Interventional Radiology is a department that, with the guidance of imaging techniques like angiography, ultrasonography, and computerized tomography, performs non-surgical treatments which are normally carried out by surgical means. Unlike other medical branches such as eye diseases or heart diseases, Interventional Radiology does not focus on a single topic or organ system. It makes possible to perform non-surgical treatments which in the past used to be done surgically with regard to several organ systems.
Interventional Radiology covers all angiographic blood vessel treatments (occlusions, aneurism, hemorrhage etc.) except for cardiac veins, along with needle biopsies and treatment of bodily fluids and cysts. It also covers the treatment of certain cancer types (in particular liver cancer), and also variceal treatment. As is seen, Interventional Radiology treats a large variety of different diseases, notably vascular diseases. The common aspect of all procedures is that they are all performed through a pinhole without the need for surgery. In Interventional Radiology, high-tech instruments are usually used to treat the patients.
Characteristics of Interventional Radiology treatments:
The most important characteristic of Interventional Radiology treatments is that they make it possible to perform non-surgical treatments which in the past used to be done surgically. Treatments are not performed in operating rooms, but either in an angiography room or regular treatment rooms. In contrast to surgery, Interventional Radiology procedures:
• do generally not require anesthesia (narcosis)
• are performed through a pinhole, without leaving any surgical scars
• patients are generally be discharged from hospital the same day
• are easier to perform and associated with lower risk
• the time to resume normal life is much shorter.
At the Interventional Radiology Clinic, a sedative and if necessary painkillers are administered to each patient prior to the procedure (sedation and analgesics). No matter how easy or convenient the procedure is, patients may feel pain due to needle insertion and it is necessary to relieve this pain by simple means. In addition, some patients may feel anxious, scared or worried before the procedure. The administration of these drugs helps to eliminate the patients' anxiety and distress about the procedure. In almost all procedures, the patient is discharged from hospital the same day. Occasionally, patients may have to stay at the hospital for a single day. 4 to 6 hours bedrest and monitoring are required subsequent to angiography, whereas the time required for other procedures is more variable. For instance, patients undergoing variceal treatment by laser or RF can be sent home right after the procedure.
Diseases treated by Interventional Radiology
1. TREATMENT OF VASCULAR DISEASES
Vascular diseases may affect the artery or vein. Arteries are vessels which take blood away from the heart and over which our pulse can be felt, whereas veins are vessels which carry the deoxygenated venous blood back to the heart. The blue blood vessels that can be seen on our arms are small veins.
Arterial Occlusions:
Arterial occlusions generally happen as result of arterial calcinosis or atherosclerosis. They can be seen in every individual. This being said, they are more common in elderly patients, diabetic patients, patients with high cholesterol and high blood pressure, and smokers. Arterial occlusions create problems in that part of the body where the affected organ is located. For instance, if affecting the arm arteries, the patients may experience complaints like fatigue when using the affected arm, hypertension if the renal arteries are constricted, or embolism of the brain if the aorta is constricted. Almost all occlusions or constrictions of blood vessels are treatable by angiography.
Leg Artery Occlusions:
Leg artery occlusions are a condition which is very commonly seen especially in elderly individuals. Like other vascular occlusions, they most frequently happen as result of atherosclerosis. In the early stages of leg artery occlusions, the affected patient will feel pain in calf muscles when walking. In advanced stages, the disease (occlusion) may cause coldness and severe pain in tiptoes, toe wounds and gangrene. The possibility of leg artery occlusion is very high if the following symptoms are present:
• Calf pain below knee level when walking
• The pain may be perceived in form of cramping at times or stiffness at other times
• The pain occurs not while sitting or standing, but only when walking
• The pain showing up when walking ceases completely after 2-3 minutes resting
• The pain appears back generally when walking the same distance
• The pain is more profound and appears more quickly when walking uphill or walking fast, whereas it is milder when walking downhill or walking slow.
Patients experiencing the above complaints are advised to get checked in terms of leg artery occlusion. Apart from physical examination, the first evaluation is generally made by colored doppler ultrasonography. If found necessary, angiography is performed by means of tomography or MRI (simple angiography).
Nowadays, most vascular constrictions and occlusions are successfully treatable by angiography. Many vascular occlusions told to be untreatable are can actually be treated by angiography. This is in generally associated with experience and good command of state-of-the-art technology. Our center is one of Turkey's most experienced centers in this regard. Our center makes use of all available methods such as balloon, medicated balloon, stent, medicated stent, thrombectomy (removal of blood clots) and atherectomy (plaque removal from blood vessels) to treat arterial occlusion and constrictions.
Diabetic Foot Wounds:
Almost half of all cases where a diabetic patient develops non-healing foot wounds are attributable to leg artery occlusion. Foot wounds generally start on the toes or heel in consequence of simple reasons such as stubbing one's toe, cutting nails, or pinching of shoes. The wounds may not heal for weeks or even months. Especially in case of wounds not healing for long time, patients are advised to get checked in terms of occlusion in their leg arteries. Failure to treat foot wounds timely may lead to amputation of the leg.
In patients with diabetic foot wounds arterial occlusions are sometimes neglected, attempting to treat the wound without relieving the occlusion. However, arterial occlusions interfere with the leg's nutrition, thereby inhibiting the nutrient and oxygen feed to wounds, which in consequence prolongs their healing. Therefore, patients with diabetic foot wounds are advised to get checked in terms of their leg arteries so that occlusions, if any, can be relieved in the first place. Treatment is generally performed by angiography since this procedure is low-risk with a high success rate. Our center is very well-experienced in this regard.
Buerger's Disease
Buerger's Disease is an occlusive arterial disease associated with smoking, which affects in particular males at the age of 20 to 40 years. The disease mostly affects the leg arteries, and sometimes those of the hands. In general, the disease causes pain in leg muscles and soles when walking, thus making it impossible to walk, due to occlusion of leg arteries. In advanced stages, severe pain in feet and hands are observed especially when resting, accompanied with wounds. The toes or feet in a significant part of patients have to be amputated by reason of non-healing wounds and gangrene. There is no definite treatment. The most important factor in treatment is to quit smoking. The progress of the disease generally stops when smoking is quit. However, it is not possible for arteries that have been occluded up to that time to get clear on their own. And there is no drug treatment, either. Only a few patients are suitable for surgical treatment (bypass surgery).
Angiographic treatment of this disease is an unfamiliar subject to patients, and even most doctors. Therefore, patients are told that there is no chance of cure, and that the only thing they can do is to take medication. Yet, angiography is the most efficient treatment method to relieve the occluded arteries of these patients. This being said, Buerger's disease is different from other vascular occlusions. As a rule, occlusions are seen in small blood vessels below knee level, which makes it more difficult to relieve them by angiography compared to other vascular occlusions. It may not be possible to relieve the vascular occlusions in every patient.
Carotid artery constrictions:
Constriction of the carotid artery may lead to embolism of the brain, resulting in paralysis. If mild, i.e. if the artery is constricted by less than 50%, the risk is considered low and drug treatment will suffice. However, if the carotid artery is constricted by more than 50%, the risk of embolism of the brain is high, which generally requires correction or repair of the constriction.
There are two treatment methods for carotid artery constrictions:
1. Surgical relieve of the constriction (endarterectomy)
2. Angiographic stent insertion
Carotid artery constrictions are treated by the Department of Interventional Radiology through angiographic stent insertion. This surgical procedure is performed by cardiovascular surgeons.
Which methods are used to relieve vascular constrictions?
Balloons and medicated balloons: These are means used to relieve vascular constrictions during angiography. During angiography, a thin long balloon is inserted into the occluded or constricted blood vessel, and then the balloon is inflated until its size reaches the diameter of that blood vessel to relieve the constriction. There are different balloon sizes for each blood vessel. The balloon is the deflated and taken out, i.e. the balloon is not left inside the body. Medicated balloons are the same as regular balloons, but with a drug-coated external surface. The drug penetrates into blood vessel walls once the balloon is inflated, thereby decreasing the possibility of repeated constriction or occlusion of the blood vessel in the long term.
Stents and medicated stents: Stents are different from balloons. They have a circular metal-mesh structure. Stents are like a tube that is not entirely closed but has a mesh structure. Likewise, stents are also inserted into the occluded or constricted blood vessel during angiography. In contrast to balloons, stents are left inside the blood vessel, i.e. are not taken out. Medicated stents are like regular stents. Like medicated balloons, a special drug coating is applied to medicated stents. The drug coating decreases the possibility of repeated constriction or occlusion of the blood vessel in the long term. These are currently available for blood vessels of the leg.
Atherectomy (plaque removal from blood vessels): Atherectomy is a procedure where plaque is removed from a constricted or occluded blood vessel using a special instrument. The removed plaque is collected in a reservoir of the instrument and taken out of the body. Atherectomy can be applied alone or together with subsequent balloon, medicated balloon or stent insertion. The purpose is to ensure that the blood vessel stays clear in the long term.
Aortic aneurysm (aneurysm of thoracic / abdominal aorta)
Aneurism is the dilation or bulging of a blood vessel. Aneurysm may occur in any blood vessel of the body. Aortic aneurysm is the bulging of the largest aorta in the body (thoracic or abdominal). Aortic bulging does usually not give rise to any complaints and is generally noticed by coincidence. If not treated, they may tear and result in serious internal bleeding and in most cases even death. Aneurysms are successfully treated at our Center by non-surgical means, i.e. using angiographic methods to insert an aortic stent graft into the bulging blood vessel.
Myoma Treatment (myoma embolization)
Myoma are benign tumors inside the uterus and are seen in one of every 3 women above the age of 35. There may be one or more intrauterine myomas. Myoma may cause menstrual irregularities, prolonged menstrual bleeding, anemia, and painful menstruation the larger they get in size and number.
While in elderly patients myomas are usually treated by complete hysterectomy of the uterus, young patients can be treated by embolization either surgically or non-surgically. In this technique, embolic agents are placed through a catheter into the artery to block blood flow to the myoma. This lack of blood flow causes the myoma to shrink, without any interference to the uterine blood flow. The most important advantage of the procedure compared to surgery is that it requires no incision and no general anesthesia, is repeatable in case of recurring myoma, and that the uterine tissue is preserved.
Varicocele treatment:
Varicocele is an enlargement and subsequent varicosity of veins within the loose bag of skin that holds the testicles (scrotum). Varicocele is mainly seen in the left testicle (approx. 85%) and bilateral in the remaining 15%. It may not cause any problems, whereas it may cause pain in a small group of patients. More commonly, it may reduce sperms and thereby result in infertility. This is the main reason why varicocele treatment is prescribed. There two treatment options: clamp or tie off the abnormal veins surgically or block the abnormal veins by angiography (i.e. venous angiography which is simpler compared to surgery).
Varicose veins and modern treatment methods:
Varicose is a very common disease of the veins. It is more common among women. In recent years, all types of varices are successfully treated by innovative methods such as laser, radiofrequency (RF), steam, or foam. There are three types of varices, while the treatment of these three types differs according to their relevant characteristics.
Capillary vessel or capillary varicose veins: Does usually cause not many complaints. Its treatment may be desirable due to aesthetic reasons. Available treatment methods are sclerotherapy (needle therapy) and transcutaneous laser/RF therapies.
Reticular varicose veins: Dark green veins, 2-3 mm in diameter. Does usually not cause any complaints. Its treatment may be desirable due to aesthetic reasons. The only treatment option is foam sclerotherapy or foam therapy. It is the most easily treatable varicose type.
Large varicose veins: Skin-colored varicose veins with up to one finger thickness. This type of varicose veins may cause complaints such as pain in the legs, fatigue, burning sense, cramping and impair one's life quality. Every person suffering from large varicose veins is usually affected by an underlying valve insufficiency of the vena cava. The priority of treatment is not the treatment of the visible varicose veins, but the venous valve insufficiency. New treatment option like intravascular laser, radiofrequency (RF), and steam therapy are all effective means to treat the underlying blood vessel problems.
Varicose treatment is painless for the patient, while the possibility of pain is eliminated by the administration of intravenous relaxant and analgesic drugs. After the procedure, patients are discharged as soon as the analgesic drug ceases its effect (in 1 to 2 hours). All varicose vein types are successfully treated non-surgically at our Center. Please visit www.bacakvarisi.com for further information on varicose veins and their treatment.
Deep Vein Thrombosis (DVT) and its treatment:
Venous occlusion can be seen in any vein, but the most common and most significant type are those seen in leg veins. Clogging and the resulting occlusion of the leg veins obstructs the blood flow back to the heart, leading to accumulation of blood, and in consequence to swelling and sometimes pain in the legs. In most cases, it is seen in a single leg, but may also affect both legs. The more veins are affected by the disease, the bigger the problem. Early diagnosis and proper treatment at early stages is essential, because failure to treat the disease in an early stage may result in life-long unhealable, irrecoverable problems.
DVT can be seen in anybody but is more common among following individuals: persons genetically prone to clotting, persons with a history of deep vein thrombosis, certain cancer patients, elderly persons, pregnancy and postpartum, intake of oral contraceptive pills, post-op period of major surgeries such as knee and hip prosthesis, plaster casting of the feet due to foot fractures or soft tissue injuries. DVT has to stages:
1. Early stage (acute) deep vein thrombosis: In early stage, the clot has just recently formed. There is prominent foot swelling due to occlusion of the vein. In one of three patients, the clot in the leg may lodge in the lungs, which is life threatening. Blood thinners are used within scope of the treatment. However, this does not dissolve the clot, but only prevent new clot formation and lodging of the embolus in the lungs. The only treatment capable to dissolve the clot is an intravascular procedure performed in an angiography room. Intravascular angiography may become necessary especially if the clot has reached the inguinal region. Treatment must take place as early as possible, because proper intravascular treatment is possible only if the clot is still fresh. Clots can be dissolved completely in the first 15 days of the disease. Thereafter, there is a decreased chance of cure. Angiographic, or in other words, intravascular treatment is carried out mostly through the vein behind the knee or sometimes through the ankle vein. Thin plastic tubes (i.e. catheters) are inserted to inject special thrombolytic drugs (thrombolysis=dissolve blood clots) or special instruments are used to mechanically remove the clot (thrombectomy=break down clots to dissolve or remove them).
2. Late stage (chronic) deep vein thrombosis: In approximately half of patients, who are not properly cured in the early stage, i.e. in the first month of the disease, a second problem emerges as they reach the late stage. This problem is referred to as chronic venous insufficiency. The embolus, not treated in the early stage, sticks to vein walls, thereby occluding the vein and also damaging the venous valves. Both conditions result in life-long foot swelling. Foot wounds may be seen in certain patients. In general, patients are told that there is no cure and that they must continue their lives wearing compression stockings. However, some of these patients are indeed treatable by relieving the occlusion and disburden the leg angiographically. Unfortunately, such treatment is known almost not at all in Turkey. But our center is quite well-experienced in this regard. In late stage deep vein thrombosis, it is not possible to dissolve or remove the clot (embolus), since it is nor fresh anymore and is sticking on vein walls. The only option is to clear the occluded blood vessels by means of a balloon or stent. Our center is capable to successfully treat both early stage and late stage deep vein thrombosis by angiographic and intravascular means.
Vascular malformation treatment:
Vascular malformation is a venous disease that can be seen in any part or organ of the body. It can be referred to as glomuvenous malformation. It resembles varicose veins but is different. In general, it is present already at very young age and tends to grow as the person gets older. It is both aesthetically disturbing for the patient and may cause pain.
There are two treatment methods: surgical removal or needle therapy (ablation treatment). Sometimes, both treatment methods are used together. Our department is performing needle therapy for non-surgical treatment of vascular malformations.
Interventional radiology in vascular access problems of dialysis patients:
Dialysis fistula may contract from time to time, get clogged and occluded, and cause arm swelling, and numbness or wound formation in fingers. What is even more important, the fistula will not function properly, and the patient will not be able to undergo dialysis. If this is the case, an intravascular catheter will have to be placed so that the patient can receive dialysis treatment, which may give rise to new vascular occlusions in the long term. Interventional radiology provides the following treatment options for dialysis patients:
1. All constrictions and occlusions seen in the fistula of dialysis patients are treated by angiography. If the fistula is clogged, the clotting is removed by non-surgical methods of thrombolysis or thrombectomy. Likewise, if a graft has been inserted for dialysis purposes, the occlusion of such graft is also relieved angiographically.
2. Serious arm swelling subsequent to fistula placement may be seen in patients with previous central venous catheter placement. This is because of occlusion of the humorous vein. Arm swelling is cured by clearing the occlusion.
3. In addition, intravascular catheter placement in any location may be required in emergency cases where hemodialysis patients need to undergo dialysis via catheter. Since all procedures are carried out with ultrasonic imaging, it is safer and less inconvenient for the patient.
2. INTERVENTIONAL RADIOLOGY IN CANCER PATIENTS
The medical services offered to oncologic (cancer) patients by interventional radiology are subdivided to two main areas:
1. Procedures supplementary to oncologic treatment
2. Procedures directly treating cancer
Interventional procedures supplementary to oncologic treatment include takin biopsy samples from masses, placement of ports and other vascular accesses to enable patients convenient administration of their medicines, relief of occlusions in bile ducts or the urinary tract, drainage of fluids accumulating in lungs, and placement of stents to treat occlusions in the esophagus, alimentary canal or the intestines (if surgical intervention is not possible).Moreover, diseases like deep vein thrombosis frequently seen in oncologic patients are treated by modern endovascular methods.
Interventional procedures to cure cancer have considerably developed especially in the last decade.
Interventional treatments in cancer patients are usually performed supplementary to chemotherapies within the scope of medical oncology. Interventional radiology is also used in cases where treatments like chemotherapy, radiotherapy or surgery are not efficient. There are two types of interventional radiology in cancer treatments:
1. Ablation therapy which a procedure where a cancerous mass is destroyed through direct insertion of needles into the solid cancerous mass in company of imaging methods (non-surgical). Ablation can be carried out by radiofrequency (RF ablation) or microwaves (microwave ablation). In liver tumors smaller than 3 cm, this method is as effective as surgery, which is considered as the best method in treating such tumors. Occasionally, in certain tumors, treatment is possible by freezing the cancerous mass (cryoablation) followed by irreversible electroporation (IRE) or application of ultrasonic waves.
2. Angiographic treatments: Transarterial chemoembolization (TACE) is an angiographic procedure where anticancer drugs are attached to small beads that are injected into an artery that feeds the tumor. Using the same method, radioactive beads can be injected instead of beads with anticancer drugs (TARE, transarterial radioembolization). Both methods are more efficient than chemotherapy. But they require angiography. There is always the chance to repeat treatment.
These treatments are most commonly applied to liver tumors. Along with liver tumors, ablation may be applied also to kidney or lung tumors. These treatment methods have recently started to be applied for several tumor types worldwide. Both ablation and angiography treatments may be performed before or after chemotherapy. They have no restricting effect on chemotherapy. There is always the chance to repeat treatment.
Ablation does not require the patient to stay in hospital. They may go home the same day. In contrast, angiographic therapies (TAKE or TARE) require minimum 6-hour stay in hospital, and sometime a whole day.
3. NON-VASCULAR INTERVENTIONAL RADIOLOGY PROCEDURES
Needle biopsies
Needle biopsy (i.e. tissue sampling) can be performed on almost every tissue or organ in the body without the need for surgery or other major procedure. The ability of Interventional Radiology to perform biopsies is by virtue of its excellent command of imaging methods such as ultrasonography or computerized tomography. Needle biopsy is different from biopsies carried out blindly without seeing the target tissue. The insides of the body are imaged during the entire biopsy procedure to ensure proper insertion of the needle to take samples.
Biopsies are generally implemented to establish a final diagnosis, i.e. determine whether tumors are of benign or malign nature and if possible identify its type. Besides, biopsies are also performed on organs like liver, kidney, and lungs to reveal any organ diseases.
Biopsies are generally simple and painless. After the procedure, patients may go home the same day after a short monitoring and bleeding control.
The collected samples are evaluated by a pathologist. How much time such evaluation will take generally depends on how the sample is processed (application of special dyes etc.).
Drainage procedures
Drainage is the transfer of a fluid from one place to another or removal of a fluid from the body. It is most frequently used in two cases. First, in case of an occlusion (e.g. occlusion of bile ducts) the bodily fluids may not drain naturally and start to accumulate, and eventually mix into blood and damage the body. If in this case the occlusion cannot relieved immediately, the accumulated fluid must be drained. In the second type of drainage, there is no occlusion, but undesired fluid accumulations occur in the body due to various diseases. For instance, fluid may accumulate in the lungs and cause respiratory distress, or excessive fluid may accumulate in the abdomen and cause pain. These fluids need to be taken out of the body. So, drainage must be applied.
Basic drainage procedures:
Drainage of biliary ducts (biliary drainage): Obstruction of biliary ducts generally in consequence of tumors gives rise to obstructive jaundice. Percutaneous biliary drainage is a procedure where a needle is inserted into the bile ducts to place a tube, so that the bile can be drained. For permanent drainage, the plastic tube is taken out by its open end and replaced by a metal stent.
Drainage of the urinary tract (nephrostomy): Obstruction of the urinary tract leads to accumulation of urine, which results in enlargement of renal collecting duct system and urinary canals, as well as functional disorder of the kidneys in the long term. In nephrostomy, a tube is placed into the collecting duct system of the kidney that collects urine and transmits it to the bladder, thereby draining urine for a certain period of time. This relieves both the kidney and kidney ducts. The tube is removed once the underlying problem is resolved.
Drainage of fluids: Mostly fluids accumulating in the lung and cause respiratory distress as well as fluids accumulating in the abdomen and cause prominent abdominal tightness and pain.
Drainage of abscesses: All abscess types that have reached a certain size in the body and used to be treated surgically can now be treated by tube drainage.
Cyst Treatment
Hydatid cysts, which are parasitic cysts in the liver and other organs, and excessively large liver or kidney cysts are drained with a needle and successfully treated non-surgically by injection drugs through the needle.
