Vascular and Interventional Radiology Principles and

Practice, 1st Edition

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Contents

List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

PART I. BASIC PRINCIPLES AND TECHNIQUES

1. Vascular and Interventional Radiology: A Brief History . . . . . . . . . . . . . 3
2. Catheters and Guidewires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3. Filming and Injection Techniques . . . . . . . . . . . . . . . . . . . . . . . . . 17
4. An Approach to Sedation and Monitoring . . . . . . . . . . . . . . . . . . . . 25
5. Magnetic Resonance and Computed Tomographic Angiography . . . . . . . 29
6. Clinical and Noninvasive Evaluation of Peripheral Vascular Disease . . . . . . 55
7. Vascular Recanalization Techniques . . . . . . . . . . . . . . . . . . . . . . . . 71
8. General Principles of Embolization and Chemoembolization . . . . . . . . . 89
9. Organ Access Techniques: General Principles for Localization, Drainage,
and Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
10. Percutaneous Needle Biopsy and Drainage . . . . . . . . . . . . . . . . . . . 109
11. Radiologic Gastrostomy and Gastrojejunostomy . . . . . . . . . . . . . . . . 123
12. Radiation Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
13. Physician Health and Safety in the Angiography Suite . . . . . . . . . . . . . 137

PART II. A SYSTEMS APPROACH TO DIAGNOSIS AND MANAGEMENT

14. Vascular Anatomy above the Diaphragm . . . . . . . . . . . . . . . . . . . . 147
15. Pulmonary and Bronchial Arteries . . . . . . . . . . . . . . . . . . . . . . . . 153
16. Diseases of the Thoracic Aorta . . . . . . . . . . . . . . . . . . . . . . . . . . 163
17. Thoracic Outlet and Upper Extremities . . . . . . . . . . . . . . . . . . . . . 179
18. Carotid, Vertebral, and Spinal Arteriography . . . . . . . . . . . . . . . . . . 189
19. Vascular Anatomy below the Diaphragm . . . . . . . . . . . . . . . . . . . . 203
20. Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities . . . . . . 211
21. Venous Thromboembolic and Vena Cava Filters . . . . . . . . . . . . . . . . 233
22. Anatomy of the Kidneys and Genitourinary Tract . . . . . . . . . . . . . . . 255
23. Vascular Manifestations of Renal Disease . . . . . . . . . . . . . . . . . . . . 267
24. Obstructive Uropathy and Renal Calculus Disease . . . . . . . . . . . . . . . 287
25. Pelvic and Obstetric Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . 297
26. Pudendal Arteriography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
27. Varicocele and Female Infertility . . . . . . . . . . . . . . . . . . . . . . . . . 317

v
vi Contents

28. Anatomy of the Gastrointestinal Tract, Liver, and Biliary System . . . . . . . 339
29. Interventional Management of Gastrointestinal Strictures . . . . . . . . . . 353
30. Nonvariceal Upper GI Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . 359
31. Liver and Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
32. The Biliary Tree and Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . 391
33. Vascular Diseases of the Lower Gastrointestinal Tract . . . . . . . . . . . . . 411
34. Arteriography and Venous Sampling of the Parathyroid Glands, Pancreas,
and Adrenal Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
35. Central Venous Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
36. Hemodialysis Access Management . . . . . . . . . . . . . . . . . . . . . . . . 459

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Contributors

Contributors

Ramsey Abadir, M.D. Kevin W. Dickey, M.D.

Horton Medical Center Assistant Clinical Professor
Middletown, New York Diagnostic Radiology
Yale University School of Medicine
and
Jacqueline Bello, M.D. Staff Interventional Radiologist
Director
Hospital of St. Raphael
Neuroradiololgy
New Haven, Connecticut
and
Professor of Clinical Radiology
Bernard G. Fish, M.D.
Albert Einstein College of Medicine Associate Clinical Professor of Pediatric Cardiology
Montefiore Medical Center Section of Pediatric Cardiology
New York, New York
New York Medical College
Valhalla, New York
Bruce Berkowitz, M.D.
Fort Collins Radiologic Associates Andrei Frost, M.D.
Fort Collins, Colorado Associate Professor of Clinical Radiology
Weiler Hospital
Albert Einstein College of Medicine
Steven E. Black, M.D. Montefiore Medical Center
Diagnostic Radiology Consultants New York, New York
Chattanooga, Tennessee
Jeffrey D. Georgia, M.D.
Steven L. Dawson, M.D. Assistant Professor of Radiology
Head, GI Interventional Radiology Uniformed Services University of Health Sciences
Department of Radiology Department of Radiology
Massachusetts General Hospital National Naval Medical Center
Boston, Massachusetts Bethesda, Maryland

Mark A. Greenberg, M.D.

Thomas J. DiBartholomeo, M.D. Division of Cardiology
Stamford Radiological Associates Montefiore Medical Center
Stamford, CT New York, New York
vii
viii Contributors

Michael J. Hallisey, M.D. Timothy P. Murphy, M.D.

Associate Professor of Medicine Associate Professor of Diagnostic Imaging
University of Connecticut, Hartford Hospital Rhode Island Hospital
Connecticut Surgical Group and
Hartford, Connecticut Brown University School of Medicine
Providence, Rhode Island
Margaret E. Hansen, M.D.
CPO Radiology Associate Irene Osborn, M.D.
Dallas, Texas Department of Anesthesiology
Mount Sinai Hospital
New York, New York
Brad Hoppenfield, M.D.
Associated Radiologists of Singer Lake Marlene Rackson, M.D.
Elmira Heights, New York Residency Program Director
Attending Radiologist
John A. Kaufman, M.D. Beth Israel Medical Center
Professor and
Dotter Interventional Institute Assistant Professor of Radiology
Oregon Health and Science University Albert Einstein College of Medicine
Portland, Oregon Department of Radiology
New York, New York

Andrew S. Kerr, M.D. Charles E. Ray, Jr., M.D.

Department of Radiology
Chief, Interventional Radiology
Metropolitan Hospital Denver Health Medical Center
New York, New York and
Associate Professor of Radiology
Philip S. Lakritz, M.D. University of Colorado Health Sciences Center
Holmdel, New Jersey Denver, Colorado

Kenneth S. Rholl, M.D.

Matthew A. Mauro, M.D.
Chief, Interventional Radiology
Professor of Radiology and Surgery
INOVA Alexandria Hospital
Vice-Chairman, Department of Radiology
Alexandria, Virginia
University of North Carolina School of Medicine
and
and
Associate Clinical Professor of Radiology
University of North Carolina Hospitals
Department of Radiology
Dept. of Radioloby
George Washington University
Chapel Hill, North Carolina

Anne C. Roberts, M.D.

Steven G. Meranze, M.D. Professor and Interim Chair
Section Chief Department of Radiology
Interventional Radiology University of California at San Diego Medical Center/
Vanderbilt University Medical Center Thomton Hospital
Nashville, Tennessee La Jolla, California

Donald L. Miller, M.D. Melvin Rosenblatt, M.D.

Professor of Radiology New Rochelle, New York
Uniformed Services and
University of Health Sciences Associate Professor
National Naval Medical Center Yale University School of Medicine
Department of Radiology Section of Vascular and Interventional Radiology
Bethesda, Maryland New Haven, Connecticut
 Contributors ix

Alla Rozenblit, M.D. Hugo Spindola-Franco, M.D.

Associate Professor of Radiology Montefiore Medical Center
Department of Radiology Albert Einstein College of Medicine
Albert Einstein College of Medicine New York, New York
Montefiore Medical Center
New York, New York Keith M. Sterling, M.D.
Department of Radiology
Michael B. Rubin, M.D. Inova Alexandria Hospital
Department of Radiology Alexandria, Virginia
Sound Shore Medical Center
New Rochelle, New York Jonathan J. Trambert, M.D.
and Clinical Director
New Rochelle Radiology & MRI Vascular and Interventional Radiology
New Rochelle, New York Department of Radiology
Montefiore Medical Center
Weiler Hospital
J. Mark Ryan, M.D.
and
Duke University Medical Center
Associate Professor of Radiology
Department of Radiology
Albert Einstein College of Medicine
Durham, North Carolina
Weiler Hospital
New York, New York
Alan H. Schoenfeld, M.S.
Department of Radiology Samuel I. Wahl, M.D.
Montefiore Medical Center Irvington, New York
New York, New York
Arthur C. Waltman, M.D.
Scott Segal, M.D. Director, Division of Vascular Radiology
Berkshire Medical Center Massachusetts General Hospital
Pittsfield, MA Harvard Medical School
Boston, Massachusetts
Randall W. Snyder III, M.D., M.A.
South Jersey Radiology Associates Kenneth M. Zinn, M.D.
Voorhees, New Jersey Radiology, Division of Interventional Radiology
Bridgeport Hospital/Advanced Radiology Consultants
Bridgeport, Connecticut
Foreword

Dr. Bakal has brought together contributors with a broad range of experience to create a
text on a current spectrum of interventional procedures. As a discipline, we have had
difficulty defining our interests and abilities. Some of the names offered include image-
guided surgery, minimally-invasive medicine, and interventional radiology. All of them
have strengths and weaknesses, confuse the public, and sometimes our professional col-
leagues. This text is the latest in an evolution, as with our discipline, from Arteriography
edited by Herbert Abrams and Interventional Radiology edited by Christos Athanasoulis et al.
Through my 30 years in interventional radiology, I have had several startling experi-
ences. One was the presentation of using arteriography to control bleeding from the
gastrointestinal tract by Stanley Baum. It was this presentation that introduced me to the
concept that a diagnostic method might also be the means to treat. Within a short span
from the presentation patients who had been badly injured and were hemorrhaging to
death from vascular injuries of the pelvis could be treated with embolization. Over the
ensuing years, other momentous experiences and device improvements occurred ex-
panding the usefulness of interventional radiology’s practioners into many diseases and
organ systems. Among these experiences are my being able to work with Andreas
Gruntzig as he was developing balloon catheters for angioplasty of atherosclerotic lesions
that eventually led to treatment for vessels from the head to the lower leg. Another was
an opportunity to collaborate with Charles Dotter, who is the father of many of the
current interventions from thrombolysis to TIPS and many catheters and devices.
Although there have been many other colleagues, too numerous to include here, with
whom I have been associated and enjoyed their many contributions and personalities, I
have really most appreciated those who trained in our department, including Dr. Bakal,
and with whom I continue to maintain close friendships. Some of these colleagues are
represented in this text and its wide scope is an example of the ingenuity and skill of the
interventionalist. This text is an attempt to pull the many different therapies together in
a format that allows one to gain the essence and approaches for these therapies without
the overwhelming detail of history and materials.
This is text for where we are and, as I tell our students after introducing them to the
Massachusetts General Hospital’s Ether Dome and the images of medicine in the 19th
century, that what we do now will also appear to be primitive in the future which is close.
I look to a future where less invasive medicine is a better way to treat a patient than as
Charles Dotter said “patients deserve to be treated better than a side of beef.”
This text is the beginning and a first step.
Arthur C. Waltman, M.D.

xi
 Preface

This project grew out of a need for a book, covering the field of vascular and interven-
tional radiology, that could be read in a month of evenings by radiology residents on a
typical vascular and interventional radiology rotation. We wanted to give an overview of
the field so that the reader could understand basic principles and approaches that were
technical, clinical, and image-based. We did not want to be too encyclopedic, nor did we
want to be only a list of differential diagnoses or a handbook. As this project moved
forward, we realized that there are others who would benefit from a book of this nature:
general radiologists, radiologic technologists, radiologic nurses, and VIR fellows early in
their training.
To best achieve our goals, I felt that material covering generalized technical and
imaging aspects should be grouped together at the beginning of the book, in Part I,
allowing easy reference to the material. Part II would concentrate on the regional anat-
omy and the clinical and radiologic problems specific to that anatomy. Many of our
chapters were written by our recent fellows or residents paired with a senior author. We
asked each of them to write about the topic in a manner that would best help them at
this stage of their career. No attempt was made to have all of the chapters conform to a
single writing style or mode of organization. In a sense, the book is a collection of
monographs covering virtually the entire spectrum of a growing and exciting field.
We hope that by reading this book, you will come to a better understanding of how
diagnostic and interventional techniques can be applied to a broad spectrum of clinical
Foreword problems.
Curt Bakal

xii
Acknowledgments

We would like to thank the many colleagues in our departments who contributed ideas
and advice.
Our assistants, Cynthia Caduhada, Cecilia Santos, and Eleanor Murphy, spent hours
organizing, transcribing, and correcting text, references, and figure legends. At Thieme,
Jane Pennington, Kathy Lyons, Diane Sardini, Anne Vinnicombe, and Becky Dille were
crucial to seeing this project from start to publication.

xiii
To Pam and Matt, my points of light,
For their love and support.
Curtis W. Bakal

In memory of Mahboobeh Yashar.

James E. Silberzweig

To Aviva and Debora E. with love.

Jacob Cynamon

To Shoshana and Sharon with love.

Seymour Sprayregen
 ■ PA RT I ■

Basic Principles and

Techniques
C. W. Bakal
Vascular and Interv entional Radiology: A Brief History

1
■■■

Vascular and Interventional Radiology

A Brief History
CURTIS W. BAKAL

Within months of Wilheim Roentgen’s discovery of the In 1974, the Society of Cardiovascular Radiology was
x-ray in 1895, Lindenthal produced the first contrast-en- founded with a membership of about 30 academic an-
hanced radiograph of the veins of the hand.1,2 Clinical giographers. In addition to diagnostic angiography,
application of contrast angiography, however, would take members of this society were beginning to expand their
more than two decades. From the 1920s through the interventions: in addition to “Dottering” obstructive le-
1950s, arteriography was performed infrequently—and by sions, they were beginning to treat gastrointestinal
the translumbar approach. Vascular surgery was in its nas- bleeding and pelvic trauma by pharmacologic infusion
cent stage, and diagnoses were made clinically without or embolization.8–13 Techniques for nonsurgical splenec-
much diagnostic testing. For example, in 1923, Leriche tomy and intravascular foreign body attraction soon
described a group of young men with decreased or absent were popularized.14 The Society was later renamed the
femoral pulses, bilateral claudication, and impotence, all Society of Cardiovascular and Interventional Radiol-
on the basis of clinical findings and history. Leriche called ogy.15 Gruentzig and others refined the Dotter angio-
this entity aortitis terminalis and suggested the possibility of plasty technique by using an expandable balloon on a
surgical intervention.3 Yet the diagnostic arteriogram as a catheter shaft, which allowed smaller punctures to be
routine clinical tool was years away. made for arterial access and larger vessels to be di-
In 1953, Seldinger described a transfemoral arterial lated.16,17 Real time ultrasound and computed tomogra-
access technique that used a puncture needle and guide- phy scanning allowed nonvascular percutaneous inter-
wire, which allowed selective catheterization.4 Coinciden- ventions to be developed and refined, notably
tally, the first use of a cloth vascular bypass graft also had intraabdominal abscess drainage.18,19 This revolution-
just been reported.5 During this decade, diagnostic arte- ized the care of many patients with abdominal infec-
riography of the cardiac and peripheral circulations was tions: Abdominal pus was no longer a surgical disease.
increasingly being used and refined. In the 1960s, radi- By 1985, small-vessel balloons and steerable guidewires
ologists began to develop “interventional” procedures. became commercially available, allowing PTA of the in-
Many point to the landmark article that first described frapopliteal vessels.20–23 Inferior vena cava filters, al-
percutaneous transluminal angioplasty (PTA) by Dotter though still large in profile, were being placed by vascu-
and Judkins as the birth of interventional radiology.6,7 lar and interventional radiologists as well as by surgical
Dotter and Judkins summarized their article by suggest- cut-down.24 Within a few years, low osmolar contrast
ing that there would be “refinements of technique as well agents were to be commonly used for peripheral arte-
as further clarification” of the role of this attack on arte- riography, increasing safety and patient comfort. Digital
riosclerotic obstructions.” The percutaneous translumi- subtraction replaced cut film, and the multiplanar C-arm
nal treatment described in this article became a basis for became standard in angiography and interventional
an emerging class of minimally invasive therapies. radiology suites; these two technical advances allowed

3
4 C. W. Bakal

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