Seminars in Interventional Radiology最新文献

Endoleaks are a common complication following endovascular aneurysm repair, despite EVAR being the preferred method for the repair of abdominal aortic aneurysms. Endoleaks are continued blood flow into the aneurysmal sac, or more broadly elevated pressure outside of the endograft, and are classified into five types based on the source of blood flow or elevated pressure. Type II endoleaks are the most common and are a result of retrograde flow to the sac most commonly from the inferior mesenteric artery or lumbar artery. Endovascular treatment options for type II endoleaks include transarterial, transcaval, translumbar, and transabdominal approaches. This review discusses the indication for endovascular treatment of type II endoleaks, the selection of approach, and technical considerations.

Thoracic endovascular aortic repair (TEVAR) and endovascular abdominal aortic aneurysm repair (EVAR) have become widely accepted techniques for the treatment of aortic aneurysms and dissections. Central to the success of TEVAR and EVAR is accurate endograft sizing. Key aspects to be discussed in this article include the importance of preprocedural centerline imaging with computed tomography angiography to evaluate the proximal and distal seal zones. This article will review TEVAR and EVAR endograft sizing, providing the interventionalist with practical advice to optimize patient selection and to improve procedural success.

Aortic pathologies such as dissection, aneurysm, or blunt aortic injury have historically been treated via open surgical repair; however, the advent of endovascular stent graft technology has allowed for endovascular aortic repair in more and more patients. With improvements in stent graft technology and delivery systems, more patients are now candidates for endovascular aortic repair; however, many will require large-bore transfemoral arterial access. Percutaneous transfemoral arterial access includes the introduction of a large-bore sheath directly into the iliofemoral arterial system for the deployment of aortic stent grafts. Advancements in percutaneous arterial closure and reductions in device delivery profiles have further refined this technique; however, careful preprocedural planning and technical precision are required to minimize complications. This article covers the fundamentals of large-bore transfemoral arterial access as well as technical pearls for successful outcomes.

Endovascular aortic repair has transformed the treatment of aortic pathologies, providing minimally invasive alternatives to traditional open surgery. Despite these advancements, endovascular procedures continue to encounter substantial challenges, including navigating tortuous and calcified vessels, precise catheterization of the aortic branch vessels in complex cases, and the significant risks of radiation exposure to both patients and operators. Recent innovations in electromagnetic (EM) tracking and 3D imaging offer a promising alternative to traditional methods. This review focuses on the Intraoperative Positioning System (IOPS), a novel EM-based image guidance system developed by Centerline Biomedical, Inc. (Cleveland, OH). IOPS uses sensorized, EM-tracked devices to enhance procedural precision and safety by minimizing reliance on ionizing radiation while improving visualization and the accuracy of catheterization in vascular anatomies. This technology enables parts of the procedure to be performed without the need for ionizing radiation, offering a safer and more efficient approach to endovascular procedures.

Approximately 40 to 70% of children with chronic medical disease (congenital or acquired respiratory, cardiac, and gastrointestinal disorders) experience feeding difficulties. Enteral feeding in pediatric patients can be administered through orogastric, nasogastric, nasojejunal (NJ), gastrostomy (G) and gastrojejunostomy (GJ) tubes, all of which can be safely placed by the interventional radiologist. This article reviews NJ, G, and GJ tube placement and adjunctive techniques to ensure safe and effective enteral access placement. While feeding can also be performed via a jejunostomy tube, these are less common in children and are typically placed via a surgical approach and will not be discussed in this review. Dose reduction techniques, an important consideration in pediatrics, are also reviewed.

Interdisciplinary teams offer potential advantages over siloed care models in complex cardiovascular disease management. Consensus guidelines for aortic management have increasingly identified the interdisciplinary aortic team as a key component in delivering quality care. Acute aortic syndromes are a subset of high acuity and lethal aortic pathologies that may benefit from an interdisciplinary approach. The advantages of the interdisciplinary aortic team model in the management of acute aortic syndromes and barriers to implementation are discussed.

Traditional open surgical repair of aortic disease distal to the ascending aorta has long been associated with significant morbidity and mortality. Two specific anatomic locations of disease have proven especially challenging to manage; the transverse aortic arch and the thoracoabdominal aorta. Hybrid approaches have the potential to limit or even eliminate the need for cardiopulmonary bypass and hypothermic circulatory arrest, thus carrying the promise of improved patient outcomes. This manuscript discusses the hybrid approach to aortic repair and recent advances made in this combined multidisciplinary approach used in these treatments.

Chronic type B aortic dissection (cTBAD) often requires intervention due to complications like aortic aneurysmal dilatation and rupture, traditionally managed via open surgery. With the continued rise of endovascular therapies, thoracic endovascular aortic repair (TEVAR) is increasingly used, although its role in cTBAD is debated due to challenges such as a thick dissection septum, poor landing zones, and persistent false lumen flow. However, mounting evidence demonstrates TEVAR is a viable option for cTBAD, particularly for patients with high risks treated with open surgery. Advances in endovascular techniques, such as false lumen obliteration techniques and landing zone optimization strategies, have enhanced its technical success rate and clinical outcomes. However, continued research is needed to validate these methods and confirm their long-term benefits. In this review article, we not only update the emerging endovascular armamentarium but also discuss the technical considerations in catheter-based treatment approaches and respective outcomes.

Percutaneous image-guided needle biopsies are a safe and minimally invasive method of obtaining tissue of bone lesions. Radiologists are an integral part of a multidisciplinary team (MDT) approach to patient care in obtaining tissue for both pathologic diagnosis and advanced genetic/molecular testing. By utilizing image guidance, radiologists can target bone lesions with a very low complication rate. This review will discuss our approach to image-guided biopsies of bone lesions. Radiologists should be familiar with patient selection and imaging workup prior to performing biopsies, as well as the importance of coordinating the biopsy approach and sampling with the patient's clinical team. Management of bleeding and thrombotic risk in patients undergoing bone biopsies is also an important preprocedural consideration and will be discussed. The majority of bone biopsies are performed utilizing moderate sedation for patient analgesia and comfort, but close attention should be paid to patient comorbidities and potential interacting medications. Although computed tomography guidance remains the mainstay of image-guided biopsy, there are some circumstances in which ultrasound or fluoroscopic guidance may be beneficial. New advances in powered drill technology have made tissue sampling of bone lesions particularly sclerotic bone lesions both safer and faster with increased tissue yield. Finally, we will discuss image-guided biopsy of difficult anatomic regions that require special techniques to yield tissue safely.

Liver biopsy is a crucial aspect of interventional radiology and plays a significant role in the management of hepatobiliary diseases. Radiologists commonly perform two major image-guided liver biopsy techniques: percutaneous and transjugular approaches. It is essential for radiologists to understand the role of liver biopsy in diagnosing and treating hepatobiliary conditions, the procedural details involved, and how to manage potential complications. This article reviews the indications, contraindications, techniques, and efficacy of image-guided liver biopsy, with a focus on both percutaneous and transjugular methods.