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Common vascular IR procedures

Arterial

Angiogram

An angiogram is an imaging technique that involves injecting a contrast dye into blood vessels to visualise their structure and diagnose any blockages or abnormalities. In simple terms, it is an X-ray of the blood vessels, arteriograms for arteries and venograms for veins.

Angiography

Angiography is the process of performing an angiogram. It is usually done by interventional radiologists, who specialise in minimally invasive procedures. During angiography, a catheter (a thin, flexible tube) is inserted into a blood vessel, typically through the groin or wrist. Using fluoroscopy (continuous X-ray), the catheter is navigated to the area of interest and contrast dye is injected to visualise the blood vessels. This allows the interventional radiologist to assess any blockages (stenoses) or abnormalities (like aneurysms or bleeding vessels) and determine the best course of action.

Angioplasty

Angioplasty is a minimally invasive procedure used to open up narrowed or blocked blood vessels. During angioplasty, a balloon-tipped catheter is inserted into the blocked artery or vein. The balloon is then inflated to widen the vessel and improve blood flow. In some cases, a stent may be inserted to keep the vessel open.

Elective Embolisation – Uterine Artery Embolisation (UAE), Prostate Artery Embolisation (PAE), Angiomyolipomas (AMLs) etc.

Elective procedures are organised non-emergency interventions. Some commonly performed elective procedures in IR are embolisations which involve intentionally blocking off the blood supply to a targeted structure. These include uterine artery embolisation for fibroids, prostate artery embolisation for benign prostatic hyperplasia and renal angiomyolipoma embolisation.

By carefully selecting and navigating catheters to the desired location, interventional radiologists can deliver embolic agents to the blood vessels supplying these structures, effectively shrinking or eliminating them. These elective embolisation procedures provide minimally invasive alternatives to traditional surgical approaches, offering patients shorter recovery times and reduced risks. They are usually day case procedures.

Endovascular Aneurysm Repair (EVAR/TEVAR/FEVAR)

An EVAR (Endovascular Aneurysm Repair) involves cleaning and numbing the insertion site over the common femoral artery then creating a small incision near the groin to gain access to the femoral artery. A guidewire is then threaded through the femoral artery and guided up to the aorta. A catheter (thin, flexible tube) is advanced over the guidewire and positioned at the site of the aneurysm. A stent graft (mesh tube) is inserted through the catheter and positioned within the aneurysm. The stent graft is deployed to create a new pathway for blood flow, bypassing the weakened area of the blood vessel. This helps to prevent the aneurysm from rupturing.

TEVAR (Thoracic Endovascular Aneurysm Repair) is a similar procedure to EVAR, but it is specifically used to treat aneurysms in the thoracic (chest) aorta. The procedure involves accessing the femoral artery and inserting a stent graft into the aorta to reinforce the weakened area and prevent rupture.

FEVAR (Fenestrated Endovascular Aneurysm Repair) is a more complex procedure used to treat aneurysms that involve the renal or visceral arteries. It involves the use of custom-made stent grafts (some are bespoke and even hand-sewn in Australia!) with holes or fenestrations that align with the openings of the target vessels. These fenestrations allow blood flow to be maintained to the vital organs while excluding the aneurysm.

Vascular surgeons and interventional radiologists decide on the treatment method for aortic aneurysms based on several factors, including the patient’s overall health, the location and size of the aneurysm, and the specific risks associated with each procedure. The main treatment options are open surgery, endovascular aneurysm repair (EVAR), thoracic endovascular aortic repair (TEVAR), and fenestrated endovascular aneurysm repair (FEVAR). Open surgery is typically considered for patients with complex abdominal aortic aneurysms (cAAA) or when endovascular options are not suitable due to anatomical constraints.

Fenestrated endovascular aneurysm repair (FEVAR) is associated with the lowest 30-day mortality risk compared to hybrid and open repair when adjusted for preoperative risk factors. However, open surgery is associated with higher overall survival and similar perioperative mortality. This is because fenestrated endovascular aneurysm repair (FEVAR) may be associated with higher complications and re-intervention rates due to the complexity of the disease and the need for renal-visceral vessel manipulation.

Endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are minimally invasive alternatives to open surgery and are associated with reduced perioperative morbidity, decreased blood loss, elimination of the need for aortic cross-clamping, and shorter recovery periods.

In summary, the choice between open surgery and endovascular options depends on the patient’s overall health, the location and size of the aneurysm, and the specific risks associated with each procedure. The decision is made on a case-by-case basis, considering the patient’s individual circumstances and the expertise of the treating team.

Neurological

Neuro - Carotid

Carotid artery stenting is a minimally invasive procedure used to treat carotid artery disease, which occurs when the carotid arteries in the neck become narrowed or blocked. During the procedure, a small incision is made in the groin to access the femoral artery. A catheter is then guided through the arteries to the carotid artery. A stent (mesh tube) is inserted into the narrowed or blocked area of the carotid artery to improve blood flow.

Neuro - Cerebral

During a diagnostic cerebral angiogram, a catheter is carefully threaded through the blood vessels to the brain. Contrast dye is then injected through the catheter, and video X-rays are taken to visualise the blood vessels. This procedure is used to diagnose conditions such as aneurysms, arteriovenous malformations (AVMs), and blockages in the blood vessels of the brain. In some cases, treatments such as endovascular coiling for aneurysms or embolisation for vascular malformations can be performed during the angiogram.

Neuro - Stroke

Interventional neuroradiologists can also perform mechanical thrombectomy procedures to treat acute ischaemic strokes. This involves inserting a catheter through a blood vessel in the groin and threading it up to the blocked blood vessel in the brain to remove the clot causing the stroke. Once the catheter reaches the clot, various mechanical devices can be used to physically break up or retrieve the clot, restoring blood flow to the brain. Mechanical thrombectomy has revolutionised stroke treatment, significantly improving outcomes and reducing disability.

In addition to mechanical thrombectomy, interventional radiologists can also perform thrombolysis for stroke patients. This involves using catheters to directly deliver clot-busting medications to the site of the clot, helping to dissolve it and restore blood flow.

Other procedures used in the treatment of stroke include angioplasty and stenting. Angioplasty involves using a balloon catheter to open up narrowed or blocked blood vessels in the brain, while stenting involves placing a small metal mesh tube in the blood vessel to keep it open. These procedures can help improve blood flow and reduce the risk of future strokes.

Venous

Fistuloplasty/Stenting

Fistuloplasty is a procedure used to treat narrowing or blockages in the veins, typically in the context of dialysis access fistulas. This is very similar to angioplasty except a balloon is inflated inside of a blocked fistula instead of an artery. In this context, the fistulae which become blocked are usually in the arms of kidney dialysis patients. In brief, a fistula is an abnormal connection between two structures, which is often a bad thing, but in this case an intentional connection has been made between a patient’s artery and vein to enable blood to be dialysed and detoxified without having functioning kidneys.

During the procedure, a catheter is inserted into the affected vein and a balloon is used to dilate the narrowed area. In some cases, a stent may be placed to keep the vein open. This procedure helps to improve blood flow and maintain the function of the fistula. Fistuloplasty/Stenting is a minimally invasive option that can help prolong the lifespan of dialysis access and improve patient outcomes.

Embolisation/Stenting

Embolisation/Stenting is a procedure used to treat various conditions involving arterial blood supply. During the procedure, a catheter is threaded through the blood vessels to the affected area. Embolisation involves the injection of small particles or coils into the blood vessels to block or reduce blood flow to abnormal or damaged tissue, such as tumours, bleeds or arteriovenous malformations (AVMs).

Stenting, on the other hand, involves the placement of a small mesh tube called a stent into a narrowed or weakened blood vessel to help keep it open and maintain proper blood flow. This procedure is commonly used to treat narrowed or blocked peripheral arteries , such as in cases of deep vein thrombosis (DVT) or chronic venous insufficiency

Inferior and Superior Vena Cava (IVC/SVC) cases

Inferior vena cava filter placement is a procedure commonly performed by interventional radiologists to reduce pulmonary embolism (PE) risk in intractable deep vein thrombosis (DVT) patients or where anticoagulants are contraindicated.

The Inferior Vena Cava is a large vein that carries deoxygenated blood from the lower body back to the heart. An Inferior Vena Cava (IVC) filter prevents blood clots from traveling to the lungs. Additionally, filter placement is sometimes performed prior to major surgeries to prevent blood clots during the procedure.

A catheter is typically inserted into the femoral vein, in the groin area, and guided using fluoroscopy to the desired location within the inferior vena cava. Once in position, the filter is deployed and held in position with tiny hooks on the filter attaching to the cava wall. The filter catches any large blood clots that may travel through the bloodstream, but allows blood to flow freely, reducing the risk of pulmonary embolism.

Patients will be monitored to ensure the filter remains in the correct position and effectively prevents blood clots. It is a temporary filter and will be retrieved and removed in due course.

Retrieval access is often via the internal jugular vein in the neck as the filter has a hook pointing upwards. It is removed using fluoroscopy for guidance, much like the game hook-a-duck.

SVC

Superior vena cava (SVC) procedures are commonly performed by interventional radiologists. They involve accessing and treating the large vein that carries deoxygenated blood from the upper body back to the heart.

Venography involves injecting a contrast dye into the vein and taking X-ray images to evaluate the venous anatomy. It helps identify any blockages or abnormalities in the superior vena cava (SVC).

For a blockage or narrowing identified in the superior vena cava (SVC), interventional radiologists can place a stent to keep the vein open and restore proper blood flow compromised by external compression or internal stenosis. The stent is a small, mesh-like tube that is inserted into the narrowed or weakened area of the vein, providing support and preventing further narrowing or blockage.

Bites

  • Vascular procedures include angioplasty, stenting, embolisation, and endovascular aneurysm repair for various conditions.
  • Venous interventions encompass fistuloplasty, stenting, and filter placement.
  • Neuroradiology procedures address carotid and cerebral issues, with a focus on stroke treatment.
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