〜Interventional Radiography〜

3RD YR | 1ST SEMESTER | PRF. BENTINGANAN

F: LESSON 1 ● Embolization
● Thrombolysis
OVERVIEW OF INTERVENTIONAL RADIOLOGY ● Balloon angioplasty
● Atherectomy

INTRO: WHAT IS INTERVENTIONAL RADIOLOGY? ● Electrophysiology

● Percutaneous biopsy
● Intervention: “ an action or process of interfering”
● Abscess drainage
● IR (medical practice): interfering with Radiology
● Percutaneous nephrostomy
in Diagnostic and/or Therapeutic Procedures.
● Percutaneous biliary drainage
● Radiofrequency ablation
IR: Image Guided Surgery/Surgical Radiology
Common Elements for Interventional Radiology:
● It is a medical subspecialty
● Puncture needle
● performs various minimally invasive procedures
● Guide wire
using medical imaging guidance such as:
● Sheath
○ X-ray fluoroscopy
● Catheters
○ CT Scan
● Medical Imaging Machine (X-ray fluoroscopy, CT
○ MRI
Scan, MRI, Ultrasound Guided)
○ Ultrasonogram
Prerequisite:
● Informed Consent
KEY TECHNIQUES IN IR
● Investigations:
Angiography, Biopsy, Drainage, Procedures, Embolization,
○ Platelet count ≥ 50,000/μL
Stenting: A Better Diagnosis Promotes Effective Solutions
○ INR ≤ 1.5
● Angiography
○ Renal Function Test: filtration function
● Biopsy
● Fasting: 4–6 hours
● Drainage
● IV Access & Hydration
● Procedures
● Parenteral Antibiotics
● Embolization
● Stenting
BASIC PRINCIPLE
Things to Remember:
● Arterial Access
● 8 out 10 procedures use skin incisions smaller
● (1953) Seldinger: described a method for
than 5mm.
catheterization of vessels.
● 9 out of 10 procedures use only local anesthetic,
● A percutaneous technique for arterial and
sometimes with sedation
venous access.
● Up to 8 out of 10 patients go home the same day.
● Femoral Artery: most commonly used.
● Site cleaned, area draped, local anesthetic given.
BRIEF HISTORY: ● The Seldinger needle is introduced into the artery.
● The first angiogram was performed only months
● When pulsating blood returns, the stylet is
after Roentgen’s discovery of X-rays
removed.
● Physicians injected mercury salts into an
● A guide wire is inserted through the needle.
amputated hand and created an image of the
● With the guide wire in the vessel, the needle is
arteries. (Post mortem injection:mercury salts in Jan. 1896)
removed.
● ANGIOGRAPHY: radiologic examination of vessels
● Catheter is threaded onto the guide wire.
after the introduction of a contrast medium.
● Under fluoroscopy, the catheter is advanced, and
● 1930s: Interventional radiologic procedures
the guide wire is removed.
began in 1930s with angiography
● Early 1960s: Mason Jones pioneered trans
Seldinger Technique:
brachial selective coronary angiography
Seldinger Needle
● Late 1960s: transfemoral angiography was
● Type: 18-gauge, single-use,
developed
sterile needle
CHARLES DOTTER (1963)
● Two parts:
● Proposed idea of IR
○ Solid inner needle
● The Father of Interventional Radiology
(stylet)
● 1964: Done percutaneous angioplasty through
○ Outer thin-walled needle
accidental operation.
for smooth passage
● Hub: good instrument balance
OVERVIEW OF THE PROCEDURE: BASIC PRINCIPLES
● Winged handle: good control

IR Examinations involve:
● Stent placement
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 〜Interventional Radiography〜
3RD YR | 1ST SEMESTER | PRF. BENTINGANAN

Step-by-step:

Common Guidewires Thickness:

● 0.014 inches (0.36 mm): Often used for
1. Insertion of Needle
microcatheter systems and in procedures
2. Placement of Needle in Lumen
requiring high flexibility.
3. Insertion of Guide Wire
● 0.018 inches (0.46 mm): Commonly used in
○ Through needle, advance 10 cm
peripheral interventions and for crossing lesions
4. Removal of Needle
in smaller vessels.
○ Guide wire remains in position
● 0.035 inches (0.89 mm): A standard size for
5. Threading of Catheter
many interventional procedures, providing a
○ To area of interest (fluoroscopy used)
balance between flexibility and support.
6. Removal of Guide Wire
● 0.038 inches (0.97 mm): Typically used for larger
○ Catheter remains in place
devices and in more demanding vascular
interventions.
TOOLS:
Guidewire Selection Considerations:
1. Needle: ● Vessel Size:
● 18-gauge angiographic puncture needle: ○ Thinner wires for smaller vessels to
One-piece open needle with a sharp beveled tip. minimize trauma.
● Guide wire: Introduced directly through the ● Procedure Type:
needle once the tip is fully within the bleeding ○ Thicker wires for complex procedures
vessel lumen. requiring support.
● This style of needle can be used for both arterial ● Device Compatibility:
and venous punctures. ○ Ensure the guide wire matches delivery
2. Guidewires: device requirements.
● Available in several thicknesses, lengths, tip ● Operator Preference:
configurations, stiffness, and materials of ○ Consider the operator's familiarity and
construction. comfort with guide wire sizes.
● The diameter is typically the same as or slightly Types of Guidewire Coating:
smaller than the lumen at the tip of the catheter ● Hydrophilic Coatings:
or device that will slide over it. ○ These coatings absorb water, creating a
○ Usually about 145 cm long. slippery surface that reduces friction.
● If the guide wire is too big, it may jam, usually at ○ Particularly useful in wet environments,
the tip of the catheter. such as blood vessels.
● If the guidewire is much smaller than the end ● Hydrophobic Coatings:
hole of the catheter or device, a gap will form ○ These coatings repel water and provide a
between the guidewire and catheter, which can: dry surface, which may be beneficial in
○ Cause vessel injury certain applications.
○ Prevent smooth movement over the ● Polymeric Coatings:
guide wire. ○ Various polymers can be used to create
● Covered by a coating: coatings that enhance performance
○ Teflon, heparin, and recently hydrophilic characteristics, such as flexibility and
polymers (glide wires) are used. strength.
○ The coating reduces friction and provides ● Metallic Coatings:
strength to the guide wire (GW). ○ Some guide wires may have metallic
● Tips at the end of GW: coatings to improve radiopacity or
○ Straight tip provide additional mechanical
○ J-tip: prevents subintimal dissection of properties.
the artery.

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 〜Interventional Radiography〜
3RD YR | 1ST SEMESTER | PRF. BENTINGANAN

3. Vascular Sheath: ● H1 or Headhunter Tip:

● Placed over the wire, ○ Used for femoral approach to

through the access site. brachiocephalic vessels.

● Open at one end and ● Simmons Catheter:

capped with a ○ For sharply angled vessels, cerebral, and

hemostatic valve at the visceral angiography.

other. ● C2 or Cobra Catheter:

● Walls are non-tapered and beveled to closely ○ Has an angled tip joined to a gentle

match the dilator sizes, providing a smooth curve; used for celiac, renal, and

transition between sheath and dilator. mesenteric arteries.

● Available in various lengths and diameters. Measurements

● The diameter of a sheath is measured in “French”. ● Outer size: Measured in French (F)
● Sheath selection is based on the intended ● Diameter of end hole: Measured in Gauge (G)
purpose. Catheter Types (Name-Based on Shape)
Designer: Simmons, Berenstein, Rosch
● Pigtail
● Cobra
● Hockey Stick
Catheter Selection
A. Tip Length:
Increased length offers more stability
with compromised maneuverability.
B. Primary Curve:
Based on the angle of the target vessel
Balkin’s Cross Over Sheath: from the parent artery.
● Placed on the contralateral side after crossing C. Secondary Curve:
over the aortic bifurcation. Based on the width of the parent vessel.
● Facilitates easy access and treatment of lesions D. Tertiary Curve:
in the iliac/SFA and high tibial arteries. Based on the normal curvature of the
parent vessel.
E. Length:
○ Shorter(50 cm): C/l iliac artery injection
○ Mid(65 cm): renal, celiac, mesenteric
○ Longer(100-125 cm): abdominal aorta
Common Catheter Shapes
4. Catheter: ● Straight
● Davis (Short angled tip)
● Made of polyurethane, polyethylene, Teflon, or
● Multipurpose (Hockey-stick)
nylon.
● Headhunter (H1)
● Catheters vary based on their intended use.
● Cobra-2 (Cobra-1 has a tighter curve, Cobra-3
○ Nonselective aortography:
has a larger and longer curve)
■ Thick-walled with a pig-tail tip
● Rösch celiac
and multiple side holes.
● Visceral (Very similar to Simmons 1)
○ Selective catheter:
● Mickelson
■ Thin-walled with a tapered tip,
● Simmons 2
single end hole, and
● Pigtail
metal/plastic strand BRAID tip.
● Tennis racket
● Diameter: Measured in French (Fr), where 3Fr =
1mm. 5. Dilator

Catheter Types: ● Plastic Catheter

● Purpose: Spread the soft tissues and vessel wall
to facilitate catheter entry.
● Sequential (1F-2F) dilatation: Prevents trauma
● Access Needle: Usually, an 18G access needle
uses 5F initially.
● Vessel Diameter: 50% diameter of the vessel
obviates manual compression.

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 〜Interventional Radiography〜
3RD YR | 1ST SEMESTER | PRF. BENTINGANAN

TEST QUESTIONS: 4. Ablative

1. A device that is used to deliver a bolus of ● Chemoembolization
contrast medium to a specific site during ● Radioembolization
angiography or other radiological procedures is ● Radiofrequency ablation
known as which of the following? ● Cryoablation
A: Catheter ● Microwave ablation
2. What type of needle is used for biopsies and 5. Genitourinary
non-vascular access?
● Percutaneous nephrostomy
A: Chiba
● Ureteral stent exchange
3. For a spinal angiogram, where is the catheter first
6. Pain Management
inserted?
● Joint and local injections
A: Groin area
○ Facet joints
○ Sacroiliac joints
THERAPEUTIC AND DIAGNOSTIC ○ Epidural joints

INTERVENTIONAL RADIOLOGY
○ Selective nerve root injection
● Chronic pelvic pain
● Palliative care
Prerequisites ● Nerve block/ablations
● Informed consent
● Investigations: IR TREATS MANY CONDITIONS:
● Platelet > 50,000 ● Varicose veins
● INR < 1.5 ● Leg arteries
● Renal function test ● Blood clots
● Fasting: 6-8 hours ● Blood vessel malformation
● IV access & hydration ● Blocked arteries
● Parenteral antibiotics ● Internal bleeding
Types of IR (Interventional Radiology) ● Aortic aneurysm
● Diagnostic ● Targeted cancer treatment
○ Angiography ● Dialysis
○ Cholangiography ● Bones & spine
○ Biopsy
● Therapeutic SCOPE OF INTERVENTIONAL RADIOLOGY
○ Vascular
○ Biliary intervention ● Blood vessel
○ Catheter placement ● Bleeding control
○ Ablative ● Cancer
○ Genitourinary
Blood Vessels
○ Pain management
● Treats blood vessels from 2mm to 30mm
● Narrowed blood vessels are stretched
THERAPEUTIC IR (angioplasty) to improve blood flow
1. Vascular ● Blocked blood vessels can be internally reopened
● Balloon angioplasty/stent in many cases
● Endovascular aneurysm repair ● Treatment of aneurysm (abnormal bulges in
● Embolization vessels)
● Thrombolysis Aortic Aneurysm
● IVC filter
● Abnormal bulge (aneurysm) of the main artery in
● TIPS
the abdomen
● Endovenous LASER treatment for varicose veins
● Risk of rupture and major bleeding
2. Biliary Intervention ● Treated by internally relining the artery
● Catheter placement for biliary bypass (Endovascular Aneurysm Repair - EVAR)
● Biliary stenting ● Major surgery avoided, with a total treatment
● Cholecystostomy time of 90 minutes
3. Catheter Placement Bleeding Bowel
● Central venous catheter placement ● Severe bleeding into the large bowel (arrow)
● Drainage catheter placement ● Treated with selective blockage of the bleeding
● Radiologically inserted gastrostomy artery
● Emergency surgery avoided

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 〜Interventional Radiography〜
3RD YR | 1ST SEMESTER | PRF. BENTINGANAN

Cancer Treatment SUMMARY:

● Thermal destruction of small cancers using
Introduction: What is Interventional Radiology?
image-guided needles
● Targeted chemotherapy into blood vessels
● Intervention: “An action or process of interfering.”
supplying the tumor ● IR (Medical Practice): Interfering with radiology
Symptom Relief for diagnostic and/or therapeutic procedures.
● Stent insertion into the bowel for relief of ● Alternate Names: Image-Guided Surgery,
Surgical Radiology.
obstruction
● Procedures Use Medical Imaging Guidance:
● Insertion of lines for delivery of chemotherapy
○ X-ray fluoroscopy
and nutrition
○ CT Scan
○ MRI
COMPLICATIONS ○ Ultrasonography

Key Techniques in IR
● Bacteremia
● Septicemia ● Techniques: Angiography, Biopsy, Drainage,
● Hemorrhage Embolization, Stenting.
● Pancreatitis ● Important Facts:
● Pneumothorax ○ 8 out of 10 procedures involve skin
● Tumor seeding incisions <5 mm.
○ 9 out of 10 procedures use local
anesthesia, sometimes with sedation.
BENEFITS ○ Up to 8 out of 10 patients are discharged
● 8 out of 10 procedures use skin incisions smaller the same day.
than 5 millimeters
● 9 out of 10 procedures use only local anesthetic, Brief History

sometimes with sedation

● 1896: First angiogram (post-mortem injection of
● Often a less invasive option than traditional mercury salts).
surgical procedures ● 1930s: Angiography introduced; first
● Up to 8 out of 10 patients go home the same day interventional radiologic procedures.
● 1960s:
○ Early: Mason Jones pioneered
TEST QUESTIONS:
trans-brachial selective coronary
1. What is the length of Chiba Needle?
angiography.
A: 15 cm ○ Late: Transfemoral angiography
2. Which of the following needle is used in case of developed.
deeper lesions? ● 1963: Charles Dotter proposed IR concept;
A: Chiba needle performed percutaneous angioplasty in 1964.
3. Which of the following is NOT an IR procedure?
Overview of Procedures: Basic Principles
A: NCCT Abdo-pelvis
4. The benefits of interventional radiology ● IR Examinations:
procedures are? ○Stent placement, Embolization,
a. Techniques that are minimally invasive Thrombolysis, Balloon angioplasty,
with lower risk compared with traditional Atherectomy, Electrophysiology.
○ Percutaneous biopsy, Abscess drainage,
surgical procedures.
Nephrostomy, Biliary drainage,
b. Procedures that are less expensive than
Radiofrequency ablation.
traditional medical and surgical ● Common Elements:
procedures. ○ Tools: Puncture needle, Guide wire,
c. Shorter hospital stays for the patient and Sheath, Catheters, Medical imaging
shorter recovery time because of a safer, machines.
○ Prerequisites:
less invasive procedure.
■ Platelet count ≥ 50,000/μL.
d. Alternatives for patients who are not
■ INR ≤ 1.5.
candidates for surgery.
■ Fasting: 4–6 hours.
A: All of the above. ■ Renal function tests, IV hydration,
Parenteral antibiotics.

Basic Principle: Seldinger Technique

● Developed: 1953 by Seldinger (arterial/venous

access).
● Steps:

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 〜Interventional Radiography〜
3RD YR | 1ST SEMESTER | PRF. BENTINGANAN

1. Insert needle into artery (local anesthesia ● Minimally invasive, lower risk, cost-effective.
used). ● Shorter recovery times and hospital stays.
2. When pulsating blood returns, remove ● Suitable for patients who cannot undergo
stylet. surgery.
3. Insert guide wire, remove needle.
4. Thread catheter over guide wire. Test Questions
5. Advance catheter under fluoroscopy,
remove guide wire. 1. Length of Chiba Needle?
A: 15 cm.
Tools Used in IR 2. Needle for deeper lesions?
A: Chiba needle.
1. Needle: 3. Which is NOT an IR procedure?
○ 18-gauge angiographic needle; A: NCCT Abdo-pelvis.
single-use, sterile, sharp beveled tip. 4. Benefits of IR procedures?
2. Guide Wires: A: All of the above (minimally invasive, lower cost,
○ Thickness: 0.014", 0.018", 0.035", 0.038". shorter recovery).
○ Coating: Teflon, heparin, hydrophilic
polymers.
○ Tips: Straight tip, J-tip.
3. Vascular Sheath:
○ Smooth transition, measured in French
(F).
○ Specialized sheaths (e.g., Balkin’s
Crossover Sheath for iliac artery access).
4. Catheters:
○ Materials: Polyurethane, polyethylene,
Teflon, nylon.
○ Diameter: Measured in French (1 F = 0.33
mm).
○ Types: Nonselective, selective (e.g.,
Headhunter, Cobra, Pigtail).
5. Dilator:
○ Plastic catheter to spread tissues and
facilitate entry.

Types of Interventional Radiology

● Diagnostic: Angiography, Cholangiography,

Biopsy.
● Therapeutic:
1. Vascular: Angioplasty, stenting,
embolization, thrombolysis, TIPS, EVAR.
2. Biliary: Catheter placement, biliary
stenting, cholecystostomy.
3. Catheter Placement: Central venous
catheter, gastrostomy.
4. Ablative: Chemoembolization,
radioembolization, thermal ablation.
5. Genitourinary: Nephrostomy, ureteral
stent exchange.
6. Pain Management: Nerve blocks, joint
injections, palliative care.

Conditions Treated by IR

● Vascular: Varicose veins, blocked arteries,

aneurysms, internal bleeding.
● Cancer: Targeted chemotherapy, thermal
ablation, symptom relief.
● Other: Dialysis access, spinal and bone
interventions.

Complications

● Bacteremia, septicemia, hemorrhage,

pancreatitis, pneumothorax, tumor seeding.

Benefits of IR

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