Nonvascular Interventions

1. NonvascularInterventions O.MelihTopcuogluM.D. Yeditepe UniversityMedical School

2. Nonvascular interventions • Image guided biopsies and drainage • Complex interventional radiological treatment of hepatic tumors • RF ablation in other organs (lung, renal and bone tumors) • Percutaneous (biliary) choledochal, cholecystic interventions (PTC, PTD, stent implant, choledochal stone removal, cholecystostomy) • Gastrointestinal interventions, endoluminalstentimplantations • Percutaneous ethanol cyst treatments • Urinary tract interventions • Percutaneous interventional methods of the muscoluskeletalsystem

3. Image guided biopsies and drainage • Types of biopsies according to needle diameter • Fine Needle Aspiration Biopsy (FNAB) • Core biopsy

4. Image guided biopsies and drainage • Types of biopsies according to image guidance • US guiding • X-ray guiding • CT guiding • MR guiding • Hybrid imaging guiding

5. Fine Needle Aspiration Biopsy (FNAB) • With 20G or thinner needles one can obtain cytological samples, thus smaller groups of cells can be aspired from a certain area

6. Core biopsy • Most often we use 14-18 G needles for these tissue samplings • With the help of an automatic biopsy gun one (or more) tissue columns are acquired of the desired area

7. Types of biopsies according to image guidance

8. X-ray guiding

9. US guiding

10. CT guiding • Ideal method if the lesion is located either in the chest, mediastinum, retroperitoneum or the pelvis.

11. MR guiding

12. Seldinger method • US or CT guided puncture of the lesion is performed with a correct needle size • A guide wire of 0,035” diameter is placed through the needle to the lesion, and the needle is removed • The guide wire is used to assist the insertion of a carefully selected, correct sized (6-14F) drainage catheter

13. Percutaneous drainage

14. Contraindications of biopsies and drainage • If no proper blood clotting parameters are met (it can be temporarily corrected for the time of the puncture with fresh frozen plasma (FFP) • If there is an unavoidable blood vessel (aorta, IVC) in the way to the lesion,

15. Complications of biopsy and drainage • Hemorrhage (subcapsular parenchymal, intraabdominal, intrathoracic, pseudoaneurysm) • Pneumothorax (thoracic, mediastinal, infraclavicular, in case of subdiaphragmatic intervention) • Perforation (it is FORBIDDEN to use core biopsy needle for lesions lying behind intestines) • Tumor spread in the cutaneous biopsy canal (the same risk factor applies in case of all guiding modalities)

16. Complex interventional radiological treatment of hepatic tumors • Percutaneous Ethanol Injection • Radiofrequency ablation (RFA) • Microwave tumor ablation • Laser tumor ablation • Cryoablation • Chemoembolization

17. Percutaneous Ethanol Injection • It is the most commonly used and cheapest percutaneous method for the treatment of primary hepatic cancer (HCC) • Sterile, 95%, absolute alcohol is injected with US guidance to the tumor • Ethanol causes dehydration and coagulation necrosis of the tumor cells, followed by fibrotic degeneration.After alcohol injection, a typical “snow storm like”, hyperechogenic area can be seen in the treated area

18. Radiofrequency ablation (RFA) • During RF ablation an electrode is positioned in the tumor. • The end of the electrode will produce extensive heat as ionizing current is generated at 460 kHz frequency, with alternating polarities • In a given (50-200 Watt) energy range it is possible to produce 50- 90C degree heat under set circumstances

19. Radiofrequency ablation (RFA) • With the use of a special RF equipment and electrode (Berthold or Radionics equipment) the internal cooling of the needle is possible with physiologic saline solution, therefore carbonization is avoidable • The complete RF ablation in the vicinity of large venous branches (hepatic vein, portal vein, IVC) is difficult to achieve, since the flowing blood of the veins cools the nearby tumor tissues

20. Radiofrequency ablation (RFA) • Another difficulty is presented with lesions lying too close to the choledochor the hepatic duct, since they poise the possibility of a serious biliary injury • The treatment of subcapsular tumors can lead to persisting pain, therefore in these cases combined methods are usually preferred (RF + chemoembolization, RF + PEI)

21. Radiofrequency ablation (RFA) • The most ideal scenario for RF ablation of liver tumors are the following: • 1. There are 4 or less lesions, • 2. lesions are equal to or less than 3cm • 3. they are each located at least 1cm below the hepatic capsule and • 4. any larger vein is located at minimum 2cm of a distance from them

22. Radiofrequency ablation (RFA) • Therapeutic success can only be hoped to achieve with a tumor of maximum 5cm diameter, however at this size multiple interventions are needed • With the help of hybrid guiding methods, larger lesions might be successfully treated in one session • Superficial lesions might be intraoperatively performed to avoid damage to the surrounding organs (diaphragm, gall bladder, large and small bowel)

23. Radiofrequency ablation (RFA) • PercutaneousRF ablation should only be performed with strong analgesia or in anesthesia. After treatment a 24 h clinical observation is necessary • The average time for the ablation of a lesion of 3cm is 8-10 minutes long. In case of 3-4 lesions the procedure can last up to 40-50 minutes • The effectiveness of the RF ablation is usually controlled by DWI

25. Microwave tumor ablation • Microwaves at a wavelength at 2450 MHz- create a very fast rotation in the water molecules of the targeted lesion • This leads to the heating up of the tissues and the coagulation necrosis in a volume with elliptic crossection

26. Laser tumor ablation • After the development of laser ablation technique, it became possible to create reproducible tissue destruction with Nd YAG (Neodymium yttrium aluminium garnet) laser

27. Cryoablation • Cold under -20, -30 C degrees produces irreversible tissue destruction • The criteria for the treatment are basically the same as for RF ablation

28. Chemoembolization • Next lecture

29. RF ablation in other organs (lung, renal and bone tumors) • Lung • For inoperable pulmonary tumors it is well accessible, peripherally localized tumors that otherwise would carry significant surgical risk can be successfully treated with this alternative method • In the vicinity of larger blood vessels (branches of the pulmonary artery, SVC) the cooling effect of the flowing blood decreases the effectiveness of the RF procedure

30. RF ablation in other organs (lung, renal and bone tumors) • Kidney • 1. Elderly patient, with relatively large surgical risks • 2. Unilateral, solitaire RCC • 3. Palliative treatment in case of a centrally located tumor • 4. Patient denies surgery • 5. According to the latest recommendations tumors up to 5cm in diameter can be treated successfully with RF

31. RF ablation in other organs (lung, renal and bone tumors) • Bone • The RF treatment of primary bone tumors and bone metastases have been the topic of several large scale studies from various centers • RF ablation is especially useful technique and has a good outcome in the direct treatment of osteiodosteomas • The invasiveness of the method is several folds smaller than orthopedic surgery

32. Percutaneous (biliary) choledochal, cholecystic interventions • Percutaneous interventions are usually necessary in case of malignant, inoperable pancreatic head tumors, if enlarged lymph nodes in the hepatichilum compress the choledoch, or in case of the various types of cholangiocellular tumors (Klatskintumor) • Among the benign lesions, primarily biliary strictures, inflammatory stenoses, and sclerotizing cholangitis cause indication for intervention

33. Percutaneous (biliary) choledochal, cholecystic interventions • In case of the failure of endoscopic biliary interventions or if there is a persisting Billroth II resection, percutaneous biliary intervention needs to be considered • It is important to note that due to the congestion of bile – which might serve as fertile ground for bacteria – one needs to provide prophylactic antibiotic therapy before the intervention.

34. Percutaneous transhepatic cholangiogrpahy (PTC) • During this procedure X-ray or US is used to guide the insertion of a 22G (Chiba needle) from a right IX. or X. intercostals position into a dilated intrahepatic biliary branch • After the Chiba needle is well positioned the intra and extrahepatic biliary tree is filled with contrast material • Under special circumstances – when the left side of the biliary branches is affected primarily - PTC can be performed from an epigastric entry towards the left lobe of the liver

36. Percutaneous transhepatic drainage (PTD) • After a diagnostic PTC is successfully performed and a guide wire is positioned over the stenotic or occluded segment of the choledochal duct an external-internal drain (PTD) can be installed • If desired, a self expanding metallic stent could be used to override the stricture

37. Percutaneous transhepatic drainage (PTD) • If one cannot pass the biliary stenosis in the initial attempts, the placement of a temporary external drainage is advisory to control the biliary congestion and cholangitis • Later during a second session the insertion of an external-internal drain will be possible • In special cases separate catheter insertion and stenting of both the left and right hepatic ducts might be necessary. This depends on the extent of the pathologic lesion (tumor or inflammation) • In case of a malignant stenosis the use of covered stents can prolong the passage in the tumor bound segment of the choledoch

38. Percutaneous cholecystostomy • Usually in case of elderly patients and in case of certain types of acalculouscholecytitis US guided precutaneous drainage of the gall bladder proves to be a very effective technique

40. Gastrointestinal interventions, endoluminalstentimplantations • GI stenting • In case of inoperable esophageal, gastric or duodenal cancer, large (15-20mm wide) endoluminal stents can be applied. • Moreover obstructive tumors on the descending colon or on the sigma can also be treated with these endoluminal stents. • The length of the stent has to be chosen so that its proximal and distal ends reach beyond the stenosis by about 2-3cm.

41. Gastrointestinal interventions, endoluminalstent implantations • Percutaneous gastrostomy • In case of swallowing impairment (usually as a result of neurological cause: severe stroke, brain damage, amyotrophic lateral sclerosis) percutaneous gastrostomyis used to temporality decompress the esophagus segment, to alleviate gastric emptying disorder or to cease intestinal obstruction. • Usually with mild sedation and local anesthesia PEG is inserted with endoscopic assistance with the use of a special catheter set.

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50. Percutaneous ethanol cyst treatments • During US and CT examinations simplex cystic lesions are often accidentally encountered that do not cause any pain for the patient. • Cysts of the liver, spleen or the kidneys cause discomfort or pain for the patients need to be therapeutically addressed. • Compared to the surgical methods of past, nowadays these cystic lesions can be successfully treated percutaneously with alcoholic cyst sclerotization