What is interventional radiology?
Interventional radiology (IR) is the application of advanced diagnostic and therapeutic methods using vascular and/or percutaneous approaches, accompanied by radiological methods, and using special equipment (needle, catheter, balloon, stent, drainage catheters, etc.).
What are the advantages of interventional radiology?
The prominent advantages of Interventional Radiology are as follows:
- It can be applied in cases where surgery cannot be performed.
- It allows many diseases to be diagnosed and treated in a less invasive way.
- It usually does not require anesthesia.
- It has similar or lower complication rates.
- It provides a short hospital stay and ease of care.
- It is usually less costly.
How is it applied?
IR is performed with the guidance of ultrasonography, fluoroscopy, computed tomography, CT fluoroscopy, digital subtraction angiography (DSA), and magnetic resonance imaging.
INTERVENTIONAL RADIOLOGY PROCEDURES
A. ONCOLOGY – CANCER PROCEDURES
1. Diagnostic Procedures – Biopsy
A biopsy is the taking of a small piece of tissue or organ to diagnose a disease. Biopsies are performed as tissue or cell/cytology using fine needle aspiration biopsy (FNAB).
- Neck: Thyroid, Parathyroid, Lymph nodes, neck masses with US-guided FNAB or tru-cut
- Thorax: Lung, mediastinal and thoracic wall masses, pleural fluid, US- or CT-guided aspiration, FNAB or tru-cut biopsy
- Abdomen: liver, pancreas, adrenal, abdominal, pelvic masses, abdominal fluid or collections with US- or CT-guided aspiration, FNAB or tru-cut biopsy, Prostate, TRUS-guided MR fusion biopsy
- Bone and Soft Tissue: Vertebrae, extremity bones, soft tissue masses or collections with US- or CT-guided aspiration, FNAB or tru-cut biopsy
2. Port Placement
Patient comfort is increased thanks to this device, which is placed under the skin near the right or left collarbone so that chemotherapy can be administered.
3. Ablation Treatments in Cancer
Tumor ablation is the application of chemical or heat (thermal) to eliminate the desired tumor or to cause a certain damage.
- a-Ablation Techniques
- – Radiofrequency ablation: Radiofrequency (RF) ablation technique is the creation of tumor death by converting the current given with the needle into heat energy within the tumor or cancer tissue.
- – Microwave ablation: Microwave ablation is a thermal treatment method and is widely used especially in liver tumors. The system is basically based on the principle of converting the kinetic energy generated by the acceleration of water molecules in the tissue and their collision with each other into thermal energy.
- – Cryoablation: It is an ablation method that freezes and destroys the targeted tumor tissue.
- b- Ablation in Liver Tumors Ablation of Primary or Metastatic Liver Tumors: It is a treatment method that prevents tumor recurrence in HCC tumors less than 3 and smaller than 3 cm, can prolong life, and can reduce tumor borders.
- c- Lung Tumor Ablation: RF Ablation (RFA, Radiofrequency Destruction method) is a treatment method used in cancer treatment that works on the principle of destroying cancer cells with heat.
- d- Renal Tumor Ablation:Cryoablation is a technique of freezing the tumor with a needle. Cryoablation is a well-known and accepted therapy for renal masses smaller than 4 cm (T1a).
- e- Bone Tumor Ablation:Optimizes tumor coverage and reduces the risk of injury. Cryoablation provides faster pain relief than radiotherapy. It is the most suitable ablation type for the use of cementoplasty in bone ablation.
4. Transarterial Chemoembolization (TACE)
It is an embolization method in which chemotherapy (chemo) drugs are administered simultaneously with high doses of particles into the tumor via the artery feeding the liver (transarterial) and the artery feeding the tumor is blocked.
5. Radioembolization (TARE);
It is the selective application of radioactive material (Yttrium 90) to the area where the tumor is located in the liver via a catheter inserted through the groin vein.
6. New Cancer Treatments
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- a- Chemosaturation
- b- LIOX
B. VASCULAR INTERVENTIONAL PROCEDURES
1. Diagnostic Angiography
It is a diagnostic method used to visualize veins.
2. Arterial Stenosis and Obstruction Treatment
Artery occlusion; arteries are our vessels that carry clean blood from the heart to all organs and tissues. Narrowing, blockage, expansion or structural disorders may develop in arteries due to many diseases. It can narrow and become blocked due to conditions such as atherosclerosis (vascular calcification), thromboembolism (blockages due to clotting), trauma, vasculitis (inflammatory conditions of the vessels (Takayasu, Wegener, Polyarteritis nodosa, Behçet’s Disease).
- a- Carotid Artery Stenosis and Obstructions:The most common cause of carotid artery stenosis is atherosclerosis, or hardening of the arteries. If the stenosis caused by plaques due to atherosclerosis that develop in the carotid artery is not treated, it can lead to blockage. Carotid artery – Carotid stent must be placed in two basic cases;
- b- Renal Artery Stenosis (Renal Artery Stenosis);Hypertension is a common disease and one of its causes is stenosis in the renal arteries. Renal artery The current approach to the basic treatment of stenosis is balloon angioplasty and stent placement performed with interventional radiology methods.
- Diabetic Foot:The main cause of diabetic foot is atherosclerosis, which is hardening or calcification of the arteries. The treatment approach in diabetic foot patients should cover all stages without delay. These are;
- Early (acute) wound intervention
- Antibiotic treatment
- Regulation of blood sugar
- Start of blood thinning medications
- Removal of vascular stenosis and occlusion,
- Long-term wound intervention, amputation if gangrene is present
- Long-term wound care
- Education and implementation of protective measures.
3. Vein Treatments
- a- Interventional Procedures in Dialysis Patients: Hemodialysis is needed for the maintenance of life in patients with impaired kidney function. Procedures performed on dialysis patients in interventional radiology departments;
- Temporary catheter placement
- Permanent tunneled catheter placement
- Catheter revision and replacement
- Treatment of venous stenosis and occlusion
- Balloon application to fistula stenosis
- Removal of clot or dissolution of clot in fistula occlusion
- b- Venous Occlusion: The methods used in treatment are as follows:
- Surgical removal of clot (thrombectomy)
- Dissolution of clot with drugs (thrombolysis)
- Catheter-tipped clot removal techniques, catheter aspiration, removal of the clot with a wide lumen catheter
- Dispersing the clot with a catheter and breaking it into small pieces and removing the main vein blockage
- Percutaneous mechanical thrombectomy, breaking up the clot with high pressure serum given with mechanical devices or negative pressure created by rapidly rotating devices and removing it by aspiration at the same time
- c- Varicose Vein Treatment:Varicose veins are a vein disease. Veins are our veins that carry dirty blood to the heart. Unlike arteries, veins have a valve system inside them. These valves allow blood to flow to the heart but prevent blood from flowing back. In the disease we call varicose veins, blood flows back to the feet due to deterioration in the valves. The blood flowing back begins to expand the veins under the skin. These enlarged veins are called “varicose veins”. Treatments applied to varicose veins;
- Laser ablation (Laser cauterization and closure)
- Radiofrequency ablation (Radiofrequency cauterization and closure)
- Microwave ablation (Microwave cauterization and closure)
- Foam sclerotherapy (Vein closure using foam drugs)
- Cyonoacrylate glue ablation (closure using adhesive drugs)
- Mechanochemical ablation treatment of varicose veins (Clarivein, combination of mechanical and chemical techniques)
4. Aneurysm and Vascular Malformation Treatments
- a- Brain Aneurysm
Brain aneurysm (cerebral aneurysm), known as a bubble in the brain veins, occurs as a result of weakening of the vascular layers due to many reasons such as genetic, traumatic, hemodynamic or inflammatory.
In GR, the treatment of aneurysm is done by entering through the vein. The procedure is performed under general anesthesia in interventional radiology units. The intervention site is usually the inguinal artery and catheters and microcatheters are performed by reaching the aneurysm in the brain with the help of guide wires. Treatment is applied depending on the preferred method through the catheters.
Endovascular Treatment:
- Simple coiling
- Coiling with balloon modeling
- Coiling with stent modeling
- Flow converter stenting
methods.
- b- Peripheral Aneurysms
Other vascular aneurysms outside the heart and brain are usually defined as peripheral aneurysms. These aneurysms usually develop from arteries in the abdomen. Although not very common, they are seen in approximately 1-2 out of every 100 people. According to the organs in which they develop, aneurysms;
- Splenic artery
- Liver artery (hepatic artery)
- Arteries feeding the intestines (gastroduodenal, superior mesenteric artery)
- Common liver and spleen artery (Celiac artery)
- Includes renal artery aneurysms.
While the treatment of aneurysms was primarily surgical in the past, today, intravenous treatments, namely endovascular treatments, applied in interventional radiology, have come to the fore due to their high success rates and short hospital stays. These treatments;
- Coil embolization
- Covered stent placement
- Flow converter stent placement.
- c- AVM-AVF Embolizations
The defective development of vessels is called anomaly. Here, no normal vessel development and tissue relationship is seen. The direct connection of the artery and vein without tissue nutrition is called arteriovenous malformation (AVM).
There are 3 basic methods used in AVM treatment. Surgery, vascular occlusion (embolization) and gamma-knife methods defined as radiotherapy. These treatment methods can be applied separately or together depending on the location of the lesion, its relationship with vital organs, and the experience of the relevant clinics, neurosurgery and interventional radiology.
AVM embolization is performed in interventional radiology departments, in the angiography unit, under general anesthesia, by entering the groin artery. Adhesive materials known as glue or onyx are used in embolization.
- d- Aortic Aneurysms
The expansion in the diameter of the aorta, the largest vessel in our body, causes rupture and life-threatening bleeding. Stent graft applications are performed in the treatment.
5. Embolization Treatments (Vascular Occlusion Treatment)
a- Myoma: Myoma is a benign tumor that develops in the uterus. After catheters are placed in the uterine arteries on both sides, particles are given through the catheter and embolization is performed. Medical support treatments necessary to relieve the patient’s pain are continued throughout the procedure. Both uterine arteries are blocked.
b- Adenomyosis Embolization: Adenomyosis is a benign disease and is the uncontrolled growth of the endometrium, the innermost layer of the uterine tissue. In GR, the treatment procedure is applied with the same technique as in myoma embolization by entering through the inguinal artery. After catheters are placed in the uterine arteries on both sides, particles are given through the catheter to perform embolization.
c- Prostate Embolization:Prostate embolization is defined as the blocking of natural blood flow by micro particles given into the prostate gland through a small catheter. This procedure is usually used to treat benign prostatic hyperplasia (BPH), which is an enlargement of the prostate gland.
d- Varicocele Embolization:Varicocele is the expansion of the veins in the scrotum, the skin bag that protects the testicles in men. In the treatment, thin tubes called catheters are inserted into the testicular veins selectively by entering from the groin or neck vein. Contrast material is given through these catheters and venography is first performed. Venography shows the backward flow of the testicular veins, that is, back towards the scrotum. After this stage, embolization is applied to the testicular veins using coils, sclerosing agents or adhesives called glue.
e- Genital Varicose Embolization: This disease, also known as the dilation of the uterine and ovarian veins, genital varicose veins, pelvic venous insufficiency, female varicocele, pelvic vascular congestion, is a cause of chronic pelvic pain lasting more than 6 months and consists of pelvic venous insufficiency and pelvic varicose veins. In treatment, the entry point to the veins can be the arm, groin or neck vein. Unilateral or bilateral ovarian vein coil embolization is the most commonly used treatment method for ovarian vein leakage.
f- Hemorrhoidal Artery Embolization: The procedure of blocking the hemorrhoidal veins that cause dilation by entering through the artery is a relatively new, effective, safe and non-surgical treatment.
g- Hemangioma and Other Vascular Maformation Embolizations: Hemangiomas found in soft tissue (under the skin, in the muscle) are usually treated by entering directly through the skin, i.e. percutaneously. First, a thin needle is inserted into the lesion and a drug called contrast medium is administered while images are taken. The sclerosant or adhesive drug to be used in embolization is decided by evaluating how much area the contrast fills in the image and how quickly it is discharged into the veins.
h- Unstoppable Bleeding Embolization: Abnormal bleeding or unstoppable bleeding is an important clinical situation because it carries a life-threatening risk. The types of bleeding we frequently encounter are; nosebleeds, coughing up blood, stomach bleeding, intestinal bleeding, bleeding in urine, vaginal bleeding, bleeding from previous surgery sites.
i- Vascular Access Procedures:Temporary catheter (hemodialysis catheter) and permanent tunneled catheter placement.
C. NON-VASCULAR - INTERVENTIONAL PROCEDURES PERFORMED BY DIRECT SKIN ENTERMENT
1. Cyst, Collection Drainages
Collection is the accumulation of fluid in any cavity. Fluid accumulation in the chest cavity is called pleural effusion, fluid accumulation in the abdominal cavity is called ascites, while fluids accumulating in limited areas instead of free fluid are also called cysts. When the fluid is not inflammatory, it is defined as a simple cyst or lymphocele, while when there is inflammation inside, it is defined as an abscess.
- a- Pleural Effusion and Ascites Drainage: It is the treatment of fluid accumulations directly from the skin by percutaneous means.
- b- Kidney Cyst Drainages: Bkidney, renal cysts are the most common disease of the kidneys.
- c- Abscess Drainages: A collection is the accumulation of fluid in any space. When the fluid becomes infected, it is called an abscess.
2. Bile Duct Obstructions
Removing bile duct stones by entering through the skin is useful in cases where surgical methods cannot be applied. After entering the bile ducts, the stone is pushed into the intestine using a balloon occlusion catheter. Transhepatic balloon application to the ampulla level also contributes to the treatment.
- a- Bile Duct Drainage – Percutaneous Transhepatic Cholangiography: It is the imaging of the bile ducts by administering contrast material after entering the bile ducts with a needle. After PTC, the obstruction is evaluated.
- b- Biliary Drainage: In bile duct obstruction, bile is delivered to the intestines with a multi-hole catheter or removed from the liver
- c- Internal Biliary Drainage: Narrowing or obstruction in the bile ducts is passed through a catheter to reach the intestines and transferring bile to the intestines
- d- Biliary Stent: Plastic or metallic tube (cage) inserted through the skin endoscopically or as an interventional radiology approach to relieve stenosis or obstruction in the bile ducts. Metallic stents have a longer patency period. Plastic stents can be removed from the bile ducts endoscopically, while metallic stents are permanent.
3. Urinary Tract Obstructions
The most common disease that causes blockage in the urinary tract is stone disease. Other causes include benign and malignant tumors. Urinary tract obstruction is treated with the following techniques:
- a- Percutaneous nephrostomy: When urine cannot reach the bladder due to obstruction in the urinary tract, enlargement of the urinary tract develops in the kidney, this is called hydronephrosis. A catheter is inserted through the skin and into the renal collecting system. The catheter is connected to the bag outside, allowing the urine to accumulate in the bag. General anesthesia and hospitalization are not required in these procedures, which are performed as day cases.
- b- Double J catheter or ureteral stent placement:Hydronephrosis occurs due to stenosis and obstruction in the ureters. If hydronephrosis is not treated early, it leads to deterioration in kidney functions. Stenosis and obstruction in the ureters are treated antegradely by entering the bladder from bottom to top or by entering the kidney directly from the skin.
4. Non-Cancer Ablation Techniques
a- Thyroid Ablation:In this technique, a thin needle is inserted into the thyroid nodule under ultrasound guidance and the nodule is destroyed by the heat generated by the laser and radiofrequency. Radiofrequency and laser ablation are the primary treatments for benign thyroid nodules. Microwave ablation is the second-stage treatment method.
b- Breast Fibroadenoma Ablation:Cryoablation Treatment in Breast Fibroadenoma Ablation is a method approved by the FDA in 2002. In cryoablation, the mass is reached with a thin needle and cooled to -80 degrees. Due to freezing, the cells in the fibroadenoma die and the mass shrinks and becomes unpalpable over months.
c- Benign Bone Tumor Ablation:Radiofrequency ablation is generally preferred for these types of tumors in GR. In this method, the tumor is destroyed by giving heat energy with a thin needle that enters the tumor. The procedure is performed with tomography.
d- Soft Tissue Tumors: Ablation can be applied in cases of recurrence of some tumors that develop in soft tissue. Diseases such as desmoid tumors and endometriomas located under the skin can be treated with cryoablation.