Interventional Radiology 介入放射学 TONG Xiao-qiang 佟小强

1. Interventional Radiology 介入放射学 TONG Xiao-qiang 佟小强 Dept. of Interventional Radiology & Vascular Surgery The First Hospital of Peking University 介入血管外科, 北京大学第一医院

2. 讲课内容 第一部分：介入放射学总论 --什么是介入放射学 --介入放射学历史 --介入放射学所需器械 --介入放射学适应证 第二部分：介入放射学各论 --介入放射学在血管系统的应用 通，堵，注，取 --介入放射学在非血管系统的应用 通，堵，注，取

3. 重 点 1. 了解介入放射学的概念 2. 了解介入放射学的适应证 3. 掌握介入放射学的技术内容： 通，堵，注，取 4. 掌握常用专业英文词汇

4. 第一部分 介入放射学总论 • 什么是介入放射学 • 介入放射学历史 • 介入放射学所需器械 • 介入放射学适应证

5. Radiology Purpose of Radiology--diagnosis • X-ray • Computed tomography (CT) • Magnetic Resonance Imaging (MRI) • Ultrasound • Radioisotope (RI) • Angiography

6. Angiography--early “Interventional Radiology” --diagnosis • Vascular disease • --Occlusion • --Stenosis • --Aneurysm • --Arterio-venous malformation • --Arteriovenous fistula • --Hemorrhage • Hypervascular tumor • --Hepatocellular carcinoma • --Renal cell carcinoma • Relationship between vessel and tumor

7. Angiography • Insert a needle or catheter directly into a vessel • Inject some contrast media (CM) • Take films/movie • Achieve diagnosis

9. DSA machine Digital subtruction angiography Traditional angiography DSA

10. Diagnosis on angiography —stenosis of artery Dilate it!!! Diagnosis Treatment Radiologist intervened clinical issues from diagnosis alone to therapeutic activities. Dr. Dotter

11. History of Interventional Radiology-1 1895：Roentgen发现X射线（诺贝尔奖） 1895：Hascnek首次在截肢术上作动脉造影尝试 1896：Morton开始做尸体动脉造影研究 1904：Dawbam开始肿瘤手术术前栓塞（颈外动脉） 1910：Franck等成功将造影剂注射到活体动物动脉内 1923：Verberich将造影剂注入到人体血管内造影 1924：Brooks成功进行第一例股动脉造影 1927：Maniz成功施行颈动脉直接穿刺造影 1929：Dos Santos成功施行经皮腹主动脉穿刺造影 1929：Forssman从上臂静脉将导尿管插入自己的右心房首创 心导管造影术（诺贝尔奖） 1941：Farmas 采用股动脉切开法施行主动脉造影 1953：Seldinger首创经皮股动脉穿刺法: 简便易行（诺贝尔奖）

12. History of Interventional Radiology-2 1956: Oedman等改进了导管头的弯度 1964: Dotter成功施行首例PTA 1967：Judkins行冠状动脉造影 1967: Richarson首先使用Fogarty球囊导管行颈动脉拉栓术 1968：Newtont成功施行脊髓血管畸形动脉栓塞 1968：Nusbaum等首先报道经动脉导管灌注血管加压素及栓塞剂治疗出血 1969：Kauae首先报道经皮肝穿胆道引流术 1972: Rosch等首先介绍对肝肾等肿瘤进行栓塞 1974: Gruentzig发明双腔球囊导管 1977: Gruentzig成功施行冠状动脉PTA 20世纪80年代：DSA技术 1983：Dotter等报道用镍钛合金支架的实验成果1985：Wright 和Palmaz分别报道金属自扩式Z型支架和球囊扩张式支架 1988：Richter等成功实施TIPS治疗严重门静脉高压 1991：Parodi首次用直型内支架行腔内隔绝术治疗腹主动脉瘤

13. 3 milestones in history of IR • 1929年: Forssman将导管插入自己心脏 • 1953年: Seldinger穿刺法 • 1964年: Dotter血管成型术

14. Never forget Wilhelm Conrad Roentgen (1845-1923) 1895: X-ray

15. Never forget Forssman 1929:cardioangiography

16. Never forget Sven Ivar Seldinger 1953:Seldinger’s technique

17. Never forget Charles Dotter (1920-1985) 1964: PTA by coaxial catheter

18. Never forget Cesare Gianturco

19. Never forget Andreas Gruentzig(1939-1985) 1974: Double-lumen balloon catheter 1977：First PTCA (Percutaneous Transluminal Coronary Angioplasty)

20. Interventional Radiology (IR) • Guided by imaging facility: X-ray, CT, US, MRI • Utilizing instruments as guidewire, catheter, et al • Minimally invasive: usually puncture • Not only diagnosis but therapeutic efficacy • 1967 Margulis :Interventional Diagnostic Radiology • -a New Subspecialty (AJR) • 1976 Wallace :Interventional Radiology (Cancer)

21. 介入放射学技术 Techniques of IR • 通Recanalization, Opening • 堵Embolization, Occlusion • 注Injection, Infusion • 取Drainage, Sampling, Biopsy, Retrieval • 其他Filter、 and ---

22. 开通或再通技术—通Recanalization • Vessel—PTA,stenting,thrombolysis • Airway—stenting • Gastrointestine —dilatation,stenting • Biliary duct —drainage,dilatation,stenting • Urinary tract —dilatation,stenting • Tubal obstruction —recanalization • Lacrimal duct obstruction —recanalization • Establish channel— TIPS,drainage

23. 栓塞技术—堵Embolization • tumor: malignancy, benign • AVM, AVF, aneurysm • bleeding • hypersplenism • others：varices, fistula, priapism

24. 动脉局部药物灌注—注 Infusion • Thrombolytic agent • Chemotherapeutics • Sclerosing agent • hemostatics • antibiotics

25. 引流/活检/血样/异物/取石—取 Retrieval • Biliary draining（tumor/lithiasis) • Percutaneous removal of biliary calculi • Percutaneous nephrostomy • Draining of cyst/abscess • Sampling/biopsy • Retrieval of foreign body • Percutaneous lumbar discectomy

26. Content of IR • Vascular IR • 经动脉栓塞: 出血,动脉瘤,动静脉畸形, 肿瘤等 • 经动脉药物注入: 抗癌药, 血管收缩/扩张剂, 血栓溶解剂 等 • 血管成型术: 气囊, 旋切, 激光, 支架等 • 血管内异物取出 • 静脉溶/取栓术 • 静脉栓塞术: 消化道静脉曲张, 精索静脉曲张等 • 下腔静脉滤器放置术 • 肝静脉-门静脉分流术 • Nonvascular IR • 支架放置术: 消化道, 气道, 胆道, 尿道等 • 引流术: 胆道, 脓肿, 囊肿等 • 造瘘术: 胃, 膀胱, 肾等 • 取石术: 胆道, 胆囊, 尿道等 • 药物注入法: 囊肿硬化, 骨硬化/成型, 溶核等 • 旋切/抽吸术: 椎间盘脱出

28. Access in vascular IR • Types of arterial approaches • Right femoral artery • Left femoral artery • Left axillary artery • Right axillary artery • Translumbar aorta • Brachial arteries • Antegrade femoral artery • Through a surgical graft • Right femoral artery is the preferred route • Easily accessible for manipulations and hemostasis • Large-caliber vessel • Well-defined landmarks exist • Most angiographers are right-handed • Low complication rate compared to other approaches

29. Anatomy of femoral puncture site 2-4cm below the inguinal ligament

30. Seldinger’s Technique guidewire needle Double wall puncture

31. Seldinger Technique-con’t sheath catheter

32. Traditional Seldinger’s technique

33. Modified Seldinger Technique Single (anterior) wall puncture

34. Modified Seldinger’s Technique

35. Complications of IR There are 4 types of complications • Puncture site complications (e.g., groin hematoma) • Contrast agent complications (e.g., anaphylactoid reaction) • Catheter-related complications (e.g., vessel dissection) • Therapy-related complications (e.g., CNS hemmorhage during UK administration)

36. Puncture site complications • Minor hematoma, >5% • Major hematoma (require surgical therapy) <0.5% • Arteriovenous fistula (AVF),0.05% • Pseudoaneurysm, 0.01% • Vessel thrombosis,0.1% • Neuritis • Infection Contrast complications • Renal failure • Cardiac failure • Phlebitis (venography) • Anaphylactoid reactions (rare with arteriography) Catheter-related complications • Cholesterol emboli • Thromboembolism • Cerebrovascular accident • Arterial dissection

37. Instruments for IR • Puncture needle • Sheath • Guidewire/microguidewire • Catheter/microcatheter • Balloon catheter • Stent • Stent-graft • Distal protection device • Coil • Filter • Snare

38. Catheter • Thermoplastic materials (polyurethane and polyethylene) • are very commonly used for catheter manufacturing • Nylon: combined with polyurethane to manufacture high-flow, • small-French catheters • Teflon: very stiff, low-friction material • Braided catheters: internal wire mesh improves torquability

39. Guidewire • All nonspecialty guidewire have a similar construction: • Central stiff steel core with a distal taper • Wire coilspring wound around core • Thin filamentous safety wire holding the other 2 components together • Most wires are coated with Teflon to decrease friction

40. Sheath • Short-cathter with valve at the end to avoid reflux • A patered dilator for smooth insertion through a wire needle sheath guidewire dilator dilator sheath

41. Double-lumen PTA balloon catheter

42. 自膨式支架 self-expanding stent

43. 球囊扩张式支架 balloon-expanding stent

44. 远端滤伞保护装置Distal Protection Device（DPD)

45. DPD FilterWire EX™ Embolic Protection System

46. DPD EV3 spider

47. stents Stainless steel, Nitinol

48. Stent-graft

49. 4 major contents of vascular IR • Embolization • Thrombolysis • Perctaneous transluminal angioplasty (PTA) • Vascular stenting

50. Embolization Indication: • Hemorrhage • --GI bleeding • --Varices • --Traumatic organ injury • --Bronchial artery hemorrhage • --Tumors • --Postoperative bleeding • Vascular lesions • --AVM or AVF • --Aneurysm/Pseudoaneurysm • Preoperative devascularization • --Renal cell carcinoma • --AVM • --Vascular bone metastases • Other • --Hypersplenism • --Gonadal varices • --Hepatic chemoembolization