VASCULAR/ INTERVENTIONAL Dr. Jeff Jaskolka University of Toronto.

VASCULAR/INTERVENTIONALDr. Jeff Jaskolka

University of Toronto

Disclosure:

Have acted as consultant for:SiemensBraccoLantheusNo bearing on the contents of this lecture

Some uses of devices shown are “off-label”

DISCLAIMER:VIR not the same as diagnosticWe are simple folkFocus on management, diagnoses straightforward

CASES

CASE 148 year old woman with hypertension

11

Diagnosis?

Best treatment?

Would you use a stent?

11

CASE 255 year old woman with hypertension

22

Diagnosis?

Best treatment?

Would you use a stent?

22

CASE 375 year old male with right leg claudication

33

RAO LAO

Diagnosis?

Best treatment?

If endovascular treatment, would you use a stent?

33

CASE 477 year old male, left leg claudication

44

Diagnosis?

Best treatment?

What would you use for endovascular treatment?

44

CASE 535 year old female, pain after eating

55

Sagittal CTA Coronal CTA

Diagnosis?

Provocative manouver?

Best treatment?

55

CASE REVIEW

Case 1: FIBROMUSCULAR DYSPLASIA (BILATERAL)

11

Gadolinium enhanced MRA

Coronal MIP

Axial MIP

Differential Diagnosis

Atherosclerosis

Standing waves

Vasculitis

1

Presentation Title - Subtitle

Key Points

NOTABLE:

more common in women, 65% bilateral

CLASSIC DESCRIPTOR:

“String of beads” appearance of renal artery

+/- webs

+/- stenosis

PEARL:

mid/distal renal artery vs. ostial/proximal 1/3

5 types, medial fibroplasia (type II) most common

1


Key Points

TREATMENT:

endovascular preferred

angioplasty alone, no stent

1


22

Case 2: RENAL ARTERY STENOSIS(ATHEROSCLEROTIC)

Frontal aortogram Left renal arteriogram post treatment


Vasculitis

Fibromuscular dysplasia

Congenital

2


Atherosclerosis

Atherosclerosis

Atherosclerosis

Key Points2


NOTABLE:

<10% cases of hypertension due to RAS

CLASSIC DESCRIPTOR:

Eccentric, ostial narrowing of renal artery with associated atherosclerotic aorta

PEARL:

>50% stenosis or >10% systolic pressure drop across lesion considered hemodynamically significant

Key Points

TREATMENT:

MEDICAL

endovascular treatment for:

failed medical therapy

renal salvage (ie. renal failure)

flash pulmonary edema

endovascular treatment is primary stent

balloon expandable for high radial force and accuracy of placement

2


33

Case 3: EXTERNAL ILIAC ARTERY STENOSIS


Atherosclerosis

Atherosclerosis

Atheroscelrosis(trauma/iatrogenic, vasculitis)

3


RAO arteriogram LAO arteriogram

Key Points3


NOTABLE:

common cause of unilateral claudication

CLASSIC DESCRIPTOR:

focal, short, eccentric stenosis

PEARL:

best, most durable treatment for all iliac lesions is surgical bypass

Key Points

TREATMENT:

best treatment is surgical bypass

many patients not candidates

multiple comorbidities

best lesions for angioplasty

concentric

short

non-calcified

stenting in external iliac artery optional

self expanding stent best

3


44

Case 4: AORTOILIAC STENOSIS


No differential

4


Key Points4


NOTABLE:

iliac bifurcation lesions extension of aortic disease

CLASSIC DESCRIPTOR:

bilateral calcified narrowing of iliac bifurcation

PEARL:

Treatment is with “kissing” balloons or stents

Key Points

TREATMENT:Aortobiiliac or aortobifemoral bypass graft

most durableEndovascular

kissing stents/balloons for simultaneous treatment of both sides or to protect unaffected side from

occlusion/dissectionballoon vs. self expanding stents

higher radial force, precise position

4


55

Case 5: MEDIAN ARCUATE LIGAMENT SYNDROME

Sagittal CTA Coronal CTA


Atherosclerosis

Vasculitis

Extrinsic compression (not truly median arcuate ligament “syndrome”)

5


Key Points5


NOTABLE:

extrinsic compression of celiac axis by median arcuate ligament

CLASSIC DESCRIPTOR:

J-shaped appearance of proximal celiac artery

PEARL:

stenosis gets worse with expiration

treatment is conservative or surgical. Endovascular treatment not appropriate

Key Points – OPENING


Not all lesions require treatment

Angioplasty is not the only treatment

Best lesions for angioplasty:

- short, concentric, non-calcified

Stenting for bailout, ostial lesions

Balloon expanding stents - ostial lesions

Self expanding stents – flexible/mobile anatomy

CASES

CASE 665 year old female, bruising 4 days post cardiac catheterization

66

Right groin doppler

Diagnosis?

Best treatment?


33

CASE 750 year old male found unconscious with hematochezia

77

Diagnosis?

Best treatment?


77

CASE 880 year old male, routine f/u post EVAR

88

Diagnosis?

Does this need treatment?

If so, what would treatment be?

33

CASE 970 year old female with massive hemoptysis

99

Diagnosis?

Treatment options?

What is the most devastating potential complication of endovascular treatment?

99

CASE 1034 year old man with scrotal mass

1010

4mm

Diagnosis?

Treatment options?


1010

CASE REVIEW

66

Case 6: COMMON FEMORAL ARTERY PSEUDOANEURYSM


True aneurysm

Mycotic aneurysm

Arteriovenous fistula

6


Right groin doppler

Needle tip

Key Points6


NOTABLE:

Common complication of femoral artery complication.

Presents with bruising, palpable lump

CLASSIC DESCRIPTOR:

Yin-yang appearance. To-and-fro flow in neck.

PEARL:

Small (<2cm) pseudoaneurysms may resolve spontaneously

Key Points

TREATMENT:

expectant (for small lesions)

ultrasound graded compression

percutaneous thrombin injection

small needle

500-1000U thrombin

must have short neck, no AVF

surgical repair

stent graft

6


77

Case 7: LOWER GI HEMORRHAGE (DIVERTICULAR)

Tc-99 RBC scan

SMA arteriogram - early

SMA arteriogram - late


Angiodysplasia

Neoplasia (polyp/carcinoma)

Colitis

7


Key Points7


NOTABLE:

divericulosis accounts for 65% of LGI hemorrhage

CLASSIC DESCRIPTOR:

extravasation of contrast, pooling on delayed phase, shape of diverticulum

PEARL:

do not image an unstable patient with lower GI hemorrage – take them straight to angio suite

Key Points

MANAGEMENT:

stabilize patient

if stable – image (CTA, Tc99 RBC scan)

if actively bleeding – to angio for diagnosis/treatment

treatment is embolization

superselective coil embolization

particles risk of ischemia

7


88

Case 8: TYPE I ENDOLEAK POST EVAR


Endoleak classification

Type I – inadequate seal proximally or distally

Type II – retrograde flow via collateral

Type III – graft failure, component separation

Type IV – porosity of graft

Type V - endotension

8


Sag 3D volume rendered CTA

Left renal arteryLeft renal artery

Pre-treatment Post-treatment

Key Points8


NOTABLE:

Type II endoleaks post EVAR are common and usually managed expectantly

Type I endoleaks more common in grafts without suprarenal fixation or in large/short necks

CLASSIC DESCRIPTOR:

contrast outside endograft, within aneurysm sac

PEARL:

Delayed imaging improves sensitivity for detection of endoleak

Key Points

TREATMENT:Type 1 endoleak

treated by extension of graft or buttress with balloon expandable stent

Type 2 endoleaktreated by embolizationdirect sac puncture vs. transarterial

Type 3 endoleaknew graft within old graft

Type 4 endoleak, usually intraoperative and resolve spontaneously

Type 5 endoleak – no treatment

8


99

Case 9:LEFT UNILATERAL VARICOCELE


Secondary varicocele

- retroperitoneal mass

- renal vein/IVC occlusion

9


4mm

Left gonadal venogram

post embolization

embolization coils

Left gonadal venogram

Key Points9


NOTABLE:

common cause of palpable scrotal mass

veins > 3mm on ultrasound are diagnostic

CLASSIC DESCRIPTOR:

“bag of worms” on ultrasound

PEARL:

most often “idiopathic”, look for a cause in cases of isolated right-side varicocele

Key Points

TREATMENT:

endovascular (embolization) vs. surgical (ligation)

both are “minimally invasive”

both have comparable outcomes

embolic material of choice is coils for large vessel occlusion

9


1010

Case 10: MASSIVE HEMOPTYSIS (ASPERGILLOMA)

Right intercostobronchial trunk arteriogram

R ICBT

Abnormal parenchymal stain


Sarcoid/TB

Neoplasm

Airway trauma

Vasculitis

10


Key Points10


NOTABLE:

defined as >500cc hemoptysis in 24 hours

multiple causes, usually blood supply is by hypertrophied bronchial artery

CLASSIC DESCRIPTOR:

hypertrophied bronchial artery with abnormal parenchymal stain +/- shunting to pulmonary artery/vein

NB - active extravasation not commonly seen

PEARL:

mainstay of therapy is bronchial embolization – BEWARE THE ANTERIOR SPINAL ARTERY

Key Points

TREATMENT:

particle embolization of bronchial artery

no coils – won’t be able to treat recurrence

BEWARE THE ANTERIOR SPINAL ARTERYvariable bronchial artery anatomy

most commonly right intercostobronchial trunk, left bronchial artery

10


Key Points - CLOSING

Sometimes surgery is the answer

Interventional options:

Embolization, covered stent, thrombin

Types of embolic agents:

permanent (PVA, glue, coils) vs temporary (gelfoam)

Coils are akin to surgical ligation

- “proximal” occlusion

- potential for collateral formation

Particles/glue

- “distal” occlusion, capillary/arteriolar level

- no collaterals, risk for ischemia


CASES

CASE 1155 year old male, hepatoma screen

1111

Arterial phase Venous phase

Diagnosis?

Potential treatment options?

1111

CASE 12:60 year old male with abdominal pain

1212

Hypoattenuating mass

Probable diagnosis?

What would be your approach to biopsy?

What are the risks of biopsy?

1212

CASE 1357 year old male, right flank pain and fever

1313

Diagnosis?

How can a radiologist help?

What are the risks of percutaneous intervention?

1212

CASE 1460 year old male, left lower quadrant pain and fever

1414

Is this drainable?

Probable diagnosis?

Is this collection drainable?

What route/guidance method would you choose?

1212

CASE 15: 70 year old female, fever and right upper quadrant pain

1515

Soft tissue massDuct dilation

Probable diagnosis?

Treatment options?

What kind of tube would you use for percutaneous intervention?

1212

CASE REVIEW

1111

Case 11: HEPATOCELLULAR CARCINOMA


Dysplastic nodule

Hemangioma

FNH-like lesion

11


Arterial phase Venous phase

RFA electrodePost ablation

Key Points11


NOTABLE:

Very common in far east, increased incidence in north america

CLASSIC DESCRIPTOR:

Arterially enhancing nodule with washout in cirrhotic liver

PEARL:

Any arterially enhancing lesion >2cm in a cirrhotic liver is HCC until proven otherwise

Only cure is liver transplantation

Key Points11


TREATMENT:

Only curative treatment for HCC is transplant

Surgical resection for surgical candidates

RFA for non-surgical candidates

+/- lesions ≤ 2.5cm

chemoembolization

radiotherapy

sorafenib

Risks of RFA: hemorrage, infection, bile duct injury, needle tract seeding, colon/GB injury

1212

Case 12: PANCREATIC ADENOCARCINOMA

Percutaneous biopsy


Pancreatic adenoCa

Focal pancreatitis

Metastasis

12


Key Points12


NOTABLE:

most commonly present in pancreatic head.

CLASSIC DESCRIPTOR:

ill-defined hypoattenuating pass pancreatic head

PEARL:

Most unresectable

Key Points12


PERCUTANEOUS BIOPSY:

ultrasound vs. CT guided

may go transgastric if needed

risks:

hemorrage

infection

tumour seeding very rare

bowel injury

coaxial technique

core biopsy preferred

1313

Case 13: PYELONEPHRITIS, OBSTRUCTING CALCULUS


Non-infected hydronephrosis

Pre-existing UPJ obstruction

13


Key Points13


NOTABLE:

99% of renal calculi depicted on non-contrast CT

Most calculi impacted at UVJ, UPJ or pelvic brim

CLASSIC DESCRIPTOR:

radioopaque calculus with associated renal enlargement, perinephric stranding, hydronephrosis/hydroureter

PEARL:

Infected calculi, hydronephrosis in solitary kidney or electrolyte disturbances are indications for urgent management

Key Points13


TREATMENT:

renal decompression

urgently for sepsis, solitary kidney, electrolyte disturbance

options:

percutaneous nephrostomy/ nephroureterostomy

percutaneous JJ stent

cystoscopic JJ stent

risks of percutaneous therapy

worsening sepsis, hemorrhage/AVF, other organ injury

1414

Case 14: DIVERTICULAR ABSCESS


Perforated colon cancer

Abscess from inflammatory bowel disease

14


Is this drainable?

18 gauge needle10Fr abscess drain

Key Points14


NOTABLE:

prevalence of diverticulosis @ 50% after age 70

complications include diverticulitis, fistula, muscular hypertrophy, lower GI bleed

CLASSIC DESCRIPTOR:

rim enahancing fluid collection in sigmoid mesentary, adjacent to inflamed diverticulum

PEARL:

always do elective sigmoidoscopy/colonoscopy to rule out underlying malignancy

Key Points14


TREATMENT:

medical

antibiotics, often successful for small collections

surgery

two stage – hartman’s with colostomy, then reversal

percutaneous

definitive management

delay surgery to elective, 1-stage procedure

Key Points14


PERCUTANEOUS TREATMENT:

US guidance – faster, safer

CT guidance – not all lesions can be seen by ultrasound

deep

gas obscuring view

Seldinger vs. Trochar

safer vs. faster, less painful

Tube size – 10 French or bigger for pus, thick bile, pleural fluid

Key Points14


WHAT IS FRENCH SIZE?!?!?!:

Circumference of tube in mm

French size/3 = diameter

Eg. 8Fr tube is ~ 2.7mm

- suitable for simple fluid

1515

Case 15: KLATSKIN TUMOUR, BILE DUCT OBSTRUCTION

Soft tissue massDuct dilation


Cholangiocarcinoma

Biliary calculus

15


Key Points15


NOTABLE:

Hilar cholangiocarcinoma, known as klatskin tumour

Often unresectable

CLASSIC DESCRIPTOR:

Hilar soft tissue mass with bilateral biliary obstruction. Lack of communication of left and right sided ducts

PEARL:

Often require biliary drainage to restore bilirubin and allow safe administration of chemotherapy

Key Points15


TREATMENT:

Medical

Surgical

Endoscopic

plastic stents

can’t be removed without endoscopy

limited access

more appropriate for low lesions

if the GB is distended – ERCP

Percutaneous

Key Points15


PERCUTANEOUS TREATMENT:

Goal is to decompress as much liver as possible

Goal is internal drainage if possible

Internal/external biliary drainage catheter

minimize manipulation if cholangitis

Either side if right and left side communicate

Right side first vs. bilateral tubes if not

Key Points – NEEDLES/DRAINS


Procedures are not without risk

Bleeding, infection, other organ injury

Internal drainage always desirable

US faster, safer when possible

Seldinger vs. trochar

- safer, slower, more painful

THANK YOU

VASCULAR/ INTERVENTIONAL Dr. Jeff Jaskolka University of Toronto.

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