricke BL, Racadio JM, Duckworth T, Donnelly LF, Tamer RM,
Johnson ND. Placement of peripherally inserted central cath-
eters without fluoroscopy in children: initial catheter tip position.
Radiology. 2005;234(3):887–92.
Gibson C, Connolly BL, Moineddin R, Mahant S, Filipescu D, Amaral
JG. Peripherally inserted central catheters: use at a tertiary care
pediatric center. J Vasc Interv Radiol. 2013;24(9):1323–31.
Gnannt R, Patel P, Temple M, Al Brashdi Y, Amaral J, Parra
D, et al. Peripherally inserted central catheters in pediatric
patients: to repair or not repair. Cardiovasc Intervent Radiol.
2017;40(6):845–51.
Kumar R, Harsh K, Saini S, O’Brien SH, Stanek J, Warren P, et al.
Treatment-related outcomes in Paget–Schroetter syndrome—a
cross-sectional investigation. J Pediatr. 2019;207:226–32.
Lindquester WS, Hawkins CM, Monroe EJ, Gill AE, Shivaram GM,
Seidel FG, Lungren MP. Single-stick tunneled central venous
access using the jugular veins in infants weighing less than 5 kg.
Pediatr Radiol. 2017;47(12):1682–7.
Miller DL, O’Grady NP. Guidelines for the prevention of intra-
vascular catheter-related infections: recommendations relevant
to interventional radiology for venous catheter placement and
maintenance. J Vasc Interv Radiol. 2012;23(8):997.
Mirza B, Vanek VW, Kupensky DT. Pinch-off syndrome: case report
and collective review of the literature. Am Surg. 2004;70(7):635.
Morello FP, Donaldson JS, Saker MC, Norman JT. Air embolism
during tunneled central catheter placement performed without
general anesthesia in children: a potentially serious complica-
tion. J Vasc Interv Radiol. 1999;10(6):781–4.
Patel PA, Parra DA, Bath R, Amaral JG, Temple MJ, John PR,
Connolly BL. IR approaches to difficult removals of totally
implanted venous access port catheters in children: a single-­
center experience. J Vasc Interv Radiol. 2016;27(6):876–81.
Shin HS, Towbin AJ, Zhang B, Johnson ND, Goldstein SL. Venous
thrombosis and stenosis after peripherally inserted central cath-
eter placement in children. Pediatr Radiol. 2017;47(12):1670–5.
Sonavane SK, Milner DM, Singh SP, Abdel Aal AK, Shahir KS,
Chaturvedi A. Comprehensive imaging review of the superior
vena cava. Radiographics. 2015;35(7):1873–92.
 55 Pediatrics – Central Venous Access 829

Toh LM, Mavili E, Moineddin R, Amaral J, John PR, Temple MJ,

et al. Are cuffed peripherally inserted central catheters superior
to uncuffed peripherally inserted central catheters? A retrospec-
tive review in a tertiary pediatric center. J Vasc Interv Radiol.
2013;24(9):1316–22.
Towbin RB, Ball JW. Pediatric interventional radiology. Radiol Clin
N Am. 1988;26(2):419–40.
Vo JN, Hoffer FA, Shaw DW. Techniques in vascular and inter-
ventional radiology: pediatric central venous access. Tech Vasc
Interv Radiol. 2010;13(4):250–7.
Wyckoff MM, Sharpe EL. Peripherally inserted central catheters:
guideline for practice. National Association of Neonatal Nurses;
2015.
Zwiebel WJ. In: Pellerito JS, editor. Introduction to vascular ultraso-
nography. Philadelphia: Elsevier Saunders; 2005. p. 19–89.
Chapter 56
Pediatrics – Enteral
Access
Harris Chengazi and Maegan Kellie Garcia Lazaga

Percutaneous Gastrostomy/Gastrojejunostomy

Evaluating the Patient

What are the most Inability to swallow, inadequate caloric

common indications intake for normal growth (failure to
for feeding tube thrive), and abnormal gastric function
access? requiring chronic drainage.
When is percutaneous When access is required long term
feeding tube placement (greater than ~6 weeks).
preferred over nasally
advanced feeding
tubes?
(continued)

H. Chengazi (*)
Department of Imaging Sciences, University of Rochester,
Rochester, NY, USA
e-mail: [email protected]
M. K. G. Lazaga
Department of Imaging and Radiology, Augusta University/
Medical College of Georgia, Augusta, GA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 831

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_56
832 H. Chengazi and M. K. G. Lazaga

What is the advantage Percutaneous feeding tube access

of using percutaneous generally has fewer complications than
feeding tube access parenteral nutrition. Complications of
over parenteral parenteral nutrition include catheter
nutrition? related infection, catheter-associated
thrombosis and embolism, and sequela
of hyperalimentation (fatty liver
disease, cholestasis, bowel atrophy, and
electrolyte and metabolic disturbances).
What are the major Gastrostomy and gastrojejunostomy.
types of percutaneous
enteral feeding access?
When is a Gastrojejunostomy is preferred when
gastrojejunostomy the patient has delayed gastric emptying
preferred over a or evidence for gastroesophageal reflux
gastrostomy for with aspiration.
feeding access?
What are the Uncorrectable coagulopathy, clinical
contraindications for instability, and anatomic limitations
percutaneous gastric (e.g., micrognathia, microgastria, and
access? intervening anatomy including bowel,
liver, and epigastric artery).

Relevant Anatomy
Where is the The ideal window for percutaneous access is
ideal access for at the lateral margin of the rectus abdominis
percutaneous muscle, below the costal margin.
gastric access?
What vessels must The epigastric arteries must be avoided
be avoided during during percutaneous gastric access.
gastric access?
What organs must The left hepatic lobe and the transverse
be avoided during colon may overlie the stomach and limit
percutaneous percutaneous access window.
gastric access?
 56 Pediatrics – Enteral Access 833

How is the The percutaneous tract should be oriented

percutaneous tract toward the pylorus. In gastrostomy patients,
ideally oriented? this orientation facilitates conversion to
gastrojejunostomy when indicated. In
gastrojejunostomy, this orientation reduces
the likelihood of tube malposition in the
stomach.
What is the Just distal to the ligament of Treitz.
ideal placement
for the tip of a
jejunostomy tube?

Pre-procedure and Technical Considerations

What are the two Percutaneous gastric access can
approaches to be performed in both anterograde
the placement of and retrograde fashion. These are
percutaneous gastrostomy/ described in further detail in the
gastrojejunostomy? ‘step-by-step’ section of the chapter.
What are the advantages of Can be performed without general
retrograde access compared anesthesia and smaller caliber tubes
to anterograde access? can be placed, which may be more
comfortable for the patient.
What are the disadvantages Retrograde access is typically
of retrograde access performed with a smaller caliber
compared to anterograde tube which increases the likelihood
access? of tube obstruction. The smaller
tubes are also more mobile
which increases the likelihood of
dislodgement.
What can be administered Thin barium administered via
to aid in the localization of nasogastric tube 4–6 hours prior
the colon? to procedure, or thin barium or
water-soluble iodinated contrast
administered via enema.
(continued)
834 H. Chengazi and M. K. G. Lazaga

What should be done to Prior to the procedure, cross-­

ensure avoidance of critical sectional imaging should be
structures during the reviewed (if available) to assess for
procedure? anatomy that intervenes between
the stomach and cutaneous tissues.
At the time of the procedure,
ultrasound should be performed to
delineate the left hepatic lobe and
epigastric arteries. A fluoroscopic
image after barium administration
should also be obtained to confirm
the position of the transverse colon.
When might a sub-xiphoid A sub-xiphoid approach is
approach be preferred? preferred in patients with high
stomach, midline stomach, or
transverse stomach.
What are the limitations to The epigastric arteries course
a trans-rectus abdominis within the rectus musculature
approach? and must be avoided. After tube
insertion, the rectus musculature
can cramp and is associated with
greater discomfort after the
procedure.
In general, how big should The skin incision should be larger
the skin incision at site of than the tube being inserted to
access be? avoid the risk of pressure necrosis,
usually about 1.5–2 cm.
What fluoroscopic A lateral fluoroscopic projection
projection is helpful to can demonstrate the stomach
confirm appropriate against the anterior abdominal
position within the wall, and contrast can be confirmed
stomach? within the lumen.
 56 Pediatrics – Enteral Access 835

Relevant Materials and Equipment

When are prophylactic Prophylactic antibiotics are indicated
antibiotics indicated? in immunocompromised patients or
those with a history of post-procedural
infections.
What size feeding tube 8–10 French nasogastric feeding tubes
is typically used for are sufficient for gastric insufflation.
gastric insufflation?
What medication can Glucagon closes the pylorus and limits
be given to improve the progression of gas into the small
gastric distension bowel by decreasing peristalsis. Weight-­
during insufflation? based dosing of Glucagon is typically
0.02–0.03 mg/kg/dose, with a maximum
dose of 0.5 mg in patients under 20 kg
and 1 mg in patients over 20 kg.
What size gastrostomy 14–16 French.
tube is typically placed
in an anterograde
fashion?
What size gastrostomy 8.5–12 French.
tube is typically
placed in a retrograde
approach?
What size tubes are 16–18 French gastrostomy tube with a
generally used for 6–9 French jejunostomy tube.
gastrojejunostomy?
What is used as local 1% Lidocaine, administered via a
anesthetic for the skin 27–30G needle.
entry site?
What sized needle An 18-gauge puncture needle.
is generally used to
puncture the abdominal
wall and stomach?
What type of guidewire A 0.035-inch non-Teflon-coated
is typically used? guidewire.
(continued)
836 H. Chengazi and M. K. G. Lazaga

What special equipment A nitinol snare is used to retrieve the

is required for an percutaneously placed guidewire for
anterograde placement? tube advancement. The 0.035-inch
guidewire is also longer than in a
retrograde approach.
What special equipment A gastropexy suture/anchor set to affix
is required for a the stomach to the anterior abdominal
retrograde placement? wall.
What is typically used A telescoping dilator, a serial dilator
to dilate the skin tract? set, or a balloon can be used to dilate
the skin tract.
How is a jejunostomy Jejunostomy tubes are usually placed
tube typically placed? coaxially, via a gastrostomy tube.

Post-procedure Care and Maintenance

How is a patient Usually for about 2 hours or return to
typically monitored baseline after anesthesia.
post procedure?
When can tubes be A tube can usually be used the day after
used for feeding? the procedure, as long as bowel sounds
have returned.
How are amounts Feeding schedule and dosing is usually
and types of feeds done with the assistance of a dietary
determined? consultation, taking into account the
patient’s size, comorbidities, and caloric
requirements.
How are initial feeds The patient is usually advanced from
administered and clear liquids to higher calorie solutions
augmented? via a continuous pump. Once this is
tolerated, the rates can be escalated to
allow for longer periods of time off the
pump each day, while maintaining caloric
intake.
 56 Pediatrics – Enteral Access 837

When should retention Retention sutures should be cut

sutures applied for after 14 days, if they do not release
retrograde approach spontaneously.
be removed?
How long does a About 4–6 weeks, the tube should not be
tract usually take to electively exchanged during this time to
mature? promote maturation.
When can a patient After complete tract maturation.
resume activities, such
as swimming and
bathing?
How often should Typically, feeding tubes can be serviced
the maintenance only on an as-needed/elective basis.
or exchange of the Small caliber tubes may require routine
G-tube be performed? servicing at 6-month intervals.
What are indications Leakage, blockage, and dislodgement.
for early tube
exchange?
What should be given A Foley catheter one size smaller than
to the parents of a the gastrostomy tube should be available
patient in the event of to the parents. The foley catheter can
a tube dislodgement? be placed in the tract to ensure patency
until intervention can be performed.
What is a low-profile A low-profile G-tube has a set distance
G-tube? from the external button and the
internal balloon, minimizing the external
portion of the feeding tube. There is no
adjustable flange, as the low-profile tube
is specific to specific tract length.
When can a low-­ Low profile G-tubes require a mature
profile G-tube be tract, so they are typically placed after
placed? 6 weeks form initial placement. A
mature tract allows for the measurement
of stoma length for appropriate sizing of
the low-profile tube.
(continued)
838 H. Chengazi and M. K. G. Lazaga

Why do patients and Low-profile tubes are more comfortable

referring providers and less likely to be pulled out by the
prefer low-profile patient.
G-tubes?

General Step by Step: Antegrade Approach

1. Administer barium orally or via enema prior to the proce-
dure to aid in localization of colon.
2. Identify the liver and spleen (if enlarged) under ultra-
sound and mark the skin. The costal margin should also
be delineated.
3. Insert nasogastric and orogastric tubes.
4. Exchange orograstic tube for snare.
5. Inflate stomach manually or with CO2 via nasogastric
tube.
6. Under fluoroscopy, puncture the stomach, avoiding the
previously delineated anatomy.
7. Insert and snare a guidewire, and retrieve via the oral
cavity.
8. Advance gastrostomy tube over wire via the mouth and
pull it through the percutaneous access site. Inject con-
trast with orthogonal views to confirm position.
9. Secure the gastrostomy tube with a flange.
10. Coaxially advance jejunostomy tube via gastrostomy tube
if required.

General Step by Step: Retrograde Approach

1. Administer barium orally or via enema prior to procedure
to aid in localization of colon.
2. Identify the liver and spleen (if enlarged) under ultrasound
and mark the skin. The costal margin should also be
delineated.
 56 Pediatrics – Enteral Access 839

3. Insert nasogastric tube and insufflate the stomach.

4. Under fluoroscopic guidance, advance gastropexy sutures
into the stomach and secure them.
5. Puncture the stomach, inject contrast to confirm position,
and advance a wire to secure access.
6. Advance a gastric tube over wire or via peel-away sheath.
7. Inject contrast with orthogonal views to confirm position.
8. Secure the gastrostomy tube with a flange.

Complications
What are the signs Fever and abdominal pain.
and symptoms of
peritonitis?
What are some Colonic injury, leakage of gastric
potential etiologies contents, and tube malposition.
for peritonitis?
How should a patient Tube feeds should be stopped
with peritoneal signs immediately, and broad-spectrum
be managed? antibiotics should be administered. A
fluoroscopic exam should be performed
to assess the position of the feeding tube
tip. If the tip is malpositioned within the
peritoneum, the tube requires removal
and replacement. If the tip of the tube is
appropriately positioned, peritonitis may
be secondary to leakage and tube upsize
may be indicated.
What imaging studies Contrast-enhanced fluoroscopy or CT of
are most useful to the abdomen can be used to confirm the
evaluate the tube tube position.
position?
(continued)
840 H. Chengazi and M. K. G. Lazaga

What should be done An attempt can be made to cannulate

if a tube is dislodged the immature tract; however, this may
before the tract be technically difficult if the internal
matures? retention sutures have dislodged or if
wire manipulation results in the creation
of a false tract. Fresh placement of the
tube is often preferred as the stomach is
directly accessed.
What should be done A Foley catheter should be placed to
if a tube is dislodged ensure the patency of the tract. A new
from a mature tract? tube can typically be placed at bedside
without the need for sedation.
What factors increase Prolonged fasting and use of beta-­
the likelihood blockers.
of hypoglycemia
after Glucagon
administration?
What can be Glucose containing maintenance fluids.
given to decrease
the likelihood
of hypoglycemia
after Glucagon
administration?
What can be done The site should be monitored and
to prevent skin cleaned frequently. Absorbent gauze can
breakdown around be placed between the button and the
the site? skin. The tube can be rotated 45 degrees
daily to avoid pressure effects in the same
location.
What increases the Leakage from the gastrostomy site
likelihood of skin due to improper tube size, granulation
breakdown around tissue, excessive sweating, and improper
the access site? hygiene all increase the likelihood of skin
breakdown.
 56 Pediatrics – Enteral Access 841

How can granulation Topical application of silver nitrate.

tissue around the
gastrostomy site be
managed?
How is a skin site A minor infection can be irrigated
infection managed? with hydrogen peroxide and topical
antibiotic cream can be applied. If topical
management is unsuccessful, the site
should be cultured and oral antibiotics
should be administered. If an abscess is
present, it can be aspirated or drained
percutaneously.
How can a can a Forceful injection of fluid via a 5 cc
blocked feeding tube syringe may be all that is required to
be unclogged? unclog a tube. If this is unsuccessful, a
3 cc syringe can be attempted. If manual
injection is unsuccessful, a flow-switch
device can be applied to allow for rapid
alternation between injection pressure
and suction. If mechanical unclogging
is unsuccessful, a solution containing
digestive enzymes can be injected to
break down the obstructing feed material.
If a tube cannot be The tube should be exchanged for a new
unclogged, what tube.
should be done next?
What can be The tube can be trimmed/shortened or
done to decrease exchanged for a different device.
the likelihood
of small bowel
intussusceptions?
842 H. Chengazi and M. K. G. Lazaga

Cecostomy

Evaluating the Patient

What is the primary Fecal incontinence. This may be due
indication for to myriad congenital, developmental,
cecostomy tube posttraumatic, and behavior issues,
placement? including Spina Bifida, cerebral palsy, and
imperforate anus.
What is the benefit A cecostomy tube allows for controlled
of a cecostomy bowel irrigation, allowing for scheduled
tube? evacuation.
What are some Nearby VP shunt tip, uncorrectable
contraindications coagulopathy, or other medical conditions
for cecostomy tube that would increase the risk of procedure
placement? or sedation are all contraindications.
At what age is a Timing is variable, but consensus from
cecostomy tube parents and patients suggests placement
ideally placed? before school age (4–6 years old) is
preferred. By this age, parents have usually
developed good understanding of their
child’s bowel behaviors, then children are
able to provide some input, and they are at
an age where they can develop a routine
that helps avoid incontinence in school.

Pre-procedure and Technical Considerations

What special Latex allergies are common in Spina
precautions must Bifida patients, so precautions must be
be taken with Spina taken.
Bifida patients?
 56 Pediatrics – Enteral Access 843

Does the patient Yes, a clear liquid diet for 2 days prior
require any bowel to the procedure and oral administration
preparation? of sodium phosphate solution the night
before the procedure. An additional dose
of sodium phosphate can be given the
morning of the procedure, as needed.
What pre-procedural Ultrasound should be performed to
imaging should be delineate the liver, gallbladder, and
performed, and which urinary bladder.
organs marked?
What prophylactic Gentamicin, ampicillin, and
antibiotics are given metronidazole are all given as a single
for the procedure? pre-procedure dose.
How is the bowel The bowel is insufflated via Foley
insufflated for access? catheter placed in the rectum, with
subsequent gas enema.
How is the position of Intermittent images should be obtained
the cecum confirmed during insufflation. This allows for the
fluoroscopically? identification of redundant loops of
bowel that may mimic the cecum.
What other structures The iliac crest and lower costal margin
should be identified should be identified and avoided.
via physical exam and Ventriculoperitoneal shunt tubing should
fluoroscopy? also be identified and avoided if present.

Relevant Materials and Equipment

Why is Glucagon often Glucagon slows bowel motility
administered during cecostomy and prolongs the effects of
tube placement? bowel insufflation.
What is used for skin access Lidocaine 1–2% administered
site anesthesia? via a 27–30G needle.
What size needle is used to An 18-gauge puncture needle.
access the cecum?
(continued)
844 H. Chengazi and M. K. G. Lazaga

What is the purpose of To hold the cecum against the

retention sutures? anterolateral abdominal wall.
What type of guidewire is A stiff 0.035-inch guidewire.
typically used for cecostomy
placement?
What size tube is typically An 8.5 French locking pigtail
placed? catheter or equivalent.

General Step by Step: Retrograde Approach

1. Administer gas enema via rectally placed foley catheter.
Intermittent fluoroscopic imaging is essential to identify
redundant loops of bowel.
2. Under fluoroscopic guidance, advance plexy sutures and
secure the cecum to the anterior abdominal wall.
3. Puncture the cecum with a needle, inject contrast to con-
firm position, and advance a wire to secure access.
4. Use a fascial dilator to prepare the tract.
5. Advance a locking pigtail catheter over wire, and inject
contrast with orthogonal views to confirm position.

Post-procedure Care and Maintenance

Does the patient require Yes, the gentamicin and ampicillin
additional antibiotics should be continued for two days, and
post-procedure? metronidazole should be given for
5 days (as an oral medication).
How often should the The catheter should be flushed twice
catheter be flushed? a day with 10 mL of saline until the
patient can start anterograde bowel
irrigation.
When can a patient Anterograde irrigation can start about
begin anterograde 10 days after tube placement. Until
bowel irrigation after that time, the patient should continue
cecostomy placement? their pre-procedural enema regimen.
 56 Pediatrics – Enteral Access 845

When should the At 14 days post-placement.

retention sutures be cut?
Is there a low-profile Yes, there is a low-profile “trap door”
tube option for option that comes with different tract
cecostomy? lengths. These can be exchanged for
after about 2 months.
How often does a tube As needed for failure, or annually.
need to be exchanged?

Complications
What should be The tube can be removed and replaced
done if the tube appropriately if tract dilation has not been
is inadvertently performed. If the tract has been dilated, the
malpositioned tube should be left in place until the tract
outside the cecum? matures. Close surveillance for signs of
chemical peritonitis should be performed in
both situations.
How is peritonitis Discontinuation of enemas and a course of
managed? broad-spectrum antibiotics.
How common is Granulation tissue is very common and
granulation tissue may be seen up two-thirds of patients.
after cecostomy This can be managed with silver nitrate
tube placement? cauterization as indicated.
What increases The longer a tube goes without exchange,
the likelihood of the more likely complications are.
tube occlusion or
leakage?
How is tube If a guidewire can be advanced, the tube
occlusion managed? can be exchanged over wire. If a guidewire
cannot be advanced and the tract is mature,
the tube may be removed and a guidewire
subsequently placed via the tract (over
which a new tube is placed).
(continued)
846 H. Chengazi and M. K. G. Lazaga

How is tube In a mature tract, a Foley catheter can

dislodgement be placed by the patient or parent, and
managed? subsequently exchanged for a new tube. If
the tract is not mature, the patient should
be seen by an interventional radiologist
who can make an attempt to access the
tract. If these attempts are unsuccessful, a
new tube insertion must be scheduled.

Further Reading
Connolly BL. Gastrointestinal interventions--emphasis on children.
Tech Vasc Interv Radiol. 2003;6(4):182–91.
Connolly BL, Chait PG, Siva-Nandan R, Duncan D, Peer
M. Recognition of intussusception around gastrojejunostomy
tubes in children. AJR Am J Roentgenol. 1998;170(2):467–70.
McHugh K. Conversion of gastrostomy to transgastric jejunostomy
in children. Clin Radiol. 1997;52(7):550–1.
Roebuck DJ, McLaren CA. Gastrointestinal intervention in chil-
dren. Pediatr Radiol. 2011;41(1):27–41.
Temple M, Marshalleck FE. Pediatric interventional radiology:
handbook of vascular and non-vascular interventions. New York:
Springer; 2014.
Towbin R, Baskin K. Pediatric interventional radiology. Cambridge,
UK: Cambridge University Press; 2015.
Towbin RB, Ball WS Jr, Bissett GS 3rd. Percutaneous gastrostomy
and percutaneous gastrojejunostomy in children: antegrade
approach. Radiology. 1988;168(2):473–6.
Chapter 57
Vascular Anomalies
Madeline Leo

High-Yield History
When are venous At birth, with slow growth over time
malformations usually
present?
When are lymphatic At birth, or sometimes prenatally on
malformations usually ultrasound
identified?
What are several periods Puberty and pregnancy - This is
of life in which vascular believed to be due to effects of
malformations are likely hormonal change.
to grow?
Why can venous Thrombosis of the lesion can occur
malformations be painful? due to the slow nature of venous
flow, which leads to inflammation
and pain. Venous dilation can also
contribute to pain.

M. Leo (*)
Department of Radiology, UPMC Medical Education,
Pittsburgh, PA, USA
e-mail: [email protected]
© Springer Nature Switzerland AG 2022 847
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_57
848 M. Leo

Evaluating the Patient

Describe the appearance of Lymphatic malformations present
lymphatic malformations on physically as soft, compressible
physical exam. masses.
Describe the physical They are soft, compressible, and
appearance of venous nonpulsatile. They can be elicited
malformations. by Valsalva maneuver. Phleboliths
are often helpful in distinguishing
venous malformations.
What imaging modalities can Ultrasound, CT, MRI, and
be used to evaluate vascular angiography can all be used to
anomalies? evaluate vascular anomalies.
Different studies are useful based
on patient anatomy and type of
anomaly.
Describe the typical
imaging appearance of
lymphatic, venous, and
high-flow malformations on
ultrasound, CT, and MRI.
 Computed tomography
Type Ultrasound (US) (CT) Magnetic resonance (MRI) Angiography
Lymphatic Anechoic spaces Low-attenuation masses Multi-cystic masses with Can show obstruction,
Possible internal Possible fluid levels from fluid-type signals on all collaterals, or possible
septations or debris low-flow state sequences lymph leak
Minimal flow Possible peripheral T2: hyperintense signals
enhancement on contrast- T1: hypointense signals
enhanced CT Can extend through soft
tissue compartments

Venous Heterogeneous or Hypoattenuating masses T1 iso/hypointense signals Venography shows

hypoechoic grayscale Dystrophic calcifications Increased fat within lesion dynamic venous
appearance sometimes present can create T1 hyperintense drainage patterns
Monophasic flow on signals Estimates the amount
57

Doppler Hyperintense signals on of sclerosing agent

T2 (usually preferred needed
sequence)
AVM Multiple well-defined Typically not performed Multiple hypertrophied Hypertrophied arteries
anechoic structures on unless concern for acute arteries with dilated veins with rapid shunting
grayscale US bleeding Signal voids on spin echo into directly connected
Pulsatile venous flow Hypertrophied vessels images outflow veins
with low resistance draining rapidly into Flow related signal on No soft tissue
arterial flow on Doppler outflow vein gradient echo sequences enhancement
Vascular Anomalies
849
850 M. Leo

What vascular malformation Venous malformation

is characterized by well
defined, rounded, scattered
calcifications within a soft
tissue mass?
What property of a vascular A low-flow state
malformation can be
deduced from visualizing
fluid levels on CT?
What malformation is An arteriovenous malformation –
characterized by a “mosaic” This is usually the area of the nidus
pattern on Doppler flow? of the malformation.
What physical exam finding Bruit
is typical of an arteriovenous
malformation?
What laboratory finding D-dimer has shown to be elevated.
is elevated in venous Low fibrinogen level has also been
malformations? described.
What are some clinical Klippel-Trenaunay
syndromes associated with Parkes Weber syndrome
vascular malformations? Sturge Weber Syndrome
Maffucci syndrome
CLOVES (congenital lipomatous
overgrowth with vascular
malformations, epidermal nevi, and
skeletal anomalies)
What is Klippel-Trenaunay A combined vascular
syndrome? malformation syndrome, associated
with capillary, venous, and
lymphatic malformations. There is
a characteristic overgrowth of the
extremity affected.
 57 Vascular Anomalies 851

Relevant Anatomy
What are the different Capillaries, veins, arteries, and
general vascular structures lymphatics can be involved.
that can be involved in Multiple types of structures can be
vascular anomalies? involved in a single lesion.
Developmental defects Embryonic lymphangiogenesis or
during what processes lead vascular morphogenesis.
to vascular anomalies?
Describe the difference Macrocystic malformations are
between macrocystic and composed of cyst spaces >2 cm,
microcystic lymphatic and microcystic are composed of
formations. spaces <2 cm.
What is the typical anatomic See below
distribution of venous
malformations?

Body part Prevalence (%)

Head and neck 40%
Extremities 40%
Trunk 20%

The capillary malformation Sturge-Weber syndrome

commonly known as a
“port-wine stain“with
a distribution over the
V1 area of the face is
commonly associated with
which syndrome?
Where do AVMs most They are most commonly reported
commonly occur? in the extremities and pelvis.
They usually expand during
adolescence. They can be treated
with transcatheter or percutaneous
nidal ablation.
(continued)
852 M. Leo

Define the “nidus” of an The nidus is the area which leads

AVM. to direct, rapid shunting of arterial
to venous flow within an AVM,
without a normal capillary network.
This is typically the directed area
of treatment. The veins are often
described as “arterialized.”

Relevant Materials
What is sclerotherapy? Sclerotherapy is the use of an agent’s
biologic, physical, and chemical
properties to induce a controlled
inflammatory response rendering
the tissue fibrosed or hardened
with drastically different functional
capability.
What are some ways that Inflammatory response
sclerotherapy effects target Thrombosis
tissue? Protein denaturation
Cell dehydration
Gives some examples Ethanol
of agents used in Sodium tetradecyl sulfate (STS)
sclerotherapy. Ethanolamine
Hypertonic saline
Bleomycin
N-Butyl-2-cyonoacrylate (NBCA)
OK 432
Identify the relationship
between vascular
malformation subtypes
and some typical types
of sclerosants used in
treatment.
 57 Vascular Anomalies 853

Type Agents used

LM Ethanol
Doxycycline
Bleomycin
OK 432
STS
VM Ethanol
STS
AVM Ethanol
NBCA

What is the mechanism STS causes endothelial damage. Risks

of action of STS? of use include pain and skin necrosis.
How is STS foam A combination of 1 mL 3% STS with
prepared? 4 mL of air is mixed to produce a
foam mixture which can be injected
via catheter access.
Which agent is a biologic OK 432
product created as a
product from group A
strep that causes natural
killer cell activation in
sclerotherapy?
What is the mechanism Bleomycin has anti-neoplastic
of action of bleomycin properties, which result in fibrosis
and what is the secondary to DNA damage. It can be
most feared toxicity used in the treatment of superficial
complication? lymphatic malformations. The most
feared toxicity is pulmonary damage
or fibrosis.
Name some Saline and glucose solutions
hyperosmotic agents used dehydrate cells, but can also carry a
in sclerotherapy. risk of causing tissue necrosis.
(continued)
854 M. Leo

What is the mechanism NBCA is an adhesive “glue” agent

of action of n-Butyl which polymerizes when exposed
cyanoacrylate (NBCA)? to ionic environments through an
exothermic reaction, and creates
fibrosis. It has been described
in the use of certain high-flow
malformations with concurrent flow
control techniques.
What are some additional Radiofrequency ablation and
therapeutic modalities laser therapy have been used in
that can be applied in the treatment of some vascular
vascular malformations malformations.
aside from sclerotherapy?

Indications/Contraindications
What are some Indications include pain, hemorrhage,
indications for high-output cardiac complications,
treating vascular and malformations that interfere with
malformations? normal growth.
Name some relative Pregnancy, iodinated contrast
contraindications anaphylaxis, sepsis, acute renal failure
for treating vascular
malformations.
Describe the Oral prednisone dosed 0.5 mg/kg
prophylactic treatment (max 50 mg) for 3 doses at 13, 7, and
of iodinated contrast 1 hours before a procedure in addition
allergy in children. to a 1.25 mg/kg dose (max 50 mg)
of diphenhydramine 1 hour before
a procedure is the current regimen
recommended for a known contrast
allergy.
 57 Vascular Anomalies 855

General Step by Step

Historically, what is the Surgical resection was historically
most common treatment preferred.
approach for lymphatic
malformations?
What medication is Antibiotic administration,
administered before treating due to risk of spontaneous
lymphatic malformations? infection, has been used. Dosing
recommendations are cefazolin
25 mg/kg in pediatric patients or
clindamycin 10 mg/kg if there is
concern for penicillin allergy.
What pre-procedural lab Complete blood count
values are important to Electrolytes
obtain prior to performing Creatinine
treatment? Coagulation studies
D-dimer
Outline the general process 1. The patient is sterilely prepped
for treating a venous and draped.
malformation. 2. Vascular access is gained into the
lesion, with contrast injected to
locate the lesion.
3. The sclerosant is injected under
fluoroscopy guidance.
4. The access devices are withdrawn
safely.
5. A sterile dressing applied.
6. Post-procedure care is initiated.
What medication can A steroid taper for 2 days can help
be given to reduce with swelling and inflammation
inflammation post-­ secondary to treatment.
procedure for a low-flow
lesion?
(continued)
856 M. Leo

What are important Bed rest, depending on if the

elements of post-procedural procedure was for a venous or
care? arterial malformation (six hours
for arterial versus two for venous).
Pain control is important, and
can usually be managed with oral
medication.
In treating high-flow The goal of treatment is to
vascular malformations such selectively target the nidus of
as AVMs, what is the goal the AVM, which is described
of treatment and what are previously. Different approaches of
some different approaches targeting the nidus include:
in achieving this goal?  Superselective catheterization
of the nidus with subsequent
sclerotherapy administration
 Direct nidus puncture using a
percutaneous approach
 Retrograde sclerotherapy
infusion through a venous
approach, with balloon-assisted
occlusion of the feeding arterial
vessel
Flow rate and necessary dosage of
therapy agent are always estimated
before using angiography.

Complications
What are some Erythema and skin breakdown,
complications of bleeding, hemoglobinuria, and DVT
sclerotherapy performed are all complications which can
for venous malformations? occur following sclerotherapy.
What are complications Non-target embolization can occur,
of treating high-flow which leads to possible ischemia
malformations? and damage if the treatment agent
goes outside of the intended lesion.
Passage of embolic agent to the
lungs is also a complication.
 57 Vascular Anomalies 857

What is the value of using CT can be used to visualize

cross-sectional imaging the compression and potential
(CT or MRI) as a modality compromise of surrounding
for evaluating lymphatic anatomic structures, such as the
malformations? airway.
Which sclerosing agent Ethanol
can cause acute pulmonary
hypertension?
What is a synovial venous A venous malformation about a
malformation? joint that can possibly extend into
the joint space and cause sequelae
of hemarthrosis

Landmark Research
Mulliken JB, Glowacki J. Hemangiomas and Vascular
Malformations in Infants and Children: a classification based
on endothelial characteristics. Plastic and Reconstructive
Surgery. 1982; 69(3): 412–22.
• Vascular anomalies classified into two groups – hemangio-
mas and vascular malformations.
• Defining characteristic of hemangioma classified as
increased mitotic activity in the cells within the lesion.
• Defining characteristic of a malformation is a lesions that
shows normal mitotic activity and does not regress through-
out life.
ISSVA Classification of Vascular Anomalies ©2018
International Society for the Study of Vascular Anomalies
Available at “issva.org/classification” Accessed 24 September
2018.
• The most updated ISSVA classification scheme is broadly
divided into vascular tumors (benign vs. malignant) and
vascular malformations (further divided into categories of
simple, combined, those of major vessels, and those associ-
ated with other anomalies).
858 M. Leo

Merrow AC, Gupta A, Patel MN, Adams DM. 2014

Revised Classification of Vascular Lesions from the
International Society for the Study of Vascular Anomalies:
Radiologic-Pathologic Update. Radiographics. 2016; 36(5):
1494–516.
• The two general classifications of vascular malformations
are low-flow malformations, which include lymphatic and
venous malformations, and high-flow malformations.
• Two examples of high-flow malformations are arteriove-
nous malformation (AVM) and arteriovenous fistula
(AVF) – AVMs are associated with syndromes and result
in primitive arteries and veins communicating, causing a
shunt of oxygenated blood away from target tissues. AVFs
are direct communications, which are often created
iatrogenically.
Cahill AM, Nijs ELF. Pediatric Vascular Malformations:
Pathophysiology, Diagnosis, and the Role of Interventional
Radiology. Cardiovascular and Interventional Radiology.
2011; 34(4): 691–704.
• The four stages of arteriovenous malformations based on
Schobinger are: 1. Quiescence; 2. Expansion; 3. Destruction;
4. Decompensation.

Common Questions
What is the most Cavernous venous malformation.
common type of vascular In general, the reported
malformation? prevalence of various vascular
malformations is:

Venous 70%
Lymphatic 12%
AVM 8%
Combined malformation syndromes 6%
Capillary malformations 4%
 57 Vascular Anomalies 859

What is the most common Infantile hemangioma or

benign vascular tumor in “strawberry” mark – they are
children? typically not present at birth, but
emerge after. They tend to involute
over multiple years. Oral propranolol
has largely become the treatment of
choice.
How long after treatment Lesions actually might appear
can a patient expect worsened and swell in the first
to see a difference in 2 weeks, but typically start to improve
appearance of venous in 4–6 weeks.
malformation?
How many treatments Treatment course and number of
are usually necessary for treatments needed is variable and
vascular malformations? patient-dependent. Some patients
only require one treatment, while
others may need many depending on
the size and symptoms of the vascular
malformation.
How long should children 10–14 days.
avoid physical activity
post procedure?
What medical Interventional radiologists can
specialties comprise an collaborate with plastic surgeons,
interdisciplinary team in orthopedic surgeons, and
caring for patients with pediatricians to care for patients with
vascular anomalies? vascular anomalies.

Further Reading
Albanese G, Kondo KL. Pharmacology of sclerotherapy. Semin
Interv Radiol. 2010;27(4):391–9.
Cahill AM, Nijs ELF. Pediatric vascular malformations: patho-
physiology, diagnosis, and the role of interventional radiology.
Cardiovasc Intervent Radiol. 2011;34(4):691–704.
Chehab MA, Thakor AS, Tulin-silver S, et al. Adult and pediatric anti-
biotic prophylaxis during vascular and IR procedures: a Society of
Interventional Radiology Practice Parameter Update Endorsed
860 M. Leo

by the Cardiovascular and Interventional Radiological Society

of Europe and the Canadian Association for Interventional
Radiology. J Vasc Interv Radiol. 2018;29(11):1483–501.
Heran MK, Marshalleck F, Temple M, et al. Joint quality improve-
ment guidelines for pediatric arterial access and arteriography:
from the Societies of Interventional Radiology and Pediatric
Radiology. J Vasc Interv Radiol. 2010;21(1):32–43.
ISSVA Classification of Vascular Anomalies ©2018 International
Society for the Study of Vascular Anomalies Available at “issva.
org/classification” Accessed 24 Sept 2018.
Merrow AC, Gupta A, Patel MN, Adams DM. 2014 revised clas-
sification of vascular lesions from the International Society for
the Study of vascular anomalies: radiologic-pathologic update.
Radiographics. 2016;36(5):1494–516.
Mulliken JB, Glowacki J. Hemangiomas and vascular malformations
in infants and children: a classification based on endothelial
characteristics. Plast Reconstr Surg. 1982;69(3):412–22.
Ng BCK, San CY, Lau EYK, Yu SCH, Burd A. Multidisciplinary
vascular malformations clinic in Hong Kong. Hong Kong Med J.
2013;19(2):116–23.
Rosen RJ, Borowski A. Arteriovenous malformations of the viscera
and extremities. In: Kandarpa K, Machan L, Durham J, editors.
Handbook of interventional radiologic procedures. Philadelphia:
Wolters Kluwer; 2016.
Sadick M, Müller-Wille R, Wildgruber M, et al. Vascular anomalies
(part I): classification and diagnostics of vascular anomalies.
Rofo. 2018;190:825–35.
Chapter 58
Pediatric Genitourinary
Interventions
Ethan J. Speir, C. Matthew Hawkins, and Anne Gill

Evaluating the Patient

What labs should be ordered prior CBC, PT/INR, and BUN/
to any GU intervention? Creatinine
For patients undergoing PCN
or stent placement, urinalysis,
and urine culture may also
be considered.
(continued)

E. J. Speir (*)
Department of Radiology and Imaging Sciences, Division of
Interventional Radiology and Image Guided Medicine, Emory
University School of Medicine, Atlanta, GA, USA
e-mail: [email protected]
C. M. Hawkins · A. Gill
Department of Radiology and Imaging Sciences, Division of
Interventional Radiology and Image Guided Medicine, Emory
University School of Medicine, Atlanta, GA, USA
Department of Radiology and Imaging Sciences, Division of
Pediatric Radiology, Children’s Healthcare of Atlanta,
Atlanta, GA, USA
e-mail: [email protected]; [email protected]

© Springer Nature Switzerland AG 2022 861

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_58
862 E. J. Speir et al.

What abnormality should be Vesicoureteral reflux (VUR).

suspected in infants and children The test of choice is voiding
with recurrent UTIs? What is the cystourethrogram (VCUG).
test of choice for diagnosing this?
In a patient with unilateral Normal.
ureteral obstruction and severe
unilateral hydronephrosis, would
serum creatinine expected to be
low, normal, or elevated?
Which patients should be Children undergoing PCN
considered for general anesthesia? or stent placement (can be
considered for renal biopsy
in younger children).
Which patients may be considered Children undergoing
for IV sedation? renal biopsy or PCN/stent
exchange.

High Yield History

You are consulted for Suspect VACTERL association
placement of a PCN
in a 3-month-old with
hydronephrosis from
ureteropelvic junction (UPJ)
obstruction. In reviewing the
patient’s chart, you notice a
history of ventricular septal
defect and trachea-esophageal
fistula. What other birth
defects should you suspect?
 V – Vertebral anomalies
 A – Anorectal malformations
(e.g., imperforate anus)
 C – Cardiovascular anomalies
 58 Pediatric Genitourinary Interventions 863

 T – Tracheoesophageal fistula

 E – Esophageal atresia
You perform a biopsy on renal WAGR (aniridia, GU
mass in 4-year-old female. abnormalities, mental
Pathology is consistent with retardation)
Wilms tumor. What associated
syndromes may be found
when reviewing the patient’s
history?
Denys–Drash syndrome
(gonadal dysgenesis,
nephropathy)
Beckwith–Wiedemann syndrome
(hemihypertrophy, macroglossia)
What aspects on a patient’s Young age (males <1-year-­
history increase their risk of old, females <4 years-old),
UTI? uncircumcised males, white
race, incomplete voiding due to
neurogenic bladder (e.g. spina
bifida), and anatomic urinary
obstruction (posterior urethral
valves, extrinsic compression of
the ureters, nephrolithiasis, etc.)
What aspects on a patient’s History of prior nephrolithiasis,
history increase their risk of family history of renal stones,
nephrolithiasis? recurrent UTI (especially
Proteus or Klebsiella infections),
structural abnormalities (e.g.
UPJ obstruction or horseshoe
kidney), metabolic disorder (e.g.,
hypercalciuria or hyperoxaluria),
and ketogenic diet.
864 E. J. Speir et al.

Indications/Contraindications
What are common Uncorrectable coagulopathy or severe
contraindications to any anemia, thrombocytopenia (platelets
GU intervention? <50,000 × 106/L), INR >1.5, serious
contrast allergy (e.g., anaphylaxis).
What are common Histologic diagnosis for rising
indications for renal creatinine and worsening renal
biopsy? function, monitoring disease
progression (e.g., lupus nephritis), and
assessing for renal allograft rejection.
What are common Relief of urinary obstruction, drainage
indications for PCN of complications of pyelonephritis,
placement? urinary diversion for urinary leaks,
antegrade pyelogram, percutaneous
calyceal access for nephrolithotomy.
What are common Congenital ureteral stenosis, fibrous
indications for dilation/ bands, postoperative stricture (e.g.,
stenting of ureteral post-transplant), and anomalous
strictures? ureteral insertions.
What are relative Strictures longer than 2 cm, active
contraindications for infection, significant segmental ureteral
dilation/stenting of ischemia, recent surgery (e.g., ureteral
ureteral strictures? implantation or renal transplant in the
last 30 days).

Relevant Anatomy
The kidneys are located in T12 to L2/L3. Due to the
the retroperitoneum at what adjacent liver, the right kidney
vertebral level? is typically slightly more
inferior compared to the left.
What is the name of the fascia Gerota’s fascia.
that defines the perirenal space?
 58 Pediatric Genitourinary Interventions 865

In standard renal arterial 30%. Accessory arteries may

anatomy, each kidney is arise from the aorta or iliac
perfused by one renal artery. arteries.
What percentage of the
population has multiple renal
arteries?
What is Brodel’s line? A relatively avascular
plane located along the
posterolateral kidney that
lies between the anterior and
posterior segmental branches
of the renal artery.

Relevant Materials
What imaging Ultrasound. CT may be used for targeted
modality is lesions not well seen on ultrasound, difficult
preferred for renal anatomy (e.g. severe scoliosis or ectopic
biopsy in pediatric kidneys), and morbidly obese patients.
patients?
What biopsy 16 G–18 G semiautomated core needle
needle (size and system.
type) should be
used during renal
biopsy?
18 G may be preferred in infants, children
<10 kg, or patients with higher bleeding risk.
What imaging Ultrasound for percutaneous access into a
modality is most calyx and fluoroscopy for placement of the
often used for catheter into the renal pelvis or bladder.
guidance during
PCN placement?
What size access 8–22 G needle.
needle should
be used for PCN
placement?
(continued)
866 E. J. Speir et al.

What guidewire Begin with 0.018″ wire advanced through

(size and type) the needle into the renal pelvis and dilate
should be used to the percutaneous tract until the wire can
advance the PCN be exchanged for a 0.035″ relatively stiff
drainage catheter? guidewire (e.g., Amplatz or Rosen).
What PCN 5–6 Fr locking (e.g., Cope loop) Pigtail
drainage catheter catheter.
(size and type)
should be used?
Larger catheters (e.g., 8–10 F) can be used
in older children >20 kg.
What imaging Fluoroscopy.
modality is most
often used to guide
dilation/stenting of
ureteral strictures?
What guidewire For particularly tight strictures, an 0.018″
(size and type) guidewire may be necessary to cross the
should be used to stenosis. Otherwise, a 0.035″ hydrophilic
traverse a ureteral guidewire is used.
stricture?
What type of Angle-tipped hydrophilic catheter, usually
catheter may be 4 Fr.
used to traverse a
ureteral stricture?
What size Balloon diameter should be 1–2 mm
angioplasty balloon wider than the normal-appearing ureter.
should be used? Measurements of the ureter should
be obtained from the nephrostogram.
Generally, 6–10 mm diameter balloons
can be used for UPJ and UVJ strictures,
whereas 4–6 mm diameter balloons are used
for ureteral strictures.
Name two types Double-J catheter (i.e., nephroureteric
of catheters that stent; internal drainage) or percutaneous
can be used for nephroureteral catheter (i.e., PCNU or
ureteral stenting. internal-external drainage).
 58 Pediatric Genitourinary Interventions 867

General Step by Step

What is ideal patient Prone or lateral decubitus with patient
positioning for renal facing away from the operator. A
biopsy? wedge can be placed under the patient,
above the iliac crest, to open the
window between the iliac crest and the
12th rib.
What anatomic Mid-scapular line.
plane can be used to
determine renal biopsy
skin entry site?
Where is the ideal site to Inferior pole (reduces risk of
biopsy the kidney? pneumothorax) along the superficial
cortex, where glomeruli are most
dense.
What is ideal patient Prone or oblique facing away from the
positioning for PCN operator.
placement?
What is the route of Traversing the renal parenchyma and
an ideal nephrostomy entering a posterior, middle, or inferior
track? calyx,
What is the Limited surrounding renal parenchyma
disadvantage of a direct to provide tamponade against bleeding
puncture of the renal or urine leak as well as greater risk to
pelvis? hilar structures (e.g., renal vein/artery).
What is the “double A small-caliber needle (e.g., 22 G) is
stick” method? used to access the collecting system
and inject a small amount of contrast
to opacify the system. An ideal calyx
is then targeted with a second needle
under fluoroscopy.
Following the return of Advance the guidewire through the
urine though the access needle, ideally into the ureter.
needle, what is the next
step?
(continued)
868 E. J. Speir et al.

What is the preferred Advance until the Cope loop can be

final position of the fully formed inside the renal pelvis.
nephrostomy catheter?
What is the route of Interpolar or upper pole calyceal
an ideal percutaneous access reduces entry angle and offers
nephrostomy track for more direct trajectory for accessing the
dilation/stenting of UPJ and ureter.
ureteral strictures?
After traversing Exchange for a stiff guidewire over
the stricture with a which the angioplasty balloon can be
hydrophilic wire and passed.
coiling it in the bladder,
what is the next step?
If the stricture persists Dilation of the stricture using a cutting
following multiple balloon.
balloon dilations, what
can be considered?
How can the length of Length (cm) = Patient age (yrs) + 10.
an internal ureteral stent
be estimated?
Alternatively, the “bent wire method”
may be used.

Complications
What are some minor Asymptomatic perinephric hematoma
complications of renal (85%) and transient gross hematuria
biopsy? (6–8%).
What are some major Hemorrhage requiring transfusion
complications of renal (1–3%), hematoma causing renal
biopsy? compression or Page kidney, vascular
injury (arteriovenous fistula or
pseudoaneurysm formation), or
pneumothorax.
 58 Pediatric Genitourinary Interventions 869

What are some minor Asymptomatic perinephric hematoma

complications of PCN and transient gross hematuria.
placement?
What are some major Hemorrhage requiring transfusion,
complications of PCN sepsis, and urine leak.
placement?
Following PCN Demerol (0.8–1 mg/kg up to 50 mg
placement, the patient IV).
develops rigors. What
is the best course of
management?
In addition, hemodynamic monitoring,
IV fluid bolus, broad-spectrum
antibiotics (e.g., Levofloxacin or
Ampicillin/Sulbactam) should be
considered.
What are some acute Acute post-procedure obstruction
complications of ureteral (especially with balloon dilation
stricture dilation/ without stent placement), transient
stenting? hematuria, ureteral rupture and urine
leak, and UTI/Urosepsis.
What are some delayed Stent migration, recurrence, and need
complications of ureteral for additional intervention, UTI/
stricture dilation/ Urosepsis.
stenting?

Common Questions
How long Although observation time varies by
following a renal institution, 98% of complications manifest
biopsy should within 24 hours.
the patient be
monitored?
How often should Approximately every 2–3 months to prevent
PCNs and stents occlusion from calcification/debris and/or
be replaced? infection.
(continued)
870 E. J. Speir et al.

Name two Dislodgement (check suture site) or

common reasons occlusion (flush with 5–10 mL of saline).
why a PCN or
stent may stop
draining.
What is Compression of the left renal vein between
Nutcracker the SMA and the abdominal aorta. This
syndrome? How results in venous hypertension which, if
do affected severe enough, can cause gross hematuria
patients often due to rupture of thin-walled varices into
present? the renal collecting system. Patients may also
present with a varicocele.

Further Reading
Barnacle AM, Roebuck DJ, Racadio JM. Nephro-urology interven-
tions in children. Tech Vasc Interv Radiol. 2010;13(4):229–37.
Kurklinsky AK, Rooke TW. Nutcracker phenomenon and nut-
cracker syndrome. Mayo Clin Proc. 2010;85(6):552–9.
Palmer J, Palmer L. A simple and reliable formula for determin-
ing the proper JJ stent length in the pediatric patient: age + 10.
Urology. 2007;70:264.
Temple M, Marshalleck F, SpringerLink (Online service).
Pediatric interventional radiology handbook of vascular
and non-vascular interventions. Available from: https://doi.
org/10.1007/978-­1-­4419-­5856-­3
Towbin RB, Baskin KM. Pediatric interventional radiology.
Cambridge: Cambridge University Press; 2015. Print.
 Part XI
Other and New Procedures
Chapter 59
Tubes and Biopsies
Oleksandra Kutsenko and Mohammed Jawed

Biopsies

Clinical Considerations
What are the Biopsies can help to diagnose
indications for malignancy, guide staging, estimate
percutaneous biopsy? prognosis, provide molecular analysis,
identify susceptibility to targeted
treatments, determine possible familial
risk, and evaluate response to treatment.
Liquid biopsies can detect circulating
tumor cells or tumor-associated proteins
in the blood or fluid collections. In
addition, biopsies can differentiate
benign lesions such as tumors, cysts,
infection, or inflammation. Finally,
sampling of an infected collection can
assess cellular and microbiologic content
as well as determine bacterial antibiotic
sensitivity to guide the treatment.
(continued)

O. Kutsenko (*) · M. Jawed

Radiology Department, SUNY Upstate University Hospital,
Syracuse, NY, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 873

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_59
874 O. Kutsenko and M. Jawed

What is the The National Cancer Institute-Molecular

significance of Analysis for Therapy Choice (NCI-­
the NCI-MATCH MATCH) trial is the largest precision
Precision Medicine medicine cancer trial to date based on
Cancer Trial? the number of patients, treatment arms,
and types of cancer being studied in a
single clinical trial. It enrolls patients
at nearly 1100 cancer centers and
seeks to determine whether matching
certain drugs or drug combinations
in adults whose tumors have specific
gene abnormalities will effectively
treat their cancer, regardless of their
cancer type. Treatment focuses on
molecular abnormalities instead of the
anatomic organ site of cancer. The trial
is inherently dependent on obtaining a
high-quality biopsy sample for molecular
and genetic analyses.
What are the No absolute contraindications. Relative
contraindications contraindications to percutaneous biopsy
to performing include uncorrectable coagulopathy,
percutaneous biopsy? large body habitus, unfavorable
location of the biopsy target, severely
compromised cardiopulmonary function
or hemodynamic instability, the patient’s
inability to cooperate, or the patient’s
refusal of the procedure.
Who has an increased Patients with congenital bleeding
risk of bleeding? diatheses, disseminated intravascular
coagulation, sepsis, and renal dysfunction
have an increased risk of periprocedural
bleeding. In addition, a bleeding episode
within 3 months of a procedure, prior
bleeding with percutaneous biopsy,
platelet abnormality, increased INR,
prior bleeding with bridging therapy,
mechanical mitral heart valve, and active
cancer further increase the risk of post-­
procedural hemorrhage.
 59 Tubes and Biopsies 875

What is the HAS-­ HAS-BLED score is often used to guide

BLED score? clinical practice in recognizing potential
factors that may increase patient-specific
bleeding risk. Assessment criteria include
hypertension, abnormal renal or liver
function, prior stroke, history of major
bleeding or predisposition to bleeding,
labile INR, age >65 years old, concomitant
use of antiplatelet agent or NSAID, and
history of alcohol or drug use. A score of
>3 predicts a bleeding event.
What are the Low bleeding risk (procedures including
recommended superficial biopsy of a palpable lesion,
laboratory test lymph node, soft tissue, breast, thyroid,
thresholds for superficial bone as well as transjugular
percutaneous liver biopsy): INR <2.0–3.0 and platelets
biopsies? >20,000 per μL.
High bleeding risk (procedures including
deep non-organ biopsies and all solid
organ biopsies): INR <1.5 and platelets
>50,000 per μL.
Biopsies in patients with chronic liver
disease: INR <2.5, platelets >30,000 per
μL, fibrinogen >100 mg/dL
What level of sedation Many of the percutaneous biopsies are
is required for performed with local anesthesia using
percutaneous biopsy? 1% or 2% lidocaine. For more complex
biopsies that may require significant
needle manipulation and/or biopsies of
the deeper structures, moderate sedation
or general anesthesia can be considered.
Does the patient need Yes, for sedation and general
to be NPO? endotracheal anesthesia (GETA).
Though it can be variable per institution,
the patient must withhold solid food
for 6 hours and clear liquids and
medications for 3 hours prior to the
procedure. Some advocate NPO for
8 hours for general anesthesia.
876 O. Kutsenko and M. Jawed

Technical Considerations
Name the types 1. Non-targeted organ biopsy—performed to
of image-guided determine a histologic pattern of generalized
percutaneous organ pathology such as hemochromatosis,
biopsies. amyloidosis, hepatic cirrhosis, chronic kidney
disease, etc.
2. Targeted tissue biopsy—performed to
identify histologic and/or genomic pattern of
a focal lesion.
3. Fluid sampling—performed to determine
cytologic and/or microbiologic content of
the fluid collection within the physiologic
or pathologic space. These may include
loculated fluid collections, pleural effusion,
ascites, pericardial effusion, etc.

What imaging modalities can be used to guide a biopsy?

Modality Advantages Disadvantages Excellent target

Ultrasound Availability Requires Any superficial
No radiation good acoustic organ or
Inexpensive window structure:
Portable thyroid, lymph
Real-time node, kidney,
Fast target etc.
localization
Multiplanar
and allows
off-plane
angulation
Computer High spatial Radiation Bone lesions,
tomography and contrast Expensive any deep
(CT) resolution Difficult structures, lung.
Precision off-plane
Multiplanar angulation
Contrast Time-­
enhancement consuming
 59 Tubes and Biopsies 877

Modality Advantages Disadvantages Excellent target

Fluoroscopy Availability Radiation Bile ducts,
Inexpensive Interposed ureters,
Real-time structures transjugular
and blood liver biopsy.
vessels are not
visualized
Magnetic High Difficult Breast, prostate.
resonance sensitivity off-plane
imaging of lesion angulation
(MRI) detection Expensive
Multiplanar Requires MRI-­
No radiation compatible
Precision equipment
Limited
availability

What are Single stick: Entire biopsy device is inserted

the two most and removed for each pass of the sampling.
common
techniques of
percutaneous
needle biopsy?
Coaxial: Trocar needle is inserted into the
target tissue and left in place while smaller
gauge needle is coaxially passed through the
trocar to take multiple samples. A coaxial
needle biopsy is a faster and safer method with
a lower rate of complications
What needle Core needle biopsy is performed for histologic
size should sampling: 18-gauge or larger needle (9–13
one choose gauge for breast tissue genomic testing)
to acquire
an adequate
sample?
Fine needle aspiration (FNA) is performed for
cytologic sampling: 22- or 25-gauge needle.
(continued)
878 O. Kutsenko and M. Jawed

What needles A Chiba needle is commonly used.

are available for Alternatively, Franseen, Westcott, Greene, and
an FNA biopsy? Spinal needles can be used.
What types Trocar needle with diamond-tip stylet and
of devices are Greene are both coaxial needle systems. Biopty
available for a and Temno are spring-activated cutting needles.
core biopsy?
What is the best The highest biopsy yield is at the periphery
biopsy target in of the lesion avoiding necrotic center. In
the lesion? complex cystic and solid or heterogenous
lesions sampling of the solid, most aggressive,
disorganized component should be obtained.
Biopsy of multiple different areas should be
attempted, while avoiding paucicellular tissues
such as fibrosis/scarring, cystic change, and
necrosis. Color Doppler can help to identify
areas of living tissue.
How to Cell culture medium is used for the sample of
preserve cells that are to be grown or subjected to flow
collected cytometry. Formalin can be used for the sample
samples? that is to be analyzed structurally.

What are some of the challenges of the image-guided

percutaneous biopsy?

Challenge Solution
Low conspicuity, isodense Contrast enhancement, dual-­
lesion modality image fusion (PET/CT,
CT/US, or MR/US fusion)
Small size, complex path to Triangulation method, gantry tilt
lesion technique, CT fluoroscopy
Overlying or intervening Patient repositioning,
structures hydrodissection
Motion Sedation, breath hold
Air introduced into target Drip sterile saline into the needle
tissue following repeated hub each time the inner needle is
insertions of the needle withdrawn
Bowel peristalsis Administer glucagon
 59 Tubes and Biopsies 879

What are the major 1. Bleeding: 5–10% with large needle, 3%

complications with small needle, and 0.1–2.0% with
associated with fine needle
image-guided
percutaneous biopsy?
2. Pneumothorax: 5% with lung biopsies
and 0.5% with non-lung biopsies
3. Infection: 1% for sterile biopsies and
2.5–3% for nonsterile prostate biopsy
4. Injury to a target organ: <2%
5. Peritonitis: 1.5%
6. Hemoptysis: 0.5% with lung biopsies
What techniques Using a coaxial approach and ablating
could be used to the tract with <2 mL of absolute ethanol
mitigate the potential induces coagulation necrosis in the tract
risk of bleeding? that not only stops the bleeding but also
mitigates the very small risk of tumor
seeding.

Organ-Specific Considerations
What is Left hepatic lobe is most accessible via epigastric
the safest subxiphoid approach that allows avoiding major
approach to vessels and pleura. Right hepatic lobe is well
perform a liver accessible via subcostal or low intercoastal
biopsy? approach. Diaphragm should be avoided.
Transparenchymal route with at least 2–3 cm of
normal hepatic tissue peripheral to the lesion is
safe as it allows the normal liver to tamponade
potential hemorrhage. In patients with
uncorrectable coagulopathy or massive ascites
requiring a non-targeted sampling a transjugular
or transfemoral transcaval liver biopsy can be
alternatively performed.
(continued)
880 O. Kutsenko and M. Jawed

Describe the The access is obtained via the right internal

technique of jugular vein, and a needle advanced through
transjugular superior vena cava, right atrium, inferior vena
liver biopsy. cava (IVC), and into the hepatic veins. Biopsy is
performed through the right or middle hepatic
vein.
What patients Patients with difficult hepatic vein cannulation
can benefit due to contractures as seen in cirrhosis or Budd-­
from a Chiari syndrome, patients with increased risk
transfemoral for arrhythmias on whom crossing right heart
transcaval is dangerous, thrombosed or scarred internal
liver biopsy jugular vein as seen in head and neck cancer
approach? patients after radiation therapy, or when single
IR operator is available for the procedure (a
second operator is needed for transjugular
biopsy to maintain the position of the cannula
in the hepatic vein while the biopsy needle is
manipulated). In these scenarios, hepatic tissue
can be obtained directly through the intrahepatic
inferior vena cava via common femoral venous
access.
What The percutaneous biopsy of the hepatic dome
adjunctive lesions is challenging due to difficult access and
techniques can increased potential for complications associated
be used in the with diaphragmatic, lung, or pleural injury.
biopsy of the Adjunctive techniques such as hydrodissection,
hepatic dome artificial pleural effusion or pneumothorax,
lesion? carbon dioxide insufflation, and angiographic
balloon interposition can minimize the risks of
the procedure.
What is Kehr’s Kehr’s sign is an acute prolonged (>5 min)
sign? shoulder pain due to the presence of blood in
the peritoneal cavity when a person is lying
down, and the legs are elevated. It suggests post-­
procedural bleeding and requires ultrasound
re-evaluation for blood in the Morrison’s pouch.
 59 Tubes and Biopsies 881

What is The biopsy of carcinoid metastasis should be

carcinoid avoided as it may cause a massive release of
crisis? vasoactive substances and cause carcinoid crisis
and potential death. A patient may experience
severe flushing, nausea, faintness, generalized
seizure activity, profound hypotension, and
cardiopulmonary arrest.
What is Cytologic evaluation of pleural fluid provides
the clinical important clinical staging information. The
significance presence of a malignant effusion upstages the
of diagnostic disease to stage IV for most cancers.
aspiration
of pleural
effusion?
What are Performing a single pleural puncture with a
the safety coaxial needle system decreases the risk for
considerations pneumothorax. Prone position is preferred to
during the minimize chest wall motion. Aim to bypass
percutaneous interlobar fissures, bullae, vessels >5 mm, and
lung biopsy? bone. Enter the lung at 90° angle to pleural
surface. The post-procedure patient should be
placed on the ipsilateral to biopsy side.
When is a Pneumothorax is a common complication of
chest tube percutaneous lung biopsy. A 8–10-Fr pigtail
required post chest tube should be placed if the patient is
lung biopsy? symptomatic or the pneumothorax continues to
enlarge on serial radiographs. Aspiration of the
air with a syringe can be attempted.
(continued)
882 O. Kutsenko and M. Jawed

What is the The BATTLE study is the first completed

significance prospective, adaptively randomized study in
of BATTLE heavily pretreated non-small cell lung cancer
clinical trial? (NSCLC) patients that mandated tumor
profiling with real-time biopsies. The trial
realizes personalized lung cancer therapy by
integrating real-time molecular laboratory
findings in delineating specific patient
populations for individualized treatment.
The results of BATTLE-1 trial demonstrated
that image-guided 20-gauge percutaneous
transthoracic core-needle biopsy is safe and
provides adequate tissue for the analysis of
multiple biomarkers in a majority of patients.
Metastatic lesions are more likely to yield
diagnostic tissue as compared with primary
tumors.
What are the Historically, all solid renal masses that lack
indications macroscopic fat required surgical resection
to perform due to the risk of upstaging the lesion and
a renal mass seeding the track. However, in recent years,
biopsy? several advances in imaging, procedural, and
cytologic techniques have allowed percutaneous
biopsy to play a larger role in the evaluation of
renal masses to avoid unnecessary surgical or
ablative therapies. Renal mass biopsy should
be considered when a mass is suspected to
be hematologic, metastatic, inflammatory,
or infectious. After a full imaging work-up
a percutaneous renal mass biopsy should be
performed in patients with known extrarenal
primary cancer, unresectable renal cancer, renal
mass that may be caused by infection, patients
with comorbidities that increase the risk of a
surgical procedure, patients with a small (≤3 cm),
hyperattenuating, homogeneously enhancing
renal mass, patients with a renal mass for
which percutaneous ablation is considered, and
indeterminate cystic renal mass.
 59 Tubes and Biopsies 883

What Non-targeted renal biopsy is performed as a

approach workup for renal failure. Lateral (lesion side
should be down) posterior approach is preferred as it
utilized for stabilizes the kidney from respiratory motion
non-focal and bowel interposition. Percutaneous biopsy is
kidney biopsy? performed using a 14- to 18-gauge cutting needle.
Samples should be obtained from the lower pole
cortex where the glomeruli yield is the highest.
This approach also minimizes complications
by avoiding the renal hilum. In patients with
uncorrectable coagulopathy, a transjugular renal
biopsy can be alternatively performed.
What is Page Page kidney should be suspected in any
kidney? patients who present with hypertension, flank
pain, and reduced renal function that started
after a percutaneous renal biopsy. Page kidney
refers to systemic hypertension secondary
to extrinsic compression of the kidney by a
subcapsular collection (e.g., hematoma, seroma,
or urinoma). Compression of the kidney results
in compression of the intrarenal vessels, which
leads to decreased blood flow to the renal
parenchymal tissue and induction of renin
secretion. Renin-angiotensin system activation
results in hypertension.
What A posterior approach in patients positioned
approach is in the ipsilateral decubitus position is most
used to biopsy commonly used. Placing the patient in a
an adrenal decubitus position restricts diaphragmatic
lesion? motion and decreases lung inflation reducing the
risk of pneumothorax. Needle transgression of
the diaphragm, kidney, aorta, and splenic vessels
should be avoided. Alternatively, right (lateral)
or left (anterior) transhepatic approaches can be
used.
(continued)
884 O. Kutsenko and M. Jawed

What structures Needle path during the transgluteal

should be percutaneous biopsy should lie posteromedial
avoided during close to the sacrum to avoid the sciatic nerve
the transgluteal anterolaterally, and below the piriformis muscle
presacral/pelvic to avoid the gluteal vessels.
mass biopsy?
Is the splenic Spleen biopsy should be performed traversing
biopsy as little parenchyma as possible, while hepatic
technique lesion biopsy should be performed traversing
different from generous amount of parenchyma to minimize
a liver biopsy? the bleeding risk.

Drainage Tubes

Clinical Considerations
What is the Percutaneous drainage is defined as the
difference placement of a catheter to provide continuous
between transorificial (transrectal, transvaginal,
percutaneous peroral) or transcutaneous drainage of a
drainage and fluid collection. Percutaneous aspiration is
aspiration? an evacuation of a fluid collection with the
immediate removal of the needle or catheter
after the aspiration.
What types of Benign cystic disease; infectious causes
collections are from bacterial, fungal, mycobacterial, or
amenable to parasitic organisms; postsurgical seromas
percutaneous or lymphoceles; perforation or rupture and
drainage or leakage from hollow viscus or conduits; and
aspiration? collections formed secondary to inflammatory
states or diseases.
 59 Tubes and Biopsies 885

What are the Not all pathologic collections require drainage.

indications for The percutaneous aspiration or drainage
percutaneous should be performed if there is a suspicion
drainage or that the fluid is infected, the collection
aspiration? communicates with an abnormal fistula,
the patient is symptomatic, or if the patient
needs an adjunctive procedure to facilitate
the improved outcome of a subsequent
intervention (paracentesis before liver
intervention, access to a cyst for drainage and
sclerosis).
What are the No absolute contraindications. Relative
contraindications contraindications include uncorrectable
for percutaneous coagulopathy, severely compromised
drainage? cardiopulmonary function or hemodynamic
instability, unfavorable location with lack
of safe pathway, the patient’s inability to
cooperate, or the patient’s refusal of the
procedure.
What are the Percutaneous drainage has a moderate risk of
recommended bleeding. Recommended INR >1.5, platelets
laboratory test >50,000 per μL.
thresholds for
percutaneous
drainage?
Is antibiotic Yes. Initiation of antibiotic therapy is
therapy recommended and should be continued after
indicated prior aspiration and drainage as manipulation
to percutaneous within the abscess with a wire or needle poses
drainage? the risk of rupturing the cavity and spilling
its contents into the surrounding space. This
generally does not affect cultures. Abdominal
abscesses are frequently polymicrobial, and
broad-spectrum antibiotic agents, such as
meropenem, imipenem/cilastatin, doripenem,
piperacillin/tazobactam, or a combination of
metronidazole with ciprofloxacin, levofloxacin,
ceftazidime, cefepime, or ampicillin/sulbactam
are warranted. For pleural abscesses, antibiotic
regimens such as, piperacillin/tazobactam or
amoxicillin/clavulanic acid are suggested.
886 O. Kutsenko and M. Jawed

Technical Considerations
Name two The trocar technique can be used for the
techniques of drainage of large superficial collections. The
percutaneous access is obtained with a 20-gauge needle,
collection drainage. the catheter is loaded on a trocar delivery
system and advanced in tandem to the
needle, the inner stylet is removed and fluid
is aspirated through the metal stiffener, then
the catheter is advanced and locked to coil
within the collection.
Modified Seldinger technique is preferred
in difficult drainages of small, remote, deep
collections with limited access. The access is
obtained with a thin needle (20-gauge Chiba
or Ring needle), the tract is serially dilated
using coaxial exchanges of guidewires and
dilators, and a large catheter is inserted
within the collection.
What size drainage The thicker the fluid, the bigger the
catheter should be drainage catheter that should be placed;
used?
Clear fluid: 6–8-Fr
Thin pus: 8–10-Fr
Thick pus: 10–12-Fr
Collections with debris: 12+ French
What amount of Small volumes of saline (5–20 mL) should
fluid should be be used and should not exceed the volume
used to irrigate the of the cavity as overdistention may cause
collection? bacteremia.
What is an An abscessogram is a fluoroscopically
abscessogram? guided contrast injection in the drainage
catheter with the goal to document
resolution of a fluid collection, identify
fistulae, or troubleshoot malfunctioning
catheters.
 59 Tubes and Biopsies 887

How should Draining catheters are typically anchored

drainage catheters to the skin with nonabsorbable suture or
be maintained? adhesive device. Catheters should be flushed
every day with at least 5–10 mL normal
saline solution to maintain patency.
When should Sinogram, CT, or US imaging demonstrating
drainage catheters diminished collection size and absence
be removed? of fistula; the patient exhibits clinical
improvement; and/or when the catheter
drains <10 mL for several days
What adjunctive Intracavitary installation of fibrinolytic
techniques can agents (4–6 mL of tissue plasminogen
be used in the activator diluted in 50 mL normal saline),
management upsizing to a larger catheter, or using a
of persistent catheter with more side holes (e.g., Cope-­
collections? type loop biliary catheter)
What major Hemorrhage, hemo−/pneumothorax,
complications are bowel or pleural transgression requiring
associated with intervention, enteric fistula, peritonitis,
percutaneous superinfection, bacteremia, and septic shock
drainage
procedures?

Organ-Specific Considerations
What is the Percutaneous drainage allows delay of surgery
significance of until inflammation resolves, nutritional
percutaneous status is optimized, and corticosteroids are
abscess drainage discontinued. This results in a decreased
in patients with extent of bowel resection and possibly a one-­
Crohn’s disease? stage surgical intervention.
What approaches Transabdominal: It usually requires a longer
can be used for path to reach the collection. Epigastric
pelvic collection arteries should be evaluated with Doppler to
drainage? prevent vascular injury and bleeding.
(continued)
888 O. Kutsenko and M. Jawed

Transgluteal: The catheter should be inserted

through the sacrospinous ligament as close
as possible to sacrococcygeal margin to
avoid sciatic nerve injury and inferior to the
piriformis muscle to spare the gluteal arteries.
Transvaginal: Often provides shortest and
safest route to drain infected gynecologic
fluid collections, recurrent endometriotic
cysts, symptomatic hemorrhagic cysts, or
postoperative collections. This route should be
favored in pregnant patients.
Transrectal: The shortest, safest, and least
painful route to drain pre-sacral collection.
It requires cleansing enema prior to the
procedure.
What anatomical Large vessels, dilated bile ducts, gallbladder,
structures and pleura.
should be
avoided during
liver collection
drainage?
What therapeutic Infected necrotizing pancreatitis has an
approach should overwhelming mortality rate of 20–40%,
be employed in and always requires an intervention. The
the management optimal interventional strategy includes
of infected image-guided percutaneous (retroperitoneal)
necrotizing catheter drainage, followed, if necessary,
pancreatitis? by endoscopic or surgical necrosectomy.
A considerable number of patients can be
successfully treated with minimally invasive
percutaneous drainage alone, sparing the
surgery. Some patients may require a step-up
approach that involves percutaneous drainage
of the pancreatic abscess collection followed
by video-assisted retroperitoneal debridement
along the route of the retroperitoneal
drainage catheter.
 59 Tubes and Biopsies 889

What is the The formation of a pancreatic fistula is the

most common most common complication and should be
complication suspected if the drainage output persists or
of infected increases. Pancreatic cutaneous fistula can
necrotizing be confirmed with amylase test. Adjunctive
pancreatitis? octreotide therapy may be helpful to close the
fistula.
Name relevant Intercostal access should be obtained above
anatomic the rib to avoid the neurovascular bundle.
structures for Typically, sixth or seventh intercostal space in
safe pleural the midaxillary line is preferred. Paravertebral
drainage. approach is less favored as the posterior
intercostal vessels course off the ribs and are
more prone to injury.
Should all No. Free-flowing small–to-moderate
parapneumonic pleural effusions do not require drainage.
effusions be Parapneumonic effusions category 3 (large
drained? >50% of hemithorax free-flowing effusion,
loculated effusion, effusions causing thickened
parietal pleura, pleural effusions with pH <7.2,
or pleural glucose <60 mg/dL) and category 4
(frank pus in pleural space) require drainage.
What is trapped The inability of the lung to re-expand after
lung syndrome? pleural effusion drainage due to thick fibrous
or malignant tissue encasing the visceral
pleura. This is a relevant contraindication to
pleural drainage as it is rarely successful.
Does lung Percutaneous drainage of lung abscess may
abscess require cause bronchopleural fistula and should be
percutaneous avoided. Drainage is, however, recommended
drainage? in patients with persistent sepsis (5–7 days
after the initiation of antibiotic therapy),
abscess size >4 cm with an air fluid level,
increased abscess size while on antibiotic
therapy, and in children <7 years old.
890 O. Kutsenko and M. Jawed

Further Reading
Abay S, Winick AB. Biopsy techniques 41. IR playbook: a compre-
hensive introduction to interventional radiology; 2018. p. 451.
Ahrar K. Fluoroscopy-guided biopsy. In: Percutaneous image-­
guided biopsy. New York, NY: Springer; 2014. p. 65–72.
American Urological Association website. Renal Mass and Localized
Renal Cancer: AUA Guideline. Accessed 16 May 2020.
Bufalari A, Giustozzi G, Moggi L. Postoperative intraabdominal
abscesses: percutaneous versus surgical treatment. Acta Chir
Belg. 1996;96(5):197–200.
Cardella JF, Bakal CW, Bertino RE, Burke DR, Drooz A, Haskal
Z, Lewis CA, Malloy PC, Meranze SG, Oglevie SB, Sacks
D. Quality improvement guidelines for image-guided percutane-
ous biopsy in adults. J Vasc Interv Radiol. 2003;14(9):S227–30.
Chehab MA, Thakor AS, Tulin-Silver S, Connolly BL, Cahill AM,
Ward TJ, Padia SA, Kohi MP, Midia M, Chaudry G, Gemmete
JJ. Adult and pediatric antibiotic prophylaxis during vascular
and IR procedures: a Society of Interventional Radiology
practice parameter update endorsed by the Cardiovascular and
Interventional Radiological Society of Europe and the Canadian
Association for Interventional Radiology. J Vasc Interv Radiol.
2018;29(11):1483–501.
Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg
B, Sahn S, Weinstein RA, Yusen RD. Medical and surgical treat-
ment of parapneumonic effusions: an evidence-based guideline.
Chest. 2000;118(4):1158–71.
Cynamon J, Shabrang C, Golowa Y, Daftari A, Herman O, Jagust
M. Transfemoral transcaval core-needle liver biopsy: an
alternative to transjugular liver biopsy. J Vasc Interv Radiol.
2016;27(3):370–5.
Dariushnia SR, Mitchell JW, Chaudry G, Hogan MJ. Society of inter-
ventional radiology quality improvement standards for image-
guided percutaneous drainage and aspiration of abscesses and
fluid collections. J Vasc Interv Radiol. 2020;31(4):662–6.
Doherty JU, Gluckman TJ, Hucker WJ, Januzzi JL, Ortel TL,
Saxonhouse SJ, Spinler SA. 2017 ACC expert consensus deci-
sion pathway for periprocedural management of anticoagula-
tion in patients with nonvalvular atrial fibrillation: a report of
the American College of Cardiology Clinical Expert Consensus
Document Task Force. J Am Coll Cardiol. 2017;69(7):871–98.
 59 Tubes and Biopsies 891

Ferraioli G, Garlaschelli A, Zanaboni D, Gulizia R, Brunetti E,

Tinozzi FP, Cammà C, Filice C. Percutaneous and surgical treat-
ment of pyogenic liver abscesses: observation over a 21-year
period in 148 patients. Dig Liver Dis. 2008;40(8):690–6.
Gurusamy KS, Belgaumkar AP, Haswell A, Pereira SP, Davidson
BR. Interventions for necrotising pancreatitis. Cochrane
Database Syst Rev. 2016;4
IAP WG, Guidelines AA. IAP/APA evidence-based guidelines
for the management of acute pancreatitis. Pancreatology.
2013;13(4):e1–5.
Jandaghi AB, Lebady M, Zamani AA, Heidarzadeh A, Monfared
A, Pourghorban R. A randomised clinical trial to compare
coaxial and noncoaxial techniques in percutaneous core needle
biopsy of renal parenchyma. Cardiovasc Intervent Radiol.
2017;40(1):106–11.
Ke L, Li J, Hu P, Wang L, Chen H, Zhu Y. Percutaneous catheter
drainage in infected pancreatitis necrosis: a systematic review.
Indian J Surg. 2016;78(3):221–8.
Kim ES, Herbst RS, Wistuba II, Lee JJ, Blumenschein GR, Tsao
A, Stewart DJ, Hicks ME, Erasmus J, Gupta S, Alden CM. The
BATTLE trial: personalizing therapy for lung cancer. Cancer
Discov. 2011;1(1):44–53.
Kutsenko O, Pinter DJ. Iatrogenic pneumothorax and other adjunc-
tive techniques for thermal ablation of hepatic dome tumors
iatrogenic pneumothorax and other adjunctive techniques
for thermal ablation of hepatic dome tumors. IO Learning.
2020;8:E16–9. Epub 2020 February 19
NCI and the Precision Medicine Initiative. National Cancer
Institute website. http://www.cancer.gov/research/key-­initiatives/
precision-­medicine. Accessed 12 May 2020.
NCI-MATCH/EAY131. ECOG-ACRIN Cancer Research Group
Web site. http://ecog-­acrin.org/nci-­match-­eay131. Accessed 12
May 2020.
Newton IG. Biopsies in the age of precision medicine the crossroads
of molecular biology and medical imaging. Endovasc Today.
2016;15(9)
Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS,
Walker TG, Saad WA, Standards of Practice Committee.
Consensus guidelines for periprocedural management of coagu-
lation status and hemostasis risk in percutaneous image-guided
interventions. J Vasc Interv Radiol. 2012;23(6):727.
892 O. Kutsenko and M. Jawed

Patel IJ, Rahim S, Davidson JC, Hanks SE, Tam AL, Walker TG,
Wilkins LR, Sarode R, Weinberg I. Society of Interventional
Radiology Consensus Guidelines for the Periprocedural
Management of Thrombotic and Bleeding Risk in Patients
Undergoing Percutaneous Image-Guided Interventions—Part
II: Recommendations: Endorsed by the Canadian Association
for Interventional Radiology and the Cardiovascular and
Interventional Radiological Society of Europe. J Vasc Interv
Radiol. 2019;
Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor
JA. Organ failure and infection of pancreatic necrosis as
determinants of mortality in patients with acute pancreatitis.
Gastroenterology. 2010;139(3):813–20.
Sainani NI, Arellano RS, Shyn PB, Gervais DA, Mueller PR,
Silverman SG. The challenging image-guided abdominal mass
biopsy: established and emerging techniques ‘if you can see it,
you can biopsy it’. Abdom Imaging. 2013;38(4):672–96.
Siewert B, Tye G, Kruskal J, Sosna J, Opelka F. Impact of CT-guided
drainage in the treatment of diverticular abscesses: size matters.
Am J Roentgenol. 2006;186(3):680–6.
Silverman SG, Gan YU, Mortele KJ, Tuncali K, Cibas ES. Renal
masses in the adult patient: the role of percutaneous biopsy.
Radiology. 2006;240(1):6–22.
van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink
MG, Gooszen HG. Systematic review of percutaneous catheter
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Chapter 60
Bariatric Embolization
Clifford R. Weiss and Godwin Abiola

Evaluating the Patient

How is obesity Obesity is normally defined by calculating

usually classified? a patient’s body mass index (BMI), which is
mass (kg)/height2(m2).

BMI Classification
18.5–25 Normal
25–30 Overweight
30–35 Moderately obese
35–40 Severely obese
40–45 Very severely obese
40+ Morbidly obese

C. R. Weiss (*)
Department of Radiology, Division of Vascular and Interventional
Radiology, The Johns Hopkins School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
G. Abiola
Beth Israel Deaconess Medical Center, Boston, MA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 893

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_60
894 C. R. Weiss and G. Abiola

What measures he most common measure of obesity is

can be used to BMI. Obesity can also be measured through
monitor obesity? waist circumference. A waist circumference
≥102 cm for men and ≥88 cm for women is
considered elevated. Formal assessment of
body fat percentage can also provide useful
information.
What are some Often, obesity can be attributed to behavioral
causes of obesity factors such as a sedentary lifestyle and high-­
to consider in a calorie diet. Other potential causes for weight
patient? gain may include hypothyroidism, Cushing’s
syndrome, polycystic ovary syndrome, genetic
disorders, or medications.
What are some Patients should be evaluated for metabolic
of the risks and syndromes, coronary artery disease and
comorbidities cardiovascular health, diabetes, hypertension,
associated with sleep apnea, osteoarthritis, dyslipidemia, non-­
obesity? acholic fatty liver disease, and gastrointestinal
disorders.
How is obesity Depending on the severity of obesity and the
typically capabilities of the patient, different therapies
managed? may be recommended. At a minimum,
lifestyle changes promoting a healthy diet and
regular exercise are typically recommended.
Other therapies include pharmacological
agents, such as orlistat, phentermine,
lorcaserin, and liraglutide, as well as
various bariatric surgeries and endoscopic
interventions.
 60 Bariatric Embolization 895

Indications/Contraindications

Who is eligible As of now, this procedure should remain in

for bariatric the purview of prospective IRB-approved
embolization? investigations. In the United States, this
procedure has been tested in severely obese
patients (BMI ≥ 40) weighing less than
400 lbs., and who are less than 65 years
of age and otherwise healthy. In non-US
studies, patients with BMIs ≥ 30 have been
included. Patients should demonstrate a
history of failed attempts at weight loss
through lifestyle modifications. Patients
should express that they are unwilling
to have bariatric surgery in the future,
because the safety of these surgeries after
embolization is not known. Patients should
also demonstrate an understanding that this
is an experimental treatment with unknown
efficacy.
Is bariatric Currently, bariatric embolization is not
embolization considered a standalone therapy. The
standalone treatment, as part of a research protocol,
therapy? should be combined with lifestyle changes
in diet and exercise that would also
promote a healthy weight loss.
When would Bariatric embolization is being explored to
bariatric be an additional option for weight loss in
embolization be patients who would not qualify for bariatric
used over bariatric surgery. Bariatric surgery has a long history,
surgeries? with a known clinical efficacy that is much
greater than early studies of bariatric
embolization. Currently, as a standalone
procedure, bariatric embolization is not
viewed as a procedure that will replace
bariatric surgery. More studies need
to be performed to solidify the role of
this therapy in the context of currently
performed weight loss interventions.
(continued)
896 C. R. Weiss and G. Abiola

What are absolute Any condition that might put a patient at

contraindications risk for gastric perforation such as active
for bariatric ulcers, gastric malignancy, a history of
embolization? gastric surgery or radiation or connective
tissue disorders. Until proven that bariatric
embolization does not preclude future
gastric bypass or sleeve gastrectomy,
patients who are willing to undergo these
procedures should be encouraged to consult
a licensed bariatric surgeon.

Relevant Anatomy

What are The main branches of the celiac artery, or trunk,

the main are the common hepatic artery, left gastric artery,
branches of and splenic artery.
the celiac
artery?
What are The most common appearance of the celiac
common axis is bifurcation of the celiac axis into a
variants to hepatosplenic trunk and left gastric artery (50–
the celiac axis 76%) or classic trifurcation of the main arteries
and major (10–19%). The left gastric artery may sometimes
adjacent come directly off of the aorta (4.4%), or share
branches of a common origin with the superior mesenteric
the aorta? artery (2.6%). In 10%, more branches may
originate directly from the celiac axis, including
the pancreatic artery, gastroduodenal artery, and
right and left hepatic arteries.
What The main hormones promoting satiety are GLP-­
hormones are 1, PYY, CCK, and leptin.
involved in
the promotion
of satiety?
 60 Bariatric Embolization 897

What The main hormone-stimulating appetite is

hormones ghrelin.
are involved
in the
stimulation of
appetite?
Where are GLP-1 and PYY are produced by L cells within
appetite-­ the ileum and colon. CCK is produced by I
regulating cells within the small bowel. Leptin is produced
hormones by adipocytes in proportion to the number of
produced in adipocytes. Ghrelin is primarily produced by
the body? X/A cells in the gastric fundus, but also in the
duodenum and pituitary gland.
What vessels The gastric fundus is primarily supplied by the
supply the left gastric artery and gastroepiploic artery
fundus of the (a terminus of the gastroduodenal artery).
stomach? Sometimes, the right gastric artery or the short
gastric arteries (off of the splenic artery) can
contribute significantly to the fundus.

Relevant Materials

What catheters A catheter allowing easy entry in the celiac

are used during access, such as a SOS selective, should initially
a bariatric be used if using a femoral approach. If using a
embolization radial approach, the Jacky, Sarah, or FishHook
procedure? may be used. A high-flow microcatheter should
then be used to subselect individual vessels.
What embolic Several embolic agents of different material and
agent is used sizes have been used in clinical trials to varying
during bariatric degrees of success. In general, the most widely
embolization? used agents for this procedure have been of
the particle agents such as polyvinyl alcohol
(PVA) or tris-acryl gelatin microspheres. Sizes
used in clinical trials have ranged from 300–
700 μm. Smaller embolics have been avoided in
clinical trials as they may run the risk of gastric
perforations.
898 C. R. Weiss and G. Abiola

General Step by Step

What are the The procedure can be performed by accessing

preferred access the femoral artery or accessing the radial
sites? artery. Although there is not a preferred site,
per se, radial access may be preferred when
treating this patient population.
How is it Pre-procedurally, CTA has been performed.
determined This both assists in eliminating unsafe
which vessels anatomic variants and provides a clear
are feeding roadmap before the procedure. After gaining
the fundus of access, angiogram of the celiac axis is
the stomach, typically performed. Contrast injection while
the target of performing a cone beam CT of the abdomen
embolization? can also help establish the perfusion of the
stomach.
How do you Embolization of the arteries is typically
know enough taken to stasis or near stasis. Typically, this
embolic has entails 4–5 cardiac beats to washout after
been given? contrast injection. Time should be allowed for
What is redistribution, and then stasis re-assessed.
the general
endpoint?
How are Patients may experience epigastric pain and
patients cared nausea soon after the procedure. IV Tylenol,
for directly after opioids and anti-nausea, anti-emetic therapy
the procedure? should be used for symptoms. Patients
should remain in the hospital overnight for
management of pain, nausea, vomiting, and
to be observed for complications. In trials,
most patients have been discharged after
24 hours, once tolerating a clear liquid diet.
Patients should follow up as per standard post-­
procedural care protocols. Endoscopy should
be performed after the procedure to assess for
ulceration. Weight management follow-up is
essential.
 60 Bariatric Embolization 899

Complications

What are Complications of bariatric embolization are

potential similar to other vascular interventions. These
complications include arterial dissection, nephrotoxicity from
to this contrast use, pseudoaneurysm, hematoma, and
procedure? nontarget embolization of nearby structures.
Potential and severe complications more
unique to bariatric embolization include
gastric ulceration requiring more than medical
management, and even gastric perforation. In
studies so far, these severe complications have
not occurred.
Many patients do develop small, superficial
ulcers after the procedure, but these are often
asymptomatic, and tend to resolve on their own.
What is the As of now, there are no reported mortalities
most lethal associated with bariatric embolization.
complication
of bariatric
embolization?

Landmark Research
Gunn AJ, Oklu R. A preliminary observation of weight loss
following left gastric artery embolization in humans. J Obes.
2014;2014:185349. doi:https://doi.org/10.1155/2014/185349.
• First retrospective study comparing weight loss in 19
patients undergoing left gastric artery embolization vs. 28
patients undergoing embolization of other branches of the
celiac axis in patients undergoing embolization for upper
gastrointestinal bleeding.
900 C. R. Weiss and G. Abiola

• Patients who underwent left gastric artery embolization

lost an average of 7.3% of their initial body weight within
3 months post embolization, which was significantly
greater than the average of 2% body weight loss observed
in patients who underwent embolization of other vessels.
• The difference in weight loss between the two groups was
greatest and most significant at 1-month post
embolization.
Kipshidze N, Archvadze A, Bertog S, Leon MB, Sievert
H. Endovascular Bariatrics: First in Humans Study of Gastric
Artery Embolization for Weight Loss. JACC Cardiovasc
Interv. 2015;8(12):1641-1644. doi:https://doi.org/10.1016/J.
JCIN.2015.07.016.
• This is the first prospective study testing the safety and
efficacy of left gastric artery embolization in 5 morbidly
obese patients.
• All patients reported decreased appetite after the
procedure.
• Mean weight loss was 10%, 13%, 16%, 17%, and 17% at 1,
3, 6, 12, and 20–24 months, respectively.
• Serum ghrelin levels dropped by 29%, 36%, and 21% at 1,
3, and 12 months, respectively.
Syed MI, Morar K, Shaikh A, et al. Gastric Artery
Embolization Trial for the Lessening of Appetite Nonsurgically
(GET LEAN): Six-Month Preliminary Data. J Vasc Interv
Radiol. 2016;27(10):1502-1508. doi:https://doi.org/10.1016/J.
JVIR.2016.07.010.
• Prospective trial testing the safety and efficacy of left gas-
tric artery embolization in 4 morbidly obese patients.
• Mean body weight loss at 6 months post procedure was
8% body weight, or 17.2% excess body weight.
 60 Bariatric Embolization 901

• Serum leptin levels decreased in 3 patients at 6 months.

• One patient included in the trial had diabetes with a
hemoglobin A1c level of 7.4%, which improved to a level
of 6.3% at 6 months.
Bai Z-B, Qin Y-L, Deng G, Zhao G-F, Zhong B-Y, Teng
G-J. Bariatric Embolization of the Left Gastric Arteries for
the Treatment of Obesity: 9-Month Data in 5 Patients. Obes
Surg. October 2017:1-9. ­ doi:https://doi.org/10.1007/
s11695-­0 17-­2979-­9.
• Prospective single center trial in China testing the safety
and efficacy of bariatric embolization in 50 patients.
• Initial report of the first 5 patients at 9 months showed a
mean weight loss of 8.28%, 10.42%, and 12.9% at 3, 6, and
9 months, respectively.
• Serum ghrelin decreased by 40.83%, 31.94% and 24.82%
from baseline at 3, 6, and 9 months.
• Patients included in this trial had a BMI >30, including
obese patients, which is different from American trials
which typically only include morbidly obese patients (BMI
>40).
Weiss CR, Akinwande O, Paudel K, et al. Clinical Safety of
Bariatric Arterial Embolization: Preliminary Results of the
BEAT Obesity Trial. Radiology. 2017;283(2):598-608.
doi:https://doi.org/10.1148/radiol.2016160914.
• Prospective trial conducted at two centers testing the
safety and efficacy of bariatric embolization in 20
patients.
• Average weight loss was 4.3%, 6.02%, 6.74%, and 5.96%,
at 1,3,6, and 12 months respectively.
• Eight of twenty patients developed small asymptotic
superficial ulcers, but no adverse events occurred.
902 C. R. Weiss and G. Abiola

Common Questions

How is it Bariatric embolization is a minimally invasive

different procedure having similar goals of weight loss
from bariatric as bariatric surgery. Though the restriction of
surgery? How the volume of food a patient is able to consume
is it similar? is one mechanism by which bariatric surgery
accomplishes the goal of weight loss, bariatric
surgery also appears to influence weight loss in
another way. The metabolic profiles of patients
tend to change after bariatric surgery, showing
decreases in the level of ghrelin. Bariatric
embolization was developed to try to emulate the
same changes in metabolism without the need for
surgical intervention. Bariatric embolization has
so far demonstrated a significantly lower efficacy
than in bariatric surgery and should be considered
an adjunctive tool, which can be used to augment
lifestyle changes. Also, bariatric surgery is an
approved procedure and is “standard of care” for
weight loss in the patient suffering from severe
obesity. Bariatric embolization is experimental.
How does The exact mechanism of bariatric embolization is
bariatric currently being investigated. The leading theory
embolization is that by restricting blood flow to the gastric
work? fundus, X/A cells will die, decreasing the amount
of ghrelin produced by the stomach, which
accounts for 90% of ghrelin produced by the
body. This in turn decreases appetite and leads to
weight loss.
 60 Bariatric Embolization 903

What lifestyle Patients should expect weight loss occurring

changes can primarily due to decreased appetite. Many
be expected patients report reduced “cravings” for specific
after bariatric foods after the procedure. It is strongly advised
embolization? that patients are supported to continue to
make healthy lifestyle decisions even after
the procedure is performed. In studies so far,
patients who have lost the most weight and
have maintained their weight loss are those who
have paired bariatric embolization with diet and
exercise.
What type Patients can follow up on an as-needed basis.
of follow-up An endoscopy is recommended to monitor the
should development of gastric ulcers after the procedure.
patients It is also recommended that patients follow up
receive with a weight management program to continue
after their maintaining a healthy diet and to enact lifestyle
procedure? changes.
How much Patients can expect to lose the most weight in the
weight first 6 months after the procedure. Weight loss can
loss can be be as much as 8% of total body weight and 17%
expected of excess body weight.
expect?

Further Reading
Anton K, Rahman T, Bhanushali AB, Nadal LL, Pierce G, Patel
AA. Weight loss following left gastric artery embolization
in a human population without malignancy: a retrospec-
tive review. J Obes Weight Loss Ther. 2015;5(6) https://doi.
org/10.4172/2165-­7904.1000285.
Arterburn DE, Courcoulas AP. Bariatric surgery for obesity and
metabolic conditions in adults. BMJ. 2014;349:g3961. https://doi.
org/10.1136/bmj.g3961.
Clinical Guidelines on the Identification, Evaluation, and Treatment
of Overweight and Obesity in Adults–The Evidence Report.
National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S.
904 C. R. Weiss and G. Abiola

Health U.S. Department of and Human Services. Reprint: 2013

AHA/ACC/TOS guideline for the management of overweight
and obesity in adults. J Am Pharm Assoc. 2014;54(1):e3. https://
doi.org/10.1331/JAPhA.2014.14502.
Jones LR, Wilson CI, Wadden TA. Lifestyle modification in the
treatment of obesity: an educational challenge and opportunity.
Clin Pharmacol Ther. 2007;81(5):776–9. https://doi.org/10.1038/
sj.clpt.6100155.
NIH conference. Gastrointestinal surgery for severe obesity.
Consensus development conference panel. Ann Intern Med.
1991;115(12):956–61.
Vix M, Liu KH, Diana M, D'Urso A, Mutter D, Marescaux J. Impact
of Roux-en-Y gastric bypass versus sleeve gastrectomy on vita-
min D metabolism: short-term results from a prospective ran-
domized clinical trial. Surg Endosc. 2014;28(3):821–6. https://doi.
org/10.1007/s00464-­0 13-­3276-­x.
Weiss CR, Gunn AJ, Kim CY, Paxton BE, Kraitchman DL, Arepally
A. Bariatric embolization of the gastric arteries for the treatment
of obesity. J Vasc Interv Radiol. 2015;26(5):613–24. https://doi.
org/10.1016/j.jvir.2015.01.017.
Zhong B-Y, Abiola G, Weiss CR. Bariatric arterial embolization for
obesity: a review of early clinical evidence. CardioVasc Interv
Radiol. 2018; https://doi.org/10.1007/s00270-­0 18-­1996-­y.
Chapter 61
Interventional Radiology-
Operated Endoscopy
Jacob J. Bundy, Jeffrey Forris Beecham Chick,
and Ravi N. Srinivasa

Evaluating the Patient

What applications Biliary endoscopy, genitourinary

exist for endoscopy endoscopy, and gastrointestinal endoscopy.
within interventional
radiology?
How should IRE be Multidisciplinary discussions should be
incorporated into held between interventional radiology, the
an interventional referring physician, and relevant medical
radiologist’s and surgical subspecialties to ensure
practice? agreement on the planned procedure and
to review all alternative treatment options.

J. J. Bundy (*)
Department of Radiology, Wake Forest Health,
Winston Salem, NC, USA
e-mail: [email protected]
J. F. B. Chick
Department of Interventional Radiology, University of Washington,
Seattle, WA, USA
R. N. Srinivasa
Department of Radiology, Division of Interventional Radiology,
University of California- Los Angeles, Los Angeles, CA, USA

© Springer Nature Switzerland AG 2022 905

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_61
906 J. J. Bundy et al.

High Yield History

What workup should Laboratory evaluation should include a

be initiated on a basic metabolic panel, complete blood
patient undergoing count, and coagulation markers.
interventional
radiology-operated
endoscopy?
What is percutaneous These techniques involve the
choledochoscopy or percutaneous transhepatic placement of
cholecystoscopy? an endoscope into either the peripheral
biliary system (choledochoscopy) or
gallbladder (cholecystoscopy) through
which forceps, lasers, and stone retrievers
may be used to aid in the treatment of
many biliary disease processes.
What is percutaneous This procedure involves obtaining
genitourinary percutaneous access into the renal
endoscopy? collecting system with an endoscope
to facilitate the placement of internal-­
external nephroureteral catheters or
internalized ureteral stents, foreign body
retrieval, and lithotripsy.
What is percutaneous This procedure involves accessing the
gastrointestinal small bowel with an endoscope through
endoscopy? a percutaneous gastrostomy to facilitate
foreign body retrieval and stenting.
Lower gastrointestinal endoscopy
involves the placement of a rigid or
flexible endoscope transrectally into
the distal colon to relieve acute colonic
obstruction through stent deployment.
 61 Interventional Radiology-Operated Endoscopy 907

Indications/Contraindications

When might Poor surgical candidates with disease

a patient be processes requiring direct visualization
considered for or procedures requiring extensive
an interventional manipulation or increased control to
radiology-operated correct abnormalities may be considered
endoscopy for interventional radiology-operated
intervention? endoscopy.
What are the These methods are used in the treatment
indications for of symptomatic biliary obstructions
percutaneous in patients who are not surgical
choledochoscopy or candidates or those with long-term
cholecystoscopy? indwelling tubes. Additionally, patients
who have failed endoscopic retrograde
cholangiopancreatography and have calculi
peripheral to the hilum of the liver may
be assisted by percutaneous endoscopic
management.
What are the Genitourinary endoscopy is useful in the
primary indications treatment of stone disease and obstructive
for genitourinary uropathy. In addition, endoscopy may aid
endoscopy? in crossing ureteral strictures and retrieving
migrated renal arterial embolization coils.
What are the Patients with altered surgical anatomy not
primary indications amenable to esophagogastroduodenoscopy
for gastrointestinal who require gastric foreign body retrieval
endoscopy? or placement of colonic stents may benefit
from gastrointestinal endoscopy.
What are the Interventional radiology-operated
contraindications endoscopy is contraindicated when the
to percutaneous international normalized ratio is greater
interventional than 1.5 and the platelet count is less than
radiology-operated 50,000/μL.
endoscopy?
908 J. J. Bundy et al.

Relevant Anatomy

What forms of Patients with duodenal diverticula,

altered anatomy prior biliary reconstructive surgeries
lend themselves such as Billroth-II or Roux-en-Y
toward interventional gastric bypass, or those who have
radiology-operated peripheral intraductal stones beyond
endoscopy within the the reach of endoscopic retrograde
biliary system? cholangiopancreatography.
What is preferred The gallbladder should be accessed
angle of access into along the long-axis to allow a more
the gallbladder for ergonomic approach for stone sweeping
cholecystoscopy? and extraction.
Where should a drain A transcystic internal-external
be placed following drainage catheter should be placed
biliary endoscopic and if cholecystoscopy is performed, a
interventions? cholecystostomy drain should also be
placed.
Where should the Generally, the upper pole of the kidney
kidney be ideally is the preferred location for IRE
accessed during access as it facilitates the progressive
genitourinary advancement of the scope along the
endoscopy? axis of the kidney with increased
visualization of the collecting system
without additional torque or angulation
required. A lower pole posterior
approach is usually utilized for simple
urinary drainage. A posterior calyx
of the upper or middle collecting
system offers the easiest access to the
ureteropelvic junction for potential
ureteral interventions.
 61 Interventional Radiology-Operated Endoscopy 909

Relevant Materials

What setup is required Generally, these procedures are

prior to initiating performed under general anesthesia
interventional given the concerns of electrolyte
radiology-operated disturbances and temperature fluctuation
endoscopy? related to the infusion of fluids through
the endoscopes. Also, an orogastric
and rectal tube should be placed for
prolonged procedures to manage fluid
shifts during the procedure.
What forms of The available endoscopes include:
endoscopes may a 7-French flexible reusable (Storz;
be used during Tuttlingen, Germany), 9.5-French
interventional flexible disposable (Boston Scientific;
radiology-operated Marlborough, MA), 9-French flexible
endoscopy? reusable (Olympus America; Center
Valley, PA), 16.5-French flexible reusable
(Olympus America), and 22.5-French
rigid reusable endoscope (Olympus
America).
What tools may be Fragmentation or stone removal is
used to facilitate facilitated by using electrohydraulic
cholelithiasis or lithotripsy devices, mechanical nitinol
nephrolithiasis stone retrieval baskets, sonographic
fragmentation lithotripsy devices, or percutaneous
during percutaneous thrombectomy devices.
endoscopy?
910 J. J. Bundy et al.

General Step by Step

How is initial Depending on the clinical scenario,

access gained for an the standard techniques used for
interventional radiology-­ cholangiography, cholecystostomy,
operated endoscopy nephrostomy, and gastrostomy are
procedure? performed in the same session as
endoscopy or at least 4–6 weeks
before endoscopy to allow time for
tract maturation.
How is access Generally two Amplatz Super Stiff
maintained during Guidewires (Boston Scientific) are
interventional radiology-­ inserted, one of which serves as a
operated endoscopy? safety wire to maintain access at all
times during endoscopy.
Following tract dilation, A peel-away sheath large enough to
how is excess fluid that accommodate the chosen endoscope
is continuous instilled and the adjacent wire is inserted over
through the endoscope one of the guidewires and allows for
to maintain clear efflux of excess fluid during endoscopy.
visualization expelled?

Complications

What further precautions Electrolyte disturbances should

should be taken prior to be corrected as these may lead to
interventional radiology-­ dangerous fluid shifts or arrhythmias
operated endoscopy to during endoscopy.
ensure safety?
What are some of the Exacerbation of congestive heart
general risks involved with failure due to saline irrigation
interventional radiology-­ during the procedures, hemorrhage,
operated endoscopy? infection related to seeding through
the access tract, and need for repeat
intervention.
 61 Interventional Radiology-Operated Endoscopy 911

When should genitourinary Endoscopy with the genitourinary

endoscopy be avoided? system should be avoid in patients
with active urinary tract infections;
once the infection is treated,
percutaneous interventions can be
reconsidered.

Landmark Research
Patel N, Chick JFB, Gemmete JJ, Castle JC, Dasika N, Saad
WE, et al. Interventional Radiology-Operated
Cholecystoscopy for the Management of Symptomatic
Cholelithiasis: Approach, Technical Success, Safety, and
Clinical Outcomes. AJR Am J Roentgenol. 2018
May;210(5):1164–71.
• Prospective review of 13 patients with symptomatic chole-
lithiasis underwent cholecystostomy followed by interven-
tional radiology–operated cholecystoscopy with stone
removal.
• Primary technical success was achieved in 11 (85%)
patients, and secondary technical success was achieved in
13 (100%) patients. The mean procedure time was 164 min-
utes with a mean time between cholecystoscopy and cho-
lecystostomy removal of 39 days.
Mauro MA, Koehler RE, Baron TH. Advances in
Gastrointestinal Intervention: The Treatment of
Gastroduodenal and Colorectal Obstructions with Metallic
Stents. Radiology. 2000 Jun.
• Comprehensive review of the literature related to the fluo-
roscopic and endoscopic placement of metallic stents for
the treatment of upper and lower GI obstructions
• Combined fluoroscopic and endoscopic-guided placement
of stents within the small and large bowel performed by
interventional radiology for either gastric outlet obstruc-
tion or inoperable malignant strictures had a clinical suc-
cess rate of 89% and 90%, respectively.
912 J. J. Bundy et al.

Srinivasa RN, Chick JFB, Cooper K. Interventional

Radiology-Operated Endoscopy as an Adjunct to Image-­
Guided Interventions. Curr Probl Diagn Radiol. 2019
Mar;48(2):184–188.
• Descriptive and pictorial discussion of the setup, equip-
ment, and potential clinical uses of interventional
radiology-­operated endoscopy.

Common Questions

How may trainees Three-dimensional endoscopic models

improve their comfort are simulation tools that may serve as
using endoscopy during effective teaching platforms to improve
interventional radiology technical skills and increase confidence
procedures? related to incorporating endoscopy into
future practice.
How successful is Recent evidence indicates that
cholecystoscopy in cholecystoscopy used for the
facilitating removal of management of cholelithiasis
chronic cholecystomy may facilitate the removal of
drains? cholecystostomy drains in upwards of
100% of patients.
When should drains The transcystic drain may be removed
be removed following 2 weeks following the procedure and
biliary endoscopic the remaining cholecystostomy tube is
interventions? downsized until it may eventually be
removed. Cholecystostomy drains may
generally be removed within 4–6 weeks
following cholecystoscopy.

Further Reading
Bundy JJ, JFB C, Weadock JW, Srinivasa R, Patel N, Johnson E, et al.
Three-dimensional printing facilitates creation of a biliary endos-
copy phantom for interventional radiology-operated endoscopy
training. Curr Probl Diagn Radio. 2018.
 61 Interventional Radiology-Operated Endoscopy 913

Chick JFB, Osher ML, Castle JC, Malaeb BS, Gemmete JJ, Srinivasa
RN. Prone transradial renal arteriography and interventional
nephroscopy for the visualization and retrieval of migrated renal
embolization coils causing flank pain and hydronephrosis. J Vasc
Interv Radiol. 2017;28(9):1314–6.
Patel N, Chick JFB, Gemmete JJ, Castle JC, Dasika N, Saad WE,
et al. Interventional radiology-operated cholecystoscopy for the
management of symptomatic cholelithiasis: approach, technical
success, safety, and clinical outcomes. AJR Am J Roentgenol.
2018;210(5):1164–71.
Picus D, Hicks ME, Darcy MD, Vesely TM, Kleinhoffer MA,
Aliperti G, et al. Percutaneous cholecystolithotomy: analysis of
results and complications in 58 consecutive patients. Radiology.
1992;183(3):779–84.
Chapter 62
Sphenopalatine Ganglion
Nerve Block
Parth Shah and Avinash Pillutla

Evaluating the Patient

What tests should be Neurological imaging should be

included in the work-up included in a patient with chronic
for a patient with chronic refractory headaches before
headaches? presuming any of the discussed
benign entities. MR imaging is
preferred over CT.
What other laboratory tests Basic blood work including CBC
should be performed? and BMP should be performed
as clinically indicated. Also, the
clinician may consider spine
imaging as well as CSF studies in
the correct clinical setting.
(continued)

P. Shah · A. Pillutla (*)

Department of Radiology, Virginia Commonwealth University
Health System, Richmond, VA, USA
e-mail: [email protected]; [email protected]

© Springer Nature Switzerland AG 2022 915

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_62
916 P. Shah and A. Pillutla

Which specific MRI 3D CISS (constructive

sequence is often requested interference in steady-state), a
in current practice by the heavily T2-weighted gradient echo
protocoling radiologist for MR sequence in addition to more
the evaluation of the cranial routine pre- and post-contrast
nerves? sequences.
What are some possible Lacrimation, conjunctival
autonomic signs of cluster injection, ptosis, miosis, rhinorrhea,
headaches? and nasal congestion can be a few
of the signs both the patient and
clinician may notice.
What current non-­ 100% oxygen or triptans can
interventional therapies exist be utilized for acute headache
for cluster headaches? management.

High Yield History

What is a cluster Classically, it is characterized as sudden

headache? bouts of orbital or temporal pain often with
possible associated autonomic symptoms.
How often do Interestingly, cluster-type headaches are
cluster headaches known to occur daily for weeks to months at
occur? a time and then go into remission for similar
periods of time or even longer. This episodic
form is the most common.
What is trigeminal Characterized as recurrent brief episodes of
neuralgia? unilateral “electric shock-like” pains that are
relatively abrupt in onset and often cease in
a similar fashion.
What other Other than trigeminal neuralgia, a primary
entities are stabbing headache, secondary cluster
included in the headache, SUNCT syndrome are all
differential of a differential considerations. A secondary
cluster headache? cluster headache is also possible and must be
considered.
 62 Sphenopalatine Ganglion Nerve Block 917

What diagnoses Vascular pathologies such as large

can cause intracranial aneurysms, meningioma,
secondary chronic nasopharyngeal carcinoma, metastatic
headaches? disease, and arteriovenous malformations are
possibilities. Thus, relevant questions must be
asked to the patient to consider any of these
entities which may be part of the patient’s
past medical and surgical history.
What Primary stabbing headaches are sharp
differentiates jabbing pains that occur predominantly in
primary stabbing the V1 distribution of the trigeminal nerve.
headache from A key distinguishing feature is that no
cluster headaches? autonomic symptoms are associated, unlike
with cluster headaches.
Who is commonly Approximately 4% of the world population
affected by chronic is affected, with women being affected 2–3
daily headaches? times more than men.
What encompasses Chronic daily headaches include subtypes
chronic daily such as cluster headache, migraine-type
headaches? headache, tension type headaches, and
medication overuse-related headaches.
Who is affected by Cluster headaches have a prevalence of
cluster headaches? less than 1 percent and have a heavily male
predominance.

Indications/Contraindications

How far back has As far back as 1908, Sluder described the
intervention regarding technique, utilizing cocaine as the agent
the sphenopalatine at that time.
ganglion been
considered?
(continued)
918 P. Shah and A. Pillutla

What are some This treatment can be considered for a

common indications variety of entities resulting in facial pain
for this procedure? that is refractory to medical therapy. This
includes trigeminal neuralgia, cluster
headaches, cancers related to the floor
of mouth and tongue resulting in pain,
and acute migraines among others.
Postherpetic neuralgia patients may also
benefit.
What medications are Assessing the status of drugs such
key considerations warfarin and other anticoagulants
prior to intervention? is essential prior beginning any
interventional procedure. The risks of
holding medication and performing
procedure must be weighed in close
coordination with the patient’s primary
care physician and cardiologist.
What is This involves either anesthetic
sphenopalatine or neurolytic intervention on the
ganglion lesioning? ganglion. In addition, radiofrequency
thermocoagulation and pulse
radiofrequency are additional techniques.
What are some 1. Infection
contraindications
to sphenopalatine
ganglion lesioning?
2. Coagulopathy including the need for
anticoagulation and greater risk than
benefit from holding medicine
3. Acute head trauma
4. Hemodynamic instability
 62 Sphenopalatine Ganglion Nerve Block 919

What are some One benefit is that this approach can

benefits of the be quickly done in many outpatient
intranasal approach? office settings. Additionally, it is less
invasive and while risk of epistaxis is not
completely mitigated, can be considered
in patients in patients in whom more
invasive techniques are restricted either
due to anatomy, comorbidities, or
inability to stop anticoagulation.

Relevant Anatomy

Where is the This is the largest of the four

sphenopalatine parasympathetic ganglions of the head
ganglion located? and is located in the pterygopalatine
fossa.
What are the borders Anteriorly located is the maxillary sinus,
of the pterygopalatine while posteriorly is the medial pterygoid
fossa? plate. Superiorly located is the sphenoid
sinus and medially is the palatine bone.
What is the location The pterygomaxillary fissure is located
of passages that laterally and the foramen rotundum,
connect to the which contains the maxillary nerve, is
pterygopalatine located superolaterally and posteriorly.
fossa? The sphenopalatine foramen is located
medially. The inferior orbital fissure is
located superiorly and anteriorly.
What major The maxillary artery and its branches.
vessel lies in the
pterygopalatine
fossa?
What nerve fibers is It is composed of sensory, sympathetic,
the sphenopalatine and parasympathetic nerve fibers.
ganglion composed
of?
(continued)
920 P. Shah and A. Pillutla

What is the function These fibers originate from primarily the

of the sensory maxillary nerve which passes through the
fibers from the sphenopalatine ganglion and innervates
sphenopalatine parts of the pharynx, the nasal membrane,
ganglion? soft palate, and parts of the hard palate.
What is the afferent Afferent fibers originate from the
and efferent superior cervical ganglion and run in the
sympathetic deep petrosal nerve, which ultimately
innervation of the joins with the greater petrosal nerve
sphenopalatine to form the vidian nerve which enters
ganglion? the ganglion. Efferent branches of the
ganglion include the greater and lesser
palatine nerves, pharyngeal branch of the
maxillary nerve and nasopalatine nerve.
What is the afferent Parasympathetic nerve fibers
and efferent within vidian nerve synapse on the
parasympathetic sphenopalatine ganglia; post-ganglionic
innervation of the nerve fibers travel to deep branches of
sphenopalatine the trigeminal nerve which innervate the
ganglion? nasal mucosa, hard palate, soft palate, and
uvula. In addition, post-ganglionic axons
within the zygomatic nerve, a maxillary
nerve branch, ultimately reach the
lacrimal gland.

Relevant Materials

What basic pre-procedural Patient positioning in supine

tasks should be considered position, IV access, consider fixation
prior to starting procedure? of head on table with adhesive tape
and/or bands, sterile preparation of
access site.
Which imaging modalities Fluoroscopic guidance is often used;
can be utilized for this however, fluoroscopy in conjunction
procedure? with CT can also be considered in
patients with complex anatomy.
 62 Sphenopalatine Ganglion Nerve Block 921

Which drugs and needles 1. 25-gauge 1.5-inch needle along

should be available for a with a 5 ml syringe and 1%
therapeutic nerve block? lidocaine or 0.25% bupivacaine for
local anesthetic at the access site
2. 22-gauge 10 cm nerve block
needle
3. 1 mL of nonionic water-soluble
contrast (check the patient’s allergy
history)
Which approach is utilized Infrazygomatic approach.
for radiofrequency
thermocoagulation and
radiofrequency pulsation?
What type of needle is Insulated RF needle with either a
utilized in radiofrequency 3 mm or 5 mm tip.
lesioning?
Which RF needle tip size is 3 mm tip is generally preferred to
preferred? avoid damage to adjacent nerves.
What materials are Cocaine is a good anesthetic to
involved in an intranasal use due to its vasoconstrictive
approach? properties. A cotton tipped
applicator is utilized to go through
the nares. Lidocaine, bupivicaine, or
ropivicaine may also be used.

General Step by Step

What approaches Intranasal, transnasal, and

are available for infrazygomatic techniques can be
sphenopalatine ganglion utilized.
nerve block?
(continued)
922 P. Shah and A. Pillutla

What type of procedural Local anesthesia as well as light

anesthesia is required? sedation with fentanyl and/or
midozalam may be required. Some
cases may require monitored
anesthesia care.
For the infrazygomatic The ipsilateral side of the nose to
approach, which the ear all the way and inferiorly
anatomical region should towards the mandible. Most experts
be prepped? recommend leaving the ipsilateral
eye open to be able to recognize
possible retrobulbar hematoma.
What initial images should A true lateral fluoroscopic view
be obtained? should be obtained and the
pterygopalatine fossa visualized. The
mandibular notch should also be
able to be seen.
How should access begin? Local anesthesia to the soft tissue
overlying the mandibular notch
should be obtained. Subsequently,
a small angiocatheter with metal
portion removed. A block needle
then is advanced medially, anteriorly,
and slightly cranially toward the
pterygopalatine fossa.
Where should the operator Obtain an AP fluoroscopic
park the block needle? image. The block needle should
be advanced toward the middle
turbinate and stop just short of or
adjacent to the palatine bone.
 62 Sphenopalatine Ganglion Nerve Block 923

What is the transnasal This involves initially anesthetizing

approach? the entry from the nares to the
nasopharynx with a cotton-tipped
applicator (similar to intranasal
approach, which is not an invasive
technique and thus will not be
described in detail in this section).
Subsequently, a 26-gauge needle
is advanced within a surrounding
sheath until it reaches the
posterolateral nasopharyngeal wall
with the bevel of the needle facing
laterally. Advance further with the
needle and inject contrast to confirm
positioning in the pterygopalatine
fossa and subsequent administration
of anesthetic and/or steroid.
Once appropriate Injection of 1 ml of contrast
positioning has been to ensure the needle is not
obtained, what is the next intravascular. Injection of local
step? anesthetic with or without steroid
can then be performed.
What indications suggest a Ipsilateral conjunctival injection,
successful diagnostic and nasal congestion, and lacrimation
therapeutic block? and resolution of pain. If the pain
does not subside, this may mean
the cause of the patient’s symptoms
are unrelated to the sphenopalatine
ganglion.
(continued)
924 P. Shah and A. Pillutla

What is a stimulation A stimulation test allows the

test relative to RF operator to optimally confirm
thermocoagulation and electrode positioning. Parasthesias
pulsed radiofrequency? in the nose indicated appropriate
positioning. Parasthesias in the
hard palate indicate palatine nerve
stimulation and the electrode
should be redirected cephalad and
medial. Stimulation in the upper lip
indicates maxillary nerve stimulation
and the electrode should be
redirected caudal and medial. This
should be performed at 45–55 Hz at
greater than 0.2 V and less than 1 V.
Once proper positioning Injection of 0.5–1 mL of 1 percent
is confirmed, what is lidocaine. After a 1-minute interval,
the next step for RF begin lesioning at 70–80 degrees
thermocoagulation? Pulsed Celsius for 2 cycles of 60–90 seconds.
radiofrequency? Pulsed radiofrequency can be
performed in 120–150 second cycles
for 2–4 cycles at a temperature of 42
degrees Celsius.

Complications

Why is epistaxis a The soft intranasal tissue can easily

risk factor with the be injured if the electrode or needle
transnasal approach? is advanced too firmly or protrudes
too far outside of the sheath prior to
adequate positioning.
What will occur if the Injury to the maxillary nerve resulting
RF needle is directed in long-term parasthesias if sensory
superolaterally? stimulation is not performed.
Why is an aspiration To avoid inadvertent intravascular
test necessary once the injection of anesthetic.
operator believes they
are in the proper space?
 62 Sphenopalatine Ganglion Nerve Block 925

What major artery is at The maxillary artery and its branches.

risk for puncture in the
pterygopalatine fossa?
The operator may This may occur in some patients and
see that the patient should subside once lesioning is over.
is bradycardic during
RF lesioning. Is this
normal?
What postprocedural Hematoma involving the cheek due
complications can to puncture of arterial supply or
occur? venous plexus, transient double vision
secondary to local spread of anesthetic,
and infection are all possibilities.
Hypesthesia of the palate and pharnyx
secondary to RF lesioning is also
possible.
What is the risk of Overall, the rate of infection is not
infection? significantly different than other similar
procedures.

Landmark Research
Sanders M, Zuurmond W. Efficacy of sphenopalatine gan-
glion blockade in 66 patients suffering from cluster headache:
a 12- to 70-month follow-up evaluation. J Neurosurg.
1997;87:876–80.
• This case series by Sanders and Zuurmond described 66
total patients with episodic and chronic cluster headaches.
34 of 56 patients with episodic headaches and 3 out of ten
patients with chronic cluster headaches showed complete
relief of symptoms at 29 months.
Bayer E, Racz GB, Day M, et al. Sphenopalatine ganglion
pulsed radiofrequency treatment in 30 patients suffering from
chronic face and head pain. Pain Pract. 2005;5:223–7.
926 P. Shah and A. Pillutla

• Bayer and colleagues studied pulsed radiofrequency of the

SPG in 30 patients with chronic face and head pain which
showed that over 85 percent of patients had mild to mod-
erate or greater pain relief. Nearly 2/3 of patients had
reduction in the amount of pain medications they needed
to take.

Common Questions

How long after the A minimum of 2 hours. It is

procedure does the patient important to monitor vital signs. In
have to be observed? addition, documentation of pain
relief is also important.
What information should Important information in regard to
be relayed to the patient’s follow-up as well as information on
caretakers? possible post-procedural symptoms
and complications as described in
the above-related section.
When can RF If block with anesthetic and/or
thermocoagulation or steroid is successful in helping treat
pulsed radiofrequency be patient’s pain, it can be inferred that
considered? pain may be related at least in part
to the sphenopalatine ganglion. A
more permanent lesioning of the
ganglion may be thus be considered.
Which patients may need Patients who are on anticoagulants.
multispecialty evaluation It is important to consider the
and input prior to an risks versus benefits in regard to
invasive nerve block performing any procedure including
procedure? pre-procedural discontinuation of
anticoagulant therapy.
 62 Sphenopalatine Ganglion Nerve Block 927

Further Reading
Bayer E, Racz GB, Day M, et al. Sphenopalatine ganglion pulsed
radiofrequency treatment in 30 patients suffering from chronic
face and head pain. Pain Pract. 2005;5:223–7.
Bolash R, Tolba R. Sphenopalatine ganglion. In: Pope J, Deer T,
editors. Treatment of chronic pain conditions. New York, NY:
Springer; 2017.
Day M. Sympathetic blocks: the evidence. Pain Pract. 2008;8:98–109.
Drummond PD. Dysfunction of the sympathetic nervous system in
cluster headache. Cephalalgia. 1988;8:181.
Drummond PD. Mechanisms of autonomic disturbance in the face
during and between attacks of cluster headache. Cephalagia.
2006;
Ferrante FM, Kaufman AG, Dunbar SA, et al. Sphenopalatine gan-
glion block for the treatment of the head, neck, and shoulders.
Reg Anesth Pain Med. 1998;23:30–6.
Fischera M, Marziniak M, Gralow I, Evers S. The incidence and
prevalence of cluster headache: a meta-analysis of population-­
based studies. Cephalalgia. 2008;28:614.
Gray H, Carter HV, Davidson G. Grays anatomy. London: Arcturus;
2017.
Hagler S, Ballaban-Gil K, Robbins MS. Primary stabbing headache
in adults and pediatrics: a review. Curr Pain Headache Rep.
2014;18:450.
Headache Classification Committee of the International Headache
Society. The international classification of hedache disorders. 3rd
ed. Cephalagia; 2013.
Headache Classification Committee of the International Headache
Society. The international classification of headache disorders.
3rd ed. Cephalagia; 2018.
Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in
the anticoagulated patient: de ning the risks (the second ASRA
consensus conference on Neuraxial Anesthesia and anticoagula-
tion). Reg Anesth Pain Med. 2003;28:172–97.
Janzen VD, Scudds R. Sphenopalatine blocks in the treatment of
pain in bromyalgia and myofascial pain syndrome. Layrngoscope.
1997;1077:1420–2.
Lu SR, Fuh JL, Chen WT, et al. Chronic daily headache in
Taipei, Taiwan: prevalence, follow-up and outcome predictors.
Cephalalgia. 2001;21:980.
928 P. Shah and A. Pillutla

May A. Cluster headache: pathogenesis, diagnosis, and management.

Lancet. 2005;366:843.
Narouze SN. Interventional management of head and face pain.
Peterson J, Schames J, Schames M, King E. Sphenopalatine ganglion
block: a safe and easy method for the management of orofa- cial
pain. J Craniomandibular Pract. 1995;13:177–81.
Raj PP, Shah RV, Kay AD, et al. Bleeding risk in the interventional
pain practice: assessment, management, and review of the litera-
ture. Pain Physician. 2004;6:3–52.
Saberski L, Ahmad M, Wiske P. Sphenopalatine ganglion block for
treatment of sinus arrest in postherpetic neuralgia. Headache.
1999;38:42–4.
Sanders M, Zuurmond W. Efficacy of sphenopalatine ganglion
blockade in 66 patients suffering from cluster headache: a 12- to
70-month follow-up evaluation. J Neurosurg. 1997;87:876–80. 21.
Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of fre-
quent headache in a population sample. Headache. 1998;38:497.
Sluder G. The role of the sphenopalatine ganglion in nasal head-
aches. NY State J Med. 1908;27:8–13.
Sluitjer M, Racz G. Technical aspects of radiofrequency. Pain Pract.
2002;2:195–200.
Vallejo R, Benyamin R, Yousuf N, et al. Computed tomogra-
phy enhanced sphenopalatine ganglion blockade. Pain Pract.
2007;7:44–6.
Varghese BT, Koshy RC. Endoscopic transnasal neurolytic spheno-
palatine ganglion block for head and neck cancer pain. J
Laryngol Otol. 2001;115:385–7.
Wang SJ, Fuh JL, Lu SR, et al. Chronic daily headache in Chinese
elderly: prevalence, risk factors, and biannual follow-up.
Neurology. 2000;54:314.
Index

A ABI test, 128

Abdominal aortic aneurysms Ablation
(AAA), 362 contraindications, 451
abdominal CT, 82 embolization materials, 470
bifurcated stent graft, 86 intraprocedural imaging, 426
bilateral common femoral modalities
arteries, 87 types of, 455
complications, 83 patient positioning, 471
contrast extravasation, 82 probe, 456
etiology of, 83 procedures, 426
EVAR, 87 of sensitive nontarget tissue,
factors are associated, 83 429
indications/contraindications, technique
84–85 cryoablation, 472
medical therapy, 83 MWA, 472
midline palpable pulsatile for RFA, 472
abdominal mass, 81 Abscessogram, 886
presentation triad, 82 Absolute ethanol, 201
retroperitoneal hematoma/ Accessory/replaced hepatic
stranding, 82 arteries, 427
risk factors, 83 Activated clotting time (ACT)
rupture and distal for stenting/intervention, 289
embolization, 83 with a point-of-care device, 38
screening for women with and Acute aortic syndromes, 29
without smoking Acute DVT, 152
history, 81 Acute limb ischemia, 134
selective one-time ultrasound Acute mesenteric embolism/
screening of men, 81 thrombosis, 185
signs of, 82 Acute mesenteric ischemia, 189
ultrasound, 82 bacterial translocation, 186
Abdominal aortic endografts, from embolic sources, 189
401

© Springer Nature Switzerland AG 2022 929

R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0
930 Index

Acute mesenteric ischemia American College of Radiology,

(cont.) contrast allergy
endovascular options for prophylaxis, 40
treatment, 181 Anaphylactoid reaction, 787
mechanism of thrombotic Anesthesia Society of America
etiologies, 189 (ASA)
morbidity/mortality, 177 guidelines, 7
mortality associated, 189 requirements for fasting, 113
patient history, 179 requirements, moderate
risk factors for embolism, 189 sedation, 40
SMA, 183 Aneurysm exclusion without
surgical approach to presence endoleaks, 87
treatment, 181 Aneurysm repair, 84
surgical options for treatment, Angiography, 122
181 Angioplasty, 132
symptoms, 178 arterial wall, 138
thrombolysis, 186 balloon, 63
Acute stroke, 8 catheter, 383
Acute thromboembolism, 266 of dialysis graft/fistula, 380
Acute variceal hemorrhage and procedure, 383
reaccumulating ascites, stenting, 132
522 Ankle brachial index (ABI), 28,
Adenocarcinoma, 446 112
Adenomyosis, 569, 576 Antecubital fossa, 814
Adrenal lesion, 883 Anterior access, 561
Afternoon rounds, 21, 22, 24, 25 Anterior mediastinum, 452
Air embolism, 234, 240 Anterior spinal artery, 737
Air kerma used in digital Anterior spinal cord, 97
subtraction Anterior spinal syndrome, 89,
angiography, 121 102
Airborne bacteria, in surgical Anterior spinal syndrome after
suite, 41 EVAR, 89
Airway, breathing, and Antibiotic-impregnated
circulation (ABCs), catheters, 238
673 Antibiotic prophylaxis, 504, 800
Alberta stroke program early CT Anticoagulation, 7
score, 604 Anti–factor Xa activity, 32
Ambulatory phlebectomy, 313, Antiplatelet therapy, 254, 264,
322 375
complications, 323 Anti-proliferative drug and
external laser therapy, 322 drug-transferring
American Association for the excipient, 65
Surgery of Trauma Antithrombotic Trialists’
(AAST), 698, 699 collaboration for
American Cancer Society (ACS), high-risk patients for
479
 Index 931

occlusive vascular symptoms, 195

events 2002, 23 types, 207
Aortic arch, 610, 611 Artery of Adamkiewicz, 89
anatomic variant, 259 ASA physical status classification
variants, 391–393 system, 113
Aortic disease and ostia, 288 Ascending aorta, 100
Aortic intramural hematoma, 29 Aspirin, 37
CT protocol, 15 Atherosclerosis, 83
Aortoenteric fistula, clinical Atherosclerosis over FMD, 285
features, 89 Atherosclerotic aorta, 288
Aortoiliac (buttock and thigh Atherosclerotic cardiovascular
claudication), 138 risk, scoring system, 8
Aortoiliac occlusive disease, Atherosclerotic RAS, 281
collateral pathways for Atherosclerotic vs. FMD lesions,
lower extremity blood 298
supply, 139 Autologous fistula, 388
APACHE II, 14 Automated spring-loaded/
Arterial access, 118 vacuum-assisted
Arterial anastomotic stenosis/ devices, 484
plug, 384 AVF access, 381
Arterial collateral pathway AVF formation, 381
between the SMA and AVF/AVG stenosis, 381
IMA, 183 AVG formation, 381
Arterial embolization AVM on MRI T1 and T2
procedures, 420 sequences, 195
Arterial embolotherapy, 415 Aynecologic disorders, 569
Arterial hypotension, 266 Azygos vein, 454
Arterial intestinal ischemia, 179 Azygos/hemiazygos system, 454
Arterial pseudoaneurysm, 30
Arterial rupture, 293
Arterial stenosis, 134 B
Arterial stent, 190 B1 and B2 varices, 536
Arteriovenous fistula, 193 Balloon angioplasty, 280
Arteriovenous malformations complications associated with,
(AVM), 193, 851, 852, 65
856, 858 stent placement, 284
access routes, 202 Balloon catheter, 64
components, 199, 209 Balloon expandable stents, 67,
embolization of the vein, 203 141
indications, 198 Balloon inflated for angioplasty,
from low-flow venous 289
malformations on Balloon-occluded antegrade
physical exam, 194 transvenous
on nidus angiographic obliteration (BATO),
morphology, 207 538
932 Index

Balloon-occluded retrograde lifestyle changes, 903

transvenous materials, 897
obliteration (BRTO), obesity, 893, 894
529, 546 procedure, 898
advantages, 530 stomach, 898
angiographic technique, 540 weight loss, 903
antibiotics prophylaxis, 538 work, 902
balloon rupture, 542 Barthel index of ADLs, 261
complications, 541 BATTLE study, 882
cone beam CT, 547 Benign and malignant back pain
contraindications, 534 anatomy, 655, 657
diminutive portal vein, 546 degenerative disc/osseous
flow stagnation and portal disease, 647
vein thrombosis, 546 discogenic pain, 648
hepatopetal flow, 533 epidural and spine nerve
indications, 529, 533 blocks, 666
long terms complications, 543 ESI, 654, 660, 661
occlusion balloon, 539 facet hypertrophy, 654
partial splenic vein facet injection, 658, 661
embolization, 541 facet joint arthropathy, 648
patient stabilization, 546 facet procedures, 660
post-procedure cone-beam history, 650
CT, 540 landmark research, 663–666
pre-existing abdominal low back pain, 648
ascites, 533 lumbar radiculopathy, 659
shunt anatomy and sizes, 546 musculoskeletal pain, 646
technical failure, 543 percutaneous sacral fixation/
treatment of gastric varices, fusion, 662
545 radiofrequency ablation, 662
Balloon-occlusion venography, sacral fracture, 649, 659
547 sacroiliac joint, 649
Barbeau test, 116 SNRB, 654, 659, 661
waveform, radial artery spinal nerve root blocks and
access, 43 epidural spinal
Barcelona clinic liver cancer injections, 658
(BCLC) staging spine injections, 661
system, 417 spine pain, 648
Bariatric embolization steroid injection, 654, 658, 661
access sites, 898 vertebral augmentation/
anatomy, 896, 897 sacroplasty, 655, 662
complications, 899 vertebral body compression
definition, 902 fractures, 647, 659, 666
follow up, 903 vertebroplasty vs.
indications/contraindications, kyphoplasty, 647
895, 896 Benign biliary obstruction, 498
landmark research, 899–901 Benign nodules on imaging, 445
 Index 933

Benign prostate hypertrophy benign lesion, 480

(BPH) mammographic findings, 480
definition, 585 palpable mass, 480
diagnosis, 583 screening in women, 479
symptoms, 579 sonographic findings, 480
Benign vascular tumors, 194 symptoms, 482
Bifurcated stent graft, 87 in U.S
Bilateral hypogastric artery incidence, 481
embolization, 89 mortality, 481
Biliary drainage, 502, 509 Breast in mammography, zones,
Biliary interventions, 506 483
Biliary obstruction, 498 Breast lesions in mammography,
inendoscopicretrogradecholangiopan- 489
creatography, 499 Breast MRI, 481
imaging studies, 499 Breast-specific gamma imaging
Biliary/genitourinary site, 39 (BSGI), 481
Biliary stents, 504 Breast ultrasound, 483
Biliary system, 908 Brodel’s line, 556, 865
drainage catheters, 505 Bronchial arteries, 30, 199
puncture, 505 supply, 736, 737
Biliary tree catheter cannulation, Bronchial artery embolization,
503 73
Biliary tree obstruction, 498 anatomy, 736, 737
BI-RADS classification, 489 angiographic appearance, 740
Bismuth-Corlette classification, arterial access, 740
500 collateral blood supply, 740
Bismuth-Corlette system, 503 complications, 741
Bland embolization, 425 history, 734, 735
Bleomycin, 853 indications/contraindications,
Blunt splenic injury, 706, 707 736
Brachial artery, 115 landmark research, 742
Brachiocephalic dialysis fistula, long-term recurrence rate, 740
381 massive hemoptysis, 742
Bradycardia, 264 materials, 738, 739
Braided catheters, 56 patient evaluation, 733, 734
Brain AVMs, 194 Rasmussen’s aneurysm, 743
Brainstem (posterior circulation) Bronchospasm, 788
stroke, 601 Budd-Chiari syndrome, 880
Branched endograft, 397
Branched EVAR
advantages, 397 C
disadvantages, 397 Caldwell variations, 737
BRCA positive, 490 Calibrated/marker pigtail/
Breast cancer straight flush catheter,
ablation, 483, 488, 490 87
age at diagnosis, 481
934 Index

Call experience, institution and medications, 261

attending physician, 27, MRA, 249, 250
30 neurological exam, 261
CAPS trials, 239 non-invasive imaging, 252
Carbon dioxide (CO2), contrast over CEA for
agent for angiography, revascularization, 257,
39 272
Carcinoid crisis, 881 relative contraindications, 258
Carotid and intracranial residual stenosis after stent
atherosclerosis, 252 placement, 264
Carotid artery revascularization, risk factors, 253
255 screening and follow-up test,
Carotid artery stenosis (CAS) 272
absolute contraindications, stent placement, 264
258 thyroid cartilage, 259
allergy to aspirin, 255 treatment, 254, 256
angiography, 263 type of catheter, 260
anticoagulation, 254, 262 type of stents, 260
arterial dissection, 266 ultrasonography, 248
arterial line, 262 ultrasound, 254
asymptomatic, 245 Carotid bulb, 259
atherosclerotic lesions, 259 Carotid duplex ultrasound, 245
balloon expandable stents, Carotid revascularization, 271
260 Catheter associated infections,
carotid bruit, 245 235
causes, 253 Catheter-directed thrombolysis
cerebral protection, 260 (CDT), 157, 158, 164,
complications, 272 165
contraindication to absolute contraindications,
re-operation, 258 158
CTA/MRA, 249, 251 activated clotting time, 161
diagnostic angiography, 263 complication, 167
evaluation of indications, 158
ASYMPTOMATIC intracranial bleeding, 167
patients, 246 laboratory guidelines, 168
grading, 253 lethal complications, 167
guide catheter, 264 thrombolytic agents, 161
indications, 246, 247 Catheter exchanges, 53, 510
indications for Catheter insertion, sterile drape,
revascularization, 255, 42
256 Catheter malfunction, 235
intraprocedural Catheter thrombectomy, 45
complications, 266 Catheter tip positions,
mechanism of ischemic complications, 233
stroke, 253 Cavoatrial junction, 815, 819
medical history, 252
 Index 935

Cavoatrial junction on AP patient positioning for

radiographs, 223 attempted IJ and
Cecostomy subclavian access, 227
complications, 845, 846 pheresis/dialysis catheters, 217
materials and equipment, 843, port “heparinized”/“packed
844 with heparin, 822
patient evaluation, 842 post-procedural bleeding, 822
post-procedure care and pre-procedural antibiotics,
maintenance, 844, 845 226
pre-procedure and technical pre-procedural prophylactic
considerations, 842, 843 antibiotics, 226
retrograde approach, 844 proximal venous system, 822
Celiac axis, 183 removal of, 220, 230
Cellulitis, antibiotics, 6 right internal jugular vein, 239
Cementoplasty, 649 sedation and anesthesia, 814
Central venous access site-specific complications,
anatomy, 819, 820 234
anesthesia/sedation, 226 subclavian and internal
antecubital fossa, 814 jugular approach, 815
antibiotic-impregnated subcutaneous port catheter,
catheters, 225 217
anticoagulation medications, tunneled catheter, 217
227 type of, 217, 224
catheter securement, 229 venospasm, 822
catheter tip position, 815 venotomy site, 229
cavoatrial junction, 815 Central venous air embolism, 123
coagulation status, 216 Central venous catheterization,
complications, 233, 823–825 transient right bundle
electrolyte level, 216 branch block, 45
femoral access, 814 Central venous ischemia, see
femoral artery, 224 Stroke
femoral catheter, 814 Central venous stenosis, 379
history, 815–817 Centrally inserted central venous
IJV, 221 catheters, 219
indications/contraindications, Cephalosporins, 6
218, 219, 817, 818 Cerebellar stroke, 601
internal jugular vein Cerebrovascular stroke, 102
approach, 821 Charcot’s triad, 499
laboratory tests, 813 Chemical endovenous ablation,
landmark research, 825 319
length of therapy, 215 Chemoembolic emulsion, 428
location for, 222, 815 Chemotherapeutic/ethiodized oil
materials, 820, 821 emulsion, 426
micropuncture kit, 224 Chest pain post-biopsy, 458
non-tunneled access, 217 Chest wall vasculature, 453
NPO, 813 chEvar registry, 408
936 Index

Child-Pugh scoring system, 15, Cluster headaches, 916, 917

416, 531 Coaxial catheter combination
Chimney/Snorkeling, 394 with an outer guiding
Chimney stent graft sizing, 398 catheter and smaller
Cholangiocarcinoma, 503 inner catheter/
Cholangiogram, 14 microcatheter, 60
Cholecystostomy, 501 Coaxial system, 455
Choledocholithiasis on Coil-assisted retrograde
transabdominal US, transvenous
500 obliteration (CARTO),
Chronic daily headaches, 917 538
Chronic headaches, 915, 917 Coil packing density, 73
Chronic kidney disease (CKD), Collateral pathways between the
216 celiac axis and SMA,
patients, lab findings, 12 183
Chronic limb ischemia, 134 Collateral veins, 541
patients, medications, 13 Colon, 555
Chronic limb-threatening Colonic ischemia, 89
ischemia” (CLTI Colorectal cancer liver
vs.“critical limb metastases, 420
ischemia” (CLI), 129 Common femoral artery (CFA),
Chronic mesenteric ischemia 44, 115
endovascular options for optimal access, 44
treatment, 182 Compartment syndrome, 723,
mechanism of thrombotic 724
etiologies, 189 COMPASS trial, 25
patient history, 179 Complex abdominal aortic
surgical options for treatment, aneurysm (AAA), 393,
182 394, 401
symptoms, 177 Complex aortic hybrid repairs,
Chronic mesenteric stenosis/ 389, 400, 406
thrombosis, 184 intraoperative support/
Chronic unilateral obstruction monitoring, 403
due to malignancy, 552 Complex hybrid thoracic aortic
Chronic venous insufficiency, 306 repair, 406
Chyle, 798, 808 Complex TEVAR, 401–402
Chylothorax, 805 Complex thoracic hybrid repair,
Chylous effusion, 793, 795, 796, 393
807 Compliant and non-compliant
Circle of Willis (COW), 598, 611 balloons, 140
Circumaortic left renal vein, 354 Compliant balloon angioplasty,
Clamp test, 403 101
Clopidogrel, 37 Compression stockings, pressure,
Closure device, 144 317
CLTI and infrapopliteal disease, Compression therapy, 313, 316,
139 317
 Index 937

complications, 323 Curaçao diagnostic criteria for

Congenital hemangiomas, 194 hereditary hemorrhagic
Congenital syndromes, venous telangiectasia, 196–197
insufficiency, 311 CVC infection
Continuous cardiac monitoring, complication, 384
163 management, 384
Contrast allergy prophylaxis, 40 CVC occlusion, 236
Contrast extravasation, 786 Cysterna chylii, 800
Contrast-induced nephropathy,
279
Contrast reaction, 785–788 D
COOL-1, 239 Dacron elephant trunk graft, 398
COOL-2, 239 Dacron retention cuffs, 226
CORAL trial, 296 DEB-TACE, 426, 432–433
Core needle biopsies (CNB), 484, Declot procedure, 383
486 Declot techniques, 384
advantages, 484 Declotting agents, 236, 241
disadvantages, 484 Deep femoral and superficial
vacuum-assisted device, 484 femoral vein, 223
Corona mortis, 30, 724 Deep hypothermic circulatory
Couinaud classification of liver arrest, 404
segments, 502 Deep vein thrombosis (DVT),
Couinaud system of liver 151, 155, 305, 349
segmentation, 9 classification, 152
Covered stent (stent graft), 68 management, 165
Crawford classification, 393 treatment, 157
CREST-2 trial, 271 Deep veins of the calf, 160
Critical stenosis, 134 Deep venous system, 116
Crohn’s disease, 887 Degenerative low back pain, 648,
Cryoablation, 424, 470, 471, 487 649
advantages, 485 Desmopressin, 32, 38
complication, 424 Diabetes mellitus (DM), 216
devices, 491 Diagnostic fistulogram, 383
in early-stage breast cancer, Dialysis-access grafts, 68
491 Dialysis catheter, 241
freeze/thaw cycles, 491 Dialysis fistulas stenose/occlude,
vs. lumpectomy in early-stage 15
breast cancer, 492 Dialysis graft stenosis, 14
mechanism of action, 485 Digital subtraction angiography,
Cryoablation and RFA/MWA, 120
476 Digital subtraction angiography
Cryoprobes, 487 (DSA) of aortic arch,
Cryoshock, 424 252
CT protocol, aortic intramural Dilation of the intrahepatic
hematoma, 15 parenchymal tract, 520
938 Index

Direct arterial connection pelvic collection drainage, 887,

between the SMA and 888
IMA, 183 percutaneous drainage and
Direct IVC (translumbar), 223 aspiration, 884, 885
Direct renal pelvis access, 556 safe pleural drainage, 889
Direct right atrial, 223 size drainage catheter, 886
Distal aortic occlusion/ trocar technique, 886
unfavorable renal Draining veins, 536
artery angle, 288 Drug coated balloon matrix
Distal embolization, 373 coating
Distal lower extremity DVT, 353 components of, 65
Distal vessel embolization, 684 Drug-eluting beads loaded with
Dominant peroneal artery, 140 Irinotecan (DEBIRI),
Dominant venous outflow 420
occlusion, 201 Drug eluting embolization
Dorsal pedal lymphangiography, (DEE), 475
801 Drug eluting stents, 68, 142
Dose reduction strategies/ DSA projection, 121
sequential sessions/ Dual antiplatelet therapy, 261,
fractionation, 430 264
Double flush technique, 56 Ductal strictures, 505
Double-J catheter, 866 Ducts of Luschka (subvesicular
Double rupture phenomenon, ducts), 503
376 Duplex sonography, 112
Double stick method, 867 Duplex ultrasonography, 248
Drainage catheters,
decompression of the
biliary system, 509 E
Drainage tubes Echocardiogram, pulmonary
abscessogram, 886 embolism, 153
adjunctive techniques, 887 Ehlers-Danlos syndrome, 95
amount of fluid, 886 Elephant trunk technique, 399
antibiotic therapy, 885 Embolic agents, classifications, 71
complications, 887 Embolization
contraindications, 885 dextrose solution, 72
Crohn’s disease, 887 temporary agents, 71
infected necrotizing Embolization coils, properties of,
pancreatitis, 888, 889 73
laboratory test, 885 Embolization in AVMs, 200
liver collection drainage, 888 Embolization of the embolic
lung abscess, 889 agent/air into the
lung syndrome, 889 pulmonary circulation,
maintainance, 887 204
modified Seldinger technique, Emergent decompression, 554
886 Endobronchial blocker, 738
parapneumonic effusions, 889
 Index 939

Endograft imaging surveillance, Endovascular methods, type II

EVAR, 90 endoleaks, 45
Endograft landing zones, 96 Endovascular procedure
Endoleak, 88, 102 complications, 144
after ETG complex thoracic Endovascular renal
repair, 407 revascularization, 290
with fEVAR, 407 Endovascular revascularization,
types, 88, 106, 107 290, 297
Endoprosthesis device, with stent placement in
components of, 86 atherosclerotic RAS,
Endoscopes, 909 290
Endoscopic biliary drainage, 508 Endovascular therapies, 318
Endoscopic variceal banding, 530 over surgical repair, 198
Endoscopy with/without Endovascular thoracic aortic
endoscopic ultrasound repairs, 393
(EUS), 530 Endovascular vs. open repair of
Endovascular AAA repair asymptomatic popliteal
anatomic consideration for artery aneurysm, 374
access, 86 Endovenous ablation, external
Endovascular access site laser therapy, 322
interventions, 381 Endovenous therapy, 326
Endovascular aneurysm repair Enteral access
(EVAR) cecostomy
advantages, 90 complications, 845, 846
arterial access, 400 materials and equipment,
complications, 89 843, 844
imaging surveillance, 91 patient evaluation, 842
vs. open surgical repair in the post-procedure care and
early perioperative maintenance, 844, 845
period, 90 pre-procedure and
postoperative surveillance, technical
406 considerations, 842, 843
preoperative imaging, 389 retrograde approach, 844
prescribed status post percutaneous gastrostomy/
complex aortic repair, gastrojejunostomy
406 anatomy, 832, 833
utilization trend, 90 antegrade approach, 838
zone 2 repair, 399 complications, 839–841
Endovascular aneurysm sealing materials and equipment,
system, 397 835, 836
Endovascular carotid artery patient evaluation, 831,
stenting (CAS), 255 832
Endovascular coil treatment post-procedure care and
(ECT), 612 maintenance, 836–838
Endovascular intervention, 185
complication rate, 293
940 Index

Enteral access (cont.) Femoral, 223

pre-procedure and Femoral and iliac vasculature, 94
technical Femoral artery aneurysms
considerations, 833, 834 (FAA), 368
retrograde approach, 838, Femoral artery aneurysms less
839 favorable for
EOI administration, 542 endovascular repair,
Epidural spinal injections (ESIs), 370
658, 661 Femoral venous access
Epidural steroid injections (ESI), post-procedural care, 232
654, 660 without sonography, 232
Epistaxis, 209, 924 Femoropopliteal (calf
Escherichia coli, 563 claudication), 138
Esophageal varices, 530 Fenestrated endografts, 396
ETG identified during the 2nd Fenestrated endovascular aortic
stage endovascular repair (fEVAR), 396
repair, 398 advantages, 396
Ethanol, 200 disadvantages, 397
Ethanol vs. embolic agents, 200 Fenestrated grafts, 396
EUCLID study, 24 Fentanyl, 5
EVAR options for complex Fertility, 575
aortic repair, 393 FEVAR vs. Ch-EVAR, 408
EVAR via parallel techniques Fibrin sheath, 823
(chEVAR), 395 Fibroadenoma, ultrasound
EVAR vs. open surgical repair, features, 480
90 Fibromuscular dysplasia (FMD),
Events in a Global Smoking 280
Cessation Study angioplasty in patients with
(EAGLES), 25 hypertension, 291
Expiratory wheezing, 788 characteristic appearance, 280
External biliary drain, 504 characteristic location, 286
External iliac artery, 368 HTN, 280
External laser therapy, 319 primary patency of
complications, 322 angioplasty, 291
Extra renal complications, 294 RVH, 298
technical success rate of
angioplasty, 291
F Fine needle aspiration (FNA)
Facet injections, 658 advantages, 484
Facet joint arthropathy, 648 approach, 486
FDA-approved endovascular disadvantages, 484
AVF devices, 382 Fistula, 387
Fecal incontinence, 842 maturation, doses, 387
Feeding schedule and dosing, 836 Fistula first initiative, 380
Feeding tube, 831, 832, 835, 837, Fistulogram
841
 Index 941

anterograde puncture towards Genitourinary (GU)

the venous outflow, 383 interventions
indications, 380 anatomy, 864, 865
ultrasound, 382 complications, 868, 869
Fixation by internally cemented “double stick” method, 867
screw (FICS), 649 hydrophilic wire and coiling,
Flow-control devices, 59 868
Fluid sampling, 876 indications/contraindications,
Flumazenil, 39 864
Fluoroscopic fade, 121 materials, 865, 866
Fluoroscopy, 4 nephrostomy catheter, 868
Flush catheters, 118 Nutcracker syndrome, 870
FMD arteriovenous fistulas, 280 patient evaluation, 861, 862
Foam sclerosants, 537, 542 patient history, 862, 863
Foam sclerotherapy, 320 PCN placement, 867
Foley catheter, 840 renal biopsy, 867, 869
Future liver remnant (FLR) renal pelvis, 867
before surgical ureteral stent, 868
resection in patients Genitourinary endoscopy, 907
with cirrhosis/chronic Gerota’s fascia, 864
hepatitis, 436 Ghrelin, 897, 902
Glasgow Blatchford scoring
system, 750
G Gore TAG thoracic branch
Gallbladder, 908 endoprosthesis (TBE),
Gastric distension, 835 402
Gastric fundus, 897 Graft failure, primary
Gastric variceal hemorrhage, 545 complications, 387
Gastric varices, 530, 532, 533, 543, Graft stenosis, 522
544 Great radicular artery of
Gastric varices secondary to Adamkiewicz, 97
splenic vein Groin hematoma and puncture
thrombosis, 532 site trauma, 293
Gastric-variceal system, 534 GSV ablation, 320
Gastroesphageal varices, 535 Guidewire, 117, 866
Gastrointestinal bleeding, 682 and tactile feedback, 52
Gastrointestinal endoscopy, 907 columnar strength (stiffness),
Gastrorenal and gastrocaval 51
varices, 534 components of, 50
Gastrorenal shunt, 534 lubricity, 52
Gelfoam, 677, 682 removal, catheter, 57
General endotracheal anesthesia Guiding catheter
(GETA), 875 components of, 56
Generic fEVAR layers of, 55
procedure, 401 Gutter formation, 396
942 Index

H Hepatic resection, 419

Hand hygiene, spread of Hepatocellular carcinoma
infection, 41 (HCC)
HAS-BLED score, 875 ablative margins, 426
HD vascular access, 380 latency period, 418
preferred mode, 380 liver directed therapies, 436
Heart outcomes prevention risk factors, 418
evaluation (HOPE) TACE, 419
trial, 26 3-year survival, 418
Heat sink effect, 476 with vascular invasion/
Hemangiomas of infancy, 194 extrahepatic spread,
Hematemesis, 530 437
Hematoma, 925 Hepatorenal syndrome (HRS),
Hemiarch replacement, 404 516
Hemiazygos vein, 454 Hereditary hemorrhagic
Hemispheric stroke, 601 telangiectasia (HHT),
Hemodynamic instability, 718 195, 209
Hemodynamic stability, 675 consensus of the clinical
Hemoptysis, 459 diagnostic criterion,
Hemorrhagic stroke, 597, 602 196
Heparin activity, reverse effects prevalence, 195
of, 262 Hereditary papillary renal cell
Heparin allergy, 5 cancer syndrome, 467
Heparinized patients, activated High flow (dialysis/pheresis)
clotting time, 99 catheters, 222
Hepatic arterial branch pattern High-flow mesenteric AVMs in a
from celiac trunk, 421 staged fashion, 200
Hepatic arterial injuries after Hilar overlay, 455
percutaneous biliary Hives/diffuse erythema, 787
interventions in the era Homocysteine levels, 133
of laparoscopic surgery Hybrid aortic repair, staging, 390
and liver Hybrid TEVAR, 390
transplantation, 507 Hybrid thoracic aortic aneurysm
Hepatic arterial interventions, repair, 390
427 Hydrodissection, 471
Hepatic arterial oncologic Hydrophilic coatings, 50, 53
interventions, cone- Hydrophilic wires, 286
beam CT, 423 Hydrophobic coatings, 50, 53
Hepatic arterial supply, 116 Hypercoagulable states
Hepatic artery variants, 422 acquired causes, 155
Hepatic capsular perforation, 518 genetic causes, 155
Hepatic dome lesions, 880 Hyperhomocysteinemia, 133
Hepatic embolotherapies, 415 Hypesthesia, 925
Hepatic encephalopathy, 544 Hypoxia, 788
 Index 943

I Interventional radiology-
Idiopathic varicoceles, 335 operated endoscopy
Iliac and renal veins on a (IRE)
cavogram, 356 access maintainance, 910
Iliac veins, 162 anatomy, 908
Iliofemoral thrombus biliary endoscopic
aggressive therapy, 158 interventions, 912
Image-guided breast biopsies, chronic cholecystomy drains,
482, 488 912
Image-guided central venous clinical scenario, 910
access, complication complications, 910, 911
rates, 233 excess fluid, 910
Image-guided thermal ablation, indications/contraindications,
448 907
Inadvertent air embolus, 57 landmark research, 911, 912
Infantile hemangiomas, 194 materials, 909
Infected central venous catheter, patient evaluation, 905
825 patient history, 906
Infected necrotizing pancreatitis, three-dimensional endoscopic
888, 889 models, 912
Inferior mesenteric artery Intervertebral discs, 631
(IMA), 183, 767, 768 Intra-arterial (IA) alteplase, 611
Inferior phrenic veins, 535 Intra-articular injection, 660
Inflammatory peritonitis, 574 Intracerebral hemorrhage, 267,
Infrainguinal arterial disease, 44 615
Infrapopliteal (plantar Intracranial atherosclerosis, 252
claudication), 138 Intraprocedural bradycardia, 263
Infrazygomatic approach, 922 Intraprocedural vasospasm, 263
Inguinal lymph nodes, 799 Intrathoracic lymphatic
INPACT trial, 146 structures, 454
Intercostal arteries, 97 Intravascular ultrasound (IVUS),
Intermediate high-risk, 152 68
Intermediate low-risk, 152 Intravenous contrast-allergy
Intermediate-risk PE, 152 premedication, 786
Intermittent fluoroscopy, 538 Iodinated contrast allergy, 350
Internal biliary stents, 502 Ipsilateral external carotid artery,
Internal jugular (IJ), 221 259
Internal jugular vein (IJV), 221 IR emergencies, 29
Internal-external biliary drain, IR physician review, 111
504 IR-related emergencies, 29
Internal spermatic vein, 338 Irreversible electroporation
International normalized ratio (IRE), 425
[INR], 112 Ischemic rest pain, 133
International Prostate Symptom Ischemic strokes, 597, 598,
Score (IPSS), 580 600–603, 610
Interventional radiology, 11 Isosorbide mononitrate, 589
944 Index

ISV and collateral flow, 340 Limb ischemia, classification

IVC accessed via a translumbar system for acute and
approach, 224, 232 chronic, 8
IVC filter be after deployment, Liver biopsy
356 carcinoid crisis, 881
IVC filter induced thrombus, 15 hepatic dome lesions, 880
IVC filter placement, 350, 353 Kehr's sign, 880
complications, 356, 357 pleural effusion, 881
IVC filter removal, 353 safest approach, 879
transfemoral transcaval
approach, 880
J transjugular liver biopsy, 880
Jejunostomy tubes, 836 Liver directed therapies, HCC,
Juxta-renal aneurysm, 84 415, 417, 429, 436
Liver failure, 420
Liver necrosis, 420
K Liver reserve/cirrhosis
Kasabach-Merritt syndrome, 18 mortality, 416
Kehr's sign, 880 Lobectomy with mediastinal
Kidney, 908 nodal sampling, 448
Klippel-Trenaunay syndrome Loeys-Dietz syndrome, 95
(KTS), 197, 850 Longitudinal stress, 64
Kommerell's Low flow catheters, 222
diverticulum, 376 Low molecular weight heparin
Kyphoplasty, 632, 636–638 (LMWH), 5
Low pressure connection tubing,
61
L Lower extremity
Lactulose, 759 DVT, 166, 353
Laparoscopic cholecystectomy, proximal arteries, 368
500 VTE, 162
Laplace’s law, 90 Lower gastrointestinal bleeding
Large bore tunneled central (LGIB)
venous catheters in anatomy, 767, 768
coagulopathic patients, complications, 771
238 embolic agent, 770
Large vessel occlusion (LVO), glucagon, 769
599 hemorrhage, 769
Laryngeal edema, 788 history, 765
Lead gowns, 4 incidence, 772
Lead lined eye glasses, 4 indications/contraindications,
Left biliary system, 505 765, 766
Left subclavian artery (LSA), landmark research, 771, 772
402 mild-moderate hypovolemia,
Leptin, 897 773
Leriche’s syndrome, 133 patient evaluation, 763, 764
 Index 945

post-procedural assessment, Lymphatic malformations, 848,

771 855
sheath size, 768 Lymphatic system, 797, 798
target embolization, 770
treatment, 769
vessels, 768 M
Lower urinary tract symptoms Macrocystic malformations, 851
(LUTS), 580, 583 Maffucci syndrome, 197
Low-flow venous malformations, Major bleeding, 562
194 Major hemorrhage, 506
Low-profile G-tube, 837, 838 Malignant biliary obstruction,
Low-risk PE, 152 498
treatment, 158 Malignant nodules
LSA and LCCA ligated (coiled) on imaging, 445
during zone 1 repair, Marfan syndrome, 95
402 Massive hemoptysis, 30, 734–736
LSA revascularization, 399 May Thurner syndrome, 19, 154
Luer-lock and a Luer-slip Mechanical obstruction using
connection, 59 embolic agent, 425
Lumbar radiculopathy, 659 Mechanical thrombectomy, 161,
Lung ablation, 457 162
complications, 458 Medial branch nerve block
Lung biopsy, 443, 450, 455, 456, (MBB), 660
459, 881, 882 Median lobe, 585
absolute contraindications, Medical internal radiation dose
450 (MIRD)., 436
relative Medical shock, types, 6
contraindications, 450 MELD score, 40
Lung biopsy/ablation, 459 MELD-Na score, 14
chest CT, 444 Melena, 747
complication, 443 Menorrhagia, 568–570
medications, 444 Menstrual cycle, breast MRI, 490
Lung cancer Mesenteric collateral pathways, 9
average age of diagnosis, 444 Mesenteric interventions, 185
gender difference, 444 upper extremity access, 185
prevalence, 444 Mesenteric ischemia
risk factors, 444 acute, 177
screening, 445 chronic, 177
second-hand smoke, 444 embolic event, 184
types, 446 endovascular treatment, 187
Lung nodules, 450 imaging tests, 178
types, 445 interventions, 190
Lung shunt fraction (LSF), 416, laboratory tests, 178
428 surveillance, 190
Lung shunting, 429 vessel stenosis/thrombosis,
Lungs, pleural layers, 451 184
946 Index

Mesenteric venous thrombosis, (NCI-­MATCH) trial,

180, 186 874
SMV, 184 National Institute of Health
treatment strategies, 182 Stroke Severity
Mesenteric vessels (NIHSS) Score, 599
angioplasty and/or stenting, NBCA embolization, 201
187 n-Butyl cyanoacrylate (NBCA),
Metastatic lung nodule, 450 201, 854
Methylprednisolone-based Neck hematoma due to venous/
regimen, 785 arterial rupture, 266
Microcatheters, 118 Nephrectomy, 473
Microcystic lymphatic Nephrogenic systemic fibrosis,
formations, 851 787
Microwave ablation technique, Nephrolithiasis, 863
424, 427, 470 Nephron-sparing surgery (NSS),
Middle mediastinum, 452 468
Migration of the embolic device/ Nephrostomy, 553
material, 73 access, 555
Milan criteria, 20 catheter, 557
Milan criteria for liver placement, 553
transplantation, 418 Neurologic complications, 99
Mirizzi syndrome, 500 Nidus, 852
Mixing ethiodized oil (Ethiodol) Nitrogen/argon gas, 485
with NBCA glue, 201 Nitroglycerine, 589
Model for end-stage liver disease Nominal and burst pressure, 141
(MELD) score, 516, Nominal pressure, 64
532 Non-arterial cause of mesenteric
Modified Allen test, 116 ischemia, 180
Modified Mallampati score, 8 Non-compliant pressure tubing,
Modified Rankin scale, 261, 603 61
Modified Seldinger technique, Non-coring needle, 826
886 Non-inflammatory vasculitis, 280
Morning rounds/morning report, Nonocclusive mesenteric
17, 19 ischemia (NOMI), 180
MRI-guided breast biopsy, patient history, 180
483–487 Non-retrievable filter, types and
Multivessel supply for pelvic their composition, 355
AVMs, 200 Nonselective flush catheters, 55
Musculoskeletal pain, 646 Non-small cell lung cancer
(NSCLC)
staging, 447
N treatment, 448
National Cancer Institute- types of surgical treatments,
Molecular Analysis for 448
Therapy Choice Nontarget embolization, 73
Non-targeted organ biopsy, 876
 Index 947

Non-targeted renal biopsy, 883 Parapneumonic effusions, 889

Non-traumatic chylous effusion, Parasthesias, 924
795 PARC study, 145
Non-tunneled catheters for HD, Parenchymal atrophy, 500
380 Parkes-Weber syndrome (PWS),
Non-tunneled central venous 197
catheters, 219 Passive support, 56
contraindications, 220 Patent vena marginalis lateralis,
Non-tunneled CVC, 241 197
Nothing by mouth (NPO), 786, Patient-specific anatomy and
813 specifications, 11
Nutcracker syndrome, 870 PAVM nidus, 199
PAVMs undergo embolotherapy,
208
O PAVMs vs. complex PAVMs, 199
Obesity, 893, 894 PAVMs with feeding artery, 206
Occlusion balloon, 537 PE intervention, access site, 162
Occlusion balloon inflation, 540 Pelvic pain, 650
Occlusive dissection/perforation, Pelvis
289 angiography and
Oil-based contrast agents, 61 embolization, 719
Onyx administration, 205 arterial access, 722
Open surgical repair, 84 arterial bleeding, 716
Open surgical repair and thoracic arterial/venous injury, 726
endovascular aortic catheter, 722
repair with Zenith collateral blood supply, 723
TX2, 105 collateral supply, 721
Operator-dependent catheter compartment syndrome, 723,
manipulation, 56 724
Organ ischemia, 72 corona mortis, 724
Osler-Weber-Rendu syndrome, external iliac artery, 727
195 fractures, 728
Osteopenia, 639 history, 714, 716–718
Osteoporosis, 628, 639 iliopectineal and ilioischial
Oswestry Disability Index, 650 lines, 715
Overactive bladder (OAB), 580 imaging, 714, 715
initial evaluation and
management, 713
P injection rate, 722
Packing density, 73 internal iliac (hypogastric)
Page kidney, 883 artery, 720
Paget–Schroetter’s disease, 827 landmark research, 725, 726
Pancake breast, 490 materials, 721, 722
Paradoxical embolism, 154 pelvic arteriography and
Parallel endografts, 395 embolization, 719
Parallel grafting technique, 400 physical examination, 714
948 Index

Pelvis (cont.) complications, 506

recurrent bleeding, 727 tract placement, 507
retroperitoneal bleeds, 719 Percutaneous drainage, 884
signs, 714 Percutaneous ethanol ablation,
surgical exploration and 423
repair, 718 Percutaneous gastrointestinal
surgical treatment, 718 endoscopy, 906
Penetration power, 52 Percutaneous gastrostomy/
Penetration power of a wire, 117 gastrojejunostomy
Penumbra, 604 anatomy, 832, 833
Percutaneous ablation, 419 antegrade approach, 838
indications, 418 complications, 839–841
non-target anatomy, 421 materials and equipment, 835,
Percutaneous biliary 836
interventions, 501, 502 patient evaluation, 831, 832
Percutaneous biliary stent post-procedure care and
placement, 497 maintenance, 836–838
Percutaneous biopsy pre-procedure and technical
adrenal lesion, 883 considerations, 833, 834
challenges, 878 retrograde approach, 838, 839
complications, 879 Percutaneous genitourinary
contraindications, 874 endoscopy, 906
devices, 878 Percutaneous nephrostomy, 29,
FNA biopsy, 878 554
HAS-BLED score, 875 indications, 554
indications, 873 Percutaneous nephrostomy
laboratory test thresholds, 875 (PCN)
liver biopsy, 879–881 catheter placement, 551
lung biopsy, 881, 882 complications, 506
NCI-MATCH trial, 874 placement, 864, 865
needle size, 877 procedure
non-focal kidney biopsy, 883 antibiotics, 558
NPO, 875 coagulopathy, 552
Page kidney, 883 collecting system, 559
renal mass biopsy, 882 complication, 560
risk of bleeding, 874, 879 imaging technique, 558
sedation, 875 laboratory studies, 551
single stick and coaxial, 877 patient position, 551
spleen, 884 pertinent imaging, 551
target, 878 platelet count, 552
transgluteal presacral/pelvic Posterior calyx, 556
mass biopsy, 884 safest target for, 556
types of image-guided sequential dilatation of
percutaneous biopsies, the tract, 559
876 signs of infection, 551
Percutaneous cholecystostomy ultrasound and/or
(PC), 497, 509, 906, 907 fluoroscopy, 558
 Index 949

tract placement, 507 transpedicular approach, 633,

Percutaneous primary and 634
secondary biliary types, 638
stenting for malignant VCF
biliary obstruction, 508 back pain, 630
Percutaneous thrombectomy, 158 clinical presentation, 628
Percutaneous transhepatic biliary evaluation and diagnosis,
drainage (PTBD), 497, 628
501, 508 lumbodorsal
complications, 506 junction, 628
Percutaneous transhepatic medical therapy, 638
cholangiography pathophysiology, 629
(PTC), 497, 501 prevalence, 627
cause of sepsis, 506 prevention, 639
complications, 506 risk factors, 628
Percutaneous transluminal treatment, 629
angioplasty (PTA), 382 vertebral bodies and spinal
Percutaneous vertebral cord, 632
augmentation (PVA) Perforating veins, 315
arthroplasty, 633 Peripheral Academic Research
complications, 634, 635 Consortium (PARC),
contraindications, 630 145
extrapedicular vs. preferred Peripheral arterial disease
transpedicular (PAD), 112
approach, 630 Peripheral artery aneurysms
general anesthesia, 633 (PAA), 361, 362
imaging, 629 complication rate, 373
improvement, 637 complications arise from
indications, 630 endovascular repair,
injection, 634 373
intervertebral discs, 631 endovascular management
kyphoplasty, 638 techniques, 370
landmark research, 636, 637, endovascular repair, 369
639 endovascular treatment, 371
lumbar vs. thoracic vertebrae, incidence, 363
631 indication, 366, 367
origins, 638 multilayered stents, 369
osteoporosis and osteopenia, natural history, 365
639 open surgical intervention,
posterolateral approach, 632 366
post-operative management, physical exam, 363
634 risk factors, 365
preprocedural steps, 633 stent-grafts, 369
procedure, 632 treatment for, 370
spine, 631 ultrasound guided thrombin
structure, 631 injection, 367
950 Index

Peripheral artery disease (PAD) Pleural effusion after ablation,

access, 142 459
angioplasty and stenting, 135 Pleurisy, 204
arterial claudication, 131 Pneumonectomy, 448
characteristic clinical Pneumothoraces, 459
symptoms in patients, Pneumothorax, 561
132 Polymethyl methacrylate
clinical follow-up, 148 (PMMA), 659
development of CLTI, 130 Polyvinyl alcohol (PVA), 739
endovascular therapy, 138 Popliteal aneurysms, 18
imaging technique/protocol, Popliteal artery, 115, 368
147 Popliteal artery aneurysm, 366
indications, 135 Portal hypertension, 9
physical exam, 128 Portal vein embolization (PVE),
prevalence, 127 436
risk factors, 132 Portal vein thrombosis, 533, 546
Peripheral ischemia, 203 Portal venogram, 520
Peripheral venous access for IVC Port-wine stain, 851
filter placement, 356 Positron emission mammography
Peripherally inserted central (PEM), 481
venous catheter Post ablation syndrome, 459, 460
(PICC), 816–819, 822 Post embolization syndrome
Periprocedural prophylactic (PES) after renal
anti-thrombotics for artery embolization,
peripheral arterial 473
interventions, 38 Post-ablation multiphase CT
Periscope graft, 395 scan, 472
Periscope graft in a TEVAR, 401 Post-embolization syndrome, 429,
Peritonitis, 839 473, 575, 685
Peroneal magnus, 140 spleen, 705
Persistent left sided SVC Posterior mediastinum, 452
(PLSVC), 454 Posterior pleura, 555
Persistent sciatic artery, 140 Posterior spinal cord, 97
PESI score, 14 Postimplantation syndrome, 102
Pharmacologic CDT, infusion Post-lung ablation, 461
system, 161 Post-procedure encephalopathy,
Pharmacomechanical CDT, 161 516
Pharmacomechanical Post-procedure mammogram,
thrombectomy, 162 486
Phlebitis, 343, 823 Post-thrombotic syndrome
Plain old balloon angioplasty (PTS), 154
(POBA) to treat an Power injection pumps, 61
arterial atherosclerotic Prednisone-based regimen, 785
stenosis, 64 Pre-filter placement cavogram,
Plaque morphology, 143 354
 Index 951

Preoperative lumbar drain LUTS, 580, 592

placement, 404 materials, 587
Pre-operative renal artery median lobe, 585
embolization (PRAE), microcatheter navigation, 589
475 OAB, 580
Pre-procedural skin preparation, preprocedural antibiotics, 587
42 pre-procedure medications,
Pre-procedure, 31–33 587
Pre-procedure note prostatic artery, 585, 586, 588
elements, 113 storage and voiding
Primary and accessory symptoms, 579
neurovascular bundles, TURP, 592
453 urodynamic studies, 583
Primary lung cancer, 450 zones, 585
Procedural bleeding risk, 31 Protamine, 262
Prophylactic antibiotic Prothrombin time (PT), 112
recommendations for Proximal deep veins of the lower
planned procedures, 7 extremity, 160
Prophylactic antibiotics, 39, 835 Proximal occlusion of the
Prophylactic CSF drainage, 102 feeding artery, 202
Prophylactic vena cava filter, 358 Proximal vessel embolization,
Prospective observational 684
vascular injury PSA formation, 366
treatment Pseudoaneurysm (PSA)
(PROOVIT), 687, 688 formation, 123, 364
Prostate specific antigen (PSA), PTA of stenotic lesions, 383
372, 373, 583 high-pressure non-compliant
Prostatic artery (PA), 585, 586 balloons, 382
Prostatic artery embolization PTA treatment of failing fistula,
(PAE) 384
access, 588 Pterygopalatine fossa, 919, 925
bladder catheter, 588 Pulmonary arterial levels, 160
BPH Pulmonary arteries, 199
definition, 585 angiography, 120
diagnosis, 583 catheterization
symptoms, 579 cardiac precautions, 163
clinical metrics, 583 Pulmonary AVMs (PAVMs), 195
complications, 589, 590 clinical manifestations, 195
cone beam CT, 589 complications, 196, 205
contraindications, 584 lower lobes, 209
embolic material, 589 Pulmonary embolism (PE), 151,
history, 583, 584 152, 165
imaging, 583 computed tomography
indications, 584 pulmonary
laboratory results, 583 angiography, 156
landmark research, 590, 591 echocardiogram, 153
952 Index

Pulmonary embolism (PE) Renal artery anatomy, 285

(cont.) Renal artery aneurysm, 376
electrocardiographic Renal artery embolization, 468,
considerations, 156 472
plain film, 156 adverse effects of, 473
scoring system, 13 anatomic variants, 469
symptoms, 154 benefits of, 473
Pulmonary embolism severity contraindications, 468
index (PESI), 153 Renal artery stenosis (RAS)
Pulse volume recordings, 112 causes of, 298
Pyonephrosis, 551, 552, 563 Doppler
direct signs of, 278
indirect signs of, 278
Q follow-up imaging modality,
QuickSOFA (qSOFA) score, 21, 298
560 initial/screening imaging
study, 278
non-inflammatory vasculitis,
R 280
Radial stress, 64 renal arterial interventions,
Radiation lobectomy, 436 286
Radiation segmentectomy, 420 screening, 298
Radical nephrectomy, 468, 473 Renal biopsy, 864, 865, 867, 868
Radiocephalic dialysis fistula, 381 Renal cell carcinoma (RCC)
Radiofrequency ablation (RFA), detection rates of, 465
424, 470, 474, 475, 487 diagnosis, 466
mechanism of action, 485 differential diagnosis, 466
temperature, 435 five-year survival, 467
Radiofrequency pulsation, 921 gender predilection, 466
Radiofrequency imaging features, 466
thermocoagulation, 921 incidence, 465
Rapid exchange (monorail) interventional radiology, 467
system, 57 risk factors, 466
Rasmussen’s aneurysm, 743 subtypes of, 466
Rated burst pressure, 64 symptoms, 465
Real-time ultrasound- guided types, 465
vascular access, 43 Renal disease, 814
Recanalization of the occluded Renal Doppler ultrasound, 290
jugular veins, 221 Renal dysfunction after
RELAY Endovascular Registry revascularization, 292
for Thoracic Disease II Renal mass biopsy, 882
(RESTORE II) study, Renal revascularization
106 procedure, 287
Renal anatomy, 469 Renal scintigraphy, 553
Renal angioplasty, risk of vessel Renal tumor thermal ablation,
rupture, 293 468
 Index 953

Renal vein renin sampling, 285, Reperfusion brain edema, 267

287, 292 Reperfusion injury, 187
contraindications, 285 Reticular veins, 315
indications, 285 Retrograde access, 833
Renovascular hypertension Retrograde transvenous
(RVH), 277, 298 obliteration, 756
absolute contraindications, Retrograde type A dissection
284 (RTAD), 406, 407
atherosclerosis, 294 Retrograde ureteral stent, 469
balloon diameter, 286 Revascularization, pressure
BP monitor, 290 gradient, 289
bypass in surgical Reverse-curve catheters, 683
revascularization, 281 Reynold’s pentad, 499
causes, 278 RFA in early-stage breast cancer,
coagulation parameters 491
pre-endovascular RFA in the breast, 490
intervention, 287 RFA vs. lumpectomy, 491
definition, 278 Right femoral venous approach,
diagnostic methods, 279 538
digital subtraction Right hepatic vein (RHV), 517
angiography, 279 Right-sided biliary drainage, 504
endovascular treatment, 281 Roadmap, 121
etiologies, 280 Rutherford classification for
flank/abdominal bruit, 278 chronic limb ischemia,
indications for 128
revascularization, 283 RV to LV ratio, 157
in-stent stenosis, 291 RVH causing cardiac
medications, 290 destabilization, 299
non-invasive imaging
modality, 278
pathophysiology of RAS, 279 S
patient presentation, 282 SAAG score, 15
primary stent placement, 291 Sacral fractures, 659
prophylactic pre-procedural Sacroiliac (SI) joint, 649
antibiotics, 287 SAFARI technique, 53
relative contraindications, 284 Salvage AV access procedures,
restenosis after stenting, 291 self-expanding covered
severe acute presentation, 278 stents, 382
surgical vs. endovascular Sandwich technique, 395
revascularization, 281, Saphenofemoral junction (SFJ),
295 315
30-day surgical mortality, 294 Sclerosant, 537
treatment, 281 Sclerosant-induced hemolysis, 542
unrelated angiographic Sclerotherapy, 319, 852–854
imaging, 278 complications, 323
vascular access, 288 external laser therapy, 322
954 Index

Scrotal swelling, 333 complications, 924, 925

Segmentectomy and wedge diagnostic and therapeutic
resection, 448 block, 923
Seldinger technique, 47, 119 indications/contraindications,
Selective catheters, 55 917–919
Selective embolization, 538 infrazygomatic approach, 922
Selective nerve root blocks invasive nerve block
(SNRB), 654, 659, 661 procedure, 926
Self-expanding stent, 67 landmark research, 925, 926
Sepsis, 560 local anesthesia, 922
Septic shock, 560 materials, 920, 921
Severe hemorrhage, 459 patient evaluation, 915, 916
Severe pulmonary hemorrhage/ patient history, 916, 917
hemothorax, 459 patient’s caretakers, 926
Severe pulmonary hypertension RF thermocoagulation and
when embolizing pulsed radiofrequency,
PAVM, 198 924, 926
Shock transnasal approach, 923
clinical features, 7 Spina Bifida patients, 842
signs and symptoms, 7 Spinal cord ischemia, 102
Shortness of breath post-biopsy, Spinal nerve root blocks, 658
457 Spine, 631
Sickle cell trait, 467 injections, 661
Skin ulcers, 204 pain, 648
Slow-flow venous malformation, Spleen
197 AAST splenic injury grading
Small cell carcinoma, 446 scale, 698, 699
Small-cell lung (SCLC) cancer anatomy, 702, 703
chemoradiation therapy, 449 biopsy, 884
staging, 449 clinical manifestations, 697
Small dermotomy, 227 complications, 705, 706
Society of Interventional FAST exam, 697
Radiology (2010) history, 700
guidelines, 501 imaging characteristics, 699
Sodium tetradecyl sulfate (STS), indications/contraindications,
537, 853 701, 702
Soft tissue AVMs, 193 landmark research, 706, 707
Solumbra technique, 611, 614 materials, 703, 704
SPACE-2 trial, 271 monitoring, 704
Spetzler-Martin grading scale for morbidity and mortality, 705
intracranial AVMs, 204 non-operative management,
Sphenopalatine ganglion 699
lesioning, 918 normal daily activities and
Sphenopalatine ganglion nerve return to sports, 705
block SAE, 704
anatomy, 919, 920 vaccination, 708
 Index 955

Western Trauma Association endovascular treatment vs. IV

Algorithm, 700 alteplase, 618
Splenic artery aneurysms and follow-up, 620
arterial calcification, imaging study, 599
366 IMS III, SYNTHESIS, and
Splenic artery embolization MR RESCUE trials,
(SAE), 701, 702, 704 618
Splenic artery, VAA, 369 intervention, 612, 613
Splenic vein thrombosis, 532 intraarterial alteplase, 611
Squamous cell carcinoma, 446 intracranial berry (saccular)
Steal syndrome, 384 aneurysms, 621
Stent configurations, types, 141 intracranial hemorrhage vs.
Stent graft, 86 subarachnoid
device, 87 hemorrhage, 602, 603
types, 86 intubation/supplemental
Stent restenosis, 284 oxygen, 605
Stent-graft placement in a IV alteplase, 605–607, 609, 620
descending TAA, 98 long-term anticoagulation,
Stents patency, 134 620
Stereotactic ablative LVO, 599
radiotherapy (SABR), mechanical thrombectomy,
448 607, 608, 610, 611, 613,
Stereotactic biopsy, 482 620
Stereotactic breast biopsy, 484, modifiable and non-
485 modifiable risk factors,
Stereotactic procedure, 485 600, 601
Steroid injection, 654, 658, 661 modified Rankin scale, 603
Stroke mTICI, 615
ADAPT, 612 non-imaging tests, 599
alteplase administration, 606 pathophysiology, 598
aortic arch, 610, 611 penumbra, 604
ASPECTS score, 604 RCTs, 618
ASTER trial, 619 signs, 603
blood pressure, 614 Solumbra technique, 611, 614
catheters, 612 symptoms, 601, 602
Circle of Willis, 611 thrombolytic agents, 614
classifications, 597, 604 TIA, 597
clinical patient assessment t-PA, 605, 609, 610
tool, 599 Sturge-Weber syndrome, 851
COMPASS trial, 619 Subarachnoid hemorrhage
complications, 615–617 (SAH), 617
DAWN and DIFFUSE trials, Subclavian artery, 368
617 Subclavian vein, 222, 819
double-flush technique, 620 accessed without fluoroscopy,
ECT, 612 231
fluoroscopy, 231
956 Index

Sub-internship, role of, 3–5, 8, 9 Symptomatic carotid stenosis

Suboptimal ablation, 456 from atherosclerosis,
Substantial cement leaks, 635 254
Sub-xiphoid approach, 834 Synovial venous malformation,
Superficial femoral artery (SFA), 857
115, 139 Systemic anticoagulation
Superficial venous insufficiency absolute contraindications,
absolute/relative 352
contraindications for relative contraindications, 352
treatment, 312
adjunctive therapy, 314
anatomical variations, 316 T
complications, 306, 327 TACE, 428
conservative (compression to ablation, 420
therapy and lifestyle chemotherapeutic dosing, 425
modifications), 316 complications, 430
endovascular treatment over ethiodized oil, 425
surgery, 325 imaging response, 428
endovenous (thermal and medications, 427
non-thermal), 316 procedures, 422
evaluation, 304 Tachycardia, 787
external laser, 316 TAPVR, 454
imaging modality, 304 TARE, 416
indications, 311 complications, 430
lifestyle modifications, 311 contraindications, 419
open/surgical, 316 cystic artery, 430
pathophysiology, 325 indications, 419
pertinent history, 310 intra-arterial locoregional
reflux on ultrasound therapy in treating
examination, 305 CRC metastases, 420
risk factors, 311 medications, 428
sclerotherapy, 316 nontarget embolization, 431
symptoms, 310 surface radiation dose, 436
treatment approach, 314 TACE, 420
Superficial venous system, 116 Targeted therapy, role of, 449
Superior mediastinum, 452 Targeted tissue biopsy, 876
Superior mesenteric artery TASC II classification of
(SMA), 183, 767, 768 aortoiliac disease, 136
direct puncture, 185 TASC II classification of
Superior sulcus tumors, 449 femoral-popliteal
Suprarenal IVC filter placement, disease, 137
353 Telangiectasias, 315
Surgical carotid endarterectomy Temporary non-tunneled
(CEA), 255 catheter, 220
Swan-Ganz monitoring when Temporary non-tunneled dialysis
using absolute ethanol, catheters, 225
203 TEVAR, 96, 404
 Index 957

medical conditions, 95 Thoracic duct embolization

Therapeutic anticoagulation, 166 (TDE)
Therapeutic inferior vena cava anatomy, 797–799
filter, 159 antibiotic prophylaxis, 800
Thermal ablation, 470, 475 catheterization, 803
absolute contraindications, chyle, 808
468 chylothorax, 805
compare to nephrectomy, 476 clinical success rate, 807
relative contraindications, 468 complications, 804, 805
Thermal endovenous ablation of dorsal pedal
the GSV, 320 lymphangiography, 801
Thermal endovenous ablation of indications/contraindications,
the saphenous vein, 321 796, 797
Third generation cephalosporins, landmark research, 805
6 lymphangiographic
Thoracic aneuryms with TEVAR presentations, 806
treatment of, 104 materials, 799, 800
Thoracic aorta, components, 96 patient evaluation, 793, 794
Thoracic aortic aneurysm repair patient history, 795
advantages, 96 procedure, 804
indications, 95 process, 803
Thoracic aortic aneurysms progress of
(TAA) lymphangiography, 802
chest x-ray findings, 93 transabdominal puncture site,
complications, 101 802
computed tomography, 94 transnodal lymphangiography,
diagnosis, 94 802, 806
gender predominance, 94 Thoracic endograft stent, 398
imaging modalities, 94 Thoracic hybrid procedures, 390
imaging modality, 94 Thoracic stent-graft, 100
intravascular ultrasound, 94 delivery system, 100
localized dilatation, 93 deployment, 100
magnetic resonance Thoracic stent-graft placement,
angiography, 94 99
prevalence, 94 arterial pressure, 98
risk factors, 94, 95 early and late complications,
surgical reconstruction, 95 101
symptoms, 95 Thrombolysis, complication, 186
transesophageal echo, 94 Thrombolytic therapy, 182
types of, 93 Thrombosed fistula, 380
Thoracic aortic hybrid Thrombosed hemodialysis
procedures, 390 fistula/graft, 45
Thoracic aortic injury, 97 Tip load, 52
Thoracic aortic interventions, 392 Toe-brachial index (TBI), 130
Thoracic duct disruption (TDD), Torsional stress, 64
803
958 Index

Total anomalous pulmonary post-sinusoidal portal

venous return hypertension, 515
(TAPVR), 454 pre-procedural imaging
Total thoracic aortic aneurysm procedures, 515
repair, 403 pre-sinusoidal, 515
Touhy-Borst rotating hemostatic pressure gradient, 520
valve, 60 relative contraindications, 517
Transarterial embolization of the right internal jugular vein via
inflow and outflow ultrasound-guidance,
arteries, 45 519
Transarterial radioembolization, shunt severe stenosis/
433–435 occlusion, 522
Transgluteal presacral/pelvic sinusoidal, 515
mass biopsy, 884 stent/stent graft diameter
Transhepatic IVC/hepatic venous sizes, 519
catheters, 223 ultrasound features, 522
Transient ischemic attack (TIA), upper endoscopy, 515
597 Translumbar IVC access, 224, 232
Transjugular intrahepatic Transnodal lymphangiography,
portosystemic shunt 802, 806
(TIPS), 532 Transrenal, 223
absolute contraindications, Transurethral resection of the
517 prostate (TURP), 592
acute postprocedural Trauma embolization
complications, 521 active hemorrhage, 678
anatomic relationship angiography, 678
between the RHV and celiac trunk, 680
RPV, 517 complications, 685
angioplasty balloons, 519 contraindications, 679
antibiotic allergies, 514 embolization coils, 681
cirrhotic patient’s history, 513 Gelfoam, 677, 682
embolization of varices, 521 hard signs of arterial injury,
encephalopathy, 521 676
guidewires, 519 imaging modality, 674
hepatorenal syndrome, 517 intra-abdominal hemorrhage,
indications, 517 674
mental status on physical landmark research, 686–689
exam, 513 liver blood supply, 680
peri-procedural mortality risk, organ injury, 675
521 patient’s history, 675
physical exam, 514 pelvic/extremity trauma, 675
platelet/INR values, 514 physical examination, 676
post-procedural proximal vessel embolization
intraperitoneal vs. distal vessel
bleeding, 521 embolization, 684
 Index 959

proximal vs. distal vessel Type B3 varices, 536

embolization, 679 Type II endoleak after popliteal
reverse-curve catheters, 683 artery aneurysm repair,
risk factors, 677 376
setting, 673, 676
SMA and IMA, 680
soft signs of arterial injury, U
676 UCSF criteria, 418
superior mesenteric artery, Ultrasound-guided thrombin
680 injection of PSA, 373,
techniques/tools, 681 375
temporary and permanent Ultrasound guided vascular
embolic agents, 679, access, 119
681 Uncorrectable coagulopathy, 554
treatment failure, 684 Unfractionated heparin, 5
vascular access, 682 United States Preventive
vasopressin, 682 Services Task Force
Traumatic chylous effusion, 795 (USPSTF), 479
Tributary veins, 315 Upper extremity PAA, 362, 363
Trigeminal neuralgia, 916 Upper gastrointestinal bleeding
Trocar technique, 886 (UGIB)
Truncal veins, 315 access options, 754
Tube occlusion, 845 anatomy, 753
Tuberous sclerosis, 467 BRTO/CARTO/PARTO, 756
Tumescent anesthesia, 318 cardiopulmonary health
Tumor ablation, 472 status, 751
adverse effects of, 473 causes of, 751, 758
Tumor ablation for RCC, 469 complications, 756, 757
Tumor ablation treatment of embolization, 755
renal malignancies, 468 endoscopic failure, 758
Tumor seeding from RFA, 429 etiology, 751
Tunneled catheters, 228 hemodynamic instability, 747
Tunneled central venous access, imaging modalities, 749
indication, 240 indications/contraindications,
Tunneled central venous 752
catheters, 225, 241, 818 IR procedures, 750
contraindications, 220 lactulose, 759
Tunneled dialysis catheters, 237 landmark research, 757, 758
types, 225 materials, 753, 754
Tunneled hemodialysis catheters medical management, 748
by interventional neurological symptoms, 752
radiologists, 237 in patients with portal
Turner syndrome, 95 hypertension, 531
Type 1 varices, 539 scoring systems, 749, 750
Type 2 varices, 539 signs and symptoms, 747
Type 3 varices, 540 TIPS, 755, 758
960 Index

Upper gastrointestinal bleeding post fibroid embolization, 573

(UGIB) (cont.) specialty, 567
transfusion thresholds, 749 symptoms, fibroids, 567
treatment, 750 treatment, 573, 577
workup and management, 748 uterine artery embolization,
Uremic platelet dysfunction, 781
medication, 5 uterine malignancy, 568
Ureteral obstruction, 554 Uterine AVM, 200
Ureteral stenting, 866
Ureteral stricture dilation/
stenting, 869 V
Ureteropelvic junction (UPJ) Vacuum-assisted devices, 484
obstruction, 862 VALOR Trial, 103
Urinary tract obstruction and Valved PICCs and ports, 226
accumulation of pus in Vancomycin, 6
the collecting system, Variceal bleeding, 516, 530
563 portal-systemic gradient, 19
US-guided breast biopsy, 482, Variceal hemorrhage, 200
484, 488 Varicoceles
Uterine artery embolization associated with infertility, 336
(UAE) collateral pathways, 338
access options, 781 complications, 341
access sites, 572 contraindications for
adenomyosis, 576 percutaneous
anatomy, 570, 571, 780 endovascular
catheters, 572 treatment, 336
causes of, 784 contraindications for surgical
complications, 574, 575, 782 treatment, 337
contraindications, 570, 780 definition, 337
embolic material, 572 development of infertility, 335
follow-up, 569 embolic agents, 339, 343
history, 569, 576 fluoroscopic equipment, 339
identification, 573 grading criteria, 334
imaging, 568 indications for surgical
incidence, 784 treatment, 336
indications, 570, 780 inheritance factor, 335
landmark research, 575, 576, inpatient hospitalization, 343
782, 783 laboratory workup, 339
leiomyosarcoma, 576 non-compressibility and
materials, 780, 781 right-sided
ovarian arterial supply, 573 presentation, 334
patient evaluation, 777–779 percutaneous endovascular
patient history, 779 treatment, 336
pelvic angiograms, 572 physical exam findings, 333
post embolization aortogram, in the post-pubertal
781 population, 335
 Index 961

post-procedure pain control, prevalence, 858

339 sclerotherapy, 852–854
retrograde advancement, 340 treatment, 855, 859
scrotal ultrasound, evaluating Vascular malformations, 198, 850
men with infertility, 335 Vascular plug-assisted retrograde
sonography, 334 transvenous
spermatic cord, 338 obliteration (PARTO),
surgical vs. endovascular 538
treatment of Vascular pressure transducer, 519
varicoceles, 337 Vasopressin, 682
symptoms, 341 Vasovagal reaction, 787
technical success rate, 343 Vein vs. artery on ultrasound, 44
treatment, 336 Vena cava filter, 349, 351, 352,
Varicose vein, 315 354, 356–358
pedal pulses, 303 Vena cava filter removal, 358
physical exam, 303 contraindications, 353
Varicosities in the setting of deep Venography, 164
venous system Venous access intervention,
obstruction, 312 absolute
Vascular access contraindication, 381
closure devices, 46 Venous anastomotic stenosis, 382
complications, 122 Venous collaterals, 383
creation/ insertion Venous drainage patterns of a
patency, 387 varix, 536
failure, 379 Venous inflow patterns, 536
needles, 116 Venous intestinal ischemia, 179
Vascular access patency Venous malformations, 848
surveillance Venous punctures, 123
imaging modality, 379 Venous reflux, 304, 305
Vascular access selection factors, Venous stenting, 69
379 Venous stents, 162
Vascular access site, types of Venous thromboembolic disease
complications, 102 (VTE)
Vascular anomalies management, 351
anatomy, 851, 852 transient risk factors, 350
AVMs, 856 Venous thrombus on duplex
benign vascular tumor, 859 ultrasound, 349
complications, 856, 857 Venous/arterial rupture, 267
history, 847 Vertebral body compression
indications/contraindications, fractures, 659
854 Vertebral compression fracture
interdisciplinary team, 859 (VCF)
landmark research, 857, 858 back pain, 630
lymphatic malformations, 855 clinical presentation, 628
patient evaluation, 848, 850 evaluation and diagnosis, 628
post-procedural care, 855, 856 lumbodorsal junction, 628
962 Index

Vertebral compression fracture Wedged hepatic venography/

(VCF) (cont.) ultrasound, 518, 520
medical therapy, 638 Weight loss, 895, 902, 903
pathophysiology, 629 Wells score, 155
prevalence, 627 Wire/catheter induced
prevention, 639 vasospasm, 123
risk factors, 628 Worsening right-to-left shunting
treatment, 629 in PAVM, 199
Vessel injury, 65
Vessel wall stretching, 65
Virchow’s triad, 155, 350 Y
Visceral artery aneurysms Y-90 deposition in tumoral tissue,
(VAA), 363, 365, 367 429
Visceral embolization, 429 Y-90 radioembolization, mapping
Von Hippel-Lindau (VHL), 467 procedure, 423
Y-90 resin microspheres, 435

W
Wall stresses involved with Z
balloon angioplasty, 64 Zone 0 hybrid repair, 403, 406
Zone 1 hybrid repair, 402